The principles and practice of modern surgery

by Roswell Park

Thoracotomy.

—The term thoracotomy implies an incision made through the chest wall, usually for withdrawal of fluid, with or without removal of some portion of its bony structure. Thoracotomy performed for pericardial collections of fluid has been described. That for removal of ordinary empyemic collections is usually a simple measure. It may be practised under local anesthesia. In a general way the extent of the fluid collection is made out by percussion, and its character by exploratory puncture. The endeavor should be to make the opening laterally and posteriorly near the lower aspect of the cavity to be emptied in order that it may drain by ordinary force of gravity with the patient in the dorsal position. Unless it be intended to remove a portion of rib the incision need not be more than one inch in length.

Ordinarily the skin is pushed a little one way or the other so that a rib can be seen underlying it, in order to steady it for the external incision. Then it is allowed to glide back to its normal position and the knife-blade is so directed as to at once enter the thoracic cavity. Only rarely is it necessary to make a careful dissection. It is not often that vessels of importance will be divided, and one may usually proceed boldly with the incision. It will be promptly followed by appearance and usually by forcible expulsion of fluid, perhaps even in a jet, for which a basin should be provided. In fresh cases this fluid will be thin; in old empyemic cases there will be so much caseous material mixed therewith that it may obstruct the opening and check escape of fluid. In these cases it may be pushed aside with forceps or by the introduction of a finger. When such material is present, however, there is need also for its evacuation, and in such cases the incision should be extended and an inch or more of rib may be removed in order to afford sufficient exit.

The objection above mentioned regarding speedy evacuation applies theoretically rather than practically to this procedure, for when it is necessary to open the chest cavity widely it is because the walls of the cavity thus opened have already become so thickened or stiffened by the disease process that there is not the danger of sudden change of position of the thoracic viscera which obtains in the less serious and more acute cases.

The fluid having been removed the next question is one of irrigation. This is only rarely necessary or even justifiable. Even in cases where the evacuated pus has a more or less offensive odor it is found sufficient to remove it, while experience shows the inadvisability, sometimes the practical danger of prolonging the procedure and trying at this time to wash out the chest cavity. If irrigation be practised it should be with a bland fluid, for antiseptics are here peculiarly irritating.

The third question is one of drainage. In recent cases it will often be sufficient to insert some flexible material, like a piece of oiled silk folded upon itself, secured externally by a safety-pin, or stitched to the skin in such a way that it shall not be lost within the cavity. In the older and more serious cases more complete drainage should be provided. This is usually effected with a short piece of rubber tubing, which needs to be amply secured against loss, either with a large safety-pin or by being stitched to the skin with silk rather than with gut, lest the latter soften too soon. This tube should ordinarily be quite short, in order that it may not irritate the pleural surface of the expanding lung. It is rarely necessary to make valve-like protection of the opening, nor is it usually advisable to insert any sutures in the external wound. These openings in most instances close too soon rather than too slowly.

The surgeon should avoid making the opening too low, lest the diaphragm, having been pushed downward by the accumulation above it, rise and cover the end of the tube. Well-marked cases of empyema will often improve more quickly if a counteropening be made. It is an easy matter to introduce the end of a long forceps and determine the best point at which to make this opening. The forceps being then held at this point, one may easily cut down upon its end, force it through, and utilize it for drawing backward, completely through the chest, a long piece of perforated drainage tube, which perhaps may be eventually replaced by a few strands of silkworm gut. A very large and copious external dressing should be applied, and changed as often as need be, in order to receive and provide for such discharge as may take place. Sometimes this will be quite considerable, and necessitate, for the first two or three days, a change every few hours.

Some surgeons have endeavored to make drainage more complete by a vacuum irrigating apparatus, on the Bunsen pump principle. Should it be necessary to resort to this the more complicated older methods may be supplanted by the simple procedure, illustrated later in this work, for continuous drainage or siphonage of the bladder.

One should never attack a case of this kind without being prepared to remove a section of one or more ribs. Indications for this will be found in the character of the contained fluid, or in the thickness of the wall of the abscess, i. e., the old pleural cavity. The difficulty usually is that these openings tend to close too promptly, and that, especially in children, the proximity of the ribs to each other affords too small space for the maintenance of drainage. When it becomes necessary to remove a piece of one or more ribs there is little object in trying to preserve the periosteum, and the operation may be made within a few seconds by simply retracting the skin wound and the musculature, introducing the bone-cutting forceps, with which the rib or ribs are divided at points one inch or more apart, the intervening portion being promptly lifted out with forceps and cut away with strong scissors. The operation of dividing the rib will often so compress the intercostal arteries that there will be little hemorrhage from this source. Should they bleed too much strong forceps should be used to compress the lower edge of the rib, and, by crushing it produce hemostasis, as though the artery were itself seized with forceps, or the vessel itself may be seized and secured. A special form of forceps for dividing ribs, known as the costotome, has been devised and has proved serviceable, since it is so made as to prevent easy slipping of the rib from the grasp of the blade.

The larger opening thus made is treated in practically the same way as the smaller. Through it the fingers or a blunt spoon may be inserted and any cheesy material lifted out, or a sponge or gauze swab held in the grasp of a long forceps may be introduced, and with it the cavity thus opened may be wiped out or swabbed. In this way a considerable amount of caseous material or shreds of membrane may be removed. The more that can be removed the better, since there is so much less to come away later. Such manipulation is, however, sometimes attended by embarrassment of respiration, and one should use discretion in the extent to which he practises it. Hemostasis having been secured, it will depend on the case and its extent whether any effort is made to partially close the wound or whether it should be left open. Even large defects thus made usually heal kindly and fine or careful suturing is rarely needed.