Thoracotomy is a major surgical maneuver—the first step in cardiothoracic surgery, which involves major procedures such as coronary artery bypass surgery and lobectomy or pneumonectomy for lung cancer—and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation.
Median sternotomy provides wide access to the mediastinum and is the incision of choice for most open-heart surgery and access to the anterior mediastinum.
Posterolateral thoracotomy is a very common approach for operations on the lung or posterior mediastinum, including the esophagus. When performed over the 5th intercostal space, it allows optimal access to the pulmonary hilum (pulmonary artery and pulmonary vein) and therefore is considered the approach of choice for pulmonary resection (pneumonectomy and lobectomy).
Anterolateral thoracotomy is performed upon the anterior chest wall; left anterolateral thoracotomy is the incision of choice for open chest massage, a critical maneuver in the management of traumatic cardiac arrest. Anterolateral thoracotomy, like most surgical incisions, requires the use of tissue retractors—in this case, a "rib spreader" such as the Tuffier retractor.
Bilateral anterolateral thoracotomy combined with transverse sternotomy results in the "clamshell" incision, the largest incision commonly used in thoracic surgery.
Upon completion of the surgical procedure, the chest is closed. One or more chest tubes—with one end inside the opened pleural cavity and the other submerged under saline solution inside a sealed container, forming an airtight drainage system—are necessary to remove air and fluid from the pleural cavity, preventing the development of pneumothorax or hemothorax.