Thoracotomy, Intercostal Space Incisions, and Rib Excision

The surgical creation of an opening through the thoracic wall to enter a pleural cavity is a thoracotomy An anterior thoracotomy may involve making H-shaped cuts through the perichondrium of one or more costal cartilages and then shelling out segments of costal cartilage to gain entrance to the thoracic cavity. The posterolateral aspects of the 5th–7th intercostal spaces are important sites for posterior thoracotomy incisions. In general, a lateral approach is most satisfactory for entry through the thoracic cage. With the patient lying on the contralateral side, the upper limb is fully abducted, placing the forearm beside the patient’s head. This elevates and laterally rotates the inferior angle of scapula, allowing access as high as the 4th intercostal space. Surgeons use an H-shaped incision to incise the superf i cial aspect of the periosteum that ensheaths the rib, strip the periosteum from the rib, and then excise a wide segment of the rib to gain better access, as might be required to enter the thoracic cavity and remove a lung (pneumonectomy), for example. In the rib’s absence, entry into the thoracic cavity can be made through the deep aspect of the periosteal sheath, sparing the adjacent intercostal muscles. After the operation, the missing pieces of ribs regenerate from the intact peri osteum, although imperfectly.