Lung Surgery

Approach to a patient with a Lateral Thoracotomy Scar


Any rib resection?

  • Suggests possible thoracoplasty for TB in the past. Look for phrenic nerve crush scar, kyphosis and apical fibrosis suggestive of TB.

Is the underlying lung normal without chest flattening?

  • Lobectomy and transmitted sounds (hyperinflation of other lobes masking signs)
  • Bullectomy for COPD which is currently well-controlled
  • Lung transplant: look for signs of steroid use, gum hypertrophy, tremor, hypertrichosis, wrist tag, maybe abnormal lung on the other side
  • Open lung biopsy
  • Pleurectomy
  • Decortication

Abnormal underlying lung e.g. reduced breath sounds, added sounds, chest flattening?

  • Lobectomy
  • Pneumonectomy
  • Lung volume Reduction Surgery for COPD
  • Bullectomy for COPD
  • Lung transplant with complications



Present to the examiner:


This patient has a right sided lateral thoracotomy scar

Comment on whether there is chest asymmetry with flattening on the right +/- rib resection

The trachea was central/deviated towards the right

The chest expansion was reduced in the upper right hemithorax

The apex beat was (un)displaced

The percussion note was dull in the upper right hemithorax

Breath sounds were vesicular but decreased on the right upper hemithorax

Vocal resonance was decreased

There were (no) crepitations/wheeze


Comment on whether there was evidence of respiratory failure or cor pulmonale


I suspect this patient has had a right upper lobectomy


With regards to the cause:

  1. Lung cancer: tar staining, clubbing, lymphadenopathy, cachexia, radiotherapy tattoo, horners, small hand muscle wasting, signs of chemo such as hair loss, HPOA
  2. Localised bronchiectasis with (un)controlled symptoms: clubbing, coarse crepitations, sputum pot at bedside. NB: may have portacath if cystic fibrosis
  3. Pulmonary AVM as part of Hereditary haemorrhagic telangiectasia: telangiectasia
  4. COPD: wheeze, inhalers, tar staining, hyperinflation (lung volume reduction surgery/bullectomy)
  5. TB thoracoplasty: phrenic nerve crush scar in supraclavicular fossa, apical crepitations, kyphosis (spinal TB)


Differential Diagnosis of lateral thoracotomy scar:


  1. Lobectomy (for cancer usually NSCLC or secondary, infection e.g. localised bronchiectasis/CF with recurrent infection or haemoptysis, lung abscess, aspergilloma, TB, infarction, bleeding, pulmonary nodule, trauma, sarcoidosis)
  2. Pneumonectomy (for cancer involving more than 1 lobe/diaphragm/pleura/pericardium, infection e.g. bronchiectasis, multiple abscesses) NB: dull percussion note and reduced/absent breath sounds over the entire affected hemithorax
  3. Open lung biopsy (NB: incision will likely be shorter)
  4. Lung volume reduction surgery (for COPD)
  5. Single lung transplant (for pulmonary fibrosis, alpha1-antitrypsin deficiency, sarcoidosis) NB: other lung may be abnormal, there may be signs of immunosuppressive therapy, patient may be wearing a wrist tag
  6. Pleurectomy (for recurrent pneumothoraces/effusions)
  7. Bullectomy (for COPD)
  8. Thoracoplasty (for TB)
  9. Decortication (for empyema)


Criteria for lung surgery:


FEV1> 1.5

Transfer factor >50%

No evidence of severe pulmonary hypertension

No evidence of metastases

Good WHO functional status


Contraindications: T4, N3, M1, tumour potentially curable by radiotherapy


Clamshell Incision Scar (transverse sternotomy) suggests possible bilateral lung transplant for cystic fibrosis, bronchiectasis, COPD, pulmonary fibrosis, pulmonary artery hypertension, sarcoidosis, alpha-1 antitrypsin deficiency


Present to the examiner:


There is a transverse sternotomy/clamshell incision scar

The trachea is central, the apex beat is undisplaced, chest expansion is equal and not reduced

The percussion note was resonant throughout

Breath sounds were vesicular and VR was normal

Comment on whether there was evidence of respiratory failure or cor pulmonale.

The patient was wearing a wrist tag.


I suspect this patient may have had a bilateral lung transplant and is currently clinically well


Comment on whether there was evidence of immunosuppressive therapy:

  • Steroid toxicity: bruising, cushingoid, proximal myopathy, kyphosis
  • Ciclosporin: tremor, gum hypertrophy, hypertrichosis
  • Suspicious skin lesions


Comment on whether there were any clues to the cause:

  1. Cystic fibrosis: clubbing, short stature, chronic liver disease signs, portacath/Hickman line
  2. Bronchiectasis : clubbing
  3. COPD: tar staining
  4. Pulmonary fibrosis: clubbing
  5. Pulmonary hypertension
  6. Alpha-1 antitrypsin deficiency
  7. Sarcoidosis


Comment on whether there were any clues to possible complications:

  • Fine late crepitations may indicate Bronchiolitis Obliterans Syndrome post lung transplant



Median Sternotomy scar in station 1 may indicate heart and lung transplant for pulmonary hypertension, congenital heart disease causing Eisenmengers, cystic fibrosis


Complications of lung transplant:

  1. Rejection (acute and chronic) including bronchiolitis obliterans syndrome
  2. Infection e.g. CMV, HSV, aspergillus, PCP, bacterial pneumonia
  3. Immunosuppression therapy side effects




Written by Dr Sarah Kennedy


Resources used to write this document are listed in the references section of this webpage