World J Surg (2014) 38:1001–1002 DOI 10.1007/s00268-013-2253-9

On the Ideal Emergency Thoracotomy Incision Pantelis Vassiliu • Tugba Yilmaz • Elias Degiannis

Published online: 18 October 2013 Ó Socie´te´ Internationale de Chirurgie 2013

To the Editor, We read with interest the article titled ‘‘Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomical study’’ [1]. It is an interesting report, showing the enthusiasm of the authors in furthering the management of trauma by comparing the different thoracic incisions and evaluating their access to intrathoracic organs in cadavers. Having ourselves a reasonable thoracic trauma experience, we agree with the authors that 2nd and 3rd intercostal space incisions are obsolete. It becomes impossible to spread the ribs far enough to provide adequate visual contact and access to injured viscera at that level. Median sternotomy is ideal for injuries of the anterior mediastinum, giving excellent access to the ascending aorta, the aortic arch and its branches, and the heart. It also has the advantage over the left anterolateral thoracotomy, in the presence of hemopericardium originating from an injury of the ascending aorta, which can be managed with greater ease through a median sternotomy [2, 3]. Management of the right chambers of the heart can easily be dealt with through both incisions, if we are prepared to occasionally split the sternum transversely, as a continuation of the left anterolateral thoracotomy [2].

P. Vassiliu (&) 4th Surgical Clinic, Attikon University Hospital, Athens, Greece e-mail: [email protected] T. Yilmaz Department of Surgery, Baskent University, Ankara, Turkey E. Degiannis Trauma Unit, Department of Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa

From the above assessment it is possible to see that we more or less agree with the authors. Yet we totally disagree with their recommendation of clam shell incision for access to intra-thoracic injuries, particularly if the surgeon is not ‘‘very experienced.’’ This is a very extensive incision and has intrinsic problems that cannot be assessed in the cadaver. (1)

(2)

(3)

There is a tendency of the cranial and caudal segments of the thoracic wall incision to move superiorly and inferiorly with regard to the coronal plane, making the operation technically challenging. Most of the time containment of this movement requires an assistant to stabilize the two parts of the incision at the thoracic wall level. There is no comparison between the median sternotomy and the clamshell incision for access to the superior mediastinum. Median sternotomy is superior in this aspect, and the patient has an easier postoperative course with more easily controlled pain and fewer respiratory complications. To obtain access the chest, we suggest, for the moribund patient where there is a suspicion of cardiac injury or left pulmonary injury, using the left anterolateral thoracotomy. For physiologically stable patients where there is a suspicion of cardiac injury and for all patients with suspicion of mediastinal vascular injury, we again recommend median sternotomy. If both thoracic cavities have to be accessed, we recommend left and right anterolateral thoracotomy incisions, leaving intact the sternum, as this provides stability of the anterior thoracic cage, facilitating the operation. Only in exceptional circumstances of bilateral thoracotomy in which mediastinal injury is unexpectedly found, do we proceed to

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World J Surg (2014) 38:1001–1002

a join the two incisions by transversely splitting the sternum (clamshell) or by adding a median sternotomy incision as dictated by the injury [2, 3]. We accept that our approach may not be practiced by all trauma surgeons, but our experience supports the choices described above. We also think that, although there is need for anatomical studies on cadavers, we should be very cautious in making recommendations on the basis of cadaveric anatomical approaches, as there are considerable differences in behavior of the tissues, and recommendations can be made without always taking into consideration the living patient’s physiology. Maybe it is time to introduce to our reports a ‘‘Level of Clinical Applicability’’ alongside the ‘‘Level of Evidence.’’

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References 1. Simms ER, Flaris AN, Franchino X et al (2013) Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomical study. World J Surg 37:1277–1285. doi:10.1007/s00268-013-1961-5 2. Brown CVR, Green DJ (2012) Emergency department thoracotomy. In: Velmahos GC, Degiannis E, Doll D (eds) Penetrating trauma. A practical guide on operative technique and perioperative management. Springer, New York, pp 75–84 3. Calderbank PR, Tai NRM, Bowley DM (2012) Mediastinal vessels. In: Velmahos GC, Degiannis E, Doll D (eds) Penetrating trauma. A practical guide on operative technique and perioperative management. Springer, New York, pp 267–275

On the ideal emergency thoracotomy incision.

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