Overview
Definition:
Clamshell thoracotomy, also known as an anterior clamshell incision or transverse sternotomy, is an emergency surgical approach that provides wide exposure of both hemithoraces, the mediastinum, and the heart
it is typically employed in life-threatening thoracic trauma or cardiac emergencies requiring rapid access for resuscitation and definitive repair.
Epidemiology:
While not a common procedure, clamshell thoracotomy is primarily indicated in severe, high-energy thoracic trauma cases, particularly those with exsanguinating hemorrhage or suspected massive intrathoracic injury
its incidence is directly related to the prevalence of severe trauma requiring emergent thoracotomy, with estimated rates of 0.1% to 1% of all emergency department thoracotomies.
Clinical Significance:
This technique is critical for rapid control of life-threatening bleeding from great vessels, cardiac rupture, or massive hemothorax
it allows for immediate cardiac resuscitation, tamponade release, and access to both lungs and the entire thoracic cavity, making it a vital skill for trauma surgeons and cardiothoracic surgeons managing critically ill patients.
Indications
Emergency Indications:
Massive hemothorax with hemodynamic instability
cardiac tamponade requiring emergent decompression
exsanguinating hemorrhage from thoracic great vessels (aorta, pulmonary artery, vena cavae)
suspected cardiac rupture or great vessel injury in a hemodynamically unstable patient
blunt chest trauma with flail chest and severe respiratory compromise unresponsive to ventilation.
Relative Indications:
Complex bilateral pulmonary contusions with refractory hypoxemia
severe esophageal or tracheal injury requiring immediate repair
suspected aortic transection in a hemodynamically compromised patient.
Contraindications:
Non-survivable injuries (e.g., extensive brain injury, avulsed organs)
patient refusal
severe coagulopathy precluding surgical intervention
lack of appropriate surgical expertise or resources.
Preoperative Preparation
Patient Assessment:
Rapid assessment of ABCs (Airway, Breathing, Circulation)
immediate hemodynamic monitoring (arterial line, central venous access)
initiation of massive transfusion protocol if indicated
rapid intubation and mechanical ventilation
portable chest X-ray if time permits, but not to delay intervention.
Surgical Team Readiness:
Ensure availability of a surgical team experienced in thoracic surgery and trauma
confirm availability of all necessary surgical instruments, including sternal saw, rib retractors, and hemostatic agents
prepare for massive blood product transfusion.
Anesthesia Considerations:
General anesthesia with controlled ventilation
initiation of neuromuscular blockade
careful fluid management and hemodynamic support
readiness for rapid induction and maintenance of anesthesia under stressful conditions.
Procedure Steps
Incision Placement:
A transverse incision is made across the sternum, typically from the anterior axillary line on one side to the anterior axillary line on the opposite side, curving superiorly around the breasts
it can be extended superiorly around the clavicles if needed for superior mediastinal access.
Sternal Division:
The sternum is divided longitudinally using a sternal saw, from the suprasternal notch to the xiphoid process
care is taken to avoid injury to underlying mediastinal structures, particularly the heart and great vessels.
Retraction And Exposure:
A large rib spreader or sternal retractor is used to spread the sternal halves apart, creating a wide opening to expose both pleural cavities and the mediastinum
this "clamshell" opening allows for unparalleled access.
Surgical Intervention:
Immediate identification and control of bleeding sources
management of cardiac tamponade by evacuation of pericardial effusion
repair of cardiac or great vessel injuries using sutures, vascular grafts, or other hemostatic techniques
lung repair or resection as needed
control of massive hemothorax by direct ligation or cautery.
Closure:
After hemostasis is achieved and injuries are repaired, the sternum is approximated and secured with sternal wires
ribs are approximated, and chest tubes are inserted into each hemithorax for drainage
the overlying soft tissues are closed in layers.
Postoperative Care
Monitoring:
Intensive care unit (ICU) admission is mandatory
continuous hemodynamic monitoring, including arterial and central venous pressures
mechanical ventilation with gradual weaning
close monitoring of chest tube output and respiratory status.
Pain Management:
Aggressive pain control is crucial, often requiring patient-controlled analgesia (PCA) with opioids or epidural analgesia
adequate pain relief facilitates deep breathing and mobilization.
Chest Tube Management:
Serial chest X-rays to ensure proper lung expansion and drainage
management of chest tubes to prevent kinking or dislodgement
monitor for signs of pneumothorax or hemothorax recurrence.
Rehabilitation:
Early mobilization as tolerated
pulmonary physiotherapy and breathing exercises to prevent atelectasis and pneumonia
gradual return to normal activity levels.
Complications
Early Complications:
Hemorrhage from great vessels or heart injury
cardiac arrhythmias
mediastinal hematoma
pneumothorax
infection
wound dehiscence
respiratory failure
acute kidney injury.
Late Complications:
Chronic pain at the sternotomy site
sternal non-union or malunion
restrictive lung disease
paradoxical chest wall movement
adhesions and chronic pleural effusion
incisional hernia.
Prevention Strategies:
Meticulous surgical technique to avoid iatrogenic injury
prompt recognition and management of bleeding
adequate chest tube drainage
aggressive pain control and pulmonary physiotherapy
judicious use of antibiotics
careful wound closure.
Key Points
Exam Focus:
Clamshell thoracotomy is an emergent procedure for severe thoracic trauma or cardiac arrest with reversible cause
it offers bilateral chest exposure for rapid resuscitation and repair
indications include massive hemothorax, cardiac tamponade, and great vessel injury in unstable patients.
Clinical Pearls:
This is a salvage procedure
speed is paramount
anticipate massive hemorrhage and have blood products ready
careful sternal division and retraction are key to avoiding further injury
chest tube management is critical post-operatively.
Common Mistakes:
Delaying the procedure in a hemodynamically unstable patient
inadequate exposure leading to incomplete control of bleeding
iatrogenic injury to great vessels or heart during sternal division
insufficient postoperative pain management hindering lung expansion.