1. The ‘Clamshell’ approach to Emergency Department Thoracotomy
Authors: E Shaun Goh, Yee Lee Cheah, Kenneth SW Mak
Institution: Khoo Teck Puat Hospital, Singapore
Aim
Within the thorax, a large tense bluish appearance of the pericardium was seen which confirmed the presence of a pericardial tamponade. A small incision of the pericardium was then done anteriorly with the scalpel and the pericardium blunt dissected inferiorly and superiorly. This allowed relief of the tamponade. Blood was suctioned off and clots evacuated from the thorax. The heart was directly inspected and found to have a ruptured right atrium measuring about 1.5 cm. The edges of the rupture were clamped with an arterial forceps and internal cardiac massage was initiated. Bright red blood was then seen actively collecting within the right haemothorax. There was suspicion of a pulmonary laceration. The right lung was mobilized by dissection through the inferior pulmonary ligament and a right lung twist was performed. Subsequently the cardiac rhythm showed ventricular fibrillation. Defibrillation was carried out via external pads with successful cardioversion to a sinus rhythm. The patient was transferred immediately to operating theatre with on-going internal cardiac massage.
In operating theatre the findings were that of a ruptured right atrium appendage and right lung laceration. Both were repaired successfully and the patient survived past closure. Unfortunately he died later from disseminated intravascular coagulopathy and multiple organ failure.
To highlight the potential of the ‘clamshell’ thoracotomy approach as a reasonable first-choice for acute trauma resuscitation in the emergency department.
Introduction
The emergency department (ED) thoracotomy is a desperate resuscitative procedure employed when trauma patients are too unstable to be transferred directly from the resuscitation room to the operating theatre. The aims of this procedure are to relieve tension or tamponade physiology, achieve proximal haemostasis control and to restore circulationi. This is achievable by means of rapid access, visualization and quick management of injury.
The ‘clamshell’ thoracotomy approach is well taught and utilized for trauma in the United Kingdom within the emergency departments and prehospital environmentii. This approach has also been gaining recent interest in the United States of Americaiii. It is currently not the standard approach to ED thoracotomy in Singapore.
Case report
A 16 year old young man in deliberate suicide jumped from the 5th storey of his apartment and landed on concrete ground. When attended to by the Emergency Medical Services, he was described as semi-conscious, confused and combative. There were obvious injuries seen to his chest and head. His initial vitals at the scene were heart rate of 120 beats per minute (bpm), Systolic blood pressure (SBP) of 120 mmHg, Diastolic blood pressure (DBP) of 70mm Hg and oxygen saturations (SaO2) of 95% on room air (RA). Glasgow Coma Scale was 12.
At the emergency department, rapid sequence induction followed by prompt intubation was performed. Shortly after intubation, it was noted that he rapidly went into pulseless electrical activity (PEA). Cardiopulmonary resuscitation was commenced and bilateral pleural decompressions performed with no obvious release of tension or significant haemothorax. A rapid bedside focused assessment by sonography in trauma (FAST) scan was done which revealed a large pericardial effusion. Decision was then made for an ED thoracotomy.
The ED thoracotomy was performed by means of a large incision that extended across the chest along the 4th intercostal space from mid axillary to mid axillary landmarks through the sternum. To gain access, a no. 10 scalpel was first used to incise the skin and subcutaneous tissue across the chest from the thoracostomy sites to the sternum following the convexity of the rib space as close as possible. Further dissection was done through deep fascia, intercostal muscles and parietal pleural down into the pleural cavity. A curved Mayo scissors was then used to further cut through deep fascia and intercostal muscles along the intercostal space from the point of incision extending to the sternum on both sides. The sternum was cut with straight Mayo scissors thus completing the ‘clamshell’ thoracotomy. The thoracic cavity was then exposed by means of a sternal retractor placed at both ends of the cut sternum and extended.
Discussion
The‘Clamshell’ thoracotomy had allowed easy immediate access to the entirety of the thoracic cavity. Achievable in one incision rather than multiple incisions at different times.
Injuries were identified almost immediately
Haemostatic procedures were carried out promptly and in a safe manner.
In comparison, a unilateral left thoracotomy would have been a much smaller window leading to poor visualization of the injuries. In this case, access and visualization to the right atrial injury would have been challenging, as well as the clamping of the ruptured right atrium.
The clamshell allowed for easy exposure of the right hemithorax. The injury to the right lung was rapidly identified and temporizing procedure done promptly with ease.
Other potential advantages of the ‘clamshell’ technique include better visualization of the ascending and descending aorta allowing for safer manipulation and clamping.
Complications from the clamshell thoracotomy relate to post-operative recovery where there is a higher rate of sternal wound complications and sternal healing complicationsiv. These complications are reduced with proper definitive sternal fixationv,vi.
Studies that compared the clamshell against sternal sparing incisions from elective surgery had found that overall outcomes in terms of survival, length of ICU stay and postoperative function were similarvii. Also there was no evidence from those studies to indicate that there was any increase in immediate or early mortality or morbidity relating to the clamshell incision
Conclusion
The ‘clamshell’ incision is a good first-choice approach to the ED thoracotomy
Advantages of this incision include
Rapid and easy access to all structures within the thoracic cavity with one incision
Improved visualization, assessment and identification of injuries to the thoracic structures, e.g heart.
Immediate exposure of right hemithorax and allows for easy manipulation of right thoracic structures
Fig 1. Clamshell thoracotomy in a trauma patient. Right hilar clamp applied.
Fig 2. Open cardiac massage in a trauma patient being done anteriorly following a clamshell thoracotomy
References
i Wise D, Davies G, Coats T, et al. Emergency rhoracotomy: “how to do it”. Emerg Med J Jan;22(1):22-4
ii Davies GE, Lockey DJ. Thirteen survivors of prehospital thoracotomy for penetrating trauma: a prehospital physician-performed resuscitation procedure that can yield good results. J Trauma 2011 May;70(5):E75-8
iii Simms ER, Flaris AN, Franchino X, et al. Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study. World J Surg 2013 Jun;37(6):
iv Macchiarini P, Ladurie FL, Cerrina J, et al. Clamshell or sternotomy for double lung or heart-lung transplantation? Eur J Cardiothorac Surg Mar;15(3):333-9
v Brown RP, Esmore DS, Lawson C. Improved sternal fixation in the transsternal bilateral thoracotomy incision. J Thorac Cardiovasc Surg Jul;112(1):137-41
vi Gandy KL, Moulton MJ. Sternal plating to prevent malunion of transverse sternotomy in lung transplantation. Ann Thorac Surg 2008 Oct;86(4):1384-5
vii Arndt G, Granger E, Glanville A, Malouf A. Clamshell incision vs Sternal-sparing incision in Lung transplantation. The journal of Heart and Lung Transplantation 2013 Apr;32(4),: S265
Fig 4. Clamshell thoracotomy in a pig during training which shows improved visualization and access of thoracic structures.
Fig 3. Left lateral thoracotomy in a pig during training which shows the left lung and the heart. This highlights the visual and access limitations with this approach