Chest Trauma – Clamshell Incision, a Step-by-Step Description of the Technique

Introduction

The aim of this post is to give an account of the steps involved in performing a resuscitative clamshell thoracotomy for chest trauma. I will highlight some of the relevant technical as well as a few non-technical pitfalls. Please refer to my  previous post on the indications for a clamshell incision.

It is exceptional for any one civilian general surgeon, working outwith a large trauma centre, to perform more than a handful of resuscitative trauma thoracotomies in the course of her/his career. As a result, this limited personal experience needs to be supplemented by simulation training on anaesthetised animals and/or human cadavers.

The less experienced surgeon has a significant psychological barrier to overcome before deciding to perform a resuscitative thoracotomy. The surgeon’s unease to act and the inevitable delay in the decision making that follows, could be further reinforced by the cognitive biases  such as the “diagnostic momentum” bias. In diagnostic momentum, the surgeon continues a clinical course of action already instigated by the team without considering changing the plan, particularly when the original plan is commenced by a senior clinician. Diagnostic momentum is a potential bias for the unwary junior member of any multidisciplinary team.

It is worth remembering that the clamshell incision is only a means to an end, and the main focus should be on the surgical manoeuvres potentially needed for damage control following gaining access. Resuscitative thoracotomy should ideally be done in a well-equipped environment and only by those who have the necessary experience in dealing with the range of injuries commonly encountered.

I hope it is clear from the above description that the challenges of performing a resuscitative thoracotomy include the ability to decide when to operate, possessing the technical skills for performing a thoracotomy incision, and the surgical experience to know what to do once in the chest.

Clamshell incision

  1. If the patient is stable enough, transfer the patient to the operating theatre. This will delay the procedure but with a trade-off of a far superior surgical environment. If the patient is unstable, proceed to performing an emergency room thoracotomy.
  2. Use an antiseptic solution to rapidly sterilise the anterior and lateral thoracic wall.
  3. Wear sterile gloves, eye protection and a gown.
  4. It is essential to remain calm; give clear instructions.
  5. Think one step ahead at all times and verbalise your thoughts for the team.
  6. Don’t injure yourself or others!
  7. Work in a well-lit area.
  8. Privacy from the gaze of the other patients/relatives is essential.
  9. The anaesthetist should ET tube the patient with both arms positioned above the patient’s head. The latter will help to maximise the intercostal spaces.
  10. Stand to the patient’s left side.
  11. having an assistance is a luxury.
  12. Use any large (No. 21) blade.
  13. Diathermy has no use.
  14. Feel for the xiphoid process and locate the inframammary folds (in females you may have to lift the breasts up).
  15. Make an incision along the left 4th or 5th intercostal space over the inferior breast crease, starting an inch lateral to the edge of the sternum and finishing at the mid axillary line. The incision should be well above the costal angle and above the xiphisternum.
  16. Make confident, deep, and long strokes with the scalpel. Avoid making light, multiple strokes; it slows you down and makes the wound bleed more.
  17. Ignore any bleeding points from the skin, fat, serratus anterior and intercostal muscles.
  18. Use heavy Mayo-type scissors to complete the division of the intercostal muscles and pleura.
  19. Use a Finochietto rib spreader to open the intercostal gap. The spreader should be placed at the most inferolateral aspect of the incision so that it does not obscure access. This completes the left anterolateral thoracotomy.
  20. If required, extend this left sided incision over onto the right side by make a symmetrical incision on the right chest (clamshell).
  21. Sternotomy is best done after completion of both left and right anterolateral thoracotomies. Divide the sternum using a Lebsche knife and a mallet. You can use a Gigli saw, a bone cutter, plaster cast scissors or even your hands to crack open the sternum if you have to. You need to be making rapid progress.
  22. The internal mammary vessels may not bleed due to hypotension. However, these will bleed postoperatively if not secured. Identify them carefully and tie them securely during the thoracotomy closure.
  23. Lift the sternum and run your fingers gently along the fibrous plane between the posterior surface of sternum and the heart. The sternum is lifted up, like opening the front car bonnet.
  24. A second Finochietto may be applied to the right thoracotomy if available. This completes the clamshell thoracotomy.

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