Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited

BACKGROUND

The clamshell incision (CI) offers a better exposure than the left anterolateral thoracotomy (LAT) as a resuscitative thoracotomy. Most surgeons will have to manage a heart wound only once or twice in their career. The patient's survival depends on how fast the surgeon can control the heart wound; however, it is unclear which of the two incisions allows for faster control in the hands of inexperienced surgeons. The aim of this study was to compare the time needed to access and control a standardized stab wound to the right ventricle, by inexperienced surgical trainees, by LAT or CI; we hypothesized that the CI does not take longer than the LAT.

METHODS

Sixteen residents were shown a video on how to perform both procedures. They were randomly assigned to control a standardized stab wound of the right ventricle on perfused human cadavers by LAT (n = 8) or CI (n = 8). Access time (skin to maximal exposure), control time (maximal exposure until control of the heart wound) and total time (the sum of access and control times) were recorded.

RESULTS

Total time was 6.62 min [3.20-8.14] (median [interquartile range]) for LAT and 4.63 min [3.17-6.73] for CI (p = 0.46). Access time was 2.39 min [1.21-2.76] for LAT and 2.33 min [1.58-4.86] for CI (p = 0.34). Control time was 4.16 min [2.32-5.49] for LAT and 1.85 min [1.38-2.23] for CI (p = 0.018).

CONCLUSIONS

The time needed from skin incision until cardiac wound control via CI was not longer than via LAT and the easier control of the cardiac wound when using CI was confirmed.

Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma

INTRODUCTION

Penetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging.

PRESENTATION OF CASE

A 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation.

DISCUSSION

We review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians.

CONCLUSION

A high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.

Emergency thoracotomy in thoracic trauma-a review

Thoracic trauma is one of the leading causes of death in all age groups and accounts for 25-50% of all traumatic injuries. While the majority of patients with thoracic trauma can be managed conservatively, a small but significant number requires emergency thoracotomy as part of their initial resuscitation. The procedure has been advocated for evacuation of pericardial tamponade, direct control of intrathoracic haemorrhage, control of massive air-embolism, open cardiac massage and cross-clamping of the descending aorta. Emergency thoracotomy can be defined as thoracotomy "occurring either immediately at the site of injury, or in the emergency department or operating room as an integral part of the initial resuscitation process". Following emergency thoracotomy, the overall survival rates for penetrating thoracic trauma are around 9-12% but have been reported to be as high as 38%. The survival rate for blunt trauma is approximately 1-2%. The decision to perform emergency thoracotomy involves careful evaluation of the scientific, ethical, social and economic issues. This article aims to provide a review of the current literature and to outline the pathophysiological features, technical manoeuvres and selective indications for emergency thoracotomy as a component of the initial resuscitation of trauma victims with thoracic injury.