Emergency Anterior Bilateral Thoracotomy

This video demonstrates a bilateral anterior thoracotomy or clamshell thoracotomy. A clamshell thoracotomy is used primarily to treat cardiac tamponade as a potential cause of death. The goals are to release cardiac tamponade, control hemorrhage, and restart the heart. Still, the survival rate for this procedure remains less than 10 percent.

The main indication is cardiac arrest with loss of output less than 10 minutes prior with a history of penetrating trauma to the chest. Indications in blunt trauma are debatable.

To complete the procedure, surgeons used a scalpel, trauma shears, artery forceps, skin stapler, rib spreader and a Gigli saw.

First, the team identified the sternal notch, the angle of Louis, and the second rib on each side. They then counted down to the fifth rib bilaterally and aimed to cross the sternum on the superior border of the fifth rib in the fourth intercostal space.

Next, the patient was placed in a supine position with abducted arms at 90 degrees. A curvilinear bilateral submammary incision was made extending from one midaxillary line to the other on the anterior chest wall.

The skin, subcutaneous tissue, and muscle were then incised with a single incision. Shears were used to cut all layers protecting the underlying lungs. Surgeons used their fingers and avoided cutting across the ribs.

The sternum is then divided with the Gigli saw. Rib spreaders were then used at each side of the wound. The structures were identified, and a 10 cm anterior longitudinal incision was made in the pericardium in an inverted T fashion, avoiding the phrenic nerves.

Blood clots were removed to release the tamponade and the heart was inspected for any lacerations. The team can use digital occlusion or skin staples as required and consider internal cardiac massage with two hands if required.

The patient was then transferred to an operating room since there was return of spontaneous circulation (ROSC) and bleeding had been properly stabilized.

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