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World J Surg (2014) 38:10031005 DOI 10.1007/s00268-013-2368-z
Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomical Study: Reply
Eric J. Voiglio Eric R. Simms Alexander N. Flaris
Xavier Franchino Michael S. Thomas
Jean-Louis Caillot
Published online: 20 December 2013 Socit Internationale de Chirurgie 2013
Thank you for your interest in our article, Bilateral Anterior Thoracotomy (Clamshell Incision) Is The Ideal Emergency Thoracotomy Incision: An Anatomical Study [1]. We have read your letter and are pleased to have this type of important dialogue regarding these different thoracic incisions in both cadavers and real patients.
We understand your point that median sternotomy is ideal for injuries of the anterior mediastinum, providing excellent access to the heart, ascending aorta, and the aortic arch and its branches (although access to the left subclavian artery remains difcult through median sternotomy). It is the timing and ease of this difcult incision in the hands of the inexperienced practitioner that we nd gives the edge to the clamshell incision for rapid access to thoracic structures.
With respect to the proposed intrinsic difculties of the clamshell incision in living/moribund patients, you mentioned the following points as problematic.
The cranial and caudal segments of the thoracic wall incision tend to move superiorly and inferiorly relative to
the coronal plane, making the operation technically challenging and most of the time requiring an assistant to stabilize the two parts of the incision at the thoracic wall level.
We do not precisely understand the problem to which you are referring. If you are suggesting that the edges of the incision spontaneously open once the sternum is divided transversely, this is typically not an issue (and can be considered an advantage) as an assistant is sufcient to provide wide access and stabilize the thorax, rendering the Finocchietto retractor nonessential. If you mean that the cranial and caudal segments tend to move ventrally and dorsally relative to the coronal plane, this occurs only at closure of the incision. Starting the closure with a crossed wire stitch on the sternum is the solution [2]. The incision is then sutured closed as two separate thoracotomies. Clamshell incision is similar to median sternotomy in that an assistant is advisable. Only in the most austere environments would a surgeon...