Trauma: Thoracic Incisions

Median Sternotomy

Access

  • Anterior Mediastinum
  • Heart
  • Innominate Artery
  • Proximal Common Carotid Arteries
  • Proximal Right Subclavian Artery
  • Limited Exposure of the Left Subclavian Artery

Technique

  • Vertical Incision Centered Over the Sternum
  • Carry Down onto the Anterior Sternum
  • Superiorly
    • Incise the Interclavicular Ligament
    • Digitally Clear the Tissue from the Posterior Manubrium
  • Inferiorly
    • Clear Tissue Off the Xiphoid Process
    • Digitally Clear the Tissue from the Posterior Xiphoid/Sternum
    • May Require Division or Excision of the Xiphoid
  • Divide the Sternum
    • Use Sternal Saw or Lebsche Knife
      • Other Options: Bone Cutter or Trauma Shears
    • Great Care to Stay in Midline – Closure Significantly Complicated if Off Midline
  • Use a Finochietto Retractor to Open the Space

Median Sternotomy

Thoracotomy

Resuscitative Thoracotomy

Bilateral “Clamshell” Thoracotomy

  • Bilateral Anterolateral Thoracotomies Through the Fifth Intercostal Spaces
  • Sternum is Transected with a Lebsche Knife, Rib Cutter, Trauma Shears or Gigli Saw
  • Provides Excellent Access to the Mediastinum, Great Vessels & Hilar Structures Bilaterally
  • Internal Mammary Arteries Must Be Identified & Ligated if Cardiac Output is Regained – Division Can Cause Significant Blood Loss

Posterolateral Thoracotomy

  • Generally Avoided in Trauma
  • Only Considered in Stable Patients if Other Life-Threatening Injuries are Ruled Out
  • Can Provide Superior Access to Lateral & Posterior Wounds

Resuscitative Thoracotomy

Supraclavicular Incision

Access

  • Mid-Distal Subclavian Artery
  • Vertebral Artery (Segment V1)

Technique

  • Incision Parallel & 1 cm Above the Clavicle
  • Carried Down Through Platysma
  • Divide the Clavicular Attachment of the SCM to Expose the Internal Jugular Vein & Scalene Fat Pad
  • Divide the Anterior Scalene Muscle to Expose the Subclavian Artery
    • Anterior Scalene Lies Between the Subclavian Vein & Artery
    • Preserve the Phrenic Nerve Coursing Obliquely Over the Muscle
  • Vertebral Artery (Segment V1) Can Be Identified Around the Medial Portion of the Subclavian Artery

Clavicular Resection

  • May Require Addition of Median Sternotomy to Improve Proximal Access
  • Incision: Over the Anterior Surface of the Clavicle from the Sternoclavicular Junction to the Mid-Clavicle & Down Over the Deltopectoral Groove
  • Clear Circumferentially of All Tissues
  • Use Gigli Saw to Divide in the Mid Portion
  • Dissect the Sternal Head Free to Remove the Clavicle
  • Can Replace Clavicle When Done (But Not Mandatory)

Supraclavicular Incision

Clavicular Incision with Resection