A clamshell thoracotomy provides almost complete exposure
to both thoracic cavities. In general, the indications
for performing a clamshell thoracotomy are when you need
access to both sides of the chest, or just when you need
better access than a unilateral thoracotomy can give you.
- To improve exposure and access to the heart (especially
right sided structures) following a left anterolateral
thoracotomy performed for profound hypotension or traumatic
- To provide access to the right chest in transmediastinal
injuries or multiple penetrating injury to both the
left and right chest.
- To allow cardiac massage following a right-sided thoracotomy.
The only part of the thoracic cavity that is not easily
reached through a clamshell incision is the very superior
mediastinal vessels. If there is an injury here, the sternum
can be split to provide wide exposure to this area.
The clamshell thoracotomy usually starts
as a standard left anterolateral thoracotomy - often an
thoracotomy for traumatic arrest as in this case.
The left thoracotomy is placed in the 5th intercostal
space (just below the nipple).
Access following a left anterolateral thoracotomy is
fairly limited. The clamshell is made by performing a
right sided thoracotomy in the same interspace:
Once the full thoracotomy has been completed on both
sides, the sternum must be split. This can be accomplished
with a Gigli saw or, more usually, a heavy pair of trauma
scissors or other shears:
(Note the correct technique for bimanual cardiac massage
and a cross clamp on the descending aorta in the above
Dividing the sternum will also divide the inferior mammary
arteries on both sides. Usually these do not bleed at
this stage due to profound hypotension, but will start
to bleed once blood volume and flow is restored. These
will need to be ligated at some point in the future.
The rib retractor is placed between the cut ends of the
sternum and opened. The fibrofatty tissue between the
sternum and the anterior pericardium should be divided
This allows the sternum to be fully elevated and provides
excellent exposure to the heart and both thoracic cavities.
The patient in this series had a gunshot injury to the
right middle lobe and main pulmonary artery.
Closing the incision
Don't forget to check the inferior mammary arteries and
ligate both ends if you haven't done so already.
Large bore chest drains should be placed in both thoracic
cavities, the mediastinum and pericardium (if opened).
The thoracotomy incision is closed in layers as with
the standard anterolateral thoracotomy. The sternum can
be re-approximated with sternal wires or with 5 Ethibond
Occasionally attempts to close the chest will result
in cardiac arrest as the heart has become so oedematous
it does not tolerate the compression. In this case, a
temporary closure is performed with a plastic bag (3L
cystostomy irrigation fluid bag or similar) and the chest
closed at a subsequent procedure when the swelling has
trauma.org (10:4) April 2005