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Mon, 17 Mar 2003 16:52:44 EST

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After much discussion, very similiar to the arguments cited on the list, we 
placed tha patient in the  LEFT side up position, performed a posterolateral 
thoracotomy and planned to enter the  7th interspace, preserving the 
intercostal bundle to cover the esophageal repair.  We found that the bullet 
had distroyed the interspace, so we took the 8th rib and preserved a long 
tongue of 8th intercostal muscle, nerve, artery, and vein bundle.  We then 
entered the left cavity, discovering a through and through Left lower lobe 
lung injury and a large hole in the pericardium through which blood was 
slowly bleeding.   This hole was posterior to the vagus nerve and would have 
been very difficult to see through a left anterolateral incision, and would 
have been impossible to see through a mediansternotomy or a right 
anteriolateral or even a right posterolateral thoracotomy.   

Now, we are faced with a hole in the pericardium, no exit is seen, and a 
known injury to the esophagus, and a known injury to the liver.    

Should we proceed to work on the esophagus, open the pericardium and  look at 
(and or repair) a possible heart injury, or just what are your concerns at 
this point.   

k 

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<HTML><FONT FACE=3Darial,helvetica><FONT  SIZE=3D2 FAMILY=3D"SANSSERIF" FACE=
=3D"Arial" LANG=3D"0">After much discussion, very similiar to the arguments=20=
cited on the list, we placed tha patient in the&nbsp; LEFT side up position,=
 performed a posterolateral thoracotomy and planned to enter the&nbsp; 7th i=
nterspace, preserving the intercostal bundle to cover the esophageal repair.=
&nbsp; We found that the bullet had distroyed the interspace, so we took the=
 8th rib and preserved a long tongue of 8th intercostal muscle, nerve, arter=
y, and vein bundle.&nbsp; We then entered the left cavity, discovering a thr=
ough and through Left lower lobe lung injury and a large hole in the pericar=
dium through which blood was slowly bleeding.&nbsp;&nbsp; This hole was post=
erior to the vagus nerve and would have been very difficult to see through a=
 left anterolateral incision, and would have been impossible to see through=20=
a mediansternotomy or a right anteriolateral or even a right posterolateral=20=
thoracotomy.&nbsp;&nbsp; <BR>
<BR>
Now, we are faced with a hole in the pericardium, no exit is seen, and a kno=
wn injury to the esophagus, and a known injury to the liver.&nbsp;&nbsp;&nbs=
p; <BR>
<BR>
Should we proceed to work on the esophagus, open the pericardium and&nbsp; l=
ook at (and or repair) a possible heart injury, or just what are your concer=
ns at this point.&nbsp;&nbsp; <BR>
<BR>
<BR>
k </FONT></HTML>

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