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Wed May 2 12:37:18 BST 2007

Well said Tim. 

It is a sad observation, but after being in the same place for a while, and seeing many "frequent flyers", ligation of the internal mammaries tends to not be a major issue in many of these gang bangers....they haven't lived long enough to ever need a CABG  Just the same, your point is a good one!

Take care,
Ron

>>> "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za> 5/2/2007 7:31 AM >>>
Ian

Advantage of clamshell - better exposure
Disadvantage - cut through sternum and ligate both internal thoracic arteries (not good if he needs a coronary bypass in the future). Also cannot get to the major vessels for control (but then the same applies to the LAL).

Access to heart not necessarily that much better, but easier to see. For a moribund patient I would always START with a LAL, progressing to a clamshell if required; less scarring that way.

Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za 
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

-----Original Message-----
From: trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Ian Seppelt
Sent: Wednesday, May 02, 2007 9:54 AM
To: KMATTOX at aol.com; trauma-list at trauma.org 
Subject: Re: s/w to box

We've been through this before, but could an expert surgeon please
explain specifically the pros and cons of left anterolateral thoracotomy
versus bilateral clamshell thoracotomy.

Thanks, Ian

Ian Seppelt FANZCA FJFICM
Senior Staff Specialist
Dept of Intensive Care Medicine
The Nepean Hospital, PO Box 63 Penrith NSW 2751
Director of Clinical Research, Sydney West AHS
Clinical Lecturer, University of Sydney

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