incision and chest exposure in Emergency, this presentation is about main incisions of thorax and approach to thorax in different trauma cases .

1. Incision and Chest
Exposure in emergency
DR AWANEESH KATIYAR
M.Ch. Senior Resident
Trauma Surgery & Critical Care
All India Institute of Medical Sciences
Rishikesh, UK

2. Overview of presentation
1. Anatomy overview
2. Incisions and site
3. Exposure
4. Summary
5. Take home massage.
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3. Chest
Neck
Abdomen
Trajectory don’t follow our
plans , we have to plan
according to trajectory
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Chest is the mother of all vessels

4. 3Don’t forget to ligate internal mammary – you may forget it to ligate , it will not forget you

5. 4

6. Overview of presentation
1. Anatomy overview
2. Incisions and site
3. Exposure
4. Summary
5. Take home massage.
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7. Incisions and Site
 Anterolateral
 Left anterolateral (MOST COMMON)
 Right anterolateral
 Clamshell (AL – Extended to other
side)
 High Anterolateral
 Posterolateral
 Right PL
 Left PL
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 Median sternotomy
 Extended neck exploration
 Thoracolaparotomy
 Book/Trapdoor thoracotomy
1. Anatomy overview
2. Incisions and site
3. Exposure
4. Summary
5. Take home massage.

10. Overview of presentation
1. Anatomy overview
2. Incisions and site
3. Exposure
4. Summary
5. Take home massage.
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11. 8
Left Anterolateral thoracotomy
• Utility emergency thoracotomy- for unstable patient
• It is made from the sternal edge, under the mammary
fold, and in a curvilinear fashion toward the axilla,
staying in close proximity to the fourth or fifth
intercostal space.
• This incision should not be a straight line incision nor
be carried through the female breast
• Provides exposure – Heart, Aorta and Left Lung with
hilum and any time can be extended to other side.
1. Anatomy overview
2. Incisions and site
3. Exposure
4. Summary
5. Take home massage.

12. Clamshell thoracotomy
• Most of the time its extended
from Left AL thoracotomy
• Provides better exposure to
Both side lung with hilum,
heart and descending aorta.
• Not good for Superior
mediastinum, trachea, other
great vessels.
• Avoid to cut breast tissue in
female patient.
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13. High Left Anterolateral thoracotomy-
Left subclavian artery injury
Very specifically - should be
done in left subclavian artery
injury – to take proximal
control
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14. Median sternotomy
• Its time taking procedure
over Anterolateral
thoracotomy
• Preferred in superior
mediastinum hematoma,
precordial stab, to take
proximal control for other
bleeding vessels
• May be part of neck
exploration, thoraco-
laparotomy.
Median sternotomy avoided in EDT, Precordial Gunshot, trachea-bronchial injuries 11

15. Median sternotomy
with neck extension
Trapdoor/book
thoracotomy
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16. Posterolateral thoracotomy
• Provides better exposure to posterior
mediastinum
• Most preferred – stable patient for
exposure esophagus, trachea, retained
hemothorax
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17. Overview of presentation
1. Anatomy overview
2. Incisions and site
3. Exposure
4. Summary
5. Take home massage.
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18. Summary
Indications Preferred incision Remarks
Emergency thoracotomy
(EDT )
Left anterolateral (AL)
Utility thoracotomy –
Pericardiotomy , cross
clamp, hilar twist, hilar
clamp, cardiac massage.
Precordial stab Median sternotomy
Not good for
mediastinum and
posterior cardiac surface
Precordial Gun shot
wound (GSW)
Left Anterolateral
Can reach to
mediastinum and
posterior heart
Lung GSW
Ipsilateral AL or convert
into clamshell
Better exposure and
easy to reach
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19. Indications Preferred incision Remarks
Tracheal injury –
proximal half
Collar incision – T
shaped incision
No extra-exposure get
from full Median
Sternotomy,
Left proximal main
bronchus also visualized
better
Distal half
Right posterolateral
thoracotomy
Right main bronchus Right Posterolateral Don’t go for posterolateral
incision if patient in-
extremis.
Left distal main
bronchus
Left Posterolateral
Right subclavian
artery
Medial sternotomy
Right AL difficult to reach
at origin.
Left subclavian artery
High anterolateral
thoracotomy with neck
incision
For non bleeding artery
supraclavicular incision is
best.
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20. Indications Preferred incision Remarks
Carotid artery injury Median sternotomy For better proximal
control
Abdominal Aortic injury Left anterolateral
thoracotomy
Aorta better visualized
from left side
Azygous vein injury Right posterolateral
thoracotomy
Its very rare and also
difficult to make the
diagnosis
Thoracic duct injury Right/ left
posterolateral
thoracotomy
Depends on side of
injury – difficult to
identify
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21. Indications Preferred incision Remarks
Superior vena cava Right Anterolateral
thoracotomy
Always keep in the
mind patient may
require median
sternotomy for SVC
Inferior vena cava Right Anterolateral
thoracotomy
Depends on site of
injury still its better
visualized from right
side.
Upper thoracic
Esophagus
Right posterolateral
thoracotomy
Better visualize
Lower thoracic
Esophagus
Left posterolateral
thoracotomy
Upper part is poorly
visualized – great
vessels
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22. Incision Left anterolateral Clamshell Median
sternotomy
• ED thoracotomy
(crashing, bedside
thoracotomy )
• EDT (mostly
extended from
Left ALT)
• Very selected
cases
Indication • All in-Extremis patient.
• Cardiac stab/GSW
• Cross clamping of aorta
• Left lung penetrating
injury
• Both lung
penetrating
injury
• Associated
cardiac injury
• Cardiac stab-
low velocity
• Sup mediastinal
hematoma.
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23. CONCLUSION: We strongly recommend that patients who present pulseless with signs of life after
penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who
present pulseless and have absent signs of life after penetrating thoracic injury, present or absent
signs of life after penetrating extra-thoracic injury, or present signs of life after blunt injury. Lastly,
we conditionally recommend against EDT for pulseless patients without signs of life after blunt
injury.
(J Trauma Acute Care Surg. 2015;79: 159Y173. Copyright * 2015 Wolters Kluwer Health, Inc. All
rights reserved.)
Review of literature
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24. Conclusion: When the cumulative impact of penetrating injury mechanism, ED
SOL, and number of CGV(cardiac and great vessel) wounds was analyzed together,
we established that those sustaining multiple CGV GSWs (regardless of ED SOL)
were nearly unsalvageable. These results indicate that when multiple CGV GSWs
are encountered after EDT, further resuscitative efforts may be terminated without
limiting the opportunity for survival.
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25. Overview of presentation
1. Anatomy overview
2. Incisions and site
3. Exposure
4. Summary
5. Take home massage.
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26. Take home massage
 Proper selection of incision gives – better exposure and control
 Don’t hesitate to give another incision if exposure is not proper
 Don’t put in harm to your team – for in-extremis patients – most of the
patients are risk of transmission of infection.
 Identify early and stop resuscitation in non-survivor – save energy for next
patient.
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27. Thank you
Or Mail me @
drawaneeshkatiyar@gmail.com
Asking questions?make you wise.