Left anterolateral thoracotomy incision
Manual compression of the aorta
Clamping the aorta
Opening the pericardium
Cardiac massage—notice two hands
Clamshell thoracotomy
Pitfalls
The incision does not follow the intercostal space, making the entry into the chest difficult. Incision should curve upward towards the axilla
Excessive rib spreading may cause rib fractures and increased pain in the postoperative course.
The retractor may cause injury to the internal mammary artery, leading to subsequent bleeding.
Indications for Median Sternotomy
This is the preferred incision for penetrating injuries to the anterior chest, allowing exposure of the heart, lungs, middle-to-distal trachea, and the left main bronchus.
This does not allow exposure to the posterior mediastinal structures and does not provide the ability to cross clamp the aorta for resuscitation purposes. The median sternotomy allows exposure to the upper mediastinal vessels and can be extended on to the neck with a sternocleidomastoid incision or a clavicular incision to allow more exposure to the carotid or subclavian vessels.
Operative Technique for Median Sternotomy
Prep the patient from chin to mid-thigh.
Make a vertical midline incision over the center of the sternum from the suprasternal notch to the xiphoid.
Continue the incision down through the decussation of pectoralis fascia onto the sternum with electrocautery.
The interclavicular ligament, at the suprasternal notch, is cleared using a combination of sharp and blunt dissection. Make sure to finger sweep below the manubrium to release areolar attachments. This moves the innominate vein and surrounding tissues posterior so they are not injured with the sternal saw (Fig. 2.7).
Bluntly detach the underlying fat below from the xiphoid.
Score the sternum with electrocautery in the midline to direct the pneumatic saw or Lebsche knife.
Place the hook of the pneumatic saw under the suprasternal notch and lift the sternum upward.
Ask anesthesia to hold ventilation and divide the sternum along the midline. Maintain upward traction along the entire length. Toeing the right-angle piece upward will help the saw stay on the sternum.
When using a Lebsche knife, it is best to start inferiorly to superior due to the force required when hammering the knife. Ideally, it should only take four blows of the hammer to split the sternum. Due to the strength of the strike, the patient’s head would impede the force required to hit the knife.
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