Appendix A: Specific Thoracic Procedures 19,20

Tube Thoracostomy

1. Antibiotic prophylaxis (with gram positive coverage) should be given prior to tube thoracostomy to reduce infectious complications, provided this will not lead to a clinically significant delay in treatment. 21, 22
2. There is no need to position the ipsilateral arm over the patient’s head.
3. If time allows, prep the anterior and lateral chest on the affected side and administer antibiotics prior to incision.
4. Plan an incision at nipple level (male) or at the inframammary crease (female), centered over the anterior axillary line.
5. Infiltrate local anesthesia for a stable, awake patient.
6. After a generous transverse incision (2-4cm) into the sub-dermal fatty tissues, a curved clamp is used to bluntly dissect the muscle and soft tissue down to the level of the rib. A blunt clamp is then directed over the top of the rib into the pleural space. A rush of air or blood out of the chest will confirm a pneumothorax or hemothorax respectively.
7. The clamp should be spread within the chest wall, followed by digital palpation to confirm pleural space entry, and insertion of a chest tube in an apical and posterior direction.
8. For combat trauma injuries, a chest tube size of at least 24-french is appropriate. In the setting of known or suspected hemothorax, a tube size of at least 28-french is desirable to reduce the risk of tube occlusion from clotted blood.
9. After the tube is sutured securely to the skin, it should be attached to a closed drainage system. In the field setting, a one-way Heimlich valve may be used for temporary drainage.

Subxiphoid Pericardial Window

1. Only appropriate for a stable patient. Prep the patent widely for potential sternotomy and/or thoracotomy.
2. After a 4–6 cm vertical midline incision centered over the xiphoid process, dissect through the skin and fascia with knife or electrocautery.
3. The xiphoid process can then be grasped/lifted with a Kocher clamp or can be excised with a heavy scissor or with electrocautery to facilitate exposure.
4. Blunt dissection deep to the xiphoid, directed in a cephalad direction will expose fatty tissue over the anterior pericardium. If the diaphragm is encountered, the dissection should be redirected in a more cephalad direction.
5. After removing or dissecting this fatty tissue to expose the underlying whitish pericardium, the pericardium should be grasped with a forceps or clamp and sharply incised.
6. Any gross blood in the pericardial space indicates a positive pericardial window and mandates sternotomy.
7. Clear pericardial fluid indicates no injury. Occasionally, absence of pericardial fluid may indicate clot in the pericardium and further investigation, such as irrigation with warm saline, should be performed.
8. There is no need to close the pericardium after a negative pericardial window.

Trans-Diaphragmatic Pericardial Window

1. If there is concern for intra-pericardial injury in a patient undergoing laparotomy for penetrating trauma, a trans-diaphragmatic pericardial window is rapid and highly effective in evaluating for such an injury.
2. The central tendinous portion of the diaphragm is grasped with clamps and incised vertically for 3-4cm to expose the underlying whitish fibrous pericardium. The pericardium is then grasped and sharply incised to assess the pericardial space for any gross blood. If there is none, the pericardium need not be re-approximated, although the diaphragm should be repaired with permanent suture.

Median Sternotomy

1. Indicated for suspected cardiac/great vessel injury based on ultrasound or positive pericardial window. In the setting of an obvious concomitant pleural space hemorrhage, anterolateral thoracotomy is preferable to sternotomy (with plans for conversion to a clamshell or trap door incision as needed to expose the heart or great vessels).
2. Does not provide for adequate exposure of left subclavian artery, distal aortic arch, or descending aorta, and provides for only limited exposure of the pleural spaces.
3. Begins with midline skin incision from sternal notch to just below xiphoid process, followed by sharp/blunt dissection both superiorly and inferiorly just deep to the sternum.
4. The sternum is divided in the midline with a sternal saw or Lebsche knife.
5. Bone wax can be used to decrease bleeding on the cut edges of the sternum, and cautery should be used to control bleeding from the sternal periosteal edges.
6. Both pleural spaces should be entered and opened widely where possible. This is facilitated by elevating the hemi-sternum, briefly holding ventilation, then opening the pleura overlying the lung with scissors or electrocautery. After the pleural space is entered, a suction device should be introduced to evacuate any blood.
7. After opening the pleural spaces, a standard chest retractor is placed. Mediastinal fat will be visible and should be divided in the midline down to the level of the fibrous pericardium. At the superior limit of the incision, the innominate vein will be located within the mediastinal fat and care must be taken to avoid injury to this structure.
8. The pericardium is then grasped and opened sharply in the midline. A finger is then inserted into the pericardial space to allow opening the midline pericardium down to the level of the diaphragm and up to the level of the innominate vein using scissors or electrocautery. The pericardium should then be opened laterally in either direction along the diaphragm to facilitate exposure.
9. Heavy sutures should be placed in the pericardial edges on both sides then tied under tension to the skin edges or secured under tension to clamps overlying the chest wall. These sutures will minimize interference from the ventilating lungs and facilitate exposure of the heart and great vessels.
10. A sternotomy can be extended into a neck exploration incision if there is concern for carotid, jugular, or tracheal injury. For suspected proximal right subclavian vascular injury, sternotomy can be extended to a right supraclavicular incision. For suspected proximal left subclavian vascular injury, the incision can be extended into an anterolateral thoracotomy (or to a trap door incision, described below).
11. There is no indication to re-approximate the pericardium. For sternotomy closure, chest tubes are placed into the mediastinum (and into any open pleural space) and the sternum is re-approximated with a series of heavy interrupted wire sutures. Typically 3 wires are placed through each side of the manubrium, 1-2cm from the edge of the bone. For the sternal body, 3-4 additional wires are placed directly through the halves of the sternum or around the sternum through the costal interspaces. If wire is not available, large permanent suture (e.g., polyester suture, #2 or larger) is appropriate.
12. For a patient undergoing sternotomy in the setting of hemodynamic instability or ongoing massive resuscitation, temporary chest closure is advised in most cases. After placement of a laparotomy pad or wound vacuum sponge beneath the edges of both sides of the sternum to avoid laceration of the heart from movement, an occlusive adherent dressing is placed and chest tubes are placed to suction to evacuate any residual bleeding.

Anterolateral Thoracotomy

1. Refer to JTS CPG on Emergency Resuscitative Thoracotomy.8
2. Useful for massive hemothorax; allows access to lung parenchyma, hilum, chest wall, and subclavian vessels.
3. For proximal left subclavian control, anterior thoracotomy in the 3rd interspace (above the 4th rib) will generally be adequate. See JTS Vascular Injury CPG.12
4. For general access to the pleural space, the 4th interspace is centered over the pulmonary hilum. Anterolateral thoracotomy at this level will provide access to most structures within the chest. The inframammary crease overlies the 5th rib medially in most patients, and therefore this crease provides a reasonable landmark for a 4th interspace anterolateral thoracotomy.
5. After incision of the skin and soft tissues parallel to the clavicle, from one fingerbreadth off of the sternum medially to the anterior or mid-axillary line laterally, divide the pectoralis major muscle in the direction of its fibers, then bovie or cut the remaining fibrovascular tissues down to the top of the rib at the desired interspace.
6. Incise the intercostal muscle over the rib with electrocautery, then enter the pleural space using a blunt clamp, protect the lung, and divide the remaining muscle over the rib. Stop the intercostal incision about two finger-breadths lateral to the edge of the sternum to avoid the mammary vessels, but carry the intercostal incision as far laterally as safely possible to allow for maximal exposure.
7. Place a rib-spreader into the wound.
8. If additional exposure is needed, division of the medial costal cartilage will allow for additional rib spreading, or the incision can be extended to include a sternotomy and clavicular incision. (See description of trap door incision below.)
9. For thoracotomy closure, after the placement of chest tubes through separate stab incisions, “pericostal” sutures should be placed around the upper and lower ribs at the incision. Typically 3-5 sutures are needed, and any heavy suture (#1 or larger) may be used (although monofilament suture may have more of a tendency to dig into the intercostal muscle tissue when tied). Care must be taken to avoid the intercostal bundle with these sutures, by hugging the top of the upper rib but avoiding the bottom of the lower rib.
10. After chest tube and pericostal suture placement, the muscle is reapproximated with absorbable suture and the skin closed with staples.

Clamshell Incision (Bilateral Thoracosternotomy)

1. Highly versatile incision, which provides adequate surgical access to virtually any structure in the thoracic cavity (with the exception of the esophagus and descending thoracic aorta).
2. Rarely appropriate as an initial incision (due to high level of incisional morbidity). Generally implemented after anterolateral thoracotomy if there is suspicion for bleeding into the contralateral pleural space, or heart or great vessel injury, or when there is inadequate exposure for an ipsilateral pleural space injury.
3. After anterolateral thoracotomy, divide the sternum transversely with a Lebsche knife, Gigli saw, or heavy shears. Both internal mammary vascular pedicles will need to be divided and controlled with ties or clips; bleeding from these may be unrecognized until adequate perfusion has been restored.
4. Create a contralateral thoracotomy (generally in the same intercostal space). Place bilateral rib spreading retractors. After initiating retraction, use scissors or cautery to release the sternum from the anterior pericardium to improve exposure.

Supraclavicular Incision

1. Most often indicated for suspected proximal or mid-subclavian vascular injury.
2. After an incision one fingerbreadth above and parallel to the clavicle from the midline to the distal clavicle, superficial fatty tissues, lymphatics and venous branches are divided and controlled to expose the sternal and clavicular heads of the sternocleidomastoid muscle and the carotid sheath (located between the two muscle bellies).
3. After division of the sternocleidomastoid muscle heads just above their distal attachments, the proximal subclavian artery and its branches will be palpable and visible.
4. The anterior scalene muscle will be visible coursing anterior to the subclavian artery (posterior to the vein) and may need to be divided for adequate exposure. If this is the case, it is critical to free up and preserve the phrenic nerve, which runs directly along this muscle in a transverse direction.
5. The subclavian vein will be anterior and caudal to the artery.
6. For complex injuries, division of the clavicle (with a Gigli saw) or removal of part of the clavicle may facilitate additional exposure. Alternatively a supraclavicular incision can be combined with a separate infraclavicular exposure (for more distal subclavian access) or with a third interspace anterolateral thoracotomy (for control of the left subclavian artery at its origin).

Infraclavicular Incision

1. If there is a known subclavian venous injury, an infraclavicular incision may provide for better exposure. This approach also provides better exposure of the more distal subclavian artery and its branches.
2. After an incision one fingerbreadth below and parallel to the clavicle from the mid-clavicular level to the lateral border of the pectoralis muscle, the pectoralis major muscle is opened transversely in the direction of its fibers.
3. The underlying clavipectoral fascia and pectoralis minor muscle are divided to expose the distal subclavian and axillary vessels. In this location, the artery will be posterior and cephalad to the vein, and the brachial plexus cords are closely associated with the artery.

Trap Door Incision

1. Combination of clavicular (or neck) incision, partial or complete median sternotomy and anterolateral thoracotomy (described above).
2. May be useful for combined penetrating cervical and mediastinal injuries or a severe injury to the proximal subclavian vessel/branches.
3. Rarely used as an initial incision due to high incisional morbidity (including risk of injuring the ipsilateral phrenic nerve, brachial plexus, thoracic duct, or other structures).
4. May be necessary for inadequate exposure after sternotomy and clavicular incisions (for right-sided injuries), or after left anterior thoracotomy and clavicular incisions (for left-sided injuries).
5. After supraclavicular incision, perform complete median sternotomy or partial median sternotomy to 4th intercostal space.
6. Incise the skin, soft tissues and muscle out to the anterior axillary line.
7. Divide the sternum laterally with sternal saw or a Lebsche knife, ligate the left internal mammary vessels, and continue the incision into the pleural space above the appropriate rib as an anterolateral thoracotomy.

Thoracoabdominal Incision

1. Indicated for combined thoracic and abdominal injuries. May be particularly helpful for retrohepatic vena caval exposure.
2. May be created by continuing a resuscitative thoracotomy incision medially and inferiorly across the costal margin into the abdominal midline or by creating a separate midline abdominal incision after thoracotomy.

Posterolateral Thoracotomy

1. Provides optimal exposure for esophagus, chest wall, descending thoracic aorta, and posterior hilum.
2. Rarely appropriate in the acute trauma setting, particularly in a multiply injured or acutely bleeding patient. This incision limits ability to treat concomitant injuries, limits anesthesia access for additional resuscitation lines, and limits ability to protect the spine. In addition, it generally requires ipsilateral lung isolation (using mainstem intubation, bronchial blocker, or double-lumen endotracheal tube), and potentially places the contralateral lung at risk for injury due to pooling of blood or secretions.
3. May be appropriate at Role 3 or higher level of care for evacuation of retained hemothorax or for addressing a complex lung injury or esophageal injury.
4. If beanbag is available, place on OR table; otherwise use large IV bags wrapped in towels placed in front of and behind the patient to secure him/her in a stable lateral position (in addition to strapping and taping the patient’s hips and legs to the table).
5. Once the patient is in a secure lateral decubitus position, place a pillow between the legs, place the lower arm on an arm board straight at the elbow but flexed slightly at the shoulder, and place the higher arm in a flexed position at the elbow on a pillow or folded blankets.
6. After a wide prep and draping, mark mid-way between the medial border of the scapula and the vertebrae. Make a second mark one fingerbreadth below the inferior-most tip of the scapula. A posterolateral thoracotomy should connect these two marks in a gentle curve, then continue anteriorly parallel to the ribs.
7. After incising the skin and fatty subcutaneous tissue, divide the latissimus dorsi muscle transversely in the posterior aspect of the incision. The serratus anterior muscle, which runs anterior and deep to the latissimus, can be partially divided or mobilized and retracted anteriorly.
8. For most trauma situations, entering the chest right above the level of the tip of the scapula will provide an appropriate level for adequate exposure. After using electrocautery to divide the intercostal muscle along the top of the rib at this interspace, enter the pleural space with a blunt clamp. Then pack the lung away with a moist laparotomy pad to allow extension of the intercostal incision widely along the top of the rib.
9. Encircling the lower rib at the posterior aspect of the incision with a right angle (taking care to avoid the intercostal bundle injury) will allow division of the rib with a rib shear to facilitate adequate retraction and exposure. However, this step is not mandatory. The creation of a “controlled fracture” by gradually opening a rib spreader will have the same desired effect of allowing adequate space to fit a hand comfortably into the pleural space.
10. Place a rib spreader.
11. For thoracotomy closure, after the placement of chest tubes through separate stab incisions, “pericostal” sutures should be placed around the upper and lower ribs at the incision. Typically 3-5 sutures are needed, and any heavy suture (#1 or larger) may be used (although monofilament suture may have more of a tendency to dig into the intercostal muscle tissue when tied). Care must be taken to avoid the intercostal bundle with these sutures, by hugging the top of the upper rib but avoiding the bottom of the lower rib.
12. After chest tube and pericostal suture placement, the muscle is reapproximated with absorbable suture and the skin closed with staples.