How to perform an anterolateral emergency thoracotomy

Incision

1. Perform a bold incision through the skin with a size 10 (or size 22) scalpel from the midline towards the axilla. Continue as far laterally as possible.

2. Incise sharply through the subcutaneous fat and the muscle fascia.

3. Palpate a suitable intercostal space.

Opening the Pleura and the Intercostal Space

1. Enter the pleural cavity bluntly just over the cranial edge of the inferior rib to avoid injury to the intercostal neurovascular bundle running below the rib. Use a curved instrument (Mayo scissors, Crawford or Roberts clamp), as if preparing to place a chest tube.

2. Perform the finger sweep to free the pleural space.

3. Extend the opening by sliding the open tip of the heavy Mayo scissors along the cranial surface of the inferior rib anteriorly and posteriorly.
   Don't go too far anteriorly in order to avoid the internal thoracic artery (internal mammary artery) running along the sternal border.

4. Once you’ve advanced posteriorly, slide your hand under the latissimus dorsi muscle and the scapula, in order to make way for opening the intercostal space.
   Then, using scissors, divide the posterior intercostal space further.

5. Place a Finochietto retractor into the intercostal space and open it gradually. Continue the thoracotomy in turns, by opening the Finochietto more and dividing sharply the intercostal muscles anteriorly and posteriorly as you progress to minimize the risk of fracturing the ribs.
   In emergency setting, prioritize stabilizing hemodynamics. Cautery of smaller vessels may not be needed initially. Achieve thorough hemostasis once the patient's hemodynamics are stable.

6. The size of a thoracotomy is considered adequate when it allows sufficient visualization and access to the structures within the thoracic cavity for the necessary interventions.

Once Inside the Chest Cavity

After the thoracic cavity is exposed sufficiently, the sequence of action depends on the clinical scenario. Yet, the initial moves are mostly the same and described below.

• Rapidly scoop out blood with your hands to gain better visibility. Have a tray of kidney dish receivers ready for collecting the blood, and hand them over to the assistant nurse for cell saving.

• Feel for adhesions between parietal and visceral pleura and try to release them bluntly or sharply without initially wasting too much time on this (blunt dissection might induce superficial laceration of the lung).

• If your goal is to release cardiac tamponade, push the lung dorsally for visualizing the pericardium. Look for the strand of adipose tissue running on the pericardium in a craniocaudal direction. The phrenic nerve runs here, usually visible in this fat.
  Avoid the phrenic nerve by incising the pericardium (with a scalpel; you cannot grasp the tense pericardium with forceps) anterior to and parallel to it. Enter sharply, and as the blood gushes out, enlarge the opening with scissors. This gives you visibility of the left side of the heart (left ventricle, left atrial appendage).

• If indicated, you can now temporarily cover any cardiac laceration with a finger, perform open cardiac massage and defibrillate the heart with intrapericardial defibrillator (if available; external defibrillator pads should be placed preoperatively) through this exposure.
  Open cardiac massage should be performed bimanually, with “the heart in your hands”. This will allow you to adjust the compression rate to the filling of the heart, as well as to advise the anesthesia team on the volume replacement status.
  A simple left ventricle laceration may be sutured from left sided thoracotomy with U-stitches (felt-enforced, if possible). Left thoracotomy enables usually insufficient exposure to the right ventricle and atrium of the heart, as well as the inferior and the superior vena cava or ascending aorta, and the incision may have to be advanced to bilateral sternothoracotomy (clam shell). With suspected cardiac injuries (penetrating injury to the cardiac box), the initial approach should be medial sternotomy with readiness for cardiopulmonary bypass, if possible.

• If the patient is extremely hypovolemic and the goal is to centralize the circulation by clamping the thoracic aorta, you need to get the lung out of the way by dividing the inferior pulmonary ligament at the medial aspect of the lower lobe.
  Retract the lower lobe towards you and sharply divide the ligament. You will more likely feel the ligament than actually see it. With some experience, this ligament can be released with your fingertips, by pulling the lower lobe of the lung.
  However, the inferior pulmonary vein runs at the end of the ligament, and you should take caution here: damaging the vein could end the operation.
  Immediately posterior to the ligament is the aorta (on the left side) and esophagus (on the right side) that should not be damaged either.
  Once the inferior pulmonary ligament is out of the way, you can control the lung hilum and/or push the lung anteriorly to gain better visibility of the thoracic aorta.

• To clamp the aorta, divide the mediastinal part of the pleura anterior and posterior to it. If the pleura is left unopened, aortic pulsation will hammer the clamp off in no time due to rising blood pressure.
  Accommodate the clamp cautiously over the aorta, dodging the intercostal artery branches leaving the aorta dorsally. Make sure to note and communicate the time of aortic occlusion to the anesthesia team.

• Hilar clamping of the lung can be performed with a large Satinsky clamp or a Rummel tourniquet. If you are in a hurry, you can improvise by using a Foley catheter instead of the Rummel tourniquet. Hilar clamping is indicated when repairing the lung or when temporary single lung ventilation (in order to gain better visibility of the operative field) is necessary. The left lung may be collapsed also by asking the anesthesiologist to advance the intubation tube into the right main bronchus.
  The anesthesiology team should be well aware of your maneuvers in order to adjust ventilation and prevent barotrauma to the contralateral lung.

Closure of Anterolateral Thoracotomy

1. Before closure, make sure that all bleeding is controlled, and the lung is fully ventilated and anatomically oriented correctly. Minor air leaks from the lung can be left to resolve by themselves, but massive bubbling must be addressed prior to closure with hemostatic products or by suturing.
   Meticulous hemostasis is warranted especially if the thoracotomy is performed in hemodynamic collapse and no bleeding has been imminent in the beginning. Once the circulation is re-established, the patient starts to bleed.

2. Place 1-2 intercostal drains into the pleural cavity under direct vision. In case of thoracotomy, you can insert them 1-2 intercostal spaces caudally to the incision. One drain should be left dorsally and the other ventrally. Secure the drains adequately before proceeding with the closure.

3. Place 5-8 strong sutures (or 3-4 X-sutures) around the two ribs. The thread can be anything from 0 to 2 (e.g. Vicryl, PDS, or Ethibond). Approximate the ribs and tighten the sutures sequentially.

4. Once the intercostal space is closed, suture the muscles and the fascia with a running absorbable suture in an air-tight fashion. E.g. 0 Vicryl (or any equivalent) will do the job.
   Continue by approximating the subcutaneous tissue (2-0 thread), and finally, the skin. You can use skin clips for this. For patients with cardiac involvement, a running mattress suture may be preferred (the wound may be rapidly reopened if rapid re-entry is required).

5. Activate the chest drains and summarize the operation and planned aftercare with your team. Brief the intensivist personally to make sure that no critical information is missed or overlooked when the patient is handed over to the ICU. Wean the patient from ventilator only when all the physiological aberrations are corrected.