Thoracic Approaches and Incisions

Abstract

Don’t confuse war surgery with elective thoracic practice. You need simple, reproducible, feasible, and fast solutions set in your mind for the various scenarios. Always prep your patients for the maximum, and be flexible after you make your initial move. Think about the compartments – where is the bleeding happening now? Be paranoid about the other compartments until you clear or control them one way or another. Never be afraid to extend your incision or make one somewhere else. For precordial wounds without pleural hemorrhage, think about a sternotomy. For inadequate exposure after anterolateral thoracotomy or suspected right pleural space hemorrhage, move to clamshell. Proximal left subclavian artery injuries are notoriously challenging, but a high left anterior thoracotomy is a key first move. Reserve posterolateral thoracotomy for delayed problems in stable patients with isolated unilateral chest trauma. No matter what the situation is, remember that you have within you the courage, intellect, audacity, perseverance, and proper training, and you will save your patient. And if all else fails, left anterolateral thoracotomy is a good place to start.