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MMCTS (August 10, 2006). doi:10.1510/mmcts.2006.001867
Copyright © 2006 European Association for Cardio-thoracic Surgery

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Procedure


Clamshell and hemiclamshell incisions

Nicolas Dürrleman and Gilbert Massard*

Hôpitaux Universitaires de Strasbourg, Département de Chirurgie Thoracique, Hôpital Civil, 1 Place de l'Hôpital, 67000 Strasbourg, France

* Corresponding author: * Tel.: +33-38-811 6202; fax: +33-38-811 6077. E-mail: gilbert.massard{at}chru-strasbourg.fr


   Summary
Top
 Summary
Introduction
 Technique
 Pitfalls
 Discussion
 Combined approaches
 Conclusion
 References
 
Sternotomy is one of the most frequent accesses in cardio-thoracic surgery. Transverse sternotomy with bilateral thoracotomy and combined approaches are developed. Surgical techniques, indications and pitfalls of these incisions are described.

Key Words: Bithoracotomies • Clamshell incision • Hemiclamshell incision • Transverse sternotomy


   Introduction
Top
 Summary
 Introduction
Technique
 Pitfalls
 Discussion
 Combined approaches
 Conclusion
 References
 
Indication
As an excellent alternative to median sternotomy for bilateral general thoracic surgical procedures, this incision is used for surgery of bilateral metastases, pericardiectomy, or giant anterior mediastinal tumors. More recently, it gained interest with the advent of bilateral lung transplantation.

It has been described as a useful alternative to sternotomy in patients with tracheostomy: it allows to avoid the communication between superior mediastinum and lower cervical level [1].

Historically, it has been the standard approach to the pericardial contents in the early years of open heart surgery, until it was replaced by the less aggressive median sternotomy.

Position
The patient is placed in a supine position with the entire anterior chest exposed from the neck to the umbilicus and laterally to each anterior axillary line. The patient's arms at the side do not compromise the exposure. However, some surgeons prefer to abduct the arms, or to lift them upwards and to fix them to the ether screen (Video 1).


Figure 1
Click on image to view video		 Video 1 The patient is placed in a supine position with the entire anterior chest exposed from the neck to the umbilicus and laterally to each anterior axillary line. The patient's arms at the side do not compromise the exposure. However, some surgeons prefer to abduct the arms, or to lift them upwards and to fix them to the ether screen.
 

   Technique
Top
 Summary
 Introduction
 Technique
Pitfalls
 Discussion
 Combined approaches
 Conclusion
 References
 
A curvilinear bilateral submammary incision is performed, extending from one midaxillary line to the opposite across the anterior aspect of the chest. For cosmetic reasons, the incision follows the submammary fold which is located at the level of the anterior arch of the 6th rib (Video 2). The skin incision is carried down to the superficial pectoral fascia overlying the pectoralis major muscles, the sternum and the fascia overlying the serratus anterior muscles at the lateral ends of the wound (Video 3). The pectoralis major muscle is separated from its inferior and medial attachments and lifted up with its overlying skin and soft tissues. This maneuver exposes the underlying chest wall (Video 4). The pectoral muscles are elevated to gain access to the fourth intercostal space bilaterally whereupon the chest is entered and the incision completed towards the sternum bilaterally. Laterally, access to the intercostal space requires division of the serratus, which is easily obtained by splitting the muscle between its fibers. The division of the intercostal muscles continues far more laterally and posteriorly than the skin incision to maximize rib spreading (Videos 5, 6 and 7). The internal mammary vessels are isolated at the anterior end of each intercostal space, tied with a suture and sectioned (Video 8). The sternum is divided transversally at the level of the fourth intercostal space with an oscillating saw (Video 9). The ribs are retracted bilaterally with rib spreaders. Hemostasis of the sternal marrow is completed with bone wax. Smooth opening of the bilaterally placed retractors exposes the retrosternal space; both pleura are severed along the retrosternal reflexion, and the retrosternal space is swept by blunt dissection (Videos 10 and 11).


Figure 2
Click on image to view video		 Video 2 A curvilinear bilateral submammary incision is performed, extending from one midaxillary line to the opposite across the anterior aspect of the chest. For cosmetic reasons, the incision follows the submammary fold which is located at the level of the anterior arch of the 6th rib.
 

Figure 3
Click on image to view video		 Video 3 The skin incision is carried down to the superficial pectoral fascia overlying the pectoralis major muscles, the sternum and the fascia overlying the serratus anterior muscles at the lateral ends of the wound.
 

Figure 4
Click on image to view video		 Video 4 The pectoralis major muscle is separated from its inferior and medial attachments and lifted up with its overlying skin and soft tissues. This maneuver exposes the underlying chest wall.
 

Figure 5
Click on image to view video		 Video 5 The pectoral muscles are elevated to gain access to the fourth intercostal space bilaterally whereupon the chest is entered and the incision completed towards the sternum bilaterally. Laterally, access to the intercostal space requires division of the serratus, which is easily obtained by splitting the muscle between its fibers. Pleura is secondarily opened.
 

Figure 6
Click on image to view video		 Video 6 The division of the intercostal muscles continues far more laterally and posteriorly than the skin incision to maximize rib spreading.
 

Figure 7
Click on image to view video		 Video 7 A rigorous hemostasis is done to promote a bloodless surgical field in this invasive incision.
 

Figure 8
Click on image to view video		 Video 8 The internal mammary vessels are isolated at the anterior end of each intercostal space, tied with a suture and sectioned.
 

Figure 9
Click on image to view video		 Video 9 The sternum is divided transversally at the level of the fourth intercostal space with an oscillating saw corresponding to a transversal sternotomy.
 

Figure 10
Click on image to view video		 Video 10 The ribs are retracted bilaterally with rib spreaders. Hemostasis of the sternal marrow is completed with bone wax. Smooth opening of the bilaterally placed retractors exposes the retrosternal space; both pleura are severed along the retrosternal reflexion, and the retrosternal space is swept by blunt dissection.
 

Figure 11
Click on image to view video		 Video 11 Sternomediastinal ligaments are progressively freed to allow a non traumatic opening of the chest and to offer a maximal exposure.
 
To close the wound, pericostal stitches are placed as usual. The sternum is best repaired by two heavy ‘figure-of-8’ sutures; the authors' preference is a heavy absorbable polydioxanone suture. Muscles and subcutaneous tissue are closed in layers (Photo 1).


Figure 1
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  		Photo 1 Post operative aspect of clamshell incision. Even in men, a sub-mammary incision must be strictly respected. Successful cosmetic results are obtained by respecting the physiological reliefs and by closing them in specific layers. It is imperative to stay in the groove.

 

   Pitfalls
Top
 Summary
 Introduction
 Technique
 Pitfalls
Discussion
 Combined approaches
 Conclusion
 References
 
Many reports underline the risk for sternal override or pseudoarthrosis. In the case of bilateral lung transplantation which does not require cardiopulmonary bypass, sternal sparing has been demonstrated to be safe [2]. Some authors recommend the placement of several Kirschner wires – MMCTSLink 106 – in the reapproximated sternum to reduce override and shifts of the sternal wedges, although complications due to migration of Kirschner wires are well documented. It is useful to offset the sternal tables by beveling the incision to allow a more stable closure. This can be accomplished by tipping the sternal saw to a 45° angle from the vertical plane.

The internal thoracic pedicle must be ligated to avoid intraoperative or postoperative bleeding (Video 12).


Figure 12
Click on image to view video		 Video 12 The internal thoracic artery. It is a classical etiology of rethoracotomy for bleeding.
 

   Discussion
Top
 Summary
 Introduction
 Technique
 Pitfalls
 Discussion
Combined approaches
 Conclusion
 References
 
The bilateral transverse bithoracosternotomy redescribed in 1991 by Cooper [3] is now called clamshell incision or crossbow incision. Its use has been emphasized by Bains in thoracic oncologic surgery [4].

The transternal bilateral thoracotomy incision was used as the standard approach to the pericardial contents in the early eras of open heart surgery until it was replaced by the less traumatic median sternotomy.

Actually, its use has been rediscovered as the gold standard incision for sequential bilateral lung transplantation [6]. This incision provides an excellent exposure for safe division of pleural adhesions. Both hilae can be approached with excellent visibility, including both lower lobes. In addition, it promotes an adequate exposure for cannulation and initiation of a cardiopulmonary bypass [5].

Disadvantages include increased pain and risk of sternal complications [7,8,9,10]. Therefore, its use is rare outside of transplant surgery.


   Combined approaches
Top
 Summary
 Introduction
 Technique
 Pitfalls
 Discussion
 Combined approaches
Conclusion
 References
 
A first variant is the so-called hemiclamshell incision (Photo 2).


Figure 2
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  		Photo 2 Post operative aspect of a hemiclamshell incision. A good symmetry between both nipples signs a successful combined incision.

 
A partial vertical median sternotomy is combined with an anterior thoracotomy in the 4th intercostal space. This type of incision has been designed on the left side to perform left tracheal sleeve pneumonectomy, and aortic surgery. Grillo has proposed this incision with a right thoracotomy for lower tracheal resections; he created the name of ‘trap door incision’ [11,12]. Bains outlined the interest of this incision for Pancoast tumors.

Dartevelle described a cervical approach with excision of the internal half of the clavicle for radical resection of Pancoast tumors involving the subclavian artery [13]. This has to be combined with a lateral thoracotomy to complete with lobectomy and lymph node dissection. Grunenwald [14] modified the cervical approach by an L-shaped manubriotomy, which allows lifting up the clavicle without resecting it.


   Conclusion
Top
 Summary
 Introduction
 Technique
 Pitfalls
 Discussion
 Combined approaches
 Conclusion
References
 
"To be well exposed, it's the half of the success of a surgical procedure"



   References
Top
 Summary
 Introduction
 Technique
 Pitfalls
 Discussion
 Combined approaches
 Conclusion
 References
 

  1. Marshall WG Jr, Meng RL, Ehrenhaft JL. Coronary artery bypass grafting in patients with a tracheostoma: use of a bilateral thoracotomy incision. Ann Thorac Surg 1988;46:465–466.[Abstract]
  2. Meyers BF, Sundaresan RS, Guthrie T, Cooper JD, Patterson GA. Bilateral sequential lung transplantation without sternal division eliminates post-transplantation sternal complications. J Thorac Cardiovasc Surg 1999;117:358–364.[Abstract/Free Full Text]
  3. Cooper JD. Current status of lung transplantation. Transplant Proc 1991;23:2107–2114.[Medline]
  4. Bains MS, Ginsberg RJ, Jones WG 2nd, McCormack PM, Rusch VW, Burt ME, Martini N. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg 1994;58:30–33.[Abstract]
  5. Shimizu J, Oda M, Morita K, Watanabe S, Ohta Y, Hayashi Y, Murakami S, Watanabe Y. Evaluation of the clamshell incision for bilateral pulmonary metastases. Int Surg 1997;82:262–265.[Medline]
  6. Macchiarini P, Ladurie FL, Cerrina J, Fadel E, Chapelier A, Dartevelle P. Clamshell or sternotomy for double lung or heart-lung transplantation? Eur J Cardiothorac Surg 1999;15:333–339.[Abstract/Free Full Text]
  7. Luciani GB, Starnes VA. The clamshell approach for the surgical treatment of complex cardiopulmonary pathology in infants and children. Eur J Cardiothorac Surg 1997;11:298–306.[Abstract]
  8. Lardinois D, Sippel M, Gugger M, Dusmet M, Ris HB. Morbidity and validity of the hemiclamshell approach for thoracic surgery. Eur J Cardiothorac Surg 1999;16:194–199.[Abstract/Free Full Text]
  9. Wright C. Transverse sternothoracotomy. Chest Surg Clin N Am 1996;6:149–156.[Medline]
  10. Brown RP, Esmore DS, Lawson C. Improved sternal fixation in the transsternal bilateral thoracotomy incision. J Thorac Cardiovasc Surg 1996;112:137–141.[Abstract/Free Full Text]
  11. Grillo HC, Ojemann RG, Scannell JG, Zervas NT. Combined approach to ‘dumbbell’ intrathoracic and intraspinal neurogenic tumors. Ann Thorac Surg 1983;36:402–407.[Abstract]
  12. Grillo HC. Tracheal surgery. Scand J Thorac Cardiovasc Surg 1983;17:67–77.[Medline]
  13. Dartevelle PG, Chapelier AR, Macchiarini P, Lenot B, Cerrina J, Ladurie FL, Parquin FJ, Lafont D. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg 1993;105:1025–1034.[Abstract]
  14. Grunenwald D, Spaggiari L. Transmanubrial osteomuscular sparing approach for apical chest tumors. Ann Thorac Surg 1997;63:563–566.[Abstract/Free Full Text]


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N. Durrleman and G. Massard
Elective anterior and posterior thoracotomies
MMCTS, August 10, 2006; 2006(0810): 1446.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Summary Freely available
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Right arrow Author home page(s):
Nicolas Dürrleman
Gilbert Massard
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Right arrow Articles by Dürrleman, N.
Right arrow Articles by Massard, G.
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