From the Guidelines
A clamshell procedure in trauma surgery is an emergency surgical technique that involves making a bilateral anterior thoracotomy incision across the chest, creating a "clamshell" appearance when the chest is opened, as recommended for wounded soldiers with cardiac arrest and impending cardiac arrest 1. This procedure is used to gain rapid access to both sides of the chest, the heart, and major blood vessels when a patient has life-threatening injuries. The technique involves connecting the two incisions by dividing the sternum transversely, allowing surgeons to quickly control bleeding, repair cardiac injuries, access both lungs simultaneously, cross-clamp the descending aorta, and perform internal cardiac massage if needed. Some of the key indications for a clamshell procedure include:
- Penetrating trauma to the chest
- Cardiac arrest due to thoracic injuries
- Massive hemorrhage in the chest cavity that cannot be controlled through a standard thoracotomy The clamshell thoracotomy is more invasive than a standard thoracotomy but provides superior exposure when bilateral access is required, as noted in the Chinese expert consensus on echelons treatment of thoracic injury in modern warfare 1. However, it carries significant risks including:
- Infection
- Bleeding
- Respiratory complications and is generally considered a last-resort procedure with high mortality rates even when performed correctly. The decision to perform this procedure is made rapidly in trauma settings when less invasive measures would be insufficient to save the patient's life, and is typically classified as a Class B/Category IIa recommendation 1.
From the Research
Definition and Purpose of Clamshell Procedure
- The clamshell procedure, also known as bilateral anterior thoracotomy, is a surgical technique used in trauma surgery to provide rapid access to intrathoracic structures 2.
- This procedure involves making an incision on both sides of the chest, allowing for better exposure and control of the thoracic cavity 2, 3.
- The clamshell approach is used to treat various conditions, including extensive thoracic aortic disease, complex cardiopulmonary pathology in infants and children, and select aortic arch pathologies 3, 4, 5.
Advantages and Outcomes
- The clamshell procedure provides superior access to all intrathoracic structures, making it an ideal choice for emergency thoracotomies 2.
- Studies have shown that the clamshell approach is a safe and effective procedure for patients with extensive thoracic aortic disease and concomitant cardiac lesions 3.
- The clamshell procedure has also been used successfully in infants and children with complex cardiovascular and pulmonary anomalies, allowing for single-stage surgical repair 4.
- A study comparing the clamshell procedure to an anterolateral approach for resuscitative thoracotomy found that the clamshell procedure did not increase complications and facilitated thoracic life-saving procedures 6.
Indications and Applications
- The clamshell procedure is indicated for patients with severe thoracic trauma, extensive thoracic aortic disease, and complex cardiopulmonary pathology 2, 3, 4.
- The procedure is also used for single-stage repair of select aortic arch pathologies, including focal arch dissection, extensive arch aneurysm or pseudoaneurysm, and complex pediatric coarctation 5.
- The clamshell approach can be used in various clinical settings, including emergency thoracotomies, elective surgeries, and trauma cases 2, 3, 6.