What is the step-by-step procedure for performing a thoracotomy to evacuate a severe hemothorax in a young to middle-aged adult patient with a history of trauma, possible bleeding disorders or anticoagulant use, and potential underlying conditions?

Emergency Thoracotomy for Hemothorax: Detailed Step-by-Step Procedure

Indications for Thoracotomy

Thoracotomy for hemothorax is indicated when initial tube thoracostomy fails to control hemorrhage, specifically when >1,500 mL of blood is evacuated initially or when ongoing blood loss exceeds 200 mL per hour. 1, 2

Additional indications include:

• Progressive massive hemorrhage despite closed thoracic drainage 1
• Continuous hemorrhage in the thorax with persistent dyspnea unrelieved by chest tube 1
• Hemodynamic instability with suspected intrathoracic vascular injury 1
• Cardiac arrest or impending cardiac arrest from exsanguinating thoracic hemorrhage (resuscitative thoracotomy) 1

Pre-Operative Preparation

Patient Assessment and Stabilization

• Establish large-bore IV access (two sites minimum) and initiate massive transfusion protocol immediately 1, 3
• Measure core temperature and begin active rewarming if <35°C to prevent coagulopathy 1, 3
• Obtain baseline coagulation parameters: PT ratio (target <1.2), platelet count (target >100,000/μL), and fibrinogen levels 3
• Correct severe coagulopathy with blood products before or during surgery 1, 3
• Monitor for the "lethal triad" of hypothermia, acidosis (pH <7.2), and coagulopathy 3, 4

Anticoagulation Considerations

• Patients on preinjury anticoagulants require heightened surveillance and consideration for earlier surgical intervention due to increased complication rates and longer hospital stays 5
• Reverse anticoagulation immediately with appropriate agents based on the specific anticoagulant used 5

Operating Room Setup

• Position patient supine with affected side elevated 30-45 degrees using a roll under the ipsilateral shoulder 1
• Prepare for anterolateral thoracotomy approach on the affected side (left-sided for resuscitative thoracotomy) 1
• Have equipment ready for potential clamshell extension if bilateral access or cardiac intervention is needed 1
• Ensure availability of vascular instruments, rib spreaders, and lung staplers 1

Surgical Technique: Step-by-Step

Step 1: Incision and Chest Entry

• Make an anterolateral incision in the 4th or 5th intercostal space, extending from the sternum to the mid-axillary line 1
• Incise through skin, subcutaneous tissue, and pectoralis major muscle using electrocautery 1
• Identify and divide the intercostal muscles along the superior border of the lower rib to avoid neurovascular bundle injury 1
• Enter the pleural space and evacuate blood and clots manually or with suction 1

Step 2: Exposure and Assessment

• Insert a rib spreader and open the chest gradually to avoid rib fractures 1
• Perform rapid systematic assessment: lung parenchyma, hilum, heart/pericardium, great vessels, chest wall, and diaphragm 1
• If clamshell extension is needed, continue the incision across the sternum to the contralateral 4th/5th intercostal space 1
• Divide the sternum transversely with a Gigli saw or sternal saw, protecting underlying structures 1

Step 3: Hemorrhage Control Based on Source

For Pulmonary Parenchymal Injuries

• Apply direct pressure with laparotomy pads to temporarily control bleeding 1, 6
• For minor lacerations: perform direct suture repair using 3-0 or 4-0 absorbable sutures with pledgets 1, 6
• For moderate lacerations: perform tractotomy (open the wound tract) to identify and ligate bleeding vessels directly 1, 6
• For severe lacerations with ongoing hemorrhage: perform anatomic resection (lobectomy or segmentectomy) using staplers 1, 6
• For uncontrollable hemorrhage: consider hilar torsion (twist the hilum 180-360 degrees) as a temporary damage control measure 1, 6
• Pneumonectomy is the absolute last resort with mortality exceeding 50% 6

For Chest Wall Vessel Injuries

• Identify bleeding intercostal or internal mammary arteries 7, 2
• Ligate vessels proximally and distally with 2-0 silk sutures or clips 7, 2
• For inaccessible posterior chest wall bleeding, consider intraoperative angiography and embolization if patient is stable 7

For Great Vessel Injuries

• Obtain proximal and distal vascular control immediately with vascular clamps 1
• Perform primary repair with 4-0 or 5-0 polypropylene suture for small injuries 1
• For extensive injuries, perform vascular bypass surgery or graft interposition 1
• Clamp the descending aorta if exsanguinating hemorrhage prevents adequate visualization 1

For Cardiac Injuries

• Open the pericardium anterior to the phrenic nerve with a longitudinal incision 1
• Control cardiac hemorrhage with finger pressure or Foley catheter balloon tamponade 1
• Repair cardiac lacerations with 3-0 or 4-0 polypropylene horizontal mattress sutures with pledgets 1
• Perform internal cardiac massage if cardiac arrest occurs 1

Step 4: Damage Control Principles

If the patient develops severe coagulopathy (PT ratio >1.2), profound hypothermia (<34°C), or severe acidosis (pH <7.2) during the procedure, abort definitive repair and transition to damage control surgery. 3, 4

• Pack all bleeding sites with laparotomy pads 4
• Achieve temporary hemostasis without attempting complex repairs 4
• Close the chest temporarily with towel clips or running suture without approximating ribs 4
• Transfer to ICU for resuscitation: rewarm to >36°C, correct pH to >7.2, and reverse coagulopathy with massive transfusion protocol 4
• Return to OR for definitive repair only after physiologic parameters are restored 4

Step 5: Definitive Hemostasis and Inspection

• Systematically re-inspect all potential bleeding sources after initial control 1
• Ensure lung is fully expanded and check for air leaks by submerging in saline while ventilating 1
• Place chest tubes (typically two: one apical for air, one basilar for fluid) under direct visualization 1, 8
• Irrigate the pleural cavity with warm saline to remove clots and debris 1

Step 6: Closure

• Approximate ribs with pericostal sutures using #1 or #2 absorbable suture 1
• Close intercostal muscles in layers 1
• Reapproximate pectoralis major muscle 1
• Close subcutaneous tissue and skin in standard fashion 1
• If clamshell incision was used, reapproximate the sternum with sternal wires 1

Post-Operative Management

Immediate Post-Operative Care

• Administer antibiotic prophylaxis for 24 hours (cephalosporin for blunt trauma; broader spectrum for penetrating trauma) 1
• Monitor chest tube output hourly; re-exploration may be needed if output exceeds 200 mL/hour 2, 9
• Maintain normothermia (36-37°C) to prevent recurrent coagulopathy 1, 3
• Serial coagulation monitoring and correction as needed 3

Complications to Monitor

• Retained hemothorax occurs in 2-25% of cases and increases risk of empyema and pneumonia 1, 8
• Post-traumatic empyema develops in 2-25% of cases, with S. aureus responsible for 35-75% of infections 1
• Consider early VATS if retained hemothorax is identified within first few days 8, 2

Critical Pitfalls to Avoid

• Never delay thoracotomy in unstable patients for additional imaging or "optimization"—immediate surgical control is required 1, 4
• Do not rely solely on CT angiography to exclude bleeding; venous injuries and parenchymal oozing may not be visualized 4, 7
• Avoid prolonged attempts at definitive repair in the face of the lethal triad; transition to damage control immediately 3, 4
• Do not perform thoracentesis or observation alone for traumatic hemothorax; early tube thoracostomy minimizes morbidity 9
• Never leave clotted blood in the pleural space; inadequate drainage leads to empyema and fibrothorax 8, 2, 9
• Recognize futility early in patients with ≥4 organ failures after adequate treatment 4