World Journal of Surgery

, Volume 38, Issue 7, pp 1726–1729 | Cite as

Transdiaphragmatic Resuscitative Open Cardiac Massage: Description of the Technique and a First Case-Series of an Alternative Approach to the Heart

  • Beat Schnüriger
  • Peter Studer
  • Daniel Candinas
  • Christian A. SeilerEmail author



The purpose of this paper is to describe the transdiaphragmatic approach to the heart for open CPR in patients that arrest at laparotomy and to present a first case series of patients that have undergone this procedure.


All patients who had undergone intraperitoneal transdiaphragmatic open CPR between January 1, 2002 and December 31, 2012 were retrieved from the operation registry at Bern University Hospital, Switzerland. Transdiaphragmatic access to the heart is initiated with a 10-cm-long anterocaudal incision in the central tendon of the diaphragm—approximately at 2 o’clock. Internal cardiac compression through the diaphragmatic incision can be performed from both sides of the patient. From the right side of the patient, cardiac massage is performed with the right hand and vice versa.


A total of six patients were identified that suffered cardiac arrest during laparotomy with open CPR performed through the transdiaphragmatic approach. Four patients suffered cardiac arrest during orthotopic liver transplantation and two trauma patients suffered cardiac arrest during damage control laparotomy. In three patients, cardiac activity was never reestablished. However, three patients regained a perfusion heart rhythm and two of these survived to the ICU. One patient ultimately survived to discharge.


In patients suffering cardiac arrest during laparotomy, the transdiaphragmatic approach allows for a rapid, technically easy, and almost atraumatic access to the heart, with excellent CPR performance. After this potentially life-saving procedure, pulmonary or surgical site complications are expected to occur much less compared with the conventionally performed emergency department left-sided thoracotomy.


Cardiac Arrest Trauma Patient Orthotopic Liver Transplantation Cardiac Massage Thoracic Injury 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Conflict of interest

None of the authors has any potential or real conflicts of interest that could inappropriately influence (bias) their work.


  1. 1.
    Briggs BD, Sheldon DB, Beecher HK (1956) Cardiac arrest; study of a thirty-year period of operating room deaths at Massachusetts General Hospital, 1925–1954. J Am Med Assoc 160:1439–1444PubMedCrossRefGoogle Scholar
  2. 2.
    Delguercio LR, Feins NR, Cohn JD et al (1965) Comparison of blood flow during external and internal cardiac massage in man. Circulation 31(Suppl 1):171–180PubMedGoogle Scholar
  3. 3.
    Turk LN 3rd, Glenn WW (1954) Cardiac arrest; results of attempted cardiac resuscitation in 42 cases. N Engl J Med 251:795–803PubMedCrossRefGoogle Scholar
  4. 4.
    Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma (2001) Practice management guidelines for emergency department thoracotomy. J Am Coll Surg 193:303–309CrossRefGoogle Scholar
  5. 5.
    Martin SK, Shatney CH, Sherck JP et al (2002) Blunt trauma patients with prehospital pulseless electrical activity (PEA): poor ending assured. J Trauma 53:876–880 (discussion 880–871)PubMedCrossRefGoogle Scholar
  6. 6.
    Rhee PM, Acosta J, Bridgeman A et al (2000) Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg 190:288–298PubMedCrossRefGoogle Scholar
  7. 7.
    Schnuriger B, Talving P, Inaba K et al (2012) Biochemical profile and outcomes in trauma patients subjected to open cardiopulmonary resuscitation: a prospective observational pilot study. World J Surg 36:1772–1778. doi: 10.1007/s00268-012-1583-3 PubMedCrossRefGoogle Scholar
  8. 8.
    Suresh Kumar S, Saith V, Chawla R et al (2001) Successful transdiaphragmatic cardiac resuscitation through midline abdominal incision in patient with flail chest. Resuscitation 50:239–241PubMedCrossRefGoogle Scholar
  9. 9.
    Deakin CD, Nolan JP, Soar J et al (2010) European resuscitation council guidelines for resuscitation 2010 section 4. Adult advanced life support. Resuscitation 81:1305–1352PubMedCrossRefGoogle Scholar
  10. 10.
    Rosemurgy AS, Norris PA, Olson SM et al (1993) Prehospital traumatic cardiac arrest: the cost of futility. J Trauma 35:468–473 (discussion 473–464)PubMedCrossRefGoogle Scholar
  11. 11.
    Powell DW, Moore EE, Cothren CC et al (2004) Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation? J Am Coll Surg 199:211–215PubMedCrossRefGoogle Scholar
  12. 12.
    Sheppard FR, Cothren CC, Moore EE et al (2006) Emergency department resuscitative thoracotomy for nontorso injuries. Surgery 139:574–576PubMedCrossRefGoogle Scholar
  13. 13.
    Fialka C, Sebok C, Kemetzhofer P et al (2004) Open-chest cardiopulmonary resuscitation after cardiac arrest in cases of blunt chest or abdominal trauma: a consecutive series of 38 cases. J Trauma 57:809–814PubMedCrossRefGoogle Scholar
  14. 14.
    Demetriades D, Rabinowitz B, Sofianos C (1987) Emergency room thoracotomy for stab wounds to the chest and neck. J Trauma 27:483–485PubMedCrossRefGoogle Scholar
  15. 15.
    Ivatury RR, Kazigo J, Rohman M et al (1991) “Directed” emergency room thoracotomy: a prognostic prerequisite for survival. J Trauma 31:1076–1081 (discussion 1081–1082)PubMedCrossRefGoogle Scholar
  16. 16.
    Schnuriger B, Inaba K, Branco BC et al (2010) Organ donation: an important outcome after resuscitative thoracotomy. J Am Coll Surg 211:450–455PubMedCrossRefGoogle Scholar
  17. 17.
    Lustenberger T, Labler L, Stover JF et al (2012) Resuscitative emergency thoracotomy in a Swiss trauma centre. Br J Surg 99:541–548PubMedCrossRefGoogle Scholar
  18. 18.
    Asensio JA, Stewart BM, Murray J et al (1996) Penetrating cardiac injuries. Surg Clin N Am 76:685–724PubMedCrossRefGoogle Scholar
  19. 19.
    Homvises B, Sirivatanauksorn Y, Limsrichamrern S et al (2008) The minimal flush volume for washout of preservation fluid in liver transplantation. Transplant Proc 40:2123–2126PubMedCrossRefGoogle Scholar
  20. 20.
    Shi XY, Xu ZD, Xu HT et al (2006) Cardiac arrest after graft reperfusion during liver transplantation. Hepatobiliary Pancreat Dis Int 5:185–189PubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2014

Authors and Affiliations

  • Beat Schnüriger
    • 1
  • Peter Studer
    • 1
  • Daniel Candinas
    • 1
  • Christian A. Seiler
    • 1
    Email author
  1. 1.Department of Visceral and Transplant SurgeryBern University HospitalBernSwitzerland

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