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Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomic Study

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Emergency thoracotomy (ET) is a procedure that provides rapid access to intrathoracic structures for thoracic trauma patients arriving at the hospital in extremis. This study assesses the accessibility of intrathoracic structures provided by six different ET incisions. We hypothesize that the bilateral anterior thoracotomy (“clamshell” incision) provides the most rapid and definitive accessibility to intrathoracic structures.


Six ET incision types (left anterolateral thoracotomy, right anterolateral thoracotomy, left 2nd intercostal space incision, left 3rd intercostal space incision, median sternotomy, and bilateral anterior thoracotomy) were performed multiple times on eight cadavers. The critical intrathoracic structures were assessed for rapid accessibility and control, and they were characterized as “readily accessible,” “accessible,” and “inaccessible” on anatomic accessibility maps.


Median sternotomy provided better access to intrathoracic structures than left and right anterior thoracotomies. Definitive control of the origin of the left subclavian artery was difficult with left 2nd or 3rd intercostal space incisions. Bilateral anterior thoracotomy, the clamshell incision, was easy to perform and gave superior access to all intrathoracic structures.


In severe thoracic trauma, specific injuries are unknown, even if they can be anticipated. The best incision is therefore one that provides the most rapid and definitive access to all thoracic structures for assessment and control. While the right and left anterolateral incisions may be successfully employed by surgeons with extensive experience in ET, the clamshell incision remains the superior incision choice.

Level of Evidence II

Observational study.

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Correspondence to Eric J. Voiglio.

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Illustrations by Eric R. Simms and Eric J. Voiglio.

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Simms, E.R., Flaris, A.N., Franchino, X. et al. Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomic Study. World J Surg 37, 1277–1285 (2013).

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