Eric J. Voiglio

Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study.

BackgroundEmergency 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.MethodsSix 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.ResultsMedian 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.ConclusionsIn 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 IIObservational study.

Clamshell Incision Versus Left Anterolateral Thoracotomy. Which One is Faster When Performing a Resuscitative Thoracotomy? The Tortoise and the Hare Revisited

BackgroundThe clamshell incision (CI) offers a better exposure than the left anterolateral thoracotomy (LAT) as a resuscitative thoracotomy. Most surgeons will have to manage a heart wound only once or twice in their career. The patient’s survival depends on how fast the surgeon can control the heart wound; however, it is unclear which of the two incisions allows for faster control in the hands of inexperienced surgeons. The aim of this study was to compare the time needed to access and control a standardized stab wound to the right ventricle, by inexperienced surgical trainees, by LAT or CI; we hypothesized that the CI does not take longer than the LAT.MethodsSixteen residents were shown a video on how to perform both procedures. They were randomly assigned to control a standardized stab wound of the right ventricle on perfused human cadavers by LAT (nxa0=xa08) or CI (nxa0=xa08). Access time (skin to maximal exposure), control time (maximal exposure until control of the heart wound) and total time (the sum of access and control times) were recorded.ResultsTotal time was 6.62xa0min [3.20–8.14] (median [interquartile range]) for LAT and 4.63xa0min [3.17–6.73] for CI (pxa0=xa00.46). Access time was 2.39xa0min [1.21–2.76] for LAT and 2.33xa0min [1.58–4.86] for CI (pxa0=xa00.34). Control time was 4.16xa0min [2.32–5.49] for LAT and 1.85xa0min [1.38–2.23] for CI (pxa0=xa00.018).ConclusionsThe time needed from skin incision until cardiac wound control via CI was not longer than via LAT and the easier control of the cardiac wound when using CI was confirmed.

Feasibility of Catheter Placement Under Ultrasound Guidance for Progressive Preoperative Pneumoperitoneum for Large Incisional Hernia with Loss of Domain

AbstractIntroductionnLarge incisional hernias with loss of domain (LIHLD) of the abdominal wall remain a therapeutic challenge due to the difficulty of replacing the contents of the hernia sac into the peritoneal cavity. Preoperative progressive pneumoperitoneum (PPP) is a valuable option. The purpose of this study was to evaluate the feasibility of peritoneal catheter insertion under ultrasound guidance for PPP and to compare the morbidity and mortality of this new technique to previously used techniques in our department.nMethodsMedical records were reviewed retrospectively from February 1989 to April 2013 in a single institution. Three different techniques of PPP were evaluated: surgical subcutaneous implantable port (SIP), surgical peritoneal dialysis catheter (PDC), and radiologic multipurpose drainage catheter (MDC). Collected data included patients’ age, sex, body mass index, medical and surgical history, hernia location, PPP technique, length of hospitalization, volume of air injected, morbidity and mortality linked to PPP, and the procedure of hernia repair.ResultsThirty-seven patients with a mean age of 63.1xa0years were evaluated. Progressive preoperative pneumoperitoneumxa0was performed using SIP, PDC, and MDC for 14, 11, and 12 patients, respectively. Overall morbidity related to the technique was seen in 36xa0% of SIP, 27xa0% of PDC, and 0xa0% of MDC. One patient from the SIP group died on the 3rd postoperative day due to septic shock following aspiration pneumonia. No postoperative mortality in the other groups was observed.ConclusionThe MDC is an interesting modification of the original technique and is a safe procedure. It is a minimally invasive technique with a very low risk of perforation of the viscera. Therefore, the use of a non-absorbable prosthesis with MDC technique can be offered for all patients undergoing PPP without increasing the risk of infection.

Fixed-Distance Model for Balloon Placement During Fluoroscopy-Free Resuscitative Endovascular Balloon Occlusion of the Aorta in a Civilian Population

Importance Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an innovative procedure in the treatment of noncompressible truncal hemorrhage. However, readily available fluoroscopy remains a limiting factor in its widespread implementation. Several methods have been proposed to perform REBOA without fluoroscopic guidance, and these methods were adapted predominantly from the military theater. Objective To develop a method for performing REBOA in a civilian population using a standardized distance from a set point of entry. Design, Setting, and Participants A retrospective study of whole-body computed tomographic (CT) scans from a cohort of 280 consecutive civilian trauma patients from University Hospitals of Lyon, France, was used to calculate the endovascular distances from both femoral arteries at the level of the upper border of the symphysis pubis to aortic zone I (descending thoracic aorta) and zone III (infrarenal aorta). These whole-body CT scans were performed between 2013 and 2015. Data were analyzed from July 16 to December 7, 2015. Main Outcomes and Measures Two segments (1 per zone) common to all CT scans were isolated, and their location, length, prevalence in the cohort, and predicted prevalence in the general population were calculated by inverting 99% certainty tolerance limits. Results Among the 280 trauma patients (140 men and 140 women) in this study, the mean (SD) height was 170.7 (8.7) cm, and the mean (SD) age was 38.8 (16.5) years. The common segment in zone I (414-474 mm) existed in all CT scans. The common segment in zone III (236-256 mm) existed in 99.6% and 97.9% of CT scans from the right and left femoral arteries, respectively. These segments are expected to exist in 98.7% (zone I) and 94.9% (zone III) of the general population. Conclusions and Relevance Target distances for blind placement of REBOA exist with more than 94% prevalence in a civilian population. These findings support the expanded use of REBOA in emergency department and prehospital settings. Validation for safety and efficacy on cadaveric and clinical models is necessary.

Kendrick's extrication device and unstable pelvic fractures: Should a trochanteric belt be added? A cadaveric study

INTRODUCTIONnPre-hospital pelvic stabilisation is advised to prevent exsanguination in patients with unstable pelvic fractures (UPFs). Kendricks extrication device (KED) is commonly used to extricate patients from cars or crevasses. However the KED has not been tested for potential adverse effects in patients with pelvic fractures. The aim of this study was to examine the effect of the KED on pubic symphysis diastasis (SyD) with and without the use of a trochanteric belt (TB) during the extraction process following a MVC.nnnMATERIALS AND METHODSnLeft-sided open-book UPFs were created in 18 human cadavers that were placed in seven different positions simulating pre-extraction and extraction positions using the KED with and without a TB in two different positions (through and over the thigh straps). The SyD was measured using anteroposterior radiographs. The effects of the KED with and without TB, on the SyD, were evaluated.nnnRESULTSnThe KED alone resulted in a non-significant increase of the SyD compared to baseline, whereas the addition of a TB to the KED resulted in a significant reduction of the SyD (p<0.001). The TB through the straps provided a significantly better reduction than the TB over the straps in the extracted position (p<0.05).nnnCONCLUSIONnOur study demonstrated that a TB in combination with the KED on UPFs is an effective way to achieve early reduction. The addition of the TB in combination with the KED could be considered for Pre-Hospital Trauma Life Support (PHTLS) training protocols.

What Kind of Incision Should Be Used in Thoracic Trauma Patients in Emergent Cases? Reply

We would like to thank Dr. Gökalp and his colleagues for their interesting comments on our study, ‘‘Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited’’ [1]. The question asked is which incision provides superior access to an underlying thoracic lesion. The authors propose a comparison between median sternotomy, left anterolateral thoracotomy, and the clamshell incision when performed on patients with cardiac or pulmonary lesions that do not necessitate a resuscitative approach. To answer the question from an anatomical point of view, our group in a previous study created anatomic accessibility maps of intrathoracic structures for the following incisions: left and right anterolateral thoracotomies, median sternotomy, and the clamshell incision [2]. We found that the clamshell incision provides total exposure to almost all intrathoracic structures. To answer the question from a functional point of view, thoracic incisions have to be further classified into different groups according to patient status. As Dr. Gökalp and colleagues suggested in their letter, thoracic incisions can be divided into two groups: those performed on patients in extremis (resuscitative thoracotomy) and those performed on patients in a less critical albeit emergent condition. Despite recent controversy [3, 4], and especially when the non-specialist has to perform a resuscitative thoracotomy, the clamshell incision is the right call, for four reasons: (1) the uncertainty about the location of the underlying lesions, which necessitates a wide incision that will cover all possibilities, (2) the clamshell’s superb exposure [2], (3) the ease with which it can be performed by non-specialists [5– 7], and (4) the simple instruments needed to perform it [8] (as opposed notably to median sternotomy). On the other hand, when the patient is not in extremis, there is time to choose the most appropriate incision depending on the most probable lesion. If a cardiac lesion necessitating an operation is found, median sternotomy is an excellent incision offering direct access to the heart [2]. Beşir et al. observed that when compared to the left anterolateral thoracotomy, median sternotomy resulted in a shorter duration of operation and hospital stay [9], important results indicating that median sternotomy is the right call for cardiac lesions in an emergent but not in an extremis situation. Since the indications for these two incisions, clamshell versus median sternotomy, are completely different, they cannot be functionally compared. It cannot be said that one is superior to the other, since they are generally not employed in the same setting. In summary, when a patient with thoracic lesions is in extremis, the clamshell incision should be preferred & Alexandros N. Flaris alexander.flaris@gmail.com

Ergonomie de la table SECTRA® et première prise en main par les étudiants à Lyon

Objectif La table SECTRA est une table d’anatomie 3D permettant de confronter l’anatomie radiologique et morphologique. Le but de cette etude etait de questionner les etudiants a l’issue de leur premiere utilisation de la table, ainsi que d’evaluer leur temps de prise en main de certaines fonctions de cet outil. Materiel et methodes Nous avons evalue des moniteurs en 3e annee de medecine, n’ayant jamais utilise la table SECTRA. Chaque etudiant etait chronometre individuellement pour la realisation des 3xa0epreuves suivantesxa0: identifier des structures anatomiques, detourer un os grâce a l’outil d’isolement de structures, optimiser la visualisation d’une structure avec l’outil scalpel. Apres la seance, il etait demande aux etudiants de remplir un questionnaire d’evaluation en ligne. Resultats Parmi 15xa0participants, le temps moyen de realisation des epreuves a ete de 8xa0minxa0±xa01xa0min 36xa0s. Tous ont decrit la table SECTRA comme etant un outil intuitif, ergonomique, et adapte a former des etudiants a l’anatomie. Avec ces seances, nous sommes arrives a 87xa0% des moniteurs capables de s’en servir, et a obtenir 80xa0% des moniteurs se jugeant susceptibles d’etre a leur tour formateur. Conclusion Cet outil est percu comme etant ergonomique et intuitif. Il semble egalement facile de former des etudiants a la transmission des notions de bases pour son utilisation.