Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 105 • Subclavian Artery Stab 1167

Anterior sternoclavicular

ligament

Sternohyoid muscle

Thoracic duct

Internal jugular

vein

Deep cervical

lymph nodes

Sternothyroid muscle

Recurrent

laryngeal nerve

Phrenic nerve

Inferior thyroid

artery

Thoracic

duct

Contents of carotid sheath

Subclavius muscle

Subclavian vein

Suprascapular artery

Phrenic nerve

Omohyoid fascia

Transverse cervical artery

FIGURE 105 –1

1168 Section XVI • Operations—Elective and Trauma

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Operative approach to stab wounds of the subclavian vessels is based on the patient’s clinical

(i.e., hemodynamic) status. In patients who present with massive bleeding in extremis, initial

attempts at digital compression through the wound or a limited second intercostal anterior

thoracotomy with compression of the vessels by insertion of two ﬁ ngers may allow tempo-

rary control, permitting resuscitation and surgical exposure.

◆ In patients with near normal vital signs or who stabilize with initial resuscitation, imaging

studies, either angiogram or computed tomography (CT) angiogram that provides anatomic

deﬁ nition, can guide decisions on surgical approach. Both the right and left subclavian

vessels can be approached by medial clavicular resection. If it is suspected that proximal

control at either the innominate or aortic junction will be needed, a median sternotomy

may be required.

STEP 3: OPERATIVE STEPS

◆ The incision is at the second interspace.

◆ A curvilinear incision 5 to 7 cm in length is rapidly created, beginning at the lateral

border of the sternum through the pectoralis into the pleura (Figure 105-2).

◆ The right second and third ﬁ ngers are inserted and used to apply pressure superiorly and

medially to compress the subclavian artery and vein against the clavicle (Figure 105-3).

◆ After the hemorrhage is controlled, the subclavian vessels can be exposed by resecting

the medial clavicle.

CHAPTER 105 • Subclavian Artery Stab 1169

Incision at second

interspace

Clavicle

Subclavius muscle

Subclavian vein

Subclavian artery

FIGURE 105 –3

FIGURE 105 –2

1170 Section XVI • Operations—Elective and Trauma

◆ Clavicular resection

◆ The incision is begun at the midline and extended laterally, directly over the clavicle to

the deltopectoral groove (Figure 105-4, A). Subcutaneous tissue and the anterior perios-

teum can be quickly dissected with electrocautery.

◆ The periosteum is separated from the clavicle circumferentially using periosteal elevators

(Figure 105-4, B).

◆ The clavicle is then transected at the lateral aspect of the exposure using a Gigli saw

(Figure 105-4, C).

◆ The medial aspect is retracted medially and superiorly, allowing separation of the

sternoclavicular joint with sharp dissection or electrocautery.

◆ The posterior periosteum is incised at the lateral aspect of the incision and extended

medially (Figure 105-4, D).

◆ Placing two self-retaining retractors beneath the incised periosteum will allow dissection

of the subclavian artery and vein, permitting proximal and distal vascular control in

preparation for vascular repair (Figure 105-4, E-F).

Periosteum

FIGURE 105 –4

CHAPTER 105 • Subclavian Artery Stab 1171

Posterior periosteum

Thoracic duct

Subclavian artery

Vertebral artery

Subclavian vein

Internal

jugular vein

FIGURE 105 –4, cont’d

1172 Section XVI • Operations—Elective and Trauma

Left jugular vein

Left

subclavian vein

Left subclavian

artery

Sternocleido-

mastoid muscle

Phrenic

nerve

Anterior scalene

muscle

Left common

carotid artery

FIGURE 105 –4, cont’d

CHAPTER 105 • Subclavian Artery Stab 1173

STEP 4: POSTOPERATIVE CARE

◆ Patient should wear a shoulder immobilizer.

STEP 5: PEARLS AND PITFALLS

◆ Although numerous references suggest replacement and reconstruction of the clavicle, it

may be unnecessary. If the patient’s condition allows, replacement of the medial clavicle

with internal ﬁ xation should be attempted to reduce long-term morbidity.

SELECTED REFERENCE

1. Thal ER, Weigelt JA, Carrico CJ: Operative Trauma Management: An Atlas, 2nd ed. New York,

McGraw Hill, 2002, pp 110-114.

1174

STEP 1: SURGICAL ANATOMY

The following structures must be observed:

◆ Xiphoid process

◆ Fifth intercostal space

◆ Latissimus dorsi muscle

◆ Sternum

◆ Clavicles

◆ Pericardium

◆ Phrenic nerves

◆ Lungs

◆ Intercostal muscles

◆ Intercostal vessels

◆ Internal mammary vessel

CHAPTER

106

Thoracotomy for Trauma

William J. Mileski

CHAPTER 106 • Thoracotomy for Trauma 1175

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Patients with combined cardiac and pulmonary injuries or bilateral thoracic injuries may

require a bilateral anterior lateral thoracotomy, or “clamshell thoracotomy,” which provides

exposure of bilateral hemithoraces, the pulmonary hila, and the mediastinum.

◆ Emergent thoracotomy requiring extension from left anterior lateral thoracotomy to right

thoracotomy is infrequently needed but may be necessary when penetrating injuries

unexpectedly require exposure of both right and left hemithoraces. Median sternotomy

would be preferred for treating penetrating cardiac injuries.

◆ There is generally insufﬁ cient time for formal preparation. Rapid painting with povidone-

iodine (Betadine) is generally performed. The neck, entire thorax, abdomen, and upper

thighs should be included. The incision of the thigh may facilitate use of mechanical

cardiopulmonary support.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The incision begins at the junction of the xiphoid process and sternum and is extended

laterally in a curvilinear fashion to the anterior border of the latissimus dorsi

(Figure 106-1).

◆ The incision should be carried down to the intercostal muscles on the superior aspect of

the ﬁ fth or sixth rib, with care given not to cut through the intercostals into the underlying

pulmonary parenchyma (Figure 106-2).

FIGURE 106 –1

FIGURE 106 –2

1176 Section XVI • Operations—Elective and Trauma

2. DISSECTION

◆ The intercostal muscles and pleura are best taken down using a curved Mayo scissors,

partially opened, pressed on the superior aspect of the rib, and advanced lateral to medial.

At the medial aspect, the internal mammary vessels are often transected and require ligation

if resuscitation is successful.

◆ A rib spreader is inserted and retracted.

◆ The pericardium is inspected if indicated, and pericardiotomy is performed in a

longitudinal fashion, anterior to the phrenic nerve.

◆ In the absence of a source of hemorrhage in the left hemithorax or a cardiac injury and

suspected hemorrhage in the right hemithorax, the incision may be rapidly extended to the

right hemithorax in a mirrored fashion.

◆ The xiphisternal junction may be transected with an osteotome, Lebsche knife, or

sternal saw.

◆ Again, the internal mammary vessels are transected and ligated (Figure 106-3).

◆ The superior thoracic cage can then be retracted cephalad, exposing the anterior medias-

tinum and bilateral hemithoraces and the pulmonary hila (Figure 106-4).

3. CLOSING

◆ If resuscitation is successful and a treatable injury is identiﬁ ed and repaired, thoracic closure

should be rapidly accomplished.

◆ Bilateral 36F thoracostomy tubes are placed, the ribs are approximated with interrupted

#1 Vicryl suture, the subcutaneous tissue is reapproximated with absorbable suture, and

the skin is closed with staples.

STEP 4: POSTOPERATIVE CARE

◆ Pain control and respiratory therapy are critical to recovery.

STEP 5: PEARLS AND PITFALLS

◆ Care must be exercised to avoid damage to the phrenic nerve when pericardiotomy is

performed.