Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

C H A P T E R 105 • Subclavian Artery Stab 1169

Incision at second interspace

FIGURE 105–2

Clavicle

Subclavius muscle

Subclavian vein

Subclavian artery

B

A

FIGURE 105–3

C H A P T E R 105 • Subclavian Artery Stab 1171

C

Posterior periosteum

D

Vertebral artery

Thoracic duct

Internal jugular vein

Subclavian artery

Subclavian vein

E

FIGURE 105–4, cont’d

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Anterior scalene Phrenic muscle

nerve

Sternocleidomastoid muscle

Left subclavian artery

Left common carotid artery

Left jugular vein

Left subclavian vein

F

FIGURE 105–4, cont’d

C H A P T E R 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 fixation 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.

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

3. CLOSING

If resuscitation is successful and a treatable injury is identified 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.

C H A P T E R 106 • Thoracotomy for Trauma 1177

Sternum

Left lung

FIGURE 106–3

FIGURE 106–4

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SELECTED REFERENCES

1. Wright C: Transverse sternothoracotomy. Chest Surg Clin N Am 1996;6:149-156.

2. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons, Committee on Trauma: Practice management guidelines for emergency department thoracotomy. J Am Coll Surg 2001;193:303-309.

3. Baxter BT, Moore EE, Moore JB, et al: Emergency department thoracotomy following injury: Critical determinants for patient salvage. World J Surg 1988;12:671-675.

4. Biffl WL, Moore EE, Harken AH: Emergency department thoractomy. In Mattox KL, Feliciano DV, Moore EE (eds): Trauma, 4th ed. New York, McGraw-Hill, 2000, p 245.

5. Feliciano DV, Mattox KL: Indications, technique and pitfalls of emergency center thoracotomy. Surg Rounds 1981;4:32.