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Loss oftheChest Wall
muscle tearing
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JohnC.Mayberry
45.1 Field Management ofChest Wall Loss
andOpen Pneumothorax
Signicant loss of the chest wall occurs in a variety of trauma
scenarios including high-velocity rie bullet penetrations,
close-range shotgun blasts, explosions with secondary projectiles, industrial mishaps, and impalements during a fall or
vehicular crash. Many patients with chest wall loss do not
survive more than a few minutes because of exsanguination
from within the thorax and/or associated injuries. This chapter outlines the recommended eld, emergency department,
and operating room procedures that will be effective in those
patients who are discovered alive. A damage control operative strategy with the goal of ultimate closure of the defect
with minimal risk of infection and with preservation of as
much of the chest wall’s mechanical integrity as possible
will be described. These injuries in their severest form are
rare, and therefore, no single surgeon has vast experience.
Surgeons are thus encouraged to tailor these recommendations to t the particular scenario.
Most patients with traumatic chest wall loss will be in
acute respiratory distress from the incompetent pulmonary
mechanics associated with the open pneumothorax. As the
patient attempts to breathe, air preferentially ows through
the defect into the pleural space, and the patient’s ability to
inspire air into their airway and expand their lungs is greatly
compromised. Lesser degrees of chest wall loss, e.g., an
open pneumothorax with a chest wall defect 5–10 cm in
diameter (Fig.45.1) may be tolerated for a short transport by
an otherwise healthy patient, but for most patients, qualied
providers in the eld should provide an airway and respiratory support. Chin lift, jaw thrust, oropharyngeal or nasopharyngeal airways, and bag-valve-mask ventilation are effective
temporizing measures until you can place an endotracheal
tube. If the defect is on the left chest wall and there appears
J. C. Mayberry (*)
Acute Care Surgery & Trauma, Saint Alphonsus Regional Medical
Center, Boise, ID, USA
e-mail: john.mayberry@sarmc.org; mayberry@slhs.org
45
Intercostal
Fig. 45.1 Chest wall defect 5–10cm in diameter with open pneumothorax, comminuted rib fractures, intercostal muscle tearing, and underlying pulmonary injury
to be a pulmonary laceration with air loss, attempt a blind
right mainstem bronchus intubation (deep intubation) in
order to exclude the severely injured lung from ventilation.
This maneuver will not only prevent unnecessary air loss
from the injured parenchyma and tracheobronchial tree but
may also prevent venous air embolism. If endotracheal intubation is not successful, a multi-lumen esophageal airway
and laryngeal mask airway are less desirable alternatives.
After airway management, examine the edges of the chest
wall defect for signicant bleeding. Many experienced rst
responders are capable of clamping an arterial or venous
bleeder in the chest wall, assuming they have an appropriately sized clamp. It does not make sense to embark on a
signicant transport to a higher level of care while an easily
accessible vessel continues to hemorrhage. The chest wall
contains numerous named arteries and veins, e.g., the intercostal arteries and veins as well as the muscular branches of
the subclavian and axillary vessels, any of which can exsan-
Comminuted
rib fracture
Left lung
blast injury
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_45
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J. C. Mayberry
guinate the patient. Any continuous bleeding during transport can lead to a coagulopathy that will be difcult to reverse
even once the patient arrives at a hospital. Only the most
obvious sites of hemorrhage should be clamped and not
more than 3min should be spent under austere conditions.
First responders would not be expected, however, to try to
clamp a pulmonary laceration within the thorax or attempt to
control a source of mediastinal hemorrhage. In the case of
severe pulmonary or mediastinal bleeding, however, following airway control, the hemithorax should be tightly packed
with gauze in the hope of at least slowing the hemorrhage.
You should cover the defect itself with a sterile or clean
dressing, e.g., dry gauze, petrolatum gauze, or plastic wrap,
and secure it on three sides only so that the accumulating pleural air, e.g., from a pulmonary or tracheobronchial laceration,
can escape from the pleural space. This measure will prevent
the development of a tension pneumothorax and will also prevent further contamination of the wound from the outside.
Because these patients have a high risk of deterioration
and will likely require immediate surgery, transport to a designated trauma center should not be further delayed. During
transport, a hypotensive strategy of resuscitation should be
employed to minimize blood loss, dilutional coagulopathy,
and pulmonary edema.
45.2 Emergency Department Management
For a patient with a larger and more destructive chest wall
injury, the emergency department (ED) should be bypassed
for direct transport to the operating room (OR). If an OR is
not ready, ED management should be limited to life-saving
procedures that cannot wait until an OR is available. For
example, you can address exsanguinating hemorrhage from
the edges of the defect, within the pulmonary parenchyma,
or in the mediastinum. Hilar clamping and the pulmonary
hilar twist are effective means of temporarily controlling pulmonary hemorrhage. Time spent in the ED can also be used
to obtain a blood specimen for type and cross, to ensure adequate venous access, to obtain a chest radiograph, and to
begin a blood product transfusion.
If the chest wall defect is smaller and hemorrhage is controlled, you can start a search for associated injuries in the ED
prior to operative repair. In cases where the chest wall defect
resulted from an explosion or a severe blunt mechanism,
extrathoracic injuries may take precedence in the treatment
plan. Head, neck, and torso CT scans may be indicated.
to the patient prophylactic intravenous antibiotic coverage for
Gram-positive organisms. The rst operation consists of
wound cleansing and debridement of devascularized skin,
subcutaneous fat, muscle, and bone. If the defect involves
only the intercostal muscle between two ribs and wound contamination is nil or very minimal, debride the defect and close
it in a single operation. The intercostal muscle defect is closed
by approximating the two ribs together with an absorbable
suture, taking care not to entrap the intercostal nerve. The best
way to approximate the ribs without nerve entrapment is to
drill four holes in each rib and cerclage the two ribs together
with gure-of-eight ties. Then close the skin over a bulb suction drain.
If the defect involves comminuted rib fractures, tissue
loss, and contamination, then at least two operations are necessary. Excise the portions of the rib that are partially devoid
of muscular attachments because the de-vascularized bone
will not survive and will later become a nidus for osteomyelitis. If contamination is nil or minimal, a biologic tissue
patch derived from the human or porcine dermis can be
sutured circumferentially to the defect in the rst operation
(Fig. 45.2). Such tissue patches provide protection to the
underlying lung, effectively bridging the defect with a rm
yet exible platform, and are less prone to infection than a
nonbiologic prostheses. If along one of the edges of the
defect, a rib fracture or even a comminuted rib fracture with
a small tissue gap is present, afx an absorbable, polylactide
fracture repair plate to the rib to provide a stronger edge to
which to anchor the patch (Fig.45.2 inset).
Biologic
tissue patch
45.3 Operative Management
You can safely and effectively manage the smaller defect of
5–10cm in diameter (Fig.45.1) with minimal contamination
of dirt and debris in one to three serial operations: Administer
Fig. 45.2 A biologic tissue patch derived from human or porcine dermis is sutured circumferentially to the defect. If a comminuted rib fracture is present, an absorbable plate is afxed to the rib to provide a
stronger edge to which to anchor the patch (inset). Partially devascularized bone should be excised
Pleural
45 Loss oftheChest Wall
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drainage tube
Pleural
drainage
tube
377
Fig. 45.4 Large chest wall defect, >10–15cm in diameter, with underlying pulmonary laceration
Closed suction drain
Fig. 45.3 A vacuum suction dressing is placed over the biologic patch
Place an anterior 32 or 36 French chest tube, either
straight or right-angled, to underwater seal/wall suction to
drain air and uid that will accumulate. Dress the wound
with a vacuum suction dressing over the biologic patch
(Fig.45.3) for at least 2 and as long as 3days. The patient
can be extubated postoperatively depending on the extent of
the pulmonary injury and any associated injuries. The
vacuum dressing can be expected to provide an adequate
degree of chest wall stability for this smaller-sized defect.
At the second operation, examine the wound for persistent contamination or dead tissue that must be debrided. The
surgeon decides whether an additional 2–3days of vacuum
dressing is necessary or whether the wound can be closed by
undermining skin and subcutaneous tissues and closing over
a bulb suction drain.
The larger chest wall defect, >10–15cm in diameter, is
considerably more challenging to repair (Fig. 45.4).
Depending on the mechanism of injury, it is much more
likely that a signicant pulmonary injury will be present,
such as a large laceration, contusion, or intraparenchymal
hematoma. You will have to manage this pulmonary injury
simultaneously. Nonanatomic surgical resection may be necessary to control bleeding and air leaks (Fig.45.5). As in the
smaller defect, you should commence immediately with
wound cleansing and debridement of devascularized skin,
subcutaneous fat, muscle, and bone. The defect resulting will
Fig. 45.5 Nonanatomic pulmonary resection with stapling device
seem formidable, but you can set up a good outcome by following the basic principles of debridement and damage control. In cases of a thoracoabdominal defect, the transposition
of the diaphragm to convert the thoracic defect to an abdominal defect should be considered.
At the conclusion of the rst operation, place a 32–36
French chest tube through an anterior stab incision into the
pleural space and tuck a plastic sheet under the chest wall
defect in the same fashion as described for an open abdominal defect (Fig. 45.6). Pack the wound with moist gauze
(Fig.45.6 inset) and apply a vacuum suction dressing. In this
case, do not extubate the patient postoperatively since the
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Latissimus
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J. C. Mayberry
dorsi muscle
Tucking plastic
sheet into
pleural space
Fig. 45.6 A plastic sheet is tucked under the chest wall defect. The
wound is then packed with moist gauze (inset) and a vacuum suction
dressing is applied
extent of chest wall loss will preclude effective, non-assisted
pulmonary mechanics.
Depending on associated injuries, you should take back
the patient to the OR at 2–3day intervals for debridements
and surgical management of the underlying pulmonary
injury as necessary. When the wound is clean and the
pulmonary injury stable, a large biological tissue patch is
sutured to the chest wall with absorbable suture in a similar
fashion to the smaller defect shown in Fig.45.2. The wound
is again dressed with a vacuum dressing and attempts are
made to wean the patient from the ventilator. A tracheostomy may be indicated for ventilator weaning if, after
5–7 days, the weaning progress has stalled. When the
patient’s pulmonary status is substantially improved and
the wound is stable (7–14days), a latissimus dorsi vascularized muscle ap is used to ll the defect and cover the
biologic patch (Fig.45.7). A bulb suction drain should be
placed between the biologic patch and the muscle ap to
prevent seroma formation and allow the muscle to adhere to
the patch. A split-thickness skin graft will be necessary to
cover the external surface of the muscle ap since the
patient’s own chest wall skin will have been debrided very
signicantly (Fig.45.7 inset).
Removal of drains should follow standard surgical principles of ≤200cc uid per day and no air leak for tube thoracostomies and ≤30cc uid per day for bulb suction drains.
You should tailor the antibiotic management to the amount
and type of contamination, but in general, 48 h of Grampositive coverage should be sufcient.
Fig. 45.7 A latissimus dorsi vascularized muscle ap is used to ll the
defect and cover the biologic patch. A split-thickness skin graft is used
to cover the external surface of the muscle ap (inset)
45.4 Recovery andRehabilitation
Patients with smaller defects repaired may have little functional loss of their pulmonary mechanics and should recover
completely. They will always, however, be at risk for pulmonary hernia development over months to years that may need
elective repair. Larger defects will require longer intensive
care unit and hospital stays and more days on the ventilator.
These patients will be at higher risk for pulmonary hernia
development. Chest wall replacement with more rigid prostheses should wait, however, for several months until the risk
of prosthetic infection returns to that expected for a clean,
noncontaminated, nontraumatic operation. If a tracheostomy
is required, it can be downsized and eventually removed
when the patient can tolerate tracheostomy plugging for
1–2days without respiratory decompensation.
Important Points
• Most chest wall loss patients will need immediate airway
and ventilator control. If the defect is on the left chest wall
and there is a pulmonary laceration, blind right mainstem
bronchus (deep) endotracheal intubation should be
attempted.
• Patients with lesser-sized chest wall defects, e.g., <5 or
10cm diameter, who are otherwise stable and cooperative, can be supported with intermittent bag-valve-mask
ventilation during transport.
45 Loss oftheChest Wall
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379
• If able, the rst responder is advised to briey try to clamp
intercostal arterial or venous bleeding or other chest wall
muscular vessel bleeding from which the patient may
exsanguinate during transport.
• Signicant pulmonary or mediastinal bleeding can be
tightly packed with gauze and an occlusive dressing in the
hope of slowing the hemorrhage during transport.
• In the eld, the defect is covered with a dressing and
secured on three sides only so that the accumulating pleural air can escape. This will prevent the development of a
tension pneumothorax and will also prevent further contamination of the wound from the outside.
• For a patient with a large, destructive chest wall injury,
the emergency department (ED) should be bypassed for
direct transport to the operating room (OR).
• A destructive chest wall defect will seem formidable, but
the surgeon can set up a good outcome by following the
basic principles of debridement, damage control, and
stage operations.
• Portions of the rib that are partially devoid of muscular
attachments should be excised because the de- vascularized
bone will not survive and will later become a nidus for
osteomyelitis.
• Biologic mesh should be used to bridge the defect because
of the lesser risk of prosthetic infection compared to standard prosthetic mesh. For a larger defect, a vascularized
muscle ap will be necessary to ll the defect.
Suggested Reading
Lucas CE. Torso challenges for the acute care surgeon: techni-
cal solutions for large torso defects. J Trauma Acute Care Surg.
2013;74:17–25.
Mayberry JC, Terhes JT, Ellis TJ, Wanek S, Mullins RJ.Absorbable
plates for rib fracture repair: preliminary experience. J Trauma.
2003;55:835–9.
Schreiber MA, Meier EN, Tisherman SA, etal. A controlled resusci-
tation strategy is feasible and safe in hypotensive trauma patients:
results of a prospective randomized pilot trial. J Trauma Acute Care
Surg. 2015;78:687–97.
Seder CW, Allen MS, Nichols FC, etal. Primary and prosthetic repair
of acquired chest wall hernias: a 20-year experience. Ann Thorac
Surg. 2014;98:484–9.
Part IV
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Surgical Strategies in Penetrating Trauma to the
Abdomen and Pelvis
Access totheAbdomen: Emergency
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Laparotomy
GeorgeC.Velmahos
46
The emergency laparotomy includes tasks and strategies that
are drastically different than the elective laparotomy. The
surgeon is constantly ghting an unforgiving foe: time. A
moderately longer operation has little effect on the outcome
of a patient who is physiologically stable and not losing
blood. On the other hand, every intraoperative minute counts
on patients in metabolic disarray and hemodynamic collapse.
Therefore, the entire philosophy of emergency abdominal
access is dominated by the focus on minimizing time, while
not compromising adequate exposure and technique.
Standardization of tasks will prevent missed injuries, wrong
procedures, or retained sponges, all of which are associated
with emergency operations.
46.1 Position andPreparation
Always place the patient supine on the operating table. There
is really no other choice. Left and right lateral positions may
offer better access to specic retroperitoneal structures under
elective circumstances, but do not allow adequate exploration of the entire abdomen and are time-consuming for opening and closing. If there is a suspicion that a thoracotomy
may be used (as it may happen with a thoracoabdominal penetrating injury), then a pillow under the patient’s relevant
hemithorax will offer enough area for an adequate anterolateral thoracotomy. Under emergency conditions, a posterolateral thoracotomy is not advisable.
Prep the patient from neck to mid-thighs. One never
knows what cavity should eventually require access. A variety of injuries, for example, require access to multiple areas:
a thoracoabdominal injury producing signicant injuries
across the diaphragm; a retrohepatic inferior vena cava
G. C. Velmahos (*)
Massachusetts General Hospital, Harvard University Medical
School, Boston, USA
e-mail: gvelmahos@partners.org;
GVELMAHOS@mgh.harvard.edu
injury, requiring total liver isolation and clamping of the
intrapericardial cava through a sternotomy; a thoracic or
abdominal vascular injury, requiring a saphenous vein graft
for the groin; etc.
Similarly, the drapes should be placed in such a way that
will allow access to multiple areas. A narrow surgical eld is
the wrong principle for an emergency operation.
46.2 Incision
It is commonly suggested that the only proper way to explore
the abdomen is a long midline incision from the xiphoid to
the pubic symphysis. This certainly stands true for many
cases. Nothing can be more frustrating for the surgeon and
unsafe for the patient than trying to nd and repair injuries
through inadequate exposure. On the other hand, the length
of the incision correlates with postoperative pain and complications. Therefore, not every incision needs to stretch
from top to bottom. I see little reason to extend an upper
midline incision far beyond the umbilicus in a thoracoabdominal wound with a clear high upper abdominal trajectory.
Similarly, there is little justication for doubling the length
of a lower midline incision made for a bladder rupture by
extending it over the umbilicus. Having said that, you should
have a very low threshold of extending an incision; if the
exposure is inadequate, a satisfactory exploration cannot be
achieved or the repair is compromised.
There is hardly any other incision for entering the abdomen than a midline laparotomy for a traumatic emergency.
Infrequently, there are reports of using subcostal incisions to
access the liver or spleen for a subacute traumatic condition,
as it would be with splenic necrosis and abscess following
embolization for trauma. This is acceptable although the
benets of the midline laparotomy are hard to match. In true
emergency situations, enter the abdominal cavity in the following steps:
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_46
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1. Incise the skin and subcutaneous tissue with the scalpel.
Ignore the bleeding. Typically, if you place a gauze at the
edges of the incision to retract the skin laterally, most of
the bleeding will have stopped by the end of the incision.
There is no reason to create a large thermal wound by
electrocoagulating every possible small vessel (Fig.46.1).
2. Incise the linea alba with the scalpel. Remember that the
linea alba is narrow close to the xiphoid and wide close to
the umbilicus. Incise it rst in the immediate supraumbilical area. With incremental cuts of your knife, extend
the linea alba incision upward. Do not yet cut through the
preperitoneal fat and peritoneum that lies under the linea
alba (Fig.46.2).
3. Grasp the left side of the fascia with a Kocher clamp midway between the xiphoid process and the umbilicus, and
with a gauze bluntly dissect the preperitoneal fat away
from the overlying fascia moving laterally. You will realize that the thick fatty tissue lying under the midline transitions to a thin and almost transparent peritoneal layer
lying under the fascia laterally to the midline. You can
usually enter the peritoneal cavity bluntly by pushing
your digit through this thin peritoneal layer (Fig.46.3).
4. Under direct vision, incise the peritoneum up and down.
5. Insert your hand to protect the bowel, and with electrocoagulation, extend the incision below the umbilicus. As
G. C. Velmahos
Fig. 46.2 Incising the linea alba with incremental cuts upward
Fig. 46.1 Skin and
subcutaneous tissue incision
with the scalpel, while
counter traction is applied on
the two edges of the wound
46 Access totheAbdomen: Emergency Laparotomy
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Fig. 46.3 Peritoneum
laterally to the midline
becomes thin and can easily
be violated by pushing a digit
through it
385
opposed to the supraumbilical midline, on which the fascia fuses in the relatively avascular linea alba below the
midline, there is no linea alba and electrocoagulation will
help in minimizing the bleeding from the muscle
(Fig.46.4).
6. It is now time to check for any major bleeding from the
walls of the incision. Usually, there is none, but if any, use
electrocoagulation to control it.
If the operation is not a true emergency, more time can be
spent to open the abdomen along with elective operation
principles. In general, I dislike the attempts to control every
small and temporarily bleeding subcutaneous vessel with
electrocoagulation, as this causes an extensive thermal burn.
If you place a gauze while retracting the edges of the wound
laterally, the bleeding stops. At the end of the incision, you
can electrocoagulate only the few remaining sites that continue to bleed.
Fig. 46.4 With one hand in the abdomen, protecting the viscera, incise
the muscle under the umbilicus with electrocoagulation
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G. C. Velmahos
46.3 Bleeding andContamination Control
The standard teaching is to pack the four quadrants as soon
as you enter in the peritoneal cavity. I believe that blind
packing is ineffective and unnecessary. Suction the blood
that is in the abdomen and localize its source. Then, pack this
area meaningfully to achieve temporary control. It makes
little sense to pack the entire abdomen if the bleeding comes
from the spleen!
Once you have packed, and with the bleeding controlled,
make sure there is no other bleeding site. Often, there is more
than one. You do not want to pack only the spleen when an
insidious mesenteric tear continues to shed blood in the pelvis and fail to discover it before a substantial amount of
blood is lost.
Your focus now should shift to the control of contamination. Have a quick look to check for perforations of any hollow viscus. If there is any, control it by placing a Babcock
clamp or a quick occluding suture.
With the bleeding and contamination temporarily controlled, it is time to return to the bleeding site. Unpack carefully and check the extent of the injury. If there is something
that can easily be repaired or ligated, then do so. Otherwise,
repack, as your next step is to explore the entire abdomen.
46.4 Systematic Exploration
The exploration of the abdominal cavity should be performed
systematically, following a routine that avoids missing injuries. I always start from the left upper quadrant and visualize
the stomach, spleen, left diaphragm, and left lobe of the liver.
Then, I move to the right upper quadrant, retracting the liver
and visualizing its superior and inferior surfaces, the right
diaphragm, the duodenum, and the hepatic hilum.
At this point, the assistant holds up the transverse mesocolon and the surgeon pulls all the small bowel toward the
right side. This exposes the ligament of Treitz, and the exploration of the small bowel begins by “running” it segment by
segment while ipping it over every time to inspect the anterior and posterior surfaces of it up to the ileocolic area. Then,
the colon is inspected in detail all the way to the rectum and
the peritoneal reection. The pelvis is checked for retroperitoneal hematomas.
I do not routinely open the mesocolic ligament to inspect
the pancreas and posterior surface of the stomach unless if
there is a specic indication.
Missed injuries occur if the above routine changes or if
the described maneuvers are not performed diligently. I list
below areas that I have frequently seen to be inadequately
explored, resulting in missed injuries:
(a) The diaphragms: The stomach, colon, and spleen on the
left side and the liver on the right side must be manually
pushed downward in order to reveal the diaphragms.
Injuries can easily be missed, particularly in the posterior portions of the diaphragms, if this is not done.
(b) The colon (particularly, the transverse colon): A small
perforation can be missed in an obese person with a
large amount of fat tissue around the colon. In particular,
omental attachments or the gastrocolic ligament may
conceal a hole. Small hematomas close to the colon wall
should be carefully explored. The gastrocolic ligament
should be divided if necessary to look at the posterior
side of the transverse colon. Upon appropriate indications, the peritoneal attachments should be incised to
check the retroperitoneal colon. In penetrating injuries,
the rule is that there should be an even number of holes
in the lumen of a hollow viscus. If the number is odd,
search hard for the missing through-and-through
perforation.
(c) The posterior side of the stomach: The rule of even holes
applies here too. If there is a perforation of the anterior
wall of the stomach, open the gastrocolic ligament to
inspect the posterior wall.
(d) The retroperitoneum: Although the retroperitoneal struc-
tures do not routinely require direct inspection, you
should inspect the retroperitoneal areas and explore
them as needed. As a general rule, retroperitoneal hematomas after blunt trauma should be explored if they lie
centrally and left alone if in the pelvis or the lateral
aspects. Retroperitoneal hematomas after penetrating
trauma should be explored, unless there is a very high
degree of condence that no signicant injury is present.
There are exceptions to both rules. A blunt pelvic retroperitoneal hematoma could be explored for a known
transaction of a major vessel. On the other hand, a blunt
retrohepatic hematoma that is stable may be best left
undisturbed. Similarly, a penetrating injury to the lateral
edge of the kidney that causes a lateral hematoma may
be safely observed without exploration.
46.5 Closure
Close the midline laparotomy in a single layer. I routinely
use a single, long, running monolament suture, starting
from the lower end and nishing at the upper end. Having the
left lobe of the liver under the incision when I am placing my
last few sutures with limited visualization is much safer than
having loops of the bowel. For this, I always end my fascial
suturing at the upper side. I never use subcutaneous sutures
and close the skin routinely with staples.
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