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Displays how the incision was extended by a right anterolateral thoracotomy, performed through the third intercostal space.
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Figure 1: Displays how the incision was extended by a right anterolateral thoracotomy, performed through the third intercostal space.

Mentions: On surgery, due to clinical impression of injury to the distal subclavian artery, a right supraclavicular incision was performed first. Following incision of the platysma and division of the right sternocleidomastoid muscle, significant hemorrhage appeared in the surgical field that was temporally controlled by direct digit pressure application. Recognizing this to be hemorrhage possibly arising from major vessels in Zone I of the neck, a full mid sternotomy was performed to allow proper exposure and vascular control. However, even following sternotomy, the athletic habitus of the patient did not allow delineation and approach to the major sources of bleeding. The incision was extended by a right anterolateral thoracotomy (Fig 1), performed through the third intercostal space. This right-sided "trapdoor incision" allowed adequate exposure and proximal control of the mediastinal vessels. Tears of both the right common carotid artery and the right innominate artery were found at their confluence. The right jugular vein was injured as well. Repair of the arterial injury was achieved by placing a graft patch modified from a collagen coated knitted polyester vascular prosthesis (Silver Graft, Datascope, Montvale, USA). The vein was repaired by primary suture of the tear. At this stage of operation the patient was hypothermic (34┬░Celsius) and there was clinical evidence of coagulopathy. We decided not to continue with the exploration of the distal subclavian artery. The operation was promptly terminated by packing the neck and upper mediastinum, followed by temporary closure of the wounds. Overall, the operation lasted 2 hours and 47 minutes.

Right-sided "trapdoor" incision provides necessary exposure of complex cervicothoracic vascular injury: a case report

Kessel B, Ashkenazi I, Portnoy I, Hebron D, Eilam D, Alfici R - Scand J Trauma Resusc Emerg Med (2009)

Bottom Line: Combined cervicothoracical vascular traumas are very uncommon, mostly resulting from penetrating injuries.These injuries are accompanied with very high morbidity and mortality rates.Incorporation of such incision in the surgical arsenal may be very effective in selective cases.

Affiliation: Hillel Yaffe Medical Center, Hadera, Israel. blko2@yahoo.com

ABSTRACT
Combined cervicothoracical vascular traumas are very uncommon, mostly resulting from penetrating injuries. These injuries are accompanied with very high morbidity and mortality rates. In this manuscript we present a case of hemodinamycally unstable trauma patient whose major injury was penetrating trauma of both cervical and mediastinal major vessels. The standard surgical approach of median sternotomy and neck incision was insufficient, and the patient's instability forced the authors to improvise previously not described right-sided trap-door thoracomy. Incorporation of such incision in the surgical arsenal may be very effective in selective cases.

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