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Bilateral Clamshell or Left Anterolateral Thoracotomy?

April 16, 2021

Written by Clay Smith

Spoon Feed
The modified bilateral anterior clamshell thoracotomy (MCT) technique was as fast (faster for some) as the left anterolateral thoracotomy (LAT), resulted in fewer iatrogenic injuries, and was favored by emergency physicians.

Why does this matter?
Performing a resuscitative thoracotomy is one of the most dramatic procedures in EM. Usually it means a LAT – a slash down the left thorax, spreading the ribs, and gaining access to the heart by opening the pericardium, +/- cross clamping the aorta. An easier approach might be the MCT.

Trauma surgery for non-trauma surgeons
This was a randomized trial of 16 emergency physicians (about half senior residents, half attending) in the cadaver lab. They were trained in LAT and MCT and then randomized to perform one technique first, followed by the other, and timed on delivery of the heart from the pericardium plus 100% cross clamping of the thoracic aorta. There was no statistical difference in success: 67% MCT vs 40% LAT, difference -27% (95%CI -61% to 8%). The subset of emergency medicine staff (i.e. attending physicians) had significantly higher success with MCT vs LAT. 100% of the LAT trials resulted in some form of iatrogenic injury vs 67% of the MCT trials. Physicians overwhelmingly preferred MCT over LAT 87% vs 13%, difference 74% (95%CI 23-97%).

Prospective Randomized Trial of Standard Left Anterolateral Thoracotomy Versus Modified Bilateral Clamshell Thoracotomy Performed by Emergency Physicians. Ann Emerg Med. 2021 Mar;77(3):317-326. doi: 10.1016/j.annemergmed.2020.05.042. Epub 2020 Aug 15.

Another Spoonful
First, you must watch EMCrit’s Crack to Cure video. Next, the Thoracotomy Masterclass. Also, if you want to see how great Essentials of EM is, check out this video on performing a LAT!

What are your thoughts?