Thoracic Incision Options
A. The median sternotomy is the standard incision for anterior cardiac and thoracic outlet vascular injury, but is not an appropriate incision for approach to posterior mediastinal structures or the pulmonary hilum.
B. A median sternotomy with an anterior neck or supraclavicular extension is used for thoracic outlet great vessel injuries to Zone 1 of the neck.
C. The anterolateral incision, particularly on the left, is the utility emergency thoracotomy for trauma and resuscitation. It is made from the sternal edge, under the mammary fold, and in a curvilinear fashion toward the axilla, staying in close proximity to the fourth or fifth intercostal space. This incision should not be a straight line incision nor be carried through the female breast.
D. Bilateral anterolateral incisions may be either separate or combined and transternal. When transternal, the sternum is traversed with a Gigli saw or other cutting device, and the internal thoracic arteries are ligated on both sides on the upper and lower incision sites (four ligatures). Both incisions should be curvilinear, with the transternal cut high enough on the sternum to expose the mid-portion of the heart and also with sufficient sternum to accomplish a solid bony closure. On occasion, when a right-sided injury is suspected high in the pleural cavity, the incision might even be above the right nipple.
E. In the female, the anterolateral incision is at the inframammary fold and is accomplished by moving the breast tissue cranially.
F. With the patient in a lateral decubitus position, a posterolateral fourth or fifth interspace incision can be made from near the area of the nipple, laterally around to near the spinal canal. This incision for trauma traverses the latissimus dorsi muscle and portions of other chest muscles. The scapula must be retracted superiorly to achieve fourth or fifth interspace incisions. This incision provides exposure of posterior mediastinal structures, such as the aorta, lung hilum, esophagus, trachea, and azygos vein.