Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited

World J Surg. 2015 May;39(5):1306-11. doi: 10.1007/s00268-014-2924-1.


Background: The clamshell incision (CI) offers a better exposure than the left anterolateral thoracotomy (LAT) as a resuscitative thoracotomy. Most surgeons will have to manage a heart wound only once or twice in their career. The patient's survival depends on how fast the surgeon can control the heart wound; however, it is unclear which of the two incisions allows for faster control in the hands of inexperienced surgeons. The aim of this study was to compare the time needed to access and control a standardized stab wound to the right ventricle, by inexperienced surgical trainees, by LAT or CI; we hypothesized that the CI does not take longer than the LAT.

Methods: Sixteen residents were shown a video on how to perform both procedures. They were randomly assigned to control a standardized stab wound of the right ventricle on perfused human cadavers by LAT (n = 8) or CI (n = 8). Access time (skin to maximal exposure), control time (maximal exposure until control of the heart wound) and total time (the sum of access and control times) were recorded.

Results: Total time was 6.62 min [3.20-8.14] (median [interquartile range]) for LAT and 4.63 min [3.17-6.73] for CI (p = 0.46). Access time was 2.39 min [1.21-2.76] for LAT and 2.33 min [1.58-4.86] for CI (p = 0.34). Control time was 4.16 min [2.32-5.49] for LAT and 1.85 min [1.38-2.23] for CI (p = 0.018).

Conclusions: The time needed from skin incision until cardiac wound control via CI was not longer than via LAT and the easier control of the cardiac wound when using CI was confirmed.

Publication types

  • Comparative Study
  • Randomized Controlled Trial

MeSH terms

  • Cadaver
  • Emergencies
  • Heart Injuries / surgery*
  • Heart Ventricles / injuries
  • Humans
  • Internship and Residency
  • Resuscitation
  • Thoracotomy / methods*
  • Time Factors
  • Wounds, Stab / surgery*