Historical Observations on Clamshell Thoracotomy

Abstract

Bilateral transverse thoracosternotomy, known colloquially as “clamshell thoracotomy,” provides quick and extensive exposure to the thoracic organs. The origins of the radical incision are unclear, and its influence on historical developments in surgery has not been elaborated. Transsternal extension to bilateral thoracotomy likely occurred during World War I and was designated as Tuffier's method by 1922. Théodore Tuffier had already solidified his reputation as a trailblazing thoracic surgeon in Paris when the French army summoned him to design triage systems for trauma patients during the Great War. Following World War II, cardiac surgery grew tremendously during the 1950s, and many pioneering open‐heart procedures utilized the bilateral incision for safe exposures with satisfactory results. Median sternotomy became the incision of choice for open‐heart surgery by the early 1960s; however, thoracotomy remained important to the trauma surgeon's repertoire. Transsternal conversion was only briefly mentioned in trauma literature through the 1980s, although up to one‐half of reported emergency thoracotomies at busy trauma centers were clamshells. The moniker clamshell thoracotomy came in 1994 when thoracic surgical oncology and lung transplantation flourished with complex operations requiring larger incisions. The twenty‐first century has brought two iterations of evidence‐based guidelines for emergency thoracotomy, but incision choice has not been formally discussed. Renewed conversation in recent years has advocated for the clamshell as arguably the best approach for patients in extremis. Given these trends, the tortuous history of this controversial incision deserves attention.

A Comparative Study of a Sternum-Sparing Procedure and Clamshell Incision in Bilateral Lung Transplantation

“…However, it is difficult to reduce the occurrence of sternal dehiscence due to osteomalacia following a long preoperative treatment period, use of high doses of immunosuppressive drugs, and extensive surgical trauma accompanied by ligation of the bilateral mammary artery. 1 2 3 …”

“…Although various wiring and transverse sternotomy methods have been used to reduce the incidence of these complications, most of them are complicated and need to be more clearly advantageous, compared to conventional techniques. 1 2 3 …”

Application of the Clamshell Thoracotomy in an Infant with a Large Mediastinal Tumor

“…It was during the First World War that the French surgeon Théodore Tuffier modified the traditional bilateral thoracotomy by adding a transsternal extension in the fourth intercostal space (ICS). [ 1 ] Popularly known as the “trapdoor” or clamshell thoracotomy, it is reportedly the most radical approach in thoracic surgery. Allowing simultaneous exposure of the mediastinum and both pleural spaces, structures uniquely accessible with the clamshell incision include the thoracic aorta, posterior heart, pulmonary circulation, both atria, mainstem bronchi, diaphragmatic crura, and the azygos vein.…”

Letter to the Editor. Historical Observations on Clamshell Thoracotomy

“…With great interest, we read the article by Ehrhardt et al [1] and congratulate them for the quality of the profound review carried out on the historical evolution of clamshell thoracotomy, which will undoubtedly be widely consulted by cardiothoracic surgeons who love the history of this beautiful specialty.…”