The Clamshell Incision

Talking about the clamshell incision in thoracic, cardiac and vascular surgery. Also, soliciting surgical photographs.

The Clamshell Incision

The clamshell incision, also known as a transverse sternotomy, is one of my favorite surgical incisions utilized in thoracic surgery.  As surgical procedures become more and more minimally invasive with the use of robotics, and thoracoscopy, we sometimes forget the beauty of the clamshell incision for large-scale thoracic surgeries.

As a frequent observer in the operating rooms of a variety of surgeons employing an array of surgical techniques and operative philosophies, I have a greater opportunity than most to consider the distinct advantages and disadvantages of this surgical approach.

The clamshell incision is shaped like a curved ‘W”, and is typically performed in the anatomic skin / rib groove below the breasts.  The surgeon then dissects through the tissue, and intercostal muscles to enter the pleural space bilaterally.   It allows greater access than the traditional sternotomy, and has become more popular for bilateral lung transplantation (Durrleman & Massard, 2006).  This technique has also been used to salvage lungs in donors that would have otherwise gone unused due to previous sternotomies (Zuin, Marulli, Loy & Rea, 2008).

This incision gives the surgeon easy access to the heart and both lungs, and the great vessels and is sometimes used by cardiovascular surgeons for repair of the thoracic aorta and aortic arch. (Doss et al. 2003).

example of surgical exposure with hemi-clamshell incision

Somewhat ironically, one of the things I like best about this very large surgical incision is the cosmetic results after a successful surgery. Due to the location of anatomical skin folds beneath the breasts, particularly in females – the incision is minimized, and more cosmetically pleasing that standard sternotomy incisions.  (There is a nice photo of a healed clamshell incision at this neighboring blog.)

This disadvantages of this incision are obvious; as a large chest incision; longer hospital stays, infection/ poor wound healing, and increased pain but when compared to a similar incision such as a sternotomy, the clamshell may prove superior.

* If you have any medical photographs showing clamshell incisions that you would like featured at cirugia de, please contact me.


Doss M, Woehleke T, Wood JP, Martens S, Greinecker GW, Moritz A.  (2003).  The clamshell approach for the treatment of extensive thoracic aortic disease.  J Thorac Cardiovasc Surg. 2003 Sep;126(3):814-7.

Doss, M., Woehlecke, T., Wood, J. P., Martens, S., Greinecker, G. W. & Moritz, A. (2003).  The clamshell approach for the treatment of extensive thoracic aortic disease.  Journal of Thoracic & Cardiovascular Surgery, 2003 Sept., 123(3); 814 -817.

Durrleman, N. & Massard, G. (2006).  Clamshell and hemi-clamshell incisionsMulti-media manual of cardio-thoracic surgery, 2006, Issue 0810.  Full-text article with discussion of incisions, and intra-operative photos.

Wise, D., Davies, G., Coats, T., Lockey, D., Hyde, J. & Good, A.  (2005).  Emergency thoracotomy: How to do itEmergency Medical Journal, 2005;22:22-24. Full-text article with photos showing planned incision and exposure created by the clamshell incision.

Mediastinitis: a potentially lethal infection

Exploring the causes of mediastinitis in non-cardiac surgery patients with review of recent cases in the literature.

Mediastinitis is a serious, and potentially life-threatening infection of the mid-chest area (or mediastinum.) While it most commonly occurs after cardiac surgery* (and is a dreaded complication of), it can also occur after large thoracic procedures or blunt trauma. 

Sternotomy incisions, along with clamshell/ hemi-clamshell incisions may be utilized for large anterior mediastinal tumor resections, which places patients at the same risk of mediastinitis as traditional cardiac surgery procedures.

Blunt trauma can include injuries such as an esophageal tear that allows bacterial/ food/ fluids to seep from the torn esophagus into the chest.   In rare cases, it can occur due to the spread of an infection affecting the head /neck.  Recently, there have been several case reports of mediastinitis resulting from necrotizing fascitis which is particularly devastating, with cases originating as dental infections.

If untreated, mediastinitis can rapidly progress to sepsis (a systemic bloodstream infection causing numerous serious sequelae) and death.  Mortality related to the development of mediastinitis ranges from 21 – 60% (depending on sources).

Additional Risk Factors for the development of mediastinitis

Any condition that delays or impedes healing can promote the development of mediastinitis – particularly in post-surgical patients.  This includes diabetes, patients taking immunosuppressive therapies (such as Rheumatoid arthritis treatments, COPD and other patients on prednisone (and other steroids), transplant recipients and cancer patients receiving chemotherapy.)  This is why care of sternotomy or large chest incisions should be taken very seriously. 

Prevention of mediastinitis in patients with sternotomy incisions:  (s/p thymectomies, mediastinal mass resections etc.)

Patients should be sure to follow all lifting or movement restrictions (sternotomy precautions) and report any drainage from their incisions.  Patients should also contact their surgeons if they develop any wound dehiscence (wound edges come apart) or development fluctuance or swelling around the surgical site.  Fever following discharge from the hospital should be reported to the surgical service, particularly if it accompanies any signs of wound breakdown.

Patients with diabetes or elevated serum blood glucose need to be aggressive in the treatment of hyperglycemia.  Even patients who were previously well controlled on oral agents may require basal or correction insulins post-operatively to prevent elevated glucose, and increased risk of infection. 

Large breasted female patients, or obese males should wear a support bra to keep gravity from pulling breast tissue apart, and placing stress on the healing incision.  This is one of the most common reasons for poor wound healing of sternotomies.  (This will also significantly reduce post-operative pain.)

Post-thoracic surgery patients receiving radiation early in the course of their surgical recovery are also at risk, even from smaller procedures such as mediastinoscopies and Chamberlain procedures.  Aggressive surveillence and regular inspection of all wounds may help detect early signs of superficial infection/ wound breakdown to prevent the development of more serious complications.

Do not apply creams, lotions or ointments to incisions without speaking to your surgeon.  Avoid overly harsh anti-bacterial soaps and scrubs.  These products may actually damage the delicate tissues and promote infection.

Diagnosis may require CT scans of the chest to detect the development of a fluid collection within the chest.

Treatment of Acute Mediastinitis

Early treatment and surgical debridement of infected material (dead tissue, pus, etc) are essential for optimal results.  Intravenous antibiotics are a crucial part of this treatment to help prevent / and treat possible sepsis.  In patients presenting with more advanced infection – fluid resuscitation and treatment of underlying sepsis and sepsis related complications (organ failure) may be required along with other supportive measures.  Urgent evacuation of mediastinal space should remain a priority, even in the critically ill and unstable patient to prevent further spread of infection, particularly if necrotizing organisms are suspected.

* Sternotomy or the surgical division of the sternum was actually first adopted by a thoracic surgeon to access the anterior chest and mediastinum almost fifty years prior to its use in cardiac surgery.  Sternotomy remains one the primary ways (along with clamshell and hemi-clamshell incisions) that surgeons can access the anterior mediastinum for large tumor resections.

Additional References and Information about Mediastinitis

New York Times article on mediastinitis

Banazadeh M.  (2011).  Successful management of acute necrotizing mediastinitis with trans-cervical drainage.  Ann Thorac Cardiovasc Surg. 2011 Oct 25;17(5):498-500. Epub  2011 Jul 13. 

Dajer-Fadel, et al (2012).  Thoracic necrotizing fasciitis due to snake ointment that progressed to a mediastinitis. Interact Cardiovasc Thorac Surg. 2012 Jan;14(1):94-5. Epub  2011 Nov 18.  Story of fatal case of mediastinitis in Mexico City, Mexico.  Please note: photos are fairly graphic.

Kim, et. al. (2011).  Application of radiographic images in diagnosis and treatment of deep neck infections with necrotizing fasciitis: a case report.  Imaging Sci Dent. 2011 Dec;41(4):189-93. Epub  2011 Dec 19.  Discussion of case of serious, necrotizing infection originating from a dental infection- with CT images showing close proximity of infection to thoracic cavity. [Patient in case report did not develop mediastinitis.]

Mahmodlou (2011).  Aggressive surgical treatment in late-diagnosed esophageal perforation: a report of 11 cases.  ISRN Surg. 2011;2011:868356. Epub  2011 Jun 22.  Iran case reports of mediastinitis after esophageal injury.

Saha et. al (2011).  Perils of prolonged impaction of oesophageal foreign bodies.  ISRN Surg. 2011;2011:621682. Epub  2011 Jun 13.  2 Cases (with color photos and CT scans) of mediastinitis after foreign body ingestion.