FIGURE 6 Alternative Approach to Interposition Grafting for an Injury to the Proximal Internal Carotid Artery

A. Following proximal and distal control and instillation of local heparinized saline, the area of injury is resected, and the external carotid artery is mobilized for a distance sufficient to bridge the gap for the injured internal carotid artery

B. The origin of the proximal internal carotid artery is oversewn, and one anastomosis is accomplished using the mobilized external carotid artery branch to beyond the injury on the internal carotid artery. Ligation of one or two branches of the external carotid artery may be required to accomplish significant mobilization

FIGURE 7 Repair of a Combined Injury to the Trachea and Esophagus

A. Following repair using interrupted absorbable sutures on the trachea, a vascularized muscle pedicle (such as the sternal head of the sternocleidomastoid muscle) is interposed between these two tubular structures to reduce the postrepair complication of fistula formation

B. The procedure demonstrated in cross section

FIGURE 8 Control of Injured Vertebral Artery

A. The vertebral artery lies deep in the neck inside the transverse foramen of the cervical vertebra. For uncontrolled bleeding from an injured vertebral artery within the transverse foramen of the neck, dissection and unroofing of this bony covering can be difficult and even produce additional injury and complications

B. Bone wax pressed into the area of bleeding can rapidly control persistent bleeding

FIGURE 9 Tube Thoracostomy, the Most Commonly Performed Thoracic (Operative) Procedure

A. The lateral anatomy in the auscultatory triangle at the fourth intercostal space in the midclavicular line is the point for chest tube insertion

B. Following adequate anesthesia, skin incision, and dissection of subcutaneous tissue are accomplished, and a large clamp or dissecting scissors are used to spread the intercostal muscles. The pleura is entered with the probing finger. Up to 25% of patients have some element of pleural symphysis, and entering the pleura with a Trocar or other similar instrument risks producing an iatrogenic lung injury. The finger allows digital exploration to discern the pericardium or a diaphragmatic injury and/or release pleural adhesions

C. After an appropriately sized hole is created, a chest tube is introduced with the aid of a large curved clamp attached to the tip and directing the tube to the posterior apex location of the pleural space. The tube is attached to an appropriate collection, water seal, and negative pressure device

D. The chest tube is aimed toward the apex of the pleura, with the last hole in the tube inside the chest wall

FIGURE 10 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

FIGURE 11 Technique for Performing Median Sternotomy

A. With the patient appropriately prepped and draped, a skin incision is made from the manubrial notch to below the xiphisternum

B. Using blunt dissection, the fingers are inserted just beneath the sternum from below and above, carefully dissecting the pericardium and loose fatty tissue away from the back of the sternum

C. Using a sternal saw, keeping in the midline of the sternum, and exerting upward pressure on the saw, the total length of the sternum is cut. Care is taken not to divert to the right or left chest cavity

D.

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