No one is going to thank you for making fewer or smaller incisions on a corpse: leave your handbook of minimally invasive keyhole surgery at home – this is no boutique affair. And we are not here to cure cancer or treat structural heart disease. You will find that stuff in a handbook of elective cardiothoracic surgery . That’s for the specialized and circulatory-supported surgeons who are regularly entering the chest back home. This is a place where a general surgeon is the only hope a patient has to survive a thoracic wound. That hope is vested in you. Fortunately, it’s also where an experienced general surgeon is likely to know a lot about the priorities and pitfalls of thoracic surgery for trauma. Out here the chest is in YOUR WHEELHOUSE. But the rub is that even among seasoned general surgeons, there is limited (though highly intense) individual experience. It’s a difficult area to build a wealth of experience in, given that less than half of penetrating chest wounds even require a thoracic operation. In those that do require surgery however, the stakes couldn’t be higher. Death, with scythe in hand, will hover over you in the OR and stalk your patient long after you have placed the last staple in the incision (or incisions) you have made.

This chapter is not about when to dive into the chest. It’s not even really about what to do when you get there. These topics are well covered elsewhere in this book. It’s about how to begin and adapt an operation based on knowledge and skills YOU BRING to the situation you face. Utility for exposure and control of the thoracic vessels and organs IN YOUR HANDS is the single most important factor in choosing an incision and keeping your options open. Be ready to cut based on limited information; you don’t have the luxury of waiting for an extensive secondary survey and adjunctive data. Also, be ready to modify or abandon your initial incision based on what you do – or maybe even more likely – do not find. The utility of the incision you choose (the extent of exposure and control it provides) is inversely proportional to the amount of preoperative information – especially imaging – you have available.

With penetrating injury to the torso in a combat zone, hemorrhage is generally multi-cavitary, non-compressible, and exsanguinating. This means your patient is bleeding to death two or three times faster and in more places than they do back home. They are also colder, probably got to you later, and – look around – you don’t have all the cool stuff and great help like you do back at the big house. Multiple fragment wounds or a single bullet can create audible torrential misery in several compartments at once. You know from your training that this is happening in one or more of five contiguous areas: right chest, left chest, mediastinum , peritoneum , and retroperitoneum . Therefore, like a special operator taking down a house, you must clear each of these “rooms” by any means necessary. Generally, that’s your eyes, ears, hands, and brain, and if you are lucky, a bedside FAST and portable CXR. Fortunately, the principles of Special Operations do apply. A simple plan, repeatedly and realistically rehearsed and executed with speed and purpose AS A TEAM, is what you are after. This, combined with your best emulation of Carl von Clausewitz’ moral factors of courage, intellect, boldness, and perseverance, and you will dominate the frictions of war.¹

You are dealing with multi-cavitary wounding and multifocal exsanguination until proven otherwise. Accordingly, your best approach to positioning the patient is supine with arms out and prepped from chin to knees and chest to elbows, circumferential where possible and down to the table everywhere else (obviously making appropriate modifications for missing limbs, maxillary/facial trauma, back wounds, etc.). This provides you the best opportunity to extend the incision, make new ones, harvest conduit, and gain junctional access and gives YOUR TEAM a straightforward, reproducible approach for every patient you bring back. With a few prep sticks, a groin towel, and two split sheets, you can prep anybody for anything. Leverage the principles of simplicity and repetition. Drill it with your crew and get a picture up on the wall. One less thing to worry about = more time for you to think.

A good plan to always have in the back of your mind is what to do if your patient suddenly crumps from a hemodynamic standpoint somewhere along your little trauma train. The expeditious deployment of bilateral chest tubes and a crash laparotomy with pericardial window through the anterior diaphragm immediately provide you with the bleeding status of all major compartments and, importantly, position you to actually do something about it. You can move to sternotomy if the window is positive, particularly if you think you might have an anterior cardiac or great vessel wound, and the pleural output is reassuring or to anterolateral thoracotomy if you see blood pouring into one of the pleurovacs on either side.

A second situation to consider is the ipsilateral penetrating chest wound with instability that worries you for unmitigated thoracoabdominal mischief going on under the diaphragm. This scenario is not uncommon and often initially best approached with chest tube and laparotomy, with options for pericardial window or thoracotomy from there depending on what is coming out of the chest tube and what you are finding in the belly. At the end of the day, you may find laparotomy and a chest tube were all you needed to definitively manage what at first appeared to be a primary chest problem. And this is particularly true on the right side, where there is no big ventricle to injure and a more likely source of bleeding is the liver. Right chest tube and laparotomy in these patients, at least statistically speaking, are a good place to start.

Once you have made a decision, and committed up front to the belly or one of the chest compartments, always assume the patient is bleeding to death from somewhere else until proven otherwise. If the initial compartment appears uninjured, or if you have found and fixed a problem and the patient is still not responding to resuscitation, obviously you know you need to look elsewhere fast. Your patient may also be trying to die from bleeding across the diaphragm, up in the pericardial sac, or over in the contralateral pleura . Be on the lookout for hypotension that is not getting better despite seemingly good moves on your part in whatever compartment you are presently in. You must find out why your patient is still “tree-topping” before it’s too late. Keep COMMO lines open across the drape with your anesthesia partner. Do they look even more frightened and anxious than they usually do? Is the patient not responding to your great surgery and all the blood products? Are the central pressures now up and you are missing tamponade? Is the diaphragm in your face and filling up your thoracotomy workspace because the belly is actually full of blood? Did the airway pressures just spike or the SaO₂ just tank because you have a chest cavity full of blood, or now there’s a lung down under tension? The signs can be subtle, and it pays to be crazy anal-retentive in this matter. They may call you paranoid, but sometimes the patient really is bleeding to death from several places at one time, and YOU are the patient’s last line of defense.

As you can see ad nauseam from this discussion, the quandary of what incision to make first in trauma chest surgery is almost a cliché in books like this. That’s because it’s hard, and you are going to get it wrong a good bit of the time. But once you are engaged, trying to understand the mechanical situations at play in the various compartments can be informative. Chest tube output is helpful if it is positive, but don’t assume that the compartment is controlled if not much is coming out and you are still having a problem. Tubes kink, get fissured or clogged up with blood and tissue debris, and can even end up in a love handle or the axillae and never make it in the chest in the first place. Even positive chest tube output can be misleading. Abdominal blood can be pouring into the chest through a hole in the diaphragm and right out your tube. Now you know you need to move rapidly from wherever you are to the belly, and deal with the problem directly. The pericardial sac can also fool you – tamponade can be fluid-responsive for a while and develop over time. So if you are in the belly or an ipsilateral chest, and things still aren’t right, have a low threshold to open the pericardium and control the space.

Basically, now’s the time to bury the ego, resist the flail, and be prepared to just make your hole a lot bigger, make an incision somewhere else, or both. Recognize that a laparotomy readily extends to sternotomy and vice versa. Anterior thoracotomy can become a clamshell . Lateral neck incision flows right into sternotomy and vice versa if you need to chase combined injuries up into the neck or down into the mediastinum. Sternotomy to anterior thoracotomy can also make sense, particularly on the left side depending on the situation. Sternotomy also can be transitioned out to right or left clavicular exposure as need be (Fig. 14.1). Laparotomy can even be hockey-sticked up into the left chest across the diaphragm for exposure of the descending aorta. Don’t let some anatomical barrier come between you and saving your patient. Exploiting these relationships and responding to new information dynamically by extending your incision or making a new one is a good thing, not a referendum on where you started and what you got wrong. War surgery is a process, not a procedure. Embrace it and move on.

If your combat trauma patient has just arrested, or is about to arrest from a potentially reversible cause, the left anterolateral (resuscitative) thoracotomy is your “go-to” weapon of mass destruction. It’s maximally invasive, resource intensive, and can put your team at risk, and the probability of success in any given case is not exactly a “confidence builder.” This deal is a direct action mission emphasizing the principles of surprise, speed, audacity, and purpose that can accordingly cause some collateral damage in the process. But if you think you need to address life-threatening intrathoracic bleeding, reverse tamponade, do open massage, deal with massive air embolus, or clamp the aorta to improve cerebral perfusion or gain some proximal control – and you have the resources and no major competing priorities elsewhere – you probably need to pull the trigger. Main reasons to hold fire here are patients with blunt trauma with arrest before arrival and no signs of life (came in dead, stayed dead) and during resource-intensive MASCAL events where your precious personnel capital, blood products, table time, bed space, and adjunctive technologies are best directed at more survivable casualties.

This eventuality is definitely one you can prepare for and LIKELY WILL experience during the course of your deployment. Make sure you got all the supplies (it’s not much really) packaged up in several places in the trauma bay and the OR stored for easy access and checked regularly to make sure they don’t need a re-up. A full-up kit might include:

Your goal here, basically, is to try to convert a dead person into a really sick person. Key objectives are to identify and release tamponade, control major bleeding in the left chest, do open cardiac massage, and cross-clamp the descending aorta. Moves available from there include separate right anterolateral thoracotomy (if the mediastinum has been cleared), and you think you are dealing with a life-threatening right chest problem or extension to clamshell if you have been dealt an anterior cardiac or proximal great vessel injury. Leverage your potential for success where possible by starting with an intubated patient who has good access (ideally both above and below the heart) and is getting a proper blood product resuscitation. You will also be glad you got a gastric tube down to have the stomach decompressed (and to aid in palpation of the esophagus to minimize the chances of injuring it during temporary aortic clamping) and a right chest tube in place so you can have some idea what’s happening on the other side. You need good suction, and generally it takes two to make one. Make sure you and everybody around have on some eye protection, gown, and gloves (mainly for one’s own protection rather than some sterility benefit for the patient). Obviously, if you recognize that arrest is imminent when the patient hits the trauma bay (or know from the 9-line beforehand), taking the patient directly to the OR and doing everything there makes a bad situation a whole lot less challenging to deal with effectively.