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1. Median Sternotomy

Posterio-lateral thoracotomy

• Access to hilum and pleural cavity

1. Curved incision 2cm below scapula
2. Dissect through skin, fat
3. Divide latissimus dorsi fibres
4. Spread off serratus anterior
5. Divide through intercostal muscles (at level of 5th rib - count from second rib)
6. Enter pleural cavity

 Closure

1. Appose ribs
2. Sew deep fascia onto intercostal muscles
3. Close serratus anterior layer
4. Sew latissimus dorsi
5. Close skin

Emergency Thoracotomy

Indications

• Penetrating injury with cardiac arrest
• Massive thoracic bleeding

Procedure

1. Positioned obliquely with ipsilateral hip and shoulder supported on sandbags
2. Submammary incision made starting near midline and extending into axilla
3. Pass through all layers to enter chest in 5th ICS
4. Ribs separated with spreader
5. Pericardium can be opened anteriorly and parallel to phrenic nerve - decompress tamponade