title: The clamshell approach for the surgical treatment of complex cardiopulmonary pathology in infants and children.
abstract: BACKGROUND
  The surgical approach to children with complex cardiovascular and pulmonary anomalies is still controversial. Staged operations through multiple incisions are often performed in this setting.
  
  
  OBJECTIVE
  The different applications and clinical advantages of a bilateral thoracosternotomy approach to complex cardiothoracic disease requiring surgical repair were reviewed retrospectively.
  
  
  METHODS
  Between January 1993 and June 1995, 33 patients, aged between 2 months and 17 years (mean 7.8 +/- 5.3) underwent surgical treatment of complex cardiovascular or pulmonary disease using a clamshell approach. Twenty-one patients (64%) had undergone 1-5 previous surgical procedures (mean 2.5 +/- 1.0/patient). The technique involved supine position placement, submammary incision, access to the pleural space bilaterally through the fourth intercostal space and transverse division of the sternal body.
  
  
  RESULTS
  Four groups of patients were operated on via this approach: (1) patients undergoing lobar, lung or heart-lung transplantation (40%); (2) patients undergoing repair of tetralogy of Fallot/pulmonary atresia (36%); (3) patients with previously corrected miscellaneous procedures (12%), including completion of Fontan, one-stage repair of left main bronchial stenosis and atrial septal defect, one-stage repair of partial anomalous pulmonary venous connection and aortic coarctation, and repair of congenital pulmonary venous stenosis. There were two early (< 30 days) deaths, giving a perioperative mortality of 6% for the entire series. Complications included postoperative hemorrhage in 4 patients (12%), prolonged ventilation time due to mechanical failure in 4 (12%). There were no wound infections. Analysis of complications by group showed the lung transplant group to be more affected (18% of patients experienced complications). Except for 2 infants undergoing complete unifocalization and presently awaiting completion of repair of tetralogy of Fallot/pulmonary atresia, in the remaining 31 (94%) a definitive surgical treatment could be performed in one-stage.
  
  
  CONCLUSIONS
  The bilateral thoracosternotomy allows optimal exposure of all intrathoracic anatomic structures making one-stage surgical repair possible in a variety of complex cardiovascular and pulmonary anomalies. Early mortality and technique-related morbidity do not differ from those reported with the conventional approaches to the different disease conditions. A wider application of the clamshell approach for the management of complex intrathoracic pathology in infants and children is advocated.
authors.affiliation: Department of Surgery, Children's Hospital Los Angeles, USC School of Medicine, USA.
authors.forename: G B
authors.initials: GB
authors.lastname: Luciani
authors.forename: V A
authors.initials: VA
authors.lastname: Starnes
mesh_terms: D000293:Adolescent; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D005260:Female; D006330:Heart Defects, Congenital / Q000401:mortality / Q000601:surgery*; D016041:Heart-Lung Transplantation / Q000379:methods; D006801:Humans; D007223:Infant; D016040:Lung Transplantation / Q000379:methods; D008297:Male; D011183:Postoperative Complications / Q000401:mortality; D018633:Pulmonary Atresia / Q000401:mortality / Q000601:surgery; D012189:Retrospective Studies; D013249:Sternum / Q000601:surgery*; D015996:Survival Rate; D013771:Tetralogy of Fallot / Q000401:mortality / Q000601:surgery; D013908:Thoracotomy / Q000379:methods*; D014188:Transposition of Great Vessels / Q000401:mortality / Q000601:surgery