title: Transdiaphragmatic resuscitative open cardiac massage: description of the technique and a first case-series of an alternative approach to the heart.
abstract: BACKGROUND
  The purpose of this paper is to describe the transdiaphragmatic approach to the heart for open CPR in patients that arrest at laparotomy and to present a first case series of patients that have undergone this procedure.
  
  
  METHODS
  All patients who had undergone intraperitoneal transdiaphragmatic open CPR between January 1, 2002 and December 31, 2012 were retrieved from the operation registry at Bern University Hospital, Switzerland. Transdiaphragmatic access to the heart is initiated with a 10-cm-long anterocaudal incision in the central tendon of the diaphragm--approximately at 2 o'clock. Internal cardiac compression through the diaphragmatic incision can be performed from both sides of the patient. From the right side of the patient, cardiac massage is performed with the right hand and vice versa.
  
  
  RESULTS
  A total of six patients were identified that suffered cardiac arrest during laparotomy with open CPR performed through the transdiaphragmatic approach. Four patients suffered cardiac arrest during orthotopic liver transplantation and two trauma patients suffered cardiac arrest during damage control laparotomy. In three patients, cardiac activity was never reestablished. However, three patients regained a perfusion heart rhythm and two of these survived to the ICU. One patient ultimately survived to discharge.
  
  
  CONCLUSIONS
  In patients suffering cardiac arrest during laparotomy, the transdiaphragmatic approach allows for a rapid, technically easy, and almost atraumatic access to the heart, with excellent CPR performance. After this potentially life-saving procedure, pulmonary or surgical site complications are expected to occur much less compared with the conventionally performed emergency department left-sided thoracotomy.
authors.affiliation: Department of Visceral and Transplant Surgery, Bern University Hospital, 3010, Bern, Switzerland.
authors.forename: Beat
authors.initials: B
authors.lastname: Schnüriger
authors.forename: Peter
authors.initials: P
authors.lastname: Studer
authors.forename: Daniel
authors.initials: D
authors.lastname: Candinas
authors.forename: Christian A
authors.initials: CA
authors.lastname: Seiler
mesh_terms: D000007:Abdominal Injuries / Q000601:surgery; D000328:Adult; D000368:Aged; D002648:Child; D003964:Diaphragm / Q000601:surgery*; D005260:Female; D006323:Heart Arrest / Q000628:therapy*; D006336:Heart Massage / Q000379:methods*; D006801:Humans; D007431:Intraoperative Complications / Q000628:therapy*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D012042:Registries; D013534:Survival; D055815:Young Adult