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Sternotomy First?

Steven L. Moulton, MD; Frank P. Lynch, MD; Timothy G. Canty, MD; David L. Collins, MD; David B. Hoyt, MD

Arch Surg. 1991;126(10):1262-1266.

Abstract
• Major hepatic vein and retrohepatic vena caval injuries are often fatal because of massive uncontrollable hemorrhage. Children with these injuries can be identified by their unique and dramatic clinical presentation and the selective use of computed tomographic imaging. Volume resuscitation promotes abdominal wall tamponade and hemodynamic stability until the abdomen is opened, at which point there may be sudden exsanguination before vascular control can be obtained. An alternative approach is to open the sternum before opening the abdomen. Management in this sequence provides rapid vascular control and improves the efficiency of hepatic exclusion. To date, five children with major hepatic vascular injuries have been treated with the sternotomy-first approach and four have survived; an atriocaval shunt was used on two occasions. Although sternotomy before laparotomy improves the efficiency of hepatic exclusion and may offer improved survival, accurate preoperative case selection limits its routine use.

(Arch Surg. 1991;126:1262-1266)

Author Affiliations
From the Division of Trauma, Children's Hospital, San Diego (Drs Lynch, Canty, and Collins); the Department of Surgery, University of California, San Diego (Drs Moulton, Lynch, Canty, and Hoyt); and the Trauma Research and Education Foundation, San Diego (Drs Lynch and Hoyt).

Footnotes
Accepted for publication July 18, 1991.

Presented at the 62nd Annual Scientific Meeting of the Pacific Coast Surgical Association, Pebble Beach, Calif, February 20, 1991.

Reprint requests to the Division of Pediatric Surgery, Children's Hospital, 8001 Frost St, San Diego, CA 92123 (Dr Canty).

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