A clamshell thoracotomy is a large surgical incision that crosses the entire front of the chest, cutting through both sides between the ribs and dividing the breastbone in the middle. The result is a hinged opening that swings upward like the shell of a clam, giving the surgeon rapid access to both lungs, the heart, and the major blood vessels all at once. It is used most often as an emergency procedure in trauma, but it also has a well-established role in planned operations like lung transplantation and the removal of large tumors deep in the chest. The incision’s sheer size is both its greatest advantage and the source of its most significant complications, and the decision of when to choose it over smaller approaches is one of the more consequential calls in thoracic surgery.
What the Incision Actually Involves
The procedure starts with bilateral anterolateral incisions, one on each side of the chest, typically in the fourth or fifth intercostal space (the gap between the fourth and fifth ribs). Each incision runs from roughly the midaxillary line, near the side of the torso, toward the sternum. Once both sides are open, the sternum is divided transversely with a Gigli saw, a bone-cutting saw, or heavy trauma shears. The two halves of the chest wall then fold upward, exposing the entire thoracic cavity in a way no single-sided incision can match. In the trauma setting, the whole process can be completed in under a minute by an experienced team.
The exposure this creates is unmatched for situations where the surgeon does not yet know which side of the chest holds the injury, or when pathology spans both sides. Both lungs, the pericardium, both pleural cavities, the thoracic aorta, and the great vessels at the top of the chest are all within reach. One anatomical study concluded that because the source of bleeding in severe thoracic trauma is often unknown before the chest is opened, the clamshell incision remains the superior choice because it provides the most rapid and definitive access to all thoracic structures for assessment and control.1PubMed. Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study That same breadth of exposure makes it valuable for planned surgeries involving giant or deep mediastinal tumors, where vascular control or dissection from multiple angles is necessary.2PubMed Central. Clamshell thoracotomy for mediastinal mass resection: technical refinements and short-term outcomes in the largest single-center cohort
Emergency Trauma and Resuscitative Thoracotomy
The most dramatic use of the clamshell is as a resuscitative thoracotomy, an operation performed on a patient who is in or near cardiac arrest from a chest injury. When someone arrives at a trauma center with no pulse after a stab wound or gunshot wound to the torso, opening the chest is sometimes the only chance at survival. The surgeon can directly compress the heart, clamp the aorta to redirect blood to the brain, and repair whatever is bleeding. In blunt trauma, such as a motorcycle crash causing cardiac rupture, the clamshell allows repair of lacerations to the heart chambers that would be unreachable through a one-sided incision.3Japanese Journal of Cardiovascular Surgery. Clamshell Thoracotomy for Two Cases of Blunt Traumatic Cardiac Rupture
Survival rates after emergency thoracotomy are sobering. Reported figures run roughly 9 to 12 percent for penetrating trauma and only 1 to 2 percent for blunt trauma.4PubMed Central. Life-saving emergency clamshell thoracotomy with damage-control laparotomy Those numbers reflect the fact that the patients undergoing this procedure are, by definition, at death’s door. The survival rate is not a measure of the incision’s quality; it is a measure of how close to death these patients already are when the procedure begins.
Among those who do survive, neurological outcome is a real concern. One large meta-analysis of over 4,600 patients found that normal neurological outcomes were observed in about 92 percent of survivors.5Journal of Surgical Case Reports. A series of successful emergency department thoracotomies with expeditious recovery That means most people who make it through the procedure wake up neurologically intact, but a meaningful minority do not. How quickly the chest is opened and blood flow is restored to the brain matters enormously.
Clamshell Versus Left Anterolateral Thoracotomy in Emergencies
The traditional emergency thoracotomy is a left anterolateral thoracotomy, a single incision on the left side of the chest. It is faster to start, requires less tissue disruption, and provides good access to the left side of the heart and the descending aorta. For a straightforward left-sided penetrating injury, it can be all that is needed. The clamshell, however, has gained traction in the emergency setting because it removes the guesswork. If the source of bleeding turns out to be on the right side, or if the injury involves structures that sit behind the heart, the surgeon does not have to scramble to extend the incision mid-operation.
Data from the American Association for the Surgery of Trauma’s registry showed that compared with a left anterolateral thoracotomy, the clamshell improved the ability to manage both pulmonary and cardiac sources of hemorrhage without delaying resuscitative goals or increasing complications.6Journal of the American College of Surgeons. Does Clamshell Thoracotomy Better Facilitate Thoracic Life-Saving Procedures Without Increased Complication Compared with an Anterolateral Approach to Resuscitative Thoracotomy? A separate comparison in a live-tissue training model found that staff emergency physicians succeeded significantly more often with a modified bilateral clamshell than with the left anterolateral approach (roughly 88 percent versus 25 percent), and physician preference overwhelmingly favored the clamshell at 87 percent.7Annals of Emergency Medicine. A Comparison of Resuscitative Thoracotomy Techniques: Left Anterolateral Thoracotomy Versus Modified Bilateral Anterior Clamshell Thoracotomy The modified version used in that study was developed by clinicians at London’s Air Ambulance and is designed to be especially feasible for emergency physicians who are not trained surgeons.8PubMed. Prospective randomized trial of standard left anterolateral thoracotomy vs modified bilateral clamshell thoracotomy performed by emergency physicians in a live tissue penetrating cardiac injury model
Prehospital Thoracotomy
In a handful of advanced prehospital systems, physicians perform thoracotomies before the patient reaches the hospital. The largest published experience comes from London, where a study tracked 601 patients who underwent prehospital resuscitative thoracotomy after traumatic cardiac arrest. The vast majority of cases (about 88 percent) involved penetrating injuries. Overall, 30 patients survived to hospital discharge, a 5 percent survival rate. Among those survivors, about three-quarters had favorable neurological outcomes.9JAMA Surgery. Prehospital Resuscitative Thoracotomy for Traumatic Cardiac Arrest
The data revealed a sharp divide by cause. Patients whose arrest was caused by cardiac tamponade, where blood fills the sac around the heart and prevents it from beating, had a 21 percent survival rate. Patients bleeding out from torn vessels survived at only about 2 percent. Nobody survived when tamponade and exsanguination occurred together. Equally striking was the time window: no tamponade patient survived beyond 15 minutes of cardiac arrest, and no exsanguination patient survived beyond 5 minutes.10JAMA Surgery. Prehospital Resuscitative Thoracotomy for Traumatic Cardiac Arrest These numbers underscore how narrow the opportunity is, and why the speed advantage of a well-practiced clamshell matters in the field.
Planned Surgery and Lung Transplantation
Outside the trauma bay, the clamshell has its longest track record in lung transplantation. Double lung transplants require the surgeon to remove two diseased lungs and implant two donor lungs, and the clamshell gives bilateral access without repositioning the patient mid-operation. Since the early 1990s, transplant centers have performed the procedure routinely using fourth- or fifth-interspace clamshell incisions.11PubMed. Clamshell or sternotomy for double lung or heart-lung transplantation? The incision also found its way into thoracic oncology in the mid-1990s for bilateral pulmonary metastases and large mediastinal tumors, and the name “clamshell thoracotomy” itself came from that era.12PubMed. Historical Observations on Clamshell Thoracotomy
The alternatives in elective surgery are a median sternotomy (splitting the breastbone vertically, as in open-heart surgery) or bilateral anterolateral thoracotomies (separate incisions on each side without dividing the sternum). Each has trade-offs. A sternotomy tends to cause less chest-wall morbidity than the clamshell and allows easy connection to a heart-lung machine when needed; one center reported equivalent to better short-term outcomes with sternotomy, including earlier extubation and fewer transfusions.13PubMed Central. Sternotomy versus thoracotomy lung transplantation: key tips and contemporary results Another study comparing sternotomy and clamshell for double lung transplantation found that operative time and bypass time were longer in the clamshell group, though overall survival did not differ between the two approaches.14PubMed. Impact of Surgical Approach in Double Lung Transplantation: Median Sternotomy vs Clamshell Thoracotomy
When bilateral anterolateral thoracotomies were compared against the clamshell in lung transplant patients, the anterolateral approach was associated with less blood loss, less need for extracorporeal circulation, fewer wound complications, and shorter ICU stays, though operating time was actually longer. Survival was similar between the groups. The higher use of extracorporeal circulation in the clamshell group appeared to drive many of the downstream differences in outcomes.15PubMed Central. Anterolateral vs Clamshell Thoracotomy for Bilateral Lung Transplantation Surgeons choosing between these approaches often weigh the superior exposure of the clamshell against the lighter recovery profile of the alternatives.
Sternal Healing and Dehiscence
Dividing the sternum transversely creates a unique healing challenge. Unlike a vertical sternotomy, which splits the bone along its long axis and can be wired shut under relatively symmetrical tension, the transverse cut of a clamshell crosses the sternum at its widest point. The two halves are pulled apart every time the patient breathes, coughs, or moves their arms. In lung transplant patients, who are placed on immunosuppressive drugs that impair wound healing, the problem is compounded. Dehiscence rates for the transverse sternotomy have been reported in the range of about 7 to 36 percent, a wide spread that reflects differences in closure technique and patient population.16PubMed Central. Novel Repair of Clamshell Thoracotomy Sternal Dehiscence after Lung Transplant: A Case Report
One transplant center found an overall sternal complication rate of about 11 percent, with the typical reoperation occurring roughly three months after the transplant. Male sex and postoperative acute kidney injury were independent risk factors for sternal complications.17PubMed Central. Risk factors associated with sternal complication after lung transplantation with transverse sternotomy
How the sternum is put back together matters a great deal. Traditional wire cerclage, the method borrowed from vertical sternotomy closures, tends to perform worse in this context. A systematic review found that alternative closure techniques consistently outperformed wiring. In one series, a two-plate closure system produced complications in only about 1 in 20 cases, compared with roughly 1 in 2 for wire closure. Another center reported zero complications in 22 patients closed with a fiber-tape system, compared with over half of patients closed with reinforced wiring.18European Journal of Cardio-Thoracic Surgery. Sternal Complications After Clamshell Surgery for (Heart-)Lung Transplantation—A Systematic Literature Review Some centers have moved toward avoiding sternal division entirely, using bilateral anterolateral thoracotomies, to sidestep this complication altogether.
Chest-Wall Function After Surgery
Even when the sternum heals without complication, the clamshell incision can leave its mark on how the chest wall moves. A study comparing lung function in transplant patients who received clamshell incisions versus sternotomies found that the clamshell group had significantly worse chest-wall mechanics afterward, as measured by vital capacity and forced expiratory volume. The intrinsic function of the airways themselves was not different between the groups, meaning the lungs were fine but the muscles and bones surrounding them did not move air as efficiently.19European Journal of Cardio-Thoracic Surgery. Clamshell or sternotomy for double lung or heart-lung transplantation? For patients receiving new lungs that should be working well, reduced chest-wall compliance is an unwelcome limitation. This is one of the reasons transplant programs have gradually explored whether sternotomy or bilateral anterolateral incisions can achieve equivalent transplant results with less chest-wall disruption.
Pain Management After a Clamshell
A bilateral chest incision with divided ribs and a transected sternum creates formidable postoperative pain. Inadequate pain control not only causes suffering but prevents the patient from breathing deeply and coughing effectively, which raises the risk of pneumonia and lung collapse. Traditional approaches rely heavily on intravenous opioids and thoracic epidural catheters, but epidurals can be risky in patients on blood thinners or extracorporeal support.
Regional nerve blocks have emerged as useful alternatives. Bilateral erector spinae plane blocks, in which local anesthetic is infused near the muscles running alongside the spine, have been used successfully in clamshell patients. In one case, continuous bilateral infusions were maintained for 10 days, and the patient reported zero pain upon extubation.20Regional Anesthesia & Pain Medicine. Erector erector spinae block for analgesia in a patient having undergone clam shell thoracotomy Another approach combines superficial parasternal intercostal plane blocks with serratus anterior plane blocks, targeting different layers of the chest wall. A retrospective study in lung transplant patients found that these blocks were associated with faster extubation and lower opioid consumption, even in patients on extracorporeal membrane oxygenation.21Regional Anesthesia & Pain Medicine. Additive value of superficial parasternal intercostal plane block and serratus anterior plane block in lung transplantation surgery: a retrospective exploratory study The trend across anesthesia practice is toward multimodal pain strategies that stack several regional techniques together, reducing the need for systemic opioids and their well-known side effects.
Training for a Rare Procedure
Clamshell thoracotomy sits in an awkward educational space. It is rare enough that many emergency physicians and even trauma surgeons may go years without performing one, yet when it is needed, hesitation or unfamiliarity can be fatal. Simulation-based training has stepped in to fill this gap. A low-cost, reusable chest model was developed specifically for clamshell training, and after using it, trainees showed significant improvements in both knowledge and confidence, with the largest gains in confidence in actually performing the procedure.22PubMed Central. Development of a Low-Cost, High-Fidelity, Reusable Model to Simulate Clamshell Thoracotomy
Cadaveric workshops offer a higher-fidelity alternative. One program designed for emergency physicians demonstrated that hands-on practice on cadavers increased their confidence in performing rarely needed but life-saving procedures.23PubMed. A human cadaveric workshop: One solution to competence in the face of rarity A separate pilot study confirmed that the clamshell itself can be taught to emergency physicians using cadavers and performed rapidly with minimal equipment.24PubMed. Clamshell thoracotomy and open heart massage–A potential life-saving procedure can be taught to emergency physicians: An educational cadaveric pilot study The emphasis in all these programs is not just on technical steps but on decision-making: recognizing the moment when a one-sided incision is not enough and committing to the bilateral approach without wasting time.
Pediatric Considerations
Children can sustain the same life-threatening chest injuries as adults, and the same basic principles of resuscitative thoracotomy apply. However, the anatomy is different enough, and the clinical experience sparse enough, that performing a clamshell on a child carries additional uncertainty. A collaborative effort among major trauma surgery organizations produced a clinical decisions algorithm and procedural guide specifically for pediatric emergency resuscitative thoracotomy, acknowledging that the pediatric population requires its own decision-making framework rather than a scaled-down version of adult protocols.25Journal of Trauma and Acute Care Surgery. Pediatric emergency resuscitative thoracotomy: A Western Trauma Association, Pediatric Trauma Society, and Eastern Association for the Surgery of Trauma collaborative critical decisions algorithm The smaller chest, more compliant rib cage, and different injury patterns in children all influence the technical approach and the threshold for proceeding.
How the Incision Got Its Name
The technique is considerably older than its name. Transverse sternal extension of a bilateral thoracotomy likely first occurred during World War I and was designated as “Tuffier’s method” by 1922, named after Théodore Tuffier, a Parisian thoracic surgeon who had been recruited by the French army to design triage systems for wartime trauma patients. After World War II, the bilateral incision enjoyed a period of popularity for pioneering open-heart operations during the 1950s, before median sternotomy replaced it as the standard cardiac surgery approach by the early 1960s. The incision persisted in trauma surgery, with up to half of emergency thoracotomies at busy trauma centers reported as clamshells, though the trauma literature barely mentioned the approach through the 1980s. The actual term “clamshell thoracotomy” did not appear until 1994, coined during a period when thoracic oncology and lung transplantation demanded larger incisions for increasingly complex operations.26PubMed. Historical Observations on Clamshell Thoracotomy The name stuck because it is immediately descriptive in a way that “bilateral anterolateral thoracotomy with transverse sternotomy” never could be.