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Year : 2023  |  Volume : 28  |  Issue : 2  |  Page : 170-172

Application of the clamshell thoracotomy in an infant with a large mediastinal tumor

Department of Pediatric Surgery, B J Wadia Hospital for Children, Mumbai, Maharashtra, India

Date of Submission04-Jul-2022
Date of Decision22-Oct-2022
Date of Acceptance20-Nov-2022
Date of Web Publication03-Mar-2023

Correspondence Address:
Pradnya S Bendre
Department of Pediatric Surgery, B J Wadia Hospital for Children, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaps.jiaps_91_22

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Historically it was recommended for emergency thoracotomy in thoracic trauma as the last resort when there was cardiopulmonary arrest. Nowadays, the only indications are lung transplantation and huge mediastinal masses. We report the use of a clamshell thoracotomy in a 7-month-old boy with a large anterior mediastinal mass extending into the bilateral thoracic cavities.

Keywords: Clamshell, mediastinal mass, teratoma

How to cite this article:
Bendre PS, Banerjee A, Munghate G, Karkera PJ, Bodhanwala M. Application of the clamshell thoracotomy in an infant with a large mediastinal tumor. J Indian Assoc Pediatr Surg 2023;28:170-2

How to cite this URL:
Bendre PS, Banerjee A, Munghate G, Karkera PJ, Bodhanwala M. Application of the clamshell thoracotomy in an infant with a large mediastinal tumor. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Nov 30];28:170-2. Available from: https://www.jiaps.com/text.asp?2023/28/2/170/371172

   Introduction Top

It was during the First World War that the French surgeon Théodore Tuffier modified the traditional bilateral thoracotomy by adding a transsternal extension in the fourth intercostal space (ICS).[1] Popularly known as the “trapdoor” or clamshell thoracotomy, it is reportedly the most radical approach in thoracic surgery. Allowing simultaneous exposure of the mediastinum and both pleural spaces, structures uniquely accessible with the clamshell incision include the thoracic aorta, posterior heart, pulmonary circulation, both atria, mainstem bronchi, diaphragmatic crura, and the azygos vein. Historically it was recommended for emergency thoracotomy in thoracic trauma as the last resort when there was cardiopulmonary arrest. Nowadays, the only indications are lung transplantation and huge mediastinal masses. However, experience with the clamshell incision in infants is limited and is not usually considered part of the armamentarium of pediatric surgeons.

   Case Report Top

A 7-month-old boy was admitted with increased respiratory activity and features of superior vena cava (SVC) syndrome. Chest X-ray showed a large retrocardiac opacity and echocardiography revealed a solid mass with cystic cavities in the anterior mediastinum compressing on the right atrium along with another cystic mass in the left posterior mediastinum. Tumor markers (α-fetoprotein and β-human chorionic gonadotropin) were within normal limits.

A computed tomography scan of the chest showed a large (10 cm × 7 cm × 8.7 cm) heterogeneous mass in the anterior mediastinum extending into the bilateral thoracic cavities with multiple necrotic/cystic areas and few calcific foci. The tumor also showed a heterogeneous postcontrast enhancement. The tumor extended from the anterior thoracic wall to the pulmonary veins, the anterior wall of the trachea, and the esophagus posteriorly. Medially abutting on the right atrium, SVC, inferior vena cava, free wall of the left atrium, and ascending aorta with its major branches, the mass reached up to the suprasternal notch superiorly [Figure 1].
Figure 1: (a and b) Axial CT images showing the tumor and its relation with the aorta (A), pulmonary artery (P), trachea (*), and esophagus (arrow); (c) CT (3D reconstruction) showing the large mediastinal mass. CT: Computed tomography, 3D: Three-dimensional

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We chose to go in through a clamshell thoracotomy (keeping in mind the mammoth extension of the tumor into the bilateral thoracic cavities) after extensive multidisciplinary discussions involving the pediatricians, anesthesiologists, cardiac surgeons, pediatric cardiac anesthesiologists, and otolaryngologists. The cardiac surgical team along with provisions for extracorporeal circulation (ECC) and cardiopulmonary bypass was kept on standby.

With the child in a supine position under general anesthesia, a clamshell incision was taken, extending from one anterior axillary line to another at the level of the fourth ICS. The thoracic cavity was entered through the fifth ICS on the right side and the fourth ICS on the left. The sternum was cut using a Gigli saw wire and a four-blade retractor was used for exposure of the mediastinal mass [Figure 2]. The predominantly cystic component in the left upper hemithorax was adherent to the aortic arch and its branches. It was excised first after carefully dissecting from the chest wall, aorta, and pericardium. The mass in the right hemithorax was predominantly solid. It was infiltrating the pericardium over the right atrial appendage and also had dense adhesions to the descending aorta. We excised the pericardium over the right auricle along with the intrapericardial extension of the tumor. After the tumor was completely excised, bilateral intercostal drains were kept in the pleural cavities. The sternum was repaired using stainless steel sutures before closing the incision.
Figure 2: Intraoperative image showing the two distinct components of the mediastinal mass

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The postoperative course was uneventful. Histopathological examination suggested a mature teratoma with 2% immature neuroepithelium. The child was discharged on the 11th postoperative day and is healthy and thriving well for 1 year since the surgery.

   Discussion Top

A historical clamshell incision is an appropriate approach for large midline tumors arising from the anterosuperior mediastinum with bilateral thoracic extensions. It provides excellent exposure up to the lung apices and thoracic outlet and is associated with minimal respiratory complications and a low rate of sternal nonunion or wound infection. Moreover, there is no significant difference in total time required compared to the left anterolateral thoracotomy.[2]

Children with mediastinal masses are at a higher risk than adults for anesthesia-related respiratory complications. This is largely attributable to the underestimation of the severity of the problem as a result of their greater pulmonary reserve and status as poor historians, as well as to their more compressible elastic cartilaginous airways.[3]

The usual anesthesiological considerations comprise the maintenance of spontaneous ventilation, awake fiberoptic intubation, short-acting medications, large-bore venous access in the lower extremity, provisions for double-lumen intubation (except for infants), and intraoperative transesophageal echocardiography.[4] Preoperative case discussions with the anesthesiologist should always include surgical access and approach, positioning of the patient, estimation of the risk of the mediastinal mass syndrome, and the potential need for ECC.

Surgical approaches which require the patient to be in a supine position are usually preferred as it facilitates the approach to the femoral vessels for cannulation (in readiness for ECC) even before the induction of anesthesia.[4] Although cardiac compression may occur in the supine position in patients with large anterior mediastinal tumors, this is usually predictable after a detailed history taking and routine physical examination in the ward.

Among the various surgical approaches for mediastinal tumors, the midline sternotomy approach, or an anterolateral or posterolateral thoracotomy approach are most often utilized.[5] The classic clamshell or hemiclamshell incision is used sporadically. Surgical excision of a mediastinal teratoma becomes complicated due to its involvement of vital structures, owing to strong inflammatory adhesions, and erosion of surrounding mediastinal structures by proteolytic enzymes produced by the teratoma.[5]

Most authors would advocate for an anterolateral thoracotomy based on their experience and existing literature as most anterior mediastinal teratomas extend into either the right or the left hemithorax. Extensive bilateral thoracic extensions are almost unheard of, especially in children. Hence, the most adequate surgical approach is the one that permits safe dissection. There are no documented evidence-based guidelines for the selection of the clamshell incision in pediatric thoracotomies. However, this approach is safe and provides the best exposure of the bilateral thoracic cavities simultaneously facilitating complete tumor excision and repair of vital structures. The mortality or morbidity due to the incision is no more than what is already expected based on the primary nature of the condition or the surgical management thereof. Therefore, even in the age of minimally invasive surgery, the clamshell incision is relevant in children for the surgical repair of complex intrathoracic anomalies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Ehrhardt JD Jr., Baroutjian A, McKenney M, Elkbuli A. Historical observations on clamshell thoracotomy. World J Surg 2021;45:1237-41.  Back to cited text no. 1
Flaris AN, Simms ER, Prat N, Reynard F, Caillot JL, Voiglio EJ. Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited. World J Surg 2015;39:1306-11.  Back to cited text no. 2
Slinger P, Karsli C. Management of the patient with a large anterior mediastinal mass: Recurring myths. Curr Opin Anaesthesiol 2007;20:1-3.  Back to cited text no. 3
Li WW, van Boven WJ, Annema JT, Eberl S, Klomp HM, de Mol BA. Management of large mediastinal masses: Surgical and anesthesiological considerations. J Thorac Dis 2016;8:E175-84.  Back to cited text no. 4
Razafimanjato NN, Rajaoharimalala TG, Rabi RA, Ravoatrarilandy M, Rajaonera AT, Hunald FA, et al. Huge mediastinal teratoma in children: Anesthesiological approach, surgical strategy and literature review. J Xiangya Med 2019;4:35-9.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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