Incisions in Aortic Surgery
Median Sternotomy
Alone
Neck extension
Trap Door extension
Additional thoracotomy
Clamshell
Incision - Bilateral Sub mammary Incision
Hemi Clam Shell
Minimally
invasive incision
Thoracotomy single rib space
Thoracotomy double rib space
Thoracoabdominal incision
Thoracoabdominal laparotomy
Laparotomy intra peritoneal
Laparotomy extra peritoneal
Superior mediastinum exploration
Axillary artery cannulation
Median Sternotomy
Alone
Standard approach to the heart, root, ascending and arch of aorta.
Neck extension
When innominate and carotid artery access is necessary
or 
Trap Door extension
Useful in trauma and when distal aortic arch and proximal descending aortic
access is necessary.
Additional thoracotomy
Clamshell
Incision - Bilateral Sub mammary Incision
Gains wide access to both pleural cavities, the heart, root, ascending, arch
and proximal descending aorta. Has major repercussions with respect to post
operative pain control and ventilation.
How to do a Clamshell incision
Hemi Clam Shell
An unusual incision in aortic surgery, common in trauma surgery!
or 
Minimally invasive
incision
Thoracotomy single rib space
Can be right or left sided. Access to whole length of aorta in thoracic
cavity can be difficult with single rib space incision, particularly in long
chests.
Thoracotomy double rib space
Classically left sided, for thoracoabdominal work. Gives access to whole
length of aorta in thoracic cavity particularly in long chests.
Thoracoabdominal incision
A fundamental principle is the importance of adequate exposure. The
thoracoabdominal incision varies in length and level, depending on
the anticipated extent of aortic replacement. When the aneurysm
extends into the superior aspect of the thorax (Crawford extents I
and II), the upper portion of the thoracoabdominal incision is
through the 6th intercostal space or the bed of the resected 6th rib.
In recent years, we have routinely removed a rib. When the interspace
is used, the upper rib may be divided at the neck for additional
proximal exposure. With lower aneurysms (Crawford extents III and
IV), an incision through the 7th, 8th, or 9th interspace is employed
according to the desired level of exposure. A straight transverse
incision through the 10th or 11th interspace is used in patients with
aneurysms between the diaphragm and aortic bifurcation (Crawford
extent IV). In all others, a gentle curve to reduce the risk of
tissue necrosis at the apex of the lower portion of the
musculoskeletal tissue flap is made as the incision crosses the
costal margin. In patients with proximal aneurysms, the posterior
portion of the incision is located between the scapula and the spinal
processes. The distal extent of the incision is carried down to the
level of the umbilicus.
(A) Location of proper incision for extensive thoracoabdominal aortic
replacement and position of the body showing the relationship between the hip
(placed at 30° and the shoulders (at 60°) for maximal exposure of the
thoracoabdominal aorta and access to the left inguinal region.
(B) Bypass circuit from left atrium to left common femoral artery using a
Biomedicus pump. The proximal aorta is clamped between the left common carotid
and left subclavian arteries. The left subclavian artery is occluded separately.
A distal aortic clamp is placed to isolate the proximal aortic segment.
(C) The aorta is completely transected immediately distal to the left
subclavian artery and separated from the esophagus. The false lumen, because of
its lateral position, generally is entered first. The aortic tissue separating
the true and false lumina is opened and completely excised.
(D) Proximal intercostal arteries are oversewn by direct suture. An
end-to-end anastomosis is performed with running suture immediately distal to
the left subclavian artery.
Thoracoabdominal laparotomy (trauma case)
Laparotomy intra peritoneal
Laparotomy extra peritoneal
Superior mediastinum exploration
Axillary artery cannulation
Useful for axillary artery cannulation in work involving the aortic arch.
Video 1
Video 2