Dear Editor,
With great interest, I read the article by Flécher et
al1 and congratulate them on the quality of the review
carried out on the history of surgical treatment of cardiac wounds. It
is an exciting topic, so I would like to briefly comment on some facts
narrated in this work.
The well-known surgical approach to the heart, described by Larrey in
the subxiphoid region, should not be placed in a close historical
relationship with the pericardiotomy he performed in 1810 through a
thoracotomy. It was not until 1824 that, after treating a soldier who
had suffered a penetrating wound between the xiphoid appendix and the
7th costal cartilage, the French surgeon began experimenting on cadavers
in search of a faster route to the heart. In 1829 he proposed his
oblique subcostal incision which is currently practically not
used.2
During Milton’s service in Egypt, he surely performed several thoracic
surgeries in extremis situation, but there is no evidence to support the
claim that median longitudinal sternotomy (MLS) was created during an
emergency approach3 or that has been designed for this
type of procedure. When he decided to operate on a living human being on
January 25, 1897, he used it for an elective total sternectomy in a
patient with sternal tuberculosis and ruled out its use in patients with
true mediastinal tumors, who needed more urgent surgeries.
On the other hand, it can hardly be said that MLS is currently the gold
standard for cardiac surgeons to safely and quickly manage a cardiac
stab wound. In patients such as those shown in the
article,1 an approach using a MLS would be very
difficult since lateral mobilization of the costal wall during the
necessary separation of the two halves of the sternum would displace the
knife, causing probably fatal bleeding.
In the emergency room, the gold standard for quickly managing a
penetrating cardiac injury is anterolateral thoracotomy in the fifth
intercostal space. A 1906 article on experimental surgery in dogs has
led some authors to mistakenly consider Spangaro to be the creator of
this incision.4 They forget that in 1893 Daniel Hale
William performed his famous pericardioraphy (the second in history)
precisely using that approach.5
References
1. Flécher E, Leguerrier A, Nesseler
N. An odyssey of suturing cardiac wounds: Lessons from the past. J Card
Surg. 2020;35(7):1597-9.
2. López de la Cruz Y, Quintero
Fleites YF. Modifications to the classic simple-longitudinal inferior
pericardiotomy (Sauerbruch technique). CorSalud. 2019;11(3):225-32.
3. Milton H. Mediastinal Surgery.
Lancet. 1897;1:872 - 5.
4. Pust GD, Namias N. Resuscitative
thoracotomy. International Journal of Surgery. 2016;33:202-8.
5. Buckler H. Doctor Dan. Pioneer in
American surgery. Boston: Little, Brown and Company; 1954.
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