LAUSR

We sincerely thank Drs. Lopez-De la Cruz and PerezMachado for their thoughtful correspondence regarding our recently published article titled ‘‘Historical Observations on Clamshell Thoracotomy’’ [1, 2]. This provides an excellent opportunity to dig deeper into the history of thoracic surgery and acknowledge the giants on whose shoulders we stand. Our history of clamshell thoracotomy was conveyed separately from other thoracic incisions in that era. While other approaches may have incorporated the sternum, they were conducted as part of quadrangular flap hinge incisions, which were popular at the turn of the twentieth century. Rising rates of penetrating knife and musket ball injuries during western urbanization prompted late nineteenthcentury surgeons to develop approaches for emergent mediastinal exploration. American surgeons Henry Dalton and Daniel Hale Williams sutured pericardial lacerations in 1891 [3]. German surgeon Ludwig Rehn demonstrated successful cardiorrhaphy in 1896, a feat celebrated across the western world [4]. Luther Leonidas Hill performed the first successful cardiorrhaphy in the USA in 1902 with his patient lying on a kitchen table under chloroform anesthesia in Birmingham, Alabama [5]. None of these revolutionary cases utilized thoracotomy as surgeons conceive it today. The earliest incisions were made directly over the third, fourth, or fifth anterior ribs, and partial costal resections were commonly required in order to gain exposure for inspecting the pericardium. Rehn made a 14-cm fourth intercostal space incision and divided the fifth rib in his landmark operation. Hill used a ‘‘trap door’’ approach for his 1902 cardiorrhaphy, where two parasternal intercostal incisions at the third and sixth intercostal spaces were connected with a vertical incision at the anterior axillary line. He subsequently divided the third, fourth, and fifth ribs, creating a three-sided musculo-osseous flap that raised like a door to expose the mediastinum and left pleural space. These incisions provided emergent access to the pericardium and heart in an era before sternum and rib retractors existed. Modern thoracotomy emerged in 1906. Italian surgeon Saverio Spangaro advocated for a left anterolateral incision originating at the anterior axillary line and advanced toward the sternum. Spangaro’s incision gained applause at the 1906 Congress of Italian Surgeons and has persisted unaltered to this day [6]. By 1909, New York surgeon Charles Peck compiled 158 cardiorrhaphy operations from 1896 to 1908 with a survival rate of 36% [7]. Most cases occurred before 1906 and utilized flap incisions, but Peck heralded the new thoracotomy as the most rapid and efficient method for opening the chest. Nine cases from the period 1898–1906 involved partial sternum resections, but this only occurred as part of quadrangular flap hinge incisions. Despite these advancements and incision modifications, the modern clamshell approach had not yet appeared. Our historical interpretation of clamshell thoracotomy is an anterolateral thoracotomy, as Spangaro first described in 1906, which is extended across the sternum to provide two equally sized thoracotomies to explore both hemi-thoraces. This approach, performed by spreading the ribs versus creating flaps by dividing ribs or costal cartilages, was most likely not utilized until World War I gave the timely invention of rib-spreading thoracic retractors. & Adel Elkbuli [email protected]