‘Torso-Tractotomy’- A New and Apt Terminology for a Novel Surgical Incision and Approach for Managing Penetrating Torso Injuries, Particularly Impalement or Transfixation Injuries: Naming and Report of a Technique
Department of Surgery, JPN Apex Trauma Center, All India Institute of Medical Sciences (AIIMS), India
Submission: December 12, 2016; Published: December 29, 2016
*Corresponding author: Biplab Mishra, Department of Surgery, Room 304, JPNATC, AIIMS, Raj Nagar, New Delhi, India, Tel: +918010135279; Email: email@example.com
How to cite this article: Biplab M, Sushma S, Subdoh K, Mohit J, Chhavi S. et al. ‘Torso-Tractotomy’- A New and Apt Terminology for a Novel Surgical Incision and Approach for Managing Penetrating Torso Injuries, Particularly Impalement or Transfixation Injuries: Naming and Report of a Technique. Open Access J Surg. 2016; 2(1): 555577. DOI: 10.19080/OAJS.2016.02.555578
Objective: In surgical teachings and literature, there is a lack of terminology for a particular kind of surgical approach which is used by many by ‘joining the entry to exit wound’ for impalement and transfixation injuries. We propose a terminology to them and describe the technique in detail.
Material and methods: We describe the operative technique in two cases of penetrating torso injuries (impalement and gunshot) and discuss the pros and cons of this approach. We review the literature for management of impalement/transfixation injuries and type of surgical approaches/incisions used for them.
Result: We propose the term ‘torso’, ‘thoracic’ or ‘abdominal’ tractotomy as appropriately depending on the site of injury for these kinds of injuries which we found innovative, highly effective and versatile with respect to standard incisions. One of the technical aspects we described is ‘multiple costotomies’ and their fixation with steel wires and to the best of our knowledge this has rarely been described in literature.
Conclusion: Though ‘torso-tractotomy’ expands the horizon of surgical options for a particular surgery, they represent one type of surgical approach and must not be considered solution for every penetrating or impalement injury. They should be used judiciously taken into consideration the suitability for a particular surgery.
Keywords: Redo Mitral Valve; Beating Heart; Right Thoracotomy
The ease and success of a surgical procedure is significantly dictated by the pre-operative planning, type and placement of an incision and surgical approach along with positioning of the patient. The ultimate goal of incision and approach is adequate exposure of ‘area of interest’ along with optimal healing, cosmesis and functional outcome. Some of the general principles which should be followed to achieve these goals are use of minimal ‘possible’ length of incision, minimal tissue handling including minimal possible retraction of tissues, appropriate patient positioning, and avoidance of iatrogenic injuries especially to important /vital structures like major vessels, spinal cord, bowels, etc.
There are many types of surgical incisions and approaches tailored to a particular surgery. Most of these are described in textbooks and literature and therefore well known with designated names like abdominal incisions can be ‘midline’, ‘sub costal’, ‘transverse’, ‘gridiron’, ‘Lanz’, etc. and thoracic incisions can be ‘posterolateral thoracotomy’, ‘sternotomy’, ‘clamshell’, ‘hemi clamshell’, ‘vertical midaxillary’, etc. A particular operation can be done by different incisions and approaches usually dictated by
the ‘disease site’ and surgical area of interest along with
surgeon’s preference and comfort. But there is a particular
type of surgical incision surgeons had already been using
especially for torso impalement /transfixation injuries, but
which can also be used for other conditions like penetrating injuries, tumors, etc [1-8] (Table 1). Though impalement
cases are usually challenging and varied, these incisions
can be used very effectively in an innovative way to suit a
particular surgery by providing excellent exposure and
outcome, thus can have advantages over classical incisions.
To the best of our knowledge, no terminology has been
given to these kinds of incisions yet in literature though
these same incisions are usually described by surgeons as
‘incision joining the entry and exit sites’ . Also the detailed
technique of these incisions is rarely described. We term
these incisions as: ‘torso-tractotomy’- for thoracoabdominal
incisions, ‘thoracic tractotomy’- for thoracic incisions,
‘abdominal tractotomy’- for abdominal incisions, ‘extended
tractotomy’- when the incision is extended in line of incision
and ‘composite tractotomy’- when the incision is combined
with other classical incision (these terms have originally
been proposed by the communicating author who also
operated upon the thoracoabdoinal impalement case in
2008 using thoracoabdominal tractotomy, described in the
article by Chhavi Sawhney et al. .
We describe here two cases in short focusing on the
technique and surgical approach.
22 year old male with iron angle impalement/
transfixation injury of upper abdomen and thorax (Figure 1).
General anesthesia: Patient was intubated in semi
Position of the patient: Right lateral, single operation
theatre (OT) table used (also dictated by the protruding iron
angle (Figure 1).
d) Surgical technique: Left sided torso-tractotomy.
Skin incision made joining entry and exit wounds (shortest
possible length). Soft tissue including abdominal and thoracic
muscles cut in the line of incision. Four ribs (left 6, 7, 8,9)
were encountered in the line of incision, so they were sharply
divided with saw (multiple costotomies) instead of trying to
go through the intercostal spaces (ICS) which avoided extra
tissue dissection as well as spreading (retraction) of ICS
(Figure 2). Left sided pleural cavity entered which revealed
‘the iron angle piercing through upper anterior abdominal
wall (epigastrium) and anterior diaphragmatic attachments,
then passing under the diaphragm through peritoneal cavity,
coming out again into the left pleural cavity posteriorly
injuring the diaphragm second time and exiting by shattering
the left 10th rib through the chest wall posteriorly’ (Figure 3).
Since the diaphragm was hiding intra-abdominal injuries,
it was opened from entry to exit wounds from around the
peripheral attachments (curvilinear incision: ‘phrenotomy/
phreno-tractotomy’) so that injury to left phrenic nerve was
avoided [9-11]. Now the peritoneal cavity was also exposed
along with the left pleural cavity fully exposing the iron angle
(Figure 4). The iron angle was carefully ‘lifted out’ (laterally)
rather than ‘pulled out’. Hemostasis secured for bleeding
from stomach, splenic vessels and spleen. The intra-operative
findings recorded: lacerated left lobe of liver, major lacerations
of stomach at three sites, significant left sided diaphragmatic
injuries both anteriorly and posteriorly, shattered upper half of
the spleen, left lower lobe lung laceration (minor), comminuted
rib fracture (10th rib), anterior abdominal and posterior chest
e) The procedure done: stomach debrided and primarily
repaired, splenectomy, liver laceration cauterized, primary
repair of left lung laceration, thorough thoraco-abdominal
lavage, abdominal drain placed and left intercostal drainage
(ICD) tube placed. Tractotomy reconstruction done by repair
and reconstruction of diaphragm with non absorbable
sutures, the ribs were fixed with dental steel wires and
muscles repaired in layers (Figure 5). Entry and exit wounds
debrided and skin left open for delayed closure . Patient
had uneventful and dramatic post-op recovery.
22 year male with gunshot injury to right lateral chest wall
(‘through and through wound’). Contrast enhanced CT scan
(CECT) of torso showed the trajectory of the bullet along with
diaphragmatic rupture and liver injury. Focused assessment
sonography in trauma (FAST) was negative. Patient was vitally
stable but was bleeding continuously from the chest tube
(probable cause was intermittent negative pleural pressure
transmitted to lacerated liver). Patient was taken to OT for
Surgical technique: Thoracic tractotomy done (Figure 6),
costotomies of four ribs done in line of the incision, lacerated
diaphragm and underlying bleeding liver exposed (without the
need for mobilizing the liver or giving abdominal incisions).
Phrenotomy done to expose the injured liver (Figure 7).
Hemostasis secured, drain placed, phrenotomy primarily
repaired, ribs fixed with dental steel wires, skin and soft tissues
closed primarily. Post-op recovery was excellent with no
significant post op pain.
The words impalement and tranfixation injury are often used
interchangeably in literature. ‘Impalement’ has originally been
defined as a method of execution, in the form of penetration of
a human body by an object such as stake, pole, spear, etc. often
by complete or partial perforation of torso. When impalement
injury becomes ‘through and through’, it is called ‘transfixation’
injury. Thus transfixations have both entry and exit wounds but
impalements may not have exit wounds. Transfixation is also a
type of impalement injury.
General principles of management of impalement and torsotractotomy:
Cautious extrication and rapid transportation to
nearest appropriate facility.
Appropriate shortening of impaled object from just
outside the body. This may need metal cutter or special saws.
Adequate protection of the patient from thermal injuries
while cutting and minimal manipulation of the impaled
object are also essential.
Initial management and resuscitation should be based
on ‘ABCDE’ protocol of Advanced Trauma Life Support
Protrusion of impaled object may still cause difficulty in
positioning of the patient on OT table. Therefore intubation
and positioning may require innovation at times.
The impaled object must never be pulled out (not even
in the emergency department (ED). It should be removed
under full vision on the OT table, only after the patient is
Incision is made by joining the entry and exit wounds
usually in the shortest possible length or as appropriate.
Incision is deepened and tissue cut (fat, fascia, muscle, ribs
etc.) in the line of incision till the impaled object is reached,
taking special care not to injure any vital structures in which
case the tractotomy is either not attempted or special care is
taken. This is followed by retraction of the wound.
The impaled object is handled carefully. It is ‘lifted out’
and not ‘pulled out’ and this is facilitated by tractotomy and
not usually by standard incisions. This maneuver prevents
friction injuries along with further contamination. Also
surgeons can easily access the bleeder in the case of bleeding
secondary to loss of tamponade by the removal of the
impaled object. A word of caution here: proximal and distal
control of vessels may not be possible in such cases.
Debridement of tissues especially entry and exit
wounds should be done.
Wide drainage and debridement are warranted if
contaminated or dirty material is present.
Injuries should be managed with appropriate
It allows easy hemostasis and other repair/
reconstruction procedure following removal of impaled
It is usually the shortest possible incision with respect
to other classical incisions.
It requires less mobilization and retraction of tissues
for exposure with respect to other standard incisions.
Patient’s OT table positioning usually is compatible
but may require two OT tables together for appropriate
If more exposure is needed, the incision can be
combined with other standard incisions or the tractotomy
incision can itself be extended along the line of incision.
In case 1, the tractotomy incision made the challenging
surgery relatively easy which can be gauged by the fact that the
iron angle was removed within twenty minutes of the start of the
surgery. There were no post-operative residual complications or
disabilities in both the cases. Though multiple ribs were divided
(costotomies) in line of incisions, patients had no significant
post-operative pain or neurological symptoms. In fact it is our
observation that pain is significantly more when thoracotomy is
done by retracting the intercostal spaces (by spreading the ribs)
rather than performing costotomies in the line of incision. Also soft tissue dissection is significantly less when costotomies are
used as compared to thoracotomy using intercostal spaces. It
is to be noted that costotomies are also routinely employed for
excision of large chest wall tumors.
‘Otomy’ means ‘to make an incision or cut into’ and
‘tractotomy’ means ‘laying open of the tract’. Such terminologies
are already there in surgical practice like pulmonary tractotomy
(used for penetrating lung injuries), fistulotomy (laying open of
fistula tract), etc. The described torso-tractotomy is in reality
‘opening up of the tract made by the impaled object through the
torso’ but in a major way.
We have reviewed the literature of impalement injuries
and found that many surgeons have already used this incision
though in a different way (Table 1). But we could not find the
use of costotomies in line of incisions anywhere; rather surgeons
have used standard thoracotomy (entering the chest through
retraction of ICS) in combination with tractotomy involving only
It is our humble suggestion that the term ‘Torso-tractotomy’,
‘Thoracic tractotomy’ or ‘abdominal tractotomy’ should be
used as appropriately when such surgeries are performed for
impalements or transfixation injuries. Though at times these
types of incisions and approaches have excellent advantages,
it must be remembered that they represent only one type of
surgical approach and should be judiciously used taking into
consideration the suitability of a particular surgery.