Clamshell and Hemiclamshell Incisions for Complex Intrathoracic Tumors: A Retrospective Analysis of Indications and Outcomes.

INTRODUCTION: Clamshell and hemiclamshell incisions are uncommon approaches in thoracic oncology. This study aims to describe indications and outcomes of surgical resection using these two incisions and to propose criteria that may prompt their use. METHODS: We retrospectively reviewed patients undergoing tumor resection via clamshell or hemiclamshell incision between 2009 and 2024. Patient characteristics and outcomes were descriptively analyzed. RESULTS: Clamshell and hemiclamshell approaches were used in 36 and 55 cases, respectively. Median tumor diameter was 10 cm (IQR: 6.4-14.0). Pneumonectomy, vascular resections, and tracheo/bronchoplastic procedures were performed in 41.4%, 33%, and 12.1% of cases; extracorporeal support was required in 11%. Distinct patterns of tumor histology and intrathoracic location were observed between the two approaches. Pneumonectomy and tracheo-carinal resections were mainly performed through clamshell, while pleural resections were predominantly carried out through hemiclamshell (p < 0.05). Postoperative hospital stay was longer in the clamshell group (13 vs. 11 days), whereas other early outcomes were comparable. Overall survival and cause-specific mortality were similar. CONCLUSION: This study provides a descriptive analysis of the clinical use of clamshell and hemiclamshell incisions in thoracic oncology. Distinct indications emerged for each approach, reflecting tumor location and extent. Both techniques were associated with acceptable perioperative outcomes, while long-term results appeared to be mainly influenced by tumor characteristics. The proposed illustrative algorithm may aid in selecting surgical access for complex intrathoracic tumors.