119 ISSN 2073-9990 East Cent. Afr. J. surg. (Online) East and Central African Journal of Surgery. March/April 2011; Volume 16 Number 1 Basic Surgical Skills Corner Chest Tube insertion – The need for safe practices S.A. Salati King Fahad Medical City, Riyadh, Saudi Arabia. Email : docsajad@gmai.com Cases are regularly being reported in literature regarding complications arising out of chest tube insertion 1-4 indicating the need to propagate and educate safe methods of chest tube insertion. Careless approach by the medical practitioner can cause morbidities and mortalities and guidelines and recommendations for safer practice are being published from time to time 5 . I would like to stress the following factors related to chest tube insertion : 1. Consent: The importance of informed and documented consent needs to be highlighted.In developing and underdeveloped world, the consent in its true sense is usually neglected due to economic and educational backwardness of the masses. The patient irrespective of his social status has the right to know about his disease and the proposed procedure alongwith the possible complications and alternatives. 2. Pre-procedure preparation: The most important factor is to arrange an operator knowing the procedure fully. In a published study from western literature where doctors were asked to indicate where they would insert a chest drain, 45% indicated they would insert the drain at a wrong site 6 . Preoperative preparation would also involve proper imaging (except in tension pneumothorax) and to rule out conditions likely to cause complications like coagulopathy. 3. Site of insertion: Immediately prior to the procedure the identity of the patient should be verified and the site and side for insertion of the chest tube confirmed by reviewing the clinical signs and the chest radiograph. Proper positioning needs to be ensured .For chest tube insertion, the concept of Safety Triangle 5 (Fig 1) needs to be taught and it will be really helpful if this figure is hung over the walls of emergency rooms along with other commonly used figures like Glasgow Coma scale , Wallace’s rule of 9 etc. This is the triangle bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, a line superior to the horizontal level of the nipple, and an apex below the axilla. This position minimises risk to underlying structures (eg internal mammary artery) and avoids damage to muscle and breast tissue resulting in cosmetically disagreeable scarring. Figure 1. Safety triangle for chest tube insertion (yellow area pointed with black arrows)