- Email: [email protected]
A useful technique for closure of pulmonary lacerations
A Useful Technique for Closure of Pulmonary Lacerations Robert L. Fulton, MD, and Mark Dickson, MD Department of Surgery, University of Louisville School of Medicine, and the Trauma Program in Surgery, Humana Hospital University, Louisville, Kentucky; and Texas Tech University, Health Sciences Center, Lubbock, Texas
Methods of closing lung tissue with stapling devices or simple sutures are usually adequate. In some patients lung tissue is so friable that reinforcement of the sutures with tissue flaps is beneficial. Felt bolsters or pledgets can also be used as we describe. (Ann Thoruc Surg 2990;50:14950)
L
acerations, perforations, and resections of pulmonary tissue if not sealed properly may allow prolonged air leak and hemorrhage [l].Currently accepted methods of closure, using stapling devices or simple sutures, occasionally fail [2, 31 and cause further lung damage [4, 51. This is particularly true of contused or overexpanded lung. We have used felt pledgets or bolsters for reinforcing suture lines in several situations. Prolonged air leak, continued hemorrhage, or both were avoided in all patients.
Technique
also is not easily amenable to simple suture methods. Likewise, the overexpanded lung encountered in bulla emphysema is difficult to close, and prolonged air leak is a recognized hazard of bleb resection (71. The use of felt pledgets or bolsters to prevent tearing of pulmonary tissue has proved satisfactory in our practice. The method is quite simple, and because the sutures are held by the felt, the suture line is maintained without further tearing even with overexpansion of lung due to disease or mechanical ventilation. Concern about placing foreign bodies in apposition to an open airway is real. It would be thought that the use of such material in an injured lung or patient treated by steroids would increase the incidence of empyema, particularly with prolonged air leak. However, postoperative empyema is a function of poorly drained and incompletely closed pleural spaces that allow air leaks and poor expansion of the lung [8].Intrapleural infection has not developed in any of the patients in whom we have used felt material. Without further experience, however, it would not be recommended that this method of lung
Long felt (either Dacron or Teflon) bolsters are used to stabilize suturing of massively lacerated lung as shown in Figure 1. The bolster can be placed with a single running suture. Bolsters also can be sutured to each side of the laceration and a tertiary suture line used to approximate the severed lung. Nonabsorbable 3-0 sutures have been used effectively. In addition to using this technique in traumatically induced lacerations, we have successfully employed the method to close lung after resection of giant bullae as shown in Figure 2.
Comment The usual repair of torn or resected lung involves the use of either a mechanical stapling device or simple suturing of the disrupted tissue [2, 3). Several examples of pulmonary pathology occur in which this technique may not be satisfactory, allowing for prolonged hemorrhage or air leak. Fibrotic lung, particularly in the patient who has been maintained on long-term steroids, may not hold sutures, leading to unsatisfactory air leak (61. Badly contused lung resulting from penetrating or blunt trauma Accepted for publication April 10, 1990. Address reprint requests to Dr Fulton, Department of Surgery, University of Louisville, 550 South Jackson St, Louisville, KY 40202. 0 1990 by The Society of Thoracic Surgeons
Fig 1 . Repair of the severely lacerated lung with felt pledgets. 0003-4975/90/$3.50
150
HOW TO DO IT FULTON AND DICKSON CLOSURE OF PULMONARY LACERATIONS
Ann Thorac Surg 1990;50 14%50
Fig 2 . Resection of giant bullae with closure of lower lobe under bolsters.
closure be used in patients with pulmonary infection or long-term bronchopleural fistula.
References 1. Hood RM. Trauma to the chest. In: Sabiston DC Jr, Spencer FC, eds. Gibbon’s surgery of the chest. Philadelphia: W.B. Saunders, 1983:291-317. 2. Ellison RG. Bullous and bleb diseases of the lung. In: Shields TW, ed. General thoracic surgery. 2nd ed. Philadelphia: Lea & Febiger, 1983:67&94. 3. Naclerio EA. Wounds of the lung. In: Chest injuries: physiologic principles and emergency management. New York: Grune & Stratton, 1971, 249-57. 4. Piarolero PC, Payne WS. The surgical management of recur-
rent or persistent pneumothorax: abrasive pleurodesis. In: Kittle CF, ed. Current controversies in thoracic surgery. Philadelphia: W.B. Saunders, 1986:4%57. Yormans CR, Williams RD, McMinn MR, Derrick JR. Surgical management of spontaneous pneumothorax by bleb ligation and pleural dry sponge abrasion. Am J Surg 1970;120:644-8. Eastridge CE, Hamman JL. Pneumothorax complicated by chronic steroid treatment. Am J Surg 1973;1267&1-7. Delarue NC. Chronic lung disease: emphysema, blebs and bullae. In: Glenn WWL, Liebow AA, Lindskog GE, eds. Thoracic and cardiovascular surgery with related pathology. New York: Appleton-Century-Crofts, 1983:292-307. Brooks JR. Complications following pulmonary lobectomy. In: Cordell AR, Ellison RG, eds. Complications of intrathoracic surgery. Boston: Little, Brown, 1979:239-45.
Methods of closing lung tissue with stapling devices or simple sutures are usually adequate. In some patients lung tissue is so friable that reinforcement of the sutures with tissue flaps is beneficial. Felt bolsters or pledgets can also be used as we describe. (Ann Thoruc Surg 2990;50:14950)
L
acerations, perforations, and resections of pulmonary tissue if not sealed properly may allow prolonged air leak and hemorrhage [l].Currently accepted methods of closure, using stapling devices or simple sutures, occasionally fail [2, 31 and cause further lung damage [4, 51. This is particularly true of contused or overexpanded lung. We have used felt pledgets or bolsters for reinforcing suture lines in several situations. Prolonged air leak, continued hemorrhage, or both were avoided in all patients.
Technique
also is not easily amenable to simple suture methods. Likewise, the overexpanded lung encountered in bulla emphysema is difficult to close, and prolonged air leak is a recognized hazard of bleb resection (71. The use of felt pledgets or bolsters to prevent tearing of pulmonary tissue has proved satisfactory in our practice. The method is quite simple, and because the sutures are held by the felt, the suture line is maintained without further tearing even with overexpansion of lung due to disease or mechanical ventilation. Concern about placing foreign bodies in apposition to an open airway is real. It would be thought that the use of such material in an injured lung or patient treated by steroids would increase the incidence of empyema, particularly with prolonged air leak. However, postoperative empyema is a function of poorly drained and incompletely closed pleural spaces that allow air leaks and poor expansion of the lung [8].Intrapleural infection has not developed in any of the patients in whom we have used felt material. Without further experience, however, it would not be recommended that this method of lung
Long felt (either Dacron or Teflon) bolsters are used to stabilize suturing of massively lacerated lung as shown in Figure 1. The bolster can be placed with a single running suture. Bolsters also can be sutured to each side of the laceration and a tertiary suture line used to approximate the severed lung. Nonabsorbable 3-0 sutures have been used effectively. In addition to using this technique in traumatically induced lacerations, we have successfully employed the method to close lung after resection of giant bullae as shown in Figure 2.
Comment The usual repair of torn or resected lung involves the use of either a mechanical stapling device or simple suturing of the disrupted tissue [2, 3). Several examples of pulmonary pathology occur in which this technique may not be satisfactory, allowing for prolonged hemorrhage or air leak. Fibrotic lung, particularly in the patient who has been maintained on long-term steroids, may not hold sutures, leading to unsatisfactory air leak (61. Badly contused lung resulting from penetrating or blunt trauma Accepted for publication April 10, 1990. Address reprint requests to Dr Fulton, Department of Surgery, University of Louisville, 550 South Jackson St, Louisville, KY 40202. 0 1990 by The Society of Thoracic Surgeons
Fig 1 . Repair of the severely lacerated lung with felt pledgets. 0003-4975/90/$3.50
150
HOW TO DO IT FULTON AND DICKSON CLOSURE OF PULMONARY LACERATIONS
Ann Thorac Surg 1990;50 14%50
Fig 2 . Resection of giant bullae with closure of lower lobe under bolsters.
closure be used in patients with pulmonary infection or long-term bronchopleural fistula.
References 1. Hood RM. Trauma to the chest. In: Sabiston DC Jr, Spencer FC, eds. Gibbon’s surgery of the chest. Philadelphia: W.B. Saunders, 1983:291-317. 2. Ellison RG. Bullous and bleb diseases of the lung. In: Shields TW, ed. General thoracic surgery. 2nd ed. Philadelphia: Lea & Febiger, 1983:67&94. 3. Naclerio EA. Wounds of the lung. In: Chest injuries: physiologic principles and emergency management. New York: Grune & Stratton, 1971, 249-57. 4. Piarolero PC, Payne WS. The surgical management of recur-
rent or persistent pneumothorax: abrasive pleurodesis. In: Kittle CF, ed. Current controversies in thoracic surgery. Philadelphia: W.B. Saunders, 1986:4%57. Yormans CR, Williams RD, McMinn MR, Derrick JR. Surgical management of spontaneous pneumothorax by bleb ligation and pleural dry sponge abrasion. Am J Surg 1970;120:644-8. Eastridge CE, Hamman JL. Pneumothorax complicated by chronic steroid treatment. Am J Surg 1973;1267&1-7. Delarue NC. Chronic lung disease: emphysema, blebs and bullae. In: Glenn WWL, Liebow AA, Lindskog GE, eds. Thoracic and cardiovascular surgery with related pathology. New York: Appleton-Century-Crofts, 1983:292-307. Brooks JR. Complications following pulmonary lobectomy. In: Cordell AR, Ellison RG, eds. Complications of intrathoracic surgery. Boston: Little, Brown, 1979:239-45.