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Reinforced staple line in severely emphysematous lungs
J
THORAC CARDIOVASC S URG
1989;97 :362-3
Reinforced staple line in severely emphysematous lungs In severely empbysemat~ or otherwise destroyed lung parenchyma, staples often cut through, which causes prolonged postoperative air leakage. A mechanical suture line reinforced by a polydioxanone ribbon is a simple, safe, and effective method for closure of air leaks, resection, or biopsy in such
cases. F.-M. Juettner, MD, P. Kohek, MD, H. Pinter, MD, G. Klepp, MD, and G. Friehs, MD, Graz, Austria
From the Department of Thoracic and Hyperbaric Surgery, University Medical School of Graz, Graz, Austria . Received for publication March 8, 1988. Accepted for publication July 20, 1988. Address for reprints: F.-M. Juettner, MD, Dept. Thoracic & Hyperbaric Surgery, University Medical School of Graz , A-8036 Graz, Austria.
Rrenchymal stapling in severely emphysematous lungs always invites air leakage, inasmuch as the lungs does not hold the staples well, which allows the staples to pull loose or to cut through. Prolonged postoperative suction drainage or even secondary operative procedures may be necessary. Therefore, manually reinforced matress sutures or ligation has been proposed for parenchymal
Fig. 1. Polydioxanone ribbon is placed at site planned for suturing, with care taken not to twist or crease fabric (a). Stapler is aligned parallel to margin of ribbon. Both sides of If-shaped polydioxanone loop must lie within staple line. Note that retaining pin has been removed from cartridge (b). If resection is necessary, parench yma is severed at about 5 mm distance from suture line (c).
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Volume 97 Number 3
March 1989
suturing in such cases.':" We have developed a simple, safe, and time-saving method of parenchymal stapling in severe emphysema.
Technique The area of lung planned for resection, biopsy, or closure of air leakage is grasped with a Duval lung forceps and tented out. A loop of absorbable polydioxanone ribbon (PDS-ribbon, Ethicon, Hamburg, Federal Republic of Germany) is placed around the lung at the site chosen for the suture line. The loop is tented out as well by an atraumatic forceps placed at its loose ends (Fig. I, a). A stapling instrument of appropriate length (TA 30, 55, or 90, Auto Suture Company Division, United States Surgical Corporation, Norwalk, Conn.) charged with a 4.8 mm staple cartridge is prepared by removal of the retaining pin, which would otherwise catch hold at the ribbon and prevent a proper closure of the instrument. The sta pIer is closed over both ribbon and lung, creating a "sandwich" effect (Fig. I, b). Once the staples have been fired, the excess length of the ribbon is severed. If lung tissue has to be resected, it is cut with the margin of the ribbon used as a guide (Fig. I, c). Though air leakage or hemorrhage from the suture line are unlikely with this technique, they can be easily controlled by using the ribbon as reinforcement for additional manual sutures.
Comment The method described results in a tight closure of the parenchyma. The suture can be applied with the lung
Reinforced staple line in emphysematous lungs
363
collapsed or inflated. We have not met with any problems so far in our experience on 14 patients (two cases of substantial panlobular emphysema, one of lymphangioleiomyomatosis, two of destroyed lungs as a result of generalized bullous disease, seven of bullous deformities of the upper lobe, and two of silicosis). In particular, there were no bronchopleural fistulas or infectious complications during the median follow-up of 8.3 months (range 2 to 14 months). Because the polydioxanone ribbon will be absorbed within a few weeks,' there is less risk of implant infection than there is with nonabsorbable material. REFERENCES 1. Allen TH. Technique of resection for localized bullous disease of the lung. Am Surg 1971;37:671-6. 2. Hood RM. Stapling techniques involving lung parenchyma. Surg Clin North Am 1985;64:469-80. 3. Ray lA, Doddi N, Regula D, Williams lA, Melveger A. Polydioxanone (PDS), a novel monofilament synthetic absorbable suture. Surg Gynecol Obstet 1981;153:497501.
THORAC CARDIOVASC S URG
1989;97 :362-3
Reinforced staple line in severely emphysematous lungs In severely empbysemat~ or otherwise destroyed lung parenchyma, staples often cut through, which causes prolonged postoperative air leakage. A mechanical suture line reinforced by a polydioxanone ribbon is a simple, safe, and effective method for closure of air leaks, resection, or biopsy in such
cases. F.-M. Juettner, MD, P. Kohek, MD, H. Pinter, MD, G. Klepp, MD, and G. Friehs, MD, Graz, Austria
From the Department of Thoracic and Hyperbaric Surgery, University Medical School of Graz, Graz, Austria . Received for publication March 8, 1988. Accepted for publication July 20, 1988. Address for reprints: F.-M. Juettner, MD, Dept. Thoracic & Hyperbaric Surgery, University Medical School of Graz , A-8036 Graz, Austria.
Rrenchymal stapling in severely emphysematous lungs always invites air leakage, inasmuch as the lungs does not hold the staples well, which allows the staples to pull loose or to cut through. Prolonged postoperative suction drainage or even secondary operative procedures may be necessary. Therefore, manually reinforced matress sutures or ligation has been proposed for parenchymal
Fig. 1. Polydioxanone ribbon is placed at site planned for suturing, with care taken not to twist or crease fabric (a). Stapler is aligned parallel to margin of ribbon. Both sides of If-shaped polydioxanone loop must lie within staple line. Note that retaining pin has been removed from cartridge (b). If resection is necessary, parench yma is severed at about 5 mm distance from suture line (c).
362
Volume 97 Number 3
March 1989
suturing in such cases.':" We have developed a simple, safe, and time-saving method of parenchymal stapling in severe emphysema.
Technique The area of lung planned for resection, biopsy, or closure of air leakage is grasped with a Duval lung forceps and tented out. A loop of absorbable polydioxanone ribbon (PDS-ribbon, Ethicon, Hamburg, Federal Republic of Germany) is placed around the lung at the site chosen for the suture line. The loop is tented out as well by an atraumatic forceps placed at its loose ends (Fig. I, a). A stapling instrument of appropriate length (TA 30, 55, or 90, Auto Suture Company Division, United States Surgical Corporation, Norwalk, Conn.) charged with a 4.8 mm staple cartridge is prepared by removal of the retaining pin, which would otherwise catch hold at the ribbon and prevent a proper closure of the instrument. The sta pIer is closed over both ribbon and lung, creating a "sandwich" effect (Fig. I, b). Once the staples have been fired, the excess length of the ribbon is severed. If lung tissue has to be resected, it is cut with the margin of the ribbon used as a guide (Fig. I, c). Though air leakage or hemorrhage from the suture line are unlikely with this technique, they can be easily controlled by using the ribbon as reinforcement for additional manual sutures.
Comment The method described results in a tight closure of the parenchyma. The suture can be applied with the lung
Reinforced staple line in emphysematous lungs
363
collapsed or inflated. We have not met with any problems so far in our experience on 14 patients (two cases of substantial panlobular emphysema, one of lymphangioleiomyomatosis, two of destroyed lungs as a result of generalized bullous disease, seven of bullous deformities of the upper lobe, and two of silicosis). In particular, there were no bronchopleural fistulas or infectious complications during the median follow-up of 8.3 months (range 2 to 14 months). Because the polydioxanone ribbon will be absorbed within a few weeks,' there is less risk of implant infection than there is with nonabsorbable material. REFERENCES 1. Allen TH. Technique of resection for localized bullous disease of the lung. Am Surg 1971;37:671-6. 2. Hood RM. Stapling techniques involving lung parenchyma. Surg Clin North Am 1985;64:469-80. 3. Ray lA, Doddi N, Regula D, Williams lA, Melveger A. Polydioxanone (PDS), a novel monofilament synthetic absorbable suture. Surg Gynecol Obstet 1981;153:497501.