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Use of the Endostitch device for closure of pharyngeal traumatic lacerations
Use of the Endostitch Device for closure of pharyngeal traumatic lesions
SCOTT HARDEMAN, MD, ARTEMUS J. COX III, MD, ANDREW JOHNSON, ORT, and BRENDAN C. STACK, JR, MD, St Louis, Missouri
Lacerations of the pharynx provide management dilemmas in both closure and access. Most surgeons use an open neck approach for access. The decision to close a possibly contaminated wound harbors potential complications including mediastinitis.1 An open neck incision and exploration places the patient’s cranial nerves at risk and involves possible wound complications, patient discomfort,1 and disfigurement. A 17-year-old male patient was the unrestrained driver in a motor vehicle accident and reported striking the steering wheel with his neck. He had no respiratory compromise or change in voice. Flexible endoscopy showed a normal, functioning larynx without evidence of fracture or mucosal injury. A 4-cm vertical laceration was noted in the posterior midline of the hypopharynx extending to the cricopharyngeus inferiorly. CT revealed air in the mediastinum down to the carina and diffusely in the neck, with no evidence of tracheal compromise. While the patient was under general anesthesia, a CroweDavis mouth gag was inserted, and the laceration was visualized. An endoscopic camera was used to inspect the entire laceration, which showed no evidence of infection with the mucosal edges viable and in close approximation. The wound was irrigated with bacitracin solution. With the Endostitch device (Autosuture, US Surgical, Norwalk, CT) under endoscopic guidance, 5 interrupted sutures of 3.0 Vicryl were placed, and excellent closure was achieved (Fig 1). The patient received 6 doses of perioperative intravenous clindamycin. He remained afebrile, was tolerating clear liquids well on postoperative day 2, and had a normal white blood cell count. He was discharged on a soft diet and 7 days of oral clindamycin. At follow-up he noted no fever and no dysphagia and had no complications.
geon’s hands has led to its use in other forms of surgery. Urologic surgeons use the Endostitch device when performing laparoscopic pyeloplasty, and gynecologic surgeons have found this a useful alternative when performing sacrospinous ligament fixation.2,3 Blunt trauma resulting in a nondevitalized linear laceration of the pharynx in an otherwise healthy and asymptomatic patient is a rare event. Nonetheless, endoscopic closure with the Endostitch device offered excellent repair with minimal morbidity in our patient. The unique technology of placing sutures distal from the surgeon’s immediate access may be applicable to other otolaryngologic procedures. REFERENCES 1. Tostevin P, Hollins L, Bailey C. Pharyngeal trauma in children—accidental and otherwise. J Laryngol Otol 1995;109: 1168-75. 2. Chen R, Moore R, Kavoussi L. Laparoscopic pyeloplasty. Urol Clin North Am 1998;25:323-30. 3. Schlesinger R. Vaginal sacrospinous ligament fixation with the Autosuture Endostitch device. Am J Obstet Gynecol 1997;176: 1358-62.
A
DISCUSSION The Endostitch device was designed for abdominal endoscopic surgery. However, the ease of placing sutures distal to the surThis section is made possible through an educational grant from AstraZeneca, LP, makers of Rhinocort Aqua. From the Department of Otolaryngology–Head and Neck Surgery, St Louis University (Drs Hardeman, Cox, and Stack); and the Operating Room, St Louis University Hospital, Tenet Healthcare Inc (Dr Johnson). Reprint requests: Brendan C. Stack, Jr, MD, Department of Otolaryngology–Head and Neck Surgery, Pennsylvania State University College of Medicine, 500 University Dr, H091, Hershey, PA 17033. Otolaryngol Head Neck Surg 2000;122:942. Copyright © 2000 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2000/$12.00 + 0 23/11/103079 doi:10.1067/mhn.2000.103079 942
B
Ima ge a va ila ble in print only
Fig 1. A, Endoscopic view of the Endostitch placing the fifth (of 5) 3-0 Vicryl suture in the posterior wall of the pharynx. The endotracheal tube is seen anteriorly. B, Schema of Endostitch device function.
SCOTT HARDEMAN, MD, ARTEMUS J. COX III, MD, ANDREW JOHNSON, ORT, and BRENDAN C. STACK, JR, MD, St Louis, Missouri
Lacerations of the pharynx provide management dilemmas in both closure and access. Most surgeons use an open neck approach for access. The decision to close a possibly contaminated wound harbors potential complications including mediastinitis.1 An open neck incision and exploration places the patient’s cranial nerves at risk and involves possible wound complications, patient discomfort,1 and disfigurement. A 17-year-old male patient was the unrestrained driver in a motor vehicle accident and reported striking the steering wheel with his neck. He had no respiratory compromise or change in voice. Flexible endoscopy showed a normal, functioning larynx without evidence of fracture or mucosal injury. A 4-cm vertical laceration was noted in the posterior midline of the hypopharynx extending to the cricopharyngeus inferiorly. CT revealed air in the mediastinum down to the carina and diffusely in the neck, with no evidence of tracheal compromise. While the patient was under general anesthesia, a CroweDavis mouth gag was inserted, and the laceration was visualized. An endoscopic camera was used to inspect the entire laceration, which showed no evidence of infection with the mucosal edges viable and in close approximation. The wound was irrigated with bacitracin solution. With the Endostitch device (Autosuture, US Surgical, Norwalk, CT) under endoscopic guidance, 5 interrupted sutures of 3.0 Vicryl were placed, and excellent closure was achieved (Fig 1). The patient received 6 doses of perioperative intravenous clindamycin. He remained afebrile, was tolerating clear liquids well on postoperative day 2, and had a normal white blood cell count. He was discharged on a soft diet and 7 days of oral clindamycin. At follow-up he noted no fever and no dysphagia and had no complications.
geon’s hands has led to its use in other forms of surgery. Urologic surgeons use the Endostitch device when performing laparoscopic pyeloplasty, and gynecologic surgeons have found this a useful alternative when performing sacrospinous ligament fixation.2,3 Blunt trauma resulting in a nondevitalized linear laceration of the pharynx in an otherwise healthy and asymptomatic patient is a rare event. Nonetheless, endoscopic closure with the Endostitch device offered excellent repair with minimal morbidity in our patient. The unique technology of placing sutures distal from the surgeon’s immediate access may be applicable to other otolaryngologic procedures. REFERENCES 1. Tostevin P, Hollins L, Bailey C. Pharyngeal trauma in children—accidental and otherwise. J Laryngol Otol 1995;109: 1168-75. 2. Chen R, Moore R, Kavoussi L. Laparoscopic pyeloplasty. Urol Clin North Am 1998;25:323-30. 3. Schlesinger R. Vaginal sacrospinous ligament fixation with the Autosuture Endostitch device. Am J Obstet Gynecol 1997;176: 1358-62.
A
DISCUSSION The Endostitch device was designed for abdominal endoscopic surgery. However, the ease of placing sutures distal to the surThis section is made possible through an educational grant from AstraZeneca, LP, makers of Rhinocort Aqua. From the Department of Otolaryngology–Head and Neck Surgery, St Louis University (Drs Hardeman, Cox, and Stack); and the Operating Room, St Louis University Hospital, Tenet Healthcare Inc (Dr Johnson). Reprint requests: Brendan C. Stack, Jr, MD, Department of Otolaryngology–Head and Neck Surgery, Pennsylvania State University College of Medicine, 500 University Dr, H091, Hershey, PA 17033. Otolaryngol Head Neck Surg 2000;122:942. Copyright © 2000 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2000/$12.00 + 0 23/11/103079 doi:10.1067/mhn.2000.103079 942
B
Ima ge a va ila ble in print only
Fig 1. A, Endoscopic view of the Endostitch placing the fifth (of 5) 3-0 Vicryl suture in the posterior wall of the pharynx. The endotracheal tube is seen anteriorly. B, Schema of Endostitch device function.