Interactive Cardiovascular and Thoracic Surgery 2:503-505(2003)
© 2003 European Association of Cardio-Thoracic Surgery
New ideas - Thoracic general |
Improvement of air tightness of stapled lung parenchyma using fascia lata
Thomas F. Molnara,*,
Szilard Rendekib,
Laszlo Lukacsa and
Örs Peter Horvatha
a Faculty of Medicine, Department of Surgery, Division of Thoracic Surgery, University of Pecs, Ifjusag u 13, H-7636 Pecs, Hungary
b Faculty of Medicine, Department of Anaesthesia and Intensive Therapy, University of Pecs, Ifjusag u 13, H-7636 Pecs, Hungary
* Corresponding author. Fax: +36-72-536-127
mft{at}iseb.pote.hu
Received January 19, 2003;
received in revised form April 25, 2003;
accepted May 29, 2003
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Abstract
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Postoperative air leakage, a seemingly minor complication following procedures on emphysaematosus lung parenchyma can lead to very serious consequences. It is best treated if prevented. We report a technical modification of buttressing stapled resection line using autologuous fascia lata.
Key Words: Emphysaema; Postoperative air leakage; Buttressing; Staplers
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1. Introduction
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Prolonged air leak following lung parenchyma resection can result in significant morbidity extended duration of hospital stay and higher costs as well. Long stay on tubes and bottles causes nuisance and discomfort to the patient and the surgeon as well. The wide range of techniques aiming to reduce the frequency of this potentially triggering complication is mirroring the unresolved nature of the problem. Neither local application of fibrin glue [1] nor the LASER-like effects of the Argon-Beam Coagulator [2] gave a final solution of the problem of postoperative air leakage of troublesome lung parenchyma.
Lung volume reduction surgery significantly challenges thoracic surgeons to overcome this question. The application of bovine pericardium [3] is widely accepted and its efficacy is proven [4] not only in pneumonoplasty but also for other types of parenchymal resections, if the condition of the lung parenchyma requires an extra security. The disadvantages of the technique are the cost of the implant and the unfavourable effect of foreign material [5]. To avoid xenoimplantation [6] and suffering from restrictions of a permanently limited hospital budget, an alternative technique was looked for. An old neurosurgical solution of harvesting fascia lata to cover large defects [7] was modified and applied to the thoracic field of surgery.
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2. Technique
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Harvesting of the fascia lata is performed by a junior team member simultaneously with the lung resection, a 15 cm longitudinal incision over the lateral surface of the thigh gives a good access to the thick fascial plane covering the vastus lateralis muscle. A 20x10 cm section of the thickest part of the fascia was sharply dissected free and then cut off (Fig. 1).
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Fig. 1 Longitudinal incision of the lateral surface of the mid-thigh in a length of 8–10 cm gives a good access to the preparation.
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The fascia was kept in a bowl containing normal saline until application. Subsequently the harvested piece was longitudinally divided into slices of 5x2 cm, and then tied to each of the jaws of the cartridges fitting to any of the staplers used. Usually three to four ties of 3/0 absorbable sutures were enough to fix the slices safely (Fig. 2). The stapling procedure was carried out as normally. On completing the parenchymal resection the ties were simply cut off from the jaws.
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Fig. 2 Absorbable ties are used to affix the fascia lata slices to the surfaces of the jaws of the stapler.
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3. Comments
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Eighteen patients with pulmonary emphysaema were operated on where the lung parenchyma was secured using the described method exclusively or alternating with the bovine pericardium technique during the last 4 years. No procedure related complications like wound infection or significant pleural effusion requiring extension of drainage were encountered. The femoral wound did not interfere with the mobility of the patient, as the standard thoracic epidural anesthesia provided a sufficient pain control. Single shot Augmentin 1.2 g iv perioperative antibiotic prophylaxis was administered.
No air-leakage lasted more than 5 days (average 3.2 days). Only one unfortunate case who has undergone a bilateral lung volume reduction died after 2 months. We thus had an opportunity to compare the fate of the implanted xeno and homografts at a post mortem examination as the two sides were operated on using both of the techniques alternatively. No significant differences were detected at microscopic examination proving that the described method is not inferior to the standard methods. Any of the available thoracoabdominal staplers can be armed this way. Using two staplers simultaneously, a delay in time is avoidable as the swab nurse can prepare the tools reloading the cartridges and arming them with the slices. If one faces problematic lung parenchyma and for some reasons is reluctant to use the xenoimplant technique the presented method is applicable to reduce the complication rate.
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Appendix A
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ICVTS on-line discussion
Author: H.V. Rajashekara Reddy, Specialist Registrar, Norfolk & Norwich University Hospital, Department of Thoracic Surgery, Norwich, UK
Date: 29-Jul-2003
Message: Good results in preventing prolonged air leaks after surgery on emphysematous lungs with the use of, versatile, tensor fascia lata from the thigh to butress the stapler. We have often used the parietal pleura to reinforce the stapler line while dealing with secondary pneumothoraces and appears to be good.
doi:10.1016/S1569-9293(03)00126-9
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References
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- Dahan M, Berjaud J, Mazeres F, Ike O. The importance of biological glue for the prevention of air leakage in pulmonary surgery fibrin sealing in surgical and non-surgical fields. Schlag G, Wolner E, Eckersbergber F. Cardiovascular surgery, thoracic surgery. Berlin, Heidelberg: Springer Verlag; 1995. p. 113–116
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- Thammavaram KV, Benzel EC, Kesterson L. Fascia lata graft as a dural substitute in neurosurgery. South Med J. 1990;83:634–636[Medline]
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Abstract
1. Introduction