Suture technique for severe lung laceration with preservation of lobe for thoracic trauma
Su Zhiyong
From June 1995 to July 2008, 84 cases of severe lung laceration were repaired by lobe preserving severe lung laceration suture technique, and the corresponding compound injuries inside and outside the thorax were treated, and the fractured ribs were fixed by absorbable rib nails and other methods with good results. Su Zhiyong, Department of Cardiothoracic Surgery, Affiliated Hospital of Chifeng College
1 Data and methods
There were 84 patients, 21 female and 63 male, aged 15-61 years old, with an average of 38 years old. Traffic injury 68 cases, mining machinery injury 5 cases, crush injury 1 case, fall injury 10, clinical manifestations: all have chest pain after injury, including hemoptysis and hematochezia 76 cases, dyspnea 52 cases, subcutaneous emphysema 33 cases, yoked chest paradoxical breathing 46 cases, shock 5 cases, coma 2 cases, chest film and CT examination: rib fracture 3 to 10, all combined with hemopneumothorax and different degrees of traumatic wet lung manifestations, including sternal 4 cases of fracture, 3 cases of tracheal rupture, 2 cases of heart injury, 1 case each of diaphragmatic hernia, splenic rupture and lower esophageal rupture, and and 3 cases of traumatic brain injury, and 9 cases of clavicle limb fracture.
Suturing method for severe lung laceration.
Unidirectional deep to superficial suture method is suitable for lacerations with larger and more open trauma, the premise of which is to stop bleeding and suture the fractured trachea to prevent the formation of pulmonary hemopneumocyst by coughing up blood and leaking air after surgery, and the suture is drawn together from deep to superficial with absorbable thread avoiding the vascular trachea.
Bidirectional dorsal suture from deep to shallow: When the laceration is narrowly tunneled through the lung lobe, the laceration margin can be enlarged appropriately, hemostasis is applied to repair the tracheal air leak, and the section is closed with absorbable sutures from deep to shallow in both directions from the center.
Artificial lung laceration suture method: Applicable to lung laceration not completely penetrated, near the lung margin, laceration surface without intersegmental arteries and veins and segmental bronchial laceration, instead of pulling the section together and suturing, each section will be manually or instrumentally sutured into a method similar to artificial lung laceration, this method of suture hemostasis and air leakage are more complete.
Pulmonary cut and fold caulking suture method: When the laceration becomes a deeper tunnel, a part of the split section can be sutured bare, and then the laceration can be caulked deeper to achieve compression and hemostasis, and then another bare section can be sutured after hemostasis and superimposed on it, with the premise that hemostasis should be complete without active intersegmental arteriovenous bleeding and air leakage from tracheal injury.
Pulmonary vascular block repair or lung segment resection method is suitable for active intersegmental arteriovenous hemorrhage with narrow and deep field of view, which can be revealed with its upper in lobe fissure dissection or total trunk block after revealing the vessels with 4-0 or more prolene suture, if intersegmental artery cannot be repaired can be ligated or lung segment resection can be performed.
Sleeve anastomosis for simultaneous tracheal laceration repair, for patients with tracheal rupture combined with pulmonary laceration repair by the above method first, if there is no obvious active bleeding at the rupture opening, then trim the ruptured trachea for sleeve anastomosis, after the anastomosis, the lung should be expanded to observe the reopening of the repaired lobe.
Instrument cutting and suturing method: Avoid the main trachea and large blood vessels with linear cutting and suturing device, remove the heavier lung tissue from the laceration locally, or select the edge of the laceration, first instrument part of the suture to remove the laceration to make the laceration shallow, retain a fish mouth-like laceration as the observation port, and use silk thread to avoid blood vessels from the bottom of the laceration through the suture.
Bio-adhesive or hemostatic sponge caulking suture was used for narrow and deep laceration without active inter-segmental pulmonary arteriovenous bleeding and tracheal injury with air leak, which could be placed with bio-adhesive or hemostatic gauze and antibiotic powder, caulking and compression followed by penetrating suture, but no active bleeding and attention to infection prevention were required.
Among 84 patients, 24 patients were treated with unidirectional deep-to-superficial sutures, 12 patients with bidirectional back-to-back deep-to-superficial sutures, 14 patients with instrument cut sutures, 13 patients with artificial lung laceration sutures, 7 patients with lung cut and folded caulking sutures, 5 patients with bioadhesive or hemostatic sponge caulking sutures, 6 patients with pulmonary vascular block or lung segment resection, and 3 patients with sleeve anastomosis of the trachea. In 8 cases, small hematomas and pneumocysts appeared in the postoperative chest films, which were completely absorbed within three months. 32 patients were discharged from the hospital after 1-6 days of ventilator support, except for one case with sudden abdominal hemorrhage on the third postoperative day, which was analyzed as a ruptured traumatic abdominal aortic aneurysm and died.
Discussion We defined severe pulmonary laceration as: pulmonary laceration of one or more lobes with a depth greater than 3 cm, narrow or penetrating laceration; with significant intrapulmonary hematoma or intrapulmonary traumatic cysts and foreign bodies; with tracheal, subdivided trachea and vascular injury; combined with more severe pulmonary contusion, traumatic wet lung and ARDS. We observed that most of the severe lung laceration cases are laceration along the direction of tracheal vascular pathway, different degrees of longitudinal or through avulsion, accompanied by inter-segmental tracheal injury and arteriovenous hemorrhage, part of the formation of hematoma traumatic cyst, this characteristic is very instructive for designing laceration wound suture pathway, hemostasis and tracheal vascular repair, choosing the shallowest and shortest pathway as close as possible to the site of bleeding and tracheal air leak, If necessary, the superficial tracheal laceration without large blood vessels can be enlarged or fully opened for hemostasis repair, and the subsegmental trachea and blood vessels within the laceration should be repaired as much as possible to prevent active bleeding and air leakage.
The comprehensive application of lung laceration suturing techniques with preservation of the lung lobes largely avoids lung resection and maximizes preservation of lung function. In designing the suturing method, the ideas should always run through how to suture and pull together the laceration lung tissue, how to deal with vascular bleeding, how to suture the tracheobronchial tubes with air leakage, how to leave no gap to reduce blood leakage and air leakage to form a hemopneumocyst. The correct use of instruments can shorten the operation time and reduce the chance of contamination and bleeding.1 However, attention should be paid to the selection of suitable nail height, reasonable hemostasis of the nail surface, and prevention of incomplete bleeding and air leakage from the nail, and hemostatic gauze compression filling should be used with caution because of the risk of infection. For elderly patients with emphysema in particular, we should design the suture route according to the degree of trauma and try to use instruments with spacers, and spray biogel on the cutting surface to prevent air leakage, and repair trauma should not neglect the investigation of the original underlying lung disease in individual patients and the correction of traumatic coagulation disorders in some patients with severe trauma and close hemostasis to prevent postoperative bleeding.
Patients with severe pulmonary laceration mostly have coughing blood, often combined with hemopneumothorax, shackle chest and compound injuries inside and outside the chest, in recent years, it is advocated that the treatment of severe pulmonary contusions should be accompanied by necessary fixation and ventilator support for severe floating chest wall, which can reduce the incidence of bleeding and ARDS.2,3 In this group, wire fixation of rib fractures with gram pins was used in the early stage, and in recent years, absorbable rib nails and circumferential fixation were used to stabilize the chest wall, and pulmonary contusions often cause pulmonary tissue hemorrhagic edema, ventilation function, oxygen diffusion dysfunction and increased intrapulmonary shunt, decreased pulmonary compliance, resulting in hypoxemia and respiratory distress, pulmonary contusion exudation peak 12~24h after injury, often developing into ARDS within 24h.4 Postoperatively, especially in patients with multiple rib fractures combined with shackle chest and severe lung laceration, the necessary postoperative short-term ventilator support, in preventing secondary respiratory failure rapid The necessary short-term postoperative ventilatory support is important in preventing secondary respiratory failure and nosocomial infection. In our group of 32 patients, after 1-6 days of ventilator support, there were often lamellar shadows on the postoperative chest radiographs after repair. Early high-dose short-term administration of hormones could reduce capillary permeability, stabilize cell walls and lysosomes, reduce intra-alveolar edema and interstitial edema, relieve tracheal spasm, improve ventilation, and at the same time, high-dose application of mucosolvan prevented the occurrence of pneumonic atrophy. In eight patients in the group, small hemocysts appeared after repair, and the treatment in this case focused on the prevention of bacterial-fungal infections. Small intrapulmonary hemopneumocysts are often absorbed in about ten days, and larger lesions can be absorbed within three months without affecting pulmonary function or leaving a sigmoid shadow.
Author Affiliation：024001 Department of Thoracic Surgery, Affiliated Hospital of Chifeng College, Inner Mongolia
Corresponding author: Zhiyong Su Email :[email protected] Mobile 13088405635
Reference.
［1］ Tang JM,Chen G,Wu YL,et al. The application of instrumented surgical techniques in lung resection,Chinese Journal of Thoracic and Cardiovascular Surgery 2009,25(6):410-411
[2] Shi YK. Advances in the diagnosis and treatment of thoracic trauma [J]. Chinese Journal of Trauma,1998,14(2):66.
[3] Wang Guoqing, Li Xingdi, Treatment of traumatic floating chest wall, Chinese Clinical Journal of Thoracic and Cardiovascular Surgery, 1996, 3(1):29-30
[4] Zhong Yuanbo, Liang Xiongbin. Diagnosis, treatment and prognosis of acute respiratory distress syndrome caused by severe thoracic trauma. Journal of Modern Clinical Medical Bioengineering,2004,3:257-258.