Ann Thorac Surg 2004;78:2165-2166
© 2004 The Society of Thoracic Surgeons
Case report
Video-Assisted Bronchial Stump Reinforcement With an Intercostal Muscle Flap
Motoyasu Sagawa, MDa,*,
Makoto Sugita, MDa,
Yuji Takeda, MDb,
Hirohisa Toga, MDb,
Tsutomu Sakuma, MDa
a Department of Thoracic Surgery, Ishikawa, Japan
b Department of Respiratory Medicine, Kanazawa Medical University, Ishikawa, Japan
Accepted for publication July 21, 2003.
* Address reprint requests to Dr Sagawa, Department of Thoracic Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Ishikawa 920-0293, Japan
sagawam{at}kanazawa-med.ac.jp
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Abstract
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For lobectomy patients at considerable risk of developing a postoperative bronchopleural fistula, the bronchial stump reinforcement with an intercostal muscle flap is sometimes performed. This procedure usually requires a standard thoracotomy, even if video-assisted thoracoscopic surgery (VATS) is better for the patient. Our patient was a 76-year-old male with lung cancer and severe diabetes mellitus. He underwent lobectomy and systematic nodal dissection combined with bronchial stump reinforcement using an intercostal muscle flap, performed as a VATS procedure. No postoperative complications were observed. This procedure is applicable to patients who are candidates for VATS lobectomy.
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Introduction
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There is a growing consensus that certain patients with clinical stage I lung cancer are candidates for video-assisted thoracoscopic surgery (VATS) lobectomy, especially in elderly patients [1–3]. However, for the patients who are exposed to a considerable risk of developing postoperative bronchopleural fistula, bronchial stump reinforcement using an intercostal muscle flap is sometimes performed. This is a procedure that usually requires a standard thoracotomy, even if a VATS lobectomy would be better for the patient. Using VATS to perform this procedure would be beneficial to a number of patients. We herein present a patient who underwent right upper lobectomy and systematic nodal dissection, combined with bronchial stump reinforcement using an intercostal muscle flap, all of which was performed under VATS.
A 76-year-old man was admitted to our hospital for the investigation of an abnormal chest shadow in the right upper lung field, detected by lung cancer mass screening. The patient's medical history was significant for diabetes mellitus, for which he had refused treatment. A subsequent chest roentgenogram and computed tomography (CT) scan revealed a pulmonary tumor measuring 37 x 35 mm, located in his right S3 segment, adjacent to the thoracic wall. The tumor was diagnosed as adenocarcinoma by transbronchial lung biopsy. Chest CT, brain CT, bone scintigram, and abdominal CT revealed neither lymph node involvement nor distant metastases, indicating stage IB disease. Blood laboratory findings were normal, except for HBA1C, which was 10.2% (normal: < 5.8%). After 2 weeks of insulin therapy, HBA1C decreased to 9.5% and the fasting blood glucose level normalized, and we decided to perform pulmonary resection.
A skin incision 8 cm in length was made at the midaxillary line in the fourth intercostal space. Two thoracoports were placed, one at the midaxillary line in the seventh intercostal space, and the other at the posterior axillary line in the sixth intercostal space. Neither pleural dissemination of carcinoma nor direct invasion to the parietal pleura was observed. Before proceeding with right upper lobectomy, the intercostal muscle flap was prepared. The anterior serratus muscle was split and the latissimus dorsi muscle was retracted posteriorly. Then, under direct visualization with a headlight, the fourth intercostal muscle was separated from the fourth and the fiveth ribs using an electric scalpel. The anterior margin of the muscle flap was then ligated and cut. After the rib spreader was set, right upper lobectomy followed by systematic nodal dissection was conducted as our ordinary VATS lobectomy [3]. Thereafter, the 4th intercostal muscle flap was lengthened under thoracoscopic visualization (Fig 1A) and fixated to the bronchial stump with three sutures of absorbable threads. Then the bronchial stump was covered with the flap by several additional sutures (Fig 1B). His postoperative course was uneventful, and he did not experience severe pain, nor did he develop a bronchopleural fistula.
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Fig 1. Preparation of the intercostal muscle flap and reinforcement of the bronchial stump. (A) The fourth intercostal muscle (black arrows) was separated from the ribs. After the muscle flap was lengthened sufficiently, it was fixated around the bronchial stump (white arrows). (B) The stump was covered with the flap by several additional sutures. (PA = pulmonary artery; SVC = superior vena cava.)
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Comment
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Video-assisted thoracic surgery lobectomy combined with systematic nodal dissection is becoming an important option for elderly patients who have clinical stage I lung cancer. However, for the patients with severe diabetes mellitus, arteriosclerosis, or pulmonary infectious disease, the bronchial stump reinforcement with an intercostal muscle flap is sometimes performed in order to prevent bronchopleural fistula. Although this procedure is usually performed under standard thoracotomy, VATS approach would be beneficial to several patients.
Suturing the intercostal muscle flap to the bronchial stump and surrounding tissues is as easy as other maneuvers performed under VATS. Watanabe and colleagues [4] reported similar impressions in their experience with the pericardial fat pad. However, preparing an intercostal muscle flap using a small skin incision with a limited field of view requires a greater degree of caution. The skin incision should not be in the subscapular region, but in the axillary region. With a subscapular incision, ligation of the intercostal vessels at the frontal margin of the muscle flap would be more difficult.
Our experience with this patient demonstrates that bronchial stump reinforcement with an intercostal muscle flap can be performed under VATS. This is a procedure that can be applied to patients who need VATS lobectomy, but have a considerable risk of developing a postoperative bronchopleural fistula.
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References
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- McKenna R Jr, Wolf RK, Brenner M, Fischel RJ, Wurnig P. Is lobectomy by video-assisted thoracic surgery an adequate cancer operation? Ann Thorac Surg. 1998;66:1903–1908[Abstract/Free Full Text]
- Landreneau RJ, Mack MJ, Dowling RD, et al. The role of thoracoscopy in lung cancer management. Chest. 1998;113:6S–12S[Abstract/Free Full Text]
- Sagawa M, Sato M, Sakurada A, et al. A prospective trial of systematic nodal dissection for lung cancer by VATS: can it be perfect? Ann Thorac Surg. 2002;73:900–904[Abstract/Free Full Text]
- Watanabe A, Abe T, Yamauchi A, Ichimiya Y. Reinforcement of a bronchial stump in VATS lobectomy. Thorac Cardiovasc Surg. 2000;48:242–243[Medline]
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T. Maniwa, Y. Saito, H. Kaneda, and H. Imamura
Bronchial stump reinforcement with the intercostal muscle flap without adverse effects.
Eur. J. Cardiothorac. Surg.,
October 1, 2006;
30(4):
652 - 656.
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Abstract
Introduction
