Ann Thorac Surg 2005;79:750
© 2005 The Society of Thoracic Surgeons
Correspondence
Use of Intracostal Sutures Reduces Thoracotomy Pain With Possible Risk of Lung Hernia: Another Measure for Prevention of Pain
Lucas H. A. Sanders, MD, FCS(SA),
Mark A. J. Newman, MBBS, FRACS
Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, WA 6009, Australia
lucmedi{at}hotmail.com
To the Editor:
We read with interest the article by Cerfolio and colleagues [1] on decreased thoracotomy pain with the use of intracostal sutures. Since 1998, one of the surgeons in our group has routinely used four No. 2 Vicryl (Ethicon, Somerville, NJ) intracostal sutures for closure of thoracotomy wounds. Our technique for thoracotomy is similar to that described by Cerfolio and coauthors. Intercostal nerve block before spreading the ribs is not used.
In addition to the measures discussed by Cerfolio and associates, we also try to prevent possible damage to the intercostal nerve of the top rib. The periosteum (and intercostal bundle) of the inferior surface of the top rib is stripped over an appropriate length to prevent impingement of the intercostal nerve by the blade of the retractor. No trials have been performed in our hospital to test the effectiveness of these measures in reducing thoracotomy pain. It is our impression that they have resulted in a decrease, especially in long-term postthoracotomy pain.
The holes for the intracostal sutures are made with a hand-held drill. Set-up time and additional costs associated with the drill are negligible. With the use of a short drill and deflation of the lung, the possibility of damage to underlying structures is much reduced. In our experience, splitting of ribs has not occurred.
Although lung herniation was not observed, Cerfolio and co-workers noted ribs drifting apart in 2 elderly ladies receiving steroids. We have seen only one instance of separation of the ribs, and this resulted in lung herniation. The patient was 175 cm tall and weighed 84 kg. He had undergone an elective right upper lobectomy for squamous cell carcinoma. Twenty-four hours after the operation, a sudden separation of the ribs was seen on the chest roentgenogram; there were no specific symptoms. The patient was discharged 15 days postoperatively after a prolonged air leak. Six weeks later, he was well at examination. Eight months postoperatively, he was re-referred by his respiratory physician because of a painful, irritable cough and bulging of the chest wall. The lung hernia was repaired, and the ribs were approximated using No. 5 Ethibond (Ethicon) pericostal sutures. At repair, no drill holes or evidence of rib fracture was noted. It was presumed that the sutures had broken. One month later, the patient again was seen with lung herniation. This time repair was performed with a 2-mm Gore-Tex soft tissue patch (expanded polytetrafluoroethylene; W.L. Gore & Associates, Inc, Flagstaff, AZ).
The most common cause of lung herniation after thoracotomy is failure of closure [2]. Mechanisms causing separation of the ribs are delayed wound healing and fracture of the intracostal sutures. The sharp edge of the hole drilled through the ribs can fray and fracture the suture, especially in heavily built patients. Suture material for intracostal closure should be of adequate strength. If the possibility of fraying is observed, additional intracostal or pericostal sutures should be placed.
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References
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- Cerfolio RJ, Price TN, Bryant AS, Bass CS, Bartolucci AA. Intracostal sutures decrease the pain of thoracotomy. Ann Thorac Surg. 2003;76:407–412[Abstract/Free Full Text]
- Weissberg D, Refaely Y. Hernia of the lung. Ann Thorac Surg. 2002;74:1963–1966[Abstract/Free Full Text]
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