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: Reply
Robert J. Cerfolio, MD
Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 1900 University Blvd, THT 712, Birmingham, AL 35294, USA
robert.cerfolio{at}ccc.uab.edu
To the Editor:
My colleagues and I appreciate the comments of Sanders and Newman. As we mentioned in both the report and the discussion [1], the concept of drilling holes in the rib to avoid entrapment of the intercostal nerve during closure is not new. Many surgeons have been doing this for several decades. We, too, have moved to a hand-held drill, but prefer one that is battery powered as opposed to one that is hand cranked. Splitting of the rib will and can occur, although it is rare. It happens as the ribs are brought together. The holes should be drilled at the end of the operation, and the retractor should not be placed after the drilling is done, especially in patients with thin ribs. Over the past year, we have used a smaller drill (Stryker Corporation, San Jose, CA) and now use a 2.5-mm bit and a battery, which clips on to the bottom of the drill. We prefer it to the drill described in the report because it does not require a console for setup. This saves even more time.
Sanders and Newman mentioned the concept of avoiding impairment of the nerve with the retractor. We had a similar idea. Since showing that avoiding the nerve during closure decreases pain, we have asked ourselves if avoiding the nerve during entry can decrease pain as well. We have performed intercostal muscle flaps in more than 350 patients to buttress the bronchus that is at risk for a fistula and have noticed that these patients seem to have less pain. It took 1 year to design, set up, and obtain institutional review board approval for a prospective, randomized trial to examine this issue, but this new study is now well underway. One group of patients receives the muscle-, rib-, and nerve-sparing thoracotomy described in our article. Another group receives identical entry and closure except the intercostal muscle is harvested from the top rib with a Bovie before the chest retractor is placed. This technique provides a versatile pedicled muscle flap that is devoid of periosteum and does not calcify. In addition, it protects the nerve from being crushed by the top blade of the retractor. By verbal report, others including some outside the United States have performed this technique, but it has never been critically studied. We look forward to completing this study and presenting the data.
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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]
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