Ann Thorac Surg 2005;79:1431-1432
© 2005 The Society of Thoracic Surgeons
How to do it
A New, Easy Method for Putting "U" Stitches Inside the Chest Wall
Atsushi Watanabe, MD*,a,
Toshiaki Watanabe, MDa,
Hiroki Satoh, MDa,
Tohru Mawatari, MDa,
Hisayoshi Ohsawa, MDa,
Noriyuki Takahashi, MDa,
Tomio Abe, MDa
a Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
Accepted for publication December 12, 2003.
* Address reprint requests to Dr Watanabe, Sapporo Medical University School of Medicine, Chuo-ku South 1, West 16, Sapporo 060-8543, Japan
atsushiw{at}sapmed.ac.jp
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Abstract
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In this report, we describe a new, easy method for putting "U" stitches inside the chest wall. The method does not require extension of the skin incision nor subcutaneous dissection and it minimizes chest wall injury. This method may also be applied to other surgical fields where needles can penetrate the wall of the cavity when it is difficult to stitch from the inside of the cavity.
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Introduction
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In general thoracic surgery, reconstruction of the diaphragm is sometimes required in cases of patients with pulmonary or pleural neoplasm invading the diaphragm [1, 2] and in cases of congenital defects of the diaphragm [3, 4]. There is not always a sufficient margin of diaphragm to sew the pleural side of the chest wall. When the margin of the diaphragm connected to the chest wall is slim, it is difficult to place the stitches on the pleural side of the chest wall because there is not enough solid tissue in the area and because the diaphragm is perpendicular to the chest wall. Therefore, additional skin incisions or subcutaneous dissections are required and a stitch is passed through the subcutaneous layer from the outside of the chest wall, or additional thoracotomy is required in order to stitch from the pleural side. We have established a new method for putting a single "U" stitch in the pleural side of the chest wall from the outside. This method does not require either extension of the skin incision or subcutaneous dissection in order to reconstruct defective diaphragms, even when patients have only a slim margin of diaphragm.
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Technique
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A 67-year-old woman was admitted to our hospital for examination and treatment of an abnormal shadow on a chest roentgenogram, which was revealed during an examination of a mass. A computed tomographic scan showed a round mass of fat density, which was well delineated, homogenous, and 50 x 70 x 80 mm in size, located in the right back, bottom of the thoracic wall just above the right diaphragm. The mass was diagnosed as a lipoma, and resection by video-assisted thoracoscopic surgery was scheduled. A 40-mm long skin incision was made as an access port on the sixth intercostal space on the middle axillary line, and two 15-mm long skin incisions were made as utility ports on the fourth and fifth intercostal space on the anterior axillary line. There was no abnormal pleural adhesion or effusion. The mass was dissected from the thoracic wall and moved toward the retroperitoneal space through a defect in the diaphragm, which was not preoperatively detected. As much adipose tissue was removed as possible, and the defect in the diaphragm was closed with a direct suture using the new method mentioned as follows.
A 19-gauge needle was inserted into the right pleural cavity through the skin lying over the intrathoracic site, and a 3-0 Prolene suture (Ethicon, Somerville, NJ) was passed through the inner cavity of the needle. The end of the suture was held by endoscopic forceps in the pleural cavity. The 19-gauge needle was pulled partially out until the tip was located in the muscle or subcutaneous layer, and then the direction of the needle was changed so that the tip penetrated the chest wall in the proper position. The needle was reinserted into the right pleural cavity, and the other end of the suture was passed through the inner shaft of the needle. The needle was pulled out, and the end of the suture was held by endoscopic forceps in the pleural cavity. Both ends of the suture were threaded through needles and moved from the abdominal side to thoracic side of the diaphragm. Furthermore, absorbable pledgets were placed on the thoracic side of the diaphragm. The other stitches were made using the same method. All sutures were ligated in the right pleural cavity after their placement using the same method. Using video-assisted thoracic surgery, the procedure was performed in the right pleural cavity (Fig 1).
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Fig 1. A new, easy method for putting "U" stitches inside the chest wall. (A) A 19-gauge needle was inserted into the right pleural cavity through the skin. (B) A suture was passed through the inner cavity of the needle. (C) The needle was pulled partially out until the tip was located in the muscle or subcutaneous layer. (D) The direction of the needle was changed so that the tip penetrated the chest wall in the proper position. (E) The needle was reinserted into the right pleural cavity, and the other end of the suture was passed through the inner shaft of the needle. (F) The needle was pulled out, and the end of the suture was held by endoscopic forceps in the pleural cavity.
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We used our method on 2 more patients with pleural mesothelioma during the reconstruction of their diaphragms after extrapleural pneumonectomy. These 3 patients have developed neither diaphragmatic hernia nor wound troubles during the 6- to 24-month observation period.
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Comment
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Diaphragm reconstruction is sometimes required in cases of patients with pulmonary or pleural neoplasm invading the diaphragm and in cases of patients with congenital diaphragm defects. The diaphragm is usually reconstructed using prosthetic material such as polytetrafluoroethylene [5] or auto material of reverse latissimus dorsi flap [6, 7] if the defect size is large or if there is tension during the close. In these cases, we sometimes encounter patients who have a slim margin of diaphragm in the pleural side of their chest wall that needs stitches. However it is difficult to sew stitches from the intrathoracic side, because the first intercostal space is too narrow to stitch if the needle is perpendicular to the rib. Also the ribs get in the way when stitching, and there is positional difficulty in placing stitches if the site is tangential to a thoracotomy. Therefore, we sometimes have to put stitches in the chest wall from the outside after extending the skin incision and dissection between the subcutaneous layer and muscle layer, which occasionally causes extensive wound pain and seroma. Because of this, we developed an easier and safer method using "U"-shaped stitches. This new method does not require either extension of the skin incision or dissection of subcutaneous tissue, and only needle punctures remain on the skin where the needle penetrated. When there is not a sufficient solid margin of diaphragm to put stitches in the chest wall, this new method is very safe and useful for connecting the diaphragm with sutures to the lateral chest wall within the intrathoracic space, if the intrathoracic procedure was performed using video-assisted thoracic surgery. Furthermore, our method enables us to get sufficient buttressing tissue such as intercostal muscle or ribs, even if these tissues are not exposed. We believe this method will be of benefit to other general thoracic surgeons because it does not require any special material or instrument. In addition, we believe this method can be applied to other surgical fields where needles can penetrate the wall of the cavity when it is difficult to stitch from the inside of the cavity, and also when it is necessary to place some stitches in a perpendicular wall without a sufficient margin to sew. We recommend the use of this method in such cases.
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References
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- Song HK, Leibold TM, Gal AA, Miller JI Jr. Extraskeletal osteosarcoma of the diaphragm presenting as a chest mass. Ann Thorac Surg. 2002;74:565–567[Abstract/Free Full Text]
- Bedini AV, Andreani SM, Muscolino G. Latissimus dorsi reverse flap to substitute the diaphragm after extrapleural pneumonectomy. Ann Thorac Surg. 2000;69:986–988[Abstract/Free Full Text]
- de Kort LM, Bax KM. Prosthetic patches used to close congenital diaphragmatic defects behave well: a long-term follow-up study. Eur J Pediatr Surg. 1996;6:136–138[Medline]
- Glavas M, Drazinic I, Pikot D, Altarac S. Patch reconstruction of hemidiaphragm agenesis by the polypropylene mesh prosthesis. Croat Med J. 2000;41:333–335[Medline]
- Chapelier A, Macchiarini P, Rietjens M, et al. Chest wall reconstruction following resection of large primary malignant tumors. Eur J Cardiothorac Surg. 1994;8:351–357[Abstract]
- Bianchi A, Doig CM, Cohen SJ. The reverse latissimus dorsi flap for congenital diaphragmatic hernia repair. J Pediatr Surg. 1983;18:560–563[Medline]
- Bedini AV, Andreani SM, Muscolino G. Latissimus dorsi reverse flap to substitute the diaphragm after extrapleural pneumonectomy. Ann Thorac Surg. 2000;69:986–988
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Abstract
Introduction
