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Ann Thorac Surg 1999;68:1059-1060
© 1999 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, 25 Prescott St, Suite 3416, Atlanta, GA 30308, USA
Invited commentary
This paper presents an unusual reported complication of laparoscopic surgery. The patient was a 46-year-old female who underwent a laparoscopic cholecystectomy 4 months before admission. At the time of surgery, a clip was inadvertently placed on the common bile duct. A percutaneous cholangiogram revealed complete occlusion of the common duct consistent with surgical ligation.
The patient underwent a percutaneous transhepatic biliary drainage. Subsequently, she was readmitted to her local medical center and then transferred to the University of Indiana, where she was found to have a right lower lobe pneumonia consistent with Klebsiella pneumoniae. She was transferred to the intensive care unit and placed on ventilatory support. A spiral computed tomography showed a 5.5-cm cavity in the area of the right lower lobe of the lung with communication in the dome of the right hemidiaphragm. She was ultimately taken to the operating room, where she underwent bilobectomy with severance of the communication between the subphrenic abscess and the right lower lobe of the lung. She was then treated with a five-rib thoracoplasty with complete obliteration of the subphrenic abscess and space. She was weaned from the ventilator and discharged on her 22nd hospital day.
The authors have correctly pointed out that fistulous communications between the biliary tree, pleura, and lung have been associated with both neoplasms and benign inflammatory processes. The primary area of concern in this patient presented in the right subhepatic space with subsequent development of an abscess into the right lower lobe of the lung. The authors then proceeded with bilobectomy and complete obliteration of the space by five-rib thoracoplasty.
I would differ with the authors on their surgical approach to the inferior thoracic space. They proceeded with a direct five-rib thoracoplasty to obliterate the space. However, in this modern era of thoracic surgery, thoracoplasty is rarely required and is a procedure of last resort. First, I am surprised plastic surgery was not consulted in this case, or other techniques of space obliteration were not considered. They were left with a fairly large space, of which there are a number of means of obliterating, without resorting to a five-rib thoracoplasty. There are essentially six means of eliminating an inferior thoracic space without resorting to thoracoplasty, which would be the last procedure of choice. These are: (1) modified Lyman-Brewer maneuver; (2) pneumoperitoneum; (3) diaphragmatic elevation by plication and realignment with synthetic grafts or diaphragmatic reattachment; (4) phrenic nerve crush if adequate pulmonary reserve is present; (5) intrathoracic muscle transposition with either rectus abdominis or latissimus dorsi; or (6) Inferior right-angle chest tubes with high suction. As a last resort, thoracoplasty could be performed. Frequently, several of these maneuvers are used in various combinations. All of these would have far less physiologic and anatomic disfigurement problems than the thoracoplasty that was performed.
Although the operation was successful, they have left the patient with an anatomic defect that is unnecessary on the basis of current applications of inferior space manageent.
Related Article
Ann. Thorac. Surg. 1999 68: 1058-1059.
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