Mattress Stitch Research Articles

Massive hepatic resection in the treatment of severe liver trauma

The incidence of severe liver trauma is rising. Violence in the cities and high speed highway accidents are the most important contributing factors in civilian cases whereas penetrating, high velocity missile wounds account for the largest part of the military experience. Management of severe liver injury has traditionally been directed toward controlling exsanguinating hemorrhage and has been characterized by large isolating mattress stitches, packing with gauze or absorbent materials, and drainage. The mortality has been high (between 40 and 60 per cent) and the rate of serious complications approximately 50 per cent in the survivors [I$]. Most of the postoperative complications can be attributed to (1) continued bleeding, (2) necrosis of devitalized liver, and (3) subphrenic collections of blood and bile which become septic [3,4]. The increasing experience with elective liver resections for malignancy, both primary and metastatic, and the conviction that in many instances extensive damage to the liver from trauma may best be treated by formal hepatic resection rather than by attempts to reconstruct a badly fragmented lobe, have resulted in a growing body of clinical material which supports the concept of resection of devitalized tissues, drainage of injured areas, and vigorous postoperative metabolic support [6,6].

Ventricular cannulation during open cardiotomy

T HE AD~A~TTAGE of an approach through a Ieft posteroIatera1 thoracotomy for open operations on the mitral valve has been well described [r]. In our opinion, exposure of the mitra1 vaIve from the left side is superior to that obtained through a right thoracotomy. The vaIve is immediately beIow the Ieft atria1 incision and not at the end of a long atria1 tunne1 as it is when a right approach is used. In addition, decompression of the Ieft side of the heart is easiIy accomplished by inserting a smaI1 cannuIa into the apex of the Ieft ventricIe. With a right thoracotomy, a catheter must be passed through the Iong atria1 tunne1 and through the mitral valve to vent the Ieft ventricle. With a right thoracotomy, air may be trapped beneath the mitral vaIve Ieaffets, beIow the aortic cusps or in the right puImonary veins. In the left IateraI position, air emboIism is Iess of a probIem. In this case, the Ieft ventricIe is the uppermost chamber of the heart and consequentIy, air in the Ieft side of the heart accumuIates in the apex where it is evacuated through the vent. With a Ieft thoracotomy, venous bIood is best removed from the right side of the heart by pIacing a large cannuIa in the right ventricutar outflow tract. CannuIation of the right atria1 appendage is dangerous because of the difhcuIty in obtaining a good exposure. Even cannuIation of the right ventricuIar outflow tract may be diffrcuIt as it Iies beneath the sternum. Therefore, it is essentia1 that the surgeon have compIete controI of the site of the ventricuIotomy during cannuIation and decannuIation. WhiIe observing this operation at other hospitaIs, we noted that either a purse-string or a mattress suture was pIaced in the right ventricIe at the site of venous cannuIation. This suture was tied down tightIy after the cannuIa was introduced. Another knot was pIaced in the loose ends and the suture tied to the intracardiac cannuIa to fix it in piace. Such a suture tends to cut through the ventricular myocardium when tied down, and since the suture was knotted after cannuIation, it could not be used to contro1 bIeeding from the ventricuIotomy after decannuIation. We have used a method of cannuIating the right ventricuIar outflow tract for venous drainage and the Ieft ventricIe for venting, which is safe, quickly and easiIy accompIished, and reIativeIy bloodless. This method is undoubtedly used eIsewhere but we have not seen it described in the Iiterature. The technic is so superior to the one just mentioned that it seems worth whiIe to set it forth in detai1. The Ieft hemithorax is opened through the fifth intercosta1 space. The incision is carried nearly to the IateraI sterna1 border. The pericardium is wideIy incised anterior to the phrenic nerve. Hemostats are placed on the anterior, inner aspect of the pericardia1 sac. Traction on these hemostats rotates the right side of the heart into view. An avascular area in the right ventricuIar outflow tract is chosen for cannuIation. A horizonta1 mattress stitch is placed in this location using a Iarge atraumatic needIe with a swedged No. I-O silk suture. The suture is passed through strips of Teffon@ feIt at its points of entry into and exit from the myocardium and is so pIaced that its free ends point cephaIad. (Fig. IA.) The Ioose ends of the mattress suture are passed through a 5 to 6 cm. segment of a 16 F. red rubber

An Improved Method of End to Lateral Intestinal Anastomosis; A New Mattress Stitch

An Improved Method of End to Lateral Intestinal Anastomosis; A New Mattress Stitch