Routine Closure Research Articles

Two-Stage Sternal Closure after Repair of Congenital Heart Disease in Neonates

Closure of the longitudinal sternal incision can lead to unacceptable impairment of the haemodynamic state after prolonged operation for complex congenital heart disease associated with decreased cardiac function which is caused by cardiac dilatation. Between 1981 and 1991, a two-stage sternal closure was used in 21 neonates with dilatation of the heart and low cardiac output after correction of congenital heart disease. The mean age at operation was 14 (range 4-30) days. In 15 patients (group 1), primary closure of the sternum was considered impossible in the operating room; in the remaining six (group 2), the sternum was reopened on the day of operation or on the first or second day after repair. Three of these newborn infants had a total anomalous pulmonary venous connection and 18 a simple transposition of the great arteries. In all patients, temporary closure of the thorax with a dura mater patch was performed. The patch was usually removed on day 4 after operation in the intensive care unit and followed by uncomplicated routine chest closure. There were no problems with mediastinitis, wound infection, osteomyelitis or instability of the sternum. Subsequent deformity of the thorax was not observed. Some 11 of 15 children (73%) of group 1 and four of six (66%) of group 2 survived. Leaving the sternum open resulted in a significant improvement in the haemodynamics in all patients. The technique of two-stage closure of the sternum is very effective after lengthy corrective operation in children with congenital malformations of the heart who require long periods of perfusion or ischaemia.

The natural course of atrial septal defect in adults — A still unsettled issue

Atrial septal defect is the most frequently encountered major congenital cardiac disorder in the adult population, with a prevalence of 0.2 to 0.7 per thousand. Several patients tolerate large unrepaired defects for 80 years or even longer without serious disability. However, it is assumed that, as a rule, atrial septal defect reduces life expectancy, the average age at death not exceeding 50 years. This estimation is based on studies derived mainly from necropsy series or from the admission profile of patients undergoing late operative repair. The onset of atrial fibrillation, with an incidence ranging from 13 to 52 percent among patients older than 40 years, as well as the progression of pulmonary arterial hypertension in up to 53 percent of patients, results in congestive heart failure and functional limitation. On the other hand, very few longitudinal studies thus far have directly and systematically followed the course of adults with unrepaired defects. Thus, many issues regarding the natural history and prognosis of atrial septal defect still remain unresolved. Follow-up series of older patients with nonoperated defects could yield valuable information even in an era when routine early surgical closure is increasingly being recommended.

Extrapericardial tamponade with herniated omentum after transhiatal esophagectomy

An unusual complication following transhiatal esophagectomy for lower esophageal carcinoma is reported in which extrapericardial tamponade and profound shock occurred secondary to a herniated section of omentum in the immediate postoperative period. The two-dimensional echocardiogram was nondiagnostic, but the diagnosis was confirmed during reexploration of the abdomen. Anatomic and pathophysiologic considerations of this unusual but life-threatening complication are discussed. The literature suggests that computed tomography is the study of choice to confirm the clinical diagnosis of pericardial pathology, and this case report is yet another example to support routine closure of the esophageal aperture.

Pericardial closure after cardiac operations: An animal study to assess currently available materials with particular reference to their suitability for use after coronary artery bypass grafting

An experimental study to assess the performance of currently available pericardial substitutes is described with particular reference to their use after coronary artery bypass grafting. Seventy-two ewes, (six groups of 12 animals) had a 7 x 5 cm portion of the pericardium excised. Each group had either the defect left open, primarily resutured, replaced with coarse Dexon No. 2 mesh (American Cyanamid Co., Danbury, Conn.), replaced with fine Dexon No. 8 mesh, replaced with glutaraldehyde-preserved bovine pericardium, or replaced with polytetrafluoroethylene 0.1 mm surgical membrane. Six animals from each group were assessed at 3 months and the remaining six animals were assessed at 6 months. The open-defect and resutured groups served as control animals. None of the substitutes proved superior to the open-defect group in the prevention of chest wall/lung-to-pericardium adhesions at either 3 or 6 months. The limitations of the animal model in assessing this aspect of substitute performance are discussed. Whereas the bovine pericardium, polytetrafluorethylene, and Dexon No. 8 mesh groups were superior to the resutured group in the prevention of pericardium-to-epithelium adhesions in the area of the patch, this advantage was lost at 6 months when resuturing proved as effective as polytetrafluoroethylene and bovine pericardium. In all groups there was little tendency to produce generalized pericardial adhesions. At 3 months Dexon No. 8 mesh and bovine pericardium produced the least amount of significant epicardial reaction. In two animals in the 3-month polytetrafluoroethylene group and in one animal in the 6-month polytetrafluoroethylene group, a "fibrous peel" was encountered on the inner surface of the patch, which had also become adherent to the epicardium and had obscured the underlying anatomy. At 6 months the open-defect, resutured, and bovine pericardium groups had produced no significant epicardial reaction. In one animal at 6 months the bovine pericardium had become markedly thickened and degenerative. We do not recommend routine closure of the pericardium after coronary artery operations with any of the substitutes investigated in our study.

Vein patch versus primary closure for carotid endarterectomy A randomized prospective study in a selected group of patients

During a 4-year period, 136 patients undergoing 152 carotid endarterectomies consented to be randomized to primary or saphenous vein patch closure of the arteriotomy. At operation, before randomization, careful assessment of arterial dimensions and anatomy was made. Patients who had an internal carotid artery (ICA) diameter less than 5 mm, arteriotomy extending more than 3 cm beyond the origin of the ICA, or tortuous or kinked ICAs were not randomized; they received obligatory vein patch closure (necessary in 20% cases). All patients were followed up every 3 months for 1 year and every 6 months thereafter with duplex scanning, ocular pneumoplethysmography, and neurologic assessment. The incidence of atherosclerotic risk factors was equal in the groups and all except one of the patients were male. Perioperative morbidity was not significantly different among those having primary closure (n = 60), saphenous vein patch closure (n = 62), and obligatory vein patch closure (n = 30). Operative time among patients having primary closure (122 ± 4 minutes) was significantly less (p < 0.001) than among those having saphenous vein patch closure (150 ± 3 minutes). Three perioperative strokes were evenly distributed among the groups (2% for all procedures); no deaths and no acute postoperative occlusions occurred. Recurrent disease occurred in 12.9% of patients having saphenous vein patch closure compared with its occurrence in 1.7% of those having primary closure (p < 0.05). However, most recurrences were moderate stenoses (25% to 50% diameter reduction), all were smooth-surfaced, and none required a second operation. All except one of the recurrences among those patients with saphenous vein patch closure were in the bulb and the origin of the ICA; two had evidence of regression. This finding suggested that thrombus layering in the dilated part of the saphenous vein patch reconstruction was the cause. This study demonstrates that in men with carotid arteries of predetermined minimal dimensions undergoing carotid endarterectomy routine saphenous vein patch closure does not produce superior results, is associated with a higher incidence of early recurrence, and increases operative time. In selected patients with anatomic risk factors for recurrent disease or acute postoperative occlusion, saphenous vein patch closure is appropriate.

Bretylium and diltiazem in porcine cardiac procedures.

The use of miniature swine as a model for cardiovascular diseases of humans is becoming more popular for many reasons. One of the problems involved in using swine is their propensity for fatal cardiac arrhythmias during surgical procedures requiring general anesthetics, especially cardiac procedures. In preparation for use as a model of human atherosclerotic coronary artery disease, 30 three-month-old (15 kg) Hanford miniature swine underwent left heart catheterization, coronary angiography, and abrasion of the left anterior descending coronary artery. All pigs were treated with diltiazem HCl 30-60 mg (2-4 mg/kg) three times daily and aspirin 25 mg once daily, both given orally for three days before surgery. General anesthesia was induced with a combination of ketamine HCl 25 mg/kg, atropine sulfate 0.1 mg/kg, and acepromazine 0.22 mg/kg, all given intramuscularly. Halothane 1-2% and nitrous oxide 30% were used to maintain general anesthesia after endotracheal intubation. After successful cannulation of the femoral artery, all animals were given 200 units/kg heparin and 5 mg/kg bretylium tosylate intravenously. The electrocardiogram and mean blood pressure were monitored throughout the procedure. No significant change in blood pressure was noted during the procedure. Intracoronary nitroglycerin 200 micrograms was administered prior to abrasion of the left anterior descending with a 2.0-mm angioplasty balloon. The pigs were allowed to recover after routine closure of the incision. One pig (1/30) died during the abrasion procedure as a result of ventricular fibrillation. This represents a low, acceptable mortality using the present regimen compared with other regimens.

Closure of extensive and complicated laminectomy wounds. Operative technique.

Fifty-eight patients with previously irradiated intramedullary spinal cord astrocytomas underwent laminectomy for radical excision of their tumors. A high incidence of postoperative cutaneous cerebrospinal fluid fistulas and large pseudomeningoceles following routine closure prompted the development of an alternative method of wound closure using mobilized musculofascial flaps. The authors describe the surgical techniques and pitfalls to be avoided during the closure of complicated laminectomy wounds.

Immediate hemodynamic effects of pericardial closure after open-heart surgery.

Acute hemodynamic effects of a routine pericardial closure after cardiopulmonary bypass was studied in 29 patients undergoing cardiac surgery. Clinically, the pericardial closure was well tolerated. Pericardial closure resulted in an 8% decrease of cardiac output (p less than 0.01) while cardiac index remained normal (2.9 l/min/m2 +/- 0.6 SD). The effect of the pericardium on pulmonary arterial and wedge pressures, and on systemic arterial pressure was not significant. Central venous pressure increased from 8 +/- 2 mmHg to 9 +/- 3 mmHg (p less than 0.05) after pericardial closure and decreased to 7 +/- 3 mmHg (p less than 0.05) when the pericardium was reopened. Left ventricular end-diastolic cavity diameter by echocardiography decreased in 19 of the patients studied from 46 +/- 6 mm to 41 +/- 5 mm (p less than 0.01) when the pericardium was closed, and increased to 45 +/- 6 mm (p less than 0.01) after re-opening of the pericardiotomy incision. The hemodynamic effects of pericardial closure seem to result from limited ventricular filling.

Methylmethacrylate reconstruction of large iliac crest bone graft donor sites.

INTERNATIONAL ABSTRACTS OF PLASTIC AND RECONSTRUCTIVE SURGERY: SURGICAL MANAGEMENT: Techniques and Instruments: PDF Only

Methylmethacrylate Reconstruction of Large Iliac Crest Bone Graft Donor Sites

Often full-thickness iliac crest grafts are necessary for various reconstructive procedures. Sometimes large defects remain in the donor ilium subsequent to their removal. Several complications have occurred as a result of these bony defects. Although several reports have been published regarding the repair of iliac herniae, little has been written about procedures to prevent these complications. A technique was devised to reconstruct the ilium with methylmethacrylate. After preparation of the defect, malleable retractors are bent to conform to the contour of the iliac crest. Methylmethacrylate is then packed into the mold made by the retractors. After hardening, the methylmethacrylate casting of the defect is trimmed and routine soft tissue closure is performed. This technique has been used in eight patients without any complications. The appearance of the waist and crests has been excellent; there have been no fractures or displacements of the mass of cement and there have been no infections. All these reconstructions have been mechanically stressed as all patients had well molded postoperative casts and/or braces. Reconstruction of the ilium with methylmethacrylate after removal of full-thickness grafts appears to be a reliable, safe, and easy technique based on a short-term follow-up of up to three years.

Evisceration Secondary to Blunt Trauma

We present a case of evisceration of the stomach, small bowel, and colon through an old incisional hernia in a 75-year old woman following blunt automobile trauma to the abdomen. Following routine surgical closure and debridement of excess skin the patient recovered uneventfully with no recurrence of the hernia.

Preventing Disruption of Abdominal Wounds

The use of silver wire retention sutures requires added operating room time and expense, and it incurs the potential hazards of caught viscera, the possibility of more adhesions, leakage of intraperitoneal fluid through the exit wound, mild infection of exit wounds, and, on removal of the sutures, pain despite sedation, cutting of viscera, and a residual cross-hatched scar. Nevertheless, we believe that use of the technic is amply justified by the prevention of abdominal wound disruption, ease in visualization of the wound, ease in providing equal distribution of wound tension and periodic adjustment of it, and in reapproximation of superficial tissues in the event of wound breakdown, as well as in the elimination of need for any external supportive device. The existence of a voluminous literature on the placing, making, and closing of abdominal incisions suggests that no single ideal method exists. Major disruption of abdominal wounds continues to be a serious problem, despite the infrequency of its occurrence. The use of through-and-through semirigid silver wire retention sutures with adjustable tension as a complement to the routine layered closure can prevent disruption of abdominal wounds while causing only minor complications.

Role of Dextran 70 in Microtubal Surgery

Pelvic adhesion formation represents a major problem following fallopian tube surgery for infertility. Intraperitoneal dextran may prevent pelvic adhesions. Extensive personal clinical experience (W. H. U.) with intraperitoneal dextran organ-flotation on completion of tubal and ovarian surgery has appeared to limit adhesions. A specific study was designed to test the validity of this theory. Four randomized groups of rabbits were subjected to bilateral tubocornual division and microsurgical reanastomosis with total hemostasis and pelvic lavage. Routine peritoneal closure was performed on one group, but followed instillation of 30 to 50 ml of normal saline into the peritoneal cavities of the second group, and 30 to 50 ml of 6% dextran 70 into those of the third. Study of fourth group, which received 32% dextran 70 in the peritoneal cavity, was discontinued because of complications. A second laparotomy was performed 4 weeks later for precise assessment and photography of adhesion formation. Each animal was mated 4 weeks after the second operation in order to determine fertility rates. Reduced adhesion formation and increased fertility rates following the instillation of dextran are reported. A role for dextran 70 in infertility surgery is recommended.

Use of Synthetic Absorbable Sutures for Abdominal and Chest Wound Closure

The advent of synthetic collagen suture (polyglycolic acid and polyglacin 910) has provided a new dimension in surgical suturing. However, surgeons in general have not yet taken full advantage of the potential that this new material offers. Associated evisceration and wound dehiscence rates as well as the incidence rate of wound infection were assessed since these represent standards by which the suture material can be evaluated. In an entire series of 650 cases, there has been one case of wound dehiscence with evisceration. The incidence of infection has been less than 1%, which is comparable to previous experience with interrupted, nonabsorbable sutures. The time required for closure using the new material has been approximately one third of that associated with the use of conventional interrupted closure sutures. This implies a substantial cost reduction for the patient. As a result of this experience, the synthetic absorbable sutures seem to represent the material of choice for routine abdominal or chest wound closure.

Pleural Flap Closure of Pericardial Defects Following Intrapericardial Pneumonectomy

Persistent pericardial defects following intrapericardial pneumonectomy are, historically, the major cause of iatrogenic cardiac herniation. This complication is uniformly fatal when unrecognized and untreated and has been associated with a 43% mortality even with surgical correction. Suture approximation of all small defects is recommended, and a technique for routine pleural flap closure of moderate to large-sized defects is described.

Gastroschisis

Two cases of gastroschisis are presented. Both were operated upon, one survived. This rare congenital anomaly is described as congenital evisceration through an extraumbilical defect in the anterior abdominal wall. Since there is no protective covering membrane the eviscerated bowels form a tightly adherent, discolored, thickened mass. Fourteen cases fulfilling the criteria outlined by Moore and Stokes have previously been presented in the literature. Surgical repair was attempted in twelve; seven survived. Our two cases bring the total number of reported cases of gastroschisis to sixteen and the total surviving to eight. It appears desirable to close the abdominal wall primarily in cases of gastroschisis in which there is minimal disproportion between the eviscerated mass and the size of the abdominal cavity. However, there is usually marked disproportion between the coelomic cavity and its eventrated contents, because the volume of the viscera is larger than the capacity of the abdominal cavity. The method advocated by Gross for the repair of large omphaloceles, namely, covering the defect with skin only, seems to be an extremely useful device when primary routine closure is not possible.