Nakajima Y
Department of Thoracic Surgery, National Hospital Organization Tokyo National Hospital, Kiyose, Japan.
Kyobu Geka. 2010 Jul;63(8 Suppl):684-91.
Open window thoracostomy for thoracic empyema: Open window thoracostomy is a simple, certain and final drainage procedure for thoracic empyema. It is most useful to drain purulent effusion from empyema space, especially for cases with broncho-pleural fistulas, and to clean up purulent necrotic debris on surface of empyema sac. For changing of packing gauzes in empyema space through a window once or twice every day after this procedure, thoracostomy will have to be made on the suitable position to empyema space. Usually skin incision will be layed along the costal bone just at the most expanded position of empyema. Following muscle splitting to thoracic wall, a costal bone just under the incision will be removed as 8-10 cm as long, and opened the empyema space through a costal bed. After the extension of empyema space will be preliminarily examined through a primary window by a finger or a long forceps, it will be decided costal bones must be removed how many (usually 2 or 3 totally) and how long (6-8 cm) to make a window up to 5 cm in diameter. Thickened empyema wall will be cut out just according to a window size, and finally skin edge and empyema wall will be sutured roughly along circular edge. Muscle flap transposition for empyema space: Pediclued muscle flap transposition is one of space-reducing operations for (chronic) empyema Usually this will be co-performed with other several procedures as curettages on empyema surface, closure of bronchopleural fistula and thoracoplasty. This is radically curable for primarily non fistulous empyema or secondarily empyema after open window thoracostomy done for fistula. Furthermore this is less invasive than other radical operations as like pleuro-pneumonectomy, decortication or air-plombage for empyema. There are 2 important points to do this technique. One is a volume of muscle flap and another is good blood flow in flap. The former suitable muscle volume is need to impact empyema space or to close fistula, and the latter over-elongation and bending of pedicles should be avoided. Actually, after removing several costal bones on the empyema space, empyema wall will be incised for about 2/3 of total empyema length along costal beds. Then muscle flap will be introduced into cleaned up space and sutured on empyema surface at several points. It is better to lay small vacuum drain tubes along flap within empyema space.
开窗胸廓造口术是治疗胸腔积脓的一种简单、可靠且最终的引流手术。它对于从脓腔引流脓性积液最为有用，特别是对于伴有支气管胸膜瘘的病例，以及清理脓腔表面的脓性坏死碎屑。在此手术后，为了每天一到两次通过窗口更换脓腔内的填塞纱布，胸廓造口术必须在脓腔的合适位置进行。通常皮肤切口将沿着肋骨在脓腔最膨大的位置进行。沿胸壁劈开肌肉后，将切口下方的一根肋骨切除8 - 10厘米长，通过肋床打开脓腔。在通过初始窗口用手指或长镊子初步检查脓腔扩展情况后，将决定必须切除多少根肋骨（通常总共2或3根）以及多长（6 - 8厘米）以形成一个直径达5厘米的窗口。增厚的脓腔壁将根据窗口大小切除，最后皮肤边缘和脓腔壁将沿圆形边缘大致缝合。用于脓腔的肌瓣转移术：带蒂肌瓣转移术是（慢性）胸腔积脓的缩窄手术之一。通常这将与其他几种手术联合进行，如脓腔表面刮除术、支气管胸膜瘘闭合术和胸廓成形术。这对于原发性非瘘性胸腔积脓或因瘘行开窗胸廓造口术后的继发性胸腔积脓可达到根治效果。此外，与其他根治性手术如胸膜肺切除术、纤维板剥脱术或脓腔填充术相比，它的创伤较小。进行这项技术有两个要点。一个是肌瓣的体积，另一个是肌瓣良好的血流。前者需要合适的肌肉体积来填充脓腔或闭合瘘口，后者应避免蒂部过度延长和弯曲。实际上，在脓腔去除几根肋骨后，沿肋床将脓腔壁切开约占脓腔总长度的2/3。然后将肌瓣引入清理后的空间并在脓腔表面的几个点缝合。最好在脓腔内沿肌瓣放置小的负压引流管。
