| Introduction
Gunshot wounds or deep lacerations to the lung cannot
be simply oversewn. Blood vessels deep within the tract
of the injury will continue to bleed and form a haematoma
- which may subsequently form an abscess. More importantly,
open bronchial injuries can lead to air embolism as air
is entrained into open pulmonary veins.
A pulmonary tractotomy opens the tract of the injury
so that open bronchi and vessels can be ligated. Although
initially described as a damage control technique, it
has advantages over formal segmental lung resection as
it preserves healthy pulmonary parenchyma.
Technique
Following a thoracotomy and identification
of a through-and-through injury to the lung, one limb
each of two long clamps (soft bowel clamps in this case)
are passed into the wound tract:
The lung between the two clamps is divided top open up
the base of the tract:
Alternatively, one limb of a linear cutting stapler can
be inserted into the tract and the stapler fired to achieve
the same result very quickly.
Bleeding vessels in the base of the track can now be
oversewn with a figure-of-8 monofilament suture such as
polypropylene. Smal bronchi are identified by small bubbles
of air leaking from the base of the tract, and these are
dealth with in a similar fashion.
Finally the edges of the track between the clamps are
oversewn by running a continuous monofilament suture over
and over the clamps and then back underneath them as a
horizontal mattress suture. If a linear stapler has been
used to open the tract, this step is not necessary.
References
Wall MJ Jr, Hirshberg A, Mattox KL. Pulmonary
tractotomy with selective vascular ligation for penetrating
injuries to the lung. Am J Surg. 1994;168:665-9
Asensio JA, Demetriades D, Berne JD et al. Stapled
pulmonary tractotomy: a rapid way to control hemorrhage
in penetrating pulmonary injuries. J Am Coll
Surg. 1997;185:486-7
Wall MJ Jr, Villavicencio RT, Miller CC et al. Pulmonary
tractotomy as an abbreviated thoracotomy technique.
J Trauma. 1998;45:1015-23
Velmahos GC, Baker C, Demetriades D. et al. Lung-sparing
surgery after penetrating trauma using tractotomy, partial
lobectomy, and pneumonorrhaphy. Arch Surg. 1999;134:186-9
Cothren C, Moore EE, Biffl WL. Lung-sparing techniques
are associated with improved outcome compared with anatomic
resection for severe lung injuries. J Trauma.
2002;53:483-7
trauma.org (10:4) April 2005 |
