Modified Technique of Closing the Port Site After Multiport Thoracoscopic Surgery Using the Shingled Suture Technique: a Single
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Xu et al. BMC Surg (2021) 21:223 https://doi.org/10.1186/s12893-021-01220-4 RESEARCH ARTICLE Open Access Modifed technique of closing the port site after multiport thoracoscopic surgery using the shingled suture technique: a single centre experience Haitao Xu, Shuai Ren, Tianyu She, Jingyu Zhang, Lianguo Zhang, Teng Jia and Qingguang Zhang* Abstract Background: Due to improvements in operative techniques and medical equipment, video-assisted thoracoscopic surgery has become a mainstay of thoracic surgery. Nevertheless, in multiport thoracoscopic surgery, there have been no substantial advances related to the improvement of the esthetics of the site of the chest tube kept for postopera- tive drainage of intrathoracic fuid and decompression of air leak after thoracoscopic surgery. Leakage of fuid and air around the site of the chest tube can be extremely bothersome to patients. Methods: From March 2019 to April 2020, we used a modifed technique of closing the port site in 67 patients and the traditional method in 51 patients undergoing multiport thoracoscopic surgery due to lung disease or mediasti- nal disease. We recorded patients’ age, gender, body mass index, surgical method, postoperative drainage time, and postoperative complications.The NRS pain scale was used to score the pain in each patient on the day of extubation. The PSAS and the OSAS were used for the assessment of scars one month after surgery. Results: In the modifed technique group, only one patient (1.49%) had pleural efusion leakage, compared with fve patients (9.80%) in the traditional method group (P < 0.05). There were no signifcant diferences in the pain of extubating and wound dehiscence between the two groups. However,the incidence rates of wound dehiscence in the modifed technique group were lower than in the traditional method group. There were no post-removal pneu- mothorax and wound infection in either of the groups. Signifcant diferences in the PSAS and OSAS were observed between the groups,where the modifed technique group was superior to the traditional method group. Conclusions: The modifed technique of port site closure is a leak-proof method of fxation of the chest tube after multiport thoracoscopic surgery. Moreover, it is efective and preserves the esthetic appearance of the skin. Keywords: Multiport, Video‐assisted thoracoscopic surgery, Chest tube, Suture Background Tere are diferent approaches to video-assisted thora- coscopic surgery, such as multiport and uniport approaches. Since Gonzales frst reported uniport thora- coscopy for a lobectomy in 2011 [1], diferent operative *Correspondence: [email protected] procedures [2, 3] and techniques for fxation of post- Department of Thoracic Surgery, Binzhou Medical University Hospital, No. operative drainage tubes [4, 5] have attracted attention. 661 Huanghe 2nd Road, Binzhou 256603, Shandong, People’s Republic of China Nevertheless, in multiport thoracoscopic surgery, there © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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BMC Surg (2021) 21:223 Page 2 of 6 have been no substantial improvements in the esthetic Surgical technique management of the port site or in the optimal means of For multiport thoracoscopy, the thoracoscopic incision assuring an adequate watertight fxation of the chest tube was about 15 mm long and was made in the seventh or to prevent leakage of fuid or air around the postopera- eighth intercostal space at the mid-axillary line. A 12 mm tive drainage tube. Here, we shared our experience using Trocar (Ethicon, Somerville, NJ, US) was used to estab- a new method of thoracoscopy port site closure that lish a path for the thoracoscopy camera. A second work- improves both the esthetic appearance of thoracoscopy ing port site incision (30 mm) was made in the fourth or port site and the fxation and function of the postopera- ffth intercostal space at the anterior axillary line, and a tive chest tube. third working port site incision (20 mm) was made in the eighth intercostal space at the scapular line. After fnish- ing the intrathoracic aspect of the operation, a chest tube Methods was inserted through the smallest incision for postop- Patients erative evacuation of any accumulated intrathoracic fuid We retrospectively analyzed patients with lung disease and decompression of any air leak. For our technique, or mediastinal disease who had undergone multiport we divided the thoracoscopy port site incision where the thoracoscopic surgery in the Binzhou Medical University chest tube is to exit into three zones: T C was the region Hospital between March 2019 and April 2020. A total of located in the center of the site of the drainage tube, 67 patients received a modifed technique of closing the while TL and TR were the regions to be closed located at port site using the shingled suture technique (the modi- both sides of the chest tube. fed technique group) by the team of Haitao Xu. A total Before inserting the chest tube, two separate 2-0 Vic- of 51 patients received the traditional method of fxa- ryl sutures (Ethicon, Somerville, NJ, US) were used to tion of the chest tube using two nonabsorbable sutures approximate the deep muscle layers with their investing to close the skin on each side of the drainage tube (the fascia, one on each side (the midpoints of T L and TR); traditional method group) by another team. We recorded however, after the sutures were placed, they were not tied patients’ age, gender, body mass index (BMI), surgical at this point, but the ends were exteriorized out the inci- method, postoperative drainage time, and postopera- sion to be tied later. After the chest tube was inserted, tive complications. Postoperative complications included the sutures were tied to approximate the muscle layer pleural efusion leakage, post-removal pneumothorax, (Fig. 1a). Because the port site opening was narrow, this wound infection, and wound dehiscence. Te Numeric approach facilitated placing the sutures for optimal clo- rating scale [6] (NRS) pain scale was used to score the sure of the muscle layer without the chest tube interfer- pain in each patient on the day of extubation. Te Patient ing with the placement of the sutures, which ensured a Scar Assessment Scale [7] (PSAS) and the Observer Scar tight closure of this deep space. Assessment Scale [7] (OSAS) were used for the assess- Next, four separate 1 -0 Vicryl sutures (Ethicon, ment of scars one month after surgery. Tis study was Somerville, NJ, US) were used for intermittent suture approved by the Ethics Committee of the Binzhou Medi- of the subcutaneous adipose tissue at 1/4 and 3/4 of cal University Hospital. the distance between T L and T R to ensure an eventual Fig. 1 a Intermittent suture of the deep muscles of the port site. b Intermittent suture of the subcutaneous adipose tissue of the port site. c Removal-free, absorbable, continuous intradermal suture of the skin Xu et al. BMC Surg (2021) 21:223 Page 3 of 6 tight closure of the subcutaneous tissue of the port site Statistical analysis around the exiting chest tube (Fig. 1b). SPSS 22.0 statistical software was used for data analysis. Next, two separate 1-0 silk braided nonabsorbable Te measurement data were analyzed by independent sutures (Ethicon, Somerville, NJ, US) were sewn into sample t-test and expressed in the form of mean ± stand- subcutaneous tissues near the chest tube, one on each ard deviation. Te counting data were compared by the side, and tied about 3–5 cm above the skin around the chi-square test or Fisher’s test. A value of P < 0.05 was chest tube to fx the chest tube securely. Again, these considered statistically signifcant. sutures for tube fxation were not tied in the subcu- taneous tissues. Finally, a 3-0 unidirectional, barbed, absorbable suture (Angiotech, Aguadilla, Puerto Rico) Results was used for a continuous intradermal suture closure of Te clinical characteristics of the patients are shown in the port site skin. Te suture went around one side of Table 1. Tere were no signifcant diferences in clinical the chest tube with the 1-0 silk braided sutures posi- features between the two groups (P > 0.05). Te chest tioned between the chest tube and the intradermal tubes were removed 2–13 days after the thoracoscopic suture. Several centimeters of the ends of the intrader- procedure. Table 2 shows a comparison of the postop- mal suture were left outside the incision at one end, and erative complications between the two groups. Tere the end of the suture was pulled to tighten the intra- was a signifcant diference in the rate of pleural efusion dermal wound closure (Figs. 1c and 2a). Tese intrader- leakage between the two groups (P = 0.04).