Closure of Fenestra in Clagett Procedure: Use of Rectus Abdominis Musculocutaneous Flap Hisao Asamura, MD, Tomoyuki Goya, MD, Tsuguo Naruke, MD, Ryosuke Tsuchiya, MD, Haruhiko Kondo, MD, Keiichi Suemasu, MD, and Takashi Nakatsuka, MD Divisions of Thoracic Surgery and Plastic and Reconstructive Surgery, Department of Surgery, National Cancer Center Hospital, Tokyo, Japan
Empyema developed in a 62-year-old man after right pneumonectomy for lung cancer. According to the Clagett procedure, an open window thoracostomy was made with two ribs removed. After 5 weeks, primary closure of the fenestra was attempted. Because the fenestra was too large to be primarily closed, a rectus abdominis musculocutaneous flap was successfully transposed to cover the
chest wall. There was no evidence of recurrence of empyema during 11 months’ observation after closure. In patients with a large fenestra and with little tissue left for closure, the rectus abdominis musculocutaneous flap could be of great help in completing the Clagett procedure. (Ann Thoruc Surg 1992;54:147-9)
ing to the Clagett procedure. An open window thoracostomy was performed immediately; about 10 cm of the anterior end of the thoracotomy incision was reopened and a 6-cm segment of the underlying sixth rib was removed. As the fifth rib had already been removed in the previous operation, two ribs were missing in the fenestra. The empyema cavity was thoroughly irrigated, and the wound was debrided. The edges of the skin flaps were sutured down to the parietal pleura to form an epithelized tract. Chest roentgenogram after fenestration (Fig 1) revealed a large remaining cavity, which did not seem able to be filled with transposed muscle or omentum alone. The empyema cavity had been dressed once a day for 5 weeks. The primary closure of the fenestra in this case, however, seemed to be extremely difficult for the following reasons: the fenestra was so large that two ribs and associated intercostal tissue were missing; the compliance of the chest wall was greatly reduced owing to contraction after healing of the empyema; the patient was very thin (weighing only 40.5 kg) and short (160.5 cm), and therefore little subcutaneous tissue and musculature for coverage were left. We chose the rectus abdominis musculocutaneous flap. Latissimus dorsi and pectoralis major muscles might be alternatively used, but they had the limitation of a long transposing distance for adequate coverage. First, the rectus abdominis musculocutaneous flap was prepared (Fig 2) under general anesthesia. An ovoidshaped area of skin, 9 x 6 cm, was sought on the abdominal wall so that the distances between the costal arch and the fenestra (top X in Fig 2A) and between the costal arch and the skin flap (bottom X in Fig 2A) would be equal. The full-thickness structure, including the rectus abdominis muscle, anterior sheath, subcutaneous tissue, and the skin itself, was then released from the posterior sheath after dividing the inferior epigastric vessels. Dur-
ostpneumonectomy empyema (PPE) still remains the most troublesome complication of modern pulmonary resections. The infected empyema space has been managed by thoracostomy drainage with a chest tube [l] or pleurostomy followed by a relatively mutilating staged thoracoplasty, the latter associated with considerable pain, high mortality, and often unsatisfactory results . Clagett and Geraci  in 1963 described the successful management of 3 patients with PPE. First, an openwindow thoracostomy was made in the chest wall by resection of one rib for drainage and antiseptic irrigation of the space. Six to 8 weeks later, when the space became clean and sterile, the window was primarily closed surgically in layers under general anesthesia, after the space had been filled with 0.25% neomycin solution. The Clagett procedure has, indeed, provided a less mutilating and more successful method of managing PPE, with lowered morbidity and mortality, but there are still some problems in the case of a large fenestra. We therefore present our method for closing a large fenestra in this classic management of PPE. A 62-year-old man had undergone a right pneumonectomy for large cell carcinoma 15 months before this admission. Wound dehiscence occurred unexpectedly 2 months after the initial operation, and followed the unusual course of recurring four times during the next 13 months in spite of repeated resutures. As the infection penetrated the entire chest wall, inducing empyema, he was admitted. Because there was no evidence of a persisting bronchopleural fistula, we decided to treat the patient accordAccepted for publication Oct 14, 1991 Address reprint requests to Dr Asamura, Division of Thoracic Surgery, Department of Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104, Japan.
1992 by The Society of Thoracic Surgeons
CASE REPORT ASAMURA ET AL MODIFICATION IN CLAGETT PROCEDURE
Ann Thorac Surg 1992;54:147-9
Fig 1. Chest roentgenogram taken after fenestration. The remaining cavity is so large that it cannot be filled by muscular or omental transposition alone.
ing this maneuver, full attention was paid to avoiding injury to the superior epigastric vessels, the nutrient vessels for this musculocutaneous flap. Next, the fenestra was prepared to be closed: the granulation tissue was completely removed, and the infolded skin was released
Fig 2 . Preparation of the rectus abdominis musculocutaneous pap: drawing of flap design (A) and an operative view of the transposed flap (B). In the drawing. the skin and musculature to be transpo:ied are on the right side of the patient, and the posterior sheath and nutrient vessels, the superior epigastric vessels, are on the left side .
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Fig 3. How to transpose the pap: a subcutaneous tunnel is made between the fenestra and the abdominal incision, through which the Pap is retracted upward and sutured to the edges of the fenestra in two layers.
from the parietal pleura. The muscle and fascia1 layers were identified and mobilized. Between the fenestra and the abdominal incision, a subcutaneous tunnel was made, through which the flap was tra.nsposed (Fig 3). The flap and chest wall were then sutured in two layers. At the
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Ann Thorac Surg 1992;54: 147-9
Fig 4. Photograph taken 2 months after the closure. The transposed flap (arrow) has adapted well. Owing to the Dacron mesh applied at the defect of the muscle sheaths, no herniation is evident. A “normal“ postpneumonectomy state is achieved.
lower portion of the abdominal incision, where both anterior and posterior sheaths were lacking, a doubly folded Dacron mesh was applied and sutured to the edges of the anterior sheath to prevent herniation. The abdominal skin and subcutaneous tissue were sutured in a T shape. In contrast with Clagett’s original procedure, a chest tube was left in the pleural cavity as an information drain, which was removed 5 days later after injection of antibiotics. The patient was discharged 16 days after operation and has been followed up for 11 months. The adaptation of the transposed flap was satisfactory (Fig 4), and there was no evidence of recurrence of the empyema. He is back at work and doing well.
Comment Secondary closure of the established fenestra in the management of PPE is controversial. In the original Clagett procedure , the fenestra might be primarily closed after sterilization of the empyema space. Some authors [4, 51, however, have insisted that the closure should not be attempted routinely for two reasons: a permanent ”pouch” is well tolerated and most patients can manage
well in domiciliary care, and the rate of recurrence of empyema after fenestra closure is high. On the contrary, we think the patients are best treated when the fenestra is closed, because they can achieve a normal postpneumonectomy state and be released from troublesome daily wound care. The second operation for closure of the established fenestra has been regarded as “a minor procedure” . Primary closure, however, is unexpectedly difficult in patients with several conditions: a large open fenestra with multiple rib and, especially, associated soft tissue resections; marked contraction of the chest wall; and decreased volume in tissue planes for coverage owing to a chronic inflammatory state. It must be stressed that the initial fenestra should not be too large with regard to the soft tissue. In such conditions, a musculocutaneous flap serves well. For a chest wall fenestra, rectus abdominis, pectoralis major, and latissimus dorsi muscles could be candidates, of which the latter two have the limitation of long transposing distance. The fact that the latissimus dorsi muscle is usually transected in the initial posterolatera1 thoracotomy further limits its use. On the other hand, the rectus abdominis muscle, usually intact, can be removed with minimal loss of function if the posterior rectus sheath is strong enough to prevent an abdominal hernia . In our case, the doubly folded Dacron mesh was sufficient for this purpose. The Clagett procedure is still a useful way to manage PPE, and full efforts should be made to restore a normal postpneumonectomy state to the patient. In cases in which primary closure of the established fenestra is difficult, plastic surgical modification using a rectus abdominis musculocutaneous flap provides another possibility.
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