We retrospectively analyzed patients with lung disease or mediastinal disease who underwent multiport thoracoscopic surgery in the Binzhou Medical University Hospital between March 2019 and April 2020. A total of 67 patients received modified technique of closing the port site using the shingled suture technique (modified technique group).A total of 51 patients received traditional method of fixation of the chest tube use two sutures to close the skin on each side of the drainage tube (traditional method group). The data of the patients included age,gender,body mass index (BMI), surgical method,postoperative drainage time and postoperative complications was recorded.Postoperative complications include subcutaneous emphysema,fluid extravasation, post-removal pneumothorax,wound infection,wound dehiscenc.This study was approved by the Ethics Committee of the Binzhou Medical University Hospital.
For multiport thoracoscopy, the thoracoscopic incision is about 15 mm long and is made in the seventh or eighth intercostal space at the mid-axillary line. A 12 mm Trocar (Ethicon, Somerville, NJ, US) is used to establish a path for the thoracoscopy camera. A second working port site incision (30 mm) is made in the fourth or fifth intercostal space at the anterior axillary line and a third working port site incision (20 mm) is made in the eighth intercostal space at the scapular line. After the intrathoracic aspect of the operation is finished, a chest tube is inserted through the smallest incision for postoperative evacuation of any intrathoracic fluid that accumulates and for decompression of any air leak. For our technique, we divide the thoracoscopy port site incision where the chest tube is to exit into three zones: TC is the region that is located in the center of the site of the drainage tube, while TL and TR are the regions to be closed that are located at both sides of the chest tube.
Before inserting the chest tube, two separate 2-0 Vicryl sutures (Ethicon, Somerville, NJ, US) are used to approximate the deep muscle layers with their investing fascia, one on each side (the midpoints of TL and TR); however, after the sutures are placed, they are not tied at this point, but the ends are exteriorized out the incision to be tied later. After the chest tube is inserted, the sutures are tied to approximate the muscle layer (Fig. 1a). Because the port site opening is narrow, this approach facilitates placing the sutures for optimal closure of the muscle layer without the chest tube interfering with placement of the sutures, which assures a tight closure of this deep space.
Next, four separate 1-0 Vicryl sutures (Ethicon, Somerville, NJ, US) are used for intermittent suture the subcutaneous adipose tissue at 1/4 and 3/4 of the distance between TL and TR to assure an eventual tight closure of the subcutaneous tissue of the port site around the exiting chest tube (Fig. 1b).
Then, two separate 1-0 Silk brarded non-absorbable sutures (Ethicon, Somerville, NJ, US) are sewn into subcutaneous tissues near the chest tube, one on each side, and tied about 3–5 cm above the skin around the chest tube to fix the chest tube securely. Again, these sutures for tube fixation are not tied in the subcutaneous tissues. Finally, a 3-0 unidirectional, barbed, absorbable suture (Angiotech, Aguadilla, Puerto Rico) is used for a continuous intradermal suture closure of the port site skin. The suture goes around one side of the chest tube with the 1-0 Silk brarded sutures positioned between the chest tube and the intradermal suture. Several centimeters of the ends of the intradermal suture are left outside the incision at one end, and the end of the suture was pulled to tighten the intradermal wound closure (Fig. 1c, Fig. 2a). These intradermal sutures do not need to be removed and will be resorbed over the next few weeks. This approach leads to a more scarless result.
When the time is right to remove the chest tube, the incision is disinfected, and the two separate 1-0 Silk brarded sutures used for fixing the drainage tube are cut where they are fixed to the chest tube and removed from the subcutaneous tissues. Then, multiple layers of sterile gauze are used to cover the site of the drainage tube, the patient is instructed to inhale deeply and to hold breath, and while applying pressure on the sterile gauze, the chest tube is removed rapidly. Then the end of the unidirectional barbed suture is tightened to close the skin incision and the suture is cut near the end of the incision (Fig. 2b).We call this a “shingled suture technique” (Fig. 2c).
SPSS 22.0 statistical software was used for data analysis.The measurement data were analyzed by independent sample t-test and expressed in the form of mean±standard deviation. The counting data were compared by the chi-square test or fisher test for clinical characteristics. A value of P < 0.05 was considered statistically significant.