|Year : 2015 | Volume
| Issue : 2 | Page : 25-28
The technique of horizontal mattress suture closure of chest wall wound in penetrating chest trauma: Experience with 65 cases
Kelechi E Okonta1, Tombari J Gbeneol2, Emmanuel O Ocheli2
1 Department of Surgery, University of Port Harcourt Teaching Hospital, Rivers State; Department of Surgery, Federal Medical Centre, Owerri, Nigeria
2 Department of Surgery, University of Port Harcourt Teaching Hospital, Rivers State, Owerri, Nigeria
|Date of Web Publication||19-May-2016|
Kelechi E Okonta
Department of Surgery, University of Port Harcourt Teaching Hospital, PMB 6173, Rivers State
Source of Support: None, Conflict of Interest: None
Background: The treatment protocol for penetrating chest injury has not been previously documented in our setting for open pneumothorax. We decided to use the horizontal mattress suture closure (HMSC) because of the initial problems of using the traditional three taping method to abolish the open pneumothorax following penetrating chest injury. This retrospective study was to evaluate the effect of HMSC of open pneumothorax in penetrating chest trauma and to determine the outcome. Methods: We retrospectively examined 65 patients with open peumothorax following penetrating chest trauma treated at the Thoracic Surgery Unit of University of Port Harcourt Teaching Hospital and the Federal Medical Centre, Owerri between January 2012 and December 2014. We assessed the impact of HMSC on chest wound following penetrating thoracic trauma. Excluded were patient who required a thoracotomy. No ethical consideration was required for this retrospective study. Results: Sixty-five (25.4%) patients out of 256 who had chest trauma were managed for open pneumothorax following penetrating chest injury. There were 59 males and 6 females, aged 4-55 years (mean age, 29.9 ± 9.7 years). The causes of penetrating chest injury were gunshot injury in 44 patients (68%), stab injury in 20 patients (30%), and gunshot and stab injury in two patients (3%). The mean time between sustaining the injury and presentation at the emergency was 16.1 ± 34.2 h with 40 patients (61.5%) presenting within 12 h. Thirty-three patients had pneumohemothorax, 12 had only pneumothorax and 20 had subcutaneous emphysema with "sucking" chest wound and the sizes of the chest wall defects were between 3-8 cm. The mean volume drainage at the insertion of closed tube thoracostomy drainage was 724.4 ± 557.6 ml while the total drainage was 1115 ± 724 ml, three patients (4.6%) had empyema thoracis, three patients (4.6%) died and the total number of days on admission was 13.2 ± 7.8 days. The diagnosis of open pneumothorax was made by clinical evaluation of the patient. Conclusion: The technique of HMSC for open pneumothorax and insertion of a chest tube is a useful method for the treatment of penetrating chest injury and pleural fluid collections and, therefore, the method is recommended in well-selected patients.
|How to cite this article:|
Okonta KE, Gbeneol TJ, Ocheli EO. The technique of horizontal mattress suture closure of chest wall wound in penetrating chest trauma: Experience with 65 cases. Niger J Surg Sci 2015;25:25-8
|How to cite this URL:|
Okonta KE, Gbeneol TJ, Ocheli EO. The technique of horizontal mattress suture closure of chest wall wound in penetrating chest trauma: Experience with 65 cases. Niger J Surg Sci [serial online] 2015 [cited 2019 Dec 12];25:25-8. Available from: http://www.njssjournal.org/text.asp?2015/25/2/25/182675
| Introduction|| |
Penetrating chest injuries are occurring in increasing frequency in our environment, especially from increased use of firearms for assault purposes. , Gunshot injury accounts for >60% of all the causes of penetrating chest injuries in our setting. , However, other reports outside the country showed that stab injury was more common than gunshot injury. ,,
The expeditious and initial management of penetrating chest injury is very important considering the fact that it is an open wound and complications such as tension pneumothorax, empyema thoracic, and even death  may arise. Previous guidelines stated that the initial management of penetrating chest injury with open pneumothorax involves the application of tape in three areas (right, left, and the bottom sides) on the chest wound defect. , The three taping method is thought to abolish the valve - like movement of air into the pleural space that progresses to respiratory distress.  This study was carried out to share our experiences in the unit with the care of patient with penetrating chest injuries using the horizontal mattress suture closure (HMSC) technique.
| Methods|| |
We retrospectively examined 65 patients with open pneumothorax following penetrating chest trauma treated at the Thoracic Surgery Unit of University of Port Harcourt Teaching Hospital and the Federal Medical Centre between January 2012 and December 2014. We have attempted to assess the impact of HMSC on open pneumothorax following penetrating thoracic trauma. Excluded were patients who required thoracotomy from excessive bleeding as seen from the chest tube drainage. The theatre records (A/E and main theatre) generated the list of patients whose case notes were subsequently retrieved and information on the age and sex of the patients; the mechanism of a chest injury, cause of chest injury, and treatment offered were entered into a proforma. The data were analyzed using SPSS version 20.0 Windows (Statistical Package SPSS Inc., Chicago, IL, USA).
The technique of using HMSC for the immediate abolishment of abnormal air movement in a chest wall defect was adopted in our unit for convenience and expeditious management of patient since 2012.
Subsequently, the initial management of a patient with open pneumothorax in our setting required that wounds were closed with either single or double or more horizontal mattress sutures using Nylon 2 under local infiltration of xylocaine after minimal debridement in the accident and emergency unit of the hospitals. It was followed by the immediate institution of closed tube thoracostomy drainage (CTTD) by creating another opening distal to the wound to drain the pleural space and effect of lung re-expansion. The chest tube insertion must be done as the chest wound is being closed to avoid tension pneumothorax. Prophylactic antibiotics comprising of ciprofloxacin and metronidazole in all cases with tetanus prophylaxis and, analgesics comprising of ibuprofen, tramadol, and paracetamol are given. Postintubation chest radiograph was done and repeated when necessary. Chest physiotherapy and deep breathing exercise were done. The Intercostal drains may be removed after a clinical and radiological evaluation showed adequate lung re-expansion and evacuation of the pleural collection.
| Results|| |
Sixty-five (25.4%) patients out of 256 who had chest trauma were managed for open pneumothorax following penetrating chest injury. There were 59 males and 6 females; aged 4-55 years (mean age, 29.9 ± 9.7 years) (see Graph 1 [Additional file 1]). The month with the highest number of injury was April (14) while there was none in October; the number of days admission was 13.2 days ± 7.8. The causes of penetrating chest injury were gunshot injury in 44 patients (68%), stab injury in 20 patients (30%), and gunshot and stab injury in two patients (3%) (see Graph 2 [Additional file 2]). The mean time between sustaining injury and presentation was 16.1 ± 34.2 h with 40 patients (61.5%) presenting within 12 h. Thirty-three patients had pneumo-hemothorax, 12 had only pneumothorax and 20 had sucking wound. The mean drainage at the insertion of CTTD was 724.4 ± 557.6 ml while the total drainage was 1115 ± 724 ml, three patients (4.6%) had empyema thoracis and 3 (4.6%) patients died while on admission. The diagnoses of pneumothorax were made by clinical evaluation of seeing sucking wound and radiological evaluation.
| Discussion|| |
An open pneumothorax is the presence of air in the pleural space that communicates with the exterior via the chest wall defect.  For open pneumothorax and "sucking" chest wound to occur the chest wall defect must be large such that the diameter of the defect is >3 cm or two-third or 0.75 of the trachea. ,
This may result in respiratory embarrassment - as in the mechanics of breathing, during inspiration, a negative intrathoracic pressure - is created which allows air to enter both through the defect and the trachea. However, the air entering through the defect is more because of the short distance between the chest wall and the pleural cavity, thus reducing the anatomic dead space, as against the distance between the oronasal openings and the trachea that offers more resistance. Furthermore, the air will not leave the pleural space at expiration due to the valvular mechanism. Thus, there is a progressive accumulation of air in the ipsilateral hemithorax with lung collapse. And, if unchecked may lead to tension pneumothorax, hemodynamic instability, and compressive atelectasis of the contralateral lung, severe hypoventilation and hypoxia.  Since air is heard and seen being sucked into the chest this is also known as a "sucking chest wound." 
In other to abolish and reverse the aforementioned mechanism, the immediate closure of the defect with a sterile occlusive dressing taped on three sides was advocated. This closure will act as a flutter-type valve or flap valve dressing. Hence, at inspiration this dressing will occlude the chest wound thereby preventing air from entering the pleural cavity to create pneumothorax. However, on expiration air escapes from the pleural space thereby reducing the pneumothorax.  The patient can be intubated or a chest tube inserted distally to evacuate the pleural fluid collections as soon as possible.  If there is any concern about a possible tension pneumothorax, decompression is performed simultaneously with a large bore needle, and once the patient is stabilized, definitive treatment is performed. Under general anesthetic the wound is explored, debrided and closed, and chest drain is left in-situ. This treatment is not permanent and taping in three places is relatively inefficient because the tapes stick poorly, in addition to continuing breathing/movement and the continuous soilage from the wound (personal communication).
The presence of subcutaneous emphysema was not identified as a need for surgical intervention.  However, the presence of sucking wound was an indication for surgical intervention to prevent respiratory distress and other complications. Furthermore, the "sucking" wound, besides being a strong indication for surgical intervention will also mean that the decision to insert an intercostal drain in chest injury could be necessary; and urgent too, without a the need for a chest radiograph.  Similarly, most of our patients required initial stabilization before chest radiograph was sought as that saved time by eliminating the time needed to procure the chest radiograph.
The advantages of closing the wound are that it also will help reduce blood loss due to the tamponading effect of approximating the bleeding skin and subcutaneous tissue edges. The mobilization of the skin to cover the defect from penetrating chest wound can be achieved as the skin of the chest wall is fairly mobile and thus approximation during closure is fairly easy. The other advantage is that once the defect is closed, the pleural space can be expeditiously evacuated by the institution of a chest tube for the evacuation of the pleural space. This achieves two things: Abolishing the sucking wound and the immediate evacuation of the pleural space.
The previous report had indicated that late presentation was associated with a poor prognosis.  Most of the patients presented within 12 h from the time of sustaining the injury. The reason for this substantial number presenting early was because the nature and mechanism of the injury (sucking wound) create a lot of fear in both the medical officer and patient and hence the urgent need to seek for specialist medical care instead of being managed at the secondary health centers.
About one-quarter (25.4%) of the patients sustained penetrating chest injury; most were males in their early 30s with gunshot injuries remaining the commonest cause of penetrating chest injuries. This was expected considering the involvement of firearms in political violence, cultism, robbery, kidnapping, etc., in our setting.
Gunshot wounds of the thorax remain more lethal than stab wounds.  And also commoner than stab injury in causing penetrating chest injury as noted from our review and importantly, penetrating injuries to the chest requiring a thoracotomy are still uncommon.  As most our patients were managed with chest tube insertion after closing the chest wall defect.
Two patients (3%) sustained penetrating chest injury from both stabbing and gunshot. To the best of our knowledge, this pattern of chest injury has not been reported in the literature previously. It, therefore, remains peculiar to our environment as the assailants were both armed with guns and knives.
The thinking as published in the literature over four decades ago, that early repair of associated injuries and complete evacuation of a pleural fluid collection in chest trauma, could reduce the incidence of empyema  is still very much the same. The suturing technique provides an airtight repair against leakages in a chest wall defect and ensured the passage of chest tube for effective evacuation of the pleural space. In this review, there was a low rate of empyema thoracis which can be explained by the expeditious evacuation of the pleural space containing blood or retained hemothorax which would have served as a good nidus for the formation of the plural space infection. 
| Conclusion|| |
The technique of HMSC of sucking wound with open pneumothorax and the immediate insertion of a chest tube is a useful procedure for the treatment of penetrating chest injury and pleural collection. This technique can be used as a first-line procedure in the majority of cases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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