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figure 43-1 Gordon Jack's method of closure after right pneumonectomy. A, Transverse line of bronchial division is shown. The posterior line of tracheobronchial division to facilitate closure is indicated proximally. B, Anterior line of tracheobronchial incision is indicated. C, Closure of the trachea and bronchus. Adapted from Sarsam MA and Moussali H.2

prudent precaution. In 1953, Brewer and colleagues reported favorable results with the pericardial fat pad, both experimentally and clinically.11 The incidence of bronchopleural fistula in humans was reduced from 8% to zero in a consecutive case series with routine use of this flap. Current options include pleura, local mediastinal tissue, pericardium, pericardial fat pad, intercostal muscle, pedicled diaphragm, chest wall muscles (serratus or latissimus), and the omentum.14-17 Our preference is intercostal muscle or the pericardial fat pad for low-risk closures, and extrathoracic muscles or the omentum for high-risk closures. Pleura is usually too thin and flimsy to provide adequate coverage. The tissue flap should be carefully sutured around the circumference of the main bronchus to ensure adequate coverage.

Prolonged drainage of a sterile hemithorax after pneumonectomy is to be avoided since the chest tube can act as a site of ingress by skin bacteria, turning the site into a perfect culture medium of pleural fluid. When pleural contamination has occurred intraoperatively (such as a ruptured lung abscess), additional measures should be employed beyond culturing the pus, copious irrigation of the cavity, and pro-

figure 43-2 Lyman Brewer's method of main bronchial stump closure after pneumonectomy, with a posterior membranous wall flap to reduce tension on the suture line. Adapted from Brewer LA et al.11

longed postoperative antibiotics. We have found it useful to irrigate the hemithorax postoperatively through a high anteriorly-placed intercostal catheter, with drainage through a basilar intercostal catheter connected to an underwater seal drainage. Irrigation for several days with warm saline containing dilute antibiotic selected by intraoperative cultures has met with uniform success in preventing postoperative empyemas. We considered this to be a "preemptive" Clagett procedure.

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