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eComment: Skin isle as a potential bronchoscopic monitoring isle in latissimus dorsi flap surgery for bronchus stump insufficiency

Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover 30625, Germany

The role of muscle flap in preventing bronchus stump insufficiency after pneumonectomy for malignant pleural mesothelioma in high-risk patients

We read with great interest the recent report by Dr. Beshay and coworkers [1]. Bronchus stump insufficiency with or without the development of the post-pneumonectomy empyema is one of the most serious conditions after pneumonectomy. The authors reported on 28 patients receiving a buried pedicled latissimus flap without any skin isle. This muscle flap is a work horse in plastic reconstructive surgery for soft tissue coverage since its introduction by Dr. Igidio Tansini in 1906 for thoracic wall defects more than 100 years ago [2]. The use of a pedicled latissimus dorsi muscle flap to cover bronchial fistulas has been reported [3]. The latter authors stress that a deepithelized skin side rather than muscle is sutured to an opening of the bronchus. However, it remains unclear why a de-epithelized skin should be superior in this situation.

We propose a slight modification of the aforementioned technique. Since flap monitoring is essential to evaluate flap perfusion and to determine as early as possible arterial occlusion or venous congestion necessitating revision surgery, a buried flap is not approached by visual external inspection. Non-invasive laser Doppler and spectrophotometry systems, such as the Oxygen-to-see system (LEA Medizintechnik, Giessen, Germany), which has been reported in buried flap monitoring up to 1 cm tissue depth [4], are not in range from the chest surface.

We report a case of a bronchus stump insufficiency after pneumonectomy in a homeless male suffering open tuberculosis. A latissimus flap was harvested with a skin isle which was sutured onto the bronchus stump. The skin perfusion was monitored by serial bronchoscopies. The additional skin isle is easy to harvest and the closure of the harvesting defect is uncomplicated. The skin isle allows flap monitoring in these patients by direct visualisation via bronchoscopy.

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1. Beshay M, Carboni G, Hoksch B, Reymond MA, Schmid RA. The role of muscle flap in preventing bronchus stump insufficiency after pneumectomy for malignant pleural mesothelioma in high-risk patients. Interact Cardiovasc Thorac Surg 2008;7:621–625.[Abstract/Free Full Text]
2. Tansini I. Sopra il mio nuovo processo di amputazione della mammella. Gazetta Medica Italiana 1906;57:141.
3. Katsuragi N, Nakajima Y, Shiraishi Y, Hashizume M, Takahashi N. Closure of a large bronchial fistula with a latissimus dorsi myocutaneous flap. Jpn J Thorac Cardiovasc Surg 2005;53:440–442.[Medline]
4. Knobloch K, Gohritz A, Vogt PM. Noninvasive monitoring of microcirculatory perfusion and oxygenation in subcutaneous microsurgical flaps. J Reconstr Microsurg 2008;24:69.[CrossRef][Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Google Scholar Articles by Knobloch, K. Articles by Vogt, P. M. PubMed Articles by Knobloch, K. Articles by Vogt, P. M.