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Between January 1987 to January 2001, a total of 2268 patients underwent major thoracotomy. We exclude from the analysis the less thoracotomy, generally effected for bioptic operations on mediastinal masses, and the sternotomy. This for working on more possible homogeneous datas.
From 1987 to 1997 thoracotomic incisions were 1482. We performed backlateral and/or anterolateral or lateral thoracotomy with saving of rib. The backlateral accesses have always required the great Dentato muscle’s section. Skin incision is made with blade for ( the ) subcutaneous. Muscular and Fascial plans are lanced with electric scalpel in coagulation formality (method). In this period muscolar plans reconstructions have been performed with separate stitches in riabsorbable material (Vycril). The skin has been sutured with separate stitches in silk. Skin disinfection has been made with the same methodical; two passage with Betadine ( iodiopoidone al 10% ), after cleanliness with ether, in previously prepared surgical field with bilaterally extensive to armpits depilation effected with blades. From 1997 to 2000 backlateral thoracotomy were 786. Muscle Great Dentato’s dissection dropped progressively, for maintaining the sparing of such muscle, only operating an incision of his back fascia. In this we have been facilitated by our adjustment to Finocchietto’s ribbing (costal) (divaricatore), which we applied a third mobile valve on the lever arm. In this manner it takes place (si verifica ) the separation of Dentato’s muscolar fascia from the back wound margin. From 2000 we can define as sporadic the thoracotomy performed with (anterior)dentate muscle. Always from 1987 we changed the muscular plans reconstruction. We execute more and more the suture of Dentato’s fascia in continuous with riabsorbable thread ( Vycril or other similar ), and of the superimposed Great Dorsal plan. Previously such structures underwent synthesis with separate stitches. Always, anyway, in riabsorbable material ( Vycril ). From 2000 thoracotomy without plans synthesis in continuous technical are sporadic. Since 1987 skin synthesis is prevalently performed with metallic stitches using a mechanical applier. On average we use 28/30 stitches for backlateral thoracotomy and 12/14 stitches for anterior thoracotomy. From 1997 we performed a variation about the preparation of operatingfield (campo operatorio), with the progressive and by now constant use of a transparent seal ( steridap ) as protection of the cutaneous working area. Steridap is applied before incision and successively removed after skin synthesis only. At the end of the cutaneous synthesis process, the wound is cleaned with physiological, then covered with a sterile dressing. Since 1987 such dressing is a premeditated type. While before it was effected with a gauze outfit in side by a silk or mepore plaster. The not secreting dressing is normally removed in post-operative second day. Wounds are daily medicated since post-operative second day. Dressing technical plans the cleaning with a volatile solution of ether or petrol. Then we use to ultimate the cleaning with Eosina in alcoholic solution at 2%. This solution has been adopted since 1985; before we used the Ziehl’s liquid (basic fuchsina) + phenol +ethyl alcohol . With first dressing, if wound doesn’t present marks of secretion, the surgical access is left uncovered, after air drying of the applied disinfectant ( Eosina at 2% in alcoholic solution ) Such method permits the continuous evaporation of the aqueous tone from the cutaneous surface of incision, avoiding the continuation of an excessive local dampness, possible and probable pabulum of bacterial colonies. Moreover always this method immediately makes evident the formation both of the local (gathering) with well-known swellings of the margins and of the possible located secretions. In fact, the secretions flow away from wound and decolorize the interested cutaneous area. Immediately this draw itself both to the surgeon’s sight and ( to the ) patient’s sight. Such operating method exposes the wound to the contact with the garment of the patient and with the linen of the bed. Nevertheless the wound is protected by the colouring/disinfectant film. Stitches removal is normally performed, in partial way, at the fifth or sixth day and totally at the seventh or eighth day, often after the resignation of the patient nearby our outpatients’ department. We consider suppurated the wound that has required the undercutaneous or underfascial (???) drainage, with or without bacteriological comparison of the evacuated material. Between January 1987 to January 2002 we number 18 suppurated wounds (0.79%) in accordance with such trend. Until 1997 ( year of introduction of solid modifications in the operating treatment of the surgical incision ) suppurated wounds were 14 (0.94%). From 1997 to 2002 the suppurations were 4 (0.51%). Therefore, with the reduction of the muscular sacrifice and the cutaneous synthesis of the metallic material operated since 1997, the incidence of the suppurated wounds, however already low, is reduced. Disinfection technical by our operated, always by our defined as “ an uncovered wound “, consent low suppurative risk and allow a remarkable sparing of the consumption material and of the dressing time. Besides it consents an attentive and continuos valuation of possible changes of the wound by health operators and by patient. Then it permits to operate the most rapid intervention on the same, so as to avoid the local propagation of infections. We must report a greater relative incidence of infectious opening of the wounds in the surgical treatment of the pleuric empyema ( 2 suppurated injuries were found in such pathology ). We place this result in correlation with the septic tone of such disease. In spite of the fact that most part of the reference literature advises the protection of the post-operative wounds with dressing material, our data don’t demonstrate that to leave uncovered the injury from the second post-operative day caused any damage for the recovery.
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