Case Report
Loop-Shaped Placement of Subcutaneous Drain for Extensive Subcutaneous Emphysema
Yuki Takahashi, Masahiro Miyajima, Makoto Tada, Ryunosuke Maki, Miho Okawa, Wataru Arai, Taijiro Mishina and Atsushi Watanabe*
Department of Thoracic Surgery, Sapporo Medical University, School of Medicine and Hospital, Japan
*Corresponding author: Atsushi Watanabe, Department of Thoracic Surgery, Sapporo Medical University, School of Medicine and Hospital, Sapporo, Hokkaido 060-8556, Japan
Published: 12 Oct, 2018
Cite this article as: Takahashi Y, Miyajima M, Tada M,
Maki R, Okawa M, Arai W, et al. Loop-
Shaped Placement of Subcutaneous
Drain for Extensive Subcutaneous
Emphysema. Clin Surg. 2018; 3: 2154.
Abstract
Subcutaneous drain for extensive subcutaneous surgical emphysema is performed for patients, who are not adequately responsive to chest drainage on suction, especially those without lung collapse and sufficient space for placement of another chest tube in thoracic cavity. We describe the use of the minimally invasive drain with puncture needle, placement in a loop shape, puncture and division of the tunica muscular is, and use of a sustained suction bottle for extensive subcutaneous surgical emphysema.
Introduction
Although subcutaneous surgical emphysema is typically self-limiting with no life-threatening complications after lung resection, it is extremely uncomfortable for the patient because it extends into the neck and face, causing distress to the patient in the form of temporary visual impairment and neck tightness with dyspnea. Multiple methods of subcutaneous drain have been reported [1-4]. We report a new, minimally invasive method of subcutaneous drain with puncture needle, placement in a loop shape, and use of a sustained suction bottle for extensive subcutaneous surgical emphysema.
Technique
Subcutaneous drain for extensive subcutaneous surgical emphysema is performed for patients
who are not adequately responsive to chest drainage on suction, up to -20 cm H2O, without lung
collapse and sufficient space for placement of another chest tube in the thoracic cavity.
After local anesthetic along the route of the subcutaneous drain, a 5-mm transverse skin incision
was made at the anterior axillary line, lateral to the nipple; then, a 10-mm transverse skin incision
was made at the midclavicular line, lateral to the axilla, and a 5-mm transverse skin incision was
made at the level of the sternocostal joint, lateral to the nipple (Figure 1 and 2). Muscle layer was
exposed at each skin incision. The muscle layer under each skin incision was punctured and divided
by using a Pean Forceps to deair submuscular and muscle-layer emphysema. A 19-Fr drain with
puncture needle was inserted between the subcutaneous and the muscle layer by using the puncture
needle to pass through the incision at the anterior axillary line. It was pushed forward through
the skin incision at the midclavicular line, passing between the subcutaneous and muscle layers,
and then placed outside of the body from the skin incision at the midclavicular line (Figure 1A).
The puncture needle of the drain was returned between the two layers through the skin incision
at the midclavicular line; it was then pushed forward through the skin incision at the level of the
sternocostal joint, passing between the two layers and placed outside of the body from the skin
incision at the level of the sternocostal joint (Figure 1B). After the procedure, the drain was placed
in a loop shape. This is similar to the technique required to make an artificial vascular shunt. The
loop-shaped placement facilitated deairing of the wide area of the emphysema. After the puncture
needle was cut, the skin incisions were sutured and the drain was connected to a sustained suction
bottle (Figure 2).
The chest drain provided continuous suction and the subcutaneous drain also applied sustained
negative pressure. After the air leak disappeared from the chest tube, negative pressure was not
stopped in the subcutaneous drain suction bottle; thus, the patient’s symptoms of subcutaneous
emphysema were improved on chest X-ray examination. Therefore, the chest drain was removed
first (Figure 3A, 3B). The subcutaneous drain was removed a few days later, as the subcutaneous
emphysema had continuously improved.
Figure 1
Figure 1
(A) Drain with puncture needle through the 5-mm skin incision at
the anterior axillary line, lateral to the nipple, to the 10-mm skin incision at
the midclavicular line, lateral to the axilla, passing between the subcutaneous
and muscle layers (arrow indicates the puncture needle); (B) needle returned
through the skin incision at the midclavicular line to the 5-mm skin incision at
the level of the sternocostal joint, lateral to the nipple, passing between the
subcutaneous and muscle layers.
Figure 2
Figure 2
View after placement of the subcutaneous drain (*indicates the
chest drain and arrow indicates the subcutaneous drain and suction bottle).
Comment
Subcutaneous surgical emphysema occurs because of the tracking
of air into subcutaneous tissue via the drain site and surgical wounds.
Furthermore, development of extensive subcutaneous emphysema
is frequently accompanied by a persistent air leak. Although chest
drainage on suction is standard treatment for extensive subcutaneous
emphysema, it is occasionally insufficient for symptoms of
subcutaneous emphysema. Cerfolio et al. [5] reported that 33% of
subcutaneous surgical emphysema patients exhibited recalcitrant
subcutaneous emphysema, despite maximizing chest tube suction;
they suggested that single-incision video-assisted thoracoscopic
surgery with pneumolysis and chest tube placement was effective
treatment that significantly shortened the duration of hospital
stay for those patients. Boulemden et al. [2] reported that 67% of
patients with extensive surgical subcutaneous emphysema exhibited
associated prolonged air leakage; within 2 days, subcutaneous drain
improved the symptoms of all patients with extensive surgical
subcutaneous emphysema. Patients with extensive subcutaneous
surgical emphysema who experience difficulty in the initial operation
(because of severe pleural adhesion and/or pulmonary emphysema)
have a high risk of complications in the second operation for
subcutaneous surgical emphysema. The subcutaneous drain may
be considered for management of extensive subcutaneous surgical
emphysema before surgical treatment.
A few methods of subcutaneous drain placement for
subcutaneous emphysema have been reported [1-4]. Sherif et al. [1]
recommended a subcutaneous drain method that comprised Jackson-
Pratt drains placed on each side of the midclavicular line with 15-
mm skin incisions. Beck et al. [2] reported the use of two 14-gauge
angiocatheters created fenestrations when inserted bilaterally
into the chest subcutaneous space. Funakoshi et al. [4] suggested
management of subcutaneous emphysema by the use of penrose
drains. Here, we describe a new method of subcutaneous drainage
for extensive subcutaneous surgical emphysema by the use of a 19-
Fr drain with puncture needle, inserted between the subcutaneous
and muscle layers. The puncture needle is useful for easy insertion
between the two layers. Furthermore, the puncture and division of
the tunica muscular is was effective for deairing the submuscular
and intramuscular emphysema. In our technique, the loop-shaped
portion of the subcutaneous drain can be placed in the wide space of
the chest by using three small skin incisions to facilitate deairing of
the subcutaneous emphysema.
In conclusion, we report a new, minimally invasive method for
extensive surgical subcutaneous emphysema by use of the drain with
puncture needle for subcutaneous drain, placement in a loop shape,
puncture and division of the tunica muscular is, and use of a sustained
suction bottle for extensive subcutaneous surgical emphysema.
Figure 3
Figure 3
(A) Lateral view chest radiograph at the time of subcutaneous
drain placement, which shows extensive emphysema without lung collapse;
(B) chest radiograph at 10 days showing improvement of subcutaneous
emphysema.
References
- Sherif HM, Ott DA. The use of subcutaneous drains to manage subcutaneous emphysema. Tex Heart Inst J. 1999;26:129-31.
- Beck PL, Heitman SJ, Mody CH. Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema. Chest. 2002;121:647-9.
- Boulemden A, Aifesehi P, Pajaniappane A, Lau K, Bajaj A, Nakas A, et al. Subcutaneous drain insertion in patients with post-operative extensive subcutaneous surgical emphysema: a single centre experience. Gen Thorac Cardiovasc Surg. 2010;61:707-10.
- Funakoshi Y, Ohmori K, Takeda S. Drainage for subcutaneous emphysema after pulmonary resection. Kyobu Geka. 2016;69:337-40.
- Cerfolio RJ, Bryant AS, Maniscalco LM. Management of subcutaneous emphysema after pulmonary resection. Ann Thorac Surg. 2008;85:1759-65.