负压封闭引流联合局部浸润麻醉下清创并手术缝合修复胸部正中切口愈合不良的临床应用  

Clinical application of vacuum sealing drainage combined with debridement under local infiltration anesthesia and surgical suture to repair sternal incision nonunion

作　　者：朱喆辰 史京萍[1] 王鸣[1] 姚刚[1] 阮姝婕 Zhu Zhechen;Shi Jingping;Wang Ming;Yao Gang;Ruan Shujie(Department of Plastic and Burns Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China)

机构地区：[1]南京医科大学第一附属医院整形烧伤科,210029

出　　处：《中华损伤与修复杂志（电子版）》2021年第4期316-321,共6页Chinese Journal of Injury Repair and Wound Healing(Electronic Edition)

摘　　要：目的探讨应用负压封闭引流(VSD)联合局部浸润麻醉下清创并手术缝合修复胸部正中切口术后愈合不良的治疗效果。方法选取2016年5月至2019年6月在南京医科大学第一附属医院行胸部正中切口手术术后切口愈合不良的患者51例。所有患者均在局部浸润麻醉下沿原切口将存在皮下潜腔的部位彻底敞开,清除切口及周围软组织坏死筋膜、脂肪组织,先予3%过氧化氢溶液,再予0.9%氯化钠溶液彻底冲洗切口,清创后于切口内放置VSD材料并封闭创面,维持VSD治疗1周,压力约-40 kPa,如VSD治疗后局部感染无好转且分泌物较多,VSD引流不畅时需更换VSD材料或再次手术清创。VSD治疗1周后如创周炎症反应情况好转,引流液清亮且无脓性分泌物,引流量减少,于局部浸润麻醉下行手术缝合修复切口,于胸肌筋膜层分离切口两侧,切除少量切缘陈旧肉芽组织和内翻上皮组织,放置切口深部高真空引流管,逐层缝合切口,确保切口内无死腔形成。如胸骨钢丝或金属固定器周围经VSD治疗仍有脓性分泌物,予手术去除,彻底清创后同期缝合修复切口。术后患者予胸带固定胸廓,切口覆盖敷料见分泌物时及时换药,如无明显分泌物每2 d换药1次。引流管留置1周后如引流量稳定,每日低于10 mL即予以拔除,引流量较多则适当推迟拔管时间,拔管后可安排出院。出院后门诊隔日复诊换药至术后2周拆线,年龄大于60岁且有基础疾病者,推迟拆线时间。如切口愈合不良,继续隔日门诊换药治疗。患者住院期间予基础疾病治疗并根据切口分泌物培养结果进行抗生素治疗。若缝合修复手术术后短期内切口再次感染破溃,需再次对切口分泌物进行细菌培养并根据药物敏感试验结果行抗感染治疗,切口换药治疗,清除炎性肉芽组织,碘仿纱条填塞,保守治疗1个月后若局部皮肤红肿无好转,切口仍未愈合,需考虑胸骨骨髓炎可能,再Objective To explore the therapeutic effect by vacuum sealing drainage(VSD)combined with debridement under local infiltration anesthesia and surgical suture to repair postoperative sternal incision nonunion.Methods Fifty-one patients with sternal incision nonunion after median thoracic incision surgery admitted in First Affiliated Hospital of Nanjing Medical University from May 2016 to June 2019 were enrolled in the research.Under local infiltration anesthesia,all patients were completely opened the subcutaneous cavity along the original incision,removed the incision and surrounding soft tissue necrosis,fascia,and adipose tissue,washed the incision thoroughly with 3%hydrogen peroxide and then 0.9%sodium chloride solution,and then,placed VSD material in the incision and sealed the wound after debridement.VSD treatment was maintained for about one week at the pressure of about-40 kPa.New VSD material and once more debridement was taken if local infection did not improve or the secretion did not gradually reduced after VSD treatment.After 1 week of VSD treatment,if the inflammation around the wound improved,the drainage fluid was clear and there was no purulent secretion,and the drainage was reduced,the incision was repaired by suture under local infiltration anesthesia,and both sides of the incision were separated on the pectoral muscle fascia and a small amount of old margins granulation tissues and inverted epithelial tissues were removed,a high-vacuum drainage tube was placed in the deep part of the incision,and the incision was sutured layer by layer to ensure that no dead space was formed in the incision.If there were still purulent secretions around the sternum wire or metal fixator after VSD treatment,they should be removed surgically,and the incision should be repaired at the same time after thorough debridement.The patients were fixed with chest band after suture.The dressing should be changed in time when secretions were seen from the incision covering dressing.If there was no obvious secretion,the dressi

关 键 词：胸骨切开术 感染 负压伤口疗法 局部麻醉 

分 类 号：R47[医药卫生—护理学]