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Chapter XII

Contents

CHAPTER XII

Reparative Surgery

Thomas H. Burford, M.D.

GENERAL CONSIDERATIONS

The reparative phase of the management of thoracic wounds was considered to have begun as soon as initial wound surgery had been completed in a forward hospital and the patient was sufficiently stabilized after it to be safely transportable to a fixed hospital. A large experience with these wounds in MTOUSA (Mediterranean (formerly North African) Theater of Operations, U.S. Army), showed that most thoracic casualties could be safely transported to fixed hospitals in the base within a week after initial wound surgery, regardless of the type of operation that had been done in the forward hospital.

As the war progressed, two policies widened the scope, and increased the effectiveness, of reparative surgery. One was the deployment of general hospitals in close support of the Fifth U.S. Army as it moved up the Italian Peninsula. The other was the use of air evacuation, which was first employed in North Africa. These two policies made it possible to institute reparative surgery at a time of maximum benefit for both casualty and theater manpower. The earlier a casualty underwent reparative surgery, the greater were his chances of prompt recovery and the better the outlook for his return to duty within the theater holding period.

The reparative phase of wound surgery, which was developed originally in the Mediterranean theater, furnished another illustration of the intelligent integration of the administrative and professional functions that, together, produced effective continuity of medical care. The procedures of reparative surgery were based on principles designed to prevent or minimize infection and to assure as rapid anatomic and functional restoration to normal as the nature of the wound permitted. Progress in the reparative phase of management of chest injuries was not less significant than was the progress achieved in their initial management.

Mission of Fixed Hospitals and Thoracic Surgery Centers

When policies in the Mediterranean theater were stabilized, casualties with chest injuries who required more than simple wound closure were usually cared for in chest centers. The mission of general and station hospitals and of thoracic surgery centers in base areas has been outlined in detail under those various headings (p. 97).


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Specifically, the procedures of reparative surgery for chest wounds carried out in fixed hospitals in the base were:

1. Delayed primary closure1 of wounds not completely closed at the time of forward surgery.

2. The management of hemothorax, including its complications of clotting, organization, and infection.

3. The management of posttraumatic (hemothoracic) empyema.

4. The performance of pulmonary decortication for organizing hemothorax or hemothoracic empyema.

5. The precise localization of intrathoracic foreign bodies, with their removal on strict indications.

6. The management of complications of thoracoabdominal wounds.

7. The management of other complications related to the chest wound.

Except for delayed primary wound closure, all of these procedures are discussed in detail in the second volume of the thoracic surgery series.

DELAYED PRIMARY WOUND CLOSURE

The dangers of primary closure of battle-incurred wounds of the chest were as great as those of primary closure of other wounds. Since there was no basic difference between soft-tissue wounds elsewhere in the body and wounds of the chest wall or the soft-tissue component of intrathoracic wounds, the policies evolved for the management of soft-tissue wounds elsewhere in the body were entirely applicable to chest wounds and were employed for them.

Indications and contraindications-As pointed out elsewhere (p. 140), the entire program of delayed primary wound closure in World War II reflected a complete departure from the elaborate bacteriologic concepts and practices by which this technique was employed in World War I. The shift was from emphasis on the flora of the wound, as demonstrated by microscopic and cultural methods, to the gross surgical pathology of the wound, as determined by clinical inspection alone. When the program of delayed primary wound closure was fully developed, the procedure was as follows:

1In the Mediterranean theater, the division of the surgery of combat-incurred wounds into initial wound surgery, reparative surgery, and reconstructive surgery was conceived by Col. Edward D. Churchill, MC, Consultant in Surgery, Office of the Surgeon, Headquarters, MTOUSA, who also introduced the term "delayed primary wound closure" to describe the final step in the closure of combat-incurred wounds. By the spring of 1944, it had become the general practice, at initial wound surgery for thoracic wounds as for other soft-tissue wounds, to leave the skin and subcutaneous tissues open, for later suture in hospitals to the rear. Many surgeons in the theater objected to the nomenclature, on the ground that to employ the words "delayed" and "primary" in juxtaposition was a contradiction in both term and concept. The nomenclature, nonetheless, came into general use in the Mediterranean theater and was adopted by some, though not by all, surgeons in the European theater. It might be added that many surgeons objected, with equal vigor, to the use of the term "secondary closure" for suture of the skin and subcutaneous layers of the wound, on the ground that it implied a previous attempt, which had not been made, to close these layers.


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1. A clean wound, in which there was no evidence of infection and in which there was no devitalized sloughing tissue, was considered fit for immediate closure. In most hospitals, the condition of the wound was determined by inspection in the operating room, when the dressings were removed for the first time. In a few hospitals, as already mentioned, it was the practice, when the patient was first examined, to elevate the outer dressing and inspect the wound through the fine-mesh gauze immediately over it. The dressing was then replaced, and the gauze was removed with the dressing in the operating room.

2. A wound that was indurated or showed any other evidence of infection was treated for from 24 to 72 hours before closure by dressings soaked in warm physiologic salt solution.

3. A wound that harbored necrotic tissue or otherwise showed that debridement had been inadequate was treated by redebridement before wound closure, or, if conditions justified it, closure was delayed for several additional days. In the early months of the war, it was repeatedly necessary to redebride wounds in base hospitals because initial debridement had been inadequate or had been omitted. Failure to debride a wound simply because it was small or had been made by a high-velocity missile was found to be an invitation both to wound infection and to pleural infection. Even later in the war when penicillin was available, a subcutaneous area of tissue destruction out of all proportion to the size of the wound of entry was invariably found in these wounds, and many times, direct extension of the infection to the pleural space could be demonstrated.

Timing-When delayed primary wound closure was first used in the Mediterranean theater, the timelag between wounding and closure was often from 15 to 21 days. This was too long. At the end of this period, scar tissue had frequently developed, and excision of the wound was necessary to effect satisfactory closure.

As time passed, initial debridement became more effective, and the advantages of earlier wound closure were increasingly appreciated. The timelag was successively reduced, first to from 7 to 10 days and later to from 5 to 6 days. When closure was accomplished within these time limits, suture approximation was frequently all that was necessary.

Results-The policy of delayed primary closure of wounds that had been properly debrided in forward hospitals was attended with generally good results. At the 53d Station Hospital, Bizerte, for instance, there were 125 primary unions in the first 144 chest injuries treated by this technique. The average time from wounding to final closure was 14 days. While no controlled studies were carried out, an analysis of roughly comparable groups of injuries indicated that approximately 7 weeks' time was saved in wound healing when delayed primary wound closure was employed. The use or omission of local sulfanilamide therapy did not alter results to any significant degree. There were 8 failures in 15 closures undertaken on 3 patients (5 closures on each


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patient), which suggested to the surgeons that not more than 3 closures should be attempted at a single sitting unless there was a complete change of gloves and instruments.

There were 111 primary unions in 118 wound closures carried out at the 21st General Hospital, Bou Hanifia, Algeria. The explanation of the seven failures was as follows:

1. Incomplete debridement, with foreign bodies and small bits of necrotic muscle left in situ to serve as sources of infection.

2. Unrecognized infection present at the time of closure.

3. Undue delay in closing the wound, thus permitting scar tissue to form.

4. Closure under tension, chiefly due to insufficient undermining of the wound edges before closure. In two or three of these cases, the use of small split-thickness skin grafts would have been wiser. This was another technique which often saved weeks of healing time.

As the figures in these 144 cases show, once the indications and contraindications for delayed primary wound closure had been established, primary healing was the rule. The technique had a number of other advantages:

1. Whatever other reparative procedures were necessary could be carried out in a solidly healed chest wall, which was found to be an essential protection against wound infection and subjacent pleural contamination.

2. The use of this technique materially increased the number of reparative procedures that could be completed within the period of the theater holding policy.

3. This technique permitted turnover of hospital beds at a rate previously unobtainable, and the patients were in generally better condition when they were evacuated to a reconditioning center or to the Zone of Interior for further treatment.

Chemotherapy and antibiotic therapy-The excellent results secured in the first cases of delayed primary wound closure led some uncritical observers to ascribe them to the use of the sulfonamides. The later results were sometimes ascribed, equally uncritically, to the use of penicillin. It would have been desirable, from a research standpoint, to run control series, in which these agents were withheld from alternate patients whose wounds were serious enough to require them, but this was obviously unthinkable. There was no doubt, however, in the minds of experienced surgeons, that the value of both chemotherapy and antibiotic therapy was far less than the value of adequate debridement. In their opinion, it was that procedure that made delayed primary wound closure so successful.

REPLACEMENT THERAPY

In spite of vigorous transfusion therapy in forward areas, the majority of thoracic casualties arrived in base hospitals with hematocrit values well below normal. It was the practice to give daily transfusions of from 500 to 1,000 cc. of blood until a hematocrit value of at least 40 was reached. This often


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required several transfusions. In one group of 648 casualties, 1,047 transfusions of 500 cc. each were required, an average of 800 cc. per patient.

If major reparative surgery was performed, the need for whole blood was greatly increased. The amount required varied with the magnitude of the procedure. Thoracotomy for the removal of an intrathoracic foreign body usually required, in the absence of complications, no more than 1,500 cc., including the amounts administered before, during, and after operation. A difficult, time-consuming thoracotomy usually required at least 2,500 cc., and as much as 4,000 cc. was necessary in many cases.

REPARATIVE SURGERY AND THE LEARNING CURVE

An evaluation of reparative surgery is made somewhat difficult by the fact, to which attention has already been called, that in the first months of the war, conditions were listed as irreversible complications that later were recognized merely as indications for surgical attack. The recorded incidence of complications at this time was further affected by the tactical situation: Patients who were safely transportable could not be held in general hospitals for longer than 3 weeks. For these reasons, the incidence of complications in these first months of fighting in North Africa seems smaller than it actually was. The peak incidence of complications that required therapy was during the Sicilian and the early Italian campaigns. At this time, the incidence was 52 percent, as shown by an analysis of 870 thoracic wounds collected from seven general hospitals, four of which at times operated as thoracic centers. By the end of the war, the incidence had declined to 15 percent.

This highly favorable trend meant that, as the war progressed, more and more men with chest injuries were making uneventful recoveries from their wounds. Less and less major surgery was required in fixed hospitals because of the improved quality of forward surgery. Clarification of the indications for thoracotomy in forward hospitals (p. 200), improved methods of resuscitation, and the introduction of penicillin all played their part in the decrease of intrathoracic complications that required surgery in base hospitals. The improvement must, in the main, be credited to the so-called learning curve, already commented upon, which implied that both forward and base surgeons increased in experience and skill as the war progressed.

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