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。

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，再次清创后胸骨缺损处二期采用胸大肌肌瓣填塞。换药时观察切口皮肤颜色，是否存在红肿表现；观察引流管是否通畅，引流量，引流液性状；切口正常愈合后每3个月通过门诊或网络随访患者，记录切口愈合情况。记录治疗期间患者有无血栓、出血、心脏意外等并发症发生。

51例患者经清创、VSD治疗后缝合修复切口，术后所有患者引流管均引流通畅，术后每日最大引流量均小于30 mL，引流液颜色均由鲜红转为暗红。正常愈合的切口皮肤由术后早期的微红逐渐恢复正常皮肤颜色。随访3~24个月，51例患者中有42例切口愈合良好，在随访期间未再出现切口破溃。术后愈合不良的9例患者中，有6例患者术后1周起出现切口处点状皮肤红肿，换药治疗后红肿未消退，后出现局部破溃，经换药治疗1个月后愈合；1例患者术后拆线时切口愈合良好，在术后5个月时因钢丝刺破皮肤外露行手术去除钢丝再次缝合治愈，2例患者出现皮肤红肿破溃后，经换药治疗1个月无好转，后再次住院行手术清创，胸大肌肌瓣填塞胸骨缺损治愈。治疗期间所有患者均未发生血栓、出血、心脏意外等并发症。

应用VSD技术联合局部浸润麻醉手术下清创并手术缝合修复胸部正中切口愈合不良，手术创伤小，麻醉风险小，患者预后良好，是修复胸部正中切口愈合不良的简单有效的方法。

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.

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 dressing should be changed every 2 days. After the drainage tube was left for 1 week, if the drainage volume was stable, it would be removed if the drainage volume was less than 10 mL per day. If the drainage volume was large, the time of extubation would be delayed appropriately, and discharge could be arranged after extubation. After discharge from the hospital, the patient would return to the outpatient clinic every other day and change the dressing before removal of the stitches 2 weeks after the operation. If the patient was older than 60 years old or had systemic diseases, the time of taking out the stitches would be delayed. If the incision did not heal well, the outpatient dressing change continued every other day. During the hospitalization, the patients were treated for systemic diseases and antibiotics were given according to the results of culture of the incision secretions. If the incision became infected and ruptured again within a short period of time after the suture repair operation, the excretion of the incision should be cultured again and anti-infective treatment should be performed according to the results of the drug sensitivity test, dressing change with iodoform gauze and local debridement of inflammatory granulation tissue were the main therapy for the next month until the incision was fully expanded and filled. If the local skin redness and swelling did not improve after 1 month of conservative treatment, and the incision had not healed, the possibility of sternal osteomyelitis should be considered. After through debridement, the sternum defect was filled with pectoralis major muscle flap in the second stage.The skin color of the incision should be observed for signs of redness and swelling and the drainage tube should be inspected to make sure it was unobstructed and calculated by its fluid quantity while the dressing was changed. After the incision healed, the patient was followed up through the outpatient clinic or online every 3 months to record the healing of the incision. During the treatment period, whether the patient had any complications such as blood clots, bleeding, and cardiac accidents were recorded.

Fifty-one patients were sutured to repair the incision after debridement and VSD treatment. After the operation, the drainage tubes of all patients were drained smoothly, the maximum drainage volume was less than 30 mL every day after the operation, and the color of the drainage fluid changed from bright red to dark red. The normally healed incision skin gradually returned to its normal skin color postoperatively. During the follow-up period from 3 to 24 months, 42 of the 51 patients had incisions healed well, and no incision rupture occurred during the follow-up period. Among the 9 patients with poor postoperative healing, 6 patients had incision skin redness about 1 week after the operation. The redness and swelling did not subside after dressing change, and local ulceration occurred later. They were treated with dressing change and healed within a month. Another patient healed well at first and were removed of the stitches puncturely. But his incision ulcered 5 months after sucture because of exposure of sternum fixation wire. The patient was cured after being removed of the steel wire and sutured again. The other two patients had skin redness, swelling and ulceration and they did not improve after dressing change for 1 month. They were hospitalized again for surgical debridement, and the sternum defect was cured by filling the pectoralis major muscle flap. During the treatment, all potients had no complications such as thrombosis, bleeding and cardiac accidents occurred.

VSD combined with surgical suture repair under local anesthesia is a simple and effective method to repair sternal wound nonunion, with advantages of less surgical trauma, less anesthesia risk and satisfying prognosis.