Supraclavicular thoracotomy for diagnosis of apical lung and superior mediastinal lesions.

Despite the use of mediastinoscopy, anterior mediastinotomy, transcarinal biopsy, needle biopsy, and transbronchial fluoroscopic brushing, thoracotomy is necessary to obtain tissue for diagnosis in patients suspected of having carcinoma of the lung. A technique we have employed is exploratory thoracotomy, as described for the approach to cervical and upper dorsal sympathetic ganglion, with entrance into the pleural space through a supraclavicular incision. Five patients, 3 with marginal pulmonary function and 2 with brachial plexus and upper mediastinal or vertebral involvement, had tissue diagnosis of lung carcinoma by this method without postoperative complication. Supraclavicular thoracotomy offers a safe, easy, and definitive method of tissue diagnosis of apical lung and superior mediastinal lesions.

Management of renal arterial injuries secondary to penetrating abdominal trauma.

Renal vascular injuries are found relatively frequently after non-penetrating abdominal trauma. Penetrating renal arterial lesions occur much less frequently, involving less than 5 per cent of all penetrating arterial injuries. The association of bowel and other organ injuries makes diagnosis and treatment somewhat complex. Four cases of penetrating renal arterial injuries were seen from January 1972 to June 1976. All patients had multiple bowel lacerations. All arrived in the emergency room in hypovolemic shock. Two patients were resuscitated and successfully treated. Three patients had complete transections and 1 had major branch transection. Two patients had an associated parenchymal lesion. One patient had a through-and-through ureteropelvic injury. Preoperative arteriography was not done because of vascular instability. Renal arterial injuries were suspected by loss of psoas shadow on abdominal x-rays and by retroperitoneal hematomas. Retroperitoneal hematomas were explored to eliminate the possibility of renal injury. Both of the patients operated upon attained good renal function after surgical repairs. Postoperative renal scans and arteriograms showed initially decreased function, which returned toward normal. Repair of renal arterial lesions is possible with good functional result. Preoperative arteriography, renographic scan or excretory urography is not justified routinely because of the seriousness of commonly associated injuries.

Popliteal artery injury following fracture or dislocation at the knee. Diagnosis and management.

Fracture dislocations or dislocations of the knee can produce an arterial injury that may be difficult to evaluate clinically. Aggressive diagnosis and treatment can produce satisfactory results in both vascular and orthopedic situations if performed early after the injury. Five cases of popliteal arterial injury were seen from April 1974 to August 1976. Three cases were following posterior knee dislocation, one was a femoral fracture displacement, and one was a rotary tibiofibular displacement. Four of the patients had complete popliteal artery transection and one had intramural hematoma and spasm. Initial diagnosis of severe arterial injury, although suspicious on clinical grounds, was not conclusive. Use of a Doppler flowmeter and arteriography was essential for the diagnosis of arterial injury. Peroneal nerve injury was present in two of five patients. Vascular surgery was successful in all cases. Skeletal instability was corrected at the time of vascular exploration, usually through same incision. Leg compartment edema or hematoma was common, but responded to fasciotomy in all cases. Vein graft reconstruction was preferred to direct repair because of wall contusion and the need for additional vessel length over edematous and contused tissue. Acceptable knee stability was obtained from initial repair in all cases.

Traumatic rupture of thoracic aorta. Diagnosis and management.

Of six cases of thoracic aortic rupture, four were acute and two were chronic. In the four acute cases, suspicious findings were an appreciably widened mediastinum, upper-extremity hypertension, change in pulse amplitude, or, more hopefully, generalized hypertension, left intraclavicular systolic murmur, and loss of posterior aortic shadow on chest x-ray film. Preoperative angiography was essential. Three of four acute aortic transections (one with aortic arch involvement) had complicated associated injuries that necessitated delay in aortic surgical repair; antihypertensive drugs, including propranolol hydrochloride, were used for support in the interval. Perfusion by femoral vein-femoral artery cardiopulmonary bypass was used. All four patients were operated on successfully without residual complications. Two patients with chronic conditions were recommended for surgery; one was successfully operated on, using aorto-aortic bypass. Another patient, 27 years postinjury, refused operation. Postoperative arteriograms were performed for baseline observations of graft and suture-line characteristics in all cases.