A Lap-protector is a device used to keep an incision open and protect the wound margins during endoscopic surgery [3, 4]. We performed fenestration without rib resection using a Lap-protector for postoperative BPF. The procedure is very simple: (1) Make a skin incision along the intercostal space. (2) Dissect the subcutaneous tissue and muscular layer (the intercostal muscles are separated in the center between the ribs to avoid exposure of the ribs). (3) Insert a Lap-protector to widen the intercostal space . An advantage of this method is that it does not require resection of the ribs, unlike conventional fenestration that is performed with rib resection. Thus, this technique provides better postoperative pain control. Moreover, the fenestration wound is not exposed during insertion of the Lap-protector, and the pain associated with wound dressing changes is minimal.
Limitations of this procedure are as follows: (1) it is unclear whether fenestration without rib resection adequately controls infection associated with postoperative BPF and, (2) prolonged use of a Lap-protector may injure the skin and tissues, and leading to infection. With respect to the limitation described under no. 1, fenestration performed even without rib resection provides adequate expansion and exposure of the wound and the intercostal space. In this case, we could clearly observe the fistula and the fenestration cavity through the fenestration wound, which helped with effective drainage and infection control. With respect to the limitation described under no. 2, manipulation of a Lap-protector is associated with minimal tissue injury because the force of application is distributed equally around the incision margin . Nonetheless, using too large protector leads to ischemia around the wound, and we should be concerned about the ischemic damage in the select of the optimal size protector. Moreover, the Lap-protector attachment part may easily get infected; therefore, frequent confirmation of the wound is necessary. We changed the Lap-protector on the 2nd postoperative day and confirmed no adverse event had occurred. The replacement interval was gradually extended and finally replaced at 2-week intervals. In this case, the condition of the patient’s skin and tissues was unremarkable even at the time of his 1-year postoperative follow-up. Therefore, above two limitations are acceptable and this procedure is considered to be reasonable for postoperative BPF.
Unfortunately, in this patient, closure of the BPF and the thoracic cavity were not achieved. However, using this fenestration, the control of infection in the thoracic cavity could be sufficiently performed without complications such as pain and pneumonia, and his routine activities were unaffected postoperatively.