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Chest drainage, open insertion in Bülau technique

general and visceral surgery
Reading time readingtime 13:27 min.
Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Skin Incision

    Video
    Skin Incision
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    Note: For didactic reasons, the video was recorded in lateral position.

    In the “Safe Triangle” between the lower edge of the pectoralis major muscle, the anterior edge of the latissimus dorsi muscle and the nipple line, a skin incision of 1-2cm is made directly at the level of the rib .

    Tip: To avoid subcutaneous emphysema, the skin incision should be just wide enough so that the index finger can be easily passed through the incision. With the finger, blunt dissection can be performed and the drain placed under finger guidance.

  2. Blunt Dissection

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    Blunt Dissection
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    After the skin incision, initial blunt dissection with scissors is performed down to the rib. The further dissection then proceeds cranially to the upper edge of the rib.

    Tip: Tunneling the soft tissues creates a so-called curtain phenomenon, which ensures an airtight tunnel.

  3. Minithoracotomy

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    Minithoracotomy
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    Always strictly at the upper edge of the rib after spreading the musculature with scissors, the parietal pleura is reached. This is bluntly opened either with the finger (as shown in the graphic) or with the scissor tip. The pleural space should be palpated with the finger if pleural adhesions/scar tissure are to be expected.

    Note: In pneumothorax, one hears a “hissing” at this point due to the escape of air; in hemothorax or pleural effusion, the fluid drains out.

  4. Inserting and Positioning the Drainage

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    Inserting and Positioning the Drainage
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    The drainage is grasped without a guide rod but possibly with forceps and, if necessary, advanced approximately 20 cm into the thoracic cavity under guidance of the index finger (apical for air, dorso-basal for fluid).

    Note: Exit of fluid (hemothorax or pleural effusion) or fogging (pneumothorax) of the drainage indicate the correct position of the drainage.

  5. Suturing

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    Suturing
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    Tight wound closure and fixation using U-suture, connection to the system; X-ray control.

    Note: Alternatively, the fixation can be performed using a pre-placed loose purse-string suture, which can be used to close the insertion tract when pulling the drainage.

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