Abstract
We report an alternative method in the application of bowel clamp for ischemic preconditioning of pedicled flaps. The proposed method minimizes tissue damage and patient discomfort.
Keywords: Bowel clamp, DuoDERM, ischemic preconditioning, pedicled flap
INTRODUCTION
According to Cheng et al,1 the concept of ischemic preconditioning was first reported by Murray et al in 1986 on myocardial muscle by inducing multiple episodes of brief ischemia that were followed by prolonged ischemia. This concept was later applied by Mounsey et al to the latissimus dorsi flap in a pig model that has been shown to exert a protective effect on skeletal muscle.1 Ischemic preconditioning is believed to attenuate vasospasm and ischemic reperfusion injury and to increase capillary perfusion and tissue oxygenation, allowing for earlier division of a pedicled flap and improved survival.1–3
TECHNIQUE
Cheng et al1 describe the bowel clamp technique as readily available and as easy to apply. However, the technique is associated with marked discomfort and often is not tolerated.1 We describe a modification of this technique using DuoDERM Extra Thin (ConvaTec Ltd, Deeside, Flintshire, England) on the serrated edges of the bowel clamp blades and elastic traction to obtain sustained pressure to prevent excessive pressure and patient discomfort.
The DuoDERM is cut into 2 strips and is applied to the noncrushing bowel clamps (Figure 1). The modified bowel clamp is then applied to the pedicled flap, which requires ischemic preconditioning before definitive division (Figure 2). The bowel clamp is secured using an elastic band to achieve the desired pressure. Local pain will subside gradually because of tolerance and decreased ischemia by neovascularization.1 The elastic band is gradually tightened according to patient tolerability several times a day over the next few days.
Figure 1. DuoDERM Extra Thin cut in strips and applied to bowel clamps.
Figure 2. “DuoDERMed” bowel clamp for ischemic preconditioning.
CONCLUSION
This modified bowel clamp technique allows for pressure to be applied evenly across the pedicle, and tightness can be easily controlled using a rubber band until the clamp can be locked. It is an effective method for assessment and ischemic preconditioning of a pedicled flap to facilitate early division.
REFERENCES
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