II．呼吸器領域：2．膿胸における開窓術と筋肉充填術

Open window thoracostomy for thoracic empyema：Open window thoracostomy is a simple, certainand final drainage procedure for thoracic empyema. It is most useful to drain purulent effusion fromempyema space, especially for cases with broncho-pleural fistulas, and to clean up purulent necroticdebris on surface of empyema sac. For changing of packing gauzes in empyema space through a windowonce or twice every day after this procedure, thoracostomy will have to be made on the suitableposition to empyema space. Usually skin incision will be layed along the costal bone just at the mostexpanded position of empyema. Following muscle splitting to thoracic wall, a costal bone just under theincision will be removed as 8〜10 cm as long, and opened the empyema space through a costal bed.After the extension of empyema space will be preliminarily examined through a primary window by afinger or a long forceps, it will be decided costal bones must be removed how many （usually 2 or 3totally） and how long（ 6〜8 cm） to make a window up to 5 cm in diameter. Thickened empyema wallwill be cut out just according to a window size, and finally skin edge and empyema wall will be suturedroughly along circular edge.Muscle flap transposition for empyema space：Pediclued muscle flap transposition is one of spacereducingoperations for（ chronic） empyema. Usually this will be co-performed with other several proceduresas curettages on empyema surface, closure of bronchopleural fistula and thoracoplasty. This isradically curable for primarily non fistulous empyema or secondarily empyema after open window thoracostomydone for fistula. Furthermore this is less invasive than other radical operations as like pleuropneumonectomy,decortication or air-plombage for empyema. There are 2 important points to do thistechnique. One is a volume of muscle flap and another is good blood flow in flap. The former suitablemuscle volume is need to impact empyema space or to close fistula, and the latter over-elongation andbending of pedicles should be avoided. Actually, after removing several costal bones on the empyemaspace, empyema wall will be incised for about 2/3 of total empyema length along costal beds. Thenmuscle flap will be introduced into cleaned up space and sutured on empyema surface at several points.It is better to lay small vacuum drain tubes along flap within empyema space.