A NEW CLAMP FOR SURGICAL DIVISION OF THE

PATENT DUCTUS ARTERIOSUS

WILLIS J. POTTS, M.D.l

I T is generally agreed by cardiologists that the majority of patent ducti

should be treated surgically. Whether the ductus should be ligated or cut and su': tured has not been decided. Because a certain number of ducti recanalize after ligation, Gross (1) advises surgical di­vision. Blalock (2) recognizes the danger of uncontrollable operative hemorrhage and advises double ligation and trans­fixion with fairly heavy silk and final snug ligation with umbilical tape. Jones (3) has discontinued ligation because of recanalization and local infection and advises surgical division. Wangensteen, in his discussion of the paper by Gross (1), states that they now divide all patent ducti.Others are of divided opinion. We have successfully ligated 22 patent ducti without mortality or later complications. However, it does not seem presumptive to state that if the danger of severe hemorr­hage from accidental slipping of a clamp could be eliminated, most surgeons would prefer surgical division and suture with fine silk to ligation with rather large amounts of non absorbable foreign ma­terial.

To obviate the danger of hemorrhage during operation new ductus clamps have been devised. 2 Experimental work on dogs and clinical experience with 16 con­secutive patients, ages 2 to 13 years, in whom the ductus has been cut and su­tured, have demonstrated that the clamps are simple, safe and nontraumatic. One of these children, age 12 years, had had a previous end-arteritis which respoI}ded to penicillin. There have been no deaths; no

lFrom the Children's Memorial Hospital and the De­partment of Experimental Surgery of Northwestern Uni-versity Medical School. Received for publication, June ~UR .

' Made by Bruno Richter and Co., 843 Duane Ave., Glen Ellyn, Illinois.

The ductus clamps have been used satisfactorily for other types of vascular surgery. Coarctation clamps de­veloped on this same principle appear promising. Similarly bulldog clamps of this type are simple and effective.

operative or postoperative complications. The principle of the clamp is embodied

in a row of very fine teeth in the opposing jaws (figs. 1,2 and 3). The opposing teeth on each jaw are so constructed that if the clamp could be closed beyond a certain point they would interdigitate. However, the hub of the clamp allows complete closure but prevents the teeth from inter­digitating regardless of the pressure made on handles. The serrated portion of the jaws of the clamp is 1 mm. wide. Each side is hollow ground so that at the base of the teeth the clamp is about .5 mm. wide. There are 40 teeth to the inch (16 to 1 cm.). Each tooth, pointed but not sharp, is about 1 mm. long. The distal portion of the jaws which is serrat.ed measures seven eighths of an inch (21 mm.). Because the teeth are so fine and so close together and because the jaws of the clamp can be closed only to the point of contact there is no danger of injmy to the vessel. The teeth of the clamp when closed embed themselves in the adventitia and will not slip.

The clamps 7 inches (17.7 cm.) long are made of stainless steel to prevent bending and are made in pairs. The clamp for the aortic side of the ductus (fig. 2a and b) is bent at a 30 degree angle to allow more room for cutting and sewing. The clamp for the pulmonary side (fig. la and b) is straight.

There are three fine locks on the handles. Although we have demonstrated on the aorta of dogs that closure of the clamp to the first or second notch will prevent bleeding, clinically we routinely close the clamp to the third notch for that extra feeling of comforting security. Closure to the third notch will not injure the media and will not leave a mark on the intima. The jaws of the clamp are very thin. By placing one clamp well on

. the aortic side of the ductus and the other well on the pulmonary side, practically

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322 QUARTERLY BULLETIN, N.U.M.S.

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Figs. la and lb. Anteroposterior and ll!'teral views of the clamp used on the pulmonary stde of the ductus.

the entire length of the ductus is available between the clamps for division and suture.

SURGICAL TECHNIQUE

The operative technique is as follows (fig. 4): Under intratracheal anaesthesia a cannula is placed in the saphenous vein of the right ankle. (We always have 500 cc. of blood available, although to date we have had no use for it). The patient is turned on the righ t side and the chest is entered through the left fourth inter­space. In older children the fifth rib is sometimes resected. The left lung is col­lapsed, covered with a pad, and retracted downward. The phrenic nerve is easily identified and about 1 cm. lateral to it the mediastinal pleura is opened over the region of the ductus. The vagus nerve is then identified and dissected from its bed until the recurrent laryngeal nerve is seen

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2a

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Figs. 2a and 2b. The angled clamp for the aortic side of the ductus.

curving about the ductus. A few lymph glands lying along the inferior margin of the ductus are dissected out if they inter­fere with adequate visualization. The lappet of pericardium which usually over­lies the ductus is dissected off and held out of the way with a long suture grasped by a forceps. If the line of cleavage in the adventitia about the ductal wall is found, the dissection will be greatly simplified. The posterior portion of the ductus is freed blindly but gently with a blunt curved hemostat. After the hemostat has found its way beneath the ductus a strip

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Figs. 3. Enlarged drawing to illustrate the arrangement of teeth in the clamp; actually they are not as sharp as they appear.

POTTS-- PATENT DUCTUS ARTERIOSUS 323

Ductus at't._

Mediastinal pleut'a

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Figs. 4. Technique of surgical division of the patent ductus arteriosus.

of umbilical tape is drawn through to hold the ductus forward while the dissection of the aortic and pulmonary portions is com­pleted posteriorly.

The tape is then removed and a narrow, closed, curved clamp is slipped beneath the ductus to elevate it and put it on a very slight stretch while the angled ductus clamp is applied as near the aorta as possible. In fact, the edge of the aorta is caught in the clamp. While elevating the ductus slightly with the clamp that has just been applied, the straight clamp is . now placed similarly on the pulmonic side. Slight traction is made on both clamps to bring the entire ductus into

view and with a straight, fine scissors, designed by Dr. Sidney Smith, a small cut is made in the ductus. If no bleeding oc­curs (none has) the ductus is completely severed.

The aortic side is sutured first with a continuous double row of No. 5-0 Dek­natel silk on a curved No.9 atraumatic needle. The clamp is gently partially released. If there is any bleeding between sutures, the clamp is closed and an extra stitch put in. The pulmonary side of the ductus is sutured in a similar manner.

The mediastinal pleura is closed with a few interrupted stitches of fine silk. As the last stitch is put in, 100,000 units of

324 QUARTERLY BULLETIN, N.U.M.S.

penicillin are squirted over the aortic and pulmonic sutures. This may be unneces­sary but it makes us feel better.

The lung is re-expanded. We routinely drain the chest. A Pezzer catheter with all but the flange cut off is inserted into the chest through the sixth interspace from the inside out. The chest is closed with two catgut sutures encircling adjoining ribs. The suture about the lower rib is put in subperiosteally to avoid pressure on the nerve. The muscles are closed in layers with fine running catgut sutures. The skin is closed with silk. While the anaesthesiologist makes pressure on the anaesthetic bag to completely expand the lung and force all air from the chest, the drainage catheter is clamped off t ightly. After the patient has been returned to the room the catheter is attached to a water seal. On the second or third day the catheter is removed. The patient is given

30,000 units of penicillin postoperatively every three hours for five to seven days.

SUMMARY

A new clamp for surgical division of a patent ductus arteriosus is described. It is simple, safe and nontraumatic.

The technique of surgical division of a patent ductus arteriosus is outlined.

REFERENCES

1. Gross, R. E. : Complete Division for the Patent Ductus Arteriosus, J. Thoracic ~urg., 16:314-327, 1947.

2. Blalock, Alfred: Operative Closure of the Patent Ductus Arteriosus, Surg. Gynec. and Obst ., 82:113-114, 1946.

3. Jones, J . : Surgical Division of Patent Ductus Arteriosus. Paper read at the meeting of the American Academy of Pediatrics, Dallas, Texas, December 8, 1947.