EA038181B1 - Method of mini-vac-rethoracotomy - Google Patents

Abstract

The invention is related to medicine, in particular to thoracic surgery, and can be used for surgical treatment of gangrenous abscess of the lungs and loculated empyema. Purpose of the proposed invention is to develop an effective method of mini-vac-rethoracotomy allowing low-trauma and adequate access to a suppurative focus without forming a thoracic wall defect. Said purpose is achieved by performing mini-thoracotomy through the resected rib bed, tightness of vacuum dressing is ensured by skin closure above it, and further change of vacuum dressing is performed during mini-rethoracotomy. Advantages of the disclosed method are: use of adequate low-trauma access; avoidance of thoracic wall defects that require anaplerosis; reduced treatment cost due to consumables saving.

Description

The invention relates to medicine, namely to thoracic surgery, and can be used in the surgical treatment of gangrenous abscesses of the lungs and encapsulated pleural empyema.

There is a method of VAC- (Vacuum-Assisted Closure) -toracostomy, which consists in the fact that after treatment of the focus of infection, a thoracostomy is formed, into which microporous silicone pads are placed to the pericardium and the remaining pulmonary parenchyma [1]. A polyurethane foam sponge is placed in the residual empyema cavity, a drainage tube is attached to it, and the thoracostomy is sealed with an adhesive film. The drainage tube is connected to a vacuum source and a vacuum is created in the system of -50 mm Hg. Art. The vacuum dressing is changed through a thoracostomy every 2-3 days.

There is a method of VAC-thoracostomy, in which sterile gauze wipes are used to isolate the chest organs from the polyurethane foam sponge [2].

The known method of intrathoracic VAC therapy, in which a polyurethane foam sponge is installed, but does not isolate it from the chest organs [3].

The disadvantages of these methods include the presence of a significant defect in the chest wall - thoracostomy, which further requires plastic closure.

Also known is the method of intrathoracic VAC therapy, which consists in performing a thoracotomy. After surgical treatment of the focus of infection, a layer of sterile gauze napkins is placed on the mediastinum. The residual pleural cavity is loosely filled with polyurethane foam sponges. The thoracotomic wound is sutured and sealed with an adhesive film. Subsequent changes of vacuum dressings are performed under general anesthesia through the previously used access during rethoracotomy [4].

The disadvantage of this method is the use of a wide thoracotomy access with excessive trauma to the tissues of the chest wall and pleural cavity with small and delimited pathological processes.

The prototype of the proposed invention is a method of mini-VAC-thoracostomy, which consists in the use of minithoracostomy [5]. With this method, under general anesthesia in the projection of the localization of the pathological process, a minithoracotomy 5-7 cm long is performed through the intercostal space (without rib resection). After removal of pus and necrotic tissues, the residual cavity is washed with 0.9% NaCl solution or antiseptic solution. A retractor is installed in the wound, which is a flexible polymer membrane in the form of a cylinder with semi-rigid polymer rings at each end. In this case, one ring is placed in the pleural cavity, and the second ring is tightened and a polymeric membrane is wound on it until it touches the chest wall, which ensures tissue retraction in the access zone by 360 °. To prevent pressure ulcers, a sponge lining is placed under the outer ring of the retractor. A polyurethane foam sponge is placed into the residual cavity through a retractor, a drainage tube is attached to it, and the mini-thoracostomy is sealed with an adhesive film. The drain tube is connected to a vacuum source and a vacuum is created in the range from -75 to -125 mm Hg. Art. The change of the vacuum dressing is carried out through the formed minithoracostomy every 2-3 days.

The disadvantage of the prototype is the small size of the access through the intercostal space, which makes it difficult to inspect and sanitize the purulent focus; the need to use a retractor that exerts pressure on the surrounding soft tissues in the period between sanitization; the presence of a defect in the chest wall, which in some cases requires plastic closure. The objective of the proposed invention is to develop an effective method of mini-VAC-retorαcotomy, which allows to obtain low-traumatic and adequate access to the purulent focus without the formation of a defect in the chest wall.

This task is achieved due to the fact that the mini-thoracotomy is performed through the bed of the resected rib, the tightness of the vacuum dressing is ensured by suturing the skin above it, and the subsequent change of the vacuum dressing is performed during mini-rethoracotomy.

The proposed method is illustrated by the following graphic materials:

the figure shows a diagram of a mini-VAC rethoracotomy with a lung abscess on a section of the chest.

The method is carried out as follows.

The operation is performed under general anesthesia with separate intubation of the main bronchi. Depending on the localization of the pathological process, the patient is placed on a healthy side, abdomen or back. Above the rib closest to the purulent focus, the skin and subcutaneous tissue are dissected for 6 cm, the muscles are separated and removed. The periosteum is incised along the rib, peeled it off to the upper and lower edges of the rib with a Farabeuf bone rasp. Separate the periosteum from the inner surface of the rib with a Doyen costal raspatory. A portion of the rib is resected for 4-5 cm. A purulent cavity is opened through the bed of the resected rib. To access the abscess, the adjacent necrotic lung tissue, which is its outer wall, is dissected and excised. At the same time, due to the resection of the rib section, after dilution of the wound edges, sufficient access is created for revision and sanitation of the pathological focus. After surgical treatment of the focus of infection, the existing cavity is washed with antiseptic solutions. Through the minithoracotomic access, a polyurethane foam sponge of appropriate size and shape is placed into the existing residual cavity (1). The polyurethane foam sponge should loosely fill the residual cavity, in contact with the entire zone of residual purulent-necrotic lesion. Drainage PVC tube (2) with a diameter of 10 mm from 2-3 sides

- 1 038181 holes (3) at the end are passed inside the polyurethane foam sponge, fixed to it with a seam (4) and taken out through a separate puncture of the chest wall (5), fix the drainage with a seam (6) to the skin. The skin (7) and subcutaneous tissue (8) of the minithoracotomy wound (9) are hermetically sutured with single interrupted sutures (10). The drainage PVC tube (2) is connected through a container for collecting liquid to a vacuum pump. The system creates a vacuum in the range from -100 to -125 mm Hg. Art. The change of the vacuum dressing and subsequent sanitation of the purulent focus is carried out depending on the clinical situation with a frequency of 2-5 days with mini-rethoracotomy through the previously used access. The advantages of the proposed method are the use of an adequate low-traumatic access; no chest wall defect requiring plastic closure; reduction of material costs for treatment due to savings in consumables.

The proposed method was used to treat two patients with gangrenous abscesses of the lungs and one patient with encapsulated pleural empyema at the stage of organization.

Clinical example No. 1.

Patient Sh., 57 years old, became acutely ill on September 20, 2018, when he noted the appearance of general weakness, cough with sputum, an increase in body temperature to 39 ° C, and a lack of appetite. He abuses alcohol, smokes. In the period from September 22, 2018 to October 16, 2018, he was examined and treated at the central city hospital at the place of residence with a diagnosis of Community-acquired right-sided middle lobe pneumonia. Encapsulated right-sided pleurisy. DNO-i .. Against the background of conservative treatment, hyperthermia persisted up to 38 ° C, leukocytosis in the general blood test, encapsulated effusion in the right pleural cavity, and therefore, for further examination and treatment, the patient was transferred to the surgical thoracic purulent department of the UZ Vitebsk Regional clinical hospital (UZ VOKB).

He was admitted to the department on 10/17/2018. The body temperature on admission is 37.8 ° C. In the general analysis of blood at admission: leukocytes - 14.1x10 ⁹ / l, ESR - 50 mm / h. According to the computed tomography (CT) of the chest organs (CT) from 10/11/2018, infiltration of lung tissue with visible lumens of the bronchi was determined in the middle lobe of the right lung; between the posterior surface of the lower lobe of the right lung and the parietal pleura, an enclosed fluid formation of heterogeneous density was determined. 56.3x81.5x102.3 mm with leakage along the interlobar pleura measuring 18.3x28.9x55.4 mm. The patient was prescribed antibacterial and detoxification therapy.

On October 18, 2018, the patient underwent puncture of the right pleural cavity in the VIII intercostal space along the scapular line. Puncture resulted in a serous-purulent effusion. At the puncture site, the right pleural cavity was drained according to Bulau. Up to 10 ml of serous effusion was discharged through the drainage. Control X-ray examination of the OGK in two projections from 19.10.2018 showed fibrotic changes in the pulmonary pattern of the middle lobe of the right lung; in the posterior parts of the right hemithorax, an enclosed fluid formation of the same size with a drainage tube inside in the region of the lower pole was determined. Was diagnosed with community right-sided mid-lobe pneumonia with an outcome in pulmonary fibrosis. Encapsulated pleural empyema on the right in the stage of organization. DN0-1.

On October 19, 2018, the patient was operated on. Under general anesthesia with separate intubation of the main bronchi in the prone position of the patient along the posterior surface of the chest in the projection and along the VII rib, a 6 cm long incision was made in the skin and subcutaneous tissue.The muscles were bluntly pulled apart in layers, and a section of the VII rib was exposed. Subperiosteal resection of the 7th rib section 5 cm long was performed. Through the bed of the resected section of the rib, an enclosed empyema cavity was opened, containing a cloudy, thick yellow pus with fibrin and fibrinous casts. A leak was opened along the interlobar pleura. After removal of pus and fibrinous deposits, partial decortication and ultrasonic (US) cavitation, the empyema cavity was washed with 0.02% chlorhexidine bigluconate solution and drained. A polyurethane foam sponge of the appropriate size was placed in the empyema cavity through a minithoracotomic approach. A drainage tube with lateral holes was passed inside the polyurethane foam sponge, fixed to it with a suture and brought out to the outside of the chest wall below the wound through the channel through which drainage was previously carried out. The drainage tube was sutured to the skin. The skin and subcutaneous tissue of the minithoracotomy wound were hermetically sutured with four single interrupted sutures. Aseptic dressings were applied to the wounds. The drainage tube was connected through a container for collecting liquid to a medical aspirator V-40A (NPO Visma-Planar, Republic of Belarus). A constant vacuum of -15 kPa (~ 112.5 mm Hg) was created in the system. In the postoperative period, there was an improvement in the general well-being of the patient, the normalization of body temperature from 20.10.2018.A small amount of serous effusion was drained through the drainage.

On October 24, 2018, in the operating room under endotracheal anesthesia in the prone position of the patient, the sutures were removed from the minithoracotomy wound, minirethoracotomy was performed, and the polyurethane foam sponge was removed. On examination, the cavity was significantly reduced in size and actively granulated. The cavity was rinsed with 0.02% chlorhexidine digluconate solution and drained. A drainage tube with side holes was installed inside the residual cavity and brought out to the outside of the chest wall below the wound

- 2 038181 along the canal, through which drainage was carried out earlier, and fixed with a suture to the skin. The minithoracotomy wound was sutured in layers. Aseptic dressings were applied to the wounds. The drainage tube was connected through a container for collecting liquid to a medical aspirator V-40A (NPO Visma-Planar, Republic of Belarus). A constant vacuum of -15 kPa (~ 112.5 mm Hg) was created in the system.

A control X-ray of the OGC in two projections from 10/25/2018 showed a drainage tube in the posterior parts of the pleural cavity, while the residual cavity was almost completely obliterated.

There was no discharge from the pleural cavity. On October 28, 2018, active aspiration was removed and the patient was transferred to Bulau drainage. On October 29, 2018, the drainage tube was removed. The control radiography of the OGK in two projections from 30.10.2018, the residual pleural cavity was not visualized.

In a satisfactory condition, the patient was discharged on October 30, 2018 with a recommendation to remove the stitches from the wounds on an outpatient basis.

Clinical example No. 2.

Patient R., 41 years old, became acutely ill on September 20, 2018, when he noted the appearance of general weakness, cough with sputum, an increase in body temperature to 39 ° C, and a lack of appetite. He abuses alcohol, was on a binge on the eve of the disease, smokes. For a long time he did not seek medical help. On October 12, 2018, he applied to the emergency department of the Vitebsk City Clinical Emergency Hospital, where an abscess of the middle lobe of the right lung was revealed during examination. For further examination and treatment, he was sent to the surgical thoracic purulent department of the UZ VOKB.

He was admitted to the department on 12.10.2018. The condition at admission was of moderate severity. The patient had an asthenic constitution with symptoms of severe exhaustion (body mass index (BMI) -13.9 kg / m ² ). In the general analysis of blood at admission: leukocytes - 20.77x109 / l, ESR - 46 mm / h. CT scan of 10/12/2018 in the middle lobe of the right lung revealed an extensive cavity of pulmonary tissue destruction containing sequesters, against the background of infiltrative changes in the upper and lower lobes of the right lung; on the outer surface of the middle lobe of the right lung, an enclosed effusion with a thickness of up to 10 mm was determined. After further examination, the diagnosis was made: Acute infectious destruction of the lungs: gangrenous abscess of the middle lobe of the right lung. Right-sided polysegmental pneumonia. Encapsulated pleural empyema on the right in the purulent-fibrinous stage. Syndrome of systemic inflammatory response (according to Sepsis-3). Purulent-resorptive exhaustion. Harmful alcohol abuse. Alcoholic disease. Chronic alcoholic pancreatitis. Pancreatogenic diabetes mellitus type 2, stage of insulin demand, clinical and metabolic decompensation. Alcoholic polyneuropathy. Chronic viral hepatitis B .. The patient was prescribed antibacterial, detoxification and nutritive-metabolic therapy.

On October 16, 2018, the patient was operated on. Under general anesthesia with separate intubation of the main bronchi in the position of the patient on the left side, along the lateral surface of the chest on the right in the projection and along the IV rib, a 6 cm long incision was made in the skin and subcutaneous tissue. ribs. Subperiosteal resection of the IV rib section 5 cm long was performed. Through the bed of the resected rib section, the enclosed empyema cavity, containing up to 40 ml of turbid thick gray pus with fibrin, was opened. In the middle lobe of the right lung, there was a gray area of necrotic tissue. The described area was delimited from the free pleural cavity by an adhesive process. The outer wall of the abscess was excised and the abscess cavity was opened. Pus and sequesters were removed from the abscess cavity. Ultrasonic cavitation of the abscess cavity was performed. The abscess cavity was washed with 0.02% chlorhexidine bigluconate solution and drained. When the right lung was switched on in breathing, the mouths of small bronchial fistulas and air discharge through them were visualized. In connection with the pronounced inflammatory changes in the pulmonary parenchyma, it was decided to refuse fistula suturing. A polyurethane foam sponge of appropriate size was placed into the cavity of the lung abscess and the adjacent cavity of the encapsulated empyema of the pleura through the minithoracotomy access. A drainage tube with lateral holes was passed inside a polyurethane foam sponge, fixed to it with a suture and brought out below the wound through a separate puncture of the chest in the V intercostal space. The drainage tube was sutured to the skin. The skin and subcutaneous tissue of the minithoracotomy wound were hermetically sutured with five single interrupted sutures. Aseptic dressings were applied to the wounds. The drainage tube was connected through a container for collecting liquid to a medical aspirator V-40A (NPO Visma-Planar, Republic of Belarus). A constant vacuum of -15 kPa (~ 112.5 mm Hg) was created in the system.

In the postoperative period, an improvement in general well-being was noted. Serous effusion in a volume of 150-200 ml per day was discharged through the drainage, no air release was noted. Leukocytes in the general blood test from 16.10.2018 - 11.12x109 / l, from 18.10.2018 - 9.7x109 / l. With radiography of the OGK from

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On October 17, 2018 and October 18, 2018, a polyurethane foam sponge with a drainage tube was visualized in the projection of the abscess cavity of the middle lobe of the right lung; a decrease in the size of the abscess cavity was observed in dynamics. CT CT scan from October 18, 2018 showed a decrease in infiltrative changes in the right lung, pleural effusion was detected in the posterior lower parts of the right pleural cavity up to 30 mm wide.

On October 19, 2018, the vacuum dressing was changed, for which, in the operating room under general anesthesia with separate intubation of the main bronchi in the patient's position on the left side, the sutures were removed from the minithoracotomy wound, minirethoracotomy was performed, and the polyurethane foam sponge was removed. It was noted that the abscess cavity decreased in size, cleared, actively granulates, and inflammatory changes in the surrounding lung tissue decreased. When the right lung was switched on in breathing, the mouths of small bronchial fistulas, the number of which decreased, and air discharge through them were visualized. The abscess cavity was washed with 0.02% chlorhexidine bigluconate solution and drained. A polyurethane foam sponge of appropriate size was placed into the cavity of the lung abscess and the adjacent cavity of the encapsulated empyema of the pleura through the minithoracotomy access. A drainage tube with lateral holes was passed inside a polyurethane foam sponge, fixed to it with a suture and brought out below the wound along a canal in the V intercostal space. The drainage tube was sutured to the skin. The skin and subcutaneous tissue of the minithoracotomy wound were hermetically sutured with five single interrupted sutures. Aseptic dressings were applied to the wounds. The drainage tube was connected through a container for collecting liquid to a medical aspirator V-40A (NPO Visma-Planar, Republic of Belarus). A constant vacuum of -15 kPa (~ 112.5 mm Hg) was created in the system. A puncture of the right pleural cavity was also performed in the VIII intercostal space along the scapular line, in which a serous effusion was obtained. At the puncture site, the right pleural cavity was drained according to Bulau. The drainage drained 100 ml of serous effusion.

In the postoperative period, an improvement in the patient's general well-being was noted, the body temperature returned to normal from 20.10.2018.A serous effusion in the amount of 50-100 ml per day was released from the polyurethane foam sponge drainage, there was no air release. There was no discharge from the pleural cavity.

On October 22, 2018, in the operating room under endotracheal anesthesia with the patient on the left side, the sutures were removed from the minithoracotomy wound, minirethoracotomy was performed, and the polyurethane foam sponge was removed. It was noted that the abscess cavity was significantly reduced in size, completely cleared, actively granulating. The cavity was washed with 0.02% chlorhexidine bigluconate solution and drained. A drainage tube with lateral holes was installed inside the abscess cavity and brought out to the outside of the chest wall below the wound along the canal in the V intercostal space. The minithoracotomy wound was sutured in layers. Aseptic dressings were applied to the wounds. The drainage tube was connected through a container for collecting liquid to a medical aspirator V-40A (NPO Visma-Planar, Republic of Belarus). A constant vacuum of -15 kPa (~ 112.5 mm Hg) was created in the system.

On October 25, 2018, the appearance of local emphysema in the minithoracotomy access zone was noted, the occurrence of which was caused by the unauthorized disconnection of the patient from vacuum suction for a long time. Subcutaneous emphysema went away on its own within 5 days without any action.

X-ray examination of the OGK from October 29, 2018 showed a significant decrease in the abscess cavity of the middle lobe of the right lung in size, there was no pleural effusion. On October 29, 2018, the drainage was removed from the pleural cavity. There was no air release during active aspiration through drainage from the middle lobe abscess. On 10/30/2018, active aspiration was removed and drainage was transferred to drainage according to Bulau. After that, when talking and coughing, air was released through the drainage. CT scan of 10/30/2018 in the projection of the middle lobe revealed a drainage tube surrounded by zone pulmonary fibrosis.

During treatment, the patient gained weight to 10 kg, BMI of 05.11.2018 was 16.9 kg / m ^2. Leukocytes in the general blood test from November 6, 2018 - 5.7x10 ⁹ / l. Air discharge through the drainage from the abscess cavity of the middle lobe of the right lung completely stopped on November 7, 2018. X-ray examination of the OGK dated November 8, 2018, in the middle lobe of the right lung, revealed a drainage tube with a surrounding zone of pneumofibrosis. On November 8, 2018, the drainage was removed from the middle lobe of the right lung. X-ray of the OGK from November 9, 2018, in the middle lobe of the right lung, only the zone of pulmonary fibrosis was determined.

In a satisfactory condition, the patient was discharged on November 9, 2018 with a recommendation to remove the stitches from the wounds in the drainage sites on an outpatient basis.

The proposed method can be recommended for use in the practical work of the departments of thoracic surgery.

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Literature:

1. Ditterich D, Rexer M, Rupprecht H. Vakuumtherapie beim Pleuraempyem - Erste Erfahrungen mit der Anwendung im Pleuraspalt. Zentralbl. Chir. 2006Apr; 131 Suppl LS133-8. doi: 10.1055 / s-2006-921499.

2. Perentes JY, Abdelnour-Berchtold E, Blatter J, Lovis A, Ris HB, Krueger T, Gonzalez M. Vacuum-assisted closure device for the management of infected postpneumonectomy chest cavities. J. Thorac. Cardiovasc. Surg. 2015 Mar; 149 (3): 745-50. doi: 10.1016 / j.jtcvs.2014.10.052

3. Varker KA, Ng T. Management of empyema cavity with the vacuumassisted closure device. Ann. Thorac. Surg. 2006 Feb; 81 (2): 723-5. doi; 10.1016 / j. athoracsur .2004.10.040.

4. Saadi A, Perentes JY, Gonzalez M, Tempia AC, Wang Y, Demartines N, Ris HB, Krueger T. Vacuum-assisted closure device: a useful tool in the management of severe intrathoracic infections. Ann. Thorac. Surg. 2011 May; 91 (5): 1582-9. doi: 10.1016 / j.athoracsur.2011.01.018.

5. Sziklavari Z, Ried M, Hofmann HS. Intrathorakale Vakuumtherapie beim Pleuraempyem und Lungenabszess. Zentralbl. Chir. 2015 Jun; 140 (3): 321-7. doi; 10.1055 / s-0034-1383273.

Claims (1)

CLAIM The method of mini-VAC-rethoracotomy, including the performance of a minithoracotomy with the installation of a vacuum dressing, characterized in that the minithoracotomy is performed through the bed of the resected rib, the tightness of the vacuum dressing is ensured by suturing the skin above it, and the subsequent change of the vacuum dressing is performed during mini-rethoracotomy.