RU2207063C1 - Method for preventing recanalization of main bronchus - Google Patents

Abstract

FIELD: medicine, thoracic surgery. SUBSTANCE: main bronchus should be dissected between sutures. One should mobilize thymus and parathymic fatty fiber upon nutritive vascular pedicle to obtain glandular-fatty fragment of 10 cm length. Aorta should be replaced medially with the help of Bujalsky's spade-like instrument. Peripheral stump of main bronchus and peripheral department of glandular-fatty fragment should be sutured with atraumatic needle. Glandular-fatty fragment is descended along ligature into interstump space to be fixed there. The method enables to decrease risk of recanalization development of main bronchus' stump. EFFECT: higher efficiency of prophylaxis.

Description

 The invention relates to medicine, namely to thoracic surgery.

 The operation of occlusion of the main bronchus is used in the surgical treatment of patients with empyema with bronchial fistula after pulmonectomy. The operation is performed from transsternal access. One of the complications of the operation is the failure of the stitches of the stumps of the bronchus and its recanalization. In this regard, the search for ways to prevent recanalization of the main bronchus is relevant.

 As a prototype, the authors propose a method for transsternal extrapericardial occlusion of the main bronchus without crossing the branch of the pulmonary artery. // Khovanov A.V., Petyushkin V.F., Samokhina M.V., Nechaev V.I., Krylov V.V. Treatment of pleural empyema with bronchial fistula using transsternal occlusion of the main bronchus. // IV Congress of the scientific and medical association of TB specialists. / Abstracts. - Moscow-Yoshkarola. - 1999 .-- S. 174-174.

 The operation begins with longitudinal complete sternotomy. The edges of the sawn sternum are bred with a rack retractor and the anterior mediastinum is exposed. Stupidly through the aortocaval gap expose the anterior wall of the bifurcation of the trachea.

 The right (left) main bronchus is mobilized bluntly with a finger. After complete mobilization of the bronchus, a rubber holder is brought under it. Sipping the holder up, under the bronchus, the branch of the apparatus for the stapler of the bronchus stump (UKB-25) is brought in and the proximal part of the bronchus is flashed. After that, sipping the holder, under the bronchus again, in the same way, the branch of the device UKB-25 is brought down. A second row of sutures is applied to the distal part of the main bronchus. The peripheral part is cut off by the closed branches of the apparatus and treated twice with a solution of iodine. The tightness of the central suture is checked by creating tension in the anesthesia apparatus with fluid poured into the wound (furatsillin solution 1: 3000, isotonic solution), which allows air leakage to be detected by the appearance of blisters in the stump of the bronchus. In this case, impose additional nylon seams on atraumatic needles. Poured liquid is removed with tampons or suction. The wound is powdered with antibiotics.

 A microirrigator is brought to the cult, which is removed under the sternum into the jugular notch. A thin drainage is placed in the anterior mediastinum, which is removed through a separate incision under the xiphoid process.

 Sawed halves of the sternum are reduced to the contact edges of the cut and tightly fixed with transosseous kapron sutures. The skin is sutured, a bandage is applied, which is fixed with cleol without bandaging.

 The disadvantage of this method, according to the authors, is that after the intersection of the main bronchus, its stumps are located next to each other. This contributes to the occurrence of recanalization of the main bronchus with the failure of the sutures of the stumps of the bronchus.

 The authors propose the following method for performing transsternal occlusion of the main bronchus.

 The operation is carried out in the traditional manner previously described until the stage of intersection of the main bronchus between the hardware sutures. Acutely and bluntly mobilize the thymus and paratymic fatty tissue on the feeding vascular pedicle until a 10 cm long glandular-fatty flap is obtained. Using the Buyalsky's scapula, the aorta is displaced with a medially, atraumatic needle, the peripheral stump of the main bronchus and the peripheral part of the glandular-fatty flap, which are lowered according to the ligature, are sutured. into intercultural space and fix in it, tying a ligature.

 Complete the operation in the traditional manner previously described.

 The advantage of the method is that the interposition of a thymic gland-fat flap on the feeding vascular pedicle into the intercultural space reduces the risk of developing inconsistency of the sutures of the stumps of the main bronchus and its recanalization.

 Clinical example. Patient III., Medical history N 168 (tuberculosis sanatorium "Chernogubovo"). Received about fibro-cavernous tuberculosis, tuberculous empyema on the right. Previously, a resection of the upper lobe to the right, a staged upper posterior 7-rib thoracoplasty to the right, were performed. Upon receipt, the condition is relatively satisfactory. Respiratory rate 24 per minute. The chest is deformed after thoracoplasty on the right, lags behind in the act of breathing. In the right scapular region, a tumor-like formation of 12 • 15 cm, runs, with puncture a turbid fluid is obtained, in which mycobacterium tuberculosis was detected during bacterioscopy and inoculation. On the right, breathing is sharply weakened, on the left - vesicular. On the radiograph on the right, the rib cage is deformed after thoracoplasty, in the collapsed right lung there are small ring-shaped shadows, small focal shadows in all fields. To the right is a paracostally small amount of fluid.

 The patient was repeatedly punctured by a tumor of the right scapular region with the evacuation of contents. Within 3 months, the patient underwent preoperative preparation: antibiotic therapy (3 drugs). Operation: removal of a tumor of the right scapular region. During the operation, the cystic cavity 10 • 15 cm comes from the pleural cavity, is removed, the defect of the chest wall is sutured. Postoperative course without features. 3 months after surgery, relapse of a tumor of the right scapular region. When cardiotrast is introduced into the cavity formation of the right scapular region, the contrast enters the pleural cavity.

 Operation transsternal extrapericardial occlusion of the right main bronchus. The operation began with a longitudinal complete sternotomy.

 The edges of the sawn sternum are divorced by a rack retractor and the anterior mediastinum is exposed. Stupidly through the aortocaval gap, the anterior wall of the bifurcation of the trachea is exposed.

 The right main bronchus was mobilized bluntly with a finger. After complete mobilization of the bronchus, a rubber holder was placed under it. Sipping the holder up, under the bronchus summed up the branch of the device UKB-25 from top to bottom. Sipping the holder in the medial direction, they moved the UKB-25 device by 2.5 cm and stitched the distal part of the bronchus. Sipping the holder up, under the bronchus again, in the same way, the branch of the UKB-25 was brought down from the top. Sipping the holder in the lateral direction, a suture was placed on the proximal section of the main bronchus at the site of its discharge from the trachea. The peripheral part was cut off by closed branches of the apparatus and treated twice with iodine solution.

 Thymus and paratymic fatty tissue was mobilized sharply and bluntly on the feeding vascular pedicle to obtain a 10 cm long glandular-fatty flap. Using the Buyalsky's scapula, the aorta was replaced with a medially, noninvasive needle, and the peripheral stump of the right main bronchus and the peripheral part of the glandular-fatty flap were sutured. ligature into the intercultural space and fixed in it, tying a ligature.

 We checked the tightness of the central suture, creating tension in the anesthesia apparatus with liquid poured into the wound (furacilin solution 1: 3000), there was no air leakage. The poured liquid was removed by suction. 2 g of streptomycin and 4 million ME of penicillin were poured into the wound.

 A microirrigator is brought to the cult, which is brought out under the sternum into the jugular notch with a separate incision. A rubber drainage is installed in the anterior mediastinum through a separate incision under the xiphoid process.

 Layered suture of the wound, aseptic dressing.

 Drainage from the mediastinum was removed on the second day after the operation, began to walk from the second day after the operation, healing of the postoperative wound by primary intention.

 Three months after the operation, the patient's condition improved significantly, positive dynamics on the radiographs of the lungs. Right condition after occlusion of the main bronchus. Diastasis between the tantalum sutures is 3 cm. The mediastinum is shifted to the right, uniform hemithorax to the right. When sputum was studied by flotation and inoculation, Koch's bacillus was not detected.

 In this case, a relapse of the empyema cavity in the right scapular region indicates low reparative capabilities of the body. In this regard, the risk of recanalization of the stump of the main bronchus after occlusion is very high. Only the interposition of the thymus into the intercultural space allowed us to obtain a favorable clinical result.

Claims (1)

 A method for the prevention of recanalization of the main bronchus, including dissecting it between the sutures, characterized in that thymus and paratymic fatty tissue are mobilized on the feeding vascular pedicle to obtain a 10 cm long glandular-fatty flap, the aorta is displaced using the Buyalsky scapula medially, the peripheral stump of the main stitch is sutured with an atraumatic needle the bronchus and the peripheral part of the glandular-fatty flap, which are reduced along the ligature into the intercultural space and fixed in it.