RU2259170C1 - Method for carrying out laryngoplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves using bilaminar cutanomuscular flap for repairing larynx lumen. To produce the flap, an exposed fragment is longitudinally cut and folded in a way that one side of the flap skin surface is used for forming internal surface of the larynx lumen and the other one is used for closing skin wound. Laryngeal skin surface facing larynx lumen is de-epithelized, perforated and re-epithelized by fixing buccal mucous membrane plates in produced lacunas. The internal flap part is attached to laryngostoma boundary in the larynx lumen after introducing perforated obturator stent. The external flap part is attached to skin wound boundary.

EFFECT: enhanced effectiveness in repairing laryngeal mucous membrane and air-conducting paths integrity; minimized buccal mucous membrane wound size.

Description

The invention relates to medicine, in particular to surgery, and can be used in otolaryngology for resection of the larynx in connection with cancer, trauma or postoperative stenosis of the upper respiratory tract.

A known method of plastic surgery of the larynx and trachea, including restoring the integrity of organs using a periosteal-spongy autograft from the grip and body of the sternum on the feeding muscle legs of one or both sternal portions of sternocleidary muscles (RF patent No. 2137431, publ. 09/20/99, Bull. No. No. 26). The disadvantages of this method are:

- the inability to model the cartilaginous skeleton in the form of a defect;

- the absence of all constituent elements of the organ, including the mucous membrane, which leads to atresia of the organ and complicates the subsequent rehabilitation of the patient.

There is also a method of treating cicatricial stenosis of the larynx and cervical trachea, which consists in the fact that on the wound surfaces in the larynx and cervical trachea, a mucus-muscular flap from the cheek tissue is fixed (RF patent No. 2028090, publ. 09.02.95, Bull. No. 4). The disadvantages of this method are:

- limited use due to the limit of the mucosa of the cheek flap;

- the probability of bias with the introduction of a fixing stent.

The closest to the claimed invention method of the same purpose is a method of surgical rehabilitation of patients after complete removal of the larynx affected by a tumor, which consists in the formation of an artificial larynx from a skin-muscle flap on a vascular pedicle cut out with a protrusion from the pectoralis major muscle into the skin inside (patent RF No. 2115376, published on July 20, 1998, Bull. No. 20). Adopted for the prototype.

The disadvantages of this method, preventing the achievement of the following therapeutic results, are:

- the possibility of use only in cases of complete removal of the larynx;

- the lack of a dividing mechanism that ensures the full functioning of the artificial larynx.

The invention is aimed at solving the problem of larynx reconstruction after resection with restoration of a functionally sufficient volume and shape of the organ, as well as its constituent elements, including the epithelial lining.

Use in clinical practice of the proposed method allows to achieve several therapeutic results:

- restoration of airway continuity;

- restoration of the mucous membrane of the larynx;

- restoration of voice function;

- providing the dividing function of the larynx.

These therapeutic results in the implementation of the invention are achieved due to the fact that, as in the known method, the reconstruction of the larynx is carried out using a musculocutaneous flap from the pectoralis major muscle on the vascular pedicle. A feature of the invention is that the restoration of the lumen of the larynx is carried out by a two-layer musculocutaneous flap, for the formation of which the selected fragment is dissected in the longitudinal direction and folded so that one side of the skin surface of the flap serves to form the inner surface of the lumen of the larynx, and the other is used to close skin wounds, the skin surface of the flap facing the lumen of the larynx, de-epidermize, carry out its perforation and re-epithelialization by fixing the plates the mucous membrane of the cheek in the formed holes, the inner part of the flap is fixed into the lumen of the larynx to the edges of the laryngostomy after the perforated stent-obturator is inserted, the outer part of the flap is fixed to the edges of the skin wound.

The invention consists in the following.

The developed method for larynx reconstruction can be used in otolaryngology for laryngeal resections in connection with cancer, trauma or postoperative stenosis of the upper respiratory tract.

The most important advantage of the proposed method is the ability to restore the mucous membrane of the larynx. Moreover, the use of the proposed method provides the ability to minimize the size of the donor wound on the mucous membrane of the cheek. The indicated therapeutic result is achieved due to the fact that the skin surface of the flap facing the larynx is de-epidermized, it is perforated and then re-epithelized by fixing the plates of the mucous membrane of the cheek in the formed holes. The introduction of a perforated stent-obturator allows you to prevent saliva from flowing into the airway and thereby ensures the separation function of the larynx. At the same time, a skin-muscle flap formed in accordance with the claimed method in combination with a stent-obturator successfully performs the frame function of the larynx and does not require the use of heterografts.

The method is as follows.

Under intubation anesthesia, a skin incision is made along the front surface of the neck in the midline. Skin flaps are removed to the sides, the front muscles of the neck are secreted and bred to the sides. Thyroid and, if necessary, cricoid cartilages of the larynx are isolated. A musculocutaneous flap is formed from the pectoralis major muscle while preserving the internal pectoral arteries and veins. The size of the skin area is determined in accordance with the size of the defect of the larynx. A two-layer musculocutaneous flap is formed, folded, dissected in the longitudinal direction and placed so that one side of the skin surface of the flap is turned into the lumen of the larynx, and the other facing the edges of the skin defect. The surface of the flap facing the lumen of the larynx is de-epidermized with a dermatome. On the epidermal surface of the flap with a scalpel, incisions are made 3 mm deep in the direction perpendicular to the surface of the skin flap. In the formed wells, plates taken from the mucous membrane of the cheek, with an area of 0.5 cm ² each, are inserted. Each of the plates of the mucous membrane is fixed with separate sutures to the edges of the notch using an atraumatic needle. Re-epithelialized skin flap is fixed in the larynx to the edges of the laryngostomy with separate sutures after the introduction of a perforated stent-obturator filled with foam and 1% dioxidine solution.

The second part of the flap is fixed to the edges of the skin wound. The lower tracheostomy is made out. The wound is sutured in layers tightly, leaving active drainage in the donor wound.

Clinical example

Patient M., 46 years old, diagnosis: laryngeal cancer T1NOMO. Conducted remote radiation therapy in SOD - 40 Gy. The tumor is localized in the area of the right vocal fold. Below the vocal fold on the right wall is a tumor infiltration of 4 × 4 mm. Under ETN, a lower tracheostomy is applied according to the accepted procedure. Reintubation. A skin incision was made along the front surface of the neck along the midline. The edges of the wound are separated. The muscles of the anterior neck group are diluted longitudinally. The cricoid, thyroid cartilage and the dihedral angle of the larynx are highlighted. The thyroid cartilage is longitudinally dissected along the midline. During the audit revealed a tumor lesion in the form of ulceration with infiltration of surrounding tissues, occupying the fold and subclad sections of the larynx on the right wall. Performed a frontolateral laryngeal resection on the right with a resection of the anterior commissure and cricoid cartilage on the right. The skin incision is extended down to the front surface of the chest wall. A musculocutaneous flap was isolated from the pectoralis major muscle with preservation of the vascular feeding leg. The skin area is folded and dissected longitudinally along the fold line. The part of the skin flap facing the lumen of the larynx is de-epidermized and perforated, that is, notches are made on it, in which sections of the mucous membrane of the cheek are placed. Fragments of the mucous membrane of the cheek are fixed to the edges of the skin incisions using an atraumatic needle.

A stent-obturator was introduced into the lumen of the larynx to form the lumen of the larynx. The edges of the epidermal flap are fixed to the edges of the laryngeal wound. The second part is to the edges of the skin wound. Layer wound closure with drainage was performed.

With control fibrolaryngoscopy, the lumen of the larynx is wide. The patient underwent replacement of the Portex 9.0 tracheostomy tube with a double-lumen No. 5. Breathing is free. Nutrition per os. Voice function restored.

Thus, the claimed method has significant advantages compared with known methods of the same purpose and meets the criteria of patentability.

Claims (1)

A method of reconstructing the larynx using a musculocutaneous flap from the pectoralis major muscle on the vascular pedicle, characterized in that the lumen of the larynx is restored by a two-layer musculocutaneous flap, for the formation of which the selected fragment is dissected in the longitudinal direction and folded so that one side of the skin surface the flap serves to form the inner surface of the lumen of the larynx, and the other is used to close the skin wound, the skin surface of the flap facing the lumen of the larynx, epidermize, carry out its perforation and re-epithelialization by fixing the plates of the cheek mucosa in the formed holes, the inner part of the flap is fixed into the lumen of the larynx to the edges of the laryngostomy after the perforated stent-obturator is inserted, the outer part of the flap is fixed to the edges of the skin wound.