RU2269304C2 - Method for surgical access to the whole thoracic aorta - Google Patents

Abstract

FIELD: medicine, cardiosurgery.

SUBSTANCE: the present innovation deals with operative interferences upon any department of thoracic aorta. Against parasternal line under the teat in men and along inferior edge of mammary gland in women up to posterior auxiliary line one should made a single cutaneous incision followed by carrying out a double thoracotomy along IV and then along VI intercostals at complete cross-sectional sternal crossing along IV intercostals. The innovation enables to decrease traumatism of soft tissues and operative interference, widen the volume of surgical manipulations upon descending thoracic aorta, particularly at its diaphragmatic part and, also, increase the access to its all departments.

EFFECT: higher efficiency.

3 dwg, 2 ex, 4 tbl

Description

The invention relates to cardiac surgery and relates to surgical access in the treatment of aneurysms of the entire thoracic aorta and associated thoracic aortic aneurysms.

Known transverse bilateral transpleural access through the IV intercostal space. This access is performed as follows: the patient’s position on the back with arms apart, with the left half of the chest turning 30-40 ° from the operating table. A skin incision is made from the middle axillary line on the left to the anterior axillary line on the right 2 cm below the nipples. The length of the skin incision is 45.0 ± 5.0 cm. The subcutaneous tissue and breast tissue are mobilized up to the required level throughout. A thoracotomy is made along the upper edge of the fourth rib, first from one side, then from the other side. The sternum is stitched, ligated and crosses the internal thoracic arteries and veins. Jigli saw cross the sternum transversely. The ribs are widely bred with large retractors, while the fingers of the mediastinum from the sternum are peeled off with fingers and tuffs. This opens up wide access to the ascending part and the aortic arch, and when you turn the table to the right and take the lung forward, to the entire descending part of the aorta. The pericardium is opened by a longitudinal section with a transverse cutoff from the diaphragm. This creates wide access to the heart, the ascending part, the arch and the entire descending section of the aorta. At this access, the sternum is restored with a cruciform suture through the upper and lower intercostal space, the ribs are brought together with one “polispas” on each side. (A.B. Stepanenko. Surgical approaches in the treatment of thoracic and thoracoabdominal aortic aneurysms. Reconstructive surgery of thoracic and thoracoabdominal aortic aneurysms, Moscow, 2000, pp. 80-85).

The disadvantage of this access is a large skin incision, a large area of soft tissue trauma, an opening of both pleural cavities, and limited access for surgical procedures on the descending thoracic aorta in its diaphragmatic part.

The objective of the proposed method is to reduce trauma to soft tissues by reducing the skin incision, reducing the invasiveness of surgery by opening only one pleural cavity, expanding the scope of surgical procedures on the descending thoracic aorta, namely on its diaphragmatic part, increasing access to all parts of the thoracic aorta.

The task in the method of surgical access to the entire thoracic aorta, including combined left-side thoracotomy with complete transverse intersection of the sternum, with surgical procedures along its entire length, characterized in that from the right parasternal line below the nipple in men and along the lower edge of the mammary gland in women a single skin incision is made to the posterior axillary line, followed by double thoracotomy from this section through IV, and then along the VI intercostal space with full transverse intersection g ruins on the IV intercostal space.

The proposed method and the features that distinguish it from the known ones are not found in the medical and patent literature, which allows us to conclude that it meets the criterion of "novelty."

The essence of the invention consists in the fact that from the right parasternal line below the nipple in men and along the lower edge of the mammary gland in women to the posterior axillary line, a single skin incision is made, followed by a double thoracotomy from this section through IV, and then through VI intercostal space with full cross-section of the sternum along the IV intercostal space

It is these distinctive signs that allow us to solve the problem: to increase the field of surgical action of the surgeon during manipulations in the chest cavity, to expand the volume of surgical intervention throughout the chest aorta, namely from the level of the ascending aorta to the diaphragmatic aorta. A single skin incision can significantly reduce the length of the skin incision, which reduces the time for ligation of bleeding vessels from the soft tissues of the chest wall, reduces the area of trauma to the soft tissues of the chest wall and the invasiveness of the operation. Double thoracotomy with the intersection of the sternum allows manipulation on the entire thoracic aorta, including its diaphragmatic part.

The combination of all these distinguishing features allows you to get a positive result.

Access is illustrated by drawings.

Figure 1. Combined left-sided thoracotomy along the IV intercostal space with complete transverse intersection of the sternum and along the VI intercostal space from the same skin incision, where the solid line shows the thoracotomy with sternotomy, and the dotted line shows the skin incision.

Figure 2. Type of skin incision with left-sided double thoracotomy with the intersection of the sternum.

Figure 3. General view of the double thoracotomy with the intersection of the sternum.

The method is as follows. The patient lies strictly on his right side. A skin incision is performed from the right parasternal line in the fourth intercostal space below the nipple in men and along the lower edge of the mammary gland in women to the posterior axillary line. Subcutaneous tissue with breast tissue is mobilized up to the fourth intercostal space. Thoracotomy with a transverse intersection of the sternum is performed along the IV intercostal space. Ribs are bred maximally from the sternum to the spine. In this case, the right internal thoracic artery does not cross. To exclude damage to the right internal thoracic artery, the right edge of the sternum is isolated along the same intercostal space. Then subcutaneous tissue with tissues is mobilized down to the sixth intercostal space. Thoracotomy is performed along the VI intercostal space. Manipulations on the ascending aorta, the arch and the proximal section of the descending thoracic aorta are performed from the access through the IV intercostal space. Surgical manipulations on the aorta above the diaphragm are performed from thoracotomy along the VI intercostal space. At this access, the sternum is restored with a cruciform suture through the upper and lower intercostal space, the ribs are brought together with one "polyspas".

The method is implemented in specific examples.

1. The corpse of a man B., 69 years old, (autopsy No. 357) with a posthumous diagnosis: Acute myocardial infarction. Atherosclerosis of the aorta, heart vessels. Hypertension III Art. Date of study: February 26, 2003

The position of the corpse is strictly on the right side. A skin incision was performed from the right parasternal line in the fourth intercostal space below the nipple to the posterior axillary line. The length of the skin incision was 31.0 ± 4.0 cm. The subcutaneous tissue was mobilized up to the IV intercostal space. Thoracotomy with a transverse intersection of the sternum was performed along the IV intercostal space. Ribs were bred maximally from the sternum to the spine. In this case, the right inner thoracic artery was not crossed. To exclude damage to the right internal thoracic artery, the right edge of the sternum was isolated along the same intercostal space. Then, subcutaneous tissue with tissues was mobilized down to the VI intercostal space. Thoracotomy was performed according to the VI intercostal space. Manipulations in the ascending aorta, arch and proximal descending thoracic aorta were performed from access through the IV intercostal space. Surgical manipulations on the aorta above the diaphragm were performed from thoracotomy along the sixth intercostal space. At this access, the sternum was restored with a cruciform suture through the upper and lower intercostal space, the ribs were brought together with one “polyspas”.

2. The corpse of a woman A., 77 years old, (autopsy No. 303) with a posthumous diagnosis of cerebral infarction. Cerebral atherosclerosis. Cerebral edema. Dislocation syndrome. Date of study: 02.17.2003

The position of the corpse is strictly on the right side. A skin incision was performed from the right parasternal line in the fourth intercostal space along the lower edge of the mammary gland to the posterior axillary line. The length of the skin incision was 31.5 ± 4.0 cm. The subcutaneous tissue with breast tissue was mobilized up to the IV intercostal space. Thoracotomy with a transverse intersection of the sternum was performed along the IV intercostal space. Ribs were bred maximally from the sternum to the spine. In this case, the right inner thoracic artery was not crossed. To exclude damage to the right internal thoracic artery, the right edge of the sternum was isolated along the same intercostal space. Then, subcutaneous tissue with tissues was mobilized down to the VI intercostal space. Thoracotomy was performed according to the VI intercostal space. Manipulations in the ascending aorta, arch and proximal descending thoracic aorta were performed from access through the IV intercostal space. Surgical manipulations on the aorta above the diaphragm were performed from thoracotomy along the sixth intercostal space. At this access, the sternum was restored with a cruciform suture through the above and the underlying intercostal space, the ribs were brought together with one "polyspas".

We presented comparative data of the anatomical experiment performed by the proposed method, and the study of the parameters of the surgical wound with transverse bilateral transpleural access along the IV intercostal space. Objective criteria characterizing the conditions of surgical access were: the depth of the wound, the angle of the surgical action and the angle of inclination of the axis of the surgical action.

The studies were performed on 26 corpses of adults of both sexes who died from causes not affecting the syntopy of the chest and abdominal organs, aged 47 to 81 years. Male objects - 14, female - 12. Transverse bilateral transpleural access along the IV intercostal space - 13, combined left-side thoracotomy along the IV intercostal space with full transverse intersection of the sternum and along the VI intercostal space from one skin incision - 13. The following parameters were examined in the study of access parameters: right atrium, ascending aorta, arch, isthmus of the aorta, aorta at the level of the 7th rib, aorta at the level of the diaphragm.

The experimental work was carried out on the basis of the pathanatomical department of NIISP N.V. Sklifosovsky (head of the department - doctor of medical sciences G.P. Titova). The studied anatomical material is presented in table 1.

Table 1
Characterization of anatomical material Name of material amount abs. % men fourteen 54 women 12 46 Total 26 one hundred

Comparative characteristics of spatial relationships in the wound from transverse bilateral transpleural access along the IV intercostal space and combined left-side thoracotomy along the IV intercostal space with complete transverse intersection of the sternum and along the VI intercostal space from one skin incision are presented in table 2 and 3:

table 2
Transverse bilateral transpleural access along the IV intercostal space Access Objects Wound Options GR (see) UOD (gr.) UNOOD (gr.) Right atrium 6.5 + 1.0 95.0 + 3.0 85.0 + 3.0 Ascending aorta 6.5 + 1.0 95.0 + 2.0 75.0 + 3.0 Aortic arch 8.0 + 2.0 80.0 + 4.0 77.0 + 4.0 Isthmus of the aorta 10.0 + 3.0 60.0 + 5.0 65.0 + 5.0 Aorta at 7th rib level 12.0 + 2.0 70.0 + 4.0 80.0 + 5.0 Diaphragm aorta 15.0 + 3.0 40.0 + 5.0 55.0 + 5.0

Table 3
Combined left-side thoracotomy along the IV intercostal space with full transverse intersection of the sternum and along the VI intercostal space from one skin incision Access Objects Wound Options GR (see) UOD (gr.) UNOOD (gr.) Left-sided thoracotomy along the IV intercostal space with full transverse intersection of the sternum Right atrium 7.0 + 1.0 80.0 + 4.0 70.0 + 3.0 Ascending aorta 7.0 + 1.0 80.0 + 4.0 70.0 + 3.0 Aortic arch 8.0 + 2.0 80.0 + 4.0 77.0 + 4.0 Isthmus of the aorta 9.0 + 3.0 70.0 + 5.0 75.0 + 5.0 Aorta at 7th rib level 11.0 + 2.0 75.0 + 4.0 70.0 + 5.0 Diaphragm aorta 15.0 + 3.0 40.0 + 5.0 55.0 + 5.0 Left-side thoracotomy along the VI intercostal space Aorta at 7th rib level 10.0 + 2.0 85.0 + 3.0 85.0 + 4.0 Diaphragm aorta 12.0 + 2.0 85.0 + 4.0 80.0 + 3.0

In a comparative assessment of the parameters of the surgical wound at the indicated accesses, we found that with transverse bilateral transpleural access through the IV intercostal space of the aorta at the diaphragm level for surgical procedures it is difficult to achieve, and with thoracotomy according to the proposed method, the entire thoracic aorta is accessible from the ascending to the diaphragmatic section.

The positive results obtained in this way allow us to expect that the proposed method will find wide application in aortic surgery.

The proposed access allows you to:

1) significantly reduce the invasiveness of surgery by reducing the length of the surgical wound and the wound surface of the chest wall;

2) carry out surgical procedures on the entire thoracic aorta without opening the right pleural cavity;

3) significantly increase manipulation at the level of the diaphragmatic aorta;

4) expand the scope of surgical procedures on the thoracic aorta;

5) maintain the integrity of the right internal thoracic artery.

Claims (1)

A method of surgical access to the entire thoracic aorta, including combined left-side thoracotomy with complete transverse intersection of the sternum, with performing surgical procedures along its entire length, characterized in that from the right parasternal line below the nipple in men and along the lower edge of the mammary gland in women to the posterior axillary the lines produce a single skin incision followed by a double thoracotomy from this section along the IVth, and then along the VIth intercostal spaces with a complete transverse intersection of the sternum on the IVth Reber.

Images