RU2280413C1 - Method for surgical treatment of destructive forms of pulmonary tuberculosis - Google Patents

Abstract

FIELD: medicine, thoracic surgery, phthisiology.

SUBSTANCE: the present innovation deals with surgical treatment of destructive forms of pulmonary tuberculosis due to endoscopic technique. At the level of the third or the fourth rib it is necessary to make paravertebral incision of 4-5 cm length, isolate and resect a costal part at the length of about 4-6 cm. Then it is necessary to isolate a posterior periosteal folium against parietal pleura, dissect it along removed rib and exfoliate costal pleura. In the third or the fourth intercostal area along posterior-auxiliary line one should introduce a trocar into developed cavity to introduce a thoracoscope supplied with a video-camera. Then one should carry out extrapleural pneumolysis under video control followed by applying a netting out of polypropylene upon a lung to be fixed with the help of endosurgical instruments. The innovation enables to decrease traumatism, intra- and post-operational complications and, also, avoids the necessity for conducting thoracoplasty due to applying a reticular implant.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to thoracic surgery and phthisiology.

A known method of surgical treatment of destructive forms of pulmonary tuberculosis by open surgery (V.D. Yampolskaya "Extrapleural pneumothorax and oleothorax in pulmonary tuberculosis". M: Medgiz, 1963, p.27-121), including performing an incision in the axillary or paravertebral region, dissection of the skin and muscles over a length of 10-12 cm, resection of the third or fourth rib, detachment of the bone pleura with subsequent management of the created cavity in the form of extrapleural pneumothorax or oleothorax.

The disadvantage of this method is its invasiveness. It is often accompanied by complications such as intra- and postoperative bleeding, the addition of a purulent infection. Postoperative and rehabilitation periods have long periods. Relapses occur. For these reasons, the method is currently rarely used.

As the closest analogue, the method of surgical treatment of destructive forms of pulmonary tuberculosis by open surgery is adopted (AF Kravchenko "Improving thoracoplastic surgeries with common destructive forms of pulmonary tuberculosis", abstract of a doctoral dissertation. M., 2003). The operation is performed under endotracheal anesthesia. An incision of the skin and muscles is made by lateral access, the intercostal bundles are freed from the parietal pleura, extrapleural pneumolysis of the apical segments of the lung is performed, after which a mesh implant is applied to the apex of the lung and it is fixed to the anterior and posterior segments of the underlying ribs. A mesh implant measuring 10 × 14 cm is made manually on the eve of an operation from an absorbable semi-synthetic suture material - polysorb. Grid resorption period 60-90 days. Extrapleural pneumolysis is supplemented with four-, five- or six-rib options for thoracoplasty.

However, the known method has several significant disadvantages. The operation is traumatic. Performing a long incision with massive intersection of the muscular-fascial layers is accompanied by damage to the nerve and vascular trunks, paresthesia, blood loss, and resection of four or more ribs leads to impaired respiratory function due to loss of chest frame. Often such a traumatic operation is accompanied by purulent complications. The postoperative period is characterized by the severity of the course and duration. In 28 percent of patients, this surgery is ineffective, which requires repeated operations and significantly prolongs the length of hospital stay.

The objective of the invention is to provide a highly effective method for the treatment of destructive forms of pulmonary tuberculosis, which helps to prevent possible complications, reduce the invasiveness and invasiveness of surgical intervention, reduce the time of treatment and rehabilitation.

The essence of the invention lies in the fact that in a method of surgical treatment of destructive forms of pulmonary tuberculosis, including extrapleural pneumolysis with collapse of the apical segments of the upper lobe of the lung, applying a mesh net implant to the apex of the lung, fixing it to the lower ribs, followed by suturing of the wound, previously at the level of the third or fourth ribs perform a paravertebral incision 4-5 cm long, isolate and resect one of the ribs, separate the posterior sheet of the periosteum from the parietal pleura, dissect it removes the costal pleura, bluntly or through a 1 cm long incision in the third or fourth intercostal space along the posterior axillary line, a trocar is installed, through which a thoracoscope is inserted with a video camera connected to it, while extrapleural pneumolysis is carried out under video control of the image on the monitor screen with using an ultrasound operating unit, a mesh made of polypropylene is used to form a mesh implant, the fixation of which is performed using endosurgical instruments s "EndoANCHOR" company Ethicon.

Using the invention allows to obtain the following technical result.

The method is highly effective. It allows you to prevent possible complications associated with direct surgical intervention: bleeding, hematoma formation, suppuration of the wound.

The invasiveness of surgical intervention and tissue trauma are minimized, and the use of video-surgical technique eliminates the need for a large incision.

The duration of the operation is 40-60 minutes (in the known method - 1.5-2 hours). The terms of the immediate postoperative period are reduced to 5-7 days (in the known method 10-14 days). The rehabilitation period is reduced to 2-3 weeks.

The technical result is achieved due to the video surgical technique developed by the authors to sequentially perform the extrapleural pneumolysis operation using a complex of the latest technologies - a video camera, an ultrasound surgical unit Ultrasision, endosurgical instruments (clamps, dissectors, endostic, herneostepler), and modern Johnson & Johnson synthetic nets .

The use of a video camera and endosurgical instruments allows you to abandon a large traumatic access, because visualization of the surgical field is achieved by its image on the monitor screen. The use of an ultrasound operating unit significantly reduces the area of tissue necrosis in the separation of the parietal pleura and prevents possible complications, including bleeding due to simultaneous dissection of tissues and hemostasis. Fixation of the lung with a mesh eliminates the need for thoracoplasty, extrapleural pheumothorax, oleothorax, or other options for filling the extrapleural cavity. The use of a mesh made specifically for implantation during surgical operations avoids local tissue reactions to a foreign body and guarantees its reliability. It should be noted that for thoracic operations, the mesh was used by the authors for the first time.

The method is as follows.

The operation is performed under endotracheal anesthesia in the position of the patient on the abdomen with the upper limb allotted at right angles to the side of the intervention. At the level of the third or fourth rib, a 4–5 cm long skin incision is made along the paravertebral line. The third or fourth rib (depending on clinical data) is isolated and resected in a blunt and sharp way for 4–6 cm. The posterior sheet of the periosteum is carefully separated from the parietal pleura and dissect along the remote part of the rib. Dull way in the direction of axillary lines exfoliate the costal pleura. In the third or fourth intercostal space, on the posterior axillary line, a 10 mm trocar is inserted bluntly or through a 1-cm incision, through which a thoracoscope with 30 ° optics and a connected video camera is inserted into the cavity formed. Extrapleural pneumolysis is carried out under video control of the image on the screen of the monitor using the manipulator of the ultrasound operating unit "UltraSizhn". Lung detachment during superior pneumolysis is performed anteriorly to the III-IV ribs, posteriorly to the VI-VII ribs, medially from the superior mediastinum, to the right to v.azigos with exposure of the superior superior vena cava, left to the aortic arch. With lower pneumolysis, lung detachment is performed 2-3 ribs above the cavity, medially to the spine, anterior to the anterior axillary or mid-clavicular line, down to the diaphragm. Hemostasis is carried out using an ultrasound operating unit. The formed cavity is sanitized with tissues moistened with an aqueous solution of chlorhexidine. Johnson & Johnson company cut out the necessary implant from a standard polypropylene mesh or Vipro mesh (30 × 30 cm). Usually its dimensions do not exceed 18 × 12 cm. A mesh implant is placed on the top of the lung and fixed around the perimeter to the posterior and anterior segments of the underlying ribs using the Endican instrument EthoCon EthoCon.

The resulting cavity is filled with collagen manufactured using the SIC BNT VILAR technology or sterile petroleum jelly, drained with silicone drainage with a diameter of 10 mm through the wound into which the trocar was inserted, with the drainage connected to active aspiration. A layered suture is placed on the surgical wound.

Example. Patient K, 35 years old, was admitted to the hospital for fibro-cavernous pulmonary tuberculosis. Sick for 8 months, is in hospital for 3 months, chemotherapy is carried out. When radiography, tomography reveals a cavity of 5 × 4 cm in region S2 of the upper lobe of the left lung. With repeated sputum examination, mycobacterium tuberculosis is detected. Abacilation could not be achieved. Due to the ineffectiveness of the treatment, the patient is offered surgical treatment. The operation was performed under endotracheal anesthesia in the position of the patient on the abdomen. At the level of the fourth rib, a 4 cm long skin incision was made along the paravertebral line. A fourth rib was selected and resected with a blunt and sharp path over a length of 6 cm. The parietal pleura was peeled off with a blunt path in the direction of the axillary lines. A thoracoscope with 30 ° optics was inserted into the formed cavity through a 10 mm trocar in the 4 intercostal space along the posterior axillary line. Video-controlled extrapleural pneumolysis was performed in front of the III rib, posterior to the VI rib, medially from the upper mediastinum to the aortic arch. Pneumolysis and hemostasis were performed using an ultrasound operating unit. A 16 × 10 cm Vipro mesh is applied to the apex of the lung, which is fixed to the posterior and anterior segments of the underlying ribs using the EndoANCHOR endosurgical instrument. The resulting cavity is filled with collagen and drained with silicone drainage with a diameter of 10 mm through the wound into which the trocar was inserted, with the drainage connected to active aspiration. A layered suture was placed on the surgical wound. The duration of the operation was 60 minutes. The postoperative period was uneventful, without complications. Primary wound healing. During X-ray monitoring, the cavity is not determined, the collapse of the upper lobe is satisfactory, mycobacterium (MCB) sputum analysis was not detected, abacilation was noted. After 4 weeks he was discharged under outpatient supervision by a TB specialist.

Claims (1)

A method of treating destructive forms of pulmonary tuberculosis by extrapleural pneumolysis, including applying a mesh implant to the lung and fixing it to the lower ribs, characterized in that pneumolysis is carried out endosurgically, for this, a paravertebral incision 4-5 cm long is performed, a paravertebral incision is made, 4-5 cm long, and a portion of the rib is resected for 4-6 cm, the posterior sheet of the periosteum is separated from the parietal pleura and dissected along the removed rib, the costal pleura is exfoliated, in the tre rd or fourth intercostal space at zadneaksillyarnoy line set formed cavity trocar through which is introduced with thoracoscopy connected thereto a video camera, and is carried out under video extrapleural pnevmoliz followed by application to a light mesh of polypropylene and fixing it using endosurgical instruments.