RU2285462C2 - Method for plasty of the wall of tracheal cervical department - Google Patents

Abstract

FIELD: medicine, thoracic surgery.

SUBSTANCE: the present innovation deals with closing fenestrated tracheal defects. Thus, at first, one should form a muscular-cartilaginous fragment due to preimplanting cartilaginous strips out of costal cartilage into the great pectoral muscle. The obtained combined transplant should be applied into tracheal defect being upon nourishing vascular pedicle. The innovation enables to develop a highly blood-supplied transplant for tracheal plasty being of high mechanical strength that prevents transplant's falling back behind tracheal lumen and requires no necessity for applying microvascular anastomoses for transplantation.

EFFECT: higher efficiency.

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Description

The invention relates to medicine, more specifically to surgery.

A known method for closing tracheal defects in the trachea, which consists in the transplantation of a free radiation skin-bone autograft to the defect area with the restoration of blood circulation in it using microvascular anastomoses (Milanov N.O., Gudovsky L.M., Parshin V.D. , Trofimov EI Surgical autoplasty of extensive defects of the trachea. // Annals of plastic, reconstructive and aesthetic surgery; 1998, No. 2, pp. 9-17).

The disadvantages of this method are: a large thickness of the graft, hair growth in the lumen of the trachea, maceration of the skin, the complexity of the operation and the limitation of indications for it due to the presence of a microvascular stage, a high probability of impaired forearm functions after graft removal.

A known method is that when closing a tracheal defect, lyophilized larynx allo-cartilage installed on the defect area without preliminary preparation is used as a scaffold for replaced tissues (Gorbunov V.A. Reconstructive surgery of injuries of the larynx and cervical trachea. N., 1999).

The disadvantages of this method are: a high risk of cartilage resorption and purulent complications, as the result of lyophilization is the death of living cartilage substrate, and transplantation is performed in an area with a low degree of blood supply.

The closest analogue is a method for closing tracheal defects, which consists in preliminarily implanting strips of cartilage of the auricle on the surface of the forearm's own fascia for two months. Then carry out free autologous transplantation of a complex of tissues from their own fascia and cartilage to the defect area (PRDelaere, R.Hermans, J.Hardillo, B. Van Den Hof Prefabrication of composite tissue for improved tracheal reconstruction. // Ann. Oto. Rhino. Laryngol, 2001; 110: 849-860).

The main disadvantage of this method is the need for the application of microvascular anastomoses for revascularization of the graft, which limits the possibility of performing such an operation and indications.

The objective of the invention is the creation of a well-circulated transplant for tracheal plasty having high mechanical strength preventing the graft from falling into the tracheal lumen and not requiring microvascular anastomoses for transplantation.

The problem is solved in that in the method of plasty of the wall of the cervical trachea with a soft tissue autograft reinforced with cartilaginous strips, the autograft is formed from the pectoralis major muscle, into which strips of costal cartilage are previously implanted, and then the combined graft on the vascular pedicle is transferred to the tracheal defect.

The method is as follows.

Initially, the formation of a muscular-cartilaginous flap is carried out. An incision of soft tissues along the costal arch provides access to the cartilaginous parts of the IX and X ribs. Then, from the surface layers of the costal cartilage, the required number of cartilage strips with a thickness of not more than 0.5 cm and a width of 0.5-0.7 cm is cut using a scalpel. This muscle is accessed by a separate cut along the lower edge of the pectoral muscle, then it is separated from underlying tissues. Then, tunnels are formed in the thickness of the pectoralis major muscle in the cranial direction by the number of strips cut out at a distance of 1.0-1.5 cm from each other. Strips of costal cartilage are implanted in the tunnels formed. Then they are fixed to the muscle with separate interrupted sutures. After a period of at least 6 weeks, a tracheal defect is plasticized with a muscular-cartilaginous flap. The skin and wall of the trachea are excised around the defect, then a fragment of the pectoralis major muscle containing implanted cartilage is cut to the required size. The vascular leg of the transplant is isolated - a. thoracoacromialis with accompanying veins. After mobilization of the flap in the subcutaneous tissue, a tunnel is formed through which it is passed to the neck to the defect of the trachea. The graft is fixed to the edges of the defect, orienting the cartilage grafts perpendicular to the longitudinal axis of the trachea, i.e. parallel to undamaged rings. The outer surface of the graft is covered with an autoderm graft.

Clinical example.

Patient A., 21 years old, with a terminal defect in the anterolateral walls of the cervical trachea 6 × 2 cm in size.

The operation of preliminary formation of the combined graft was performed on July 22, 2004. An incision along the lower edge of the costal arch from the xiphoid process of the sternum to the level of the midclavicular line allowed access to the cartilaginous part of the IX-X ribs. 3 cartilaginous strips 5.0 cm long, 0.5 cm wide, 0.4-0.3 cm thick were cut out from the surface layers of these ribs with a scalpel. This muscle was accessed from a separate section along the lower edge of the pectoralis major muscle. Three tunnels 7 cm long with a distance between them of 1 cm were formed in the cranial direction from the lower edge of this muscle. Cartilage strips were implanted in these tunnels.

The operation of the trachea plasty was performed on October 27, 2004. The edges of the tracheal defect were excised, the size of the defect 6 cm along the axis and 2 cm wide. Then a large pectoral muscle was mobilized from a separate incision, from which a flap on a vascular pedicle (a thoracoacromialis with accompanying veins) was cut, containing implanted cartilage strips. The size of the flap was 4 × 7 cm. A tunnel was formed in the subcutaneous tissue, through which the flap was passed to the neck, where it was laid on the defect of the trachea and fixed with sealing sutures. Part of the graft is covered with its own skin of the neck, part (3 × 4 cm) is covered with an autoderm graft. The course of the postoperative period without complications. The patient was extubated on the third day after the operation, after which normal breathing resumed.

Thus, using the proposed method, the following effect is achieved: since the implanted cartilage is located in the pectoralis major muscle (tissue with a high degree of blood supply), the risk of resorption of cartilage and purulent complications is reduced; the use of costal cartilage as a framework allows the formation of a transplant of the required size to replace any length and width of the tracheal wall defects without significant damage in the donor area; the use of the method of plasty with a flap moved on a vascular pedicle avoids the complicated, risky and not all surgeons accessible stage of microvascular graft revascularization.

Claims (1)

Method of plasty of the wall of the cervical trachea with a soft tissue autograft reinforced with pre-implanted cartilage strips, characterized in that the cartilage strips are formed from costal cartilage and implanted into the pectoralis major muscle, the resulting combined graft is transferred to the tracheal defect on the feeding vascular leg.