RU2326607C1 - Method of mammary gland reconstruction - Google Patents

Abstract

FIELD: medicine; plastic surgery.

SUBSTANCE: reconstruction of mammary gland is performed by means of TRAM-graft transfer if there is median vertical scar. Free TRAM-graft is created including two low epigastric vascular fascicles from right and left side followed with application of microvascular anastomosis.

EFFECT: enables to improve blood supply of TRAM-graft; to reduce traumatizing of anterior abdominal wall; to enhance cosmetic effect.

1 dwg, 2 ex

Description

The invention relates to medicine, namely to oncology and is intended for the reconstruction of the mammary gland after mastectomy for cancer.

Currently, the TRAM flap is the best method for reconstructing the breast after a mastectomy. There are many methods for the formation and movement of the flap, depending on the sources of its blood supply. The standard methods described in the literature are a TRAM flap on the feeding leg of the rectus abdominis muscle and a free TRAM flap, the blood supply of which is due to the lower epigastric vessels. Both of these methods are successfully used to restore the mammary gland with an intact anterior abdominal wall.

In cases where there are vertical postoperative scars on the anterior abdominal wall (after lower midline laparotomy), the ability to move the entire TRAM flap is limited. In such situations, to increase the volume of the flap being moved, its connection with both rectus abdominis muscles is necessary.

One of the methods for forming a TRAM flap in the presence of scars on the abdominal wall is a TRAM flap on two feeding legs.

So there is a known method of breast reconstruction by moving from the anterior abdominal wall of a transverse TRAM flap on the feeding legs of both rectus abdominis muscles, equipped with upper epigastric vessels. (See Stephen J. Mathes, Vincent R. Hentz Plastic Surgery, Second Edition, Vol. VI, p. 733).

This method is quite reliable, but it is not without drawbacks, the main of which is a significant violation of the supporting function of the anterior abdominal wall and frequent herniation after the removal of both rectus abdominis muscles. This type of complication is highly undesirable, as it requires additional operations.

Known for the closest in technical essence and achieved effect and taken as a prototype method for breast reconstruction by moving from the anterior abdominal wall of a TRAM flap equipped with a vascular pedicle of the upper epigastric vessels and lower epigastric vessels from the opposite side, which anastomose with the thoracodorsal artery and vein (See patent RU No. 2133588, class A61B 17/00, application. 10.09.96, publ. 07.27.99).

However, the disadvantage of this method is the insufficient blood supply to that half of the TRAM flap, which is supplied with the upper epigastric vessels, which is associated with an indirect type of arterial blood supply, compared with direct blood supply from the system of lower epigastric vessels. As a result, the volume of surviving flap tissue is reduced.

In addition, in the known method, as well as in the analogue, the support function of the anterior abdominal wall is broken after the removal of one rectus abdominis muscle, which leads to the formation of hernias. In addition, in the process of moving the flap, a subcutaneous tunnel is formed, which leads to a deterioration in the cosmetic result of the operation.

The objective of the invention is to improve blood supply to the TRAM flap, a significant reduction in trauma to the anterior abdominal wall and an improvement in the cosmetic effect.

The technical result in the presence of a middle vertical scar on the front wall of the abdomen is to create an optimal method for forming a TRAM flap by including two lower epigastric vascular bundles isolated on different sides of the scar, which enhance blood flow in the flap.

The problem is achieved in that in the method of reconstructing the mammary gland by moving the TRAM flap in the presence of a middle vertical scar, according to the invention, a free TRAM flap is formed with two lower epigastric vascular bundles on the right and left sides, followed by the application of microvascular anastomoses.

Studies on the sources of patent and medical information have shown that the set of essential features of the invention is unknown and does not follow explicitly from the material studied, therefore, it has a "novelty" and "inventive step".

The proposed method for breast reconstruction can be applied in oncology hospitals with plastic surgery departments using equipment and instruments produced by both domestic and foreign industry, therefore, meets the criterion of "industrial applicability"

Distinctive essential features of the invention is that

- form a free TRAM flap with the inclusion of two lower epigastric vascular bundles on the right and left sides, followed by the application of microvascular anastomoses, which improves blood supply, significantly reduces trauma to the anterior abdominal wall, and as a result, reduces the likelihood of postoperative ventral hernias, as well as improving the cosmetic result of the operation by increasing the volume of the flap, for example, in the presence of scars after lower mid laparotomy.

Thus, the set of essential features ensures the achievement of a technical result, namely, if there is a middle vertical scar on the front wall of the abdomen, the creation of an optimal method for the formation of a TRAM flap by including two lower epigastric vascular bundles isolated on different sides of the scar, which enhance blood flow in the flap.

The proposed method is confirmed by the drawing, where a transverse TRAM flap from the anterior abdominal wall is highlighted, on which there is a vertical scar from the navel to the pubic region from the previous operation.

The method is carried out as follows.

Under general anesthesia with an ellipsoidal incision on the anterior abdominal wall with the upper border at the level of the umbilical ring, the lower border 2 cm above the pubis and the side walls, a TRAM flap is cut out in the projection of the external superior iliac spine, including a vertical scar in the middle part from a previous operation.

After determining the location of the perforating vessels along the right rectus abdominis muscle, a section of the aponeurosis of the indicated muscle is cut out, starting at the level of 2 cm above the umbilical ring and 6 cm more caudally, 4 cm wide. The section of the rectus sheath vagina is extended along the lateral edge to the level of the inguinal fold . The lower epigastric vascular bundle is isolated from the site of its branch from the external iliac vessels to the place of flow into the rectus abdominis muscle. The islet of the rectus abdominis muscle is cut off from the main muscle mass while maintaining blood supply due to the lower epigastric vessels. The vascular bundle is crossed at the level of its branch from the external iliac vessels. The same operation is performed on the left.

The TRAM flap is moved to the wound on the chest on the left and fixed with 3-0 prolene internal nodular sutures. A vascular bundle is isolated in the right axillary region: a.subscapularis, a.circumflecsa scapulae, a.toracodorsalis. The artery enveloping the scapula is secreted over 4 cm, removed to the wound and crossed. The peripheral end of the vessel is ligated, the central one is taken on a clip, preparing for the application of an anastomosis. The thoracodorsal artery is bandaged immediately below the artery of the envelope of the scapula. Blood supply to the right half of the flap is restored by superimposing microvascular anastomoses between the right lower epigastric artery and vein and the right artery and the vein that goes around the scapula, end-to-end surgilene type 8-0.

For revascularization of the left half of the flap, the right inner thoracic vessels are used. The head of the second rib on the left is resected. Dissect the fascia. The internal thoracic artery and vein are isolated. The peripheral ends of the vessels are ligated, the central ones are taken on a clip, preparing for the application of anastomoses. The blood supply to the left half of the flap is restored by superimposing microvascular anastomoses between the left lower epigastric artery and vein and the right intra-thoracic artery and vein, end-to-end surgilene type 8-0.

Clinical example 1:

Patient Emelyanova E.S., 46 years old, medical record No. 286, complained of a tumor in the left mammary gland, which she discovered on her own 3 months ago. Based on the examination data, the diagnosis was established: cancer of the left breast T2N1MO IIb stage, nodular form.

On examination: the mammary glands are symmetrical, of the correct form. Skin, nipple-areolar complexes are not changed. The right mammary gland is soft. In the left mammary gland, in the lower lateral quadrant, a dense tuberous tumor with no clear boundaries of 3.0 cm is determined. In the left axillary region, a single dense displaced lymph node is determined up to 1.5 cm.

Surgical treatment is planned in the volume of a radical mastectomy with simultaneous reconstruction. For reconstruction, it was decided to use a TRAM flap. However, the patient has a history of lower midline laparotomy for an ectopic pregnancy. On the anterior abdominal wall there is a vertical postoperative scar from the navel to the pubic region. In this regard, the TRAM flap was taken according to a new modification.

On October 4, 2006, they performed an operation in the scope of a Payty mastectomy on the left with simultaneous reconstruction of the organ with a TRAM flap on the two lower epigastric arteries.

Description of the operation: Under endotracheal anesthesia, a skin incision was made bordering the left areola with access to the left axillary region. Produced separation of the skin of the left breast in the usual volume. Milk milk is reduced laterally. M.pectoralis major is dissected at the border of the clavicular and thoracic part. M.pectoralis minor is cut off at the site of attachment of the scapula. The subclavian vein is skeletonized. Removed subclavian tissue. The subscapular and axillary lymphadenectomy was performed. The mammary gland is removed in a single block with the subclavian, subscapular and axillary tissue and the pectoralis minor muscle.

An ellipsoidal incision on the anterior surface of the abdominal wall with an upper border at the level of the umbilical ring, a lower border 2 cm above the pubis and lateral tram flap was cut in the projection of the external superior iliac bones.

After determining the location of the perforating vessels along the right rectus abdominis muscle, a section of the aponeurosis of the indicated muscle was cut, starting at the level of 2 cm above the umbilical ring and 6 cm more caudally, 4 cm wide. The section of the rectus sheath was extended along the lateral edge to the level of the inguinal fold . The lower epigastric vascular bundle is distinguished from the place of its branch from the external iliac vessels and to the place where it flows into the rectus abdominis muscle. The islet of the rectus abdominis muscle is cut off from the main muscle mass with the preservation of blood supply due to the lower epigastric vessels. The vascular bundle is crossed at the level of its branch from the external iliac vessels. The same operation is performed on the left.

The TRAM flap was moved to the wound on the chest on the left and fixed with internal interrupted sutures by 3-0 proline. A vascular bundle was isolated in the left axillary region: a.subscapularis, a.circumflecsa scapulae, a.toracodorsalis. The artery enveloping the scapula is highlighted over 4 cm, withdrawn into the wound and crossed. The peripheral end of the vessel is bandaged, the central one is taken on a clip and prepared for the application of anastomoses. The thoracodorsal artery is bandaged immediately below the discharge of the artery enveloping the scapula. Blood supply to the left half of the flap was restored by superimposing microvascular anastomoses between the left lower epigastric artery and vein and the left artery and the vein that goes around the scapula, end-to-end surgilene type 8-0. The blood flow recovered immediately.

For revascularization of the right half of the flap, the left inner thoracic vessels were used. The head of the second rib on the left is resected. The fascia is dissected. Highlighted the internal thoracic artery and vein. The peripheral ends of the vessels are bandaged, the central ones are taken on a clip and prepared for the application of anastomoses. The blood supply to the right half of the flap was restored by superimposing microvascular anastomoses between the right lower epigastric artery and vein and the left intrathoracic artery and vein, end-to-end type 8-0 surgilienum. The blood flow recovered immediately.

Hemostasis during the operation. The flap is fixed to the chest by separate internal prolate sutures 3-0. The wounds on the chest and in the axillary region were sutured tightly with interrupted and interdermal sutures with a 3-0 proline with removal of drainage with active aspiration. The TRAM flap of the anterior abdominal wall is mobilized to the level of the hypochondria. Along the wound of the anterior abdominal wall, drains with active aspiration are installed. The wound on the abdomen is stitched in layers by capron and 3-0 prolene with the removal of the navel on the feeding leg through an additional incision. Aseptic dressing. Cold.

The postoperative period was uneventful. Complete engraftment of the displaced flap was noted. Sutures were removed on day 13. Axillary drainage removed on day 17. The patient was discharged to continue treatment in satisfactory condition.

Clinical example No. 2

Patient P.M.K., 56 years old, medical record No. 243 complained of a tumor in the right mammary gland, which was revealed during a physical examination 2 months ago. Based on the survey data, the diagnosis of right breast cancer T2NOMO stage II, nodular form, was established.

On examination: the mammary glands are symmetrical, of the correct form. Skin, nipple-areolar complexes are not changed. The left mammary gland is soft. In the right mammary gland, a dense tuberous tumor without clear boundaries of 3.0 cm in size is determined in the lower medial quadrant. Regional lymph nodes are not palpated.

Surgical treatment is planned in the volume of a radical mastectomy with simultaneous reconstruction. For reconstruction, it was decided to use a TRAM flap. However, the patient has a history of cesarean section. On the anterior abdominal wall there is a vertical postoperative scar from the navel to the pubic region. In this regard, the TRAM flap was taken according to a new modification.

On October 08, 2006, an operation was performed in the scope of a Payty mastectomy on the right with a simultaneous reconstruction of the organ with a TRAM flap on two lower epigastric arteries.

Description of the operation: Under endotracheal anesthesia, a skin incision bordering the right areola with access to the right axillary region. Produced separation of the skin of the right breast in the usual volume. The mammary gland is reduced laterally. M.pectoralis major is dissected at the border of the clavicular and thoracic part. M.pectoralis minor is cut off at the site of attachment to the scapula. The subclavian vein is skeletonized. Removed subclavian tissue. The subscapular and axillary lymphadenectomy was performed. The mammary gland is removed in a single block with the subclavian, subscapular and axillary tissue and the pectoralis minor muscle.

An ellipsoidal incision on the anterior surface of the abdominal wall with an upper border at the level of the umbilical ring, a lower border 2 cm above the pubis and lateral tram flap was cut in the projection of the external superior iliac bones.

After determining the location of the perforating vessels along the right rectus abdominis muscle, a section of the aponeurosis of the indicated muscle was cut, starting at a level of 2 cm above the umbilical ring. The vascular bundle is crossed at the level of its branch from the external iliac vessels. The same operation is performed on the left side.

The TRAM flap was moved to the wound on the chest on the left and fixed with 3-0 prolene internal interrupted sutures. A vascular bundle was isolated in the right axillary region: a.subscapularis, a.circumflecsa scapulae, a.toracodorsalis. The artery enveloping the scapula is isolated for 4 cm, excreted into the wound and crossed, the peripheral end of the vessel is bandaged, the central one is taken on a clip and prepared for the anastomosis. The thoracodorsal artery is bandaged immediately below the discharge of the artery enveloping the scapula. The blood supply to the right half of the flap was restored by superimposing microvascular anastomoses between the right lower epigastric artery and vein and the right artery and the vein that goes around the scapula, end-to-end, with surgilene 8-0. The blood flow recovered immediately.

For revascularization of the left half of the flap, it was decided to use the right inner thoracic vessels. The head of the second rib on the left is resected. The fascia is dissected. Highlighted the internal thoracic artery and vein. The peripheral ends of the vessels are bandaged, the central ones are taken on a clip and prepared for the application of anastomoses. Blood supply to the left half of the flap was restored by superimposing microvascular anastomoses between the left lower epigastric artery and vein and the right intrathoracic artery and vein, end-to-end, with surgerie 8-0. The blood flow recovered immediately.

Hemostasis during the operation. The TRAM flap is fixed to the chest by separate internal prolate sutures 3-0. The wounds on the chest and in the axillary region were sutured tightly with interrupted and interdermal sutures with a 3-0 proline with removal of drainage with active aspiration. The skin-fascial flap of the anterior abdominal wall is mobilized to the level of the hypochondria. Along the wound of the anterior abdominal wall, drains with active aspiration are installed. The wound on the abdomen is stitched in layers by capron and 3-0 prolene with the removal of the navel on the feeding leg through an additional incision. Aseptic dressing. Cold.

The postoperative period was uneventful. Complete engraftment of the displaced flap was noted. Sutures were removed on day 12. Axillary drainage removed on day 16. The patient was discharged to continue treatment in satisfactory condition.

The method of breast reconstruction compared to the prototype has an improved blood supply to the TRAM flap with a significant reduction in trauma to the anterior abdominal wall and an improvement in the cosmetic effect of the operation.

Claims (1)

A method for reconstructing the mammary gland by moving a TRAM flap in the presence of a middle vertical scar on it, characterized in that a free TRAM flap is formed with the inclusion of two lower epigastric vascular bundles on the right and left sides, followed by the application of microvascular anastomoses.

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