RU2331368C1 - Method of surgical access in case of injury of pharynx and cervical part of esophagus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery and can be used in case of surgical access when treating injuries of pharynx and cervical part of esophagus. Essence of the invention consists in operative exposing of textus cellulosus of neck and esophagus: cutting the skin, subcutaneous paracervix, superficial fascia, opening fascia of nodding muscle, exposing vascular-nerve fascicle, moving nodding muscle aside. For operative exposing of textus cellulosus of neck and esophagus, hinge hooks installed on casing are used. Hooks are made in the form of blunt-pointed two- or three-tooth spades placed in couples oppositely. During access superficial fascia, fascia of nodding muscle and the third fascia of neck are cut, dissection of omohyoid muscle is performed by means of one pair of spades, the muscle is moved aside until fourth neck fascia is exposed. The latter is moved aside by means of opposite pair of spades. Then, dissection of thyroid artery is performed by means of spades, thyroid artery is then moved into lower, farthest from lower jaw corner of the wound and kept there until the end of operation. Application of the proposed method is aimed at reduction of traumaticity of surgical access and at preservation of organ.

EFFECT: reduction of traumaticity of surgical access in case of injury of pharynx and cervical part of esophagus.

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Description

The invention relates to medicine and can be used in the treatment of patients with diseases and injuries of the pharynx and cervical esophagus.

A known method of surgical access in the treatment of diseases and injuries of the pharynx and cervical esophagus through the classical operation of cervical mediastinotomy according to V.I. Razumovsky, which consists in a wide opening of the cellular spaces of the neck and providing access to the esophagus and pharynx ("Guide to Operative Surgery and Topographic Anatomy" edited by V. Kovanov, 1978, p. 301).

The known method consists in dissecting the skin, subcutaneous tissue, superficial fascia along the inner edge of the sternocleidomastoid muscle. The external jugular vein located under the skin is displaced to the side or intersected after ligation. The cervical aponeurosis is dissected along the grooved probe, the fascia of the sternocleidomastoid muscle is opened, the neurovascular bundle is bluntly exposed, spreading the sternocleidomus and larynx to the side. The tracheal wound is sutured in the transverse, the esophagus in the longitudinal direction.

To fix the esophagus and trachea, exposed in a known manner, use Mosquito or Kocher clamps with single-tooth hooks, traumatic tracheal rings and the wall of the esophagus. At the same time, temporary ligation with “holders” enhances tissue damage.

During the operation, with the traditional use of Farabef hooks, the surgeon is forced to cross the scapular-hyoid muscle and the superior thyroid artery, since the use of coarse early-expanding hooks does not technically allow you to save thin anatomical cultures and their injury is inevitable. Due to the lack of elasticity of the tissues crossing the surgical field in the transverse direction, in its middle region the inevitable intersection of the scapular-hyoid muscle further leads to a violation of the mobility of the larynx, a violation of voice and speech. Ligation of the upper thyroid artery leads to a decrease in thyroid function - the development of hypothyroidism and its cystic degeneration. To divert the upper part of the larynx to the midline, and the sternocleidomastoid muscle, one of the Farabef hooks is moved above the hyoid bone, closer to the upper edge of the wound, and the other hook is located in the bifurcation area of the common carotid artery, diverting it laterally. In this case, as a rule, the opposed reaction of traction to the edges of the wound is violated, the geometry of the wound becomes diagonally elongated. This complicates the anatomical and topographic orientation of the surgeon.

The number of complications in the postoperative period when using the known method reaches from 6 to 24% due to the invasiveness of the operation, the formation of hematoma and emphysema, damage to the trachea and esophagus and their cicatricial stenosis. Complications are associated with excessive trauma to the soft tissues in the wound, significant damage to the trachea, which are difficult to avoid when using Farabeff hooks, used both to move and hold tissues, despite the fact that the working parts of these hooks have an unchanged geometry.

The invention is aimed at improving the results of treatment of injuries of the pharynx and cervical esophagus, in particular, reducing the time of hospitalization and disability of patients, reducing the number of complications.

The technical means for the implementation of the claimed method is the well-known retractor for operations in traumatology and orthopedics, manufactured by the SAN company, Yekaterinburg (Patent RU 56158, publ. 2006), equipped with special obtuse miniature two-pointed and adapted to surgery of the neck and esophagus three-tooth hooks in the form of blades with a C-shaped working part.

The use of a known device - an annular retractor for the implementation of the claimed method required the creation of a new sequence of methods of operation. The novelty of the method lies in the fact that the operative exposure of the cellular spaces of the neck and esophagus is carried out with the help of hinged hooks mounted on a clip made in the form of blunt two-or three-pronged scapulae, placed in pairs opposite, while cutting the fascia fascia, stigma and third fascia of the neck , one of the pairs of shoulder blades dissect the scapular-hyoid muscle and take it away to expose the fourth fascia of the neck, which is pushed back by the oncoming pair of shoulder blades, then making shoulder blades thyroid artery dissection, it is removed into the lower, distal from the lower jaw, wound angle and held there until the end of the operation.

The use of the articulated mounted blunt-ended double- or tridental shoulder blades in the claimed manner allows us not to cross the upper thyroid artery and scapular-hyoid muscle and create an organ-saving surgical access technique in the treatment of patients with injuries of the pharynx and cervical esophagus.

In addition, the use of an annular retractor optimizes the process of suturing a defect in the esophagus and trachea due to the reliability of their fixation. The design features of miniature scapulae exclude the possibility of trauma to the trachea and esophagus tissues, provide optimal conditions for conducting an exploratory audit of the hollow organs of the neck.

A new technical result achieved using the inventive method consists in organ-saving and reducing the morbidity of surgical access.

The claimed method was carried out as follows. After introducing into anesthesia and establishing a nasogastric tube, a roller was placed under the patient’s shoulders, his head was thrown back and turned to the right or left, depending on the location of the neck wound. A skin incision was performed along the anterior margin of m.sternocleidomastoideus 3-4 cm long at the level of the thyroid cartilage.

After dissection of the skin, subcutaneous tissue, and the first fascia of the neck (fasia colli superficialis) with the subcutaneous muscle (m.platisma), v.jugularis anterior was ligated and crossed. The vagina of m.sternocleidomastoideus was opened along its front edge, a muscle was bluntly released from it and it was pulled laterally with the help of scapular ring-shaped dilators. Next, the inner vaginal plate of m.sternocleidomastoideus was cut and, together with it, the third fascia of the neck (lamina profunda fasciae colli propriae). Then, the scapular-hyoid muscle was dissected for its functional preservation and the abdomen was removed with miniature scapulae. This technique allows you to maintain the function of the muscles involved in breathing and voice formation. After performing this technique, the fourth fascia of the neck (fascia endocervicalis) was opened in the depths of the wound, which forms cases for the trachea, esophagus, thyroid gland and neurovascular bundle, which were moved away by two oncoming scapulae. In the presence of ongoing bleeding from the vessels of the neck, the latter stood out and were taken on the turnstiles. For good access to the SHOP, a.thyroidea superior ligation and intersection has traditionally been performed. But since the intersection of the thyroid artery disrupts its nutrition with the development of hypothyroidism and cystic-nodular formations, it is advisable to maintain the integrity of the artery and the nutrition of the thyroid gland. For this, a careful dissection of the artery was carried out throughout. The artery was removed by the shoulder blades to the lower, farthest from the lower jaw, the angle of the wound and held in this position until the end of the operation. Subsequently, the neurovascular bundle together with m.sternocleidomastoideus was captured and abducted laterally by the scapulae, while mm.sternohyoideus (sternohyoid) and et sternothyreoideus (sternohyroid) together with the thyroid gland - medially. After that, the cervical spine was felt with the index finger of the right hand, then, turning the finger with the palm surface forward, the cervical spine located between the vertebral bodies and the trachea was determined. The search and isolation of the esophagus was facilitated by the probe installed in its lumen. In the future, the esophagus was isolated, carefully preparing with a tuffer. The most important aspect of the operation is suturing the wound of the esophagus, while the surgeon is experiencing difficulties due to the anatomical features of the structure of the esophagus, which is the posterior wall of the trachea and is in constant motion synchronously with breathing. At this stage, the place of suturing the esophagus with both pairs of shoulder blades is fixed. In this case, the surgical field remains stationary, which creates optimal conditions for suturing. Using the proposed technology allows to minimize damage to the esophagus and trachea, to provide optimal conditions for suturing wounds of the esophagus and trachea, to reduce the number of postoperative complications due to the failure of the seams of the esophagus and trachea.

Example. Patient P., 28 years old, medical history No. 086, was delivered to the Municipal Clinical Hospital No. 23 on January 11, 2006 by an ambulance an hour after receiving a knife wound to the neck. Upon admission, the patient's condition is extremely serious. Consciousness is sharply inhibited, does not answer questions. The skin is pale. Pulse 106 beats per minute. Blood pressure 90/60 mm Hg Bloody discharge from the mouth. The bandage on his neck was wet with plenty of blood. Behind the left sternocleidomastoid muscle 2 cm from the mastoid process, a stab-wound 1.5 cm long was determined, from which scarlet blood flowed abundantly. Bleeding is temporarily stopped by finger pressing the carotid artery to the VI cervical vertebra. The patient, bypassing the emergency room, was taken to the operating room, where anti-shock measures, transfusion of red blood cells, and freshly frozen plasma were started. Clinical blood test - hemoglobin 80 g / l, red blood cells 2.6 · 10 ¹² / l, white blood cells 18 · 10 ⁹ / l: stab - 21, segmented - 65, lymphocytes - 8, monocytes - 6, ESR - 25 mm / h . Blood type - B (III) Rh (+).

Emergency surgery under endotracheal anesthesia. Performed a longitudinal minicollotomy on the left using a ring-shaped retractor. The wound channel is located back to front, from bottom to top and penetrates the pharynx. At 3 cm from the bifurcation of a.carotis communis sinistra, 3/4 circumference of a.carotis interna sinistra was revealed. The carotid artery was taken on the turnstile, a vascular suture was put on the damaged artery. Hemostasis is reliable.

Given the depth of the wound and the direction of its movement to the lateral pharyngeal wall, fibroesophagogastroscopy was performed intraoperatively. In this case, damage to the left side wall of the pharynx, abundant bloody contents in the oral cavity were revealed. A penetrating wound of the posterolateral pharyngeal wall was sutured with vicryl on the left, with Pirogov-Mateshuk interrupted sutures. The neck wound was drained with Redon drainage discharged through contraperture. Sutures on the skin, aseptic dressing. The postoperative period was uneventful, the drainage was removed on the 5th day after the operation, the postoperative neck wound healed per primam. In the postoperative period, damage to the truncus sympathicus fibers was revealed (weakness, decreased sensitivity in the right upper limb, deterioration in visual acuity of the right eye, photophobia). The patient in satisfactory condition was discharged for outpatient treatment.

According to this method, 14 people were operated on, no complications were observed. In this case, no suppuration of the wound, bleeding, hematomas in the postoperative period was found, the period of wound healing was reduced by half. The method allows to reduce the number of painful dressings and manipulations in the wound and create the prerequisites for a less painful and more comfortable postoperative period for the patient.

Claims (1)

A method of surgical access for injuries of the pharynx and cervical esophagus, including operative exposure of the cellular spaces of the neck and esophagus by dissecting the skin, subcutaneous tissue, superficial fascia, opening the fascia of the sternocleidomastoid muscle, exposing the neurovascular bundle, leading to the sternocleidomast, for operative exposure of the cellular spaces of the neck and esophagus using hooks, characterized in that the operational exposure of the cellular spaces of the neck and esophagus is carried out using the articulated hooks made in the form of blunt two- or three-pronged scapulae arranged in opposite pairs, while cutting the surface fascia, striae muscle fascia and the third fascia of the neck, one of the pairs of shoulder blades dissect the scapular-hyoid muscle and take it to the exposure of the fourth the fascia of the neck, which is pushed back by an oncoming pair of scapulae, then the thyroid artery is dissected by the scapula, removed to the lower, farthest from the lower jaw angle of the wound, and held there until the operation is completed.