RU2358671C2 - Microsurgical reconstruction of facial nerve - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to surgery and can be applied for microsurgical reconstruction of facial nerve by forming interneural anastomosis between distal part of facial nerve and proximal part of other pre-crossed motor nerve. It is followed with peri- and epineural suturing and microsurgical autotransplantation of free revasculised epiploic flap circularly covering the microneural suture zone with cuff fixation round nerve trunks within 5 cm from anastomosis zone.

EFFECT: method allows creating adequate microcirculation around microneural suture and improving the functional result.

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Description

The invention relates to medicine, namely to reconstructive plastic surgery, and can be used to regenerate a nerve trunk in the area of a microneurovascular suture.

The most common way to reinnervate the facial nerve is to create an end-to-end anastomosis between its peripheral segment and the central segment of a specially crossed other motor nerve (phrenic, sublingual, accessory, glossopharyngeal). The most acceptable are the facies-facies and facies-sublingual anastomoses, since the use of a healthy nerve as a donor nerve entails the development of additional neurological disorders. For the first time, anastomosis VII-XII was proposed by Korfe (1903 g).

The main reason for the failure of neural plastic surgery of the facial nerve is the fact that in addition to restoring the anatomical integrity of the nerve, it is necessary to create favorable conditions for its regeneration in the anastomotic zone and to prevent scarring processes. This problem can be solved by creating a coupling around the area of the microneurovascular anastomosis.

There are several options for creating these couplings.

A known method of plastics defect of a nerve trunk, including the creation of a graft from a fragment of the gastrocnemius nerve with the formed clutch of fascial-cellular islet flap (RU 2176482). This option cannot be used when the main trunk of the nerve is lost, which requires the use of a proximal fragment of another motor nerve. Also, it does not allow you to restore the volume of soft tissue removed during surgical treatment of tumor pathology.

The closest to the claimed invention in terms of features is a method of reconstructive treatment of the consequences of damage to the ulnar neurovascular bundle, including performing microsurgical epineural suture of the ulnar nerve, transplanting the vascular-tissue complex, stitching the tissue complex around the nerve in the form of a sleeve or half-sleeve throughout the entire open epineuria (RU 2214171). Adopted for the prototype. The disadvantages that impede the achievement of the following therapeutic results are:

- inadequacy of microcirculation in the area of the formed microneurovascular anastomosis due to damage and cicatricial changes in the surrounding structures;

- the development of tunnel syndrome due to cicatricial changes in tissues in the area of the nerve suture;

- the inability to use a free neural transplant (insert) with a lost proximal fragment of the resected nerve.

In addition, when using the above methods for the treatment of patients with tumor pathology, for example, during surgery on the parotid salivary gland, as a rule, there are difficulties associated with the need to restore the volume of tissue damaged or lost during surgery, as well as due to exposure on them damaging factors (radiation, drug therapy) that cause the development of fibrosis.

The claimed invention is aimed at solving the problem of creating optimal conditions for the regeneration of nerve fibers in the area of the microneutral suture.

Using in clinical practice the proposed method allows to achieve several technical (therapeutic) results:

- the formation of a zone of privileged microcirculation around the microneutral suture;

- improving the results of plastic surgery on the nerve trunk in the face of negative factors of influence (tumor process, radiation therapy, chemotherapy);

- restoration of the volume of tissue lost during surgery.

The indicated technical and therapeutic results in the implementation of the invention are achieved due to the fact that, as in the known method, microsurgical reconstruction of the facial nerve is carried out by forming a neurovascular anastomosis with epineural and perineural sutures and a sleeve-like covering of the microneutral suture zone.

A feature of the proposed method lies in the fact that they form a neurovascular anastomosis between the distal segment of one nerve and the proximal segment of a specially intersected other motor nerve, carry out microsurgical autotransplantation of a free revascularized omental flap and circularly cover the area of the micro-neural suture with a transported free omental ganglus, which is closed with an omental gland. 5 cm from the zone of anstomosis.

The invention consists in the following.

Surgical interventions on the parotid salivary gland (hereinafter referred to as OSJ) are associated with a certain risk of damage to the branches of the facial nerve, which carries out motor innervation of the facial muscles of the face, and the large ear nerve, which is responsible for the sensitive innervation of the skin of the outer ear and parotid-masticatory region. Paresis and paralysis of the facial muscles are found in subtotal resection of the coolant, with parotidectomy, with the extrusion of the coolant. The problem lies in the variety of functional changes (facial expressions, the act of chewing, closing the eyes). Functional disorders lead to facial asymmetry, the development of conjunctivitis and keratitis and, as a result, depression of the patient's psyche. A microsurgical method in facial nerve surgery is mandatory, given the small diameter and length of the stitched nerves, and the small number of large bundles in the nerve trunk.

The use of the inventive method in clinical medicine makes it possible to create optimal conditions for the regeneration of the nerve trunk in the area of the micro-neural suture, and also allows you to restore the volume of tissue lost during surgery due to the formation of a privileged microcirculation zone around the micro-neural suture. This effect is achieved by creating a sleeve from a fragment of the greater omentum, which is revascularized and transplanted into the region of the micro-neural suture.

The method is as follows.

In order to restore innervation, an interneural anastomosis is formed between the distal segment of one nerve and the proximal segment of a specially crossed other motor nerve, epi-and perineural sutures 9.0-10.0. A microsurgical autotransplantation of a free omental flap is performed, which is clutch-like fixed by circular covering of the zone of the micro-neural suture and 5 cm of nerve trunks. This creates an area of privileged microcirculation.

Execution example.

Patient K., was admitted to the Department of Microsurgery MNIIO them. P.A. Herzen on 02.24.05 with a diagnosis of cancer of the left parotid salivary gland with metastasis to the parotid lymph node T4N1M0. From the anamnesis: about two years ago, pain and numbness appeared in the region of the left cheek and ear. About a year ago, paresis of the branches of the facial nerve appeared. Examination in January 2005 revealed a tumor of the left parotid salivary gland. Upon admission: in the left maxillary region, a tumor is defined with fuzzy uneven contours, dense consistency, about 3.0 cm in size. Paresis of the branches of the facial nerve. Lymph nodes on the neck are not palpable. Ultrasound: in the left parotid region, a nodular formation of 32.5 × 30 mm is determined. Nearby is an altered lymph node of 6.8 × 5.8 mm. On the neck on both sides hyperplastic lymph nodes up to 17 × 11 mm. With CT: in the left parotid salivary gland, an infiltrative tumor of 52 × 48 × 46 mm in size is determined. The contours of the infiltrate are uneven, fuzzy. When cytological examination: No. 1081/05 - adenogenic cancer. The patient was discussed at a consultation with a surgeon, chemotherapist, and radiologist. A combination treatment plan with surgical treatment at stage I has been developed.

03/31/05 performed the operation: Parotidectomy on the left. Lymphadenectomy on the neck from two sides. Microsurgical reconstruction of the facial nerve with autologous graft flap.

Under ETN, a skin incision was made in the parotid region on the left, extended to the submandibular region and along the lateral surface of the neck to the supraclavicular region. The skin edges of the wound are separated with excision of the skin above the tumor. The subcutaneous muscle of the neck with the external jugular vein and submandibular salivary gland with adjacent fiber was removed, and lymph nodes suspicious of mts were identified. The sternocleidomastoid muscle is highlighted. The internal jugular vein is skeletonized. In an acute and blunt way, fiber was removed along the neurovascular bundle of the neck, the accessory region, supraclavicular region, the lateral triangle of the neck, and the pre-angular region. The mobilization of the surface portion of the parotid salivary gland with the intersection of the branches of the facial nerve was made. The tumor was removed in a single block with the main trunk of the facial nerve, with resection of the mastoid process and marginal resection of the ascending branch of the lower jaw. The descending branch of the hyoid nerve is isolated and rotated in the buccal region. Under optical magnification using microsurgical technique, two neural anastomoses were formed between the muscular branch of the hyoid nerve and the buccal branch of the facial nerve, end to end, and the muscle branch of the hyoid nerve and the zygomatic branch of the facial nerve, end to end. Next, a lower middle laparotomy was performed. Using endoscopic techniques, a flap from a large omentum with a feeding leg from the right gastro-omental vessels was formed under video-assisted control. The flap is crossed and moved to the neck. Two microvascular anastomoses were formed under the optical magnification using microsurgical technique between the right gastro-omental gland and the superior thyroid artery end-to-end, and the right gastro-omental gland and superior thyroid vein end-to-end. The start of blood flow. Flap viability restored. The stuffing box flap clutch-like enveloped the zone of neural anastomoses and the soft tissue defect of the parotid region was restored. The wound is sutured in layers tightly. The abdominal cavity is sutured in layers tightly.

The postoperative period is smooth. Wound healing by primary intention. In the postoperative period, remote radiation therapy was performed. The final functional result is satisfactory. Recovery of static muscle tone and sensitivity in the area of surgery.

The inventive method has significant advantages and meets the criteria of patentability.

Claims (1)

A method of microsurgical reconstruction of the facial nerve, including the formation of an interneural anastomosis between the distal part of the facial nerve and the proximal part of the previously crossed other motor nerve, characterized in that after the peri-and epineural sutures are applied, the microsurgical autotransplantation of a free revascularized omental flap is used, which circularly covers the microwaves clutch-like fix around the nerve trunks for 5 cm from the anast zone omoz.