RU2372864C1 - Method of surgical treatment of funnel-shaped chest deformity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatology and orthopedics and can be applied for surgical treatment of funnel-shaped chest deformity. Xiphoid process is cut off breast bone. Cartilage zones of IV-V ribs are resected, VI, VII and VIII ribs are cut off breast bone. Metal plate is installed behind breast bone in transversal direction. Plate edges are fixed to bone parts of ribs from both sides. Cut-off rib arches are pulled medially and upward taking into account their yielding, laid on plate and sewn on two ribs higher than place of their anatomical fixation in such way that VI rib was on the place of fixation of resected cartilage zones of IV rib, and VII and VIII - on places of V and VI ribs respectively. Rib arches are fixed to breast bone. Drainage tube is installed behind breast bone. Xiphoid process is sewn to place of its anatomical fixation.

EFFECT: method allows to reduce traumaticity of intervention, insure more expressed cosmetic effect.

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Description

The invention relates to medicine, namely to thoracic surgery, and can be used for surgical treatment of all types of congenital or acquired funnel-shaped chest deformities in both adults and children of any age group.

Funnel chest deformity (VDHC) is a complex bone pathology, the only treatment for which is surgery - thoracoplasty.

All existing methods of treatment of VDHK by technical essence can be divided into five main groups.

1. Without the use of fixing structures.

A known method of surgical correction of VDGK proposed by Ravitch M.M. (Ravitch M.M .: The operative treatment of pectus excavatum. Ann. Surg. 1949, 129: 429-444), including the mobilization of the anterior sternum-skeleton from the second ribs to the costal arches, inclusively, the percutaneous resection of the costal cartilage from the third to eighth ribs on both sides, the oblique intersection of the second ribs in the cartilage region and the implementation of a transverse sternotomy at this level, followed by manual straightening of the sternum and its fixation in the intersection region with interrupted sutures.

However, the wide mobilization of the sternocostal complex requires a large longitudinal incision of the skin and its wide detachment, which is disadvantageous cosmetically and entails complications associated with the formation of extensive subcutaneous "pockets" and violation of the trophism of the exfoliated skin flap. Resection of most of the cartilage zones of the ribs is traumatic and leads to significant violations of the protective function of the chest frame.

The postoperative period provides for long-term disability of the patient for 2 months of bed rest and up to a year - the exception of physical activity.

2. Using external fixing structures.

The most widely used method is that of six small skin incisions, lateral chondrotomy and a T-shaped sternotomy are performed, followed by fixation of the sternum on the splint, proposed by I.A. Marshev. (Bairov G.A., Marshev I.A. Congenital deformities of the chest. In the book Surgery of malformations in children. L .: Medicine. 1968. S.116-135).

The disadvantage of this method is the need for a long-term - up to 6 months disability of the patient, as well as the presence of communication of the anterior mediastinum with the environment, which can lead to the development of purulent complications.

3. The method of fixation of the sternum using external and internal fixators is magnetosurgical (Geraskin V.I., Rudakov S.S., Vasiliev G.S., Gerberg A.N. “Magnetosurgical correction of the funnel chest deformity”, M. Medicine, 1986 city, p. 85-136).

Elimination of deformation occurs due to the attractive force of two magnets, one of which is installed behind the sternum, and the other is mounted in a special corset from the outside. (Geraskin V.I., Rudakov S.S., Vasiliev G.S., Gerberg A.N. “Magnetosurgical correction of the funnel chest deformity”, M. Medicine, 1986, p. 85-136).

The disadvantage of this method is the percutaneous resection of the ribs from III to VIII on both sides, which leads to a loss of carcass of the anterior chest wall, significantly reducing its protective properties. The presence of a corset in the postoperative period interferes with chest excursions, making breathing more difficult. Wearing a corset requires constant monitoring and correction of its position in order to prevent the displacement of the traction vectors of the magnets. The presence of an external structure significantly complicates access to the postoperative wound, which interferes with the observation and care of it.

4. A method involving mobilizing the sternum with cutting it off from the costal cartilage, flipping it 180 ° and fixing it to the cartilage at the cutting site (Hawkins JA, Ehrenhalft JL, Doty DB "Repair of pektus excavatum by sterna eversion", Ann Thorac Surg, 1984 Oct., 38: 4, 368-373).

However, the method is not popular, as it leads to a large number of complications. Complete mobilization of the sternum and cutting it off from the costal cartilage is highly traumatic. After mobilization of the sternum and turning it through 180 °, necrosis is possible due to an excess of blood vessels. The new position of the sternum leads to the formation of keeled chest deformity.

5. Fixation of the sternum complex using internal fixators.

A known method of treating funnel chest deformity (A.S. No. 1703080, class IPC: A61B 17/56, 1992), adopted as the closest analogue.

The method consists in performing a transverse skin incision at the level of the deformation center from the right midclavicular line to the left. Skin flaps with subcutaneous tissue exfoliate up and down. Stratify the pectoral muscles in the area of the most deformed costal cartilage, one or two ribs on both sides. Carry out a periapical resection of the changed cartilage, a transverse wedge-shaped sternotomy, the xiphoid process is excised, costal arches are cut off. A titanium plate with a width of 20 mm and a length of 100 to 200 mm is installed behind the sternum, depending on the age of the patient, and fixed to the bone stumps of the resected ribs. The costal arches are sutured to the sternum body. In the anterior mediastinum, drainage is established. The wound is sutured in layers. A removable cosmetic seam is applied to the skin.

However, the known method has several significant disadvantages. The use of a wide submammary incision, combined with a wide detachment of skin flaps, causes trophic disturbances that threaten the development of necrosis and lead to the formation of a rough postoperative scar. Access to the deformed costal cartilage with stratification of the muscles of the anterior chest wall is a traumatic manipulation that creates inconvenience for percutaneous resection. Installation of a metal plate behind the sternum does not provide reliable fixation of the costal arches, which leads to their retraction in the postoperative period and relapse of deformation. The known method does not eliminate the deformation of the costal arches, which in most cases does not allow to achieve the optimal cosmetic effect. The lack of adequate drainage of the exfoliated skin flap creates the conditions for the formation of subcutaneous hematomas, which in turn leads to a “flap disease” and the occurrence of inflammatory complications.

The objective of the invention is to create a less traumatic method of surgical treatment of funnel chest deformity, which reduces the risk of postoperative complications and obtain a pronounced cosmetic effect.

The essence of the invention lies in the fact that the method of surgical treatment of funnel chest deformity is characterized by the fact that two skin incisions are made on the anterior chest wall along the skin fold under the pectoralis major muscles, the skin and subcutaneous fat are peeled off with exposure of the pectoralis major muscles at their attachment site , large and small pectoral muscles on both sides exfoliate from the costal framework, the xiphoid process is excised from the sternum, through the resulting defect, the parietal pleura is bluntly exfoliated from the costal the surface, the cartilage zones of the IV-V ribs are resected. The ribs VI, VII and VIII are cut off from the sternum, behind the sternum, in the transverse direction, a metal plate is installed so that the lower edge of the plate is flush with the lower edge of the sternum, creating support for the rib arches, the edges of the plate are fixed to the bone parts of the ribs from both of the sides, the cut off costal arches, taking into account their pliability, are pulled up medially and upward, laid on the plate and sutured above the place of their anatomical attachment by one or two ribs, so that the VI rib is at the place of attachment of the resected cartilage zones IV-th, and VII and VIII - in places V and VI, respectively, moreover, with pronounced deformation of the proximal part of the costal arch, deformed sections are additionally resected, then the costal arches are fixed to the sternum, a drainage tube is installed behind the sternum, the xiphoid process is sutured to its place anatomical attachment, after which muscle plasty is performed by moving the detached pectoral muscles and stitching their lower edges with the upper edges of the rectus abdominis muscles, while closing the small bone defects formed during the resection cartilaginous portions ribs medial edge delaminated muscle sewn with each other and with the front wall of the sternum, delamination under the skin and subcutaneous fatty tissue via a separate puncture set drainage tube, cutaneous incisions are sutured.

Using the invention allows to obtain the following technical result.

The method is simple and accessible to a wide range of surgeons.

A pronounced and lasting cosmetic result is achieved. Correction of the funnel-shaped deformation of the chest allows you to eliminate compression of the internal organs, to avoid the development of related diseases of the heart, major vessels of the lungs.

Low trauma to organs and tissues with an operation duration of 2-3 hours, the absence of respiratory mechanics and hemodynamic indicators in the postoperative period, the anatomy of the anterior chest wall can be activated on the third day after the operation and avoid complications such as local purulent-inflammatory processes, hypodynamic disorders, respiratory and cardiological disorders.

Surgical correction of the funnel-shaped deformation of the chest by the claimed method completely solves the problem of social adaptation of the patient in society.

The technical result is achieved by fixing on the metal plate of the rib arches. The location of the plate at the lower edge of the sternum and the fixation of the costal arches on it eliminates the possibility of relapse associated with the displacement of the ribs forming the costal arches in the postoperative period.

Shortening and moving the costal arches above the place of their anatomical attachment allows you to save the sternocostal frame, eliminate the deformation of the costal arches, create a higher and narrower waist, which guarantees the preservation of the ideal cosmetic result in the long term and eliminates the risk of relapse.

The method is as follows.

An indication for thoracoplasty is any form of funnel chest deformity, including relapse after previously undergoing thoracoplasty.

The operation is performed under intubation anesthesia.

Two skin incisions are performed on the anterior chest wall: in women, submammally in the skin fold, in men in the skin fold under the large pectoral muscles. The skin and subcutaneous fat are exfoliated with exposure of the pectoralis major muscles at their attachment site. Large and small pectoral muscles on both sides exfoliate from the costal skeleton, which makes it possible to expose the sternocostal complex without significant injury to muscle tissue. The xiphoid process is cut off from the sternum. Through the resulting defect, the parietal pleura is stupidly peeled off from the bony surface. The cartilaginous zones of the IV-V ribs are resected bilaterally. VI, VII and VIII ribs forming the costal arches are cut off from the sternum. For the sternum, in the transverse direction, a metal plate with a width of 20 mm and a length of 150 to 300 mm is installed, depending on the age and anthropometric parameters of the patient, so that the lower edge of the plate is at the same level with the lower edge of the sternum, which creates support rib arches and prevents their displacement in the postoperative period. The edges of the plate are fixed to the bone parts of the ribs on both sides. The cut off costal arches are pulled up medially and upwards taking into account their pliability, imposed on the plate and sutured above the site of their anatomical attachment by one or two ribs, depending on the number of cartilage resected, so that the VI rib is at the place of attachment of the resected cartilage zones of the IV and VII and VIII in places V and VI, respectively. This technique allows you to eliminate the defect of the costal framework, while maintaining the protective function of the anterior chest wall. The movement of the rib arches makes the waist narrower and higher, which gives the operation a more pronounced cosmetic effect. With a pronounced deformation of the proximal part of the costal arches, the latter are pulled as medially and upward as possible, imposed on the sternum, according to the planned place of their fastening. The possible level of their shortening is determined and noted with the aim of excising the deformed sections. After resection, costal arches are fixed to the sternum. Behind the sternum, through a separate puncture, a tubular drainage is installed on the skin. The xiphoid process is sutured to the site of its anatomical attachment. Muscular plastic surgery is performed by moving the detached pectoral muscles and stitching their lower edges with the upper edges of the rectus abdominis muscles, which makes it possible to close small bone defects formed during the resection of the cartilaginous sections of the ribs. The medial edges of the exfoliated muscles are stitched together with each other and with the front wall of the sternum. Under exfoliated skin and subcutaneous fat through a separate puncture establish a tubular drainage. Skin incisions are sutured in layers with cosmetic sutures.

Example. Girl A. 15 years old was admitted to the clinic in February 2007 for surgical treatment with an asymmetric form of a funnel-shaped chest deformity of the III degree (Fig. 1). After preoperative preparation, the operation is performed according to the method described in this application.

Two cuts of the skin and subcutaneous fat were performed submammally along the skin fold. Skin flaps with subcutaneous fat are exfoliated from the anterior chest wall up to the III rib and down to the lower edge of the costal arches. The xiphoid process is cut off from the sternum. Through the resulting defect, the parietal pleura is stupidly detached from the sternum and the anterior bone surface of the chest. Large and small pectoral muscles on both sides are mobilized. Percutaneous resection of IV and V ribs on both sides was performed. The costal arches are cut off from the sternum. The sternum is brought forward to the anatomically correct position. A titanium plate with a width of 20 mm and a length of 250 mm is installed behind the sternum in the transverse direction, so that the lower edge of the plate is at the level of the lower edge of the sternum. The edges of the plate through the holes in them are fixed to the bone parts of the ribs. The costal arches are captured by the claws, pulled upward and medially, laid on the sternum so that the VIth upper rib forming the costal arch is at the level of attachment of the resected cartilaginous part of the IVth rib to the sternum. The excess length of the deformed proximal part of the costal arch is marked by an electric knife. The costal arcs were shortened on both sides according to the marks made. The costal arches are laid on a plate and hemmed to the sternum two ribs above the place of their anatomical attachment. The sternum is drained by a tubular drain, which is removed through a separate puncture to the skin. The xiphoid process is hemmed to the sternum. The lower edges of the mobilized pectoral muscles are pulled down and stitched with the upper edges of the rectus abdominis muscles. The medial edges of the pectoral muscles are stitched together and the center of the sternum. A tubular drainage is installed in the subcutaneous tissue, which is removed through a separate puncture to the skin. The wounds were sutured in layers with the application of a skin cosmetic suture.

Minor blood loss of 300 ml. The duration of the operation was 2 hours 15 minutes.

The postoperative period is smooth, without complications. Drainages removed on the 3rd day. The girl began to walk on the 4th day. On the 10th day the seams were removed. Primary healing. Received a pronounced clinical and cosmetic result (figure 2). In satisfactory condition she was discharged home on the 10th day.

The observation period is 5 years. The patient is socially adapted, works in the modeling business.

The method has undergone clinical trials at the Department of Pediatric Surgery RMAPO (head of the department, Prof. Yu.Yu. Sokolov) on the basis of MDGKB St. Vladimir (head physician P.P. Kasyanov). Operated 108 children, aged 3 to 17 years. Among them, 91 boys and 17 girls. No complications were noted. All patients achieved good cosmetic and clinical results. There were no relapses. Duration of observation from 3 months to 5 years.

Claims (1)

A method for surgical treatment of funnel chest deformity, characterized in that two skin incisions are made on the anterior chest wall along the skin fold under the pectoralis major muscles, the skin and subcutaneous fat are peeled off with exposure of the pectoralis major muscles at the attachment site, pectoralis major and minor on both sides they are peeled off from the costal skeleton, the xiphoid process is cut off from the sternum, through the resulting defect the parietal pleura is bluntly peeled from the costal surface, cartilage zones are resected The IV-V ribs, VI, VII and VIII ribs are cut off from the sternum, a metal plate is installed in the transverse direction behind the sternum so that the lower edge of the plate is flush with the lower edge of the sternum, creating support for the costal arches, the edges of the plate are fixed to the bone parts ribs on both sides, the cut off rib arches are pulled up medially and upwards taking into account their compliance, put on a plate and hem above the place of their anatomical attachment on two ribs so that the VI rib is at the place of attachment of the resected cartilage exit zones of the IVth, a VII and VIII - in places V and VI, respectively, and with severe deformation of the proximal part of the costal arch, deformed areas are additionally resected, then the costal arches are fixed to the sternum, a drainage tube is installed behind the sternum, the xiphoid process is sutured to its place anatomical attachment, after which muscle plasty is performed by moving the detached pectoral muscles and stitching their lower edges with the upper edges of the rectus abdominis muscles, while closing the small bone defects formed during the incisions the cartilaginous sections of the ribs, the medial edges of the exfoliated muscles are sutured with each other and with the front wall of the sternum, a drainage tube is installed under a separate puncture through a separate puncture, and skin incisions are sutured.

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