RU2385673C1 - Method for preventing prolonged lymphorrhea following radical mastectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, specifically to surgery and can be used for radical breast surgeries. Mammary gland, subclavian, axillary and subscapular fats are removed en bloc. At the end of the operation, smaller pectoral muscle is transected at an attachment point to ribs and laid on subclavian vein, anchored to lateral piece of axillary excision fat with tamponing axillar region. A lateral skin flap is anchored to the lateral surface of anterior chest wall.

EFFECT: method allows preventing prolonged lymphorrhea.

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Description

The invention relates to medicine, namely to surgery, and can be used for radical operations on the mammary glands,

A known method of radical mastectomy (Patey D, Dyson W, 1948) is the removal of the affected mammary gland in one block with the subclavian, axillary and subscapular tissue. The disadvantage of this method is that there is free space after lymphadenectomy, in which serous fluid accumulates for a long time.

A known method is the closure of the "dead space" in the axillary region by suturing skin flaps to the underlying muscles of the chest wall (Aitken D.R., 1984). This helps to reduce the volume of fluid produced (from 393 ml to 272 ml) and a significant decrease in the number of seromas (from 85% to 25%)). With a combination of hemming of skin flaps to the underlying tissues with early removal of drainage (in the first 48 hours after surgery), only small seromas were formed in 8.1% of cases. Disadvantage - the amount of lymphorrhea decreases, but the length of time often remains.

A known method is the treatment of the axillary zone after removal of regional fiber with autologous fibrin (Moore M.M., et al., 1993), which has adhesive and hemostatic properties. This procedure, according to the data obtained, led to a decrease in the volume of aspirated fluid from 467 to 198 ml and contributed to a more rapid removal of drainage (in the control, without fibrin treatment, on the 7th day, after the use of fibrin on the 4th). The disadvantage is infection of the postoperative wound, which leads to suppuration and necrosis of the skin flap.

A known method is the drainage of the axillary-subscapular space was carried out through a perforated tube, the upper end of which through the clavicular part of the pectoralis major muscle was displayed on the skin of the upper flap in the midclavicular line, and the lower - in the middle axillary line on the skin of the lower flap. The elimination of the free space in the axillary-subclavian region began with the sequentially applying U-shaped “stitches of the holders”, while the thread was passed through the skin. the latissimus dorsi in the projection of the vessels enveloping the scapula and subclavian portion of the pectoralis major muscle. To reduce the pressure on the skin and prevent the eruption of sutures when they are tightened, polyvinyl chloride tubing was used. The latter, 2-4 cm long, was placed at 3 points on the skin of the chest: along the midclavicular line (the site of exit of the anterior segments of the sutures), on the skin of the upper flap at the site of the injection and puncture, and along the posterior axillary line (the site of exit of the posterior segments) (Kochetkov R. I., 2003). The disadvantage is coarse scars at the site of “sutures - holders”, necrosis of the skin flap.

The aim of the invention is the prevention of prolonged lymphorrhea.

This goal is achieved by the fact that according to the method of radical mastectomy by removing a single block of the mammary gland together with subclavian, axillary and subscapular tissue, at the end of the operation, the pectoralis minor muscle is crossed at the site of attachment to the ribs, separated and covered with the subclavian vein, sutured to the lateral part of the fiber axillary cavity, tamponing the axillary region. The lateral skin flap is sutured to the lateral surface of the anterior chest wall.

The claimed method eliminates the "dead" space after lymphadenectomy.

The proposed method is as follows: the patient is laid with his hand on the surgical armrest. A roller is placed under the chest. The surgical field is treated with an antiseptic solution, limited to sterile sheets. Under general anesthesia, a skin incision is made that borders the mammary gland (retreating from the tumor by 5 cm in all directions). Skin flaps are separated upwards - to the subclavian vein, downwards - to the edge of the costal arch, medially - to the middle of the sternum and laterally - to the posterior axillary line. The mammary gland is separated from the pectoralis major muscle. Perform subclavian, subscapular and axillary lymphatic dissection, the drug is removed in a single block. Next, the pectoralis minor muscle is crossed at the attachment site to 2-5 ribs, separated and laid on the subclavian vein, sutured to the lateral part of the tissue of the axillary cavity, plugging the axillary region. The lateral skin flap is sutured to the lateral surface of the anterior chest wall. Careful hemostasis. Through contraperture, suction drainage with constant vacuum discharge is introduced into the side of the wound until the secretion ceases and the adhesive process develops. The edges of the skin flaps are sutured with nylon threads. Lymphorrhea stops at the end of the first week.

Example 1

1. Gafiyatullina S.Sh., 65 years old.

Height - 152 cm. Weight - 84 kg. A / D - 160/100 mm Hg

Diagnosis: Cancer of the right breast pT4N2M0 Er +++; Pr +++ neu +. Obesity 2 tbsp. Allergic bronchial asthma of moderate severity. DN - 1. Hypertension 2 tbsp.

Anamnesis: Sick for about 5 months. Conducted 4 courses of polychemotherapy in a neuvuvannym mode according to FAS.

Status localis: The right mammary gland is compacted. A tumor without clear contours, painless. Size up to 1.5 cm. Axillary lymph nodes are not palpable.

Spent 23.03.06 operation: Mastectomy by Patty on the right.

The postoperative period was uneventful.

Analyzes: Biochemical blood test:

Tot. Bil - 16.6 mkmol / 1 (3.4-20.0); Bun - 5.6 mmol / 1 (2.5-6.4);

Glucosae - 6.51 mrnol / 1 (3.61-6.10); Tot / Protein - 82.3 g / 1 (60.0-83.0);

prothrombin time of the patient in the blood - 16 s;

control prothrombin time - 15 s;

thrombin time - 18 s (N - 15 + - 2 s);

the amount of fibrinogen in the blood is 4.0 g / l;

APTT - 20.5 s (N 20-30 s).

General blood analysis:

WBC - 6.8 * 10 9 / L (4.0-8.8); RBC- 4.29 * 10 12 / L (3.5-5.5);

HBV - 134 g / 1 (115-165); HCT -, 389 1/1 (, 360-, 540);

PLT - 263 * 10 9 / L (180-400); PCT - 220 * 10 1 / L (, 100-, 500);

ESR - 19 mm / hour;

lym - 28.7 (18.0-40.); mon - 4.8 (3.0-11.0); gra - 66.5% (45.5-83.0).

General analysis:

color - salt / yellow; transparent; specific gravity - 1015; pH - 5;

protein - neg .; sugar - neg .; L - 0-1 in s / sp;

squamous epithelium in the room; salts of oxalates +.

Example 2

Petrova E.M., 46 years old.

Height - 156 cm. Weight - 69 kg. A / D - 110/80 mm Hg

Diagnosis: Cancer of the right mammary gland p T2N2M0. Er -; Pr ++; neu +

Hyperplasia of the thyroid gland.

Anamnesis: Sick for about one year. I did not seek medical help. Status localis: In the upper right inner quadrant, tumor formation up to 2.5 cm in diameter with fuzzy contours, dense-elastic consistency, mobile. One lymph node is palpated to the right up to 1.5 cm in diameter. The left mammary gland without pathologies.

An operation was performed on March 24, 2006: a Payty mastectomy on the right with video-assisted thoracoscopic assistance.

Histology: Infiltrating ductal breast cancer with metastases in 7 axillary lymph nodes (out of 9) with capsule infusion. There are no metastases in the parasternol l / nodes.

The postoperative period was uneventful.

Tests:

Blood chemistry:

Tot.Bil - 17.6 mkmol / 1 (3.4-20.0); Bun - 4.5 mmol / 1 (2.5-6.4);

Glucosae - 7.2 mmol / 1 (3.61-6.10); Tot.Protein - 79.0 g / 1 (960.0-83.0);

prothrombin time of the patient in the blood - 14 s;

control prothrombin time - 15 s;

thrombotest - IV; thrombin time 16.5 s (15 ± 2 s);

The amount of fibrinogen in the blood is 2.66 g / l.

APTT - 21.3 s (20-30).

General blood analysis:

WBC - 4.0 * 10 9 / L (N 94.0-8.80); RBC - 4.10 * 10 12 / L (N 3.5-5.5);

HGB - 117g / 1 (115-165); HCT-.3401 / 1 (.360-.540);

PLT - 225 * 10 9/1 (180-400); PCT - 194 * 10-2 1/1 (, 100-.500);

LYM - 36.4% (18.0-40.0); MON - 3.7% (3.0-11.0);

GRA - 59.9% (45.5-83.0); ESR - 6 mm / h.

General urine analysis:

color - straw yellow, transparent; specific gravity - 1016;

pH - 5; protein - neg., sugar - neg .; L 0-1 in p / vision;

squamous epithelium 1-2-3 in s / vision; Er 2-3 in p / sp;

oxalates ++.

Example 3

Khuzina F.Kh., 68 years old.

Height - 158 cm; Weight - 55 kg; A / D - 140/90 mm Hg

Diagnosis: Cancer of the left breast pT2N0M0. Hypertension 3 tbsp. Varicose disease of the lower extremities.

Anamnesis: Tumor-like formation was discovered in February 2006. Not treated.

Status localis: At the border of the upper quadrants of the left mammary gland, the tumor formation is up to 3 cm in diameter, with a dense-elastic consistency, mobile. Bloody discharge from the nipple. Regional lymph nodes are not palpable.

The figures to the method are explained how the operation is performed.

Figure 1 shows a wound after a radical mastectomy: 1 - upper mastectomy flap, 2 - lower mastectomy flap, 3 - pectoralis major muscle, 4 - pectoralis minor muscle, 5 - latissimus dorsi muscle, 6 - anterior-lower dentate muscles, 7 - subclavian neurovascular bundle.

Condition after removal with a single block of the mammary gland, together with subclavian, axillary and subscapular tissue.

Figure 2 is a view after crossing the pectoralis minor muscle:

1 - upper mastectomy flap, 2 - lower mastectomy flap, 3 - pectoralis major muscle, 4 - pectoralis minor muscle, 5 - latissimus dorsi muscle, 6 - antero-inferior dentate muscles, 7 - subclavian neurovascular bundle.

The pectoralis minor muscle is crossed at the attachment site to 2-5 ribs.

Figure 3 shows the view after laying the pectoralis minor muscle and fixing the lateral mastectomy flap to the chest wall: 1 - the upper mastectomy flap, 4 - the pectoralis minor muscle, 8 - the fixation of the lateral mastectomy flap to the chest wall, 9 - perforated polyvinyl chloride (drainage) tube .

The pectoralis minor muscle is separated and covered on the subclavian vein, sutured to the lateral part of the fiber of the axillary cavity, plugging the axillary region. The lateral skin flap is sutured to the lateral surface of the anterior chest wall.

In Fig. 4, the final view of the sutured wound after a mastectomy is given: 10 - skin sutures, 9 - polyvinyl chloride drainage, 11 - accordion vacuum aspirator.

Information sources

1. Patey D., Dyson W., 1948.

2. Aitken D.R., Hunsaker R., et al., 1991.

3. Coveney E.C., O'Dwyer P. L., 1993.

4. "Oncology." 2002. Textbook edited by V. I. Chissov.

Claims (1)

A method for the prevention of prolonged lymphorrhea after radical mastectomy by removing a single block of the mammary gland, subclavian, axillary, and subscapular tissue, characterized in that at the end of the operation, the pectoralis minor muscle is crossed at the site of attachment to the ribs and placed on the subclavian vein, sutured to the lateral part of the axillary cavity fiber , tamponing the axillary region, while the lateral skin flap is sutured to the lateral surface of the anterior chest wall.

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