RU2410034C1 - Method for inraoperative prevention of lymphorrea in radical mastectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: intraoperative lymphatic ligation is involved. Transected lymphatic vessels of an axillary subclavian infrascapular region is detected with using a binocular microsurgical loupes; transected ends of each detected lymphatic vessel are ligated with a single interrupted suture; the lymphatic vessel is embedded in a fatty tunnel created around the vessel from an adjacent fatty tissue or muscular tissue by applying an uninterrupted suture along the full length of the vascular trunk until approaching the fatty tissue or muscular tissue; the surrounding adjacent lymphatic vessels are covered when creating the tunnel. It is followed with fixing with the interrupted suture, and anchoring the infrascapular region in layers with a three- and four-row suture.

EFFECT: method allows to prevent lymphorrhea from a vascular lumen and to create conditions for the following lymphorevascularisation due to a contact of a vascular wall and the fatty tissue or muscular tissue.

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Description

The invention relates to medicine, namely to surgery, and can be used to prevent lymphorrhea after radical mastectomy.

The peculiar course of breast cancer (hereinafter referred to as MF) and the biological features of this tumor determine the use of all existing methods of treatment - surgical, radiation, chemotherapeutic, but the surgical stage is the main one in the complex treatment of breast cancer. Despite the continuous improvement of the surgical treatment of breast cancer, the introduction into clinical practice of organ-preserving and reconstructive plastic surgery, the incidence of early and late complications continues to remain at a high level. A constant early complication of surgical treatment of breast cancer for any type of radical surgery is lymphorrhea. Radical mastectomy according to Halstead-Meyer, Payty-Dysen, Madden, organ-preserving breast surgery for breast cancer (radical resection, hemimastectomy with lymphadenectomy, subcutaneous radical mastectomy) are accompanied by axillary-subclavian-subscapular lymphadenectomy, which leads to a significant amount of overacturing lymphatic vessels (LS) from the lymph nodes of these areas and to the formation of a cavity, the size of which affects the frequency of postoperative complications. Due to the insufficient adhesion of skin flaps to the chest wall and the intersection of a significant number of drugs, serous and hemorrhagic fluid accumulates in the wound, which, in turn, contributes to the formation of lymphocele (seroma) in the area of the postoperative wound. Most often, lymphocele is localized in the armpit and somewhat less frequently in the area of widely separated skin flaps. The accumulation of fluid in significant quantities can lead to infection of the wound and other local complications, such as skin necrosis, divergence of the edges of the wound, as well as to general complications (septicemia). Long-term lymph loss in large quantities causes a decrease in the level of total protein, a violation of the percentage of plasma fractions and free amino acids in the blood and lymph, and redistribution of electrolytes. Abundant lymphorrhea, the formed lymphocele leads to a pronounced proliferation of scar connective tissue in the areas of lymphadenectomy, in the areas of the separated skin flaps, which contributes to the development of postmastectomy syndrome. Often, long-existing lymphocele is the cause of repeated surgical interventions.

Postoperative complications lead to a delay in the initiation of adjuvant therapy, accompanied by prolonged hospitalization of patients, and, consequently, the large financial costs of a medical institution.

A large number of means and methods are known to reduce lymphorrhea.

A well-known set of measures aimed at treating lymphorrhea and lymphocele after operations on the vessels of the lower extremities (Abalmasov K.G., Malinin A.A. Pathogenesis and tactics of treating lymphorrhea and lymphocele after vascular operations on the lower extremities // Surgery. Journal of N.N. I. Pirogov - 2004. - No. 3. - p.23-30), including

- transdermal ligation of drugs in 2 versions: 1 - flashing of tissues in the projection of the damaged lymphatic collector with interrupted suturing each other, partially capturing the previous one, 2 - re-flashing of the wound edges with U-shaped reinforcing sutures using vital dyes ( indigo carmine, Evans blue, patented Blue Blau, isosulfan) for detecting damaged lymph vessels in a wound;

- external drainage through a catheter inserted into the lymphatic cavity using a trocar, while constant drainage is carried out using suction;

- daily aspiration of the contents of the lymphatic cavity with the help of puncture, the application of pressure dressings on the area of lymphocele, elastic bandaging of the limb;

- daily introduction through the cutaneous-lymphatic fistula into the cavity of the ointment "Levomekol", preheated to a liquid state;

- operations with perforated tubes in the subcutaneous fatty tissue to divert lymph into intact tissues, where it is absorbed;

- the formation of lymphovenous anastomoses below the formed lymphatic cavity.

By the number of observations, the number of treatment methods for lymphatic complications, the work is very significant, however, methods for the prevention of lymphorrhea are carried out in the postoperative period.

There is also known a technique for the prevention of lymphorrhea, including the preliminary removal of adipose tissue of the axillary region by liposuction, which contributes to a better visualization of the anatomical structures, the possibility of their targeted ligation and in patients with increased weight leads to a significant decrease in the frequency of lymphorrhea (Giard S., Laurent JC et al. Axillary lymphadenectomy prepared by fat aspiration versus functional axillary lymphadenectomy: preliminary results of randomized prospective study // Bull. Cancer. - 1997. - Vol. 84 (3). - P.254-258). However, the use of this method requires additional equipment - an ultrasonic lipodestructor. In addition, observance of oncological positions during lipo-destruction of regional regions is currently doubtful in connection with the possible exit of the metastatic process from regional lymph nodes into adipose tissue.

The closest to the claimed invention in terms of features is a method for the prevention of lymphorrhea, which consists in selective dressing during an operation of drugs contrasted with indirect color lymphography using blue Evans (Ramonova L.P. Early complications of radical mastectomy and their prevention. Diss. M.S. - M., 1991, - 120 p.). Adopted as a prototype. In accordance with the prototype method 24-48 hours before surgery, 1 ml is injected into the outer quadrant of the breast free tumor, and 0.5 ml of a 5-7.5% Evans blue solution is introduced into the skin. In the lower layers of the skin of the I and IV interdigital spaces of the brush on the side of the operation, 0.5 ml of 5-7.5% Evans blue is additionally introduced. A solution of this concentration stains well and allows visualization during radical mastectomy of all groups of lymph nodes of the subclavian, axillary and subscapular regions and their bringing and carrying drugs. Drugs intersecting during surgery are bandaged. In this case, part of the drugs of the upper extremity that did not fall into the block of tissue removed is preserved. This method allowed the authors to reduce the number of wound complications of radical mastectomy by 3 times. Lymphorrhea in the main group (50 patients) was observed in 18% (versus 54% in the control). The average daily lymph loss decreased by 2 times, and the average lymph loss during the period of vacuum wound drainage decreased (280 ml versus 546 ml). The average duration of lymphorrhea in the main group was 8 days (versus 17 days in the control). A decrease in the severity of lymphorrhea contributed to a decrease in the number of seromas (12% versus 36%), as well as other wound complications.

This technique led to a positive effect, however, for its implementation it is necessary to use contrast lymphotropic drugs introduced into the breast with a malignant tumor. Only visible stained drugs are ligated, other small, macroscopically invisible drugs are not bandaged, and therefore lymphorrhea is preserved.

The invention is aimed at solving the problem of developing a method for the effective prevention of prolonged and severe lymphorrhea in patients after radical mastectomy.

Use in clinical practice of the proposed method allows to achieve several technical (medical) and economic results:

- primary surgical prophylaxis of lymphorrhea, carried out intraoperatively,

- prevention of the formation of lymphocele in the axillary region and the resulting pronounced cicatricial changes,

- prevention of other wound complications (suppuration of a postoperative wound, divergence of wound edges, regional necrosis of skin flaps, septicemia),

- prevention of postmastectomy edema of the upper limb by reducing scarring in the axillary region,

- reducing the morbidity of radical mastectomy due to the possibility of excluding the installation of vacuum drainage,

- creating conditions for subsequent lymphorevascularization due to the contact of the vessel wall with fiber,

- acceleration and improvement of social and labor rehabilitation of patients with breast cancer,

- reduction of the hospital stay of patients radically operated on for breast cancer.

The specified technical and therapeutic results in the implementation of the invention are achieved due to the fact that, as in the known method, intraoperative prophylaxis of lymphorrhea with radical mastectomy is carried out by ligation (ligation) during surgery.

A feature of the proposed method is that after the stage of radical mastectomy, crossed drugs of the axillary-subclavian-subscapular region are detected using binocular microsurgical loops, the crossed ends of each of the detected drugs are ligated with a single nodal suture, the drugs are immersed in the cellular tunnel formed from the adjacent fiber from the adjacent fiber or muscle tissue by applying a continuous suture throughout the visible trunk of the vessel until it enters adipose tissue or muscle tissue. At the same time, during the formation of the tunnel, the surrounding surrounding drugs are captured, fixed with a nodal suture and the axillary region is sutured in layers with a three-, four-row suture.

The invention consists in the following.

Known methods for the prevention of lymphorrhea after radical mastectomy, which can completely prevent this complication or effectively reduce the incidence and volume of lymphorrhea, are carried out already in the postoperative period. It is relevant to develop methods for the prevention and reduction of lymphorrhea in patients with stage I-IV breast cancer when performing radical resections of the breast, functionally sparing radical mastectomies.

Removal of axillary, subclavian, subscapular lymph nodes leads to the intersection of drugs that connect them and, therefore, are found in the areas of their location.

The inventors have developed an original technique for immersing crossed drugs in a cell tunnel. The result of the application of this technique is to prevent the outflow of lymph from the lumen of the vessel and the creation of conditions for subsequent lymphorevascularization due to the contact of the vessel wall with fiber or muscle tissue.

The length of the seam is determined by the length of the crossed drug and in most cases is from 7 to 10 cm. In the absence of fiber, muscle fibers located along the periphery of the vessel are captured and the vessel is immersed in the muscle channel.

The use of binocular loops allows you to detect macroscopically invisible drugs in stitched fiber and immerse them in the cell tunnel. In the process of formation of the cell tunnel, the smallest drugs located in the wall of the cell tunnel are captured and doped, which excludes lymphorrhea from these vessels and subsequently creates the prerequisites for lymphorevascularization. In the process of flashing drugs with the capture of surrounding fiber and / or muscle fibers, the axillary region is sutured in layers with a three-, four-row suture. Thus, the totality of the techniques used can minimize postoperative lymphorrhea.

The scheme of immersion of the crossed drug in the fiber tunnel is shown in the drawing, a, b - scheme of applying the first fixing suture, c, d - scheme of applying a continuous seam with immersion of drugs in the tunnel formed from the surrounding fiber (1 - first fixing suture, 2 - fiber, 3 - LS, 4 - continuous seam).

The method is as follows.

After the stage of radical mastectomy, the wound is washed with a solution of furacilin. Using binocular microsurgical loops of the company "Carl Zeiss" find crossed drugs axillary-subclavian-subscapular area. The area of fiber adjacent to the drug is captured with an atraumatic needle — an injection at a distance of 0.5 cm from the drug, an injection at a distance of 0.1 cm from the vessel on one side, then an injection at a distance of 0.1 cm from the vessel and an injection at a distance of 0.5 cm from the vessel wall on the opposite side. Next, this seam is alternated throughout the visible trunk of the vessel until it enters the fatty tissue. Thus, the drug is immersed in the emerging "tunnel" from the surrounding fiber vessel. At the end, the “tunnel” is fixed with a nodal seam. This technique is applied to all visible with the help of microsurgical drugs magnifiers. The seam length is determined by the length of the crossed drug and in most cases is from 7 to 10 cm. In the absence of fiber, muscle fibers located along the periphery of the vessel are captured and the vessel is immersed in the muscle channel. The use of binocular loops allows you to detect drugs of a smaller caliber than the bindable lymphatic trunk in stitched fiber and immerse them in the emerging “tunnel”. Thus, in the process of flashing visible drugs with the capture of surrounding fiber and / or muscle fibers, the axillary region is sutured in layers with a three-, four-row suture.

Execution example

Patient B., 62 years old, was in the General Oncology Department of the Moscow Research Institute of Oncology with a clinical diagnosis of PMRM: 1) Cancer of the right breast of the 1st stage. T1N0M0. Condition after combined treatment in 1988-89 (operation + LT); 2) Cancer of the left breast of the I st. T1N0M0 from 01.19.09 to 02.02.09. 01/22/09 a radical Madden mastectomy was performed with drug ligation using a microsurgical technique without the installation of a vacuum drainage installed with standard radical Madden mastectomy.

The skin and subcutaneous tissue were dissected by two semi-oval incisions bordering the left breast. The left breast is mobilized. To access the subclavian region with the aim of ligating the subclavian drugs in the projection of the upper 1/3 of the pectoralis major muscle, a linear incision was made 5 cm long. Access was made to the subclavian vein and the crossed drugs below the vein. The left breast was removed in a single block with fiber and lymph nodes of the axillary, subclavian, subscapular regions. Hemostasis. Dry. The wound is washed with a solution of furacilin.

Using binocular loops, it was found that drugs are determined: 1) along v. axillaris; 2) at the base of the removed regional fiber in the center of the base of the axillary cavity; 3) in the space between the inner edge of the latissimus dorsi muscle and the front dentate muscle, between the inner edge of the subscapular muscle and the front dentate muscle, along the vasa thoracica lateralia; 4) in the fatty tissue of the outer wall of the axillary cavity; 5) in the subclavian region in the area of subclavian lymphadenectomy.

Using atraumatic filament Vicryl 3/0 with the capture of the surrounding fiber and with the stitching of the fibers of the subclavian muscle with a double twisted seam, the subclavian drugs were ligated. The wound in the pectoralis major muscle is sutured with separate interrupted sutures with an atraumatic thread. In the axillary region, the fiber located at the periphery of the vessel was captured and the fiber was flashed with the drug immersed in the channel formed from this fiber with a continuous suture throughout the vessel. The length of the seam was 7 cm. Identified drugs of a smaller caliber in the stitched fiber, which are ligated by a continuous seam in the process of forming the tunnel. This method performed the tunneling of 8 lymphatic trunks and the smallest drugs located in the wall of the cell tunnel. Thus, in the process of flashing visible drugs with the capture of surrounding fiber and muscle fibers, the axillary region is sutured in layers by a three-row suture.

Sutures on the subcutaneous tissue and skin without installing vacuum drainage. In the postoperative period, lymphorrhea and wound complications were not observed in the patient.

The object of the study were 124 patients with breast cancer. The control group consisted of 78 patients who underwent Madame RME according to standard methods. In the main group (46) patients 0 tbsp. TisN0M0 amounted to 2.2% (1), I st. - 17.4% (8), IIA Art. - 46% (10), IIB - 8.7% (4), IIIA - 46% (10), IIIB - 8.7% (4), IIIC - 6.5% (3), IV - 10.8 % (5). The average age is 60.3. 32.6% of patients were in a socially active working condition. 52% of patients had concomitant cardiovascular disease. All patients of the main group underwent RME according to Madden with ligation of drugs of the axillary, subclavian, subscapular regions, determined using binocular microsurgical loops. In 18 patients of this group there was a drainless method of postoperative period management.

In the control group, after Madden's RME, the mean volume (cpV) of LR was 1746 ml with an average number of days - lymph evacuation (CDEL) - 19, early wound complications (inflammatory changes in the wound area) were detected in 17 (21.8%) patients. postmastectomy edema (PMOK) of the I-II degree developed in 48%, pain in 32.7%. In the main group, cpV of LR was 385 ml with CDEL = 5. Inflammatory changes in the wound area were noted in 1 patient (4.6%), pain, arrested by the introduction of non-steroidal anti-inflammatory drugs, in 5 (10.8%), first-degree PMCI in 4 (8.7%) patients, which in 3 - early PMOK with a decrease after conservative treatment.

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

Claims (1)

A method for intraoperative prophylaxis of lymphorrhea during radical mastectomy, including ligation (ligation) during an operation of the lymphatic vessels, characterized in that, after the stage of radical mastectomy, crossed lymphatic vessels of the axillary-subclavian-subscapular region are detected using binocular microsurgical loops, the crossed ends of each of the identified lymphomas are ligated. vessels using a single nodal suture, immerse the lymphatic vessel in the cellular formed around the vessel the tunnel from the adjacent fiber or muscle tissue by applying a continuous suture throughout the visible trunk of the vessel until it enters the fatty tissue or muscle tissue, while in the process of formation of the tunnel, the surrounding adjacent lymphatic vessels are captured, fixed with a nodal suture and the axillary region is sutured in layers of three , four-row seam.

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