RU2440789C1 - Method of replacing fenestrated tracheal and laryngeal defects - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to field of medicine, namely to reconstructive-restorative surgery and otolaryngology, and can be applied in replacement of fenestrated tracheal and laryngeal defects. Method includes sampling and formation of free revascularisable cutaneous-fascial autotransplant with its further sewing into defect with skin inwards with support of rigid component against anterior and lateral walls of defect, recovery of blood supply in autotransplant. In formed autotransplant cutaneous part corresponds to defect dimensions. Flap of subcutaneous adipose cellular tissue and superficial fascia exceeds it by 5-10 mm. Onto fascial surface of autotransplant laid is mesh implant with cell size 200-500 mcm, projecting beyond autotransplant edges by not less than 10 mm. Implant is woven from superelastic nickelide-titanium thread with diameter 60-90 mcm. Linear cut is made in implant and supplemented by cutting out circular hole for placement of autotransplant vascular pedicle. After that, it is fixed through tissue thickness to autotransplant skin with superelastic nickelide-titanium thread with diameter 40-60 mcm. Knots are tied up on implant surface. After that, reinforced with mesh implant autotransplant is placed into defect and autotransplant skin is fixed to trachea and/or larynx defect edges with further covering of suture line with autotransplant tissues. Projecting edge of mesh implant, from composition of formed autotransplant, is fixed to trachea and/or larynx walls. ^ EFFECT: application of said invention makes it possible to eliminate fenestrated tracheal and laryngeal defects of any size by means of autotransplant which is well-supplied by blood with minimal anatomical-functional or cosmetic damage for donor zone, simplify surgeon's actions and reduce operation trauma. ^ 2 ex, 3 dwg

Description

The invention relates to medicine, namely to reconstructive surgery, otorhinolaryngology and thoracic surgery, and may find application in the replacement of terminal defects of the trachea and larynx.

It is known to use for the replacement of terminal defects of the cervical trachea and larynx skin-muscle, three-layer skin-muscle-skin autologous flaps formed from different areas of the neck or moved on the feeding leg from the upper half of the chest [1]. However, the absence of soft tissues suitable for plastic replacement on the neck and upper half of the chest (coarse scars, atrophy of the subcutaneous tissue, marked inflammatory process) does not allow the use of autografts taken from these anatomical regions. At the same time, due to structural features, plastic surgery for defects in the walls of the trachea and larynx requires not only soft, but also supporting tissues.

Various implants were used as a frame structure during the formation of an autograft from adjacent tissues and on a displaced feeding leg to replace extensive terminal defects of the larynx and trachea: nets made of medical steel, tantalum, titanium, silver, polypropylene, marlex, polytetrafluoroethylene, etc. [2]. The disadvantages of these methods are insufficient biochemical and biomechanical compatibility of implants. As a result, after the growth and maturation of the connective tissue, they become rigid, deform and contract, contribute to excessive growth of the connective tissue, which can lead to airway restenosis. These implants are not resistant to infection, cause pressure sores of adjacent vessels (brachiocephalic trunk, etc.) and arrosive bleeding.

Known methods for eliminating extensive defects of the trachea and larynx with the help of complex skin-bone, skin-muscle-bone, skin-cartilage autografts, including those previously prepared by implantation of an auto- or allotissue (cartilage of the costal arch, auricle, nasal septum, etc. d.) [3]. The disadvantages of the methods are the high morbidity associated with the fence of supporting autotissues (bone, cartilage), the likelihood of resorption of the bone or cartilage supporting component and the loss of the skeleton properties of the graft in the long term, which can lead to restenosis of the trachea and larynx, or prolapse of the flap into the lumen of the respiratory tract. Methods with preliminary implantation of cartilage or bone are characterized by multi-stage and duration of treatment, which reduces the quality of life of this category of patients. In addition, when using your own cartilage of the costal arch, auricle or nasal septum, anatomical and cosmetic and cosmetic defects occur in the donor area, which may necessitate their plastic restoration.

A known method for eliminating defects of the trachea and larynx, including the formation of a free revascularizable autograft on the vascular pedicle, then flashing it with separate interrupted sutures, conducting them over the bone on one side and through the dermis of the skin on the other, suturing the autosurgery into the defect with the skin inside, after which the vascular pedicle is carried out into the previously formed subcutaneous tunnel connecting the wound in the trachea and the selected recipient vessels, the application of an anastomosis between the flap vessels and the branches of the carotid artery and jugular us [4]. The method has significant disadvantages. An autograft with a supporting bone fragment has a flat shape, thereby not ensuring the creation of a physiological (semi-ring) shape of the trachea or larynx and allows you to reliably repair defects no more than 1/3 of their circumference. The lack of fixation of the bone fragment in the composition of this flap can lead to tissue migration in the early postoperative period and narrowing of the lumen of the upper respiratory tract. In conditions of tissue deficiency in the recipient region, difficulties may arise when stitching the edges of the skin wound due to the significant thickness of the tissue complex. In the donor area, bone strength decreases, which can lead to a fracture, and to prevent this complication, prolonged immobilization of the limb and limitation of physical activity reduces the quality of life of patients. In addition, the method is characterized by the complexity of surgical operations and the morbidity associated with the collection of a bone fragment.

Closest to the proposed (prototype) is a method for eliminating defects of the trachea and larynx, including the formation of a free revascularizable autograft on the vascular pedicle, for this, cartilage fragments are first collected, wedge-shaped resections are performed in the middle part of the cartilage, preserving one of the surfaces, then the sutures are brought together cartilage edges in the resection area, forming grafts in the form of arches. In the donor region, a bed is formed in the form of separate channels for previously prepared cartilage fragments with preservation of septa with perforating vessels between them on the surface fascia in the projection of the supply vessels of the autograft being taken. In the formed bed, grafts are placed with the convex preserved surface to the fascia, concave to the skin, followed by fixation of the cartilage fragments to the skin of the autograft with sutures. The autograft thus formed is taken in a single complex with cartilage fragments and placed inside the defect with the skin resting on the anterior and lateral walls of the defect, the blood supply in the autograft is restored and the cartilage fragments in the autograft are fixed with sutures to the cartilage of the trachea and / or larynx [5] . However, the method has disadvantages due to the complexity of the formation of a semi-circular form of the lumen of the trachea and / or larynx as a result of the design features of an autograft with a supporting cartilage fragment; the cartilaginous component in the flap may be lysed in the long-term postoperative period, which will lead to the loss of the skeleton properties of the graft and narrowing of the lumen of the upper respiratory tract with respiratory failure; also, after an auto-cartilage is taken, anatomical and functional and cosmetic defects occur in the donor area; plastic restoration may also be necessary. In addition, the method is notable for the complexity of surgical operations and the trauma associated with the collection of a cartilage fragment.

A new technical task is the elimination of terminal defects of the trachea and larynx of any size with a well-supplied autograft with minimal anatomical, functional or cosmetic damage to the donor zone, simplification of the surgeon's actions and reduction of the invasiveness of the operation, increasing its viability.

To solve the problem in a method for replacing traumatic defects of the trachea and larynx, including the collection and formation of a free revascularizable skin-fascial autograft, stitching it into the defect with the skin inward with the support of the rigid component on the front and side walls of the defect, restoring blood supply in the autograft, in the formed autograft the skin part of which corresponds to the size of the defect, and the flap of subcutaneous fatty tissue and superficial fascia exceeds 5-10 mm beyond its limits, A mesh implant is placed on the fascial surface of the autograft, woven from superelastic nickelidotitanium yarn with a diameter of 60-90 microns with a mesh size of 200-500 microns, protruding beyond the edges of the autograft by at least 10 mm, and a linear incision is made in the implant, which is complemented by cutting a round hole for placement of the vascular pedicle of the autograft, then it is fixed to the skin through the thickness of the tissues with a super-elastic nickelidotitan thread with a diameter of 40-60 microns, knots are knotted on the surface of the implant ata, after which the autograft strengthened with a mesh implant is placed on the defect and the skin of the autograft is fixed to the edges of the defect of the trachea and / or larynx, followed by covering the suture line with the tissues of the autograft, then the protruding edge of the mesh implant from the formed autograft is fixed to the walls of the trachea and / or .

The technical result is achievable due to the whole set of interrelated essential features, the determining ones of which are the preliminary strengthening of a free revascularizable autograft with a mesh implant based on titanium nickelide with a cut hole for the vascular pedicle and its fixation with superelastic nickelidotitanium thread, as well as the covering of the first row of sutures and tracheostoma between the autotrans or larynx with a flap of subcutaneous fat and superficial fascia of an autograft that one. The porous scaly surface of the nickelidotitan filament gives it high adaptability in the tissues of the body. The cell size is 200-500 microns, the thickness of the thread for weaving the implant is 60-90 microns and the fixing ligature 40-60 microns are selected experimentally and are optimal for creating a frame and reliable fixation of tissues. The cut-out roundish hole in the implant, on the one hand, allows you to optimally position the feeding leg and prevent its compression at the stage of strengthening the autograft, on the other hand, prevents the displacement of the implant in the early postoperative period. The shape of the implant pattern and the connection option combined autograft-trachea and / or larynx reliably isolate the feeding leg from the first row of the suture, thus, in case of partial failure, thrombosis or arrosive bleeding from the vessels of the feeding leg is prevented. In addition, the use of a three-row suture (10) increases the tightness of the connection of the combined autograft and the walls of the trachea and / or larynx (Fig. 3).

Due to biomechanical and biochemical compatibility with the surrounding tissues, the pores of the filament and the implant cells germinate with fibroblasts, capillaries and newly formed vessels, are filled with connective tissue with the formation of a single tissue regenerate, which ensures reliable retention in the tissues, prevents the implant from shifting relative to the defect of the trachea and / or larynx, eliminates walls respiratory tract. The mesh structure and the total thickness of the implant (at least 120 μm), proposed by us, provides sufficient mechanical stability and, when germinating with connective tissue, does not interfere with minimal mobility in the replaced area of the trachea, which is necessary for adequate tracheobronchial drainage and during the act of breathing. The total thickness of the implant is not more than 200 μm does not prevent close contact of the autograft with surrounding tissues, facilitates their fusion with each other. A mesh implant based on superelastic nickelidotitan yarn is a good plastic material, it allows you to easily and simply simulate any desired shape in the implantation area, and is resistant to infection. The elastic properties of the mesh nickelidotitan implant and the respiratory tube are similar, so when tensile, the deformation of the formed trachea-implant complex is consistent. This reduces the risk of postoperative complications, increases the strength of the connection and provides anatomical and physiological restoration of this area. In the indicated sequence of technical solutions, the duration of the stage of strengthening the autograft and, as a result, the time of the entire operation is greatly simplified and reduced by several times.

The absence in the world literature and in patent information sources of solutions with a similar set of essential features testifies to the correspondence of the proposal by the authors with the criteria of “novelty” and “inventive step”. The invention is illustrated by schemes for performing specific techniques and examples of individual operations in the experiment.

The illustrations show:

figure 1. The shape of the mesh implant pattern: 1 - a linear section, 2 - a rounded hole to accommodate the autograft feeding leg;

figure 2. The replacement pattern of the tracheal terminal defect. Stage of suturing of a revascularized combined autograft: 3 - tracheal defect, 4 - combined autograft, 5 - revascularized feeding leg in a cut out hole of a mesh implant;

figure 3. Operation scheme: tracheal defect is replaced by a combined autograft, its blood supply is restored. A cross section is schematically indicated at the level of the replaced defect of the trachea: 6 - tracheal wall, 7 - skin-fascial autograft, 8 - mesh nickelidotitan implant, 9 - fixing sutures between the skin-fascial autograft and mesh implant, 10 - three-row suture between the combined autograft and graft trachea.

The method is as follows. After the incision bordering the tracheostomy or laryngotracheostomy, the skin is mobilized around the defect and the lateral walls of the trachea and / or larynx are isolated, while 5 mm of skin is left along the perimeter to suture it to the edges of the skin part of the autograft. In the event of a post-resection defect during surgery, the autograft is fixed directly to the wall of the trachea and / or larynx. In the donor area, a free revascularizable skin-fascial autograft corresponding to the size of the defect is taken, in which the skin part corresponds to the size of the defect, and the flap of subcutaneous fatty tissue and superficial fascia exceed it by 5-10 mm. Then, a mesh implant with a cell size of 200-500 μm is placed on the fascial surface of the autograft, protruding beyond the edges of the autograft by at least 10 mm, woven from superelastic nickelidotitan yarn with a diameter of 60-90 microns, and a linear incision is made (1) in the implant and supplement it by cutting out a rounded hole (2) to accommodate the vascular leg of the autograft (5) (Fig. 1), fix it through a thickness of tissues to the skin of the autograft with a superelastic nickelidotitanium thread (9) with a diameter of 40-60 μm, knot knots on a turn Nost implant. An autograft strengthened with a mesh implant (4) is placed in the defect (3) and the autograft skin is fixed to the edges of the defect in the trachea and / or larynx (6), followed by covering the suture line with autograft tissues (Fig. 2) that protrude beyond the edge of the skin part. The free edge of the mesh implant (8), from the composition of the formed autograft (7), is fixed to the front and side walls of the trachea and / or larynx (Fig. 3). Blood supply in the autograft is restored. Wounds are sutured and drained.

The verification test of the attainability of the technical result is the experimental testing of the proposed method for replacing traumatic defects of the trachea and larynx in 8 outbred dogs weighing 10-16 kg. Animal experiments were performed in the Department of Experimental Surgery of the Central Research Laboratory of GOU VPO SibGMU in Tomsk. The study was carried out according to the ethical principles set forth in the "European Convention for the Protection of Vertebrate Animals Used for Experimental and Other Scientific Purposes", all manipulations and removal of animals from the experiments were carried out under general anesthesia. In the postoperative period, clinical observation, x-ray, endoscopic control, histological examination of the preparations was carried out.

Example 1 (mongrel dog weighing 14 kg with a pre-formed laryngotracheostomy). After hair removal around the laryngotracheostomy and in the inguinal region (donor area), treatment of the surgical field with antiseptics under general anesthesia with controlled breathing, a fringing laryngotracheostomy incision was performed, the skin was mobilized around the defect, leaving 5 mm of skin along the perimeter, and the side walls of the trachea were isolated. A free skin-fascial inguinal flap was cut out in accordance with the location of the epigastric neurovascular bundle and the size of the tracheal defect, in which the skin part corresponds to the size of the defect, and the layer of subcutaneous fatty tissue and superficial fascia exceeded it by 10 mm. Then, a mesh implant with a mesh size of 200 μm, protruding at least 10 mm beyond the edges of the autograft, woven from a super-elastic nickelidotitan yarn with a diameter of 60 μm, was placed on the fascial surface of the inguinal autolosug, a linear incision was made in the implant, and then it was supplemented with a rounded hole to accommodate the feeding leg autograft, fixed through the thickness of tissues to the skin of the autograft with interrupted elastic sutures of nickelidotitanic thread with a diameter of 40 μm, tying knots on the surface and plantata. The autograft reinforced with a mesh implant was placed inside the defect with the skin inside and the autograft skin was fixed to the edges of the trachea and larynx defect, the suture line was covered with a flap of subcutaneous fatty tissue and the autograft fascia protruding beyond the edge of the skin. The free edge of the mesh implant from the formed autograft was fixed to the front and side walls of the trachea and larynx. Blood supply in the autograft restored. The wounds are gone. The autograft has taken root. No respiratory failure was observed.

Example 2 (mongrel dog weighing 16 kg). After hair removal in the inguinal region (donor area), treatment of the surgical field with antiseptics under general anesthesia with controlled breathing, cervicotomy was performed, the trachea was mobilized, an extensive defect was formed on the front wall of the cervical trachea. A free skin-fascial inguinal flap was cut out in accordance with the location of the epigastric neurovascular bundle and the size of the tracheal defect, in which the skin part corresponds to the size of the defect, and the layer of subcutaneous fatty tissue and superficial fascia exceeded it by 5 mm. Then, a mesh implant with a mesh size of 500 μm, protruding at least 10 mm beyond the edges of the autograft, woven from superelastic nickelidotitan yarn with a diameter of 90 μm, was placed on the fascial surface of the inguinal autolap flap, a linear incision was made previously in the implant, and it was supplemented with a rounded hole to accommodate the feeding leg autograft, fixed through the thickness of tissues to the skin of the autograft with interrupted elastic sutures of nickelidotitanium thread with a diameter of 60 μm, tying knots on the surface and plantata. The autograft reinforced with a mesh implant was placed inside the defect with the skin inside and the autograft skin was fixed to the edges of the tracheal defect, the suture line was covered with a flap of subcutaneous fatty tissue and the autograft fascia protruding beyond the edge of the skin. The free edge of the mesh implant, from the composition of the formed autograft, was fixed to the front and side walls of the trachea. Blood supply in the autograft restored. The wounds are gone. The autograft has taken root. No respiratory failure was observed.

The results of experimental testing confirm the efficiency of the proposed method and the attainability of the technical result. The readiness of the operation for clinical use indicates the compliance of the proposal with the criterion of "industrially applicable".

Thus, the proposed method allows to eliminate terminal defects of the trachea and larynx of any size with a well-supplied autograft with minimal anatomical and cosmetic or cosmetic damage to the donor zone, to simplify and shorten the duration of the operation, to increase its viability.

Information sources

1. Parshin V.D., Porkhanov V.A. Tracheal surgery with an atlas of operative surgery. M .: Aldi-print, 2010 .-- S.248-261.

2. Yagudin R.K., Yagudin K.F. Alloplasty of laryngotracheostomy with Esfil polypropylene mesh // Bulletin of Otorhinolaryngology. - 2007. - No. 1. - S. 32-36.

3. Reconstructive surgery and microsurgery of cicatricial stenosis of the trachea / V.D. Parshin, I.O. Milanov, E.I. Trofimov, E.A. Tarabrin - M .: GEOTAR-Media, 2007. - P. 41-42.

4. Pat. 2125415, IPC ⁶ А61В 17/24. The way to eliminate defects of the trachea and larynx / L. M. Gudovsky, N. O. Milanov, E. I. Trofimov, V. D. Parshin, No. 97102177; claimed 12/02/1997; publ. 01/27/1999 (Russia).

5. Pat. 2296520, IPC A61B 17/24, A61F 2/04. The way to eliminate the defect in the wall of the trachea and larynx / N.O. Milanov, E.I. Trofimov, V.D. Parshin and others No. 2005120032; claimed June 28, 2005; publ. 04/10/2007, Bull. No. 10, Priority 06/28/2005 (Russia). 9 sec

Claims (1)

A method for replacing tracheal and laryngeal terminal defects, including sampling and forming a free revascularizable skin-fascial autograft, stitching it into the defect with the skin inward with the support of the rigid component on the front and side walls of the defect, restoring blood supply to the autograft, characterized in that the skin part in the formed autograft corresponds to the size of the defect, and the flap of subcutaneous fatty tissue and superficial fascia exceeds it by 5-10 mm, on the fascial surface of the autograft a mesh implant with a cell size of 200-500 microns, protruding beyond the edges of the autograft by at least 10 mm, woven from a super-elastic nickelidotitanium yarn with a diameter of 60-90 microns, and a linear incision is made in the implant and supplemented by cutting a round opening for placement of the vascular the legs of the autograft are fixed through the thickness of the tissues to the skin of the autograft with a 40-60 micron super-elastic nickelidotitan thread, knots are knotted on the surface of the implant, and then fixed with a mesh implant the autograft is placed in the defect and the skin of the autograft is fixed to the edges of the defect of the trachea and / or larynx, followed by covering the suture line with the tissues of the autograft, then the protruding edge of the mesh implant from the formed autograft is fixed to the walls of the trachea and / or larynx.

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