RU2449733C1 - Method of trachea plasty with local tissues with reinforcement of anterior wall with plate from porous titanium nickelide and sternoclavicular-mastoid muscles - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to reconstructive-restorative operations in case of trachea pathology. Essence of method lies in application of local tissues of anterior neck surface and plate from porous titanium nickelide. Bordering skin incision is made around trachea defect with formation of skin flaps on perimetre. Flaps are mobilised and sewn on median line. In upper and lower wound poles lifatures-holders are formed. On sewn flaps laid is plate from porous titanium nickelide with size which is 1 cm large than stoma edges. Said construction is covered with mobilised and pexed to median line medial portions of sternoclavicular-mastoid muscles. All layers of anterior trachea wall are fixed to external trachea wall by means of preliminarily formed ligatures.

EFFECT: application of claimed invention makes it possible to reduce the number of postoperative complications, provide additional reinforcement of anterior wall with medial portions of starnoclavicular-mastoid muscles, eliminate floatation of newly formed trachea wall.

5 dwg, 1 ex

Description

The invention relates to medicine, mainly to reconstructive surgery for defects in the trachea.

The known method of surgery to close the tracheostomy using skin-muscle-skin flaps [B.V. Elantsev. Operative otorhinolaryngology. 1959, prototype]. The essence of the method is that under local anesthesia around the tracheostomy, a half-moon skin incision is performed parallel to the edges of the stoma, at a distance of 0.5-0.75 cm from the edge. On the sides of the stoma, two skin flaps form with the epidermis facing the lumen of the larynx, then they are sutured along the midline without piercing the epidermis. The same ligatures staple sterno-thyroid and sterno-hyoid muscles. Thus, skin flaps are simultaneously pulled out of the lumen of the larynx. The disadvantage of this method is:

1. The inability to use it with extensive defects of the trachea.

2. The formation of secondary tracheal fistula.

3. The development of cicatricial stenosis of the trachea.

4. Flotation of the newly formed front wall of the trachea.

The closest in technical essence is the method of closing the defect of the anterior wall of the trachea using a combined flap of arterialized muscular-fascial flaps of the sternocleidomastoid muscle with costal allochondrium [S.A. Gyusan. The method of plastic surgery of the defect of the anterior wall of the trachea, 2007, analogue]. The essence of the method is to eliminate the tracheal defect using a graft, which is previously taken from the cartilage and imposed on the defect of the trachea. In this case, the tracheal defect is eliminated with a combined flap of arterialized muscular-fascial flaps of the sternocleidomastoid muscle with costal allochondrium. One of the two muscular-fascial flaps is moved through the defect and fixed with sutures to the opposite de-epithelialized edge of the laryngeal defect, and then a strip of allo-cartilage is laid over this layer in the transverse direction. In this case, the cartilages of the larynx and trachea are isolated, they are fixed to the perichondrium, allohristil by allotissinous filaments, and the connection between the cartilage of the trachea and allochondral is limited by allogeneic fascia. Then the second muscle flap is moved from above, which is sutured to the opposite de-epithelialized edge of the laryngotracheostomy, and the external wound is sutured after the skin edges are mobilized. This method allows one-step restore the anatomical integrity of the larynx and trachea. However, it has disadvantages in the form of:

1. The inability to use for defects in the lateral walls of the trachea.

2. Rejection of the displacement of the cartilage graft into the lumen of the trachea.

3. The development of cicatricial stenosis of the trachea.

The objective of the invention is to improve the functional results of treatment and reduce the number of postoperative complications of tracheal plasty, using a titanium nickelide plate and strengthening the anterior wall with medial portions of the sternocleidomastoid muscles.

This result is achieved in the following way. Under endotracheal anesthesia with intubation through the mouth, with the cuff of the endotracheal tube beyond the level of the tracheal defect, a bordering skin incision is made around the tracheal defect with the formation of skin flaps along the perimeter. Then they are mobilized and sewn along the midline of the epidermis into the lumen of the trachea. In the upper and lower poles of the wound form ligatures-holders. Then, a porous titanium nickelide plate is placed on sutured skin flaps so that its edges protrude at least 1 cm beyond the defect level of the anterior tracheal wall. The medial legs of the sternocleidomastoid muscles are mobilized and sutured along the midline to create the anterior skeleton tracheal wall. The ligatures-holders formed at the stage of suturing the skin flap, are removed under the sternocleidomastoid muscle, and, thus, the inner skin layer is fixed to the titanium nickelide implant and the outer wall of the wound. Then skin flaps are formed to create the external lining of the wound, sutured with interrupted sutures. The advantages of this method are:

1. The lack of flotation of the newly created front wall of the trachea.

2. The implant is not lysed over time.

3. It has shape memory, inertness, superelasticity, and the ability to deposit medicinal substances.

An example implementation of the claimed method.

We give the following observation as an example. Patient T., 20 years old, medical history No. 2619, was admitted to the department of the FSI NCC “Otorhinolaryngology” FMBA of Russia on June 15, 2010 with complaints of a defect in the larynx and trachea. From the anamnesis it is known that the trauma of 01/26/09 was on mechanical ventilation for 4 days, after which a tracheotomy was performed, healed by secondary intention. From 02.26.09, noted difficulty in breathing, shortness of breath appeared. 02/27/10, performed retracheostomy. Over the next two months, there was a persistent deterioration in breathing, an increase in the phenomena of stenosis, which required reconstructive surgery in several stages. 04/09/10 - reconstructive surgery on the cervical trachea and larynx with the formation of persistent laryngotracheostomy and reinforcement of both walls of the trachea with allochondral. Entered for the second stage of surgical treatment.

When viewed on the front surface of the neck, a postoperative scar is visualized, tight, without signs of inflammation at the level of the thyroid and cricoid cartilage. There is a defect in the anterior wall of the trachea measuring 6 × 2 cm.

With closed laryngotracheostomy, breathing is free, NPV is 16 per minute, there are no signs of respiratory failure. When laryngoscopy: the entrance to the larynx is free, the epiglottis is not changed, the vocal folds are gray, close completely, the mobility of the larynx is full, the mucous is pink, smooth. FVD from 06.21.10, with closed laryngotracheostomy - an obstructive type of respiratory failure. 06/23/10, the second stage of surgical treatment under endotracheal anesthesia performed the operation: laryngotracheoplasty with reinforcing the front wall of the trachea with a titanium nickelide plate according to the specified method. Under the endotracheal anesthesia, a skin incision bordering the laryngotracheostomy was made, departing 1 cm from the edge of the stoma, an inner layer was formed from the resulting flaps, wrapped in the trachea with the epidermis, and sutured subcutaneously. The upper and lower edges of the wound are taken on ligatures. A titanium nickelide plate was laid on the inner layer, 1 cm indented from the edge of the wound. The medial legs of the sternocleidomastoid muscle were mobilized, shifted to the midline of the neck and stitched to create the skeleton of the anterior wall of the larynx and trachea. Formed skin flaps on the lateral surface of the neck, fixed with separate interrupted sutures along the midline. The postoperative period was uneventful, the wound healed by first intention, the sutures were removed on the 7th day.

Condition at discharge is satisfactory. With fibrolaryngoscopy, the entrance to the larynx is free, the epiglottis is not changed, it is movable, the glottis is up to 1.5 cm, the back space is free, the front wall of the trachea without signs of inflammation is covered with fibrin plaque. Breathing through the natural paths is free at rest and under load, the voice is sonorous. FVD from 07.07.10, at rest - the norm; FVD from 07/08/10 after physical activity - the norm. With control fibroscopy on 10.28.10, the entrance to the larynx is free, the epiglottis is not changed, it is mobile, the glottis is up to 1.5 cm, the back space is free, the anterior wall of the trachea is epithelized. Breathing through natural ways in full, sonorous voice.

On FVD from 10.28.10 at rest and under load - the norm for all major indicators.

Figure 1. View before surgery.

Figure 2. Incision, the formation of skin flaps.

Figure 3. Installation of a titanium nickelide plate.

Figure 4. Strengthening of the anterior wall of the trachea with medial portions of the sternocleidomastoid muscle.

Figure 5. The result of the operation.

Claims (1)

The method of plasty of the anterior wall of the trachea, which consists in using local tissues of the anterior surface of the neck and a plate of porous titanium nickelide, characterized in that they make a bordering skin incision around the defect of the trachea with the formation of skin flaps along the perimeter, the flaps are mobilized and sutured along the midline, in the upper and lower holder ligatures are formed on the poles of the wound, a plate of porous titanium nickelide with dimensions exceeding the stoma edges by 1 cm is laid on the sutured flaps, this design is covered with mobilized and eksirovannymi medial to the midline portions sternocleidomastoid muscle, fixed in advance ligatures formed all layers anterior tracheal wall to the outer wall of the wound.

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