RU2456938C1 - Method of plasty of anterior trache wall with cutaneous-subcutaneous-platismal flap - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to reconstructive-restoring surgery, and can be applied in covering defects of cervical part of trachea. Essence of method lies in application of local tissues from anterior surface of neck and chest. Two horizontal parallel to each other cuts are made at the level of upper and lower edges of defect with mobilisation of cutaneous-subcutaneous-platismal layer in all directions. Mobilisation is performed in cranial direction to the level of hyoid bone body and in caudal direction to the 1-st rib. In this way, two flaps are formed. The lower flap is given tongue-like shape by excision of two rectangles in its lateral parts. Upper edge of tongue-like flap is sewn to lower edge of stoma, pulling it and turning the epidermis into trachea lumen. After that, it is successively fixed to lateral walls with interrupted sutures. Formed in such way internal layer of anterior wall of trachea is covered with upper cutaneous-subcutaneous-platismal flap.

EFFECT: application of claimed invention makes it possible to improve functional and cosmetic results of treatment, reduce number of postoperative complications.

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Description

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

A known method of forming a U-shaped sliding flap to close a wound defect. [K.P. Pshenisnov. Plastic Surgery Course 2010 - prototype]. The essence of the method is that they form a rectangular or square flap with a free part at the edge of the defect, mobilize the skin, subcutaneous tissue of the flap, and excise two triangles at the base. Move the flap forward and stitch with the opposite edge of the wound. Sliding and stretching the flap is ensured by the elasticity of the skin and excision of the triangles at its base. The disadvantage of this method is the following.

1. The absence of the epidermis of the inner lining of the created tracheal wall.

2. The impossibility of its use with extensive defects of the trachea.

3. Infectious and inflammatory complications.

The closest in technical essence is the method of closing the defect of the anterior wall of the trachea using two rectangular flaps. [B.V. Elantsev Operative otorhinolaryngology. 1959 - prototype]. The essence of the method is to eliminate the tracheal defect using two rectangular flaps, one of which has a base at the edge of the stoma, the other is the free edge of the stoma. The width of the flaps should be the same, the length exceeding the stoma at the top and bottom by 0.5 cm. The flap with the leg at the edge of the stoma is turned with the skin surface into the lumen of the trachea and sutured to the previously refreshed edges of the hole. The second flap is applied to the first and fixed to the underlying skin areas. This method allows you to restore the anatomical integrity of the trachea. However, it has the following disadvantages.

1. The lack of framework and the associated flotation of the formed wall of the trachea, the risk of restenosis.

2. The accumulation of exudate between the inner and outer flaps.

3. High risk of postoperative infectious and inflammatory complications, the formation of secondary fistulas.

4. Unsatisfactory cosmetic result due to stitching of flaps over the defect.

The objective of the invention is to improve the functional and cosmetic results of treatment and to reduce the number of postoperative complications of cervical plasty using skin-subcutaneous-platysmal flaps.

This result is achieved in the following way. Under endotracheal anesthesia with intubation through the mouth, with the cuff of the endotracheal tube held for the level of the tracheal defect, an incision is made bordering the laryngotracheostomy, the scars around it are excised, and linear flaps are excised along the lateral surface of the defect. Then, two horizontal incisions parallel to each other are performed at the level of the upper and lower edges of the defect with mobilization of the cutaneous-subcutaneous-platysmal layer in all directions, while mobilization occurs in the cranial direction to the level of the hyoid bone body, caudally to the level of the 1st rib. Next, the lower flap is given a tongue-like shape, excising two rectangles in its lateral parts. At this stage, it is necessary to ensure that the size of the formed lower flap coincides with the size of the defect. To form the inner lining, the upper edge of the tongue-like flap is sutured to the lower edge of the stoma, pulling it and wrapping the epidermis into the lumen of the trachea sequentially, fixing it to the side walls with interrupted sutures. To prevent the accumulation of wound exudate between the inner and outer lining, they are sutured with a U-shaped suture without piercing the skin of the inner layer, but passing the ligature through the subcutaneous muscle. After that, the epidermis is excised at the site of lower flap inversion and the wound is sutured in layers, a subcutaneous suture is applied to the skin.

The advantages of this method are as follows.

1. Reducing the number of infectious and inflammatory complications due to the fixation between the inner and outer layer.

2. Reducing the formation of secondary tracheal fistula.

3. The rigidity of the wall is achieved by the inclusion of a platysmal muscle in the flap.

4. Lack of seams over the defect.

5. Improving the cosmetic result.

An example implementation of the claimed method

We give the following observation as an example. Patient M., 56 years old, medical history No. 1276, was admitted to the department of the Federal State Institution NCC “Otorhinolaryngology” of the FMBA of Russia on March 15, 2011 with complaints of a defect in the larynx and trachea. From the anamnesis it is known that after CCI on 02/12/10, he was on mechanical ventilation for 3 days, after which a tracheotomy was performed, healed by second intention, a month later noted breathing difficulties, shortness of breath appeared, on March 21, 10, a retracheostomy was performed. Over the next three months, there was a persistent deterioration in breathing, an increase in the phenomena of stenosis, which required reconstructive surgery in several stages. 06/23/10 reconstructive surgery on the cervical trachea and larynx with the formation of a persistent laryngotracheostomy, excision of granulations of the back lining of the larynx and cervical trachea, a T-shaped silicone tube was installed. Entered for the final stage of surgical treatment.

When viewed on the front surface of the neck, a defect in the anterior wall of the trachea is 4 × 2 cm in size, a T-shaped silicone tube is installed.

With a closed tracheostomy, breathing is free, NPV-17 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 of 03.16.11, with a closed tracheostomy, is an obstructive type of respiratory failure. 03.17.11, the second stage of surgical treatment under endotracheal anesthesia performed the operation: tracheoplasty with a cutaneous-subcutaneous-platysmal flap according to the specified technique. Under the endotracheal anesthesia, the bordering edge of the tracheostomy was produced. Then, two horizontal incisions were made parallel to each other at the level of the upper and lower edges of the defect with mobilization of the cutaneous-subcutaneous-platysmal layer in all directions, cranially to the level of the hyoid bone body, caudally to the level of the 1st rib. Skin flaps located on the sides of the stoma and in the lateral parts of the lower flap are excised. The upper edge of the tongue-like flap is hemmed to the lower edge of the stoma, sequentially fixed to the side walls with interrupted sutures. A U-shaped suture is applied through all layers of the upper and muscle layer of the lower flaps. After that, the epidermis is excised at the site of lower flap inversion, the wound is sutured in layers, and the subcutaneous suture on the skin. The postoperative period was uneventful, the wound healed by first intention, the sutures were removed on the 9th day, the U-shaped suture was removed on the 14th day.

Condition at discharge is satisfactory. On examination, the postoperative wound healed by first intention, a scar is determined. 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 03/27/11, at rest - the norm; FVD from 03/27/11, after physical activity - the norm.

Claims (1)

The method of plasty of the anterior wall of the trachea, which consists in using local tissues from the anterior surface of the neck and chest, characterized in that two horizontal, parallel to each other incisions are made at the level of the upper and lower edges of the defect with mobilization of the cutaneous-subcutaneous-platysmal layer in all directions, while the mobilization is carried out in the cranial direction to the level of the hyoid bone body and caudally to the level of the 1st rib, thereby forming two flaps, they give the lower tongue-like shape, excising two rectangles the oligarch in its lateral parts, the upper edge of the tongue-like flap is sutured to the lower edge of the stoma, pulling it and wrapping the epidermis in the lumen of the trachea, sequentially fixing to the side walls with interrupted sutures, the inner layer of the anterior wall of the trachea formed in this way is covered with an upper skin-subcutaneous-platismal flap.