RU2463967C1 - Method of reconstructive operation on larynx - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to surgery and otolaryngology, and can be applied in surgery caused by locally advanced laryngeal cancer. Essence of method consists in performing larynx resection within healthy tissue. Resection is carried out together with underlying part of thyroid cartilage, preserving upper pert of thyroid cartilage plate on the side of affection in form of horizontal plate. Skin flap cut out on neck, which in width by 0.5-1.0 cm is larger than and in length twice exceeding formed larynx defect, is thrown over remaining fragment of thyroid cartilage. Thus duplication is formed. After that, it is sewn with separate interrupted sutures to healthy mucosa of preserved part of larynx on defect perimetre. Laryngostome, tracheostoma are formed, tracheostomic tube No 4-5 is introduced. Bandage is applied.

EFFECT: application of claimed invention makes it possible to carry out tumour ablation with simultaneous reconstruction of larynx, ensuring rehabilitation of its main functions.

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Description

The invention relates to medicine, namely to surgery, and can be used in surgical interventions for the removal of laryngeal tumors with unilateral damage to all parts of the larynx and spread to the thyroid cartilage.

A known method of lateral resection of the larynx, in which the vocal and vestibular folds, anterior commissure and part of the thyroid cartilage corresponding to the boundaries of the tumor enter the block of removed tissues. The defect is closed by local tissues - the external perichondrium of the thyroid cartilage and the rectus muscles of the neck. Both arytenoid cartilage are preserved. Laryngostoma is made. (Paches A.I. “Tumors of the head and neck.” - Medicine, 2000. S. 362-367).

This operation allows you to radically remove the tumor and maintain healthy sections of the larynx. The disadvantage of the operation is the appearance in the postoperative period of laryngeal stenosis due to cicatricial changes in the rectus muscles of the neck used to close the thyroid cartilage defect.

A known method of replacing a defect in the thyroid cartilage after performed anterolateral resection of the larynx with a titanium nickelide implant. (E. Choinzonov et al. “Rehabilitation of patients with head and neck tumors”, - Tomsk: “Publishing house of scientific and technical literature”, 2003, p. 78-90). This intervention, according to the authors, can be performed at the end of radiation therapy as the second stage of the combined treatment, since postoperative radiation causes tissue inflammation due to the presence of a metal supporting structure. In the postoperative period, patients experience cicatricial deformities of the newly formed laryngeal wall.

Surgical interventions for the removal of locally advanced laryngeal tumors with unilateral lesions of all three of its departments, as a rule, must meet two principles:

1) compliance with oncological radicalism;

2) the maximum possible rehabilitation of the functions of the larynx: respiratory, voice, dividing after surgery.

When the tumor spreads to the perichondrium and cartilage of the larynx, the requirements of ablasticity dictate the need to remove not only the mucous membrane affected by the tumor process, but also part of the cartilage skeleton of the larynx. In the absence of a cartilaginous framework, stenosis of the laryngeal lumen occurs, which causes impaired breathing and speech.

All this served as the basis for the search for new methods of reconstruction of the distant part of the larynx.

The aim of the invention is the ablastic removal of a laryngeal tumor and the rehabilitation of its functions.

The goal is achieved as follows. From the skin of the neck, on the side of the tumor, a tongue-like flap is cut out and mobilized, 0.5-1.0 cm wide and twice as long as the size of the postoperative laryngeal defect (Fig. 1). An anterolateral resection of the larynx is performed together with the underlying fragment of the thyroid cartilage, leaving the upper part of the plate of the thyroid cartilage not affected by the tumor in the form of a horizontal bar (Figs. 2, 3). The flap is thrown over the remaining part of the plate of the thyroid cartilage, forming the lateral wall of the larynx in the form of a skin duplicate, mounted on a fragment of the preserved thyroid cartilage. A skin flap from above is fixed to the edges of the mucosa of the remaining fragment of the thyroid cartilage and the mucosa of the opposite side (half) of the larynx. Duplicate flap stitched along the lower horizontal edge of the wound. A laryngostomy is formed, which is plugged for 7-10 days before the graft is engrafted. To form a stable lumen of the larynx, regular laryngostomy tampons are performed for 3-4 weeks. After 2 months, in the absence of relapse, plastic laryngostomy is performed.

The novelty of the proposed method lies in a non-traditional, previously unknown method of reconstructing the anterolateral wall of the larynx with a skin flap thrown and fixed to the mucous membrane of the saved fragment of the plate of the thyroid cartilage and the mucous membrane of the saved opposite half of the larynx, which allows to fill in the defect and restore the lateral wall of the larynx speech.

The proposed method is original, non-obvious. In well-known open sources of information in Russia, the CIS countries and abroad, no indications of such have been found.

The invention is industrially applicable, since it can be repeatedly repeated and reproduced by oncologists of maxillofacial surgery when removing malignant tumors of the larynx with unilateral damage to all its departments in medical hospitals and surgical departments.

The method is as follows.

Intubation through the mouth. A tongue-like skin incision is performed along the front surface of the neck from the projection of the hyoid bone to the level of the 2nd tracheal ring, measuring 0.5-1 cm larger in width, resulting in a defect after surgery. The size of the flap is determined by preliminary endoscopy. Skeletonation of the anterior edge of the thyroid cartilage is performed, laryngofissure is performed. Retreating 0.5 cm from the boundaries of the tumor process, the latter is resected together with the underlying plate of the thyroid cartilage, leaving the upper part of the cartilage plate as a crossbar. After hemostasis, the laryngeal wall defect is replaced. A skin flap is thrown over the edge of the remaining upper fragment of the thyroid cartilage and sutured to the mucous membrane of the preserved healthy part of the larynx along the edges of the defect along the perimeter, forming the lateral wall of the larynx in the form of skin duplicate. The skin from the healthy side is sutured to the healthy mucous membrane of the larynx. A laryngostomy is formed. Laryngostoma is plugged. Tracheostomy is superimposed. A tracheostomy tube No. 4-5 is inserted. A bandage is applied.

An example of a specific application of the method is an extract from the patient’s case history, born in 1957, case history No. 45673 / s, entered the Department of Head and Neck Tumors of the Rostov Cancer Research Institute on 05/18/2010 with a diagnosis of laryngeal cancer (with laryngoscopy - the tumor affects the vestibular and vocal folds, laryngeal ventricles) St III (T3 N0 M0) Cl. gr. 2. The diagnosis is verified: G.A. No. 34756/10 - squamous cell carcinoma G1.

05/20/2010 - the operation was performed: anterolateral resection of the larynx on the right with reconstruction by a skin flap. Histological analysis of the removed preparation No. 31765-69 / 10 "squamous cell carcinoma G1".

Natural nutrition from the 1st day of the postoperative period - the dividing function of the larynx is not impaired.

On the 12th day after the operation, the patient was discharged from the department in satisfactory condition. Since 06/03/10. on 02.07.10.g. a course of radiation therapy was carried out on the larynx and the path of lymph outflow with SOD = 40 Gy. After 2 months (02.09.10), a follow-up examination in the clinic of the RNII - without relapse. 08/23/10 was performed plastic laryngostomy.

The technical and economic efficiency of the larynx reconstruction method consists in: performing a functionally gentle operation without compromising the radical nature of the treatment; maintaining the natural function of breathing, speech; a decrease in the number of postoperative inflammatory complications in the form of perichondritis of the cartilage of the larynx; reducing the morbidity of the operation and the duration of the patient’s hospital stay; improving the quality of life of the patient in the near postoperative period; opportunities without delaying the postoperative course of radiation therapy.

Claims (1)

A method of reconstructive surgery on the larynx, including removal of the tumor, characterized in that the laryngeal resection is carried out within the healthy tissue together with the underlying part of the thyroid cartilage, while maintaining the upper part of the thyroid cartilage plate on the lesion side in the form of a horizontal plate, a skin flap cut at the neck by 0, 5-1.0 cm in width and length, twice the resulting defect in the larynx, are thrown over the remaining fragment of the thyroid cartilage, forming a duplicate, and hemmed with separate interrupted sutures to the healthy howl mucous stored portion larynx defect perimeter formed laryngitis, tracheostomy administered tracheostomy tube № 4-5, bandage.

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