RU2466684C1 - Method for surgical approach to whole aorta - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: investing tissues, pectoral fascia and presternum are reciprocally incised at 1.0 cm from sternal borders at the level of I hypochondrium at 20-30 degrees to a horizontal line. Investing tissues are incised along a left border of mesosternum, ends of II-VII ribs are detached therefrom, and anterior mediastinum is exposed. An anterior mediastinocostal fold of parietal pleura is incised, and a pleural cavity is exposed. A diaphragm portion of pericardium is separated from diaphragm. The incision of investing tissues is extended from a left border of mesosternum along a medial border of abdominal rectus muscle and finished at 5 cm from a femoral arch. An anterior wall of rectus sheath is incised, the muscle is mobilised and brought to the outside. Laparotomy is performed through a centre of a posterior wall of sheath. An abdominal peritoneum is incised from the abdominal cavity along a left lateral, retroperitoneal fat with descending segmented intestine, left kidney, pancreas is detached from a posterior abdominal wall, and brought to the right turning about vascular pedicles. The whole abdominal aorta is exposed. Pericardial diaphragm is incised from an angle of sternocostal triangle to an aortic foramen with opening a portion of descending thoracic aorta through a diaphragm incision.

EFFECT: method enables reducing sternal, muscular and neurovascular injuries.

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Description

The invention relates to medicine, namely to cardiac surgery, and can be used in operations of simultaneous prosthetics of the entire aorta.

Known operative accesses to the thoracoabdominal aorta.

1. Thoracophrenopararectal access.

During the operation, to the left of the scapular angle along the VI or VII intercostal space, the integumentary tissues, the latissimus dorsi, and the anterior dentate muscle are dissected, the integument is cut down along the outer edge of the left rectus abdominis muscle and is completed 5 cm from the inguinal ligament; perform thoracotomy along the VI intercostal space, dissect the costal arch and the anterolateral wall of the bed of the left rectus abdominis muscle, take the muscle outward, laparotomy perform along the posterior wall of the bed of the rectus abdominis muscle. To approach the abdominal aorta, the parietal peritoneum is exfoliated from the lateral and posterior walls of the abdominal cavity together with retroperitoneal and perinephric tissue, the left kidney, pancreas and is removed medially, from the VI rib to the aorta, the diaphragm is cut in the area of the pleural portion. This access causes inconvenience during manipulations on the distal part and isthmus of the aorta [1], and its drawbacks are trauma associated with the dissection of muscle arrays, neurovascular bundles, pleural diaphragm and branches of the left phrenic nerve, which manifests itself in severe postoperative pain and violation of the function of external respiration, in the long term - relaxation of the left dome of the diaphragm and the left rectus abdominis muscle [1].

2. Modified thoracophrenopararectal access.

In the patient’s position on the right side, the incision of the integumentary tissues begins from the left posterior axillary line from the level of the 3rd rib and continues arcuately down to the outer edge of the left rectus abdominis muscle, is led along it and ends 5 cm from the inguinal ligament. The latissimus dorsi muscle is retracted posteriorly, the pectoralis major muscle is anteriorly performed, thoracotomy is performed along the III intercostal space, all underlying ribs are cut, the costal arch, laparotomy is performed along the dissection line of the integumentary tissues. To approach the abdominal aorta, the parietal peritoneum is exfoliated from the lateral and posterior walls of the abdominal cavity together with retroperitoneal and perinephric tissue, left kidney, pancreas and is medially removed, from the intersection of the VI rib to the aorta, the pleural diaphragm is cut [2, 3].

However, the disadvantages of this access are significant surgical trauma and a high risk of postoperative complications due to dissection of the ribs with damage to the intercostal and lumbar neurovascular bundles along the lateral edge of the rectus abdominis muscle, dissection of the diaphragm and branches of the left phrenic nerve, severe pain syndrome, relaxation of the left dome of the diaphragm and anterior abdominal wall.

3. Median sternotomy and laparotomy with rotation of the internal organs.

With this access, a total median sternum dissection and median laparotomy are performed, a peritoneal peritoneum is cut from the abdominal cavity along the left lateral canal with exfoliation of part of the abdominal internal organs from the posterior abdominal wall with their medial rotation.

The disadvantages of this access are severe sternal injury: stopping bleeding from the spongy layer by rubbing a mixture of wax and paraffin, which is a foreign material, there is a violation of the integrity of the bone rings of the upper and lower chest apertures, which creates instability of fragments of the sternum in the postoperative period, which forces the patient to be held for a long time strict bed rest, forbidding him to move his arms after surgery, but even these precautions do not guarantee the fusion of fragments of the sternum, and DKO late after operation develops their suppurative osteomyelitis and front mediastinitis [2, 3].

4. "Side-ways-τ-shaped" access.

With this access, thoracotomy is performed along the IV intercostal space in combination with longitudinal and transverse dissection of the lower part of the sternum and complete median laparotomy. Access allows you to open the abdominal aorta and the distal thoracic aorta [3].

The disadvantage of this access is that with partial lower median and transverse sternotomy, multiple fractures of its fragments often occur, often complicated by osteomyelitis and anterior mediastinitis at various times after surgery [5, 6].

Known combined access to the aorta in all departments [2]

1. Left-sided thoracotomy and mediastinotomy with a transverse section of the sternum in the IV intercostal space with thoracophrenopararectal access through the VII intercostal space.

A cut of the integumentary tissues begins from the right to the left edge of the sternum in the IV intercostal space, and a thoracotomy is performed on its projection with a complete transverse intersection of the sternum body, the sternum-pericardial ligament and the anterior pericardial wall are dissected up to the transitional fold of the aorta and down to the diaphragm. The second stage involves thoracophrenotomy on the left along the VII intercostal space and diaphragmotomy and pararectal retroperitoneal access to the abdominal aorta.

The disadvantages of this access are similar to the disadvantages of previous accesses.

2. Transverse trans-dupleural thoracotomy along the IV intercostal space with a transverse section of the sternum, supplemented by thoraphrenopararectal access along the VII intercostal space.

An incision of the integumentary tissues begins on both sides along the V intercostal space from the middle axillary lines, a layered bilateral thoracotomy is performed with a cross section of the sternum body, ligation of the internal mammary arteries and veins. The second stage of access is thoracotomy along the VII intercostal space, pararectal retroperitoneal access to the abdominal aorta, and diaphragmotomy is performed from the site of cutting the costal arch in the direction of the aorta.

However, all combined accesses to the aorta are inherently highly traumatic at the stage of their execution, due to the opening of both pleural cavities, transverse dissection of the sternum body, intersection and ligation of the internal thoracic vessels, segmental lumbar neurovascular bundles along the lateral edge of the left rectus abdominis muscle throughout its entire length; dissection of the pleural diaphragm and damage to the branches of the left phrenic nerve causing respiratory failure, prolonged exposure of the patient to controlled breathing in the early postoperative period, relaxation of the left dome of the diaphragm and rectus abdominis muscle in the long term. At the same time, the combined approaches do not provide a good exposure of the aortic arch and the isthmus in the wound.

Closer to the offer is Crawford access, starting with a cut of the integumentary tissues from the left outer edge of the extensor extensor and 3 cm above the lower angle of the scapula, extending from the bottom to the V intercostal space and curved down to the midline of the abdomen to the pubic joint. After dissection of the integumentary tissues of the chest, the latissimus dorsi, the front dentate muscle are dissected, a thoracotomy is performed with resection of the VI rib intersecting the V rib closer to the neck, the left rectus abdominis muscle is cut, the costal arch and the pleural portion of the diaphragm from the VI rib to the aortic orifice, the median is performed ; from the abdominal cavity, the parietal peritoneum is dissected along the left lateral canal, retroperitoneal tissue with the descending part of the colon, left kidney, pancreas is peeled from the posterior abdominal wall, shifting them anteriorly. After diluting the edges of the wounds of the chest and abdominal walls, an overview of the thoracoabdominal aorta is opened [1].

The disadvantages of this access are severe trauma associated with its implementation, and a high risk of postoperative complications. At the same time, Crawford access does not provide a satisfactory view of the distal part of the arch and the aortic isthmus due to the large depth of the wound equal to 22.0 ± 4.0 cm, the small size of the angle of the surgical action and the angle of inclination of the axis of the surgical action is 29.0 ± 2.0 and 27.0 ± 3.0, respectively, complicating the surgical actions of the surgeon [2].

The objective of the proposed method is to reduce trauma to the sternum, muscle and neurovascular formations at the stage of operative access to the aorta, to reduce the risk of postoperative complications.

The problem is solved due to the fact that: retreating from the edges of the sternum by 1.0 cm at the level of the 1st intercostal space, cover tissues, own fascia and the sternum handle, along the left edge of the sternum body are cut with counter cuts at an angle of 20-30 degrees to the horizontal line dissecting the integumentary tissue, separating the ends of the II-VII ribs from it and opening the anterior mediastinum, dissecting the anterior rib-mediastinal fold of the parietal pleura and opening the pleural cavity, the edges of the wound are diluted with an expander, mobilize the lesion from the pleural cavity a phrenic nerve, the diaphragmatic portion of the pericardium is separated from the diaphragm, the incision of the integumentary tissues is extended from the left edge of the sternum down the medial edge of the rectus abdominis muscle and is completed 5 cm from the inguinal ligament, the anterior wall of the vagina of the rectus abdominis muscle is dissected, the muscle is mobilized and removed outside, through laparotomy is performed in the central part of the posterior wall of the vagina, the parietal peritoneum is cut from the abdominal cavity along the left lateral canal, retroperitoneal tissue is exfoliated from the descending abdominal wall they department colon, left kidney, pancreas and assign them to the right, turning around a vascular leg, exposing the entire abdominal aorta, dissected pericardial diaphragm separated from the corner sterno-costal triangle to the aortic orifice opening part of the descending thoracic aorta through the aperture section; Before suturing the surgical wound, the anterior mediastinum, pericardial cavity, left pleural and abdominal cavities are drained, the edges of the wounds of the diaphragm, sternum, intercostal space and anterior abdominal wall are sutured with interrupted sutures, the sternum with ribs are sutured along the edges of dissected fascia, without suturing the cartilaginous ends.

The method is as follows: retreating from the edges of the sternum by 1.0 cm at the level of I intercostal space, cover tissues are cut with counter cuts at an angle of 20-30 degrees to the horizontal line, own fascia and sternum handle, cover tissues are cut along the left edge of the sternum body, the ends of the II-VII ribs are separated from it (Fig. 1) and the anterior mediastinum is opened, the anterior rib-mediastinal fold of the parietal pleura is dissected and the pleural cavity is opened, the edges of the wound are diluted with an expander, mobilized from the pleural cavity a phrenic nerve, the diaphragmatic portion of the pericardium is separated from the diaphragm, the incision of the integumentary tissues is extended from the left edge of the sternum down the medial edge of the rectus abdominis muscle and ends 5 cm from the inguinal ligament (Fig. 1), the anterior wall of the rectus sheath is dissected, the muscle is mobilized and take it outside, through the central part of the posterior wall of the vagina, a laparotomy is performed, from the side of the abdominal cavity, the parietal peritoneum is cut along the left lateral canal, retroperitoneal tissue is removed from the posterior abdominal wall with n the descending part of the colon, the left kidney, pancreas and take them to the right, turning around the vascular legs, expose the entire abdominal aorta, the pericardial part of the diaphragm is dissected from the corner of the sternocostal triangle to the aortic opening (Fig. 2), revealing a part of the descending part of the thoracic aorta through the diaphragm section.

Before suturing the surgical wound, the anterior mediastinum, pericardial cavity, left pleural and abdominal cavities are drained. The edges of the wounds of the diaphragm, sternum, intercostal space and the anterior abdominal wall are sutured with interrupted sutures. The sternum with ribs is sutured along the edges of the dissected fascia, without stitching the cartilaginous ends.

The proposed method allows you to: exclude the dissection of the latissimus dorsi, most of the pectoralis major and anterior dentate muscles, the pleural portion of the diaphragm and branches of the left phrenic nerve, nerves of the rectus abdominis muscle, provide a good exposure of all sections of the aorta convenient for surgical procedures, exclude postoperative sternum osteomyelitis, anterior mediastinitis, paresis and relaxation of the muscles of the diaphragm and the anterior abdominal wall.

Bibliography

1. Belov Yu.V. A guide to vascular surgery with an atlas of surgical techniques. - 2nd ed., Rev. and add. - M. - 2011 .-- S.315-389.

2. Radnaev Ch. D. Surgical access to thoracic thoracoabdominal aortic aneurysms: a dissertation for the degree of candidate of medical sciences. - M. - 2004. - P.40-78.

3. Belov Yu.V., Komarov R.N. Guide to thoracoabdominal aortic aneurysm surgery. - M. - 2010. - P.232-305.

4. Kunihara T., Shiiya N., Kamikudo Y. et al. Midline exposure of the thoracoabdominal aorta // Ann. Thorac. Surg. - 2000. - 69. - C.1951-1953.

5. Okada K., Sueda T., Kazumasa O. et al. The distal perfusion first technique for complicated Stanford Type B aortic dissection // Ann. Thorac. Cardio Vase. Surg. - 2004. - No. 10. - C.61-63.

6. Yamashiro S., Kuniyoshi Y., Arakaki K., Inafuku H., Morishima Y., Kise Y. Aortic Replacement via Median Sternotomy with Left Anterolateral Thoracotomy // Asian Cardiovasc. Thorac. Ann. - 2009. - No. 17. - C.373-377.

Claims (1)

The method of operative access to the entire aorta, including thoracotomy, diaphragmotomy, laparotomy, characterized in that, departing from the edges of the sternum by 1.0 cm at the level of I intercostal space, the integumentary tissues are cut with counter cuts at an angle of 20-30 ° to the horizontal line, their own fascia and the sternum handle, along the left edge of the sternum body, integumentary tissues are dissected, the ends of the II-VII ribs are separated from it and the anterior mediastinum is opened, the anterior mediastinal fold of the parietal pleura is dissected and the pleural cavity is opened, the edges of the wound develop dressed with an expander, mobilize the left phrenic nerve from the pleural cavity, separate the diaphragmatic portion of the pericardium from the diaphragm, extend the incision of the integumentary tissue from the left edge of the sternum down the medial edge of the rectus abdominis muscle and finish 5 cm from the inguinal ligament, dissect the anterior vaginal wall of the rectus abdominis muscle , the muscle is mobilized and taken outward, a laparotomy is performed through the central part of the posterior wall of the vagina, the parietal peritoneum is cut from the abdominal cavity along the left lateral canal, retrieve retroperitoneal tissue from the posterior abdominal wall with the descending part of the colon, the left kidney, pancreas and take them to the right, turning around the vascular legs, expose the entire abdominal aorta, the pericardial part of the diaphragm is dissected from the angle of the sternocostal triangle to the aortic opening, opening thoracic aorta through the incision of the diaphragm; Before suturing the surgical wound, the anterior mediastinum, pericardial cavity, left pleural and abdominal cavities are drained, the edges of the wounds of the diaphragm, sternum, intercostal space and anterior abdominal wall are sutured with interrupted sutures, the sternum with ribs are sutured along the edges of dissected fascia, without suturing the cartilaginous ends.

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