RU2467703C1 - Method for surgical approach to thoracic aorta - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely cardiosurgery, and can find application in surgeries of prosthetic repair of aneurisms of the entire thoracic aorta. Substance of the method consists in intercostal thoracotomy and transverse incision of sternum. The sternal edges are at 1.0 cm at the level of I intercostal space. Investing tissues, pectoral fascia and presternum are incised by counter incisions inclined at 20-30 degrees to a horizontal line. The investing tissues are incised along a left border of mesosternum. Ends of II-V ribs are separated therefrom, and anterior mediastinum is exposed. Pleural fold is incised and pleural cavity is exposed. In V intercostal space, internal thoracic vessels are ligated and transected, intercostal thoracotomy is performed to left posterior axillary line. Intercostal wound edges are opened with a dilator. Sternal rib ends separated from sternum together with attached greater pectoral muscle bundles are dislocated towards I rib and brought entoectad by another dilator. A lower fragment of the incised sternum is brought inwards. From the pleural cavity, left diaphragm nerve is separated from pericardium. A diaphragm portion of pericardium is separated from diaphragm to a right-side seam. Lung and heart apex are antepositioned. That is followed by exposure of all portions of thoracic aorta so that to create vascular anastomoses. Closure of the incisional wound is preceded by drainage of anterior mediastinum, pericardium cavity, and left pleural cavity. The wound along the sternum is closed by edges of periosteum, pectoral fascia and tendon elements of sternocostal joint capsules. Sternum is repaired by through interrupted sutures.

EFFECT: use of the given invention allows minimising a sternal injury at the stage of the surgical approach to thoracic aorta and a probability of developing sternal osteomyelitis and anterior purulent mediastinitis in the remote postoperative period, improving parameters of the incisional wound.

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Description

The invention relates to medicine, namely to cardiac surgery, and can be used in prosthetic surgery for aneurysms of the entire thoracic aorta.

Known operative accesses to the thoracic aorta:

1. Complete median sternotomy according to Milton.

During the operation, the patient’s position on the back, arms are laid apart. The integumentary tissues and sternum are dissected along the midline from the jugular notch to the end of the xiphoid process of the sternum, fragments of the sternum are bred to the sides by the rack expander to a distance sufficient to perform operative reception on the heart, the ascending part, the arch and the upper descending part of the aorta [1].

However, the disadvantage of this access is severe trauma to the sternum, especially its body, which is the spongy bone, and 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, forces the patient to be kept in strict bed rest for a long time, and forbid him to move hands. Stopping bleeding from the spongy layer of the sternum is performed by rubbing a mixture of wax with paraffin at its edges. The mobility of fragments of the sternum, the presence of foreign material between its fragments prevents their coalescence and in 8-23% of cases leads to osteomyelitis and anterior purulent mediastinitis in various long-term periods after the operation.

2. Left-sided thoracotomy along the IV intercostal space with the intersection of the sternum.

During surgery, the patient’s position on the right side. Incision of integumentary tissues and thoracotomy is performed along the IV intercostal space from the rear axillary line to the edge of the sternum and the intersection of the sternum [1].

However, the disadvantages of this access are significant trauma at the stage of its implementation, the risk of developing sternal osteomyelitis and anterior purulent mediastinitis in the long-term after surgery. In addition, this access creates inconvenience during manipulations on the ascending part of the aorta, which is associated with a large depth of the surgical wound, a small angle of the surgical action and the angle of the axis of the surgical action [2].

3. Transverse bilateral transpleural access through the IV intercostal space in Block.

During surgery, the patient’s position on the back. In the course of the IV intercostal space, the integumentary tissues from the middle axillary lines to the edges of the sternum body are cut in layers from both sides, and bilateral thoracotomy and dissection of the sternum body are performed [2].

However, this access is associated with even greater trauma, since it involves bilateral thoracotomy, transverse dissection of the sternum body, which leads to a violation of the function of external respiration and prolonged exposure of the patient to machine breathing in the early postoperative period and the development of sternal osteomyelitis and anterior purulent mediastinitis in the long-term after surgery. In addition, this access does not provide satisfactory conditions for manipulations on the distal and isthmus of the thoracic aorta, which is associated with a large depth of the surgical wound, small angles of the operative action and the angle of the axis of the operative action [2].

4. "Side-ways-τ-shaped" access.

With this access, a total dissection of the sternum along the longitudinal axis and thoracotomy along the IV intercostal space, complemented by a transverse dissection of the left fragment of the sternum body, are performed [3, 5, 6].

However, the disadvantage of this access, as of the previous ones, is a longitudinal section of the sternum, supplemented by a transverse section of the left fragment of her body, in the use of a mixture of wax with paraffin when stopping bleeding from spongy fragments of the body of the sternum, and in violation of the integrity of the bone apertures of the chest.

Closest to the proposed access is a double thoracotomy on the left along the IV and VI intercostal space with a complete transverse intersection of the sternum in the IV intercostal space. Manipulations in the ascending part, on the arch and on the proximal part of the descending part of the thoracic aorta are carried out from the access to the IV intercostal space, in the distal part - through the VI intercostal space [2].

However, this access is not only traumatic, but also does not have metric parameters sufficient for the convenience of the surgeon's manipulations on the aortic isthmus.

The objective of the proposed method is to minimize sternal injury at the stage of operative access to the thoracic aorta and the likelihood of developing sternal osteomyelitis and anterior purulent mediastinitis in the long-term after surgery, to improve the parameters of the surgical wound, providing the surgeon with satisfactory conditions for manipulation in all its departments.

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 dissect the integumentary tissue, separate the ends of the II-V ribs from it and open the anterior mediastinum, dissect the pleural fold and open the pleural cavity, in the V intercostal space ligature and intersect the internal thoracic vessels and perform intercostal thoracotomy to the left posterior of the muscular line, the edges of the intercostal wound are diluted with the dilator, the sternal ends of the ribs, separated from the sternum, together with the bundles of the pectoralis major muscle attached to them, are displaced to the I rib and the second expander is removed outside, and the lower fragment of the dissected sternum is directed inside, from the pleural cavity, the left diaphragmatic the nerve is separated from the pericardium, the diaphragmatic portion of the pericardium is separated from the diaphragm to the right-hand line of their fusion, the lung and the apex of the heart are taken anteriorly and expose all sections of the thoracic aorta in an exposure convenient for For the application of vascular anastomoses, the anterior mediastinum, pericardial cavity, left pleural cavity are drained before suturing the surgical wound, the wound along the sternum is sutured over the edges of the periosteum, own fascia and tendon elements of the capsule of the sternocostal joints, the sternum is restored through through interrupted sutures.

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-V ribs are separated from it and the anterior mediastinum is opened, the pleura is dissected and the pleural cavity is opened, the inner thoracic vessels are ligated and intersected on the V intercostal space and intercostal thoracotomy is performed (Fig. 1) to the left posterior of the muscular line, the edges of the intercostal wound are diluted with the dilator, the sternal ends of the ribs, separated from the sternum, together with the bundles of the pectoralis major muscle attached to them, are displaced to the I rib and the second extender is removed outwards, and the lower fragment of the dissected sternum is directed inside, from the pleural cavity, the left diaphragmatic the nerve is separated from the pericardium, the diaphragmatic portion of the pericardium is separated from the diaphragm to the right-hand line of their fusion, the lung and the apex of the heart are taken anteriorly and expose all sections of the thoracic aorta in an exposure convenient for the imposition of vascular anastomoses.

Before suturing the surgical wound, the anterior mediastinum, pericardial cavity, left pleural cavity are drained, the wound along the sternum is sutured over the edges of the periosteum, own fascia and tendon elements of the capsule of the sterno-costal joints, the sternum is restored with through interrupted sutures.

The proposed method eliminates double intercostal thoracotomy, minimizes damage to the sternum, the likelihood of developing osteomyelitis and anterior purulent mediastinitis in the long term after the operation, provides parameters of the surgical wound sufficient for the surgeon to manipulate all parts of the thoracic aorta.

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)

A method of operative access to the thoracic aorta, including intercostal thoracotomy and cross section of the sternum, 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, own fascia and sternum handle, integumentary tissues are dissected along the left edge of the sternum body, the ends of the II-V ribs are separated from it and the anterior mediastinum is opened, the pleura is dissected and the pleural cavity is opened, in the V intercostal space they are ligated and intersected the internal pectoral vessels and perform intercostal thoracotomy to the left rear axillary line, the edges of the intercostal wound are diluted with the dilator, the sternal ends of the ribs, separated from the sternum, together with the bundles of the pectoralis major muscle attached to them, are displaced to the 1st rib and the second dilator is removed outward, and the lower fragment is dissected the sternum - inside, from the pleural cavity the left phrenic nerve is separated from the pericardium, the diaphragmatic portion of the pericardium is separated from the diaphragm to the right-hand line of their fusion, lung and apex in the heart they take it anteriorly and expose all sections of the thoracic aorta in an exposure convenient for the application of vascular anastomoses; Before suturing the surgical wound, the anterior mediastinum, pericardial cavity, left pleural cavity are drained, the wound along the sternum is sutured over the edges of the periosteum, own fascia and tendon elements of the capsule of the sternocostal joints, the sternum is restored through through interrupted sutures.

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