RU2470604C2 - Method of extrapleural bone-muscular thoracoplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to thoracic surgery, and can be applied in performing extrapleural thoracoplasty for the treatment of destructive forms of pulmonary tuberculosis. Essence of method lies in paravertebral access, subperiosteal resection of III and IV ribs from spine to the middle axillary line, extrapleural pneumolysis from dome to root of lung with pleuropneumopexy to posterior part of VI rib. Additional access on the edge of latissimus dorsi muscle is performed. Thoracodorsal muscular flap on vascular pedicle is isolated. Flap dimensions correspond to the volume of formed extrapleural cavity. Tunnel under teres major muscle is formed in proximal part of axillary crease. After that, flap is moved through intercostal defect, filling completely earlier formed extrapleural cavity of any volume.

EFFECT: application of claimed invention makes it possible to reduce the volume of pleural cavity and achieve collapsosurgical effect with little trauma and cosmetic defect due to maximal filling of any volume of extrapleural cavity, formed after pneumolysis.

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Description

The invention relates to thoracic surgery of tuberculosis. Currently, in thoracic surgery, the 5-rib osteoplastic thoracoplasty proposed by the Novosibirsk Research Institute of Tuberculosis (Borovinsky A.I. et al. Probl. Tuberculosis, 1984, No. 6), which we have chosen as an analogue, is most often used as collapse surgery. The operation consists in paravertebral access bordering the scapula, the intersection of the V, IV, III and II ribs at the spine and subperiosteal resection of 7 cm, 5 cm, 3 cm and 1 cm, respectively, the intersection of the first rib at the spine, extrapleural pneumolysis to the root of the lung with further pleuropneumopexy to the VI rib, subsequent reduction of the I, II, III, IV, V ribs and fixation to the VI rib (when crossing the I-II ribs at the sternum from additional parasternal access).

The disadvantage of the above operation is:

- cosmetic defect, consisting in deformation of the shoulder girdle and chest (deepening of the supra- and subclavian fossa on the side of the operation);

- high morbidity associated with the movement of the ribs.

The aim of our study was to develop an operational manual devoid of the above disadvantages.

We propose changing the technology for performing extrapleural collapse surgical thoracoplasty with the aim of alternative treatment of destructive forms of pulmonary tuberculosis.

The technical result contributes to a more gentle and cosmetically beneficial result that meets all the necessary requirements for collapse surgery.

The technical result consists in the following: from the paravertebral access (linear incision up to 10 cm), the rib cage from the II to V ribs is exposed, intersect at the spine and subperiosteal resection of the III and IV ribs from the spine to the middle axillary line. Next, extrapleural pneumolysis is performed from the dome to the root of the lung, pleuropneumopexy to the posterior segment of the VI rib. From additional access along the edge of the latissimus dorsi, a linear incision of up to 10 cm, a certain mass is allocated corresponding to the volume of the formed extrapleural cavity, a thoracodorsal muscle flap on the vascular pedicle. In the proximal armpit, a tunnel forms under the plexus muscle, then the thoracodorsal muscle flap moves through the formed tunnel and intercostal defect, completely filling the previously formed extrapleural cavity. The proposed surgical benefits were applied in 18 patients with destructive pulmonary tuberculosis. Postoperative complications in 2 patients (the formation of subcutaneous seroma at the site of thoracodorsal flap isolation) were eliminated by puncture. In one patient, 4 months after musculoskeletal thoracoplasty, the second stage performed upper lobectomy, in other patients positive dynamics from treatment in the form of closure of decay cavities and abacillation was achieved.

The proposed method of musculoskeletal surgery has the following advantages:

1) less pronounced operational injury;

2) the maximum filling of any volume of the extrapleural cavity formed after pneumolysis;

3) the absence of a postoperative cosmetic defect (chest deformity) significantly improves the quality of life and social adaptation of patients with pulmonary tuberculosis after surgical treatment.

Clinical example

Patient T., born in 1965, homeless, does not work. He sought medical help in September 2009 with complaints of weakness, cough, fever. An X-ray examination revealed changes in the left lung. Previous fluorogram 2 years ago, without pathology. Examined. On radiographs and computed tomography from 09.29.09-01.10.09 in the upper lobe of the left lung against the background of an enhanced pulmonary pattern, multiple tricks, polymorphic foci. Two large infiltrates with decays are connected by a path to the root. In S _6, multiple foci of seeding. Right lung without features. 10/02/09 was hospitalized in the State Institution "Tuberculosis Dispensary" with a diagnosis of infiltrative tuberculosis of the upper lobe of the left lung in the phase of decay and seeding. Microbiological examination of sputum from 10/05/09 revealed KUM 2 (+). The patient was prescribed an intensive course of treatment according to 1 chemotherapy regimen (isoniazid - 0.6, rifampicin - 0.6, ethambutol - 1.6, pyrazinamide - 2.0). He tolerated the treatment satisfactorily. In the third month of treatment, sputum negation was achieved, but the radiological dynamics was negative, a cavity was formed. 02/03/09 consulted by a phthisiosurgeon. The patient was offered surgical treatment. Given the prevalence of the process, the patient was planned on stage surgical treatment. 02/17/10 performed musculoskeletal thoracoplasty. From the paravertebral access, the rib cage from the II to V ribs is exposed, crossed at the spine and the subperiosteal resection of the III and IV ribs from the spine to the middle axillary line. Next, extrapleural pneumolysis was performed from the dome to the root of the lung, pleuropneumopexy to the posterior segment of the VI rib. A thoracodorsal muscle flap on a vascular pedicle corresponding to the volume of the formed extrapleural cavity was isolated from additional access. In the proximal armpit, a tunnel under the large round muscle is formed, then the thoracodorsal muscle flap is moved through the formed tunnel and intercostal defect, completely filling the extrapleural cavity. Drainage with one silicone tube. Layered stitches for wounds. Active aspiration. On the first day, 650 ml of hemorrhagic fluid was allocated for drainage, on the second day 230 ml of hemorrhagic fluid, on the third day, 100 ml of serous-hemorrhagic fluid, the drainage was removed. On the control x-ray from 03/23/10 on the left state after thoracoplasty. The left lung is reduced in volume, in S _1-2 , S ₆ against the background of fibrosis dense grouped lesions. The patient was discharged from the hospital for outpatient treatment with the recommendation of a follow-up examination at the hospital to resolve the issue of the second stage of the operation. Examined on September 29, 10, on the roentgenogram the left lung was reduced in volume. In the upper parts of the left lung pleuropneumofibrosis. On spiral computed tomography from 09.25.10 positive dynamics. Infiltrative changes, decay cavities, focal changes were not detected. In the upper zone on the left revealed pneumopleurofibrosis. Volumetric formations, enlarged lymph nodes, bone-destructive changes were not found. The posterior segments of 3-4 ribs are resected. The first operation achieved a positive treatment effect for 7 months of treatment. The second stage is not shown.

Claims (1)

A method of extrapleural musculoskeletal thoracoplasty, including paravertebral access, subperiosteal resection of the III, IV ribs from the spine to the middle axillary line, extrapleural pneumolysis from the dome to the root of the lung with pleuropneumopexy to the posterior part of the VI rib, and characterized by isolation from the latissimus on the edge of the wider access, back, thoracodorsal muscle flap on the vascular pedicle, size corresponding to the volume of the formed extrapleural cavity, formation in the proximal the axillary cavity of the tunnel under the large round muscle, then with the flap moving through the intercostal defect, with the complete filling of the previously formed extrapleural cavity of any volume.