RU2502478C1 - Method of instant mastectomy and reconstruction of mammary gland with auto tissues - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to mammology. After mastectomy manipulator or circular suturing apparatus is introduced through lower edge of post mastectomy wound into abdominal cavity. Edge of greater omentum is hitched up. Omentum is brought out through tunnel and laid on wound surface of chest wall. Cutaneous-muscular thoracodorsal flap is formed on pedicle and laid in "sandwich" type on greater omentum. Edges are fixed, sutures are applied on skin.

EFFECT: method ensures recovery of mammary gland volume, reduction of lymphorrhagia terms, economical expenditures on surgery.

3 cl, 8 dwg

Description

The invention relates to medicine, in particular to the treatment and rehabilitation of patients with malignant neoplasms of the mammary gland.

Breast cancer (BC) is the most common cancer among women in most countries. Most patients with breast cancer are detected in the IIB and IIIA stages (up to 50% of cases) [1, 2]. Almost all patients receive complex or combination therapy, in which the main component is a radical mastectomy. Despite the increase in the number of patients who managed to save the mammary gland, radical mastectomy remains the main treatment.

Modern methods of surgical treatment of breast cancer can save the lives of many patients, but this goal is achieved at the cost of causing serious aesthetic damage to a woman.

There is a method of restoring the volume of the mammary gland with its own tissues by forming a TRAM flap (from the English abbreviation - Transverse Rectus Abdominis Myocutaneous) from a transverse flap of the rectus abdominis muscle, which today has found the greatest distribution. For the reconstruction of the mammary gland, several variants of the TRAM flap are used: 1) on the feeding leg and 2) free. The main disadvantages of the first option are unreliable blood supply and significant trauma to the anterior abdominal wall, difficulties in restoring the edges of the wound, and the development of a postoperative hernia. The main disadvantage of the second option is the technical complexity and the need to use microsurgical equipment [3].

There is also known a method of restoring the volume of the mammary gland by forming a horizontal torocodorsal flap on the vascular and nerve pedicle, selected as a prototype. The markup of the flap is carried out in the upright position of the patient. The exact location is determined so that the postoperative scar can be hidden under the edge of the bra. The ellipsoid flap moves to the postoperative donor wound after removal of the mammary gland on the neurovascular leg with the possibility of direct suturing [4]. However, using the classical method of breast reconstruction with a toro-dorsal flap, the own tissues of the dorsal flap are not enough, and therefore, additional use of silicone implants or expansion of tissue intake is supposed due to the adjacent subcutaneous fat up to the upper corner of the scapula, the middle of the lumbar region and almost the entire latissimus muscle back, which leads to a certain asymmetry of the back and limitation of the functions of the shoulder girdle.

There is also known a method [6] for closing the wound surface of the chest wall with non-healing (radiation) ulcers with a large omentum transported from the abdominal cavity by laparotomy. A large omentum has good blood supply and engraftment (adhesion) due to suction hatches and drainage functions [5]. However, as an independent material, it is insufficient to replenish the volume of the mammary gland; to mobilize the greater omentum, a laparotomy with its subsequent suturing is required.

The objective of the invention is the provision of restoration of the volume of the mammary gland, reduction of lymphorrhea and other complications and reduction of the economic costs of surgical intervention.

This task is achieved by the fact that, according to the method of simultaneous mastectomy and breast reconstruction, radical mastetomy is performed using own tissues (Fig. 1), the second team performs a video laparos copy (with positive steroid receptors, the presence of ovarian cysts, bilateral ovariectomy is performed simultaneously), under the control of laparoscope 1 through the lower edge of the postmastectomy wound below the costal arch or in the junction of the angle of the xiphoid process and costal arch produce a cruciform aponeurosis 3. The abdominal cavity is administered manipulator 2 and a brush with soft bellied thickening at the end of the dormant. The brush is pulled out of the tubular manipulator, rotational movements capture the lower edge of the large omentum and roll it into a roll, if necessary, additionally mobilized under the control of a laparoscope. You can use the apparatus for circular suturing of the intestine (Fig 3). The last lower edge of the gland is clamped by the head of the working end 4 by metering with a nut 5 at the proximal end of the manipulator. In a similar way, a large omentum is twisted into a roll and lifted to the anterior abdominal wall, pulling the peritoneum sheets associated with the transverse colon. The latter are easily incised, and the vessels are clamped or coagulated with a special device from the laparoscope set (Fig. 4). As a result, a large gland can be mobilized throughout if necessary.

In a sharp and blunt way, a subcutaneous “tunnel” is formed along the manipulator. Traction of a large omentum is made through the tunnel with control of its free passage. For the prevention of infringement, an aponeurosis of the external oblique muscle is crosswise dissected (Fig. 2 and Fig. 3). Roll unroll. A large omentum 6 is placed on the wound surface of the chest wall (Fig. 5), fixed at the edges and in the zone of the tunnel without trapping the vessels. The video laparoscope is removed.

The patient is placed on the opposite side of the operated mammary gland. Then, after cutting the skin along the entire circumference of the ellipse (Fig.6), the axis of which passes along the marking of the belt of the lower edge of the bra, subcutaneous fatty tissue is selected taking into account the volume of the removed gland.

They mobilize the latissimus dorsi muscle along the inner surface, focusing on the lateral edge, form and cut off the musculoskeletal torcodorsal flap 7, corresponding to the size of the missing volume of the reconstructed mammary gland. The flap is raised, its vascular pedicle is isolated. For better mobilization, the broadest muscle is cut off in the armpit, leaving the neurovascular bundle intact. The flap is moved to the wound surface of the chest wall (Fig.7), placed like a sandwich on a large omentum, fixing the edges with a cosmetic suture to the dermis and skin 8. Active drainage into the axillary zone 9.

This task is achieved by the combined use of closing a postmastectomy wound with a mobilized large omentum using a video laparoscope and a torocodorsal flap, which differs from the known one in that the latter is laid like a sandwich on a large omentum, creating the missing volume of the mammary gland and representing a unique plastic material for vascularization and drainage.

Figure 1 shows the introduction of the manipulator 2 with a soft brush and a button-shaped thickening at the end in a hidden state through the lower edge of the postmastectomy wound below the costal arch or in the junction of the angle of the xiphoid process and costal arch in the abdominal cavity.

Figure 2 shows the folding of a large oil seal into a roll using a manipulator with a soft brush.

Figure 3 shows, as an option, the use of an apparatus for circular suturing of the intestine.

Figure 4 - the sheets of the peritoneum of the greater omentum with the transverse colon intestine are easily incised, and the vessels are clamped or coagulated with a special device from the laparoscope set.

Figure 5 - mobilized large omentum stacked on the pectoralis major muscle and is fixed.

Figure 6 shows the formation of a torocodorsal flap and laying like a sandwich on a large gland.

7 shows the final version after applying cosmetic sutures to the skin of the toricodorsal flap and active drainage in the axillary zone.

The method is carried out in stages: - after a mastectomy, a tubular manipulator 2 with a soft brush and a buttoned thickening in a hidden state is inserted into the abdominal cavity under the control of a video laparoscope 1 under the control of a video laparoscope 1. In the abdominal cavity, the brush is pulled out and a large gland, starting from the lower - lateral edge, is turned into a roll 3 by circular rotation with the fibers of the brush, if necessary, it is additionally mobilized under the control of a video laparoscope. A tunnel is formed with a cross-shaped dissection of the aponeurosis of the external oblique muscle of the abdomen for free movement of the greater omentum into the wound after mastectomy, the roll is deployed, laid on the wound surface, fixed along the edges and in the tunnel zone. A torocodorsal flap 7 is formed, it is moved to the anterior chest wall 8, laid on a large gland like a sandwich, fixed with absorbable sutures to the fascia of the pectoralis major muscle; 9 - active drainage in the axillary zone. Stitches to the skin.

Experimental and clinical trials were conducted in the regional clinical oncology clinic in Veliky Novgorod. The test results of the method are presented in the table (Fig. 8).

The method was tested in 8 patients for breast cancer (T1-2No-1Mo-1).

These tables show that the application of the proposed method allowed in all cases to perform subcutaneous mastectomy with a tumor in one block. From a separate incision, with the exception of 3 patients, axillary lymphadenectomy was performed. In the latter cases, second-level lymphadenectomy was performed from an incision for mastectomy. At the same time, laparoscopy is performed, including in 8 with bilateral ovariectomy, including in 2 with removal of ovarian cysts in order to conduct antihormonal therapy.

Photo. 1. Patient D., 32 years old, diagnosis: cancer with a tumor status of the left breast TINoMo, ER - 6, PP - 7.

In all cases, using a manipulator under the control of a video laparoscope, a large omentum is rolled up with its partial mobilization at the transverse colon and after excision of the aponeurosis is brought to the wound surface of the chest wall. The roll is deployed, a large omentum is placed on the pectoralis major muscle, fixed at the edges with interrupted sutures. The second stage (after laying the patient on the opposite side) formed a torocodorsal flap 7, moved it to the anterior chest wall 8, laid it on a large gland like a “sandwich”, fixed it with absorbable sutures to the sections of the fascia of the pectoralis major muscle, installed active drainages 7 in the axillary zone . Cosmetic seams on the skin.

There were no complications after reconstructive plastic surgery by the type of sandwich.

Thus, the proposed method for the implementation of breast plasty is the method of choice in young women, especially with a positive receptor status of the tumor. The proposed method is less traumatic, reduces the time of lymphorrhea due to the suction functions of the greater omentum up to 7-10 days. The method provides a cosmetic effect to the size of the opposite breast.

Information sources

1. Chissov V.I., Starinsky V.V., Petrova G.V. The status of cancer care in 2009 in Russia. M. 2010.

2. V.F. Semiglazov, V.V. Semiglazov, A.E. Kletsel. Non-invasive and invasive breast tumors. St. Petersburg, 2006, p. 5.

3. S.A. Vasiliev. Plastic surgery in oncology. Ed. Chelyabinsk MA, 2002, 261 p.

4. Kharchenko V.P., Rozhkova N.I., Vozny E.K., Galil - Ogly G.A., Panshin G.A. Radiation diagnosis of breast diseases, treatment and rehabilitation (practical guide), issue 4, 2001.

5. Libermann D., Harvey White. The greater omentum. Springer-Verlag. Berlin Heidelberg New York. 1983, 336 p.

6. Jackson, I.T., 1985 (cited from Libermann D., Harvey White.)

Claims (3)

1. A method of simultaneous mastectomy and reconstruction of the mammary gland with its own tissues, including radical mastectomy and its reconstruction with a thoracodorsal flap, characterized in that after mastectomy, a manipulator or a circular manipulator is inserted into the abdominal cavity under the control of video laparoscopy, under the control of video laparoscopy, and with they cling to the lower edge of the greater omentum and fold it into a “roll”, if necessary, additionally mobilize, then form the subcutaneous tubes in a sharp and blunt way “Tunnel”, a large omentum is rolled up, transferred through a tunnel to the wound surface of the chest wall, the roll is deployed, a large omentum is placed on the wound surface of the chest wall, imitating the tissue of the mammary gland, fixed along the edges and in the tunnel area, then formed and cut off a muscular thoracodorsal flap on the neurovascular leg corresponding to the amount of the missing volume of the reconstructed mammary gland, the flap is moved to the wound surface of the chest wall, laid by type "Sandwich" on the greater omentum, fix the edges of the broadest muscle and sutured to the skin. 2. The method according to claim 1, characterized in that when using the manipulator with a soft brush and a button-shaped thickening at the end, the brush is pulled out of the tubular manipulator, the lower edge of the large gland is caught by rotational movements. 3. The method according to claim 1, characterized in that when using the stapler, the head of the working part of the apparatus is opened, the lower part of the lock of the large gland is inserted into the stem area and clamped in a measured manner.

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