RU2535408C1 - Pleurodesis technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: using a harmonic scalpel provides running the boundary lines of an intraoperative manipulation with costal pleura. The boundaries extend in the medial direction up to a spinal column, upwards - as far as apical pleura merges into mediastinal one and downwards - to reach a diaphragm. Attaching a ball-tipped coagulator follows to perform the subsequent exposure of the costal pleura at frequency 55500 Hz by means of providing a tight contact of the instrument and the pleura surface until observing a parietal pleura oedema and having small superficial veins coagulated. The pleura exposure is from up to down along intercostal spaces.

EFFECT: method provides the effective obliteration of the pleural cavity that can accompany an endoscopic or upfront pleural surgery, including intra- and postoperative complications.

1 ex

Description

The invention relates to medicine, in particular to thoracic surgery, and can be used in the treatment of various types of emphysema.

There is a method of pleurodesis by introducing talc into the pleural cavity (1).

The disadvantages of this method are pain and the need for the appointment of analgesics, inadequate provision for obliteration of the pleural cavity and a high frequency of relapse.

A known method of pleurodesis by electrocoagulation of the parietal pleura (2).

The disadvantages of this method are the risk of developing intra- and postoperative complications due to burning of all layers of the pleura, the risk of bleeding due to damage to large vessels of the chest wall — intercostal arteries and veins, the internal thoracic artery and vein, exposure to an electric shock on the human body, and also insufficient effectiveness, manifested by recurrence of pneumothorax.

This method is taken by us as a prototype.

The aim of the claimed method is to increase the efficiency of obliteration of the pleural cavity, the exclusion of intra- and postoperative complications, the reduction of postoperative pain, the exclusion of temperature reaction, improving the quality of life of patients.

This goal is achieved by the fact that intraoperatively outline the boundaries of the processing of the costal pleura using an ultrasonic harmonic scalpel, which extend medially to the spinal column, up - to the point of transition of the apical pleura to the mediastinal, down to the diaphragm; further, a “ball-coagulator” working nozzle is installed and, in the mode of operation with a frequency of 55500 Hz, sequential processing of the costal pleura is carried out by tightly touching the instrument and the pleura surface; pleura treatment is carried out from top to bottom along the intercostal space.

The principle of operation of an ultrasonic scalpel is based on the transformation of electrical energy coming from the generator into ultrasonic mechanical due to the piezoceramic elements that are in the handle of the device. High-frequency mechanical vibrations are transmitted to the nozzle blade, as a result of which the tip moves in the longitudinal direction with a frequency of 55500 vibrations per second. By such an effect, characteristic pleural edema and coagulation of small superficial vessels, the development of aseptic inflammation, with subsequent active exudation and obliteration of the pleural cavity are achieved.

Distinctive features of the prototype is that it excludes the effects of electric current on the human body;

the impact of an ultrasonic harmonic scalpel eliminates the burning of all layers of the pleura and the risk of bleeding due to damage to large vessels of the chest wall. The advantages are also the absence of a pronounced pain syndrome requiring the administration of narcotic analgesics, as well as the high efficiency, manifested by the absence of recurrence of pneumothorax.

The method is as follows.

After the main stage of the operation, open or video-assisted thoracoscopic resection of the lungs begins to perform ultrasound pleurodesis.

To do this, outline the boundaries for processing the costal pleura using an ultrasonic harmonic scalpel, which extend medially to the spinal column, up - to the place of transition of the apical pleura to the mediastinal, down to the diaphragm; further, a “ball-coagulator” working nozzle is installed and, in the mode of operation with a frequency of 55500 Hz, sequential processing of the costal pleura is carried out by tightly touching the instrument and the pleura surface; pleura treatment is carried out from top to bottom along the intercostal space.

The criterion for achieving changes in the parietal pleura is the appearance of its edema and coagulation of small superficial vessels.

Pathomorphological changes are based on coagulation and aseptic inflammation, which then occurs in the pleura.

Signs confirming this are increased exudation in the first 2 days, which then passes into the productive phase and ends with obliteration of the pleural cavity. The operation is completed by drainage of the pleural cavity at two points.

The method is illustrated by the following example.

Patient E., 20 years old (medical history No. 38592121). The diagnosis is bullous pulmonary emphysema with damage to the upper lobes of the lungs. Secondary recurrent spontaneous pneumothorax on the right.

Condition upon admission to a hospital of moderate severity. Complaints of shortness of breath with minimal physical exertion, pain in the right half of the chest. After physical examination revealed pneumothorax on the right, which was subsequently confirmed radiographically. A history of 2 years ago, the first episode of pneumothorax on the right. Performed drainage of the right pleural cavity in the 4 intercostal space along the anterior axillary line. On the control x-ray, the lung did not completely straighten, there was a small apical pneumothorax. Computed tomography revealed bulls in the upper lobes of both lungs. Given the recurrence of pneumothorax and the presence of bullae of the lung, indications were made for video thoracoscopy on the right, resection of the upper lobe with bullae, pleurodesis. Intraoperatively after the main stage, the boundaries of the treatment of the costal pleura with the help of an ultrasonic harmonic scalpel were identified, which spread medially to the spinal column, up - to the place of transition of the apical pleura to the mediastinal, down to the diaphragm; then a “ball-coagulator” working nozzle was installed and in the mode of operation with a frequency of 55500 Hz a sequential processing of the costal pleura was performed by tightly touching the instrument and the pleura surface. The pleura was treated from top to bottom along the intercostal space. The criterion for achieving changes in the parietal pleura is the appearance of its edema and coagulation of small superficial vessels. The operation is completed by drainage of the pleural cavity at two points.

A temperature reaction, pain in the postoperative period was not observed. The patient was discharged from the hospital on the 10th day after surgery with recovery. Dynamic monitoring of the patient for 6 months did not reveal a relapse of pneumothorax. According to the proposed method, 50 patients were treated. In all patients, reliable pleurodesis was achieved without the development of relapses of pneumothorax, a temperature reaction and pain were not observed. The observation time ranged from 3 to 8 months.

Thus, the proposed method ensures reliable pleurodesis, eliminates intra- and postoperative complications and pain, does not require the use of narcotic analgesics, is not accompanied by a temperature reaction, prevents the development of relapses, is performed during endoscopic or open surgery in the pleural cavity.

The method is recommended for use in thoracic surgery.

Information sources

1) Olanisun Adewole, MD; De Keukeleire, MD; Marc Noppen, MD; Greg Erhabor, MD Outcome of Thoracoscopic Talc Pleurodesis for Treatment of Complicated Spontaneous Pneumothorax - A Preliminary ReportFree, CHEST. October 2011; 140 (4_MeetingAbstracts): 484A-484A. doi: 10.1378 / chest.1108487.

2) Sushko A.A. Videothoracoscopic surgery of recurrent spontaneous pneumothorax and its complications. Abstract of dissertation for the degree of candidate of medical sciences. Minsk, 2007

Claims (1)

The method of pleurodesis, carried out by physical action on the entire costal parietal pleura, characterized in that intraoperatively outline the boundaries for processing the costal pleura using an ultrasonic harmonic scalpel, which extend medially to the vertebral column, upward - to the point of transition of the apical pleura to the mediastinal, down to the diaphragm ; then a “ball-coagulator” working nozzle is installed and in the operating mode with a frequency of 55500 Hz sequential treatment of the costal pleura is carried out by tightly touching the instrument and the pleura surface until edema of the parietal pleura and coagulation of small superficial vessels appear; pleura treatment is carried out from top to bottom along the intercostal space.