RU2570166C2 - Method of surgical access in case of cervical lymph node dissection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: surgical access in case of cervical lymph node dissection is realised in form of two cuts. First cut is made in prootic area in tragus base to earlobe, moving on mandibular angle with continuation in chin and submental area. Second cut is started on mastoid process with further movement on posterior contour of sternocleidomastoid muscle with transition on its anterior surface in middle third and to sternum. Triangular flap, which is withdrawn to middle line of neck, is formed.

EFFECT: method makes it possible to improve functional and aesthetic results of operations on lymphatic system of neck, monitor facial nerve, simultaneously perform operations on larynx and pharynx due to making two cuts, performing lines of cuts in zones of natural skin folds in accordance with force lines of neck and preservation of subcutaneous muscle.

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Description

The invention relates to medicine, mainly to ENT, oncology, head and neck surgery.

The literature describes surgical access to perform fascial-fascial excision of the lymph nodes of the neck (Tumors of the head and neck, A. I. Paches, Moscow: “Medicine”, 2000, pp. 113-120), which is as follows. A transverse incision is 2-3 cm below the lower edge of the lower jaw, from the outer edge of the sternocleidomastoid muscle along the chin. A vertical incision from the angle of the lower jaw to the medial leg of the sternocleidomastoid muscle. After mobilization of skin flaps, an operative field is formed, covered by the subcutaneous muscle of the neck, within the following boundaries: posterior edge of the sternocleidomastoid muscle, midline of the neck, clavicle, lower edge of the lower jaw. Removal of fiber and lymph nodes is carried out within the specified area, the subcutaneous muscle of the neck is included in the preparation.

The disadvantages of the method are:

1. Horizontal and vertical cuts on the lateral surface of the neck, not corresponding to the lines of force, subsequently leading to scarring and impaired voluntary movements.

2. The inclusion of subcutaneous muscle in the block of tissue removed causes deformation of the lateral surface of the neck, increases scarring of soft tissues, thereby causing a restriction of free movement of the head.

3. This access makes it difficult to view the facial nerve when mobilizing the lower pole of the parotid salivary gland.

The closest in technical essence (prototype) is access for cervical lymphatic dissection according to Brown (Tumors of the head and neck, A. I. Paches, Moscow: “Medicine”, 2000, p. 109). When implementing this method, the incision begins from the attachment point of the sternocleidomastoid muscle to the mastoid process down the front edge of the muscle to the angle of the lower jaw and then parallel to the edge of the lower jaw with an indent of 1 cm in the submental and submental region. The second incision begins at the angle of the lower jaw from the first down to the place of attachment of the medial portion of the sternocleidomastoid muscle to the clavicle. After mobilization of skin flaps, they begin to remove fiber and lymph nodes of the neck, and the subcutaneous muscle of the neck is included in the preparation.

The disadvantages of this method are the following: the mismatch of the skin incision lines to the force lines and the inclusion of subcutaneous muscle in the preparation leads to cicatricial deformity of the neck; inadequate overview of the post-accessory area during surgery and an increased risk of trauma to the trapezius branch of the accessory nerve; lack of the ability to visually monitor the facial nerve; increased risk of marginal necrosis at the junction of the vertices of the skin triangular flaps.

The aim of the invention is to improve the functional and aesthetic results when removing the lymph nodes of the neck; providing access for visual neuromonitoring of the facial nerve.

This goal is achieved in that the transfer of incision lines into areas of natural skin folds in accordance with the lines of force of the neck and preservation of the subcutaneous muscle allows you to obtain a satisfactory functional, cosmetic result. In this case, it becomes possible to excise the lower pole of the parotid salivary gland, included in the volume of the cervical lymphadenectomy, as a single unit with fiber and lymph nodes of the neck, as well as simultaneously perform operations on the larynx and pharynx. Providing access to the neck area around the angle of the lower jaw allows you to monitor the facial nerve from the point of exit from the skull.

The novelty of the proposed method lies in the fact that the incision is performed in the anterior region at the base of the tragus to the earlobe with a transition to the angle of the lower jaw and continues into the chin and submental region. The second incision begins in the behind-the-ear region, on the mastoid process, at the site of attachment of the sternocleidomastoid muscle, goes down the posterior contour of the specified muscle with a transition to its front surface in the middle third and continues to the place of attachment of the muscle to the sternum. The skin, subcutaneous fat, subcutaneous muscle and the triangular flap thus formed are subsequently dissected to the midline, opening a review to remove fiber and lymph nodes of the anterior triangle of the neck and larynx. The lateral flap is brought back, providing access to remove fiber and lymph nodes of the posterior triangle of the neck.

Technical solutions that have features that match the distinguishing features of our proposed method are not identified, which allows us to conclude that the proposed method meets the criterion of "inventive step".

The invention is illustrated by the following figures:

FIG. 1. View of the lateral surface of the neck with a cut line;

FIG. 2. The appearance of the wound after separation of the flaps.

The proposed method of surgical access for cervical lymphadenectomy is as follows.

First, incision 1 is performed (Fig. 1) in the forehead region at the base of the tragus to the earlobe with transition to the angle of the lower jaw and continues into the chin and submental region. The second incision 2 (Fig. 1) begins in the behind-the-ear region, on the mastoid process, at the site of attachment of the sternocleidomastoid muscle, goes down the posterior contour of the specified muscle with a transition to its front surface in the middle third and continues to the place of muscle attachment to the sternum. The skin, subcutaneous fat, subcutaneous muscle is sequentially dissected, and the triangular flap 1 (Fig. 2) thus formed is retracted to the midline, opening a review to remove fiber and lymph nodes 2 (Fig. 2) of the anterior triangle of the neck and larynx. The lateral flap 3 (Fig. 2) is taken back, making access to remove fiber and lymph nodes of the posterior triangle of the neck.

Example 1

Patient B., 66 years old, was admitted to the hospital on 01/26/12, diagnosis: Cancer of the larynxopharynx III st. T2N1M0, II class. column Complaints of tickling in the throat, difficulty swallowing solid food, a sore throat radiating to the right ear have been disturbing for more than 6 months, and have not sought medical help. With endoscopy of the larynx, the tumor has a mixed growth form, occupies the right pear-shaped sinus, spreads to the scaly palatine fold. Glottis about 8 mm. According to the ultrasound of the lymph nodes of the neck, modified, enlarged to 2 cm lymph nodes in the IIb and III levels of the neck are determined. According to histological and cytological studies, highly differentiated squamous cell carcinoma. The primary lesion in the larynxopharynx was treated with the chemoradiation method: remote gamma therapy in a total focal dose of 72 Gy with xeloda radio modification. On examination, after completion of chemoradiotherapy, enlarged lymph nodes on the neck on the right are preserved, and cervical lymphadenectomy is recommended.

Protocol of operation: Under endotracheal anesthesia, a skin incision was made in the anterior region from the base of the tragus to the earlobe, then with a transition to the angle of the lower jaw and to the chin and submental region. The second incision in the behind-the-ear region from the attachment point of the sternocleidomastoid muscle to the mastoid process, down the posterior edge of the sternocleidomast transition to its anterior surface in the middle third and to the attachment to the sternum. The skin, subcutaneous fat, subcutaneous muscle was sequentially dissected, a triangular flap was formed, retracted to the midline, the sternocleidomium retracted. The main neurovascular bundle was mobilized, altered lymph nodes of the III, IIb levels were revealed. From the bottom up, fiber, lymph nodes of the anterior triangle of the neck and the lower pole of the parotid salivary gland are mobilized and excised in a single block. The stinging muscle is retracted anteriorly, the lateral flap is retracted, fiber and lymph nodes of the posterior triangle of the neck are mobilized and dissected with the preservation of the accessory nerve. Aspiration drainage, layered wound closure, aseptic dressing.

Postoperative histological examination No. 1342 - 67 of 02/06/12: in the lymph nodes of the neck level IIb - metastases of squamous cell carcinoma. The wound healed by first intention, the sutures were removed on the 10th day, was discharged 02.21.2012.

Example 2

Patient V., 59 years old, was admitted to the department 02.15.13 with a diagnosis of Cancer of the larynx IVb Art. T4N2M0. Complaints of hoarseness, difficulty breathing under exertion, the presence of a neck tumor on the right, concern about 8 months. With endoscopy of the larynx, a tumor of a mixed growth form occupies the right half of the larynx on the right, passes to the left. With phonation, the larynx is stationary on the right, mobility is limited on the left, and the glottis is up to 6 mm. On the neck on the right, at the IIb level, a metastatic node enlarged to 3 cm in diameter is determined, tightly soldered to the sternocleidomus and the parotid salivary gland. Histology No. 1942-45 / 13: low-grade squamous cell carcinoma.

At the preoperative stage, the patient underwent preventive tracheostomy, 02/21/13 under radical endotracheal anesthesia expanded radical, cervical lymphadenectomy and expanded laryngectomy. Surgery protocol: the right neck skin incision specified in the procedure. Formed skin-subcutaneous-platysmal triangular flap, allotted anteriorly. The main neurovascular bundle of the neck is mobilized. During the audit: in the parotid region, metastatic lymph nodes up to 3 cm are soldered to the lower pole of the parotid salivary gland, sternocleidomastoid muscle. The lymph nodes, cellulose of the anterior triangle of the neck and conglomerate of lymph nodes were removed at level IIb with the inclusion of the lateral lobe of the parotid salivary gland and part of the sternocleidomastoid muscle. The application of the described access method made it possible to monitor the facial nerve. Fiber and lymph nodes of the posterior triangle of the neck were mobilized and removed, and the accessory nerve was preserved. Laryngectomy with the inclusion of a thyroid isthmus, 4 tracheal rings and anterior laryngeal muscles in the preparation. Hemostasis, drainage, wound closure, aseptic dressing.

Postoperative histological examination No. 2245 - 79 dated 02.27.13: larynx with the growth of low-grade squamous cell cancer, the growth of thyroid cartilage, no tumor cells were found at the edges of the resection. In the fiber of the anterior triangle of the neck on the right - metastases of squamous cell carcinoma. Healing by first intention, the sutures were removed on the 9th day, the nasogastric tube on the 14th day, was discharged 03/15/2013. When examining the patient's face is symmetrical, there are no signs of paresis of the facial nerve. At the time of the examination, November 21, 2013, a relapse-free course of the disease is noted.

The proposed method of surgical access for cervical lymphadenectomy is used in oncological, surgical and lorstation centers, where operations are performed to remove metastatically affected lymph nodes of the neck.

Claims (1)

A method of surgical access for cervical lymphadenectomy, which consists of two incisions, characterized in that the first incision is made in the anterior region at the base of the tragus to the earlobe, passing to the angle of the lower jaw, and continues into the chin and submental region, and the second incision begins on the mastoid process, then pass down the posterior contour of the sternocleidomastoid muscle with the transition to its front surface in the middle third and to the sternum, forming a triangular flap that is led to the midline of her.

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