RU2587314C1 - Method for myoplasty after oncoplastic operations for mammary gland - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to surgery. Subcutaneous tissue is removed from breast tumour, subclavian-axillary-subcapular lymphadenectomy. Method includes closing armpit neurovascular bundle collagen plate series stacked in form of a rhombus so that axis of symmetry of rhomb is directed along armpit neurovascular bundle, mainly, along an axillary vein with location of proximal end of rhomb at small pectoral muscle, closing of neurovascular bundle and adjacent to it fibre from top and bottom angles opposite axis of symmetry of rhombus. Method includes performing one-step myoplasty with lateral edge of broadest muscle of back with preserved its fascia to front toothed muscle and layer wound closure. Two collagen plates are used to close neurovascular bundle. First is placed in proximal direction on axillary neurovascular bundle. Second is placed distally overlapping first, and a lateral edge of broadest muscle of back is anchored to front toothed muscle continuous double-row blanket suture. Further, lateral lower adipocutaneous flap chest wall is fixed with three interrupted sutures to lower surface of lateral edge of greater pectoral muscle and postoperative wound using non-drainage method.

EFFECT: method does not affect motion in shoulder joint after operation, reduces formation of lymph in operative wound, reduces stay in hospital with 21 to 12-14 days, reduces consumption of dressing material.

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Description

The invention relates to medicine, namely to breast surgery, and can be used in the treatment of patients with breast cancer with the aim of preventing postoperative lymphorrhea.

A known method for the prevention of lymphorrhea after radical mastectomy. After removal of the mammary gland in a single block with fiber and lymph nodes of the axillary, subclavian and subscapular regions, myoplasty is performed, for which, using an electric knife, the outermost latissimus dorsi muscle fragment is sequentially separated in the position of the patient on the back. A fragment of the latissimus dorsi muscle is separated to the middle of the distance between the posterior axillary and scapular lines. The fascia is removed from the inner surface of a fragment of the latissimus dorsi muscle with the size necessary to close the axillary-subclavian-subscapular area, using the blunt and sharp path, as well as using an electric knife. The formed flap of the latissimus dorsi muscle is moved sequentially to the subscapular, axillary and subclavian regions, making up for tissue deficiency. The hemming of the muscle is performed with a two-row, and in some cases a three-row suture. The first row of sutures is applied between the inner surface of the flap with the latissimus dorsi muscle and fibers of the anterior dentate muscle (2-3 nodal sutures with atraumatic thread Vicryl No. 2-3). The second row of sutures is applied between the inner surface by the latissimus dorsi muscle, fibers of the anterior dentate and pectoralis minor muscles in the middle of the distance between the anterior axillary and midclavicular lines (2 nodal sutures with atraumatic thread Vicryl No. 2-3), covering the subscapillary region. The flap of the latissimus dorsi muscle is moved under the pectoralis minor muscle and the distal edge of the displaced flap is fixed to the inner edge of the pectoralis minor muscle (2 nodal sutures with atraumatic thread Vicryl No. 2-3) with the third row of sutures, thus covering the subclavian region. An additional U-shaped suture is possible between the inner edge of the flap of the latissimus dorsi muscle and the pectoralis major muscle in the projection area of this edge. Thus, a tissue deficiency formed by the removal of fiber and lymph nodes of the axillary, subclavian, subscapular areas is filled with a flap of the latissimus dorsi on the muscle leg without fascia from the inside. The operation is completed by layer-by-layer suturing of the postoperative wound with the vacuum drainage left through the counter-hole through the middle axillary line according to the traditional method. (Pak D.D., Ermoshchenkova M.V., Saribekyan E.K. "Simultaneous myoplasty with radical mastectomy for the prevention of postoperative complications. M: FGU" MIIOI named after PA Herzen of the Russian Medical Technologies, 2008, - 6 il . - 5, 6, 7, 8, 9 pp.)

The disadvantages of the method are: the lack of closure of the axillary neurovascular bundle, where there are the largest accumulations of crossed lymphatic vessels after lymphadenectomy, which can be the cause of lymphorrhea, in addition, simultaneous myoplasty with the latissimus dorsi to the anterior dentate muscle, small and large pectoral muscles with separate nodal sutures It does not provide tight muscle fixation (myopexy) and helps to limit movements in the shoulder joint.

A known method for the prevention of lymphorrhea after radical organ-saving operations on the mammary gland. After resection of the tumor, sector or quadrant of the mammary gland with the tumor and subclavian-axillary-subscapular lymphadenectomy, at the end of the operation, the axillary neurovascular bundle is closed with a collagen plate containing coagulation factors - fibrinogen and thrombin, laying it in a diamond-like manner so that the axis of symmetry of the rhombus is directed along the axillary neurovascular bundle, mainly along the axillary vein, with the proximal end located under the pectoralis minor muscle, and angles opposite the axis of symmetry II rhombus, close the neurovascular bundle and adjacent tissue, above and below, then perform simultaneous myoplasty with the latissimus dorsi muscle with preserved fascia to the anterior dentate muscle with a continuous double-row suture with an overlay, after which the wound is sutured in layers with fixation of breast tissue and subcutaneous fat to the pectoralis major and latissimus dorsi, and they lead a wound in the postoperative period without drainage method (Soloviev V.I., Semkina E.N., Anokhin A.S. "The method of myoplasty after radical organ-preserving operations on the mammary gland." Patent for invention No. 2436521).

The disadvantages of the method are: incomplete shelter of the axillary neurovascular bundle with a collagen plate, insufficiently tight fixation of the lateral edge by the latissimus dorsi to the anterior dentate muscle and skin-fat flap to the pectoralis major muscle, which leads to complications and slows the healing process.

Methods for the prevention of lymphorrhea during radical oncoplastic operations have not been found in the literature.

The technical result of the use of the invention is the prevention of postoperative complications, accelerating the recovery and improving the quality of life of women due to the mechanical compression of the crossed lymphatic vessels in the axillary neurovascular bundle with collagen plates and their tight fixation, as well as the maximum reduction of the postoperative cavity by simultaneous intraoperative plasty with local tissues, which involves wound management in a drainless manner.

The essence of the proposed method of myoplasty after oncoplastic operations on the mammary gland, including subcutaneous removal of breast tissue with a tumor, subclavian-axillary-subscapular lymphadenectomy, closure of the axillary neurovascular bundle with a collagen plate superimposed in the form of a rhombus so that the axis of symmetry of the rhombus is directed along neurovascular bundle, mainly along the axillary vein with the location of the proximal end of the rhombus under the pectoralis minor muscle, closure of the vascular-n of the neural bundle and adjacent fiber from above and below by angles opposite the rhombus axis of symmetry, simultaneous myoplasty with the lateral edge of the latissimus dorsi with its preserved fascia to the anterior dentate muscle and layered suturing of the wound consists in the use of two neurovascular bundles to close collagen plates, the first is laid proximally on the axillary neurovascular bundle, the second is distally lapped with the first, and the lateral edge of the latissimus dorsi is sutured to the anterior dentate muscle continuously m with a double-row twisted seam, after which the lateral skin-fat flap of the chest wall is fixed with three interrupted sutures to the lower surface of the lateral lateral edge of the pectoralis major muscle and wound in the postoperative period without drainage.

The use of two collagen plates allows hermetically covering the axillary neurovascular bundle throughout due to mechanical compression of the lumen of the walls of small blood and lymph vessels with the adhesive surfaces of the plates, providing impermeability to liquids (blood and lymph). Their location in a diamond-shaped manner ensures maximum closure of the neurovascular bundle along its entire axis, as well as the adjacent fatty tissue and tissues, above and below. The application of a continuous double-row twisting stitch between the latissimus dorsi and the front dentate muscle provides tight muscle fixation (myopexy) and unlimited mobility in the shoulder joint. Suturing of the subcutaneous tissue with nodal sutures to the lower and upper surfaces of the lateral edge of the pectoralis major muscle provides strong tissue fixation in the wound and also closes the surgical wound as much as possible, therefore there is no need to install drainage.

The essence of the method is illustrated by figures, where figure 1 shows the localization of two collagen plates; in figures 2 and 3 shows the technique of simultaneous myoplasty; the figure 4 presents the layered suturing of the wound with interrupted sutures between the subcutaneous tissue and the lower surface of the lateral edge of the pectoralis major muscle; figure 5 shows the nodal joints between the subcutaneous fat and the upper surface of the lateral edge of the pectoralis major muscle.

The method is as follows.

After subcutaneous removal of breast tissue with a tumor from a separate lower paraareolar incision, a silicone implant or expander is immediately installed under a skin-fat flap, from a separate semi-oval incision along the edge of the hairline in the axillary region, subclavian-axillary-axillary lymphadenectomy is performed, at the end of the operation on the axillary neurovascular bundle 1 overlap two Tachocomb collagen sponges of 4.8 × 4.8 × 0.5 cm in size, with components of fibrin glue (highly concentrated fibrinogen and thrombin) 2 and 3, for the entire length of the axillary neurovascular bundle exposed from the subcutaneous fat and lymph nodes along the neurovascular bundle 1 under the pectoralis minor muscle 4. The first collagen plate 2 is laid proximal to the axillary neurovascular bundle, the second 3 - distally overlapping the first. Before applying the collagen sponges "Tachocomb" 2 and 3, the wound surface is maximally cleaned of blood and lymph (figure 1). The side covered with coagulation factors and marked in yellow is applied to the wound surface and pressed for 5 minutes to glue the crossed lymphatic vessels and small blood vessels, which ensures the prevention of postoperative lymphorrhea and bleeding from small vessels. Sponges are left in the wound. Then produce simultaneous myoplasty with the lateral edge of the latissimus dorsi muscle 5 to the anterior dentate muscle 6 with atraumatic thread Vikril (3-0), and the fascia of the latissimus dorsi muscle is not removed. The first row of sutures 7 is imposed from the inside by the latissimus dorsi muscle 5 perpendicular to its fibers at the middle of the distance between the edge of the muscle and the lower corner of the wound (Figure 2), the latissimus dorsi 5 is sutured to the anterior dentate muscle 6 with a continuous twisted stitch 7, the distance between the stitches 2, 0 cm. The second row of sutures 9 is applied as follows: the angle of the latissimus dorsi muscle 5 and the anterior dentate muscle 6 are fixed with a knot, then the edge of the latissimus dorsi muscle 5 is sutured, making the needle injection 2.0 cm from its edge, to the anterior dentate muscle 6 continuous about ivnym seam 9, the distance between stitches 2,0 cm (figure 3). At the same time, the major 8 and minor 4 pectoral muscles are not fixed by sutures to the latissimus dorsi and when contracting, they glide unhindered. During myoplasty, the fascia of the muscle is not removed, and therefore there is no bleeding from the muscle, the formation of intermuscular hematoma and exudate in the wound. Since there is no operating cavity after plastic surgery with local tissues, no drainage is installed in the wound. The wound is sutured in layers as follows: the first row of three nodal sutures with nylon suture (3-0) 10 is applied between the subcutaneous tissue of the lower skin-fat flap 11 and the lower surface of the lateral edge of the pectoralis major muscle 8 (figure 4), and the second row of three nodal sutures of nylon thread (3-0) 12 is applied between the subcutaneous tissue of the upper skin-fat flap 13 and the upper surface of the pectoralis major muscle 8 (figure 5), after which sutures are applied to the skin. The wound after subclavian-axillary-subscapular lymphatic dissection in the postoperative period is conducted by a drainless method. Sponges left in the wound for 12 weeks are absorbed, decompose during fibrinolysis and activation of phagocytosis, turning into granular tissue rich in collagen.

Example. Patient S., 42 years old, was admitted to the surgical thoracic department of the Kaluga Regional Clinical Oncology Center on November 28, 2014.

Clinical examination revealed cancer of the right breast of stage I T1N0M0 I, confirmed by a morphological study. Mammographically, a tumor with a diameter of up to 2 cm was located in the upper-outer quadrant of the right mammary gland. Lack of a secondary-edematous form of breast cancer, nodular type of tumor, small tumor size at 3 breast size, distance from the upper edge of the tumor to the skin surface more than 3 cm, distance from the distal edge of the tumor to the edge of the areola more than 2.5 cm, patient's desire maintaining the shape of the mammary gland was an indication for oncoplastic surgery - a radical skin-preserving mastectomy with preservation of the nipple-areolar complex and simultaneous installation of a silicone endoprosthesis.

After appropriate preparation, December 6, 2014, the operation was performed: radical subcutaneous drainageless mastectomy with the simultaneous installation of TM F3-345 silicone endoprosthesis with myoplasty. Under anesthesia, a lower paraareolar incision was made according to Horton, skin was opened up to 12.0 cm long, subcutaneous tissue was 1-1.5 cm deep to the tissue of the right mammary gland. Between cellulose and tissue of the mammary gland with a hemostatic purpose, a tumescent solution was introduced, the entire tissue of the right mammary gland with fascia of the pectoralis major muscle was removed. Thorough wound hemostasis. A silicone endoprosthesis of TM F3-345 with a volume of 345 ml was installed under the skin-fat flap. The wound was sutured with a two-row suture: the first intradermal twisted 5-0 nylon thread, the second intraepidermal PDS II 4-0 thread without drainage. A separate semi-oval incision was made in the projection of the lateral edge of the pectoralis major muscle along the front edge of the hairline up to 8 cm long. The superficial fascia was cut along the lateral edge of the pectoralis major muscle, the fascia was partially detached from the posterior edge of the pectoralis major muscle, ligating and intersecting the vessels between the small and large pectoral muscle. With a wide hook, the lateral edge of the pectoralis major muscle is laid up. Fascia was dissected along the entire medial, and under the vessels, and the lateral edge of the pectoralis minor muscle. Cellulose is selected in the area of the medial part of the subclavian vein and then in the lateral direction to the subscapularis muscle and the edge of the latissimus dorsi muscle. The selected fiber with lymph nodes of the subclavian, axillary and subscapular areas is excised. Thorough wound hemostasis. Two collagen plates coated with fibrin and thrombin were applied to the axillary neurovascular bundle for the purpose of preventing lymphorrhea and with hemostatic purpose. The Tachocomb is 4.8 × 4.8 × 0.5 cm in a diamond-shaped manner: the axis of symmetry of the rhombuses is directed along the axillary vein , and the angles opposite the axis of symmetry of the rhombus encompass the neurovascular bundle above and below. The first collagen plate is laid proximal to the axillary neurovascular bundle, the second distally overlap. In order to prevent postoperative lymphorrhea and lymphocele, simultaneous myoplasty of the latissimus dorsi to the anterior dentate muscle with atraumatic suture 3–5 continuous continuous double-row twisted seam was performed. The latissimus dorsi muscle is taken by two Kocher clamps. The first row of sutures is applied from the inside by the latissimus dorsi muscle perpendicular to its fibers at the middle of the distance between the edge of the muscle and the lower angle of the wound, the distance between the stitches is 2.0 cm. The second row of sutures is laid as follows: the angle of the latissimus dorsi and anterior dentate muscle is fixed by a knot, then the edge of the latissimus dorsi is sutured to the anterior dentate muscle with a continuous twisting seam, the distance between the stitches is 2.0 cm, injecting a needle 2.0 cm from the edge of the latissimus dorsi. The wound was sutured in layers: the first row of three-node sutures with kapron thread (3-0) between the subcutaneous tissue and the lower surface of the lateral edge of the pectoralis major muscle, and the second row of nodal sutures between the subcutaneous tissue and the upper surface of the pectoralis major muscle, then sutures were applied to the skin.

The histological conclusion No. 548585-97 - infiltrating ductal breast cancer of 2 degrees of malignancy. Outside the tumor, fibrocystic disease. A tumor with a diameter of 1.8 cm. In the lymph nodes: subclavian, axillary, subscapular metastases. There is no tumor growth at the edges of the resection.

The immediate postoperative period was uneventful. There was no increase in temperature reaction. Dressing was carried out 5 times: 1 day after the operation, then a day later and on the day of discharge, it was performed in the form of a dressing change with fixation by compression underwear. The wound healed by first intention, the sutures were removed on the 12th day after the operation, and the patient was discharged for further treatment: hormone therapy.

During the control ultrasound examination of the right axillary region on the day of discharge of fluid (lymph) was not found. An ultrasound of a skin-fat flap with an implant revealed the formation of a fibrous capsule. After 10 days, a control ultrasound in the axillary region of the fluid (lymph) was also not found.

In total, 12 patients with stage I-II breast cancer aged 37 to 43 years were operated on using this technique. No complications after operations were observed, the functions of the upper limbs were not impaired. The quality of life of patients has improved markedly, all patients live a full life. The average hospital stay after surgery is 12-14 days. In no case was it necessary to install drainage in the wound.

The proposed method of myoplasty (prevention of lymphorrhea) after breast cancer surgery provides the following advantages:

1) easy to perform and does not require special surgical skills;

2) significantly reduces the formation of lymph in the surgical wound, due to the absence of the surgical cavity and gluing of the crossed lymphatic vessels with the Tachocomb collagen sponge, which implies wound management by a drainless method;

3) resorption of the lymph is carried out by local tissues, and preservation of the fascia of the latissimus dorsi does not lead to the formation of postoperative hematomas and exudate;

4) the lack of fixation of the latissimus dorsi muscle to the pectoralis major and minor muscles ensures their smooth gliding during contraction, which does not impair movement in the shoulder joint;

5) reduces the postoperative bed-day and the total hospital stay from 21 to 12-14 days;

6) reduces the consumption of dressings;

7) significantly improves the quality of life of women after cancer surgery on the mammary gland.

Claims (1)

A method of myoplasty after oncoplastic operations on the mammary gland, including subcutaneous removal of breast tissue with a tumor, subclavian-axillary-subscapular lymphadenectomy, closure of the axillary neurovascular bundle with a collagen plate superimposed in the form of a rhombus so that the axis of symmetry of the rhombus is directed along the axillary vascular nerve bundle, mainly along the axillary vein with the proximal end of the rhombus under the pectoralis minor muscle, closure of the neurovascular bundle and adjacent fiber to it from above and below by angles opposite the rhombus axis of symmetry, simultaneous myoplasty with the lateral edge of the latissimus dorsi with its fascia to the anterior dentate muscle and layered suturing of the wound, characterized in that two collagen plates are used to close the neurovascular bundle, the first is laid proximal to the axillary neurovascular bundle, the second distally overlap the first, and the lateral edge of the latissimus dorsi muscle is sutured to the anterior dentate muscle with a continuous double-row twisted a suture, after which the lateral lower skin-fat flap of the chest wall is fixed with three interrupted sutures to the lower surface of the lateral edge of the pectoralis major muscle and the wound is maintained in the postoperative period without drainage.

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