RU2610828C1 - Method of pharynx defect plastic repair - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to the medicine, surgery. At the first stage, a thoracodorsal musculocutaneous flap is formed. A perforated cutaneous flap is prepared and sewn on the thoracodorsal one. At the second stage, after 10 days, a tunnel in the subcutaneous fat is made. The flap on a vascular pedicle is brought through the tunnel in the subcutaneous fat from the underarm area. The flap is sewn on the pharynx defect edges.

EFFECT: method of covering of the pharynx defect with the musculocutaneous flap protected by skin from both sides provides adequate blood supply of the formed flap, reducing of the injury rate of the operation, improvement of cosmetic result, reduction of frequency of complications, flap infection and necrosis during the pharynx defect plastic repair in patients radically operated in terms of malignant tumors of the pharynx, larynx, and cervical esophagus.

1 ex, 13 dwg

Description

The invention relates to medicine, namely to surgery, and can be used when performing plastic surgery of a pharyngeal defect in patients radically operated on for malignant formations of the pharynx, larynx, and cervical esophagus.

The elimination of pharyngeal defects after radical surgery for malignant formations of the larynx, pharynx and cervical esophagus requires compensation for the lack of tissue in the mucous and muscular membranes of the pharynx, as well as the defect of the external integument. To achieve this goal, various methods of plasty using local tissues, skin-fascial and muscle-skin flaps on the feeding leg from the chest or lateral surface of the neck, Filatov stalk, a combination of muscle-skin rags on the feeding leg with cleavage of the skin graft are used (Nerobeev A.I. Plastic surgery of defects in the head and neck. // Surgery. - 1982. - No. 11. - P. 68-71 .; AI Nerobeev. Plastic closure of extensive defects of the pharynx and neck of the esophagus with skin-fat and muscular-skin flaps with axial blood circulation. // Bulletin of otorino Laryngology. - 1982. - No. 3. - P. 47-51 .; Nerobeev AI Microsurgical autotransplantation of a skin-fat flap from the scapular region on the head and neck. // Problems of microsurgery. - M. - 1985. - P. 40-41).

The disadvantages of the above methods include their multi-stage, trauma, the risk of infectious complications, low efficiency in patients undergoing radiation therapy, as well as a long postoperative period.

The closest analogue of the claimed method for plastic surgery of the pharyngeal defect after radical surgical treatment for malignant neoplasms of the larynx, pharynx and cervical esophagus is the method of plasticity of the pharyngeal defect by creating an internal and external lining using a graft from a complex flap containing skin, subcutaneous fat and pectoralis major muscle , the inner surface of which is covered with a deep plate of its own fascia of the pectoralis major muscle, which serves as the inner lining of the head TKI (RF patent №2008805, publication date 15.02.1994 years).

The disadvantages of this method are the long period of epithelization of the musculoskeletal flap, since its inner surface facing the side of the pharyngeal cavity remains not covered by the epithelial structure, which requires additional plastic surgery to close the inner surface of the musculoskeletal flap; unsatisfactory cosmetic results, the difficulty of ensuring adequate blood supply to the formed flap, a large invasiveness.

The technical result of the invention is the closure of a pharyngeal defect with a combined combined musculocutaneous flap protected on both sides by the skin, ensuring adequate blood supply to the formed flap, reducing the invasiveness of the operation, improving cosmetic results, reducing the frequency of complications such as infection and necrosis of the formed flap.

The specified technical result is achieved by the fact that in the method of plasticity of the pharyngeal defect in patients radically operated on for malignant formations of the pharynx, larynx and cervical esophagus, including the formation of the shape and size of the defect of the musculoskeletal flap on the vascular feeding leg, the formation of a tunnel in the subcutaneous fat cellulose from the axillary region to the supraclavicular region to conduct the formed flap from the place of formation to the pharyngeal defect through the tunnel in the subcutaneous fat, odshivanie flap is formed to the edges of existing defect, according to the invention, the operation is carried out in two stages:

at the first stage, a skin flap is formed on the anterior abdominal wall, it is cleaned from subcutaneous fat and perforated, then in the thoracodorsal region a combined skin-muscle flap is formed corresponding to the size of the pharyngeal defect, including skin with subcutaneous fat and the latissimus dorsi, to its internal surfaces hem the previously formed perforated skin flap freed from subcutaneous fat; at the second stage, a diagonally oriented tunnel in the subcutaneous fatty tissue is formed, a combined thoracodorsal flap on the vascular feeding leg is cut off from the latissimus dorsi muscle immediately after the vessels depart, pass through the subcutaneous tunnel above the pectoralis major muscle and sutured to the previously separated edges of the pharyngeal defect.

An advantage of the claimed method for throat defect plasty is the coating of the thoracodorsal flap on the inside of the skin, which eliminates the subsequent stages of the operation aimed at covering the inner surface of the newly formed pharynx, and eliminates the cosmetic consequences of surgery.

Compared with the closest analogue, where the epithelization period of the inner surface of the flap takes 2 months, the proposed method does not require additional epithelization and the term of complete healing is no more than 20 days.

The proposed method was operated on 3 people.

The method is illustrated in FIG. 1-9, where the steps of the operation are presented:

In FIG. 1 shows the formation of a preform for a combined muscular cutaneous thoracodorsal flap;

In Fig 2 - sewing free perforated skin flap on the inner surface of the workpiece of the skin-muscle thoracodorsal flap:

In FIG. 3 - marking the skin incision in the direction from the formed (combined) muscle-skin thoracodorsal flap to the armpit;

In FIG. 4 - cutting out of the thoracodorsal flap with the release of the thoracodorsal artery and vein;

In FIG. 5 - the formation of a thoracodorsal flap on the vascular pedicle;

In FIG. 6 - performing a skin incision along the sternocleidomastoid near an existing pharyngeal defect;

In FIG. 7 - the formation of a subcutaneous tunnel in the direction from the armpit to the supraclavicular region;

In FIG. 8 - holding a flap on the neck through the subcutaneous tunnel;

In FIG. 9 - suturing of the thoracodorsal flap to the edges of the pharyngeal defect;

In FIG. 10 shows a view of a patient before starting treatment using the claimed method for laryngeal defect plasty;

In FIG. 11 is a view of the formed thoracodorsal flap after the first stage of the operation;

In FIG. 12 is a view of the patient after the second stage of the operation.

The method is as follows.

At the first stage, a fusiform skin incision is made in the region of the anterior abdominal wall, skin flaps are separated, separated from subcutaneous adipose tissue, perforated are obtained free skin flaps. The skin and subcutaneous fatty tissue of the resulting defect of the anterior abdominal wall are sutured in layers. In the thoracodorsal region, a second fusiform skin incision is performed and a thoracodorsal flap consisting of skin, subcutaneous adipose tissue and latissimus dorsi muscle is separated (Fig. 1). To the inner surface of the latissimus dorsi muscle, which is part of the thoracodorsal flap, a previously formed free (freed from subcutaneous fat) perforated skin flap from the anterior abdominal wall is sutured (Fig. 2). The wound of the thoracodorsal region is tightly plugged with gauze balls in order to provide conditions for the flaps to grow together. Thus, the result of the first stage of the operation is the formation of a combined thoracodorsal flap covered on both sides with skin.

Ten days later, the second stage of reconstructive plastic surgery is performed. A skin incision is performed along the latissimus dorsi muscle from the combined thoracodorsal flap formed at the first stage of the operation to the armpit (Fig. 3). The thoracodorsal artery and vein are secreted in the armpit, the subscapular artery, the branches extending to the anterior dentate muscle are ligated. The lateral part of the latissimus dorsi muscle is separated from the anterior dentate muscle to provide better access to the thoracodorsal artery and vein (Fig. 4, 5). In the subcutaneous fatty tissue, above the pectoralis major muscle, in the diagonal direction, from the incision in the axillary cavity to the subclavian region, a tunnel is formed (Fig. 7), through which the formed combined thoracodorsal flap on the vascular pedicle is carried out and out through the skin incision on the neck, made along sternocleidomastoid muscle next to an existing pharyngeal defect (Fig. 8). Skin flaps around the pharyngeal defect are separated and sutured to the combined thoracodorsal flap through a subcutaneous tunnel (Fig. 9). Thus, an existing pharyngeal defect on the outside and inside turns out to be covered by skin.

The method is illustrated by the following clinical example (Fig. 10, 11, 12).

Example. Patient R., 57 years old, was admitted as planned with a diagnosis of laryngeal cancer. Condition after combined treatment. Condition after extended laryngectomy with plastic formation of a tracheostomy. Condition after the formation of oropharyngostomy. Complaints about the presence of a tracheostomy, the inability to take food through the mouth.

Inspection: general condition is satisfactory. The position is active. Consciousness is clear. The skin and visible mucous membranes are clean, pale pink. Body temperature 36.6 ° C. With comparative percussion of the lungs, the percussion sound is clear pulmonary. Hard breathing in the lungs, no wheezing. Hemodynamics is stable. The pulse is rhythmic, with a frequency of 70 per minute of satisfactory filling and tension. Blood pressure 140/90 mm Hg The tongue is wet, clean. The abdomen is symmetrical, actively participates in the act of breathing. With superficial palpation, soft, painless. Symptoms of peritoneal irritation are negative. Lumbar region unchanged. The chair is regular, decorated. Diuresis is adequate.

Local status: an oropharyngostomy is visualized on the neck. It is functioning. The surrounding skin is clean, with no signs of inflammation. Tracheostomy opening without signs of stenosis, the surrounding skin is clean. Lymph nodes of the neck are not enlarged, painless.

The patient was offered two-stage surgical treatment according to the claimed method.

At stage 1, a fusiform skin incision was made in the region of the anterior abdominal wall on the left. Skin flaps are separated. The flap is cleaned from subcutaneous fat. Hemostasis. Subcutaneous fat is sutured with Vicril 3.0 leaving a single drainage vacuum. The skin is sutured Vicril 3.0., Treatment of wounds with an antiseptic. To form a musculocutaneous flap in the thoracodorsal region, a spindle-shaped skin incision was made on the right. Skin flaps along with subcutaneous fatty tissue, latissimus dorsi muscle are separated. Subcutaneous fatty tissue is sutured to the muscle. The branches of the sterno-dorsal artery that feed the formed flap are highlighted. A previously prepared perforated skin flap is hemmed to the inner surface of the formed thoracodorsal flap. To improve the healing of the skin flap, the wound is plugged with gauze balls. A drainage is installed in the postoperative wound. Hemostasis. The wound was sutured in layers leaving a vacuum drainage.

After 10 days, the patient completed the second stage of surgical treatment.

A skin incision was made along the latissimus dorsi muscle from the formed combined thoracodorsal flap to the armpit. The formed thoracodorsal flap is partially cut off along with the muscle bundle. Separated the lateral part of the latissimus dorsi from the anterior dentate muscle. A vascular pedicle (thoracodorsal artery and vein) is isolated in the axillary fossa. The subscapular artery, branches to the anterior dentate muscle are bandaged, stitched and crossed. A vascular bundle was isolated. The flap is completely cut off from the latissimus dorsi muscle immediately after the passage of the vessels. A tunnel was formed towards the right clavicle diagonally in the subcutaneous fat over the pectoralis major muscle. A longitudinal skin incision was made on the right neck parallel to the right sternocleidomastoid muscle to the orostomy, connected subcutaneously to the tunnel on the chest. Skin flaps are separated. The harvested flap was passed through the tunnel over the pectoralis major muscle, and was brought to the neck. The orostomy was sutured by suturing the skin flap on the vascular pedicle to the hole formed in the orostomy region. Skin flaps on the neck are sewn to a previously prepared skin flap. Postoperative wounds were sutured leaving three vacuum drains. Hemostasis.

The patient was discharged in satisfactory condition after 10 days.

The proposed method was operated on 3 patients with a satisfactory result.

The proposed method allows for the closure of a pharyngeal defect with a combined combined musculocutaneous flap protected on both sides by the skin, to provide adequate blood supply to the formed flap, reduce the invasiveness of the operation, improve the cosmetic result, and reduce the frequency of complications, such as infection and necrosis of the formed flap.

Claims (3)

A method for plasty of a pharyngeal defect in patients radically operated on for malignant formations of the pharynx, larynx and cervical esophagus, including the formation of a musculocutaneous flap on the vascular feeding leg in the shape and size of the defect, the formation of a tunnel in the subcutaneous fat from the axillary region to the supraclavicular region for conducting the formed flap from the place of formation to the pharyngeal defect through the tunnel in the subcutaneous fat, stitching the formed flap to the edges of the existing Fecteau, characterized in that the operation is carried out in two stages: at the first stage, a skin flap is formed on the anterior abdominal wall, it is cleaned from subcutaneous fat and perforated, then in the thoracodorsal region a combined skin-muscle flap is formed corresponding to the size of the pharyngeal defect, including skin with subcutaneous fat and the latissimus dorsi, to its internal surfaces hem the previously formed perforated skin flap freed from subcutaneous fat; at the second stage, a diagonally oriented tunnel in the subcutaneous fatty tissue is formed, a combined thoracodorsal flap on the vascular feeding leg is cut off from the latissimus dorsi muscle immediately after the vessels depart, pass through the subcutaneous tunnel above the pectoralis major muscle and sutured to the previously separated edges of the pharyngeal defect.

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