RU2625283C1 - Method of surgical access to structures of lateral department of neck - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: perform a linear incision of the skin in the nasal part of the occipital region from the projection of the condylar fossa of the occipital bone down and proximal to the midline of the neck along the hair growth line. Dissect the subcutaneous fat, the superficial fascia, the surface plate of the fascia and the fibers of the trapezius muscle. The lateral portion of the fibers of the ascending part of the trapezius muscle is withdrawn upwards. A small occipital nerve is excreted, prepared and taken to the upper corner of the wound. In the upper parts of the scapula-clavicular triangle, the necks produce dissection over the deep plate of the fascia. Under the control of a rigid endoscope, a tunnel is formed parallel to the line of projection of the edge of the body of the lower jaw. They reveal the fascial vagina of the sternocleidomastoid muscle. Perform a fascial submuscular dissection and lift up the sternocleidomastoid muscle. Taking down the internal jugular vein. Then continue to access the lateral cyst, or the lower pole of the parotid salivary gland, or submandibular salivary gland.

EFFECT: reduction of traumatism, reduction of risk of damage to the marginal branch of the facial nerve, large ear nerve, reduction in the risk of hematoma formation, gray.

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Description

The invention relates to medicine, namely to maxillofacial surgery, and can be used to perform surgical access to the structures of the lateral neck.

Surgical interventions for various pathological conditions of the organs of the lateral neck, such as lateral cysts, pathological conditions and benign neoplasms of the submandibular salivary gland, benign neoplasms of the lower pole of the parotid salivary gland, pathological conditions of the lymph nodes, require improved methods of surgical access to the structures of the lateral neck.

There is a method of surgical access to the structures of the lateral neck, in which a transverse incision is made with a length of not more than 2.0 cm along the natural cervical fold, followed by layer-by-layer dissection of tissues and endovideo-associated dissection for removal of lateral cysts and submandibular salivary glands, correction of torticollis (J O Guerrissi Innovation and surgical techniques: endoscopic resection of cervical branchiogenic cysts. J Craniofac Surg. 2002 May; 13 (3): 478-82).

The main disadvantage of this method is the scar, although smaller, but undesirable in patients with a predisposition to the formation of keloid scars. When performing operative access in this way, regional trauma to the skin wound as a result of retraction leads to regional ischemia, which increases the risks of the formation of a pathological scar.

There is a method of surgical access to the structures of the lateral neck, in which, under the control of the endoscope, a subfascial tunnel is formed under the subcutaneous muscle of the neck from the armpit to the upper third of the side surface of the neck (Ming J, Fan Z, Gong Y, Yuan Q, Zhong L, Fan L Endoscopic excision of branchial cleft cyst in the neck using mammary areolae and axilla approach: a case report. Surg Laparosc Endosc Percutan Tech. 2012 Oct; 22 (5): e284-7).

This method is technically complex and time consuming. Intraoperatively, there are risks of skin damage, since the tunnel is often formed under a very thin layer of subcutaneous fat. Due to the long length of the tunnel, technical difficulties arise related to the visualization and dissection of the neoplasm, and the accuracy of surgical procedures. During dissection, the neurovascular bundle of the neck can be damaged. In a long and narrow wound channel (tunnel), it is extremely difficult to perform adequate hemostasis. In addition, in the early postoperative period, one has to deal with intra- and subdermal scars along the tunnel; there is a high probability of the formation of subcutaneous emphysema, seroma in places of detachment.

A known method of surgical access to the structures of the lateral neck, in which an incision is made in the behind-the-ear area and in the area of the scalp. Skin flap is detached in the behind-the-ear area under a very thin layer of skin, and then subplatmically (Brad LeBert, Sean R Weiss, Jonas T Johnson, Rohan R Walvekar, Retroauricular Hairline Approach for Excision of Second Branchial Cleft Cysts, International Journal of Head and Neck Surgery , 2011, January-April, Volumn: 2, Number: 1, Pages: 75, Pages No: 49-52).

The disadvantage of this method is the high morbidity associated with the vast area of the detachment of skin and subplatismal flaps. Complications are possible, such as the occurrence of hematomas, seromas, marginal ischemia of the flap in the behind-the-ear region, damage to the marginal branch of the facial nerve, and damage to the large ear nerve.

The technical result of the invention is the reduction of intraoperative trauma, the duration of surgical intervention, the improvement of functional and aesthetic results.

The specified technical result is achieved in the method of surgical access to the structures of the lateral neck, according to which a linear skin incision is made in the scalp from the projection of the condylar fossa of the occipital bone downward and proximal to the midline of the neck along the hairline, cut subcutaneous fat, superficial fascia, the surface plate of the own fascia and trapezius muscle fibers, then the lateral portion of the fibers of the ascending part of the trapezius muscle is brought up, highlighting t, the small occipital nerve is dissected and removed to the area of the upper corner of the wound, in the upper sections of the scapular-clavicular triangle of the neck, dissection is performed over the deep plate of the own fascia, under the control of the rigid endoscope, a tunnel is formed parallel to the projection line of the edge of the lower jaw body, the fascial-clavicular fagina is opened -mastoid muscle, perform fascial submuscular dissection and lift up the sternocleidomastoid muscle, retract the internal jugular vein and

with a lateral cyst of the neck, fascial dissection is performed between the front edge and the lower surface of the sternocleidomastoid muscle and the distal-outer surface of the internal jugular vein and the lateral cyst is visualized,

in pathological conditions of the lower pole of the parotid salivary gland, tunnel dissection is continued in the carotid triangle in the same direction until the lymph nodes and the lower pole of the parotid salivary gland are visualized,

in benign neoplasms and pathological conditions of the submandibular gland, tunnel dissection continues over the posterior abdomen of the bibdomous muscle in the submandibular triangle until the submandibular salivary gland is visualized.

Performing an incision in the scalp allows you to hide the postoperative scar, get a cosmetic effect and observe anatomical landmarks when forming a tunnel access.

The formation of a submuscular tunnel helps to prevent the formation of intra- and subdermal cicatricial cords along the tunnel, resulting from excessive skin tension during retraction.

The implementation of the incision of the proposed method eliminates the scar in the functionally and aesthetically significant area. When performing the method, the fibers of the subcutaneous muscle of the neck are not cut, which eliminates the raising of the angle of the mouth.

The formation of a submuscular tunnel, taking into account the anatomical structures, allows minimizing the trauma of dissection: avoiding extensive subplatmal detachment and the formation of a multilayer scar. During the operation, the tissue of the triangles of the neck is preserved and the postoperative defect and deformation are not formed, the marginal trauma of the wound is minimized, there are no paresis of the facial muscles, hematomas, sulfur and emphysema in the postoperative period, due to which high functional and aesthetic results are achieved.

In FIG. 1 is a diagram of access formation.

The method is carried out, for example, as follows.

Under endotracheal anesthesia in the patient’s position on the back with the head turned to the side opposite to the side of the surgical intervention, the occipital region and lateral surface of the neck are infiltrated with an epinephrine solution of 1: 200000; make a linear incision of the skin in the occipital region from the projection of the condylar fossa of the occipital bone 1 — the lateral (mastoid) edge of the lower excavation line, the elevation of the external occipital protuberance — and then down and proximal to the midline of the neck, along the hairline or departing from it; the length of the cut corresponds to the width of the retractor. Subcutaneous fatty tissue, superficial fascia, and superficial fascia lamina are dissected deep into the exact cut line described below. After dissection of the latter, trapezius muscle 2 fibers are visualized. Using a retractor, a lateral portion of the fibers of the ascending part of the trapezius muscle is brought up, as a result of which wounds are found at the bottom of the wound. fibers of the belt muscle of the head 3, covered with a deep plate of the own fascia of the neck. When the upper wall of the tunnel is abducted, a small occipital nerve is found in the region of the upper (outflow) wound edge, which confirms the correctness of the chosen dissection layer. The nerve is secreted, dissected and removed to the area of the upper corner of the wound. Further, in the upper sections of the scapular-clavicular triangle of the neck 4, detachment is performed supra-facies above the deep plate of the neck’s own fascia using the tunnel method under the control of a rigid endoscope 0 °, 30 °, 10 mm in diameter. The tunnel vector is directed parallel to the projection line of the lower jaw body edge. Further, in the tunnel wound, the posterior edge of the sternocleidomastoid muscle 5 is found in the region of its upper third. Open the vagina of the sternocleidomastoid muscle 5 and with the help of a retractor lift it up. In the wound, the internal jugular vein is visualized. In this case, lymph nodes accompanying the neurovascular bundle can also be visualized. The sheath of the neoplasm 6 - the lateral cyst of the neck - is found in the carotid triangle of the neck when performing fascial dissection between the front edge and the lower surface of the sternocleidomastoid muscle 5 and the distal outer surface of the internal jugular vein. It is advisable to perform a partial aspiration of the contents of the cyst before performing dissection of its shell.

In pathological conditions of the lower pole of the parotid gland, tunnel dissection is continued in the carotid triangle. After visualization of the internal jugular vein, the tunnel continues forward in the same direction; the sternocleidomastoid muscle is retracted upward, and the neurovascular bundle remains at the bottom of the wound. The maxillary vein (common facial vein) is visualized in the wound. A vein is ligated or clipped.

With continued dissection in the indicated direction, lymph nodes and the lower pole of the parotid salivary gland are found in the upper outer wound. Its dissection can be performed intra- and supracapsularly. The proposed access allows you to sufficiently visualize the lower pole of the parotid salivary gland and, accordingly, remove the pathological neoplasms located in it.

When passing over the posterior abdomen of the double-abdominal muscle in the submandibular triangle, the submandibular salivary gland is found. Isolation of the gland is produced from the posterior pole, while intra- and supracapsular dissection options are also possible; Facial artery and anterior facial vein, excretory duct of the gland are ligated.

The achievement of the technical result is confirmed by clinical examples.

Example 1. Patient G., 48 years old, was admitted with complaints of swelling in the upper third of the lateral surface of the neck on the left. According to ultrasound: under the superficial fascia, hypoechoic is noted, with clear contours with a heterogeneous (fine-grained) content, the cystic formation is 4.81 × 2.02 × 4.68 cm in size.

An operation was performed using the proposed surgical access. Under endotracheal anesthesia with intubation through the mouth, infiltration of the occipital region on the left, lateral surface of the neck on the left, a linear incision was made in the occipital region on the left, up to 7.0 cm long (from the projection of the condylar fossa of the occipital bone, and then down and proximal, parallel to the hairline and departing from her 1.5 cm). Subcutaneous adipose tissue, superficial fascia, and superficial fascia lamina are dissected deep into the exact cut line just below the cut line. After dissection of the latter, trapezius muscle fibers are visualized. A small occipital nerve was found in the region of the upper (“outflow”) wound edge, the nerve was isolated, dissected, and diverted to the region of the upper corner of the wound. Further, in the upper sections of the scapular-clavicular triangle of the neck, detachment was performed supra-facies above the deep plate of the neck’s own fascia by the tunnel method under the control of a rigid endoscope 30 °, 10 mm in diameter. The tunnel vector is directed parallel to the projection line of the lower jaw body edge. A tunnel was formed, the vagina of the sternocleidomastoid muscle was opened in the region of its upper third. With the help of a retractor, the sternocleidomastos is retracted upward. The neurovascular bundle (internal jugular vein) is visualized. Dissection of the inner surface of the vaginal bundle was performed; a neoplasm is visualized in a gray-yellow shell with an even, clear outline. An ultrasound study was performed intraoperatively. In a dull and sharp way, with the help of a dissector, the neoplasm is isolated and removed. Wound healing by primary intention, sutures were removed on the 8th day. Pathomorphological conclusion: lateral cyst of the neck.

Example 2. Patient Ch., 27 years old, was admitted with complaints of swelling in the submandibular region on the right. According to ultrasound, a neoplasm with a clear contour of 19.4 × 20.2 mm, located under the capsule of the submandibular salivary gland on the right, is determined by a hypoechoic homogeneous structure.

An operation was performed using the proposed access. A linear incision was made in the occipital region to the right of the projection of the condylar fossa of the occipital bone, and further down and proximal, parallel to the hairline and departing from it 1.5 cm, the length of the incision was 8.0 cm. Then, deep into the exact cut line described, cut subcutaneously fatty tissue, superficial fascia, superficial lamina of the own fascia, after dissection of the latter, trapezius muscle fibers are visualized. Using a retractor, the lateral portion of the fibers of the ascending portion of the trapezius muscle is retracted upward. At the bottom of the wound, fibers of the head belt muscle were found, covered with a deep plate of the neck’s own fascia. A small occipital nerve was found in the region of the upper (“outflow”) edge of the wound, the nerve was isolated, dissected, and diverted to the region of the upper corner of the wound, then in the upper sections of the scapular-clavicular triangle of the neck, the detachment was performed supra-facially over the deep plate of the own fascia of the neck by the tunnel method endoscope 30 °, diameter 10 mm. The tunnel vector is directed parallel to the projection line of the lower jaw body edge. A tunnel was formed, the vagina of the sternocleidomastoid muscle was opened in the region of its upper third. With the help of a retractor, the sternocleidomastos is retracted upward. The neurovascular bundle (internal jugular vein) is visualized. Dissection of the sheath of the sheath over the internal jugular vein was performed, the neurovascular bundle was diverted to the bottom of the wound. Dissection is continued in the previous layer and direction, the maxillary vein (common facial vein) is visualized; the vein is ligated with an ultrasound instrument, lymph nodes and the lower pole of the parotid salivary gland are found in the upper outer wound; Further, the tunnel was held above the posterior abdomen of the biceps in the submandibular triangle, the submandibular salivary gland was found. A gland with a neoplasm is isolated from the posterior pole supracapsularly; using an ultrasound instrument, the facial artery and the anterior facial vein and the excretory duct of the gland are ligated.

The surgical material is aimed at histological examination. Wound healing by primary intention, sutures were removed on the 8th day. Pathomorphological conclusion: pleomorphic adenoma with a predominance of the chondroid component; tissue fragments of the salivary gland with secretory stasis, small focal fresh hemorrhages; a fragment of fibro-muscular tissue with areas of hyalinization, mild lymph histiocytic infiltration with a small lymph node with nonspecific hyperplasia.

In total, the proposed method performed 15 surgical interventions. In all cases, a high functional and aesthetic result was achieved.

Thus, the proposed method of surgical access to the structures of the lateral neck is a tunic posterior cervical endovideo-associated submuscular access and allows to improve the functional and aesthetic results of endoscopically associated surgical interventions, to avoid postoperative defects and deformations, paresis of facial muscles, hematomas, sulfur and emphysema.

Claims (3)

1. A method of surgical access to the structures of the lateral neck, which consists in performing a linear skin incision in the scalp from the projection of the condylar fossa of the occipital bone downward and proximal to the midline of the neck along the hairline, cut subcutaneous fat, superficial fascia, the surface plate of the own fascia and trapezius muscle fibers, then the lateral portion of the fibers of the ascending part of the trapezius muscle is taken up, isolated, dissected and removed to the area in a small occipital nerve in the upper corner of the wound, in the upper sections of the scapular-clavicular triangle of the neck, a dissection is performed over the deep plate of the own fascia, under the control of the rigid endoscope, a tunnel is formed parallel to the projection line of the lower jaw body edge, the fascial vagina of the sternocleidomastoid muscle is opened, and the fascial submuscular dissection and lift up the sternocleidomastoid muscle, take down the internal jugular vein, perform fascial dissection between the front edge and the lower surface of the sternocleidomastoid muscle and the distal-outer surface of the internal jugular vein and visualize the lateral cyst. 2. A method of surgical access to the structures of the lateral neck, which consists in performing a linear skin incision in the scalp from the projection of the condylar fossa of the occipital bone downward and proximal to the midline of the neck along the hairline, cut subcutaneous fat, superficial fascia, the surface plate of the own fascia and trapezius muscle fibers, then the lateral portion of the fibers of the ascending part of the trapezius muscle is taken up, isolated, dissected and removed to the area in a small occipital nerve in the upper corner of the wound, in the upper sections of the scapular-clavicular triangle of the neck, a dissection is performed over the deep plate of the own fascia, under the control of the rigid endoscope, a tunnel is formed parallel to the projection line of the lower jaw body edge, the fascial vagina of the sternocleidomastoid muscle is opened, and the fascial submuscular dissection and lift up the sternocleidomastoid muscle, divert the internal jugular vein, continue tunnel dissection in the carotid triangle in the previous I take the direction to visualize the lymph nodes and the lower pole of the parotid salivary gland. 3. The method of surgical access to the structures of the lateral neck, which consists in performing a linear skin incision in the scalp from the projection of the condylar fossa of the occipital bone downward and proximal to the midline of the neck along the hairline, dissect subcutaneous fat, superficial fascia, the surface plate of the own fascia and trapezius muscle fibers, then the lateral portion of the fibers of the ascending part of the trapezius muscle is taken up, isolated, dissected and removed to the area in a small occipital nerve in the upper corner of the wound, in the upper sections of the scapular-clavicular triangle of the neck, a dissection is performed over the deep plate of the own fascia, under the control of the rigid endoscope, a tunnel is formed parallel to the projection line of the lower jaw body edge, the fascial vagina of the sternocleidomastoid muscle is opened, and the fascial submuscular dissection and lift up the sternocleidomastoid muscle, take down the internal jugular vein, continue the tunnel dissection above the posterior abdomen biceps muscle in the submandibular triangle to visualize the submandibular salivary gland.

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