RU2632529C1 - Method of reconstruction of larynx - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: laryngostomy lining is formed due to the inner surface of the pre-thyroid muscles, which are covered by the locally displaced mucosa from the side of the laryngeal lumen. A stent-obturator with an irrigation system is installed in the laryngeal lumen. For its production the following is used: a fragment of foam rubber with a volume corresponding to the laryngeal lumen, a subclavian catheter with an internal diameter of 1.4 mm and length of 18 centimeters, fingertip or finger from glove rubber, suture material. Perforations are made with scissors in the subclavian catheter. The foam component is stitched with a catheter and folded so that the curved knee of the subclavian catheter does not rest against the walls of the obturator. Next, pack into the finger of a rubber glove or fingertip, leaving the end of the catheter from the outside. Then, the front wall of the larynx is formed. In this case, a wavy seam is applied from the top down, alternately picking up the edges of the preteroid muscles of each of the opposite sides to the lower edge of the operating defect. In the same way leading the seam up to the place of the first injection on the opposite side of the wound.

EFFECT: method allows to achieve reconstruction of the laryngeal lumen with a functionally sufficient volume, to reduce the number of postoperative complications due to mobilization of the anterior neck muscles sewn longitudinally by the longitudinal continuous suture and by using the stent with the irrigation system.

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Description

The invention relates to medicine, in particular otolaryngology, and can be used for resection of the larynx in oncopathology, with traumatic injuries of the larynx, postoperative stenosis of the larynx, to restore its lumen and respiratory function.

A known method of surgical restoration of the function of the larynx using its resection and subsequent heterogeneous plasty with local tissues (A.V. Kozlova et al., 1979, M., Medicine). It consists in the following: a resection of the affected larynx fragment within healthy tissues is performed. The resulting organ defect is not immediately tightly sutured, since this is fraught with the development of cicatricial narrowing of the lumen of the larynx, therefore, a planned laryngostomy is formed. Restoration of the lumen of the larynx and plastic closure of the laryngostomy with local tissues is performed on average 3-4 months after a radical operation. In some patients, in case of suppuration of the wound and the formation of laryngeal fistulas, the restoration of the lumen of the larynx requires several stages of surgical intervention. Currently, this method is unacceptable.

Currently, not only the radical removal of the tumor, but also the simultaneous restoration of the physiological functions of the operated organ is considered the “gold standard” of organ-preserving surgery for laryngeal cancer.

Reconstruction of the lumen of the larynx in the presence of scar-changed tissues around the laryngostomy is a difficult task.

Hair growth inside the lumen of the larynx when using the skin as a plastic material to close the laryngostomy significantly reduces the effectiveness of rehabilitation.

The prototype is a larynx reconstruction method that facilitates the rehabilitation of larynx function and the prevention of postoperative stenosis (RF Patent No. 2137430 dated February 11, 1998). This technical result is obtained as follows. The patient is given intubation anesthesia either through a previously applied tracheostomy, or issued during the operation. The larynx and upper part of the trachea are exposed, not only the larynx is resected, but also, according to indications, the trachea. Next, a polymer biocompatible prosthesis is installed in the larynx and trachea, having the form of a hollow cylinder with an internal lumen of 10-12 mm, the front muscles of the neck are sutured, the fastening threads of the prosthesis are brought out through the soft tissues of the neck to its front-side surface and fixed to the latter with the help of fixators. Use the serial polymer endoprosthesis EG-1, 2, 3, 4, TU 42-2-467-85, developed in NShNT. The patient's breathing in the postoperative period is through the inner lumen. The disadvantages of this method, preventing the achievement of the following therapeutic effect, are:

- the threat of emphysema in the early postoperative period and the infection of surrounding tissues due to the mismatch between the diameter of the endoprosthesis and the lumen of the reconstructed larynx and with the patient re-intubation into the prosthesis;

- the threat of asphyxia when filling the lumen of the prosthesis with blood or sputum;

- the complication of anesthetic management and postoperative care.

To eliminate these drawbacks, we propose a method for reconstruction of the larynx after resection, which consists in the formation of a lining of the laryngostomy due to the inner surface of the prethyroid muscles, which cover the locally displaced mucosa from the lumen of the larynx, and then a stent-obturator with irrigation is installed in the lumen of the larynx system for the manufacture of which the following materials are used: a fragment of foam rubber with a volume corresponding to the lumen of the larynx, a subclavian catheter with an internal diameter trom 1.4 mm, 18 cm long, fingertip or finger from glove rubber, suture material, make perforations in the subclavian catheter with scissors, the foam component is stitched with a catheter, then folded so that the curved knees of the subclavian catheter do not rest against the walls of the obturator and are packaged in finger of a rubber glove or fingertip, leaving the end of the catheter outside.

The technical result of the invention is the reconstruction of the lumen of the larynx with a functionally sufficient volume, and the relief of respiratory function is achieved by mobilizing the front muscles of the neck, sutured in the longitudinal direction by a longitudinal continuous suture, and the prevention of wound complications and the restoration of functionally sufficient lumen of the organ is achieved through the use of rubber-foam stent-obturator (Fig. 1), equipped with an irrigation system, formed so as to perform as iratsiyu exudate and deliver drugs in the operated area in the postoperative period, thereby preventing the threat of asphyxia and preventing the development of complications associated with infection of the wound surface. A stent-obturator is used as a support for the formation of the larynx.

The method is as follows. Under general anesthesia, a resection of the larynx is performed through a tracheostomy. Reconstruction of the larynx is carried out by forming the lining of the laryngostomy due to the inner surface of the prethyroid muscles, in particular the thyroid hyoid muscle, which is covered by a locally displaced mucosa from the lumen of the larynx. Establish a nasogastric tube. A stent obturator with an irrigation system is installed in the lumen of the larynx (the patient’s respiration in the postoperative period is through the tracheostomy). For the manufacture of a stent-obturator with an irrigation system, the following materials are used: a foam rubber fragment with a volume corresponding to the lumen of the larynx, a single-use subclavian catheter, sterile, Luer, with an inner diameter of 1.4 mm, TU-64-3-15-115-86 , 18 cm long, fingertip or finger of a rubber glove, suture material. Previously, perforations are made in the catheter with scissors to aspirate the exudate and introduce drugs into the stent in the postoperative period. The foam component is flashed with a subclavian catheter, then rolled so that the bent knees of the subclavian catheter do not rest against the walls of the obturator and are packed in a finger of a rubber glove or fingertip, leaving the end of the catheter externally 6-8 cm long, then ligatures are made to fix the stent-obturator to the skin neck of the patient in the middle and lower parts. Then the front wall of the larynx is formed as follows: with a needle with an atraumatic thread of vicryl or prolene, a wavy seam is applied from top to bottom, alternately grabbing the free edges of the prethyroid muscles from top to bottom to the edge of the defect and thus leading the seam up to the site of the first injection. They make sure of the tightness of the latter and impose a knot on the ligatures. The wound is sutured in layers, leaving for 2-3 days aspiration drainage. Apply an aseptic dressing. Install the Portex tracheostomy tube with an inflatable cuff No. 8.5 or 9.0. Removal of the stent-obturator from the lumen of the larynx is performed on day 14 in the postoperative period with the formed lumen of the larynx.

An example of a specific implementation.

Patient K., 58 years old. Diagnosis: laryngeal cancer T3N0M0. Histological conclusion: moderately differentiated cancer. Upon admission to the hospital: a tumor of a mixed nature of growth, spreading to the posterior two-thirds of the vocal fold and scyphoid cartilage with limited mobility of the left half of the larynx. 04/29/09, an operation was performed in the volume of fronto-lateral resection of the larynx on the left with the removal of 3/4 of the plate of the thyroid cartilage with the underlying tissues with the preliminary application of a tracheostomy. Next, the inner lining of the laryngostomy is formed due to the inner surface of the prethyroid muscles, in particular the thyroid gland muscle, which cover the place of the displaced mucosa from the mucosa of the larynx lumen. Establish a nasogastric tube. For installation in the larynx, a stent-obturator is made - a rubber balloon filled with foam and impregnated with dioxidine and perforated with a reinforced catheter with an irrigation system. A fragment of foam is taken, which is congruent with the lumen of the reconstructed larynx and perforated with a subclavian catheter. Previously, perforations are applied in the catheter to bring the drugs to the wound surface. With tweezers, the stitched foam rubber is rolled into a tube so that the bent knee of the subclavian catheter does not rest against the walls of the obturator and is placed in a finger from a rubber glove or fingertip. The stent-obturator in the middle part is pulled by ligatures, with which the latter is attached to the lateral surface of the skin of the neck, and through the tracheostomy to the front surface of the neck to ensure mobilization. After this, the stent is perforated and 1% solution of dioxidine is introduced until a solution appears on its surface.

Then form the front wall of the larynx as follows. A needle with an atraumatic vicryl thread is applied from top to bottom a wavy seam to the edge of the defect, alternately grabbing the edges of the prethyroid muscles of each of the opposite sides to the lower edge of the surgical defect and in the same way lead the seam up to the site of the first injection on the opposite side of the wound. Achieve tightness of the wound by pulling the ligatures and impose a node. The wound is tightly sutured with a suction drainage of 2 days. A stent-obturator is installed in the lumen of the larynx and fixed to the lateral and front surface of the neck. A Portex tracheostomy tube No. 8.5 was inserted into the tracheostomy. In the postoperative period after 7 days, 1% solution of 10 ml of dioxidine was supplied to the wound surface through an irrigation system. On day 14, a stent-obturator with an irrigation system was removed from the lumen of the larynx, as well as a nasogastric tube. With control laryngoscopy, the larynx is free for breathing.

The proposed method operated on 20 patients. The postoperative period was uneventful, with control laryngoscopy they observed restoration of the lumen of the larynx, restoration of the protective and speech function of the larynx, followed by decanulation after 1 month. The use of the claimed invention in medical practice allows reconstruction of the larynx after resection of the larynx. The claimed method allows to achieve the restoration of functionally sufficient volume and shape of the organ, and also allows you to restore the continuity of the airways, mucous membrane of the larynx and voice function after resection of this organ.

Claims (1)

The method of reconstruction of the larynx after resection, which consists in the formation of the lining of the laryngostomy due to the inner surface of the prethyroid muscles, which cover the locally displaced mucosa from the lumen of the larynx, then a stent-obturator with an irrigation system is installed in the larynx, for the manufacture of which the following are used materials: a fragment of foam rubber with a volume corresponding to the lumen of the larynx, a subclavian catheter with an internal diameter of 1.4 mm, a length of 18 cm, a fingertip or finger from the pepper of rubber, suture material, make perforations in the subclavian catheter with scissors, the foam component is flashed with a catheter, then rolled so that the curved knees of the subclavian catheter do not rest against the walls of the obturator and are wrapped in a finger of a rubber glove or fingertip, leaving the end of the catheter outside, then form the front the wall of the larynx, while applying a wave-like suture from top to bottom, alternately picking up the edges of the prethyroid muscles of each of the opposite sides to the lower edge of the surgical defect one and the same seam lead upwards to the place of the first puncture on the opposite side of the wound.

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