RU2681916C1 - Method of defect plastics of tracheo-angled segment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and may be applicable to plastics of defects of the tracheo-angled segment. Arched implant made of Ecoflon material with a thickness of 2 mm is cut out according to the size of the existing defect. Edges of the formed implant are perforated and hemmed with support on the preserved lateral fragments of the semi-rings of the tracheo-angled segment, and the implant is additionally fixed to the inner seam formed from the separated skin. Implant is covered from above with an additionally formed muscle-fascial flap from the surrounding tissue defect.

EFFECT: method allows to reduce the trauma, reduce inflammatory changes.

1 cl, 1 ex, 10 dwg

Description

The invention relates to medicine, namely to otorhinolaryngology and surgery, and is intended for plastics defects of the tracheogortic segment.

The problem of treating chronic cicatricial stenosis of the larynx and cervical trachea is one of the urgent in modern laryngology due to the increase in the number of injuries of the hollow organs of the neck of various etiologies, especially iatrogenic. Unresolved issues of restoring the supporting frame of the respiratory tract, such as the larynx and trachea, with extensive defects of their walls as a result of cicatricial stenosis. Improvement of surgical treatment in recent years is on the path to finding materials that can recreate the lost cartilage frame of the larynx and trachea.

There is a method of plastic surgery of the anterior wall of the larynx and trachea (RU 2456959, A61F 2/20, A61В 17/00, published on July 27, 2012) with a pectoral flap reinforced with a plate of porous titanium nickelide, in which, when forming the flap, an incision is made over the clavicle and a circular submammary incision. The feeding leg of the flap is carried out under the collarbone. In addition, the formed skin-muscle flap is strengthened with a plate of porous titanium nickelide, and it is fixed to the muscular surface of the flap.

Also known from the prior art is a method for replacing traumatic defects of the trachea and larynx (RU 2440789, A61B 17/00, A61B 17/24, published on January 27, 2012), the closest in technical essence and adopted by us as a prototype. The method includes sampling and forming a revascularizable skin-fascial autograft with subsequent stitching of it into the defect with the skin inward with support of the hard component on the front and side walls of the defect, restoration of blood supply in the autograft. Moreover, in the formed autograft the skin part corresponds to the size of the defect. The flap of subcutaneous fat and superficial fascia exceeds it by 5-10 mm. A mesh implant with a cell size of 200-500 microns, protruding beyond the edges of the autograft by at least 10 mm, is placed on the fascial surface of the autograft. The implant is woven from superelastic nickelidotitan yarn with a diameter of 60-90 microns. Moreover, they make a linear incision in the implant and supplement it by cutting a rounded hole to accommodate the vascular pedicle of the autograft. Then, they are fixed through the thickness of tissues to the skin of the autograft with a superelastic nickelidotitanium thread with a diameter of 40-60 microns. Knots are knotted on the surface of the implant. Then the autograft strengthened with a mesh implant is placed in the defect and the autograft skin is fixed to the edges of the defect in the trachea and / or larynx, followed by covering the suture line with autograft tissues. The protruding edge of the mesh implant from the formed autograft is fixed to the walls of the trachea and / or larynx.

The disadvantages of these methods are technical difficulties in the formation of the flap using microvascular technology, as well as the fixation of a nickelidotitan implant in the lumen of the larynx or trachea. The presence of foreign material causes inflammatory changes in the postoperative wound, which lengthens the recovery of breathing through the natural airways. The multi-stage of the described methods significantly lengthens the rehabilitation period and creates huge problems in case of failure.

Thus, there is a need for a method for repairing defects in a tracheogortic segment without the above disadvantages.

The technical result of the proposed method is simplicity, increasing efficiency and reducing the morbidity of treatment of patients with defects of the larynx and trachea due to a certain sequence of surgical procedures with fixation of the arch implant "Ecoflon", as well as reducing the frequency of postoperative complications.

To solve the indicated technical result, a method is proposed for plastic surgery of defects in the tracheoglottal segment, which includes the formation of a lost wall due to the skin surrounding the defect, followed by reinforcing it using the Ecoflon arched implant with the support of the rigid component on the side walls of the defect. Moreover, in the formed autograft, the skin part corresponds to the size of the defect, characterized in that the autograft is formed by separating the skin bordering the defect, 1 cm from the edge, as a hard component, cut out the size of the existing defect with an Ecoflon 2 mm thick implant, perforate the edges of the formed implant and hem it with support on the preserved lateral fragments of the semicircles of the tracheogortic segment, additionally fix the implant to the internal part formed from the separated skin light on the internal lining of the individual seams harboring implant further formed on top of musculo-fascial defect graft from the surrounding tissue.

In the presented figures 1-10, the main stages of plastic surgery of the tracheogortic segment by the proposed method are reflected.

The method is as follows.

The formation of a revascularizable skin-fascial autograft is carried out from the skin surrounding the defect (Fig. 1, Fig. 2 - photo of the defect in magnification). A skin incision is made, departing from the edge of the defect about 1 cm, the skin bordering the defect is separated (Fig. 3), then the epidermis is turned inward and sutured with separate sutures (Fig. 4). In this way, the inner lining of the lumen of the tracheogortic segment is formed (Fig. 5). Moreover, in the formed autograft the skin part corresponds to the size of the defect.

As a rigid component, the Ecoflon arched implant 2 mm thick is cut to the size of the existing defect, the edges of the formed implant are perforated (Fig. 6) and hemmed with support on the preserved lateral fragments of the half rings of the tracheogortic segment (Fig. 7). Additionally, the implant is fixed to the inner lining formed from the separated skin by separate seams, the implant is covered from above with an additionally formed flap from the tissues surrounding the defect (Fig. 8).

At the final stage of the operation, skin plasty of the existing wound defect is performed (Fig. 9). If the size of the defect is extensive, and it is not possible to close it by comparing the edges of the skin after their preliminary mobilization, in such cases resort to the use of locally displaced skin flaps (Fig. 10).

In the early postoperative period, the state of the operating zone, the severity of reactive phenomena, the position and fixation of the implant are taken into account. In the long term, the lumen and condition of the cartilage frame of the larynx and trachea, respiratory function are assessed. Of the objective methods, we focused on endoscopic data.

"Ecoflon" in chemical composition is a synthetic material polytetrafluoroethylene. Implants are made by powder sintering. The result is a porous structure, suggesting the possibility of growing a connective tissue capsule inside the implant. An important advantage of this material is the availability of the manufacture of individual implants. Ecoflon implants are more compliant with biocompatibility requirements and minimize impact on adjacent tissues. Ecoflon has a number of positive qualities for plastics: density, elasticity, good survival, bioinertness. It is easy to carve out an implant according to an existing defect; it does not cause an organism reaction to a foreign body (from the development of granulations and scars around the implant to its complete rejection). It is stored for a long time, after opening the package, sterilization of the remaining material is possible.

4 patients aged from 24 to 36 years (men) were operated on with chronic post-intubation Cicatricial stenosis of the larynx and trachea. All patients at the initial stage of treatment had cicatricial atresia of the lumen of the laryngeal-tracheal section with a length of 1.5 - 3.0 cm and a tracheostomy. After stage reconstructive plastic surgeries on the larynx and trachea - laryngotracheoplasty with excision of scar tissue, reduction of the cartilage of the larynx and trachea and further formation of the recreated airway on the T-shaped tube, all patients had an extensive laryngotracheal defect with significant damage to the skeleton department of the trachea. Thus, the study group included patients with extensive laryngotracheostomy, i.e. having a defect in the walls of the larynx and trachea without stenosis of the cavity. All patients underwent plastic full or partial closure of the laryngotracheal defect using the Ecoflon material. We used 2 mm thick EcoFlon arched implants made by the manufacturer on our order.

No cases of infection in the postoperative period were observed. The postoperative period was uneventful - there was no migration, exposure and rejection of the implant, in all cases the wound healed by first intention, the formed airway lumen remained stable. The long-term results of the operation that we examined for 6 months using the Ecoflon implant indicate persistent preservation of the formed lumen.

Example. A 24-year-old patient with an extensive laryngotracheal defect.

Performed plastic tracheogortic segment (extensive laryngotracheal defect) by the proposed method. The size of the defect did not allow it to be closed by comparing the edges of the skin after their preliminary mobilization. There was a need for the use of locally displaced skin flaps.

After surgery, the patient was in satisfactory condition. The wound healed by first intention, the reactive phenomena of the surrounding soft tissues were minimal, swelling, increased exudation was not observed. The implant is well fixed in the surrounding tissues, not displaced. 6 months after surgery, the postoperative area without signs of inflammation, the implant is well fixed in the surrounding tissues. With control fibrolaryngotracheoscopy, the lumen of the larynx and trachea is wide, free. Breathing through the natural paths is free.

Thus, the proposed method is simple, can increase the efficiency and reduce the morbidity of treatment of patients with defects of the larynx and trachea due to a certain sequence of surgical procedures with fixation of the arch implant "Ecoflon", as well as reduce the frequency of postoperative complications. The use of "Ecoflon" in the proposed method makes it possible to manufacture the implant of the required shape and allows to restore the supporting skeleton of the larynx and trachea. "Ecoflon" does not cause a rejection reaction and takes root well.

Claims (1)

A method for plasty of defects in a tracheogortic segment, including the formation of a revascularizable skin-fascial autograft with its subsequent stitching into the defect with the skin inside, the installation of a rigid component based on the side walls of the defect, characterized in that the autograft is formed by separating the skin bordering the defect, departing from it edges by 1 cm, as a rigid component, cut out the size of the existing defect arched implant from the material "Ecoflon" with a thickness of 2 mm, perforate the edges of the formed the implant and hem it with support on the preserved lateral fragments of the half rings of the tracheogortic segment, additionally fix the implant to the inner lining formed from the separated skin with separate sutures and cover the implant from above with an additionally formed muscle-fascial flap from the tissues surrounding the defect.

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