RU2694518C1 - Method of cervical lymphadenectomy in advanced cancer of posterior oral and oropharynx - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for cervical lymphadenectomy in advanced oral and pharyngeal cancer. Mandibulotomy is performed. Sternoclavicular-mastoid muscle and muscles of the suprahyoid triangle are incised: styloglossus, musculus stylohyoideus, musculus stylopharyngeus and posterior abdomen of the digastricus muscle. Joint and lower jaw fragment mobility is achieved. Jaw is removed. Upper cervical metastases and the neurovascular bundle are exposed at the entrance of the skull cavity, including an internal carotid artery. Radical cervical lymphadenectomy is performed in a radical manner, including the tumors affected by the external carotid arteries within the healthy tissue. Resected suprahyoid muscles, soft tissues and skin are sutured together.EFFECT: method enables radically removing cervical metastases.1 cl, 7 dwg

Description

The invention relates to medicine, more precisely to surgery, and can be used in patients with locally advanced cancer of the posterior oral cavity and oropharynx during surgical interventions - lymphadenectomy of the upper cervical metastasis.

Known methods of surgery for the defeat of the lymph nodes of the neck by metastasis of malignant tumors in the form of surgery Krayl and fosialno-case excision of the cervical tissue (see Pasches AI Head and neck tumors. M .: Medicine, 2000, p.106-119).

The methods proposed by the author provide operative intervention to remove cervical metastases. However, in these operations, metastases are removed in the lateral and submandibular regions of the neck without access to the metastases covered by the angle and branch of the mandible.

There is a method of surgery on the neck when removing the lymph nodes of the neck, carried out by two incisions. The first one is produced in the pre-ary region at the base of the trestle of the ear to its lobe, moving to the angle of the lower jaw, then to the submental and submental area. The second incision begins on the mastoid process, passing down the posterior contour of the sternocleidomastoid muscle with the transition to its front surface in the middle third (see patent RU 2570166 C2, publ. 10.12.2015, Bull. No. 34).

The proposed method allows the authors to carry out cervical lymph node dissection with a single unit with fiber, neck lymph nodes and excision of the lower pole of the parotid salivary gland, including it in the volume of cervical lymph node dissection. Providing access for the neck around the corner of the lower jaw, the authors retain the facial nerve from the exit of the skull. Using the proposed method provides access to cervical metastases. However, when it is performed, a sufficient overview of the neurovascular bundle is not achieved, at the entrance to the cranial cavity and affected tissues covered with the angle and branch of the mandible.

The technical result of the invention is a radical removal of cervical metastases in patients with advanced cancer of the posterior oral cavity and oropharynx.

The technical result is achieved by dissecting the sternocleidomastoid muscle and the pemphigus pemphigus after the preliminary mandibulotomy: the stylopex, the stylopezyzlyuchnyu stylopharyngeal and the rear abdomen of the double-abdominal muscle, the mobility of the articular head and a fragment of the lower jaw is removed, the maxillary pemphigus muscle is removed, the maxillary moss and the maxillary pemphigus muscles are reached. - the nerve bundle at the entrance to the cranial cavity, including the internal carotid artery, radically conduct the upper cervical lymphadenectomy, including the affected cervix olyu vessels of the external carotid artery within the healthy tissue are sewn resected suprahyoid muscles, soft tissue and skin.

The novelty is that at the location of metastases in areas difficult for review and operation, due to topographic-anatomical features: in the fossa, carotid and submandibular triangles, surgical interventions are used to ensure the possibility of a radical removal of metastases.

The description includes figures to explain the method.

FIG. 1. Presents a general view of the patient with dissected snapping muscle. With a surgical hook, the angle and branch of the resected lower jaw are pushed back. Exposed vessels and muscles of the suprahyoid neck area:

1 - Styloid muscle (m.styloglossus)

2 - stylopharyngeal muscle (m.stylopharyngeus)

3 - stylo-sublingual muscle (m.stylohyoideus)

4 - posterior abdomen of digastric muscle (m. Digastricus)

5 - dissection line of supra-sublingual muscles

FIG. 2. A local view of the topography of the muscles and vessels of the neck in the suprahyoid region is presented. Dissected and pushed back muscle (m.sternocleidomastoideus) covering the internal jugular vein, common carotid with external and internal carotid arteries. The dotted arrow shows the possibility of displacement of a fragment of the jaw.

1 - Styloid muscle (m.styloglossuss)

2 - stylopharyngeal muscle (m.stylopharyngeus)

3 - stylo-sublingual muscle (m.stylohyoideus)

4 - posterior abdomen of digastric muscle (m. Digastricus)

5 - dissection line of supra-sublingual muscles

FIG. 3. Patient L., 42 years old. Entered the RNII with a diagnosis of relapse of advanced cancer of the posterior oral cavity and oropharynx (root of the tongue). Condition after previously performed non-radical surgery and radiation therapy (40 Gy.) In the regional oncologic dispensary.

FIG. 4. MRI of patient L. 42 years. A common tumor process of the oral cavity and oropharynx descending into the lower parts of it.

FIG. 5. MRI of patient L. 42 years. Metastasis to the cervical lymph nodes prior to the projection of the branches of the external carotid artery.

FIG. 6. Angiography of the neck vessels. The repulsion from the outside of the external and internal carotid arteries, without damaging the walls of the internal carotid artery

FIG. 7. Radical cervical lymphadenectomy. The nodal muscle and the muscles of the suprahyoid and carotid triangles are dissected. Hook pushed the branch fragment of the lower jaw. Under visual control of the internal carotid artery (clamping the fascia covering it was diluted) and the proximal internal jugular vein at the entrance to the skull, upper cervical metastases with resection and ligation of the external carotid arteries infiltrated with metastases were removed. The method is as follows.

First, a patient is examined with the establishment of the spread of the primary tumor process and the scale of metastasis to the cervical lymph nodes.

In the presence of metastases located in the zones covered by the lower jaw and representing the difficulty for their removal, first under endotracheal anesthesia, traditional lymphadenectomy is performed. In the process of its implementation, the area of metastasis is specified.

When identifying metastases covered with jaws, difficult to remove, the surgical wound is sutured by preventive imposition of skin sutures.

Begin to remove the primary tumor process. For this, mandiblotomy is performed in a known manner (see Patent RU 2556604 C1, publ. 10.07.2015, Bull. No. 19). Spreading the lower jaw fragments, the tumor is removed in the mouth and in the oropharynx. Removed skin seams on the neck. The styloid, stylopharyngeal, stylohypoglossal and posterior abdominal digestive muscles are exposed and dissected in the center of the upper and lower third of the sternocleptus, and the labial portion of the articular process and fragment of the mandible is reached. Surgical hooks are moved up or down, depending on the structure of the skull (dolichocephalic-oblong, or brachiocephalic-compressed), which has become mobile, a fragment of the lower jaw with exposure of the metastases left before covered with the jaw (see Fig. 1, Fig. 2). Metastases and tumorous tissues are removed. The operation is carried out under the control of the course of the main trunk of the facial nerve and the internal carotid artery, the injury of which is fraught with mortality. Stitching restores the integrity of the resected muscles. Stitched on soft fabrics and neck skin.

The skin graft is harvested in the neck and submandibular region. From the left resected tissue and the formed skin flap is carried out by a known method of plastic surgery of the oral cavity and pharynx (see Patent RU 2391923 Сё1, publ. 20.06.2010, Byul. 17). Formed on the affected side by a known method orostoma. Osteosynthesis of the mandible is carried out by one or two titanium miniplates. Stitches on the skin. A nasoesophageal probe and tracheotomy tube are inserted.

An example of a specific implementation method can serve as an extract from the history of the disease.

Patient L., 42 years old, was sent from the Rostov City Oncologic Dispensary with the diagnosis: Recurrence of cancer of the root of the tongue, condition after surgery: removal of the tumor by the intraoral method with postoperative exposure to SOD - 40 Gr. The histological conclusion is squamous cell carcinoma.

At the time of examination of the patient is determined by the tumor in the posterior regions of the floor of the mouth with the transition to the root of the tongue, the mobility of which is limited (see Fig. 3). On the neck in the upper sections of IB, IIA-B, III levels, enlarged lymph nodes are palpated.

During endoscopy, tumor infiltration of the right half of the oropharynx was established. Puncture biopsies from the primary focus and cervical lymph nodes confirmed the presence of squamous cell carcinoma with metastases.

MRI data revealed a common tumor process in the oral cavity and oropharynx, descending into its lower sections to the pear-shaped fossa and metastasis to the cervical lymph nodes prior to the projection of the external carotid artery branches (see Fig. 4. Fig. 5). Contrast radiography of the neck vessels revealed that the tumor had pushed the internal carotid artery without germination into its wall (see Fig. 6).

Diagnosed: The common recurrence of cancer of the posterior parts of the oral cavity and oropharynx with metastasis to the cervical lymph nodes.

The patient underwent an operation according to the proposed method.

Under endotracheal anesthesia, through a pre-imposed tracheostomy, the procedure was performed according to the generally accepted method, right-sided cervical lymphadenectomy with external carotid artery ligation above the thyroid artery branch. Radical lymphadenectomy failed because metastasis spread to the upper sections of the neck, covered with the lower jaw.

The surgical wound is covered with skin with suture fixation.

A skin incision was made, bordering the chin with exposure of the anterior surface of the lower jaw. Mandibulotomy by a known method. Extending the lower jaw fragments and pushing the tongue out onto the holder, we revisited the surgical field to determine the boundaries of the tumor and healthy tissues. Removed tumors in the mouth and in the oropharynx, hemostasis.

Given the presence of metastases in the upper parts of the suprahyoid and carotid triangles, it was decided to revise them.

Removed preventive stitches, applied to the skin after the performed lmphadenectomy of the neck. Sinus muscle split on the border of the upper and middle thirds. They exposed and dissected the stylo-pong, stylopharyngeal, stylo-sublingual and posterior abdomen of the digestive muscles in the center. Surgical hook pulled down and laterally, which became mobile, a fragment of the jaw. Revision of the wound. The metastasis infiltrated part of the fork of the bandaged external carotid artery. The trunk of the facial nerve was outside of metastasis. Radical removal of metastases. The integrity of the resected muscles is restored by stitching. Stitches on soft tissue and neck skin.

From the left resected tissues of the oral cavity and pharynx (mucous membrane and resected muscles) and the formed cervico-submaxillary skin flap, plastic surgery was performed in the oral cavity and pharynx in a known manner. From the skin of the submandibular region formed on the affected side of the orostoma by a known method. Osteosynthesis of the lower jaw is carried out by a single titanium plate. Stitches on the skin. A nasoesophageal probe and tracheotomy tube are inserted.

The patient underwent surgery satisfactorily. Postoperative healing on the head and neck passed without suppuration. On the 10th day, the nasoesophageal probe and trotheomic tube were removed. Discharged in satisfactory condition by the end of the 3rd week. Natural breathing, whisper speech and swallowing were restored. Viewed through 2 months. - remission. Restored speech.

According to this method, 5 patients were operated on. The operation and the postoperative period were uneventful.

Technical and economic efficiency of the method lies in the fact that it provides optimal access to the upper anatomical neck, covered with the jaw, where the neurovascular bundle, including the internal carotid artery and the jugular vein, and the branch of the external carotid artery and facial nerve. The method provides a radical removal of cervical metastases in patients with advanced cancer of the oral cavity and oropharynx.

Claims (1)

A method of cervical lymphadenectomy for advanced cancer of the posterior part of the oral cavity and oropharynx; , the stylopharyngeal and posterior abdomen of the digastric muscle, the mobility of the articular head and the mandible fragment is reached, the jaw is moved back, the upper e cervical metastasis and neurovascular bundle at the entrance to the cavity of the skull, including the internal carotid artery, jugular upper radically carried lymphadenectomy, including tumor blood vessels affected by external carotid artery within healthy tissue resected crosslinked suprahyoid muscles, soft tissue and skin.

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