RU2723137C2 - Method of lung parenchyma separation in thoracoscopic lobectomy - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, particularly to thoracic surgery and oncology. After anterior and posterior mediastinotomy with removal of the root cellulitis with lymph nodes through an intervenous gap, an artery wall of basal segments of the lower lobe is visualized, its fascial case is incised, identifying reed arteries and an artery of the apical segment of the lower lobe and through the formed "tunnel", the upper wall of which is the lung parenchyma, and the lower pulmonary artery, a stapling apparatus is carried out and the lobes are separated, thereafter, arterial segmental vessels and vein are undergone hardware suture, and the lobar bronchus is treated by mechanical suturing. In the operation on the right lung, the structure of the middle lobe is identified: arteries, vein and bronchus, which are a reference point for the apparatus for stitching and intersection of the lung parenchyma and further treatment of the broncho-vascular structures of the removed lobe.EFFECT: invention enables to perform radical thoracoscopic lobectomy in the patients with a non-expressed or completely invaded interlobar sulcus, minimizing a pulmonary parenchyma injury, thereby significantly reducing air leak in postoperative period; in this regard, reduced risk of postoperative respiratory disorders, which promotes fast rehabilitation of patient, and in turn, reduced length of stay of patient in hospital.1 cl, 1 ex, 6 dwg

Description

The invention relates to medicine, in particular to thoracic surgery and oncology.

Lobectomy is one of the most frequently performed lung surgeries for malignant neoplasms. Currently, there is a clear tendency to increase the diagnosis of lung tumors in the early stages of development (I-II stages), which is a consequence of the improvement of diagnostic equipment, the introduction of screening programs, as well as the popularization of preventive examinations among the population. This contributes to the active introduction of the method of thoracoscopic anatomical resection of the lung in the amount of lobectomy in the cancer network and its use in the vast majority of specialized institutions in the world. Its advantage over "open" surgery has been proven. Thoracoscopic lobectomy in primary primary lung cancer according to the recommendations of ESMO (European Society for Medical Oncology) is the operation of choice, and since 2013 it has been adopted by NCCN (National Comprehensive Cancer Network) as an alternative to thoracotomy access.

The thoracoscopic lobectomy method in comparison with thoracotomy access has several advantages. A smaller chest injury significantly reduces postoperative pain, contributes to a more rapid recovery of the patient, thereby shortening the length of hospital stay. Studies have confirmed the best immediate as well as long-term results.

The first thoracoscopic lobectomy experiment was held by Landreneau RJ and Mack MJ in 1992 (Landreneau, RJ Video-assisted thoracic surgery: basic technical concepts and intercostal approach strategies / RJ Landreneau, MJ Mack, SR Hazelrigg et al. // Ann. Thorac. Surg. - 1992. - N 54. - P. 800-807). In the same year, Roviaro G performed a lower right lobectomy using this technique (Roviaro, G. Videoendoscopic pulmonary lobectomy for cancer / G. Roviaro, C. Rebuffat, F. Varoli et al. // Surg. Laparosc. Endosc. - 1992. - N 2. - P. 244-247). The operation was performed with four 10-mm thoracoports and a 4 cm thoracotomy.

In Russia, the first thoracoscopic lobectomy was performed by Professor E.I. Seagal in 1994 (Seagal, E.I. First experience of thoracoscopic operations / E.I.Sigal // Kazan. Medical journal. - 1994. - No. 6. - S. 74-81).

In recent years, many options for thoracoscopic lobectomy have been proposed: multi-and single-port, the use of mini-thoracotomy access and “full thoracoscopy”, caudal and subxiphoid access techniques, as well as robotic surgery (Hansen, N. J. Video-assisted thoracoscopic surgery (VATS ) lobectomy using a standardized anterior approach / HJ Hansen, RH Petersen, M. Christensen // Surg. Endosc. - 2011. - N 25. - P. 1263-1269; Walker, WS Thoracoscopic pulmonary lobectomy. Early operative experience and preliminary clinical results / WS Walker, FM Carnochan, GC Pugh et al. // J. Thorac. Cardiovasc. Surg. - 1993. - N 106. - P. 1111-1117; Dolci, G. A New approach for video-assisted thoracoscopic lobectomy "the caudal position" / G. Dolci, A. Dell'Amore, N. Daddi et al. // J. Thorac. Dis. - 2015. - N 7. - P. 2348-2351; Dolci, G. Video- assisted thoracoscopic surgery lobectomy using "the caudal approach": results and evolution / G. Dolci, A. Ca mpisi, D. Giunta et al. // J. Vis. Surg. - 2017. - N 3. - P. 187. - DOI: 10.21037 / jovs.2017.11.07.07; Chen, S. Techniques for lung surgery: a review of robotic lobectomy / S. Chen, T. C. Geraci, R. J. Cerfolio et al. // Expert Rev Respir Med. - 2018 .-- N 12 (4). - P. 315-322. - DOI: 10.1080 / 17476348.2018.1448270; Gonzalez-Rivas. DUnisurgeon 'uniportal video-assisted thoracoscopic surgery lobectomy / D Gonzalez-Rivas // J Vis Surg. - 2017. - N 3. - P. 163. - DOI: 10.21037 / jovs.2017.10.07. eCollection 2017; Yang, X. The feasibility and advantages of subxiphoid uniportal video-assisted thoracoscopic surgery in pulmonary lobectomy / X. Yang, L. Wang, C. Zhang et al. // World J. Surg. - 2019 .-- N. 43 (7) .- P. 1841-1849.-DOI: 10.1007 / s00268-019-04948-6).

However, despite the different approaches to performing the operation, a special place in the discussion of complications is leakage of the lung parenchyma. In various studies, its frequency is from 1.5 to 13.6%. The European Society of Thoracic Surgeons defines aerostasis insufficiency as prolonged with air intake of more than 5 days. Air leakage after resection of the lung is observed relatively often and usually the management of the patient is conservative. This requires prolonged drainage of the pleural cavity, additional supportive therapy.

There is literature data on the intraoperative use of adhesive compositions, argon plasma, laser, electro- and cold plasma coagulation, as well as hemostatic sponges and strips of absorbable material for sealing the lung (Bordakov, V.N. Use of the local drug “Fibrinostat” for laparoscopic cholecystectomy / B .N. Bordakov, MV Doronin, ED Rasyuk and others // Military medicine. - 2008. - No. 4. - P. 105-109; Popov, VA. Latex tissue glue and its application in surgery / V.A. Popov, N.V. Sirotkin, V.A. Golovachenko, etc. // Video-assisted thoracoscopic lung resection in thoracic surgery // Scientific and practical journal "Polymers and Medicine". - 2006. - No. 2 ( 1). - S. 25-26; Horio, N. Impact of additional pleurodesis in video-assisted thoracoscopicbullectomy for primary spontaneous pneumothorax / H. Horio, H. Nomori, R. Kobayashi et al. // Surgical Endoscopy - 2002. - N16 (4) .- P. 630-634).

However, the technical component of the operation underlies the "surgical" prevention of leaking parenchyma, in particular the treatment of branches of the pulmonary artery with no severity or complete absence of interlobar furrow. Lobectomy involves the treatment of segmental arteries and in the “open” version of the operation, their isolation is most often performed by dividing the parenchyma over the artery using blunt or acute dissection, electrocoagulation, followed by suturing of the lung defect. This approach requires revision when using the thoracoscopic technique, since suturing of defects of the pulmonary parenchyma endoscopically can be difficult, and this in turn increases the time of the operation and the risk of prolonged air leakage in the postoperative period. In this regard, the technique of maximum use of staplers during the operation seems to be the most acceptable. The proposed "tunnel" method allows you to split the lung parenchyma in the first stages of the operation, before processing the broncho-vascular structures.

The analysis of the use of "traditional" treatment of lung structures during lobectomy in comparison with the "tunnel". The last method, which allowed avoiding an open defect of the parenchyma above the pulmonary artery, exceeded the “traditional” one: the duration of air supply in the postoperative period was much shorter, which made it possible to remove drainage at an earlier date (on average, 2 days after surgery).

The closest is the "unidirectional" surgical method, which allows you to avoid working with the vessels and bronchus intraparenchymally. This method allows to process the broncho-vascular lung structures without preparation (Liu L, Che G, Pu Q. et al. A new concept of endoscopic lung cancer resection: Single-direction thoracoscopic lobectomy. // Surg Oncol 2010; 19: e71-7; Liao H, Liu C, Mei J, Lin F, Pu Q, Liu L. Single-direction thoracoscopic lobectomy: right side. // J Thorac Dis. 2018 Oct; 10 (10): 5935-5938; Liao H, Mei J , Lin F, Liu C, Pu Q, Liu L. Single-direction thoracoscopic lobectomy: left side. // J Thorac Dis. 2018 Oct; 10 (10): 5932-5934).

However, given the anatomical structure of the lungs, the use of this method may be optimal when removing the lower lobes, and the treatment of broncho-vascular structures of the middle and upper lobes is difficult, which is a disadvantage of this method.

The technical result of the invention is the performance of a thoracoscopic lobectomy of any anatomical localization in patients with an unexpressed or completely healed interlobar groove, in which it is impossible or extremely difficult to isolate broncho-vascular structures without significant damage to the parenchyma, thereby ensuring persistent postoperative aerostasis.

The specified technical result is achieved by the fact that, as in the known method, the broncho-vascular structures of the lung are processed without preparation, bypassing the lung parenchyma.

A feature of the proposed method is that after the anterior and posterior mediastinotomy with the removal of root fiber with lymph nodes through the intravenous gap, the artery wall of the basal segments of the lower lobe is visualized, its fascial case is dissected, the lingual arteries and the artery of the apical segment of the lower lobe are identified and through the formed “tunnel” ", The upper wall of which is the lung parenchyma, and the lower pulmonary artery, a stapler is inserted and the lobes are separated, then the arterial segmental vessels and veins are hardware stitched, then the lobar bronchus is treated with hardware stitching. During surgery on the right lung, the structure of the middle lobe is identified: arteries, veins and bronchus, which are the guidelines for the apparatus for flashing and crossing the lung parenchyma and further processing of the broncho-vascular structures of the removed lobe (upper, middle and lower).

The invention is illustrated by a detailed description, clinical example and illustrations, which depict:

FIG. 1 - through the intervenous gap visualized lower lobar bronchus and artery of the basal segments.

FIG. 2 - summing up the stapler for separating the parenchyma into the formed “tunnel” in the intervenous space.

FIG. 3 - the parenchyma is divided between the lobes.

FIG. 4 - the intersection of the artery of the lower lobe.

FIG. 5 - the intersection of the inferior pulmonary vein.

FIG. 6 - the intersection of the lower lobe bronchus.

The method is as follows.

At the first stage of the operation, root fiber with lymph nodes is removed, the artery wall of the basal segments of the lower lobe is visualized from the intervenous gap. Dissect its fascial case, and reed arteries and an artery of the apical segment of the lower lobe are identified (Fig. 1). Through the formed “tunnel”, the upper wall of which is the lung parenchyma, and the lower pulmonary artery, a stapler is inserted and lobes are separated (Fig. 2, 3). After this, hardware stitching of arterial segmental vessels and veins is performed, then lobar bronchus is treated with hardware stitching (Figs. 4, 5). And during surgery on the right lung, the structure of the middle lobe is identified: arteries, vein and bronchus, which are the guidelines for the apparatus for flashing and crossing the lung parenchyma and further processing of the broncho-vascular structures of the removed lobe (upper, middle and lower).

In these embodiments, identification of the vascular structures and bronchus is required in accordance with the removed lobe. The operation is completed by drainage of the pleural cavity (one drainage).

Clinical example.

Patient V., 57 years old, with prof. examination revealed the formation in the lower lobe of the left lung, interpreted as peripheral cancer. A tumor 2.5 cm in size with spiculate contours was located deep in the lung parenchyma. When bronchoscopy with a sampling of material from interested bronchi for a cytological study of tumor pathology was not detected. Taking into account the topical location of the formation, as well as taking into account the bright radiological semiotics of the malignant tumor, additional verification attempts are considered inappropriate. The operation is shown in the volume of the lower lobectomy on the left.

The operation has been completed.

Adhesive process and fluid in the pleural cavity, dissemination of the pleura is not revealed. Due to the deep location in the parenchyma, the tumor was not detected. Noteworthy was the poorly expressed interlobar sulcus. Isolation of the artery of the lower lobe through the interlobar sulcus is not considered appropriate in view of the inevitability of significant parenchyma defects. After the anterior and posterior mediastinotomy and removal of root fiber from the intervenous space, the wall of the lower lobe bronchus and artery of the basal segments of the lower lobe was visualized (Fig. 1). Its fascial case was dissected, while the arteries of the reed segments and the artery of the apical segment of the lower lobe were identified. A stapler was passed through the formed “tunnel” and the lobes of the lung were divided (Fig. 3). After that, the apparatuses processed the lower pulmonary vein and artery (Fig. 4, 5, 6). The drug is removed. An urgent intraoperative histological examination diagnosed pulmonary adenocarcinoma. Taking this into account, a mediastinal lymphadenectomy was performed.

The postoperative period was uneventful. Drainage from the pleural cavity was removed 2 days after surgery. The patient spent 5 hospital days in a hospital.

Retrospectively evaluating this clinical situation, the “tunnel” method made it possible to process vascular structures without an open parenchyma injury, thereby avoiding the leakage of air from the lung in the postoperative period.

The use of this method in clinical practice makes it possible to perform a thoracoscopic lobectomy bypassing damage to the parenchyma and thereby significantly reduce the postoperative prolonged air discharge.

Thus, the claimed invention allows to perform a radical thoracoscopic lobectomy in patients with an unexpressed or completely healed interlobar groove, minimizing the injury of the pulmonary parenchyma, thereby significantly reducing air leakage in the postoperative period. In this regard, the risk of joining postoperative respiratory disorders is reduced, which contributes to the early rehabilitation of the patient and, in turn, the length of stay of the patient in the hospital is reduced.

Claims (2)

1. The method of separation of the lung parenchyma during thoracoscopic lobectomy, including non-processing treatment of the broncho-vascular structures of the lung, bypassing the lung parenchyma, characterized in that after the anterior and posterior mediastinotomy with the removal of root fiber with lymph nodes through the venous gap, the artery wall of the basal segments of the lower lobe is visualized dissect its fascial case, identify the reed arteries and the artery of the apical segment of the lower lobe and through the formed “tunnel”, the upper wall of which is the lung parenchyma, and the lower pulmonary artery, the stapler is inserted and the lobes are separated, then the arterial segmental vessels are hardwarely stitched and veins, then hardware stitching process the lobar bronchus. 2. The method according to p. 1, characterized in that during surgery on the right lung, the structure of the middle lobe is identified: arteries, veins and bronchus, which are a guideline for stitching and crossing the lung parenchyma and further processing of the broncho-vascular structures of the removed lobe.

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