RU2745190C2 - Method for microsurgical reconstruction of the tongue and the bottom of the oral cavity after extended hemigloseectomy - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to oncology and to maxillofacial surgery. A musculocutaneous flap is formed from the fibers of the serratus anterior muscle, according to the size of the tongue defect, on the vascular branch extending from the thoracodorsal vessels to the anterior dentate muscle. The long pectoral nerve is included in the flap. The vascular pedicle and the nerve of the formed flap are transected. The flap is transferred to the area of ​​the defect. The posterior part of the flap is fixed to the root of the tongue, and the anterior part of the flap is fixed to the apex of the tongue. In this case, the remaining unfixed edges of the flap are distributed without tension and sutured along the perimeter to the remaining half of the tongue and the remaining part of the floor of the mouth. After that, microvascular anastomoses are formed between the donor and recipient vessels and between the long thoracic nerve and the hypoglossal nerve.EFFECT: method allows to eliminate defects in the oral cavity after extended hemiglossectomy with resection of the muscles of the floor of the oral cavity and to restore the shape and mobility of the tongue, as well as its functions: swallowing and speech production.1 cl, 3 dwg, 1 ex

Description

The invention relates to medicine, namely to oncology, to maxillofacial surgery and is intended for the reconstruction of the tongue after its half resection with partial removal of the tissues of the floor of the oral cavity in cancer patients, as well as for the elimination of post-traumatic defects of the tongue.

The known method of reconstruction of the tongue with a free reinnervated radial flap, which consists in the fact that the lost tissue of the tongue is restored using a free reinnervated skin-fascial radial flap, the blood supply of which is restored due to microsurgical anastomosis of the vessels of the neck and flap vessels. Reinnervation is performed by microsurgical anastomosis of the lingual nerve and cutaneous nerve of the forearm (Kuriakose MA, Loree Th.R., Spies A., Meyers S., Hicks WL Sensate Radial Forearm Free Flaps in Tongue Reconstruction. Arch Otolaryngol Head Neck Surg. 2001 ; 127 (12): 1463-1466). As a result of the studies carried out, the authors note that after the operation, sensory sensitivity is restored after 8 months, and the sensory function of the flap approaches the function of the rest of the tongue.

Despite the above therapeutic results, this method has a number of disadvantages:

- there is no additional plastic material, namely the muscular component of the flap for plastic elimination of larger, volumetric defects in the oral cavity;

- with reinnervation of the flap, only the sensory function is restored, but the motor function of the graft is not restored and, as a result, this leads to a violation of the function of chewing, swallowing, speech production in case of larger defects in the oral cavity;

- possible ischemia of the upper limb against the background of the development of radial artery dysfunction;

- impossibility of closure of the donor defect with local tissues;

- a cosmetic defect on the part of the donor area is often negatively assessed by patients due to its location in a conspicuous place;

- severe atrophy of the flap in the postoperative period.

Closest to the claimed method is a method of surgical reconstruction of soft tissues of the lower zone of the face and oral cavity, which consists in the fact that plastic is performed with an "insular" musculocutaneous flap, including the latissimus dorsi muscle with thoraco-dorsal vessels (Haughey, V.N .: Tongue Reconstruction: Concepts and Practice Laryngoscope 103; 1132-1141, October 1993). Adopted as a prototype.

The prototype method allows in one surgical stage to restore the integrity of the tongue and the floor of the mouth. Reinnervation of the motor thoraco-dorsal nerve allows for muscle contractility of the flap during the restoration of the tongue.

However, the known method has several disadvantages:

- the volume of the flap tissue is often excessive, due to its subcutaneous component, especially in people with increased body mass index, which can cause impaired flap perfusion in the early postoperative period;

- when using this technique, the mobility of the remaining part of the tongue is impaired due to the pronounced muscular component of the grafted flap, which leads to impaired articulation and swallowing function;

- donor damage, in the form of limiting the extension of the arm in the shoulder joint, since the muscle is completely intersected.

The technical result of the proposed invention is the possibility of simultaneous elimination of the tongue defect after extended hemiglossectomy with partial removal of the muscles of the floor of the oral cavity on the side of the pathological process and restoration of the functions of swallowing and speech production.

This problem is solved by the fact that, as in the known method, a free musculocutaneous flap is formed.

A feature of the proposed method is that from the vascular branch extending from the thoraco-dorsal vessels to the serratus anterior muscle, a musculocutaneous flap is formed from the fibers of the serratus anterior muscle according to the size of the tongue defect, including the long pectoral nerve, the vascular pedicle and the nerve formed flap, the flap is transferred to the defect area and the posterior part of the flap is fixed to the root of the tongue, and the anterior part of the flap to the apex of the tongue, while the remaining unfixed edges of the flap are distributed without tension and sutured along the perimeter to the remaining half of the tongue and the remaining part of the floor of the mouth, after which form microvascular anastomoses between donor and recipient vessels and between the long thoracic nerve and the hypoglossal nerve.

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

FIG. 1 - photo illustration: the markings of the flap shape are shown.

FIG. 2 - photo illustration: a formed flap.

FIG. 3 - a diagram of the location of the musculocutaneous flap from the fibers of the serratus anterior muscle.

The method is carried out as follows.

After the resection stage according to standard oncological principles
in the patient's supine position, according to preliminary marking (Fig. 1) with the retracted upper limb, a musculocutaneous flap is formed from the fibers of the serratus anterior muscle of the back on the thoraco-dorsal vessels and the vascular branch extending from them to the serratus anterior muscle, a musculocutaneous flap is formed a flap from the fibers of the serratus anterior muscle with the inclusion of the long pectoral nerve. When forming a musculocutaneous flap, the size, shape of the skin cushion and its direction relative to the location of muscle fibers are determined using a stencil taken in accordance with the size of the post-resection defect in the oral cavity. The vascular pedicle and the long thoracic nerve of the previously formed flap are transected (Fig. 2). The flap is transferred to the defect area, the posterior part of the flap is fixed with separate interrupted sutures to the root of the tongue, the anterior part of the flap is to the apex of the tongue, the remaining unfixed edges of the flap are distributed without tension and sutured along the perimeter with separate interrupted sutures to the remaining half of the tongue and the remaining part of the floor of the mouth, thereby, the integrity of the tongue is recreated in accordance with the physiological anatomical position (Fig. 3). Further, microvascular anastomoses are formed between donor and recipient vessels and between the long pectoral nerve and the hypoglossal nerve from the side of the pathological process.

Clinical example.

Patient O., 37 years old, was undergoing treatment at the Department of Microsurgery of the Moscow Scientific Research Oncological Institute named after I.I. P.A. Herzen - a branch of the Federal State Budgetary Institution "National Medical Research Center of Radiology" of the Ministry of Health of Russia with clinical diagnosis: cancer of the left half of the tongue, stage III. setT3N2M0. Condition after chemoradiation therapy in May-July 2019. SOD 72 Gr. Continued tumor growth.

Morphologically highly differentiated squamous cell carcinoma, with metastases to the lymph nodes of the neck on the left.

On admission: when viewed through the mouth, the tongue is fixed to the bottom of the mouth on the left. On palpation of the tongue, a tumor formation is determined on the lateral surface on the left of a predominantly endophytic form of growth, without clear, even contours measuring 2x3 cm, occupying the middle and posterior third of the tongue. On palpation of the neck in the upper third of the neck on the left, metastatic named lymph nodes are determined with a maximum size of up to 2 cm in diameter, of a dense elastic consistency.

Magnetic resonance imaging of the facial region of the skull reveals zones of the altered MR signal on the left lateral surface of the tongue and partially of the root 23x9x33mm. The distance to the midline is at least 5 mm (in middle calving). In the upper neck on the left, a changed l / u 13x10 mm is visualized. The lumen of the nasopharynx and laryngopharynx is preserved, symmetrical. The oropharynx is deformed due to the enlarged root of the tongue on the left.

According to the results of additional research methods, convincing data for metastasis and other focal pathology have not been obtained.

Taking into account the young age of the patient and to shorten the period of medical rehabilitation, it was decided to remove the tumor with one-stage microsurgical reconstruction with a reinnervated musculocutaneous flap from the fibers of the serratus anterior muscle.

The operation was performed: under endotracheal anesthesia, the tumor of the tongue was removed according to oncological standards, in the volume of hemiglossectomy on the left with resection of the muscles of the floor of the mouth on the left and lymphadenectomy on the left neck (removal of 1-5 groups of lymph nodes). Additionally, the facial vessels in the distal region and the hypoglossal nerve on the left were isolated and prepared for subsequent microsurgical reconstruction. Further, according to preliminary markings (Fig. 1), an incision was made in the skin of the left lateral surface of the chest along the latissimus dorsi muscle 4 cm long. Skin and fat flaps were mobilized, divorced. The thoraco-dorsal neurovascular bundle and branches to the serratus anterior muscle were identified. A skin incision was made, bordering the skin area in accordance with the size of the post-resection defect in the oral cavity leaving it on the muscle. Formed musculocutaneous flap on the vascular branch extending from the thoraco-dorsal vessels to the serratus anterior muscle measuring 7x6 cm with the inclusion of a long thoracic nerve in the flap (Figure 2). The flap was transferred to the defect area. The musculocutaneous fragment of the flap from the fibers of the serratus anterior muscle is placed in the projection of the tongue, the skin portion is fixed to the remaining fragment of the tongue on the right, to the lower jaw mucosa on the left, in the distal part to the root of the tongue along the perimeter. The leg of the flap was brought to the vessels of the neck. Using microsurgical techniques, under optical magnification, anastomosis was made between the facial arteries and the thoraco-dorsal artery in the end-to-end manner, between the facial vein and the thoraco-dorsal vein in the end-to-end manner, between the long thoracic nerve and the hypoglossal nerve on the left "end to end". Starting blood flow. The flap was restored to its vitality. The donor area and the neck wound were sutured in layers.

The wounds were healed by primary intention. No necrotic changes in the flap were observed in the postoperative period. In the early postoperative period, nutrition was carried out through a naso-gastric tube. By the end of the 3rd week, the naso-gastric tube was removed, the patient was transferred to a natural diet with liquid food. By the end of the fourth week, the patient regained independent swallowing without choking, feeding on soft and semi-liquid food. 2 months after the operation, satisfactory results of the swallowing function and phonation were observed, the mobility of the remaining part of the tongue was preserved.

The proposed method allows you to eliminate defects in the oral cavity after extended hemiglossectomy with resection of the muscles of the floor of the mouth and restore the shape and mobility of the tongue, as well as its functions: swallowing and speech production.

Claims (1)

A method of microsurgical reconstruction of the tongue and the floor of the oral cavity after extended hemiglossectomy, including the formation of a free musculocutaneous flap, characterized in that on the vascular branch extending from the thoracodorsal vessels to the serratus anterior muscle, a musculocutaneous flap is formed from the fibers of the serratus anterior muscle according to the size of the defect tongue, including the long pectoral nerve in its composition, the vascular pedicle and the nerve of the formed flap are crossed, the flap is transferred to the defect area and the posterior part of the flap is fixed to the root of the tongue, and the anterior part of the flap to the apex of the tongue, while the remaining unfixed edges of the flap are distributed without tension and sutured along the perimeter to the remaining half of the tongue and the remaining part of the floor of the oral cavity, after which microvascular anastomoses are formed between the donor and recipient vessels and between the long pectoral nerve and the hypoglossal nerve.

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