RU2794629C1 - Method for surgical treatment of oral cancer with functional reconstruction - Google Patents

Abstract

FIELD: medicine; reconstructive surgery; oncology.

SUBSTANCE: invention relates to medicine, specifically to reconstructive surgery and oncology and was designed for use in oral cavity and tongue tissue repair after the oncological phase of surgery and subsequent rehabilitation. Measure the length of the tongue from its tip to the root (x) and the distance between the right and left central molars of the lower jaw (y) at the preoperative stage. Organize parallel operation of two surgical teams - team No. 1 and team No. 2. Team No. 1 performs surgery on the head and neck. At the same time, perform lymph node dissection precisely with preservation of great auricular nerve, descending branch of the hypoglossal nerve, common, external and internal carotid arteries, internal jugular vein and its branches. At the same time, team No. 2 is performing surgery on the left thigh. Take musculocutaneous flap from the anterolateral surface of the thigh. For this purpose draw flap form interoperatively on sterile paper. In this case, the form has rectangular shape: the width ab corresponds to the length of the resected tongue x with addition of 20% of the length, the length bc is calculated using the formula bc=2.6⋅ y, where y is the distance between the right and left central molars of the low jaw. Place the prepared form on the anterolateral surface of the left thigh. Mark projection of the ground neurovascular bundle course over the form. Perform steps of isolating rectangular-shaped musculoskeletal flap with vascular-muscular pedicle with inclusion of two nerves: motor branch of the femoral nerve and saphenous thigh nerve. Next, the teams change surgical areas. Team No. 1 closes the donor wound in layers, fix two drains with active aspiration into the intermuscular and subcutaneous spaces. Team No. 2 prepares the flap. The flap is given the shape of complex three-dimensional geometric figure that combines cone as tip of the tongue, and half-cylinder as body of the tongue. The cone is formed with symmetrical wedge-shaped de-epidermization of the lateral rectangular triangles of the flap with angle of 22.5°. At the same time: in case of oral cavity damage predominantly on the right, connect points ad, in case of oral cavity damage predominantly on the left connect points bc. Then place the flap in the area of repaired defect in the oral cavity. Fix the flap at the base of lower alveolar ridge at two opposite points, place the vascular pedicle on the neck. Then, perform end-to-side arterial anastomosis of the donor descending branch of the lateral circumflex femoral artery to the recipient external carotid artery with Prolene 8/0 thread under microscopic magnification. Perform two venous anastomoses of the flap comitant veins to the internal jugular vein "end to side" or to the branches of the internal jugular vein "end to end" with Prolen 8/0 thread. Perform two epiperineural anastomoses of the donor femoral nerve motor branch to the recipient descending branch of the hypoglossal nerve and the donor saphenous thigh nerve to the proximal end of the great auricular nerve with Prolen 9/0 thread under microscopic magnification. Perform electrical stimulation of the great auricular nerve below the neural anastomosis zone in the postoperative period once a day with a frequency of 50 Hz, duration of 20 μs and a current of 30-40 mA for 10 minutes.

EFFECT: method allows to repair tissues of the oral cavity and tongue after the oncological stage of the surgery, to achieve an adequate recovery of swallowing and speech production functions, and to shorten the operative time.

1 cl, 2 dwg, 2 ex

Description

The invention relates to medicine, namely to reconstructive plastic surgery and oncology, and is intended for use in restoring tissues of the oral cavity and tongue after the oncological stage of the operation and subsequent rehabilitation.

Further in the text, the applicant provides an explanation that is necessary to facilitate an unambiguous understanding of the essence of the claimed materials and to eliminate contradictions and / or controversial interpretations when performing an examination on the merits:

A flap is a term in plastic and reconstructive surgery, which is a piece of tissue of any type, which is surgically removed from the donor site and moved to the recipient site while maintaining its own blood supply.

Reinnervation - restoration of sensory or motor innervation by anastomosing the nerves in the tissue of the flap to the nerves of the recipient area.

Lymph node dissection (lymphadenectomy) is the surgical removal of lymph nodes for malignant tumors.

From the studied level of technology, it is known that in Russia in 2021 alone, 16,550 malignant tumors of the oral cavity, oropharynx, and lips were initially detected. At the same time, 64.7% of oral cavity tumors were detected in the late stages (III-IV), which is comparable to the figures for 2022 - 70.5% [The state of oncological care for the population of Russia in 2021 / Ed. HELL. Kaprina, V.V. Starinsky, A.O. Shakhzadova - M.: MNIOI im. P.A. Herzen - branch of the Federal State Budgetary Institution "NMITs Radiology" of the Ministry of Health of Russia, 2022. - ill. - 239 p.]. Despite the development of microsurgery and the use of various types of autografts, the reconstruction of the oral cavity after radical surgical treatment still remains an urgent problem for surgeons. An ideal reconstruction should not only replenish the volume of resected tissues, but also perform the functions of lost organs. Fundamental is the restoration of swallowing, speech, sensitivity, prevention of aspiration. The difficulty lies in recreating the former biomechanics and anatomical relationships of the tongue with the oral cavity and pharynx, the impossibility of restoring the native movements of the tongue in triorthogonal planes. With extensive combined defects in the oral cavity, it is important to create the volume and shape of the neo-tongue to ensure contact with the hard palate, which improves the results of speech and swallowing. Reinnervation of the flap is also an important step in functional reconstruction, which allows maintaining the symmetry of the reconstructed tongue, reducing tissue atrophy, promoting faster recovery of discriminatory sensitivity, thereby potentially preventing bites and burns, and reducing the sensation of a “cold foreign body in the mouth” [Manrique O. J. et al. Optimizing Outcomes following Total and Subtotal Tongue Reconstruction: A Systematic Review of the Contemporary Literature // Journal of Reconstructive Microsurgery. 2017. V. 33. No. 2. S. 103-111].

The applicant conducted a patent information search in Russian and foreign databases, Internet resources, identified various methods for reconstructing the organs of the oral cavity.

An invention is known according to the patent of the Russian Federation No. 2546097 "Method of reconstructing the tongue and the bottom of the mouth", the essence is a method of reconstructing the bottom of the mouth and tongue by moving the musculoskeletal flap of the neck, including the sternohyoid muscles, and supplied by the branches of the superior thyroid artery, characterized in that that plastic surgery of the tissues of the floor of the oral cavity and tongue is carried out with a musculocutaneous flap, including the skin area of the anterior surface of the neck, sternohyoid muscles, supplied with blood by branches of the superior thyroid artery, innervated by the descending branch of the hypoglossal nerve, while the formed flap is moved into the oral cavity with a skin area in the position of the mucous membrane of the floor of the oral cavity and tongue, soft tissues of the floor of the oral cavity, tongue, submandibular region are restored with a muscle fragment of the flap.

The disadvantage of the known technical solution is:

- small volume of the flap, insufficient for the reconstruction of subtotal and total defects of the tongue;

- additional trauma in the neck area during flap sampling and subsequent formation of cicatricial deformity;

- lack of sensitive reinnervation of the flap;

- delayed restoration of innervation due to the lack of a technical solution for electrical stimulation of the neural anastomosis zone in the early postoperative period;

- lack of calculation of the required size of the flap, taking into account the subsequent partial shrinkage of transplanted tissues (flap).

An invention is known according to the patent of the Russian Federation No. 2629792 "Method of microsurgical reconstruction of the tongue", the essence is a method of microsurgical reconstruction of the tongue, including plastic surgery with a displaced "island" musculocutaneous flap formed from the latissimus dorsi muscle with thoracodorsal vessels and a nerve, characterized in that from the vascular branch , extending from the thoracodorsal vessels to the serratus anterior muscle, an additional muscle flap is formed from the fibers of the serratus anterior muscle, the facial artery, vein and hypoglossal nerve are isolated and prepared for anastomosis, the vascular pedicle of the previously formed flap is crossed, the flap is rotated into the defect area, anastomosis is performed "end to the end" between the facial arteries and the thoracodorsal artery, between the facial vein and the thoracodorsal vein, between the thoracodorsal nerve and the hypoglossal nerve, then the flap is transferred and rotated into the oral cavity, fixed with separate interrupted sutures to the root of the tongue, and the diaphragm of the bottom of the cavity is formed from the anterior serratus muscle mouth.

The disadvantage of the known technical solution is:

- the skin portion of the flap has a fairly pronounced subcutaneous layer and is redundant for the reconstruction of the tongue, which adversely affects the functional results and requires a number of corrective operations;

- lack of sensitive reinnervation of the flap;

- delayed restoration of innervation due to the lack of a technical solution for electrical stimulation of the neural anastomosis zone in the early postoperative period;

- lack of calculation of the required size of the flap, taking into account the subsequent partial shrinkage of transplanted tissues (flap);

- functional damage and cicatricial deformity of the donor area.

The article “A novel anatomy-based five-points eight-line-segments technique for precision subtotal tongue reconstruction: A pilot study” [Fan S. et al. // Oral Oncology. 2019. V. 89. S. 1-7]. The essence is a new anatomically based technique of subtotal tongue reconstruction, which consists in cutting out a flap of the anterior lateral surface of the thigh, which has a unique design, by marking five points on the surface of the thigh and forming two irregular pentagons on them, which are then sutured, forming the body and the tip of the neotongue . Next, plastic surgery of the tissues of the floor of the oral cavity is carried out, according to the marked points, after which the sensory saphenous nerve of the thigh is anastomosed either to the lingual or to the glossopharyngeal nerve.

The disadvantage of the known technical solution is

- delayed restoration of innervation due to the lack of a technical solution for electrical stimulation of the neural anastomosis zone in the early postoperative period;

- violation of the integrity of the lower jaw due to the implementation of the median mandibulotomy with subsequent metal osteosynthesis.

The closest to the proposed method, chosen by the applicant as a prototype, is the invention according to the patent of the Russian Federation No. 2736613 "Method of reconstruction of extensive and complex defects of the tongue and oral cavity after performing radical resections in locally advanced stages of tumors", the essence is a method of reconstruction of extensive and complex defects of the tongue and oral cavity after performing radical resections in locally advanced stages of tumors, including the formation of the tongue and oral cavity using a musculocutaneous flap, while the tongue is reconstructed from the skin portion of the flap, and the bottom of the oral cavity is formed due to the muscle portion, the imposition microvascular anastomoses between the vessels of the flap and vessels of the neck and suturing the nerves of the compared structures, characterized in that an anterolateral thigh flap is used for reconstruction, for which, after the oncological stage of the operation, the facial artery and vein are isolated from the surrounding tissues and prepared for microvascular anastomoses on the left, isolated and modeled in size, shape and thickness, the anterolateral musculoskeletal flap is adequate to the formed defect, transferred to the area of the defect in the oral cavity and tongue, a median mandibulotomy is performed, a neural suture is placed between the branch of the lateral cutaneous nerve of the thigh, which goes in the skin portion of the flap, and the lingual nerve, then distribution of the skin portion of the flap in the oral cavity, the vascular pedicle of the flap and the motor branch of the femoral nerve from the muscle portion of the flap are taken out around the angle of the lower jaw in the area of the upper third of the neck and freely, without tension, they are placed there, then microvascular anastomoses are applied between the vessels of the flap and the vessels of the neck , one arterial and two venous anastomoses are applied using an operating microscope and microsurgical instruments, Prolen 9-0 suture material, after all vascular anastomoses are applied, the blood supply to all portions of the flap is assessed, hemostasis is performed in the wound, then bone osteosynthesis is performed in the mandibulotomy area using titanium plates and miniscrews, after that, the plasticity of the muscles of the floor of the mouth is performed by placing the muscle portion of the flap in the area of the bottom of the mouth, fixing its one edge to the hyoid bone, and the other to the lower jaw and the area of the skin portion of the flap, while fixing the muscle portion the flap is performed with Vicryl 3-0 suture material, then a neural suture is applied between the motor branch of the femoral nerve of the flap running in the muscle portion with the hypoglossal nerve using microsurgical techniques, after performing the reconstructive stage of the operation, blood flow is re-controlled in all portions of the flap and hemostasis is controlled, the wound on the neck is sutured leaving active drainage.

The disadvantage of the prototype is:

- delayed restoration of innervation due to the lack of a technical solution for electrical stimulation of the neural anastomosis zone in the early postoperative period;

- lack of calculation of the required size of the flap, taking into account the subsequent partial shrinkage of transplanted tissues (flap);

- violation of the integrity of the lower jaw due to the implementation of the median mandibulotomy with subsequent metal osteosynthesis;

- insufficient reliability of blood supply to the flap due to the arterial anastomosis of the donor artery to the facial vessels "end to end".

The technical result of the claimed technical solution is to eliminate the shortcomings of the prototype, namely:

- improved restoration of flap innervation due to electrical stimulation of the neural anastomosis zone of the lateral saphenous nerve of the thigh to the greater auricular nerve in the early postoperative period;

- achievement of the required volume of the flap by preliminary calculation of its size, taking into account the subsequent partial shrinkage of the transplanted tissues (flap);

- preservation of the integrity of the lower jaw due to the implementation of lateral pharyngotomy and the formation of a tunnel from the surface of the neck to the oral cavity for subsequent passage of the vascular pedicle of the flap to the neurovascular bundle of the neck;

- improving the reliability of blood supply to the flap by performing an arterial anastomosis of the donor artery to the external carotid artery "end-to-side";

- organization of parallel work of two operating teams, which allows to reduce the duration of the operation.

At the same time, an adequate restoration of the functions of swallowing and speech formation is achieved due to the unique design of the flap.

The essence of the claimed technical solution is a method of surgical treatment of oral cancer with functional reconstruction, which consists in the fact that first a preoperative stage is carried out: perforating vessels of the descending branch of the lateral artery circumflexing the thigh are marked on the left thigh using an ultrasound machine in Doppler mode, then the operating stage is carried out: an operation is performed on the head and neck area in the volume required by oncological principles - resection of the tongue and tissues of the floor of the mouth, cervical lymphadenectomy on the affected side, a musculoskeletal flap is taken from the anterolateral surface of the thigh: for this, an incision is made along the line markings in the projection of the course of the vascular pedicle, while determining the groove between the rectus femoris muscle and the tensor fascia lata of the thigh, bluntly separate the tensor of the broad fascia of the thigh and the rectus femoris, then the rectus femoris muscle is retracted medially, after which the vascular bundle becomes visible, consisting of one arteries - the descending branch of the lateral artery, enveloping the thigh, two comitant veins and the motor branch of the femoral nerve; then the tissues of the flap are dissected along the neurovascular bundle in the direction of the marked perforating vessels, the skin area is cut out along the marking line, including the deep fascia and the adjacent area of the anterior edge of the vastus lateralis muscle in the composition of the flap tissues, the flap is continued to be isolated in the proximal direction along the vascular pedicle, the the vascular pedicle of the required length and cross it proximally with suturing and ligation, as a result, a musculoskeletal flap is obtained, the donor wound is sutured in layers, the flap is placed in the area of the defect to be repaired in the oral cavity, then, under microscopic magnification, neural anastomoses, one arterial and two venous anastomoses are applied , then in the oral cavity, the flap is sutured along the perimeter to the edges of the defect of the floor of the mouth, characterized by the fact that at the preoperative stage: planning the resection volume and the corresponding volume of donor tissues, measuring the length of the tongue from its tip to the root - x, and the distance between the right and left middle molars of the lower jaw - y; at the operational stage: they organize the parallel work of two surgical teams - brigade No. 1 and brigade No. 2; team No. 1 performs an operation on the head and neck, while at the first stage of the operation, a tracheostomy is performed, a tracheostomy tube is installed, re-intubation is performed, lymphadenectomy is performed upper zonal or classical from a T-shaped access, while lymph node dissection is performed precisely while preserving the large ear nerve for subsequent sensitive reinnervation of the flap, the descending branch of the hypoglossal nerve as a motor recipient nerve, while maintaining the common, external and internal carotid arteries, the internal jugular vein and its branches; further, in the submandibular region between the hyoid bone and the body of the lower jaw, a lateral pharyngotomy is performed and a tunnel is formed from the surface of the neck to the oral cavity for the subsequent passage of the vascular pedicle of the flap and the performance of microvascular and neural anastomoses on the neck; at the same time, team No. 2 performs an operation on the area of the left thigh, while sampling a musculoskeletal flap from the anterolateral surface of the thigh, for which a flap template is interoperatively drawn on sterile paper, while the template has a rectangular shape, the calculated length and width: the width ab corresponds to the length resected tongue x with the addition of 20% of the length, taking into account the subsequent shrinkage of the flap; the length bc is calculated using the formula bc=2.6•y, where y is the distance between the right and left middle molars of the lower jaw, the prepared template is placed on the anterolateral surface of the left thigh, placing the midline of the template along its long side along the descending branch of the lateral artery, the circumflex thigh, while placing the central part of the template over the perforating vessels, marking is applied to the skin according to the template, the projection of the course of the main neurovascular bundle is marked over the template, the stages of flap extraction are carried out, after identifying the perforating vessels, the template is taken again and the final marking is applied to the skin, positioning in the same way, as a result, a rectangular-shaped musculoskeletal flap is obtained, having a vascular-muscular pedicle, with the inclusion of two nerves, the motor one - the motor branch of the femoral nerve, and the sensory one - the saphenous nerve of the thigh; then the teams change operating fields, team No. 1 sutures the donor wound in layers, installs two drains with active aspiration into the intermuscular and subcutaneous spaces, while the tissues are compared without tension, the skin is sutured with a cosmetic suture, sterile dressings are applied; team No. 2 prepares the flap, while: - if the lesion of the oral cavity is localized mainly on the right and lymph node dissection was performed on the right, then the points ad are connected, - if the lesions of the oral cavity are localized mainly on the left and lymph node dissection was performed on the left, then the points bc are connected, the flap is shaped into a complex volume a geometric figure that combines a cone - the tip of the tongue, and a semi-cylinder - the body of the tongue, the cone is formed by symmetrical wedge-shaped de-epidermization of the lateral rectangular triangles of the flap, having an angle of 22.5 °, the bases of which are located along the long side of the rectangle, and the vertices reach the midline, the lower the surface of the formed cone is fixed with interrupted sutures; then the flap is placed in the area of the oral defect to be repaired, while the musculovascular pedicle is passed through the previously formed tunnel, while in order to avoid displacement of the flap, it is fixed at the base to the alveolar process of the lower jaw at two opposite points, the vascular pedicle is positioned on the neck area ; then, under microscopic magnification, an “end-to-side” arterial anastomosis of the donor descending branch of the lateral artery around the thigh is performed to the recipient external carotid artery with Prolen 8/0 thread, then two venous anastomoses of the comitant veins of the flap to the internal jugular vein “end-to-side” are performed, or to the branches of the internal jugular vein "end-to-end" with the Prolen 8/0 thread, then the blood flow is started, the adequacy of the flap perfusion is checked, and hemostasis is performed; then, under microscopic magnification, two epiperineural anastomoses are performed with the Prolen 9/0 thread of the donor motor branch of the femoral nerve to the recipient descending branch of the hypoglossal nerve, the donor saphenous nerve of the thigh to the proximal end of the greater auricular nerve, taking into account the direction of the nerve fibers from the cervical plexus to the auricle; further, a permanent marker on the skin marks a point above the anastomosis zone to the large ear nerve; the wound on the neck is sutured in layers, then in the oral cavity the flap is sutured with nodal eight-shaped sutures along the perimeter to the edges of the defect in the floor of the mouth, replenishing the volume and shaping the previously resected tissues; at the postoperative stage: electrical stimulation of the large ear nerve is performed below the neural anastomosis zone, for which an electrical stimulator is taken with the ability to reproduce transcutaneous electrical nerve stimulation, on the neck, at a point marked during the operation above the anastomosis zone, a disposable active electrode is fixed, and a passive electrode is fixed along the way nerve 3 cm above the previous electrode, connect the terminals of the wires of the electrical stimulator to the electrodes, within 10 days after the operation, electrical stimulation is performed once a day with a frequency of 50 Hz, a duration of 20 μs and a current of 30-40 mA for 10 minutes.

The claimed technical solution is illustrated in Fig.1 - Fig. 2.

Figure 1 shows the layout of the flap of the anterolateral surface of the thigh of a rectangular shape, with the inclusion of the motor branch of the femoral nerve and the lateral cutaneous nerve of the thigh, where:

a, b, c, d – flap angles,

x - the length of the tongue from its tip to the root (indicated by a horizontal double-sided arrow),

y is the distance between the middle molars of the lower jaw (indicated by a vertical double-sided arrow),

1 - anterior superior iliac spine,

2 - descending branch of the lateral artery around the thigh,

3 - lateral cutaneous nerve of the thigh,

4 - motor branch of the femoral nerve,

5 - lateral edge of the patella,

dotted line along the thigh from top to bottom - the axial line marking the skin area of the flap, connecting points 1 and 5.

Figure 2 shows the layout of the electrodes for transcutaneous electrical nerve stimulation of the anastomosis zone of the large auricular nerve to the lateral cutaneous nerve of the thigh, where:

3 - lateral cutaneous nerve of the thigh,

6 - disposable passive electrode,

7 - zone of neural anastomosis,

8 – disposable active electrode,

9 - projection of the large ear nerve,

10 - apparatus for transcutaneous electrical nerve stimulation, for example, "Electronics EPB 50-01" (electrostimulator).

Next, the applicant provides a description of the claimed technical solution.

The claimed technical result is achieved by developing a method for the surgical treatment of oral cancer with functional reconstruction.

The peculiarity of the claimed method lies in the fact that plastic surgery of the tissues of the floor of the mouth and tongue is carried out with a musculoskeletal flap of the anterior-lateral surface of the thigh, supplied with blood by the branches of the descending branch of the lateral artery that surrounds the thigh, which has a (flap) rectangular shape, the length of the sides, which are calculated depending on on the length of the resected tongue and the distance between the middle molars of the lower jaw (y) according to the formula bc=2.6y. The flap is shaped into a complex three-dimensional geometric figure that combines a cone (tip of the tongue) and a half-cylinder (body of the tongue), connecting the ends of the long side of the rectangle, while the cone is formed by symmetrical wedge-shaped de-epidermization of the lateral right-angled triangles of the flap, having an angle of 22.5 ° C, the bases of which are located on the long side of the rectangle, and the tops reach the midline. The formed flap is moved into the oral cavity, with the skin platform in the position of the mucous membrane of the bottom of the oral cavity and tongue. The muscle fragment of the flap restores the soft tissues of the floor of the mouth, tongue, submandibular region.

For double reinnervation of the flap, the donor motor branch of the femoral nerve is anastomosed to the recipient descending branch of the hypoglossal nerve, the donor saphenous nerve of the thigh to the proximal end of the greater auricular nerve. In the early postoperative period, electrical stimulation of the large ear nerve is performed below the zone of the neural suture.

A feature of the method is the reconstruction of the functional volume, bulge and tip of the tongue, due to the unique design of the flap.

Next, the applicant shows the sequence of actions of the claimed method.

preoperative stage.

Plan the volume of resection and the corresponding volume of donor tissue.

On the area of the left thigh, the perforating vessels of the descending branch of the lateral circumflex artery are marked using an ultrasound machine in Doppler mode.

The length of the tongue is measured from its tip to the root (x) and the distance between the right and left middle molars of the lower jaw (y).

Operational stage.

They organize the parallel work of two surgical teams - brigade No. 1 and brigade No. 2.

Team No. 1 performs an operation on the head and neck.

The patient under endotracheal anesthesia is placed in the supine position, with a roller placed under the shoulder blades. A nasogastric tube is installed and fixed to the bridge of the nose, for example, with adhesive tape. Next, two operating fields are processed and prepared for the simultaneous operation of two surgical teams.

At the first stage of the operation, a tracheostomy is performed, a tracheostomy tube is installed, and reintubation is performed.

Team No. 1 performs an operation on the head and neck in the volume required by oncological principles - they perform a resection of the tongue and tissues of the floor of the mouth. Next, cervical lymphadenectomy is performed on the side of the lesion - upper zonal or classic from the T-shaped access in the submandibular region and in the projection of the anterior edge of the sternocleidomastoid muscle. In this case, lymph node dissection is performed precisely with the preservation of the large ear nerve for subsequent sensitive reinnervation of the flap, the descending branch of the hypoglossal nerve as a motor recipient nerve. At the same time, neck tissue is isolated in a single block along the main vascular bundle with preservation of the common, external and internal carotid arteries, internal jugular vein and its branches.

Further, in the submandibular region between the hyoid bone and the body of the lower jaw, a lateral pharyngotomy is performed and a tunnel is formed from the surface of the neck to the oral cavity for subsequent passage of the vascular pedicle of the flap and performing microvascular and neural anastomoses on the neck region.

At the same time, team No. 2 performs an operation on the area of the left thigh (Figure 1),

at the same time, a musculocutaneous flap is taken from the anterolateral surface of the thigh.

To do this, draw the axial line of the flap (indicated by a dotted line in Fig.1) along the bone landmarks, connecting the anterior superior iliac spine (pos. 1) and the lateral edge of the patella (pos. 5).

Next, a flap template is interoperatively drawn on sterile paper (it is possible to use paper from sterile gloves), while the template has a strictly rectangular shape, the calculated length and width:

– width ab corresponds to the length of the resected tongue (x) with the addition of about 20% of the length, taking into account the subsequent shrinkage of the flap;

– length bc is calculated by the formula bc = 2.6 ⋅ y, where y is the distance between the right and left middle molars of the lower jaw.

A factor of 2.6 is calculated from the formula for calculating the length of the semicircle above the line connecting the right and left mandibular middle molars, adding the length of the base itself, which is the diameter of the semicircle, as follows:

bc=yπ/2+y

bc=y(π/(2 )+1)

at π=3.14

bc=2.57•y

rounding, we get

bc=2.6⋅y

The prepared template is placed on the anterolateral surface of the left thigh, placing the midline of the template along its long side along the descending branch of the lateral artery that goes around the thigh (pos. 2), while placing the central part of the template above the perforating vessels, marked using Doppler ultrasound on the preoperative stage.

Using a solution of brilliant green, markings are applied to the skin according to the template, and a projection of the course of the main neurovascular bundle is marked over the template.

An incision is made along the marking line in the projection of the course of the vascular pedicle. At the same time, a groove is determined between the rectus femoris muscle and the tensor fascia lata. The tensor fascia lata and the rectus femoris are separated in a blunt way, then the rectus femoris is retracted medially, after which the vascular bundle becomes visible, consisting of one artery - the descending branch of the lateral artery that surrounds the thigh (pos. 2), two comitant veins and a motor branch femoral nerve (pos.4).

Next, the flap tissues are dissected along the neurovascular bundle in the direction of the marked perforating vessels, which perforate the vastus lateralis muscle of the thigh along its front edge (usually 2-3 perforating branches pass to the skin area of the flap).

After identifying the perforating vessels, the template is taken again and the final marking is applied to the skin, placing it in the same way (placing the midline of the template along its long side along the descending branch of the lateral artery that surrounds the thigh (pos. 2), while placing the central part of the template above the perforating vessels ).

The skin area is cut out along the marking line, including the deep fascia and the adjacent area of the anterior edge of the vastus lateralis muscle in the composition of the flap tissues. At the same time, during the preparation of the flap, a search is made for the sensitive lateral cutaneous nerve of the thigh (pos. 3) (which pierces the wide fascia in the upper third of the thigh and branches in the skin into several small and two or three large nerves, towards the knee joint).

The flap is continued in the proximal direction along the vascular pedicle, not skeletonizing the vessels, but including the surrounding muscle tissues, for the subsequent placement of the musculovascular pedicle on the neck area, which makes it possible to replenish the volume of the neck tissues on which lymphadenectomy was performed and close the main vascular nerve bundle of the neck.

Allocate a vascular pedicle of the required length (on average, it is possible to isolate a vascular pedicle 8-10 cm long).

The vascular pedicle is transected proximally with suturing and ligation.

The cut-off flap is moved to a sterile tray and transferred to the head and neck area.

As a result, a rectangular musculoskeletal flap is obtained, having a vascular-muscular pedicle, with the inclusion of two nerves, the motor one - the motor branch of the femoral nerve (pos. 4), and the sensory one - the lateral cutaneous nerve of the thigh (pos. 3).

Next, the brigades change the operating fields.

Team No. 1 sutures the donor wound in layers, installs two drains with active aspiration into the intermuscular and subcutaneous spaces. In this case, the tissues are compared without tension, the skin is sutured with a cosmetic suture, and sterile dressings are applied.

Team No. 2 prepares the flap (Figure 1), for example, on the preparation table, while:

- if the lesion of the oral cavity is localized mainly on the right and the lymph node dissection was performed on the right, then the ad points are connected,

- if the lesion of the oral cavity is localized mainly on the left and the lymph node dissection was performed on the left, then the bc points are connected.

The flap is shaped into a complex three-dimensional geometric figure that combines a cone (tip of the tongue) and a half-cylinder (body of the tongue), the cone is formed by symmetrical wedge-shaped de-epidermization of the lateral right-angled triangles of the flap, having an angle of 22.5°, the bases of which are located along the long side of the rectangle, and peaks reach the midline. The lower surface of the formed cone is fixed with interrupted sutures.

Next, the flap is placed in the area of the defect to be repaired in the oral cavity. At the same time, the musculovascular pedicle is passed through a previously formed tunnel from the oral cavity to the zone of recipient vessels and nerves of the neck region. To avoid displacement of the flap, it is fixed at the base to the alveolar process of the lower jaw at two opposite points with a thread, for example, capron 5/0. The vascular pedicle is positioned on the neck area.

A microscope and microsurgical instruments are prepared for performing microvascular and neural anastomoses. Under microscopic magnification, an end-to-side arterial anastomosis is performed from the donor descending branch of the lateral circumflex artery to the recipient external carotid artery with a Prolene 8/0 thread. Next, two venous anastomoses of the comitant veins of the flap are performed to the internal jugular vein "end-to-side" or to the branches of the internal jugular vein "end-to-end" with Prolen 8/0 thread. Next, blood flow is started, the adequacy of flap perfusion is checked, and hemostasis is performed.

Then, under microscopic magnification, two epiperineural anastomoses are performed with the Prolen 9/0 thread of the donor motor branch of the femoral nerve to the recipient descending branch of the hypoglossal nerve, the donor saphenous nerve of the thigh to the proximal end of the greater auricular nerve (pos. 9), taking into account the direction of the nerve fibers from the cervical plexus to auricle.

Next, a permanent marker on the skin marks a point above the anastomosis area to the large ear nerve.

The wound on the neck is sutured in layers, without tension, leaving passive rubber graduates (active aspiration is unacceptable due to the likelihood of damage to the vascular anastomoses).

Further, in the oral cavity, the flap, previously fixed with leading sutures, is sutured with interrupted eight-shaped sutures along the perimeter to the edges of the defect in the floor of the mouth, replenishing the volume and shaping the previously resected tissues. Perfusion of flap tissues is controlled, hemostasis is controlled. Several drains made of glove rubber are introduced into the intersutural region.

The oral cavity is washed with an aqueous solution of chlorhexidine, dried and a solution of Vinylin is applied.

Postoperative stage (Figure 2).

At the postoperative stage, electrical stimulation of the large ear nerve is performed below the neural anastomosis zone (pos. 7). To do this, take an electrical stimulator (pos. 10) with the ability to reproduce transcutaneous electrical nerve stimulation (TENS), for example, "Electronics EPB 50-01". On the neck area, at a point marked during the operation over the anastomosis zone, a disposable active electrode (pos. 8) is fixed, and a disposable passive electrode (pos. 6) is fixed along the nerve, for example, 3 cm above the previous electrode. Connect the wire terminals of the electrostimulator apparatus to the electrodes. Within 10 days after the operation, electrical stimulation is performed once a day with a frequency of 50 Hz, a duration of 20 μs and a current of 30-40 mA for 10 minutes.

Further, as a rehabilitation, a number of complex measures are carried out, including classes with a speech therapist as early as possible. Control of swallowing function is assessed using radiography with contrast.

Further, the applicant provides examples of the implementation of the claimed technical solution.

The feasibility of the technical result is confirmed by clinical examples of the application of the method in the reconstructive treatment of patients with tumors of the tongue and floor of the mouth in the oncology department of surgical methods of treatment of the University Clinical Hospital No. 1 (Sechenov University).

Example 1. Surgical treatment of oral cancer with functional reconstruction with upper zonal lymphadenectomy.

Patient H., 36 years old, diagnosed with cancer of the lateral surface of the tongue on the right pT3N0M0, G1, stage III. Condition after 2 courses of neoadjuvant polychemotherapy according to the TPF scheme (Docetaxel, Cisplatin, 5-fluorouracil).

The operation was carried out according to the claimed method.

preoperative stage.

Planned resection in the amount of subtotal glossectomy.

The perforating vessels of the descending branch of the lateral circumflex artery were marked on the area of the left thigh using an ultrasound machine in Doppler mode.

We measured the length of the tongue from its tip to the root (x=10 cm) and the distance between the right and left middle molars of the lower jaw (y=6 cm).

Operational stage.

The patient under endotracheal anesthesia was placed in the supine position, with a roller placed under the shoulder blades. A nasogastric tube was installed and fixed to the bridge of the nose with adhesive tape. Then, two operating fields were processed and prepared for the simultaneous work of two surgical teams.

At the first stage of the operation, a tracheostomy was performed, a tracheostomy tube was installed, and reintubation was performed.

Team No. 1 performed an operation on the head and neck in the volume required by oncological principles - they performed a resection of the tongue and tissues of the floor of the oral cavity. Next, an upper zonal cervical lymphadenectomy was performed on the side of the lesion - from a 6-cm incision in the submandibular region. At the same time, the large ear nerve was preserved for subsequent sensitive reinnervation of the flap, and the descending branch of the hypoglossal nerve as a motor recipient nerve. At the same time, neck tissue was isolated in a single block along the main vascular bundle with preservation of the common, external and internal carotid arteries, internal jugular vein and its branches.

Further, in the submandibular region on the right, between the hyoid bone and the body of the lower jaw, a lateral pharyngotomy was performed and a tunnel was formed from the surface of the neck to the oral cavity for subsequent passage of the vascular pedicle of the flap and performing microvascular and neural anastomoses on the neck region.

At the same time, team No. 2 took a musculoskeletal flap from the anterolateral surface of the thigh.

To do this, we interoperatively drew a flap template on sterile paper (we took paper from sterile gloves), while the template has a strictly rectangular shape, the calculated length and width:

- the width ab corresponds to the length of the resected tongue (x=10 cm) with the addition of about 20% of the length, taking into account the subsequent shrinkage of the flap, that is, the length is 12 cm;

– length bc is calculated by the formula bc=2.6⋅6, where 6 cm is the distance between the right and left middle molars of the lower jaw. bc = 15.6 cm, rounded up, got 16 cm.

The prepared template was placed on the anterolateral surface of the left thigh, placing the midline of the template along its long side along the descending branch of the lateral circumflex artery, while placing the central part of the template over the perforating vessels, marked using Doppler ultrasound at the preoperative stage.

Using a solution of brilliant green, markings were applied to the skin according to the template, and a projection of the course of the main neurovascular bundle was marked over the template.

An incision was made along the marking line in the projection of the course of the vascular pedicle. At the same time, a groove was identified between the rectus femoris muscle and the tensor fascia lata. The tensor fascia lata and the rectus femoris were divided bluntly, then the rectus femoris was retracted medially, after which the vascular bundle became visible, consisting of one artery - the descending branch of the lateral artery circumflexing the thigh, two comitant veins and the motor branch of the femoral nerve.

Next, the tissues of the flap were dissected along the neurovascular bundle in the direction of the marked perforating vessels that pierce the vastus lateralis muscle of the thigh along its anterior edge, 2 perforating branches were identified.

After identifying the perforating vessels, the template was taken again and the final marking was applied to the skin, positioning it in the same way (placing the midline of the template along its long side along the descending branch of the lateral artery that envelopes the thigh, while placing the central part of the template above the perforating vessels).

The skin area was cut out along the marking line, including the deep fascia and the adjacent area of the anterior edge of the vastus lateralis muscle in the composition of the flap tissues. At the same time, during the preparation of the flap, a search was made for the sensitive lateral femoral cutaneous nerve.

We continued to isolate the flap in the proximal direction along the vascular pedicle, without skeletonizing the vessels, but including the surrounding muscle tissues, for subsequent placement of the musculovascular pedicle on the neck area, which makes it possible to replenish the volume of the neck tissues on which lymphadenectomy was performed and close the main vascular nerve bundle of the neck.

A vascular pedicle 7 cm long was isolated.

The vascular pedicle was transected proximally with suturing and ligation.

The dissected flap was placed in a sterile tray and transferred to the head and neck area.

As a result, a rectangular musculoskeletal flap 12x16 cm in size was obtained, having a vascular-muscular pedicle, with the inclusion of two nerves, the motor one - the motor branch of the femoral nerve, and the sensory one - the saphenous nerve of the thigh.

Next, the brigades changed the operating fields.

Team No. 1 sutured the donor wound in layers, installed two drains with active aspiration into the intermuscular and subcutaneous spaces. At the same time, the tissues were compared without tension, the skin was sutured with a cosmetic suture, and sterile dressings were applied.

Team No. 2 shaped the flap (Figure 1) on the preparation table, while:

– since the lesion of the oral cavity is localized mainly on the right and the lymph node dissection was performed on the right, the ad points were connected.

The flap was given the shape of a complex three-dimensional geometric figure, combining a cone (tip of the tongue) and a semicylinder (body of the tongue), the cone was formed by symmetrical wedge-shaped de-epidermization of the lateral right-angled triangles of the flap, having an angle of 22.5°, the bases of which are located along the long side of the rectangle, and peaks reach the midline. The lower surface of the formed cone was fixed with interrupted sutures.

Next, the flap was placed in the area of the defect to be repaired in the oral cavity. At the same time, the musculovascular pedicle was passed through a previously formed tunnel from the oral cavity to the zone of recipient vessels and nerves of the neck region. To avoid displacement of the flap, it was fixed at the base to the alveolar process of the lower jaw at two opposite points with a 5/0 capron thread. The vascular pedicle was positioned on the neck area.

We prepared a microscope and microsurgical instruments for performing microvascular and neural anastomoses. An end-to-side arterial anastomosis was performed under microscopic magnification of the donor descending branch of the lateral circumflex artery to the recipient external carotid artery with a Prolene 8/0 thread. Next, two venous anastomoses of the comitant veins of the flap to the internal jugular vein were performed, one - "end-to-side", the second - to the branch of the internal jugular vein "end-to-end" with Prolen 8/0 thread. Next, the blood flow was started, the adequacy of the flap perfusion was checked, and hemostasis was performed.

Then, under microscopic magnification, two epiperineural anastomoses were performed with the Prolen 9/0 thread of the donor motor branch of the femoral nerve to the recipient descending branch of the hypoglossal nerve, the donor saphenous nerve of the thigh to the proximal end of the greater auricular nerve, taking into account the direction of the nerve fibers from the cervical plexus to the auricle.

Next, a point above the area of anastomosis to the greater ear nerve was marked with a permanent marker on the skin.

The wound on the neck was sutured in layers, without tension, leaving passive rubber graduates.

Further, in the oral cavity, the flap previously fixed with leading sutures was sutured with interrupted eight-shaped sutures along the perimeter to the edges of the defect in the floor of the mouth, replenishing the volume and shaping the previously resected tissues. Carried out the control of perfusion of the tissues of the flap, carried out the control of hemostasis. Three drains made of glove rubber were introduced into the intersutural region.

The oral cavity was washed with an aqueous solution of chlorhexidine, dried and a solution of Vinylin was applied.

postoperative stage.

At the postoperative stage, electrical stimulation of the greater ear nerve was performed below the neural anastomosis zone. To do this, they took an electrical stimulator with the ability to reproduce transcutaneous electrical nerve stimulation (TENS), "Electronics EPB 50-01". On the neck area, at a point marked during the operation over the anastomosis zone, a disposable active electrode was fixed, and a passive electrode was fixed along the nerve 3 cm above the previous electrode. The terminals of the wires of the apparatus "Electronics EPB 50-01" were connected to the electrodes. Within 10 days after the operation, electrical stimulation was performed once a day with a frequency of 50 Hz, a duration of 20 μs and a current of 40 mA for 10 minutes.

Further, as a rehabilitation, a number of complex measures were carried out, including classes with a speech therapist as early as possible. Swallowing function control was assessed by radiography with contrast.

The patient was decannulated 2 weeks after surgery. The nasogastric tube was removed 3 weeks after the operation.

As a result, at a follow-up period of 6 months after the operation, restoration of the sensitive innervation of the flap was achieved, which is confirmed by the patient's sensation of hot and cold, the presence of a tingling sensation in the neotongue during electrical stimulation of the neural anastomosis zone, and the discriminatory sensitivity was less than 5 mm.

There was a reduction in the volume of the flap by 15%, while it retained its shape, bulge and protruding tip, which made it possible to restore adequate swallowing and speech function to the satisfaction of the patient.

There were no functional or aesthetic complaints from the donor wound of the left thigh.

Achieved nutrition with pureed food.

In the early postoperative period, complications in the form of impaired flap perfusion or partial flap necrosis were not observed, which indicates a reliable blood supply.

Example 2. Surgical treatment of oral cancer with functional reconstruction with classical lymphadenectomy.

Patient M., 56 years old, diagnosed with cancer of the lateral surface of the tongue on the left pT4aN0M0, G2, stage IVa. Condition after 3 courses of photodynamic therapy against the background of the introduction of Cisplatin.

The operation was carried out according to the claimed method.

preoperative stage.

Planned resection in the amount of total glossectomy.

The perforating vessels of the descending branch of the lateral circumflex artery were marked on the area of the left thigh using an ultrasound machine in Doppler mode.

We measured the length of the tongue from its tip to the root (x=9 cm) and the distance between the right and left middle molars of the lower jaw (y=7 cm).

Operational stage.

The patient under endotracheal anesthesia was placed in the supine position, with a roller placed under the shoulder blades. A nasogastric tube was installed and fixed to the bridge of the nose with adhesive tape. Then, two operating fields were processed and prepared for the simultaneous work of two surgical teams.

At the first stage of the operation, a tracheostomy was performed, a tracheostomy tube was installed, and reintubation was performed.

Team No. 1 performed an operation on the head and neck in the volume required by oncological principles - they performed a total glossectomy and resection of the tissues of the floor of the oral cavity. Next, a classic cervical lymphadenectomy was performed on the left from a T-shaped access in the submandibular region and in the projection of the anterior edge of the sternocleidomastoid muscle. At the same time, the large ear nerve was preserved for subsequent sensitive reinnervation of the flap, and the descending branch of the hypoglossal nerve as a motor recipient nerve. At the same time, neck tissue was isolated in a single block along the main vascular bundle with preservation of the common, external and internal carotid arteries, internal jugular vein and its branches.

Further, in the submandibular region on the left, between the hyoid bone and the body of the lower jaw, a lateral pharyngotomy was performed and a tunnel was formed from the surface of the neck to the oral cavity for subsequent passage of the vascular pedicle of the flap and performing microvascular and neural anastomoses on the neck region.

At the same time, team No. 2 took a musculoskeletal flap from the anterolateral surface of the thigh.

To do this, we interoperatively drew a flap template on sterile paper (we took paper from sterile gloves), while the template has a strictly rectangular shape, the calculated length and width:

- the width ab corresponds to the length of the resected tongue (x=9 cm) with the addition of about 20% of the length, taking into account the subsequent shrinkage of the flap, that is, the length is 11 cm;

– length bc is calculated by the formula bc=2.6⋅7, where 7 cm is the distance between the right and left middle molars of the lower jaw. bc = 18.2 cm, rounded up, got 18 cm.

The prepared template was placed on the anterolateral surface of the left thigh, placing the midline of the template along its long side along the descending branch of the lateral circumflex artery, while placing the central part of the template over the perforating vessels, marked using Doppler ultrasound at the preoperative stage.

Using a solution of brilliant green, markings were applied to the skin according to the template, and a projection of the course of the main neurovascular bundle was marked over the template.

An incision was made along the marking line in the projection of the course of the vascular pedicle. At the same time, a groove was identified between the rectus femoris muscle and the tensor fascia lata. The tensor fascia lata and the rectus femoris were divided bluntly, then the rectus femoris was retracted medially, after which the vascular bundle became visible, consisting of one artery - the descending branch of the lateral artery circumflexing the thigh, two comitant veins and the motor branch of the femoral nerve.

Next, the flap tissues were dissected along the neurovascular bundle in the direction of the marked perforating vessels that pierce the vastus lateralis muscle of the thigh along its anterior edge; 3 perforating branches were identified.

After identifying the perforating vessels, the template was taken again and the final marking was applied to the skin, positioning it in the same way (placing the midline of the template along its long side along the descending branch of the lateral artery that envelopes the thigh, while placing the central part of the template above the perforating vessels).

The skin area was cut out along the marking line, including the deep fascia and the adjacent area of the anterior edge of the vastus lateralis muscle in the composition of the flap tissues. At the same time, during the preparation of the flap, a search was made for the sensitive lateral femoral cutaneous nerve.

We continued to isolate the flap in the proximal direction along the vascular pedicle, without skeletonizing the vessels, but including the surrounding muscle tissues, for subsequent placement of the musculovascular pedicle on the neck area, which makes it possible to replenish the volume of the neck tissues on which lymphadenectomy was performed and close the main vascular nerve bundle of the neck.

A vascular pedicle 8 cm long was isolated.

The vascular pedicle was transected proximally with suturing and ligation.

The dissected flap was placed in a sterile tray and transferred to the head and neck area.

As a result, a rectangular musculoskeletal flap 11x18 cm in size was obtained, having a vascular-muscular pedicle, with the inclusion of two nerves, the motor one - the motor branch of the femoral nerve, and the sensory one - the saphenous nerve of the thigh.

Next, the brigades changed the operating fields.

Team No. 1 sutured the donor wound in layers, installed two drains with active aspiration into the intermuscular and subcutaneous spaces. At the same time, the tissues were compared without tension, the skin was sutured with a cosmetic suture, and sterile dressings were applied.

Team No. 2 shaped the flap (Figure 1) on the preparation table, while:

- since the lesion of the oral cavity is localized mainly on the left and lymph node dissection was performed on the left, the points bc were connected.

The flap was given the shape of a complex three-dimensional geometric figure, combining a cone (tip of the tongue) and a semicylinder (body of the tongue), the cone was formed by symmetrical wedge-shaped de-epidermization of the lateral right-angled triangles of the flap, having an angle of 22.5°, the bases of which are located along the long side of the rectangle, and peaks reach the midline. The lower surface of the formed cone was fixed with interrupted sutures.

Next, the flap was placed in the area of the defect to be repaired in the oral cavity. At the same time, the musculovascular pedicle was passed through a previously formed tunnel from the oral cavity to the zone of recipient vessels and nerves of the neck region. To avoid displacement of the flap, it was fixed at the base to the alveolar process of the lower jaw at two opposite points with a 5/0 capron thread. The vascular pedicle was positioned on the neck area.

We prepared a microscope and microsurgical instruments for performing microvascular and neural anastomoses. An end-to-side arterial anastomosis was performed under microscopic magnification of the donor descending branch of the lateral circumflex artery to the recipient external carotid artery with a Prolene 8/0 thread. Next, two venous anastomoses of the comitant veins of the flap to the internal jugular vein were performed, one - "end-to-side", the second - to the branch of the internal jugular vein "end-to-end" with Prolen 8/0 thread. Next, the blood flow was started, the adequacy of the flap perfusion was checked, and hemostasis was performed.

Then, under microscopic magnification, two epiperineural anastomoses were performed with the Prolen 9/0 thread of the donor motor branch of the femoral nerve to the recipient descending branch of the hypoglossal nerve, the donor saphenous nerve of the thigh to the proximal end of the greater auricular nerve, taking into account the direction of the nerve fibers from the cervical plexus to the auricle.

Next, a point above the area of anastomosis to the greater ear nerve was marked with a permanent marker on the skin.

The wound on the neck was sutured in layers, without tension, leaving passive rubber graduates.

Further, in the oral cavity, the flap previously fixed with leading sutures was sutured with interrupted eight-shaped sutures along the perimeter to the edges of the defect in the floor of the mouth, replenishing the volume and shaping the previously resected tissues. Carried out the control of perfusion of the tissues of the flap, carried out the control of hemostasis. Three drains made of glove rubber were introduced into the intersutural region.

The oral cavity was washed with an aqueous solution of chlorhexidine, dried and a solution of Vinylin was applied.

postoperative stage.

At the postoperative stage, electrical stimulation of the greater ear nerve was performed below the neural anastomosis zone. To do this, they took an electrical stimulator with the ability to reproduce transcutaneous electrical nerve stimulation (TENS), "Electronics EPB 50-01". On the neck area, at a point marked during the operation over the anastomosis zone, a disposable active electrode was fixed, and a passive electrode was fixed along the nerve 3 cm above the previous electrode. The terminals of the wires of the apparatus "Electronics EPB 50-01" were connected to the electrodes. Within 10 days after the operation, electrical stimulation was performed once a day with a frequency of 50 Hz, a duration of 20 μs and a current of 30 mA for 10 minutes.

Further, as a rehabilitation, a number of complex measures were carried out, including classes with a speech therapist as early as possible. Swallowing function control was assessed by radiography with contrast.

The patient was decannulated 3 weeks after surgery.

The nasogastric tube was removed 4 weeks after the operation.

As a result, at a follow-up period of 6 months after the operation, restoration of the sensitive innervation of the flap was achieved, which is confirmed by the patient's sensation of hot and cold, the presence of a tingling sensation in the neotongue during electrical stimulation of the neural anastomosis zone, and the discriminatory sensitivity was 5-10 mm.

There was a reduction in the volume of the flap by 20%, while it retained its shape, bulge and protruding tip, which made it possible to restore adequate swallowing and speech function to the satisfaction of the patient.

There were no functional or aesthetic complaints from the donor wound of the left thigh.

Achieved nutrition with pureed food.

In the early postoperative period, complications in the form of impaired flap perfusion or partial flap necrosis were not observed, which indicates a reliable blood supply.

The patient returned to her professional activities.

Thus, from the above, we can conclude that the applicant has achieved the claimed technical result:

- improved restoration of flap innervation due to electrical stimulation of the neural anastomosis zone of the lateral saphenous nerve of the thigh to the greater auricular nerve in the early postoperative period;

- the required volume of the flap has been achieved by preliminary calculation of its dimensions, taking into account the subsequent partial shrinkage of the transplanted tissues (flap);

- the integrity of the lower jaw is preserved due to the lateral pharyngotomy and the formation of a tunnel from the surface of the neck to the oral cavity for subsequent passage of the vascular pedicle of the flap to the neurovascular bundle of the neck;

- improved reliability of blood supply to the flap by performing an arterial anastomosis of the donor artery to the external carotid artery "end-to-side";

the operation time was reduced due to the organization of parallel work of two surgical teams.

Claims (1)

A method for surgical treatment of oral cancer with functional reconstruction, which consists in the fact that first a preoperative stage is carried out: perforating vessels of the descending branch of the lateral artery around the thigh are marked on the left thigh using an ultrasound machine in Doppler mode, then the operating stage is performed: perform an operation on the head and neck in the volume required by oncological principles - resection of the tongue and tissues of the bottom of the mouth, cervical lymphadenectomy on the side of the lesion; legs, at the same time, they determine the groove between the rectus femoris muscle and the tensor fascia lata of the thigh, bluntly separate the tensor of the wide fascia of the thigh and the rectus femoris, then the rectus femoris is retracted medially, after which the vascular bundle becomes visible, consisting of one artery - the descending branch of the lateral the circumflex artery, two comitant veins and the motor branch of the femoral nerve; then the tissues of the flap are dissected along the neurovascular bundle in the direction of the marked perforating vessels, the skin area is cut out along the marking line, including the deep fascia and the adjacent area of the anterior edge of the vastus lateralis muscle in the composition of the flap tissues, the flap is continued to be isolated in the proximal direction along the vascular pedicle, the the vascular pedicle of the required length and cross it proximally with suturing and ligation, as a result, a musculoskeletal flap is obtained, the donor wound is sutured in layers, the flap is placed in the area of the defect to be repaired in the oral cavity, then, under microscopic magnification, neural anastomoses, one arterial and two venous anastomoses are applied , then in the oral cavity, the flap is sutured along the perimeter to the edges of the defect of the floor of the mouth, characterized in that at the preoperative stage: the volume of resection and the corresponding volume of donor tissues are planned, the length of the tongue is measured from its tip to the root - x, and the distance between the right and left middle molars of the lower jaw - y; at the operational stage: organize the parallel work of two surgical teams - brigade No. 1 and brigade No. 2; team No. 1 performs an operation on the head and neck, while at the first stage of the operation, a tracheostomy is performed, a tracheostomy tube is installed, re-intubation is performed, lymphadenectomy is performed upper zonal or classical from a T-shaped access, while lymph node dissection is performed precisely while preserving the large ear nerve for subsequent sensitive reinnervation of the flap, the descending branch of the hypoglossal nerve as a motor recipient nerve, while maintaining the common, external and internal carotid arteries, the internal jugular vein and its branches; further, in the submandibular region between the hyoid bone and the body of the lower jaw, a lateral pharyngotomy is performed and a tunnel is formed from the surface of the neck to the oral cavity for the subsequent passage of the vascular pedicle of the flap and the performance of microvascular and neural anastomoses on the neck; at the same time, team No. 2 performs an operation on the area of the left thigh, while sampling a musculoskeletal flap from the anterolateral surface of the thigh, for which a flap template is interoperatively drawn on sterile paper, while the template has a rectangular shape, the calculated length and width: the width ab corresponds to the length resected tongue x with the addition of 20% of the length, taking into account the subsequent shrinkage of the flap; the length bc is calculated using the formula bc=2.6•y, where y is the distance between the right and left middle molars of the lower jaw, the prepared template is placed on the anterolateral surface of the left thigh, placing the midline of the template along its long side along the descending branch of the lateral artery, the circumflex thigh, while placing the central part of the template over the perforating vessels, marking is applied to the skin according to the template, the projection of the course of the main neurovascular bundle is marked over the template, the stages of flap extraction are carried out, after identifying the perforating vessels, the template is taken again and the final marking is applied to the skin, positioning in the same way, as a result, a rectangular-shaped musculoskeletal flap is obtained, having a vascular-muscular pedicle, with the inclusion of two nerves, the motor one - the motor branch of the femoral nerve, and the sensory one - the saphenous nerve of the thigh; then the teams change operating fields, team No. 1 sutures the donor wound in layers, installs two drains with active aspiration into the intermuscular and subcutaneous spaces, while the tissues are compared without tension, the skin is sutured with a cosmetic suture, sterile dressings are applied; team No. 2 prepares the flap, while: - if the lesion of the oral cavity is localized mainly on the right and lymph node dissection was performed on the right, then the points ad are connected, - if the lesions of the oral cavity are localized mainly on the left and lymph node dissection was performed on the left, then the points bc are connected, the flap is shaped into a complex volume a geometric figure that combines a cone - the tip of the tongue, and a semi-cylinder - the body of the tongue, the cone is formed by symmetrical wedge-shaped de-epidermization of the lateral rectangular triangles of the flap, having an angle of 22.5 °, the bases of which are located along the long side of the rectangle, and the vertices reach the midline, the lower the surface of the formed cone is fixed with interrupted sutures; then the flap is placed in the area of the oral defect to be repaired, while the musculovascular pedicle is passed through the previously formed tunnel, while in order to avoid displacement of the flap, it is fixed at the base to the alveolar process of the lower jaw at two opposite points, the vascular pedicle is positioned on the neck area ; then, under microscopic magnification, an “end-to-side” arterial anastomosis of the donor descending branch of the lateral artery around the thigh is performed to the recipient external carotid artery with Prolen 8/0 thread, then two venous anastomoses of the comitant veins of the flap to the internal jugular vein “end-to-side” are performed, or to the branches of the internal jugular vein "end-to-end" with the Prolen 8/0 thread, then the blood flow is started, the adequacy of the flap perfusion is checked, and hemostasis is performed; then, under microscopic magnification, two epiperineural anastomoses are performed with the Prolen 9/0 thread of the donor motor branch of the femoral nerve to the recipient descending branch of the hypoglossal nerve, the donor saphenous nerve of the thigh to the proximal end of the greater auricular nerve, taking into account the direction of the nerve fibers from the cervical plexus to the auricle; further, a permanent marker on the skin marks a point above the anastomosis zone to the large ear nerve; the wound on the neck is sutured in layers, then in the oral cavity the flap is sutured with nodal eight-shaped sutures along the perimeter to the edges of the defect in the floor of the mouth, replenishing the volume and shaping the previously resected tissues; at the postoperative stage: electrical stimulation of the large ear nerve is performed below the neural anastomosis zone, for which an electrical stimulator is taken with the ability to reproduce transcutaneous electrical nerve stimulation, on the neck, at a point marked during the operation above the anastomosis zone, a disposable active electrode is fixed, and a passive electrode is fixed along the way nerve 3 cm above the previous electrode, connect the terminals of the wires of the electrical stimulator to the electrodes, within 10 days after the operation, electrical stimulation is performed once a day with a frequency of 50 Hz, a duration of 20 μs and a current of 30-40 mA for 10 minutes.

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