RU2456930C1 - Method of plasty of gaping trachea defects - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to surgery of trachea, and can be applied in plasty of gaping trachea defects. Essence of method lies in layer-by-layer closing of a gaping defect with local tissues in combination with reinforcing implant from titanium nickelide. As reinforcing implant used is flap of fabric from titanium nickelide thread. Flap is preliminarily introduced between skin and fascia on neck section adjacent to the gaping defect, to prepare by prefabrication with local tissues. After that, it is kept for 1.5-2 months. Prepared flap is separated on pedicle, placed on the edges of the gaping defect and fixed with sutures. Wound above the flap is sewn with local tissues layer-by-layer.

EFFECT: application of claimed invention makes it possible to facilitate proper rigid frame of anterior wall without its ballottement during forced breath and cough, which results in high operation consistency and reduction of treatment terms.

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Description

The invention relates to a medical technique for the surgical treatment of tracheal diseases.

Plastic surgery of gaping tracheal defects of various genesis, such as non-closing postoperative tracheostomy, traumatic injuries, is performed by layer-by-layer closure with soft tissues of the neck, mobilized and drawn from areas adjacent to the defect. Such reconstruction of the tracheal wall is effective for transverse defect sizes not exceeding 10 mm. With large sizes, the stretched covering tissues do not have proper rigidity and are susceptible to balloting under conditions of forced respiratory or coughing tension. The task is complicated in pediatric surgery, in working with emerging, more delicate and thinner than in adults, tissues of children.

To counter the phenomena of prolapse, balloting, and in extreme cases, rupture of replacement tissues, a method of reinforcing them with moderately rigid sheet biocompatible and deformation-cycling materials is used. The consistency of such operations is largely determined by the relevance of the implants used, the improvement of which is one of the tasks of modern materials science.

In the chronology of this prior art, osteo- or chondroplasty is preceded. Yawing defects of the trachea are covered with allogeneic fragments of bones or cartilage taken from the tibia, ribs or patella [Bogomilsky RD The use of marlex with plastic removal of tracheostomy in children // Bulletin of otorhinolaryngology. 1968, No. 5. P.85-89], autogenous flaps from the fibrous layer of the mucous membrane of the lower nasal concha [Gorbunov VA, Vakhmyanin AP, Viktorova TI, Lekishvili MV New materials in reconstructive laryngotracheoplasty // 16th Congress of Otorhinolaryngologists of Russia: abstract. doc. Minsk, 2000. S.464-466] and other autografts. A number of difficulties in collecting allo and autografts, their low survival rate and, consequently, the viability of the entire surgical intervention limited the use of these materials and forced others to search in conjunction with other treatment methods. The success was facilitated by synthetic materials, the common advantage of which is the exclusion of additional trauma to the patient in the donor area and an unlimited resource of material for implantation.

A known method of plastic surgery postoperative tracheostomy using a mesh marlex. This polymer is sufficiently dense and moderately elastic so that it can solve the problem even in delicate pediatric surgery [Bogomilsky R.D. The use of marlex with plastic removal of tracheostomy in children // Bulletin of otorhinolaryngology. 1968, No. 5. S.85-89]. In the long term, the implant grows with connective tissue, increasing the strength of the reconstructed wall.

Insufficient biocompatibility of polymers, manifested in chemical instability, allergic activity, limit their use in surgery, in particular in the plastic of gaping defects of the trachea. Progress in this area was marked with the advent of medical materials based on titanium nickelide. High biocompatibility of these materials allowed to avoid the above-mentioned disadvantages and contributed to their widespread distribution.

A known method of plasticity of gaping defects of the trachea formed as a result of cancer operations on the larynx and trachea [Shinkarev SA, Mukhamedov MR et al. Clinical method of using material based on porous titanium nickelide in the surgical treatment of advanced thyroid cancer // Materials with shape memory and new technologies in medicine. Ed. prof. V.E. Gunther. Tomsk, NIIMM, 2007. P.118]. It performed endoprosthetics of the resected tracheal wall with a plate of porous titanium nickelide with fixing covering with a flap from the left sternocleidomastoid muscle. Against the background of the general success of the operation, a long implant engraftment period was revealed as a disadvantage of the method.

To a large extent, this drawback has been eliminated in another known method for plasty of gaping defects of the trachea [Method for plasty of gaping defects of the trachea / A.V. Starokha et al. / Application for invention No.2010149887 / 14 (072054), priority 03.12.2010]. In it, the gaping defect of the trachea is closed with a skin-fascial flap cut out on a leg from the neck, adjacent to the defect. To accelerate the repair and strengthen the reconstructed area in the flap, 3-5 months before the operation, a reinforcing plate of permeable-porous titanium nickelide is inserted between the skin and fascia between the skin and fascia. During the operation, the prepared composite flap is hemmed to the edges of the refreshed defect with the skin layer inside the tracheal cavity. The wound is sutured with tension. The method significantly increases the viability of the operation compared with the above counterparts. The overall timing of complex intervention and convalescence remains unsatisfactory. The mobility of the restored tracheal wall is insufficiently adequate. By the greatest similarity of the composition and essence of the features, this analogue is selected as a prototype of this solution.

The technical result of the proposed method is a reduction in treatment time, an increase in adequate mobility of the restored tracheal wall. The specified technical result is achieved by the fact that in the method of plasty of gaping defects of the trachea, which includes layer-by-layer closing of the gaping defect with local tissues in combination with a titanium nickelide reinforcing implant, a nickel-titanium filament tissue flap is used, which is preliminarily inserted between the skin and fascia on the neck area adjacent to the gaping defect, for preparation by prefabrication with local tissues and incubated for 1.5-2 months, the prepared flap is isolated on the leg, overlapping they are wound on the edges of the gaping defect and fixed with sutures, the wound over the flap is sutured with local tissues. The attainability of the technical result is dominantly due to the use of a reinforcing element in the covering composite, the element material and the preparation of the reinforcing element, i.e. prefabrication (germination of its own tissues).

Mesh fabric of any technology, unlike a rigid plate (prototype), combines elasticity and mechanical strength. These tissue properties give the reconstructive wall of the trachea functional mobility that is most adequate to natural tissues and the absence of balloting of the wall during forced breathing and coughing. The paratracheal tissue sprouted in its lumen promotes the speedy integration of the composite flap with the edges of the wound. When preparing the flap, its germination occurs faster (1.5-2 months) than that of the porous structure of the prototype. These factors contribute to a reduction in the overall duration of treatment. The flap surface turned inside the trachea over time is covered with epithelial cells, simulating the mucous membrane. This situation eliminates the possibility of hair growth of the skin facing the tracheal cavity, as is the case in the prototype method.

The final investigative result of the distinctive actions is the restoration of adequate mobility of the reconstructed wall, increasing the viability of the operation and the quality of life of the patient. The scientific nature of the search, the absence in the prior art of a similar complex of features of the method indicate the non-obviousness of the solution to the problem, i.e. its compliance with the patentability criterion of "inventive step".

The illustrations show:

Figure 1. Appearance of nickel-titanium fabric.

Figure 2. The introduction of a flap of nickel-titanium tissue for germination. Stage of operation.

Figure 3. The disposition of the flap when suturing the defect.

Figure 4. The final stage of the operation. Healed wound.

The attainability of the technical result after experimental testing and verifying the operability of the method is confirmed by clinical examples of the treatment of non-closing defects of the trachea carried out in the clinic of the Tomsk branch of the Federal State Institution “NCC Otorhinolaryngology FMBA of Russia” and the head and neck tumors department of the Oncology Research Institute of the Siberian Branch of the Russian Academy of Medical Sciences.

Example. Big S., 33 years old. In the history of the disease: when falling from a snowmobile, he received a blunt injury to the chest and neck with a rupture of the trachea. The patient underwent an emergency tracheostomy operation with resection of three damaged tracheal semirings. In the postoperative period, cicatricial stenosis of the trachea developed for 4 years and the patient was operated on as planned. In the operation of laryngotracheoplasty, a cannulaless tracheostomy was formed. A T-shaped laryngeal-tracheal silicone prosthesis is installed in the restored tracheal lumen for stenting. Within 12 months, an unclosed tracheostomy with an area of more than 3 square meters was formed on the front surface of the neck. see. To close the tracheostomy, a two-stage plastic surgery was performed according to the method of the proposed method, which was carried out in the following way. In the soft tissues of the neck, in close proximity to the left edge of the tracheostomy, a bed is formed between the skin and fascia (Fig. 2) for a mesh flap of nickel-titanium tissue (Fig. 1) cut out with dimensions exceeding the size of the tracheostomy by 4-5 mm . The flap is placed in a box and left for prefabrication. After 45 days, in a circular cut, 5 mm departing from the borders of the projection of the flap, the latter was separated on the supply leg, transported with a gaping defect placed on the edges and fixed to them with acrylic sutures that did not penetrate into the lumen of the trachea (Fig. 3). External muscles of the neck are mobilized to touch and fixed with sutures. The surrounding skin is mobilized from the underlying tissues to contact and fixed with sutures (figure 4). For drainage of the wound, glove rubber drainage was used, which was removed after 24 hours. In the postoperative nursing of the patient, the rigid frame of the anterior wall of the trachea and the claimed attainability of the technical result are confirmed.

The technical and technological readiness of the method for clinical use indicates its compliance with the criteria of the invention of "industrial applicability".

Claims (1)

The method of plasty of gaping defects of the trachea, including layer-by-layer closing of the gaping defect with local tissues in combination with a titanium nickelide reinforcing implant, characterized in that a nickel-titanium filament tissue flap is used as the reinforcing implant, which is preliminarily inserted between the skin and fascia on the neck, adjacent to the gaping defect, for preparation by prefabrication with local tissues and incubated for 1.5-2 months, the prepared flap is isolated on the leg, applied to the edges of the gaping defect and fix They are sutured, the wound over the flap is sutured in layers with local tissues.

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