RU2843462C1 - Method for left pulmonary artery defect prosthetics after circular resection of the left pulmonary artery in lung cancer with an autopericardium graft - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to cardiovascular surgery and oncology. Lobectomy is performed, branches of the left pulmonary artery are mobilized, tourniquets are applied thereon. Then diameter of pulmonary artery is measured below proximal tourniquet and above distal tourniquet, distance between proximal and distal tourniquets is measured. A circular resection of the tumour with a fragment of the left pulmonary artery is performed. A patient’s free pericardium graft is formed with the free pericardium graft folded in half along a long axis so that an inner surface of the pericardium is found inside, and an outer one is found outside. A pulmonary artery diameter is measured in its proximal portion below a proximal tourniquet and marked with a marker; in its distal portion, the pulmonary artery diameter is measured above the distal tourniquet and marked with a marker. A vascular clamp is further applied along the pericardium autograft so that an outer side of the branches extends along the previously made marker marks at 4 mm from the vascular clamp branch; the excess pericardium is cut off. A continuous vascular suture is applied on the autopericardium outside from the branch of the vascular clamp with a suture. Then the proximal end of the crossed left pulmonary artery is anastomosed with the proximal end of the pericardium graft, and the distal end of the left pulmonary artery is anastomosed with the distal end of the autopericardium graft.

EFFECT: method allows to form an anastomosis between the crossed ends of the left pulmonary artery and the tubular pericardium autograft, which allows to eliminate the defect of the left pulmonary artery that occurred after the circular resection of the left pulmonary artery, thereby preserving the blood flow of the lower lobe of the left lung, in addition, the autograft is biocompatible and has individual dimensions, suitable for a particular patient, which allows to avoid intra- and postoperative complications.

1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine and can be used for prosthetic repair of a left pulmonary artery defect with a biocompatible, individually formed tubular transplant from autopericardium in order to preserve arterial blood flow in the lower lobe of the left lung.

A method of autoplasty of the walls of the heart and main vessels with autopericardium is known [1]. A method of surgical treatment of the incomplete form of the common atrioventricular canal, including suturing the split leaflet of the atrioventricular valve and closing the primary type of atrial septal defect, characterized in that the latter is closed with a flap cut from the lateral wall of the atrium, with the base preserved, and the resulting defect in the wall of the right atrium is closed with a flap cut from autopericardium, with the nutrient base preserved.

The disadvantage of this method is the mandatory use of an artificial blood circulation apparatus. It is used exclusively for plastic surgery of the donor zone of the right atrium with a cut out flap of autopericardium with preservation of the feeding base. When preserving the feeding base, the pericardium is slightly mobile, use for plastic surgery of the left pulmonary artery defect can cause cutting of sutures, bleeding, due to traction of the low-mobility autopericardium transplant.

A method of surgical correction of the aorto-left ventricular tunnel is also known [2]. To eliminate blood flow through the aorto-left ventricular tunnel, a patch is applied along the border of the aneurysmally altered tissues of the aortic sinus. The size of the patch corresponds to the size of the sinus cross-section at the border of the aneurysmally altered tissues. The patch can be fixed with a continuous suture. The method eliminates sinus dilation, strengthens its wall and restores laminar blood flow through the aortic root.

The method cannot be used to close the left pulmonary artery circular defect with a pericardial patch. The method requires a "bridge" of a pulmonary artery wall fragment between the proximal part of the defect of this vessel and its distal part to fix the edges of the pericardial patch, and in some cases, narrowing of the lumen of the left pulmonary artery in the anastomosis area will occur. The development of an aneurysmal protrusion is not excluded, in which laminar blood flow will be impossible, which can lead to thrombus formation in the cavity of the left pulmonary artery with subsequent pulmonary embolism (PE).

The closest to the claimed technical solution in terms of technical essence and achievable technical result is a method for forming a systemic-pulmonary anastomosis without opening the pericardium (extrapericardially) [3]. Two stay sutures are applied to the right or left lateral wall of the ascending aorta behind the adventitial layer and the lateral wall of the superior vena cava in the projection of the ascending aorta and superior vena cava. Next, a "bed" is formed for the prosthesis by resecting the paraaortic and paratracheal lymph nodes. The pericardium is peeled off from the anterior wall of the right or left pulmonary artery, and it is mobilized from the bifurcation to the division into lobar branches. A vascular clamp is applied proximal to the bifurcation of the pulmonary artery trunk on the right or left pulmonary artery, while 2 cm of the right or left pulmonary artery are isolated with subsequent formation of anastomosis between the PTFE prosthesis and the right or left pulmonary artery. The method allows preserving native autopericardium as a plastic material for subsequent stages of surgical treatment, and also prevents the development of adhesions in the anterior mediastinum, reduces the risk of complications during subsequent resternotomy due to the formation of a systemic-pulmonary anastomosis without opening the pericardial cavity.

The method is labor-intensive and requires the mandatory use of an artificial blood circulation apparatus. The pulmonary artery defect is replaced with a polytetrafluoroethylene (PTFE) prosthesis, an artificial material that may cause paraprosthetic infection, which may lead to melting of the walls of the main vessel and massive bleeding. The diameter of the proximal and distal parts of the PTFE prosthesis is the same, while the diameter of the proximal end of the transected left pulmonary artery may differ significantly from the diameter of the distal transected end of the left pulmonary artery, and it is necessary to use known methods to match the anastomosed ends of the main vessel and the graft. This complicates the imposition of the anastomosis and may lead to an increase in the duration of the angioplastic stage of the operation, which is undesirable in conditions of circulatory arrest of the left lung.

The technical task of the invention is to replace the defect of the left pulmonary artery with a prosthesis formed specifically for each patient, which will ensure maximum adaptation of the edges of the formed anastomoses between the crossed ends of the pulmonary artery and the transplant, using an economically advantageous biocompatible material.

The task was solved as follows: the transplant was anastomosed with the proximal and distal ends of the transected left pulmonary artery.

The peculiarity of the method is that the transplant is formed from a free flap of the anterior surface of the pericardium, therefore it is completely biocompatible, while the diameters of the proximal and distal ends of the prosthesis are formed taking into account the diameters of the proximal and distal ends of the crossed left pulmonary artery, and the length of the prosthesis taking into account the distance between the crossed ends of the pulmonary artery. This method does not involve the purchase of a special transplant, since the transplant is cut out of the patient's pericardium, there is no additional economic burden on the hospital.

The essence of the invention is explained by the following figures:

Fig. 1 shows a diagram of the surgical wound during lateral thoracotomy on the left. 1 - intended pericardial flap. 2 - left pulmonary artery. 3 - area of the left pulmonary artery defect after radical combined upper lobectomy on the left with resection of the left pulmonary artery. 4 - fragment of the inferior pulmonary artery in the area of division into basal branches and branch A6;

Fig. 2 shows a mobilized free flap of autopericardium folded in half with the visceral part inward and the parietal part outward, taken with a vascular clamp;

Fig. 3 shows the process of applying a continuous wrapping suture - the process of forming a tubular autopericardial transplant;

Fig. 4 shows the formed tubular transplant from autologous pericardium.

The first stage involves an extended upper lobectomy on the left using a well-known technique. Access: lateral thoracotomy in the 4th intercostal space, two costal retractors are installed, then anterior mediastinotomy and upper lymphadenectomy are performed, lymph nodes of groups 4, 5 and 6 are removed while preserving the branch of the recurrent nerve. Then posterior mediastinotomy and lower lymphadenectomy are performed, while the pulmonary branches of the vagus nerve are crossed, the tissue in the projection of groups 7, 8 and 9 lymph nodes is removed. After that, the superior pulmonary vein is treated with a suturing device and crossed. Next, mobilization of the interlobar groove is performed using one of the well-known techniques. In our practice, we use the well-known "Tunnel" method. In the interlobar fissure, we bluntly find a branch of the inferior pulmonary artery, as well as the A6 artery. Next, a tunnel is made anterior to the inferior pulmonary artery using a blunt technique, separating S5 and S7, a sling is inserted, after which the parenchyma of the upper and lower lobes anterior to the inferior pulmonary artery is separated using a suturing device. After which the parenchyma of S2 is separated from S6 in a similar manner, the interlobar groove is completely mobilized. Next, the branches of A4-5 are visualized and mobilized, processed using a suturing device or clipped, and intersected. Next, the superior lobar bronchus is mobilized and intersected using a sharp technique.

Vascular control is performed using a well-known technique: the branch of the left pulmonary artery above the invasion tumors is mobilized and, having retreated from it by at least 10 mm, a tourniquet is applied. The branches of the lower pulmonary artery and the A6 artery are mobilized, a tourniquet is applied. The tourniquets are not tightened, the blood flow in the left pulmonary artery is maintained at this stage.

Next, the diameter of the pulmonary artery below the proximal tourniquet and above the distal tourniquet is measured with a ruler, and the distance between the proximal and distal tourniquets is measured.

The pericardial fat is mobilized with a harmonic dissector, an area is marked in the zone of the anterolateral surface of the pericardium and a rectangular flap is cut out 20 mm longer than the distance between the proximal and distal tourniquets, and 4 diameters of the pulmonary artery below the proximal tourniquet are wide (Fig. 1).

After which the free pericardial flap is folded in half longitudinally along the long axis so that the inner surface of the pericardium is inside and the outer surface is outside (Fig. 2). In its proximal part, the diameter of the pulmonary artery below the proximal tourniquet is measured and a mark is made with a sterile marker. In its distal part, the diameter of the pulmonary artery above the distal tourniquet is measured and a mark is made with a sterile marker. Next, a vascular clamp is applied along the pericardial autograft so that the outer side of the branches passes along the previously made marker marks. Having retreated 4 mm from the branches of the vascular clamp, the excess pericardium is cut off with scissors. A continuous vascular suture is applied to the autopericardium outside the branches of the vascular clamp with 5-0 Prolene thread on an atraumatic needle (Fig. 3). As a result of the actions taken, we obtain a biocompatible, individually formed tubular autopericardial transplant (Fig. 4).

The tourniquets are tightened, the fragment of the left pulmonary artery between the tourniquets is exsanguinated. Using a #11 scalpel, a circular dissection of the pulmonary artery is made between the tourniquets, at least 4 mm away from the macroscopically determined tumor, the preparation of the upper lobe of the left lung with the tumor and a fragment of the affected left pulmonary artery is removed from the pleural cavity.

After that, the pulmonary artery fragment is replaced with a parachute technique so that the proximal end of the transected left pulmonary artery is anastomosed with the proximal end of the pericardial graft, and the distal end of the left pulmonary artery is anastomosed with the distal end of the autopericardial graft. After the proximal anastomosis is imposed, but before tightening the last reinforcing knot of the distal anastomosis, the proximal tourniquet is slightly loosened in order to remove air from the graft with the blood flow and the proximal tourniquet is tightened again. The fixing knot of the distal anastomosis of the pulmonary artery and autograft is tightened. Then the distal tourniquets are loosened, checking for tightness. After that, the proximal tourniquet is loosened, checking for tightness.

Finally, in order to prevent possible cardiac infringement, the pericardial defect in the donor area is replaced with a polypropylene mesh, fixing the latter with nodal sutures to the edges of the pericardial defect.

Clinical example

Patient, 52 years old, diagnosis before surgery: cancer of the upper lobe of the left lung, stage IB, T2N0M0. Squamous cell variant. Diagnosis after surgery: cancer of the upper lobe of the left lung, stage IIIA, T4N0M0. Squamous cell variant.

After processing the surgical field with the patient in the right lateral position, with separate bronchial intubation, an access of up to 10 mm was made in the 7th intercostal space on the left along the mid-axillary line, then an access of 30 mm was made along the anterior axillary line on the left in the 4th intercostal space. Upper and lower mediastinal lymphadenectomy (systematic lymphadenectomy) was performed. The vein of the upper lobe was isolated, the presence of the inferior pulmonary vein was traced: present. The superior pulmonary vein was treated with the Echelom flex 45 mm white cassette stapler. After transecting the vein, an impression was formed about the ingrowth of the tumor node of the upper lobe into the left pulmonary artery in the area of the A1-3 orifice. The superior lobar bronchus was isolated, the clearance from the tumor along the bronchus is 20 mm, however, treatment of the bronchus with a stapler raises concerns in terms of damage to the left pulmonary artery in the area of the supposed tumor ingrowth. The upper lobar bronchus is transected sharply. Tumor infiltrate growth into the left pulmonary artery in the area of the A1-3 orifice is visually determined. The interlobar groove is mobilized, A4-5 is isolated and mobilized, clipped, and transected. A2 is isolated and mobilized, clipped, and transected.

In order to perform an organ-preserving operation, namely, to preserve blood flow in the lower lobe, a decision was made to perform an angioplastic upper lobectomy, with circular resection of the left pulmonary artery trunk, and plastic surgery of the defect with a tubular transplant from autopericardium.

Conversion, access to the 4th intercostal space was extended in both directions, lateral thoracotomy was performed.

The pericardial fat was mobilized with a harmonic dissector, the area in the zone of the anterolateral surface of the pericardium was marked, a rectangular flap was cut out 20 mm longer than the distance between the proximal and distal tourniquets: the width was 4 diameters of the pulmonary artery below the proximal tourniquet.

After that, the free pericardial flap is folded in half longitudinally along the long axis so that the inner surface of the pericardium is inside and the outer surface is outside. In its proximal part, the diameter of the pulmonary artery below the proximal tourniquet is measured and marked with a sterile marker. In its distal part, the diameter of the pulmonary artery above the distal tourniquet is measured and marked with a sterile marker. Next, a vascular clamp is applied along the pericardial autograft so that the outer side of the branches passes along the previously made marker marks. Having retreated 4 mm from the branches of the vascular clamp, the excess pericardium is cut off with scissors. A continuous vascular suture is applied to the autopericardium outside the branches of the vascular clamp with Prolene 5-0 thread on an atraumatic needle. As a result of the actions taken, we obtain a biocompatible tubular individually formed autopericardial transplant.

Vascular control was performed: the left pulmonary artery proximal to the tumor by 20 mm was taken on a tourniquet, tourniquets were also applied to the branches of the inferior pulmonary artery at a distance of 15 mm from the tumor: the basal pyramid, A6. After which, at a distance of 10 mm from the edges of the macroscopically determined tumor, circular resection of the left main healthy tissues was performed. The upper lobe of the left lung was removed with the neoplasm, a fragment of the left pulmonary artery and regional tissue. Then anastomoses were applied, first a proximal one, between the proximal end of the transected left pulmonary artery and the proximal end of the autograft. And then a distal anastomosis was applied between the distal end of the transected left pulmonary artery and the distal end of the tubular autograft from the pericardium. The pleural cavity was drained.

The postoperative period was uneventful, the drainage was removed on the 3rd day, the patient was discharged on the 10th day.

The technical result is the formation of an anastomosis between the crossed ends of the left pulmonary artery and the tubular autograft from the pericardium, which made it possible to eliminate the defect of the left pulmonary artery that arose after circular resection of the left pulmonary artery, thereby preserving the blood flow of the lower lobe of the left lung. Thanks to the use of the method, it was possible to perform a radical organ-preserving operation: instead of pneumonectomy, which the patient would have had to undergo without the use of the method, it was possible to perform an extended upper lobectomy.

The invention makes it possible to restore the defect of the left pulmonary artery with a biocompatible individually formed tubular transplant from autopericardium, thereby preserving the arterial blood flow of the lower lobe of the left lung and avoiding pneumonectomy.

List of references

1. RU 2130289 “Method of autoplasty of the walls of the heart and main vessels using autopericardium”.

2. RU 2332937 “Method of surgical correction of aortoleft ventricular tunnel”.

3. RU 2782293 “Method for forming a systemic-pulmonary anastomosis without opening the pericardium (extrapericardial)”.

Claims (1)

A method for repairing a left pulmonary artery defect after circular resection of the left pulmonary artery in lung cancer with an autologous pericardial graft, comprising forming a tubular graft, characterized in that lobectomy is performed, the branches of the left pulmonary artery are mobilized, tourniquets are applied to them, then the diameter of the pulmonary artery is measured below the proximal tourniquet and above the distal tourniquet, the distance between the proximal and distal tourniquets is measured, circular resection of the tumor with a fragment of the left pulmonary artery is performed, then a graft is formed from the patient's free pericardial flap, for this purpose the free pericardial flap is folded in half longitudinally along the long axis so that the inner surface of the pericardium is inside and the outer surface is outside, the diameter of the pulmonary artery is measured below the proximal tourniquet in its proximal part, a mark is made with a marker, the diameter of the pulmonary artery is measured above the distal tourniquet in its distal part, a mark is made with a marker, then along A vascular clamp is applied to the pericardial autograft so that the outer side of the branches passes along the previously made marker marks, stepping back 4 mm from the branches of the vascular clamp, excess pericardium is cut off, a continuous vascular suture is applied to the autopericardium outside the branches of the vascular clamp with a thread, then the proximal end of the transected left pulmonary artery is anastomosed with the proximal end of the pericardial graft, and the distal end of the left pulmonary artery is anastomosed with the distal end of the autopericardial graft.