RU2845864C2 - Method for influencing phrenic nerve in integrated treatment of destructive pulmonary tuberculosis using parasternal videothoracoscopy access - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to thoracic surgery, phthisiology, and may be used in the integrated treatment of destructive pulmonary tuberculosis. Videothoracoscopy is performed, at which two thoracocenteses are performed along a parasternal line at level of 3–6 intercostal spaces. Thoracoports are installed, in one of which video thoracoscope is introduced, endoscopic instrument in the other one. Phrenic nerve is visualized, located anteriad from the root of the lung, which is then traced to division into branches at the diaphragm, where phrenemphraxis is performed with coagulation with an endoscopic electrocoagulator, or phrenemphraxis with coagulation with an endoscopic ultrasonic instrument, or transection of the phrenic nerve.

EFFECT: method eliminates possibility of damage of nerves and vessels of neck and development of complications associated with disturbed innervation of heart, lungs and abdominal cavity organs due to intrathoracic parasternal endoscopic approach with selective effect on intramammary portion of phrenic nerve.

1 cl, 1 dwg, 1 ex

Description

The invention relates to medicine, namely to thoracic surgery, phthisiology and can be used in the complex treatment of destructive pulmonary tuberculosis.

At the present stage of development of phthisiology and thoracic medicine, drug therapy, endobronchial methods of treatment (including bronchial blocking), various methods of collapse therapy and resection surgery of the lungs are used in the complex treatment of destructive pulmonary tuberculosis. Among the methods of collapse therapy, one can distinguish minimally invasive (artificial pneumoperitoneum and pneumothorax) and surgical (various types of thoracoplasty, videothoracoscopy with thoracocaustic, extrapleural pneumo- and oleothorax and operations on the cervical part of the phrenic nerve).

The operation of cutting the cervical segment of the phrenic nerve was proposed by Sturtz in 1911. It was developed to replace artificial pneumothorax to some extent. However, simple cutting of the phrenic nerve often did not produce an effect. And only after Felix introduced the so-called phrenic exeresis in 1922 did this operation become widespread. In 1942, Professor M. L. Borovsky proposed a new method of surgery on the phrenic nerve, which consisted of injecting alcohol into its peripheral end after cutting the nerve.

In the 40-50s of the last century, variants of this operation were widely used. By the 70s of the 20th century, as a result of the development of thoracic surgery and a significant increase in the number of lung resections, as well as the emergence of new anti-tuberculosis drugs, many methods of collapse therapy, including phrenicoexeresis, phrenicotomy and phrenicoalcoholization operations, fell out of use. At present, in the context of the prevalence of multiple and extensive drug resistance of MBT, as well as HIV-tuberculosis co-infection, the use of collapse therapy methods in the complex treatment of pulmonary tuberculosis is of great importance.

A method of influencing the phrenic nerve by mechanically compressing it with a clamp (phrenitripsy) at the level of the lower third of the intrathoracic region during lower lobectomy is known in order to reduce the volume of the pleural cavity due to relaxation of the diaphragm (G.S. Levin. Surgical treatment of patients with pulmonary tuberculosis (to help the practicing physician). Second revised and supplemented edition. - State Publishing House of the USSR. Minsk. - 1962. - P. 275).

The disadvantage of this method is the high trauma of access.

The closest analogue, accepted as a prototype, is the method of influencing the phrenic nerve, described in the operation of phrenic exeresis, which consists of removing the phrenic nerve by twisting it, while all its anastomoses and the so-called accessory nerve are torn off (N. S. Pilipchuk. Collapse surgery of pulmonary tuberculosis. - Kyiv. - 1960. - P. 162).

The operation is performed under local anesthesia with 0.5% novocaine solution. The patient is positioned on his back, the head is turned as much as possible in the opposite direction.

Access is achieved by a longitudinal incision along the edge of the clavicular pedicle of m. sterno-cleido-mastoidei and a transverse incision one and a half to two fingers above the clavicle, about 3-4 cm. The external jugular vein that falls into the incision is preserved or crossed, having been previously tied with two ligatures. After dissection of the platysmae myoides, the clavicular pedicle of m. sterno-cleido-mastoidei is exposed, which is moved inward with a hook. After shifting the underlying tissue, the anterior surface of the anterior scalene muscle is revealed, covered with fascia, through which the phrenic nerve, directed from top to bottom and from outside to inside, is normally clearly visible. The fascia is incised, the nerve is carefully isolated from the muscle and fascia and captured with a hook.

The phrenic nerve is grasped with a Kocher clamp and cut with scissors 1-1.5 cm higher, after which the nerve is pulled out by twisting it on the clamp, and this twisting should be done slowly, constantly pushing away the tissue that is pulled behind the nerve. Pulling out the nerve is accompanied by pain in the chest, back, heart, and sometimes in the abdomen. If significant resistance is felt when pulling out the nerve, this indicates that the nerve is enclosed in adhesions; in these cases, it is better not to strive for complete removal of the nerve, but to cut it as low as possible. At the end of the operation, the wound is sutured tightly.

The disadvantage of this method is the risk of serious complications, which include: 1) damage to nerves mistaken for the phrenic nerve, in particular the sympathetic trunk, which results in Horner's symptom; 2) damage to blood vessels, the most dangerous being injury to the internal jugular vein, which threatens air embolism, even death; 3) intersection of the phrenic nerve at such a high level inevitably entails disruption of the innervation of the heart, lungs and abdominal organs.

The problem of the claimed invention is the development of a method for influencing the phrenic nerve in the complex treatment of destructive pulmonary tuberculosis, eliminating the possibility of damage to the nerves and vessels of the neck and the development of complications associated with impaired innervation of the heart, lungs and abdominal organs.

The technical result of the claimed invention is a reduction in trauma, elimination of the possibility of damage to the nerves and vessels of the neck and the development of complications associated with impaired innervation of the heart, lungs and abdominal organs.

In order to achieve the stated technical result in the method of influencing the phrenic nerve in the complex treatment of destructive pulmonary tuberculosis according to the invention, videothoracoscopy is performed, during which two thoracocenteses are performed along the parasternal line at the level of 3-6 intercostal spaces, with the installation of thoracoports, into one of which a videothoracoscope is inserted, into the other - an endoscopic instrument, then after examining the pleural cavity, the phrenic nerve is visualized, located in front of the root of the lung, which is then traced to the division into branches at the diaphragm, where phrenicotrypsy is performed with coagulation with an endoscopic electrocoagulator or endoscopic ultrasonic instrument, or transection of the phrenic nerve.

Intrathoracic parasternal endoscopic access eliminates the possibility of damage to the nerves and large vessels of the neck.

Selective action on the intrathoracic section of the phrenic nerve at the level of division into branches at the diaphragm prevents the development of complications associated with impaired innervation of the heart, lungs and abdominal organs.

The invention is illustrated by drawings.

Fig. 1 shows a method of influencing the phrenic nerve in the complex treatment of destructive pulmonary tuberculosis using parasternal videothoracoscopy access.

The method is carried out as follows.

Patient position: on the back with the upper limb on the side of the operation abducted to the side with a roller under the shoulder blades.

Anesthesia: combined anesthesia with tracheal intubation or laryngeal mask. Next, videothoracoscopy is performed, during which two thoracocentesis are performed along the parasternal line at the level of the 3rd-6th intercostal spaces, into one of which a videothoracoscope 6 is inserted, into the other - an endoscopic instrument 5. Then, after examining the pleural cavity, the phrenic nerve 2 is visualized, located in front of the root of the lung 3, which is then traced to the division into branches at the diaphragm 4, where the nerve 2 is affected by an endoscopic instrument in order to turn off its function.

In a preferred embodiment of the invention, phrenicotrypsy with coagulation by an endoscopic electrocoagulator or an endoscopic ultrasound instrument is performed as an effect on the phrenic nerve 2 in order to turn off its function. Also, transection of the phrenic nerve (phrenicotomy) can be used as an effect on the nerve.

The operation ends with the installation of a pleural drainage of 12-15 Fr for 1-3 days.

After the operation, a long-term paresis (paralysis) of the phrenic nerve is caused for up to 6-12 months, which leads to relaxation of the dome of the diaphragm by 2-4 intercostal spaces and, accordingly, to a limitation of the excursion of the lung and a decrease in the volume of the pleural cavity and collapse of the lower parts of the lung affected by tuberculosis.

Indications for surgical intervention according to the claimed method are:

1. Single caverns located in the lower and middle lobes, lingual and axillary segments of the upper lobe of the lung;

2. Caverns and fibrous caverns located in any part of the lung in the presence of seeding;

3. Common destructive forms of pulmonary tuberculosis.

The claimed method can be used as a stage of preoperative preparation, or as an independent method of collapse therapy in the complex treatment of destructive pulmonary tuberculosis.

Thus, the claimed invention makes it possible to eliminate the possibility of damage to the nerves and large vessels of the neck, as well as to prevent the development of complications associated with impaired innervation of the heart, lungs and abdominal organs.

Example 1.

Patient K, 26 years old, disabled person of group II, was admitted to the 2nd surgical department of the Chelyabinsk Clinical Regional Anti-Tuberculosis Dispensary on July 26, 2006 with the diagnosis: Polycavernous tuberculosis of the left lung, cavernous tuberculosis S6 of the right lung. Condition after combined upper lobectomy with resection of part of S10 on the left. Cultitis of the left VDB MDR (S H R E Rh K). MBT (+). Moderate type 2 diabetes mellitus.

X-ray examination: 27.07.06, in comparison with previous data, the process is progressing: a giant cavity remains in the upper lobe on the left, foci of seepage of a confluent nature throughout the lung and in the middle field. On the right, in comparison with 04.06, the dynamics are negative.

OAC: 05.03.07 - er.4.5x1012/l, Hb - 141 g/l, CP 0.9, L - 5.6x10 ⁹ /l, e-2, p-9, s-64, l-18, m-9, ESR 34 mm/h.

BAC: 01/26/07 - bil - 8.3 μmol/l, direct - 2.0 mmol/l, thymol - 5.2 U, protein - 80 g/l, sial - 4.2 mmol/l, urea - 6 mmol/l, creatinine -84.0 μmol/l, ALT - 17.7 U, AST - 15.8 U.

Glycemic profile 03/05/07 12.2-14.7-11.8 mmol/l.

OAM: 05.03.07 g. s/f, transparent. weight - 1012 Protein - no, sugar - 1%. Sour. Leuk 1 - 3 in the field of vision. Epithelial pl. 3 - 4 in the field of vision.

LMOM: 01.08.06 KUM (+) from 2.08.06 to 11.12.06 KUM (-) in crops during this time there was a constant increase in MBT +++.

RW 06/27/06 negative. ELISA HIV antibodies 07/27/06 - not detected. 07/27/06 ELISA HCV antibodies not detected, ELISA HBsAg not detected.

Blood type: B (III) Rh (+) positive.

ECG: short PQ syndrome Indirect signs of left ventricular myocardial hypertrophy.

FIL: moderately expressed mixed disorders of 1-11 degrees.

FBS: 01/16/2007 postoperative stump of the left VDB, Histological examination: tuberculosis of the stump of the right VDB.

The operation was performed: 21.11.2006 - parasternal videothoracoscopy with coagulation phrenicotripsy on the right.

The operation lasted 20 minutes. Blood loss was 5.0 ml. Anesthesia was intravenous anesthesia, local anesthesia was 0.5% novocaine - 60.0 ml.

DESCRIPTION OF OPERATION

Thoracocentesis in the 3rd and 4th interstitial veins along the parasternal line on the right. During revision, the pleural cavity is free. Minor adhesions in the anterior sinus. The parietal pleura is pale and unremarkable. The visceral pleura is pink. The phrenic nerve is visualized. Its coagulative phrenicotripsy is performed. Hemostasis. Aerostasis. 1 drainage is inserted. Gas and liquid are aspirated until hermetic. Drainage according to Bulau.

Postoperative course: without complications, sutures were removed on 05.12.06, healing of the postoperative wound by primary intention

X-ray examination: 26.02.07, in dynamics from 09.06. and 01.07. a cavity up to 15 mm is detected in C6 on the right, foci of a confluent nature in the upper lobe and in C6 around the cavity. The left resected lung is reduced in volume, massive infiltration in the anteroinferior section, in the projection of C1-2 a large cavity up to 70 mm in diameter remains. High position of the domes of the diaphragm on both sides.

Treatment performed: regimen - individual, floracid - 51 g, amikacin - 32.25 g, ciprofloxacin - 24 g, phenazid - 25 g, tavanic - 27 g, aquacipro - 10.8 g, kapocin - 71.5 g, cefotaxime - 20 g, inhalations with antiseptics, sanitation bronchoscopies, endotracheal infusions, hepatoprotectors, vitamins, insulin (actropid, protafan).

Drug intolerance: pyrazinamide - urticaria, protionamide - vomiting.

FINAL DIAGNOSIS: Polycavernous tuberculosis of the left lung. Cavernous tuberculosis of C6 of the right lung. Condition after upper lobectomy with resection of part of C10 on the left. Cultitis of the left VDB MDR (HSREKRh) Operation: 21.11.06 parasternal videothoracoscopy with coagulation phrenicotripsy on the right. DN grade 1

CONCOMITANT: Moderate type 2 diabetes mellitus.

The patient was discharged on 19.03.2007 to continue treatment at the PTD at her place of residence.

Claims (1)

A method of influencing the phrenic nerve in the complex treatment of destructive pulmonary tuberculosis, characterized in that videothoracoscopy is performed, during which two thoracocenteses are performed along the parasternal line at the level of the 3rd-6th intercostal spaces, with the installation of thoracoports, into one of which a videothoracoscope is inserted, into the other - an endoscopic instrument, then after examining the pleural cavity, the phrenic nerve is visualized, located in front of the root of the lung, which is then traced to the division into branches at the diaphragm, where phrenicotripsy is performed with coagulation by an endoscopic electrocoagulator, or phrenicotripsy with coagulation by an endoscopic ultrasonic instrument, or transection of the phrenic nerve.