RU2848901C1 - Method for closing the wound surface of the orbit after subconjunctive excision of the orbit - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: skin flap is preformed from the middle third of the inner surface of the shoulder in a rectangular shape measuring 5×3 cm. The flap is soaked for 10 minutes in saline solution and freed from subcutaneous fatty tissue. Fold the flap in half along the longer side. Suture the flap from one edge along the shorter side with a continuous suture to form a cone-shaped funnel. Immerse the funnel into the orbit with the tip of the cone towards the top of the orbit and fix it to the skin edges of the orbit, first with temporary knot sutures, and then with a continuous upholstery suture. Perforate the flap over its entire surface and tamponade the orbital cavity.

EFFECT: closure of the wound surface of the orbit after subperiosteal exenteration, reduces the duration of postoperative rehabilitation of patients and subsequent ectoprosthetics, while minimising the risk of postoperative infectious complications and reducing the area of facial deformation.

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Description

The invention relates to ophthalmology and is intended for closing the wound surface of the orbit after subperiosteal exenteration.

Orbital exenteration is a radical surgical procedure that involves the removal of all contents of the orbit, including the eyeball, muscles, nerves, vessels, and surrounding soft tissues [Kennedy R.E. Indications and surgical techniques for orbital exenteration. Ophthalmology. 1979; 86 (5): 967-73]. In some cases, resection of adjacent bone structures may be required. The operation is performed for malignant orbital tumors, severe infections, trauma, and some congenital anomalies [Sagili S, Malhotra R. Orbital exenteration: indications, techniques, and complications. Expert Revi Ophthalmol. 2016; 11 (3): 201-213.].

Orbital exenteration is considered one of the most mutilating ophthalmic surgeries, as it results in complete loss of vision and significant cosmetic defects. However, in some cases, it is the only way to save the patient's life and prevent tumor spread or severe infectious complications [Aryasit O, Preechawai P, Hirunpat S, Horatanaruang O, Singha P. Factors related to survival outcomes following orbital exenteration: a retrospective, comparative, case series. BMC Ophthalmol. 2018;18(1):186.].

In orbital surgery, microsurgical techniques, laser technologies, and custom-made endoprostheses are actively used, which improves the functional and aesthetic results of treatment [Sipkin A.M., Akhtyamova D.V., Chumakov A.V., Vasiliev Yu.L., Kytko O.V., Bogoyavlenskaya T.A., Shcherbyuk A.N. Reconstruction of the orbit with soft tissue flaps, ectoprosthesis after its exenteration. Operative surgery and clinical anatomy (Pirogov Scientific Journal). 2021; 5 (4): 50-57.].

Indications for orbital exenteration are malignant tumors of the orbit and surrounding structures (melanoma, retinoblastoma, squamous cell and basal cell skin cancer of the eyelids, sarcomas (rhabdomyosarcoma, angiosarcoma), adenocarcinoma of the lacrimal gland, metastatic tumors) [Andreev T.R., Kropotov M.A., Azizyan R.I. et al. Tumors of the orbit and periorbital zone: 20-year experience of the N.N. Blkhin National Medical Research Center of Oncology. Head and Neck Tumors 2024; 14 (4): 33-41.].

There are several types of orbital exenteration, differing in the volume of tissue removed. Classic (total) exenteration - all soft tissues of the orbit are removed, including the eyeball, muscles, nerves and vessels. Exenteration with removal of bone structures - is used when the tumor invades the bones of the orbit, requires reconstructive interventions. Modified exenteration - some structures are preserved, for example, the conjunctiva or skin of the eyelids, which facilitates subsequent rehabilitation. Radical exenteration - is performed when the pathological process extends beyond the orbit (for example, with tumor lesion of the paranasal sinuses or the base of the skull) [. Mohr C., Esser J. Orbital exenteration: surgical and reconstructive strategies. Graefes Arch Clin Exp Ophthalmol 1997; 235 (5): 288-95; Lazarev A. Yu., Khusainov M. P. Malignant orbital tumors, surgical treatment tactics and outcome assessment. Volga Region Oncology Bulletin. 2018; 4 (36): 13-17.

Orbital exenteration remains a complex and traumatic procedure requiring a multidisciplinary approach. Currently, considerable attention is paid to methods of reconstruction and rehabilitation of patients after surgery, including the use of implants, skin flaps, and 3D prosthetics [Andreev T.R., Kropotov M.A., Azizyan R.I. et al. Tumors of the orbit and periorbital zone: 20-year experience of the N.N. Blokhin National Medical Research Center of Oncology. Head and Neck Tumors 2024; 14(4):33–41].

Incorrect choice of defect closure tactics after orbital exenteration can lead to a number of serious complications, including infection (if the wound surface remains open or is not closed securely, the risk of infection, such as orbital osteomyelitis and intracranial complications, increases). Reconstruction failure: insufficient blood supply to the flap or its necrosis can lead to suture dehiscence, tissue necrosis, and the formation of a chronic wound. Formation of cicatricial deformities: improper closure can lead to excessive scarring, deformation of the surrounding tissues, which will complicate subsequent prosthetic replacement. Fistula formation: if closure is not performed securely, orbital-maxillary or orbital-temporal fistulas may develop, requiring repeated interventions. Secondary defect and aesthetic problems: an incorrect choice of reconstruction method (for example, an inadequate skin flap or improper use of a free graft) can lead to significant aesthetic and functional deficiencies. Therefore, the choice of tactics for defect closure should take into account the extent of resection, the anatomical features of the patient and the predicted functional rehabilitation.

A known method for orbital replacement after exenteration involves closing the orbital wound surface with two pedicled skin flaps from the forehead and cheek, which are then transferred into the orbital cavity with a pre-applied fibrin matrix. The matrix is prepared as follows: 20 ml of the patient's blood is collected and placed in a container containing sodium citrate, which binds calcium ions, thereby blocking the entire clotting process. The resulting mixture is centrifuged twice to activate and aggregate platelets, and 5 ml of calcium chloride is added to the platelet-rich plasma. Next, the formed flaps are placed on the postoperative surface of the orbit so that they are in close contact with the orbital walls, the displaced flaps are fixed with interrupted sutures to each other and to the skin edges of the defect, the cavity is tamponed with an ointment swab, an aseptic dressing is applied, after removing the sutures, 2-3 weeks after the surgery, external prosthetics of the eyeball, eyelids and surrounding tissues are performed with a prosthesis manufactured according to the generally accepted technique. [Method of orbital prosthetics. Engibaryan M.A.; Pustovaya I.V. RU 2011137687].

However, this method can further increase the patient's facial cosmetic defect, increase the surgical area, and prolong the surgical time. Furthermore, inaccurate flap size calculations can lead to wound margin incompetence and exposure of the orbital bone. Furthermore, treatment of the orbital wound surface with fibrin matrix requires additional technical equipment for its production.

The objective of the invention is to develop a method for closing a wound surface with a free skin flap after performing subperiosteal exenteration of the orbit.

The technical result of the proposed invention is a reduction in the time frame for postoperative rehabilitation of patients and subsequent ectoprosthetics while minimizing the development of risks of postoperative infectious complications and reducing the area of facial deformation.

The technical result is achieved by forming an adequate skin flap from the middle third of the inner surface of the shoulder with its subsequent adaptation to the wound surface.

We operated on 26 patients with malignant neoplasms (TNM staging T4N0M0). In all cases, tumor spread to the deep orbit was clinically and instrumentally proven: 7 patients with basal cell carcinoma of the eyelids, 7 patients with choroidal melanoma with extrabulbar spread, 4 patients with conjunctival melanoma, and 4 patients with meimbal gland cancer. In some cases, the malignant neoplasms were primary orbital tumors: 2 patients with primary orbital melanoma, 1 patient with fibrosarcoma, and 1 patient with orbital liposarcoma. The morphological diagnosis was verified in all cases.

The method is carried out as follows.

First, a rectangular skin flap measuring 5 x 3 cm is created from the middle third of the inner surface of the upper arm. The flap is soaked in saline for 10 minutes, freed of subcutaneous fat, folded in half along the long side, and sutured at one edge along the short side with a continuous suture to form a cone-shaped funnel. The funnel is inserted into the orbit with the apex of the cone facing the orbital apex and secured to the skin margins of the orbit, first with provisional interrupted sutures and then with a continuous upholstered suture. The flap is perforated over the entire surface, and the orbital cavity is packed.

Example 1. Patient V., 50, presented to the Helmholtz National Medical Research Center of Eye Diseases of the Russian Ministry of Health with a diagnosis of a T4NoMo epibulbar tumor in the right eye extending into the orbit and pain. Ophthalmological examinations performed:

1) Visometry: Visus OD = vision cannot be tested due to an epibulbar neoplasm.

OS=0.5 s sph+2.5=1.0

2) Tonometry: IOP OD - tonometry cannot be performed, OS - 20 mmHg.

3) Biomicroscopy: OD - Severe swelling of the eyelids and periorbital tissues. The bony edges of the orbit are palpable, smooth, and even. Hyperemia of the skin of the eyelids and periorbital tissues is present. A lumpy, gray-pink mass, painful to palpation, is observed epibulbarly, filling the entire palpebral fissure. Dark crusts of dried blood are visible on its surface. Serous discharge is present. The eyeball is not differentiated within the mass. Failure of the palpebral fissure to close. Severe pain in the eyelids and periorbital tissues.

4) OS - The orbit and surrounding tissues are unchanged. The bony edges of the orbit are even and smooth. The conjunctiva is calm. The cornea is transparent. The anterior chamber is of medium depth, the aqueous humor is transparent. The iris is structured, the pigment border is preserved. The pupil is round. The pupillary reaction to light is brisk. The lens is transparent. The vitreous body is transparent. Main fundus: the optic disc is pale pink, with clear borders. The course and caliber of the vessels are normal. The reflex in the visual acuity is clear. There is no pathology in the periphery.

5) Direct ophthalmoscopy: OD - not ophthalmoscoped.

OS - the optic disc is pale pink, the boundaries are clear, the course and caliber of the vessels are unchanged, in the macular zone and on the periphery there is no focal pathology.

6) CT scan of the orbits - In the soft tissues of the eyelids on the right, there is a solid volumetric formation of a heterogeneous structure, irregular in shape, widely extending into the anterior parts of the orbit to the equator of the eye, measuring 42 × 23 × 42 mm, with the inclusion of gas bubbles, intimately adjacent to the anterior and lateral surfaces of the right eyeball (its membranes at the site of adhesion are deformed, unclear).

The structures of the left orbit are unremarkable.

The patient underwent subperiosteal exenteration of the right orbit.

A rectangular skin flap measuring 5x3 cm was formed from the middle third of the inner surface of the shoulder, soaked for 10 minutes in a saline solution, freed from subcutaneous fat, folded in half along the larger side, sutured from one edge along the folded smaller side with a continuous suture to form a cone-shaped funnel, the funnel was immersed in the orbit with the apex of the cone to the apex of the orbit and fixed to the skin edges of the orbit first with provisional interrupted sutures, and then with a continuous upholstered suture, the flap was perforated over the entire surface and the orbital cavity was tamponed.

Pathological conclusion: adenocarcinoma of the meibomian gland.

Following surgery, the patient was placed under a pressure dressing for 3 days. The dressing was then changed, which involved removing the pressure dressing and removing the cavity packing, soaking the packing with 3% hydrogen peroxide. The cavity was then cleaned with saline to remove dry, serous discharge. Objectively, the flap adhered fully to the orbital bony walls, the sutures were adequate throughout, and there was no effusion under the flap. The cavity was reapplied with Levomekol ointment, followed by a looser packing and an aseptic patch. The cavity cleaning regimen consisted of repeating the procedures every other day, with the packing being reduced until the flap healed.

Dynamic observation over 1.5-2 months showed complete engraftment and integration of the flap to the wound surface, the absence of inflammatory complications, and therefore ectoprosthetics was prescribed after 2.5 months.

Further observation by an ophthalmologist and oncologist at the place of residence is recommended.

Patient G., 77, presented to the Helmholtz National Medical Research Center of Eye Diseases of the Russian Ministry of Health with a diagnosis of a neoplasm of the lower eyelid, outer corner of the eye, extending into the orbit, T4N0M0. Ophthalmological examinations performed:

1) Visometry: OD 0.2 sph+6.0 cyl - 1.0 ax 90 g=0.9 - 1.0

OS 0.2 sph + 6.0 = 0.4

2) Tonometry: IOP OD 17.0 mm Hg OS 23.0 mm Hg

3) OD - The orbit and surrounding areas are unchanged. The position of the eye in the orbit is correct, movements are within a full range. The eyelids are unchanged, closure is complete. The width of the palpebral fissure is 11 mm. Exophthalmometry is 18 mm, p 103 mm. The conjunctiva is calm. The cornea is transparent, shiny, spherical. The anterior chamber is of medium depth, its humor is transparent. The iris is structural, the pupil is round in the center, the reaction to light is brisk. The pigment border is preserved. Initial opacities are in the nuclear-cortical layers and under the posterior capsule. Filamentous destruction of the vitreous body. On the fundus: the optic disc is pale pink with clear borders, the reflex is not expressed in the macular zone. The course and caliber of the vessels are unchanged. There are no focal pathologies on the periphery.

OS - Moderate edema of the eyelids and periorbital tissues. The lower eyelid is absent in the outer and middle third, ulceration of the lower eyelid extending into the orbit; thickening of the outer orbital margin extending deep into the orbit. Partial ptosis of the upper eyelid. The bony margins of the orbit are even and smooth. The width of the palpebral fissure is 14 mm. Widening of the palpebral fissure in the outer part due to a defect of the lower eyelid. Exophthalmometry is 19 mm, p 103 mm. The position of the eye in the orbit is correct, outward mobility is limited. The conjunctiva is irritated, mixed conjunctival injection. No discharge. Corneal epitheliopathy. Dilation of the vessels in the episcleral regions. The anterior chamber is of medium depth, its humor is transparent. The iris is structured, the pupil is round in the center, the reaction to light is lively. The pigment border is preserved. Initial opacities of the cortical layers of the lens. Filamentous destruction of the vitreous. Fundus examination: the optic disc is pale pink with clear borders; no reflex is present in the macular area. The course and caliber of the vessels are unchanged. No focal pathology is observed in the periphery.

4) CT scan of the orbit (OS): in the area of the inferior-outer angle of the anterior third of the left orbit, a "plus" tissue of irregular shape is detected, measuring approximately 12.4 x 12.9 mm, with a density of +44 UDN, adjacent to the ocular membranes. The posterior pole of the tissue extends to the scleral end of the lateral rectus muscle; the superior pole is not differentiated from the lacrimal gland tissue. The EOM and optic nerve of the OS are unchanged. No bone-destructive changes were detected.

The patient underwent subperiosteal exenteration of the left orbit.

No plastic or reconstructive procedures were performed after the surgery. The wound surface was left to heal. The orbital cavity was packed with sterile swabs and Levomekol ointment.

After surgery, the patient was placed under a pressure dressing for 5 days. The dressing was then changed, which involved removing the pressure dressing and removing the packing material from the cavity, soaking the packing material in 3% hydrogen peroxide. The cavity was then treated with saline to remove any serous discharge. Objectively, initial growth of granulation tissue was noted, and serous discharge persisted.

The cavity was re-treated with Levomekol ointment, followed by a looser packing and an aseptic dressing. The cavity treatment regimen consisted of repeating the procedures every three days, with the packing becoming less dense until complete epithelialization of the wound surface, which lasted up to three months.

A 6-month follow-up without a skin flap revealed slower healing with the formation of irregularly protruding granulation tissue. Additionally, a rhino-orbital fistula was observed (most likely due to lysis of the thin inner portion of the orbital wall) with mucous membrane spreading from the nasal cavity into the orbital cavity, increasing the risk of infection. Ectoprosthetic replacement is scheduled for 7 months.

Further observation by an ophthalmologist and oncologist at the place of residence is recommended.

Thus, the proposed method of closing the orbital wound surface after subperiosteal exenteration allows for a reduction in the length of hospital stay, acceleration of postoperative rehabilitation of patients, a reduction in the number of dressing procedures, a reduction in the recovery period and the duration of cosmetic rehabilitation, which affects the improvement of the quality of life and social adaptation of patients.

Claims (1)

A method for closing the wound surface of the orbit after subperiosteal exenteration of the orbit, characterized in that a skin flap of a rectangular shape measuring 5x3 cm is first formed from the middle third of the inner surface of the shoulder, the flap is soaked for 10 minutes in a physiological solution, freed from subcutaneous fat, folded in half along the longer side, sutured from one edge along the shorter side with a continuous suture to form a cone-shaped funnel, the funnel is immersed in the orbit with the apex of the cone to the apex of the orbit and fixed to the skin edges of the orbit first with provisional interrupted sutures, and then with a continuous upholstered suture, the flap is perforated over the entire surface and the orbital cavity is tamponed.