RU2820325C1 - Method for plastic closure of posterior membranous wall of trachea or bronchus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to thoracic surgery. After removal of tumour of membranous wall of trachea or bronchus, wedge-shaped excision of lateral cartilaginous walls of trachea or bronchus is performed. Lateral cartilage walls are tightened with interrupted sutures. Membranous wall edges are brought together. Membranous wall defect is closed. Additionally, the suture line is covered with a mediastinal vascularized pleurocellular flap.

EFFECT: method enables preserving blood microcirculation within the anastomosis, suturing the membranous wall without considerable tension.

1 cl, 8 dwg, 1 ex

Description

The method of plastic closure of a defect in the posterior membranous wall of the trachea or bronchus relates to medicine, namely to thoracic surgery and can be used in oncology for isolated resection of the wall of the trachea or large bronchus for benign tumors and tumors with a low malignancy index, such as adenoma, chondroma, fibroma , pleomorphic adenoma, mucoepidermoid, carcinoid and granulosa cell tumors, adenoid cystic cancer, fibrous histiocytoma, hemangiopericytoma, etc. For tumors of large size and on a broad basis, it is sometimes necessary to remove relatively large sections of the bronchial or tracheal wall along with the tumor, which sometimes creates insurmountable difficulties during recovery integrity of the tracheobronchial tree. This problem is most sensitive when a defect in the wall of the trachea or bronchus is formed during the removal of a tumor arising from the membranous wall. The large diastasis between the proximal and distal edges of the membranous wall in the area of resection does not allow bringing them closer together, due to the large tension, the danger of cutting sutures on the fragile membranous wall and the development of anastomotic failure, as well as deformation and narrowing of the lumen of the trachea or bronchus. In these cases, surgeons resort to complex reconstructive operations - circular resection of the trachea or bronchus with the formation of intertracheal, interbronchial, tracheobronchial or polybronchial anastomoses (Grillo N.S.; 2004, pp. 599-617.). There are more complex reconstructive operations on the bronchi and tracheal bifurcation with the movement of segments of the trachea and bronchi (Barclay R., McSwan N., Welsch T.; 1957), sometimes with additional mutilating pneumonectomy (Grillo N.S. 2004, pp. 612-614 ) or leaving one lung in atelectasis (Petrovsky B.V., Perelman M.I., Koroleva N.S.; 1978, pp. - 185-186). These surgeries are traumatic and have a high risk of severe complications. Therefore, in a number of patients, surgical treatment is limited to a trial thoracotomy or palliative recanalization of the trachea and large bronchi is performed with the formation of a tracheostomy (Petrovsky B.V., Perelman M.I., Koroleva N.S. (1978)), stenting of the trachea and bronchi (Grillo N. .S. 2004, p. 763).

The prototype of the proposed reconstruction method should be considered the method that was described in the monograph by Grillo N.S. in 2004, pp. 602-603, where he suggests, after circular resection of the tracheal bifurcation during the formation of a new carina, after suturing along the medial wall of the main bronchi, to bring the trachea and bronchi closer together, at the beginning, apply and tie traction sutures, which are applied to the 2 cartilaginous half rings from the cut line of the wall of the trachea or bronchi. Then the previously applied sutures of the tracheobronchial anastomosis are tied (Fig. 1, 2). In this case, the sutures placed on the membranous wall of the anastomosis are tied last, taking into account the danger of their cutting through.

The method we propose differs from the prototype in that it is used without circular intersection of the trachea or bronchus, and this preserves blood microcirculation in the area of the anastomosis. There is no need to apply additional traction sutures, which may not protect the anastomosis along the membranous wall from failure and may themselves cut through under high tension.

The essence of the invention. In patients with a defect of significant size in the membranous wall of the trachea or bronchus (Fig. 3, 4), an additional wedge-shaped excision of the lateral cartilaginous walls of the trachea or bronchus is performed at the level of the resected section of the membranous wall (Fig. 5). Then the lateral cartilaginous walls are tightened with interrupted sutures (Fig. 6,7), bringing together the edges of the membranous wall, followed by suturing of the membranous wall defect (Fig. 8). The suture line is additionally covered with a mediastinal pleurocellular flap on a vascular pedicle.

Surgical treatment is performed under endotracheal anesthesia with ventilation of the right or left lung, depending on the location of the tumor. The patient's position on the operating table is also determined by the location of the tumor. When accessing the cervical and upper thoracic trachea, the patient is placed on the operating table in the supine position with the neck extended. A longitudinal median incision is used to dissect the skin and platysma, spread the anterior muscles of the neck, and cross the isthmus of the thyroid gland. The cervical and upper thoracic trachea are isolated while preserving the recurrent nerves. To access the bifurcation of the trachea, a posterior approach is used in the VI intercostal space with the intersection of the VI rib paravertebrally and the VII rib along the anterior axillary line. Access to the distal part of the left main bronchus is carried out from the posterolateral approach on the left in the 5th intercostal space. When tying the anastomotic sutures, the head is brought to the anterior chest wall.

To ensure adequate ventilation of the lungs during manipulation of the trachea and bronchi, a second special, elongated endotracheal tube connected to an anesthesia machine is periodically inserted into the transected main bronchus through an open surgical wound to perform ventilation of the lung through the surgical wound (shunt breathing). During anastomosis, high-frequency ventilation can be used.

Example. To illustrate the proposed method of safe plastic closure of a defect in the membranous wall of the bronchus after a fenestrated resection for a tumor, we present the observation of patient K., 48 years old, who was admitted to the surgical clinic of the Russian Research Center for Radiotherapy on January 26, 2018 with complaints of shortness of breath, cough with slight sputum and hemoptysis. The patient had been bothered by a cough for the last 5 years with periodic attacks of suffocation, sometimes with loss of consciousness. MSCT of the chest in the right main bronchus at the border with the intermediate bronchus revealed a hypervascularized formation measuring 25x24 mm, with a wide base adjacent to the posterior membranous wall and almost completely blocking the lumen of the main bronchus. The picture of pneumonia in the middle and lower lobes on the right was determined. During videotracheobronchoscopy, the right main bronchus is almost completely obstructed by a tuberous tumor with areas of necrosis and blood clots on the surface. Increased bleeding was noted on biopsy. Histological examination of the obtained material revealed a typical carcinoid. The study of respiratory function revealed a mixed type of impairment of the ventilation function of the lungs of moderate severity, vital capacity - 52% of the expected value. Lung perfusion scintigraphy showed a sharp decrease in the accumulation of radiopharmaceuticals (RP) throughout the right lung, which amounted to 12%, and in the left lung - 88%. After anti-inflammatory treatment, the patient underwent surgery using a right-sided lateral thoracotomy approach along the 5th intercostal space. The right lung and right main bronchus were mobilized. On palpation, a tumor of soft elastic consistency up to 22 mm in diameter was determined along the membranous wall of the main bronchus in the area of its division into the upper lobe and intermediate. A bronchotomy was performed, which made it possible to establish that the tumor originates from the membranous wall of the right main bronchus on a wide base and practically overlaps the main and partially intermediate bronchus (Fig. 3). Under visual control, retreating at least 5 mm from the edge of the tumor, the posterior, membranous wall of the main bronchus was resected along with the tumor (Fig. 4). To close the resulting round defect in the bronchial wall measuring 25×24 mm, an additional wedge-shaped resection of the lateral cartilaginous walls of the right main bronchus and partially the upper lobe bronchi was performed (Fig. 5). Then, the cartilaginous parts of the main, upper lobe and intermediate bronchi were pulled together with interrupted sutures, which made it possible to bring together the edges of the defect in the membranous wall of the main bronchus and apply interrupted vicryl sutures with atraumatic needles to the membranous wall of the main bronchus without significant tension (Fig. 7, 8). The suture line was additionally covered with a mediastinal pleurocellular flap on a vascular pedicle. The postoperative period was uneventful, and no air flow through the pleural drainage was observed. Histological examination of the surgical material confirmed the presence of a typical bronchial carcinoid with invasion of all layers of the bronchial wall without metastases in 13 distant regional lymph nodes. On X-ray examination, both lungs expanded to normal sizes, without focal changes. Control perfusion pneumoscintigraphy revealed equalization of radiopharmaceutical accumulation in both lungs: on the left - 47%, on the right - 53%. 5 years after the operation, the patient’s condition is satisfactory, breathing is free, there is no cough or shortness of breath. The patient works and leads an active lifestyle. With MSCT of the chest and video tracheobronchoscopy, the lungs are straightened, the lumens of the trachea, main, lobar and segmental bronchi are free, there is no evidence of tumor recurrence. The sutures on the wall of the bronchi are not visible.

Literature

1. Barclay R., McSwan N., Welsch T. Tracheal reconstruction without the use of grafts. - "Thorax", 1957, v. 12, p. 177-180.

2. Grillo H.C., Bendixen H., Gephart T. Resection of the carina and lower trachea. - "Ann. Surg.", 1963, v. 158, p.889-893.

3. Grillo H.C. Surgery of the Trachea and Bronchi //VS Decker Inc. - 2004. - P. 423-443, P. 599-617.

4. Kharchenko V.P., Chkhikvadze V.D. Surgical treatment of patients with neuroendocrine tumors (carcinoids), trachea, bronchi and lungs. Oncology. Journal named after P.A. Herzen. 2019; 8 (6):407

5. Petrovsky B.V., Perelman M.I., Koroleva N.S. Tracheo-bronchial surgery. M.: Medicine. 1978. - Page. 185-186.

Brief description of drawings

Figure 3 - Carcinoid of the membranous wall of the right main bronchus

Figure 4 - Defect in the membranous wall of the main bronchus after tumor removal

Fig 5 - Additional wedge-shaped excision of the lateral and medial cartilaginous wall of the main bronchus.

Fig 6 - Provisional sutures for bringing together the cartilaginous walls of the main bronchus

Fig 7 - Tightening of the cartilaginous walls of the main bronchus with interrupted sutures.

Fig 8 - Completion of interbronchial anastomosis after bringing the edges of the defect together without tension on the membranous wall of the main bronchus.

Claims (1)

A method of plastic closure of a defect in the posterior membranous wall of the trachea or bronchus, including removal of the tumor, after which the edges of the resected membranous wall are brought together, characterized in that a wedge-shaped excision of the lateral cartilaginous walls of the trachea or bronchus is performed, then the lateral cartilaginous walls are pulled together with interrupted sutures, bringing the edges of the membranous wall together , followed by suturing of the membranous wall defect, additionally the suture line is covered with a mediastinal pleurocellular flap on a vascular pedicle.