A method for developing the thoracic duct during pneumatic mediastinoscopy for esophagectomy

Abstract

The present invention discloses a method for developing the thoracic duct during inflatable mediastinoscopy for esophagectomy, and specifically relates to the technical field of medical esophagectomy, wherein the method comprises the following steps: percutaneous ICG injection of inguinal lymph nodes, neck incision and establishment of surgical channel, transcervical mediastinal approach and exposure of surgical area, ICG thoracic duct development, abdominal operation, and neck anastomosis. The present invention combines percutaneous ICG injection of inguinal lymph nodes, cervical esophageal mobilization, inflatable mediastinoscopy for esophageal mobilization, translaparoscopic ICG thoracic duct development, laparoscopic gastric mobilization, laparoscopic mediastinal lymph node resection, and esophagogastric cervical anastomosis. Through the method for developing the thoracic duct, the disadvantage of being unable to identify and locate the thoracic duct under mediastinoscopy is overcome, the safety of the operation is improved, and the damage of the thoracic duct during the operation is avoided.

Description

Technical Field

[0001] The invention relates to the technical field of medical esophageal cancer surgery, and more specifically to a method for developing a thoracic duct during an inflatable mediastinoscope esophagectomy. Background Art

[0002] It is known that esophageal cancer is one of the common malignant tumors in China with a high mortality rate. Currently, the main treatment for patients with resectable esophageal cancer is still comprehensive treatment with surgery as the main method.

[0003] With the popularization of minimally invasive surgery and the advancement of laparoscopic technology, pneumatic mediastinoscopic esophagectomy has become the preferred surgical procedure for early esophageal cancer in recent years. Compared with traditional thoracoscopic surgery, it has the advantages of less trauma, less requirements and impact on cardiopulmonary function, fewer perioperative complications, and better short- and long-term efficacy.

[0004] However, pneumatic mediastinoscopic esophagectomy is performed in a smaller space, especially when the thoracic duct runs along with the esophagus and crosses with variations and branches, which makes it difficult to identify the thoracic duct during surgery. If thoracic duct damage is found during surgery, the more difficult thoracic duct ligation is performed in the limited space of the mediastinoscope, but it still seriously affects the safety of the operation, resulting in complications such as chylothorax and chylous leakage after surgery. Therefore, it is important to accurately identify the thoracic duct during mediastinoscopic surgery to avoid postoperative chylous leakage.

[0005] Among them, the main methods for preventing chylothorax during esophageal cancer surgery include: preventive thoracic duct ligation during surgery, oral olive oil filling of the thoracic duct before surgery, and indocyanine green fluorescence laparoscopic thoracic duct imaging; however, there are some problems with the above methods:

[0006] If preventive thoracic duct ligation is used, a more difficult thoracic duct ligation surgery is added, increasing the risk of complications;

[0007] If olive oil is taken orally before surgery, it will increase the patient's discomfort such as nausea, vomiting and diarrhea, increase the risk of anesthesia aspiration, and the actual development time is not ideal. There is also a risk of accidental injury during surgery due to excessive filling of the chest duct.

[0008] If indocyanine green fluorescence laparoscopic thoracic duct angiography is used, the injection site affects the imaging effect, which not only has certain requirements on the laparoscopic equipment, but also there is no uniform standard for the injection method and imaging time of indocyanine green. There are problems such as weak fluorescence imaging, the need for early injection, which may miss the best imaging time, and pain and trauma to the patient.

[0009] Currently, there is no effective method for displaying the chest duct visualization to prevent postoperative chylous leakage during pneumatic mediastinoscopic esophagectomy, and the operation is performed only based on experience. Therefore, the present invention proposes a method for displaying the chest duct during pneumatic mediastinoscopic esophagectomy as a further improvement. Summary of the invention

[0010] In order to overcome the above-mentioned defects of the prior art, an embodiment of the present invention provides a method for developing the thoracic duct during an inflatable mediastinoscope esophagectomy to solve the problems raised in the above-mentioned background technology.

[0011] To achieve the above object, the present invention provides the following technical solution: a method for developing the thoracic duct during inflatable mediastinoscope esophagectomy, characterized in that the method comprises the following steps:

[0012] S1: First, the patient is intubated and given intravenous general anesthesia; then the superficial lymph nodes outside the bilateral inguinal femoral arteries of the patient are located and disinfected, and then a certain amount of contrast agent is subcutaneously injected into the superficial lymph nodes outside the bilateral inguinal femoral arteries in turn;

[0013] S2: Neck operation and establishment of transcervical mediastinal access: First, make an incision on the left side of the patient's neck, cut the platysma muscle, and expose the sternocleidomastoid muscle along the inner side of the anterior neck muscle; then free the cervical esophagus and part of the upper thoracic esophagus, and clear the lymph nodes beside the left recurrent laryngeal nerve; then, insert the incision protective cover into the neck incision to close the gap; finally, form a closed mediastinal operation space by inflation;

[0014] S3: Transcervical esophageal mobilization and lymph node dissection:

[0015] Exploration: A 4K endoscope fluorescence imaging system is inserted through the endoscope hole; during the operation, the chest duct area is explored using the ordinary white light mode, and then the fluorescence imaging mode, i.e., the black and white fluorescence mode, is switched to explore the chest duct imaging intensity, clarity, position and shape in the chest cavity, and finally the fusion imaging mode is switched during the operation;

[0016] Free and Sweep:

[0017] If the patient has enlarged cervical lymph nodes, the esophagus is dissected with an ultrasonic scalpel, and the artery and esophagus are pulled with a retractor. When freeing the thoracic esophagus: first free the left and posterior walls of the esophagus, then free the anterior and right walls of the esophagus, and advance in a circular manner; then peel off the esophagus and the lymph nodes around the left recurrent laryngeal nerve along the left esophageal wall above the aortic arch to separate it from the aortic arch; then free the lymph nodes from the tracheal wall and push them to the level of the tracheobronchial junction; then free the esophageal tracheal ligament above its venous arch; complete the whole block clearance: lymph nodes around the left recurrent laryngeal nerve, esophageal, tracheobronchial and subcarinal lymph nodes;

[0018] If B-ultrasound and CT scans of the neck show no enlarged lymph nodes in the patient's neck, the lymph nodes near the right recurrent laryngeal nerve will be cleared from the front of the trachea and the right subclavian artery.

[0019] S4: Laparoscopic mobilization of the stomach and abdominal lymph node dissection: Use ultrasonic scalpel to free the greater and lesser curvatures of the stomach and the abdominal esophagus, and use hemolock to ligate the left gastric blood vessels and then sever them; and dissect the abdominal lymph nodes; after opening the diaphragmatic hiatus, free the lower thoracic esophagus until it completely penetrates the mediastinum; simultaneously remove the supradiaphragmatic lymph nodes and the lower paraesophageal lymph nodes; remove the neck gloves and incision protective cover, lift the free cervical esophagus, ligate the distal end of the esophagus, cut the esophagus, insert the base of the stapler, suture and ligate, and then cut the esophageal muscle layer and mucosal layer in layers; make a tube stomach.

[0020] S5: Neck anastomosis: The cervical esophagus is transected through a left cervical incision, and a tubular stomach is made and lifted to the cervical esophagus for anastomosis.

[0021] Furthermore, in S1, the injected imaging agent needs to be dissolved in sterile water for injection.

[0022] Furthermore, in S2, the patient is required to be in a supine position, with a single-lumen endotracheal tube for bilateral lung ventilation and under general anesthesia.

[0023] Furthermore, in S3, the anatomy of the thoracic duct and potential intraoperative damage are checked again after the operation; for patients in whom thoracic duct damage is found during the operation, the thoracic duct damage is located under the guidance of the fluorescent fusion mode, and the thoracic duct is ligated with hemolock at the upper and lower parts of the rupture.

[0024] Furthermore, in the above S4, during the process of freeing the stomach, care is taken to protect the right omental artery, and the lymph nodes near the cardia, left gastric vessels, common hepatic artery, proximal splenic artery and celiac trunk are removed.

[0025] Furthermore, in S4, the esophageal muscle layer is cut: first, the esophageal muscle layer is cut in a complete circle at a certain distance from the ligature, and then the mucosal layer is cut while keeping the mucosal layer intact; the distal esophageal ligature is connected to one end of the Pan's tube.

[0026] Furthermore, in S4, a tube stomach is made: a small auxiliary incision is made in the middle of the upper abdomen, the free stomach and thoracic esophagus are pulled out from the abdominal incision, and a linear cutting suture device is used to make a tube stomach along the lesser curvature of the stomach.

[0027] Technical effects and advantages of the present invention:

[0028] 1. Compared with the prior art, the present invention innovatively applies the fluoroscopic chest duct visualization technology to pneumatic mediastinoscopy surgery, filling the gap in the current chest duct visualization method in pneumatic mediastinoscopy esophageal cancer surgery;

[0029] 2. The problem of unstable development effect of indocyanine green injected subcutaneously through the groin in the chest duct development technology has been solved. The innovative method of injecting indocyanine green into the bilateral inguinal lymph nodes under the guidance of B-ultrasound has better development effect and 100% development rate compared with unilateral subcutaneous injection, and the injection under the guidance of B-ultrasound is more accurate. It provides a method for accurately displaying the chest duct for inflatable mediastinoscope esophageal cancer surgery, ensuring the safety of the operation and avoiding the occurrence of postoperative chyle leakage.

[0030] 3. The present invention is specially designed for inflatable mediastinoscopic esophageal cancer resection surgery. While designing a method for intraoperative chest duct visualization, it also designs a method and position for preoperative injection of indocyanine green to ensure chest duct visualization, thereby ensuring the effect of intraoperative chest duct visualization. BRIEF DESCRIPTION OF THE DRAWINGS

[0031] Figure 1 It is a schematic diagram of the process of the present invention. DETAILED DESCRIPTION

[0032] In order to make the purpose, technical solution and advantages of the present invention more clearly understood, the present invention is further described in detail below in conjunction with the accompanying drawings and embodiments. It should be understood that the specific embodiments described herein are only used to explain the present invention and are not intended to limit the present invention.

[0033] As attached Figure 1 A method for developing the thoracic duct during inflatable mediastinoscope esophagectomy is characterized in that the method comprises the following steps:

[0034] S1: First, the patient is intubated and given intravenous general anesthesia; then the superficial lymph nodes outside the bilateral inguinal femoral arteries of the patient are located and disinfected, and then a certain amount of contrast agent is subcutaneously injected into the superficial lymph nodes outside the bilateral inguinal femoral arteries in turn;

[0035] Example: Take a 25mg indocyanine green bottle produced by Danhong Medical Innovation Pharmaceutical Co., Ltd. of Liaoning Province, China, calculate the dosage of 0.5mg / KG according to the patient's weight, and dissolve it in 50ml of sterile water for injection; disinfect the bilateral groin areas of the patient with iodine tincture, first locate the femoral artery at the right groin with a B-ultrasound probe, and gradually push the needle from deep to subcutaneous injection 25ml at the lateral edge of the femoral artery 1cm, and withdraw the needle after completion; then locate the femoral artery at the left groin with a B-ultrasound probe, and gradually push the needle from deep to subcutaneous injection 25ml at the lateral edge of the femoral artery 1cm, and withdraw the needle after completion; after the bilateral injection is completed, rub the injection site locally for 1min to promote drug absorption.

[0036] S2: Neck manipulation and establishment of the transcervical mediastinal approach:

[0037] First, make an incision on the left side of the patient's neck: make a 5 cm incision on the anterior edge of the left sternocleidomastoid muscle;

[0038] Cut the platysma muscle: Cut the skin, subcutaneous tissue, and platysma muscle layer by layer; then expose the sternocleidomastoid muscle along the inner side of the anterior cervical muscle;

[0039] Free the cervical esophagus and part of the upper thoracic esophagus: first free the space between the left carotid artery, jugular vein and esophagus, then free the tissue space between the esophagus and the thyroid gland and trachea; thus fully free the cervical esophagus and part of the upper thoracic esophagus;

[0040] Clear the lymph nodes around the left recurrent laryngeal nerve; free the cervical esophagus and part of the upper thoracic esophagus, free the left recurrent laryngeal nerve along the left edge of the trachea under direct vision, and remove the lymph nodes around the left recurrent laryngeal nerve;

[0041] Subsequently, the incision protection cover is inserted into the neck incision to close the gap; finally, a closed mediastinum operating space is formed by inflation; wherein, the closed mediastinum operating space is formed by inflation with 6-10 mmHg (1 mmHg = 0.133 kPa) of carbon dioxide.

[0042] S3: Transcervical esophageal mobilization and lymph node dissection:

[0043] Exploration: A 4K endoscopic fluorescence imaging system was used through the endoscope port;

[0044] Embodiment: The imaging system is manufactured by Nanjing Nuoyuan Medical Instrument Co., Ltd., equipment model FI L-20A;

[0045] During the operation, the chest duct area is explored using the ordinary white light mode, and then the mode is switched to the fluorescent image mode, i.e., the black and white fluorescent mode, to explore the intensity, clarity, position and shape of the chest duct in the chest cavity, and finally the mode is switched to the fusion image mode during the operation;

[0046] Free and Sweep:

[0047] If the patient has enlarged cervical lymph nodes, the esophagus is dissected with an ultrasonic scalpel, and the artery and esophagus are pulled with a retractor. When freeing the thoracic esophagus: first free the left and posterior walls of the esophagus, then free the anterior and right walls of the esophagus, and advance in a circular manner; then peel off the esophagus and the lymph nodes around the left recurrent laryngeal nerve along the left esophageal wall above the aortic arch to separate it from the aortic arch; then free the lymph nodes from the tracheal wall and push them to the level of the tracheobronchial junction; then free the esophageal tracheal ligament above its venous arch; complete the whole block clearance: lymph nodes around the left recurrent laryngeal nerve, esophageal, tracheobronchial and subcarinal lymph nodes;

[0048] If B-ultrasound and CT scans of the neck show no enlarged lymph nodes in the patient's neck, the lymph nodes near the right recurrent laryngeal nerve will be cleared from the front of the trachea and the right subclavian artery.

[0049] S4: Laparoscopic gastric mobilization and abdominal lymph node dissection: Use ultrasonic scalpel to free the greater and lesser curvatures of the stomach and the abdominal esophagus, ligate the left gastric blood vessels with hemolock and then sever them; and dissect the abdominal lymph nodes; after opening the diaphragmatic hiatus, free the lower thoracic esophagus until it completely penetrates the mediastinum; simultaneously remove the supradiaphragmatic lymph nodes and the lower paraesophageal lymph nodes; remove the neck gloves and incision protective cover, and lift the free cervical esophagus;

[0050] Among them, the distal end of the esophagus was ligated with 7# silk thread;

[0051] Subsequently, the esophagus is cut open, the base of the stapler is inserted, and after suturing and ligation, the muscular layer and mucosal layer of the esophagus are cut open in layers to make a tube stomach.

[0052] S5: Neck anastomosis: The cervical esophagus is transected through a left cervical incision, and a tubular stomach is made and lifted to the cervical esophagus for anastomosis.

[0053] Among them, the other end of the Pan's tube is lifted up from the neck incision, and the hand enters the esophageal hiatus in the abdominal cavity to explore whether the tube stomach is sufficiently pulled. A 2 cm incision is made from the top of the tube stomach from the neck incision, and the tubular stapler main unit is placed into the tube stomach. Under the condition of ensuring that there is no tension, the stapler needle is passed through the posterior wall of the tube stomach, and after it is aligned with the base of the esophageal end, the esophageal-gastric cervical anastomosis is completed; the residual end of the tube stomach is closed with a linear cutting suture.

[0054] In a preferred embodiment, as shown in the attached Figure 1 In said S1, the injected imaging agent needs to be dissolved in sterile water for injection; wherein, the dosage is calculated according to the patient's weight, 0.5 mg / KG, and dissolved in 50 ml of sterile water for injection.

[0055] In a preferred embodiment, as shown in the attached Figure 1 In S2, the patient is required to be in a supine position, with a single-lumen endotracheal tube for bilateral lung ventilation and under general anesthesia.

[0056] In a preferred embodiment, as shown in the attached Figure 1 In S3, the anatomy of the thoracic duct and potential intraoperative damage are checked again after the operation; for patients with thoracic duct damage found during the operation, the thoracic duct damage is located under the guidance of the fluorescent fusion mode, and the thoracic duct is ligated with hemolock at the upper and lower parts of the rupture.

[0057] In a preferred embodiment, as shown in the attached Figure 1 In the S4, during the process of freeing the stomach, attention should be paid to protecting the right omental artery, and the lymph nodes beside the cardia, left gastric vessels, common hepatic artery, proximal splenic artery and celiac trunk should be removed.

[0058] In a preferred embodiment, as shown in the attached Figure 1In S4, the esophageal muscle layer is cut: first, the esophageal muscle layer is cut in a complete circle at a certain distance from the ligature, and then the mucosal layer is cut while keeping the mucosal layer intact; the distal esophageal ligature is connected to one end of the Pan's tube.

[0059] The embodiment includes: using an electric knife to completely incise the esophageal muscle layer at a distance of 5 mm from the ligature; completely incising the mucosa by retaining 5 mm of the mucosal layer; and connecting the distal end of the esophagus to one end of the Pan's tube through a 7# ligature thread.

[0060] In a preferred embodiment, as shown in the attached Figure 1 In S4, a tube stomach is made: a small auxiliary incision is made in the middle of the upper abdomen, the free stomach and thoracic esophagus are pulled out from the abdominal incision, and a straight line cutting suture device is used to make a tube stomach along the lesser curvature of the stomach.

[0061] Embodiment: A 5 cm auxiliary small incision was made in the middle of the upper abdomen; the width of the tube stomach was 3-5 cm; 2-3 stitches of 4# silk thread were used to suture the upper end of the tube stomach for traction and lifting, and the tube stomach was firmly connected with the same end of the Pan's tube.

[0062] It should be noted that, in this article, relational terms such as first and second, etc. are only used to distinguish one entity or operation from another entity or operation, and do not necessarily require or imply any such actual relationship or order between these entities or operations. Moreover, the terms "include", "comprise" or any other variants thereof are intended to cover non-exclusive inclusion, so that a process, method, article or device including a series of elements includes not only those elements, but also other elements not explicitly listed, or also includes elements inherent to such process, method, article or device.

[0063] Although embodiments of the present invention have been shown and described, it will be appreciated by those skilled in the art that various changes, modifications, substitutions and variations may be made to the embodiments without departing from the principles and spirit of the present invention, and that the scope of the present invention is defined by the appended claims and their equivalents.

Claims

1. A method for developing the thoracic duct during pneumatic mediastinoscopic esophagectomy, characterized by: The method comprises the following steps: S1: First, the patient is intubated and given intravenous general anesthesia; then the superficial lymph nodes outside the bilateral inguinal femoral arteries of the patient are located and disinfected, and then a certain amount of contrast agent is subcutaneously injected into the superficial lymph nodes outside the bilateral inguinal femoral arteries in turn; S2: Neck operation and establishment of transcervical mediastinal access: First, make an incision on the left side of the patient's neck, cut the platysma muscle, and expose the sternocleidomastoid muscle along the inner side of the anterior neck muscle; then free the cervical esophagus and part of the upper thoracic esophagus, and clear the lymph nodes beside the left recurrent laryngeal nerve; then, insert the incision protective cover into the neck incision to close the gap; finally, form a closed mediastinal operation space by inflation; S3: Transcervical esophageal mobilization and lymph node dissection: Exploration: A 4K endoscope fluorescence imaging system is inserted through the endoscope hole; during the operation, the chest duct area is explored using the ordinary white light mode, and then the fluorescence imaging mode, i.e., the black and white fluorescence mode, is switched to explore the chest duct imaging intensity, clarity, position and shape in the chest cavity, and finally the fusion imaging mode is switched during the operation; Free and Sweep: If the patient has enlarged cervical lymph nodes, the esophagus is dissected with an ultrasonic scalpel, and the artery and esophagus are pulled with a retractor. When freeing the thoracic esophagus: first free the left and posterior walls of the esophagus, then free the anterior and right walls of the esophagus, and advance in a circular manner; then peel off the esophagus and the lymph nodes around the left recurrent laryngeal nerve along the left esophageal wall above the aortic arch to separate it from the aortic arch; then free the lymph nodes from the tracheal wall and push them to the level of the tracheobronchial junction; then free the esophageal tracheal ligament above its venous arch; complete the whole block clearance: lymph nodes around the left recurrent laryngeal nerve, esophageal, tracheobronchial and subcarinal lymph nodes; If B-ultrasound and CT scans of the neck show no enlarged lymph nodes in the patient's neck, the lymph nodes near the right recurrent laryngeal nerve will be cleared from the front of the trachea and the right subclavian artery. S4: Laparoscopic mobilization of the stomach and abdominal lymph node dissection: Use ultrasonic scalpel to free the greater and lesser curvatures of the stomach and the abdominal esophagus, and ligate the left gastric blood vessels with hemolock and then sever them; and dissect the abdominal lymph nodes; after opening the diaphragmatic hiatus, free the lower thoracic esophagus until it completely penetrates the mediastinum; simultaneously remove the supradiaphragmatic lymph nodes and the lower paraesophageal lymph nodes; remove the neck gloves and incision protective cover, lift the free cervical esophagus, ligate the distal end of the esophagus, cut the esophagus, insert the base of the stapler, suture and ligate, and then cut the esophageal muscle layer and mucosal layer in layers; make a tube stomach. S5: Neck anastomosis: The cervical esophagus is transected through a left cervical incision, and a tubular stomach is made and lifted to the cervical esophagus for anastomosis.

2. The method for developing the thoracic duct during pneumatic mediastinoscopic esophagectomy for esophageal cancer according to claim 1, characterized in that: In the above-mentioned S1, the injected imaging agent needs to be dissolved in sterile water for injection.

3. The method for developing the thoracic duct during pneumatic mediastinoscopic esophagectomy for esophageal cancer according to claim 1, characterized in that: In S2, the patient is required to be in a supine position, with a single-lumen endotracheal tube for bilateral lung ventilation and under general anesthesia.

4. The method for developing the thoracic duct during pneumatic mediastinoscopic esophagectomy for esophageal cancer according to claim 1, characterized in that: In S3, the anatomy of the thoracic duct and potential intraoperative damage are checked again after the operation. For patients in whom thoracic duct damage is found during the operation, the thoracic duct damage is located under the guidance of the fluorescent fusion mode, and the thoracic duct is ligated with hemolock at the upper and lower parts of the rupture.

5. The method for developing the thoracic duct during pneumatic mediastinoscopic esophagectomy for esophageal cancer according to claim 1, characterized in that: In the above-mentioned S4, during the process of freeing the stomach, care is taken to protect the right omental artery, and lymph nodes beside the cardia, left gastric vessels, common hepatic artery, proximal splenic artery and celiac trunk are removed.

6. The method for developing the thoracic duct during pneumatic mediastinoscopic esophagectomy according to claim 1, characterized in that: In S4, the esophageal muscle layer is cut: first, the esophageal muscle layer is cut in a complete circle at a certain distance from the ligature, and then the mucosal layer is cut while keeping the mucosal layer intact; the distal esophageal ligature is connected to one end of the Pan's tube.

7. The method for developing the thoracic duct during pneumatic mediastinoscopic esophagectomy for esophageal cancer according to claim 1, characterized in that: In S4, a tube stomach is made: a small auxiliary incision is made in the middle of the upper abdomen, the free stomach and thoracic esophagus are pulled out from the abdominal incision, and a straight-line cutting suture device is used to make a tube stomach along the lesser curvature of the stomach.

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