Method for extrapleural pneumolysis with capitonage of cavity in fibrocavernous tuberculosis of pulmonary

Abstract

FIELD: medicine; thoracic phthisiosurgery.SUBSTANCE: operation is performed under endotracheal anesthesia with the patient lying on his stomach. A 12 cm long paravertebral skin incision is made from the level of the 7th cervical vertebra. The trapezius and rhomboid muscles are intersected in the paravertebral direction along 2 / 3 of their length. The scapula is abducted laterally. The soft tissues are dissected down to the periosteum of the ribs. The 4th rib is subperiosteally isolated, mobilized and resected along the length from the costotransverse joint to the angle of the rib. In the bed of the 4th rib, the musculoperiosteal layer is distinguished. The parietal pleura is separated paracostally and mediastinally. The integrity of the pleura is not violated. The 1st rib is isolated and resected along its entire length. The 2nd rib is isolated and resected from the costotransverse joint to a level of 2 cm from the sternum. The 3rd rib is isolated and resected from the costotransverse joint to a level of 4 cm from the sternum. During the course of rib resection, extrapleural pneumolysis is performed in stages in the muscular-periosteal layer of the apical, mediastinal and paracostal parts of the lung. When examining the accessible parts of the lung, a cavity in the lung is identified. The walls of the cavern are immersed into the lumen of its cavity. Using non-absorbable monofilament thread No. 3, four interrupted fixing sutures are placed at the point of contact between the walls of the cavern and the intussusception around the circumference of the cavern, capturing both walls of the cavern in the suture, fixing the intussusception in the cavity of the cavern. Then, at the level of the parietal pleura, a second level of fixing sutures is applied with continuous non-absorbable monofilament thread No. 3 in the form of the digital 8. A drain is placed in the postoperative wound and the wound is sutured layer by layer.EFFECT: method allows to eliminate the cavity, stop bacterial excretion, and prevent the accumulation of serous fluid in the area of surgical intervention.1 cl, 2 ex

Description

[0001] The invention relates to medicine, in particular to thoracic surgery, namely to phthisiosurgery, and concerns methods of extrapleural pneumolysis in fibrocavernous tuberculosis of the lungs.

[0002] A known method of extrapleural pneumolysis for pulmonary tuberculosis involves performing an intercostal thoracotomy followed by extrapleural separation of the apex of the affected lung and the creation of an extrapleural cavity. A soft tissue flap is then created, using a muscle flap from the latissimus dorsi muscle. When mobilizing the flap, the long lateral and posterior sternal nerves, as well as the muscle bundles at its attachment to the humerus and axillary region, are maximally preserved. The flap is moved into the formed extrapleural cavity through the thoracotomy opening and fixed to the dome and costal surfaces of the chest (Giller D.B., Ivanov A.V., Giller B.M., Giller G.V., Tokayev K.V., Bagirov M.A., Bondarev G.B. / Patent for invention “Method of extrapleural pneumolysis surgery for pulmonary tuberculosis” No. 2290878 dated 10.01.2007, Bulletin No. 1).

[0003] The disadvantages of this method include the need to isolate and move the muscle flap, which prolongs the operation time and also creates the preconditions for damage to blood vessels and nerves, and also increases the risk of developing postoperative seromas in the area of ​​muscle flap collection.

[0004] A method of superior-posterior extrapleural thoracoplasty for destructive pulmonary tuberculosis is known. This method involves performing a paravertebral incision with division of the trapezius muscle, isolating the tendinous edge of the rhomboid major muscle at the edge of the spine, and transecting it along the tendinous edge without damaging the muscle structures. The first rib is resected to the cartilaginous portion, the second rib to the midclavicular line, the third and fourth ribs to the midaxillary line, and the fifth rib to the posterior axillary line. The rib is fixed to the intercostal muscles with P-shaped sutures, leaving the tendinous edge intact. The tendinous edge of the rhomboid muscle is dislocated under the aponeurosis of the superior posterior serratus muscle and under the edge of the erector spinae muscle, and secured to the latter with single P-shaped sutures (Avetisyan A.O., Kudryashov G.G., Serezvin E.S., Chausov A.V., Vasiliev I.V., Yablonsky P.K. / Patent for invention “Method of upper-posterior extrapleural thoracoplasty for destructive pulmonary tuberculosis” No. 2743457 dated 02 / 18 / 2021).

[0005] A disadvantage of this method is the need to further isolate and relocate the tendon edge of the rhomboid muscle and then fix it to the muscle fibers of the back muscles. This technique is only feasible in cases of well-developed muscle structures and their tendons. Patients with chronic infections typically have low body weight and degeneration of the trunk's muscular framework. Furthermore, fixation of the aponeurosis to muscle fibers creates the potential for long-term suture failure due to the heterogeneity of the tissues being sutured and the risk of ligature cuts through the muscle tissue.

[0006] This method was taken by the authors as a prototype.

[0007] The objective of the invention is to create a method for extrapleural pneumolysis with capitonnage, which allows for the elimination of a cavity of up to 10 cm in diameter, securely fixing the visceral and parietal pleural layers over the capitonnage zone, and preventing the straightening of the cavity in the postoperative period.

[0008] The technical result achieved by the invention is the elimination of the cavity, the elimination of bacterial secretion, and the prevention of the accumulation of serous fluid in the area of ​​surgical intervention.

[0009] The stated technical result is achieved by making a 12-cm-long skin incision intraoperatively, under endotracheal anesthesia, with the patient in the prone position, paravertebrally from the level of the 7th cervical vertebra. The trapezius and rhomboid muscles are transected paravertebrally at two-thirds of their length. The scapula is retracted laterally, and the soft tissues are dissected down to the costal periosteum. The 4th rib is exposed subperiosteally, mobilized, and resected along its length from the costotransverse joint to the costal angle. The musculoperiosteal layer in the bed of the 4th rib is exposed, and the parietal pleura is separated paracostally and mediastinally, without violating the integrity of the pleura. The 1st rib is exposed and resected along its entire length. The second rib is isolated and resected from the costotransverse joint to a level of 2 cm from the sternum. The third rib is isolated and resected from the costotransverse joint to a level of 4 cm from the sternum.During rib resection, extrapleural pneumolysis is performed in stages in the musculoperiosteal layers of the apical, mediastinal, and paracostal regions of the lung. During exploration of the accessible lung regions, the cavity is identified. Four interrupted fixation sutures are placed with #3 non-absorbable monofilament suture at the cavity capitonnage site around the intussusception, ensuring that both walls of the cavity are included in the suture, thereby securing the intussusception within the cavity. A second level of fixation sutures is then placed at the level of the parietal pleura using continuous #3 non-absorbable monofilament suture in a figure-8 pattern. A drain is placed in the postoperative wound. The wound is closed layer by layer.

[0010] Thus, performing a paravertebral incision allows for adequate selection of the ribs for resection, partial dissection of muscle fibers allows for preservation of their function and anatomical location, during the process of invagination of the cavern walls, fixing them to each other with a monofilament non-absorbable thread creates a reliable capitonnage of the cavity, additional fixation of the parietal pleura in the area of ​​​​invagination with a continuous monofilament thread in the form of a figure 8 knot allows for enhancing the fixing effect and preventing the straightening of the cavern cavity.

[0011] In practice, extrapleural pneumolysis with cavity capitonnage for fibrocavernous pulmonary tuberculosis is performed as follows. Intraoperatively, under endotracheal anesthesia, with the patient in the prone position, a 12-cm-long skin incision is made paravertebrally from the level of the 7th cervical vertebra. The trapezius and rhomboid muscles are transected paravertebrally at two-thirds of their length. The scapula is retracted laterally, and the soft tissues are dissected down to the costal periosteum. The 4th rib is exposed subperiosteally, mobilized, and resected from the costotransverse joint to the costal angle. In the bed of the 4th rib, the musculoperiosteal layer is exposed, and the parietal pleura is separated paracostally and mediastinally, without violating the integrity of the pleura. The first rib is isolated and resected along its entire length. The second rib is isolated and resected from the costotransverse joint to a level of 2 cm from the sternum.The third rib is isolated and resected from the costotransverse joint to a level 4 cm from the sternum. During rib resection, extrapleural pneumolysis is performed in stages in the musculoperiosteal layers of the apical, mediastinal, and paracostal regions of the lung. During exploration of the accessible lung regions, the cavity of the lung is identified. Four interrupted fixing sutures are placed with #3 non-absorbable monofilament suture at the site of the cavity capitonnage around the circumference of the intussusception, ensuring that both walls of the cavity are included in the suture, thereby securing the intussusception within the cavity. A second level of fixing sutures is then placed at the level of the parietal pleura using continuous #3 non-absorbable monofilament suture in a figure-8 pattern. A drain is placed in the postoperative wound. The wound is closed layer by layer.

[0012] The method of extrapleural pneumolysis with cavity capitonnage for fibrocavernous pulmonary tuberculosis was tested on 35 patients of the tuberculosis pulmonary surgical department of the Republican Clinical Anti-Tuberculosis Dispensary in Ufa, Republic of Bashkortostan, and positive results were obtained.

[0013] The method allows to eliminate the cavity, stop the release of bacteria, and prevent the accumulation of serous fluid in the area of ​​​​surgical intervention.

[0014] The method of extrapleural pneumolysis with capitonnage of the cavity in fibro-cavernous tuberculosis of the lungs can be recommended for use in phthisiosurgical departments.

[0015] The implementation of the method is explained with clinical examples.

[0016] Clinical example 1.

[0017] Patient R., 43 years old, diagnosed with fibrous-cavernous tuberculosis of the upper lobe of the right lung, MBT+, HIV infection, was admitted to the tuberculosis pulmonary surgery department of the Republican Clinical Anti-Tuberculosis Dispensary in Ufa, Republic of Bashkortostan on March 12, 2019. She has been ill for 14 months. Upon admission, her condition was moderate. A CT scan of the chest organs revealed a destructive cavity in the S2 segment on the right, 8 cm in diameter, with foci of perivascular lesions in the S6 segment on the right. Infiltration in the upper and lower lobes of the left lung was also detected. Specific anti-tuberculosis polychemotherapy was administered for 5 months. At the same time, infiltration in the left lung decreased, a zone of destruction appeared in the S6 segment on the left, and abacillary ablation was not achieved.

[0018] On August 15, 2019, intraoperatively, under endotracheal anesthesia, with the patient in the prone position, a 12-cm-long paravertebral skin incision was made to the right of the 7th cervical vertebra. The trapezius and rhomboid muscles were transected paravertebrally along 2 / 3 of their length. The scapula was retracted laterally, and the soft tissues were dissected down to the periosteum of the ribs. The 4th rib was exposed subperiosteally, mobilized, and resected along its length from the costotransverse joint to the rib angle. In the bed of the 4th rib, the musculoperiosteal layer was exposed, the parietal pleura was separated paracostally and mediastinally, while the integrity of the pleura was not violated. The 1st rib was exposed and resected along its entire length. The second rib was isolated and resected from the costotransverse joint to a level of 2 cm from the sternum. The third rib was isolated and resected from the costotransverse joint to a level of 4 cm from the sternum.During rib resection, extrapleural pneumolysis was performed in stages in the musculoperiosteal layers of the apical, mediastinal, and paracostal regions of the lung. During exploration of the accessible lung regions, a cavernous cavity with a diameter of 8 cm was identified. Four interrupted fixation sutures with #3 non-absorbable monofilament suture were placed at the cavern capitonnage site around the circumference of the intussusception, ensuring that both walls of the cavity were included in the suture, thereby securing the intussusception within the cavity. A second level of fixation sutures with continuous #3 non-absorbable monofilament suture in a figure-8 pattern was then placed at the level of the parietal pleura. A drain was placed in the postoperative wound. The wound was closed layer by layer.

[0019] Postoperatively, a control chest X-ray revealed no cavity in the upper lobe of the right lung. On the fourth day, the drainage was removed. Sputum testing for Mycobacterium tuberculosis after three weeks was negative. The long-term outcome was assessed after six months: the cavity in the upper lobe of the right lung was obliterated.

[0020] The use of this method of extrapleural pneumolysis with cavity capitonnage in fibro-cavernous tuberculosis of the lungs made it possible to completely eliminate the cavity with a diameter of 8 cm and stop the excretion of bacteria.

[0021] Clinical example 2.

[0022] Patient Sh., 59 years old, diagnosed with fibrous-cavernous tuberculosis of the upper lobe of the right lung, MBT+, pulmonary emphysema, stage 1 respiratory failure, was admitted to the tuberculosis pulmonary surgery department of the Republican Clinical Anti-Tuberculosis Dispensary in Ufa, Republic of Bashkortostan on May 3, 2020. He has been ill for 28 months. Upon admission, his condition is moderate. According to computed tomography of the chest organs, a zone of destruction in the S1 + S2 segment on the left with a diameter of 9 cm was revealed, foci of destruction with a diameter of up to 2 cm were also detected in the lower lobe of the left lung and the upper lobe of the right lung. Polychemotherapy for 9 months. External respiratory function indicators: FEV1 - 40%, FVC - 45%.

[0023] 09 / 02 / 2021 On 05 / 02 / 2021, intraoperatively, under endotracheal anesthesia, with the patient in the prone position, a 12-cm-long skin incision was made paravertebrally to the left of the 7th cervical vertebra. The trapezius and rhomboid muscles were transected paravertebrally along 2 / 3 of their length. The scapula was retracted laterally, and the soft tissues were dissected down to the periosteum of the ribs. The 4th rib was exposed subperiosteally, mobilized, and resected from the costotransverse joint to the rib angle. In the bed of the 4th rib, the musculoperiosteal layer was exposed, the parietal pleura was separated paracostally and mediastinally, while the integrity of the pleura was not violated. The first rib was isolated and resected along its entire length. The second rib was isolated and resected from the costotransverse joint to a level of 2 cm from the sternum. The third rib was isolated and resected from the costotransverse joint to a level of 4 cm from the sternum.During rib resection, extrapleural pneumolysis was performed in stages in the musculoperiosteal layers of the apical, mediastinal, and paracostal lung regions. During exploration of the accessible lung regions, a pulmonary cavernous cavity measuring 9 cm in diameter was identified. Four interrupted sutures were placed with #3 non-absorbable monofilament suture at the cavern capitonnage site around the circumference of the intussusception, ensuring that both walls of the cavity were captured within the suture, thereby securing the intussusception within the cavity. A second level of continuous, figure-8 sutures with #3 non-absorbable monofilament suture was then placed at the level of the parietal pleura. A drain was placed in the postoperative wound. The wound was closed layer by layer.

[0024] Postoperatively, a control chest X-ray revealed no cavity in the upper lobe of the left lung. The drainage was removed on the third day. Sputum testing for Mycobacterium tuberculosis after 4 weeks was negative. The long-term outcome was assessed after 6 months: the cavity in the upper lobe of the left lung was obliterated.

[0025] The use of this method of extrapleural pneumolysis with cavity capitonnage in fibrous-cavernous tuberculosis of the lungs made it possible to completely eliminate the cavity with a diameter of 8 cm and stop the excretion of bacteria.

Claims

A method of extrapleural pneumolysis with cavity capitonnage in fibrocavernous pulmonary tuberculosis, including performing an operation under endotracheal anesthesia with the patient in the prone position, performing a paravertebral skin incision, characterized in that the incision is made from the level of the 7th cervical vertebra with a length of 12 cm; while the trapezius and rhomboid muscles are transected in the paravertebral direction along 2 / 3 of their length, the scapula is abducted laterally, the soft tissues are dissected to the periosteum of the ribs, the 4th rib is exposed subperiosteally, mobilized and resected along the length from the costotransverse joint to the angle of the rib; in the bed of the 4th rib, the musculoperiosteal layer is exposed, the parietal pleura is separated paracostally and mediastinally, the integrity of the pleura is not violated;The 1st rib is isolated and resected along its entire length, the 2nd rib is isolated and resected from the costotransverse joint to a level of 2 cm from the sternum, the 3rd rib is isolated and resected from the costotransverse joint to a level of 4 cm from the sternum; during the resection of the ribs, extrapleural pneumolysis is performed in stages in the musculoperiosteal layer of the apical, mediastinal and paracostal parts of the lung: during the revision of the accessible parts of the lung, the cavity of the cavern in the lung is determined; the walls of the cavern are immersed into the lumen of its cavity;using non-absorbable monofilament thread No. 3, four nodal fixing sutures are applied at the point of contact between the walls of the cavern and the intussusception around the circumference of the cavern, capturing both walls of the cavern in the suture, thereby fixing the intussusception in the cavity of the cavern, then at the level of the parietal pleura, a second level of fixing sutures is applied with a continuous non-absorbable monofilament thread No. 3 in the form of the figure 8, drainage is installed in the postoperative wound, the wound is sutured layer by layer.