Surgical approaches for lung cancer. Topography of the pleura and lungs
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Extrapleural– without opening the pleura. Advantage: there is no depressurization of the pleural cavity, there is no need to transfer the patient to artificial respiration. Disadvantage: very limited field of action for the surgeon.
Transpleural– opening of 1 or both pleural cavities. Anesthesia support is required. The operation and postoperative period are more difficult.
Wide intercostal incisions and dissection of the sternum - sternotomy. The approaches when the patient is positioned on the back are called anterior, on the stomach - posterior, on the side - lateral.
With an anterior approach, the patient is placed on his back. The arm on the side of the operation is bent at the elbow joint and fixed in an elevated position on a special stand or arc of the operating table.
The skin incision begins at the level of the third rib cartilage from the parasternal line. An incision is made around the bottom of the nipple in men, and the mammary gland in women. The incision is continued along the fourth intercostal space to the posterior axillary line. The skin, tissue, fascia and parts of two muscles - the pectoralis major and the serratus anterior - are dissected in layers. The edge of the latissimus dorsi muscle at the back of the incision is pulled laterally with a blunt hook. Next, the intercostal muscles, intrathoracic fascia and parietal pleura are dissected in the corresponding intercostal space. The chest wall wound is opened with one or two dilators.
For the posterior approach, the patient is placed on his stomach. The head is turned in the direction opposite to the operation. The incision begins along the paravertebral line at the level of the spinous processes of the III-IV thoracic vertebrae, goes around the angle of the scapula and ends, respectively, in the middle or anterior axillary line at the level of the VI-VII rib. In the upper half of the incision, the underlying parts of the trapezius and rhomboid muscles are cut layer by layer, in the lower half - the latissimus dorsi muscle and the serratus anterior muscle. The pleural cavity is opened along the intercostal space or through the bed of a previously resected rib. With the patient positioned on the healthy side with a slight tilt on the back, the incision begins from the midclavicular line at the level of the fourth - fifth intercostal space and continues along the ribs to the posterior axillary line. The adjacent parts of the pectoralis major and serratus anterior muscles are dissected. The edge of the latissimus dorsi muscle and the scapula are pulled back. The intercostal muscles, intrathoracic fascia and pleura are dissected almost from the edge of the sternum to the spine, i.e. wider than the skin and superficial muscles. The wound is diluted with two dilators, which are placed mutually perpendicular.
Lung operations.
Access to the organs of the thoracic cavity can be pleural and extrapleural. Intrapleural approaches provide good exposure, but there is a danger of pus penetrating into the pleura and the development of retropulmonary shock. Extrapleural approaches do not have these disadvantages, but their criteria are sharply reduced compared to the first ones and they are difficult to achieve.
Pulmonectomy.
Indications: lung cancer, multiple abscesses, widespread bronchiectasis, pulmonary tuberculosis.
Access: anterolateral, posterolateral.
Technique: Thoracotomy is performed using a lateral approach along the 5th intercostal space, a posterior access along the 6th intercostal space, or an anterior approach along the 4th or 5th intercostal space. The lung is completely isolated, the pulmonary ligament is ligated and dissected. Dorsal to the phrenic nerve and parallel to it, the mediastinal pleura is dissected above the root of the lung. During right-sided pneumonectomy, after dissection of the mediastinal pleura, the anterior trunk of the right pulmonary artery is discovered in the upper part of the lung root. In the mediastinal tissue, the right pulmonary artery is found and isolated, processed, ligated with suturing, and transected. The superior and inferior pulmonary veins are also treated and divided. The right main bronchus is isolated to the trachea, sutured with a UO apparatus and transected. The suture line is pleurized with a mediastinal pleura flap. In left-sided pneumonectomy, after dissection of the mediastinal pleura, the left pulmonary artery and then the superior pulmonary vein are immediately isolated, processed and transected. Pulling the lower lobe laterally, the inferior pulmonary vein is isolated, treated and transected. The bronchus is pulled out from the mediastinum and isolated to the tracheobronchial angle, processed and transected. There is no need to pleurize the stump of the left main bronchus, since it goes into the mediastinum under the aortic arch.
Lobectomy. Video-guided thoracoscopy (VTK) - a new approach in thoracic surgery .
Indications. The impossibility of performing radical surgery and peripheral localization of the tumor less than 4 cm in size, tuberculous cavities, echinococcal and bronchogenic cysts. Contraindications include patient intolerance to lung collapse, tumor ingrowth into the chest, tumor invasion proximal to the lobar bronchus, severe pleural adhesions, calcification, or severe inflammatory changes in the lymph nodes.
Access: anterolateral with the intersection of the 5th and 6th ribs.
Technique: The patient is placed on his left side. The lung should be completely collapsed. The first trocar is installed in the VII intercostal space along the anterior axillary line. For upper, middle or lower lobectomy, incisions are made in the IV-V intercostal spaces along the posterior axillary line. A 6-7 cm long thoracotomy is performed from the mid-axillary line towards the anterior surface of the chest. An incision 1.5 cm long is made in the 5th intercostal space along the posterior axillary line. To install a drainage tube after surgery, an additional trocar may be required, which is inserted through the 7th intercostal space along the posterior axillary line. Using trocars and thoracotomy, the chest is examined for the presence of pleural dissemination, metastases in the lymph nodes and pulmonary nodes.
Right upper lobectomy. The lung is pulled back, the phrenic nerve is held on a holder. After double ligation, the superior pulmonary vein is ligated and divided. The anterior trunk of the pulmonary artery is ligated and crossed from the front, a holder is inserted under the azygos vein and the vein is pulled back, after which ligation and intersection are performed. After ligation and isolation of the pulmonary artery, the bronchus of the upper lobe of the lung is taken on a holder and the procedure is completed by suturing. The area around the bronchus is identified, the holder is passed through the lower slit and separated with a clip-on plicator. Isolation of the bronchus is performed together with lymph node dissection.
Middle lobectomy. The operation is performed with ligation and intersection of the middle lobe vein, then dissection of the pulmonary artery and middle lobe bronchus is performed along with the root lymph nodes located around the middle lobe bronchus.
Upper lobectomy on the left. After harvesting the phrenic nerve, the operation begins with ligation and division of the pulmonary vein. If the pulmonary vein has a short trunk, it is separately ligated and divided. It is possible to apply a suture with a stapler if it can pass under the blood vessel, otherwise clamps are used.
Lower lobectomy. In right- and left-sided operations, double ligation is usually performed, followed by division of the pulmonary artery through the interlobar fissure.
Segmentectomy.
Indications: tuberculous cavities, echinococcal and bronchogenic cysts within the segment.
Access: depending on the location of the affected segment.
Technique: An ultrasonic scalpel is used. Thoracoports are positioned in the same way as during a lobectomy; the mediastinal pleura is opened along the anterosuperior semicircle of the root lobe, but more distally than during a lobectomy. The central segmental vein is identified, treated with clips and transected. Then the segmental artery is isolated. After clipping and dividing the artery, a segmental bronchus is isolated and temporarily clamped with a soft endoscopic clamp. Using a small breath with an Ambu bag into the bronchial canal of the endotracheal tube, the correct isolation of the bronchus and the border of the removed segment are monitored. The bronchus is sutured using the Endo-GIA 2 Roticulator stapler, then traction of the segment is created upward by the bronchus and the intersegmental plane is separated with an ultrasonic scalpel. The advantage is a completely sealed intersegmental plane, there is no need for detailed topographic orientation in the intersegmental veins, because When dividing the intersegmental plane with an ultrasonic scalpel, only the veins coming from the segment to be removed are intersected.
Dangers and complications: to bleeding, n incompetence of the bronchial stump, pneumothorax , P neumpleuritis.
Access to the organs of the thoracic cavity is divided into two groups: A. Extra-pleural approaches. B. Through pleural approaches 1. In the direction Longitudinal Transverse Combined 2. From the surface Anterolateral Lateral Posterolateral 3. Along the dissected elements of the chest Along the intercostal spaces (unilateral, bilateral) With intersection or resection of the ribs With dissection of the sternum (longitudinal, transverse, combined sternotomy) Combined
Anterolateral approach (Lezius, 1951) Pros: technically simple and least traumatic. easy treatment of the lung favorable conditions for the functioning of the heart and the opposite lung Cons: inconvenient for a full revision and removal of tissue and lymph nodes
Access to the lungs, mediastinal organs (mainly the anterior heart), diaphragm, lower thoracic esophagus. Position the patient on his back. A roller is placed longitudinally under the breast. The incision begins at the level of the third rib, slightly outward from the parasternal line and, bending along an arc, is carried out immediately below the nipple and further to the posterior axillary line.
The skin, subcutaneous tissue, own fascia, sternal and costal portions of the pectoralis major muscle are dissected in layers, the attachments of the serratus anterior muscle are cut off in the posterior part of the incision and then its bundles are bluntly stratified posteriorly, the protruding edge of the latissimus dorsi muscle is peeled off and pulled outward, the intercostal muscles open the parietal pleura between nipple and anterior axillary lines
Lateral thoracotomy (Sweet 1950). Access to the anterior and posterior parts of the lung, heart, pericardium, mediastinum, diaphragm. Position on the healthy side with the arm of the opposite side abducted upward and slightly forward. A cushion is placed under the breast at the level of the nipples. The skin incision begins at a distance of 2-3 cm outward from the midclavicular line in the fifth or sixth intercostal space and continues to the scapular line.
The skin, subcutaneous tissue, own fascia, serratus anterior muscle, latissimus dorsi muscle are dissected layer by layer, we pull the scapula with a blunt hook along the fifth intercostal space, and for intervention on the lower parts of the lung and on the diaphragm - along the sixth or seventh intercostal space.
Posterolateral thoracotomy. lselin and Overholt (1947). Used more often for “wet lung” Disadvantages: highly traumatic difficult access to the vessels of the root of the lung Not convenient for the anesthesiologist Position on the stomach with the arm retracted anteriorly on the side of the operation. A cushion is placed longitudinally under the chest and the body is given a semi-lateral position with an inclination to the side opposite to the one being operated on. The incision begins at the level of the VI rib paravertebrally, continues downwards and outwards to the seventh intercostal space, bending around the angle of the scapula. The incision is completed along the midaxillary line
The skin, subcutaneous tissue, and fascia are dissected, the back muscles are separated from the ribs along their long axis, and the lower fibers of the trapezius muscle and under it the lower fibers of the rhomboid major muscle are taken to the spine in the vertical part with a blunt hook; in the horizontal part, the broad dorsi muscle and partially the serratus muscle are dissected. The pleural cavity is opened along the intercostal space or through the bed of a previously resected rib
After the main intervention, the pleural cavity is freed from residual blood and accumulated fluid with wet wipes or an electric suction device. The nerves of the superior and underlying intercostal spaces are subjected to alcoholization (2 ml of 96° alcohol and 8 ml of 0.25% novocaine solution). Drainage - insert a thick drainage tube into the eighth, or less often, into the ninth intercostal space of the chest wall along the posterior axillary line. A tube with side holes is placed along the back surface of the lung and attached to the skin with a silk suture, which is tied on the tube. Before suturing the chest wall, you need to remove the cushion from under the patient, then the intercostal spaces will come closer.
The wound is sutured in several layers. The first row of sutures ensures maximum approximation of the ribs above and below the dissected intercostal space. The nearest ribs, intrathoracic fascia, parietal pleura and crossed intercostal muscles are captured. The second row of stitches - suturing the muscles of the chest wall. Depending on the type of thoracotomy, the dissected edges of the muscles along with their fascia are sutured in layers with separate interrupted or 8-shaped catgut sutures. The third row of sutures - separate interrupted sutures are placed on the skin and subcutaneous tissue. A thick layer of the subcutaneous base is sutured separately with interrupted catgut sutures. The skin is often closed with an intradermal Halstead cosmetic suture.
Longitudinal (median) sternotomy. Position the patient on his back. A median skin incision along the sternum begins 2-3 cm above its manubrium and continues 3-4 cm below the xiphoid process (Fig. 8).
The fascia and periosteum of the sternum are dissected, which is separated with a rasp along the wound. In the lower part of the wound, the linea alba of the abdomen is dissected over several centimeters. Using a blunt instrument or index finger, a tunnel is formed between the posterior surface of the sternum and the sternal part of the diaphragm and penetrates into the cellular space of the mediastinum. The sternum is lifted with a hook, a sternotome is inserted into the wound, and a sternotomy is performed along the entire length of the bone. The Gigli saw can be used for the same purpose. After incision of the sternum, careful hemostasis is necessary. Bleeding from the bone edges is stopped by rubbing sterile wax. After the operation is completed and the mediastinum is drained, the edges of the sternum are compared, fastening them with five to six strong lavsan or tantalum sutures.
Longitudinal sternotomy provides wide access to the organs of the anterior mediastinum. In some cases, longitudinal sternotomy, which is not carried out along the entire length of the sternum, can be supplemented by its transverse dissection with a Gigli saw (Fig. 9).
Transbipleural transverse approach. A skin incision is made along the fourth intercostal space on the right, starting from the mid-axillary line, and passed through the sternum along the corresponding intercostal space on the opposite side (Fig. 10). The internal mammary vessels are ligated on both sides and crossed between the ligatures. The periosteum of the sternum is dissected and along this line it is crossed transversely with a sternotome or bone scissors. Bleeding from the edges of the sternum is stopped by rubbing sterile wax. Using a retractor, the ends of the crossed sternum are separated along with the ribs, thus exposing the heart and roots of the lungs. After completing the main stage of the operation, the chest wall is sutured in layers using pericosteal and interrupted synthetic sutures. The sternum is sewn together with two or three tantalum sutures.
Rice. 10. Thoracotomy from a transverse bipleural approach. Transbipleural access makes it possible to approach the heart and pericardium, large vessels, the root of the lung, and the pulmonary parenchyma.
Thoracolaparotomy. This combined surgical approach, along with a wide field of activity, presents quite large surgical possibilities. It is used in operations on the esophagus and cardia, and is used to remove tumor-affected kidneys, adrenal glands, and an enlarged spleen. Access is convenient in surgery of the diaphragm and thoracoabdominal aorta. The patient is placed on the right side with a posterior tilt of 45° and secured in this position. The left limb is fixed on the arc of the operating table. A skin incision is made in the 7th intercostal space and continues on the abdomen down the white line (Fig. 11).
Rice. 11. Thoracolaparotomy The costal arch is cut with a scalpel in the 7th intercostal space. The diaphragm is crossed parallel to the chest wall, approximately 2 cm from it, for a distance of 8-10 cm. When closing the surgical wound, the diaphragm is sutured with strong silk sutures and the costal arch is restored.
Errors and complications. Injury to intercostal vessels. To prevent it, it is better to make the incision along the upper edge of the underlying rib. The damaged vessel is grabbed with a clamp and, together with the tissues, is stitched and bandaged. Injury to the internal mammary artery. It happens when making an anterolateral incision. This will not happen if you dissect the intercostal space in the anterior section no further than 2-3 cm anterior to the angle formed by the costal cartilage (2-2.5 cm from the edge of the sternum). Rib fractures. They occur when the ribs are pushed apart until tissue is cut in the anterior and posterior intercostal spaces. In the area of cartilage there are no external, and posterior to the angle of the scapula there are no internal intercostal muscles. Therefore, in these sections the muscles should not be cut, but separated by pressing on them with a finger or a tuffer.
Dislocation of the costal cartilage at the sternocostal joint or at the joint between the cartilage and the bony part of the rib. It is not recommended to excise the cartilage, since the development of chondritis is possible, and dislocation does not pose any danger. Development of subcutaneous emphysema after leaky wound suturing. The drainage tube is not installed correctly.
1. Revision of the pleural cavity. After opening the pleural cavity, the collapsed lung is grabbed with pulmonary forceps and retracted downwards. If there are adhesions, they are separated with a tupper or scissors.
2. Isolation of the ductus botallus. Palpation determines the intensely pulsating pulmonary artery through the mediastinal pleura, as well as the localization of the ductus arteriosus. A rough systolic-diastolic tremor is felt in this place. To block reflexogenic zones, as well as for hydropreparation, a solution of novocaine is injected into this area under the pleura. The mediastinal pleura behind the phrenic nerve is cut first with a scalpel and then with long scissors from the root of the lung to the upper edge of the aortic arch. Take the vagus nerve on a holder (it is best to prepare a braid for the holder) and take it to the side. The braid should be fed clamped at the tip of a long Billroth clamp. An assistant holds the end of the tape with a clamp. The ductus arteriosus is isolated using blunt and sharp methods. The pulmonary artery and aorta are taken with provisional ligatures (pieces of braid or nipple rubber 40-50 cm long) above and below the duct. To hold the ends of provisional ligatures, it is convenient to use Billroth clamps.
Landmarks for the location of the ductus botalus:
Above is the aortic arch,
Posterior recurrent nerve
Below is the pulmonary artery.
After the duct is isolated, 2 strong silk ligatures (No. 4-5) are placed under it using a Deschamps needle or curved tweezers and tied at a distance from each other: at the aortic end, the other at the pulmonary artery; after this, the flow is crossed between the ligatures (you don’t have to cross).
Considering the danger of relaxation of the ligatures, the duct can be cut between two clamps and the ends sutured with a continuous vascular suture (A.N. Bakulev, P.A. Kupriyanov, etc.)
There are 2 main ODs for performing heart surgery:
1) Extrapleural - penetrate into the mediastinum through the interpleural space (longitudinal dissection of the sternum along its entire length according to Milton, with a T-shaped incision according to Magignac, which consists in the fact that, along with a longitudinal section of the lower part of the sternum, a transverse one is also made.)
2) Transpleural (transpleural) - opening of one or both pleural cavities (access is carried out from an anterolateral incision along 3 or 4 intercostals on the left with the intersection of 2-3 costal cartilages. The incision extends from the sternum to the anterior axillary line.
42. Surgical anatomy of the lungs. Root of the lung. Lobar and segmental structure of the lungs. Operative approaches to the lungs, their topographic and anatomical assessment. (413-416,453-455, Ostroverkhov)
A) The lungs are paired organs that occupy most of the chest cavity. Located in the pleural cavities, the lungs are separated from each other by the mediastinum. In each lung, there is an apex and three surfaces: the outer, or costal, which is adjacent to the ribs and intercostal spaces; the lower, or diaphragmatic, adjacent to the diaphragm, and the internal, or mediastinal, adjacent to the mediastinal organs. Each lung has lobes separated by deep fissures. The left lung has two lobes (upper and lower), and the right lung has three lobes (upper, middle and lower). The oblique fissure, fissura obliqua, in the left lung separates the upper lobe from the lower, and in the right - the upper and middle lobe from the lower. In the right lung there is an additional horizontal fissure, fissura horizontails, extending from the oblique fissure on the outer surface of the lung and separating the middle lobe from the upper lobe. Lung segments. Each lobe of the lung consists of segments - sections of lung tissue ventilated by a third-order bronchus (segmental bronchus) and separated from neighboring segments by connective tissue. The shape of the segments resembles a pyramid, with the apex facing the hilum of the lung and the base facing its surface. At the top of the segment is its pedicle, consisting of a segmental bronchus, a segmental artery and a central vein. Only a small part of the blood from the tissue of the segment flows through the central veins, and the main vascular collector collecting blood from the adjacent segments is the intersegmental veins. Each lung consists of 10 segments.
B) Gates of the lungs, roots of the lungs. On the inner surface of the lung there are the gates of the lungs, through which the formations of the roots of the lungs pass: bronchi, pulmonary and bronchial arteries and veins, lymphatic vessels, nerve plexuses. The hilum of the lungs is an oval or diamond-shaped depression located on the inner (mediastinal) surface of the lung slightly above and dorsal to its middle. The root of the lung is covered with the mediastinal pleura at the point where it transitions to the visceral pleura. Inward from the mediastinal pleura, the large vessels of the pulmonary root are covered with the posterior layer of the pericardium. All elements of the lung root are subpleurally covered with spurs of the intrathoracic fascia, which forms fascial sheaths for them, delimiting the perivascular tissue in which the vessels and nerve plexuses are located. This fiber communicates with the mediastinal fiber, which is important in the spread of infection. At the root of the right lung, the uppermost position is occupied by the main bronchus, and below and anterior to it is the pulmonary artery, below the artery is the superior pulmonary vein. From the right main bronchus, even before entering the gates of the lungs, the upper lobe bronchus departs, which is divided into three segmental bronchi - I, II and III. The middle lobe bronchus breaks up into two segmental bronchi - IV and V. The intermediate bronchus passes into the lower lobe bronchus, where it breaks up into 5 segmental bronchi - VI, VII, VIII, IX and X. The right pulmonary artery is divided into lobar and segmental arteries. The pulmonary veins (superior and inferior) are formed from intersegmental and central veins. At the root of the left lung, the pulmonary artery occupies the most superior position; the main bronchus is located below and posterior to it. The superior and inferior pulmonary veins are adjacent to the anterior and inferior surfaces of the main bronchus and artery. The left main bronchus at the hilum of the lung is divided into lobar bronchi - upper and lower. The upper lobe bronchus splits into two trunks - the upper one, which forms two segmental bronchi - I-II and III, and the lower, or lingular, trunk, which is divided into IV and V segmental bronchi. The lower lobe bronchus begins below the origin of the upper lobe bronchus. The bronchial arteries that feed them (from the thoracic aorta or its branches) and the accompanying veins and lymphatic vessels pass and branch along the walls of the bronchi. The branches of the pulmonary plexus are located on the walls of the bronchi and pulmonary vessels. The root of the right lung bends around in the direction from back to front by the azygos vein, the root of the left lung - in the direction from front to back by the aortic arch. The lymphatic system of the lungs is complex, it consists of superficial, connected to the visceral pleura and deep organ networks of lymphatic capillaries and intralobular, interlobular and bronchial plexuses of lymphatic vessels, from which efferent lymphatic vessels are formed. Through these vessels, lymph flows partially into the bronchopulmonary lymph nodes, as well as into the upper and lower tracheobronchial, peritracheal, anterior and posterior mediastinal nodes and along the pulmonary ligament into the upper diaphragmatic nodes associated with the nodes of the abdominal cavity.
B) Operational accesses. For radical operations on the lung, the chest cavity can be opened with an anterolateral or posterolateral incision. Wide intercostal incisions and dissection of the sternum - sternotomy. The main requirement for choosing a surgical approach is the ability to carry out the main stages of the operation through it: removal of the lung or its lobe, treatment of large pulmonary vessels and bronchus . The approaches when the patient is positioned on the back are called anterior, on the stomach - posterior, on the side - lateral.
With an anterior approach, the patient is placed on his back. The arm on the side of the operation is bent at the elbow joint and fixed in an elevated position on a special stand or arc of the operating table. The skin incision begins at the level of the third rib cartilage from the parasternal line. An incision is made around the bottom of the nipple in men, and the mammary gland in women. The incision is continued along the fourth intercostal space to the posterior axillary line. The skin, tissue, fascia and parts of two muscles - the pectoralis major and the serratus anterior - are dissected in layers. The edge of the latissimus dorsi muscle at the back of the incision is pulled laterally with a blunt hook. Next, the intercostal muscles, intrathoracic fascia and parietal pleura are dissected in the corresponding intercostal space. The chest wall wound is opened with one or two dilators.
For the posterior approach, the patient is placed on his stomach. The head is turned in the direction opposite to the operation. The incision begins along the paravertebral line at the level of the spinous processes of the III-IV thoracic vertebrae, goes around the angle of the scapula and ends, respectively, in the middle or anterior axillary line at the level of the VI-VII rib. In the upper half of the incision, the underlying parts of the trapezius and rhomboid muscles are cut layer by layer, in the lower half - the latissimus dorsi muscle and the serratus anterior muscle. The pleural cavity is opened along the intercostal space or through the bed of a previously resected rib. With the patient positioned on the healthy side with a slight tilt on the back, the incision begins from the midclavicular line at the level of the fourth - fifth intercostal space and continues along the ribs to the posterior axillary line. The adjacent parts of the pectoralis major and serratus anterior muscles are dissected. The edge of the latissimus dorsi muscle and the scapula are pulled back. The intercostal muscles, intrathoracic fascia and pleura are dissected almost from the edge of the sternum to the spine, i.e. wider than the skin and superficial muscles. The wound is opened with two dilators, which are placed mutually perpendicular. Puncture and drainage of the pleural cavity
RADICAL LUNG OPERATIONS
Radical operations on the lungs are performed mainly for malignant neoplasms, bronchiectasis, and pulmonary tuberculosis
Surgeries on the lungs are among the most complex surgical interventions that require the doctor to have a high level of general surgical training, good organization of the operating room and great care at all stages of the operation, especially when treating elements of the lung root. When determining the volume of surgical intervention, one should strive to preserve as much of the healthy lung tissue as possible and limit oneself to removing the affected area of the lung. At the same time, establishing the boundaries of the spread of the process in the lung according to clinical, radiological and other research methods is not always possible; therefore, “economical” operations (removal of a segment of a part of the lung lobe) have limited indications, especially in the treatment of lung tumors. For solitary tuberculous cavities, segmental lung resections are widely used.
To perform surgery on the lungs, in addition to general surgical instruments, you need windowed clamps for grasping the lung, long curved clamps with and without teeth: long curved scissors; dissectors and Fedorov clamps for isolating pulmonary vessels and performing ligatures; Vinogradov's sticks; long needle holders; bronchial holders; probe for isolating elements of the lung root; hook-scapula for mediastinal abduction; bronchial constrictor; chest wound retractors; hooks for bringing the ribs together and a vacuum apparatus for suctioning sputum from the bronchi.
Anesthesia. Lung operations are performed mainly under intratracheal anesthesia using antipsychotic substances, relaxants and controlled breathing. At the same time, pain and neuro-reflex reactions are suppressed to the greatest extent, and sufficient ventilation of the lungs is ensured.
Despite good inhalation anesthesia, it is extremely important to additionally infiltrate reflexogenic zones in the area of the lung root and aortic arch with a 0.5% novocaine solution, as well as block the intercostal nerves both at the beginning of the operation and at the end of it in order to eliminate postoperative pain. Surgical interventions on the lungs can also be performed under local infiltration anesthesia.
For radical operations on the lung, the chest cavity can be opened with an anterolateral or posterolateral incision. Each of them has its own advantages and disadvantages. The main requirement for choosing a surgical approach is the ability to carry out the main stages of the operation through it: removal of the lung or its lobe, treatment of large pulmonary vessels and bronchus. It is also necessary to take into account, in addition to technical conveniences when performing the operation, the position of the patient on the operating table, which is desirable to give in this case. This is important, for example, during operations for purulent lung diseases, when there are significant accumulations of pus in the pathological cavities of the lung and bronchus. In such cases, the position of the patient on the healthy side is undesirable, since in the process of isolating the lung from the adhesions, pus may flow into the healthy lung. For this reason, in case of purulent diseases (bronchiectasis, multiple abscesses), it is more advisable to use a posterolateral incision, in which the patient is placed on his stomach.
The supine position (with anterolateral access) minimally limits the volume of respiratory movements of the healthy lung and the activity of the heart, while when positioned on the side, the mediastinal organs are displaced and the excursion of the healthy half of the chest is sharply limited.
The posterolateral surgical approach is more traumatic than the anterolateral one.
matic, as it is associated with the intersection of the back muscles. At the same time, the posterolateral approach also has advantages: it makes it easier to approach the root of the lung. For this reason, the use of a posterolateral approach is especially indicated when removing the lower lobes of the lung, as well as when resecting segments located in the posterior parts of the lung.
Anterolateral approach. The patient is placed on his healthy side or on his back. The skin incision begins at the level of the third rib, slightly outward from the parasternal line. From here, the incision is made down to the level of the nipple, around it from below and the incision line continues along the upper edge of the 4th rib to the middle or posterior axillary line. In women, the incision passes under the mammary gland, at a distance of 2 cm from the lower fold. The mammary gland is retracted upward. After dissecting the skin, fascia and pectoralis major muscle in the posterior section of the wound, the serratus anterior muscle is cut. The protruding edge of the latissimus dorsi muscle at the back of the incision is pulled outward with a hook; if it is extremely important to expand access, they resort to partial intersection of this muscle. After this, the soft tissues are dissected in the third or fourth intercostal space and the pleural cavity is opened. The choice of intercostal space for opening the pleural cavity is determined by the nature of the upcoming surgical intervention. To remove the upper lobe, an incision is made along the third intercostal space; to remove the entire lung or its lower lobe, the pleura is incised along the fourth or fifth intercostal space. First, the pleura is cut over a short distance with a scalpel, and then this incision is widened with scissors. In the medial corner of the wound, avoid damage to the internal mammary vessel, which can cause excessive bleeding. If it becomes extremely important to expand access, the IV or V costal cartilage is intersected, 2-3 cm from the sternum, or one rib is resected along the entire length of the wound.
Posterior - lateral access. The patient is placed on his healthy side or stomach. The soft tissue incision begins at the level of the spinous process of the IV thoracic vertebra along the paravertebral line and continues to the angle of the scapula. Having gone around the corner of the scapula from below, continue the incision along the sixth rib to the anterior axillary line. Along the incision, all tissues are dissected to the ribs: the lower fibers of the trapezius and rhomboid major muscles, in the horizontal part of the incision - the broad dorsi muscle and partially the serratus muscle. The VI or VII rib is resected.
Taking into account the dependence of the localization of the pathological process and the nature of the surgical intervention, the pleural cavity with posterolateral approaches is opened at different levels: for pneumonectomy, for example, the VI rib is often chosen, when removing the upper lobe - the III or IV rib, and the lower lobe - the VII rib. The pleural cavity is opened along the bed of the resected rib. If it is extremely important to expand access, an additional 1-2 ribs are crossed near their vertebral end.
