Operational access to the lungs. Topography of the pleura and lungs
The requirements for online access are the anatomical accessibility of the object of intervention and the technical feasibility of all stages of the operation.
All approaches to the organs of the chest cavity are divided into two groups: extrapleural and transpleural. When performing extrapleural accesses, the exposure of the anatomical formations of the mediastinum occurs without depressurization of the pleural cavities. The possibility of performing these accesses is determined by the position and ratio of the anterior and posterior borders of the pleura.
With transpleural accesses, one or two (with the so-called transdouble-pleural accesses) pleural cavities are opened. Transpleural accesses can be used for operations both on the organs of the mediastinum and on the lungs.
To perform a longitudinal sternotomy, a skin incision is made along the midline above the sternum, starting 2-3 cm above the sternum handle and ending 3-4 cm below the xiphoid process. Then the periosteum of the sternum is dissected and displaced by 2–3 mm to the sides of the incision line with a raspator. In the lower part of the wound, the white line of the abdomen is dissected for several centimeters and a tunnel is formed between the posterior surface of the sternum and the sternal part of the diaphragm in a blunt way (with a finger, a swab). Protecting the underlying tissues with Buyalsky's scapula (or in another way), a longitudinal sternotomy is performed. The edges are widely bred to the sides with a screw retractor, while trying not to damage the mediastinal pleura. After the end of the operation, the edges of the sternum are compared and fastened with special brackets or strong sutures.
Anterolateral incision at the level of the fifth or fourth intercostal space. This is one of the most commonly used, "standard" accesses. The incision starts from the parasternal line and, continuing it along the intercostal space, is brought to the posterior axillary line. After dissection of the superficial layers of the chest wall, the edges of the wound are moved apart with hooks and the intercostal muscles and the corresponding ribs are exposed, after which they proceed to the dissection of the intercostal muscles and pleura.
With lateral access, the chest cavity is opened along the V-VI ribs from the paravertebral to the mid-clavicular line.
To perform a posterolateral approach. the soft tissue incision begins at the level of the spinous process of the III–V thoracic vertebra and continues along the paravertebral line to the level of the angle of the scapula (VII–VIII ribs). Having rounded the angle of the scapula from below, an incision is made along the VI rib to the anterior axillary line. Sequentially dissect all tissues to the ribs. The pleural cavity is opened along the intercostal space or through the bed of the resected rib. To expand the operational access, resection of the necks of two adjacent ribs is often resorted to.
Transverse sternotomy is used in cases where it is necessary to expose not only the organs, but also the vessels of the mediastinum and nearby areas. The incision is made along the fourth intercostal space from the midaxillary line on one side, through the sternum, to the midaxillary line on the opposite side.
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During surgical interventions on the lungs, several well-developed surgical approaches to the organs of the chest cavity are used: anterior-lateral (anterior) - in the position of the patient on the back, lateral - in the position on the healthy side and postero-lateral (rear) - in the position on the stomach.
The method of operative access in lung cancer is determined mainly by the features of the planned surgical intervention and the prevalence of pathological changes. With extended lung resections for cancer, the most difficult and critical part of the operation is the removal of the regional lymphatic apparatus, including its sections located in the mediastinum. The safety and availability of an extended surgical intervention, its radicalness largely depend on the convenience, reliable visual control of all surgical actions taken within the mediastinum, this area of the chest cavity, which is topographically, anatomically and physiologically complex. Conditions are noticeably more complicated during operations performed on patients with advanced stages of the disease.
Over many years of development of this problem in the clinic, approaches and attitudes towards the selection and evaluation of various surgical approaches used in extended lung resections have undergone some changes. In the first years of work, the advantage was given to the anterior-lateral thoracotomy. At that time, this approach seemed to be the safest for the patient, both from the standpoint of anesthetic management and surgical intervention. The main type of surgical interventions for lung cancer then was the removal of the entire lung - performing extended pneumonectomy.
Detailed clinical and morphological studies clarified the indications, volume and features of mediastinotomy with wide lymphadenectomy. By the mid-1960s, extended pneumonectomy for lung cancer had taken its place in the surgical treatment of this disease. In those years, in our clinic, as well as in a number of leading thoracic hospitals and institutions of the country, they shared the position on the need to perform a wide removal of lymph nodes and mediastinal tissue in cancer, guided by a peculiar rule. It consisted in the fact that in all cases of lung cancer, pneumonectomy should be undertaken, since only such a volume of resection provides the possibility of a wide removal of the regional lymphatic apparatus of the lung in the mediastinum, both with obvious and potential metastases. This ensures oncological radicalism of surgical intervention.
Further development of the problem, the desire to preserve the parts of the lung not affected by the blastomatous process without reducing the boundaries of mediastinal lymphadenectomy and without compromising oncological principles prompted a revision of the operative approach. Performing extended lobar resections of the lung ensured the admissibility of surgical treatment for a larger number of patients with lung cancer, mainly due to persons of the older age group, as well as those with reduced functional and reserve capabilities of the body. In many ways, this problem was successfully solved along with the formation and subsequent development of anesthesiology and resuscitation, the introduction of new techniques into surgical practice, including reconstruction and plastic surgery of the bronchi.
Lateral thoracotomy has been used to perform extended lobar resections of the lung in cancer. Compared to the antero-lateral approach, this approach is more traumatic, with a risk of leakage of pathological contents from the bronchi of the affected lung into a healthy one, special conditions and a regimen for artificial ventilation during anesthesia are required, including taking into account the positional limitation of the mobility of the opposite side of the chest. However, at present, with the current level of anesthetic care, which is constantly being improved, these shortcomings do not pose a serious danger.
At the same time, lateral access significantly expands the possibilities of surgical action on the mediastinal organs during surgical interventions for lung cancer, especially in patients with advanced stages of the disease. It provides full accessibility of the preparation of regional lymph nodes of the lung in the interlobar fissure, within each of its lobes, in the region of the root and mediastinum. If it is necessary to perform bronchoplastic surgery, lateral access creates the most convenient conditions for this. Lateral access in lung cancer should be considered as the most appropriate for the task of performing all options for radical extended surgical interventions in the vast majority of patients with advanced stages of the disease.
The technique for performing lateral access in the IV or V intercostal space is described in detail in numerous manuals on pulmonary surgery. It should be noted that in order to provide the most convenient access to the deeply located parts of the regional lymphatic collector of the lung within the mediastinum, it is advisable to use two retractors to perform a wide lymphadenectomy. In difficult situations: with pronounced adhesions in the pleural cavity, paracancer changes, etc. it is permissible to cross the cartilage of one or two ribs, as is done with anterior-lateral thoracotomy. This provides a good overview of the anatomical formations and organs of the mediastinum, creates the possibility without risk for the patient to perform a wide removal of the lymph nodes and tissue of the mediastinum while maintaining most of the lung tissue not affected by the tumor.
With regard to performing extended combined lung resections, each of the surgical approaches has its own advantages and disadvantages, which can either make it difficult or greatly facilitate the implementation of surgical intervention.
The main advantages of anterior-lateral access are: the possibility of a wide view of the entire anterior and lateral surface of the lung, the best approach to the vessels of the lung root, the superior vena cava, less trauma, the possibility of expanding the operational access by crossing the cartilage above or below the lying ribs. It creates the best operating conditions for the germination of the anterior surface of the pericardium, involvement in the tumor process of the anterior or anterior-lateral wall of the superior vena cava, pulmonary artery. The main disadvantages of access include the difficulty of manipulations in the localization of the tumor in the posterior medial lung with invasion of the organs of the posterior mediastinum, the posterior surface of the pericardium and pulmonary vessels, the inability to operate on the bronchi before ligation of the pulmonary vessels, the difficulty of performing mediastinal lymphadenectomy, which requires constant traction of the heart. Certain inconveniences arise when the tumor grows into the diaphragm.
The most suitable for the tasks of surgical treatment in advanced stages of lung cancer is the lateral approach. It provides a wide view of almost all parts of the chest cavity, it is possible to manipulate both the posterior and anterior surfaces of the lung root, which provides an approach to the vessels of the lung and bronchi. From the lateral access, it is convenient to perform resection of the tracheal wall, and from the right-hand side, and bifurcation. It provides a wide approach to the organs of the posterior mediastinum, the most convenient and safe for suspected tumor lesions of the descending aorta.
With lateral access, there is a wide approach to the main interlobar fissure and the performance of mediastinal lymphadenectomy is greatly simplified. The main disadvantage should be considered the high traumatism of the lateral approach, because. this requires a wide intersection of the muscles of the lateral and posterior surfaces of the chest. Sparing access options, in which the latissimus dorsi muscle is not crossed, but stretched with the help of a retractor, when performing extended combined lung resections, are inappropriate, because manipulations on the root of the lung have to be performed at great depth, in a narrow surgical field, which, if large vessels and the heart wall are involved in the tumor process, significantly increases the risk of surgery.
The use of a posterolateral approach to perform extended combined lung resections is the least justified. Its advantage is the convenience in manipulations on the main bronchi, and from the right-hand access and on the bifurcation of the trachea. However, with it, it is difficult to approach the vessels of the lung root, the superior vena cava, the lateral and anterior surfaces of the pericardium, the diaphragm, and the aorta. It is technically difficult to perform mediastinal lymphadenectomy from the posterior-lateral approach, especially with left-sided thoracotomy.
Bilateral anterior-lateral access with transverse sternotomy in advanced stages of lung cancer, as a rule, is not used. In rare cases, mainly with the development of complications, there is a need to expand the surgical approach for anterolateral thoracotomy by transverse sternotomy.
Bisenkov L.N., Grishakov S.V., Shalaev S.A.
Operations on the lungs.
Access to the organs of the chest cavity are pleural and extrapleural. With intrapleural accesses, a good exposure is provided, but there is a risk of pus penetrating into the pleura and developing retropulmonary shock. Extrapleural accesses are free from these shortcomings, but their criteria are sharply reduced in comparison with the first ones and they are difficult to implement.
Pulmonectomy.
Indications: lung cancer, multiple abscesses, widespread bronchiectasis, pulmonary tuberculosis.
Access: anterolateral, posterolateral.
Technique: Thoracotomy is performed by lateral access through the 5th intercostal space, posterior access through the 6th, or anterior access through the 4th or 5th intercostal space. Completely isolate the lung, ligate and dissect the pulmonary ligament. Dorsal to the phrenic nerve and parallel to it, the mediastinal pleura is dissected above the root of the lung. With right-sided pneumonectomy, after dissection of the mediastinal pleura, the anterior trunk of the right pulmonary artery is found in the upper part of the lung root. In the fiber of the mediastinum, the right pulmonary artery is found and isolated, processed, tied up with stitching and crossed. Also process and cross the upper and lower pulmonary veins. The right main bronchus is isolated to the trachea, stitched with a UO apparatus and crossed. The suture line is pleurised with a flap of the mediastinal pleura. With left-sided pneumonectomy, after dissection of the mediastinal pleura, the left pulmonary artery is immediately isolated, and then the upper pulmonary vein, processed and crossed. Pulling the lower lobe laterally, the lower pulmonary vein is isolated, treated and transected. The bronchus is pulled out of the mediastinum and isolated to the tracheobronchial angle, processed and crossed. It is not necessary to pleurisy the stump of the left main bronchus, since it goes into the mediastinum under the aortic arch.
Lobectomy. Video-guided thoracoscopy (TVC) – a new approach in thoracic surgery .
Indications. The impossibility of performing a radical operation and the peripheral localization of the tumor less than 4 cm in size, tuberculous caverns, echinococcal and bronchogenic cysts. Contraindications include intolerance by patients of 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 5 and 6 ribs.
Technique: The patient is placed on the left side. The lung must be fully collapsed. The first trocar is placed in the 7th intercostal space along the anterior axillary line. For upper, middle or lower lobectomy, incisions are made in the 4th-5th intercostal space along the posterior axillary line. A thoracotomy 6-7 cm long is performed from the mid-axillary line towards the anterior surface of the chest. A 1.5 cm long incision 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. With the help of trocars and thoracotomy, the chest is examined for the presence of dissemination along the pleura, metastases in the lymph nodes and pulmonary nodes.
Upper lobectomy on the right. The lung is pulled back, the phrenic nerve is taken on a holder. After double ligation, the superior pulmonary vein is ligated and divided. The anterior trunk of the pulmonary artery is ligated and transected from the front, a holder is inserted under the unpaired vein and the vein is pulled back, after which ligation and transection 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 isolated, the holder is passed through the lower slit and separated with a clip-applicator. Isolation of the bronchus is performed together with lymph node dissection.
Medium lobectomy. The operation is performed with ligation and intersection of the middle lobe vein, then dissection of the pulmonary artery and the middle lobe bronchus is performed along with the root lymph nodes located around the middle lobe bronchus.
Upper lobectomy on the left. After taking the phrenic nerve on a holder, the operation begins with ligation and intersection of the pulmonary vein. If the pulmonary vein has a short trunk, separate ligation and cross. It is possible to suture with a stapler if it can pass under the blood vessel, otherwise clamps are used.
Lower lobectomy. With right-sided and left-sided surgery, double ligation is usually performed, followed by crossing 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 located in the same way as in lobectomy, they open the mediastinal pleura along the anterior superior semicircle of the lobe root, but more distally than in lobectomy. The central segmental vein is isolated, treated with clips and crossed. The segmental artery is then isolated. After clipping and crossing the artery, a segmental bronchus is isolated, which is temporarily clamped with a soft endoscopic clamp. With the help of a small breath with an Ambu bag into the bronchial canal of the endotracheal tube, the correct selection of the bronchus and the border of the removed segment are controlled. The bronchus is sutured using an Endo-GIA 2 Roticulator stapler, then the segment is traction upwards behind the bronchus, and the intersegmental plane is separated with an ultrasonic scalpel. when separating the intersegmental plane with an ultrasonic scalpel, only the veins coming from the removed segment are crossed.
Dangers and complications: to bleeding, n Bronchial stump failure, pneumothorax , P neumopleuritis.
Choice questions online access, in our opinion, are of no particular importance, although they determine the sequence of the stages of the operation on the root of the lung. Here I would like to emphasize that when using a lateral surgical approach, the treatment of the bronchus stump with UKL or UKB devices is fraught with the possibility of an imperceptible rupture of its central part with a sharp bend of the bronchus. We have seen a similar case. The main and determining factor, in our opinion, is the depth of the main bronchus, which should be isolated to the edge of the trachea.
At the same time, they should be tied up and intersected all neurovascular connections. With complete isolation and complete amputation of the main one, all arguments about its blood supply and trophism of the wall of its stump lose any meaning.
In a special literature For many years, there has been an in-depth discussion on the advantages of various types of sutures, including hardware ones, used to suture the stump of the main bronchus (the edge of the trachea!). We mainly used three fundamentally different types of sutures on the edge of the bronchus or trachea: with UKL-60 (UKL-40), UKB-25 (UKB-16) devices and manual sutures through the zee layers of the edge of the bronchus (trachea) according to Suit.
Approximately 24% of operations the mechanical seam was supplemented with separate seams according to Suit. We failed to note significant differences in the frequency of formation of bronchopleural fistulas with the use of UKL, VHF and Sweet devices.
At present, according to our opinion, contraindications to the application of the UKL-60 light apparatus to the entire root of the lung apparatus should also be revised at a new level. This is due not so much to the technique of the operation, but to the tactics of the pulmonary surgeon in the course of performing severe and traumatic operations. In this case, after the mobilization of the lung and the destruction of the pulmonary ligament, the UKL apparatus is applied as the first stage to the root of the lung.
After stitching the fabrics of the gate lung, cutting off and removing the affected lung from the pleural cavity, optimal conditions are created not only for the revision of the cavity and hemostasis, but also for the immediate implementation of the second stage of the operation: partial destruction of the tantalum staple suture and separate isolation and reamputation of the main bronchus. For this purpose, a small tunnel is created between the trunk of the stump of the main bronchus and the main trunk of the pulmonary artery of the operated side behind the line of UKL staples. Then, under the control of the finger, 2-3 sutures are applied to the edge of the bronchus behind the staples and a powerful clamp through the line of staples to the edge of the pulmonary artery.
Scissors cut the line paper clips and release the edges of the bronchus. Later, after reamputation of the stump of the main bronchus along the edge of the trachea, either the incised edge of the pulmonary artery is sutured with atraumatic sutures, or a ligature is applied more neutral than the UKL suture, or the entire, now soft and pliable, UKL suture is taken on the sutures-holders and, pulling the UKL suture outward , for the second time, the UKL apparatus is applied to the block of vessels of the lung root centrally to the first suture, which can then be cut off.
Application of such methods recommended by us when performing pulmonectomy or pleuropulmonectomy in patients with a non-collapsing lung after mobilization (common asbestos pneumonia with “suspension” of the lung parenchyma, some cases of caseous pneumonia), with severe pleural empyema, including after partial resections of the lung and, especially, during operations about profuse pulmonary bleeding, when the main task of the surgeon is to quickly disconnect the source of bleeding from the bronchial tree of the opposite lung (prevention of aspiration).
