What is thoracoplasty for lung surgery. Varieties of thoracoplasty of the chest with a description

Surgical treatment of pulmonary tuberculosis

In the complex of modern methods of treating patients with pulmonary tuberculosis, timely surgical interventions are important, and sometimes decisive. Over the past two decades, due to the success of antibiotic therapy, anesthesiology and thoracic surgery, the possibility of using and the range of surgical interventions for pulmonary tuberculosis has significantly expanded, and the therapeutic efficiency of operations has increased.

Numerous surgical interventions used for pulmonary tuberculosis can be classified as follows.

1. Operations correcting artificial pneumothorax: a) thoracoscopy and thoracocaustics, b) open intersection of adhesions.
2. Collapse-therapeutic operations: a) extrapleural pneumolysis with pneumothorax, filling and oleothorax, b) thoracoplasty.
3. Lung resection. A. Operations on the cavity: a) drainage of the cavity, b) cavernotomy.
4. Operations on the bronchi: a) ligation of the bronchus, stitching and dissection of the bronchus, b) resection and plastic surgery of the bronchus.
5. Operations on the pulmonary vessels: a) ligation of the pulmonary veins, b) ligation of the pulmonary arteries.
6. Operations on the nervous system: a) operations on the phrenic nerve, b) operations on the intercostal nerves.
7. Lung decortication and pleurectomy.
8. Removal of caseous lymph nodes.

Of these operations, some are performed often (lung resection, thoracoplasty), others are extremely rare (operations on nerves and blood vessels). For all surgical interventions for pulmonary tuberculosis in the preoperative and postoperative periods, complex treatment is carried out in the form of a hygiene-dietary regimen and the use of antibacterial drugs. When indicated, stimulating, desensitizing and hormonal therapy is also carried out. Let's consider the most important surgical interventions for pulmonary tuberculosis.

Thoracoscopy and thoracocaustics

One of the important methods of collapse therapy of pulmonary tuberculosis is artificial pneumothorax, which is often ineffective due to the presence of various intrapleural adhesions that prevent concentric collapse of the lung. In the absence of a positive clinical effect, treatment with artificial pneumothorax is impractical: adhesions contribute to the spread and exacerbation of the tuberculous process, make it dangerous for an anatomically defective pneumothorax to open.

In 1910-1913. The Swedish phthisiatrician Jacobeus designed and used a special instrument with an optical system and a small electric lamp at the end to examine the pleural cavity - a thoracoscope. Soon a galvanoscope was added to the thoracoscope. With the help of these instruments, in the presence of a sufficient intrapleural gas bubble, it was possible to examine the pleural cavity in detail and burn the pleural cords under thoracoscopic control. This operation of closed burning of pleural adhesions is called thoracocaustics.

In the USSR, M. P. Umansky successfully produced thoracocaustics (1929); KD Esipov and especially the founder of Soviet phthisiosurgery N.G. Stoyko did a lot to improve and promote the burning of adhesions. In a short time, thoracocaustics was mastered by hundreds of surgeons and phthisiatricians in our country, becoming a method "without which artificial pneumothorax loses half of its value" (N. G. Stoiko).

At first, thoracocaustics was accompanied by a significant number of complications, the main ones of which were bleeding and damage to the lung tissue. Over time, pleural adhesions were studied in detail, indications for surgery were clarified, instrumentation was improved, and the surgical technique of intervention was improved.

Comparison of clinical, radiological and thoracoscopic data shows that only thoracoscopy can give a reliable idea of \u200b\u200bthe presence, number, nature and operability of adhesions. The number of adhesions detected by thoracoscopy is always more than the X-ray examination establishes. Therefore, thoracoscopy should be considered fundamentally shown in each case of pneumothorax application, taking into account the negative role of adhesions (N.G. Stoiko, A.N. Rozanov, A.A. Glasson, etc.)

Sometimes the indications for thoracoscopy can be urgent. This applies to cases of stretching of a thin-walled, subpleurally located cavern with cords, with pulmonary hemorrhages that intensify after inflation, spontaneous pneumothorax, if there is reason to believe that the cause of the rupture of the lung tissue was the fusion fixing it.

The widespread use of antibacterial drugs has significantly reduced the risk of an outbreak after thoracoscopy and thoracocaustics. However, thoracoscopy should not be done in the acute course of the pulmonary process and acute pneumopleuritis. The presence of purulent exudate or tubercle lesions of the pleura is a contraindication to burning out adhesions. The most favorable time for the operation is 3-5 weeks after the imposition of artificial pneumothorax.

Before carrying out thoracoscopy and thoracocaustics, the gas bubble in the pleural cavity should be of sufficient volume for free work with instruments: it is necessary that it occupy at least a third of the pulmonary field. The points for the introduction of instruments are planned before the operation, making fluoroscopy at various positions of the patient. The pressure in the pleural cavity should be brought to atmospheric or close to it.

Thoracoscopy and thoracocaustics are conveniently performed in a darkened operating room. In this case, local anesthesia is usually used. After the introduction of the thoracoscope through the intercostal space, the state of the pleura and lung is examined, and the existing adhesions are examined.

The ability to navigate the thoracoscopic picture, to understand the anatomical structure of adhesions and to establish the possibility of burning them out is the most difficult part of the operation. If, after examining the pleural cavity, a decision is made to burn through the adhesions, a second instrument is introduced - a galvanocauter. The loop of the cauter is hidden in a special metal case put on it. After bringing the cauter to the seam, the loop is pushed out, the current is turned on and the seam is burned with a heated loop. The effect of the intervention can be noted not only with thoracoscopy, but also radiographically (Fig. 90 and 91).

When burning through adhesions, special care is taken with respect to the large vessels of the chest cavity (subclavian artery, aorta, etc.) and the lung tissue drawn into the union. The rule is to burn through the fusion after accurate topographic and anatomical orientation, and as close as possible to the chest wall. Currently, thoracocaustics are used much less frequently than in the 30s and 40s, since the indications for the imposition of artificial pneumothorax are narrowed.

Extrapleural pneumolysis with pneumothorax, filling and oleothorax

Extrapleural pneumolysis is understood as the detachment of the parietal pleura and lung from the fascia lining the chest cavity from the inside.

In 1910, Tuffier and Martin proposed the injection of air or nitrogen into the cavity formed after such a detachment of the lung in tuberculosis and abscess. The injections were unsuccessful, after which Tuffier began to fill the cavity with a fatty filling, and Ver - with paraffin. Later, other filling materials were also tried (pieces of ribs, canned cartilage, celluloid balls, methyl methacrylate balls, etc.). N.G. Stoyko paid much attention to the method of extrapleural pneumolysis followed by filling with paraffin.

Due to frequent complications, the operation of extrapleural pneumolysis with filling is now rarely used. The filling is usually inserted extramusculo-periosteally, that is, between the ribs on one side, detached to the lung, and the costal periosteum and intercostal muscles, on the other. Extrapleural pneumolysis with subsequent maintenance of the air bubble between the chest wall and the parietal pleura - extrapleural pneumothorax - has become more widespread.

To create an extrapleural pneumothorax, a wider pneumolysis is required than for a filling. The operation is usually performed from the posterior or axillary approach after resection of a small portion of the rib. The lung is exfoliated from the front to the III rib, from the back - to the VI-VII ribs, laterally - to the IV rib and medially - to the root. After stopping minor bleeding, the chest cavity is hermetically sutured. As a rule, patients tolerate this relatively low-traumatic operation well.

Postoperative management of extrapleural pneumothorax is difficult, especially at first, and requires some experience. After the intervention, the lung tends to expand, and bloody fluid accumulates in the artificially formed cavity. In order to avoid this, with systematic X-ray control, punctures are performed to extract fluid and, if indicated, additional air is introduced into the extrapleural cavity. As the gas bubble forms, the bottom of the extrapleural cavity gradually acquires a concave shape (Fig. 92). When the extravasate no longer accumulates and there is a sufficient air bubble, the management of extrapleural pneumothorax becomes quite simple. By this time, the patient can be transferred for further treatment to a phthisiatrician and be under outpatient supervision.

If the extrapleural cavity tends to wrinkle or it is impossible to maintain a gas bubble for some other reason, you can replace air with oil, that is, go to oleothorax (Fig. 93). The most suitable in these cases is vaseline oil (300-400 ml), which after sterilization is introduced in several stages, extracting an appropriate amount of air or liquid from the cavity. Vaseline oil dissolves very slowly, so it usually does not need to be added for several months. Transfer to oleothorax and the addition of oil are carried out under stationary conditions: the introduction of oil under high pressure is dangerous, as it can cause perforation of the lung and fat embolism.

The duration of treatment with extrapleural pneumothorax and oleothorax depends on the nature of the process for which the operation was performed and the condition of the cavity. With a smooth course of extrapleural pneumothorax, imposed due to a fresh process, the gas bubble should be maintained for 1.5-2 years. Oleothorax in such cases should not last more than 3 years (T.N. Khrushcheva). After this period, it is necessary to periodically extract the oil in separate portions.

In the course of treatment with extrapleural pneumothorax, complications can be observed in the form of the appearance of exudates in the cavity, specific and nonspecific suppurations, and the formation of internal bronchial fistulas. Air embolism is a rather rare but dangerous complication. With oleothorax, oil can penetrate the soft tissues of the chest wall or break into the bronchus. The latter is manifested by coughing and the release of vaseline oil with phlegm. To avoid aspiration of oil and the development of pneumonia in such cases, it is necessary to puncture the cavity and suck the oil. Further treatment consists in resection and decortication of the lung or in opening the cavity, its debridement and subsequent thoracoplasty.

With a stable immunobiological state of the body and obliteration of the pleural cavity, the indication for extrapleural pneumothorax is unilateral upper lobe cavernous and partly fibrous-cavernous processes. Pneumolysis is not indicated in generalized processes, severe fibrosis, subpleural cavities and multiple cavities. Contraindications to the upper and lower extrapleural pneumolysis are also cirrhotic processes, bronchiectasis, bronchial stenosis, atelectasis, giant and swollen cavities, tuberculomas, generalized processes. Serious specific bronchial lesions, established bronchoscopically, must be treated before surgery.

Functional disturbances after extrapleural pneumolysis are small. The results of extrapleural pneumolysis followed by pneumothorax and oleothoracooma, as observed by T.N. Khrushcheva, were good in 66% of patients 6-15 years after surgery. It should be noted that antibiotic therapy was not used in most patients. The efficiency of extrapleural pneumolysis is significantly reduced if this operation is performed according to "extended indications", that is, when lung resection or thoracoplasty is more indicated.

Thoracoplasty

Clinical observations of the use of artificial pneumothorax have shown the importance of the collapse of the affected parts of the lung and changes in its blood and lymph circulation in the treatment of the tuberculous process.

In 1911-1912. Sauerbruch proposed a new thoracoplasty technique with the following distinctive features:

1. only the paravertebral segments of the ribs are removed, because first of all, the degree of the resulting chest collapse depends on them;
2. the resection of the ribs is performed subperiosteally, which ensures their regeneration and the subsequent stability of the corresponding half of the chest;
3. necessarily remove the first rib, thereby causing the lung to fall in the vertical direction.

Sauerbruch considered it necessary to resect 11 ribs even with limited lesions, since he believed that only extensive decomposition creates rest for the lung and prevents the possibility of aspiration of sputum into its lower parts.

Postoperative mortality is 10-15%, however, a major drawback of this operation was the exclusion of a large part of the lung from breathing, even with a small spread of the process. Further study of thoracoplasty showed that with limited processes there is no need to remove segments from 11 ribs and it is possible to obtain the full effect in a more economical operation.

The mechanism of the beneficial action of thoracoplasty is that after resection of the ribs, the volume of the corresponding half of the chest decreases and, therefore, the degree of elastic tension of the lung tissue in general and the affected parts of the lung in particular decreases. This creates conditions for the collapse of the cavity and facilitates the natural tendency to wrinkling, which manifests itself during reparative processes in the lung affected by tuberculosis. The movement of the lung during breathing becomes limited due to the violation of the integrity of the ribs and the function of the respiratory muscles, as well as the formation of motionless bone regenerates from the left costal periosteum. In the collapsed lung, the absorption of toxic products sharply decreases, which affects the improvement of the general condition of the patient. Favorable conditions are created for the development of fibrosis, isolation and replacement of caseous foci with connective tissue. Thus, along with the mechanical effect, thoracoplasty also causes certain biological changes that contribute to the processes of localization and reparation in tuberculosis.

Against the background of clinical cure, the cavity after thoracoplasty rarely heals through the formation of a scar or a dense closed caseous focus. Much more often it turns into a narrow slit with an epithelialized inner wall. In many cases, the cavity only collapses, but remains lined from the inside with a specific granulation tissue with foci of cheesy necrosis. Naturally, the preservation of such a cavity can lead to outbreaks of the process and metastasis of the infection at various times after the operation.

Determination of indications for thoracoplasty in a patient with pulmonary tuberculosis is a responsible task. Most of the failures are associated with incorrect indications for this serious operation. When assessing the indications for thoracoplasty, it is necessary to analyze the shape and phase of the process on the side of the proposed operation, the state of the second lung, the age and functional state of the patient.

As a rule, thoracoplasty is performed in cases of impossibility of partial lung resection with destructive forms of tuberculosis. It is necessary to operate in the phase of sufficient stabilization of the process. The most favorable results are obtained with small and medium-sized cavities, if advanced fibrosis has not yet developed in the lung tissue and the wall of the cavity. Bleeding from the cavity can be an urgent indication for thoracoplasty. Thoracoplasty is often an irreplaceable operation for residual cavities in patients with chronic empyema and, along with other plastic operations, is widely used to close bronchial fistulas. If necessary, partial thoracoplasty can be performed on both sides.

If there are fresh focal or infiltrative changes in the lung on the side of the proposed operation, preparation for the intervention with antibacterial drugs and other measures is necessary. Specific changes in the bronchial tree, detected during bronchoscopy, it is advisable to treat before surgery with cauterization and the use of antibacterial drugs.

Contraindication to lung thoracoplasty all fresh infiltrative and cavernous forms of tuberculosis in the outbreak phase, extensive bilateral lesions, widespread cirrhotic processes with bronchiectasis, bronchial stenosis, atelectasis, tuberculomas, severe emphysema, fibrothorax on the opposite side serve. With giant and swollen cavities, thoracoplasty as an independent operation in most cases does not give an effect. The operation is contraindicated in case of generalization of the tuberculous process with damage to the intestines, kidneys, etc. When deciding about thoracoplasty, the age of the patients should be taken into account. The operation is well tolerated by people of young and middle age, after 45-50 years it is necessary to operate with great care.

The choice of the thoracoplasty method is important, sometimes decisive. With limited processes, there is no need to perform total thoracoplasty, on the contrary, you need to strive for selective intervention and preservation of the function of healthy parts of the lung. A number of Soviet surgeons have developed options for partial plastics, which take into account the size and topography of the main lesion, the cavity. If extensive thoracoplasty is necessary, especially in significantly weakened patients, it is preferable to operate in two or even three stages. With intervals between stages of 2-3 weeks, the effectiveness of the operation as a whole does not decrease, while patients tolerate the intervention easier. Plastic surgery with total empyema can be divided into several stages.

The most widespread are currently one-stage and two-stage upper-posterior thoracoplasty with resection of segments of 5-7 ribs, and 1-2 ribs below the location of the lower edge of the cavity. For large upper lobe cavities, the upper 2-3 ribs should be removed almost completely. In some cases, thoracoplasty is combined with apicolysis, intussusception of the cavity area and other techniques that promote better lung collapse. After the operation, a pressure bandage is applied for 5-2 months.

Of the postoperative complications, the most important are specific and nonspecific pneumonia, atelectasis. The widespread use of modern antibacterial drugs and methods of prevention and treatment of respiratory failure has sharply reduced the danger of these, previously very formidable complications. Deaths directly related to thoracoplasty are rare (0.5-1.5%).

The total efficiency of thoracoplasty with long-term observation of patients varies, according to different authors, within 50-75%. A. A. Savon points to good long-term results after extended thoracoplasty in 83%. At the same time, the functional state of patients, even with bilateral operations, is satisfactory (T.N. Khrushcheva).

If 20-25 years ago extrapleural thoracoplasty was the most common and reliable method of surgical treatment of pulmonary tuberculosis, now it has been largely replaced by lung resection. However, there is a significant contingent of patients for whose treatment thoracoplasty continues to be the method of choice.

Its importance for the treatment of patients with tuberculous empyema is fully preserved, if pleurectomy is contraindicated. Since patients with empyema are often significantly weakened, and surgical intervention is very traumatic, it is necessary to perform thoracoplasty not simultaneously, but fractionally, dividing it into 3-5 stages. For total empyema complicated by bronchopleural fistulas, it is better to pre-sanitize the pleural cavity (wide thoracotomy, ointment tamponade according to A.V. Vishnevsky), and then perform thoracoplasty in 2-3 stages. If necessary, during the last stage, excision of the parietal pleura and muscle plastic of the bronchial fistula are also performed. In the course of treatment, antibiotic therapy, blood transfusions and physiotherapy exercises are widely used.

Lung resection

Indications for lung resection in tuberculosis can be absolute and relative. With absolute indications, other methods of treatment seem to be ineffective, and only resection of the lungs can count on success. With relative indications, other methods of treatment are possible - conservative and surgical. In clinical practice, it is most often necessary to operate on patients with pulmonary tuberculosis, cavernous and fibrous-cavernous tuberculosis.

Tuberculoma is, as a rule, a rounded focus of caseous necrosis with a diameter of at least 1.5-2 cm, covered with a fibrous capsule. Among the caseous masses in tuberculoma, there may be remnants of elements of the pulmonary parenchyma, for example, elastic fibers, vascular walls or bronchi. Sometimes calcareous inclusions are observed in tuberculomas. Most patients with pulmonary tuberculomas have various signs of the activity of the tuberculous process and its progression is often noted, especially often observed in cases where there are several tubercles in one lobe of the lung.

At present, it can be considered established that various methods of chemotherapeutic treatment and collapse therapy for the treatment of tuberculosis are ineffective. Therefore, lung resection in this category of patients is the method of choice. The operation should be considered indicated for all clinical signs of the activity of the tuberculous process, in particular in the presence of low-grade fever, various symptoms of intoxication, with bacillus excretion, an increase in the size of tuberculoma, established by dynamic X-ray examination, specific lesions of the bronchi. A direct indication for surgery is also the difficulty of differential diagnosis between tuberculoma and lung cancer. In some cases, it is necessary to operate on patients with tuberculomas, if the presence of tuberculoma interferes with work in the specialty (teachers, pediatricians, etc.).

In patients with cavernous tuberculosis, pulmonary resection is indicated in cases of ineffectiveness of various methods of conservative treatment in combination with collapse therapy, as well as in cases of ineffectiveness of conservative treatment, if there is one or more of the following complicating factors: bronchoconstriction, a combination of a cavity and tuberculoma, multiple cavities in one lobe, localization cavities in the middle or lower lobe of the lung. In fibro-cavernous pulmonary tuberculosis, the morphological features of the process are such that cure, as a rule, can only be achieved by various surgical methods. The main method of surgical treatment of fibrocavernous tuberculosis is lung resection, since it provides a sufficiently radical removal of irreversibly altered areas of the pulmonary parenchyma and bronchial tree.

However, it should be noted that the modern contingent of patients with fibrocavernous tuberculosis is very difficult, and therefore lung resection can be performed in no more than 10-12% of all patients.

When deciding on lung resection for tuberculosis, great importance should be attached to assessing the phase of the tuberculous process. Thus, during the outbreak phase, operations often give poor results and, as a rule, should not be performed. The prevalence of pathological changes in the lungs is extremely important, since with very extensive lesions, resection may be impossible. It is especially necessary to approach the issue of lung resection with particular caution in bilateral processes, since extensive resections are possible and permissible only under particularly favorable circumstances.

The volume of lung resection is mainly determined by the extent of the lesion and the characteristics of changes in the lungs and bronchi. Pulmonectomy, that is, complete removal of the lung, with tuberculosis should be done relatively rarely and mainly only with unilateral lesions. Pulmonectomy is indicated for a polycavernous process in one lung, with fibrous-cavernous pulmonary tuberculosis with extensive bronchogenic seeding, giant cavities, extensive lung damage with the presence of simultaneous empyema of the pleural cavity. Indications for lobectomy are cavernous or fibrocavernous tuberculosis with several cavities in one lobe of the lung. Lobectomy is also performed in the presence of a large tuberculoma with foci in a circle or several tubercles in one lobe, with ineffectiveness in complications after artificial pneumothorax, extrapleural pneumothorax, oleothorax, or partial thoracoplasty.

At the present time, economical lung resections are most often performed; of these, segmental resections, or, as they are otherwise called, segmentectomy, are especially appropriate. During these operations, as a rule, one or two bronchopulmonary segments are removed, and the interventions themselves are performed within the anatomical intersegmental boundaries. Indications for segmental resection are tuberculomas and cavities, which are located within one or two segments of the lung without significant seeding in the circumference and without affecting the lobar bronchus.

Wedge-shaped and various atypical resections of the lungs have also become widespread in recent years, especially due to the widespread use of various stapling devices, primarily the UKL-60 apparatus. However, it should be borne in mind that all wedge-shaped and atypical lung resections are performed without observing strict anatomical rules and therefore have significant drawbacks from the point of view of theoretical premises. We are supporters of wedge-shaped resections only with well-delimited and superficially located tuberculomas in cases where there are no obvious symptoms of damage to the draining bronchus and focal seeding in the circumference. In all other cases, preference is given to operations in compliance with anatomical principles - lobectomy and segmental resection with removal of the corresponding lobar or segmental bronchus.

Lung resections for tuberculosis are well tolerated by children and adolescents, middle-aged people are quite satisfactory and elderly people are much worse. Therefore, the age factor in determining contraindications for lung resection should always be given due attention.

In the process of preoperative preparation before lung resection, it is important to pay attention to chemotherapy, the purpose of which is to stabilize the tuberculous process as much as possible. Simultaneously with chemotherapy, measures to reduce purulent intoxication, blood transfusions, all measures aimed at normalizing the functions of the cardiovascular system, liver and kidneys are useful in the cases shown.

Lung resection in patients with tuberculosis and virtually all lung operations should be performed under general anesthesia with separate bronchial intubation. During the operation, it is necessary to carry out a toilet of the bronchial tree, since the ingress of infected sputum from the affected lung into a healthy one can cause serious postoperative complications. Of the various surgical approaches, we prefer the lateral one along the 4th, 5th or 6th intercostal space. The lung, as a rule, must be carefully selected, avoiding damage to the pulmonary parenchyma, and examined in detail in order to determine the amount of necessary resection with the greatest possible accuracy.

During lobectomy and pulmonectomy, if the lobar or main bronchus has an almost normal wall, it is permissible to process it with a mechanical suture using the UKL-40 or UKL-60 devices. If the wall of the bronchus is thickened, fragile or rigid, manual suture of the bronchus stump is preferable. Before completing lung surgery, it is advisable to perform sufficient pneumolysis and decortication so that the remainder of the lung (after partial resection) is well expanded.

If many tuberculous foci are palpated in the rest of the lung, or if the lung volume is too small to fill the pleural cavity, additional measures are needed to reduce its volume: thoracoplasty or upward movement of the diaphragm.

A specific feature of the postoperative period after lung resection in patients with tuberculosis is the need for specific chemotherapy; it needs to be carried out for a long time, up to 6-8 months or more. After discharge from the surgical hospital, the patient should be sent to a sanatorium. This combination of surgical, antibacterial and spa treatment after lung resection is now considered essential.

The results of lung resection in tuberculosis are very favorable. After economical resections of the lungs - segmental and wedge-shaped - postoperative mortality is less than 1%; after lobectomy, it is 3-4%, and after pulmonectomy - about 10%. In the long term after operations, exacerbations and relapses of tuberculosis are detected in approximately 6% of operated patients. Thus, resection of the lungs in tuberculosis is one of the most effective operations, thanks to which a significant number of patients are currently cured that cannot be helped by conservative or other surgical methods.

The following observation illustrates the effectiveness of lung resection in severe fibrocavernous tuberculosis.

Patient I., 29 years old, was admitted with complaints of high temperature, chills, shortness of breath, cough with phlegm and weight loss. In June 1955, X-ray revealed focal pulmonary tuberculosis, CD (+). She was treated in the hospital for two months and was discharged with improvement. In December 1956, there was an outbreak of the process in the right lung. Superimposed pneumoperitoneum. The state of health was satisfactory until April 1959, when the temperature increased and the general condition worsened. The pneumoperitoneum is dissolved. Chemotherapy started.

On admission, the food is sharply reduced. Height 150 cm, weight 45 kg. The skin and mucous membranes are pale, the lips are somewhat cyanotic. Temperature in the evenings up to 38 °, sputum 40-50 ml per day. The right half of the chest lags behind when breathing. Above the right lung, there is a shortening of the percussion sound and a weakening of breathing with a small number of different-sized moist rales. Heart sounds are clear; blood pressure 90/60 mm Hg. Art.

Blood test: Нb 8 g%, er. 3,000,000, l. 8000, e. 1%, p. 14%, p. 66%, limf. 13%, e. 7%; ROE 57 mm per hour. Sputum mucopurulent, BK (+), EV (+). Mycobacterium tuberculosis is resistant to 25 units of streptomycin and 20 units of ftivazide.

X-ray examination - a picture of fibro-cavernous tuberculosis with multiple cavities, polymorphic foci and cirrhotic changes in the right lung (Fig. 94 and 95). Bronchoscopy revealed no pathological changes in the large bronchi.

Diagnosis: fibrous-cavernous tuberculosis in the seeding phase, CD (+). Complex treatment with streptomycin, ftivazide, PASK and chloramphenicol was started. The general condition has improved somewhat. The temperature dropped to subfebrile. In December 1958, during treatment, the condition worsened again, the temperature increased, the amount of sputum increased, and cycloserine was additionally prescribed. However, it was not possible to eliminate the outbreak within 3 months. In total, the patient received 144 g of streptomycin, 234 g of ftivazide, 2.7 kg of PASK, 40 g of tubazide, 75 g of metazide, 0.6 g of tibone, 13.2 g of cycloserine. In view of the ineffectiveness of conservative treatment, it was decided to remove the right lung. Before the operation, the temperature is subfebrile; ROE 36 mm per hour.

On 15/3 1960 the operation was performed - pleuropulmonectomy on the right.

The postoperative course is smooth. The temperature and blood count quickly returned to normal. She was discharged in satisfactory condition on 24/IV 1960. After 6 years the patient feels quite satisfactory. There are no active tuberculous changes in the remaining lung.

Currently, lung resection for tuberculosis is widely used not only in large institutes and clinics, but also in a number of regional, city and district tuberculosis hospitals and dispensaries. It can be stated that lung resection for tuberculosis has already played a significant role in the fight against tuberculosis in our country. At the same time, a certain system of treatment of patients with tuberculosis has developed, which boils down to the following. With timely detection and not far from the process, the patient undergoes long-term and intensive conservative treatment. If it does not lead to a complete cure of the tuberculous process, then 5-8 months after its beginning, an economical lung resection is performed. After the operation, chemotherapy and spa treatment are continued. Such a system of therapeutic measures for tuberculosis allows to cure about 90% of patients.

Cavern drainage

Drainage of the cavity with constant aspiration of the contents was proposed in 1938 by the Italian surgeon Monaldi. This method promotes the healing of the cavity and improves the conditions for its healing. The operation consists in introducing a rubber catheter into the cavity through a puncture of the chest wall. Suction is carried out by means of a water jet or some other aspirator under the control of a manometer. The negative pressure is maintained at 20-30 cm H2O.

In favorable cases, the contents of the cavity gradually become more liquid, transparent and becomes serous. Mycobacterium tuberculosis in the cavity contents disappear. The cavity decreases in size. There was a marked clinical improvement. Duration of treatment is 4-6 months.

Drainage is most indicated in patients with large and giant isolated cavities without significant infiltration in the circumference. Obliteration of the pleural cavity is a prerequisite for the operation.

The study of Monaldi's operation showed that it usually does not lead to the healing of cavities. Even in seemingly effective cases, relapses occur after a while and cavities are found again. Therefore, drainage of the cavity has lost its significance as an independent method. Currently, Monaldi's operation with the introduction of streptomycin into the cavity is sometimes used before thoracoplasty for large cavities and before lung resection.

Cavernotomy

Cavernotomy - an operative opening of pulmonary cavities - began to be used earlier than other surgical methods of treating pulmonary tuberculosis (Barry, 1726). However, the results of this operation were so poor that it did not become widespread until the last decade.

Cavernotomy (opening and subsequent open treatment of the cavity) makes sense in cases where the cavity is the main source of intoxication and progression of the tuberculous process. A necessary condition is a relatively satisfactory general condition of the patient. As an independent operation, cavernotomy is mainly indicated for patients with large isolated caverns. With fibrotic changes in the walls of the cavity, the operation can be preliminary before thoracoplasty. Finally, cavernotomy can be used after ineffective thoracoplasty or extrapleural pneumolysis in the presence of residual and deformed caverns.

Cavernotomy is less traumatic and makes less functional demands on the patient's body than extensive resection of the lung. Therefore, it becomes possible to operate on such patients for whom lung resection is contraindicated due to the poor general condition or the nature of the tuberculous process. Opening of caverns can be sequentially performed on both sides with a certain time interval between interventions. The presence of an effective artificial pneumothorax or partial thoracoplasty on the second side is not a contraindication to cavernotomy.

Before the operation, an accurate topical diagnosis of the cavity, carried out using an X-ray examination, is required. With tuberculous lesions of the bronchial tree or focal seeding of the surrounding lung tissue cavity, antibiotic therapy is advisable for 2-3 weeks.

The caverns of the upper lobes are opened from the axillary approach with resection of 4 upper ribs. It is preferable to open the lower lobe cavities with a posterolateral incision, removing 3-4 ribs. With obliteration of the pleural cavity, cavernotomy is usually performed simultaneously. If the pleural cavity is not overgrown, which is often revealed only during surgery, it is safer to perform a cavernotomy in two stages. The interval between stages should be 8-12 days. During this time, the fusion of the pleural sheets in the operation zone has time to occur. They always try to open the cavity as wide as possible, its walls are treated with a solution of trichloroacetic acid, tampons with Vishnevsky's ointment are introduced into the cavity.

In the postoperative period, along with general therapeutic measures, local treatment is used, aimed at improving the cavity and stimulating reparative processes. The bronchial orifices, which are usually visible at the bottom of a deep cavity formed after cavernotomy, require special attention. It is advisable to cauterize them with lapis during dressings for 1-2 months, which can lead to closure of the lumen of small bronchi. After 1.5-2 months, with a smooth course of the postoperative period, the general condition of the patients is quite satisfactory, the temperature is normalized, tuberculous mycobacteria disappear from the sputum and wound discharge. In most patients, self-healing of the healthy cavity in the lung and bronchial fistulas does not occur. Therefore, 2-3-4 months after cavernotomy, it is usually necessary to raise the question of additional surgical interventions - thoracoplasty and plastic surgery using muscle and musculocutaneous flaps. Only with relatively small cavities of the lower lobes, the wall of which after opening and processing appears to be sufficiently sanitized, sometimes it is possible to use a one-stage operation - cavernotomy and muscular plasty of the cavity (cavernonlasty).

The length of stay in the hospital for patients undergoing cavernotomy is often very long (3-6 months or more). A significant improvement in the results of cavernotomy in recent years has led to the fact that this operation has taken a certain place among other methods of surgical treatment of pulmonary tuberculosis and in the cases shown - mainly with large isolated caverns - can be successfully used.

Operations on the bronchi

Operations on the bronchi - ligation of the bronchus, as well as stitching and dissection of the lobar bronchus allow to obtain obstructive atelectasis of the affected lobe of the lung. As a result of such atelectasis, conditions are created for reparative processes in the region of the cavity, and the closure of the lumen of the bronchus contributes to the cessation of bacillus excretion (Letsius, 1924). The effectiveness of operations aimed at creating a lobar atelectasis is relatively often reduced due to recanalization of the bronchus, since there are still no technical techniques that allow to completely reliably close the lobar bronchus. However, there is no doubt that the ligation of the bronchus in a number of patients is accompanied by a pronounced therapeutic effect. For upper lobe cavities (if lobectomy is contraindicated), this operation can be combined with thoracoplasty, cavity drainage, and cavernotomy. The indications for such interventions and their plan should be strictly individualized.

Resection and plastic surgery of the bronchi with the imposition of interbronchial anastomoses are indicated in three groups of patients with pulmonary tuberculosis.

• The first group - patients with a complicated primary complex, who have a serious local lesion of the wall of the main or intermediate bronchus in good condition of the pulmonary parenchyma ventilated by these bronchi.
• The second group - patients who have the upper lobe of the lung and have persistent, incurable by conservative methods of tuberculosis of the mouth of the upper lobe bronchus.
• The third group - patients with cicatricial post-tuberculosis stenosis of the main bronchus, and sometimes of the intermediate bronchus.

According to our data, indications for plastic surgery on the bronchi in tuberculosis are relatively rare. But the possibility of preserving the lung or one or two lobes, opened by bronchial plastic surgery, makes it possible to consider these interventions as valuable surgical aids, allowing to avoid complete removal of the lung in a number of patients.

Literature [show]

1. Bogush L. K. Surgery, 1960, No. 8, p. 140.
2. Bogush L.K., Gromova L.S. Surgical treatment of tuberculous empyema. M., 1961.
3. Gerasimenko N.I.Segmental and subsegmental lung resection in patients with tuberculosis. M., 1960.
4. Kolesnikov I.S.Lung resection. L., 1960.
5. A multivolume guide to surgery. T. 5.M., 1960.
6. Perelman M.I.Lung resection for tuberculosis. Novosibirsk, 1962.
7. Rabukhin A.E. Treatment of a patient with tuberculosis. M., 1960.
8. Rabukhin A.E., Strukov A.I. Multivolume guide to tuberculosis. M., 1960, t. 1, p. 364.
9. Sergeev VM Surgical anatomy of the vessels of the lung root. M., 1956.
10. Rubinstein G.R.Pleuritis. M., 1939.
11. Rubinstein G.R. Differential diagnosis of lung diseases. T. 1, M., 1949.
12. Einis V.L. Treatment of a patient with pulmonary tuberculosis. M., 1949.
13. Yablokov D. D. Pulmonary hemorrhage. Novosibirsk, 1944.

A source: Petrovsky B.V. Selected Lectures on Clinical Surgery. M., Medicine, 1968 (Textbook.Lit. for the student.med.in-tov)

Thoracocentesis.A linear skin incision is made one rib below the puncture point parallel to the edge of the rib. A trocar is inserted into the skin wound. By displacing the soft tissues, place it in the site designated for puncture. With rotational movements it is carried out through the intercostal tissue. After penetration into the chest, the trocar mandrel is removed and a rubber tube is quickly passed through its lumen into the pleural cavity. The outer end is connected to an electric pump, a water-jet pump, or lowered into a jar with furacilin, putting a valve in the form of a longitudinally dissected Bulau glove finger on the tube.

Pleurectomy and decortication of the lung.Perform while maintaining the ability of the lung to expand.

Thoracoplasty.Perform if it is impossible to expand the lung. The essence of thoracoplasty is the formation of a compliant chest wall due to subperiosteal resection of the ribs (Fig. 17.6). Complete thoracoplasty is distinguished, when 11 ribs are resected on the affected side, and partial, when the ribs are removed over the residual cavity. According to the same principles, thoracoplasty is used in phthysiosurgery to close large cavities in fibrocavernous tuberculosis, when radical treatment is impossible, and conservative measures (including the creation

Figure: 17.6.Subperiosteal rib resection:

a - the periosteum of the outer surface and the upper and lower edges of the rib are exfoliated; with a Doyenne dilator exfoliate the periosteum of the inner surface of the rib; b - the rib is crossed at one end, the costal cutters are brought in to cross the other end of the artificial pneumothorax) have exhausted themselves. The following types of thoracoplasty are distinguished.

Extrapleural thoracoplasty. The ribs are resected without opening the pleural cavity. Compression bandages are used for good compression. It is best to perform a complete extrapleural thoracoplasty. An operation in this volume is carried out in phthisiatric practice in the treatment of small empyema with adequate drainage.

Intrapleural thoracoplasty. This method was first proposed by Shede. A U-shaped incision is made over the residual empyema cavity. The base of the skin incision should be approximately 5 cm wider than the diameter of the residual cavity. After dissection of the muscles of the chest wall, the resulting U-shaped skin-subcutaneous-muscle-fascial flap is separated from the ribs upwards. After suctioning the contents of the pleural cavity, the ribs located above the residual cavity, the periosteum, the intercostal muscles, the parietal pleura and the moorings that envelop it are resected. The muscles of the chest wall, subcutaneous tissue and skin are sutured in layers.

Stair thoracoplasty according to B.E. Linberg. It is currently considered the most effective and least traumatic operation. An incision is made along the medial edge of the scapula to the level of the fistula or the lower point of the purulent cavity. The incision at the bottom is folded anteriorly and upward, which makes it resemble the Shede's access. Subperiosteal extrapleurally resect the ribs over the purulent cavity. The posterior periosteum is dissected longitudinally, opening the empyema cavity. At the same time, soft tissue bridges are created above the purulent cavity, formed in the center by the muscles of the intercostal space, and along the edges - by areas of the periosteum. These bridges are crossed sequentially at the thoracic, then at the vertebral edge. The resulting muscle flaps are placed in the residual cavity, placing them on the pulmonary pleura, one on top of the other, like stairs. A rare layer-by-layer suture is applied to the skin wound.

Staircase thoracoplasty according to Linberg is less traumatic than Schede and more advanced than extrapleural thoracoplasty.

The operation of thoracoplasty ladder gives a wide access for examination and treatment of the cavity of chronic empyema throughout. After subperiosteal resection of the ribs over the entire empyema cavity, along the course of each resected rib, the posterior periosteum is incised until the empyema cavity is opened. Intercostal spaces containing muscles, blood vessels, nerves, and the edges of the periosteum of the ribs form, as it were, the rungs of a ladder, and therefore the operation is called "ladder" thoracoplasty.

From the formed intercostal “crossbars”, mooring overlays on the parietal pleura are cut off until the muscles are exposed, which gives them free deflection to the surface of the lung, promotes the growth of fresh granulations and the overgrowth of the empyema cavity. This mainly differs from the operation proposed by Heller, who expects the growth of mooring overlays and recommends keeping them, which is unreasonable, since the mooring lines have few blood vessels, the growth of healthy tissue does not give and contain foci of infection.

Ladder thoracoplasty surgery technique

If the operation is repeated after a previous thoracoplasty, then it is better to apply general anesthesia. With local anesthesia with 0.25% novocaine, alcoholization of the intercostal nerves should be added, injecting 2-3 ml of 85% alcohol under each rib near the spine.

The incision passes through the skin and muscles from top to bottom along the posterior edge of the scapula 10 cm from the spinous processes, then bent anteriorly through the fistula (with excision of the fistula) and slightly anteriorly from the fistula rises slightly upward.

By raising the musculocutaneous flap, the ribs near the fistula are exposed and the underlying rib is resected for 10 cm.

An incision is made along the posterior periosteum of the resected rib before opening the cavity. In the direction of the cavity, the second rib is resected with 2 cm over its edges on each side.

The ribs are resected up to the upper edge of the cavity and one rib above. As the ribs are removed, the musculocutaneous flap rises up. Through the slits in the posterior periosteum, the visceral pleura, which makes up the empyema wall, is examined.

Mooring overlays are cut off from the intercostal "crossbars". If the empyema cavity has a shallow depth, then the "bars" freely bend to the surface of the visceral pleura, if the depth of the cavity exceeds 3 cm, then the "bars" are crossed at the edge of the cavity in turn - one in front, the other behind, and the formed flaps are immersed to the visceral pleura. The empyema cavity is wiped with a dry swab, then alcohol. A tampon is loosely placed in each slot, without moving it under the "crossbars". All tampons

Lung resection volume with satisfactory functional parameters, it depends mainly on the extent of the lesion and the characteristics of changes in the lungs and bronchi. Pulmonectomy, that is, complete removal of the lung, with tuberculosis is relatively rare, mainly with unilateral lesions. Pulmonectomy is indicated for a polycavernous process in one lung, fibrous-cavernous pulmonary tuberculosis with extensive bronchogenic seeding and giant cavities. With extensive damage to the lung with the simultaneous presence of empyema of the pleural cavity, pleuropulmonectomy is shown, i.e., simultaneous removal of the lung and the entire pleural purulent sac. Indications for lobectomy are cavernous or fibrocavernous tuberculosis with one or more caverns in one lobe of the lung. Lobectomy is also performed for large tuberculomas with foci in one lobe.

Most common in tuberculosis make economical lung resections. Of these, segmental resections (segmentectomy) are most appropriate. Typically, one or two bronchopulmonary segments are removed within their anatomical boundaries. Indications for segmental resections are tuberculomas and small cavities within 1-2 segments without significant seeding in the circumference and without affecting the lobar bronchus. Various atypical lung resections are also widely used in tuberculosis. This is partly due to the widespread use of the UO-40 and UO-60 staplers. However, it should be borne in mind that wedge-shaped and other atypical resections are performed without observing the anatomical boundaries between the lobes and segments of the lungs. They are advisable only with well-delimited and superficially located tuberculomas, in the absence of damage to the segmental bronchus and focal seeding in the circumference. In other cases, preference should be given to lobectomy and segmental resection.

A feature of the postoperative period after lung resection in patients with tuberculosis, it is necessary to carry out specific chemotherapy and sanatorium treatment. Specific chemotherapy after surgery should be carried out for a long time (6-8 months or more).

Lean results lung resections for tuberculosis - segmental and wedge-shaped - very favorable. The number of recovered patients reaches 90-95% with a postoperative mortality rate of 1-2%. The results of lobectomies and especially pulmonaryctomies are somewhat worse. Exacerbations and relapses of tuberculosis in the long term after operations are detected in approximately 4-6% of operated patients. Thus, lung resections in tuberculosis are effective operations, thanks to which a significant number of patients will be cured. Epidemiologically significant is the fact that the majority of patients stop excretion of bacilli immediately after the operation.

Collapse therapy operations

Efficient action mechanism thoracoplasty consists in the fact that after resection of the ribs, the volume of the corresponding half of the chest decreases and, therefore, the elastic tension of the lung tissue in general and the affected parts of the lung in particular decreases. Conditions are created for the cavity to collapse. The movement of the lung during breathing becomes limited due to the violation of the integrity of the ribs and the function of the respiratory muscles, as well as the formation of motionless bone regenerates from the left costal periosteum. In the collapsed lung, the absorption of toxic products sharply decreases, which is manifested by an improvement in the general condition of the patient. Favorable conditions are created for the development of fibrosis, limitation and replacement of caseous foci by connective tissue. Thus, along with the mechanical effect, thoracoplasty also causes certain positive biological changes. However, after thoracoplasty, the cavity rarely heals through the formation of a scar or a dense closed cassozial focus. Much more often it turns into a narrow slit with an epithelialized inner wall. In many cases, the cavity only collapses, but remains lined with a specific granulation tissue from the inside with foci of caseous necrosis. Naturally, the preservation of such a cavity can lead to new outbreaks of the process and metastasis of the infection at various times after the operation.

Determination of indications for thoracoplasty in a patient with pulmonary tuberculosis, is a responsible task. Most of the failures are due precisely to the wrong indications for this serious operation. When assessing the indications for thoracoplasty, it is necessary to carefully analyze the form and phase of the process on the side of the proposed operation, the state of the second lung, the age and functional state of the patient. Thoracoplasty is performed, as a rule, in cases of impossibility of lung resection in destructive forms of tuberculosis.

Most favorable results are obtained with small and medium-sized cavities, if far-reaching fibrosis has not yet developed in the lung tissue and the wall of the cavity. Cavernous bleeding may be an urgent indication for thoracoplasty. Often, thoracoplasty is an irreplaceable operation for residual cavities in patients with chronic empyema and, along with other plastic operations, is widely used to close bronchial fistulas. It is necessary to operate in the phase of sufficient stabilization of the process. If in the lung on the side of the proposed operation there are fresh focal or infltrative changes, preparation for the operation is necessary by conducting tuberculostatic therapy and other measures. Specific changes in the bronchial tree, revealed by bronchoscopy, it is advisable to undergo treatment with cauterization and local use of tuberculostatic drugs before surgery. If necessary, partial thoracoplasty can be performed on both sides. When deciding on thoracoplasty, the age of the patients should be taken into account. The operation is well tolerated by people of young and middle age. After 45-50 years, you need to operate with great care.

Method selection thoracoplasty is important, sometimes decisive. One-stage thoracoplasty with subperiosteal resection of the posterior segments of the upper 5-7 ribs is more often used. Always remove 1-2 ribs below the location of the lower edge of the cavity. With large upper lobe cavities, the upper 2-3 ribs should be removed almost completely. After the operation, a pressure bandage is applied for 1.5-2 months.

Subperiosteal resection of several ribs is called thoracoplasty.

At the beginning of the development of this operation for pulmonary tuberculosis, it was used in the form of a one-stage removal of eleven ribs. A number of traumatic modifications of this difficult operation are of only historical interest.

At present, thanks to the works of M.G. Stoiko, N.V. Antelava, A.G. Gilman, A.A. Savon, and others, partial, selective modifications of upper thoracoplasty are often used. If it is necessary to perform a complete or extended thoracoplasty, the operation is divided into several stages. 4-5 ribs are removed in one step with an interval of 2-4 weeks.

Correct indications for various variants of thoracoplasty, division of the operation into stages and a thorough assessment of the general condition of the patient and his cardiovascular system in the preoperative period allowed reducing the operative mortality to 2%.

Most often, the upper posterior (paravertebral) thoracoplasty is performed.

Indications for thoracoplasty... The main indication for the use of thoracoplasty is unilateral chronic fibro-cavernous pulmonary tuberculosis in the general satisfactory condition of the patient and in the impossibility of treating him with artificial pneumothorax due to obliteration of the pleural cavity.

There may be deviations from these classic indications. Thus, thoracoplasty can be performed if there is an effective pneumothorax on the other side, and partial upper thoracoplasty can be performed on both sides.

Patients with cardiovascular insufficiency are contraindicated for thoracoplasty surgery. Therefore, before the operation, it is necessary to conduct a thorough study of the functional state of cardiac activity and respiration.

The operation is contraindicated in patients during the period of infiltrative outbreaks and exacerbations, as well as in patients with subacute hematogenous disseminated processes. The use of thoracoplasty is not indicated in patients with giant cavities.

Thoracoplasty does not lead to closure of the cavity in the presence of specific changes or narrowing of the bronchus draining the cavity. Based on this, each patient should undergo bronchoscopy before deciding on the use of thoracoplasty. Detection of specific changes in the bronchi requires treatment with streptomycin, which is administered intratracheally.

If a persistent narrowing of the bronchus is established, one should refrain from using thoracoplasty and choose another surgical intervention for the patient.

The works of S. I. Lapin, A. A. Savon, A. G. Kiselev and others have established that not only a thorough examination of the patient and a correct assessment of the nature of his process play a role in the effectiveness of the operation. An important role in obtaining a long-term and stable therapeutic effect belongs to the radical nature of the operation itself. Therefore, you should always choose the most radical version of the operation, which should correspond to the nature and extent of the process in the lungs.

It is necessary to take into account the size of the cavity and the nature of its walls, as well as its location in the lung tissue.

If, with a small cavity, located in the posterolateral part of the upper lobe, it is possible to restrict oneself to the upper-posterior thoracoplasty, then with a large-sized cavity and with its location in the anterior or medial parts of the upper lobe, one of the options for extended anteroposterior thoracoplasty should be used or the operation should be combined with apicopneumolysis.

The radicalism of the operation consists in creating conditions for the complete collapse of the affected part of the lung and cavity and fixing it in a collapsed state for the entire period of the long-term repair process.

This provision obliges the surgeon to think over the operation plan based on the examination data and mainly on the basis of radiological data.

To create the most complete, concentric collapse of the upper lobe, it is necessary to remove the neck of the upper resected ribs and simultaneously exfoliate the apex of the lung along with the parietal pleura.