CAVERNOTOMY (Latin caverna cave, cavity + grech, tome section, section; synonym speleotomiya) — operation of opening of a tubercular cavity in various bodies (a lung, a kidney, a prostate gland). Most often To, it is applied at tuberculosis of a lung.
In surgery of pulmonary tuberculosis To. is the oldest operation. The first messages on it are published in 1726 by Barry (E. Barry). In 1844 R. Storks successfully opened a cavity of an upper lung lobe. However imperfection of diagnostic methods and limitation of surgical opportunities of that time were the cause of bad outcomes of the majority of operations. At the end of 19 century the greatest experience To. Tyuffye possessed (T. Tuffier) which in 1897 in Moscow reported about 26 operations with 13 lethal outcomes. In the next years To. made also seldom. Only in 1939 N. G. Stoyko returned to open treatment of cavities of a lung again. After the Great Patriotic War To. it was in details developed in the USSR by L. K. Bogush., then G. G. Gorovenko, Yu. A. Ennulo, etc.
Indications and Contraindications
Indications to To. depend on various conditions — duration of existence of a cavity, its size, a form, character of a wall, localization, a condition of the patient, etc.
To. can be operation independent, preliminary or additional. As independent it is shown at big (to dia. 4 — 7 cm) the single peripheral located cavities without sharply expressed fibrous changes in surrounding pulmonary fabric and at a zarashchenny interpleural crack. As preliminary operation K. it is carried out at big and huge cavities against the background of fibrosis when the thoracoplasty with a myoplasty (is necessary for closing of a residual cavity in a lung and bronchial fistulas see. Thoracoplasty ). As additional operation K. it is shown to patients with peripheral located single cavities after earlier postponed thoracoplasty or with again arisen cavities after a pneumonectomy in the absence of considerable focal planting in a circle. If cavities are located close from each other (the second and sixth segments of a lung) and the partial pneumonectomy cannot be for various reasons executed, then in such cases To. serves as method of the choice. To. it is possible also at patients with bilateral defeats (operation is made in 2 stages) and on the only lung (after a pneumonectomy). After operation prolonged treatment is required; additional interventions for closing of a residual cavity and bronchial fistulas are probable. Thus, To. it is applied when the pneumonectomy and a thoracoplasty are not shown.
Contraindications to To. generally the serious general condition of the patient, the central arrangement of a cavity, multiple cavities, plentiful focal damage of a lung are.
Technology of operation
To. make under anesthetic. At superlobar cavities of the patient stack on a healthy side. Make a vertical axillary section, to-rogo bend the bottom on the course of an edge (fig. 1) forward. Podnadkostnichno is resected by upper 4 edges, crossing them in front at cartilages and it is behind possible closer to a backbone. At nizhnedolevy cavities apply posterolateral access in position of the patient on a healthy side or on a stomach. Also resect 3 — 4 edges from a backbone to the average axillary line over area of an arrangement of a cavity. After a resection of edges intercostal muscle bundles otslaivat from a parietal pleura, releasing the surface of a lung where the cavity is located. Intercostal muscle bundles keep as plastic material.
At a zarashchenny pleural cavity To. do in one step. For definition of the place of the closest prileganiye of a wall of a cavity to a parietal pleura L. K. Bogush suggested to be guided on «a symptom of peep». This symptom arises during percussion of a lung a finger-tip is passable cases when the cavity contains air and the bronchial tube draining it. Make a trial puncture of a cavity: at hit of a needle in it the syringe possible to suck away air or pus. Open a cavity with an electroknife or a thermocauter (see. Thermocoagulation ), and then widely excise an outside wall then the draining bronchial tubes (fig. 2) are at once visible. Delete purulent contents and a detritis from a cavity, 80% with solution trichloroacetic to - you grease its walls. Operation is finished with introduction to a cavity of the tampons impregnated with solutions of antibiotics.
At patients with a free pleural cavity single-step opening of a cavity is contraindicated because of danger of a collapse of a lung and emergence of an empyema of a pleura therefore To. at them make in two stages. First stage of operation: after a resection of edges and peeling of intercostal muscle bundles on a parietal pleura in the field of a cavity impose a metal ring to dia. 2 — 3 cm. The ring serves as a reference point at the subsequent rentgenol. researches. The wound is tamponed a gauze and not sewn up. In 10 — 15 days when pleural unions are formed, the cavity is opened. In certain cases To. combine with bandaging of bronchial tubes, kavernoplastiky (is more often with sewing up).
In the postoperative period against the background of the general antitubercular therapy topical treatment of a cavity is carried out. It consists in bandagings with change of tampons, processing of a wall of a cavity of 3% by solution of hydrogen peroxide, solutions of proteolytic enzymes and antibiotics. Mouths of bronchial tubes which open at the bottom of a cavity after emergence of granulations cauterize 80% solution trichloroacetic to - you, 30% solution of caustic silver.
Outcomes and the main complications
Later To. pheumothorax, an empyema of a pleura, flash of tubercular process, an air embolism can be observed. Their frequency is rather small.
At 80% operated the abatsillyarnost and elimination of tubercular intoxication is reached. Further apply a thoracoplasty, muscular or musculocutaneous plastics, bandaging of a bronchial tube to closing of a residual cavity and fistulas.
A postoperative lethality at To. — 2 — 5%. Full the wedge, treatment is observed at 80 — 86% of patients.
See also Cavity .
Bibliography: Bogush L. K. A cavernotomy at suffering from tuberculosis lungs, M., 1955, bibliogr.; Gorovenko G. G. Surgical treatment of cavities at a pulmonary tuberculosis by their opening, Kiev, 1954, bibliogr.; A cavernotomy and other methods of topical treatment of pulmonary tuberculosis, the lane with English, under the editorship of N. Chuzo, M., 1972, bibliogr.; N. G. O of a cavernotomy, Probl, a tube is firm.,& JM 4, page 3, 1946; E N of N at l about Yu. A. Kavernotomiya in surgeries of a pulmonary tuberculosis, Tallinn, 1964, bibliogr.
M. I. Perelman.