LARYNGECTOMY (Greek larynx, laryng[os] a throat + ektome excision, removal) — full removal of a throat. It is made most often concerning cancer affecting the most part of a throat is more rare at other malignant new growths (sarcoma, a melanoblastoma) and boundary tumors (a tsilindroma, an enchondroma). Experimentally (at dogs) this operation was for the first time executed in the late twenties 19 century.
The first L. at the person it was made in 1866 by J. A. Watson who removed the throat affected with syphilis for prevention of hit in a trachea of decomposition products, food and saliva.
The first extirpation of a throat concerning cancer is manufactured by T. Billroth in 1873, in Russia — P. Ya. Multanovsky in 1875. In the 80th 19 century over thirty L were made., generally from the failure.
However development of a method continued, and by the end of 19 century in the world literature the St. 100 L were described.
The result of operation improved only at the beginning of 20 century.
There are three types of L. — typical, expanded and reconstructive. The first two look has broad use, the last is in a stage of development.
In the 20th V. P. Voyachek offered a way sparing (counterablastous) L., differing in the fact that after an exposure of a throat the last is cut by a vertical section on a corner of a thyroid cartilage and, depending on spread of a tumor, is removed one or both of its half. This transitional between L. and partial removal of a throat (resection) the method did not gain further distribution, however the resection of a throat began to be applied widely and contains several tens of types — from removal of one anatomic part before removal of a half of a throat (gemilaringektomiya). It is reasonable to resection to classify depending on the plane, in a cut operation is carried out and to divide on frontal, sagittal, diagonal and horizontal.
The typical laryngectomy
the Typical laryngectomy is carried out in two options — on Billroth (1873) way and on Gluck's way (1897). The first option is advanced modification of the operation for the first time executed by T. Billroth and differs in the fact that the throat is excreted from below up: crossing of a trachea is made at the beginning of operation, and the throat is cut from a throat at the end of it. Gluck's way improved by Serensen (S. Soerensen, 1920), differs in the fact that allocation of a throat is made from top to down: crossing of a throat is one of the first, and crossing of a trachea one of the last moments of operation. The first operation of this kind was performed in 1877 (before Gluck) by the domestic surgeon V. S. Kosinsky; a sore vein of 13 months after operation.
The indication to typical L. the tumor affecting more than three anatomic parts of a throat, but not extending to the next bodies is. The choice of this or that option is defined by localization of a tumor: at preferential damage of upper parts the lower option is more preferable, at an arrangement of ground mass of a tumor in the bottom of a throat it is more reasonable upper. Operation can be executed under local anesthesia, however is more often carried out under anesthetic.
Typical L. it can be executed by means of a usual set of surgical instruments with addition of a mechanical suction, the device for a surgical diathermy and a set of tracheotomic tubes; besides, special sets of tools for surgical intervention on a throat are created. At a preparation for surgery sanitation of an oral cavity and upper respiratory tracts is necessary. Since the main contingent are elderly people, the special attention should be paid to identification and treatment of associated diseases. The perspective of heavy operation with the subsequent loss of a voice depresses mentality of the patient therefore it is necessary to carry out psikhol, training of the patient for the forthcoming operation and its effects. The most efficient means is communication with the patients who transferred L., the prof. who seized a sonorous voice and continuing activity.
Modern equipment L. considerably differs from described by the above-stated authors. Therefore it is more correct to tell about typical L. by the lower or upper option. The lower option in its modern look is carried out as follows. Under local anesthesia do a section of skin (fig. 1) and make separating of rags. The hypodermic muscle of a neck is outlined a section at the level of a hypoglossal bone, jugular cutting and on medial edge grudino - a clavicular and mastoidal muscle and deleted together with a throat. Cross in the bottom scapular and hypoglossal, grudinopodjyazychny and grudinoshchitovidny, allocate nadpodjyazychny muscles, a hypoglossal bone (fig. 2, a). Displace down or stitch and cross an isthmus of a thyroid gland. Allocate a neurovascular bunch of a throat; tie up its vessels and cross an upper guttural nerve. Cross the lower constrictor of a throat and allocate sidewalls of a throat (fig. 2,6). Cross a trachea, enter a tracheotomic or endotracheal tube for carrying out artificial ventilation of the lungs and an inhalation anesthesia into its gleam (fig. 2, c). Separate (a stupid way) a throat from a gullet and drinks to the level of the upper edge of a cricoid. Open a gleam of a throat in the field of a pear-shaped pocket on the party opposite to localization of a tumor. Cross a throat, delete a throat usually together with a hypoglossal bone. Through a nasal cavity enter the probe for food. Put stitches on defect of a throat (fig. 2, d), create a tracheostoma (see. Tracheostomy ), put stitches on a skin wound.
The upper option differs in the fact that allocation of a throat is made from top to down. Cross nadpodjyazychny muscles, exempt a hypoglossal bone from surrounding fabrics and after crossing of the lower constrictor of a throat together with a throat dislocate forward. Open a gleam of a throat and cut a throat. On defect of its wall put stitches. Cross a trachea and create a tracheostoma, put stitches on a wound.
At any option L. it is necessary to be convinced of sufficient radicalism of intervention by an urgent gistol, a research of the pieces of fabric taken on edge of an operational wound after removal of a throat. For creation of the wide tracheostoma saving the patient from need of carrying a tracheotomic tube it is reasonable to cut a trachea at an angle in 45 — 50 °, opened knaruzh. Tightness of the stitch put on defect of a throat is of great importance for smooth healing of an operational wound first intention. Different types of seams (purse-string, semi-purse-string, two-layer submersible) and various suture materials are for this purpose offered (silk, flax, capron, nylon, orsilon, etc.). Apply the special staplers imposing tantalic brackets to mending of defect of a throat.
For reduction of a possibility of infection of a wound with contents of a throat some surgeons leave an upper part of a wound open, creating a so-called planned faringostoma.
L. it is applied at cancer therapy of a throat generally in combination with radiation therapy (the combined method) and it is very rare as an independent type of treatment. Various options of a combination of beam and surgical methods with hormonic and chemotherapy are possible. Combinations of beam and surgical methods of treatment are various: radiation — operation, radiation — operation — radiation (way «sandwich»), operation — radiation. The indication to L. as to the first stage of treatment need of urgent intervention — bleeding from the breaking-up tumor or existence of contraindications to radiation therapy is.
In the postoperative period the main objective — the prevention of the general and local complications. Their probability depends on a condition of the patient and on an exposure dose, received before operation. The number of local complications sharply decreases if the total exposure dose does not exceed 6000 is glad on the center. Features of postoperative leaving are defined by existence of a tracheostoma and character of food. It is necessary to monitor carefully breath, several times a day to clean a plug-in pipe of a tracheotomic cannula, at least once a day a cannula to take out and clear edges of a tracheostoma of slime and crusts. Food is carried out or via the probe entered into a gullet (to the level of its average third through a nasal cavity or faringosty), or parenterally. At probe feeding liquid or semi-fluid food is entered each four hours, intravenously enter a whole blood, plasma or other blood-substituting liquids.
An expanded laryngectomy
Attempts to expand the volume of surgical intervention at the tumors extending out of limits of a throat belong To the end of 19 century. So, B. Langenbek in 1875 removed a cancer-stricken throat, a part of language, a throat and gullet. The patient lived four months and died from metastasises in cervical limf. nodes. Kazelli (G, A. Caselli) in 1879 removed a throat, a part of a throat and a soft palate concerning widespread sarcoma at the 19-year-old patient, edge was observed within 20 months. Only in the middle of 20 century improvement of the technology of operations and anesthesia, use of antibiotics of a broad spectrum of activity and replacement therapy, development of methods of resuscitation allowed to expand the volume of surgical intervention, to develop the equipment of expanded L. and to establish indications to them.
Depending on the direction of growth of a tumor the following types expanded are allocated to L.: upper, front, side, back and lower. The indication to expanded with L. spread of a tumor out of limits of a throat on the next bodies is. Local contraindications for all types expanded with L. are: spread of a tumor out of limits of a neck, existence of the motionless regional metastasises soldered to nearby bone educations and the remote metastasises. As surgical intervention at throat cancer is made according to vital indications, the general contraindications are only associated diseases with the heavy forecast: 1) a stroke within 6 months from the beginning of a disease, and at irreversible paralyzes irrespective of term; 2) a myocardial infarction till 4 months from the beginning of a disease; 3) heavy cachexia; 4) senile dementia. The majority of associated diseases which can serve as relative contraindications is demanded by treatments in the preoperative period.
Indications for separate types expanded with L.: for upper — spread of a tumor on a root of language; for a lobby — damage of cartilages of a throat and soft tissues of a front surface of a neck; for side — germination of a tumor in a thyroid gland; for back — transition of a tumor to a throat; for lower — germination by a tumor of a trachea. Contraindications: to upper — spread of a tumor out of limits of a root of language on its average third; to a lobby — spread of a tumor on a vascular bundle of a neck when intervention on vessels is impossible; to side — involvement in tumoral process of both shares of a thyroid gland, germination of a tumor in a prevertebral fascia and a backbone; to back — spread of a tumor on chest department of a gullet; to lower — germination of a tumor in a chest part of a trachea.
Combinations of different types expanded with L are possible. From such combinations are admissible the anterosuperior and combined expanded verkhnezadny L. Sochetaniye combined expanded of three types expanded with L. contraindicated. More often expanded with L. it is necessary to combine with excision limf, ways and cellulose of a side surface of a neck. This operation is carried out in two options: more radical, at Krom delete deep limf, a chain and cellulose of a lateral triangle of a neck together with a deep jugular vein and grudino - a clavicular and mastoidal muscle — Krayla operation (see), and sparing — fascial futlyarnoye excision of cellulose of a side surface of a neck, at Krom both the vein, and a muscle remain. Considering that expanded with L. usually make on the fabrics which underwent radiation it is necessary to avoid wide cuts which are applicable only at operations without preliminary radiation. All types expanded with L., except for the lobby demanding the bordering section can be executed during the use of linear midsection. The spread of a tumor found during operation usually surpasses assumed on the basis of the researches made in the presurgical period. During the performance of front option audit begins with inspection of a condition of vascular bundles of a neck. At detection of changes make the corresponding interventions on the main vessels (a resection, shunting, prosthetics, bandaging). After removal of the struck fabric control — an express biopsy of the pieces of fabric on edge of an operational wound taken in the direction of the movement of an hour hand and numbered is necessary gistol. The wound is sewn up or a deaf seam, or in an upper part it is left faringosty.
Expanded with L. is very traumatic intervention. At persons who usually are exposed to such operation fiziol, functions are broken by both tumoral process, and associated diseases. It defines features of preoperative preparation and postoperative treatment. At patients with widespread throat cancer disturbances from cardiovascular system are most often observed and dysfunction of external respiration. In the preoperative period the corresponding treatment shall be carried out. As under the influence of the radiation preceding operation the quantity of pathogenic flora in oral cavities and throats increases, it is reasonable to carry out the general and local (irrigation of an oral cavity and throat) treatment by the corresponding antibiotic. A problem of postoperative treatment is the prevention of the general and local complications. Prevention of the most frequent of the general complications — pneumonia consists in early activation of the patient, use of respiratory gymnastics and treatment with antibiotics. Holding the listed actions allowed to reduce number of these complications almost ten times. The most frequent of local complications is discrepancy of seams that involves prolonged postoperative treatment and leads to formation of the resistant faringostoma needing afterwards plastic closing. In certain cases there is suppuration of a wound that can lead to the heaviest of local complications — to arrosive bleeding from the main vessels of a neck. For the prevention of local complications, in addition to a careful hemostasis during operation, make drainage of an operational wound. The lower ends of drainage tubes through counteropenings remove outside and connect a tee through which by means of vacuum adaptation of this or that design continuous suction separated wounds is made. In addition to care of a tracheostoma, it is necessary to suck away slime from a trachea (several times within a day), to periodically investigate flora and to apply the corresponding antibiotic. The percent of local complications continues to remain high, primary healing is observed in only 35,9% of cases.
Purpose reconstructive L. preservation of a normal respiratory way and creation of the best conditions for formation of a so-called pseudo-voice is. It is reached by a podshivaniye of a trachea to walls of a throat (trakheofaringopeksiya) or to a hypoglossal bone (trakheokhioidopeksiya). For the first time operation of this kind for cancer executed in 1898 Mr. Federl (O. Foderl), he observed the patient within 8 months. In 1967 G. Serafini published work about a possibility of preservation of breath in normal ways and phonations after removal of a throat. For improvement of a phonation of Asai (R. Asai, 1967) offered so-called shunting — creation of the narrow skin channel between a trachea and a throat. Limited indications and quite often observed lack of the expected effect demand further development of this type of L.
The forecast and rehabilitation
the Combined treatment, at Krom of L. it is applied as a surgical component, gives apprx. 90% of primary izlecheniye and 50 — 60% of the favorable long-term results. Is less effective L., executed after ineffectual radiation therapy (38,2% of resistant izlecheniye after typical and 26,3% after expanded with L.).
Rehabilitation after L. is a difficult task as operation puts to the patient a severe physical and mental injury, depriving of it an organ of speech — one of the main components of the second alarm system. Rehabilitation after L. develops of rehabilitation anatomic and functional. Rehabilitation anatomic — closing of a faringostoma, creation of the gleam of a throat providing a possibility of normal food, and formation of the tracheostoma saving the patient from constant carrying a tracheotomic tube. Anatomic rehabilitation is carried out by different use of plastic surgeries (see. Laryngoplasty ). Funkts, rehabilitation consists of rehabilitation physical and rehabilitations of a phonation. Physical. rehabilitation consists in selection of work, the cut can be engaged in the patient depending on his state (age, activity fiziol, systems, ability to physical. loading). For recovery of a phonation different types of an artificial throat are offered. The majority of designs of an artificial throat demands preservation of a constant faringostoma; those models in which air delivery in a throat is carried out through a nasal cavity are bulky and unsatisfactory in the cosmetic relation. Devices with electronic strengthening of the shepotny speech are created. The voice is formed rather loud, but monotonous, deprived of any emotional coloring. An optimum form of rehabilitation of function of a phonation is so-called. pseudo-voice (see) — the voice formed by fluctuations of folds of a mucous membrane of a throat and the upper parts of a gullet set in motion by the swallowed air. The pseudo-voice can be formed by self-training or training in specialized logopedic institution. Funkts, rehabilitation in the social relation is especially important for persons of intellectual work since she allows them to continue work.
(From additional materials).
Recovery of the speech at the patients who transferred a laryngectomy (see) is made by development of an esophageal voice (see Psevdogolos), and also by means of a plastic surgery and technical means, a version to-rykh are golosoobrazuyushchy devices (an artificial throat, an electrothroat, a prosthesis of a throat, speech and voice prostheses) allowing the person to reproduce the articulate speech in the absence of a throat (without use of an esophageal voice).
The Golosoobrazuyushchy device shall create the main tone, frequency to-rogo depends on a sex of the patient and to do his speech whenever possible more natural, providing creation of sound vibrations in an oral cavity of the patient. It is reached by external vibration influence, napr, on soft tissues of a perednebokovy surface of a neck of the patient, to a cut the vibrating membrane of the device is put. On fabrics vibration reaches an oral cavity, exciting in it sound vibrations, to-rye to a certain extent replace fluctuations of phonatory bands. The advantage of the devices constructed on an elektrovibratsion-noma to the principle, in particular the device A G-61 (fig., a) or AG-80, is simplicity of a design and convenience of operation. Devices, actions to-rykh the electro-acoustic principle is the cornerstone, allow to enter the sound vibrations created by the electro-acoustic converter into an oral cavity. A lack of such devices — more difficult design.
Basic element of golosoobrazuyushchy devices — the generator of electric fluctuations with a frequency of the main tone. The generator is arranged or as the breaker electric
Fig. the Golosoobrazuyushchy device (AGMI.>: and — outward; — the elementary electric circuit; 1 — the case; 2 — the switch; 3 — the vibrating membrane; 4 — a winding of an electromagnet; 5 — the core; in — the rechargeable battery;
7 — the electric breaker.
chains with an electromagnet (fig., 6) or as the electronic generator, fluctuations to-rogo move on an electro-acoustic radiator. During the use of devices with the electro-acoustic converter the patient carries the generator and the power supply in a pocket. The electro-acoustic radiator is built in in a-point frame; the tube zvukoprovo departs from a radiator - yes. edges it is entered into a mouth of the patient. Bibliogrchistov and p L. And. and d r Physiology of the speech, L., J 976: Me Kai
of 522 LEBEDEVA
B. G. a. Pillsbury Y. R «A modified intraoral electrolarynx, Arch. Otola-ryng., v. 105, p. 360, 1979;
Z w i t-rn a n D. H., K n o r r S. G. a. So n-d e r m a n J. C. Development and testing of an intraoral electrolarynx for laryngectomy patients, J. Speech Dis., v. 43, p. 263, 1978. L. A. Vodolazsky.
LEBEDEVA Maria Nikolaevna (1897 — 1974) is the Soviet microbiologist, professor (1942), zasl. scientist of RSFSR (1960) «pupil P. V. Tsikl and certain. Member of the CPSU.
In 1924 ended medical f-t of the 2nd MSU (since 1930
the 2nd MMI). Worked in the same place at department of microbiology. Since 1936 the associate professor, from 1942 to 1945 professor felts of m ik robi-olopsh the 2nd MMM. Along with 1930 for 1941 the senior research associate and the head of laboratory of chemotherapy in f e to tsi about N and y x z and Bol e in and and and y In with e about oyu z - but go N and at the h but - is with l e to in and bodies s to go x and - a miko-fa of a rm tsevticheeky in-that nanometer *
S. Ordzhonikidze, C 1945 for 1968 the department chair of microbiology of the 1st MMI.
M. I. Lebedeva one of the first in the Soviet Union was engaged in studying of sulfanamide drugs, having generalized the received results in dokt. theses on the subject «Chemotherapy of Bacterial Infections Soviet Sulfanamide Drugs» (1940). Under its management and with its participation the first are carried out a wedge, tests of these pharmaceuticals.
M. N. Lebedeva is an author apprx. 100 scientific works devoted to questions of microbiology and immunology, including the monograph on medicinal stability of microorganisms (1960) and the textbook on microbiology (I960, 1969). It «The guide to a practical training on medical microbiology» sustained
5 editions and was translated into several languages of the people of the USSR and a number of the socialist countries.
M. N. Lebedeva was a member of presidium and the honorary member Vsesoyuznogo and Moscow about-in microbiologists, epidemiologists and infectiologists, the associate editor of «The magazine of microbiology, epidemiology and immunology», hl. editor of the State publishing house of medical literature.
It is awarded by the Orders of Lenin, the Labour Red Banner and medals.
Works: Chemotherapy of bacterial infections Soviet sulfanamide drugs, yew., M., 1940; The Guide to a practical training to medical microbiology, the 1st prod. M, 1946, 5 prod., 1973; Medicinal stability of microorganisms, M., 1960 (sovm. from Voropayeva S. D.); Medical mikoobiologiya, M., 1960, 1969.
Bibliogr.: To the 75 anniversary since the birth of M. N. Lebedeva, Zhurn. mikr., epid. and immun., No. 3, page 142, 1972; Maria Nikolaevna Lebedeva, in the same place, No. 1,
page 147, 1975. A. S. Bulls, E. P. Pashkov.
Bibliography: Voyachek V. I. Kontgablasticheskaya extirpation of a throat, Vestn, hir., t. 8, book 24, page 104, 1926; To and r-p about in N. A. Surgical cancer therapy of a throat in far come stages, Works of the 8th Meshdunarodn. anticarcinogenic congress, t. 5, page 453, M. — L., 1963; it, Results of a discussion about medical tactics at throat cancer, Zhurn, ushn., Nov. and throats, Bol., No. 2, page 63, 1978; M of wasps of t about in about y S. I. and M about sh to and N and I. F. Cancer therapy of a throat, Kiev, 1971, bibliogr.; Paches A. I., About about l c about-vab. Page itsybyrne G. A. Topical issues of surgical cancer therapy of a throat, Chisinau, 1976, bibliogr.; Discussion sur l ’6tat actuel de la Chirurgie du larynx, Rev. Larvng. (Bordeaux), t. 93, p. 97, 1972; Gollmitz H. Chirurgie des Kehlkopfkrebses, Lpz., 1965; L e r o u x-Robert J. R6sultats de la Chirurgie et des associations radio-chirurgicales dans le traitement des cancers du larynx et l’hypo-pharynx, Ann. Otolaryng. (Paris), t. 82, p. 305, 1965.
H. A. Karpov