PLEURECTOMY (Greek pleura an edge, a side + ektome excision, removal) — operation of removal of the visceral and parietal pleura forming walls of a purulent cavity at an empyema of a pleura. It is for the first time executed by G. R. Fowler in 1893.
Indication to operation empyemas of a pleura of various etiology, including a tubercular origin serve hron (see. Pleurisy ). At hron, nonspecific empyemas of the indication to P. arise in the absence of a resistant raspravleniye of a lung against the background of aspiration drainage (see) and medicinal therapy. In these cases P. is most acceptable by the outcome 4 — the 5th week of a disease on condition of reliable sanitation of a cavity of an empyema and correction of volemichesky disturbances. According to L. K. Bogush and L. S. Thunderous (1961, 1979), P. at tubercular process is shown at the unilateral empyemas which complicated artificial pheumothorax in the absence of the expressed changes in lungs or in the presence of limited changes in a lung on the party of an empyema (bronchopleural fistula, a cavity, a tuberculoma). The expressed destruction of pulmonary fabric which was the reason of an empyema of a pleura or accompanying it forces to expand the volume of an operative measure due to removal of a segment (see. Segmentectomy ), a share or all lung (see. Lobectomy , Pneumonectomy ), pleurosegmentectomy, pleurolobectomy, plevropnevmonektomiya.
Contraindication to an operative measure it serves purulent - resorptive exhaustion of the patient.
Operation P. is always planned, except for the emergency situations connected with bleeding at destruction of a lung and an empyema of a pleura. Operate under an endotracheal anesthesia with a separate intubation of bronchial tubes. Special equipment, except necessary for lung operations, is not required.
Quick access — side or posterolateral thoracotomy (see) more often with a costotomy, usually VI. At rather wide intercostal spaces access to a bag of an empyema is provided without resection of edges. On an inner surface of nearby edges a finger, a tupfer or the wide raspatory it is necessary to get to an extrapleural layer, exfoliate a parietal pleura at the distance sufficient for introduction of a ranorasshiritel. Further continue peeling of the cicatricial changed parietal pleura towards a backbone, trying not to create the narrow deep pockets complicating direct vision. First of all allocate those departments of a pleura, to-rye easier exfoliate. The mobilized sites of a parietal pleura take a plevroderzhatel or stitch the strong ligatures serving as handles. Special difficulties arise at allocation of a dome of a pleura where large vessels (proximal departments of subclavial arteries) are located. For this purpose in the field of a dome of a pleura and on large vessels leave sites of the changed parietal pleura, repeatedly processing them iodine after a scraping an acute spoon or electrothermic coagulations.
The accompanying mobilization of a lung of difficulty, napr try to remove a bag of an empyema entirely in order to avoid infection of a surgery field, but, powerful shvarta, can force to open it for simplification of manipulations. At the same time the cavity of an empyema shall be carefully processed by antiseptic agents.
After separation of a bag of an empyema from a chest wall, a diaphragm and a pericardium pass to the second phase of operation — decortications of a lung (see). Behind, usually in necks of edges on border of transition of a parietal pleura to visceral, the dense whitish plate (a transitional fold) is located. Cutting it, get access to a lung. As the most convenient place for a section of a transitional fold serves the radical zone: on the right — knaruzh from an unpaired vein, at the left — knaruzh from an aortic arch. Step by step allocate a lung from unions, taking in defects of its fabric atraumatic needles for a reliable aerostaz. Leaving of the small, intimately spliced sites of a fibrozirovanny visceral pleura is admissible. Having allocated a lung, divide sites of a visceral pleura in zarashchenny interlobar cracks, trying to obtain its full-fledged raspravleniye by build-up of pressure of gas mixture in the narcotic device.
Operation comes to an end with drainage of a pleural cavity. Drainages connect to aspiration system for deaerating and exudate (see. Aspiration drainage ) for the purpose of maintenance of a lung in the straightened state.
Wounds of large vessels, especially in the field of a dome of a pleura, wound of a diaphragm of l of pulmonary fabric are among intraoperative complications.
In the postoperative period such complications as atelectases of a lung, a kollabirovaniye of a lung are possible (see. Atelectasis ), hypodermic emphysema (see), suppuration of an operational wound, recurrence of an empyema. At a korrigirovanny hemodynamics against the background of full infusional therapy of the patient can get on feet by the end of the first day or the first days. Drainages are taken in 48 — 72 hours on condition of a full-fledged aerostaz. Write out patients at a smooth current in 12 — 15 days. Working ability of patients is recovered by the end of 2 — 3 months after operation. Long-term results favorable.
Bibliography: Dzhanelidze Yu. Yu. A decortication of a lung at chronic empyemas of a pleura of a fire origin, Surgery, No. 4, page 196, 1946; JI at to about m with to and y G. I. Nonspecific empyemas of a pleura, M., 1976; Maslov V. I. Treatment of empyemas of a pleura, JI., 1976; Surgical treatment of a pulmonary tuberculosis, under the editorship of JI. K. Bogusha, page 219, M., 1979.
G. I. Lukomsky