From Big Medical Encyclopedia

PNEUMOTOMY (grech, pneumon easy + tome a section, a section) — operation of a section of a lung for opening of abscess or removal of a foreign body from tissue of a lung. The section of a lung concerning a tubercular cavity is called cavernotomy (see).

The first authentic data on P. belong to the second half of 19 century.

In Russia the first P. was executed by M. P. Korobkin in 1883. In 1907 A. A. Opokin published the thesis «A pneumotomy in Russia», in a cut the analysis of 142 operations made by the Russian surgeons was made. Extreme imperfection of diagnostic methods and limited opportunities of surgery of that time were the cause of unsatisfactory results of the majority of the Item.

Before the Great Patriotic War and in the first years of P. after it was the main method of operational treatment of purulent processes in lungs. Items applied at acute and hron, abscesses of lungs, both single, and multiple, at abscesses of lungs with bronchiectasias, gangrene of lungs, the suppurated cysts, an actinomycosis. According to statistical data of the 40th, the lethality after P. reached 35%. At acute single abscesses of a lung the immediate and long-term results of P. were satisfactory, and in cases of other purulent diseases of lungs, especially chronic, recovery after P. was observed seldom. Due to the improvement of ways of treatment of purulent diseases of lungs (at acute abscesses of lungs apply endobronchial therapy and transthoracic drainage, and at hron, purulent diseases resort to a resection of lungs) P. at adults lost former value and is applied generally to removal of foreign bodys from lungs.

A pneumotomy for the purpose of removal of foreign bodys. Before operation with the help of a X-ray analysis in two projections and roentgenoscopy specify localization of X-ray contrast foreign bodys. Operation is made under an endotracheal anesthesia.

The technique

P.'s Technique for removal of foreign bodys can be various depending on the term of finding of a foreign body in a lung and an estimated condition of a pleural cavity.

In cases when the foreign body is in a lung a long time and the obliteration of a pleural cavity is supposed, it is desirable to perform operation in the conditions providing radiological or X-ray television control during intervention.

The section 10 — 12 cm long is made according to a projection of a foreign body to a chest wall. If necessary podnadkostnichno resect sites of one-two edges throughout 4 — 5 cm, open a parietal pleura. The foreign body is found a palpation, trial punctures of a lung a fine needle or use X-ray television control. Pulmonary fabric over a foreign body and often available fibrous capsule is cut an electroknife, the foreign body is taken tweezers, a styptic clip or fenestrated nippers of Lyuer. At removal of a foreign body give it such situation minimum to injure pulmonary fabric. The metal foreign bodys which are in tissue of a lung a long time often are exposed to corrosion and turn into unstructured weight, to-ruyu it is necessary to take out a bone spoon. Further make careful power tool cleaning of a cavity, process it antiseptic agents and antibiotics with the subsequent sewing up of a wound.

In cases of fresh wounds and the free (not obliterated) pleural cavity the foreign body in tissue of a lung, as a rule, manages to be groped. Tissue of a lung over a foreign body is cut an electroknife, the foreign body is deleted, the wound of a lung is taken in.

The pneumotomy concerning purulent diseases of lungs was carried out under local anesthesia since at an anesthesia there was a danger of hit of pus to healthy sites of a lung. Thanks to implementation in practice of an anesthesia with a separate intubation of bronchial tubes this danger managed to be eliminated.

Two methods P. — one-stage and two-stage were offered. In case of the free, not obliterated, pleural cavity it was applied two-stage by the Item. At the first stage of operation bared a parietal pleura and held the events promoting formation of pleural unions (greasing of a pleura of 3 — 5% spirit solution of iodine with the subsequent tamponade of a wound a gauze etc.). In 10 — 12 days carried out the second stage of operation — opening of abscess. However two-stage P. possessed a number of shortcomings: opening of abscess was late, and it led to further exhaustion of the patient; pleural unions were not always formed. In this regard attempts were made pneumopexies (see) just before P. by sewing together of a parietal and visceral pleura, but such operation was not widely adopted.

Fig. 1. The diagrammatic representation of a fragment of a one-stage pneumotomy with preliminary opening of a free pleural cavity and a podshivaniye of a visceral pleura to a parietal pleura and a periosteum: 1 — a lung, 2 — a parietal pleura, 3 ~ a periosteum of an edge, 4 — intercostal muscles, 5 — the resected edges.

Applied the one-stage P. with preliminary opening of a free pleural cavity described by A. N. Bakulev and S. A. Kolesnikov in 1957 more often. Technology of this operation is that in the absence of pleural unions the parietal pleura together with a back leaf of a periosteum of the resected edge is opened over the place of estimated abscess. The lung is examined, felt and the area of infiltrate noose catgut sutures is hemmed on all circle to a parietal pleura, a periosteum of edges and intercostal muscles (fig. 1). Then make P. with drainage of an abscess cavity. Use of this way allows to fix more precisely a lung and it is better to choose the place for its puncture and a section.

Fig. 2. Excision of an outside wall of abscess of a lung: 1 — an abscess cavity, 2 — an electroknife.

One-stage P. was prorgzvodit also at patients with the obliterated pleural cavity. This operation described in 1961 by A. N. Bakulev and R. S. Kolesnikova is that after an exposure of a parietal pleura over a zone of abscess, by means of a puncture find abscess, open it with an electroknife on the course of a needle and excise an outside wall of abscess (fig. 2). Delete sequesters of pulmonary fabric, pus, fibrin with the subsequent its packing from an abscess cavity or drainage (see).

In the presence of multiple abscesses of a lung so-called expanded P. is possible, at a cut nearby the located abscesses open at the same time, excising front walls and partitions between purulent cavities. The created widely open general cavity is tamponed.

Expanded P. can be followed by considerable bleeding and even at rather smooth postoperative current, as a rule, leads to formation of residual cavities in a lung with persistent bronchial fistulas. For their closing repeated plastic surgeries or a pneumonectomy are required.

After P., in the postoperative period, sick carry out correction of the vital functions of an organism, anesthesia, antibacterial therapy.

Possible complications: pheumothorax (see), atelectasis (see), pneumonia (see).

Radiological changes of a lung and pleura after a pneumotomy

If made P. for the purpose of removal from an easy foreign body (a splinter, a bullet, a knife blade, etc.), then on roentgenograms in a lung the focal shadows or blackout caused by hemorrhage on site of the taken foreign body and also on the course of dissect pulmonary fabric are visible. The described changes of tissue of lung remain usually within several days, is more rare than weeks, after operation and afterwards on their place there are hardly noticeable fibrous tyazh.

After one-stage P. with preliminary opening of a pleural cavity on the roentgenograms made soon after operation on the party of an operative measure it is, as a rule, noted pheumothorax (see) which usually disappears in the next few days. After the first stage of two-stage P. in the field of the tampon laid on a naked pleura sacculated radiological is defined pleurisy (see).

After P. undertaken for the purpose of opening of abscess of a lung, the abscess cavity gets out of the shape on the roentgenogram, decreases in sizes and gradually disappears. On its place develops pneumosclerosis (see). However at bronchographies (see) on site abscess cavities in a lung often it is possible to find a residual cavity while on the usual roentgenogram only low-intensive blackout characteristic of indurative changes is noted by this time.

The pneumotomy at children

the Pneumotomy at children is carried out preferential at foreign bodys in lungs. In a planned order operation is performed at uncomplicated foreign bodys. In cases of development of pheumothorax or a pyopneumothorax and at abscesses of a lung the emergency operative measure is shown. Unlike adults at children acute abscesses of lungs have no the expressed piogenic capsule. It limits possibilities of use of a pneumopexy and drainage of an abscess cavity. In a case hron, abscess, at suppuration of an inborn cyst of a lung their enucleating, and also a segmentectomy is shown or lobectomy (see). According to indications previously punktirut or drain a pleural cavity.

Quick access depends on localization of abscess or a foreign body. At multiple abscesses prefer the side thoracotomy allowing to manipulate on all lung lobes. After opening of a pleural cavity carry out topical diagnosis, comparing rentgenol, and endoscopic data with operational finds. Subpleural abscesses easily determine visually, deep — by infiltration of tissue of lung palpatorno. At abscesses of a lung carry out sanitation of a visceral and parietal pleura, in the stupid way otslaivat fibrinous imposings and delete them. Abscess is opened (puncture with a sharp-pointed scalpel), pus is evacuated, the cavity is sanified and taken in too much.

At foreign bodys before operation the X-ray analysis of lungs is obligatory. Items make on a projection of a foreign body. If a subject round (ball), extent of a section shall correspond to its diameter. For extraction of long and acute foreign bodys (a needle, a nail) the section 3 — 5 mm long on a projection of the acute end suffices. After removal of a foreign body the pneumo-tomichesky wound is taken in tightly. At considerable intake of air from the wound surface of a lung drainage of a pleural cavity is shown. After a raspravleniye of a lung the drainage is deleted.

See also Lungs, operations .

Bibliography: Bakulev A. N. and Kolesnikova R. S. Surgical treatment of purulent diseases of lungs, M., 1961, bibliogr.; Purulent diseases of a pleura and lungs, under the editorship of P. A. Kupriyanov, JI., 1955; Isakov Yu. F. and Oryol S. P. Foreign bodys of respiratory tracts and lungs at children, page 128, M., 1979; Operational surgery with topographical anatomy of children's age, under the editorship of Yu. F. Isakov and Yu. M. Lopukhin, page 336, 339, M., 1977; Spasokukotsky S. I. Surgery of purulent diseases of lungs and a pleura, M. — L., 1938; V. I Pods. Purulent diseases of lungs and pleura, L., 1967, bibliogr.; Bier A., Braun H. u. To u m m e 1 1 H. Chirur-gische Operationslehre, Bd 3, T. 1, S. 327, Lpz., 1971.

M. I. Perelman; E. L. Kevesh (rents.); S. Orlovsky (it is put. hir.).