SEGMENTECTOMY

From Big Medical Encyclopedia

SEGMENTECTOMY (Latin segmentum piece + Greek ektome excision, removal; synonym segmented resection, resection of a segment) — removal of one or several segments of body (e.g., a lung, a liver) within intersegmental anatomic borders. Removal of two segments is called a bisegmentektomiya, three and more segments — a polysegmented resection. Removal of one-two segments of a lung together with the cicatricial capsule empyemas (see) call a pleurosegmentectomy. In a wedge, practice S. of a lung is most often applied, is more rare — S. than a liver (see. Liver, operations ).

Segmentectomy of a lung

S. of a lung (synonym segmented pneumonectomy) it is carried out within anatomic borders of the struck segment with allocation, processing and crossing of elements of a root of a segment (an artery, a vein, a bronchial tube). In 1939 S. of a lung was applied in a wedge, the practician Cherchillom and Belsi (E. D. Churchill, R. N of R. Belsey). This operation was widely adopted since 50 — the 60th there are 20 century

Indications, Contraindications

make S. at tumors and inflammatory and destructive processes within one or several segments of a lung. At a pulmonary tuberculosis S. is shown in cases of the defeats limited to one-two segments. Usually it is focal processes, tuberculomas or cavities without considerable planting of surrounding fabrics and defeat of a lobar bronchus. At an arrangement of a tuberculoma or a cavity near division of a lobar bronchus, a caseous endobronkhnt, progressing of tuberculosis against the background of chemotherapy, the main himio-drugs resistance of mycobacteria, and also under unfavorable anatomic conditions (inflammatory, cicatricial changes, etc.) from S. it is better to refrain and prefer lobectomy (see). At bronchiectasias (see) By page it is shown to hl. obr. at children and teenagers, at adults it is applied seldom. Most often at bronchiectasias make a left-side lower lobectomy with simultaneous removal top and bottom lingular segments. Delete segments of a basal pyramid (basal segments) less often, leaving an apical (upper) segment. This operation is reasonable only in the absence of inflammatory or cicatricial changes on border of an apical (upper) segment and back basal segment. In the presence of such changes from a wound surface of an apical (upper) segment air can filter, and sewing up of this surface sharply reduces the remained segment. Even less often on the right together with an average share it is necessary to delete the struck medial (cordial) basal segment. At peripheral cancer of easy S. it can be applied at patients with limited respiratory rezervakhm in cases of subpleural tumors of the I—II stage.

Contraindications to S. are limited and caused by a serious general condition of the patient.

Preoperative preparation at S. it is carried out by the same principles, as at other lung operations (see Lungs, operations). It is reasonable to operate during sufficient stabilization of inflammatory process and at trace amount of a phlegm.

Technology of operation

S. make under endotracheal inhalation anesthesia (cm.). From special tools at S. apply rack dilators of a wound of a chest wall, long tweezers and scissors, dissectors to allocation of vessels and bronchial tubes. Processing of vessels can be made by means of devices MOUSTACHES, and bronchial tubes and pulmonary fabric — by means of devices UO (see. Staplers ).

Later thoracotomies (see) make separate allocation, processing and crossing of segmented arteries, a bronchial tube and central vein (an intra segmented part of a branch of a pulmonary vein; T.), then allocation and removal of a segment with bandaging and resettlement of the venous branches of the deleted segment falling into an intersegmental vein follows (an intersegmental part of branches of a pulmonary vein; T.). The order of processing of vessels and bronchial tubes at S. has no basic value and is defined only by anatomic and operating-technical reasons. Allocation and removal of a segment make on its anatomic borders from a root to the periphery, sipping for a peripheral stump of the crossed segmental bronchus and being guided by an intersegmental vein.

From each other most often apply two ways to department of segments. At one of them — the so-called reception of two fingers offered by Overkholt and Langer (R. The N of Overholt, L. Langer) in 1947, put a lung on an index finger of the left hand so that the palmar surface of a finger was turned towards the deleted its part, and a dorsum — towards the kept segments. At the same time a thumb of the same hand press on an intersegmental surface of the deleted segment, and the right hand make traction for a peripheral stump of the crossed bronchial tube, i.e. as if break tissue of a lung on estimated border of a resection. It allows to grope a finger border between segments, and then to take clips of a branch of intersegmental veins and thin bronchial stipitates. After their isolated processing udalyaekhmy segments of a lung separate from the left its part.

In 1962 M. I. Perelman offered other way — a so-called way of effleurage, to-ry is in what the left hand for a stump of a bronchial tube is delayed by the resected segments, and right — pokolachivat a hard gauze tupfer on pulmonary fabric on border between the deleted and remaining segments.

At correctly executed S. considerable bleeding and infiltration of air from the wound surface of a lung shall not be observed. All small bleeding vessels tie up. In a pleural cavity pour warm isotonic solution of sodium chloride, inflate a lung and under a nappe find the small broken-off bronchial stipitates, to-rye it is necessary to tie up carefully. The question of sewing up of a wound surface of a lung or leaving of its open is solved individually. Mending of a wound always in - which to a measure reduces the volume of the left part of a lung lobe, worsens its aeration. At the same time insufficient tightness can be the cause of serious postoperative complications.

Due to the features of an anatomic structure of the right and left lung removal of nek-ry segments has features on the right and at the left. In a wedge, practice most, often make the following views of the Village.

Fig. 1. Diagrammatic representation of a stage of removal of an apical segment of an upper share of the right lung (sewing up of a stump of a segmental bronchus): 1 — stitching on the central stump of a bronchial tube fixed by two seams handles; 2 — the alloyed stumps of segmented arteries and a vein; 3 — a peripheral stump of a bronchial tube (it is fixed by means of a clip); the deleted segment is delayed by means of a pulmonary clip.

Removal of an apical segment of an upper share of the right lung. Process (allocate, tie up and cross) the corresponding segmented artery (an apical branch of the right pulmonary artery of T.), tie up and cross an intra segmented part of a segmented vein (an apical branch of the right pulmonary vein, T.), find a segmental bronchus, take a clip, cross and it take in a stump (fig. 1). The segment is deleted.

Fig. 2. The diagrammatic representation of a stage of removal of apical and back segments of an upper share of the right lung (department of segments with processing of intersegmental venous bonds): 1 — the taken-in central stumps of segmental bronchi (are fixed by seams handles); 2 — the alloyed intersegmental veins; 3 — peripheral stumps of segmental bronchi (are fixed by means of a clip); 4 — the alloyed stumps segmented arteries and veins; the deleted segments are delayed by means of a pulmonary clip.

Removal of apical and back segments of an upper share of the right lung. The segmented artery of an apical segment and the corresponding segmental bronchi are crossed and processed, access to a segmented artery of a back segment opens after that, to-ruyu alloy and cross. Then allocate, tie up and cross usually accurately expressed central vein of a verkhushechnony segment. The central vein of a back segment is more deeply than the dispersed stumps of the crossed back segmental bronchus. It collects also blood from a front segment of an upper share therefore it is desirable to keep its main trunk on a surface of this segment and to cross only the branches falling into it bearing blood from the deleted back segment (fig. 2). After processing of veins segments delete.

Removal of apical and back segments of an upper share of the left lung. The vascular network of an upper share of the left lung is very variable therefore each arterial and venous branch is tied up and cross at full confidence in its belonging to the deleted segments. Tie up and cross the central vein of an apical segment, a segmented artery - an apical segment (an apical branch of the left pulmonary artery, T.), segmented artery of a back segment (back branch of the left pulmonary artery; T.). This manipulation is carried out or from a back surface of a lung, or from an interlobar crack. Then allocate and process the general for apical and back segments a bronchial tube. The central vein of a back segment usually is intersegmental, in this regard it is better to tie up the venous branches falling into it during division of segments. After removal of segments the wound surface is not taken in.

Fig. 3. Diagrammatic representation of a stage of removal of lingular segments of an upper share of the left lung (closure of a bronchial stump of lingular segments): 1 — the central stump of a bronchial tube fixed by means of a clip and a seam handle; 2 — the alloyed stumps of the central vein of lingular segments (a lingular branch of an upper pulmonary vein); the deleted segments are delayed by means of a pulmonary clip.

Removal top and bottom lingular segments of an upper share of the left lung (resection of lingular segments). The resected segments delay lateralno and process their central vein — a lingular branch of an upper pulmonary vein. Immediately under a vein find a bronchial tube of lingular segments, to-ry cross and take in his stump (fig. 3). After processing of a bronchial tube access to the general lingular artery comes off, to-ruyu alloy and cross. Sipping for a peripheral stump of a bronchial tube, lingular segments delete.

Removal of an apical (upper) segment of the lower share. Processing of segmented arteries and bronchial tube is made from an interlobar crack or from the dorsal surface of a lung. Sipping for peripheral stumps of a bronchial tube and vessels, the segment is deleted, the wound surface of basal segments is not taken in.

Removal of basal segments. After crossing of a pulmonary sheaf open an interlobar crack and at its bottom, at border of dorsal and average thirds, find, tie up and cross an artery of basal segments (a basal part of a pulmonary artery, T.). Delay lateralno the lower share and process a vein of basal segments. From an interlobar crack allocate, cross and take in a bronchial tube of basal segments. Sipping for peripheral stumps of a bronchial tube and vessels, basal segments delete, trying to remove from them a rag of a visceral pleura. This rag it is possible to lay ra a wound surface of an apical (upper) segment and to fix to its edges noose sutures. In cases of very mobile apical (upper) segment it is reasonable to fix it to a back segment of an upper share.

After all S. the pleural cavity is drained, as a rule, two drainages.

Postoperative period and the next complications after operation essentially do not differ from those after a lobectomy (see). The patient allow to sit down in 8 — 10 hours after operation and to get up on 2 — the 3rd day. In 2 weeks after operation at a favorable current of the patient it can be written out from a hospital. Rentgenol. changes after S. are minimum, and in several weeks after operation on roentgenograms it is difficult to find aberrations.

See also Lungs, postoperative period .

The forecast

the Short-term and long-term results of S. depend on character of a basic disease. At a pulmonary tuberculosis recovery occurs more than at 90% of patients, at bronchiectasias good results are noted in 70 — 75% of cases.



Bibliography: The atlas of chest surgery, under the editorship of B. V. Petrovsky, t. 1, page 105, M., 1971; Bogush JI. K. A segmented pneumonectomy at tuberculosis, Probl. ‘tube., No. 3, page 16, 1956; To l and m and nanosecond to and y V. A. Surgical pathology of lungs at children, page 38, M., 1975; The Guide to pulmonary surgery, under the editorship of I. S. Kolesnikov, page 412, L., 1969; Bier A., Braun H. and. Kiimmell H. Chirur-gische Operationslehre, Bd 3, T. 1,S. 351, L p z., 1971; Overholt B. H. a. Langer L. A new technique for pulmonary segmental resection, Surg. Gvnec. Obstet., v. 84, p. 257, 1947.


M. I. Perelman.

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