THORACOPLASTY (Greek thorax, thorakos a breast, a thorax + plastike sculpture, plastics) — the surgery consisting in a resection of edges and made for the purpose of reduction of volume of a chest cavity.
Development of T. it is closely connected with attempts of operational treatment of a pulmonary tuberculosis (see Tuberculosis of a respiratory organs). The idea of a resection of edges for to lay down. impacts on a tubercular cavity arose at the end of
19 century. It was based on the fact of treatment or a zatikhaniye of tubercular process in the easy ambassador of reduction of volume of the corresponding half of a chest cavity. First T. H. I. Quincke in 1886 is executed. In 1890 She (M. Schede) for treatment hron. suggested to delete empyemas of a pleura over a residual cavity of an edge together with a periosteum, intercostal muscles, a reinforced pleura. Spengler (S. of Spengler) entered the term «thoracoplasty». Further improvement of methods T. it is closely connected using artificial pheumothorax (see Pheumothorax artificial) as method of a collapsotherapy (see) pulmonary tuberculosis. In 1907 Brouwer (L. Vgaiyeg) offered extensive removal of a costal framework in cases when imposing of artificial pheumothorax was impossible because of pleural unions. The first such operation in 1909 was executed by P. Friedrich. However the thoracoplasty according to Brouwer — to Friedrich was not widely adopted owing to injury and weight for the weakened TB patients and a high postoperative lethality.
In further development of T. researches Gourde were important (J. Gourdet, 1895), to-ry showed that reduction of volume of a chest cavity depends first of all on a resection juxtaspinal (back, or paravertebral) pieces of edges.
In 1911 — 1912 F. Zauerbrukh developed a new technique of T., at a cut only juxtaspinal pieces of edges were removed. The resection of edges was carried out podnadkostnnchno that provided their regeneration in a new position and the subsequent stability of a chest wall, and for the purpose of reduction of the size of a chest cavity in the vertical direction surely deleted the first edge. T. Zauerbrukh considered necessary a resection of ten — eleven edges even at rather limited defeats as believed that only the extensive resection of edges creates rest for a lung and the possibility of aspiration of a phlegm in his lower parts warns. However further studying of outcomes of T. showed that at limited processes good results can be received also at more economical, selection (partial) operations. At the same time it is necessary to resect all edges above and one — two edges are lower than the level of the bottom edge of a cavity defined rather back pieces of edges on the roentgenogram of lungs in a direct projection. In need of extensive T., especially at the weakened patients, it is reasonable to divide a resection of edges into two or three stages. Intervals between stages shall not exceed 2 — 3 weeks in order to avoid regeneration of edges from the left periosteum. At such sparing technique efficiency of operation in general does not decrease, patients transfer it easier.
More than 20 ways and modifications of T are described. Modern types of the selection T. are highly effective operative measures, at to-rykh rough deformations of a thorax and disturbances of a bearing are not observed. Therefore old ideas of T. as about the crippling and spoiling operation can be related only to very seldom made now (hl. obr., at heavy tubercular empyemas of a pleura at patients after pneumonectomies) total T. or gemitoraksektomiya (unilateral resection of all edges).
In development of the selection T. the big contribution was made by the Soviet surgeons N. V. Antelava, L. K. Bogusha B. M. Garmsen, A. G. Gilman, Yu. Yu. Dzhanelidze, K. D. Yesipova I. S. Kolesnikov, N. G. Stoyko, etc.
From the middle of the 20th to the middle of the 50th of 20 century. T. was the main method of operational treatment of destructive forms of a pulmonary tuberculosis. Then it began to lose quickly the value thanks to achievements of chemotherapy (see) and to implementation in practice of direct surgeries on a lung. However and to a crust, time has a certain contingent of TB patients and other diseases of lungs, for treatment to-rykh
T. V is shown to the USSR apply the selection T. following types: extrapleural verkhnezadny T., intrapleural upper T., ladder
T., expanded and stage T., the selection T. with a myoplasty.
Indications. The main indications to T. destructive forms of a pulmonary tuberculosis and an empyema of a pleura (see Pleurisy) various genesis are. T. can be the main method of surgical treatment or additional, corrective operation. As the main method of surgical treatment of a pulmonary tuberculosis of T. it is shown at fibrous and cavernous tuberculosis with a cavity in an upper lung lobe and the centers in other shares, and also in case of preservation of a cavity after its drainage (see) or cavernotomies (see). It is reasonable to make operation in a phase of stabilization of process, but in cases of pulmonary bleeding, a plentiful pneumorrhagia and the expressed persistent intoxication of T. it can be made also in a phase of an aggravation according to urgent and emergency indications. The indication to T. there can be a tubercular or nonspecific empyema of a pleura both with bronchial fistulas, and without them. As additional, corrective operation T. apply for the purpose of reduction of volume of a pleural cavity or to elimination of various bronchopleural and pulmonary complications after a pneumonectomy, a pneumonectomy (see) and other operative measures on bodies of a chest cavity.
Contraindications to T. at
a pulmonary tuberculosis multiple cavities in different lung lobes, stenoses of large bronchial tubes, a pulmonary heart are (see. A pulmonary heart), and at an empyema of a pleura fistula of the primary or lobar bronchus, a so-called trellised lung (see. Bronchial fistula).
Preoperative preparation for T. suffering from tuberculosis lungs consists in complex treatment for the purpose of elimination of an aggravation of process, removal of tubercular intoxication, reduction of quantity of a phlegm, improvement of respiratory function. The main component of preoperative treatment is the combined specific antibacterial therapy. With an empyema of a pleura it is important to achieve the maximum sanitation of a cavity by means of pleurocenteses or aspiration from patients (see. Aspiration drainage. Pleura, Pleurocentesis). Duration of preoperative preparation — of 1 — 2 week to several months.
Anesthesia. Operation is made under an endotracheal anesthesia (see. Inhalation anesthesia). In the presence of bronchial fistulas the intubation of a bronchial tube of the opposite side or a separate intubation of bronchial tubes is shown (see the Intubation).
Technology of operation. T. make ekstraplevralno or nntraplev-ralno. At extrapleural T. the resection of edges is made without opening a pleural cavity, and at intrapleural — the pleural cavity is opened to, in time or after a resection of edges. Ekstraplevra lny T. apply generally to treatment of destructive forms of a pulmonary tuberculosis, and intrapleural — to reduction of volume of a chest cavity after a resection of lungs, to treatment of empyemas and bronchial fistulas. T. it can be executed consistently on both sides.
The extrapleural verkhnezadny thoracoplasty is shown at fibrous and cavernous tuberculosis, a residual cavity of a cavity after drainage or a cavernotomy, a residual apical pleural cavity after a pneumonectomy.
The section of skin and hypodermic cellulose begin at the level of I chest vertebra and conduct caudally, bending around a shovel, to the back axillary line at the level of VII edge. Podnad-kostnpchno is allocated and resected lower of the edges which are subject to removal — VII, VI or V. Further exempt from a periosteum and resect overlying edges from cross shoots of vertebrae to the average or front axillary line. The I edge is resected the last.
At patients with a cavity in an apical segment of a pla with a residual juxtaspinal cavity it is better also. to remove (to exarticulate) necks and heads of edges (except the first). Bleeding from a bed of the deleted edges is stopped diathermocoagulation (see) and a tamponade (see).
At T. with a resection of pieces of seven edges the shovel with the muscles fixed to it sinks down in the formed defect of a costal framework and strengthens fall of a lung. At the same time after a resection of five or six edges the bottom corner of a shovel can remain over the lower edge and at the movements to touch upper of the remained edges, causing pain and breaking mobility of a shoulder. In this regard it is reasonable to resect a podostny part of a shovel, previously otsloiv from it a periosteum with the attached muscles. L. K. Bogush (1936) suggested to finish operation with a pneumolysia (see) tops of a lung for the purpose of strengthening of a collapse of an upper share.
After a resection of edges along all wound stack a drainage tube with several side openings, over a cut layer-by-layer sew soft tissues. Apply a compressing bandage with wadded and gauze; or porolonovy rollers in subclavial and axillary areas. A hand on the party of operation bend in an elbow joint iod a right angle and for 3 — 4 days fix to a trunk. Then gradually begin exercises for a shoulder joint of the operated party. In
2 — 3 weeks after operation apply a compressing bandage on 1V2 — 2 month for the best retraction and modeling of a chest wall in the resected edges.
The intrapleural upper (corrective) thoracoplasty is developed in 1954 by L. K. Bogush. It is shown at an insufficient raspravleniye of the remained departments of a lung after a resection of an upper lung lobe or its segments.
T. make after the end of operation on a lung. The resection of edges is made from a pleural cavity without additional section. In the beginning podnadkostnichno resect the I edge. Then podnadkostnichno resect the II edge from the level of a cross shoot of the II chest vertebra to the front axillary line. If necessary III and IV edges resect also pieces. As a result the mobile site of a chest wall caves in in inside and fills a residual cavity. The pleural cavity is drained, soft tissues take in layer-by-layer.
The ladder thoracoplasty is offered by Geller (N. to Heller, 1922) and B. E. Linberg (1945). Operation is shown at hron. to an empyema of a pleura without bronchial fistulas or with fistulas of small bronchial tubes in cases when there are contraindications to a pleurectomy (see) and decortications of a lung (see).
The section of soft tissues of a chest wall is begun according to the upper edge of a residual pleural cavity and conducted between a backbone and medial edge of a shovel with continuation in the ventral direction, at the same time excise fistula. Podnadkostnichno is resected adjoining fistula one — two edges. Longwise cut a deep part of a periosteum of the resected edge with the subject reinforced fabrics of a chest wall, getting into a cavity of an empyema. Consistently resect all edges over a residual cavity, opening it through a bed of each remote edge therefore the intercostal spaces separated from each other by cuts form a number of crossbeams, and the chest wall over a residual cavity takes a form of a ladder. Over the upper bound of a cavity resect one more edge without section of a deep part of a periosteum. From an inner surface of crossbeams excise thick pleural shvarta to an exposure of muscles, then stack «crossbeams» on a bottom of a residual cavity as plastic material. One drainage tube with several side openings is stacked on the surface of a lung, the second — on crossbeams, the wound of soft tissues is taken in. Ladder T. often combine with a myoplasty of a residual cavity (see below).
The expanded stage thoracoplasty, silt and
stage t about r and to about t about m and I, is developed by JI. K. Bogush (1947, 1979). Operation is made at a tubercular empyema of a pleura when there are contraindications to other types of operations.
First stage of expanded T. the wide thoracotomy (see), the second — extrapleural verkhnezadny T is. (see above), the third — a myoplasty of a residual cavity. Make the arc-shaped section from the outer edge of long muscles of a back on an edge, the corresponding bottom edge of a cavity, to the average axillary line. Podnadkostnichno is resected by pieces of three — four edges 15 — 18 cm long. After broad opening of a pleural cavity excise a reinforced parietal pleura, mobilizing intercostal muscular rags, make a careful toilet of a cavity of an empyema. Intercostal muscular rags stack in a costal and phrenic sine. In the postoperative period carry out open treatment, in process to-rogo a wall of a pleural cavity are cleared of the caseous masses, fibrinopurulent imposings and become covered with granulyatsionny fabric. In
2 — 4 weeks after a thoracotomy produce extrapleural verkhnezadny T. with removal of the remained pieces of upper edges and flaking of a dome of a pleura from a chest wall and a side surface of a backbone. Still through 1V2 — 2 month if the residual pleural cavity remains, delete the regenerating edges and close a cavity muscular rags on a leg, to-rye create of the broadest muscle of a back, a big pectoral muscle, intercostal muscles.
The selection thoracoplasty with muscular and l and with t and to about y is shown at limited hron. to an empyema of a pleural cavity without bronchial fistulas or at their existence.
Operation usually is atypical, its course depends on existence or lack of defect of a chest wall or plevrotorakalny fistula. It consists in rather wide subperiostal resection of edges over a cavity of an empyema, sewing up of bronchial fistula, cutting out of well vaskulya-rizirovanny rags from a big pectoral or broadest muscle of a back. The residual cavity is filled with muscular rags, to-rye reliably fixed seams; then enter a drainage tube and take in soft tissues.
Complications during T. at its correct and careful performance are observed seldom. The majority of complications is connected with an injury of fabrics and bodies, adjacent to edges: opening of a free pleural cavity at extrapleural T., injury of a lung, perforation of a cavity, damage of subclavial vessels, a brachial plexus during removal of the first edge.
Possible postoperative complications are disturbance of tracheobronchial passability, an atelectasis (see), pneumonia (see), a pulmonary heart (see. Pulmonary heart). Early activation of patients, respiratory gymnastics, bronkhofibroskopiya are necessary for prevention of postoperative complications (see B a ronkhoskopiya, a bronkhofibroskopiya, t. 15, additional materials) or catheterization of bronchial tubes with a toilet of a bronchial tree (see Bronchial tubes, surgical treatment). At the patients operated concerning an empyema of a pleura, the postoperative current can be complicated by infection of a wound with a delay of pus and development of a septic state. Prevention and treatment of this complication consist in full aspiration drainage and the directed use of antibiotics of a broad spectrum of activity.
A X-ray pattern after a thoracoplasty. On survey roentgenograms and tomograms after extrapleural T. reduction of volume of the operated half of a thorax and falling off of the corresponding lung is defined. Extent of reduction of volume of a thorax and lung on the operated party depends on a look and volume T. Rentgenol. changes in lungs are observed during the developing of the pneumonia sometimes complicating a postoperative current. In the first days after operation there can be massive atelectases which in turn are complicated by pneumonia. After extensive T. the flotirovaniye (pendulum shift, synchronous with breath) mediastinums in the field of defect of a chest wall disappearing in process of an osteanagenesis from the remained periosteum of edges can be observed.
In the remote terms after operation the fallen-down lung partially finishes and its ventilation improves due to increase in amplitude of respiratory movements of a diaphragm and edges on the party of an operative measure that clearly is defined on a rentgenokimogramma (see Rentgenokimografiya). In some cases the raspravleniye of a lung in the remote terms does not occur owing to development in it after operation of a pneumosclerosis (see), and sometimes in the subsequent — broikhoekta-call (see).
The T defined later. shadows of the regenerating edges, especially against the background of massive pleural shvart, complicate recognition of residual cavities and slit-like residual cavities of empyemas in case of inefficient operation. The tomography (see) facilitates diagnosis of cavities in the fallen-down lung, and a fistulogra-fiya (see) and a bronchography (see) — identification of residual cavities.
Forecast. A postoperative lethality among the patients who transferred T. concerning a destructive pulmonary tuberculosis, less than 1%. The full wedge, effect with permanent disappearance of mycobacteria of tuberculosis from a phlegm and closing of a cavity is noted at 75 — 85% of the operated patients. After T. concerning an empyema of a pleura the lethality makes 5 — 8%, closing of a cavity is reached at 70 — 75% of patients.
Bibliography: Antelava N. V. Surgery of bodies of a chest cavity, page 46, M., 1952; The Atlas of chest surgery, under the editorship of B. V. Petrovsky, t. 1, page 82, M., 1971; Bogush L. K. and To and l and N and h e in G. A. Corrective operations at a resection of lungs, Tbilisi, 1979; R about t e M.'s N-feld 3. Radiological observations over the mechanism of lung ventilation at an expanded upper back thoracoplasty, Surgery, No. 8, page 68, 1950; The Guide to pulmonary surgery, under the editorship of. And. S. Kolesnikova, page 308, JI., 1969; N. G Is firm. Surgical treatment of pulmonary tuberculosis, M., 1949; Surgical treatment of a pulmonary tuberculosis, under the editorship of D. K. Bogush, page 72, M., 1979; Bier A., Braun H. and. To y sh-m e 1 1 H. Chirurgische Operationslehre, Bd 3/1, S. 402, Lpz., 1971; Di Rien-z about S. Rontgenologie der operierten Lunge, Fortschr. Rontgenstr., Bd 78, S. 400, 1953.
M. I. Perelman, E. JI. Kevesh (rents.).