right pneumonectomy

Pneumonectomy is an effective treatment for certain intrapulmonary or bronchial diseases. Depending on the nature, extent of the lesion and the patient's lung function, all lungs on one side (ie, pneumonectomy) can be removed, or partial lung resection (including lobectomy, segmentectomy, or wedge resection) can be performed. The lobes of the lungs, or the lungs plus the lungs (or wedges), sometimes can be cut off at the same time (or stage) for both lobes or segments of the lungs. For some patients, the mediastinal lymph nodes, pleural wall layer or part of the diaphragm are often removed while the lung or whole lung is being removed. In principle, the scope of lung resection should be sufficient, so that the lesions in the lungs are completely removed, and no recurrence can be left, but should be cut as little as possible to save as much normal lung tissue as possible to maintain better lung function. Treatment of diseases: tuberculosis of lung cancer Indication 1. Pulmonary laceration: severe lung laceration, can not be repaired, should be used for local lobectomy or pneumonectomy. 2. Bronchopulmonary tumors: The opinions on the scope of resection of malignant tumors have not been consistent. Most people believe that as long as there is no distant metastasis, the lymph nodes of one or two lobe and hilar, paratracheal and subcarinal lobe where the tumor is located are removed. The same effect as pneumonectomy can be obtained, but the surgical damage and complications can be reduced, and the postoperative lung function can be preserved more. For metastatic cancer that is confined to one leaf, or if the nature of the tumor is undetermined and cannot be ruled out as a benign tumor or tuberculoma, lobectomy should be performed. In summary, when considering the scope of resection, the type, location, metastasis, respiration, circulatory function, and patient's tolerance to surgery should be fully estimated. Such as lung cancer patients have cachexia, severe chest pain, fever, x-ray examination showed that the protuberance has been widened, the cancer shadow and the chest wall or mediastinum have been connected, no gap, or see pleural effusion, bronchoscopy see protuberance Widening, fixation, tumor less than 2cm from the protrusion, lactate dehydrogenase determination is higher than 400 units, etc., the possibility of surgical resection will be small, or can not be removed. If lung cancer has distant metastasis, or has invaded the phrenic nerve, recurrent laryngeal nerve and mediastinal vessels, contraindications are contraindicated. 3. Tuberculosis: Surgical treatment of tuberculosis is an integral part of the comprehensive treatment of tuberculosis and is only suitable for some patients with tuberculosis. Appropriate timing should be chosen and must be closely coordinated with other therapies to reduce treatment time, expand treatment coverage, and reduce recurrence rates. When selecting a treatment, the patient's general condition, type of disease, progression of the disease, and response to previous treatments must be fully considered and carefully determined based on the positive and lateral radiographs of the x-ray within the last 3 weeks. Under normal circumstances, patients with tuberculosis should first undergo a certain period of drug treatment, such as the lesion can not be cured, but suitable for surgery, that is, surgery should be timely, do not wait until all anti-tuberculosis drugs are ineffective after trial, so as not to miss the opportunity. In addition, when considering the surgical method, it is necessary to estimate the surgical effect, the burden of the patient, the degree of loss of lung function, and the possibility of recurrence of the residual lung lesion, and the safest, simplest, and effective surgery. At present, the risk and complications of pneumonectomy have been greatly reduced, but those who are not suitable for pneumonectomy should not be forced to use it. (1) Tuberculosis ball: The diameter is more than 2cm, and the drug treatment does not disappear after more than 6 months. Even if the center finds liquefied cavity or has an expanding trend, it should be removed. If the nature of the spherical lesion is not certain, it should not be waited for, and the surgery should be performed immediately. (2) Cheese lesions: cheese lesions or a pile of cheese lesions greater than 2cm, drug treatment for 6 months to more than 1 year is invalid, continue to sterilize, surgery should be considered. (3) Cavity: due to bronchial tuberculosis caused by granulation hyperplasia or scarring caused by stenosis of the lumen, the formation of tension holes in the distal cavity, or due to the long time of the lesion, the fibrous tissue around the cavity proliferate, forming thick-walled cavities, should be removed. Generally, the cavity is still not closed after the drug is actively treated for 6 months to 1 year. Regardless of whether or not the sputum is sterilized, surgery should be considered to avoid hemoptysis and dissemination in the future. (4) bronchial tuberculosis: active treatment of drugs for 6 months to more than 1 year of ineffective, even due to stenosis (or complete obstruction) caused by atelectasis; or due to extensive wall destruction, the formation of bronchiectasis, should be removed. (5) Destroy the lung: All or most of the lungs of one or one lobe are destroyed, forming cheese lesions, cavities, lung atrophy, fibrosis, bronchiectasis, emphysema, etc., should be considered for resection. If there are lesions such as cheese lesions, tuberculoma or cavities on the contralateral side, surgical problems should be carefully studied. (6) After the surgical collapse therapy, the cavity is still not closed in June to 1 year, and the acid-fast bacteria positive or intermittent positive is detected. When the patient's general health condition permits, the lung resection can be performed again. 4. Bronchiectasis: Bronchial angiography confirms the limitation of the lesion. If there are obvious symptoms, the diseased lung segment, lung lobe or whole lung should be surgically removed. If the symptoms are not obvious, surgery is not necessary. For example, bilateral bronchus has localized lesions, and the scope is small, and can be resected in stages. The heavier side of the lesion is cut first. If there are still symptoms after operation, the contralateral side is confirmed by angiography again, and then the second operation is performed. . The scope is too broad, and those who have no chance of surgery can only use body position drainage and Chinese and Western medicine treatment. 5. Lung abscess: After active medical treatment for more than 3 months, clinical symptoms and x-ray films are not improved, should be used for lobectomy or pneumonectomy. Because the range of inflammation is often extensive, it is not appropriate to consider the removal of the lung segment to avoid residual lung disease. For some extremely weak patients, the symptoms of poisoning are serious, can not tolerate lung surgery and the lesions are located in the superficial part of the lungs, and can be used for incision and drainage. 6. Others: Congenital pulmonary cysts, pulmonary bullae or pulmonary isolation, if symptoms appear, should be used for lung, lung or partial resection. All types of patients above should be tested for lung function before deciding on a pneumonectomy. If preoperative lung capacity and maximum ventilation account for more than 60% of the predicted value, lung surgery is safer; those below 60% should be treated with caution. In addition, if the patient has chronic heart and renal insufficiency, it will be difficult to tolerate surgery. Preoperative preparation 1. It is necessary to have a positive and lateral x-ray of the chest within 3 weeks before surgery in order to determine the location, extent and nature of the lesion. If the patient is a malignant tumor, there should be a chest radiograph within 2 weeks. In addition, chest fluoroscopy should be performed to observe the diaphragmatic activity to estimate whether there is sacral nerve involvement and pleural adhesion. 2. Pneumonectomy has a certain effect on respiratory function; especially after thoracoplasty after resection, the effect will be more serious. The more the range of resection, the greater the impact. Therefore, patients with lung resection should be asked in detail about the history of respiratory diseases, check respiratory function, and perform sub-pulmonary function tests if necessary to correctly estimate postoperative respiratory function. Surgical procedure 1. After complete separation of pleural adhesions, the mediastinal pleura of the anterior, posterior and superior margins of the lungs are all cut open, and the lungs are pulled downwards. The plexus of the vagus nerve to the hilum can be seen above the hilum and accompanying Small blood vessels should be completely cut and ligated. The mediastinal connective tissue under the confluence of the azygous vein and the superior vena cava is separated, and the right pulmonary artery trunk and the anterior segment of the superior apical artery can be exposed. The front of the lower right pulmonary artery is covered by the right superior pulmonary vein. 2. The upper pulmonary vein is exposed on the posterior side of the sacral nerve and separated in the sheath of the trunk. If the trunk is short and the separation length is not enough, the branch trunks of the upper and lower lobes, the anterior and posterior segments, and the branches of the inner and outer segments of the middle lobe can be separated on the far side. Care should be taken when separating the posterior wall to avoid breaking the vein or the lower right pulmonary artery immediately behind it. After the main pulmonary vein is ligated and sutured, it is cut off; or the main trunk is ligated and sutured, and cut at the distal end of the upper and middle branches. 3. The right pulmonary artery has a short trunk. The anterior superior apical artery and the right pulmonary artery trunk (including the lower trunk) should be separated, ligated and sutured, and the pulmonary artery has a long stump. The ligature is not easy to slip off. . 4. Pull the lungs upwards, hold the lower ligaments of the lungs with two hemostats, and ligature them after cutting them. Find the lower pulmonary vein near the hilar lymph node. This vein is the thickest and shortest of the three movements and veins in the right lung. Special care should be taken during treatment to prevent breakage. If the pulmonary veins are exposed under the influence of lymph nodes, they can be removed first. The lower pulmonary vein is separated and ligated, sewed and cut. If the stump is too short, it can be added as a continuous suture to avoid large bleeding caused by slippage. 5. The right common bronchus behind the remaining artery is connected to the diseased lung. The surrounding tissues of the bronchi can be separated by gauze ball and curved hemostat. If there is lymph node separation, it can be removed first. The bronchial artery was sutured separately. The bronchial forceps were placed at the distal end of the bronchus and the diseased lung was pulled outward The upper and lower edges of the bronchus adjacent to the protuberance are made of a thin suture through a thin suture, and the auxiliary bronchus is cut by the assistant to remove the diseased lung. When cutting the total bronchus, the proximal bronchus should be cut, sewed, and tightened. After the diseased lungs are removed, they are ligated separately, or two bronchial forceps are clamped first. The bronchus is cut between the tongs, and the lungs are removed and then trimmed. Bronchial stump. 6. After checking for no air leaks or bleeding, the bronchus and the stumps of each blood vessel are covered with a mediastinal pleura. complication 1, bronchopleural fistula The incidence of tuberculosis patients is clearly higher than that of non-tuberculosis patients. The reasons are: 1 endometrial tuberculosis in the bronchial stump, resulting in poor healing. 2 stump infection or pleural cavity infection erodes the bronchial stump, causing inflammatory edema or suture loss leading to stump cracking. 3 improper treatment of the bronchial stump, such as excessive tissue stripping around the stump to cause damage to the blood supply, or the stump suture is not properly covered with viable pedicle soft tissue to promote healing, or the stump is too long, causing secretions to store infection, Or the postoperative residual cavity was not properly treated, or the bronchial stump was closed poorly, resulting in repeated stumps. If there is air in the pleural cavity, it will continue to exist after 10-14 days of drainage, plus the patient has fever, irritating cough, the operation side is intensified in the upper lying position, cough and bleeding sputum, suspected and complicated bronchus Pleural rash. After injecting 1-v2 ml of methylene blue solution into the pleural cavity, the patient can be diagnosed if the patient coughs up the blue sputum. The treatment of sputum depends on the time of sputum after surgery. In the early stage, the mouth can be re-surgically repaired, the stump is dissected freely, the epithelium on the bronchial mouth is removed, the fresh stump is sutured, and then properly embedded in the nearby tissue. Later, it is advisable to place closed drainage to empty the infected pleural fluid. If the drainage is still closed for 4^-6 weeks, it should be treated according to chronic empyema. 2, intractable gas-containing cavity Most of them do not produce symptoms. This cavity can be kept sterile, can be closely observed and treated with drugs, and gradually disappears after several months. A small number of signs of difficulty breathing, fever, hemoptysis or persistent alveolar leakage require repeated treatment according to the bronchus. 3, empyema The residual cavity left after tuberculosis lung resection is easy to cause empyema, and its incidence is much higher than that of non-tuberculosis patients. The principle of diagnosis and treatment can be found in empyema. 4, tuberculosis spread If you can use effective anti-tuberculosis drugs for preoperative preparation before surgery, strictly control the surgical indications and timing of surgery, especially those with negative sputum, this complication is rare. On the contrary, the number of sputum positive sputum is too high, active tuberculosis can not be effectively controlled, plus anesthesia techniques, poor postoperative sputum sputum and concurrent bronchus and other factors can lead to tuberculosis spread. The above complications often affect each other and occur less frequently. Therefore, attention should be paid to the overall treatment of tuberculosis in order to obtain better curative effect.

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