Muscle flap and omentum tamponade

By transferring the vascular pedicled chest wall muscle flap and/or the greater omentum into the thoracic cavity, filling the infected pleural space, treating empyema with or without bronchopleural fistula, not only reduces the patient's thoracic surgery Postoperative deformity, and surgery can be completed in one stage. Muscle flap and omental tamponade can be used alone to treat chronic empyema, or in combination with thoracoplasty and pleural stripping. Often used to fill the abscesses are the latissimus dorsi, anterior serratus, pectoralis major, omentum and rectus abdominis. After normal pneumonectomy, the whole thoracic cavity is filled with the chest wall muscle. The size of each muscle flap is measured according to the operation and cadaveric material. The latissimus dorsi muscle can fully fill 30%-40% of the unilateral thoracic cavity and 10% of the anterior serratus muscle. ~ 15%, pectoralis major muscle 20% ~ 30%, chest small muscle 0 ~ 2%, greater omentum 5% ~ 15% and rectus abdominis 5% ~ 15%. The blood supply to the latissimus dorsi muscle is mainly from the thoracodorsal artery. The pectoralis major muscle is from the intercostal artery branch of the thoracic and aortic arteries and the internal mammary artery. The rectus abdominis is supplied by the superior abdominal wall artery. The muscles used to fill the abscess must protect the vascular pedicle. The omentum can be used to cover the bronchial stump with bronchopleural fistula. At 48 hours after surgery, neovascularization occurred in the omentum covering the bronchial stump, and it was easy to block the bronchial pleural effusion with the omentum. The omentum can enter the chest through a subcutaneous tunnel or through the ventral foramen of the diaphragm. Special attention should be paid to the prevention of complications such as abdominal infection, gastric torsion, gastric perforation, sputum and omental vascular pedicle due to compression and distortion caused by necrosis. The omentum is generally not used unless there is an intractable bronchopleural fistula or a residual cavity that is difficult to fill with the chest wall muscle alone. Treatment of diseases: chronic empyema Indication Muscle flap and omental tamponade are suitable for: Similar to the surgical indications for thoracoplasty, it is more suitable for the treatment of chronic empyema after bronchial pleural effusion and pneumonectomy. For the treatment of postoperative empyema, benign disease takes 3 months after surgery, and malignant disease takes 6 to 12 months after surgery, which proves that there is no metastasis in the whole body, and there is no recurrence before surgery. Preoperative preparation 1. Strengthen nutrition and correct anemia and hypoproteinemia. 2, has been chest drainage of chronic empyema, if the patient still has fever, loss of appetite and other symptoms of poisoning, should improve drainage or do fenestration, until the symptoms are controlled and then surgery. 3, preoperative examination of heart and lung function, do pus culture and drug sensitivity, for tuberculous empyema patients with infection, preoperative use of effective anti-tuberculosis drugs and broad-spectrum antibiotics, anti-tuberculosis treatment takes 2 to 4 weeks, so that The erythrocyte sedimentation rate is close to normal. 4, according to the results of abscess angiography, CT scan and MRI examination, determine the size and location of the abscess, carefully design the muscle flap required to fill the abscess. Surgical procedure 1. Patients with empyema after surgery can be inserted into the chest by the original incision. After the chest is removed, the unhealthy granulation tissue is removed, and then wetted with warm saline to coagulate and stop bleeding. 2. Fill the abscess with the anterior serratus and latissimus dorsi. If the left lower lobe is resected and the empyema is accompanied by bronchopleural fistula, the stump of the bronchiectal fistula should be carefully separated and re-trimmed to present a fresh wound, then re-sewed and covered with a pedicled intercostal muscle flap before use. The serratus and latissimus dorsi fill the abscess. 3, showing the right upper lobe resection after bronchial pleural fistula and empyema. From the front of the armpit to the chest, under the premise of retaining the blood supply of the pectoralis major, fully dissect the pectoralis major muscle, and disconnect the pectoralis major muscle from the starting point of the pectoralis major muscle, remove the first rib and the second rib length 7cm, the chest The large muscles are all transferred into the thoracic cavity, closing the leak in the right upper lobe bronchus stump and filling the abscess in the upper right chest. Before filling the abscess with the pectoralis major, it is essential that the abscess completely debride and trim the bronchial stump. 4, after the right upper lobe resection, bronchial pleural effusion, but also the posterior lateral incision, fully dissecting the anterior serratus and latissimus dorsi. Because the blood supply to the anterior and latissimus dorsi muscles comes from the thoracodorsal artery, the latissimus dorsi muscle is often cut by the posterolateral incision due to thoracotomy, thus affecting the use of the latissimus dorsi, but affecting the anterior serratus. Smaller. In order to prevent the compression and distortion of the vascular pedicle of the muscle flap, the 7 cm section of the second rib was removed as the entrance of the muscle flap into the chest. 5, the abscess is completely debrided, after the bronchial stump is trimmed and sutured, the anterior serratus flap transferred into the chest is closed to cover the bronchial stump, and the latissimus dorsi can also be filled into the chest at the same time. 6, when the need for large omentum into the chest filling the abscess and closing the bronchial stump, should replace the surgical gown and gloves, re-sterilize the abdominal skin, and then open the abdomen to dissect the free omentum. It can also be done by two groups of surgeons. The greater omentum was shown to be inserted into the thoracic ventral approach from the left iliac crest; the bronchial stump was covered and the omentum was fixed to the bronchial stump with a 3-0 nylon thread. 7. Show the position of the entrance and filling of the empyema, pectoralis major, latissimus dorsi, anterior serratus and rectus abdominis into the chest after total pneumonectomy. 8. The abscess of the localized abscess is small. After removing the ribs outside the abscess and thickening the pleural membrane, the granulation tissue is scraped off. After thorough debridement, the anterior serratus and latissimus dorsi near the abscess are used. The muscles such as the sacral spine are filled and then pressure bandaged.

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