segmentectomy

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; partial lung resection (including lobectomy, segmentectomy, or wedge resection) can also be performed; The lung lobes, or the lungs plus the lung segment (or wedge). Treating diseases: multiple lung infections 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 and fixation, the tumor is less than 2cm from the bulge; the lactate dehydrogenase is more than 400 units, and the possibility of surgical resection is 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, the distal cavity forms a tension cavity; or because of the long time of the lesion, the fibrous tissue around the cavity proliferates, 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. Such as bilateral bronchus have localized lesions, and the scope is small, can be resected, first cut the heavier side of the lesion; if there are still symptoms after surgery, confirmed by contrast from the contralateral side, and then the second surgery . 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. Contraindications 1, with systemic diseases, can not tolerate surgery. 2, local infection, not suitable for surgery. Preoperative preparation 1. There must be 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. 3. Tuberculosis patients, especially those with irritating cough and sputum acid-fast bacteria, should be examined by bronchoscopy to determine whether the mucosa of the bronchial stump to be resected is normal, so as to avoid bronchial tuberculosis due to residual endobronchial tuberculosis. Serious complications such as pleural fistula and empyema. 4. For patients with pulmonary suppuration (including bronchiectasis), positional drainage should be strengthened, and appropriate antibiotics should be used according to the results of sputum culture and antibiotic susceptibility test, and the daily sputum should be reduced to a minimum (preferably at 50 ml). the following). The morning of the operation should be drained again to avoid sputum occlusion, suffocation, or secondary infection of the contralateral lung. Bronchoscopy and suction can be performed weekly if necessary. The effect of positional drainage depends on whether the draining bronchus is unobstructed, whether the patient's position is correct, and whether the time and number of fluid guiding positions are sufficient. In addition, it can also be combined with tinctures and bronchial expectorants. The position of drainage in different lung segments is shown in Table 1 (1 hour each time, 2 to 3 times a day): 5. In addition to the corresponding antibiotics in patients with suppurative disease before surgery, generally before the elective pneumonectomy, 1 day of injection of streptomycin and streptomycin should be given; tuberculosis patients should be injected with streptomycin and oral isoniazid before surgery. 1 to 2 weeks, penicillin was added 1 day before surgery. 6. Postoperative sputum and deep breathing can prevent complications and promote the expansion of the remaining lungs. If the posterior lateral incision is scheduled, emphasis should be placed on the early exercise of the upper arm in the early postoperative period to avoid adhesion of the scar near the incision and affect the arm activity. Surgical procedure Each segment of the lung has an independent set of bronchial tubes, arteries, and intersegmental veins shared with adjacent segments. If it is removed according to its anatomy, it may not damage other segments of the lung. Therefore, for some limited benign lesions, segmental lung resection can preserve as much normal lung tissue as possible. The most common indication for lung segment resection is bronchiectasis; in the past, it has been widely used in tuberculosis, but the rate of postoperative bronchospasm and recurrence of lesions is quite high, and has been strictly controlled recently. The steps for each segment of the lung are the same. First, the pulmonary artery is identified, and it is cut and ligated. After finding the segmental bronchus near the pulmonary artery, use a bronchial forceps (or hemostat) to gently inflate to determine if the clamp is accurate. In the vicinity of the bronchus, the inter-segmental vein can be seen, and the ligation and severing can be performed first (but the venous trunk does not have to be cut off in most of the segments, and only the branches are cut off when the segment is separated), and then the bronchial forceps are used to clamp the segmental bronchus. Cut and suture the proximal stump. Lift the bronchial forceps of the distal bronchi of the clamp, or find another tissue clamp to clamp the distal bronchus, and blow it through the anesthesia machine to dilate the remaining healthy lung segments, which can clearly distinguish the boundary between the diseased lung and the healthy lung. Along the dividing line, the visceral pleura on the surface of the lung is cut open. In the case of continuous inflation, while pulling the distal bronchi, while using a finger to squeeze and knead the tissue near the gap, the segment gap can be smoothly separated. In the process of separation, if the finger touches the tough thin cord-like tissue, most of them are small blood vessels or bronchioles, which should be cut and ligated after clamping, so as to avoid bleeding and leakage of the surface. After the end of the separation, after removing the diseased lung, it can be seen that the remaining segment has a well-distributed inter-segmental vein. If it is incomplete, some of the veins should be stripped when covered by lung tissue. When there is obvious bleeding point or leaking hole in the inspection section, it should be clamped and then ligated, or 8-shaped suture to avoid blood or bronchospasm. The small alveolar air leaks can be blocked by the film formed by plasma within 24 hours, and there is no need to suture too much, so as not to affect the expansion of the residual lung.

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