extrapleural thoracolasty

Extrapleural thoracoplasty is a procedure in which a set of ribs is removed under the periosteum to collapse the local chest wall to reduce the chest cavity. The ribs from the periosteum will remain partially collapsed 6 to 8 weeks after surgery, so that the chest cavity will shrink forever. Treatment of diseases: tuberculosis in the elderly Indication 1. Chronic fibrovascular tuberculosis, the cavity wall is not thick, located on the outside of one side, the lower lobe has a wide range of small lesions, the contralateral lung is disease-free or only slightly stable lesions, no endobronchial tuberculosis, whole lung It is a pity that the resection is performed; or the age is over 45 years old, the general condition is not good, and it is estimated that the lobectomy has more difficulties and dangers. 2. One side destroys the lung, the mediastinum shifts to the disease side, and the contralateral side also has lesions. The lung function and general condition do not allow for total lung resection. 3. After partial pulmonary resection of pulmonary tuberculosis, there are less stable lesions in the remaining lungs. The extrapleural thoracoplasty can be performed at the same time as the lung surgery or 2 to 3 weeks after the operation, so that the lungs do not cause modern compensatory expansion. The lesion ruptured, relapsed or spread. 4. After tuberculosis or other diseases for partial lung resection, if there is extensive fiber changes in the residual lung, it will not be able to compensate for expansion, so that the residual cavity can not be eliminated, the cavity continues to accumulate, and even secondary infection or bronchopleural fistula occurs. Local pleural thoracoplasty should be performed to eliminate residual cavity and prevent or treat bronchopleural fistula and residual cavity infection. 5. After total pneumonectomy, the intra-thoracic fluid is contracted, which can cause the mediastinum to shift to the surgical side, causing distortion of the trachea and large blood vessels, causing palpitations, shortness of breath, and cough. Thoracicplasty corrects mediastinal shifts and improves symptoms. Contraindications 1. Tuberculosis is unstable and has symptoms of poisoning; the lesion is located in the lower part of the lung or close to the mediastinum; the wall thickness of the cavity is a large tension cavity; the contralateral lung or other parts of the body have active tuberculosis; the endobronchial membrane is diffuse. Tuberculosis or stenosis, and there are bronchiectasis. 2. Both sides are damaged by the lungs. 3. The age is too large, and the lung function is significantly reduced. Preoperative preparation 1. Patients with tuberculosis should be treated with anti-tuberculosis drugs for 1 to 2 weeks, and penicillin should be added 1 to 2 days before surgery. After the pneumonectomy, the money cavity can not be eliminated, and the thoracoplasty should be performed 2 to 3 weeks after the operation. For example, there is no infection in the thoracic cavity. In addition to the need to continue the injection of streptomycin, penicillin can be injected 1 to 2 days before surgery. If there is an infection, effective antibiotic treatment should be applied early. 2. Patients with effusion in the thoracic cavity should be treated with thoracic puncture before operation, and the effusion should be drained and penicillin should be injected into the chest. If the infection is serious, chest drainage should be performed first, and thoracicplasty should be performed after the symptoms of poisoning subsided. 3. The general condition and respiratory function of the patient should be improved as much as possible. Patients who stay in bed for a long time should get up for 1 to 2 hours a day until they are free from air movements. When they are quiet, the pulse should not exceed 100 times per minute before surgery can be performed. Surgical procedure 1. Incision: standard posterolateral thoracotomy, the upper end of the incision should be flat or slightly over the shoulder, and the lower end of the incision bypasses the lower scapula and forwards to the midline. The thoracodorsal muscle layer such as the trapezius muscle, the latissimus dorsi, and the rhomboid muscle are sequentially cut, the shoulder blade is lifted, the serratus muscle is cut off, and the shoulder blade is pulled with a shoulder blade to pull the shoulder blade upward to expose the upper rib. 2. Remove the 4th (or 3rd) ribs by cutting the upper ribs and continue to remove the 3rd, 2nd, and 1st ribs. The posterior rib posterior, thoracic transverse process should be removed and advanced to the costal cartilage. In order to avoid chest wall instability and prevent abnormal breathing, the number of ribs to be removed at one time should be 3 to 5, otherwise postoperative complications may occur. After separating the anterior serratus at the attachment point of the superior rib, the posterior 2/3 of the entire second rib and the third rib are removed under the periosteum. The first rib is short and horizontal, with a subclavian vein passing through the anterior portion, a subclavian artery after the anterior scalene tendon attachment point, and a brachial plexus root before the first rib posterior and the first thoracic transverse process. When the first rib periosteum is removed and resected, care must be taken to protect the vascular nerves above, and manipulation in the periosteal sheath can avoid damage to them. First, the periosteum under the anterior edge of the first rib was cut open, and the underside of the rib was peeled off. Then, under the guidance of the finger, the rib was placed on the rib under the periosteum and the rib was slowly peeled off to protect the subclavian artery and vein. Do not remove the stripper beyond your fingertips. When peeling off the first rib, it is best to peel off the two sides of the anterior scalene nodule. When there is a gap, the anterior scalene tendon is cut tightly against the rib. At this time, the subclavian artery, vein and brachial plexus can be Was pushed away. Cut the first rib from the rear with the first rib scissors or wire saw, pull the first rib that has been cut down, expose the spirotone ligament, and cut the first, second, and third spirometry ligaments so that the chest top is better. Collapse. Pulling the first rib that has been cut down also helps to expose and separate the anterior rib cartilage joint. In thoracoplasty, it is still controversial whether to remove the first rib. To achieve adequate apical collapse in the treatment of tuberculosis, the first rib should be removed. If the thoracoplasty is performed to eliminate the infected cavity or prevent the residual cavity after pneumonectomy, it is not necessary to remove the first rib, which is important for maintaining the integrity of the neck, scapula and thorax. If the first thoracic transverse process is not removed, and whether the transverse process below the second thoracic vertebra is removed, it depends on the requirement of collapse. Generally, in order to minimize collapse, the thoracic transverse process corresponding to the resection of the rib should be mostly removed. If extensive collapse is not required, the thoracic transverse process is not necessary. When resecting the posterior rib and transverse thoracic vertebrae, first peel off the lateral part of the posterior serratus muscle and the sacral spine, pull the hook to the midline, and then use the straight end bifurcated periosteum stripper to peel off along the posterior segment of the rib. Care should be taken to protect the pleura from tearing. The mediastinum of the pleura is separated from the posterior and transverse processes of the ribs. The posterior ribs and the transverse process are removed with a square skull clamp, and the gauze is used to stop bleeding or suture to stop bleeding. After the rib is removed, the bleeding is completely stopped, the wound is washed, the wound is sutured layer by layer, and the drainage is generally not allowed. When the pleural rupture is performed, the thoracic cavity should be closed. When it is estimated that there is more bleeding and seepage, a vacuum suction tube can be placed to draw out the liquid. Finally, the wound is pressure bandaged to avoid abnormal breathing. 3. The second stage of thoracoplasty is performed according to the patient's recovery. It is usually performed 3 weeks after the operation, and the original incision is made, but the upper part can not be cut, and the 4th to 7th ribs or the 5th to 8th ribs are removed. To retain the proper length, the length of the retention is increased from top to bottom, but the longest one should not exceed the midline of the iliac crest.

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