apical cancer resection

At present, the treatment of apical cancer is mostly based on a comprehensive surgical approach. Most scholars advocate that preoperatively given moderate dose (30 ~ 45Gy) radiotherapy, especially in a wide range of tumor invasion, may reduce the scope of the lesion or more limited, not only can increase the chance of surgical radical resection, but also may reduce The spread of intraoperative cancer cells. Postoperative radiotherapy can be given to patients who have not been able to undergo radical resection or intrathoracic lymph node metastasis and cannot be completely removed. Adjuvant chemotherapy was routinely given after surgery. Treatment of diseases: small cell lung cancer Indication 1. Pulmonary cancer is estimated to be surgically resectable. 2. After radiotherapy, the lesions are significantly reduced or limited, and it is estimated that they can be removed. 3. Preoperative pathology is diagnosed as small cell lung cancer with limited lesions. Surgical treatment may be considered after 1 to 2 courses of neoadjuvant chemotherapy. Contraindications 1. Patients with severe cardiopulmonary insufficiency or other serious organ diseases that cannot tolerate surgery. 2. Brachial plexus, paravertebral regions (especially intervertebral foramen), vertebral bodies or lamina are widely affected. 3. The tumor has distant metastasis. 4. Patients with severe tumor invasion and superior vena cava syndrome. Preoperative preparation 1. Prepare for general lung cancer before surgery. 2. Suspected that the subclavian artery may be involved in the removal of blood vessels, prepare artificial blood vessels and patches. Surgical procedure 1. posterolateral approach (Paulson surgery) Take the lateral position, the affected side is upward, and the upper limb of the affected side extends to the front of the head and is fixed, revealing the armpit and shoulder area. Disinfect the field, from the root to the neck, down to the rib arch, front to front of the midline, back to the side of the shoulder. Take an extended posterolateral oblique incision with the posterior edge parallel to the scapula, up to the level of the scapula, and 2 laterally to the lower scapula to stop at the anterior line. The trapezius and latissimus dorsi muscles are separated and cut, and the serratus muscle is cut at the high ribs, especially the attachment points of the second rib and the rhomboid muscle. Retract the scapula and expose the upper thoracic scapula. Cut the posterior serratus from the 2nd to 5th rib attachment points and separate it to the side for use. From the lower part of the planned rib to enter the pleural cavity, for example, the third rib is invaded, and the incision should be on the upper edge of the fifth rib. If the first and second ribs are to be removed, the upper edge of the third rib should be inserted into the chest. The hand is inserted into the thoracic cavity to explore the tumor, to determine the extent of the tumor, the presence or absence of metastasis of the hilar and mediastinal lymph nodes, the extent of chest wall and vertebral body involvement, etc., to determine whether radical resection can be performed. The rib distractor is placed between the scapula and the third or fourth rib, and the anatomical separation can be divided into three steps: the front part, the upper part and the back part. Anterior anatomy: cut the third and second ribs and intercostal blood vessels, nerves, intercostal muscles, the front boundary is at least 5cm from the tumor, after confirming the subclavian vein, the first rib bone is dissected forward, using the first rib scissors Or the wire saw disconnects the first rib. Upper anatomy: The first rib is pulled downward to expose the attachment point of the anterior scalene muscle to the first rib oblique angle nodule. The front is the subclavian vein and the posterior is the subclavian artery. The anterior scalene muscle was cut, and the brachial plexus was dissected backward, and the middle scalene muscle was cut from the first rib attachment point between the first rib nodule and the subclavian artery groove. Posterior anatomy of the surgical field: the hand is probed into the thoracic cavity, and the first rib is cut from the rib neck or the attachment to the transverse process of the vertebral body. The first rib is pulled downward and the brachial plexus is cut and the second and third ribs are cut. Continue to dissect downward, retract the sacral spine muscle, cut off the transverse rib nucleus nodules or determine the extent of the transverse process or vertebral body resection according to the tumor invasion. The posterior anatomy of the surgical field can also be performed from the bottom up, that is, the 3rd, 2nd, and 1st ribs are cut in order. Tumor involving the subclavian vein or its genus can be removed together, involving the subclavian artery can be separated from the outer membrane surface or local resection and reconstruction (end end anastomosis or intervening artificial blood vessels). If necessary, the subclavian artery branches, including the internal mammary artery, the thyroid neck, and the vertebral artery can be removed. When the tumor involves the vertebral body, it can be separated and removed by means of the pseudo-capsular of the tumor. The invasion of the bone can be carefully removed. The removal of the affected vertebral body 1/4 does not affect the stability of the spine. If preoperative CT and myelography show that the vertebral body is destroyed to the epidural space (stage IIIb), it is generally not resectable; if the tumor is confined to a vertebral body, there may still be selective surgical treatment in order to delay or prevent spinal cord compression. At this point, the chest wall is completely free except for the part connected to the tumor. According to the lung cancer, the extent of lung resection is determined by the lung cancer. Most of the lung resection is performed, and the hilar and mediastinal lymph nodes are removed. Two chest drainage tubes are routinely placed. The chest wall defect is treated as appropriate, and the posterior serratus muscle and the back muscle are generally sutured. If more than 3 ribs are removed and the chest wall is large, the artificial material should be used to repair the defect as appropriate. 2. Trans-cervical approach (Dartevelle procedure) Take the supine position, a soft pillow on the shoulder and back pad to tilt the head and neck, the head is biased to the healthy side, and the upper limb of the affected side is abducted. The field of disinfection, ranging from the mastoid to the xiphoid plane, the medial to the medial to the contralateral clavicle, and the lateral to the midline. The "L"-shaped neck incision was used, first along the anterior border of the sternocleidomastoid muscle, and turned under the collarbone to the level of the ipsilateral thoracic deltoid muscle groove. After cutting the skin, separate it with an electric knife. The sternal end of the sternocleidomastoid muscle was cut off, and the clavicular end and the upper end of the pectoralis major muscle were removed from the clavicle, and the musculocutaneous flap was opened to fully expose the neck and neck and chest joints. The lower abdomen of the scapula is cut off, the fat pad of the scalene muscle and the lymph nodes inside it are removed, and the sternum thyroid muscle and the sternohyoid muscle are removed. The surgeon explores the ipsilateral superior mediastinum by hand along the tracheal esophageal sulcus to confirm that the tumor can be resected. Then remove the proximal 1/2 of the clavicle. The jugular vein is first cut, and then cut to the branches of the subclavian vein, and the thoracic duct is to be ligated on the left side. Cutting the internal jugular vein, the external jugular vein and the distal jugular vein are beneficial to reveal the confluence of the innominate vein. The internal jugular vein can be used to increase the subclavian vein. If the subclavian vein is invaded, the tumor can be directly invaded. Veins can also be considered for removal. At the first rib oblique muscle nodule, the electric scale cuts the anterior scalene muscle, and if the tumor invades the upper part of the muscle, it is cut at the attachment point of the cervical 3 to the cervical vertebral body transverse process. Pay attention to the position of the phrenic nerve before treating the anterior scalene muscle, so as to avoid unnecessary damage and affect the postoperative recovery. Separation of the subclavian artery: the branch of the subclavian artery is severed to increase its mobility. The vertebral artery can be disconnected only when it is violated or if there is no obvious extracranial obstructive disease by preoperative ultrasound Doppler. The tumor is attached to the subclavian artery and can be dissected under the adventitia. If the vessel wall is invaded, some of the subclavian artery should be removed after controlling the distal and proximal ends. The revascularization after tumor resection is usually free. The end of the arterial and subclavian artery is cut at the end of the cut end. It is also possible to use a 6mm or 8mm PTFE intervascular space. The tumor invading condition of the mid-slanted muscle is cut off at the attachment point or high position of the first rib, especially when the tumor invades the middle part of the upper thoracic region, the attachment point of the posterior nodules of the cervical 2 to the cervical vertebral body should be cut off. The neck 8 and thoracic 1 nerve roots are easily identified and separated from the outer to the inner to the combined brachial plexus. The anterior vertebral muscle, sympathetic chain and stellate ganglion are cut in front of the neck 7 to the chest 1 vertebral body, so that the purpose of the oncological examination of the main lymphatic drainage of the upper thoracic cavity can be achieved, and the intervertebral foramen can be well displayed. The thoracic 1 nerve root is cut off at the side of the intervertebral foramen near the tumor, and sometimes the tumor involves the higher plane of the brachial plexus. Generally, the nerve root of the plane above the chest 1 is not required to be removed to achieve the brachial plexus. Care should be taken to avoid damage to the extrathoracic and thoracic nerves to avoid pterygopalatine after surgery. Continue to complete the removal of the chest wall, the first rib is cut from the rib and cartilage junction, the second rib is cut from the middle of the rib arch, the third rib is peeled off along the upper edge of the rib angle, and the rear rib is from the first, second or third The transverse process of the vertebral body is broken, and the tumor and the upper lobe are removed in one piece. Generally, it is not necessary to add a posterior thoracotomy, and the upper lobectomy and the chest wall resection of the first to fourth ribs can be completed by the anterior cervical incision alone. The upper thoracic closed drainage tube is placed, and the neck incision is placed on the skin or latex tube as appropriate. After suturing the sternocleidomastoid muscle, the neck incision is closed by two layers of suture. complication After the removal of apical cancer, in addition to the common complications after pneumonectomy such as hemorrhage, hemothorax, pulmonary infection, bronchopleural fistula and empyema, the following special complications may occur: 1 Resection of sympathetic nerves After the chain and stellate ganglia, the patient developed secondary Horner syndrome; 2 after the 8th cervical nerve root and the 1st thoracic nerve root were cut off, the distribution of sensory abnormalities occurred, but did not affect the motor function; 3 damage the dura mater If it is not treated in time, cerebrospinal fluid leakage may occur, and the infection may have serious consequences.