Extrathoracoplasty

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. Treating diseases: tuberculosis 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 Take the first extrapleural thoracoplasty as an example. 1. Position, incision: lateral position, the side of the arm is disinfected and bandaged, placed next to the body, so that the shoulder blade is relaxed, in order to lift the bone during surgery. For the posterior lateral incision, the upper end from the upper edge of the scapula or the scapular plane, along the midline between the spinous process and the inner edge of the scapula, and about 3 cm below the lower scapula, bypass the lower scapula, straight to the 6th or 7th rib. 2. Expose the upper ribs: After cutting the skin and subcutaneous tissue, the muscle layer is exposed, the trapezius muscle and the rhomboid muscle are cut in the posterior segment of the incision, and the latissimus dorsi and the anterior serratus are cut in the anterior segment. Separate the loose tissue under the shoulder and lift the shoulder blade. An automatic hook between the shoulder blade and the fifth rib is used to lift the shoulder blade upwards to reveal the ribs below the second rib. The upper back saw and the anterior serratus above the fifth rib are cut off at the attachment of the ribs, and the exposure is further enlarged. The anterior serratus attachment point below the sixth rib generally does not require cutting. 3. Identify the first and second ribs: the shape of the first and second ribs is different from that of the other tibias, and the upper and lower sides of the two ribs are widened into a face, and the inner and outer sides are thinned into a rim, that is, upper, lower and inner. The outer edge; while the other ribs have upper and lower edges and inner and outer. On the middle section of the second rib, in addition to the attachment of the anterior serratus muscle, there is a posterior scale muscle attachment; the first rib has a medium scalene muscle on the upper side, a anterior serratus on the outer edge, and a anterior oblique on the inner edge nodule. The horn muscle is attached. There is a subclavian vein in front of the anterior scalene muscle nodules, and a subclavian artery after the nodule, which is close to the first rib and turns to the armpit. When exposing the 2nd and 1st ribs, these muscle attachment points must be cut off; when cutting the anterior scalene muscles, great care must be taken to avoid damage to the subclavian veins and veins, causing a risk of major bleeding. 4. Cut the third rib: Cut the third rib. The transverse intersexual tendons and ligaments were cut up and down in the transverse process, and a rongeur was used to bite the transverse process and the remaining ribs. The stump was temporarily stuffed with gauze to stop bleeding. If the front end is not enough, the periosteum can be used to peel the periosteum: first peel the inner surface, then peel the upper and lower edges, then the outside will separate itself; then, use the rongeur or bone to cut the rib cartilage joint. 5. Excision of the second rib: After the shear, the scalene muscle is attached to the second rib, and the second rib is removed under the periosteum. Since the slope of the second rib is different from that of the third rib, the periosteum of the outer edge should be cut and peeled off first, then the upper and lower sides are peeled off, and finally the inner edge is peeled off. 6. Excision of the first rib: The first rib is revealed after the second rib is removed. Special care must be taken when removing the 1st rib. After cutting the attachment of the anterior serratus and the middle scalene muscle, the periosteum of the outer edge of the first rib is carefully cut, and the periosteum of the outer edge is peeled off with a periosteal stripper (sometimes the intercostal muscle attachment can be cut when it cannot be peeled off), Then peel off the ribs. When peeling, the direction of force should be parallel to the direction of the ribs, and the stripper should be held with both hands, and the left hand should be held in the front part of the stripper to make the peeling action smooth, and not slip inward and accidentally injure the lower clavicle, vein or brachial plexus. After peeling off the lower side, use the round blade stripper to peel off the top of the rib in the same way. Finally peel off the inner edge. When peeling off, care should be taken to protect the tip of the stripper from the left finger to separate it from the lower clavicle. After the inner edge of the periosteum is peeled off, it can be seen that the anterior scalene muscle is attached to the anterior scalene muscle nodule; similarly, under the protection of the finger, it should be close to the bone surface to cut off the attachment. After the inner edge is separated, the lower clavicle movement and vein in the upper part of the anterior segment of the first rib collapses. The back section of the first rib is cut, and the bone is pulled outward to make the front section more satisfactory. After peeling the periosteum that has not been completely dissected in the anterior segment, the first rib can be removed by cutting it close to the sternum. 7. Drainage and suture: check the wound after no bleeding; if there is bleeding in the rib stump, use bone wax to stop bleeding. Finally, the scapula was repositioned and the incision was layered. The lower part of the scapular region discharges blood (usually 300 to 400 ml in 24 hours), which not only reduces compression but also reduces the chance of infection. A large amount of gauze was placed on the upper chest and under the arm, and the band was pressure-wrapped with a tape to keep the partial chest wall collapsed.