Thoracoplasty of the chest in tuberculosis. Surgical methods of treatment of pulmonary tuberculosis

Pulmonary tuberculosis is an infectious disease characterized by the formation of specific foci of inflammation and affecting the general state of health.

The disease requires qualified treatment, which consists in taking anti-tuberculosis drugs.

However, sometimes conservative therapy is not enough. In this case, surgical intervention is applied.

Indications for surgery

Surgery for pulmonary tuberculosis is indicated in such cases:

• The lack of positive dynamics in the treatment with anti-tuberculosis drugs, which may be due to the resistance of bacteria to the drugs used.
• The development of complications (irreversible morphological changes) with an advanced form of the disease, a weakened general condition and in the case of a secondary infection.
• The occurrence of complications that are life-threatening. These conditions include: purulent processes in the bronchi, bleeding in the lungs, proliferation of connective tissue, which disrupts the normal functioning of the organ, and so on.

In 90% of cases, lung surgery for tuberculosis is planned. The need for emergency surgery is extremely rare, for example, with severe bleeding or accumulation of air in the pleural region.

Types of surgery

For the treatment of pulmonary tuberculosis in surgery can be used different kinds operations, depending on the form of the disease, the degree of damage and the presence of complications.

A lobectomy is a surgical intervention during which a lobe of the lung is removed if the respiratory function of the rest of the organ is normal.

For the operation, an open method or a minimally invasive one can be used. In the first case, the doctor makes an incision in the side chest(when removing the posterior lobe, the incision is made from the posterolateral incision).

If necessary, the rib is removed to provide the surgeon with full access to the organ.

Using a minimally invasive technique, the doctor makes several incisions in the chest area. Through them, a surgical instrument and a mini-camera are inserted, which allows you to monitor the progress of the operation.

After such an intervention, less recovery time is required. However, its use requires high professionalism and qualifications of the doctor.

During the operation, the surgeon removes the lobe of the lung, blood vessels, omentum, and also blocks Airways.

He then expands the remaining lobes of the lung by injecting high-pressure oxygen. Drains are installed to remove fluid that may accumulate in the organ.

Pneumoectomy is a type of surgery that involves the removal of the lung. It is used in exceptional cases, when irreversible changes are observed in most of the organ.

Pneumoectomy often causes a number of serious complications that are dangerous to the health and life of the patient (respiratory failure), therefore, it is used in exceptional cases.

Another type of lung surgery is thoracoplasty. It is used in cases where organ resection is contraindicated. Its essence is the removal of ribs from the side of the affected lung.

Such manipulation leads to a decrease in the volume of the chest, a decrease in tension and elasticity of the lung tissue. This contributes to the reduced absorption of toxins by the body.

Thoracoplasty is a minimally invasive method of surgical intervention, which is often used in cases where it is necessary to sanitize an organ without the need for its resection.

This method brings quick relief, does not require long-term recovery and wound healing.

Contraindications for surgery

Surgery on the lungs is contraindicated in violation of the function of respiration, circulation, diseases of cardio-vascular system, liver, kidneys, and also if extensive damage to the organ has occurred.

In such cases, the risk of complications or death is too high.

If you stop the pathological process and achieve remission, you can use conservative treatment surgery is also contraindicated.

The course of lung surgery for tuberculosis

The surgical intervention is preceded by a thorough diagnosis of the patient. Be sure to evaluate the functioning of the cardiovascular system and the clinical picture of the blood.

The doctor carefully examines the anamnesis of the patient's life and diseases.

The list of medications taken by the patient is specified. If necessary drug therapy corrected, in particular, canceled drugs that promote blood thinning.

An obligatory component of diagnostics is the study respiratory function patient and assessing the ability of the healthy part of the organ to perform its "work".

Surgical intervention permissible in the stage of remission of the disease, which can be achieved with drugs.

The patient should be treated with special anti-tuberculosis drugs that inhibit the spread of the disease and maintain the patient's health.

In this case, the patient must be under the constant supervision of a doctor, because the absence of a positive effect from drugs for a long time and postponing the operation can lead to irreversible serious consequences.

At the preparatory stage, the patient is assigned analgesics, tranquilizers, sleeping pills and antihistamines.

These drugs prepare the body for anesthesia. A few hours before the procedure, tranquilizers, Promedol and Atropine are prescribed.

The operation for pulmonary tuberculosis begins with the introduction of the patient into general anesthesia. For this purpose, derivatives of barbituric acid are used.

When choosing an intubation method, the anesthesiologist prefers the one that is able to provide optimal gas exchange, preserve healthy parts or lobes of the lungs from the penetration of pathological elements into them, and will not interfere with the operation.

The further course depends on the type of operation.

With an open cavity, the chest is opened and the ribs are removed to obtain maximum access to the organ.

Then an incision is made in the pleural cavity and a resection of the affected part (lobe) of the lung is performed. Carried out cauterization of blood vessels, blocking the airways and washing from blood clots.

To check the tightness of the seams, the cavity is filled with saline. If air bubbles appear, additional sutures are placed.

At the end of the operation, the chest incisions are sutured and a drain is inserted to drain the fluid.

With a minimally invasive method, several incisions are made for surgical instruments. The operation is carried out under the control of a video camera.

Risks and complications after surgery

Surgical intervention is a risk for the patient, which consists in large blood loss, disruption of the functioning of the organ, complications after anesthesia, gas exchange disorder, infection, sepsis, etc.

After the operation, the following phenomena may be observed:

• respiratory failure;
• oxygen starvation;
• shortness of breath that occurs even at rest;
• cardiopalmus;
• headache and dizziness.

Often, all negative postoperative symptoms disappear after 3-6 months.

As complications, chest congestion, the formation of a bronchial fistula, and the development of pleurisy may occur.

In this case, additional diagnostics of the patient and the use of drug therapy are required, and in exceptional cases, repeated surgical intervention.

After pneumoectomy, an empty cavity is formed, which is filled with fluid mixed with blood and air.

Over time, only transparent protein content remains or tissue proliferation occurs.

In order to avoid possible complications, the resulting cavity is filled artificially. To do this, a balloon is placed in it, which is filled with liquid. After a few days, it is removed.

With a competent and qualified operation, the normal functioning of the healthy part of the organ is preserved and the person recovers quickly enough.

In rare cases, patients complain of pain and discomfort while eating.

If after lung removal with tuberculosis, a second healthy organ is damaged, it is important to take the necessary emergency measures to save it.

Removal of the second lung is a priori impossible.

In this case, the patient is prescribed drugs that strengthen the immune system and help fight infectious diseases viral or bacterial.

Rehabilitation

The operation does not guarantee a complete recovery, so after it you should definitely continue drug therapy prescribed by the doctor.

At first, the patient experiences severe pain. To alleviate his condition, painkillers are prescribed.

Further rehabilitation depends on the type of operation performed, age, general condition health and other factors.

• Adjustment of nutrition, taking into account the recommendations of the attending physician. The diet should definitely include foods rich in vitamins, micro- and macroelements, which will strengthen the body.
• Reception of vitamin-mineral complexes and immunostimulating drugs.
• Performing special breathing exercises that will help increase lung capacity, eliminate shortness of breath and avoid respiratory failure. At the same time, it is worth limiting intense physical activity so as not to increase the load on the organ.
• Under the absolute taboo forever falls alcohol and smoking (including passive).
• Maintaining the physical shape of the body, preventing the accumulation of excess weight.
• Carrying out special physiotherapy procedures.

Surgical treatment of pulmonary tuberculosis is an extreme measure that is used in the absence of therapeutic effect from drug treatment for a long time.

The operation must be preceded by a thorough diagnosis of the patient, the introduction of the disease into remission and the preparation of the patient (physical and psychological).

After the procedure, the patient expects a long recovery period, which requires compliance with the doctor's instructions, willpower and patience.

4879 0

The main operations on the chest wall for pulmonary tuberculosis were and remain thoracoplasties. The goal of thoracoplasty is to achieve collapse and scarring of the tuberculous cavity easy way reduction in the volume of the chest cavity.

Thoracoplasty for pulmonary tuberculosis was first performed by J. Estlander in 1879; M.S. Subbotin, in 1888, in the history of phthisiosurgery, more than 50 different methods of thoracoplasty and their modifications have been proposed, clinical effect which depends on a number of reasons. First of all, it is the technique of operation, clinical form tuberculosis, duration of the disease, phases of the tuberculosis process.

The success of lung resection and antibiotic therapy in the 20th century led to a reduction in the number of such operations. Now thoracoplasty is used for pulmonary tuberculosis according to the following main indications:
- as an independent (therapeutic) operation for destructive forms of pulmonary tuberculosis;
- as a corrective operation, hemithorax with post-resection residual cavities;
- as an auxiliary operation for empyema, bronchopleural and post-resection complications.

Further evolution of the surgical technique of interventions on the chest wall in pulmonary tuberculosis followed the path of reducing trauma and increasing the effectiveness of the impact on the diseased lung.

Within the scope of this chapter, it is not possible to describe in detail all the techniques. Therefore, we will confine ourselves to a presentation of the reasons that led to the development of our own modifications of operations on the chest wall and lung in tuberculosis, indications, surgical technique and results of clinical application.

Common disadvantages of collapse surgery for pulmonary tuberculosis

Despite the many different methods of collapse surgery, it is not always possible to achieve sufficient collapse of the lung apex. In this regard, many surgeons supplement thoracoplasty with various plastic surgery on the cavity and parenchyma of the lung.

So, with large and giant cavities, thoracoplasty began to be supplemented with extrapleural suturing of the lung cavity. Cavernoplasty is performed by stage-by-stage immersion of the outer wall of the cavity inside - "cavity intussusception" - followed by its suturing and applying a Z-shaped suture (Fig. 1).

Rice. 1. Cavernoplasty by the method of "cavity intussusception".

Rice. 2. Fixation of the apex of the lung according to B.M. Garmsen.

A feature of cavity myoplasty is the excision of its walls, followed by processing of the draining bronchi (Fig. 3).

Rice. 3. Cavernomioplasty.

Rice. 4. Cavernomioplasty - tamponade of the cavity with muscle flaps.

Rice. 5. Apical osteoplastic thoracoplasty according to V. Bjork. Mobilization of the apex of the lung.

Rice. 6. Thoracoplasty according to V. Bjork. Movement and fixation of the apex of the lung.

Subperiosteal resection of several ribs is called thoracoplasty.

At the beginning of the development of this operation for pulmonary tuberculosis, it was used in the form of a simultaneous removal of eleven ribs. A number of traumatic modifications of this difficult operation is of historical interest only.

At present, thanks to the works of M. G. Stoyko, N. V. Antelava, A. G. Gilman, A. A. Savon and others, partial, selective modifications of upper thoracoplasty are more often used. If it is necessary to perform a full or extended thoracoplasty, the operation is divided into several stages. 4-5 ribs are removed in one stage with an interval of 2-4 weeks.

The correct indications for various variants of thoracoplasty, the division of the operation into stages, and a thorough assessment of the general condition of the patient and his cardiovascular system in the preoperative period made it possible to reduce the surgical mortality to 2%.

The most common is upper-posterior (paravertebral) thoracoplasty.

Indications for thoracoplasty. The main indication for the use of thoracoplasty is unilateral chronic fibrous-cavernous pulmonary tuberculosis in the general satisfactory condition of the patient and if it is impossible to treat him with artificial pneumothorax due to obliteration of the pleural cavity.

There may be deviations from these classical indications. Thus, thoracoplasty can be performed in the presence of an effective pneumothorax on the other side, and partial upper thoracoplasty can be performed on both sides.

Patients with insufficiency of the cardiovascular system are contraindicated for thoracoplasty. Therefore, before surgery, it is necessary to conduct a thorough study of the functional state of cardiac activity and respiration.

The operation is contraindicated in patients during infiltrative outbreaks and exacerbations, as well as in patients with subacute hematogenous disseminated processes. The use of thoracoplasty is not indicated in patients with giant caverns.

Thoracoplasty does not lead to closure of the cavity in the presence of specific changes or narrowing of the bronchus draining the cavity. Based on this, each patient should be subjected to bronchoscopy before deciding on the use of thoracoplasty. Detection of specific changes in the bronchi requires treatment with streptomycin, which is administered intratracheally.

If a persistent narrowing of the bronchus is established, it is necessary to refrain from using thoracoplasty and choose another surgical intervention for the patient.

The works of S. I. Lapin, A. A. Savon, A. G. Kiselev and others established that not only a thorough examination of the patient and a correct assessment of the nature of his process play a role in the effectiveness of the operation. A big role in obtaining a long and lasting therapeutic effect belongs to the radical nature of the operation itself. Therefore, you should always choose the most radical version of the operation, which should correspond to the nature and prevalence of the process in the lungs.

It is necessary to take into account the dimensions of the cavity and the nature of its walls, as well as its location in the lung tissue.

If with a small cavity located in the posterolateral part of the upper lobe, it is possible to confine oneself to superoposterior thoracoplasty, then with a cavity of considerable size and located in the anterior or medial parts of the upper lobe, one of the options for extended anteroposterior thoracoplasty should be used or the operation should be combined with apicopneumolysis.

The radicalism of the operation is to create conditions for the complete subsidence of the affected lung and cavity and fix it in a collapsed state for the entire period of a long reparation process.

This provision obliges the surgeon to think over the operation plan on the basis of examination data and mainly on the basis of radiological data.

To create the most complete, concentric collapse of the upper lobe, it is necessary to remove the necks of the upper resected ribs and simultaneously exfoliate the apex of the lung along with the parietal pleura.

Pulmonary tuberculosis is a disease that affects an increasing number of people. Therapy of the disease is carried out in various ways, the most cardinal of which is surgery for tuberculosis. However, the procedure is prescribed only in hopeless cases, when other methods of treatment are ineffective.

When is an operation needed?

Among the obvious indications for human lung surgery for tuberculosis:

• lack of results of therapy with anti-tuberculosis drugs;
• the appearance of complications in the later stages of the disease (we are talking about irreversible changes in the morphological nature)
• development of purulent inflammation;
• tissue growth;
• bleeding in the respiratory tract

Attention! Most often, such surgical intervention is carried out on a planned basis. Emergency operations in practice are very rare.

When is the operation not performed?

Lung surgery for tuberculosis is not carried out for persons with malfunctions in the process of breathing, circulatory disorders, heart ailments, kidney and liver diseases and with volumetric organ damage.

In these cases, there is an increased likelihood negative consequences procedure and death of the patient.

Varieties of the operation

The type of operation is selected based on the form of the disease, the extent of the lesion and the risk of complications. Among the probable surgical procedures for tuberculosis are the following types of operations:

• resection or removal of the lesion;
• pulmonectomy - removal of the entire lung for tuberculosis;
• thoracoplasty - a decrease in the space that the organ occupies in the chest;
• pleurectomy (remove the parietal pleura with fibrinous deposits and adhesions);
• decortication of a paired organ;
• cavity surgery (dissection, plastic surgery, drainage);
• resection of lymph nodes;
• operations on the bronchi (removal, plastic surgery, occlusion).

Features of surgical intervention

Resection tuberculoma of the lungs carried out according to a specific plan, including four stages:

1. Antibacterial treatment is carried out. Frequent indication to a similar extent - intoxication of the body.
2. A person is being prepared for surgery - antibacterial agents are prescribed. Anesthesia is introduced, sometimes equipment is turned on, which is designed to maintain the functionality of the second part of the paired organ.
3. The selected type of operation is carried out (usually the process takes no more than an hour).
4. The patient wakes up after anesthesia (within 1-5 days). Starts physical activity.

Recovery period

Operations performed for pulmonary tuberculosis do not guarantee full recovery of the affected organ. That is why the patient will have to continue treatment with medicines for some time. During this period, the patient may complain of a pronounced pain syndrome, which usually manifests itself during meals. In the described case, the doctor prescribes painkillers (Paracetamol, Ibufen, Nosh-pa).

Further move rehabilitation after lung surgery will depend on the age indicator, the condition of the patient and other nuances.

1. Adjust your diet. Include in the menu foods fortified with vitamins and nutrients.
2. Use vitamin complexes and immunostimulating drugs.
3. Do specific breathing exercises. They are designed to increase the volume of the body, eliminate respiratory failure and respite. However, significant exercise stress prohibited. Otherwise, through Airways too much oxygen passes through - the lung is overstrained.
4. Eliminate alcoholic beverages, forget about cigarettes, including passive smoking.
5. Maintain physical form control body weight.
6. Undergo special physical therapy activities prescribed by a specialist.

Postoperative disability

Disability after surgery for pulmonary tuberculosis gives the patient temporary disability. To set the group among the main ones, the following clinical indicators are taken into account:

• pathology prediction;
• features of changes occurring inside the body;
• recurrence of the disease;
• need for the help of others;
• the ability not to constitute the former workplace;
• the need for a new working environment.

The patient will have to choose facilitated working conditions - a 3rd disability group is assigned. Over time, circumstances develop depending on the speed of a person's rehabilitation.

Under such circumstances, 2 conversion options are possible clinical picture:

1. There are additional diseases provoked by the surgery. They do not allow the patient to continue work - group 2 is assigned.
2. An organ is removed or parts of the lung are resected on both sides - group 1 or 2 is shown.

The group is followed by a rehabilitation period. After 1-3 years, the dynamics of the patient's condition is examined. In the event of a complete recovery of the patient, disability is canceled. If there is no significant improvement, the person is unable to continue labor activity, 3rd disability group is left.

Possible postoperative complications

Any surgical intervention, including human lung surgery for tuberculosis, accompanied by significant blood loss, a violation in the functional activity of the organ, the likely consequences after anesthesia, failure of gas exchange, etc.

After lung surgery for tuberculosis phenomena such as:

• failures in the process of breathing;
• lack of oxygen;
• shortness of breath even in the absence of physical activity;
• rapid heart rate;
• migraine;
• dizziness;
• temperature after surgery for tuberculosis.

Usually, all unpleasant postoperative phenomena disappear after 3-6 months.

Among the possible complications are: the inflow of the chest, the formation of a fistula in the bronchi, the appearance of pleurisy. In any of the above cases, the patient needs to undergo additional diagnostics and be treated with medications. In rare cases, resort to a secondary operation, for example, lung resection for tuberculosis.

If the second lung is damaged as a result of the removal of the affected organ, emergency measures must be taken to restore it promptly. Removal of the second part of the paired organ is impossible for obvious reasons. Under such circumstances, the patient is shown taking medication to strengthen immune system and support the body in fighting infections caused by viruses or bacteria.

If the operation was performed by a qualified specialist, the functioning of the healthy part of the lung is partially restored.

Thus, lung surgery for tuberculosis is an extreme measure of the treatment course. Surgery is performed in various forms and is determined depending on the clinical picture and the patient's condition. Recovery period proceeds safely, provided that the person complies with all medical recommendations. Disability group 3 after surgery for pulmonary tuberculosis appointed in case of transfer of the operated person to light work.

18+ Video may contain shocking material!

Thoracoplasty is an operation performed to remove ribs to improve the functionality of the lungs, pleura, or heart. This is one of the varieties of surgery for tuberculosis and other similar indications.

What is thoracoplasty

Thoracoplasty is not so much an aesthetic as a medical operation, which is designed to alleviate the patient's condition. It is used exclusively according to indications and only with a satisfactory condition of the patient.

concept

Thoracoplasty is one of the types of surgical treatment. It is carried out by resection of the ribs on the side of the tuberculous damage. After the intervention, the volume of the chest in the affected area decreases, which helps to reduce the tension and elasticity of tissues. Accordingly, the degree of absorption of toxins in the lung decreases due to the removed ribs respiratory movements limited.

Kinds

There are generally intrapleural and extrapleural.

• At extrapleural several ribs are partially or completely removed without dissection of the parietal pleura.
• At interpleural thoracoplasty removes the ribs, intercostal muscle tissue, parietal pleura. The cavity is relieved of pus and the cavity is covered with a flap remaining from the chest.

By volume, the operation can be partial with resection of parts or several ribs or complete with resection of all ribs from one row. Also do according to the execution method:

• Intrapleural according to Shede, which is used for tuberculosis (the stage at which the length in the empyema cavity reaches impressive severity);
• Intrapleural according to Limberg considered the least traumatic in comparison with others;
• Geller operation used for achalasia cardia;
• By Nass the chest is given a normal shape by the introduction of a metal plate.

There are other types of procedures, but they are used much less frequently.

Indications

The indications are:

• Chronic forms of tuberculosis of the fibrous-cavernous type (with a depth of location of single cavities no more than 3 cm);
• Purulent pleurisy in the presence of a residual cavity;
• With difficulty in the use of artificial pneumothorax in the pleural region;
• Bleeding from the cavity.

The condition of the person who is going to be prepared for the operation must be satisfactory.

Contraindications

Contraindications are:

• Exacerbation of diseases of internal organs;
• The presence of a subacute hematogenous disseminated process;
• The presence of large caverns.

Comparison with similar methods

If we take similar operations in the chest area, then these are:

• Surgical intervention that affects the cavity;
• Thoracostomy;
• Excision of pathological adhesions of the pleura;
• Resection of regional lymph nodes.

All of these operations serve different purposes. At the same time, they are used exclusively according to indications and require a preliminary serious examination.

Holding

Carrying out such an intervention requires serious preparation, since it is carried out with serious indications. At the same time, the intervention itself often causes many complications, and the rehabilitation period lasts a very long time - up to several years.

Necessary analyzes and activities

Held preliminary diagnosis, consisting of:

• and blood (specific, pathogens and other diseases, and so on);
• X-rays of light;
• Consultation with specialized specialists.

The phthisiosurgeon examines the patient, after which he decides whether the patient needs preoperative preparation in the form of therapy with specific antibiotics, bed rest. It is also important to normalize blood counts and temperature.

Algorithm

The operation is considered one of the most difficult. It is carried out according to the following scheme:

• The patient is placed on the chest.
• This is followed by the introduction of anesthesia of the endotracheal type.
• If bronchial fistulas are present, then bronchial intubation is indicated.
• An incision is made in the intervention area.
• The incision starts from the first thoracic vertebra and is led lower, bending around the scapula to the posterior axillary line at the level of the 7th rib.
• Next, thoracoplasty is performed, depending on the type of procedure: a one-stage intervention is usually used, in which subperiosteal resection of the posterior segments of the ribs of the upper row (5-7 elements) is performed. Always remove 1-2 ribs lower than the edge of the cavity. If the upper lobe cavities are large, then 2-3 ribs are removed completely.
• After removing the ribs, it is laid drainage tube with side holes.
• The area is then covered soft tissues and a flap of skin, stitched in layers.
• A tight bandage is applied to the ribs.

A tight pressure-type bandage is applied to the operation area for 1.5-2 months.

Carefully! Video showing Nass thoracoplasty (click to open)

[hide]

Possibility of combining with other types of plastics and cosmetology

The operation is very difficult. She often calls serious complications and consequences. Therefore, it is not combined with other types of intervention.

Rehabilitation

Rehabilitation in such patients is quite difficult and can last up to 2 years. Recommended during the recovery period.