RADICAL LUNG OPERATIONS

Radical operations on the lungs are performed mainly for malignant neoplasms, bronchiectasis, and pulmonary tuberculosis

Lung operations are among the most complex surgical interventions that require a high level of general surgical training from the doctor, good organization of the operating room and great care at all stages of the operation, especially when treating elements of the lung root. When determining the scope of surgical intervention, one should strive to preserve as much of the healthy lung tissue as possible and limit oneself to removing the affected area of ​​the lung. However, establishing the boundaries of the spread of the process in the lung according to clinical, radiological and other research methods is not always possible, therefore “economical” operations (removal of a segment, part of a lung lobe) have limited indications, especially in the treatment of lung tumors. For solitary tuberculous cavities, segmental lung resections are widely used.

To perform surgery on the lungs, in addition to general surgical instruments, you need windowed clamps for grasping the lung, long curved clamps with and without teeth: long curved scissors; dissectors and Fedorov clamps for isolating pulmonary vessels and performing ligatures; Vinogradov's sticks; long needle holders; bronchial holders; probe for isolating elements of the lung root; hook-scapula for mediastinal abduction; bronchial constrictor; chest wound retractors; hooks for bringing the ribs together and a vacuum apparatus for suctioning sputum from the bronchi.

Anesthesia. Lung operations are performed mainly under intratracheal anesthesia using antipsychotic substances, relaxants and controlled breathing. At the same time, pain and neuro-reflex reactions are suppressed to the greatest extent, and sufficient ventilation of the lungs is ensured.

Despite good inhalation anesthesia, it is necessary to additionally infiltrate reflexogenic zones in the area of ​​the lung root and aortic arch with a 0.5% novocaine solution, as well as block the intercostal nerves both at the beginning of the operation and at the end of it in order to eliminate postoperative pain. Surgical interventions on the lungs can also be performed under local infiltration anesthesia.

During radical operations on the lung, the chest cavity can be opened with an anterolateral or posterolateral incision. Each of them has its own advantages and disadvantages. The main requirement for choosing a surgical approach is the ability to carry out the main stages of the operation through it: removal of the lung or its lobe, treatment of large pulmonary vessels and bronchus. It is also necessary to take into account, in addition to the technical conveniences when performing the operation, the position of the patient on the operating table, which it is desirable to give in this case. This is important, for example, during operations for purulent lung diseases, when there are significant accumulations of pus in the pathological cavities of the lung and bronchus. In such cases, the position of the patient on the healthy side is undesirable, since in the process of releasing the lung from the adhesions, pus may flow into the healthy lung. Therefore, for purulent diseases (bronchiectasis, multiple abscesses), it is more advisable to use a posterolateral incision, in which the patient is placed on his stomach.

The supine position (with anterolateral access) minimally limits the volume of respiratory movements of the healthy lung and the activity of the heart, while when positioned on the side, the mediastinal organs are displaced and the excursion of the healthy half of the chest is sharply limited.

The posterolateral surgical approach is more traumatic than the anterolateral one.

matic, as it is associated with the intersection of the back muscles. However, the posterolateral approach also has advantages: it makes it easier to approach the root of the lung. Therefore, the use of posterolateral access is especially indicated when removing the lower lobes of the lung, as well as when resection of segments located in the posterior parts of the lung.

Anterolateral approach. The patient is placed on his healthy side or on his back. The skin incision begins at the level of the third rib, slightly outward from the parasternal line. From here, the incision is made down to the level of the nipple, around it from below and the incision line continues along the upper edge of the 4th rib to the middle or posterior axillary line. In women, the incision is made under the mammary gland, at a distance of 2 cm from the lower fold. The mammary gland is retracted upward. After dissecting the skin, fascia and pectoralis major muscle in the posterior part of the wound, the serratus anterior muscle is cut. The protruding edge of the latissimus dorsi muscle at the back of the incision is pulled outward with a hook; if necessary, to expand access, they resort to partial intersection of this muscle. After this, the soft tissues are dissected in the third or fourth intercostal space and the pleural cavity is opened. The choice of intercostal space for opening the pleural cavity is determined by the nature of the upcoming surgical intervention. To remove the upper lobe, an incision is made along the third intercostal space; to remove the entire lung or its lower lobe, the pleura is incised along the fourth or fifth intercostal space. First, the pleura is cut over a short distance with a scalpel, and then this incision is widened with scissors. In the medial corner of the wound, avoid damage to the internal mammary vessel, which can cause excessive bleeding. If there is a need to expand access, the IV or V costal cartilage is intersected, 2-3 cm away from the sternum, or one rib is resected along the entire length of the wound.

Posterior - lateral access. The patient is placed on his healthy side or stomach. The soft tissue incision begins at the level of the spinous process of the IV thoracic vertebra along the paravertebral line and continues to the angle of the scapula. Having gone around the corner of the scapula from below, continue the incision along the sixth rib to the anterior axillary line. Along the incision, all tissues are dissected to the ribs: the lower fibers of the trapezius and rhomboid major muscles, in the horizontal part of the incision - the latissimus dorsi muscle and partially the serratus muscle. The VI or VII rib is resected.

Depending on the localization of the pathological process and the nature of the surgical intervention, the pleural cavity is opened at different levels using posterolateral approaches: for pneumonectomy, for example, the VI rib is often chosen, when removing the upper lobe - the III or IV rib, and the lower lobe - the VII rib. The pleural cavity is opened along the bed of the resected rib. If it is necessary to expand access, an additional 1-2 ribs are crossed near their vertebral end.

3422 0

During surgical interventions on the lungs, several well-developed surgical approaches to the organs of the thoracic cavity are used: anterolateral (anterior) - in the position of the patient on the back, lateral - in the position on the healthy side, and posterolateral (posterior) - in the position on the stomach.

The method of surgical access for lung cancer is determined mainly by the characteristics of the planned surgical intervention and the extent of pathological changes. During extended lung resections for cancer, the most difficult and responsible part of the operation is the removal of the regional lymphatic system, including its parts located in the mediastinum. The safety and accessibility of extended surgical intervention and its radicalness largely depend on the convenience and reliable visual control of all surgical actions taken within the mediastinum, this topographically, anatomically and physiologically complex area of ​​the thoracic cavity. Conditions become noticeably more complicated during operations performed on patients with advanced stages of the disease.

Over the many years of development of this problem in the clinic, approaches and attitudes towards the selection and evaluation of various surgical approaches used for extended lung resections have undergone some changes. In the first years of work, preference was given to anterolateral thoracotomy. At that time, this access seemed to be the safest for the patient, both from the standpoint of anesthesia and surgical intervention. The main type of surgical intervention for lung cancer at that time was the removal of the entire lung - an extended pneumonectomy.

Detailed clinical and morphological studies were used to clarify the indications, scope and features of mediastinotomy with wide lymphadenectomy. By the mid-60s, extended pneumonectomies for lung cancer took their place in the surgical treatment of this disease. In those years, in our clinic, as well as in a number of leading thoracic hospitals and institutions in the country, they shared the position on the need to perform extensive removal of lymph nodes and mediastinal tissue in case of cancer, guided by a unique rule. It was that for lung cancer, pneumonectomy should be undertaken in all cases, since only such a volume of resection provides the possibility of widespread removal of the regional lymphatic apparatus of the lung in the mediastinum with both obvious and potential metastases. This ensures oncological radicalism of surgical intervention.

Further development of the problem, the desire to preserve parts of the lung not affected by the blastomatous process without reducing the boundaries of mediastinal lymphadenectomy and without compromising oncological principles, prompted a revision of the surgical approach. The implementation of extended lobar resections of the lung ensured the permissibility of surgical treatment for a larger number of patients with lung cancer, mainly due to people in the older age group, as well as those with reduced functional and reserve capabilities of the body. In many ways, this problem was successfully solved along with the formation and subsequent development of anesthesiology and resuscitation, the introduction of new techniques into surgical practice, including reconstruction and plasty of the bronchi.

To perform extended lobar resections of the lung for cancer, thoracotomy from a lateral approach began to be used. Compared to the anterolateral approach, this approach is more traumatic; it poses a risk of pathological contents flowing from the bronchi of the affected lung into the healthy one; special conditions and a regimen for artificial ventilation during pain relief are required, including taking into account the positional limitation of mobility of the opposite side of the chest. However, at present, with the modern level of anesthesia, which is constantly being improved, these shortcomings do not pose a serious danger.

At the same time, the lateral approach significantly expands the possibilities of surgical action on the mediastinal organs during surgical interventions for lung cancer, especially in patients with advanced stages of the disease. It ensures complete accessibility of the preparation of regional lymph nodes of the lung in the interlobar fissure, within each of its lobes, in the region of the root and mediastinum. If it is necessary to perform bronchoplastic surgery, the lateral approach creates the most convenient conditions for this. The lateral approach for lung cancer should be considered as most responsive to the task of performing all options for radical extended surgical interventions in the vast majority of patients with advanced stages of the disease.

The technique of performing a lateral approach to the IV or V intercostal space is described in detail in numerous manuals on pulmonary surgery. It should be noted that to ensure the most convenient access to the deep-lying parts of the regional lymphatic collector of the lung within the mediastinum: when performing a wide lymphadenectomy, it is advisable to use two retractors. In difficult situations: with pronounced adhesions in the pleural cavity, paracancrosis changes, etc. It is permissible to intersect the cartilages of one or two ribs, as is done with an anterolateral thoracotomy. This provides a good overview of the anatomical formations and organs of the mediastinum, creating the opportunity, without risk for the patient, to perform wide removal of lymph nodes and mediastinal tissue while preserving most of the lung tissue not affected by the tumor.

In relation to performing extended combined lung resections, each of the surgical approaches has its own advantages and disadvantages, which can either complicate or significantly facilitate the implementation of surgical intervention.

The main advantages of the anterolateral approach are: the possibility of a wide view of the entire anterior and lateral surface of the lung, the best approach to the vessels of the root of the lung, the superior vena cava, less trauma, the possibility of expanding surgical access by intersecting the cartilages above or below the underlying ribs. It creates the best operating conditions when the anterior surface of the pericardium grows and the anterior or anterolateral wall of the superior vena cava or pulmonary artery is involved in the tumor process. The main disadvantages of the approach include the difficulties of manipulation when the tumor is localized in the posteromedial parts of the lungs with invasion of the organs of the posterior mediastinum, the posterior surface of the pericardium and pulmonary vessels, the inability to operate on the bronchi before ligating the pulmonary vessels, and the difficulty of performing mediastinal lymphadenectomy, which requires constant traction of the heart. Certain inconveniences arise when a tumor grows into the diaphragm.

The lateral approach best suits the objectives of surgical treatment for advanced stages of lung cancer. It provides a wide view of almost all parts of the thoracic cavity; it is possible to manipulate both the posterior and anterior surfaces of the lung root, which provides access to the lung vessels and bronchi. From the lateral approach it is convenient to perform resection of the tracheal wall, and from the right side - also the bifurcation. It provides a wide approach to the organs of the posterior mediastinum, and is most convenient and safe if a tumor lesion of the descending aorta is suspected.

With the lateral approach, there is a wide approach to the main interlobar fissure and significantly simplifies the performance of mediastinal lymphadenectomy. The main disadvantage should be considered the high traumatic nature of the lateral approach, because this requires a wide intersection of the muscles of the lateral and posterior surface of the chest. Gentle access options, in which the latissimus dorsi muscle is not crossed, but is stretched using a retractor, are not practical when performing extended combined lung resections, because manipulations on the root of the lung have to be performed at great depth, in a narrow surgical field, which, when large vessels and the heart wall are involved in the tumor process, significantly increases the risk of surgery.

The use of posterolateral access to perform extended combined lung resections is the least justified. Its advantage is the ease of manipulation on the main bronchi, and from the right-sided approach on the tracheal bifurcation. However, it makes it difficult to approach the vessels of the lung root, superior vena cava, lateral and anterior surface of the pericardium, diaphragm, and aorta. It is technically difficult to perform mediastinal lymphadenectomy from the posterolateral approach, especially with a left-sided thoracotomy.

Bilateral anterolateral approach with transverse sternotomy is usually not used for advanced stages of lung cancer. In rare cases, mainly with the development of complications, there is a need to expand the surgical approach for anterolateral thoracotomy by transverse sternotomy.

Bisenkov L.N., Grishakov S.V., Shalaev S.A.

For radical operations on the lung, the chest cavity can be opened with an anterolateral or posterolateral incision. Each of them has its own advantages and disadvantages. The main requirement for choosing a surgical approach is the ability to carry out the main stages of the operation through it: removal of the lung or its lobe, treatment of large pulmonary vessels and bronchus. In addition to the technical conveniences when performing the operation, one should also take into account the position of the patient on the operating table, which it is desirable to give in this case. This is important, for example, during operations for purulent lung diseases, when there are significant accumulations of pus in the pathological cavities of the lung and bronchus. In such cases, positioning the patient on the healthy side is undesirable, because in the process of releasing the lung from the adhesions, pus can flow into a healthy lung. Therefore, for purulent diseases (bronchiectasis, multiple abscesses), it is more advisable to use a posterolateral incision, in which the patient is placed on his stomach.

The supine position (with an anterolateral approach) minimally limits the volume of respiratory movements of the healthy lung and the activity of the heart, while when positioned on the side, the mediastinal organs are displaced and the excursion of the healthy half of the chest is sharply limited.

The posterolateral surgical approach is more traumatic compared to the anterolateral one, because it is associated with the intersection of the back muscles. However, the posterolateral approach also has advantages: it makes it easier to approach the root of the lung. Therefore, the use of posterolateral access is especially indicated when removing the lower lobes of the lung, as well as when resecting segments located in the posterior parts of the lung.

Anterolateral approach

The patient is placed on his healthy side or on his back. The skin incision begins at the level III ribs, slightly outward from the parasternal line. From here, the incision is made down to the level of the nipple, around it from below and the incision line continues along the upper edge of the 4th rib to the mid or posterior axillary line . In women, the incision is made under the mammary gland, at a distance of 2 cm from the lower fold. The mammary gland is retracted upward. After dissecting the skin, fascia and pectoralis major muscle in the posterior part of the wound, the m. serratus anterior. Projecting edge m. The latissimus dorsi in the posterior part of the incision is pulled outward with a hook; if necessary, to expand access, they resort to partial intersection of this muscle. After this, the soft tissues are dissected in the third or fourth intercostal space and the pleural cavity is opened. The choice of intercostal space for opening the pleural cavity is determined by the nature of the upcoming surgical intervention. To remove the upper lobe, an incision is made along the third intercostal space; to remove the entire lung or its lower lobe, the pleura is incised along the fourth or fifth intercostal space. First, the pleura is cut over a short distance with a scalpel, and then this incision is widened with scissors. In the medial corner of the wound, damage to the vasa thoracica interna, which can cause excessive bleeding, should be avoided. If there is a need to expand access, the IV or V costal cartilage is intersected, 2-3 cm from the sternum, or one rib is resected along the entire length of the wound.

Posterolateral approach

The patient is placed on his healthy side or stomach. The soft tissue incision begins at the level of the spinous process of the IV thoracic vertebra along the paravertebral line and continues to the angle of the scapula. Having gone around the corner of the scapula from below, continue the incision along the VI rib to the anterior axillary line . Along the incision, all tissues are dissected to the ribs: the lower fibers of the trapezius and rhomboid major muscles, in the horizontal part of the incision - the broad dorsi muscle and partially the serratus muscle. The VI or VII rib is resected.

Depending on the localization of the pathological process and the nature of the surgical intervention, the pleural cavity is opened at different levels using posterolateral approaches: for pneumonectomy, for example, the VI rib is often chosen, when removing the upper lobe, the III or IV rib, and the lower lobe, the VII rib. The pleural cavity is opened along the bed of the resected rib. If it is necessary to expand access, an additional 1-2 ribs are crossed near their vertebral end.

Removal of a lung - pneumonectomy (pneumonectomia)

Indications. Lung cancer, multiple abscesses, widespread bronchiectasis, pulmonary tuberculosis.

Technique for removing the right lung (according to Kupriyanov)

The pleural cavity is opened using one of the approaches. The edges of the wound are spread apart with a dilator and the pleural cavity and lung are examined. If there are adhesions between the lung and the parietal pleura, they are separated bluntly or crossed with scissors between two ligatures. Then, using a gauze ball in a Mikulicz clamp, the adhesions between the visceral and mediastinal pleura are separated and approached to the root of the lung. By hand, push the lung slightly to the side and find the anterior fold of the mediastinal pleura, which passes from the pericardium to the vessels of the root of the lung. Carefully incise the pleura below v.azygos with a scalpel from the upper edge of the root to the lower and push the edges of the pleura apart with gauze balls, after which the vessels of the lung root become visible. This manipulation is best done after infiltration of the anterior surface of the lung root with a 0.25% novocaine solution.

The identifying landmark of the right pulmonary artery is v.azygos: the artery is located in the root of the lung ventrally and slightly below this vein.

The mediastinal pleura is gradually shifted with a gauze ball from the anterior surface of the pulmonary artery, from the anterior, inferior and posterior surfaces of the pulmonary veins to bypass the root of the lung from behind. Then they proceed to separate isolation and ligation of the artery and veins of the lung root. The superior pulmonary vein is carefully pushed down and the superior vena cava is moved medially. The v.azygos is crossed between the two ligatures, then the main trunk of the pulmonary artery is exposed, a curved Fedorov clamp or dissector is placed under it, the end of which is grasped and first one and then the second silk ligature is passed, with the help of which the pulmonary artery is ligated. First the central and then the peripheral part of the pulmonary artery is ligated. Next, the vessel is lifted with a curved probe, sutured and bandaged at a distance of 3-5 mm from the proximal ligature. To apply a stitching ligature, silk No. 3-4 is used. After this, the artery is crossed closer to the distal ligature.

The advisability of ligating the pulmonary artery in the first stage of treating the elements of the lung root is dictated not only by the topographic-anatomical position of this artery (most anterior in the wound), but also by the need to stop blood access to the lung in order to avoid dangerous bleeding during subsequent stages of the operation. Instead of the main trunk of the pulmonary artery, it is sometimes necessary to ligate its upper and lower branches separately.

Next, we begin to isolate the superior pulmonary vein. After isolating this vein near the pericardium, a provisional ligature is applied to it and they begin to isolate the inferior pulmonary vein, located in the upper part of the pulmonary-phrenic ligament and being the lowest and posterior element of the lung root. The superior and inferior pulmonary veins are ligated and divided in the same way as the pulmonary artery. The bronchus is released as close as possible to the tracheal bifurcation, a bronchial fixator is applied and a powerful Kocher forceps is applied 1-2 cm distal from it. The bronchus is crossed between the clamps and its stump is sutured. The bronchial stump is sutured with a two-layer silk suture: first, the edges of the stump are sutured through all layers with 5-6 silk sutures, and several more peribronchial sutures are placed above them. The bronchial fixator is removed, the sutures are checked for tightness by increasing intratracheal pressure using the breathing bag of the anesthesia apparatus. If the bronchial stump is not sealed sufficiently, air will pass into the wound. After removing the bronchial fixator, it is necessary to find the stump a. bronchialis and bandage it. It is recommended to cover the bronchial stump with a free flap of pleura.

Currently, the UKB-7 apparatus and UKL-60 apparatus are used for suturing the bronchial stump and the vessels of the lung root.

Having completed the intersection of the pulmonary vessels and bronchus, they begin to free the lung from the remaining undivided parietal and diaphragmatic adhesions. After this, the lung remains fixed on the mediastinal layer of the pleura covering the root of the lung from behind; the pleura is crossed between two ligatures. The lung is removed. The leaves of the mediastinal pleura are sutured with interrupted silk sutures and this closes the stumps of the vessels and bronchus (pleurization). After suturing the mediastinal pleura, antibiotics are injected into the mediastinum. Before suturing the chest wound, an incision is made in the eighth or ninth intercostal space along the midaxillary line and drainage is carried out through it with a forceps into the costophrenic sinus. The drainage is left in the pleural cavity for 24-36 hours. The chest is closed in layers. The ribs are brought together using catgut sutures passed through the intercostal spaces.

Removal of a lobe of the lung - lobectomy (lobectomia)

The purpose of this operation is to remove the affected lobe of the lung within the anatomical boundaries with the intersection of the lobar vessels and bronchus. Removing a lobe of a lung is a technically more difficult operation than removing the entire lung. Performing this operation requires precise orientation in the topographic-anatomical relationships of the lobar vessels and the bronchus, which is often difficult due to the closure of the interlobar fissures.

Indications. Chronic suppurative processes (abscesses, bronchiectasis) and tumors within one lobe, tuberculous cavities.

Removal of any lobe of the right and left lung can be done from the anterolateral or posterolateral approach, used to remove the entire lung. If the localization of the pathological process is not sufficiently determined before surgery, the intersection of the cartilage of the third rib is added to the intercostal incision to approach the apex of the lung, or the intersection of the V and VI ribs is added to access the lower lobe. After opening the pleural cavity, a retractor is inserted and the possibility of removing a lobe of the lung is determined. The adhesions of the visceral and parietal pleura are crossed with scissors between two ligatures. If there is an infiltrate in the root of the lung and difficult to separate interlobar adhesions, it is more advisable to begin the operation by isolating the main vessels of the lung root and placing provisional ligatures under them, and then separating the interlobar spaces. This reduces the risk of bleeding and air embolism. To improve orientation within the boundaries of the lung lobes, the pressure in the anesthesia machine system is increased and they begin to separate them along the interlobar cracks.

The technique for removing the lobes of the lung is basically the same, but at the same time there are some peculiarities in the treatment of the lobar vessels and bronchus.

Technique for removing the upper lobe of the left lung

After opening the pleural cavity, the root of the lung is exposed. The mediastinal pleura is dissected above it and the main trunk of the pulmonary artery is isolated, under which a provisional ligature is placed. Lifting the vessel with a ligature, using a gauze ball held in a long clamp, they push the pleura and tissue towards the hilum of the lung and in this way reach the place where the main trunk of the pulmonary artery divides into lobar branches. The first upper lobe branch of the artery is isolated, which is usually divided here into two segmental arteries (for the apical and anterior segments of the upper lobe). The artery is ligated and cut between the ligatures.

Then the second upper lobe branch of the pulmonary artery is isolated (to the posterior segment). To do this, the pleura is dissected in the interlobar fissure and a branch to the posterior segment is found, which is crossed between two ligatures, and slightly below this artery a branch to the lingular segments is found and ligated. Having finished treating the arteries of the upper lobe, they return to the root of the lung and ligate the upper pulmonary vein here. After dissecting this vessel, the peribronchial tissue is separated and the upper lobe bronchus is exposed.

Next, the upper lobe bronchus is clamped with a bronchial fixator, a Kocher clamp is applied distal to it and the bronchus is crossed between them. The bronchial stump is treated in the same way as for pneumonectomy. The lung lobe is cut off and removed. When crossing the upper lobe bronchus, it is necessary to remember that the descending trunk of the pulmonary artery is adjacent to it behind. The bronchial stump is carefully sutured with a layer of mediastinal pleura.

When removing the upper lobes, two drainage tubes are usually used: one is inserted into the pleural cavity through a small incision in the eighth intercostal space along the posterior axillary line, the other - in front along the second intercostal space. It can be drained with one long tube with many holes, passed through an incision in the eighth intercostal space. The tube is fixed from the inside to the chest wall with one catgut suture. The chest wound is sutured in layers.

After suturing the chest wall wound, to straighten the lung, it is necessary to suck out the air from the pleural cavity using a Janet syringe or an aspirator.

Resection of a lung segment (segmentectomy)

Indications. Tuberculous cavity, echinococcal and bronchogenic cysts.

Operation technique. Depending on the segment planned for removal, the appropriate access is selected. Thus, it is more convenient to remove the apical and anterior segments from the anterolateral incision, and the posterior and apical segments from the posterolateral one. The pleural cavity is opened along one of the intercostal spaces adjacent to the projection of the lesion on the chest wall. If there are adhesions between the lung and the parietal pleura, the lung is carefully detached in a small area using a blunt method. Then they spread the ribs, penetrate with their fingers between the lung and the chest wall and continue to dissect the intercostal space up and down under the control of the fingers so as not to damage the lung.

The lung is freed from adhesions from all sides. If the pleural adhesions are strong, it is better to resort to cutting them sharply. This is helped by hydraulic preparation with a 0.25% solution of novocaine, which promotes the separation of adhesions (L.K. Bogush).

Having freed the lung from adhesions, the area of ​​the lung root is anesthetized and they begin to isolate the vascular-bronchial bundle of the segment. For this purpose, the fold of pleura that passes from the lung to the pericardium is dissected. In this case, you should not move away from the root of the lung, because The division of lobar vessels and bronchi into segmental ones occurs directly at the gates of the lung. The dissected fold of the mediastinal pleura (at the root of the lung) is gradually grabbed with Billroth hemostatic forceps and separated with small tuffers until the elements of the lung root are exposed on all sides. The vessels and bronchus of the removed segment are isolated, after which separate ligatures are applied to the vessels and bronchi. When isolating and ligating the vessels of the lung, one must remember that the veins have thin walls and that rough manipulation with instruments can lead to perforation with serious complications (bleeding, air embolism). The sequence of dressing is determined by the topographic-anatomical relationship of the elements of the segment being removed, because there are differences in the location of the vessels and bronchi of different segments. After ligating the artery, vein and bronchus, the removal of the affected segment begins. Isolation of a segment within its boundaries is carried out bluntly in the direction from the root of the segment to the periphery. Hemostasis of the lung wound is performed, then the lung is inflated using an anesthesia machine, and the bed of the removed segment is sutured with interrupted sutures. In some cases, the lung tissue defect is covered by suturing the mediastinal pleura. The chest wound is sutured in layers.

Through an additional incision along the eighth intercostal space, a drainage tube is inserted into the pleural cavity and active aspiration is established for 24-48 hours, which ensures not only suction of the contents, but also expansion of the lung.

Theoretical questions for the lesson:

1. Lungs: surfaces, lobar and segmental structure.

2. Borders of the lungs, interlobar fissures.

3. Thoracic part of the trachea, projection, bifurcation, syntopy.

4. The concept of the gate and root of the lung.

5. Blood supply and innervation of the lungs.

6. International clinical classification of the mediastinum.

7. Contents of the anterior mediastinum.

8. Contents of the posterior mediastinum.

9. Stages of surgical intervention on the lungs (pulmonectomy, lobectomy, segmentectomy).

Practical part of the lesson:

1. Determination of the boundaries of the lungs, pleura, interlobar fissures.

2. Determination of the boundaries of the dome of the pleura and the apex of the lung.

3. Determination of the projection of the costophrenic sinus

Questions for self-control of knowledge

1. Projection of the lobes of the lungs onto the chest and segmental structure of the lungs

2. Projection of the pleural sinuses onto the chest wall.

3. What is the root of the lung?

4. What organs belong to the anterior mediastinum?

5. What vessels depart from the aortic arch?

6. Name the organs of the posterior mediastinum?

7. Topographic-anatomical relationship between the esophagus and the thoracic aorta?

8. What is the pleural sinus?

A. Access to various parts of the lungs during thoracoplasty

1. Friedrich-Brauer incision for complete extrapleural thoracoplasty; runs from the spinous process of the II thoracic vertebra down along the linea paravertebralis along the long muscles of the back to the IX thoracic vertebra, then arcs anteriorly, crossing the axillary lines.

2. Access for anterosuperior thoracoplasty according to N.V. Antelava; two incisions are made: the first - in the supraclavicular fossa parallel to the clavicle, followed by phrenico-alcoholization, scalenotomy and biting of the three upper ribs in the vertebral region; the second incision (after 10–12 days) is arcuate from the anterior edge of the axillary fossa along the posterior edge of the pectoralis major muscle, going around the mammary gland (complete removal of the upper three ribs and removal of the sternal sections of the IV, V and VI ribs for 6–8 cm).

3. Access to the apex of the lung according to Coffey-Antelava is through the supraclavicular fossa. The incision is made along the bisector of the angle between the clavicle and the sternocleidomastyl muscle. After crossing between ligatures v. transversa scapulae, v. jugularis externa, v. transversa colli move apart the fatty tissue with lymph nodes, push it upward a. transversa colli and downwards a. transversa scapulae and perform frenicoalcoholization, scalenotomy, resection of the three upper ribs and extrafascial apicolysis, i.e., liberation of the pleural dome from adhesions. The goal of the operation is to cause collapse and immobilization of the apical cavities.

4. The approach for subscapular paravertebral subperiosteal thoracoplasty according to Brouwer involves two incisions: the first incision is from the II thoracic vertebra down paravertebral and the second incision is parallel to the edge of the sternum, also in the vertical direction. The operation is carried out in two stages. The first moment: resection of the II–V ribs and the second moment – ​​resection of the first rib with an incision along the trapezius muscle (performed 2 weeks after the first operation).

5. Access for posterosuperior thoracoplasty is carried out by an incision made vertically in the middle of the distance between the spinous processes and the vertebral edge of the scapula from the level of its spine and arched at the angle of the scapula anteriorly to the posterior axillary line. In this case, the trapezius muscle is partially intersected, and deeper - the rhomboid muscles and the latissimus dorsi muscle (most often the upper seven ribs are removed; the size of the removed areas increases gradually, going from top to bottom, starting from 5 to 16 cm).

B. Access to the root of the lung

1. Access to the upper lobe vein according to L.K. Bogush for the purpose of ligating it is carried out by making a transverse incision 9–11 cm long from the middle of the sternum above the III rib on the right (for the right lung) and above the II rib on the left (for the left lung); The pectoralis major muscle moves apart along the fibers.

2. Access for ligation of the pulmonary artery according to Bakulev-Uglov is made using the same incisions as in the previous case. Ligation of the main branches of the pulmonary artery is done for bronchiectasis as a preliminary step before pneumonectomy and as an independent operation.

B. Approaches for lobectomy and pneumonectomy

Currently, two approaches are used to remove the lung or its lobe - posterolateral and anterolateral. Most surgeons prefer a posterolateral incision, as it creates freer access to the organ. Some surgeons use the anterolateral approach, based on the fact that the anatomical elements of the lung root are better exposed from the front with this approach.