Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3600_Библиотеки_им_академика_М_И_Перельмана
.pdf
134
M. Farid et al.
accompanies arteries, namely, the thoracodorsal vein with
a similar average length and diameter to the thoracodorsal
artery. Secondary venous drainage with concomitant veins
follows perforating secondary arteries [11]. The motor supply is from the thoracodorsal nerve (posterior cord brachial
plexus) which runs parallel to the vascular pedicle and innervates the LD muscle [16]. The sensory supply to the muscle is from the posterior branches of the lateral cutaneous
branches of intercostal nerves laterally, and lateral branches
of posterior rami (VI-XII) posteriorly. These branches are
valuable to preserve sensation when raising a reverse LD ap
based on intercostal perforators [11].
14.3 Preoperative Investigation
The free or pedicled LD ap is not associated with particular
preoperative investigations or imaging modalities [11]. This is
predominantly related to the consistent anatomy of the pedicle.
The underlying factor to determine the feasibility of raising LD
ap is a thorough examination to rule out any potential contraindications. Palpation of the muscle bulk with shoulder extension, medial rotation and adduction against examiner’s hand is
indicated [1]. A pinch test for skin paddle orientation is crucial
for the myocutaneous LD ap to determine if primary closure
is feasible. If the muscle function is thought to be compromised
due to previous injury (damage to the thoracodorsal pedicle),
pathology or surgery (posterolateral thoracotomy), then preoperative imaging (Doppler ultrasound) would be essential
to determine adequate LD perfusion. Nonetheless, a recent
study indicated the benet of reduction in surgical time and
identifying thoracodorsal pedicle with a preoperative CT-A in
those with previous axillary surgery or irradiation. Other relative contraindications to perform LD ap is insufcient donor
LD bulk, hobbies like climbing causing shoulder weakness and
inability to achieve lateral decubitus position to harvest the ap
[16, 17, 18, 19, 20].
14.4 Flap Design andMarkings
Flap design is based on LD landmarks, muscle harvest, skin
paddle and indication for reconstruction. Preoperatively, the
LD muscle is palpated along its anterior border with a pinch
test for skin paddle and forceful contraction to visualise it.
All markings in standing position preoperatively are checked
intraoperatively. Anteriorly, a vertical line is drawn from midaxillary point to mid-point between ASIS and PSIS to mark the
most anterior border of the LD muscle. Another line is oblique
above the inferior border of the scapula from the posterior axillary fold and along tip of the scapula to meet vertebral column,
where a vertical line is drawn marking the most posterior border of thoracolumbar fascia. A horizontal line marking the iliac
crest identies the most inferior part of the LD ap. The variability in marking is based on whether a skin paddle is raised or
a muscle-only ap. Intraoperatively, the patient is in the lateral
decubitus position with arm rested on a board at 90 degrees
shoulder and elbow exion [21]. The skin paddle is safely
marked within the borders of the LD muscle (tip of the scapula
superiorly, iliac crest inferiorly, vertebral column posteriorly).
Design of the paddle is either transverse (horizontal), oblique or
vertical (Figs.14.1, 14.2 and 14.3) [1]. Thoracodorsal perforators can be mapped with handheld Doppler to be incorporated
within the skin paddle [14].
Fig. 14.1 Marking of the
inferior border (iliac crest),
posterior border (vertebral
column) of LD ap and an
oblique skin paddle
Oblique LD Skin Paddle
Tip of Scapula
Iliac Crest
Vertebral Column
14 Thoracodorsal Artery Flap: Latissimus Dorsi Flap
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 14.2 Large skin paddle over LD muscle design to correspond to
defect size
Fig. 14.3 Borders of LD
muscle ap
135
14.5 Flap Raise/Elevation: AStep-by-Step
Guide
Step 1. Incision and Anterior Flap Dissection The
exact incision is based on either a muscle-only ap or a
myocutaneous ap. The rst incision is along the posterior axillary fold and corresponding to the anterior border
of the skin paddle (Fig. 14.4) reaching above the iliac
crest margin. Dissection to the fascial plane (Fig.14.5) is
continued and a subcutaneous ap is raised anterior to the
skin paddle to identify the anterior border of the LD muscle (Fig.14.6).
Step 2. Posterior Flap Dissection A subcutaneous ap is
raised posterior to the skin paddle edge to further dene the
posterior border of LD muscle (Fig.14.7). The muscle edges
are identied below the aps and the skin paddle is located
Superior border
Anterior border
Posterior border
Inferior border
136
Fig. 14.4 LD skin paddle
anterior incision along
posterior axillary fold
M. Farid et al.
LD Skin Paddle
Anterior Incision
Fig. 14.5 LD skin paddle
anterior incision down to
fascial plane
LD Skin Paddle –fascial incision
to identify anterior border
14 Thoracodorsal Artery Flap: Latissimus Dorsi Flap
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 14.6 LD skin paddle
anterior subcutaneous border
raised to reveal LD anterior
border
137
LD Skin Paddle –anterior
subcutaneous border raised
Fig. 14.7 LD skin paddle
posterior subcutaneous border
raised to reveal LD posterior
border
LD Skin Paddle –posterior
subcutaneous flap raised
138
M. Farid et al.
on the LD muscle. Multiple perforators from the posterior
intercostal arteries are encountered and isolated with ligaclips throughout LD dissection posteriorly (Fig.14.8).
Step 3. LD Muscle Raising The LD muscle is detached anteriorly along the posterior axillary line. Teres major and serratus
anterior muscles are identied by observing the muscle contrac-
Fig. 14.8 LD posterior
border and undersurface
demonstrating intercostal
perforators
tion and the orientation of the bres. The teres major is noted
above the tip of the scapula while the serratus anterior is between
the latissimus dorsi and pectoralis major muscle. Then, the
lower edge is separated from the iliac crest and thoracolumbar
insertion. The posterior border along midline is divided
(Fig.14.9), so the skin paddle with the LD muscle is free along
the anterior, inferior and posterior borders (Fig.14.10).
LD Muscle –Posterior
border raised
Fig. 14.9 LD posterior and
inferior borders raised with
skin paddle
Posterior Intercostal
Artery Perforator Ligated
LD Muscle
posterior border
LD Muscle
Inferior border
14 Thoracodorsal Artery Flap: Latissimus Dorsi Flap
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
139
Step 4. Identication of Thoracodorsal Pedicle Continue
to raise the LD myocutaneous ap from caudal to cranial.
The plane is identied along a layer of loose areolar tissue.
Dissection is away from the LD muscle, ensuring the vascular pedicle is preserved (Fig.14.11). The pedicle location is
consistent being few centimetres from the anterior edge of
LD muscle cranially. Retraction of the pedicle allows visualisation of the remaining LD muscle and its attachment.
Fig. 14.10 LD posterior, inferior, anterior border elevation
Step 5. Muscle Separation As dissection progresses caudally, identify the tip of the scapula which marks the superior
border of LD ap. Continue dissection of the LD from the
inferior border of the trapezius muscle. Anteriorly, ensure
that the serratus anterior is separated from LD muscle on the
inferior- posterior margin (Fig. 14.12). Careful attention is
needed when reaching this point to separate muscles rather
than en bloc dissection of both muscles which is a common
pitfall.
Step 6. Flap Division/Isolation The proximal humeral
insertion is identied through careful dissection along a tunnelled plane. The vascular pedicle underneath the LD tendon
is protected with operating surgeon’s ngers while carefully
dividing the tendon at insertion. The ap is raised with its
vascular supply at this level as free ap or kept attached as a
pedicled ap (Fig.14.13). A headlight or lighted retractor is
useful in this phase of the operation to clearly identify the
tendon insertion and the pedicle.
Step 7. Closure The donor site is closed in a tensionless
fashion; multilayered (2/0 PDS and 3/0 Monocryl) and
two drains are left in situ (Fig. 14.14). Towel clips are
used to help facilitate closure sequentially (Figs. 14.15
and 14.16).
Fig. 14.11 LD muscle
undersurface demonstrating
thoracodorsal vascular pedicle
and pedicle supplying the
serratus anterior muscle
LD Muscle
Branch to
serratus anterior
Thoracodorsal
artery pedicle
140
Fig. 14.12 Continuation of
anterior-superior LD muscle
and separation from the
serratus anterior
M. Farid et al.
Fig. 14.13 LD ap raised
reaching superior border of
tendinous insertion
LD
Serratus Anterior
LD tendinous insertion
superior border
14 Thoracodorsal Artery Flap: Latissimus Dorsi Flap
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
141
Fig. 14.14 Insertion of two drains and sequential closure of donor site
Fig. 14.16 LD donor site
closure, dressing applied and
drains secured
Fig. 14.15 Use of towel clip to facilitate tensionless closure of donor
site
Drains
compression in the axillary tunnel. The thoracodorsal nerve
14.6 Core Surgical Techniques inFlap
Dissection
Skin Paddle Temporary interrupted sutures are placed between
the skin paddle and LD muscle to prevent shear that may injure
perforators (Fig.14.17). The orientation of the skin paddle is ideally based on perforators along the perforators of the thoracodorsal artery.
Thoracodorsal Pedicle Protection A cuff of the fascia and
fat is to be kept around the pedicle to prevent kinking or
may be divided to avoid muscle contraction at recipient site
and animation from shoulder movement.
Venous Congestion The creation of the tunnel should allow
for the surgeon’s hand to t at least prior to detachment of
humeral insertion of the LD.The main issue with a narrowed
tunnel is risk of venous congestion secondary to vascular
compression of a pedicled ap.
Arc of Rotation The anterior arc allows the ap to reach
the trunk and neck while posterior arc for vertebral defects
142
Fig. 14.17 Interrupted
temporary sutures to stabilise
skin paddle to LD muscle
M. Farid et al.
Interrupted
Sutures
between
LD and
skin paddle
Fig. 14.18 Division of LD
muscle tendinous humeral
insertion
Division
of LD
tendinous
Humeral
insertion
(cervical to lumbar). This is determined by humeral attachment, other muscle insertion (pectoralis minor) and vascular
perforators of lumbar, intercostal or serratus anterior muscles. The subscapular artery recruitment would increase the
length and diameter of the pedicle. The length and size of the
ap also determine arc of rotation in reaching defect.
Humeral Insertion Division This constitutes one of the
nal steps allowing the ap to mobilise further or detach as a
free ap. This is particularly crucial for ipsilateral shoulder
defect reconstruction or breast reconstruction as a pedicled
ap (Fig.14.18).
14 Thoracodorsal Artery Flap: Latissimus Dorsi Flap
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
14.7 Clinical Scenario
Case 1 Right shoulder reconstruction with pedicled LD
ap. This 67-year-old gentleman had a total shoulder arthroplasty. The prosthesis became infected and was subsequently
removed by the orthopaedic team. After debridement a pedicled myocutaneous LD ap was performed to cover exposed
shoulder joint. The patient had an uneventful recovery
(Figs.14.19, 14.20, 14.21, and 14.22).
Fig. 14.19 Right shoulder
defect post-debridement and
removal of prosthesis
143
Fig. 14.20 LD myocutaneous ap islanded
LD muscle skin paddle
Right Upper Shoulder Defect
Соседние файлы в папке Библиотека им академика М.И. Перельмана