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_630_Библиотеки_им_академика_М_И_Перельмана
.pdf
1
Folded sheet
under shoulders
Transverse incision
2
Sternal notch
3
Thyroid cartilage
Incision through
skin, fat, and muscle
4
Anterior
jugular vein
7
Sternohyoid
muscle
Index nger
on trachea
Pretracheal
venous plexus
8
Isthmus
of thyroid
Trachea palpated
by index nger
5
6
Ligated anterior
jugular vein
Hook elevating
9
the tracheal cartilage
10
Incising
the trachea
Knife spreading
the incision
Cruciate
incision
Tape holding tracheotomy
tube in place
403
PLATE
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
187
INDICATIONS Indications for percutaneous dilational tracheotomy (PDT)
are similar to those for open tracheotomy (OT) and include providing a
portal for pulmonary toilet in debilitated patients or patients with neuromuscular disease, and providing a means for prolonged ventilatory support.
Similar to OT, PDT should be considered in patients requiring mechanical
ventilation to days following initial intubation. If prolonged intubation
is expected based on patient circumstances (high spinal cord or traumatic
brain injury), earlier tracheotomy may be considered.
Advantages of PDT over a prolonged translaryngeal intubation include
a reduced risk of direct endolaryngeal injury, decreased risk of ventilatorassociated pneumonia (VAP), more e ective pulmonary toilet, increased
airway security and ease in weaning from mechanical ventilation, improved
patient comfort with decreased requirements for sedation, and earlier discharge from the intensive care unit (ICU). In suitable patients, the major
advantage of PDT to OT is that it is performed as a bedside procedure,
obviating the need for operating room time and patient transport, as well
as being signi cantly more cost e ective.
When evaluating a patient for PDT, a thorough history and physical
examination will identify anatomic contraindications, including previous
di cult tracheal intubation, morbid obesity, obscure cervical anatomy, goiter, short thick neck, previous neck surgery (especially tracheotomy), cervical infection, facial or cervical trauma/fractures, halo traction, or known
presence of subglottic stenosis. Physiologic contraindications to PDT
include hemodynamic instability, requirement of FiO
end-expiratory pressure (PEEP) > cm H
thy. Cervical deformity, previous radiation therapy, edema, or tumor can
also make tracheal cannulation di cult and increase the risk of morbidity.
e need for emergency control of the airway is an absolute contraindication to PDT.
Complications of PDT include injury to posterior tracheal wall resulting
in a tracheoesophageal stula, injury to cupula of lung with pneumothorax,
tracheal ring rupture, recurrent laryngeal nerve injury, paratracheal insertion, tube dislodgement with loss of airway, stomal hemorrhage, peristomal
cellulitis, subglottic or tracheal stenosis, or a tracheoinnominate stula. A
guidewire placed too deep in the trachea during the procedure can potentially cause bronchoconstriction or lung injury.
PREOPERATIVE PREPARATION Several components are required for
PDT placement, and these include bronchoscope, medications, tracheotomy insertion kit, and tracheotomy tube. Kits are available for either the
single or the serial dilator technique, and either a standard or a percutaneous tracheotomy tube may be used. e tube cu must be checked for leaks
and then be well lubricated prior to placement. We recommend that the
operator develop a materials checklist to facilitate gathering of the critical
components prior to the procedure.
ANESTHESIA A three-drug regimen including sedative, analgesic, and
nondepolarizing muscle relaxant agents facilitates placement. It is important to maintain immobility during insertion of the introducer needle,
guidewire, dilators, and tracheotomy tube to prevent inadvertent punc-
T, P D
> ., a positive
O, or uncontrolled coagulopa-
ture of the posterior tracheal wall. Direct manipulation of the trachea
(particularly during dilation) is cough provoking, thus the recommendation for paralytics.
POSITION Positioning is aided with a shoulder roll to allow maximal
extension of the neck during the procedure. Neck extension elevates the
trachea out of the mediastinum and displaces the chin to allow greater
access to the anterior neck. e palpable anatomic landmarks are shown in
figure 1. e exposed neck can then be prepped with a standard surgical
scrub and sterile drapes applied.
OPERATIVE PREPARATION e procedure requires two operators: one
performing the tracheotomy and the second providing tracheal visualization with exible beroptic bronchoscopy. Identi cation and transillumination of the area between the second to fourth tracheal rings with visual
con rmation of proper tracheotomy tube positioning improves success
in patients with poorly palpable surface anatomy. A respiratory therapist
maintains the endotracheal tube (ETT) position and ventilation with
oxygen. A er all equipment is gathered, the correct level of placement
of the ETT being used for control of ventilation is veri ed by passing a
beroptic bronchoscope into the trachea by way of a special anesthesia
adapter (figure 2a). e skin is prepped with an antiseptic, and a sterile
draping is done.
INCISION AND EXPOSURE e tracheotomy is performed between the
second and fourth tracheal rings. Placing the tracheotomy tube above
this level may result in injury to the rst ring or cricoid cartilage, which
increases the risk of subglottic stenosis or bleeding from the thyroid
isthmus. Placing it too low can predispose to tracheoinnominate stula. A
point midway between the cricoid cartilage and the sternal notch is palpated
and marked. Local anesthesia is in ltrated in the skin and subcutaneous
tissues, as well as into the trachea (figure 3). A vertical skin incision is
made in the midline from the level of the cricoid cartilage and extending
. to . cm downward.
e second or third tracheal interspace is visualized in preparation for
the tracheotomy.
DETAILS OF PROCEDURE e ETT should be withdrawn to cm above the
anticipated needle insertion site under bronchoscopic or transillumination
guidance. In average-sized adults, the tube can be withdrawn to about the
-cm mark at the teeth. e bronchoscope can show indentation of the trachea with palpation, locating the tracheotomy site. A -gauge sheathed introducer needle is then advanced in the midline, angling posterior and caudad
(figure 4). Aspiration with an attached syringe containing a small amount
of water will indicate when the tracheal wall has been punctured. Puncture of
the trachea is con rmed bronchoscopically to ensure midline needle placement (figure 4). e stylet or needle is removed leaving the outer cannula
in the trachea. e “J”-tip guidewire is advanced through the cannula into
the trachea toward the carina (figure 5). A er cannula removal, a short
-French mini-dilator is advanced over the guidewire using a slight twisting
motion and then removed (figure 6).
CONTINUES
404
405
PLATE
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
188
DETAILS OF PROCEDURE For the single dilator systems,
activate the coating by immersing the distal end of the dilator in sterile
water or saline. Slide the dilator up to the safety ridge on the guiding catheter, then with concurrent bronchoscopic visualization, advance the dilator
assembly using the Seldinger technique over the guidewire into the trachea.
A er passage to the appropriate depth (marked on the dilator), it is withdrawn and advanced several times to dilate the tract (figure 8). For multiple dilator systems, serial dilation is performed with incrementally larger
dilators (figures 7 and 8).
The lubricated tracheotomy tube (loaded on a dilator/guiding
catheter unit) is then advanced over the guidewire into the trachea
(figure 9). The guidewire and dilator are then removed, leaving the
tracheotomy tube in place. The cuff of the tracheotomy tube is inflated
and the inner cannula inserted. The ventilator tubing or an Ambu bag
device is disconnected from the ETT and attached to the PDT tube
(figure 10). The translaryngeal ETT is not removed until correct
intratracheal placement of the tracheotomy tube has been confirmed
visually by bronchoscopy (figure 10).
T, P D
CLOSURE e incision is typically just large enough to accommodate the tra-
cheotomy tube and does not require closure. Nonabsorbable suture is used to
secure the tracheotomy cu to the skin and securing tapes are placed to hold
the PDT tube in place usually over a dry sterile gauze dressing (figure 11).
POSTOPERATIVE CARE A chest x-ray is ordered to con rm tracheotomy
tube position and evaluate for pneumothorax or pneumomediastinum. Elevate
the head of the patient’s bed to degrees immediately following the procedure and suction any bloody secretions. e tracheal tapes and cu sutures
should not be removed until the rst tracheotomy tube change. Ideally, the
rst tube change should not be attempted until the tract has matured, which
requires at least to days. If accidental decannulation occurs within the rst
days of PDT, an oral ETT should be placed instead of attempting reinsertion
of the tracheotomy tube through the stoma. Dislodgement of a tracheotomy
tube that has been in place weeks or longer can o en be managed simply by
replacing the tube through the mature tract. Humidi cation and frequent tracheal suctioning is recommended to prevent inspissation of secretions, which
can result in mucous plugging and tracheotomy tube obstruction. ■
406
407
PLATE
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
189
INDICATIONS ere are two major indications for radical neck dissection.
e rst is for the removal of palpable metastatic cervical lymph nodes,
and the second is for the removal of presumed occult metastatic disease in
the neck. e latter indication has been termed “prophylactic neck dissection.” “Elective neck dissection” better describes this operation, since it is
not intended to prevent metastasis but to remove occult metastatic lymph
nodes.
Before radical neck dissection is performed, the surgeon must have
assurance that the primary lesion can be controlled either by simultaneous
en bloc removal with the radical neck dissection or by radiation therapy.
However, curative radiation for cervical metastases must be con ned to a
single node or small group of nodes, because patients cannot tolerate radical surgery plus radiation therapy to the entire neck. Node xation, invasion of adjacent tissues, bilateral or contralateral, and distant metastases are
relative contraindications to this procedure. In general, radical dissection
of the cervical lymph nodes in a patient who is a reasonable surgical risk
remains the preferred treatment for metastatic disease of the neck.
e usual patient with metastatic cancer in the neck from an unknown
primary source should be treated as if the primary tumor were controlled.
If surgical treatment of the cervical metastasis is deferred until the primary
neoplasm becomes obvious, the opportunity to control the neck disease is
sometimes lost.
PREOPERATIVE PREPARATION e patient’s general medical status
should be assessed and corrective measures instituted for any treatable
abnormalities. Intraoral ulcerations represent a potential source of pathogenic material. e liberal preoperative use of nonirritating solutions (e.g.,
diluted hydrogen peroxide) can signi cantly reduce the danger of postoperative infection.
Only rarely will primary cancers of the hypopharynx, cervical esophagus, larynx, and so forth produce respiratory obstruction or interference
with alimentation signi cantly enough to require preoperative tracheostomy or insertion of a feeding tube.
ANESTHESIA e major consideration is a free airway. e equipment
should allow free movement of the head and easy access to the endotracheal tube.
e choice of anesthetic agents varies. Consideration must be given to
the individual needs of the patient and to the need for cautery. General
endotracheal anesthesia is preferred.
Complications at surgery are the carotid sinus syndrome, pneumothorax, and air embolus. e carotid sinus syndrome, consisting of hypotension, bradycardia, and cardiac irregularity, can usually be corrected by
in ltrating the carotid sinus with a local anesthetic agent. Intravenous
atropine sulfate will usually control the syndrome if the local anesthetic
fails. Pneumothorax may result from injury of the apical pleura. It is
treated with a closed-tube thoracostomy through the second intercostal
space anteriorly.
POSITION e patient is placed in a dorsal recumbent position. e head
of the table is somewhat elevated to lessen the blood pressure, particularly
the venous pressure, in the head and neck and thus reduce blood loss. e
bend of the neck should be placed on the hinge of the headpiece so that the
head may be either exed or extended as needed. A small sandbag should
be placed under the shoulders so that the head and neck are extended while
the chin remains on a plane horizontal with the shoulders.
OPERATIVE PREPARATION e patient’s hair should be completely cov-
ered by a snug gauze cap to avoid contamination of the operative eld. Once
the patient has been correctly positioned on the table, the skin is prepared
routinely. e preparation should include a large portion of the face on the
R N D
side of the dissection, the neck from the midline posteriorly to the sternocleidomastoid muscle of the opposite side of the neck, and the anterior
chest wall down to the nipple. e entire eld of dissection is outlined with
sterile towels secured by either skin staples or sutures. A large sheet about
the head and neck area completes the draping.
INCISION AND EXPOSURE Radical neck dissection is described and
illustrated. Radical neck dissection refers to the removal of all ipsilateral
cervical lymph node groups extending from the inferior border of the
mandible superiorly to the clavicle inferiorly and from the lateral border of
the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the
digastric muscle anteriorly to the anterior border of the trapezius muscle
posteriorly. Today most surgeons employ a modi ed radical neck dissection or functional neck dissection.
Modi ed radical neck dissection is de ned as the excision of all lymph
nodes routinely removed in a radical neck dissection with preservation of
one or more nonlymphatic structures (spinal accesory nerve , internal jugular vein, and strenocleidomastoid muscle).
e surgeon stands on the side of the proposed dissection. Many types
of incision have been used. e incision illustrated allows maximum anatomic visualization, whereas many surgeons prefer two nearly parallel,
oblique incisions with an intervening skin bridge that is broadly based
at both ends. e most useful incision is a modi cation of the double
trifurcate incision (figure 1), in which the angles of the skin aps are
obtuse and connected by a short vertical incision. Some prefer to make
only the upper transverse incision with a single vertical extension that proceeds to the sternocleidomastoid muscle edge and then takes a lazy-S posterior course to the clavicle, as shown by the dashed line in figure 1. e
upper arm of the double Y extends from the mastoid process to just below
the midline of the mandible. e lower arm extends from the trapezius in
a gentle curve to the midline of the neck. is incision allows the greatest
exposure of the neck area while producing a good cosmetic result. Creation of the skin aps includes the platysma muscle (figure 2). In most
instances, if the skin aps are developed without inclusion of the platysma
muscle, poor wound healing and uncomfortable scarring with xation of
the skin to the deep neck structures will result. e two lateral skin aps
are turned back, the posterior ap is extended as far as the anterior edge of
the trapezius muscle, and the anterolateral ap is extended to expose the
strap muscles covering the thyroid gland. In developing the superior skin
ap, care must be taken to preserve the mandibular marginal branch of the
facial nerve (figure 2). is branch of the facial nerve innervates the lower
lip. In the majority of cases the nerve can be identi ed as it crosses over the
external maxillary artery and the anterior facial vein beneath the platysma
muscle. Usually, it lies parallel to the lower border of the mandible. Occasionally, the nerve will lie much higher, and it may not be visualized during
the neck dissection. As suggested by others, a useful maneuver to preserve
this nerve is to identify the external maxillary artery and the anterior facial
vein at least cm below the lower border of the mandible (figure 2). A er
identi cation, the nerve is retracted and covered by securing the upper end
of the vascular stump to the platysma muscle. If obvious or strongly suspected tumor is present in this area, the branches of this nerve are sacri ced
voluntarily. e inferior skin ap should be re ected down to expose the
superior aspect of the clavicle.
DETAILS OF PROCEDURE Once the four skin aps have been created, the
inferior limits are outlined. e sternocleidomastoid muscle is severed just
above its insertion into the clavicle and the sternum (figure 3). e dissection is then shi ed to the posterior cervical triangle. Using both sharp and
blunt dissection, the surgeon exposes the anterior border of the trapezius
muscle (figure 4).
CONTINUES
408
1
Incision
External maxillary artery
and facial vein
External jugular vein
Marginal mandibular branch
of the facial nerve
2
Anterior jugular vein
Greater auricular nerve
Mandible
Tail of parotid gland
3
Cervical cutaneous nerve
4
Hyoid bone
External
jugular vein
Sternocleidomastoid
muscle
Clavicle
Trapezius muscle
409
PLATE
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
190
DETAILS OF PROCEDURE As one approaches the most
posteroinferior angle of the neck dissection, the rst important structure to be seen is the external jugular vein. It is ligated and divided at
the posteroinferior corner (figure 5). en the posterior cervical triangle can be completely cleaned of its areolar and lymphatic tissues. e
spinal accessory nerve should be preserved as long as it is not involved
with tumor or enlarged lymph nodes. e spinal accessory nerve must
be divided (figure 6) if clean dissection of this area is impossible. Dissection is carried forward along the superior aspects of the clavicle. e
posterior belly of the omohyoid muscle and the transverse cervical artery
and vein are visualized (figure 6). e posterior belly of the omohyoid
muscle is severed (figure 7) in order to allow greater exposure of the
deep muscles and the brachial plexus. e phrenic nerve is found lying
upon the anterior scalene muscle between the brachial plexus and the
internal jugular vein (figure 8a). To avoid paralysis of the correspond-
ing leaf of the diaphragm, this nerve should be preserved unless it has
R N D
been invaded by the cancer. e phrenic nerve lies upon the scalenus
anticus muscle. Its exposure has been facilitated by the previous transection of the lower end of the sternocleidomastoid muscle. Just medial to
the phrenic nerve, the internal jugular vein is seen (figure 8a). is
vessel, which lies within the carotid sheath (figure 8b), is dissected free
(figure 9), doubly ligated by a stick tie on the inferior ligation, and
then divided (figure 10). By division of the internal jugular vein, avoiding the thoracic duct on the le side, the dissection has been carried
down to the prevertebral fascia overlying the deep muscle structures of
the neck. e inferior compartment of the neck is then outlined medially
by division of the pretracheal fascia just lateral to the strap muscles of
the thyroid (figure 11). is facilitates exposure of the common carotid
artery, which permits the dissection to be carried superiorly. With the
lateral limits of the dissection de ned and the common carotid artery
exposed, dissection is started inferiorly and extended superiorly, following the oor of the neck or the prevertebral fascia.
CONTINUES
410
External jugular vein
5
7
Omohyoid muscle
6
Spinal
accessory nerve
External jugular vein
8a
Middle
scalene
muscle
Brachial
plexus
Anterior
scalene
muscle
Subclavian
vein
Divided spinal
accessory nerve
Omohyoid muscle
Stylohyoid muscle
Brachial
plexus
9
Phrenic nerve
Internal
jugular vein
8b
Vagus nerve
Right lymphatic duct
Phrenic nerve
Phrenic nerve
Anterior
Posterior
Carotid sheath
Carotid sheath
Internal jugular vein
Medial
Clavicle
Phrenic nerve
Vagus nerve
10
Internal jugular vein
11
Internal jugular vein
Carotid artery
411
PLATE
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
191
DETAILS OF PROCEDURE is dissection consists of turn-
ing up the areolar and lymphoid tissues of the neck lying along the course
of the internal jugular vein, which is re ected upward with these structures (figure 12). All loose areolar tissue about the carotid artery is completely removed. is dissection may be carried out without danger to any
of the vital structures, since both the vagus nerve and the common carotid
artery are in full view and the other important nerve structures—namely,
the phrenic nerve and the brachial plexus—are covered by the prevertebral
fascia (figure 12). As the dissection proceeds superiorly, branches of the
cervical plexus are seen penetrating the fascia; they should be divided as
they emerge through the fascia.
In the anterior part of this phase of the dissection, tributaries of the
superior thyroid, superior laryngeal, and pharyngeal veins are seen as they
cross the operative eld to enter the jugular vein. ese may be ligated as
the dissection proceeds. e carotid bifurcation can usually be identi ed by
the appearance of the superior thyroid artery (figure 12). With reasonable
care this vessel can be preserved. A er exposure of the bifurcation, dissection proceeds superiorly with some caution to expose the hypoglossal
nerve as it crosses both the internal and external carotid arteries cm or so
above the carotid bifurcation (figure 12). e surgeon should watch for
this nerve as it emerges deep to the posterior belly of the digastric muscle.
R N D
e hypoglossal nerve continues forward into the submaxillary triangle,
where it lies inferior to the main submaxillary salivary duct.
A er identi cation of the hypoglossal nerve, attention should be directed
to the submental area of the neck. e fascia from the midline of the neck
is divided (figure 13). is facilitates exposure of the anterior belly of the
digastric muscle and the underlying mylohyoid muscle. Complete exposure of the digastric muscle in the submental compartment is necessary
to remove the paired submental nodes (figure 13 or 14). By following the
anterior digastric muscle from anterior to posterior, the submaxillary gland
is exposed. e submaxillary gland is dissected from its bed by approaching the gland anteriorly (figure 15). By mobilizing the gland from its bed
from anterior to posterior, the lingual nerve, which lies in the most superior
aspect of the submaxillary space, the submaxillary duct, which lies in the
midportion of the compartment, and the hypoglossal nerve, which lies in
the most inferior aspect of the area, are identi ed (figure 16). is exposure may be eased by traction on the submaxillary gland with a tenaculum.
is allows the surgeon to visualize the posterior edge of the mylohyoid
muscle and to retract this muscle anteriorly (figure 16), thereby exposing the three important structures: the lingual nerve, the salivary duct, and
the hypoglossal nerve. To facilitate removal of the submaxillary gland, the
major salivary duct is divided and ligated.
CONTINUES
412
Соседние файлы в папке Библиотека им академика М.И. Перельмана