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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_747_Библиотеки_им_академика_М_И_Перельмана
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224 Postpneumonectomy empyema
https://t.me/med1917
After ligation, the ventral end of the flap is divided.
3e
3e
Operation 225
https://t.me/med1917
The parietal pleura is
3f,g
tended course of the flap.
removed along the in-
3f
3g
226 Postpneumonectomy empyema
https://t.me/med1917
3h,i,j
The flap is fixed to the bronchial stump and to
3h
the thoracic wall with interrupted sutures.
3i
Operation 227
https://t.me/med1917
EXTRATHORACIC MUSCLE FLAPS
All extrathoracic flaps can also be used to obliterate the
pleural space in case of recalcitrant empyema or fistula recurrence. Closed suction drains are left in the body wall donor
sites.
3j
THE PECTORALIS MAJOR MUSCLE FLAP
Like the diaphragm, the m. pectoralis major usually is not
damaged by thoracotomy. If this muscle is used, the loss of
the anterior axillary fold has to be accepted as a cosmetic
handicap.
228 Postpneumonectomy empyema
https://t.me/med1917
4a
An incision is made along the lower margin of the
4a
extension of a posterolateral thoracotomy. The lateral end of
the muscle, creating the anterior axillary fold, is then identified, and the muscle is separated from the underlying m. pectoralis minor. Then, the subcutaneous layer is separated from
the muscle surface until the muscle insertion along the lateral
border of the sternum, and the inferior margin of the clavicle
is visible.
m. pectoralis major to the anterior axillary fold or by
Operation 229
https://t.me/med1917
4b
The sternal attach-
4b,c
cautery, and the flap is rotated
upwards so that its inferior surface
with the vascular pedicle can be
identified. The muscle is divided
along its clavicular origin between
the sternum and the vascular pedicle. The lateral end of the muscle is
divided, again preserving the thoracoacromial artery.
ment is divided with
Thoracoacromial
artery
Pectoralis minor
4c
230 Postpneumonectomy empyema
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The lateral muscle
4d–e
prevent hematoma. Then, 5–10 cm of
the second or third rib are removed in
the midclavicular line to allow tension-free intrathoracic transposition
of the flap.
stump is oversewn to
4d
4e
THE LATISSIMUS DORSI FLAP
https://t.me/med1917
Normally, this muscle is divided during dorsolateral
5a
proximal to the division can still be used as a flap. The latissimus dorsi muscle is approached via a dorsolateral thoracotomy, and the skin is separated from the muscle surface.
thoracotomy. However, sometimes the portion
Operation 231
The anterior border of the muscle is identified and
5b
bluntly dissected.
the plane between the latissimus and the serratus
5a
5b
232 Postpneumonectomy empyema
https://t.me/med1917
The muscle is divided at its posterior and the inferior
5c
attachment.
The flap is elevated towards the axilla, where the
5d
face. The branches of the thoracodorsal artery to the serratus
anterior muscle can be divided. Between 5 and 10 cm of the
second or third rib are resected in the posterior axillary line as
a portal of entry into the thorax.
thoracodorsal artery is visualized on its costal sur-
5c
Thoracodorsal artery
Lateral
thoracic
artery
5d
Operation 233
https://t.me/med1917
THE SERRATUS ANTERIOR FLAP
During primary thoracotomy, the serratus anterior muscle
may have been divided in its lower fifth. Usually, enough
muscle is left to allow intrathoracic transposition. If necessary, the branch of the thoracodorsal artery to the serratus
After posterolateral thoractomy, the anterior margin
6a
separated from the underlying serratus anterior muscle.
Then, the latissimus dorsi muscle is transected.
of the latissimus dorsi is elevated and bluntly
can be divided. Although winging of the medial border of the
scapula may occur after flap dissection, very few patients
complain about that problem. If possible, the most cranial
two to three attachments of the serratus anterior should be
preserved to avoid scapular winging.
6a
After the latissimus has been turned upwards, the
6b
the serratus anterior. Then, the chest wall attachments are
divided with cautery, preserving the lateral thoracic artery
and the most cranial insertion at the first and second ribs.
6c
rior and from inferior to superior to the scapular tip.
lateral thoracic artery is identified on the surface of
The serratus anterior muscle is transected at the
lower margin and mobilized from anterior to poste-
6b,c
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