RU2815285C1 - Method of forming a tracheostoma in coagulopathy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to anaesthesiology, neurosurgery, surgery, traumatology, otorhinolaryngology, oncology. When forming a tracheostoma on the anterior surface of the neck in a projection of the trachea, an isosceles triangle is constructed, the vertex of which is a jugular notch. An upper horizontal line is drawn at distance of 5 cm from the apex of the triangle, from which a skin incision of 3.5 cm is made vertically downwards along the middle line of the neck. Before dissection of tissues along the access line, tissues are coagulated. Then tissue is moved apart with a clamp. After tracheal dissection, wound edges on trachea are coagulated. Before wound closure, a haemostatic sponge is inserted into the wound and tamponed with gauze trailers from above and below the tracheostomy cannula. Then the upper and lower corners of the skin wound are closed. Gauze trailers are removed from wound on 3rd postoperative day.

EFFECT: method makes it possible to form a tracheostoma in coagulopathy, to improve the results of treatment in patients with impaired function of external respiration and coagulopathy, reduce complications at the moment of tracheostomy formation and in the early postoperative period.

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Description

The method of forming a tracheostomy for coagulopathy relates to medicine, it makes it possible to facilitate the surgical technique and reduce complications in the postoperative period, and can be used in anesthesiology, neurosurgery, surgery, traumatology, otorhinolaryngology, oncology, as well as in all patients in need of resuscitation care.

There is a known method of open tracheostomy, which consists in dissecting the skin in the longitudinal or transverse direction, separating the soft tissues and the thyroid gland to the anterior wall of the trachea. Depending on the level of intersection of the tracheal wall with a scalpel, an upper tracheostomy is identified - above the isthmus of the thyroid gland, a middle one at the level of the isthmus with its resection, a lower one - below the level of the isthmus of the thyroid gland, the tracheal aperture is carried out in an open way using a Trousseau retractor from a standard tracheostomy set with insertion into the trachea tracheostomy cannula [1].

The disadvantage of this method is the absence of dilatation of the tracheal aperture, which may be accompanied by injury to both the tracheal mucosa and the cuff of the tracheostomy cannula.

There is a known method of forming a temporary tracheostomy by making a cruciform incision in the anterior wall of the trachea [2].

The disadvantage of this method is the absence of an element of dilatation of the tracheal aperture, which can lead to damage to the cuff of the tracheostomy cannula and trauma to the tracheal mucosa when the tracheostomy cannula is inserted into the trachea using a Trousseau retractor.

A well-known puncture-dilatation method of tracheostomy using the Ciaglia method, including puncture of the anterior wall of the trachea with a cannula 1.5 cm above the jugular notch, strictly along the midline of the neck under the control of a bronchoscope and bougienage of the soft tissues and trachea along a flexible conductor with a dilator to a mark corresponding to the expansion of 38 Fr with subsequent insertion of a tracheostomy cannula into the trachea [3].

The disadvantage of this method is bleeding from the wound, the need to use a bronchoscope, inconvenience of use, the technique involves the formation of a dilated tracheal aperture in the interannular space without crossing the tracheal ring, which can cause trauma to the tracheal wall and its inconsistency with the diameter of the tracheostomy cannula. The technique cannot be used in patients with obesity, an enlarged thyroid gland, coagulopathy, or with an increased risk of tissue bleeding.

There is a known method of transcutaneous puncture-dilation tracheostomy according to the Griggs method, including percutaneous puncture of the soft tissues of the neck and anterior wall of the trachea, passing a conductor through the cannula under bronchoscopy control, and dilatation of the soft tissues and the anterior wall of the trachea along the conductor with a Howard-Kelly clamp to a diameter of 38 Fr, followed by insertion of a tracheostomy cannula into the trachea through a guidewire [4].

The disadvantage of this method is bleeding from the wound, the need to use a bronchoscope, inconvenience of use, the technique involves the formation of a dilated tracheal aperture in the interannular space without crossing the tracheal ring, which can cause trauma to the tracheal wall and its inconsistency with the diameter of the tracheostomy cannula. The technique cannot be used in patients with obesity, an enlarged thyroid gland, coagulopathy, or with an increased risk of tissue bleeding.

There is a known method of forming a dilated puncture tracheostomy in patients with multiple organ failure, which includes preventing respiratory disorders during surgery by extubating the trachea and performing artificial ventilation through a laryngeal mask [5].

The disadvantage of this method is bleeding from the wound, the need to use a bronchoscope, inconvenience of use, the technique involves the formation of a dilated tracheal aperture in the interannular space without crossing the tracheal ring, which can cause trauma to the tracheal wall and its inconsistency with the diameter of the tracheostomy cannula. The technique cannot be used in patients with obesity, an enlarged thyroid gland, coagulopathy, or with an increased risk of tissue bleeding.

There is a known method of temporary tracheostomy in adults by making a longitudinal incision of the skin over the trachea, opening the anterior wall of the trachea in a blunt manner with spreading the jaws of the clamp in the transverse direction, and then bougiening the tracheal aperture with a finger using rotational movements with visual and tactile control. Hemostasis is carried out by obturation of the wound cavity with a tracheostomy cannula inserted along the trajectory of the finger [6].

This technique is taken as a prototype of the method of forming a tracheostomy for coagulopathy, since it combines the advantages of open surgery and the dilatation technique and subsequent hemostasis from the wound by obstruction.

The purpose of the invention is to improve the configuration of the wound of the anterior wall of the trachea when performing tracheostomy, reducing the incidence of damage to the tracheostomy cuff, the risk of reducing damage to the tracheal mucosa, ease of use and reducing treatment time.

This goal is achieved by the fact that the incision of the skin and soft tissues in the projection of the trachea is selected by constructing an isosceles triangle, the apex of which is the jugular notch, while at a distance of 5 cm from the apex of the triangle, an upper horizontal line is drawn, from which an incision is made vertically down the midline of the neck skin 3.5 cm long, before tissue dissection along the access line, tissue coagulation is performed, and then they are pulled apart with a clamp, after trachea dissection, the edges of the wound on the trachea are coagulated, before suturing the wound, a hemostatic sponge is inserted into it and tamponed with gauze turundas above and below the tracheostomy cannulas, and then the upper and lower corners of the skin wound are sutured, the turundas are removed from the wound on the 3rd day after surgery.

A comparison of the proposed method with other known methods of tracheostomy has shown that it meets the criteria of the invention.

The method is illustrated with graphic material.

In fig. Figure 1 shows a longitudinal image of the neck at the level of tracheostomy formation with the construction of an isosceles triangle for making a skin incision.

The method of forming a tracheostomy for coagulopathy is performed under general anesthesia with artificial ventilation (ALV) through an endotracheal tube, the skin incision is carefully planned to reduce the risk of tissue bleeding. To do this, construct an isosceles triangle (1) on the neck, the apex of which is the jugular notch of the sternum (2), while at a distance of 5 cm from the apex of the triangle, an upper horizontal line (6) is drawn, from which vertically down the midline of the neck (5) a skin incision (7) 3.5 cm long is made, in Fig. 1 the left (3) and right (4) walls of the trachea are indicated, then coagulation of all bleeding areas in the wound is carried out, the tissues are moved apart with a Billroth clamp to the fascia of the neck. Then I coagulate the line of the intended incision on the fascia of the neck and spread it with a Mosquito and Billroth clamp to the required size, the wound on the neck is expanded with Farabeuf hooks. The pretracheal muscle group in the projection of the incision is also first coagulated and then pulled apart using Mosquito and Billroth clamps. After this, along the line of the intended incision, the 4th fascia of the neck and the tissue of the pretracheal space are coagulated, followed by spreading all the tissues to the anterior wall of the trachea using Mosquito and Billroth clamps. Using a single-tooth hook, pull the anterior wall of the trachea up, clean the entire anterior wall of the trachea so that 3 rings of the trachea are visible. A vertical incision of the trachea is made with the intersection of one tracheal ring and a transverse incision in the interring space so that a cross-shaped incision is obtained. After this, the edges of all incisions on the tracheal wall are coagulated until the bleeding stops completely. According to the standard technique, a tracheostomy cannula is inserted into the trachea, the cannula cuff is inflated, and mechanical ventilation is performed through the cannula. Before suturing the wound, a hemostatic sponge is inserted into it and tamponed with gauze turundas above and below the tracheostomy cannula, and then the upper and lower corners of the skin wound on the neck are sutured. Turundas are removed from the wound on the 3rd day after surgery.

Clinical example 1. Patient Ts., 43 years old, on December 26, 2022, was admitted to the traumatology department of the State Budgetary Healthcare Institution of the State Clinical Hospital named after. N.I. Pirogov No. 1 with a diagnosis mixed fracture of the upper third of the left shoulder, liver cirrhosis, anemia, bleeding from the esophageal veins, alcoholism, coagulopathy, prolonged mechanical ventilation. 01/16/23 14.00-14.20. Operation. Lower tracheostomy. Under general anesthesia, an isosceles triangle was built on the anterior surface of the neck, the apex of which is the jugular notch of the sternum, and the sides are the left and right walls of the trachea at a distance of 5 cm from the apex along the midline of the neck. After this, a skin incision 3.5 cm long was made from the upper horizontal line of the isosceles triangle strictly vertically down the midline of the neck. Bleeding from the wound was stopped by coagulating the tissue with a bipolar coagulator. Using Farabeuf hooks, the skin wound was widened until the 2nd fascia of the neck was visible. Coagulation of the tissues was carried out along the incision line, and then the tissues were not cut, but pulled apart with mosquito and Billroth clamps. Thus, only after coagulation of the tissues was their separation carried out. This technique allowed us to avoid bleeding from the tissues. In this way, the anterior wall of the trachea was exposed, a single-tooth hook was placed on the 3rd ring of the trachea, which pulled the trachea up. Tissue coagulation was carried out along the incision line of the tracheal wall, a tracheal aperture was made with a scalpel using a cross-shaped approach, the edges of the tracheal aperture were coagulated to stop bleeding. Using a Trousseau retractor, the tracheal aperture was expanded, a tracheostomy cannula No. 8.5 was inserted into the trachea, its cuff was inflated, the bougie guide was removed, mechanical ventilation was carried out through the tracheostomy cannula, and the endotracheal tube was removed. The wound on the neck was carefully examined, all suspicious areas were additionally coagulated, a hemostatic sponge was inserted into the wound above and below the tracheostomy cannula and gauze turundas were additionally inserted there, skin sutures were applied to the upper and lower corners of the wound. There were no complications in the postoperative period. The gauze turundas were removed on the 3rd day after surgery.

Clinical example 2. Patient R., 72 years old, on January 5, 2023, was admitted to the urology department of the State Budgetary Healthcare Institution of the State Clinical Hospital named after. N.I. Pirogov No. 1 with a diagnosis of acute pyelonephritis, urosepsis, necrosis of the colon on the right, coagulopathy, January 6, 2023. Surgery. Right hemicolectomy, ileostomy, prolonged mechanical ventilation. 01/09/23 Operation. Lower tracheostomy. Under general anesthesia, an isosceles triangle was built on the anterior surface of the neck, the apex of which is the jugular notch of the sternum, and the sides are the left and right walls of the trachea at a distance of 5 cm from the apex along the midline of the neck. After this, a skin incision 3.5 cm long was made from the upper horizontal line of the isosceles triangle strictly vertically down the midline of the neck. Bleeding from the wound was stopped by coagulating the tissue with a bipolar coagulator. Using Farabeuf hooks, the skin wound was widened until the 2nd fascia of the neck was visible. Coagulation of the tissues was carried out along the incision line, and then the tissues were not cut, but pulled apart with mosquito and Billroth clamps. Thus, only after coagulation of the tissues was their separation carried out. This technique allowed us to avoid bleeding from the tissues. In this way, the anterior wall of the trachea was exposed, a single-tooth hook was placed on the 3rd ring of the trachea, which pulled the trachea up. Tissue coagulation was carried out along the incision line of the tracheal wall, a tracheal aperture was made with a scalpel using a cross-shaped approach, the edges of the tracheal aperture were coagulated to stop bleeding. Using a Trousseau retractor, the tracheal aperture was expanded, a tracheostomy cannula No. 8.5 was inserted into the trachea, its cuff was inflated, the bougie guide was removed, mechanical ventilation was carried out through the tracheostomy cannula, and the endotracheal tube was removed. The wound on the neck was carefully examined, all suspicious areas were additionally coagulated, a hemostatic sponge was inserted into the wound above and below the tracheostomy cannula and gauze turundas were additionally inserted there, skin sutures were applied to the upper and lower corners of the wound. There were no complications in the postoperative period. The gauze turundas were removed on the 3rd day after surgery.

The use of the method of forming a tracheostomy for coagulopathy made it possible to improve the results of treatment in patients with impaired external respiratory function and reduce complications, both at the time of formation of the tracheostomy and in the early postoperative period due to the implementation of preventive measures at each stage of the operation and careful hemostasis at the time of the operation, the use of hemostatic sponges and gauze turundas before suturing the skin wound. There were no complications associated with the use of the dilation tracheostomy method. The method of forming a tracheostomy was used in 27 patients, proved its effectiveness, is reliable, and can be widely used in clinical practice in the treatment of patients with impaired external respiratory function.

INFORMATION SOURCES.

1. Parshin V.D. Tracheostomy. Indications, technique, complications and their treatment. - M.: GOETAR-media, 2008. - P.-30-40.

2. Patent RU 2 409 326 C2, Aperture of the anterior wall of the trachea. Izmailov E.P., Tikholoz Yu.L., Nagoga A.G., Zhadyaev N.A., bull. No. 2, dated January 20, 2011.

3. Ciaglia P., Firsching R.N., Synies C. Elective percutaneous dilational tracheostomy // Chest. - 1985. - Vol.87. - P.715-719.

4. Griggs W.M., Worthley L.I.G., Gilligan J.E., Thomas P.D., Myburg J.A. (1990) A simple method of percutaneous tracheostomy. Surg Gynecol Obstet. 170: 543-545].

5. Patent RU2419461C1. Method of tracheostomy in patients with multiple organ failure. Khaes B.L., Plotnikov G.P., Grigoriev E.V., Kheraskov V.Yu., Barbarash L.S., Popkov A.N., bull. No. 15, dated 05/27/2011.

6. Patent RU2561297C. Method of performing temporary tracheostomy in adults. Gurshenkov A.V., Maistrenko A.D., Evstigneev M.V., Selivanov M.V., Gordeev M.L., bull. No. 27, dated 08/27/2015.

Claims (1)

A method of forming a tracheostomy for coagulopathy under general anesthesia with artificial ventilation of the lungs (ALV) through an endotracheal tube by cutting the skin and soft tissues on the neck in the projection of the trachea, pulling the anterior wall of the trachea up with a single-tooth hook, crossing one ring of the trachea in the longitudinal direction with an additional transverse incision in interannual space in the form of a cross, deflating the cuff of the endotracheal tube, removing the endotracheal tube from the trachea, widening the wound in the transverse direction with a Trousseau retractor, introducing a tracheostomy cannula through the aperture into the trachea, removing the tracheostomy cannula guide, removing the Trousseau retractor from the trachea, inflating the tracheostomy cuff, performing mechanical ventilation through the tracheostomy cannula, removing the endotracheal tube, suturing the wound to the tracheostomy cannula, fixing the tracheostomy cannula with straps placed around the neck, characterized in that on the anterior surface of the neck in the projection of the trachea, an isosceles triangle is constructed, the apex of which is the jugular notch, while At a distance of 5 cm from the apex of the triangle, an upper horizontal line is drawn, from which a skin incision 3.5 cm long is made vertically down the midline of the neck; before tissue dissection along the access line, tissue coagulation is performed, and then they are pulled apart with a clamp, after dissection of the trachea, the edges of the wound the trachea is coagulated, before suturing the wound, a hemostatic sponge is inserted into it and tamponed with gauze turundas above and below the tracheostomy cannula, and then the upper and lower corners of the skin wound are sutured, the turundas are removed from the wound on the 3rd day after the operation.