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Section 4. Medical science
Karimov Shavkat Ibrohimovich, Academician, Rector of the Tashkent Medical Academy, Professor in the department of faculty and hospital surgery of the Tashkent Medical Academy, Republic of Uzbekistan
E-mail: tta2005@mail.ru Berkinov Ulugbek Bozorbaevich, Professor in the department of faculty and hospital surgery of the Tashkent Medical Academy, Republic of Uzbekistan
E-mail: ulugbek_b@mail.ru Fayzullaev Erjan Ruslanovich, Head of emergency thoraco-vascular department of 2-clinic of the Tashkent Medical Academy, Republic of Uzbekistan
E-mail: erik1991@mail.ru Abdullaev Javlonbek Subkhonalievich, 3-year Master-degree of department of faculty and hospital surgery of the Tashkent Medical Academy, Republic of Uzbekistan E-mail: www.je-mundei15@mail.ru
Videoassisted thoracoscopic fixation of floating rib fragments
Abstract: We examined the results of videoassisted thoracoscopic (VATS) fixation of floating rib fractures in 16 patients with blunt chest traumas. The method, which was used, was described by K. G. Zhestkov and improved by the authors of this article. Indications for ribs fixation were prolapse of ribs fragments into the pleural cavity with the lung injury (7 patients) and functionally significant abnormal mobility of multiple rib fractures (9 patients). It is shown that the proposed method ofVATS ribs fixation at pathological mobility can reliably stabilize the chest wall without wide dissection of injured soft tissue. Keywords: chest injury, fractured ribs, abnormal mobility, videothoracoscopy.
Barskiy B. V., Voskresenskiy O. V. [7]; Korotkov N. I., Kutirev E. A., Kukushkin A. V. [2].
So, that's why methods of fixation of floating rib fractures performed during VATS procedures. Material and Methods
VATS interventionsatblunt chest trauma in the 2nd clinic of the Tashkent Medical Academy are applied since 2006. Among patients with blunt chest injury indications for its implementation are determined at 146. Frequentlyblunt chest trauma is occurred at men — 102 (69.9 %). The age of patients ranged from 16 to 82 years (mean age 37.8 ± 1.5 years). The most common injury was transport — in 69 (47.3 %) patients, then household injuries — in 58 cases (39.7 %). 68 % of the patients were taken to the hospital through the emergency room, 32 % of the patients came themselves. Mainly patients were delivered during the first six hours after the trauma, although there have been cases of late treatment: for example, 9.7 % of patients were hospitalized a day after the injury.
Traumatic injuries of the chest from the right and left sides were ocured at approximately the same rate (respectively 48 and 52 %), 12 % of damages were bilateral.
Blunt chest injury were combined with cranial trauma in 85 (58.2 %) cases, with fractures of the long bones — in 38 (26.0 %), pelvic bones — in 19 (13.0 %), injuries of the abdominal cavity — 28 (19.2 %), retroperitoneal space — in 23 (15.8 %).
In a state close to satisfactory, we received 57 (39.0 %) patients, moderate — 65 (44.5 %), in heavy — 25 (17.1 %).
On the basis of X-ray investigation hemothorax was detected in 30 (20.5 %) patients, pneumothorax — in 24 (16.4 %), hemopneu-mothorax — in 91 (62.3 %).
Rib fractures were observed in 91 (62.3 %) patients: single rib fracture was observed in 66 (45.2 %), multiple — in 80 (54.8 %), including the formation of the rib valve — 9 (6.2 %).
In recent years there has been a significant increase in road accidents, that defines the appearance of a large number of patients with severe traumatic injuries in general and injuries of the chest, in particular. In peacetime injuries of the chest are the third most common, and blunt chest trauma account for up to 90 % of cases Vag-ner E. A. [4]; Wanek S., MayberryJ. C. [5].
Despite improvements in diagnostictechniques, infusion-transfusion therapy, modern methods of mechanical ventilation, mortality in presence of severe injuries to the chest reaches 35-45 %, and with concomitant injury chest, accompanied by shock, reaches to 63-68 % Korotkov N. I., Kutirev E. A., Kukushkin A. V. [2]; Ahmed N., Jones D. [1].
The leading role in the development of complications and deaths in case of blunt chest trauma belongs to severe progressive respiratory disorders. One of the causes of such condition is a violation of the integrity of the rib frame associated with broken ribs. The frequency of rib fractures at patients with a closed chest trauma varies from 35 to 92 %, and deaths from injuries to the chest with a floating rib fractures are occured in 52.1-63.6 % of cases Zhestkov K. G., Barskiy B. V., Voskresenskiy O. V. [7]; Korotkov N. I., Kutirev E. A., Kukushkin A. V. [2]; Moore F. O., Goslar P. W., Coimbra R. et al. [3]; Wilson H., Ellsmere J., Tallon J., Kirkpatrick A. [6]. Therefore the search for ways to reduce disordered breathing is an important part of pathogenetic therapy at these patients.
Existing methods of stabilization the floating rib fractures (fixation of bone fragments surgically and "internal pneumatic" stabilization by a prolonged mechanical ventilation (AV/1) with positive expiratory pressure) do not fully satisfy clinicians, as they are relatedwith a lot of inflammatory complicationsof breast tissue during surgical stabilization, and at artificial lung ventilation — broncho-pulmonary and intrapleural complications. All this makes it necessary to find other approaches Zhestkov K. G.,
Videoassisted thoracoscopic fixation of floating rib fragments
The indications for VATS with closed chest trauma were medium and large (with late treatment of the patient) hemothorax, hemopneumothorax, unresolved pneumothorax, clotted hemothorax.Videothoracoscopy was not been performed in case of hemodynamic instability, reliable signsof the tracheal and large bronchi rupture, as well as the previous thoracotomy on the affected side.
Videothoracoscopy was carried out usually under anesthesia with separate tracheal intubation. Detectable traumatic injuries requiring surgical correction were eliminatedwith the VATS.
So, VATS stop ofbleeding from intermuscular vessels and parietal pleura was performed in 75 (51.4 %) patients, bone fragments of ribs — in 43 (29.5 %), from the intercostal artery — in 12 (8.2 %), suturing of ruptures of lung tissue — in 13 (8.9 %), electrocoagulation of ruptures — in 19 (13.0 %), suturing ofbull — in 2 (1.4 %), the elimination of coagulated hemothorax — 11 [7; 5].
It should be noted that all these interventions were often performed in patients with a blunt chest trauma with broken ribs, especially with multiple. Typically, in such cases, there was marked a rupture of the parietal pleura at rib fracture site, which became a source of intrapleural bleeding. In 7 patients with prolapse of bone fragment into the pleural cavity, there was a necessity to fix the ribs.
In these cases, and in 9 patients with functionally significant floating ribs during VATS intervention was made a fixation of them.
Criteria for fixing the ribs were the following: involving in the act of breathing of skeletal muscles (superficial muscles of the chest and neck), respiratory rate more than 30 in 1 minute, PaC0 2 — more than 40 mm. Hg., Pa0 2 — less than 92 % in 30-40 minutes after intramuscular administration of analgesics and local anesthetics. It should be noted that the expressed respiratory insufficiency (Breath rate more than 35, PaC0 2 — more than 50 mm. Hg., Pa0 2 — less than 90 %) were indication for pneumatic fixation during mechanical ventilation. As a rule, the latter was observed in bilateral fractures of the ribs withflotation of the sternum.
Fixation of ribswas carried by the method, which was described by Zhestkov K. G. and improved by us. During a thoracoscopy there was made an external finger pressure on the chest to determine the most mobile segments of floating ribs or fragments, perforating parietal pleura. To carry out the fixing matherial (absorbable suture material "Vicryl 0") under the front and back-stable segments and on both sides of the floating ribs segment was used Fur needle. Then we performed a small skin incision over the site of the stable edges in 3-4 cm. from the fracture and through
this incision subfascially to the fracture line summed spoke. With the help of superimposed suture material we pulled up with a view to reposition the floating segment. Spoke was carried out along the floating segment to another stable segment of the rib. After this we tightened pre-imposed pericostal seams, fixing stable segments and the floating segment to the spoke. In the same manner we fixed the remaining edges.
It should be noted that patients with broken ribs for the purpose to reliefpain intraoperatively under controlled videothoracoscopy we introduced catheters for postoperative novocaine blockade into intramuscular subfascial space.
All 16 patients VATS fixation has eliminated paradoxical movement, as well as stabilized the rib.
8 (50 %) patients were extubated in the first day, 3 (18.8 %) — on the second, 2 (12.5 %) — in the third, 3 (18.8 %) patients due to the severity of associated trauma mechanic ventilation was conducted for 11-13 days.
Lethal outcome occurred in 2 (12.5 %) patients due to the increase ofrespiratory failure associated with a massive injury of the lung tissue [1] and progression of cerebral coma due to a brain injury [1].
In 2 (12.5 %) patients in the postoperative period after the imposition of the spokes was marked suppuration of intramuscular hematoma. In the remaining patients the postoperative period was uneventful.
The duration of hospital stay ranged from 8 to 22 days. Spokes were removed on the 30-40 th day in the outpatient department.
Thus, in addition to a high diagnostic efficiency videothoracoscopy can be used as therapeutically. It allows you to solve one of the very complex problems — to remove floating broken ribs in violation of the integrity of the skeleton of the chest wall. The advantage of the proposed method is the possibility of simultaneous execution of all necessary procedures to remove lesions from minimally invasive thoracic access.
Conclusions:
1. Videothoracoscopy at chest trauma allows us accurately set the topical diagnosis. Furthermore, in contrast to existing methods of diagnosis, allowing simultaneously remove these injury with minimally invasive surgery, especially at patients with floating rib fractures.
2. The applied technique of restoring the integrity of the chestin case of floating rib fracture under VATS control allows to securely stabilize the chest wall without resorting to a wide dissection of injured soft tissue.
References:
1. Ahmed N., Jones D. Video-assisted thoracic surgery: state of the art in trauma care//Int J Care Injured. - 2004. - 35: 479-489.
2. Korotkov N. I., Kutirev E. A., Kukushkin A. V. Videothoracoscopic interventions: diagnostic and treatment//Surg. Endoscopy. -2006. - 2: 62.
3. Moore F. O., Goslar P. W., Coimbra R. et al. Blunt Traumatic Occult Pneumothorax: Is Observation Safe? - Results of a Prospective, AAST Multicenter Study// J. Trauma. - 2011. - 70: 1019.
4. Vagner E. A. Surgery of thoracal injuries. - M.: Medicina, 1981.
5. Wanek S., Mayberry J. C. Blunt thoracic trauma: flail chest, pulmonary contusion, blast injury//Crit Care Clin. - 2004. - 1.
6. Wilson H., Ellsmere J., Tallon J., Kirkpatrick A. Occult pneumothorax in the blunt trauma patient: tube thoracostomy or observation & Injury. - 2009. - 40: 928.
7. Zhestkov K. G., Barskiy B. V., Voskresenskiy O. V. Less invasive surgery in treatment of floating rib fractures//Pacific Medical Journal. - 2006. - 1: 62-65.
