Surgical approaches and resection
The technique of performing a pneumotomy begins with the correct choice of surgical approach, which directly depends on the localization of the pathological process in the lung tissue.
- Upper lobe cavities: the approach is performed from the side of the axillary fossa, with a strictly vertical skin incision.
- Lower lobe cavities: the incision is made below the inferior angle of the scapula and directed along the course of the ribs.
In both cases, the length of the skin incision ranges from 12 to 15 centimeters. After dissecting the soft tissues, surgeons proceed to the osseous stage: it is necessary to subperiosteally resect 2–3 ribs. The length of the removed fragment on each rib is 10–12 centimeters. This creates a sufficient surgical window for subsequent manipulations.
Revision of the pleural cavity
After rib resection, a critically important diagnostic stage begins. Through a small, neat incision of the posterior layer of the periosteum and parietal pleura, the surgeon determines the condition of the pleural cavity. The main task is to find out whether the cavity is free or obliterated (fused) by adhesions. The entire subsequent surgical strategy fundamentally depends on this status.
Tactics for an adhered pleural cavity
If complete obliteration of the pleural cavity is confirmed, the operation is completed in a single stage, since there is no risk of pleural infection.
- Trial puncture. A needle with a syringe is inserted into the pulmonary cavity. The syringe must be partially filled with an isotonic NaCl solution — this is necessary to prevent air from entering the vessels and the development of an air embolism.
- Opening. If pus is obtained during the puncture, the cavity is safely opened with an electrosurgical knife.
- Sanation. All pus and necrotic masses are thoroughly removed from the opened cavity.
- Excision of the walls. The outer wall of the cavity or abscess is excised as widely as possible to ensure good outflow.
- Tamponade and marsupialization. The cavity is tightly packed with gauze. The edges of the skin wound are inverted inward and sutured to the edges of the periosteum and thickened parietal pleura.
Tactics for a free pleural cavity
If there are no adhesions between the pleural leaves, simultaneous opening of the abscess is strictly prohibited: this will inevitably lead to the breakthrough of contents and severe purulent pleurisy. In this case, a decision is made to perform a two-stage surgery.
- First stage (creation of adhesions). The surgeon enlarges the opening in the parietal pleura to 5–7 centimeters. Then the parietal pleura is sutured to the edges of the formed window. The skin edges, as in the single-stage technique, are inverted and sutured to the periosteum. The wound is tightly packed to provoke inflammation and adhesion of the pleural layers.
- Second stage. After 10–12 days, when reliable and strong adhesions are formed that isolate the free pleural cavity, the final opening and tamponade of the purulent cavity in the lung itself are performed.
Briefly: answers to topical questions
Which anatomical layers of the chest wall are sequentially dissected during access to the pleural cavity?
When accessing the pleural cavity from outside in, the following anatomical layers of the chest wall are sequentially dissected:
- Skin — thin, mobile on the anterior surface.
- Subcutaneous adipose tissue — contains superficial vessels and nerves.
- Superficial fascia — covers the underlying structures.
- Deep fascia of the chest (fascia pectoralis) — covers the pectoralis major muscle.
- Pectoralis major muscle (m. pectoralis major) — muscle layer.
- Clavipectoral fascia (fascia clavipectoralis) — covers the pectoralis minor muscle.
- Pectoralis minor muscle (m. pectoralis minor) — deep muscle layer.
- Intercostal muscles and ribs — form the intercostal space.
- Endothoracic fascia (fascia endothoracica) — covers the walls of the thoracic cavity from the inside.
- Parietal pleura — the internal layer lining the cavity.
What special surgical instruments are used for subperiosteal rib resection?
The following special surgical instruments are used for subperiosteal rib resection:
- Curved raspatory (e.g., Farabeuf raspatory) — used to detach the periosteum (periosteum) from the outer (anterior) surface of the rib.
- Doyen raspatory (raspatorium Doyeni) — introduced under the rib to detach the periosteum from the inner (posterior) surface, protecting the pleura and the neurovascular bundle.
- Rib shears (bone cutters, costotome) — used to transect (osteotomize) the segment of the rib freed from the periosteum.
What intraoperative complications are possible when performing a pneumotomy?
The following intraoperative complications are possible when performing a pneumotomy and concomitant rib resection:
- Purulent pleurisy — occurs if the lung abscess is opened in the presence of a free (non-adhered) pleural cavity.
- Air embolism — the risk arises when performing a trial puncture, so the syringe must be partially filled with isotonic NaCl solution.
- Damage to the neurovascular bundle — can occur if the raspatory slips into the intercostal space during detachment of the anterior layer of the periosteum.
To easily remember the surgical tactics: "Pleura adhered — cut boldly (1 stage). Pleura free — wait for adhesions (2 stages, 10–12 day interval)."
Class and exam questions
Why are indications for pneumotomy currently sharply limited?
In modern thoracic surgery, pneumotomy is rarely used and is mainly limited to the treatment of fibrous-cavernous tuberculosis, as well as rare cases of acute lung abscess.
What approach is used when a cavity is localized in the upper lobes?
To access the upper lobes, the incision is made from the axillary fossa. It has a vertical direction and a length of 12–15 cm.
Why is isotonic NaCl solution drawn into the syringe during a test puncture?
An isotonic solution in the syringe is necessary to prevent a formidable complication — air embolism, which can occur when puncturing lung tissue.
What is marsupialization in pneumotomy?
Marsupialization consists in turning the skin edges inward into the wound and suturing them to the edges of the periosteum and the thickened parietal pleura, forming an open cavity for packing.
What else to study on this topic
- Topographic anatomy of the axillary fossa and intercostal spaces
- Technique of subperiosteal rib resection
- Mechanism of development of air embolism during lung surgery
- Pathophysiology of pleural adhesion formation
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