Phrenicoexaeresis

PHRENICOEXAERESIS, PHRENICOTOMY (phrenicoexaeresis, phrenicotomia) are used primarily for tuberculosis of the lungs. The purpose of these operations is to obtain paralysis of the corresponding half of the diaphragma by interrupting the conductivity of the phrenic nerve by cutting its trunk (phrenicotomy) or excising part of it (resection) or twisting it out (phrenicoexaeresis). The operation was first proposed by Sturz and Schepelman (Sturz,

Figure 1. X-ray before operation; cavity on the right.

Figure 2. Same patient 2 months after operation; cavity, VK and elastic fibers have disappeared.

Figure 3. Before operation; voluminous cavity.

Figure 4. Same patient 3¹/₂ months after operation; diaphragma has risen well; cavity is not visible; clinically - no VK or elastic fibers.

Figure 5. Before operation; cavity in the middle lobe.

Fig. 6. Same patient 24% months after operation; cavity has disappeared; clinically - recovery.

Figure 7. Incomplete effect from cauterization according to Jacobaeus; two cavities are gaping.

Figure 8. Same patient 8 months after phrenicoexaeresis; clinically - recovery; cavities have disappeared.

Schepelmann) in 1911 and developed by Sauerbruch and his school (Walter and others).-Technique of the operation. Access to the nerve is achieved along its cervical part, at the point where it crosses the anterior scalene muscle (see Supraclavicular fossa, fig. 4). For this purpose, the surgeon's knife must pass, besides the skin and the platysma myoides behind it, through 3 layers: the first aponeurosis, which in its layers includes the m. sternocleidomastoideus, the second aponeurosis with the m. omohyoideus embedded in it, and finally the glandular cellular tissue with the vascular branches of the subclavian vein and artery (a. and v. transversa colli) and the supraclavicular glands, which in tuberculous patients sometimes have voluminous sizes. The operation is usually performed under local anesthesia, infiltrative along the line of incision and regional-by inserting a needle at the outer edge of the sternocleidomuscle in the area where the trunk of the n. supraclavicularis emerges from under it (approximately one transverse finger above the point where this muscle crosses the external jugular vein). A deep injection here of 30.0-40.0 cm³ of a ¹/_i% solution of novocaine is sufficient to perform the entire operation completely painlessly. The patient is laid with the head thrown back and to the healthy side so that the supraclavicular area is well stretched and the supraclavicular fossa is as flattened as possible. Two types of skin incision are used: longitudinal along the outer edge of the lower part of the sternocleidomuscle and transverse, 2-3 cm above the clavicle, crossing the said muscle. The first is considered easier for beginners, the second has all the advantages from a cosmetic point of view. After incising the skin and platysma, the edges of the wound are retracted with hooks in a transverse direction, a longitudinal incision is made along the outer edge of the sternocleidomuscle (medial to v. jugularis externa), the muscle is bluntly dissected from the fascial sheath and retracted inward. With two forceps, the thin posterior leaf of this sheath is torn or cut with a knife, and behind it the second aponeurosis over the obliquely crossing the operative field m. omohyoideus. In the depth of the wound lies the last layer, which must be displaced to see the scalene muscles and n. phrenicus-this is the glandular cellular tissue and glands. The cellular tissue is torn with forceps and strongly stretched with hooks to the sides. The nerve lies on the anterior surface of the exposed muscle (m. scalenus anticus) under a thin prevertebral fascia and cannot be displaced during the search for it as long as this fascia is intact. Therefore, to prevent confusion of the sought nerve with the n. vagus or n. sympathicus, it should not be torn by the operator until the n. phrenicus is found (see Supraclavicular fossa, fig. 4 and 5). In case of its atypical location, the adjacent cellular tissue at the inner edge of the scalene muscle should be examined, in the vicinity of the ascending trunk of a. thyreoideae inf. (sometimes the nerve can be found without special trauma if the scalene muscle is grasped transversely with forceps and rotated outward). In rare cases, the nerve may be located along the outer edge of the muscle, in the vicinity of the brachial plexus (see Phrenicus nervus). When the nerve is found, its processing is begun. The prevertebral fascia is incised over it, the nerve is bluntly dissected and hooked. A drop of a 5% solution of novocaine is injected into its thickness. If the nerve is crossed along a. and v. transversae colli (there are usually two veins), these vessels are retracted with a hook downward if necessary. In phrenicotomy, the nerve is severed (the operation is now rarely performed and only for special indications), in phrenicoexaeresis-it is grasped with Kocher's clamp, cut above, and then carefully twisted around its axis along the clamp, while the nerve is constantly being freed from the loose cellular tissue surrounding it. In the case of an accessory nerve, both nerves are severed above and they are twisted out together. To give support to the clamp during twisting, the ends of an anatomical forceps are placed under it on both sides of the nerve being stretched. Depending on the condition of the cellular tissue surrounding the nerve in the area of the pleural dome and mediastinum, the release of the nerve during exaeresis occurs with greater or lesser ease. In favorable cases, the nerve is pulled out of its bed and breaks off over a length of 10-30 cm, sometimes even with its branches in the diaphragm. In the presence of significant scar changes in the perineurium, the nerve has to be severed. At the end of the operation after hemostasis, if it has not passed, as usual, bloodlessly, the wound is sutured in layers tightly. During the operation, complications may arise, mostly due to insufficient caution or incomplete orientation in the topographic-anatomical relationships. Bleeding is most frequently noted, which can occur during the search for the nerve in the cellular tissue of the angulus scaleno-vertebralis. Its source may be injury to the v. vertebralis, v. transversae colli and even the v. subclaviae. On the left side, injuries to the ductus thoracicus have been described, which usually occur without serious consequences. In atypical positions of the thoraco-abdominal nerve, confusion with the vagus or sympathetic nerve may occur. Finally, if insufficient freeing during twisting from the perineurium in cases of deep scar changes in the peridiaphragmatic cellular tissue, injury to the pleura is possible if excessive force is applied despite resistance. The result of the operation under favorable conditions is paralysis of the diaphragm and complete atony, due to which abdominal pressure gains predominance, the diaphragm rises, and the lung is compressed in the vertical direction, which weakens its longitudinal tension. The cessation of traction in this direction during respiratory movements places the lung in a state of rest, which favorably affects the healing and reverse development of inflammatory phenomena in the tuberculous cavernous focus of lung tissue. This effect is manifested not only in the lower lobes of the lung but also in the apex of its dome. In successful cases, the relaxed diaphragm undergoes degeneration and in a short time turns into a thin connective tissue plate. However, such success depends on the complete removal of all nerve branches affecting the muscle tone of the diaphragm. Study of its innervation in this respect, undertaken by Felix, students of Sauerbruch, and especially by a number of Japanese authors, showed that to ensure a complete effect, it is necessary to remove the sympathetic branches arising from the lower cervical and upper thoracic sympathetic nodes, i.e., in other words, the thoraco-abdominal nerve must be removed over a length of at least 8-10 cm. This circumstance explains the insufficiency of simple phrenicotomy and the introduction by Felix of the above-mentioned exaeresis of the nerve instead of it. For the same reasons, Gotze, who abandoned twisting the nerve after a serious complication from pleural rupture, proposed radical resection of the nerve. For this purpose, he dissects the n. phrenicus as low as possible, in the area of the aperturae thoracis, visually cuts off the branches approaching it from the ganglion cervicale and stellatum, and supplements this operation with resection of the n. subclavii, for which he widely exposes the brachial plexus. Indications. In successful cases, the clinical effect of phrenicoexaeresis is manifested in the closure of the cavity in a short time (1-2 months after the operation) (see separate table, fig. 1 and 2), disappearance of tubercle bacilli and elastic fibers in the sputum, decrease in temperature and cessation of hemoptysis. This effect is most frequently manifested in cavities located in the lower lobes (see separate table, fig. 3 and 4), but there are cases of similar success with cavities located in the upper or middle lobe (see separate table, fig. 5 and 6). This operation is more often resorted to when it is impossible to perform a more radical operation. Often the operation is used as a preliminary, trial operation to test the biological resistance of the other, healthier side before performing thoracoplasty, although clinical experience shows that a positive result here does not always have absolutely reliable significance. As such a test, it is very appropriate to replace phrenicoexaeresis with measures that only temporarily block the nerve, such as freezing with chloroethyl, injecting alcohol into the nerve, crushing the nerve and severing it. Phrenicoexaeresis has become widely used as an additional measure in incomplete artificial pneumothorax (necessarily with basal apposition of the lung), as the first phase of operative intervention in thoracoplasty, and finally in insufficient cauterization of apical pulmonary adhesions according to Jacobaeus (see separate table, fig. 7 and 8).-The best effect of phrenicoexaeresis is obtained in fibrous cavernous forms, it is used less frequently and with much less chance of success in exudative processes. Phrenicoexaeresis is more often indicated in unilateral processes, but with carefully considered conditions, success of this type of operation is also possible in bilateral lesions. As for the type of diseases, phrenicoexaeresis is performed not only in tuberculosis of the lungs.

Its favorable effect is also manifested in persistent non-absorbing pleural exudates and hemothorax, and much less frequently in bronchiectasis and lung abscess. Contraindications for phrenicoexaeresis are an active, progressive tuberculous process on the other side, a morbid condition of the vital internal organs, lesions of the intestine, and cardiac and renal insufficiency. According to literary data, the clinical outcome of phrenicoexaeresis amounts to 64-81% positive results. The variations in success depend on differences in indications. The assessment mostly refers to immediate results. A count of remote outcomes based on materials from the Moscow Regional Tuberculosis Institute, conducted by I. Freydovich, B. Zvonnikov, and N. Shmelev on 219 cases operated on from 1928 to 1932, showed 54.8% positive effect (disappearance or reduction of cavity) in unilateral processes. Of these, complete recovery was in 16.1%, disappearance of the cavity but preservation of tubercle bacilli and elastic fibers in 14.5%, and 23.5% positive effect in bilateral fibrinous-productive processes, of which complete recovery was only in 5.5%. 70% of clinical success in unilateral lesions concerned the location of cavities in the lower lobes and 26% in the upper lobes. 17 cases of application of phrenicoexaeresis in exudative processes convinced the authors that when the process had a tendency to caseation, phrenicoexaeresis did not give satisfactory results, while the group of infiltrates, especially in the lower lobes, almost invariably showed marked improvement.