Trendelenburg operation for pulmonary embolism
The surgeon Friedrich Trendelenburg developed the Trendelenburg operation for pulmonary embolism during his time in Leipzig. The operation consists in the surgical removal of the embolus , usually a blood clot, from the main trunk and branches of the pulmonary artery . It is "by far the most dramatic of all surgical interventions" - the most dramatic of all surgical interventions.
Initial description
Trendelenburg spoke "About the operative treatment of embolism of the pulmonary artery" on April 21, 1908 at the 37th meeting of the German Society for Surgery . In the same year the article appeared in print.
Trendelenburg first describes the clinical picture and then continues: “If the embolism leads to a complete closure of the pulmonary nerve , death occurs so quickly, almost instantaneously or after 1–2 minutes, that there is no time for an operation more remains. But in my experience, the cases in which the conclusion is only a partial one and death only occurs after a quarter of an hour or later are more common than the very sudden deaths. ... It may be that coincidence played a role in my little statistics from the Leipzig hospital in favor of the slower deaths, but I would certainly like to believe that at least 15 minutes will be available in at least half of the cases, that is enough time in a hospital to be able to try an operation which itself does not take much time. The nursing staff only has to be familiar with the symptoms of the embolism, a surgeon has to be on the spot quickly, and the instruments have to be at hand in aseptic condition at all times. "
- Trendelenburg's publication 1908
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Cut
He then describes animal experiments and finally the surgical procedure for the patient with the incision shown in the figure. For a short period of time, both the pulmonary arteries and the aorta must be clamped, and during this time the pulmonary artery must be incised and the embolus or emboli withdrawn.
“As mentioned, the incision, the extraction of the emboli and the clamping of the artery must not take more than about three quarters of a minute. But it is a much longer time for just a few simple hand movements than you think it takes less. 30 seconds will usually be enough, there may be nothing in the way of temporarily clamping the opened artery after this time, letting the blood flow through, compressing it again after a few minutes and repeating the manipulations. However, despite the hurry, the operations must be carried out with calm and caution , as the wall of the pulmonary artery is more like a vein wall in terms of fragility and tearability. ... The suturing is the most difficult part of the operation, as the heart has meanwhile started to beat again. "
Unfortunately, Trendelenburg was unable to report a successful operation. You can see his disappointment about it. The one patient he tried to operate on died during the operation.
Further development
16 years passed before the first success: 1923–1924 a patient survived at least 1 year and 4 months. The surgeon, Martin Kirschner in Königsberg , reported on this on April 23, 1924 at the 48th meeting of the German Society for Surgery - the chairman congratulated him and Friedrich Trendelenburg.
The 38-year-old patient had to be operated on March 14, 1923 because of a pinched femoral hernia. Following this, a fever developed. March 18, 1923: “The assistant in charge put the patient up in bed to examine the lungs. As she lay back, the patient suddenly throws both arms in the air, then presses her hands on her chest in the greatest fear, falls back pale as a sheet on the pillow and struggles for breath. 'It's coming to an end, say hello to my father!' We watch them for about 8 minutes. During these 8 minutes the condition worsens by the minute and is soon catastrophic. The initially changing pulse can no longer be felt, the patient is only breathing weakly, she gives the impression of a dying person who must be over in a few minutes.
The patient is now driven in great haste over a distance of 115 m into the operating room and after a short disinfection ... the operation is started with the embolic instruments that are always available from us, 15 minutes after the embolism has occurred . Anesthesia is not required as the woman is already unconscious. During the operation, she receives oxygen from the overpressure apparatus provided.
- Kirschner's publication in 1924
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Extracted emboli
I operated exactly according to the instructions given by Trendelenburg . ... I quickly drive the grasping forceps into the right, then into the left branch of the pulmonary artery and each time I pull out a large clot. ... From the skin incision to the moment when the goal of Trendelenburg's operation, the restoration of free blood passage, has been achieved, only 4 minutes have passed . The speed of the operation was greatly enhanced by the fact that there was no bleeding at all. I operated on the unconscious patient as completely bloodless as on the carcass. ...
July 1, 1924. Correspondence: The patient is doing very well. She is fully able to work and has again gained several pounds. "
Later doctors read Trendelenburg's 1908 essay with admiration. According to an American surgeon in 1990: Trendelenburg's act was "an intelligent and courageous attempt to treat massive pulmonary embolism surgically, using methods that have been carefully worked out experimentally" (from English). Similarly, a German surgeon in 1994: “One of the great ideas of therapy, the unprecedented incarnation of acute surgery, the impressive possibility of saving an otherwise healthy person with the help of a local, short-term intervention because of an acute illness localized at this point would be doomed. A thought of unusual boldness and precision, the execution was almost completely thought out, so that success could still be achieved with it 16 years later. "
Today, Trendelenburg's operation, modified primarily by angiography of the pulmonary artery and the use of a heart-lung machine , is, in addition to thrombolysis, still a therapeutic option for massive or high-risk pulmonary embolism. The prognosis remains serious. Of 96 patients operated on in Paris from 1968 to 1988, 37.5% died in hospital.
The operation in popular culture
In Rolf Hansen's feature film The Great Temptation (1952), the operation is successfully carried out by a war returnee ( Dieter Borsche ), who conceals from his employer that he has not yet formally completed his medical studies.
See also
A second operation is named after Friedrich Trendelenburg: the Trendelenburg operation for varicose veins .
Individual evidence
- ↑ a b James E. Dalen: Pulmonary embolism: what have we learned since Virchow? In: Chest 2002; 122: 1801-1817
- ↑ F. Trendelenburg: About the operative treatment of the embolism of the pulmonary artery . In: Archive for Clinical Surgery 1908; 86: 686-700
- ↑ M. Kirschner: A case of embolism of the pulmonary artery cured by the Trendelenburg operation . In: Archive for Clinical Surgery 1924; 133: 312-359
- ^ John A. Meyer: Friedrich Trendelenburg and the surgical approach to massive pulmonary embolism . In: Archives of Surgery 1990; 125: 1202-1205
- ^ Karl-Ludwig Schober: Tragik im Terror 1933: Arthur Woldemar Meyer . In: Jahrbuch 1994. Leopoldina (R. 3) 40: 489-508 (1995)
- ↑ whonamedit.com
