Topographic anatomy and operative surgery of the chest wall and organs of the chest cavity Lecturer - Art. teacher S. I. Veretennikov

Borders of the chest wall Above - the jugular notch of the sternum, the clavicle and the line from its acromial end to the spinous process of the VII cervical vertebra; Below - a line from the xiphoid process along the edge of the costal arch and along the XII rib to the XII thoracic vertebra; On the sides: in front along the line sulcus deltoideopectoralis, behind - along the medial edge of m. deltoideus.

Lines of the chest wall 1 linea axillaris posterior; 2 linea axillaris media; 3 linea axillaris anterior; 4 linea medioclavicularis; 5 linea parasternalis; 6 linea sternalis; 7 linea mediana anterior; 8 linea mediana posterior; 9 linea vertebralis; 10 linea paravertebralis; 11 linea scapularis.

Breast forms Wide and short chest Narrow and long chest Epigastric angle greater than 100 degrees Wide intercostal spaces and sternum Epigastric angle less than 100 degrees, narrow intercostal spaces and sternum

The shape of the chest in children under 3 years old - cone with the base down by 5 years - cylindrical by 7 years - cone with the base up by 12-13 years - the formation of the chest ends

Age features of the chest ribs are located horizontally up to 3 years 3 free ribs by 5-6 years rib groove begins to form by 12 years the intercostal neurovascular bundle is hidden in the groove jugular notch of the sternum is projected at the level of the upper edge of Th I, by 7 years - Th II

Funnel-shaped deformity of the chest Shoemaker's chest (pectus excavatum - curvature of the sternum and anterior sections of the ribs, leading to a decrease in the sterno-vertebral distance, chest volume, compression and displacement of the mediastinal organs, causing functional disorders of the cardiovascular and respiratory systems.

Gizhitskaya index for determining the degree of chest deformity I degree more than 0.7 II degree from 0.7 to 0.5 III degree less than 0.5

Methods of surgical treatment of VDHK Without fixators of the sternocostal complex With the use of external fixators With the use of internal fixators Operations of turning the sternum by 180°

Operations without fixators of the sternocostal complex (Thoracoplasty according to Ravitch M.) a) removal of costal cartilages, cutting off b) sternotomy and installation of a cartilage spacer in the sternotomy area. xiphoid process; fixation of the II costal cartilage in the form of a “tile”

Operations without fixators of the sternocostal complex (Thoracoplasty according to N. I. Kondrashin) a) skin incision line; b) cartilage excision and wedge-shaped chondrotomy; wedge and transverse sternotomy

180-degree sternal flip surgery Wada surgery (free sternum flip) Jung A surgery (muscle pedunculated sternum flip) Taguchi K. surgery (sternum flip with vascular bundle preservation)

Operations with the use of internal fixators Thoracoplasty according to Rehbein F. Thoracoplasty according to Paltia V. and Sulamaa M.

The most optimal methods are operations using internal fixation devices: less traumatic, easier to tolerate by patients, does not interfere with an active lifestyle, the rehabilitation period is shorter

Results of treatment of pectus excavatum III degree a) before surgery b) 6 months after surgery

Costo-muscular defect (Poland's syndrome) in 80% on the right, absence of pectoralis major and/or minor muscles, deformity or absence of several ribs, decrease in the thickness of subcutaneous fatty tissue, absence of hair in the armpit, absence of the nipple (atelia) and/or the mammary gland itself (amastia) ), partial or complete fusion of fingers (syndactyly) and their shortening (brachydactyly)

Development of the diaphragm Primary diaphragm - is formed at 4-6 weeks in the form of a connective tissue septum from the mesoderm Secondary diaphragm - is formed by 3 months due to the growth of myomers (muscle tissue) into the connective tissue plate

Diaphragmatic hernias If development is disturbed at the stage of the primary diaphragm, a defect remains in the diaphragm and a false diaphragmatic hernia is formed (more often in the costovertebral region, Bogdalek's hernia) If development is disturbed at the stage of the secondary diaphragm, myomers do not germinate, connective tissue weaknesses remain and a true diaphragmatic hernia is formed

Classification of diaphragmatic hernias 1. Congenital diaphragmatic hernias: diaphragmatic-pleural hiatal hernias, parasternal frenopericardial hernias 2. Acquired diaphragmatic hernias: traumatic

Methods of surgical treatment of diaphragmatic hernias 1. Chiatoplasty - suturing of the hernial orifice with U-shaped sutures to the left and right of the esophagus 2. Diaphragmocurrorrhaphy - suturing the legs of the diaphragm behind the esophagus 3. Gastropexy - after moving the stomach into the abdominal cavity, its fixation to the anterior abdominal wall in combination with narrowing esophageal opening With a radical method, the following is carried out: bringing down and fixing the stomach in the abdominal cavity, creating an acute angle of His, narrowing the dilated esophageal opening of the diaphragm. These methods include: 1. Esophagofundopexy - the fundus of the stomach is sutured to the wall of the esophagus. The second row to the anterior surface of the esophagus, as a result of which the fundus of the stomach covers the abdominal esophagus by 23, forming an acute angle between them. Then the bottom of the stomach is sutured to the lower surface of the diaphragm. 2. Fundoplication according to Nissen - around the esophagus they form a muff with the bottom of the stomach.

Fundoplication according to Nissen a) creation of an artificial ligamentous apparatus with the formation of an acute angle of His b) the final view of the formed cuff around the esophagus

Topographic anatomy of the pleura Pleura: parietal layer visceral layer Pleura sections: costal pleura diaphragmatic pleura mediastinal pleura costal mediastinal: anterior left is usually projected near the left edge of the sternum; the anterior right is located near the midline on the left; diaphragmatic-mediastinal - completely performed by the lungs when inhaling

Projection of the boundaries of the lungs, their lobes and the parietal pleura on the chest (front view) 1 lower lobes of the right and left lungs; 2 middle lobe of the right lung; 3 upper lobes of the right and left lung

Dome of the pleura - a section of the parietal pleura, protruding above the upper aperture of the chest and fixed by the costal-pleural and vertebral-pleural ligaments. Laterally and from above - adjacent to the scalene muscles Medially and behind - to the trachea and esophagus Anteriorly to the subclavian artery and vein From above - to the brachial plexus

Types of pneumothorax By origin: traumatic spontaneous artificial By volume of air: limited complete According to communication with the external environment, open closed valve

Emergency care for open pneumothorax First aid - the imposition of an aseptic occlusive dressing on the wound, vagosympathetic blockade. Surgical treatment: primary surgical treatment of the wound and sealing of the pleural cavity: wound suturing method: pleuromuscular sutures, intercostal sutures (polyspastic suture), subperiosteal resection of the rib. the use of plastic methods: plastic with a muscle flap on a leg, a diaphragm, a lung edge, a patch of synthetic material.

Treatment of the wound in case of open pneumothorax Resection of the ends of the ribs Closure of the wound defect of the chest wall using a pedunculated muscle flap

Hemothorax (accumulation of blood in the pleural cavity) Classification according to P. A. Kupriyanov: Small hemothorax - within the diaphragmatic sinus Medium hemothorax - up to the level of the angle of the scapula Large hemothorax - above the angle of the scapula

Puncture of the pleural cavity with hydrothorax A) the position of the patient during puncture B) a puncture along the upper edge of the underlying rib so as not to damage the intercostal neurovascular bundle

Puncture of the pleural cavity with hydrothorax Puncture with a Dufo needle in the 7 8th intercostal space between the scapular and posterior axillary lines with a rubber valve (drainage according to N. N. Petrov), followed by active aspiration.

Complications of pleural puncture 1 needle inserted into the tissue of the lung; 2 the needle is inserted into the pleural cavity above the fluid level; 3 the needle is inserted into the adhesions between the sheets of the pleura of the costo-phrenic sinus; 4, the needle is inserted through the costo-phrenic sinus and diaphragm into the abdominal cavity.

Resection of the rib Separation of the periosteum from the upper and lower edges of the rib Separation of the periosteum from the inner surface of the rib and transection of the rib

Drainage of the pleural cavity Indications: hemothorax, pyothorax, chylothorax. Surgical technique: skin incision (1 cm) in the 7th intercostal space along the posterior axillary line, a trocar is inserted, the stylet is removed, drainage is performed (latex or silicone tube) and a system for active aspiration is connected.

Anterolateral thoracotomy access through 4 (5-6) intercostal space, incision along the upper edge of the underlying rib, 2 cm do not reach the sternum

Posterior lateral thoracotomy Position: prone or semi-lateral. Incision: at the level of 3-4 thoracic vertebrae along the paravertebral line to the angle of the scapula, then bending around the scapula to the anterior axillary line

Longitudinal median sternotomy The incision along the midline begins 2 cm above the manubrium of the sternum and continues 3 cm below the xiphoid process

Transverse combined transbipleural approach Bilateral thoracotomy along the 6th intercostal space on the right, with a transverse intersection of the sternum at the level of the intercostal space and continuation of the thoracotomy along the 6th intercostal space on the left

Topography of the esophagus Cervical honor, pars cervicalis, is located from the level of the VI cervical vertebra to the I-II thoracic. Its length ranges from 5 to 8 cm. The thoracic part, pars thoracica, has the greatest length - 15 18 cm and ends at the level of the IX X thoracic vertebrae at the point where the esophagus enters the esophageal opening of the diaphragm. The abdominal part, pars abdominalis - from the esophageal opening of the diaphragm to the cardiac opening of the stomach, the shortest (13 cm). 4 bends: two in the sagittal plane and two in the frontal plane.

Narrowing of the esophagus 3 narrowings: a - at the place where the pharynx passes into the esophagus, (15 cm from the edge of the teeth) b - at the place where the esophagus is adjacent to the aortic arch, (25 cm from the edge of the teeth) c - at the place where the diaphragm passes through the esophageal opening - physiological cardiac sphincter (38 cm from the edge of the teeth)

The thoracic part of the esophagus Syntopia: - the upper third (level TIII) is closed in front by the trachea, connected to it by connective tissue bridges - the middle third (TIV VI) in front of the aortic arch, tracheal bifurcation and left ch. bronchus - lower third (TVII TX) parallel to the aorta, at the diaphragm, the esophagus bends to the left

Innervation: plexus esophageus (n. vagus and truncus sympathicus) Blood supply: cervical part - rr. esophageales from a. thyreoidea inferior; chest part - rr. esophageales or aorta thoracica, abdominal part - rr. esophageales from a. gastric sinistra and a. phrenica inferior sinistra. Venous outflow: from the cervical part in v. thyreoidea inferior, and then in v. brachiocephalica; from the chest part - in v. azygos and v. hemiazygos; from the abdominal part - in v. gastrica sinistra and then to v. portae. Lymphatic outflow: from the cervical part in nodi lymphatici tracheobronchiales superiores et inferiores, paratracheales and paraverlebrales; from the thoracic part - into nodi lymphatici tracheobronchiales inferiores and mediastinals posteriores: from the abdominal part - into anulus lymphatici cardii.

Malformations of the esophagus atresia of the esophagus (the method of treatment depends on the distance between the blind ends of the esophagus) Esophageal-tracheal fistulas (often in the middle or lower third, the method of treatment depends on the diameter of the fistula) diverticulum cardiostenosis

Cardiostenosis, achalasia of the cardia According to BV Petrovsky (1957) distinguishes four stages of the disease: I functional spasm without expansion of the esophagus; II persistent spasm with moderate expansion of the esophagus; III cicatricial changes in the muscle layers with a pronounced expansion of the esophagus; IV cardiostenosis with a large expansion of the esophagus and its S-shaped curvature.

Treatment of cardiostenosis Conservative Instrumental (cardiodilation) causes stretching and partial damage to the circular muscles and myoneural connections. hydraulic cardiodilators pneumatic cardiodilators mechanical cardiodilators (Stark)

Surgical treatment of cardiostenosis of extramucosal esophagocardiomyotomy, which consists in dissecting only the muscular layer of the esophagus to the mucous membrane (Gottstein 1901, Heller 1913). myotomy according to Geller, myotomy with plasty of the formed defect with a diaphragm flap (B. V. Petrovsky 1949), omentum (I. M. Chuikov 1932), stomach (T. A. Suvorova 1960, A. A. Shalimov 1976). extramucosal esophagocardiomyotomy with plastic surgery of the esophagus with the anterior wall of the stomach (Gottstein Geller Suvorova operation) from the thoracotomy access. resection of the thoracic esophagus and cardia of the stomach with simultaneous plastic surgery of the stomach with achalasia of the cardia of stage III and IV (B. I. Miroshnikov et al., 2001). Satisfactory results of surgical treatment of cardiostenosis were obtained in 80-87% of patients. Mortality is about 1%.

Esophageal diverticula 1. Pharyngeal esophageal diverticula (63%) simultaneous diverticulectomy from an incision along the inner edge of the sternocleidomastoid muscle on the left.) 2. Epiphrenal (20%) diverticulectomy more often from the right-sided thoracotomy access. 3. Bifurcation (17%) simultaneous diverticulectomy or diverticulum intussusception from the right transpleural approach

Operations on the esophagus Esophagotomy - dissection of the esophagus. For extraction of foreign bodies and elimination of congenital strictures. Operation Dobromyslov-Torek. When the tumor is located in the middle third. Access is right-sided, transpleural. Resection of the esophagus, immersion of the lower stump into the stomach, and the proximal stump onto the neck. Creation of a gastric stoma. Resection of the lower third of the esophagus with anastomosis or its replacement with the gastric wall along the greater curvature (Gavrilov's operation). Anastomosis with the small intestine. Esophagoplasty - replacement of the esophagus with a small or large intestine (antethoracic plastic according to Roux Herzen Yudin).

Resection of the esophagus Separation of the esophagus with surrounding tissue and lymph nodes from the posterior mediastinum Separation of the anterior wall of the esophagus from the pericardium.

Resection of the esophagus Separation of the posterior wall of the esophagus from the aorta. Crossing and ligation of the esophageal branches of the thoracic aorta.

Resection of the esophagus Crossing the distal end of the thoracic esophagus Serosuscular interrupted sutures above the mechanical suture line in the cardia

Posterior mediastinum 1 - a. carotis communis; 2 - esophagus; 3-n. recurrences; 4-n. vagus; 5 – a. subclavia; 6 - aortic arch; 7 - left main bronchus; 8 - thoracic aorta; 9 - abdominal esophagus; 10-a. coeliaca; 11 - diaphragm; 12 - lymph nodes; 13 - I rib; 14 - trachea; 15 - larynx; 16-v. azygos; 17 - thoracic lymphatic duct

Drainage of the mediastinum Transcervical mediastinotomy according to V. I. Razumovsky (in case of damage to the cervical and upper thoracic esophagus) Transdiaphragmatic mediastinotomy according to Rozanov Savinykh (in case of damage to the lower thoracic and abdominal parts of the esophagus) Transsternal drainage Extrapleural parasternal drainage with resection of 2 3 costal cartilages according to Madelung. Transesophageal drainage (while maintaining the mediastinal pleura) Transpleural mediastinotomy according to V.D. Dobromyslov (for injuries of the thoracic esophagus with damage to the mediastinal pleura) Posterior extrapleural mediastinotomy according to I.I. Nasilov with resection of several ribs

Approaches for anterior mediastinitis 1 - cervical mediastinotomy, 2 - suprasternal incision according to Razumovsky, 3 - incision according to Madelung, 4 - transphrenic mediastinotomy

Topography of the heart The sternocostal surface faces the sternum, costal cartilages, and partly the mediastinal pleura. The diaphragmatic surface in the upper sections faces the esophagus and thoracic aorta, the lower sections are adjacent to the diaphragm.

Topography of the heart The sternocostal surface consists of the anterior surfaces of the right atrium, right auricle, superior vena cava, pulmonary trunk, right and left ventricles, as well as the apex of the heart and the apex of the left auricle. The diaphragmatic surface in the upper sections is made up of the posterior surfaces of the predominantly left and partly of the right atria, in the lower sections - the lower surfaces of the right and left ventricles and partly of the atria.

Projection of the openings of the heart on the anterior wall of the chest Left atrioventricular opening to the left of the sternum in the third intercostal space; mitral valve sounds (2 x cuspid valve are heard at the apex of the heart. The right atrioventricular opening is behind the right half of the sternum, on a line drawn from the point of connection with the sternum of the cartilage of the left III rib to the point of connection with the sternum of the cartilage of the right VI rib; tones of the 3 fold valve are heard on the right at the level of the cartilages of the V-VI ribs and the adjacent part of the sternum.

Projection of the openings of the heart on the anterior wall of the chest The opening of the aorta is located behind the sternum, closer to its left edge, at the level of the third intercostal space; sounds of the aortic valve are heard on the right at the edge of the sternum in the second intercostal space. The opening of the pulmonary trunk is located at the level of attachment of the cartilage of the left third rib to the sternum; Tops of the valve of the pulmonary trunk are heard on the left at the edge of the sternum in the second intercostal space.

Surgical anatomy of the coronary arteries (according to A. A. Shalimov) Right coronary artery: I segment from the mouth to the origin of the artery of the sharp edge of the heart (length from 2 to 3.5 cm); II segment from the branch of the sharp edge of the heart to the origin of the posterior interventricular branch of the right coronary artery (2, 2 3, 8 cm); III segment of the posterior interventricular branch of the right coronary artery. Left coronary artery: I segment - from the mouth to the place of division into main branches II segment - the first 2 cm of the anterior interventricular branch of the left coronary artery III segment - the next 2 cm of the anterior interventricular branch of the left coronary artery IV segment - the distal section of the anterior interventricular branch V segment envelope branch of the left coronary artery to the point of origin of the branch of the obtuse margin of the heart VI segment - distal section of the circumflex branch of the left coronary artery (artery of the obtuse margin of the heart) VII segment - diagonal branch of the left coronary artery

Types of blood supply to the heart right coronary type, most parts of the heart are supplied with blood by branches of the right coronary artery; left coronary type most of the heart receives blood from the branches of the left coronary artery; medium (uniform) type, both coronary arteries are evenly distributed in the walls of the heart. Transitional types of blood supply to the heart: middle right middle left

Arteries of the heart Extraorganic: - right coronary artery (two branches: right marginal and posterior interventricular) - departs from the right sinus of the aortic bulb, supplies blood to the right atrium, part of the anterior and entire posterior wall of the right ventricle, the IPP and part of the IZHP; left coronary artery - from the left sinus of the aortic bulb (two branches: anterior interventricular and envelope - supply blood to the left atrium, part, most of the posterior wall of the left ventricle, part of the anterior wall of the pancreas, part of the IVS. Intraorganic: arteries of the atrium, heart ears, septa, ventricles and papillary muscles.

Innervation of the heart Nerves: vagus branches, sympathetic trunks, phrenic and hypoglossal nerves. Conducting system: Sinus node (lies in the wall of the right atrium). If its integrity is violated, supraventricular arrhythmias of various types occur; Atrioventricular node (Ashof-Tovara) - in the wall of the RA and through the IVS to the RV and LV.

Congenital heart defects 1. Heart defects with normal blood flow through the lungs coarctation of the aorta by adult type 2. Heart defects with increased blood flow through the lungs open ductus arteriosus atrial septal defect coarctation) 3. Heart defects with reduced blood flow through the lungs triad, tetrad, pentad of Fallot

Aortogram of a patient with aortic coarctation According to Abbott statistics, aortic coarctation accounts for 14.2% of all congenital heart defects, other authors give a figure of 6 7%. Congenital narrowing of the aorta is located at the junction of the aortic arch into the descending aorta distal to the left subclavian artery.

Pulmonary valve Located in the fibrous ring in front of the arterial valve Has 3 sinuses of the pulmonary trunk and 3 semilunar valves Pulmonary trunk diameter 2.5 - 3 cm

Aortic valve Located in the annulus fibrosus connected to the membranous portion of the IVS. It has 3 semilunar valves attached to the lower edges of the 3 aortic sinuses; From the right sinus begins the right coronary artery, from the left sinus - the left; The coronless sinus is located extracardiac, in contact with the cavity of the transverse sinus of the pericardium.

Indirect revascularization of the heart 1. The organopexy method was used to suture vessels of adjacent organs (lung, diaphragm, omentum) to the heart. 2. Talc was poured into the pericardial cavity, pericarditis developed with the formation of adhesions, in adhesions the vessels approach the walls of the heart. 3. 1939 Fieschi 2-sided dressing and cutting a. thoracica interna. This leads to an increase in blood flow in a. pericarodiaca phrenica (by 20%). It is also an inefficient method. 4. 1945 Weinberg direct implantation a. Thoracica interna into the thickness of the myocardium: blood passes through the tunnel between the muscle fibers and subsequently collaterals develop. Used for diffuse lesions of the coronary arteries.

Direct cardiac revascularization 1. 1960 mammary coronary anastomosis – a. thoracica interna and is sutured into the coronary artery distal to the lesion. Demikhov V.P. experiment. In 1967, the same operation was performed on a human by Kolesov. 2. 1967 - Favaloro aortocoronary bypass surgery.

Endovascular Interventions 1978 Gruntzig. 1. Balloon dilatation of the mouth of the coronary artery under local anesthesia, using a catheter with a tip during coronary angiography. The effect persists for 3 years. 2. Chazov injects thrombolytics through a catheter. 3. Laser photocoagulation laser light guide, at the end of the sapphire tip (heated up to 400 (C), they touch the plaque.

Mitral stenosis (narrowing of the left atrioventricular opening) stenosis in the form of a "jacket loop" - thickening and unexpressed fusion of the leaflets (commissurotomy is possible) stenosis in the form of a "fish mouth" - a pronounced fusion with a change in the subvalvular apparatus (valve prosthetics is necessary)

Ball-and-socket mechanical prosthetic heart valves (MICS) Starr-Edwards valve – the first MICS interferes with blood flow Starr-Edwards valve

Disk mechanical artificial heart valves Bicuspid valve Sant Jude Medical - Regent Valve Med. Ing

Biological artificial heart valves (BIHS) Supported valve: Carpentier Edwards porcine valve Carpentier Edwards pericardial valve Supportless valve: Toronto porcine valve Freestyle

Suturing the wound of the heart in the area of ​​the coronary artery U-shaped suture to avoid ligation of the coronary arteries

Segmental structure of the right lung (mediastinal surface) Upper lobe SI segmentum apicale; SII segmentum posterius; SIII segmentum anterius. The average share of SIV segmentum laterale; SV segmentum mediale. Lower lobe of SVI segmentum apicale; SVII segmentum basale mediale (cardiacum) SVIII segmentum basale anterius; SIX segmentum basale laterale; SX segmentum baseal posterius.

Segmental structure of the left lung (mediastinal surface) Upper lobe SI+II segmentum apicoposterius; SIII segmentum anterius; SIV segmentum lingulare superius; SV segmentum lingulare inferius. Lower lobe of SVI segmentum apicale; SVII segmentum basale mediale (cardiacum) SVIII segmentum basale anterius; SIX segmentum basale laterale; SX segmentum baseal posterius.

The roots of the lung in the horizontal plane Anteriorly - the pulmonary veins Behind them - the branches of the pulmonary artery Most posteriorly - the main bronchus (surrounded by branches of the vagus nerve and sympathetic trunk)

Resection interventions on the lungs Wedge-shaped resection of the lung (with the imposition of a continuous continuous suture); Removal of a segment of the lung (segmentectomy Removal of a lobe of the lung (lobectomy); Removal of the lung (pneumonectomy); Sewing up the wound of the main bronchi (wedge excision, end-to-end anastomosis).

Pulmonectomy Displacement of tissue and lymph nodes, intersection of the pericardial arterial ligament Processing of the main vessels of the root of the right lung

Pulmonectomy Crossing the main bronchus leaving one half-ring of cartilage Sewing up the stump of the main bronchus with interrupted sutures on atraumatic needles

Mistakes and dangers of operations on the lungs In 34% of cases, the arteries of the 4th and 5th segments depart SEPARATELY from the interlobar artery. When removing the middle lobe, the middle lobe bronchus is first crossed, and then the artery; With an atypical outflow of the veins of the 3rd and 4th segments, complications may arise when the upper and lower pulmonary veins are isolated during resection of the middle and upper lobes of the right lung; With an atypical discharge of the arteries of the 3rd segment from the upper trunk, resection of the reed segments is dangerous; With a mixed type of venous outflow (the vein of the first segment flows into the vein of the third), damage to the veins of the 3rd segment is dangerous. Inflow of veins of the reed segments into the inferior pulmonary vein can lead to erroneous ligation of the veins of the 3rd segment instead of the veins of the 4th and 5th segments.

Suturing of wounds of the lung Access: anterolateral or lateral thoracotomy along the IV-V intercostal space. Operations: for stab wounds - nodal sutures. With linear wounds of more than 1 cm - the crucible suture. Bronchial wounds are sutured with atraumatic needles. For a gunshot wound, a segment, forehead, pneumonectomy are used.

Layers of the chest wall superficial layer - skin, subcutaneous tissue and mammary gland muscular-fascial layer - in front - large and small pectoral muscles, on the side - anterior serratus muscles, behind - the latissimus dorsi muscle deep layer - intercostal muscles and bone and cartilage base

The surface layer of the chest wall The skin is thin, contains hair follicles, sweat and sebaceous glands (atheromas develop when the excretory ducts are blocked); Subcutaneous fatty tissue contains superficial vessels: branches of the posterior intercostal arteries (from the aorta), anterior intercostal arteries (from the internal thoracic) and lateral thoracic (from the axillary artery); The superficial fascia extends from the collarbone and forms the mammary gland capsule (the ligament that supports the mammary gland)

Deep layer of the chest wall Osteocartilaginous base: sternum (handle, body and xiphoid process), spine (I-XII thoracic vertebrae), ribs. Intercostal spaces: external intercostal muscles (do not reach the sternum) internal intercostal muscles (go from the sternum to the costal angles behind) between the muscles - intercostal vessels, nerve (in the groove, the ribs go to the midaxillary line) and lymphatic vessels. Puncture of the sternum: in the midline at the level of the first ribs

Classification of mastitis Acute Chronic galactophoritis (inflammation of the milk ducts) areolitis (inflammation of the glands near the nipple circle) diffuse purulent: characterized by the formation of small abscesses and pronounced induration of the surrounding tissue; plasma cell (non-purulent): it is mandatory to perform mammography, cytological examination of punctate, histological examination of removed tissues. With ineffectiveness within 2 weeks of conservative treatment - sectoral resection.

Classification of mastitis depending on localization 1 subareolar 2 intramammary 3 - premammary (subcutaneous) 4 retromammary

Classification of mastitis depending on the stage of the inflammatory process serous (initial) infiltrative infiltrative purulent (apostematous by the type of "honeycomb") abscessing phlegmonous gangrenous

Pericardial puncture - Larrey's point between the xiphoid process and the left costal arch (cartilaginous surface of the VII rib), Marfan's point under the top of the xiphoid process, Pirogov Karavaev's point in the fourth intercostal space to the left, 2 cm outward from the sternum. Delorme Mignon's point in the sixth intercostal space on the left side of the sternum

Breast cancer (lymphogenic metastasis) axillary scapular subclavian l / y; parasternal, supraclavicular, cervical and l / a mediastinum (central cancer); cross-metastasis (axillary nodes of the opposite side); distant metastasis: vertebral bodies, pelvic bones, lung, liver, brain, etc.

Simple mastectomy (Maden operation) - the entire mammary gland is removed; regional axillary lymph nodes do not remove the large and small pectoral muscles.

Radical mastectomy (Halstead operation) - the entire mammary gland is removed; regional axillary lymph nodes are removed; pectoralis major and minor muscles are removed; the long pectoral nerve is left.

Rib cage- bone base of the chest wall. Consists of XII thoracic vertebrae, XII pairs of ribs and sternum.

Chest wall:

The back wall is formed by the thoracic part of the spinal column, as well as the posterior parts of the ribs from the head to their corners.

The anterior wall is formed by the sternum and cartilaginous ends of the ribs.

The side walls are formed by the bony part of the ribs.

The upper thoracic inlet is limited by the posterior surface of the manubrium of the sternum, the inner edges of the first ribs and the anterior surface of the first thoracic vertebra.

The lower aperture of the chest is limited by the posterior surface of the xiphoid process of the sternum, the lower edge of the costal arch, the anterior surface of the X thoracic vertebra. The lower aperture is closed by a diaphragm.

skeleton of the chest, a - front view. 1 - upper thoracic aperture; 2 - jugular

tenderloin; 3 - handle of the sternum; 4 - body of the sternum; 5 - xiphoid process of the sternum; 6 - oscillating ribs (XI-XII); 7 - infrasternal angle; 8 - lower thoracic aperture; 9 - false ribs (VIII-X); 10 - costal cartilages; 1 1 - true ribs (I-VII); 12 - clavicle.

Topography of intercostal spaces.

Topography of the intercostal neurovascular bundle on the posterior and anterior surfaces of the chest
:

I - between the middle axillary and paravertebral lines;

II - between the middle axillary and midclavicular lines.

1 - fascia m. latissimus dorsi; 2 - m. latissimus dorsi; 3 - fascia thoracica; 4-v. intercostalis;

5 – a. intercostalis; 6-n. intercostalis; 7 - m. Intercostalisexternus; 8 - m. intercostalis internus;

9 - fascia endothoracica; 10 - prepleural fiber; 11 - pleura parietalis;

12 - fasciapectoralis; 13 - m. pectoralis major.

In the spaces between the ribs are the external and internal intercostal muscles, fiber and neurovascular bundles.

External intercostal muscles (mm. intercostalisexterni) go from the lower edge of the ribs obliquely from top to bottom and anteriorly to the upper edge of the underlying rib. At the level of the costal cartilages, the muscles are absent and are replaced by an external intercostal membrane.

Internal intercostal muscles (mm. intercostales interni) go obliquely from the bottom up and back. Posterior to the costal angles, the muscle bundles are absent and are replaced by an internal intercostal membrane.

The space between adjacent ribs, bounded from the outside and from the inside by the corresponding intercostal muscles, is called the intercostal space. A vein is located in it, below it is an artery, even below it is a nerve.

Posterior intercostal arteries(IX-X pairs) depart from the aorta, located in the intervals from III to XI ribs, the twelfth artery, lying under the XII rib, was called the hypochondrium artery (a. subcostalis). Branches:

Dorsal branch (r. dorsalis) goes to the muscles and skin of the back

Lateral and medial skin branches (r. cutaneus lateraliset medialis) go to the skin of the chest and abdomen

Lateral and medial branches of the mammary gland (rr. mammariilateralisetmedialis)

Topographic anatomy of the chest and organs of the chest cavity

1. Upper - along the jugular notch, along the upper edge of the clavicles, clavicular-acromial joints and along conditional lines drawn from this joint to the spinous process of the VII cervical vertebra.

2. Lower - from the base of the xiphoid process, along the edges of the costal arches to the X ribs, from where along conditional lines through the free ends of the XI and XII ribs to the spinous process of the XII thoracic vertebra. The chest area is separated from the upper limbs on the left and right by a line passing in front along the deltoid-pectoral groove, and behind - along the medial edge of the deltoid muscle.

Layered topography of the chest wall along the midclavicular line

1. The skin on the front surface is thinner than in the back, contains sebaceous and sweat glands, is easily mobile, with the exception of the sternum and posterior median region.

2. Subcutaneous fat is more developed in women, contains a dense venous network, numerous arteries that are branches of the internal thoracic, lateral thoracic and posterior intercostal arteries, superficial nerves originating from the intercostal and supraclavicular nerves of the cervical plexus.

3. The superficial fascia in women forms a capsule of the mammary gland.

4. Mammary gland

5. Own fascia (thoracic fascia) consists of two sheets - superficial and deep (clavicular-thoracic fascia), forming fascial cases for the pectoralis major and minor muscles, and on the back wall - for the lower part of the trapezius muscle and latissimus dorsi. In the region of the sternum, the fascia passes into the anterior aponeurotic plate, which is fused with the periosteum (there is no muscle layer in this area).

6. Large pectoral muscle.

7. Superficial subpectoral cellular space.

8. Small pectoral muscle.

9. Deep subpectoral cellular space - subpectoral phlegmons can develop in these spaces.

10. Intercostal space - a complex of formations (muscles, vessels, nerves) located between two adjacent ribs.

The most superficially located are the external intercostal muscles, which perform the intercostal space from the tubercles of the ribs to the outer ends of the costal cartilages. In the region of the costal cartilages, the muscles are replaced by fibrous fibers of the external intercostal membrane. The fibers of the external intercostal muscles run from top to bottom and from back to front.

Deeper than the outer are the internal intercostal muscles, the direction of the fibers of which is opposite to the course of the external intercostal muscles, i.e., from the bottom up and back to front. The internal intercostal muscles occupy the intercostal spaces from the corners of the ribs to the sternum. From the corners of the ribs to the spinal column, they are replaced by a thin internal intercostal membrane. The space between the external and internal intercostal muscles is made with a thin layer of loose fiber, in which the intercostal vessels and nerves pass.

The intercostal arteries are divided into anterior and posterior. The anterior arteries are branches of the internal mammary artery. The posterior intercostal arteries, except for the two upper ones, which depart from the costocervical trunk of the subclavian artery, start from the thoracic aorta.

The intercostal vein is located above, and the intercostal nerve is located below the artery. From the corners of the ribs to the midaxillary line, the vessels of the intercostal space are hidden behind the lower edge of the rib, the nerve runs along this edge. Anterior to the midaxillary line, the intercostal neurovascular bundle exits from under the lower edge of the rib. Guided by the structure of the intercostal space, it is advisable to carry out chest punctures in the VII-VIII intercostal space between the scapular and middle axillary lines along the upper edge of the underlying rib.

11. Intrathoracic fascia is more pronounced in the anterior and lateral regions of the chest wall, less pronounced in the spinal column.

12. Prepleural tissue.

13. Pleura.

mammary gland

Skeletotopia: between the III and VI ribs from above and below and between the parasternal and anterior axillary lines from the sides.

Structure. It consists of 15–20 lobules, surrounded and separated by processes of the superficial fascia. The lobules of the gland are arranged radially around the nipple. Each lobule has its own excretory, or milky, duct with a diameter of 2-3 mm. The lactiferous ducts converge radially to the nipple and expand in an ampulla-like manner at its base, forming the lactiferous sinuses, which outwardly narrow again and open at the apex of the nipple with pinholes. The number of holes on the nipple is usually less than the number of lactiferous ducts, since some of them at the base of the nipple are interconnected.

Blood supply: branches of the internal thoracic, lateral thoracic, intercostal arteries. The deep veins accompany the arteries of the same name, the superficial ones form a subcutaneous network, some branches of which flow into the axillary vein.

Innervation: lateral branches of the intercostal nerves, branches of the cervical and brachial plexuses.

Lymph drainage. The lymphatic system of the female mammary gland and the location of regional lymph nodes are of great practical interest due to the frequent damage to the organ by a malignant process.

The main way of outflow of lymph is to the axillary lymph nodes in three directions:

1. through the anterior thoracic lymph nodes (Zorgius and Bartels) along the outer edge of the pectoralis major muscle at the level of the second or third rib;

2. intrapectorally - through Rotter's nodes between the pectoralis major and minor muscles;

3. transpectorally - along the lymphatic vessels penetrating the thickness of the pectoralis major and minor muscles; nodes are located between their fibers.

Additional ways of outflow of lymph:

1. from the medial section - to the lymph nodes in the course of the internal thoracic artery and anterior mediastinum;

2. from the upper section - to the subclavian and supraclavicular nodes;

3. from the lower section - to the nodes of the abdominal cavity.

Diaphragm

The diaphragm is a muscular-fascial formation, the basis of which is a wide, relatively thin muscle that looks like a dome, the bulge of which is turned upward towards the chest cavity. The diaphragm is represented by two sections: tendon and muscle.

The tendon part forms the right and left domes, as well as an impression from the heart. It distinguishes between the right and left lateral, as well as the anterior sections. In the anterior section there is an opening for the inferior vena cava.

The muscular section of the diaphragm, according to the points of its fixation along the circumference of the lower aperture of the chest, is divided into three parts: lumbar, sternal and costal.

1. The lumbar part starts from the four upper lumbar vertebrae with two legs - right and left, which, forming a cross in the form of the number 8, form two openings: the aortic, through the ĸᴏᴛᴏᴩᴏᴇ pass the descending part of the aorta and the thoracic lymphatic duct, and the esophageal - the esophagus and vagus trunks . Between the muscle bundles on the sides of the legs of the diaphragm are unpaired, semi-unpaired veins and splanchnic nerves, as well as the sympathetic trunk.

2. The sternal part starts from the inner surface of the xiphoid process of the sternum.

3. The costal part starts from the VII-XII ribs.

Weak spots:

1. lumbar-costal triangles (Bohdalek) - waiting for the lumbar and costal parts of the diaphragm;

2. sternocostal triangles (right - Morgarya's fissure, left - Larrey's fissure) - between the sternal and costal parts of the diaphragm.

In these muscle gaps, the sheets of the intrathoracic and intra-abdominal fascia come into contact. These sections of the diaphragm are the site of the formation of diaphragmatic hernias, and when the fascia is destroyed by a suppurative process, it becomes possible to transfer it from the subpleural tissue to the subperitoneal and vice versa. The esophageal opening also belongs to the weak point of the diaphragm.

Blood supply: internal thoracic, superior and inferior phrenic, intercostal arteries.

Innervation: diaphragmatic, intercostal, vagus and sympathetic nerves.

Mediastinum

The mediastinum is a space filled with a complex of organs and neurovascular formations, bounded laterally by the mediastinal pleura, in front, behind and below - by the intrathoracic fascia, behind which the sternum is located in front, behind - the spinal column, below - the diaphragm.

Classification:

1. The upper mediastinum includes all anatomical formations lying above the conditional horizontal plane drawn at the level of the upper edge of the roots of the lungs.

Contents: aortic arch; brachiocephalic trunk; left common carotid artery; left subclavian artery; thymus gland; brachiocephalic veins; superior vena cava; phrenic nerves; vagus nerves; recurrent laryngeal nerves; trachea; esophagus; thoracic lymphatic duct; paratracheal, upper and lower tracheobronchial lymph nodes.

2. The anterior mediastinum is located below the indicated plane, between the sternum and the pericardium.

Contents: loose fiber; peristernal and upper diaphragmatic lymph nodes; thymus gland and intrathoracic arteries.

3. Middle mediastinum

Contents: pericardium; heart; ascending aorta; pulmonary trunk; pulmonary arteries and pulmonary veins; right and left main bronchi; upper segment of the superior vena cava; right and left phrenic nerves; pericardiodiaphragmatic arteries and veins; lymph nodes and cellular tissue.

4. The posterior mediastinum is located between the pericardium and the spinal column.

Contents: descending aorta; esophagus; vagus nerves; border sympathetic trunk and large and small celiac nerves; unpaired vein; semi-unpaired vein; accessory semi-unpaired vein; thoracic lymphatic duct; lymph nodes and cellular tissue.

The pleura forms two serous sacs. Between the two layers of the pleura - visceral and parietal - there is a slit-like space, ĸᴏᴛᴏᴩᴏᴇ is commonly called the pleural cavity. Given the dependence on the area that the parietal pleura lines, it distinguishes between:

1. costal,

2. diaphragmatic,

3. mediastinal pleura.

Parts of the pleural cavity, which are located at the points of transition of one section of the parietal pleura to another, are called pleural sinuses:

1. costophrenic sinus;

2. costal-mediastinal sinus;

3. diaphragmatic-mediastinal sinus.

In each lung, three surfaces are distinguished: the outer, or costal, diaphragmatic and medial.

Each lung is divided into lobes. In the right lung, there are three lobes - upper, middle and lower, in the left two lobes - upper and lower. Lungs are also divided into segments. Segment - a section of the lung ventilated by a bronchus of the third order. Each lung has 10 segments.

On the medial surface of each lung are its gates. Here are the anatomical formations that make up the root of the lung: bronchus, pulmonary arteries and veins, bronchial vessels and nerves, lymph nodes. Skeletotopically, the root of the lung is located at the level of V-VII thoracic vertebrae.

Syntopy of the components of the root of the lung

1. From top to bottom: in the right lung - the main bronchus, pulmonary artery, pulmonary veins; in the left - pulmonary artery, main bronchus, pulmonary veins. (BAV, ABV)

2. From front to back - veins are located in both lungs, then the artery and the bronchus occupies the rear position. (VAB) Pericardium

The pericardium is a closed serous sac that surrounds the heart, the ascending part of the aorta until it passes into the arch, the pulmonary trunk to the place of its division, the opening of the hollow and pulmonary veins.

The layers of the pericardium are:

1. external (fibrous);

2. internal (serous):

‣‣‣ parietal plate;

‣‣‣ visceral plate (epicardium) - covers the surface of the heart.

In those places where the epicardium passes into the parietal plate of the serous pericardium, the sinuses are formed:

1. transverse, located in the region of the ascending aorta and pulmonary trunk;

2. oblique - located in the lower part of the posterior pericardium;

3. anterior-inferior, located in the place where the pericardium enters the angle between the diaphragm and the anterior chest wall.

Topographic anatomy of the chest and organs of the chest cavity - concept and types. Classification and features of the category "Topographic anatomy of the chest and organs of the chest cavity" 2017, 2018.

Common data. Borders of the chest: from above and in front - a line drawn from the notch of the sternum handle along the collarbone to the acromioclavicular joint; behind - straight lines connecting the acromioclavicular joints with the spinous process of the VII cervical vertebra; below - a line drawn from the xiphoid process along the edge of the costal arch to the X rib, then through the ends of the XI and XII ribs to the spinous process of the XII thoracic vertebra.

These lines do not reflect, however, the true boundaries of the chest cavity, since at the top the dome of the pleura protrudes above the clavicle. At the bottom, the dome of the diaphragm rises into the chest cavity, which naturally leads to a decrease in its volume.

Distinguish: anterolateral, posterolateral and lower wall of the chest. The entrance to the chest cavity (apertura thoracis superior) is limited: behind - by the spine, from the sides - by the 1st rib and in front - by the handle of the sternum.

The lower opening of the chest cavity (apertura thoracis inferior) is limited: behind the body of the XII thoracic vertebra, XII and partially XI rib, from the sides - costal arch and in front - the xiphoid process.

The tissues involved in the formation of the walls of the chest cavity can be divided into three layers: 1) the surface layer, which includes tissues involved in the formation of integuments of the whole body, 2) the middle layer, which includes tissues common to both the shoulder girdle and neck, and for neighboring areas (abdomen, lower back), and, finally, 3) a deep layer, which includes tissues related directly to the wall of the chest cavity proper.

Anatomical structures that form the walls of the chest cavity

In the deep layers of the chest wall, the segmentation of the structure is most clearly expressed, which manifests itself in the location of the ribs, muscles, nerves and blood vessels.

In the middle layers, segmentation is disturbed due to the complexity of the formation of the upper limbs. The skin of the axillary fossae is very thin and mobile, on the back it is significantly thickened and is hardly folded. Sweat and sebaceous glands are located in the thickness of the skin. Arteries and veins in the thickness of the skin form a multilayer network - superficial and deep. The first, small-looped, is located in the papillary layer, the second, wide-looped, is in the lower layers of the skin proper.

From the skin of the posterior surface of the chest, lymph flows both to the nodes of the axillary cavity and to the nodes located in the intermuscular spaces of the posterior wall of the chest.

Innervation of the skin in front, in the region of the subclavian fossae, is carried out by branches of the cervical plexus arising from CIII, CIV - nn. supraclavicularis, nn. cutanei colli, in front and from the sides - branches of seven paired intercostal nerves. The skin of the back is innervated by the posterior branches of the thoracic nerves from ThI to ThIX.

The degree of development of subcutaneous tissue is individually different. In the anterior sections of the chest, the subcutaneous tissue is loose, large-lobed, while on the back it is small-lobed and contains many connective tissue elements that sharply limit the mobility of the skin.

In fatty tissue are arteries that feed the skin (branches a. thoracica interna, intercostal and lateral chest). Veins form individually differently expressed venous network.

The subcutaneous tissue veins in the region of the anterior surface of the chest are connected by anastomoses both with the system of the inferior vena cava and with the system of the superior vena cava, as a result of which, with tumors of the mediastinum that cause difficulties in the outflow of blood in the trunk, one can see the expansion of the saphenous veins, and sometimes, with pronounced stagnation , swelling of the cellular tissue is noted.

With difficulty in the outflow of blood into the system of the inferior vena cava, the expansion of the saphenous veins is noted in the anteroinferior and lower lateral sections of the anterior wall of the chest.

Lymphatic pathways and nerve branches supplying the skin pass through the subcutaneous tissue, while the mammary glands are also located in the thickness of the subcutaneous tissue.

middle layer. Due to the fact that the composition of the middle layer of the chest wall includes formations that are common to the chest and neighboring areas (shoulder girdle, neck, abdomen, lower back), the structure and topography of the chest wall in different parts of it are not the same. Based on practical considerations, it is advisable to consider the middle layer of the wall by regions.

Distinguish: anteroposterior region of the chest, anteroinferior, posterior superior and posterior inferior regions.

The boundaries of the anterior upper region of the chest (regio thoracis anterior superior) are: the upper one is the clavicle, the lower one is the edge of the pectoralis major muscle, the outer one is the middle axillary line, which at the top passes into the line corresponding to sulcus deltoideo-pectoralis, the inner one is lin. sternalis.

The fascial layer of this area is formed by the breast's own fascia (fascia pectoralis propria), in which two plates are distinguished - superficial and deep.

The superficial plate (lamina superficialis fasciae pectoralis propriae) forms the sheath of the pectoralis major muscle and in the upper section connects to the periosteum of the clavicle and the fascia of the neck; laterally, this leaf passes into the axillary fascia and the fascia of the deltoid muscle, medially into the aponeurotic plate of the sternum - membrana sterni anterior.

The pectoralis major muscle (m. pectoralis major) consists of three parts: pars clavicularis, pars sternalis and pars abdominalis. All three parts of the muscle form one flat tendon, which is attached to the crista tuberculi majoris humeri. The degree of muscle development varies from person to person. Sometimes you can see a partial or complete congenital absence of this muscle.

Between m. deltoideus and the clavicular part of the pectoralis major muscle in sulcus deltoideo-pectoralis passes v. cephalica, which in the trigonum deltoideo-pectorale (Morenheim's fossa) plunges into the depths and flows into v. subclavia.

Vascularization of the pectoralis major muscle is carried out by branches a. thoraco-acromialis, a. axillaris. The main arteries enter the muscle in its upper outer section.

Muscle veins are tributaries of the veins that accompany the above arteries.

The lymphatic vessels of the clavicular part of the muscle flow into the supraclavicular nodes, the medial part - into the retrosternal (lnn. sternalis), the outer part - into the subclavian and lower - into the lnn. subpectorales located along the lower edge of the muscle.

Innervation is provided by branches of the anterior thoracic nerves (nn. thoracalis anteriores), arising from CV - CVIII. The deep plate of the own fascia of the breast (lamina profunda fasciae pectorales propriae) is a rather dense formation. The fascia is fixed to the coracoid process of the scapula, collarbone and ribs, and therefore is called fascia coracoclavicostalis.

It forms the vagina, which contains the pectoralis minor muscle. In the upper part of the fascia, the branches of truncus thoraco-acromialis and nn. thoracales anteriores. Between the posterior surface of the pectoralis major muscle and the coraclavicular-costal fascia there is a layer of fiber - the first deep cellular space.

Small pectoral muscle - m. pectoralis minor starts from III, IV and V ribs and is attached to the processus coracoideus scapulae. Muscle vessels are branches a. thoracoacromialis, a. axillaris. Veins of the same name accompany the arteries. Together with the vessels, nn penetrate the muscle. thoracales anteriores. Lymph flows into the substernal nodes. The subclavian muscle (m. subclavius) is located between the clavicle and the 1st rib and is surrounded by a dense sheath formed by the coraco-clavicular-costal fascia. The muscle is innervated by the nerve of the same name, arising from the brachial plexus.

The anterior serratus muscle (m. serratus anterior) within this area is located 4-5 upper teeth.

The clavicular-thoracic triangle (trigonum clavipectorale) is limited from above by the lower edge of the clavicle with the subclavian muscle, from below - by the upper edge of the pectoralis minor muscle, from the inside - by the chest wall.

After removal of fiber and fasciae coracoclavicostales within the triangle, a second deep cellular space opens, in which the neurovascular bundle of the upper limb is located.

Here in the fiber are the subclavian lymph nodes lnn. infraclaviculares, from which vessels are formed that form the subclavian lymphatic duct.

The fiber that performs trigonum clavipectorale communicates with the cellular space of the neck and posterior chest wall, which should be borne in mind in suppurative processes. In addition to the described triangle, in this area there are also thoracic and infra-breast triangles, the practical significance of which is relatively small.

The boundaries of the anteroinferior region of the chest (regio thoracis anterior inferior) are: above - the lower edge of the pectoralis major muscle, below - the costal arch, outside - the middle axillary line, inside - lin. sternalis. The main layers of the region are formed by the fascia of the chest itself, which continues downward into the own fascia of the abdomen, and medially participates in the formation of the anterior wall of the vagina of the rectus abdominis muscle, and the anterior serratus muscle (m. serratus anterior). The latter begins with 8-9 teeth from the same number of upper ribs and forms a muscular plate that covers the anterior-lateral and partially posterior walls of the chest and is attached to the vertebral edge of the scapula. Throughout the muscle is enclosed in a fascial sheath formed by the own fascia of the chest.

The arterial supply of the muscle occurs due to branches arising from a fairly large number of sources (a. thoracalis lateralis - the main source, aa. intercostales and a. thoracodorsalis).

The outflow of blood occurs through the veins of the same name. Lymphatic vessels flow into the lymph nodes, which in the amount of 2-5 are located on the outer surface of the muscle along a. thoracalis lateralis from the 2nd to the 6th ribs (D.A. Zhdanov). n is involved in the innervation of the muscle. thoracalis longus, located next to a. thoracalis lateralis. The external oblique muscle of the abdomen (m. obliquus abdominis externus) occupies the lower part of the described area. The teeth of this muscle alternate with the teeth of the anterior scalene muscle, and downward and backward - with the teeth of m. latissimus dorsi. The most medial tooth of the external oblique muscle of the abdomen is located at the anterior end of the V and VI ribs, from here the broken line of contact of this muscle with the anterior dentate stretches downward and outward.

The rectus abdominis muscle (m. rectus abdominis) occupies only the lower medial part of this area and is located under the initial part of the external oblique abdominal muscle.

Between the chest wall and the serratus anterior muscle there is a thin layer of loose fiber, which posteriorly passes into the fiber of the prescapular fissure. Purulent-inflammatory processes can spread in this layer.

The boundaries of the anteromedian region of the chest (regio thoracis mediana anterior) are the outlines of the sternum, and therefore they are as different as the shape of the sternum is inconsistent.

The own fascia of the chest is reinforced here with tendon fibers and fused with the periosteum of the sternum. As a result, a thick plate is formed - membrana sterni anterior. There is no muscle layer, except for the initial bundles of the pectoralis major muscles.

Borders of the posterior superior region of the chest (regio thoracis posterior superior): at the top - a line connecting the acromion with the spinous process of the VII cervical vertebra; below - a horizontal line drawn along the lower corner of the scapula; outside - the posterior edge of the deltoid muscle and inside - the vertebral line.

The own fascia of the chest in this area has a very complex structure, as it takes part in the formation of fascial cases of numerous muscles. In it, it is conditionally possible to distinguish between superficial and deep plates.

The surface plate forms the vagina m. trapezius and m. latissimus dorsi. The trapezius muscle, starting from the occipital bone and the spinous processes of the cervical and thoracic vertebrae, is attached to the spina scapulae, acromion and the outer part of the clavicle. The muscle is only partially located within this area. Muscle arteries arise from a. transversa colli, a. transversa scapulae from the posterior branches of aa. intercostals. The veins accompany the arteries of the same name. Lymphatic vessels accompany the arteries and flow into the lower cervical nodes.

In the innervation of the muscle involved n. accessorius and rr. musculares pl. cervicale (CIII - CIV). The deep plate of its own fascia is involved in the formation of the supraspinatus and infraspinatus of the bone-fibrous space of the posterior surface of the scapula.

Within the area are the following muscles attached to the shoulder blade: m. levator scapulae, attached to the inner corner of the scapula, mm. rhomboidei major et minor, attached to the vertebral edge of the scapula, and m. teres major, starting from the outer edge of the lower angle of the scapula. The first three muscles are supplied with blood from a. transversa colli. The outflow of blood takes place in the veins of the same name. Innervation is carried out by branches n. dorsalis scapulae. The arteries of the teres major muscle are branches of aa. circumflexa scapulae, thoracodorsalis and circumflexa humeri posterior. Innervation is carried out due to nn. subscapulares (CV-CVII). The supraspinous bone-fibrous space of the scapula is formed by the edges of the supraspinous fossa and a deep plate of its own fascia thickened due to fibrous fibers.

This space is made by the muscle of the same name, fiber, vessels and nerves.

The loose tissue of this space communicates with the tissue of the infraspinatus and the paraarticular tissue of the shoulder joint.

The infraspinatus bone-fibrous space of the scapula is made by the infraspinatus muscle starting here and the small round muscle separated from it by a thin fascial sheet. Both of these muscles attach to the greater tubercle of the humerus.

In the blood supply to the supraspinatus, as well as the infraspinatus muscles, a. takes the main part. transversa scapulae, which is located directly on the bone. In addition, the muscles of the infraspinatus receive blood from a. circumflexa scapulae, which anastomoses with the aforementioned artery. The outflow of blood occurs through the veins of the same name. Lymphatic vessels flow into the node located at the notch of the scapula, and further into the supraclavicular nodes. The innervation of the muscles of both spaces is carried out by the branches nn. suprascapulares, formed from the brachial plexus (CIV - CVI), which is located next to a. transversa scapulae.

The subscapular bone-fibrous space (spatium subscapulare) is formed by the concave anterior surface of the scapula - fossa subscapularis and a fairly strong fascial sheet - fascia subscapularis, which is attached along the edges of the bone.

This space contains the subscapularis muscle, which, starting from the anterior surface of the scapula, is attached by a flat short tendon to the lesser tubercle of the humerus. The tendon is adjacent to the capsule of the shoulder joint. There is also a mucous bag (bursa mucosa subscapularis), which usually communicates with the cavity of the shoulder joint.

Muscle arteries arise from a. subscapularis and sometimes branches directly from a. axillaris. Blood flows into veins, which are the same name as arteries. Lymphatic vessels empty into lnn. subscapulares, located in the foramen trilaterum, as well as in the supraclavicular and subclavian nodes.

Several short branches extend from the brachial plexus to the muscle - nn. subscapulares. Between the wall of the chest itself and the anterior surface of the scapula with its muscles there is a gap, which is divided into two gaps by the serratus anterior muscle passing here, attached to the inner edge of the scapula - the posterior and anterior prescapular gaps.

The posterior prescapular fissure is located between the anterior surface of m. subscapularis with the fascia covering it - behind and the serratus anterior - in front. This gap is made of fiber, which is part of the fiber of the axillary cavity. Branches are located in the fiber a. axillaris and veins flowing into the axillary vein or its tributaries; in addition, here are the lymph nodes and pass nn. subscapulares and n. thoracodorsalis.

The anterior prescapular fissure is formed by the serratus anterior and the fascia covering it behind and the fascia covering the ribs and intercostal muscles in front. The gap is completely closed, it contains loose connective tissue, sometimes there are mucous bags. With purulent-inflammatory processes, pus can accumulate in this gap without spreading to neighboring areas.

The boundaries of the posterior region of the chest (regio thoracis posterior inferior) are: at the top - a horizontal line passing through the lower angle of the scapula; below - a line drawn along the XII rib through the anterior ends of the XI and X ribs; outside - middle axillary line; inside - the vertebral line.

Own fascia of the chest forms two plates here: superficial and deep.

The surface plate forms the vagina m. latissimus dorsi. Due to the fact that m. latissimus dorsi starts from several points, it is distinguished: the vertebral, iliac and costal parts. A powerful flat tendon is attached to the scallop tuberculi minoris humeri. The arteries of the muscle are multiple and arise from the branches of the intercostal arteries. Veins accompany arteries. Lymphatic vessels carry lymph to the nearest lymph nodes - at the top in lnn. subscapulares, below in lnn. intercostales and lnn. lumbales. The main nerve is n. thoracodorsalis. The deep plate of its own fascia is located under m. latissimus dorsi and forms a sheath for m. serratus posterior inferior and m. serratus anterior, which is only partially included in the region. Between the superficial plate of the fascia with the muscle enclosed in it and the deep one there is a layer of adipose tissue, which spreads to neighboring areas of the chest, which has to be borne in mind during purulent-inflammatory processes.

The posterior median region of the chest (regio thoracis mediana posterior) corresponds to the projection of the spine and organs of the posterior mediastinum. The boundaries of the region are: from above - a horizontal line drawn through the spinous process of the VII cervical vertebra; below - a horizontal line drawn through the spinous process of the XII thoracic vertebra; on the right and left - vertical lines drawn along the ends of the transverse processes.

After the removal of the surface plate of the own fascia of the breast in this area, together with the initial part of m. trapezius, as well as the deeper rhomboid muscle and the initial part of m. latissimus dorsi, you can see a deep plate of the own fascia of the chest (lamina profunda fasciae pectoralis propriae). The latter in this area is particularly strong and fuses along the midline with the spinous processes of the vertebrae, and from the sides - with the corners of the ribs and forms paravertebral bone-fibrous canals. These channels are made by a complex system of muscles of various sizes and lengths, which ensure the mobility of the spine. arteries rr. posteriores aa. intercostalis are distributed in the muscles strictly segmentally and are interconnected by numerous anastomoses. The veins form a plexus here (plexus venosus vertebralis exterior posterior), which is part of the system of venous plexuses located in the spinal canal and associated with the unpaired and semi-unpaired veins and, therefore, with v. cava superior. Lymphatic vessels form segmentally and carry lymph to the intercostal nodes located in each intercostal space at the heads of the ribs.

The innervation of the muscles enclosed in the bone-fibrous canals is carried out by segmentally running posterior branches of the thoracic nerves nn. thoracales. In addition to the listed formations, in this area there is a well-developed fiber that fills numerous intermuscular spaces.

deep layer(actual chest). The sternum, ribs, thoracic spine, intercostal muscles and fascia, in particular fascia endothoracica, which lines the chest cavity, take part in the formation of the chest proper. These elements are interconnected both anatomically and functionally. The chest is a very stable elastic formation, the shape of which changes relatively easily depending on the state of the organs contained in it. The topography of the layers of the wall of the chest cavity is different. First, one should consider the structural features of the individual elements that take part in the structure of the wall.

The sternum (sternum) is a flat bone consisting of three parts: the handle, the body and the xiphoid process. The shape of it as a whole and its constituent parts is individually different. The length varies widely - from 16 to 23 cm. The thickness of the bone is not constant and is related to the degree of development of the spongy layer, the thickness of which ranges from 4 to 13 mm, more often, however, it is within 8 mm. In some cases, one can encounter a sharp thinning of the body of the sternum up to the formation of holes, which must be borne in mind during sternal punctures. Often, the xiphoid process can also be expanded or deformed. Arterial supply and outflow of blood are carried out by vasa mammariae internae.

Articulations of the sternum. The sternoclavicular joint (art. sternoclavicularis) is formed by the clavicular notch of the sternum and the sternal end of the clavicle. Sternocostal joints (art. sternocostales) are not the same in their structure. So, there is no joint between the 1st rib and the sternum. The articulation of the sternum with the II, III, and sometimes IV ribs is a flat joint, and with the V, VII and XII ribs - syndesmoses.

Ribs (costae) are long, flat, arcuately curved bones, twisted along the axis. I rib has a number of features. While on all ribs, the outer convex and inner concave surfaces are distinguished, on the 1st rib, the upper and lower surfaces, the convex outer and concave inner edges are distinguished. In addition, three departments, or segments, are distinguished in the I rib. The vertebral segment is equipped with a head that has one articular platform, as it articulates only with the 1st vertebra, a short round neck and a pronounced tubercle that articulates with the transverse process. In this place, the rib is sharply curved anteriorly. The middle segment of the 1st rib, called the muscle segment, has a tuberosity where the middle scalene muscle is attached. The anterior segment is vascular, the longest and widest; on it you can see the grooves according to the location of the subclavian artery and vein.

The costal cartilages are composed of hyaline cartilage, in which lime begins to be deposited with age, which can cause them to become completely ossified.

The cartilages of the first seven ribs are directly connected to the sternum, and the lower the rib, the greater the angle formed between the cartilage and the rib. The cartilages of the VIII, IX and X ribs, sequentially connecting with each other, form a costal arch, which is connected to the cartilage of the VII rib. The cartilages of the XI and XII ribs are short and lie freely in the soft tissues. Sometimes intercartilaginous joints are formed between the cartilages of adjacent ribs.

The thoracic spine, consisting of 12 vertebrae, has a sharp posterior curvature, reaching a maximum in the region of the VI, VII and VIII vertebrae.

The mobility of the thoracic spine is sharply limited almost along its entire length, however, mobility is noted within the I and XII vertebrae.

The external intercostal muscles perform the intercostal space from the junction of the tubercle with the transverse process of the vertebra to the junction of the rib into the cartilage. Further, anterior to the sternum, the muscle is replaced by tendon fibers that form the external intercostal ligament. The direction of the muscle fibers is oblique - from top to bottom and from back to front. The internal intercostal muscles have the opposite direction of the fibers. They fill the intercostal space from the corners of the ribs to the outer edge of the sternum.

Vascularization and innervation of both muscles is carried out by the intercostal neurovascular bundle.

Due to the fact that in the most medial part of the intercostal space, from the angle of the rib to the spine, there are no internal intercostal muscles, the neurovascular bundle is covered here only by intrathoracic fascia, loose tissue and pleura. The transverse muscle of the chest (m. transversus thoracis) is located on the inner surface of the sternum and is, as it were, a continuation of the transverse abdominal muscle. It starts from the lower half of the sternum with 4-3 teeth on each side and is attached at the junction of the bone part to the cartilaginous II - XII ribs. The innervation of the muscle occurs due to the branches of the intercostal nerves. The largest artery of the chest - the paired internal thoracic artery (a. thoracica interna) - arises on each side from the subclavian artery.

At level II of the rib, the artery approaches the anterior wall of the chest and then is located on the costal cartilages and the internal intercostal muscle parallel to the edge of the sternum at a distance of 1.5 - 2 cm from it.

Throughout its length, the internal thoracic artery gives off a number of branches: R.r. thymici, R.r. mediastinales, a. pericardiacophrenica, etc. In each intercostal space, branches depart from the artery - anastomoses with intercostal arteries. In addition, both aa. thoracicae internae are interconnected by anastomoses through the vessels of the sternum. Below, at the level of the VII costal cartilage, the artery divides into its terminal branches - a. musculophrenica and a. epigastrica superior, which is connected by anastomoses with the lower artery of the same name.

The intercostal arteries arise from two sources: the truncus costocervicalis and the thoracic aorta.

A comes out of the truncus costocervicalis. intercostalis suprema, the trunk of which runs in front of the first six ribs, and the intercostal arteries of the first and second intercostal spaces, and sometimes the third and even the fourth, depart from it. From the posterior semicircle of the thoracic aorta, the intercostal arteries depart segmentally, the number of which corresponds to the number of intercostal spaces. In cases where the intercostal arteries of the third and fourth intercostal spaces are branches of the truncus costocervicalis, the number of arteries extending from the aorta decreases accordingly. However, it must be borne in mind that in some cases, 2 and 3 intercostal arteries can depart from the aorta in one trunk, the common trunk of which can be located vertically in the region of the necks of the ribs. The intercostal arteries in the region of the heads of the ribs are divided into two main branches - anterior and posterior.

From the posterior branch, branching in soft tissues, small branches also extend to the vertebrae and ramus spinalis, which passes into the intervertebral foramen and supplies blood to the membranes of the spinal cord.

In the initial section, the left intercostal arteries lie on the anterolateral surface of the vertebral bodies, then they are located posterior to the border trunk and semi-unpaired vein. The right ones pass along the anterior surface of the vertebral bodies and are also behind the sympathetic nerve and v. azygos. In the posterior sections in the region of the costal angle, the artery lies below the rib, the vein of the same name is located somewhat higher, and the intercostal nerve can be located in different ways. Further, anteriorly, the artery is located in the sulcus costae and passes between the intercostal muscles. The veins of the chest accompany the arteries of the same name and are single or double.

In the chest cavity, visceral lymphatic vessels and nodes, parietal and located in the mediastinum, can be distinguished. Here we will consider parietal, which are divided into two main groups - anterior intercostal and posterior.

The anterior intercostal nodes are located on the inner surface of the anterior chest wall along the edges of the sternum in the intercostal spaces. Their number is not constant. Usually they are well expressed in the first five intervals. The anterior intercostal nodes receive lymph from the tissues of the anterior chest wall. The outflow of lymph from the anterior intercostal nodes on the right and left goes in different ways. So, according to D.A. Zhdanov, on the left, the efferent vessels flow into the arch of the thoracic duct or into the axillary trunk. On the right, the lymphatic trunks usually flow into the right subclavian duct, sometimes into the jugular duct. Often (in 10% of cases), the lymphatic vessels leaving the chain of the right nodes are connected to the vessels of the left nodes.

The posterior intercostal nodes are located near the spine and receive lymph from the intercostal lymphatic vessels. They are associated with the vessels of the pleura and mediastinal organs. The vessels draining lymph from the posterior intercostal nodes flow into the right and left lymphatic ducts, respectively.

The intercostal nerves, upon exiting the intervertebral foramen, are divided into three branches: ramus meningeus, ramus posterior, ramus anterior. The latter is actually the intercostal nerve. In addition to the listed branches, at the place of division is ramus communicans, which connects the thoracic nerve with the border trunk of the sympathetic nerve.

The intercostal nerves are located strictly segmentally, corresponding to the intercostal spaces.

The territory of their distribution is far from corresponding only to the region of the chest, in the innervation of which the first six to seven intercostal nerves take part. The rest innervate the muscles of the anterior abdominal wall.

Throughout the intercostal space, the nerve lies between the oblique muscles or between the bundles of the internal oblique. As a rule, the nerve is located slightly below the vessels.

The nodes of the border trunk are located on the heads of the ribs, corresponding to the intervertebral foramens. The number of nodes does not always correspond to the number of ribs; it is not uncommon to see an increase in nodes up to 16 or a decrease in them to six or seven. A change in the number of nodes affects their shape, size, and topography.

The first thoracic node, as a rule, is connected in one piece with the VIII cervical, resulting in the formation of a stellate node. Almost always there is a second thoracic node. Each node is vertically connected to each other by means of rami interganglionares, the length and number of which are related to the number of nodes in the boundary shaft.

The visceral branches depart from the sympathetic nerve, taking part in the innervation of the organs of the mediastinum and abdominal cavity, and parietal. The latter include rami communicantes, consisting of white preganglionic and gray postganglionic fibers that connect the border trunk and intercostal nerves.

The upper border of the chest area runs along the upper edge of the manubrium of the sternum, collarbones, acromial processes of the scapula and further to the spinous process of the VII cervical vertebra; under the lower border is meant a line passing from the xiphoid process of the sternum along the edges of the costal arches, then along the lower edge of the XII rib to the spinous process of the XII thoracic vertebra.

When considering topographic and anatomical features, the following concepts are used: chest (bone frame formed by the ribs, sternum and thoracic vertebrae); chest wall (a formation that includes the bones of the chest, intercostal muscles, muscles of the shoulder girdle, upper abdominal muscles, fascia and cellular layers) and the chest cavity (the space bounded in front, behind and from the sides by the chest wall, below the diaphragm, above the chest cavity communicates with the cavity of the neck, inside lined with intrathoracic fascia).

There are three serous sacs in the chest cavity: two pleural and one pericardial. The mediastinum is located between the pleural sacs in the chest cavity, in which a complex of organs is placed, which includes the heart with the pericardium, the thoracic part of the trachea, the main bronchi, the esophagus, vessels and nerves, surrounded by a large amount of fiber. The diaphragm with its dome protrudes high into the chest, as a result of which the lower border of the chest is located significantly below the lower border of the chest cavity. As a result, some organs of the abdominal cavity (cardial part of the stomach, liver, spleen) are projected onto the lower parts of the chest wall. The tops of the right and left domes of the pleura will stand above the collarbones and thus go into the neck area. These anatomical features must be taken into account when diagnosing combined injuries of the neck, chest and abdomen in case of injuries.

The anterior and posterior surfaces of the chest are conditionally divided along the midaxillary line. On each of them conditionally allocate 5 anatomical regions. On the anterior surface - anteromedian (limited on the sides by parasternal lines) and paired (right and left) antero-superior and anterior-inferior (the border between them runs along the lower edge of the pectoralis major muscle). On the posterior surface, there are: posterior median (limited laterally by paravertebral lines), and paired posterior-superior and posterior-inferior regions (the border between the latter runs at the level of the angle of the scapula). The division of the chest wall into these areas is due to differences in the bone base and the structure of the soft tissue layers.

The anterior upper-outer region incorporates well-developed pectoralis major and minor muscles, it is rich in intermuscular fiber, and the mammary gland is located in the surface layer. Between the clavicle and the upper edge of the pectoralis minor muscle, under the pectoralis major muscle, trigonum clavipectorale is isolated. In this triangle, under the fascial leaf (fascia clavi pectoralis) are the subclavian artery, vein and brachial plexus. The close proximity of the neurovascular bundle with the clavicle causes injury to the artery and vein when the fragments of the clavicle are displaced. In the lower sections of the chest wall, the muscles of the abdominal wall (m. rectus, m. obliquus abdominis externus) are attached in front; behind the superficial layer of muscles is formed by the latissimus dorsi, under which lie the anterior and posterior dentate muscles. The deep layer of the muscles of the chest wall is represented mainly by the external and internal intercostal muscles, which fill the intercostal spaces. In this case, the external intercostal muscles are observed along the length from the tubercles of the ribs (near the transverse processes of the vertebrae) to the line of transition of the ribs into cartilage. Throughout the cartilaginous part of the ribs, they are replaced by a dense fibrous ligament (lig. Intercostale externum). The internal intercostal muscles occupy the intercostal spaces from the edge of the sternum to the costal angle. For the rest of the length (from the costal angle to the spine), the internal intercostal muscles are replaced by the internal intercostal ligament (lig. intercostal internum).

The main source of blood supply and innervation of the chest wall are the intercostal neurovascular bundles passing through the gap between the external and internal intercostal muscles and the lower edge of the rib. The position of the neurovascular bundle along the intercostal space is not the same. From the paravertebral to the scapular line, the neurovascular bundle runs approximately in the middle of the intercostal space between the internal intercostal ligament and the external intercostal muscles. Since fascial fibers are woven into the wall of the intercostal artery, the artery does not collapse when damaged, its lumen gapes, which explains the strong, sometimes gushing bleeding.

From the scapular to the mid-axillary line, the neurovascular bundle lies between the external and internal intercostal muscles in the sulcus costalis, hiding behind the lower edge of the rib, which contributes to its injury in rib fractures. For the same reason, when puncturing the chest cavity, the needle is passed along the upper edge of the rib. Anterior to the midaxillary line, the intercostal neurovascular bundle emerges from the sulcus costalis and runs into the intercostal space near the lower edge of the rib. When damaged, bleeding from the intercostal arteries is profuse (up to 10% of those killed on the battlefield wounded in the chest die from bleeding of the intercostal arteries). This is due to the departure of the intercostal arteries directly from the aorta with high blood pressure in them; fusion of the walls of the arteries with the fascial fibers of the intercostal spaces (therefore, in case of damage, these arteries do not collapse); anastomoses with branches of the internal thoracic artery, passing along the edge of the sternum under the fascia endothoracica, which leads to the formation of a closed arterial ring in each intercostal space. In addition to the intercostal vessels, the internal thoracic artery and vein, which pass along the inner surface of the chest (near the edge of the sternum), take part in the blood supply to the chest wall. The latter is often used for myocardial revascularization in coronary insufficiency.

The shape of the chest is in accordance with the shape and position of the organs of the chest cavity. Individual differences in the external shape of the breast, the direction of the ribs, the width of the intercostal spaces are taken into account when choosing surgical approaches and examining patients. With a short and wide chest, the ribs occupy a position close to horizontal, the intercostal spaces are wide, the upper chest aperture is small, the epigastric angle reaches 120 °, there is usually a “transverse” position of the heart, the border of which protrudes to the left beyond the midclavicular line. With a long and narrow chest, the ribs are inclined anteriorly, the intercostal spaces are narrow, the upper aperture of the chest is wide, and the epigastric angle is about 80°. there is usually a "drop-shaped" heart.

1. Topographic anatomy and operative surgery of the breast

The mammary gland is located in women at the level of the III-VI ribs between the parasternal and anterior axillary lines. The superficial fascia of the chest, which is divided into two sheets at the level of the third intercostal space, forming a capsule for the mammary gland, is fused with the clavicle and forms a lig. suspensorium mammae. The capsule gives off spurs that go into the depth between the lobules of the gland from the nipple in the radial direction. Usually there are 15 to 20 cloves. Parallel to the connective tissue septa, their excretory ducts of the mammary gland are also oriented. The connective tissue stroma of the gland is associated with the superficial fascia and the skin covering the mammary gland.

The size of the mammary gland and the shape are determined by its functional state and the amount of fatty tissue. It is important to note that there are several layers of fiber in the area of ​​the mammary gland: between the skin and the superficial fascia; between sheets of superficial fascia (inside the capsule of the gland); under the superficial fascia (between the posterior leaf of the capsule of the gland and its own fascia).

When breastfeeding, the skin in the area of ​​the nipple of the breast is easily damaged, which can serve as an entrance gate for infection. The latter penetrates deep into the connective tissue septa and excretory tubules and causes inflammation of the mammary gland (mastitis). Depending on the localization of the process in one or another layer of fiber, the following forms of mastitis can be distinguished: antemammary (subcutaneous, in the first layer of fiber); intramammary (in the second layer of fiber); retromammary (in the third layer of fiber). A radical way to treat purulent mastitis is to open the abscess. In case of antemammary and intramammary mastitis, it is recommended to open the purulent cavity with a radial incision on the anterolateral surface of the gland, without affecting the areola and nipple. For a better outflow of purulent discharge, as a rule, an additional incision (counter-opening) is made. Produce a thorough digital revision of the wound with the destruction of all jumpers and opening of streaks. If the radial connective tissue interlobular septa are intact, then they are preserved; otherwise, it is necessary to interconnect the purulent cavities by making additional radial incisions. Purulent cavities are drained with a silicone or PVC tube, in some cases with glove rubber. In the presence of several disjunct intramammary abscesses, each of them is drained from a separate incision. With deep intramammary abscesses and retromammary phlegmons, the arcuate incision of Bardengeyer (1903) along the lower edge of the gland, along the transitional fold, has advantages. At the same time, after dissection of the superficial fascia, the posterior surface of the gland, covered with a deep sheet of the superficial fascia, is exfoliated, penetrating into the retromammary tissue. The skin of the anterior surface of the gland is not damaged, and the scar along the transitional fold of the skin after the wound has healed is almost invisible. Surgical treatment of purulent mastitis is combined with antibiotic therapy and physiotherapy.

Breast cancer is one of the most common localizations of malignant growth and ranks first in the structure of cancer incidence among women in Russia. The peak incidence occurs at the age of 50–69 years.

The growth of a malignant tumor of the mammary gland is accompanied by the germination of neighboring tissues (skin, own fascia, muscles, ribs), penetration into the lymphatic channel and into the lymph nodes, first in the regional, and then in the distant ones (metastasis of tumor cells), and therefore it is important know the ways of lymphatic drainage. The most important route for lymph drainage and spread of tumor cells is the axillary route. The outflow of lymph from the mammary gland and the spread of tumor cells to the lymph nodes of the armpit occurs through the anterior thoracic lymph nodes (Zorgius nodes), located under the lower edge of the pectoralis major muscle at the level of the second rib; through Rotter's lymph nodes located between the pectoralis major and minor muscles; through the lymphatic vessels, in the thickness of the large and small pectoral muscles; through nodes located inside the muscles, between their fibers. Axillary lymph nodes, the number of which ranges from 10 to 75, are located along the axillary vein and form two groups - anterior and posterior (some authors distinguish five groups: anterior, posterior, medial, lateral, upper). Lymph is drained here mainly from the lateral part of the mammary gland. From the medial section of the mammary gland, lymph flows through the vessels, which through the first to fifth intercostal space penetrate into the depth and flow into the parasternal lymph nodes located along the internal thoracic artery and vein. From the upper part of the mammary gland, lymph outflow occurs in the subclavian and supraclavicular lymph nodes. Finally, from the lower part of the gland, the lymph flows into the lymph nodes and vessels of the preperitoneal tissue and into the subdiaphragmatic nodes. Enlargement of regional lymph nodes is one of the early symptoms in most breast cancer patients. Assessment of the state of the lymph nodes, along with determining the size and localization of the tumor, allows you to get an idea of ​​​​the operability of the tumor.

Currently, the treatment of breast cancer is complex, including surgical, radiation and chemotherapy methods. However, the leading role is still played by surgical intervention. Basic principles of surgery for breast cancer: radical (removal of the tumor and accessible lymph nodes); observance of the rules of ablastic and antiblastic.

In breast cancer, several types of surgical interventions are mainly used: radical mastectomy; extended radical mastectomy; mastectomy with preservation of the pectoralis major muscle; resection of the mammary gland (extended sectoral resection, quadrantectomy). Recent studies have shown that superradical surgeries do not have clear advantages, but this is not recognized by all surgeons.

Radical mastectomy consists of four stages: access; removal of a breast tumor within healthy tissues; removal of regional lymph nodes; suturing the wound. The skin incision should be made at a distance of at least 5-6 cm from the edges of the palpable tumor; the most commonly used is an oval (fusiform) incision, the upper end of which is projected onto the lateral third of the clavicle, and the lower end is located in the epigastric region, lateral to the midline. Orr's combined wavy incision is used less often and Beck's rectangular incision is used.

After dissection of the skin, the edges of the incision are prepared medially to the middle of the sternum, lateral to the edge of the latissimus dorsi, upwards to the collarbone, downwards to the epigastric region. The thickness of the fiber on the prepared skin should not exceed 5–7 mm. The second stage is based on one of the main methodological principles of ablastics - "anatomical casing of surgical intervention". Observing this principle, it is necessary to operate within the limits of the corresponding fascial cases, delimiting the spread of the tumor. Taking into account the structure of the mammary gland, the implementation of this principle consists in the removal of a single block of the mammary gland together with the tumor, the pectoralis major muscle within the sternoclavicular fascia. The selection of the block starts from the sternum, for which the fibers of the pectoralis major muscle are exposed and crossed at the point of attachment to the sternum. This technique not only begins the mobilization of the muscle, but also interrupts the path of lymph outflow from the mammary gland to the parasternal lymph nodes. The pectoralis major is then transected as close as possible to its insertion on the humerus. Next, the sternoclavicular fascia is dissected along the lower edge of the clavicle and the pectoralis minor muscle is exposed. Under the free edge of the pectoralis minor muscle, at the place of its attachment to the ribs, a finger or a probe is brought in, after which the muscle is crossed and the entire block of tissues is separated from the chest wall. The second stage is completed with a single-block removal of the entire excreted drug or, without removing the block of the mammary gland with pectoral muscles, as if “hanging” on a fascial-fatty pedicle, which continues into the axillary fossa, proceed to the removal of all regional (axillary) lymph nodes. With a radical mastectomy, it is necessary to remove not only enlarged lymph nodes, but also all outwardly unchanged nodes located in the tissue along the vein. In practice, this can be achieved by successively separating from the vein in a blunt and sharp way in a single block all the fiber, together with the lymph nodes, from top to bottom - from the collarbone to the mammary gland. When performing this manipulation, the axillary vein should be spared as much as possible, since damage to it can lead not only to bleeding, but also to the development of an air embolism. In addition, when separating the tissue along with the lymph nodes from the vein, one should not “skeletonize” the remaining elements of the neurovascular bundle, since lymphatic vessels pass along the axillary artery and the brachial plexus, providing lymph outflow from the upper limb. It is necessary to remove the anterior thoracic Zorgius nodes located on the anterolateral wall of the chest under the pectoralis major muscle. Taking into account the principles of antiblastics, the electrosurgical method of operating in breast cancer is often used. To improve the outflow of the wound discharge outwards from the lower angle of the scapula, an additional skin incision is made and a drainage tube is passed deep into the axillary fossa. After that, proceed to the fourth stage of the operation. It consists in closing the surgical wound. If possible, bring together and sew the edges of the wound. With a slight tension of the edges of the wound along its periphery, laxative incisions are made on the skin in a checkerboard pattern. If it is impossible to tighten the edges of the wound, it has to be closed with skin grafting. If metastases are detected not only in the axillary, but also in the parasternal lymph nodes, an extended radical mastectomy according to Urban-Holdin is performed, which differs from the Halsted mastectomy by resection of the sternum at the level of the I rib, II–V ribs for 3–4 cm from the sternum costal joints and mobilization of fiber and removal of lymph nodes along a. and v. thoracica interna. The chest wall defect is covered with the remaining medial part of the pectoralis major muscle.

The use of combined methods of treatment with the use of radiation and chemotherapy allows the use of less traumatic operations for breast cancer in the early stages of the disease. These include mastectomy with preservation of the pectoralis major muscle and extended sectoral resection.

In a mastectomy with preservation of the pectoralis major muscle (according to Pati), after performing a skin incision and separating the mammary gland with its capsule and subcutaneous adipose tissue, the formed block of tissues is displaced towards the armpit. The pectoralis minor muscle is isolated and cut off from the coracoid process of the scapula. After that, the axillary lymph nodes with fiber are removed, which, together with the pectoralis minor muscle and the mammary gland with a tumor, are removed. Resection of the mammary gland (extended sectoral resection, quadrantectomy) consists in removing the sector of the mammary gland in one block with the subclavian and axillary lymph nodes. The excision of the sector (quadrant) is performed taking into account the location of the interlobular fascial septa, observing the principles of sheathing.

2. Operative access to the organs of the chest cavity

The requirements for operative access are the anatomical accessibility of the object of intervention (organ, pathological focus) and the technical feasibility of all stages of the operation.

All approaches to the organs of the chest cavity are divided into two groups: extrapleural and transpleural. When performing extrapleural accesses, the exposure of the anatomical formations of the mediastinum occurs without depressurization of the pleural cavities. The possibility of performing these accesses is determined by the position and ratio of the anterior and posterior borders of the pleura. The projections of the lines of transition of the costal pleura to the mediastinal anteriorly on the right and left sides are asymmetric. On the right, the anterior border often starts from the sternoclavicular joint, then goes down and medially, through the manubrium of the sternum and passes to the right of the midline, arcuately curving to the right. It can lie throughout to the right of the median line, or it passes near the left edge of the sternum. There is a dependence of the position of the right pleural border on the shape of the chest structure: the greater the value of the chest width index, the farther to the right from the midline of the sternum the right border of the pleura is projected. On the left, the anterior border of the pleura, as a rule, begins at the left sternoclavicular joint, and then goes along the left edge of the sternum until the sixth costal cartilage is attached to it. Further, according to the position of the border of the heart, this line continues downward and laterally. The extreme fluctuations of the left border is its location either in the middle of the body of the sternum, or to the left of the left edge of the sternum. When comparing the anterior borders of the right and left costal-mediastinal sinuses, it can be noted that at the top, to the level of II-IV ribs, these borders are relatively far apart from each other, at the level of II-IV ribs they approach each other almost to the point of contact, and below IV ribs diverge again. Thus, it is possible to distinguish the upper and lower extensions of the anterior interpleural space and its narrowed middle part. Through these interpleural spaces, it is possible to perform extrapleural access to the organs and vessels of the anterior mediastinum, the advantage of which is the preservation of the tightness of the pleural cavities, which avoids typical complications. One of the significant drawbacks is the limitation of the surgeon's actions in a narrow gap between the pleural sacs.

With transpleural accesses, one or two (with the so-called trans-two-pleural accesses) pleural cavities are opened. Transpleural accesses can be used for operations both on the organs of the mediastinum and on the lungs. The direction of the incisions on the chest wall when accessing the organs of the chest cavity can be different. In this regard, accesses to the organs and vessels of the chest cavity are divided into longitudinal, transverse and combined. Depending on which surface of the chest wall the incision is made on, there are anterolateral, lateral, and posterolateral incisions. Also, depending on the tissues being dissected, accesses are distinguished through the intercostal spaces (one-sided and two-sided); accesses with dissection of the sternum (longitudinal, transverse and combined sternotomy); combined approaches, in which the intersection of soft tissues along the intercostal space is combined with sternotomy and intersection of the rib or with resection of one (or several) ribs.

To perform a longitudinal sternotomy, a skin incision is made along the midline above the sternum, starting 2–3 cm above the sternum handle and ending 3–4 cm below the xiphoid process. Then the periosteum of the sternum is dissected and displaced by 2–3 mm to the sides of the incision line with a raspator. In the lower part of the wound, the white line of the abdomen is dissected for several centimeters and a tunnel is formed between the posterior surface of the sternum and the sternal part of the diaphragm in a blunt way (with a finger, a swab). Protecting the underlying tissues with Buyalsky's scapula (or in another way), a longitudinal sternotomy is performed. After dissection of the sternum, hemostasis is performed by rubbing the wax paste into the spongy substance of the sternum. The edges are widely bred to the sides with a screw retractor, while trying not to damage the mediastinal pleura. After the end of the operation, the edges of the sternum are compared and fastened with special brackets or strong sutures.

An example of transpleural access, which allows performing operations on the lung, its root, as well as on the heart and diaphragm, is an anterolateral incision at the level of the fifth or fourth intercostal space. This is one of the most commonly used, "standard" accesses. The incision starts from the parasternal line and, continuing it along the intercostal space, is brought to the posterior axillary line. In women, the incision borders the mammary gland. After dissection of the superficial layers of the chest wall, the edges of the wound are moved apart with hooks and the intercostal muscles and the corresponding ribs are exposed, after which they proceed to the dissection of the intercostal muscles and pleura. To avoid damage to the intercostal vessels and nerve, the incision should be made closer to the upper edge of the underlying rib.

Caution is also required when approaching the sternum: the incision is completed without reaching its edge, with one transverse finger so as not to damage the internal thoracic artery. The parietal pleura is dissected simultaneously with the internal intercostal muscles. After opening the pleural cavity, a retractor is introduced into the wound. Edge crossings are generally not required. In case of insufficiency of access, it is necessary to cross the cartilages of adjacent ribs after ligation of the vessels.

With lateral access, the chest cavity is opened along the V-VI ribs from the paravertebral to the mid-clavicular line. Lateral intercostal access creates good conditions for manipulations in almost all parts of the chest. The disadvantage of lateral access can be considered the forced position of the patient on a healthy side.

To perform a posterolateral access, the patient is placed on the stomach or given a position on the healthy side with an inclination forward. The soft tissue incision begins at the level of the spinous process of the III–V thoracic vertebra and continues along the paravertebral line to the level of the angle of the scapula (VII–VIII ribs). Having rounded the angle of the scapula from below, an incision is made along the VI rib to the anterior axillary line. Sequentially dissect all tissues to the ribs. The pleural cavity is opened along the intercostal space or through the bed of the resected rib. To expand the operational access, resection of the necks of two adjacent ribs is often resorted to. The posterior approach is the most traumatic, since it is necessary to dissect a thick layer of muscles and often resect the ribs.

Transverse sternotomy is used in cases where it is necessary to expose not only the organs, but also the vessels of the mediastinum and nearby areas (brachiocephalic trunk, subclavian arteries). It is used in operations under cardiopulmonary bypass and complex reconstructive surgeries and transplantations. The incision is made along the fourth intercostal space from the midaxillary line on one side, through the sternum, to the midaxillary line on the opposite side. Bandage and cross them between the ligatures of the internal thoracic vessels on both sides. After dissection of the periosteum of the sternum and pushing it upwards and downwards with a raspator, a transverse intersection of the sternum is performed using a sternotomy or a Gigli wire saw. Having opened the right and left pleural cavities throughout the incisions, the edges of the sternum with ribs are spread with a retractor. Through bipleural access makes it possible to approach all parts of the heart and large vessels, but it is very traumatic.

Currently, minimally invasive methods are often used: thoracoscopy and video endosurgical method of performing operations on the organs and vessels of the chest cavity. Thoracoscopy is usually performed for diagnostic purposes. For its implementation, it is necessary to impose an artificial pneumothorax, in which instruments can be inserted into the pleural cavity and manipulated. The pressure in the pleural cavity is brought to atmospheric level. This requires a full function of the second lung. The puncture of the chest wall with a trocar for the introduction of a thoracoscope is usually performed on the right in the third or fourth intercostal space along the posterior axillary line, on the left - in the second or third intercostal space along the anterior axillary line. To facilitate the introduction of the trocar and reduce the risk of complications (vascular damage), thoracocentesis is performed. To do this, a skin incision 2–3 cm long is made in the place intended for insertion of the trocar to the intercostal muscles, and under the control of vision, the trocar stylet is inserted along the upper edge of the underlying rib perpendicular to the surface of the chest. In this case, it is necessary to ensure that the stylet face is facing the intercostal neurovascular bundle. After removing the stylet, a thoracoscope is inserted into the chest cavity and the chest cavity is examined through the eyepiece. Diagnostic videothoracoscopy is often used, in which an approximate and enlarged image of the pleural cavity and its contents is displayed on the monitor screen and recorded on digital and analog media, which makes it possible to provide a multilateral visual assessment of the pathological focus against the background of a functioning organ by all members of the surgical team and other specialists.

Modern capabilities of endovideo technology allow performing a significant part of intrathoracic operations. In this case, depending on the proposed operation (object of intervention), several thoracoports (a special tube for inserting a thoracoscope and manipulators) with a diameter of 10 or 5 mm are installed.

The advantages of the video endosurgical method for operations in the chest cavity include a decrease in the invasiveness of the operation (due to a decrease in the invasiveness of the surgical access); the possibility of a full revision of the organs of the chest cavity; reducing the risk of purulent complications; a significant reduction in pain in the postoperative period.

However, in some cases, especially in oncological processes, the endovideosurgical method of surgery is contraindicated. Video endosurgical equipment can be used in combination with conventional thoracotomy. This combined method is called video support. It combines the advantages of both methods.

3. Pathological conditions and surgical techniques on the organs of the chest

One of the most common causes of breast surgery is wounds. They occur not only with the direct impact of firearms or edged weapons: organs are often damaged by fragments of the bone frame of the chest (ribs, sternum), which become additional sources of damage.

All chest injuries are divided into two groups:

1) non-penetrating - without damage to the intrathoracic fascia;

2) penetrating - with damage to the intrathoracic fascia and parietal pleura in those places where it is adjacent to this fascia.

The direction of the wound channel for penetrating wounds may be different. The most dangerous are sagittal injuries near the midline, since in these cases the heart and large vessels (aorta, vena cava, pulmonary artery) are often damaged.

Methods for the treatment of penetrating chest wounds (including surgical ones) are aimed at preventing complications (traumatic shock, bleeding, infections) and correcting developing functional disorders.

Shock. The course of shock resulting from penetrating wounds of the chest is characterized by the manifestation of a syndrome of cardiopulmonary disorders. The developing phenomena of shock are most severe in the wounded with hemo- and pneumothorax. In these cases, severe respiratory disturbances occur, leading to profound disturbances in gas exchange.

Anti-shock measures are aimed at combating respiratory disorders, eliminating the pain factor, compensating for blood loss, correcting metabolism; vagosympathetic blockade according to Vishnevsky is used as one of the anti-shock measures.

Hemothorax. The accumulation of blood in the pleural cavity is the result of internal bleeding from injuries of the heart, lung vessels, main vessels of the mediastinum, as well as damage to the vessels of the chest wall. Often hemothorax is combined with the ingress of air into the pleural cavity. This condition is called hemopneumothorax. Hemothorax can be free or (in the presence of adhesions) encysted. Allocate small - within the costal-diaphragmatic sinus; middle - to the level of the IV rib in front; total - from the diaphragm to the dome of the pleura. To determine whether bleeding has stopped or continues, the Ruvelua-Gregoire test is used: a few milliliters of blood aspirated from the pleural cavity with a puncture needle is poured into a test tube. Rapid blood clotting indicates ongoing bleeding, non-clotting indicates its cessation. With stopped bleeding, the removal of the blood contained in the pleural cavity by pleural puncture and the introduction of antibiotics is indicated.

With persistent bleeding due to damage to the intercostal arteries and the internal mammary artery, emergency thoracotomy is indicated. After its implementation, the revision of the pleural cavity is continued, the damaged vessel is found and ligatures are applied to it.

Pneumothorax. This is an accumulation of air in the pleural cavity. With wound pneumothorax, air can enter the pleural cavity in two ways: through a hole in the chest wall with a penetrating wound, accompanied by damage to the parietal pleura (external pneumothorax); through a damaged bronchus (internal pneumothorax). It is customary to distinguish three types of pneumothorax: closed, open, valvular. With a closed pneumothorax, air enters the pleural cavity at the time of injury. This leads to atelectasis of the lung on the affected side. As a result of the collapse of the walls of the wound channel, which has a small size, the hole in the parietal pleura closes, which leads to separation of the pleural cavity from the atmosphere.

In the absence of bleeding (hemothorax), the wounded with closed pneumothorax, as a rule, do not require surgical intervention: the air resolves after 7-12 days, the lung expands.

In the presence of a large volume of air in the pleural cavity, especially with pneumohemothorax, removal of blood and air by pleural puncture is indicated.

The most dangerous are open and valvular pneumothorax.

Open pneumothorax occurs more often with a gaping wound of the chest wall. This forms a free communication between the pleural cavity and atmospheric air. Much less often, an open internal pneumothorax develops when the main bronchus or trachea is damaged. Open pneumothorax leads to a very serious condition, often ending in the death of the victim. First aid for open pneumothorax consists in applying an aseptic occlusive dressing, adhesive plaster, gauze dressing moistened with water or soaked in oil to the wound. Surgical treatment of open pneumothorax consists in urgent surgical closure of the chest wall wound and drainage of the pleural cavity, the purpose of which is the complete expansion of the lung. The operation begins with the primary surgical treatment of the wound of the chest wall, which is performed sparingly, excising only obviously non-viable tissues. In the absence of signs of ongoing internal bleeding, thoracotomy is not performed and surgical closure of the chest wall defect is started.

All methods of surgical closure of a chest wall defect and sealing of the pleural cavity can be divided into two groups:

1) suturing the wound;

2) plastic closure of the wound.

The technique of suturing the wound of the chest wall with open pneumothorax

Simple suturing of the wound is performed with a small defect.

The sealing of the pleural cavity is achieved by applying a two-row suture. The first row is a pleuromuscular suture, which is applied with catgut. For greater strength, the parietal pleura, intrathoracic fascia and intercostal muscles must be included in the suture. When tightening the sutures, they try to achieve adhesion to each other of the sheets of the parietal pleura covering the edges of the wound.

The second row of sutures is placed on the superficial muscles of the chest wall. In this case, it is desirable that the seams of the second row are projected onto the gaps between the seams of the first row in order to achieve better tightness.

Several layers of muscle can be sewn with three rows of stitches. When suturing superficial muscles, it is imperative to include your own fascia in the suture, usually synthetic threads are used.

With a "deficiency" of the intercostal muscles along the edges of the wound or the inability to pull them together with extensive damage, the adjacent ribs are brought closer to the remnants of soft tissues by suturing with a thick catgut capturing adjacent ribs. The most effective in this case is the use of a seam in the form of the number 8 (poly-paste seam).

The next step is to mobilize the chest wall.

With relatively large defects of the chest wall, it is possible to mobilize the edges of the wound by resection of one or two ribs lying above and below the wound. After such mobilization, soft tissues, as a rule, can be brought together and the open pneumothorax is sutured with a two-row suture.

Plastic methods of closing a chest wall defect in open pneumothorax. Plastic surgery with a muscle flap on a leg, which is cut out from the muscles adjacent to the wound. For wounds located in the lower parts of the chest, where there are few superficial muscles, diaphragmopexy can be used - pulling up and suturing the diaphragm to the edges of the wound of the pleural cavity around the entire perimeter.

Pneumopexy - pulling up the lung and suturing it to the edges of the wound.

Valvular pneumothorax occurs when a valve is formed from the tissues around the wound, through which air enters the pleural cavity at the moment of inspiration, and when exhaling, the valve closes and does not release air back from the pleural cavity. Valvular pneumothorax often develops with injuries of the bronchus (internal pneumothorax) and, less often, with injuries of the chest wall (external pneumothorax). Valvular pneumothorax, as well as open, is accompanied by the development of pleuropulmonary shock. With this type of pneumothorax, with each breath, the pressure in the pleural cavity is constantly increasing, which aggravates the clinical picture. With valvular pneumothorax lies the decompression of the pleural cavity and the elimination of a sharp displacement of the mediastinum. The easiest way to do this is to puncture the pleural cavity with a thick needle in the second intercostal space along the midclavicular line. On the needle sleeve there should be a simple rubber valve, made, for example, from an incised finger of a rubber glove. This valve serves as a kind of nipple that lets air out of the pleural cavity, but excludes its entry inside.

Surgical care for valvular pneumothorax that develops when the chest wall is damaged consists in excising the valve from the soft tissues during the primary surgical treatment and suturing the wound using one of the methods described when considering an open pneumothorax.

With internal valvular pneumothorax associated with damage to the bronchus, active aspiration of pleural fluid is possible through a drain inserted in the seventh to eighth intercostal space along the middle or posterior axillary line.

Emphysema. This is the ingress of air into the fiber, there are two types: subcutaneous and mediastinal. Subcutaneous emphysema is formed with external valvular pneumothorax. It does not pose a danger and dissolves after the elimination of the source of air intake. Mediastinal emphysema occurs when air enters the mediastinal tissue from the pleural cavity, through a defect in the mediastinal pleura when the bifurcation of the trachea or main bronchus ruptures with the formation of a valve mechanism.

Accumulating in the fiber of the mediastinum, the air causes compression of the heart and large vessels (primarily veins), difficulty breathing. Treatment consists in urgent drainage of the anterior mediastinum. To do this, a longitudinal or transverse incision is made in the suprasternal fossa, from where, in a blunt way, the surgeon penetrates the tissue of the anterior mediastinum and introduces drainage (a thick tube with several outlet holes).

Suturing the wound of the lung. With shallow wounds on the surface of the lung, to stop bleeding, it is enough to apply several interrupted sutures with thin round needles with synthetic or silk threads. To prevent the eruption of sutures, the Tigel-Melnikov technique is used, a feature of which is the preliminary holding of "support" threads along the edges of the wound through the thickness of the parenchyma of the lung, and then the imposition of interrupted sutures outside of them, passing under the bottom of the wound.

With marginal damage to the lung tissue, accompanied by bleeding, a wedge-shaped resection is performed. For its implementation, two hemostatic clamps are applied to the lung tissue on both sides of the wound. They overlap at an angle to each other and meet at their ends. Along the edges of the clamps facing inward, the affected area of ​​the lung is excised in the form of a wedge. After that, a twisting seam is applied through the clamps, which, as they are gradually tightened, are carefully removed and removed from under the seam loops.

With a greater degree of destruction, a segment, a lobe of the lung is removed, and even pulmonectomy is resorted to.

4. Damage to the pericardium and heart with penetrating wounds of the chest

Heart injuries are divided into two groups: non-penetrating - without damage to the endocardium; penetrating - with damage to the epicardium. Among non-penetrating wounds, there are: isolated myocardial wounds; injuries of the coronary vessels; combined injuries of the myocardium and coronary vessels.

Bleeding from heart injuries is often intrapleural. With bleeding into the myocardial cavity, cardiac tamponade may develop. Acute cardiac tamponade is manifested by Beck's triad (falling blood pressure, a sharp increase in central venous pressure and weakening of heart sounds). Emergency help with threatening tamponade is a pericardial puncture. The puncture is performed with a thick needle. With the Marfan method, a puncture is made under the xiphoid process strictly along the midline, moving the needle from bottom to top to a depth of 4 cm, and then deflecting its end posteriorly. According to the Pirogov-Delorme method, a puncture is made at the left edge of the sternum in the fourth or fifth intercostal space, in the medial direction, behind the sternum, to a depth of 1.5–2 cm.

According to Larrey, the needle is injected into the angle between the attachment of the left seventh costal cartilage and the base of the xiphoid process to a depth of 1.5–2 cm, and then it is deflected upward parallel to the chest wall. According to the Kurshman method, the puncture is performed in the fifth intercostal space, retreating 4-6 cm from the edge of the sternum. The needle is passed in the medial direction (towards the apex of the heart).

The success of treatment for a heart injury is determined by: the delivery time of the victim to a medical institution, the speed of surgical intervention and the effectiveness of intensive care. In recent years, lateral thoracotomy along the fourth or fifth intercostal space from the left edge of the sternum to the posterior axillary line without cutting the costal cartilages has been widely used. After opening the chest cavity, the pericardium is widely dissected with a longitudinal incision in front of the phrenic nerve.

When revising the heart, it is necessary to examine its posterior surface along with the anterior one, since the wounds can be through. Inspection should be done by bringing the palm of the left hand under the top of the heart and slightly "dislocating" it into the wound. Round (preferably atraumatic) needles are used for suturing the wound of the heart. Synthetic threads are used as suture material. The suture of the walls of the ventricles of the heart should capture the entire thickness of the myocardium, but the threads should not penetrate into the cavity of the heart, in order to avoid the formation of blood clots. With small wounds of the heart, interrupted sutures are applied, with wounds of a significant size, mattress sutures are used. When suturing the wound of the ventricle, the injection of the needle is done in such a way that the second movement of the needle immediately captures the other edge of the wound. The sutures are tightened carefully so as not to cause tissue eruption. After the myocardium, the pericardium is sutured with rare single sutures.

Treatment of chylotrax

Chylothorax is an accumulation of lymph in the pleural cavities due to damage to the thoracic duct or its tributaries. Methods of treatment of chylothorax are divided into conservative and operational. Conservative methods include repeated punctures of the pleural cavity with the removal of lymph. Surgical treatment of lymphorrhea and chylothorax is performed from a transpleural (usually right-sided) thoracotomy with ligation of the ends of the thoracic duct with thin silk ligatures.

Damage to the esophagus in chest injuries are observed relatively rarely (0.3%). The entry into the tissue of the mediastinum and into the pleural cavities of the contents of the esophagus leads to the development of purulent mediastinitis and pleurisy. Penetrating wounds of the esophagus, found during the revision of the chest cavity, are subject to suturing. On the edges of the wound of the esophagus impose two rows of sutures with synthetic threads. The wound of the esophagus is sutured in the transverse direction to avoid narrowing of its lumen. The operation ends with drainage of the pleural cavity or mediastinum and the introduction of a nasogastric tube through the esophagus or the application of a gastrostomy to feed the patient.

Pleural empyema

This is an accumulation of pus in the pleural cavity, often resulting from infection in the wounded with hemothorax, open pneumothorax, mediastinal emphysema, as a result of a breakthrough of pus into the pleural cavity from a lung abscess, suppuration of bronchiectasis, and collapse of the pneumonic focus. According to the prevalence of the process, free or encysted empyema is distinguished; according to the nature of the clinical course, acute and chronic.

Surgical treatment of acute empyema consists in draining the pleural cavity in order to remove purulent contents and ensure lung expansion.

The simplest method of surgical treatment of acute empyema is the removal of pus by puncture of the pleural cavity. With free empyema, pus accumulates in the costophrenic sinus. The puncture in this case is performed in the eighth intercostal space along the scapular or posterior axillary line.

With small encysted empyema, the localization of the abscess is established percussion and radiographically. The puncture site is chosen near the lower border of the purulent cavity.

Under local anesthesia, the needle is inserted closer to the upper edge of the underlying rib, in order to avoid damage to the neurovascular bundle, then advanced in depth until the feeling of "failure" that appears when the thickened parietal pleura is punctured.

In chronic empyema, an extensive purulent cavity is formed, surrounded by connective tissue growths, granulations, and fibrin deposits. Surgical operations for chronic empyema are aimed at emptying the purulent cavity, removing adhesions and pathological granulations, and eliminating the cavity.