Along which edge of the rib do the intercostal vessels pass? Topographic anatomy of the chest. Topography of intercostal spaces. What are the main methods of treatment of intercostal neuralgia

Topography of intercostal spaces:

In the intervals between the ribs are the external and internal intercostal muscles, mm. intercostales externi et interni, fiber and neurovascular bundles.

External intercostal muscles 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 external intercostal muscles are absent and replaced by the external intercostal membrane, membrana intercostalis externa, which preserves the direction of the connective tissue bundles corresponding to the course of the muscles.

Deeper located internal intercostal muscles, whose beams go in the opposite direction: from bottom to top and back. Behind the costal angles, the internal intercostal muscles are no longer there, they are replaced by the boggy bundles of the internal intercostal membrane, membrana intercostalis interna.

The space between adjacent ribs, bounded from the outside and from the inside by the corresponding intercostal muscles, is called intercostal space spatium intercostal. It contains intercostal vessels and a nerve: a vein, below it is an artery, and even lower is a nerve (VAN). The intercostal bundle in the area between the paravertebral and middle axillary lines lies in the groove, sulcus costalis, of the lower edge of the overlying rib.

Anterior to the midaxillary line, the intercostal vessels and nerves are located in the intermuscular tissue and are not protected by the ribs, so it is preferable to make any chest punctures posterior to the midaxillary line along the upper edge of the underlying rib.

Posterior intercostal arteries depart from the aorta front from the internal mammary artery. Due to numerous anastomoses, they form a single arterial ring, the rupture of which can lead to severe bleeding from both ends of the damaged vessel. Difficulties in stopping bleeding are also explained by the fact that the intercostal vessels are closely connected with the periosteum of the ribs and the fascial sheaths of the intercostal muscles, which is why their walls do not collapse when injured.

intercostal nerves upon exiting the intervertebral foramina, giving back branches, they go outward. From the side of the chest cavity to the angle of the rib, they are not covered with muscles and are separated from the parietal pleura by bundles of the internal intercostal membrane and a thin sheet of intrathoracic fascia and subpleural tissue. This explains the possibility of involvement of the intercostal nerves in the inflammatory process in diseases of the pleura. The lower 6 intercostal nerves innervate the anterolateral abdominal wall.

The next layer of the chest wall is intrathoracic fascia, fascia endothoracica, lining the inside of the intercostal muscles, ribs and costal cartilages, the sternum, as well as the anterior surface of the thoracic vertebrae and the diaphragm. The fascia over each of these formations has the corresponding name: fascia costalis, fascia diaphragmatica, etc. In front, in close connection with the intrathoracic fascia, there is a. thoracica interna.

Primary surgical treatment of penetrating wounds of the chest wall.

Indications: stab, stab-cut, cut, gunshot wounds with open or intense pneumothorax, intrapleural bleeding.

Anesthesia: the operation is performed under endotracheal anesthesia, if possible with separate bronchial intubation. The skin and muscle wound is excised with a fringing incision within healthy tissues. Excised damaged intercostal muscles and parietal pleura.

Revision of the pleural cavity. The parietal pleura is opened wide enough and the pleural cavity is examined. Foreign bodies, blood clots and liquid blood are removed from it. In some cases, mainly in stab and stab wounds, liquid blood is filtered and used for back transfusion into a vein. The sources of bleeding and air leakage are determined, after which hemostasis and aerostasis are performed. They carry out an audit of the adjacent organs, mediastinum and diaphragm, taking special measures in cases of damage.

One or two drains are introduced into the pleural cavity above the diaphragm - anterior and posterior. The main one is the posterior drainage, which is inserted into the seventh-eighth intercostal space along the posterior axillary line and laid along the posterior chest wall to the dome of the pleural cavity. Anterior drainage is introduced in the fourth-fifth intercostal space with insufficient or doubtful aerostasis and is placed between the lung and the mediastinum. The end of the drain must also reach the dome of the pleural cavity.

Suturing the wound of the chest wall. The main principle of suturing the wound of the chest wall is the imposition of layered sutures in order to create complete tightness. If possible, which happens, as a rule, only in cases of small wounds, the first row of interrupted sutures is applied to the pleura, intrathoracic fascia and intercostal muscles. The main interrupted sutures are applied in layers to the more superficial muscles of the chest wall. Further

sutured own and superficial fascia with subcutaneous tissue, and then the skin. The diverged ribs are brought together with one, two or three polyspast sutures, and defects in the pleura and muscles are closed with the help of muscle flaps, which are cut out from the pectoralis major, latissimus dorsi, and trapezius muscles, thus achieving complete tightness.

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The space between the ribs is filled with intercostal muscles, ligaments, vessels and nerves (see Fig. 9).

The external intercostal muscles have a direction of fibers from top to bottom and from back to front. The muscle bundles are covered with a thin fascia, which is easily separated from the muscles, but is fused with the periosteum of the ribs. Throughout the cartilaginous part of the ribs, to the outer edge of the sternum, the bundles of the external intercostal muscle are replaced by shiny tendon bundles, which are called the external intercostal membrane. The direction of the muscle bundles of the internal intercostal muscle is opposite to those of the external intercostal muscle. Between the costal angle and the spine, on the path of the continuation of the internal intercostal muscles, there are internal intercostal membranes.

Between the external and internal intercostal muscles there is a gap filled with loose fiber, in which the intercostal neurovascular bundle is located: artery, vein and nerve. The posterior intercostal arteries arise from the thoracic aorta, with the exception of the first two, originating from the costocervical trunk. The right posterior intercostal arteries cross the spinal column in front, passing behind the esophagus, thoracic duct and unpaired vein, and then behind the thoracic sympathetic trunk.

The left posterior intercostal arteries run directly into the intercostal spaces, crossing the semi-azygous vein and the thoracic sympathetic trunk from the dorsal surface. The posterior intercostal arteries have well-defined anastomoses with the anterior ones, which are branches of the internal thoracic artery (see Fig. 6). In the posterolateral parts of the chest wall, the intercostal neurovascular bundle is adjacent to the costal groove. Here it is covered by the lower edges of the ribs. Behind the scapular and in front of the anterior axillary line, the neurovascular bundle occupies a median position in the intercostal space.

The intercostal muscles, ribs and costal cartilages are lined from the inside with intrathoracic fascia. Deeper than the intrathoracic fascia is a layer of loose fiber, which separates this fascia from the parietal fascia at the pleura.
The parietal pleura is divided into costal, diaphragmatic and mediastinal pleura.

The costal pleura is the largest part of the parietal pleura. It extends from the lateral surface of the vertebrae to the heads of the ribs and further forward to the sternum. It covers the posterior surface of the sternum for a short distance and passes into the mediastinal pleura. The costal pleura is adjacent to the intrathoracic fascia.

Between them, in areas from the 1st rib to the upper edge of the 4th rib, the dome of the pleura and its posterior section, there is loose fiber, due to which the pleura can be easily peeled off in this area. In zone IV-VII of the ribs and from them to the diaphragm, the pleura is more or less firmly connected to the fascia.

The mediastinal pleura is located in the sagittal plane from the sternum to the spine. At the root of the lung, it passes into the visceral pleura, and below the root of the lung forms a fold, the so-called pulmonary ligament. Below, the mediastinal pleura passes into the diaphragmatic, and in front and behind - into the costal pleura. The mediastinal pleura forms the upper and lower interpleural fields. In the upper field are the thymus, brachiocephalic veins, aortic arch and its branches, trachea, esophagus, in the lower - pericardium, heart and esophagus. On the left, the mediastinal pleura covers the phrenic nerve, the left lobe of the thymus, the upper left surface of the left brachiocephalic vein, the left subclavian artery, the esophagus, and the thoracic aorta.

In the lower sections, it approaches the pericardium and, quite near the diaphragm, to the esophagus. On the right, the mediastinal pleura is adjacent to the phrenic nerve, the right lobe of the thymus gland, the right surface of the right brachiocephalic vein and the superior vena cava, the right subclavian artery and vein, the arch of the unpaired vein, the right surface of the trachea and the right bronchus, the esophagus and a narrow strip to the thoracic aorta. Pronounced paraorgan loose fiber prevents the fixation of the mediastinal pleura to the organs and during surgical interventions it can easily be exfoliated. The exception is the pericardium, with which it is firmly connected.

The diaphragmatic pleura lines the diaphragm, except for the area covered by the pericardium. The pleura here is closely fused with the diaphragmatic fascia and the diaphragm, therefore it exfoliates from them with great difficulty.

The arterial blood supply of the costal pleura is carried out from the posterior intercostal and partially internal thoracic arteries, and the diaphragmatic - from the upper diaphragmatic and muscular-diaphragmatic, posterior intercostal arteries and anterior intercostal branches of the thoracic aorta.

The costal pleura is mainly innervated by the intercostal nerves, the diaphragmatic pleura by the phrenic and lower intercostal nerves, the mediastinal pleura by the phrenic nerves and the autonomic plexus of the mediastinum.

The dome of the pleura, rising above the upper opening of the chest, closes the pleural cavity from the side of the neck.

It is fixed to the surrounding bone formations by means of connective tissue strands of the prevertebral fascia. The height of the dome of the pleura above the clavicle is determined by constitutional features and may change during pathological processes of the apex of the lung. The dome of the pleura is adjacent to the head and neck of the 1st rib, the long muscles of the neck, the lower cervical node of the sympathetic nerve, outside and in front - to the scalene muscles, the brachial plexus, from the inside - to the brachiocephalic trunk (right) and the left common carotid artery (left), in front - to the vertebral artery and vein.

The projection on the chest wall of the lines of transition of one section of the pleura to another is defined as the boundaries of the pleura. So, the anterior border of the pleura is the line of transition of the costal pleura to the mediastinal one. Right and left it is not the same. The anterior border of the right pleura goes behind the sternum, reaches the midline, and then, at the level of the sixth intercostal space, passes into the lower border. The anterior border of the left pleura, descending from top to bottom, reaches the cartilage of the IV rib, then deviates to the left, crossing the cartilage, reaches the VI rib, passing into the lower border. Thus, the right and left mediastinal pleurae at the level of III-IV costal cartilages come close to each other, in some places close. Above and below this level, free triangular interpleural spaces remain, the upper one is filled with fatty tissue and remnants of the thymus gland, and the lower one is filled with the pericardium.

The position of the anterior border of the pleura and its other parameters vary and depend on the shape of the chest. With a narrow chest, the interpleural fields are long and narrow, and with a wide chest, they are short and wide. In pathological conditions, the position of the pleura compared to the norm can also change.

The lower borders of the pleura from the cartilage of the VI rib turn down and outward and cross the VII rib along the midclavicular middle axillary, scapular and paravertebral lines. In a wide chest, the lower borders of the pleura occupy a high position, and in a narrow one - low.

The posterior border of the pleura on the right lies closer to the vertebral bodies, and its projection line corresponds to the spinous processes. On the left, it remains on the paravertebral line and can sometimes pass 1 cm lateral to it, which corresponds to the position of the aorta.

In the place of transition of one department of the parietal pleura to another, pleural sinuses are formed. Under normal conditions, the sheets of the parietal pleura are in close contact, but when pathological fluid accumulates, they diverge.

The deepest of the sinuses is the costophrenic. It is located in the angle formed by the diaphragm and costal pleura. The sinus goes in the form of a semicircle from the VI costal cartilage to the spine. Its depth at the midaxillary line is 6 cm. Costal-mediastinal sinuses can only be spoken of below the level of the IV rib and, first of all, on the left side, where the pleura and lung follow the bulge of the heart. The fold of the fold of the pleura extends further between the heart and the chest wall. This area at the level of the IV-V ribs is considered a sinus, which, when inhaled, serves as an additional space for the anterior edge of the left lung. Its value depends on the size of the heart.

The diaphragmatic-mediastinal sinus is formed between the mediastinal and diaphragmatic pleura. The shape and size of this sinus change and depend solely on the shape and topography of neighboring organs. The sinus passes sagittally along the arches of the diaphragm and from behind passes into the costophrenic sinus. Anteriorly, this sinus follows the lateral bulge of the heart. Under the heart, the phrenic-mediastinal sinus has a sharper angle.

A.A. Vishnevsky, S.S. Rudakov, N.O. Milanov

Right lung: right parasternal line - 6th intercostal space, midclavicular - 7th rib, anterior axillary - 8th rib, middle axillary - 8th intercostal space, posterior axillary - 9th rib, scapular - 10th rib.

Left lung: anterior axillary - 7th rib, middle axillary - 7th intercostal space, posterior axillary - 8th rib, scapular - 9th rib.

The mobility of the pulmonary edge is 6 cm.

The chest is painless on palpation.

Auscultation of the lungs: vesicular breathing over the entire surface of the lungs, side respiratory sounds are not heard.

Bronchophony is not defined.

The cardiovascular system:

The chest over the region of the heart is not deformed. The apex beat is determined in the 5th intercostal space, 1 cm outward from the midclavicular line. Pathological pulsation of vessels in the neck and epigastrium is not observed. The pulsation of the vessels of the feet is distinct.

Pulse - 74 beats per minute, rhythmic, satisfactory filling and tension, the same on both hands. There is no pulse deficit.

The apex beat is palpated in the 5th intercostal space 1 cm outward from the mid-clavicular line, diffuse, of medium strength, with an area of about 2 cm.

The upper limit of the relative dullness of the heart passes in the second intercostal space.

The border of the heart on the right is along the right edge of the sternum. The border of the heart on the left is 2 cm outward from the mid-clavicular line.

The tones are rhythmic. The first tone is muted. An accent of the second tone is heard on the aorta. At the apex, a systolic murmur is heard, which is not conducted anywhere.

The pulsation of the peripheral arteries is preserved.

Blood pressure is the same on both hands and amounted to 140/75.

Digestive organs:

The oral cavity is sanitized.

The oral mucosa is moist, pale pink in color, shiny.

The tongue is pale pink, moist, without plaque, no ulcers or cracks.

The gums are pale pink, without pathological changes.

Zev is calm, there are no dyspeptic disorders at the time of curation.

The abdomen is symmetrical, rounded, participates in the act of breathing. The skin of the abdominal wall is of normal color, there is no visible peristalsis.

Percussion sound over the entire surface of the abdomen is the same. There is no free gas in the abdominal cavity. On superficial palpation: the abdomen is soft, painless.

Deep palpation of the caecum and transverse colon revealed no pain. Palpation of the sigmoid colon moderate pain. Symptoms of peritoneal irritation are negative.

The lower edge of the liver is palpated along the edge of the costal arch, smooth, elastic, painless. Ortner-Grekov's symptom is negative, Mussi-Georgievsky's symptom is negative.

The size of the liver according to Kurlov: right - 9 cm, median - 8 cm,

oblique - 7 cm.

The spleen is not palpable. The size of the spleen. revealed during percussion: longitudinal - 6 cm, transverse - 4 cm.

Examination of the anus area did not reveal external hemorrhoids, inflammation, or neoplasms. Examination of the rectum revealed: sphincter tone is normal, palpation is painful. There is a small amount of scarlet blood and feces on the glove.

The stool is frequent, liquid, which the patient associates with taking a laxative.

Urinary system:

The skin in the area of the anatomical projection of the kidneys of normal temperature and color.

Urination regular, painless.

The kidneys are not palpable on both sides.

The symptom of tapping (Pasternatsky) is negative on both sides.

The bladder is not percussed.

The ureteral points are painless.

Neurological status:

Intelligence and emotions correspond to age. Pathology of the cranial nerves according to the examination was not revealed.

Physiological reflexes:

abdominal reflexes - present;

tendon reflexes from the arms and legs are present.

Endocrine system:

The proportions of the trunk and limbs correspond to age.

Sexual organs correspond to age. Exophthalmos and other eye symptoms are absent.

Provisional diagnosis:

Regarding complaints about:

Frequent, painful, bloody stools

Weakness

Medical history:

Examination in hospital No. 30 and exclusion of acute dysentery

Data from an objective study:

Rectal examination showed traces of feces mixed with red blood on the glove.

Cr of the rectosigmoid region

Accompanying illnesses:

Angina pectoris 2 f.cl.

Hypertension stage 2

Objective examination of the patient (Status praesens)

Page 1

General inspection

The patient's condition is satisfactory, body temperature is 36.6 C. Consciousness is clear. The position is active. Facial expression is calm. Height 170 cm, weight 65 kg. Normosthenic body type. Posture is straight.

The skin is dry, pale pink. There are no scars, scratches, visible tumors. Its elasticity is preserved, there are no hemorrhages, scars, ulcers, tumor formations, "spider veins". Turgor is preserved. The nails are oval in shape, there is no deformation of the nail plates. Hair is thick, dry, shiny, does not split. Visible mucous membranes of the nose, mouth, conjunctiva, soft palate, palatine arches are pale pink, shiny, clean. The tonsils are not enlarged, pale pink in color, there is no plaque or swelling. Sclera white. The food is satisfactory. Subcutaneous fat is moderately developed, evenly distributed, there is a small accumulation of fat in the abdomen, there is no pain and crepitus on palpation. The thickness of the fat fold in the area of the shoulder blades was 1.0 cm. No edema was detected.

Peripheral lymph nodes: occipital, parotid, submandibular, supra- and subclavian, axillary, ulnar, inguinal, popliteal - not enlarged, not palpable.

The muscular corset is developed satisfactorily, the tone and strength of the muscles are normal, the same on both sides, there is no pain and compaction.

The bones are not deformed, painless on palpation. The skull is rounded, medium in size. The shoulder blades are symmetrical, the angles of the shoulder blades are directed downward. The physiological curves of the spine are sufficiently pronounced, there are no pathological curves.

Joints of the correct form, movements in full, swelling, hyperemia and pain on palpation are absent. The nail phalanges of the fingers are not changed.

Respiratory system

Examination: The nose has a normal shape. Breathing through the nose is free, there is no discharge from the nose and nosebleeds. Deformations of soft tissues, redness and ulceration at the outer edge of the nostrils, herpetic rash was also not found. The condition of the nasal mucosa is satisfactory. The larynx is of normal shape. There is no swelling in the larynx. The voice is quiet. The mucous throat is not hyperemic. The tonsils are not enlarged.

The chest is conical, normosthenic type, supraclavicular and subclavian fossae are slightly smoothed, equally expressed on the right and left, the width of the intercostal spaces is 1 cm, the epigastric angle is straight, the shoulder blades fit snugly against the posterior surface of the chest. The ratio of the anteroposterior and lateral dimensions is approximately 2:3, the chest is symmetrical. There is no pronounced curvature of the spine. The circumference of the chest is 92 cm. The excursion of both sides of the chest during breathing is uniform - 2 cm. Type of breathing - chest. Breathing is rhythmic with a frequency of 18 respiratory movements per minute, of medium depth. Respiratory movements are symmetrical, one half of the chest lags behind, there is no participation of additional muscles in breathing.

Palpation of the chest. On palpation of the chest along the intercostal nerves, muscles and ribs, there is no pain. The integrity of the chest is not broken, elasticity is preserved. Voice trembling is not changed, the same on both sides.

Percussion. Comparative percussion of the lungs revealed a clear pulmonary sound over the entire surface of the lungs. Topographic percussion data:

Apex height



	At the level of the spinous process of the 7th cervical vertebra

The width of the apical fields (Krenig fields) is 4.1 cm on the right and 4.2 on the left.

Topographic percussion results:

Bottom line:
topographic lines	Right lung	Left lung
peristernal	VI intercostal space
mid-clavicular
anterior axillary
Middle axillary		VIII intercostal space
Posterior axillary
scapular
Perivertebral		Spinous process of XI thoracic vertebra

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Operations for purulent mastitis . Surgical treatment of purulent mastitis consists in opening and draining accumulations of pus in the mammary gland. General anesthesia is always used. Opening of subcutaneous abscesses and relatively superficial accumulations of pus in the lobules of the mammary gland is performed by linear incisions that are directed radially with respect to the nipple, without moving to the area of the areola. The opened cavity is emptied of pus, drained and partially sutured. With deep-seated abscesses and phlegmon of the mammary gland, radial incisions can also be used. After deep incisions in the upper quadrants, significant deformation and disfigurement of the gland often occurs. Therefore, it is advisable to open deeply located abscesses and phlegmons from an arcuate incision made along the skin fold under the mammary gland or parallel to it. Breast after skin incision

and subcutaneous tissue is pulled up. Its posterior surface is exposed and the purulent cavity is opened with a radial incision of the gland tissue. All opened cavities are emptied of pus and necrotic masses, examined with a finger, and bridges and deep pockets are eliminated. After the introduction of tubular drains with side holes, the mammary gland is placed in place. The edges of the skin incision can be brought together with sutures.

Radical mastectomy :

Indications: breast cancer. Anesthesia - endotracheal anesthesia. The position of the patient on the back. The shoulder on the side of the operation is retracted to the side at a right angle. The mammary gland is bordered by two skin incisions in the form of semi-ovals. The distance between the incisions and the edge of the tumor should be at least 6-8 cm. The medial incision begins at the outer third of the clavicle, leads towards the middle of the sternum, continues down the parasternal line and ends at the costal arch. The lateral incision connects the beginning and end of the medial incision, passing along the outer edge of the mammary gland along the anterior border of the axillary fossa. The edges of the skin with a scalpel or electric knife are widely separated to the sides, leaving only a thin layer of subcutaneous fatty tissue on the skin. Subcutaneous tissue and fascia are dissected near the base of the prepared skin edges along the entire perimeter of the wound. The tendon part of the pectoralis major muscle, which is attached to the humerus, is isolated and crossed. Next, this muscle is separated from the clavicle and sternum, keeping its clavicular portion. The pectoralis minor muscle is cut off from the coracoid process of the scapula and pulled down, exposing the subclavian tissue and blood vessels. Fiber and lymph nodes are widely removed along the course of the axillary and subclavian vessels. After that, the mammary gland with the large and small pectoral muscles, adjacent fascia, fiber and lymph nodes is removed in one block in a sharp and blunt way. Bleeding from the resulting abundant wound surface is stopped by the imposition of simple and piercing ligatures. A conservative version of radical mastectomy is also used, in which the pectoralis major muscle is preserved.

Sectoral resection of the mammary gland:

Indications: benign tumors, fibrocystic mastopathy, cysts. Sectoral resection of the mammary gland is also a biopsy method for suspected malignant tumors. The operation is performed under local anesthesia or endotracheal anesthesia. The skin incision is made radially from the edge of the areola above the palpable pathological formation. The edges of the skin and subcutaneous tissue are separated to the sides. The corresponding lobules of the mammary gland are excised. Thoroughly stop bleeding. The cavity in the gland is eliminated by applying deep interrupted sutures. The wound is drained with tubular drainage. Sutures are placed on the subcutaneous tissue and skin.

№ 29 Topography of intercostal spaces. Subperiosteal resection of the rib.

Topography of intercostal spaces:

External intercostal muscles

Deeper located internal intercostal muscles

intercostal space

Posterior intercostal arteries depart from the aorta front- from the internal mammary artery.

intrathoracic fascia,

Rib resection. Removal of one or more ribs is used to expand surgical access to the organs of the chest cavity, wide drainage of the pleural cavity, in various inflammatory diseases and tumors of the rib.

The skin, subcutaneous tissue, and superficial muscle layers are dissected over the rib to be removed. The anterior periosteum is cut longitudinally with a scalpel or electric knife. At the beginning and end of the incision, two transverse notches are made. The periosteum is separated from the anterior surface of the upper and lower edges of the rib with a raspator. The direction of movement of the raspator along the edge of the rib should correspond to the course of the fibers of the intercostal muscles attached to the rib. The posterior periosteum is separated from the rib with a Doyen rasp. The rib freed from the periosteum is excised with rib scissors.

№ 30 Topography of intercostal spaces. Primary surgical treatment of penetrating wounds of the chest wall.

Topography of intercostal spaces:

In the intervals between the ribs are the external and internal intercostal muscles, mm. intercostales externi et interni, fiber and neurovascular bundles.

The space between adjacent ribs, bounded from the outside and from the inside by the corresponding intercostal muscles, is called intercostal space spatium intercostal. It contains intercostal vessels and a nerve: a vein, below it - an artery, and even lower - a nerve (VAN). The intercostal bundle in the area between the paravertebral and middle axillary lines lies in the groove, sulcus costalis, of the lower edge of the overlying rib.

Posterior intercostal arteries depart from the aorta front- from the internal thoracic artery. Due to numerous anastomoses, they form a single arterial ring, the rupture of which can lead to severe bleeding from both ends of the damaged vessel. Difficulties in stopping bleeding are also explained by the fact that the intercostal vessels are closely connected with the periosteum of the ribs and the fascial sheaths of the intercostal muscles, which is why their walls do not collapse when injured.

Primary surgical treatment of penetrating wounds of the chest wall.

Indications: stab, stab-cut, cut, gunshot wounds with open or intense pneumothorax, intrapleural bleeding.

One or two drains are introduced into the pleural cavity above the diaphragm - anterior and posterior. The main one is the posterior drainage, which is inserted into the seventh-eighth intercostal space along the posterior axillary line and laid along the posterior chest wall to the dome of the pleural cavity. Anterior drainage is inserted in the fourth or fifth intercostal space in case of insufficient or doubtful aerostasis and is placed between the lung and the mediastinum. The end of the drain must also reach the dome of the pleural cavity.

No. 31 Topography of the diaphragm. Topographic and anatomical substantiation of the formation of diaphragmatic hernias.

The diaphragm separates the chest cavity from the abdominal cavity; it is an elliptical thin tendon-muscle plate in the form of a dome, facing the bulge towards the chest cavity.

In the muscular part of the diaphragm, the sternal part, pars sternalis, is distinguished; costal (lateral) part, pars costalis; lumbar, pars lumbalis (consists of two muscle parts - right and left legs).

The tendon center, centrum tendineum, is often triangular in shape and occupies the middle of the diaphragm.

The left dome of the diaphragm is projected from the front at the level of the upper edge of the V rib, and from behind - at the level of the ninth intercostal space.

The right dome is located one intercostal space above the left. Between the muscular parts of the diaphragm, slit-like spaces of a triangular shape are often formed, with their apex facing the tendon center, in which there are no muscle bundles, as a result of which the sheets of the intrathoracic and intra-abdominal fascia come into contact. These gaps are weak areas of the diaphragm and can serve as places of hernial protrusions, breakthrough of pus from under the pleural tissue into the subperitoneal and back.

Diaphragm holes .

The aorta and adjacent to it on the right and behind the thoracic lymphatic duct, ductus thoracicus, pass into aortic orifice, hiatus aorticus.

esophageal opening, hiatus esophageus, is formed by legs continuing upward, the internal muscle bundles of which are pre-crossed with each other. The esophageal opening can serve as an outlet to the posterior mediastinum of diaphragmatic hernias (usually their contents are the cardial part of the stomach).

opening of the inferior vena cava, foramen venae cavae, located in the tendon center of the diaphragm. Through other intermuscular fissures of the lumbar part of the diaphragm, the splanchnic nerves pass, nn. splanchnici, sympathetic trunks, trunci sympathici, unpaired and semi unpaired veins, vv. azygos et hemiazygos.

№ 32 Topography of the pleura and lungs. Segmental structure of the lungs. Operative access to the organs of the chest cavity.

Topography of the pleura. The pleura is a thin serous membrane that covers each lung, grows together with it, and passes to the inner surface of the walls of the chest cavity, and also delimits the lung from mediastinal formations. Between the visceral and parietal sheets of the pleura, a slit-like capillary space is formed - the pleural cavity, in which there is a small amount of serous fluid. There are costal, diaphragmatic and mediastinal (mediastinal) pleura. On the right, the anterior border crosses the sternoclavicular joint, goes down and inward along the manubrium of the sternum, runs obliquely from right to left, crossing the midline at the level of the cartilage of the II rib. Then the border runs vertically down to the level of attachment of the cartilage of the VI rib to the sternum, from where it passes into the lower border of the pleural cavity. At the level of II-IV costal cartilages, the right and left anterior pleural folds come close to each other and are partially fixed with connective tissue cords. Above and below this level, the upper and lower interpleural spaces are formed. The lower boundaries of the pleural cavities run along the midclavicular line - along the VII rib, along the midaxillary line - along the X rib, along the scapular line - along the XI rib, along the paravertebral line - along the XII rib. The posterior borders of the pleural cavities correspond to the costovertebral joints. The dome of the pleura protrudes above the clavicle into the neck region and corresponds behind the level of the spinous process of the VII cervical vertebra, and in front it is projected 2-3 cm above the clavicle. The pleural sinuses form part of the pleural cavity and are formed at the points of transition of one section of the parietal pleura to another. There are three pleural sinuses. The costophrenic sinus is the largest. It is formed between the costal and diaphragmatic pleura and is located at the level of attachment of the diaphragm in the form of a semicircle from the cartilage of the VI rib to the spine. Other pleural sinuses - mediastinal-diaphragmatic, anterior and posterior costal-mediastinal - are much smaller and are completely filled with lungs during inspiration. Along the edges of the gates of the lungs, the visceral pleura passes into the parietal, adjacent to the mediastinal organs, as a result of which folds and depressions form on the pleura and lungs.

Topography of the lungs . The lungs are paired organs that occupy most of the chest cavity. Located in the pleural cavities, the lungs are separated from each other by the mediastinum. In each lung, the apex and three surfaces are distinguished: the outer, or costal, which is adjacent to the ribs and intercostal spaces; the lower, or diaphragmatic, adjacent to the diaphragm, and the internal, or mediastinal, adjacent to the organs of the mediastinum. In each lung, lobes are distinguished, separated by deep fissures.

The left lung has two lobes (upper and lower), while the right lung has three lobes (upper, middle and lower). An oblique fissure, fissura obliqua, in the left lung separates the upper lobe from the lower lobe, and in the right lung, the upper and middle lobe from the lower lobe. In the right lung there is an additional horizontal fissure, fissura horizontails, extending from the oblique fissure on the outer surface of the lung and separating the middle lobe from the upper lobe.

Lung segments . Each lobe of the lung consists of segments - sections of lung tissue ventilated by a third-order bronchus (segmental bronchus) and separated from neighboring segments by connective tissue. In shape, the segments resemble a pyramid, with the top facing the gates of the lung, and the base - to its surface. At the top of the segment is its stalk, consisting of a segmental bronchus, a segmental artery and a central vein. Only a small part of the blood from the tissue of the segment flows through the central veins, and the main vascular collector that collects blood from the adjacent segments are the intersegmental veins. Each lung consists of 10 segments. Gates of the lungs, roots of the lungs. On the inner surface of the lung there are gates of the lungs, through which the formations of the roots of the lungs pass: bronchi, pulmonary and bronchial arteries and veins, lymphatic vessels, nerve plexuses. The gates of the lungs are an oval or diamond-shaped depression located on the inner (mediastinal) surface of the lung, somewhat higher and dorsal to its middle. The root of the lung is covered with a mediastinal pleura at the site of its transition to the visceral. Inward from the mediastinal pleura, large vessels of the lung root are covered with the posterior leaf of the pericardium. All elements of the lung root are subpleurally covered with spurs of the intrathoracic fascia, which forms fascial sheaths for them, delimiting the perivascular tissue, in which the vessels and nerve plexuses are located. This fiber communicates with mediastinal fiber, which is important in the spread of infection. At the root of the right lung, the main bronchus occupies the highest position, and below and anterior to it is the pulmonary artery, below the artery is the superior pulmonary vein. From the right main bronchus, even before entering the gates of the lungs, the upper lobe bronchus departs, which is divided into three segmental bronchus - I, II and III. The middle lobe bronchus splits into two segmental bronchi - IV and V. The intermediate bronchus passes into the lower lobe where it splits into 5 segmental bronchi - VI, VII, VIII, IX and X. The right pulmonary artery is divided into lobar and segmental arteries. The pulmonary veins (superior and inferior) are formed from intersegmental and central veins. At the root of the left lung, the pulmonary artery occupies the highest position, below and behind it is the main bronchus. The superior and inferior pulmonary veins are adjacent to the anterior and inferior surfaces of the main bronchus and artery. The left main bronchus at the gates of the lung is divided into lobar - upper and lower - bronchi. The upper lobe bronchus splits into two trunks - the upper one, which forms two segmental bronchi - I-II and III, and the lower, or reed, trunk, which is divided into IV and V segmental bronchi. The lower lobe bronchus begins below the origin of the upper lobe bronchus. The bronchial arteries feeding them (from the thoracic aorta or its branches) and the accompanying veins and lymphatic vessels pass and branch along the walls of the u1073 bronchi. On the

The walls of the bronchi and pulmonary vessels are located branches of the pulmonary plexus. The root of the right lung goes around the unpaired vein in the direction from back to front, the root of the left lung - in the direction from front to back, the aortic arch. The lymphatic system of the lungs is complex, it consists of superficial, associated with the visceral pleura and deep organ networks of lymphatic capillaries and intralobular, interlobular and bronchial plexuses of lymphatic vessels, from which the efferent lymphatic vessels are formed. Through these vessels, lymph flows partially into the bronchopulmonary lymph nodes, as well as into the upper and lower tracheobronchial, near-tracheal, anterior and posterior mediastinal nodes and along the pulmonary ligament into the upper diaphragmatic nodes associated with the nodes of the abdominal cavity.

operational access. Wide intercostal incisions and dissection of the sternum - sternotomy. Accesses with the position of the patient on the back are called anterior, on the abdomen - posterior, on the side - lateral. With anterior access, the patient is placed on his back. The arm on the side of the operation is bent at the elbow joint and fixed in an elevated position on a special stand or arc of the operating table.

The skin incision begins at the level of the cartilage of the third rib from the parasternal line. The nipple is bordered with a cut from below in men, and in women - the mammary gland. Continue the incision along the fourth intercostal space to the posterior axillary line. The skin, tissue, fascia and parts of two muscles are dissected in layers - the pectoralis major and the serratus anterior. The edge of the latissimus dorsi muscle in the back of the incision is pulled laterally with a blunt hook. Further, in the corresponding intercostal space, the intercostal muscles, intrathoracic fascia and parietal pleura are dissected. The wound of the chest wall is bred with one or two dilators.

With posterior access, the patient is placed on the stomach. The head is turned in the direction opposite to the operation. The incision begins along the paravertebral line at the level of the spinous processes of the III-IV thoracic vertebrae, goes around the angle of the scapula and ends, respectively, in the middle or anterior axillary line at the level of the VI-VII rib. In the upper half of the incision, the underlying parts of the trapezius and rhomboid muscles are dissected in layers, in the lower half - the latissimus dorsi and serratus anterior. The pleural cavity is opened along the intercostal space or through the bed of the previously resected rib. In the position of the patient on a healthy side with a slight inclination to the back, the incision starts from the midclavicular line at the level of the fourth-fifth intercostal space and continues along the ribs to the posterior axillary line. The adjacent parts of the pectoralis major and serratus anterior muscles are dissected. The edge of the latissimus dorsi muscle and the shoulder blade are pulled back. The intercostal muscles, intrathoracic fascia and pleura are dissected almost from the edge of the sternum to the spine, i.e. wider than the skin and superficial muscles. The wound is diluted with two dilators, which are mutually perpendicular.

№ 33 Topography of the pleura and lungs. Segmental structure of the lungs. Puncture and drainage of the pleural cavity.

Topography of the pleura and lungs. Segmental structure of the lungs - see question number 32

Puncture and drainage of the pleural cavity .

Indications: exudative pleurisy, pleural empyema, hydrothorax, hemothorax, chylothorax, spontaneous or traumatic pneumothorax. The position of the patient sitting on the dressing table. The head and trunk are tilted forward, and the shoulder on the side of the puncture is pulled up and forward to widen the intercostal spaces. The site for puncture to remove fluid is the seventh and eighth intercostal space between the midaxillary and scapular lines. To suck air, a puncture is made in the second or

third intercostal space in the midclavicular line. Puncture, as a rule, is performed under local anesthesia with a 0.5% solution of novocaine (10-15 ml), which is used to infiltrate the chest wall in layers at the site of the intended puncture. For puncture, a long and thick needle is used, connected to a syringe with a rubber tube 10-15 cm long or a tap. Direct connection of the needle to the syringe should not be used, as this always threatens to allow air from the atmosphere to enter the pleural cavity at the moment the syringe is disconnected. The direction of injection of the needle is perpendicular to the skin. At a depth of 3-5 cm, depending on the thickness of the chest wall, it is often possible to feel a puncture of the parietal pleura. When sucking air or fluid from the pleural cavity, before disconnecting the syringe, clamp the rubber tube or close the tap. In the course of removing the pleural contents, sometimes the needle is somewhat advanced or removed, its direction is changed.

№ 34 Topography of the mediastinum. Vessels, nerves and nerve plexuses of the posterior mediastinum. Operational access to the anterior and posterior mediastinum.

The mediastinum is bounded anteriorly by the sternum and retrosternal fascia, and posteriorly by the thoracic spine, necks of the ribs, and prevertebral fascia. The lateral borders are the mediastinal pleura and adjacent sheets of the intrathoracic fascia. The lower border of the mediastinum is formed by the diaphragm and diaphragmatic fascia. At the level of the intersection of the esophagus with the aorta, the pleural sheets move away from each other, but can touch in the gap between the esophagus and the aorta. It is conventionally divided into 4 sections: superior, anterior, middle and posterior mediastinum. superior mediastinum includes all formations located above the conditional plane drawn at the level of the upper edge of the roots of the lungs: thymus gland, brachiocephalic veins, vv. brachiocephalicae, upper part of the superior vena cava, v. cava superior, aortic arch, arcus aortae, Anterior mediastinum located below the conditional plane between the body of the sternum and the anterior wall of the pericardium; contains fiber, spurs of the intrathoracic fascia, in the sheets of which, outward from the sternum, there are internal chest vessels, peristernal, prepericardial and anterior mediastinal lymph nodes. Middle mediastinum contains the pericardium with the heart enclosed in it and the intra-pericardial sections of large vessels, the bifurcation of the trachea and the main bronchi, the pulmonary arteries and veins, the phrenic nerves with their accompanying phrenic-pericardial vessels, fascial-cellular formations, and lymph nodes. In the posterior mediastinum descending aorta, unpaired and semi-unpaired veins, vv. azygos et hemiazygos, sympathetic trunks, splanchnic nerves, nn. splanchnici, vagus nerves, esophagus, thoracic duct, lymph nodes, fiber and spurs of the intrathoracic fascia surrounding the mediastinal organs and forming fascial-cellular spaces.

For anterior access the patient is placed on his back. The arm on the side of the operation is bent at the elbow joint and fixed in an elevated position on a special stand. The skin incision begins at the level of the cartilage of the third rib from the parasternal line. The nipple is bordered with a cut from below in men, and in women - the mammary gland. Continue the incision along the fourth intercostal space to the posterior axillary line. The skin, tissue, fascia and parts of two muscles are dissected in layers - the pectoralis major and the serratus anterior. The edge of the latissimus dorsi muscle in the back of the incision is pulled laterally with a blunt hook. Further, in the corresponding intercostal space, the intercostal muscles, intrathoracic fascia and parietal pleura are dissected. The wound of the chest wall is bred with one or two dilators.

For posterior access the patient is placed on the stomach. The head is turned in the direction opposite to the operation. The incision begins along the paravertebral line at the level of the spinous processes of the III-IV thoracic vertebrae, goes around the angle of the scapula and ends, respectively, in the middle or anterior axillary line at the level of the VI-VII rib. In the upper half of the incision, the underlying parts of the trapezius and rhomboid muscles are dissected in layers, in the lower half - the latissimus dorsi and serratus anterior.

№ 35 Topography of blood vessels, nerves and nerve plexuses of the mediastinum. reflex zones.

Brachiocephalic veins, superior vena cava . The right and left brachiocephalic veins are formed behind the respective sternoclavicular joints by the confluence of the internal jugular and subclavian veins.

Right brachiocephalic vein projected onto the right edge of the sternum. The left brachiocephalic vein is projected at the level of attachment to it of cartilage I, less often II, ribs. The junction of the right and left brachiocephalic veins into the superior vena cava is projected at the right edge of the sternum at the level of attachment of the cartilage of the 1st rib to it (more often, the trunk of the superior vena cava protrudes from the right edge of the sternum by half the diameter of the vessel). The projection of the superior vena cava corresponds to the right edge of the sternum along the I-III ribs. The brachiocephalic and superior vena cava are surrounded by cellular tissue, in which the lymph nodes are located.

Left brachiocephalic vein in front it is covered with the thymus gland or its replacement tissue, and behind it is in contact with the brachiocephalic trunk and partially with the left common carotid artery. The right brachiocephalic and superior vena cava are covered by the thymus gland and the right mediastinal pleura. Behind and to the left, the trachea is adjacent to the superior vena cava. An unpaired vein flows into the posterior, less often into the right wall of the vein at the level of the middle third of its length. Below its confluence, the superior vena cava is adjacent to the root of the right lung. In the tissue behind the superior vena cava, the right vagus nerve passes, and along its right wall, the right phrenic nerve. Aortic arch, arcus aortae, is a continuation of the ascending aorta located intrapericardially, aorta ascendens. The beginning of the aortic arch corresponds to the level of attachment of the cartilage of the II rib to the left edge of the sternum. The place of transition of the aortic arch to its descending section is projected on the left at the level of the IV thoracic vertebra. The middle section of the aortic arch is covered in front by the thymus gland and adipose tissue, in which the lymph nodes are located. The posterior surface of the aortic arch is in contact with the anterior surface of the trachea, forming a slight depression on it. At the level of transition of the aortic arch into the descending aorta behind it is the esophagus. Behind the aortic arch, the right pulmonary artery passes towards the hilum of the right lung. The left vagus nerve is adjacent to the left surface of the arch, from which, at the level of the lower edge of the arch, the left recurrent laryngeal nerve departs, enveloping the aortic arch from below and behind. Outward from the vagus nerve on the anterior - left surface of the aortic arch are the left phrenic nerve and the vasa pericardiacophrenica accompanying it. Large branches depart from the upper semicircle of the aortic arch: the brachiocephalic trunk, the left common carotid and the left subclavian artery. The brachiocephalic trunk, truncus brachiocephalicus, is the first branch of the aortic arch, departs somewhat to the left of the midline and is divided into the right subclavian and common carotid arteries.

Shoulder head trunk it is projected onto the handle of the sternum, from which it is separated by the left brachiocephalic vein, sternohyoid and sternothyroid muscles. Along the right wall of the brachiocephalic trunk is the right brachiocephalic vein. The left common carotid artery departs from the aortic arch 1.0-1.5 cm to the left and posterior to the place of origin of the brachiocephalic trunk, anterior to the initial section of the left subclavian artery. The descending part of the aorta, pars descendens aortae, is a continuation of the aortic arch and is divided into the thoracic, pars thoracica, and abdominal, pars abdominalis, parts. The root of the left lung and the left vagus nerve are adjacent to the anterior surface of the aorta, and the semi-azygous vein and left intercostal veins are behind. The branches of the sympathetic trunk and the plexuses they form are adjacent to the outer surface of the fascial sheath of the aorta. The esophagus and vagus nerves are adjacent to the anterior right surface of the aorta, and the mediastinal pleura is on the right. The thoracic lymphatic duct is adjacent to the posterior surface of the aorta on the right. Lymph nodes are located in the peri-aortic tissue. The thoracic part of the aorta is surrounded by a fascial membrane associated with its adventitia and the formations surrounding the aorta: mediastinal pleura, prevertebral fascia, fibrous pericardium. The pulmonary trunk, truncus pulmonalis, originates at the level of attachment of the cartilage of the third left rib to the sternum, and the place of division into the right and left pulmonary arteries corresponds to the level of the upper edge of the cartilage of the second left rib. Upon exiting the right ventricle, the pulmonary trunk is located in the pericardial cavity in front and to the left of the ascending aorta.

Nerves. Wandering nerves. The right vagus nerve, when passing into the chest cavity, lies in front of the right subclavian artery, at this level, the right recurrent laryngeal nerve departs from it, n. laryngeus recurrens, enveloping the subclavian artery from below and behind. It goes behind the right brachiocephalic and superior vena cava, gives branches to the esophageal plexus and passes along with the esophagus into the abdominal cavity. The left vagus nerve passes in front of the initial section of the left subclavian artery, posterior to the left brachiocephalic vein, along the left side of the aortic arch, where the left recurrent laryngeal nerve departs from it, enveloping the aortic arch from below and behind. After the departure of the recurrent laryngeal nerve, the left vagus nerve passes into the gap between the aortic arch and the left pulmonary artery.

The vagus nerves form the esophageal plexus associated with the sympathetic trunks and spinal nerves. Sympathetic trunks, trunci symphatici, in the thoracic region are formed by 11-12 thoracic nodes, ganglia thoracica, connected by interganglionic branches, and are located in the sheets of the prevertebral fascia on the surface of the heads of the ribs. The sympathetic trunk runs anterior to the intercostal vessels, outward from the unpaired (right) and semi-unpaired (left) veins. The branches of the sympathetic trunk, together with the vagus nerves, participate in the formation of the nerve plexuses of the chest cavity, give connecting branches to the intercostal nerves, form the large and small splanchnic nerves, n. splanchnicus major (from V-IX chest nodes) and n. splanchnicus minor (from X-XI chest nodes).

Nerve plexuses are reflexogenic zones of the chest cavity. Branches from the sympathetic trunks, vagus nerves, phrenic nerves to the tissue of the mediastinum form numerous connections that are unevenly located, concentrating in certain areas in the form

nerve plexuses, which also contain nerve cells and nerve nodes.

The main plexuses are :

1) superficial left cardiopulmonary plexus. Branches depart from the plexus to the aortic arch, heart and pericardium, left lung;

2) deep right cardiopulmonary plexus. Branches depart from the plexus to the aortic arch, pericardium, right lung;

3) the esophageal plexus gives branches to the esophagus, lungs;

4) prevertebral plexus. The plexus is formed mainly by branches of the sympathetic trunks.

№ 36 Topography of the heart and pericardium. Topography of the thoracic aorta. Pericardial puncture.

Pericardium - a closed sac that surrounds the heart, the ascending aorta until it passes into the arch, the pulmonary trunk to the place of its division, the mouth of the hollow and pulmonary veins. It consists of the outer fibrous pericardium, pericardium fibrosum, and the serous pericardium, pericardium serosum, in which the parietal plate, lamina parietalis, and the visceral plate, or epicardium, lamina visceralis (epicardium) are distinguished. The parietal plate of the serous pericardium passes into the visceral layer - the epicardium. Between the parietal and visceral (epicardial) plates of the pericardium is a serous pericardial cavity, cavitas pericardialis, in which there is a small amount of serous fluid. Areas of the heart not covered by the pericardium: the posterior surface of the left atrium in the area where the pulmonary veins flow into it and part of the posterior surface of the right atrium between the mouths of the vena cava.