mediastinum posterius, surrounded anteriorly by the bifurcation trachea, bronchopericardial membrane and posterior pericardium, posteriorly by the fourth-XII thoracic ridges, covering the prevertebral fascia. In the posterior middle, the lower aorta and stravochid, unpaired and semi-unpaired veins, sympathetic storms, visceral nerves, bloody nerves, thoracic duct and lymph nodes have been unpaired. In the Danish hour, we see a few ways of draining posterior middle: a) through the posterior postpleural approach from the side of the back on the pivn root of the lung according to I.I.Nasilov (3, 5); b) through the lateral access by late opening along the inner edge of the nodal mucosa through the canal formed by vessels, trachea, thyroid gland and by the trachea down to the point of purchase, pus and introduction, there is a drainage tube; c) through the pleural emptying path by a wide anterior-bichny thoracotomy in the VII mid-ribs according to V.D. Dobromislov (3); d) through the empty tube with the upper-middle laparotomy according to B.S. Rozanova (7); e) transesophageal access with the introduced drainage in the posterior middle through a pompous path in the perforation of the stem of the stratohode, or of the growths on the pins of the gnar, vikonaniy through the tube of the Mezlin esophagoscope according to A. Seiffer

Anatomical and surgical priming of accesses to the upper top of the black empty.

Access to the organs of the abdomen Rozrizi cherevnoї stinki: Pozdovzhni: middle laparotomy: upper middle (belly button); lower middle (lower than the navel); total (povna) from the sword-like outgrowth to the pubis) bypassing the navel of evil (to the right to pass the umbilical vein); Sharovically open: shkіra, pіdshkіrnu klіtkovina, superficial fascias, bіla linіyu, paired necks Kosі razrіzi - along the line directly fast mowing mucous belly sprout і ін. Lateral rosters - for decking of the junior paths, collar, shlunka, spleen, POK (do not repetitively cross the mouth) to the navel or from the right oblyamіvkoy breast cancer and black emptying for access to the drainage pipe, drainage pipe, ERW, etc.) Pararectal access - growth parallel to the lateral edge of the straight abdomen; Transrectal access - through a direct link above the middle of the її summit. Paramedian access - above the medial edge of the straight muscle (or lower than the navel);

ticket number 21

1. Principles of operations on peripheral nerves: neurotomy, neurolysis, neurorrhaphy, plastic.

neurorrhaphy (nerve suture) and neuroplasty (reconstructive plastic surgery). Neurotomy - overwhelming nerves. The operation is given Smelling with spastic paralysis of the mucous membranes, with causalgia, and also with a decrease in the acid-producing function of the slunk in case of twisting ailment of the 12 intestine (vagotomy). Suture of the nerve (neurophysiology) - development for the show and the minds of the wounds: - first (vikonutsya at the first surgical treatment of the wound); - second (early - up to 2-3 m / s. Pislya start, pizniy - pislya 3 m / sec.) Seam. Vimogami to the suture of the nerve є: 1) ideally closing the ends of the nerve stub without changing along the axis and along the area, without restraining and deforming, without interposing navkolishnykh tissues, with hermetic suturing; 2) imposition of sutures on the health of the nerve stub burr with optimal indicators of electrical conductivity and tissue operability. 3) atraumatic operation daily visibility seam tightness). For satisfaction, the named vimogs are drawn in: 1) until the nerve is seen from the grooves, canals and intermediate protrusions on the significant protrusion (allowing the nerve to “podovzhit” by 2-3 cm); 2) until the nerves are displaced in the muscular-fascial bed (allowing the nerve to be pushed up by 5-7 cm); 3) before the resection of the cyst (allowing the nerve to be lifted by 8-10 cm); 4) until the nerve is seen from cicatricial tissue (neurolysis) from the resection of injured and cicatricial changes. Even if the display of the minds is not important, the application of the first seam is not recommended, it is more important to go in before the second early seam. Access to the nerve stubs is the same, as to the stumps, at the nerves of the nerve (brachial gossip - pidclavicular, groin artery; middle, liktoviy nerves - brachial artery; staginal nerve - stalk, nerve artery; tibial artery). Direct access to the exchange and the central nerve is available through the projection lines. The intervertebral nerve is denuded at the upper and middle third of the posterior region of the shoulder in the brachio-intestinal canal between the middle and medial, and in the lower one - with the outer heads of the trigeminal mucosa of the shoulder. The central nerve is denuded in the central area and in the back of the bead, as the two-headed bead is called stegna, for example, the tendon and in the middle - up to the middle. Neurolysis - nerve injury from cicatricial tissue, for example, in case of cicatricial hematoma (in case of fractures of the brachial, promenade, cysts of gomilka and in.) ... For the visualization of the scars in the middle of the nerve stump, it is inserted to the so-called internal neurolysis, if, according to the optical microscope, the dissection of the neurological and the dissection of the scar between the nerve bundles. As well as cicatricial changes have buried nerve stovbur and it is not a good idea to develop intra-trunk neurolysis; Then we can see the seam of the nerve. Yakshcho the seam of the viconati is uncomfortable; Neuroplasty depends on the following methods: - plastics of a nerve with a bundle of cranial nerves, for example, a pedicle nerve; - plastics of more functionally significant nerves with grafts of less significant ones. For example, when it is on the shoulders, in the middle area, or on the front of the middle and middle nerves, there is a dilenca of the middle nerve for the renewal of the middle nerve; - the suture of the central end is functionally significant from the peripheral end is more significant (the suture of the pod'yazikovy or additional nerve from the lyceum).

2. Anatomical and surgical priming of access to organs babies: Sertsyu, lung, stravohod.

All access to the organs of the empty breast is divided into two groups: out-of-pleural and trans-pleural. In case of out-pleural access to the anatomical cavity, the middle should be removed without sealing the pleural empty space. The possibility of determining these accesses starts from the position and the relation to the anterior and posterior cordons of the pleurisy. Transple-oral access can be used for operations on the organs of the middle, as well as on the lungs. an outgrowth. Then the sternum openings are expanded and the sternum changes by 2-3 mm in the direction of the line of growth with a raspor. V lower view wounds on the arms of decilkoh centimeters are extended to the line of the abdomen and with a blunt way (finger, tampon) form a tunnel between the posterior surface of the sternum and the sternal part of the diaphragms. Seek out the fabrics with the Buyalsky's shovel (or in the same way), and then turn the ster-note. The land is widely planted in the sides by gunting Ranorozsiryuvach, when they are not covered with mediastinal pleura. When the operation is completed, the edge of the sternum is set and scraped with special bows or small seams. One of the most frequently implanted, "standard" accesses. The growth is repaired from the parasternal line and, while continuing to the middle line, to bring it to the rear groin line. Use the rosette of the superficial spheres of the chest wall to expand the edge of the wound with knobs and open the middle ribs and open the ribs, in order to start up the middle ribs in the middle of the ribs for the pleural access. lіnіі.For visonannya posterolateral access. repair the growth of soft tissues on the edges of the spinous outgrowth of the III-V thoracic ridge and advance along the paravertebral line to the edge of the shoulder blade (VII-VIII ribs). Having bent around the top of the scapula from the bottom, carry out the rozriz along the VI rib to the front groin line. Lastly, all fabrics are sorted to the ribs. The pleural empty space is dissected along the intercostal space, or through the bed of the resected rib. For the expansion of the operative access, it is not easy to protrude to the resection of the sheaths of the two abdominal ribs. The transverse sternotomy is used in cases of the need for wide skin not only in organs, but rather in the middle and in adjacent areas. Razrіz is carried out along the fourth intercostal-Rue from the middle groin line from one side, through the sternum, to the middle groin line of the protidal side.

middle, mediastinum- space, included between the internal surfaces of the lungs from the covering of the pleurora. It extends to the upper and lower surfaces.

All anatomical structures are visible up to the upper middle; the boundaries of the upper middle є the upper aperture of the breast bone and line, held between the cut of the sternum and the mid-spine disc Th4-Th5.

The lower middle is surrounded by the upper edge of the pericardium from above and by the diaphragm from below. It extends to the front, middle and rear sides.

Front middle. The anterior middle is flanked by the sternum anteriorly, the pericardium and the brachiocephalic vessels posteriorly. In the new heart with the pericardium, thymus, viscid aorta, aortic arch, arterial duct of the leg artery, upper and lower empty veins, leg veins, as well as abdominal nerves and judges.

Vilochkova zalosa, glandula thymus, Zalyagaє in area interpleurica superior, Behind the handle of the sternum. There are 2-3 years of development within the child's reach, and the distance is arrogant to the process of development. Above, on the deyak_y vіdstanі from the thymus gullet, the thyroid gallbladder grows; below the anterosuperior surface of the heart bursa; from the sides of the border between the mediastinal pleura. Near the circumference, the anterior mediastinal lymph nodes grow larger in front of the fatty cells, l-di mediastinales anteriores in number 10-12.

pericardium,pericardium... Heart bag emptying, cavum pericardii I have a cone-like shape, the base of which is diaphragmatic to the top, facies diaphragmatica, Roztashovane at the bottom and extended to the tendon part by diaphragms. Steppingly, the top of the burned out cob viddil aorta sounded.

Razr_znyayut such parts of the heart bag:

1. Pars sternocostalis pericardii- the sterno-rib part of the heart bag - is straightened forward and down to the lower edge of the chest, as well as to the inner parts of the fourth and fifth mid-ribs.

2. Partes mediastinales pericardii dextra et sinistra- right and left the mediastinal parts of the heart bursa - to expand from the sides to the heart and between the mediastinal parts of the pleura. Here are the diaphragmatic nerves, nn. phreniciі pericardial-abdominal vessel, vasa pericardiacophrenica.

Z. Pars vertebralis pericardii- the ridge part of the heart bursa is straightened back towards the ridge. Stravohid, azygous vein, thoracic duct and thoracic part of the aorta lie down to the posterior surface.

4. Pars diaphragmatica- the abdominal surface of the heart bursa - mitsno grows up to the tendon center and partly to the myasoma part of diaphragms.

The heart's bag is reinforced in its own camp:

1. The diaphragmatic surface of the heart bursa is mintly enlarged from the tendon part by diaphragms. Here the bed of the heart is called so.

2. The pericardium in the mountains grows to the aorta, the leg artery and the upper empty vein.

3. Take care of the fate of a special ringing device in the changing bags:

a) lig. sternocardiacum superius- the upper sternocardial ligament - to stretch from the handle of the sternum to the heart sternum;

b) lig. sternocardiacum inferius- the lower sternocardial ulcer - is pulled along the posterior surface of the sword-like appendage and the anterior surface of the pericardium.

Blood circulation of the pericardium zd_ysnyuєt for the rahun of the offensive Sudins:

1. a. pericardiacophrenica- pericardial diaphragmatic artery a. thoracica interna, supervidzhuє n. phrenicusі spread out in the heart of the heart and diaphragms, without the blood of the child and the front side.

2. Rami pericardiaci- pericardial veins - to go without middle out of the thoracic aorta and pump blood into the back wall of the heart bag.

Venous veins go through the pericardial veins, vv. pericardiaci, Bezposredno in the system of the upper empty veni.

Innervation of the heart bag, go to the heart of the heart gossip.

Limfovidtіkannya from the heart bag go to the next lіmfovzli:

1. L-di sternales- sternum lymph nodes - to expand from the side of the sternum along the way vаsa thoracica interna.

2. L-di mediastinales anteriores- anterior mediastinal lymph nodes - lay on the anterior surface of the aortic arch.

3. L-di phrenici anteriores- anterior diaphragmatic lymph nodes - anterior mediastinal lymphatic nodes are seen by name, so they lay on the diaphragm on a sword-like protuberance.

4. L-di mediastinales posteriores- posterior mediastinal lymph nodes take lymph from the posterior pericardium.

Lymphatic judges from the anterior and posterior mediastinal nodes reach the thoracic duct, and the right-handed person - the right lymph duct.

Topography of the heart. The heart of your goodwill grows in half of the breast bed in the boundaries front middle... The sides are surrounded by leaves of the mediastinal pleura. The third of the heart grows to the right of the middle line and to go into the right half of the breast.

The upper border of the heart runs along the cartilage of the third ribs. The lower boundary goes obliquely towards the cartilage attachment of the V rib to the fifth mid-ribbed edge of the left side. The right border should be repaired from the upper edge of the third rib by 1.5-2 cm, called from the edge of the sternum, then just to the point where the cartilage of the right V rib is attached to the sternum. Liva border is opukla, at 3-3.5 cm called from the edge of the sternum, and 1.5 cm down to the middle towards the midclavicular line.

Syntopy heart. In front - in the risnogo step, covered with leaves of the mediastinal pleura. The name of the heart is from that side of the lungs to close the anterior costal-mediastinal sinuses. Back to heart, lay down the organ of the posterior middle: stravohid with bloody nerves, thoracic aorta, right-handed - an unpaired vein, malice - a semi-unpaired vein in the unpaired aortic groove, sulcus azygoaortalis- thoracic duct, ductus thoracicus... From the sides to the heart, they lay down the walls of the mediastinal pleura, and behind them - the lungs. Above at the heart there are great judges. At the front viddili to the new pristine, there is also a thymus salmon, glandula thymus, For grown-ups - surplus. At the bottom, the heart is tied to the anterior arch of the tendinous center folium anterius diaphragmaticum... The system of vintsevic arteries and venous vessels of the heart form the third stake for blood circulation in humans.

Congenital defects of the septum in front of the heart and in the heart... The size of the openings varies from decilkokh mіlіmetriv up to 2 cm and more. The stench can be closed with functional valves, such as chorda tendinea and special for new papillary ointment. When there is a gap between the anterior and the middle septum, the offense of the atrio-mucous membrane is open to get angry in one. The defect between the anterior septum and the ulceration of the two-stalk valve is characterized by hypoplastic lesion. In the right half of the heart, in a small amount of blood circulation in such drops, there is an excess of blood.

visible aorta. Aorta ascendens to fix the heart on the level of the third mid-ribbed industry. Vaughn grows behind the sternum. Dovzhina 5-6 cm arcus aortae... Three great Sudins are the basis of the heart of the visible aorta є in order by another vessel: the right-handed person is from her v. cava superior, And evil - a. pulmonalis.

Aortic arch, arcus aortae... The aortic arch is repaired on the ryvny of the other right sternal-costal joint and fixing the arch, the upper part of which is pointed to the center of the sternum handle. Above to duzi, liva is unchanged vein, v. anonyma sinistra, Below, pass the transverse sinus of the heart, sinus transversus pericardii, Bifurcation of the legacy artery, livy rotary nerve, n. recurrens sinister, I obliterated arterial duct, ductus arteriosus (Bоtаlli).

Coarctation of the aorta. Zvuzhennya isthmus of the aorta is small. Children can have a ringing sound with a span of decilkoh centimeters. For older adults, it is counted in millimeters, with a large increase in diameter of offense aa. subclaviae before the size of the aorta. Let's grow in the diameter of all gilts aa. subclaviae, especially truncus thyreocervicalis, truncus costocervicalis, a. transversa colli, a. thoracica interna, - spines of the cranial wall, sharply enlarged all the mid-ribs and transverse arteries, as well as the judgment of the spinal canal and the spinal cord.

arterial duct. Ductus arteriosus (Bоtаlli) Abo the botalle duct - the whole anastomosis between the aortic arch and the leg artery, which is more significant in the uterine blood circulation. For a child, up to 3-6 months, the life of the wine is deserted and transformed into an obliterated arterial ring, lig. arteriosum.

If the duct is not overgrown through the opening of a part of blood from the aorta, it will fall into the Legenev's artery. As a result, a large amount of blood circulation is due to a lack of blood, and in a small amount - a loss.

Legeneva artery. A. pulmonalis go out of the arterial cone, conus arteriosus, Right Slinky. There lie evil from the viscid aorta. The ear of the ear is indicative of another mid-ribbed advance of evil.

Legendary artery stenosis... When a wadi is diagnosed, a grip is put into the right slit, so that the myocardial hypertrophy is victorious, an hour of wickedness is added to the legenevian artery of blood and the destruction of the whole cycle is seen.

Fallot's tetrad. Vada vada heart, which includes: obstruction of the outward appearance of the right slunker, defect of the mid-slit septum, dextraposition of the aorta and hypertrophy of the right slunker. With tsom venous roof from the empty veins of the patient through the defect in the aorta. There is a change in arterial and venous blood, even before cyanosis appears, and a number of symptoms characteristic of this defect.

Upper empty Vienna . V. cava superior pretend to be angry with two brachiocephalic veins, vv. brachiocephalicae dextra et sinistra, On the edge of the attachment of the first costal cartilage to the sternum. Dovzhina її 4-5 cm. Valves її are installed at a great number at the time of the connection of the accessory veins from the internal jugulars. At the level of the third costal cartilage, it flows into the right atrium. Lower її viddіl go into the empty heart bag v. azygos.

Lowlights Vienna. V. cava inferior pierces the diaphragm, passing through the opening of the lower empty vein or chotiricutne openings, foramen venae cavae inferioris s. quadrilaterum, I penetrate into the empty heart bag. The viscera falls into the lower viddil of the right atrium.

abdominal nerves... Diaphragmatic nerve, n. phrenicus- to enter the gossip, along the anterior surface of the anterior vanishing muzzle go down and penetrate through the upper chest opening into the chest emptying.

Right abdominal nerve A. pericardiacophrenica, Pass through the right mediastinal pleura and upper empty vein.

Livy pectoral nerve, supravascularization also A. pericardiacophrenica, Penetrates into the thoracic emptying in front of the aortic arch and the ligament between the mediastinal pleura and the heart sac.

Trachea and bronchi. The trachea emerges from the breast at the top of the breastbone by 3-4 cm, and in the area of ​​bifurcation by 6-12 cm. It extends behind the aortic arch to the right and left side of the bronchus, confirming the IV breast on the project the upper middle and three lower).

The right bronchus is short and wider than the left one; From the front to the bifurkats to pass the rights of the Legendary artery, from the bottom to the right to the front of the heart. Behind the posterior and upper stage of the right head bronchus pass v. azygos,. Reinforcement of the right tracheal surface in nasal tracheal cells n. vagus dexter.

In front of the left bronchus pass the arch of the aorta, the arch goes from the front to the back, and to the back of the left bronchus: stravohid, the arch of the aorta n. vagus sinister... From the front to both bronchi, there is a partial connection of the Legendary artery.

Back middle. The anterior border of the posterior middle is the pericardium and the trachea, the posterior is the ridge. In a new way: thoracic aorta, unpaired and semi-unpaired veins, thoracic duct, stravohid, bloody nerves and pretty near-cordonny stovburi and enter through them with internal nerves.

stravohid, oesophagus, Stretch from the VI shiyny to the XI thoracic ridge. Wine is a meat tube with internal ring and latent balls. Close to 15 cm. Yakshcho 3 4 cm

Syntopy stravohodu. When passing through the stravohode from the shoulder to the chest empty, the trachea will expand in front of the new one. Having penetrated into the rear middle, the stravohid step-by-step started to get better at the level of the 5th chest ridge and in front of it crossed the bronchus. From the thoracic level, the thoracic aorta gradually move to the posterior surface of the stravohode. In the mountains to the IV thoracic ridge, the stravohid lie between the ridge and lie flat in front of the trachea. The lower level of the stravohid hooked up the jolobok between the unpaired vein and the aorta, sulcus azygoaortalis... Back to the stravohodu, the thoracic duct і ridge; in front of him to close the heart and the judgment; right-handed - v. azygos; zlyva - chest part of the aorta.

atresia to stravohodu- a defect in the development, with any upper path to the stravohode it will end slinky. The lower end of the body most often gets from the trachea. Anatomical forms of the atresia of the trachea are seen in the trachea, as well as in the tracheopathic fistula. With another option of atresia, the upper pathway is located on the level of the II-III thoracic ridge, and the lower pathway is Svishchev's course from the rear or bicular wall of the trachea or the bronchus.

fistula stravohodu... Slid development of fistulas with organs of dichanium, middle, pleurisy and callous. Significant fistulas in the bladder pass through the ventral duct, in the thoracic bladder - through the pleural empty space. Fistulas are cancerous, traumatic, infectious and pislyoperative.

low aorta. Aorta descendensє the third form of the aorta. Vaughn go to the chest and neck. Breast aorta, aorta thoracalis, Stretch from IV to XII thoracic ridge. At the level of the XII thoracic ridge, the aorta through the aortic opening with diaphragms, hiatus aorticus, Ide in the open space behind the belly. The thoracic aorta is right-handed between the thoracic duct and the unpaired vein, the sinus is with the unpaired vein, in front is the pericardium and the bronchus livium, and behind is the ridge. From the thoracic aorta to go through the throat to the organs of the thoracic emptying - the internal throat, rami visceralis, І pristіnkovі gіlki, rami parietales... 9-10 pairs of intercostal arteries are applied to the wall arteries, aa. intercostales.

Introduce to the internal tubes:

1. Rami bronchiales- bronchial blood vessels - in the number 2-4, partly to supply blood to the bronchi and lungs.

2. Rami oesophageae- to the stravohode of the artery - in the number 4-7, to supply blood to the stravohode.

Z. Rami pericardiaci- the heart bag spouts will pump blood into the back wall.

4. Rami mediastinales- mediastinal spines - supply blood to lymph nodes and cells of the posterior middle.

unpaired Vienna, v. azygosє bezposredny advances of the right upper cross vein, v. lumbalis ascendens dextra... Vaughn, having passed between the inner and middle diaphragms in the rear middle, go up the hill and move the right-handed man through the aorta, thoracic duct and til ridges. On its way, there are 9 lower midcostal veins of the right side, as well as a vein to the stravohode, vv. oesophagea, Posterior bronchial veins, vv. bronchiale posteriores, 1st veni of the rear middle, vv. mediastinales posteriores... On the IV-V thoracic ridges, the vein is unpaired, bending around the right root of the lung backward in front, to bend into the upper empty vein, v cava superior... You can fall into the right at the front of the heart, into the right-sided vein, into the right-hand unchangeable vein, into the left-sided vein, or into the left-hand empty vein with sinus inversus.

semi-unpaired vein, v. hemiazygos- it appears to the continuation of the left side of the cross vein, v. lumbalis ascendens sinistra, Penetrating through the slit-like opening between the inner and middle diaphragms and heading to the rear middle. Vona yde behind the thoracic aorta, far up on the left sides of the til ridges and a large part of its intercostal veins on the left side.

The upper half of the intercostal veins emerge into the anterior vein, v. hemiazygos accessoria, The yaka should be poured into an unpaired vein. Rebaptism with an extra-paired vein of the ridge is found in different variants: at the level of VIII, IX, X or XI chest ridges.

Thoracic lymph duct... In the boundaries of the posterior middle, the sternum of the thoracic duct grows, pars thoracalis ductus thoracici From the aortic opening, open the diaphragms to the upper thoracic aperture. We warm the thoracic duct of the frog into the unpaired aortic groin, sulcus azygoaortalis... Close the diaphragms of the thoracic duct to cover the edge of the aorta, and in front of it, curl up the posterior surface of the stravohode. At the chest viddili in the new fall on the right and the evil of the mid-ribbed lymph judges, which pick up the lymph from the posterior viddle of the breast, as well as the broncho-medullary stovbur, truncus bronchomediastinalis, An open light from the organs of the half of the breast empty. Drive uphill to the III-IV-V thoracic ridge, the duct to rob the turn to the left to the left pidclavicular vein behind the stravohode, the aortic arch and distant to the VII thier ridge through aperture thoracis superior... Dovzhina of the thoracic duct reaches 35-45 cm with a diameter of 0.5-1.7 cm. Nybilsh is a thin thoracic duct in its middle part, on the level of IV-VI thoracic ridges. The thoracic ducts are promoted in the viglyad of one stovbur - monomagistral, the paired thoracic ducts are bi-magistral, the thoracic ducts are similarly split, or to fix one or two loops on their own way - the loops. Single, sub-loop and third-party loops and winding in some of the same loops are available. The blood flow of the duct is going to go behind the rakhunok of the gillok of the intercostal arteries and the arteries of the stravohode.

bloody nerves... Livy bloody nerve penetrates into the thoracic emptying in the gap between the hypogastric sleepy arteries and the lymphatic arteries and reclines the aortic arch anteriorly. On the edge of the lower edge of the aorta of the lions n. vagus viddaє livy rotary nerve, n.recurrens sinister, Yakiy oginaє arch of the aorta behind and turn to the area of ​​shia. The lower part of the bloody nerve trails along the posterior surface of the bronchus and far along the anterior surface of the tract.

The right bloating nerve enters the sternum emptying, growing into the gap between the right clavicular vessels - the artery and the vein. Leaning ahead of the clavicle artery, the bloating nerve viddaє n. recurrens dexter When I go back to the right side of the clavicle artery, I can also turn around. The lower right blokayuyu nerve pass behind the right bronchus, and then lie on the back surface of the stravohode.

The blue nerves on the stravochannel fit the loops and the stray strings, chordae oesophageae.

From the thoracic view of the blukus nerve to enter the following veins:

1. Rami bronchiales anteriores- anterior bronchial tubes - go along the anterior surface of the bronchus to the lung and form the anterior gossip with the jaws of a pretty near-cordon stovbur, plexus pulmonalis anterior.

2. Rami bronchiales posteriors- rear bronchial tubes - they also anastomose with the bells of a pretty near-cordon stove and enter into the gates of the leg, de-fix the back-end gossip, plexus pulmonalis posterior.

3. Rami oesophagei- to the stravohode of the head - on the front surface of the stravohode to form the front stravohode of gossip, plexus oesophageus anterior(For the rakhunok of the left bloody nerve). Analogous gossip - plexus oesophageus posterior(For the rakhunok of the right bloating nerve) - to grow on the back surface of the stravohode.

4. Rami pericardiaci- heart bag spikes - go in with other spikes and inner bag.

cute stoves. Truncus sympathicus- the guy will learn - roztashovutsya from the side of the ridge. From the organs of the posterior middle of the wines, the most lateral and іdpovіdaє to the level of the rib heads.

Kozhen vuzol of the prikordon stovbur, ganglion trunci sympathici s. vertebrale, Viddaє bіla with a received gіlku, ramus communicans albus and I will have a good drink, ramus communicans griseus... The spinal cord is represented by mid-center pulpy nerve fibers that pass through the anterior cortex, radix anterior, To klin ganglion vertebrale... Ci fibers are called before nodal fibers, fibrae praeganglionares... Sira is a spoluchna gilka, ramus communicans griseus Carry the serenity of the fibers ganglion vertebrale and go to the warehouses of the spinal nerve. Fiber is called post-knot fibers, fibrae postganglionares.

middle(Mediastinum)

It is a space filled with a complex of organs (heart with pericardium and cardiac vessels and other organs). Organize the middle of the otocheny cells.

ahead the middle is surrounded by the sternum and partly by the cartilage of the ribs, covered with the intrathoracic fascia.

behind it is surrounded by a thoracic ridge ridge, ribs, which are covered with an intrathoracic (prevertebral) fascia.

bichnimi With the walls - go directly into the sagittal leaflets of the intrathoracic fascia and adjoin them to the middle part of the parietal pleura (Fig. 1).

lower The middle point is set by the diaphragm and the diaphragmatic fascia.

upper the middle point is to become around the fascial strains and leaves, rostatovanii between organs and vessels and upper part parietal

fascia of the breasts - membrana suprapleuralis - on the level of the upper aperture of the breast cell.

Upper middle (mediastinum superius)

At the beginning of the process of growing: the thorny lobe and the surplus, the upper head veins, the extra-cardiac parts of the upper empty vein, the endless part (throat) of the unpaired vein (v.azygos), which falls into the upper part of the right vein at the IV intercostalis superior dextra (v. intercostalis superior dextra); evil coils of pre-paired veni (v. hemiazygos accessorius); arch of the aortic and thigh artery (brachiocephalic artery, livaya zagalnaya sleepy and liva pidclinic artery), diaphragmatic and blunt nerves, pericardial-diaphragmatic artery and vein, livial nerves rotational palatine artery parts of the stravohod.

Thymus

Reachє its maximum development in childish... For the statistic maturity, the growth will develop, and the process of innovation will be repaired up to 25 times, so that it will be replaced with fatty tissue.

The thymus is made up of two parts - right and left, with a rikhloi with good cloth... Roztashovuєtsya out in the upper Interpleural gap of the upper middle. Children of early age have the reach of the isthmus of the thyroid gland and the superior space of the shia. In older people, as a rule, the shinny viddil zalozi vidday. The replacement of the thymus zone of the clytkina is made with a thin fascial case, we will tie it with the fascial grooves of the great sudins, the costal-mediastinal folds of the pleura and the intrathoracic fascia. Behind the thymus, there is a rosette of the upper head and shoulder veins, the arch of the aorta and the head, below is the pericardium.

Blood is supplied to the thymus zalosa for the rakhunok of the right and left inner chest, lower thyroid arteries and brachiocephalic stool.

During the day, they fall into the inner chest, shoulder head and lower thyroid veins.

Lymphatic cannabis go to lymphatic universities, roztasvani behind the sternum. It is innervated by the throats of the bloody and sympathetic nerves.

Shoulderhead veins (vv. Brachiocephalicae)

roztasovany in upper viddili of the upper middle, pretending to be the path of evil of the inner jugular and subclavian vein in the prelude to the shia.

Skeletotopic examination of the brachiocephalic veins is visible from the posterior surface of the sternocleidomastoid joint. The lva brachiocephalic vein is brought to the right, where the evil is to the right, from top to bottom, in front of the great sudins, which comes out of the arch of the aorta and behind the handle of the sternum. The right brachiocephalic vein is shorter than the left one, pass vertically up to the level of the cartilage attachment of the first right rib to the sternum, get angry from the left and open the upper empty vein (v. Cava superior) (Fig. 3).

Lower edge v. brachiocephalica sinistra was added to the rosette back and forth from the aorta. Behind the veni pass: on the right - truncus brachiocephalicus, zilova - a. carotis communis sinistra, more or less - a. subclavia sinistra.

At the cells of the back of the right brachiocephalic vein, pass the item Vagus dexter.

In children of early age, the brachiocephalic vein can be removed by 1.5-2.0 cm in the jugular branch of the sternum handle, in the superior space, as a memory for the lower tracheostomy.

In the coffin, statements about the brachiocephalic veins, or in the left brachiocephalic vein, in the part of the vipads, the lower thyroid vein falls, where the isthmus of the thyroid gland falls.

extracardiac parts v Upper empty veni It is a wide and short stovbur with a length of 3-4 cm. Vaughn set up on the level of the I right sternocostal joint, go down and at the height of the II mid-ribbed prominence enter the empty pericardium. Before that, the upper void vein is curled by the pericardium, there is an unpaired vein in itself, and the right upper intercostal vein (v. Intercostalis superior dextra) falls into the left, to pretend to be angry three upper right back veins.

Back and forth to the extracardiac appearance of the upper empty vein of the trachea.

on right v. cava superior lie down to the right middle of the pleura.

Between the veins and the middle of the pleuroses, pass the item Phrenicus dexter et vasae pericardiac-phrenici.

evil to the upper empty vein on the arch of a small protrusion, the cob part of the aortic arch (immediately when the pericardium is empty).

behind a part of the upper empty vein, in the cells to pass the right bloody nerve.

Destruction of the blood stream along the upper empty vein can occur with thrombosis, with puffins in the upper middle (thymoma, bronchogenic cancer of the right leg), with aneurysm of the aortic arch. It is manifested in viglyadi syndrome of the upper empty vein: top kintsivok... Noses and bleeding are not common. Stagnation of blood in the veins is manifested in swelling (Stokes symptom, Sabat symptom).

When the upper empty vein is slowed down, the veins of the venous flow develop towards the head and the upper tips for the expansion of the veins of the pedicle and groin veins (v. Thoracic v. Thoracica laterala, v. Thorac. Behind it, the roof goes down, to the anterior wall of the abdomen, and then for the opening of the cava-caval anastomoses, it is consumed in the system of the lower empty vein and unpaired vein, through which venous blood comes to the right front of the heart.

Arch of the aorta (arcus aortae)

Є continuation of the visual aorta. Make a straight line from right to left and from front to back. At the level of the IV thoracic ridge, it spreads over the bronchial tubes, reaching the anterior surface of the ridge and passing into the lower part of the aorta.

Pochatkovy and kintseviy arches of the aortic arch over the costal-mediastinal pleural sinuses.

from upper to enter the surface of the aortic arch (from right to left): brachiocephalic stovbur (truncus brachiocephalicus), liva zagalna sleepy artery(A. Carotis communis sinistra) і liva subclavicular artery (a. Subclavia sinistra). In 5-10% of the vipads from the aortic arch, there is the lower artery of the thyroid cavity (a. Thyroidea ima), which goes vertically up to the isthmus of the thyroid cavity.

Front The middle of the arc is the vilny one of the pleurisy, the edge of the forks and the rickets, the lymph nodes are in the middle.

In front і zlyvaїї loosening nerve. Here, there is a pivotal nerve, like the arch of the aorta below and behind. The name of the bloody nerve passes through the phrenic nerve and vasa pericardiac-phrenica.

below, Pid the arch of the aorta, roztashovuatsya the rights of the Legend's artery.

On the anterior surface of the aortic arch of the navpak, there is a place where the arterial ligament is attached, lig. arteriosum, which is an obliteration of the arterial (botal) duct.

The fetus wines pov'yu legeneviy stovbur with the aorta. Until the moment of the populace of the child, the duct grows overgrown, replacing it with an arterial ring. Children of such a growth cannot be found, and a defect of the heart is the unbroken duct of botals. When accessing the duct without overgrowing with the help of a ligation, the diaphragmatic nerve, which passes 1-2 cm before the arterial ligament, is arranged with the help. Immediately, the botalov lіmphatic vuzol arterіalnoї zyazyazki roztashovusya.

behind from the aortic arch lie the trachea, stravochid, thoracic (lymphatic) duct, pivotal nerve.

Topography of the aortic arch will explain the development of a whole series of symptoms in aneurysms (pathological enlargement) of the aortic arch. The aorta can squeeze the trachea and the trachea, rupture and dichotomize, and can also lead to a hoarse voice through the squeezing of the rotary laryngeal nerve.

Below and behind the aortic arch right-handed pass the right of the Legendary artery right up to the right of the legend.

Dilianka of the aorta is called the isthmus of the aorta before the transition to the deciduous aorta.

At the end of the day, aortic ulceration, called coarctation, can be seen. Most often, coarctation is natural. With a large amount of blood, the lower half of the body is lacking in blood, and the veins of the aortic arch expand. Collateral blood flow is through the system of subclavicular arteries. The leading role in a wide play is a. thoracica interna and go through its front inter-ribbed arteries, as well as a. thoracica lateralis. Coarctation of the aorta Danish hour is successfully absorbed by the surgical path.

At the same time, the transition of the aortic arch into the descending її ії ідділ is designed to take place at the level of the IV thoracic ridge. At the end of the mice, the aortic arch goes to the cob part of the left bronchus from front to back and from right to left.

At the circumference of the aortic arch and the lower part of the aortic-cardiac nerve expansion, the plexus is fixed by the jaws of both the bloating nerves and the sides of the sympathetic nerve burrows.

Shoulder-head stovbur, truncus brachiocephalics, є the first and the most prominent aortic arch. The shoulder-head stopper extends from the aorta approximately along the middle line and is projected onto the handle of the sternum. Then there is a direct fire and on the flats of the right sternoclavicular corner to continue on the right side of the clavicle and backward dream of the artery. Truncus brachiocephalicus rostashovana v. brachiocephalica dextra. The offense of the judge is on the right and in the front partly covers the middle of the pleurora.

Liva zhalna sleepy artery, a. carotis communis sinistra, ascending from the aortic arch by 1-1.5 cm to the left and from the back as seen from the shoulder-catching stovbur. Between the brachiocephalic trunk and the lateral sleepy artery, behind them, there is the trachea.

Liva is an artery, a. subclavia sinistra, the aortic arch is stepping on, it is possible to come in more of a sleepy one, more often than not. In the front, the middle of the pleurisy is curved.

Sounding or obstruction of one or more deciduous throats, when coming out of the aortic arch, manifests itself in the eyes of Takayasu syndrome (aortic arch syndrome or “aortic pain in the heartbeat”). The reason for this sound may be atherosclerosis or arteritis. With the sound of the clavicular artery, the mucous membrane atrophies, the bone is cold, arterial vise lowered, the pulse on the promenade artery of weakening abo vidsutniy. The breakdown of sleepy arteries, or spine arteries, which come in from the clavicular ones, manifest themselves with headaches, zapamorochennyam, dislocation of memory and zoru, hemiparesis.

Diaphragmatic nerves (nn. Phrenici)

Throat gossip penetrates into the upper middle, spreading between the clavicular vein and artery, lateral to the bloody nerves. In the upper third thoracic emptying of the right phrenic nerve, it grows between the upper empty vein and the right mediastinal pleura, the left nerve spins in front of the aortic arch lateral to the bloody nerve.

(It is important to see the diaphragmatic nerve from the bloody one, so as the stench on the other protrusion goes in parallel to one to one.

Thoracic part of the trachea (pars thoracica trachealis) pass at a vertical straight line, looking at the wedge to the right in the middle line. The upper boundary of the thoracic part of the trachea is designed on the edges of the sternum in front and the other thoracic ridge behind. The lower boundary of the rose of the sternum, and posteriorly - of the mid-spinal cartilage of the IV-V thoracic ridges. At the same time, the trachea extends into the right and left side of the bronchus.

behind trachea pass stravohid.

ahead the trachea is repressed by the aortic arch, passing through the vessels.

on right from the trachea there are the right middle of the pleurisy, the right bloating nerve and the brachiocephalic stovbur.

evil- enduocystis of the aortic arch, livy rotary nerve, livia posterior sleep and subclavicular artery.

Similar information.

TOPOGRAPHY ORGANIV middle

Meta tsiy nauchalnogo posibnik - viclast of the frost-freezing of organs of breast emptying, seeing topographic features, which is of interest for setting a clinical diagnosis, as well as giving an understanding of the main problems in the middle of the day.

Seredostinnya - a part of the thoracic emptying, roztashovana between the thoracic ridges behind, the sternum in front and two leaves of the mediastinal pleura laterally. At the top, the middle is surrounded by the upper aperture of the breast plate, at the bottom - by the diaphragm. Obsyag і form of the vastness of the wandering at the dichanna і for a quick heart.

With the help of a lodging, I will describe the mutual development of the surrounding organs in the middle of the period, taken into parts. Moreover, in conjunction with this, the daytime observational anatomical and physiological between the various parts, in new literary dzherels, try to be reasonable.

In the surroundings of the handcuffs from the systemic and topographic anatomy, two middle areas are seen: anterior and posterior. Cordon between them є frontal area, drawn through the root of the lung.

In the case of handlers from surgery, it is possible to establish a middle ground on the right and left. At the same time, you will lie down to the right mediastinal pleurisy, above all, venous judgment, and to the left - arterial.

It’s an hour to stay in the anatomical and clinical literature most often to learn to describe the organs of the breast emptying at the connection with the upper and lower mediastinum; Ostannim, v. his curry, p_drozd_lyaєtsya on the front, middle and back. Such a reason is to be found in the view of the international anatomical nomenclature of the last glance and is laid down in the basis of the material in this methodical book.

UPPER SHEDOSTENIE (mediastinum superior) - space, spread between two leaves of mediastinal pleurisy and surrounded from above by the upper aperture of the breast cage, below - by the area, held between the cut of the sternum and the quadruple.

The key structure of the upper "middle" - the aortic arch (arcus aonae). Vona repair on the edge of the other right sternocostal joint, go uphill, approximately 1 cm, arched to the left side, often descend to the bottom three aorta Three great judges appear on the side of the aortic arch (Fig. 1, 2).

1.brachiocephalic stovbur (truncus brachiocephalicus) - to enter the upper edge of the cartilage of the other rib and go up to the right sternoclavicular joint, to expand to the right back of the sleep and on the key artery.

2. Liva zalnaya sleepy artery (a.carotis communis sinistra) - take the ear of evil from the brachiocephalic stool, head to the left sternocleidomastoid artery і dalі triva.

3. Liva subclavian artery (a.subclavia sinistra) - from the mice of your ear through the upper aperture of the breast to enter the shia.

In front and right-handed from the arch of the aorta, the following structures are formed:

A thorny gland (tymus), which is stored in two parts and goes out from the handle of the sternum with a retrosternal fascia. The maximum "growth of the thymus" can be reached in children, and then there is an evolution.

Shoulder-head veins (vv. Brachiocephalicae) - lie behind the thymus. The judgment is formed in the lower part of the body as a result of the evil of the internal jugular and subclavian veins. Liva brachiocephalic vein is three times to the right and overflows the upper middle from top to bottom, left to the right. At the right edge of the sternum, on the ryvny cartilage of the first rib of the brachial head, veins get angry, as a result of which an upper empty vein is formed;

Upper empty vein (v. Cava superior) - to go down the bridle to the right edge of the sternum to the other middle, de entering the empty space of the pericardium;

Right diaphragmatic nerve (n. Phrenicus dexter) - go into the upper middle through the right side veins and artery, the bridle of the lateral surface of the brachial head and upper empty leg veins go down;

Shoulder lymph nodes (nodi lymphatici brachiocephalici) -tacked in front of the same veins, pick up lymph from thymus and thyroid glands, pericardium.

In front of and from the arch of the aorta, it is shattered:

Liva upper intercostal vein (v. Intercostalis superior sinistra), take shelter from the upper three intercostal spaces and flow into the left brachiocephalic vein;

Livy diaphragmatic nerve (n. Phrenicus sinister) - go into the upper middle in the middle of the middle, with the backward sleepy and clavicular arteries, fluttering backwards to the left brachial vein, and then the frog in the front;

Livy bloody nerve (n.vagus sinister) - lies down to the aortic arch and overflows with the phrenic nerve, spreading backwards.

Behind the aortic arch, it grows: - the trachea (trachea) - pass at a vertical straight line, facing the right side of the middle line. On the level of the fourth thoracic ridge, the trachea grows into two head bronchi;

Stravohid (oesophageus) is in direct contact with the right mediastinal pleura, spreading backwards from the trachea and from the sides of the ridges, from which one appears to the pre-vertebral membrane and intravertebral tissue;

The right bloating nerve (n. Vagus dexter) - to enter the upper middle in front of the clavicular artery, at the lower edge of the i-th coast of the ear, the right rotational laryngeal nerve. Then n.vagus posteriorly of the brachioral vein to go to the lateral trachea, which leads to the root of the leg;

Livy rotary laryngeal nerve (n. Laryngeus recarrens sinister) - to repair from the bloating nerve, from the bottom of the aortic arch, and then in the boron between the trachea and the trachea to go to the shia. Growth of the laryngeal nerve in case of aneurysm of the aortic arch, or in case of syphilic infection, it is clear that such ailments have a hoarse voice and it was tough not to have a dry cough. Other symptoms can also be associated with lung cancer in connection with nerve tears with lymph nodes in the growths.

Thoracic duct (ductus thoracius) - to pass through the pathway from the stray duct and in the area where it flows into the venous cut (the place of the internal jugular and subclavicular veins);

Paratracheal lymph nodes (nodi lymphatici paratracheales) - rots around the trachea and picks up the lymph from the upper and lower tracheobronchial lymph nodes.

The anterior middle (mediastinum anterior) is folded in front of the pericardium and is surrounded at the top by a flat area, from the bottom edge of the sternum from the lower edge of the fourth thoracic ridge, below - by the diaphragm, in front - by the sternum. To take revenge in your warehouse:

Near-ore lymph nodes (nodi lymphatici parasternales) - rots along the a. thoracica interna і take lymph from the milky zone (medial lower quadrant), the upper third of the anterior abdominal wall, glib structures of the anterior thoracic wall and upper surface of the liver;

-
upper diaphragmatic lymph nodes (nodi lymphatici superiores) - are located at the base of the sword-like sprout and pick up the lymph from the upper surface of the liver and the anterior diaphragm.

Z
Rare middle (mediastinum medium) - including the pericardium, right and left phrenic nerves, pericardial phrenic arteries and veni.

Pericardium (pericardium) - folds into two leaves: outer - fibrous (pericardium fibrosum) and internal - serous (pericardium serosum). At its core, the serous pericardium is divided into two plates: the parietal one, whistling in the middle of the fibrous pericardium and the visceral one - curving the judgment and the heart (epicardium). Vilny space between two plates of pericardium serosum is called pericardial emptying and in the norm is reserved for a small number of serous ridinia.

At the warehouse of the pericardium, there is a relocated lower structure.

The heart (cor), which is designed on the front surface of the breasts, between the chotirma points, rosette: perch - on the cartilage of the right third rib in 1 - 1.5 centimeters from the edge of the sternum; a friend - on the ryvny cartilage of the left third rib, 2 - 2.5 centimeters from the edge of the sternum; the third - on the level of the right sternocostal joint; and the fourth - in the fifth mid-rib at the distance of 1 - 1.5 centimeters in the middle of the left midclavicular line.

Visible part of the aorta (pars ascendens aortae) - to repair from the left slunk on the ryvni cartilage of the third rib, from the sternum, go up the hill to the cartilage of the other rib, before going out from the empty to the pericardium.

The lower segment of the upper empty vein, when I am going to enter, into the pericardium at the level of the 2nd mid-ribs ends in the right anterior.

Legeneviy stovbur (truncus pulmonalis) - to repair from the right duck and go from right to left, from front to back. In this case, the trunk is located ventrally, and then a spike is located in the upper part of the aorta. Behind the pericardial boundaries, to the bottom of the aortic arch, there is a bifurcatio trunci pulmonalis. Repairs in a whole lot of legacy arteries are directed to the legacy. At the same time, the Legend's artery passes in front of the lower part of the aorta, right - behind the upper empty vein and the upper part of the aorta. The bifurcation of the legendary stovbur sits behind the lower surface of the aortic arch behind the auxiliary arterial ligament, which is a functional vessel in the fetus - the arterial (Botalov) duct.

Legenevi veni (vv. Pulmonales) - go into the empty pericardium without a bar when going out of the lung and end in the left front of the heart. At a number of two right legenevia, pass from the back to the upper empty vein, two livi - ventrally to the lower part of the aorta.

The diaphragmatic nerves in the middle middle pass through the right and left medial pleura from one side and the pericardium - from the other. Nerves supervise pericardiophragmatic vessels. Arteries - є gilkami internal chest arteries, veins - tributaries w. ihoracicae, internae. According to the international anatomical nomenclature, two sinuses are seen in the pericardial empty space:

It is transverse (sinus transversus), surrounded in front by the aorta and a Legeny stovbur, at the back - by the foreheads, by the right Legeny artery and the upper empty vein (Fig. 4);

The scythe (sinus obliquus), surrounded in front by the front of the eyes, behind by the parietal plate of the serous pericardium, from the top and the evil - by the leg veins, from the bottom and right-handed - by the lower empty vein (Fig. 5).

In the clinical literature, the third pericardial sinus is described, rosted in the middle of the transition of the anterior to the lower.

The posterior middle (mediastinum posierius) is surrounded by the back of the fifth-twelfth chest ridges, in front - by the pericardium, laterally - by the mediastinal pleuro, from below - by the diaphragm, from above - by the area of ​​the lower chest edge. The key structure of the posterior middle є is the decaying part of the aorta (pars desdendens aortae), which lies on the left side of the ridges, and then moves to the middle line (Fig. 6). From the lower part of the aorta to enter the attack of the judgment:

Pericardial gilki (rr. Pericardiaci) - to bleed the posterior part of the pericardium;

Bronchial arteries (aa. Bronchioles) - blood flow to the wall of the bronchi and to the legene tissue;

Stravohidnі arterії (aa.oesophageales) - blood sucking the wall of the thoracic viddіlu stravohodu;

Mediastinalnyh gilki (rr. Mediastinales) - blood flow to lymphatic universities and to the full tissue of the middle;

Rear intercostal arteries (aa. Inrercosiales posreriores) - pass through the intercostal spaces, blood flow to the spine and the spinal cord, spinal cord, anastomoses - to the anterior intercostal arteries;

The upper diaphragmatic artery (a. Phrenica superior) is located on the upper surface of the diaphragms.

Near the lower part of the aorta, the following structures develop.

Right and left head bronchi (bronchus principalis dexter et sinister) - repair from the bifurcation of the trachea on the lower edge of the fourth thoracic ridge. Livius head bronchus enters at 45 ° along the mid-area and go Behind the aortic arch up to the leg. The right cephalic bronchus extends from the trachea along the 25 ° cut along the extension to the middle area. It is shorter than the head bronchus and is larger in diameter. The setting explains in a meaningful way the more frequent occurrence of third-party objects in the right bronchus in normal conditions.

Stravohid (oesophageus) - lying with a hand behind the left atrium and right-handed from the lower part of the aorta. At the lower third of the mediastinum, the stravochid intertwines the aorta in front, to move from it to to the left sideі It starts in the boundaries of the stravochid tricycle, the boundaries of which є: in front of the pericardium, behind - the decaying part of the aorta, below - the diaphragm. On the anterior and posterior surfaces of the stravohode, there is a stravohode of gossip (plexus oesophagealis), in the form of which two bloody nerves take part, as well as the throat of the thoracic universities of a pretty stovbur.

With roentgenologic and endoscopic dosages, a number of thoracic sounds appear in the stravohode, tied together with a strong interconnection of the stigma with suspicious organs. One of them is the dusi aorta, and the second is the mismatch of the stratohode from the head bronchial tubes. The enlargement of the frontal frontal part can also be used to improve the education of the stravohode when the radiopaque contrast of speech is stored.

Unpaired Vienna (v. Azygos) - repaired in a deep vein, pass in the rear middle right-hander from til ridges to the level of Th4, the right head bronchus and an empty vein in the empty pericardium pose. By tributaries, all the rear inter-ribs on the right side, as well as bronchial, strato-duct and medical veins.

Semi-unpaired vein (v. Hemiazygos) - to be repaired in the umbilical space. At the posterior middle, pass behind the lower part of the aorta, at the level of the 7-8th thoracic ridge, go to the right and fall into the unpaired vein. By tributaries of unpaired veins є five lower (livi) intercostal veins, stravohode, mediastinal, as well as dodatkov semi-unpaired veins.

Dodatkov semi-unpaired vein (V hemiazygos accessoria) - descend from the left side of the spinal stump. She has 5-6 posterior (livi) intercostal veins.

Thoracic duct (ductus thoracicus) - to repair in the belly space. At the posterior middle, pass through the unpaired vein and the lower part of the aorta to the level of the second - the fourth thoracic ridge, then go to the left side, straddling the back of the stravochid and the lower part of the aorta.

Operations on the organs of the middle to follow the advance indicators:

1. Thymus, thyroid and parathyroid swellings, as well as neurogenic swells.

The swelling of the thymus most often grows in front of the aortic arch and in front of the heart. It is even early to prevent infection of cych puffins in the wall of the upper empty vein, pleura and pericardium. Dilution of the left brachiocephalic and upper empty veins by the time of the frequency of borrowing another place due to obstruction of cychsudin by metastases in lung cancer.

With a retrosternal goiter, the thyroid tissue on the thyroid gland most often grows in the gap, organically from the bottom we rule the head bronchial tubes, laterally - the mediastinal pleuroy, in front - the upper empty vein, medially - we rule the flabby nerve, the tracheal part.

Puffs of neurogenic nature are the most common middle puffs. Even more stinks are tied from the rear middle and formed from a cute stove or mid-ribbed nerves. At a number of vipadkiv, the chickens appear on the ground, and then go down to the upper middle. At the junction of the time, the swelling is formed close to the spinal openings, the stench can enter the spinal canal, causing pressure to the spinal cord.

Yak can be accessed promptly when you see the middle of it.

Lower shiyny rozriz;

Middle sternotomy;

Mіzhreberna torokotomy.

2. mediastinitis. It is formed, as a rule, as a result of the broadening of infection from the kitchen spaces, or when perforating the strand.

Roztin and the drainage of the upper midline rise through the arc-like opening of the shoulder on the shoulder above the sternum handle (supra-sternal mediastinotomy) by the way of the root canal behind the sternum. Razrіz can be carried out by means of the anterior edge of the sternocleidomastoid nipple-like muscle with the further growths of the neurovascular bundle or along the pathway of the cellular tissue space.

Drainage of the anterior midline is established through the development of the midline of the anterior abdominal wall. Roztin gn_ynika zd_dysnyuєtsya roztinu diaphragms, without damaging the integrity of the queue.

Roztin gnіynikіv of the rear middle, go from the side of the black emptying (transabdominal mediastinotomy), for the display of bichnіy torokotomiі in the VII lіvіvnі mezhreberi (transpleural medіastin).

3. Pericarditis. It is characterized by inflammation of the visceral and parietal plates of the serous pericardium, vines as the inheritance of bacterial or viral infections, rheumatism or uremia. Pericarditis can be produced to the tamponade of the heart. With the help of a visualization of the tamponadi, the puncture of the pericardium (Larrey's method) is observed.

For a sick person in a sitting position, a head is injected into the cut between the sword-like growth and the cartilage of the ribs. Moreover, the head is arranged perpendicularly to the surface of the anterior abdominal wall.

4. Wounded heart. Wound suturing is carried out by vuzlovy (line wound) or U-shaped (lacerated wound) suture sutures, endocard and coronary heart disease. The edges of the pericardium are closed with loose sutures, the pleural empty space is drained.

5. Krim pererakhovanih vipadkiv, surgery on the organs of the middle to vikonuyutsya:

For bleeding, due to trauma, or for the correction of abdominal defects (stenosis, aneurysm);

In case of swelling, injuries, or vrogenih wads, the development of the stravohode;

With the drive of inconvenient and overwhelming hearts, as well as with hospitals and chronic coronary deficiencies.

14.1. CORDONU TA BREAST AREA

Breasts - the upper part of the tulub, the upper border, which runs along the edge of the jugular vius of the sternum, clavicle and distant along the line of acromioclavicular slopes to the top of the spinous ridge of the VII ridge. The lower border runs along the base of the sword-like outgrowth of the sternum along the edges of the costal arches, the anterior ends of the XI and XII ribs and along the lower edge of the XII ribs to the spinous outgrowth of the XII chest ridge. In the breasts, the chest wall and the chest empty.

On the chest wall (anterior and posterior), there is an onset of the topographic and anatomical areas (Fig. 14.1):

The pre-breast area, or the anterior mid-area of ​​the breasts;

Breast area, or the front upper breast dilyanka;

The sub-chest region, or the anterior lower region of the breasts;

The spinal region, or the back middle region of the breasts;

Lopatkova area, or the back upper dilyanka of the breasts;

The subscapularis region, or the posterior lower region of the breasts. The remaining three areas of international anatomical terminology refer to the areas of the back.

Breast emptying - the whole of the internal space of the breasts, between the intrathoracic fascia, which whistles the breast tissue and diaphragm. Take revenge on the middle, two pleural empty spaces, right and left easy.

To the base of the warehouse is the breast cage, fixed by the sternum, 12 pairs of ribs and the thoracic ridge of the ridge.

Small. 14.1. Breast areas:

1 - pre-breast area; 2 - right chest area; 3 - liva chest area; 4 - right chest area; 5 - liva chest area; 6 - ridge area; 7 - liva lopatkova area; 8 - right scapular area; 9 - liva pidlopatkova region; 10 - the rights of the pidlopatkiv region

14.2. CHEST WALL

14.2.1. Pre-breast area, or the anterior mid-area of ​​the breasts

Mezhithe pre-breast area (regio presternalis) leads to the cordon in the projection of the sternum.

Names of the organization: the handle of the sternum, only the sternum, the sternum kut, the sword-like growth of the sternum, the jar of the handle of the sternum.

Shari.The skin is thin, nervoma, innervated by the head of the supraclavicular nerves. pidshkirna fatty cells it is not rotated, in ny roztashovani pedshkirni veni, arteries and nerves. The superficial fascia grows from the hairy fascia, yaka has the character of the cleft aponeurotic plate, which is folded over the sternum.

Arteries, veni, nerves, lymphatic universities. The inner thoracic artery passes through the sternum edge and grows on the posterior surface of the rib cartilages. Vona anastomoses with the intercostal arteries, superimposes the same veins. Along the course of the internal chest vessels in the mid-ribs of the rostasovani, the near-chest lymph nodes.

14.2.2. Chest area, or anterior upper region breasts

Mezhichest area (Regio pectoralis): the upper - the lower edge of the clavicle, the lower - the edge of the III rib, median - the edge of the sternum, lateral - the anterior edge of the deltoid meatus.

Names of the organization: clavicle, ribs, mid-ribs, rostral ridge of the scapula, lateral edge of the great thoracic meatus, pidclavicular fossa, anterior edge of the deltoid-like ossicle, deltoid-thoracic groove.

shari(Fig.14.2). The skin is thin, loose, taken into a fold, appendages of the skin: sweat, oily hair, hair follicles. The innervations of the shkiri are connected by the throat of the supraclavicular nerves (the throat of the gossip), the nodule of the first-third intercostal nerves. The pidshkirna of the cell is weakly rotated, to avenge the venous hem (vv. Perforantes), the artery, to live the skin (aa. Perforantes), and the supraclavicular nerves of the lateral gossip, as well as the anterior and lateral nerves Superficial fascias to ave the fibers of m. platysma. Vlasna fascia of the breasts is represented by a thin plate, yak pass laterally into the groin fascia, and in the mountains it is confined to the superficial leaf of the vascular fascia. Fascia pokrivaє the great pectoral m'yaz, the front toothed m'yaz. Descending downward, the hairline fascia of the breasts goes over to the hairline fascia of the abdomen.

The great chest m'yaz is the first m'yaz ball. The step ball is a gliba of the fascia of the breasts, or the clavicular-thoracic fascia (to adhere to the coracoid ridge of the scapula, collarbone and upper ribs), as an example for the pelvic and small chest mucosa (other) brachial gossip in the area of ​​the clavicle and the coracoid appendage, represented by the cradle plate; at the lower edge of the great breast meat grows behind the hairy fascia of the breasts.

In this region there are two main areas. The superficial subpectoral cellular tissue space of the types is located between the great thoracic ointment and the clavicular-thoracic fascia, most of the collarbone, appearing from the groin groin depressions. Glyboka subpectoral cellular space is rosted between the posterior surface of the small breast tissue and a lumpy leaf of the clavicular-thoracic fascia.

Small. 14.2.The scheme of the spheres of the thoracic region on the sagittal vision: 1 - shkira; 2 - pidshkirna klitkovina; 3 - surface fascia; 4 - milky salty; 5 - hairy fascia of the breasts; 6 - great chest m'yaz; 7 - interthoracic cellular space; 8 - clavicular-thoracic fascia; 9 - key-clutch mu'az; 10 - malium breast m'yaz; 11 - subpectoral cellular space; 12 - call of mezhreberna m'yaz; 13 - inner mid-ribbed m'yaz; 14 - intrathoracic fascia; 15 - prepleural cell; 16 - parietal pleura

Arteries, veni and nerves. Gilka bichny thoracic, intercostal, internal thoracic and thoracic acromial arteries. Arteries supervise the same veni. The muscles are innervated by the veins from the lateral and medial thoracic nerves and the cerebral veins of the brachial vertex.

lymphatic vidtik in the chest, groin and near-chest lymphatic universities.

14.2.3. Topography of inter-regional industries

Mіzhrebernyh promіzhok - the space between the arched ribs, surrounded by the zoni thoracic fascias, from the middle - the inner

breast fascia; take revenge

external and internal intercostal mucosa and intercostal nerve bundle (Fig. 14.3).

The name of the mid-rib cartilage is in the middle of the rib cartilage from the back to the rib cartilage in front, from the rib cartilage to the sternum and the aponeurosis, right to the muscle fibers - obliquely from top to bottom and forward. Internal inter-ribbed joints go from the grooves of the ribs to the sternum. M'yazov_ fibers can be drawn in a straight line - from bottom to top and back. Between the callous and the inner mid-ribbed muzzles, the cells grow, in which the inner mid-ribs and the nerves grow. Between the ribs and the nerves go along the lower edge of the rib from the rib cage to the middle groin line in the rib furrow, far away the rib-nerve bundle is not preyed by the rib. The most prominent position is the intercostal vein, the artery lies below it, and the lower part is the intercostal nerves. I look at the position of the neurovascular bundle, the pleural puncture must be carried out in the eighth-eighth mid-ribbed positions.

Small. 14.3.Topography of inter-regional industries:

I - rib; 2 - mіzhreberna vein; 3 - mіzhreberna artery; 4 - intercostal nerves; 5 - inner midgeburn m'yaz; 6 - call of the mezhreberna m'yaz; 7 - easier; 8 - visceral pleura; 9 - parietal pleura; 10 - empty pleurisy;

II - intrathoracic fascia; 12 - own breast fascia; 13 - anterior toothing m'yaz

di middle groin line, without middle at the upper edge of the lower rib.

Behind the internal intercostal mucus of rosetting there is a small ball of fluffy cotchinoid, distal - intrathoracic fascia, prepleural cotkovina, parietal pleural leaf.

The peculiarities of the anatomical budov and topography of the mid-ribs are more important than the clinically significant ones, as it is often the case for pleural puncture and thoracotomy (breast emptying) during operations on the leggings.

14.3. KLINICHNA ANATOMIYA dairy zolozi

Milk salmon grows in females on the edges of the III-VII ribs between the parasternal and anterior groin lines. Behind Budova milky zloza є folding alveolar zloza. It is stored in 15-20 parcels, separated and divided by the superficial fascias, from the top of the phyxus to the collarbone with an appendage. Particles zolozi roztashovuyutsya radially, vividny ducts go along the radii to the nipple, then end with openings, fixing in front of the viglyadny ampoules. In the area of ​​milk formation, there are a number of spheres of the cellulite: between the skin and the superficial fascia, between the leaves of the superficial fascia, between the posterior leaf of the superficial fascia and the pulmonary thoracic fascia. With glib balls, the shkiri zaliza is tied up with metal fabric partitions.

bloodstendingmilk frogs are seen from three dzherel: from the inner thoracic, lateral thoracic and intercostal arteries.

venous vidtikfrom the surface parts of the vein, enter into the pedicle venous border and into the groin vein, from the tissue glibok_ veni, Yaki supervodzhuyut znacheni vische arterii.

Innervation.Shkira in the area of ​​the dairy zone is innervated by the throat of the supraclavicular nerves (throat gossip), the throat of the other intercostal nerves. The innervations of the tissue are covered with the throats of the first-fifth intercostal nerves, the supraclavicular (the spine gossip), the anterior pectoral nerves (from the brachial gossip), as well as the fibers of the pretty nerves, which are within the reach of the blood vessels.

way to limfovidcurrent (Figure 14.4). Lymphatic lymph nodes and regional lymph nodes in the milk field may be more important than the clinically important, the first for all the way to metastasize the cancer of the milk field. In the hallway, there are two lymph heels - the surface and the side, tightly knitted between themselves. Introduce lymphatic judges from the lateral viddila zalozi head to the groin

Small. 14.4.The lymph flow from the milk frog (c: Peterson B.E. ta in., 1987):

I - post-chest lymph nodes; 2 - near-chest lymph nodes; 3 - interthoracic lymph nodes (Rotter); 4 - lymphatic judges to the universities of the epigastric period; 5 - Bartels' lymphatic university; 6 - Zorgius's lymphatic university; 7 - pediatric lymphatic universities; 8 - lateral groin lymph nodes; 9 - central educational institutions; 10 - multi-key lymphatic universities;

II - supraclavicular lymphatic universities

lymphatic universities, while in most cases, there are lymphatic universities and universities (Zorgius), rostasovanim on the lower edges of the great breast on the ribs. ci

universities in case of breast cancer are treated earlier. Od upper vіddіlu zalozi vіdtіk lіmfi vіdbuvaєtsya perevazhno in pіdklyuchichnі i nadklyuchichnі and takozh pahvovі lіmfatichnі vuzli, od medіalnogo vіddіlu molochnoї zalozi - in okologrudіnnaya lіmfatichnі vuzli, roztashovanі downstream vnutrіshnoї grudnoї arterії i Veni, od Lower vіddіlu zalozi - in lіmfatichnі vuzli i sudini predbryushіnnoy cells in sub-phrenic lymph nodes. From the big balls, the lymphatic ones go to the lymphatic universities, they grow up between the great and small breast muscles.

With breast cancer, you can see the onset of the metastases:

Pectoral - in paramammary and dal in the groin lymph universities;

Pidklyuchichny - in pidklyuchny lymphatic universities;

Parasternal - in the vicinity of the lymph nodes;

Postersternum - without middle lymph nodes, minayuchi parasternal;

Perekhresny - in the groin lymph nodes of the protylezhny side and in the milk zone.

14.4. Pleurisy and pleural emptying

Pleura is a serous sheath, rosted in the thoracic emptying on the sides towards the middle. In the dermal half of the breast emptying in the pleura, there is a parietal and visceral, or even Legenev, pleura. In the parietal pleura, the rib, middle and diaphragmatic parts are seen. Between the parietal and visceral pleuroses, a closed slit-like vozhninupleuria is established, or pleural voids, so that a small amount (up to 35 ml) of serous ribs and nasal flanks of the lung can be avenged.

Visceral pleura is lighter. At the root of the leg, the visceral pleura go into the middle part of the parietal pleura. At the bottom of the root of the lung, the tsei will pass through the legendary sound.

Mezhi.The very upper part of the parietal pleura - the dome of the pleura - goes through the upper thoracic aperture into the lower part of the sheath, reaching the ryvnia of the transverse protuberance of the VII shyny ridge.

In addition, the injury to the lower part of the shia can be superficially caused by pleurisy and pneumothorax.

The anterior pleurisy is the purpose of the transition of the costal part of the pleura to the middle. The front cordon of the left and right pleurisy, behind the sternum, on the level of the II-IV ribs, is stitched vertically, parallel to one to one. It grows between them up to 1 cm. The appendage and the lower level of the anterior cordon of the right and left pleura diverge, establishing the upper and lower interpleural fields. In the upper interpleural field in children, thymus growth is observed, in older adults - adipose tissue. In the lower one, the interpleural field is without middle to the sternum, lie down to the heart, cover with the pericardium. With percussion in the chih between the boundaries, an absolute heart dullness begins.

The lower boundary of the parietal pleura (Fig. 14.5) is repaired along the cartilage of the VI rib, heading downwards, called and in the middle, the VII rib, along the middle groin line along the X rib, on the shoulder blades of the XI rib

Pleural sinuses. From the pleural sinus, there is a loss of pleural emptying, the loss of the line of transition of one part of the parietal pleura into the insha.

Small. 14.5.Skeletotopia of pleurisy and legends: a - anterior view; b - the viglyad behind. Dotted line - pleural boundary; line - border of the leg.

1 - upper interpleural field; 2 - lower interpleural field; 3 - costal-diaphragmatic sinus; 4 - lower part; 5 - middle part; 6 - upper part

In the cutaneous pleural emptying, there are three pleural sinuses: costo-diaphragmatic (sinus costodiaphragmaticus), costo-mediastinal (sinus costomediastinalis) and diaphragmatic-mediastinal (sinus diaphragmomediastinalis).

The most important and clinically significant are costal-diaphragmatic sinus, expansion of the malignancy and on the right near the corresponding dome of diaphragms in the junction of the costal part of the parietal pleura into the diaphragmatic. Naybіlsh gliboky wіn back. It is easier not to enter into the sinus at the maximum expansion into the inhalation phase. Costal-diaphragmatic sinus is the most frequent method of performing pleural puncture.

14.5. KLINICHNA LUNG ANATOMY

In the cutaneous lung, the top and bottom, rib, middle and diaphragmatic surface are developed. In the middle of the surface, the gates of the leg grow out, and in the middle of the leg - the heart is depressed (Fig. 14.6).

Nomenclature of bronchogenic segments (Fig.14.7)

Liva legend is divided into two parts: upper and lower. The right legacy of the two interlobar gaps is divided into three parts: upper, middle and lower.

The head bronchus of the cutaneous lung extends into parts of the bronchi, from which the bronchi enter the 3rd order (segmental bronchi). Segmental bronchi at the same time with navkolishny tissue of the lung fix broncholegenic segments. Broncholegenic segment - a lung dilencus, in which a segmental bronchus is formed

Small. 14.6.Medial surfaces and gates of legends (from: Sinelnikov R.D., 1979)

a - liva legend: 1 - top of the legend; 2 - bronchopulmonary lymph node; 3 - right cephalic bronchus; 4 - the rights of the Legenev artery; 5 - Rebrov to the surface; 6 - right legenevia; 7 - ridge part; 8 - Legeneva link; 9 - diaphragmatic to the top; 10 - bottom edge; 11 - middle part; 12 - impressed in the heart; 13 - front edge; 14 - mediastinal part; 15 - upper part; 16 - mice pleurisy;

b - right to the legend: 1 - top of the legend; 2 - mice of pleurisy; 3 - mediastinal part; 4 - upper part; 5 - livi legenevia veni; 6 - upper part; 7 - impressed in the heart; 8 - heart virus; 9, 17 - spit virizka; 10 - the tongue of the legends; 11 - bottom edge; 12 - lower part; 13 - Legeny sound; 14 - bronchopulmonary lymph node; 15 - Rebrov to the surface; 16 - livy head bronchus; 18 - liva legeneva artery

Small. 14.7.Segment Legen (s: Ostroverkhov G.E., Bomash Yu.M., Lubotskiy D.N.,

2005).

a - Rebrov to the surface: 1 - upper segment of the upper part; 2 - posterior segment of the upper part; 3 - anterior segment of the upper part; 4 - lateral segment of the middle part on the right, upper-ovarian segment of the upper part of the mallet;

5 - medial segment of the middle part of the evil, the lower ovarian segment of the upper part on the right; 6 - upper segment of the lower part; 7 - medial basal segment; 8 - anterior basal segment; 9 - lateral basal segment; 10 - posterior basal segment;

6 - mediastinal surface: 1 - upper segment of the upper part; 2 - posterior segment of the upper part; 3 - anterior segment of the upper part; 4 - lateral segment of the middle part on the right, upper-ovarian segment of the upper part of the mallet; 5 - medial segment of the middle part of the evil, the lower ovarian segment of the upper part on the right; 6 - upper segment of the lower part; 7 - medial basal segment; 8 - anterior basal segment; 9 - lateral basal segment; 10 - posterior basal segment

arteries of the 3rd order. Segments are divided with semi-tissue partitions, in which there are intersegmental veins. The skin segment, the name of the one, as the image of the camp in the lung, there is no ordinal number, the same in both legends.

In legends, the upper and posterior segments can merge into one, upper-posterior (C I-II). It can also be located in the medial basal segment. In such cases, the number of segments in the legends changes to 9.

root of the legend(Radix pulmonis) - the structure of the anatomical statements, which are spread between the mediastinum and the gates of the lung, and the intermittent pleura. Before the warehouse of the root of the lung, enter the head bronchus, the Legenevian artery, the upper and the lower Legenevian veins, the bronchial arteries and the veins, the Legenevian nerve gossip, the lymphatic judges and the vuzli, Rikhl Klitkovin.

At the roots of the cutaneous lung, the cephalic bronchus occupies the posterior position, and the leg artery and the leg veins grow in front of each other. In the vertical right at the roots and gates of the legends, the most prominent position is the Leheneva artery, lower and backwards - the head bronchus and in front and below - the Legendary veni (A, B, C). At the root and gate of the right leg of the upper-posterior position is the head bronchus, in front and lower - the leg artery and the lower lung veins (B, A, C). The skeletal roots of the legends rise to the level of III-IV ribs in front and V-VII of the thoracic ridges behind.

Syntopy of the roots of the lungs. In front of the right bronchus, the upper emptying vein, the viscid aorta, the pericardium, in the right anterior part of the heart, and the unpaired vein above and behind are spread. Behind the root of the right legacy in the cells, we rule the head bronchial tubes and the unpaired vein lies the right bloody nerve. Up to the left bronchus, the aortic arch is lying on top. Yogo's rear surface is covered with a stravohode. The livus vagus nerve is folded back behind the livial cephalic bronchus. The diaphragmatic nerves melt the roots of both legs in front, passing through the cells between the leaves of the middle of the pleura and the pericardium.

Mezhi legend.The upper boundary of the leg is spread 3-4 cm anteriorly to the clavicle, posteriorly to the spinous projection of the seventh spine ridge. Between the anterior and posterior edges of the lungs, the space between the pleura is located. Bottom may be aware of.

The lower boundary of the right leg is visible behind the sternum line of the cartilage of the VI rib, along the midclavicular - the upper edge of the VII

ribs, along the middle groin - VIII rib, on the shoulder blades - X rib, paravertebrally - XI rib.

The lower boundary of the left legacy should be repaired on the cartilage of the 6th rib along the parasternal line for the manifestation of the heart virus, in the cordon, as in the right legion.

Syntopy of the lungs. The name of the surface of the leg is lying down to the inner surface of the ribs and sternum. In the middle of the surface of the right legacy є death, to which in front of the right front of the heart, in the mountains - a furrow from the depressed lower empty vein, close to the top - a furrow from the right pidclavicular artery. Behind the door to lie dead towards the stravohode and the thoracic ridges. On the medial surface of the legends, in front of them, there is a heart that is prone to a lingual slit, on the other side there is an arched furrow like the cob on the side of the aortic arch, near the top there is a boron of the lithic and arterial sleepiness. Posteriorly, it collapses to the middle of the surface of the thoracic aorta. The lower, diaphragmatic, the surface of the leg is turned up to diaphragms, through the diaphragm to the right, the leg is lying down to the right part of the stove, and the left leg is up to the slunk and the spleen.

bloodstendingto follow the system of legenevic and bronchial vasculature. Bronchial arteries go through the thoracic aorta, spread along the bronchial tubes and blood flow to the Legenev tissue, except for the alveoli. Legendary arteries display gas exchange function and alveolar harvesting. Mіzh bronchialnymiysalosis and legenevny arteries є anastomoses.

venous vidtikfrom the fabric of the legend, go through the bronchial veins into the unpaired or semi-unpaired vein, to the system of the upper empty vein, as well as in the veins.

інnervatsіyawake up with the throat of a cute stove, the throat of the bloating nerve, as well as the phrenic and intercostal nerves, so that the anterior and the most swirling of the posterior nerves gossip.

Lymphatic judges and universities. Lymphatic vidtіk from the lungs zd_snyu on the large and superficial lymphatic vessels. Offenders are anastomosed by themselves. Lymphatic judges of the superficial hemorrhage in the visceral pleura are sent to the regional bronchopulmonary lymph nodes. Gliboka lymph lymph nodes were removed near the alveoli, bronchial tubes, along the bronchial tubes and blood-bearing vessels, in semi-tissue

partitions. Lymphatic judges are directly connected to the bronchial tubes and to the lungs to the regional lungs, to the lungs to the lungs, to the lungs to the lungs, to the lungs to the lungs, the lungs to the distant lungs, to the distant lungs The grapes of the judges fall into the upper and lower tracheobronchial nodes, the lymph nodes of the anterior and posterior middle, into the thoracic duct of the evil and into the right lymphatic duct.

14.6. middle

Before the mediastinum (mediastinum) there is a complex of organs and anatomical devices, which occupy the middle position in the chest empty and encirclement in front of the sternum, backwards - with the thoracic ridge ridge, from the sides - in the middle part of the plate.

In general anatomy and medicine, the middle is taken on the front and back, and the front - on the upper and lower sides.

Cordon between the anterior and posterior middle є the frontal area, which is carried out along the posterior walls of the trachea and the head bronchi. The trachea spreads to the left and right head bronchi on the level of the IV-V chest ridges.

At the upper end of the anterior middle, lastly from the front to the back, it grows: the thornbone, the right and the left shoulder head and the upper end of the vein, the aortic arch and the cob come out of some of the shoulder head, the sleepy articulate chest widdil trachea.

The lower view of the anterior middle is the most important, representations of the heart and pericardium. In the posterior middle, the thoracic viddil of the stravohode, the thoracic aorta, unpaired and semi-unpaired veins, livy and right bloody nerves, the thoracic duct develop.

In international anatomical terminology, the classification is induced, according to which the upper and lower middle are seen, and in the lower - the front, middle and rear.

In the center of the anterior middle terminology - the whole cellular space between the posterior surface of the sternum and the anterior pericardium, in which the left and right internal chest arteries with the subalternary veins and the anterior pericardial ligaments are expanded. The middle middle is to avenge the heart from the pericardium.

Small. 14.8.Topography of organs of the middle. The rights of the part (z: Petrovsky B.V., ed., 1971):

1 - shoulder gossip; 2 - right keypad artery; 3 - clavicle; 4 - the right is the key to the vein; 5 - stravohid; 6 - trachea; 7 - right bloody nerve; 8 - right diaphragmatic nerve and pericardial-diaphragmatic artery and vein; 9 - upper empty vein; 10 - internal chest artery and vein; 11 - Liva Legeneva Artery and Vienna; 12 - liva legeneva Vienna; 13 - heart with pericardium; 14 - right bloody nerve; 15 - ribs; 16 - diaphragm; 17 - unpaired vein; 18 - cute Stovbur; 19 - right cephalic bronchus; 20 - middle artery, vein and nerve

Small. 14.9.Topography of organs of the middle. Liva chastina (z: Petrovsky B.V., ed., 1971):

1 - dome of the pleura; 2, 12 - ribs; 3, 8 - mіzhrebernі m'yazi; 4 - livy bloody nerve; 5 - rotary nerve; 6 - cute Stovbur; 7 - intercostal forehead-nerve bundle; 9 - livy head bronchus; 10 - great cranial nerve; 11 - semi-unpaired vein; 13 - aorta; 14 - diaphragm; 15 - heart with pericardium; 16 - diaphragmatic nerve; 17 - pericardial-diaphragmatic artery and vein; 18 - legeny veni; 19 - Legeneva artery; 20 - internal chest artery and vein; 21 - upper empty vein; 22 - stravohid; 23 - thoracic lymph duct; 24 - clavicle; 25 - liva pidclavicular vein; 26 - liva pidclavicular artery; 27 - shoulder gossip

14.7. KLINICHNA ANATOMIYA SERTSYA

Small. 14.10.Heart. Front view. (Z: Sinelnikov R.D., 1979). 1 - right keypad artery; 2 - right bloody nerve; 3 - trachea; 4 - thyroid cartilage; 5 - thyroid gland; 6 - diaphragmatic nerve; 7 - liva zagalna sleepy artery; 8 - shchitosheyny trunk; 9 - shoulder gossip; 10 - front descent m'yaz; 11 - liva pidclavicular artery; 12 - internal thoracic artery; 13 - livy bloody nerve; 14 - aortic arch; 15 - visual appearance of the aorta; 16 - liva vushko; 17 - arterial cone; 18 - liva legend; 19 - front midshlunochkovo boron; 20 - livy crook; 21 - top of the heart; 22 - costal-diaphragmatic sinus; 23 - right crotch; 24 - diaphragm; 25 - diaphragmatic pleura; 26 - pericardium; 27 - Pleura ribs; 28 - right to the legend; 29 - right to Vushko; 30 - legeneviy stovbur; 31 - upper empty vein; 32 - shoulder head stovbur

Anatomical characteristics.

the formі rosemary. The shape of the heart of the grown-ups is close to the flattening of the cone. The heart of the cholovik is more cone-shaped, the females have a larger oval shape. The size of the heart in older adults: 10-16 cm in size, 8-12 cm in width, anteroposterior size of 6-8.5 cm.Massa heart in older adults in the middle of 200-400 g, storage in the middle in the choloviks 300 g, in females 220 m

The name of Budova. The heart has a base, top and surface: anterior (sterno-costal), posterior (ridge), lower (diaphragmatic), bichni (legenevia; it is often described as the left and right edge of the heart).

On the surfaces of the heart, 4 furrows grow: vintsev (sulcus coronarius), front and back of the middle (sulci interventriculares anterior et posterior), middle (Fig. 14.10).

Chamber and valve heart. In the right atrium, there are 3 views: the sinus of the empty veins, the atrium and the right side. At the sinus of the empty veins, they flow from the top of the upper, from the bottom of the lower empty veins. In front of the flap of the lower empty vein, the vintsevian sinus of the heart appears in the atrium. Lower the right side of the head into the front of the heart, and once the front veins of the heart fall into the empty side.

On the mid-anterior septum, an oval fossa is formed on the side of the right anterior, surrounded by a swollen edge.

At the left front of the heart, like the right, there are 3 views: the sinus of the leg veins, the front of the heart, and the front of the head. The sinus of the Legenevian veins become the upper part of the anterior part and open 4 Legeny veins along the cuts of the upper wall: two right (upper and lower) and two left (upper and lower).

The emptying of the right and left anterior opening is seen with the emptying of the external slings through the right and the left anterior-slunochny openings, according to the number of stools of the atrioventricular - ventricular valve: the right - the third In front of the heart-shlunochkovі, open the enclosed fibrous rings, such as the hundredth part of the connective tissue skeleton of the heart (Figure 14.11).

On the right side, there are 3 views: an inlet and a backbone, which store a breeze, and an outboard, or an arterial cone, as well as 3 sides: front, back and medial.

Livy sklunochok - the most needed viddil heart. Yogo inner surface of a small number of meat trabeculi, large

Small. 14.11.Fibrous skeleton of the heart:

1 - legeneviy stovbur; 2 - aorta; 3 - stools of the tricuspid valve; 4 - stools of the mitral valve; 5 - peretinkov part of the middle partitions; 6 - to the right fibrozne circle; 7 - lіve fіbrozne kіlce;

8 - central fibrous tilo і right fibrous tricycle;

9 - livy fibrozny trikutnik; 10 - connection of the arterial cone

thin, lower at the right duck. In the lіvuyu slunochka, the input and output wedges or roztashanі pіd gostry kutom one to one and three way up to the top in the main ointment wіddіl.

Wired heart system (Figure 14.12). At higher educational institutions of the providinal system, the heart is automatically vibrated in the singing rhythm, the impulses of the stimulation, which are carried out to the contractile myocardium, are automatically carried out.

Prior to the wired system, there is a sinus-atrial and anterior-aperitic vascular, where the bundles of the heart go from these vodules to conduct myocytes and nodules in the anterior and the mucous cells.

The sinus-atrial vuzole is rosted under the epicardium on the upper point of the right atrium and the upper arm of the empty vein and we rule the vushkom. The university will take revenge on two types of cells: pacemaker (R-cellini), which generates impulses for energy, and conductors (T-cells), which conduct cyclones.

Small. 14.12.Diagram of the wired system of the heart:

1 - sinusitis-anterior vuzole; 2 - upper bundles; 3 - lateral bundles; 4 - lower beam; 5 - anterior horizontal bundle; 6 - posterior horizontal bundle; 7 - anterior inter-nodal bundle; 8 - posterior inter-nodal bundle; 9 - anteropodermis-shlunochkovy vuzole; 10 - anterioplastic bundle (Gisa); 11 - liva bottom of the Gis bundle; 12 - right bottom of the Gis bundle

From the sinus-atrial node to the walls of the right and left atrium, there are such conductive bundles: the upper bundles (1-2) go into the stage of the upper empty vein on the right of the wine; the lower bundle is directed along the posterior stints of the right atrium, spreading 2-3 heads, up to the hand of the lower empty vein; lateral bundles (1-6) widen at right angles to the top of the right side, end in the comb-parts; medial bundles (2-3) go up to the intervenous bundle, which is expanded vertically on the posterior wall of the right anterior heart from the hand of the lower empty to the wall of the upper empty vein; the anterior horizontal bundle passes through the anterior surface of the right atrium

vlevo and myocardium reach; the posterior horizontal bundle is directed to the left anterior, and even to the mouth of the legene veins.

Anteroventricular (atrioventricular) vuzole grows away from the endocarditis of the medial stage of the right atrium on the right fibrous tricuspid of the middle third of the septal stool of the right atrioventricular valve. In the atrioventricular node, P-clitin is significantly less than in the sinus-atrial one. The collapse to the apical-apical node from the sinus-apical one expands by 2-3 intra-node bundles: anterior (Bachmann's bundle), middle (Wenkenbach's bundle) and posterior (Torel's bundle). The mіzhvuzlovі bundles are expanded in the stіntsі of the right atrium and in the middle of the anterior septum.

From the atrioventricular institute to the myocardium of the shlunochkiv enter the atrio-shlunochkovy bundle of Gis, which penetrates through the right fibrous tricycle into the overflow part of the midshlunochkovy septum. Above the crest of the muscular part of the partition, the bundle is distributed on the left and on the right of the bottom.

Liva nizhka, bolsha and shirsha, niz right, the endocarditis grows on the surface of the middle partitions and grows on 2-4 grids, as if it comes out to carry out the small fibers, purring

The right to lie down for endocarditis on the right surface of the mid-slit septum at the viglyad of a single stove, from where the jug goes to the myocardium of the right slur.

topography of the pericardium

The pericardium (pericardium) will drain the heart, the lower aorta, the legnevius stovbur, the throat of the empty and legene veins. It is stored from the last fibrous pericardium and the serous pericardium. Fibrous pericardium goes over to the walls of the extra-cardiac arteries of the Great Sudins. The serous pericardium (parietal plate) along the between the viscous aorta and the arch on the legeny stovbury before the thymus on the arms of the empty and legene veins go into the epicardium (visceral plate). Between the serous pericardium and the epicardium, the pericardial is closed to the empty space, which drains the heart and replaces 20-30 mm of the serous line (Fig. 14.13).

In the pericardial emptying, there are three sinuses, which are of practical importance: antero-inferior, transverse and braid.

heart topography

Holotopia.Cover the heart with the pericardium, move into the chest emptying and become the lower part of the anterior middle.

The spaciousness of the heart and the yogo viddіlіv viglyadє the offensive rank. According to the date to the middle line, about 2/3 of the heart grows backward and 1/3 is on the right. The heart in the chest clits is the position of the spit. Later, the heart is hanging, right down the middle of the first asleep from the top, it sweeps straight up and down, right to left, back to front, and the top is straight to the left, down and forward.

Small. 14.13.Pericardial emptying:

1 - antero-inferior sinus; 2 - sinus braid; 3 - transverse sinus; 4 - legeneviy stovbur; 5 - upper empty vein; 6 - viscid aorta; 7 - lower empty vein; 8 - upper right Legeny Vienna; 9 - lower right Legeny Vienna; 10 - upper liva Legeneva Vienna; 11 - nizhnia liva legeneva vienna

The vastness of each of the blue chambers of the heart is based on three anatomical rules: perche - the little ones of the heart will grow lower or more in front of the heart; the other is right and foremost (in front of the heart and in the mouth); third - the aortic cybulin with a valve in the central position in the heart and be in direct contact with the skin for 4 times, as the bi is darkened near her.

Skeletotopia.On the front sternum, the frontal outline of the heart, the frontal surface and the great vessels, is projected. Rise to the right, to the left and to the lower boundary of the frontal shape of the heart, to start on the living heart percussion or radiological.

In older adults, the right between the heart runs vertically towards the upper edge of the cartilage of the II rib at the junction to the sternum down to the V rib. In the other mid-ribbed one, it grows 1-1.5 cm from the right edge of the sternum. From the edge of the upper edge of the third edge of the right, the border of the right edge of the sternum, the tuberosity of the beast to the right, in the third and fourth edge of the edge, go 1-2 cm from the right edge of the sternum.

At the level of the V, the ribs of the right border pass into the lower one, as it goes obliquely downward, and the sternum is melted over the edge of the sword-like ridge, and the distance of the fifth mid-rib is 1.5 cm to the middle of the midclavicular middle, in the design of the project.

Liva border is carried out from the lower edge of the 1st rib to the 2nd rib by 2-2.5 cm more than the left edge of the sternum. On the edge of the other intercostal space and III, the ribs of the won pass by 2-2.5 cm, the third intercostal space - by 2-3 cm, called from the left edge of the sternum, and then steeply left, making an arc, called the drop, the edge of which is in the fourth and The fifth mid-ribs start by 1.5-2 cm to the middle of the middle clavicular line.

The heart is attached to the anterior chest wall, not all of its front surface; To that, in the class of meaning skeletal cordon, it is described as an inter-common heart dullness. The anterior surface of the heart is percussed percussion cordon, bezposeredno (through the pericardium) adjacent to the anterior chest wall, it is described as between absolute heart dullness.

On a straight roentgenogram of the right to the left edge of the heart, the last arcs are folded from the last arcs: 2 along the right edge of the heart and 4 along the left. The upper arch of the right edge is fixed by the upper empty vein, the lower one - to the right in front of the heart. On the left edge last

from top to bottom, the perch arc is fixed by the aortic arch, the other - on the legnevius with the trunk, the third - lіvim vushkom, the fourth - lіvim slunochkom.

Variations in the shape, size and position of the edges of the arcs represent the changes in the appearance of the heart and blood vessels.

The projection of the openings and valves of the heart onto the anterior chest wall is presented in an offensive view.

To the right and left of the antero-lingual opening of the valve is designed along the line, carried out from the point of attachment to the sternum of the cartilage of the V right rib to the point of attachment of the cartilage of the third left rib. The right opening and the tristle valve occupy the right half of the sternum on the same line, and the left opening and the bicuspid valve - the left half of the sternum on the same line. The aortic valve is designed behind the left half of the sternum at the level of the third mid-ribs, and the valve of the leg-burr - at the left edge at the level of the cartilage of the third rib to the sternum.

Slide a clear view of the anatomical projection onto the anterior chest wall of the openings and valves of the heart from the listening points of the robotic heart valves on the anterior chest wall, the position of the projection of the anterior chest wall

The robot of the right atrioventricular valve can be heard at the front of the sword-like outgrowth of the sternum, the mitral valve - in the fifth intercostal space on the projection of the top of the heart, the aortic valve - at the other mid-ribs - at the right edge of the left sternum, valve sternum.

Syntopy.The heart from the sides is drained by the pericardium and through the new bed to the sides of the breast emptying and to the organs (Fig. 14.14). The anterior surface of the heart slopes down to the sternum and cartilage and III-V ribs (right side and right side). In front of the right anterior and the front of the louse, the rib-middle of the sinus of the left and right pleura and the front edges of the legs grow. In children, in front of the upper end of the heart and pericardium, there is the lower part of the thymus.

The lower surface of the heart is to lie on the diaphragm (it is also the tendon center), with the whole part of the diaphragms the left part of the liver and the slurry will be rotated.

Livoruch and right-handed to the heart prilyagaє mediastinal pleura and legends. The stench of a spike goes into the back surface of the heart. Ale is the main part of the back surface of the heart, the head rank, the liva in front of the heart, between the arms of the legenevian veins, stick through the stravohode, the thoracic aorta, the bloating nerves, in the upper

viddili - from the head bronchi. The part of the posterior wall of the right atrium is located in front of and below the right head bronchus.

Blood circulation and venous appearance

Blood vessels of the heart to form vintsevial ​​blood circulation, in which development of vintsevic arteries, 14 great subcardiac arteries, internal arteries, microcirculatory bloodstream, internal coronary artery, 14.

Small. 14.14.The horizontal cut of the breasts at the level of the VIII chest ridge (s: Petrovsky B.V., 1971):

1 - the right legend; 2, 7 - cute stovbur; 3 - unpaired vein; 4 - thoracic lymph duct; 5 - aorta; 6 - semi-unpaired vein; 8 - pleura ribs; 9 - visceral pleura; 10 - liva legend; 11 - blunt nerves; 12 - ogina gilka livoi vintsevoi artery; 13 - empty frontal front; 14 - empty lіvogo shlunochka; 15 - mіzhshlunochkovo ї partitions; 16 - the empty part of the right snorkel; 17 - costal-mediastinal sinus; 18 - internal thoracic artery; 19 - the rights of the vintseva artery; 20 - emptying of the right front of the heart; 21 - stravohid

Small. 14.15.Arteries and veins of the heart.

Front panel (s: Sinelnikov R.D., 1952):

1 - liva pidclavicular artery; 2 - aortic arch; 3 - arterial sound; 4 - liva legeneva artery; 5 - legeneviy stovbur; 6 - vushko of the left atrium; 7 - liva vintseva artery; 8 - oginaє gіlka lіvoї vіntsevoї artery; 9 - front midshlunochkovo gilku livoi vintsevoy artery; 10 - great vein of the heart; 11 - the anterior posterior region is bordered; 12 - lіviy slunchok; 13 - top of the heart; 14 - right snorkel; 15 - arterial cone; 16 - anterior vein of the heart; 17 - vintseva boroza; 18 - the rights of the vintseva artery; 19 - vusko of the right atrium; 20 - upper empty vein; 21 - ascending aorta; 22 - the rights of the Legenev artery; 23 - shoulder head stovbur; 24 - liva zagalna sonna artery

Small. 14.16.Arteries and veins of the heart. Viglyad zzada (z: Sinelnikov R.D., 1952): 1 - liva zagalna sleep artery; 2 - shoulder head stovbur; 3 - aortic arch; 4 - upper empty vein; 5 - the rights of the Legenev artery; 6 - right legenevia; 7 - right crotch; 8 - lower empty vein; 9 - small vein of the heart; 10 - the rights of the vintseva artery; 11 - shutter of the screw sine; 12 - vintseviy sinus of the heart; 13 - back of the mid-section head of the right vintsevo artery; 14 - right snorkel; 15 - middle vein of the heart; 16 - top of the heart; 17 - livy snatch; 18 - posterior vein of the lіvogo shlunochka; 19 - oginaє gіlka lіvoї vіntsevoї artery; 20 - great vein of the heart; 21 - braid vein of the left atrium; 22 - livi legenievi veni; 23 - in front of the heart; 24 - liva legeneva artery; 25 - arterial sound; 26 - liva pidklyuchichna artery

The head dzherel is the blood flow of the heart є the right and the liva of the artery of the heart (aa. Coronariae cordis dextra et sinistra), which comes from the cob aorta. In most people, the vintseva artery is larger than the right one and supplies blood to the anterior, anterior, lateral and larger part of the rear wall of the lilac snail, a part of the anterior wall of the right slit, front 2/3 The right vintseva artery supplies blood to the right anterior, a larger part of the anterior and posterior wall of the right slug, a small part of the posterior wall of the lvl slung, and the posterior third of the midshlunochkovy septum. Tse rіvnomіrna form of blood posture of the heart.

Individual indications in the blood loss of the heart are surrounded by two extreme forms: left-wing and right-wing, in case of which there is a significant increase in the development and zones of blood loss in the right-hand side of the blood.

The venous appearance from the heart is seen in three ways: along the head - subcardial veins, which fall into the vintsevic sinus of the heart; along the anterior veins of the heart, which spontaneously falls into the right atrium, from the anterior wall of the right slug; on the lowest veins of the heart (vv. cordis minimae; veins of Viessen-Tebeziya), roztashovanim at the intracardiac septum and emerges in the right front of the heart and the duck.

Up to the veins, which fall into the heart's sinus, the great vein of the heart passes through, which passes into the anterior middle vein, the middle vein of the heart, is inserted into the back mid-heart, the small vein of the heart, the back

Innervation.My heart is pretty, parasympathetic and sensitive energy (Fig. 14.17). dzherelom sympatheticє shiyni (upper, middle, middle) and thoracic nodes of left and right sympathetic stubbles, from which go to the heart of the upper, middle, lower and chest nerves. Dzherelo parasympathetic and sensitive innervations - bleak nerves, from which come the upper and lower and chest hearts. In addition, with a supplementary dzherel sensitive energy of the heart and the upper thoracic spinal cord.

Small. 14.17.Innervation of the heart (s: Petrovsky B.V., 1971): 1 - upper sheath nerve; 2 - left gossip; 3 - liviy prikordonny pretty stovbur; 4 - livy bloody nerve; 5 - livy diaphragmatic nerve; 6, 36 - front gathering m'yaz; 7 - trachea; 8 - liva shoulder gossip; 9 - liva pidclavicular artery; 10 - lіviy lower sheyny cervical nerve; 11 - liva zagalna sleepy artery; 12 - aortic arch; 13 - livy rotary laryngeal nerve; 14 - liva legeneva artery; 15 - anterior anteriorly gossip; 16 - legenevia veni; 17 - liva vushko; 18 - legeneviy stovbur; 19 - liva coronary artery; 20 - front gossip; 21 - livy snatch; 22 - right snorkel; 23 - right front gossip; 24 - vuzlov field in the area of ​​the arterial cone; 25 - rights of the coronary artery; 26 - right to Vushko; 27 - aorta; 28 - the upper empty vein; 29 - the rights of the Legenev artery; 30 - lymphatic university; 31 - unpaired vein; 32 - right lower cervical nerve; 33 - right rotary laryngeal nerve; 34 - lower right shiina sertseva gіlka; 35 - right breast university; 37 - right bloody nerve; 38 - right prikordonny pretty stovbur; 39 - right rotary laryngeal nerve

14.8. SURGERY FOR GIENT MASTITIS

Vengeance is a fiercely fiery fabric of milk. The reasons for the diagnosis are milk congestion in pregnant mothers, nipple trilogy, drinking infections through the nipple, ghostre zapalennya zolozi in the period of statistic maturity.

Falsely from the localization they see subareolar (in the light near the areola), antemammary (pidshkirny), intramammary (in the middle without the middle in the tissue), retromammary) (in the retromammary (fig. 148) mastitis.

sun love:internal anesthesia, intravenous infiltration anesthesia, 0.5%, novokainu, retromammary blockade, 0.5%, novokainu.

Surgery of the field in the rosette and drainage of the forest in the fallow of the localization. When carrying out the development of the nipple and the nipple

Small. 14.18.Rise of the type of mastitis and growth in case of new: a - the scheme of different types of mastitis: 1 - retromammary; 2 - interstitial; 3 - subareolar; 4 - anthemammary; 5 - parenchymal; b - size: 1, 2 - radial; 3 - pіd with milky zalose

gurtok. Radial growth of stagnation with anti-mammary and intramammary mastitis. Razrіzi should be carried out on the front surface of the ground over the place of the gorge and hyperemia of the shkіri. For short messages, you can use the same rosters. Carry out a revision of the wound, run all the jumpers і numb, rinse the empty ones with an antiseptic and drain. Retromammary phlegmon, as well as glibocyte intramammary abscesses, are opened with an arc-like cut along the lower edge of the fold along the transitional fold (Bardengeyer's growth). By sending the rosette of the superficial fasces, the posterior surface is peeled off, penetrating and draining the retromammary cell. The subareolar gn_ynik is opened with a circular growth, it is possible to open it with a small radial growth, without overturning on the colossal rim.

14.9. Puncture of pleural emptying

show:pleurisy, hemothorax of great obsyag_v, valve pneumothorax.

sun love:

The position of the sick: sitting or lying on the back, the hand on the side of the puncture is wound behind the head.

instrumentation:Throw a golka from the plantation on the pavilion with a gum pipe, the one who made it up with a syringe, the blood-spinning one.

Punctuation technique. Before the puncture, it is necessary to carry out an X-ray examination. With the manifestation of a fiery exudate, or the purchase of blood in the empty pleurisy, the puncture is violated at the point of the most dullness, which should start percussion. The shkiru of the breast clitine is covered, yak for training before the operative engagement. In order to carry out anesthesia in a medical center. When the line is moving in the pleural empty space, the standard point for the puncture is the є point, which is spread in the eighth intercostal space along the back or middle groin line. Hirurg fiksu at a similar mid-ribbed grip with the thumb of his left hand to the shkiru on the missed shot and lightly annoyingly to the side (schob on the knight's head, shake off the lively channel). The head is carried out in the middle along the upper edge of the lower rib,

schob not poskoditi intercostal forehead-nerve bundle. The moment I pierce the parietal leaf of the pleura, I see it as a failure. Shelter from the empty pleural space is necessary to see more, more generally, in order not to suffer reflex changes of the heart and mental activity, as it can occur when the organs of the middle are sensitive. At the moment of withdrawal of the syringe, the tube is guilty, but it is overstretched with a screwed-up squeeze to prevent drinking it into the pleural empty space. When the punctuation is finished, the child should be covered with iodine infusion and an aseptic bandage or a sticker should be applied.

If there is evidence of a stressed pneumothorax, when you see it, it’s better to paint it over the head, then you put it on the screen with plaster and cover it with a bandage.

14.10. PERICARDE EMPTY PUNCTION

show:hydropericardium, hemopericardium.

sun love:Misceva Infiltration Anesthesia 0.5% by Novokain.

The position of the sick: sit down. instrumentation: Tovsta golka with a syringe.

Punctuation technique. Often the puncture of the pericardium is shown in the point of Larrey, as it is designed in the laval sterno-rib cod, so as it will be used most of the baking (Fig. 14.19). pislya

Small. 14.19.Puncture of the pericardium (z: Petrovsky B.V., 1971)

Anesthesia of the child and pediatric adipose tissue of the head is zanuruyut on a glybin of 1.5-2 cm, direct the burn down to 45? і to pass to a depth of 2–3 cm. When the head is full, pass through Larrey's tricycle with diaphragms. Pierce the pericardium without special zusil. If you get into the empty space, you start to see yourself in the world of close proximity to the heart by transmitting pulse speeds. When the puncture is finished, the heads are injected with iodine infusion and an aseptic bandage or a sticker is applied.

14.11. OPERATION FOR penetrating wounds of breasts

Two groups of injuries are seen: non-penetrating injuries of the breasts - without causing the intrathoracic fascia, penetrating - with damage to the intrathoracic fascia and part of the pleura. In case of penetrating wounds of the breasts, there may be lungs, trachea, great bronchi, stravohid, diaphragm, most not safe wounds near the middle line, which can lead to the death of the heart of the great judges. When breasts are pooled, there is an acceleration in cardiopulmonary shock, hemothorax, pneumothorax, chylothorax, emfizemia.

Hemothorax is the purchase of blood in the empty pleura as a result of the loss of blood vessels or the heart. Wіn can be wіlnіm аbo іs encumbered. Diagnostics should be performed X-ray and after additional puncture of the pleural emptying. In case of uninterrupted bleeding and significant hemothorax, thoracotomy and ligation of the venous vessel are performed. Hemopneumothorax is the purchase of blood and liquor in the pleural empty space.

Pneumothorax is the purchase of pleural effusion as a result of pleural effusion. Pneumothorax can be closed, open and valve. In case of closed pneumothorax, when the pleural empty space is consumed, it is consumed at the moment of injury and is characterized by insignificant changes in the organs of the middle to the healthy side, which can be self-sustained. The onset of pneumothorax is in the case of a dull wound of the chest wall, as well as the appearance of pleural emptying and atmospheric fever. First aid - the application of an aseptic occlusive dressing, in a given term, closing the chest wall wounds (with a path to suturing abo plastics),

drainage of pleural emptying. Sewing up of an open pneumothorax is good for patients with endotracheal anesthesia with separate intubation. Putting a sick person on the back or on a healthy boat with a fixed hand. To carry out a retinal surgical treatment of a chest wound, dressing of a sudinum, to bleed; as there is no lung ear, it is necessary to rotate the suturing and drainage of the chest wounds. When closed, open in the pleura in the suture to swallow the inner thoracic fascia and a thin ball of the adjoining mucous membranes (Fig. 14.20). In case of lesions, the wound is sewn in or to carry out a resection;

Naybіlsh unfailing valve pneumothorax, which is a blight when formed near the wound of the valve, through which, at the moment of inhalation, it penetrates into the pleural empty space, when seen, the valve closes and does not let go of the empty pleurisy. Vinikє so the ranks of stresses pneumothorax, compression of the lung is seen, the change of organs in the middle to the opposite side. Valve pneumothorax can be both external and internal. In case of zvnіshny valvular pneumothorax, sew and drain the wound of the chest wall. With internal valvular pneumothorax, one constantly sees the pleural empty space by stretching decile days behind additional drainage. In the event of an absence, it is necessary to carry out a radical involvement with the reasons for pneumothorax.

Small. 14.20.Sewing of penetrating wounds of the chest wall (c: Petrovsky B.V., 1971)

Operations for wounds of the heart. It’s hard to get the heart out of the picture, the slips, the exact same, the penetrating and the non-penetrating. Penetrating wounds of the heart are supravodzhuyutsya twisting, often fatal bleeding. Impenetrable injuries may be surprisingly friendly overruns. I will help you with great care. With endotracheal anesthesia, the anterior or the anterior access through the fifth-second intercostal space should be left behind, as a result of the localization of injuries. Open the pleural empty space, see the roof, open the pericardium widely. To see the blood from the empty pericardium, press the wound of the heart with the finger of your left hand and put the vuzlovy sutures on the myocardium, sew the pericardium with ridged sutures. Suture the wound of the chest wall, drain the pleural empty space.

14.12. RADICAL LUNG OPERATIONS

Operative access for operations on the legs є anterolateral, bichna, posterolateral thoracotomy (thoracic rosette).

Prior to radical operations on the legends, they include: pneumonectomy, lobectomy and segmental resection, or segmentectomy.

Pneumonectomy - the whole operation of the legacy. The key stage of pneumonectomy is peretin of the root of the lung for anterior ligation or stitching of the main elements: the head bronchus, the leg artery and the leg veins.

In the current surgery legends of the stage, they can be found from the staple staples: UKB - Bronchial staple suture - for stapling a staple suture on the head bronchus and a staple of the lung root - for applying a two-stranded staple staple stitching

Lobectomy is an operation of the vision of one part of the legend.

Segmental resection is an operation of seeing one or more deciduous segments of the leg. Such operations are the most sparing and often stagnate in the middle of radical operations on legends. Vikoristannya at cich operations of sewing machines (ukl, UO - sewing organs) for sewing fabrics

lung and segmental women I will ask for the operation technique, in a short time it will be announced, and the need for operational technology will be improved.

14.13. OPERATIONS ON THE HEART

Operations at the heart form the basis of a great deal of modern surgery - cardiohirurgia. Cardiohirurgia was formed until the middle of the 20th century and is actively developing. The rapid development of cardiac surgery was extended to a whole range of theoretical and clinical disciplines, up to which new data on the anatomy and physiology of the heart, new methods of diagnostics (catheterization of coronary heart disease, well equipped cardio-rurgical center.

Until the present hour, the following operations will be performed in the heart, depending on the type of pathology:

Operations in case of wounds of the heart in viglyadi suturing of wounds of the heart (cardiography) and visualization of the side of the heart and empty heart;

Operations for pericarditis;

Operations in the presence of spirits and wads of the heart;

Operations for ischemic ailments of the heart;

Operations for heart aneurysms;

Operations for tachyarrhythmias and blockages;

Heart transplant surgery.

In such a rank, with all the main types of battle of the heart, it is possible to show surgical treatment... At the same time, there are a lot of operations in case of heart disease and heart ailments, which are the basis of the current cardiohirurgia.

Operational involvement, how to be victorious at the wads of the heart and the great Sudins, presented in the offensive classifications.

See the operation at the heart of the Great Sudan: I. Operations on the atrial blood vessels.

A. Operations with an apparent arterial prototype:

1. Ligation of the arterial duct.

2. Development and suturing of the arterial duct.

3. Resection and suturing of the artery duct.

B. Operations for coarctation of the aorta:

1. Resection with anastomosis from the end to the end.

2. Resection and prosthetics of the aorta.

3. Іstmoplasty.

4. General aortic shunt.

B. Intervascular anastomoses in Fallot's tetrad. G. Operations in the transposition of sudins.

II. Operation on the intracardiac septum.

A. Operations for defects of the anterior septum in the viglyad

suturing abo plastic defect. B. Operations in case of defects of the interstitial septum at the viglyad

suturing abo plastic defect.

III. Operations on the valves of the heart.

A. comissurotomy and valvulotomy in case of stenosis of valves: mitral, tricuspid, aortic valves and legene stovbur.

B. Prosthetic valves.

B. Plastic stool valves.

A classification has been introduced and a statement about the versatility of operations in the case of older children and wads of the heart has been introduced.

Significant opportunities in their own order of cardiohirurgia in the liking of ischemic ailments of the heart. Prior to such operations, it is known:

1. Aortocoronary shunt, the day of a yak polyagus in a vicious mild autograft from a great pediatric vein of a sickly, which is anastomosed with one kidney from an abdominal aorta, and in the middle of a distal ulcer

2. vintsevo-thoracic anastomosis, in which case one of the inner thoracic arteries is anastomosed from the vintsevo artery or gilkoy.

3. Balloon of dilatation of the vocal artery of the vintsevo artery behind the aid of the catheter inserted into the artery with the expansion of the balloon.

4. Stenting of the vintsevo artery, which is stored at the place inserted in the ear through the internal vascular catheter of the stent - an attachment that transmits the artery.

The first two operations will cover the blood loss of the myocardium with the direction of the main path for blood in the round of the sound of the vintsevo artery of the Great Gilka. The steps of the two operations expand the sounds of the vintsevo artery, and turn the blood circulation of the myocardium by themselves.

14.14. TEST VVDANNA

14.1. Check the latency of the swelling of the breast balls in the anteroposterior area of ​​the breasts:

1. The chest m'yaz is great.

2. Internal thoracic fascia.

3. Breast fascia.

4. Shkira.

5. Small pectoralis and clavicular-thoracic fascia.

6. Parietal pleura.

7. Superficial fascia.

8. Pidshkirna fatty cells.

9. Ribs and inter-ribbed joints.

10. subpectoral cellular space.

14.2. In the milk hall, there is one thing:

1. 10-15.

2. 15-20.

3. 20-25.

4. 25-30.

14.3. The milk capsule is filled:

1. Clavicular-thoracic fascia.

2. Superficial fascia.

3. The superficial leaf of the vaginal fascia of the breasts.

14.4. Metastasis in case of breast cancer can be found in different groups of regional lymphatic universities for a number of specific minds, including the localization of chubby. Look for the best group of lymphatic universities, where metastases can occur, with the localization of swelling in the upper form of the milk layer:

1.sternum.

2. Key words.

3. Pakhvovi.

4. subpectoral.

14.5. Roztashuvannya sudin and nerve in the intercostal vascular bundle from the top downward:

1. Artery, vein, nerve.

2. Day, artery, nerve.

3. Nerve, artery, vein.

4. Vіden, nerve, artery.

14.6. The intercostal vesicular bundle is the most prominent at the edge of the rib:

1. On the anterior chest wall.

2. On the bicniy station of the breasts.

3. On the back of the breasts.

14.7. Vip in the pleural emptying before starting to accumulate in the sinuses:

1. Costo-phrenic.

2. Costal-middle.

3. middle-diaphragmatic.

14.8. Visually start the most common pleural puncture with the shutter of one digital and one letter version.

1. Between the front and middle groin lines.

2. Between middle and rear lines.

3. Between the middle groin and scapula lines.

A. In a small, abo somu mіzhreber'ї. B. At the eighth intercostal space.

B. At the eighth and ninth midreber.

14.9. In case of pleural puncture, the following should be carried out through the intercostal spaces:

1. At the lower edge of the ribbed rib.

2. In the middle of the ribs.

3. At the upper edge of the lower rib.

14.10. Pneumothorax yak accelerated pleural puncture can be found:

1. When you have a lot of legends.

2. With small diaphragms.

3. Through the punctuation of the goalkeeper.

14.11. Intravascular bleeding as a result of accelerated pleural puncture can be caused by:

1.diaphragms.

2. Pechinki.

3. spleen.

14.12. At the gates of the Legend's head, the head bronchus and the Legend's judges grow from top to bottom in an offensive order:

1. Artery, bronchus, veni.

2. Bronchus, artery, veni.

3. Day, bronchus, artery.

14.13. At the gates of the right leg, the head bronchus and the leg of the court will grow from top to bottom in an offensive order:

1. Artery, bronchus, veni.

2. Bronchus, artery, veni.

3. Day, bronchus, artery.

14.14. Podovzhny bronchus in the reddened bronchial tubes of the lung є:

1. bronchitis of the 1st order.

2. bronchitis of the 2nd order.

3. bronchitis of the 3rd order.

4. bronchitis of the 4th order.

14.15. Segmental bronchus in the reddened bronchial tubes of the lung є:

1. bronchitis of the 1st order.

2. bronchitis of the 2nd order.

3. bronchitis of the 3rd order.

4. bronchitis of the 4th order.

14.16. The segment of the lung is a chain of the lung, in which:

1. Segmental bronchus grows.

2. The segmental bronchus and the leg artery of the 3rd order are distributed.

3. Segmental bronchus grows out, the third order of the leg artery is formed and a vein is formed.

14.17. The number of segments in the right legend is one:

1. 8.

2. 9.

3. 10.

4. 11.

5. 12.

14.18. The number of segments in the legends is often one:

1. 8. 4. 11.

2. 9. 5. 12.

3. 10.

14.19. Establish the concatenation of the names of the segments in the upper and middle parts of the right leg with their serial numbers:

1. I segment. A. Lateral.

2. II segment. B. Medialny.

3. III segment. V. Verkhivkovy.

4. IV segment. G. Front.

5. V segment. D. Zadniy.

14.20. The upper part of the right legend є segment:

1. Verkhivkovy, lateral, medial.

2. Verkhivkovy, posterior, anterior.

3. Upper, upper and lower tongue.

4. Anterior, medial, posterior.

5. Anterior, lateral, posterior.

14.21. Upper and lower tongue segments є in:

14.22. Medial and lateral segments є in:

1. The upper part of the right legend.

2. The upper part of the legends.

3. The middle part of the right legend.

4. The lower part of the right legend.

5. The lower part of the legends.

14.23. Establish the concatenation of the names of the segments in the lower lobes of the left and right legends with their serial numbers:

1. VI segment. A. Anterior basal.

2. VII segment. B. Posterior basal.

3. VIII segment. V. Verkhivkovy (upper).

4. IX segment. D. Lateral basal.

5. X segment. D. Medial basal.

14.24. In the middle of the segments of the upper part of the legends there can be two angry people:

1. Verhivkovy.

2. Back.

3. Front.

4. Upper ovarian.

5. Lower ovarian.

14.25. In the middle of the reinforced segments in the lower part of the legacy, there may be some of the following:

1. Verkhivkovy (upper).

2. Posterior basal.

3. Lateral basal.

4. Medial basal.

5. Anterior basal.

14.26. Most important damage is caused by pneumothorax:

1. As a matter of fact.

2. Close up.

3. valve.

4. spontaneously.

5. Combinations.

14.27. Establish the type of organs in the middle:

1. Front middle. A. Timus.

2. Back middle. B. Stravohid.

B. Heart with pericardium. G. Trachea.

14.28. Set the status of the vessel to the middle of the month:

1. Front middle.

2. Back middle.

A. Upper emptying vein.

B. Internal chest arteries.

B. Viscous aorta. G. Nemovlya duct. D. Doug aorta.

E. Legeny trunk.

J. Low aorta.

Z. Unpaired and semi-unpaired veni.

14.29. First, start the last of the anatomical statements from front to back:

1. Arch of the aorta.

2. Trachea.

3. Thymus.

4. brachiocephalic vein.

14.30. Bifurcation of the trachea according to the height to the thoracic ridges is located at the level:

14.31. The heart grows in the lower part of the anterior middle asymmetrically in terms of maturity to the middle area of ​​the floor. Check the correct version of this rosetting:

1.34 PLN, 1/4 right handed

2. 2/3 PLN, 1/3 right handed

3.1 / 3 PLN, 2/3 right handed

4.14 PLN, 3/4 right-handed

14.32. Establish the correspondence between the positions of the shells of the heart and its nomenclature names:

1. The inner shell of the wall of the heart A. Myocardium.

2. The middle shell of the wall of the heart B. Perikard.

3. The name of the shell of the wall of the heart V. Endocard.

4. Pericardial sac by G. Epicard.

14.33. Substitute the name of the surface of the heart to represent its spaciousness and presentation to the most vivid anatomical devices. Establish the type of synonyms the name of the surface of the heart:

1. Bichna.

2. Back.

3. Lower.

4. Front

A. Grudino-Rebrova. B. Diaphragmatic.

B. Legeneva.

G. Khrebetna.

14.34. The grown-ups have the right between their hearts to project in another, fourth, most often:

1. Along the right edge of the sternum.

2. On 1-2 cm name from the right edge of the sternum.

3. On the right of parasternal lines.

4. For the right middle clutch line.

14.35. The older ones have the highest heart to project:

1. In the fourth mid-clavicular line.

2. At the fourth mіzhreber'y before the middle of the midclavicular line.

3. The fifth mid-ribbed line is called the middle clutch line.

4. In the fifth mid-ribbed line to the middle of the middle clavicular line.

14.36. The anatomical projection of the tricuspid valve is located behind the right half of the sternum on the line, which is located at the back of the sternum:

14.37. The anatomical projection of the mitral valve is located behind the left half of the sternum on the line, which is from the same point to the sternum:

1. 4th right and 2nd left rib cartilage.

2. 5th right and 2nd left rib cartilage.

3. 5th right and 3rd left rib cartilage.

4. 6th right and 3rd left rib cartilage.

5. 6th right and 4th left rib cartilage.

14.38. The aortic valve is designed:

1. Behind the left half of the sternum on the back of the other rib cartilages.

2. Behind the left half of the sternum on the edge of the third intercostal space.

3. Behind the right half of the sternum on the edges of the attachment to other rib cartilages.

4. Behind the right half of the sternum on the edge of the attachment of the third rib cartilage.

14.39. The valve of the legendary stove is designed:

1. Behind the left edge of the sternum on the edge of the attachment of other rib cartilages.

2. Behind the right edge of the sternum on the івні attachment to other rib cartilages.

3. Behind the left edge of the sternum on the edge of the attachment of the third rib cartilage.

4. Behind the right edge of the sternum on the edge of the attachment of the third rib cartilage.

14.40. During auscultation, the heart of the robot's mitral valve is most easily heard:

2. Viscera anatomical projection in another mezhreber'y evil from the sternum.

3. Lower and more anatomical projection in the fourth mid-ribs from the sternum.

4. Lower and more anatomical projection in the fifth middle edge at the top of the heart.

14.41. During auscultation, the heart of the robotic tristula valve is most easily heard:

1. At the point of the anatomical projection.

2. Viscera of anatomical projection on the handle of the sternum.

3. Lower anatomical projection on the level of the attachment to the sternum of the 6th right costal cartilage.

4. Lower anatomical projection on the xiphoid outgrowth.

14.42. During auscultation, the heart of the robot valve of the Legendary Stovbur can be heard:

1. At the point of the anatomical projection.

14.43. During auscultation, the heart of the robotic aortic valve becomes audible:

1. At the point of the anatomical projection.

2. At the other mіzhreber'ї bіlya the right edge of the sternum.

3. The other mid-ribs have the left edge of the sternum.

14.44. Set the correct sequence of parts of the wire system of the heart:

1.mіzhvuzlovym beams.

2. Lips of the atrioventricular bundle.

3. Atrio-slurry bundle (Gisa).

4. Atrial slurry vuzol.

5. Anterior fascicles.

6. Sinus-atrial vuzole.

14.45. Great Vienna heart to grow:

1. At the front mid-cut and the right to see the furrow.

2. In the anterior mid-cut and in the left form of the vintsevo furrow.

3. At the rear mid-cut and right-sided vintsevo furrow.

4. At the back of the middle and middle of the winter furrow.

14.46. Vinets sinus heart to grow:

1. At the front mid-cutter boron.

2. At the back of the midwife.

3. In the first form of the vine furrow.

4. At the right side of the vine furrow.

5. At the rear end of the vintsevo furrow.

14.47. The sinus of the heart flows into:

1. Superior empty vein.

2. Inferior empty vein.

3. Right at the front.

4. Liva in front of the heart.

14.48. The anterior veins of the heart fall into:

1. Have a great vein in the heart.

2. In the sinus of the heart.

3. At the right anterior.

14.49. Puncture of the pericardium is displayed at the point of Larrey. Introduce a miscellaneous roztashuvannya:

1. Between a sword-like child and a livid ribbed arc.

2. Between the sword-like child and the right costal arch.

3. At the fourth mezhreber'yi zilova from the sternum.

1. Під кутом 90? to the surface of the floor.

2. Vgora pid kutom 45? to the surface of the floor.

3. Up and down the road 45? to the surface of the floor.

14.51. In case of pericardial puncture, the head should be carried out in the pericardium emptying cavity:

1. Scythe.

2. antero-inferior.