ANSWERS 2 - HEAD, NECK AND CHEST

   Topographic anatomy and operative surgery of head and neck

1. Topographic anatomy of brain department of the head (fronto-parieto-occipital, temporal, mastoid regions).

Brain department is divided into skull fornix and skull base

(internal and external surfaces are distinguished in each of them).

Border between skull fornix and skull base passes through external

occipital tuber, upper nuchal line, base of mastoid process,

infratemporal crest.

Following regions are located within the bounds of skull fornix:

fronto-parieto-occipital (unpaired), temporal (paired) and mastoid

(paired). Mastoid region is a part of skull base, but on character and

layer-by-layer topography it does not differ from other areas of skull

fornix and is studied together with them.

Fronto-parieto-occipital region

Borders: in front – supraorbital edge of frontal bone and glabella,

from behind – upper nuchal line, from outside – superior temporal line.

Layer-by-layer topography

Skin is thick, сovered by hair with plenty of sudoriferous and sebaceous glands.

Subcutaneous fat is evident and divided into cells by vertical

intersections containing connective tissue fibres, which go from the

skin to underlying layer – epicranial aponeurosis. Basic vessels pass in

this layer. Hemorrhage and inflammatory processes are straightly

limited.

Epicranial aponeurosis (galea aponeurotica) is a tendinous plate

located between frontal and occipital belly of occipitofrontal muscle.

Prolongation of it in lateral departments of the head is superficial fascia

of temporal region. Fascial intersections wich pass in subcutaneous fat

provide strong connection of epicranial aponeurosis with the skin. Due

to this fact and great mobility of galea aponeurotica (as it separated

from periosteum by light fat), "scalping" type wound often occures in

this region.

Subaponeurotic fat tissue is light (not solid) fat without

intersections. Hemorrhage and inflammatory processes in this layer

have diffuse character, distribute within the limits of the region.

Periosteum grows together with a bone in places of sutures. At all

the rest distance it is separated from them by light fat.

Subperiosteal fat is well developed thanks to the fact that

periosteum is easily scaled from the bone. Hemorrhage and

inflammatory processes in this layer are separated as periosteum grows

together with a bone and doesn't give an opportunity for distribution of

the processes.

Bones of skull fornix consist of external and internal plates,

between which spongy substance – diploe is located. Internal plate has

smaller radius of curvature than external (and consequently more

fragile). It is called vitreous plate. Diploic veins are located in spongy

substance.

Dura mater consists of two layers and forms venous sinuses.

Temporal region

Borders of temporal region correspond to limits of distribution of

temporal muscle.

Layer-by-layer topography

Skin is thin, mobile in front departments of the region and denser

in back.

Subcutaneous fat is not significantly expressed. Superficial

temporal artery passes here.

Superficial fascia is prolongation of epicranial aponeurosis.

Temporal (proper) fascia is dense aponeurotic plate. It begins

from superior temporal line and attaches to anterior and posterior

surface of zygomatic arch by superficial and deep layers (it is divided

into two layers in lower third of the region).

Interaponeurotic fat space is located between layers of proper

fascia. Medial temporal artery passes here.

Subaponeurotic fat space is better developed in lower part of the

rigion. Lower than zygomatic arch and zygomatic bone it passes into

fat body of cheek.

Temporal muscle begins from inferior temporal line and passes in

a powerful tendon behind zygomatic arch, which is attached to

coronoid process and anterior edge of lower jaw. Deep temporal artery

and nerve pass through it.

Temporal osteomuscular space is presented by the layer of light

fat.

Periosteum is connected with a bone in lower department of the

region, in other parts there is small layer of subperiosteal fat under it.

Temporal bone is thin (thickness is not more than 2 mm), without diploe. Besides, it is necessary to remember, that medial meningeal

artery is adjacent to internal surface of the bone. So the injuries of

temporal bone are dangerous and can be accompanied by artery rupture

with subsequent profuse bleeding and epidural hematoma.

Mastoid region

Borders correspond to location of mastoid process of temporal

bone.

Layer-by-layer topography

Skin is thin, not mobile.

Subcutaneous fat is not significantly expressed. Superficial fascia and posterior auricular muscle are located there.

Superficial fascia

Proper fascia

Muscles which are attached to mastoid process

(sternocleidomastoid muscle, splenius muscle of head, posterior

ventricle of digastric muscle, longissimus muscle of head).

Periosteum is densely attached to the bone except of smooth

triangular platform corresponding to trephine Shipos' triangle. Due to

subperiosteal fat Periosteum easely scales of from the bone in this

place. Borders of Shipos' triangle: upper – prolongation of the upper

edge of zygomatic arch, anterior – external edge of acustic duct,

posterior – mastoid crest.

Bone has cellular structure. Several types of mastoid process

distinguish uppon degree of development of these cells: pneumatic

(much cells in all bone), sclerotic (few cells in all bone) and mixed.

Mastoid antrum is the largest cell, which is connected with cavity of

middle ear. Therefore at purulent otitis, arising more often at children,

as complication after a grip, measles, scarlatina, pus can penetrate from

middle ear into cells of the bone (mastoiditis). This fact also is

promoted by structure of mastoid process (at children remindes spongy

substance of bones of skull fornix).

2. Topographic anatomy of face department of the head (deep and parotidomasseteric regions).

Parotidomasseteric region

Borders: upper – zygomatic arch, lower – lower edge of mandible,

anterior – anterior edge of masseter muscle, posterior – posterior edge

of lower jaw branch.

Layer-by-layer topography

Skin is thin, flexible, covered with hair at men.

Subcutaneous fat is well developed, pierced by fascial

intersections, located between skin and proper fascia. Superficial fascia

divides subcutaneous fat into two layers. Branches of facial nerve pass

in a deep layer of fat.

Proper (parotidomasseteric fascia) forms a capsule for parotid

salivary gland and covers the chewing muscle.

Parotid salivary gland places mostly in retromandible fossa.

Proper fascia forms capsule for the gland and divides it into lobules by

fascial intersections. There are two weak places in parotid salivary

gland. The first one is located in the upper part nearby external acoustic

meatus, where the gland and its capsule is pierced with lymphatic vessels. Another one corresponds to pharyngeal process (medial part of

the gland) – the region which is not covered by fascia and

communicates with peripharyngeal space. This fact explains an

opportunity pus distribution from parotid salivary gland into

peripharyngeal space and external acoustic meatus at purulent parotitis

or penetration of pyoinflammatory process from external ear into the

glands. External carotid artery and its terminal branches, retromandible

vein, auriculotemporal and facial nerve, superficial and deep parotid lymph nodes pass in glands bed. Facial nerve there is divided into 5

groups of branches: temporal, zygomatic, buccal, cervical and terminal

branch of lower jaw.

Excretory duct of parotid salivary gland is located in a horizontal

direction in parallel and below to zygomatic arch, on external surface

of masseter muscle. At anterior edge of the muscle duct turns inside

under a direct corner, perforates buccal muscle and opens in vestibule

of mouth between the first and second upper molars.

Masseter muscle.

Massetericomandibular osteofibrous space.

Branch of lower jaw.

Deep regions of the face

Deep region of the face can be seen after branch of lower jaw,

masseter muscle and zygomatic arch removal. The region represents

space bounded laterally by the lower jaw, from the front – by maxillary

tuber, medially – by pterygoid process of sphenoid bone, from above –

by basis of the skull. It is filled by muscles (lateral and medial pterygoid, temporal muscles), fat, vessels and nerves.

Two interfascial fat compartments are located in this region:

1. pterygotemporal space (between lateral pterygoid and temporal

muscles) – contains maxillary artery and its branches and

numerous veins, which form pterygoid venous plexus;

2. interpterygoid space (between lateral and medial pterygoid

muscles) – contains pterygoid venous plexus, maxillary artery and

its branches and mandibular nerve.

Pterygotemporal space communicates with:

 fat body of cheek and pterygopalatine fossa;

 skull cavity – through round foramen;

 orbital cavity – through inferior orbital fissure;

 nasal cavity – through pterygopalatine foramen;

 oral cavity – through greater palatine canal.

Interpterygoid space communicates with:

 pterygotemporal and peripharyngeal spaces;  skull cavity – through oval and spinous foramens;

 floor of oral cavity – upon lingual nerve.

3. Topography and projections of vessels and nerves of the head. Topographic anatomy of venous system of the head. Anastomoses between superficial and intracranial veins of the head, practical significance. 2

Venous system of skull fornix

Venous system of skull fornix is well developed and settles down

in three floors.

 The first floor is presented by subcutaneus veins of the head,

which go together with same arteries. Venous outflow from them

goes into external jugular vein and internal jugular vein by facial

and retromandibular veins.

 The second floor – diploic veins, which are located in flat bones

of the skull.

 The third floor is presented by intracranial venous sinuses of dura

mater of the brain.

All three floors are connected among themselves by emissary

veins. The largest emissary veins are located in occipital, parietal and

mastoid bones and go through small apertures in skull fornix. In case of

purulent inflamation of soft tissues septic thrombosis of subcutaneus

veins can occur. It results to retrograde ouflow of infected blood uppon

emissary veins into sinuses of dura mater with subsequent thrombosis

of them, development of meningitis and meningoencephalitis.

Venous system of face department of the head

Normal venous outflow from face department of the head is done

by facial (from front region) and retromandible (from lateral region)

veins to internal jugular vein. Facial vein also has anastomoses with

superior orbital vein by angular vein (blood outflows into cavernous

sinus) and pterygoid venous plexus by deep facial vein. Pterygoid

venous plexus links with facial, retromandible (main outflow), inferioir

orbital veins and cavernous sinus by medial meningeal and emissary

veins.

In cases of inflammatory diseases of the face a septic thrombosis of

facial vein may reveal, it leads to retrograde outflow of venous blood

into orbital cavity and pterygoid venous plexus, and then to cavernous

sinus, resulting in meningitis or its thrombosis.

Projections

4. Surgical d-bridement of wounds (penetrating and not penetrating) of the head. Ways of arrest of bleeding from vessels of soft tissues, diploic veins, venous sinuses.

Initial surgical d-bridement of wounds of the head

The wounds of skull fornix can be not penetrating (without

damage of dura mater) and penetrating (with damage of dura mater).

They also can be classified as open (skin is injured) and closed (skin is

not injured).

Stages of initial surgical d-bridement:

 Economical excision of soft tissues taking into account anatomic

features of the region: skin is dissected together with subcutaneous

fat and aponeurosis 3-5 mm aside from edges of the wound. Arrest

of bleeding from vessels of soft tissues is done by:

1. digital pressing of soft tissues to the bone (digital occlusion

of vessels);

2. suturing the soft tissues around the wound together with

vessels of subcutaneous fat with thick silk (way of

Heydenhane);

3. putting on hemostatic forceps (clamps) with subsequent

ligation of vessels;

4. putting on metal surgical staples;

5. electrocoagulation.

 Economical excision of damaged periosteum, removal of foreign

bodies and bony fragments that are not connected with

periosteum. Widening of bone wound with the help of Luer's

forceps. Making its edges even. Arrest of bleeding from diploic vessels of the bone is done by:

1. rubbing-in wax paste;

2. crushing the bone with the help of Luer's forceps with a

purpose to draw together the internal and external plates of

the bone.

 D-bridement of dura mater:

1. at not penetrating wounds and absence of pressure of dura

mater (well pulses) – it is not opened;

2. if subdural hematoma is shining through tense, poorly pulsing

dura mater – it is aspirated through a needle;

3. if hematoma is not aspirated by such way or at penetrating

wounds – crucial incision or section of dura mater in radial

direction is done for operative approach to a wound of the

brain.

Strong bleeding from venous sinuses can occur at injuries of dura

mater or during removal of bony fragments that cover wounds of

sinuses. Such bleeding is controled by following methods:

1. putting in sutures on small line wounds;

2. making plastics of a sinus wall with flaps from external layer

of dura mater or femoral fascia, or with a piece of muscle;

3. in case of total rupture tamponade of a sinus by gauze

turunda, which should be removed in 6 days, or ligation of a

sinus is used.

 D-bridement of wound of the brain. Sanation of the wound canal is done by washing away brain detritus and fine foreign bodies by a

jet of warm physiologic saline. Increasing of intracranial pressure

is used for better removal of wound canal contents. In patient

tussiculation or straining effort is ordered if he(she) is operated

under local anaesthesia. Pressing of jugular veins is applied if the

patient is operated under general anesthesia. Arrest of bleeding

from brain vessels is done by:

1. electrocoagulation;

2. filling the wound canal with fibrinogen and thrombin mass.

 Wound closing. Dura mater is sutured by thin silk ligatures. Then

sutures are put on periosteum by thin silk or polymer material. Soft

tissues are connected by silk interrupted sutures.

 5. Operation at injury of medial meningeal artery.

Ligation of medial meningeal artery

Indications: bleeding with formation of epidural hematoma leading

to compression of the brain.

Operative approach is usualy done in place of artery injury.

Approach to the trunk of medial meningeal artery is done (temporal

region) in case of not clear localization.

Stages of operation:

1. arcuate incision of soft tissues with basis directed downwards;

2. section of temporal fascia, interaponeurotic fat and temporal muscle in a vertical direction up to periosteum;

3. formation of osteoperiosteal flap (by general rules) and turning

downwards;

4. ligation of artery in epidural space (two ligatures on central end,

one on distal);

5. dura mater investigation (subdural hematoma is washing away by

jet of warm physiologic solution in case of its injury);

6. layer-by-layer suturing.

6. Anthrotomy: indications, technique, complications.

Trepanation of mastoid process (anthrоtomia)

Indications: primary or secondary purulent inflammation of

mastoid process.

Stages of operation:

1. section of soft tissues up to the bone 1 cm backwards and across

the line of ear bowl attachment;

2. separation of periosteum from the bone in place of trepanation

triangle;

3. removal of external wall of mastoid process within the limits of

Shipos' triangle by bone gouge and hammer;

4. destruction of intersections between cells, removal of pus;

5. drainage of bony wound.

Complications occur in case of deviation from the Shipos'

triangle. The surgeon can hurt:

 above – contents of medial cranial fossa;

 from behind – sigmoid sinus;

 in front – facial nerve.

7. Surgical treatment of purulent parotiditis.

Operations at purulent parotiditis

The aim of operation is lancing of purulo-necrotic focus and

wound drainage.

Technique:

1. skin, subcutaneous fat and glands’ capsule are dissected in a sharp

way according to the course of facial nerve branches (vertical

incision behind the branch of lower jaw is done if purulo-necrotic

focus is located in retromandibular part of parotid salivary gland

or radial incision in a point of maximal fluctuation is done in case

of focus location in parotidomasseteric region);

2. tissues of the gland are disconnected in a blunt way (by forceps or

finger) to prevent injury of facial nerve and other structures

located in glands’ bed;

3. purulo-necrotic focus drainage.

 8. Osteoplastic and decompressive trepanation of the skull. Indications, technique.

Trepanation of skull fornix (craniotomy)

There are two kinds of craniotomy: osteoplastic (single-flap and

double flap), which provides only operative approach for the brain and

decompressive, which is palliative operation including operative

approach and surgical maneuver.

Osteoplastic trepanation

Indications: abscess, hematoma, tumour of the brain.

Stages of double-flap osteoplastic trepanation:

1. formation of fasciocutaneous flap;

2. processing of periosteum (section and displacement of periosteum

in places of subsequent trephine openings and between them);

3. drilling of trephine openings, sawing of the osteal intersections

between the holes and turning back the osteoperiosteal flap with

saving of vascular pedicle of the flap;

4. arcuate incision of dura mater and manipulations on the brain;

5. closing of dura mater defect, putting of osteoperiosteal flap in

initial position and suturing of periosteum, sutures on soft tissues.

The advantages of double-flap osteoplastic trepanation (in

comparison with single-flap) include an opportunity of wide opening of

skull cavity by formation of osteoperiosteal flap of any size and

prevention of fasciocutaneous flap strangulation.

Decompressive trepanation

Decompressive trepanation is palliative operation which is carried

out in case of inoperable tumors of brain, progressive cerebral edema

with the purpose to eliminate or reduce the pain by reduction of

intracranial pressure.

The purpose of operation is to make a defect of the bone and dura

mater in skull fornix. Reduction of intracranial pressure is realized by

bulging of substance of the brain in formed defect. It is often

performed in temporal region but sometimes directly in projection of a

tumor.

Stages of operation:

1. arcuate incision of skin and subcutaneous fat with basis directed

downwards to the level of zygomatic arch;

2. section of temporal fascia, interaponeurotic fat and temporal

muscle in a vertical direction up to periosteum;

3. section and separation of periosteum from the bone in area of 6

cm2;

4. drilling of trephine opening with its subsequent dilatation by

Luer's forceps to defect 6х6 cm;

5. crucial incision of dura mater;

6. suturing of temporal muscle and soft tissues of the region.

 9. Classification and topography of fascias of the neck. Practical significance.

Fascias of the neck and their practical significance

Functions of the neck fascias:

 protection;

 fixation;

 promotion of biomechanics (contraction) of muscles;

 separation of fat spaces;

 regulation of blood outflow from the brain because of the veins

are dilated as its wall grows together with fascias (also air

embolism can occur as in case of injury veins do not collapse and

the influence of negative pressure in the chest and right atrium

still exists).

Classification of fascias of the neck

 Classification of fascias of the neck by V.N. Shevkunenko:

1. Superficial fascia of the neck is a part of superficial fascia of

a human body. Covers cutaneous muscle of the neck (m.

platisma).

2. Superficial layer of propriate fascia of the neck forms

sheaths for sternocleidomastoid and trapezius muscles and

capsule for submandibular gland. Below it is attached to

anterior surface of the clavicle and sternum, above – to the

edge of lower jaw, on each side gives connective-tissue

intersections to transverse process of cervical vertebras

which divide the neck into anterior and posterior departments.

3. Deep layer of propriate fascia of the neck (omoclavicular

aponeurosis of Rishe) places at anterior region between

hyoid bone from one side, clavicle and breast bone from

another. Lateral borders to this fascia are omohyoid

muscles. It forms sheaths for omohyoid, sternothyroid,

sternohyoid and thyrohyoid muscles. The second and the

third fascias grow together 3 cm higher than jugular incisure

on median line and form there white line of the neck (2 - 3

mm in width).

4. Endocervical fascia consists of two layers: parietal and

visceral. Parietal layer forms fascial compartment for the

basic neurovascular fascicle and surrounds all neck organs

together. Visceral – covers each organ separately (pharynx,

oesophagus. larynx, trachea, thyroid gland).

5. Prevertebral fascia covers sympathetic trunk and muscles

laying on bodies and transverse process of cervical vertebras

(mm. longus colli and longus capitis). It forms sheaths for

scalene muscles and neurovascular fascicle of lateral

triangle of the neck (subclavian vessels and brachial plexus).

In lateral departments prevertebral fascia is connected with

transverse process of cervical vertebras, below - passes into

endothoracic fascia.

 International classification of fascias of the neck:

1. Superficial fascia (corresponds to the second fascia by V.N.

Shevkunenko).

2. Pretracheal fascia (corresponds to the third fascia by V.N.

Shevkunenko).

3. Prevertebral fascia (corresponds to the fifth fascia by V.N.

Shevkunenko).

4. Fascia of basic neurovascular fascicle of the neck.

10. Triangles of the neck. Practical significance.

Triangles of the neck and its practical significance

1. Medial triangle (bounded by edge of the lower jaw,

sternocleidomastoid muscle and median line of the neck):

 submandible triangle (bounded by edge of lower jaw,

anterior and posterior bellies of digastric muscle), its

contents: submandibular gland and same lymph nodes,

facial artery, lingual artery and hypoglossal nerve;

 carotid triangle (bounded by posterior belly of digastric,

anterior edge of sternocleidomastoid and superior belly of

omohyoid muscles), its contents: basic neurovascular

fascicle of the neck, including common carotid artery,

internal jugular vein and vagus nerve;

 omotracheal triangle (bounded by superior belly of

omohyoid, sternocleidomastoid muscles and median line of

the neck), its contents: common carotid artery, vertebral and

inferior thyroid vessels, vagus, sympathetic cardiac and

inferior laryngeal nerves, cervical ansa.

2. Lateral triangle (bounded by the clavicle, sternocleidomastoid

and trapezius muscles):

 omotrapezoid triangle (bounded by sternocleidomastoid,

lateral edge of trapezius and inferior belly of omohyoid

muscles), its contents: cervical plexus and its cutaneous

branches;

 omoclavicular triangle (bounded by sternocleidomastoid,

inferior belly of omohyoid muscles and the clavicle), its

contents: subclavian vessels, fascicles of brachial plexus,

thoracic duct.

11. Projections and topographic anatomy of neurovascular fascicles of the neck. Reflexogenic zones of the neck, practical significance.

Reflexogenic zones of the neck

Reflexogenic zones of the neck are the zones of increased

sensitivity. Injuries of this site during operations or outside forces can

result in development of traumatic shock. Reflexogenic zones of the

neck are following:

1. basic neurovascular fascicle of the neck (common carotid

artery, vagus nerve, internal jugular vein) is projected from

the point in the middle of distance between angle of lower

jaw and mastoid process to sternoclavicular joint;

2. carotid sinus reflexogenic zone (bifurcation of common

carotid artery) is projected by the upper edge of thyroid

cartilage 1 cm outside;

3. ganglions of the sympathetic trunk: the upper ganglion is

projected into transverse process of the third cervical

vertebra, the middle ganglion – to transverse process of the

sixth cervical vertebra, cervicothoracic ganglion – to neck of

the first rib;

4. cervical plexus is projected in the middle of posterior edge of

sternocleidomastoid muscle;

5. brachial plexus is projected between the middle and lower

third of posterior edge of sternocleidomastoid muscle;

6. subclavian artery and trunks of brachial plexus are projected

in the middle of the clavicle.

12. Topographic anatomy of neck organs: larynx, trachea, pharynx, esophagus, thyroid gland.

Larynx

Larynx skeleton is formed by nine cartilages (three pair and three

unpaired). The basis of skeleton is cricoid cartilage located at the level

of the sixth cervical vertebra. Thyroid cartilage connected with hyoid

bone by hyothyreoid membrane is located above than cricoid cartilage.

Two cartilages are connected by cricothyreoid ligament and muscles.

Parts:

1. upper (vestibule) – from epiglottis up to false vocal

ligament;

2. middle (glottic space) – within false and true vocal ligament;

3. lower (subglottic space).

Skeletotopy. Larynx is located from the fourth to the lower edge of

sixth cervical vertebra.

Syntopy. In front it is covered by prelaryngeal muscles, from the

sides – lateral lobes of thyroid gland, from behind – pharynx; by the

upper part reaches a root of tongue, below passes into trachea.

Blood supply: branches of superior and inferior thyroid arteries.

Innervation: superior and inferior laryngeal nerves; branches of

sympathetic nerve.

Trachea

Trachea consists of separate cartilage rings back wall of which is

replaced by membranous plate from dense connective tissue with

elastic and smooth muscle fibers. There are two parts in trachea:

cervical and thoracic. Cervical part consists of 6-8 cartilages.

Skeletotopy: from the lower edge of sixth cervical to the upper edge

of fifth thoracic vertebras where the place of tracheal bifurcation is

located.

Syntopy. The initial part of trachea is covered in front by isthmus

of thyroid gland, from the sides – by its lobes. Below the gland

previsceral fat space is located. Esophagus is behind from trachea; at

jugular incisure common carotid arteries adjoin the organ.

Blood supply of the cervical part: branches of inferior thyroid

artery.

Innervation: recurrent laryngeal nerve.

Pharynx

Parts:

1. upper (rhinopharynx) – from base of the skull up to hard

palate;

2. middle (oropharynx) – up to the body of hyoid bone.

3. lower (laryngopharynx) – up to esophagus.

Lymphoid tissue of oropharynx, rhinopharynx and organ’s

mucous layer is called lymphoid [Waldeyer's throat] ring and includes

single follicles, palatine, pharyngeal, lingual tonsils and tonsil of torus

tubaris.

Skeletotopy: from skull base to the lower edge of sixth cervical

vertebra.

Syntopy. Behind laryngopharynx long muscles of the neck are

located, in front - larynx, from the sides – upper poles of thyroid gland

and common carotid arteries.

Blood supply: ascending pharyngeal, ascending and descending

palatin, superior and inferior thyreoid arteries.

Innervation: vagus, glossopharyngeal and cervical sympathetic

nerves, which form pharyngeal plexus.

Esophagus

Parts: cervical, thoracic and abdominal.

Constrictions: in the begining, at tracheal bifurcation level, while

passing through diaphragm.

Skeletotopy: from the lower edge of sixth cervical to eleventh

thoracic vertebras.

Syntopy. In front of esophagus cricoid cartilage and trachea are

located; behind – spinal column and long muscles of the neck; from the

sides – lower poles of thyroid gland and common carotid artery. Within

the neck borders esophagus deviates to the left from median line

forming sulcus together with trachea, through which left recurrent

laryngeal nerve passes. The right one passes behind trachea, on lateral

surface of esophagus.

Blood supply: branches of inferior thyroid arteries.

Innervation: recurrent laryngeal nerves.

Thyroid gland

Thyroid gland consists of two lobes and isthmus. In each lobe

upper and lower poles are distinguished. Approximately in one third of

cases additional lobe passes upwards from isthmus of the gland –

pyramidal process. Sometimes the process is conected with lobes and

quite often reaches hyoid bone.

Thyroid gland has its own capsule in the form of thin fibrous

plate and fascial sheat which is formed by visceral layer of the fourth

fascia. Between the gland's capsule and its sheat light fat with nerves,

vessels and parathyroid glands are located.

Syntopy. Thyroid gland isthmus is located in front of trachea at

the level of first up to third (or from second up to fourth) rings, and

quite often covers part of cricoid cartilage. Lobes adjoin to trachea,

larynx, pharynx and esophagus and cover partially common carotid

artery. In front it is covered by muscles (sternohyoid, sternothyreoid

and omohyoid muscles).

Blood supply: superior and inferior thyroid arteries.

Innervation: from the sympathetic trunk and recurrent laryngeal

nerves.

Parathyroid glands

Four parathyroid glands are located on the back side of thyroid

gland lobes between capsule and its fascial sheat. Upper glands lay at

the level of lower edge of cricoid bone; lower glands – one cross finger

higher than lower poles of the thyroid gland.

13. Fat spaces of the neck. Ways of pus distribution.

Fat spaces of the neck

Fat spaces of the neck are located between fascias and can be

divided into two groups – closed and communicating (open).

Closed fat spaces of the neck

1. Suprasternal interfascial space is located between the second

and the third fascias of the neck. Contents: jugular venous

arch connecting anterior jugular veins. It communicates with

Grubers’ cul-de-sacs - continuation of the space behind the

sternocleidomastoid muscle.

2. Fascial sac of the sternocleidomastoid muscle is located

between deep and superficial layers of the second fascia.

3. Submandible gland space is located between deep and

superficial layers of the second fascia and lower jaw.

Contents: submandible salivary gland, facial artery and vein,

lymphatic nodes.

4. Thyroid gland space is located between capsule of the thyroid

gland and visceral layer of the fourth fascia. Contents: terminal branches of thyroid arteries.

5. Prevertebral space is located between the fifth fascia and

vertebral bodies. Contents: long muscles of the head and

neck, sympathetic trunk.

Communicating fat spaces of the neck

1. Previsceral space is located between visceral and parietal

layers of the fourth fascia. Ways of pus distribution:

downwards to anterior mediastinum.

2. Retrovisceral space is located between parietal layer of the

fourth fascia and the fifth fascia. Ways of pus distribution:

downwards to posterior mediastinum.

3. Basic neurovascular fascicle space is formed by parietal layer

of the fourth fascia. Ways of pus distribution: downwards to anterior and posterior mediastinum, upwards to the skull

base.

4. Lateral neck triangle space is located between the second and

the fifth fascias. Ways of pus distribution: in lateral direction

to the fat spaces of the shoulder girdle, downwards to

anterior mediastinum.

14. Levels and technique of ligation of carotid arteries. Ways of collateral circulation. Features of operations on veins of the neck.

Ligation of carotid arteries

Indications: injuries, aneurysms.

Approach: along the anterior edge of sternoclaidomastoid muscle

(ligation in carotid triangle).

Rules.

 Ligation of common, external and internal carotid arteries is done

1-1.5 cm indent from carotid bifurcation:

 bifurcation is carotid sinus reflexogenic zone irritation of

which results in disorders of cerebral circulation;

 thrombus which is formed at the place of vessel ligation can

close bifurcation – the basic way of collateral circulation.

 External carotid artery is usually ligated distally from the origin of

the superior thyroid artery.

Collateral circulation

After ligature of the common carotid, the collateral circulation can be perfectly established, by the free communication which exists between the carotid arteries of opposite sides, both without and within the cranium, and by enlargement of the branches of the subclavian artery on the side corresponding to that on which the vessel has been tied.

The chief communications outside the skull take place between the superior and inferior thyroid arteries, and the deep cervical artery and the descending branch of the occipital artery; the vertebral artery takes the place of the internal carotid artery within the cranium.

The features of operations on veins of the neck

 profuse bleeding from veins of the neck (high blood pressure

arises at straining efforts and cough due to the fact that veins

grow together with fascias of the neck); operation is perforemed

only under total anesthesia;

 friability of veins; hemostatic forceps on vessels should not be

left in a wound and piercing instruments should not be used;

 danger of air embolism development (due to close location of

heart and and negative pressure in pleural cavity); anatomical

operating under direct vision (fist of all ligation of vein is done if

it is necessary to sect it).

 15. Operation of tracheostomy. Kinds, indications, technique, complications.

Tracheostomy is a section of tracheal wall with following

introduction of tracheal cannula into its lumen.

Three ways of tracheostomy are distinguished according to the

place of trachea section in relation to isthmus of thyroid gland:

1. upper – section of the 2-3rd tracheal rings over the isthmus of

thyroid gland (section of the 1st ring is not allowed, it can result in

trachea deformation);

2. middle – section of the 3-4th tracheal rings at the level of thyroid

isthmus (with its section);

3. lower – section of the 4-5th tracheal rings below the isthmus of

thyroid gland (often is performed in children, ‘cause the isthmus of

thyroid places is higher).

Indications:

1. Mechanical asphyxia:

 foreign bodies of the upper respiratory tracts (when it is

impossible to remove them by direct laryngoscopy or

tracheobronchoscopy);

 disturbance of larynx and trachea patency at open and closed

injuries;

 laryngeal stenosis in case of infectious diseases (diphtheria,

influenza [flu], pertussis [whooping cough]), inflammatory

diseases (angine [acute tonsillitis], laryngitis), tumors,

allergic edema.

2. Weakness of breathing – in case when longterm artificial

pulmonary ventilation is necessary (operations on heart, lungs,

craniocerebral trauma).

Patients position: patient lies on his back with swab under

shoulders (in emergent cases a patient sits throwing his head a little bit

back). The middle of the chin, middle of thyroid cartilage incisure,

middle of jugular incisure should be on one line.

Upper tracheostomy

Stages:

 vertical incision of skin, subcutaneous fat and superficial fascia

taking the course of middle neck line from the middle of thyroid

cartilage downwards on 6-7 cm (also transverse incision can be

done at the level of cricoid cartilage);

 section of the “white line” of the neck in longitudinal direction;

 section of endocervical fascia;

 separation of thyroid gland isthmus from trachea; moving isthmus

down with a plane hook;

 fixation of larynx by sharp pronged laryngeal hook;

 section of the second or third tracheal rings directing scalpels

belly upwards from the isthmus to larynx (often trachea is sected

in cross direction between the second and third rings but not more

than half of its diameter to prevent injury of recurrent laryngeal

nerves); scalpel should be limited by plaster to remain 1 cm of its

cutting surface to prevent damage of tracheal back wall and esophagus;

 introduction of tracheal cannula and checking of its patency;

 suturing of fascias around tracheal cannula;

 loose closure of wound;

 fixation of tracheal cannula around the neck.

Advantages. Large approach to trachea due to its superficial

location and absence of large vessels in this place.

Disadvantages. Location of tracheal incision and cannula near by

cricoid cartilage and vocal apparatus.

Middle tracheostomy

Middle tracheostomy is done at wide isthmus of thyroid gland

when separation and displacement of it downwards cant be achived.

Isthmus is sected between forceps, both half of it are tied up and

capsule is sutured above them. The further stages of tracheostomy are

described above.

Lower tracheostomy

Stages:

 vertical incision of skin, subcutaneous fat, superficial and

superficial layer of deep fascias from cricoid till jugular incisure;

 disconection of suprasternal interfascial fat space in a blunt way

and displacement of jugular venous arch downwards;

 section of deep layer of propriate fascia and endocervical fascia;

 ligation of vessels of previsceral space; separation of thyroid

gland isthmus from trachea and its displacement upwards in a

blunt way;

 section of the 4-5th tracheal rings (or between them) directing

scalpels belly upwards from breast bone to the isthmus to prevent

brachiocephalic trunk injury;

 the further stages of tracheostomy are described above in upper

tracheostomy.

Advantages. Stenosis of upper respiratory tracts and injury of

vocal apparatus occur infrequently.

Disadvantages. Danger of brachiocephalic trunk injury.

Complications of tracheostomy:

1. bleeding in case of blood vessels injury;

2. air embolism in case of neck veins injury;

3. incomplete section of tracheal wall leads to the detachment of

mucous layer by cannula;

4. injury of back tracheal wall and esophagus, when scalpel is

not limited;

5. injury of recurrent laryngeal nerves when transverse section

of trachea is done;

6. discrepancy between the length of incision of trachea and

diameter of cannula: when cannula is wider necrosis of

tracheal cartilage may occur, if it is narrower subcutaneous or

mediastinal emphysema may reveal;

7. respiratory standstill as the result of reflex bronchial spasm;

8. heart arrest as the result of tracheovagal reflex.

16. Operations on thyroid gland (resection, enucleation of the node). Stages. Complications and prevention of them.

Operations on the thyroid gland

The following kinds of operations on the thyroid gland are

distinguished:

1. resection;

2. enucleation of the node;

3. combination of resection and enucleation;

4. extirpation (total removal of gland in case of tumors).

The most often pathology of thyroid gland is diffuse thyrotoxic

goiter. The method of subtotal, subfascial resection developed by O.V.

Nikolaev in case of this disease is widely adopted. Postoperative

lethality and complications of surgical treatment of Graves' disease has

decreased due to its application.

Subtotal subfascial resection of thyroid gland by O.V. Nikolaev

Patients position: lies on his back with swab under shoulders.

Stages:

 transverse incision of skin, subcutaneus fat and superficial fascia

1-1.5 cm above jugular incisure between anterior edges of

sternocleidomastoid muscles;

 longitudinal section of superficial and deep layers of propriate

fascias between sternohyoid and sternothyroid muscles;

 gripping by two surgical forceps, section and ligation of median

veins of the neck and anterior jugular veins located in or under

the second fascia;

 section of endocervical fascia;

 separation of thyroid gland from its capsule;

 section of thyroid gland isthmus between two surgical forceps;

 separation of poles of thyroid gland from its capsule;

 sequential subfascial and subcapsular grippins of thyroid gland

vessels and right lateral lobe excision;

 careful hemostasis;

 suturing of capsule by uninterrupted sutures;

 bathing of operational wound with novocain solution (for removal

of hormones which come out after thyroid gland section);

 removal of left lateral lobe of the thyroid gland by the same

methods;

 surgical revision, checking on hemostasis, layer by layer suturing.

This method allows avoiding complications connected with injury

of laryngeal nerves and parathyroid glands providing minimal

traumatisation of tissues due to ligation of thyroid vessels in space

between visceral layer of endocervical fascia and capsule of the gland.

By this way of removal blood supply of the remaining parts of gland is

very good and the risk of bleeding is minimal. Also probability of

revealing of myxedema is diminished as not whole gland is removed

(subtotal).

Complications:

1. bleeding;

2. recurrent laryngeal nerves injury with revealing of dysphonia

(in unilateral incision) and aphonia or asphyxia (in bilateral

incision);

3. removal of parathyroid glands (tetany);

4. tracheal or laryngeal injury in case of gland separation or its

goiter compression;

5. air embolism (cutting of veins after ligation);

6. thyreotoxic shock (not adequate bathing of operational

wound with novocain solution or postoperative drainage);

7. myxedema (at big amount gland tissue removal);

8. asphyxia (at big goiter leading to lysis of tracheal rings).

 17. Technique of drain of the retropharyngeal abscess. Incisions at phlegmons of the neck.

Lancing of retropharyngeal abscess

Approach – through mouth (intraoral).

Patients position – sitting.

Technique:

1. the blade of scalpel should be wraped up with a gauze or limited by

a clamp, leaving only 1 cm of its sharp end in order to prevent an

injury of tissues of oral cavity;

2. vertical 2 cm incision is made in place of bulging of the pharynx

back wall;

3. to avoid an aspiration of pus it is necessary to stoop the patient's

head forward or to use aspirator.

Operations at abscesses and phlegmons of the neck

Abscesses and phlegmons of the neck more often appear after

purulent lymphadenitis developing as a result of carrying [bringing] of

infection at tonsillitis, inflammation of upper and lower jaws, oral

cavity, middle ear, nasal cavity.

Abscesses and phlegmons of the neck are divided into superficial

and deep. Besides complications of general character, deep

inflammatory focuses of the neck are dangerous by their distribution

into fat of anterior and posterior mediastinum. This fact can lead to

trachea compression or laryngeal edema, involving in process walls of

large vessels (profuse bleeding may occur) that quite often resulting in

fatal outcome.

The basic principle of abscesses and phlegmons of the neck

treatment is incision making in order to provide complete opening and

draining of pathological focus. The incision should be strictly level-by level.

After skin section other tissues are disconnected in a blunt way

(grooved probe, closed scissors) not to hurt changed blood vessels by

pathological process. Treatment of neck phlegmons depends on their

localization.

 18. Indications and technique of vagosympathetic block by Vishnevsky.

 Topographic anatomy and operative surgery of the chest

 1. Topographic anatomy of mammary gland. Lymphatic outflow. Ways of metastasis at cancer of mammary gland. Classification of mastitis, surgical treatment. Operations at cancer of mammary gland.

Mammary gland

Skeletotopy. It is located in the region of IIIrd to IVth ribs between

parasternal and anterior axillary lines.

Structure. Superficial fascia forms a capsula of mammary gland

and divides it into 15-20 lobules by fascial septums. Every lobule ends

with milk duct. Ducts go radially to the nipples’ area and pour together

forming milk sinuses. Sinuses are opened at the nipple with milk pores.

Blood supply: branches of internal and lateral thoracic, intercostal

arteries. Deep veins correspond to the same arteries, superficial – form

rich network with many anastomoses.

Innervation: lateral branches of intercostal nerves, branches of

cervical and brachial plexuses.

Limphatic outflow. Limphatic system of the female mammary

gland and location of regional nodes represent great practical interest in

connection with involvement of the organ into malignant process.

The main way of lymphatic outflow to axillary lymph nodes occurs

through three directions:

1. through anterior pectoral lymphatic nodes which are located

at the level of the 2nd-3rd ribs by external edge of the greater

pectoral muscle;

2. intrapectorally – through nodes between greater and small

pectoral muscles;

3. transpectorally – by lymphatic vessels passing through

greater and small pectoral muscles (nodes are located

between fibrs of muscles).

Additional ways of lymphatic outflow:

 from medial part – into nodes along the internal thoracic

artery and nodes of the anterior mediastinum;

 from upper part – into supraclavicular and infraclavicular

nodes;

 from lower part – into nodes of abdominal cavity.

Operations on the mammary gland

Mastitis

Classification of suppurative mastitis:

1. superficial (premammary) mastitis developes in areolar zone or in

subcutaneous fat (between skin and capsule of the gland);

2. intramammary mastitis developes inside the gland (between

lobules);

3. retromammary mastitis developes behind the gland (between

posterior layer of capsule and pectoral fascia).

In case of premammary mastitis paraoreolar incisions or sections

in radial direction are done not affecting areola and nipple,

disconecting skin and subcutaneous fat.

In intramammary mastitis incisions in radial direction are done

not affecting areola and nipple 6-7 cm in length. Stages:

 section of skin, subcutaneous fat, tissue of the gland;

 opening of pyogenic abscess;

 destruction of intersections in a blunt way with neighboring

abcesses for formation of the united cavity;

 removal of necrotic tissues;

 careful washing of abscess cavity by antiseptic solution;

 drainage.

In case of retromammary mastitis arched incision is done along

the underbreast fold, disconecting skin and subcutaneous fat. Then the

gland is scaled off from the deep fascia and pyogenic abscess should be

opened. The cavity of the abscess is also drainaged through additional

section in the opposite side from the place of operative approach.

Surgical treatment of mammary gland tumors

 Treatment of benign [innocent] tumors

Sectoral resection of mammary gland is removal of the affected

gland sector.

 Treatment of malignant tumors

A. Radical

 Standard radical mastectomy by Halsted is removal

of the mammary gland together with greater and

small pectoral muscles, fat and lymph nodes of

axillary, subclavian and scapular regions.

 Economical

 Radical mastectomy with preserving (saving) of

greater pectoral muscle by Peyti. It is removal of

the mammary gland together with small pectoral

muscle, fat and lymph nodes of axillary,

subclavian and scapular regions.

 Radical mastectomy by Madden is removal of the

mammary gland together with fat and lymph

nodes of axillary, subclavian and scapular

regions.

 Organopreserving

 Radical sectoral resection of the mammary gland

with lymphodissection – removal of a gland’s

sector together with fat and axillary lymph nodes,

subclavian and scapular regions.

B. Palliative

Simple [total] mastectomy is removal of mammary

gland. It is applied in tumor degradation (danger of

bleeding, sepsis from infected tumor) and evident pain

syndrome.

Breast cancer spread occurs through lymphatic and

hematogenous channels. Outer quadrant and centrally

located lesions typically spread first to the axillary nodes.

Those in the medial inner quadrants often travel first to

lymph nodes along the internal mammary arteries. More

distant dissemination eventually ensues, and can involve

virtually any organ or tissue in the body. Favored locations

are the lungs, skeleton, liver, adrenals, and (less commonly)

brain, but no site is exempt. Metastases may come to clinical

attention many years after apparent therapeutic control of the

primary lesion, sometimes as long as 15 years later. Nevertheless,

with each passing year without disease recurrence, the

likelihood of cure increases.

2. Topographic anatomy of intercostals space, pleural cavity, lungs. Pleuracentesis: indications, technique, complications.

Intercostal space is a space between over- and underlying ribs

bounded by external and internal intercostal muscles, containing fat

tissue with intercostal vessels and nerves.

External intercostal muscles are located between tubercles of ribs

and external edges of costal cartilages. In the region of costal cartilages

muscles are replaced by external fibrous intercostal membrane. The

direction of fibres of external intercostal muscles – from above

downwards and from behind to front.

Internal intercostal muscles are located between costal angle and

breast bone. From the costal angles till vertebral column muscles are

replaced by thin internal fibrous intercostal membrane. The direction

of fibres of internal intercostal muscles – from below upwards and

from behind to front.

Intercostal arteries can be divided into anterior (branches of

internal thoracic artery) and posterior (begin from thoracic aorta except

two superior arteries – start from costocervical trunk of subclavian

artery).

Intercostal vein is located higher and intercostal nerve lower than

artery. From the spinal column to the angle of the rib (to posterior

axillary line) intercostal fascicle passes in groove of rib and is covered

by the rib. To the front of posterior axillary line it goes from under the

rib. Because of topographoanatomical features of neurovascular

fascicle punctures of pleural cavity are done in VII-VIII intercostal

spaces by the upper edge of the rib between scapular and posterior

axillary lines.

Pleura

Pleura forms two serous sacs. Between two layers (parietal and

visceral) there is small space – pleural cavity. Parietal pleura covers

internal walls of the thoracic cavity and bounds mediastinum. This way

three parts are distinguished in the parietal pleura: costal,

diaphragmatic and mediastinal. The places of pleural cavity which are

located between parts of parital pleura are called sinuses or recesses

(costodiaphragmatic, costomediastinal, phrenicomediastinal).

Visceral pleura covers lungs.

Lungs

Three surfaces are distinguished in every lung: external or costal,

diaphragmatic and medial.

Each lung is divided into lobes. Three lobes are located in the

right lung (superior, middle and inferior) and two in the left lung

(superior and inferior). Lungs are also divided into segments.

Bronchopulmonary segment is a part of lung, which is ventilated by the

third order bronchus (segmental bronchus) and supplied by segmental

vessels. There are 10 segments in each lung.

Gates are located on medial surface of each lung. Anatomic

formations of lung root passes in them: bronchus, pulmonary arteries

and veins, bronchial vessels and nerves, lymph nods. Skeletotopy of

lungs' root: V-VII thoracic vertebras.

Syntopy of elements of lungs' root:

 top-down: right lung – primary bronchus, pulmonary artery,

pulmonary veins; left lung – pulmonary artery, primary

bronchus, pulmonary veins.

 front to back – pulmonary veins, pulmonary artery, primary

bronchus in each lung.

Pleuracentesis (puncture of pleural cavity)

Indications:

1. specification of the diagnosis (for effusion character

detection);

2. removal of exudate in case of exudative pleuritis, hemo- or

hydrothorax;

3. removal of air in case of pneumothorax.

Patient’s position: sitting, leaning on back of chair, the hand from

the of puncture side is abducted behind the head.

Technique:

 local infiltrative anesthesia of soft tissues;

 displacement of the skin downwards; 3-4 cm puncture by the

"closed needle" (at the end of the needle a rubber tube closed by

hemostatic forceps must be placed to prevent development of

pneumothorax) of intercostal spaces by the upper edge of the rib

(to prevent injury of intercostal neurovascular fascicle);

 in case of hydrothorax puncture is made in VII-VIII intercostal

spaces between scapular and posterior axillary lines (in case of

pneumothorax – in II intercostal space along medial clavicular

line);

 the needle is placed on the syringe and contents is removed (fluid

is evacuated slowly by portions of 10-20 ml and no more than 1 l

at once).

Complications:

1. injury of intercostal neurovascular fascicle;

2. injury of lungs, diaphragma, liver, spleen;

3. pleuropulmonary shock (in case of rapid evacuation of fluid);

4. pneumothorax (when punction is made with «unclosed»

needle).

 3. Topographic anatomy of organs of mediastinum.

Mediastinum

Mediastinum is the complex of organs, vessels and nerves,

bounded by mediastinal pleura from sides, behind – by bodies of thoracic

vertebras and ribs, infront – by sternum, from below – by diaphragm,

above communicates with neck spaces.

Classification:

1. Superior mediastinum is located from the upper border of thoracic

cavity to tracheal bifurcation.

42

Contents: arch of aorta; brachiocephalic trunk; left common

carotid artery; left subclavian artery; thymus; brachiocephalic

veins; superior vena cava; phrenic nerves; vagus nerves; recurrent

laryngeal nerves; trachea; esophagus; thoracic duct; paratracheal,

superior and inferior tracheobroncheal lymph nodes, fat.

2. Anterior mediastinum is located between sternum and pericardium

lower than tracheal bifurcation.

Contents: parasternal and superior phrenic lymph nodes; thymus

and internal thoracic arteries, fat.

3. Middle mediastinum

Contents: pericardium; heart; ascending aorta; pulmonary trunk;

pulmonary arteries and veins; primary bronchi; superior segment

of superior vena cava; phrenic nerves; pericardiacophrenic

arteries and veins; lymph nodes, fat.

4. Posterior mediastinum is located between pericardium and spinal

column.

Contents: descending aorta; esophagus; vagus nerves;

sympathetic trunk and greater and lesser splanchnic nerves;

azygos vein; hemiazygos vein; thoracic duct; lymph nodes, fat.

 4. Pneumothorax. Kinds. First aid, first medical assistance and specialized treatment of pneumothorax.

Pneumothorax

Pneumothorax is accumulation of the air in the pleural cavity.

Classification:

 external – air comes into the pleural cavity from outside through

the hole in the chest when parietal pleura is injured;

 internal – air comes into the pleural cavity through the wound of

bronchus or lung when visceral pleura is injured.

External and internal pneumothoraxes are divided into closed,

open and valvate one.

1. Closed. Single penetration of the air into the pleural cavity with

subsequent isolation of pleural cavity from outside environment.

2. Open. Circulation of the air in the pleural cavity, bilateral

communication between pleural cavity and outside environment

(air penetrates into pleural cavity during inspiration and leaves it

at expiration);

3. Valvate. Air passes only into the pleural cavity and doesn’t leave

it due to the valve. The most severe form of valvate pneumothorax

when the pressure in the pleural cavity becomes equal to

atmospheric or even higher is called pressure pneumothorax. In the

result the air can’t penetrate into the pleural cavity anymore. It

results in dislocation of mediastinum with compression of organs.

Treatment of pneoumothorax:

First aid: use of occlusive dressing onto the wound (in external

pneumothorax).

First medical assistance: treatment of pleuropulmonary shock;

pleurocentesis in cases of considerable air accumulation at risk of

patient’s death.

Specialized help

 In case of external pneumothorax initial surgical d-bridement with

tight wound closure should be used.

 In case of internal pneumothorax:

1. in closed pneumothorax if the lung is compressed more than

1/4 of its volume pleurocentesis is performed (small amount

of air (300-500 сm3) is spontaneously absorbed during 2-3

weeks).

2. in open pneumothorax operation is directed on licvidation of

injury. Approach to the thoracic cavity and closure of the

wound of bronchus or lung is performed.

3. in valvate pneumothorax the principle of operation is

following: thoracotomy with suturing of bronchus or lung

wound and active or passive drainage of the pleural cavity.

 5. Resection of the rib. Kinds, indications, technique, complications.

Resection of the rib

Classification:

1. subperiostal;

2. transperiostal.

Subperiostal resection of the rib

Indications: operative approach to pleural cavity and organs of

thoracic cavity at thoracoplasty; in osteomyelitis or tumors of the rib

when periosteum is not involved in the process; drainage of pleural

empyema and abscesses of the lung; as plastic material for osteoplasty.

Transperiosteal resection of the rib

Indications: osteomyelitis of the rib.

The feature of operation consists in impossibility to exfoliate

periosteum along the all extent from the involved part of the rib. The

essence of operation consists in separation of the rib from intercostal

muscles and resection of the involved part together with periosteum

and scar tissue.

Complications:

 bleeding in case of intercostal vessels injury;

 pneumothorax in case of parietal pleura injury;

 hemopneumothorax in combined injury.

 6. Approaches to organs of the thoracic cavity.

Operative approaches to organs of thoracic cavity

(thoracotomy)

Anterolateral thoracotomy – incision is done through the fourth

intercostal space from parasternal till posterior axillary line (section of

the third or fourth costal cartilages is done when it is necessary to

expand approach in pleural cavity or mediastinum).

Posterolateral thoracotomy – incision is done through the fourth

intercostal space from paravertebral till anterior axillary line (resection

of neck of III-IV ribs is done to expand approach in pleural cavity or

mediastinum).

Lateral thoracotomy – incision is done along V-VI ribs from

paravertebral till medial clavicular line.

Longitudinal sternotomy – incision is started 2-3 cm higher than

manubrium of sternum and is finished 3-4 cm lower than xiphoid

process.

Transverse sternotomy – section of sternum is done at the level of

IV intercostal space.

 7. Operations on the lungs: pneumotomy, pulmonectomy, resection (lobar, segmental).

Operations on lungs

Pneumotomy

Classification:

1. single-stage pneumotomy is performed when there are adhesions

between parietal and visceral pleura;

2. double-stage pneumotomy is performed when there are no

adhesions between parietal and visceral pleura;

Indications: abscesses, caverns, foreign bodies of the lung.

Technique:

 subperiosteal resection of the rib;

 section of periosteum;

 section of parietal pleura at the lewel of adhesions 6-8 cm in

length (at adhesions absence they must be formed by connection

of parietal and visceral pleura);

 puncture of abscess cavity by long needle with wide lumen;

 lancing of abscess along the needle;

 drainage.

Pulmonectomy

Technique:

 posterolateral approach;

 pneumolysis (separation of the lung from pleural adhesions);

 section of mediastinal pleura;

 sequential processing of elements of lung root (ligation of

structures): artery, vein and bronchus (at cancer – vein, artery,

bronchus);

 removal of the lung;

 checking the bronchial stump tightness (hermiticity) – pour

physiological saline into pleural cavity and blow out lungs,

watching blebs (bubbles);

 putting drainage into pleural cavity;

 wound closure.

8. Technique of wound closure of the heart. Pericardiocentesis. Concept about aortocoronary by-pass, balloon angioplasty, stentation and heart transplantation. Methods and complications.

Suturing of heart injuries

 approach is made by the course of wound canal;

 longitudinal section of pericardium in front of phrenic nerve;

 the wound is usualy closed by interrupted sutures (endocardium is

not sutured);

 revision of the opposite heart wall;

 removal grumes from pericardial cavity;

 loose closure of pericardium wound.

Pericardiocentesis

Indications: specification of the diagnosis or treatment of

exudative pericarditis.

Technique of pericardiocentesis by Larrey:

 puncture is done between xiphoid process and costal arch from

the left under corner 45° to the surface of human body on depth

1-1,5 cm by thick needle;

 than the needle is moved in parallel to the sternum into

anteroinferior part of pericardial cavity (till needle pulsation);

 removal of exudate from pericardial cavity.

Technique of pericardiocentesis by Marphan

 puncture is done under the top of xiphoid process out of internal

thoracic artery projection.

Surgical treatment of ischemic heart-disease

Closed methods include balloon dilatation, stenthation of

coronary arteries.

Open methods include aortocoronary bypass, implantation of

internal thoracic artery into myocardium, pericardiacocardiopexy,

omentocardiopexy, diaphragmocardiopexy, jejunocardiopexy, ligation

of internal thoracic arteries.

Stages of aortocoronary bypass:

1. operative approach to the heart (median sternotomy);

2. autograft intake (deep artery of thigh, inferior epigastric,

radial, gastroepiploic and internal thoracic arteries, great

saphenous vein);

3. connection of medical blood circulation apparatus;

4. anastomosis between aorta and coronary artery;

5. disconnection of medical blood circulation apparatus;

6. wound closure and drainage of pericardial cavity.

Heart transplantation

For the first time heart transplantation was made in 1967 by

Christian Bernard. The patient died 16 days after operation from

bilateral pneumonia and graft rejection.

Indications: end-stage heart failure, severe coronary artery

disease.

Period of conservation of the heart in clinic is not more than 3-4

hours. Heart selection for sizes is very important to prevent serious

inadequacy at creation of atrial and vascular anastomoses. The

extremely important method of research is echocardiography allowing

to estimate heart contractility and to reveal focal lesion of contractile

muscle function.

Kinds of heart transplantation:

 orthotopic procedure implies that the patient's own heart is

removed;

 heterotopic procedure implies that the patient's own heart is left in

to support the donor heart.

Technique of orthotopic heart transplantation:

 patient is attached to cardiopulmonary bypass;

 the failing heart is removed by transecting the great vessels and a

portion of the left atrium (major part of left atrium and all right

atrium with other vessels are not removed);

 suturing of donor heart in such sequence: left atrium, interatrial

septum, pulmonary artery, aorta;

 heart is restarted, the patient is weaned from cardiopulmonary

bypass.

Post-operation survival period now averages 15 years.

 9. Topographic anatomy of diaphragm.

Diaphragm

Diaphragm is musculotendinous formation, basis of which is wide

and thin muscle with cupula inverted upwards into thoracic cavity.

There are two parts in diaphragm: tendinous and muscular.

Tendinous part forms right and left cupulas and also cardiac

impression of diaphragm. Anterior, right and left lateral departments

are distinguished in it. Aperture for inferior vena cava is located in

anterior part.

Muscular part of diaphragm is divided into three departments:

lumbar, sternal and costal.

1. Lumbar part begins from four upper lumbar vertebras by right

and left crura of diaphragm. In lumbar part two apertures are

formed by crossing of crura as figure 8: aortic hiatus, through

which descending part of aorta and thoracic duct pass and

esophageal opening – esophagus and vagus nerves. Azygos and

hemiazygos veins, splanchnic nerves and sympathetic trunk pass

between muscular fascicles from sides of crura of the diaphragm.

2. Sternal part begins from internal surface of the xiphoid process.

3. Costal part begins from VII-XII ribs.

Weak areas:

 lumbocostal triangles (Bochdalek's gap) are located between

lumbar and costal parts of the diaphragm;

 sternocostal triangles are located between sternal and costal

parts of the diaphragm.

Endothoracic and endoabdominal fascias adjoin in these areas.

Diaphragmatic hernias and pus from subperitoneal fat can come into

subpleural space at destruction of fascial sheats by suppurative

processes through these weak areas. Esophageal opening is another

weak area of diaphragm.

Blood supply: internal thoracic, superior and inferior phrenic,

intercostal arteries.

Innervation: phrenic, intercostal, vagus and sympathetic nerves.

10. Concept about surgical treatment of acquired and congenital heart [valvular] diseases. Esophagoplasty.

Operations at heart deseases

Valvular insufficiency of tricuspid and mitral valves is a

replacement of the valve by mechanical or biological prosthesis.

Stenosis of tricuspid and mitral valves is valvuloprserving

operation: open commissurotomy and annuloplasty (restoration of

blocking function of mitral valve with the help of a rigid basic ring).

Atrial septal [atrioseptal] defect is suturing of a defect in patients

with presence pulmonary hypertension or plastics of septum by piece

from autopericardium (synthetic tissue) in case of large diameter of a

defect.

Ventricular septal defect.

 radical operation is defect closing by interapted sutures or plastics

of septum by piece from synthetic tissue or biological material at

great diameter of defect.

 palliative operation is contraction of pulmonary artery by a cuff

(it decreases blood shunting through defect and reduces volume

of pulmonary blood flow and pressure in pulmonary artery).

Non-closed arterial [Botallo's] duct is ligation of the duct by two

ligatures.

Coarctation of aorta is resection of the aorta at the site of

constriction with subsequent prosthetics by synthetic transplant or

making shunt between subclavian artery and aorta lower than place of

stenosis.

Surgical treatment of ischemic heart-disease

Closed methods include balloon dilatation, stenthation of

coronary arteries.

Open methods include aortocoronary bypass, implantation of

internal thoracic artery into myocardium, pericardiacocardiopexy,

omentocardiopexy, diaphragmocardiopexy, jejunocardiopexy, ligation

of internal thoracic arteries.

Stages of aortocoronary bypass:

1. operative approach to the heart (median sternotomy);

2. autograft intake (deep artery of thigh, inferior epigastric,

radial, gastroepiploic and internal thoracic arteries, great

saphenous vein);

3. connection of medical blood circulation apparatus;

4. anastomosis between aorta and coronary artery;

5. disconnection of medical blood circulation apparatus;

6. wound closure and drainage of pericardial cavity.

Heart transplantation

For the first time heart transplantation was made in 1967 by

Christian Bernard. The patient died 16 days after operation from

bilateral pneumonia and graft rejection.

Indications: end-stage heart failure, severe coronary artery

disease.

Period of conservation of the heart in clinic is not more than 3-4

hours. Heart selection for sizes is very important to prevent serious

inadequacy at creation of atrial and vascular anastomoses. The

extremely important method of research is echocardiography allowing

to estimate heart contractility and to reveal focal lesion of contractile

muscle function.

Kinds of heart transplantation:

 orthotopic procedure implies that the patient's own heart is

removed;

 heterotopic procedure implies that the patient's own heart is left in

to support the donor heart.

Technique of orthotopic heart transplantation:

 patient is attached to cardiopulmonary bypass;

 the failing heart is removed by transecting the great vessels and a

portion of the left atrium (major part of left atrium and all right

atrium with other vessels are not removed);

 suturing of donor heart in such sequence: left atrium, interatrial

septum, pulmonary artery, aorta;

 heart is restarted, the patient is weaned from cardiopulmonary

bypass.

Post-operation survival period now averages 15 years.