Veterinary medicine for all - all for veterinary medicine. Conicotomy.

When resection of the rib the edge of the shoulder along the lower edge of the rib is easier to move, if it is straight from the front to the back, and along the upper edge of the navpak - from the rear edge of the wound forward. It should be explained directly by the muscular fibers of the larger straining ball of the mid-ribbed mussels, going from the top to the back - downward forward.

at rosin pleural emptying along the intercostal space without resection of the rib, bleeding is not possible, if the joints are distributed exactly along the middle line of the intercostal prominences. When there are rosters along the edge of the rib, the hemostasis is viral. In case of emptying pleural emptying by the method of removing the lung with a scalpel. In order to uniquely unify the legends, it is easy to create a small space in the great country - 5-6 cm. From the skin ball, the assistant spread the edge of the branching fibers of the branches of the Kocher’s lock and podsushu tupfom.

pislya distribution of both balls of the interregional rings and a leaf of the internal thoracic fascia contains one leaf of the parietal pleurisy, across the surface of the collapsed lung can be seen. At the moment, the parietal pleura is not broken with a scalpel, but pierced in a blunt way, for example, with the handle of a scalpel.

It is even more evident in the functional related open the pleural emptying behind the ribs from the edges of the side according to Johnson, Kirby (1954). With the same method of opening the edges, they protrude 5-7 mm from the upper edge of the rib along the front surface, then peel off from the last surface of the rib to the upper edge and then from internal surface the ribs extend 7-8 mm behind the ribs of the margin, the inner fascia of the breasts and the pleura with a scalpel 2-3 cm in length, and if the pneumothorax is established and the legs fall off, continue the opening with knives in front and back. With this method, inter-hair loss, energy and blood circulation are obtained.

zakritta raani breastfeeding after the end of the main stage of the operation, carry out in batches. To remove the mid-ribs from the ball with access without resection of the rib, complete the two ribs with ligatures from a tovst catgut. When resecting the ribs of the mid-ribbed joint, it is necessary to sew on the whole protrusion with extraordinary vuzluvaty sutures from the catgut or nylon with gaps of 10-12 mm. Sealing of inter-ribbed joints with a "chrestopodibnym" suture fixing the ribbing with the shortened edge of the muffs on the wall, so that at the other half of the stench the bridles of the ribs will stretch.

vilny edge From the west to the chest emptying, farther away the overlap of the seams will slow down, the seam becomes leaking. The price of the tightness of the muscles of the bridle of the ribs becomes the reason for the tricky ones in the early stages of the operation because of the intercourse of the mental collars.

Z'єdnannya m'yaziv breast to carry out thoroughly the following: a line of seams on the jaw of the back from the front cut of the wound to the posterior edge of the anterior jaw and another row of seams on the best of the back and on the fascia of the breasts. Z'єdnannya both m'yazіv one row of shvіv mensh docіlno. On the right, when the fibers of the ciches of the muffs grow out perpendicularly one to one and the functions of the prototypes: the anterior tooth muff replaces the scapula and the shoulder girdle forward, and m.latissimi dorsi bring the shoulder and the shoulder girdle forward.

Moreover, with z'єднанніїх one row of shvіv (tacitly іn order to hesitate a lot of surgeries for an early hour of the operation) we must take into account the renewal of the functions of the upper picture and a trivial hour (up to 6 months of Russian)

Superficial fascia of breasts dozіlno z'єdnuvati we will surround a number of shvіv. As a result, the oper- ating cicatrix takes on a linear form and does not transform into a wide swamp.

Operations at the Ministry of Health.

1. Operations for mastitis.

Classification of mastitis:

1. Premammary.

2.intramammary.

3. retromammary.

4. Subalveolar.

technology: hіd rozrіzu Doctor of Biological Sciences do not pass over to the areola near the nipple (rhizic malignization, milk fistula can be established), D.Sc. reach wide (width is 2 times greater than gibini). Trivial hour the abscess is localized in 1 part, ale m. and in 2 pieces. A wound in the edge is important to get rid of and drenuvati.

2. Operations for cancer MH.

‣‣‣ Radical mastectomy for Halstead. The bordering height is 5-6 cm along the edge of the puff - the spindle-shaped approach. Visible mm. pectoralis major et minor і l / u from the groin fossa.

‣‣‣ Expanded mastectomy for Urban (do not get stuck). At the same time, the ribs are resected, and the l / y can be seen along the a. thoracica interna.

‣‣‣ Mastectomy by Petit - to save m. pectoralis major . At times yaksho< опухоль и нет метастазов.

‣‣‣ Sectoral resection of the Ministry of Health. Once you have it< опухоль и нет метастазов.

show:

1. For prompt access to the pleural empty space.

2. When thoracoplasty.

3. With lesions of the ribs, osteomyelitis.

4. For draining pleurisy.

read:

1. subperiosteal.

2. Chreznadkostnichnaya.

thoracoplasty- XO is straightened on ↓ chest empty. The operation will continue.

show:

1. Cavernous form of tuberculosis.

2. Chronic pleurisy rate.

Classification:

1. Extrapleural.

2.intrapleurally.

‣‣‣ Sposib Shede – vykryuєtsya shkіrno-pіdshkіrny klapot, resected ribs, see mu'yazyu, bandage the judges, m'yaki pryvlyuyutsya in the middle.

‣‣‣ Sposib Linberg (Shodova thoracoplasty) - one rib is resected from below, the posterior wall of the eye is removed, the edge of the empty space is cut and the ribs are gradually incised and the edges are opened to create the meshes. Їх rise along the call and in the middle and press in the middle.

Puncture of pleural emptying. Frequent operation.

show: Vidalennya krovі, exudate lіmfi, povіtrya і T. D.

Vykonutsya in 7-8 mid-ribs on the scapula or back groin lines. The cordon is used percussion and radiological.

technology: The position is sedentary, anesthesia is carried out, the screen is moved to the bottom, with a syringe with an adapter, a puncture is made along the upper edge of the lower edge of the cutting edge perpendicularly by 3-4 cm, then turn up the hill. Only one time I see no more than 1 liter.

expedited:

1. Poshkojennya of the neurovascular bundle.

2. Poshkojennya pechinki.

3. Hit the pleural empty space. Vidalennya povitrya - along the midclavicular line in 2-3 mіzhreber'ї.

pneumothorax- drinking in the pleural empty space.

Classification:

1. Inspection.

2. Zakritiy.

3. Valve.

For the obviousness of the business breast cancer:

1. Zovnishniy.

2. Internal.

‣‣‣ zakritiy - a one-time meal of the meal (if there is a small stab wound, there is a substitution of mutilation). After 7 days, it’s getting wet on its own.

‣‣‣ vidkritiy - a permanent link with a navkolishn_m middle. Vinnikal change of organs of the middle, decay of the leg, pleuropulmonary shock.

‣‣‣ valve - as soon as there is a navkolishnіm middle, the valve is formed. I get into the breath, but I can't get through to the vidiha. Severe pleuropulmonary shock.

Aid for pneumothorax infection:

‣‣‣ 1st help - rose by the appearance of the middle middle (occlusive dressing).

‣‣‣ Lykarska dopoga - change in the effectiveness of the dressing, prevention of pleuropulmonary shock (vagosympathetic blockade according to Vishnevsky).

‣‣‣ Hirurgic additional help - to visit the thoracic viddil enii (cleaning of the wound, aspirating blood, suturing tissue).

The first help with valve pneumothorax is a puncture of the chest wall with a bare one (re-adaptation of the valve pneumothorax in vidkritias). The main operation is thoracotomy for suturing the wound of the lung or the bronchus. Drainage according to Petrov, according to Bulau.

Rib resection. - understanding and seeing. Classification and features of the category "Rib resection." 2014 rock, 2015.

At the surgery of milk cancer, in the given hour, the onset of the operative engagement will take place:

A. Radicals:

I. Standard radical mastectomy (According to V.Hol-

Stead і V. Meyer) - a view of the milky zone with a chubby single block with a small and large breast ointments and a clutch of subcrillus, subclavicular and subscapular areas with lymph nodes.

59

II. economy:

1. Radical mastectomy for the preservation of the great breast meat(According to Petya) -vidualnya milky zolozi with tumors, a single block with a small thoracic ointment and clavicular groin, pidclavicular and subscapularis areas with lymph nodes.

2. Radical mastectomy according to Madden– vividly

lokochnaya zolozi with a chubby single block with cells of the pid-myazovoi, subclavicular and subscapular regions with lymph nodes.

III. organ preservation:

Radical sectoral resection of the milk layer with lymphodissection-Visibility in the boundaries of healthy tissues of the affected sector zolozi with cells of groin, subclavicular and subscapular regions with lymph nodes.

B. Paliativny:

Simple (sanitary) mastectomy - you can see only a dairy zolozi with chubby. Stagnation in case of swelling (threat of bleeding, development of sepsis with inflamed swelling) and severe pain syndrome.

rib resection

Classification:

1) subperiosteal;

2) transperiosteal.

subperiosteal resection

showing: Prompt access to emptying pleura and organs of breast emptying during thoracoplasty; striking the ribs with os-teomielit or chubby, if in the process you overshadow the posture with respectful over-hand; draining pleurisy and lung abscess; rejection of plastic material.

Excessive resection of the rib

show: the striking of the ribs osteomyelitis.

To the peculiarities of the operation, it is recognized that it is unfortunate to trace the edge on the whole protrusion of the damaged rib. The essence of the operation of the clearing is at the raised ribs from the inter-Bernese muses and resection of the lesion at the same time from the Nadkamy-stnitsy and scar tissue.

Folding for rib resection:

bleeding in case of ushkodzhennі interstitial vasculature; pneumothorax in case of partial parietal pleurisy;

pneumothorax and hemothorax with one-hour delayed pleurisy and sudin.

Peratsimu with the growth of grizzly diaphragms

with a central grizzly rosette and a small defect, there is a little bit of gryzhovoy defect, and the edge of the defect is sewn with a noble suture seam;

where the area of ​​the thinned tendon part with diaphragms passes through half of the dome, the defect with diaphragms is

We are greeted with a little bear on the statements of the dubs, who go to the edges with the help of diaphragms. With pomilkovy gryzha diaphragms - bringing organs

black emptying and suturing to a defect with diaphragms with a path from the edges of the edges with vuzluvatiy abo mattress seams. For a great defect, a vicious defect in the way of bi plastics.

surgical treatment leikopodibnoi i keeled breasts

To carry out with the manifestation of a great deformation of the breast cell with a distribution of the function internal organs from vіtsі up to 7 -8 rockіv. The operation is carried out until the sternum is reclined and the rib cartilage is cut with the onset of fixation in the normal position.

Puncture of the pleural emptying Shown:

1) clarification of the diagnosis (with the mark of the character of the vipot);

2) seeing eksudat on the next

pleural emptying Lykarskiy rechovin;

3) seeing the show.

The position of the sick: seated, spiraling onto the back of the stile, the hand to the side is inserted behind the head.

technology

Infiltration anesthesia of soft tissues; replacement to the bottom of the shkiri, vkaluvannya heads 3-4 cm on top

ny edge of the lower rib (the head is guilty of buty

that with a hum pipe, a tampon is applied to the yak);

in case of hydrothorax, a puncture of the pleurisy should be carried out in 7-8 mid-ribs along the posterior groin or the scapula (in case of pneumothorax, the puncture of the empty pleura is carried out in 2-3 mid-ribs along the midclavicular line);

donating a syringe and seeing it together (when it comes to dry, not more than one liter).

expedited:

1) injury of mid-ribs and nerves;

2) popping legends, diaphragms, liver, spleen and in.;

3) pleurisy-pulmonary shock (with a quick evacuation instead of emptying the pleura);

4) pneumothorax (with "non-closed" golts).

Puncture of the pericardium Shown: with diagnostic abnormalities,

it is important for vip pericarditis.

Puncturing technique by Larry

puncture of the mallet between the sword-like spine and the ribbed arc along the 45 ° cut to the surface of the floor for a 1-1.5 cm depth with a solid bare;

nahil the heads to the bottom, right parallel to the sternum, and letting go in the anterior lower pericardial cavity (seeing the pulsation of the head);

vityag eksudatu from pericardial emptying.

Puncturing technique according to Marfan

the puncture point is located at the top of the sword-like overhang, the position of the projection of the internal thoracic artery.

pneumothorax

Pneumothorax is a manifestation of a pleural effusion.

Classification:

call- Penetrating through the wound of the breast tissue, tobto. in case of partial pleurisy;

internal-When there is a lung wound, or if the bronchus is obstructed, tobto. with posture visceral pleurisy.

The name and internal pneumothoraxis are: twisted, open and valve.

1) zakritiy- one-time drinking of pleurisy and emptying of pleurisy with the atmosphere;

2) vidkritiy- after the appearance of the pleural cavity with atmospheric conditions (for an hour the air is inhaled through the wound into the pleural empty space, and when you see it, you will be called);

3) valve- the need to drink only in the pleural empty through the presence of the valve (increasing accumulation of energy in the pleural empty).

Etapi additional help with pneumothorax:

Uninvolved medical aid-imposition of a wound occlusive dressing (in case of pneumothorax).

lykarska help-wrestling with pleurisy-pulmonary sho-com; punctation of the emptying of the pleurisy (with a stressed pneumothoracic).

special assistance

In case of acute pneumothorax, it is the primary surgical treatment of the wound and hermetic suturing.

With internal pneumothorax:

1. With closed pneumothorax: if it is easier to get rid of it by 1/4 of its volume - pleural point (there is not a large number of twigs (300-500 cm 3) to blot out 2-3 times).

2. When pneumothorax is diagnosed, the operation is aimed at eliminating pneumothorax: testing of thoracotomy and suturing of a lung wound.

3. In valvular pneumothorax, the main operation is thoracotomy with sutures of the lung wound or bronchus and active or passive drainage of the pleural tissue.

Growth in mastitis.

Molochna zloza - can stretch from II to YI ribs in the anterior-upper region of the breasts. Zaliza lie on the great breast meat and partly - on the anterior teeth, moreover, it is seen from them by the hairy fascia of the breasts.

Molochnaya zloza is otochened by a capsule, approved on top of their fascias, as it lasts for 2 leaves, so that it will hunt the zloza from the front and from the back. Fascia to attach to the collarbone, attaching to the sound of the lick (lig. Suspenorium mammae) or Cooper's sound (Cooper, 1845).

Frequently, the hairy tissue on the milky zone grows up to the groin fossa near the groin of the groin (tail) of Spence; The top of the whip penetrates into the fossa axillaris through the fissure in the hairy fascia, called the Langera opening.

The zalosa is stored in 12-15 parcels, radially roasted. The nipple is pricked, discharge with a pigmented areola, there can be 4 types of budovi: cone-shaped, knotted with sweats, cylindrical and retracted.

The nature of operations in case of ginny mastitis will lie at the stage of broadening and localization of the ignition process.

Razrіznyayut such types of mastitis: superficial, і intramammary and retromammary.

The superficial mastitis grows in the peri-ocular zone, or above the stroma, zolozi without the middle before the shkiroyu. From a small part of the gn_ynniki, they are crushed by a capsule of milk.

Intramammary abscesses roztashovani in pieces of self. Rozpodil їkh on parenchymal and interstitial lay in the way of penetrating infectious ear.

In case of parenchymatous mastitis, striking a small part of it along the milk paths;

In the case of interstitial ones, a second igniting reaction of the nobles of the introduction of the infection along the lymphatic paths develops.

The retromammary abscess grows out of the lumpy leaf of the milk capsule, back and forth between the superficial leaf of the fascia of the breasts, which covers the great breast mucus.

In case of superficial mastitis, it is possible to control radial growth on the screen and on the pediatric cells.

Intramammary abscesses also develop with radial growths of up to 6-7 cm, as do not go beyond the navkoloskovy rim. When the wounds of the septum are closed, the septum grows open, there is wide access for the discharge of pus.

In case of multifocal phlegmonous mastitis, a few radial changes are carried out, but not infrequently until the lactation function is destroyed. In case of single and isolated gnaric infections, an enlarged aspiration puncture with pus with further prominences and antibiotic abscesses introduced into the empty abscess.

The retromammary phlegmon is opened along the transitional storage of the milk layer by means of Bardengeier's filling, carried out along the ridge fold under the layer.

Pozharovno roztinayut shkіra and pedshkіrna klіtkovina, stupidly penetrate into the space between the back surface of the milky zone and the front surface of the great breast meat. Drenched the wound.

For the whole dairy plant, it is necessary to burn and carry out the growth along the transition folds, penetrating into the depth of tissue between the back surface of the plant and the fascia, so that the great breast mucus is curved, and it is not bought up. In case of manifestation of malignant internal iron mastitis with radial growths on the back (bare) surface, open the gland in the head.

Radical mastectomy.

Breast cancer is one of the most widespread poop in females in 45-55 years and is estimated at 125 per 100 yew. Population. bum pathogenetic factor It is hormonal overbudding, it is not included in the genetic strength and varied genesis. To obey voryuvannya with the appearance of lonely cancer cells zazvychay in the last upper quadrant of the zolozi.

The development of the role of secondary and regional lymphatic vascular disease in metastatic cancer of the lactic acidosis was allowed to arise, so that the lymphatic drainage occurs in the next steps:

1. For the groove, go to the anterior chest lymph nodes and distant through the groin, and sometimes through the pedclavian nodes to the supraclavicular ones. The smacking of groin universities, like the first bar on the way of chubby clits, will appear at 1 / 2-2 / 3 of the operative ailments with cancer of the milk frog.

2. Behind the clavicle path to the current, through the comradeship of the great breast and interpectival - between the great and the small breast to the lymph universities of Rotter.

The smashing of the switchyears of higher education is promoted in approximately 1/4 of the operating ailments. I will look at the tight connections between the supraclavicular universities and the supraclavicular ones, the possibility of direct expansion of the swelling into the venous blood flow with the invasion of the collector has a significant prognosis.

3. For the parasternal route to the universities, which were roasted along the vasa thoracica interna in the cases between the mid-ribs and the intrathoracic fascia, between I and Y between the ribs along the edge of the sternum.

4. Behind the mediastinal path to the current, tightly tied with the parasternal collector. Whenever a judge is brought in, they go directly to the parasternal universities, so they go to the thymus, tracheo-bronchial and peribronchial universities.

5. For the mid-ribbed path, go to the parasternal universities and pleurisy, or along the mid-ribbed vessels to the rear group of intermediate universities.

6. Behind the groin pediatric lymphatic vessels to the contralateral inguinal lymphatic universities and milk lobes. Tsei shlakh widened pukhlini, titles are also perehresy, start functions during the blockade of the main lymphatic collectors.

7. Until the end of the road through the milky zone, behind the yachts, the plump elements can collapse, bring the drainage of the lymph through the net of the lymphatic vessels that have grown in the upper and lower areas.

The numerical anastomoses between small vessels, passing through the offense of the right abdominal mucosa, flow into the lymphatic border of the pre-abdominal cell and the area of ​​the liver coronal ligament.

8. By the small dodatkovy way to the current є drainage along the inner and middle lymph vessels of the cranial wall in the course of the gillok aa.epigastrica sup. et inf. to pre-vaginal and inguinal lymphatic universities, in worms and yєchniki.

Surgical treatment of milk cancer is present in the bagatov history. The first riddle about the amputation of milky zalozi with swelling or swelling is to be found in the eight-volume Celsus kernel.

The first surgeon, they thought they saw not only the disease, but the first lymph nodes for cancer of the milk ball, by the name of Marcus Aureulius Severinus.

Uzagalnnya to the sage of bagatokh hirurgs allowed W. Halsted in 1882 to break the string system radical mastectomy... It became a viral type of cleansing of the groin depressions, parasternal, supra-clavicular areas such as cellulitis and lymphatic valleys, at once from the visible m.pectoralis major, ale from the redundant m.pectoralis minor.

A vivid milky grip at the same time with a great breast ointment, albeit from unnecessary little - to be called a simple mastectomy.

The author has seen a thought about the adolescence of Klitkovini's vision lymphatic universities front middle to relieve ailments from the development of metastases in them.

The unpleasant results of such an operation served as a drive for the development of Meyer in 1884, a more expanded method of pectoralisation with the appearance of a small breast meat.

In such a rank, seeing the milky zone at the same time with the great and small breasts and inguinal lymph nodes, I call it a radical mastectomy according to Halsted - Meyer.

Most of the results are reached during operations with the drive of "minimal milk cancer", if the size of the chubby does not change 2 cm in diameter. Five-fold visibility in the number of drops to become 90%. A slide of memory about the so-called biological deterioration of overcoming the cancer of the milk frog. In 1/3 of the cases, breast cancer does not metastasize and the operation produces excellent results. In 1/3 of the cases, as no operation was carried out, it was insisted on early and early generalization of the process with a lethal result. I nareshti, in 1/3 of the cancerous process, schilia to stepwise enlargement. In cich vipadkakh virіshalnym є early development of chubby and early radical operation.

The complex for the treatment of breast cancer includes R-therapy, which changes by 15% risk of muscle muscle relapses, chemotherapy, hormonal therapy (castration is indicated in premenopause); In older children, children also experience adrenalectomy and hypophysis.

It is very quickly possible to get rid of milk cancer by priming on the next three basic principles:

1. Not taking the rules of ablastics transferring to the whole preparation in one block without exposing the primordial puffy head and lymphatic universities, and repetitive lymphatic and blood-bearing vessels far beyond the boundaries of the organ.

2. After the anti-blastic visits are direct to the world in the early days of the living, plump clitines.

The number of visits to include before the operation exchange therapy, as the case of the puffy clitini before the devitalization; electro-surgical method of operation; one-time vikorystannya of blood-backed cuffs, servetki, bagatorazovy mitty of hands; internal introduction of chemotherapeutic agents.

3. Taking into account the principle of radicalism, it is tied to the principles of ablastic and antiblastic, so that in the first place there will be seen the vision of lymphatic collectors in the boundaries of the anatomical zones and fascial cases.

The price was set in 1960 by A.I. Rakov. In general, he adheres to the principles of radical mastectomy according to Halstead - Mayor. Vona polyagaє in a one-step single-block visualization of all the milky areas with the great and small breast meat, groin, podclavicular, subscapularis in the anatomical cases.

The first stage of the operation of the radical mastectomy.

The right-hander and the hand-handler from the dairy zone should be carried out in order to improve the children’s needs. The first rose (medial semi-oval) repair at the third third of the clavicle, advance it straight to the sternum and down the parasternal line, ending at the costal arch and firing in such a rank the dairy room from the medial side.

The other root (lateral semi-oval) is repaired in the same place, de and first, push down the front edge of the groin depression and close in the area of ​​the costal arch with a first root.

Another stage is the identification of small valves from the chest wall, from the appearance of the attachment of m.pectoralis major et minor.

The third stage is the visualization of lymphatic universities and cells of the main neurovascular bundle of the groin depression.

Quarterly stage - blockly visible to the whole affected organ at the same time from the breast muscles.

P'yatie stage. Rethelial hemostasis. Drenuvannya podkriltsovoy depression. Shvi on the shkira. To crush.

It is necessary to think that the mastectomy is only radical in combination with chemotherapy and exchange therapy, which can improve the efficiency of treatment. It's a pity that the average triviality of the sick for the radical mastectomy does not change 5-6 rockies.

At the same hour, the development of postmastectomy syndrome in 40% of females who have been given a radical drug to drive breast cancer was associated with a loss of pre-medication. For the prevention of post-mastectomy syndrome of the surgeon, it is already stretching out the rocky vikoristoyuyu ukrittya pidclavicular-inguinal vessels with the ointments, rosted in the operative early. With less success, it is possible to reach with sparing small chest muzzle, with great success - when the wide back muzzle is moved to the front chest wall. Qiu metu peredlivav і P a t e y, since in 1948 the mastectomy was proponated to the preservation of the great breast meat. In the rest of the rock, the operation is growing more and more wider at the end of the super-detailed shows.

Medium: surgical anatomy, surgery on the organs of the middle.

Seredostinnya - tse part of the breast emptying, surrounded by the sides of the middle of the pleura, behind the tails of the thoracic ridges, in front - by the posterior surface of the sternum.

At the bottom of the middle it is surrounded by a diaphragm, and at the top it is easy to get through the empty shia through the apertura thoracis superior.

The middle distance extends to the front and back, by cordon between the yakims and the area, carried out on the equal bifurcation of the trachea.

On the sagittal cut of the breasts, it is possible to bachiti the so-called retrosternal space, a part of the anterior middle is located in an infection behind the sternum. Space is kindly done with x-ray dosage. Yogo widened is meant for increased thistle, for example, with puffins - Tim.

The retrocardial space is located behind the left atrium. When vibuhanni signs of the left atrium sound like a symptom of stagnation of blood in the left atrium, for example, with a mitral porocy. With X-ray contrast, the stratohode arches like a backward in the retrocardial space, I also know the improvement of the front of the heart when the heart is wading.

The middle area is wide connections from the kitchen spaces, the signs of pathological processes can pass into the anterior and posterior middle.

Spatium praetracheale grows from the anterior mediastinum.

Spatium retroviscerale - back.

Spatium vasonervorum is widespread from the anterior mediastinum.

In the course of the cattle breeder, the shija move from the rear center of the cattle. Swallowing abscesses, especially in children, with a poor transition of the process behind the Y-th fascia in the posterior middle.

The middle space is seen through the vaginal space along the pedicle through the hiatus oesophageus with diaphragms, along the aorta - through the hiatus aorticus, and also along the ductus thoracicus, v.azygos, n.splanchnicus majoris et minor, probing the diaphragms

With the introduction of povitra into the paravertebral cell, in front of the cupric, the veins can rise in the middle of the route, but you can use it for X-ray contrast of the organs of the middle (pneumomediastinum). The Іnshy path of the stem of the pneumo-mediastinum is the introduction of a twist from above from the suprasternal fossa behind the handle of the sternum.

Ductus thoracicus.

The thoracic lymph duct is stored in 3 sections: Cherevny, thoracic and shinny (Fig.). There is a large part of the yogo dojini (35-45 cm) of the seizure on the chest viddil. The thoracic duct is taken out of 3/4 of all lymphs from the lower bones, pelvic organs, black and chest empty.

In cysterna chyli, there are numerous lymphatic vertebrae of the intestines and other organs of the abdomen and male truncus lumbalis.

In the chest emptying ductus thoracicus pass through hiatus aorticus with diaphragms and dal frogs on the right into sulcus azygoaorticus mіzh v. to the left side ridge, roztashovuyuchis posterior to the aortic arch. Pass through the middle, the duct goes backwards v. Jugularis internus and v. Subclavia and straight forward flows into the middle of the zlittya - angulus venosus juguli. Most often, at the point of entry of the duct into the venous cut, є enlargement - sinus, one of the ducts grows on a splinter of thin veins.

Ushyvannya. and ligation of ductus thoracicus is indicated for chilothorax - accumulated lymph in the right or left pleural cells due to injuries of the chest cell. As the lymph accumulates on the right, then the newest channel is located below the level of Th-III. Loose chylothorax characteristic of ductus thoracicus wounds in Th-III. Wide posterolateral Thoracotomy is used for access. Before the operation, I give the patient a bottle of milk to make a milk-white farbuvannya stovbur ductus thoracicus. For dressing ductus thoracicus, collateral lymphocytes develop rapidly.

The fistula ductus thoracicus is carried out in two types:

1.for the stem of the tim-hour immuno-parallax from the hour to the crisis of the administration of the halogen transplant;

2. for detoxification with cholangitis, peritonitis, pancreatitis.

In the rest of the fall into the Persha doba, if from the fistuli come the chorous lymph, I see. For viplivas from the fistula lymph to pick up in plastic mice and for cleaning for additional adsorbents, again pouring over the ailment (lymphosorption). This procedure is necessary, so as not to undergo immunosuppression through the massive visualization of lymphocytes and salts and bile, so that it can take place in lymphocytes.

Olennya ductus thoracicus should be carried out on the sheath with a horizontal opening of the sheath over the collarbone (Fig.). For the rosette of the adipose tissue and fascias (Fig. 1, 2 and 3) m. ... In the midst of evil, the last of them know the arms of the ductus thoracicus. The duct rozs_kayut, bandage the central yogo end. In the case of peripheral enlightenment, insert a plastic tube, which is micro-fixed in the prototype. The vilny cut of the plastic tube is removed on the front wall of the breasts and the plastic mouse is attached to the lymph.

Truncus sympathicus.

The thoracic appearance of tr.sympathicus has 10-11 ganglia, which lie in the posterior middle on the ribs of the costal heads. In case of C-YIII with Th-I, one pretends to be ganglion stellatum, lying on the cordon apertura thoracis sup. on the head of the I rib in tr.scalenovertebralis. The nurses of the nursing universities form the plexus aorticus and plexus pulmonalis. The lower hearts of the head come from ganglion stellatum. From the Y-IX ganglion, it becomes great, and from the X-XI, malium is fraught with nerves (n.splanchnicus major et minor), as at once from v.azygos it passes through the wormwood, straight up to plexus coeliacus and the nervous gossip of the tavern. Organ_v.

For B.V. Ognev (1951), all the institutions of the higher education system innervate the arterial, and the right - the venous system.

Vikorinennya ganglion stellatum. Or another new blockade can lead to a positive result in some types of angina pectoris.

Vikorinennya Th-III. According to B.V. Ognev is indicated for Raynaud's ailments.

The third university is seen from the posterior approach of the extrapleural for resection of the head of the III rib according to Swithhwick and Telford.

OPERATION ON a grubber.

Topographic obruntuvannya of operations on a grubber.

The esophagus є for the advancement of the pharynx and repair on the івні lower edge of the cricoid cartilage, but the skeletotopic form C YI.

For a larger part of the shepherd, become a chest viddil (15-18 cm); shiyny viddil dorivnyuє (5-8 cm), cross - (1-3 cm). The grub-guide has є 3 sounds: the upper one - at the level C-YI, the middle one - at the equal trachea bifurcation - Th-Y and the lower one - when the piper passes through the diaphragm - Th-X, transitions to the cardial one.

To the principles of surgical anatomy and especially to the principles of the clientele, it is divided into 4 parts, proponated by V.N. Shevkunenko, G.T. Dubinkin, R. Demel:

1.shiina chastina - from the pharynx to the upper edge of Th-III;

2. bifurkats_ynyh part - from the shiyno part to the level of the lower edge of Th-IY;

3. sternum - from the bifurcation part to diaphragms;

4. cherevna chastina - from diaphragms to cardia.

Pishevod in the sagittal area of ​​the viginous ridge.

If you look at the waist of the pishevoda from the front (frontally), then the esophagus in its own way from the shia to the shlunk is S-podibny vigin. On the whole, there is an increase in the middle line, in the case of the upper third of the breasts; far down in the middle third of the breasts, the esophagus go to right side and in the lower third of the aorta, it is again turned left, overturning in front of the lower third of the aorta. The same is the provision for the specialty of surgical accesses to early visits to the stravohod: evil to a shyny viddil, right-handed person - to the middle third breastfeedingі evil - to the lower і cranial wіddіlakh.

Stovbur of the left bloody nerve pass at once with the grub into the empty black hole, spreading along the anterior left surface.

Stovbur right n.vagus lie on the back right surface of the pishevod. The blood posture of the pedigree is seen from the young dzherel segmentarono (Fig.). The venous admission enters the system of paired and unpaired veins. At the point of transition of the pishevoda into the shlun, venous submucosal gossip is established, so that the submucosal path goes through: burn up - into the v.cava sup system. and from bottom to the v.portae system.

In case of cirrhosis of the pishevoda, the veins of the pishevoda expand (hemorrhoids of the pishevoda according to B.V. Ognev) and may become a dzherel of severe bleeding.

Prompt access to the chest viddil stravohodu.

Folding topographic and anatomical connections between the grub, aorta and elements of the root of the legends, as well as the safety of the surgical pneumothorax, it is possible to see the onset of the operative access to the tract:

1. through the urea;

2. through diaphragm-Seredostinnya with diaphragmotomy and crurotomy according to A.G. Savinikh (1943) and K.P. Sapozhkov;

3. extrapleural access according to I.I.Nasilov (1888) - from the resection of the ribs Y, YI, YII, YIII along the paravertebral line.

4. Transpleural thoracoabdominal access according to V.D. Dobrom and the word (1900) go through the development of the YI or YII intercostal space, which at once open the pleural and empty space. Apparently, before the viginas of the driver, they should carry out either right-handed or right-handed.

5. Lіviy orevini-pleural access - according to S.S. Yudin.

6. Right-sided queue-pleural access - according to Lewis.

Ezofagotomієyu - development of the grower. Zastosovuєtsya for the use of alien til or the use of native strictures. On a wide operation, carry out the left-sided growth of the shkiri along the front edge of the m.sterocleidomastoideus.

At the same time, with a neurovascular bundle, pull out with a dull knob named and see the esophagus, based on the sulcus tracheoesophageus and the front surface of the ridges. Pishevod rozs_kayut across or bridle fibers over alien til, like vityagayut, sew the pishevod's wound with a noble suture.

at good chicks pishevoda (fibroids) with the most beautiful operation є subsensory visualization of chubby without rostynu education.

In case of malignant puffs, two types of operations are performed: resection of the hedgehog with overlapping two hundredths - shear and shlunkovaya (Dobromislov-Torek operation, 1913) and resection of the hedgehog due to innovations herbal tract by way of an overlay of shlunkovo-pechevodny abo intestinal-pechevodny anastomoses.

The Dobromislov-Torek operation is indicated for swelling in the middle of the third third. Access - right-handed, transpleural.

The main stages of the operation are as follows:

1. right-sided thoracotomy along the YI-YII intercostal space;

2. vision of the puffer, the value between the puff, the growth of the puffer, and the bottom of the puff;

3. suturing and sealing was lost after resection of the mucus stravohode;

4. bore the lower kuksi into the chute;

5.free development of schools in the wider world with images and mobility shyny viddilu stravohodu;

6. a knight proximal to a kuksi to a stravohode from a breast empty;

7. Formation on the esophageal stoma by the way of distribution of the territories to the distribution of the stravohode to the shkiri;

8. the stem of the shlunkovaya stoma with one of the accepted methods (according to Vitzel, Toprover).

Resection of the stravohode in the lower third. .Access - free thoracoabdominal. For the resection of the lower part of the thoracic tract, there can be three ways of renewal without interruption to the travohode:

1.application of the anastomosis between the ends of the resected stravoduct;

2. Replacing the part of the drain with a shlunk or a pipe, razrizanii z the great curvature of the shlunk according to Gavrilov.

3. Applying the anastomosis between the travoduct and inserted by the loop of the small intestine.

Anastomozy stravohod kinets in kinets often has fistulas, so as a stravohid can't bedding and covetousness in the minds of hermetic sealing and craftsmanship do not expect to come out. At bagatokh vipadkah, the operation will end with gastrostomy overlays. Nadal more than the stem of the piece pishevod from the small intestine.

Esophagoplasty - the stem of a new pishevod, is indicated for cicatricial strictures of the pishevod (when opiates with acids and meadows) for unsuccessful attempts to expand their education for an additional bougie.

A tube opening for saving the saved part of the windshield with the slurry using the slurry can be done using the following methods:

1. Antethoracic plastic surgery according to Bircher-Rovzing-Braitsev.

For all the anterior aspect of the breasts, they later develop the shorts and cover them in the middle of the epidermis, open the tube. Above її cover with a mobile phone on the sides of the tube. Oral end of the tube should be inserted into the shiyny in the drain, and the lower end is sewn into the shlunk. Qiu operation in the main viglyadі in this hour is not shy.

2. Antethoracic plastics of the pishevod according to Roux-Herzen-Yudin.

The blissful achievements of the surgery of the XX century deserved to be entwined with the stem of a piece breeder.

The first two tests were performed in 1894 by Genrikh Bircher.

Wolstein in 1904, having broken it on corpses and tested it on dogs, combined plastic with a shkin valve and a part of the mobilized small intestine.

The idea of ​​speeding up a thin gut for the plastic surgery of the new pedigree was born by Caesar Roux at the stage of a similar operation, by the viconious surgeon Tavel for 2 years before.

Tavel implanting a short vidrizok small intestine one end in a shlunok, and those who are in the school of epigastric dilyantsi replace the Vitselevskaya gastrostomy for the sickness of the sick with cancer of the peasant. It opens a wide fistula, which allows passing through to reach the great grub breasts, and at the same time the isoperistaltic transplantation of intestinal loops guarantor of the vitality of the name of the creeping juices.

In 1907, the Swiss surgeon R u (Roux) described for the first time the operation that was violated by him, virnishe, the first stage of the stem of the piece-cutter from the small intestine by the type of oesophago-jejuno-gastrostomia.

Same R u zvernuvu respect for free vascularization of the small intestine. Vin meaning that the intestinal arteries create arcades, rostasovany single-topped in the breech of the small intestine. The lower end of the intestine, Ru, was implanted in the anterior surface of the slunk close to the cardia, and the upper end was carried out in the opening of the pedicle canal on the shoulder.

Incomplete operations of Ru:

1) difficult operations and triviality;

2) the majesty of the growth of the root of the breech;

3) poor blood circulation in the isolation of the intestine;

4) the possibility of twisting the nizhki;

5) compression of the transverse colon intestine.

Vidatny Russian surgeon P.A.Gertsen has quite refined the method of operation of the center for the first time in the world in 1908 after completing the pre-breast renewal of the breeder.

Pavel Herzen went into the singing world and put the shortcomings in such a way: the author divided the operation of the mute into two, and into three stages:

1) conduction of the small intestine in the shkirnoy tunnel to the shia;

2) stem anastomosis of the small intestine with a slurry;

3) the naked part of the intestine and the root of the anastomosis of the intestine with the small intestine.

To secure the compression of the transverse colon with a transplant P.A. Gertsen proponuvav the post of the mesocolon transversum.

Transfers of the proponated modifications:

1) the growth of the root of the breech is much shorter;

2) the intestine of the frog directly on the slunker, so for a later implantation in a new non-consumable state;

3) by the way of the small intestine, at the bottom of the transverse colon, the possibility of twisting is assimilated.

4) the stem of the mind, which reduces blood circulation in the mobilizuvati of the intestines.

Priyuyutsya on the pits of Ts.Ru and P.A. Herzen, a prominent Radiansky surgeon S.S. Yudin, having broken the original technique of mobilization of the small intestine, based on the peculiarities of blood loss of the small intestines, the establishment of a large-scale duct of the small intestine ...

In surgery, there are 2 principled advances in approach to nutritional information about the type of esophagoplasty: one - in case of elimination of cicatricial ulcers of the stomach due to opiate symptoms, and the other - in case of swelling of the pectoral cavity.

In the first vipad, as a rule, the renewal of the stravohode is successful for the additional antetorocal small bowel plastics, without the visualization of the sounding pishevod.

For another, before the upgrade to the airway, it is not necessary to have a foldable surgical involvement in the rear middle, as it is very difficult to have a quick access, as well as in the visible swelling itself.

It is essential to the method of renewal without interruption of the patient (esophagoplasty) and the growth of the patient to the breastbone, the middle organs and easy development:

1 pre-breast (antetorocal) method according to Roux-Herzen-Yudin;

2 retrosternal (front-middle) ways;

3 rear-Seredostinnya ways;

4 Extrapleural way;

5 transpleural ways.

Technics behind the Ru-Herzen-Yudin method:

Stage I - during the laparotomy, to know flexura duodenojejunalis and, having entered it by 8-10 cm, expand the small intestine and repair the bridle. Step-by-step to bandage the root of the brijah of the judgment, taking care of the first arcade and of a different order. The visualization of the loops of the small intestine should be continued until quietly, as long as there is no need to see the loops of the small intestine with an undisturbed arch of the arch.

The upper part of the intestinal loop, closer to the flexura duodenojejunalis, is overlapped with two Payer's clamps. The central short section of the intestine is immediately zaslisyuyut on the muscle, enlighten the peripheral shape at once, with a twisted catgut suture, over which a net suture is applied. Fit the intestine, positioning it without tension in front of the sternum right up to the thyroid cartilage, so as not to damage the blood circulation of the visible intestine.

Anastomosis is made in the small intestine with a short duodenal bow, and introduced with the colony of the mobilized part of the intestine at sleep. At the breech of the transverse colon and lig.gastrocolicum, they protrude an aperture, through the yak to conduct visions of the small intestine and lay it in front of the slunk. To impose an anastomosis of the intestine with a slurry and immediately close the gastrostomy for residual formation of the back on the neck. Pislya tsyo proceed to the approval of the pedagogical tunnel. At the upper end of the pediatric tunnel, to curb a small growth of the shkiri, through the new one lead the forceps down to a gnarly wound, to snatch the end of the purse-string suture applied to the intestine, and to protect the health of the burned through the tunnel. To the wall of the intestinal loop, at the point of the transition to the pediatric tunnel, we make the chain. Sew up the cartilage wound, insert gum drainage.

The II stage of the operation should be carried out in 15-16 days. Conduct a narrowing of the anterior margin of the m. Sternoclaidomastoidea, expose the marginal side of the intestinal tract and impose an anastomosis between the intestine and the food.

Folding small intestinal esophagoplasty:

1) the unpleasantness of bringing the transplant to the thigh and partial abnormal necrosis of the thymus;

2) fistula, which develops due to lack of seams through the grub and intestine;

3) cicatricial ulceration of the anastomoses and the intestine - it is possible to start, according to the strength of peristalsis and enlargement, to bring the end of the intestinal tube.

If necessary, substitution distal view The stravohod should use the Gavrilov method.

The shlunks are closed with two holes parallel to the great curvatures, they cut the flap, which is molded into the tube, 15 cm slugs, zednan with the empty shlunks. Qia tube is better than blood flow for rakhunok a.gastroepiploica sin. і aa. gastricae breves.

Vilny end of the formed tube is sewn to the end of the trachea, which is seen in the middle to the level of bifurcation of the trachea.

Operations for cardiospasm.

Cardiac spasm or achalasia is a disease that occurs in children and grown-ups in 3-20% of cases when they become ill. It is characterized by periodic or post-lingual closure in the area of ​​the entrance of the stravohode to the shlunka in conjunction with reflex spasm of the cardiac pulp. Stravohid, at a time, expands, in new kharchovy masi... Prior to the operative treatment, if conservative methods are unsuccessful, they are the most effective є expansion of the card for the help of a cardiodulator, a balloon is used to inflate any safety issues, so that the cardiac sound zone is maintained.

Extramucous cardioplasty was promoted by Geller in 1913. Near the ringing zone, a later expansion of the anterior and posterior walls to the trawler and part of the shlunka is carried out by up to 8-10 cm to the lug ball. There is a prolapse of the mucous membrane, a sufficient expansion of the cardiac spasm. 70-95% of vipadk_v have garnished results.

B.V. Petrovsky (1956) proponuving a part of the serous-myazovaya stinka stravohode and cardia and podshivati ​​to the resulting defect of the myazovy valve with a size of 10x3.5 cm, the microscope is behind the diaphragms.

Operations for diverticula stravohode.

There are 3 types of diverticulums: shiiny abo tsenker, bifurcation and supraphrenal (epiphrenal). We can remember the description of the wall to the stravohod, if in the illumination of the diverticulum it takes the part of all the stravohove, and it is incomprehensible, as it is only vypinaetsya slizova, delaminating the ball of the muzzle.

With small deviations, there are 2 types of operations:

1.Hanging the diverticulum between the clamps and the stitching of the wall and the overlays of the noble suture

2. Invasion of the diverticulum in the enlightenment of the stravohode with overlays to produce the seams.

With supraphrenic diverticula, viroblast esophagofundostomy according to Heyrovsky.

Develop late stravohid in the diverticulum zone and the bottom of the shlunka and impose a shlunkov-stravochidny anastomosis, maximizing the maximum expansion of the flow into the shlunka.

Puncture of pleural emptying.

Puncture of the pleurisy is violated to clarify the diagnosis (with the mark of the character of the exudate, lykuvalnoy metoyu- for visualization of the exudate and for the introduction of lykarsky rivers into the pleural empty space. If there is a strong drop in the pleural mouse, it is punctured at the lowest point of emptying, or below the level of birth, established by physical and radiological predictions.

Puncture of the pleurisy to stifle in the center of the percussion dullness, often in the YII-YIII mid-ribs along the posterior groin or the scapula of the line.

Diagnostic punctuation to check for help with a head of up to 6-8 cm; a special trocar is used for the visualization of the pleural empty space.

Technique: in case of viral pleural puncture of ailments, sit leaning on the back of the stylus, the hand on the side of the puncture is inserted behind the head. A lot of people to carry out the infiltration anesthesia of soft tissues. It is possible to pull the skirting along the edge to the bottom, for which it is hard to pull 3-4 cm along the upper edge of the lower rib, which is unique to the descent of the midcostal nerve bundle. At the same time, it is necessary to remember that the player can pass over the vipot in lung tissue or to penetrate through the costal-diaphragmatic sinus into the cellulose void. To unite such an acceleration, it is necessary to direct the head of the burner parallel to the dome of the diaphragms when piercing the chest wall. Having crossed over so that the head is empty, bring the syringe and proceed until you can see the gum tube and Janet's syringe. When you pull out the syringe from the tube, stop it with a grip, so that no powder penetrates into the empty pleura.

RESECTION OF THE RIB.

Resection of the rib can be performed by 2 methods:

In 1857, Roser had a slightly resected subperiosteal spine of the ribs with a chronic pleural tempo.

In 1898, M.S. Subbotin broke the thoracoplasty technique with the subperiosteal overset of the ribs without being seen.

The resection of the ribs is stuck for operative access until the pleura is emptied and the organs of the thoracic emptying (thoracotomy), with thoracoplasty, with damaged ribs, osteomyelitis or swelling, for draining pleurisy.

Technique:

1. After an hour of active fluoroscopy, the patient should stand in empty pleurisy, vibrate a test puncture, and if the syringe is removed from the syringe, proceed to the resection of the rib.

2. There is a resection of the YIII or IX ribs between the scapula and the middle groin lines.

3. Having felt the edge, draw 6-8 cm along the middle of the edge of the head. Draw later along the entire length of the wound, adding two short transverse edges on the ends.

4. Farabef's raspator is used to open the edge from the front surface of the rib to the upper edge, and then to the lower edge.

5. For the rib subperiosteally lead the vignutius of the doyenne rasp and with the collar of the bridle of the ribs outward from the posterior surface of the rib.

6. Do not use a raspator, use rib cutters to overhang the rib in two pieces.

7. Scalpel the back wall of the outer pleura and the parietal pleura, penetrating into the empty space.

Excessive resection of the rib with osteomyelitis. A special operation is those that do not come out of the hole here on the entire protrusion of the resected rib dilenca. Therefore, in such drops, the rib is removed from the intercostal mucosa and resected the urazhene at once from the okis and scar tissue. Mіzhrebernі judges cross-flow between two ligatures.

BLOCKADE of intercostal nerves.

Indicated: for rib fractures i important blows breast cancer.

Technique: the ailment is on the back or on a healthy boat. For anesthesia, the shkiri should be inserted until it is closed from the surface of the lower edge of the rib. Then it is easy to pull up and direct to the bottom, wary of m'yak_ fabricі skovzuyuchi from the edge of the rib. With insignificant penetration into the grip of the head, the head is poured into the zone of the neurovascular bundle, then 10-30 ml of 0.25% novokaine should be injected. In case of fractures of the ribs, novokain should be inserted into the hematoma of the fracture.

OPERATIVE LIKUVANNYA pneumothorax.

Injuries to the breast cells spread into penetrating and non-penetrating.

Penetrating wounds, in their own heart, add up to wounds with a pneumothorax that is without a new one.

For the fight against pneumothorax - one of the unsafe expedited operations on the lung, a lot of methods have been proponated.

K.S. Sapezhko and Ru (Roux) in 1890 was recommended to inject into the pleural empty space 10-12 days before the operation a variety of speech (tincture of iodine or 1% formalin) decay of the leg at the time of thoracotomy.

Penetrating wounds of the breast cancer are superfluous:

1) pneumothorax - a collapse of the lung as a result of rapt

penetration of atmospheric suck into the pleural empty space;

2) hemothorax - hemorrhage in the empty pleura;

3) pleuropulmonary shock.

There are 3 types of pneumothorax: discharge, closure and valve.

The manifestation of pneumothorax is characterized by non-mediated occurrence of pleural emptying with atmospheric symptoms through the wound of the chest wall. For an hour, I breathe through the wound, it penetrates into the pleural empty space, and when I see it, I go out. Easier with a lot of interest in collaboration and included in the ventilation.

Zakrytiy pneumothorax in the case of malignant or chest disease, or lenevoi parenchyma. In both cases, the accident penetrates into the empty pleural space only at the time of injury. In case of minor injuries of the breast tissue, the edge of the wound quickly wiggles and it is more appropriate to lean back into the pleural empty space. As soon as you put yourself on the edge or cut the legacy fabric, once you go into the pleural empty space until quiet times, as long as the legacy continues and the wound is shrunk. A small number of twigs (300-500 cubic cm) are swollen with a stretch of 2-3 tins. Iakshko lighter pіdіbganі more nіzh by 1/4 of its volume, slіd zrobiti pleural puncture and the maximum amount of food.

Valvular pneumothorax is especially problematic. This type of pneumothorax can be caused by injury, chest pain, and lesions. It allows the fabric to serve as a loose valve, allowing only the emptying of the pleural space to pass, as a result of which it is not safe to press down the leg, growing with the dermal inhalation of the sick person.

There are two types of valve pneumothorax: external and internal.

The name valve pneumothorax is susceptible to quiet drops, if the atmosphere penetrates through the wound of the chest wall only towards the pleural empty space.

Internal valvular pneumothorax in the presence of valvular lung injury or bronchial obstruction.

PERVINNA HIRURGICHNA TREATMENT OF THE RAS OF THE TREATMENT OF THE TREATMENT WITH Pneumothorax.

if given inconvenient help put an occlusion on the wound, so that an airtight bandage is applied, which is folded behind a ball of gauze servet; the upper ball of gauze which represents a pummeled fabric.

The operation for wounds of the chest with visible pneumothorax is carried out until excision of the edges of the wound in the boundaries of healthy tissues, revision of the lung and the reduction of pleural emptying, tobto until the resection of the open-ended pneumothorax.

In the first suture, there is a burst of the parietal pleura, the internal breast fascia, the occlusion and the interstitial mucosa (pleura-mucous suture). Before tightening the last sealed suture, insert a catheter into the empty pleura to remove blood and blood in during the operational period.

Put another row of seams on top of the joints and fascias. Рідкісні шви на шкіра.

Operatively lykuvannya valve pneumothorax.

First aid in case of valve pneumothorax polyagi in puncture of the chest wall is so bare, as well as reducing the sharp movements of the intrapleural vise.

The main operation, which assimilates the valve pneumothorax, is a cethoracotomy with suturing a lung wound or a bronchus, through a yak to go into the empty pleura.

More accessible way of eliminating valve pneumothorax є continuous draining of pleural emptying by way of overlapping - intercostal drainage according to Bulau, or active aspiration behind the auxiliary water pump.

Sewing up the wound of the LUNG

Indicated before the suturing of a lung wound, most often there are bleeding from the leg tissue and signs of closed pneumothorax. Food about the bleeding in case of popping, or in case of legends, is of great practical importance.

In that and in the first place, in the first place, in the first place, you can go to the inloco ligatures (on the mischief of the innocent judge), I would like it to be possible in some cases of blood to be judged more often.

Bleeding can be buti zupineno:

1) overlays of seams;

2) overlays of ligatures in the area of ​​wounds and on the arms of the vessels.

When a suture is applied to the lung, it is difficult to bleed and mintly trimmed, followed by the topography of the sudins.

For the preservation of zskovzuvannya and weakening of the middle seams on the legacy fabric, vikoristovuvati vuzluvati shvi is shown. The wound of the lung is sewn up with catgutovimi sutures, the tissue is flushed to the bottom with such a cut, so that the thread is tightened without overflowing. The seam is lightly tightened until the edges of the wound are closed. Shvi are applied according to the course of the ships. The quality of the seam is based on trapped vessels and bronchial tubes, which are often squeezed by them. When suturing all wounds, it is necessary to put on an additional syro-serous suture of the pleural pleura, and as soon as possible, one hour to sew the wound to the parietal pleura.

thoracoplasty

Thoracoplasty - hanging of a part of the cyst skeleton of the thoracic clitine (ribs) with the help of the root of the malleability of the thoracic wall for bringing in the retinal and visceral pleurisy, for the development of the disease of the pelvic tissue

The idea of ​​thoracoplasty was first captured in 1875 by the Frenchman Letyvan, and the operation on the ailing one was first taken care of by Estlander.

To the evidence of a chronic tempo of the pleural emptying, one cavity of the upper part of the leg is rosted on the glybin not more than 3 cm from the surface of the leg.

There are two types of thoracoplasty: intrapleural and extrapleural.

Intrapleural thoracoplasty according to Sheda Bula was proponated in 1898 and in the field of the well-known chest wall: ribs, intercostal joints and parietal pleurisy. The emptying of the emptiness was overflowing with the shkirno-myazovym valve of the chest wall. The operation is traumatic and has lost its senses in an hour.

Intrapleurally "descending" thoracoplasty of the bull was proponated by B.E. Linberg, as most often it is stagnated for treatment chronic emotions pleurisy. That’s what I’ll call it, because the resection of the ribs and the opening of the posterior leaf of the mucosa of the muzzle lead to the feud of similar gatherings.

With a wide range of methods, it is most common to stagnate the growth of Fridrikh-Brauer. Growth leads from the level II to IX of the thoracic ridge to the paravertebral line, then it is called and it goes forward to the middle groin line,

"Skhodov" thoracoplasty is made up to the main or partial resection of the small ribs (from one side) without rosette of the parietal pleura. Stagnant operation for cavernous tuberculosis.

To carry out the bridle of the medial edge of the scapula above the surplus empty space, the ball of the thinnest tissue should be bridged, and in front of it, it will be visible to the noritsa run. Shkіrno-myazovy klapot vіdtyaguyut naznі, fistulous fistula hіd.

Proceed to the lateral resection of the lower rib. For a large number of ribs in the area of ​​projection through the late viz. ... The ribs of the bed open up later, and the ribs of the bed open up last, then at the chest, then at the ridge edge.

It is not possible to bring them into the middle of the visceral pleurora and the lungs, completely overwhelmed with empty pieces. Persh nіzh zanuriti vіlnі kіntsі mіzhrebernyh muzyazіv, іх sound from granulation nasharuvans, pleural emptyness is dried and rubbed with alcohol.

Proceed to the end of the resection of the lower rib, protruding 2 cm beyond the edge of the skin side, and again open the empty pleura.

In this way, the ribs are subsequently resected and the pleura is opened on the cutaneous edges of them.

Then there is the middle of the line, one in front, and the bottom of the line is at the top, so it’s pretending to “go down”. Skin razkritiy prom_zhok tampon, pressing the tissue to the visceral pleura.

For a lot of surgical engagement, thoracoplasty is needed, when all the ribs of one side are extended, and a small part, if you see a little more ribs.

Extrapleural thoracoplasty takes two groups in Danish hour: total thoracoplasty and selective or partial thoracoplasty.

With total thoracoplasty, 11 ribs are seen, with selective - only 3.5 and 7 ribs.

PRINCIPLES OF RADICAL LUNG OPERATIONS.

Try it out, radical operations on legends have been carried out for a long time. So, Pean in 1861 p resected a part of the leg.

Makіv in 1897, and then і Kummel in 1910 virobili vyvalennya lung (pneumonectomy) with the drive of cancerous swelling.

Radical operations on legends are used to treat malignant swelling, tuberculosis, bronchiectatic ailments.

In the midst of new surgical accesses, which were broken up for viral operations on the lung, the most widening of the anterior and posterior accesses were built up.

Anterior - lateral access of detailed fractures by P.A. Kupriyanov in 1955.

With anterior-lateral access, lay the patient on his back. The position on the back is the least dykhalny ruhu and heart activity, I am not safe, the sputum is shrinking in the opposite lung, very useful for the anesthesiologist.

The frontal access is less traumatic, so when a new one is overturned, there are more thin miishtsi. Win yes good access to legendary artery and the upper legendary veni. However, the frontal access does not give the necessary freedom for the whole pleural emptying. Yaksho dressing of the legendary artery i upper veni It is easy to get there from the access, then the obstruction of the bronchus is twisted, and the ligation of the lower leg vein, the expansion of adhesions in the costal-diaphragmatic sinus, is not relieved. Manipulation on the rear sides of the lungs. Nadіyne zakrittya thoracic cells, especially in individuals with rotten muscles, can make it difficult.

Technique: with anterior-lateral access, the hulls are repaired along the III ribs, three leading to the parasternal lines, going down to the nipple, for a milky zone, firing from the bottom, and moving backwards along the I-ribs The empty chest is opened with a gap along the III intercostal space for going up to the upper part and along the IY or Y intercostal space - for going up to all the light or the lower part.

With posterior-lateral access, the patient should be put on the living. Lying on the stomach slows down the mental movement and changing the life of the legends, rather than replacing the bronchial tubes in the opposite lung, giving the opportunity to fly on the very cob of the operation and break the bronchus. The posterior-bichesky access is significantly more traumatic than the anterior-bichesky access, as in the process of developing a great array of mutilations and oversetting 2 sumy ribs. The appearance of a great array of mutilations in the back will provide good airtightness when suturing a wound.

Technique: in case of back-lateral access, repair on the Rivne Th III-IY, go down the paravertebral line to the Rivne Y-YI rib, round the shoulder blade and allow to carry out the razors along the forward ribs to the front.

Exposed two ribs are resected. Open the pleural empty space. To see all the legends, go through the YI edge, for the lower part - through the YII edge.

Daily access is the most rational for all types of operations, vibrated on the lungs. It will be shown to all vimogs, which are presented before access: I will preserve the wide openness of the breast, so that there is the possibility of being able to visibly manipulate the entire lung. Everyday access to unifications in that kind of information, however, can be easily seen, however, whether it is a part of it, everything is easier to carry out a partial resection of something from a legacy fabric. Nareshty, it will ensure good airtightness when the pleural emptying is closed, it provides a great breast mouth for further plastic surgeries.

Technique: development is carried out along the paravertebral to mid-clavicular line along the Y edge. In front of the wines, the bunches of the great and small pectorals are melted, on the bichny surface of the anterior toothache, in the posterior viddili there is the widest junction of the back. Glibocytes of the back and trapezoidal joints do not overflow. The pleural empty space opens up along the intercostal space, and the intercostal mucosa extends along the upper edge of the rib, which is preceded by the intercostal nerve bundle. Stagnation of the lungs and wide openings of the pleural emptying will cause harmless and without changes in manipulation as the lung grows, as well as in the sinuses of the pleural emptying.

With the viconious radical operations on the legends, the keruvatis followed by a whole low foreign principles techniques of resection.

1. Skin radical surgery to repair pneumolysis - a vision of the lung with the development of urahuvannya їkh pivotalosti, widenosti and the volume of vikonuvanny operative involvement. Pneumoliz lead yak yak gostry, so dumb way.

For mediastinal pleura, go to the root of the legend and see your items.

2. The processing of the Legendary Sudins and the bronchial tubes is carried out in an isolated manner, fixing it up and down - from the Legendary artery. In case of cancerous lesions, the order changes - a sprinkle of veins grows, which zapobihaє wikid cancerous cells in the bloodstream when the lung is visible. The processing of the Legendary vessels is subject to the rules of the court surgery, with the upcoming technical rules:

a) for the processing of the Legendary vessels, it is necessary to see the judgment beforehand if it is notched with a completely woven case. The whole rule is absolutely binding when you see the legendary arteries.

b) overgold rule of Overgold: seeing the judge from the side of the case should be repaired from the side, until there is no access, then the view of the other's sides of the judge and the vision of the case will end up lying on its side.

The dressing of the Legenevian vessels should be carried out with an offensive rank: before the vessel is fed with Fedorov's lock and the central ligature should be carried out, yaku to tie it up. Apply a peripheral ligature to a friend 2 cm lower, yaku can be tied tightly. Nareshty, on the doorway between two ligatures, apply a third - stitched ligature. Tsim will become aware of the hope of screaming with the kuksoy of judgment.

3. Peretin of the Legenevich Sudins should be carried out with ligatures.

4. Ligation of the bronchial artery.

5. For the fillet of the vessels, move until the bronchial tubes are visible from the navkolishny tissues. On viddil impose a tampon like Fedorov with a time frame, while the excess of the excess kuksi did not move 5-7 mm. Peretin of the bronchus viroblyayut evenly, but offending yogo lips and buli of the same dovzhini. Carry out the processing of the bronchus kuksi behind the help of the broncho-Zshivachi. When the device is outside central viddil The bronchus kuksi are applied with two small holders, the kuksi are sutured in with single-row suture sutures, which do not penetrate through the infiltrated mucous membrane of the bronchus (Metras, 1951).

Then we carry out pleurisy of the marginal suture of the mediastinal pleurora.

The method of ukrittya kuksi bronchus in the class of stagnant plastic materials: such as the pericardium, the valve with diaphragms on the vital lower part, the omentum of the fascia, the omentum-supraplastic, etc. hirurgiv stasis mediastinal pleura. To reconsider the airtightness of the bronchial mucus and it has become overtaken by the leg parenchyma, for which the pleural empty space is poured warm physiological breakdown... To judge about the tightness by the visibility of the gas bulbs when they are blown out to the side of the anesthetic apparatus for 10-15 seconds. After the end of the operation, they are performed, the drainage of the pleural emptying is carried out through the puncture of the chest wall in the YIII-IX intercostal space along the middle groin line. Suture the wound of the breast bone.

OPERATION FOR funnel-like breasts.

The chest in children up to 3-4 rocks has a cone shape with a base, brutal to the bottom. Up to 7-8 rocks in children, the breast cage swells in the shape of a cone, a little on the right side. Until 12-13 years, the form will end, and I will get rid of the hair that is characteristic of the grown-ups.

The ribs in children are dull, elastic, and sometimes the fractures are much older, lower in the grown-ups. That is, when resecting the ribs in children of the first fate of life, the stench is easy to break with knives and do not use the cyst instrument.

The position of the ribs, especially the lower ones, is even more horizontal in the newborn, and the cut from the ridge is close to the straight, the middle edges are very wide. In addition, the breast cage of newborns is short and wide. In addition, the ribs and the upper aperture take a larger position, and the intermediate edges are sounded.

Between the ribs of the judgment and the nerves in an early child's life, they are prickly at the slight turn of the costal furrow, they are less likely to lie down to the brush and spread closer to the lower edge of the inner surface of the rib.

The funnel-like breast cage is a form of development, which is superimposed on the retraction of the sternum and anterior chest wall. The first funnel-shaped deformity of the thorax of the bull was described in 1600 r by G. Bauchin.

Literature does not have a single thought about the optimal way for the operation of children. G.A. Bayrov (1968), N.I. Kondrashkin (1970) vvazayut shown operation in children over 5 years old. We recommend operating children up to 2-3 years (M. Ravitch, 1961).

Until the present hour, 30 methods are close prompt engagement with l_ykopodibnoy deformity of the breast tissue. Їх can be divided into 2 groups:

1.Thoracoplasty without fixing tractor seams or fixing tori;

2.Thoracoplasty due to internal or external fixation.

The first operation in case of leyko-like deformation of the Viconan bull in 1911 R. L. Meyer.

Among the surviving surgeries, the first one was a similar operation among the grown-ups N.A. Bogoraz (1949), and among the children G.A. Bayrov in 1960.

The most widespread nabula thoracoplasty was proponated to Ravich.

Technique: in lads it should be carried out vertically, above the sternum, in females - in a similar manner, submammary. Shkira from the child's wedge is peeled off in the offending sides, the sternum is peeled and peeled off from the ribs. sword-like sprout see from the breast and see. The sternum with a blunt way exfoliates the pleural sheets in the offending sides, increasing the posterior surface of the sternum. Along the offense of the parasternal lines II and III, the ribs are melted into an oblique straight line. Above the deformed rib cartilage ditches (zazvychay from II to YII), the perichondrium is raised from both sides in a lateral direction. The ribs overhang at the sternum and along the last line of deformation, the deformations of the ribs on both sides are visible underneath. The sternum is raised on both sides of the soft tissue, at which the inner chest arteries are ligated and the sternum is ligated to burn as much as possible behind the distal end. Changing the back plate with a chisel and inserting a wedge-like rosette into the shape of a chisel; The wedge is fixed to the sternum with nylon sutures. Kintsi obliquely crossed ribs from both sides are sewn one with one nylon sutures, so that the medial part is rostered on the lateral. The overshoot of the sternum from both sides extends to the sternum. It is important to close the surface with wounds. On the shkіra put seam seams.

Thoracoplasty according to N.I. Kondrashin is a transfer of a wedge-shaped resection of small portions of rib cartilages along the last inter-deformity and repetition of deformed ribs at the sternum, as well as transverse wedge-shaped sternotomy along the upper inter-deformation. In addition, there is a wider view of the diaphragms from the costal arches. Ribs cartilage in the area of ​​wedge-like resection is sewn, on the sternum in the area of ​​overturning sutures are applied, in order to tighten it in the position of hypercorrection.

Radical thoracoplasty with the back of the tractor seams was carried out by A. Oshner and M. DeBakey (1939). For mobilization of the cartilaginous part of the anterior wall of the thoracic tissue, partial resection of the rib cartilages, wedge-like sternotomy and hanging of the sterno-diaphragmatic ligament in the intraoperative surgery

Thoracoplasty according to Bairova is stagnant among the number of methods in our land.

Carry out 6 small changes: late - on the upper edge of the sternum deformity, transverse - on the equal sword-like outgrowth, and two lateral breaks from both sides of the sternum in the area of ​​the outer deformity between the sternum. A sword-like outgrowth extends from the sternum and deformed ribs. From the upper lateral development to the transverse wedge-shaped sternotomy. Three parasternal transverse razrіzіv recalculate deformed costal cartilage at the sternum. From lateral transverse razrіzіv wedge-like chondrotomy on the last between deformations. In the area of ​​transverse sternotomy, the sternum is sutured with nylon sutures. In the area of ​​wedge-like resection, the ribs are also sewn with nylon sutures, up to the sternum, the ribs are cross-cut. The sternum is stitched in the middle third with a commercially available nylon and suture thread for a further post-wear. Shchelkovo sewing is applied to the school in the area of ​​development. If there is a deformation in the area of ​​the ribs, pass an additional traction suture through the lateral rib. For a permanent traction, the threads are fixed on special tires of the march, like a change on the chest plate with an emphasis on non-smart parts of the ribs. Vityaguvannya is known for children up to 6 years on 14-18 days, up to 12 years - after 3 days and for older children - after 24-27 days.

In the last few years, expanded operations were started, with some thoracoplasty, there was an increase in the internal fixation of the sternum and ribs in the coriguvati placed behind the ancillary spokes, metal plates, cyst homologous autografts.

Topography of diaphragms (especially in children).

For children of the first rock of life, the right dome with diaphragms is designed on Th-YII-IX, and for children older than 7 rocks - on Th-X-XI. Livy's dome is located one ridge lower. Medial nizhki in children usually hunt the esophagus, at that hour the older ones are more likely to be more likely to be in the area of ​​the peasant opening. In a childish vіtsі, the sterno-costal tricycle turns well, so it itself is transverse-costal.

Puncture of empty pleurisy (especially in children).

Puncture of pleurisy in children with pneumothorax, hemothorax and total emptiness develop in the YII-YIII mid-ribs along the scapula or the posterior groin line.

Intermediate advances in newborns and small children are altogether wide. With a bare diameter not less than 1 mm, with a single short gum tube with a syringe, pierce the chest wall along the upper edge of the lower rib. The penetration of the head into the empty pleurisy is seen on the raptus pinned support. I mark the pooperzhennya zvorotny zmoktuvannya povitrya empty pleurisy, in front of the skin zenyatty syringe gum tube re-tighten the gum tube.

OPERATION WHEN ATREASING the stravohode.

The atresia of the pishevod is a defect of development, when the upper one ends up blindly, and the lower one falls into the trachea in large numbers, confirming the result.

One of the first who described the development of a vice was Th.Hill (1840).

The first test of the doctor's atresia was reduced to palatal operations - gastrostomy (H o f f m a n, 1899).

The first successful operation in a child with an atresia of a pedicle without a fistula was broken by J. Donovan (1935) and a fistula by W. Ladd and N. Leven (1939). A gastrostomy tube was applied, then the ligation of the tracheo-sinus fistula and a patch of esophagostomy were applied. In our land, I will have a successful operation with G.A. Bayrov in 1955

The frequency of atresia of the pishevoda, according to the data of G.A. Bayrov (1969), is numbered in the boundaries of 1 per 2500-3000 newborns.

In the case of the most frequent form of atresia with a distal tracheo-insidious fistula, it is most important to repair a thoracotomy and a sub-tracheo-insidious fistula.

I do not change diastasis between the tips of the pishevoda and 1.5 cm, apply a straight anastomosis. In a large number of types, there is a subtotal gatstomy overlay, which can be used to shorten the anastomosis and harchuvannya for starting the anastomosis. In the rest of the rocks, the broadened method of raising the proximal bladder by means of a bougienage path (4-10 times) (R. Howard, N. Myyers).

Buzhuvannya can reach an increase in the proximal end and decrease in dyastasis, which allows the viconati to direct diastasis without tension. In case of unpleasantness of the insertion of a straight anastomosis, the operation is completed by the separation of the tracheo-intestinal fistula and the sacrifice of the gastrostomy. The second option is the operation of sublinear esophagostomy according to Baire in case of gastrostomy and shiina esophagostomy with advancing plastic of the esophagus with intestinal or shlunkovy graft.

With atresia of the intestine with a proximal tracheo-intestinal fistula, the fistula was submerged in a relatively slow mediastinotomy. With the presence of a subiliac fistula from the proximal and distal tract fistulas, the fistulas are violated during thoracotomy.

Deyakі authorize to admit the possibility of vіkonannya during atresia of the patient of the simultaneous operation of plastic surgery of the intestine (D. W a t e r s t o n, 1967).

There are two approaches to the stravoduct: transpleural and retropleural.

Carry out the transppleural access along the Y edge of the right-hand hanger from the nipple line to the scapula. Above the unpaired vein, the mediasthenal pleura is raised, the vessel is bandaged and reclined.

The mediastinal pleura above the travoduct extends later to the dome of the pleura and from the bottom to the diaphragms. Conduct mobilization of the stravohode. The upper segment of the stravoduct is known by the catheter introduced into the new one before the cob of the operation through the nis. Possibility to know the lower segment of the stravohode, operating in the bladder nerve. The lower segment of the stravohode is mobile on a small protrusion of 2-2.5 cm, so it can lead to the destruction of blood. Then, before the anastomosis is applied, the anastomosis is transversely right across the atraumatic head according to the end-to-end type.

Apply the first row of edge seam seams through all the balls of the lower end to the stravohode and the mucous membrane of the upper end. Pass the other row through the ball of both segments in the straw. For the suturing of the mediastinal pleurisy, close the thoracic wall tightly with a one-hour expansion of the lungs with an anesthesia apparatus.

Retropleural approach (according to I.I.Nasilov): repair on the ridge of the II ribs, coming out of the ridge to the right by 1.5-2 cm, and conducting vertically down to the YI rib, if you want to continue to order the names M'yazi stupidly shave in the course of the rise and strip the ribs. The II-Y ribs are resected subperiosteally, repaired from the side of the shoulder, 1.5-2 cm in length. From the posterior surface of the thoracic tissue, the parietal pleura are exfoliated with a tupfer. Go to the unpaired veni, need to remember about the need to cut the pleurisy, yak, there’s a slapstick. The unpaired vein is rectified between two ligatures. Then we proceed to the mobilization of segments in the stravohode.