Operation to open the chest. Opening of the chest. Anesthesia or anesthesia

After inspecting the cavity of the belly, an opening of the chest is proceeded. However, before opening the chest, it is once again examined, already nude, and the shape, value, symmetry and asymmetry are noted; Then mark the shape of the sternum (for example, "chicken" breasts, etc.) and its attitude to ribs, the places of connection of the ribs with cartilage, the place of operations, etc.

To prevent the lungs to prevent the pendant to open the chest to tangle the trachea to be able to judge the expansion of lungs and atelectasis. The latter may occur and be fatal after intubation anesthesia and after operations on the heart and lungs.

Now, taking a rib-cartilage knife into the fist (Fig. 32) and keeping it horizontally, put its cutting edge on the cartilage of the rib. The eye is scheduled to the line of its movement, which should go through the cartilages of all ribs from II to X, 0.5 cm from the place of joining the cartilage with edges.

For development greater power Left hand palm presses the knife to the finishing of the second rib. Now all the rib cartilage on the planned line are declined by one hand movement. This operation is performed first to the right, and then on the left.

It is necessary to work strongly and confidently, but carefully not to damage the adjacent organs. It is easier to observe, giving the blade a knife position parallel to the surface of the chest, cutting the entire cutting side and making a quick movement. The latter circumstance ensures the rapid knife hit to the next edge cartilage and prevents it in depth penetration.

If there is no rib cartilaginous knife, then this operation can be made with a small sectional knife, observing the same conditions.

Along with the intersection of the cartilage, intercostal muscles and antennaery pleura dissect.

Having captiously with his fingers from a mild hand, it is somewhat lifted and the sectional knife is cut off from it a diaphragm and mediastinal tissue, holding the knife all the time as close as possible to the rib cartilage and sternum, so as not to damage the organs and not open the heartfelt.

Now, taking a sectional knife into a fist for the handle and holding it vertically aspopped up and the blade from myself forward and lifting my sternum with my left hand, at the same time weigh it into the left side of the corpse, the fist in the chest cavity under the sternum so that the knife's blade appears outside the right Ringing cut. Sending the blade to the outward, left from ourselves, cut the cartilage of the rib on the right and further, without effort turning the blade inside, to the right from ourselves, to the midline, then forward, to the head, easily produce a dissection of stern and cure articulation with the right, and then From the left side. With the right movements it is possible to easily and the vessels are not wound.

Then they cut down soft parts from the sternum handle, remove the sternum, look at its inner surface and set aside, on the section table.

When examining, the sternum draw attention to the fiber of its rear surface, on the periosteum.

To determine the elasticity, the sternum is flexed, to determine the density, the knife is sticking into it, for inspection and study of the bone marrow, they cut it and squeeze the edge of the cut to squeeze the bone marrow, make the plane cut in the breast, on which the bone marrow is widely exposed.

Inspect the rib cartilage and celebrate the sighture, the ossification (elderly age), thickening (rachitic "rosary"), separation of cartilage from ribs, hemorrhage (grief, Barlov's disease). It is useful to make a longitudinal ribs to inspect the bone marrow.

This operation is an opening of the chest - it is easy to perform in children's corpses and the corpses of young subjects; The elderly and old people occur the edge of the rib cartilage, starting with the I rib. Therefore, troupes

Such entities cut the cartilage I edge, and it needs to be born with rib scissors (Fig. 33). With the ossification of all the rib cartilage and the ankylosis of the breast-clavical joint, the dissection has to be carried out by rib scissors or saw.

For a wider opening of the chest cavity, the ribs are cut by scissors on an axillary line. This is recommended to do when opening the corpses of newborns and young children.

Water test

If the pneumothorax is suspected to open the chest, it is necessary to separate the skin-muscle flap from the chest in the form of a pocket, pour water into it and cut the intercostal gap under water, of course, not the wound easy. The appearance of bubbles will indicate a positive water trial on the pneumothorax.

If the Heart Embolism is suspected, the opening starts not from the skull, but from the abdominal and thoracic cavity. It is necessary to work extremely careful not to damage the vessels.

It is better to start the main incision on the neck, but on the basis of the handle of the sternum. Counting of the first ribs and breast-clavical articulations are better not to touch.

Separating the sternum, it is lifted and either fix the binter or cord for the head of the corpse, if the Helper, the Libr is repaired at the level of the second intercostal intervals. Cardiac shirt is opened with a linear cut scissors. Furously capturing the edges of the edge of the sortie, bred them and, having passed to keep the assistant, pour water into the heart shirt. Now a pointed scalpel under water is cutting the wall of the right ventricle of the heart. If there is air in it, it will go through the water with bubbles.

This is a water test on the air emblem of the heart.

It should be borne in mind that at a late autopsy, body gases may form.

River cartilage cut off and turn off the clavicle only on the right side of the corpse. The assistant standing on the left of the corpse pulls the sternum on himself, like a lid, for the cut crane, wrapped it with a towel, so as not to damage his hands, creating access to extract the organs of the neck and chest.

The preservation of the rib cartilage on the left prevents the sternum after sewing the corpse and the associated breast deformation.

N. F. Melnikov-divers (1922) for a detailed examination of the lungs before their extraction suggested cutting through all intercostal intervals and exchass some ribs. Through the resulting holes (windows), it is possible to examine well and in detail and feel lungs, explore injuries, topography of them, the nature of the battles, etc. This method can be recommended to study the wounds of the lungs, inspection of jet changes around the wound channel, exudates, etc.

In case of wound injured or mediastinum tumors, the sternum should not be separated: it must be removed with the organs and then to come up depending on the need.

G. A. Berlov (1953) proposed a modification of the method of Melnikov-Detail for the study of the lungs when infecting pleural cavities and for the orientation of pathological processes towards ribs.

The skin flap of the torsa is separated to the rear swelling line. Light dissect through intercostal gaps up to the spinal column.

Riding the ends of the ribs by 15-35 cm, it is possible to investigate the lungs on the cuts in detail and orient pathological changes towards the ribs.

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thoracotomy
Thoracotomy (from DR. Greek. θώραξ - breasts and τομή - section, dissection) - surgical operation consisting in opening the chest through the chest wall to examine the contents of the pleural cavity or performing surgical interventions on the lungs, heart or other organs located in the chest (Fig. 1). It is one of the thoracic access in thoracic surgery, which involves penetration of the chest vehicle through the chest wall (as opposed to unknown and combined access).

1 varieties of thoracotomy
- 1.1 Advanced Thoracotomy
- 1.2 posterior thoracotomy
- 1.3 Side Thoracotomy
- 1.4 Axillary Thoracotomy
- 1.5 Parastinal Thoracotomy
2 complications
3 cm also
4 Notes
5 literature
6 Links

Toracotomy varieties

Advanced Thoracotomy

It is convenient for wide access to the front surface of the light and vessels of the root of the lung.

Patient position on the table: on the back with a raised sideline; The sore hand is bent in the elbow joint and fixed over the patient's head.

Execution technique: The incision is made in the course of the ris from the edge of the sternum to the middle axillary line, the duck is given the widest muscle of the back. The opening of the pleural cavity is made in IV or V inter estreon: intercotherr fabrics are dissected throughout the skin of the skin. If you need to expand access, we crosses the overlying (III or IV) Riber cartilage.

Application: right-sided and left-sided pneumonectomy, removal of the upper and middle shares of the right lung.

Advantages: Small trauma, ease of body position for the patient for the anesthesia and operational intervention, preventing bronchial content to the opposite light, the convenience of allocating the main bronchus and removal of tracheobronchial lymph nodes.

Disadvantages: only anterior mediastinum is available, difficulties in the injury and sealing of the wound.

Predar Thoracotomy

It is rarely used

Patient position on the table: on the stomach.

Implementation technique: cut between the inner edge of the blade and spine. The trapezoidal and both diamond muscles are dissected. The corner of the blade is enveloped to the middle axillary line (to the edge of the big breast muscle). Subdosny resection of VI ribs is performed, the cervix V and VII Ryuber are driving.

Application: Open arterial (Botallah) Doc (with surgical treatment). Resection of the rear sections of the lung, mobilization of the lower trachea and its bifurcation, including the control of the main bronchus, pneumonectomy with circular resection of trachea bifurcation.

Advantages: Convenient for intervention on the bronchial tree, there is an opportunity to connect an extensive resection] of the chest wall with thoracoplasty without changing the position of the patient's body.

Disadvantages: High trauma.

Left-sided side thoracotomy. Patient position on the table Left-sided side thoracotomy. Skin cut Left-sided side thoracotomy. Rybra diluted with an invalid

Side Thoracotomy

Is the most common.

Patient position on the table: on a healthy side, under which a roller is placed at the level of a large breast muscle (at the breast level in women). The hand on the execution side of the operation is bent in the elbow joint and is settled up and the sideline is fixed above the patient's head. The pelvic belt is in the side position (Fig. 2).

Execution technique: Skin cut in the course of V ribs from the corner of the blade or rear axillary line, below and by 2-3 cm knutrice from the nipple (in women - a ribbon of the milk gland from below) to the midcurbicular line (Fig. 3). The widest muscle of the back dishes only 3-4 cm. Muscle fibers of the anterior gear muscle are stratified. The interrochemical muscles are dissected along the front surface of the chest, and the post from the front axillary line the finger breaks up to the heads of the edge (it is possible to divide and on the front surface to the sternum). The pleural cavity is opened in the inter estreon (Fig. 4).

Application: Different surgery on lightness regardless of the localization of the pathological process, as well as operations on the mediastinal and aperture.

Advantages: Maloveraumatic. Allows you to approach any anatomical formation of pleural cavity and mediastinum. Creates good conditions for manipulations in all departments of the pleural cavity.

Disadvantages: The risk of bronchial content to the opposite light in the absence of separate intubation.

Axillary Thoracotomy

Refers to minimally invasive access.

Patient position on the table: on the side. The hand on the execution side of the operation is bent in the elbow joint and is set up up and the sideline is fixed above the patient's head so that the axillary region is well accessible.

Effectory technique: Railway from the edge of the widest muscles of the back from top to bottom in the oblique direction to the side edge of the big breast muscle. The front gear muscle dissect or disseminate. The opening of the pleural cavity is made in IV or V inter estreon.

Application: Small operational interventions on the surface of the lung.

Advantages: The absence in the area of \u200b\u200bthe cut of a large muscular massif, the incrementability of the postoperative scar.

Disadvantages: the impossibility of approaching the root of the lung.

Parastinal thoracotomy

The position of the patient on the table: on the back with a 3.5 cm roller on the spine on the spine on the spinning side.

Execution technique: section parallel and 3 cm lateral of sternum edge 6 cm with subsequent subpercultural resection 2 (or more) of the editorial cartilage for 2-3 cm. Internal pectoral artery and veins are allocated medial. Nude pleura is allotted laterally or, if necessary, revealed.

Application: Paraspinal biopsy, mediastinoscopy, revision and biopsy of mediastinal tumors.

Disadvantages: the ability to revise the mediastinum only on the one hand.

Complications

Complications after thoracotomy occur in 6-12% of cases. The main ones are:

pain syndrome;
binding postoperative wound;
bleeding.

Notes

1 2 3 4
1 2 3 4 5

Literature

Vishnevsky A. A., Rudakov S. S., Milanov N. O. Surgery of the chest wall: Guide. - M.: Vidar, 2005. - P. 268-286. - 312 p. - 1000 copies. - ISBN 5-88429-085-3.
Trachtenberg A. H., numbers V. I. Clinical oncopulmonology. - M.: Gootar Medicine, 2000. - P. 266-269. - 600 p. - 1500 copies. - ISBN 5-9231-0017-7.
Ferguson M. K. Atlas Toracal Surgery. - M.: Gootar Media, 2009. - P. 14-31. - ISBN 978-5-9704-1021-9.

Links

thoracotomy

Thoracotomy information O.

The most common is typical thoracotomy by SWEET (1950), produced in the side position of the cut along the ribs, with the back on the front surface of the chest. In this case, access becomes equally well available in front and rear of the roots of the lung, heart and mediastinum. In addition, right-hand access allows you to approach the trachea, the middle and top of the esophagus. Left-sided access opens the lower part of the esophagus and the descending part of the aorta. Depending on the level of the produced thoracotomy, you can access the dome of the pleura and to the diaphragm (rear-side access).

If, however, the patient to lay a slightly more on the back and extend the incision of the Kepent, then access will be called the front-side (Lezius, 1951).

The incision turns the blade by passing the stop and upstairs through the trapezoid muscle and both diamond muscles. If the incision is extended by the kepent, it passes through the wide muscle of the back, the front toothed muscle and reaches the edge of the big breast muscle. Thus, access can be expanded at wishes both the kleedi and the stop. It presents the best orientation and the best features for the preparation. However, at the same time, the position of the patient on the operating table bronchi of the operated half empty in the opposite easy thing, which can hire a certain danger. The bloody or infected discharge can penetrate the bronchial tree below the lung and complicate the operation of the anesthesiologist, especially if the patient is so-called. "Wet light" (bronchitis, bronchiectasia, lung abscesses, pulmonary bleeding). In such cases, we apply the intubation of the underlying bronchus or we have a patient in such a way that the painful of the bronchi of the patient's patient did not fall into a healthy light.

There is no doubt that with a lateral position, the possibility of mediastinal flotation depending on the respiratory phases is the greatest. In the same time, this was considered as a circumstance, aggravating operation and fraught with a great danger. Modern combined anesthesia with muscle relaxation and controlled breathing eliminated this problem (M.N. Anichkov). With a well-conducted anesthesia, the mediastinal flotation and gas exchange will turn out to be undisturbed.

The shoulder of the patient lying on the side is attached to the operating table arc in such a way that the axillary part is well accessible. The incision is carried out from the well-visible edge of the wide muscle of the spin of oblique, from top to bottom to the side edge of a big breast muscle. Formed after a cut, the skin scooter in length at 12-14 cm becomes almost imperceptible. The big advantage of this cut is that only one-only insignificant muscle in relation to the function comes across its length. However, this muscle does not necessarily dissect. It is possible in the direction of the skin section to bundle muscle fibers according to their move, while the multidirectional lines of the section of different layers occur. Further suitable for the IV-VI edge in the axillary direction, and thoracotomy is performed according to the principle described.

This technique has some drawbacks. When the pleural sheets are soldered on a wide distance, the release of the lung, especially in the diaphragm, becomes very difficult. Lung root lies very deeply and only with difficulty can be examined. If there are unforeseen complications (bleeding), then the surgeon's actions are very difficult, and it can happen that the planned intervention will become impracticable. In this case, it is necessary to expand the access of the kpeed and down, in the submarine direction. From the cosmetic considerations of this kind, the access is carried out primarily in women, while the seam of the submammmar section is carried out.

In connection with the marked gaging circumstances, axillary thoracotomy can be applied on limited indications. First, in the lung surgery, when radiologically determines the round shadow of tuberculoms, a benign tumor or cyst located to the periphery. This access can then be applied to the lung biopsy in order to diagnose disseminated pulmonary diseases. Finally, it can also be applied to the upper thoracic sympathectomy. If there is a suspicion of the defeat of the bronchine carcinoma, then we do not recommend this access, for it does not make it possible to produce expanded resection and radical removal of lymph nodes.

Thoracotomy in the position of the patient on the stomach

This access was introduced by LSELIN and Overholt (1947). The latter designed a device lengthening the operating table with the creation of support for the head, shoulders and patient's clavicle. The pelvis is fixed to the operating table with straps. The chest is free and easily accessible from the back side and side surfaces. The incision turns the blade and after the dissection of the trapezoidal and diamond muscles can be extended upward. However, in the front-side direction, it does not go further by the average axillary line.

The position on the stomach is especially recommended for thoracotomy in patients with "wet light." In such cases, bronchi empty through the trachea, and aspiration does not occur. The liberation of the bronchial tree can be improved by the Regulation on Trendelenburg. When operating on the lungs, it is very important to quickly reach the bronchi root of the lung, quickly pass and cross it. Thus, over the next steps of the operation, the possibility of receipt of the contents of the bronchi patient's bronchi is eliminated. On the other hand, the trunk vessels of the root of the lung, pulmonary artery and pulmonary vein are accurately becoming inaccessible. Their processing can be produced only after crossing the bronchi. Therefore, this access with tumor infiltrations or scaport changes in the field of lung root does not apply.

This access has inconveniences for anesthesia. It is difficult to control the eye reflexes, and if during the operation for some reason the need for reintubation will arise, then it is impossible at the same time. Resuscitation is significantly difficult.

This access is applicable almost exclusively only during operations in children about bronchiectasis, since in children due to the narrow lumen of the bronchi, the bronchi and the Carens tube may be non-applicable tamponade. For the same reason, they may have a quick aspiration of bronchi content leading to severe hypoxia. Therefore, in such cases, the stomach position provides a greater guarantee against possible complications. For the premises of children on the operating table there is no need for its elongation, which is connected only with inconvenience. Lining pillows under the pelvis and sternum you can create a good position on any operating table.

Thoracotomy in the position of the patient on the back

From the point of view of breathing and blood circulation, the patient's position on the operating table on the back is the best. The vital functions of the patient are well controlled, which greatly facilitates the work of the anesthesiologist. However, in this position, only the anterior mediastinization organs is easily available.

Front intercostal thoracstomy

This access often used Rienhoff (1936). The incision follows the front bend of III or IV edges, from the front axillary line to the sternum. Women conduct a submammar incision, after the milk gland and raising it will reach the need for the necessary intercostal. Between the fibers of a large breast muscle, after the dissection of a small breast muscle reach the rib. The pleural cavity is revealed on the intercosta. Rebar resection leads to the formation of an imperial defect. If the incision reaches the sternum, they are running on the internal artery and vein of the breast, which dissect after their ligation. In order to expand access through intercotors, one or two rib cartilage can be used. But in this case, access does not become, of course, in all respects sufficient and convenient.

With the position of the patient on the back it becomes possible to easily tele the surface vessels of the lung. Pericardi becomes easily accessible. It is difficult to intervene on the prescribed midstland, for example, the processing of the bronchi of the root of the lung. It also seems to close the wound wound from the long distance of the ribs from each other. If apparent edible cartilage was dissected, it is connected by a thin wire or chrome-ketgut to prevent the paradoxic movement of the chest wall. The hermetic closure is difficult and insufficient even when, overlapping the seams, use the fibers of a large breast muscle, stitching them with intercostal muscles.

Based limited opportunities This access and aggravating its circumstances, we cannot recommend it.

Middle Sterotomy

In the Heart Surgery, the median sternotomy is the most common access, due to which the front mediastum is becoming well available and large vessels.

They produce the middle incision from the cutting of the sternum to the middle of the epigastria. Electroboma dissects the sternum sternum in the middle line, and then the subcutaneous muscle and surface fascia of the neck - at the top of the cut. This ensures access to the progressable space. Then the distal part of the sternum will be prepared. The moon-shaped process is captured by the clip and remove or only remove to the side. After that, the index finger of the left hand is introduced from above and the index finger of the right hand from the bottom for the sternum to release the retrosternal space. It is usually additionally introduced in both directions of the Tunnel to complete the formation of the tunnel.

The sternum is dissected with bone scissors, sword or saw OIGLI (P. A. Kupriyanov). These tools have rounded ends, which allows them to be easily carried out through the fingers formed by the tunnels both from above and below. The most applies various mechanical saws that produce fast and gentle dissection of the sternum under the control of the vision, when the assistant spreads the ends of the sternum with hooks.

Middle sternotomy provides extrapleural access. If the need arises, then you can open for the examination of both pleural cavities. The edges of the dissected sternum are divorced by the rib or sternum expander, which allows you to get good review front mediastinum and hearts. The operating wound in the median sternotomy should be securely closed at the end of the operation. If the frame of the edges of the wound is not sufficiently dense and the bone edges are shifted, then the discrepancy between the edges of the sternum with the development of mediastinite occurs.

Before closing, the sternum through a separate hole is carried out under the sternum drainage with holes. Then sheer is pierced on both sides of the dissected sternum 3-5 holes through which the thick stainless wire is carried out. IN recent times The sternum is not drilled, but spend the wire along the bone edge of the sternum through the intercosta of both sides. The wire is inhabited through a thick needle's ear, which is carried out through the sternum or intercostal intervals. When removing the needle, it should be easily wire.

The ends of the thick wire are twisted with forceps by 3-4 turns, then they are lifted by forceps and re-twisted. This most achieved a dense fit of the dissected half of the sternum. Wire ends shortened, bend and plunged into fabrics. Frequent seams are securely stitched by the perception. Skin, subcutaneous fiber is stitched by noded seams. In the median sternothy, in the postoperative period, the breathing of the patient is less difficult than with lateral thoracotomy.

Transverse Sternotomy

The incision is carried out waveguide under the milk glands. If you need to access your heart, then reveal both pleural cavities in the IV intercore. After the bilateral dressing of the internal arteries and the veins of the breast, dissect or repaid the sternum. At the end of the operation in both pleural cavities and damage injected. The ends of the dissected sternum are combined with wire. When closing the occasional intercostal, the difficulties of sealing described previously described.

The transverse storotomy is not advantageous, as both pleural cavities are revered, which violates the stack of the chest. In the postoperative period, this leads to severe respiratory disorders. Currently, this access is applied only in the form of an exception: when removing tumors located in the mediastinum and penetrating both pleural cavities.

Thoracolaparotomy

As combined access to the organs of the chest and abdominal cavity in the last 20-30 years is used toracolaparotomy (B. V. Petrovsky). Thoracolaparotomy, along with a wide field of activity, provides some safety, guaranteeing a wide orientation. This access both in oncology and in traumatology provides almost unlimited operational capabilities.

After dissection of the rib arc and penetration through the diaphragm, the space is well accessible under the diaphragm. Thoracolaparotomy is used mainly during cardia and the esophagus operations. This access is also used when removing increased kidneys, adrenal glands, with liver tumors, highly enlarged spleen and when imposing porticaval and splenorenal anastomoses. It also applies with penetrating thoracoabdomominal wounds, when there is suspicion of simultaneous damage to breast and abdomen. Thoracolaparotomy is also used in the diaphragm surgery, when the thoracic and abdominal cavities are often revealed simultaneously. This access is convenient in the surgery of the Toraco-Abdominal part of the aorta (A. V. Pokrovsky).

Closing of the chest

With the rear and lateral intercostal thoracotomy, the closure of the chest is not possible, since the intercostal spaces in these places are narrow. Closing with anterior thoracotomy due to the large intercostal space is associated with difficulties, which does not depend on the applied suture material. It is advisable first to impose several nodal seams so that pleura under the control of vision was captured in the seams. Then rib hooks or rib retractor bring the neighboring rib edges, tying the seams.

There are other possibilities for the closure of the pendant of the chest, for example, bring the adjacent ribs of the pericostal seam bridgeing disconnected by cut. To do this, as suture material best suits chrome-ketgut. He, despite the subsequent resorption, sufficiently strong.

If access is carried out through the periosteum, then in this place, they lower the partially reciprocated edge and stitch the intercostal muscles under it.

Indications:long defeat of unclear origin , pulmonary changes in unclear etiology, with the ineffectiveness of other methods of diagnosis, damage to organs and vessels of the chest cavity.

Depending on the location of the operated organ and the type of pathology, it is distinguished: the front, rear, side.

Accessories:front, side, rear.

Equipment : For front access The patient is placed on the back. The hand on the side of the operation is bent in the elbow joint and fixed in a high-rise position on a special stand or an operating table arc. The incision begins at the level of cartilage III ribs from the parastinal line. It turns out the cut from the bottom of the nipples from the bottom, and in women - milk gland. Continue incision along the fourth intercosta to the rear axillary line. Layerly cut the skin, fiber, fascia and parts of two muscles - large chest and front gear. The incision is carried out in the middle of the intercostal. When carrying out the cut of the intercostal muscles too close to the lower edge of the overlying rib, the danger of nerve damage is created. The incision of the intercostal should be wider than skin cut - almost from the edge of the sternum to the blade line. In the medial corner of the cut, they try not to cross inland breast vessels. The wound of the chest wall is bred by one or two expansion.

Side. In the position of the patient on a healthy side with a small inclination on the back, the incision starts from the middle of the clavical line at the level of the fourth - the fifth intercostal and continue along the edges of the rear axillary line. Layerly dissect: skin, subcutaneous fatty, surface, chest fascia, M.Serratus Anterior, mm. INTERCOSTALES EXT. ET int., Intrangy fascia, suspending tissue and parietal pleura. The wound is bred by two expansion, which are mutually perpendicular. The wound sewing begins with the imposition of pharmacular nodal seams on the pleura and intercostal muscles in the medial corner. Then 2-3 polyspusny seams brought away the diluted ribs. Tie superimposed piercing seams. In lay of layers impose assembly seams on muscles, fascia with subcutaneous tissue and skin.

For back access: It is used to conduct operational access on the main armor. Patient - abdominal. Head turn to the side opposite operations. The shoulder on the side of the operation is dried over the edge of the operating table, the forearm and brush are fixed to the operating table. The incision is starting along the octopotable line at the level of ostic processes of III-IV of breast vertebrae, enhance the angle of the blade and finish with an average or anterior axillary line at the level of VI-VII ribs. In the upper half of the section, layers are cut into part of the trapezoidal and diamond muscles to be partitioned, in the lower - the widest muscles of the back and the front gear muscle. The pleural cavity is opened on the intercostal or through the bed of the previously rested ribs.

From topographic point of view Operations of the nesting of the chest cavity can be divided into operational operations of the pleural cavity - thoracotomy and the operation of the navigation of the mediastinum - mediastinotomy.

With thoracotomy breast cavity Open with a large incision, which is performed in parallel to ribs in one of the intercectures, or produced after the substitute resection of one of the ribs.

IN dependencies on the topography of the organTo which access is accessed, several types of thoracotomy are used.
Side Thoracotomy. The skin section starts from the medium-crooked line, carried out along the v ribs, ribbing the corner of the blade and finish on the occupatic line cut the skin, subcutaneous base, surface fascia. In the middle department, the wounds are distinguished by a large thoracic muscle, in the back - the widest muscle of the back. The fibers of these muscles dissect up the skin of the skin. In the front corner of the wounds expose the ribs and outdoor intercostal muscles. On the middle and rear wound sections, the fibers of the anterior gear and diamond muscles are exposed, which also intersect. Introducing the ribs and intercostal intervals, on the upper edge of V or Vi ribs dissect exterior and inner intercostal muscles, intrathorad fascia and parietal sheet of pleura. Initially, the pleural cavity is opened at a short extent, then the incision is extended for the entire length of the skin. In case of an insufficient width of the operating room, a substitute resection of one of the ribs is performed.

With advanced thoracotomy The skin is started along the ocolidate line, carried out parallel to IV or V edge to the average axillary line. Dock the skin, subcutaneous base, surface fascia, the fibers of the big breast muscle and the small thoracic muscle under it. The broadest muscle of the back is removed by the kice without crossing. Intercostal muscles dissect, intragenuous fatty and parietal sheet of pleura. Sometimes they cross the cartilage of one or two ribs, which makes it possible to significantly expand the operational wound.

With the posterior thoracotomy The skin incision starts from the front axillary line at V or VI ribs, carried out parallel to the ribs before the vertebral line, the rich angle of the blade. After the dissection of the skin, the subcutaneous base and surface fascia, the 1st layer of muscles is isolated - the widest muscle of the back and the trapezoidal muscle, which intersect the skin of the skin. Then they allocate the 2nd layer of muscles - the front gear and diamond-shaped, which also intersect. Under these layers there are muscles of the 3rd layer - the long muscles of the back, which are not crossing the hide.

One of the intercores Intercostal muscles dissect, intrabriety fascia and parietal sheet of pleura, reveal the pleural cavity. Sometimes, for the expansion of the operating room, the vertebral edge crosses one or two ribs or resets them substandard.

Emission of the operating room. When the wound stroke after thoracotomy, much attention is paid to ensuring the tightness of the pleural cavity, which is achieved by maximizing the ribs adjacent to the wound and layer-by-layer embeding of soft tissues above the dissected intercreic. The wound tightness is easier to provide in the case when during thoracotomy did not resection of the ribs.

Wound ears In several layers. The first number of seams provides the maximum rapprochement of the ribs above and below the dissected interbry. Tolstoy Ketgutoy thread (often double) impose a flea-cut polyspakny seam in which the nearest ribs, the intrathorad fascia, the parietal sheet of pleura and the crossed intercostal muscles needle are carried out from the outside in the upper edge of the supervised rib, piercing intercostal muscles, intrabrudal fascia and parietal sheets of pleura. They roll out the needle from the side of the pleural cavity at the lower edge of the following edge. Then the same thread is again carried out from the outside in the upper edge of the advanced ribs at a distance of 4-5 cm from the site of the previous rope of the needle and are fluttered from the side of the pleural cavity at the same distance. Tie tie. Depending on the length of the wound, another 1-2 block-shaped polyspaste seams are superimposed and after tensioning the threads, making sure the edges of the edges tie them in a sufficient convergence of the edges.

The second series of seams - Eat the muscles of the chest wall. Depending on the type of thoracotomy, the dissected edges of the muscles together with their fascias are embeded by individual nodal or 8-shaped ketgut seams.

Third row of seams - impose separate nodal seams on the skin and the subcutaneous basis. The thick layer of the subcutaneous base is squeezed by nodal ketgut seams separately.
Skin Often feed intradermal cosmetic chooth suture.