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Lecture notes, cheat sheets
Operative surgery. Lecture notes: briefly, the most important
Directory / Lecture notes, cheat sheets Table of contents
LECTURE #1 Introduction to operative surgery. The doctrine of the operation Operative surgery (the science of surgical operations) studies the technique of surgical interventions. Topographic (surgical) anatomy - the science of the relationship of organs and tissues in various areas of the human body, studies their projection on the surface of the human body; the ratio of these organs to non-displaced bone formations; changes in the shape, position and size of organs depending on body type, age, sex, disease; vascularization and innervation of organs, lymphatic drainage from them. Based on modern achievements in anatomy and physiology, operative surgery develops methods for the rational exposure of organs and the implementation of certain influences on them. Topographic anatomy describes the layered arrangement and relationship of organs by region, which allows you to determine the affected organ, choose the most rational operational access and reception. The first work on operational and topographic anatomy was written by the Italian surgeon and anatomist B. Jeng in 1672. The founder of topographic anatomy as a science is the brilliant Russian scientist, anatomist and surgeon N. I. Pirogov. For the first time the department of operative surgery and topographic anatomy appeared on his initiative at the St. Petersburg Military Academy in 1867, the first head of the department was Professor E. I. Bogdanovsky. Topographic anatomy and operative surgery have received special development in our country in the works of V. N. Shevkunenko, V. V. Kovanov, A. V. Melnikov, A. V. Vishnevsky and others. According to N. N. Burdenko, the surgeon during the operation should be guided by three main provisions: anatomical accessibility, technical feasibility and physiological permissibility. This implies knowledge of topographic anatomy to perform an anatomically sound incision with minimal damage to blood vessels and nerves; operative surgery to select the most rational intervention on the affected organ, physiology to anticipate possible functional disorders during and after surgery. One of the main methods for studying operative surgery and clinical anatomy is independent work on a corpse, which allows you to consider the relationship of organs and tissues, and also teaches you to identify anatomical objects according to specific local features (depth of occurrence, direction of muscle fibers, relative position of organs, structure of fascia, etc.). d.). But work on a corpse does not provide mastery of the necessary condition - stopping bleeding from damaged vessels, and therefore it is necessary to carry out surgical interventions on living animals, performed in compliance with all anesthetic requirements. Working on live animals makes it possible to master the skills and techniques of stopping bleeding, the ability to handle living tissues, and assess the condition of the animal after surgery. In recent years, thanks to the development of computer graphics, it has become possible to model three-dimensional images of complex anatomical regions, reproduce them from various angles, at various stages of surgical intervention. Any operation consists of two main stages: operational access and operational acceptance. 1. Online access Operative access is those actions of the surgeon that provide exposure of the affected or damaged organ by the pathological process. Online access must meet certain requirements, which can be divided into qualitative and quantitative. The criteria for a qualitative assessment of surgical access are: breadth; the shortest distance to the operation object; compliance with the direction of the main vessels and nerves; good blood supply to the edges of the surgical wound (which contributes to rapid healing); distance from infected foci. The breadth of access is necessary to ensure the freedom of action of the surgeon. It depends on a number of factors: the degree of development of fatty tissue in a patient (both subcutaneous and intermuscular); the depth of the location of the organ, the need to revise other organs; the nature and complexity of the proposed operation. When performing a minimal access, the surgical trauma is reduced and the cosmetic effect is better achieved. But in case of severe complications and a high probability of death of the patient, they resort to large accesses, since with a small access the surgeon will not establish an accurate diagnosis, since he will not be able to examine neighboring organs, will not completely remove effusion from the chest or abdominal cavities, etc. Attempts to mechanically expand the surgical access due to tissue elasticity can lead to tissue damage, compression of blood vessels and worsen the results of wound healing. But too large accesses are not only traumatic, ugly, but also lead to the formation of postoperative hematomas, wound suppuration, eventration. To obtain a good overview with a small access, it is necessary to ensure the optimal position of the patient on the operating table. Using the design of a modern operating table, it is possible, by giving an appropriate position to the patient's body or using a system of rollers, to bring the operated organ closer, which is necessary not only for better surgical intervention, but also to reduce tissue tension and, accordingly, eruption of sutures when closing the wound. To reduce the eruption of sutures, it is necessary to operate the patient under anesthesia with good relaxation; make a dissection of the aponeurosis a little more than the length of the skin incision, since the tendon practically does not stretch; use mirrors, retractors and retractors. Rack or screw retractors that evenly stretch the wound are applicable if the object of surgical intervention is located in the center of the wound, but if the object of the operation is displaced to the corner of the wound, the wound should be opened using hooks or mirrors, visually controlling the degree of visibility of the wound. It must be taken into account that access should pass through the least number of layers, along the shortest distance to the organ. To achieve this goal, it is necessary that the incision is located in the projection zone of the organ. In addition, the surgeon must take into account that the tissues forming the access margins must fuse well after the operation, i.e. they must be well supplied with blood. Due to poor blood supply, the edges of the wound grow together for a long time. Therefore, in order to avoid divergence of the wound and prolapse of the entrails, it is not advisable to use such accesses in the elderly, oncological patients and patients with severe chronic pathology. Access should not be located near infected (contaminated) areas of the body. Failure to comply with this requirement can lead to purulent complications in the postoperative period. The quantitative assessment of surgical approaches is based on the criteria developed by A. Yu. Sozon-Yaroshevich. The criteria objectively evaluating operational access are as follows. Axis of operation. This is understood as a line connecting the surgeon's eye with the deepest point of the surgical wound (or the most important object of surgical intervention). Most often, the axis of the surgical action passes along the axis of the cone of the surgical wound or is the bisector of the angle between the side walls of the wound cavity. A prerequisite for using this criterion is that the surgeon examines the object of the operation in a certain position, without losing the most important object of the operation from the control of the organ of vision. The direction of the axis of the operational action is determined in relation to the frontal, sagittal and horizontal planes. Accordingly, the analysis of the direction of the axis of the surgical action is carried out both qualitatively, using the appropriate terms (top-bottom, front-back, lateral-medial), and in degrees relative to the plane of the wound aperture. The use of a stereotaxic method of performing operations (for example, on brain structures) is a classic example of a quantitative assessment of the direction of the axis of the operational action in degrees. The stereotaxic method is a set of techniques and calculations that allow, with great accuracy, the introduction of a cannula (electrode) into a predetermined, deeply located structure of the brain. To do this, it is necessary to have a stereotaxic device that compares the conditional coordinate points (systems) of the brain with the coordinate system of the apparatus, an accurate anatomical determination of intracerebral landmarks, and stereotaxic atlases of the brain. It makes no sense to study the axis of operational action in superficial wounds or wounds in which the organ is removed to the surface. However, in narrow surgical wounds, when the operated organ remains at a considerable depth, the role of this criterion is great. The value of the direction of the axis of the surgical action determines the angle from which the surgeon will see the object of the operation and the layers that he must sequentially dissect, opening the object of the operation. The angle of inclination of the axis of the operational action. This term refers to the angle formed by the axis of the surgical action and the surface of the patient's body within the operating zone (the plane of the wound aperture). The angle of inclination of the axis of the surgical action determines the angle of view from which the surgeon views the object of the operation. The best conditions for the operation are created if the angle is 90° and the surgeon looks directly at the object of the operation. Practice shows that when this angle is less than 25°, it is difficult to operate, and it is better to make a new access that combines the projection of the operation object with the wound aperture. Operating angle. This angle is formed by the walls of the cone of the surgical wound; it determines the freedom of movement of the surgeon's fingers and instruments in the wound. That is, the larger this angle, the easier it is to operate. When the angle of the surgical action is more than 90°, the operation is performed easily, as if the organ lies on the surface. When the angle is from 89° to 26°, manipulations in the wound do not cause any particular difficulties. With an angle of 15-25°, manipulations are difficult. When the angle is less than 15°, the operation is almost impossible. It should be borne in mind that if the edges of the surgical wound are formed by soft tissues, then with the help of hooks, retractors, its geometric characteristics can be significantly improved. One of the ways to improve the characteristics of the wound is to mobilize the corresponding part of the organ. If the edges of the wound are formed by rigid elements (bones of the cranial vault, ribs, sternum, etc.), then the possibilities for improving the parameters of the angle of the surgical action are limited. Wound depth. This term refers to the distance between the planes of the upper and lower apertures of the wound. The depth of the wound is determined by the axis of the cone, which is also the axis of the surgical action, or by the bisector of the angle of the surgical action. This is a segment of the axis of the surgical action from the plane of the wound aperture to the object of intervention. The depth of the wound determines the ease of action of the surgeon's fingers and instruments. When working with conventional instruments, the depth of the wound should not exceed 150-200 mm. To characterize the depth of the wound, the wound depth index can be used, defined as the ratio of the depth of the wound to the value of the upper aperture, multiplied by 100. The access zone in the classical sense is the area of the bottom of the surgical wound. Measured in absolute terms, it is not very informative. At the same time, the ratio of the values of the upper aperture and the bottom of the wound is indicative. If the ratio of values is approximately 1:1, then this indicates the shape of the wound in the form of a cylinder or a well and indicates the rationality of access. This ratio must be adjusted to the depth of the wound. If the area of the upper aperture of the wound is many times greater than the area of the lower aperture, this indicates an unreasonably long incision with a relatively superficial location of the object of intervention. Modern technologies (video endosurgical equipment) allow, after a minimal incision of the abdominal or chest wall, to introduce a miniature television lens and a powerful light source for revision or intervention on almost all organs of the abdominal and chest cavities. In these cases, the viewing area will be many times greater than the area of the wound aperture (puncture holes). This ratio indicates a low traumatic surgical approach. The choice of online access should take into account the following conditions. 1. Physique (constitution) of the patient. A significant role is played by the degree of development of adipose tissue. 2. Features of the operation being performed. 3. The risk of surgery. 4. The patient has a large scar after a previous operation. On the one hand, it is more profitable to make an access with excision of an existing scar both in terms of preventing new scars and from a cosmetic point of view. However, when the scar is excised, the vessels or internal organs involved in this scar may be damaged. In addition, with a tendency to form a keloid scar, excision can lead to an even greater proliferation of connective tissue. 5. Possibility of wound infection. The presence of an infected wound in a patient or the fear that a colostomy, tracheostomy, bladder fistula can serve as a source of infection after surgery makes it necessary to seek surgical access as far as possible from them. 6. Cosmetic considerations. To achieve the best effect, you should pay attention to the amplitude and direction of muscle movements (carry out the incision so that it is perpendicular to the direction of these movements throughout); the direction of the Langer lines (i.e., the course of collagen and elastic fibers, the incision is made parallel to these lines); the course and direction of skin folds and wrinkles; topographic and anatomical features of the operation area. 7. Compliance with the rules of ablastics. To comply with ablastics, an approach to the tumor from the periphery is used, isolation of dissected healthy tissues, an electric knife, a laser or plasma scalpel are used. 8. The presence of pregnancy. The uterus should be away from surgical access to avoid premature stimulation; access should be made taking into account the displacement of organs by the uterus depending on the duration of pregnancy. 2. Operational reception Surgical reception - direct actions at the object of surgical intervention, aimed at removing the altered organ or pathological focus. Performing an operative technique involves a sequence of actions when removing an organ or part of it, restoring the patency of the gastrointestinal tract, restoring blood or lymph flow through the corresponding vessel, etc. Certain requirements are imposed on the operative technique, it should be radical, minimally traumatic, and if possible bloodless ; minimally disrupt the vital activity of the body, ensuring the best elimination of the cause of the disease. The radicality of the surgical technique is understood as the most complete removal of the focus of the disease, often not only with the affected organ, but, for example, with malignant tumors, with regional lymph nodes or even part of neighboring organs. The bloodlessness of the surgical intervention is ensured by a thorough sequential stop of bleeding as the manipulations are carried out. In some cases, it is recommended to pre-ligate large arterial and venous trunks involved in the blood supply to the region. This is done during complex operations in the head and face, producing a preliminary ligation of the external carotid artery, the branches of which supply the maxillofacial region and the cranial vault. It is important to preserve (or restore) the function of the organ after the operation. It provides for the mandatory inclusion in the operation plan of the restoration of a particular organ and its functions after the operation. The requirements for operational access and reception are highly controversial; it is almost impossible to comply with all of them. As a rule, one operational access corresponds to one operational reception. Sometimes two accesses correspond to one operational reception. Of interest are situations where several approaches are performed from one access or the patient undergoes several accesses and surgical techniques during the operation. 3. Types of transactions There are several types of operating aids. Emergency (urgent, urgent) - are made according to vital indications immediately. Planned - are made after examining the patient, establishing an accurate diagnosis, long-term preparation. Elective surgeries pose less danger to the patient and less risk to the surgeon than emergency surgeries. Radical - completely eliminate the cause of the disease (pathological focus). Palliative surgery does not eliminate the cause of the disease, but only provides temporary relief to the patient. The operation of choice is the best operation that can be performed for a given disease and which gives the best treatment result at the current level of medical science. Necessity operations are the best possible option in this situation; depends on the qualifications of the surgeon, the equipment of the operating room, the condition of the patient, etc. Also, operations can be single-stage, two-stage or multi-stage (one-, two- or multi-stage). One-stage operations - operations in which, during one stage, all the necessary measures are performed to eliminate the cause of the disease. Two-stage operations are performed in cases where the patient's state of health or the risk of complications do not allow to complete the surgical intervention in one stage, or, if necessary, prepare the patient for a long-term dysfunction of any organ after the operation. Multi-stage operations are widely practiced in plastic and reconstructive surgery, and in oncology. In recent years, due to the increase in life expectancy, there has been a trend towards an increase in the number of patients suffering from several surgical diseases. Improvement in diagnostics, improvement of surgical technique and advances in the field of anesthesiology and resuscitation contributed to the expansion of indications for combined (simultaneous) surgical interventions. Combined (or simultaneous) operations are performed during one surgical intervention on two or more organs for various diseases. An extended operation is characterized by an increase in the volume of surgical admission for a disease of one organ due to the characteristics or stage of the pathological process. A combined operation is associated with the need to increase the volume of surgical treatment for one disease that affects neighboring organs. Evaluation of surgical operations. Evaluation is based on the results of the operation. They are divided into immediate and remote. Immediate results are determined by mortality on the operating table and in the coming days and weeks after surgery. The quality of immediate results largely depends on the surgeon himself. Long-term results are determined by the patient's condition months and years after the operation. LECTURE #2 Basic surgical instruments Any operation consists of three elements: tissue separation, bleeding control and tissue connection. To perform these actions, a number of devices (tools) are used. The main ones, used in almost every operation, can be grouped according to their purpose into four groups: tools for separating tissues (knives, scissors, etc.); hemostatic instruments (clamps, ligature needles); auxiliary tools (tweezers, hooks, mirrors, etc.); tools for connecting tissues (needle holders with needles, staples, staplers, etc.). 1. Blade, scissors The surgical separation of tissues is based on the principle of sequential layer-by-layer separation of the skin, subcutaneous tissue, muscle layers, etc. Instruments for mechanical separation of tissues are the oldest and most diverse. The cutting element is a blade made in the form of a wedge with a certain sharpening (sharpening) angle, the value of which depends on the purpose. The blades used for cutting soft tissues have a sharpening angle from 12° to 25°; for cartilage dissection - from 30° to 35°; for cutting bone tissue - 40 °. The smaller the sharpening angle, the sharper the knife, and the faster it loses its sharpness. There are three main ways to hold a scalpel in your hand: in the form of a bow, in the form of a writing pen and in the form of a table knife. When puncturing, the scalpel blade should be at an angle of 90° to the tissue surface, and when performing a dissection, at an angle of approximately 45°. The cutting edge of the blade can be of different shapes: straight, curved, closed circle. In general surgical practice, abdominal, pointed scalpels are most often used (scalpels with a removable blade are widespread); amputation knives. There are also many varieties of special cutting tools. To prevent corrosion, surgical knives are made of high carbon steel and coated with a layer of chromium and nickel. The cutting edge of the tool is not protected from corrosion and needs constant care. Scissors are another type of surgical instrument designed to separate tissues or separate their parts. They have two blades, which, when moving in the opposite direction, cut tissue. There are two types of surgical scissors: articulated and guillotine. Hinge-type shears operate on the principle of two wedges, which are in close contact with the tips at the moment they pass against each other at the cutting point. Usually they are used to cut layers that have a small thickness. For the convenience of working in deep wounds, the working part of the scissors can be bent vertically (Richter) or flat (Cooper). Guillotine-type shears have blades moving one on top of the other in special guides. They are used to cut ribs, costal cartilage, etc. The scissors sharpening angle usually corresponds to 70-85 °. In surgical interventions, as a rule, blunt-pointed scissors are used. Working with scissors can be convenient only with constant control of the movement of each branch, this is achieved only with the correct holding of the scissors: the nail phalanx of the IV finger must be inserted into the right ring of the scissors: the III finger rests on the ring indicating the lock (screw). Like surgical knives, scissors are made of high-carbon steel with an anti-corrosion coating. At present, more and more often, high-tech methods are used for tissue separation, which have a number of advantages over the traditional use of a knife or scissors. These include electrosurgical, cryosurgical devices, the use of ultrasound, plasma flow or laser for tissue dissection. 2. Electrosurgical devices In 1907, the American Lee De Forest designed an apparatus that dissected tissue using high-frequency alternating current. In Russia, electric current for the surgical treatment of tumors began to be used in 1910-1911. at the Military Medical Academy. Electrosurgery is based on the conversion of electrical energy into heat. A high-frequency electric current is used to cut and coagulate the tissue. To work in the coagulation mode, a modulated (pulsed) electric current of high frequency is used. To work in the "cutting" mode, unmodulated alternating current of low voltage is used. The effect of electrosurgical cutting is optimal when the tip of the electrode is in close proximity to the tissues, but does not touch them. Tissue cutting is more efficient if the electrode has a sharp edge, which ensures maximum energy density. Low-vascularized tissues (adipose tissue) have a relatively high tissue resistance, so the dissection of such tissues requires higher power. To dissect tissues with good blood supply (muscles, parenchyma), a minimum power is sufficient. Depending on the method of applying high-frequency current, the following methods are distinguished: monopolar (the surgeon's working tool is an active electrode, while the passive electrode provides electrical contact with the patient's body outside the operating field; heat is generated in the dissected tissue area due to the difference in the size of the electrodes); bipolar (both outputs of the generator are connected to active electrodes, the thermal effect is carried out in a limited space between the two electrodes). 3. Cryosurgical instruments and devices The essence of the method is to eliminate the pathological formation by its rapid local freezing. The working part of the devices for cryosurgery are rapidly cooled tips. As a rule, liquid nitrogen, the boiling point of which is -196 °C, freon (-12 °C), etc., serve as a cryoagent. A cryoinstrument with a contact tip can only be considered as a point source of cold. Therefore, it is impossible to freeze large arrays of pathological neoplasms and the possibilities of cryosurgical technique are limited to the removal of only small pathological formations. As a result of the different properties of water at a high cooling rate, thermomechanical stresses arise in the tissue, the tissue structure is deformed and displacements and cracks are formed, which are most pronounced along the edges of the pathological focus, as a result of which the frozen zone can be removed in the form of a kind of "ice ball". Local blood flow during cryotherapy practically does not change. The cryosurgical method has found application in oncology, ophthalmology, dermatology, urology, proctology, etc. Local freezing is one of the main methods of destruction in stereotaxic neurosurgery. 4. Ultrasonic devices for tissue separation Such devices are in most cases based on the conversion of electric current into an ultrasonic wave (magnetostrictive or piezoelectric phenomenon). The operation of magnetostrictive transducers is based on the ability of bodies made of iron, nickel, their alloys and some other materials to periodically change their dimensions in an alternating magnetic field. In ultrasonic surgery, instruments are used, the cutting edge of which continuously fluctuates with frequencies of 10-100 kHz and an amplitude of 5-50 microns. The mechanism of the effect of ultrasound on tissues is based on the fact that high-frequency vibration leads to mechanical destruction of intercellular bonds; and on the cavitation effect (the creation of negative pressure in the tissues in a short period of time, which leads to the boiling of intracellular and intercellular fluid at body temperature; the resulting steam leads to tissue separation). Coagulation also occurs due to protein denaturation. The resulting coagulation film is so strong that modern ultrasonic scalpels allow even large (up to 7-8 mm) vessels to be cut without prior ligation. The use of an ultrasonic knife is most appropriate when isolating and excising scars, removing tumors, opening inflammatory foci, as well as when performing plastic surgeries. In addition, the ultrasonic knife can be used as an ultrasonic probe for finding metal and other foreign bodies in the tissues (i.e., it works on the principle of echolocation). This does not require contact with the object. Particularly suitable for working on bones. The basis of tissue dissection by a plasma flow is the formation of a plasma flow when a high-strength electric current is passed through a high-speed jet of an inert gas (argon). The power of the resulting plasma jet is usually about 100 watts. The manipulators of the installations are interchangeable metal cylinders with a pointed part and a nozzle with a diameter of 2 mm (coagulator) or 0,6 mm (destructor), which are pre-sterilized in formalin vapor. The greatest efficiency is achieved when working with muscles, lung tissue, when dissecting the tissue of parenchymal organs, when the diameter of the vessels and ducts damaged during the incision does not exceed 1,5 mm (coagulation effect). Vessels and ducts with a diameter of more than 1,5 mm must be stitched or clipped; during operations on the stomach and intestines, plasma scalpels are used to cut the walls of hollow organs. Plasma effect on the tissue is accompanied by ultraviolet radiation and the release of atomic oxygen, which contributes to additional sterilization of the wound. In addition, the plasma flow has a pronounced analgesic effect, allows you to treat any point of the surgical wound, and does not adversely affect the reparative processes. 5. Lasers in surgery The mechanism of action of a laser scalpel is based on the fact that the energy of a monochromatic, coherent light beam sharply increases the temperature in a corresponding limited area of the body and leads to its instantaneous combustion and evaporation. In this case, the thermal effect on the surrounding tissues extends over a very short distance, since the width of the focused beam is 0,01 mm. Under the influence of laser radiation, "explosive" destruction of the tissue also occurs due to the impact of a kind of shock wave, which is formed during the instantaneous transition of tissue fluid into a gaseous state. Features of the biological action of laser radiation depend on a number of its characteristics: wavelength, pulse duration, tissue structure, physical properties of the tissue. Consider the characteristics of the main lasers used in surgery. Laser with a wavelength of 1064 nm. The radiation penetrates relatively deep, up to 5-7 mm. At temperatures above 43 ° C, protein molecules are irreversibly damaged (denatured), the tissue dies, undergoing thermal coagulation; at temperatures above 100 °C, water begins to evaporate; at temperatures above 300 °C, combustion occurs with the release of combustion products and their deposition on the surface of the crater. The destruction of tissue by the formation of a crater, hole or incision during the laser operation is called ablation, and the conditions under which it occurs are called the ablation mode of the laser. At low radiation power and short-term exposure, tissue heating is relatively small and only its coagulation or melting occurs (subablation mode). A laser with a wavelength of 3 to 10 nm acts on soft tissues in a similar way. These lasers usually operate in a pulsed mode. They are most often used in cosmetic procedures on the skin. Excimer lasers with a wavelength of 300 nm have the highest power compared to other groups of lasers. Energy is intensively absorbed by non-aqueous components of soft and hard tissues, including DNA proteins. The zone of thermal damage when exposed to it is several micrometers. The hemostatic effect is weakly expressed. The copper vapor laser with wavelengths of 578 and 585 µm has interesting properties. The skin is "transparent" for him, the substance that perceives the radiation is melanin and hemoglobin, which provides unique opportunities in the treatment of hemangiomas, etc. with excellent cosmetic results. Due to its high coagulating and hemostatic properties, the laser has found wide application in operative endoscopy. The use of a laser scalpel is convenient for opening the lumen of hollow abdominal organs, resection of the intestine, formation of an inter-intestinal or gastrointestinal anastomosis, while the most crucial moment of the operation is performed on a "dry" field. In oncological patients, the risk of spreading malignant tumor cells outside the surgical field is reduced due to the coagulating and ablastic effects of the laser beam. Healing of laser wounds is accompanied by a minimal inflammatory response, which dramatically improves cosmetic results. 6. Hemostatic instruments Represented by clamps, ligature needles, etc. The most commonly used are various types of hemostatic clamps. The most common are the clamp with oval jaws (Peana), the straight serrated clamp with notches (Kocher), the straight and curved clamp with notches without teeth (Billroth), the mosquito clamp (Halsted). The serrated clamp holds more firmly than the others, but punctures the tissue being gripped. Hold the hemostat in the same way as scissors. Only with this position of the fingers can you accurately aim the clip where you want it. When grasping a vessel or tissue, try to keep the clamp as perpendicular to the object as possible. The tip of the clamp should be as free as possible. The superimposed clamp should not be displaced unnecessarily, pulled by it, etc. The clamp is removed after tightening the first turn of the ligature. To stop bleeding from small vessels in surgery, the method of diathermocoagulation has become widespread. Auxiliary instruments are represented by a variety of tweezers, hooks, mirrors, retractors, etc. Most often, three types of tweezers are used during operations: anatomical, surgical and pawl. They differ in the device of grasping cheeks. On the cheeks of anatomical tweezers there are blunt transverse notches (used to work with delicate tissues), surgical tweezers have sharp teeth (used to hold rough formations), and paws have rounded paws with denticles. The length of the tweezers is from 15 cm to 20 cm or more. It is recommended to grab the tweezers with fingers in its middle part on one side with the thumb, and on the other side with the index and middle. Instruments for connecting tissues are represented by needle holders with needles, staples, staplers, etc. Surgical ones come in a wide variety of shapes, sizes, sections. They serve to connect or stitch tissues and organs. Modern surgical needles are equipped not with an ordinary eye, but with a springy dovetail split, which makes it possible to insert sutures almost automatically. The most commonly used cutting needle for stitching mostly coarse fabrics consists of three parts: an eye adjacent to the eye of a dihedral landing site for the needle holder and a working trihedral cutting part ending in a point. To hold the needles during the sewing process, special tools that firmly hold the needles are used - needle holders. This makes it possible to sew in the depths of the wound or cavity without touching the tissue with your hands. When suturing the heart, blood vessels, and intestines, atraumatic needles are often used. One end of these needles is sharpened, the other has a gap into which the thread is firmly rolled. The most common needle holders are the Hegar needle holder (with ring handles) and the Mathieu (with curved handles). As a rule, the needle is grasped closer to the eye so that at least 2/3 of the length of the needle (counting from the tip) is free. LECTURE #3 Ways to stop bleeding There are the following types of bleeding: according to the source of bleeding - arterial, venous, arterio-venous and capillary (parenchymal); in the direction of blood flow, external and internal are distinguished; according to the time of occurrence, primary and secondary are distinguished. Damage to large arterial trunks is dangerous for the victims: there is a threat of death due to blood loss, necrosis of the distal part of the limb is possible. To stop arterial bleeding, various methods are used, but among them there are no universal ones. It is necessary to clearly know the indications for the use of one or another method of stopping bleeding, to confidently master the entire arsenal of available means. 1. Ways of temporary and final stop of bleeding With the development of bleeding from a large artery, the best method is to stop it completely, but if this turns out to be impossible, methods of temporarily stopping bleeding are used, which do not require special tools, are quick and easy to use. They are used as an emergency first stage before the final stop of bleeding. One way to temporarily stop bleeding is to finger press the artery to the bone above the injury site. The possibility of stopping bleeding by pressing the artery to the bone with a finger is determined by: the superficial location of the artery (there should be no dense, powerful muscles between the surgeon's finger and the artery); the location of the bone close to the artery, directly below it. However, the combination of such topographic and anatomical features is not found in all areas. Places of possible finger pressing of the arteries: on the neck, the common carotid artery can be pressed against the carotid tubercle on the transverse process of the VI cervical vertebra. In the supraclavicular fossa, the subclavian artery can be pressed against the tubercle of the anterior scalene muscle on the XNUMXst rib. In the axillary fossa, the axillary artery can be pressed against the head of the humerus. The femoral artery is pressed under the inguinal ligament to the anterior branch of the pubic bone. To properly perform digital pressure on the artery, you need to know the topographic anatomy of the relevant areas: the position of the artery, the area of \uXNUMXb\uXNUMXbthe bone to which it is pressed, as well as the features of the relationship of muscles, fascia, neurovascular bundles, etc. This determines not only the point of pressure of the artery located at the intersection of the projection line of the artery with the underlying bone, but also the vector of digital pressure, which allows you to reliably stop bleeding and avoid complications. Stopping bleeding by finger pressure on the artery has the disadvantage that the method is applicable only for a short period of time. Therefore, finger pressure can only be used as an emergency measure, the first stage, after which you need to go to the final stop of bleeding or apply another method, for example, you can use a tourniquet. A modern standard tourniquet is an elastic rubber strip with a device for tightening and fastening in the form of buttons. In the absence of a standard tourniquet, an impromptu waist belt, scarf, towel, etc. can be used. The tourniquet is applied above (proximal) to the wound, as close as possible to it, since the circular compression of the tissues by the tourniquet almost completely eliminates the possibility of blood circulation below the site of its application. But, when choosing the place of application of the tourniquet, it is necessary to take into account some topographic and anatomical features. It is considered the most rational imposition on those parts of the limb where there is only one bone (shoulder, thigh). The application of a tourniquet to those parts of the limb in which there are two bones (forearm, lower leg) is less effective, since some of the vessels in these areas, especially in the lower parts, are located between the bones, and stopping bleeding is not always effective. The advantages of using a tourniquet include speed and ease of use. A significant disadvantage is that the tourniquet can be used for a limited time (no more than 2 hours) without the risk of complications: gangrene of the distal part of the limb, paralysis of the nerves as a result of their compression, the so-called tourniquet shock, which develops after removal of the tourniquet as a result of acute intoxication of the body with metabolic products. , accumulating in damaged and devoid of blood supply tissues below the tourniquet. The methods of temporarily stopping bleeding can also include the imposition of a tight gauze bandage applied to the wound using an individual dressing bag. After the victim has been delivered to an institution where qualified surgical care can be provided to him, it is necessary to make a final stop of bleeding. 2. Groups of final methods for stopping bleeding It is customary to distinguish several groups of final methods for stopping bleeding: mechanical (ligation); physical (electro- and thermocoagulation); biological (hemostatic sponges, tamponade of biological tissues, etc.); chemical (hydrogen peroxide, iron sesquichloride solution, etc.); a special place among the methods for the final stop of bleeding is the restoration of the integrity of the damaged main artery with the help of a vascular suture. 3. Ligation of blood vessels in the wound Most often, for the final stop of bleeding, the imposition of ligatures on the ends of the vessels is used, there is a ligation of the vessels in the wound. In most cases, one ligature is applied to the end of the vessel. When stopping bleeding from large arteries, two ligatures can be applied. The operation of ligation of the vessel begins with a wide dissection of the wound, which must be performed along the course of the neurovascular bundle. Dissection of tissues is performed only after a temporary stop of bleeding with a tourniquet or finger pressure. After finding the ends of the damaged artery, clamps are applied to them. In this case, the clamp is superimposed so that its end is a continuation of the axis of the vessel. After applying a hemostatic clamp to the end of the artery with tweezers, it is necessary to carefully select it from the surrounding adipose and connective tissue in a 1-2 cm long area. If the artery is properly isolated, its wall becomes dull. With the correct application of the ligature, the pulsation of the end of the artery along with the ligature applied to it is detected. The condition for the reliability of stopping bleeding by ligating the artery in the wound is the mandatory application of ligatures to both the central and peripheral ends of the artery. Even if the peripheral end of the artery does not bleed, it still needs to be found and ligated during the operation, since after some time bleeding from it may resume, especially during transportation, which is due to an increase in blood pressure, as well as against the background of blood replacement therapy during avulsion still fragile thrombus during the movement of the limb. Therefore, after ligation of the vessels in the wound, the limb must be immobilized. In some cases, it is not possible to ligate the vessel in the wound: when it is localized in topographic and anatomical areas with particularly complex relationships between the elements, where the ends of the vessels are difficult to reach or can hide in the bone holes. 4. Ligation of arteries Ligation of arteries throughout can be used not only as a way to stop bleeding from a damaged vessel, but also as a method of preventing it before performing some complex operations. For the correct exposure of the artery for the purpose of ligation throughout, it is necessary to perform an operative access, which requires knowledge of the projection lines of the arteries. It should be especially emphasized that for drawing the projection line of the artery, it is preferable to use the most easily defined and non-displaceable bone protrusions as a guide. The use of soft tissue contours can lead to an error, since with edema, development of a hematoma, aneurysm, the shape of the limb, the position of the muscles may change and the projection line will be incorrect. To expose the artery, an incision is made strictly along the projection line, dissecting the tissues in layers. Such access is called direct access. Its use allows you to approach the artery in the shortest way, reducing surgical trauma and operation time. However, in some cases, the use of direct access can lead to complications. To avoid complications, an incision to expose the arteries is made somewhat away from the projection line. Such access is called roundabout. The use of a roundabout approach complicates the operation, but at the same time avoids possible complications. Operative method of stopping bleeding by ligating the artery throughout excludes the isolation of the artery from the sheath of the neurovascular bundle and its ligation. To avoid damage to the elements of the neurovascular bundle, novocaine is first introduced into its vagina for the purpose of "hydraulic preparation", and the vagina is opened using a grooved probe. Before ligation, the artery is carefully isolated from the surrounding connective tissue. However, ligation of large main arteries not only stops bleeding, but also dramatically reduces blood flow to the peripheral parts of the limb, sometimes the viability and function of the peripheral part of the limb is not significantly impaired, but more often due to ischemia, necrosis (gangrene) of the distal part of the limb develops. In this case, the frequency of gangrene development depends on the level of arterial ligation and anatomical conditions, the development of collateral circulation. 5. Collateral circulation The term collateral circulation is understood as the flow of blood into the peripheral parts of the limb along the lateral branches and their anastomoses after the lumen of the main (main) trunk is closed. The largest ones, which take over the function of the switched off artery immediately after ligation or blockage, are referred to as the so-called anatomical or pre-existing collaterals. According to the localization of intervascular anastomoses, pre-existing collaterals can be divided into several groups: collaterals connecting the vessels of a basin of a large artery are called intrasystemic, or short paths of roundabout blood circulation. Collaterals connecting pools of different vessels with each other (external and internal carotid arteries, brachial artery with forearm arteries, femoral arteries with lower leg arteries) are referred to as intersystemic, or long, roundabout ways. Intraorganic connections include connections between vessels within an organ (between the arteries of adjacent lobes of the liver). Extraorganic (between the branches of the own hepatic artery in the gates of the liver, including with the arteries of the stomach). Anatomical pre-existing collaterals after ligation (or blockage by a thrombus) of the main arterial trunk take on the function of conducting blood to the peripheral parts of the limb (region, organ). At the same time, depending on the anatomical development and functional sufficiency of the collaterals, three possibilities are created for restoring blood circulation: the anastomoses are wide enough to fully ensure the blood supply to the tissues, despite the shutdown of the main artery; anastomoses are poorly developed, roundabout blood circulation does not provide nutrition to the peripheral sections, ischemia occurs, and then necrosis; there are anastomoses, but the volume of blood flowing through them to the periphery is small for a full blood supply, and therefore newly formed collaterals are of particular importance. The intensity of the collateral circulation depends on a number of factors: on the anatomical features of the preexisting lateral branches, the diameter of the arterial branches, the angle of their departure from the main trunk, the number of lateral branches and the type of branching, as well as on the functional state of the vessels (on the tone of their walls). For volumetric blood flow, it is very important whether the collaterals are in a spasmodic or, conversely, in a relaxed state. It is the functionality of collaterals that determines regional hemodynamics in general and the magnitude of regional peripheral resistance in particular. To assess the sufficiency of collateral circulation, it is necessary to keep in mind the intensity of metabolic processes in the limb. Considering these factors and influencing them with the help of surgical, pharmacological and physical methods, it is possible to maintain the viability of a limb or any organ in case of functional insufficiency of pre-existing collaterals and promote the development of newly formed blood flow pathways. This can be achieved either by activating collateral circulation or by reducing tissue uptake of blood-borne nutrients and oxygen. First of all, the anatomical features of the pre-existing collaterals must be taken into account when choosing the site for applying the ligature. It is necessary to spare as much as possible the existing large lateral branches and apply a ligature as far as possible below the level of their departure from the main trunk. Of certain importance for collateral blood flow is the angle of departure of the lateral branches from the main trunk. The best conditions for blood flow are created with an acute angle of origin of the lateral branches, while an obtuse angle of origin of the lateral vessels complicates hemodynamics due to an increase in hemodynamic resistance. When considering the anatomical features of pre-existing collaterals, it is necessary to take into account the varying severity of anastomoses and the conditions for the development of newly formed blood flow pathways. Naturally, in those areas where there are many vascular-rich muscles, there are also the most favorable conditions for collateral blood flow and neoplasms of collaterals. It must be taken into account that when a ligature is applied to an artery, irritation of sympathetic nerve fibers, which are vasoconstrictors, occurs, and a reflex spasm of collaterals occurs, and the arteriolar link of the vascular bed is switched off from the bloodstream. Sympathetic nerve fibers run in the outer sheath of the arteries. To eliminate the reflex spasm of the collaterals and maximize the opening of the arterioles, one of the ways is to cross the artery wall along with sympathetic nerve fibers between two ligatures. Periarterial sympathectomy is also recommended. A similar effect can be achieved by introducing novocaine into the periarterial tissue or novocaine blockade of sympathetic nodes. In addition, when the artery is crossed, due to the divergence of its ends, the direct and obtuse angles of the lateral branches are changed to an acute angle more favorable for blood flow, which reduces hemodynamic resistance and improves collateral circulation. 6. General surgical measures in case of injury to the main vessel Blood loss, accompanied by a sharp decrease in blood pressure, adversely affects the restoration of collateral circulation. Therefore, it is imperative for the victim to carry out blood-substituting therapy and maintain blood pressure at a normal level. A beneficial effect on the functioning of collaterals is provided by regional hemoperfusion of the arterial bed below the site of ligation. It is necessary to maintain an adequate temperature regime of the tissues of the extremities. It is optimal to keep the limb at room temperature and local warming of the vessel ligation site to improve the functioning of the collaterals. But the damaged limb should not be overheated, as this leads to an increase in tissue metabolism. Local hypothermia for the ischemic limb seems to be very logical, although there is not enough evidence to support its positive effect in the treatment of the wounded. Of great importance in creating favorable conditions for the functioning of collaterals and maintaining viability is the provision of rest of the injured limb (immobilization). One of the measures that contribute to the development of collaterals after arterial ligation is the simultaneous application of a ligature to the accompanying vein in order to limit the outflow of blood from this vascular area, to bring it into line with the reduced inflow. 7. Method of temporary prosthetics To restore blood flow for a relatively short period of time, the method of temporary prosthetics is used. It is used for wounds of the femoral, popliteal or other large main arteries (at least 6 mm). Temporary prosthetics is performed using a plastic tube (polyvinyl chloride, silicone, polyethylene, etc.) or a special T-shaped cannula. A plastic tube washed with a heparin solution is inserted into the distal and proximal ends of the damaged artery, securing it with a tourniquet. If a standard T-tube is used, then a heparin solution and antiplatelet agents are injected into the artery through its spur. The victim with a temporary prosthesis can be transported (within, as a rule, no more than 72 hours) to a medical institution for specialized medical care. A vascular suture that restores the integrity of the vessel and, consequently, normal blood circulation and nutrition of the limb is ideal from a physiological point of view. Indications for the use of a vascular suture are: damage to large main arteries (carotid, femoral, popliteal, subclavian, axillary); limb avulsions with the possibility of replantation. Contraindications to the imposition of a vascular suture in vascular injuries are suppuration in the wound, extensive defects in the damaged artery. In addition, an injury to one of the paired arteries of the extremities (arteries of the forearm, lower leg) is not considered an indication for the imposition of a vascular suture, given the relative sufficiency of collaterals. Considering that with a significant tension of the edges of the sutured artery, suture eruption occurs, diastasis between the parted ends of the artery is not more than 3-4 cm. cm; by bending the limb in the nearest joints and immobilizing it in a given position. A vascular suture around the circumference, applied with a complete rupture or violation of the circumference by more than two thirds of its length, is called circular. A vascular suture applied to the edges of a vessel wound that does not exceed one third of the circumference is called a lateral suture. Currently, more than 90 different ways of applying a vascular suture are known. All methods of applying a vascular suture are divided into two groups: manual suture of the vessel and mechanical suture of the vessel. 8. Rules for performing a vascular suture For the successful implementation of the vascular suture, certain rules and conditions must be observed: wide access to the site of the damaged vessel; preservation of blood supply and innervation of the ends of the sutured vessel, careful selection of its ends. If, for ligation, the ends of the vessel are isolated from the connective tissue until the adventitia is removed, then before applying the vascular suture, the connective tissue around the ends of the vessel should be preserved in order not to disturb their blood supply and innervation. Carefully preserve the side branches extending from the vessel near the site of injury; carry out careful, gentle handling of the vessel wall. To temporarily stop bleeding and fix the vessel, only special soft clamps made of elastic metal, or clamps with an adjustable gap between the branches, should be applied to its ends. In order for these clamps to injure the vessel wall less, soft rubber is usually put on the ends of the instruments. In some cases, the ends of the vessel are clamped by rubber turnstiles. Failure to comply with this rule, damage to the vessel wall and the inner lining will lead to failure due to the formation of a blood clot. The next rule is an economical excision ("refreshment") of the ends of the damaged vessel. The crushed ends of the vessel, the damaged intima, as well as the excess of the outer adventitia, should be excised, since these tissues contain a lot of thrombokinase, which contributes to the formation of a thrombus in the lumen of the vessel after suturing. In case of wounds inflicted with cold weapons, sections of the vessel up to 0,5 cm on each side are excised, with gunshot wounds up to 10 mm. Excision of the edges of the vessel wound should be carried out with an impeccably sharp scalpel or razor. It is impossible to allow the wound and the vessel wall to dry out, as this increases the traumatization. When applying a vascular suture, it is necessary to prevent the occurrence of conditions conducive to the vortex movement of blood and slowing down the blood flow velocity at the suture site, which can lead to thrombosis. The seam line must be completely sealed. It is unacceptable to get adventitia between the ends of the sutured vessel, leading to thrombosis at the site of the suture. Immediately before performing the vascular suture, it is necessary to excise the adventitia, which usually hangs from the ends of the damaged vessel. Suture material, if possible, should not protrude into the lumen of the vessel and delay blood flow. However, in practice this is difficult to implement, therefore, a suture material is used for the suture that does not cause subsidence of uniform elements and blood clotting (supramid, polyamide, sutralen, etc.). Before tightening the sutures, blood clots are carefully removed from the lumen of the connected ends of the vessel, washing them with a heparin solution; narrowing of the lumen of the vessel at the site of suture should not be allowed, since this forms a parietal vortex that promotes thrombosis. To prevent narrowing of the vessel, the sutures should be applied, stepping back from its edge no further than 1 mm. It is necessary to carefully restore the tightness along the line of contact between the edges of the vessel wall and in the places where the suture material passes. The suture stitches are carried out at a distance of 1 mm from each other using very fine threads and atraumatic needles. Most modern methods of manual vascular suture are based on the technique of the classic vessel suture according to A. Carrel. After applying small clamps to the vessel and refreshing its ends, their circumference is divided into three equal parts. Along the borders of the third, atraumatic needles are used to suture the holder, the tension of which turns the circle into an equilateral triangle. Sewing three straight sections after connecting the corresponding holders and accurately matching the ends of the vessel does not present a great technical difficulty. As a rule, a continuous suture is used, making sure that when it is tightened, the intima of the ends of the vessel fits well. After a vascular suture is applied to the artery, its lumen is smoothly filled with blood. To do this, first carefully open the peripheral clamp and only then the central one. It is impossible to immediately open the central end, because the site of the vascular suture can be destroyed by a sharp hemodynamic impact. If leakage of blood between the sutures is detected, the bleeding is stopped with hot saline or separate additional sutures are applied. 9. Principle and advantages of mechanical vascular suture The principle of a mechanical seam is that the ends of the vessel are passed through special bushings, the inner diameter of which corresponds to the outer diameter of the vessel. Then the ends of the vessel are turned inside out (flared) on these bushings. The ends of the vessel come together, and by pressing the lever of the apparatus, the flared sections of the vessel are stitched with metal clips, similar to how the sheets of a school notebook are connected. After that, it remains only to release the vessel from the clamps and bushings. The essential advantages of a mechanical vascular suture are: ensuring a good fit of the intima to the intima and sealing the suture line; the speed of vessel stitching. However, it also has a number of disadvantages: the device can only work on sufficiently elastic vessels, the ends of which can be easily twisted; atherosclerotic changes in the vascular wall and its calcification make it difficult to use a mechanical suture; the operation of the device requires a relatively large operational access and the allocation of a vessel over a considerable distance. Thus, stopping bleeding by applying ligatures is a relatively simple and effective method, however, having a significant drawback - impaired blood circulation in the peripheral part of the limb. More promising is to stop the bleeding by restoring the continuity of the vessel and blood flow, but this method, which is based on the suture of the vessel, requires a highly skilled surgeon, the availability of special tools and mastery of the vascular suture technique. LECTURE #4 Operations on limbs. Operations for damage to the nerves and tendons of the extremities. Limb amputations 1. Operations for nerve damage The frequency of damage to the nerves of the extremities is significant, especially in wartime, and tends to increase. In the First World War, injuries of peripheral nerves accounted for 3% of the total number of all injuries. During the Great Patriotic War, the frequency of nerve injuries became much higher and reached 8-10% of all injuries. In modern local conflicts, the frequency of damage to peripheral nerves is 12-14%, which is associated with an increase in the intensity of fire, the creation of new weapon systems with significant explosive power. At the same time, the nerves of the upper extremities suffer 1,5 times more often than the nerves of the lower extremities. Types of nerve damage Nerve injuries are divided into closed and open. With closed injuries, the integrity of the outer sheath of the nerve is preserved. Depending on the nature of morphological changes in the nerve at the level of injury (among closed injuries), concussion is distinguished, which occurs as a result of the force of a side impact of a wounding projectile when it passes through the tissues away from the nerve; morphological changes in the nerve trunk cannot be detected, but short-term conduction disturbance is observed. Nerve contusion occurs with more severe impacts of a wounding projectile or blunt trauma with the formation of morphological changes inside the trunk (hemorrhages, axonal stretching, rupture of individual fibers or bundles). At the same time, the nerve maintains anatomical continuity (there is no break visible to the eye). Nerve compression is caused by foreign bodies, bone fragments, paraneural hematomas, excessive and prolonged compression of the limb with a tourniquet. The conduction disorder can easily recover if the factor causing the compression is removed shortly after the injury. In the case of nerve compression, ischemia develops in it, axonal atrophy occurs, and then a dense connective tissue scar is formed, leading to a persistent violation of conduction. Nerve compression can occur a considerable time after the injury when it is involved in adjacent scars or calluses. At the same time, conduction disturbance does not appear immediately after the injury, but after a certain period of time and increases over time. Dislocation of the nerve occurs as a result of damage to the fascial bridge that fixes it to the bone groove. As a result of repeated dislocations, traumatic neuritis develops with local thickening of the nerve due to growth and scarring of the connective tissue. Nerve sprains usually develop as a result of dislocations and fractures of bones, accompanied by a sharp stretching of the limb and nerve trunks beyond their elasticity and extensibility. Open injuries (wounds) of the nerve trunk are accompanied by the destruction of both the outer sheath and axons. Nerve wounds are divided into stab wounds and gunshot wounds. Ruptures or anatomical interruption of the nerve can be complete or partial: a partial interruption of the nerve in most cases occurs with a tangential wound, less often with a "perforated" wound, when a small injuring projectile passes through the thickness of the nerve trunk. With a complete rupture, the ends of the nerve diverge and are often displaced from their usual places, such damage leads to a complete loss of nerve function. When nerves are damaged, motor, sensory, vasomotor, secretory and trophic disorders occur. Movement disorders are manifested by muscle paresis or paralysis, muscle atrophy, decreased tone, and impaired tendon and periosteal reflexes. In the remote period, the development of movement restrictions in the corresponding joints is possible. Sensitivity disorders are manifested in the form of prolapse (hypoesthesia, anesthesia) and irritations (hypersthesia, pain). According to the degree of severity of violations, an autonomous zone is distinguished (the area of innervation by only one nerve) and a mixed zone (the area of \uXNUMXb\uXNUMXbinnervation by the fibers of neighboring nerves). Trophic disorders are the most severe. They manifest themselves in the form of turbidity, striation and brittleness of the nails, peeling of the epidermis, hyperkeratosis, the appearance of “conflict” on the fingertips with a serous-bloody effusion and long-term non-healing trophic ulcers of the limb, more often in the places of support, injured when walking. Basic principles of reconstructive operations on peripheral nerves Immediately after an injury, accompanied by a violation of the integrity of the nerve fibers, the processes of degeneration and regeneration develop in the nerve. These phenomena are closely interconnected and synchronized. It is known that the simpler the nerve trunk is arranged, the fewer connections and connective tissue in it, the more complete the regeneration is, the lower the nerve trunk is damaged, the faster and more complete the regeneration is, therefore, damage to the proximal (high) parts of the nerve has a worse prognosis compared to damage to the distal (lower) parts of the nerve (Eckzold's law). All nerves can be divided into three groups according to the completeness of recovery: 1) nerves with the best regenerative capacity: radial and musculocutaneous; 2) nerves with the worst regenerative capacity: ulnar, sciatic and common peroneal; 3) nerves with intermediate regenerative capacity: axillary, median and tibial. Suturing One of the main conditions for the regeneration of an injured nerve is the absence of diastasis between its ends, which requires their comparison with the help of sutures. The first successful experiments confirming the regeneration of a nerve after suturing its ends date back to the first half of the 3th century. and belong to Floreno. Depending on the timing of the operation, primary interventions are distinguished, in which the nerve suture is performed simultaneously with the primary surgical treatment of the wound; delayed (early) operations, in which the nerve is sutured in the first weeks after the injury, and late, if the nerve is sutured later than XNUMX months after the injury. There is still no unequivocal answer to the timing of interventions. A primary nerve suture may be placed under the following conditions: 1) for wounds that, after primary surgical treatment, can be sewn up tightly; 2) in cases where the surgeon has the appropriate qualifications and there is time for leisurely work; if it is possible to conduct a neurological examination of the patient before the operation; with appropriate technical equipment of the operating room. The advantages of a delayed suture are: suture performed by a physician experienced in peripheral nervous system surgery; execution of a seam in a specialized institution after a qualified examination of the patient; less risk of infectious complications after surgery; it is easier to determine the boundaries of the necessary resection of the nerve, since at this time scarring is already detected in the areas of intrastem damage and a thickening of the epineurium is noted around the damaged area, which contributes to a stronger connection. Nerve repair operations are usually performed under local infiltration anesthesia. This method of anesthesia allows you to clearly identify even the smallest vascular and nerve branches, which protects them from accidental damage; contact with the patient during electrodiagnostics on the operating table. The choice of nerve access is a complex issue. With the primary suture of the nerve, the access made during the primary surgical treatment of the wound is usually used. With delayed operations, access must be made with the obligatory consideration of changes that occur after injury. Access requirements are as follows. They should be long enough to expose the nerve above and below the injury site within healthy tissues, this allows the surgeon to understand all the topographic and anatomical relationships and assess the nature of the injury and possible outcomes. Preference is given to roundabout or extra-projective approaches, in which the incision lines of the skin and fascia do not coincide with the projection of the nerve. This makes it possible to avoid the formation of a common scar between the sheaths of the nerve and the skin. Types of operations on peripheral nerves There are two main types of operations on peripheral nerves: neurolysis and nerve suture. The purpose of the neurolysis operation is to free the nerve from compression by its cicatricial adhesions, with which it is tightly fused. The operation is carried out "acute way". After performing an operative approach and exposing the nerve within healthy tissues, the nerve is gradually isolated from the scars with simultaneous excision of the altered surrounding tissues using eye tweezers and a scalpel. Then the remnants of the scar tissue directly surrounding the nerve are removed in the form of a thin and dense case, avoiding damage to the underlying nerve bundles. The released nerve trunk must be placed in a specially created bed between the muscles. Neurolysis allows to obtain positive results (restoration of nerve conduction) in approximately 50% of cases. The main surgical technique in reconstructive surgery of the nerve trunks is the suture of the nerve. Surgical reception consists of the following points: isolation of the nerve, mobilization of the nerve to eliminate its tension, resection of damaged areas, application of epineural sutures. Resection is performed after the introduction of 2 ml of a 1% solution of novocaine under the epineurium with an ideally sharp instrument (scalpel, safety razor blade) in a strictly transverse direction. An indicator of correct resection (sufficiency of excision) is good bleeding of the vessels of the epi- and perineurium (the bleeding is stopped by a ball with warm saline). The imposition of epineural sutures should be carried out in such a way that there is no twisting of the nerve and displacement of the intratruncal structures around the longitudinal axis. In addition, it is necessary to ensure that when tightening the seams, the bundles are not squeezed, not bent or bent. The first sutures are placed on the epineurium along the outer and inner edges of the nerve at strictly symmetrical points. The injection and puncture of the needle is carried out along the nerve, retreating 2-3 mm from the edge (the sutures in the transverse direction are stronger, but they can compress the bundles). A small diastasis may remain between the ends, but it should not exceed 1 mm. The free gap between the ends of the nerve will be filled with a hematoma, and later a connective tissue layer will form, through this hematoma and connective tissue strands of Schwaszyuvian cells and newly formed axons will grow. In recent years, mechanical sutures with tantalum staples applied to the perineurium have been used. The nerve repair operation is completed by suturing the wound. Before suturing the wound, it is necessary to form a bed for the nerve from the surrounding tissues to prevent coarse cicatricial adhesions, compression and deformities of the nerve trunk, especially in the suture area. To do this, the sutured nerve is placed in the wound in a muscular sheath so that it is covered by muscles and does not come into direct contact with aponeuroses, fascia and skin. After the operation, it is necessary to immobilize the limb for 2-3 weeks with fixation of the above and below the joint with a plaster splint or splint in a position in which the nerve trunk experiences the least tension. 2. Operations for tendon injuries Fundamentals of operative technique of tendon suture Scientific research in the field of operative repair of tendons began in the last century after the reports of Anders (1875) and Küster (1876) about the successful suturing of the flexor tendons of the fingers. In subsequent years, tendon surgery has developed along three lines: 1) stitching the torn ends of the tendons together; 2) plastic replacement of a tendon defect with grafts; 3) connection (transplantation) of the tendon of the paralyzed muscle to one of the adjacent muscles or tendon. Tendon injuries are divided into the following groups: closed injuries (subcutaneous ruptures), open injuries, incised wounds, lacerations, gunshot wounds. When wounded by a cutting object (knife, glass), the tendon is incised or completely intersected. When wounded with a blunt object, it is torn partially or completely (machine damage, transport injury). Most often, the tendons of the hand are damaged. There is a significant difference in the surgical treatment of the flexor and extensor tendons of the fingers, due to the anatomical features of their structure. The extensor tendons lie relatively superficially, do not have tendon sheaths for a considerable length, and their ends do not diverge far when crossing. This creates favorable conditions for the imposition of a primary suture with good functional results. It is much more difficult, due to the complexity of the anatomical structure, to ensure the restoration of the function of the fingers in case of damage to the flexor tendons, especially within the synovial-tendon tunnel. The primary suture of the flexor tendons can only be performed in a hospital setting by a qualified surgeon. If these conditions are not present, then it is more expedient to limit the treatment of the skin wound, and to perform the suture of the tendons and nerves in 2-2,5 weeks in a planned manner, since up to 3 weeks of obliteration of the tendon sheaths does not occur. The process of tendon repair The process of tendon repair begins immediately after surgery and continues for several weeks. On the 1st week, an unstable fibroblastic adhesion is formed at the junction of the ends, unable to withstand even the slightest tension. During the 2nd week there is a rapid connective tissue proliferation and vascularization. By the 9th day, the ends of the tendons are connected by means of still fragile collagen fibers, which, with increased muscle contraction, can break. In the same period, cicatricial adhesions appear between the tendon and surrounding tissues. On the 3rd week, the gap between the ends of the tendon is completely filled with newly formed tissue, connective tissue fibers become similar to tendon fibers. During this period, conditions are created for the start of active movements. Adhesions with surrounding tissues are still fragile and are easily destroyed when the tendons move. By the end of the 4-6th week, regeneration ends, the strength of the connection reaches the norm. The term for the final formation of the newly formed tendon tissue is 2-4 months. Yu. Yu. Dzhanelidze (1936) formulated the requirements for the suture of tendons, which remain unchanged to this day: the suture must be simple and easy to perform; the suture should not disrupt the blood supply to the tendon, for which it is necessary to capture the minimum number of tendon bundles in knots and loops; the seam should provide a smooth, sliding surface of the tendon, a minimum number of threads should remain on its surface; the suture should firmly hold the ends and not deflate the tendon; if possible, a fascial or synovial sheath should be restored over the tendon. The tendons are sutured with silk, nylon, nylon, and tantalum wire with a diameter of 0,1 mm. Access to the damaged tendon in open injuries is carried out through the wound. When the wound is insufficient in size, it is expanded by making additional incisions, taking into account the topographic and anatomical features of the area. In particular, transversely oriented wounds are conveniently expanded with an incision from the corners of the wound upwards and downwards. For closed injuries and delayed operations, an incision should be made away from the tendon, and in order to avoid wide exposure of the synovial-aponeurotic apparatus, the incisions are made at an angle to the course of the tendon. Nerve suture and tendon suture are specialized operations that require highly qualified surgeons and knowledge of a number of biological laws and principles of operative surgery. 3. Amputations of limbs Amputation of a limb is a difficult and complex operation, including the separation (removal) of the peripheral part along the bone. Removal of a limb with the intersection of soft tissues at the level of the joint space is called exarticulation. Amputation of a limb is one of the mutilating operations. A person with a removed limb or the absence of a part of it becomes disabled, and in the eyes of others - flawed. But in surgical practice, both in peacetime and especially in wartime, these interventions are indispensable. In peacetime, 47% of amputations are performed due to complications of vascular diseases of the extremities and 43% due to trauma. There are indications for performing an amputation operation, which are divided into two groups: 1) absolute (or primary) indications, when the peripheral part of the limb is not viable, but the processes occurring in it do not threaten the life of the victim; 2) relative (or secondary) indications, when the peripheral part of the limb is viable, but the processes occurring in it threaten the life of the victim. Absolute (primary) indications: necrosis of the distal limb, gangrene caused by occlusion of the supply vessels; detachment of the distal limb when its replantation is impossible. However, for the replantation of a limb after its complete detachment, conditions are necessary, including the preservation of the viability of tissues, especially the main vessels, the high qualification of the surgeon, the possibility of follow-up, etc. Combined injuries of limb tissues include injuries in which the following are observed at the same level: fragmentation of a bone or bones; complete rupture of all neurovascular bundles; destruction of more than 2/3 of the muscle volume. But if one of the elements of the tissues of the limb is not destroyed (the bones are crushed and the muscles are torn, and the neurovascular bundles are intact), then an additional assessment of the preservation of the peripheral part of the limb is required to resolve the issue of amputation, since it has been experimentally and clinically proven that if more than 2/ 3 muscle volumes are destroyed, then the number of lateral branches is not enough for adequate blood supply to the peripheral part of the limb. Therefore, to resolve the issue of amputation, the condition of the soft tissues (muscles) is of decisive importance. Relative (secondary) indications are most often due to intoxication that develops under the following pathological conditions: anaerobic infection (gas gangrene); acute purulent inflammation (for example, drives) with the threat of developing sepsis; chronic nonspecific (for example, chronic osteomyelitis), specific (tuberculosis of bones and joints) inflammatory process that cannot be cured for a long time and threatens with amyloid degeneration of internal organs (liver, kidneys); malignant tumors of the tissues of the extremities; deformities of the limbs (the sixth finger of the hand), acquired deformities that cannot be corrected. An important point before the operation is the choice of the level of amputation. The level of amputation is the place where the bone was cut, which determines the length of the stump and its functionality. Among representatives of different surgical schools, the level of amputation is not the same. With all the diversity, two main directions are distinguished: displacement of the amputation level as distally as possible to the site of injury or pathological focus. Such amputations, as a rule, are performed in wartime, are preliminary (similar to the type of primary surgical treatment of the wound) and are performed without a blind suture or with delayed sutures of the stump, given that in the future many victims will be shown reamputation or reconstructive surgery. The stump becomes suitable for prosthetics after a series of rehabilitation operations; an individual prosthesis can be made for it. In peacetime, it is possible to use this method for amputations with the imposition of primary sutures on the tissues of the stump. Carrying out amputation within pre-selected "optimal" zones The amputation technique includes three stages. Stage I - dissection of soft tissues; Stage II includes the processing of the periosteum and cut the bone; Stage III is the so-called "toilet of the stump", which includes ligation of the vessels at the end of the stump of the limb and truncation of the nerves to prevent the occurrence of "phantom pains"; Stage IV - the operation ends with suturing the wound surface. Amputations are divided into different types depending on the method of dissection of soft tissues. On this basis, circular and patchwork amputations are distinguished. With a circular amputation, soft tissues are cut with an amputation knife perpendicular to the length of the limb, as a result, its cross section resembles. It is preferable to perform these amputations in single bone areas. In some cases, the soft tissue section plane is directed at an angle relative to the longitudinal axis of the limb. At the same time, its cut resembles an ellipse. This type of amputation is called an ellipsoid amputation, is rarely used, is technically more complex than a circular amputation, and the benefits are minimal. Depending on the method of dissection of the soft tissues of the limb, performed with one, two or three circular movements of the knife, circular amputations are divided into: 1) one-time; 2) two-stage; 3) three-moment. Often the operation is performed with a tourniquet applied to prevent bleeding and blood loss. Before amputation, the tourniquet is not applied in case of gas gangrene, since tissue ischemia caused by the tourniquet contributes to the activation of anaerobic bacteria, and after removing the tourniquet, toxins can quickly enter the bloodstream; sclerotic vascular lesions, since under the action of the tourniquet mechanical damage to the arteries and their thrombosis occurs with the development of ischemia of the distal stump, in the presence of contraindications, and also in cases where amputation is performed in the proximal limb (in the upper third of the thigh or shoulder). Amputation is performed after preliminary ligation of the artery along or with finger pressure on the artery. One-stage circular amputation. It consists in the fact that all the soft tissues of the limb are dissected to the bone in one circular motion. If the bone is sawn at the same level, then such amputation is called guillotine. The contractility of the skin, subcutaneous tissue, own fascia, superficial and deep muscles is not the same at the level of amputation. A consistent decrease in the elasticity of tissues from the surface layers to the deep ones leads to the fact that after their circular intersection a cone is formed with the top facing the periphery (distally). Moreover, often its top is formed by a protruding sawdust of the bone. This leads to the subsequent formation of a stump of a sharply conical shape, unsuitable for prosthetics, which is the main disadvantage of one-stage amputation, but it is used in military field conditions, during mass defeats, during natural disasters and catastrophes. The advantages of one-stage amputation include: simplicity and speed of execution, so it is advisable to perform it in victims who are in serious condition; with a gaping transverse section of the limb. This ensures good tissue aeration. Such amputation is often used for gas gangrene. The formation of a vicious stump after a single amputation makes it necessary to correct it later with the help of reamputation. Two-stage circular amputation. A feature of the two-stage amputation technique is the circular dissection of soft tissues in two steps, which allows you to create a certain "reserve" of tissues to close the stump and avoid the formation of a vicious stump. The first point is that the skin, subcutaneous tissue, superficial and own fascia are cut in a circular motion of the amputation knife. In this case, the edge of the skin that has contracted and shifted in the proximal direction serves as a guide for the next stage. The second point is that along the edge of the reduced skin, all the muscles to the bone are dissected in a circular motion. The advantage of a two-stage amputation over a one-stage amputation is the possibility of dissecting the muscles and sawing the bone at a relatively higher level, which makes it possible to cover the end of the bone due to the elasticity of the skin and fascia. This is easily performed in the distal limbs, where there is a relatively small muscle mass. The formation of a sharply cone-shaped stump during a two-stage amputation can also be prevented by the formation of the so-called "cuff". To this end, after the first moment, the skin, subcutaneous tissue and own fascia are separated from the muscles in one block and turned up in the form of a "cuff". The second moment includes the intersection of the muscles, which is performed at the level of the base of the "cuff". After straightening the "cuff" downwards, the transverse section of the muscles and sawdust of the bones can be closed without tension by the skin with subcutaneous tissue and superficial fascia by soft tissues. Three-stage circular amputation. Three-stage cone-circular amputation was proposed by the outstanding Russian surgeon N. I. Pirogov. Its purpose is to create an array of soft tissues sufficient for reliable shelter of the stump. The first moment of amputation includes a circular incision of the skin, subcutaneous tissue and own fascia. The edge of the skin, reduced due to elasticity, is a guide for subsequent actions. The second moment is a circular intersection along the edge of the contracted skin of all muscles to the bone, then the skin and superficial muscles are maximally shifted in the proximal direction. The third moment is a repeated circular dissection of the muscles to the bone along the edge of the proximally displaced skin. The advantages of this amputation is the possibility of closing the sawdust of the bone with soft tissues with the formation of a stump suitable for prosthetics, and this amputation is also relatively simple. But there are also disadvantages: the formation of a postoperative scar on the lower surface of the stump, which makes prosthetics of the removed lower limb difficult; amputation is uneconomical, since when forming a cone facing the apex proximally, the cut has to be made at a higher level relative to the injury site (shortening of the stump due to a higher level of amputation); the impossibility of its implementation on those segments of the limb, where the skeleton is formed by two bones. Technique of patchwork amputations Lingual flaps are cut out of the tissues, which subsequently close the wound surface of the limb stump. Flap amputations are divided into single-flap and double-flap. Two-flap amputations are divided into amputations with equal or unequal length of flaps (equal and unequal flap amputations). For all types of flap amputations, the length of the flaps should be sufficient to cover the cross section of the limb at the level of the amputation. To calculate the length of the flaps, the circumference formula is used, by measuring the circumference at the level of amputation, depending on the number of flaps and their ratio, the initial length of each of them is determined. The length of the flap for a single-flap amputation should be equal to one third of the circumference, for a two-flap amputation one sixth. When performing a two-flap amputation with flaps of different lengths, their ratio may be different, but their total length should correspond to the cross-sectional diameter at the level of the amputation. Before cutting the flaps to the original (calculated) length, it is necessary to correct for skin contractility due to its elasticity; there are special tables that reflect skin contractility in various parts of the body. Using tabular data, the corresponding number of centimeters per contractility is added to the estimated length of the flap. An important point is the choice of the surface from which the flaps are cut out, as this determines the following circumstances: the postoperative scar should not be located on the working surface; the skin must be able to withstand the increased load that will be exerted on it when wearing a prosthesis. Amputation groups Depending on what tissues are included in the composition of the flaps, amputations are divided into several groups. 1. Fascial-plastic amputations. In this case, the composition of the flap includes skin, subcutaneous tissue and its own fascia. Its advantages are: the possibility of precise modeling of the shape of the stump; obtaining a mobile postoperative scar; relative ease of implementation. 2. Myoplastic amputations, where the composition of the flaps, along with the skin, subcutaneous tissue, own fascia, includes muscles. Supporters argue that the inclusion of muscles in the flap contributes to positive results in "express prosthetics", when the victim is put on a temporary prosthesis on the stump immediately after the end of the amputation, where the muscles included in the flaps play the role of "natural shock absorbers". And also, that with myoplastic amputation, due to good microcirculation of blood and lymph, the wound heals faster and the stump is formed. But according to other authors, the inclusion of muscle flaps in the composition leads to their degeneration into coarse connective tissue, which forms a conical, vicious stump. 3. Periostoplastic amputations. The method consists in the fact that the periosteum is also included in the composition of the flap. Such an amputation is used on the shins, especially in children and adolescents, since the periosteum as part of the flap ensures the fusion of the ends, the bones of the lower leg into a single block, preventing their displacement and uneven growth. In the elderly, the inclusion of the periosteum in the composition of the flap increases the support of the stump. 4. Osteoplastic amputation. The flap consists of a bone fragment covered with periosteum. They are used on the lower extremities and are aimed at creating a stump that can bear the entire weight of the body and allow the patient to use the prosthesis more freely. After any amputation, the stump is unsupported for a long time, which is associated with pain at the end of the stump due to edema, infiltration, incipient scarring and other phenomena that cause irritation of the crossed nerve conductors and their endings; as well as with the loss of support of the bone sawdust. In addition, the absence of the periosteum leads to impaired proprioceptive sensitivity, which plays an important role in the regulation of limb movements. "Toilet of the stump" includes stopping the bleeding and treating the nerve trunks. Vessels are ligated at the end of the stump; truncation of nerves in order to prevent "phantom pains". Vessel ligation Vessel ligation consists of two elements: ligation of vessels of large and medium caliber. Without removing the tourniquet (elastic bandage) applied before amputation, the main arteries and veins are found on the transverse section of the limb, using knowledge of topographic and anatomical features and observing the rules for ligation of vessels in the wound. It is recommended to apply two ligatures to large vessels (femoral, axillary arteries) for greater reliability. On a smaller artery, one is enough. Vessels, even large ones, are tied up with catgut, i.e., absorbable suture material. Silk is used in cases where the victim is to be transported, excluding the possibility of constant medical supervision. The second point is the ligation of small-caliber vessels. To do this, weaken the pressure of the tourniquet, which leads to the appearance of minor bleeding and "marking" of the vessels. Ligatures in these cases should be applied by chipping. Good hemostasis at the end of the stump is the prevention of hematomas, which can cause suppuration, focal necrosis, rough connective tissue scars. Ways to treat nerves There are many ways to treat nerves, the main goal of which is to prevent the formation of a neuroma at the end of the nerve. Neuroma is a manifestation of regenerative growth, belongs to the category of "physiological protective measures." There are mechanical, chemical, thermal methods of influencing the cut nerve: the Kruger method, in which the nerve is crushed with a clamp and its bandaging is distal to the crush site; Leven's method - freezing the nerve stump with carbonic acid; Foerster's method - the introduction of a 5% formalin solution into the perineurium; Guedry's method, in which the end of the nerve is cauterized with a thermocautery, etc. The following methods are aimed at slowing down the formation of a neuroma until the amputation stump is fully formed, in order to prevent adhesions and compression of the neuroma by the surrounding tissues: the Veer method, where the nerve stump is closed with an epineurium flap; Ritger's method - wedge-shaped excision of the end of the nerve, followed by stitching the edges; Chapple's method - closing the nerve stump with an epineurium cuff; the Moshkovich method - suturing the crossed nerves to the muscle; Bardengeier's method - the formation of a loop from the terminal section of the nerve. None of the presented methods prevents the formation of a neuroma at the end of the nerve. To prevent the "growing" of the neuroma into the postoperative scar, each of the nerves is truncated 2-3 cm above the level of amputation when performing the toilet of the stump. In order for the injury during truncation of the nerve to be minimal, and, consequently, connective tissue growths do not lead to the formation of a large neuroma , truncation of the nerve is performed with one movement of the blade of a safety razor. Before crossing the nerve, a 1% solution of novocaine must be injected under the epineurium. Before this manipulation, the tissues surrounding the nerve are carefully moved apart to the level of the intended intersection. To prevent phantom pain in the stump, all nerves are shortened in the manner described, including the cutaneous ones. Amputation ends with suturing the surgical wound, only in cases of suspected gas gangrene, the stump is not sutured. Produce suturing on its own and superficial fascia, which ensures the formation of a mobile postoperative scar. For suturing, catgut is used, except for the skin. The use of absorbable suture material reduces the development of connective tissue around the ligatures and ultimately contributes to the formation of a mobile postoperative scar. The wound is sutured so that the scar, if possible, is not located on the working surface. Requirements for a full-fledged cult Must have a steady shape and dimensions; should be painless; joints located proximal to the level of amputation should maintain normal mobility; the skin of the stump should be able to bear the load "on the stop". The shape of the stump is divided into cylindrical, conical, clavate. The shape of the stump is of great importance. The main conditions for normal "fitting" of the stump of a truncated limb in the prosthesis and its good fixation is the largest number of points of contact of the stump with the inner surface of the prosthesis sleeve. From this point of view, the cylindrical shape of the stump is most advantageous. Stumps that are not suitable for prosthetics are called vicious. Causes of the "viciousness" of the stumps: the location on the "working surface" of a rough, motionless scar soldered to the bone, insufficient or excessive length of the stump, contractures and ankylosis of the joints, sharp pain in the stump; chronic inflammatory processes in the stump; high location of truncated muscles and "protrusion" of the end of the bone from the skin or scar, excess soft tissue, attachment of muscles to the skin scar, osteophytes. The usefulness of the stump, or its "functionality", depends on the correct choice of the method of amputation and compliance with all the rules of the technique for its implementation; qualified postoperative period. LECTURE #5 Topographic anatomy and operative surgery of the head region The head region is of interest to specialists of various profiles: general surgeons, traumatologists, neurosurgeons, otorhinolaryngologists, dentists, maxillofacial surgeons, cosmetologists, ophthalmologists and other specialists. This area has a number of topographic and anatomical features that necessitate compliance with both the general rules for performing surgical interventions and a number of specific requirements. The head is divided into brain and facial sections (areas), which have significant topographic and anatomical features. The medulla of the head is delimited from the front by a line drawn from the glabella along the upper orbital margin and zygomatic arch to the external auditory canal. The brain department is divided into the vault and base of the skull by a line drawn along the infratemporal crest (projection at the level of the zygomatic arch), the base, the mastoid process and the superior temporal line to the occiput). On the cranial vault, an unpaired frontal-parietal-occipital region is distinguished, including the frontal, parietal and occipital regions and paired temporal regions. The cranial vault also includes mastoid regions corresponding to the contours of the mastoid processes. The facial section is divided into anterior (middle) and lateral regions. In the anterior region of the face, there are: 1) eye socket area (steam room); 2) nose area; 3) mouth area; 4) chin area. In the lateral region of the face, the paired parotid-masticatory and buccal regions are of the greatest practical interest. Significant topographic and anatomical differences between the brain and facial sections determine the features of the technique for performing surgical operations in each of them. 1. Topographic and anatomical features of the cranial vault and some surgical techniques The skin of the fronto-parietal-occipital region is characterized by considerable thickness and low mobility (the skin in the occipital region is thicker than in the frontal region). In the temporal region, the skin is thin and mobile, in the upper section it is somewhat thicker and less mobile. Since the skin has a low displacement, its excision during the primary surgical treatment of a wound in the region of the cranial vault should be carried out extremely economically. The subcutaneous fatty tissue is cellular due to the connective tissue septa connecting the skin with the tendon helmet. The thickness of the tissue is small, sometimes it can reach 2 cm. Elastic subcutaneous fatty tissue serves as a kind of shock absorber that protects tissues. The cellular structure of the subcutaneous adipose tissue determines the limitation of inflammatory processes. Blood vessels and nerves passing in the subcutaneous tissue of the fronto-parieto-occipital region have the following features: 1) radial direction relative to the top point of the head (crown), which determines the lines of incisions during the primary surgical treatment of the wound or during accesses; 2) the ascending course of the arteries, taking into account which the base of the soft tissue flap, when performing osteoplastic trepanation, should be turned downwards; 3) superficial location of the main arteries and veins, fixing their walls to the connective tissue bridges between the skin and the tendon helmet; 4) the presence of a rich network of arterial anastomoses between the branches of the external and internal carotid arteries, which is essential for maintaining sufficient blood supply to tissues, even if relatively large arteries are damaged or when they are alloyed, and also provides conditions for good wound healing; 5) the presence of anastomoses between the superficial (extracranial) and deep (intraosseous and intracranial) veins affects the spread of purulent soft tissue infection into the cranial cavity. Stopping bleeding from the vessels of the fronto-parietal-occipital region is performed by pressing the soft tissues to the bones of the cranial vault with fingers, as well as sequentially suturing the soft tissues around the wound together with the vessels passing in the subcutaneous tissue, applying hemostatic clamps, followed by alloying of the vessels. The aponeurotic helmet lying under the subcutaneous tissue is a tendon stretching of the frontal and occipital muscles, it is firmly connected to the skin by connective tissue bridges. Loose tissue is located under the aponeurosis. The next feature of the fronto-parieto-occipital region are three layers of fiber: subcutaneous, subaponeurotic; subperiosteal. The temporal region, in contrast to the frontal-parietal-occipital, is covered with thin, mobile skin, under which subcutaneous fat and superficial fascia are located. A large superficial temporal artery passes through the fiber, accompanied by a vein of the same name, the next layer is the temporal fascia, which covers the corresponding muscle. The fascia is attached to the zygomatic arch with two sheets. The temporal bone is thin, fragile. Between bone and the muscle has fiber, one of the features of the temporal region is the presence of 4 layers of fiber: subcutaneous, interaponeurotic (between the sheets of the temporal fascia), subgaleal, axillary (between the temporal muscle and the periosteum of the temporal bone). With the development of phlegmon in this area, there is difficulty opening the mouth, due to inflammatory contracture of the temporal muscle. To open the phlegmon of the temporal region, incisions are possible: horizontal, along the upper edge of the zygomatic arch, arcuate along the line of attachment of the temporal muscle (with deep phlegmon of the axillary tissue); radial from the tragus of the ear (with superficial phlegmon), taking into account the located abscess and the direction of the branches of the facial nerve and superficial temporal artery. The bones of the cranial vault have a different structure in the fronto-parietal-occipital and temporal regions. The thinnest is the scales of the temporal bone, there is almost no spongy substance in it. This bone is very fragile, which predetermines the greatest probability of its cracks and fractures during injuries. The frontal and especially the occipital bones in adults sometimes reach a thickness of up to 2,5 cm. The features of the bones of the cranial vault include: 1) "arched" structure, giving the vault of the skull a special resistance to mechanical stress; 2) "three-layer" bones, consisting of outer (up to 1 mm thick) and inner (about 0,5 mm thick) plates, between which there is a spongy substance. The inner plate (vitreous), in case of injuries of the skull, it is one of the first to be destroyed, often over a greater extent than the outer one. It often happens when the inner plate breaks, and the outer one remains intact. These lesions can only be detected by X-ray examination. Diploic veins are located in the spongy substance of the bones of the cranial vault, which are a source of bleeding during injuries and operations. To stop bleeding, gauze swabs moistened with hot saline are applied to the site of bone damage to accelerate blood clotting and thrombosis of diploic veins, and also apply "biological tamponade" with a piece of muscle or putty from a mixture of bone sawdust with blood clots, hemostatic sponges. During operations on the skull and its contents, it is necessary to open the cranium, which is called craniotomy. There are resection and osteoplastic methods. With the resection method of trepanation, one or more trepanation holes are applied using a special cutter, followed by "biting out" or sawing out the required size of the bone fragment above the intracranial (intracerebral) focus. Upon completion of the operation, soft tissues are sutured over the bone defect. Osteoplastic trepanation is performed with a temporary resection of the bone. It is produced by forming a bone flap on the leg, which includes the periosteum. This allows at the end of the operation to close the defect after laying the bone flap in place. At the same time, one-flap, two-flap are distinguished, the essence of which is the separate cutting out first of a soft tissue flap, consisting of skin, subcutaneous tissue and tendon helmet, and then the second osteoplastic flap, which provides greater freedom of action for the formation of a bone flap, but is more laborious and takes more time. Among the surgical interventions performed on the skull, it is especially necessary to highlight the primary surgical treatment of wounds. This operation is emergency, and its technique differs from that used in other areas due to the anatomical and physiological features of the skull and its contents (brain). There are two types of skull wounds: penetrating and non-penetrating. Penetrating wounds are those in which there is damage to the dura mater, and wounds that are not accompanied by a violation of the integrity of the dura mater are non-penetrating. The dura mater delimits the "internal environment" of the brain (liquor-bearing channels and spaces, the brain's own vessels, the arachnoid and choroid) from the external. Therefore, the prognosis for penetrating wounds of the skull is always very serious, during such injuries severe complications are often observed. The dura mater is not only a protective barrier for the medulla, it also plays an important role in the spatial fixation of the brain, by creating a connective tissue framework. 2. Topographic and anatomical features of the face and their significance for the choice of surgical technique in this area The face area is distinguished by a number of anatomical and physiological features that are necessary when performing operations. These include compliance with cosmetic requirements, the superficial location of numerous and large vessels and nerves, the complex relief of the bones of the facial skeleton, the presence of cellular spaces and infected oral and nasal cavities with paranasal sinuses. Of particular importance for choosing the direction of incisions in the face is the position of the branches of the facial nerve, which provide innervation of the facial muscles. Damage to the facial nerve or its large branches entails paralysis of the corresponding muscle group, disfigurement of the face, serious functional disorders (lagophthalmos, salivation, impaired articulation of speech). The exit point of the facial nerve from the stylomastoid foramen on the face is projected at the base of the earlobe, 1,5-2 cm below the external auditory canal. Having penetrated into the thickness of the parotid salivary gland, the nerve divides into branches, which form the parotid plexus in the capsule of the gland. Five groups of branches of the facial nerve depart from the latter (large crow's foot), heading radially from the tragus of the ear to the facial muscles: 1st group - 2-4 temporal branches: up and forward to the upper edge of the orbit; 2nd group - 3-4 zygomatic branches: obliquely through the middle of the zygomatic bone to the outer edge of the orbit; 3rd group - 3-5 buccal branches: across the cheek and below the zygomatic bone to the wings of the nose and upper lip; 4th group - marginal branch of the lower jaw; 5th group - cervical branch: down behind the angle of the lower jaw to the neck. The branches of the facial nerve pass in the deep layer of the subcutaneous tissue of the corresponding areas, therefore, when dissecting the skin and superficial layers of the subcutaneous tissue, their damage can be avoided. Deep incisions, especially in the lateral part of the face, are oriented radially from the ear tragus. The openings through which the branches of the trigeminal nerve enter the face are projected on a vertical line drawn along the border of the medial and middle thirds of the upper edge of the orbit. For the supraorbital branch - at the upper edge of the orbit; for the infraorbital branch - 0,5-1 cm below the lower edge of the orbit; for the mental branch - in the middle of the distance between the lower and alveolar edges of the lower jaw. Primary surgical treatment of wounds of the soft tissues of the face is carried out at the same time and at the earliest possible time; When the tongue is injured, suturing the wound of the tongue only in the longitudinal direction plays an important role, because this is the only way its function is preserved. Numerous veins and venous plexuses play an important role in the spread of infection and purulent foci on the face. With thrombophlebitis of these veins, infection can spread along their anastomoses into the system of intracranial sinuses. This is facilitated by a change in the direction of blood flow in vein thrombosis. The most common source of infection are lesions localized in the area of the upper lip. Therefore, between the two nasolabial folds and the upper lip, the so-called "triangle of death" is sometimes described, manipulations on the soft tissues of which must be done with extreme caution. The skeleton of the face (the facial part of the skull) represents its basis, the "bearing" structure. Injuries (fractures) of the bones of the facial part of the skull are severe injuries, leading to serious deformities and violations of many functions. Immobilization of bone fragments is performed after the completion of the surgical treatment of the bone, but before suturing the soft tissues. LECTURE #6 Topographic anatomy and operative surgery of the neck 1. Triangles, fasciae of the neck, vessels, organs of the neck area Neck - an area whose upper border runs along the lower edge of the lower jaw, the top of the mastoid process and the upper nuchal line. The lower border corresponds to the jugular notch of the sternum, the upper edges of the clavicles and the line connecting the acromial process of the scapula with the spinous process of the VII cervical vertebra. In the anterior part of the neck, separated from the posterior frontal plane, there are organs - the trachea, esophagus, thyroid gland, neurovascular bundles, the thoracic duct is located in the cervical vertebrae passing through the transverse processes. In the back of the neck there are only muscles enclosed in dense fascial cases and adjacent to the cervical vertebrae. Neck triangles. By a horizontal plane drawn at the level of the body of the hyoid bone, the anterior neck is divided into suprahyoid and infrahyoid regions. The muscles located in the suprahyoid region form the bottom of the oral cavity, in this area three triangles are distinguished: unpaired submental, the sides of which are formed by the hyoid bone and two anterior bellies of the digastric muscles; paired right and left submandibular triangles formed by the lower edge of the lower jaw and both bellies (anterior and posterior) of the digastric muscles. The sublingual region is divided by the median line into the right and left sides. On each side, two large triangles and a rectangle are distinguished. The medial triangle is formed by the median line, the posterior belly of the digastric muscle, and the anterior edge of the sternocleidomastoid muscle; lateral triangle - the posterior edge of the sternocleidomastoid muscle, the upper edge of the clavicle and the lateral edge of the trapezius muscle. Between these triangles is a rectangle - the sternocleidomastoid region. In the medial triangle, two triangles are formed - the scapular-tracheal and the scapular-hyoid (carotid triangle), since the common carotid artery and its bifurcation are located within it. Fascia of the neck. The clearest description was given by Academician V. N. Shevkunenko, who proposed a classification based on a genetic approach to study. By origin, all fasciae are divided into three groups: 1) fasciae of connective tissue origin, formed as a result of compaction of loose connective tissue and fiber around muscles, blood vessels and nerves; 2) fascia of muscular origin, formed at the site of reduced muscles or flattened and stretched tendons (aponeurosis); 3) fasciae of coelomic origin, which are formed from the inner lining of the primary embryonic cavity or from the reducing sheets of the primary mesentery. In this regard, 5 fasciae are distinguished on the neck. The first fascia of the neck - the superficial fascia is of muscular origin, it is found in all parts of the neck. On the front surface of the neck, this fascia can be stratified by accumulations of adipose tissue into several plates. In the anterolateral sections, the superficial fascia forms a case for the subcutaneous muscle and, together with its fibers, continues to the face, and below to the subclavian region. In the back of the neck, numerous connective tissue bridges stretch from the superficial fascia to the skin, dividing the subcutaneous adipose tissue into numerous cells. This feature of the structure of the subcutaneous fat leads to the development of carbuncles in this zone (sometimes), accompanied by extensive necrosis of the fiber, reaching the fascial muscle cases. The second fascia of the neck - a superficial sheet of its own fascia - in the form of a dense sheet surrounds the entire neck, including both its anterior and posterior sections. Around the submandibular gland, sternocleidomastoid, and trapezius muscles, this fascia splits and forms a sheath. The spurs of the second fascia extending in the frontal direction are attached to the transverse processes of the cervical vertebrae and anatomically divide the neck into two sections: anterior and posterior. Due to the presence of a dense fascial plate, purulent processes develop in isolation, either only in the anterior or only in the posterior parts of the neck. The third fascia (deep sheet of the own fascia of the neck) is of muscular origin. It is a thin but dense connective tissue plate stretched between the hyoid bone and the collarbone. At the edges, this fascia is limited by the scapular-subclavian muscles, and near the midline by the so-called "long muscles of the neck" (sternohyoid, sternothyroid, sublingual thyroid) and resembles a trapezoid (or sail) in shape. Unlike the 1st and 2nd fascia, which cover the entire neck, the 3rd fascia has a limited extent and covers only the scapular-tracheal, scapular-clavicular triangles and the lower part of the sternocleidomastoid region. The fourth fascia (intracervical) is a derivative of the tissues that form the lining of the primary cavity. This fascia has two sheets: parietal and visceral. The visceral sheet covers the organs of the neck: the trachea, esophagus, thyroid gland, forming fascial capsules for them. The parietal layer surrounds the entire complex of organs of the neck and the neurovascular bundle, consisting of the common carotid artery, the internal jugular vein, and the vagus nerve. Between the parietal and visceral sheets of the 4th fascia, anterior to the organs, a slit-like cellular space is formed - previsceral (spatium previscerale, spatium pretracheale). Behind the 4th fascia of the neck, between it and the fifth fascia, there is also a layer of fiber - the retrovisceral (spatium retroviscerale) space. The fourth fascia, surrounding the organs of the neck, topographically does not go beyond the median triangle of the neck and the region of the sternocleidomastoid muscle. In the vertical direction, it continues upward to the base of the skull (along the walls of the pharynx), and descends downward along the trachea and esophagus into the chest cavity, where its analogue is the intrathoracic fascia. From this follows an important practical conclusion about the possibility of spreading (formation of a streak) of a purulent process from the cellular spaces of the neck into the tissue of the anterior and posterior mediastinum with the development of anterior or posterior mediastinitis. The fifth fascia (prevertebral) covers mm. longi colli lying on the anterior surface of the cervical spine. This fascia is of connective tissue origin. Continuing in the lateral direction, it forms a case (fascial sheath) for the brachial plexus with the subclavian artery and vein and reaches the edges of the trapezius muscles. Fascial cases often serve as pathways for the spread of hematomas in case of injuries of the blood vessels of the neck and the spread of purulent streaks in case of phlegmon of various localization. Depending on the direction of the fascial sheets, the formation of spurs and connections with bones or neighboring fascial sheets, the cellular spaces of the neck can be divided into two groups: closed cellular spaces and open cellular spaces. Closed cellular spaces are represented by the following formations. Suprasternal interaponeurotic space located between the 2nd and 3rd fascia of the neck; case of the submandibular gland, formed by splitting the 2nd fascia of the neck, one of the sheets of which is attached to the lower edge of the jaw, the second to the linea mylohyoidea; case of the sternocleidomastoid muscle (formed by splitting the 2nd fascia). Unclosed cellular spaces include: the previsceral space located between the parietal and visceral sheets of the 4th fascia in front of the trachea from the level of the hyoid bone to the jugular notch of the sternum (at the level of the sternum handle by a fragile transverse septum, separated from the anterior mediastinum); retrovisceral space (located between the visceral sheet of the 4th fascia, surrounding the pharynx, trachea and esophagus, and the 5th fascia, continues into the posterior mediastinum); the fascial sheath of the neurovascular bundles of the neck, formed by the parietal sheet of the 4th fascia (at the top it reaches the base of the skull, and at the bottom it leads to the anterior mediastinum); fascial sheath of the neurovascular bundle, formed in the lateral triangle of the neck by the 5th fascia (penetrates into the interstitial space and then goes to the subclavian and axillary regions). The main principle in the treatment of neck abscesses is a timely incision that provides a wide opening of all pockets in which pus can accumulate. Depending on the localization of the purulent focus, various incisions are used for its drainage. With phlegmon of the suprasternal interaponeurotic cellular space, it is advisable to make an incision along the midline from the jugular notch of the sternum from the bottom up. If the process extends into the supraclavicular interaponeurotic space, counter-opening can be applied by making a transverse incision above the clavicle with the introduction of drainage from the outer edge of the sternocleidomastoid muscle. In severe cases, it is possible to cross one of the legs (sternal or clavicular) of the muscle. With phlegmon of the sac of the submandibular gland, the incision is made parallel to the edge of the lower jaw, 3-4 cm below. After dissection of the skin, subcutaneous tissue and the 1st fascia of the neck, the surgeon penetrates deep into the gland case in a blunt way. The cause of such phlegmon may be carious teeth, the infection of which penetrates into the submandibular lymph nodes. With submental phlegmon, a median incision is made between the two anterior bellies of the digastric muscle. With phlegmon of the vascular sheaths, the incision is made along the anterior edge of the sternocleidomastoid muscle or above the clavicle, parallel to it, from the posterior edge of the sternocleidomastoid muscle to the anterior edge of the trapezius. The phlegmon of the vagina of the sternocleidomastoid muscle is opened with incisions along the anterior or posterior edge of the muscle, opening the sheet of the 2nd fascia, which forms the anterior wall of the muscle sheath. Phlegmon of the previsceral space can be drained by a transverse incision over the jugular notch of the sternum. Phlegmons of the retrovisceral space are opened with an incision along the inner edge of the sternocleidomastoid muscle from the notch of the sternum to the upper edge of the thyroid cartilage. The pharyngeal abscess is opened through the mouth in the zone of greatest fluctuation, with the patient in a sitting position. Topography and access to the carotid arteries The common carotid artery is the main artery located in the neck. She, along with the vagus nerve and the internal jugular vein in the lower half of the neck, is projected into the regio sternocleidomastoideus. Slightly below the level of the upper edge of the thyroid cartilage, the artery emerges from under the anterior edge of the muscle and divides into the internal and external carotid arteries. The bifurcation of the artery is located at the level of the notch of the thyroid cartilage and is projected in the carotid triangle of the neck. Within this triangle, both the common carotid artery and both of its branches are most accessible for exposure. The classical projection line of the common carotid artery is drawn through points, the upper of which is located midway between the angle of the lower jaw and the apex of the mastoid process, the lower one corresponds to the sternoclavicular joint on the left, and is located 0,5 cm outward from the sternoclavicular joint on the right. To verify (identify) the external and internal carotid arteries, the following features are used: the internal carotid artery is located not only posteriorly, but, as a rule, also lateral (outward) from the external carotid; branches depart from the external carotid artery, while the internal carotid artery does not give branches on the neck; temporary clamping of the external carotid artery above the bifurcation leads to the disappearance of pulsation a. temporalis superficialis and a. facialis, which is easily determined by palpation. It should be remembered that forced ligation of the common or internal carotid artery in case of injury in 30% of cases leads to death due to severe disorders of cerebral circulation. Equally unfavorable is the prognosis for the development of a bifurcation thrombus, which sometimes develops with an incorrect choice of the level of ligation of the external carotid artery. To avoid this complication, the ligature on the external carotid artery must be applied above the origin of its first branch - a. thyreoidea superior. Topography of the cervical part of the thoracic lymphatic duct Injuries to the cervical part of the thoracic duct are observed during sympathectomy, strumectomy, removal of supraclavicular lymph nodes, endarterectomy from the common carotid artery. The main clinical manifestation of a violation of the integrity of the thoracic duct is chylorrhea - the outflow of lymph. Measures to eliminate chylorrhea are tamponade of the wound or ligation of the ends of the damaged duct. In recent years, the operation of imposing a lymphovenous anastomosis between the end of the damaged thoracic duct and the internal jugular or vertebral vein has been used. The thoracic duct is accessed and isolated for repair of injury or for catheterization and drainage, typically along the medial border of the sternocleidomastoid muscle. It should be emphasized that the cervical part of the thoracic duct is difficult to access for direct examination. Tracheostomy is the operation of opening the trachea with the subsequent introduction of a cannula into its lumen in order to provide immediate air access to the lungs in case of obstruction of the overlying sections of the respiratory tract. The first operation was carried out by the Italian Antonio Brassavola (1500-1570). Classic indications for tracheostomy: foreign bodies of the respiratory tract (if it is impossible to remove them with direct laryngoscopy and tracheobronchoscopy); impaired airway patency in wounds and closed injuries of the larynx and trachea; acute stenosis of the larynx in infectious diseases (diphtheria, influenza, whooping cough, measles, typhus or relapsing fever, erysipelas); stenosis of the larynx with specific infectious granulomas (tuberculosis, syphilis, scleroma, etc.); acute stenosis of the larynx in nonspecific inflammatory diseases (abscessing laryngitis, laryngeal tonsillitis, false croup); stenosis of the larynx caused by malignant and benign tumors (rarely); compression of the tracheal rings from the outside by struma, aneurysm, inflammatory infiltrates of the neck; stenoses after chemical burns of the mucous membrane of the trachea with acetic essence, caustic soda, sulfuric or nitric acid vapors, etc.; allergic stenosis (acute allergic edema); the need to connect artificial respiration apparatus, artificial lung ventilation, controlled breathing in case of severe traumatic brain injury; during operations on the heart, lungs and abdominal organs; in case of poisoning with barbiturates; with burn disease and many other less common conditions. Tracheostomy requires both general surgical instruments (scalpels, tweezers, hooks, hemostatic forceps, etc.) and a special set of instruments. The set of the latter usually includes: tracheostomy cannulas (Luer or Koenig), a sharp single-tooth tracheostomy hook of Chessignac, a blunt hook for pushing back the isthmus of the thyroid gland; tracheo dilator for pushing the edges of the tracheal incision before inserting a cannula (Trousseau or Wulfson) into its lumen. Depending on the place of opening of the trachea and in relation to the isthmus of the thyroid gland, there are three types of tracheostomy: upper, middle and lower. With an upper tracheostomy, the second and third tracheal rings are cut above the isthmus of the thyroid gland. The intersection of the first ring, and, moreover, the cricoid cartilage, can lead to stenosis and deformation of the trachea or chondroperichondritis, followed by stenosis of the larynx. With a middle tracheostomy, the isthmus of the thyroid gland is dissected and the third and fourth tracheal rings are opened. With a lower tracheostomy, the fourth and fifth tracheal rings are opened below the isthmus of the thyroid gland. During the operation, the patient can be either in a horizontal position, lying on his back with a roller placed under the shoulder blades, or in a sitting position with his head slightly thrown back. The operator becomes to the right of the patient (with the upper and middle tracheostomy) or to the left (with the lower one). The patient's head is held by an assistant in such a way that the middle of the chin, the middle of the upper notch of the thyroid cartilage and the middle of the jugular notch of the sternum are located on the same line. The incision is made strictly along the midline of the neck. With an upper tracheostomy, the incision is made from the level of the middle of the thyroid cartilage down by 5-6 cm. The "white line" of the neck is dissected along the probe and the long muscles located in front of the trachea are bred to the sides. Immediately below the thyroid cartilage, the visceral sheet of the 4th fascia is dissected in the transverse direction, fixing the isthmus of the thyroid gland to the trachea. With a lower tracheostomy, the incision of the skin and subcutaneous tissue starts from the upper edge of the jugular notch of the sternum and is carried out upwards by 5-6 cm. The 2nd fascia of the neck is dissected, the tissue of the suprasternal interaponeurotic space is bluntly stratified, if necessary, it is bandaged and the arcus venosus juguli located here is crossed. The 3rd fascia is cut along the probe and the sternohyoid and sternothyroid muscles are moved apart. Below the isthmus, the 4th fascia is incised and the isthmus is displaced upward, exposing the 4th-5th tracheal rings. Before opening the trachea to suppress the cough reflex, it is recommended to inject 1-1,5 ml of a 2% dicaine solution into its lumen with a syringe. The opening of the trachea can be done either by a longitudinal incision or a transverse one. According to special indications (for example, in patients who are on controlled breathing for a long time), a tracheostomy method is used with cutting out a flap according to Bjork or excision of a section of the wall to form a "window". During a longitudinal dissection of the trachea, the scalpel is held at an acute angle to the surface of the trachea (not vertically), with the belly up and 2 rings are crossed after tracheal puncture by moving from the isthmus of the thyroid gland and from the inside outward, as if "ripping" the wall. This technique allows avoiding injury to the posterior wall of the trachea, as well as dissecting the movable mucous membrane along the entire length of the incision. With a longitudinal dissection of the trachea, the integrity of the cartilage is inevitably violated, which in the future can lead to cicatricial deformity and the development of tracheal stenosis. Complications: bleeding from damaged cervical veins, carotid arteries or their branches, veins of the thyroid plexus, innominate artery, as well as when the isthmus of the thyroid gland is injured; incomplete dissection of the mucous membrane, which leads to its exfoliation with cannulas; "falling through" the scalpel and wounding the posterior wall of the trachea or esophagus; recurrent nerve damage. After opening the trachea, respiratory arrest (apnea) is possible due to reflex spasm of the bronchi. Topographic anatomy and operative surgery of the thyroid gland Surgeons began to develop operations on the thyroid gland from the end of the last century. Of the foreign surgeons, Kocher (1896) should be noted, who developed in detail the technique of operations on the thyroid gland. In Russia, the first operation was performed by N. I. Pirogov in 1849. The thyroid gland consists of two lateral lobes and an isthmus. The lateral lobes are adjacent to the lateral surfaces of the thyroid and cricoid cartilages and the trachea, reach the lower pole of 5-6 tracheal rings and do not reach the upper edge of the sternum by 2-3 cm. The isthmus lies in front of the trachea, at the level of its 4th rings. The upper edge of the isthmus sometimes comes into contact with the lower edge of the thyroid cartilage. The gland is closely connected with the underlying tissues by loose connective tissue and ligaments, especially with the larynx and the first tracheal rings. Due to this fixation, it follows the movements of the pharynx and trachea during swallowing. Palpation of the gland at the time of swallowing helps to detect even small enlargements and seals, especially in the lower parts of the gland. The posterior medial surfaces of the lateral lobes of the thyroid gland are adjacent to the esophageal-tracheal grooves, in which the recurrent nerves are located. In this zone, exfoliation of a thyroid tumor requires special care, since aphonia may develop if the recurrent nerves are damaged. The neurovascular bundles of the neck (common carotid artery, vagus nerve and internal jugular vein) are adjacent to the outer sections of the lateral lobes of the gland. In this case, the common carotid artery is so closely in contact with the gland that a longitudinal groove is formed on it. The lateral lobes touch the anterolateral wall of the esophagus. The blood supply to the gland is carried out by branches of the external carotid and subclavian arteries. Paired superior thyroid arteries, arising from the external carotid arteries, approach from the posterior surface to the upper poles of the lateral lobes and branch mainly in the anterior sections of the gland. Paired inferior thyroid arteries, arising from the subclavian arteries (truncus thyreocervicalis), approach the lower poles of the lateral lobes and supply mainly the posterior sections of the gland with branches. In 10-12% of cases, the inferior thyroid artery is involved in the blood supply, which directly departs from the aorta and enters the lower isthmus of the gland. One of the most common thyroid surgeries is a strumectomy. The technique of the most frequently used operation was developed by O. V. Nikolaev (1964). It is called subtotal subcapsular resection of the thyroid gland. Surgical access is carried out by a horizontal arcuate incision 1-2 cm above the jugular notch of the sternum 8-12 cm long along one of the transverse skin folds ("collar" incision). When dissecting soft tissues, a thorough ligation of the vessels is performed. The resulting flaps, including the skin, subcutaneous tissue and superficial fascia, are peeled off in a blunt way and bred up and down. The sternohyoid muscles are transversely crossed. After the introduction of novocaine under the sternothyroid muscles and into the fascial sheath of the thyroid gland, the muscles are moved apart from the midline, and the parietal sheet of the 4th fascia of the neck is dissected. Displacing the edges of the dissected fascia in a blunt way, they provide an approach to the thyroid gland and begin to perform an operative technique. The isolation of the organ begins with the "dislocation" of the gland, usually from the right lobe, depending on the situation from the upper or lower poles. After the release of the right lobe, the isthmus of the thyroid gland is crossed along the probe (or under the control of the finger). As the isthmus is dissected, hemostatic clamps are applied sequentially. Less often, the isthmus is crossed between the clamps, followed by stitching its tissue and tightening the ligatures. This is followed by a "navicular" excision of the tissue of the right lobe of the gland, which is performed under the control of the finger. This moment requires a thorough stop of bleeding and the imposition of a large number of clamps. By controlling the movement of the scalpel with a finger under the gland, a narrow plate of gland tissue is left in the area that is considered a "dangerous" zone, since the recurrent nerve and parathyroid glands are adjacent to it behind. The remaining part of the gland (a plate of tissue of the right and left lobes a few millimeters thick) should be sufficient to prevent hypothyroidism. The medial and lateral edges of the left parenchyma of the gland are sutured to each other in the form of two valves. The bed of the removed gland and the remaining stump is covered by the sternothyroid muscles. Then the sternohyoid muscles crossed during access are sutured and sutures are applied to the skin. 2. Features of primary surgical treatment of neck wounds Neck wounds have the following features: the wound channel, due to the large displacement of tissues, becomes tortuous and the outflow of wound contents is difficult; often observe simultaneous damage to large vessels and organs of the neck; wounds of the larynx, trachea and esophagus become infected not only from the outside, but also due to the contents; possible aspiration of blood into the respiratory tract, asphyxia. The wound channel is opened widely, the direction of the incision is chosen depending on the localization of the wound. In the medial part of the neck, transverse incisions are preferable, in the region of the sternocleidomastoid muscle - longitudinal incisions corresponding to the direction of its fibers. In the lateral part of the neck, transverse or oblique transverse incisions are made (along the clavicle or subclavian vessels and the brachial plexus). Soft tissues are excised sparingly, as contractures can form as a result of scarring. Extremely carefully excised tissues in the depth of the wound in view of the danger of damage to large vessels and nerves. If it is necessary to cross the veins, they are preliminarily bandaged to prevent air embolism. When performing manipulations in the outer triangle of the neck, it should be remembered that in adults the dome of the pleura protrudes 3 cm above the collarbones. All opened cellular spaces are carefully drained. Surgical treatment of wounds of the larynx and trachea consists in the economical excision of damaged tissues and the obligatory imposition of a tracheostomy. The damaged pharynx and esophagus are sutured with a double-row suture with synthetic threads, after which not only the paraesophageal and peripharyngeal tissues are drained, but also the posterior mediastinum. LECTURE #7 Operative surgery and topographic anatomy of the chest The upper border of the chest area runs along the upper edge of the manubrium of the sternum, collarbones, acromial processes of the scapula and further to the spinous process of the VII cervical vertebra; under the lower border is meant a line passing from the xiphoid process of the sternum along the edges of the costal arches, then along the lower edge of the XII rib to the spinous process of the XII thoracic vertebra. When considering topographic and anatomical features, the following concepts are used: chest (bone frame formed by the ribs, sternum and thoracic vertebrae); chest wall (a formation that includes the bones of the chest, intercostal muscles, muscles of the shoulder girdle, upper abdominal muscles, fascia and cellular layers) and the chest cavity (the space bounded in front, behind and from the sides by the chest wall, below the diaphragm, above the chest cavity communicates with the cavity of the neck, inside lined with intrathoracic fascia). There are three serous sacs in the chest cavity: two pleural and one pericardial. The mediastinum is located between the pleural sacs in the chest cavity, in which a complex of organs is placed, which includes the heart with the pericardium, the thoracic part of the trachea, the main bronchi, the esophagus, vessels and nerves, surrounded by a large amount of fiber. The diaphragm with its dome protrudes high into the chest, as a result of which the lower border of the chest is located significantly below the lower border of the chest cavity. As a result, some organs of the abdominal cavity (cardial part of the stomach, liver, spleen) are projected onto the lower sections of the chest wall. The tops of the right and left domes of the pleura will stand above the collarbones and thus go into the neck area. These anatomical features must be taken into account when diagnosing combined injuries of the neck, chest and abdomen in case of injuries. The anterior and posterior surfaces of the chest are conditionally divided along the midaxillary line. On each of them conditionally allocate 5 anatomical regions. On the anterior surface - anteromedian (limited on the sides by parasternal lines) and paired (right and left) anterior superior and anterior inferior (the border between them runs along the lower edge of the pectoralis major muscle). On the posterior surface, there are: posterior median (limited laterally by paravertebral lines), and paired posterior-superior and posterior-inferior regions (the border between the latter runs at the level of the angle of the scapula). The division of the chest wall into these areas is due to differences in the bone base and the structure of the soft tissue layers. The anterior upper-outer region incorporates well-developed pectoralis major and minor muscles, it is rich in intermuscular fiber, and the mammary gland is located in the surface layer. Between the clavicle and the upper edge of the pectoralis minor muscle, under the pectoralis major muscle, trigonum clavipectorale is isolated. In this triangle, under the fascial leaf (fascia clavi pectoralis) are the subclavian artery, vein and brachial plexus. The close proximity of the neurovascular bundle with the clavicle causes injury to the artery and vein when the fragments of the clavicle are displaced. In the lower sections of the chest wall, the muscles of the abdominal wall (m. rectus, m. obliquus abdominis externus) are attached in front; behind the superficial layer of muscles is formed by the latissimus dorsi, under which lie the anterior and posterior dentate muscles. The deep layer of the muscles of the chest wall is represented mainly by the external and internal intercostal muscles, which fill the intercostal spaces. In this case, the external intercostal muscles are observed along the length from the tubercles of the ribs (near the transverse processes of the vertebrae) to the line of transition of the ribs into cartilage. Throughout the cartilaginous part of the ribs, they are replaced by a dense fibrous ligament (lig. Intercostale externum). The internal intercostal muscles occupy the intercostal spaces from the edge of the sternum to the costal angle. For the rest of the length (from the costal angle to the spine), the internal intercostal muscles are replaced by the internal intercostal ligament (lig. intercostal internum). The main source of blood supply and innervation of the chest wall are the intercostal neurovascular bundles passing through the gap between the external and internal intercostal muscles and the lower edge of the rib. The position of the neurovascular bundle along the intercostal space is not the same. From the paravertebral to the scapular line, the neurovascular bundle runs approximately in the middle of the intercostal space between the internal intercostal ligament and the external intercostal muscles. Since fascial fibers are woven into the wall of the intercostal artery, the artery does not collapse when damaged, its lumen gapes, which explains the strong, sometimes gushing bleeding. From the scapular to the mid-axillary line, the neurovascular bundle lies between the external and internal intercostal muscles in the sulcus costalis, hiding behind the lower edge of the rib, which contributes to its injury in rib fractures. For the same reason, when puncturing the chest cavity, the needle is passed along the upper edge of the rib. Anterior to the midaxillary line, the intercostal neurovascular bundle emerges from the sulcus costalis and runs into the intercostal space near the lower edge of the rib. When damaged, bleeding from the intercostal arteries is profuse (up to 10% of those killed on the battlefield wounded in the chest die from bleeding of the intercostal arteries). This is due to the departure of the intercostal arteries directly from the aorta with high blood pressure in them; fusion of the walls of the arteries with the fascial fibers of the intercostal spaces (therefore, in case of damage, these arteries do not collapse); anastomoses with branches of the internal thoracic artery, passing along the edge of the sternum under the fascia endothoracica, which leads to the formation of a closed arterial ring in each intercostal space. In addition to the intercostal vessels, the internal thoracic artery and vein, which pass along the inner surface of the chest (near the edge of the sternum), take part in the blood supply to the chest wall. The latter is often used for myocardial revascularization in coronary insufficiency. The shape of the chest is in accordance with the shape and position of the organs of the chest cavity. Individual differences in the external shape of the breast, the direction of the ribs, the width of the intercostal spaces are taken into account when choosing surgical approaches and examining patients. With a short and wide chest, the ribs occupy a position close to horizontal, the intercostal spaces are wide, the upper chest aperture is small, the epigastric angle reaches 120 °, there is usually a "transverse" position of the heart, the border of which protrudes to the left beyond the midclavicular line. With a long and narrow chest, the ribs are inclined anteriorly, the intercostal spaces are narrow, the upper aperture of the chest is wide, and the epigastric angle is about 80°. usually there is a "drop-shaped" heart. 1. Topographic anatomy and operative surgery of the breast The mammary gland is located in women at the level of III-VI ribs between the parasternal and anterior axillary lines. The superficial fascia of the chest, which is divided into two sheets at the level of the third intercostal space, forming a capsule for the mammary gland, is fused with the clavicle and forms a lig. suspensorium mammae. The capsule gives off spurs that go into the depth between the lobules of the gland from the nipple in the radial direction. Usually there are 15 to 20 cloves. Parallel to the connective tissue septa, their excretory ducts of the mammary gland are also oriented. The connective tissue stroma of the gland is associated with the superficial fascia and the skin covering the mammary gland. The size of the mammary gland and the shape are determined by its functional state and the amount of fatty tissue. It is important to note that there are several layers of fiber in the area of the mammary gland: between the skin and the superficial fascia; between sheets of superficial fascia (inside the capsule of the gland); under the superficial fascia (between the posterior leaf of the capsule of the gland and its own fascia). When breastfeeding, the skin in the area of the nipple of the breast is easily damaged, which can serve as an entrance gate for infection. The latter penetrates deep into the connective tissue septa and excretory tubules and causes inflammation of the mammary gland (mastitis). Depending on the localization of the process in a particular layer of fiber, the following forms of mastitis can be distinguished: antemammary (subcutaneous, in the first layer of fiber); intramammary (in the second layer of fiber); retromammary (in the third layer of fiber). A radical way to treat purulent mastitis is to open the abscess. In case of antemammary and intramammary mastitis, it is recommended to open the purulent cavity with a radial incision on the anterolateral surface of the gland, without affecting the areola and nipple. For a better outflow of purulent discharge, as a rule, an additional incision (counter-opening) is made. Produce a thorough digital revision of the wound with the destruction of all jumpers and opening of streaks. If the radial connective tissue interlobular septa are intact, then they are preserved; otherwise, it is necessary to interconnect the purulent cavities by making additional radial incisions. Purulent cavities are drained with a silicone or PVC tube, in some cases with glove rubber. In the presence of several disjunct intramammary abscesses, each of them is drained from a separate incision. With deep intramammary abscesses and retromammary phlegmons, the arcuate incision of Bardengeyer (1903) along the lower edge of the gland, along the transitional fold, has advantages. At the same time, after dissection of the superficial fascia, the posterior surface of the gland, covered with a deep sheet of the superficial fascia, is exfoliated, penetrating into the retromammary tissue. The skin of the anterior surface of the gland is not damaged, and the scar along the transitional fold of the skin after the wound has healed is almost invisible. Surgical treatment of purulent mastitis is combined with antibiotic therapy and physiotherapy. Breast cancer is one of the most common localizations of malignant growth and ranks first in the structure of cancer incidence among women in Russia. The peak incidence occurs at the age of 50-69 years. The growth of a malignant tumor of the mammary gland is accompanied by the germination of neighboring tissues (skin, own fascia, muscles, ribs), penetration into the lymphatic channel and into the lymph nodes, first in the regional, and then in the distant ones (metastasis of tumor cells), and therefore it is important know the ways of lymphatic drainage. The most important route for lymph drainage and spread of tumor cells is the axillary route. The outflow of lymph from the mammary gland and the spread of tumor cells to the lymph nodes of the armpit occurs through the anterior thoracic lymph nodes (Zorgius nodes), located under the lower edge of the pectoralis major muscle at the level of the second rib; through Rotter's lymph nodes located between the pectoralis major and minor muscles; through the lymphatic vessels, in the thickness of the large and small pectoral muscles; through nodes located inside the muscles, between their fibers. Axillary lymph nodes, the number of which ranges from 10 to 75, are located along the axillary vein and form two groups - anterior and posterior (some authors distinguish five groups: anterior, posterior, medial, lateral, upper). Lymph is drained here mainly from the lateral part of the mammary gland. From the medial section of the mammary gland, lymph flows through the vessels, which through the first to fifth intercostal space penetrate into the depth and flow into the parasternal lymph nodes located along the internal thoracic artery and vein. From the upper part of the mammary gland, lymph outflow occurs in the subclavian and supraclavicular lymph nodes. Finally, from the lower part of the gland, the lymph flows into the lymph nodes and vessels of the preperitoneal tissue and into the subdiaphragmatic nodes. Enlargement of regional lymph nodes is one of the early symptoms in most breast cancer patients. Assessment of the state of the lymph nodes, along with determining the size and localization of the tumor, allows you to get an idea of the operability of the tumor. Currently, the treatment of breast cancer is complex, including surgical, radiation and chemotherapy methods. However, the leading role is still played by surgical intervention. Basic principles of surgery for breast cancer: radical (removal of the tumor and accessible lymph nodes); observance of the rules of ablastic and antiblastic. In breast cancer, several types of surgical interventions are mainly used: radical mastectomy; extended radical mastectomy; mastectomy with preservation of the pectoralis major muscle; resection of the mammary gland (extended sectoral resection, quadrantectomy). Recent studies have shown that superradical surgeries do not have clear advantages, but this is not recognized by all surgeons. Radical mastectomy consists of four stages: access; removal of a breast tumor within healthy tissues; removal of regional lymph nodes; suturing the wound. The skin incision should be made at a distance of at least 5-6 cm from the edges of the palpable tumor; the most commonly used is an oval (fusiform) incision, the upper end of which is projected onto the lateral third of the clavicle, and the lower end is located in the epigastric region, lateral to the midline. Orr's combined wavy incision is used less often and Beck's rectangular incision is used. After dissection of the skin, the edges of the incision are prepared in the medial side to the middle of the sternum, in the lateral side - to the edge of the latissimus dorsi muscle, up - to the collarbone, down - to the epigastric region. The thickness of the fiber on the prepared skin should not exceed 5-7 mm. The second stage is based on one of the main methodological principles of ablastics - "anatomical case of surgical intervention". Observing this principle, it is necessary to operate within the appropriate fascial sheaths that limit the spread of the tumor. Taking into account the structure of the mammary gland, the implementation of this principle consists in the removal of a single block of the mammary gland together with the tumor, the pectoralis major muscle within the sternoclavicular fascia. The isolation of the block starts from the sternum, for which the fibers of the pectoralis major muscle are exposed and crossed at the point of attachment to the sternum. This technique not only begins the mobilization of the muscle, but also interrupts the path of lymph outflow from the mammary gland to the parasternal lymph nodes. The pectoralis major is then transected as close as possible to its insertion on the humerus. Next, the sternoclavicular fascia is dissected along the lower edge of the clavicle and the pectoralis minor muscle is exposed. Under the free edge of the pectoralis minor muscle, at the place of its attachment to the ribs, a finger or a probe is brought in, after which the muscle is crossed and the entire block of tissues is separated from the chest wall. The second stage is completed with a single-block removal of the entire isolated drug or, without removing the block of the mammary gland with pectoral muscles, as if “hanging” on a fascial-fat pedicle that continues into the axillary fossa, proceed to remove all regional (axillary) lymph nodes. With a radical mastectomy, it is necessary to remove not only enlarged lymph nodes, but also all outwardly unchanged nodes located in the tissue along the vein. In practice, this can be achieved by successively separating from the vein in a blunt and sharp way in a single block all the fiber, together with the lymph nodes, from top to bottom - from the collarbone to the mammary gland. When performing this manipulation, the axillary vein should be spared as much as possible, since damage to it can lead not only to bleeding, but also to the development of an air embolism. In addition, when separating the tissue along with the lymph nodes from the vein, one should not “skeletonize” the remaining elements of the neurovascular bundle, since lymphatic vessels pass along the axillary artery and the brachial plexus, providing lymph outflow from the upper limb. It is necessary to remove the anterior thoracic Zorgius nodes located on the anterolateral wall of the chest under the pectoralis major muscle. Taking into account the principles of antiblastics, the electrosurgical method of operating in breast cancer is often used. To improve the outflow of the wound discharge outward from the lower angle of the scapula, an additional skin incision is made and a drainage tube is passed deep into the axillary fossa. After that, proceed to the fourth stage of the operation. It consists in closing the surgical wound. If possible, bring together and sew the edges of the wound. With a slight tension of the edges of the wound along its periphery, laxative incisions are made on the skin in a checkerboard pattern. If it is impossible to tighten the edges of the wound, it has to be closed with skin grafting. If metastases are detected not only in the axillary, but also in the parasternal lymph nodes, an extended radical mastectomy according to Urban-Holdin is performed, which differs from the Halsted mastectomy by resection of the sternum at the level of the I rib, II-V ribs for 3-4 cm from the sternum costal joints and mobilization of fiber and removal of lymph nodes along a. and v. thoracica interna. The use of combined methods of treatment with the use of radiation and chemotherapy allows the use of less traumatic operations for breast cancer in the early stages of the disease. These include mastectomy with preservation of the pectoralis major muscle and extended sectoral resection. In a mastectomy with preservation of the pectoralis major muscle (according to Pati), after performing a skin incision and separating the mammary gland with its capsule and subcutaneous adipose tissue, the formed block of tissues is displaced towards the armpit. The pectoralis minor muscle is isolated and cut off from the coracoid process of the scapula. After that, the axillary lymph nodes with fiber are removed, which, together with the pectoralis minor muscle and the mammary gland with a tumor, are removed. Resection of the mammary gland (extended sectoral resection, quadrantectomy) consists in removing the sector of the mammary gland in one block with the subclavian and axillary lymph nodes. The excision of the sector (quadrant) is performed taking into account the location of the interlobular fascial septa, observing the principles of sheathing. 2. Operative access to the organs of the chest cavity The requirements for operative access are the anatomical accessibility of the object of intervention (organ, pathological focus) and the technical feasibility of all stages of the operation. All approaches to the organs of the chest cavity are divided into two groups: extrapleural and transpleural. When performing extrapleural accesses, the exposure of the anatomical formations of the mediastinum occurs without depressurization of the pleural cavities. The possibility of performing these accesses is determined by the position and ratio of the anterior and posterior borders of the pleura. The projections of the lines of transition of the costal pleura to the mediastinal anteriorly on the right and left sides are asymmetric. On the right, the anterior border often starts from the sternoclavicular joint, then goes down and medially, through the manubrium of the sternum and passes to the right of the midline, arcuately curving to the right. It can lie throughout to the right of the median line, or it passes near the left edge of the sternum. There is a dependence of the position of the right pleural border on the shape of the chest structure: the greater the value of the chest width index, the farther to the right from the midline of the sternum the right border of the pleura is projected. On the left, the anterior border of the pleura, as a rule, begins at the left sternoclavicular joint, and then goes along the left edge of the sternum until the sixth costal cartilage is attached to it. Further, according to the position of the border of the heart, this line continues downward and laterally. The extreme fluctuations of the left border is its location either in the middle of the body of the sternum, or to the left of the left edge of the sternum. When comparing the anterior borders of the right and left costal-mediastinal sinuses, it can be noted that at the top, to the level of II-IV ribs, these borders are relatively far apart, at the level of II-IV ribs they approach each other almost to the point of contact, and below IV ribs diverge again. Thus, it is possible to distinguish the upper and lower extensions of the anterior interpleural space and its narrowed middle part. Through these interpleural spaces, it is possible to perform extrapleural access to the organs and vessels of the anterior mediastinum, the advantage of which is the preservation of the tightness of the pleural cavities, which avoids typical complications. One of the significant drawbacks is the limitation of the surgeon's actions in a narrow gap between the pleural sacs. With transpleural accesses, one or two (with the so-called trans-two-pleural accesses) pleural cavities are opened. Transpleural accesses can be used for operations both on the organs of the mediastinum and on the lungs. The direction of the incisions on the chest wall when accessing the organs of the chest cavity can be different. In this regard, accesses to the organs and vessels of the chest cavity are divided into longitudinal, transverse and combined. Depending on which surface of the chest wall the incision is made on, there are anterolateral, lateral, and posterolateral incisions. Also, depending on the tissues being dissected, accesses are distinguished through the intercostal spaces (one-sided and two-sided); accesses with dissection of the sternum (longitudinal, transverse and combined sternotomy); combined approaches, in which the intersection of soft tissues along the intercostal space is combined with sternotomy and intersection of the rib or with resection of one (or several) ribs. To perform a longitudinal sternotomy, a skin incision is made along the midline above the sternum, starting 2-3 cm above the sternum handle and ending 3-4 cm below the xiphoid process. Then the periosteum of the sternum is dissected and displaced by 2-3 mm to the sides of the incision line with a raspator. In the lower part of the wound, the white line of the abdomen is dissected for several centimeters and a tunnel is formed between the posterior surface of the sternum and the sternal part of the diaphragm in a blunt way (with a finger, a swab). Protecting the underlying tissues with Buyalsky's scapula (or in another way), a longitudinal sternotomy is performed. After dissection of the sternum, hemostasis is performed by rubbing the wax paste into the spongy substance of the sternum. The edges are widely bred to the sides with a screw retractor, while trying not to damage the mediastinal pleura. After the end of the operation, the edges of the sternum are compared and fastened with special brackets or strong sutures. An example of transpleural access, which allows performing operations on the lung, its root, as well as on the heart and diaphragm, is an anterolateral incision at the level of the fifth or fourth intercostal space. This is one of the most commonly used, "standard" accesses. The incision starts from the parasternal line and, continuing it along the intercostal space, is brought to the posterior axillary line. In women, the incision borders the mammary gland. After dissection of the superficial layers of the chest wall, the edges of the wound are moved apart with hooks and the intercostal muscles and the corresponding ribs are exposed, after which the intercostal muscles and pleura are dissected. To avoid damage to the intercostal vessels and nerve, the incision should be made closer to the upper edge of the underlying rib. Caution is also required when approaching the sternum: the incision is completed without reaching its edge, with one transverse finger so as not to damage the internal thoracic artery. The parietal pleura is dissected simultaneously with the internal intercostal muscles. After opening the pleural cavity, a retractor is introduced into the wound. Edge crossings are generally not required. In case of insufficiency of access, it is necessary to cross the cartilages of adjacent ribs after ligation of the vessels. With lateral access, the chest cavity is opened along the V-VI ribs from the paravertebral to the mid-clavicular line. Lateral intercostal access creates good conditions for manipulations in almost all parts of the chest. The disadvantage of lateral access can be considered the forced position of the patient on a healthy side. To perform a posterolateral access, the patient is placed on the stomach or given a position on the healthy side with an inclination forward. The soft tissue incision begins at the level of the spinous process of the III-V thoracic vertebra and continues along the paravertebral line to the level of the angle of the scapula (VII-VIII ribs). Having rounded the angle of the scapula from below, an incision is made along the VI rib to the anterior axillary line. Sequentially dissect all tissues to the ribs. The pleural cavity is opened along the intercostal space or through the bed of the resected rib. To expand the operational access, resection of the necks of two adjacent ribs is often resorted to. The posterior approach is the most traumatic, since it is necessary to dissect a thick layer of muscles and often resect the ribs. Transverse sternotomy is used in cases where it is necessary to expose not only the organs, but also the vessels of the mediastinum and nearby areas (brachiocephalic trunk, subclavian arteries). It is used in operations under cardiopulmonary bypass and complex reconstructive surgeries and transplantations. The incision is made along the fourth intercostal space from the midaxillary line on one side, through the sternum, to the midaxillary line on the opposite side. Bandage and cross them between the ligatures of the internal thoracic vessels on both sides. After dissection of the periosteum of the sternum and pushing it upwards and downwards with a raspator, a transverse intersection of the sternum is performed using a sternotomy or a Gigli wire saw. Having opened the right and left pleural cavities throughout the incisions, the edges of the sternum with ribs are spread with a retractor. Through bipleural access makes it possible to approach all parts of the heart and large vessels, but it is very traumatic. Currently, minimally invasive methods are often used: thoracoscopy and video endosurgical method of performing operations on the organs and vessels of the chest cavity. Thoracoscopy is usually performed for diagnostic purposes. For its implementation, it is necessary to impose an artificial pneumothorax, in which instruments can be inserted into the pleural cavity and manipulated. The pressure in the pleural cavity is brought to atmospheric level. This requires a full function of the second lung. The puncture of the chest wall with a trocar for the introduction of a thoracoscope is usually performed on the right in the third or fourth intercostal space along the posterior axillary line, on the left - in the second or third intercostal space along the anterior axillary line. To facilitate the introduction of the trocar and reduce the risk of complications (vascular damage), thoracocentesis is performed. To do this, in the place intended for the introduction of the trocar, a skin incision 2-3 cm long is made to the intercostal muscles, and under the control of vision, the trocar stylet is inserted along the upper edge of the underlying rib perpendicular to the surface of the chest. In this case, it is necessary to ensure that the stylet face is facing the intercostal neurovascular bundle. After removing the stylet, a thoracoscope is inserted into the chest cavity and the chest cavity is examined through the eyepiece. Diagnostic videothoracoscopy is often used, in which an approximate and enlarged image of the pleural cavity and its contents is displayed on the monitor screen and recorded on digital and analog media, which makes it possible to provide a multilateral visual assessment of the pathological focus against the background of a functioning organ by all members of the surgical team and other specialists. Modern capabilities of endovideo technology allow performing a significant part of intrathoracic operations. In this case, depending on the intended operation (object of intervention), several thoracoports (a special tube for inserting a thoracoscope and manipulators) with a diameter of 10 or 5 mm are installed. The advantages of the video endosurgical method for operations in the chest cavity include a reduction in the invasiveness of the operation (due to a decrease in the invasiveness of the surgical access); the possibility of a full revision of the organs of the chest cavity; reducing the risk of purulent complications; a significant reduction in pain in the postoperative period. However, in some cases, especially in oncological processes, the endovideosurgical method of surgery is contraindicated. Video endosurgical equipment can be used in combination with conventional thoracotomy. This combined method is called video support. It combines the advantages of both methods. 3. Pathological conditions and surgical techniques on the organs of the chest One of the most common causes of breast surgery is wounds. They occur not only with the direct impact of firearms or edged weapons: organs are often damaged by fragments of the bone frame of the chest (ribs, sternum), which become additional sources of damage. All chest injuries are divided into two groups: 1) non-penetrating - without damage to the intrathoracic fascia; 2) penetrating - with damage to the intrathoracic fascia and parietal pleura in those places where it is adjacent to this fascia. The direction of the wound channel for penetrating wounds may be different. The most dangerous are sagittal injuries near the midline, since in these cases the heart and large vessels (aorta, vena cava, pulmonary artery) are often damaged. Methods for the treatment of penetrating wounds of the chest (including surgical ones) are aimed at preventing complications (traumatic shock, bleeding, infections) and correcting developing functional disorders. Shock. The course of shock resulting from penetrating wounds of the chest is characterized by the manifestation of a syndrome of cardiopulmonary disorders. The developing phenomena of shock are most severe in the wounded with hemo- and pneumothorax. In these cases, severe respiratory disturbances occur, leading to profound disturbances in gas exchange. Anti-shock measures are aimed at combating respiratory disorders, eliminating the pain factor, compensating for blood loss, correcting metabolism; vagosympathetic blockade according to Vishnevsky is used as one of the anti-shock measures. Hemothorax. The accumulation of blood in the pleural cavity is the result of internal bleeding from injuries of the heart, lung vessels, main vessels of the mediastinum, as well as damage to the vessels of the chest wall. Often hemothorax is combined with the ingress of air into the pleural cavity. This condition is called hemopneumothorax. Hemothorax can be free or (in the presence of adhesions) encysted. Allocate small - within the costal-diaphragmatic sinus; middle - to the level of the IV rib in front; total - from the diaphragm to the dome of the pleura. To determine whether bleeding has stopped or continues, the Ruvelua-Gregoire test is used: a few milliliters of blood aspirated from the pleural cavity with a puncture needle is poured into a test tube. Rapid blood clotting indicates ongoing bleeding, non-clotting indicates its cessation. With stopped bleeding, the removal of the blood contained in the pleural cavity by pleural puncture and the introduction of antibiotics is indicated. With persistent bleeding due to damage to the intercostal arteries and the internal mammary artery, emergency thoracotomy is indicated. After its implementation, the revision of the pleural cavity is continued, the damaged vessel is found and ligatures are applied to it. Pneumothorax. This is an accumulation of air in the pleural cavity. With wound pneumothorax, air can enter the pleural cavity in two ways: through a hole in the chest wall with a penetrating wound, accompanied by damage to the parietal pleura (external pneumothorax); through a damaged bronchus (internal pneumothorax). It is customary to distinguish three types of pneumothorax: closed, open, valvular. With a closed pneumothorax, air enters the pleural cavity at the time of injury. This leads to atelectasis of the lung on the affected side. As a result of the collapse of the walls of the wound channel, which has a small size, the opening in the parietal pleura closes, which leads to separation of the pleural cavity from the atmosphere. In the absence of bleeding (hemothorax), the wounded with closed pneumothorax, as a rule, do not require surgical intervention: the air resolves after 7-12 days, the lung expands. In the presence of a large volume of air in the pleural cavity, especially with pneumohemothorax, removal of blood and air by pleural puncture is indicated. The most dangerous are open and valvular pneumothorax. Open pneumothorax occurs more often with a gaping wound of the chest wall. This forms a free communication between the pleural cavity and atmospheric air. Much less often, an open internal pneumothorax develops when the main bronchus or trachea is damaged. Open pneumothorax leads to a very serious condition, often ending in the death of the victim. First aid for open pneumothorax consists in applying an aseptic occlusive dressing, adhesive plaster, gauze dressing moistened with water or soaked in oil to the wound. Surgical treatment of open pneumothorax consists in urgent surgical closure of the chest wall wound and drainage of the pleural cavity, the purpose of which is the complete expansion of the lung. The operation begins with the primary surgical treatment of the wound of the chest wall, which is performed sparingly, excising only obviously non-viable tissues. In the absence of signs of ongoing internal bleeding, thoracotomy is not performed and surgical closure of the chest wall defect is started. All methods of surgical closure of a chest wall defect and sealing of the pleural cavity can be divided into two groups: 1) suturing the wound; 2) plastic closure of the wound. The technique of suturing the wound of the chest wall with open pneumothorax Simple suturing of the wound is performed with a small defect. The sealing of the pleural cavity is achieved by applying a two-row suture. The first row is a pleuromuscular suture, which is applied with catgut. For greater strength, the parietal pleura, intrathoracic fascia and intercostal muscles must be included in the suture. When tightening the sutures, they try to achieve adhesion to each other of the sheets of the parietal pleura covering the edges of the wound. The second row of sutures is placed on the superficial muscles of the chest wall. In this case, it is desirable that the seams of the second row are projected onto the gaps between the seams of the first row in order to achieve better tightness. Several layers of muscle can be sewn with three rows of stitches. When suturing superficial muscles, it is imperative to include your own fascia in the suture; synthetic threads are usually used. With a "deficiency" of the intercostal muscles along the edges of the wound or the inability to pull them together with extensive damage, the adjacent ribs are brought closer to the remnants of soft tissues by suturing with a thick catgut capturing adjacent ribs. The most effective in this case is the use of a seam in the form of the number 8 (poly-paste seam). The next step is to mobilize the chest wall. With relatively large defects of the chest wall, it is possible to mobilize the edges of the wound by resection of one or two ribs lying above and below the wound. After such mobilization, soft tissues, as a rule, can be brought together and the open pneumothorax is sutured with a two-row suture. Plastic methods of closing a chest wall defect in open pneumothorax. Plastic surgery with a muscle flap on a leg, which is cut out from the muscles adjacent to the wound. For wounds located in the lower parts of the chest, where there are few superficial muscles, diaphragmopexy can be used - pulling up and suturing the diaphragm to the edges of the wound of the pleural cavity around the entire perimeter. Pneumopexy - pulling up the lung and suturing it to the edges of the wound. Valvular pneumothorax occurs when a valve is formed from the tissues around the wound, through which air enters the pleural cavity at the moment of inhalation, and when exhaling, the valve closes and does not release air back from the pleural cavity. Valvular pneumothorax often develops with injuries of the bronchus (internal pneumothorax) and, less often, with injuries of the chest wall (external pneumothorax). Valvular pneumothorax, as well as open, is accompanied by the development of pleuropulmonary shock. With this type of pneumothorax, with each breath, the pressure in the pleural cavity is constantly increasing, which aggravates the clinical picture. With valvular pneumothorax lies the decompression of the pleural cavity and the elimination of a sharp displacement of the mediastinum. The easiest way to do this is to puncture the pleural cavity with a thick needle in the second intercostal space along the midclavicular line. On the needle sleeve there should be a simple rubber valve, made, for example, from an incised finger of a rubber glove. This valve serves as a kind of nipple that lets air out of the pleural cavity, but excludes its entry inside. Surgical care for valvular pneumothorax that develops when the chest wall is damaged consists in excising the valve from the soft tissues during the primary surgical treatment and suturing the wound using one of the methods described when considering an open pneumothorax. With internal valvular pneumothorax associated with damage to the bronchus, active aspiration of pleural fluid is possible through a drain inserted in the seventh to eighth intercostal space along the middle or posterior axillary line. Emphysema. This is the ingress of air into the fiber, there are two types: subcutaneous and mediastinal. Subcutaneous emphysema is formed with external valvular pneumothorax. It does not pose a danger and dissolves after the elimination of the source of air intake. Mediastinal emphysema occurs when air enters the mediastinal tissue from the pleural cavity, through a defect in the mediastinal pleura when the bifurcation of the trachea or main bronchus ruptures with the formation of a valve mechanism. Accumulating in the fiber of the mediastinum, the air causes compression of the heart and large vessels (primarily veins), difficulty breathing. Treatment consists in urgent drainage of the anterior mediastinum. To do this, a longitudinal or transverse incision is made in the suprasternal fossa, from where, in a blunt way, the surgeon penetrates the tissue of the anterior mediastinum and introduces drainage (a thick tube with several outlet holes). Suturing the wound of the lung. With shallow wounds on the surface of the lung, to stop bleeding, it is enough to apply several interrupted sutures with thin round needles with synthetic or silk threads. To prevent the eruption of sutures, the Tigel-Melnikov technique is used, a feature of which is the preliminary holding of "support" threads along the edges of the wound through the thickness of the parenchyma of the lung, and then the application of interrupted sutures outside of them, passing under the bottom of the wound. With marginal damage to the lung tissue, accompanied by bleeding, a wedge-shaped resection is performed. For its implementation, two hemostatic clamps are applied to the lung tissue on both sides of the wound. They overlap at an angle to each other and meet at their ends. Along the edges of the clamps facing inward, the affected area of the lung is excised in the form of a wedge. After that, a twisting seam is applied through the clamps, which, as they are gradually tightened, are carefully removed and removed from under the seam loops. With a greater degree of destruction, a segment, a lobe of the lung is removed, and even pulmonectomy is resorted to. 4. Damage to the pericardium and heart with penetrating wounds of the chest Heart injuries are divided into two groups: non-penetrating - without damage to the endocardium; penetrating - with damage to the epicardium. Among non-penetrating wounds there are: isolated myocardial wounds; injuries of the coronary vessels; combined injuries of the myocardium and coronary vessels. Bleeding from heart injuries is often intrapleural. With bleeding into the myocardial cavity, cardiac tamponade may develop. Acute cardiac tamponade is manifested by Beck's triad (falling blood pressure, a sharp increase in central venous pressure and weakening of heart sounds). Emergency help with threatening tamponade is a pericardial puncture. The puncture is performed with a thick needle. With the Marfan method, a puncture is made under the xiphoid process strictly along the midline, moving the needle from bottom to top to a depth of 4 cm, and then deflecting its end posteriorly. According to the Pirogov-Delorme method, a puncture is made at the left edge of the sternum in the fourth-fifth intercostal space, in the medial direction, behind the sternum, to a depth of 1,5-2 cm. According to Larrey, the needle is injected into the angle between the attachment of the left seventh costal cartilage and the base of the xiphoid process to a depth of 1,5-2 cm, and then it is deflected upwards parallel to the chest wall. According to the Kurshman method, the puncture is performed in the fifth intercostal space, retreating 4-6 cm from the edge of the sternum. The needle is passed in the medial direction (towards the apex of the heart). The success of treatment for a heart injury is determined by: the delivery time of the victim to a medical institution, the speed of surgical intervention and the effectiveness of intensive care. In recent years, lateral thoracotomy along the fourth or fifth intercostal space from the left edge of the sternum to the posterior axillary line without cutting the costal cartilages has been widely used. After opening the chest cavity, the pericardium is widely dissected with a longitudinal incision in front of the phrenic nerve. When revising the heart, it is necessary to examine its posterior surface along with the anterior one, since the wounds can be through. Inspection should be done by bringing the palm of the left hand under the top of the heart and slightly "dislocating" it into the wound. Round (preferably atraumatic) needles are used for suturing the wound of the heart. Synthetic threads are used as suture material. The suture of the walls of the ventricles of the heart should capture the entire thickness of the myocardium, but the threads should not penetrate into the cavity of the heart, in order to avoid the formation of blood clots. With small wounds of the heart, interrupted sutures are applied, with wounds of a significant size, mattress sutures are used. When suturing the wound of the ventricle, the injection of the needle is done in such a way that the second movement of the needle immediately captures the other edge of the wound. The sutures are tightened carefully so as not to cause tissue eruption. After the myocardium, the pericardium is sutured with rare single sutures. Treatment of chylotrax Chylothorax is an accumulation of lymph in the pleural cavities when the thoracic duct or its tributaries is damaged. Methods of treatment of chylothorax are divided into conservative and operational. Conservative methods include repeated punctures of the pleural cavity with the removal of lymph. Surgical treatment of lymphorrhea and chylothorax is performed from a transpleural (usually right-sided) thoracotomy with ligation of the ends of the thoracic duct with thin silk ligatures. Damage to the esophagus in chest injuries are observed relatively rarely (0,3%). The entry into the tissue of the mediastinum and into the pleural cavities of the contents of the esophagus leads to the development of purulent mediastinitis and pleurisy. Penetrating wounds of the esophagus, found during the revision of the chest cavity, are subject to suturing. On the edges of the wound of the esophagus impose two rows of sutures with synthetic threads. The wound of the esophagus is sutured in the transverse direction to avoid narrowing of its lumen. The operation ends with drainage of the pleural cavity or mediastinum and the introduction of a nasogastric tube through the esophagus or the application of a gastrostomy to feed the patient. Pleural empyema This is an accumulation of pus in the pleural cavity, often resulting from infection in the wounded with hemothorax, open pneumothorax, mediastinal emphysema, as a result of a breakthrough of pus into the pleural cavity from a lung abscess, suppuration of bronchiectasis, and collapse of the pneumonic focus. According to the prevalence of the process, free or encysted empyema is distinguished; according to the nature of the clinical course, acute and chronic. Surgical treatment of acute empyema consists in draining the pleural cavity in order to remove purulent contents and ensure lung expansion. The simplest method of surgical treatment of acute empyema is the removal of pus by puncture of the pleural cavity. With free empyema, pus accumulates in the costophrenic sinus. The puncture in this case is performed in the eighth intercostal space along the scapular or posterior axillary line. With small encysted empyema, the localization of the abscess is established percussion and radiographically. The puncture site is chosen near the lower border of the purulent cavity. Under local anesthesia, the needle is inserted closer to the upper edge of the underlying rib, in order to avoid damage to the neurovascular bundle, then advanced in depth until the feeling of "failure", which appears when the thickened parietal pleura is punctured. In chronic empyema, an extensive purulent cavity is formed, surrounded by connective tissue growths, granulations, and fibrin deposits. Surgical operations for chronic empyema are aimed at emptying the purulent cavity, removing adhesions and pathological granulations, and eliminating the cavity. LECTURE #8 Hernias. their places of origin. Principles and technique of operations for hernias 1. Hernias and places of their occurrence Hernia of the anterior-lateral abdominal wall is a common disease (up to 7% of men and 2,5% of women). Often there is an infringement of the hernial contents, which requires emergency surgical treatment and is accompanied by a much higher mortality compared to a planned operation. The boundaries of the anterior-lateral wall of the abdomen are: at the top of the costal arches and the xiphoid process of the sternum; below the inguinal folds, pubic tubercles and the upper edge of the pubic symphysis; on the right and on the left, the border is a vertical line connecting the end of the XI rib with the iliac crest (Lesgaft line). The basis of the anterior-lateral abdominal wall is 4 pairs of muscles: on the right and left, the external oblique, internal oblique and transverse muscles; in front of the rectus abdominis muscles with longitudinally oriented fibers. Behind are the muscles that straighten the spine. All of these muscles form a ring in which the abdominal organs are enclosed. Muscles are constantly in a certain tone, more pronounced in a standing position, less in a horizontal position of the body. Most of the abdominal muscles reduce the volume of the abdominal cavity during contraction, except for the muscles that straighten the spine, which make up its support. Tendon bridges in the muscles, uniting the points of application of the forces of the muscle fibers, determine the stress vector. The combination of muscle tension of the abdominal wall with the elasticity of blood-filled parenchymal organs and peristaltic hollow abdominal organs determine the occurrence of intra-abdominal pressure. The value of intra-abdominal pressure ranges from 15 to 150 mm of water column, and depends on the tone of the abdominal muscles and the condition of the abdominal organs. Intra-abdominal pressure helps to maintain the normal function of the abdominal organs, activates blood and lymph circulation in the abdominal cavity and performs a number of other functions. Suffice it to say that, according to a number of foreign authors, the cause of death in the intensive care unit of a surgical hospital in at least 10% is the so-called syndrome of increased intra-abdominal pressure. If the value of intra-abdominal pressure rises for a long time and does not correspond to the mechanical strength of the abdominal wall, the viscera may be "pushed" out of the abdominal cavity. A similar phenomenon can occur with a single excessive physical effort, with an "overstrain" of the abdominal press. The exit of the viscera covered with the parietal peritoneum occurs through weak points in the muscular-aponeurotic layer of the abdominal wall, pelvic floor, and diaphragm. It is important to emphasize that with a hernia, the viscera that extend beyond the abdominal wall are necessarily covered by the peritoneum. The phenomenon when the viscera exit the abdominal cavity through a rupture of the parietal peritoneum is called eventration. The factors contributing to the occurrence of hernias are very diverse, and can be both general (congenital weakness of the muscles of the abdominal wall, sudden weight loss, etc.) and local (congenital or acquired "weak spots" of the abdominal wall). Among all the factors and causes of hernia formation, it is necessary to highlight two: the “predisposing factor” (the presence of “weak spots” in the muscular aponeurotic layer of the abdominal wall) and the “producing factor” (a sharp increase in intra-abdominal pressure). The following elements of hernial protrusion are distinguished. 1. Hernial orifice - a defect in the layers of the abdominal wall, through which the abdominal organs exit. Hernial gates can have a different structure and are divided into two groups: simple and complex. Simple hernial gates look like a ring. Complex ones are represented by interaponeurotic or intermuscular fissures and channels. 2. Hernial sac - a parietal sheet of the peritoneum, pushed out of the exiting viscera from the abdominal cavity. In the hernial sac, the neck, body and bottom are distinguished. The neck is called the area of the peritoneum, located at the level of the gate and is the anatomical boundary between the peritoneal cavity and the cavity of the hernial sac. The expanded part of the hernial sac is called the body, the final part of which forms the bottom. 3. The contents of the hernial sac. It can be almost any organ of the abdominal cavity, except for the head of the pancreas. Most often, the contents of the hernial sac are the greater omentum and loops of the small intestine as organs with the greatest mobility. Weak places of the anterior-lateral wall of the abdomen are located where there are holes in the fascia and aponeuroses, gaps between connective tissue fibers or between the edges of the muscles, and also where there is an "incomplete set" of muscular-aponeurotic layers that make up the abdominal wall. In those areas where there are few muscular-aponeurotic layers, or their weakened areas are located one above the other, simple hernial gates (umbilical hernia) are formed. When the outer and inner rings are displaced relative to each other, a channel is formed in the abdominal wall, complex hernial gates (inguinal hernias) are formed. The number and size of weak areas varies from person to person. Their severity depends on the physique, age, gender, muscle fitness and other factors. All of them can be conditionally divided into holes and fissures in the white line of the abdomen; gaps in the aponeuroses of the external, internal oblique and transverse muscles; canals (inguinal, femoral). The white line of the abdomen has a different shape depending on the severity and level of location of the widest part. There are four forms of variability of the white line: with an extension at the level of the navel; with an extension above the navel; with an extension below the navel; white line of uniform width at all levels. The most common are the first and second forms. The white line of the abdomen is always wider in women than in men, with age it expands: in women in adulthood, in men after 50-60 years. Approximately 20% of people with a wide white line of the abdomen have gaps up to 1-1,5 cm in size in it. In 16% of cases, preperitoneal lipomas are noted, sometimes protruding into these gaps. Under the influence of prolonged tension of the anterior abdominal wall, the tendon fibers that form the white line can stretch and move apart. As a result, the gaps in the white line expand, new ones appear. Often these gaps correspond to the places of passage through the white line of blood vessels and nerves. With a significant increase in the size of the cracks, preperitoneal tissue can protrude through them, and then the parietal peritoneum with the formation of a hernia. Hernias of the white line are more often localized above the navel, where its width is greater, and the tendon fibers are less dense. Of particular importance is the umbilical ring, located approximately in the middle of the length of the white line. In the intrauterine period, the umbilical cord passes through a hole in the white line. After the birth of a child, it closes with a connective tissue scar. The edges of the opening, formed by aponeurotic fibers, thicken and form the umbilical ring. Under the scar tissue covering the umbilical ring, there is no subcutaneous tissue, very thin skin is fused with the scar tissue. On the other hand, the intra-abdominal fascia and parietal peritoneum are fused with scar tissue. In most people, the umbilical ring is located 2-3 cm below the middle of the distance between the base of the xiphoid process and the symphysis. In half of the people (more often in women), the navel is 0,5-3,5 cm displaced to the right of the midline. The shape of the umbilical ring is usually oval. Its diameter in men ranges from 0,5 to 1,8 cm, in women - from 0,6 to 3,2 cm. Anatomical features that predispose to the formation of umbilical hernias are: poor development of the umbilical fascia (part of the intra-abdominal fascia); an increase in the diameter of the ring; the presence of peritoneal diverticula in the region of the umbilical ring. The aponeurosis of the external oblique muscle of the abdomen has a mesh structure and consists of powerful longitudinal (continuing the direction of the muscle) and thinner transverse fibers. Between the bundles of longitudinal fibers, gaps are formed, which are unequally expressed in different people. The number and size of the gaps determine the strength of the aponeurosis of the external oblique muscle of the abdomen. There are three forms of the structure of the aponeurosis, which differ in strength. In one form, observed in 26,4% of cases, along the entire length of the aponeurosis, not only longitudinal, but also transverse fibrous fibers are well expressed, the gaps are narrow or absent. In another form (up to 41%), the transverse fibers are expressed only in some places, mainly in the medial areas and above the inguinal ligament. In 32,6% of cases, the structure of the aponeurosis is characterized by weak development of transverse fibers and the presence of numerous fissures. Individual differences in the structure of the aponeurosis are a predisposing factor to the formation of hernias and force the use of methods for strengthening the aponeurosis during surgical interventions for a hernia. In the epigastric region to the right and left of the corresponding rectus muscles, the edge of the aponeurosis of the internal oblique muscle of the abdomen does not reach the costal arch. It follows from the end of the IX rib to the outer edge of the sheath of the rectus muscle, where it is part of the walls of the sheath of the muscle one "diameter" of the finger below the xiphoid process. Thus, between the upper edge of the aponeurosis of the internal oblique muscle, the costal arch and the lateral edge of the rectus muscle, the right and left hypochondral triangles are formed. They are weak points of the abdominal wall, since their bottom is the aponeurosis of the transverse muscle, and on top they are covered by a tendon stretch (aponeurosis) of the external oblique muscle. The sizes of the hypochondrium (muscleless) triangles vary individually, and they also increase in the elderly and senile age. Along the line of transition of the fibers of the transverse muscle to the tendon stretch, relatively weak sections of the anterior abdominal wall are also located. This line has a crescent shape and is called the lunar (or Spigelian). In the upper abdomen, the aponeurosis of the transverse muscle goes behind the rectus muscle and, fusing with the posterior plate of the aponeurosis of the internal oblique muscle, participates in the formation of the posterior wall of the sheath of the rectus muscle. Below the navel, the aponeurosis passes to the anterior surface of the rectus muscle, fuses with the aponeurosis of the internal oblique muscle and participates in the formation of the anterior wall of the rectus sheath. The border of the transition of the muscular part of the transverse muscle to the aponeurosis is not the same in different people. At the edge of the costal arch, it is often located behind the rectus abdominis muscle, medially to the outer edge of the latter. The line of transition of the muscle into the aponeurosis usually emerges from the outer edge of the rectus muscle in the area between the xiphoid process and the umbilicus. Its lower end often goes to the medial half of the inguinal ligament. In persons with a wide upper abdomen, the semilunar line is removed from the midline in the upper two thirds of the abdomen and closer in its lower third. In persons who have a belly with a wider lower section, this line is relatively removed from the midline in the lower section and approaches it in the upper two thirds of the abdomen. Under unfavorable conditions, the Spigelian line can be a weak point, especially in the lower sections, where the abdominal wall is relatively weakly strengthened. Predisposing factors for the formation of hernias of the Spigelian line are gaps along the vessels and nerves. The most constant weak spot is located near the outer edge of the rectus abdominis muscle, 2-5 cm below the navel. The formation of hernias at this level is also facilitated by the fact that there is a redistribution of fibrous fibers of the aponeurosis of the transverse muscle, passing to the anterior wall of the sheath of the rectus muscle along the arcuate line of Douglas (linea arcuata). Of particular importance for the appearance of hernias are the canals of the abdominal wall, which are its weakest points. Characteristic of the channels of the abdominal wall is their constancy; the presence inside the canals of relatively large anatomical formations (the spermatic cord in the inguinal canal, the neurovascular bundle in the obturator canal); "through" defect of the abdominal wall. The most common site for hernia formation is the inguinal canal (groin hernias account for 63 to 90% of all abdominal hernias). In the inguinal canal, the superficial and inner rings and the inguinal gap, which is the actual canal in the abdominal wall, are distinguished. The external opening of the inguinal canal is formed by fibers of the aponeurosis of the external oblique muscle of the abdomen, which, approaching the pubic symphysis, split into two legs. One of them (medial) is attached to the upper edge of the pubic symphysis, the other (lateral) - to the pubic tubercle. At the upper lateral end of the oblique triangular fissure formed by the longitudinal fibers of the aponeurosis, there are clearly defined transverse and arcuate tendon fibers. They are called interpeduncular. Near the pubic symphysis, the medial and lateral crura join each other with a third crus that runs behind the spermatic cord. It is a continuation of the fibers of the aponeurosis of the external oblique muscle of the opposite side and is called lig. reflexum. The third leg of the superficial inguinal ring is not always well defined. The shape and size of the superficial inguinal ring depend on the location of all three legs and interpeduncular fibers. In most men and women, it has the shape of an irregular oval or gap, less often it is wide, approaching the shape of a circle. The width of the ring (horizontal diameter) for men ranges from 1 to 4,5 cm, for women - from 0,4 to 1,8 cm. The height of the ring (vertical diameter) varies in men from 0,6 to 3 cm, in women - from 0,4 to 1,8 cm. The size of the ring in men, as a rule, is larger, and after 34 years they tend to expand. The deep inguinal ring, or the internal opening of the inguinal canal, topographically corresponds to the lateral inguinal fossa and is located 1-1,5 cm above the middle of the inguinal ligament. It is a funnel-shaped opening in the intra-abdominal fascia through which the spermatic cord passes in men and the round ligament of the uterus in women. The spermatic cord and the round ligament do not perforate the fascia, but invaginate it; in men, the fascia covers both the spermatic cord and the testis, forming their common vaginal membrane. The dimensions of the deep inguinal ring in men reach 7,8 and 12 mm. In women, it is narrower, but higher than in men (6,2 and 13,2 mm). The shape of the ring in women is influenced by the function of the round ligament of the uterus, which, holding the uterus, stretches the deep inguinal ring. The size of the inner ring in men also increases with age. Of great importance in the pathogenesis of inguinal hernias are differences in the position of the lower edge of the internal oblique muscle relative to the deep inguinal ring. In 15-17% of cases, a high level of position of the edge of the internal oblique muscle is observed. In this case, the edge of the muscle does not reach the upper edge of the inguinal ring. At the same time, the deep inguinal ring is not covered by muscles, which creates anatomical prerequisites for the formation of a hernia. In 26% of cases, the lower edge of the internal oblique muscle of the abdomen partially, and in 57% completely, covers the deep inguinal ring, playing the role of a kind of "flap" that prevents the exit of the viscera. A significant role is assigned to the shape of the inguinal gap. The inguinal gap is the space between the medial part of the inguinal ligament and the lower edges of the internal oblique and transverse abdominal muscles. The shape of the inguinal gap depends on the direction of the lower fibers of the internal oblique and transverse abdominal muscles. If these fibers are arcuately bent over the spermatic cord or the round ligament of the uterus, then an inguinal gap of a slit-like (oval) shape is formed. With this form of the inguinal gap, during muscle contraction, the arc formed by them straightens, and the upper edge of the gap approaches the bottom, i.e. to the inguinal ligament. The inguinal gap narrows and the inguinal canal closes. Thus, the function of a "muscular damper" is carried out, preventing the passage of a hernia. In 32% of men and 14% of women, the lower fibers of the internal oblique muscle of the abdomen run horizontally and only the lower edge of the transverse muscle forms an arc above the spermatic cord or round ligament of the uterus. This shape of the inguinal gap is described as triangular. With this form, the "shutter" function is not fully realized. Finally, variants are observed in which both the internal oblique and transverse abdominis muscles are horizontally directed over the medial half of the inguinal ligament. At the same time, the "closing mechanism" of the inguinal gap is completely absent (it occurs in 5,2% of men). It is also known that in women the slit-like shape of the inguinal gap dominates, in men it often approaches the triangular one. Of great importance as an anatomical structure that resists the formation of hernias is the intra-abdominal fascia. In 33,1%, it is supported by muscle and tendon fibers that separate from the transverse abdominal muscle, especially in the lower sections of the abdominal wall, where it sometimes (with a high inguinal gap) forms the posterior wall of the inguinal canal. At this level, near the lateral edge of the rectus abdominis muscle, the transverse fascia is strengthened by a tendon-aponeurotic stretching of the internal oblique muscle of the abdomen and the transverse muscle, which is called the inguinal sickle, or ligament of Henle. With a transitional (oval-triangular) shape of the inguinal gap, the inguinal sickle is formed by the tendon of only the transverse muscle, it is thinner. The inguinal sickle fuses closely with the intra-abdominal fascia, which becomes thicker and stronger. The width of the inguinal sickle ranges from 0,5 to 3,5 cm. With a triangular shape of the inguinal gap, the inguinal sickle is weakly expressed, and sometimes absent. The clinical significance of the ligament of Henle lies in the fact that it limits the hernial ring on the medial side with a direct inguinal hernia and strengthens the medial part of the inguinal gap. The lateral part of the posterior wall of the inguinal canal is also strengthened by a bundle of arcuate tendon fibers that envelop the medial edge of the deep inguinal ring. These fibers are called the interfoveal ligament, or Hesselbach's ligament. This ligament is a bundle of fibrous fibers in the thickness of the intra-abdominal fascia, rising up between the internal and external inguinal fossae. In shape, the ligament resembles a triangle, the upper part of which merges with the edge of the sheath of the rectus abdominis muscle, and the lateral part merges with the roller of the inner ring of the inguinal canal and the inguinal ligament. With the destruction or pronounced thinning of the Hesselbach's ligament, a message is formed between the lateral or medial inguinal fossae. Thus, the posterior wall of the inguinal canal is destroyed, which leads to the formation of an oblique inguinal hernia with a straightened inguinal canal. Another practically significant formation (compaction) of the intra-abdominal fascia is the so-called iliopubic tract, or Thomson's ligament. The iliopubic tract is a dense cord located behind, parallel to, and somewhat below the inguinal ligament. The strength of Thomson's ligament, its constant severity and position behind the inguinal ligament allows it to be used as one of the main supporting structures in radical operations for inguinal hernias. In addition, it is important to emphasize that it forms the lower border of the hernial orifice in inguinal hernia. The ligament is expressed in 90,12% of cases and has a multilayer fascial membrane. Only in 9,1% of Thomson's ligament is indistinct, but in these cases, its location corresponds to some thickening of the intra-abdominal fascia. In close proximity to the inguinal canal is the internal opening of the femoral canal. It is limited: in front by the inguinal ligament, behind by the pubic bone, laterally by fascial fibrous fibers connecting the medial end of the inguinal ligament with the periosteum of the pubic bone near the pubic tubercle. These fibers form a small but dense triangular plate known as the lacunar ligament. Between the listed formations, limiting the inner femoral ring, there is a large lymph node (Rosenmuller-Pirogov node) with incoming and outgoing lymphatic vessels. When a hernia is formed, the node is "pushed" out of its bed and the hernial sac comes out on the anterior surface of the thigh between the sheets of the fascia lata, which become the walls of the femoral canal. The outer femoral ring is an oval opening in the superficial sheet of the fascia lata, bounded by the crescent-shaped edge of the latter. The "weak point" that determines the possibility of the formation of femoral hernias is the internal opening of the canal, located under the pupart ligament on the border between the anterior abdominal wall and the pelvic cavity. From the side of the abdominal cavity, the inner femoral ring is covered only by a sheet of intra-abdominal fascia and the parietal peritoneum, on which there is a small depression - the femoral fossa (fossa femoralis). The dimensions of the inner femoral ring vary individually. In addition, in women, the opening is wider and its position is closer to the horizontal plane due to the anatomical differences between the male and female pelvis. This is one of the reasons why femoral hernias are more common in women than in men. Preperitoneal tissue separates the intra-abdominal fascia from the parietal peritoneum. It is unequally expressed in different areas of the abdominal wall and changes with age. In children, preperitoneal fiber is poorly expressed, it reaches its greatest development by the age of 40-60, especially in women, and gradually becomes thinner in old age. In adults, the smallest layer of preperitoneal fiber on the anterior abdominal wall is observed behind the white line and rectus muscles above the navel. Below the navel, there is more preperitoneal fiber, it is looser, and reaches its greatest development in the suprapubic and iliac regions. Outwardly and backwards, the preperitoneal tissue continues into the retroperitoneal. Loose and mobile preperitoneal tissue sometimes penetrates into the fascial fissures and openings of the anterior wall of the abdomen, forming preperitoneal wen (lipomas), which contribute to the gradual expansion of the openings, becoming a predisposing factor in the development of hernias. Predispose to the formation of hernias are also observed in various places depressions and pits on the parietal peritoneum. On the inner surface of the lower part of the anterior-lateral abdominal wall above the inguinal ligament, the parietal peritoneum forms several pits and folds. In the midline of the abdomen, from the top of the bladder to the navel, a cord stretches, which is the remnant of an obliterated urinary duct. The elevation of the peritoneum above it in the form of a fold is called the median umbilical fold. Somewhat lateral to the median fold and the lateral surfaces of the bladder, two paired medial umbilical folds of the peritoneum also extend to the navel, corresponding to the course of the obliterated umbilical arteries. Even more lateral, also on both sides, the peritoneum above the lower epigastric arteries passing under it forms lateral umbilical folds. Between the folds of the peritoneum, paired depressions, or fossae, are formed: between the median and medial - supravesical fossa; between the medial and lateral folds - the medial inguinal fossa; outward from the lateral fold is the lateral inguinal fossa. The lateral inguinal fossa is of the greatest practical importance, since its position corresponds to the deep inguinal ring. The medial fossa corresponds to the center of the inguinal gap, and its projection coincides with the projection of the external opening of the inguinal canal. Below the medial end of the inguinal ligament, above the horizontal branch of the pubic bone, the peritoneum also forms a depression corresponding to the position of the internal opening of the femoral canal. It is also necessary to note the diverticula of the parietal peritoneum in the region of the umbilical ring. The pits and diverticula of the peritoneum, the position of which in most cases coincides with the localization (projection) of the weak points of the abdominal wall, under certain conditions, apparently, become "points of application of forces", contributing to hernia formation. In this regard, when operating on a patient for a hernia, they try not only to strengthen the hernial orifice, but also to eliminate the funnel-shaped depression on the peritoneum. 2. Operation for hernia Surgery for abdominal hernia should be as simple as possible and least traumatic, however, it is necessary to ensure the radical treatment, which requires an individual approach for each patient (rather than a template, as is often done). The key to the success of the operation is its impeccable technical performance, maximum asepsis and careful hemostasis. Operations for a hernia of the anterior abdominal wall are conditionally divided into three stages: access to the hernial orifice and hernial sac; processing and removal of the hernial sac; elimination of the defect of the abdominal wall (closure of the hernial ring). The following requirements are imposed on accesses for radical operations for a hernia: simplicity, safety; the possibility of a wide view of the hernial canal or hernial opening. In addition to direct accesses, in which tissues are cut in layers directly in the area of the hernial orifice, roundabout accesses are also used in surgical practice. Treatment and removal of the hernial sac constitute the second stage of the operation. This stage consists of several successive steps. First of all, the parietal peritoneum, which makes up the hernial sac, is carefully isolated from the surrounding tissues. This is achieved using the so-called "hydraulic preparation" method, i.e., introducing a 0,25% solution of novocaine around the wall of the hernial sac to facilitate the separation of the parietal peritoneum from adjacent tissues. With incomplete removal of the neck of the hernial sac, a pocket of the parietal peritoneum remains, which contributes to the recurrence of the hernia. To prevent this, the neck of the hernial sac is isolated to the hernial orifice. Next, an audit of the contents of the hernial sac is carried out in order to identify pathological changes in the hernial contents, dissection of adhesions (resection of necrotic parts of organs with strangulated hernias, etc.). After the revision, the neck of the hernial sac is sutured and bandaged to seal the abdominal cavity, followed by cutting off the sac over the ligatures. After cutting off the hernial sac, the preperitoneal tissue is removed from the hernial orifice. Then proceed to the final stage of the operation - the closure (plasty) of the hernial ring. There are many hundreds of ways to close or strengthen the hernial orifice. It is reasonable to divide them into three groups: 1) simple; 2) reconstructive; 3) plastic. Simple ways to strengthen the hernia orifice include such surgical techniques that involve closing an existing abdominal wall defect with sutures. They can be used only for relatively small hernias, their superficial location, simple structure of the hernia ring, good tissue elasticity. An example is the Lexer method used for umbilical hernias, which consists in imposing a purse-string suture around the expanded umbilical ring. For small inguinal hernias in children, a simple Roux method is used, which consists in applying several interrupted (or U-shaped) sutures to the aponeurosis of the external oblique muscle, narrowing the expanded external inguinal ring. The inguinal canal is not opened. All of them refer to tension methods for closing the hernia orifice, they are not radical and have limited application. Reconstructive methods are aimed at changing the design of the hernial orifice in order to strengthen them. Reconstruction can be performed either using fascia and aponeurosis (fascial-aponeurotic methods, duplication) or using both muscles and aponeuroses (muscle-aponeurotic methods). The duplication of the aponeurosis of the external oblique muscle of the abdomen is used to strengthen the anterior wall of the inguinal canal according to Martynov. According to this technique, duplication is created by suturing the upper edge of the aponeurosis of the external oblique muscle of the abdomen dissected along the inguinal canal to the inguinal ligament and then applying the lower edge of the aponeurosis of the same muscle to it. When using the aponeurosis of the external oblique muscle of the abdomen, one must keep in mind the presence of the anterior and posterior plates of the own fascia, covering its corresponding surfaces. Fastening the fibers of the aponeurosis to each other, the fascial plates play a strengthening role. After their removal, the elasticity and strength of the aponeurosis of the external oblique abdominal muscle are significantly reduced. Therefore, when releasing the aponeurosis of the external oblique muscle of the abdomen in a blunt way from the loose fiber covering it during hernia repair, care is required so that when removing the fiber, these fascial plates are not destroyed. Another example of a fascial-aponeurotic reconstructive method is the Mayo and Sapezhko methods used to strengthen the umbilical ring. With the Mayo method, the umbilical ring is cut with two transverse incisions over the entire width of the white line, opening the sheath of the rectus muscle until its inner edge appears. Then U-shaped sutures are applied so that the lower edge of the incision lies under the upper one. With the second row of interrupted sutures, the upper aponeurotic edge is attached to the lower one. A relative disadvantage of this method is the expansion of the white line of the abdomen and the deformation of the rectus muscles. Sapezhko's method is deprived of these shortcomings, according to which the hernial orifice is cut several centimeters up and down. After that, sutures are applied, capturing the edge of the aponeurosis on one side and the posterior wall of the rectus sheath on the other, to create a duplication in the longitudinal direction. The second suture connects the remaining free edge of the incision of the white line with the anterior wall of the sheath of the opposite rectus muscle. Another method of reconstruction, used more often, is the strengthening of the hernial ring with muscular aponeurotic tissues. In this case, either the anterior or posterior wall of the inguinal canal is strengthened. Methods for strengthening the posterior wall of the inguinal canal include the Bassini method, in which, after opening the inguinal canal and excising the hernial sac behind the spermatic cord, sutures are placed between the edge of the rectus abdominis muscle with its sheath and the periosteum of the pubic tubercle, and then the internal oblique and transverse muscles are sutured with intra-abdominal fascia to the inguinal ligament. This eliminates the inguinal gap. Also, the methods of strengthening the posterior wall of the inguinal canal include the Kukudzhanov method, during which the deep inguinal ring is narrowed. To do this, according to the Ioffe method, clamps are applied to the upper and lower edges of the medial part of the deep inguinal opening, under which, using an atraumatic needle with a thin synthetic thread, the hole is sutured with a twisting suture to the required diameter. With the last stitches, the sheath of the spermatic cord is also stitched. This suture technique prevents damage to the inferior epigastric artery, which runs 0,5 cm medial to the inner edge of the deep inguinal opening. Then stitches are placed between the sheath of the rectus abdominis muscle and the pubic ligament of Cooper. The closure of the hernial orifice is completed by suturing that connects the inguinal falx and the upper edge of the dissected intraperitoneal fascia with the inguinal ligament. Another way to strengthen the posterior wall of the inguinal canal is the McVay method. When it is performed, the intra-abdominal fascia, together with the combined tendon of the internal oblique and transverse muscles, is sutured to the Cooper (pubic) ligament. When strengthening the posterior wall of the inguinal canal in any way, it is necessary to restore and strengthen the intra-abdominal fascia and narrow the inner ring of the canal. Methods for strengthening the anterior wall of the inguinal canal are usually used for oblique inguinal hernias. According to Bobrov's method, the free edges of the internal oblique and transverse muscles are sutured to the inguinal ligament anterior to the spermatic cord or round ligament of the uterus. Then the edges of the aponeurosis of the external oblique muscle dissected during access are connected. According to the Bobrov-Girard method, the internal oblique and transverse muscles are sutured to the inguinal ligament throughout the inguinal canal anterior to the spermatic cord. Then a second row of sutures is placed between the upper edge of the dissected aponeurosis of the external oblique muscle of the abdomen and the inguinal ligament. After that, the lower edge of the aponeurosis is placed over the sutured to the inguinal ligament, forming a duplication. The disadvantage of this method is the multi-row stitches on the inguinal ligament. In the Bobrov-Girard-Spasokukotsky method, to strengthen the anterior wall of the canal, the edges of the internal oblique and transverse muscles are sutured to the inguinal ligament of muscles along with the aponeurosis of the external oblique muscle adjacent to them. After that, a duplication is formed from the aponeurosis of the external oblique muscle, as in the Girard method. Muscular-aponeurotic strengthening of the anterior or posterior wall of the inguinal canal in most cases ensures the radicalness of the surgical intervention, closing the inguinal gap. The disadvantage of these methods of reconstruction is the relative fragility of the postoperative scar due to the connection of dissimilar tissues. Kimbarovsky's seam is used to connect the fabrics of the same name with one thread. The most effective of reconstructive plasty methods is a combination of creating duplications, using muscles and aponeuroses. One of these methods is multilayer hernioplasty (Sholdis method). To this end, in order to strengthen the posterior wall of the inguinal canal, the lateral edge of the intra-abdominal fascia is sutured to the medial, behind the sheath of the rectus muscle, with the first continuous suture (in the original with a thin steel wire). This suture is tied at the pubic tubercle and the long end of the thread is continued in the lateral direction. At the same time, the lateral edge of the intra-abdominal fascia is connected to the inner ring with the posterior (facing into the abdominal cavity) surface of the medial edge. Then the suture is turned in the opposite direction and the medial edge of the intra-abdominal fascia is sutured to the inguinal ligament up to the pubic tubercle, forming a duplication. The second continuous suture starts from the inner ring, connecting the internal oblique muscle and the inguinal sickle with the posterior surface of the aponeurosis of the external oblique muscle immediately above the inguinal ligament. This suture is continued to the pubic tubercle, then the next row of sutures is applied with the same thread again, connecting the internal oblique muscle with the aponeurosis of the external oblique, slightly retreating from the previous row, in the direction from the pubic tubercle to the internal opening of the canal. The spermatic cord is laid on the internal oblique muscle and the edges of the aponeurosis of the external oblique muscle of the abdomen are sutured over it or another duplication is formed from the leaves of the aponeurosis. The operation is completed by suturing the skin. Another method of multilayer hernioplasty is the Postemsky method. This method involves the complete elimination of the inguinal gap and the creation of an inguinal canal with a completely new direction. In this case, the spermatic cord is displaced in the lateral direction and the inner ring of the canal is sutured from the medial side. To displace the spermatic cord, the oblique and transverse muscles are sometimes cut. After that, the cord is moved into the resulting incision in the upper lateral direction. The muscles under the cord are sutured so that they tightly, but without compression, cover the spermatic cord. Then, from the medial side, the tendon of the internal oblique and transverse muscles (inguinal sickle) is sutured to the superior pubic ligament (Cooper's ligament), which is located on the upper surface of the symphysis and is stretched between both pubic tubercles. Next, the intra-abdominal fascia, oblique and transverse muscles, as well as the upper edge of the aponeurosis of the external oblique abdominal muscle, are sutured in layers to the iliopubic tract and inguinal ligament using U-shaped sutures. The lower flap of the aponeurosis of the external oblique muscle is fixed to the upper flap in the form of a duplicate. The third group of methods for closing the hernial orifice includes plastic methods. As a plastic material, aponeurotic or muscle flaps on a pedicle from nearby areas, autodermal grafts, preserved allografts from the dura mater, and synthetic materials are used. Synthetic materials for closing hernial gates (lavsan, fluorolone, etc.) are widely used. Synthetic meshes retain their strength for a long time, rarely cause rejection reactions, and grow well with connective tissue during implantation. It is believed that with hernias of the anterior abdominal wall, it is more advantageous to place the explant under the muscles, sewing it in the form of a patch to the hernial orifice from behind. In this case, the synthetic mesh replaces the area of the intra-abdominal fascia, which is usually thinned here and does not have mechanical strength. Currently, new synthetic plastic materials are constantly being developed, many manufacturers produce ready-made meshes for typical operations, a significant proportion of hernia repair (especially in foreign clinics) is performed using laparoscopic techniques. However, for all the severity of the issue, the problem of relapse is far from a final solution. LECTURE #9 Operational access to the abdominal organs. Operations on the abdominal organs Given that surgical interventions on the abdominal organs dominate in surgical practice, it is necessary to consider the clinical anatomy of the abdomen and the technique of surgical interventions in this area. 1. Clinical anatomy of the abdomen The boundaries of the abdomen are considered to be at the top - the costal arches and the xiphoid process, below - the inguinal folds, pubic tubercles and the upper edge of the pubic symphysis. But these formations limit only the anterior wall of the abdomen. The boundary between the cavities of the abdomen and small pelvis is conditional and corresponds to a plane drawn through the boundary line. Since there is no anatomical barrier between the abdominal cavity and the pelvic cavity, fluids formed during pathological processes in the abdominal cavity (pus, effusion, intestinal contents), as well as blood from damaged parenchymal organs and blood vessels, often drain into the small pelvis, which leads to secondary inflammation of the lining his peritoneum and organs. According to Shevkunenko, two extreme forms of the abdomen are distinguished in the form of a pear with a different orientation of the base: with the base turned upward; with the base facing down. The first form of the abdomen corresponds to a wide lower aperture of the chest, and the distance between the lower points of the X ribs at the level of the midaxillary line exceeds the distance between the anterior superior iliac spines. The second form is combined with a wide entrance to the pelvis. In this case, the distance between the lower points of the X ribs is less than the distance between the upper anterior iliac spines. The shape of the abdomen with a wide lower thoracic aperture and a narrow pelvis is more often observed in people with a brachymorphic physique, the second (narrow thoracic aperture, wide pelvis) - in individuals with a dolichomorphic constitution. For people with a brachymorphic physique, the high standing of the diaphragm is also characteristic and, in accordance with this, the high position of the liver, transverse colon, cecum, attachment of the root of the mesentery of the small intestine is oriented almost horizontally, and the loops of the small intestine take a position close to transverse. In people with a dolichomorphic physique, on the contrary, there is a relatively low standing of the diaphragm. At the same time, the abdominal organs are located relatively low: there is a relatively low position of the greater curvature of the stomach and a high position of the cardia. The transverse colon sags downward. The liver often protrudes from under the costal arch, the caecum descends into the cavity of the small pelvis. The line of attachment of the root of the mesentery approaches the vertical direction, the loops of the small intestine take a position close to the longitudinal one. In the position of the internal organs, not only individual, but also age-related variability is observed. In children of the first years of life, the abdomen is relatively larger in the upper sections, the abdominal wall is protruded in the epigastrium due to the fact that the relative volume of the organs of the upper floor of the abdominal cavity, especially the liver, is much larger in them, and the lower floor is smaller compared to adults . In elderly and multiparous women, the stomach in a vertical position is usually protruded in the lower sections, and in the prone position - in the lateral ones, which is associated with a decrease in the tone of the abdominal press and the phenomenon of general visceroptosis. The shape of the abdomen can change significantly during pathological processes: accumulation of fluid, swelling of intestinal loops with intestinal obstruction, tumors, hernias, etc. When studying the abdomen, you need to know the following concepts. The walls of the abdomen are muscular-fascial layers that surround the internal organs on all sides. The abdominal cavity is the space lined by the intra-abdominal fascia. The abdominal cavity is a space lined with a parietal sheet of the peritoneum, which, in the form of a bag, surrounds the organs lying inside it. The peritoneal cavity is a slit-like space between the parietal and visceral sheets of the peritoneum, containing a small amount of serous fluid. Preperitoneal space - a layer of fatty tissue between the parietal peritoneum and the intra-abdominal fascia lining the anterior abdominal wall. Retroperitoneal space - between the parietal peritoneum and the intra-abdominal fascia lining the back wall of the abdomen; it contains organs and large vessels (kidneys, pancreas, aorta, inferior vena cava, etc.). Considering the walls of the abdomen, one can conditionally distinguish between the anterolateral wall, bounded from above by the costal arches, from below by the inguinal folds, from the sides by a continuation of the middle axillary lines, and the posterolateral wall, bounded from above by the XII rib, from below by the iliac crest, from the sides by a continuation of the middle axillary line. The anterolateral wall is the area through which most accesses to the abdominal organs are carried out; the state of this wall (pain, muscle tension, skin temperature, etc.) is influenced by functional and pathological changes in the internal organs. The back wall of the abdomen is formed mainly by the muscles that are located along the spine. Anatomically, it is referred to the lumbar region, through which access to the organs of the retroperitoneal space is carried out. For convenience, when examining a patient, it is customary to divide the anterolateral wall of the abdomen into areas using conditional lines. Two of them are carried out horizontally - through the lower edges of the costal arches and the anterior superior iliac spines. As a result, three sections are distinguished - epigastric, celiac, hypogastric. Then draw vertical lines along the outer edges of the rectus abdominis muscles. As a result, each of the departments is divided into three areas: 1) epigastrium - on the epigastric and hypochondrium regions (right and left); 2) the stomach - on the umbilical and lateral regions (right and left); 3) hypogastrium - on the pubic and inguinal regions (right and left). In each of the selected areas of the anterolateral wall of the abdomen, the corresponding organs of the abdomen or their departments are projected, but it is necessary to make adjustments taking into account the peculiarities of the constitution (body shape), age and gender differences, the functional state of the organs (filling or emptying, spasm or paresis, etc.). ), body position during the examination. 2. Access to the abdominal organs To date, many options for access to the abdominal organs have been developed. General requirements for access for operations on the abdominal organs. The first requirement is a good view of the abdominal organ that is the object of the operation, which is ensured by opening the abdominal wall in accordance with the projection of the organ. The location of the incision determines the shortest path to the exposed organ. The distance from the skin surface to the object of the operation, i.e. the depth of the surgical wound, determines the greater or lesser freedom of movement and the performance of the necessary manipulations. In addition, a good overview of the desired organ is provided by a sufficient size of the incision (width of access). The length of the abdominal wall incision should be as long as necessary and as short as possible. The incision should ensure the accessibility of any department of the organ and the feasibility of prompt reception. The second requirement for access is low trauma. This implies minimal damage to the musculoaponeurotic layers of the abdominal wall during access to the abdominal organs, preservation, if possible, of the neurovascular bundles, careful handling of tissues, etc. The third requirement for the incision of the anterolateral wall of the abdomen is the simplicity and speed of the incision. The fewer layers of the abdominal wall that have to be dissected, the easier and faster the incision can be made. The fulfillment of this requirement is facilitated by the absence of large vessels in the incision area, the damage of which leads to bleeding. The fourth requirement is the possibility (if necessary) of extending the incision in the right direction (expansion of access). This may be due to the atypical position of the organ, the detection of tumor growth beyond the "accessibility zone" during the operation, and the detection of pathological changes in neighboring organs. The fifth requirement for access is the possibility of reliable closure and good healing of the edges of the surgical wound. As a rule, the abdominal wall is sutured in layers after the operation. The smaller the number of stitched layers, the faster this stage of the operation can be performed, but the strength of the scar may be insufficient, especially in the low-vascular zone. When choosing an access, it is necessary to establish in which section of the abdominal wall it is advisable to make an incision. To expose the abdominal organs, accesses through the anterolateral abdominal wall are most often used. Through this area, you can approach almost all organs of the abdominal cavity in the shortest way. In addition, a large area of the anterior-lateral wall of the abdomen allows for wide accesses and provides the possibility of extending the incisions in the required direction. Lateral accesses to the abdominal organs from the sides are used less frequently. They are unsuitable because they violate the integrity of the broad abdominal muscles. In addition, these accesses allow you to operate on the organs of only the corresponding side - right or left. They are used in operations on individual organs (spleen, liver, right and left flanks of the large intestine). Very rarely, the abdominal organs are exposed from behind - through the lumbar region. This zone is small in size, limited by bone formations - the iliac crest, XII ribs and the spine, which does not allow large incisions. The soft tissues of this department have a significant thickness, when accessing the abdominal organs, it is necessary to open the retroperitoneal cellular spaces, etc. Accesses through the lumbar region are used mainly for operations on the pancreas and duodenum, kidneys, i.e., on organs, partially or completely located in the retroperitoneal space. All accesses to the abdominal organs through the anterior abdominal wall can be divided into two groups: 1) general (universal) accesses, allowing to expose almost all organs of the abdomen; 2) special accesses for operations on one organ or on a group of closely spaced organs. In the direction of the cut, accesses of both one and the other group are divided into four types: longitudinal, transverse, oblique, angular (combined). A typical representative of the general longitudinal accesses is the median laparotomy. Depending on the length and location of the incision, the following types of median laparotomy can be distinguished: upper median (above the navel); lower median (below the navel); total median (from the xiphoid process to the pubic symphysis). The most complete overview of the organs is achieved with a median total laparotomy. With the upper and lower laparotomy, more limited access is provided, respectively, to the organs of the upper and lower floors of the abdominal cavity. Median laparotomy has the following advantages: it allows a good view of most of the abdominal organs; when dissecting tissue does not damage the muscles; when performing a median laparotomy, it keeps large vessels and nerves intact; access is technically simple - almost three layers are dissected: 1) skin with subcutaneous tissue; 2) the white line of the abdomen with the superficial fascia adjacent to it; 3) parietal peritoneum. If necessary, the upper median laparotomy can be extended downwards, the lower median laparotomy can be extended upwards. That is, special access can be transformed into general access. A total midline laparotomy can be supplemented with a transverse incision or an angled lateral incision (such an approach is called an angled approach). The disadvantages of median laparotomy include a relatively slow fusion of the edges of the wound due to poor blood supply to the aponeuroses of the broad abdominal muscles along the white line. In the postoperative period, the suture line experiences a strong load due to the traction of the wound edges in the transverse direction. In some cases, this can lead to the formation of an inferior scar and postoperative hernias. Wide access to the organs of the abdominal cavity can be provided by performing transverse incisions. A transverse incision of the abdominal wall, carried out 3-4 cm above the navel from one mid-axillary line to the other, allows you to examine most of the abdominal organs. In this case, the organs lying at the side walls of the abdomen (the ascending and descending parts of the colon) are especially accessible. It is somewhat more difficult to operate in the upper and lower sections (subdiaphragmatic space, pelvic organs). However, if necessary, the transverse incision can be supplemented by dissection of the white line of the abdomen. If there is no need for a complete revision of the organs, the transverse laparotomy may be more limited both in the length of the incision and in the level of its execution (upper transverse or lower transverse laparotomy). In transverse incisions, the latissimus abdominis muscles are dissected (dissected), and one or both rectus abdominis muscles are transected (Czerny's approach). With some methods of transverse laparotomy, the rectus muscles can move apart (Pfannenstiel's suprapubic approach). Advantages of transverse approaches: preservation of the integrity of the intercostal neurovascular bundles, since the incisions are made parallel to their course; accesses can easily be extended to the lateral side almost to the midaxillary line; the edges of the wound grow together well, since the pull of the muscles perpendicular to the length of the wound is relatively small. Disadvantages of transverse accesses: 1) relative limited visibility - access allows you to well examine the organs of only one floor (upper or lower); 2) labor intensity during dissection and subsequent restoration of the rectus abdominis muscles. Special Access 1. Longitudinal incisions through the sheath of the rectus muscle. Paramedian cut. This incision is carried out over the medial edge of the rectus abdominis muscle, while dissecting the anterior leaf of her vagina in the same direction. The advantage of this incision is the formation of a strong postoperative scar due to the "rocker" displacement of the rectus abdominis muscle and the mismatch of the projections of the incisions of the anterior and posterior layers of her vagina. Transrectal incision (access through the thickness of the rectus abdominis). The incision is made parallel to the outer edge of the rectus abdominis muscle. The anterior wall of the vagina of the muscle is dissected, its edge is retracted medially, and then the posterior wall of the vagina and the parietal peritoneum are dissected. The incision can only be made over a limited extent. When trying to expand the access, the intercostal nerves that approach the muscle from the lateral side are damaged. 2. Oblique cuts. The subcostal oblique incision is widely used to perform operations on the biliary tract and spleen. The incision is made from the xiphoid process down and outward with a bend parallel to the costal arch, departing from it by 2-3 cm. Oblique incisions can also be made in other parts of the abdominal wall, Volkovich-Dyakonov-McBurney oblique access. Angular (combined) incisions of the abdominal wall are used if access is needed to be expanded, sometimes, by "combining" a longitudinal incision with an oblique one, a massive flap is formed, which allows opening a wide view of the corresponding area. Minimally invasive methods of operations performed with the help of endovideosurgical equipment are widely used in modern surgery, which ensures minimal invasiveness and good cosmetic results. Surgical interventions performed in abdominal surgery, according to the urgency of execution, can be divided into emergency and planned. Emergency interventions can be performed for diseases, postoperative complications or trauma to the abdominal organs. 3. Closed injuries and wounds of the abdomen Closed injuries and wounds of the abdomen have always been a complex surgical problem. In case of damage to the abdominal organs, accurate and rapid diagnosis, well-thought-out surgical tactics, and adequate therapy are required. In the structure of traumatism in peacetime, closed abdominal injuries account for 2-4% of all types of injuries, while mortality ranges from 10-57,5%. The modern period is characterized by a tendency both to a general increase in the number of injuries to the abdomen, and to an increase in the relative number of gunshot wounds. All injuries of the abdominal cavity are divided into open and closed, penetrating and non-penetrating. Non-penetrating wounds of the abdomen should be considered damage to the walls (often anterolateral and posterior) without damage to the peritoneum. Penetrating wounds of the abdomen are wounds accompanied by damage to the peritoneum. Closed lesions present significant diagnostic difficulties. The basis of the clinical picture is the manifestations of shock, internal bleeding (with ruptures of the liver, spleen, pancreas, mesentery of the intestine, liver) and peritonitis (when opening the lumen of a hollow organ). Abdominal punctures, laparocentesis using a "groping catheter" and emergency laparoscopy are effective methods for recognizing internal organ injuries in blunt abdominal trauma. Abdominal puncture reveals effusion, blood. First performed by Mikulich in 1880 in a patient with a suspected perforated ulcer. Exudate during puncture is detected if its amount exceeds 300-500 ml. A typical place to perform a puncture of the abdomen is the middle of the distance between the navel and the upper edge of the pubic symphysis. If there is a suspicion of accumulation of blood in the small pelvis, a diagnostic puncture of the posterior fornix of the vagina in women or the anterior wall of the rectum in men is possible. The topographic and anatomical prerequisite for performing these manipulations is the position of the peritoneal sheet, which passes from the anterior abdominal wall to the upper and posterolateral walls of the bladder, and then (in men) covers the anterior wall of the rectum, a depression is formed, called excavatio rectovesicalis. In women, the peritoneum, passing from the bladder to the anterior surface of the uterus, forms excavatio vesicouterina, and behind the uterus - excavatio rectouterina (Douglas space). In the lower, deepest part of this space, the peritoneum that forms it is in contact with the posterior fornix of the vagina, which makes it possible to perform a diagnostic puncture to detect pathological fluids in the Douglas space. Technique: after processing the surgical field, the skin and deep layers of the abdominal wall are anesthetized with a 0,5% novocaine solution. The skin at the puncture site is incised with the tip of a scalpel. The puncture is made with a trocar, perpendicular to the surface of the abdomen. The possibilities of diagnostic puncture are limited by the detection of pathological contents in the abdominal cavity and the determination of its nature (blood, gas, intestinal contents, exudate), and only with a large amount of it. Laparocentesis has wider diagnostic possibilities. It is performed in places of the most pronounced soreness and muscle protection, as well as dullness of percussion sound. The classic location for laparocentesis is 2-3 cm below the navel in the midline. Under local anesthesia, a skin incision 1-2 cm long is made and the aponeurosis is exposed, on which two silk handles are applied. The last to pull the abdominal wall forward. The abdominal wall is pierced between the holders with a trocar, and the stylet is removed. Through the trocar, a catheter is inserted into one or another part of the abdominal cavity - the right subdiaphragmatic space, the right side canal, the left subdiaphragmatic space, the left side canal, the right and left mesenteric sinuses, the small pelvis ("rumbling catheter"). As the catheter moves, the contents are aspirated. To increase the diagnostic value, an aseptic solution (200-400 ml) can be introduced into the abdominal cavity, followed by aspiration. The use of diagnostic laparocentesis allows you to confidently diagnose damage to internal organs with a closed abdominal injury and decide on the need for urgent surgery. In the mid-1960s, in addition to laparocentesis, laparoscopy was firmly established in emergency surgery. It is indicated not only for closed abdominal trauma, but also for an unclear clinical picture of an "acute abdomen", as well as for penetrating wounds in order to determine the localization and nature of organ damage. The introduction of the laparoscope is preceded by the imposition of pneumoperitoneum. Veress needle puncture is performed, as a rule, 2-3 cm below the navel in the midline. Control of the entry of the needle into the abdominal cavity - the free flow of novocaine through the needle from the syringe without piston pressure. After performing gas insufflation, the laparoscope is inserted. The place of introduction of the trocar intended for the laparoscope is selected taking into account clinical manifestations so as to provide the optimal angle of bringing the laparoscope to the alleged site of damage and ease of viewing. Under appropriate conditions, laparoscopy is performed using video endosurgical equipment. When establishing the diagnosis of damage to internal organs and ongoing profuse bleeding with a closed abdominal injury, an urgent operation is indicated. Surgical intervention begins with an incision in the anterior abdominal wall and opening the abdominal cavity (laparotomy). The exact definition of laparotomy is the opening of the abdominal cavity for diagnostic or therapeutic purposes. The incision should provide an opportunity to examine all parts of the abdominal cavity and good access to damaged organs. As a rule, a median incision is used above or below the umbilicus (upper or lower midline laparotomy). This incision provides the best access to the abdominal organs. It is simple to perform, provides rapid penetration into the abdominal cavity. At the end of the operation, suturing the wound is quite simple. Thus, one of the basic rules of emergency abdominal surgery is observed: rapid entry into the abdominal cavity and rapid exit from it. In addition, it is very important to be able to easily expand the incision up or down, and, if necessary, to the right or left by the transverse intersection of the rectus muscles. The purpose of further actions of the operating surgeon is to establish the localization and nature of pathological changes, as well as to determine their severity. Inspection of organs is called revision. The primary task is the early detection of the source of bleeding and reliable hemostasis. When examining the abdominal cavity, the peculiarities of the location of the mesentery, ligaments, and relatively fixed organs, the topography of which is relatively constant and changes little in pathological conditions, can serve as natural landmarks. Such a landmark should be considered, first of all, the mesentery of the transverse colon, which divides the abdominal cavity into the upper and lower floors. In the first of them on the right is the liver, in the epigastric region - the stomach, and in the left hypochondrium - the spleen. Above the right lobe of the liver, between it and the dome of the diaphragm, there is the right subphrenic space (bursa hepatica), which opens into the right lateral canal of the lower floor of the abdominal cavity downward and to the right. The left subdiaphragmatic space is located above the upper edge of the spleen and fundus of the stomach. Below the spleen, a relatively wide ligament is stretched - ligamentum phrenicocolicum, closing the blind sac of the spleen (saccus coecus lienis) and delimiting the left half of the upper floor of the abdominal cavity from the left lateral canal located on the lower floor. In front of the stomach, between its anterior surface and the parietal peritoneum of the anterior abdominal wall, is the pregastric bag (bursa praegastrica). In case of injuries or perforation of the anterior wall of the stomach, the contents of the latter can drain along the anterior surface of the greater omentum (preomental gap) and accumulate in the peritoneal pockets of the small pelvis (spatium rectovesicale in men, Douglas space in women), and pathological contents may not be detected in the lower floor of the abdominal cavity . This circumstance makes a special examination of the pelvic pockets especially necessary (the introduction of electric suction tips, control gauze swabs). To understand the features of the topography of the organs and the techniques used by the surgeon during the revision, it is necessary to mention the existence of the so-called stuffing bag (bursa omentalis) behind the stomach, limited by the peritoneum sheets. The latter is limited in front by ligaments forming a small omentum (lig. hepatoga-stricum, hepatoduodenale, phrenicogastricum), the posterior wall of the stomach and the gastrocolic ligament (lig. gastrocolic). The lower wall of the stuffing bag is the mesocolon transversum. From above, the bag is bounded by the peritoneum lining the lower surface of the diaphragm, from behind - by the parietal peritoneum covering the pancreas. The bag, therefore, is closed on all sides and communicates with other parts of the abdominal cavity only through a relatively small omental opening (foramen epipioiicum Winslowi). The latter is located behind lig. hepatoduodenal. Its upper border is the caudate lobe of the liver, the back is the peritoneum, passing from the lower surface of the liver to the right kidney (lig. hepatorenale), lower lig. duodenorenale. The lower floor of the abdominal cavity contains loops of the small intestine, surrounded on the sides and top by various sections of the large intestine (on the right - caecum, colon ascendens; on top - colon transvesum with its mesentery; on the left - colon descendens, turning into colon sygmoideum). Lateral to the ascending and descending colons are the right and left lateral canals of the abdominal cavity. The space located medially from the colon ascendens and colon descendens is divided by the root of the mesentery of the small intestine into two mesenteric sinuses, the right of which is relatively closed due to the horizontal position of the mesentery ileum terminate, and the left one opens into the small pelvis along the mesentery of the sigmoid colon. The blood found in the abdominal cavity is removed using an electric suction or large gauze napkins. At the same time, when aspirating liquid blood and removing clots, it should be borne in mind that the main places for fluid accumulation are the right lateral canal, where blood enters, first of all, with liver injuries; the left lateral canal and the blind sac of the spleen, filled with blood when the spleen ruptures. The presence of blood in the mesenteric sinuses or the detection of retroperitoneal hematomas indicates damage to the kidneys, injury to the branches of the superior or inferior mesenteric arteries. To examine the liver, it is necessary to lift the costal arch. Continued bleeding from the liver can be stopped by packing the wound with hot saline pads. With significant bleeding, you can use the technique of clamping the fingers of the hepatic artery and portal vein, which pass as part of the hepatoduodenal ligament along with the common bile duct. To do this, the index finger of the left hand should be inserted into the omental opening, the anterior wall of which is the hepatoduodenal ligament. The ligament, together with the hepatic artery and portal vein located in it, is compressed between the first and second fingers (no more than 5-7 minutes), which ensures a temporary cessation of parenchymal bleeding from the liver wound and allows you to examine it well. For a better revision of the convex (diaphragmatic) surface of the liver, the round and partially falciform ligaments are crossed. Poorly accessible for inspection, the posterior semicircle of the diaphragmatic surface is examined with a hand inserted into the subdiaphragmatic space up to the coronary ligament located in the frontal plane. The task of the surgeon is to treat the hepatic wound and finally stop the bleeding. Treatment of the wound consists in the economical removal of non-viable tissue, blood clots, foreign bodies. Common ways to stop bleeding from the liver when it was injured during the Great Patriotic War of 1941-1945. was tamponade of the wound with gauze, muscle or omentum. The omentum was most often used, both as an isolated area and as a flap on its supply leg. To stop bleeding, the prepared section of the omentum was inserted into the wound and fixed to the edges of the latter with several sutures. It is believed that superficial non-bleeding wounds with a depth of 2-3 cm should not be sutured. If the wound is located on a convex surface, hepatopexy according to Clari can be performed: the free anterior edge of the liver is fixed with sutures to the parietal peritoneum and muscles along the edge of the first costal arch, pressing the liver to the diaphragm. The damaged gallbladder is usually removed. In case of damage to the spleen, it is currently proposed to use various types of organ-preserving operations. Indications for removal of the spleen: detachment of the spleen from the vascular pedicle; complete crush or multiple fragmentation of the spleen; damage to the spleen in combination with multiple trauma to other internal organs; finally, bleeding from a ruptured spleen, which does not stop after tamponade with an omentum and suturing the parenchyma. The technique of inspection, stopping bleeding and, if necessary, removing the spleen is as follows. Examine the anterior end and the part of the surface of the spleen visible in the wound. The diaphragmatic surface and the posterior end of the spleen are examined with a hand inserted into the left subphrenic space. If damage is detected, especially in the region of the upper edge and posterior end of the spleen, the surgical approach should be expanded by transversely crossing the left rectus abdominis muscle and, if necessary, dissecting the transverse and oblique abdominal muscles in the lateral direction. With significant bleeding from the parenchyma of the spleen, pinch its vascular pedicle with your fingers or apply an elastic vascular clamp to it. For a complete revision of the organ, it is necessary to mobilize the spleen and remove it into the surgical wound. For this purpose, the spleno-phrenic ligament, as well as part of the gastro-splenic ligament with the short arteries of the stomach, are crossed between the hemostatic clamps. The intersection of the ligaments allows you to bring the spleen together with the tail of the pancreas into the surgical wound and examine it from all sides. In the presence of single cracks in the parenchyma, tamponade is performed with an omentum on the feeding leg and the spleen is sutured, always passing the threads under the bottom of the wound. When the pole of the spleen is torn off, a resection of the organ can be performed with wrapping the wound surface with an omentum and applying hemostatic sutures. U-shaped sutures or Kuznetsov-Pensky sutures can be used as hemostatic sutures. If indicated, a splenectomy is performed. In the region of the gate of the spleen, an artery and a vein are isolated and strong ligatures are applied to these vessels. It is recommended to apply a ligature to the splenic vessels as close as possible to the hilum of the spleen in order to avoid exclusion from the blood flow of the arterial branches to the tail of the pancreas with necrosis of the latter. The artery and vein must be ligated separately. After splenectomy, the splenic bed is usually drained. Performing a revision of the liver and spleen, it is necessary to carefully examine the right and left subdiaphragmatic spaces, respectively, in order to identify possible damage (ruptures) of the diaphragm. Due to the negative pressure in the pleural cavities, the movable organs of the abdomen can be drawn into the chest cavity. After organ extraction, the diaphragmatic wound must be sutured with two rows of sutures. The pleural cavity is drained at the end of the operation. The source of bleeding in the lower floor of the abdominal cavity may be the branches of the superior and inferior mesenteric arteries. Damaged vessels should be carefully tied up, while preferably piercing ligatures should be applied to prevent them from slipping off a bleeding, even a relatively small, vessel. At the bottom of the sinuses, the kidneys are probed and examined. The scope of the operation was determined by the nature of the damage. The method of choice is an organ-preserving operation, if it is necessary to remove a kidney, it is necessary not only to make sure that there is another one, but also that it is functional (excretory urography). The parietal peritoneum after the end of the operation on the kidney should be sutured. The retroperitoneal space is drained through an incision in the lumbar region. Having completed the stop of bleeding and surgical interventions on the parenchymal organs, they proceed to the revision of the hollow organs of the abdomen. Examination of the hollow organs of the abdomen (alimentary tract) is performed in a strict sequence, starting from the abdominal esophagus and cardia of the stomach to the rectum. Before the start of the examination, additional anesthesia is recommended by introducing a warm 0,25% solution of novocaine into the root of the mesentery of the small intestine, the mesentery of the colon and into the lesser omentum. The audit of hollow organs begins with an examination of the anterior wall of the stomach, starting from the cardiac section. Pay attention to the vessels of the stomach passing along the greater and lesser curvature, evaluate their pulsation, reveal subserous hematomas, etc. It is obligatory to examine the wall of the stomach, which is turned backwards, into the omental bag, and is not available for direct examination. For revision of the posterior wall of the stomach, it is necessary to cut the gastrocolic ligament (lig. gastrocolicum). This technique allows you to take the large curvature of the stomach forward and upward, which provides a fairly good view of not only the posterior wall, but the entire stuffing bag. Particular attention should be paid to the condition of the pancreas, located under the parietal peritoneum, lining the posterior wall of the omental sac. When opening the omental bag, it must be remembered that the gastrocolic ligament, especially in its left part, often comes into contact with the upper surface of the mesentery of the transverse colon. Therefore, the dissection of the ligament and the application of ligatures to its vessels is recommended to begin in the middle part of the ligament and further manipulations should be carried out under the control of a finger placed under the ligament in order to avoid accidental capture of the vessels feeding the transverse colon into the ligature and necrosis of the wall of the latter. After examining the stomach and performing the necessary operational assistance, the surgeon proceeds to the revision of other parts of the gastrointestinal tract. Inspection begins from the duodenal-jejunal fold, corresponding to the beginning of the small intestine. To detect it, the transverse colon along with the greater omentum should be brought into the wound and, thus, the possibility of a free approach to the organs of the lower floor of the abdominal cavity should be provided. The topography of the flexura duodenojejunalis is such that it is located at the root of the mesentery of the transverse colon immediately to the left of the spine. Visually, a fold of the peritoneum (plica duodenojejunalis) is detected. Starting from the duodenal-jejunal flexure, all loops of the small intestine are examined, sequentially removing them from the abdominal cavity. Particular attention is paid to the mesenteric edge of the intestine. Large subserous hematomas are subject to opening and emptying. Of particular difficulty for inspection are the immovable sections of the intestine - the duodenum, the ascending and descending sections of the colon. The duodenum has an intraperitoneal upper horizontal part, which is examined simultaneously with the stomach, as well as retroperitoneally descending and lower horizontal parts. Examination of the retroperitoneal parts of the duodenum is performed from the side of the omental bag, simultaneously with the revision of the pancreas, and also from the side of the lower floor of the abdominal cavity, when examining flexura duodenojejunalis. Examining the duodenum, pay attention to the presence of hematomas in the retroperitoneal space, swelling with greenish-yellow soaking of the retroperitoneal tissue in this area, gas bubbles. If these signs are detected, it is necessary to mobilize the duodenum according to Kocher. To do this, lifting the right lobe of the liver with a wide blunt hook and shifting the pyloric section of the stomach downwards and to the left, the hepatoduodenal ligament is pulled. A leaf of the parietal peritoneum is dissected along the right contour of the duodenum along the transitional fold, starting from the lower edge of the foramen epiploicum. The retroperitoneal tissue is bluntly stratified, displacing the duodenum to the left to make its posterior surface accessible for inspection. Inspection of the colon presents some technical difficulties due to the topographic and anatomical features of this section of the gastrointestinal tract. In particular, this applies to the ascending and descending colon, since they are inactive, located at a considerable distance from the midline incision used for revision, and have wide extraperitoneal areas inaccessible for direct examination. For revision of the posterior wall of the ascending or descending colon, it is necessary to make an incision in the parietal peritoneum along the transitional fold along the lateral wall of the intestine. Peeling the intestine from the fiber, it is displaced in the medial direction and the back wall is examined. It must be remembered that the branches of the mesenteric artery supplying the intestine approach it from the medial side and are located directly under the parietal peritoneum lining the mesenteric sinuses. In addition, behind the intestine, separated from it by retroperitoneal fascia and fiber, the right and left kidneys with their vessels are located. Examination of the abdominal cavity ends with a revision of the pelvic organs, where, in addition to the rectum, the bladder is located, and in women - the uterus. Indirect signs of extraperitoneal ruptures of the bladder or rectum are swelling of the pelvic tissue, subperitoneal hematomas. In case of damage to hollow organs, their integrity is restored, the damaged areas are isolated from the abdominal cavity and, if indicated, drained. Although the nature of the operations performed for abdominal wounds, their volume and degree of complexity are very different, they all require the use of special sutures to restore the tightness and integrity of the gastrointestinal tract. All types of sutures used in abdominal surgery are collectively known as intestinal sutures. Currently, a two-row, or two-tier, Albert suture is generally accepted, representing a combination of two types of intestinal sutures: through all layers - the serous, muscular and mucous membranes - the suture of Jelly and the serous-serous suture of Lambert. More physiological and promising is a single-row intestinal suture (serous-muscular-submucosal suture - Pirogov, muscular-submucosal), widely used in operations on the stomach and small intestine. When modified with tying knots inside the lumen of a hollow organ, they speak of a suture according to Mateshuk. The use of a three-row or twisted suture to connect hollow organs is unacceptable from modern surgical positions. Along with the above-described methods of applying an intestinal suture during conventional and endoscopic accesses, special devices are used to speed up and automate the stitching of the edges of the intestinal wound. Increasingly, the microsurgical technique of intestinal suture is being used. Often in emergency surgery there is a need for resection of a hollow organ. The most commonly performed resection of the stomach and small intestine. When deciding on resection, it should be remembered that the outcome of the operation is affected by the size of the resected area. It is known that resection of a section of the intestine up to 50 cm long is relatively easily tolerated by the wounded, with resection of more than 1 m of the intestine, mortality is high. Techniques for bowel resection can be divided into several main stages. The first of these is the mobilization of the loop to be resected, i.e. ligation of all vessels suitable in the composition of the mesentery to the damaged and subject to removal of the intestinal loop. The second stage of the operation is the removal of the damaged and mobilized section of the intestine. As a rule, to perform this stage of the operation, it is necessary to delimit the removed part of the intestine with special intestinal sphincter. The pulp is applied at an angle of 30° to the long axis of the intestine in such a way that the free edge of the intestine is cut off to a greater extent than the mesenteric. The excision of the removed part of the intestine is performed between the sphincter, after which they begin to apply the anastomosis. There are 3 types of interintestinal anastomoses: end-to-end, side-to-side, and end-to-side. The most physiological is the end-to-end anastomosis, however, due to the simplicity and reliability in emergency surgery, side-to-side anastomosis is more often used. After applying the anastomosis, regardless of its type, it is necessary to suture the mesenteric defect. This final stage of bowel resection should be performed in such a way that the sutures do not compress the vessels passing through the mesentery. If it is not possible to suture the wound of the intestine and if there are contraindications to resection (for example, the condition of the wounded is extremely serious), a method can be used to remove the damaged loop from the abdominal cavity. This operation consists in the fact that the loop of the intestine is removed into the wound of the abdominal wall and sutured around the entire circumference to the parietal peritoneum. In case of damage to the ascending colon, the operation of choice is suturing the wound with the simultaneous application of a cecostomy to unload the damaged area. In case of wounds of the transverse colon, small defects are sutured with a three-row suture. In connection with the mention of such terms as fecal fistula (colostomy, cecostoma, sigmostoma) and unnatural anus (anus praeternaturalis), it is necessary to dwell on the differences in the technique of performing these operations and indications for them. A fecal fistula is formed by a surgeon either to isolate (remove from the abdominal cavity) the damaged area of the colon, or to "unload" (removal of gases and, in part, intestinal contents) the underlying area. Technical implementation consists in suturing to the parietal peritoneum of the serous cover of the large intestine around the existing wound. At the same time, in order to avoid infection of the tissues of the abdominal wall, it is recommended to pre-sew the edge of the parietal peritoneum to the skin around the circumference of the surgical wound. With a fecal fistula, part of the intestinal contents is released outside (through the fistula), part passes through the intestine to the underlying sections (partial unloading). With the imposition of an unnatural anus, the goal of the operation is the complete removal of the intestinal contents through the wound of the abdominal wall, the isolation of the underlying sections of the intestine from the entry of intestinal contents into them. This is achieved either by bringing the adductor and efferent ends of the intestine onto the abdominal wall after its resection, or by forming the so-called "spur". The latter is a fold of the intestinal wall at the site of its inflection and is formed by the surgeon with the help of special sutures that are applied to the walls of the afferent and efferent loops in contact with each other on both sides of the mesentery. As in the case of a colostomy, the serosa of the intestine around the area with the formed spur is sutured to the parietal peritoneum. Opening the wall of the withdrawn loop above the spur 24-48 hours after the operation, the openings of the adducting and discharging ends of the intestine (double-barreled) separated by the first spur are formed. Another resection operation, quite often performed both in emergency and in delayed and planned orders, is gastric resection (removal of part or all of the stomach). According to the volume of the part to be removed, there are: 1) total resection (gastrectomy), when the entire stomach is removed; 2) resection of 3/4 of the stomach; 3) resection of 1/2 of the stomach. According to the method of execution, two main types of operation are distinguished: 1) Billroth-I resection; 2) Billroth-II resection. During resection of Billroth-I, the stumps of the stomach and duodenum are connected end to end. During Billroth-II resection, the remaining part of the stomach is connected to the small intestine brought to it. The first type of operation is more physiological, as it preserves the normal movement of food from the stomach into the duodenum. During resection of Billroth II in the Hofmeister-Finsterer modification, after mobilization of the stomach by crossing its ligaments (lig. gastrocolicum, lig. hepatogastricum) with simultaneous ligation of the vessels, the stomach is cut off along the right border of the resection and the duodenal stump is processed. Before that, the initial loop of the jejunum is found and through the hole made in the mesocolon, it is brought out to the upper floor, into the bursa omentalis. The stomach stump is covered with a large gauze napkin and folded to the left. Proceed to close the stump of the duodenum, for which it is immersed in two pouches and sutured with the second row of interrupted sutures. Then proceed to the removal of the stomach and the imposition of the gastrointestinal anastomosis. Two Kocher clamps are applied along the line of the left border of the resection in the direction transverse to the axis of the stomach, the resected area is cut off with a scalpel along the crushing pulp, the upper part of the stomach stump is sutured along the clamp applied from the side of the lesser curvature. The withdrawn loop of the jejunum is sewn to the unsutured part next to the serous-muscular sutures, anastomosis is applied and fixed in such a way that the leading end of the loop is directed upwards, to the lesser curvature of the stump, and the leading end to the greater curvature. During the Billroth I operation, the duodenum is mobilized according to Kocher until the resected area is cut off, then an end-to-end or end-to-side anastomosis is applied between the stomach and the duodenum. Another of the common operations on the stomach is a gastrostomy (the imposition of an alimentary gastric fistula). It is produced when it is impossible to take food through the mouth. First performed on animals in 1842 by V. A. Basov. The first operation on a human was performed by Zedillo (1849). When applying a gastrostomy according to Witzel, a transrectal incision is made on the left. The anterior wall of the stomach is brought into the wound. In the middle of the distance between the lesser and greater curvature of the body of the stomach along its long axis, closer to the cardial section, a rubber tube with a diameter of 0,8 cm is applied and immersed in a gutter formed by two folds of the stomach wall and fixed with 5-7 serous-muscular interrupted silk sutures, to the left of the last seam, another one is applied in the form of a pouch, leaving it loose. Inside it, the wall of the stomach is dissected, the end of the rubber tube is inserted into the hole formed to a depth of 5 cm and the purse-string suture is tightened. Thus, the rubber tube is located in the channel opening into the stomach cavity. If it is necessary to remove it, the channel usually closes on its own. The most common operation in abdominal surgery is appendectomy. The first successful appendectomy in 1887 was made by William T. Morton, in Russia in 1890 by A. A. Troyanov. Many options for the operation have been proposed. In our country, the Mac Burney-Volkovich method is the most common. An incision 8-10 cm long is made at the border of the middle and outer third of the line connecting the anterior superior iliac spine with the navel, perpendicular to it, and its upper third should be above it, and the lower two thirds - below. Dissect the skin, subcutaneous tissue, aponeurosis of the external oblique muscle. Under the aponeurosis, the internal oblique is stupidly pushed apart parallel to the fibers, and deeper - the transverse abdominal muscle and stretched with Farabef hooks. The transverse fascia of the abdomen is dissected, the wound is covered with gauze napkins, the fold of the parietal peritoneum raised by two anatomical tweezers is cut and its edges are fixed to the napkins. After opening the abdominal cavity, the wound is stretched with lamellar hooks and the search for the appendix is started. The caecum is recognized by its position, grayish color, by the presence of muscle bands (taenia). The appendix is pulled upward so that its entire mesentery is clearly visible. The mesentery of the process is dissected between sequentially applied clamps up to its base. After crossing the mesentery, the captured areas are tied up. A silk serous-muscular purse-string suture is applied to the wall of the caecum, 1,5 cm from the base of the process, leaving its ends untightened. The appendix is squeezed at its base with a clamp, a ligature is applied to the squeezed place, and its ends are cut off; distal to the ligation site, a clamp is applied to the process. Holding the base of the process with anatomical tweezers, it is cut off over the ligature immediately below the applied clamp. The stump of the appendix is cauterized with iodine and immersed into the intestinal lumen with anatomical tweezers; the pouch is tightened and after the tweezers are removed, they are tied in a knot. A serous-muscular suture in the form of the Latin letter z is applied over the purse-string suture, which is tightened after cutting off the ends of the purse-string suture. The caecum is pushed into the abdominal cavity. The abdominal cavity is dried, drained if necessary, the wound is sutured in layers. LECTURE #10 Topographic anatomy and operative surgery of the pelvic organs Under the "pelvis" in descriptive anatomy is meant that part of it, which is called the small pelvis and is limited to the corresponding parts of the ilium, ischium, pubic bones, as well as the sacrum and coccyx. At the top, the pelvis communicates widely with the abdominal cavity, at the bottom it is closed by the muscles that form the pelvic diaphragm. The pelvic cavity is divided into three sections, or floors: peritoneal, subperitoneal, subcutaneous. The peritoneal region is a continuation of the lower floor of the abdominal cavity and is delimited from it (conditionally) by a plane drawn through the pelvic inlet. In men, in the peritoneal part of the pelvis, the part of the rectum covered by the peritoneum, as well as the upper, partially posterolateral and, to a small extent, the anterior wall of the bladder, are located. Passing from the anterior abdominal wall to the anterior and upper walls of the bladder, the peritoneum forms a transverse cystic fold. Further, the peritoneum covers part of the posterior wall of the bladder and, in men, passes to the rectum, forming the rectovesical space, or notch. From the sides, this notch is limited by rectovesical folds stretched in the anteroposterior direction between the bladder and the rectum. In the space between the bladder and the rectum, there may be part of the loops of the small intestine, sometimes the sigmoid colon, less often the transverse colon. In women, the same parts of the bladder and rectum as in men, and most of the uterus with its appendages, wide uterine ligaments and the upper part of the vagina are placed in the peritoneal floor of the pelvic cavity. When the peritoneum passes from the bladder to the uterus, and then to the rectum, two peritoneal spaces are formed: the anterior (vesicouterine space); posterior (rectal-uterine space). When moving from the uterus to the rectum, the peritoneum forms two folds that stretch in the anteroposterior direction and reach the sacrum. They are called sacro-uterine folds and contain ligaments of the same name, consisting of muscular-fibrous bundles. In the recto-uterine space, intestinal loops can be placed, and in the vesico-uterine space - a greater omentum. The recto-uterine recess (the deepest part of the peritoneal cavity in women) is known in gynecology as the pouch of Douglas. Here, effusions and streaks can accumulate during pathological processes both in the pelvic cavity and in the abdominal cavity. This is facilitated by the mesenteric sinuses and canals mentioned in the previous lecture. The left mesenteric sinus of the lower floor of the abdominal cavity continues directly into the pelvic cavity to the right of the rectum. The right mesenteric sinus is delimited from the pelvic cavity by the mesentery of the terminal portion of the ileum. Therefore, the accumulations of pathological fluid formed in the right sinus are initially limited to the boundaries of this sinus and are sometimes encapsulated without passing into the pelvic cavity. Inspection of the peritoneal pelvis and organs located there can be performed through the anterior abdominal wall by lower laparotomy or using modern endovideoscopic (laparoscopic) methods. The endoscope can also be inserted through the posterior fornix of the vagina. Among the urgent surgical interventions in the peritoneal floor of the pelvis, operations for complications of ectopic pregnancy are among the most frequent. Ectopic pregnancy is one of the main causes of internal bleeding in women of childbearing age. Access to the peritoneal floor of the pelvis in a disturbed ectopic pregnancy can be either "open" (laparotomy) or "closed" (laparoscopy). In the first case, a lower median or lower transverse laparotomy is used for access. After performing access to the wound, the fallopian tube is removed and the place of its rupture is determined. Apply a Kocher clamp to the uterine end of the tube (at the corner of the uterus). The second clamp captures the mesosalpinx. Scissors cut off the tube from her mesentery. Ligatures are applied to the vessels and the uterine end of the tube. The stump of the tube (corner of the uterus) is peritonized using the round ligament. Liquid blood and blood clots are removed from the abdominal cavity. Produce an audit of the pelvic organs and sutured the surgical wound. The second floor (subperitoneal) is enclosed between the peritoneum and the sheet of the pelvic fascia, which covers the muscles of the pelvic floor. Here, in men, there are retroperitoneal (subperitoneal) sections of the bladder and rectum, the prostate gland, seminal vesicles with their ampoules, and the pelvic sections of the ureters. Women have the same sections of the ureters, bladder and rectum as men, as well as the cervix, the initial section of the vagina. The internal and external iliac arteries, passing in the subperitoneal pelvis, are branches of the common iliac arteries. The place of division of the abdominal aorta into the right and left common iliac arteries is more often projected onto the anterior abdominal wall at the intersection of the midline with the line connecting the most protruding points of the iliac crests, but the level of bifurcation often varies from the middle of the III to the lower third of the V lumbar vertebrae. Various methods of vascular surgery (prosthesis, shunting, endovascular methods, etc.) are used for the surgical treatment of diseases of the aorta of the iliac or iliac-femoral segments of the arteries of the lower limb. In operative gynecology, situations sometimes arise that require ligation of the internal iliac artery. Depending on the indications, it is possible to conditionally distinguish between emergency and planned ligation of the internal iliac artery. The need for emergency dressing may arise with massive bleeding, uterine rupture, crushed wounds of the gluteal region, accompanied by damage to the upper and lower gluteal arteries. Planned ligation of the internal iliac artery is performed as a preliminary stage in cases where the upcoming threatens the possibility of massive bleeding. Ligation of the internal iliac artery is a complex intervention, associated with a certain risk. When applying ligatures to the iliac arteries, as well as during operations on the pelvic organs, especially when removing the uterus and its appendages, one of the serious complications is damage to the ureters. Treatment of ureteral injuries is almost always surgical. The primary suture of the ureter is rarely used, only for surgical injuries recognized during surgery. In the primary surgical intervention, they are limited to diversion of urine by nephropyelostomy and drainage of urinary streaks. After 3-4 weeks after the injury, a reconstructive operation is performed. During the operation of ureteroanastomosis, the ends of the damaged ureter are connected with several interrupted catgut sutures. For the purpose of diverting urine, sewing the end of the ureter into the intestine or removing it to the skin (palliative surgery) is sometimes used. With low ureteral injury in the pelvis, ureterocystoanastomosis should be considered the method of choice, which can be performed in various ways. This operation requires high professional technique and is usually performed in specialized clinics. With urinary retention and the inability to perform catheterization (urethral injury, burns, prostate adenoma), a suprapubic puncture of the bladder can be performed. The puncture is made with a long thin needle (diameter 1 mm, length 15-20 cm) 2-3 cm above the symphysis. If necessary, the puncture can be repeated. For long-term and permanent diversion of urine, thoracic puncture of the bladder can be used. Puncture of the bladder during thoracic epicystostomy is performed 3-4 cm above the pubic symphysis with the bladder filled with 500 ml of an antiseptic solution. After removing the stylet, a Foley catheter is inserted into the bladder cavity along the trocar sleeve, which is pulled up to a stop and tightly fixed with a silk ligature to the skin after the trocar tube. During the operation of the suprapubic vesical fistula, drainage is installed in the lumen of the bladder. Access to the bladder - median, suprapubic, extraperitoneal. The bladder incision around the drainage tube is sutured with a double-row catgut suture. The wall of the bladder is fixed to the muscles of the abdominal wall. Then the white line of the abdomen, subcutaneous tissue and skin are sutured. The drainage tube is fixed with two silk sutures to the skin. Fascia and cellular spaces of the pelvis. Purulent inflammatory processes that develop in the cellular spaces of the small pelvis are particularly severe. For drainage of abscesses in the cellular spaces of the subperitoneal pelvis, various accesses are used depending on the localization of the focus. The introduction of drainage can be carried out either from the side of the anterior abdominal wall, or from the side of the perineum. To access the subperitoneal cellular spaces of the pelvis from the side of the abdominal wall, incisions can be made: 1) in the suprapubic region - to the prevesical space; 2) above the inguinal ligament - to the paravesical space, to the parametrium. Perineal accesses can be performed using incisions: along the lower edge of the pubic and ischial bones; through the center of the perineum anterior to the anus; along the perineal-femoral fold; behind the anus. The third floor of the pelvis is enclosed between the sheet of the pelvic fascia, which covers the pelvic diaphragm from above, and the skin. It contains parts of the organs of the genitourinary system and the final section of the intestinal tube passing through the pelvic floor, as well as a large amount of fatty tissue. The most important is the fiber of the ischiorectal fossa. Topographically, the lower part of the pelvis corresponds to the region of the perineum, the frontiers of which are the pubic and ischial bones in front; from the sides - ischial tubercles and sacrotuberous ligaments; behind - coccyx and sacrum. The line connecting the ischial tubercles, the perineal region is divided into the anterior section - the genitourinary triangle and the posterior - anal triangle. In the anal perineum there is a powerful muscle that lifts the anus and a more superficially located external sphincter of the anus. The lateral walls of the fossa are: the lateral-internal obturator muscle with the fascia covering it; the medial-inferior surface of the levator ani muscle, the fibers of which run from top to bottom and from outside to inside towards the anus. The fiber of the ischiorectal fossa is a continuation of the subcutaneous fat layer. Inflammation of the perirectal tissue, which is part of the tissue of the ischiorectal fossa, is called paraproctitis. By localization, the following types of paraproctitis are distinguished: subcutaneous submucosal, ischiorectal, pelviorectal. With paraproctitis, surgical intervention is indicated. Drainage incisions are made depending on the location of the abscess. Low-lying submucosal paraproctitis can be opened through the wall of the rectum. With subcutaneous paraproctitis, an arcuate incision is recommended, bordering the external sphincter of the anus, sometimes a longitudinal incision is made between the anus and the coccyx along the midline of the perineum (with abscesses behind the rectal tissue). For drainage of deeply located abscesses of the ischiorectal fossa, an incision is made along the branch of the ischium and penetrate into the depth along the outer wall of the fossa. If it is necessary to drain the pelviorectal space, the fibers of the levator ani muscle are stratified from the indicated access, and a thick drainage tube is inserted into the purulent cavity. The pelviorectal cellular space can also be drained from the side of the anterior abdominal wall by an incision above the inguinal ligament. Less commonly, for drainage of the ischiorectal fossa, access is made from the side of the thigh through the obturator foramen. To do this, the patient is placed on the edge of the table in a position for perineal operations. The thigh is retracted outward and upward until the fine muscle is tense. Departing from the inguinal fold down by 2 cm, an incision of the skin and subcutaneous tissue 7-8 cm long is made along the edge of this muscle. After dissection of the skin and subcutaneous tissue, the thin muscle is retracted upward. The adjacent short adductor muscle is also retracted upward. The large adductor muscle moves downward. The external obturator muscle is stratified in a blunt way and moved apart to the sides, the muscle is dissected at the lower inner edge of the obturator foramen. After emptying the abscess, an elastic tube with side holes is inserted into the ischiorectal fossa. LECTURE #11 Topographic anatomy and purulent surgery Purulent-septic diseases or complications are observed in about a third of the total surgical contingent of patients; no practitioner can avoid encountering purulent diseases and their complications. The spread of purulent processes occurs in the subcutaneous and intermuscular tissue, along the cases of the neurovascular bundles, along the fascial cases and interfascial fissures, through the intermuscular spaces, etc. The primary pathways are those in which the distribution occurs without destruction of the anatomical structures and elements, as the fiber gradually "melts" in the natural interfascial and intermuscular spaces. Connective tissue, adipose tissue is the area through which pus spreads. The spread of pus along the secondary paths is accompanied by the destruction of anatomical elements and structures, a breakthrough from some relatively closed fascial cases or intermuscular spaces to neighboring ones. The features of clinical manifestations during the development of a purulent process in a case for any muscle group are influenced by the following topographic and anatomical features: a discrepancy between the relatively large internal volume of the entire case, which includes a group of muscles (this volume reaches several tens of cubic centimeters) and the relatively small capacity of the slit-like space between fascia and muscles. This predetermines a relatively small amount of pus inside the case, as well as a weak severity of local signs of inflammation (redness, swelling, pain and dysfunction) with a deep localization of the purulent process. The muscles located in the fascial sheath are rich in blood and lymphatic vessels and represent a large resorptive surface, which determines the absorption of toxins and the severity of general symptoms of inflammation. The significant thickness of the wall of the fascial case makes it almost impossible for the purulent process to pass from one case to another. Examples of cases for individual muscles are fascial sheaths on the neck - for the sternocleidomastoid muscle; on the thigh - for a thin muscle, a sartorius muscle, etc. Due to the closeness of the space and the relatively small volume of the fascial case, during exudation and the gradual accumulation of pus, pressure increases inside it, which can lead to compression of the vessels and nerves supplying the muscle and a rapid increase in ischemic pain symptom. In severe cases, muscle ischemia can go into a necrotic phase. Another of the topographic and anatomical features of the fascial cases is their large length, which determines the so-called "jumping" nature of the spread of the purulent process, despite the closed nature of the muscle cases, there are always holes in their walls through which neurovascular bundles approach the muscles (" muscle gate). These holes are "weak spots" through which pus can break through into adjacent fascial cases. Some characteristic features differ in the primary pathways for the spread of purulent processes, formed by tendon sprains (aponeurosis) and wide fascial sheets, "replacing" the reduced muscles. The most typical and practically significant are the palmar and plantar aponeuroses. They are characterized by: a cellular structure that occurs due to the interweaving of longitudinal and transverse strong fibrous fibers. In this case, the cells (holes) between the fibers of the aponeuroses have a variety of shapes and sizes. The largest (commissural openings) serve for the passage of small vessels from deep layers to the surface and reach a diameter of 2-3 mm. A strong connection of these aponeuroses is provided by numerous connective tissue bridges with the skin. These jumpers subcutaneous fatty tissue is divided into separate cells. The noted features of the structure of aponeuroses determine the directions of possible ways for the spread of purulent processes on the palm and sole. With a superficial purulent focus (skin, subcutaneous tissue), the spread of pus in the subcutaneous tissue above the aponeurosis is limited by connective tissue bridges, therefore, at first serous and then purulent exudate, not being able to break through the skin to the outside, spreads in depth, as if "falling through" through commissural openings - into the subaponeurotic and subtendonous cellular spaces of the palm and foot. When the purulent process spreads through the fine-mesh structures of the palmar or plantar aponeuroses, the abscess that forms has the form of a "cufflink" or "hourglass". At the same time, the superficial part of the abscess is small and limited by connective tissue bridges between the skin and the palmar (plantar) aponeurosis. But the deep part of the abscess is widely distributed in the subaponeurotic space of the palm or sole, along the tendons and neurovascular bundles. When an abscess is formed in the form of a "cufflink" or "hourglass", one of the features of the clinical picture is the discrepancy between weak "point" pain on palpation in the projection of the aponeurosis cell and the general condition of the patient, the severity of which is due to the spread of the purulent process in the subaponeurotic cellular space and developing intoxication. The conditions for the spread of purulent processes along the fascia, formed as a result of complete or partial muscle reduction, are basically similar to those described for aponeuroses. The orientation of such fascial sheets in a plane, usually parallel to the surface of the corresponding area, determines the spread of phlegmon over the entire width of the fascia, which is accompanied by a gradual increase in local symptoms of inflammation (the "spreading" effect). Unlike aponeuroses, fascial plates do not have through holes, and therefore the purulent process, as a rule, does not go beyond the corresponding cellular layer, and the fascia formed at the site of the reduced muscles are fixed at the edges to the bone protrusions, which contributes to the delimitation abscess from neighboring areas. Features of the spread of purulent processes in paraangial cases were first described in detail by N. I. Pirogov in the book "Surgical Anatomy of Arterial Trunks and Fascias" and subsequently received the name "Pirogov's three laws". The first law: all vascular sheaths are formed by "fibrous" (according to N. I. Pirogov), i.e., dense connective tissue and represent a doubling of the wall (often the back) of the muscular sheaths. The second law: in cross section, the connective tissue sheath has a triangular ("prismatic") shape, which determines the special strength and rigidity of its design. The third law emphasizes the fixation of the vascular sheaths to the bones of the limbs. According to the description of N. I. Pirogov, one of the facets of the vagina, as a rule, "is in a mediocre or direct connection with the nearby bones." That is, they have relatively thick and significantly strong walls, forming a trihedral space in which neurovascular bundles pass, surrounded by loose fiber. Cases have a constant orientation along the axis of the limb due to rigid fixation to the underlying bones. What is important for understanding the nature of the spread of purulent processes in paraangial cases and some clinical manifestations. The closed nature of the connective tissue case, the density of its walls and close adherence to the elements of the neurovascular bundle makes it possible for the purulent process to quickly pass to the walls of the artery, vein and nerve damage. Purulent and purulent-necrotic forms of arteritis are accompanied by the formation of a thrombus and the destruction of the artery wall, which becomes the cause of life-threatening bleeding in large arteries. When the vein wall is involved in the process, purulent phlebitis and thrombophlebitis develop. 1. Topographic and anatomical features of the distribution of purulent processes in the fascia of primary coelomic origin The fasciae of primary coelomic origin include the fasciae lining the inside of the body cavity, the "endofascia". With the genetic identity of these fascias, the layers of fiber adjacent to these fascias also have similar features, which predetermines the possibility of a wide spread ("spreading") of the purulent process along the plane of the fascial sheets lining the cavity, and sometimes the transition from one cavity to another, and it is also possible the formation of pus streaks in the direction not only from top to bottom, but also from bottom to top, which is facilitated by the suction action of the respiratory movements of the diaphragm. Under the fascia of secondary coelomic origin, one should understand the connective tissue plates formed as a result of the reduction and transformation of the embryonic mesentery of the internal organs in the process of ontogenesis (posterior colonic fascia, retroperitoneal fascia (with its pre- and retrorenal sheets). Inflammatory processes can be localized in different layers of the retroperitoneal tissue and, depending on the topography, are called paranephritis, paracolitis, etc. The spread of the purulent process in the indicated cellular spaces is distinguished by the following features: 1) the defeat of not only the tissue surrounding the corresponding organ (fat capsule), but also the possibility of streaks along the fascial sheets into the paraorganic tissue of another organ, usually belonging to the same anatomical system (for example, with paranephritis, spread to the periureteral and perivesical tissue ; 2) the purulent process rarely goes beyond the layer limited by the fascial sheets. With purulent processes developing in body cavities (thoracic, abdominal, pelvic), streaks may form in neighboring areas along the fascial sheets, neurovascular bundles and intermuscular spaces outside the cavity bounded by coelomic fascia. This occurs through anatomical openings, limited by bone-ligamentous and muscular elements. 2. Secondary ways of spreading purulent processes The secondary pathways for the spread of purulent processes include those that are formed as a result of the destruction (purulent fusion) of anatomical elements. With the accumulation of pus in muscle cases and a significant increase in pressure, it is most often the rupture of the common connective tissue wall and the transition of the purulent process from the muscle to the vascular receptacle that occurs. The weak points of the joint capsules were described by V. F. Voyno-Yasenetsky, who found that in those areas where the tendons are closely adjacent to the capsule, its thinning is observed due to a significant decrease in fibrous bundles. In particular, in the area of the tendon of the long flexor of the thumb near the talus, the capsule of the ankle joint is devoid of fibrous bundles reinforcing it, the tendon of the muscle directly touches the synovial membrane of the ankle joint, which determines the possible place of rupture during the spread of the purulent process. The treatment of purulent diseases is based on an integrated approach. The classical rule known for centuries "Ubi pus, ibi evacu" has not lost its relevance in the era of antibiotics, and the opening of a purulent focus, wide drainage is the main surgical technique. The goals of the operation in the treatment of a purulent process are as follows: elimination of a purulent necrotic focus, limitation of the purulent process, prevention of complications, and the fight against intoxication. The operation begins with a wide incision, which is performed directly above the purulent focus, in compliance with the basic rule of tissue dissection - maintaining the integrity of the main neurovascular bundles. When making incisions, pus is evacuated, purulent-necrotic foci are removed and conditions are created for outflow (drainage), to limit the spread of the process, eliminate purulent intoxication and for secondary wound healing. Incisions at the opening of a purulent focus have some features: for a better outflow of wound discharge, the length of the incision should be twice the depth; after emptying the purulent focus, a revision of the wound is mandatory in order to detect and open purulent streaks, while maintaining the integrity of the connective tissue partitions that delimit the purulent cavity from neighboring, healthy tissues. If the main incision to open the purulent focus does not create an effective outflow of purulent discharge, it is necessary to apply a counter-opening that provides outflow from the deepest part of the wound by gravity, or drains and drainage systems. If necessary, several counter-openings can be applied. LECTURE #12 Endoscopic surgery 1. The concept of endoscopic surgery and the history of development In modern surgery, minimally invasive methods of operations performed with the help of endovideosurgical equipment are increasingly being used. Endoscopic surgery is a field of surgery that allows performing radical operations or diagnostic procedures through pinpoint tissue punctures (laparoscopic, thoracoscopic, arthroscopic, and other operations), or through natural physiological openings (with fibroesophagogastroduodenoscopy, colonoscopy, bronchoscopy, cystoscopy, etc.). The idea of performing a visual examination of the internal organs without a wide dissection of the integument was put forward in 1901 by G. Kelling. He performed laparoscopy in an experiment on a dog, inserting a cystoscope into the abdominal cavity after blowing air into it. In the same year, a gynecologist from St. Petersburg, D. O. Ott, reported on an examination of the abdominal cavity using a candle, a frontal mirror, and a tube inserted through the culdotomy opening. In 1910, the Swedish physician Hans Christian Jacobeus applied this technique to a human being, and he also introduced the term "laparoscopy" into practice. Further progress in endoscopy was associated with the development of optics. In 1929, the German hepatologist H. Kalk developed oblique lenses for the laparoscope; 5 years later, biopsy forceps were built into the laparoscope. In 1938, J. Veresh (Hungary) developed a safe and equipped with a spring obturator needle for applying pneumothorax. After the needle has passed into the cavity, the spring-loaded obturator covers the tip of the needle and prevents accidental perforation or damage to internal organs. Currently, the Veress needle is used to apply pneumoperitoneum. In 1947, R. Palmer put forward the principle of controlling intra-abdominal pressure during insufflation (gas injection), while the German gynecologist and engineer, Professor K. Semm, developed an automatic insufflator for this purpose. In the 1960s he also replaced 78% of open gynecological operations with laparoscopic ones with an overall complication rate of 0,28%, thereby demonstrating the safety and effectiveness of laparoscopy. In the 1960s-1970s. laparoscopy temporarily fell out of favor when computed tomography improved and ultrasound-assisted biopsies became widely available. In the Soviet Union, laparoscopy became widespread in the 1970s and 1980s. primarily as a diagnostic manipulation; its development is associated with surgical teams led by V. S. Saveliev, O. S. Kochnev, V. S. Mayat, and others. In 1977, De Kock began performing appendectomies with partial laparoscopic support. Thanks to the use of laparoscopy in the examination of young women who were admitted with suspected acute appendicitis, there was a decrease in the frequency of removal of unchanged appendix by 50%. After the design by a group of Japanese engineers of a photosensitive matrix that allows transforming a video signal for transmission to a monitor and magnifying an image by 30-40 times, a revolution in endoscopic technology occurred in 1987, which made it possible to start performing radical surgical interventions. In 1987, Philippe Mouret, a French surgeon from Lyon, performed the first successful laparoscopic cholecystectomy. 1990s began with the rapid spread of endosurgery around the world. Today, this approach is used in 90% of operations for cholelithiasis and in gynecology. There is a rapid development of operative thoracoscopy, laparoscopic operations on the colon and stomach, hernia and vascular surgery. In the mid 1990s. laparoscopic interventions have gained popularity and become routine. In Russia, the first laparoscopic cholecystectomy was performed in 1991. Yu AND. Gallinger. Also, the widespread clinical introduction of laparoscopy in the 1970s. contributed to the creation of fiber optics, powerful sources of "cold" light, tools and manipulators of various designs. The design of modern video complexes provided the opportunity for a panoramic view of the abdominal cavity, as well as multiple magnification of the image of organs on the monitor screen. The high resolution of the optical system made it possible to carry out microsurgical operations. Compared with open operations, endosurgery has the following advantages: low trauma, which manifests itself in the form of a decrease in postoperative pain, a quick (1-2 days) recovery of physiological functions; short hospital period; reduction of the period of disability by 2-5 times; good cosmetic effect (traces of 5-10 mm punctures are not comparable with the scars left after traditional operations); economic efficiency (despite the higher cost of the operation, the treatment is more cost-effective due to the saving of medicines, reducing the length of the hospital period and the patient's rehabilitation period). Indications for endosurgical intervention in most cases are the same as for the operation performed by the open method. Contraindications to endosurgical interventions are somewhat wider. This is determined by increased intra-abdominal pressure associated with the creation of pneumoperitoneum, a decrease in venous return and lung excursion. Physiological changes in pneumoperitoneum become clinically significant in concomitant diseases of the cardiovascular and pulmonary systems, this also occurs if the operation lasts more than 2 hours. Insufflation of carbon dioxide causes hypercapnia and acidosis, which subsequently resolve rapidly; gas insufflation-induced pneumoperitoneum reduces venous return and reduces cardiac output. Violated venous circulation in the basin of the inferior vena cava. Pneumoperitoneum increases systemic vascular resistance and increases diastolic blood pressure. There is a violation of blood flow in the arteries of the abdominal cavity. A decrease in residual capacity and an increase in dead space occurs when the lungs are compressed when the diaphragm is raised. Relative contraindications obstructive pulmonary disease; cardiovascular insufficiency of 2-3 degrees; transferred myocardial infarction; transferred operations on the heart and large vessels; congenital and acquired heart defects. In these situations, surgery is possible without the imposition of pneumoperitoneum (using a laparolift) or traditional laparotomic access. Diffuse peritonitis requires a traditional abdominal surgery, requiring careful sanitation of all parts of the abdominal cavity. In case of doubt in the diagnosis, it is useful to start the operation with a diagnostic laparoscopy. Previous intracavitary operations, due to a pronounced adhesive process, can become an obstacle to the introduction of trocars and the implementation of the intervention itself by the endosurgical method. This is most likely after several surgeries. The risk of bleeding in severe coagulopathies may be the cause of complications and subsequent conversion. The introduction of a trocar is difficult for patients suffering from obesity of 3-4 degrees, having a thick layer of adipose tissue. An enlarged uterus in late pregnancy can become an obstacle to creating an intra-abdominal space sufficient for laparoscopic interventions. However, up to the third trimester of pregnancy, endoscopic appendectomy and cholecystectomy are successfully performed. Portal hypertension, especially with varicose veins of the anterior abdominal wall, contributes to a significant increase in the risk of bleeding. Contraindications for individual operations largely depend on the experience of the specialist. Preparation for laparoscopic surgery with preparation for open surgery. In the event of technical difficulties or complications, the patient must be psychologically prepared for the transition to immediate laparotomy. Decompression is characterized by the insertion of a tube into the stomach and a catheter into the bladder. The operation is performed under anesthesia due to poor tolerance by awake patients of abdominal wall stretching during gas insufflation, especially when using carbon dioxide, which has an irritating effect on the peritoneum. Endosurgical operations require special, rather complex and expensive equipment and instruments. This list includes equipment and instruments for applying pneumoperitoneum: an electronic laparoflator (insufflator) for supplying gas and maintaining constant pressure in the cavity; Veress needle; syringe 10 ml; telescopes (straight, with a viewing angle of 30°, diameter 10 mm; angular, with a viewing angle of 45°, diameter 10 mm); trocars with a diameter of 5,7 and 10 mm; electrosurgical unit (equipment for hemostasis - combined electrosurgical apparatus for mono- and bipolar electrocoagulation); light source and video equipment: a xenon light source with a power of at least 175 W, a fiber-optic light guide, an endovideo camera, a color monitor, a video recorder or other device for recording an image for later viewing or analysis of the operation in case of complications; aquapurator - a device for suction and injection of fluid into the cavity; cannula with a diameter of 5 mm; electrosurgical instruments with a dielectric coating: loop, spherical and L-shaped electrodes, a dissector and scissors, a group of plucked instruments (surgical and anatomical clamps, instruments for passing and tightening a ligature, applying clips to tubular formations), instruments for puncturing organs and taking a biopsy. All equipment is usually located on the operating rack (mobile rack). The optimal composition of the operating team: surgeon; two assistants; operating nurse; junior nurse. The imposition of pneumoperitoneum is one of the important stages of laparoscopy. The introduction of gas into the abdominal cavity is necessary to increase its volume and create free space necessary for moving instruments and improving conditions for viewing the insides. At the same time, it should be borne in mind that it is precisely with the imposition of pneumoperitoneum that complications such as injuries to the intestines, omentum, and blood vessels most often occur. The safety of the introduction of the first (blind) trocar depends on the accuracy of this manipulation. For introduction into the abdominal cavity, carbon dioxide or nitrous oxide is used. The use of oxygen or air is not recommended due to the risk of explosion and fire. Preference is given to carbon dioxide. His choice is explained by the availability, low cost and the fact that CO2 does not support combustion. Rapid release of carbon dioxide occurs during respiration, is easily absorbed by tissues, has a high diffusion coefficient, which is important for the prevention of gas embolism. Thoracoscopy does not require gas insufflation, since the skeleton function and the maintenance of the necessary space are performed by the chest itself. However, it would be desirable to conduct a separate intubation of the bronchi, since thoracoscopic operations are best performed with a collapsed lung. For the imposition of pneumoperitoneum produce a puncture of the abdominal wall. When choosing a puncture point, topographic and anatomical features of the abdominal wall are taken into account, especially the position of blood vessels, nerves, and the presence of cicatricial changes. Location matters a lot. the state of intracavitary formations (bloating of intestinal loops, the size and localization of neoplasms, etc.), as well as variants of the topography of the main vessels (aorta, vena cava, etc.). In typical cases, the optimal location for gas insufflation is the point located at the intersection of the midline of the abdomen with the lower edge of the umbilical ring. At this level, a small incision is made in the skin and subcutaneous tissue, after which they proceed to the puncture. For the imposition of pneumoperitoneum, as already mentioned, a special needle is used - the Veress needle. It has a length of 10 cm. A feature of its design is the presence of a blunt springy mandrin protruding beyond the tip of the needle in the absence of resistance from the outside and protecting the abdominal organs from damage. The mandrin has an internal channel through which gas is injected into the abdominal cavity. When a Veress needle is inserted into the abdominal cavity, injuries to the walls of hollow organs and damage to blood vessels can be observed. In order to prevent them, it is necessary immediately before the introduction to make sure that the spring mechanism of the Veress needle and the patency of the mandrin are in good condition. When traction of the needle, it is necessary to hold it with the index and thumb in such a way as not to fix the movable safe mandrel. The needle is immersed in the tissue evenly with a constant force until the effect of falling through and the appearance of a click of the spring mechanism are felt. The Veress needle is connected to an electronic insufflation device that allows you to objectively control the introduction of gas and automatically turns on alarms at critical values of intra-abdominal pressure. Possible complications with the introduction of gas: the ingress of gas into the subcutaneous fat, preperitoneal tissue, omentum, intestine, blood vessels; complications caused by a sharp and significant increase in intra-abdominal pressure (hemodynamic and respiratory disorders). Subcutaneous and preperitoneal emphysema are easily recognized and do not pose a danger to the patient, they are easily diagnosed and do not require special treatment. When gas is insufflated into the greater omentum, a pneumomentum is formed, which quickly resolves. Insufflation of gas into the intestinal lumen is dangerous, since the integrity of the wall is violated, which threatens with peritonitis. The introduction of gas into the lumen of the vessel can lead to an embolism with a fatal outcome. It is possible to avoid these complications with strict observance of the rules for the introduction of the Veress needle, careful control of its position. Hemodynamic disorders with an excessive increase in intra-abdominal pressure are the result of a redistribution of blood in the body, a decrease in cardiac output as a result of compression of the inferior vena cava and impaired blood flow to the right heart, etc. One of the formidable complications of the respiratory system is pneumothorax, which is formed as a result of gas penetration through congenital defects in the diaphragm or when it is damaged during puncture. If a tension pneumothorax occurs, puncture of the pleural cavity with a needle or trocar and subsequent drainage is necessary. Measures to prevent complications caused by gas insufflation into the abdominal cavity are reduced to careful control over the rate and volume of insufflated gas, as well as monitoring the activity of the cardiovascular system. It is possible to use a laparolift (a device for mechanically lifting the abdominal wall), while through a puncture or mini-access (1,5-2 cm), a frame is inserted into the abdominal cavity, which automatically raises the abdominal wall and creates a working space. In repeated operations, when an adhesive process is likely to develop in the abdominal cavity, and blind insertion of a needle and a trocar is dangerous by damaging internal organs, an alternative (open) method of creating pneumoperitoneum is used. This requires a microlaparotomy. A vertical dissection of the skin occurs below the navel for 2-2,5 cm, while exposing the white line of the abdomen. A purse-string suture is placed around the future incision. Under the control of the eyes, the aponeurosis and peritoneum are opened. A trocar without a stylet is inserted into the free space. The suture is tied and gas insufflation begins. Thanks to this technique, there is a prevention of perforation or damage to the organs of the abdominal cavity, which occasionally occurs when using the blind trocar insertion technique. After gas insufflation into the peritoneal cavity, laparoscopic trocars are introduced. The introduction of the first trocar is the most important step in the laparoscopy technique. When performing it, special care is required to avoid damage to internal organs or blood vessels. Before the introduction of the trocar, the height of the free space of the abdominal cavity, created with the help of the piumoperitoneum, is determined. For this, the Palmer test is used: a 15 cm long needle is connected to a 20 ml syringe, from the piston of which the sealing ring has been previously removed. The syringe is filled with 5-10 ml of saline and in a vertical position the needle is inserted into the abdominal cavity along the midline of the abdomen, stepping back 1 cm from the sub-umbilical incision. When the needle enters the abdominal cavity, the liquid in the syringe under the influence of intra-abdominal pressure (pneumoperitoneum) pushes the piston. The needle is slowly advanced deeper until the displacement of the piston stops. The height of the pneumoperitoneum corresponds to the length of the immersed part of the needle. The optimal place for the introduction of the first trocar is the point of intersection of the lower border of the umbilical ring and the midline of the abdomen, corresponding to the point of entry of the Veress needle. Before the puncture, the lateral edges of the skin incision are fixed with claws and lifted anteriorly and to the sides by an assistant. Thus, additional elasticity of the anterior abdominal wall is provided, and the volume of the peritoneal cavity increases. The trocar is grasped with the right hand, while the stylet cap rests against the palm, and the index finger is directed along the trocar sleeve, preventing the trocar from falling sharply into the abdominal cavity. The introduction of the trocar is made in a Z-shaped movement - first, the trocar is inserted through the skin incision along the midline of the abdomen in the direction of the pubic symphysis at a depth of 1 cm, then the stylet tip is shifted to the right. At 2-3 cm from the midline, the instrument is transferred to a vertical position and the abdominal wall is punctured to the parietal peritoneum. After that, the stylet is removed, a telescope with an illuminator is inserted into the cannula, a free area of the peritoneum is visually determined and it is pierced. A special feature of the trocar is the presence of a special valve in its cannula, which prevents gas from escaping from the abdominal cavity, but allows the introduction of laparoscopes or remote manipulators. After removing the stylet, a telescope eyepiece with an illuminator is inserted into the abdominal cavity, connected to a video camera, and the abdominal cavity is examined. The review begins with a study of the space located immediately near the insertion site of the Veress needle and trocar to exclude possible damage to the internal organs and bleeding from the vessels of the anterior abdominal wall. Then, starting from the right subdiaphragmatic space, the abdominal organs are examined sequentially (clockwise). If a more detailed examination of the organs is required, a clamp is additionally inserted through a five-millimeter trocar. The state of the gallbladder, colon, pelvic organs, anterior surface of the stomach and liver can be assessed without difficulty. For a detailed examination of other organs, change the position of the body and introduce a soft clamp-manipulator. After making sure that there are no complications, they proceed to the introduction of other trocars for instruments and manipulators. With the introduction of additional trocars, the puncture of the anterior abdominal wall must be carried out outside the area where the epigastric vessels and their large branches are located. To ensure convenient operation of manipulators, trocars for inserting instruments are placed at a distance of at least 12 cm from each other. Given that the introduction of additional trocars is carried out under visual control (according to the image on the monitor), the risk of damage to internal organs is minimal. The greatest danger is the injury of the epigastric vessels. In this regard, it is useful to recall that the inferior epigastric artery, as a rule, is projected in the hypogastric region at the outer edge of the rectus abdominis muscle; at the level of the navel - approximately halfway between the outer and inner edges of the rectus muscle. At the level of the IX-X ribs, the main trunk of the artery approaches the midline of the abdomen. The superior epigastric artery enters the sheath of the rectus abdominis muscle in the area between the cartilage of the VII rib and the xiphoid process and goes along the posterior surface of the muscle to the navel. Usually the artery comes out from under the edge of the costal arch at a distance of 5-7 cm from the xiphoid process. Characteristically, the sharper the epigastric angle, the lower is the exit point of the superior epigastric artery from under the edge of the costal arch and the closer to the midline its trunk is projected. Damage to these vessels by a laparoscopic trocar is manifested by bleeding into the abdominal cavity from the puncture site of the abdominal wall or by the appearance of an increasing preperitoneal hematoma. With severe bleeding, an expansion of the incision of the abdominal wall, detection and stitching along the damaged vessel is shown. With a small bleeding, hemostasis is provided by coagulation of the peritoneum on both sides of the trocar along the course of the epigastric vessels. In order to avoid injury to the epigastric vessels, the introduction of additional trocars is sometimes preceded by diaphanoscopy: the surface of the parietal peritoneum in the area of the proposed puncture is illuminated from the inside with a telescope. Dissection of tissues and ensuring hemostasis in endosurgery is based on the use of high-frequency electric current from an electrosurgical generator. Current is applied to special tools with a dielectric coating. Tissue preparation is carried out in cutting and coagulation mode. A ligature, a metal clip, or staplers are used on large tubular structures. The range of the latter is expanding every year. It was their appearance that made it possible to perform endoscopic operations such as gastrectomy, hemicolectomy, etc. In recent years, in addition to electric current, new ultrasonic devices for hemostasis and bloodless dissection of tissues have appeared in the arsenal of surgeons in recent years, which allow, without prior ligation, to cross arterial vessels from 4 mm in diameter or more. Overall mortality in endoscopic surgery is 0,5%, and the complication rate is 10%. Wound infection is observed in 1-2% of cases, which is acceptable and comparable to the frequency of wound suppuration in similar operations performed using an open technique. Complications such as pneumomediastinum or subcutaneous emphysema result from the creation of pneumoperitoneum under high pressure (above 16 mm Hg). They are prone to spontaneous resorption and rarely lead to cardiac rotation or compression of the tracheal bifurcation. The development of pneumothorax during laparoscopy may be due to a wound in the diaphragm, a large diaphragmatic hernia, or spontaneous rupture of a lung cyst. There is a development of gas embolism as a result of direct puncture of the vessel with a Veress needle or as a result of the pressure of a gas embolus into the gaping lumen of the vessel, damaged during tissue preparation. This very rare complication can be fatal. Electrosurgical injuries are characterized by tissue burns or low-frequency electric shock. Of particular danger are intestinal damage, which for several days (up to the moment of perforation) may remain unrecognized and lead to the development of diffuse peritonitis. Cardiovascular collapse due to reduced venous return and low cardiac output may result in pneumoperitoneum in patients with severely impaired heart and lung function. Pain after surgery in the right shoulder can be caused by irritation of the diaphragm with carbon dioxide or its rapid expansion during insufflation. The pain is short-lived and resolves on its own. Damage to the vessels or nerves of the anterior abdominal wall can be caused by trocars. With a decrease in the risk of these complications, it is necessary to avoid holding the instruments in the projection of the rectus abdominis muscles. Sometimes the formation of hernias of the abdominal wall occurs at the sites of introduction of ten-millimeter trocars. 2. What is laparoscopy Sometimes, despite the high qualifications, experience of the doctor and the help of the patient, determining an accurate diagnosis for diseases and disorders in the pelvic and abdominal cavity causes some difficulties. In this case, diagnostic laparoscopy takes place, which today is one of the most common modern diagnostic (and in some cases, therapeutic) procedures aimed at examining the abdominal organs. Laparoscopy is an operative method of research. Several (usually two) tiny incisions are made in the abdominal cavity, after which air is injected. Through one incision, a device is inserted - a laparoscope (a thin tube with a lens at one end and an eyepiece at the other; or one end of the laparoscope can be connected to a video camera, the image from which is transmitted to the screen during manipulations), a manipulator device is inserted through another incision, serving in order to help the doctor examine the internal organs in detail, displacing them. Laparoscopy is a method used by a doctor and helping him visually, with his own eyes, examine the internal organs of the abdominal cavity and their possible changes. The air in this procedure increases the field of view of the specialist. The purpose of this procedure is to establish an accurate diagnosis. 3. Indications for laparoscopy Indications for laparoscopy in gynecological practice is infertility. This technique is a tool for quickly and painlessly determining the presence of physiological disorders that prevent pregnancy, as well as their elimination. For example, the so-called obstruction of the fallopian tubes, which is a consequence of infertility in about a third of women, experts advise to identify and simultaneously eliminate it with the help of laparoscopy. In the case of an ectopic pregnancy, laparoscopy can save the fallopian tubes, and, therefore, the woman retains the ability to conceive and give birth to a child. Also, laparoscopy is widely used for ovarian cysts, uterine fibroids, endometriosis and other inflammatory diseases of the internal genital organs. It is necessary to carry out laparoscopy in severe forms of secondary dysmenorrhea. Here, the operation is carried out not so much for diagnosis, but for the direct treatment of the disease. At the same time, approximately 80% of women suffering from secondary dysmenorrhea experience a significant improvement in their condition after laparoscopy. 4. Laparoscopy technique Since, in essence, laparoscopy is a surgical operation, then, as well as before other surgical interventions, before the procedure, it is required to carefully prepare the patient for it, which includes: 1) a general clinical blood test (moreover, its results are valid only for two weeks); 2) general urinalysis and fecal analysis; 3) x-ray or fluorography according to the doctor's indications; 4) electrocardiogram; 5) Ultrasound of the internal genital organs; 6) conclusion of the therapist about the absence of contraindications to laparoscopy; 7) abstinence from food before the procedure for 8 hours. The conclusion of the therapist should be given special attention, because, despite the harmlessness and safety of laparoscopy, nevertheless, as with any treatment method, there are a number of individual contraindications to laparoscopy. After preoperative preparation, before the operation itself, a premedication procedure is performed, which is the introduction of special medications to the patient, which enhance subsequent pain relief. After that, an experienced anesthesiologist makes general anesthesia (basically, a special mask with a breathing mixture is applied to the face). The respiratory system during the operation is under careful control all the time, and its successful functioning is ensured by special devices. Laparoscopy can also be performed under local anesthesia, this issue is decided individually with each patient. The beginning of the operation occurs with the fact that the abdominal cavity is inflated with carbon dioxide, which contributes to the elevation of the abdominal wall and the best access to the internal organs. The next step is the introduction of a special needle through the navel, with which a small puncture is made. Pre-treatment of the entire abdomen of the patient is carried out with an antiseptic solution, which prevents bacteria or other microorganisms from entering the wound. It must also be taken into account that the wound is so small and insignificant that after it there are absolutely no scars left, which is an important point for any woman. After reaching a certain gas pressure in the abdominal cavity, the surgeon introduces a special device called a laparoscope. It is characterized by a small diameter and the presence of a micro-camera that displays a view of the internal organs on the monitor, which helps specialists to obtain the most complete and reliable information about the state of the body and about the causes of any failures. According to the doctor's recommendations, after laparoscopy, it is necessary to stay in the hospital for at least a day. This need is due to the need to control the condition of the woman and the healing process. 5. Contraindications for laparoscopy Absolute contraindications to laparoscopy include the so-called terminal conditions of the patient (agony, preagony, clinical death, coma), severe disturbances in cardiopulmonary activity, sepsis or purulent peritonitis. Relative contraindications (that is, those in which the operation is in principle possible, but there is a certain amount of risk): 1) extreme degree of obesity; 2) blood clotting disorders; 3) late pregnancy; 4) general infectious diseases; 5) recently transferred open abdominal operations. 6. Pros and cons of laparoscopy In modern gynecology, laparoscopy is perhaps the most advanced method for diagnosing and treating a number of diseases. The positive aspects are the absence of postoperative scars and postoperative pain, which is largely due to the small size of the incision. Also, the patient does not have to comply with strict bed rest, and the restoration of normal health and performance occurs very quickly. At the same time, the period of hospitalization after laparoscopy does not exceed 2-3 days. This operation is characterized by very little blood loss, extremely low injury to body tissues. In this case, there is no contact of tissues with the surgeon's gloves, gauze wipes and other means, inevitable in a number of other operations. As a result, the likelihood of the formation of the so-called adhesive process, which can cause various complications, is reduced to the maximum. Among other things, the undoubted advantage of laparoscopy is the ability to conduct diagnostics simultaneously with the elimination of certain pathologies. At the same time, as noted, such organs as the uterus, fallopian tubes, ovaries, despite surgical intervention, remain in their normal state and function in the same way as before the operation. The disadvantage of laparoscopy, as a rule, is the use of general anesthesia, which, however, is inevitable in any surgical operation. It is worth remembering that various contraindications to anesthesia are clarified even in the process of preoperative preparation. Given this, the specialist concludes that general anesthesia is safe for the patient. If there are no contraindications to laparoscopy, the operation can be performed under local anesthesia. 7. Mode after laparoscopy Bed rest after laparoscopy is no more than a day, although a 2-3-day stay in the hospital is possible at the request of the patient, but for medical reasons this is rare. Wound healing is practically not accompanied by various painful sensations, so there is no need to use strong painkillers, especially narcotic analgesics. Very often, patients are concerned about the problem of contraception after laparoscopy. Contraceptives are selected on the basis of consultation with a specialist. At the same time, some women, without any reason, believe that after the operation some time should pass before conceiving a child. In general, we can say that after laparoscopy there is no special regimen that must be strictly observed. The only thing that is required is to carefully monitor your health and regularly undergo examination by a qualified gynecologist. Author: Getman I.B.
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