Parts of the diaphragm and place of their start. The diaphragm is the domed barrier between the thoracic and abdominal. Topography of the diaphragm. Triangles

Lower wall breast cavity It is represented by a muscle partition - a diaphragm, which rises with its dome up - right to the level of cartilage IV ribs and left to the level V rib. With acts of breathing, the diaphragm shifts 2-3 cm.

The diaphragm consists of a tendral center - Centrum Tendineum and muscular beams converging to it (Fig. 115).

Fig. 115. Diaphragm.
1 - Trigonum Sternocostale Sinister (Larreya slot); 2 - Greet; 3 - Pars Sternalis Diaphragmatis and Trigonum Sternocostale Dexter (Morganya Glock); 4 - diaphragmal part of the pericardium; 5 - v. Cava Inferior; 6 - n. phrenicus; 7 - Parscostalis Diaphragmatis; 8 - NN. Vagi; 9 - esophagus; 10 - v. azygos; 11 - breast lymphatic duct; 12 - TRIGONUM LUMBOCOSTALE (Bochdalek's gap); 13 - Pars Lumbalis Diaphragmatis; 14 - Truncus Sympathicus; 15 - breast aorta; 16 is a tendon center of the diaphragm. Diaphragm legs: I - internal; II - average; III - external; 17 - m. Quadratus Lumborum; 18 - m. psoas; 19 - Azygos and N. splanchnicus; 20 - Truncus Sympathicus.

According to the test of fixation, these muscles are divided into parts: sternum (Pars Sternalis), starting from a sword-shaped process, rib (Pars Costalis), starting from the VII-XII ribs, and lumbar (Pars Lumbalis) is a lumbar spine. The right and left half of the lumbar portion of the diaphragm are formed in the legs: 1) internal (Crus Mediale), beginning from the bodies of the thoracic and first 3-4 lumbar vertebrae, 2) medium, or intermediate (Crus intermedius), following the body II-III lumbar The vertebrae, and 3) external (Crus Laterale), departing up from the internal and external gallery arcs. Internal arcs (Arcus Lumbocostalis Medialis) are stretched from the body I or II of the lumbar vertebra to its transverse process. Outdoor arcs (Arcus Lumbocostalis Lateralis) follow from the transverse process of the mentioned vertebrae to the free edge of the XII rib. A large lumbar muscle comes from under the first arc (m. Psoas Major), from under the second - square lumbar muscle (m. Quadratus Lumborum).

The diaphragm has a number of holes. The inner legs of its lumbar part, fixed to the spine, form the cross in the form of figures 8, thereby limiting the two holes. Through the front hole (HIATUS Oesophageus) pass the esophagus and accompanying his wandering nerves, through the back (Hiatus Aorticus) - Aorta with her nervous plexus surrounding it, and behind it - the lymphatic duct. In the gap between the inner and medium legs, the unpaired (right) and the semi-regional (left) vein, large and small ventricular nerves are followed (the latter can spread the middle leg). Between the middle and outer leg, there is a border trunk of a sympathetic nervous system. The tendral part of the diaphragm has a hole for the lower vein hollow (for. Venae Cavae Inferior). The diaphragm there are still small-free triangular form of space: 1) between the sternum and the ribous part - the Trigonum Sternocostale Morgania (right) and the Larrey (left) transmitting a. ET V. Epigastrica Superiores, and 2) between lumbar and rib parts - Trigonum Lumbocostale Bohdalek. Through the holes in the diaphragm, the formation of hernia and the spread of infiltrate is possible.

The diaphragm is bloodshed in suitable on top of aorta AA. Phrenicae Superiores) branches from the inner chest artery: aa. Musculophrenica, Pericardiacophrenica and the following from the aorta AA. Phrenicae Inferiores and branches from AA. intercostales Venous blood flows through AA. Pericardia-Cophrenicae et vv. Phrenicae in hollow and intercostal veins. The main lymph paths are removed lymph into mediastinum nodes. Innervation is carried out by diaphragmal and VII-XII intercostal nerves.

Within cavity chest There are two pleural bags surrounding the lungs, and the mediastum is space between these bags.

The belly is divided into areas that make it possible to conclude about the projection of organs on the abdominal walls within these areas.

Right hypochrit region - Liver (most of the right lobe), the liver curvature of the colon, part of the right kidney.

Actually, the nasty region - the liver (most of the left lobe), gallbladder, stomach (part of the body and the pylorial department), a small gland, including a liver-duodenal bundle with a common bull duct, a liver artery, a mustache vein, the upper half of 12 guts, pancreatum, Parts of the kidneys, pellets, adrenal glands, aorta, solar plexus, section of pericardia.

Left hypochritic region - stomach (cardia, bottom, part of the body), liver (minor part of the left lobe), spleen, tail of pancreatic, spray curvature of the colon, part of the left kidney.

The right side area is an upward colon, a slight piece of Ileum, part of the left kidney, left ureter.

Underfloor area is a large curvature of the stomach, cross-border bowel, large gland, part 12 guts, loop of a skinny and iliac intestine, part of the right kidney, aorta, lower hollow vein.

The left side area is a descending colon, looped jadzhunum, left ureter.

The right ink-iliac area is the blind intestine with Appendix, the intestinal vertebral division.

Supported area-loop of thin intestines, bladder, part of a sigmoid gut, turning into a straight, uterus with a filled bubble or a rectum.

Left iliac-groove area-sigmoid gut, loops of thin intestines.

38.Topography of the diaphragm. Triangles.

The diaphragm (Diaphragma) in the form of a dome-shaped partition separates the chest cavity from the abdominal and consists of muscle and tendon parts. From the side of the chest cavity, it is covered with parietal pleutra, from the abdominal cavity side - parietal peritoneum. The right dome of the diaphragm, reaching the level of the IV rib, is standing above the left, which reaches V ribs.

In the muscular part of the diaphragm there are beams starting from the sword-shaped beam (Pars Sternalis), from the VII-XII edges (Pars Costalis) and from four upper lumbar vertebrae (Pars Lumbalis). Considering in the radial direction, the muscle fibers of the diaphragm go to its tendon (Centrum Tendineum), in the right half of which there is a hole transmitting the lower vein and the branches of the right-hand diaphragm nerve.

The lumbar part of the diaphragm forms three legs on each side: media, middle and lateral. The medial legs of the diaphragm (right and left), forming the crossing in the form of the number 8, limit the two holes: 1) Hiatus Aorticus through which the aorta passes and behind it the chest lymphatic duct, and 2) HIATUS OESOPHAGEUS, located up and kaperi from the previous one, - It misses the esophagus with wandering nerves. Both holes are located on the left of the midline. Muscular fibers of the diaphragm, directly surrounding the esophagus, form the esophagus sphincter - m. Sphincter Oesophagi. Despite the presence of a sphincter, the esophageal hole can serve as a seat in the rear media2 of the diaphragmal hernia, and the contents of them in these cases are usually the cardiac part of the stomach.

The gap between the inner and middle leg of the diaphragm passes V. Azygos (Right), N. Hemiazygos (left) and NN. Splanchnici, and between the middle and outer leg - the border trunk of the sympathetic nerve.

In addition to serous leaflets covering the upper and lower surfaces of the diaphragm, the fascial sheets are adjusted directly to it: at the top - Fascia Endothoracica (between Fascia and Pleverra there is a small layer of tubular fiber), below - Fascia Endoabdominalis, called Fascia Diaphragmatica (between fascia and peritoneum there is a small layer of podbrichlyo fiber).

In the diaphragm there are areas where there are no muscle fibers and leaflets of intrathoras and intra-abdominal fascia. These "weak parts" of the diaphragms sometimes serve as in places of the rehabilitation of the diaphragmal hernia, and the destruction of the named fascia as a result of the suppuration determines the possibility of transition of infection from the tubular tissue into the abnormality and back. There is also a triangular gap - Trigonum Sternocostale, who is also called Larreya's Trigonum Sternoi, is also a triangular interval - TRIGONUM Sternocostale (here produced here! Focol pericardia according to the method of Larreya); The interval contains the Vasa Thoracica Interna surrounded by fiber. A similar interval to the right of the sword-shaped process is called Morgania's gap. Two more gaps are on each side between the root of the diaphragm and the outer leg of its lumbar part (TRIGONUM LUMBOCOSTALE) - they are called often boosters of Bochdall.

The diaphragm is abundantly supplied with blood and is innervated from numerous sources. Arterial supply of the diaphragm carry out branches of both AA. THORACICAE INTERNAE, AA. Phrenicae Inferiores (the main arteries of the diaphragm), AA. Phrenicae Superiores, AA. intercostales

The innervation of the diaphragm is carried out by Nn. Phrenici, NN. INTERCOSTALES, BATHES NN. Vagi and Sympathici. The structure of the diaphragm, its abundant vascular-risitation and innervation give the basis for widespread use of the diaphragm (by flap on the leg) for plastic purposes during operations on the esophagus, pericardia, heart and other organs (B. V. Petrovsky). The best material for plastic is the ribra part of the left half of the diaphragm.

DIAPHRAGM (Greek, diaphragma. partition; syn. midriff) - a muscular tendon partition separating the thoracic cavity from the abdominal, which performs the function of the main respiratory muscle.

EMBRYOLOGY

Bookmark D. is carried out in a three-week embryo at the level of the IV-V cervical segment, from it by the 4th week. The cross-section of Gis (Septum Transversum) is developing, K-paradium shares the primary whole (see) on the abdominal and pleurropericarodial cavity. Theter's outer cherry-like folds located along the side departments of the body are beginning to be formed, the pleuroperitoneales (Membranae Pleuritoneales), designed to form a majority of domes, and the lumbar part of D is formed from the rear sickle folds. These departments grow ahead to the transverse partition, connect to it, But they leave the pleuroperitoneal channel on each side (Ductus PleuroPeritonealis), reporting the pleural and abdominal cavity. By the 8th week There is a firework of all Bookmarks D., K-Paradium at this I stage is a connective tissue plate, a fully insulating breast cavity from the abdominal. In the formation of a narrow rim along the edge of the diaphragm, the derivative of the body of the body is involved - the secondary edge part (Pars Costalis). In stage II, the conjunction of the connective tissue plate is transformed into a tendonous formation due to the differentiation on the site of the muscles from myoblasts located in the respective bookmarks of D. and emanating from III-V or IV-V Motomes. By the 24th week. D. differs from D. newborn only less thick muscle fiber.

The arising at the level of the cervical segments, D. is gradually removed from the site of the initial bookmark as the heart and lungs develop, push it down, and by the end of the 3rd month. Located at the level of its usual attachment.

Violation of the bookmarks of D. or their steady leads to D. Development Vices, such as the congenital absence of D. or its congenital defects. Violation of muscle development leads to the fact that D. remains at the connective tissue stage of development, as a result of which congenital relaxation D.

ANATOMY

D. is a flat thin muscle (m. Phrenicus), fiber to-swarm, starting around the circumference of the bottom aperture of the chest, go up and, converging radially, go into a tendon stretching, forming the right and left of the dome-shaped convexity with a pressing center for the heart (Planum Cardiacum). Accordingly, this in D. allocate the central tendon part (Pars Tendineum), or a tendon center (Centrum Tendineum), and a more extensive edge muscle part (Pars Muscularis), in which three parts are isolated: sternum, rib and lumbar.

Sodden part (Pars Sternalis) is weakly expressed, consists of several short muscle beams that depart from the inner surface of the breasts of the sword-shaped process. The sternum portion is separated from the edge narrow triangular slit filled with fiber - the soften-ripe space (Spatium Sternocostale) - the triangle of Larrey.

Register D. (Pars Costalis) begins from the inner surface of the cartilage VII-XII edges with separate beams, reaching up and turning into a tendon center. Triangular gap, Triangle Bohdlek (Trigonum Lumbocostale) separates the ribid part of D. from the lumbar.

Lumbar part (Pars Lumbalis) consists of each side of three legs (color. Fig. 1): outer, intermediate and internal. The outer leg (CRUS LATERALE) begins on the outer lumbar arc (Areus Lumbocostalis med.), Located between the XII edge and the transverse process L 1-2, and the inner lumbar-rib arc (Areus Lumbocostalis Med.) These vertebrae and attaching to its transverse process. The intermediate leg (crus intermedium) begins from the front surface of the body L 2-3, it is sent upwards and the duck, connecting with the fibers of the outer leg, and goes into the tendon center. There is a sympathetic barrel between the intermediate and outer legs (truncus sympathicus), and between the intermediate and the inner - right of the ventilation nerves and the unpaired vein, on the left - the semi-singing vein.

The inner leg (Crus Mediale) begins on the bodies L 3-4 and the front longitudinal bundle of the spine. Internal legs, connecting, first form an arc (Lig. Arcuatum), which limits the aortic hole (HIATUS AORTICUS), also passes the chest duct. Rear the aortic opening is limited by the spine.

The esophageal hole D. (HIATUS Esophageus) is formed due to the right leg; Left leg takes part in its formation only in 10% of cases.

The right leg is distinguished by three muscle beam, of which the right does not take part in the formation of the esophageal hole, and part of the medium beam fibers and the beam passing on leftform a muscular loop around the esophagus.

The esophagus is a channel with a width of 1.9 to 3.0 cm and a length of 3.5 to 6 cm. The distance between the esophageal and the aortic holes approx. 3 cm, very rarely there is a common esophageal and aortic hole.

Through the esophageal hole D. also wandering nerves (NN. Vagi).

In the tendon center of D. There are three departments: two side and front (medium), in which there is a hole for the lower vein (Foramen Venae Cavae s. Quadrilaterum).

From above, D. is covered with intrathoramic fascia, pericardium in the Planum Cardiacum zone, as well as pleural in the place of contact with light and in the sinus zone - the diaphragm-mediastinal and diaphragmalnoreberne. The latter is the latter and reaches 9 cm, but never reaches the level of attachment D. to the ribs, thereby producing a narrow prediaphraggmal space of 3-4 cm (spatium praediaphragmaticum), bounded by the upper-glass surface D., the inner surface of the ribs, pleural and filled with loose fiber.

The bottom of D. is covered with intra-abdominal fascia, on a large length of the peritoneum, missing only between the leaflet of the liver, around the holes of the esophagus, the lower hollow vein and on the entire lumbar and the last teeth of the root part of D. to this retroperitonear part of D. Pancreas and duodenum , as well as surrounded by a fat capsule of the kidney and adrenal glands. The liver goes to most of the right dome and to the inner department of the left domed, the bottom of the stomach and spleen also come into contact. These organs are connected to D. by means of appropriate ligaments. Of great importance in the hernias of the esophageal hole D. has a diaphragm-esophageal bunch (Lig. Phrenicoesophageum), covering the front surface of the esophagus. The lower boundary of D. is stable and corresponds to the place of attachment, while the position of the domes is very variable and depends on the constitution, age, various pathol, processes. Typically, the top of the right dome is at level IV, and the left - V intercostal gap. When inhaling Domes D. lowered by 2-3 cm and flattened.

Blood supply It is carried out by a paired muscular-diaphragmal artery (a. musculophrenica) from internal chest arteries, upper diaphragmal artery (a. Phrenica sup.) and lower diaphragmal (aortic (a. Phrenica inf.) From aorta and six lower intercostal arteries (AA. INTERCOSTALES). The outflow of venous blood takes place along the parallel veins, walking in parallel with the arteries, and, in addition, on the unpaired Vienna to the right and semi-regional - on the left, as well as on the veins of the esophagus (china. Fig. 2).

Lymph, vessels D. form, according to various authors, from two (D. A. Zhdanov, 1952) to three (I. N. Millokin, 1949) and even five networks: pleural, podelivinal, intrapleural, sub-repity, peritoneal (M. Josephs, 1930; M.S. Ignashina, 1961). D. Lymphs. Play a role in the spread of inflammatory processes from the abdominal cavity in pleural and vice versa, thanks to the system of lymph, vessels, proofing D. They are located mainly along the esophagus, aorta, the lower hollow vein and other vessels and nerves passing through D.

The outflow of lymphs from D. is carried out from above through the prelastropericarodial and rear mediastinal nodes, from the bottom - through subiaphragmal: paraportal and accumulative.

Innervation. Each half of D. is innervated by the diaphragmal nerve (n. Phrenicus), the branches of the six lower (VII-XII) intercostal nerves and the fibers of the diaphragmal plexus (Plexus diaphragmaticus) and solar plexus.

The only motor nerve of the corresponding half D. is a diaphragmal nerve, which is formed mainly from C3-4 spinal nerves. It has in its composition motor and sensitive fibers, which matters in the occurrence of Fralenic symptom (see). The branches of the lower intercostal nerves are only sensitive and vasomotor nerves of a narrow (up to 1-2 cm) peripheral diaphragm zone.

PHYSIOLOGY

D. performs two functions: static and dynamic. Static (reference) function is to maintain normal relationships between the organs of the chest and abdominal cavities, it depends on the muscle tone D. The violation of this function leads to the movement of the abdominal organs into the chest.

Dynamic (Motor) function is associated with the effects of alternately cutting and relaxing D. on the lungs, heart and abdominal organs.

As a result of the movements of D., the main volume of ventilation of the lower lobes and 40-50% of ventilation - upper fractions, K-paradium is ensured mainly by the edge-breast mechanism.

D. Inhalation reduces intrapleural pressure, contributing to the filling of the venous blood of the right hearts, and presses on the liver, spleen and abdominal organs, contributes to the outflow of them of venous blood, acting by the type of pump.

The impact of D. on the digestive organs consists of a massaging effect on the stomach and intestines, with a reduced tone D. increases the amount of air in the stomach and intestines.

Research methods

When percussion, it is possible to find a change in the level of standing D. or suspect the movement of the abdominal cavity organs into the chest based on the appearance of a blunt and tympanite zones over it, in combination with listening in this area of \u200b\u200bintestinal peristalsis and weakened respiratory noise.

Changing the position and function D. is often accompanied by a decrease in the respiratory volume of the lungs (see the life capacity of the lungs) and the change in functional respiratory trials, and with changes in the position of the heart - changes in the ECG.

Laboratory data in the diagnosis of diseases D. independent values \u200b\u200bdo not have.

X-ray study is the main objective method of diagnosing damage and diseases D. In a direct projection of D. represents two continuously convex arcs: the top of the right is at the level of the river in front, left - one edge below. With a profile study, the front part of D. is located above, and then it goes the Zosos down. With the calm breath of Domes D. descend 1-2 cm (perin), when forceing inhale and exhalation, the excursion D. reaches 6 cm. High standing of both Damars D. takes place during pregnancy, ascites, and in combination with mobility disorders - With paralytic intestinal obstruction, diffuse peritonitis. The high standing of one of the domes is marked with paralymps and paresis, relaxation of D., large tumors and cysts, liver abscesses, subadiaphragmal abscesses.

Low standing of D. D. (Franoptosis) is noted in the asthenic constitution, viscecoptosis, the defects of the anterior abdominal wall and the lung emphysema, and the latter is observed and limiting their mobility.

With paralymps and relaxation of D., the paradoxical movement of the dome may be observed, when it rises when inhaling, and when exhaling it is descended. The nature of the movements of D. and its functional state is investigated using special X-ray, methods. In polygraphy, there are usually two snapshots (diplogram) on one film with an exposure of 75% of the usual, first in the position of D. on the maximum exhalation, and then in the breath (see printing).

Uninacked X-ray, two-dollar or multiple with the use of a special lattice allows you to study the direction, amplitude and shape of the respiratory teeth D. (see x-ray), and X-rayEelectrokimography (see Electrocimography) - get a record of the details of the contour of any section D. Registration of D. D. D. Possible and with radiociomatography (see). To target the details of the details of the individual sections D., especially at cysts and tumors, tomography can be applied (see). On the status and condition of D. can be indirectly judged by the contrasting study of the adjacent organs (esophagus, stomach, intestines).

Isolate image D. from the adjacent organs in the absence of battles help diagnostic pneumoperitoneum (see), pneumothorax (see pneumothorax artificial) and pneumomediastinum (see pneumomediastinography).

PATHOLOGY

Development defects

The most frequently encountered malformations of D. - the incoming of a pleurroperitoneal channel or a violation of the capture of individual bookmarks D. with the formation of congenital false hernias (defects) D. very rarely meets the complete absence of the dome or even less often - all D., usually incompatible with life. Along with this, there is congenital underdevelopment of muscle tissue in both or one dome or some kind of its department with the development of congenital complete or partial relaxation D. to developmental defects also include extremely rare cases. Uncomplication D., when the place of its attachment to the thoracic wall and the spine is located above the usual one.

Damage

They can be divided into open (firearms, crushing) and closed (traumatic); The latter are divided into direct, indirect and spontaneous. All thoracoccudal injuries with damage to the internal organs are accompanied by damage to D. (see Thorocoabdominal Damage). Occasionally, there are isolated injuries without damaging the organs adjacent to it. Closed damage to D. occur during transport injuries and drops from height. The break of D. is most often due to a sudden increase in intra-abdominal pressure, much less often a similar mechanism can be noted in injuries of the chest, in 90-95% of cases with a closed injury D. The left half of it is affected; Very rarely observed the gap of both domes. As a rule, the tendon part of the dome is ruined or the separation of it from the muscular department. Less likely there is a gap of the lumbar part with damage to the esophageal hole or the separation of D. from the place of its attachment. There are also direct closed damage to D. when it breaks a broken edge. Insulated closed damage to D. Also observed rarely, they usually combine with damage to the bones of the pelvis and abdominal organs.

Through the gap of D. both at the open and closed damage to the pleural cavity, the abdominal bodies can fall - more often the stomach, gland, looping of the thick and small intestine. Occasionally, with large gaps, the liver can fall into the defect, and on the left of the spleen. The fallout may occur both immediately after injury and after one or another period of time.

Clinical picture It is usually masked by manifestations of concomitant injury (pleurpulmonal shock, respiratory and cardiovascular insufficiency, hemopneumothorax, peritonitis, bleeding, bone fractures). Independent diagnostic significance, only signs of the lung and displacement of the heart displaced into the chest abdominal organs are also available and especially the symptoms of their compression or infringement. Recognize damage to D. hard. The auxiliary feature of the thoracoabdominal injury in open damage is the direction of the wound channel. A reliable diagnosis can be supplied at open damage on the basis of falling into the wound of the chest of abdominal organs or the elapses of the feces and urine, as well as the detection in the chest of hollow organs of the abdominal cavity with a mandatory in such cases, as well as when closed damage, X-ray research.

The presence of gem or pneumothorax during belly damage causes suspicion of possible damage to D.

With laparotomy about the injury of belly or thorapotomy during damage to the bodies of the chest cavity, it is necessary to examine D. to exclude its rupture.

Treatment. With a diagnosed break D., it shows a simple embossing (Fig. 1) with separate seams of non-disseminating suture after the reduction of abdominal organs and excision of non-viable tissues of the diaphragm through the same access, to-ryy used for revision (thoraco or laparotomy). To strengthen the seams, the formation of duplication D. need is possible in the plastic strengthening of D., as a rule, does not occur, since extensive damage that gives a large defect is usually accompanied by an incompatible injury of adjacent organs.

Diaphragmal hernia

The diaphragmal hernia is the movement of the abdominal organs into the chest cavity through a defect or a weak zone of D. It is characterized by the presence of a junk gate, a hernial bag and hernia content. In the absence of a hernial bag, hernia is called false (Hernia Diaphragmatica Spuria), and if it is true (Hernia Diaphragmatica Vera); In these cases, the herniated bag is necessarily covered in the bottom of the parietal peritoneum, and from above - parietal pleutra.

All hernia D. shared according to the classification B. V. Petrovsky, H. N. Kanshin, N. O. Nikolaev (1966), on traumatic and non-immoral.

Non-massive herniaIn turn, are divided into false congenital hernias (defects) D., the true hernia of the weak zones D., the true hernia of atypical localizations, hernia of the natural holes of the D.- esophageal hole, rare hernia of natural holes D.

Of non-immovable hernia false are also congenital hernias (defects) D., which are often incorrectly called eggentrations, they can also be observed in adults.

The true hernias of weak zones include parastinal hernias (Fig. 2), for the designation of which also use the terms "front diaphragmal hernia", "Retroxifoid", "subskosnal", "sub-locomotive", "subcosteal", "Hernia Morgany", "Hernia Larrey " Paraspinal hernia can be retrocatenient, leaving through the breast-rib triangle Larreya, it can be called hernias of Larrey, and a retrosternal, associated with the underdevelopment of the sternum part of D. Usually the contents of the hernial bag in parasol hernias are the gland and transverse colon, but the parastinal lipomas are often found. , in which through the hernia Gate to D., as with a sliding hernia, preventive fatty fiber is protruded. True hernia lumbar triangles are very rare. A casuistic rarity represent the true hernia of atypical localization, there are no pronounced hernias with them. Among the hernia of natural holes D. The hernia of the esophagus is found very often and in connection with the peculiarities anatomical structureClinics and treatment represent a special group of diaphragmal hernia. There are separate cases of rare hernias of other natural holes d.: The slit of the sympathetic nerve, the holes of the lower hollow vein.

Traumatic hernia There are due to theracoabdominal wounds and breaks of D. and the very rare exceptions are false. The hernia gate can be localized in any department D., most often in the left dome. Rarely occurs a traumatic phrenopericardial hernia, usually with the loss of the gland to the pericardia cavity, and the intercostal diaphragmal hernia, which occurs with simultaneously damage to D. in the region of the diaphragm-ripe sinus and the chest wall, when the abdominal organs through the intercole or the area of \u200b\u200bthe damaged ribs are protruding out.

Symptomatics. In some cases (with a wide hernial gate, a gradual and insignificant loss of abdominal organs), diaphragmal hernias may not give symptoms for a long time.

The appearance of them depends on the compression of the lung and the displacement of the hearts with abdominal organs in the chest, as well as from the compression and the inflection of the fallen bodies, in these cases the symptoms are more pronounced with a narrow junk gate. Accordingly, it is usually marked by cardiovascular, jam.-Kish. and general symptoms. The most characteristic of pain in pain in the opposite region, chest, hypochondrium, shortness of breath, heartbeat, vomiting, feeling of gravity in the opposite region after meals. It is often noted bouffaging and rivant in the appropriate half of the chest.

With frequently observed at large diaphragm hernias, the breakdown of the stomach, accompanied by the inflection of the esophagus, is observed paradoxical dysfagia when the swords of the fluid is delayed, and the solid food passes well. The pronounced wedge, the picture is observed with the improved diaphragmal hernias. There is an attack of the abundant pain and a feeling of compression in the appropriate half of the chest or the upper body of the abdomen, often with irradiation in the back, the blade. An indomitable vomiting appears, first the reflex, and then (when the intestine) is associated with intestinal obstruction. Often develops a shock state. When the intestine is infrained, intoxication develops. The infringement of the hollow organ of the abdominal cavity may be accompanied by its necrosis and perforation with the development of popenemotrax (see).

Diagnosis. The presumptive diagnosis of the diaphragmal hernia is established on the basis of the instructions on the trauma of the abdomen and the chest (at traumatic hernias) indicated above complaints, determining the dullness or tympanite over the appropriate half of the chest, changing the intensity depending on the filling of the stomach and intestines, listen to intestinal noise in this zone . Finally, the diagnosis is established with X-ray, study.

X-ray, the picture depends on the nature and volume of displaced organs. When the stomach falls, a large horizontal level may be observed (Fig. 3) in the left half of the chest with the level of air above it; When the intestines are fraud - separate sections of enlightenment and dimming. D. contours can not be clearly defined. A contrast study of the stomach and intestines allows to determine the character (hollow or parenchymal) of the resulting organs, clarify the localization of the herniated gate (Fig. 4) based on the compression of the displaced organs at the hole level in D. (symptom of the hernial gate).

The hardest differentiation of the hernia and relaxation D. However, there are a number of x-ray, signs that allow it.

Treatment. The established diagnosis of the diaphragmal hernia due to the possibility of infringement is an indication to the operation, with the exception of the sliding hernia of the esophageal hole D., in which the infringement does not happen.

Anesthesia - endotracheal anesthesia with the use of muscle relaxants (see). The choice of access depends on the side of the lesion, the localization of the hernial gate and the character of hernia. With rare right-sided localization, the operation is possible only through transducer access to IV intercostal. With parastinal hernias, both on the right and left is the best access - upper median laparotomy. (cm.). With left-sided hernias, due to the possibility of battles with light, which are difficult to divide with laparotomy, shows transducer access to the VII-VIII intercostal system with the intersection of the rib arc. However, in cases of congenital posterior defects D., access can be successfully applied below and parallel to the rib arc. The operation consists in dividing the battles of the abdominal organs with light and in the area of \u200b\u200bthe hernial gate. Special caution should be observed when the spleen falls out, the damage to therch usually forces the splectomy (see).

After separating the battles and the complete liberation of the edges of the defect, the fallen bodies in the abdominal cavity are reduced and the defect is sutured. In the overwhelming majority, it is possible by imposing individual seams to form a duplication. Often with traumatic hernias of the edge of D. they are fused and grow together with a chest wall, which creates the impression of the complete absence of D. Selection of the edges of the defect allows you to straighten them and sew. If this fails, you have to resort to a number of techniques, for example, the mobilization of D., in particular due to the dissection of the diaphragm-ripe sinus. You can use alloplastic strengthening D. tissue from polymers, k-room is stitched to D. by type of patch from the inside and the edges of the defect (Fig. 5) are sewn over it. If it is impossible, the boost is sewn over the gap. With lateral defects due to the separation of D. It is fixed to the intercotheric fabric; With large defects, it is resorted to alloplastic fortification (Fig. 6), and the fabric crane is sewn with such a calculation so that it can be 1.5 cm per edge D.

With parastinal hernias, after reducing the displaced entrants, the hernia is turned and cut off from the neck. Then on the edges of D. and the rear sheet of the vagina of the abdominal muscles, as well as the vessels of the sternum and the ribs apply the seams (Fig. 7), usually p-shaped, which are sequentially tying.

The posterior defects are invented by transabdommenidly separate seams with the formation of duplication and leaving in the pleural cavity of the drainage introduced through D.

Operations about the disadvantaged diaphragmal hernias have their own characteristics. Access with the controversial diaphragmal hernias installed before the operation must be translate. Therefore, in cases where the disadvantaged diaphragmal hernia is found during laparotomy about the acute abdomen, after a significant time after infringement, it is advisable to switch to thoracotomy (see) to avoid the threat of a breakdown of the infringent organ and not infect the abdominal cavity. In the absence of pronounced necrotic changes, the infringerating ring along the grooved probe is first cutting and explore the state of the disadvantaged organ. In confidence in his vitality, the fallen body is immersed in the abdominal cavity and erupt the defect in D., which usually does not cause difficulties in connection with the narrow hernial gate. With irreversible changes, the affected department is resteed, and then ears D., leaving drainage in the pleural cavity.

The hernia of the teaching hole of the diaphragm can be sliding (axial) and parasezophageal (Fig. 8). The sliding hernia was half a million because when moving the cardia along the esophagus axis above D. Cardial dialing of the stomach due to the mesoperitoneal position takes part in the formation of the wall of the hernial bag. Sliding hernias (Fig. 8, 2, 3, 9-12) of the esophageal hole D. are divided into esophageal, cardiac, cardioofundal and giant (subtotal and total gastric hernias, in which the stomach in the chest) occurs). The sliding hernia can be fixed and non-fixed, congenital and acquired. In addition, due to the characteristics of the anatomy, clinics and treatment, the acquired short esophagus I and II degree and congenital short esophagus (chest stomach) associated with preventing it in the abdominal cavity in the embryonic period. The blood supply to the chest stomach in these cases is carried out from the branches of the intercostal arteries.

With parasezophageal hernias, the stomach or intestine displacement is shifted through the esophageal hole D. next to the esophagus, while the cardia remains in place.

This, unlike sliding hernia, determines the possibility of infringement. Parasezophageal hernias in the nature of the resulting organs are divided into the foundal, anthral, \u200b\u200bintestinal, gastrointestinal, salon (Fig. 8, 4-8).

In the development of the acquired sliding hernia of the esophageal hole D. The main difference is to reduce the longitudinal muscles of the esophagus as a result of its irritation, reflex with the stomach and adjacent organs with bark sickness, ulcers, etc. It is possible to develop the traumatic hernia of the esophageal hole after surgery on D. and the stomach.

For hernias of the esophageal hole There is a straightening of the corner of the GISA, which is generated between the esophagus and the bottom of the stomach, smoothing the gubareva valve (luxurious fold of the mucous membrane at the venue of the esophageal transition in the stomach) and there is a lack of cardia with a gastroofing reflux (see).

Symptomatics. The most frequent symptom is burning or stupid pain in the opposite area, behind the sternum and in the left or less often in the right hypochondrium with irradiation in the region of the heart, the blade, left shoulder. The pain is enhanced after eating and in the horizontal position of the patient, accompanied by belching, joining, heartburn. Of course, dysphagia is often noted, especially with the complication of the stricture of the esophagus, and anemia due to the hron, bleeding. Often there is a reflex angina (see).

Diagnosis. These complaints and wedges, symptoms allow to suspect the hernia of the esophageal hole D. The final diagnosis is set at a x-ray, the study, with the continuation of the folds of the charter of the stomach above the diaphragm (Fig. 9) with the shortening of the esophagus (or without it), and reflux contrast substance from the stomach in the esophagus. Reflux must be checked in the horizontal position of the patient when pressing the stomach.

With concomitant reflux-esophagite (see Ezophagitis), the esophagus can be expanded and shortened. The X-ray diffraction pattern is characterized by the presence of "backs", separating cards) from the gastrointestinal antifreeze.

Ezophagoscopy is used for diagnostics (see), which allows you to explore the condition of the mucous membrane of the esophagus and state the presence of refrigera-esophagitis.

Treatment. With uncomplicated shapes of the hernia of the esophageal hole D., conservative treatment is shown - the same as at ulcer disease (see). In the absence of Ahilia, food should be taken with small portions 5-6 times a day. After eating the patient should not fall, the last meal must be at least 3 hours before sleep. Do not be abundantly drinking, because it contributes to regurgitation (see). It should be avoided pronounced slopes of the body and sleep with a raised top of the body. Drug therapy is aimed at reducing secretion (both for peptic ulcer), to eliminate constipation, includes the reception of antacid drugs and sedatives.

Indication K. surgical treatment It serves as an unsuccessfulness of a long re-conservative treatment in patients with severe wedges, manifestations of hernia, as well as with the complication of the hernia of the peptic stricture of the esophagus and bleeding. TRANS -ABDY access is used, except for cases of extended peptic stictions of the lower third of the esophagus, when transducer access is required.

A large number of different operational methods were proposed, from which the Nissen's Fundoplikation (Fig. 10) was obtained, aimed at restoring the cardinal valve function.

After mobilizing the abdominal dialing of the esophagus, the rear wall of the feet of the stomach is carried out behind the esophagus and stitched with its front wall by a two-row seam, breathtaking the wall of the esophagus. The cuff is formed, the surrounding esophagus, thanks to which the sharp corner of Gis is restored. Isolated gastropkaxia (see), esophagofundorafia should be left as not enough effective. Also inefficiently embedding the esophageal hole, since it does not restore the valve function of the cardia, and with a short esophageal, this method is not applicable at all.

In shortening the esophagus to eliminate the reflux, the valve gastroplation can be used (by H. N. Kanchin). In this case, the Fundopling is performed not around the esophagus, but around the mobilized cardiac ventilation department. A number of surgeons use an operation of a collis, consisting in disseminating the moved upward stomach from top to bottom along the esophagus parallel to a small curvature by 12-15 cm with its elongation due to the resulting gastric tube.

In the treatment of peptic strictures of the esophagus, in the event of failure of repeated dilacies, the resection of a narrowed plot with valve esophagogroatomosis is shown by special buckets.

Parasezophageal hernias give more pronounced symptoms associated with the squeezing of hernia content, and the ability to infringe the operation shown immediately to establish a diagnosis. The operation consists in the reduction of abdominal organs and the stones of the hole in D.

With infrained hernias operate the same way as with other diaphragmal hernias.

The relaxation of the diaphragm is a sharp thinning of the devoid of muscles of D. with a displacement of it together with the organs of the abdominal cavity in the thoracic. The attachment line D. remains at normal location. As a rule, it comes to the lung on the side of the lesion and the displacement of the heart in the opposite direction (Fig. 11), there is a transverse and longitudinal turn of the stomach, so that the cardia and the antral department turn out to be at the same level.

Relaxation is congenital (on the soil of the muscle aplasia) and the acquired (most often due to damage to the diaphragmal nerve; in this case, the remains of atrophic muscle fibers can be detected during histol, study of D.).

Relaxation is complete (a whole dome is amazed, more often left) and limited (some kind of department D., more often the front medial on the right).

Clinical picture. Limited right-sided in advanced relaxation usually proceeds asymptomatic, represents a random x-ray, find. With left-sided relaxation symptoms are the same as with a diaphragmal hernia, but, unlike

The latter, due to the lack of tearing orphans, impossible is impossible. With a gradual displacement of the organs, the disease can proceed asymptomatic.

The diagnosis is made on the basis of signs of displacement of the abdominal organs into the appropriate side of the chest cavity and confirm with X-ray, the study. Unlike hernia, over the displaced abdominal organs, the shadow is usually defined by the shadow of a highly located D., under a swing of the stomach and the thick intestine give a symptom of open corners. Limited right-hand advanced relaxation has to differentiate. With tumors and liver cysts, pericardia and lung.

Treatment. The operation is shown only in the presence of pronounced wedges, symptoms and consists of either in the formation of the duplication of the thinned D., or in its plastic strengthening using alloplastic materials. For this purpose, Aivalon (sponge from a polyvinyl alcohol) is suitable, which in the form of a special patch is sewn between the duplication sheets of D. along the line of its attachment (Fig. 12).

Diaphragmal hernia in children It occurs more often as a result of D. Development Vices, less often - due to injury, a purulent-inflammatory or infectious process, so they are customary to divide into congenital and acquired. Congenital hernias are divided into true (Fig. 13, 1-3), having a hernia bag, and false (Fig. 13, 4-6), in which the abdominal organs through the through defect D. directly contact with light and heart. The frequency of congenital shelter D. is 1 to 1,700 newborns (S. Ya. Doletsky, 1976). The combination of hernia D. with other defects (congenital dislocation of thighs, krivoshes, pylororostenosis, embryonic hernia, heart disease, narrowing of the pulmonary artery, etc.) is observed in 6-8% of cases.

Acquired hernia D. shall be divided into traumatic and non-produce. The causes of traumatic hernia can be: D. breaks (acute and chronic) and relaxation D. (due to the injury of the diaphragmal nerve). Non-immature hernias may occur under through D. defects (as a result of an abscess, located under or over D.) and during relaxation D. (after polio or tuberculosis).

The hernia of the esophageal hole D. (Fig. 13, 7 and 8) in children are developing due to the slowdown in the rate of lowering the stomach of the thoracic cavity in the abdominal and the absence of obliteration of air-intestinal pockets, which is the result of the occurrence of hernia bags. Congenital hernia D., including with aluminum defects, as well as Franopericardial hernias (Fig. 13, 9 and 10) arise in anatomically "weak" departments by the D. - the inferior interval, lumbar triangle, etc. Education of thinned Zones or end-to-end defects D. occurs in the early stages of the development of the embryo and the fetus. Violation of trophic processes in the muscular bookmark D. leads to a slow-down development rate of D., elevated compared with intrapleural intraperous pressure - to the introduction of the abdominal bodies in the chest, which is in the last weeks of intrauterine life. Postnatal development D. is accompanied by its relative atrophy due to the growing value of the function of intercostal muscles. Breast-rib and lumbar triangles are progressively reduced, the area of \u200b\u200bthe tendon center is increasing due to muscle departments. The weight of D. is reduced relative to the weight of the whole body.

Acquired hernias D. arise as a result of an open or closed injury. Often, the break of D. followed by the development of a traumatic diaphragmal hernia occurs at a fracture of the pelvis due to a sharp increase intra-abdominal pressure. The tuberculous bronchodenit and the nonspecific inflammatory process in the mediastum may be complicated by the damage to the diaphragmal nerve with the atrophy of the part or the entire dome D. and the development of its relaxation. With subiaphragmal abscess or prolipers, as a result of a long drainage of the pleural cavity, the formation of a defect in D. is possible with the subsequent movement of the abdominal cavity organs into the chest.

Clinical picture. In newborns with a slick-like defect in the backyard D. (Triangle Bohdleleka), cyanosis, vomiting, heart displacement, lady-shaped belly ("asphying") are observed. When moving the significant amount of abdominal organs in the breast, there is a lag in the development of a child, shortness of breath when running, thoracic deformation. In the hernia of the esophageal hole, anemia is noted, vomiting with blood, pain, phenomena of erosive esophagitis. In some cases, the diaphragmal hernias can proceed asymptomatic (or with an unusual combination of ordinary symptoms). They are detected with X-ray, the study of the chest, carried out on another occasion.

The infringement of the diaphragmal hernia is characterized by a combination of signs of intestinal obstruction and respiratory failure (see).

Diagnosis. The diagnosis of the traumatic diaphragmal hernia contributes to the existence of an injury in history or scars on the skin of the chest. Physical symptoms in the zones of the hernia projection (shortening of the percussion sound or tympanitis, intestinal noises, splash, etc.) give reason to suspect the diaphragmal hernia and produce x-ray. Research to establish a final diagnosis. X-ray, signs of the diaphragmal hernia are the disappearance of the contour D. ("borderline line"), its characteristic deformation, separate darkens and enlightenment of the pulmonary field, levels in the cavities, "symptom of variability" - a significant sign of X-ray. Pictures with repeated studies. In doubtful cases, they produce a contrasting study of Zappa.-Kish. tract.

In newborns, the differential diagnosis is carried out with Partare D. due to the generic injury. With a paresa dome D. after 1 - 2 months. It takes the correct position. In some cases, due to the displacement of the heart to the right and cyanosis, they make an erroneous diagnosis of dextrocardia or heart defect. R-ray is crucial in diagnosis. Study of the chest.

Treatment operational. The exception is limited relaxation and complete relaxation of D. When its domes are located not higher than IV ribs and small hernias of the esophagus hole, provided that there are no complaints, patol, deviations, child backlog in development. In the presence of pain, vomiting, recurrent intestinal obstruction, jam.-Kish. Bleeding shows an operation in an institution where experience in interventions of this kind in children. The emergency operation is performed with a suphinic infringement in a newborn, with a break of D. and the infringent hernia D. of any localization.

The operation is more often produced by transabdominal access under intubation anesthesia (see inhalation anesthesia). With the true hernias, D. The hernia sip is sutted by assembling seams or with the creation of duplication. Exhausting a hernia bag is not necessary. With slick and significant defects, D. reduction of organs contributes to the introduction of air to the pleural cavity through the hernia with a metal catheter.

Defects D. erect one number of nodal unproductive seams. With phrenopericardial hernias and a significant hernial gate, a defect is applied by the defect with alloplastic material (Ivalon, Teflon, nylon), with a mandatory removal of the latter from the pleural or pericardial cavity of the peritonese leaflet on the leg, fascia or the gland. Excision of a junk bag with front and parasepal hernias is not necessary; The peritoneum dissect around the perimeter of the hernial gate to sew dessert fabrics. The success of the operation is associated with the movement of the esophagus in the front of the esophageal opening, the ears of the feet of D. behind the esophagus, aortic aortion, creating an acute esophageal and gastric angle by fixing the abdominal segment of the esophagus to the stomach and fixation of the dance of the stomach to the diaphragm in their natural contact. The operation is completed by pinoroplasty in order to avoid persistent vomiting due to pylorospasm (see) due to injury of wandering nerves. In the newborn, with a small volume of the abdominal cavity, which is not accompanying the organs, rendered from the pleural cavity, the first stage creates an artificial (artificial) ventral hernia, by K-Rui eliminate from 6 days to 12 months. After the first operation. The drainage of the pleural cavity in newborns produce on Buleuu (see Buleu drainage), avoiding the forced fragrance of the lung and the occurrence of acute emphysematous pneumonia. Drainage can be carried out below xi -xii ribs transabdomomomotionally to avoid its inflection when disgraceing the lecturess.

Postoperative complications are observed more than 50% of the operated children. There are general complications (hyperthermia, oppression of the respiratory center, violation of water-salt metabolism), pulmonary (atelectasis, swelling, pneumonia, pleurisy), abdominal (dynamic and mechanical intestinal obstruction), as well as excessive increase in intra-abdominal pressure (see), accompanied by restriction Excursions D. and the syndrome of the lower hollow vein (see hollow veins). Recurrements are most often observed in parasezophageal hernias.

Failure after surgery for the diaphragmal hernia in children is 5-8% (in newborns - up to 10 - 12%).

Diseases

Symptoms of diseases D. are associated with a change in its position (high standing, relaxation, tumor) or the movement of the abdominal organs into the chest at a diaphragmal hernia.

Depending on the prevalence of wedge, the manifestations of these symptoms can be divided into three main groups: common, cardiovascular, gentlemen. - Kish. These symptoms are not specific, they may be observed in some other diseases and acquire diagnostic significance only with certain objective data.

Inflammation of the diaphragm - diaphragmatites (or diaphragmitis) are divided into acute and chronic, specific and non-specific. In the overwhelming majority of cases, they are secondary. CHRON, diaphragmatites are usually specific - tuberculosis, syphilitic or fungal (actinomycosis) and self-wedge, values \u200b\u200bdo not have, as well as hron, nonspecific diaphragmitis associated with the chron, inflammatory processes of adjacent organs.

Acute nonspecific diaphragmatitis is almost always secondary and only occasionally depends on the hematogenous spread of infection from remote purulent foci. In the overwhelming majority, it takes place during acute pleurisites and light-grade lung abscesses or under subadiaphragmal abscesses.

Wedge, manifestations of acute diaphragm at the diaphragmatic symptom complex, described by M. M. Vicker: sharp pains in the lower chest deposits corresponding to the place of attachment D., pain in this area during palpation, the local rigidity of the abdominal muscles. A characteristic feature of acute diaphragmatitis V. I. Sobolev (1950) considers the high standing of the affected dome D. with the restriction of its mobility and flattening, shortening of sinuses, thickening of contours of D. in the presence of changes from the adjacent lung or subadiaphraggmal space. Since such diaphragmatites are secondary, treatment is aimed at eliminating the main process. The existence of sharp primary diaphragmatites in the literature is challenged, wedge, they do not have values.

Also rare and primary tumors of D. According to B. V. Petrovsky, H. N. Kanshin and N. O. Nikolaev (1966), in the world literature, 68 primary tumors d.: 37 benign (lipoms, fibrolipers, fibromes, leiomiomes , neurofibromes, lymphangiomas) and 31 malignant (of which 24 of the sarcoma, and the remaining hemangio- and fibroangioendothelioma, hemangiocitoma, mesothelioma, synovia). In subsequent years, only single observations are described.

Symptoms in a certain extent degree depend on the size and localization of cysts or tumors.

With small tumors and cysts, D. Symptoms are practically absent. At large tumor sizes, there may be signs of compression of light and displacement of the mediastinum organs with the development of hron phenomena, hypoxia (see), symptom of "drum sticks" (see drum fingers), and at large right-hand cysts and tumors there are symptoms from the bodily sides Cells, and at left-sided - they are mainly due to the compression of abdominal organs or esophagus. In secondary cysts and tumors growing in D. on the part of the adjacent organs, and with metastatic lesions, there are pain and symptoms that are determined by the main pathol, the process.

Diagnosis of primary tumors and cyst D. Ch. arr. X-ray and is based on discovery with benign tumors of a rounded shadow, merging with a shadow of D. Benign tumors and the cysts of the left domes are clearly visible on the background of a lightweight, deformed gas bubble of the stomach or spleen corner of the colon, and with right-sided localization they merge with the shadow of the liver, which makes Differentiate them with right-hand limited relaxation by D., tumors and liver cysts or similar formations in the lower share of the lung.

In these cases, diagnostic pneumoperitoneum or pneumothorax can be used.

For malignant tumors, infiltrating D., there is no clear definition of education, there is only thickening and deformation of the dome, which in some cases are disguised as pleural effusion.

Treatment. The initiated diagnosis of primary cyst or tumor D. is an indication for surgical intervention, carried out, as a rule, translate. The operation consists in raising a benign cyst or tumor D. either in excision of it within the limits of healthy tissues (if a malignant character is suspected), followed by the embossing of the defect D. separate silk seams. For large sizes of a defect formed after tumor removal, certain plastic methods can be applied to its closure.

Removal of secondary tumors and cysts D. are produced in cases where it is possible according to the same principles simultaneously with the removal of the main focus.

Consolidated data on damage and major diseases D. are shown in the table.

Table. Classification and clinical diagnostic characteristics of some damage and diaphragm diseases

Damage to the disease	Etiology and pathogenesis	Symptoms	Special research	X-ray symptoms	Medical
Damage
Closed (straight, indirect, spontaneous)	Most often - road and industrial injury, drop from height, compression; It is often a component of a combined injury. The gap in 90-95% is localized to the left. Through the formed defect in the chest cavity, abdominal organs are shifted, forming an acute diaphragmal hernia. Offset organs can occur at the time of injury or significantly later	The pain at the top of the abdomen and the corresponding half of the chest with irradiation into the test area, neck, hand. Dyspnea. Cyanosis. Tachycardia. Possible phenomena of partial intestinal obstruction. Displacement of the stupidity of the mediastinum into a healthy side. Tympanite or dull within the lung field. Variability of percussion data and auscultation. Detection of the discontinuity of the diaphragm at laparotomy in a patient with a trauma of the abdomen (the gap in 90-95% is localized from the left)	Radioscopy and radiography of the chest and abdominal cavity. If the patient's condition is allowed, the study of the stomach and intestines with the barial slut. With the difficulty of diagnosis - diagnostic pneumoperitoneum	Increase the level of standing of the diaphragm, limiting its mobility, sometimes deformation of the dome; The accumulation of fluid (blood) in the ripenodiaphragmal sine. Under the abdominal prolapse - darkening of the pulmonary field with enlightenment, sometimes with horizontal levels of fluid. Displacement in the chest cavity of contrasted stomach or intestinal loops	Treatment operational. Access - thoracotomy or laparotomy. After reducing the abdominal cavity of the displaced organs, stitching the aperture of the diaphragm with seams of non-disseminating material
Open (Koloto-cut, firearms)	Mandatory component of any thoracoabdomomominal injury	The severity of the patient's condition is due to combined damage to the breasts and abdomen, pneumothorax, shock, bleeding. Three types of clinical painting distinguish: 1) the predominance of symptoms from the abdomen (bleeding, peritonitis); 2) the predominance of symptoms from the bodily cavity (hemotorax, pneumothorax); 3) Symptoms from the bodies of the chest and abdominal cavity are equally expressed. Wound into the wound of the abdominal organs or the expiration of their contents, pneumatic and hemotorax in the wounded in the stomach, the symptoms of hemoperitoneum or peritonitis when breast injuries	Radioscopy and radiography of the chest cavity. Thoracocentsis or laparocentsis. In difficult cases - diagnostic pneumoperitoneum. Study of the stomach and intestines with barius slightening contraindicated	Detection of pneumatic and hemotorax when injuries of the abdomen, as well as symptoms of closed diaphragm damage	The audit of the abdominal organs, eliminating their possible damage. Sewing of the diaphragm damage, the elimination of gem and pneumothorax, drainage of the pleural cavity
Foreign bodies	Blind injuries (especially multiple convolver and fractional)	Specific, as a rule, are missing or can correspond to the symptoms of diaphragm	X-rayMiography, diagnostic pneumoperitoneum and pneumothorax	Moving the shadow of the foreign body with breathing together with the diaphragm, especially in the conditions of diagnostic pneumoperitoneum and pneumothorax	With a long existence and absence of symptoms, operational treatment is not? Showing. With recently penetrating sharp foreign bodies (eg, needles) and with the symptoms of suppuration: the removal is shown by thorerapotomy
Acute diaphragmatitis
non-specific secondary	Transition of infection on a diaphragm during pleurite, lung abscess, subadiaphragmal abscess, liver abscess, peritonitis	Triad of signs: 1) pain in the lower chest deposits, increasing when inhaling, cough, but not when driving; 2) when pressed in the intercotrixes, pain in the zone of distribution of pain is not enhanced; 3) the rigidity of the muscles of the front abdominal wall. With auscultation, a noise of friction of pleura is possible. Increase temperature, intoxication	Radiography, tomography, radiopymography. In suspected of the presence of empya, the pleura - diagnostic puncture	Flooding, high standing and blurred contours of the affected diaphragm dome with a sharp limitation or absence of mobility (sometimes paradoxical movements). Cluster of fluid in rib-diaphragmal sinuses. As appropriate, low-fat pneumonia, signs of liver abscesses, subadiaphragmal abscess	Conservative or surgical treatment: the main disease
nonspecific primary	Hematogenic or lymphogenic penetration of the pathogen in the stroke of the diaphragm	The same as during secondary diaphragmatite			Usually conservative antibacterial and anti-inflammatory treatment
Chronic diafragmatitis
nonspecific	Consequence of transferred acute diaphragm, less often primary-chronic defeat	The same as residual phenomena Pureurrites: chest pain, intensifying when inhaling, moderate shortness of breath, dry cough		A higher standing of the affected diaphragm section with flattening and deformation, with a fuzziness of contours, a limited adhesive process, limited, and sometimes paradoxical movements	Anti-inflammatory treatment, physiotherapy
specific	Tuberculosis, syphilis, fungal lesions (actinomycosis)		The same as in acute diaphragm	Same as under nonspecific diaphragm	Specific
	Correspond to similar cysts of other localizations	Associated with the character, dimensions, localization of education and depend mainly from the compression of adjacent organs. With large formations - local dullness, weakening or absence of respiratory noise. With echinococcosis - eosinophilia, the positive reaction of Casoni	Radiography, tomography, diagnostic pneumothorax and pneumoperitoneum. Ultrasonic location	The cysts of the left dome of the diaphragm are visible against the background of gas-containing organs (lung, stomach, spley corner of the colon). With right-sided localization they merge with the shadow of the liver	Operational removal (thoracotomy)
Benign	The origin and structure correspond to benign tumors of other localization. There are rare	Same as at cysts
Malignant (primary - sarcoma, synovia; secondary)	Primary tumors are rare, secondary often (lung cancer metastases, stomach, liver, etc.)	The combination of symptoms of diaphragm and the cysts of the diaphragm. With secondary tumors - symptoms of the underlying disease, often the symptoms of the presence of pleural exudate	If there is pleural exudate, puncture and cytol, the study of the point, thoracoscopy	Often the presence of symptoms of pleural exudate. Other symptoms like at cysts	In primary malignant tumors - resection of the dome of the diaphragm with single-stage plastics. With secondary - the treatment of the main disease
Diaphragmal hernia
Traumatic (false hernias)
acute, chronic	Consequence of open and closed diaphragm damage	With acute hernia - see damage; When hron, hernia can be two types: 1) gastrointestinal (pain in the opposite region, hypochondrium, chest, upwards, dying, vomiting); 2) cardiorespiratory (shortness of breath, heartbeat, amplifying after eating, with physical voltage). When prolapping into the chest occasion of the stomach, gastric bleeding with the development of anemia is possible; pointing the percussion sound or tympanitis over the pulmonary field; Absence or weakening of respiratory noise, rumbling, peristaltic noise, spruce noise with thoracic auscultation	Radioscopy and radiography of the chest and abdominal cavity. According to the testimony - the study of Zan.-Kish. The tract with the barius slighter. Diagnostic pneumoperitoneum	Dependes on which organs are moved to the pleural cavity. When the stomach is displaced, a large horizontal level can be observed in a pleural cavity with a level of air above it. When the intestine is displaced, separate sections of enlightenment and dimming. The contours of the diaphragm can not be clearly defined. Specific research specifies the nature of the displaced authorities	Emergency treatment is shown
infringed	The same as when breeding ventral hernia	Sharp pain in the chest and the upper parts of the abdomen; vomiting, shortness of breath, heartbeat, often phenomena of shock; When embanking the intestine - signs of intestinal obstruction. Subsequent - increasing intoxication	X-ray, including in Lateroposition. Study of the stomach and intestines with barium slightening	Signs of hernia and signs of compression of the regulating body in the hernial gate	Emergency operation. Access is determined by the "Localization of hernia, the size of a defect, the patient's condition
Nonhamatatic
false congenital hernias (congenital defects)	Pulk development of the diaphragm, meets mainly in children	Most patients with symptoms (cyanosis, shortness of breath, vomiting) arise from the moment of birth. In the future, the backlog in physical is joined. Development, Adamina, Bad Appetite	Diagnostic pneumoperitoneum	See traumatic diaphragmal hernia	Showing operational treatment
True hernia of weak zones of the diaphragm (parastinal, lumbokostal hernia boobdalek)	Congenital large sizes of slots between the anatomical diaphragm departments, an increase in intra-abdominal pressure	Depend on the nature and volume of hernia content. With small hernias, symptoms may be absent	For differential diagnosis between hernias and parasal wen, pneumoperitoneum and air introduction to prevental fiber are used	Same as with traumatic diaphragmal hernias	Emergency treatment is shown
Grooming Ecoming Hole Sliding (Cardial, Subtotal Gastric and Total Gastric)	Increased intra-abdominal pressure and longitudinal decrease in esophagus, as well as constitutional weakness of intermediate tissue. Through the extended esophageal hole of the diaphragm in the mediastinum shifts cardia with a greater or less part of the stomach	Pain and burning in the epigastrics and beast, heartburn, air belching, tightening, sometimes intermittent dysphagia. The most pronounced at high acidity and during the shortening of the esophagus. A large diagnostic value is increased symptoms after eating, in a horizontal position, with slopes of the body. Never joined. Vomiting with blood admixture. Anemia	Ezophagoscopy (to eliminate esophageal cancer and cardiac stomach), esophagomanometry	It is detected in a contrasting study of the esophagus and stomach on the Trichoscope	Operational treatment is shown at large sliding hernias with severe wedges, manifestations, occasionally with cardiac hernias, accompanied by heavy reflux-esophagitis (especially ulcerative and stenozing), resistant to conservative therapy
Parasezophageal (Foundal, Anthral, \u200b\u200bIntestinal, Salt)	Congenital unexpected embryonic recessus Pneumatoentericus. The bottom of the stomach, its anthral department, intestinal loop or gland coated with a jewelry bag are rotated into the mediastinum next to the esophagus while maintaining the subadiaphragmal arrangement of the cardia. There are rare	Periodically, the pain occurs high in the epigastria. Bleeding from the stomach with the development of anemia is possible. When infringement - an attack of a sharp pain with the development of dysfagia due to the compression of the esophagus in the hernial gate	The same as in the hernias of the esophageal hole of the diaphragm	Contrast examination of the esophagus and stomach. Foundal hernia from sliding cardioofundal distinguishes subiaphragmal map	Emergency treatment is shown
Rare hernias of the natural holes of the diaphragm (hernia of the slit of the sympathetic barrel; hernia of the hole of the lower vein; hernia of the intercore nerve hole)	Congenital expansion of these holes. The hernias are true. There are very rare	Do not have specific symptoms. Refinement of the character of the hernial gate is possible only when surgery or autopsy			Emergency treatment is shown
Relaxation	With congenital relaxation - underdevelopment of muscular elements of the diaphragm; With the acquired - atrophy, they are due to inflammatory changes or damage to the diaphragmal nerve. The thinned dome of the diaphragm (or its plot) shifts high upward, causing the lungs, mediastum displacement, moving up abdominal organs, lung compression	Pain in epigastric or hypochondrium, shortness of breath, soles of heartbeat, feeling of gravity after eating, belching, nausea, constipation, weakness. Pneumonia of the Lowned Localization	Diagnostic pneumoperitoneum	High standing one of the diaphragm domes or part of it. Paradoxical movements of the corresponding dome ("symptom of a swing") or restriction of mobility during partial relaxation. Partial relaxation requires differential diagnosis with tumors (cysts) of lung, diaphragm, liver	Operational treatment is shown ch. arr. With total relaxation with severe wedges, manifestations. In partial relaxation, the operation is shown if it is impossible to exclude a tumor of a diaphragm or liver

Bibliography: Bairov G. A. Emergency Surgery of Children, L., 1973; Dolletsky S. Ya. Diaphragmal hernia in children, M., 1960, Bibliogr.; Nesterenko Yu. A., Klim and Nekiya I. V. and Lelhekhova N. I. Razznes of the right dome of the diaphragm, Surgery, No. 4, p. 106, 1975; Petrovsky B.V., Kanshin H. N. and Nikolaev N. O. Surgery of the diaphragm, L., 1966, bibliogr.; Utkin V.V. and Apsitis B. K. Grooms of the esophageal hole of the diaphragm, Riga, 1976; FEKETE F., C 1 O T P. Etlortat-Jacob J. L. Ruptures du Diaphragme, Ann. Chir., T. 27, p. 935, 1973; H e i m i n g E., E B E 1 K. D. U. G H a R I B M. Komplikationen Bei Zwerchfellanomalien, Z. Kinderchir., BD 15, S. 147, 1974; KOSS P. U. R E I T T T E R H. Erkrankungen Des Zwerchfells, Handb. d. Thoraxchir., HRSG. v. E. Derra, BD 2, T. 1, S. 191, B. U. a., 1959; Olafsson G., Rausing A. a. H O 1 E N O. PRIMARY TUMORS OF THE DIAPHRAGM, CHEST, V. 59, p. 568, 1971; STRUG B., NOON G. P. A. B E A 1 1 A. S. Traumatic Diaphragmatic Hernia, Ann. Thorac. Surg., V. 17, \\ e. 444, 1974.

B. V. Petrovsky; S. Ya. Doletsky (ped.), Compiled by Table. H. N. Kanshin.

(Diaphragma, S.M. Phrenicus) is a movable muscular-tendon partition between thoracic and abdominal cavities. The diaphragm has a domestic form due to the position of the internal organs and the pressure difference in the chest and abdominal cavities. The convex side of the diaphragm is directed to the chest cavity, concave - down, in the abdominal cavity. The diaphragm is the main respiratory muscle and the most important organ of the abdominal press. Muscular bundles of the diaphragm are located along the periphery, have a tendral or muscular beginning on the bone of the lower edges or rib cartilage surrounding the bottom aperture of the chest, on the back surface of the sternum and lumbar vertebrae. Considering the upstairs, to the middle of the diaphragm, muscle beams are moving to the tendon center (Centrum Tendineum). Accordingly, the beginning is distinguished by the lumbar, rib and sneaker parts of the diaphragm. Muscle bugs of the lumbar part (Pars Lumbalis) The diaphragms begin on the front surface of the lumbar vertebrae, forming the right and left legs (Crus Dextrum et Crus snistrum), as well as on medial and lateral arcuate bundles. Medial arcuate bunch(Lig. Arcuatum Mediale) stretched over the large lumbar muscle between the lateral surface 1 of the lumbar vertebra and the top of the transverse process of the II lumbar vertebra. Lateral arcuate bunch(Lig. Arcuatum Laterale) passes transversely in front of a square loaf of the loaf and connects the top of the transverse step 11 of the lumbar vertebra with the XII edge.

The right leg of the lumbar part of the diaphragm is developed more and begins on the front surface of the body I-IV lumbar vertebrae. Left leg originates on the first three lumbar vertebrae. The right and left legs of the diaphragm at the bottom are woven into the front longitudinal bunch of the spine. At the top, the muscle bundles of these legs crossed in front of the body i of the lumbar vertebra, limiting the aortic hole (HIATUS AORTICUS). Through this hole pass the aorta and chest (lymphatic) duct. The edges of the aortic hole of the diaphragm are limited to bunches of fibrous fibers - this middle arcuate bundle(Lig. Arcuatum Medianum). With the reduction of muscle beams of the feet of the diaphragm, this bunch protects the aorta from the compression. Above and left the aortic hole muscle bundles of the right and left legs of the diaphragm again crossed out, and then disagree again, forming an esophageal hole (Hidtus esophageus). Through this hole, the esophagus together with the wandering nerves passes from the thoracic cavity to the abdominal. The corresponding sympathetic barrel, large and small crank nerves, as well as the unpaired vein (right) and the semi-singular vein (on the left) and separpart vein (left) are held between the muscular beams of the right and left legs of the diaphragm.

On each side between the lumbar and edge parts of the diaphragm there is a triangular form of a plot deprived of muscle fibers - the so-called lumbar-rib triangle.Here the abdominal cavity is separated from the chest cavity only by thin plates of intraperous and intrathless fascia and serous shells (peritoneum and pleural). Diaphragmal hernias can be formed within this triangle.

The rebellious part (Pars Costalis) of the diaphragm begins on the inner surface of the six-seven lower edges with separate muscle beams, which are wedged between the teeth of the transverse muscle of the abdomen.

The breast part (Pars Sternalis) of the diaphragm is the narrowest and weak, starts on the rear surface of the sternum.

There are also triangular sections between the breast and edge parts of the diaphragm - breast-rib triangles, where, as noted, breast fascia and abdominal cavities are separated from each other only incessant and intra-abdominal fascia and serous shells (pleural and peritone). Here also can form diaphragmal hernias.

In the tendral center of the diaphragm on the right there is a hole of the lower vein (ForaMen Venae Cavae), through which this vein passes from the abdominal cavity in the chest.

Diaphragm function: When reducing the diaphragm, its dome is complied, which leads to an increase in the chest cavity and a decrease in the abdominal. With simultaneous reduction with the muscles of the abdomen, the diaphragm helps to increase intra-abdominal pressure.

Diseases of the diaphragm

The diaphragm damage can be with penetrating injuries of breast and abdomen and with injury closed, mainly with a transport or catatram (drop from height). Against this injury, the diaphragm damage is not always determined clinically, but in all cases of damage to the breast and the abdomen of the diaphragm must be examined at mandatory, and it must be remembered that the left dome is damaged in 90-95% of cases.

The most frequent pathology of the diaphragm are hernia. The localization distinguishes the hernia of the dome of the diaphragm and the esophageal hole. Extremely rarely there are hernias of the slit of the sympathetic barrel, the lower hollow vein, the openings of the intercostal nerve, but they do not give clinics and more often serve as an operating find. By the origin, hernia is divided into congenital and acquired, with a missed break. Clinical manifestations depend on the magnitude of the hernial gates and tissues overlooking them in the chest cavity. With small size and regulation only the gland clinical manifestations The hernia may not be. The disadvantaged hernias of the diaphragm dome (hernia of the esophageal hole are never increasing): a sudden attack of sharp pain in the epigastria and a chest, even pain shock, palpitations, shortness of breath, vomiting, when embanking the intestine - signs of intestinal obstruction.

The sliding hernia of the dome of the diaphragm, more often traumatic genesis, but can be formed when the diaphragm is underdeveloped with localization in the region of the rib-lumbar triangle, usually on the left (Bogdilen hernia), are accompanied by two syndromes: gastrointestinal and cardio respiratory or combination. Gastrointestinal syndrome is manifested by pain in the epigastrium and hypochondrium (more often in the left), the chest, reaching the neck - in the neck, hand, under the blade, stupid, vomiting, sometimes with blood, paradoxical dysfagia (hard food is fluid, the rhodes are lingering ). When the stomach is prolapping into the chest cavity, gastric bleeding can be. The cardiorespiratory syndrome is manifested by cyanosis, shortness of breath, palpitations that are enhanced after eating, physical exertion, when a tilt position. In physical examination of the chest, there may be a change in the percutaneous sound (tympanite or stupidity), weakening or lack of breathing in lower dollars can be detected intestinal noises, etc.

The hernia of the diaphragmal openings is accompanied by pain and burning in epigastrics and behind the sternum, heartburn, belching air, joining, sometimes dysfagia. Symptoms are enhanced after meals, in a horizontal position, slopes of the body. Can be formed by SENA syndrome: the combination of the hernia of the esophagus, bile sickness and diverticulites of the colon. Rarely can occur the relaxation of the diaphragm: congenital, caused by the underdevelopment of muscles, and acquired, forming when inflammatory processes In the diaphragm, damage to the diaphragmal nerve. Accompanied by pains in epigastrics and hypochondrium, shortness of breath, attacks of heartbeat, feeling of gravity after eating, belching, nausea, constipation, weakness. In patients with frequent recurrent pneumonia of lower dollars.

The survey complex should include: lungs and abdomen, according to indications, conduct a study with contrasts of the stomach and intestines by bariry slightening and pneumoperitoneum (carefully, with a ready-made set for puncture of the pleural cavity or thoracotenate), laparoscopy or thoracoscopy with artificial pneumothorax, FGS. The purpose of the study is not only to establish a diaphragm pathology, but also to hold differential diagnosis with esophageal tumors, tumors and cysts in the liver, spleen.

Tactics: Treatment is carried out operational, the examination is complex, therefore the patient must be hospitalized in the thoracic separation, less often in the separation of abdominal surgery.

The diaphragm is a tendon-muscular dome-shaped ellipped form of a plate separating the thoracic cavity from the abdominal. The skeletonic dome of the diaphragm on the right corresponds to the IV edge, on the left - V. there is a difference in it: most of the muscular, smaller - tendon. In the muscular department, they allocate: the sternular part - starts from the rear surface of the lower edge of the sword-shaped process; rib - starts from the inner case of the cartilage of six lower edges; Lumbar - represented by powerful muscle bundles, which form three pairs of legs.

1. Internal begins with long tendons from the front surface of the body of the I-IV lumbar vertebrae; At the level of the XII breast vertebra, muscle fibers limit the hole for the descending part of the chest aorta, and on the right and behind it - the breast lymphatic duct. At the level of the XI of the chest vertebral, a hole for the esophagus, the front and rear wandering nerves is formed due to the right inner leg.

2. Intermediate legs originated from the side surface of the body II of the lumbar vertebra and medial arcuate folds. Between the intermediate and inner legs, an intertensive gap is formed, which passes into the rear media to the right - v. Azygos, left - v. Hemiazygos. In the opposite direction through the gap pass through a large and small inner nerves.

3. The lateral legs start from the side surfaces of the body II and I of lumbar vertebrae and from lateral arcuate ligaments. A sympathetic trunk is trained in the intertensive gap formed by the intermediate and outer legs into the retroperitoneal space.

All muscle bundles converge in the middle of the diaphragm and form a triangular shape of the tendon center, in the right part of which there is a hole for the lower vein hollow and the branches of the right diaphragmal nerve.

In the muscle diaphragm, there are triangular intervals facing the vertex to the tendon center, in which muscle fibers are missing, these triangles are weak diaphragm places. Breast-roar triangle (Larage slot) is located between the sternum and the rib parts of the diaphragm to the left of the sword-shaped process, through which the inner breast vessels pass is better expressed on the left. A similar triangle (Morgani gap) is distinguished to the right of the sword-shaped process. Between the root and lumbar parts of the diaphragm and the upper edge of the XII edges are lumbly-rib triangles (Bohdal's triangles).

Blood supply: AA. Phrenicae Superiores Et Inferiores (from the downstream part of the aorta); AA. INTERCOSTALES; AA. Thoracica Interna. Blood outflow - in veins of diaphragms; The top fell into internal breasts; Bottom - to the lower hollow vein.

Innervation: NN. phrenici; NN. Ntercostales; NN. Vagi et Sympatici.

In the chest cavity include lungs, surrounded by pleural bags and the mediastinum, in which there are pericardium, heart and large vessels, nerves, forkry gland, esophagus, trachea, main bronchi, chest lymphatic duct, lymph nodes, fascial cells. Plevra forms two serous bags. There is a cavity of the pleura between the parity and visceral leaves of the pleura. Three parts of the pleura: edge, diaphragmal, mediated. Borders: Front and rear - projection lines of the transition of the edge pleura in the diaphragmal: The front border right goes behind the sternum, reaching the middle line and at the level of the sixth intercostal interval goes into the lower. The front limit of the left pleura, reaching the IV ribs, deviates to the left, crossing the cartilage of the edge, reaching the VI, goes into the lower border. The lower boundaries of the pleurr from the cartilage Vi ribs turn down and the dust and intersect in the middle-clavical line VII edge, along the middle axillary line - x edge, on the bladder - XI edge, in paravertebral - XII edge. The rear boundary of the left pleura corresponds to the joints between the ribs and the vertebra; The rear boundary of the right pleura enters the front surface of the spine, the height of the distance of the dome of the pleura in front of 2-3 cm. Above the clavicle, rear - corresponds to the level of an accelerated process of the VII or I breast vertebra.

Pearral sinuses:

1) edge-diaphragmal; maximum height (6-8 cm.) The sinus reaches at the level of the middle axillary line;

2) media-diaphragmal;

3) rib media.

Topographic anatomy of mediastinal organs.

Lungs

In each lung, there are three surfaces: outer (rib); lower (diaphragmal); Internal (media). In the mediated surface of the lung there is a deepening - the gate of the lung, where the root of the lung (armor, pulmonary arteries and veins, bronchial vessels, nerves, lymphatic vessels, nodes) are located. The projection of the gates of the lungs on the chest wall corresponds to the V-VIII breast vertebrae from behind and II-IV edges in front. In the right light, three stakes: the upper, medium, lower; In the left - upper and lower. The oblique gap in the right easily separates the upper and middle lobe from the bottom (projected along the line conducted from the spiny process III of the thoracic vertebrae to the place of transition VI ribs in cartilage), and in the left lung - the upper share of the bottom. In the right lung there is an additional horizontal slit (projection on the line from the place of crossing the projection of the skeleton of the groove with a medium axillary line at the level of the IV rib before attaching its cartilage to the sternum).

Each lung has a bronchial wood, consisting of the main, equity and segmental bronchi. Each share of the lung consists of bronchopal segments. At the top of the latter there is its lower leg consisting of segmental bronchi, segmental artery and central veins.

Bronchople segments: 1) right light:

a) upper share (top, rear front);

b) the average share (lateral, medial);

c) lower share (top, medial basal, rear

basal).

2) Left light:

a) upper share (2 top-rear, front, upper branch,

lower branch);

b) lower share (top, medial basal, rear

basal).

The roots of the lungs: in the left lung gate at the top there is a pulmonary artery, the left master bronchus is lower and the stop from it. At the gate of the right lung - the right main armor is above, and pulmonary artery is lower and ahead of him. The pulmonary veins occupy the front position, and the rear armor.

Blood supply: The system of pulmonary and bronchial vessels participate. The first carry respiratory lunge, the second is the function of the nutrition of the pulmonary fabric. There are anastomoses between them.

The venous outflow is carried out in pulmonary veins, bronchial veins flowing into v. Azygos or v. Hemiazygos. Innervation is carried out by branches of sympathetic and wandering nerves, which form the front and rear pulmonary plexuses. And also participate in the branches of the diaphragm nerves. Lymphatic vessels fall into intimate nodes that are located in the Bronchi division places, and the discharge vessels in the nodes of the lung root, and then to the nodes located in the trachea.

The organs of the anterior mediastination include pericardium and heart.

Pericard - a closed serous bag as a result of attaching its parietal sheet to a large heart vessels, where he goes into visceral. From above, epicard is attached to the aorta, pulmonary artery, the upper vein, bottom - to the pulmonary veins, the bottom of the vein, the diaphragm. The ventricles are completely covered with pericardium, and atrium: a small part of their rear surface (between the mouths of the veins) outside the pericardia cavity. In front of the pericardial cavity are located, considering in order to right left: the final department of the upper hollow vein, the rising aorta, the pulmonary trunk. Kepened from the lower hollow vein and the aorts is located the right ear, and the left ear is adjacent to the left seamlessness of the pulmonary trunk.

In the pericardia allocate:

1) front - breast-roar department;

2) side - pleural;

3) rear - meduated department;

4) Nizhny - a diaphragmal department.

In the pericardial cavity, sinuses are distinguished:

1) front-bottom (at the front of the front pericardic front ventilator to the diaphragmal).

2) transverse (limited to top and front of the back surface of the ascending aorta and the pulmonary trunk, behind the right pulmonary artery and the rear wall of the pericardium, from the bottom - the deepening between the left ventricle of the heart and the atrium).

3) oblique (limited in front of the back surface of the left atrium, behind the rear wall of the pericardium, on the left and above - the final departments of the pulmonary vein, on the right and from the bottom - the lower hollow vein). Blood supply to pericardo-diaphragmal, intercostal, bronchial and esophageal arteries; back wall - branches of the descending part of the aorta; Visceral leaf - coronary arteries of the heart. Venous outflow - in the unpaired, upper diaphragmal, sympathetic and wandering.

A heart

Heart surfaces: Breast-rib (front); diaphragmal (lower); pulmonary (side); Rear (vertebral). Much of its part lies in the left half of the chest cavity, less - in the right. The longitudinal axis is directed by Kosovo: from top to bottom, right to left and in the back in advance. The front of the heart is formed: on the right - a small part of the right atrium and the right ear and the final department of the upper vein, to the left of it - the right ventricle with the pulmonary artery, hereinafter - the longitudinal groove of the heart and the vessels passing in it (the descending branch of the left corneous artery and the big vein of the heart ), the greatest part of the left ventricle with the top, left ear. Rear surface: left atrium and part of the right atrium and left ventricle. Lower surface: left ventricle and a small livland of the right atrium. The right border of the heart belonging to the upper hollow vein and right atrium comes from the upper edge of the III of the rib cartilage to the lower edge of V rib cartilage, at a distance of 2-2.5 cm. The dust from the right sterling line.

The lower limit belonging to the right ventricle and in a small part of the left, comes from the lower edge of the rib cartilage to the fifth left intercostal gap between the parasonal and the mid-coster line. The left border belonging to the left ventricle, the left ear, the pulmonary artery, comes upward from the previous one to the level of the III edge, not reaching 1.5-2 cm. To the left middle-clearable line. From here rises up to the second intercostal edge of the left ear.

Blood supply: right and leftistful arteries from the ascending aorta; The hearts of the heart form a collector - a spray sinus, which is located on the back surface of the heart in the coronary brorace and opens into the right atrium.

Innervation: branches of both wandering nerves; Both sipotic nerve trunks, both diaphragm nerves. All form aortic heart plexus, in which the surface is distinguished (located on the front surface of the aorta arc), deep (on the front surface of the trachea) of the plexus. Limphootok: regional lymph nodes of the heart are bifurial and upper front mediocked nodes.

Top hollow vein.

It is formed when the fusion of both shoulder-head veins go along the right edge of the sternum; Without reaching Pericarda, it takes V. Azygas. To the right of Vienna adjacent to the right medium Plegre, to the left - to the aortic arc. A right-hand diaphragmal nerve is running between the vein and meduminated Pleverra, the right pulmonary artery is, above the last bronchus.

Ascending aorta.

Its length is 5-6 cm. The beginning of it is covered in front and on the left of the pulmonary artery, in front and right - right ear. Behind the aorta lies the right pulmonary artery, on the right - the upper hollow vein.

Aortic arch

The initial department is covered in front with a right pleural bag, the final - left pleural bag. The middle department is covered with a fork iron, fatty tissue with upper front medioched lymph nodes. Behind the arc lies trachea, esophagus, chest duct, with lymph nodes. Behind the arc is a trachea, esophagus, chest duct, left return nerve, right - the initial segment of the upper hollow vein. Crossing the arc of the aortic arc in front, passes the wandering nerve, and Kepened and Knutrice from the wandering nerve at the level of the aorta arc goes the left diaphragmal nerve. From above and in front of the aorta arc passes the left shoulder-head vein. The right pulmonary artery and the left bronchum is adjacent to the arc, through which the arc rolls down, turning into a downward aorta.