They are located in the upper half of the anterior mediastinum. Boundaries of the posterior mediastinum

Mediastinum is a complex of organs located between the right and left pleural cavities. The mediastinum is limited in front by the sternum, in the back by the thoracic spine, and on the sides by the right and left mediastinal pleura. Superiorly, the mediastinum extends to the superior aperture chest, below - to the diaphragm.

In surgery, the mediastinum is divided into anterior and posterior. The boundary between the departments is the frontal plane drawn through the trachea and the roots of the lungs. In the anterior mediastinum there are the heart with large vessels leaving and entering it, the pericardium, aortic arch, thymus, phrenic nerves, phrenic-pericardial blood vessels, internal thoracic blood vessels, parasternal, mediastinal and superior phrenic lymph nodes. In the posterior mediastinum there are the esophagus, thoracic aorta, thoracic lymphatic duct, azygos and semi-gypsy veins, right and left vagus and splanchnic nerves, sympathetic trunks, posterior mediastinal and prevertebral lymph nodes.

According to the International Anatomical Nomenclature, the mediastinum is divided into upper and lower, the boundary between them is a horizontal plane drawn through the connection of the manubrium with the body of the sternum in front and the intervertebral disc between the IV and V thoracic vertebrae. In the upper mediastinum are the thymus, the right and left brachiocephalic veins, the upper part of the superior vena cava, the aortic arch and the vessels extending from it (brachiocephalic trunk, left common carotid and left subclavian arteries), trachea, upper part of the esophagus and the corresponding parts of the thoracic (lymphatic) duct, right and left sympathetic trunks, vagus and phrenic nerves.

The lower mediastinum, in turn, is divided into anterior, middle, and posterior. The anterior mediastinum, lying between the body of the sternum in front and the anterior wall of the pericardium in the back, contains the internal mammary vessels (arteries and veins), parasternal, anterior mediastinal and prepericardial lymph nodes. In the middle mediastinum there is the pericardium with the heart located in it and the intracardial sections of large blood vessels, the main bronchi, pulmonary arteries and veins, the phrenic nerves with the accompanying phrenic-pericardial vessels, the lower tracheobronchial and lateral pericardial lymph nodes. The posterior mediastinum is bounded by the pericardial wall anteriorly and the vertebral column posteriorly. The organs of the posterior mediastinum include the thoracic part of the descending aorta, the azygos and semi-gypsy veins, the corresponding sections of the left and right sympathetic trunks, splanchnic nerves, vagus nerves, esophagus, thoracic lymphatic duct, posterior mediastinal and prevertebral lymph nodes.

Cellular spaces of the chest cavity

The cellular spaces of the chest cavity are divided into parietal (behind the sternum, above the diaphragm, at the spine and on the side walls of the cell chest) and into anterior and posterior mediastinal.

Parietal cellular spaces

Parietal tissue also called extrapleural, subpleural, retropleural. Four areas of parietal tissue can be distinguished.

The area of the upper ribs and the dome of the pleura is distinguished by the presence of a significant layer of loose fiber, which allows the pleura to peel off freely.

The second area is located 5-6 cm to the right and left of the spine. It has a well-defined layer loose fiber and without sharp boundaries passes into the next area.

The third area is downward from the IV rib to the diaphragm and anteriorly to the junction of the ribs into the costal cartilages. Here, the loose tissue is weakly expressed, as a result of which the parietal pleura is difficult to separate from the intrathoracic fascia, which must be kept in mind during operations on the chest wall.

The fourth region of the costal cartilages, where only at the top (up to the third rib) there is a significant layer of loose fiber, and towards the bottom the fiber disappears, as a result of which the parietal pleura here is firmly fused with the fibers of the transverse muscle of the chest, and on the right - with the muscular-diaphragmatic vascular bundle .

Retrosternal cellular space- a layer of loose fiber, delimited in front by the fascia endothoracica, on the sides by the mediastinal pleurae, and behind by a continuation of the layer of cervical fascia (fascia retrosternalis), supported on the sides by bundles coming from the fascia endothoracica. Here are the parietal lymph nodes of the same name, internal thoracic vessels with anterior intercostal branches extending from them, as well as anterior intercostal lymph nodes.

The fiber of the retrosternal space is separated from the fiber spaces of the neck by a deep layer of the neck's own fascia, which is attached to the inner surface of the sternum and the cartilage of the 1st - 2nd ribs. Downwards, the retrosternal tissue passes into the subpleural tissue, which fills the gap between the diaphragm and the ribs downward from the costophrenic sinus of the pleura, the so-called Luschka fat folds, which lie at the base of the anterior wall of the pericardium. On the sides, Lyushka's fat folds look like a ridge up to 3 cm high and, gradually decreasing, reach the anterior axillary lines. The accumulation of fatty tissue on the upper surface of the sternocostal triangles of the diaphragm is characterized by great constancy. Here the fiber does not disappear even in the case when there are no pronounced triangles. The retrosternal cellular space is limited and does not communicate with the cellular spaces and fissures of the anterior and posterior mediastinum.

Prevertebral cellular space located between the spinal column and intrathoracic fascia; it is filled with a small amount of fibrous connective tissue. The prevertebral cellular fissure is not a continuation of the cellular space of the same name in the neck. Cervical region The prevertebral space is delimited at the level of the II - III thoracic vertebrae by the attachment of the long muscles of the neck and the prevertebral fascia of the neck, which forms cases for them.

Anterior to the intrathoracic fascia is the parietal prevertebral space, which contains especially a lot of loose fiber in the area of the paravertebral grooves. Extrapleural tissue on both sides is separated from the posterior mediastinum by fascial plates running from the mediastinal pleura to the anterolateral surfaces of the thoracic vertebral bodies - the pleuro-vertebral ligaments.

Cellular spaces of the anterior mediastinum

Fascial sheath of the thymus or the adipose tissue replacing it (corpus adiposum retrosternale) is located in the anterior mediastinum most superficially. The case is formed by a thin fascia, through which the substance of the gland is usually visible. The fascial sheath is connected by thin fascial spurs to the pericardium, mediastinal pleura and fascial sheaths of large vessels. The superior fascial spurs are well defined and include the blood vessels of the gland. The fascial sheath of the thymus occupies the upper interpleural field, the size and shape of which depend on the type of structure of the chest.

The upper and lower interpleural fields have the form of triangles with their vertices facing each other. The lower interpleural field, located downward from the IV rib, varies in size and is often located to the left of the midline. Its size and shape depend on the size of the heart: with a large and transversely located heart, the lower interpleural field corresponds to the entire body of the sternum along the IV, V and VI intercostal spaces; When a small heart is positioned vertically, it occupies a small area of the lower end of the sternum.

Within this field, the anterior wall of the pericardium is adjacent to the retrosternal fascia and fibrous spurs, described as pericardial ligaments, are formed between the fibrous layer of the pericardium and this fascia.

Along with the type of structure of the chest, the general development of adipose tissue in a person is also important to determine the shape and size of the upper and lower interpleural tissue spaces. Even at the place where the pleural sacs are closest to each other level III the ribs, the interpleural space reaches 2-2.5 cm with a thickness of subcutaneous fat of 1.5-2 cm. When a person is exhausted, the pleural sacs come into contact, and with severe exhaustion they overlap each other. In accordance with these facts, the shape and size of the interpleural fields change, which is of great practical importance for surgical access to the heart and large vessels of the anterior mediastinum.

In the upper part of the anterior mediastinum around large vessels, fascial sheaths, which are a continuation of the fibrous layer of the pericardium. In the same fascial sheath is the extrapericardial part of the arterial (botallian) duct.

Outside the fascial sheaths of large vessels is located fatty tissue the anterior mediastinum, which accompanies these vessels and into the root of the lung.

Anterior mediastinal tissue surrounds the trachea and bronchi, forming the peritracheal space. The lower border of the peritracheal tissue space is formed by the fascial sheath of the aortic arch and the root of the lung. The peritracheal cellular space is closed at the level of the aortic arch.

Down from both bronchi there is a fascial-cellular gap filled with fatty tissue and tracheobronchial lymph nodes.

In the peritracheal tissue space, in addition to blood vessels, lymph nodes, branches of the vagus and sympathetic nerves, there are extraorgan nerve plexuses.

Fascial-cellular apparatus lung root It is represented by fascial sheaths of the pulmonary vessels and bronchi, surrounded almost throughout by layers of the visceral pleura. In addition, the anterior and posterior lymph nodes and nerve plexuses are included in the pleural-fascial sheath of the lung root.

From the anterior and posterior surfaces of the lung root, the pleural layers descend downwards and attach to the diaphragmatic fascia at the border of the muscular and tendon parts of the diaphragm. The pulmonary ligaments formed in this way (lig. pulmonale) fill the entire slit-like space from the root of the lung to the diaphragm and are stretched between the inner edge of the lower lobe of the lung and the mediastinum. In some cases, the fibers of the pulmonary ligament pass into the adventitia of the inferior vena cava and into the fascial sheath of the esophagus. In the loose tissue between the layers of the pulmonary ligament there is the inferior pulmonary vein, which is 2-3 cm (up to 6) from the other components of the lung root, and the lower lymph nodes.

The tissue of the anterior mediastinum does not pass into the posterior mediastinum, since they are separated from each other by well-defined fascial formations.

Cellular spaces of the posterior mediastinum

Peri-esophageal cellular space limited in front by the preesophageal fascia, in the back by the retroesophageal fascia, and on the sides by the parietal (mediastinal) fascia. From the esophagus to the walls of the fascial bed there are fascial spurs in which blood vessels pass. The paraesophageal space is a continuation of the retrovisceral tissue of the neck and is localized in upper section between the spinal column and the esophagus, and below - between the descending part of the aortic arch and the esophagus. In this case, the fiber does not descend below the IX-X thoracic vertebrae.

The lateral pharyngeal-vertebral fascial spurs traced on the head and neck, separating the retropharyngeal space from the lateral ones, continue into the chest cavity. Here they are thinned and attached on the left to the fascial sheath of the aorta, and on the right to the prevertebral fascia. In the loose tissue of the paraesophageal space there is, in addition to the vagus nerves and their plexuses, the venous paraesophageal plexus.

Fascial sheath of the descending thoracic aorta formed behind by the retroaortic fascia, in front by the retroesophageal fascia, and on the sides by the mediastinal spurs of the parietal fascia. The thoracic lymphatic duct and azygos vein are located here, and closer to the diaphragm, the semi-gypsy vein and large splanchnic nerves also enter here. Higher up, that is, in the upper parts of the chest, all these formations have their own fascial sheaths and are surrounded by a greater or lesser amount of loose or fatty tissue. The greatest amount of fiber is found around the lymphatic duct and azygos vein, the least - around sympathetic trunk and splanchnic nerves. The fiber around the thoracic lymphatic duct and azygos vein is penetrated by fascial spurs extending from the adventitia of these formations to their fascial sheaths. The spurs are especially well defined in the peri-aortic tissue.

Mediastinal surgery, one of the youngest branches of surgery, has received significant development due to the development of issues of anesthesia, surgical techniques, diagnosis of various mediastinal processes and neoplasms. New diagnostic methods make it possible not only to accurately establish the localization of a pathological formation, but also make it possible to assess the structure and structure of the pathological focus, as well as obtain material for pathomorphological diagnosis. Recent years have been characterized by the expansion of indications for surgical treatment of mediastinal diseases, the development of new highly effective, low-traumatic treatment methods, the introduction of which has improved the results of surgical interventions.

Classification of mediastinal disease.

Mediastinal injuries:

1. Closed trauma and wounds of the mediastinum.

2. Damage to the thoracic lymphatic duct.

Specific and non-specific inflammatory processes in the mediastinum:

1. Tuberculous adenitis of the mediastinum.

2. Nonspecific mediastinitis:

A) anterior mediastinitis;

B) posterior mediastinitis.

According to the clinical course:

A) acute non-purulent mediastinitis;

B) acute purulent mediastinitis;

B) chronic mediastinitis.

Mediastinal cysts.

1. Congenital:

A) coelomic pericardial cysts;

B) cystic lymphangitis;

B) bronchogenic cysts;

D) teratomas

D) from the embryonic embryo of the foregut.

2. Purchased:

A) cysts after hematoma in the pericardium;

B) cysts formed as a result of the disintegration of a pericardial tumor;

D) mediastinal cysts arising from the border areas.

Mediastinal tumors:

1. Tumors arising from the organs of the mediastinum (esophagus, trachea, large bronchi, heart, thymus, etc.);

2. Tumors arising from the walls of the mediastinum (tumors of the chest wall, diaphragm, pleura);

3. Tumors arising from the tissues of the mediastinum and located between organs (extraorgan tumors). Tumors of the third group are true tumors of the mediastinum. They are divided according to histogenesis into tumors from nerve tissue, connective tissue, blood vessels, smooth muscle tissue, lymphoid tissue and mesenchyme.

A. Neurogenic tumors (15% of this location).

I. Tumors arising from nervous tissue:

A) sympathoneuroma;

B) ganglioneuroma;

B) pheochromocytoma;

D) chemodectoma.

II. Tumors arising from nerve sheaths.

A) neuroma;

B) neurofibroma;

B) neurogenic sarcoma.

D) schwannomas.

D) ganglioneuromas

E) neurilemmomas

B. Connective tissue tumors:

A) fibroma;

B) chondroma;

B) osteochondroma of the mediastinum;

D) lipoma and liposarcoma;

D) tumors arising from blood vessels (benign and malignant);

E) myxomas;

G) hibernomas;

E) tumors from muscle tissue.

B. Tumors of the thymus gland:

A) thymoma;

B) thymus cysts.

D. Tumors from reticular tissue:

A) lymphogranulomatosis;

B) lymphosarcoma and reticulosarcoma.

E. Tumors from ectopic tissues.

A) retrosternal goiter;

B) intrathoracic goiter;

B) adenoma about thyroid gland.

The mediastinum is a complex anatomical education, located in the middle of the thoracic cavity, enclosed between the parietal leaves, the spinal column, the sternum and below the diaphragm, containing fiber and organs. The anatomical relationships of the organs in the mediastinum are quite complex, but knowledge of them is mandatory and necessary from the standpoint of the requirements for providing surgical care to this group of patients.

The mediastinum is divided into anterior and posterior. The conventional boundary between them is the frontal plane drawn through the roots of the lungs. In the anterior mediastinum there are: the thymus gland, part of the aortic arch with branches, the superior vena cava with its sources (brachiocephalic veins), the heart and pericardium, the thoracic part of the vagus nerves, the phrenic nerves, the trachea and the initial sections of the bronchi, nerve plexuses, lymph nodes. In the posterior mediastinum there are: the descending aorta, azygos and semi-gypsy veins, the esophagus, the thoracic part of the vagus nerves below the roots of the lungs, the thoracic lymphatic duct (thoracic region), the border sympathetic trunk with the splanchnic nerves, nerve plexuses, lymph nodes.

To establish a diagnosis of the disease, localization of the process, its relationship to neighboring organs, in patients with mediastinal pathology, it is first necessary to conduct a full clinical examination. It should be noted that the disease is initial stages is asymptomatic, and pathological formations are an incidental finding during fluoroscopy or fluorography.

The clinical picture depends on the location, size and morphology pathological process. Typically, patients complain of pain in the chest or heart area, interscapular area. Often pain preceded by a feeling of discomfort, expressed in a feeling of heaviness or foreign formation in the chest. Shortness of breath and difficulty breathing are often observed. When the superior vena cava is compressed, cyanosis of the skin of the face and upper half of the body and their swelling may be observed.

When examining the mediastinal organs, it is necessary to conduct thorough percussion and auscultation to determine the function external respiration. Important during the examination are electro- and phonocardiographic studies, ECG data, x-ray examination. Radiography and fluoroscopy are carried out in two projections (direct and lateral). When a pathological focus is identified, tomography is performed. The study, if necessary, is supplemented with pneumomediastinography. If the presence of a substernal goiter or an aberrant thyroid gland is suspected, ultrasound examination and scintigraphy with I-131 and Tc-99 are performed.

IN recent years When examining patients, instrumental research methods are widely used: thoracoscopy and mediastinoscopy with biopsy. They allow a visual assessment of the mediastinal pleura, partly the mediastinal organs, and collection of material for morphological examination.

Currently, the main methods for diagnosing mediastinal diseases, along with radiography, are computed tomography and nuclear magnetic resonance.

Features of the flow individual diseases mediastinal organs:

Damage to the mediastinum.

Frequency - 0.5% of all penetrating chest wounds. Damage is divided into open and closed. Features of the clinical course are caused by bleeding with the formation of a hematoma and compression of organs, vessels and nerves.

Signs of mediastinal hematoma: slight shortness of breath, mild cyanosis, swelling of the neck veins. X-ray shows darkening of the mediastinum in the area of the hematoma. Often a hematoma develops against the background of subcutaneous emphysema.

When the vagus nerves are imbibited by blood, vagal syndrome develops: respiratory failure, bradycardia, deterioration of blood circulation, and confluent pneumonia.

Treatment: adequate pain relief, cardiac support, antibacterial and symptomatic therapy. With progressive mediastinal emphysema, puncture of the pleura and subcutaneous tissue chest and neck with short and thick needles to remove air.

When the mediastinum is injured, the clinical picture is complemented by the development of hemothorax and hemothorax.

Active surgical tactics are indicated for progressive impairment of external respiratory function and ongoing bleeding.

Damage to the thoracic lymphatic duct can occur with:

1. closed injury breasts;
2. knife and gunshot wounds;
3. during intrathoracic operations.

As a rule, they are accompanied by severe and dangerous complication chylothorax. If unsuccessful conservative therapy Within 10-25 days, surgical treatment is necessary: ligation of the thoracic lymphatic duct above and below the injury, in rare cases, parietal suturing of the duct wound, implantation into the azygos vein.

Inflammatory diseases.

Acute nonspecific mediastinitis- inflammation of the mediastinal tissue caused by a purulent nonspecific infection.

Acute mediastinitis can be caused by the following reasons.

Open mediastinal injuries.
1. Complications of operations on the mediastinal organs.
2. Contact spread of infection from adjacent organs and cavities.
3. Metastatic spread of infection (hematogenous, lymphogenous).
4. Perforation of the trachea and bronchi.
5. Perforation of the esophagus (traumatic and spontaneous rupture, instrumental damage, damage by foreign bodies, tumor disintegration).

The clinical picture of acute mediastinitis consists of three main symptom complexes, the varying severity of which leads to its diversity clinical manifestations. The first symptom complex reflects the manifestations of severe acute purulent infection. The second is associated with the local manifestation of a purulent focus. The third symptom complex is characterized by the clinical picture of damage or disease that preceded the development of mediastinitis or was its cause.

General manifestations of mediastinitis: fever, tachycardia (pulse - up to 140 beats per minute), chills, decreased blood pressure, thirst, dry mouth, shortness of breath up to 30 - 40 per minute, acrocyanosis, excitement, euphoria with transition to apathy.

With limited posterior mediastinal abscesses, the most common symptom is dysphagia. May be dry barking cough up to suffocation (involvement of the trachea in the process), hoarseness (involvement of the recurrent nerve), as well as Horner's syndrome - if the process spreads to the sympathetic nerve trunk. The patient's position is forced, semi-sitting. There may be swelling in the neck and upper chest. On palpation there may be crepitus due to subcutaneous emphysema, as a result of damage to the esophagus, bronchus or trachea.

Local signs: chest pain is the earliest and most persistent sign of mediastinitis. The pain intensifies when swallowing and throwing the head back (Romanov's symptom). The localization of pain mainly reflects the localization of the abscess.

Local symptoms depend on the location of the process.

Anterior mediastinitis	Posterior mediastinitis
Chest pain	Chest pain radiating into the interscapular space
Increased pain when tapping the sternum	Increased pain with pressure on the spinous processes
Increased pain when tilting the head - Gehrke's symptom	Increased pain when swallowing
Pastiness in the sternum area	Pastosity in the area of the thoracic vertebrae
Symptoms of compression of the superior vena cava: headache, tinnitus, facial cyanosis, bloating of neck veins	Symptoms of compression of the paired and semi-gypsy veins: dilation of the intercostal veins, effusion in the pleura and pericardium
With CT and NMR - a darkened zone in the projection of the anterior mediastinum	With CT and NMR - a darkened zone in the projection of the posterior mediastinum
X-ray - shadow in the anterior mediastinum, presence of air	X-ray - shadow in the posterior mediastinum, presence of air

When treating mediastinitis, active surgical tactics are used, followed by intensive detoxification, antibacterial and immunostimulating therapy. Surgical treatment consists of providing optimal access, exposing the injured area, suturing the rupture, draining the mediastinum and pleural cavity (if necessary) and applying a gastrostomy tube. Mortality in acute purulent mediastinitis is 20-40%. When draining the mediastinum, it is best to use the method of N.N. Kanshin (1973): drainage of the mediastinum with tubular drainages, followed by fractional rinsing with antiseptic solutions and active aspiration.

Chronic mediastinitis divided into aseptic and microbial. Aseptic include idiopathic, posthemorrhagic, coniotic, rheumatic, dysmetabolic. Microbial diseases are divided into nonspecific and specific (syphilitic, tuberculous, mycotic).

What is common to chronic mediastinitis is the productive nature of inflammation with the development of sclerosis of the mediastinal tissue.

Idiopathic mediastinitis (fibrous mediastinitis, mediastinal fibrosis) is of greatest surgical importance. In a localized form, this type of mediastinitis resembles a tumor or mediastinal cyst. In the generalized form, mediastinal fibrosis is combined with retroperitoneal fibrosis, fibrous thyroiditis and orbital pseudotumor.

The clinical picture is determined by the degree of compression of the mediastinal organs. The following compartment syndromes are identified:

Superior vena cava syndrome
Pulmonary vein compression syndrome
Tracheobronchial syndrome
Esophageal syndrome
Pain syndrome
Nerve compression syndrome

Treatment of chronic mediastinitis is mainly conservative and symptomatic. If the cause of mediastinitis is determined, its elimination leads to a cure.

Mediastinal tumors. All clinical symptoms of various mediastinal masses are usually divided into three main groups:

1. Symptoms from the mediastinal organs, compressed by the tumor;

2. Vascular symptoms resulting from compression of blood vessels;

3. Neurogenic symptoms developing due to compression or sprouting of nerve trunks

Compression syndrome manifests itself as compression of the mediastinal organs. First of all, the brachiocephalic and superior vena cava veins are compressed - superior vena cava syndrome. With further growth, compression of the trachea and bronchi is noted. This is manifested by cough and shortness of breath. When the esophagus is compressed, swallowing and passage of food are impaired. When the tumor of the recurrent nerve is compressed, phonation disturbances, paralysis of the vocal cord on the corresponding side. When the phrenic nerve is compressed, the paralyzed half of the diaphragm stands high.

With compression of the borderline sympathetic trunk of Horner's syndrome - prolapse upper eyelid, constriction of the pupil, retraction eyeball.

Neuroendocrine disorders manifest themselves in the form of joint damage, heart rhythm disturbances, and disturbances in the emotional-volitional sphere.

The symptoms of tumors are varied. The leading role in making a diagnosis, especially in early stages before the appearance of clinical symptoms, belongs computed tomography and the X-ray method.

Differential diagnosis of mediastinal tumors themselves.

		Location		Content		Malignancy	Density
Teratoma	The most common tumor of the mediastinum	Anterior mediastinum	Significant	Mucous membrane, fat, hair, organ rudiments	Slow		Elastic
Neurogenic	Second most common	Posterior mediastinum	Significant	Homogeneous	Slow			Fuzzy
Connective tissue	Third most common	Various, most often anterior mediastinum	Various	Homogeneous	Slow
Lipoma, hibernoma		Various	Various	Mixed structure	Slow			Fuzzy
Hemangioma, lymphangioma		Various						Fuzzy

Thymomas (tumors of the thymus) are not classified as mediastinal tumors themselves, although they are considered together with them due to the peculiarities of localization. They can behave both benign and malignant tumors, giving metastases. They develop either from epithelial or lymphoid tissue of the gland. Often accompanied by the development of myasthenia gravis. The malignant variant occurs 2 times more often, is usually very severe and quickly leads to the death of the patient.

Surgical treatment is indicated:

at established diagnosis and suspected mediastinal tumor or cyst;
for acute purulent mediastinitis, foreign bodies mediastinum, causing pain, hemoptysis or suppuration in the capsule.

The operation is contraindicated for:

established distant metastases to other organs or cervical and axillary lymph nodes;
compression of the superior vena cava with transition to the mediastinum;
persistent paralysis of the vocal cord in the presence of a malignant tumor, manifested by hoarseness;
dissemination of a malignant tumor with the occurrence of hemorrhagic pleurisy;
in general in serious condition a patient with symptoms of cachexia, hepatic-renal failure, pulmonary and heart failure.

It should be noted that in choosing the volume surgical intervention in cancer patients, one should take into account not only the growth pattern and extent of the tumor, but also general condition patient, age, condition of vital organs.

Surgical treatment malignant tumors mediastinum gives poor results. Hodgkin's disease and reticulosarcoma respond well to radiation treatment. For true mediastinal tumors (teratoblastomas, neuromas, connective tissue tumors), radiation treatment is ineffective. Chemotherapy methods for the treatment of malignant true tumors of the mediastinum are also ineffective.

Purulent mediastinitis requires emergency surgical intervention as the only way saving the patient regardless of the severity of his condition.

To expose the anterior and posterior mediastinum and the organs located there, various surgical approaches are used: a) complete or partial longitudinal dissection of the sternum; b) transverse dissection of the sternum, in which both pleural cavities are opened; c) both the anterior and posterior mediastinum can be opened through the left and right pleural cavity; d) diaphragmotomy with and without opening abdominal cavity; e) opening the mediastinum through an incision in the neck; f) the posterior mediastinum can be penetrated extrapleurally from behind along the lateral surface of the spine with resection of the heads of several ribs; g) the mediastinum can be entered extrapleurally after resection of the costal cartilages at the sternum, and sometimes with partial resection of the sternum.

Rehabilitation. Work ability examination.

Clinical examination of patients

To determine the ability of patients to work, general clinical data are used with a mandatory approach to each person examined. During the initial examination, it is necessary to take into account clinical data, the nature of the pathological process - disease or tumor, age, complications from the treatment, and in the presence of a tumor - possible metastasis. It is common to be placed on disability before returning to professional work. At benign tumors after them radical treatment the prognosis is favorable. The prognosis for malignant tumors is poor. Tumors of mesenchymal origin are prone to relapses followed by malignancy.

Subsequently, the radicality of the treatment and complications after treatment are important. Such complications include lymphostasis of the extremities, trophic ulcers after radiation treatment, violations of the ventilation function of the lungs.

Security questions

1. Classification of mediastinal diseases.
2. Clinical symptoms mediastinal tumors.
3. Methods for diagnosing mediastinal tumors.
4. Indications and contraindications for surgical treatment of tumors and mediastinal cysts.
5. Operational accesses into the anterior and posterior mediastinum.
6. Causes of purulent mediastinitis.
7. Clinic of purulent mediastinitis.
8. Methods for opening ulcers with mediastinitis.
9. Symptoms of esophageal rupture.

10. Principles of treatment of esophageal ruptures.

11. Causes of damage to the thoracic lymphatic duct.

12. Chylothorax clinic.

13. Causes of chronic mediastinitis.

14. Classification of mediastinal tumors.

Situational tasks

1. A 24-year-old patient was admitted with complaints of irritability, sweating, weakness, and palpitations. Ill for 2 years. The thyroid gland is not enlarged. Basic exchange +30%. A physical examination of the patient did not reveal any pathology. An X-ray examination reveals a rounded formation 5x5 cm with clear boundaries in the anterior mediastinum at the level of the second rib on the right, the lung tissue is transparent.

Which additional research necessary to clarify the diagnosis? What is your tactic in treating a patient?

2. Patient, 32 years old. Three years ago I suddenly felt pain in my right hand. She was treated with physiotherapy - the pain decreased, but did not go away completely. Subsequently I noticed on the right side of the neck clavicular region dense, lumpy formation. At the same time, the pain in the right half face and neck. At the same time I noticed a narrowing of the right palpebral fissure and a lack of sweating on the right side of the face.

Upon examination, a dense, lumpy, immobile tumor and an expansion of the superficial venous section of the upper half of the body in front were discovered in the right clavicular region. Slight atrophy and decreased muscle strength of the right shoulder girdle and upper limb. Dullness of percussion sound over the apex of the right lung.

What kind of tumor can you think of? What additional research is needed? What's your tactic?

3. Patient, 21 years old. She complained of a feeling of pressure in her chest. Radiologically, on the right, an additional shadow is adjacent to the upper part of the mediastinal shadow in front. The outer contour of this shadow is clear, the inner one merges with the shadow of the mediastinum.

What disease can you think about? What is your tactics in treating the patient?

4. Over the past 4 months, the patient has developed vague pain in the right hypochondrium, accompanied by increasing dysphagic changes. An X-ray examination on the right revealed a shadow in the right lung, which is located behind the heart, with clear contours about 10 cm in diameter. The esophagus at this level is compressed, but its mucous membrane is not changed. Above the compression there is a long delay in the esophagus.

What is your presumptive diagnosis and tactics?

5. A 72-year-old patient immediately after fibrogastroscopy developed substernal pain and swelling in the neck area on the right.

What complication can you think of? What additional studies will you perform to clarify the diagnosis? What is your tactics and treatment?

6. Sick 60 years. A day ago in the hospital, a fish bone was removed at level C 7. After which swelling appeared in the neck area, temperature up to 38°, abundant salivation, palpation on the right began to detect an infiltrate of 5x2 cm, painful. X-ray signs of phlegmon of the neck and expansion of the mediastinal body from above.

What is your diagnosis and tactics?

1. To clarify the diagnosis of intrathoracic goiter, it is necessary to carry out the following additional methods examinations: pneumomediastinography - to clarify the topical location and size of tumors. Contrast study of the esophagus - to identify dislocation of mediastinal organs and displacement of tumors during swallowing. Tomographic examination - to identify narrowing or pushing aside of the vein by a neoplasm; scanning and radioisotope study of thyroid function with radioactive iodine. Clinical manifestations of thyrotoxicosis determine the indications for surgical treatment. Removal of a retrosternal goiter in this location is less traumatic to be carried out using a cervical approach, following the recommendations of V. G. Nikolaev to cross the sternohyoid, sternothyroid, and sternocleidomastoid muscles. If there is a suspicion of fusion of the goiter with surrounding tissues, transthoracic access is possible.

2. You can think about a neurogenic tumor of the mediastinum. Along with a clinical and neurological examination, radiography in direct and lateral projections, tomography, pneumomediastinography, diagnostic pneumothorax, angiocardiopulmography is necessary. In order to identify disorders of the sympathetic nervous system The Linara diagnostic test is used, based on the use of iodine and starch. The test is positive if, during sweating, starch and iodine react, taking on a brown color.

Treatment of a tumor causing compression nerve endings, surgical.

3. You can think about a neurogenic tumor of the posterior mediastinum. The main thing in diagnosing a tumor is to establish its exact location. Treatment consists of surgical removal of the tumor.

4. The patient has a tumor of the posterior mediastinum. The most likely neurogenic character. The diagnosis can be clarified by a multifaceted X-ray examination. At the same time, it is possible to identify the interest of neighboring authorities. Considering the localization of pain, the most probable cause- compression of the phrenic and vagus nerves. Treatment is surgical, in the absence of contraindications.

5. One can think about iatrogenic rupture of the esophagus with the formation of cervical mediastinitis. After an X-ray examination and X-ray contrast examination of the esophagus, an urgent operation is indicated - opening and drainage of the rupture zone, followed by sanitation of the wound.

6. The patient has perforation of the esophagus with subsequent formation of phlegmon of the neck and purulent mediastinitis. Treatment is surgical opening and drainage of neck phlegmon, purulent mediastinotomy with subsequent sanitation of the wound.

Anatomy

For various purposes (describing the localization of a pathological process, planning radiation therapy or surgical intervention) the mediastinum is usually divided into upper and lower floors; anterior, middle and posterior sections.

Superior and inferior mediastinum

TO superior mediastinum include all anatomical structures lying above the upper edge of the pericardium; The boundaries of the superior mediastinum are the superior thoracic outlet and the line drawn between the angle of the sternum and intervertebral disc Th4-Th5.

Inferior mediastinum limited by the upper edge of the pericardium and the diaphragm, in turn divided into anterior, middle and posterior sections.

Anterior, middle and posterior mediastinum

Depending on the goals, either only the lower floor or the entire mediastinum is divided into anterior, middle and posterior mediastinum.

Anterior mediastinum limited to the sternum anteriorly, the pericardium and brachiocephalic vessels posteriorly. The anterior mediastinum contains the thymus, anterior mediastinal lymph nodes and internal mammary arteries and veins.

Middle mediastinum contains the heart, ascending aorta and aortic arch, superior and inferior vena cava; brachiocephalic vessels; phrenic nerves; trachea, main bronchi and their regional lymph nodes; pulmonary arteries and pulmonary veins.

Anterior border posterior mediastinum are the pericardium and trachea, the back is the spine. The posterior mediastinum contains the thoracic part of the descending aorta, esophagus, vagus nerves, thoracic lymphatic duct, azygos and semi-gypsy veins, and posterior mediastinal lymph nodes.

Images

What are malignant neoplasms of the anterior mediastinum?

Malignant neoplasms of the anterior mediastinum in the structure of all oncological diseases make up 3-7%. Most often, malignant neoplasms of the anterior mediastinum are detected in persons 20-40 years old, i.e., in the most socially active part of the population.

Mediastinum is called the part of the thoracic cavity limited in front by the sternum, partially by the costal cartilages and retrosternal fascia, behind by the anterior surface of the thoracic spine, the necks of the ribs and prevertebral fascia, and on the sides by the layers of the mediastinal pleura. The mediastinum is limited below by the diaphragm, and above by a conventional horizontal plane drawn through the upper edge of the manubrium of the sternum.

The most convenient scheme for dividing the mediastinum, proposed in 1938 by Twining, is two horizontal (above and below the roots of the lungs) and two vertical planes (in front and behind the roots of the lungs). In the mediastinum, therefore, three sections (anterior, middle and posterior) and three floors (upper, middle and lower) can be distinguished.

IN anterior section The upper mediastinum contains: the thymus gland, the upper section of the superior vena cava, the brachiocephalic veins, the aortic arch and its branches, the brachiocephalic trunk, the left common carotid artery, left subclavian artery.

In the posterior part of the upper mediastinum there are: the esophagus, the thoracic lymphatic duct, the trunks sympathetic nerves, vagus nerves, nerve plexuses of organs and vessels of the chest cavity, fascia and cellular spaces.

In the anterior mediastinum there are: fiber, spurs of the intrathoracic fascia, the leaves of which contain the internal mammary vessels, retrosternal lymph nodes, and anterior mediastinal nodes.

In the middle section of the mediastinum there are: the pericardium with the heart enclosed in it and the intrapericardial sections of large vessels, the bifurcation of the trachea and the main bronchi, the pulmonary arteries and veins, the phrenic nerves with the accompanying phrenic-pericardial vessels, fascial-cellular formations, and lymph nodes.

In the posterior part of the mediastinum there are: the descending aorta, azygos and semi-gypsy veins, trunks of sympathetic nerves, vagus nerves, esophagus, thoracic lymphatic duct, lymph nodes, tissue with spurs of the intrathoracic fascia surrounding the organs of the mediastinum.

According to the departments and floors of the mediastinum, certain preferential localizations of most of its neoplasms can be noted. Thus, it has been noticed, for example, that intrathoracic goiter is often located in the upper floor of the mediastinum, especially in its anterior section. Thymomas are found, as a rule, in the middle anterior mediastinum, pericardial cysts and lipomas - in the lower anterior. The upper floor of the middle mediastinum is the most common location of teratodermoids. In the middle floor of the middle part of the mediastinum, bronchogenic cysts are most often found, while gastroenterogenic cysts are detected in the lower floor of the middle and posterior parts. The most common neoplasms of the posterior mediastinum along its entire length are neurogenic tumors.

Pathogenesis (what happens?) during malignant neoplasms of the anterior mediastinum

Malignant neoplasms of the mediastinum originate from heterogeneous tissues and are united by only one anatomical border. These include not only true tumors, but also cysts and tumor-like formations of different localization, origin and course. All mediastinal neoplasms according to their source of origin can be divided into the following groups:
1. Primary malignant neoplasms of the mediastinum.
2. Secondary malignant tumors of the mediastinum (metastases of malignant tumors of organs located outside the mediastinum to the lymph nodes of the mediastinum).
3. Malignant tumors of the mediastinal organs (esophagus, trachea, pericardium, thoracic lymphatic duct).
4. Malignant tumors from tissues limiting the mediastinum (pleura, sternum, diaphragm).

Symptoms of malignant neoplasms of the anterior mediastinum

Malignant neoplasms of the mediastinum are found mainly in young and middle age (20 - 40 years), equally often in both men and women. During the course of the disease with malignant neoplasms of the mediastinum, an asymptomatic period and a period of pronounced clinical manifestations can be distinguished. Duration asymptomatic period depends on the location and size of the malignant neoplasm, growth rate, relationship with organs and formations of the mediastinum. Very often, mediastinal neoplasms are asymptomatic for a long time, and they are accidentally discovered during a preventive X-ray examination of the chest.

Clinical signs of malignant neoplasms of the mediastinum consist of:
- symptoms of compression or tumor growth into neighboring organs and tissues;
- general manifestations of the disease;
- specific symptoms characteristic of various neoplasms;

Most frequent symptoms are pains that arise as a result of compression or tumor growth into nerve trunks or nerve plexuses, which is possible with both benign and malignant neoplasms of the mediastinum. The pain is usually mild, localized on the affected side, and often radiates to the shoulder, neck, and interscapular area. Pain with left-sided localization is often similar to pain caused by angina pectoris. If bone pain occurs, the presence of metastases should be assumed. Compression or germination of the borderline sympathetic trunk by a tumor causes the occurrence of a syndrome characterized by drooping of the upper eyelid, dilation of the pupil and retraction of the eyeball on the affected side, impaired sweating, changes in local temperature and dermographism. Defeat of the return laryngeal nerve manifested by hoarseness of the voice, the phrenic nerve - a high standing dome of the diaphragm. Compression spinal cord leads to spinal cord dysfunction.

Manifestation compression syndrome There is also compression of large venous trunks and, first of all, the superior vena cava (superior vena cava syndrome). It is manifested by a violation of the outflow of venous blood from the head and upper half of the body: patients experience noise and heaviness in the head, aggravated in an inclined position, chest pain, shortness of breath, swelling and cyanosis of the face, upper half of the body, swelling of the veins of the neck and chest. Central venous pressure rises to 300-400 mmH2O. Art. When the trachea and large bronchi are compressed, coughing and shortness of breath occur. Compression of the esophagus can cause dysphagia, an obstruction in the passage of food.

In the later stages of development of neoplasms, the following symptoms occur: general weakness, increased body temperature, sweating, weight loss, which are characteristic of malignant tumors. Some patients experience manifestations of disorders associated with intoxication of the body by products secreted by growing tumors. These include arthralgic syndrome, reminiscent of rheumatoid polyarthritis; pain and swelling of the joints, swelling of the soft tissues of the extremities, an increase in heart rate, cardiac arrhythmia.

Some mediastinal tumors are characterized by specific symptoms. So, itchy skin, night sweats are characteristic of malignant lymphomas (lymphogranulomatosis, lymphoreticulosarcoma). A spontaneous decrease in blood sugar levels develops with mediastinal fibrosarcomas. Symptoms of thyrotoxicosis are characteristic of intrathoracic thyrotoxic goiter.

Thus, clinical signs neoplasms, mediastinum are very diverse, however, they manifest themselves in the late stages of the disease and do not always allow an accurate etiological and topographic-anatomical diagnosis to be established. Important for diagnosis are radiological and instrumental methods, especially for recognizing the early stages of the disease.

Neurogenic tumors of the anterior mediastinum are the most common and account for about 30% of all primary mediastinal neoplasms. They arise from nerve sheaths (neurinomas, neurofibromas, neurogenic sarcomas), nerve cells(sympathogoniomas, ganglioneuromas, paragangliomas, chemodectomas). Most often, neurogenic tumors develop from elements of the border trunk and intercostal nerves, rarely from the vagus and phrenic nerves. Regular localization of these tumors is the posterior mediastinum. Much less often, neurogenic tumors are located in the anterior and middle mediastinum.

Reticulosarcoma, diffuse and nodular lymphosarcoma(gigantofollicular lymphoma) are also called "malignant lymphomas." These neoplasms are malignant tumors of lymphoreticular tissue, most often affect young and middle-aged people. The tumor initially develops in one or more lymph nodes and then spreads to neighboring nodes. Generalization occurs early. In addition to the lymph nodes, the metastatic tumor process involves the liver, bone marrow, spleen, skin, lungs and other organs. The disease progresses more slowly in the medullary form of lymphosarcoma (gigantofollicular lymphoma).

Lymphogranulomatosis (Hodgkin's disease) usually has a more benign course than malignant lymphomas. In 15-30% of cases in stage I of the disease development, primary local lesion mediastinal lymph nodes. The disease is more common between the ages of 20-45 years. The clinical picture is characterized by an irregular wave-like course. Weakness, sweating, periodic rises in body temperature, and chest pain appear. But skin itching, enlargement of the liver and spleen, changes in the blood and bone marrow characteristic of lymphogranulomatosis are often absent at this stage. Primary lymphogranulomatosis of the mediastinum can be asymptomatic for a long time, with enlargement of the mediastinal lymph nodes for a long time may remain the only manifestation of the process.

At mediastinal lymphomas The lymph nodes of the anterior and anterior upper parts of the mediastinum and the roots of the lungs are most often affected.

Differential diagnosis is carried out with primary tuberculosis, sarcoidosis and secondary malignant tumors of the mediastinum. A test of radiation can be an aid in diagnosis, since malignant lymphomas are in most cases sensitive to radiation therapy (the “melting snow” symptom). Final diagnosis is established by morphological examination of the material obtained from a biopsy of the neoplasm.

Diagnosis of malignant neoplasms of the anterior mediastinum

The main method for diagnosing malignant neoplasms of the mediastinum is x-ray. The use of a comprehensive X-ray examination allows in most cases to determine the localization of the pathological formation - the mediastinum or neighboring organs and tissues (lungs, diaphragm, chest wall) and the extent of the process.

To mandatory X-ray methods examinations of a patient with a mediastinal tumor include: - fluoroscopy, radiography and tomography of the chest, contrast study of the esophagus.

Fluoroscopy makes it possible to identify a “pathological shadow”, get an idea of its location, shape, size, mobility, intensity, contours, and establish the absence or presence of pulsation of its walls. In some cases, one can judge the connection between the identified shadow and nearby organs (heart, aorta, diaphragm). Clarification of the localization of the tumor in to a large extent allows you to predetermine his character.

To clarify the data obtained during fluoroscopy, radiography is performed. At the same time, the structure of the darkening, its contours, and the relationship of the neoplasm to neighboring organs and tissues are clarified. Contrasting the esophagus helps to assess its condition and determine the degree of displacement or growth of a mediastinal tumor.

Endoscopic research methods are widely used in the diagnosis of mediastinal tumors. Bronchoscopy is used to exclude bronchogenic localization of a tumor or cyst, as well as to determine whether a malignant tumor has invaded the mediastinum of the trachea and large bronchi. During this study, it is possible to perform a transbronchial or transtracheal puncture biopsy of mediastinal formations localized in the area of the tracheal bifurcation. In some cases, mediastinoscopy and videothoracoscopy, in which the biopsy is performed under visual control, turns out to be very informative. Taking material for histological or cytological examination it is also possible with transthoracic puncture or aspiration biopsy performed under x-ray control.

If there are enlarged lymph nodes in the supraclavicular areas, they are biopsied, which makes it possible to determine their metastatic lesions or establish a systemic disease (sarcoidosis, lymphogranulomatosis, etc.). If mediastinal goiter is suspected, scan the neck and chest area after injection radioactive iodine. If compression syndrome is present, central venous pressure is measured.

Patients with mediastinal tumors undergo general and biochemical analysis blood, Wasserman reaction (to exclude the syphilitic nature of the formation), reaction with tuberculin antigen. If echinococcosis is suspected, determination of the latexagglutination reaction with echinococcal antigen is indicated. Changes in the morphological composition of peripheral blood are found mainly in malignant tumors (anemia, leukocytosis, lymphopenia, increased ESR), inflammatory and systemic diseases. If systemic diseases are suspected (leukemia, lymphogranulomatosis, reticulosarcomatosis, etc.), as well as immature neurogenic tumors, a bone marrow puncture is performed with the study of a myelogram.

Treatment of malignant neoplasms of the anterior mediastinum

Treatment of malignant neoplasms of the mediastinum- operational. Removal of tumors and cysts of the mediastinum must be done as early as possible, as this is the prevention of their malignancy or the development of compression syndrome. The only exceptions may be small lipomas and coelomic cysts of the pericardium in the absence of clinical manifestations and a tendency to their increase. Treatment of malignant tumors of the mediastinum in each specific case requires individual approach. Usually it is based on surgical intervention.

The use of radiation and chemotherapy is indicated for most malignant tumors of the mediastinum, but in each specific case their nature and content are determined by the biological and morphological features tumor process, its prevalence. Radiation and chemotherapy are used in combination with surgical treatment, and independently. As a rule, conservative methods form the basis of therapy for advanced stages of the tumor process, when radical surgery is impossible, as well as for mediastinal lymphomas. Surgical treatment for these tumors can be justified only in the early stages of the disease, when the process locally affects a certain group of lymph nodes, which is not so common in practice. In recent years, the videothoracoscopy technique has been proposed and successfully used. This method allows not only to visualize and document mediastinal tumors, but also to remove them using thoracoscopic instruments, causing minimal surgical trauma to patients. The results obtained indicate the high effectiveness of this treatment method and the possibility of carrying out intervention even in patients with severe concomitant diseases and low functional reserves.

The anterior part of the mediastinum occupies thymus(glandula thymus). It functions and is expressed in children younger age. It consists of two lobes, covers in front not only the large vessels of the mediastinum, but extends down to the heart, up to the neck and to the sides, approaching the roots of the lungs. With age, the gland atrophies. In an adult, it is represented by a plate of connective tissue with fatty inclusions. The thymus gland is supplied with blood mainly from the branches of the internal thoracic artery.

Rice. 119. Topography of the anterior mediastinum after detachment of both pleural sacs. 1 - a. carotis communis sinistra; 2 - a. subclavia sinistra; 3 - collarbone; 4 - rib; 5 - v. brachiocephalica sinistra; 6 - arcus aortae; 7 - a. pulmonalis sinistra; 8 - truncus pulmonalis (relief); 9 - left bronchus; 10, 18 - n. phrenicus and a. pericardiacophrenica; 11 - left ear of the heart (relief); 12 - left pleural sac; 13 - pericardium; 14 - prepleural (parapleural) tissue; 15 - f. endothoracica; 16 - right pleural sac; 17 - right ear of the heart (relief); 19 - v. cava superior; 20 - v. brachiocephalica dextra; 21 - thymus gland; 22 - truncus brachiocephalicus.

The cardiovascular complex practically occupies the entire rest of the anterior mediastinum. Large vessels lie at the top, and the heart at the bottom. Both the heart and blood vessels are surrounded for some distance by the cardiac membrane.

Pericardium(pericardium) is the third serous sac of the chest cavity. It consists of a superficial layer (pericardium) and a deep visceral layer (epicardium). The transition of one leaf to another occurs along the hollow veins, the ascending aorta, pulmonary artery, pulmonary veins and on the posterior wall of the left atrium. The epicardium is firmly attached to the heart muscle and the vessels it facilitates. The cavity of the cardiac membrane contains a small amount of fluid and has bays or sinuses. The transverse sinus of the pericardium (sinus transversus pericardii) is located behind the ascending aorta and pulmonary artery. The entrance to it on the right opens with abduction to the right and posteriorly of the superior vena cava and to the left and forward of the aorta, and the entrance on the left is located to the left and posterior to the pulmonary artery. The presence of a sinus allows the aorta and pulmonary artery to be bypassed from behind. The oblique sinus of the pericardium (sinus obliquus pericardii) is located behind the left atrium, laterally limited by the transition of the pericardium to the epicardium on the pulmonary veins, the apex reaches the right branch of the pulmonary artery. Down the sinus is open. The posterior wall of the oblique sinus is the pericardium, adjacent to the esophagus and descending aorta. This sinus can be a place where pus accumulates and is difficult to drain. The anterior inferior sinus (sinus anterior inferior pericardii) is located at the transition point of the anterior wall of the pericardium to the lower one. This sine is where it gathers greatest number fluids for effusion pericarditis and blood for wounds.

The heart sac is supplied with blood from a. pericardiacophrenica, arising from the internal mammary artery at the level of the first intercostal space, and the pericardial branches of the aorta. Venous blood via vv. pericardiacae flows into the superior vena cava system. The cardiac membrane is innervated by the branches of the thoraco-abdominal, vagus and sympathetic nerves.

Heart(cor) - hollow muscular organ, consisting of the right, venous, half and left - arterial. Each half consists of an atrium and a ventricle.

The borders of the heart, projected onto the anterior wall of the chest, are as follows: the upper one passes at the level of the cartilage of the third rib, the right border follows a curve protruding to the right of the sternum by 1.5-2.5 cm and extending from the upper edge of the cartilage of the third rib to the lower one edges of the cartilage of the 5th rib, the left border also runs along a curve extending significantly to the left of the sternum and at the apex of the heart, not reaching only 1 cm to the midclavicular line and running from the cartilage of the 3rd rib to the fifth intercostal space, the lower border is projected, following obliquely through base of the xiphoid process. The apex beat of the heart is determined in the fifth left intercostal space 1.5 cm medially from the midclavicular line. Projected onto the anterior wall of the chest right atrium, right ventricle and left ventricle in the form of a narrow strip. The left atrium, a small part of the left ventricle and the right atrium face the posterior mediastinum. Adjacent to the diaphragm are the left ventricle, a small part of the right ventricle and the right atrium.

The heart is supplied with blood from two arteries starting in the initial part of the aorta. The left cardiac artery (a. coronaria sinistra) along the border between the left atrium and the ventricle is directed to the posterior surface of the heart, where it anastomoses with the right artery of the heart. Going under the left ear, it gives down the anterior interventricular artery, located corresponding to the cardiac septum. The right artery of the heart (a. coronaria dextra) follows the course of the left artery, but follows in the opposite direction. The veins of the heart accompany the arteries. Merging, they form the coronary sinus, which flows into the right atrium.

The lymphatic vessels of the heart are represented by three networks related to the endocardium, myocardium and pericardium. Lymph from the heart flows into the nodes of the bifurcation of the trachea and the upper anterior part of the mediastinum.

The innervation of the heart is carried out by the branches of the vagus and sympathetic nerves, and to a lesser extent by the branches of the phrenic nerves. From the branches of these nerves the aortic-cardiac plexus is formed and, on the heart itself, the extracardiac plexuses are formed, and from their branches the intracardial plexuses are formed.

In the upper part of the anterior mediastinum, behind the thymus gland, there are large vessels belonging to the cardiovascular complex.

Superior vena cava(v. cava superior) is formed from the confluence of the right and left brachiocephalic veins against the substernal area of the cartilage of the first rib on the right and follows down along the sternum. At the level of the cartilage of the third rib, the vein flows into the right atrium. The length of the vena cava is 4-5 cm. The vessel on the right and in front is lined with the pleura of the mediastinum. Lower section it is covered by the epicardium and is accessible from the cavity of the cardiac membrane. By right wall veins to the level of the second rib, until the vein goes into the pericardial cavity, the right phrenic nerve passes. Near the atrium, on the posterior wall of the superior vena cava, at the level of the IV thoracic vertebra, the mouth of the azygos vein (v. azygos) opens.

Brachiocephalic veins(vv. brachiocephalicae) are formed from the confluence of the jugular and subclavian veins behind the sternoclavicular joint of the corresponding side. From here the right vein descends almost vertically downwards with a short trunk. The left vein follows obliquely down and to the right, covering in front the vessels extending from the aortic arch. It is located behind the manubrium of the sternum and the tissue of the thymus gland, crossing the mediastinum. Vv. drains into the brachiocephalic veins. thymicae, thoracicae interna, thyreoideae inferior.

Ascending aorta(aorta ascendens) exits the left ventricle at the height of the third intercostal space at the left edge of the sternum. It, bending in an arc forward and to the right, rises to the level of attachment of the cartilage of the second right rib, where it turns into an arch. The length of the ascending aorta is 5-6 cm. In the initial part it has a bulbous extension, from where the arteries of the heart arise. The ascending aorta on the right, in front and partially behind, is enveloped in the epicardium and is adjacent to the cavity of the cardiac sac. To the right of the aorta is the superior vena cava, separated from it by a gap in the cavity of the cardiac membrane leading to the transverse sinus. The pulmonary artery is adjacent to the aorta in front and to the left. Behind it is the transverse sinus of the chamber of the heart and above it is the right branch of the pulmonary artery and the right bronchus.

Aortic arch(arcus aortae) rises to the level of the first intercostal space and follows through the mediastinum back and to the left, heading to the left side of the IV thoracic vertebra, where it passes into the descending aorta. The posterior half of the left surface of the aorta is lined with pleura. In the anterior sections, a layer of fiber is wedged between the vessel and the pleura. The superior vena cava is adjacent to the arch on the right. Behind and to the right of it are the trachea and esophagus. Under the aortic arch there is the place where the pulmonary artery divides into branches and, somewhat posteriorly, the left bronchus and the ligamentum arteriosus (obliterated ductus arteriosus). On the left, the aortic arch is crossed by the left phrenic and vagus nerves.

The brachiocephalic, left common carotid and subclavian branches extend from the aortic arch from right to left. left artery. The brachiocephalic artery (truncus brachiocephalicus) begins to the left of the midline of the body and therefore, as it rises, it simultaneously deviates to the right. Having reached the level of the sternoclavicular joint, the vessel divides into the right common carotid and subclavian arteries. The brachiocephalic artery passes in front of the trachea, crossing it obliquely. The pleura of the mediastinum is adjacent to the vessel to the right, the left brachiocephalic vein crosses it in front and the left common carotid artery is located to the left. The left common carotid artery ascends the neck and passes to the left of the trachea. The vessel is separated from the left pleural sac by a small layer of fiber. Even further to the left and closer to the spine, the left subclavian artery departs from the aorta. It rises up and extends in an arc over the first rib. The artery passes to the left of the esophagus and on the right comes into contact with the pleura of the mediastinum. Its arc follows in front of the dome of the pleura.