In the upper half of the anterior mediastinum are located. Borders of the posterior mediastinum

Mediastinum- This is a complex of organs located between the right and left pleural cavities. The mediastinum is bounded anteriorly by the sternum, posteriorly by the thoracic spine, laterally by the right and left mediastinal pleura. Above, 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 flowing into it, the pericardium, the aortic arch, the thymus, the phrenic nerves, the diaphragmatic-pericardial blood vessels, the internal thoracic blood vessels, the parasternal, mediastinal and upper diaphragmatic lymph nodes. In the posterior mediastinum are the esophagus, thoracic aorta, thoracic lymphatic duct, unpaired and semi-unpaired 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 border between them is a horizontal plane drawn through the connection of the handle 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 (the brachiocephalic trunk, the left common carotid and left subclavian arteries), the trachea, the upper part of the esophagus and the corresponding sections of the thoracic (lymphatic) duct, right and left sympathetic trunks, vagus and phrenic nerves.

The lower mediastinum, in turn, is subdivided 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 thoracic vessels (arteries and veins), parasternal, anterior mediastinal and prepericardial lymph nodes. In the middle mediastinum are the pericardium with the heart located in it and the intracardiac sections of large blood vessels, the main bronchi, pulmonary arteries and veins, phrenic nerves with their accompanying phrenic-pericardial vessels, 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 descending aorta, the unpaired and semi-unpaired 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, near the spine and on the side walls of the chest) and into the anterior and posterior mediastinal.

Parietal cellular spaces

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

The region 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 place where the ribs pass into the costal cartilages. Here, loose fiber is poorly expressed, as a result of which the parietal pleura is difficult to separate from the intrathoracic fascia, which must be borne in mind during operations on the chest wall.

The fourth region of the costal cartilages, where only at the top (up to the III rib) there is a significant layer of loose fiber, and downward the fiber disappears, as a result of which the parietal pleura 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 - fascia endothoracica, from the sides - by mediastinal pleura, behind - a continuation of the sheet of the cervical fascia (fascia retrosternalis), reinforced from the sides with bundles coming from fascia endothoracica. Here are the parietal lymph nodes of the same name, the internal thoracic vessels with the anterior intercostal branches extending from them, as well as the anterior intercostal lymph nodes.

The cellular tissue of the retrosternal space is separated from the cellular spaces of the neck by a deep sheet of the neck's own fascia, which is attached to the inner surface of the sternum and cartilage of the 1st and 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, the fat folds of Lyushka look like a ridge up to 3 cm high and, gradually decreasing, reach the anterior axillary lines. The accumulation of adipose tissue on the upper surface of the sternocostal triangles of the diaphragm is distinguished by great constancy. Here, fiber does not disappear even 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 neck of the same name. cervical The prevertebral space is delimited at the level of 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 a particularly large amount of loose fiber in the region 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 - 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 usually shines through. 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 case 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 facing each other with vertices. The lower interpleural field, located downward from the IV rib, varies in size and is more 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 throughout the IV, V and VI intercostal spaces; with a vertical arrangement of a small heart, 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, form between the fibrous layer of the pericardium and this fascia.

Along with the type of structure of the chest, to determine the shape and size of the upper and lower interpleural cellular spaces, the general development of adipose tissue in humans is also important. Even at the site of maximum convergence of the pleural sacs on level III ribs, the interpleural gap reaches 2-2.5 cm with a thickness of subcutaneous fat of 1.5-2 cm. When a person is depleted, the pleural sacs come into contact, and when a person is depleted, they overlap each other. In accordance with these facts, the shape and size of the interpleural fields change, which is of great practical importance in the operational access to the heart and large vessels of the anterior mediastinum.

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

Outside of the fascial cases of large vessels is adipose tissue anterior mediastinum, which accompanies these vessels and into the root of the lung.

Fiber of the anterior mediastinum surrounds the trachea and bronchi, forming the peritracheal space. The lower border of the peritracheal cellular space is formed by the fascial case 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 cellular space, in addition to blood vessels, lymph nodes, branches of the vagus and sympathetic nerves, there are extraorganic nerve plexuses.

Fascial-cellular apparatus lung root It is represented by fascial cases of pulmonary vessels and bronchi, surrounded almost all over by sheets 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 sheets descend downward 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 sheets of the pulmonary ligament are the lower pulmonary vein, which is 2-3 cm (up to 6) from other components of the lung root, and the lower lymph nodes.

The fiber 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

Perioesophageal cellular space limited in front by the preesophageal fascia, behind - by the posterior esophageal and from the sides - by the parietal (mediastinal) fascia. Fascial spurs run from the esophagus to the walls of the fascial bed, in which blood vessels pass. The periesophageal 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. At the same time, 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 are attached to the fascial sheath of the aorta on the left, and to the prevertebral fascia on the right. In the loose fiber of the periesophageal space, in addition to the vagus nerves and their plexuses, there is a venous paraesophageal plexus.

Fascial sheath of descending thoracic aorta formed behind the posterior aortic fascia, in front - posterior esophageal, and on the sides - mediastinal spurs of the parietal fascia. The thoracic lymphatic duct and the unpaired vein are located here, and closer to the diaphragm, the semi-unpaired vein and large celiac nerves also enter here. Above, that is, in the upper chest, all these formations have their own fascial cases and are surrounded by more or less loose or fatty tissue. The greatest amount of fiber is found around the lymphatic duct and unpaired vein, the smallest - around sympathetic trunk and splanchnic nerves. The fiber around the thoracic lymphatic duct and the unpaired vein is penetrated by fascial spurs running from the adventitia of these formations to their fascial cases. The spurs are especially well expressed in the peri-aortic tissue.

Mediastinal surgery, one of the youngest branches of surgery, has received significant development due to the development of anesthetic management, surgical techniques, and diagnostics of various mediastinal processes and neoplasms. New diagnostic methods allow not only to accurately determine the localization of a pathological formation, but also make it possible to assess the structure and structure of the pathological focus, as well as to obtain material for pathological 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 diseases of the mediastinum.

Mediastinal injuries:

1. Closed trauma and injuries 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.

By clinical course:

A) acute non-purulent mediastinitis;

B) acute purulent mediastinitis;

C) chronic mediastinitis.

Mediastinal cysts.

1. Congenital:

A) coelomic cysts of the pericardium;

B) cystic lymphangitis;

C) bronchogenic cysts;

D) teratoma

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 collapse of the pericardial tumor;

D) mediastinal cysts emanating from the border areas.

Tumors of the mediastinum:

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

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

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

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

I. Tumors originating from the nervous tissue:

A) sympathoneuroma;

B) ganglioneuroma;

B) pheochromocytoma;

D) chemodectoma.

II. Tumors arising from nerve sheaths.

A) neuroma;

B) neurofibroma;

C) neurogenic sarcoma.

D) schwannomas.

D) ganglioneuromas

E) neurilemmomas

B. Connective tissue tumors:

A) fibroma;

B) chondroma;

C) osteochondroma of the mediastinum;

D) lipoma and liposarcoma;

E) tumors emanating from the vessels (benign and malignant);

E) myxomas;

G) hibernomas;

E) tumors from muscle tissue.

B. Tumors of the thymus:

A) thymoma;

B) cysts of the thymus gland.

D. Tumors from the reticular tissue:

A) lymphogranulomatosis;

B) lymphosarcoma and reticulosarcoma.

E. Tumors from ectopic tissues.

A) retrosternal goiter;

B) intrasternal goiter;

B) an adenoma thyroid gland.

The mediastinum is complex anatomical education, located in the middle of the chest cavity, enclosed between the parietal sheets, 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 their knowledge is obligatory 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 conditional boundary between them is the frontal plane drawn through the roots of the lungs. In the anterior mediastinum are located: the thymus gland, part of the aortic arch with branches, the superior vena cava with its origins (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 are located: the descending part of the aorta, the unpaired and semi-unpaired 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 celiac nerves, nerve plexuses, lymph nodes.

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

The clinical picture depends on the location, size and morphology pathological process. Usually patients complain of pain in the chest or heart area, interscapular region. Often pain preceded by a feeling of discomfort, expressed in a feeling of heaviness or foreign formation in the chest. Often there is shortness of breath, shortness of breath. With compression of the superior vena cava, cyanosis of the skin of the face and upper half of the body, their swelling can be observed.

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

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

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

Features of the flow certain diseases mediastinal organs:

Mediastinal injury.

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

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

With imbibition of the blood of the vagus nerves, a vagal syndrome develops: respiratory failure, bradycardia, worsening of blood circulation, pneumonia of a confluent nature.

Treatment: adequate pain relief, maintenance of cardiac activity, antibacterial and symptomatic therapy. With progressive mediastinal emphysema, a 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 supplemented by the development of hemothorax and hemothorax.

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

Damage to the thoracic lymphatic duct can be caused by:

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

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

Inflammatory diseases.

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

Acute mediastinitis can be caused by the following reasons.

Open injuries of the mediastinum.
1. Complications of operations on the organs of the mediastinum.
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 injury, damage by foreign bodies, tumor decay).

The clinical picture of acute mediastinitis consists of three main symptom complexes, the different severity of which leads to a variety of its 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.

Common 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, agitation, euphoria with a transition to apathy.

With limited abscesses of the posterior mediastinum, dysphagia is the most common symptom. May be dry barking cough up to suffocation (involvement in the process of the trachea), hoarseness (involvement of the recurrent nerve), as well as Horner's syndrome - if the process spreads to the sympathetic nerve trunk. The position of the patient is forced, semi-sitting. There may be swelling of 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 constant sign of mediastinitis. The pain is aggravated by swallowing and tilting the head back (Romanov's symptom). The localization of pain mainly reflects the localization of the abscess.

Local symptoms depend on the localization of the process.

Anterior mediastinitis	Posterior mediastinitis
Pain behind the sternum	Pain in the chest radiating to the interscapular space
Increased pain when tapping on the sternum	Increased pain with pressure on the spinous processes
Increased pain when tilting the head - Gercke's symptom	Increased pain when swallowing
Pastosity in the sternum	Pastosity in the region of the thoracic vertebrae
Symptoms of compression of the superior vena cava: headache, tinnitus, cyanosis of the face, swelling of the veins of the neck	Symptoms of compression of the paired and semi-unpaired veins: dilation of the intercostal veins, effusion in the pleura and pericardium
CT and NMR - blackout zone in the projection of the anterior mediastinum	CT and NMR - blackout zone in the projection of the posterior mediastinum
X-ray - a shadow in the anterior mediastinum, the presence of air	X-ray - a shadow in the posterior mediastinum, the presence of air

In the treatment of mediastinitis, active surgical tactics are used, followed by intensive detoxification, antibacterial and immunostimulating therapy. Surgical treatment consists in the implementation of optimal access, exposure of the injured area, suturing of the gap, drainage of the mediastinum and pleural cavity (if necessary) and the imposition of a gastrostomy. Mortality in acute purulent mediastinitis is 20-40%. When draining the mediastinum, it is best to use the technique of N.N. Kanshin (1973): drainage of the mediastinum with tubular drains, followed by fractional washing with antiseptic solutions and active aspiration.

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

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

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

The clinic is due to the degree of compression of the mediastinal organs. The following compression syndromes are identified:

superior vena cava syndrome
Compression syndrome of the pulmonary veins
Tracheobronchial syndrome
Esophageal syndrome
Pain syndrome
Nerve compression syndrome

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

Tumors of the mediastinum. All clinical symptoms of various volumetric formations of the mediastinum are usually divided into three main groups:

1. Symptoms from the organs of the mediastinum, squeezed by the tumor;

2. Vascular symptoms resulting from vascular compression;

3. Neurogenic symptoms that develop due to compression or germination of nerve trunks

Compression syndrome is manifested by compressed organs of the mediastinum. First of all, the veins of the brachiocephalic and superior vena cava are compressed - the syndrome of the superior vena cava. With further growth, compression of the trachea and bronchi is noted. This is manifested by coughing and shortness of breath. When the esophagus is compressed, swallowing and the passage of food are disturbed. When a tumor of the recurrent nerve is compressed, phonation is disturbed, paralysis of the vocal cord on the corresponding side. With compression of the phrenic nerve - high standing of the paralyzed half of the diaphragm.

With compression of the border sympathetic trunk of Horner's syndrome - omission upper eyelid, pupillary constriction, retraction eyeball.

Neuroendocrine disorders are manifested in the form of damage to the joints, heart rhythm disturbances, disorders of the emotional-volitional sphere.

Symptoms of tumors are varied. Leading role in diagnosis, especially on early stages before the onset of clinical symptoms, computed tomography and radiological method.

Differential diagnosis of mediastinal tumors proper.

		Location		Content		malignancy	Density
Teratoma	Most common mediastinal tumor	Anterior mediastinum	Significant	Mucous, fat, hair, organ rudiments	Slow		elastic
neurogenic	Second in frequency	Posterior mediastinum	Significant	homogeneous	Slow			Fuzzy
Connective tissue	Third in frequency	Various, more 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 proper, although they are considered together with them due to localization features. They can behave both as benign and as malignant tumors, giving metastases. They develop either from the epithelial or from the lymphoid tissue of the gland. Often accompanied by the development of myasthenia gravis (Miastenia gravis). The malignant variant occurs 2 times more often, usually proceeds very hard and quickly leads to the death of the patient.

Surgical treatment is indicated:

at established diagnosis and suspicion of a tumor or cyst of the mediastinum;
with acute purulent mediastinitis, foreign bodies mediastinum, causing pain, hemoptysis or suppuration in the capsule.

The operation is contraindicated in:

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

It should be noted that in choosing the volume surgical intervention in oncological patients, it is necessary to take into account not only the nature of growth and the prevalence of the tumor, but also general state patient, age, condition of vital organs.

Surgery malignant tumors mediastinum gives poor results. Radiation treatment responds well to lymphogranulomatosis and reticulosarcoma. With true tumors of the mediastinum (teratoblastomas, neurinomas, connective tissue tumors), radiation treatment is ineffective. Chemotherapeutic methods of treatment of malignant true tumors of the mediastinum are also ineffective.

Purulent mediastinitis requires urgent surgical intervention as the only way rescue the patient, regardless of the severity of his condition.

To expose the anterior and posterior mediastinum and the organs located there, various operational approaches are used: a) full or partial longitudinal dissection of the sternum; b) transverse dissection of the sternum, while both pleural cavities are opened; c) both the anterior and posterior mediastinum can be opened through the left and right pleural cavities; d) diaphragmotomy with and without opening abdominal cavity; e) opening of 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 near the sternum, and sometimes with partial resection of the sternum.

Rehabilitation. Employability examination.

Clinical examination of patients

To determine the working capacity of patients, general clinical data are used with a mandatory approach to each examined person. During the initial examination, it is necessary to take into account clinical data, the nature of the pathological process - the disease or tumor, age, complications from the treatment, and in the presence of a tumor - and possible metastasis. Transfer to disability before return to professional work is usual. At benign tumors after them radical treatment the prognosis is favorable. In malignant tumors, the prognosis is poor. Tumors of mesenchymal origin tend to develop relapses with subsequent malignancy.

In the future, the radical nature of the treatment, complications after treatment are important. Such complications include lymphedema of the extremities, trophic ulcers after radiation treatment, violations of the ventilation function of the lungs.

Control questions

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

10. Principles of treatment of ruptures of the esophagus.

11. Causes of damage to the thoracic lymphatic duct.

12. Clinic of chylothorax.

13. Causes of chronic mediastinitis.

14. Classification of tumors of the mediastinum.

Situational tasks

1. A 24-year-old patient was admitted with complaints of irritability, sweating, weakness, and palpitations. Sick for 2 years. The thyroid gland is not enlarged. Main exchange +30%. Physical examination of the patient revealed no pathology. An X-ray examination in the anterior mediastinum at the level of the II rib on the right determines the formation of a rounded shape 5x5 cm with clear boundaries, the lung tissue is transparent.

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

2. The patient is 32 years old. Three years ago I suddenly felt pain in right hand. She was treated with physiotherapy - the pain decreased, but did not completely disappear. Subsequently, I noticed on the neck on the right in over clavicular region dense, bumpy formation. Simultaneously, the pain in right half face and neck. Then she noticed a narrowing of the right palpebral fissure and the absence of sweating on the right half of the face.

On examination in the right clavicular region, a dense, tuberous, immobile tumor was found and an expansion of the superficial venous section of the upper half of the body in front. Slight atrophy and decreased muscle strength of the right shoulder girdle and upper limb. Dullness of percussion sound above the apex of the right lung.

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

3. The patient is 21 years old. She complained of a feeling of pressure in her chest. X-ray on the right to the upper part of the mediastinal shadow adjoins an additional 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 of? What is your strategy in treating the patient?

4. During the last 4 months, the patient developed vague pain in the right hypochondrium, accompanied by increasing dysphagic changes. 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 is compressed at this level, but its mucosa is not changed. Above compression, there is a long delay in the esophagus.

Your presumptive diagnosis and tactics?

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

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

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

What is your diagnosis and tactics?

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

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

Treatment of a tumor causing compression nerve endings, surgical.

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

4. A patient has a tumor in the posterior mediastinum. Most likely neurogenic. The diagnosis allows you to clarify a multifaceted x-ray examination. At the same time, the interest of neighboring organs can be identified. Considering the localization of pain, the most probable cause- compression of the phrenic and vagus nerves. Surgical treatment, in the absence of contraindications.

5. You can think of an iatrogenic rupture of the esophagus with the formation of cervical mediastinitis. After 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 debridement of the wound.

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

Anatomy

The mediastinum for different purposes (description of the localization of the pathological process, planning of radiation therapy or surgical intervention) 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 aperture of the chest and the line drawn between the angle of the sternum and intervertebral disc Th4-Th5.

inferior mediastinum limited to the upper edge of the pericardium and the diaphragm, in turn is 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 in front, pericardium and brachiocephalic vessels behind. The anterior mediastinum contains the thymus, the anterior mediastinal lymph nodes, and the 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.

front border posterior mediastinum are the pericardium and trachea, the back is the spine. In the posterior mediastinum are the thoracic descending aorta, esophagus, vagus nerves, thoracic lymphatic duct, unpaired and semi-unpaired veins, posterior mediastinal lymph nodes.

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What is a malignant neoplasm 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 people 20-40 years old, that is, in the most socially active part of the population.

mediastinum called the part of the chest cavity, limited in front - by the sternum, partially by the costal cartilages and the retrosternal fascia, behind - by the anterior surface of the thoracic spine, necks of the ribs and prevertebral fascia, from the sides - by the sheets of the mediastinal pleura. From below, the mediastinum is limited by the diaphragm, and from above - by a conditional horizontal plane drawn through the upper edge of the sternum handle.

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, thus, three sections (anterior, middle and posterior) and three floors (upper, middle and lower) can be distinguished.

IN anterior section of the upper mediastinum are: the thymus gland, the superior section of the superior vena cava, the brachiocephalic veins, the aortic arch and branches extending from it, the brachiocephalic trunk, the left common carotid artery, left subclavian artery.

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

In the anterior mediastinum are located: fiber, spurs of the intrathoracic fascia, the sheets of which contain the internal chest vessels, retrosternal lymph nodes, 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 their accompanying diaphragmatic-pericardial vessels, fascial-cellular formations, lymph nodes.

In the posterior mediastinum are located: the descending aorta, unpaired and semi-unpaired veins, trunks of sympathetic nerves, vagus nerves, esophagus, thoracic lymphatic duct, lymph nodes, fiber with spurs of the intrathoracic fascia surrounding the mediastinal organs.

According to the departments and floors of the mediastinum, certain predominant localizations of most of its neoplasms can be noted. So, it is noticed, for example, that intrathoracic goiter is more 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 localization of teratodermoid. In the middle floor of the middle mediastinum, bronchogenic cysts are most often found, while gastroenterogenic cysts are detected in the lower floor of the middle and posterior sections. The most common neoplasms of the posterior mediastinum throughout 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 boundaries. These include not only true tumors, but also cysts and tumor-like formations of various localization, origin and course. All neoplasms of the mediastinum according to the source of their 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 that limit 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 the organs and formations of the mediastinum. Very often, neoplasms of the mediastinum are asymptomatic for a long time, and they are accidentally detected during a preventive x-ray examination of the chest.

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

Most frequent symptoms are pains arising from compression or germination of the tumor in the nerve trunks or nerve plexuses, which is possible with both benign and malignant neoplasms of the mediastinum. Pain, as a rule, is not intense, localized on the side of the lesion, and often radiates to the shoulder, neck, interscapular region. Pain with left-sided localization is often similar to the pain of angina pectoris. If bone pain occurs, the presence of metastases should be assumed. Compression or germination of the tumor of the borderline sympathetic trunk causes the occurrence of a syndrome characterized by drooping of the upper eyelid, dilated pupil and retraction of the eyeball on the side of the lesion, impaired sweating, changes in local temperature and dermographism. Defeat returnable laryngeal nerve manifested by hoarseness of voice, phrenic nerve - high standing of the dome of the diaphragm. compression spinal cord leads to dysfunction of the spinal cord.

Manifestation compression syndrome is the compression of large venous trunks and, first of all, the superior vena cava (syndrome of the superior vena cava). It is manifested by a violation of the outflow of venous blood from the head and upper half of the body: patients have 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 mm of water. Art. With compression of the trachea and large bronchi, cough and shortness of breath occur. Compression of the esophagus can cause dysphagia - a violation of the passage of food.

In the later stages of the development of neoplasms, there are: general weakness, fever, sweating, weight loss, which are characteristic of malignant tumors. In some patients, manifestations of disorders associated with intoxication of the body with products secreted by growing tumors are observed. These include arthralgic syndrome, resembling rheumatoid arthritis; pain and swelling of the joints, swelling of the soft tissues of the extremities, an increase in heart rate, heart rhythm disturbance.

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

Thus, Clinical signs neoplasms, the mediastinum is very diverse, but they appear in the late stages of the development of the disease and do not always allow an accurate etiological and topographic anatomical diagnosis to be established. X-ray data are important for diagnosis. instrumental methods especially for recognizing the early stages of the disease.

Neurogenic tumors of the anterior mediastinum are the most frequent and account for about 30% of all primary mediastinal neoplasms. They arise from the sheaths of nerves (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. Usual 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, affect more often persons of young and middle age. Initially, the tumor develops in one or more lymph nodes with subsequent spread to neighboring nodes. Generalization comes early. In the metastatic tumor process, in addition to the lymph nodes, the liver, bone marrow, spleen, skin, lungs and other organs are involved. 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 the first stage of the development of the disease, primary local lesion mediastinal lymph nodes. The disease is more common at the age of 20-45 years. The clinical picture is characterized by an irregular undulating course. There is weakness, sweating, periodic rises in body temperature, pain in the chest. But skin itching, enlargement of the liver and spleen, changes in the blood and bone marrow, which are characteristic of lymphogranulomatosis, are often absent at this stage. Primary lymphogranulomatosis of the mediastinum can be asymptomatic for a long time, while an increase in 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 mediastinum, 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 irradiation can be of help in the diagnosis, since malignant lymphomas are in most cases sensitive to radiation therapy (the "melting snow" symptom). Final Diagnosis is established during the morphological study of the material obtained by biopsy of the neoplasm.

Diagnosis of malignant neoplasms of the anterior mediastinum

The main method for diagnosing malignant neoplasms of the mediastinum is radiological. The use of a complex X-ray study 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 prevalence of the process.

To obligatory radiological methods Examinations of a patient with a mediastinal neoplasm include: - X-ray, X-ray and tomography of the chest, contrast study of the esophagus.

X-ray makes it possible to identify the "pathological shadow", to get an idea of its localization, shape, size, mobility, intensity, contours, to establish the absence or presence of pulsation of its walls. In some cases, it is possible to judge the connection of the revealed shadow with the organs located nearby (heart, aorta, diaphragm). Clarification of the localization of the neoplasm in to a large extent allows you to determine its nature.

For specification of the data received at a roentgenoscopy make a roentgenography. At the same time, the structure of the blackout, its contours, the relationship of the neoplasm to neighboring organs and tissues are specified. Contrasting the esophagus helps to assess its condition, to determine the degree of displacement or germination of the mediastinal neoplasm.

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

In the presence of enlarged lymph nodes in the supraclavicular regions, they are biopsied, which allows them to determine their metastatic lesion or establish a systemic disease (sarcoidosis, lymphogranulomatosis, etc.). If a mediastinal goiter is suspected, a scan of the neck and chest area is used after injection. radioactive iodine. In the presence of compression syndrome, central venous pressure is measured.

Patients with neoplasms of the mediastinum perform a general and biochemical analysis blood, the Wasserman reaction (to exclude the syphilitic nature of the formation), the reaction with tuberculin antigen. If echinococcosis is suspected, the determination of the latex agglutination reaction with the echinococcal antigen is indicated. Changes in the morphological composition of peripheral blood are found mainly in malignant tumors (anemia, leukocytosis, lymphopenia, elevated 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 a myelogram study.

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. An exception may be only 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 case requires individual approach. Usually it is based on surgery.

The use of radiation and chemotherapy is indicated for most malignant tumors of the mediastinum, but in each case their nature and content are determined by the biological and morphological features tumor process, its prevalence. Radiation and chemotherapy are used both in combination with surgical treatment, as well as 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 very common in practice. In recent years, the technique of videothoracoscopy has been proposed and successfully used. This method allows not only to visualize and document neoplasms of the mediastinum, but also to remove them using thoracoscopic instruments, causing minimal surgical trauma to patients. The results obtained indicate the high efficiency of this treatment method and the possibility of intervention even in patients with severe comorbidities and low functional reserves.

The anterior 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 - clavicle; 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 - goiter; 22 - truncus brachiocephalicus.

The cardiovascular complex practically occupies the rest of the anterior mediastinum. Large vessels lie above, the heart below. Both the heart and the vessels are surrounded by a heart shirt for some distance.

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 sheet to another occurs along the hollow vei, 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 heart shirt contains a small amount of fluid, 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 when the superior vena cava is retracted to the right and posteriorly and to the left and anteriorly of the aorta, and the entrance to the left is located to the left and behind the pulmonary artery. The presence of the 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, from the sides it is 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 pus-filled and difficult to drain. The anteroinferior sinus (sinus anterior inferior pericardii) is located at the point of transition of the anterior wall of the pericardium to the lower one. This sine is where the the largest number fluids in effusion pericarditis and blood in wounds.

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

Heart(cor) - hollow muscular organ, consisting of the right, venous, half and left - arterial. Each half is made up 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 III ribs, the right border follows a curve protruding to the right from the sternum by 1.5-2.5 cm and extending from the upper edge of the cartilage of the III rib to the lower edges of the cartilage of the 5th rib, the left border also runs along a curve extending much to the left of the sternum and at the apex of the heart not reaching only 1 cm to the mid-clavicular 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 mid-clavicular 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 is the left ventricle, a small portion 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 goes to the posterior surface of the heart, where it anastomoses with the right artery of the heart. Leaving under the left ear, she gives down the anterior interventricular artery, located in accordance with the cardiac septum. The right artery of the heart (a. coronaria dextra) repeats 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 mediastinum.

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

In the upper part of the anterior mediastinum, behind the goiter, 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 chest section of the cartilage of the 1st 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 mediastinal pleura. lower division it is covered by the epicardium and is accessible from the side of the cavity of the cardiac shirt. By right wall veins to the level of the II 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 unpaired 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 down with a short trunk. The left vein follows obliquely down and to the right, covering the vessels from the aortic arch in front. It is located behind the handle of the sternum and tissue of the goiter, crosses the mediastinum. Vv flows 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 forward and to the right in an arc, rises to the level of attachment of the cartilage of the II right rib, where it passes into an arc. The length of the ascending aorta is 5-6 cm. In the initial part, it has a bulbous expansion, from where the arteries of the heart depart. The ascending aorta on the right, in front and partially behind, is shrouded in the epicardium, adjacent to the cavity of the heart shirt. To the right of the aorta is the superior vena cava, separated from it by a gap in the cavity of the heart shirt leading to the transverse sinus. The pulmonary artery adjoins the aorta in front and to the left. Behind it is the transverse sinus of the cavity of the heart shirt and above - 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 adjoins the arch to the right. Behind and to the right of it are the trachea and esophagus. Under the aortic arch is the place where the pulmonary artery divides into branches and somewhat posteriorly - the left bronchus and arterial ligament (obliterated ductus arteriosus). On the left, the aortic arch is crossed by the left phrenic and vagus nerves.

Brachiocephalic, common carotid left and subclavian depart 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, rising up, it simultaneously deviates to the right. Having reached the level of the sternoclavicular articulation, the vessel divides into the right common carotid and subclavian arteries. The brachiocephalic artery passes in front of the trachea, crossing it obliquely. The mediastinal pleura 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 more to the left and closer to the spine, the left subclavian artery departs from the aorta. It rises and arcs over the 1st rib. The artery passes to the left of the esophagus and to the right is in contact with the mediastinal pleura. Its arc follows in front of the dome of the pleura.