Venous outflow from the thoracic esophagus occurs. Abdominal esophagus

Blood supply the thoracic part of the esophagus is carried out from many sources, is subject to individual variability and depends on the part of the organ. Thus, the upper part of the thoracic part is supplied with blood mainly by the esophageal branches of the lower thyroid artery, starting from the thyroid trunk (truncus thyrocervicalis), as well as by the branches of the subclavian arteries. The middle third of the thoracic part of the esophagus always receives blood from the bronchial branches of the thoracic aorta and relatively often from the I-II right intercostal arteries. The arteries for the lower third of the esophagus arise from the thoracic aorta, II-VI right intercostal arteries, but mainly from III, although in general intercostal arteries participate in the blood supply to the esophagus only in 1/3 of cases.

The main sources of blood supply to the esophagus are branches extending directly from the thoracic aorta. The largest and most permanent are the esophageal branches (rr. esophagei), the peculiarity of which is that they usually run along the esophagus for some distance, and then are divided into ascending and descending branches. The arteries of all parts of the esophagus anastomose well with each other. The most pronounced anastomoses are found in the lowest part of the organ. They form arterial plexuses, located mainly in the muscular layer and submucosa of the esophagus.

Venous drainage. The venous system of the esophagus is characterized by uneven development and differences in the structure of the venous plexuses and networks within the organ. The outflow of venous blood from the thoracic part of the esophagus is carried out into the system of the azygos and semi-gypsy veins, through anastomoses with the veins of the diaphragm - into the system of the inferior vena cava, and through the veins of the stomach - into the portal vein system. Due to the fact that the outflow of venous blood from the upper esophagus occurs into the superior vena cava system, the venous vessels of the esophagus are the connecting link between the three main venous systems (superior and inferior vena cava and portal veins).

Lymphatic drainage from the thoracic part of the esophagus occurs in various groups of lymph nodes. From the upper third of the esophagus, lymph is directed to the right and left paratracheal nodes, and some of the vessels carry it to the preventricular, lateral jugular and tracheobronchial nodes. Sometimes the lymphatic vessels of this section of the esophagus flow into the thoracic duct. From the middle third of the esophagus, lymph is directed primarily to the bifurcation nodes, then to the tracheobronchial nodes and then to the nodes located between the esophagus and the aorta. Less often, 1-2 lymphatic vessels from this section of the esophagus flow directly into the thoracic duct. From the lower part of the esophagus, the lymphatic drainage goes to the regional nodes of the stomach and mediastinal organs, in particular to the pericardial nodes, less often to the gastric and pancreatic nodes, which is of practical importance in the metastasis of malignant tumors of the esophagus.

Innervation the esophagus is carried out by the vagus nerves and sympathetic trunks. The upper third of the thoracic part of the esophagus is innervated by the branches of the recurrent laryngeal nerve (n. laryngeus recurrens dexter), as well as by esophageal branches extending directly from the vagus nerve. Due to the abundance of connections, these branches form a plexus on the anterior and posterior walls of the esophagus, which is vagosympathetic in nature.

The middle section of the esophagus in the thoracic part is innervated by branches of the vagus nerve, the number of which behind the roots of the lungs (at the site of passage of the vagus nerves) ranges from 2-5 to 10. Another significant part of the branches, heading to the middle third of the esophagus, arises from the pulmonary nerve plexuses. The esophageal nerves, just like in the upper section, form a large number of connections, especially on the anterior wall of the organ, which creates a kind of plexus.

In the lower part of the thoracic part, the esophagus is also innervated by the branches of the right and left vagus nerves. The left vagus nerve forms the anterolateral plexus, and the right one forms the posterolateral plexus, which, as they approach the diaphragm, form the anterior and posterior vagus trunks. In the same section, one can often find branches of the vagus nerves that arise from the esophageal plexus and go directly to the celiac plexus through the aortic opening of the diaphragm.

Sympathetic fibers originate from the 5-6 upper thoracic segments of the spinal cord, switch in the thoracic nodes of the sympathetic trunk and approach the esophagus in the form of visceral branches.

The esophagus is a hollow, flexible, tubular organ that connects the pharynx to the stomach. Its upper border is located at the level of the lower edge of the cricoid cartilage (body of the VI cervical vertebra), and the lower border corresponds to the place of transition to the stomach, i.e., the level of the X-XII thoracic vertebrae.

There are four sections (segments) in the esophagus: pharyngoesophageal, cervical, thoracic and abdominal (abdominal).

The pharyngoesophageal region is the transition zone of the pharynx to the cervical segment of the esophagus. Its posterior surface is lined with dense fibrous tissue. In this area, well-defined muscles of the pharynx, running from top to bottom and to the sides from the middle lip, as well as thinner muscles of the esophagus, going from bottom to top and to the sides, form a diamond-shaped area. It is crossed by the cricopharyngeal muscle, as a result of which two triangles are formed on the posterior wall of the pharynx: Lannier-Heckermann (between the inferior pharyngeal constrictor and the cricopharyngeal muscle) and Lemaire-Killian (between the cricopharyngeal muscle and the esophageal muscle). The latter are weak zones of the esophageal-pharyngeal junction: the site of damage to the esophagus during fibrogastroscopy, localization of Zenker's diverticulum.

The cervical region is 5-6 cm long. This part of the esophagus is mobile; in its circumference there is a large amount of fiber, connecting with the loose connective tissue of the retropharyngeal space at the top and the upper mediastinum at the bottom.

The upper boundary of the thoracic esophagus is the lower edge of the 1st thoracic vertebra, the lower is the diaphragmatic opening (level X-XII of the thoracic vertebrae). The thoracic region is divided into upper, middle and lower parts. The length of the upper part is 5 cm, the middle part is 5-7 cm, the lower part is 6-7 cm.

The abdominal esophagus begins at the diaphragmatic opening and ends at its junction with the stomach. It is 1-2 cm long.

The esophagus lies behind the trachea, anterior to the spine. surrounded by loose connective tissue with lymphatic and blood vessels, vagus nerves and a sympathetic trunk passing through it.

In the pharyngoesophageal part, the esophagus lies along the midline, in the cervical part it deviates to the left of the midline, protruding from under the trachea. The lower thoracic esophagus again deviates to the left, anteriorly, bending around the aorta in front. The abdominal segment of the esophagus lies to the left and anterior to the aorta.

The unequal anatomical location of the esophagus serves as a justification for the use of certain approaches to its segments: left-sided - to the cervical, right-sided transpleural - to the middle thoracic, left-sided transpleural - to the lower thoracic.

For practical purposes, it is extremely important to know the relationship of the esophagus with the mediastinal pleura. In the middle part of the thoracic region, the esophagus contacts the right mediastinal pleura over the root of the lung in a small area. Below the root of the lung, the pleura covers both the right and posterior walls of the esophagus, forming a pocket between the spine and the esophagus. In the lower third of the esophagus, the left mediastinal pleura covers its anterolateral wall.

There are four physiological narrowings in the esophagus: 1) cricopharyngeal (mouth of the esophagus, Killian’s mouth) - located at the level of the VI thoracic vertebra. The inferior pharyngeal constrictor and cricoid cartilage are involved in its formation; 2) aortic - located at the level of the VI thoracic vertebra. It occurs as a result of the intersection of the esophagus with the aortic arch; 3) bronchial - lies within the V-VI thoracic vertebrae and is formed as a result of pressure of the left main bronchus on the esophagus; 4) diaphragmatic - corresponds to the level of the X-XII thoracic vertebrae and is caused by the passage of the esophagus through the diaphragmatic ring.

The wall of the esophagus consists of three membranes: mucous, muscular and outer. The mucous membrane is formed by 4 layers: epithelium, lamina propria, lamina muscularis mucosa, and submucosa. The epithelium of the esophagus and supradiaphragmatic part is multilayered, flat, non-keratinizing. It resembles the epithelium of the oral mucosa. Below the diaphragm, the epithelium of the esophageal mucosa sharply, in the form of a jagged line, passes into columnar epithelium, which, like the epithelium of the stomach, contains a large number of mucous cells and glands. The glands of the esophagus are represented by their own glands (deep), located in the submucosa on. throughout the entire esophagus, and cardiac glands (superficial), located in the lamina propria of the mucous membrane at two levels of the esophagus: at the level of the cricoid cartilage and at the junction of the esophagus with the stomach. Secretory cells of the esophagus's own glands produce mucus and partially serous secretion. The cardiac glands are similar in structure and function to the cardiac glands of the stomach.

The muscular lining of the esophagus is formed by striated and smooth muscle fibers. The largest number of striated fibers is found in the lower part of the pharynx and the upper part of the esophagus. In a downward direction, the number of transverse fibers decreases, and smooth muscle fibers increase. In the lower third of the esophagus, the only type of muscle fibers are smooth muscle fibers. Muscle fibers form two muscle layers of the esophagus: circular (internal) and longitudinal (external). The circular layer is located throughout its entire length and is thickest at the diaphragm. Most authors believe that it is in the lower third of the thoracic part of the esophagus that the functional esophageal sphincter (lower esophageal sphincter) is located, which has not yet been discovered anatomically. Longitudinal muscle fibers arise from the tendon plates on the posterior surface of the cricoid cartilage in the form of three separate bundles. Gradually connecting, they thicken on the distal esophagus.

The outer shell, with the exception of the area where the esophagus enters the stomach, is represented by adventitia. The abdominal segment of the esophagus also has a serous membrane.

The blood supply to the esophagus is carried out segmentally, which must be taken into account when performing it. The main source of nutrition for the cervical esophagus is the branches of the inferior thyroid artery. To a lesser extent, branches of the pharyngeal arteries and non-permanent branches from the subclavian artery (artery of Luschka) participate in the blood supply to this segment. Blood flow to the thoracic region is ensured by the bronchial and intercostal arteries, aortic esophageal branches. The most constant large aortic esophageal branch is the Ovelyakh artery, which arises from the aorta at the level of the VIII thoracic vertebra. The abdominal esophagus receives blood from the ascending branch of the left gastric artery and the gastric branch of the left inferior phrenic artery. In the wall of the esophagus, the arteries form two vascular networks: on the surface of the muscular layer and in the submucosal layer, from where blood enters the mucous and muscular membranes.

It should be borne in mind that mobilization of the esophagus above the VIII thoracic vertebra during ligation of the left gastric artery, as well as cutting off the esophagus with its mobilization and tension of the anastomosis lead to a significant deterioration in the blood supply to the remaining part of the lower esophagus with incompetence of the formed anastomosis.

Venous drainage from the mucosal and intramural venous plexuses of the upper esophagus goes through the inferior thyroid, azygos and semi-gypsy veins into the superior vena cava. From the lower part of the esophagus, venous blood flows into the splenic and then into the portal vein.

Lymphatic drainage from the upper two-thirds of the esophagus is directed upward, and from its lower third downward. For the cervical esophagus, the regional lymph nodes are the upper paratracheal lymph nodes and the deep cervical lymph nodes. The outflow of lymph from the upper and middle thoracic parts of the esophagus is directed to the tracheobronchial, bifurcation, paravertebral lymph nodes. Part of the lymphatic vessels of the esophagus opens into the thoracic lymphatic duct, which explains the earlier appearance of Virchow metastasis compared to metastasis from regional lymph nodes. In addition, the location of large lymphatic vessels directly on the submucosal layer of the esophagus promotes intraorgan metastasis upward along the submucosal layer, which must be taken into account when crossing the esophagus along the upper border during its resection.

The innervation of the esophagus is provided mainly by the vagus nerves, which form the anterior and posterior plexuses on the surface of the esophagus. Fibers extend from them onto the wall of the esophagus and form the intramural nerve plexus: intermuscular (Auerbachian) and submucosal (Meissnerian). Sympathetic innervation of the esophagus occurs through the nodes of the border and aortic plexuses, as well as the splanchnic nerves; The innervation of the cervical esophagus involves the recurrent thoracic nerves - branches of the vagus nerves and fibers of the sympathetic nerve, and the lower - branches of the splanchnic nerve.

The junction of the esophagus and stomach is called the cardia. Here are located the physiological cardiac sphincter and the transverse fold of the mucous membrane - the Gubarev valve. They pass food in only one direction: from the esophagus to the stomach, which is ensured by the passage of food masses through the cardia under a pressure of 4 mm Hg. Art. If the pressure in the fundus of the stomach increases to 80 mm Hg. Art. gastroesophageal reflux occurs.

The angle formed by the left wall of the esophagus and the fundus of the stomach is called the angle of His.

The article was prepared and edited by: surgeon

The esophagus is a tube that runs from the throat to the stomach. The length of the esophagus depends on gender, age, head position (when flexed, it shortens, when extended, it lengthens), and averages 23-24 cm in women and 25-26 cm in men. It begins at the level of the VI cervical vertebra and ends at the level of the XI thoracic vertebra.

The esophagus consists of 4 sections:

Cervical.
Chest.
Diaphragmatic.
Abdominal.

Cervical region. It goes from the VI cervical to the II thoracic vertebra. The entrance to the esophagus depends on the position of the head: when flexed - at the level of the VII cervical vertebra, when extended - at the level of V-VI. This is important when identifying foreign bodies. The inner upper border of the esophagus is a labial fold, which is formed by a hypertrophied muscle (cricopharyngeus). When inhaling, this muscle contracts and closes the entrance to the esophagus, preventing aerophagia. The length of the cervical esophagus is 5-6 cm. In older people, it is shortened due to the prolapse of the larynx. In this section of the esophagus, 2/3 to 3/4 of all foreign bodies are retained. The outside of the esophagus in this section is covered with loose fiber, providing it with high mobility. This fiber passes into the upper mediastinum - if the esophagus is damaged, air enters the upper mediastinum. The esophagus in this section is adjacent to the spine at the back, to the trachea at the front, and the recurrent nerves and the thyroid gland are located on the sides.

Thoracic department. It goes from the II thoracic vertebra to the esophageal opening of the diaphragm (IX thoracic vertebra). This is the longest section: 16-18 cm. On the outside, it is covered with a thin layer of fiber and is fixed to the spinal fascia. At the level of the V thoracic vertebra, the left main bronchus or the tracheal bifurcation area is adjacent to the esophagus. Congenital and acquired tracheoesophageal fistulas often occur in this area. On the sides of the esophagus there are large paraesophageal and bifurcation lymph nodes. When they increase, depressions in the esophagus are visible.

Diaphragmatic section. Most important functionally. Its length is 1.5-2.0 cm. It is located at the level of the esophageal opening of the diaphragm. At this level, the adventitia of the esophagus is closely connected to the phrenic ligaments. Here, esophageal-diaphragmatic membranes are formed, which play a role in the formation of hiatal hernias

Abdominal section. The most variable: from 1 to 6 cm. It goes from the esophageal opening of the diaphragm to the XI thoracic vertebra. With age, this section lengthens. The outside is covered with loose fiber, which provides greater mobility in the longitudinal direction. The inner and lower border of the esophagus is the cardiac fold.

In addition to three anatomical narrowings, there are 4 physiological narrowings in the esophagus:

The mouth of the esophagus (VI cervical vertebra).
In the area of intersection with the aortic arch (III-IV thoracic vertebra) it is less pronounced. The frequent localization here of post-burn scars, as well as foreign bodies, is explained not only by the presence of an aortic narrowing of the esophagus, but also by the lateral bending of the esophagus above it.
In the area of the bifurcation of the trachea (V-VI thoracic vertebrae) and the intersection with the left main bronchus, where the latter is somewhat pressed into the esophagus.
In the area of the esophageal opening of the diaphragm (IX-X thoracic vertebra).

Distance from the maxillary incisors to the constrictions:

16-20 cm.
23 cm.
26 cm.
36-37 cm.

The distance from the incisors of the upper jaw to the cardia is 40 cm. The diameter of the esophagus in the cervical region is 1.8-2.0 cm, in the thoracic and abdominal regions 2.1-2.5 cm. The diameter of the esophagus increases when inhaling, and decreases when exhaling.

The wall of the esophagus consists of 4 layers:

Mucous membrane:
- epithelium,
- lamina propria of the mucous membrane,
- muscular plate of the mucous membrane.
Submucosal layer.
Muscle layer.
- circular muscle layer,
- longitudinal muscle layer.
Adventitia.

The epithelium is multilayered, flat, non-keratinizing. The mucous membrane is normally light pink in color with a delicate vascular pattern. In the area of the cardia, the stratified squamous epithelium of the esophagus passes into the columnar epithelium of the stomach, forming a dentate line. This is important when diagnosing esophagitis and cancer of the esophagus, in which the clarity of the line is lost; with cancer, the edges may be corroded. There may be up to 24 layers of epithelium. The upper and lower cardiac glands are located in the mucous membrane of the cervical and abdominal parts of the esophagus. There are 5 times more of them in the abdominal esophagus than in the stomach. They contain endocrine glands that secrete intestinal hormones: gastrin, secretin, somatostatin, vasopressin. Gastrin and secretin are involved in motility and trophism of the digestive tract. The glands are located in the lamina propria of the mucosa. The muscular plate of the mucous membrane consists of smooth muscle fibers.

The submucosal layer is formed by loose connective tissue, the severity of which determines the size of the folds.

The muscular layer consists of 2 types of fibers:

Cross-striped - located mainly in the upper 1/3 of the esophagus, in the middle 1/3 they become smooth.
Smooth muscle fibers - the lower 1/3 of the esophagus consists exclusively of them.

The muscular layer consists of two layers - the inner circular and outer longitudinal. The circular layer, located throughout its entire length, is thinner in the initial part of the esophagus; gradually thickening, it reaches its maximum size at the diaphragm. The layer of longitudinal muscle fibers thins in the area of the esophagus located behind the trachea, and in the final sections of the esophagus it thickens. In general, the muscular lining of the esophagus in the initial section, especially in the pharynx, is relatively thin; gradually it thickens towards the abdominal part. Both layers of muscle are separated by connective tissue in which the nerve plexuses lie.

Adventitia is loose connective tissue surrounding the outside of the esophagus. Well expressed above the diaphragm and at the junction of the esophagus and stomach.

Blood supply to the esophagus developed to a lesser extent than in the stomach, because there is no single esophageal artery. Different parts of the esophagus are supplied with blood differently.

Cervical region: inferior thyroid, pharyngeal and subclavian arteries.
Thoracic region: branches of the subclavian, inferior thyroid, bronchial, intercostal arteries, thoracic aorta.
Abdominal: from the left inferior phrenic and left gastric arteries.

Venous drainage carried out through veins corresponding to the arteries supplying the esophagus.

Cervical region: into the veins of the thyroid gland and into the innominate and superior vena cava.
Thoracic region: along the esophageal and intercostal branches into the azygos and semi-gypsy veins and, consequently, into the superior vena cava. From the lower third of the thoracic part of the esophagus, venous blood is sent through the branches of the left gastric vein and the upper branches of the splenic vein to the portal system. The left inferior phrenic vein drains part of the venous blood from this part of the esophagus into the inferior vena cava system.
Abdominal region: into the tributaries of the portal vein. In the abdominal region and in the area of the cardioesophageal junction there is a porto-caval anastomosis, which primarily expands in liver cirrhosis.

Lymphatic system formed by two groups of lymphatic vessels - the main network in the submucosal layer and the network in the muscular layer, which partially connects with the submucosal network. In the submucosal layer, lymphatic vessels run both in the direction of the nearest regional lymph nodes and longitudinally along the esophagus. In this case, lymphatic drainage in the longitudinal lymphatic vessels in the upper 2/3 of the esophagus occurs upward, and in the lower third of the esophagus - downward. This explains metastasis not only to the nearest, but also to distant lymph nodes. From the muscular network, lymphatic drainage goes to the nearest regional lymph nodes.

Innervation of the esophagus.

Parasympathetic:

nervus vagus,
recurrent nerve.

Sympathetic: nodes of the border, aortic, cardiac plexuses, ganglia in the subcardia.

The esophagus has its own innervation - the intramural nervous system, which is represented by Dopple cells and consists of three closely connected plexuses:

adventitial,
intermuscular,
submucosal.

They determine the internal autonomy of innervation and local innervation of the motor function of the esophagus. The esophagus is also regulated by the central nervous system.

Cardia. This is the junction of the esophagus with the stomach, acting as a functional sphincter and preventing the reflux of gastric contents into the esophagus. The cardiac sphincter is formed by thickening of the circular muscular layer of the esophagus. In the area of the cardia its thickness is 2-2.5 times greater than in the esophagus. In the area of the cardiac notch, the circular layers intersect and pass onto the stomach.

The closing function of the cardia depends on the physiological usefulness of the muscle fibers of the lower esophageal sphincter, the function of the right diaphragmatic leg and the muscles of the stomach, the acute angle between the left wall of the esophagus and the fundus of the stomach (the angle of His), the Laimer diaphragmatic-esophageal membrane, as well as the folds of the gastric mucosa (Gubarev's folds ), which, under the influence of the gastric gas bubble, fit tightly to the right edge of the esophageal opening of the diaphragm.

(thoracic region)

The thoracic esophagus, together with the descending aorta, occupies the entire space of the posterior mediastinum. In accordance with the floors of the posterior mediastinum, the esophagus is divided into three parts - thirds. The upper third is supraaortic, the middle third is behind the aortic arch and tracheal bifurcation, the lower third is behind the pericardium. The complex topographical relationships of the esophagus with the organs of the posterior mediastinum affect its position and determine the so-called bends of the esophagus. There are bends in the sagittal and frontal planes. The esophagus enters the mediastinum along the midline and deviates to the left at the level of the 3rd and 4th thoracic vertebrae. In the middle third, at the level of the 5th thoracic vertebra, the esophagus again deviates towards the midline and even goes slightly to the right; this bend is determined by the aortic arch and extends to the 8th thoracic vertebra. In the lower third from the 8th to 10th thoracic vertebrae, the esophagus deviates anteriorly from the aorta and to the left by 2-3 cm. The degree of bending of the esophagus is expressed individually and depends on the body type. In young children, the curves are weakly expressed. The bends of the esophagus determine the choice of surgical access to it at different levels. For operations in the middle 1st region, access is used in the 4th and 5th intercostal spaces on the right. For operations on the lower segment, access to the 7th intercostal space on the left, or thoracolaparotomy, is used.

The stability of the position of the esophagus in the mediastinum is ensured by the presence of a ligamentous apparatus in the esophagus, which fixes it at different levels. The following ligaments of the esophagus are distinguished: I) esophageal-tracheal (upper third); 2) the ligament that suspends the esophagus and aortic arch to the spine - the Rosen-I-Anserov ligament (middle third); 3) esophageal-bronchial; 4) esophageal-aortic; 5) interpleural ligaments of Morozov (Avvina, fixing the esophagus in the opening of the diaphragm.

The esophagus has three narrowings: pharyngeal, aortic and diaphragmatic. A narrowing of the esophagus can become a site for the wedging of foreign bodies; traumatic damage to the esophagus often occurs in places of narrowing, including chemical burns. Tumors of the esophagus are more often localized in areas of narrowing.

The relationship of the esophagus with the mediastinal pleura is especially important during operations on the esophagus. They are not the same throughout the intrathoracic esophagus. Above the root of the lung, the right pleura directly covers the esophagus in a limited space of 0.2 to 1 cm, and the left mediastinal pleura forms a fold inserted between the left subclavian artery and the esophagus, which can reach the wall of the esophagus. At the level of the roots of the lungs, the esophagus is separated from the mediastinal pleura: on the right by the azygos vein, on the left by the aorta. Bypassing the roots of the lungs, the right pleura in most cases covers not only the lower side wall of the esophagus, but also its posterior wall, forming a pleural pocket between the spine and the esophagus. The bottom of this pocket extends to the left beyond the midline of the body.

The esophagus receives arterial blood supply from different sources depending on the area of its location. The cervical region and the upper third of the thoracic region are supplied with blood from the inferior thyroid artery. The middle third is from the bronchial arteries. The middle and lower parts of the esophagus are supplied with blood from the aorta, which complicates the isolation of the esophagus when it is removed. The abdominal esophagus receives its supply from the left gastric artery. The venous outflow from the esophagus goes from the upper 2/3 to the basin of the superior vena cava, from the lower third and abdominal region - to the portal vein. Thus, a natural portacaval anastomosis is formed in the lower segment of the esophagus, which becomes of great importance in the syndrome of portal hypertension. In this case, the veins of the esophagus dilate significantly and become pathways for collateral outflow from the portal vein basin. Varicose nodes form in the submucosal layer, which, with a sharp increase in portal pressure, are destroyed and become a source of life-threatening bleeding.

In the posterior mediastinum, the esophagus has a complex relationship with the vagus nerves. On the posterior surface of the root of the lung, the vagus nerves divide the hea into bronchial and esophageal branches. The latter form the esophageal plexus - another anatomical factor that makes it difficult to isolate the esophagus when it is removed.

Topographic anatomy of the diaphragm. The diaphragm (septum, thoraco-abdominal barrier) is a muscular aponeurotic formation that separates the thoracic cavity from the abdominal cavity. It is a flat, thin muscle in the shape of a dome, convexly facing upward and covered with a parietal layer of the pleura. The lower part is covered with a parietal layer of peritoneum. The muscle fibers of the diaphragm, starting from the edges of the lower opening of the chest, are directed radially upward and, connecting, form a tendon center. The muscular part of the diaphragm has lumbar, costal and sternal sections. At the boundaries between the departments, paired triangular areas are formed that do not have muscle tissue: the sternocostal and lumbocostal triangles. In the lumbar region of the diaphragm, the muscle bundles are divided into paired legs: lateral, medial and internal. The internal legs, crossing, form a figure eight and limit the openings for the porta and esophagus, with the latter passing into the abdominal cavity. In addition, the thoracic duct, sympathetic trunks, celiac nerves, azygos and semi-gypsy veins pass through the lumbar part. The inferior vena cava passes through the openings in the tendon center of the diaphragm on the right. Usually the apex of the right dome is at the level of the 4th, and the left - at the level of the 5th intercostal space. Blood supply is provided by the superior and inferior phrenic, musculophrenic and pericardiodiaphragmatic arteries. They are accompanied by veins of the same name. The diaphragm is innervated by the phrenic nerves.

The main function of the diaphragm is breathing. As a result of the movements of the diaphragm, which together with the pectoral muscles determine inhalation and exhalation, the main volume of ventilation of the lungs is carried out, as well as fluctuations in intrapleural pressure, which promote the outflow of blood from the abdominal organs and its inflow to the heart.

Diaphragmatic hernia is the movement of abdominal organs into the thoracic cavity through a defect or weak area of the diaphragm. There are traumatic and non-traumatic hernias. Non-traumatic hernias can be congenital or acquired. I lo localizations include hernias of weak areas of the diaphragm and hernias of natural openings, mainly the esophageal opening (hiatal hernia).

Pericardial puncture is a surgical procedure in which a percutaneous puncture of the parietal layer of the 11th pericardium is performed.

Indications. Exudative pericarditis, hemopericardium.

Anesthesia. Local anesthesia with a 1% solution of novocaine or lidocaine.

Position. On the back with a raised head end.

Larrey technique. The patient is placed on his back. A long needle placed on a syringe is used to puncture the skin at a point located on the left at the junction of the xiphoid process with the costal arch. Having advanced the needle inward by 1-2 cm (depending on the development of the subcutaneous fat layer), it is turned upward and inward, moving further by 3-4 cm. A puncture of the cardiac membrane is felt by overcoming the elastic resistance from the pericardium. 10-12 ml of colored liquid is injected into the pericardial cavity. When repeating this exercise, the injected liquid is suctioned (Fig. 106). Marfin technique. A puncture is made under the xiphoid process in the midline, obliquely upward to a depth of 4 cm, then the needle is turned slightly posteriorly and penetrates into the pericardial cavity.

Test tasks (choose the correct answer)

1. Indicate the direction of movement of the fibers of the external intercostal muscles:

2. Indicate the direction of movement of the fibers of the internal intercostal muscles:

1) from top to bottom, back to front;

2) from top to bottom, front to back;

3) from bottom to top, back to front;

4) from bottom to top, front to back.