TORAKOTOMYYa (Greek thorax,
tho-rakos a breast, a thorax - | - tome a section, a section) — surgery of opening of a chest cavity by a section of a chest wall. T. — quick access for performance of operations on bodies of a chest cavity.
Fig. The diagrammatic representation of skin cuts (black lines) at a thoracotomy: and — at perednebokovy access (a skin section in the fourth mezhreberye from
parasternal to the front axillary line); — at posterolateral access (the koshny section bordering a shovel passes from the III—IV level of chest vertebrae to the average axillary line at the level of VII edge).
The puncture of a chest wall a needle or a trocar is called a thoracocentesis, or a pleurocentesis (see).
Usually at T. at the same time open also a pleural cavity, i.e. make a pleurotomy. Sometimes the parietal pleura is otslaivat and kept unimpaired (extrapleural T.); it is applied to access to a backbone, a gullet, a sympathetic trunk, for operation of an extrapleural pneumolysia (see). The thoracotomy can be unilateral and bilateral. Distinguish also diagnostic T., when opening of a chest cavity is made first of all for specification of the diagnosis, and trial, or eksplorativny, by T., when performance of the planned intervention was impossible. Opening by one section of a chest and abdominal cavity is called a thoracolaparotomy (see the Laparotomy).
Type of T. in each case depends on character patol. process; at the same time consider age of the patient, a shape of a thorax, a condition of muscles, width of intercostal spaces. Unilateral (both right-, and left-side) T. carry out in position of the patient on spin, on a stomach or on one side with use of front, back, side, and also front and side and posterolateral accesses. Two last accesses gained the greatest distribution.
T. with use of perednebokovy access make in position of the patient on a healthy side with a body tilt back. The hand of the patient on the party of operation is taken away up and forward, fixing it to a special prefix of the operating table. The section of skin, hypodermic cellulose and a fascia make along the fourth or fifth mezhreberye from parasternal to a lobby or the back axillary line (fig., a). Cut a front gear muscle and lateral edge of the broadest muscle of a back. The shovel is delayed, bare the corresponding intercostal space and widely open a pleural cavity on the upper edge of an edge: in front — almost to edge of a breast, behind — to a backbone. The wound is parted with two big rack dilators (see), to-rye established in mutually perpendicular directions: one moves apart edges, the second — a front corner of a wound and edge of partially dissect broadest muscle of a back. At the same time in many cases the broadest muscle of a back can be not cut, and only to delay back together with a shovel. Other reception reducing injury of T., opening of a pleural cavity not through an intercostal space, and by a section of a periosteum is, to-ruyu otslaivat from the upper edge of an edge on front and its back surface. At this way intercostal muscles, vessels.i nerves are not injured, and during the mending the pleural cavity is well pressurized.
T. with use of posterolateral access make in position of the patient on a healthy side with a body tilt forward. The hand of the patient on the party of operation is raised up and bent in an elbow joint so that the forearm was near the head. The skin section bordering a shovel is carried out from the level of acanthas of the III—IV chest vertebrae to the average axillary line at the level of VII edge (fig., b). Cut hypodermic cellulose, a fascia, trapezoid and widest muscles of a back, a front gear muscle. The pleural cavity is opened on the fifth or sixth mezhreberye. Edges move apart one or two rack dilators.
It is convenient to make removal of an average share of a lung in position of the patient on spin with use of front access (the section will be out on the fourth or fifth mezhreberye), and operations on chest department and bifurcation of a trachea, and also primary bronchi — in position of the patient on a stomach using back access. At such access near a backbone podnadkostnich-but excise necks of two edges, tie up intercostal vessels and open a chest cavity but boundaries-reberyyu. It is possible not to excise necks of edges, and widely podnadkostnichno to resect the V edge and to open a chest cavity but its box. For single-step bilateral T. make or a median oterpoto-miya (see the Mediastinotomy) with the subsequent opening of both pleural cavities, or in position of the patient on spin provide chrezdvukhplevralny access with a cross section of a breast.
After T. over a diaphragm through separate punctures of a chest wall enter one or two drainage tubes into a pleural cavity with an internal diameter not less than 5 — 6 mm. The operational wound is sewn up layer-by-layer. At edge of a breast and at a backbone it is desirable to put several provisional eight-figurative stitches on intercostal muscles together with a parietal pleura. Then 2 — 4 strong seams pull together edges and tie provisional seams. Muscles sew up with noose sutures or the continuous resolving suture. On a fascia and hypodermic cellulose put thin noose sutures (see Seams surgical). Skin is sewn up tightly.
Pleural drainages connect to asiiratsioniy system (see. And sleep-ratsionnoye drainage) and delete in 1 — 3 days after operation.
Bibliography: The atlas of chest surgery, under the editorship of B. V. Petrovsky, t. 1, page 97, M., 1971. M. I. Perelman.