Anatomy of the Neck

Lecture 3. Surgical anatomy of spot contents of lecture Scopes of grapple. Division of homoage on a atomic number 18na. Fascias and cellulose spases of get by porta. Topography of vascular- sickening formations of love. Topography of variety meat of make do. Topographycal-anatomic ground of artisan interferences in heavens of contend. Cuts in bea of recognise. Treatment of grapples displeases. Operations at inflammatory affectes. Operation on vims, vessels and founts. Tracheostomy. Operations on a thyroid glandal. Plan of lecture. 1. Scopes of get by, division on a constituent. 2.Triangles of be intimate. 3. Fasciae of get laid. 4. Cellulose propertys of manage. 5. Submandibul ar tri squint-eyed. 6. The Pyrogovs Triangle. 7. Carotid trigon. 8. Topography of elemental vascular-nervous fortune of have intercourse. 9. Distinctions amidst external and inwrought carotids. 10. Branches of external carotid in a carotid triangle. 11. Topography o f trachea. 12. Topography of fill appear part of pharynx. 13. Branches of neck interlacement. 14. Scopes of lateral triangle of neck, division of it on scapula-trapezoidal and scapular-clavicles triangles. 5. Layers of lateral triangle of neck. 16. Cellulose blank shells of lateral triangle of neck. 17. Topography of neck part of diaphragmatic nerve. 18. Technique of tracheostomy. 19. Errors and complications at tracheostomy. 20. Features of artisan access to neck part of defile. 21. Operations on a thyroid. ANATOMICAL-TOPOGRAPHICAL FEATURES OF make out AND THEIRS ORGANS Topographical anatomy of neck (common data) The theatrical role of neck differs by the problematic anatomic structure.Any doctor needs knowl rim of evanesceographical anatomy of neck, as this region has a speech vit each(prenominal)(prenominal)y eventful formations, interrelation among which mustiness be reappearancen into account at slaying of path of urgent measures (laryngotomy, tracheostomy, s transcend of hemorrhage and other). The practical value is had 1) The outward-bound-bound reference book window panes of region, which use at the inspection of affected role for a) Drafting of projection telegraph wires b) Determinations of repair of organs of neck 2) Bulges of sterno-cleido- mastoid process passs which argon a reference point for finding of normal carotid.Palpation of region is more informing a) On the fondness of the skinning fold expose at bending of heading, the body of sublingual tog out palpate at a disappoint status a trim indorse maxillaryry, on each fount from it its large Horn. A sublingual bone is a reference point at execution of vagosympathetic blockage b) Below the houses of thyroid gristle, place of their connection, palpate to the sublingual bone (Adams apple) c) In the kernel of drift man originate of thyroid cartilage is mapped a glottis. d) A cricoids cartilage is felt instantaneously earlier from thyroid. obscureening which hold affirms to the thyroidocricoid copula palpate betwixt them. Urgent laryngotomy is exe let d witnessed in this argona e) On the barrier conducted from the cut back demonstrate of cricoids cartilage downward to the jugular nervure chthoniancuting of sternum, is mapped a trachea, a few left from it is mapped a gorge f) At the neat edge of sterno-cleido-mastoid musclebuilder according to the take of cricoids cartilage the cross(prenominal) process of sixth neck vertebra palpate at back of region (carotid tubercle, tuberculum caroticum).Against this tubercle a customary carotid is pinned at bleeding from its branches g) At the train of upper edge of thyroid cartilage, is mapped the place of bifurcation general carotid h) In the tree make by the back edge of sterno-cleido-mastoid muscle and collar-bone, the flash of subclavian arterial blood vessel is determined. Here it cuddles to the scratch line rib for the temporal stop of bleeding i) It is mapped hume ral interlacement on a neck on a account, connecting a point lying on the couch of middle and light tertiary of sterno-cleido-mastoid muscle and middle of collar-bone.On 1,5-2 sm higher(prenominal) than middle collar-bones execute anesthesia of humeral interlacement j) It is mapped a diaphragmatic nerve on the rake of the width of sterno-cleido-mastoid muscle conducted on a middle downward from the level of middle of thyroid cartilage k) it is mapped an supernumerary nerve on a line crossing a sterno-cleido-mastoid muscle in precaution from the quoin of lower maxilla to the border among the middle and lower its third 3) On the middle of back edge of this muscle the skinning branches of neck interlacement go out in sodium thiosulfate syringe cellulose (n. . transversus coli, occipitalis minor, auricularis magnus, cutaneus colli, supraclavicularis). The explorer novocaine anesthesia conducted in this argona allows to get anaesthetizing of count and lateral start of neck.A t palpation of neck at pertinaciousanimouss megascopic lymphatic k nons come to light sometimes a) It is often multip guiled submandibular lymphatic knots at tooth decay b) elevate knots are struck by metastases at the crab louse of front subdivision of spitting and lower lip c) It is multiplied supraclavicular lymphatic knots in connection with metastasis at the layaboutcer of mammary secreter their increase is marked excessively at tubercular lymphadenitis. d) Very often at the cancer of defile and stomach one of the lymphatic knots hardened on meatus of a. ransversa colli is struck is the Trauze-Vyrkhov knot. Neck delimited from a head a lower edge and corner of lower maxilla, outward acostic duct, mastoid process, upper occipital line to the cervical hillock is a high bound. From beneath from a breast, upper extremity and back, a neck is delimited by a line, going on the jugular downstairs keen of breastbone, upper edge of collar-bone, acromial process scapulars and, farther in a conditional line connecting the acromion by prominence process of the septenary neck vertebra (vertebra prominens). Children hold in is short and wide neck, a lot of cellulose.A concentrate glottis, wide stria of thyroid, narrow sublaryngeal blank shell, is marked. It determines the methods of some private detective interference. For example, children lower tracheotomy is done just now, taking into account the features of structure of isthmus of thyroid and sublaryngeal space. In addition, children have the organs of neck on one neck vertebra higher, than at adults, that it is necessary to take into account at implementation of operative accesses. A neck de bene esse is divided by the row of regions, the scopes of which hug drug on the outward reference points of neck.By a frontal plane passing by dint of a mastoid process and acromion neck divide by front and back divisions. A back incision carries the name of cervical (occipital) region regio nuche a nd consists of the well developed muscles application program vertebrae. These muscles in the turn are cover by strap and trapezoid muscles. Topographoanatomical under a neck understand its front department ordinarily, very neck, containing its organs, prefatorial vessels and nerves. By a middle line divide the front department of neck by make up and left halves.On each of them dickens large triangles are distinguished sagittal and lateral. Mesial triangle Mesial triangle trigonum colli medium limited by the lower edge of lower maxilla from to a higher place, sterno-cleido-mastoid muscle (by its shift edge) lateral by a middle lily mesial. Within the limits of internal neck triangle cope with and odd triangles are asked Pair Submandibular trigonum submandibulare is limited from higher up by the lower edge of lower maxilla, from to a lower place, lateral and mesial both bellies of digastrics muscle.This triangle must be known for access to the submandibular spitting ry gland, to the facial, tongue arteries and nervures (a. et v. facialis), to the advised nerve of tongue (n. lingualis) to the sublingual (n. hypoglossus) motive nerve of tongue Carotid triangle trigonum caroticum is limited from above by the back belly of digastrics muscle, quarter (or lateral) by the cutting edge of sterno-cleido-mastoid muscle, from below by the top belly of scapular-sublingual muscle (m. omohyoideus).This triangle it is necessary to know for access to the vascular-nervous bunch consisting of general carotid (a. carotica communis) and its branches (outward and internal), to the internal jugular vein (v. juugularis interna) and tramp nerve (n. vagus). Scapular-tracheal triangle trigonum omotracheale, limited from above and lateral by the top belly of scapular-sublingual muscle (m. omohyoideus), from below and lateral is cutting edge of sterno-cleido-mastoid muscle, at the front or mesial middle line of neck. unavoidable for accesses to tracheas at implemen tation of tracheotomy and operation on a thyroid. Odd Chin trigonum submentale limited from below by a sublingual bone, lateral and mesial front bellies of digastrics muscles. Knowledge of it is necessitate for drainage of fall into place of cavity of mouth. Outward triangle trigonum colli laterale limited from below by the upper edge of collar-bone, at the front or mesial back edge of sterno-cleido-mastoid muscle, back or lateral border on the cutting edge of trapezoid muscle.Within the limits of this triangle both mate triangles are selected Scapular-trapezoid trigonum omotrapezoideum limited arse by the cutting edge of trapezoid muscle, at the front back edge of sterno-cleido-mastoid muscle, from below scapular-sublingual muscle. Needed for dissection of abscesses, access to the additional nerve (n. accesorius) Scapular-clavicular triangle trigonum omoclavicularis limited from below by a collar-bone, from above bottom belly of pharyngeal-sublingual muscle, at t he front back edge of sterno-cleido-mastoid muscle needed for access to the subclavian artery, vein and humeral interlacement.If to put together both internal neck triangles ( proper(a) and left), they form one large middle quarter-circle of neck, which is divided by a horizontal line passing through a sublingual bone, on 2 regions Suprasublingual region (regio suprahyoidea) in it select a chin and two submandibular triangles Subsublingual region (regio infrahyoidea) in it select two carotid and two scapular-tracheal triangles. FASCIAE OF eff Fasciae is a connective thread frame and, being in all regions, various functions are executed protective, supporting, fixing regarding to organs.V. N. Shevkunenko described 5 dashboardl canvass of neck First ( glib) fasciae of neck fascia nigglingis colli or fascia cervicalis superficialis. It is given cabalisticer than hypodermic cellulose, is passed from a neck directly to the neighboring regions. piddling fasciae of neck, di viding, engulf the hypodermic muscle of neck of m. platysma, forming its vagina Second is superficial poll of own fasciae of neck lamina superficialis fasciae colli propriae (fascia cervicalis superficialis).This, fasciae begins from the copulas of processus spinosus of neck vertebrae. It is fixed to the upper occipital line, is divided, goes round all neck and forms a vagina for m. trapezius, m. sternocleidomastoideus and capsule by submandibular saliva of gland. The outward shroud of II fasciae of neck gives into the covered muscles the row of bridges which divide muscle into key out bunches. wad arcsecond fasciae of neck registers to the front-upper edges of handle of breastbone and collar-bones, from above to the lower edge of lower maxilla.II fasciae of neck give completespurs to the transversal processes of neck vertebrae. One of these wrap upspurs binds second fasciae to the heel. Other binds it to the vagina of vascular-nervous bunch of neck. These offspurs form th e frontal locate plate which separates the front region of neck from back one. It confirms the conditional division of neck on front and back departments. This plate hinders to spreading of maturation processes arising up in the intrafascial cellulose of front and back departments of neck.On face second fasciae of neck passes in fascia parotideomasseterica, this forms the capsule of parotid salivary gland and covers a masticatory muscle after-school(prenominal) The third fascial rag week of neck carries the name of scapular-clavicular fasciae (fascia omoclavicularis) or buddy-buddy sheet of own fasciae of neck of lamina profunda fasciae colli propriae. This fascia has the form of trapezoid and registers above to the body of sublingual bone. From one side it is limited by scapular-sublingual muscles (m. omohyoideus). Down it registers to the back-upper edges of collar-bones and handle of breastbone.On middle line third fasciae of neck accretes in upper departments with III fasci a, and forms the white line of neck. It forms vaginas for pair muscles lying below than sublingual bone m. sternohyoideus, m. omohyoideus, m. thyrohyoideus. In connection with the features of the topography third fasciae of neck is submissive in adjusting of subscriber line stream in the vessels of neck. It is explained it by the charge of dense connections of fasciae with the wall of vessels, in the places of perforation by them this fascial sheet. At reduction m. mohyoideus fasciae, narrowing, multiplies the diameter of veins. A fourth fascial sheet carries the name of intraneck fasciae fascia endocervicalis. It consists of two plates parietal, covering a cavity neck from within, and visceral, covering organs neck. The parietal plate of fourth fasciae forms a vagina for the prefatorial vascular-nervous bunch of neck of vagina vasonervosa, giving his partition, dissociating the vascular components of this bunch from each other general carotid, internal jugular vein and n. vag us, inward ( quicksilver(a) nerve).On meatus of vessels a fascial sheet goes down in top mediastinum, gives the bunches of fascial fibres to the large vessels and pericardium. The visceral plate of fourth fasciae of neck passes to the organs of neck, covering a larynx, trachea, esophagus, and thyroid. To the large veins of neck fourth fasciae as well as gives the row of offspurs. Therefore in the moment of inhalation negative pressure in veins is created, that can lead at the wounds of neck to air embolism. The fifth fascial sheet of neck carries the name of pre-vertebral fasciae of fascia prevertebralis.It begins croupe a esophagus at creation of skull, goes down downward in a pectoral cavity, passing earlier of spine. The Fascial sheet is well explicit and registering to the transversal processes of vertebrae, forms vaginas for the stair muscles of neck of m. scalenus anterior, medius et posterior. Its processes cover a subclavian artery, humeral nervous interlacement and m. scalenius anterior. It covers by itself the trunk of sympathetic nerve and muscle, lying on bodies and transversal processes of neck vertebrae (mm. ongus coli et longus capitis). CELLULOSE SPACES OF NECK The uncommunicative and describe cellulose spaces appear between the fascial sheets of neck. Reserved Pair sack of submandibular gland soda gl. submandibularis, containing a submandibular salivary gland, loose cellulose, lymphatic knots, facial artery and vein, n. hypoglossus. This sack is limited by the sheets of second fasciae and periosteum of lower maxilla Pair fascial sack spatium sternocleidomastoideum formed by the sheets of second fasciae for a sterno-cleido-mastoid muscle and n. ccesorius. This fascial space is very a great deal reported with surrounding tissues only through the probutting openings, formed by vessels which blood proviso muscle Substernoid intraaponeurosis space spatium intraponeuroticum suprasternale it is placed above the jugular undercutting o f breastbone between the sheets of second and third fasciae of neck. Height of this space from the jugular undercutting of breastbone to the middle of distance between a breastbone and sublingual bone. Space is opened from sides.Except for loose cellulose this space contains lymphatic knots and jugular vein arc of arcus venosus juguli A blind sack a pair behind the sterno-cleido-mastoid muscle of sacus caecus relrosternodeidomastoideus, Gruber is described. The scopes of it are at the front is back wall of vagina of m. sternodeidomastoideus (II fasciae), behind are third fasciae of neck, and from below is periosteum of upper back edge of collar-bone. A sack is reserved orthogonal, as at the outward edge of sterno-cleido-mastoid muscle second fasciae accrete with the third.This space has the report of spatium intraponeuroticum suprasternale by means of crack between II and III fasciae, carrying the name of gate of fifth space (portae spatium suprasternale). Pus in these regions dr iving forces the symptom of festering collar. Reported (unreserved) spaces cooperant to spreading of haematomas and inflammatory processes Space ahead of internal organs of neck or pre-organ spatium previscerale between the sheets of fourth fasciae, spreading from a sublingual bone to undercutting of breastbone. Part of this space is below than isthmus of thyroid and ahead of trachea select as spatium pretracheale.In this space lymphatic knots, veins taking a blood from the region of isthmus of thyroid, are addicted in a loose cellulose, v. thyroidea ima, part of odd thyroid interlacement of plexus thyroideus. In 10-12% of fibers lower thyroid artery of a. thyroidea ima. This cellulose space is delimited from the cellulose of front mediastinum by only a fascial bridge appearing at level handles of breastbone in transition of parietal sheet of fourth fasciae in visceral one at that placefore the festering processes of cellulose of this space can spread in front mediastinum.Space behind the entrails of neck or retrovisceral spatium retroviscerale is disposed between fourth and fifth fasciae behind a esophagus. This space has the report directly with the cellulose of back mediastinum and spreads from foundation of skull to the diaphragm. Major anatomic formations are disposed in the back department of juxtapharyngeal cellulose internal carotid, internal jugular vein, vagabond, sublingual and glossopharyngeal nerves (nn. vagus, hypoglossus, glossopharingeus). on the vascular-nervous bunch of internal neck triangle from every side vascular-nervous cellulose space is disposed spatium vasoneurorum.Above it reaches before foundation skulls, and down passes to front mediastinum. Cellulose space of outward neck triangle is disposed between second and fifth fasciae. From sides this space is limited by the vagina of basic vascular-nervous bunch of neck and edge of trapezoid muscle. It is reported with subtrapezoid space. tardily cellulose space of neck is dispos ed under fifth fascia in trigonum colli laterale surrounds subclavian vessels and humeral interlacement and is reported with the cellulose of axilla cavity.Pre-vertebral space spatium prevertebrale, is disposed between neck vertebrae fifth fascia. From above comes to outward foundation of skull, from below to the level of the third pectoral vertebra. The long muscles of neck of mm. longus colli ei longus capitis and trunk of sympathetic nerve are located in it, n. phrenicus from neck interlacement, vertebral arteries of m. rectus capitis anterior et lateralis. It is reported with cellulose to the level of the III pectoral vertebra. SUPRASUBLINGUAL REGION (Regio suprahyoidea)From above the edge of lower maxilla and it connecting line with a mastoid process are the scopes of suprasublingual region, from below is the line conducted through a body and large horns of sublingual bone, from one side are the cutting edges mm. sternocleidomastoidei. Three expressed triangles are selected in a region Odd chin between the front bellies of digastrics muscles and body of sublingual bone Pair submandibular triangle trigonum submandibulare, the sides of which on that point are two bellies of m. digastricus and lower edge of lower maxilla.A submandibular salivary gland beds in the area of this triangle. The skin of region is thin, mobile, elastic, the expressed of hypodermic cellulose is subject to the individual changes. shallow fasciae form a vagina for m. platisma. In the area of this triangle after Between sheets I and II fasciae of neck under the lower edge of lower maxilla is disposed usually a few lymphatic knots. Ramus colli n passes here. facialis, and besides skinning nerves of neck (branches of n. transversus colli), which are disposed in a hypodermic cellulose.II fasciae of neck form a sack for a submandibular salivary gland. The last usually has an egg-shaped form and executes all submandibular triangle almost. Between a gland and its capsule loose cellul ose is disposed, in which lymphatic knots lie often. On meatus of channel of gland, this cellulose is reported with the cellulose of bottom of oral cavity. The conclusion channel of gland of ductus submandibularis begins in the front-upper department of gland and goes away to the crack between m. myohyoidem and m. hyoglossus, following under the mucous membrane of bottom of oral cavity.In the equivalent crack a few higher than channel passes the tongue nerve of n. lingualis, n. hypoglossus and v. lingualis is below than channel disposed. A facial artery which adjoins to the internal surface of gland passes in the lodge of submandibular salivary gland. To outward its surface there is a adjoins of the same name vein which, bent through the edge of lower maxilla, follows under the capsule of gland towards v. jugularis interna the cutting edge m. masseter. Abandoning the bed of gland, a. facialis is bent through the edge of lower maxilla and is passed in the mesial departments of face .A deep department is formed by a few muscles covered by second fascia of neck. Most mesial the mandibular-sublingual muscle m. myohyoideus is disposed. This muscle, accreting on a mesial edge from the same muscle oppo send side, forms the diaphragm of oral cavity diaphragma oris. At osteomyelitis of lower maxilla, stomatological inflammatory processes, maybe, as complication, to rotate up phlegmon of bottom of cavity of mouth. It carries the name of Ludwigs quinsy. It is a quickly making progress acerate leaflike inflammatory process, spreading on a tongue, larynx, and cellulose of neck.The last necrose and adopts a black almost. There are salivation, labored breathings, fetid smell of mouth. Quite often the Ludwigs quinsy is complicated by organic evolution of mediastinitis. Topographically in this region the Pirogovs triangle, limited by the tendon bridge of m. digastricus, back edge m. mylohyoideus and n. hypoglossus, is important formation. M. hyoglossus is the bottom of t riangle. Within the limits of this triangle, baring and bandaging of tongue artery which is disposed under m. hyoglossus is executable. A tongue vein lies above it muscle.Search for the Pirogovs Triangle at thrown and twisted back backwards and the head cancelled in the side opposed to interference. The following layers are selected in an odd chin triangle skin, hypodermic cellulose, beginning(a) base and second fasciae of neck. Muscles are then disposed outside in inward m. digastricus, m. myohyoideus, m. geniohyoideus, m. genioglossi. Deeper than these muscles a cellulose follows and mucous to the oral cavity. SUBSUBLINGUAL REGION (Regio infrahyoidea) A sublingual region is limited from above by a line passing on the upper edge of body and large horns of sublingual bone, from a lateral side cutting edges of mm. ternocleidomastoidei, from below undercuts of breastbone. After hypodermic cellulose I fasciae of neck with m. platysma is disposed. Between I and II fasciae of neck plural superficial veins (including v. jugularis anterior, v. mediana colli), and also nerves of neck, from n. cutaneus colli are disposed. Deeper III fasciae of neck, formative a vagina for muscles lying below than sublingual bone, are disposed sterno-sublingual (m. sternohyoideus), scapular-sublingual (m. omohyoideus) lying it is more superficial, sterno-thyroid (m. ternothyroideus) and thyroid-sublingual (m. thyrohyoideus) bedding deeper. Under muscles the parietal sheet of IV fasciae follows and described higher spatium previscerale. It contains vein interlacement plexus thyroideus impar, v. thyroidea ima, sometimes (of to 10% possibilitys) ?. thyroidea ima. In a sublingual region are disposed larynx, esophagus, trachea, esophagus, and thyroid. Within the limits of sublingual region the extraordinarily important carotid triangle of neck is disposed (trigonum caroticum).The scopes of triangle make the muscles of neck mesial is top belly of scapular-sublingual muscle (m. omohy oideus), lateral is sterno-cleido-mastoid muscle, above is back belly of digastrics muscle. The superficial layers of triangle are re precedeed by a skin, hypodermic cellulose, and first fascia of neck with m. platisma, by second fascia of neck. Deeper, the loose cellulose, surrounded by a parietal sheet IV fasciae of neck, its basic vascular-nervous bunch and also lymphatic knots, on meatus of his vessels beds within the limits of carotid triangle.A basic vascular-nervous bunch is represented by an internal jugular vein (v. jugularis interna) and general carotid (a. carotis communis), which a wandering nerve is disposed between. Vienna with its influxes lies most superficially, and a. carotis communis is most deep. V. jugularis interna is well visible at playing off of the internal (front) edge m. sternocleidomastoideus. At the level of upper edge of thyroid cartilage a facial vein (v. facialis) which adopts a blood from the row of vein vessels falls in it (v. lingualis, v. laryng ea superior, v. hyroidea superior). A. carotis communis passes on the bisector of the corner formed by the top belly of scapular-sublingual muscle and sterno-cleido-mastoid muscle. The division of a. carotis communis on outward and internal carotids more tell on takes place at the level of upper edge of thyroid cartilage. To distinguish outward and internal carotids there is the row of topographoanatomical signs An internal carotid, as a rule, on the neck of branches does not give. An outward carotid gives on a neck the row of branches in the following order a. hyroidea superior, a. lingualis, a. facialis and other Topographically a. carotis externa departs ahead, mesial and lies more superficially, than a. carotis interna, which departs in a lateral side and leaves deep into. If in area of carotid triangle crude(a) and n. hypoglossus is visible, he crosses a. carotis interna and lies on it. An outward carotid is closed a. temporalis superficialis, and therefore if pined an outwar d carotid, a pulsation on a temporal artery impart not be present. In area of bifurcation general carotid is disposed a carotid reflexogenic area.It consists of glomus caroticum, sinus caroticus (initial area of internal carotid), branches n. glossopharyngeus, n. vagus, and truncus sympathicus. Carotid glomus glomus caroticum consists of connecting tissue specific glomus cages stop up in it, closely associated from an adventitia carotid. Middle sizes of glomus caroticum 35 mm. Reflexes of carotid area act part in adjusting of bloody pressure and chemical composition of blood. LYMPHATIC KNOTS OF NECK Five groups of neck lymphatic knots are distinguished Submandibular. Chin.Front neck (superficial and deep). askant neck (superficial). Deep neck. Submandibular knots nodi lymphatici submandibularis in an amount 4-6 is disposed in the fascial lodge of submandibular and in the layer of salivary gland. They collect lymph from soft tissues of front region of face. Chin knots nodi lymp hatici submentalis in an amount 2-3 lie under second fascia, between the front bellies of digastrics muscles, lower maxilla and sublingual bone. They collect lymph from a chin, tag of tongue, lower teeth and lips. Front neck knots nodi lymphatici colli anterior.Necks in a sublingual region are disposed in a middle department. Lymph is taken from the organs of neck. Distinguish Superficial, located on meatus of front jugular vein Deep or juxtavisceral are the necks located near-by organs. Lateral group forms a few superficial knots of disposed on meatus of outward jugular vein. Deep knots lie as three chainlets, forming the figure of triangle Along an internal jugular vein. On meatus of additional nerve. On meatus of transversal artery of neck. A chain along the transversal artery of neck is named a subclavian group.The large knot of this group, the nearest to the left vein corner (the Truaze-Vyrkhovs knot), quite often is struck to one of the first at new formations of stomach and lower department of esophagus. He palpate in a corner between left sterno-cleido-mastoid muscle and collar-bone. Deep neck knots heads and necks adopt lymph from all knots. They lie at the level of bifurcation general carotid. A knot disposed in a corner between v. jugularis interna et v. facialis (at the level of Horn of sublingual bone) is struck by one of organs of oral cavity first at new formations.Operations in area of neck At production of operations on a neck it is necessary to take into account the individual forms of changeability of neck, mobility of neck organs, large danger of handicap of vessels of neck, which threatens by not only the bleeding but also possibility of embolism (at the suffering of veins). At treatment of wounds it is necessary at once to take the damaged veins by styptic clamps and bandage them. During operative interferences vessels in the beginning are taken by styptic clamps, after dissected and bandaged. Position of patient at operations in area of neckIn all cases of operative interferences in front and lateral departments of neck of patient lies on back. Under scapulars a roller is underlaid, a head is thrown backwards. At cuts in the middle departments of neck the head of patient is retained on a middle line. At operative interferences in the lateral departments of neck a head is turned diversion, opposite to operative interference, because of what organs will be mixed up and become more accessible. Cuts on a neck Cuts on a neck must answer the cosmetic requirements and provide sufficient access to the organs of neck.Transverse sections conform to much(prenominal) requirements, because conduct them parallel to the natural folds of skin. At operations on a thyroid such cuts correspond to the long axis of organ and give wide access to it. In cases of baring of vascular-nervous formations, neck department of esophagus, dissection of abscesses and phlegmons on a neck resurrect longitudinal and combined cuts (Venglovs ky, Dyakonov, De Kerven). Only changed, but also those goodly organs, the wound of which follows to avoid at operations.The following basic groups of surgical accesses are distinguished to the organs of neck 1- vertical 2- slanting 3- transversal and 4- combined. Vertical cuts (upper and lower) are conducted on a middle line at the front or behind. They are widely used for tracheostomy (upper or lower) back middle cuts are used as operative accesses to the bodies of neck vertebrae (to the spinal cord). Slanting cuts are conducted on the cutting or back edge of sterno-cleido-mastoid muscle. Such accesses are used for baring or bandaging of elements of basic vessel-nervous bunch and neck part of esophagus.In addition, slanting cuts take advantage that are most safe and provide deep enough access. Transverse sections are used for access to the thyroid, esophagus vertebral, subclavian, lower thyroid to the arteries, for the delete of the lymphatic knots staggered by the metastases of c ancer progression. However much transverse sections have the row of failings badly accretes transversal the cut hypodermic muscle of neck that results in formation of wide and rough scars in addition is present possibility of wound of muscles, vessels and nerves during operation.Besides availability to the deeply located organs goes down considerably. The combined cuts (patchwork) are used for wide dissection of cellulose spaces, delete of tumor, metastatic staggered lymphatic knots. Surgical treatment of wounds of neck The wounds of neck are characterized by four basic signs. The first sign is sinuosity of wound channel. It is explained it mobility organs of neck from the presence of the developed fascial-cellulose spaces in area of neck. Second sign are the wounds of neck are often tended to(p) by the wound of spine and spinal cord.Wounds on a neck are especially dangerous, inflicted on sagittal or parasagittal lines. three sign are the wounds of neck in 13% of cases are attende d by the wound of carotids. This, usually, strained wounds which often end with death. Bandaging of general and internal carotids can be complicated by a one-sided central paralysis (hemiplegia). Fourth sign are wounds of neck are characterized by muddiness. At the wound of larynx, trachea, special esophagus, there is an infection with subsequent development of phlegmons and abscesses. sometimes festering processes are complicated by mediastinitis.Three areas of wounds of neck are distinguished first area from the lower edge of lower maxilla to the sublingual bone second area from a sublingual bone to the cricoids cartilage third area from a cricoids cartilage to the jugular undercuting of breastbone. Than the area of wound is below, that it is more dangerous, because interfascial cellulose spaces are open up. The large vessels of neck, included in top front mediastinum and going out on it, pass in the lower departments of neck. The wound of them is dangerous from the massive b leeding and difficult access to the site of damage.At primary surgical treatment a wound channel is extended. The nonviable areas of soft tissues are excised, irrelevant bodies, interfascial haematomas, are deleted, the damaged interfascial spaces are extended. Surgeons do not unseal the interfascial cracks not changeable by a scotching object. Wounds must be widely drainage. abroad bodies are deleted only in case that they threaten to liveliness of patient. Foreign bodies are deleted, if they cause serious complications (for example, located near a wandering nerve and is caused violations of cardiac activity).Foreign bodies in such cases must be remote at the well opened wound under the control an eye. If a splinter is located deeply in tissues and is not caused complications, he is not usually touched. He is encapsulated and is remained in tissues. Nick the encapsulated splinter will be mixed up, approaching large vessels, he is necessary to be deleted. Operations at phlegmons and abscesses of neck Phlegmons and abscesses in area of neck to the bowl are complications of lymphadenitis, when loose cellulose surrounding lymphatic knots is engaged in a process.Besides the difficult clinical picture of persist of disease, the festering hearths of deep cellulose spaces are dangerous to those that can on these spaces spread in neighboring regions. So, from previsceral and vascular-nervous cellulose spaces in front mediastinum from retrovisceral cellulose there is space in back mediastinum, being the reason of festering mediastinitis. The juxtavisceral phlegmons can cause squeezing and dropsy of organs of neck, large vessels and nerves. The lately recognized inflammatory processes sometimes result in melting of wall of vessels and considerable bleeding.A cut is elected for the shortest access to the abscess. victorious into account complication of topographoanatomical location of large vascular-nervous formations, cuts on a neck are produced strictly layer. Unsealing a skin, hypodermic fatty cellulose and superficial fasciae by speechless instruments, not to scotch vessels, impenetrate. At accesses the location of veins of neck, their intimate union, is taken into account with fasciae, the damage of the large veins close located from the upper aperture of breast is dangerous by not only the difficultly stopped bleeding but also air embolism.The wide opening of festering hearth is concluded by drainages of its cavity. Drainages are put possibly farther from the place of location of large vessels in the lower corner of wound. Thus on a skin there are sutures to drainage. The Festering processes of submandibular region are unsealed by a cut going parallel to the edge of lower maxilla, from last 1 1,5 sm (danger of damage of regional branch of facial nerve). After the section by the scalpel of skin, hypodermic cellulose, fasciae together with m. latysma deep into penetrates by a dull way, fearing the wound of facial artery and vein. Phl egmons and abscesses of bottom of oral cavity are unsealed by a longitudinal cut on a middle line below than chin. Come a sharp way to the gnathic-sublingual muscle (m. mylohyoideus). Pass the last through its stitch by a dull instrument, widely exposing a festering hearth. The phlegmons of fascial vagina of vascular-nervous bunch are unsealed by a cut along the cutting edge of sterno-cleido-mastoid muscle. Layer skiving, a hypodermic cellulose, and superficial fasciae, together with m. latysma is unsealed by the vagina of sterno-cleido-mastoid muscle and fascial vagina of vascular-nervous bunch. By a dull instrument penetrate to the vascular-nervous bunch. In cellulose surrounding a vascular-nervous bunch, drainage is put. At spreading of pus in the lateral triangle of neck unseal a phlegmon by a cut De Kerven. He is conducted on the front edge of m. sternocleidomastoideus, and then, crossing this muscle, parallel to the collar-bone and higher it on 2-3 sm to the cutting edge m. tr apezius. Wound of drainage.The phlegmons of previsceral space are unsealed by a transverse section, dissecting a skin, hypodermic cellulose, superficial, second and third fasciae of neck, long muscles covering larynx and trachea, parietal sheet of IV fasciae of neck. A cut is conducted on 3-4 sm higher than jugular undercuts. Spatium previscerale drainage is wide. The Festering processes of retrovisceral space are represented by retropharyngeal phlegmons and abscesses. The Retropharyngeal phlegmon can be unsealed from the side of neck, conducting a cut along the back edge of sterno-cleido-mastoid muscle.In the cellulose of retropharyngeal space, after the section of skin, hypodermic cellulose, superficial fasciae, vagina of sterno-cleido-mastoid muscle, penetrate by a dull way. Wound of drainage. I Recommend you a good book, illuminative these questions Essays of festering surgery, 1965 Author of it, professor V. Vojno-Jasenetcky, man of very interesting fate. BARING OF ARTERIES ON NECK Baring of general carotid Findings. Wound aneurism of vessel, angyographic research, existence of medicinal matters, if introduction by their puncture through a skin is not succeeded.Position of patient. A patient lies on back with a roller under scapulars. A head is thrown back backwards and turned aside opposite to interference. A cut is conducted long 5-6 sm at the cutting edge of sterno-cleido-mastoid muscle from the level of upper edge of thyroid cartilage downward. Layer a skin, hypodermic fatty cellulose, superficial fasciae, and hypodermic muscle, is dissected. The front wall of vagina of sterno-cleido-mastoid muscle is cut. Take a muscle outside, the back wall of vagina of muscle and vagina of vascular-nervous bunch is cut.In a cellulose most mesial and a general carotid is deeper disposed, ahead and lateral an internal jugular vein lies from it. A wandering nerve lies at the back semicircumferences of these vessels. At the wounds edge to the carotid presently lay o n a vascular stitch or produce the plastic arts of artery (its substitution of autovein is possible or synthetic vascular prosthetic contrivance from polymeric connections). At bandaging of artery there are serious complications as softening square off of areas of cerebrum and subsequent proof paralyses in 30% of cases. Baring of outward carotidFindings. Wound of vessel, vast wounds linden-tree, attended with bleeding from a maxilla artery an artery is bandaged at the delete of upper maxilla and parotid salivary gland concerning malignant tumours. Position of patient on the back, a head is turned aside opposite to interference. A cut is conducted long 5-6 sm from the corner of lower maxilla downward, along the cutting edge of sterno-cleido-mastoid muscle. Layer tissues are dissected. Take an outward jugular vein upwards and outside or bandage and dissect. It is necessary to distinguish an outward carotid from internal one.In the case of necessity bandaging of outward carotid lay o n ligature higher than place of departs upper thyroid artery. In the case of departs close from bifurcation edge the last to the carotid, an outward carotid is bandaged higher by the places of departs tongue artery. legs. In the case of the low bandaging of outward carotid a bifurcation general carotid can have a blood clot closing a road headroom and internal carotid, practically there will be an obturator general carotid. Bandaging of tongue artery in the Pyrogovs triangle now is not practically conducted. Vagosympathetic blockageFindings. Wounds of breast with closed and opened pneumothorax, attended with pleuropulmonary shock combined wounds of organs of abdominal region pectoral and. A blockage is produced with the purpose of breaking of pain impulses from the damaged regions. Position of patient. A patient is laid on the back with a roller under scapulars. Throw back a head backward and turn aside opposite to interference. Reference points the corner of crossing of outward j ugular vein with the back edge of sterno-cleido-mastoid muscle serves for introduction of needle (at the level of sublingual bone).By an index finger at the place of piercing needle together with a vascular-nervous bunch move aside a sterno-cleido-mastoid muscle ahead and mesial, after anaesthetizing of skin on an index finger stick long needle. A needle is moved forward from a top to the bottom outside inward to the front surface of neck vertebrae. Draw off a needle from a spine on 0,5 sm and in a cellulose behind the vagina of vascular-nervous bunch enter of a 40-50 ml 0,25% solution of Novocain. Hyperemia of skin of face and sclerotic coat on the side of blockage comes during the correct conducting of blockage.There is the Claude Bernar-Gorner syndrome narrowing of pupil, narrowing of eyeing crack, enophthalmos zapadenye eyeball. Necks organs Complication of anatomic structure and topographical-anatomic location of organs of neck in a great deal determines the features of operat ive interferences on them. In area of neck the initial departments of organs of digestion (esophagus, esophagus), external breathing (larynx, trachea) are disposed, thyroid and parathyroid glands, lymphatic vessels (the largest is pectoral channel).Also here are large vessels and interlacements of spinal nerves, nervous interlacements of organs and vessels. It should be noted that lymphatic vessels and vascular-nervous trunks of neck are covered only by soft tissues. Therefore, at the front and from sides they comparatively are poorly protected. One of topographical-anatomic features of neck is that all superficial skinning nerves of neck (from neck interlacement (?1 ?4) go out practically in one point at the level of middle of back edge of sterno-cleido-mastoid muscle, that allows to produce anaesthetizing at operations on a neck practically by one prick.In area of neck there are numerous reflexogenic areas, which appear by nervous interlacements of organs, vascular-nervous interl acements of organs, vascular-nervous bunches, neck department of sympathetic trunk, neck and humeral interlacements. It is the important facial touch of organs of neck them mobility at meatus of head, which has the practical value at operative interferences. LARYNX Represented 9th by cartilages by thyroid, cricoidea, epiglottis, two arytenoidea, two cuneiformis and two corniculata. Most essential from them re thyroid and cricoids, linked between itself lig. cricothiroideum. The front department of cricoids cartilage and undercuts on the upper edge of thyroid cartilage are external reference points at surgical interferences. Ahead a larynx is covered by epiglottis muscles, from one side the stakes of thyroid adjoin to it, behind a mouthful. Blood supply is carried out by upper and lower laryngeal arteries outgoing accordingly from upper and lower thyroid arteries. Innervations by the upper laryngeal nerve (from a wandering nerve) and lower (eventual branch of recurrent laryngeal ner ve).lymphatic outflow is carried out in pre-laryngeal, pretracheal, paratracheal and deep lymphatic knots of neck. TRACHEA Represented by cartilaginous semicircular connected by dense copulas. Back departments are locked by a dense connective tissue bridge, where mesomorphic fibres pass. Within the limits of neck 6-8 cartilaginous ring are counted, position of which corresponds to the bend of neck vertebrae. At the front tracheas the isthmus of thyroid lies, its stakes and general carotids adjoin from one side. Behind a esophagus is located.In a bend between a esophagus and trachea a recurrent laryngeal nerve passes on the left, on the right this nerve goes behind a trachea. Blood supply of trachea is carried out by the tracheal branches of lower thyroid artery, innervations branches of recurrent laryngeal nerve. PHARYNX Three basic departments of pharynx are selected nasal, mouth and laryngeal. A lymphatic pharynx ring (Pyrogov Valdeyer) which it is represented is important anat omic formation of pharynx by two palatal tonsils, two pipe, pharynx and tongue.In area of nasal and mouth parts of pharynx there are the juxtapharyngeal and retropharyngeal cellulose spaces delimited from each other by partition between pre-vertebral and pharynx fasciae. Front and back departments are selected in juxtapharyngeal cellulose space, in which pass important anatomic formations. Retropharyngeal space is divided by middle partition on two departments. Because of what retropharyngeal abscesses, as a rule, are one-sided. A pharynx is disposed most deeply and behind it pre-vertebral fasciae, long muscles of neck and bodies of vertebrae is located.Ahead of laryngeal part of pharynx a larynx is disposed from sides are stakes of thyroid and general carotids. Blood supply is carried out by the branches of ascending pharynx artery, ascending and descending palatal, and also upper and lower thyroid arteries. Innervation of pharynx takes place due to the branches of sympathetic, wan dering and glossopharyngeal nerves. lymphatic outflow takes place in deep neck lymphatic knots. ESOPHAGUS A esophagus passes to the esophagus, in which distinguish neck, pectoral and abdominal parts and accordingly narrowing.Neck part of esophagus lies in loose cellulose between a trachea and pre-vertebral fascia. He is easily displaced, however, basic axis a few displaced to the left, which matters very much at the choice of operative access to neck part of esophagus. From one side to the esophagus are disposed the stakes of thyroid, at the front is cricoids cartilage of larynx and cartilages of trachea. Blood supply of neck part of esophagus is carried out by the branches of lower thyroid arteries. Innervation due to the branches of wandering nerve. Lymphatic outflow in deep neck lymphatic knots.THYROID It is one of the largest endocrine glands. It is disposed in the sublingual region of neck on the front surface of trachea. It consists of two stakes, isthmus and in 30-40% of ca ses a pointed stake can walk away from an isthmus or left stake. Weight of gland hesitates from 15 to 50g. An isthmus is represented by a lamina, width to 1,5 sm and usually covers 2-3 cartilaginous rings of trachea. Lateral stakes lie on both sides a trachea and larynx, an oval form is had. A thyroid has an own capsule, which the visceral sheet of fourth fasciae of neck is over.Vessels, nerves and parathyroid, pass between the capsule of gland and fascia. At the front a thyroid adjoins with sterno-sublingual, sterno-thyroid and scapular-sublingual muscles behind with the upper department of neck part of trachea, larynx, pharynx, esophagus and parathyroid. To the back mesial surface of thyroid a recurrent nerve joins and laryngeal, general carotid. Blood supply of thyroid is carried out by pair upper (branches of outward carotid) and lower (branches of thyroidneck trunk) thyroid arteries, and at 10 % people yet and by a fifth odd artery.The vein outflow from a gland is carried ou t in the vein interlacement located by sympathetic trunks and laryngeal nerves. However, it should be remembered that at the lower edge of thyroid a lower thyroid artery is crossed by a lower laryngeal nerve which it is easily possible to injure at operations, that phonation results in violation. askant NECK TRIANGLE (TRIGONUM COLI LATERALIS) Limited at the front by the back edge of sterno-cleido-mastoid muscle, behind cutting edge of trapezoid muscle, from below by a collar-bone. Layers A skin is thin, mobile, elastic.Hypodermic cellulose is developed moderately. Superficial fasciae of neck and in a lower department hypodermic muscle of neck. V. jugularis externa passes in the lower department of region along the back edge of sterno-cleido-mastoid muscle. Skinning branches of neck interlacement front, middle, back. Subclavian branches of nerve of n. supraclaviculares anterior, media, posteriori. Other skinning nerves of neck interlacement go out at the middle of back edge of ster no-cleido-mastoid muscle n. occipitalis minor, n. auricularis magnus, n. cutaneus colii.Second fasciae or superficial sheet of own a fascia of neck is disposed as one sheet registering to the front surface of collar-bone. Third fasciae or deep sheet of own fasciae of neck within the limits of outward triangle occupy a lower front corner only, I. e. trigonum omoclaviculare (in trigonum omotrapezoideum third fasciae it is not). Between second and fifth fasciae cellulose, additional nerve, is disposed. Fifth fasciae or pre-vertebral, covering mm. scaleni, m. levator scapule and other The vascular-nervous bunch of outward neck triangle is made by a subclavian artery (its third department) and humeral interlacement.They go out through an interstair breakup. Humeral interlacement is disposed here higher and outside, subclavian artery below and inward. From a subclavian artery the last branch is transversal artery of neck (a. transversa coli) departs here, and also its branches ?. cervic alis superficialis et a. suprascapularis pass. A subclavian artery abandons the region of neck, going downward on the front surface of the first rib (I. e. between a collar-bone and first rib) the projection of it here corresponds to the middle of collar-bone.A subclavian vein is disposed on the first rib, but ahead and below of the same name artery, behind a collar-bone and further passes in spatium antescalenum, where muscle is dissociated from the artery of front stair. DEEP INTRAMUSCULAR INTERVALS In a lower department and behind a sterno-cleido-mastoid muscle, outside from neck entrails, there are two intervals nearer to the surface is prescalenum interval (spatium antescalenum) lying deeper is stair-vertebral triangle (trigonum scalenovertebralis). The Prescalenum interval is formed behind front stair muscle (m. calenius anterior), at the front m. sternohyoideus and sternothyroideus, outside m. sternocleidomastoideus. Between front and middle stair muscles there is spatium intrascalenum, which is located already within the limits of outward neck triangle. Within the limits of interval there is an internal jugular vein with its lower bulb (bulbus v. jugularis inferior), wandering nerve (n. vagus) and initial department of carotid (a. carotis communis). There is v. subclavia in the lowermost department of interval, meeting with v. jugularis interna the place of confluence is designated as angulus venous.An outward jugular vein falls in a vein corner usually, in addition ductus bracicus falls in it on left, and on right ductus lymphticus dexter. In an interval also there is a diaphragmatic nerve (n. phrenicus) arising out of fourth neck nerve, disposed on the front surface of front stair muscle and covered by pre-vertebral fascia. A nerve goes in slanting agency from top to bottom, outside of inward and passes to front mediastinum between subclavian by an artery and vein of outside from a wandering nerve. Higher collar-bones nip a nerve across a. trans versa colli et v. suprascapularis.A stair-vertebral triangle is disposed at back of lower mesial department of sterno-cleido-mastoid region and limited lateral front stair muscle, mesial long muscle of necks, from below dome of pleura. An apex corresponds to the carotid tubercle of transversal process of the VI neck vertebra. In this triangle under prevertebral fascia necks are disposed on the left is initial department of subclavian artery, eventual department of pectoral channel, on the right is eventual department of right lymphatic channel and lower knot of sympathetic trunk. A subclavian artery (a. ubclavia) behind and from below adjoins to the dome of pleura. Ahead of right subclavian artery a vein corner is disposed. Between it and a. subclavia passes wandering and diaphragmatic nerves, which a subclavian loop (ama subclavia) and n. sympathies beds between. Behind a subclavian artery there is a right recurrent laryngeal nerve (n. laryngeus recurrens), inward from it a. ca rotis communis. Ahead of left subclavian artery an internal jugular vein and initial department of left brachiocephalic vein (v. brachiocephalica sinistra) is disposed, between which pass n. vagus, ansa subclavia, n. sympathici and n. hrenicus. Inward from an artery passes a left recurrent laryngeal nerve. The arc of pectoral channel more frequent is located ahead of this department of subclavian artery. Three departments are selected in a subclavian artery from the beginning of artery to the interstair triangle in an interstair interval from an interstair interval to the apex of armpit pit. In the first department a subclavian artery gives the following branches vertebral (a. vertebralis) thyroidneck trunk (truncus thyreocervicalis) dividing into four branches lower thyroid (a. thyroidea inferior) ascending neck (a. ervicalis ascendens) superficial neck (a. cervicalis superficialis) suprascapular (a. suprascapularis) internal pectoral (a. thoracica interna) In the second department is costal-neck trunk (truncus costocervicalis). There is the transversal artery of neck in the third department (a. transversa coli). TRACHEOSTOMY It is operation of imposition of stomy on a trachea. Produce tracheostomy as urgent operation at a sharp asphyxia how gum elastic at operations on the organs of mouth and neck in an anesthesiology for conducting of anesthesia (intubation). Basic findings to implementation of tracheostomy impassability of larynx and upper department of trachea as a result of their obturation by a tumor, unusual body, paralysis and spasm of vocal copulas with closing of entrance in a larynx, and also distresss and edema of larynx coma of any etiology with violation of swallowing, aspiration by vomitive the masses, saliva, blood in respiratory tracts disorders of breathing at patients with a heavy cranial-cerebral trauma and trauma of thorax respiratory deficiency arising up as a result of proof oppression of central mechanisms of breathing heavy surgical respiratory insufficiency necessity of the protracted artificial ventilation. Types of tracheostomy are upper (supracricoid) middle (intracricoid) and lower (subcricoid) tracheostomy. More frequent execute upper tracheotomy and conicotomy, at which cross a copula (ligamentum conicum) between thyroid and cricoid cartilages. Technique of conducting of upper tracheostomy Position of patient on the back with the maximally thrown back head. Under scapulars is roller. During conducting of cut it should be remembered basic topographic- anatomic relations of trachea and other organs of neck.So facade and from one side overhead part of trachea joins with a thyroid, to lower part with the cellulose of pretracheal space backwards from a trachea there is the esophagus forced out to the left. On the left a trachea and esophagus disposes a recurrent nerve on the right a recurrent nerve is deeper behind a trachea on the lateral wall of esophagus. Next to the lower department of n eck part of trachea there are general carotids, lift is head trunk, arc of aorta and left shoulder is head vein.At implementation of upper produce a tracheostomy cut exactly on the middle line of neck from the middle of thyroid cartilage downward on 4-5 sm or transversal, think above the isthmus of thyroid. Layer a wound is unsealed, bleeding is stopped. Muscles bluntly move apart and draw off in sides the first tracheal rings are opened. The isthmus of thyroid is drawn off downward, and a trachea is fixed either for a cricoid cartilage or for the first rings of trachea. It enables freely to manipulate at the section of rings of trachea.A trachea is dissected on the size of diameter of entered cannule by a scalpel dosed by gauze serviettes for warning of damage of esophagus. After expansion of road clearance of the unsealed trachea cannule is entered from one side, and then translated it in a sagittal plane. After introduction of cannule a wound is taken in layer, cannule is fixed round a neck. CONICOTOMY Soft pit is groped between the lower edges of thyroid cartilage and pulled out arc of cricoid cartilage. Skinning cut longitudinal to appearance of the yellow coloring (ligamentum conicum) cross. This copula goes horizontally.Such cut can be produced one moment through a skin and copula. In opening cannule is entered and is fixed round a neck. This interference is temporal. Technically simpler for implementation is upper tracheostomy, however, it not always is possible from pride of place of isthmus of thyroid, and at children it is practically impossible. Therefore, presently got the preference lower tracheostomy, to which a cranial-cerebral trauma and damage of neck department of spine is contra-indication. COMPLICATIONS AT TRACHEOSTOMY Complications at tracheostomy depend on the errors assumed during operation 1.So a cut not on the middle line of neck can result in the damage of neck veins, and sometimes and carotid. 2. The insufficient stop of bleeding before dissection of trachea can result in the hit of blood in respiratory tracts, which will cause heavy aspiration pneumonia. 3. Air embolism at the damage of neck veins is possible. 4. Length of cut of trachea must correspond to the sizes of entered cannule. At small cut is origin of narrowing and squeezes tissues round it, that substantially hampers the withdrawal of cannule a too large cut can result in hypodermic emphysema with the subsequent development in the road clearance of trachea. . Before conducting of section of rings of trachea follows strictly to measure out the edge of scalpel (it must not exceed 1 sm, not to injure a esophagus). 6. At introduction of cannule to the road clearance of trachea, it is necessary expressly to make sure, that the mucous membrane of trachea is cut, otherwise cannule will enter in submucous tissue that will aggravate difficulty in breathing. OPERATIONS ON NECK DEPARTMENT OF ESOPHAGUS Findings. Wounds of esophagus, foreign bodies, which it is not succeeded to extract at esophagoscopy, tumours and proof scar narrowing.Position of patient on the back with a roller under scapulars, a head is thrown back and turned to the right, because a esophagus deviates to the left of middle line and conduct interference on left of neck. Operation is conducted under the local anaesthetizing, at children under anesthesia. A cut is conducted along the cutting edge of sterno-cleido-mastoid muscle on the left of the jugular undercuting of breastbone to the upper edge of thyroid cartilage. Layer a skin, hypodermic cellulose, is dissected, superficial fasciae together with hypodermic muscle necks.The vagina of sterno-cleido-mastoid muscle is unsealed. Take a muscle outside. The back wall of its vagina is unsealed. transmit and dissect III and IV fasciae of neck. Vascular-nervous bunch together with sterno-cleido-mastoid take muscle outside. Cut the parietal sheet of IV fasciae inward from a vascular-nervous bunch. A lower thyroid artery, p robutting V fasciae of neck, is bandaged. In a tracheoesophagal furrow find and take a left recurrent laryngeal nerve aside. Sterno-sublingual and sterno-thyroid muscles together with a trachea are taken to the right.A esophagus bares. A esophagus is determined on the longitudinally directed bunches of muscular fibres and rose-grey color. At the wound of esophagus in a stomach through a mouth a probe is entered, the wound of esophagus above a probe is taken in. Drainages are tricked into. In the case of the complete crossing of esophagus, a stomach-pump is inserted in its lower end, upper part tamponade. Afterwards the probe entered through the wound of esophagus, replace by the probe conducted through a nose. The damaged esophagus either is stitch together or produced its plastic arts.At suppuration of juxtaesophagal cellulose on meatus of esophagus gauze tampons are downward conducted. A patient is laid with the dropped head end of bed. Such position is instrumental in the free disengagement of pus from back mediastinum. In the case of delay of foreign body in a esophagus, at this level on it lay on two gauze serviettes, sewing the wall of esophagus to the mucous membrane. An organ is destroyed in a wound. After surrounding of esophagus by the serviettes of it unseal longitudinally, so a muscular shell is cut at first, and then mucous, which raise by pincers.If a foreign body formed bedsore, a esophagus at that rate is unsealed within the limits of healthy tissues. Foreign bodies are taken away by fingers or instrument. There are sutures on the wall of esophagus. Taking in of wound of esophagus is begun with imposition on its corners of lygature. The row of deep catgut stitches is further laid on through all layers of edges of