Lateral triangle of the neck (trigonum cervicis laterale) limited medially and superiorly by the sternocleidomastoid muscle (i. stemocleidomastoideus), below - collarbone (clavicula), lateral - trapezius muscle (t. trapezius)(Fig. 7-9).

Lateral triangle of the neck by the inferior belly of the omohyoid muscle (venter inferior m. omohyoidei) divided into scapular-acclavicular and scapular-trapezoid triangles (trigonum omoclaviculare et trigonum omotrapezoideum).

Scapuloclavicular triangle

Scapuloclavicular triangle (trigonum omoclaviculare) bounded anteriorly by the posterior edge of the sternocleidomastoid muscle (i.e. stemocleidomastoideus), behind - the anterior edge of the lower belly of the omohyoid muscle below - collarbone.

The following manipulations are performed within the scapuloclavicular triangle.

Access to the subclavian artery or one-

nominal vein. Ligation of the subclavian artery due to insufficient development of the roundabout circulation causes disruption of the blood supply to the upper limb, which can lead to amputation.

Access to the phrenic nerve, located

resting on the anterior surface of the anterior scalene muscle (i.e. scalenus anterior).

Anesthesia of the brachial plexus using the method

Kulenkampf during operations on the upper limb.

Access to the thoracic duct for

lymphosorption or for dressing for lymphorrhea.

In the area of ​​the scapuloclavicular triangle, the external jugular vein (v. jugularis externa), inferiorly flowing into the jugular venous angle (angulus venosus juguli), and saphenous supraclavicular nerves from the cervical plexus (supraclaviculars intermedii,

Rice. 7-9. Lateral triangle

neck. 1 - sensory nerves of the cervical plexus, 2 - sternocleidomastoid muscle, 3 - anterior scalene muscle, 4 - trunks of the brachial plexus, 5 - subclavian vein, 6 - subclavian artery. (From: Shevkunenko V.N. A short course in operative surgery with topographic anatomy. - M., 1951.)

586 «TOPOGRAPHIC ANATOMY AND OPERATIVE SURGERY ♦ Chapter 7

mediates et laterates). Deeper within the triangle is the interscalene space (spatium interscalenum).

Interscalene space (spatium interscalenum)- a triangular gap bounded anteriorly and medially by the anterior scalene muscle (i.e. scalenus anterior), posteriorly and laterally - by the middle scalene muscle (i.e. scalenus medius), from below - the first rib (Fig. 7-10). This gap gradually widens downwards. The interscalene space is of great practical importance, since in its lower part, adjacent to the first rib, the subclavian artery passes (a. subclavia), and above it pass the trunks of the brachial plexus (trunci plexus brachiales).

On the first rib next to the groove of the subclavian artery (sulcus a. subclaviae) the tubercle of the anterior scalene muscle is located (tuberculum t. scaleni anterioris). In case of arterial bleeding from the arteries of the upper limb, the subclavian artery can be pressed against it to temporarily stop the bleeding.

Rice. 7-10. Interstitial space. 1 - longus capitis muscle, 2 - longus colli muscle, 3 - anterior scalene muscle, 4 - middle scalene muscle, 5 - posterior scalene muscle, 6 - interscalene space, 7 - prescalene space.

Upper, middle and lower trunks of the brachial plexus (truncus superior, truncus medius el truncus inferior) located one above the other in the frontal plane and below touching the subclavian artery (a. subclavia)(see also section 1 “Topography of the brachial plexus”), §

When ligating the subclavian artery in the first supraclavicular fossa, i.e. when a vessel exits the interscalene fissure, you should especially vni-i It is important to differentiate the elements of the vascular-nervous bundle of the lateral triangle of the neck, since there are known cases of erroneous ligation instead of an artery of one of the trunks. I Checking the pulsation of the artery, used at this moment by the surgeon, can mislead him, since when placing a finger I on the trunk, a transmitting pulsation emanating from the artery can be felt (see also i I section “Exposure and dressing subclavian artery" in Chapter 8).

Scapular-trapezoid triangle (trigonum omotrapezoideum) bounded on the upper inner side by the posterior edge of the sternocleidomastoid muscle (i.e. sterno-cleidomastoideus), from the lower inner side - the lower belly of the omohyoid muscle (venter inferior t. omohyoidei), behind - the anterior edge of the trapezius muscle (t. trapezius).

Within the scapulo-trapezoid triangle behind the middle of the sternocleidomastoid muscle, sensory branches of the 1st cervical plexus exit from the inside to the fatty deposits: greater auricular nerve I (p. auricularis magnus), going up to the area of ​​the external ear and mastoid opening, medial, intermediate and lateral supraclavicular nerves (pp. supraclaviculars I mediates, intermedii et laterates), guiding 1 down through the collarbone within the connective | cervical region, lesser occipital nerve 1 (p. occipitalis minor), running backward and upward to the occipital region, transverse cervical nerve (n. transversus colli), passing in the transverse direction 1 to the midline of the neck I (Fig. 7-11).

Topographically and anatomically, four regions are distinguished on the neck: anterior, sternocleidomastoid, lateral and posterior [nuchal]. Within these areas, a number of muscle triangles are distinguished, which are important landmarks during surgical interventions on the organs of the neck.

Neck areas

Anterior neck, regio cerviccalis anterior - has the shape of a triangle, the base of which faces upward. This area is limited: from above - by the base of the lower jaw; below - the jugular notch of the sternum, and on the sides - the anterior edges of the right and left sternocleidomastoid muscles. The anterior midline divides this area of ​​the neck into the right and left medial neck triangles.
Sternocleidomastial region, regio stemocleidomastoidea - extends in the form of a strip from the mastoid process (above and behind) to the sternal end of the clavicle (below and in front).
Lateral neck region, regio cervicis lateralis - has the shape of a triangle, the most acute angle of which faces upward. This area is located between the posterior edge of the sternocleidomastoid muscle in front and the lateral edge of the trapezius muscle in the back, limited below by the clavicle.
Posterior neck area[nuchal region], regio cervicis posterior - on the sides limited by the lateral edges of the trapezius muscles; above - the upper nuchal line; below - a transverse line connecting the right and left acromion and passes through the spinous process VII. The posterior midline divides this area of ​​the neck into right and left parts.

Neck triangles

The midline, which is drawn from the chin to the jugular notch, divides the anterior region of the neck into the right and left parts, in which the anterior cervical triangle and the posterior cervical triangle are distinguished.
Anterior cervical triangle, trigonum colli anterius - paired, located in the anterior region of the neck. It is limited by the lower edge of the lower jaw, the anterior edge of m. sternocleidomastoideus and the midline of the neck. Upper abdomen m. omohyoideus divides it into several smaller triangles.
1. Sleepy triangle, trigonum caroticum - limited to the posterior abdomen of m. digastricus and the upper abdomen of m. omohyoideus and the anterior edge of m. sternocleidomastoideus. It contains the joint carotid artery, which is divided into the external and internal carotid arteries, as well as the internal jugular vein and the vagus nerve. Within this triangle, the external carotid artery is ligated to prevent bleeding during surgical interventions on the face and tongue (B.V. Ognev, V.X. Frauchi, I960).
2. Scapular-tracheal triangle, trigonum omotracheale - limited to the upper abdomen of m. omohyoideus, anterior-inferior edge of m. sternocleidomastoideus and the midline of the neck. Within this triangle there are vital organs: the carotid artery and the jugular vein. Surgical interventions are performed here (tracheotomy, strumectomy, laryngectomy, ligation of the common carotid artery and internal jugular vein).
3. Submandibular triangle, trigonum submandibular (fossa submandibularis) - limited by the anterior and posterior abdomen of m. digastricus and the lower edge of the lower jaw. It contains the submandibular salivary glands and contains the facial artery and vein, lingual and hypoglossal nerves. Within this triangle, incisions are made for phlegmon of the floor of the mouth, submandibular salivary glands are removed for neoplasms, and lymph nodes are removed for cancer of the tongue and lip (B.V. Ognev, V.X. Frauchi, 1960).
4. Pirogov triangle, trigonum Pirogowi (lingual triangle, trigonum linguale) - located in the submandibular triangle. It is limited: from below - by the tendon (posterior belly), m. digastricus, in front - by the posterior edge of m. mylohyoideus; from above - a segment of the hypoglossal nerve. Within its boundaries, the lingual vein and artery are designed, which must be taken into account in clinical practice. Access to the lingual artery is carried out in this triangle by cutting the fibers of the hyoid-lingual muscle, which are directed obliquely and longitudinally.
Posterior cervical triangle, trigonum cervicale posterius - paired, located between the posterior edge of m. stemocleidomastoideus and the anterior edge of the trapezius muscle and the clavicle. The inferior belly of the omohyoid muscle divides it into smaller triangles.
1. Scapuloclavicular triangle, trigonum omoclaviculare - formed: in front - by the rear edge of m. sternocleidomastoideus-, below - clavicle; behind - lower abdomen m. omohyoideus. It contains: the external jugular vein, the suprascapular artery and vein, on the left - the thoracic duct, and on the right - the right lymphatic duct. In this triangle, supraclavicular ligation of the subclavian artery and vein is performed, as well as anesthesia of the brachial plexus during operations on the upper limb (B.V. Ognev, V.X. Frauchi, 1960).
2. Scapular-trapezoid triangle, trigonum omotrapezoideum, - limited: behind - m. trapezius; front - rear edge m. sternocleido-mastoideus; below - lower abdomen m. omohyoideus. It contains: the subclavian artery and its branches, the superficial cervical artery and the transverse artery of the neck, the accessory nerve, n. accessorius, three long bundles and short branches of the brachial plexus and cutaneous branches of the cervical plexus.
3. Extramandibular fossa, fossa retromandibular - limited: posteriorly - by the mastoid process and m. sternocleidomastoideus; above - by the external auditory canal, in front - by the posterior edge of the ramus mandibulae; the medial styloid process and the muscles that originate from it (mm. stylohyoideus, styloglossus, stylopharyngeus). The premaxillary fossa is filled with the posterior part of the parotid gland, the facial and auriculotemporal nerves, the external carotid artery and the maxillary vein, v. retromandibular. On the neck between the scalene muscles there are two triangular spaces: interscalene and prescalene:
1) Interscalene space, spatium interscalenum - limited by the anterior and middle scalene muscles, and below by the 2nd rib. It contains the subclavian artery and brachial plexus;
2) Anterior space, spatium antesc.alenum - located between the anterior scalene muscle at the back and the sternothyroid and sternohyoid muscles at the front. It contains the subclavian vein, suprascapular artery and phrenic nerve.

Neck connects the head to the body, supports it and allows it to make movements. It consists of a musculoskeletal and visceral part. The musculoskeletal part of the neck is adapted to the vertical position of the human body.

The visceral part includes upper respiratory tract, including the larynx, which plays the role of a sphincter and vocal apparatus; the thyroid gland, the carotid fascial sheath located on either side of the midline, and the lymph nodes with a network of lymphatic vessels.

Upper border of the neck passes along the lower edge of the lower jaw, through the apex of the mastoid process to the external occipital protrusion. From a clinical and surgical point of view, the suprahyoid triangle is considered to be part of the neck. The inferior border of the neck is a plane passing through the jugular fossa, the clavicles and the spinous process of C7.

Lateral edges of the trapezius muscle form a border with the back of the neck. The shape of the neck and its plastic anatomy depend on the constitution of the individual and his body. In men, the plates of the thyroid cartilage, connecting at an angle, form a protrusion, also called the Adam's apple, and the sternocleidomastoid muscles are well developed. In women, these anatomical landmarks are less pronounced.

Sternocleidomastoid muscles and the edges of the trapezius muscle on each side, the hyoid bone, the plates of the thyroid cartilage and the cricoid cartilage participate in the formation of the profile of the neck, are clearly visible during examination and are easily palpated.

An enlarged thyroid gland (goiter) and tumors are easily noticeable upon examination and can also be easily palpated.

Areas and important triangles of the neck:
1 - submandibular triangle; 2 - submental triangle;
3 and 3a - sleepy triangle; 3b - sublingual triangle;
4 - lateral triangle of the neck, which is divided into the posterior triangle of the neck (4a) and the scapuloclavicular triangle (4b);
5 - small supraclavicular fossa; 6 - hyoid bone;
7 - anterior belly of the digastric muscle; 8 - sternocleidomastoid muscle;
9 - posterior cervical region with trapezius muscle.
a Most of the neck areas are visible or palpable.
b Side view on the right.

Neck areas

From clinical considerations neck divided into medial and lateral regions, the border between which corresponds to the sternocleidomastoid muscle.

Medial neck area: inferior to the hyoid bone are a) the superior carotid triangle, which has important clinical significance, with boundaries formed by the anterior edge of the sternocleidomastoid muscle, the superior belly of the omohyoid muscle and the posterior belly of the digastric muscle, and

b) the small inferior carotid triangle, the boundaries of which are the anterior and posterior edges of the sternocleidomastoid muscle, the medial edge of the omohyoid muscle and the base of the neck (sternocleidomastoid region). The suprahyoid triangle is divided into the submandibular and submental triangles.

Lateral neck region The lower belly of the scapulohumeral muscle is divided into two triangles. The lower, scapuloclavicular triangle is bounded by the scapulohyoid muscle, the clavicle and the internal jugular vein. It corresponds to the supraclavicular fossa.

:
1 - sternocleidomastoid muscle; 2 - posterior belly of the digastric muscle; 3 - upper belly of the omohyoid muscle;
4 - common carotid artery; 5 - internal jugular vein;
6 - deep cervical lymph node; 6a - lymph node of the jugular-facial venous angle;
7 - vagus nerve; 8 - hypoglossal nerve; 9 - superior laryngeal neurovascular bundle;
10 - neck loop; 11 - lower pole of the parotid gland; 12 - submandibular gland;
13 - facial artery and vein; 14 - hyoid bone.

Educational video of topography and anatomy of the triangles of the neck

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Operative surgery: lecture notes by I. B. Getman

1. Triangles, fascia of the neck, vessels, organs of the neck area

The neck is an area whose upper border runs along the lower edge of the lower jaw, the apex of the mastoid process and the upper nuchal line. The lower border corresponds to the jugular notch of the sternum, the upper edges of the clavicles and the line connecting the acromial process of the scapula with the spinous process of the VII cervical vertebra.

In the anterior section of the neck, separated from the posterior frontal plane, there are organs - the trachea, esophagus, thyroid gland, neurovascular bundles, the thoracic duct is located in the transverse processes of the cervical vertebrae. In the back of the neck there are only muscles enclosed in dense fascial sheaths and adjacent to the cervical vertebrae.

Neck triangles. By a horizontal plane drawn at the level of the body of the hyoid bone, the anterior part of the neck is divided into the suprahyoid and infrahyoid regions. The muscles located in the suprahyoid region form the floor of the oral cavity; in this area, three triangles are distinguished: the unpaired submental triangle, the sides of which are formed by the hyoid bone and the two anterior bellies of the digastric muscles; paired right and left submandibular triangles formed by the lower edge of the lower jaw and both bellies (anterior and posterior) of the digastric muscles. The subhyoid region is divided by the midline into right and left sides. On each side there are two large triangles and a rectangle.

The medial triangle is formed by the midline, the posterior belly of the digastric muscle and the anterior edge of the sternocleidomastoid muscle; lateral triangle - the posterior edge of the sternocleidomastoid muscle, the upper edge of the clavicle and the lateral edge of the trapezius muscle. Between these triangles there is a rectangle - the sternocleidomastoid region. In the medial triangle, two triangles are formed - the scapular-tracheal and the scapular-hyoid (carotid triangle), since within its boundaries there is the common carotid artery and its bifurcation.

Fascia of the neck. The most clear description is given by Academician V.N. Shevkunenko, who proposed a classification based on a genetic approach to study.

Based on their origin, all fascia are divided into three groups:

1) fascia of connective tissue origin, formed as a result of compaction of loose connective tissue and fiber around muscles, blood vessels and nerves;

2) fascia of muscular origin, formed in place of reduced muscles or flattened and stretched tendons (aponeuroses);

3) fascia of coelomic origin, which are formed from the internal lining of the primary embryonic cavity or from the reducing layers of the primary mesenteries.

In this regard, 5 fascia are distinguished on the neck. The first fascia of the neck, the superficial fascia, is of muscular origin and is found in all parts of the neck. On the anterior surface of the neck, this fascia can be separated by accumulations of adipose tissue into several plates. In the anterolateral sections, the superficial fascia forms a sheath for the subcutaneous muscle and, together with its fibers, continues onto the face, and below into the subclavian region. In the posterior part of the neck, numerous connective tissue bridges stretch from the superficial fascia to the skin, dividing the subcutaneous adipose tissue into numerous cells. This structural feature of subcutaneous fatty tissue leads to the development of carbuncles in this area (sometimes), accompanied by extensive necrosis of the tissue, reaching the fascial sheaths of the muscles. The second fascia of the neck - the superficial layer of its own fascia - in the form of a dense layer surrounds the entire neck, including both its anterior and posterior sections. Around the submandibular gland, sternocleidomastoid, and trapezius muscles, this fascia splits and forms a sheath. The spurs of the second fascia extending in the frontal direction are attached to the transverse processes of the cervical vertebrae and anatomically divide the neck into two sections: anterior and posterior. Due to the presence of a dense fascial plate, purulent processes develop in isolation, either only in the anterior or only in the posterior sections of the neck. The third fascia (the deep layer of the cervical fascia) is of muscular origin. It is a thin but dense connective tissue plate stretched between the hyoid bone and the clavicles. At the edges, this fascia is limited by the scapular-subclavian muscles, and near the midline by the so-called “long muscles of the neck” (sternohyoid, sternothyroid, hyoid-thyroid) and is shaped like a trapezoid (or sail). Unlike the 1st and 2nd fascia, which cover the entire neck, the 3rd fascia has a limited extent and covers only the scapulotracheal, scapuloclavicular triangles and the lower part of the sternocleidomastoid region. The fourth fascia (intracervical) is a derivative of the tissues that form the lining of the primary cavity. This fascia has two layers: parietal and visceral. The visceral layer covers the organs of the neck: trachea, esophagus, thyroid gland, forming fascial capsules for them. The parietal layer surrounds the entire complex of organs of the neck and the neurovascular bundle, consisting of the common carotid artery, internal jugular vein and vagus nerve. Between the parietal and visceral leaves of the 4th fascia, in front of the organs, a slit-like cellular space is formed - previsceral (spatium previscerale, spatium pretracheale). Behind the 4th fascia of the neck, between it and the fifth fascia, there is also a layer of fiber - the retrovisceral space (spatium retroviscerale). The fourth fascia, surrounding the organs of the neck, does not extend topographically beyond the median triangle of the neck and the region of the sternocleidomastoid muscle. In the vertical direction, it continues upward to the base of the skull (along the walls of the pharynx), and descends downward along the trachea and esophagus into the chest cavity, where its analogue is the intrathoracic fascia. This leads to an important practical conclusion about the possibility of spread (formation of a leak) of a purulent process from the cellular spaces of the neck into the cellular tissue of the anterior and posterior mediastinum with the development of anterior or posterior mediastinitis. The fifth fascia (prevertebral) covers mm. longi colli, lying on the anterior surface of the cervical spine. This fascia is of connective tissue origin. Continuing laterally, it forms a sheath (fascial sheath) for the brachial plexus with the subclavian artery and vein and reaches the edges of the trapezius muscles. Between the 5th fascia and the anterior surface of the spine, a bone-fibrous sheath is formed, filled mainly with the long muscles of the neck and loose tissue surrounding them.

Fascial sheaths often serve as routes for the spread of hematomas in case of injuries to the blood vessels of the neck and the spread of purulent leaks in case of phlegmon of various localizations. Depending on the direction of the fascial sheets, the formation of spurs by them and connections with bones or adjacent fascial sheets, the cellular spaces of the neck can be divided into two groups: closed cellular spaces and open cellular spaces. Closed cellular spaces are represented by the following formations. The suprasternal interaponeurotic space, located between the 2nd and 3rd fascia of the neck; case of the submandibular gland, formed by splitting the 2nd fascia of the neck, one of the leaves of which is attached to the lower edge of the jaw, the second to the linea mylohyoidea; sheath of the sternocleidomastoid muscle (formed by the splitting of the 2nd fascia). Unclosed cellular spaces include: previsceral space, located between the parietal and visceral leaves of the 4th fascia in front of the trachea from the level of the hyoid bone to the jugular notch of the sternum (at the level of the manubrium of the sternum by a fragile transverse septum, separated from the anterior mediastinum); retrovisceral space (located between the visceral layer of the 4th fascia, surrounding the pharynx, trachea and esophagus, and the 5th fascia, continues into the posterior mediastinum); fascial sheath of the neurovascular bundles of the neck, formed by the parietal layer of the 4th fascia (at the top it reaches the base of the skull, and at the bottom it leads to the anterior mediastinum); fascial sheath of the neurovascular bundle, formed in the lateral triangle of the neck by the 5th fascia (penetrates the interscalene space and then goes to the subclavian and axillary regions).

The main principle of treatment of neck abscesses is a timely incision, ensuring a wide opening of all pockets in which pus can accumulate. Depending on the location of the purulent focus, various incisions are used to drain it. For phlegmon of the suprasternal interaponeurotic cellular space, it is advisable to make an incision along the midline from the jugular notch of the sternum from bottom to top. If the process extends into the supraclavicular interaponeurotic space, a counteraperture can be applied by making a transverse incision above the clavicle with the introduction of drainage from the outer edge of the sternocleidomastoid muscle. In severe cases, it is possible to intersect one of the legs (sternal or clavicular) muscles. For phlegmon of the submandibular gland sac, the incision is made parallel to the edge of the lower jaw, 3–4 cm below. After dissecting the skin, subcutaneous tissue and 1st fascia of the neck, the surgeon penetrates deep into the gland sheath in a blunt manner. The cause of such phlegmon can be carious teeth, the infection of which penetrates into the submandibular lymph nodes. For submental phlegmon, a midline incision is made between the two anterior bellies of the digastric muscle. For phlegmon of the vascular sheaths, the incision is made along the anterior edge of the sternocleidomastoid muscle or above the collarbone, parallel to it, from the posterior edge of the sternocleidomastoid muscle to the anterior edge of the trapezius. The phlegmon of the sheath of the sternocleidomastoid muscle is opened with incisions along the anterior or posterior edge of the muscle, opening the layer of the 2nd fascia, which forms the anterior wall of the muscle sheath. Cellulitis of the previsceral space can be drained with a transverse incision above the jugular notch of the sternum. Phlegmons of the retrovisceral space are opened with an incision along the inner edge of the sternocleidomastoid muscle from the sternal notch to the upper edge of the thyroid cartilage. The retropharyngeal abscess is opened through the mouth in the area of ​​greatest fluctuation, with the patient sitting.

Topography and access to the carotid arteries

The common carotid artery is the main artery located in the neck. It, together with the vagus nerve and the internal jugular vein in the lower half of the neck, is projected into the regio sternocleidomastoideus. Somewhat below the level of the upper edge of the thyroid cartilage, the artery emerges from under the anterior edge of the muscle and divides into the internal and external carotid arteries. The bifurcation of the artery is located at the level of the notch of the thyroid cartilage and projects in the carotid triangle of the neck. Within this triangle, both the common carotid artery and both of its branches are most accessible for exposure. The classic projection line of the common carotid artery is drawn through points, the upper of which is located in the middle of the distance between the angle of the lower jaw and the apex of the mastoid process, the lower one on the left corresponds to the sternoclavicular joint, on the right is 0.5 cm outward from the sternoclavicular joint. To verify (identify) the external and internal carotid arteries, the following signs are used: the internal carotid artery is located not only posteriorly, but, as a rule, also laterally (outward) from the external carotid; branches arise from the external carotid artery, while the internal carotid artery in the neck does not give branches; temporary clamping of the external carotid artery above the bifurcation leads to the disappearance of pulsation a. temporalis superficialis and a. facialis, which is easily determined by palpation.

It should be remembered that forced ligation of the common or internal carotid artery in case of injury in 30% of cases leads to death due to severe cerebrovascular accidents. The prognosis for the development of a bifurcation thrombus, which sometimes develops when the level of ligation of the external carotid artery is chosen incorrectly, is equally unfavorable. To avoid this complication, the ligature on the external carotid artery must be placed above the origin of its first branch - a. thyreoidea superior.

Topography of the cervical part of the thoracic lymphatic duct

Damage to the cervical part of the thoracic duct is observed during sympathectomy, strumectomy, removal of lymph nodes in the supraclavicular region, and endarterectomy from the common carotid artery. The main clinical manifestation of a violation of the integrity of the thoracic duct is chylorrhea - the leakage of lymph. Measures to eliminate chylorrhea are wound tamponade or ligation of the ends of the damaged duct.

In recent years, the operation of lymphovenous anastomosis between the end of the damaged thoracic duct and the internal jugular or vertebral veins has begun to be used. Access to the thoracic duct and its isolation to eliminate damage or perform catheterization and drainage in typical cases is carried out along the medial edge of the sternocleidomastoid muscle. It should be emphasized that the cervical part of the thoracic duct is difficult to access for direct inspection.

Tracheostomy is an operation of opening the trachea with subsequent insertion of a cannula into its lumen in order to provide immediate access of air to the lungs in case of obstruction of the overlying sections of the respiratory tract. The first operation was performed by the Italian Antonio Brassavola (1500–1570). Classic indications for tracheostomy: foreign bodies of the respiratory tract (if it is impossible to remove them with direct laryngoscopy and tracheobronchoscopy); obstruction of the airway due to wounds and closed injuries of the larynx and trachea; acute stenosis of the larynx due to infectious diseases (diphtheria, influenza, whooping cough, measles, typhus or relapsing fever, erysipelas); laryngeal stenosis with specific infectious granulomas (tuberculosis, syphilis, scleroma, etc.); acute laryngeal stenosis in nonspecific inflammatory diseases (abscessing laryngitis, laryngeal tonsillitis, false croup); laryngeal stenosis caused by malignant and benign tumors (rare); compression of the tracheal rings from the outside by struma, aneurysm, inflammatory infiltrates of the neck; stenosis after chemical burns of the tracheal mucosa with vinegar essence, caustic soda, sulfuric or nitric acid vapor, etc.; allergic stenosis (acute allergic edema); the need to connect artificial respiration devices, artificial ventilation, controlled breathing in case of severe traumatic brain injury; during operations on the heart, lungs and abdominal organs; in case of barbiturate poisoning; for burn disease and many other less common conditions. To perform a tracheostomy, both general surgical instruments (scalpels, tweezers, hooks, hemostatic clamps, etc.) and a special set of instruments are required. The set of the latter usually includes: tracheostomy cannulas (Luer or Koenig), a sharp single-pronged Chessignac tracheostomy hook, a blunt hook for retracting the isthmus of the thyroid gland; a trachea dilator for spreading the edges of the tracheal incision before inserting a cannula (Trousseau or Woolfson) into its lumen. Depending on the location of the opening of the trachea and in relation to the isthmus of the thyroid gland, three types of tracheostomy are distinguished: upper, middle and lower. With an upper tracheostomy, the second and third rings of the trachea are cut above the isthmus of the thyroid gland. Intersection of the first ring, and especially the cricoid cartilage, can lead to stenosis and deformation of the trachea or chondroperichondritis with subsequent stenosis of the larynx. With a middle tracheostomy, the isthmus of the thyroid gland is incised and the third and fourth tracheal rings are opened. With a lower tracheostomy, the fourth and fifth rings of the trachea are opened below the isthmus of the thyroid gland. During the operation, the patient can be either in a horizontal position, lying on his back with a cushion placed under his shoulder blades, or in a sitting position with his head slightly thrown back. The operator stands to the right of the patient (with upper and middle tracheostomy) or to the left (with lower). The patient's head is held by an assistant so that the middle of the chin, the middle of the superior notch of the thyroid cartilage and the middle of the jugular notch of the sternum are located on the same line. The incision is made strictly along the midline of the neck. With an upper tracheostomy, the incision is made from the level of the middle of the thyroid cartilage down 5–6 cm. The “white line” of the neck is dissected along the probe and the long muscles located in front of the trachea are pulled apart. Immediately below the thyroid cartilage, the visceral layer of the 4th fascia, which fixes the isthmus of the thyroid gland to the trachea, is dissected in the transverse direction. With a lower tracheostomy, the incision of the skin and subcutaneous tissue begins from the upper edge of the jugular notch of the sternum and is carried up 5–6 cm. The 2nd fascia of the neck is dissected, the tissue of the suprasternal interaponeurotic space is bluntly dissected, if necessary, the arcus venosus juguli located here is ligated and crossed. The 3rd fascia is cut along the probe and the sternohyoid and sternothyroid muscles are pulled apart. Below the isthmus, the 4th fascia is incised and the isthmus is shifted upward, exposing the 4th–5th rings of the trachea. Before opening the trachea, to suppress the cough reflex, it is recommended to inject 1–1.5 ml of a 2% dicaine solution into its lumen with a syringe. Opening the trachea can be done either by a longitudinal or transverse incision. For special indications (for example, in patients who have been on controlled breathing for a long time), a tracheostomy method is used with cutting out a Bjork flap or excision of a section of the wall to form a “window”. When performing a longitudinal dissection of the trachea, the scalpel is held at an acute angle to the surface of the trachea (not vertically), belly up, and the 2 rings are crossed after puncturing the trachea with a movement from the isthmus of the thyroid gland and from the inside out, as if “ripping open” the wall. This technique allows you to avoid injury to the posterior wall of the trachea, as well as to dissect the mobile mucous membrane along the entire length of the incision. When longitudinally dissecting the trachea, the integrity of the cartilage is inevitably compromised, which can subsequently lead to scar deformation and the development of tracheal stenosis. Transverse dissection of the trachea between the rings is less traumatic.

Complications: bleeding from damaged neck veins, carotid arteries or their branches, veins of the thyroid plexus, innominate artery, as well as from injury to the isthmus of the thyroid gland; incomplete dissection of the mucous membrane, which leads to its peeling off with a cannula; “failing” of the scalpel and injury to the posterior wall of the trachea or esophagus; damage to the recurrent nerves. After opening the trachea, breathing may stop (apnea) due to a reflex spasm of the bronchi.

Topographic anatomy and operative surgery of the thyroid gland

Surgeons began developing operations on the thyroid gland from the end of the last century. Of the foreign surgeons, it should be noted Kocher (1896), who developed in detail the technique of operations on the thyroid gland. In Russia, the first operation was performed by N.I. Pirogov in 1849. The thyroid gland consists of two lateral lobes and an isthmus. The lateral lobes are adjacent to the lateral surfaces of the thyroid and cricoid cartilages and the trachea, reach 5–6 rings of the trachea with their lower pole and do not reach the upper edge of the sternum by 2–3 cm. The isthmus lies in front of the trachea, at the level of its 4th rings. The upper edge of the isthmus sometimes comes into contact with the lower edge of the thyroid cartilage. The gland is closely connected to the underlying tissues by loose connective tissue and ligaments, especially to the larynx and the first tracheal rings. Thanks to this fixation, it follows the movements of the pharynx and trachea during swallowing. Palpation of the gland at the time of swallowing helps to detect even small enlargements and densities, especially in the lower parts of the gland. The posteromedial surfaces of the lateral lobes of the thyroid gland are adjacent to the esophageal-tracheal grooves, in which the recurrent nerves are located. In this area, enucleation of a thyroid tumor requires special care, since damage to the recurrent nerves may lead to the development of aphonia. The neurovascular bundles of the neck (common carotid artery, vagus nerve and internal jugular vein) are adjacent to the outer sections of the lateral lobes of the gland. In this case, the common carotid artery is in such close contact with the gland that a longitudinal groove is formed on it. The lateral lobes touch the anterolateral wall of the esophagus. The gland is supplied with blood by the branches of the external carotid and subclavian arteries. The paired superior thyroid arteries, arising from the external carotid, approach from the posterior surface to the upper poles of the lateral lobes and branch mainly in the anterior parts of the gland. The paired inferior thyroid arteries, arising from the subclavian arteries (truncus thyreocervicalis), approach the lower poles of the lateral lobes and supply branches mainly to the posterior parts of the gland. In 10–12% of cases, the blood supply involves the inferior thyroid artery, which directly arises from the aorta and enters the lower part of the isthmus of the gland.

One of the most common operations on the thyroid gland is strumectomy. The technique of the most frequently used operation was developed by O. V. Nikolaev (1964). It is called subtotal subcapsular resection of the thyroid gland. Surgical access is made through a horizontal arcuate incision 1–2 cm above the jugular notch of the sternum, 8–12 cm long, along one of the transverse skin folds (“collar” incision). When dissecting soft tissues, careful ligation of blood vessels is performed. The resulting flaps, including skin, subcutaneous tissue and superficial fascia, are peeled off bluntly and spread up and down. The sternohyoid muscles are transversely intersected. After introducing novocaine under the sternothyroid muscles and into the fascial sheath of the thyroid gland, the muscles are moved apart from the midline, and the parietal layer of the 4th fascia of the neck is dissected. By bluntly displacing the edges of the dissected fascia, an approach to the thyroid gland is provided and the surgical procedure begins. Isolation of the organ begins with “dislocation” of the gland, usually from the right lobe, depending on the situation from the upper or lower poles. After the right lobe is released, the isthmus of the thyroid gland is crossed using a probe (or under finger control). As the isthmus is dissected, hemostatic clamps are applied sequentially. Less commonly, the isthmus is crossed between the clamps, followed by suturing its tissue and tightening the ligatures. This is followed by a “scaphoid” excision of the tissue of the right lobe of the gland, which is performed under finger control. This moment requires careful stopping of bleeding and the application of a large number of clamps. By controlling the movement of the scalpel with a finger placed under the gland, a narrow plate of gland tissue is left in the area that is considered a “dangerous” zone, since the recurrent nerve and parathyroid glands are adjacent to it behind. The remainder of the gland (a few millimeters of tissue from the right and left lobes) should be sufficient to prevent hypothyroidism. The medial and lateral edges of the remaining gland parenchyma are sutured together in the form of two flaps. The bed of the removed gland and the remaining stump is covered by the sternothyroid muscles. Then the sternohyoid muscles crossed during access are sutured and sutures are placed on the skin.

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PLAN

1. External landmarks, conditional boundaries of the neck. Division into areas and triangles.

2. Layer-by-layer structure of the neck: fascia and cellular spaces.

3. Topography of the carotid triangle and Pirogov’s triangle.

4. Treatment of phlegmon and neck abscesses.

5. Tracheostomy.

6. Subtotal subcapsular resection of the thyroid gland according to O.V. Nikolaev.

Upper limit neck is drawn in the form of a circular line along the edge of the lower jaw, from the angle of the lower jaw to the apex of the mastoid process, along the upper nuchal line to the external occipital protuberance.

Bottom line corresponds to a conventional line drawn along the edge of the manubrium of the sternum, the upper edge of the clavicle, from the acromial process of the scapula to the spinous process of the VII cervical vertebra.

According to the anterior edges of the trapezius muscle, the neck is divided into the anterior and posterior surfaces, and the latter, along the spinous processes of the cervical vertebrae, into the right and left regions.

On the front surface of the neck there is suprahyoid and subhyoid areas, separated by the hyoid bone.

In the suprahyoid region there are:

- submental triangle, limited on the sides by the anterior abdomens of m. digastricus, and below - the hyoid bone.

- submandibular triangle(paired), anteriorly and posteriorly limited by the anterior and posterior abdomens of m. digastricus, and from above - by the edge of the lower jaw.

The subhyoid region is divided by the sternocleidomastoid muscle into the medial surface of the neck (between the inner edges of the muscle) and the lateral triangle of the neck (on the sides of the outer edge of the muscle).

In the medial region there are:

- sleepy triangle, the boundaries of which are from above - the posterior abdomen m. digastricus, medially – the upper belly of the omohyoid muscle, laterally – the inner edge of the sternocleidomastoid muscle.

- pretracheal triangle, bounded centrally by the midline of the neck, superiorly and laterally by the superior belly of the omohyoid muscle, and below and laterally by the inner edge of the sternocleidomastoid muscle.

In the lateral triangle of the neck there are:

- Scapuloclavicular triangle(supraclavicular), limited below by the upper edge of the clavicle, medially by the outer edge of the sternocleidomastoid muscle, above by the lower belly of the omohyoid muscle.

- scapular-trapezoid triangle, the boundaries of which are medially - the outer edge of the sternocleidomastoid muscle, below - the lower belly of the omohyoid muscle, above - the anterior edge of the trapezius muscle.

In general, dividing the neck into regions and triangles is justified by the projection of the internal organs of the neck and large neurovascular bundles into them.

LAYERED STRUCTURE OF THE NECK

According to the layer-by-layer structure, Shevkunenko identified in the neck area five fasces.

Skin: thin, flexible, easily folded.

Subcutaneous fat: loose.

- superficial fascia (1st according to Shevkunenko) in the form of a circular case, it covers the entire surface of the neck, splits into two leaves and forms a case for m. platisma. Below it are the superficial and anterior jugular veins of the neck. All saphenous veins of the neck gape due to intraoperative damage; due to negative pressure, air enters the vein cavity, and an air embolism is formed. The superficial fascia freely passes to the chest from below and the head from above.

- superficial layer of the fascia of the neck (2nd according to Shevkunenko). From above it is attached to the bony landmarks of the upper border of the neck, goes down and forms cases for the submandibular salivary gland, m. digastricus and muscles of the floor of the mouth, sternocleidomastoid and trapezius muscles. From below it fuses with the outer surface of the manubrium of the sternum and clavicles. Deep into the neck it forms two frontal spurs to the transverse processes of the cervical vertebrae and a sagittal spur to the spinous processes. Thus, the neck is anatomically divided into anterior and posterior regions, and the latter into right and left. This limits the spread of phlegmon throughout the cellular spaces.

- deep leaf of the neck's own fascia (3rd according to Shevkunenko) has the shape of a trapezoid. It is attached above to the hyoid bone, below - to the inner surface of the manubrium of the sternum and clavicle, on the sides - by the omohyoid muscle. It is expressed in the medial part of the subhyoid region and forms cases for the sternohyoid, thyrohyoid, sternothyroid and omohyoid muscles. In the center of the neck, the 2nd and 3rd fascia fuse, not reaching the sternum 1.5 cm, and form the white line of the neck, which is used for surgical approaches.

- splanchnic fascia of the neck (4th according to Shevkunenko) is divided into two layers: parietal, surrounding all the organs of the neck from the outside and forming a case for the main neurovascular bundle on the sides, and visceral, forming capsules for the internal organs of the neck.

- prevertebral fascia (5th according to Shevkunenko) forms cases for the long muscles of the head and neck, scalene muscles and sympathetic trunk, subclavian neurovascular bundle.

The interfascial spaces of the neck are formed:

- interfascial suprasternal tissue space: located between the second and third fascia of the neck above the sternum and clavicles, delimited from above by the white line of the neck, from the sides it passes into the blind bags of Grubber behind the sternocleidomastoid muscle. It contains the jugular venous arch.

- previsceral (pretracheal) cellular space located between the leaves of the third and fourth fascia of the neck. It communicates along the anterior wall of the trachea with the anterior mediastinum.

- retrovisceral (retroesophageal) fiber space is located between the fourth and fifth fascia of the neck and communicates above - with the retropharyngeal tissue, below - with the posterior part of the mediastinum.

- cellular space of the main neurovascular bundle limited by its case. It communicates from above - with the base of the skull, from below - with the tissue of the thoracic cavity.

- cellular space of the lateral triangle of the neck located between the second and fifth fascia of the neck. It contains the cervical plexus at the top, the subclavian vessels and the brachial plexus at the bottom. Communications are realized along the subclavian arteries with the subclavian and axillary regions.

TOPOGRAPHY OF THE SLEEPY TRIANGLE

Borders:

above – posterior abdomen m. digastricus;

medially – the upper belly of the omohyoid muscle;

laterally – the inner edge of the sternocleidomastoid muscle.

In this triangle, the main neurovascular bundle of the neck is projected along the bisector of the angle formed by the upper belly of the omohyoid muscle and the inner edge of the sternocleidomastoid muscle. It includes:

The common carotid artery (to the left departs from the aortic arch, to the right from the brachiocephalic trunk) is located medially and medially;

The internal jugular vein (originates from the sigmoid venous sinus of the dura mater and exits the cranial cavity through the jugular foramen of the posterior cranial fossa) lies laterally and lateral to the artery;

The vagus nerve (leaves the cranial cavity through the jugular foramen) is located posterior to the vessels and between them the posterior surface is adjacent to the retrovisceral cellular space.

At the level of the V cervical vertebra (the upper edge of the thyroid cartilage of the larynx) there is a bifurcation zone of the common carotid artery. The external carotid artery passes inward and medially and along its length gives off branches, and the internal carotid artery is located outward and laterally, does not give off branches on the neck and enters the cranial cavity through the anterior section of the lacerated foramen, lies on the sides of the sella turcica in the groove of the same name and forms the anterior and middle cerebral arteries.

The external carotid artery gives off the following branches in the neck:

Superior thyroid artery (superior laryngeal artery);

Lingual artery;

Facial artery;

Posterior auricular artery;

Occipital artery;

Ascending artery of the pharynx.

Behind the main neurovascular bundle of the neck, medially to the vagus nerve, is the sympathetic cervical trunk. It has three main nodes: upper, middle and lower, which are connected by vertical nerve fibers. Sometimes an additional node is isolated. The upper node is located at the level of 2-3 cervical vertebrae, the middle one is located at the level of the 6th cervical vertebra, the intermediate one is at the level of the 7th, and the lower one most often merges with the first thoracic vertebrae, forming a stellate node (in the scalene-vertebral space at level 1 th thoracic vertebra).

TOPOGRAPHY OF THE PIROGOV TRIANGLE

Borders:

Medially: free edge of the mylohyoid muscle;

Laterally and inferiorly: tendon of the posterior belly of m. digastricus;

Above is the hypoglossal nerve.

The bottom of the triangle is m. hyoglossus. Below it is the lingual artery.

TOPOGRAPHY OF THE STAIMOVERTEBRAL SPACE

Behind the lower part of the sternocleidomastoid muscle there are deep intermuscular spaces of the neck:

The prescalene space is bounded posteriorly by the anterior scalene muscle, and anteriorly by mm. sternotyreoideus and. sternohyoideus. It contains the inferior bulb of the internal jugular vein, the common carotid artery, the vagus nerve, the confluence of the subclavian and internal jugular veins (venous angle of Pirogov). The thoracic lymphatic duct flows into the left one, and the right lymphatic duct flows into the right one), the phrenic nerve.

The scalene-vertebral interval, the boundaries of which are: outside - the anterior scalene muscle, inside - the length of the neck muscle, below - the dome of the pleura, above - the carotid tubercle of the transverse process of the VI cervical vertebra. It contains the initial section of the subclavian artery, the arch of the thoracic lymphatic duct, the middle, intermediate and lower nodes of the sympathetic trunk.

The interscalene space is located between the anterior and middle scalene muscles. It contains the middle section of the subclavian artery.

In these spaces, the following depart from the subclavian artery:

Internal thoracic artery;

Vertebral artery;

Thyrocervical trunk (inferior thyroid artery, ascending cervical artery, superficial cervical artery and suprascapular artery);

Costocervical trunk (deep neck artery, highest thoracic artery);

Transverse artery of the neck).

SURGERY OF PHLEGMON AND ABSCESSES OF THE NECK

Surgical access to the neck is determined by the localization of phlegmon or abscess in a certain cellular space and is carried out according to external landmarks.

Phlegmon submandibular salivary gland bed: The incision is made 1 cm inferiorly and parallel to the edge of the lower jaw.

Phlegmon of the main neurovascular bundle of the neck: an incision is made along the anterior or posterior edge of the sternocleidomastoid muscle.

Phlegmon suprasternal interaponeurotic and previsceral (pretracheal) cellular spaces: opened with a transverse tissue incision parallel to the edge of the jugular notch of the manubrium of the sternum or with a lower vertical incision along the midline of the neck.

Phlegmon retrovisceral (retrovertebral) cellular space: The incision is made along the anterior edge of the sternocleidomastoid muscle.

Cellulitis cellular space of the outer triangle of the neck: opened along the posterior edge of the sternocleidomastoid muscle or with a transverse incision 1 cm above and parallel to the clavicle.

General principles of surgical treatment of abscesses and phlegmons of the neck: an incision of at least 7-8 cm in length is made in layers. In order to prevent damage to blood vessels and nerves, opening a purulent focus can be carried out in three ways:

The opening is performed with a scalpel using a grooved probe;

The abscess is opened using a hemostatic clamp, which is inserted into the abscess cavity. Then the jaws of the clamp open, increasing the incision deep into the wound.

The abscess is punctured with a needle, and then it is opened with a scalpel using a needle.

After opening, emptying and washing the abscess, a drainage tube is installed in its cavity. Drainage is not recommended for large vessels, as a bedsore may form on their walls.

TRACHEOSTOMY

Tracheostomy– operation of placing an ostomy on the windpipe.

Indications: injuries of the larynx and upper trachea; entry of foreign bodies into the upper respiratory tract; tumors that impair breathing; acute and chronic inflammatory processes accompanied by stenosis of the upper respiratory tract (diphtheria); severe traumatic brain injury, chest injury with multiple rib fractures; after extensive surgical interventions on the chest organs, brain, etc.