Surgical diseases lecture 1. IV year VII semester.pdf

SURGICAL DISEASES
Lecture N1
1. Topography of thorax.
2. Thoracotomy.
3. Methods of examination in
thoracic surgery.
4. Chest injuries.

The term "surgery" means action, craft, skill. Such a narrow understanding of surgery does not correspond to the
content of this subject and has a purely historical significance, when surgeons were mainly engaged in "manual" - the
correction of dislocations, treatment of wounds and bloodletting. Currently, surgery is understood as the division of
medicine, where besides conservative (therapeutic) methods of treatment, operative (surgical) treatment is used.
From earliest recorded history through late in the 19th century, the manner of
surgery changed little. During those thousands of years, surgical operations were always frightenin
g, often fatal, and
frequently infected. In this prescientific, pre-anesthetic, and pre-antiseptic time, procedures were perf
ormed only for the most dire
of necessities and were unlike anything seen today; fully conscious
patients were held or tied down to prevent their fleeing the surgeon’s unsparing knife. When t
he surgeon, or at least those persons who used the sobriquet“surgeon,” performed an operation, it was
inevitably for an ailment that could be visualized (i.e., on the skin
and just below the surface, on the extremities, or in the mouth).
It would take several more decades, well into the 20th century, for administrative and
organizational events to occur before surgery could be considered a bona fide profession.
The explanation for the slow rise of surgery was the protracted
elaboration of four key elements (knowledge of anatomy, control
of bleeding, control of pain, and control of infection) that were
more critical than technical skills when it came to the performance
of a surgical procedure. These prerequisites had to be understood
and accepted before a surgical operation could be considered a viable therapeutic option. The
first
two
elements
started
to
be
addressedinthe16thcentury,andalthoughsurgerygreatlybenefited
fromthebreakthroughs,itsreachwasnotextendedbeyond
the exterior of the body, and pain and infection continued to be
issuesforthepatientandthesurgicaloperation.Overtheensuing
300years,therewaslittlefurtherimprovementuntilthediscovery
INTRODUCTION TO THE SURGICAL DISEASES

Surgical diseases can be divided into the following groups:
1. Defects of development and ugliness (imperforate anus, cleft palate, congenital heart
disease, etc.).
2. Тrauma (wounds, dislocations, fractures, burns, frostbite, electric trauma).
3. Surgical infection (abscesses, phlegmon, osteomyelitis, osteoarticular tuberculosis, etc.).
4. Tumors (benign and malignant).
5. Necrosis.
Many diseases are treated not only by surgeons, but also by other specialists. These
diseases include peptic ulcer of the stomach and duodenum, lung abscess, inflammation of the
gallbladder and many others.
INTRODUCTION TO THE SURGICAL DISEASES

Topography of the Thorax
Walls of the Thorax Thoracic cavities
1.own layers 1. right pleural
2. sliding layers 2. left pleural
3. mediastinal
4. pericardial
The so-called sliding layers are the same in all regions, such as the skin, fatty tissue, fasciae and muscles with their peculiarities
in each region.
The own layers include the bones of the thorax (vertebrae, sternum, ribs), the intercostal muscles, the thoracic transverse muscle
and f. endothoracica.
In topographic anatomy of the chest the anterior superior thoracic region interests us most of all, because the breast containing
mammary gland is situated here

TOPOGRAPHICAL ANATOMY OF THE
THORAX
The thorax extends between the neck and
abdomen. The superior boundary of the thorax
is the superior margin of manubrium sterni and
clavicles, an imaginary line which extends
between acromions and spinous process of the
7-th cervical vertebra. The inferior boundary is
the xiphoid process, costal arches (arcus
costae), and free ends of the 11th and 12th ribs,
inferior margin of 12-th pair of ribs till spinous
process 12-th thoracic vertebra. The thorax
consists of the thoracic wall and cavity. The
thoracic cavity includes 4 cavities (1 fibrous, 3
serous) the mediastinum is fibrous and pleural,
pericardial cavities are serous. The wall
consists of so called movable and own layers.

Boundaries of the thoracic cavity
1. The upper border of the thoracic
cavity is jugular notch of the
sternum, first rib, body of the first
thoracic vertebra (apertura
thoracis superior).
2. The lower border is the xyphoid
process of the sternum, costal
arches, 11 and 12 free ends of the
ribs, body of the 12 thoracic
vertebra (apertura thoracis
inferior).

THORAX
We describe several imaginary lines on the thoracic
wall. It is necessary for the description of wounds and organs,
which are situated in the thoracic cavity. We use the
following imaginary lines (all of these lines are parallel to
each other):
1. Linea mediana anterior passes through the midline of
the sternum.
2. Linea sternalis passes through the lateral margin of
the sternum.
3. Linea medioclavicularis passes through the middle
point of the clavicle.
4. Linea parasternalis passes through the middle point
of the distance between linea sternalis and linea
medioclavicularis.
5. Linea axillaris anterior begins from the inferior
border of the m. pectoralis major.
6. Linea axillaris posterior begins from the inferior border of the m. latissimus dorsi.
7. Linea axillaris media passes through the middle point of the distance between linea axillaris anterior and linea axillaris posterior.
8. Linea scapularis passes through the inferior angle of the scapula.
9. Linea vertebralis passes through the lateral margins of the thoracic vertebrae.
10. Linea paravertebralis extends in the midpoint of the distance between linea vertebralis and linea scapularis.
11. Linea mediana posterior passes through the spinous processes of the thoracic vertebrae.
A.Linea pectoralis (on the level of 5 rib, or on the level of inferior margin of m. pectoralis major;
B.Linea scapularis horizontalis.
A B

The thorax is divided into anterior and
posterior parts by a plane, which traverses
through the middle axillary lines. By means of
the sternal and vertebral lines, the thorax is
divided into the following regions:
5. Regio sternalis;
5. Regio vertebralis;
1-2 Regio thoracalis anterior superior and
inferior
(3-4). The border between these 2 regions is an
imaginary line, which passes through the
inferior margin of the 5th pair of ribs (or
inferior margin of m. pectoralis major).
1-2 Regio thoracalis posterior superior and
inferior (3-4). The border between these regions
is an imaginary line, which passes through the
THORAX
The so-called movable layers are the same in all regions, such as the skin, fatty tissue, fasciae and muscles
with their peculiarities in each region.
The own layers include the bones of the thorax (vertebrae, sternum, ribs), the intercostal muscles, the thoracic
transverse muscle and f. endothoracica.

1. Anterolateral thoracotomy. It is convenient for wide
access to the anterior surface of the lung and the vessels of the
root of the lung.
The position of the patient on the table: On the back.
Technique of execution: The incision is made along the
V rib from the edge of the sternum to the middle axillary line,
the latissimus dorsi is retracted outward. The pleural cavity is
opened in the IV or V intercostal space: intercostal tissue is
dissected throughout the skin wound. If it is necessary to
expand access, can be incised also and overlying (III or IV)
costal cartilages.
Application: Right-sided and left-sided pneumonectomy,
removal of the upper and middle lobe of the right lung.
Advantages: Low morbidity, convenience of the patient’s
body position for anesthesia and surgical intervention,
prevention of bronchial contents getting into the opposite lung,
ease of isolating the main bronchus and removing
tracheobronchial lymph nodes.
Disadvantages: Only the anterior mediastinum is
available, difficulties in suturing and sealing the wound.
Thoracotomy

Thoracotomy
1.To perform posterolateral thoracotomy, the
patient is placed on the stomach or attached to a
semi-lateral position (on a healthy side with an inclination
forward). The soft tissue incision begins at the level of the
spinous process of the III-IV thoracic vertebra and,
rounding the corner of the scapula, continue along the VI
rib to the front axillary line. All soft tissues are
sequentially dissected up to the ribs, the pleural cavity is
opened along the intercostal space or through the bed of
the resected rib. The posterolateral thoracotomy is more
traumatic, because it is necessary to dissect the thick layer
of the back muscles and resect the ribs.

Thoracotomy
3. In case of lateral thoracotomy, the
chest cavity is opened along the V-VI ribs from
the paravertebral to the midclavicular line.
Lateral access creates good conditions for
manipulation in almost all parts of the chest
cavity - from the dome of the pleura to the
diaphragm, from the spine to the sternum. Lack
of lateral access is considered to be the patient's
forced position on the healthy side, which
makes breathing more difficult and, during
operations, for purulent lung diseases,
predisposes to a flow of purulent discharge in
the bronchi of the healthy side.

Thoracotomy
4. The clamshell thoracotomy usually starts as a
standard left anterolateral thoracotomy - often an
emergency department thoracotomy for traumatic arrest
as in this case. The left thoracotomy is placed in the 5th
intercostal space (just below the nipple). Access
following a left anterolateral thoracotomy is fairly
limited. The clamshell is made by performing a right
sided thoracotomy in the same interspace.
Once the full thoracotomy has been completed on
both sides, the sternum must be split. This can be
accomplished with a Gigli saw or, more usually, a heavy
pair of trauma scissors or other shears. Dividing the
sternum will also divide the inferior mammary arteries on
both sides. Usually these do not bleed at this stage due to
profound hypotension, but will start to bleed once blood
volume and flow is restored. These will need to be
ligated at some point in the future. The rib retractor is
placed between the cut ends of the sternum and opened.
The fibrofatty tissue between the sternum and the anterior
pericardium should be divided with scissors.

Thoracotomy
A traditional sternotomy incision commences at the
midpoint of the manubrium and is carried down to the
xiphoid. The sternum is split through the middle with a
sternal saw. It is essential that gentle upward force and a
backward tilt be applied to the saw to prevent it from
engaging the lung or soft tissues in the anterior
mediastinum. Once the sternotomy is completed, the
periosteum of the posterior table is cauterized, and a
passive hemostatic agent such as bone wax or a
reconstituted mixture of vancomycin may be used to
prevent bleeding from the marrow. The most important
consideration during the sternotomy is staying in the
midline because the most common cause of sternal
dehiscence is an off-midline sternotomy and the
consequent technically suboptimal closure. Other potential
problems associated with the sternotomy include indirect
injury to the liver and direct injury to the heart, innominate
vein, and lungs. It is widely used incision, which provides
good access to the thoracic cavity and the mediastinum. It
can predispose to significant scar formation and chronic
chest pain.

Methods of Study.
1.Anamnesis and physical examination: Complains, anamnestic data of the patient, clinical study data
(examination, palpation, percussion, auscultation) are of great importance for diagnosis of the diseases of
chest organs.
2. Instrumental methods, which confirm the diagnosis, topic and the prevalence of the process, also the
functional condition of the patient.
A. X-ray study is the most important method, which is done for the first almost to all the patients. Plain
x-ray with roentgenography and roentgenoscopy are used in both- anterio-posterior and lateral positions.
In great majority of cases x-ray is enough to make correct diagnosis. The investigation of trachea and
bronchi with the help of contrast agent helps to detect constrictions and dilatations of bronchi, changes of
residual cavities, occurrence of bronchopleural fistulas. For examination of pulmonary artery and its
branches also contrast method - angiopulmonarography is needed.
Pleurography is a contrast study of cavities developed in pleural cavity as a result of different
processes. It is used at empyemas to detect the cavity size and bronchopleural fistulas.
- Computer tomography in a number of cases it is necessary to make a computer tomography (CT). It
allows detecting the tissue density or its contents and finding out if we deal with the tissue or the liquid.
CT also helps to specify the depth of the process extension, analyze the changes in trachea and bronchus
lumen, which can not be detected at roentgenological study. CT also allows to specify the interrelation of
pathologic focus and the surrounding tissues, the occurrence of affected lymph nodes, study the condition
of trachea and bronchi walls. Magnetic resonance tomography helps to differentiate cysts, vascular
pathology and tumor extension.
METHODS OF EXAMINATION IN THORACIC SURGERY

Selective left pulmonary
angiogram shows abrupt
tapering of the segmental
pulmonary arteries
(arrow) with
heterogeneous
opacification of the
parenchyma. Mean
pulmonary arterial
pressure was 40 mmHg.
These findings are
consistent with chronic
pulmonary
thromboembolism.

Methods of Study.
B. Ultrasound examination allows detecting even little fluid accumulation in pleural cavity, often in costo-
diaphragmatic sinuses and detecting the place of punction. The tumor of chest wall can be detected also by
means of sonography. The usage of ultrasound study at chest pathologies is limited.
C. The endoscopic methods of study are widely applicable, first of all tracheobronchoscopy. It allows to
examine the walls of thachea and bronchi from inside, take material for bacteriological, cytological and
histological studies (lavage fluids, parts of mucous membrane, tumor). With the help of bronchoscopy it is
possible to perform sanation of bronhial tree (lavage, introduction of medicine, removal of foreign bodies).
Another endoscopic method of study is mediastinoscopy, which allows to examine the anterior mediastinum
visually. Medistinoscope is introduced through jugular fossa, extended along the anterior wall to the tracheal
bi-furcation.
3. Laboratory methods Bacteriological and cytological studies of sputum and lavage fluids of pleural cavity
are of exclusive value. Histological study of biopsy material, taken at endoscopic or open biopsy of lungs and
pleura. |Biochemical and general analysis of blood. Determination of acid-base balance and blood gases.
4. Functional study allows to judge about spare capacities of organism to choose the most rational method of
treatment, to plan the extent of operation and evaluate the results of treatment. Spirometry (meaning the
measuring of breath) is the most common of the pulmonary function tests (PFTs). It measures lung function,
specifically the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled. Spirometry is
helpful in assessing breathing patterns that identify conditions such as asthma, pulmonary fibrosis, cystic
fibrosis, and COPD. It is also helpful as part of a system of health surveillance, in which breathing patterns are
measured over time.

Methods of Study.
4. Functional study: Spirometry
The amount of air breathed in or out
during normal resting respiration is called –
Tidal volume – Vt. The volume of air an
individual is normally breathing in and out is
500 ml. The additional 1500 ml of air that can
be inhaled after maximal exhalation is called
inspiratory reserve volume -IRV.
Approximately the same volume can be
exhaled at maximal expiration - expiratory
reserve volume, ERV.
Summing up tidal and reserve volumes we get vital capacity volume – VC. Normally, on an
average, VC makes 3.5-5.5 liters.
The volume of air which can be exhaled during one minute at quite breathing is called minute volume -
MV. A normal minute volume is about 6–8 liters per minute.
Maximal lung ventilation – MLV –volume of air exhaled in one minute at maximal volume and
frequency of respiration (normally 110-120 liter per min.). Air volume left in lungs after maximal
expiration is called residual volume – RV (approximate. 1liter).
Also data of partial pressure of oxygen (pO2) and carbon dioxide (pCO2) are of great importance.
Normally they are correspondingly 90-120 and 34-46 mm mercury column.

CHEST INJURIES
Chest injuries can be open and closed. Injuries
with not injured skin integrity are called closed.
A. Closed (blunt) injuries can be with or without
damages of bone skeleton and /or internal organs.
Chest injuries are the result of direct influence of
mechanical force on the given area (impact, falling
from height etc.). Hemorrhages, rib and breast bone
fractures, injuries of internals are possible in these
cases. The injuring factor can also cause rib
deformation without fracture, lung injury with
bleeding, alveoli and alveolar septum injuries. There
is also a possibility of traumatic pneumonia with
possible abscess and lung gangrene. At rib fractures
the displaced fragments can injure intercostal vessels,
pleura, lungs and heart.

CHEST INJURIES
A. Close injuries
Such injuries are often combined with pneumothorax, hemothorax,
subcutaneous and mediastinal emphysema, atelectasis. Hemothorax is
blood accumulation in pleural cavity. It is a result of lung, heart, vessels and
chest injuries. The accumulation of air in pleural cavity is called
pneumothorax. At closed pneumothorax, the air does not contact with
atmospheric air. The causes of closed pneumothorax at closed injuries are
the injuries of air containing organs (trachea, lungs, bronchi, esophagus).
At simultaneous injury of visceral pleura and chest wall tissues, air
penetrates to subcutaneous fat, causing subcutaneous emphysema, it can
spread up to the neck, the face, the abdominal wall and even the scrotum. At
examination typical swelling of skin is observed, palpation detects
crepitation, percussion – tympanic sound. At mediastinal emphysema
through the injured area of parietal pleura the air penetrates to mediastinum
and then to the neck.

CHEST INJURIES
A. Close injuries
In contrast to lung pressuring (compression), when lung collapse is being developed, the ventilation
atelectasis is conditioned by obturation of bronchi with clots, blood, mucus. Dischargings of this kind from
bronchi occur with difficulties because of pains, flexure, rupture of bronchi, bronchospasm, disorder of
surfactant synthesis and edema.
In shock lung considerable disorders
in processes of blood oxygena-tion take
place as a result of lessening of the number
of functioning capillaries because of their
obstruction by blood corpuscles,
microembolias, and also increase of the
number of arteriovenous shunts. Surfactant
synthesis is disturbed as a result of lung
alveolus trophism disorders, which causes
micro- and macroatelectases. Heavy
disorders of ventilation and hyperkalemia
and also cardiac decompensation are hard
yielded to correction and often bring to
fatal outcome.
At blast wave occur concussions, hemorrhages, lung tissue rupture and emphysema. This kind of trauma
can become complicated by air or fat embolism of brain vessels and development of shock lung syndrome.

CHEST INJURIES
A. Close injuries
Signs and symptoms. Clinic is characterized by the kind of lesion (bone fractures, injuries of
internals), extent of blood loss, ventilation disorder, evidence of pain syndrome, presence of combined
injuries. Usually the diseased person complains of pains, which increase at inhaling and moving. Pain is
especially expressed at rib fractures. The diseased also suffer from blood spitting, bronchial hemorrhage,
dyspnea, dizziness. On the area of injury hemorrhages are observed.
Multiple rib fractures, especially fenestrated fracture, when some ribs are injured in two places,
cause the formation of a rib valve; also occurrence of paradoxical respiration is possible ("flail chest") –
at inspiration the valve moves inside, at expiration – out.
Pneumothorax is characterized
with the presence of box sound at
percussion and absence of respiratory
noises at auscultation. Hemothorax
and atelectases are characterized with
dull percussion sound. At valvular
pneumothorax a quick development
of respiratory insufficiency takes
place. The corresponding part of
chest strains, intercostal spaces
widen, percussion detects high
tympanic or box sound.
Flail chest can weaken the chest wall significantly so that when the patient inspires, the chest near the flail segment recedes due to negative
intrathoracic pressure and when the patient expires, the segment protrudes (a condition known as paradoxical respiration).

CHEST INJURIES
A. Close injuries
Diagnosis. Rentgenological study has exclusive value, it helps to specify the occurrence of fractures,
pneumothorax, hemothorax, and emphysema. Rentgenological study can identify the signs of “shock lung”. Usually, on
the area of injury, decrease of air content in lung tissue, increase of lung pattern, multiple atelectases and infiltrative
changes are observed.
Punction of pleural cavity, which specifies the character of pleural cavity content (blood, limpha) is of great
importance in diagnosis of chest injuries. Punction allows to specify if bleeding to pleural cavity has stopped or is
continuing. At continuing bleeding the blood, obtained by means of punction, clots, and a drop of this blood leaves a
double spot on gauze– a small clot in the center with transparent serum around. The old laky blood does not clot, it is
dark in color and leaves homogeneous brown spot on gauze. At clotted hemothorax it is possible to aspirate only a small
quantity of dark blood with “warm like” clots. Except its diagnostic meaning, punction of pleural cavity also has
therapeutic possibilities.
Evacuation of pleural cavity
content assists the lung expanding,
allows sanation with introduction of
antiseptics for infection development
prevention. Infection of pleural cavity
content is also specified by means of
bacteriological test.
In a number of cases
thoracoscopy is performed in order to
specify the character of injury of
internals.

CHEST INJURIES
A. Close injuries
Treatment. At closed injuries therapeutic approach includes measures against pain, asphyxia,
respiratory failure and cardiac decompensation , bronchial hemorrhage, restoration of lost blood
(volume), measures for lung expanding (aspiration of blood or air from pleural cavity), restoration of
patency of bronchi, prevention of infectious complications of lung and pleura. The results of treatment
depend on adequate first medical aid, which includes:
Restoration patency of bronchi
Anesthesia
Decompression of pleural cavity at tension pneumothorax
Introduction of heart preparations and antibiotics
Oxygenotherapy
The patient is transfered to a qualified and specialized institute for obtaining further help.
At fractures anesthesia is made by novocaine blocks (intercostals,
paravertebral, epidural). On the area of fracture 50-100 ml of novocaine
solution is injected. For continuous anesthesia alcohol-novocaine block is
made – 1 part 96% of alcohol and 3 parts 0.5% of novocaine, 3-5 ml for
each injection. The latest is especially indicated at rib (costal) valve
formation, the mobility of which is limited by special fixing constructions.
Besides, inner pneumatic stabilization can be performed, by making
appa-rate respiration – artificial ventilation of lungs (AVL), which provides
tem-porary fixation of the rib valve.

CHEST INJURIES
A. Close injuries
Treatment. At significant movements of the rib
fragments or laceration of the lung tissue by the sharp
fractures ends, their fixation with sutures is offered.
Drainage of pleural cavity at adequate patency of airways
will help lung expanding. Drainage helps to diagnose the
bleeding continuation, prevents the development of
clotted hemothorax, also allows introduction of
antibiotics and fibrin- proteolytic preparations at clotted
hemothorax.
Development of infectious complications is
possible to prevent by the sanation of tracheobronchial
tree (bronchoscopy, respiratory gymnastics, inhalation of
antibiotics, mucolytics). For prophylaxis and treatment of
shock lung development, besides the mentioned
measures, liquidation of hypovolemia by means of blood
components introduction is very important.
Almost every 5th patient with chest injury thoracotomy is offered. Thoracotomy is indicated in case
of continuing intrapleural bleeding, about which testify the symptoms of growing anaemia, discharge of
blood from pleural drainage - more than 250ml/h , internal and external pericardial tamponade, growing
valvular pneumothorax and mediastinum emphyse-mia, in spite of pleural cavity drainage.

CHEST INJURIES
B. OPEN INJURIES. CHEST WOUNDS
Chest wounds can be non-penetrating and penetrating (when the
parietal pleura is damaged). Penetrating injuries can be with or without
bone structure trauma and injuries of internals. Gunshots (bullet, splinters)
represent more serious danger. Except direct influence of bullets or
splinters on tissues, there is a possibility of injuring the tissues which are
located far from the wound canal (side impact). Usage of bullets with
relocated center of gravity causes different injuries as a result of the bullet
forwarding through tissues with complicated trajectory. At peace time non
gunshot wounds predominate, caused by thrusting and cutting subjects.
At chest wounds pneumothorax can be open, closed and tension -
valvular (see below).
Diagnosis and treatment. Clinical presentation of penetrating
wounds depends more on the character of injury, hemothorax sizes and
pneumothorax. Study of inlet locus, reduction of inlets and outlets,
roentgenological study, exploratory puncture, in obscure cases also
thoracoscopy, help to diagnose the injuries of internals ( all diagnostic
methods,used in case of closed wound will be used hear also.
At first medical aid to patients with open pneumothorax, immediate
chest hermetization, first with occlusive dressing, then with the help of
primary surgical debridement are required. Pleural cavity is drained and
connected with apparatus of passive aspiration.

CHEST INJURIES
Diagnosis and treatment. The wound canal undergoes surgical
treatment, drainage and suturation. Gunshot wounds are not sutured.
Wound canal of the chest wall has to be inspected till bottom. Urgent,
wide thoracotomy is made in case of cardiac arrest threatening,
lifethreatening bleeding (heart and big vessels wounds). Suspect on
heart wound appears, when the wound canal inlet is localized in the area
adjacent to the 2nd rib from above, costal margins from bottom,
midaxillary line on the left and parasternal line on the right. It is
reasonable to reinfuse the blood, which has streamed into pleural cavity
to the wounded during 24 hours (autohemotransfusion). For this reason
blood is collected into vessels and on each 500 ml of blood 1000 units
of heparin or 4% of citrate sodium is added. It is desired to filter blood
through 8 layers of gauze.
Urgent thoracotomy is also performed at massive injuries of lung,
trachea, large bronchi, esophagus, also at thoracoabdominal wounds.
Omentum prolapse from wound, outflow of intestinal or biliary contents
testify thoracoabdominal wounds. Suspects on diaphragm damage
appear if the wound is localized on the area adjacent to nipples from
above, the 11th ribs from below. Laparoscopy and laparocentesis
confirm the presence of thoracoabdominal wounds

CHEST INJURIES
Diagnosis and treatment.
Clinic of thoracoabdominal wounds is changeable. In some cases
symptoms of chest organs injury prevail, which dictate the necessity of
thoractomy. After surgical intervention on the chest organs, it is
necessary to widen the diaphragm wound, make sure if it penetrates to
the abdominal cavity or the lumbar region and repair the injuries of
organs. If there is a suspicion on full revision of abdominal cavity, then
laporotomy is performed. If the injury of abdominal cavity comes
forward, then laporotomy is performed, injuries are removed, the
diaphragm is sutured.
At the absence of significant bleeding into pleural cavity, drainage
of pleural cavity is enough. The same is done at penetrating wound of
chest. when there are no significant injuries of heart and lung and
massive bleedings. Usually there is a necessity of wide thoracotomy in
5-15% of cases.
At late stages thoracotomy is made at clotted hemothorax, pleural
empyema (sanation, and if needed - decortication of lung is performed).
A-A – m. latissimus dorsi crosses at
the line of skin incision, B-B- m.
serratus anterior crosses closer to the
6th, the 7th and the 8th ribs, C-C
intercostals muscles cross at the
upper border of the rib

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