Anatomy of the Neck

Lecture 3. Surgical anatomy of neck Contents of lecture Scopes of neck. Division of neck on a region. Fascias and cellulose spases of neck. Topography of vascular-nervous formations of neck. Topography of organs of neck. Topographycal-anatomic ground of operative interferences in area of neck. Cuts in area of neck. Treatment of neck’s wounds. Operations at inflammatory processes. Operation on muscles, vessels and nerves. Tracheostomy. Operations on a thyroid. Plan of lecture. 1. Scopes of neck, division on a region. 2.Triangles of neck. 3. Fasciae of neck. 4. Cellulose spaces of neck. 5. Submandibulare triangle. 6. The Pyrogov’s Triangle. 7. Carotid triangle. 8. Topography of basic vascular-nervous bunch of neck. 9. Distinctions between external and internal carotids. 10. Branches of external carotid in a carotid triangle. 11. Topography of trachea. 12. Topography of neck part of pharynx. 13. Branches of neck interlacement. 14. Scopes of lateral triangle of neck, divisi on of it on scapula-trapezoidal and scapular-clavicles triangles. 5. Layers of lateral triangle of neck. 16. Cellulose spaces 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 operative access to neck part of esophagus. 21. Operations on a thyroid. ANATOMICAL-TOPOGRAPHICAL FEATURES OF NECK AND THEIRS ORGANS Topographical anatomy of neck (common data) The region of neck differs by the difficult anatomic structure.Any doctor needs knowledge of topographical   anatomy of neck, as this region has a row vitally important formations, interrelation between which must be taken into account at implementation of row of urgent measures (laryngotomy, tracheostomy, stop of bleeding and other). The practical value is had: 1) The outward reference points of region, which use at the inspection of patient for: a) Drafting of projection lines; b) Determinations of location of organs of neck 2) Bulges of sterno-cleido-mastoid muscles which are a reference point for finding of general carotid.Palpation of region is more informing: a) On the middle of the skinning fold exposed at bending of head, the body of sublingual bone palpate under a lower maxilla, on each side from it it’s large Horn. A sublingual bone is a reference point at implementation of vagosympathetic blockage; b) Below the plates of thyroid cartilage, place of their connection, palpate to the sublingual bone (Adam's apple); c) In the middle of front surface of thyroid cartilage is mapped a glottis. d) A cricoids cartilage is felt directly ahead from thyroid.Deepening which corresponds to the thyroidocricoid copula palpate between them. Urgent laryngotomy is executed in this area; e) On the line conducted from the lower edge of cricoids cartilage downward to the jugular undercuting of breastbone, is mapped a trachea, a few left from it is mapped a esophagus; f) At the cutting edge of s terno-cleido-mastoid muscle according to the level of cricoids cartilage the transversal process of sixth neck vertebra palpate at back of region (carotid tubercle, tuberculum caroticum).Against this tubercle a general carotid is pinned at bleeding from its branches; g) At the level of upper edge of thyroid cartilage, is mapped the place of bifurcation general carotid; h) In the corner formed by the back edge of sterno-cleido-mastoid muscle and collar-bone, the pulsation of subclavian artery is determined. Here it cuddles to the first rib for the temporal stop of bleeding; i) It is mapped humeral interlacement on a neck on a line, connecting a point lying on the border of middle and lower third of sterno-cleido-mastoid muscle and middle of collar-bone.On 1,5-2 sm higher than middle collar-bones execute anesthesia of humeral interlacement; j) It is mapped a diaphragmatic nerve on the line of the width of sterno-cleido-mastoid muscle conducted on a middle downward from the level of mi ddle of thyroid cartilage; k) it is mapped an additional nerve on a line crossing a sterno-cleido-mastoid muscle in direction from the corner of lower maxilla to the border between 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 hypodermic cellulose (n. . transversus coli, occipitalis minor, auricularis magnus, cutaneus colli, supraclavicularis). The explorer Novocain anesthesia conducted in this area allows to get anaesthetizing of front and lateral surface of neck.At palpation of neck at patient’s megascopic lymphatic knots come to light sometimes: a) It is often multiplied submandibular lymphatic knots at tooth decay; b) Chin knots are struck by metastases at the cancer of front department of tongue and lower lip; c) It is multiplied supraclavicular lymphatic knots in connection with metastasis at the cancer of mammary gland; their increase is marked also at tubercular lymphadenitis. d) Very often at the cancer of esophagus and stomach one of the lymphatic knots located on meatus of a. ransversa colli is struck is the Trauz'e-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 below from a breast, upper extremity and back, a neck is delimited by a line, going on the jugular undercutting of breastbone, upper edge of collar-bone, acromion scapulars and, further in a conditional line connecting the acromion by prominence process of the VII neck vertebra (vertebra prominens). Children have is short and wide neck, a lot of cellulose.A narrow glottis, wide isthmus of thyroid, narrow sublaryngeal space, is marked. It determines the methods of some operative interference. For example, children lower tracheotomy is done only, 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 pass on the outward reference points of neck.By a frontal plane passing through a mastoid process and acromion neck divide by front and back departments. A back department carries the name of cervical (occipital) region – regio nuche – and consists of the well developed muscles covering vertebrae. These muscles in the turn are covered by strap and trapezoid muscles. Topographoanatomical under a neck understand its front department usually, actually neck, containing its organs, basic vessels and nerves. By a middle line divide the front department of neck by right and left halves.On each of them two large triangles are distinguished: mesial and lateral. Mesial triangle Mesial triangle – trigonum colli medium limited by the lower edge of lower max illa from above, sterno-cleido-mastoid muscle (by its cutting edge) – lateral by a middle lily mesial. Within the limits of internal neck triangle pair and odd triangles are selected: Pair: Submandibular – trigonum submandibulare is limited from above by the lower edge of lower maxilla, from below, lateral and mesial – both bellies of digastrics muscle.This triangle must be known for access to the submandibular salivary gland, to the facial, tongue arteries and veins (a. et v. facialis), to the sensible 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, behind (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 wandering 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.Needed for accesses to tracheas at implementation 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 needed for drainage of bottom 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 two pair triangles are selected: Scapular-trapezoid – trigonum omotrapezoideum – limited behind 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 the 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 (right and left), they form one large middle quadrant of neck, which is divided by a horizontal line passing through a sublingual bone, on two 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 NECK Fasciae is a connective tissue frame and, being in all regions, various functions are executed: protective, supporting, fixing regarding to organs.V. N. Shevkunenko described 5 fascial sheets of neck: First (superficial) fasciae of neck – fascia superficialis colli – or fascia cervicalis superficialis. It is disposed deeper than hypodermic cellulose, is passed from a neck directly to the neighboring regions. Superficial fasciae of neck, dividing, engulf the hypodermic muscle of neck of m. platysma, forming its vagina; Second is superficial sheet 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 sheet of II fasciae of neck gives into the covered muscles the row of bridges which divide muscle into separate bunches. Down second 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 offspurs to the transversal processes of neck vertebrae. One of these offspurs binds second fasciae to the heel. Other – binds it to the vagina of vascular-nervous bunch of neck. These offspurs form the frontal located 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 festering 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 outside; The third fascial sheet of neck carries the name of scapular-clavicular fasciae (fascia omoclavicularis) or deep 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 fascia, 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 instrumental in adjusting of blood stream in the vessels of neck. It is explained it by the presence 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 basic 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. vagus, inward (wandering 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 also gives the row of offspurs. Therefore in the moment of inhalation negative pressure in v eins 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 behind a esophagus at foundation of skull, goes down downward in a pectoral cavity, passing ahead of spine. The Fascial sheet is well expressed 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 reserved and reported 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, fa cial 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 practically reported with surrounding tissues only through the probutting openings, formed by vessels which blood supply muscle; Substernoid intraaponeurosis space – spatium intraponeuroticum suprasternale – it is located above the jugular undercutting of 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 r elrosternodeidomastoideus, 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 outside, 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 causes the symptom of â€Å"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 disposed in a loose cellulose, v. thyroidea ima, part of odd thyroid interlacement of plexus thyroideus. In 10-12% of cases 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; therefore 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, wandering, sublingual and glossopharyngeal nerves (nn. vagus, hypoglossus, glossopharingeus). Along 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. Deep cellulose space of neck is disposed under fifth fascia in trigonum colli laterale surrounds subclavian vessels and humeral interlacement and is reported with the cellulose of armpit 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 mus cles 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 there 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, elast ic, the expressed of hypodermic cellulose is subject to the individual changes. Superficial 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 also 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 cellulose 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 membr ane of bottom of oral cavity.In the same 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 opposite side, forms the diaphragm of oral cavity – diaphragma oris. At osteomyelitis of lower maxilla, stomatological inflammatory processes, mayb e, as complication, to arise up phlegmon of bottom of cavity of mouth. It carries the name of Ludwig’s quinsy. It is a quickly making progress sharp 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 Ludwig’s quinsy is complicated by development of mediastinitis. Topographically in this region the Pirogov's 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 triangle. Within the limits of this triangle, baring and bandaging of tongue artery which is disposed under m. hyoglossus is possible. A tongue vein lies above it muscle.Search for the Pirogov’s Triangle at thrown back backwards and the head turned in the side opposed to interference. The following layers are selected in an odd chin triangle: skin, hypodermi c cellulose, first 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-thyr oid (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% cases) ?. 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. omohyoideus), lateral is sterno-cleido-mastoid muscle, above is back belly of digastrics muscle. The superficial layers of triangle are represented 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 bun ch 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 drawing 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. laryngea 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 frequent takes place at the level of upper edge of thyroid cartilage. To distinguish outward and inter nal 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 bare 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 outward carotid, a pulsation on a temporal artery will 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 – cons ists of connecting tissue specific â€Å"glomus cages† stopped up in it, closely associated from an adventitia carotid. Middle sizes of glomus caroticum: 3Ãâ€"5 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). Lateral 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 lymphatici 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 re gion 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 Truaz'e-Vyrkhov's 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 dispos ed 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 damage of vessels of neck, which threatens by not only the bleeding but also possibility of embolism (at the damage 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 re tained on a middle line. At operative interferences in the lateral departments of neck a head is turned aside, 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 such 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 produce longitudinal and combined cuts (Venglovsky, D'yakonov, De Kerven). Only changed, but also those healthy 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. Vert ical 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 cancer 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 duri ng 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 accompanied by the wound of spine and spinal cord.Wounds on a neck are especially dangerous, inflicted on sagittal or parasagittal lines. Third sign are the wounds of neck in 13% of cases are accompanied by the wound of carotids. This, usually, heavy 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 woun d 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 cricoid’s cartilage; third area – from a cricoid’s cartilage to the jugular undercuting of breastbone. Than the area of wound is below, that it is more dangerous, because interfascial cellulose spaces are unsealed. 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 bleeding 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, foreign bodies, interfascial haematomas, are deleted, the damaged int erfascial spaces are extended. Surgeons do not unseal the interfascial cracks not unsealed by a scotching object. Wounds must be widely drainage. Foreign bodies are deleted only in case that they threaten to life 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 flow 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 edema 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. Taking 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 dull instruments, not to scotch vessels, impenetrate. At accesses the location of veins of neck, their intimate union, is taken into account with fasciae, the dama ge 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. Phlegmons 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 instrume nt, 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. trapezius. 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, parie tal 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 – â€Å"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, introduction 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 on a vascular stitch or produce the plastic arts of artery (its substitution of autovein is possible or synthetic vascular prosthetic appliance from polymeric connections). At bandaging of artery there are serious complications as softening influence 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 on 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. Complications. In the case of the low bandaging of outward carotid a bifurcation general carotid can have a blood clot closing a road clearance and internal carotid, practically there will be an obturator general carotid. Bandaging of tongue artery in the Pyrogov's 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 jugular 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 sclera 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. Neck’s organs Complication of anatomic structure and topographical-anatomic location of organs of neck in a great deal determines the features of operative 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 interlacements 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 hea d, 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 cricoid’s, linked between itself lig. cricothiroideum. The front department of cricoid’s 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 nerve).Lymphatic outflow is carried out in pre-laryngeal, pretracheal, paratracheal and deep lymphatic knots of neck. TRACHEA Represented by cartilaginous semicircular connected by dens e copulas. Back departments are locked by a dense connective tissue bridge, where muscular fibres pass. Within the limits of neck 6-8 cartilaginous rings 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 furrow 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 – Val'deyer) which it is represented is important anatomic 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 retroph aryngeal 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, wandering 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 cricoid’s 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 cases a pyramidal 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 out 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. LATERAL 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 sterno-cleido-mastoid muscle: n. occipitalis minor, n. auricularis magnus, n. cutaneus colii.Second fasciae or supe rficial 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 interval. 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 ?. cervicalis 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 direction 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. transversa 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. carotis 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); †¢ i nternal 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 prophylactic 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, foreign body, paralysis and spasm of vocal copulas with closing of entrance in a larynx, and also traumas 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 insuffici ency arising up as a result of proof oppression of central mechanisms of breathing; – heavy postoperative 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 ne rve is deeper behind a trachea on the lateral wall of esophagus. Next to the lower department of neck part of trachea there are general carotids, shoulder 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, approximate 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 â€Å"dosed by gauze serviettes† for warning of damage of esophagus. After expansion of road clearance of the unsealed trachea cannule is entered from one si de, 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 â€Å"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 growing in the road clearance of trachea. . Before conducting of section of rings of trachea follows strictly â€Å"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 tiss ue 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. Bare and dissect III and IV fasciae of neck. Vascular-nervous bunch together with s terno-cleido-mastoid take muscle outside. Cut the parietal sheet of IV fasciae inward from a vascular-nervous bunch. A lower thyroid artery, probutting 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 sewn together or produced its plastic arts.At suppuration of juxtaesophagal cellulose on meatus of esop hagus gauze tampons are downward conducted. A patient is laid with the dropped head end of bed. Such position is instrumental in the free separation 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, thus 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