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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6025_Библиотеки_им_академика_М_И_Перельмана
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34
1 Anatomy and Surgical Approaches
Fi g . 1 . 2 2 Th e st e rn al a n d cla vic ula r h ea ds o f t h e st e rn ocle id o m a st o id a re d e t a c h e d at t h e le ve l o f
the manubrium.
1 Anatomy an d Surgical Approaches 35
a
b
Fig . 1 . 2 3 ( a ) The m e dial third of the clavicle and a rectangular piece of t he m anubrium are re m oved.
(b) Retract ion of t h e vessels and t rachea expose s t he cervicot h oracic junction.
36
1 Anatomy and Surgical Approaches
c. Thoracotomy to T1–T4 (Fig. 1.24, Fig. 1.25, Fig. 1.26, Fig. 1.27, Fig. 1.28,
and Fig. 1.29).
(1) The right-sided approach is preferred to avoid the left subclavian
artery, which is m ore curved than the right brachiocephalic artery.
(2) The incision is medial and inferior to the scapula. The scapula
is ret racted laterally by dividing th e trapezius, latissim us dorsi,
rhom boids, and levator scapulae muscles.
(3) The chest is entered through the third rib.
(4) The posterior 7 to 10 cm of each of the second, third, fourth, and fth
ribs may be removed.
(5) Exposure of the vertebrae is made with an L-shaped incision in the
pleura.
a
b
Fig . 1 . 2 4 ( a ) Hig h t ra n st hora cic approach to t he u p p e r ce r vico t ho ra cic spine . (b) The t ra p e ziu s m us-
cle is divided close to the spinous processes and parallel to t he skin.
1 Anatomy an d Surgical Approaches 37
a
b
Fi g . 1 . 2 5 ( a ) The rhomboid major is divided near its insertion, and the serratus anterior muscle is
divided as caudally as possible. (b) The scapula can then be retracted superolaterally, and the periosteum can be incised.
d. The sternum-splitting approach to C4–T4.
(1) The skin incision is made anterior to the left sternocleidom astoid
muscle and extends along the midsternal area down to the xiphoid
process.
(2) After division of the platysm a muscle and super cial cervical fascia,
blunt dissection is done between the laterally situated neurovascular
bundle and medial visceral structures.
(3) The retrosternal adipose and thym us tissues are retracted from the
manubrium.
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1 Anatomy and Surgical Approaches
Fi g . 1 . 2 6 Re t r a c t o r s a r e p o s i t i o n e d a n d t h e u p p e r t h o r a c i c s p i n e is e xp o s e d .
(4) A m edian sternotomy should be perform ed carefully to prevent
injury to the pleura. The stern ohyoid, stern othyroid, and om ohyoid
muscles are identi ed and transected as necessary.
(5) The inferior thyroid artery is ligated and transected.
(6) Blunt dissection is perform ed from the cranial toward the caudal
portion until the left brachiocephalic vein is exposed.
(7) Retraction of the carotid artery laterally, brachiocephalic vein
inferiorly, and trachea m edially exp oses the vertebrae.
II. Th o r a co lu m b ar sp in e.
A. Po st e r ior a p pr o a ch e s : t h e p at ie n t is u su a lly p o s it ion e d on t h e fo u r- p os t er o r
Re l t o n - Ha ll fr am e ( Su r gm e d , Do r va l, Qu e b e c, Ca n a d a) fo r t h e t h o r a c o lu m b a r
spine and kneeling position for the lum bar spine.
1. Thoracic spine.
a. Posterior: midline exposure of the posterior elements (spinous process,
lam ina, facets, pedicle, and tran sverse processes).
(1) Transpedicular approach: the thoracic pedicle is located by crossing
a horizontal line at the midportion of the transverse process and
a vertical line at the junction between the lamina and transverse
process.
(2) Posterolateral: costotransversectom y approach:
(a) A C-shaped curved incision is made along the paraspinous
muscles, spanning about four to ve ribs.
1 Anatomy an d Surgical Approaches 39
Fi g . 1 . 2 7 Th e in cisio n e m p lo ye d fo r a t ra nst ho ra cic a pp ro ac h t o t h e sp in e .
(b) The m iddle part of the incision sh ou ld be ~ 2.5 in from the
midline.
(c) By underm ining the skin and subcutaneous tissue, exposure of
the paraspinous muscles and posterior elements of the spine is
com pleted.
(d) The trapezius and latissimus dorsi m uscles are divided either
longitudinally or transversely.
(e) The rib and transverse process are resected at one to four
levels, depending on th e extent of the lesion . The rib is exposed
subperiosteally and excised ~ 3.5 inches lateral to the vertebra and
disarticulated at the costovertebral junction.
(f) Carefu l ret ra ct ion of t h e p le u ra w ill le ad to t h e vert ebrae.
2. Lumbar spine.
a. Laminectomy or laminotomy:
(1) Expose the spinous process, lam ina, and ligam entum avum .
(2) Excise the ligam entum avum to enter the epidural space.
(3) Rem ove part of the superior facet to decom press the lateral recess.
(4) Retract the nerve root medially to rem ove the o ending disk
material.
b. Transpedicular approach (Fig. 1 .2 6 ): the pedicle is located by crossing
a horizontal line at the midportion of the transverse processes and a
vertical lin e at th e lateral edge of th e su perior facet.
B. An t e r io r a p p r o a c h e s:
1. Thoracic spine:
a. Transthoracic approach by removing a rib and dividing the pleura (Fig. 1.27).
(1) The skin incision is made along the rib intended for removal from
the anterior margin of the latissimus muscle anteriorly to the
costochon dral jun ction.
40
1 Anatomy and Surgical Approaches
a b
Fi g . 1 . 2 8 ( a ) The anterior aspect of the latissimus is divided, exposing the underlying rib. (b) The
underlying rib is dissected free of the periosteum.
Fi g . 1 . 2 9 Th e o ve rlyin g r ib is r e se ct e d n ea r it s a rt ic ula t io n w it h t h e co st o ve rt e bra l ju n ct io n. Th e p a rietal pleura is incised, and the overlying prevertebral fascia is identi ed. Shown are the ligated segmental vessels overlying the thoracic vertebrae.
1 Anatomy an d Surgical Approaches 41
(2) The anterior aspect of the latissim us muscle can be underm ined or
minimally incised, and the posterior border of the serratus anterior
muscle is mobilized or transected.
(3) The lateral margin of the trapezius muscle is m obilized and
transected if necessary.
(4) Rib resection is then perform ed by rst incising the overlying
periosteum in the midportion of the rib using electrocautery. A rib
stripper is then used to dissect o the intercostal musculature.
(5) The rib is divided at the costochondral junction anteriorly, elevated
and resected as far posteriorly as the exposure will allow.
(6) The chest is then sharply entered in the center of the rib bed, and the
lung ret racted anteriorly and inferiorly.
(7) The pleura overlying the vertebral bodies is then incised and the
segmental vessels ligated as needed in the middle of the vertebral
bodies.
b. Thoracoabdominal approach by removing the tenth rib and dividing the
diaphragm and entering through the retroperitoneal space.
(1) A skin incision is made over the tenth rib from the lateral border of
the paraspinous musculature to the costal cartilage. The incision is
curved anteriorly to the edge of the rectus sheath.
(2) The dissection is extended down to the muscle layers to rem ove the
10th rib.
(3) The costal cartilage is split after rem oval of the 10th rib. The pleura
is incised an d th e lung is retracted, and the retrop eritoneal space is
identi ed by the light areolar tissue.
(4) Blunt dissection is perform ed to mobilize the peritoneum from the
undersurface of the diaphragm and abdominal wall.
(5) After the peritoneum is retracted, the external oblique, internal
oblique, and transverse abdominis muscles of the abdomen are
divided one layer at a time.
(6) The diaphragm is incised circum ferentially 1 in from its peripheral
attachm ent to the chest wall. Marker stitches or clips are placed for
resuturing the diaphragm later.
(7) For the exposure of the T12–L1 region, the crus of the diaphragm is
cut and mobilized.
(8) The segm ental vessels are tied and ligated as necessary to mobilize
the aorta.
2. Lumbar spine.
a. Anterolateral retroperitoneal approach: lateral decubitus position.
(1) Dissection is through the external oblique, internal oblique, and
transverse abdominis muscles (skin incision depends on the level of
exposure).
(2) The retroperitoneal space is entered laterally by identifying
the retroperitoneal fat, taking care to avoid penetration of the
peritoneum just lateral to the rectus sheath.
(3) Blunt dissection anterior to the psoas muscle should lead to the
spine.
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1 Anatomy and Surgical Approaches
(4) One should identify the genitofem oral nerve on the anterior surface
of the psoas m uscle and the sympathetic chains medial to the muscle
(Fig. 1.30):
(a) The L4–L5 level is at most risk for neural and vascular injury.
(b) Preven t ion : direct visualization w h ile dissecting the psoas m uscle
with concurrent neuromonitoring.
(5) The ureter is under the peritoneum anteriorly.
(6) Vessels (aorta or vena cava) are mobilized, and segm ental vessels are
identi ed in th e m iddle port ion of the vertebral bodies and ligated as
necessary.
(7) Dissection of the psoas muscle should be accompanied w ith triggered
electromyography.
b. Anterior muscle-splitting approach.
(1) A vertical param edian incision is made from the um bilicus to the
pubis at the edge of the rectus.
(2) The fascia of the rectus abdom inis is divided, and the muscle is
retracted medially.
(3) The posterior rectus sheath is carefully divided along the peritoneal
attachm ent.
(4) Blunt nger dissection of the peritoneum leads to the lower lum bar
spine (L3–S1).
Fi g . 1 . 3 0 Th e a nt e ro lat e ra l p e rit on e al a p p ro ach d e m o n st ra t in g t he ge nit o fe m o ra l n er ve o n t he a nt e rior surface of the psoas muscle and the sympathetic chains.
1 Anatomy an d Surgical Approaches 43
c. Transperitoneal approach to lum bosacral junction.
(1) A vertical or transverse incision is m ade above to the pubis (Fig. 1.31
and Fig. 1.32).
(2) The peritoneum is entered, and the bowel structures are retracted
(Fig. 1.33a).
(3) The posterior peritoneum is lifted and divided.
(4) The iliac vessels are m obilized to expose L4–S1 (Fig. 1.33b).
Fi g . 1 . 3 1 ( a ) The transperitoneal
approach to the lumbar spine.
(b) The vertical incision splits the
rectus abdominis in the m idline
line a a lba.
a
b
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