Malformations of the chest wall. Chest malformations
Malformations chest usually detected on external examination. However, changes in the skeleton and the location of organs are specified by fluoroscopy or radiography.
Small deviations from the norm are of no practical importance. However, more pronounced ones are not only a cosmetic defect, but are also accompanied by certain violations of the functions of the lungs, heart and blood vessels. Identification of the latter determines the tactics of treatment: conservative or surgical, in the early stages or after the child reaches a certain age.
Non-closure of the sternum(sternum bifidum) is a rare developmental anomaly. It arises as a result of a delay in the fusion of paired anlages of the sternum, usually occurring at the 9th week of intrauterine development (F. N. Hanson).
Absence mergers the upper end is observed somewhat more often, less often there is non-fusion throughout the sternum or at one end, accompanied by a protrusion of the heart region in the form of the so-called ectopia of the heart: cervicothoracic at the top, thoraco-abdominal at the bottom.
Diagnosis It is usually established after examination and palpation, and is confirmed radiographically. At the same time, the non-closure of the sternum is palpated, the pulsation of the heart is visible and determined by the eye.
In published observations cleft sternum in most cases, it was combined with other developmental anomalies: underdevelopment of the anterior abdominal wall above the navel in the middle line, absence of the lower end of the sternum, -omphalocele, underdevelopment of the anterior part of the diaphragm, a defect in this part of the pericardium, congenital heart defects (JR Cantrell, JA Haller, MM Ravitch) .
The funnel chest is also called the shoemaker's chest (pectus infundibuliforme s. excavatum, funnel chest, Trichterbrust, thorax en entonnoir).
The indentation usually starts at the level of the corner sternum(Louis), reaches various depths and widths, from below ends with a protruding xiphoid process. Another type of deformation manifests itself in the form of a narrow deep depression. Asymmetric deformities are not uncommon. A chest variation is typical, with a sunken chest, a protruding belly, a round back, drooping shoulders, and a forward-leaning neck. Between the sternum and the tendon center of the diaphragm there is a short strong connective tissue cord - ligamentum substernal (N. A. Brodkin). Sometimes the anterior chest wall almost reaches the spine.
Diagnosis based on inspection. Radiographs clarify changes in the skeleton (sternum, ribs), as well as the position of the heart and the structure of the lungs.
According to severity, I, II, and III degrees of severity are distinguished deformations. A pronounced deformation is accompanied by significant disturbances in external respiration, sometimes acid-base balance and metabolic processes (N. I. Kondrashin). Insufficient supply of oxygen to the body is detected by oximetry and the use of functional tests.
The heart is usually shifted to the left and posteriorly, sometimes to the right, takes on a pseudomitral configuration. As a result of pressure on the heart, its movement to the left and turning in the direction of the clock hand, systolic murmurs and rhythm disturbances, changes in the QRS complex of the electrocardiogram, which disappear after correction of the deformity, are noted.
When catheterizing a displaced heart a proto-pastolic pressure drop with a rapid rise to a plateau at the end of diastole (Diastolic - Dip) - "diastolic diving" - resembles a picture with squeezing pericarditis.
In the diagnosis of malformations and surgical diseases of the chest organs, such symptoms as cyanosis, cough, hemoptysis, shortness of breath, stridor, vomiting, pain are of particular importance. Their severity, character, constancy, combination with each other or with other symptoms usually make it possible not only to suspect a pathological process in the chest cavity, but also to determine which organ and which group of diseases it belongs to: malformations, inflammatory processes or oncology. Only after a thorough analysis of the existing symptoms, percussion and auscultatory data, the urgency and scope of a special examination are determined, which must meet the requirement "from a simple method to a more complex one."
The respiratory surface of the lungs in children can be reduced due to the malformation of the lung (hypoplasia), inflammation, compression by a volumetric formation or air accumulated in the pleural cavity, as well as intestinal loops that have entered the chest cavity through a defect in the diaphragm.
Violation of tracheobronchial conduction in children occurs most often with swelling of the subglottic space, congenital and acquired stenoses of the trachea, foreign bodies, anomalies of the vascular ring (double aortic arch) and, finally, tumors and cysts located both in the mediastinum and in the wall of the trachea and bronchi
Cyanosis skin and mucous membranes with malformations and surgical diseases usually indicates the severity of the process. Cyanosis that occurs during exercise, combined with some puffiness of the face in a child with fingers in the form of "drumsticks", nails like "watch glasses" more often indicates prolonged hypoxia that develops in chronic pyoinflammatory diseases of the lungs. Constant cyanosis with a relatively satisfactory condition of the child and in the absence of signs of inflammation in the lung can be observed with malformations of the vessels of the lung (aneurysms). Cyanosis in newborns of the first days of life often occurs with intrathoracic tension or obstruction. respiratory tract arising from various causes, including congenital malformations of the organs of the chest cavity and diaphragm.
Cough in chronic purulent-inflammatory processes in the lungs is the leading and most early symptom. More often the cough is wet, with sputum, but young children cough badly and usually swallow sputum, the cough is most severe in the morning, at this time the largest amount of sputum is discharged
Dry hacking cough more often indicates a mechanical obstruction of the tracheobronchial tree due to a specific lesion of the lungs and bronchial lymph nodes (tuberculosis), a tumor-like process and a foreign body. In the initial reaction to a foreign body, the cough is usually paroxysmal, and over time, painful. If a foreign body has descended into the lobar and segmental bronchi, the cough becomes wet, unstable, and becomes undulating.
Hemoptysis is rare in children. It occurs mainly due to erosion of the mucous membrane of the tracheobronchial tree and bleeding from the vessels of the bronchial artery system (vascular malformations or tumors with endophytic growth). Hemoptysis can also occur during destructive processes in the lung parenchyma with abscess formation of both specific and non-specific nature. More often, hemoptysis is not abundant in the form of mucous sputum with streaks of blood. Despite this, it is important to establish its cause and source as early as possible, since a transition to more significant bleeding is always possible, and in these cases emergency surgical care or other intervention is necessary.
Stridor characterized by a noisy, vibrating or sobbing breath, occurs when the upper respiratory tract narrows at the level of the larynx, trachea. Stridor breathing is often observed in children during the first months of life; its cause is considered to be some immaturity and narrowness of the lumen of the larynx (its small size). It is very important to exclude other possible causes already at this age - congenital stenosis of the trachea or obstruction of the upper respiratory tract by cysts, a tumor process (papillomas), foreign bodies, compression of the trachea by abnormal vessels (double aortic arch, etc.).
Dyspnea in surgical pathology, it occurs as a result of insufficient oxygen saturation of the blood due to the exclusion of a section of the lungs from gas exchange or difficulty in the passage of air through the tracheobronchial tree. There are three types of dyspnea: inspiratory, expiratory and mixed. Inspiratory dyspnea is characterized by difficulty in breathing and occurs mainly as a result of impaired airway patency (foreign body, congenital stenosis, abnormal vessel, narrowing of the trachea due to tumor compression, etc.). During inspiratory dyspnea, especially with narrowing of the upper airways, as a rule, there is noisy breathing, reminiscent of stridor. Expiratory dyspnea is characterized by difficult exhalation, observed with stenosis of the small bronchi and bronchioles, bronchospasms, i.e., mainly with somatic diseases (bronchial asthma). This type of shortness of breath is characteristic of tracheobronchomalacia, when during exhalation the lumen of the trachea becomes slit-like due to the collapse of its membrane part. With surgical pathology of the lungs (congenital lobar emphysema, cysts, compression of the lung from the outside), shortness of breath is mixed.
Vomit often acts as an indefinite meaningful symptom of a variety of surgical and somatic diseases. In surgical pathology of the esophagus, vomiting in children is often the leading symptom resulting from obstruction of the esophagus due to its stenosis or due to insufficiency of its cardiac sphincter. Vomiting in the form of foamy discharge from the mouth and nose in children in the first hours after birth indicates a complete high obstruction of the esophagus (atresia). In this case, even the suction of mucus does not lead to improvement, very quickly mucus accumulates again. For the final diagnosis, probing the esophagus with a catheter through the mouth is sufficient; the absence of its passage into the stomach indicates this pathology.
With congenital narrowing of the esophagus, vomiting is absent in the first months, it appears after thick mixtures are added to the child's feeding, which, often getting stuck in the esophagus, cause dysphagia, and then vomiting. In these cases, vomiting, as a rule, is noted during feeding or immediately after it ends, while children usually eat poorly and choke. In vomit, there is no admixture of gastric juice, and there is no sour smell characteristic of gastric juice; such vomiting is called "esophageal", it is more correct to call it "regurgitation".
Vomiting with insufficiency of the cardia often appears in children in the first months of life. It usually occurs after feeding, when the child eats the full amount of food corresponding to his age. Vomiting is especially common in a child who, after feeding, is laid in a horizontal position. In an elevated position, children with cardia insufficiency hold food better. Vomit usually contains curdled milk with a sour smell, sometimes with an admixture of bile, which never occurs with pyloric stenosis (pyloric stenosis).
Blood streaks usually indicate inflammation of the esophageal mucosa (esophagitis), which occurs as a result of the aggressive action of gastric juice on it. Vomiting of coffee grounds is more often the result of bleeding from eroded dilated veins of the esophagus in portal hypertension.
Pain with surgical pathology in children, they are possible at any age, but complaints are made mainly by older children. In young children, these sensations cause anxiety, less often children take a forced position, refuse to eat. In inflammatory processes, especially when the costal pleura is involved, pain can radiate along the intercostal nerves. If the phrenic nerve is involved in the process, the pain may be localized or radiate to the area of the shoulder girdle or scapula. Pain directly behind the sternum is more often associated with an inflammatory process in the pericardium or esophagus. With pericarditis, there is some increase in pain with deep breathing and coughing. With perforation of the esophagus, the pain is acute, and it increases as the infection of the mediastinum develops and air accumulates in it. In these cases, the position of the children is forced, semi-sitting, breathing is grunting. Shortness of breath develops. In older children, pain in the chest wall is more often associated with tumors, osteomyelitis, chondritis, and rib fractures after injury.
Malformations (anomalies) of development - violations of intrauterine development of the fetus with a deviation in the structure of organs or tissues and a change or exclusion of their functions.
Deviations in the structure of organs occur in the prenatal period of development and are detected immediately at the birth of a child. Much less often, developmental anomalies appear later, when, with the growth of the child, the existing deviations in the structure of the organ progress.
Congenital developmental anomalies are a common phenomenon: according to WHO, they are found in 0.3-2% of births.
Factors contributing to the occurrence of fetal abnormalities (teratogenic) can be conditionally divided into internal and external. The action of teratogenic factors is manifested in the first weeks of pregnancy, especially from the 3rd to the 5th day and from the 3rd to the 6th week (periods of zygote implantation and organogenesis).
To internal teratogenic factors are primarily genetic defects - gametopathies (actually hereditary pathology). Gametopathies are caused by a mutation at the gene or chromosome level. With a defect in one gene, monogenic anomalies occur (for example, poly-, syndactyly). Chromosomal and polygenic mutations lead to multiple malformations. Genetic defects that cause anomalies more often (4-5 times) occur in mixed related marriages.
To external teratogenic factors include infections, the action of chemical and physical means. In a third of cases of defects caused by external factors, the cause cannot be established.
To infectious teratogenic factors include diseases of a pregnant woman, especially of a viral nature (chicken pox, measles, herpes, viral hepatitis, poliomyelitis), to a lesser extent - bacterial (for example, scarlet fever, diphtheria, syphilis, etc.), as well as some protozoal diseases (toxoplasmosis, listeriosis, cytomegalovirus infection, etc.). Penetration through the placenta of pathogens of infectious diseases can lead to impaired fetal development.
To chemical teratogenic factors include toxic chemicals: pesticides, defoliants, insecticides, and drugs
natural means (sedatives, psychotropic drugs, some antibiotics, amidopyrine, etc.). The same group of drugs includes nicotine, alcohol.
TO physical factors teratogenic effect include mechanical injuries during pregnancy, vibration, ionizing radiation, overheating, hypothermia, etc.
External causes can directly affect the fetus or disrupt intrauterine development by acting on the placenta, amnion. Thus, strands and adhesions of the amnion formed during trauma or inflammation can compress the limbs and lead to their amputation or deformation.
Taking into account the causes of congenital anomalies preventive actions carried out in two directions:
Identification of genetic abnormalities in future parents;
Eliminate the effect of external teratogenic factors on women, especially during pregnancy.
All congenital malformations can be divided according to the following main features: a change in the size, shape and position of organs, a change in the number of organs or their absence, the appearance of new rudimentary organs.
Classification of birth defects
I. Changing the size of organs: excessive development of a body part or organ - hypergenesis; incomplete development - hypoplasia (hypogenesis); complete absence of an organ - aplasia (agenesis).
II. Changing the shape of organs: clubfoot, horseshoe kidney, bicornuate uterus, etc.
III. Anomalies in the location of organs: ectopia, heterotopia (cryptorchism, aberrant thyroid gland).
IV. Increase in the number of organs: polydactyly, hermaphroditism, accessory ribs.
v. Atavisms: median, lateral cysts of the neck, fistulas.
VI. Duplicate anomalies: conjoined twins
Malformations of the skull and brain
Brain herniation (cephalocele) -hernial protrusion along the midline of the skull through a defect in the bones. Rare: 1 case per
Rice. 174.Hernia of the brain.
4000-5000 newborns. The defect in the bone is localized in front at the level of the bridge of the nose or in the occipital region. The hole in the bones of the cranial vault (“hernial gate”) is of different sizes, rounded, with smooth edges. The diameter of the hole is much smaller than the size of the protrusion. Through the hole in the subcutaneous tissue, the meninges protrude, forming a hernial sac. Its contents may be cerebrospinal fluid, brain tissue, or both. The size of the protrusion ranges from a few centimeters to the size of a child's head. The formation of an elastic consistency, when pressed, may decrease due to the reduction of the contents, the movement of fluid into the skull, which is sometimes accompanied by convulsions, loss of consciousness. The exact location and size of the defect in the bone is determined by x-ray (Fig. 174).
The defect is combined with other anomalies - dropsy of the brain, splitting of the lip, soft and hard palate, etc. Most children die soon after birth. Children sharply lag behind in mental development.
Treatmentsurgical - removal of the hernial protrusion along with its contents and plastic closure of the bone defect. The medulla, which is part of the contents of the hernia, is so degenerate that its removal does not affect the functions of the brain. The defect in the bone is closed by moving the periosteum together with the aponeurosis or bone plate (for large bone defects).
Hydrocephalus(hydrocephalia)- dropsy of the brain, associated with excessive formation and intracranial accumulation of cerebrospinal fluid. The latter can accumulate between the membranes of the brain (external form of dropsy) and lead to compression of the brain from the outside or in the ventricles of the brain (internal form of dropsy) and cause compression from the inside. The compression of the brain leads to its atrophy. The accumulation of fluid causes a sharp increase in the size of the head. The appearance of the skull is characteristic: its vault prevails over the facial skull, the forehead hangs over the eye sockets. Children develop poorly, sharply lag behind in mental development.
Treatment.In an emergency, the ventricle of the brain is punctured and the fluid is removed. The operation consists in creating an outflow of fluid from the ventricles into the jugular veins or through other drains (for example, due to a ventriculoperitoneal shunt).
Craniostenosis(craniostenosis) -anomaly in the development of the skull, caused by premature fusion of fontanelles and sutures with the formation of foci of calcification in the growth zones of the skull. As a result, the growing brain is compressed in a narrow cranium, which leads to a slowdown in its growth and atrophy with the development of microcephaly. Characterized by a decrease in the size of the cranial vault, the predominance of the size of the facial skull over the vault. Children develop poorly mentally and physically.
Treatment.An early operation is indicated - craniotomy, resection, fragmentation of the bones of the cranial vault.
Malformations of the spine and spinal cord
spina bifida - incomplete closure of the spinal canal. Under this concept, various types of anomalies of the spine are combined with a defect in the central canal, through which the membranes of the spinal cord, the brain itself and its roots can protrude with the formation of a spinal hernia.
The heaviest form complete spina bifida over a considerable extent, combined with other malformations. Children are not viable.
Partial splitting of the temples vertebrae is often manifested by the formation spinal hernias with protrusion through the split spine of the meninges. The contents of the hernia can be cerebrospinal fluid, spinal cord, elements of the cauda equina.
For spinal hernias characterized by the presence of protrusion, more often in lumbar region, round shape, elastic consistency. The skin over the protrusion is thinned, the symptom of fluc-
tuations. Possible violation of the functions of the pelvic organs - a disorder of defecation, urination, impaired innervation lower extremities. To clarify the location of the split and its length, radiography is performed.
Treatmentspinal hernia surgical, the operation is performed in infancy.
Splitting of the arches without protrusion of the meninges often doesn't show up. This pathology is characterized by increased hair growth (hypertrichosis), birthmarks, skin pigmentation, angiomas, dermoids in the lumbar region. Sometimes hidden splitting causes the development of "horse foot", clubfoot, bedwetting (enuresis), paralysis of the lower extremities. Treatment symptomatic.
Facial malformations
cleft lip(cheiloschisis),synonym: "cleft lip", cleft lip, cheiloschisis. They are rare - 1 case per 2500 newborns. The cleft can capture the red border upper lip or all the way to the nose. Sometimes the gap penetrates into the nasal cavity. The cleft may be bilateral. The child's sucking process is disturbed, he is fed with expressed milk.
The operation consists in the plastic closure of the defect by moving the flaps (Fig. 175).
cleft palate(palatoschisis uranoschisis).The prevalence is 1 case per 1000 newborns. The cause of splitting is a violation of the fusion of the maxillary processes with the vomer. Clefts can be unilateral or bilateral. It is possible that only the hard palate is non-union, as well as its combination with clefts of the soft palate.
With this defect, the oral and nasal cavities communicate: the child cannot suckle, milk flows into the nasal cavity. The child is fed from a spoon or from a drinking bowl. When a cleft palate is combined with a cleft lip, the processes of sucking and breathing are sharply disturbed.
Treatmentsurgical. The operation is performed in the early stages after birth - the oral and nasal cavities are separated by moving the tissues of the palatonasal septum.
Macrostomy(macrostomia) -non-closure of the corner of the mouth on one or both sides, an excessively wide oral fissure. At the same time, the nutrition of the child is disturbed, constant salivation, irritation and inflammation of the skin around the mouth are noted.
Treatmentsurgical - plastic elimination of the defect. The operation is performed in infancy.
Rice. 175.Stages of plastic surgery of the upper lip with its cleft: a - according to Malchen; b - according to Miro; c - according to Moreau-Simon; Mr. Koenig. Roman numerals indicate the stages of the operation.
Neck malformations
Torticollis(torticollis) -congenital fixed tilt of the head with its turn to the side, which is due to shortening of the sternocleidomastoid muscle or an anomaly of the cervical vertebrae. The position of the head, typical for this pathology, allows making a diagnosis. In order to clarify the cause of the anomaly, an x-ray of the cervical spine is performed.
A mild degree of torticollis at an early age is treated conservatively - the head is fixed with its tilt in the opposite direction. With inefficiency conservative therapy, in severe cases of torticollis, an operation is indicated - the intersection or lengthening of the tendon of the sternocleidomastoid muscle. It is better to operate at the age of 2-3 years.
Accessory cervical ribs cause shortening and deformation of the neck, change the position of the head, lead to compression of blood vessels and nerves. The diagnosis is established by X-ray examination. In case of violation of the functions of the neck, compression of the organs, an operation is performed - the removal of additional ribs.
Median cysts and fistulas of the neck (fig. 176, see color incl.) are the remains ductus thyreoglossus, from which the isthmus of the thyroid gland develops in the embryonic period. Violation embryonic development leads to the formation of a cyst or fistula. Cysts are located strictly along the midline in the projection of the hyoid bone, where they determine a dense elastic rounded formation, soldered to the skin and underlying tissues, painless on palpation. When swallowing, the formation moves with the hyoid bone. When the cyst is suppurated, a fistula is formed.
The median fistula is palpated in the form of a dense cord, running strictly along the median line upward to the level of the hyoid bone. The discharge of the fistula is serous-purulent. When probing, you can go through the probe to the hyoid bone, fistulography allows you to determine the position and direction of the fistula.
Treatmentsurgical - complete excision of a cyst or fistula (Fig. 177).
Lateral cysts and fistulas, like the median ones, they are the remains of the thyroid-pharyngeal duct. They are located between the larynx and the sternocleidomastoid muscle, go up towards the pharynx. Fistulography clarifies the position, size, direction of the fistula. Treatment surgical - excision of a cyst, fistula.
Malformations of the chest and organs of the chest cavity
Congenital deformities of the chest. funnel-shaped rib cage (thorax infundibuliformis) characterized by depression of the sternum and ribs with the formation of a funnel on the anterior surface of the chest. At keeled chest (t. carinatus) determine the protrusion
sternum together with ribs, resembling a wedge. Chest deformities are a cosmetic defect, but it is also possible to move the mediastinal organs, which leads to functional disorders.
Treatmentwith small deformations, conservative - massage, physiotherapy exercises. In severe cases - surgical correction: intersection of the ribs, sternum; the resulting movable fragment of the chest wall is set in the correct position and held with sutures and a special corset or by applying magnetic plates.
Complete cleft of the sternum (fissura stemi) meet seldom, in a combination with other defects - heart disease, an ectopia of heart.
Treatment surgical.
Kyphosis(kyphosis)due to spinal deformity. In addition to a cosmetic defect, functional disorders are possible - circulatory and respiratory disorders.
Treatmentwith functional disorders, surgical - plastic surgery on the spine.
Malformations of the lungs meet in various options, more often they are associated with underdevelopment of the organ or its elements.
Aplasia (agenesis) of the lungs [ aplasia(agenesia) pulmonia] - extremely rare pathology; usually associated with atresia
Rice. 177.Removal of the median cyst of the neck (stages of operation): 1 - the cyst was dissected to the hyoid bone; 2 - the hyoid bone is crossed on both sides of the cyst; 3 - the cyst is removed along with the middle part of the hyoid bone.
esophagus, diaphragmatic hernia. Vices are often incompatible with life.
Treatmentsymptomatic.
Hypoplasia of the lung (hypoplasia pulmonis)expressed in the underdevelopment of its bronchopulmonary structure; a special form of underdevelopment - polycystic lung. The defect is manifested by recurring pneumonia, bronchitis, sometimes retraction of the chest on the side of the lesion is possible, a shortening of the percussion sound is characteristic. X-ray reveals shading of the lung field or part of it, bronchography reveals cystic dilatation of the bronchi.
Treatmentsurgical - resection of the affected parts of the lung.
Lobar congenital emphysema (emphysema pulmonun cengenitum lobare) - a malformation of the afferent bronchus and its branches, in which the lobe of the lung is inflated and does not collapse during exhalation. The swollen lobe compresses the neighboring lobes, which leads to a shift of the mediastinum to the healthy side. The disease is manifested by shortness of breath, hypoxia. An X-ray examination reveals an increase in the transparency of the corresponding swollen lobe and a shift in the mediastinum.
Treatmentsurgical - removal of the expanded lobe.
Lung cysts(true) arise as a result of a violation of the embryonic development of the respiratory apparatus. The defect manifests itself in a complicated course - suppuration of the cyst (rupture with the formation of pneumothorax, compression of neighboring lobes).
Treatmentsurgical - resection of lung tissue along with a cyst, lobectomy.
Pulmonary sequestration (sequestratio pulmonalis),often intralobar, due to additional blood supply to the area of the lung, which is formed in isolation from bronchial system, through the aberrant artery originating from the aorta. The detached section of the lung is located inside the lobe, it is impossible to separate it from the lung tissue. The danger of vice is suppuration of the sequestered area.
Treatment- lobectomy with obligatory ligation of the aberrant vessel.
congenital heart defects
About 80 congenital heart defects are known, they are found in 0.6-0.8% of newborns. Of these patients, about a third die during the first days or months of life, since the defects cannot be corrected, blood circulation can only be normalized by a heart transplant.
The most common malformations are ventricular septal defect (11-23.7% of all malformations), open arterial (botallian) duct (10-18%), coarctation of the aorta (6.3-15%).
There are three groups of congenital malformations depending on the presence of anomalies that cause mixing of arterial and venous blood and, accordingly, a change in the color of the skin.
In the first option, arterial and venous blood does not mix, therefore skin color is normal. This group of defects includes coarctation or stenosis of the aorta, stenosis of the pulmonary artery.
For heart defects of the white (pale) type pallor of the skin and mucous membranes is characteristic, which is due to the mixing of arterial and venous blood through a defect in the atrial, interventricular septa or through an open arterial duct. More often, arterial blood enters the veins.
Blue type heart defects characterized by cyanosis of the skin and mucous membranes, shortness of breath, asthma attacks. This is due to the discharge of venous blood into the arterial bed and, as a result, a decrease in the saturation of arterial blood with oxygen.
Diagnosis of congenital heart defects is difficult, it requires special complex research methods (for example, echocardiography, dopplerography, angiocardiography, probing of the heart cavities, etc.).
Coarctation of the aorta It is characterized by a slow development of the child, sometimes infantilism is observed. To establish the diagnosis, such signs as the absence of a pulse on the vessels of the lower extremities are of great importance in the presence of a pulse of good filling and tension on upper limbs, increased blood pressure in the upper limbs. With a slight narrowing of the aorta, blood flow compensation may be sufficient, then patients live to adulthood. The optimal age for surgery is from 3 to 10 years. The operation consists in resection of the narrowed part of the aorta and restoration of its patency by applying an end-to-end anastomosis. With a significant length of the narrowing, isthmoplasty is performed using the left subclavian artery, and aortic prosthesis is less commonly used.
Open arterial (botallian) duct - white type heart disease. It is characterized by a lag in physical development from peers, frequent pneumonia. A pronounced pallor of the skin is noted, with auscultation, a coarse systolic-diastolic murmur is determined in the second intercostal space to the left of the sternum.
Treatmentoperational at any age. The operation consists in ligating the duct with a ligature or using a mechanical stapler.
seam. Recently, the method of endovascular surgery - duct embolization - has been used.
Ventricular septal defect - the most common congenital heart disease, occurs both alone and in combination with other defects. It is characterized by pallor of the skin, shortness of breath, developmental delay in the child, and is also manifested by an increase in pressure in the pulmonary circulation (shortness of breath, hard breathing, moist rales).
Treatmentsurgical. The operation is performed on a "dry" heart under cardiopulmonary bypass or deep hypothermia. The hole in the septum is sutured or plastically closed using synthetic materials.
Atrial septal defect characterized by a lag in the physical development of the child, circulatory disorders. To clarify the diagnosis, ultrasound (echocardiography), cardiac catheterization is used.
Treatmentsurgical - elimination of a septal defect by suturing it or closing it with a plastic material.
Transposition of the great vessels - blue type defect. It consists in the departure of the aorta from the morphologically right ventricle, and the pulmonary artery - from the morphologically left one (complete transposition of the great vessels). The average life expectancy with this heart disease is about 13 months. Clinically, the defect proceeds severely and is characterized by cyanosis of the skin and mucous membranes, shortness of breath, asthma attacks, aggravated by movement. Patients are immobile. To establish the diagnosis, echocardiography, radiopaque research methods are used.
Palliative operations consist in creating a shunt for mixing arterial and venous blood at the level of the atria (atrioseptostomy, atrioseptectomy). In a radical operation, the atrial septal defect is eliminated and the direction of the blood flow of the vena cava through the mitral valve to the left ventricle and pulmonary artery is changed, and the blood flow from the pulmonary veins is changed through the interatrial communication to the right heart and aorta.
Tetralogy of Fallot -the most common type of blue defect. With it, a defect of the interventricular septum of the heart, displacement to the right (dextroposition) of the aorta, stenosis of the output section of the right ventricle, hypertrophy of the myocardium of the right ventricle are detected. Clinical manifestations characteristic of blue defects: severe cyanosis, shortness of breath, asthma attacks, slowing down of physical development, limitation of mobility.
Treatment.Radical surgery is performed under cardiopulmonary bypass and hypothermia. It consists in the elimination of the defect of the interventricular septum, the plasticity of the pulmonary trunk, the removal of hypertrophied muscles of the outflow tract of the right ventricle.
Triad of Fallot.Narrowing of the pulmonary trunk or right ventricular outlet, atrial septal defect, and right ventricular myocardial hypertrophy are characteristic. Treatment is the same as for tetralogy of Fallot.
Rarely, congenital malformations of the blue type, such as the common truncus arteriosus and tricuspid valve atresia, are encountered. Surgical treatment of these anomalies is a complex reconstructive operation.
Part of congenital heart defects in modern conditions is incompatible with life: children die in the coming days or weeks (rarely months) after birth. Such defects include a two- or three-chambered heart, atresia of the aortic arch, a common arterial trunk. In recent years, it has become possible to help such patients - the first successful heart transplants have been performed.
Malformations of the abdomen and digestive organs
Umbilical fistulas- a consequence of non-closure of the vitelline duct or urinary duct (urachus). Umbilical fistulas are lined with epithelium. Vitelline duct failure can be complete, which is manifested by the formation of a fistula of the small intestine. Discharge from the fistula - intestinal contents.
With partial obliteration of the fistula, there is no communication of the intestine with the external environment through the fistula, a protrusion of the ileum in the form of a diverticulum (Meckel's diverticulum) is detected. Blind protrusion of the ileum can be of various shapes (cone, cylinder), with a diameter up to the width of the intestine, the length of the diverticulum is 3-8 cm, it is located at a distance of 30-80 cm from the ileocecal angle.
Complete cleft of the urinary duct is manifested by a functioning vesico-umbilical fistula, incomplete fusion - by the formation of a diverticulum Bladder.
The diagnosis is made by the appearance of urine or intestinal contents from the fistula when straining or pressing on the patient's abdominal wall. To clarify the diagnosis, fistulography is performed: the penetration of a contrast agent into the intestine or bladder allows you to clarify the origin of the umbilical fistula. The presence of a fistula is considered an indication for surgery - excision of the fistula.
Meckel's diverticulum may present with an inflammatory complication (diverticulitis) or intestinal obstruction.
Treatmentsurgical - removal of the diverticulum.
Embryonic hernia (hernia of the umbilical cord). With this defect, a part of the abdominal wall in the umbilical region is represented by a thin transparent membrane covering internal organs. Through the defect of the abdominal wall, internal organs protrude, covered with stretched and thinned elements of the umbilical cord and the parietal peritoneum. In a newborn, a rounded protrusion, 5-10 cm in diameter or more, is determined in the umbilical region, passing into the umbilical cord. It is covered with a shiny transparent shell. When the child cries, the protrusion increases. Through the walls of the bag can shine through the intestines, liver.
Treatmentoperational, perform according to the principles of hernia repair. The operation is carried out in the first hours after the birth of the child, since delay in the operation is fraught with the risk of developing peritonitis.
congenital pyloric stenosis (pylorostenosis congenita).The narrowing of the outlet section of the stomach is due to an anomaly of development in the form of hypertrophy of the pyloric muscles and a violation of their innervation, which creates a mechanical obstacle to the passage of food.
The disease often manifests itself at the 3-4th week, less often at the age of 4-5 months. Children appear vomiting "fountain", they lose weight. The stomach is stretched, the vomit acquires an unpleasant odor. In thin children, increased peristalsis of the stomach in the left hypochondrium can be determined.
Treatmentoperational. Pyloromyotomy is performed - a longitudinal dissection of the serous membrane, the pylorus muscles to the mucous layer.
Hirschsprung disease due to congenital underdevelopment of the nerve plexuses in the rectosigmoid colon with the expansion of its overlying sections. The intestine becomes wide, elongated, its wall is thickened (hypertrophy of the muscular layer). The disease is manifested by constipation and a sharp increase in the size of the abdomen. Constipation is often noted from the first years of life. There is sometimes no stool for several days.
With a mild course of Hirschsprung's disease, patients can live to adolescence and adulthood. X-ray examination is used to establish the diagnosis.
Treatmentoperative - resection of part of the colon.
Atresia anus and rectum. The defect is rare: 1 case per 10,000 newborns. The child has no anus, there is no excretion of meconium, feces, intestinal
cervical obstruction. The condition of the children is grave. In some cases, atresia of the anus or rectum is combined with an intestinal fistula: in boys - between the blind intestinal sac and the bladder, in girls - between the intestine and the vagina or its vestibule. In the presence of fistulas, fecal masses are excreted in the urine or into the vagina. If there is a fistula, the disease is milder.
The narrowing of the anus manifests itself after the first year of life: difficulties in the act of defecation, constipation, and fecal obstruction are characteristic.
Treatmentsurgical: the operation is performed in the first hours after birth. Its goal is to eliminate atresia and ensure the normal passage of feces.
Malformations of the genitourinary system
Anomalies of the kidneys are manifested in a change in their shape, size, quantity, position. There are the following anomalies:
Aplasia (agenesis) of the kidney - the absence of one kidney;
Accessory kidney;
Hypoplasia of the kidney - a decrease in size and a decrease in its functionality;
Kidney dystopia - a change in its position (thoracic dystopia - moving the kidney into the chest, pelvic - moving the kidney into the pelvis, etc.);
Horseshoe kidney - fusion of its upper or lower poles;
Polycystic kidney disease is always a bilateral process, characterized by the replacement of the parenchyma of the organ with multiple cysts of various sizes; kidney cyst - a solitary cavity formation in the parenchyma of an organ, filled with fluid.
Diagnosis of malformations of the kidneys is possible using special research methods (radiography, scintigraphy, echography, computed tomography, functional studies).
Treatmentconservative, symptomatic. In case of complications, surgical treatment is indicated - nephrectomy in the presence of another kidney and the preservation of its functions. In case of kidney failure, a kidney transplant is performed.
hypospadias- absence of the distal part of the male urethra. It occurs in 1 in 200-400 newborns. The opening of the urethra can open at the base of the glans penis, in the region of its trunk or near the scrotum. In the latter version, the hanging part is absent, the scrotum is split into two
half, resembling the labia, urination - according to the female type.
epispadias- non-closure of the anterior wall of the urethra in the distal penis (partial) or throughout its length (complete). The prevalence is 1 case per 50,000 newborns. With complete epispadias, urinary incontinence is noted.
Treatmentsurgical - displacement of the opening of the urethra, straightening of the cavernous bodies, plastic of the urethra.
Bladder exstrophy - the absence of the anterior wall of the bladder and the area of the anterior abdominal wall. It occurs in 1 in 50,000 newborns. The bladder is turned outward, its mucous membrane is exposed.
Treatmentsurgical - plastic of the bladder, transplantation of the ureters into the rectum.
cryptorchidism- a delay in intrauterine movement into the scrotum of one or both testicles remaining in the retroperitoneal space or inguinal canal. The diagnosis is based on the absence of one or both testicles in the scrotum.
Treatmentoperational - bringing down the testicle with its inguinal location, hormonal therapy.
Limb malformations
Violation of the development of the limbs can lead to the absence of the entire limb or part of it, fingers, as well as the appearance of additional limbs, fingers. Increase in limb length (macromelia) or individual fingers (macrodactyly) more often associated with a possible violation of blood circulation - the presence of arteriovenous fistulas. Absence of one or more limbs (ectromelia); absence of one of the limbs or part of it (hemimelia). The absence of the proximal part of the limb (shoulder, thigh) leads to the fact that normally developed lower legs, forearms, hands or feet start from the trunk (phocomelia). Improving the function of the limb can only be achieved by prosthetics performed on children to ensure their growth and development.
Congenital dislocation of the hip. The prevalence is 1 case per 1000 newborns. It is expressed in violation of the position of the femoral head: it is displaced and located outside the articular cavity. The dislocation may be bilateral. They reveal not only the violation of the position of the elements of the hip joint, but also their structural
changes: the femoral head is underdeveloped (diagnosed with its hypoplasia), the articular cavity of the ilium is thickened.
With a timely diagnosed dislocation, a complete correction is possible. The child is examined immediately after birth, a violation of passive movements in the joint (abduction, rotation) is typical for hip dislocation. If the dislocation is not diagnosed in a timely manner, then with the development of the child, a further displacement of the femoral head occurs, and the dislocation is detected when the child begins to walk. The gait is sharply disturbed: the child walks, waddling from foot to foot (“duck” gait), shortening of the leg is noted. characteristic appearance the patient in profile when examining him standing: pronounced lumbar lordosis, pelvic deformity, shortening of the limb. Radiography allows not only to clarify the diagnosis, but also to determine the degree of hypoplasia of the articular surfaces and the position of the femur.
Treatmentdislocation involves the elimination of displacement of the head - reduction of the head and immobilization of the limb with special orthopedic devices or a plaster cast.
congenital clubfoot (pes equinovarus congenitus)occurs in 1 in 1500 newborns. The diagnosis is easily established by the shape and position of the foot.
Treatmentshould start as early as possible. It includes manual foot straightening and fixation, massage and physiotherapy exercises. In later periods, surgical treatment is used: ligament transection, tendon transplantation or wedge-shaped resection of the foot bones with the foot placed in the correct position and fixed with a plaster cast.
Arthrogryposis(arthrogryposis)-multiple contractures of the joints due to underdevelopment of the muscles of the limbs with symmetrical localization. Stiffness, restriction of movements lead to the need for conservative therapy (massage, physiotherapy, physiotherapy).
syndactyly(syndactilia)expressed in the presence of adhesions between the fingers. Finger fusion can be skin or bone (Fig. 178). The defect is caused by a violation of embryogenesis: up to 2 months of intrauterine life, the fingers are connected by membranes, and then separated. The separation of the fingers is carried out surgical method at the age of 2-3 years.
Polydactyly(polydactylia)- an increase in the number of fingers. Meet both on the hands and on the legs, may be accompanied by a violation of the functions of the hand or foot. Surgical treatment - removal of additional fingers.
Rice. 178.Syndactyly: a - skin; b - bone.
macrodactyly(macrodactylia)- an increase in the volume of individual fingers. If the defect leads to dysfunction of the hand or foot, amputation of the finger is performed.
Ectrodactyly(ectrodactilia) -reduction in the number of fingers. One or more fingers or toes may be missing. To restore the functions of the hand and eliminate the cosmetic defect, they resort to transplanting fingers from the foot to the hand using microsurgical techniques.
Congenital malformations of the chest occur in about 1 in 1,000 children. Most often, in 90% of cases in relation to all types of defects, funnel chest deformity (PEH) is detected. Among the more rare forms, keeled deformity, various anomalies in the development of the ribs, splitting of the sternum and combined variants should be distinguished.
The reasons for the formation of these defects have not been fully elucidated. There is no doubt that they are congenital dysplasia or aplasia of the cartilage, less often of the bone part of the chest. Morphological studies connective tissue revealed a violation of its structure. The change in the structure of the connective tissue, in turn, is associated with a violation of metabolic processes.
The hereditary factor is of great importance. According to many authors, up to 20% of children with chest deformity have relatives with a similar pathology. To date, a large number of syndromes have been described in which one of the constituent components is anomalies of the sternocostal complex. Marfan's syndrome is the most common. In this syndrome, against the background of connective tissue dysembryogenesis, asthenic structure, arachnodactyly, subluxation and dislocation of the lenses, dissecting aortic aneurysm, funnel-shaped and keeled deformity of the chest, clear biochemical changes in the metabolism of collagen, glycosaminoglycans are noted.
Knowledge of the signs of syndromes and their identification are important in terms of determining tactics and prospects for treatment. So, with the Ehlers-Danlos syndrome (fourth ecchymotic form), in addition to bone and cartilage pathology, there are violations of the structure of the vessel wall. During surgical treatment, complications associated with increased bleeding are possible. If a child has various kinds of osteochondral deformities, it is advisable to consult a geneticist.
Funnel chest deformity
External signs of funnel chest deformity are characterized by retraction of the sternum and the adjacent part of the ribs. The costal arches are somewhat deployed, the epigastric region bulges:
Funnel chest deformity in a 4-year-old child
Clinic and diagnostics. As a rule, the deformity is determined immediately after birth, with a characteristic symptom of the paradox of inspiration (retraction of the ribs and sternum during inspiration). In about half of the patients, as they grow, the deformity progresses and becomes fixed by the age of 3-5 years. Deformation may appear at a later date - usually during the period of accelerated growth of the child. It is noted that the most profound forms of deformation appear early. Deformations that occur during puberty are rarely pronounced.
When examining a child, it is possible to identify stigmas characteristic of a particular syndrome (increased joint mobility, flat back, reduced tissue turgor, poor eyesight, gothic sky, etc.).
Along with the inspection data, radiographic and functional research methods are important. An X-ray in direct projection reveals the degree of displacement of the heart (usually to the left), which indirectly makes it possible to judge the effect of deformation on heart function. With the help of a lateral radiograph, the depth of the depression of the sternum is determined, the thoracovertebral index or the Gizhitskaya index (IG) (1962) is measured.
a) by degree - I degree IG = 1-0.7; II degree IG = 0.7-0.5; III degree IG less than 0.5,
b) in shape - symmetrical, asymmetrical, flat.
Functional changes in external respiration and hemodynamics are detected with severe deformities and directly depend on its degree. Disturbances in external respiration are manifested by a decrease in maximum ventilation of the lungs, an increase in the minute volume of breathing and an indicator of oxygen consumption per minute. The coefficient of oxygen use is reduced. ECG changes are noted. However, the most informative study of the heart is echocardiography, which allows to clarify the morphological changes in the heart. This is important due to the fact that with funnel chest deformity, especially with syndromic pathology, mitral valve prolapse is common.
Treatment. There are no conservative treatments for pectus excavatum.
indications for surgery. Indications for surgery are determined on the basis of the degree and shape of pectus excavatum. Thoracoplasty is unconditionally indicated for pectus excavatum III degree and is indicated for VDKK II degree. With funnel chest deformity of the 1st degree (with the exception of flat forms), thoracoplasty, as a rule, is not performed. [Urmonas V.K., Kondrashin N.I., 1983]. The optimal age for the operation is 5 years. With great care, one should approach surgical treatment in children with syndromic forms of deformity. Only after a comprehensive examination and in the absence of contraindications can surgery be recommended.
Recently, the Paltia method has been most widely used. The operation consists in subperichondral excision of the curved costal cartilages, transverse wedge-shaped sternotomy and fixation of the sternum in the corrected position with a metal plate.
The results of surgical correction of pectus excavatum are good (according to different authors, in 80-95% of cases). Relapses occur with insufficient fixation of the sternum and more often in children with syndromal forms operated on in the early stages.
Keeled deformity of the chest
Keeled deformity of the chest, as well as funnel-shaped, is a malformation. Often there is a hereditary transmission of the defect, which can be an integral component of one of the syndromes.
Clinic and diagnostics. The deformity is usually detected at birth and increases with age. The sternum protruding forward and the ribs sinking along its edges give the chest a characteristic keeled shape. Deformation can be symmetrical or asymmetric. With an asymmetric shape, the cartilaginous sections of the ribs lift the sternum on one side, and it curves along the axis. There are combined forms, when the upper third of the sternum is raised, and the lower part with the xiphoid process falls sharply. At the same time, pairing of the IV and V ribs was noticed, and the IV rib is located above the V rib at the place of intersection with the sternum.
Functional disorders, as a rule, are not detected. With syndromic forms and with a pronounced decrease in the volume of the chest, there may be complaints of fatigue, shortness of breath, palpitations during physical activity. However, in most cases, children and their parents are concerned about a cosmetic defect.
Treatment. Indications for surgery occur mainly in children older than 5 years with a pronounced cosmetic defect. Several methods of surgical interventions have been proposed, based on subperichondral resection of the parasternal part of the ribs, transverse sternotomy, and cutting off the xiphoid process. Fixation of the sternum in the correct position is carried out by stitching the sternum with the perichondrium and the remaining ends of the ribs. The results of surgical treatment of keeled deformity are good.
Rib anomalies
Rib anomalies may include deformation or absence of individual costal cartilages, bifurcation and synostosis of the ribs, deformation of groups of costal cartilages, absence or wide divergence of the ribs.
Bifurcation thoracic ribs (Luschke's ribs) usually appear as a dense, protruding mass next to the sternum. In rare cases, it is necessary to carry out a differential diagnosis with a tumor process. Treatment is required only for significant deformities for cosmetic purposes. It consists in the subchondral removal of deformed cartilage.
Cerebro-costo-mandibular syndrome. Rib defects (absence, bifurcation, pseudoarthrosis, etc.) are combined with non-closure of the upper palate or Gothic palate, hypoplasia of the lower jaw, micrognathia, glossoptosis, and microcephaly. Surgical treatment is indicated in extreme cases with a significant chest wall defect with paradoxical breathing.
Poland's syndrome is always characterized by a unilateral lesion, including aplasia or hypoplasia of the pectoralis major muscle, hypoplasia of the pectoralis minor muscle. It is often accompanied by the absence of part of the underlying costal cartilages and ribs, aplasia or hypoplasia of the nipple, aplasia of the mammary gland in girls, deformity of the arm and hand. Diagnosis is based on external examination. X-rays are used to clarify the condition of the ribs. In the presence of a significant defect with the formation of a pulmonary hernia, a rib defect is repaired using autotransplantation of the ribs from the healthy side. It is possible to use the above- and underlying ribs with their splitting and displacement towards the defect. Some surgeons have successfully used synthetic materials. To replace the missing muscles, the flap or the entire latissimus dorsi is moved. Operations for wide defects with paradoxical breathing are performed at an early age.
The splitting of the sternum is a rare malformation, which consists in the presence of a longitudinal gap located along the midline. The defect can vary in length and width up to complete splitting of the sternum. At the same time, a paradoxical movement of the mediastinal organs is noted, covered at the defect site only with a thinned layer of soft tissues and skin. The pulsation of the heart and large vessels is visible. The defect is detected in early infancy and increases as the child grows. Along with anatomical manifestations, functional disorders are also noted. Respiratory disturbances up to bouts of cyanosis are possible. Children usually lag behind in physical development.
The operation is performed at an early age. It consists in releasing the edges of the defect, which are sutured throughout with interrupted nylon sutures.
When examining children with malformations of the chest, attention should be paid to identifying stigmas of disembryogenesis, such as anomalies in the finger pattern, shortening of the fingers, etc. With medical genetic counseling for sporadic cases of the syndrome, the prognosis for the birth of a healthy child is favorable.
Congenital deformities of the chest depend on malformations of the spine, ribs, and sternum.
1. The absence or non-union of the sternum is explained by the cessation of the development of the sternum: the rollers from which you form) the sternum, laid symmetrically at the medial ends of the ribs, do not fuse with each other. The ribs in such cases are interconnected by a fibrous plate. The chest may be completely absent, but more often you see) partial underdevelopment of its lower end or handle. The fibrous plate at the site of the sternum with this anomaly follows the respiratory movements, sharply drawn in when inhaling and protruding when exhaling. With age, the fibrous plate becomes denser, its fluctuations decrease. Children with clefts and a complete sternum defect may develop normally.
2. Funnel-shaped chest, in which part of the chest and upper abdominal walls are funnel-shaped deepened. This deformation was called the "shoemaker's chest".
3. Keeled chest, in which, on the contrary, the sternum protrudes anteriorly.
Malformations of the mammary gland
1. Amastia - the complete absence of the mammary glands.
2. Polymastia - an excess of mammary glands.
3. Polytellia - an excessive number of nipples. Additional mammary glands or nipples are usually located along the "milk line", which runs from the axilla, along the anterolateral surface of the chest and abdomen, to the inner thighs.
4. Genikomastiya - unilateral or bilateral enlargement of the mammary gland. In men, this pathology is rare, it is associated with hormonal disorders of the gonads, pituitary gland or adrenal cortex.
congenital diaphragmatic hernia
Diaphragmatic hernia is the protrusion of the abdominal organs into the chest through a hole in the diaphragm. There are three main types of congenital hernia of the diaphragm:
1. Hernia of the diaphragm proper:
True diaphragmatic hernia - the abdominal organs exit through a defect in the diaphragm along with the peritoneum, forming a hernial sac;
False diaphragmatic hernia - there is no hernial sac, and the abdominal organs that have moved into the chest cavity are in contact with the organs of the chest cavity;
2. hernia of the esophageal opening of the diaphragm - the cardia of the stomach or the stomach is completely displaced into the posterior mediastinum;
3. anterior diaphragmatic hernia - occur in the presence of an enlarged sternocostal triangle,
4. in which the abdominal organs are displaced into the pericardial cavity. Heart defects
Heart defects are divided into congenital and acquired. Congenital heart defects include:
1. atrial septal defect;
2. ventricular septal defect, which leads to the discharge of blood into the right ventricle through a defect in the muscular or membranous part of the septum;
3. unclosed ductus arteriosus (ductus arteriosus, Botallov). The ductus arteriosus most often connects the common trunk of the pulmonary artery with the lower semicircle of the aortic arch at the level of the orifice of the left subclavian artery. When it is not closed, part of the oxygenated blood from the aorta enters the pulmonary trunk, then into the lungs. This leads to an overload of the left atrium and ventricle, causing their hypertrophy;
4. coarctation of the aorta. With stenosis of the isthmus of the aorta, hypertension rapidly progresses in the vessels of the upper half of the body and the brain. Patients are at risk of cerebral hemorrhage and other severe consequences of the defect;
5. other defects (isolated stenosis of the pulmonary artery, triad, tetrad and pentad of Fallot, etc.).
Acquired - aortic insufficiency and mitral valves. Operations on the chest wall and organs of the chest cavity Operations on the mammary gland.
Classification purulent mastitis:
1. superficial (premammary) mastitis, located in the peripapillary zone or above the stroma of the gland directly under the skin;
2. intramammary mastitis, located in the lobules of the gland itself;
3. retromammary mastitis, located under the deep sheet of the capsule of the mammary gland to the own fascia of the breast. Incisions for superficial mastitis are carried out paraoreolyarno or in the radial direction, without affecting the halo, dissecting the skin and subcutaneous tissue.
Incisions for intramammary mastitis are made at the site of greatest softening in the radial direction, 6-7 cm long, without affecting the halo.
1. dissection of the skin, subcutaneous tissue, gland tissue;
2. opening of the abscess;
3. destruction of partitions with neighboring abscesses until a single cavity is formed in a blunt way;
4. removal of necrotic tissues;
5. thorough washing of the abscess cavity with an antiseptic solution;
6. drainage (rubber strips are usually used).
To open a retromammary abscess, an incision is made along the lower transitional fold of the mammary gland. The skin and tissue are dissected in layers, the mammary gland is lifted and the pectoralis major muscle is peeled off from the fascia, and the abscess is opened. The abscess cavity is drained.