Surgical procedures and punctures

Pericardiocentesis

The intervention is indicated for fluid accumulation (hydropericardium, hemopericardium) or exudative pericarditis. The goal of the procedure can be either therapeutic or diagnostic.

Local anesthesia with a 0.5% procaine solution is used for pain relief. The insertion point is located in the angle between the xiphoid process of the sternum and the left part of the costal margin. The needle is advanced cranially at a 45° angle to the body surface.

Layers traversed:

1. Skin.
2. Subcutaneous adipose tissue.
3. Rectus abdominis muscle with its aponeurosis.
4. Anteroinferior pericardial recess.

The anatomical safety of the approach is due to the fact that the insertion passes through the safety zone of the anterior pericardium (the level of the V–VII left costal cartilages and the left half of the xiphoid process). In this area, the pericardium is not covered by the pleura, which completely eliminates the risk of damaging the pleural leaves. Fluid accumulates precisely in the anteroinferior recess, as it is the largest and most accessible. A reliable criterion for entering the cavity is the sensation of needle oscillations transmitted from heart contractions. The volume of evacuated fluid can reach 1–2 liters.

Thoracentesis and pleural cavity drainage

Puncture is recommended for moderate, large, and massive accumulations of blood or air (hemothorax, pneumothorax) to relieve respiratory disorders. Regardless of the nature of the contents (exudate, blood, or air), it is advisable to use a single point for the procedure.

The optimal zone for chest tube insertion is called the "safe triangle". Its anatomical boundaries:

• Anteriorly: lateral border of the pectoralis major muscle (m. pectoralis major).
• Posteriorly: anterior border of the latissimus dorsi muscle (m. latissimus dorsi).
• Inferiorly: horizontal line drawn at the nipple level.

The best site for thoracentesis is located in the V–VI intercostal space along the midaxillary line (linea axillaris media). Anatomical rationale for the choice: the muscular layer of the chest wall in this area is the thinnest, making the procedure the least traumatic.

Surgical tactics for moderate pneumothorax or hemothorax directly depend on the respiratory status:

• If the patient (including a child) is breathing spontaneously, a puncture is initially sufficient. Drainage is indicated only if pneumothorax persists or progresses on follow-up imaging.
• If the patient is on mechanical ventilation (artificial lung ventilation), puncture is impractical—immediate drainage of the pleural cavity is required.

Osteosynthesis in chest trauma

Surgical intervention aims to eliminate bone framework instability, correct deformities, and restore normal pleural cavity volume.

Strict rule: osteosynthesis of the sternum is always performed first, and only then do we proceed to rib fixation.

• Intrapleural osteosynthesis: used for flail fractures combined with intrathoracic organ injury. In this case, thoracotomy is completed by fixing the flail segments using pins or plates. A delayed indication for surgery is significant chest deformation.
• Surgical treatment of sternal fractures: indicated if the fragments are displaced by more than the thickness of the bone itself. Open reduction and internal fixation of fragments using screws, wire, or pins is applied.

Basic skills and principles of operative surgery

The study of topographic anatomy (the discipline's workload is 6 credits) is the foundation for mastering operative surgery. Knowledge of layered structure, holotopography, skeletotopy, and syntopy of organs allows the doctor to safely perform approaches, understand lymph drainage pathways, and predict the spread of purulent streaks.

Mastering surgical technique requires refined manual skills. The surgeon must be able to:

• Dissect tissues (skin, subcutaneous tissue, fascia, aponeuroses, muscles) and suture them, forming secure knots (simple, square, double surgical knot).
• Perform primary surgical wound debridement and provide temporary and definitive hemostasis, including through temporary bypass of main arteries.
• Perform emergency interventions: tracheotomy, chest sealing in penetrating wounds (open pneumothorax), intestinal wound suturing.
• Perform novocaine blockages (cervical vagosympathetic block according to A.V. Vishnevsky, pelvic block according to Shkolnikov-Selivanov).
• Puncture not only cavities (abdominal, pleural, pericardial) but also large joints (shoulder, elbow, hip, knee), as well as the urinary bladder and subclavian vein.

Understanding the topography of weak spots in the abdominal wall provides the anatomical rationale for the surgical treatment of hernias (inguinal, femoral, umbilical, linea alba), while knowledge of sensory and motor innervation zones is necessary for topographic diagnosis of peripheral nerve diseases.

Class and exam questions

What else to study on this topic

• Topography of fasciae and pathways of purulent streak spread
• Weak spots of the abdominal wall and hernia surgery
• Technique of intestinal anastomosis formation and gastric resection
• Primary surgical wound debridement and hemostasis
• Topography of neurovascular bundles and collateral circulation

Other topics in the "Additional Topics" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.