1. Transverse (Sinus transversus pericardii) in the transverse direction at the base of the heart. mu aorta, leg. artery and upper vena cava, right, left upper pulmonary veins. (Important for surgery on large vessels to bypass them)
2. Oblique (s. Obliquus p.) to the mu.
3. Anterior (s. Anterior inferior p.) transition point before. pariet leaf. pericardium to the bottom.
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Activities of N.I. Pirogov
Features of the primary surgical treatment of wounds of the hand, the concept of replantation of limbs and fingers with .. operational access to the femoral artery .. incisions to expose the femoral artery are carried out along the line of the projection of the vessel on the anterior inner surface of the thigh..
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Exposure of the femoral artery under the pupartite ligament
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Exposure of the femoral artery in the femoral-popliteal canal
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Surgical anatomy of the meninges of the brain. Subshell spaces. Sinuses of the dura mater. Blood supply to the brain
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Craniotomy is OD (operat.lostup) to the formations of the cranial cavity
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Fascia and cellular spaces of the neck
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The pericardium is a thin tissue membrane that directly covers the heart and large vessels emerging from it. Allocate fibrous and serous part of the "heart bag". The serous membrane, located on the inner surface of the pericardium, is called the parietal plate, and the part that goes outside the heart is called the visceral plate.
Between the sheets of the serous membrane is a small space called the pericardial cavity. In the fetus, the membranes of the heart develop in the first month of intrauterine life.
Anatomy
The pericardium is a protective sheath around the heart, located in the anterior mediastinum, limited by the diaphragm, pleura, chest wall, spinal column and nearby organs.
In the chest cavity in relation to the sagittal plane, the heart, together with the pericardium, is located asymmetrically. Most of it is on the left, and somewhere around a third of the organ is on the right.
The pericardium is a pericardial sac that has a rounded shape in children, and a cone-shaped one in adults. Such changes are due to the fact that immediately after birth the heart is spherical and is located almost in the center of the mediastinum, but over time, as a person and his internal organs grow, it shifts and takes on a teardrop shape.
Normally, between the sheets of the pericardium can be up to thirty milliliters of fluid. It reduces friction between tissues and has a shock-absorbing effect.
Blood supply and lymphatic drainage
The pericardium is the outer shell of the heart and is supplied by the aorta and thoracic artery. Anatomists identify up to seven sources of blood supply to this organ. These include diaphragmatic vessels, arteries of the mediastinum, bronchi, esophagus and thymus, as well as intercostal arteries. From the pericardium, blood flows into the superior vena cava and into the system of veins of the chest: unpaired and semi-unpaired.
A network of lymphatic vessels passes through the pericardium, which enlarge and carry lymph to the lymph nodes adjacent to the heart (diaphragmatic, bronchial, mediastinal, esophageal, and others). The pericardium is innervated by the mediastinal plexus.
Histological structure
The pericardium is a tough tissue sac that surrounds the heart. It is one of the shells of this organ, protects it from concussion and other external influences.
The structure of the pericardium is directly related to its function. The fibrous part consists of dense intersecting bundles of collagen and elastic fibers. Such dense areas are usually located near large vessels. In addition to the fibrous layer, there is also a thin serous layer, or rather layers. From the inside out, they are arranged like this:
- mesothelium;
- basement membrane;
- surface layer;
- collagen-elastic layer;
- elastic fibers;
- deep layer of collagen fibers.
Blood and lymphatic vessels pass through all pericardial tissues, feeding them and saturating them with oxygen.
Diverticula and cysts
Like other organs in the human body, the pericardium can undergo congenital and acquired mutations such as diverticula, hernias, and cysts. It is difficult to detect them, so most often it is an accidental finding during ultrasound examination already in adulthood.
Trauma and foreign bodies
Fluid in the pericardium can appear not only due to malformations, but also as a result of a banal injury. As a rule, injuries of the pericardium are not isolated, they are combined with injuries of other membranes of the heart. Rapid filling of the pericardial sac with blood can lead to tamponade and cardiac arrest.
If the liquid arrives slowly and its amount is insignificant, then there is a danger of infection and the development of purulent pericarditis, which is difficult to treat.
Fluid in the pericardium may also appear due to tumor secretion or fusion. There are benign and malignant neoplasms of the heart. They grow inside the cavity and rarely reach large sizes. There is such a thing as pseudotumors of the pericardium. These are usually large blood clots or encapsulated fluid. Such "tumors" can be the size of a human fist.
Symptoms of the neoplasm are: shortness of breath, cough, voice change, swallowing disorders, as well as progressive heart failure. There may be pathological noises over the aorta, cyanosis, blood stasis in the systemic and pulmonary circulation. Treatment is surgical if the location and size of the tumor allow it. In the case when it is impossible to remove the neoplasm, they resort to radiation and chemotherapy. This allows you to restrain the growth of new cells and prolong the life of the patient.
Diagnostics
The doctor summarizes all the results and makes the most probable conclusion about the cause of the patient's illness.
Pericardium, the pericardium is the sac in which the heart is located. It has the shape of an obliquely cut cone with a lower base located on the diaphragm and an apex reaching almost to the level of the angle of the sternum. The width of the pericardium extends more to the left side.
In the pericardium, the anterior, sternocostal, part is distinguished; posterior, diaphragmatic, part and two lateral - right and left - mediastinal parts.
The sternocostal part of the pericardium faces the anterior chest wall, from which it is separated by the lungs and pleura, with the exception of the area of the pericardium adjacent to the body of the sternum, the cartilages of the V-VI ribs and intercostal spaces, and to the left section of the xiphoid process.
The lateral sections of the sternocostal part of the pericardium are covered by the right and left sheets of the mediastinal pleura, the anterior edges of which are limited by two triangles.
In the area of the upper triangle, the sternocostal part of the pericardium is separated from the sternum by loose connective and adipose tissue, in which the thymus gland, thymus, is laid in children (see "Endocrine glands"). The compacted part of this fiber forms the so-called upper sterno-pericardial ligament, lig. sternopericardiacum superius, which fixes the anterior wall of the pericardium to the posterior surface of the manubrium of the sternum.
In the region of the lower triangle, the pericardium is also separated from the sternum by loose fiber, in which a compacted part is isolated - the lower sterno-pericardial ligament, lig. sternopericardiacum inferiuts: it fixes the lower part of the pericardium to the posterior surface of the body of the sternum.
In the diaphragmatic part of the pericardium, the upper section, which is involved in the formation of the anterior border of the posterior mediastinum, and the lower section, which covers the diaphragm, are distinguished.
The upper section is adjacent to the esophagus, thoracic aorta and unpaired vein, from which this part of the pericardium is separated by a layer of loose connective tissue and a thin fascial sheet.
The lower part of the diaphragmatic part of the pericardium, which is its base, fuses tightly with the tendon center of the diaphragm; extending slightly to the anterior areas of its muscular part, it is connected to them by loose fiber.
The right and left mediastinal parts of the pericardium are adjacent to the mediastinal pleura; the latter is connected to the pericardium by means of loose connective tissue and can be separated by careful preparation. In the thickness of this loose fiber connecting the mediastinal pleura with the pericardium, the phrenic nerve, n. phrenicus, and the accompanying pericardial-diaphragmatic vessels, vasa pericardiacophrenica.
The pericardium consists of two parts: internal serous - serous pericardium, pericardium serosum, and external fibrous - fibrous pericardium, pericardium fibrosum.
The serous pericardium consists of two serous sacs, as it were, nested one inside the other - the outer one, freely surrounding the heart, the serous sac of the pericardium itself, and the inner one, the epicardium, tightly fused with the myocardium. The serous cover of the pericardium is the parietal plate, lamina parietalis, of the serous pericardium, and the serous cover of the heart is the visceral plate (epicardium), lamina visceralis (epicardium), of the serous pericardium.
Fibrous pericardium, which is especially pronounced on the anterior wall of the pericardium, is fixed to the diaphragm, the walls of large vessels and through the ligaments to the inner surface of the sternum. 
The epicardium passes into the pericardium at the base of the heart, at the confluence of large vessels, hollow and pulmonary veins and the exit of the aorta and pulmonary trunk. Between the epicardium and the pericardium there is a slit-like space - the pericardial cavity, cavitas pericardialis. The cavity contains a small amount of fluid that wets the serous surfaces of the pericardium, causing one serous plate to slide over the other during heart contractions.
If, after the removal of the heart, the pericardium is considered from the inside, then large vessels in relation to the pericardium are located along its posterior wall along two lines - the right, more vertical, and the left, somewhat inclined to it. On the right line, the superior vena cava, two right pulmonary veins and the inferior vena cava lie from top to bottom, along the left line - the aorta, pulmonary trunk and two left pulmonary veins.
At the site of the transition of the epicardium into the parietal plate of the serous pericardium, several sinuses of various shapes and sizes are formed. The largest of these are the transverse and oblique sinuses of the pericardium.
The transverse sinus of the pericardium, sinus transversus pericardii, is bounded from above by the pericardium, from behind by the superior vena cava and the anterior surface of the atria, from the front by the aorta and pulmonary trunk; the right and left transverse sinus is open.
The oblique sinus of the pericardium, sinus obliquus pericardii, is located below and behind the heart. It is bounded in front by the posterior surface of the left atrium covered with epicardium, behind by the posterior, mediastinal, part of the pericardium, on the right by the inferior vena cava, and on the left by the pulmonary veins, also covered by the epicardium. In the upper blind pocket of this sinus there is a large number of nerve nodes and trunks of the cardiac plexus (see "Nerves of the Heart", vol. IV).
Between the epicardium covering the initial part of the aorta (up to the level of the brachiocephalic trunk leaving it), and the parietal plate of the serous pericardium continuing from it, a slight protrusion forms. On the pulmonary trunk, the transition of the epicardium to the specified parietal plate occurs at the level of the arterial ligament, lig. arteriosum (sometimes lower). On the superior vena cava, this transition is carried out below the place where the unpaired vein flows into it, v. azygos. On the pulmonary veins, the junction almost reaches the hilum of the lungs. On the inferior vena cava, the transition of the epicardium into the parietal plate of the serous pericardium is located close to its mouth. 
On the posterolateral wall of the left atrium, between the left superior pulmonary vein and the base of the left atrium, a pericardial fold passes from left to right, the so-called fold of the superior left vena cava, plica venae cavae sinistrae (exists in the embryonic period), in the thickness of which lies the oblique vein of the left atrium, v. obliqua atrii sinistri, and the nerve plexus (see Nerves of the Heart, vol. IV).
Innervation: nn. phrenici, vagi and branches of trunci sympathici.
Blood supply: branches a. thoracica interna - rr. pericardia-cophrenici and branches of aa. phrenicae superiores.
The pericardium (pericardium; from the Greek. perikardios - pericardial; synonym: pericardial bag, cardiac shirt) is a closed sac-like formation surrounding the heart and consisting of two sheets: parietal (pericardium proper) and visceral (epicardium).
Anatomy and histology. The epicardium (epicardium) directly covers the heart muscle and is fused with it. It has the structure of a serous membrane, consisting of mesothelium, a boundary membrane, a superficial wavy collagen layer, an elastic network, and a deep collagen-elastic layer (Fig. 1).
The pericardium itself consists of two layers: the inner serous (pericardium serosum) and the outer fibrous (pericardium fibrosum). The fibrous layer of the pericardium consists of superficial, medium and deep wavy collagen-elastic bundles.
Rice. 1. Scheme of the structure of the epicardium: 1 - mesothelium; 2 - boundary membrane; 3 - superficial wavy collagen layer; 4 - elastic network; 5 - deep collagen-elastic layer.
Rice. 2. Differences in the topographic and anatomical relationships of the transitional folds of the pericardium on the vessels of the root of the heart (numbers indicate the sides of the covering of the vessels by the pericardium): 1 - aorta; 2 - pulmonary trunk; 3 - left upper pulmonary vein; 4 - left lower pulmonary vein; 5 - inferior vena cava; 6 - right lower pulmonary vein; 7 - right upper pulmonary vein; 8 - superior vena cava.
The visceral layer of the pericardium (epicardium), passing into the outer layer, forms a transition line that runs at different levels from the place of entry and exit of large vessels from the heart (Fig. 2). Between the epicardium and the pericardium itself there is a slit-like cavity (cavum pericardii) with a negative pressure in it, which normally contains 15-30 ml of a clear pale yellow liquid.
The pericardium is surrounded by loose connective tissue. At the top, it passes into the adventitia of the large vessels of the heart, it is attached in front by the sterno-pericardial ligaments (ligg. sternopericardiaca) to the inner surface of the sternum, from below it is fixed to the diaphragm, on the sides it is fused with the mediastinal pleura (Fig. 3 and 4), and behind - vertebral-pericardial ligaments with prevertebral fascia.
Rice. 3. The position of the heart in the pericardial cavity (front view): 1 - n. vagus sin.; 2 - pulmo sin.; 3-a. pulmonalis; 4 - ventriculus sin.; 5 - apex cordis; 6 - diaphragma; 7 - ventriculus dext.; S - pericardium; 9 - aorta ascendens; 10-v. cava sup.; 11 - arcus aortae.
Rice. 4. Pericardium (pericardial bag) - back wall (front view): 1 - arcus aortae; 3 - ramus dext. a. pulmonalis (mouth); 3 - ramus sin. a. pulmonalis (mouth); 4 - ramus sin. a. pulmonalis; 5 - bronchus sin.; 6-plica v. cavae sin.; 7-vv. pulmonales sin.; 8 - diaphragma; 9 - plot v. cava, covered by the pericardium; 10-v. cava inf.; 11-vv. pulmonales dext.; 12. bronchus dext.; 13-v. cava sup.; 14 - the place of transition of the pericardium to the vessels; 15 - sinus obliquus pericardii; 16 - posterior wall of the pericardium.
The pericardium has the shape of a cut irregular cone, located from the upper edge of the III rib to the xiphoid process, protruding to the right beyond the edge of the sternum by 1-2 cm, to the left - by 7-8 cm.
From a surgical point of view, the pericardium can be divided into the following parts. The diaphragmatic part of the pericardium, along the plane of which the heart moves during systole and diastole, is intimately fused with the diaphragm. Between the anterior edge of the heart and the edge of the diaphragmatic part of the pericardium, there remains a free space - the anterior inferior sinus of the pericardium (in this place, the pericardium is punctured from the side of the xiphoid process).
The sternocostal part of the pericardium is covered in front by the edges of the pleural sacs, which leave a free interpleural space between them (see Pleura).
The dimensions of the interpleural space are different in normal and pathological conditions. With a significant effusion in the pericardium, this gap expands. The most constant area of the pericardium, free from the pleura, is in the IV-V intercostal spaces to the left of the sternum (“safety triangle” - A. R. Voynich-Syanozhentsky, 1897). Knowing the location of the internal thoracic arteries (0.5-1 cm outward from the edge of the sternum) allows you to avoid damage to them during pericardial puncture.
Most of the pericardium is made up of its mediastinal parts, covered with a mediastinal pleura rather tightly fused with them. Here pass the phrenic nerves with accompanying vessels. The back of the pericardium faces the spine and is separated from it by the esophagus, descending aorta, thoracic lymphatic duct, and azygous vein.
Between the aorta and the pulmonary artery, covered with common sheets of the epicardium, and located posterior to them by the superior vena cava and the wall of the atrium, a slit-like space is formed - the transverse sinus of the pericardium (sinus transversus pericardii). Its practical significance is revealed during operations on the pulmonary artery (A. N. Bakulev, 1961). In connection with the peculiarities of embryonic development, several blind pockets are formed in the places of transition of the sheets of the pericardium. The most significant is the oblique sinus of the pericardium (sinus obliquus pericardii).
The parietal layer of the pericardium receives blood through the branches of the internal thoracic, diaphragmatic, bronchial and esophageal arteries. The epicardium is supplied with blood by the peripheral coronary arteries. The outflow of blood goes through the veins of the same name. The lymphatic capillaries and vessels of the epicardium are connected with the lymphatic system of the heart. The efferent lymphatic vessels of the pericardium are directed to the regional lymph nodes of the mediastinum. This explains the pathways of transition and spread of the inflammatory process. Lymphatic and blood vessels of the serous sheets of the pericardium are involved in the exchange of pericardial fluid (see Mesothelium).
The pericardium is innervated by branches of the cervical sympathetic nodes, vagus and phrenic nerves, as well as cardiac, pulmonary and esophageal plexuses. With pericarditis, functional disorders of the esophagus, diaphragm, as well as pseudo-abdominal syndrome are observed (see).
The pericardium is a rich receptor zone, irritation of which causes changes in hemodynamic parameters and respiration.