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HbIqMK A. 3. OCHOBbI onepaTIIBHoH TeXHlIKII B xlIpyprlIlI
IIpaKTIIqeCKOenoc06IIe
TepHononb, 2003. - 204 c.
ABTOp: HbIqJ1K AHJ(PUU 3uHoBLeBu'I - KaH)J,. Me,n. HaYK, naY'IHLIU co-
TPy,nHHK MHcTuTYTa BepTe6poJIoruu U pea6UJIUTaQuu.
B KHlIre II3JIO:>KeHa MeTo,nIIKa npaBIIJIbHOrO pa3'be,nIIHeHIIH II coe,nIIHeHIIH
TKaHeH B xlIpyprlIlI. IIplIBe,neHbl KnIlHlIqeCKlIe npe,nrrOCbIJIKII BbI60pa IlIOBHoro
MaTeplIana. OnlIcaHbI OCHOBHble cnoco6bI HanO:>KeHIIH IlIBOB Ha pa3JIIIqHbIe TKa-
HII. IIpe,nCTaBJIeHbI HalI60nee ynoTpe6meMbIe BaplIaHTbI BIDaHIIH Y3JIOB PYKaMII II
C nOMOll.{blO IIHCTpYMeHToB.
M3JIO:>KeHa TeXHIIKa BJIa,neHIIH KaK KllaCClIqeCKIIMIi xlIpyprlIqeCKIIMII, TaK II
nanapocKOnlIqeCKIiMII IIHCTpYMeHTaMIi.
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KO OT,neJIbHbIX onepauliH C 6JIarOnonyqHbIM IICXO,nOM ell.{e He MorYT C03,naTb xlIpypra. Bce-TaKII,
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no BpeMeHII, nOKa HaKODJIeHHbIe TeopeTHqeCKlie 3HaHIIH, npaKTlIqeCKIiH OnbIT, npeBpaTHTCH B CO-
BepIlIeHHYIO onepaTIIBHYlO TeXHIIKY. COKpaTIITb 3TO BpeMH II nplI3BaHa npeMaraeMaH KHlIra.
)J;aHHoe PYKOBO,nCTBO HBJIHeTCH IIJIJIlOCTplipOBaHHblM nOC06IIeM no TeXHIIKe pa3'be,nHHeHIIH
II coe,nIIHeHIIH pa3JIIIqHbIX TKaHeH II CTPYKTYp.
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BHJIbHOrO BJIa,neHIIH IIHCTpYMeHTaMlI, pa3'be,D;IIHeHIIH II coe,nIIHeHIIH TKaHeH, OCTaHOBKII IIHTpaO-
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B ,naHHOM noc061I1I OC03HaHHO CTpeMRITIiCb 1I36e:>KaTb cy6'beKTIIBHOCTII B 1I3JIO:>KeHIIII MaTe-
pliana. IIpe,noCTaBJIeHHaH IIHllJopMaulIH ,nomKHa paCIlIIIplITb B03MO:>KHOCTli MaHeBpa MH xlIpypra.
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cmyaUIISI:X.
IIo onpe,neJIeHlIlO npollJeccopa r.E. OCTpoBepxoBa (1950), XUpyp2U'leCKOJl onepa14Wl- 3T0
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pa30M, nyTeM pa3'be,nIIHeHIISI: II pa3JIIIqHbIX cnoc060B coe.D:IIHeHIISI: TKaHeH.
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I - ,nocTyn K cy6CTpary onepaUIIII, pa3,neJIeHlIe TKaHeH, OCTaHOBKa KpOBOTeqeHIIH;
II - onepaTIIBHble MaHlIllynHUHII (onepaTHBHblH nplIeM);
III - BbIXO,n 1I3 onepaUHII, coe,nIIHeHlIe TKaHeH.
Ha Ka)l(,D;OM 3Tane OnepaTHBHOrO BMeIlIaTeJIbCTBa xnpypr, OCHOBblBaHc'b Ha onpe,neJIeHHbIX
YCJIOBIIHX, IICnOJIb3yeT TeXHlIqeCKlie nplieMbllI MaHlInynHUIIII, KOTopble COCTaBnHIOT onepaTIIBHYlO
TeXHIIKY oneplipYlOlI.{ero. Ha nepBbIH B3rJIM OHII Ka)!(YTCH ,nOCTaTOqHO npOCTbIMII, n03TOMY IIM,
Hepemo, He y,neJIHlOT ,nOJI:>KHOrO BHIIMaHIIH. Ha caMOM .aeJIe, qeTKOCTb, npaBIIJIbHOCTb, TlUaTenb-
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ro MaTepliana.
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y,n06HO paCCTaBlITb IIHCTPYMeHTbI, Hana,nIITb xopolliee OCBemeHlIe onepaUHoHHoro nOJIH II T.,n.
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xopornee OCBell.{eHHe II ,nocTynHoCTb onepaUlIoHHoro nonH. KaqeCTBO onepaTIIBHoH TeXHIIKII Ha-
npHMYlD 3aBliCliT OT 3Toro ycnoBIISI:: qT06bI XOpOiliO oneplipoBaTb, Ha,no XOpOlliO BH,D;eTb, qTO Tbl
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nlIIlIb Tor,na, Kor,na onepaUlIoHHoe none c,neJIaTb BH,D;IIMbIM 1lJ1I3IIqeCKli HeB03MO:>KHO.
,[{JIH xopOiliero OCBell.{eHIIH onepaUlIoHHoro nonH peKoMeHL{YIOT pa3MemaTb 6e3TeHeBYlO naM-
ny HaL{ rOJIOBOH xlIpypra. IIpli 3TOM JIytIII CBeTa He06xo,D;IIMO cllJOKYClipOBaTb Ha 3a,neHCTBOBaH-
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CH nepeMell.{eHlIeM 1lJ0Kyca JIaMnbl. ECJIII onepaUIIOHHaH paHa Tpe6yeT 60JIee IIHTeHCIIBHoro
OCBell.{eHIIH (onepaUIIII Ha cep,nue II T.n.) xnpypr MO:>KeT BOCnOJIb30BaTbCSI: no6HOH naMnOH.
BeCbMa Ba:>KHbIM YCJIOBlieM npOBe,neHIIH xupyprlIqeCKOrO BMellIaTeJIbCTBa eCTb y,n06Hoe
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nOJIOCTIi Ta3a, KaK npaBRITO, npHMeHHlOT nOJIO:>KeHlIe TpeHL{eJIeH6ypra (nplIqeM yron no,n'beMa HII)l(-
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ra, IICnOJIb3YlOT npli onepaUIIHX Ha IlIee, ronOBe, opraHax
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Ha nOqKaX, MOqeTOtIlIlIKax II JIerKlIX. EonbHoH JIe)l(lIT Ha 60KY.
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Hoe nOnO:>KeHlIe KaK MH KaMHeCeqeHIIH.
XHPypmlJECKMM MHCfPYMEHTAPHM
BbICOKoe KaqeCTBO onepaTIIBHOH TeXHIIKII onpe,neJIHeTCH He TonbKO MacrepCTBoM Bna,ne-
HHH IIHCTpYMeHTaMlI, HO II YMeHlIeM TOqHO II 6bICTpO Bbl6paTb He06xo,nIIMbIH ,nJIH peilieHIIH CeIIMH-
HyTHOH 3a,naqrr IIHCTPYMeHT.
Pa3JIIIQalOT 06IUIIH xnpyprnqeCKIiH IIHCTpYMeHTaplIH (He06xo,nlIMblH npli mo60H onepaulm)
II cneUlIanbHbIH.
1.I1HCTPYMeHThI J],JIH pa3'beJ],UHeHHH TKaHeii (pe:>KYIUHe): 1I0:HCIIUl{bl (puc. 1.5), CKWlbneJlU
(puc.1.6), nWlbl (puc.1.7).
IIo 1lJ0PMe ne3BIIH pa3JIHqalOT 6plOIDHCThle II
OCTpOKOHeqHble CKaJILneJIU; nepBble y,n06HbI MH
pa3pe3a II npenapoBKII TKaHeH, BTopble - TaM, r,ne
Ha,D.O c,neJIaTb npOKon, a 3aTeM pa3pe3 (HanpIiMep,
npII BCKpbITlI1I rHOHHIIKa). BblnycKalOTcH TaK:>Ke
CKanbneJIII co C'beMHbIMIi JIe3BIIHMII.
HmKHUQbI MorYT 6bITb rynoKOHeqHblMli npSl:-
MbIMII, TynoKOHeqHbIMIi 1I30rHYTbiMli (Kynepa), C o,n-
HIIM OCTpblM KOHUOM II ,np. ,[{mI pa3pe3aHIIH nOBH30K
IICnOnb3YIOTCH HO:>KHIIUbI C nyroBKoH, II30rHYTble no
pe6py (JIlicTepa).
2. I1HCTpYMeHTbI ,nJIH OCTaHOBKU KpOBOTe'le-
HUH: Kp0600Cmalla6JlU6alOUfue 30J1CUMbl (puc. 1.8) II
JlUZamYP"ble UZJlbl (puc. 1.9).
HalI60JIee qaCTO IIcnonb3YlOTcH 3a:>KIIMbI c Ha-
pe3KoH (EIIJIbpOTa), C Hape3KoH II 3y6uaMli (Koxe-
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HIIH cocy,na). HWI mKalleu e zlly6ulle, 230 MM; 2,3 - mynoKoHe'l-
Hble npJlMble U U3oZHymble. 140 MM; 4 - C OaHUM
OCmpblM KOHl/OM
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HO:HCU allR zunca; 6 - ocmpOKOlle'lHble U 6plOUlUCmbie CKaJlbnellU; 7 -. CKaJlbnellb co C"beMHblM lle3BUeM
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MU'IecKClJIllJ/r<!'IOeaR); 5 - a/IJI pa3pe3aHUJ/ zuncoeblX noeR3OK .
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3. BcnOMOraTeJIbHbIe HHCTpYMeHTbI: nUHl{embl (pUC. 1.10),
KplO'IKH, 30H,nbI, KopHuaHrH, 3a HMbl J{JID onepaUHOIIHoro
6eJIbD. nHIII.{eTbI pa3JIlIqalDT aHaTOMIIqeCKlie (c nonepeq-
'fJ!' HOH Hace OH Ha ry6Kax - 6paHlliax), XlIpyprH'IeCKlie (3y6-
qaTbIe) II 3y6qaTO-JIan t IaTbIC. 3a HMbI MHKYJIH'Ia CJIY:>KaT
JJ.llil nplIKpellJICHIIH CTeplIJIbHoro 6enMI K 6plOIlIIIHe; OH Ha-
nOMliHaeT 3a:>KIIM Koxepa, HO 6paHIlIli ero 1I30rHYTbI no
llJIOCKOCTIi.
KplO'IKH (puc. 1.11) CJIY:>KaT ,D;JIHpaCllIlIpeHIIHpaH,
OHII MorYT 6bITb 3y6qaTbIMli (OCTpbIMII II TYIThlMlI) II llJIac-
THHqaTblMli (KPlOqKII <1>apa6e4Ja).
30H)J.bI BblnycKalOTcH nyrOBqaTble II :>KeJI060BaTbIe,
pe:>Ke npHMeHHeTCH 306HbIH 30H)J. Koxepa.
.ZJ.M no,naqlI IIHCTpYMeHToB, CaJIllJeTOK nplIMeHHlOT
KOpHLl.aHr.
4. HHcTpYMeHTbI,W1Jl coeJ{HlleHHH TKaHeii: HrJIOAep-
aTeJIH (puc.1.12) II HrJIbI.MrnbInpe,nHa3HaqCHbI.lUIHHa-
nO:>KeHUH IlIBOB, IIrno,nep:>Ka TCJIII - ,D;JIH y,nep:>KaHIIH II npoBe-
PUC. 1.11 KplO'IKU xupypZU'leCKUe 3y6'1ambze ,neHIIH IIrn qepe3 TKaHII. TpcxrpaHHble pe:>KYIUlIe II Kpyrnble
KOJIlOIUlie IIrJIbl BbInycKalOTcH Pa3JIlIqHblX pa3MepoB II KPII-
BII3Hbi (no HOMCpaM). CYll.{eCTBYIOT TaK)!{e crreUlIanbHbIe UrJIbI JJ.llil neqeHII (c OKpYrJIeHHblM KOHUOM),
aTpaBMaTnqeCKlie IIrflbl JJ.llil neqeHII (c oKpyrncHHblM KOHUOM), aTpaBMaTlIqeCKlie IIrnbI o,nHoKpaTHO-
ro npIIMeHeHlIH.l1.IDI HanO:>KeHIIH Ha KO:>KY IICnOJIb3YIOTcj{ 1IH0r,na CK06KII II llIIHUeTbI MlIllienSl:.
10
CneUlIanbHble xlIpyprlIqecKlIe IIHCTpYMeHTbI npIiMeHSl:lOTCSI: npII onpe,neJIeHHblX BH,D;aX onepaUIiH.
1. HHcTpYMeHTLI,ZtrnI OnepaQHH Ha opraHax 6plOlUHOH nOJIOCTH (puc. 1.13): paHopacllIlI-
plITeJIIi r occe II MIIKynlIqa (c KpeManbepoH), 3epKana MH 6plOlliHOH CTeHKII, ,nJIH OTBe,neHIIH neqe-
HII, MHrKlie II pa3,naBJIIiBalOlI.{lIe :>KeJIy,nOqHble II KHllIeqHble 3a:>KIIMbI, nOnaTOqKa EYAAbcKoro, DJIa-
CTIIHKa ,nJIH OTTeCHeHIIH BHYTpeHHocTeH (ilinaTeJIb PeBep,neHa).
2. HHcTpYMeHTLI ,nJIH onepaQHH Ha oprallax rpy,nHOH nOJIOCTH (puc. 1.14): paHopacllIliplI-
TeJIb BIIHTOBOH, pe6epHble HO:>KHIIUbI rRITbOTHHHbIe II IllTlIJIJIe, pacnapaTop pe6epHbrn no TlIny )J;y-
aHeHa, lI.{IInUbl MH C6JIII:>KeHIIH pe6ep, OKOHqaTbIe lI.{lInUbl,nJIH 3aXBaTbIBaHliH nerKoro, CIlIIiBalO-
lI.{IIe annapaTbI YKE-25, YKJI-60, IIHCTpYMeHTbI ,nJIH onepaUIIH Ha cep,nue (KOMIiCCYPOTOMIIII,
BanbBYnOTOMIII11I ,np.).
3. HHCTpYMeHTLI ,nJIH OnepaQHH Ha KOCTHX: ,nonOTa (puc. 1.15) DJIOCKHe II :>Ken060BaTble,
MOJIOTOK, KycaqKII (puc. 1.16) C KPYrJIbIMIi ry6KaMli (JI103pa), C npHMbIMIi ry6KaMII (JIlicToHa),
lI.{IInUbI,nJIH y,nep:>KaHIiH KocTeH (<1>apa6ellJa, OJIbe), nlina paMOqHaH, nliJIa npOBOnOqHaH BlITaH
(.ZJ::>KlIrJIlI), pacnapaTop, nO:>KKII KOCTHbIe oCTpble (<1>OJIbKMaHa);.D:JIj{ aMnyraUHII KOHe oCTII - HO:>KII
aMnYTaUIIOHHbIe, peTpaKTop II ,np.
4. HHcTPYMeHTbI llJIH TpaxeocToMHH: TpaxeOCTOMlIqeCKlie KaHlOnlI, pacllIHplITenb Tpaxell
(Tpycco), 0.D:H03y6bIH KplOqOK.
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6, 7 - npRMou U u30zIIymblu c npRMblMU KOllbljeeblMU pY'lKaMU U KpeMaJlbepou, 160 MM
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1 - 3epKWlO ne'leHO'lHOe; 2 - 3epKWlO
aMI cmeHKU :JK:ueoma; 3 - 3epKWlO aMI
OmeeaeHUR nO'lKU; 4 - nOa'beMHUKU aMI
MH2KUX mKaHeu; 5 - 3epKWlo aMI
cepi>z{a; 6 - nOnamO'lKa EYRJlbCK020
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(cWla30'lH020 muna); 3 - eUHmoeou aMI pe6ep
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Puc. 1.16 Kyca'lKU MeaUIjUHCKUe KocmHble: 1 - c npRMblMU KonbeeUOHblMU 2y6KClMu; 2 - UlapHupHble c
aeOUHOU nepeaa'leU; 3 - u30mymble no 11.!I0CKOCmu (JIucmoHa); 4 - UlapHupHble c aeOUHOU nepeaa'leU, c
KPY2JlbiMU 2y6KaMu, u3021lymble no 1IJl0CKOCmu
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mble; 3 - JlO:J/Ce'lHble (KopHeea)
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PUC. 1.1711llcmpYMellmbl HeupoxupypZU'leCKue: 1 - KOJlOeOpOm C MeaUljUHCKUMU rjJpe3aMu (cJlueo06pa:J-
IlblMU U KOnbeeUaHblMU); 2 - Kyca'iKU /(aJ/bzpeHa; 3 - Kyca'iKU HeupoxupypZU'leCKUe; 4 - Kyca'iKU
Ezopoea-t1>peUaUHa; 5 - Kyca'iKU aJl5l 3amb1Jl0'iHOU KOcmU
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3 - :HCeJlyaO'lHbIU
14
5. HeiipoxuPypl'H'leClme UHcTpYMeHTbI (puc. 1.17): KonoBopoT C Ha60poM IlJpe3, nlIJIa
)J;:>KlIfJIlI, KycaqKII )J;anbrpeHa, EropoBa - <1>pefutIIHa, paHopacIlIHpIITeJIb YHIIBepcanbHb1H, HO:>KHII-
Ubl, HO:>KII II llinaTeJIIi HeHpoxlIpyprlIqeCKlIe, MeTanJIlIqeCKlie KJIlInCbI MR OCTaHOBKII KpOBOTeqe-
HIIH, IIHcTpYMeHTb1.D:JIH HanO:>KeHlIH IIX.
6. MHcTpYMeHTbl,nJIH ypOJIOrH'IeClmX onepal.{u": KaTeTepb1 MeTanJIlIqeCKlIe, MOqeTOqHII-
KOBble, UIICTOCKonb1, nOqeqHblH 3a:>KIIM <1>e,nopoBa, nOqeqHb1e 3epKana II ,np.
7. Mn:CTpYMeHTbI ,nJIH onepal.{u" Ha KUme'lHUKe: :>KOMbl (puc. 1.18), 3epKaJIO peKTaJIbHOe,
3a)l(IIM OKOHqaTblH reMOppOH.D.aJIbHbIH (JI103pa), lI.{lInUbl MH 6IIOnClIIi.
np ABMJIA P A3'bE)J,I1HEHMH TKAHEM
OqeHb Ba:>KHbIH MOMeHT BCHKoro onepaTIIBHoro BMeIlIaTeJIbCTBa - npaBRITbHOe pa3'be,nIIHe-
Hlie TKaHeH. OCHOBHblM nplIHUlinoM 3TOH nlfoue,nYPbI HBJIHeTCR CTpora5I nOCJIOHHOCTb.
,l],JIH pa3,neneHIIH TKaHeH, B 3aBIICliMOCTli OT IIX CBOHCTB, xlIpypr MO:>KeT Bocnonb30BaTbCH
OCmpblM (IIHCTpYMeHTaMH) RITII mynblM (nanbuaMII) nyTeM.
Tpa,nIIUIIOHHO onepaTIIBHoe BMelliaTeJIbCTBO HaqlIHalOT C pa3,neJIeHIIH TKaHeH CKaJlbneJle.M.
Pa3pe3 HO:>KOM (CKanbneJIeM) nplIMeHHeTCR KaK aKT, npe,nBapHlOIUIIH nOCTyn,no, c06CTBeHHO, nonH
onepaUHII.
CKanbneJIIi ,neJIHTCH Ha OCTpOKOHeqHble II 6plOIlIII-
CTbIe (puc. 1.19). OCTpOKOHeqHbIe qall.{e Beero IICnOnb3Y-
lOTCH MH BCKpblTHH a6cueccoB npOKonOM. Eonee llilIpOKO
B xnpyprlIlI npIIMeHHlOTC5I CKanbneJIIi 6plOIlIlIcTble.
HeCJIO:>KHble pa3pe3bI ,neJIalOT, ,nep:>Ka CKanbneJIb,
KaK CMbIqeK, pa3Mell.{aH IIHCTpYMeHT npaKTlIqeCKII napan-
neJIbHO pa3pe3aeMbiM TKaHHM. IIpli nnaCTlIqeCKIiX one-
paUIIHx, Kor,na HY:>KHbI TOqHbie II TOHKlIe ,nBII:>KeHIIH - CKaJIb-
neJIb ,nep:>KaT, KaK DlIcqee nepo, a npII OTCeqeHIIII qero-JIlI60
(K npliMepy, npli Ha,nBnaranlIlI.{HOM aMnYTaUlI1I MaTKII)-
KaK CTOnOBbrn HO:>K. B nOCJIe,D;HeM cnyqae pyqKY OXBaTbIBa-
lOT PYKOH, nOMell.{aH YKa3aTeJIbHbIH naneu Ha 06yx (ClIIIH-
KY)HO:>Ka (puc.1.20).
XOpOllilIH CKaJIbneJIb ,non:>KeH 6bITb ,nOCTaTOqHO oc-
Tpb1M. nOCKonbKY HeJIb3H C YBepeHHOCTblO pa60TaTb TY-
DblM IIHCTpYMeHTOM, TaK KaK Tpy,nHO npenaplIpOBaTb TKa-
HII II JIerKO nOpaHIITbCH caMOMY.
KaKIiM 6b1 OCTpblM HII 6bm CKanbneJIb, XOpOiliO pe-
3aTh OH MO:>KeT nlIIlIb Tor,na, Kor,na pa3pe3aeMbie TKaHIi
Heno,nBII:>KHbL ECJIII:>Ke OHII 3naCTIIqHbI (HanplIMep, KO:>Ka II
CJIII3IICTbie 060nOqKII).nx Ha,no XOpOlliO pacTHHYTb. qeM
CIIJIbHee paCT5IHYTa KO:>Ka, TeM rny6:>Ke npOHIiKaeT CKanb-
nenb npli pa3pe3e. Ha3HaqeHIIe HO:>Ka - pe3aTb, a OTHlO,nb
He KOJIOTb TKaHII: HO:>K pe:>KeT TonbKO Torna, Kor,na ero Be-
.D;yT. ECJIII nOCTaBIITb ne3BIIe Ha KO:>KY II npoCTO ,naBIITh, He
CMell.{a5I HO:>Ka, TO OHa He pa3pe:>KeTCH IIJIII pa3pe3 6y,neT
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1lJ0KYc: nOCTaBIITb Ha na,nOHb OCTpylO 6plITBY II CIIJIbHO
nplI:>KaTb, TO, KaK HII CTpaHHO, HIiKaKOrO paHeHIIH He 6y-
,neT -.D:JIH 3Toro He06xo,nIIMO, qT06bl ne3BIIe CTOAAO nep-
neH,nIIKynHpHo K KO:>Ke, a npli Ha:>KaTHIi He CMeCTIIJIOCb
no ,D;J1nHe, B npoTIIBHOM CJIyqae nonyqHTC51 rny60KHH Pa3-
pe3.
3HaMeHIITbrn B npOIlIJIOM xlIpypr JIeHreH6eK yqlIJI,
qTO ,nJIR pa3pe3a HO:>K HY:>KHO nlIllib BeCTII, BOBce He Ha-
,naBJIIIBa51 Ha Hero. IIocJIe,nHee YCJIOBlie qaCTO IIfHOpnpy-
eTCSI: HaqIIHalOll{HMH-XlIpypraMII, n03TOMY pa3pe3bl no-
nyqalOTCR Jtel{OHTpOJIlIpyeMble II HepOBHble.
IIpl1 pa60Te CO CKanbneJIeM He06xo,nI1MO nOMHIITb
o ,n03IIPOB¥'HOM paCCeqeHlI1I TKaHell. OqeHb Ba:>KHO
pa3'be,nIIHRTb IIX aHaTOMlIqeCKII, ,nenIiKaTHO (He60nbllilI-
MH MaCCIiBaMU), OCTOpO:>KHO II TOJIbKO no,n KOHTpOJIeM
3peHIIR. He06xo,nIIMO 1I36eraTb TpaBMlIpOBaHIiH IlJYHK-
QIIOHanbHbIX TKaHeH, COCy,nOB II HepBOB.
HeCOMHeHHO, 3TO 06l1.{elI3BeCTHble llJaKTbI, KOTO-
pbIMII, BnpOqeM, nonb3YlOTCH He Bce II He Bcer,na.
IIpli Bbl60pe MeCTa npOII3Be,neHIIHpa3pe3a K03ICU, nOMIiMO 06eCneqeHIIH cB060,nHoro ,no-
CTYna K onepaUIIOHHOMY noJIlO II He06xo,nIIMOCTH OTblCKlIBaHIIH pa3JIIIqHblX aHaTOMlIqeCKIIX II TO-
norpallJlIqeCKIiX no,np06HOCTeH, yqlITbIBalOT ewe II pacnOnO>KeHlIe KO:>KHbIX CKna.J:\OK. EepeTC BO
BHIIMaHlIe CBOHCTBO KO:>KII CMeIUaTb KPaH paHbI, HaHeceHHoH KonlOlI.{lIM IIJIH pe:>KYll{HM IIHCTpYMeH-
TOM B onpe,neJIeHHOM (pa3JIlIqHOM.D:JIH Ka)K)J,OH 06JIaCTI1) HanpaBJIeHIIH. OHO onpe,nemeTCH JIaHre-
pOBCKIIMIi nlIHIISl:MII (puc. 1.21). ECJIII pa3pe3 KO)l(lI npOH3Be,neH B COOTBeTCTBlI1I C HIIMII, TO paHa
He 3IIHeT, ee KpaSl: conplIKacalOTCH caMII, IIX nerKO 3allilITb, a OCTalOlI.{HHCH py6eu MaJI03aMeTHbIH.
B CBR31I C 3TIIM KO:>KY, npli npOBe,neHIIII KaKlIx-nlI60 onepaTIIBHbIX BMeIlIaTeJIbCTB, :>KeJIaTenbHO
pa3pe3aTb no JIaHrepoBCKIIM JIIIHIIHM. B TOM CJIyqae, Kor,na He06xo,nIIMO 3IIHHIIe paHbI, HanplIMep,
npli BCKpbITlI1I rJIy60Koro a6cuecca, HanpaBneHlIe pa3pe3a pacnonaralOT nepneH,l(lIKynHpHo K
HHM.
IIocJIe pa3pe3a KO:>KII KpaH paHbl pa3BO,nHT KplOqKaMIi II OCTaHaBJIIiBalOT KpOBOTeqeHlIe.
3aTeM pa3pe3alOT nodK03ICHYW KJlem'lamKY, n06epXHocmHYW tjJacu,uw II no,nxo,nHT K co6cm6e1l11OU
tjJacu,uu. B CBR3II C TeM, qTO no,n c06CTBeHHOH llJaCUlieH MOryT pacnonaraTbCH KpynHble COcy,nbl II
HepBHble CTBonbI, ee pacceKalOT C yqeTOM HX xo,na. )],JISI: 3Toro C06CTBeHHYlO llJaCUlilO 3aXBaTbIBalOT
,nBYMH xlIpyprlIqeCKIiMII nllHueTaMII, nplIno,nHIIMalOT II CKanbneJIeM RITII HO:>KHlIuaMIi ,neJIalOT He-
60nblliOH Ha,npe3. )J;aJIbille B Ha,npe3 BBO,nRT >Ken060BaTbIH 30H,n II no HeM CKanbneneM npOII3BO-
,nHT paCCeqeHlIe c06CTBeHHOH llJacUIIII. 3TY MaHlInynHUHlO MO:>KHO npOlI3BeCTli TynoKOHeqHbIMII
HO:>KHlIuaMII, no,nBo,nH nOPQIIOHHO HII:>KHlOlO 6paHlliY HO:>KHIIU no,n llJaCUlilO. BCTpeqalOlI.{lIeCSI: no
Xo,ny pa3pe3a KpOBeHOCHble COCy,nbllI HepBbI c,nBliralOT B CTOPOHY. Pa3pe3bI Mb,mu, npOll3Bo,nHTCJ1,
rnaBHblM 06pa30M, napaJIneJIbHO Xo,ny IIX BonOKOH. Ho ropa3,n0 JIyqllie, no COBeTY 3HaMeHIITOrO
xlIpypra Koxepa, pa3pe3aTb TOJIbKO CYXO:>KIIJIIIH, a caMIi MbIIlIUbI pa3,D;enHTb TynbIM nYTeM. llpli
3TOM, CYll.{eCTBeHHbIM npe,nCTaBnHeTCSI: coxpaHeHlIe HepBOB, H.D:Yll{HX K MbIlliue, nOCKOJIbKY HX no-
Bpe)l(,D;eI-me COnpOBO)l(,D;aeTCH BnOCJIe,nCTBIIII aTpollJlIeH MblllieqHblX BonOKOH. Pa3,neJIeHlIe npSl:-
MbIX MbIlliU )l(IIBOTa 60JIee ueneco06pa3HO npOlI3BO,D;IITb B nOnepeqHOM HanpaBJIeHIIII. 3TO CBH3a-
p. ' ',l'; ' '&t'
"" q;, .,,>:,
..... -----. /';:.' . . ., .
. _. -' .r-...fr . ......
. ::" :'/I - .:
/( r ",",.' ..
. -,' (- \ . . ,'.
:'/' I , :.,.
. "". t J', .
:. . ;.',1 '/'" .
,,<' ; f{. . ':<
. ,',' '..... J:f:....
" " ,{./ /'
... .,'>; i- .
\. " \ . . i/ /. .
. .. , , ,_.' ::: ' -<. 0.
'" " " \ -: i" ':'
Puc. 1.21 HanpaeJ/eHue JIaHzepoecKux
JlUHUU. Pmpe3, nPOU3eeaeHlIbiU no
HanpaeJ/eHUIO 3mux JlUHUU, He 3URem
16
HO C OC06eHHOCTHMII HX IIHHepBaUIIII. HepBbl, IIHHepBlipYlOlI.{lIe npHMble MbIlliUbl :>KIIBOTa, pacno-
JIaralOTC5I B nOnepeqHOM HanpaBJIeHIIII, II eCJIIi pa3pe3 qepe3 3TII MbIIlIUbl neJIaeTCH napaJIJIeJIbHO
6eJIOH JIIIHIIH, TO BCe, qTO HaXO,nHTCH Me,nlIaJIbHee OT HerO, HeMlIHyeMo aTpollJlIpyeTCH. II03ToMY,
pa3,neJIeHlIe npHMbIX MbilliU B nOnepe'IHOM HanpaBJIeHlI1I B nOCJIe,nYlOli.\eM Be,neT K MeHbllllIM
1I3MeHeHIIHM B HIIX, qeM npli npo,nOJIbHblX pa3pe3ax. To >Ke caMoe OTHOCIITC5I II K m. piramidalis.
Ha 6plOlliHOH CTeHKe, KaK 1I3BeCTHO, HepBbI pacnonaralOTcH TO'IHO TaK >Ke - B nOnepeqHOM
HanpaBJIeHIIII, II TonbKO Ha cpe,nHeH JIIIHIIII, r,ne IIX HeT, MO:>KHO He onacaHCb pe3aTb B npo,nOJIbHOM
HanpaBJIeHHII.
)J;JIH KaqeCTBeHHoro OCMOTpa II MaHeBpHpOBaHII5I B paHe OqeHb Ba:>KHO c,neJIaTb a,neKBaT-
Hbrn pa3pe3. ,[{JIIiHa pa3pe3a ,non:>KHa COOTBeTCTBOBaTb npe,nnOJIaraeMOMY onepaTIIBHOMY nplI-
eMY. CJIlilliKOM ManeHbKlIe pa3pe3bI ,nOCTaBHT xlIpypry Hey,n06cTBa BO BpeMH npOBe,neHIIR BMe-
IlIaTeJIbCTBa. B 3TOM CJIyqae yroJI onepaQHOHHoro neiicTBHH (puc. 1.22) - yroJI, 06pa3yeMbIH
CTeHKaMIi paHbI, He60nbllioH. B Y3KOH paHe B03paCTaeT pliCK qTO-HII6y,nb nOBpe,nlITb. IIpli yrne
onepaulIoHHoro ,neHcTBIiR B 25° MaHlInynHUlI1I xlIpypra noqTH HeB03MO:>KHbI. 3TO oc06eHHO aKTY-
anbHO y naUlIeHTOB C O:>KlIpeHlIeM, Kor,na nPIIXo,nHT-
CH pa60TaTb B my60KoH paHe. I1plI CMeHe onepa-
UHOHHOH 06CTaHoBKH (06HapY>KeHIIII oc06eHHoCTeH
naTOJIOrnqeCKorO npouecca, BOBJIeqeHlIH cocenHIIX f1"---
opraHoB II T.n.) paUIiOHaJIbHOe pacIlIlipeHlIe paHbI
n03BOJIHT 1I36e:>KaTb 3Ha lJ.IITeJIbHOH TpaBMaTH3aUIIII
TKaHeH.
,[{JIlIHa IIHCTpYMeHToB ,non:>KHa COOTBeTCTBO-
BaTb rny6IIHe onepaUlIoHHoH paHbl.I1HCTpYMeHTbI
no ra6apliTaM He ,non:>KHbI nepeKpbIBaTb ;nOCTyn K
cy6cTpaTY onepaUIIII.
ABTOp He HBmeTCJI CTOpOHHlIKOM MHHHaTlOp-
HblX pa3pe30B, 3aTpy,nHHlOli.\IIX II, CJIe,nOBaTeJIbHO,
3aMe,nJIHlOli.\IIX onepaUlIlO, HO B TO:>Ke BpeM5I GqIITa-
eT Bpe,nHbIM «Ha BCHKIIH CJIyqaH» ,neJIaTb OrpOMHbIe
pa3pe3bI, npli KOTOpbIX 6plOlliHaH nOJIOCTb 6e3
nOJIb3bI OXJIa:>KJJ:aeTC5I II Ha 60nbiliOM npOTIl:>KeHIIII co-
nplIKacaeTCH C B03,nYXOM.
06bIqHO ,neJIaeTCH pa3pe3 cpe,nHeH BeJIHqlIHbl
II B CJIY'Iae Ha,n06HOCTIi YBenlIqlIBaeM ero B npouec-
ce onepaUIIII. Bo BCRKOM cJIyqae, YMIIHIITb pa3pe3
HIIKor,na He n03,nHO.
qT06bI C03,naTb npoCTOp ,nJIH MaHlInynHUIIH,
KpOMe a,neKBarnoro pa3pe3a, Ba>KHO aHaTOMlIqeC-
KII paUIiOHanbHO paCCTaBIITb KplOqKlI II paCllilipHTe-
JIH, paCTSl:flIBalOIUHepaHY (puc. 1.23). HecoMHeHHo,
B 3TOM cJIyqae KOMIlJOpT OnepaTHBHOrO BMelliaTenb-
CTBa onpeneJIHeTCH Haxo,n'IIiBOCTblO xlIpypra II xo-
pOlliliM 3HaHlieM aHaTOMIIII, ero YMeHlIeM 6blCTpO
pacn03HaBaTb TKaHIi II opraHbI, HaBbIKaMIi TaK pac-
THHYTh KpaH paHbI II npHTHHYTb nO,nBII>KHbrn opraH
Z \
_--,.,...u _
\-7-
Puc. 1.22 06"beKmUeHble Kpumepuu OlfellKU
onepamu611O;>0 aocmyna: L - allUlIa pallbl; h -
;>lly61ma paHbl; a - YZOll onepal.{uoHHOZO i>eu-
cm6UJ/; f3 - OCb onepalJUOHHOZO i>eucmeuJ/; f3"-
YZOll HaKllOlla ocu onepaljUOHHOZO aeucmeuJ/
"
..
PUC. 1.23 PacUiupenue o630pa paHbl
uHcmpYMeHmaMU n03eOllJ/em xupypzy Y6epeHHO
MaHunYllupoeamb
17
rnaBa 1
BMecTe C oKpY>KalOlI.{lIMIi TKaHHMII, lJ.T06bI c,neJIaTb MaKCIiManbHO 0603plIMbIMIi Bce MaHlInynHUIIII.
IIpli 3TOM OqeHb Ba:>KHO, qT06bI aCCIiCTeHTbI y,nep:>KIIBanli 3TII IIHCTpYMeHTbI IIMeHHO TaK, KaK IIX
YCTaHOBRIT XIIPYPr. IIo CYTII, aCCIiCTeHT ,non:>KeH KaK 6bI 3aMepeTb B ,naHHOM nOJIO:>KeHIIII. KaKoe-
nlI60 CMemeHlIe BeneT K nOTepe BII3yanbHoro KOHTpom Han onepaUlIoHHbIM noneM - xlIpypr Y:>Ke
HlIqerO He BIIJlIIT. ACCHCTeHTY ,nOCTII'lb HenO,D;BII:>KHOCTII JIerKO JIlillib B TOM CJIyqae, Kor,na onepa-
UIIOHHoe none XOpOlliO 0603p1IMO. Kor,na :>Ke B ycnoBIIHx TeCHOTbI II rny6IIHbI paHbI nOMOmHIIK
HlIqerO He BH.D:IIT, TO OH ,non:>KeH 06JIa,naTb ,nOCTaTOqHbIM onblTOM II XOpOlliliMIi npaKTII'leCKIiMIi
HaBbIKaMII, qT06bl HelI3MeHHO coxpaHHTb O,nHO II TO :>Ke nOJIO>KeHlIe IIHCTpYMeHTa. ECJIII aCCIiCTeHTY
nplIXO,D;IITCSI: y,nep>KIIBaTb IIHCTpYMeHT BbITHHYTOH PYKOH, TO OHa OqeHb 6bICTpO YCTaHeT II OnyCTIITCSI:
BHII3, IIJIII ,na:>Ke HaqHeT ,npO:>KaTb. B TOM CJIyqae, Kor,na y,nep:>KIIBaeTCH KpOBOOCTaHaBJIIiBalOlI.{lIH
3a:>KlIM, HanO:>KeHHbrn Ha He:>KHbIe TKaHII, RITII Ha He60nblliOH cocy,n, TO OH HenpeMeHHO 060PBeTCH.
II03TOMY OnbITHbrn aCCIiCTeHT, nplIHIIMaH y,n06Hoe nOJIO:>KeHlIe, BCer,na CTapaeTCSI: Ha O- HlI6y,nb
06nOKOTIITbCH. ,[{OCTlirHYTb YMeHHH y,nep:>KIIBaTh IIHCTpYMeHTbI II YMeJIO C HIIMII 06pall.{aTbcSI: BOBce
He TaK nerKO, KaK MO:>KeT nOKa3aTbCH C nepBoro B3rnMa. OnbIT aCCIiCTlipOBaHIiH nplIxo,nIIT CO
BpeMeHeM!
CaMbIM ynoTpe6nHeMbIM IIHCTpYMeHTOM ,nJIH pa3'be,nIIHeHIISI: TKaHeH nOCJIe CKanbneJISI: HB-
mlOTCH HmKHUl1bI. ITpli onepaUHHX Ha 6plOlliHOH nOJIOCTII HO:>KHlIuaMIi nPlIxo,nIITCH pe3aTb ropa3-
,no 60nbllie, qeM CKanbneJIeM, n03TOMY YMeHlIe nonb30BaTbCH 3TIIM IIHCTpYMeHTOM He06xo,nIIMO
Ka:>K,D;0MY xnpypry.
,[{JIH IICnOJIb30BaHliH Bcex npeliMYlI.{eCTB HO:>KHIIU BO BpeMH onepaUlI1I Hano, qT06bI ,nBII-
:>KeHIIH Ka>K,nOH 6paHllili np01I3Bo,nIIJIIiCb BnOJIHe C03HaTenbHO. 3TO B03MO:>KHO TonbKO B TOM
CJIyqae, eCJIIi HayqlITbCH ,nep:>KaTb HO:>KHIIUbI TaK, KaK 3Toro Tpe6YlOT npaBIIJIa onepaTIIBHOH
XIIPYPrHlI.
HO:>KHIIUbI II Bce IIHCTpYMeHTbI, YCTpoeHHbie no IIX THny, y,nep:>KIIBalOTCH CJIe,nyIOIUHM 06pa-
30M: 60nblliOH naneu npOBo,nIITCH B O,nHO II3 KOJIeu, cpe,nHIIH (Ill), a npli IICOOnb30BaHIIII ,D;JIIIHHbIX
IIHCTpYMeHTOB, HanpliMep, rIiHeKOnOrlIqeCKlIX, 6e3bIMSl:HHbIH (IV) - B ,npyroe KOJIbUO. YKa3aTenb-
HbIH naneu pa3Mell.{aeTCH Ha 3aMKe (oKono BlIHTa) (puc. 1.24). EJIaro,napH TaKoMY pacnOnO:>KeHIIlO
naJIbueB o,nHa 6paHlIIa Bcer,na OCTaeTCSI: IlJIIKclIpoBaHHoH TpeMH nanbuaMII, a ,npyraH ,D;BlIraeTCH C
nOMOIUblO 60nbllioro nanbua. 3TO cnoc06CTByeT OC03HanHbIM II TOqHbIM ,nBII:>KeHIIHM. Bcer,na KOH-
TpOJIIiPYeTCH KOHeu II HanpaBJIeHlIe ,nBlI)l(eHIISI: Ka)[GlOH 6paHIIIII. IIpliHUlilllIanhHbIX Pa3JInqIIH Me:>K.D:Y
3aXBaTaMli HO>KHIIU TpeMH II qeThIpbMH naJIbUaMli HeT. B 3TOM cJIyqae npaBIIJIbHOCTb onpe,neJIHeT-
CSI: nplIBblqKOH II OnhITHOCTblO xlIpypra. LITO:>Ke KacaeTCH 3aXBaTa HO>KHIIU II ,nPyrlIx IIHCTpYMeHTOB
TonbKO 60nblliliM (l) II YKa3aTenbHbiM (II) naJIbuaMII, TO
He06xo,nIIMO no,nqepKHYTb, qTO 3TOT 3aXBaT B XIIPYPrHlI
nplIMeHHTh HeJIb3H, TaK KaK OH He 06eCneqlIBaeT :>Kenae-
MOH yrrpaBJIjleMOCTII IIHCTpYMeHTOM.
HO:>KHIIUbl BBO,nHT B paHY C COMKHYThIMIi 6paHIlIa-
MH, II TOJIhKO npOOnlI3IIB IIHCTpYMeHT K pa3pe3aeMOH TKa-
HII, 6paHllili paCKpblBaIOT. TaKaSl: Mepa npe,nOCTOpO:>KHOC-
TII OqeHb Ba:>KHa, oc06eHHO npII MaHlInynlIpoBaHlI1I B
rJIy6IIHe paHbl, r,ne nOBpe)l(,D;eHlIe opraHOB HO:>KHlIuaMIi
BeCbMa peanbHO.
ct IIpli pa60Te C HO:>KHIIUaMli He06xonlIMO CTapaTbCH
Puc. 1.24 Cnoc06 yaep:J/CueauUJI HO:HCHUIj
nepeceKaTb He60nbllille TKaHeBbIe MaCCIiBbI. 3T0 nOMO-
:>KeT 1I36e:>KaTb Henpe,nHaMepeHHoro paCCeqeHIIH TKaHeH
........-....
,,-c ",""",,,'
.j.-- .",
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':of
c::s '-:-"'/ '\
.'<#" \i::::fr:"'---
-". . ,"..\.1 ; .J.' .
. '/ - ",,,,,"-. :.;>"_.",-
.
18
II nOBpe)l(,D;eHHH opraHOB. HeKOTOpble xlIpyprn H3JIlIllIHe YBJIeKalOTCH npliMeHeHlIeM HO:>KHIIU, npo-
II3BO,nSl: C IIX nOMOrnblO npaKTlIqeCKIi BCe pa3'be,nIIHeHIISI: TKaHeH. Ha Haill B3rnH,D;, TaKOe YBneqeHlIe
HeOnpaB,naHHO. He06xo,nIIMO nOMHIITb, qTO HO>KHIIUbI He TonbKO pacceKalOT TKaHII, HO II c,naBnlI-
BalOT IIX ell.{e,no MOMeHTa paCCeqeHIISI:. II03TOMY, qeM MaCCIIBHee IIHCTpYMeHT, 'IeM 60nbllie nJIO-
m.a,nb pe:>Kym.eH KpOMKII, TeM 3HaqlITeJIbHee ,nonOnHlITeJIbHaH TpaBMa. B CBH31I C 3TIIM, MbllliUbI,
CYXO)l(lIJIIIH, napeHXIIMaT03HbIe opraHbI pa3pe3aTb HO>KHlIuaMIi He peKOMeH.D:YlOT.
B3HB B PYKII HO>KHlIUbI, He06xo,nIIMO nOMHIITb nOCJIOBIIUY - ceMb pa3 OTMepb, pa3 oTpe:>Kb!
ECJIII n03BOJIHlOT CBOHCTBa TKaneH, xlIpypr MO:>KeT pa3LIenSlTb IIX mynbl.M nymeM. ,[{nH 6ec-
KpOBIIOro pa3,neJIeHUH KJIeT'IaTKII nonb3YlOTCH IIJIII nanbueM, 06epHYTbIM MapJIeBOH CaJIllJeTKoH,
RITII npenaplipOBaHlIeM .D:BYMH nHHQeTaMIi. 06a 3TII nplieMa OCHOBaHbI Ha TOqHOM 3HaHHII pacnOJIO-
:>KeHIIH KJIeTqaTKII II 6JIII3KIIX K HeH no CBoeMY CTpoeHlIlO II 1lJ1I3IIqeCKliM CBOHCTBaM llJacUIiH. ,[{JIH
anOHeBpo eCKIIX llJaCUIiH II CYXO:>KIIJIIiH llJIOCKIiX MbIIlIU TaKOH cnoc06 HenplIeMJIeM, TaK KaK OHII
no,nBep:>KeHbI pa3pbIBaM.
TynbIM nYTeM qaCTO pa3'be,l(UHHIOT cpall(eHHH B 6proWHOH nOJIOCTH, oc06eHHO Te, KOTopble
HanOMlIHalOT naYTIIHY IIJIII pblXJIYlO KlleTqaTKY (K npliMepy, npliparneHHH KIIIlIeqHIIKa). ,[{mI 3TOro,
nOCJIe Ha,npe3a cparneHIIH HO>KHlIuaMII, MapneH KaK 6bI CTlipalOT npliparneHHYIO neTJIlO KlilliKII.
I1Hor,na 3TO y,naeTCH c,nenaTb 6bICTpO II JIerKO.
CBe:>KlIe cpall.{eHIIH, erne npOnHTaHHbie 1lJ1I6p1IHOM, OTJIlIqalOTCH xpynKOCTblO II CBOIiMII 1lJ1I-
3IIqeCKliMli CBOHCTBaMIi HanOMIiHalOT Cblp. OHII Bcer,na COnpOBO)l(,D;alOT rHOHHbIe CKOnJIeHIIH. IIo-
3TOMY, pa3,neJIHH IIX, He06xo,nIIMO 6bITb rOTOBbIM K Bbl)JeJIeHlIlO rHOH.
CparneHIIH, KOTopbIe Henb3H pa3,neJIlITb naJIbuaMII, nepepe3alOT HO:>KHIIl.(aMlI (puc. 1.25).
3T0 y,n06Hee, qeM CKaJIbneJIeM, TaK KaK IIM MO>KHO pe-
3aTb TonbKO XOpOiliO BH.D:IIMbIe TKaHII, a HO:>KJIIIuaMli
MHoroe MO>KHO nepeCTplIlJ.b no nanbUY.
Pa3'be,nIIHeHlIe cparneHIIH B 6plOlliHOH nOJIOCTIi
Tpe6yeT OT xlIpypra, KpoMe cOBepIlIeHHoro Bna,neHIIH
BceMIi cnoc06aMli pa3,neJIeHIIH TKaHeH, ell.{e II Tepne-
HIIH. Ka)l(,D;brn pa3, Kor,na HaqnHaellib IIX OT,neJIjlTb, H.D:SI
cnepe,n1I Ha3aI( (Brny6b 6plOlliHOH nOJIocTH), 06parna-
eilib BHIIMaHlIe, o ,neJIO H.D:eT Me,nJIeHHO, He3aBIICliMO
OT Toro 6y,nYT 3TII CpameHIISI: nepepe3aTbCH IIJIII pa3,ne-
JIHTbCH rynbIM nyTeM. IIpouecc nOH,neT HaMHoro 6bICT-
pee II nerqe, eCJIIi y,naCTCH npOHIiKHYTb nanbueM B rny-
6IIHY II HaqaTb OT,neJIeHlIe C3a,n1I Hanepe,n (K nepe,nHeH
6plOiliHOH cTeHKe). IIpli 3TOM O'IeHb qaCTO OKa3bIBaeT-
CSI:, qTO Ha naJIbue OCTaeTCH Oqenb HeMHoro TKaHeH,
KOTopbIe nY>KHO nepepe3aTb HO:>KJIIIuaMH, Tor,na KaK,
H.D:H B 06parnoM HanpaBJIeHIIII, pa3pe3aTb nplIXo,nIITCH
Ha ropa3,n0 60nbilleM npOTH:>KeHIIII. IIpOIICXO,n1IT 3TO
nOToMY, qTO MHorlie opraHbl, C KOTOpbIMIi nplIxO,D;IITCSI
IIMeTb ,neno, OqeHb paCTH:>KIIMbl II cparneHIIH C
PUC. 1.25 Pa3pe3aHue HO:JIClIUlJaMU eHympu-
6PlOUlUHHblX cnaeK. Haape3ae 6plOUlUHy, KUUlKY
np06YlOtIl OmaeRUmb mynblM nymeM. J1Umb e
mOM CRY'lae, eCRU :Jmo CaeJlllmb 1le yaaemCJl,
HO:JICIIUljaMU nepecmpuzalOm eclO mORUjY
cpaUje1lUU
19
rnaBa 1
HIIMII MOryT Ka3aTbCH 06lliIIPHbIMIi. fIo,nHIIMaH Cpall.{eHIIH cornYTblM nanbueM C3a,n1I Hanepe,n, IIX
C06IIpalOT BMeCTe. B 3TOM cnyqae OHII pacnOJIaralOTCH Ha nanbue HeCKonbKIIMIi CJIOHMII. Bce
60JIee CJIa6bIe II He:>KHble Cpall.{eHIIH npli 3TOM pa3pbIBalOTcR TeM :>Ke naJIbueM. OCTalOTcH TOJIbKO
60nee DJIOTHble, KOTopble Hy:>KHO nepepe3aTb HO:>KHlIuaMIi.
I1Hor,na B03HIIKaeT HaL{06HOCTb nepeCTplIqb HO:>KHlIuaMIi no naJIbUY nJIOTHoe Cpall.{eHlIe,
ne:>Karnee B rJIy6lIHe. 3THM nplieMoM MO>KHO cpa3Y 1I3MeillITb no,nBII:>KHOCTb Toro, qTO C06IIpalOTCH
y,nanHTb. O,nHaKo qT06bI nepepe3aTb C03HaTeJIhHO, He06xo,nIIMO C06JIlOCm HeKoTopble npe,nocTo-
pO:>KHOCTM. B npoTIIBHOM cJIY'Iae MO:>KHO OTCeqb TO, O He:>KeJIaTeJIbHO.
IIpli He06xo,nIIMOCTIi nepepe3aTb qTO-HII6y,nb no nanhUY 6e3 KOHTpom 3peHIIH, He06xo,nlI-
MO:
- TOqHO 3HaTb, O IIMeHHO 6y,neT nepepe3aHO (HanpliMep, OT'IeTnIIBO Oll.{yll.{aTb OCTpbIH
KpaH DJIOTHbIX py6UOBbIX cparneHIIH);
- KOHUbI HO:>KHIIU Becm He TonbKO no nOBepXHOCTIi nanbua, HO II TaK, qT06bl OHII nOMell.{a-
nlICb Me)l(,D;y naJIbuaMIi II TeM opraHOM, KOTOpbIH HII C qeM cnyTaTb HeJIb3S1:, II KOTOpbIH nopaHIITb
HeonaCHO.
B TOM cnyqae, eCJIIi nplIlUITO pellieHlIe 06 YCTpaHeHHH cnaeK MeTo,nOM JIanapOCKonHH, IIX
pa3,neJIeHlIe II YCTpaHeHlIe ,nellJoPMaUIiH Klillie bIX neTeJIb npo1I3Bo,nIITCSI: pa3HbiMli cnoc06aMIi.
HalI60nee 6e30nacHbIM HBnHeTCH paCCeqeHlIe cnaeK OCTpbIM nYTeM - HO>KHlIuaMIi 6e3 IICnOnb30-
BaHIiH 3neKTpoKoarYJIHUlIli IIJIII nocne npe,nBapliTenbHoro KJIlInlipOBaHIiH 06JIaCTli cocy,na. 3TII
nplieMbI C ycnexoM IICnOJIb3YlOTCSI: npli DJIOCKOCTHblX II lliHypOBlUIHblX cnaHKax, co,nep:>KaIUIIX JIIIIlIb
KanlIJIJIHpbl. fIepe,n nepeCeqeHlIeM cnaeK C xopoilieH BacKYJIHplI3aUlieH He06xo.D:IIMa 3neKTpoKo-
arymUlIH.
B JI1060M CJIY'Iae ,nJIH 60JIee 6e30nacHoro pa3,neJIeHlIH cnaHKY He06xo,nIIMO paCTHHYTb. 3TO
nerqe c,neJIaTb, IIcIIonb3YSl: ,nononHIITenbHO 3a:>KIIM IillII ,npyroH IIHCTpYMeHT.
,[{JIH pa3'be,nIIHeHIIH TRaHeH npli nanapoToMlI1I ,nOBOJIbHO qaCTO nOJIb3YlOTCH nHHQeTOM.
IIHHUeTbI MR YKa3aHHoH ueJIIi ,non:>KHbI 6blTb aHaTOMlIqeCKIiMli II ,nOCTaTOqHO MIIHHbIMII, npnro,n-
HblMIi ,nJIH pa60Tbi B rJIy6lIHe. fIplIqeM qeM rny6:>Ke B paHe nplIxo,nIITCH MaHlInYJIlipOBaTb, TeM
';::';::'lUlliee IIHCTpYMeHT He06xo,nIIMO BbI6paTb.
II paBIIJIbHO cJIe,nYeT ,nep:>KaTb nliHueT - KaK nlIcqee nepo. Ee3bIMHHHblH naJIeu II MII3IIHeu
npli 3TOM ,non:>KHbI Ha qTO-HH6y,nb OnlipaTbCH. B npoTIIBHOM cJIyqae JIerKO 060pBaTb TO, qTO y,nep-
:>KIIBaeTCH, oco6eHHO, eCJIIi y,nep:>KlIBaTb nplIxo,nlIT-
CSI:,nOJIro. TonbKO npli TaKOH IlJIIKcaUlI1i nliHueTa
B03MO:>KHbI TOqHble MaHHnYJIsrUIIII. ECJIII aCCIiCTeHT
IIJIII xlIpypr He npliBbIK npaBIIJIbHO ,nep:>Ka Tb nllH-
ueT II 6epeT ero cBepxy, KaK CMbl'lOK, nOMell.{aR
DJIaCTIIHKII Ha na,nOHb, TO OH 06peKaeT ce6H Ha He-
KOOp,nIIHlIpOBaHHble ,nBII:>KeHHH II qaCTble 06PblBbi
He:>KHbIX TKaHeH (puc. 1.26).
XOpOIlIIIH DlIHUeT ,non:>KeH 6bITb MHrOK C MII-
HIiManbHhIM conpOTIIBJIeHlIeM K C:>KaTlilO.
06paTliTe BHIIMaHlIe Ha TO, 'ITO nliHueT
npe,nHa3Ha qeH ,nJIH IlJIIKCaltlI1I TKaHeH II 06'beKTOB,
KOTopble II3MepRlOTCH MRITJIlIMeTpaMII. l1.mI 3aX-
II . C I
Puc. 1.26 3axeam nUHlJema eceu KucmblO npueoaum K
ympame mo'lHOcmu a6U.J/CeHUU
20
BaTa :>Ke TKaHeH TOJIIUIIHOH 60nbille CaHTIiMeTpa, paUIiOHanb-
Hee IICnonb30Ba Tb JIpyrlIe IIHCTpYMeHTbI.
Y,nep:>KIIBaH TKaHIi nIiHueTOM, He06xo,nIIMO IICnOJIb30-
BaTb BClO pa60qYIO DJIOIUa,nb 6paHIlIeH IIHCTpYMeHTa.l1pII 3TOM
CIiJIa c,naBlleHIIH pacnpe,neJIHeTCH Ha 60JIbilieH nJIOIUa,nlI, qTO
n03BOJIHeT 1I36e:>KaTb JIOKanbHOrO (TOqe<IHOrO) TpaBMlIpOBa-
HIIHTKaHeH (puc.1.27).
XlIpyprnqeCKlie nlIHUeThI, yqlITbIBaH IIX KOHCTpYKTHB-
HYIO OC06eHHOCTb, - CXO,nHlI.{lIeCH 3y6Ubl Ha 6paHiliax HHCTpy-
MeHTa, npeJIHa3HaqeHbl ,nJIH npoqHOrO y,nep:>KIIBaHIiH nJIOT-
HblX TKaHeH (HanpIiMep, KO)l(lI, anOHeBp03a, CYXO)l(lillIIH II T.n.).
I1pII 3TOM He06xo,nIIMO nOMHIITb, qTO OHH HaHOCHT TKaHHM
3HaqlITeJIbHYlO TpaBMY. He,nonYCTHMO IICnOJIb30BaHIIe 3TIIX
IIHCTpYMeHTOB.D:JIj{ y,nep:>KIIBaHIiH nOJIblX opraHOB, MblIlIU, CO-
Cy,nOB, HepBOB II T.n.
/; 0
, y "
1 / ;12 ' ";1,'
-< -
- ,..,,.
1]< \<..\"
. I {f\,
Puc. 1.27 3axeam mlWHeu eceu
pa60'leu noeepXHocmblO 6pallUleii
nUHtfema n03eOJlJ/em u36e:JICamb J101WJlb-
HOi!O (mo'le'llloi!o) mpa6MUpOeallUJI
IIP ABI1JIA OCT AHOBKI1 I1HTP AOIlEP AI..J.110HHOrO KPOBOTEQEHI1S1
Pa3pe3aH TKaHII, xlIPypr, HeCOMHeHHO, CTOJIKHeTCH C KpOBOTeqeHlIeM. KpOBOTeqeHlIe BO
BpeMH onepaUlI1I CTaHOBIITCH OCJIO:>KHeHHeM TOJIbKO Tor,na, Kor,na ero IIHTeHCIIBHOCTb HeB03MO:>K-
HO KOHTpOJIlipOBaTb 06bIqHbIMli nplieMaMIi (HanpIiMep, npoMoKaHlIeM) RITII Kor,na He BH,D;eH ero
IICToqHIIK. ECJIII :>Ke OCJIO:>KHeHlIe HacTynlIJIO, OqeHb Ba:>KHbI npaBIIJIbHble, 6bICTpbIe, TOqHbie ,neH-
CTBHH xlIpypra II BceH onepaUIIOHHOH 6plIra,nbI. HII B KoeM CJIyqae HeJIb3H TepHTbCH, TaK KaK Bpe-
MeHHOH llJaKTop B 3TOH 06JIacTII xnpyprlIli qpe3BblqaHHO Ba:>KeH.l1pOMeMeHlIe MO:>KeT npliBeCTIi K
HenonpaBIiMbIM nOCJIe,nCTBIIHM.
KpOBOTeqeHIIH, OCJIO:>KHHlOIUlie onepaUlIlO, MorYT 6bITb apTepHaJIbHbIMH H BeH03HbIMH.
ApTeplIaJIbHOe KpOBOTeqeHlIe CJIyqaeTCH pe,nKO. ,[{AA ero B03HIIKHOBeHIIH He06xo,nIIMO paHeHlIe
KpynHoro KpOBeHOCHoro cocy,na. B TOM cJIyqae, Kor,na IICTOqHIIK KpOBOTeqeHIIH qeTKO onpe,neJIeH,
ero JIIIKBH,D;IIPYIOT 3aIlIliBaHlieM paHbl COCy,nIICTbIM IlIBOM. ECJIII:>Ke xlIpypr ,nlIarHocTHpyeT apTeplI-
anbHoe KpOBOTeqeHlIe, HCTOqHIIK KOToporo He COBceM nOHHTeH, He06xo,nHMO ,n06IITbCH BpeMeHHoii
OCTaHOBKH KpOBOTe'leHHH. l1epBbIM ,neHCTBlIeM, OKa3blBalOlUllM nOMOilib 60JIbHOMY, HBJIHeTCH nplI-
:>KaTlie KPOBOTOqaIUerO MeCTa K 6JIII:>KaHllieH KOCTII.
PaCCMOTpIIM, K npliMepy, KpOBOTeqeHlIe, B03HIIKllIee B 06JIacTII Ta3a, KOTopaH, KaK II3BeCTHO,
06RITbHO KpOBOCHa6:>KaeTcSI:. .ZJ:JIH BpeMeHHOH OcTaHOBKII TaKoro KpOBOTeqeHIIH He06xo,nIIMO nplI-
:>KaTb aopTY K n03BOHO OMY CTOJI6y. I1pII npaBRITbHOM npOBe,neHlIlI 3Toro nplieMa BCHKoe KpOBOTe-
qeHlIe B Ta3y,non:>KHO npeKpaTlITbCH. I1plI)KaTlie aOpTbI np01I3Bo,nmCH B MeCTe, pacnOJIO:>KeHHOM BbIllie
,neJIeHIIH 3Toro cocy,na II H1I:>Ke OTXO)l(JIeHIIH nOqeqHbIX apTepIIH. AopTa npH,D;aBJIIiBaeTCH C nOMOIUblO
MapJIeBOrO KOMnpecca K n03BOHoqHIIKY ,no OKOHqaTeJIbHOrO 3aKpbITHH ee npOCBeTa. ECJIII Ha,naBJIH-
BaTb CHJIbHO, TO PYKII YCTaIOT, a nanbUbI HeMelOT. OqeHb CKOpO B03HIIKaeT nOTpe6HOCTh B nepeMeIUe-
HIIII PYK, qTO, HeCOMHeHHO, 6y,neT cOnpOBO>KlIaTbCH peWUlIIBOM KpOBOTeqeHlIH.
I1plI:>KaTlie aOpTbI n03BOnHeT OqlICTIITb nOJIe onepaUlI1I OT KpOBIi II crYCTKoB. 3aTeM, OCMOT-
peB paHY, MO:>KHO OTbICKaTb KPOBOTOqall.{lIe MecTa, HanO:>KlITb Ha HIIX 3a:>KIIMbI, KOTopble nOTOM
3aMeHHIOT JIliraTypaMIi.
21
rJIaBa 1
Y cnex onepaUlI1I BO MHorOM 3aBHCIIT OT YMeHIIH xIIpypra (acclicTeHTa) 6bICTpO npoMoKaTb
KpOBb, 3aJIliBalOIUYlO onepaUlIoHHYlO paHY. KaK npaBRITO, 3TO ,neJIaeTCH O,nHIIM qeTKIIM ,nBII:>KeHII-
eM.l1ocJIe npoMoKaHIiH KpOBIi He06xo,nIIMO pe3Ko y6paTb TaMnOH C onepaUIIOHHoro nOJIH, 06bI
BHIIMaTeJIbHO paccMoTpeTb IICTOqHIIK KpOBOTeqeHIIH II HaJIO:>KIITb KpoBooCTaHaBJIIiBalOIUIiH 3a-
:>KIIM RITII JIlirarypy.
JIumTypoil (puc. 1.28) Ha3blBalOT HIITb, HanO:>KeHHYlO Ha KpoBeHocHblH cocy,n IInII ,npyroil
nOJIbIH opraH ,nJIH CY:>KeHIIH ero BHYTpeHHero npOCBeTa. KpOBeHOCHbIH cocy,n RITII nOJIbIH opraH, Ha
KOTOpbIH HaJIO:>KeHa JIliraTypa, Ha3blBaeTCH JIUrupyeMblM cocy-
J].OM (opraHOM), a caMa npoue,nypa HaJIO:>KeHIIH JIlirarypbI - RU2U-
pOeGllUeM COCYOG (opraHa) RITII npOCTO nepeBH3KOH. IIpliMeHe-
Hlie nliraTypbl B XIIPypflIli CBH3aHO C IIMeHeM IlJpaHUY3CKoro
xlIpypra AM6pya3a l1ape (1509-1590). OH BnepBble BMeCTO ne-
peKpyqIIBaHIiH RITII nplI:>KlIraHIiH COCy,nOB npli aMnYTaUIIHx IIC-
nonb30Ban nepeBH3KY COCy,nOB HIITHMII.
KpOBOTOqaIUlIe COCy,nbl B paHe 3aXBaTblBalOT 3a:>KIIMaMIi.
)J;ml nepeBH3KII cocy,na aCCIICTeHT BHaqaJIe no,nHIIMaeT KpOBOOC-
TaHaBJIIiBalOlI.{IIH 3a:>KIIM, YCTaHaBJIIiBaeT ero nepneH,nIIKYJISl:pHO
Puc. 1.28 JIuzamypa K TKaHHM, a xlIpypr npoBo,n1IT no,n KOHUOM 3a:>KIIMa JIliraTypHYlO
HIiTb. 3aTeM npli 3aBH3blBaHIIII II 3aTHrlIBaHIIII nepBoH neTJIIi
Y3JIa, ,nJIH npe,nynpe)l(,D;eHIIH COCKaJIb3blBaHliH JIlirarypbI, aCCIiCTeHT nplIno,nHIIMaeT KOHeu 3a)l(lI-
Ma C COCy,nOM Ha,n TKaHHMII (nplIno,nHIIMaeT «HOCIIK» 3a:>KIIMa). 110cJIe 3aBH3bIBaHliH nepBOH neTJIII
Y3JIa CHIIMalOT KpoBoOCTaHaBJIIiBalOIUIiH 3a:>KIIM II OKOHqaTeJIbHO 1lJ0pMIIPYlOT Y3eJI. 113JIIIIlIKII
HIITII OTCeKaIOT.
1130JIIIpOBaHHaH JIliraTypa COCy,nOB ,neJIaeTCH no 06IUIIM npaBRITaM onepaTIIBHoH xHpyprlIli.
KOHeu cocy,na IlJIIKclipyeTcH ,nBYMH nliHueTaMIi II 3aTeM 3aBH3bIBaeTCH. Bo BpeMH 1I30JIlipOBaHliH
3TOT KOHeu y,nep:>KIIBaeTCH C nOMOIUblO KpoBooCTaHaBJIIiBalOIUero 3a:>KIIMa aCCIiCTeHTOM. Bnpo-
qeM, TaKoe 1I30JIIIpOBaHIIe nplIMeHHeTcH pe,nKo. 06bIKHOBeHHo 3aBH3blBalOT Bce TO, qTO 3aXBaqe-
HO KpOBOOCTaHaBJIIIBalOIUIIM 3a:>KIIMOM. ECJIII apTeplIH MaJIeHbKaH, TO B nOCJIe,nCTBIIII OCJIO:>KHeHIIH,
KaK npaBRITO, He Ha6mo,nalOTCH. B cnyqae MaHlIrrYJIHUIIII na KpyrrHoM cocy,ne (narrpIIMep, a.uterina
npII rliHeKOJIOrlIqeCKIiX onepaUlIHx) IICTIIHHOe 1I30JIHpoBaHlie OIJeHb He06xo,nIIMO.
IIpli 3aBH3blBaHIIII JIliraTYP, HaJIO:>KeHHbIX Ha 1I30JIlipOBaHHble COCy,nbl, Y3nbI peKOMeMYeT-
CH 3aBH3blBaTb HaCTOJIbKO Tyro, qT06bI intima apTepliH nepepe3aJIaCb II TeM caMbIM 06ecneIJIIBa-
JIlICb xopoume YCJIOBIIH.D:Jlj{ 06pa30BaHliH TpoM6a. TeopeTlIqeCKH 3TO cOBepIlIeHHo BepHO, HO npaK-
TlIqeCKII,nonycKalOTcH IICKJIlOIJeHIIH. K npllMepy, npII aTepocKllepOTIIqeCKOM nepepO:>KlIemfil COCy,nOB
Tyro HaJIO:>KeHHaH nlIraTYPa MO:>KeT «nepeKYCIITb» cocy,n II ero nplI,D;eTCH CHOBa nepeBH3bIBaTb.
He3aBIICIIMO OT Toro, TOHKaH RITII TOJICTaH B3HTa HIITKa, npli T)'rOM HaKlla;::(bIBaHIIII nlIrarypbI
en masse MO:>KeT npOlI30HTli nepepe3aHlie TKaHeH. 3TO npOIIcxo,nIIT He TOJIbKO cpa3Y nOCJIe 3aBH-
3bIBaHIIH, HO II cnYCTSI: HeKOTopoe BpeMH. B03MO:>KH0, qTO nplIqflHOH 3Toro HBJIHeTCH aCenTlIqeCKaH
BOCnaJIIITeJIbHaH peaKUIIH, KOTopaH conpOBO)l(,D;aeTCH OTeKOM.
I1plI nepeBH3bIBaHIIII TKaHeH (06bIqHO He CJIIIIlIKOM ryro) 60JIbiliOe 3HaqeHIIe IIMeeT XOpO-
IIllIH II Ha,ne:>KHbIH Y3eJI. KaK npaBRITO, JIliraTypa He IlJYHKUIiOHIiPYeT no .D:BYM np"qIIHaM: RITII Y3eJI
OCJIa6eBaeT, RITII npOlI30H,neT npope3aHlie TKaHIi. COCKanb3bIBaHlie JIIIraTypbI BO BHIIMaHlie He
6epeTCH, nOCKOJIbKY OHO MO:>KeT CJIyqlITbCH JIlIlllb BO BpeMH onepaUIIII. B nOCJIeOnepaUIIOHHOM
neplIo,ne TaKlie CJIyqalI npaKTlIqeCKIi He OTMeqalOTCH, oc06eHHO eCJIII 06pall.{aTb BHIIMaHlie Ha
npaBRITbHbIH BbI60p HIITeH, 1I36eraTb CTHrlIBaHIiH 60nbllioro KOnlIqeCTBa TKaHeH II 3aBH3bIBaHIIH
22
IlIlipOKIiX HO:>KeK. CaMa no ce6e XOpOiliO 3aBH3aHHaH JIlIraTypa OCJIa6IITbCH He MO:>KeT II3-3a BOC-
nanlITeJIbHOH peaKUIIII, COnpOBO)l(,D;alOIUeHCH OTeKOM TKaHeH. IIo 3TOH nplIqnHe JIliraTypa, cnYCTH
HeKOTopoe BpeMH, MO:>KeT CTaTb JIIIIlIb 60JIee TyrOH. I1CKJIlOqeHlIe COCTaBAAlOT KeTrYTOBble HIITII.
I1x pa3MOKaHlie B paHe nPIiBOlIlIT K YBeJImeHlIlO paCTH:>KIIMOCTII.l1plI npOBe,neHIIII xlIpyprwlecKIIX
MaHlInYJIHUIiH 3TO ,no onpe,neJIeHHOH CTeneHII ,na:>Ke :>KeJIaTeJIbHO, TaK KaK «n03BOnHeT» TKaHHM
OTeKaTb OT BOCnaJIIITeJIbHOH peaKUIIII' O,nHaKO, eCJIIi BMeCTe C TKaHHMII 3aXBaqeH 60JIbiliOH cocy,n,
TaKoe OCJIa6JIeHIIe MO:>KeT nplIBeCTIi K KpOBOTeqeHlIlO. II03TOMY 3aBH3bIBaTb KeTryTOBOH HHTblO,
oc06eHHO TOJICTOH, He peKoMeMyeTCH.
MHor,na HaJIO:>KIITb JIliraTYPY He npe,nCTaBnHeTCB B03MO:>KHbIM II nplIxo,nIITCH npOIUHBaTb
KpOBOTO'IaIU:Ce MCCTO. ,[{JIH 3Toro HaKJIalIblBaIOT norpY:>KHOH lliOB, IIJIII IlIOB, npoxo,nHIUliH Qepe3
K0:>KY, CJIII3IIcrylO RITII Cep03HYIO 060JIOqKII. B 0601IX cnyqaHX, B CYiliHOCTII, nOJIyqaeTcH JIliraTypa en
masse.
06KanblBaHIIe norpY:>KHbIM IlIBOM, KaK npaBIIJIO, nplIMeHHeTCH Ha 60JIbIlIliX cocy,nax, nplI
onaCHOCTlI COCKanb3blBaHliH npOCTOH JIliraTypbI RITH nepepe3aHliH cocy,na BCJIe,nCTBlIe xpynKoCTII,
BbI3BaHHOH aTepOCKllep030M. He60JIbllilie COCy,nbI 06KaJIbIBalOT nllilib B Tex CJIyqaHX, eCJIli OHII
CJIIIIIIKOM MaJIbl,nJIH IIX OT,neJIbHOrO nepeBH3bIBaHlIH, a OT c,naBJII1BaHIiH KpOBOOCTaHaBJIIiBalOlI.{lIM
3a:>KIIMOM KpOBOTeqeHlIe He npeKpaTIIJIOCb.
He06xo,nIIMO 3anOMHIITb KaK 06IUee npaBIIJIO, qTO nlirarypbI HaKJIa,nblBalOTCH TOJIbKO Ha
KPOBOTOqaIUlIe COCy,nbI. HeT HIiKaKoro OCHOBaHlISI: roIH JIlirlipOBaHIiH Tex H3 HIIX, KOTopbIe He KpO-
BOTOqaT, II KPOBOTOqlITb He MorYT.1103TOMY, rrepeBH3bIBaTb CJIe,nyeT JIIIIlIb apTeplIll.l1epeBH3bI-
BaTb BeHbl (,nmI OCTaHOBKII BeH03Horo KpOBOTeqeHIIH) He06xo,nIIMO TOJIbKO B IICKJIlO'IHTeJIbHblX
CJIyqaHX: 1) C ueJIblO npollJRITaKTHKII B03,nYlliHOH 3M60JIIIII - BeHbl llielI; 2) C ueJIblO rrpe,nynpe>K,lJ,e-
HIIH IIHllJeKUlIoHHoro pacnpOCTpaHeHIIH - BeHbI Ta3a; 3) npli 3KcTlipnaUIIII nOqKII ueJIeC006pa3Ho
JIlirlipOBaTb vena rena1is; 4) nPII 3KCTIIPnaUIIII CeJIe3eHKII - vena 1ienalis; 5) npli paHeHlI1I - venae
iliacae intemae RITII venae i1iacae communis. B nOCJIe,nHeM CJIyqae HaKJIa,nblBaeTCH npliCTeHOqHaH
JIliraTypa TOqHO TaK :>Ke, KaK Ha llieHHblX BeHax.
C ueJIblO reMOCTa3a HeT HIiKaKoH He06xo,nIIMOCTIi nepeBSl:3blBaTb ,npyrlIe BeHb!. ,[{a 3T0 II
nOHHTHO: eCJIIi apTeplIlI, rrpliHocHIUlie KpOBb K 3THM BeHaM nepepe3aHbI IIJIII nepeBH3aHbl, TO
KpOBb B HIIX Y:>Ke He nocTynaeT, a 3HaqHT, KpOBOTeqeHHH 6bITb He MO:>KeT. 06paTHbIH TOK KpOBli B
BeHax conpOBO)l(,D;aeTCH KpOBOTeqeHlIeM TOJIbKO B BblllienepeqlICJIeHHbIX cocy,nax.
MeTo,nLl OCTaHOBKH BeH03Horo KpOBOTC'ICHHH 1I3 nepepe3aHHbIX CTBOJIOB oc060ro orrlI-
CaHHH He Tpe6YlOT: 3TO ,neJIaeTCH no 06l1.{IIM npaBRITaM, C nOMOll.{blO JIlirarypbI RITII 06IIIIIBaHHH. IIplI
paHeHlI1I KpynHbIx BeH, HaqlIHaH C vena iliaca communis, nepeBH3blBaTb COCYlIbI HeB03MO:>KHO.
ECJIII :>Ke KpOBOTeqeHlIe He OCTaHaBnlIBaeTCH OT JIerKOH TaMnOHaUHII, peKoMeMyeTcH HanO:>KIITb
npliCTeHOqHYlO nlirarypy, RITII 3aIIIIITb nOBpe>K,lJ,eHlIe TOHKOH H1ITblO COCy,nllCTbIM IlIBOM.
qpe3BbIqaHHO onaCHO IlJIIKclipoBaTb 60KOBoe nOBpe>K,lJ,eHlIe BeHbI KoxepOBCKIiM 3a:>KIIMOM
RITII JI106bIM ,npyrlIM IIHCTpYMeHTOM C OCTpblMIi KOJIlOIUIiMIi 6paHillaMIi. IIpli 3TOM npOlIcxo,nIIT
,nOCTaTOqHO CIIJIbHOe nOBpe)l(,D;eHlIe II ero nplIXO,D;IITCH nepeXBaTblBaTb rny6:>Ke. HaKlla,nbIBaeMaH
JIlirarypa MO:>KeT CYIUeCTBeHHO YMeHbilllITb npOCBeT cocy,na. II03TOMY ,nJIH IlJIIKcaUlI1I 60KOBblX
nOBpe>K,lJ,eHIIH BeH npe,nnOqTHTeJIbHee nOJIb30BaTbCH cneUlIanbHblM IIHCTpYMeHTOM RITII, B KpaHHeM
CJIyqae, KopHuaHrOM.
110CJIe HaJIO:>KeHHH IlIBa RITII JIlIraTypbI npOCBeT neplIllJeplIqeCKOrO KOHua BeH nepeCTaeT
3IIHTb II cnaBIlIaHCH intima 3TIIX COCy,nOB CKOpO cpaCTaeTCH B pe3YJIbTaTe aCenTlIqeCKOrO BOCnaJIe-
HIIH. HanO:>KeHlIe JInraTypbI Ha neplIllJeplIqeCKIIH KOHeu BeHbI, KaK Y:>Ke 6blJIO CKa3aHO, COBepIlIeH-
HO 1I3JIlIIlIHe, TaK KaK nplIBo,nHlI.{lIe apTeplI1i Y:>Ke nepepe3aHbI. B npOTIIBHOM CJIyqae 3aBH3bIBaHlie
23
rJIaBa 1
ueHTpaJIbHOrO KOHua BeHbl MO:>KeT TOJIbKO YCRITIITb KpOBOTeqeHlIe, nOCKOJIbKY npli 3TOM JIerKO
c,naBJIIIBaIOTCH aHaCTOM03bI, JIe:>KaIUlie fJIy6:>Ke. KpOBb, KOTopaH cB060rom no HHM npoTeKana BBepx
B CIiCTeMY venae cavae, HanpaBJIHeTCH B 60KoBbIe BeTBII, KOTopbIe HaqnHaIOT KPOBOTOqIITb, eCJIII B
HIIX HeT 3aCJIOHOK (HanpIiMep, Ta30Bbie BeHbl).
He:>KeJIaTeJIbHO II 061111IBaHlie BeH. 3TO qpeBaTo npOKOJIOM He60JIbiliOH BeTOqKII. XOTH KpO-
BOTeqeHlIe II He HaIJHeTCH, HO MO:>KeT IIHIIUlIlipOBaTbCH 06pa30BaHlie TpOM6a, a BnOCJIe,nCTBIIII
ph1egmatia alba d01ena, T.e. TpoM6 Y:>Ke 60JIbiliOH BeHbl.
Bee :>Ke, npli He06xo,nIIMOCTII HaJIO:>KeHIIH JIliraTypbI, OqeHb Ba:>KHO nOMHIITb: qeM TOHbille
HaKJIaJ];blBaeMaH JIllrarypa, TeM nyqIDe (ocTaeTcH IIHOpo,nHoe TeJIO MeHbiliero 06'beMa). Ho, B TO:>Ke
BpeMH, TOHKlIe H1ITII Hepe,nKO pBYTCH. n03TOMY OqeHb Ba:>KHO HaHTIi HIITb, TonIUIiHa KOTOpOH onTII-
ManbHO COOTBeTCTBOBaJIa 6bl onepaTIIBHOMY nplieMY. B 3TOM npOHBJIHeTCH rpaMOTHOCTb xlIpypra.
Bo BpeMSI: JIanapOCKOnlIqeCKOrO BMeIlIaTeJIbCTBa, KpOMe npoqlIX npaBIiJI rOMOCTa3a, OqeHb
Ba:>KHO oueHlITb KpOBOnOTeplO..ZJ:nsr TIoro He06xo,nHM HeKOTopbIH OnbIT. C O,D;HOH CTOpOHbI, YBeJIlI-
qeHlIe BH.D:eOII306pa:>KeHIIH C03,naeT 06MaHqlIBOe BneqaTJIeHlIe 06IIJIbHOrO KpOBOTeqeHIIH, XOTH
OHO He3HaqlITeJIbHO.
C ,nPyroH - KpOBOTeqeHlIe BO BpeMH JIanapOCKonlIlI, ,na:>Ke caMoe He60JIbIlIOe, HIIKor,na He
C)Jf,,nyeT He,nooueHIIBaTb. Hea,neKBaTHaH oueHKa 06'beMa KpOBonOTepII II II3JIIIIlIHHH caMOHa,ne-
HHHOCTb MorYT npliBeCTII K nOTepe ,nparoueHHoro BpeMeHII. Ey,neT ynYll.{eH IlIaHC MH CBoeBpeMeH-
Horo nepexo,na K JIanapOTOMHII.
IIpll OCTaHOBKe KpOBOTeqeHIIH BO BpeMH JIanapOCKOnlIIJeCKIIX onepaUIiH pacnpOCTpaHeH-
HblMIi OIlIII6KaMli HBJIHlOTCH «CJIenoe» KlllIlllIpOBaHlIe, 3axBaTblBaHlie TKaHeH 3a>KHMOM RITII Koary-
JIHUIIH 6e3 qeTKOrO BII3yanbHoro KOHTpOJIH.
OCTaHOBKY KpOBOTeqeHIIH CJIe,nyeT npOlI3Bo,nIITb TOJIbKO npll HeCOMHeHHOH BII3yanbHoH
H.D:eHTIIIlJIIKaUIIIi II aKKypaTHoro OTBe,neHHH IICTOqHIIKa KpOBOTeqeHIIH OT OKpY:>KalOlI.{IIX TKaH( H.
06ecneqnTb a,neKBaTHbIH reMOCTa3 MO:>KHO TOIlbKO nOCJIe Toro, KaK IICTOqHIIK KpOBOTeqeHHH 06Ha-
py:>KeH. ,[{JIH ero OCTaHOBKII ueJIeco06pa3HO nonb30BaTbCH IIHCTpYMeHTaMll, BKlllOqalOIUIIMIi B ce6g
o,nHOBpeMeHHo II KoarYJIHTOp, II OTCOC.
TaK KaK npll npo,nOJI:>KalOIUeMCH KpOBOTeqeHlI1I BpeMeHII MH CMeHbI OTcoca Ha KpOBOOCTa-
HaBllIIBalOIUIiH IIHCTpYMeHT HelIOCTaTOIJHO, B03MO:>KeH BapllaHT BBe,neHHH OTcoca IJepe3,nonOJIHII-
TeJIbHbIH npOKOJI. IIonbITKa npOlI3BeCTlI TaKYlO cMeHY IIHcTpYMeHToB IJpeBaTa nOBTopHblM 3anlIBa-
H1IeM KpOBblO onepaUlIoHHoro nonH. ECJIII KpOBOTeqeHlIe HaCTOJIbKO 06RITbHOe, qTO 3aKpbIBaeT
. JIanapOCKOnlIqeCKIiH 0630P, TO TeJIeCKOn He06xo,nIIMO He3aMe,nJIIITeJIbHO OIJIICTlITb II BBeCTII B
,npyroM HanpaBJIeHlI1I RITII Ha 60nbilleM paCCTOHHlI1I OT MeCTa onepaUIIIi. B 3TOH CIITyaUlI1i Ha1I60-
JIee y,n06eH H30rnYTbIH TeJIeCKOn RITII TeJIeCKOn C 60KOBOH OnTHKOH. Bo BpeMH CMeHblIIHCTpYMeH-
Ta RITII OqlICTKII onTIiKII MeCTO 1\P0BOTeqeHIIH He06xo,nIIMO TaMnOHlipOBaTb TKaHHMII RITII MapJIeil:.
3aTeM, nOlIBe.rur OTCOC II KoarYJIHTOp Henocpe,nCTBeHHO K MeCTY KpOBOTeqeHIIH, TaMnOH OTBOMT II
«OTKpbIBaIOT» IICTOqHIIK KpOBOTeqeHIIH. BKlllOqaH OTCOC, o,nHOBpeMeHHO nblTaIOTCH 3axBaTHTb no-
Bpe>K,lJ,eHHbIH COCYlI. ECJIII 3TO y,nanOCb, He cneilllITe ero KoaryJIlipOBaTb. CHaIJana TlI.{aTeJIbHO 3Ba-
KYlIpYHTe KpOBb 1I3 30HbI KpOBOTeqeHlIH OTCOCOM. TonbKO 3aTeM, no,n BII3yaJIbHbIM KOHTpOJIeM,
KoarYJIlIpYHTe cocy,n.
MaJIeHbKlIe COCy,nbl KoaryJIlipYlOT MOHOnOJIHpHbIM KoarynHTopoM RITII OCTpOKOHeqnbIMIi
3JIeKTPOIUlInUaMII. IIpliMeHeHlIe KIllinc B ,naHHOH cliryaUlI1I HeueJIeco06pa3HO, nOCKonbKY IIX He06-
XO,nIIMO B,naBllIIBaTb B JIO:>Ke KpOBOTeqeHIIH. B ,naHHOM CJIyqae JIliraTypa, HanO:>KeHlraSl: C nOMoIUbIO
II30rHYTOH IIrJIbI, 60JIee 31lJIlJeKTIIBHa. B apceHaJIe xlIpypra TaK:>Ke eCTb reMOCTaTlIqeCKaH ry6Ka
RITII 1lJ1I6plIHOBbrn KneH, oc06eHHO nOne3HbIe npli ,D;IIIlJIlJY3HOM KpOBOTeqeHlIIi.
24
ECJIII KpOBOTeqeHlIe He MO:>KeT 6blTb OCTaHOBJIeHO B onpe,neJIeHHbIe CpOKII, TO He06xo,nHMO
nepeHTIi K JIanapOTOMIIII.
.ZJ:JIH Toro , qT06bI onepaUIIOHHoe nOJIe nPII OTKpblTbIX xlIpyprlIqeCKIiX BMeIlIaTeJIbCTBaX
OCTaBaJIOCb Bcer,na ,nocTynHbIM, He06xo,nIIMO 1I36eraTb HarpOMO)l(,D;eHIIH IIHCTpYMeHTOB B paHe.
HanO:>KeHlIe 3a:>KIIMa Ha rJIaBHYIO KpOBeHOCHYlO BeTEb JIOJI:>KHO COnpOBO)l(,D;aTbCH CHsrTlieM IIHCTPY-
MeHTOB C 60JIee MeJIKIIX COCy,nOB.
CHIiMaTb 3a:>KIIM C cocy,na HY:>KHO o,nHOBpeMeHHO c 3aBH3blBaHlieM nepBOH neTJIIi Y3JIa JIII-
raTypbl. Bo BpeMH 3aBepllieHIIH JIlirlipOBaHIiH HY:>KHO y,nep:>KIIBaTb 3a:>KIIMOM KOHeu cocy.n:a Ha cny-
qaH pa3pblBa HIITII npli 3aBH3bIBaHIiH.
. OqeHb Ba:>KHO YMeTb qeTKO II 6bICTpO CHlfMaTb 3a lfMbl I1plI 3TOM nOJIO:>KeHlIe IIHCTpYMeHTa
,nOJI:>KHO OCTaBaTbCH HelI3MeHHblM (TO eCTb TaKIIM, B KaKOM OHII Haxo,nIIJIIICb,nO TIoro). OqeHb
qaCTO, oc06eHHO HaqlIHalOlI.{lIe xlIpyprlI, nepeXBaTblBalOT IIJIII nepeKJIa,nbIBaIOT 3a:>KIIM 1I3 O.D:IIOH
PYKII B ,npyrylO (npaBOH (Be,nYIlIeH) PYKOH ero CHHTb JIerqe II y,n06Hee).l1plI 3TOM TKaHII, 3aXBaqeH-
HbIe 3a:>KIIMOM, MorYT 060pBaTbCH. qT06bl 3Toro He npOII30IlIJIO, Bce BHIIMaHlie ,nOJI:>KHO 6blTb CO-
cpe,nOTOqeHO Ha c,naBJIIiBalOmeM TKaHIi IIHCTpYMeUTe. PaCTHrlIBaHlie 3aMKa ,nOJI:>KHO npOII3BO-
,nIITbCH JIerKO II YBepeHHO 06elIMII pYKaMIi. TOMY, KTO HlueT, KaK paCTilllYTb 3aMOK 3a)!(IIMa, npe)l(,D;e
qeM ero CHsrTb, He06xoJIliMO peKOMeH,D;OBaTb 3apaHee n03HaKOMIITbCH C ero YCTpOHCTBOM. Toro,
KTO ,neJIaeT 3TO ,nBYMH pYKaMII, He Ha,no Bo06me no,nnYCKaTb K onepaUHoHHoMY CTOJIY. XlIpypr
06H3aH 3HaTb YCTPOHCTBO Bcex IIHCTpYMeHToB, KOTOpblMIi OH nonb3YeTCH. IIpli MIIHHMaJIbHblX CTa-
paHIIHx HeTpy,nHo HayqlITbCH 6bICTpO II JIerKO, 6e3 CMell.{eHIIH, CHIiMaTb 3a:>KIIMbI 06elIMli pYKaMII.
CaMoe npocToe TpeHlIpOBOqHoe ynpa:>KHeHlIe: OTKpOHTe 3a:>KIIMOM Kop060K CnllqeK, BbIHbTe Bce
CnlIqKII, COCTaBbTe 1I3 HIIX «KOJIo,neu», 3aTeM CHOBa CJIO:>KIITe CnlIqKII B Kop060K II 3aKpome ero.
I1po,neJIaHTe,naHHoe ynpa:>KHeHlIe BHaqane npaBOH, 3aTeM JIeBOH PYKOH. CHaqaJIa 3TO 6y,neT TPy,n-
HO, HO iJopozy OCUllum uiJyw,uii!
25
rJIaBa 1
3AKOB MEP(/>H
ECJIII KaKaH-HII6y,nb HenpHHTHoCTb MO:>KeT CJIY'llITbCH, OHa CJIyqaeTCH.
CJIFl(cmHJl:
1. Bce He TaK JIerKO, KaK Ka:>KeTCH.
2. BCHKaH pa60Ta Tpe6YeT 60JIbille BpeMeHII, qeM Ka:>KeTCH.
3.113 Bcex HenplIHTHOCTeH npolI30H,neT IIMeHHO Ta, YIUep6 OT KOTOpOH 60JIbille.
4. ECJIII qeTblpe nplIqlIHbI B03MO:>KHbIX HenplIHTHoCTeH 3apaHee YCTpaHeHbI, TO Bcer,na HaH-
,n eTCH nHTaH.
TEOPEMA CTOKMAifEPA
ECJIII Ka:>KeTCH, qTO pa60ry c,neJIaTb JIerKO, 3TO HenpeMeHHo 6y,neT Tpy,nHO. ECJIII Ha BH.D: OHa
Tpy,nHa, BbIllOJIHIITb ee a6COJIlOTHO HeB03MO:>KHO.
3AKOB IIAjJJ(EP A
Bce, o XOpOiliO Ha'illHaeTCH, KOHqaeTCH ImOxo.
Bce, o HaqlIHaeTCH MOXO, KOH'laeTCH eme xY:>Ke.
TPETHif 3AKOB l.flf3XOJIMA
JI106ble npe,D;JIO:>KeHIIH mo,D;H nOHlIMalOT IIHaqe, qeM TOT, KTO IIX BHOCIIT.
CJlE/{CTBlf.Jl:
1. ,[{a:>Ke eCJIIi BaIlIe 06'bsrcHeHlIe HaCTOJIbKO HCHO, qTO IICKlllOqaeT BCHKoe JIO:>KHoe TonKOBa-
HlIe, Bce paBHO HaH,neTCH qeJIOBeK, KOTOpbIH nOHMeT Bac HenpaBIIJIbHo.
2. ECJIII BbI YBepeHbl, qTO BallI nOCT)'IIOK BCTpeTIiT Bce06IUee 0,n06peHlIe, KOMY-TO OH 06H3a-
TeJIbHO He nOHpaBIITCH.
.. ..
26
!I.
I!'
..
" "::'"' ''::' 'j>. :"':"''''
-
rnaBR 2
"
3JIEKTf ,&,*¥prMqEC ()It
-"'< .. 7___,,"""-. .,,_. . _'_ ...
B03)J,EIlCTBIIE RA TI MIH
COBpeMeHHble onepaTIIBHbIe BMeIlIaTeJIbCTBa Tpy,nHO npe,nCTaBlITb 6e3 IICnOJIb30BaHliH
BbICOKOqaCTOTHOrO 3JIeKTpOXIIpyprlIqeCKoro B03,neHCTBIIH, n03BOnHlOlI.{erO pe3aTb II KoarYJIlIpo-
BaTb TKaHIi. TaKoe B03,neHCTBlie ,naeT xlIpypry PM npelIMymecTB:
- paCCeqeHlIe II reMOCTa3 OcymeCTBJIHeTCH O.D:IIOBpeMeHHo O,nHIIM ,nBII:>KeHlIeM IIHCTpYMeH-
Ta, qTO CymecTBeHHO YMeHbiliaeT KpOBonOTeplO II MlITeJIbHOCTb onepaUIIII;
- IICqe3aeT Ha,n06HOCTb B IICnOJIb30BaHIIII IlIOBHoro MaTepliana;
- BbICOKaH TeMnepaTypa B03JJ:eHcTBIIH OTBeqaeT Tpe60BaHlIHM aCeDTIIKII II a6JIaCTIIKII.
Bce TKaHeBbIe 31lJIlJeKTbI 3JIeKTpOXII-
pyprlIli OCHOBaHbl Ha npe06pa30BaHIIII 3JIeK-
TplIqeCKOH 3HeprIIII B TenJIOBYlO. ,[{JIH 3Toro
IICnOJIb3YlOTCH nepeMeHHbIH BbICOKOqaCTOT-
HbIH TOK (OT 500 KrU,nO 2 Mr), KOTOpblH He
BJIlIHeT Ha 3H,D;OreHHble 3JIeKTplIqeCKlie no-
TeHUlIaJIbI qeJIOBeqeCKOrO opraHlI3Ma. EbICT-
poe ,nBII:>KeHlIe 3JIeKTplIqeCKOrO nOTOKa C OJJ:-
HOH CTOpOHbl II conpOTIIBJIeHlIe TKaHeH C
,nPyroH IIHIIUIIIIPYIOT Bbl.D:eJIeHlIe Tenna II pa3-
BlITHe TKaHeBbIX 31lJIlJeKToB BblCOKOqaCTOTHOH
3JIeKTplIqeCKOH 3HeprlIli. 3TH 31lJIlJeKTbI IIC-
nOJIb3YlOT KaK ,nJIH IIX pe3aHIIH, TaK II ,nJIH KO-
aryAAUlllI.
Pa3JIIIqalOT MOHOOOJIHpHOe 0 6000-
JIHpHOe 3JIeKTpoxopypro ecKoe B03JJ:eu-
CTBoe Ha TKaHli. I1plI MOHonOAApHOM B03,neH-
CTBIIII 3JIeKTplIqeCKliH TOK npoxo,nIIT OT
3JIeKTpo,na xlIpypra K 3JIeKTpo,ny naUlIeHTa,
a npoBo,nHIIKOM HBnHeTCH Bce TeJIO 60JIbHO-
ro (puc. 2.1). 3TO n03BOnHeT KaK pa3'be,nlI-
HHTb (pe3aTb), TaK II KoarYJIlipOBaTb TKaHIi.
I1plI 6IInOJIsrpHoM 3JIeKTpOxlIpyprlI-
qeCKOM B03,neHCTBIIII reHepaTop TOKa coe,nlI-
HeH C ,nBYMH aKTIIBHbIMII 3JIeKTpo,naMII,
CMOHTlIpOBaHHbIMIi B O,nHOM IIHcTpYMeHTe. B
3TOM CJIyqae nJIaCTIiHY naUlIeHTa He nplIMe-
HHlOT, a TOK npoxo,nIIT JIlIllIb qepe3 He60nb-
1\.', F"" 1""'...........
..... - --. -. "-.",,.\, .' ,!
r:=::-
'---".- / \\
.. :
>.
",1
Puc. 2.1 Hanpa6J/eHue nPOXO:JICaeHUJI mOKa npu
MOllOnOll5lpllOM 3J/eKmpoxupypZU'leCKOM e03aeUCmeuu
-
-
... . ;
r-j \ _
A
,
1
Puc. 2.2 HanpaeJ/ellue nPOXO:JICaeHUJI mOKa npu 6uno-
J/JipHOM 3J/eK1npOxupypZU'leCKOM e03aeUC1neUU
27
rJIaBa 2
IlIYlO nopUlilO TKaHII, 3a:>KaTYlO Me)l(,D;Y 6paHillaMli 6IInOJISl:pHOrO IIHCTpYMeHTa (puc. 2.2). ElIno-
nHpHaH 3JIeKTpoxIIpyprlIH MeHee YHIIBepcanbHa, nplIMeHHeTCSI: TOJIbKO B pe:>KIIMe KoarYJIHUIIII, Tpe-
6yeT CJIO>KHbIX 3JIeKTpo,noB.
EMO<DM3MQECKME IIPEJ],nOCbIJIKM 3JIEKTPOXMPyprMQECKOrO
B03,lJ:Ei1CTBMR HA TKAHM
BbI.D:eJIeHlIe TellJIa, KaK 1I3BeCTHO, npolIcxo,nIIT Ha yqaCT-
Ke 3JIeKTplIqeCKOH uenli (OT reHepaTopa,no naUlIeHTa), IIMelO-
IUeH HalIMeHbllllIH ,nlIaMeTp, II, CJIe,nOBaTeJIbHO, HalI60JIbillYlO
nJIOTHOCTb MOIUHOCTII TOKa (BT/cM 2 ). 3TOT npouecc OqeHb no-
XO:>K Ha 3a:>KlIraHlie 3JIeKTpmecKoH JIaMnbl. I1poxo)l(,D;eHue 3JIeK-
TplIqeCKOrO TOKa npIIBO.D:IIT K HarpeBaHlilO TOHKOH BonbllJpaMo-
BOH HIITII HaKaJIIIBaHIiH. B 3JIeKTpoxIIpyprlIli 3TO npolIcxo,nIIT
Ha yqaCTKe uenlI, IIMelOIUeM MeHbIlIIiH ,nlIaMeTp II 60JIbillee co-
npOTHBJIeHlIe, T.e. B To e conplIKocHoBeHIIH 3JIeKTpo,na xnpypra
II TRaHeH naUlIeHTa (puc. 2. 3).
B 3aBIICliMOCTli OT reHeplipyeMoH TeMnepaTypbl MorYT
6blTb nOJIyqeHbl pa3JIII bIe TKaHeBbIe 31lJ1lJeKTbI. I1plI nOBblllIe-
HIIII TeMneparypbI,no 40 °C 3HaIJIITeJIbHbie TKaHeBbie nOBpe:>K-
,neHlIj{ OTCYTCTBYIOT. ,[{aJIbHeHillee MeMeHHoe HarpeBaHlie nplI-
BO,n1IT CHaqaJIa K 06paTliMbIM TepMlIqeCKIIM nOBpe:>K)J,eHIIHM, 3aBliCHIUliM OT ,nJIIITeJIbHOCTIi
B03,neHcTBIIH, a 3aTeM, HaqlIHaH C 49°C, K He06paTIiMbIM.l1plI Me,nJIeHHOM HarpeBaHIiH TKaHeH,no
TeMnepaTYPbl 70°C B pe3YJIbTaTe IIcnapeHIIH IIHTpa-1i 3KCTpaueJIJIlOJIj{pHOH )l(H)J,KOCTM ,nOCTliraeT-
CH 31lJIlJeKT xlIpyprnqeCKOH KoarynHUIIII. EblcTpoe nOBblllleHlIe TeMnepaTypbI,no 100° C rrplIBo,nIIT K
HeMe,nJIeHHOMY nepexo,ny :>KII.D:KOrO co,nep:>KIIMOrO B ra3006pa3HOe, qTO BbI3bIBaeT B3pbIB KJIeTKII,
T. e. KJIeTKa IIcnapHeTCH II TeM caMbIM )IOCTIIraeTCH pe:>KYIUIiH 31lJ1lJeKT.
YBeJIIIIJeHIIH llJIOTHOCTli MOll.{HOCTIi TOKa, II, CJIe,nOBaTeJIbHO, IIHTeHc"IlJ"KaUIII 3JIeKTpoTep-
MnqeCKOH peaKUlI1I MO:>KHO ,n06IITbCH nOBblilieHlIeM MOIUHOCTII C O,nHOH CTOpOHbI RITII YMeHbilieHlIeM
llJIoll.{a,n1I IIcnonb3yeMoro 3JIeKTpo,na - C ,npyroH. qeM MeHbille MaMeTp 3JIeKTpo,na, TeM 6blcTpee
OH HarpeBaeT npRITeralOlI.{lIe K HeMY TKaHII. 1103ToMY pe3aHMe HalI60JIee 31lJIlJeKTIIBHo II HaliMeHee
TpaBMaTlIqHO npII IICIIOJIb30BaHIIII IIrOnbqaTbIX 3JIeKTpo,nOB. 3JIeKTpo,nbI 60JIbiliOH llJIOll.{a,D.1I reHe-
PIIPYlOT 3HeprlI1O MeHbilieH llJIOTHOCTIi II 06JIa,nalOT MeHbIlIIiM pe:>KYIUIIM 31lJIlJeKToM, HO 06ecne-
qnBaIOT xopollIYlO KoaryJIHUlilO.
(
L. "--'-.
P
Puc. 2.3 BblaeRenUe :mepzuu e mO'lKe
conpUKOCllOeenWl :meKmpOaa xupypza
u mKaneu nalfuellma. CeKmop pacnpeae-
,!eHUR 3nepzuu e 30He 1IJIUCmUHbl
nalfuenma
f.\ "......-.-, /','
'f'>JI. ... ,",,-J
-- : ' <.I, 4"" . ./; .
L...-.....-__
KOJIlIqeCTBO BbI.D:eJIHeMOH 3HeprlIli 3aBII-
CMT OT llJIOll.{a,D;1I llJIaCTIIHbl naUlIeHTa. HanplIMep,
npII,nlIaTepMIIII (1lJII3IIOTepaneBTlIqeCKOM Harpe-
BaHlI1I TKaHeH) IICnOJIb3ylOT ,nBe nJIaCTIIHbI 60JIb-
IlIOH llJIOIUa,nlI. B 3TOM cnyqae, npli no,naIJe HanpH-
:>KeHIIH TOK HII3KOH llJIOTHOCTIi pacnpe,neJIHeTCH
Me)l(,D;y llJIaCTIiHaMlI, He OKa3blBaj{ 3JIeKTpoXlIpyP-
rmecKoro ,neHCTBIiH (puc. 2. 4). I1HbIMIi CJIOBaMII,
60JIbIlIaj{ BeJIlIqlIHa llJIoll.{a,n1I llJIaCTIIHbI naUlIeH-
Ta 06YCJIOBJIliBaeT pacceuBaHlie II HII3KYlO nJIOT-
HOCTb MOll.{HOCTII TOKa B 30He B03,neHcTBIDI 6e3
Puc. 2.4 PaCnpeaeReHUe ::mepzuu npu aUamepMU'leC-
KOM e030eucmeuu
28
BbI,lJ.eJIeHIIH Tenna. II03ToMy KOHTaKT llJIaCTIIHbI C KO-
:>KeH naUlIeHTa ,nOJI:>KeH 6bITb 6e3YKOp1l3HeH. B npOTIIB-
HOM CJIyqae npOlI30H.neT OnaCHaSl: KOHueHTpaum! TOKa,
COnpOBO)l(,D;alOmaHCH O:>KOrOM TKaHli (puc. 2.5).
,[{mI npe.D:OTBpameHHH OCJIO:>KHeHIIH He06xo,D;II-
MO pacnOJIO:>KIITb 3JIeKTpo,n naUlIeHTa KaK MO>KHO 6JIII-
:>Ke K 30He 3JIeKTpoxIIpyprlIqeCKOrO B03,neHcTBIIH.l1plI
onepaUIIHX B 06JIaCTli Ta3a IIJIII Ha opraHax 6plOiliHOH
nOJIOCTIi ero ueJIeC006pa3Hee pa3MemaTb no,n Sl:rO.D:II-
uaMIi. IIpli BMelliaTeJIbCTBaX B rpy,nHoH nOJIOCTII llJIIi
rOJIOBe ero IlJIIKCIiPYlOT no,n JIOnaTKaMIi RITII Ha llJIeqe.
I1plI onepaUHHx Ha KOHeqHOCTHX 3JIeKTpo,n 3aKpellJIH-
lOT npOKCIIMaJIbHee. Ho B n1060M CJIyqae, MH YJIyqIlIe-
H1IH 3JIeKTpOnpOBO.D:HOCTH, ero pacnOJIaralOT B 30He XO-
pOiliero KpOBOCHa6:>KeHIIH.
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Puc. 2.5 YMeUbUieHUe 1IJ/0Ujaau conpUKOCHO-
eeUUR l1.1laCmUllbl nal/ueuma conpoeo:J/CaaemCR
O:J/COi!OM ei!O KO:J/CU
3JIEKTPOTEPMWIECKME 3C1>CI>EKTbI BbICOKOqACTOTHOrO TOKA
3JIeKTpoxIIpyprlIqeCKOe B03,neHCTBlie Ha TRaHIi no 1lJ0PMe 3JIeKTplIqeCKOrO TOKa pa3,nenH-
lOT Ha Tpli BH,D;a: pC3aHHC II ,nBa BH,D;a KoarYJIHUlI1I - t)YJIbrypaQHH H ,nCCHKKaQHH.
)J;JIH pC3aHHH IICnOJIb3YlOT HenpepbIBHblH nepeMeHHblH TOK C HII3KIIM HanpH:>KeHlIeM (puc.
2.6). MexaHII3M pe3aHliH MO:>KHO onlicaTb CJIe,nYlOlI.{IIM 06pa30M. B03,neHcTBlie TOKa IIHIIUIIHpYeT
pe3Koe YCRITeHlIe ,nBII:>KeHIIH IIOHOB BHYTpIi KlleTKII, qTO, B CBOlO Oqepe,nb, nplIBo,nIIT K nOBblilieHlIlO
TeMileparypbllI BblIIaplIBaHlilO BHYTpHKlleTOqHOH :>KH,D;KOCTII.l1pOIICXO,nIIT «B3PbIB» - pa3pYllieHIIe
KlleTOqHOH 060JIOqKII, BocnplIHIIMaeMoe HaMIi KaK pe3aHlie. 06pa30BaHHaH TellJIOTa YXO,nIIT Ha
IICnapeHlIe ra30B, qTO, TaKIiM 06pa30M, npe,nynpe)l(,D;aeT neperpeBaHlie 60JIee rJIy60Klix CJIOeB
TKaHeH.l1plI paCCeqeHlI1I npOlIcxo,nIIT He3HaqlITeJIbHaH TenJIOnepe,naqa C 06pa30BaHlieM MIIHII-
MaJIbHOH 30HbI HeKp03a. IIoBepxHocTHaH KoarYJIHUIiH B 3TOM pe:>KIIMe 3JIeKTpoB03,neHcTBIiH 06yc-
JIOBJIHBaeT He3HaqlITeJIbHbIH reMOCTaTlIqeCKIiH 31lJ1lJeKT.
Pe3aHlie HalI60JIee 31lJIlJeKTIIBHo, Kor,na 3JIeKTpo,n np1I6JIII:>KaIOT K TKaHII, HO He KacalOTCH
ee. Ilap CIIoc06cTBYeT 06pa30BaHli1O BblCOKOH KOHuempaUlI1I IIOHOB Me:>K.D:Y 3JIeKTpo,nOM II TKaHH-
MII, qTO 06eCneqlIBaeT IIpOTeKaHlie TOKa. B npOTIIBHOM CJIyqae, eCJIIi 3JIeKTpo,n conpliKacaeTCH C
TKaHHMII RITII Haxo,nIITCH Ha 60JIbiliOM paCCTOHHlIIi OT HIIX, 31lJIlJeKTa pe3aHHH He 6y,neT. «MonHHH» OT
3JIeKTpo,na K TKaHIi HBJIHeTCH OCHOBHblM MOMeHTOM B 3JIeKTpoxIIpyprlIqeCKOM pe3aHIIII.
06meH np06JIeMOH ,nJIH xlIpyproB, IICnOJIb3YlOlI.{IIX 3JIeKTpoxIIpyprnqeCKlie MeTo,nbI, JlBJUI-
eTCH «npRITlInaHlIe» TRaHeH K 3JIeKTpo,ny. CYll.{eCTBYeT HeCKOJIbKO cnOc060B.D:JIS[ Toro, qT06bI3Toro
1I36e:>KaTb. Bo-nepBbIX, MH KOHueHTpaUlI1I TOKa II MIIHIIMII3aUIIII llJIoma,n1I conplIKocHoBeHIIH IIC-
IIOJIb3yilTe HalI60JIee TOHKlIe 3JIeKTpo,nbl. BO-BTOPblX,.D:JIH Toro qT06bI 06eCneqlITb 6bICTpoe II rna,n-
Koe pe3aHlIe, ,nep:>KIITe 3JIeKTpO,n HaJJ: 06'beKTOM, He Kaca»Cb TKaHeH. XlIpypr ,nOJI:>KeH nOMHlITb, qTO
IIHTYIITIIBHoe ,naBJIeHlIe 3JIeKTpo,nOM Ha TKaHb He nplIBo,nIIT K 60JIee rJIy60KOMY pa3pe3aHlI1O.
B-TpeTblIX; IIPII He06xo,nIIMOCTIi npe,neJIbHO TOqHOrO pa3,neJIeHIIH TKaHeH CTapaHTeCb pe3aTb Me,n-
JIeHHbIM npo,nBII:>KeHlIeM 3JleKTpo,na, IIHaqe cnpoBoUlipyeTe «BbIcyrrrIIBaHlIe», II HaKOHeqHIIK 3JIeK-
Tpo,na 6y,neT B Harape. HaKOHeu, KaK II npli pe3aHlllI CKanbIIeJIeM, TKaHII, npli llX paCCeqeHlI1I
3JIeKTpo,nOM, CJIe,nYeT ,nep:>KaTb B HaTH:>KeHIIII. OHII JIerKO pa30H.nYTCH no Mepe «BblIIapIIBaHIIH»
KlleTOK.
29
rJIaBa 2
CJIe,nyeT JIll npliMemITb :meKTpoB03,neHcTBlie ,nJIH
paCCeqeHIIH KO:>KII? 3TOT Bonpoc no HaCTOHiliero BpeMeHII
OCTaeTCH npe,nMeToM ,nIICKYCCIiH. CTOpOHHIIKII Tpa,nIIUII-
OHHoro cnoc06a pa3pe3aHliH ceTYlOT Ha 06IlIliPHYlO nJIO-
lI.{a,nb B03,neHCTBIIH npli 3JIeKTpoxlIpyprlIlI, qTO cy ecTBeH-
HO OCJIO:>KHHeT nocTonepaUlIoHHbIH nepno,n. OnnoHeHTbI
YTBep)l(,D;alOT, qTO npli IICnOJIb30BaHIIII TOHKIIX IIrOJIbqa-
TbIX 3JIeKTpo,nOB 30Ha nOBpe)l(,D;eHIIH MIIHIIManbHa II He BJIII-
HeT Ha 3a:>KIIBJIeHlIe paHb!. u,eJIeC006pa3HOCTb 3JIeKTpO-
paCCeqeHIIH KO:>KII onpeL\eJIHeTCH Ka:>K,nbIM xlIpyproM
1IH,D;IIBH.D:yanbHo, yqlITbIBaH ero OnbIT II HaMeqaeMbIH 06'beM
BMeIlIaTeJIbCTBa.
IIpaKTlIqeCKIi Bce xlIpyprlI CXO,nHTCH BO MHeHIIII, qTO
pacceqeHlIe no,nKO:>KHOH :>KlIpOBOH KlleTqaTKII CJIe,nyeT npo-
1I3BO,nllTb CKaJIbneJIeM. ,[{eJIO B TOM, qTO :>KlIpOBOH TKaHll CBOH-
CTBeHHO BbICOKoe conpOTIIBJIeHlIe II OHa nJIOXO nOMaeTCH
3JIeKTpoXIIpyprlIqeCKOMY B03,neHCTBIi1O. II03TOMY nepece-
Puc. 2.6 CPopMa 3JleKmpU'leCl<OZO mOKa U qeHHble COCy,nbI npIIXOL\IITCH KoaryJIlipOBaTb OT,neJIbHO.
«ebTnapUeaHue» mKaHeu npu pmpe3aT1UU PaCCeqeHlle llJacUIIH II MbIIlIU C ycnexoM npOII3Bo,nHT
npli nOMOmli 3JIeKTpoxIIpyprlIQeCKOrO B03,neHCTBIiH. IIpli
pa60Te C MbIIlIe OH TKaHblO, 60raTOH cocy,naMII, ,D;B1I:>KeHlIe
3JIeKTpo,na ,nOJI:>KHO 6bITb oc06eHHO MeMeHHblM II nJIaBHbIM
MH 06eCneqeHIIH nOJIHOueHHoro reMOCTa3a.
AnH KoaryJIHLt"H IICnOJIb3YIOT IIMnYJIbCHbIH nepeMeH-
HbIM TOK C BblCOKIiM HanpH:>KeHlIeM. 3TO 06ecneQlIBaeT
BcnneCK 3JIeKTplIQeCKOH aKTIIBHOCTIi c nOCJIeL\YlOIlIIiM no-
CTeneHHblM ee 3aryxaHlieM. HarpeBaHlie TKaHeH npolIcxo-
,nllT He TaK 6bICTpO, KaK nPII pe3aHIIII, a B nepepbmax Me)l(,D;y
IIMnyJIbCaMIi npOlIcxo,D;lrr IIX OCTbIBaHlie. KOpOTKIIH BcnneCK
BblCOKoro HanpH:>KeHHH nplIBo,nIIT K ,neBacKynaplI3aUIIII TKa-
HII, HO He BbmaplIBaHlIlO, KaK B CJIyqae pe3aHIiH. Bo BpeMH
naY3bI npOIICXO.D:IIT «BblcYIlIIIBaHlIe» KlleTOK. K MOMeHry CJIe-
,nYlOmero nliKa 3JIeKTpllqeCKOrO IIMnYJIbCa «cyxlIe KJIeTKII»
06JIa,nalOT B03pOCIlIliM conpOTIIBJIeHlIeM, npIIBO.D:HIUIIM K
60flbilleMY paccelIBaHlilO Tenna. IIo3ToMY 06'beKTOM aTaKII
cTaHoBsrTcH IlIapbI KJIeTOK, pacnOJIO:>KeHHbIX 60JIee rJIy60-
KO. B ueJIOM, 3TO 06eCneqllBaeT MlIHlIMaJIbHOe paCCeqeHlIe C
MaKCIIMaJIbHblM npoHIiKHOBeHlIeM 3HeprlIli B rJIy6IIHY TKa-
HeH, ,neHaTypaUlieH 6eJIKa II 06pa30BaHlieM TpOM60B B cocy-
Puc. 2. 7 CPopMa 3JleKmpU'leCKOZO mOKa U
,nax (puc. 2.7). IIo Mepe «BbIcYlliIiBaHIIH» TKaHII ee conpo-
«eblCYUlueaIlUe» mKalleU npu KoaZYJlJllJUu
TIIBJIeHlIe B03paCTaeT ,no Tex nop, nOKa ,naJIbHeHllIaH
KoarynHUIiH OKa3bIBaeTCH He31lJIlJeKTIIBHoH.
B TO:>Ke BpeMH He06xo,nIIMO nOMHIITb, qTO, HeCMOTpH Ha JIOKanbHOe B03,neHCTBlIe, npli Koa-
rymUlI1I npOIICXO.D:IIT 60KOBoe pacnpOCTpaHeHlIe Tenna, 06YCJIOBJIeHHOe TennonpOBo,nHOCTblO TKa-
HeH. TeMneparypa, ,nOCTaTOqHaH MH B03HIIKHOBeHlIH HeKp03a TRaHeH, MO:>Ke'!: 6bITb 3apernCTplI-
T
30
pOBaHa B npe,neJIax 2 CM OT TOqKII KoaryJIHUIIII. II03ToMY, Ha-
npliMep, ,nJISI: pacceqeHlISI: cnaeK B 6plOlliHOH nOJIOCTIi BO BpeMSI:
JIanapOCKOnl1qeCKOrO BMelliaTeJIbCTBa npe,nnOqTeHlIe CJIe.nyeT OT-
,naBaTb 61Ill0JIHpHOH KoarymUlI1I KaK 60JIee 6e30nacHoH. Koary-
JIlipOBaTb cnaHKII MO:>KHO Ha paCCTOHHIIII, He MeHbllieM 2- 3 MM OT
CTeHKII KlilliKlI, a npli MOHononHpHoH KoaryJISl:UIIII - He MeHbllieM
5-7 MM, nOCKOJIbKY Ha 3TO paCCTOSl:HlIe MO:>KeT pacnpOCTpaHIITbCH
TepMlIqeCKOe nOpa:>KeHlIe OT BII,D;IIMOH 30Hbl KoarynHUIIII.
npli 6ecKoHTaKTHoH spraY-KoarymUIIII, RITH PYJlbZYPOJ{UU,
3JIeKTpo,n He KOHTaKTlIpyeT C TKaHHMII. 3HeprnSl: pacnpe,neJISl:eT-
CSI: B BlI,D;e nyqKa IICKp no nOBepXHOCTIi TKaHIi. B 3TOM CJIyqae,
yqHTblBaH He60nbllIYIO nnOTHOCTb TOKa, npolICXO,D;IIT nOBepXHOCT-
Hoe MeCTHoe B03,neHCTBlie C MIIHIIMaJIbHOH rJIy6IIHoH nopa:>Ke-
HIIH (puc. 2.8). 3TO y,n06HO ,nJISI: OCTaHOBKII Herny60Koro ,n1I1lJ-
IlJY3Horo KanlIJIJIHpHOrO KpOBOTeqeHIISI: KaK 1I3 MHrKIiX TKaHeH,
TaK II 113 napeHXIIMaT03HbIX opraHOB.
B OTnlIqlIe OT pe3aHIISI: II IlJYJIbrypaUIIII, KOaryJlj{ltlIOHHOro
31lJIlJeKTa,nOCTlIraIOT npli Henocpe,nCTBeHHOM conpliKOCHOBeHlIIi
3JIeKTpo,na II TKaHeH. IIpli 3TOM yqaCTOK nOpa:>KeHlIH HeBeJIIiK no
nnOll.\a,D;II' HO 3Ha'illTeJIeH no rJIy6lIHe, qTO onpe,neJIHeT nOTeHUII-
anbHYlO onaCHOCTb npli pa60Te B 30He pacnOJIO:>KeHIIH :>K1I3HeHHO Ba:>KHbIX CTPYKryp. B TOM CJIyqae,
Kor,na 3JIeKTpO,n KaCaeTCSI: TKaHII, npOlIcxo,nIIT 60JIee rJIy60Koe «BbICYlliIiBaHlIe» - ,neCIiKKaUIIH.
IIpli pa60Te B pe:>KIIMe «KoaryJISl:UIIH» MOll.{HOCTb He ,nOJI:>KHa npeBbllliaTb 40 BT, T.e. OHa
,nOJl)l(Ha 6blTb MeHbllIe, qeM B pe:>KIIMe «pe3aHlIe», TaK KaI<
HanpSl::>KeHlIe npli KoarynHUlI1I 60JIbllie.
KpOMe nnOTHOCTIi MOll.{HOCTH TOKa, KOTopaH MO-
:>KeT peryJIlipOBaTbCSI: xnpyproM, He06xo,D;IIMO yqlITbIBaTb
II onpe,neJIeHHble xapaKTepliCTIiKII TKaHeH, oc06eHHO
:>K1I,nKOH COCTaBJIHlOll.\eH. TenJIOBaH npOBo,nIIMOCTb TKa-
HeH MeHSl:eTCSI: B 3aBIICliMOCTli OT I1X BJIarOco,nep:>KaHIISI: II
,npyrlIx 1lJ1I3IIqeCKliX CBOHCTB. qeM Bbillie co,nep:>KaHlie
:>KII,D;KOCTII B TKaHIi (HanpIiMep, npli KpOBOTOqlIBOCTli RITII
npli OTetlHOH BOCrranHTeJIbHOH IIHIlJRITb TpaulIlI B 30He ,neH-
CTBIIH 3HeprlIlI), TeM HII:>Ke Bbl3blBaeMblH KoarYJISl:UIIOH-
HblH 31lJ1lJeKT.
qacTo BO BpeMH onepaulIlI He06xo,nHMO npOlI3Be-
CTII pe3aHlie C o,nHOBpeMeHHOH KoarynHUlieH. ,[{JIH 3Toro
IICnOJIb3YlOT CMeIlIaHHbie 3JIeKTplIqeCKlie nOTOKIi. CMe-
lliaHHbIH TOK (nYJIbCOBOH C aMnJIIITy,nHOH Mo.nynHUlIeH)
OKa3bIBaeT BbIpa:>KeHHOe pe:>KYll.{ee ,neHCTBlie C BapblIpy-
lOlI.{eH KoarYJIHUlIeH_ CMelliaHHble 3JIeKTplIqeCKlie nOTO-
KII 06pa3YlOTCSI: npli HanpSl::>KeHIIII 60nbllieM, qeM npli pe-
:>KIIMe pe3aHIIH, HO MeHbllieM, qeM npli pe:>KIIMe
KoarynHUIIII. EOJIbIlIee qlICJIO HeBbma.n:alOlI.{lIX IIMnYJIb-
COB 06eCneqlIBacr «BbICYlliIiBaHlIe» npRITeralOlI.{lIX TKa-
,-.,.
t. .11
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Puc. 2.8 (/JyllbzypaIjUH.
EeCKOHmaK1nIIaR spray-
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Puc. 2.9 (/>0pMa :JlI£K1npU'leCKOZO mOKa npu
pa60me e CMeUlaHHOM pe:JK:UMe - CO'lemaHUe
KoaZYflHIjUU C pe3aHueM
31
r naBa 2
HeH (KoarYJISl:UlIlO) C o,D;HoBpeMeHHbIM pe3aHlieM (puc. 2.9). MO:>KHO nonb30BaTbCH HeCKonbKlIMIi
CMellIaHHblMIi pe:>KIIMaMIi C pa3JIIIqHbiM COOTHOilieHlIeM 060lIx 31lJIlJeKToB.
TaKIiM 06pa30M, e,nIIHCTBeHHoH 1I3MeHHeMOH BeJIlIqIIHOH, 06YCJIOBJIHBalOlI.{eH pa3):\eJIeHlIe
IlJYHKUIiH pa3Hbix BOJIH (o,nHa BOJIHa pe:>KeT, a ,npyraH KoaryJIlipyeT TKaHb), HBJIHeTCH KOJIlIqeCTBO
npolI3Bo,nIIMoro TenJIa. 3TOT llJaKTop onpe,nenHeTCSI: TlinOM nplIMeHHeMoro TOKa. 3MnliplIqeCKlie
IICCJIe,nOBaHliH nOKa3blBalOT. qTO HeMo,nYJIlipOBaHHbIH CIiHycolI,naJIbHbIH BbICOKOqaCTOTHbIH TOK
(HenpepblBHaSl: 1lJ0pMa BOJIHbl) BbI3blBaeT TOJIbKO pe:>KYll.\IIH 31lJ1lJeKT. EOJIblliOe KOJIHqeCTBO Tenno-
TbI, npolI3Be,neHHoe 6bICTpO, ,naeT pe3aHlIe, T .e. «BbmapIiBaHlIe» TKaHeH.
Mo,nYJIlIpOBaHHbIH TOK C BblCOKIiM no,n'beMOM K nliKoBoMY BOJIbTa:>KY JIlillib KoarynlIpyeT.
He60JIblliOe KOnlIqeCTBO TennOTbI, npOlI3Be,neHHoe Me,nJIeHHO, C03,naeT «BblcYlliIiBaHlIe», T.e. Koa-
ryJISl:UlIlO.
Ha npaKTIIKe KoarymulIlO MO:>KHO OCYll.{eCTBIITh O,nHlIM 1I3 Tpex MeTo,nOB:
1. 3axBaT H KoaryJIHQHH cocYJla "PH "OMOIQH 6H"OJIHpHOrO "HHQeTa. 3TO 6e30naCHbIH,
Ha.n:e:>KHbIH II HaIIMeHee TpaBMaTlIqHblH cnoc06, Tpe6YlOlI.{lIH,
o,nHaKO, CMeHbllIHCTpYMeHTa II pe:>KIIMa B03,neHCTBIiH no xo.ny
BMelliaTeJIbCTBa.
2. reMOCTa3 'Iepe3 HHcTpYMeHT: 3axBaTHB cocy,n XII-
PyprlIqeCKIiM nliHUeTOM RITII 3a:>KIIMOM II CJIerKa nplIno,nHHB
IIHCTpYMeHT, xnpypr nplIKacaeTCSI: K HeMY MOHonompHbIM 3JIeK-
TpO,nOM, KoarynnpySl: KOHeu 3a:>KaTOro cocy,na (puc. 2.10) . Ilrro-
lI.{a,nb KoarYJISl:UlIIi 6y,neT HeCKonbKO 60JIbllie, qeM B 6lInOnHp-
HOM pe:>KIIMe. II03ToMY, cocy,n :>KeJIaTeJIbHO 3aXBaThIBaTb C
MIIHIIMaJIbHbIM KOJIlIqeCTBOM oKpY:>KalOlIIIIX TKaHeH. qeM 06-
llilipHee nJIOll.{a):\b 3axBaTa TKaHlI, TeM 60JIbille KoarYJIHT. 3Ta
MeTO,D;IIKa, K CO:>KaJIeHIIIO, He6e30nacHa.I1MeHHo C HeH CBSl:3a-
HO HalI60JIblliee KOJIHqeCTBO O:>KOrOB II y,napoB TOKOM npli 3JIeK-
TpoxlIpyprnqeCKOM BMelliaTeJIbCTBe. ,lJ,oTparIiBaSl:Cb,no naUII-
Puc. 2.10 PaCnOflO:JH:eHUe uHcmpYMeH-
eHTa, xlIpypr, y,nep:>KIIBalOIUIiH 3a:>KIIM, MO:>KeT BKlllOqlITbCSI: B
3JIeKTplIqecKYlO uenb. IIo Mepe «BbIcYllIIiBaHIIH» 3aXBaqeHHOH
TKaHIi COnpOTHBJIeHlIe ee 6y,neT B03paCTaTb, II HaCTynlIT MOMeHT, Kor,na pYKa xnpypra MO:>KeT CTaTb
.D:JIjI TOKa npOBo,D;HIIKOM C HalIMeHbllilIM conpOTIIBJIeHlIeM. B03HIIKHeT aHOMaJIbHaH uenb. KOHTaKT
3JIeKTpo,na II 3a:>KIIMa MO:>KeT Bb13BaTb pa3pH,n Me)l(,D;y ,nBYMSI: MeTaJIJIlIqeCKIiMIi nOBepXHOCTSI:-
MII.Oc06eHHO 3TO onacHO, eCJIIi 3JIeKTpO,n xlIpypra aRTHBIIPYIOT B B03,nyxe, a 3aTeM npIIKlla):\blBa-
lOT K MeTanJIlIqeCKOMY 3a:>KIIMY.
IIepeqnCJIIIM MepbI 6e30naCHOCTII:
- 3a:>KIIM CJIe.nyeT 06XBaTblBaTb (,nep:>KaTb) BceH KIICTblO, TaR KaK npli 3TOM 06eCneqlIBaeTCSI:
60JIblliaSl: nnOll.{a):\b conpIiKOCHOBeHIISI:. IIocJIe,nHee YCJIOBlie He06xo,nIIMO MH npe,nOTBpaIUeHIISI:
KOHUeHTpaUlI1I TOKa;
- KacaTbCSI: 3JIeKTpo.n:OM TOH qaCTH 3a:>KIIMa, KOTopaH Haxo,nIITCSI: 6nlI:>Ke K paHeBOH nOBepXHO-
CTII (HII:>Ke ypOBHH KIICTII). 3T0 CHII3IIT BepOSl:THOCTb ,nBII:>KeHIIH TOKa no aHOMaJIbHOMY nYTH LJ:epe3
PYKY xlIpypra. HII3KIIe 3JIeKTpOnpOTeKTopHbIe CBOHCTBa pe3IIHOBbIX nepqaTOK He npe,noxpaHSl:lOT
xlIpypra OT 3JIeKTplIqeCKOrO pa3pMa II nOJIyqeHIIH O:>Kora;
- B MOMeHT KoarynHUHII HeJIb3S1: ,nOTparIiBaTbCSI:,no naUHeHTa II CTOJIa.
HaJIlIqlIe B TeJIe naUIIeHTa MeTanJIIILJ:eCKliX npe,nMeTOB MO:>KeT cnpOBOUlipOBaTb He:>KeJIa-
TeJIbHYlO KOHueHTpaUlIlO 3neKTplIqecKoro TOKa B npoQecce onepaQIIII. II03TOMY MeTanJIHqeCKlie
moe e MOMeHm KoaZ)lJ/Rl1uU
32
CK06KII, CKpenKII, IlITH4JTbI, IIMllJIaHTHpOBaHHble Kap,D;IIOCTlIMY-
JIHTOpbI IICKlllOqalOT npliMeHeHlIe :meKTpoxnpyprlIqeCKOrO B03-
,neHcTBIISI:.
3. Cocy,n KoaryJIHpyroT MOHonOJIBpHLIM 3JIeKTpo,nOM, HC-
nOJIb3YH .lummeHHe HaBCTpe'lY, B,nOJIb ero OCH (puc. 2.11). r eMO-
CTa3 MeHee Ha,n;e:>KeH, HO BblllOJIHHeTCH 6bICTpO. CJIe.n;yeT nOMHIITb,
qTO nOCJIe paCCeqeHlIH TKaHeH cocy,nbI Hepewo COKpall.{alOTCH II
«ycKOnb3alOT» C nOBepXHocTIi pa3pe3a BrJIy6b TKaHell. II03ToMY
nporpeBaHlie TKaHeH ,nOJI:>KHO 6bITb ,nOCTaTOqHO rJIy60KlIM II BbI-
nOJIHeHO nonHoueHHo.I1HTepecHo 3aMeTHTb, o apreplIH, 6JIaro-
,napSl: TOJIIUIiHe CTeHKII II B03MO:>KHOCTII UlIpKynHpHoro COKpall.{e-
HIIH, nerqe nOMalOTCSI: KoarYJISl:UHII, qeM BeHbl.
Bce 3JIeKTpoxIIpyprnqeCKlie IIHcTpYMeHTbI ,nOJI:>KHbI IIC-
nOJIb30BaTbCSI: TOJIbKO B CYXOM o epaUlIoHHoM none. CKOllJIe-
H1Ie 3HaqIITeJIbHOrO KOnlIqeCTBa KpOBIi nplIBo,nIIT K HapYllieHlIlO
II ,na:>Ke nOJIHoMY npeKpall.{eHlIlO npoBo,nIIMOCTH cpe,nbl. IIo:no-
MY, npOBo,nIITb KoaryJIHUlilO CJIe,nyeT TOJIbKO nOCJIe npe,nBaplI-
TeJIbHOH acnlIpaUHII.
KaK npli Tpa,nIIUIIOHHOM xnpyprnqeCKOM BMeIlIaTeJIbCTBe, TaK II npli JIanapOCKOnlIqeCKOM,
CJIe,nyeT C OC060H OCTOpO:>KHOCTblO nPIIMeHHTb 3neKTpOB03,neHCTBlie B 30He pacnOJIO:>KeHIISI: MarlI-
CTpanbHbIX cocy,nOB II ,npymx )l(II3HeHHO Ba:>KHbIX CTPYKTYP (:>KeJIqHbID II ceMHBblHOCSl:IUlie npOTOKII,
MOqeTOqHIIK). BHaqaJIe CJIe,nyeT 3aXBaTHTb TKaHb, OTBeCTIi ee OT ,npyrnx 06pa30BaHliH II TOJIbKO
3aTeM BKlllOqlITb HanpH:>KeHlIe. IIpli 3TOM MOIUHOCTb, YCTaHOBJIeHHaH Ha naHeJIIi 3neKTpOreHepaTO-
pa, ,nOJI:>KHa 6blTb MIIHlIMaJIbHOH, HO 06eCneLJ:IIBalOIUeH Tpe6yeMoe KaLJ:eCTBO pe3aHliH II reMOCTa3a.
B Ta6JIIIue 1, B 3aBIICliMOCTli OT 06JIaCTli npliMeHeHIIH 3JIeKTpOB03,neHcTBIISI:, nplIBe,neHa
peKOMeH,lIyeMaH MOIUHOCTb, KOTOpaSl: onpe,neJIHeTCH conpOTHBJIeHHeM TKaHeH. TaK, COnpOTHBJIe-
Hlie :>KlIpOBOH TKaHIi KOJIe6JIeTCH B npe,neJIax 800-1000 OM, 3,nOpOBOH MbllliUbl- 300-500 OM,
HepBHOH TKaHIi - TOJIbKO 100-250 OM. IIoHHTHo, LJ:TO npli pa3pe3aHIIII MbllliUbl xlIpypr ,nOJI:>KeH
IIcnOnL30BaTb MeHblliYlO MOll.{HOCTb, qeM npli pa3pe3aHlIIi :>KIIpOBOH TKaHII, II eIUe MeHbIlIYIO - ,nJIH
«BbICyuIIiBaHIIH» TKaHli rOJIOBHOrO HJIH CllIIHHoro M03ra.
06JIaCTli nplIMeHeHIIH BblCOKOqaCTOTHOH 3JIeKTpoxnpypnm onpe,neJlllIOTCjl my6IIHoH nOHJ{-
MaHIiH npOlIcxo,nHIUIiX npoueCCOB II OnblTOM xlIpypra. HeCOMHeHHO, rapMOHII oe 06'be,nIIHeHlIe
3TIIX .D:BYX COCTaBHblX n03BOJIIIT 60JIee IlIlipOKO II TBOpqeCKIi IICnOJIb30BaTb 3JIeKTpoxlIpyprlILJ:ec-
Koe B03,neHCTBlie B nOBce,nHeBHOH npaKTlIqeCKOH ,neHTeJIbHOCTIi.
)J;nSl: nplI06peTeHIISI: OnblTa peKOMeH.1IyeM CHaLJ:ana OCBOIITb npOCTeHllilIe 3neKTpOXIIPyprlI-
qeCKlie BMeIlIaTeJIbCTBa, HanpliMep, 3H,D;OCKOnlIqeCKYlO nOJIlIn3KTOMIi1O.
MO:>KHO IICnOnb30BaTb CJIe.n;ylOlI.{lIe BaplIaHTbl xlIpyprlIqeCKOH TeXHlIKII:
- KoaryJIlipOBaHlie HO:>KKII nOJIlina C nOCJIe,nYlOlI.{IIM MeXaHIILJ:eCKIiM y,naJIeHlIeM OnyXOJIII;
- KoarynlIpoBaHlie HO:>KKII nOJIlIna C nOCJIe.n;ylOIUIIM 3JIeKTpoxIIpyprlIqeCKIIM y,naneHlIeM ony-
xonlI;
.; ;- -1:-"- :,: >..
- .: ; ... ,./ (
>...
Puc. 2.11 PaCnORO:JICeHUe uHcmpy-
Menmoe e MOMenm Iwa2YRRIJuU
cocyoa aeU:JICeHUeM (waecmpe"y»,
eaORb e20 ocu
-0,D;HOMOMeHTHoe3neKTpoxlIpyprlIqeCKOeOTeeqeHlIeonyxonli.
OnepaUlilO KoaryJIHpOBaHHB HomKH nOJIHna C nOCJle.nYIOIQHM MeXaHH'IeCKHM y,naneHH-
eM onYXOJIH HaqlIHalOT C 4JIIKcaUIIII (06BIIBaHIIH) HO:>KKII neTJIeH 3JIeKTpo,na. IIocJIe llJIOTHOro 3aTSl:-
rliBaHIiH BKlllOqaIOT HanpH:>KeHlIe. Ha 3TOM 3Tane ,neHCTBYlOT nOBepXHOCTHO He60JIblliOH MOll.{HOC-
TblO 3JIeKTpOXIIpyprlIqeCKOrO reHepaTopa (l0 - 30 BT). IIo Mepe B03,neHcTBIiH TKaHb nOnHna 6eJIeeT.
33
rJIaBa 2
Ta6JIln a 1
PeKoMeH,nyeMaH MO[QIIOCTb 3JIeKTpOreIlepaTopa B 33BHCHMOCTH OT 06naCTH npH-
MeIleIlHH3JIeKTpoxHpyprH ecKorOB03 e"CTBHH
MOIUHOCfb (BT)
HII3KaH (MeHee 30) CpeJlHHH (Koarymll ml - 30-70, BI.ICOKaH (Koarymll.!HR - 60nbwe 70.
pe3aHHe 30-150) pe3aHHe 60nbwe 150)
HeHpoxnpypnrn A6AOMIJHanbHaR XHPYPrHR YponomR (TpaHcypeTpMbHaR pe-
3eK HSI)
)J;epMaToxlIpyprlIH TopaKMbHaR XHPYPrHR rHHeKonorHR (rHcTepocKonw.JecKaR
MIIOM3KTOMHR)
JIOP- XlIDVPrnH XHDvprllSI ronOBbI H well OHKoxnpyprHR
IlJIaCTIILJ:eCKaH xnpyp- COcYJlHCTaR xHpypmR
rH5I.
OqJTaJIbMOJ10rIU! OpTOneAJf'.leCKaR xHpypmSI
He,nOCTaroqHOe «BbICYlIIIIBaHlIe» npli OTCeqeHlIIi nOJIlina COnpOBO)l(,D;aeTCH BnOCJIe,nCTBIIII KpOBOTe-
LJ:eHlIeM. Ha060pOT, 1I3JIIIIlIHee 3JIeKTpOB03,neHCTBlie npliBOLlIIT K ynJIOTHeHIIIO TKaHeH II OCJIO:>KHe-
H1I1O nOCJIeLlYlOlI.{erO nepeCeqeHIIH. He06xOLllIMO nOMHIITb, qTO no Mepe 3aTSl:rIIBaHIiH neTJIIi nJIOT-
1I0CTb TOKa B03paCTaeT. n03TOMY, .D:JIH nO)J,!.J,ep:>KaHIIH nOCTOSl:HHOH ImOTHOCTIi TOKa, xnpypr ,non:>KeH
nOCTeneHHO CHII:>KaTb MOll.{HOCTb Ha npOTSI::>KeHlIII BceH llJa3bI «BbICYlliIiBaHIISI:».
HanpaBJIeHlIe KoarYJISl:UIIII OnpeLleJIHeTCH pacnOJIO:>KeHlIeM nJIaCTIIHbl naUHeHTa. He06xo-
,D;IIMO nOMHIITb, qTO B03MO:>KHbI cliryaUIIII, B KOTOpbIX TOK nOH,neT K BepXYlliKe nOJIlina II MO:>KeT
B03,neHCTBOBaTb Ha npOTIiBOnOJIO:>KHYlO CTeHKY KlilliKII (oc06eHHO B CJIyqaHX y,naJIeHlIH KpynHblx
nOJIlInOB). IIpli 3TOM CYll.{eCTByeT 60JIbiliaH BepOSl:THOCTb ee nepllJopaUlI1I (puc. 2.12). II03ToMY,
nplICTyna51. K 3neKTpoxIIpyprlIqecKoMY B03,neHcTBII1O, He06xo,nIIMO paCCqlITaTb HanpaBJIeHlIe npo-
TeKaHIiH TOKa.
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Puc. 2.12 110pa:JICellue n101WJlI
npomueOnOIlO:JICHoU cmeUKU KUUlKU
npu yi)allelluu KpynHolo nOfluna
34
,[{JIH MeXaHlIqeCKOrO cpe3aHliH nOJIlina nOCJIe npe,nBaplI-
TeJIbHOH KoarYJI5I.UHII xHpypr3aTSl:rlIBaeT neTJIeBOH :meKTpo,n. B
3T0 BpeMSI: MO:>KHO BKlllOqlITb cMelliaHHblH TOK, KOTOpblH <<,D.oKoa-
rYJIlipYeT» TKaHIi B ueHTpe HO:>KKII.
npH BTOpOM BapliaHTe 3JIeKTpoxIIpyprlIqeCKOrO y,naJIe-
HIISI: nOJIlina ,nJI5I. OTCeLJ:eIlHH IIO KH nOCJIe KoarYJIHIIHH xlIpypr
,[(OJI:>KeH pacnycTIITb neTnlO II nepeBecTIi 3neKTpo,n B pe:>KIIM pe-
3aHIISI:.
XlIpypr MO:>KeT BbIDonHHTb nOJIHn3KTOMHIO O HoMOMeIl-
TIIO. ,[{JISI: 3Toro He06xo,nIIMO 3aTSl:HYTb neTJIlO Ha HO:>KKe nonlina
II o,nHoBpeMeHHo BKJIlOqlITb pe:>KIIM pe3aHliH II KoaryJISl:WllI. £10
Mepe 3aTSl:rnBaHIISI: neTJIIi npolICxo.D:IIT nOCTeneHHoe cpe3aHlie
HO:>KKII. IIoKa3aTeJIli MOll.{HOCTII,D;JISI: OnTHMaJIbHOrO OTCeLJ:eHIISI:
3aBHCHT OT pa3Mepa nonlIna, ,nHaMe'rpa neTJIIi II TOJIIUIIHbI npo-
BOJIOKII ee 06pa3YlOIUeH. MeHblIIlIH ,nlIaMeTp neTJIII, TOHKIIH npo-
BO,n n03BOJISl:lOT nonyqlITb BbICOKYlO ImOTHOCTb 3JIeKTpoxIIPYP-
rnqeCKOrO TOKa, qTO Tpe6yeT MeHbllieH MOIUHOCTH reHepaTopa.
""'::n"""':..":«
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. MO:>KHO C YBepeHHOCTblO CKa3aTb, qTO 60JIblliYlO qaCTb n1060ro OnepaTHBHOrO BMeIlIaTeJIb-
CTBa COCTaBnSl:eT He pa3'be,nIIHeHlIe (pa3,neJIeHlIe) TKaHeH, a IIX coe,nIIHeHlIe. rJIaBHOH ueJIblO :nOH
onepaTIIBHOH MammymIl.{1I1I lBmeTCH BOCCTaHOBJIeHlIe aHaTOMlIqeCKOH ueJIOCTHOCTIi opraHOB (TKa-
HeH) II B0306HOBJIeHIIe IIX IlJYHKUIIIi. Coe,nIIHeHlIe TKaHeH ocymeCTBJISl:ercSl: HaJIO:>KeHlIeM xnpyprn-
'1eCKUX UIBOB IIJIII 6eCUIOBHLlM nYTeM.
MeTo,nIIKII 6eClliOBHoro coe,nIIHeHIIH TKaHeH no,npa3YMeBalOT IICnOnb30BaHlie Me,nIIUIIHC-
KoroKlleSl: (HanpIIMep, UliaHOKpRITaTHoro- M-l, M-2, M-3, M-4RITlinoJInypeTaHOBoro-KJI-2, KJI-
3, KOMn03IIUlIli - MK-2, MK-6), neHKOnJIaCTbipeH, ynbTpa3BYKOBOH CBapKII KOCTHOH TKaHlI, anna-
paTa ,nJISI: «3aBapIiBaHaSl:» KpynHblx COCy,nOB II T.n. B nOCJIe,nHlIe ro,nbl coe,nIIHeHlIe TKaHeH
npoM3Bo,nIITCH C nOMOll.{blO cllJoKyclipoBaHHoro ]:l0 MIIHIIMaJIbHblX pa3MepOB JIa3epHOro JIyqa. Ero
nplIMeHHIOT ,nm OCTaHOBKII KpOBOTeqeHIIH 1I3 napeHxIIMaT03HblX opraHOB, COe]:lI1HeHMH COCy,nOB
rnep,noH M03rOBOH 060JIOqKII II ,np. O,nHaKo, OTCYTCTBlie CTOHKIIX nOJIO:>KIITeJIbHbIX pe3yJIbTaTOB,
npe,ny6e)K)IeHHoe OTHOllieHlIe npaKTHKYlOII.\IIX BpaqeH, ,nOCTaTOqHO BblCOKlie ueHbI Ha 6ecIlIoBHbie
MaTeplIaJIbl cymeCTBeHHO orpaHlIqlIBalOT IIX IICnOJIb30BaHlie B xlIpyprlIlI.
I103TOMY ,D;JIH coe,nIIHeHlIH TKaHeH, B OCHOBHOM, IICnOJIb3YlOT xlIpyprnqecKlie IlIBbl. XHpyprlI-
qeCKIiH lliOB - 3TO coe,nIIHeHHe TKaHeH C nOMomblO IlIOBHoro MaTepnaJIa. OH 06eCneqlIBaeT npoq- ,
Hoe repMeTlIqHOe conpliKOCHOBeHlIe coe,nIIHHeMbiX TKaHeH Ha BpeMSI:, He06xo,nIIMoe ,nJIH 06pa30-
BaHIiH coe,nIIHIITeJIbHOrO py6ua.
IlIBbI pa3JIlIqalOT:
1) no TeXHlIKe HaJIOx.eHUH:
.' - PyqHble;
. - Mex:aHlIqeCKlie.
2) no TeXHUKe H8JIOx.eHHH U $UKC8I1HU Y3JI8:
. - OT,nenbHbIe Y3JIOBble;
111 - HenpepblBHble..
Y3JIOBOH UIOB - 3TO CoeJ!HHeHue TK8HeH CTex.K8MH. HenpepbIBHbIH - UIOB, H8KJl bl-
B8eMbIH o,nnoH HHTblO H8 'BCIO P8HY;
3) no $opMe:
35
rJIaBa 3
11& - npOCTbIe Y3JIOBble;
.. - II-06pa3Hble;
.. - Z-06pa3Hble;
.. - KJ.ICeTHble;
.. - 8-06pa3Hble.
4) no $YHKL\UU:
.. - reMOCTaTnqeCKlIe;
.. - IIHBarHHIIPYlOlI.{lIe (BBOpaqIIBalOlI.{lIe);
.. - BbIBOpaqlIBalOIUlie.
5) no KOJIH'ICCTBY pH OB:
11& - O,nHOpH,D;Hble;
.. - ,nByxpH,D;Hble;
.. - MJIOropMHble.
6) no JIUTCJIbHOCTH HaXO»\)J,CHHH B TKaIlH:
.. - C'beMHble (npedYCM£J.mpU6(110m ,ydq.JleHf,le UJQ6fLOZO Mamepuana nOCJle 6blnOJllWllWl
W,60M C60eu rjJYllKlJUU);
.. - nOCTOHHHbIe (npu HanO:J/CeHUU KornopblX UW6UblU Mamepuan 6nocJledcmeuu He yda-
man).
7) no pacnOJI02KCHHIO K TKaHHM
.. - Hapy:>KHble;
.. - BHYTpeHHlIe.
UJOB. pacnOJIO:>KeHHbIH Ha KO)!(e RITII Ha JIerKO ,nOCTynHoH ,nJISI: MaHlInYJISl:UMH CJIII3IICTOH
060nOQKe, Ha3bIBaeTCSI: HapY:>KHbIM lliBOM. ECJIII ,nJIH HaJIO:>KeHIISI: lliBa Tpe6yeTcSI: paCCeQeHlIe TKa-
HeH, TO TaKOH lliOB OTHOCSl:T K BHYTpeHHeMY. B OTnlIqlIe OT BHYTpeHHIIX IlIBOB, HapY:>KHble nOCJIe
cpaCTaHIiH TKaHeH y,naJIHlOT. .
8) npopc3LIBalOIUHccH B npocBcT opraHa (lliBbl, HaKlla,I:(blBaeMble Ha 60JIbllilIHCTBO nOJIblX
opraHoB);
9) B 3aBHCHMOCTH OT WOBHOro MaTcpHana, KOTOpblM HanO:>KeHbl norpY:>KHbIe IlIBbl:
36
.,<..fttipaccaCblBalOll{IIec$l6I1oJIoriiqeci&:e (o.nR UX Jm.no:J/CeIiUR UCnO/lb1Y'Om Ke1112ym, XPO-
MUp06Gll1lbiU 1<em2ym, KOJUlGZe1l U Op.)
. - paCCaCblBalOIUlieCH CIIHTeTHLJ:ecKlIe (O.nR UX lIQJlO:J/CeIlWI npUJWeURlOrn 6UKpWl, Oek-
COli, no.nucop6. OKl/e.nOll, KGl/e.nOll U Op.)
III -HepaCCaCblBalOlI.{lIeCH (JlQJlO:JICeflllbLe C nOMOUJblO .na6Calla, npo.nella. 6UmQ(!JOlla.
MemOJlJlUl.{eCKOU np060.n01<U U m. 11.) .
BbI60p cnoc06a II MeTO,na HanO:>KeHIIH IlIBOB Onpe,neJIHeTCSI:, C O,nHOH CTOpOHbI, OC06eHHOCTSI:-
MII COe,nIIHHeMbIX TKaHeH II OpraHOB, C ,npyroH - cBoikTBaMIi IICnOJIb3yeMoH HIITII. IIpli 3TOM He06-
XO,D;IIMO yqlITbIBaTb MHO:>KeCTBO llJaKTOpOB:
- aHaTOMlIqeCKOe II rliCTOnOrlIqecKoe CTpOeHlIe COe,nIIHHeMbIX OpraHOB II TKaHeH;
-IIX IlJYHKUIiOHanbHYlO aKTlIBHOCTb II pereHepaTOpHble CnOC06HOCTII;
- TOnorpallJlILJ:eCKlie OC06eHHOCTli II H3MeHeHIIH, B03H1IKalOlI.{IIe B TKaHHX BCJIeLlCTBlie naTO-
nOrlIqeCKOrO npouecca RITII OnepaTIIBHOrO npHeMa;
- pe3YJIbTaT B3alIMOlIeHCTBIISI: CllllIBaeMOH TKaHII II IICnOJIb3yeMoH HIITII;
- KaqeCTBO, XIIMlIqeCKIIH COCTaB II CTPYKTYPY lliOBHOrO MaTepliana II ,np.
YqlITblBaSl: 3TH llJaKTopbl, K IlIBaM npe,n'bSl:BJISl:lOTCH pa3JIIILJ:HbIe Tpe60BaHIiH. Bce OHII 1I3JIO-
:>KeHbl B COOTBeTCTBYIOli\IIX rJIaBaX. O,nHaKO He06xo,D;IIMO 3anOMHIITb: rJIaBHaH IlJYHKUnSl: lliBa -
YLlepmUBaTb pa3,neJIeHIIbIe TKaHU B COnpUKOCIIOBeHUU LlO 06pa30BaHUH Cpal.QeHUH. I1cxo,nSl:
1I3 :noro, MO:>KHO CIlJOPMYJIlipOBaTb YCJIOBIISI:, He06xo,D;IIMble ,nJISI: peaJIII3aUIIII rJIaBHOH IlJYHKUIIII
lliBa, He3aBIICliMO OT TOrO, Ha KaKYlO TKaHb IIJIII OpraH OH HaJIO:>KeH.
IIpe)l(,D;e Bcero, He06xo,nIIMO, qT06bI nOBepXHOCTII paHbI conplIKaCaJIIICb Ha BceM npOTH:>Ke-
HIIU. CJIeLlyeT TO'lHO conOCTaBUTb KpaH paUl>1 U CJIOU CUIUBaeMblX opraHOB. Me:>K,ny HlIMIi He
,nOJI:>KHO OCTaBaTbCSI: HIiKaKIiX KapMaHOB (npOCTpanCTB), r,ne MOrJIa 6bI CKanJIIiBaTbCH KpOBb IIJIII
paHeBoe OT,neJIHeMoe. CaMbIH npOCTOH cnOC061I36e:>KaTb no,n06HbIX OCJIO:>KHeHlIH - npOBeCTH limy
no,n ,nHOM paHbI. HeCOMHeHHO, B 3TOM CJIyqae HIiKaKOH nOJIOCTH 06pa30BaTbCH He MO:>KeT. IIpli
TaKOM HanO:>KeHIIII lliBa JIerqe Bcero ,nOCTHraeTCSI: prima intentio Ha BClO rJIy6IIHY paHbI. O,D;HOBpe-
MeHHO He06xo,nIIMO CTpeMIITbCSI: coe,nIIHHTb B lliBe O,nHopO,D;Hble 3a rliCTOJIOrlIqeCKOH CTPYKTypOH .
RITII 6nH3KIIe no CTpYKType TKaHIi. T OJIbKO O,D;HOpo,nHbIe TKaHli cpaCTalOTCSI: nepBIILJ:HbIM HaTj{)l(eHII-
eM C 06pa30BaHlieM He:>KHOrO II BMeCTe C TeM npOLJ:HOrO py6ua.
BTopoe YCJIOBlie ,nJIH 6b1CTpOrO 3a:>KIIBJIeHIISI: paHbl - 3TO nOJIHaH OCTaHOBKa KpOBOTe'le-
HUH nepeLl3aUIuBaHueM. 06 3TOM 3a60THTcH Bcer,na, HO B TO :>Ke BpeMH 3TOMY qaCTO He nplI,Z:(alOT
3HaqeHIIH. IlIBbI ,nOJI:>KHbI 06eCneqlIBaTb reMOCTa3 no JIIIHIIII IIX HaJIO:>KeHIISI: II, B pSl:,ne cnyqaeB,-
61I0JIOrnqeCKYlO repMeTlIqHOCTb OpraHOB.
TpeTbe YCJIOBlie - MeXaHU'IeCKaH npO'lUOCTb HUTen U OTcyrcTBue BCHKoro HaTSImeHUH
UIBOB. CIIJIa, HanpaBJIeHHaH Ha y,nep:>KaHlie cOnOCTaBJIHeMblX TKaHeH, ,nOJI:>KHa 6bITb 60JIbllie, qeM
CIiJIa pa3'be,D;IIHeHIIH, B03H1IKalOIUaH npli IIX HenpeMeHHOM OTeKe, IlJYHKUIiOHaJIbHOH aKTHBHOCTII
RITH 1lJ1I31ILJ:eCKOH HarpY3Ke. 3TO Tpe6yeT BbI60pa ,nOCTaTOqHO npOqHOH HIITII.
B TO:>Ke BpeMH, He06xo,D;IIMO 1I36eraTb Tyroro 3aBH3bIBaHliH Y3JIOB IIJIII CIIJIbHOrO CTsrrlIBaHIiH
KpaeB paHb!. B npOTIIBHOM CJIyqae, rrplIHIIMaH BO BHIIMaHlie llJaKT nOCTTpaBMaTIILJ:eCKOrO OTeKa
TKaHeH, 3TO onaCHO B03MO:>KHbIMIi OCJIO:>KHeHIIHMII. ECJIII HIITKII He 3JIaCTHLJ:HbI, TO COnOCTaBJIHe-
Mble TKaHIi OT 3TOro OTeKa (HanpIiMep, KO:>Ka) Bee-TaKIi HeMHoro npOpe:>KYTCSI: (puc. 3.1). Ha MeCTaX
37
rJIaBa 3
Puc. 3.1 11pope3allue mKalleti e 06nacmu
Ulea no npu'tu/le nocmmpaeMamu'teCKOZO
omeKa
npOKOJIOB 06pa3YlOTcSI: MaJIeHbKlIe paHbl, KOTO-
pble MOryT IIHIlJIIUlipOBaTbCH. BMeCTe C TeM, Ha-
ClInbCTBeHHoe C6nlI:>KeHlIe KpaeB COnpOBO:>K,naeT-
CH HapYilieHlIeM KpOB006pali\eHIIH, HeKp030M.
qeTBepTOe YCJIOBlie - 3TO lIa,ne*HaH acen-
THKa H allTHcenTHKa, KaK OTHOCIITeJIbHO caMIiX
lliBOB, TaK II OTHOCIITeJIbHO KO:>KH 60JIbHOrO (one-
paUlIoHHoro nonSl:). nOCKOJIbKY ynOM5IHYToe yCJIO-
Blie 06S1:3aTeJIbHO MSI: JI1060H OnepaUHH, TO Ha 3TOM
OCTaHaBnlIBaTbCSI: He 6y,neM.
)J;JIH HanO:>KeHIISI: xlIpyprHqeCKOrO IlIBa nOHa,n06S1:TCH IIrJIo,nep-
:>KaTeJIb, nliHueT, xlIpyprwleCKa5I IIrJIa II HIITKa.
I1rJIo,nep)KaTeJIb IlJIIKCIIPYIOT npaBOH KIICTblO, KaK HO:>KHlIUbI (CM.
Bbillie). YKa3aTeJIbHblH naJIeu HaXO,nIITC5I Ha nOBepXHOCTIi 6paHlli, qTO
n03BOJISl:eT ocy eCTBJIHTb TO'lHbIe, KOHTpOJIlipyeMbie ,nBII:>KeIIlIH
(puc.4.1) .l1ma IlJHKCIiPYeTCH B6JIII31I KOMqIIKa 6paHill IIrJIo,nep:>KaTeJIH
(Ha rpaHIIue ,nHCTaJIbHOH II cpe.D:HeH TpeTIi pa60qlIx KOHUOB). KpaHHe
,nIICTanbHoe pacnOJIO:>KeHHe HrJIbI B IIrJIo,nep:>KaTeJIe HeHa e:>KHOe - HrJIa
MO:>KeT BbICKaJIb3blBaTb npli npOlliliBaHlI1I nJIOTHbIX TKaHeH. He:>KeJIa-
TeJIbHO pa3MernaTb ee II B6JIII31I 3aMKa IIrJIo,nep:>KaTeJIH. B 3TOM CJIY-
qae 1I3-3a qpe3MepHOH CRITbI, nplIKJIa blBaeMOH KO'pOTKIIM pbIqarOM
6paHIIIII, IIrJIa MO:>KeT BbIBO,nIITbCH 1I3 CTpOSl: (puc. 4.2).
OCTplie IIrJIbl 06pamalOT B CTOPOHY paHbI, YlliKO BMeCTe C 3apH-
:>KeHHOH B IIrJIY HIITKOH - KBepxy (HIITKa ,nOJI:>KHa CBIICaTb cB060,nHO), nplIqeM npOLleTblH ee yqaCTOK
,nOJI:>KeH COCTaBn5ITb nplI6JIH3IITeJIbHO TPeTh BceH JIIIHbI. ,[{JIIiHa HIITKII 3aBliCIIT OT XapaKTepHCm-
KII npe,nnOJIaraeMoro IIIBa. ,[{JIH HenpepblBHbIx lliBOB HY:>KHO B3S1:Tb ,nmumylO HIITb, a.l1llil OT,neJIbHbIX
Y3JIOBbIX - MIiHa HIITII LlOJI)KHa COOTBeTCTBOBaTb cnoc06y 3aBSl:3blBaHIISI: Y3JIa.
IIIIHueT, KOTOpblM IlJIIKCIiPYlOT npollumaeMYlO TKaHb, y,nep:>KIIBalOT B JIeBOH pYKe..ZJ:JIH a,D.eK-
TEXHMKA HAnO EHM
XMPyprnQECKMX IIIBOB
p. . . . . ,' .. ..,/ . .,; .. }.'1
. .... ./ /':: 'f
"
,'-' u.
/
:;r:C
-, -Z:L
\r.,/'
//
ri-\ .. - d (.
":' c--./ ,
Puc. 4,3 PaCnOllO:JICellUe Ulllbi
OIH: " _ . .
rna-sa 4
--,
t,",
/ '.
\, ', \ j",
« , -t -/i 1 .
\'(
-,: ;, ;: ;
. .
Puc, 4.1 Cnoc06 yoep:JICu-
eaHUR ulllooep3ICamellR
,
//
..,. /
\:.... <
.;:, ',', '
"'<:..>i,y. ,
. -
Puc. 4.2 l!>uKCaI/UR UlllOaep-
:JICamelleM Ulllbi
omllocumellbllO 1lJlOCKOl'mU
npoUlueaeMou mKa1IU
Puc. 4.4 1101l03ICeHue KUcmU npu
YKolle U ebleeoelluu Ui'lIbl U3
mKaHeti
39
rJIaBa 4
( ---
L
,! . '!'-.
;Jl. I .
(' ,;' 1
;
1/-"
\,> , .-1
) !\
<iT.. t----
<, .' ." ,t ,
., 16," ....,
, '4... ',
1 , ' ::. \ ..\-
.....-' \:. '\.
;; \...,
Puc, 4.5 PaCnOflO:HCeHUe
nemeflb Y3/llJ COOK}' om paHbl
Puc. 4,6 HaHu3bleallue mKaHeu
nUHl4emOM Ha UZlly
_..JII . , .
"j("t'.\\"' ?!,
( ;;: 1
-'llJt: .
f;rc;. :(
--
Puc. 4. 7 PaCnOflO:HCeHUe Y3floe
C60KY om paHbl
BaTHOH IlJIIKcaUlI1I TKaHb CJIe,nyer 3aXBaTbIBaTb MaKCIiMaJIbHO 6JIII:>Ke K TOqKe YKOJIa IIrnb!. 3TO
06JIerqaeT npOKOJI II ee npO,nBlI)l(eHlIe. qeM nnOTHee TKaHII, TeM 6nlI:>Ke CJIe.nyeT pacrrOnaraTb 6paH-
IlIH llIIHueTa K TOqKe YKOJIa.
I1my BKaJIbIBalOT CTporO rreprreH,D;IIKymlpHo K nnOCKOCTIi npOllIliBaeMOH TKaHIi (puc. 4.3).
IIpli YKOJIe II, oc06eHHo, rrpli BbIBe,neHIIII IIrJIbI pYKa ,nOJI:>KHa Haxo,nIITbCSI: B nOnO:>KeHlIIi rrpOHauliM
(puc.44).
He06xo,nIIMO npaBIIJIbHO 1lJ0pMIIpOBaTb TpaeKToplilO .D.BII:>KeHIIH limb!. IIocJIe YKOJIa limy
Be,nYT qepe3 TKaHII' 3aCTaBJISl:H ee ,nBliraTbCH no OKpY:>KHOCTIi a,neKBaTHoH ee KpIIBII3He. B II,neane
IIrna ,non:>KHa npoxo,nIITb qepe3 06a KpM paHbI cTporo cIiMMeTplIqHO, 3aXBaTblBaH npli 3TOM B lliOB
O,D;IIHaKOBOe KOJIlIqeCTBO TKaHeH. O.D.HaKO He Bcer,na CJIe,nyeT CTpeMIITbCH K O,D;HOMOMeHTHoMy npo-
Be,neHlllO IIrJIbI qepe3 06a KpaH. ,[{BYXMOMeHTHOe npOBe,neHlIe C BblXO,nOM B rny6IIHe paHbI rr03BonH-
eT 60JIee npaBIIJIbHO cllJopMlIpoBaTb CTe:>KOK lliBa. Oc06eHHO 3T0 KaCaeTCSI: rJIy60KliX paH.
ECJIII B MOMeHT npOIlIlIBaHIIH KOHUOM IIrnbI pbIqaro06pa3HO nplIrrO,D;HIIMaTb TKamI, HaHH3bl-
BaSI: 60JIbllilie MaCCliBbl, TO IIrJIa, KaK npaBIIJIO, JIOMaeTCH.
BblKaJIblBaTb limy Ha,D.O B Herrocpe,nCTBeHHOH 6JIII30CTII K 6paHlliaM nliHueTa. KaK TOJIbKO
Ha nOBepXHOCTIi TKaHIi nOHBIiTCH KOHqlIK IIrJIbI, ero 3aXBaTbIBalOT IIrJIO.D.ep:>KaTeJIeM. IIpli :nOM
KIiCTh ,nOJI:>KHa Haxo,nIITbCH B nOJIO:>KeHIIII npOHaUIIII, qTO 06eCneqlIT ,nOCTaTOqHYlO aMnnIITY.ny noc-
ne.nylOIUIIX ,nBII:>KeHIIH npli BbIBe,neHIIII IIrJIbl. B npOTIIBHOM CJIyqae (T.e. Kor,na KIICTb Haxo,nIITCH B
nOJIO:>KeHIIII cynIIHaUIIII), 06'beM ,D;B1I:>KeHIIH 6y,neT OrpaHlIqeH, O npoBoUlipyeT He:>KeJIaTeJIbHOe
BOBJI qeHlIe npe,nnJIeqbH II nneqa.
I1my II3 TRaHeH CJIe,nYeT BbIBO,nIITb KpyroBbIM ,nBII:>KeHlIeM KIICTII (cynIIHaUIIH) no TpaeKTO-
plIlI, COOTBerCTBYlOlUeH KplIBII3He IImbI (puc. 4.5). I1plI Hec06nlO,neHIIII TIaro npaBHlla lIma BbIBO-
,D;IITCH C Tpy,nOM, nOBpe)l(,D;aH TKaHli.
IIpli ClliliBaH1I1I MSl:rKIIX TKaHeH MaHlIrrYJISl:UHII CJIe,nYeT rrpOBo,nIITb OCTOpO:>KHO, 1136eraSl: pe3-
Koro, HaCRITbCTBeHHoro npOTaJIKlIBaHIIH IIrJIbI. TKaHIi CJIe,nYeT HaHII3blBaTb Ha KOHqlIK IIrnbI aKKY-
paTHo, IICnOJIb3YH.D:JIjI 3TOH ueJIIi nliHueT (puc. 4.6).
He06xo,nIIMO npoIlIIiBaTb (<Ha ce6S1:», T.e. lImy BKaJIbIBaTb B ,nanbHlIH OT xlIpypra KpaH PaHbI,
a BbIKaJIbIBaTb - B 6nlI:>KHIIH. BMeCTe C TeM HY:>KHO nOMHIITb, qTO eCJIIi O,D;IIH 1I3 ,nBYX KpaeB paHbI
M06RITbHbIH, a BTOpOH IlJIIKClipOBaHHbIH, TO npOIlIIIBaTb, npe)l(,D;e Bcero, CJIe.nyeT M06RITbHbIH. ECJIII
npe.D.YCMaTpIiBaeTCH npOllIlIBaHlIe KpaeB, IIMelOlI.{IIX pa3HYlO TonIUIIHY, IlIIITb HaqlIHalOT C 60nee
TOHKOro.
CJIe,nyer CJIe,D;IITb 3a TeM, qT06bl paCCTOSl:HlIe OT KpaeB partbI, COOTBeTCTBeHHO, K MeCTY YKO-
JIa II K MecTy BbIKaJIbIBaHIIH, 6bmo o,nIIHaKOBbIM.
40
IIpII COe,nlIHeHIIII TRaHeH Y3JIOBbIMIi lliBaMIi aCCIICTeHT y,nep:>KIIBaer CB060,D;Hb1H KOHeu HIITII
Ha npOTSo':>KeHIIII BCeH MaHlIrrynHUIIII II 3aXBaTblBaeT ee ,npyroH KOHeu, KaK TOnbKO OH BbIH,neT II3
YiliKa IIrnbl. B npouecce HanO:>KeHHH HenpepbIBHOrO llIBa OH nocTosrHHO y,nep:>KIIBaeT KOHel..{ HIITH B
HaTH:>KeHIIII, TeM CaMblM 4JIIKCIIPYH COe,nIIHeHlIe rrpOilllITbIX TRaHeH.
)J;mI npaBlInbHOrO HanO:>KeHIIH Y3JIOBOrO lliBa Y3JIbI pacnOJIaralOT C60KY OT paHbl, a He Ha,D.
HeH (puc. 4. 7) . ECJIII KpaH paHbl IIMelOT o,nIIHaKoBYlO TOJIIUHHY, TO He IIMeeT 3Ha qeHIIH, Ha KaKOH H3
CTOpOH OHII pa3MeIUaIOTcH. Ho, Bce :>Ke, Y3JIbl :>KenaTenbHO pacnOJIaraTb rrOOqepe,nHO Ha pa3HbIX
CTopOHax paHbI. PaHbille 3TOro npaBRITa npH.D:ep:>KIIBanIiCb KaK,D;JIH rny60KlIx (norpY:>KHbIX), TaK II
,D;JIH nOBepXHOCTHbIX (C'beMHbIX) lliBOB. Cero,nHH 3TOMY He rrpH.D:aIOT oc060ro 3HaqeHIIH.
)J;nH coe,nIIHeHmI :>Ke TKaHeH c pa3HbIMII no M06RITbHOCTII KPaHMII paHbI, Y3JIbI ,non:>KHbI
pacnOJIaraTbCH Ha MeHee rro,nBII:>KHOM Kpae.
rnaBa 4
IIEPBhlH 3AKOH IIAPKHHCOHA
..". .
,.... I"
, - ".
' ..""..r- .
,,,," :
, ""If
.":. .<' """ .' /"Y
Pa60Ta 3anonHHeT Bce OTBe,neHHoe Ha Hee BpeMH; 3Ha qlIMOCTb II CJIO:>K-
Hoen ee pacTYT npHMO nponopUlioHanbHo BpeMeHII, 3aTpaqeHHoMY Ha Bbl-
nonHeHlIe.
BTOPOH 3AKOH IIAPKHHCOHA
Pacxo,nbI CTpeMHTcH cpaBHHTbCH c,noxo,naMII.
3AKOH Il)KOHCOHA H JI3P/M
3y6HaH 60nb 06blqHO HaqlIHaeTCH B HOqb Ha cy660Ty.
IIPABHJIA B3AHM03ABHCHMOCTH PHlJAPjJA
1. To. qTO BbI xpaHlITe.nOCTaTOqHO ,nOJIro. MO:>KHO BbI6poCIiTh.
2. KaK TonbKO BbI qTO-TO Bbl6poclITe, OHO BaM nOHa"u:06IITCH.
YPABHEHHE CM3H(/JY
KaK TOJIbKO BbI IIcnp06yeTe Bce B03MO:>KHble cnoc06bl perneHIIH II He HafuJ.eTe no,nxo,nHlI.{e-
ro, TYT :>Ke HaH,neTCR perneHlIe npocToe II OqeBH.D:HOe ,nJIH Bcex ,npyrlIx nlO,neH.
3AKOH MECKHMEHA
Bcerna He XBaTaeT BpeMeHII, qT06bI BbIllonHIITb pa60TY KaK Ha,D.O, HO Ha TO, qT06bI ee nepe-
,neJIaTh, BpeMSI: Haxo,nIITCSI:.
3AKOH FPEX3MA
IIYCTHKOBble BonpocbI pernalOTcH 6bICTpO; Ba:>KHble - HIIKor,na He peIlIaIOTCH.
3AKOH jJ)J(YX3HH
KOMnpOMlIcc Bcer,na 06XO,nIITCH ,nopo:>Ke, qeM JIlO6aH II3 anbTepHaT.HB.
3AKOH IIOTTEP A
BeJIlI'flma peKllaMHoH lliYMIIXIi BOKpyr TOBapa 06paTHo nponOpl.\IIOHanbHa ero peanbHoH
ueHHOCTII.
" .
42
-.,....0..--..>. .'
rmtBa 5'
;." ........
.t. ,_,. . ___ i'\ ... , :
.. . COBP MEHHbIE MATEPMAJlbI,
....;RCnOJIh3 EMbIE )].JIR HAJlQiKEHMll
XHPypriitiEcKoro IIIB
1ll0BHbIH MaTeplian - 06l1.{ee Ha3BaHlie pa3Ho06pa3HbiX MaTeplianOB (HIneH, IIrJI II np.),
IIcnonb3yeMbIx ,nJIH coe,nIIHeHIIH TKaHeH (HanO:>KeHIIH xlIpyprlIqeCKOrO lima) IIJIII nepeBH3KII co-
Cy,nOB. XIIpyprlIqeCKlie HIITII - llJaKTH1JeCKIi e,nIIHCTBeHHbIH IIHOpO.aHbIH MaTeplIan, OCTalOlI.{lIHCH B
opraHII3Me nOCJIe 3aBeprneHIIH onepal.{IIII. II03TOMY, BnOJIHe 3aKOHOMepHO, qTO ee IICxo,n HanpH-
MYlO 3aBliCliT OT CBOHCTB HIITeH II peaKUlI1I Ha HIIX OKPY:>KaIo-
lI.{lIX TKaHeH.
Ha pa3JIIIqHbIX 3Tanax pa3BIITIIH MeJJ:IIUIIHbI B KaqeCTBe
xlIpyprl1qeCKIiX HIiTeH IICnOITb30BanlI: CYXO:>KRITbHble BOJIOKHa
MJIeKOIUlTalOlI.{lIX (KpblC, KorneK, KIITa, ceBepHoro OJIeHSI:, KeH-
rypy), KO>K)' pbI6 II 3eMHOBO,D;HblX, HIITII II3 aOpTbI, llJacUHH, TBep-
,nOH M03rOBOH 060noqKII KpynHoro poraToro CKOTa, HepBHblX
BOJIOKOH c06aKlI, qeJIOBeqeCKOH nynoBIIHbI, KOHCKoro BOJIO-
ca, BonOKOH KOHOnJIII, KOKOCOBoro opexa II KayqYKoBoro ,ne-
peBa. TIplIMeHj{JIaCb TaK:>Ke B KaqeCTBe rnOBHoro MaTeplIaJIa
II pbI60JIOBHaH neCKa. O,nHaKO He,nOCTaTKII 3TIIX MaTeplIanOB
(CJIO:>KHOCTb nOJIyqeHII5I, peaKI.{IISI: TKaHeH, B03MO:>KHOCTb IIH-
IlJIIUlipoBaHIIH HIITH, He,nOCTaTOqHbIe MeXaHlIqeCKlie CBOHCTBa)
npen5lTCTBOBanli IIX IlIIiPOKOMY nPIIMeHeHlIlO.
DJIaro,napSl: .aOCTII:>KeHIIHM HaYKII II TeXHIIKII, B COBpe-
MeHHYlO xlIpyprlIlO npo o BOIlIJIII HOBbIe HIITII. OHII npaKTII-
qeCKII nonHOCTblO y,nOBJIeTBOpHlOT Tpe60BaHIISI: xlIpyproB K
IlIOBHOMY MaTePlIanY. XOTH pellilITb rnaBHYlO np06JIeMY - JIII-
IlIIITb IIX aHTlIreHHblX II peaKToreHHblX CBOHCTB nOKa qTO He
y,nanOCb.
XlIpyprlI'iecKlIe HIITII npHHHTO KllacclIllJlIUlIpm:aTb no
HeCKonbKIIM nplI3HaKaM:
I. IIo CTpoeHHIO pa3JIlIqalOT:
XMPyprMQECKME HMTM
'"
)
. "i. ..
PIIC. 5.1 CmpoeHue MOIJOt/JUJ/llMeHm-
/JOU Itumu Ita pa3pe3e
PUC. 5.2 CmpoeHue Kp)"Ie/Jou Humu
lIa pa3pe3C. KpY'IeltaJi /Jumb
nonY'IaemcJI npu CKpY'IUea/Juu
eonOKO/J no ocu
43
rnaBa 5
III - MOIlOpUJ1w>teltmltylO llumb (MOHOHlITb), KOTOpaji
npe,nCTaBmleT C060H e,nHflOe BOJIOKHO C rJIa,nKoH nOBepx-
HOCTblO (puG. 5.1), HanpliMep, npOJIeH, PDS, ;:JTIIJIOH, ,nep-
ManOH, MaKCOH, HeHnOH, cyp:>KRITeH, cyp:>KlInpO, MlipaneH,
,na IIJIOH,KOpaJIeH(IlJJIeKCaMH.D:),MaKClIJIeH,MeTaJIJIlIqec-
KaH npoBonoKa II ,np.;
-...
Wi - KOMll.1leKCllylO llumb, COCTOHIUYlO 1I3 MHO:>KeCTBa BO-
nOKOH. B 3aBIICIIMOCTII OT cnoc06a coe,nIIHeHIISI: BOJIOKOH
OHa 6blBaeT:
> KpyqeHaji - BOJIOKHa H1ITII cKpyqeHbl no OCII (neH,
KpyqeHblllilleJIK, KanpOH) (puc. 5.2).
> nJIeTeHaH - BOJIOKHa H1ITII CImeTeHbl no Tliny Ka-
Han (JIaBCaH, 3TII60H)J" MepClIJIeH, MepcIDIK, HypOJIOH, ,neK-
coHIIn,np.) (puc. 5.3).
> KOMnJIeKCHaH nOKpblTaH - ImeTeHaH HIITb, npo-
mnaHHaH II (IIJIII) nOKpbITaji nOJIlIMepHblMlI MaTeplIanaMIi
(BIIKPRIT, nOflncop6, cYP)l(l1,D;aK, TlIKpOH, 6panoH, cynpaM
IlJTOp3Kc, IlJTOpnIIH) (puc. 5.4).
PUC. 5.3 Cmpoellue nJ/emeHOU
lIumu lIa pa3pe3e
/{:],.
.4:11
Puc. 5.4 CmpoeHue KOMnJ/eKC-
HOU Humu lIa pa3pe3e. KOMn-
J/eKCHaR Humb nOJ/Y'laemCR npu
nOKpblmuu nJ/eme1l0U llumu
nOJ/UMepllblM MamepUaJ/OM
II. IIo cnoco6HoCTH K paccacblBaHulO (6HOD.eCTPYKUHU) B TKaHHX opraHu3Ma pa3nlIqaIOT
HHTII:
.. - paccacb16alOU{ueCJl (a6cop6IIPYlOIUliecH) - KeTrYT (npoCToH, XpOMlipoBaHHbIH, C
YCKopeHHbIM CpOKOM paccacblBaHIIH), MaTeplIaJIbl Ha OCHOBe nOnlIrJIIIKonH.D:OB (BIIKpIIJI,
nom1cop6, 6IIOCIIH, ,neKcoH, MaKcOH), ueJIJIlOJI03bl (OKUeJIOH, Kau.eJIOH, pIIMIIH), Ha OCHOBe
nonIirneKanpOHa-25 (MOHOKpRIT), nOJIH.D:IIOKCaHOH (PDS II PDS II), nonlIypeTaHOB (nom1-
YPeTaH);
III - YCJl06UO pacCaCb16a1oU{ueCJl- IlIeJIK (BOll.{eHbIH II 06pa60TaHHbIH CIiJIlIKOHOM),
nOnIiaMH.D: (KanpOH);
III - llepaCCaCb16a1oU{ueCJl- nonlI31lJIIPbl (MepCRITeH, 3TII60H,lJ" naBcaH, cyp:>KH.D:aK, 3THIlJ-
neKc, THKpOH), nOJIlIOnellJlIHbI (nponeH, cyp)l(lInpo, nonnnpOnRITeH, Cyp:>KRITyH, nOJIII3TRITeH),
IlJTOpnOJIlIMepbI (4JTop3CT, ropTeKc, IlJTOPJIOH, 4JTop3KC, IlJTopnlIH), nOJIlIBlIHlUIII.JJ:eHbl (Kopa-
neH), MeTanJIHqeCKaH npOBonOKa (CTanbHaH, HlIXpOMOBaH, ImaTIIHOBM), JIeH, XJIOnOK, KOH-
CKIIH Bonoc.
< ".- , .-".
. >__ .> 0 <
. " -.--;""""__' ,......, , "''''''.' ""v:.
44
III. IIo HCTO'IHHK)', 1I3 KOTOpOro rrpOlI3BOMTCH, pa3JIlIqalOT H1ITII:
III . l1pUpOOllble Op2aUUtJeCKUe (6UOfl02U'ieCKUe) - KeTrYT OBeqlIH II KpynHoro pOraTO-
1'0 CKOTa, llIeJIK, KOHCKIIH Bonoc, H1ITII 1I3 4>acUIIH, CYXO:>KRITIIH, apTeplIH, HepBOB, MycKynb-
HbIX TSI::>KeH, 6plOIlIIIHbI, TBep,nOH M03rOBOH 060JIoqKII )l(IIBOTHblX, HIITH 1I3 nyrroBIIHbl qeJIO-
BeKa, neH, npolI3Bo,nHble ueJIJIlOJI03bI (oKueJIOH, KaueJIOH, pIIMIIH);
II - npupoollble ueOp2allU'ieCKUe - MeTarlJIlIqeCKaH npOBOJIOKa (CTanbHaSl:, HlixpOMOBaH,
llJIaTIIHOBa5.1);
III - nOfluMepHble uCKyccm6eHllble U CUllmemU'ieCKue:
1. IIpOII3Bo,nHbIe nOJIlIrJIIIKOneBOH KIICJIOTbl.
- rOMOnOJII1MepbI rrOJIlIrITl1KOJIeBOH KIICJIOTbI (,neKcoH).
- COnOJIIiMep rrpolI3Bo,D;HblX rnlIKOJIeBOH II MOnOqHbIX KIICJIOT, nOJIlItnaKTIIH-91O, II3
KOToporo rrpOlI3BO.lUITCSI: CJIe,nYlOIUlie HIITII: BIIKpRIT - ruIeTeHaH HIITb C nOKpbITlIeM, COCTO-
Sl:IUHM 1I3 rrOJIlIrJIaKTIIHa-370 II KaJIbI..{IISI: cTeapaTa.
- CononlIMep rITIIKOJIII.D:a II E-KarrponaKTaMa (MOHOKpRIT).
- CononlIMep fJIlIKOJIeBOH KIICJIOTbI II TpliMeTRITeHa Kap60HaTa (MaKcoH).
2. IIPOII3Bo.r:ulliierioJIII.D:IIOKCaHOHa - PDS H PDS II,
3. IIOJIII31lJIIpbl (MepCRITeH, naBCalI, cyp:>KH.D:aK, 3TlIllJneKc, TIIKpOH, nonmCTep, ,naK
pOH, ,narpoIlJRIT, TepRITeH, aCTpaneH, 3TII60H.D:).
4. IIOJIIiOnellJ"Hbl (nponeH, cYP:>KlIrrpo, nOJIl1npOmilleH, cyp)KRJ1eu, TIOmt3THnefl).
5. <1>TopnOJIIiMepHbIeMaTeplianbl (IlJTOP3KC, 4JTOpJIIIH, IlJTop3CT, ropTeKc, IlJTOpnoH).
6. IIOJIII6YTecTepbl (HOB3<pRIT).
XlIpyprnqeCKlIe HIITII ,nOJI:>KHbI 6bITb ,nOCTaroqHO MeXaHlIqeCKIi rrpOqHblMII, 3JIaCTlIqHbIMII,
YMepeHHo paCTH:>KHMbIMII, IIMeTb rJIa,D;KYlO, POBHYlO rroBepxHocTb, XOpOiliO CKOJIb3IITb B TKaHHX,
He rrpHqlImm ,norrOITHHTeJIbHbIX nOBpe)l(,D;eHIIH npli rrpOIlIIIBaHlIII. B TO :>Ke BpeMH OHII He ,nOJI:>KHbI
06JIa,D.aTb rlirpOCKOnlIqeCKIIMII' KarrlIJImlpHbIMIi CBOHCTBaMlI, 6bITb TOKClIqHbIMII, aJIJIepreHHbl-
MII, TepaToreHHblMII, KaHl..{eporeHHblMIi B OTHOlileHlI1I opraHlI3Ma.
PaCCMOTpIiM HeKOTOpbIe rrplIBe,neHHble Tpe60BaHIIH.
IIpe)l(,D;e Bcero, xlIpyproB IIHTepecyeT MeXaHH'IeCKaH npO'IHOCTb HIITII. IIplIqeM He06xo-
,nIIMO yqlITbIBaTb He CTonbKO rrpOqHOCTb caMOH HIITH, CKonbKO ee rrpOqnOCTb B Y3JIe (60nblliIIH-
CTBO HIiTeH rrpII 3TOM TepHlOT OT 10,n0 50 % npOqHocm).
PaccaCbIBalOlI.{lIeCH MaTeplIanbl xapaKTeplI3YlOTCH ,nonOJIHIITeJIbHbIM napaMeTpoM -
CKOpOCTblO rrOTepII npOqHOcTII. OHa He ,nOJI:>KHa npeBbIIlIaTb CKOpOCTb 06pa30BaHliH py6Ua. B
a6,nOMIiHaJIbHOH XHPYPrHlI rrpII 3aIlIIIBaHHII pan :>Keny,nOqHO-KlIllieqHoro TpaKTa npOqHblH py6eU
06pa3yeTcH Ha npOTSI::>KeHIIII 1-2 He,neJIb, npII 3allilIBaHIIII TKaHeH C HeBblCOKIiMII pereHepaTop-
HbIMIi CBOHCTBaMIi (anoHeBp03) - 3-4 He,neJIb. COOTBeTCTBeHHO paccacbIBalOIUlIecH xlIpyprlI-
qeCKlie HIITH ,nOJI:>KHbI coxpaHHTb ,noCTaTOqHylO rrpOqHOCTb B TeqeHlIe 2-4 He,neJIb nOCJIe onepa-
UIIIi. B npoTIIBHOM CJIyqae, eCJIII npli 3allilIBaHIIII anoHeBp03a IICrrOJIb30BaTb HIITII, TepHlOIUlIe
npOqHOCTb ,no 14 CYTOK, cyIUecTBYeT B03MO:>KHOCTb 3BeHTepaUIIIi.
45
rnaBa 5
Ba:>KHbIM CBOHCTBOM xlIpyprlIqeCKIIX HIITeH HBJISl:eTCH TaK:>Ke IIX 6HOJIOrU'IeCKaH COBMeCTH-
MOCTL C TKaHHMH naQueHTa. Bce II3BeCTHble HIITII 06JIa,Z:(alOT aHTlIreHHblMII II peaKToreHHblMH
CBOHCTBaMIi. A6cOJIlOTHO IIHepTHbIx, apeareHHbIx MaTeplianOB He CYIUeCTBYeT. PeaKUIISI: opraHlI3-
Ma Ha IIHOPo,nHoe TeJIO (B Bll,Z:(e peaKUlI1I BocnaneHIIH II 3H.D:oreHHOH IIHTOKCIIKal.{IIII opraHlI3Ma) B
60nbilieH IIJIII MeHbilieH CTeneHII nplICYTCTByeT Bcer,na. B H.D:eaJIe CTeneHb ee npOHBJIeHIIH ,nOJI:>KHa
6bITb MIIHIIManbHOH. YqlITblBa TO, qTO Y:>Ke caM llJaKT paccaCblBaHIiH IIpe,nYCMaTpIiBaeT B3aIIMO-
,neHCTBlie HIITeH II opraHlI3Ma, norlIqHO c,neJIaTb BbIBO,n 0 ,nOCTaTOqHO BblCOKOH 6IIOCOBMeCTliMOCTli
COBpeMeHHblX HepaccaCblBalOlI.{lIXCSI: HIITeH.
BblCOKlIe rlIrpOCKonH<J:eCKlIe II KanHJIJI pHble CBOHCTBa HIiTeH CIIoc06cTBYlOT COp6UHII Ha
H1IX paHeBoro OT,neJIHeMoro. B YCJIOBIIHX ,nOCTaTOqHOrO KOnlIqeCTBa nliTaTeJIbHOrO MaTepliana .aa:>Ke
HlIqTO:>KHaH IIHllJeKUlIoHHaH IIHTepBeHUIIH 6y,neT cnoc06CTBOBaTb 6YPHOMY pa3BIITII1O BocnaneHH .
C03,naeTCH IIHllJeKToH - nOKanbHoe HaKOllJIeHlle IIHllJeKulIoHHoro MaTePlIaJIa, KOTopoe cnoc06HO
nOBpe.aIITb 61I0nOrHqecKIIe 6apbepbl. ,[{JIH CHII:>KeHIIH peaKToreHHblX CBOHCTB HIiTeH IIX nOKpbIBalOT
cneUlIanbHblM nOKpbITHeM.
Euo,nerpa.aaQHOHHLle CBOHCTBa xlIpyprHqeCKIIX HIiTeH OIIpe,neJIHlOTCH cnoc06HOCTblO pac-
caCblBaTbCH II BblBO,nIITbCH II3 opraHlI3Ma. B TO :>Ke BpeMH 6IIo,nerpa.aaUIISI: ,nOJI:>KHa HacTynaTb He
paHee onpe,neJIeHHOrO BpeMeHII, He06xo,nIIMoro ,nJIH 06pa30BaHlIH cpaIUeHIIH. TIoCJIe BbIllOJIHe-
HIIH CBoeH OCHOBHOH MIICCIIH HIITb CTaHOBIITC 6eCIIOJIe3HbIM IIHOpO,nHbIM TeJIOM. II03TOMY B H.D:e-
ane nocne BbIllOJIHeHlIH CBoeH IlJYHKUIIII ee He06xo,nllMO y,nanIiTb. I1CKJIlOqeHUe COCTaBJIHlOT JIlIllib
HIITII, coe.aIIHHlOIUlie npoTe3 C TKamIMII, TaK KaK Me)l(,D;Y HIIMII HIIKor,na He 06pa3yeTcH py6ua.
KaqeCTBO xlIpyprlIqeCKIiX HIITeH OIIpe,nenHeTCH aTpaBMaTH'IHOCTLIO. qeM 60JIee rJIa,nKYlO
CTPYKTYPY HMeeT nOBepXHOCTb HIITII, TeM MeHbille OHa nOBpe)l(,D;aeTTKaHb. YqlITbIBa HepOBHYlO
nOBepXHOCTb Bcex KpyqeHbIX II nJIeTeHblX HlITeH, IIpli IIX npOTHrHBaHlI1I <J:epe3 TKaHIi opraH1I3Ma
B03HIIKaeT (<3llJllJeKT llHJIbD> (puc. 5.5). )J;onOJIHIITeJIbHOe TpaBMlIpOBaHlIe, 6e3YCJIOBHO, YBeJIlIqlI-
BaeT peaKI.{IIlO BOCnaJIeHIIH. «31lJ1lJeKT nlIJIbD> YCRITIiBaeTCH C IICIIOnb30BaHIIeM HeaTpaBMaTlIqeC-
KHX IIrJI, r,ne HlITb IlJ"KcIiPyeTc yuIKOM IIrJIb!. IIpli 3TOM C03,naeTCSI: ,nynJIIIKarypa HIITH, qTO YBeJIlIqII-
BaeT nOBpe)l(,D;eHlIe TKaHeH npli ee npoTHrlIBaHlI1I (puc. 5.6).
C ueJIblO YMeHbilieHIIH IlIepoxoBaTocTeH HIITII, a TaK:>Ke ,nJIH nplI06peTeHII IIMII onpe,neJIeH-
HblX CBOHCTB (apeaKTIIBHoCTII, TpoM60pe3IICTeHTHoCTli II ,np.), IIX nOKpblBalOT CRITIIKOHOM, BOCKOM,
TellJJIOHOM II ,npyrlIMII BeIUeCTBaMII. O,nHaKo, Ha,no nOMHIITb, qeM 60JIee rna,nKaH nOBepxHocTb
HIITII, TeM MeHee npOqeH Y3en. II03ToMY npli IICIIOJIb30BaHlIli rJIa,Z:(KIiX MOHollJRITaMeHTHblx HIiTeH,
He06xo,nHMo 3aBH3blBaTb ropa3,n0 60JIbille Y3JIOB. B CBOlO
Oqepe,nb, JI1060H JIIIIlIHlIH Y3eJI YBeJIII<J:IIBaeT KOJIII<J:eCTBO
IIHOpo,nHoro MaTepliana B opraHlI3Me. qeM MeHbllie Y3-
nOB - TeM MeHbllIe peaKUIiH BOCnaneHIISI:.
MaHHnYJUIQHOHHLle CBOHCTBa HIiTeH onpe,neJIH-
lOTC IIX :maCTHqHOCThlO II rn6KOCThlO. 3JIaCTHqHOCTh - O,D;IIH
II3 OCHOBHblX 4>1I3IIqeCKIiX napaMeTpOB H1ITII. MaHlirrynlI-
pOBaTb :>KeCTKHMII HIITSl:MH XHpypry Tpy,nHee, qTO nplIBo,nUT
K ,nonOJIHlITeJIbHOMY nOBpe)l(,D;eHlIlO TKaHell. KpOMe Toro,
npli 06pa30BaHIIII py6ua nepBOHaqanbHO npolICXO,D;IIT BOC-
naJIeHlIe II YBeJIUqeHlIe 06'beMa TKaHeH, coe,nIIHeHHbIX
HIiTblO. 3JIaCTnqHaH HIITb no Mepe pa3BIITIiH nOCTTpaBMa-
TlIqeCKOrO OTeKa paCTHrlIBaeTCSI:, a He3{laCTlIqHaSl: - Bpe-
3aeTCH. B TO :>Ke BpeMH, 1I3JIIIIlIHHSI: 3naCTIIqHOCTb HIITlI
Puc. 5.5 TpaeMUpOeallue mKaHeU U3-3a
((3rjJrjJeKma nW/w>
46
OqeHb Ba:>KHa pe311CTeHTHOCTh xllpyprll'lecKOH
IIIITII K IIH eKQIIOIlHLIM areHTaM, 6e3ycnoBHo, nplIcyT-
CTBYlOIUIIM Ha OnepaUIIOHHOM nOJIe. B cneUlIanbHOH JIII-
TepaType n05lBIIJIliCb co06IUeHHH 0 npOII3Bo,nCTBe HIITeH
c aHTH6aKTeplIanbHbiMII CBOHCTBaMII. B 3TOM CJIyqae aH-
TH6aKTeplIaJIbHOe lleHCTBlIe lliOBHoro MaTepliana onpe-
,neJIHeTC5I BBe,neHlIeM B ero CTPYKTYPY aHTII61I0TIIKOB II
HHTpollJypaHoBblX npenapaTOB. K CO:>KaneHlIlO, HeCMOTpH
Ha Bblpa:>KeHHble aHTII6aKTeplIaJIbHbie CBOHCTBa, IlIlIpO-
Koro pacnpOCTpaHeHIIH OHII nOKa He nOJIyqlIJIH.
KpoMe nplIBe,neHHbIx xapaKTeplIcTIIK oc060e 3Ha-
qeHlIe IIMeeT cnoc06HoCTb lliOBHoro MaTepliana nO}J,L\a-
BaThCH CTepHJIH3aQuH H coxpaHHTh CTepHJIhHOCTb, He Me-
HH5I npli 3TOM CBOIiX OCHOBHblX KaqeCTB. IIpaKTlIqeCKIi
Bce COBpeMeHHbIe xlIpyprlIqeCKlie HIITH CTeplInlI3lIpYlOT-
CH IlJlIpMaMII-npOII3Bo,nIITeJIHMII. .
PaCCMOTpliM xapaKTeplICTHKII HeKOTopblX XIIPyprlIqeCKIIX HIiTeH. Tpa,nIIUIIOHHO HaqHeM C
KeTrYTa - HalI60JIee pacnpOCTpaHeHHoro II IlIlipOKO IICnOJIb3yeMoro IlIOBHoro MaTepliana.
KenJ'T - paccaCbIBalOIUlIec51 xlIpyprlIqeCKlie HIITII, 1I3rOTaBJIliBaeMbIe II3 MblIlIeqHOH 060-
JIOqKII II no,nCJIII3IICTOrO CJI051 TOHKIIX KlilliOK OBeu. Ero npllMeHHlOT ,D;JIH HanO}l(eHIIH norpY:>KHbIX
IlIBOB,.D:JIH 3aIlIliBaHIIH paH napeHxIIMaT03HblX opraHoB, 6plOllllIHbI, MblIIIl{, nOllKO:>KHOH KlleTqaTKII
II ,D;JI5I nepeBH3KII He60JIblliliX KpoBeHocHbIX cocy,nOB. B HeKoTopblX CJIyqa5lX KeTrYT IIcnonb3YlOT
npli npoIlIIiBaH1I1I KO:>KII (no,n rHllCOBOH nOBsr3KoH, npII 1lJ0pMIIpOBaHIIII «KOCMeTlIqeCKoro» IlIBa).
EeJIKOBaH CTpYKTypa KeTrYTa 3aTpy,nHHeT ero CTepIIJIH3aUII1O, TaK KaK KIIn5lqeHIIe II CYXOH
nap HIITb pa3pYlilalOT. IIo3ToMY ero CTepRITII3YlOT nYTeM 06pa60TKII pa3JI1I bIMIi aHTlIcenTIiKaMIi
RITII 06JIyqeHIIeM raMMa-JIyqaMIi.
CYIUecTByeT 13 HOMepoB KeTryTa (OT 510,n0 6) ,nlIaMeTpoM OT 0,1,n0 0,8 MM. qeM 60nbIlIe
HOMep, TeM npOqHee HIITb. TaK, npOqHOCTb Ha pa3pblB TpeXHYJIeBOrO KeTrYTa COCTaBJI5IeT no
CTaH,D;apTaM 1400 r, llIeCToro HOMepa - 11 500 r.
KeTryToBbIe HIITII He06xo.D:HMO 3aBH3bIBaTb B Y3eJI TpeMH neTJIHMII. Cpe3aTb cB060)lHble
KOHn:bI HIITH HY:>KHO Ha paCCTOHHlI1I He MeHee 0,5-1 CM OT ywa.
CpOK paccaCbIBaHII5I KeTrYTa B TKaHHX ,nOBonbHO BaplIa6eJIeH. OH Kone6neTC5I OT 2,n0 30 II
60JIee ,nHeH. IIpouecc paccaCbIBaHIiH 3aBIICliT OT TonIUIIHbl (HoMepa) HHTH, cnoc06a ee cTeplI-
nlI3aUIIII, cOCTOsrHIIH TKaHeH B 06naCTII IlIBa. BoCnanlITeJIbHbIe npon:eCCbI, HarHoeHlIe paHbl, TaK
:>Ke, KaK II nplIMeHHeMble MeCTHO Me,nIIKaMeHTbI (HanpIiMep, npOTeOJIIITlIqeCKlie llJepMeHTbl) II
IlJH3IIOTepaneBTlIqeCKlIe npon:e,nypbl, 3HaqlITeJIbHO YCKOPsrIOT paccacbIBaHlIe KeTrYTa. Ha060poT,
06pa60TKa B npouecce ero 1I3rOTOBJIeHII5I 1lJ0pMan1iHoM, XJIOpUliOM cYJIbllJaTa, XpOMOM, 30JIOTOM
II ,npyrnMII BeIUeCJ'BaMII 3aMe,D;JIsreT CpOKII paccaCbIBaHII5I.
Dbmo YCTaHOBJIeHO, qTO, Haxo,nHCb B TKaHsrx, KeTrYTOBble HIiTII Bb13bIBalOT CeHCII61IJIH3aUli1O
opraHlI3Ma. IIpII nOBTopHOM IICnOJIb30BaHIIII KeTrYTa 3HaqlITeJIbHO B03paCTaeT BepOHTHOCTb B03-
HIiKHOBeHIIH BOKpyr HIITII IIMMYHHoro aCenTlIqeCKOrO BOCnaneHHH. OHO, B CBOlO Oqepe,nb, MO:>KeT
TaK:>Ke He:>KeJIaTeJIbHa, TaK KaK MO:>KeT nplIBeCTII K pac-
XO)l(,D;eHlIlO KpaeB paHbI. OnTHManbHblM C'illTaeTCH YBe-
JIlIqeHlIe ,D;JIIIHbI HIITII Ha 10-20 % no cpaBHeHlIlO C IICXO,n-
HOll.
Puc. 5.6 Tpa6MupoeaHue mKalleu
npu ucnOJ/b30eaJlUU HeampaeMamu-
'leCKOU UZJ/bl
47
rnaBa 5
CTaTb nplIqlIHOH pa3BIITIIH HeCOCTOSI:TeJIbHOCTH lliBOB. YqlITbIBa nplIBe,neHHble llJaKTbl, npliMeHe-
HlIe Ken}'Ta MO:>KHO C'illTaTb onepaulIeH TpaHcnnaHTau"1 qY:>KepOLUIOH TKaHII. 3TO e,n:IIHCTBeHHaH
HIITb, Ha KOTOpylO nOJIyqeHa peaKUIIH aHallJRITaKTlIqeCKOrO 1lI0Ka.
3KcneplIMeHTanbHbie IICCJIe,nOBaHIIH nOKa3anlI, qTO eCJIII npII 3allilIBaHIIII qlICTOH paHbl
KeTrYTOM BBeCTII B Hee 100 MIIKp06HbIX TeJI CTaIlJIIJIOKOKKOB, TO np01I30H,neT HarHOeHlIe. EOJIee
TOrO, KeTryToBaH HIITb ,na:>Ke npli OTCYTCTBIIII MIIKp060B MO:>KeT BbI3blBaTb aCenTlIqeCKlie HeKp03bI
TKaHell. ECJIII CpaBHIIBaTb HIITII O,nIIHaKOBOrO ,nliaMeTpa, npO OCTb KeTryToBblX MeHbIlIe, qeM CIIH-
TeTmeCKIIX paCCaCbIBalOlI.{IIXCSI. K TOMY :>Ke B TeqeHlIe nepBbIX nSI:T1I ,nHeH OHII TepHlOT ,nO 90 % CBOeH
npOqHOCTII. II03TOMY, IICXO,nR 113 BCerO BbIllie II3JIO:>KeHHOrO, npliMeHSl:Tb KeTrYT He peKOMeH.D:yeTCH.
M3 paccaCblBalOlI.{IIXCH HIiTeH HaTypanbHoro npOIICXO)l(,D;eHIIH ,nOBOJIbHO qaCTO IICrrOJIb3YlOT
mCJIK llleJIKOBble HIITII, II3rOTOBJIeHHbIe 1I3 HaTypanbHoro IlIeJIKa-Cblpl..{a, paccaCbIBalOTCH Ha npo-
TH:>KeHIIII 6-12 MeCHueB. ,[{JIH YBeJIlIqeHIISI: npOqHOCTII B HIIX ,n06aBJIHlOT He60nbilioe KOnlIqeCTBO
BOJIOKOH XJIOnKa. BbInycKalOTcH KaK KpyqeHble, TaK II nneTeHble HliTli o.aIIHHa,nuaTIi HOMepOB - OT
7/0,n0 8. llleJIK N2 3/0 IIMeeT ,nlIaMeTp HIITII 0,13 MM, ero npOqHOCTb Ha pa3pblB COCTaBJIHeT He
MeHee 370 r. )J;IIaMeTp caMOH TOJICTOH HIITII (N2 8) - 0,77 MM, ee rrpOqHOCTb Ha pa3pblB - 10500 r.
HIITII HyneBblx HOMepoB coe,nIIHHlOT C aTpaBMaTHqeCKIiMII IIrJIaMIi B CTepRITbHOH ynaKOBKe.
HIITII 60nbiliero ,nlIaMeTpa BbmycKalOT B HecTeplInbHblX MOTKax IIJIII B 3anaHHHblX aMnYJIax. B
nOCJIe,nHeM CJIyqae IIX nOMalOT npe.aBaplITeJIbHOH CTeplIJIII3aUIIII raMMa-JIyqaMII.
llleJIK HYJIeBblX HOMepOB nplIMeHHlOTB COCY,D;IICTOH xlIpyprnlI, cpe,nHlIx HOMepoB (N22 - 4)-
,D;JIH coe.aIIHeHII MsrrKIIX TRaHeH. T OJICTbIMII IlIeJIKOBblMII HIITHMII 3aIlIIIBalOT nnOTHble TKaHlI. OHII
TaK:>Ke MOryT 6bITb none3HbIMli npll cTsrrlIBaHlI1I TKaHeH C YCIIJIlieM.
IlIeJIK ,nOCTaTOqHO MHrKIIH, rH6KIIH II npOqHbIH MaTeplIan, qTO n03BOnHeT 3aBH3bIBaTb B lliBe
,nByxneTeJIbHbIH Y3eJI. CB060,nHbIe KOHIU>I IlIeJIKOBblX JIlIraTYP MO:>KHO oTpe3aTb KOpOTKO, OCTa13IDIH
MaJIeHbKlIe «YCIIKII».
llleJIK 06JIa,D.aeT Bblpa:>KeHHblMIi IlJIITRITbHbIMIi cBoHCTBaMIi II rlirpocKOnlIqHOCTblO. KaK npa-
BIITIO, OH BbI3blBaeT ,D;JIIITeJIbHYlO YMepeHHo Bblpa:>KeHHYlO aCerrTlIqecKYlO BOCnaJIliTenbHYlO peaK-
I..{IIlO npelIMymecTBeHHo npOTIlIllJepaTIIBHoro xapaKTepa. B pe3YJIbTaTe 3Toro BOKpyr HIITII qaCTO
06pa3yeTcH Kancyna. IIpli IIHllJeKUlIoHHOH IIHTepBeHUlIli BOKpyr HIITII MO:>KeT pa3BIITbc rHOHHoe
BOCnaJIeHlIe, onaCHoe BnOCJIe,nCTBIIII B03HIIKHOBeHlIeM JIliraTypHblX CBlImeH. 3KcneplIMeHT nOKa-
3an, qTO ,nOCTaTOqHO 10 MIIKp06HblX TeJI CTaIlJRITOKOKKa,D;JIH HarHoeHIIH paHbI, 3aIlIIIToH IlIeJIKOBOH
HIiThlO (HanoMHIIM - npII HHblX YCJIOBIIHX He06xo,nIIMO CTO TbICHq).
DblJIO YCTaHOBJIeHO, qTO llieJIKOBble HIITII MorYT BbI3BaTb CeHCII6IIJIII3aUli1O opraHlI3Ma, B
CB 3II C qeM IIX npliMeHeHlIe npII nOBTopHblX onepaUHHx, oc06eHHo Ha opraHax DHlI.{eBapHTeJIbHOrO
annapaTa, ,nOJI:>KHO 6bITb orpaHlIqeHo.
B nOCJIe,nHlIe ro,nbI npe,nnplIHlIMalOTcH nOnblTKII YJIyqIlIHTb CBOHCTBa IlIeJIKa. .ZJ:JIH 3Toro ero
nponlITblBalOT BOCKOM RITII COJIHMII cepe6pa. IIOKpblTlIe BOCKOM pe3KO CHII:>KaeT IlJIITIIJIbHble CBOH-
CTBa, o,nHaKO oTplIuaTeJIbHO BJIIIHeT Ha Ha,ne:>KHOCTb Y3JIa. EJIaro,napH IIMrrperHaUlI1I llieJIKOBOH
HIITII COJIHMII eepe6pa co CBOHCTBeHHbIM IIM aHTIiCenTlIqeCKIIM ,neHCTBlIeM, pliCK HarHoeHIIH B
l..{eJIOM YMeHblliaeTCSI:. O,nHaKo, yqlITbIBaH Bce BblillenepeqlICJIeHHOe, peKOMeH.D:yeM KaK MO:>KHO
pe:>Ke nonb30BaTbC IlIeJIKOBbIMIi H1ITKaMlI. Ha Halli B3rnM, JIyqllie IICnOnb30BaTb CIIHTeTlIqeCKlie
lliOBHbIe MaTeplIaJIbI.
Y CJIOBHO Bce CIIHTeTlIqeCKlie paCCaCblBalOlI.{lIeCH lliOBHble MaTeplIanbI npHIDlTo pa3,nemlTb
Ha e rpynnbI:
IIcpoaH rpynna. IIonlllJ"naMeHTHble MaTeplIanbl: nonlIcop6 (Auto Suture), ,neKCOH
48
(Davis&Geck), BIIKpRIT (Ethicon), ,nap-BIIH (Ergon Sutramed), nr A (Resorba), collJRIT (B.Braun),
Helm-Syntha.
I1x OTnlIqlITeJIbHbIMIi oc06eHHoCTHMII HBJIHlOTCH: HH3KaH peaKToreHHOCTb, rlI,D;pollJ06HoCTb,
BblCOKlie MeXaHIIqeCKHe CBoHcTBa (clIHTeTHqecKlie Hl:!TII B ,nBa -Tpli pa3a npOqHee, qeM HIITII TaKoro
:>Ke ,nlIaMeTpa II3 llieJIKa). 113 BbIllie nepeqlICJIeHHbIX HIiTeH HalI60JIee npoqHblM CqlITaeTCSI: nOJIII-
cop6. OH npliMepHO B 1,5 pa3a npOqHee BIIKpliJIa II B 3 pa3a npOqHee KeTrYTa.
CIIHTeTlIqeCKlie paccaCbIBalOIUlIeCSI: nOJIlIllJlIJIaMeHTHbIe liIOBHble MaTeplianbI 06na,nalOT
XOpOllIliMII MaHlInynHUIIOHHbIMII cBoHCTBaMII, CTporo onpe,neJIeHHbIMII, OnTHManbHbIMIi cpOKaMII
nOTepII npOqHOCTII II paccaCblBaHIiH. BIIKpRIT, ,neKCOH II ,nap-BIIH TepHlOT ,no 80 '% npOqHOCTIi Ha
npOTH:>KeHIIII ,nBYX He,neJIb, nonlIcop6 - Tpex He,neJIb. PaccacblBalOTcH CIIHTeTl:!qeCKlie nOJIl:!IlJRITa-
MeHTHble MaTeplIanbl nplI6nlI3IITeJIbHO qepe3 2-3 MeCHua nOCJIe onepaulIlI.
JIIITepaTypHbie ,naHHbIe cBlI,D;eTeJIbCTBYlOT 0 TOM, qTO HaH60JIee :>KeCTKIIM B 06paIUeHlIli cpe-
,D;II nepeqlICJIeHHbIX HIiTeH HBJIHeTCH BIIKpIiJI. K TOMY :>Ke, OH 06JIa,naeT 60JIee Bblpa:>KeHHbIM <ollJ-
llJeKToM nlIJIbI». IIOKpbITHe BIIKpRITa CTeapaTOM KanbU"H (coated vicry1) cYIUeCTBeHHO ynyqIlIaeT
ero KaqeCTBa. IIpII 3TOM, TpaBMlIpYlOlI.{lIH «nRIT}lIUllH 31lJIlJeKT», HeCOMHeHHO, CHII:>KaeTCSI:, HO, BMec-
Te C TeM, CHII:>KaeTCH II npOqHOCTb Y3JIa. I1cxo,nH II3 3Toro, npII IICDOnb30BaHIIII 06blqHOrO «HenOK-
pbITOro» BIIKpRITa peKOMeIrnyeTcH 3aBH3bIBaTb HIITb B Y3eJI TpeMH neTJIHMII. ,[{JIH Ha,ne:>KHOrO 3aBH-
3blBaHHH «nOKpbIToro» BIIKpliJIa cne,nyeT BSl:3aTb He MeHee qeTblpex neTeJIb.
IIonlIMepHoe nOKpblTlie npIIMeHHeTC}l,nJISI: CHII:>KeHIISI: nlIn}lIUIiX CBOHCTB II B ,npyrlIx HIITHX
,naHHoH rpynIThI.
BTOpaH rpynna. MOHo4>RITaMeHTHble HIITH: MaKCOH (Davis&Geckn), nOJIII,D;IIOKCaHOH (PDS)
(Ethicon), 61I0CIIH (Auto Suture), MOHOKpRIT (Ethicon).
B OTJIlIqlIe OT nOJIIIIlJRITaMeHTHbIx, MOHollJRITaMeHTHble H1ITII MeHee peaKToreHHbI II npaKTII-
qeCKIi nlIllieHbl paCnRITIIBaIOIUero cBoHCTBa npli npOnITIIBaHlI1I. B TO :>Ke BpeM}l, KaK II Bce MOHollJlI-
naMeHTHble HIITII, MaKCOH II PDS II3-3a HII3Koro K034>IlJIIUlIeHTa TPeHIIH Tpe6YlOT Y3JIa CJIO:>KHOH
KOHIlJl:!rypaUIIII. ,[{JI}l Ha,D.e:>KHOrO 3aBH3blBaHHH ,nBYX RITII ,na:>Ke Tpex neTeJIb, KaK npaBRITO, He,nOCTa-
TOqHO. Y3eJI II3 PDS, HanpHMep, peKOMeIrnYlOT 1lJ0pMIIpoBaTb He MeHee, qeM 1I3 llieCTIi neTeJIb.
CpOK paccaCblBaHIiH MOHollJlIJIaMeHTHbIX HIITeH 3-6 MeCHueB. YqlIThlBaH MIITeJIbHble CpOKIi
paccacbIBaHIIH, 3T1I HIITH MorYT cnY)l(IITb IICTOqMlIKOM nHraTypHbIX cBIIIUeH IIJIII xone,nOXOJIIITHa3a
(ypOJIIITHa3a ).
MOHollJlIJIaMeHTHbIe HIITH no CBoeH npOqHOCTII npeBocxo.D;SI:T 1UIl:! cpaBHHMbI C nonlIllJRITa-
MeHTHbIMIi. IIo cpOKaM nOTepII npOqHOCTIi II paccacblBaHlIH OHII no,n06HbI HIITSI:M nepBoH rpynnbI.
TaK, MOHOKpRIT TepSl:eT 80 % npO<IHOCTII Ha npOTH:>KeHIIII BYX He,neJIb, 6IIOCIIH - qeTblpeX He,nenb.
B KaqeCTBe IlIOBHoro MaTePlIana IlIlipOKO IIcnonb3YlOT CIIHTeTlIqeCKlIe HepaccaCblBalOlI.{lIe-
CH HIITII II3 KanpoHa, HeHJIOHa, JIaBcaHa, JIeTRITaH-JIaBCaHa, ,naKpoHa, IlJTOpJIOHa II ,np. IIpli pa3pa-
60T}(e HepaccacblBalOIUlIxcH 1lI0BHblX MaTepuanoB IICCJIe,nOBaTeJIIi cTpeMHTCSI: 06eCneqnTb Xopo-
IlIlIe MaHlInYJIHUIIOHHble KaqeCTBa HIITII II MaKCIiManbHO CHII3UTb IIX peaKToreHHocTb. HecMoTpH
Ha TO, qTO HIITII II3 3TIIX MaTeplianOB He cnoc06Hbi paccaCbIBaTbCSI: II BbIBO,nIITbCH II3 opraHlI3Ma,
OHII He3aMeHIIMbI npII npOTe3IIpOBaHIIII IIJIII He06xo,nIIMOCTII ,nJIIITeJIbHOH IIMM06RITII3aUIIII CO-
e,nIIHHeMbIX TKaHeH. KpOMe Toro, OHII llilipOKO nplIMeHHlOTCSI: B xlIpyprlIlI, 6naro,napSl: ,neilieBII3He,
y,n06CTBY B pa60Te II BbICOKOH npOqHOCTIi.
KanpOH (nOJIHaMlI.lIbl) 06nal(aeT BbIpa:>KeHHbiMII peaKToreHHbIMII CBOHCTBaMII.
IIepBoHaqanbHO KanpOH (nOJIlIaMH.D:) cKpyqnBanlI, 3aTeM nOHBIIJIHCb llJIeTeHble II MOHOIlJII-
naMeHTHble H1ITII. O,nHaKO II3MeHeHIIe CTPYKTYPbl HIITII CYIUeCTBeHHO He II3MeHRITli peKToreHHOCTb
MaTepliana. lllBbl KanpOHOBOH HIITblO Hepe,nKO IICnOJIb3YlOT.D:JIH C'beMHOrO lliBa KO:>KII, 6POHXOB,
49
..
rnaBa 5
CYXO)l(HllIIH II ailoHeBp03a. XOTSI: OHII IIHHUHlIpYlOT ,D;JIIITeJIbHO TeKyIl{ylO BOCilaJIHTeJThHYIO peaKUlIIo
B coe,D;IIHHeMblX TKaHHX.
JIaBcalloBbIe (noJIu:JlJ>upllble) HIITH 60JIee IIHepTHbI, qeM nOJIlIaMH.D:bl, II Bb13blBalOT MeHb-
lliYlO TKaHeBYlO peaKUlilO. B OCHOBHOM OHII npOII3BO,D;HTCH nJIeTeHbIMII. I1x IICKJIlO'illTeJIbHYlO npoq-
HOCTb IICnOJIb3YlOT B 3H,noxlIpyprlIlI,D;JISI: IIHTpaKopnopanbHblx cnoc060B BSl:3aHIISI: Y3JIOB. ,[{eJIo B
TOM, qTO MOHOllJ1UIaMeHTHbIe HIITII II3-3a MaHIIII)'mI..(IIH IIHCTpYMeHTaMIi MOrYT nOTepsrTb npOqHOCTb
RITII BOBCe nOpBaTbCSI:.
IIoJIunponUJIell 6blJI nepBbIM 1I3 rpynnbl COBpeMeHHbIX HepaCCaCblBalOIUHXCH HHTeH, KOTO-
pbIe IIHepTHbI K TKaHHM OpraHlI3Ma. HHTII 1I3 3TOrO MaTeplIana 6bIBalOT TOJIbKO MOHoIlJRITaMeHTHbl-
M».
PeaKUIIH TKaHeH Ha nOJIIIOJIellJlIHbI IIpaKTlIqeCKII OTCYTCTByeT, n03TOMY IIX MO:>KHO IIplIMe-
HHTb B IIHllJlIUlIpoBaHHbIX TKaHHX RITII, no KpaHHeH Mepe, He y,namITb, eCITIi paHa HarHOIiJIaCb.
KpOMe Toro, MbI npHMeWleM nOITIIOJIellJHHbl B Tex CJIyqaHX, KOnIa .aa:>Ke MIIHHManbHaJI peaKUIIH
BocnaneHIIH He:>KeJIaTeJIbHa. IIOJIlInpOIIIIJIeH OCTaeTCSI: HalI60JIee nplIMeUHeMOH HIiTblO B cep,neq-
HO-COCy,nIICTOH XlIpyprlIlI, IIPII TpaHCllJIaHTaUHII OpraHOB, B XHpyprrrn: rpbI:>K, nO,D;:>Keny,nOqHOH :>KeJIt>-
3bllI,D;JIH C'beMHOrO lliBa KO:>KII. 113 Bcex MOHollJlIJIaMeHTHbIX HlITeH (3a IICKJIlOqeHlIeM 61I0CIIHa)
IIOJIIIIIpOilRITeH ,D;JIIITeJIbHO coxpaWleT Ha,ne:>KHOCTb Y3na (MO:>KHO mI3aTb Y3eJI H3 qeTbIpeX neTeJIb).
E,nIIHcTBeHHaH nplI'illHa, orpaHlIqlIBalOIUaH IlIlipOKoe nplIMeHeHlIe nonlInpOnRITeHa - ero «Hepac-
caCbIBaeMOCTb» .
B nOCJIe,nHee BpeMH nOHBIIJIIiCb co06IUeHIIH 0 pa3pa60TKe lliOBHblX MaTeplianOB, 60nee
IIHepTHblX K TKaHHM opraHlI3Ma, qeM IIOmmpOnRITeH. B nepBYIO oqepe.ab, 3TO IlJTOpnOJIlIMepbI. HIITH
1I3 BbICOKOO'illll.{eHHoro nomnerpallJTop3TIIJIeHa (Go-lex) 06na,D.a1OT nOJIHOH IIHepTHOCTblO K TKa-
HHM OpraHH3Ma, BbICOKOH TpOM60pe3IICTHOCTblO. B OCHOBHOM IIX nplIMeHHlOT B COCY.D:IICTOH XIIPYP-
rlIlI ,D;JIH no,nIlIIiBaHIIH TpaHCnJIaHTaTa, T.K. ,nlIaMeTp 3TIIX HIiTeH 60JIbille ,nlIaMeTpa IIrnbi. IIpII
npOTHrHBaH1I1I qepe3 TKaHb H1ITb 3a cqer CBoeH 3JIaCTIIqHOCTH paCTHrHBaerCSI:, a nOCJIe C:>KIIMaeTCH,
nOJIHOCTblO 3anOITHHH C060H paHeBOH KaHaJI.
.lJ.nH JIyqIlIerO KOHTpaCTlIpOBaHIiH C TKaHHMII XHPyprlIqeCKlie HIITII OKPaIlIIIBalOT B pa3JIIIQ-
Hble UBera - qepHblH, CIIHIIH, TeMHO-KOplIqHeBbIH II ,np. 3TO 06JIerqaer BII3yaJIbHbIH KOHTpOJIb npII
1lJ0pMIIpoBaHHII xHpyprlIqecKIIX llIBOB C nOMOIUblO TOHKIIX H1ITeH. Oc06eHHO 3TO aKTyanbHO B MIIK-
pOXlIpyprrrn:.
EonbIlIIIHCTBO IlJIIPM IICnOJIb3YlOT onpe.aeJIeHHYlO OKpaCKY,D;JIH onpe,neJIeHHblX rpynn HIiTeH.
3TO n03BOJIHeT onpe,nenlITb CTPYKTyPY HIITII no ee UBery. XOTH uBeTOBaH KO,nlIpOBKa He Sl:BJIHeTCH
06H3aTeJIbHOH, HO, KaK npaBIIJIO, HHTII 1I3 llieJIKa BbIIlYCKalOT 6eJIoro UBeTa. B qepHblH uBeT OKpa-
IlIIIBalOT nOJIlIaMH.D:; 3eJIeHbIH - nonlI31lJlIPbl, MaKCOH, collJRIT; CIIHlIH - nommpOnlIJIeHbI; IlJlI0neTo-
BblH - nOJIlIcop6, BIIKplIn, pe30p6a; 3eJIeHO-6eJIbIH - ,D,eKCOH. KeTrYTOBbIe HIITII Tpa.aIIUIIOHHO KO-
plIqHeBOrO RITII CBerJIO-KOplIqHeBoro UBera.
,[{JISI: coe,nHHeHIIH KOCTeH lllHpOKO IICnOJIb3YIOT MeTaJIJIU'IeCKYIO npOBOJIOKY. IIpOBOJIoq-
Hble H1ITII 6bIBalOT O,nHO:>KIIJIbHbIMIi II MHOrO:>KIIJIbHbIMII, pa3JIIIqHOrO ,nlIaMeTpa - OT 0,1 ,no 1
MM. MeTanJIlIqeCKlie CK06KII nplIMeHj{lOT B XIIPYPrHlI :>Keny,nOqHO-KIIIlIeqHOrO TpaKTa. MeXaHlIqeC-
KlIH IlIOB 3HaqlITeJIbHO 06nerqaeT II CTau,napTH3lIpyer TeXHlIKY onepaUIiH.
50
XHPYPrnQECKHE l1TJIbl
Mrna Sl:Bn5!eTCSI: Ba:>KHOH COCTaBHOH 'laCTbIO COBpeMeHHOrO IlIOBHOrO MaTepliana. Ka)l(,D;aH
IIrna, He3aBIICliMO OT ee BH,D;a, HMeeT TPII OCHOBHbIe qaCTIi - KOIl'lUK (ocmpue), Cmepmellb (mellO) U
YIUKO (puc. 5.7). IIapaMeTpbI Ka)l(,D;oH II3 3TIIX qaCTeH BJIII5!lOT Ha 06IUYlO xapaKTepllcTIiKY IIrJIbI.
tPop.Ma UVlbl MO:>KeT 6bITb Pa3JIlIqHOH: npHMoH, B BH,D;e non03a, H30rHYToH, H30rHYTo-npSl:-
MOJIlIHeHHoH.UJnpoKoe pacnpoCTpaHeHlIenonyqlIJI1i
IIrJIbI KPYTO RITII cJIa60 H30rHYTbIe. KplIBII3Ha IIrJIbI
onpe,neJIHeTCSI: TOH qaCTblO Kpyra, KOTOpylO OHa 3aHll-
MaeT. MCXo,nH 1I3 3Toro, 6bIBalOT IIrJIbI 1/4, 3/8, 1/2,
5/8 (puc. 5.8). IIoBepxHoCTHbIe IlIBbI HaKlla,nbIBaIOT
IImaMH C ManOH KplIBII3HOH, rny60KlIe -limaMIi C 60JIb-
IllOH KpIIBII3HOH.
XHPyprnqecKHe HrJIbI OTJIHqaIOTCH oJlUlloii. .ZJ:nn-
Ha IIrJIbI YKa3blBaeTCH B MlIJIJIIiMeTpax. KaK npaBIIJIO,
,D;JIH HIiTeH 60nbllilix ,nlIaMeTpoB IICnOJIb3YlOTCH 60nee
,D;JIIIHHble IIrJIbI. DpliMeHeHlIe IIrJI pa3HOH ,D;JIIIHbI ,D;JIH
HlITeHonpe,neJIeHHoro,nlIaMeTpa(HanpIIMep,HIITH
3/0 MorYT nplIMeHHTbCH C IIrJIaMli ,D;JIIiHOH OT 16,n0 36
MM) paCIllIIPHlOT xlIpypry B03MO:>KHOCTII.D:JIj{ MaHeBpa.
no tl>opMe OCTpHH (KOH'lHKa) pa3JIIIqalOT IIrJIbI
nplITynJIeHHbIe (KlillieqHbIe) II TynbIe (neqeHOqHbIe)
(puc. 5.9).
no tl>opMe Ce'leHHH TeJIa (cTepmHH) - TpexrpaH-
Hble, RITII pe:>KYIUlIe, KpYTble, KOnlOlI.{lIe II cneUlIanbHbIf
(puc.5.10).
B 3aBllCliMOCTli OT tl>OpMbI YWKa IIrJIbI 6bIBa-
IOTC nOpTHH:>KHbIMII II npy:>KHIDII:!U1MH OTKpbITbIMII.D:BOH-
HblMH MeXaHlIqeCK1IM1i YlliKaMIi (puc. 5.11).
ATpaBMaTlIqeCKlie IIrJIbI COBceM He IIMelOT
YIllKa. KOHeu HIITH Y HIIX 3arrpeccoBaH B URITlIH.D:pHqeC-
Koe OKOHqaHlie IIrJIbl.l1cnonb30BaHlle aTpaBMaTHqeC-
KIIX IIDI, B OTJIHqHe OT HeaTpaBMarnqecKIIX, npe,nOTB-
pmuaeT 06pa30BaHlie B TKaHSl:X rpy60ro paHeBoro
KaHana, KOTOpbIH 3HaqHTeJIbHO npeBbIlliaeT pa3MepbI
HIITH. K TOMY :>Ke, B pe3ynbTaTe MHoroKparnoro IIcnOJIb-
30BaHliH HeaTpaBMaTlIqeCKIiX Hrn IIX KOHqIIK nplITyn-
nHeTCH, qTO, B CBOlO Oqepe,nb, Be,neT K TpaBMlIpOBa-
HlIlO TRaHeH npli npOKaJIbIBaHlIII. I1HbIMIi CJIOBaMlI, npli
npOllIlIBaHlI1I HeaTPaBMaTlIqeCKIIMIi HrnaMH c03,naIOT-
CH YCJIOBIIH ,nJI}J. BocnaneHIIH coe,nIIHHeMblx TKaHeH.
Bo 1I36e:>KaHlIe OCJIO:>KHeHIIH HeaTpaBMaTlIqeCKlie
IImbl He06xo,nIIMO CTpeMIITbCH IICKlllOqlITb 1I3 apceHa-
JIa lliOBHbIX MaTeplIaJIOB.
B
\
/
6
Puc. 5.7 Cmpoellue xupypZU'leCKOU uznbl:
a) KOH'lUK (ocmpue); 6) cmep:J/CeHb
(meno); e) YUlKO
o
u
u
v
a
B
r
6
'---'
,n
Puc. 5.8 Pa3aeneHUe UZII1IO «pueu3He:
a) KpyZ; 6) 1/2 Kpyza; e) 5/8 Kpyza;
z) 3/8 Kpyza; a) 1/4 Kpyza
A
f1
n
a
6
r
B
Puc. 5.9 Pa3aelleHUe UZII 110 popMe ocmpUR:
a) ocmpoe; 6) pe:J/CYUjee y KonlOUjeu uznbl;
e) mynoe; z) lIaHl/emOeUaHOe
51
rJIaBa 5
Bo 1I36e:>KaHlie rpy60ro TpaBMlIpoBa-
HIIH npoIlIIiBaeMoH TKaHIi IIrJIa II.OJI:>KHa 06-
JIaJ\aTb lIJ(eanbHO rJIa,nKoH nOBepxHocTblO.
KaK II.D:JIH BCHKoro MaTeplIana,.D:JIH IIrJIbITaK-
:>Ke cYll.{eCTByeT «31lJ1lJeKT nHJIbI». IIOKpbITlie
IIrJIbl CRITIIKOHOM ynyqlliaeT CKOJIb:>KeHlIe B
TKaHHX.
qTO KacaeTcH TeJIa IIrnbI, TO OHO ,nomK-
HO nerKO npoxo,nIITb 'lepe3 TKaHb npli npo-
IlIIiBaHlIIi II B TO :>Ke BpeMH HaJ\e:>KHO y,nep:>KlI-
BaTbCH B IIrJIo,nep:>KaTeJIe. ,[{JIH 3Toro B IIrJIax
TeJIO (CTep:>KeHb) 1I3rOTOBJIHlOT nJIOCKIiM
(,na:>Ke B KOJIlOlI.{IIX). I1Hor,na, ,nJIH 60JIee Ha-
,ne:>KHOrO 3aXBaTa IIrJIbllIrJIo,nep:>KaTeJIeM, B
06naCTII TeJIa HaceKalOT npo,nOJIbHbIe 60p03-
,I:{bI.
Ba:>KHbIM napaMeTpOM xapaKTepliCTII-
KII IIrJIbI HBJIHeTCH K034>4>HQHeHT YMeHLme-
HHH ee HaMeTpa. 3TOT K03IlJIlJIIUlIeHT onpe-
,neJIHeTCH nyTeM COOTHOllieHIIH ,D;JIIIHbI OCTpliH
K ,nlIaMeTpy. Y OCTpblX IIfJI OH COCTaBJUleT 1: 12
II BbIIlIe.
Dpn Bbl60pe HrJIbl,nJIH npolliliBaHIiH
onpe,neJIeHHOll TKaHH HY:>KHO yqlITbIBaTb ee
MeXaHH'leCKHe xapaKTepHcTHKH. ,[{eJIo B
TOM, qTO npli npOKanbIBaHIIII TBep,nblX TKaHell
TOHKlIe IIrnbI MorYT crlI6aTbCH RITII JIOMaTb-
CH, qTO ,nOCTaBJIHeT xlIpypry HeMaJIO He-
y,n06CTB. MeXaHlIqeCKaH xapaKTepliCTIiKa MrJIbI onpe,neJIHeTCH ee npOqHOCTblO II KOBKOCTblO. IIpoq-
HOCTblO Ha3blBalOT cnoc06HOCTb IIrJIbI npOTl1BOCTOHTb ,ne<l>opMaUIIII npli npOXO)l(,D;eHlIIi qepe3 TKaHb.
qeM npOqHee IIrJIa, TeM ee MeHbillYlO no ,nlIaMeTpy MO:>KHO BbI6paTb ,D;JIH npOKaJIbIBaHIiH TBep,nOll
TKaHIi 6e3 pliCKa nOJIyqlITb ,nellJoPMaulIlO. KOBKOCTb - cnoc06HOCTb IIrJIbI crlI6aTbCH 6e3 1I3JI0Ma.
IIOBbIllieHHOH KOBKOCTblO 06JIaJ\alOT IIrJIbI C lIH,D;eKCOM L-300.
KOJIlOlI.{IIe l1rJIbI HMelOT npeliMYlI.{eCTBa npli pa60Te C BHYTpeHHIIMIi opraHaMIi. 3TII IIrnbI
Tpa,nIIUIIOHHO nplIMeHHlOT ,nJIH HaJIO:>KeHIIH aHaCTOM030B, lliBa MHrKIIX TKaHeH II T.n.)J;m TBep,nblX
TKaHell (anOHeBp03, COCy,nbI C KaJIbUlIllJlIKaTaMIi II T.,n.) CneUlIaJIbHO npe,nHa3Ha'leHbI KOJIlOlI.{IIe
IIrnbI C pe:>KYIUIiM KOHUOM. Pe:>KYIUHe npe,nHa3Ha qeHbl .D:JIH npOllilIBaHIIH :>KeCTKIIX, TBep,nblX TKaHeH
6e3 pliCKa CJIOMaTb RITII corHYTb IIrny. 3a CqeT TpeTbeH pe:>KYIUell KpOMKII IIrJIa nplI06peTaeT nOBbI-
llieHHYlO npOqHOCTb B 06JIaCTli OCTpliH II JIerqe npOKanbIBaeT TBep,nble TKaHli. 3TH IIrnbI IICnOJIb3Y-
lOTCsr.D:JIH lliBa anOHeBp03a,,D;JIH 3aIDliBaHliH rpbI:>KeBbIX BOpOT, ,nJIH IlIBa KO:>KII II T.n.
)J;m Y3JIOBOro lliBa paUIiOHaJIbHO IICnOJIb30BaTb 06paTHO-pe:>KYll.{lIe IIrJIbI (reverse cutting)
3a C'leT Toro, qTO IIX OCHOBaHlie 06pall.{eHO K paHe, II npli 3aTHrlIBaHIIII lliBa MeHbllie rnaHCOB
npope3aTbTKaHb (puc. 5.12).
IlInaTeJIe06pa3HbIe IIrJIbI RITII IIrJIbl C 60KOBbIMli pe:>KYIUIiMli KpOMKaMII HalI60nee y,n06Hbl
,
[.
.
.....--
6 B r ,n e
a
Puc. 5.10 Pa3iJeJlellUe UZJI no rjJopMe Ce'leHUH
Cmep:HCHH UZJlb/. TeJlo UZJlb/: a) KpYZJlOe;
6) OeaJlbllOe; e) mpexzpallllOe; z) KeaiJpam-
Hoe; iJ) npJlMOYlOJlbIlOe; e) mpanelJUeeuiJHoe.
/qi1
\,(
a
,
.....:',
.
rq
I
\" \ .
, .
.
6 '-
B
Puc. 5.11 Pa3iJeJlCHUC UZJI no KOHcmpYKljUU
YUlKa U2J1b/: a) nOpmIlJl:HCllb/C UlJlb/ c KPYZJlblM,
npJlMOYZOJlbl/blM U OeaJlbllblM om6epcmWlMU
YWKa; 6) uZJla c iJeoUHblM omKpb/mb/M
MeXaIlU'IeCKUM YUlKOM muna «JlacmO'lKUIiOZO
xeocmaJ>; e) ampaeMamU'IeCKaH uZJla
52
( .
.. .... .... 'r "
... y /£:-' ...
/ ./< u,; i. .
(J .. . . ;A . .,. ..
{p,'\.,' . f, . '
;: i..'
.....
. y.
a
6
PUc. 5.12 CPopMa 06pmoeaHHozo omeepcmUR npu npoUJuealluu pe:J/C)lUIUMU uZJ/llMU (a). 06pamnope:J/CY-
UjaJl uZJ/a ocmaeJ/J/em omeepcmue, OClloeGllue KOmopOZO 06paUjello K pane (6). 11pu 3mOM cnu:J/CaemcJ/
eepOJ/mllOcmb npope3anUR mKaneu
,nJIH npliMeHeHIIH B rJIa3HOH xlIpyprlIli. OHII npOHlIKalOT Me>K,D;Y TOHKIIMII CJIOHMII TKaHell 6e3 no-
Bpe)l(,D;eHIIH.
TynoKOHeqHbIe IITnbI paUIiOHanbHO IICnOJIb30BaTb.D:JIH npOllIliBaHIiH xpynKoH napeHXMMa-
T03HOH TKaHM. OHII pa3pa6aTbIBaJIliCb cneUHanbHO.lillH npOlliliBaHIiH TRamI neqeHH, nO'lKIi II no,n-
:>KeJIy,nOqHOH :>KeJIe3bI.
rJIaBa 5
3AKOH BEHJIEP A
. "
. .-'
':0.7'
..,
";".,-
.., '" ';;'." ';.
HeT HeBbIIIOJIHIIMOH pa60Tbi ,nJIH qeJIOBeKa, KOTOpblH He 06H3aH ,ne-
naTb ee caM.
. ' "'y'.::::, - .
'., :..
3AKOH KJIAPKA 0 PAj.(HKAJIbHbIX Hj.(EJIX
Ka)l{,naH pa,nIIKaJIbHaH lI,D;eH - B HaYKe, nOJIIITIIKe, IICKYCCTBe - BbI3bIBaeT TPII CTa,n1I1I OTBeT-
HOH peaKUIIII:
1. «3TO HeB03MO:>KHO, H He OTHIiMaHTe Y MeHSI: BpeMH!»
2. «MO:>KeT 6bITb H TaK, HO, npaBO, He CTOIiT 3a 3TO 6paTbCH».
3. «.H :>Ke Bcer,na rOBOpRIT, qTO 3T0 OTJIlIqHaH MbICJIb!»
3AKOH j.(OCTYflHOCTH !DKEKCOHA
KaK TOJIbKO lI,D;eH CTaHOBIITCH nOHHTHOH BceM, ee nopa MeHHTb.
3AKOB TPYj.(HOCTEH EEJIJIHHrCA
DOJIOBHHa TpY.D:HOCTeH npolICXO,D;IIT OTTOro, qTO MbI CJIHIlIKOM 6blCTpO rOBOpHM «.L\a» II He.D;O-
CTaTO O 6bICTpO «HeD>.
flOCTYJIA T HEBE)J(ECTBA POj.()J(EPCA
Bce HeBe)l(,D;bI, HO B pa3HbIX 06naCTHX.
PACllIHPEHHbIH 3AKOH MEPf/JH
ECJIH MOryT CJIyqlITbCH HeCKonbKO HenpmITHOCTeH, OHII npOHCXOJUIT B CaMOH He6naronplIHT-
HOH nOCJIe,nOBaTeJIbHOCTIi.
PACllIHPEHHE 3AKOHA MEPf/JH, Cj.(EJIAHHOE rATTY30
HeT TaKOH MOXOH cliTyaUHII, KOTopaH He MOrJIa 6bl CTaTb e e xY:>Ke.
3AKOH JIHHlJA
Kor,na C06bITHH nplIHlIMalOT KpYTOH 060POT, Bce CMblBalOTCjI.
3AKOH 3BAHCA H EbEPHA
KaKajl6bl HenplIHTHoCTb HH CJIY'lliJIaCb, BCerAa HaH,neTCjI TOT, KTO 3Han, O TaR OHO II 6y,neT.
. ..
54
ee"....e
ee .'
. ", ::. ,...:.,'.
.., i!6. ,.
ee ,,", ,
--*<
".""'....,..
_ frraBa 6
i:;.'<. ...
XA.I"AKTEPI1CT.HKA 11l'..1 LJlb,
IIPHMEH.sIEMbIX B XI1PyprMM
Pa3H006pa3IIe npliMeHsreMblx B xlIpyprlIH Y3JIOB on-
pe,neJIHeTCH KOM6HHaUlieH COCTaBJIjIlOIUIiX IIX neTeJIb. COOT-
BeTCTBeHHO, nOHIiMaHlie 3aKOHOB 1lJ0pMHpOBaHlijI neTeJIb H
npaBRIT lIX KOM6IIHIIpOBaHliH n03BOJIHeT xlIpypry C03,naBaTb
60JIblliOe KOJIlIqeCTBO Y3JIOB. 3T0 paCIlIlipHeT ero B03MO:>KH0-
CTH MaHeBpa a,D.eKBaTHO CJIO:>KUBllieHCH onepaUIIOHHOH CIITY-
auHH.
Bce npHMeHjIlOIUHeCH B XHpyprnH neTJIIi MO:>KHO YCJIOB-
HO pa3L!eJIlITb Ha npOCTLIe II CJIO HLIe.
O,nIIHapHoe nepenneTeHue HlITH 06pa3yeT npocT)'1O
neTJIIO. O,nHaKO, B 3TOM CJIyqae CRITa TpeHIIH Me)l(,D;y COCTaB-
JIHlOll(eH neTJIlO HHTHMII MeHbllIe CIiJIbI HaTjI)KeHlIjI coe,nIIHHe-
MblX TKaHeH. HapYiliaeTCH rJIaBHOe YCJIOBlie 06pa30BaHliH
py6ua - Heno,nBII:>KHOCTb TKaHeH. II03TOMY npHMeHeHlIe Y3-
nOB, COCTOHlI.{lIX 1I3 npOCTOH neTJIII, B xlIpyprlIu orpaHlIqeHO.
KaK npaBRITO, OHII Haxo,nHT npUMeHeHlIe TonbKO KaK COCTaB-
JIHlOIUHe lliBOB-L!ep:>KaJIOK. TaKlie IlIBbI IICnOJIb3YlOT MjI H3-
MeHeHIIH 1lJ0PMbi paHbI npH HanO:>KeHIIII KIIIIIe oro RITII cocy-
,nIICToro lliBa. IIocJIe BbInOJIHeHIIH COOTBeTCTBYlOlI.{erO 3Tana
onepaUIIl1 HX y,naJIjllOT.
B 3aBIICliMOCTli OT HanpaBneHIIH 3aTHrlIBaHliH HIITII
npOCTbIe neTnlI 6blBalOT npaBUJILHLIMU (CIiMMeTpII'IHbIMU)
(puc. 6.1) II HenpaBu.TJLHLll\1U (acIiMMeTpII'IHbIMII) (puc. 6.2).
CJIO HaH neTJIH, 06pa30BaHHmI nepenJIeTeHlIeM HH-
TeH 60JIbllie o,nHoro pa3a, 3a CqeT YBenlIqeHIIH nJIOIlIa,D.1I IIX
conpliKocHOBeHlIjI 06ecne'lIiBaeT 60JIblliYlO CIIJIY TpeHIIH Me:>K-
L!Y HIIMII (puc. 6.3, 6.4). B 3TOM cJIyqae CIiJIa TpeHIIH MO:>KeT
npeBocxo,nIITb CRITY HaTH:>KeHIIH TKaHeH. CJIO:>KHaH neTJIH cno-
Puc. 6.2 Cmpoenue npocmou aCUMMem-
c06Ha HeKoTopoe BpeMH y,nep)l(lIBaTb TKaHIi II He pacnYCKaTb-
pU'IHOU nemJ/u
CH. O,nHaKO H TaKOe nepenJIeTeHlIe He,nOCTaTOqHO ,nJIH ,D;JIH-
TeJIbHOrO y,nep:>KaHIiH TKaHeH, n03TOMY He06xo,nIIMO
C<tJOpMlIpOBaTb BTOPYlO neTnlO. Dpu 3aTHrlIBaHIIII ,nBYX neTeJIb, CllJopMHpOBaHHbIX KOHUaMli O,nHOH
HUTII, 06pa3yeTcH llByxneTeJIbHLlH YJeJI, CnOC06HbIH YL!ep)l(lIBaTb ClliliBaeMble TKaHIi C6JIII:>KeHHbl-
MH.
B Y3JIe Ka)l(,D;aH neTJIH BbInOJIHHeT CBOlO IlJYHKUlilO. IIpe,nHa3HaqeHlIe nepBOH neTnlI - C6JIII-
3IITb II y,nep:>KIIBaTb TKaHIi. <1>YHKUIIH OCTanbHbIX rIeTeJIb Y3JIa - IlJIIKcnpoBaTb nepBYlO neTnlO.
. -"'" .
..
,J-
(
)
......... . -. .-
-! .. :: -
. . :::., ". ".; ;:::.:. .: /.
. .
-.
Puc. 6.1 CmpoeHue npocmou CUMMem-
pU'l/Ioii nemJ/u
L
}
,..,.....iI,..It.
.. ".. ,.
.. -...a
: .M .. .
..- ...
.... -... '" ..-.... .
..
"
.
.
«. r o..-
. .'. '::;'\!J :. r
. -." ..
. .
< ..
.o"
4..
55
rJIaBa 6
D03TOMY, B npouecce 3aBH3bIBaHHH Y3JIa HHTb ,non:>KHa 6blTb
IlJIIKclipoBaHHoH.
06a yqaCTKa JIliraTypbl,nOJI:>KHbI 6bITb B nOCTOSI:HHOM HaTH:>Ke-
HIIH. He ,nonycKaeTCH oTnycKaHlie HIiTeH, TaK KaK npli 3TOM
MO:>KeT npOlI30HTH YMeHbllieHlIe HaTH:>KeHIIH nepBoH neTJIM,
o npHBO,D;IIT K paCXo)l(,D;eHlIlO COnOCTaBJIeHHblX TKaHeH RITII K
COCKanb3bIBaHli1O JIlIrarypbI. Bo 1I36e:>KaHlie 3TOH 01I1II6KII He-
06XO,nHMO HaTHrHBaTb KOHUbI HIITH B TeqeHlIe Bcero BpeMeHII
3aBSl:3blBaHIiH BTOpOH neTJIM. BMecTe C TeM, cne,nyeT 1I36e-
raTb qpe3MepHoro HaTH:>KeHlU! HIiTeH, TaR KaK 3TO MO:>KeT Bbl-
3blBaTb ee pa3pblB RITII nepepe3aHlie TKaHeH.
KaK npaBRITO, B KaqeCTBe nepBOH neTJIM Y3JIa IICnOnb-
3YlOT npocrylO. B YCJIOBIIRX 3aTpy,nHeHHoro conOCTaBJIeHIIH
TKaHeH (60JIblliOH ,nlIaCTa3, OTeK) RITII npll HanO:>KeHlIlIlllBOB
Ha He:>KHble II JIerKOpaHlIMble TKaHIi He06xo,nIIMO nOJIb30BaTb-
CH CJIO:>KHOH nepBOH neTJIeH. ,[{a 3TO II nomTHo: B 3TOM CJIyqae,
,nBOHHoe (a IIHor,na II TpOHHoe) nepenJIeTeHlIe HIiTeH nepBOH
neTJIIi Be,neT K B03paCTaHli1O CRITbI TpeHIIB Me)l(,D;y HIITHMII, CO-
CTaBJIHlOlI.{lIMIi neTnlO. B CBOlO Oqepe,nb, 3TO 06eCneqlIBaeT
Ha,ne:>KHOe HX conpHKOCHOBeHHe.
O,nHaKO, npaBRITO - qeM BbIllie HaTH:>KeHlIe TKaHeH, TeM
CJIO:>KHee ,nOJI:>KHO 6blTb nepenJIeTeHlIe HIiTeH nepBOH neTnH,
He06xo,nIIMO nplIMeHBTb C yqeTOM HeKOTopbIX ero HeL(OCTaT-
KOB. ,[{eJIO B TOM, qTO ,nJIHHa nepenJIeTeHIIH HHTeH B CJIO:>KHOH
nerne 60JIbllie, qeM B npOCTOM. BMeCTe C TeM, YBeJIlIqeHlIe
KOJIHqeCTBa nepeDJIeTeHIIH HIITII B neTne Be,neT 3a C060H npo-
nopUIiOHaJIbHOe YBeJIlIqeHlIe ,nJIIIHbI nepenJIeTeHIIH. II03To-
MY npli 1lJ0pMIIpoBaHIIII Y3JIa CO CJIO:>KHbIMII neTJIHMII, ,D;JIIiHY
nepenJIeTeHIIH nepBOH neTJIIi Y3JIa IIHor,na HeB03MO:>KHO c,ne-
JIaTb MeHbllie ,nnaMeTpa Konbua CTe:>KKa. IIpnqeM, qeM CJIO:>K-
Hee nepenJIeTeHlIe nepBOH neTJIIi Y3JIa, TeM 60nblliliH ,nlIa-.
MeTp lIMeeT nonHOCTblO 3aTRHYToe KOJIbUO CTe:>KKa. D03TOMY
JIlirlipOBaHHe COCy,nOB Manoro ,nlIaMeTpa C IICnOJIb30BaHlIeM
CJIO:>KHbIX neTeJIb He nplleMJIeMO. ,[{JIIiHa CJIO:>KHOrO nepenJIe-
TeHIIH HlITeH B neTne MO:>KeT OKa3aTbCH 60JIbllieH ,nlIaMeTpa
cocy,na. BCJIe,nCTBlie 3Toro, cocy,n nOJIHOCTblO He nepe:>KIIMa-
erCH, qTO, B CBOlO oqepe,D;b, MO:>KeT npnBeCTII K KpOBOTeqeHHlO
(puc. 6.5, 6.6).
KpoMe Toro, He06xo,nIIMO nOMHIITb, qTO YBeJIlIqeHHe
nOBepxHoCTII conpliKOCHOBeHIIH HIiTeH, KOTopoe ,nOCTliraeTCH
CJIO:>KHbIM nepenJIeTeHlIeM, cOnpOBO:>K,naeTCH aJ\eKBaTHblM B03paCTaHlieM «nIIJIH erQ) 31lJ1lJeKTa.
B KOHeqHOM HTore 3TO qpeBaTO B03paCTaHlieM plicKa «nepeTlipaHIIH» HHTeM.
TaK:>Ke CJIe,nyeT yqlITblBaTb onaCHOCTb 1lJ0pMIIpoBaHwI xlIpyprHqeCKOrO Y3JIa, B KOTOpOM
nepBaH neTJIH IIMeeT ,nBa nepenJIeTeHIIH, a BTopaH - O,nHO. TaKaSl: KOM6IIHaUliH MO:>KeT npliBecTIi K
,nellJoPMaUIIII 3TIIX nepenJIeTeHHH B MOMeHT 3aTHrlIBaHliB neTeJIb. PaCCMOTpIIM nplIqlIHy 3Toro
G ... _.J
-. "'- .
" ' .'.""; ' .. . . ..j
,< < .,'. ._.. ,'\-> '
:>. ':. .: ')l:;:'"
< ...
Puc. 6.3 Cmpoellue CJ/o;JICI/OU nemnu
c OeOUHblM nepennemeHueM Humu
. ¥J ." ' .i
oil... .....,.
:::- : ..;.. '..
. \:':f[; " . , y"
..
.. ..
. -.'
.
, "".
PUC. 6.4 Cmpoeuue CJ/O:J/CHOU nemnu C
mpOUHblM nepennemeHueM Humu
PUC. 6.5 n cnOJ/b30eaHue CJ/O:J/CHbIX
nemeJ/b OJ/fl nepeefl3Ku cocyooe
pa3HOZO KaJ1ll6pa. ,4J/uHa mpoimozo
nepenJ/emeHUfl CJ/o:J/CHoii nemJ/u 06ecne-
'/ueaem J/uzupoeaHue cocyoa 60J/bUiOZO
KaJ/u6pa
56
HBJIeHII . IIpe)l(,D;e BCerO, B OnlICaHHOH cHryaUlI1I He06-
XO,nHMO B3HTb BO BHHMaHlie KpOMe CRITbI HaTH:>KeHIIH
TKaHeH ,neHCTBlie e e II BHYTpeHHeH, ,neCTa6HJIII3IIPy-
IOlI.{eH Y3eJI, CRITbI ynpyroCTH ,nellJopMlIpoBaHHOH HIITII.
3Ta CRITa ynpyrocTIi onpe,nenHeTCH :>KeCTKOCTblO HIITII.
qeM 60nee :>KeCTKa HIITb IICnOJIb3yeTcH II qeM 60nb-
lliaH pa3HIIua B ,nJIIiHe nepenJIeTeHIIH neTenb Y3JIa, TeM
CRITbHee OHa BbIpa)l{eHa. Oc06eHHO BeJIIiKO BnlIHHlIe
CIIJIbI ynpyroCTIi npli 1lJ0pMIIpoBaHIIII Y3JIOB MOHoIlJRITa-
MeHTHbIMIi HIITHMII, KOTopbIe IIMelOT 60JIb1lIYlO, qeM y
,nPYrIIX KllaCCOB HIiTeH, :>KeCTKOCTb. I1HbIMIi CJIOBaMII, y
MOHollJRITaMeHTHbIX HlITeH BbIllie «naMHTb 1lJ0PMbI», TO
eCTb :>KeJIaHlie coxpaHIITb IICXO,nHYlO 1lJ0pMY. TaKa HlITb
Bcer,na CTpeMIiTCH «BbmpHMlITbCH». HalI60JIee CKllOH-
HbI K pa3BH3bIBaHli1O MOHollJRITaMeHTHbIe HIITII 60nb-
lliliX ,nlIaMeTpOB.
TaKIiM 06pa30M, HeCMOTpH Ha Bce npeHMYlI.{e-
CTBa CJIO:>KHblX nereJIb (.D:BOHHOH, TpOHHOH II T .,n.) OHII HMeIOT orpaHlIqeHHOe npHMeHeHlIe. CJIO:>KHbIe
neTJIIi MO:>KHO IICnOnb30BaTb B TOM CJIyqae, Kor,na MIiHa nepenJIeTeHIIH MeHbille ,nlIaMeTpa KOJIb-
ua CTe:>KKa. HanpliMep, npli nepemI3Ke KpynHbIx COcy,nOB RITII HaJIO:>KeHIIII JIliraTypbI en massae.
<1>opMlIpoBaHlie CJIO:>KHblX neTeJIb qaCTO CTaHOBIiTCH npoCTO He06xo,nIIMbIM npli IICnOnb30-
BaHlIIi COBpeMeHHblX MOHollJRITaMeHTHblX HHTeH IIJIII HIiTeH C nOKpbITlIeM, IIMelOlI.{HX HII3KHH K031lJ-
IlJIIUlIeHT TpeHII . CnO:>KHbIe neTnlI B 3TIIX YCJIOBIIHX HalI60JIee Hane:>KHO 3aKpellJI lOT II cTa61IJI1I31I-
PYIOT Y3eJI.
! J
. fO\:
l.;..-3I.!
.....
Puc. 6.6 Hcnonb30eaHue cnO:J/CllblX nemenb iJnJl
nepeeJl3KU cocyiJoe pa3HOi!O Kallu6pa. !JnuHa
mpoillloi!o nepenllemellUJI cno:J/Cllou nel11JlU He
06ecne'lueaem nuzupoeaHue cocyiJa MGllOi!O
Kanu6pa
57
rJIaBa 6
3AKOH XEJIP AHF A
.'"
'.:.r-.
IIOL!o)l(,D;1I - rmoxoe caMO C060H IIC'Ie3HeT n.
:( ..
3AKOH flOHCKA
HaqlIHaTb nOHCKIi Ha,D.O c caMoro Heno,nXOJJ:jlll.{ero MeCTa.
3AKOH M3PHAHHA
HaXO.D:IIllib Bcer,na TO, qTO He IICKan.
flP ABHJIO PYHA
ECJIII BaM Bce paBHo, r,ne Bbl Haxo,nHTeCb, 3HaqlIT BbI He 3a6ny.D:RIT cb.
TE3HC KOHTA-MEPf/JH OTHOCHTEJIbHO CHJIbI HEFATHBHOFO MbIillJIE-
HH.JI
OnTHMIICTa xopOllieH BeCTblO He y,nIIBHllib.
FJIABHbIH flAP AJ{OKC
OnTHMIICT BeplIT, 'ITO MbI :>KHBeM B nyqIlIeM 1I3 MHpOB. neccHMHCT 60HTCH, qTO OHO TaK H
eCTb.
3AKOH KEHC3PA
MO:>KHO c,neJIaTb 3all.{IIT)' OT ,nypaKa, HO TonbKO OT HeH306peTaTeJIbHoro.
BAPHAHT HAEJIIOJ{EHH.JI 3 TTOPE. flPEJ{JIO)J(EHHbIH O'EPAHEHOM
KaK TonbKO BbI nepeH,neTe B ,npyryro Oqepe,nb, Bailia 6blBIlIaH Ha'IHeT ,nBHraTbCjI 6blCTpee.
flPHHL(Hfl OlJEPEJI.H
qeM ,nonbllIe O:>KlI.lJ.aHMe, TeM 60nbIlIe BepOjITHOCTb, qTO Bbl CTOlITe He B TOH oqepe,nlI.
3AKOH YHTTEHA
Kor,na 6bl Bbl HII llOCTpHrJlH HOITH, cnYCTH qac OHM BaM nOHa,D.06HTCR.
, . .
58
:'
._ . ,.''''" ". tJiaB r;7
" 'f{()HeTPYKTMBJI]j ' "
:... ... - _ .... ': . ff:...'<-: . .
.. 'XAPAKTEPllCTMKH .
-.k _ _ +,.
nplIMEIDlEMbIXB XIJPyprnH Y3, qBp"
""""-
..."
.-.,
3aBH3blBaHlie Y3JIOB RBnsreTcH O HIIM 1I3 OCHOBHbIX 3neMeHTOB n1060H onepaUlI1I. Ka:>K,L1bIH
xnpypr 06H3aH He TOJIbKO 3HaTb HeCKonbKO OCHOBHbIX cnoc060B 3aBH3blBaHliH Y3nOB, HO II ,neJIaTb
3TO 6bICTpO II Ha,ne:>KHO. Bo BpeMH onepaUlI1I HHor,na npnxo,nIITCH BH3aTb 300-500 Y3JIOB. OllilI6Ka
B 3aBH3blBaHIIII XOTR 6bl o,nHoro 1I3 HIIX MO:>KeT npHBo,nlITb K pa3BIITli1O nOCJIeOnepaUIIOHHbIX oc-
nO:>KHeHIIH, a IIHor,na H K CMepTH 60JIbHoro. II03ToMY TeXHIIKY BR3aHlIH Y3JIOB He06xo,nHMO oTpa6a-
TbIBaTb nOCTOmIHO.
BbI60p KOM6IIHaUHll neTenb onpe,neJIHeTCj\ 3a,D.aqaMII, KOTopble CTaBRTCH nepell 3aBSI:3bl-
BaeMblM Y3JIOM. II03ToMY xlIpypry He06xo,nIIMO 3HaTb xapaKTepliCTlIKY HaII60nee qaCTO nplIMeHH-
eMbIX Y3JIOB. Bce OHII pa3,nenHIOTcH no CJIe,nYlOlUIiM KpIiTepIIHM:
- no KOJIU'ICCTBY neTeJIb B y3JIe: 2, 3, 4IIJIII 60nbille neTenbHbIe Y3JIbl;
- no KOJIU'IeCTBY nepenJIeTeHU" B neTJIDX Y3JIa:
..
npOCTble Y3JIbI;
..
CJIO:>KHble Y3JIbI:
. paBHOMepHble
. HepaBHOMepHbIe.
- no KOJIU'IeCTBY HUTe" B KOJIbl.{e CTe Ka:
.
11
o,nHOKonbueBbIe Y3JIbI;
,nBYXKOJIbUeBbIe Y3nbI;
ilia
TpeXKonbueBble Y3JIbl.
- no npOCTpaHCTBeHHOMY CTpoeHUIO neTeJIb B Y3JIe:
. napaJIJIenbHbleY3JIbI;
. nepeKpell.{eHHble Y3JIbl;
. CMeIlIaHHbIe y3JIbI.
59
rnaBa 7
- no HanpaBJ1eHHIO 3alllrUBaHHH neTeJ1L:
.
CHMMeTplIqHble Y3JIbI;
.
aCHMMeTpWIHble Y3JIbI:
f: CKOnb3HlI.{lIe:
a) npoCTble CKonb3RIl(lIe;
6) CKOnb3HIl(He 6JIOKlipOBaHHble.
2. IIoBepHYTbIe.
3. CMell.{eHHble.
- no cnoc06y 06pa30BaHHSI neTeJ1L:
..
p¥qHble;
.
ano,naKTRITbHbIe (c npliMeHeHlIeM IIHCTpYMeHToB).
. '," ,;''' ':--
KOJIMqECTBO nETE.JTh B Y3JIE
Y3JIbI MOryT COCTOHTb 1I3 ,nBYX, Tpex, qeTbIpex RITII 60JIbllierO KOJIlIqeCTBa neTeJIb. IIpli 1lJ0p-
MlipoBaHlI1I Y3JIa, Ka:>KeTCH, npHHUHn 1I0JI:>KeH 6bITb npocToH - qeM 60JIbllie neTeJIb B Y3JIe, TeM OH
npOqHee II Ha,ne:>KHee. OlIHaKo 3TO He COBceM TaK. ,[{eJIO B TOM, qTO IIpli B03paCTaHIIII KOJIHqeCTBa
neTeJIb (oc06eHHO 3TO KaCaeTC)! HepaccaCbIBalOIl(IIXCH HHTeH) YBeJIWIIIBaeTCH onaCHOCTb B03HIIK-
HOBeHHR BOCnaJIIITeJIbHblX OCJIO:>KHeHIIH. )J;OKa3aHO, qTO npli YBeJIlIqeH1I1I KOnlIqeCTBa neTeJIb C
Tpex,no llHTIi peaKuliH TKaHH B03paCTaeT npHMepHO B 1,5 pa3a. BMecTe C TeM, 3aBH3bIBaHlie 60nee
'leTblpex neTeJIb He nplIBo,nHT K CYIl(eCTBeHHOMY YBeJIlIqeHlIlO npOqHOCTIi M Ha,ne:>KHOCTIi Y3na. K
TOMy :>Ke, MHOrHe HIITH IIPII 3aBR3bIBaHliH 60JIblliOrO KOnlIqeCTBa neTeJIb TepHlOT CBOlO npOqHOCTb II
MorYT pa30pBaTbC}! B MOMeHT 3aTRrlIBaHliH Y3JIa. YqHTblBaH 3TO, cne,nyeT BH3aTb MIIHIIManbHO
He06xo,nIIMoe KOJIII'leCTBO neTeJIb. JIlO6aH JIHlliHHH IIeTJIH He nOBbllliaeT Ha,D.e:>KHOCTb, a nlIIlIb nplI-
Bo,nIIT K YBeJIHqeHHlO KOJIlIqeCTBa HHopo,nHoro MaTepliana.
06IUHe npMHUIIIIbI TaKOBbI: ,nJIH 60JIblliMHCTBa nonlIllJlIJIaMeHTHbIX HIITeH KOJIH'leCTBO ne-
TeJIb COCTaBnHeT qeTbIpe,.D:JIj{ 60nbllilIHCTBa MOHollJRITaMeHTHbIX - rneCTb. Ha npOqHOCTb Y3JIa 60JIb-
IlIoe BJIHRHlIe OKa3blBaeT nOJIIiMepHOe nOKpbITlIe, KOTopoe IICnOJIb3YlOT ,nJIR YMeHbilieHIIH «nRITH-
Il(ero 31lJ1lJeKTa» nOJIlIllJlIJIaMeHTHbIX HHTeM. TaK, «HenOKpbITbIH» BIIKpRIT MO:>KHO BH3aTL TpeMH
neTJIHMlI, B TO :>Ke BpeMH, nOKpbITbIH «coated» peKOMe lOT BH3aTb qeTbIpbMH.
60
KOJIHqECfBO nEPEnJIETEHMM B nETJUIX Y3JIA
Y3JIbI, COCTOllll.{He H3 IIereJIb C O,nIIHapHbIM nepenneTeHHeM HHTeM, Ha3bIBalOTCSI: npOCTbI-
MH. B TOM CJIyqae, KOr,na B Y3JIe XOTSI: 6bI O,nHa rreTnH HMeeT ,nBa
H.i11I 60nbllie nepenJIeTeHHM, Y3eJI Ha3bIBaeTCSI: CJJOIKHbIM. CJIO:>K-
HblM Y3JIaM npHCYlI.{lI Te :>Ke He,nOCTaTKH, qTO II CJIO:>KHbIM neTJISl:M.
CJIO:>KHble Y3JIbl, B CBOlO Oqepe,nb, MOrYT 6bITb ,nBYX BII,D;OB:
CJIO:>KHble HepaBHOMepHbIe H CJIO:>KHbIe paBHOMepHble. Y3JIbl, B
KOTOpblX B pa3HbiX neTnSl:X KOJIlIqeCTBO (a 3HaqlIT H lIJIIIHa) nepe-
nJIeTeHHM HIITII pa3nHqHOe, Ha3bIBalOTCSI: CJJOIKHblMH HepaBHO-
MepHbIMH. HanpHMep, HepaBHOMepHbIM xlIpyprHqeCKHM Y3en
06b1qHO COCTOIiT 1I3 ,nBYX neTeJIb, nepBa5! 1I3 KOTOpbIX IIMeeT ,nBOH-
Hoe nepenJIeTeHHe HIiTeH, a BTOpa5! - o,nIIHapHoe (puc. 7.1). Heo-
,nIIHaKOBaSl: MIiHa nepenneTeHIIH B neTnSl:X Y3JIa npHBo,nIIT K ,no-
IIOnHlITeJIbHOM ,nellJoPMaUHII Y3JIa, qTO CHII:>KaeT ero Ha,ne:>KHOCTb H
npOqHOcTb. HeKoTopbIe HepaBHoMepHble Y3JIbI cnoc06Hbi Pa3BH-
3bIBaTbC5! ,na:>Ke 6e3 BHelliHeH HarpY3KH, HCKlllO'ilITeJIbHO no,n ,neM-
CTBlieM CRITbl ynpyrOCTI1. YqlITbIBa5! 3TOT llJaKT, npli IICnOJIb30Ba-
HIIH neTnlI C MHoroKpaTHbIM nepenJIereHlIeM HHTeH Bce
IIOCJIe.nylOIUHe neTJIII Y3JIa ,non:>KHbI HMeTb o,nIIHaKoBYlO MIIHY ne-
penJIeTeHHM, T.e 6bITb CJJOIKHbIMH paBHoMepHbIMH (puc. 7.2).
3TO nOMO:>KeT 1I36e:>KaTb ,nononHIITeJIbHOM ,nellJopMaUIIII HIITH B
Y3JIe II, TeM caMblM, 06eCneqlIT ero cTa6IIJIbHOCTb.
IIpli 1lJ0pMlIpOBaHHH Y3JIa He06xo,nIIMO yqlITblBaTb llJaKTo-
pbI, BJIHSl:lOIUHe Ha ero npOqHOCTb - xapaKTepHCTIiKa HHTeM, noc-
ne,nOBaTeJIbHOCTb H BII,n neTenb, KOTopble IIcnonb3YlOTCSI: XIIPYP-
rOM. Bce MOHollJHnaMeHTHble MaTepIIaJIbl peKOMeH,D;YlOT B5!3aTb
cnoc06aMII, npe,nnOJIaralOIUHMII HanO:>KeHlIe He MeHee llieCTH ne-
TeJIb. KaK npaBRITO, 1lJ0PMHpYSl: XlIpypmqeCKIiM Y3eJI H3 MOHOIlJH-
naMeHTHbIX HHTeH, CJIO:>KHYlO nepBYlO neTnlO 06pa3YlOT ,nBOMHbIM
nepenneTeHHeM HIITH. 06'bSl:CHSl:lOT 3TO ee nOBblllieHHOH CKllOHHO-
CTblO K pa3B5!3blBaHIi1O. BTOpa5! CITO:>KHaH (,nBOHHaSl:) neTnSl: npe-
n5!TCTBYeT pa3BH3blBaHlilO Y3na. IIonHnpommeH H 6HOCIIH peKO-
MeH.L(ylOT BH3aTb qeTblpbMH-mThlO neTmMII.113 HIIX ,nBe nOCJIe,nHIIX
MO:>KHO ,neJIaTb npOCTbIMIi.
WenK MO:>KHO BSl:3aTb npOCTOM neTJIeH, CTa6RITII3IIpySl: ee
TaKO«:>Ke npOCTOH neTneM. O,nHaKO cyqeTOM Toro, qTO COBpeMeH-
HblH llienK qaCTO nOKpbIBalOT nonliMepHbIM nOKpbITlIeM, nyqllie HCIIonb30BaTb IIepBYlO IIeTnlO C
,nBOHHblM nepenneTeHHeM HIITH.
IIOJIHIlJRITaMeHTHbIe nJIeTeHbIe MaTepHanbI MO:>KHO BSl:3aTb, HCnOJIb3YSl: nepBYlO neTJIlO C,D;BOM-
HbIM nepenJIeTeHHeM HIITH. Ee nOKpbIBalOT ,nBYM5! (TpeM5!) npOCTblMII neTnHMII.
\... ........... f .
. "..IIt.
: .. ... .
.
...... ": 1\ .' . .' . .,.,...t
,- . ., $: ".
--<'.:: A :
'1;'" ...
.
....
.'"
Puc. 7.1 Cmpoenue CllO:JICllOlO
lIepaeHoMepnolo Y311a U3 aeyx
nemellb
\ :
..
:
"
..."..,... . ..
/_.... -...... J
..
:
..
.. .. --.
+ :I. .-ti
-
.
..
..
..
.
r; '
<;:.f, ...v , _..>_ >. _'
. " . . . . . " . ..n.:;,.. ..
" i, < --.- >t it'
' : ' Ii
'. . .
. ..
.. ..
. . ....
PUC. 7.2 Cmpoellue CllO:JIClIOlO
pae/IOMepll0l0 Y3J/ll U3 aeyx
nemellb
61
rJIaBa 7
Puc. 7.3 Cmpoellue Y3Jla
QP
(Q)
" 60-
Puc. Z 4 CmpoeHue Cmaif;ifJOpawau-
pCKOlO Y3JIa
l
.. "'..
.....,.....:
. I 'J . .:\
.' , " ., . . ; .: "
.. ......
... ...
PUC. 7.5 Cmpoellue napaJ/Jlellb-
HOlO Y311a
62
KOJIHqECTBO HHTEM B KOJIbUE CTE)KKA
KonbUO CTe:>KKa 60nblliHHCTBa Y3JIOB 1lJ0pMHPYeTCSI:
TonbKO O,nHOH HlITblO (o,nHOKOnbQeBble Y3JIbl). Y3eJI EapKO-
Ba (puc. 7.3) IICTallJllJop,WllaHpCKIIHY3eJI (puc. 7.4) HBnSl:IOT-
CSI: ,nBYXKonbueBbIMIi. I1CTOpHSI B03HIIKHOBeHHH Ha3BaHHSI:
IIOCJIe,nHero BeCbMa IIHTepeCHa . 3HaMeHHTbIH B npOlliJIOM
xlIpypr Lawson Tait o,nHa)l(,D;bI npoe3:>Ka no CTallJllJop}J,IllaH-
PCKOMY rpallJCTBY, pa3rmJ: bIBan YKpalliaBllilie CTeHbl Baro-
Ha rep6bl :Horo rpallJCTBa. C Y.llHBneHlleM OH 3aMeTl1JI, qTO
lliHypbI C KIiCTSl:MH, COCTaBn lOmlie npliHalUIelKHocTb 3Toro
rep6a, 3aBSl:3aHbI OqeHb npOCTbIM II npOqHbIM Y3noM, KOTO-
pbIH nOKa3aJICSI: eMY OqeHb npnro,nHblM ,nJI xlIpyprHqeCKIIX
ueJIeH. Oc06eHHo ueHHbIM 3TOT Y3eJI OKa3aJICH B cJIYqa x y,na-
neHHSI: OnyXOJIIi Ha HO:>KKe. HaKlla,nbIBaeTc OH ,nOBOJIbHO
npoCTo. CHaqaJIa HIITb npoBo,nHTC qepe3 cepe,nIIHY HO:>KKII
onyXOJIlI, 3aTeM .llpyroH KOHeu HIITH 06BO.D:IITC BOKpyr Hee H
TO:>Ke npoBO.lllITCSI: qepe3 ee Tonmy. IIocJIe 3Toro 06a KOHlJ,a
3aBSl:3blBalOTC Ha TOH qaCTblO JIHraTypbl, KOTopaS! 060llIJIa
BOKpyr HO:>KKII. EIUe ny'uue BO BpeM nOKanblBaHII HO)l(KH
paCnOnO:>KIITb HHTH TaK, qT06bI 06pa30BbIBanacb ,nBoHHaH
nepeKpemliBalOIUaHc neTnsr.
llPOCTPAHCTBEHHOECTPOEHME
IIETEJIb B Y3JIE
ECJIH HanOlKlITb O,nHY Ha ,npyrYIO ,nBe npoCTble neTnH,
TO MO:>KHO nOJIyqlITb,nBe KOM6IIHaUHH: Y3eJI eHCKIfU (6bIC-
TpO pa3BSl:3blBalOIUIIHC ) II Y3eJI MOpCKOU_ B nepBOM CJIyqae
KOHUbI 3aTSl:HYTbIX HHTOK pacnonaralOTCSI: nepneH,nIIKYJISl:p-
HO, a BO BTOpOM napanneJIbHO K neTne Y3na. TaKHe Y3nbI,
3aB 3aHHble C qepe,nOBaHlieM neTenb, Ha3blBalOTCSI: napaJI-
JIeJIbllblMIf (puc. 7.5). ,[{nSl: IIX 1lJ0pMIIpoBaHHH He06xo,nHMO
3aBSl:3blBaTb neTJIIi nOOqepe.D:Ho npaBoH H neBoH PYKOn. He-
c06nlO,neHlIe npaBHlIa qepe,nOBaHIISI: neTeJIb Be,neT K 06pa30-
BaHlilO nepeKpern.elllloro Y3JIa (puc. 7.6). OH 3HaqHTeJIbHO
ycrynaeT B Ha,ne:>KHOCTIi II npOqHOCTH napanneJIbHoMY Y3JIY,
nerKO pacnycKaeTCSI: (He3aBlicHMo OT Tlina IIcrronb3yeMoH
HIITII). I1cxo,n51 H3 3Toro, .D:JIS! nOBbIIlleHIIH Ha e:>KHOCTIi nepe-
KpeIUeHHoro Y3JIa nplIxo,nHTCS! 1lJ0pMlIpOBaTb ,nononHHTeJIb-
Hble neTJIIi. Y3JIbI 1I3 60nbilloro KOnlIqeCTBa rreTeJIb, B KOTO-
pbIX qaCTb neTenb qepe,nYlOTCSI:, a ,npyraH qaCTb - HeT,
Ha3bIBalOTCH CMem8HllblMH.
HAIIP ABJIEHME 3ATHrMBAHH5IIIETEJIb
CHMMeTpHqHbIe nerJIH 06pa3YlOTCSI: npH 3aTHrHBaHHH HHTH
B npOTHBOnOnO:>KHOM HanpaBneHHII C npHMeHeHlIeM O,nIIHaKOBOH
CRJIbI Ha 060HX ee KOHuaX. Y3eJI, COCTOSl:lI.{HH 1I3 CIiMMeTpHqHblX
neTeJIb (T.e. 3anIHYTbIX B npaBlInbHOM HanpaBJIeHIIII), Ha3bIBalOT
CHMMCTPHqHLIM. ECJIII:>Ke O,nHa HIITb «06MOTaHa» BOKpyr ,npyroH,
TO TaKOH Y3en Ha3bIBaeTCSI: CKOJIb3HInHM (puc. 7.7). BepmITHOCTb
pa3BH3bIBaHIiH CKonb3HIuero Y3JIa O'ieHb 60nblliaSl:. OHII pacnyc-
KalOTCSI: ,na:>Ke IIPH OqeHb He3HaqlITenbHoH HarpY3Ke. II03ToMY B
xnpyprlIH K HHM OqeHb HaCTOpO:>KeHHOe OTHOllieHlIe.
ECJIII nepBaH neTnH cHMMerpH'iHaSl:, a cTa6IIJIH3HPYIOlI.{He
ee 3aTSl:HYTbI B HenpaBRITbHOM HanpaBJIeHHII (aCHMMeTpHqHble),
TO Y3eJI Ha3bIBaeTCSI: nOBcpHYTblM (puc. 7.8). Ha,ne:>KHOCTb TaKoro
Y3JIa 3aBHCliT OT COOTHOllieHIISI: CIiMMeTplIqHblX II aCIiMMeTpHqHbIX
neTeJIb.
EcnH npli 3aBSl:3bIBaHIiH Y3JIa nepBaSl: neTnSl: nonyqaeTCH
aCIiMMerplIqHOH, a Bce OCTaJIbHble 3aTHHYTbI B npaBIIJIbHOM Ha-
npaBJIeHlI1I (CIiMMeTpHqHbIe), TO 1lJ0pMIIpyeTcH CMCInCHHbIU Y3CJI
(puc. 7.9). He06xo,n1IM0 yqlITbIBaTb B03MO:>KHOCTh pOTaWlH TaKoro
Y3na. B CBH31I C 3TIIM B03MO:>KHO YBeJIlIqeHHe ,D;JIIIHbI H1ITeH, co-
CTaBnHlOIUIiX CTe:>KOK lliBa. II03TOMY CMeIUeHHbIe, CKonb3HIUlie II
nOBepHYThIe Y3JIbI OTHOCHT K rpynne aCIiMMeTplIqHbIX Y3JIOB C H1I3-
KOH Ha,ne:>KHOCTblO.
HecMoTpSl: Ha aCIiMMeTpHqHOCTb neTenb, BbICOKOH Ha,ne:>K-
HOCTblO 06JIa,nalOT CKOJIb3HInHC 6JIOKHpOBaHHblc yJJIbl (puc. 7.10) .
OCHOBHbIM HX OTJIlIqHeM Sl:BJIHeTCSI: TO, qTO neTJIH B 3THX Y3JIaX
«CKOJIb3H'J) no pa3HbIM HIITHM B3aHM03aTHrIIBaHCb. IIo,n06HaH OCO-
6eHHOCTb n03BonHeT CKOJIb3S1:IUIiM 6JIOKlipOBaHHbiM Y3JIaM Bb ep-
:>KIIBaTb 3HaqHTenbHbIe HarpY3KII. Hx qaCTO npliMeHSl:lOT npli He06-
XO,nIIMOCTIi HII3Be,neHIIH Y3JIa Ha ,nHO rny60KoH paHbI, npH
BbIIIonHeHHH 3H.D:OCKOnlIqeCKIiX onepaUHH.
" f
Puc. 7.6 CmpoeHue
nepeKpeUjellllOlo Y3Jla
& ' :
;
.,., . . ..-
,,,-:: ./".... :. "
. Jr.!:..'Y'r"
',: ' > :" >- -----1f'. :"' : F. ,- }"
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. <;.' _ ,'S.:_. ;.:'"' ;. . n- : ' \'/ _'_: .
n .,
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.... . f
..
Puc. 7. 7 Cmpoellue CKOJlb3RUjUX
Y3JlOe U3 aeyx nemeJlb
63
rJIaBa 7
... . ... / ..... ';;X
0--1 ' (; ' . J
.' . ,
. .- -. '- .-
-:""':<;:} . '.
u . .:,
.. . ..
. .. .
. ....... ,..,. ._- - ',"" ...
'.!'B ir :'. ..;- . ' E::;" . -'.....".'" . .. " .' . . .!e'
" ; :/.i' {' f; ;r:{'f
.'.- .. '..-.: ..
...
Puc. 7.8 CmpoeHue noeepHymOi!O Y3Ra
....
..
.
,.
.
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.
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.
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.. ,. '\........
( 1.P
Puc. 7.9 CmpoeHue CMeUjeHHOi!O Y3Jla
PUC. 7. 10 CmpoeHue CKoRb3J/Ujei!0
6RoKupOeaHHOi!0 Y3Jla
64
2-. ::::-
naBa 8
KJIMHII'qRCKA.R
XAPAKTEPMCTIIKA nPIIMJ!:HHEIVlbIX ,-
B XMPyprl111 Y3JIQB .,-.. ",'
. , .
<:.
"5' :: ;',-!, >':'
., r -.'
rnaBHbIMH napaMeTpaMH KllIIHWIeCKOH xapaKTepHCTIiKH npHMeHHeMbIX B xlIpyprnli Y3JIOB
HBJISl:lOTCH HaL!e:>KHOCTb, npOqHOCTb, 06'beM Y3JIa (KOJIHqecTBO lliOBHoro MaTepHana) H CJIO:>KHOCTb
1lJ0pMlIpOBaHIiH. .
Cnoc06HOCTb Y3JIa BbIDonHHTb CBOH IlJYHKUHII (nOMep:>KaHHH conpIIKOCHOBeHHHTKaHeH) B
TeqeHlIe Bcero BpeMeHH, Tpe6YlOIUerOCSI:,D;JISI: 06pa30BaHIISI: npOtIHOro py6ua, Ha3bmaeTCSI: B XIIPYP-
rHII lIa.ucmHOCTblO Y3JIa. KpOMe 3Toro, O,nHlIM 1I3 HalI60JIee CYIUeCTBeHHbIX napaMeTpOB xapaKTe-
pHCTIiKH Y3JIa Sl:BJISl:eTCH ero npO'JIlOCTb - MaKCIiMaJIbHO B03MO:>KHbIH npe,neJI B03,neHCTBIiH CRITbI,
,neHCTBYlOlI.{eH Ha Y3eJI co CTOpOHbI coe,nHHSl:eMbIX TKaHeH, He nplIBo,nHlUeH K ero pa3pyrneHHlO. B
CBOlO Oqepe,nb, pa3pbIB HIITII B Y3JIe npOHcxo,nIIT no,n ,neHCTBHeM CRITbl 60JIbllieH, qeM CRITa, He06xo-
,nIIMaH L!JIH pa3pbIBa HIITII 6e3 Y3JIa.
06'bCM Y3JIa - xapaKTepHCTIIKa, onpeL!eJIHlOIUaH B03MO:>KHOCTb B03HHKHOBeHHSI: OCJIO:>KHe-
HIIH B nOCJIeOnepaUHOHHOM neplIo,ne H3-3a HanHqlIH IIHOpo,nHoro MaTepliana B paHe. qeM MeHbrne
06'beM Y3JIa, TeM HH)!(e pHCK peaKUHH TKaHeH Ha HaJ!HqlIe lliOBHoro MaTepliana.
CJIO:>KHOCTb 1lJ0pMHpOBaHHSI: Y3JIa - npOlI3Bo,nHoe OT MaHyanbHblx HaBbIKOB xHpypra. )J;JIH-
TeJThHbIe TpeHlIpOBKII nOMoryT npeHe6peraTb 3TIIM npellHTCTBHeM K npliMeHeHlIlO ,naHHoro Y3JIa.
IIpHBe,neM KpaTKlIe KllHHMqeCKlie xapaKTepHCTlIKH HaH60nee qaCTO nplIMeHHeMbIX B XIIPYP-
rlIlI Y3JIOB.
Y3JILI 1f3 ,l(BYX nETE.JTh
npOCTOH (mCIICKHH) Y3CJI. XapaKTepHCTIiKa Y3na: npOCTOH
nepeKpeIUeHHblH Y3eJI H3 ,nBYX neTenb (puc. 8.1).
Y3eJI COCTOIIT H3 ,nBYX o,nHHaKOBbIX nepeKpell.{eHHblX neTeJIb.
OH 06pa3yeTcH npH 3aBH3bIBaHIIII neTeJIb, c,neJIaHHbIX o,nHOTlinHO
O,nHOH PYKOH. 3TO caMbIH npOCTOH H3 Bcex xlIpyprHqeCKHX Y3nOB.
)J;OCTOHHCTBpM :>KeHCKOro Y3JIa Sl:BnHeTCSI: B03MO)!(HOCTb ,nOTSl:HYTb
Y3eJI nOCJIe 3aBeprneHHH 1lJ0pMHpoBaHHH BTOpOH neTnH. OL!HaKO,
Ha,ne:>KHOCTb :>KeHCKOro Y3JIa OqeHb HeBeJIHKa - OH CKOnb31IT no HHTII
,na:>Ke npH COnOCTaBJIeHlI1I TKaHeH C He3HaqHTeJIbHbIM HaTH)!(eHlIeM.
II03TOMY 3a HIIM 3aKpenMJIOCb Ha3BaHlie «Y3eJI-y6IIHua». XlIpypr
,non:>KeH nOMHIITb 06 3TOM H He nonb30BaTbCH HM B npaKTlIqeCKOH
,neSl:TeJIbHOCTII.
MOpcKOH Y3eJI. XapaKTepHCTlIKa Y3JIa: npOCTOH napaJIJIeJIb-
HbIH Y3en H3 ,nBYX neTeJIb (puc. 8.2).
'\ ..... J /..
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l
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Puc. 8.1 CmpoeHue 3ICeHCI<OZO
Y3Ra
65
rnaBa 8
MOpCKOH Y3en 06pa3ycrcH H3 ,nBYX pa3HoHanpaBneHHbix
(BcTpeqHblx) B3alIM03aTHrlIBalOIUIIXCH neTenb - npaBoH II JIeBoH.
3TO H,neanbHbIH Y3eJI MSI: llienKOBbIX HIiTeH. I1CnOJIb30BaHlie CHH-
TeTlIqeCKIiX MOHollJRITaMeHTHbIx 1lI0BHbIX MaTeplianoB C nOHII:>KeH-
HbIM K03IlJIlJIIUI1eHTOM TpeHIIH 06HapY:>KRITO He,nOCTaTKH 3TOro Y3JIa
- CKOJIb:>KeHlIe no HIITII, CKllOHHOCTb K pa3BH3bIBaH1i1O. Oc06eHHo
3TO npOSl:BJIHeTCH npH IICnOJIb30BaHHH CMOqeHbIX KpOBblO HIiTeM
RITH npH 3HaqlITeJIbHOM HaTH:>KeHIIII ClliHBaeMblX TKaHeH. n03TOMY,
xlIpyprlI Haqanli OTHOCIITbCH K MOPCKOMY Y3ny 60JIee B3BellieHHO.
XOTSI: MOpCKOH Y3eJI 60JIee Ha,ne:>KeH, qeM :>KeHCKIIH, o,nHaKO nyqllie
B031Iep:>KHBaTbCSI: OT ero npliMeHeHIISI: BO BpeMSI: onepaulIH, TaK KaK
HeT ,noCTaTOqHOH rapaHTHH Ha,ne:>KHOCTIi ero CYIUeCTBOBamrn.
Xupypru'leCKU" peJI. XapaKTeplIcTHKa Y3JIa: CJIO:>KHbIM na-
paJIJIeJIbHbIH Y3eJI, COCTOHlUHH 1I3 ,nBYX ncreJIb C ,nBOHHbIM nepe-
nJIeTeHlIeM HHTeH nepBoH nerJIIi (puc. 8.3). IIpli ero 1lJ0pMlIpoBa-
HIIH B03MO:>KHbI ,nBa Hcxo,na: 06pa30BaHlie KaK »<eHCKoro, TaK H
MopcKoro Y3JIOB, C nplIcYIUHMII HM npeHMYIUecTBaMH H He,nOCTaT-
KaMH.
XlIpyprlIqeCKHH Y3en - OlIHH 1I3 CaMbIX pacnpoCTpaHeHHblX
Y3JIOB.
HecoMHeHHbIM npelIMYIUeCTBoM xlIpyprlIqeCKOrO Y3JIa eCTb
ero BbICOKaH CTeneHb HalIe:>KHOCTH. OH OqeHb y,n06eH DpH 3aBH3bI-
BaHHII, nOCKOJIbKY nepBaH neTn5I, 6JIaro,napH ,nBOMHOMY nepenne-
TeHlIIO HIiTeH, He ,naeT pa30HTliCb C6JIII:>KaeMbIM TKaHSl:M BO BpeMSI:
MaHlInYJIHUIiH. B TO :>Ke BpeMSI:, HCnOJIb30BaHHe nepBOH CJIO:>KHOH
neTnH, KpOMe npeHMYIUeCTB, OnpelIeJISl:eT H He,nOCTaTKH xlIpyprH-
qeCKOrO Y3JIa. npli 3aTSl:rHBaHIIII nepBOH neTnH He IICKJIlO'IaeTCSI:
B03MO:>KHOCTh nepeTHpaHIiH HHTH. KpOMe Toro, IICnOJIb30BaHlie CIIH-
TeTI1qeCKIIX MOHollJRITaMeHTHblX H1ITeH C rJIa,lU<OM nOBepXHOCThlO no-
BbIllialOT pliCK pa3BSl:3bIBaHII5I xlIpyprHqeCKOrO Y3na. Oc06eHHO
eCJIH ero 1lJ0pMHPYlOT ,nOBOJIbHO TOJICTOH :>KeCTKOH HIiTbIO. B 3TOM
CJIY'Iae ,nJIlIHa ,nBOHHoro nepenJIeTeHHH nepBOH ncrJIH 60nbllie MIIHbI OlIliHapHoro nepenJIeTeHIIH
BTOpOM neTnlI, 'ITO onpe,nenSl:eT He,nOCTaTOqHbIe ee CKpennHIOIUlie CBOHCTBa. IIpH 3aTSl:rIIBaHHH
Y3JIa ,nBOHHoe nepenJIeTeHlIe ,nellJopMHpyeTcH, H Ha Y3eJI lIeHCTByeT CHJIa ynpyroCTIi He TonbKO
TKaHeH, HO H CIiJIa ynpyrocTIi HHTH B nepenneTeHlI1I nepBOM neTnH. HeCOBna,neHlIe npOqHOCTHbIX
xapaKTepliCTIiK nepBOM (CJIO:>KHOM) II BTOpOH (npOCTOH) neTeJIb nplIBo,nHT K ,neCTa6RITII3aUHII Y3JIa.
qaIUe Bcero xlIpyprlIqeCKIiH Y3eJI pa3B5I3bIBacrCSI: npH IICnOJIb30BaHHII MOHollJRITaMeHTHblX
HIiTeH, a TaK»<e HIiTeH C nOKpbITHeM, YBeJIlIqlIBalOIUIIM IIX CKOJIb3HIUHe CBOHCTBa. B CB5I31I C 3TIIM,
MSI: 1lJ0pMIIpoBaHliH ,naHHoro BH,D;a Y3JIa npe,nnOqTHTeJ1bHee nonb30BaTbCSI: H1ITHMH C nOBbIIlIeH-
HbIM K031lJ1lJIIUIIeHTOM TpeHIIH.
flpe,nOTBpaTHTb pa3BH3bIBaHlie Y3JIa MO:>KHO nYTeM ,n06aBJIeHHH TpeTbeH npOCTOH CTpaxo-
BOqHOH (<<CTonopHIUeH») neTJIH.
XHpyprlIqeCKHH Y3eJI, KaK H ,npyrlIe CJIO:>KHble Y3JIbl, K KOTOpbIM OH OTHOCHTCH, JIyqIlIe He
npIiMeHSl:Tb.D:JIj{ HanO:>KeHIIH JIliraTYP Ha MeJIKlIe COCY.D:bI. IIpH nlIflipOBaHHII cocy,na C IICnOnb30Ba-
HlieM xHpyprlIqeCKOrO Y3JIa CJIe,nyeT OlJ,eHHTb COOTHOllieHlIe MIIHbI neperurereHII5I H ,nlIaMeTpa
\ :
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Puc. 8.2 Cmpoellue MOpCI<OlO
Y3RG
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k .
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. ".'r, :'.;;". ;.:::.:>.1 ....
, ..
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AI
Puc. 8.3 Cmpoellue
xupyplu ecl<OlO Y3Ra
66
cocy,na. JIliraTypa H3 TOJICTOH HIITH, HaJIO:>KeHHaS! Ha MeJIKIIH CO-
cy,n, nOqTII HaBepHSl:Ka 6y,neT HeCOCTOS!TeJIbHOM II COCKOJIb3HeT C
ero KYJIbTIi B rrOCJIeOnepaUIIOHHOM neplIo,ne. CJIe}:(yeT PYKOBO,n-
CTBOBaTbCS! nplIHUHnOM - qeM Tomue cocy,n, TeM TomueH HIiTblO
He06xo,nIIMO ero JIlirlipOBaTb.
AKa.ueMI1'Jeclmu peJI. XapaKTeplICTHKa Y3JIa: CJIO:>KHbIH
napanJIenbHblH Y3en 1I3 }:(BYX neTeJIb C }:(BYMS! nepellJIeTeHIIHMII B
06elIx neTJIS!X (puc. 8.4) . 3TOT Y3eJI TaK:>Ke MO}i(eT 6bITb B npoCToM
(:>KeHCKoM) II MOpCKOM BapHaIlTax.
O,nIIHaKoBaS! ,D;JIIiHa nepellJIeTeHHSI: 06eHx neTeJIb B aKa,ne-
MHqeCKOM Y3ne nlilliaeT OCHOBbI «BHYTpeHHero KOHllJnIIKTa», onH-
caHHOrO,D;JIS! HepaBHoMepHbIx Y3JIOB. ,[(OCToHHcTBaMIi Y3JIa, oue-
neHHbIMH xHpypraMH, S!BJIS!lOTCH npOqHOCTb, MaKCHMaJIbHaSl:
Ha,ne:>KHOCTb, y,n06CTBO 3aBS!3blBaHHH. IIpli 3TOM BO BpeMSI: 1lJ0pMII-
Puc. 8.4 Cmpoellue (lKGOeAfU'leCKO-
pOBaHIIS! BTOpOIi neTJIIi nepBaS! rreTJISI: He pacnYCKacrcS!, a nOTOMY
Y3eJI 06blqHO MO:>KHO HCnOJIb30BaTb 6e3 TpeTbeH CTpaXOBOqHOM
neTJIH. KpOMe 3Toro, eMY rrplicyma cTa6IIJIbHOCTb nepeqlICJIeH-
HblX CBOHCTB He3aBIICliMO OT nplIpo,nbI lliOBHoro MaTeplIaJIa.
IIpoqHOCTb aKa.IJ:eMUqeCKOrO Y3JIa OKa3anaCb conoCTaBIiMoH C
npOqHOCTblO Y3JIOB, COCTOSl:ll.\HX H3 Tpex neTeJIb, npli HeCOMHeHHO
MeHbllieM pacxo,ne lliOBHoro MaTeplIaJIa Ha 1lJ0pMIIpoBaHlie aKa-
}:(eMHqeCKOrO Y3JIa.
OrpaHlIqeHIISI: Ha Hcnonb30BaHlie aKa,neMlIqeCKOrO Y3JIa
CBSl:3aHbI C O!HOCIiTenbHOH Tpy,nHOCTblO ero 3aBSl:3blBaHIISI:, 60nb-
lliliM 06'beMOM Y3JIa. Y3eJI He CJIe,nyeT nplIMeHHTb npli OCTaHOBKe
KpOBOTeqeHIIS! 1I3 COCy,nOB He60JIblliOrO ,nlIaMeTpa 1I3-3a 60nb-
llioro npOCBeTa nepBoii neTJIIi.
OnlIcaHHble npeliMYll.\eCTBa aKa,D.eMH'lecKoro Y3JIa MOTII-
BIiPYlOT nOCTeneHHYlO 3aMeHY llinpOKO npIiMenS!lOmerOCSI: B Ha-
CTOHmee BpeMS! xlIpyprH'leCKOro Y3JIa.
Y3e.TJ EapKOBa. XapaKTepliCTIiKa Y3na: npOCTOH napaJIJIeJIb-
HbIM ,nBYXKonbueBOH Y3eJI, COCTOHll.\IIH 1I3 ,nBYX rreTeJIb. DepBaS!
(BHYTpeHHS!SI:) H3 HIIX COCTOIiT H3 ,nBOHHOH, a HapY:>KHaH - 1I3 0,n1I-
HapHOMHlITIi (puc.8.5).
rJIaBHOe npe,nHa3HaqeHHe Y3JIa - 3TO JIlIrHpOBaHHe rJIy60Ko pacnOnO:>KeHHblX KPYnHblX co-
Cy,nOB, a TaK:>Ke nepeBS!3Ka COCy,nOB en massae. OH 6blBaeT OqeHb nOJIe3HbIM ,nnH conOCTaBJIeHIISI:
Man03JIaCTHqHbIX TKaHeM 3HaqlITeJIbHOH TOJIlL(HHbl, HanpnMep, npli HanO:>KeHIIII IlIBa Ha KOCTII RITII
Ha MSl:rKlie TKaIIII B JI06HO-TeMeHHO-3aTbmOqHOH 06JIaCTIi.
IIpli conOCTaBJIeHlI1I TKaHeH C HaTH:>KeHlIeM rrepBaS! neTJIS! C ,nBYMH KOJIbuaMH 60JIee Ha.IJ:e:>K-
Ha, qeM 06bI'lHM O,nHOKOJIbueBaH rreTJIS!. OHa C03,naeT B03MO:>KHOCTb OqeHb nJIOTHOrO COnOCTaBJIe-
HHS! TRaHeH. K TOMY :>Ke, npli 3aBH3bIBaHIIII BTOpOH neTJIIi Y3JIa nepBaSl: rreTJIH OCTaeTCSI: CTa6RITbHOM.
TaKOH Y3eJI caMOCTOHTeJIbHO npaKTlIqeCKI1 He pa3BSl:3bIBaeTCH.
He,nOCTaTKaMH Y3JIa EapKOBa HBJISl:lOTCSI: 60nblliOH pacxo,n lliOBHoro MaTepHana H 3HaqU-
TeJIbHbIe 3aTpaTbI BpeMeHII Ha 1lJ0pMIIpoBaHlie Y3JIa.
CKO.fIb3HInl1U peJI 113 lI.BYX neTeJIb. XapaKTepliCTIiKa Y3JIa: npOCTOH CKonb3HIillIH Y3eJI H3
t ... ..._)
t........... -.." . >O J '
..
. .........("\...
....-....... '-.:...
;>0 Y3J!a
PUC. 8.5 CmpoeHue Y3J/a
EapKoea
67
rnaBa 8
c; \ : .
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Puc. 8.6 CmpoeHue CI<0l/b3RUjecO
Y3J/a U3 oeyx nemel/b
,nBYX neTeJIb (Pl!c. 8.6). 3aTHrlIBaH KOHUbI HHTeH ,nByxneTeJIbHOrO
Y3JIa B HenpaBlInbHOM HanpaBJIeHIIH MO:>KHO nonyqHTb aCHMMeT-
plIqHble 06e neTJIH, TO eCTb, 1lJ0pMIIpyeTcH CKOnb3HIUliH Y3eJI. B Ta-
KOM Y3JIe neTJIH OKa3bIBalOTCH HaHII3aHHbiMli Ha OCHOBHYlO HIiTb.
CKOnb3HIUliH Y3eJI 1I3 ,nBYX neTeJIb OqeHb HeHa}:(e)!(eH, n03TOMY OH
OqeHb OnaCeH.
IIoBepHYTblH y:JeJI 03 ,nBYX neTeJIb. 3aTHrlIBaR nepBYlO neT-
nlO npaBRITbHO, a BTOPYlO - C nepeKpYTOM (aCIiMMeTplI'iHO), MO:>KHO
nonyqlITb nOBepHYThrn Y3eJI (puc. 8. 7) . YqnThlBM ero HeHa,D.e:>KHOCTb,
He06xo,nHMO nonHOCTblO IICKlllOqlITb ero H3 apCeHaJIa xlIpypra.
CMeIneHHblH y:JeJI 03 ,nBYX neTeJIb. ECJIII nepBaH neTnSl: B Y3ne
aCIiMMeTplIqHaH (3aTHHYTa B HenpaBHJIbHOM HanpaBJIeHIIII), a BTO-
paR - CHMMeTpHqHaSl:, TO 1lJ0pMlIpyeTcSI: CMeIUeHHblH Y3en (puc. 8).
IIo,n ,neHCTBlieM CRITbl HaTSI::>KeHIIR TKaHeH B nocJIeOnepaUlIoHHoM
nepHo,ne cMeIUeHHblH Y3eJI pOTlipyeTcH, qTO nplIBo,nIIT K yxy,nllIe-
HHlO IlJHKcaUHI1 TKaHeH. CMeIUeHHbIH Y3eJI MO:>KeT TaK)!(e TpaHcllJop-
MHpoBaTbcH B CKOJIb3RIUIIH, qTO B nOCJIe,nCTBHH MO:>KeT npliBeCTli K
6bICTpOMY ero pa3BH3bIBaHHlO.
}:y " Cv' frY
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. ......1 r..... . . ..- .
.... -\ \ .. ..
. - .
'W 1 : :...- :
. "' ;;':'< J: .::1, :. :,n';i' ':
.i,.. '. !. v. " .
f'!' .:..:i:.. -..,.
..... ..It ,J. ..--
.."
Puc. 8.7 CmpoeHue noeepHymoco Y3J/a U3 aeyx nemeJ/b
Y3JIh111.3 TPEX IIETEJTh
Puc. 8.8 Cmpoellue, CMeUjeHHOcO
Y3J/a U3 aeyx nemeJ/b
J],BOHHOH »\eHCKO" y:JeJI. XapaKTepHCTIiKa Y3JIa: npOCTOH nepeKpeIUeHHbIH Y3eJI H3 Tpex
neTeJIb (puc. 8.9).
,[(BOHHOH :>KeHCKIiH Y3eJI onee Ha,ne:>KeH, qeM 06blqHbIH :>KeHCKIiH Y3eJI. O,nHaKo npli 3aBSI:-
3bIBaHIIII ,nBoHHoro :>KeHCKOro Y3JIa He06xo,nHMO nOMHIITb 0 coxpaHeHIIH TeH,D;eHl.(HH K oCJIa6ne-
HlilO neTeJIb, npHcYIUeH 06bIQHOMY npoCToMY (:>KeHCKoMY) Y3JIY.
JIIiTepaTypHbIe ,naHHbIe CBlf.[(eTeJIbCTBYlOT, qTO ,nBOHHOH :>KeHCKHH Y3eJI, cllJopMlIpoBaHHbIH
1I3 MOHoIlJRIT eHTHblX HHTeH, pa3BSl:3bIBaeTCSI: npH cpaBHIITeJIbHO He60nbllinx HarpY3Kax. He CTO-
liT npliMeIDlTb 3TOT Y3eJI II npH HCnOJIb30BaHIIII HHTeH C nOKpblTlieM 1I3-3a onaCHOCTIi ero pa3BSl:3bI-
BaHIIH. IlJIeTeHbIe H KpyqeHb:e HHTH, 3aBH3aHHble ,nBoi;i :>KeHCKIiM Y3JIOM, 60nee Ha,ne:>KHO y,nep-
68
>IamalOTTI<aHH. O.D:HaKO, HaqlIHalOlI.{lIM xHpypraM CJIe,nyeT OTKa3aTbCSI: OT HCnOJIb30BaHIIH ,nBoihIo-
ro :>KeHCKOrO Y3na B nOnb3Y 60nee Ha,ne:>KHOrO ,nBOHHOrO MOpCKOrO.
TaKIiM 06pa30M, ,naHHbIH BM Y3JIa npe,nCTaBJISl:eT C060M OCJIO:>KHeHHbIH BapliaHT npOCTOrO
(:>KeHCKOrO) Y3JIa 6e3 Sl:BHbIX YJIyqllieHHM ero CBOMCTB H C coxpaHeHHeM onlIcaHHblX paHee He,no-
CTaTKOB.
)J.OOiiHOii MOpCKOii Y3eJI. XapaKTepHCTHKa Y3JIa: npOCTOH napannenbHbrn Y3en H3 TpeX
neTeJIb (puc. 8.10).
YHIIBepcanbHo nO,D;Xo,nIIT ,D;JISI: pa3JIII'lHblX BMOB HIiTeM. XOTSI:, yqlITbIBM B03MO:>KHOCTb oc-
na6neHIISI: nereJIb npli HCnOJIb30BaHliH MOHollJRITaMeHTHblx CHHTeTlIqeCKIIX H1ITeM, Tpe6yeT 1lJ0PMH-
pOBaTb o,nHY-,nBe ,nonOJIHHTeJIbHbIe neTnH,D;JISI: YBeJIHqeHIIH Ha,D.e:>KHOCTIi Y3JIa.
COqeTaHHe JIerKOCTIi BbIllOnHeHIISI: C Ha,ne:>KHOCTblO IlJIIKcaUHH Y3JIa Ha HIITH ,neJIalOT ero
HalI60JIee qaCTO IIcnonb3yeMbIM Y3JIOM B xlIpyprlIli.
npocToii cMernaHHblii Y3eJI 03 Tpex neTeJIb. B03MO:>KHbl ,nBa BapHaHTa HcnonHeHHH CMe-
llIaHHoro Y3JIa 1I3 Tpex neTeJIb. IIepBbIH BapHaHT npe,nYCMaTpHBaeT 1lJ0pMIIpoBaHlie CHaqana MOp-
CKoro Y3na C IlJHKcaU:HeH TpeTbeH neTJIeM 6e3 qepe,nOBaHIISI: CO BTOpOH. IIpH BTOpOM BapliaHTe
3aBSl:3bIBaHIIH BHaqane 1lJ0pMIIPYlOT :>KeHCKHH Y3eJI, a nOTOM HaKpbIBalOT ero TpeTeH neTneH, 3aBSl:3bI-
BaH ee C qepe,nOBaHHeM npaBOH II neBOH PYKII (puc. 8.11).
3TOT Y3eJI no Ha,ne:>KHOCTIi 3aHliMaeT npOMe:>KYTOqHOe nOJIO:>KeHHe Me:>K.D:Y ,nBOMHbIM :>KeHC-
KUM H ,nBOMHbIM MOpCKHM Y3JIaMH. ,[{JISI: Hero, TaK :>Ke KaK H ,D;JISI: Bcex CMelllaHHblX Y3JIOB, cnpaBe,n-
nHBO 06l1.{ee npaBHlIO - qeM 60nbllie nereJIb B Y3JIe 3amI3aHO C qepe,nOBaHlieM npaBOH II neBOH
PYKII, TeM HalIe:>KHee nonyqaeTCSI: Y3eJI, II Ha060pOT.
rnaBHbIM He,nOCTaTKOM TaKoro Y3na Sl:BJISl:eTCSI: HenponopU:HOHanbHoe YBenHqeHlIe 06'beMa
Y3JIa npli cJIa60 BbIpa:>KeHHOM YJIyqllIeHIIH ero Ha,ne:>KHOCTIi.
O,nHaKO B pH)J.e cnyqaeB npHMeHeHHe CMelliaHHoro Y3na u:eJIeC006pa3HO H He06xo,nHMO.
HanpliMep, B CJIyqajIx nlirlipOBaHIiH MeJIKOrO cocy,na B rJIy6IIHe paHbl, Kor,na He06xo,nIIMO II OqeHb
Ba:>KHO H36e:>KaTb pacnyCKaHIIH neRBOH neTJIIi npli 1lJ0pMIIpoBaHIIII nOCJIe,nYlOlI.{lIx. <1>opMHpoBaHlie
AIDI 3TOM u:enH nerJIH C ,D;BOMHbIM nepenneTeHHeM HepaUHOHanbHO - MO:>KHO OCTaBHTb He60nblliOM
npocBeT cocy,na. B TO :>Ke BpeMSI:, rny6lIHa paHbI MO:>KeT He n03BonlITb npMep:>KaTb nepBYlO neTnlO
3a:>KHMOM - c,neJIaTb 3TO HeYlI06HO H onaCHO. B TaKOH cliTyauliH ueJIeC006pa3HO Hcnonb30BaTb
CMelliaHHbIH Y3eJI. IIpH 3TOM nepBbIe ,nBe neTnH MO:>KHO nerKO 3aBSl:3aTb 6e3 qepe,nOBaHHH PYK
(06pa3YSl: :>KeHCKIiM Y3eJI), a TpeTblO - C qepe,nOBaHlieM (no OTHOllieHlIlO K npe,nbI.D:Yll.{eM neTne).
3,necb yqHTbIBaeTcH ,nOCTOHHCTBO :>KeHCKOro Y3JIa - B03MO:>KHOCTb ,nOTHHYTb Y3eJI nOCJIe
o ... :> :
I -+*
,.... E -
-'f .....
... ..
' e ' r{
.J
G . .
,,' r'}..
:.<. .
i. .
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. I
."
Puc. 8.9 CmpoeHue
aeOUHOeO 3/CeHCI<OeO
Y3Jla
Puc. 8.10 Cmpoellue
aeOUHOeO MOpCI<OeO Y3JIa
I
- .J
.
E .. ....1
....
. ....
\ .
..,... . .. .(: .". . . . 1
: ' .. l :' ._; :. .
". .' '"
- . '. .,:
....
".. ..." J
......
.
. .... ..... ) .
l. .
- . L",
-<. :::-:; :t t-:' '::: .-
:':.'- -"<" <> ...
...
PUC. 8.11 Cmpoellue npocmOeO CMeUjeHHOeO
Y3J/a U3 mpex nemeJ/b
69
rnaBa 8
3aBepllieHliS! 1lJ0pMHpOBaHHSI: BTOpOH rreTnH, TpeTbH neTnS!
II03BomleT 3aKperrlITb rrOJIY'iIIBlllYlOCH «KOHCTPYKUlIlO». Pac-
cMaTpHBaSl: cTpoeHlIe CMelliaHHoro Y3JIa MO:>KHO 06paTHTh BHII-
MaHlie Ha TO, qTO OH llJaKTlIqeCKIi COCTOHT 1I3 ,nBYX Y3JIOB. BTO-
paSl: neTJIS! nepBoro (}!(eHCKoro) Y3JIa S!BJIS!eTCSI: o,nHOBpeMeHHO
nepBOH neTJIeH BToporo (MopCKoro) Y3JIa.
YqIITbIBaS!, qTO Ha,ne:>KHOCTb CMeIlIaHllOro Y3JIa MeHbllie,
qeM rrapaJIJIeJIbHOrO, IICnOJIb30BaTb CMelliaHHbIH Y3eJI MO:>KHO
TOJIbKO B OIIlIcaHHOH BbIllie CIiTyaUHII. B CJIyqae, Kor,na Ha Y3eJI
Puc. 8.12 Cmpoellue xupypZU'ieCKOZO ,neHCTBYeT 3HaqlITeJIbHaH cRITa, nyqllie npHMemlTb ,npyrHe, 60-
nee Ha}:(e}!(HbIe Y3JIbl.
XHpyprH'leCKHH Y3eJI C TpCTbeH CTpaXOBO'IHOH neTneii.
XapaKTepHCTHKa Y3JIa: CJIO:>KHbIH rrapaJIJIeJIbHblH HepaBHoMep-
HblH Y3eJI II3 Tpex neTeJIb C ,nBOHHbIM nepeIIJIeTeHlIeM HIiTeH
nepBOHneTnlI (puc. 8.12).
Y3eJI C BbICOKOH CTeneHblO Ha,ne:>KHOCTH. IIpli 1lJ0pMlIpO-
BaHIiH 3Toro Y3JIa He06xo,nIIMO CJIe}:(HTb 3a TeM, qT06bI TpeTblO
neTnlO 3aBS!3bIBaTb C C06JIlO,neHlIeM qepe,noBaHIISI: rrpaBoH H
neBoH PYK. B npoTIIBHOM cJIyqae, 6y,neT cllJopMlIpoBaHa aCHM-
MeTpHqllaSl: (<<cKonb3S!IUaS!») neTnH, KOTopaH CHII:>KaeT Ha,ne:>K-
HOCTb xlIpypm'leCKoro Y3JIa.
IIpHMeHS!SI: xlIpyprlIqeCKHH Y3eJI C TpeTbeH CTpaXOBOq-
HOH neTJIeH Heo6xo,nIIMO nOMHIITb ero He}:(OCTaTKII - 60JIblliOH
06'beM Y3JIa (c coxpaHeHlIeM BbITeKalOlL(IIX OTClO,na OCJIO:>KHe-
HIIH) II CnO}!(HOCTb II MIITeJIbHOCTb BblllonHeHIIH. IToCJIe,nHee
KaqeCTBO MO:>KHO HeHTpaJIjl30BaTb IICnOJIb30BaHlieM paUlIo-
HaJIbHblX cnoc060B 06pa30BaHHH neTeJIb H ,nOCTH}!(eHlIeM xo-
pOlliero TeXHII'leCKOrO ypOBHSI: 3aBSl:3blBaHIISI: Y3JIa npli MHTeJIb-
HblX TpeHlIpoBKax.
J],BoiiHOii aKa,lJ.eM8'IeCKHH pen. XapaKTepliCTIiKa Y3JIa:
CJIO:>KHbIH napanJIeJIbHbIH paBHoMepHbIH Y3en H3 Tpex IIeTeJIb C
,nBYMSI: nepeDJIeTeHIISl:MII B neTJISl:X (puc. 8. 13) .
HecoMHeHHbIMli ,nOCTOIIHCTBaMIi ,nBoHHoro aKa,neMlIl.J.ec-
Koro Y3JIa HBJISl:lOTCH IICKlllOqHTeJIbHaSl: npO'lHOCTb II Ha,ne}!(-
HOCTb. OH XOpOlliO ,nep:>KlITcSI: npli IICrrOJIb30BaHIIII JI106blX HII-
TeH. K He,nOCTaTKaM,nBoHHoro aKa,neMII'leCKOrO Y3JIa OTHOCHTCH
60nbllioH 06'beM KOHCTPYKUIiII Y3JIa H MIITeJIbHOCTb 1lJ0PMlIpO-
BaHIISI:. J],JISI: YMeHbllleHHSI: plicKa 06pa30BaHIISI: BOCnanIITeJIb-
HOH peaKUlI1i TKaHeH cne,nyeT npHMeHSl:Tb cOBpeMeHHbIe ape-
aKToreHHble lliOBHbIe MaTeplIaJIbl.
CKOJIb3HU\HH pen 83 Tpex neTeJIb (puc. 8.14). HecMoT-
pH Ha YBeJIlIqeHlIe KOJIlIqeCTBa neTeJIb B CKOnb3S1:lI.{eM Y3ne
(I.J.eTbIpe, nSITb H 60JIee), 3TO He nOBbIlllaeT ero Ha,ne:>KHOCTIi. YI.J.H-
TblBaH 60JIblllYlO onaCHOCTb, KpOlOlI.{YlOCSI: npli ero IICnOJIb30BaHIIII, CKOJIb3S!IUIiH Y3eJI H3 Tpex (HllII
H3 60nbIlIero KOnHqecTBa) neTenb He06xo,nHMO IICKmOqHTb 1I3 apceHana xHpypra.
.(
)
G {
- . --"...... .. :--
,.f.! ..
.+
ii
..'"
C ' .... J .
-.w .
.
L... J
...............
-- .... 1 ---: . ; .
) , .:0-.""
. L .
" .;
.
-......
Y3JIa C mpembeu cmpaxoeo'illou
nemJleu
i..':':.O !
C: ' ) ;
\; \ . .
,'- , -j_._.
>l :i: _;.:
.....
PUC. 8.13 Cmpoellue aeoullo-
zo aKaaeMU'ieCKOZO Y3Jla
r f
.._.'-- r- '.--
': ' . . >".' : ".
, ,
, ./
PUC. 8.14 CmpoeHue
CKOJlb3HUJezo Y3Jla U3 mpex
nemeJlb
70
Y3JIbI M3 qETbIPEX IIETE.JIh
Tpoiinoil MOpCKOii Y3eJI. XapaKTepHCTHKa Y3JIa: npOCTOH napanJIeJIbHbIH Y3eJI H3 qeTblpeX
neTeJIb.
,[{06aBJIeHHe K .n:BOHHOMY MOPCKOMY Y3JIY ell.{e O,nHOH napaJIJIeJIbHOH neTnH (TpOHHOH MOp-
CKOH Y3eJI) CYlI.{eCTBeHHO YBemlqHBaeT Ha.n:e:>KHOCTb JIIIIlIb npH HC-
nOJIb30BaHliH MOHollJHJIaMeHTHbIX HHTeH HJIH HlneH C nOKpbITHeM.
IIpH IICnOJIb30BaHHH llJIeTeHbIX IIJIH KpyqeHblX KOMnJIeKCHbIX HIiTeH
pa3HIIua B Ha.n:e:>KHOCTH II npOqHOCTH Me)l(,D;Y 3TIIMH .n:BYMH Y3JIaMH
npaKTHqeCKH He3aMeTHa.
CKOJIb3HlII.Oe 6JIOKOpOBaHHbie Y3JILl 03 'IeTLlpeX neTeJIb. Xa-
paKTepHCTIIKa: npOCTbIe CKOJIb3HlI.{lIe 6JIOKHpOBaHHbIe Y3JIbI H3 qe-
TbIpeX ncreJIb (puc. 8.15) .
IIpoqHOCTb CKOJIb3HlI.{erO 6JIOKHpOBaHHoro Y3JIa Ha Kpyqe-
HOH HJIH llJIeTeHOH HHTH nOqTH He OTJIHqaeTCH OT aHaJIOrHqHbIX xa-
paKTepHCTIiK ,nBOHHoro MopCKoro Y3JIa, n03TOMY 3TOT Y3eJI MO:>KHO
npHMeHSl:Tb B XHPYPrHH 6e3 onaCHOCTH pa3BH3bIBaHHH. I1cnoJIb30-
BaTb MOHoIlJHJIaMeIl'M'ryK> HHTb HeJIb3H, TaK KaK OH B pH.n:e CJIyqaeB
6bIBaeT HeHa.n:e:>KHbIM.
,[{JIH Toro, qT06bl cllJopMlIpOBaTb CKOJIb3HlI.{HH 6JIOKlipOBaH-
HbIH Y3eJI, Ha,D;O npH 3aTHrHBaHIIII TOT KOHeu HHTH, no KOTOPOMY ,nOJI-
:>KHa CKOJIb3HTb neTnH, HanpaBHTb BBepx, .n:PyroH - Ha TY nOJIOBHHY onepaUHOHHoro nOJIH, r,ne OH
pacnOJIaranCH .n:o 3aXBaTa HHTeH. 3aTeM 3TH :>Ke MaHlInYJIHUlI1I .n:eJIalOT .n:pyroH PYKOH.
CKOJIb:>KeHHe rreTeJIb no HIITKe .n:aeT B03MO:>KHOCTb OnyCTHTb CKOJIb3HlI.{HH y3eJI H3 ,nBYX
neTeJIb B nOJIOCTb paHbI H TaM nOJIHOCTblO ero 3aTHHYTb. CJIe.n:YlOlI.{lIe JJ:Be neTJIH 1lJ0pMHPYlOT Ka:>K-
,nylO OT.n:eJIbHO H TaK:>Ke HH3BO.n:HT. 3TY oc06eHHOCTb 1lJ0pMHpoBaHliH Y3JIa qaCTO HCnOJIb3YlOT npH
He06xo.n:IIMOCTIi 3aBH3aTb CKOJIb3HlI.{HH Y3eJI BHe nOJIOCTIi paHbI, a 3aTeM cnYCTHTb ero Ha He06xo-
.n:HMYlO rny6HHY B paHY, 3aTHrlIBaSl: IlIOB. He.n:ocTaTKaMH CKOJIb3Hll{HX 6JIOKHpOBaHHbIx Y3JIOB HBJIH-
lOTCSI: 60JIbiliOH 06'beM Y3JIa H ,nJIHTeJIbHOe era 1lJ0pMHpOBaHlie.
Puc. 8.15 Cmpoellue CKOJlb3J1-
UJao 6J10KUpOea1l1LOzo Y3Jla
U3 '1emblpex nemeJlb
71
rJIaBa 8
"
3AKOH llP ABpl1BOCTl1 B PEllOPTA}J(E
1. qeM 6JI1I:>Ke BaM llJaKTbI, onHCblBaeMble B neqaTl-l, TeM OqeBIIJJ:Hee
oIlIH6KII B no,naqe TIoro MaTepliana.
2. qeM ,nanbille BbI OT TIHX llJaKToB, TeM 60nee CKJIOHHbl BepHTb co06-
lI.{eHlIlO.
3AKOH POP}J(EPCA
CTOHT CTlOap,necce pa3HeCTH naCCa:>KHpaM KollJe, KaK CaMOneTHaqnHaeT BH6pHpOBaTb.
OE'bJICHEHl1E 3AKOHA POP}J(EPCA, llPEpJIO}J(EHHOEp3Bl1COM
IIo.D:a<Ia KollJe B caMoneTe BbI3bIBaeT BH6paUIi1O.
llOCTYJIA T llEPKl1HCA
qeM HH:>Ke CH.D:HIlIb, TeM 60nbHee 6b1OT.
llOCTYJIA T XAPPl1COHA
Ha Ka:>KJ:(oe ,neHCTBHe eCTb paBHaH eMY npoTIIBo,neHCTBYlOlI.{aH KpIITHKa.
3AKOH OEP A THoro PEHCTBl1JI CT/OAPTA
JIerqe nonyqHTh npoll.{eHHe, qeM pa3peilieHlIe.
3AKOH Yl1CTJIEP A
HHKor,n He 3HalOT, KTO npaB, HO Bcer,na H3BeCTHO, KTO B OTBeTe.
3AKOHbI l1CXOPHbIXPAHHbIX
1. Ka)l(,D;bIH MO:>KeT npHHHTb pellieHHe, pacrronaraH .D:OCTaTOqHOH HHllJopMaUHeH.
2. XOpOIlIHH PYKoBO.D:HTeJIb npHHHMaeT pellieHHe H npH ee HeXBaTKe.
3. l1JJ:eanbHbIH - ,neHCTByeT B a6conlOTHoM HeBe,neHHH.
l1CXOPHbIH llPl1HI.(l1iI COI.(110-3KOHOMl1Kl1
B HepapXHqeCKOH CHCTeMe onnaTa Tpy.na npsrMo nponopUHoHanbHa nplIBJIeKaTenbHOCTH H
nerKOCTII BbIIIonHHeMOH pa6OTbl. .
.. ..
72
rnaBa ,9,' "ot
'-f
3tAnN\ OPM OBAHMM
MWrl1 cKOrO Y3JIA
.. """ .
""",
.=1'<0'
..-i
.-." ,.......
:-.
XHpyprHqeCKIIH Y3eJI - 3TO pe3YJIbTaT 3Tarmoro BbmonHeHHB KOMnneKca ,neHCTBHH. IIpH-
qeM Ka:>K,I:IblH rrOCJIe,nYlOlI.{HH 3Tan HBJIHeTCH JIOrH'leCKHM npo.n:OJI:>KeHlIeM npe.D:bI.D:YlI.{ero.
COCTaBJIHlOlI.{HMH 3JIeMeHTaMH ynoMHHyToro KOMnJIeKCa ,neHCTBHH eCTb:
- 3aXBaT HIITII;
- 1lJ0pMHpoBaHHe neTnH 3a CqeT nepenJIeTeHlIB KOHUOB HIITH;
- 3aTHrlIBaHHH neTJIH,no nOJIHOrO coe,nHHeHHSI: KpaeB paHbl.
IIpaBHnbHoe BbIllOJIHeHHe Bcex 3TanOB 06eCneqHBaeT ,nOCTH:>KeHHe BbICOKoro KaqeCTBa H
Ha.L\e:>KHOCTH XlIpyprHqeCKIiX Y3JIOB.
3aXBaT HHTH. 3Ta npOCTaH Ha nepBbIH B3mM npoue,nypa HMeeT OqeHb Ba:>KHOe 3HaqeHIIe
,D;JIH npaBHJIbHOrO 3aBSl:3blBaHHH Y3JIOB. HenpaBIIJIbHbIH 3aXBaT HHTH npe,nnOJIaraeT rrOCJIe,nylO-
lI.{He Hey.n:06cTBa MaHlmYJIHUIiH H, B KOHeqHOM IITOre, HeHa.L\e:>KHOCTb Y3JIa. IIpli npaBRITbHOM 3ax-
BaTe Y3JIbI BH:>KYTCH JIerKO, no:narrHO, 6e3 nepeKPyqHBaHIiH HIITeH. Ka:>K,I:IOMY cnoc06y 1lJ0pMlIpOBa-
ID-ur neTeJIb COOTBeTCTBYeT onpe,neneHHbrn 3axBaT. II03TOMY npH OBJIa.L\eHHII MeTO,D;IIKOH 3aBB3bIBaHIIH
neTeJIb 06paTHTe oc060e BHIIMaHlie Ha 3TOT 3JIeMeHT.
<DopMHpOBaHHe.neTJIH 3a C'IeT nepenJIeTeHHH KOH"OB HHTH. BbI60p Y3JIa 3aBHCHT OT
cnO:>KHBllieHCH onepaTIIBHOH cHTyaUHH H onpe,nemleTCH KJIIIHHqeCKHMH H KOHCTPYKTHBHblMH ero
xapaKTepHCTHKaMH. B COBpeMeHHOH xHpyprHH ,nOCTaTOqHO MHoro BII.D:OB Ha,ne:>KHbIX Y3JIOB, npa-
BRITa 1lJ0pMHpoBaHHH KOTOpblX onpe.neJIjllOTCH npHpo.n:OH HCnOJIb3yeMoro IlIOBHoro MaTepliana, xa-
paKTepOM CIlIHBaeMbIX TKaHeH H CTeneHblO IIX HaTH:>KeHHH H T .n.
3aTHrHBaHHH neTJIH ,no nOJIHoro coe,nHHeHHH KpaeB paHLl. CJIe,nYlOlI.{HM 3TanOM 3aBH bI-
BaHHH XHpyprHqeCKOrO Y3JIa HBJIjleTCH 3aTHrHBaHHH neTJIII.n:O nOJIHOrO coe,nHHeHHH KpaeB paHbI.
CllJopMYJIHpyeM HeCKonbKO npaKTlIqeCKHX COBeTOB. 3aTHrHBaTb neTnlO CJIe.nyeT nanbuaMH,
a He KHCTblO. T OqHOCTb .n:BH:>KeHIIH npH 3aTHrHBaHIIII neTJIH nanbuaMH 6e3ycnoBHo BbIIlIe, qeM npH
pa60Te KIICTblO. nO.nyrneqKII .n:HCTanbHbIX llJanaHr nanbueB, oc06eHHO 06JIa,naH nOBbIlI.{eHHOH qYB-
CTBIITeJIbHOCTblO, 06eCneqlIBalOT He06xo,D;IIMYIO aMllJIHTY.n:y ,nBII:>KeHIIH.
CYll.{eCTBYlOT pa3Hble cnoc06bI 3aTHrHBaHHH neTeJIb, Ka)l(,D;bIH H3 KOTOpbIX IIMeeT npeHMY-
lI.{eCTBa H He.n:OCTaTKH. HaH60nee y.n:06HbIM CqlITaeTCH cnoc06 3aTHrHBaHHH neTJIH II naJIbuaMH
06eHX KHCTeM (puc. 9.1). IIpH 3TOM nanbUbI pacnonaralOT B6JIH3H nepenJIeTeHIIH. HaTHrHBaH HIITII
B npoTHBOnOJIO:>KHOM HanpaBneHHH, 3aTHrHBalOT neTJIlO. YKa3aHHblH cnoc06 OqeHb y,n06eH npH
MaHlInYJIHUHHX B rny6HHe paHbI.
B Tex CJIyqaHX, Kor.n:a Tpe6YeTCH npRITO:>KIITh K HHTH CTporo ,n03HpoBaHHoe YCRITHe, HanpH-
Mep, npH JIlIrHpOBaHlI1I BocnaneHHoH H HHIlJRITbTpHpOBaHHoH 6pbl:>KeHKH qepBe06pa3Horo OTPOCT-
Ka, npH 3aTHrlIBaHIIII neTJIH H3 TOHKoro lliOBHOro MaTepHana RITH npli conOCTaBJIeHlI1I TKaHeH co
3HaqHTeJIbHbIM HaTH:>KeHlIeM HCnOJIb3YlOT npY)!(IDUIlI.{ee 3aTHrlIBaHlie neTJIH I nanbuaMH 06elIx KIIC-
TeH (puc. 9.2).
73
rJIaBa 9
Puc. 9.1 3amRzueaHue nelWlu II naJIbl,jaMU
06eux Kucmeu
Puc. 9.2 3amR2ueullue nelWlu I naJ/bljUMU
06eux Kucmeu
----
Puc. 9.3 HU3eeoellue nelWlu aUCmllJlbilOU
paJlallzou II naJIbl,ja Kucmu
Puc. 9.4 3amRzueaHue nelWlu Ha noeepxHocmu
KO:J/CU. PacnoJ/o:J/CeHue Y3J/a C60KY om J/UHUU
pmpe3a (pallbl)
TIpH 3TOM HlITb 3aXBaTbIBaIOT TpeMH naJIbuaMH, a I naJIbuaMH Ha:>KHMaIOT B6JIH3H nepe-
DJIeTeHH5I. )J.JIH 06eCneqeHUH TOqHOCTH H .D:03HpOBaHHocTIi ,nBH:>KeHHH He06xo.D:HMO corrpliKaCaTb-
C5I Me:>KllJanaHroBbIMIi cYCTaBaMH I rranbueB. B 3TOM nOJIO:>KeHHII JIerKO nOqYBCTBoBaTb «npY:>KHHH-
IUlIe» cBoHCTBa HIITII. K CO:>KaneHHlO, 3TOT cnoco6 He npHeMJIeM npH 3aTsrrHBaHHH neTeJTh B rny6HHe
paHbI.
IIpH 3aTHrHBaHHH neTeJIb rny60Ko pacrrOnO:>KeHHblX lliBOB npH Y3KOM onepaUlIoHHOM ,noc-
Tyrre MO:>KHO Bocnonb30BaTbCH crroc060M 3aTsrrHBaHHH rreTJIIi II nanbueM (puc. 9.3). TIeTJIlO 3aTH-
rHBalOT II naJIbueM KHCTII, KOTOpbIH nOMeIUalOT cBepxy npHMO Ha rrepenneTeHHe lIliTH. Ha.D:aBJIH-
BaH nanbueM Ha nepenJIeTeHHe, HH3BO,n5lT neTJIIO Brny6b paHbl. IIpH 3TOM ,npyrOH KHCTblO
HaT5IrIiBaIOT rrpoTHBOnOJIO)!(HbIH KOHeu HIITII. TIepenneTeHHe HIITH CKOJIb31IT BHH3, II MOMeHT ,noc-
TH:>KeHH5I,nHa paHbI qeTKO Oll.{yll.{aeTCH II nanbueM. TIpH ,nanbHeHllIeM HaJ];aBJIHBaHHH Ha nepenne-
TeHHe KpaH paHbl C6JIII)!(alOTc5I. HIITb rrpli TaKOM cnoc06e 3aTHrHBaHII5IIICrrbITbIBaeT He3HaqlI-
TeJIbHYlO HarpY3KY. 3TO npe,noxpaHHeT ee OT pa3pbIBa, a CIlIHBaeMble TKaHH OT TpaBMbI.
HH3Be,neHHe neTJIH B rny6b paHbI YKa3aHHbIM cnoc060M MO:>KHO npOH3BO.D:HTb II naJIbueM, KaK
npaBoH, TaK H neBOH KHCTII.
3aTHrHBaH neTnH Ha nOBepXHOCTIi KO:>Kli, He06xo.D:HMO paCnOJIO:>KHTb y3eJI C60KY OT JIIIHHH
74
pa3pe3a (paHbI) (puc. 9.4). )J;JIH 3Toro nocne 1lJ0pMHpoBa-
HHH nepBoH neTJIIi KOHl.(bI HIITH nepeBO,D;HT 6JIII:>Ke K XIIPYP-
ry. 3aTeM, Ha:>KIIMmI II naJIbueM KHCTII B6JIH3H nepenJIeTe-
HHH, 3aTHrHBalOT nepBYlO neTJIlO, pacnOJIaraH npli 3TOM
HHTII no,n yrJIOM 45° K nOBepxHocTH KO:>KH.
OnHcaHHbIe MaHHnynHUHH npIIBO.D:HT K pa3Mell.{e-
H1I1O nepenJIeTeHIIH HIiTeH C60KY OT JIIIHHH pa3pe3a (paHbI).
,[{JIH Toro, 'JT06bl He .D:OnYCTHTb CMell.{eHHH nepenJIeTeHIISI:
npli 3aBH3bIBaHliH nOCJIe,nYlOlI.{IIX neTeJIb, peKOMeH).(YeTCSI:
.D:ep:>KaTb 06e HIITII nOCTOSl:HHO HaTHHYTbIMH (puc. 9.5) H 3a-
THrHBaTh IIX, pacnoJIaraH KOHUbI B.D:OJIb paHbI (puc. 9.6).
3aTHrHBaHHe neTeJIb a,nanTHpYlOIlIHX IllBOB Ha no-
BepxHocTIi KO:>KH IIMeeT CBOH oc06eHIIoCTH. HanpHMep,
nOCJIe 1lJ0pMHpoBaHliH CTe:>KKa lliBa MaK-MIIJIJIaHa-)J;oHa-
TH HIITH HaTHrIIBalOT. .ZJ:JIH ynyqIlIeHHH COnOCTaBJIeHHH TKa-
HeH, IIX (B HaTHHYTOM COCTOHHHH) nepeBo,nHT Ha npoTIIBo-
nOJIO:>KHYlO OT JIHHIIH pa3pe3a CTOPOHY. 3aTeM 3aTHrIIBalOT
nepBYlO neTJIlO, pacnOJIaraH npH 3TOM HHTII no,n yrnoM 45°
K nOBepxHocTH KO:>KII.
CHJJa 3aTHrHBaHHH IIHTeD. 3axBaTbIBaTb HHTII
naJIbuaMIi npH 3aTHrHBaHlfII neTJIH CJIe,nyeT KaK MO)KHO
HH:>Ke K nepenneTeHlIlO HHTeH - 3TO YMeHbillaeT pHCK pa3-
pbIBa HHTHII nOBbllllaeT Ha,ne:>KHOCTb 3aTHrIIBaHHH. KpoMe
Toro, 'leM 6nH:>Ke K nepenJIeTeHHlO HIiTeH Haxo,nHTCH naJIb-
I.(bl, TeM JIYLIIlle qyBCTByeTcH CTeneHb HaTH:>KeHHH HlITeH.
Y3eJI He06xo,nHMO 3aTHr1IBaTb,n0 Tex nop, nOKa He
npeKpaTIiTCH CKOnb:>KeIIHe HHTII H npOH30fureT C6JIH:>KeHHe
KpaeB paHbI. BMeCTe C TeM, He06xo.D:HMO CTapaTbCH Ha-
Klla,nblBaTb Y3eJI 6e3 HaTH:>KeHHH H c,naBJIeHHH CIlIIiBaeMblX
TKaHeH. CJIIIIllKOM CIIJIbHOe CTHrlIBaHlle MO:>KeT BbI3BaTb IIX
IIIlIeMlIlO, 3aMe.D:Jlj{H npouecc 1lJ0pMHpoBaHIIH COe,D;llHIITeJIb-
Horo py6ua. KaK Y:>Ke ynoMHHaJIOCb, Ha3HaqeHHeM IllBa
HBJIjleTCH C6JIH:>KeHlIe TKaHeH.D:O nnonroro IIX conpIiKOCHO-
BeHHSI:. B TO :>Ke BpeMH, eCJIH Y3eJI «He.D:OTHHYT», Me)l(,D;y
KpaHMH pallbI OCTaeTCH CB060.D:HOe npOCTpaHCTBO. Co Bpe-
MeHeM OHO 3anOJIHHeTCH rpaHYJIHUIIOHHOH TKaHblO, KOTO-
paH, B CBOlO Oqepe,nb, peopraHII3yeTcH B nnOTHbIH rpy6blH py6eu. KpOMe TOro, npH He,nOCTaTOqHO
nnOTHOM COnOCTaBJIeHlfII KpaeB paHbl, KpOBb, KOTopaH HeMHHyeMo 3anOJIHHeT ynoMSl:HYToe CBO-
60,nHoe npOCTpaHCTBO, JIerKO HHIlJHUHpyeTCH. BOCnanlITeJIbHblH npouecc MO:>KeT npHBeCTIi K Hecoc-
TOHTeJIbllOCTIi IlIBa. He,nOCTaTOqHOe 3aTHrnBaHHe IllBa npH 3aIlIHBaHHH paH BHyTpeHHHX opraHOB
MO:>KeT npliBeCTH K nOTepe repMeTlIqHOcTIi. A 3TO, B CBOlO Oqepe,nb, qpeBaTO pa3BHTHeM KpOBOTeqe-
HIIH, neplITOHIITa, 3MIlJ1I3eMbI H np. .
HaqlIHalOIUlix xHpyproB 3aqacrylO BOJIHyeT Bonpoc: KaK no,n06paTb onTIiManbHYIO CIIJIY 3a-
THrHBaHHH HIITOK? OTBeT Ha Hero npHXOllHT C OnbITOM, Kor,na xupypr Ha'lHHaeT qYBCTBOBaTb TY
«rpaIIIIUY», KOTopaH OT,neJIHeT cJIa60e n n3JIHiliHee 3aTHrHBaHHe.
Puc. 9.5 3amRzueal/ue nemJIu lIa noeepxl/o-
cmu KO:JK"l/. 3amRZueaR Y3ell, pacnOllaZaJom
Ilwnu noa YZllOM 45° K noeepxllocmu KO:J/CU
Puc. 9.6 3amRzueallue nemllU 1/a noecpX1/0-
cmu KO:J/CU. Pacnollo:J/Ce1/Ue KOIIl/oe llumu
eaOllb pallbl
75
rnaBa 9
I1CnOJIb30BaHlie HHCTpYMeHToB MH 3aTHrHBamiH Y3JIa nOBbIIllaeT pHCK pa3pblBa HIITII. )J;eJIo
B TOM, qTO B MeCTe IlJHKcaUHH HHTII 6paHillaMli IIHCTpYMeHTa OHa HeMHHyeMo nOBpe:>K,lIaeTCH. Bnoc-
JIe,nCTBIIII, rrpH 3aTHrlIBaHHH neTJIH, B 3TOM MeCTe MO:>KeT npolI30HTli ee pa3pblB ,lIa:>Ke npH He3HaqH-
TenbHoH HarpY3Ke. Oc06eHHo no,nBep:>KeHbl nOBpe)l(,D;eHHlO MOHollJlIJIaMeHTHbIe IIHTH H KeTrYT. OHII
JIerKO TpaBMHpYlOTCH, npHqeM CJIe,nbI OT 3aXBaTa HHcTpYMeHTaMIi 6bIBalOT 3aMeTHbiMli ,na:>Ke HeBO-
0pY:>KeHHbIM rJIa30M.
ATpaBMaTH'IIIOCTb 3aTHrHBaIlHH. BnOJIHe nOHHTHO, qTO pHCK nOBpe)l(,D;eHHH oKpy>KalOlI.{lIX
opraHoB H TKaHeH B03pacTaeT B cJIyqae 3aBH3blBaHHH Y3JIOB C nOMOll.{blO HHcTp:YMeHTa. B 3TOM
CJIyqae rrpHKJIa,D;blBaHlie qpe3MepHoro YCRITIIH MO>KeT npHBeCTH K pa3pblBY HIITH H TpaBMaTII3aUHII
coce,nHIIX opraHoB. I1Hor,na 6paHlliaMH IIrJIO,lIep:>KaTeJIH IIJIH
3a:>KHMa BMeCTO HHTH OIllH60qHO MO:>KHO 3aXBaTHTb cTeHKY
opraHa HJIH cocy,n. Hepe,nKH CJIyqaH COCKaJIb3bIBaHHH HHCT-
PYMeHTa II nOBpe)l(,D;eHHH npH 3TOM OKPY:>KaIOlUHX TKaHeH.
M3JIHiliHee 3aTHrHBaHHe HIITII MO:>KeT pa30pBaTb (ne-
pepe3aTb) TKaHII, TpaBMlIpysr COCy,nbI, HepBbI RITII npOTOKH.
Oco6eHHo JIerKO «rrepepe3blBaIOTCH» TKaHH npH HanO:>KeHHH
IllBOB Ha nOpa:>KeHHbIH aTepOCKJIep030M cocy,n, RITII Ha BOC-
naJIeHHbIH H HHIlJRITbTplipOBaHHblH OpraH (HanpIiMep, 6pbl-
:>KeHKY IlJnerMOH03HO 1I3MeHeHIIoro qepBe06pa3Horo OTpO-
CTKa).
HanpaBJIellHe 3aTHrHBaUHSI. 3anlrHBaTb HHTH He-
06XO,nHMO B rrpaBRITbHOM HanpaBJIeHHH - 3TO CHH>KaeT CO-
rrpOTHBJIeHlIe neTJIH 3aTHrnBaHIi1O. ECJIH 3aTHrlIBaTb HIITII no
JIHHIIH CTe:>KKa, TO OHH nO>KaTCH pOBHO, YMeHbiliaeTCB nno-
lUa,nb corrpHKOCHOBeHIIH II, CJIe,lIOBaTeJIbHO, YMeHbillaeT pHCK
HX nepeTHpaHHH H pa3pbIBa. K TOMY :>Ke, ecnH HHTH neTJIH
3aTHrlIBaTb HenpaBRITbHO, TO 1lJ0pMHpyeTcH aCHMMeTplIqHaH
neTnH, KOTopaH JIerKO pa3BH3bIBaeTCH.
IIpH 3aTHrHBaHHII Y3JIa CJIaralOlUaH BeKTopa CRITbI
,lIOJI:>KHa JIH60 paBHHTbCH HYJIlO, nlI60 6bITb HanpaBJIeHa B
CTOPOHY TKaHH (puc. 9. 7) . ,[{m 3TOro CJIe.ayeT C06JIlO,naTb npa-
BRITO: nHHHH HaTsr:>KeHIIH HHTeH ,nOJI:>KHa 6blTb npsrMoH RITH
06paIlleHHOH H3rlI60M B CTOPOHY TKaHeH. HarrpaBJIeHHe BeK-
Topa CRITbI B npoTIiBOrrOJIO:>KHYlO CTOPOHY MO>KeT npliBeCTII K
OTpbIBy JIHraTypbI BMeCTe C TKaHblO.
Puc. 9.7 a.6.e HanpaeJlellue eeKmopa
CUJlbl npu 3amJ/zueaflUU Y3J1a
76
It
e
e
'} . -;,'
. .'Sf
.... , . .'!i .,,,T'JiaBa 10
w
cnOCOEbl,wOPMIIPOBAHM51
TIETEJIb PYKAMII
.:: -_.>
)J;JIH npaBRITbHoro 3aBH3blBaHHH Y3JIOB xHpypr ,nOJI:>KeH KOM6HHHpOBaTh neTJIH, HCXO,[(H H3
HX npOCTpaHCTBeHHblX CBOHCTB.
Ka)l(,D;blH crroc06 1lJ0pMHpoBaHHH neTnH He06xo,nHMO BblllOJIHIITb He TOJIbKO npaBOH, HO H
JIeBOH PYKOH. llpH BblllonHeHHH o,nHoro H Toro >Ke cnoc06a pa3HbIMH PYKaMIi nOJIY'laIOTCSI: neTJIH
npOTIiBOnOJIO:>KHbIM npOCTpaHCTBeHHbIM CTpoeHlIeM. TeXHHKa 3aBH3bIBaHIIH BTOpOH neTJIH TO O
TaKaH :>Kfi,KaK H nepBOH, HO npH 3TOM BTOpylO neTnlO 3aBH3bIBalOT npOTHBOnOJIO:>KHOH PYKOH. Bo
BpeMH 3aBH3blBaHIiH BTOpOH neTnH OCHOBHblM Tpe60BaHHeM 3Toro 3Tana HBJIHeTCH nOCTOHHHoe
HaTH:>KeHHe HHTeH. 3TO 06e30naCliT OT OCJIa6JIeHIIH rrepBOH neTJIIi Y3JIa.
CIIoeOEbI <I>OPMMPOBAHM5I IIPOeTOM IIETJIH
enoeOE 1. HeCOMHeHHblMH ,nOCTOHHCTBaMIi 3Toro cnoc06a srBJUIIOTCH CKOpOCTb tlJoPMHPO-
BaHHH neTJIIi n Ha,ne:>KHOCTb, TaK KaK B TeqeHHe Bcero BpeMeHH HHTb HeH3MeHHO HaXQ,[(HTCH B
HaTHHYToM COCTOHHHH. 1l0CTOHHHbIH KOHTpOJIb HaTH:>KeHIIH HHTeH rr03BOJIHeT npe,noTBpaTHTb pac-
nycKaHlie npe,nbI.D:YlI.{eH neTJIll.
I :nan - uKcaIluH HUTen B UCXOnHOM nOJIOiKeHUU. CB060,[(HbIe KOHUbI 06eHx HHTeH
He nepeKpell.{lIDalOT H y,nep:>KIIBaIOT TaKHM 06pa30M, qT06bI 60JIbiliOH H YKa3aTeJIbHbIH nanbUbl
06eHX PYK 6bIJIH CB060,nHbI (puc. 10.1). B npaBYlO PYKY 6epYT HHTb, lIJJ:yIUYlO OT ,[(anbHero KpaH
paHbI, a B JIeBYlO - OT 6JIH:>KHero.
II nan - nepeKpecT HUTen. HIITH nepeKpeIUHBalOT Ha no,nYIlIeqKe II naJIbua npaBoH KHCTII.
IIpH 3TOM JIeBYlO KHCTb nepeMell.{alOT «OT Ce6H» (puc. 10.2). MeCTo nepeKpeCTa IlJHKCHPYlOT cBepxy
I nanbueM npaBoH KHCTH (puc. 10.3).
III nan - 3a6op HUTU U npoBe,[(eIlue ee '1epe3 neTJUO. IIpaBYlO KHCTb POTHPYlOT rrpoTIiB
qaCOBOH CTpeJIKH H npoBoJJ:j{T ,nlIcTaJIbHYlO llJanaHry I rraJIbua npaBoH KIICTII B KOJIbUO CTe:>KKa.
JIeBoH KIiCThlO npoBo,nHT 6JIH:>KHlOlO HIITb rro,[( no,nYIlleqKY II naJIbUa (puc. 10.4). 3aTeM pe3Ko POTH-
PYH npaBYlO KHCTh no qaCOBOH CTpeJIKe, npOTaJIKHBaH 6JIH:>K-
HlOlO H1ITb II nanbueM B KOJIbUO CTe:>KKa (puc. 10.5). O,[(HoBpe-
MeHHO neBoH PYKOH oTnycKaIOT KOHeu 6JIH:>KHeH HIITH.
IV 3Tan - uKcaIluH npoBe,neHHoH '1epe3 neTJIIO llumu.
IIocJIe rrpoBe,neHHH 'lepe3 neTJIlO cB060,nHbIH KOHeu HHTH 3a-
XBaTblBalOT 60nblliliM H cpe,nHHM naJIbueM JIeBOH PYKH
(puc.1O.6).
V nan - 3aTHrUBaHue neTJIU. HHTH OTBO,nHT B npOTH-
BOnOJIO:>KHble CTOpOHbI no,n yrJIOM He MeHee 180 0 . YKa3aTeJIb-
HblMH rranbuaMH 3aTHrHBalOT neTJIlO, npHqeM HorTeBble llJa-
naHrH 060HX nanbueB ,[(OJI:>KHbI nOCTOHHHO HaX0.D:IITbCH
,...-...
.
( ' \ . h.
h'! y ) '-'........
, ,", ".oj : .
..:... ';, "'.1..
:>'. -'-To \ If
Puc. 10. J Cnoc06 J popMupoea-
/lUll npocmou nelWlu. 11 cxoalloe
nOIlO:HCe/lue
77
rJIaBa 10
y caMoH rreTnH. IIpH HrHopHpoBaHHl13TIIX Tpe60BaHliH C03.n:alOTCH YCJIOBHH ,nJIH COCKaJIb3bIBaHHH
neTnH RITH npope3aHHSI: TKaHeH.
B rny6HHe paHbI neTJIlO 3aTHrHBaIOT II nanbQeM npaBoH KHCTH (puc. 10.7).
'
,. . ,:' , )i""",\
; "..' ? , ,.:. L '
'J ' 1 ..' ' . ' . "" .... .
.. J ,... , \ \
."' J ' ,.j.Pi.l: "I
':--.,. -:- ..:.. .. .....:-:.J .. ,
: ..
. .. ---- .;. .
. .- ,.
'\ . '.
.... .
_. . '-. -." .. ij ;
----- .. .t'''' .
.'" J'.:. .
Puc. 10.2 Cnoco6 I popMUpOealluJI npocmou
nelWlu. MOMellm 06pmoealluJI nepeKpecma
Puc. 10.3 Cnoc06 I popMUpOea1/uJI npocmou
nelWlu. (]>uKcaliUJI nepeKpecma
' . '. . -. !. 1'\
J .' t
. . -': . .r.- ', . ,
..-
,I \ \' )
,<,::!. j , .:\' 'i\ '.
. ::.......
/":- J
,'--. .#1 .
£ ; 2: . -I'".:::.:,; j
< .. . .
..r ....-!..' .
. . '-" .
- \"-,,. . ,. .1- _ ;
¥. .., _.....
Puc. 10.4 Cnoc06 1 popMUpOealluJI npocmou
nelWlu. HlNW/o MOMellma npOeeaeHWI HlImu
'1epe3 nelWllO
Puc. 10.5 Cnoc06 I popMlIpOeallUJI npocmou
nelWlu. MOMeHm npoeeaellUJI Humu '1epe3 nelWllO
'r \
. .'...........t
"'; "':: l
/' - .....:
A'- " -.-4.t /
G# ltf. y?
..,.,:<-::::;:...;:;::.. ¥-;;;z=-.
Puc. 10.6 Cnoc06 I popMUpOealluJI npocmou
nelWlu. 11poaoJl:HCeHUe MOMeHma npOeeaeHWI Humu
'1epe3 nelWllO
Puc. 10.7 Cnoc06 1 popMupOeaHUJI npocmou
nemnu. 3amJI2UeallUe nelWlu
78
CilOCOI> 2. <1>opMlIpYlOlI.{aHCH npH BbIllonHeHHH 3Toro cnoc06a IlIHpoKaH neTJIH CTe:>KKa
3Ha t lHTeJIbHO 06JIerqaeT nepenJIeTeHHe HHTeH.
I 3Tan - «JIuKcaQuH HUTen B UCXO,nHOM nOJIOiKeHnu. CB060,nHbIe KOHUbI 06eHx HHTeH
He nepeKpemHBalOT H y,nep>KHBalOT ,nanbHlOlO HHTb npaBOH KHCTblO, a 6JIH:>KHlOlO HHTh - JIeBOH
(puc. 10.8).
II 3Tan - nepeKpecT HUTen. EonbllIoH naJIeu npaBoH KHCTH 3aBo,nHT 3a 6JIH:>KHlOlO HIITb
(puc. 10.9). 3aTeM ero HOITeBYlO llJaJIaHfY nOMelualOT cBepxy (puc. 10.10). POTHPYH KHCTb npoTIiB
qaCOBOH CTpeJIKH, nOBOpaqlIBalOT I naneu no,nymeqKOH BBepx. 3aTeM JIeBOH KHCTblO «OT ce6H»
nOMell.{alOT 6JIH:>KHlOlO HIITb Ha no,nYllieqKY ,nIICTanbHOH llJanaHrH I nanbua npaBoH KIICTH H IlJHKCH-
pylOT nepenJIeTeHHe II naJIbueM npaBoH KHCTII (puc. 10.11).
III 3Tan - 3a6op HUTU U npOBe,lIeHHe ee 'Iepe3 neTJIIO.
IIpaBYlO KIICTb pe3Ko pOTHPYIOT no qaCOBOH CTpeJIKe, npOTan-
KIiBaH 6JIH:>KHlOlO HHTb B KOJIbUO CTe:>KKa (puc. 10.12).
IV 3Tan - «JIuKcauuH npoBe,ncHHon 'Iepe3 neTJIIO HUTU.
EnH:>KHlOlO HHTb nOCJIe ee BbIxo,na H3 KOJIbua CTe:>KKa nepe-
XBaTblBalOT cB060,nHOH JIeBOH PYKOH (puc. 10.13).
V 3Tan - 3aTHrUBaHue neTJIU. HHTH OTBO,nHT B npoTH-
BOnOnO>KHble CTOpOHbI no,lI yrJIOM He MeHee 180 0 (puc. 10.14). Puc. 10.8 Cnoc06 2 QJOpMupoealluR
Y r 6 npocmou nemnu. l1cxoalloe nono:J/Cellue
Ka3aTeJIbHblMH nanbuaMH 3anTliBalOT neTnlO. ny OKO pac-
nOJIO:>KeHHbIe neTJIH 3aTHrHBaIOT II nanbueM npaBOH KIICTH.
.... ...."
- .- ". ,.")..
? -- ' . ' . "X_ .
. ; ;.\ ", '-Z \
/ '". \: ,<:\ I'r e
"r / /1 ' '' " . 'C"1 l j ..
.\. :;....,;, r 2fr' i
. >"". f/j
Puc. 10.9 Cnoco6 2 tjlopMupoeaHUJ/
npocmoii nemnu. MOMellm 3axeama
IIl11Y1U
\,- : '<;;.:... ,
.. "'......
'':: . . '':j
. ,
. ,}f:\ '
Puc. 10.12 Cnoc06 2 tjlopMupoea-
HUR npocmoii nemnu. MOMellm
npoeeaellUJ/ Humu '1epe3 nemnlO
. . \
,.
\ ', . q-
"i . : 4-_
,. , :/ ,- < ".,
. -
Puc. 10.10 Cnoc06 2 tjlopMupoea-
HURnpocmounemnu.MoMeHm
06pa30eaHuR nepeKpecma
' ?i\ . _ ' .-?-
e ..
@ Y{ ':.;; . ", - \
' ;1:' 1' 1 .
't7; ,
.. ;, . ..J.
I. , " .. ...?
,.
'.0:::,; .. '....
Puc. 10.13 Cnoc06 2 tjlOPMUPO-
eaHUR npocmou nemnu. (]>uKCaIjUR
nemnu
!k0
5c;K --- .. .. . .
. . " . ..
->' >t,_ '>.
'" .. .. '. '''''.''
f /.-. '../... rN\-\;I .. .
- . r ' ' 'J
.'. .':'t'.
.en,,-,._ ,1
.0;>
f / #
. \. J,
. \ -'::;;\
Puc. 10.11 Cnoc06 2 tjlOpMU-
poeaHUR npocmou nemnu.
MOMellm qJUKCaljUU nepeKpecma
/
I': ..:,....- ..1! ... .)
fi....../" ,!..r
)J''' .i
"'--.. '';'''1''""""
if \ "'\'
j"' . ."
{.i: - \-;
L".\ .',
-...J, t,,\ ;{
::
Puc. 10.14 Cnoc06 2 tjlOpMU-
pOeallUR npocmoii nemnu.
3amRzueaHue nemnu
79
rnaBa 10
enoeol> 3. 3TOT cnoc06 1lJ0pMIIpoBamHI nereJIb npOTHBOnOJIO:>KeH onHcaHHbIM paHee, qTO
n03BOJIHeT qaCTO HCnOJIb30BaTb HX B KOM6HHaUliH npli 1lJ0pMlIpoBaHHH napaJIJIeJIbHbIX Y3JIOB.
I :nan - 4>uKCaQuH HUTen B UCXO,nHOM nOJIO)KeHUH. CB060,nHble KOHl.(bI 06eHx HHTeH
He nepeKpeLl.{HBalOT II y,nep:>KHBalOT, npH:>KIIMaH Ill, IV, V nanbuaMH. EJIH:>KHlOlO HIITb 6epYT B npa-
BYlO PYKY, a ,lIaJIbHlOlO - B JIeBYIO (puc. 10.15).
n :Han - nepeKpecT HUTen. EJIH:>KHlOlO HHTb nepeMeLl.{aIOT Ha no,nyrneqKY I nanbua npaBoH
KHCTH (puc. 10.16). IIepeMell.{aSl: JIeBYlO KHCTb «Ha Ce6H», 1lJ0pMIIPYlOT nepeKpecT (puc. 10.17).
MeCTo nepeKpeCTa IlJHKCHPYlOT cBepxy II nanbueM npaBoH KHCTII. IIpaBYlO KHCTb POTIiPYlOT no
qaCOBOH CTpeJIKe, npH 3TOM II naneu (,nlICTanbHYlO ero llJanaHry) npOBO.D:HT B KOJIbUO <ITe:>KKa. )J;aJIb-
HlOlO HIiTh nOMell.{aIOT Ha no.nyIlIeqKY II nanbua (puc. 10.18).
III :Han - 3a6op HUTU U npoBe,lIeHue ee 'Iepe3 neTJIIO. IIpaBYlO KHCTb POTHPYlOT npoTHB
qaCOBOH CTpeJIKH H npOBO,lIHT ,nHCTanbHYlO llJanaHry I nanbua npaBoH KHCTli C nepeKpecToM B KOJIb-
Uo CTe:>KKa. npH 3TOM ,naJIbHHH HlITb npOTaJIKIIBaeTCH B KonbUO CTe:>KKa no,nyrneqKOH ,lIHCTanbHOH
llJanaHrH I nanbua npaBoH KIlCTH (puc. 10.19).
IV :Han - 4>HKCaQHH npOBe,lIeHHOn 'Iepe3 neTJIIO HHTH. IIocJIe npoBe,neHHSI: qepe3 neTJIlO CBO-.
60,nHbIH KOHeu HIiTli npH)l(IIMalOT 60JIbIlIliM naJIbueM K na,noHHoH nOBepxHoCTH III naJIbua JIeBOH
PYKH.
V 3Tan - 3aTHI"HBaHHe neTJIH. HHTII OTBO.D:HT B npOTIiBOnOJIO:>KHble CTOpOHbI no,lI yrnoM He
MeHee 180 0 (puc. 10.20). YKa3aTeJIbHbIMli naJIbuaMH 3aTHrlIBalOT neTnlO. rny60Ko pacnOJIO)KeH-
HbIe neTJIH 3aTHrliBalOT II nanbueM JIeBOH KHCTH.
enocol> 4. He,nOCTaTKOM cnoc06a HBJIjleTCH OTcyTCTBHe B03MO:>KHOCTli Ha,ne:>KHO KOHTp0JIIIPO-
BaTh HaTj{)l(eHlIe HHTeH BO BpeMH 3aBIDblBaHIIH yma. Y blBM 3TO, ,lIaHHbm cnoco6 :>KeJIaTeJIbHO nplIMe-
.. ____ -......; ::::::' r';...."
./.. >...)
F .;r-:;'-r: . . (">.
j,' t - ................£ >' ............
af ...." it -. -c:
. -> .... . '. "i.:
"- .'c"". .,;, 'C'."
, ..- --" 1 " >'. 't "\
. - .,. \ '"
.. ....--.. ,.
.' ---, 'k'_ " ., , ;
l -....:::.HIi
"
Puc. 10.15 Cnoc06 3 ifJOPMU-
poealluR npocmou nemJlu.
l1CXOaHOe nOIlO:JICeHUe
/ S;p(I-:'::: \
N " ;.;,
rI'........ . --1'>'-..".
{ ) L, ..
H,'o"J
.... - / :
Puc. /0.18 Cnoc06 3 POPMUPO-
eallUR npocmou nemnu. MOMeHm
pUKCa'lUU nepeKpecma
80
----.........
/. ''' ;.- .
1 ..... .,........0 . '<............
. : .;'!'
::':f 7T l.>\o \ :> .. .
I .,.....:::...:-.... ,. :... '>/1 . .I J l !
...." .
Puc. 10.16 Cnoc06 3 pOpMU-
poeUIIUR npocmou nemnu.
MOMeHm3aXeUmUllumu
. "
........ '\.
{'l( '
i -:i:' ...- '). \k:
t /?;:,-'l). ' t;. j.'
I'j 1:......:::...\,.. '-,
":'.: zj\
Puc. 10.19 Cnoc06 3 popMupoea-
HUR npocmou nemnu. MOMellm
npoeeaeuW/ Humu '1epe3 nemnlO
'> ' "
, > -:- . d ' '''' . .",?
.//' ' { ,:;.. t,' . '>
. . - 5« ......3b \;l'
. . 4'[":''' .' . <--
Puc. 10.17 Cnoco6 3 POPMUPO-
eUllUR npocmou nemnu. MOMellm
06pa30eallUR nepeKpecma
t- j
,f.;'-_...... .... n (> ::;;::;.; :.:
I" ,!-.-.;, . .
t " >-- .
l,{ -; : ,, / 1
'<:;;;;-'" .t6?- ,
,,",,'.'O/r "
\..... .
Puc. 10.20 Cnoc06 3
popMupoeallW/ npocmou
nemnu. 3amRzueaHue nemnu
HHTb ,nJIH 1lJ0pMIIpOBaIUnI nepBOH, TpeTbeH H nOCJIe,nYlOlUIiX neTeJIb, Kor,na He Tpe6yeTcH nOCTOHH-
Horo KOHTpOJIH Ha,n HaTH:>KeHlIeM HIiTeH.
I 3Tan - 4JuKCaQUH HUTcn B UCXOLl:HOM nOJIO CHUU. CB060,nHble KOHUbI 06enx HIiTeH
He nepeKpelUliBalOT II y.rxep)l(HBalOT 60JIbIlIHM 11 YKa3aTeJIbHbIM naJIbuaMIi 06elIx PYK.
EJIII:>KHlOlO HIITb 6epYT B npaBYIO PYKY, a Ll:anbHlOlO - B neBYlO (puc. 10.21).
II :Han - ncpcKpcCT HUTcn. POTlIpYH npaBYlO KHCTb no qaCOBOH CTpeJIKe nOMemalOT ee Ha,n
IlJHKclipoBaHHoH :noH PYKOH HIiTblO. HIITb, IlJIIKclipoBaHHYlO JIeBOH PYKOH nepeMell.{aH «na Ce6H»,
YKJIa,nblBalOT Ha HOITeBYlO llJanaHry III naJIbua. TaKHM 06pa30M, Ll:anbHHH II 6JIII:>KHHH HIITll nepe-
KpemllBalOTcH Ha JIa.D:OHHOH nOBepXHoCTII (HarrpaBJIeHHOH BBepx) III, IV, V nanbueB npaBoH KlICTlI. B
3T0 BpeMH I II II nanbuaMll 3TOH KIICTII npOLl:OJI)I(alOT y,nep:>KIIBaTb HIITb (puc. 10.22).
III :Hal! - 3a6op HUTU H npoBc,ncHUC cc '1CpC3 nCTnlO. HOITeBYlO llJanaHry III naJIbl(a npa-
BOH PYKII 3aBo,nHT 3a HI1Tb, IlJIIKclipoBaHHYlo 3TOH )l(e PYKOll (puc. 10.23). IIpli pa3rH6aHI1II nanbua
HlITb, pacnOJIO:>KeHHYlO Ha era TbmbHOH nOBepxHoCTII, npoBo,nHT qepe3 neTJIlO (puc. 10.24). IIocJIe
npoBe,neHIIH qepe3 neTJIlO, cB060,lJ,HblH KOlleu 6JIII:>KHeH HIITII nplI:>KIIMalOT Me)l(,D;Y 60KOBbIMli no-
BepXHOCTHMII III II IV nanbueB npaBoH KIICTII. 3aTeM, pOTHpYH rrpaBYlO KIICTb rrpOTIiB qaCOBOH crpeJI-
KH, 1I3BJIeKalOT 6JIII)I(HlOlO HHTb 1I3 Konbua CTe:>KKa (puc. 10.25).
IV :Han - 4JuKCal(UH npoBc,ncHHon '1CpC3 nCTJIIO HUTU. IIocJIe npoBe,neHIIH qepe3 neTnlO,
CB060,D;HbIH KOHeu HIITll nplI)l(IIMalOT 60JIbIlIliM rranbueM K JIa.D:OHHOH nOBepxHocTIi III nanbua. IIpH
3TOM YKa3aTeJIbHbIH naneu pacnOJIaralOT Ha,n HIiTblO.
V :nan - 3aTHI"UBalll1C nCTJIU. HHTII OTBOLl:HT B npOTI1BOnOJIO:>KHbIe CTOpOHbI nOLI: yrJIOM He
MeHee 180°. YKa3aTeJIblIblMH nanbuaMIi 3aTHrlIBalOT neTJIlO. B rJIy6HHe paHbl neTJIlO 3aTsrrHBalOT
II nanbueM JIeBOH KHCTII (puc.lO. 26).
---> _........'""-' .
.,.. ,..
!'.)\ .:; '-.. ,
'::- / : --1 1 ' : '.
'f -:_ -- - ....
. : .- --- ._-
.,.....o{ -.
- .. -::: y! .';f'J . ' . ':''\}, ... ,
/-' . / ,,,' \ '. '4.
" ..J/ J' '9 '' . / { ,j.,.- \,,;. ..,'
:r . .':J' , '-". ;' . ,
, '.. "\
'4. / "Z F_
Puc. 10.21 Cnoco6 4
tjJop-".mpoeGlluJI npocmou
nefl1Jlu. If cxoalloe nOllO:J/Cellue
Puc. 10.22 Cnoco6 4 ,popMupoeo-
IIUJI npocmou nemllU. M OAlellm
06pa30ealluJI nepeKpecma
t.,.....
. .=>...: \ '..:;,...
...r......:.:...._...-._ ..- \.......f' \-,
.....""....... _ . o;. ';, . .",'1,
,'f J-- 1--'" \1> /J .\
{ {[//;I- \ " ' ./i
: J/f I ,, .
t" . .
- " Jt
Puc. 10.24 Cnoc06 4 tjJOpMupo6a-
IlUJl npocmoii nenmu. MOMellm
npoeeaellUJl /lumu 'Iepe3 nemJl10
: " '; -f; ,
/ . \ .. \ . /-:i.
- 1 :' ../I}l I
/. ..> . ,. i,..,
. , j . --' <?
., .
.:. . X': I) >
.v '-,
Puc. 10.25 Cnoco6 4 ,pOPMUPO-
eGIlUJI npocmou nemllU. BbleeiJe-
Hue Ilumu U3 KOllb1la cme:J/CKG
-" =.. : #';.'
i< . . ...../....\
.4'-- ...'" .' .. -. ..... \ ....."'. . /.}.. '\
, }-.., \ ' . . ,'J
: //. :'/ l .
7> / ""l ;' .
. . : /" .. .. .,{.:;::.
. . (:I
Puc. 10.23 Cnoco6 4 tjJopMupoeo-
HUJl npocmou nefl1Jlu. Ha'laJIo
MOMellma npoeeaellUJl llumu
i.- . .<t',: '<
l .,
< '
..."'>\:). w
)y;.x-...r:/
:
J.\i
, ). 1:
.......-"...,.. ;
"A
::,:. h: _ ,:.;;;:----
.J.!
Puc. 10.26 Cnoc06 4
tjJopMupOeaHUJI npocmou
nenlJlU. 3amJl21160HUe nefl1Jlu
81
rJIaBa 10
cnOCOE 5.
I 3Tan - cJIuKCaQHB HUTeii B UCXO,nHOM nOJIOiKeHUH. CB060,LUIble KOHUbI 06elIx HHTeH
He nepeKpell.{lIBalOT H Y.D.ep:>KIIBalOT 60JIblliliM H YKa3aTeJIbHblM nanbQaMIi 06eHx PYK.
EJIII)KHlOlO HIITb 6epYT B npaBYIO PYKY, a,nanbHlOlO - B JIeBYlO (puc. 10.27).
II 3Tan - nepeKpecT HUTeii. III naJIeu npaBoH PYKII nOMeIUalOT Ha,n IlJIIKClipOBaIIHOH 3TOH
PYKOH HIiTblO (puc. 10.28). HIITb, IlJlIKcHpoBaHHYlO JIeBOH PYKOH, YKJIa,D;blBaIOT Ha HOITeBYIO llJanaH-
ryIllnanbua (puc.1O.29).
, >: A_ ..........:....
J/-." \...,
1J.i!..-;,.- . ......_
............- . <,,,,,, '"""..
-)F'-./:., \.
1'f'-,:'...T ./
::I;,," ---- .: . .'
. -- -,.- ...- '"'
" "
. ..\'*::' . .--,' :
Y"
Puc. 10.27 Cnoco6 5 rjJOpMU-
poeallUR npocmou nemJlu.
I1cXOaHoe nOJlO:J/CeHUe
{;1 -r
f l.; . ; /< \
....:....-..- "I I.,\..
--1 /t:i, '
. fc.''2
Puc. 10.28 Cnoc065 rjJOpMU-
poeaHuR npocmou nemJlu.
3axeamuumu
Puc. 10.31 Cnoco6 5 rjJopMupoea-
IlUR npocmou nemJlu. MOMellm
npOeeaeHUJI Humu 'Jepe3 ne11l/l1O
82
III :nan - 3a6op HUTU U npOBe,neHue ee '1epe3 neTJIIO.
HOITeBYlO llJanaHry III nanbua 3aBo,nHT 3a HHTb, IlJHKclipoBaH-
HYIO 3TOH )l(e PYKOH (puc. 10.30). IIpli pa3r1l6aHliRnanbua H1ITb,
pacnOnO:>KeHHYIO Ha ero TbmbHOH nOBepxHoCTII, npoBo,nRT qepe3
neTnlO (puc. 10.31, 10.32).
IV 3Tan - cJIuKCaQUB npOBe.D.eHHOii '1epe3 neTJIIO HUTU.
IIocJIe npoBe,neHIIH qepe3 neTIDo cB060,nHbIll KOHeu H1ITII npH)I(II-
MalOT 60nblliliM nanbueM K JIa,noHHoH nOBepxHoCTH III naJIbua.
IIpH 3TOM YKa3aTeJIbHblH naneu pacnOJIaralOT Ha,n HHTblO.
V :nan - 3aTIlrUBaHUe neTJIU. HIITII OTBO.D.HT B npOTHBO-
nOnO)l(HbIe CTOpOHbI no.D. yrnoM He MeHee 180 0 . YKa3aTeJIbHbI-
MII nanbuaMIi 3aTHrlIBalOT neTJIlO (puc. 10.33).
Puc. /0.29 Cnoc06 5 ,pOPMUPO-
eallWI npocmou nemllli. MOMeHm
o6paJoeG1lUR nepeKpecma
::.
!
J
(:r t\
· . - rOw I
Puc. 10.32 Cnoco6 5 rjJOPMUPO-
eallUR npocmou nemJlu. BbleeiJe-
H.ue lIumu U3 KOJlbl/a Cme:HCKa
Puc. 10.30 Cnoco6 5 ,pOPMUPO-
eaHUf/ npocmou nemJlu. H a'lWIO
MOMeuma npoeeaellUf/ Humu
."'.<....., .
f;b.<
.0:........1..... '
r '. . ,. J ,"""" ,
I '.. ...-.:""'
" ..... Z . <'{ , -
il _-1
. _ft_
""'-
Puc. 10.33 Cnoc06 5
rjJopMUpOeGlIUJI npocmou
nemJlu. 3amR2UeaHue nem.nu
CIIOCOE 6.
I 3Tan - cl>uKcauuH HUTen B UCXOLJ:HOM nOJIO)KeHUU. CB060.D:Hble KOHUbI HHTII He
nepeKpell.{lIBalOT 11 y,nep)l(IIBalOT 60JIbIlIliM II YKa3aTeJIbHblMnanbuaMII06elIxpYK (puc.lO.34).
,[{anbHlOlO HIITb neBOH PYKOH neperH6alOT qepe3 60KOBYlO nOBepxHoCTb III nanbua npaBoH KIICTII
(puc. 10.35) H 3aTeM 06MaTblBalOT BOKpyr III H IV nanbueB npaBoH KlICTIi (puc. 10.36).
II 3Tan - nepcKpecT HUTen. CrH6aH IV naneu npaBoH KlICTH, 3a)l(IIMalOT 6JIH)I(HlOlO HIITb
Me)l(,D;y 60KOBblMH nOBepXHOCTHMII III H IV nanbueB (puc. 10.37).
III 3Tan - 3a6op HUTU U npOBeLJ:eHUe ee 'lepe3 neTJIIO. IIpli pa3rH6aHIIII nanbua H pOTaUHII
npaBoH KIICTH npoTHB qaCOBOH CTpeJIKII HHTb npOBO,D;HT qepe3 neTJIlO BnpaBo (puc. 10.38).
IV nan - cl>uKcauuH npOBeLJ:elIHOn 'lepe3 nCTJIIO IIUTU. IIocJIe npoBe,neHHH qepe3 neTnlO CBO-
60,nHbIll KOHeu HIITII nplI:>KHMalOT 60JIblliliM nanbueM K II nanbUY. IIpH 3TOM YKa3aTeJIbHbIH naneu
JIeBOH PYKII nOMell\aWT Ha,n HHTblO (puc. 10.39).
V :nan - 3aTHrUBauue neTJIU. HIITII OTBO,nHT B npoTIiBOnOJIO)l(HbIe CTOpOHbI no,n ynIOM He
MeHee 180 0 . YKa3aTeJIbHbiMli nanbuaMIi 3aTHrlIBalOT ncrJIlo. B rny6IIHe paHbl neTJIlO 3aTHrlIBaIOT
II nanbueM JIeBOH KHCTII.
/1 -;; .>;::: ;__--
Ii ... ..J. _ j .. :
t . -_.,- X ( .-*. .- ' 1 ..
'. _. ::. -..', - "
. -_._ ''' .
. .
-'. ',,)
Puc. 10.34 Cnoco6 6 tjJopMupoea-
IIUJl npocmou nemJ/u. Jfcxoauoe
nOJ/o:J/Cellue
' 'X . ' >.
-. "..,1
i"' .-... .,
i ... ' -
.. / Lt.
. ' '
. '. 7 'J;.j . :' i <'- ' :' , \ . .
. . "' .,. . j .
... '..../ . "
.". .
,.," .. >
.....;. . '- .
" .. .
Puc. 10.37 Cnoco6 6 tjJOpMupo6a-
llUJI npocmou ne111J/u. MOMeHm
o6pa30eaHuJI nepeKpecma
.".-- -'.
/' >{ ,',;;.......- .....:.;...--
.r" ...... jJ; _.. . (__ ,- - "'v
. '\5)1 \;:'. 6:.
0e:. t \, .....f i '
. l.n. <- . f... / /'< -=: .:d
Puc. 10.35 Cnoc06 6 tjJopMupoea-
HUJI npocmoii nemJ/u. 3axeam uumu
'<;".I\
"':- - I " . \ ' \
........: ". . , :/ t. . .
//!:lL< . >f, .'{ .. ! \
:i).' o' J
........,/
Puc. 10.38 Cnoco6 6 tjJopMupoea-
HUJl npocmou nemJ/u. Bbleeoellue
Humu U3 KOJ/blJll cme:J/CKa
1
HI . ";' \
l.c>- J
..,
I ---t........
. "- :I.;'!--rT-....
t' r "' :.. -'- .. .. \
""" :.;= '.;
-"',;'" f ."" ..f ,,
"t.t= ':'::: .':"."' . \
'; ..
Puc. 10.36 Cnoc06 6 tjJOPMUPO-
eaHUJl npocmou nenl11u. 06eeoeHue
Humu eOKpyz naJ/bl./a
...,;
/- ..
f' .::;,,
"""'r
Puc. 10.39 Cnoco6 6 tjJOPMU-
poeGuuJI npocmou ne111J/u.
3amJlZUeaHUe ne111J/U
83
rJIaBa 10
enoeo}) 7.
I :nan - cJIuKcauuH HUTcn B UCXOllHOM nOJIOmCHUU. CB060llHbIe KOHUhl 06elIx HIiTeH
He rrepeKpeIUIiBalOT II y,nep:>KIIBalOT, rrplI:>KIIMa III, IV, V rraJIbuaMIi (puc. 10.40). ,[{anbHlOlO HIITb
06MaTblBaIOT OllHIIM BIITKOM CBepXY BHII3 BOKpyr II rranhua rrpaBoH KIICTII B 06nacTli llHcTanbHoH
llJanaHrH (puc. 10.41).
II :nan - ncpcKpcCT HUTcn. II naneu rrpaBoH KHCTII (c pacrrOJIO)l(eHHblM Ha HeM BIITKOM
,nanhHeH HlITH) rrOllBOllHT rro,n 6nlI:>KH101O HHTb. B pe3YJIbTaTe 6nI1)1(HHH HHTb pacnOJIaraeTCH Ha
TbmbHOH nOBepXIlOCTIi ,nIICTanbHOH llJanaHrH II rranbua npaBOH KlICTH (puc. 10.42).
III :Han - 3a6op HUTU U npoBcllclUfC cc 'ICpC3 nCTJIIO. IIpli pa3rlI6aHliH nanbua II POTaUlI1i
rrpaBoH KIICTII rrpoTIiB qaCOBOH cTpeJIKII llrraJIhueM rrpaBoH KlICTH 6nlI:>KHlOlO HIITb npoBo,n T qepe3
rreTJIlO BrrpaBo (puc. 10.43, 10.44). ,[{BII)I(eHlIe KIICTII Brrpa-
BO He06xo,D;IIMO npOBOllIlTb Ha 1lJ0He IlJIIKclipoBaHIiH 6JIII:>K-
HeH HIITH 60KOBOH rroBepxHoCTblO III rraJIbua rrpaBoH KIICTH
KOII nanbUY (puc.1O.45).
IV 3Tan - cJIuKcauuH npoBcllcHHon 'ICpC3 nCTJIIO
HUTH. IIocJIe npoBelleHIIH qepe3 rreTJIIO, cB060llHblH KOHeu
HIITH nplI:>KHMalOT 60nhlliHM rranbueM K II naJIbUY. IIpli 3TOM
YKa3aTeJIbHbIH naneu JIeBOH PYKH pacrrOJIaralOT Ha,n HlITblO
(puc. 10.46).
V 3TIln - 3aTHnfBaHUC nCTJIH. HIlTH OTBO,nHT B rrpoTH-
BOnOJIO:>KHbIe CTOpOHbI rro,n yrJIOM He MeHee 180°. YKa3a-
TeJIbHbIMH llanhuaMIi 3anlrnBalOT neTJIlO. B rJIy6IIHe paHbl
rreTnlO 3aTHrlIBalOT II nanbueM JIeBOH KHCTII.
2 ' .---.
. ", . p- .. l:.. .. ,< f.:. . . .
.. .. .cr\
.. ."..
. .
.L ' .
. R' ).
"("'-J
Puc. 10.40 Cnoc06 7 qJOpMupoealluR
npocmou nemJ/u. IfCXOaHOe nOflO:HCeHUe
../.U\
' . /' " j
.. ..:
r(; /1 / 'I.. . \
." .:;r( ". . .". {
.-' . {
\. ; t -...,".
. ........: . \ . '.
...... - '<.
A .. ". ' i'i { .
.,,,,.or ,-,\.., . i \
,-::-.-. . +:...v"" \ \
-_. -"'-C;:-L
Puc. 10.41 Cnoc06 7 rjJopMupoea-
HWI npocmou nefl1Jlu. 06eeaeHUe
Humu eOKpyz naflbl./a
......0
.... " .'.. : ;.. . .
/.. .......,..- ." . ...\ .
:r '-.- . .
1',;,51:'..- '-<1. '"
I '::-::; )...:\-:)..
t :« :
Puc. 10.44 Cnoc06 7 rjJOPMUPO"
eaHUR npocmou nefl1Jlu. BbleeiJe..
lIue Humu U3 KOflb/.{ll Cme:HCKa
84
.<' ---....
J $. t-:';' \
If . <1\
;,'l .. t ' ):f. ... . :t_... ... ,,
'1;'. .:?' ..' \
. ;; .{ 10......,.. .,
¥ -f' (. . 3___ ,..
- .. 'I>-...J
. - ..,."..\- ...- .
. - . "\: \ =--1:"'\
.....c:
Puc. 10.42 Cnoc06 7 rjJOPMU"
pOeaHUJl npocmoii nefl1Jlu.
MOMeHm o6pa30eallUR
Z . ":. (.\
t . .
:- :\::: 1 .
. :.-:.::."'. .. . , jp')
..r- ..' . , . {}
....-"'".... ...
/ "...X '.
l- JjJ '.: ..)
'''.' .. ' :.;::;
. -- ..'\".
Puc. 10.45 Cnoco6 7 rjJopMupoea-
IIUR npocmou nemflU. 3axeam IIumll,
ebleeaeHHOU U3 KOflbl./a Cme:HCKa
".--......... . .\
"--=: -..... . ..
i \. r). .1"\1;1 ' .
".' N ). T"i !I
! -. K ./ "''-L..: '.i .
I .' < . ' .''J
'. 0' .
" . . , . .....
" ' -" --\ . <.;....
'.
Puc. 10.43 Cnoco6 7 rjJ0PMUPO-
eallllR npocmou nefl1JlU. Ha'iaJIo
MOMellma ebleeiJeHWI Humu
./_...:. .
I:} . .,
V:'-F'
Puc. 10.46 Cnoco6 7 rjJOpMIl
pOeaHUJl npocmou neff/flU.
3amRZUeOlllle nemJlU
mOCOI> 8 (cnoc06H. H. <I>oMHHa).
I :nan - cJIuKCaQUH HUTen B UCXOJ)HOM nOJIOmeHUU. CB060,nHble KOH bI 06elIx mneH
He nepeKpelliliBalOT H YJ)ep:>KHBalOT 6JIII)KHlOlO HIITb 60JIblliliM H YKa3aTeJIbHbIM nanbuaMlI, a
,nanbHlOlO - 60JIblliliM H cpe,nHIIM (pUC. 10.47). YKa3aTeJIbHbIH naneu npaBoH KIICTII no,nBo,n5IT rro,n
,nanbHlOlO HHTb II HeMHoro OTBO,D;HT BBepx. III II IV rranbUbI neBOH KIICTII pa3MeIUaIOT Ha,n 6JIII:>KHeH
HIiTblO (puc. 10.48).
113Tarr - nepeKpecr HUTen. YKa3aTeJIbHbIM naJIbUeM rrpaBoH KHCTH nOJ)THrIIBalOT 6JIII:>KHlOlO
HlITb Knepe,n1I (puc. 10.49). YKa3aTeJIbHbIH rraneu rrpaBoH KUCTII OTBO,D;HT BrrpaBo H o,nHoBpeMeHHo
HeMHoro POTlipYlOT KIICTb rrpoTHB qaCOBOH CTpeJIKII. IIpH 3TOM BblBOJ)HT 6JIII:>KHlOlO HHTb 1I3-rro,n
,naJIbHeH BnpaBo B Bu,ne Konbua (puc. 10.50). O,nHoBpeMeHHo IlJHKClipYlOT ,nanbHlOlO HHTb (HH:>Ke
Konbua) Me)l(,D;Y J)IICTanbHbIMH llJanaHraMIi III H IV nanbueB neBOH KHCTII (puc. 10.51).
III 3Tan - 3a6op HUTU U rrpoBe,neHue ee qepe3 neTJIIO. IIpli pOTaulI1I JIeBOH KIICTH rro qaco-
BOH CTpeJIKe, 3a)l(aTYlO Me)l(,D;Y III II IV rranbueM JIeBOH KIICTH HlITb rrpoBoJ)SI:T qepe3 rreTnlO BJIeBO.
OTBO,D;H IIrraneu npaBoH KlICTH BnpaBO, BblBO,D;HT 6JIII:>KHlOlO HIITb
(puc.1O.52).
IV 3Tarr - cJIHKCaQHH npoBe,neHHon 'lepe3 nnJIIO HUTU.
IIocJIe npoBeJ)eHIIH qepe3 neTJIlO, cB060,nHbIH KOHeu HIITII npH-
:>KIIMaIOT 60JIbllIliM nanbueM K III nanbUY. II pH 3TOM YKa3aTeJIb-
HblH naneu JIeBOH PYKII pacnOJIaralOT Ha,n HHTblO (pUC. 10.53).
V 3Tan - 3aTHrUBaHue neTJIU. HIITII OTBOJ)HT B npoTHBo-
Puc. 10.47 Cnoc06 8 rjJopMupoeallufI
nOnO:>KHble CTopoHblno,n yrJIOM He MeHee 180 0 . YKa3aTeJIbHblMH _
npocmou nemJIu. Jfcxoalloe nOllO:J/Cellue
rranbuaMIi 3aT5IrliBalOT neTnlO. rny60Ko pacnOJIO)l(eHHbIe neTJIIi
He06xo,nIIMO 3aT5IrliBaTb I1nanbueM JIeBOH KIICTII.
Puc. 10.48 Cnoco6 8 rjJ0pMupoea-
HUR npocmou nemJIu. 06eeoellue
lIumu eOKpyz nallblja
r
.e::::::. : _w...:::::=.-
Jl
./'.";
f. . .. , . /+ . , ,
f /;Jj , :' L ' : \
2Y \ ..' ""'-. \
) J
Puc. 10.51 Cnoco6 8 rjJopMupoea-
HUfl npocmou nemJIu. Ha'l£lJ/o
MOMeHma ebleeoeHufl lIumu
"\;
\'-L___
-- \. .
. . -:--'." 7::- " :........ '.....
.. 0'.
/-, .. :- ..;........
j .'. .. .'. EO - ""<
/ . r F>:.... , .;;fr . / '. :.1 . :
, .X] . ".'.
.f\. /), (;:: :
,.:/1
'.<.", ......
Puc. 10.49 Cnoco6 8 rjJ0PMUPO-
eQ}IUJl npocmou nemllU. OKOII'la-
mellbllblU 3axeam mllnu
1'
fl . ..£- l?"
) ;::-. ....l ;' -
7 ......: .. ."
/? d< 9' .
i i ./' :';--'. t...., ' ,
i; l . '",\, , . \
I' . .:../ :\\ \{:,'"
. ../ :," .....
. .-'7 . , ?
Puc. 10.52 Cnoco6 8 rjJopMllpoea-
IIUJI npocmou nemJIu. BbleeaellUe
lIumu U3 KOllblja cme:J/CKO
../ ...... ,-.
.J tL...,....) -
;If '"I.' . "\.- II : {':' .'-\.:'I
" " ""' . "" ." ' .. '
'...... .. "z.. ',i
, .- __ £... . ,. ':J
-
..
N' -... ..,.
..c.: . _. -
", r
./.... :( 1 - "'--:"7:' 0\ ""\,..
, '. .-<\" ... .. C o. '.'.
:. ..;:p, 49.. . r <;:}':::'\" ' '.
;i.< ( \
f '
Puc. /0.50 Cnoco6 8 rjJOPMUPO-
eOHllfI npocmou nemnu. M OMellm
06pa30eollufl nepeKpecma
/ ;... "-.: :."
:;;. 1-.. (;< . . . TI '
,:' ' '\
, >.\
' 7 .'" . "'.. "'.
"' : .
. ...'"
- --:....
Puc. 10.53 Cnoco6 8 rjJopMupoeo-
Hllfl npocmou nemnu. 3axeam Ilumu,
ebleeaellllOU U3 KOJ1blja cme:J/CKa
85
rJIaBa 10
cnOCOE 9. HeB03MO:>KHOCTb nOCToHHHOro KOHTpOJIJI Ha,n HaTH:>KeHHeM HIiTeH npH 1lJ0pMII-
pOBaHlI1I neTeJIb ,naflHbIM cnoc060M OrpaHlIqlIBaeT ero npHMeHeHHe cnyqaJIMII, r,ne 3TO He Tpe6YeT-
CH (Bce neTnH, KpOMe BTOPOH).
I :nan -eJIIIKcauuH HUTen B UCXO,nHOM nOJIOmeHUU. CB0601l.Hble KOHUbI 06elIx HIiTeH He
nepeKpelUliBalOT H y,nep:>KHBalOT 6JIH)I(HlOlO HIITb 60JIblliliM H YKa3aTeJIbHbiM nanbllaMH JIeBOH
KHCTH, ,naJIbHlOlO HIITb - npaBOH KIICTblO (puc. 10.54).
II 3Tan - nepeKpecT HUTen. EJIII:>KHlOlO HHTb JIeBOH KIICTblO nepeKII,nbIBalOT qepe3 JIa,nOH-
HYlO nOBepxHoCTb I nanbua npaBoH KIICTH (puc. 10.55). CrlI6aH II naneu, 3aXBaTbIBalOT IIM 6JI11:>K-
HlOlO HIITb H npoBo,nHT ee Ha,D. ,nanbHeH HIiTblO TaK, qT06bI ,nanbHHH HHTb pacnonaranacb Ha Tbmb-
HOH nOBepxHocTIi .D.HCTanbHoH llJanaHrH nanbua (puc. 10.56).
III nan - 3a6op HUTU U npOBe.D.eHue ee 'lepe3 neTJIIO. IIpaBYIO KIICTb pe3Ko POTIiPYlOT
npoTIiB qaCOBOH CTpeJIKII, npoTanKIiBaH .D.anbHlOlO HIITb B KOJIbUO CTe:>KKa (pUc. 10.57).
IV 3Tan - cJIuKcauuH npoBeneHHon 'lepe3 neTnlO HUTU. )J;anbHlOlO HIITb nOCJIe ee BblXo,na
H3 KOJIbUa CTe:>KKa nepeXBaTbIBalOT npaBoH PYKOH (pUC. 10.58).
V 3Tan - 3aTHI"UBaHUe neTJIU. HHTII OTBO,nHT B npOTHBOnOJIO:>KHbIe CTOpOHbI no,n yrJIOM He
MeHee 180 0 . YKa3aTeJIbHbIMli nanbuaMIi 3aTHrHBalOT neTnlO. B rJIy6IIHe paHb! neTJIlO 3aTHrHBalOT
IInanbueMnpaBOHKIICTH (puc.lO.59).
.- '-<
"'" : "
. .'" . \
"r/' '""' ; . .. .
:'. ' .. " . . ..
:: .l it..
.-<1 i ;.., T
,/, . ./ , -.. .-...;: ;...........(.
.. . ' - ........,..
i v .....;. - ,. . ..
, . ' :E" --..-..
, """4'.: t : ..
t, !'0
J
Puc. 10.54 Cnoco6 9 rjJopMupOeOlluJI
npocmoii nerrVIlI. If CXOaHOe noJlo:w:ellue
,
.,, 'J'
)} J,\,\ \
b. . I
''\ ,.
'- _'0 , C":'....
. ,":,, ..
.:.".
-: ....." F '"
4.__ r;, '. '. l .
/:::./ .' \\
.;,. ". ,.:
; \." _..J<.
. ...._ .,
Puc. 10.57 Cnoco6 9 rjJopMupOea/lUJ/
npocmou nemnu. BbleeOe/lUe Ilumu U3
KOJlblja cme:W:Ka
86
-'.'o.
I f\
< . -1"t"". .. . .,....
f\ .. 'iib;,\".
7 /:'::' ---'.:)\J W'
'!."'-,
"\;.......
'}-;:.,.v
Puc. 10.55 Cnoco6 9 rjJOPMUPO-
ea/lUJI npocmou nemnu. 06eeoellue
Humu eOKpyz nWlblja
J- " .
k " :i l > . '
I .' '":.........
""... ': ,J"'''-,
0\..-' .. "\ "),
i -t'l' ,.,. \. ",' , I
..1..,- :: ..... -:"'\ \. . I
J \. '{J:' . ., }.,
. \-- }: . :-)
. "'.... .Y'" ..,
: .:;-.
Puc. 10.58 Cnoco6 9 rjJopMupoea-
HUJ/ npocmou nemnu. 3axeam /lumu.
ebleeaeHHOU U3 KOJlblja cme:J/CKa
,-----.... ::;".
I .. .. l'
( " '{./..... \ /'--='" '"
. \.. . i , .'.::/ . ' >'\ .
r i \ 'IJ/ff;,; _
, Ill,," J (-----r- ,
' / ... . '\..._. .-
--'J- ;;.,.0- ,"" l
..." /" r. - , '.. "\:. .j!)
. I'(/J. -.y .....iII '
Puc. 10.56 Cnoco6 9 rjJopJ./upoea-
IIUJI npocmoii nemnu. Ha'iWlO MOMewna
ebleeOellUJI Humu
;;:;f-i;j "-..,
}n ' . .,"
_"L{ . x.
"'( .(
t. t. l ..-..,,=
/ . .
If r11! t?
.,.,.:: '. /..j.....U/
. ::;:.---..t-="'"
Puc. 10.59 Cnoc06 9 rjJOPMUPO-
eaHUJl npocmou nemnu. 3al1JJlzu-
eaHue nemnu
CIIOCOE 10. He,nocTaTKOM ,naHHoro crroc06a HBJIHeTCH He06xo,nIIMOCTb rrepexBaTbIBaTb
,nanbHlOlO HIITb nOCJIe rrpOBe.I\eHIIH ee qepe3 rreTJIlO CTe:>KKa. HecoMHeHHo, 3TO 3aTpy,nHHeT KOHTpOJIb
xHpyproM HaTH)I(eHIIH HHTeH B TeqeHHe Bcero BpeMeHH 1lJ0pMIIpoBaHliH neTJIIi. YqlITbIBaH 3TO, He
peKOMeHJJ:yeTCH npHMeHHTb .I\aHHbIH cnoc06 ,nJIH 3aBH3blBaHIIH BTOpOH neTnH.
I 3Tan - uKcau:uH HUTen B UCXO,nHOM nOJIOmeHUU. CB060,nHbIe KOHUbl 06elIx HIiTeH He
nepeKpeIUIiBalOT II y,nep:>KIIBalOT KHCTblO (puc. 10.60). JIeBoH PYKOH 06MaTbIBalOT ,nanbHlOlO HHTb
O,nHIIM BIITKOM CHII3Y BBepx BOKpyr III H IV nanbua npaBoH KHCTH B 06JIaCTH,D;IIcTanbHOH llJanaHrlI
(puc. 10.61).
ll:nan - nepeKpeCT HHTen. Crn6aH III H IV naJIbI.U>1 npaBOH KIICTII C pacnOJIO:>KeHHblM Ha HIIX
BHTKOM ,nanbHeH HIITH no,nBO.I\HT no,n 6nH:>KHlOlO HIiTb. EJIH:>KHHH HIITb OKa3bIBaeTCH pacnOJIO)l(eH-
HOH Ha TbmbHOH nOBepxHoCTII ,nHCTanbHoH llJanaHrII II nanbua npaBoH KIICTII (puc. 10.62).
III :nan - 3a6op HUTU U npoBeJ)eHue ee 'lepe3 neTJIIO. III111V nanbI.U>1 nJIOTHO npH:>KHMaIOT
,npyr K .I\pyry, 3aXBaTbIBaH npli 3TOM IJ.anbHlOlO HHTb (puc. 10.63).
IIpli P0TaUIiH rrpaBoH KlICTIi rrpoTIiB qaCOBOH CTpeJIKII III H IV nanbuaMIi npaBoH KlICTII,naJIb-
HlOlO HIITb npoBo,nHT qepe3 neTJIIO BnpaBo. )J;BII:>KeHlIe KHCTII BnpaBo He06xo,nIIMO npOBOIJ.I1Tb Ha
1lJ0He IlJHKcHpoBaHHH 6nH:>KHeH HI1TH (puc. 10.64).
IV 3Tan - uKcau:uH npoBe,neHHon qepe3 net'JIIO HUTU. IIocJIe npoBe,neHHH qepe3 neTnlO,
cB060,nHbIH KOHeu HIITII cpa3y no,nXBaTbIBalOT JIeBOH PYKOH (puc. 10.65).
V 3Tan - 3aTHrUBaHue neTnu. HIITII OTBO,nHT B npoTIiBOnOnO:>KHble CTOpOHbI no,n yrnoM He
MeHee 180 0 . YKa3a TeJIbHblMIi nanbuaMH 3a THrHBalOT neTJIlO. B rny6IIHe paHbI neTnlO 3aTHrHBalOT
II nanbueM neBOH KHCTH.
_.
W .. ...;:?-
,;' . ;;-L ;' '\
t-, y \ )f
:Io::
Puc. 10.60 Cnoco6 10
rjJopMupOealll/R npocmou
nemllU. JfcxoiJlIoe nOllO:J/CeHue
-
,.o::{ .
_o.i-i-- ... \
........ --......,
.. '> ... ,,"\'
..' . '(. (i . !
{"-. r,---J. ¥
I . \..'!; . >. ( '- ./
l >y.v...7;; . . -) %
" lf r -=
{(\. >j.i'
' -7' ....
Puc. 10.63 Cnoco6 10 rjJOpMU-
pOeallUR npocmou nemllU. Ha'Jl1110
MOMellma ebleeaeHUR Humu
.""" ... ' . .'
/- i!t.
i -.' I'
. .. . C. . (t . -/b-\
! ti r -l-1-'FY..-....:.\ . .
. . .... '\
.°0 -::: 1£ .:\ \..' dJ O:!
......., ./
. 0
Puc. 10.61 Cnoco6 10 rjJOpMUpO-
eallUR npocmou ne1Wl1I. 06eeiJe-
Hue lIumu eOKpyz n(Ulbl./a
.d -
{ \. :\:' '\(''0..
#t.<? ' '\
... . . I'
( : \ Y .:
.-... \ \ .
. ..:.:........ _!/
Puc. 10.64 Cnoco6 10 rjJ0PMUPO-
eOIlUR npocmou ne1Wlu. BbleeiJe-
Hue lIumu U3 KOllbl./a cme:J/CKa
/ ..r-;-. '.
'I .
,
" J
Puc. 10.62 Cnoco6 10 rjJOPMUPO-
eOIlUR npocmou ne1Wlu. C/>OPMUPO-
6aHue nepeKpecma IIwneu
. : ' J . \ \.
"". . ] I
:;;,;;:;..--, _'" .
-'...... >,'t t.
/ I f;'.!{i \ i : ;-1./j/
t.,;;) \ ..':(
:::----.«
. -::::::;? -".'fIj
Puc. 10.65 Cnoc06 10
rjJopMupoealluR npocmou
ne1Wlu. 3amRzueaHue ne1Wlu
87
rJIaBa 10
enoeOE 11. Ero He,nOCTaTKII CXO,nHbI C He,nOCTaTKaMH cnoc06a 10.
I 3Tan - 4JuKCaQUH HUTeii B UCXO,nHOM nOJIO)l\elluu. CB060.D.HbIe KOHUbI 06eHx HIiTeH
He nepeKpell.{lIBaJOT H y,nep:>KIIBalOT 60JIblliliM H YKa3aTeJIbHblM naJIbuaMH 06eHX PYK.
EJIlI:>KHlOlO HHTb IlJIIKCHpYlOT JIeBOH PYKOH, a ,nanbHlOlO - rrpaBOH (puc. 10.66).
I1nan - rrepeKpecT HUTeii. IIpaBYlO KHCTb nOMell\alOT rro.D. IlJI1KCHpoBaHHYlO neBoH PYKOH
6JIH)I(HI01O HHTb. HIITb, IlJIIKClipOBaHHYlO JIeBOH PYROH, YKJIa..rrhIBalOT Ha HOITeBYlO llJanaHI)' III naJIb-
ua (puc. 10.67). )J;anhHlOlO II 6JIII:>KH101O HIITH rrepeKpell\IIBaIOT Ha na.D.OHHOH rroBepxHoCTIi (HanpaB-
neHHoH BBepx) Ill, IV, V naJIbueB rrpaBoH KIICTII. B 3TO BpeMH I H II rranbUbl npo,non)l(alOT y,nep)l(lIBaTb
,nanbHlOlO HIITb (puc. 10.68). .
III 3Tan - 3a6op HUTU U npOBe.D.eHUe ee lJepC3 rreTJIIO. CB060.D.HbIH KOHeu 6nH:>KHeH HIITII
3a:>KIIMalOT Me:>K.D:Y 60KOBbIMli nOBepxHoCTHMH II1H IV rranbueB npaBoH KIICTII (puc. 10.69). 3aTeM,
POTHpYH npaBYlO KIICTb rro qaCOBOH cTpeJIKe, 1I3BJIeKalOT 6JIII)I(-
HlOlO HIiTh 1I3 KOJIbua CTe)l(Ka III II IV rraJIbuaMH npaBoH KIICTH
(puc. 10.70).
IV 3Tan - 4JuKCaQUH npOBe.D.ellllOii lJepe3 neTJIIO HUTU.
IIocJIe npoBe,neHIIH qepe3 rreTJIIO, cB060,nHhIH KOHeu 6nH:>KHeH
HHTH3aXBaThIBalOT neBoHpYKOH (puc. 10.71).
V 3Tarr - 3aTHntBaHUC neTJIH. HIITII OTBO,D;HT B rrpOTlIBOrrO-
JIO)l(Hble CTOpOHbI rro,n yrnoM He MeHee 180°. YKa3aTeJIbHbIMIi
rranbuaMH 3aTHrlIBalOT rreTJIlO. B rJIy60KoH paHe rreTJIlO 3aTHrH-
BalOT II rranbueM npaBoH KHCTH (puc. 10.72).
_/- -:j '--" r----
, 'U-f..."..---- -......
'. . .- /" ..--.....
/( 7 "! . ;T7 ,, . : . \
--"" .-y '...: '!l. - i
' >- --,-. ''\'0. 'In
--=-. -.-:;;* .
Puc. 10.66 Cnoco6 11
rjJopMupoeallUR npocmou nemJIu.
l1cxooHoe nOR03K.eHue
Puc. 10.67 Cnoco6 1/ rjJOpMlIpO-
eallUR npocmou nemJIu. '3a:'(eam
lIumu
1 -'-'._' ;
.Ji\"'-- i "'. ' I ;o-
J. .-! ...'-
' ' -:- . ' .
- ,-..
.: ;...., :\
.! ii\\. P
,/'
Puc. 10. 70 Cnoc06 11
tjJopMupoeallufl npocmou nemJlu.
Bbl6eaeUUe Humu U3 KOl1blja
88
'l"
-::. I ;',:=::.- / ,. :':f ,':::"-
1sfl . .-...*- . f ...,
A ; 1& ". 1/ -.,- ) -..."...,
. / . /.. , - ... ... : . :. .. . l j:t' t- W... / ) . (.... . .. t \ J '
f : "') 7 v" .:::-:_0 )ff \
r )
Puc. 10.68 Cnoco6 1/
tjJopMupoealluR npocmou nemJlu.
t]J0pMupoeallue nepeKpecma
Puc. 10.69 Cnoco6 11 tjJOpMU-
poealluR npocmou nemRU. HU'IaRO
MOMeHma ebleeoellufl 1l1imU
/ /"; :\
;. )./ ._ .
, 1 ..........;...
;', -
. { ......
........... J ....,
. -!....!,-/
J;';0 \: '" }
. ... ........---
... "-.{.. .;-
/.y
.. I if;".
/I. ,\
V\ ,...... ..,' ;' (?7 ' . ;:
J . ."--
,- -"'- ""
../ ... ..
- --...
r
Puc. 10.71 Cnoc06 11 rjJOpMU-
pOeallUR npocmou nemRU. 3axeam
lIumu, ebleeaellHOU U3 KORbljG
Puc. 10.72 Cnoco6 11
rjJopMupOeallUR npocmou nemJIu.
3amRi?UeallUe nemJ/u
enoeOE 12.
I 3Tan - cJIuKcauuH HUTCD B UCXOD.HOM nOJIOmCHUU. CBo60D.Hble KOHUbI 06eHx
HHTeH He rrepeKpell.{lIBalOT II Y.D.ep:>KIIBalOT 60JIbllIliM II YKa3aTeJIbHbIM naJIbUaMIi 06elIx
PYK (puc. 10. 73). EJImKHlOlO HHTb rrepeKlI,D;blBalOT qepe3 JIa.D.DHHYlO rroBepXHOCTb lI1naJIbua
npaBoH KIICTH (puc. 10.74).
II 3Tan - ncpeKpecT flUTCD. Ha ,nHCTanbHOH llJanaHre III nanbl.{eM npaBoH KIICTII 1lJ0pMlIpYlOT
nepeKpecT (puc. 10.75). 3aTeM CHII3Y 3aBOWIT 6JIII:>KHlOlO IlIITb 3a .D.IICTanbHYlO llJanaHry III rranbua
rrpaBoH KIICTII (puc. 10.76). B 3TO BpeMH I II II naJIbUaMli rrpo,nOJI)I(alOT Y.D.ep:>KHBaTb .D.aJIbHlOlO HIiTb.
III nan - 3a6op HUTU U npOBc,nCHUC cc 'ICpC3 nCTJIIO. IIpli POTaUlI1I npaBoH KIICTII no
qaCOBOH CTpeJIKe, III nanbueM 1I3BJIeKalOT 6nlI:>KHlOlO HIITb 1I3 KOJIbua CTe:>KKa (puc. 10. 77).
IV ::ITan - cJIuKcauuH npOBC.D.CHHOD 'lCpe3 nCTJIIO IIUTH. IIocJIe rrpOBe.D.eHIIH qepe3 neTnlO,
CB060.D.HbIH KOHeu 6JIII:>KHeH HIITH 3aXBaTbIBalOT 60KOBbIMli nOBepxHoCTHMII III H IV nanbueB npa-
BOH KIICTII (puc. 10. 78). 3aTeM
nepexBaTblBalOT ee I H II rranb-
uaMIi JIeBOH KIICTII (puc. 10.79).
V 3Tan - 3aTHrUBaflue
nCTJIU. HIITII OTBO,n5lT B rrpOTH-
BOnOJIO:>KHbIe CTOpOHbI no,n yr-
JIOM He MeHee 180°. YKa3a-
TeJIbHblMli rranbuaMIi 3anlrHBa- Puc. 10.73 Cnoco6 12 tjJopMupoeaHuR
B 6 Puc. 10.74 Cnoc06 12 tjJOPMUPO-
lOT rreTJIlO. rJIY IIHe paHbI neT- npocmou nem.nu. Ifcxoalloe nO/lO:HCetlue
JIlO 3aTHrnBalOT II rranbueM JIe- eaJ/UR npocmou nem/lu. 3axeam
BOH KlICTH (pUC. 10.90).
..,
--:_
-i
/: .#: "'-... ''' ]:CY' i\
! \: .' " "'f. \. 1j"!,
i - 'f '. J 1 \, ,"j\ '
l ' y (' '\'A: ) r
, }- . ( ';
''- '--j ... _ J
Puc. 10.75 Cnoco6 12 tjJopMupoea-
/lUR npocmou nem/lu. C/>opMupoeallue
nepeKpecma Humeu
:J.":;::':' ..J:'>\
' ":: l-- . .
'-'.( . \T:
' " ".d_J
....: : " , '-
\ "": / ( ... "
"! . / ) 'J
I -..,'. ,( ,.'"
Puc. 10.78 Cnoco6 /2 tjJOpAtupOea-
HUJl npocmou nem/lu. Bb/eeiJellue
lIumu U3 KO/lblja Cme:HCKa
/-w".
// . . \j :; .. . ( J \
1.,\ / .';'\ !; "
y .; ..
" .-c::::..- -::'-;7 \ \
. -- t-'-
/""" '--""
rrr? , ),"'''\.
, r'. 7t-:f" ) .
" <':'-' {::7 / , ) ... 1"
- , .,;-.........- ..
- </f-
.
t"..,.:..,.-. . J
/ .: .
il...
...... .....__. I
Puc. 10. 76 Cnoco6 12 tjJOPAtUPO-
eallUJI npocmou nem.nu. Ha'laJlo
MOMellma ebteeiJelluR Humu
-,; .
. 7 11.
\J; .J A \
--'J7 ;/1
; " \...' ill
.'". --...i!:. ",.'
Puc. 10.79 Cnoc06 12 tjJop. tupoea-
HUJ/ npocmou nemnu. 3axeam HwnU,
eb/eeaeHlWU U3 KO/lblja cme:J/CKa
- ..:!. <:;:;,.
< 'f;"' ':: '
'J . ' .",. ." . ! q; 'l\: .. . ::- '.\ \
"'j: .1 ,.,"
/ -....::; - :" -a" "....,...
. '. I
,. ,
.\.. .1
..' " . . w '
, /;:--",
// , t :.< \
rv .,,;'
r Io..."..:?" ,-,
\-.;:"... (. :: >' -
. ; . 7:k"\
. .i--4
.-- -... ,'i l
. ":;(....... ':,
f ."""'. '':, "'. 1
-c::-::::i'\.j)1
Puc. 10. 77 Cnoco6 12 tjJOPMUPO-
eallUR npocmou nemnu. Bb/eeiJe-
lIue lIumu U3 KOJ1blJa Cme:HCKa
/-....'..
It l
/t .......",. . .
(. v;>
;..
hi:;
-?" c.,.
Puc. 10.80 Cnoco6 12
tjJopMupOealluJl npocmou nem.nu.
3amJl;?UeallUe nelll/lU
89
rJ1aBa 10
mOCOE 13.
I :nan - UKCaQUH HUTen B UCXO.lI.HOM nOJIO)KeHUU. CB060,nHhIe KOHUbl 06elIx HHTeH
He nepeKpeIUHBalOT II y,nep:>KIIBalOT JIeBOH KHCTblO, IlJHKClIpYH 60JIbllIHM II YKa3aTerrbHbIM
nanhUaMH 6JI1I)l(HlOlO HlITb, a ,nanbHlOlO 3a:>KIIMalOT Me)l(,D;y 60KOBbIMli nOBepxHoCTsrMH III II IV rraJIb-
QeB, nepeKIIl(blBaH ee qepe3 JIa,LIOHHYlO nOBepxHocTb III nanbua (puc. 10.81).
II narr - nepeKpecT HUTen. II H III nanhuaMH rrpaBoH KIICTH «HaCTynaIOT» Ha '6nlI)l(HlOlO HlITb
II HaTHrnBalOT ee «Ha Ce6H» (puc. 10. 82). O.lI.HOBpeMeHHo POTlIpysr rreBYIO KIICTb no qaCOBOH CTpeJI-
Ke, 1lJ0PMHPYIOT rrepeKpecT HIiTeH Ha 60KOBOH nOBepxHocTH II naJIhua npaBoH KIICTII (puc. 10.83).
III 3Tan - 3a6op HUTU U npOBe.lI.eHUe ee 'lepe3 neTJIIO. ,[{anhHlOlO HHTb nOMell.{alOT Me)l(,D;Y
60KOBblMH nOBepxHoCTHMH II II III nanbueB npaBoH KIICTII (puc. 10.84). II H III nanbuaMIi npaBoH
KHCTH 1I3BJIeKalOT ,nanbHlOlO HIITb 1I3 KOJIbua CTe)!(Ka cnpaBa HarreBO (puc. 10.85).
IV nan - UKcaQuH npoBe,nellHon 'lepe3 neTJIIO HUTU. IIocJIe npoBe,neHIIH qepe3 neTnlO,
cB060,nHbIH KOHeu ,nanbHeH HIITII 3aXBaTbIBalOT rrpaBoH KHCTblO.
V 3Tan - 3aTHrUBaHue neTJIU. HHTH OTBO,nHT B npoTIiBOnOJIO)!(Hble CTOpOHbI no,n yrfloM He
MeHee 180°. YKa3aTeJIbHbIMH nanbuaMH 3aTHrlIBalOT neTfllO. B rny6IIHe paHbl neTnlO 3aTHrnBaIOT
IInanbueMnpaBoHKlICTII (puc. 10.86).
/", 'C-/:....
i!{ /k 1 "' \
Ii' jj J:" 'i" '. -' .
. . . ': ./' .'--....-
\J'(..I ,...,-- " --
Puc. 10.81 Cnoco6 13
tjJopMupOeaHlIR npocmou ne1/1J/II,
IfCXOaHOe nOllO;HceHue
_I':..
,.
( i, , , )
, ..j / \. j
' \ "(fi"
Puc. 10.84 Cnoco6 13 tjJOpMU-
poeaHufI npocmou nemnu. Ha'laJIo
MOMe1lma ebleeaeHUfl lIumU
90
/,.-, \;<-;:..... :....!...1. ":
/ , . "" , ,." ....-'--',.' \ .:,:;-."..-;0.-.
. ; ':.........1" -.., . .;,.
.u , ...,;L:.' . < /('
l p / t j 'u, :l -: 7 '>:' f j '
. ..\.,
, " '\j ... .
., .
1.iti-'
Puc. 10.82 Cnoc06 13 tjJOPMUPO-
eaHUJI npocmou nemnu. 3axeam
Humu
__._ "or
"',;;f'""';:':.. .", o..<V. --- '"'--.
/ ?................ > ............' t1 .. ,.....-
/ ,....
II ' '.,?,": / r' : --\) /\
vi P: \\,
...... , ': U . \.-! , '<': I " .
., ';f .. ,/
.
: : ". "
\... ':1
....
Puc. 10.85 Cnoco6 13 tjJOpMU-
pOeaHUJI npocmou nemnu.
Bbl6eaeHUe lIumu U3 KOllblJa
....
ff J .
4 /' , ' / , -'-J1 , . , "'1 .;
' / .. (l ."
. '= \,:
...,,'" .f
Puc. 10.83 Cnoco6 13 tjJOpMU-
pOeaHUJI npocmou nemllU.
4JopMupOeallue nepeKpecma
J '
' U ' .
( }-; j , -."
\ J (17 . ....
. ' ..
...... ... ........
-. ---.".
-
Puc. 10.86 Cnoco6 13
tjJopMupoeaHuR npocmou nemJIU
3aTWIZUea1lUe nemnu
cnOCOEM OPMMPOBAHMgcrro Hb nETIVffi
CIIOCOE 1 (11. 11. EYJIbIHIIHa).
I 3Tan - «!>uKcauuH HUTeH B UCXO,nHOM nOJIo»>eHUU. CB060,nHbIe KOHUM 06eHx HHTeH
He nepeKpell.{HBalOT H y,nep:>KHBaIOT JIeBOH KHCTblO 6JIH:>KHlOlO HHTb, a npaBOH - ,naJIbHlOlO. .[(anb-
HlOlO HIiTh 3a:>KIIMaIOT III II nanbuaMH npaBOH KIICTII, nepeKH,D;bIBa5I ee Ha TbIDbHYlO nOBepXHOCTb Ill,
IV, V nanbueB (puc.10.87).
II 3Tan - nepeKpeCT HUTCH. HacTyna5I III H IV naJIbuaMIi npaBoH KIICTII Ha 6nlI:>KHlOlO HIITb H
nO,D;BOM III II IV neBoH KIICTII no,n ,nanbHlOlO HHTh, 1lJ0pMHPYlOT nepeKpeCT Ha JIa,noHHoH nOBepxHo-
CTII JIeBOH KIICTH (puc. 10.88, 10.89).
Cm6a5I III nanbUbI 06eHx KHCTeH, nepenneTaIOT HX ,nHCTanbHbIMH llJanaHraMH (puc. 10.90).
III 3Tan - 3a6op HUTU U npoBe,neHue ee '1epe3 neTJIIO. ,[{aJIbHlOlO HHTb nOMell.{aIOT Me)l(,D;Y
60KOBbIMH nOBepxHocTHMII III H IV naJIbueB npaBoH KHCTH, a
6JIII)KHlOIO COOTBeTCTBeHHO - JIeBOH (puc. 10.91). Pe3Ko POTII-
PYH JIeBYlO KHCTb no qaCOBOH CTpeJIKe, a npaBYlO npOTHB qaco-
BOH, H3BJIeKalOT HHTH 1I3 KOJIbUa CTe:>KKa (puc. 10.92).
IV 3Tan - «!>uKcauuH npoBe,neHHoH '1Cpe3 neTJIIO HUTU.
IIocJIe npOBe,neHII5I qepe3 neTJIlO, cB060,nHble KOHUbl HII-
TeH nepexBaTbIBalOT 60JIee y,n06HO.
V nan - 3aTHrUBaHue neTJIU. HHTH OTBO,nsrT B npOTHBO-
8 Puc. 10.87 Cnoc06 1 pOpMUp06a1lUH
nOJIO:>KHble CTOpOHbl no,n yrJIOM He MeHee 1 0°. YKa3aTeJIbHbl- _
CRO;)ICHOU ne/11Jlu. I1cxoalloe nORO;J/(;enue
MII nanbuaMH 3aTHrHBalOT neTnlO. B rny6IIHe paHbI neTJIlO 3aTH-
rHBaIOT II naJIbueM npaBoH KHCTII (puc. 10.93).
,. J<.1
/ ,.... ...,
. .. \<.' '/v
11.'ie..,'\ .
..; J . 'I> r [) . -= =
<t. t"J _";'1'. \
:::: / . -""," -.:;.-, y
...... " " '.. ..... "
. '-' 7:
.
..--' ..
PUC. 10.88 Cnoc06 1 POPMUPO-
601lUH CRO;Jl(."/Joij nel1V1U. 3axeam
HUmU
PUC. 10.91 Cnoc06 1 POPMUPO-
eaHWI CRO;)ICHOU ne/11Jlu. Bbl6eae-
Hue Humu U3 KORblja Cme;)ICKa
PUC. 10.89 Cnoco6 1 pOpMupoBa-
HWI CJlO;)ICHOU nemJlu. <POpMup06aHue
nepeKfJeCma lIumeu
11 .
. ./ . " ) ';':'(f . ' '
. ' 1
:.---., . '
.., "
;..,.:::-- ';:::-::... ' <
}If:;:' i .;\
/""
PUC. 10.92 Cnoc06 1 popMupoea-
HWI CJlO:HCHOU ne/11JlU. OKOIl'lameJlbIlOe
ebl6eaellUe Humu U3 KORblja cme;)ICKa
?-. , C;:S ,
/ ,<; '... A;k I
t . / l.L '-- '/J '. .
1 J r'f ----- f
(;i. [J m .;f
-- . "
!".'
l:s;:;.;;;> ." -: .
l .
./ j}. /./
r:
Puc. 10.93 Cnoc06 1 POPMUPO-
6a1lUH CRO;)IClIOU ne/11Jlu 3amH2U-
eallue ne/11Jlu
91
rnaBa 10
CIIOCOE 2.
I 3Tan - c»uKCaQUB HUTcn B UCXO,nIlOM nOJIo»>eHUU. CB060,nHbIe KOHUbI 06elIx HHTeH
He nepeKpell.{HBaIOT H y,nep:>KHBalOT 6JIII:>KHlOlO HIITb 1 H II nanbuaMH JIeBOH KIICTII, a ,naJIbHlOlO - I
H 11 nanbuaMH npaBoH KIICTII (puc. 10. 94).
II 3Tan - nepeKpecT HUTen. C6JIH:>KaH KHCTH. 1lJ0pMHpYlOT nepeKpeCT HHTeH Ha JIa,noHHoH
nOBepXHoCTH JIeBOH KIICTH. )J;JISI: 3Toro HaCTynmoT III, IV H V naJIbuaMIi JIeBOH KIICTII Ha 6JIII)KHlOlO
HIlTb II nepe6pacbIBalOT ,naJIbHlOIO HHTb qepe3 ,nHcTanbHYlO llJaJIaHry III nanbua JIeBOH KHCTII
(puc.lO.95).
III 3Tan - 3a6op HUTU U npoBe,neHue ec 'Iepe3 neTJIIO. CrlI6aH III naJIeu JIeBOH KHCTH,
no,nBO,nsrT ero no,n 6JIH:>KHlOlO HIITb II 3mKIIMalOT ee 60KOBbIMH nOBepxHoCTHMH III H IV nanbueB.
O,nHoBpeMeHHo II naJIeI.( npaBoH KHCTH npoBoMT no,n 6JIII)I<HeH HIiTblO TaK, qT06bI,nanbH51H HHTb
pacnoJIaranaCb Ha TbIJIbHOH nOBepxHoCTIi ero ,nHCTanbHoH llJanaHrH (puc. 10.96).
POTHPYH npaBYlO KHCTb npOTHB qaCOBOH CTpeJIKH, a JIeBYlO - 3a qaCOBOH, BblBOMT HHTH H3
KonbuaCTe:>KKa (puc.lO.97).
IV 3Tan - c»uKcauuH npoBe,neHHon 'Iepe3 neTJIIO IIUTU. OKOHqaTenbHo BbIBO,nHT HHTH H3
KOJIbua CTe:>KKa, y,nep:>KHBaH HX Me)l(,D;y naJIbuaMH (puc. 10.98). nOcJIe npoBe,neHHH qepe3 neTnlO,
cB060,nHbIe KOHUbI HIiTeH nepexBaTbIBalOT 60nee y,n06HO (puc. 10.99).
V 3Tan - 3aTHrUBaHue neTJIU. HIITH OTBO,nHT B npoTHBOnOJIO:>KHble CTOpOHbI no,n yrJIOM He
MeHee 180°. YKa3aTeJIbHbIMH nanbuaMH 3anlrHBalOT neTnlO. B rny6IIHe paHbI neTnlO 3anIrHBaIOT
II nanbueM npaBoH KHCTII.
//-;-';.0 \-
i" "":., ..' v\
, l"' ' ' ST ,\
...e.::.. -.. ,\.. f
. - '
PUC. 10.94 Cnoc06 2 tjJOPMUPO-
ea/IUR CR03ICIIOU nemllU. Hcxoalloe
nORO:HCe/lUe
;;' :: 1'.;A . r
A lJr , ' { j .>'"
r7 "1" }
l ..
'<;,.
Puc. 10.97 Cnoc06 2 tjJopMupoea-
HUR CRO:HClIOU netnJ/u. BbleeaellUe
Humu U3 KORblja cme3ICKa
92
/ '- :7) :;(-J::t:......
. ,..... / t
.r . , { . " , . I. - '.r--""
, {' . I 'X', . ( 1"
:t. \t!., .,\
I J ;': , ...." \
\I -"-, >- .
. -< y .:;t' \
- , .
:;" H
...lj._ A l
;1
PUC. 10.95 Cnoc06 2 tjJOPMUPO-
eUHUJI CRO:HCIIOU netnJ/U. 3axeam
HUmU
f ,-".
. I
: f ?l
,/ / f (
; sr -::::l s;.. , :
. J{.l: } )
'1
':'" -",-/
PUC. 10.98 Cnoc06 2 tjJOPMUPO-
BaHUR CllO:HCIIOU netnJ/u. OKOII'la-
meRblloe ebleeoellue lIumu U3
KORblJU cme3ICKa
d .,d'
.-_A ....
/ '-,;..,.' _. :-_.. ""-'
<. 'V""-y (
I"' _: l rj,:1(; _ :"- -
/7$.r' _
! Ai.. '('\ ....j
! - f;' 1 / ( .. ."" .. \;,
,.. '-. .
j' l 'l' '- l'
"-. . i V' '1:':' '. '.1
Puc. /0.96 Cnoc06 2 tjJOPMUPO-
eUllUJ/ CR03ICIIOU netnJ/u. c]JOPMU-
poeallue nepeKpecma Ilumeu
-_:.._ \
' S" 1 ! /:
". rJ:. o.
f.. I. .. .
(l!!
PUC. 10.99 Cnoc06 2
tjJopMupoealluR CllO:HCIIOU
netnJ/u. 3amRi?UeaHUe netnJ/u
cnOCOE 3. (E. E. rpHropbeBa).
I 3Tan - c»HKcaQHH HHTeH B HCXO,nHOM nOJIo»>eHHH. CB060,nHble KOHUbl 06eHx HHTeH
HenepeKpellUIBaIOT. Y,nep:>KIIBalOT 6nlI:>KH101O H1ITh JIeBOH PYKOH Me)K):{)' Ill, IV, V nanbuaMH. Ha HIITb
HaCTynalOT YKa3aTeJIbHbIM naJIbueM H nepeKH,D;blBalOT ee qepe3 TbIJIbHYlO nOBepxHoCTb I naJIbua.
)J,anbHlOlO HHTb y,nep:>KHBaIOT Ill, IV, V naJIbuaMH, nepe6pacbIBaH qepe3 ,nHCTaJIbHYlO llJanaHry II
naJIbua (puc. 10.100).
II :nan - nepeKpecT HHTeH. C6nH:>Ka51 KHCTII, YKa3aTeJIbHble naJIbUbI 06elIx KHCTeH BBOLIHT B
nonyqHBillYlOCH neTJIlO CTe:>KKa H, CJIerKa crn6asr HX, paCTHrHBaIOT KOJIbUO (puc. 10.101). 3aTeM,
crn6.a5l11 nanbUbl, 6JI1I:>KHlOlO HHTh pacnOJIaralOT Ha TbmbHOH nOBepxHoCTII ,nIICTanbHoH llJanaHrn II
nanbua neBoH KnCTII, a ,nanbHlOlO - Ha nmbHoH nOBepxHocTIi II naJIbua npaBoH KHCTII (puc. 10.102,
10.103).
III 3Tan - 3a6op HHTH H npoBc,neHHe ee '1Cpe3 neTJIIO.
Pa3rH6aH II naJIbUbI H pOTHpYH JIeBYlO KIICTb no qaCOBOH CTpeJI-
Ke, a npaBYlO - npoTIiB qaCOBOH CTpeJIKH, BblBO,D;HT HHTII qepe3
KonbUO CTe:>KKa (puc. 10.104).
IV 3Tan - c»HKCaQHH npoBe,neHHoH '1epe3 neTJIIO HHTH.
Y,nep:>KHBa51 HIITH Me)K):{)' 60KOBblMH nOBepxHocTsrMH II H III nanb-
ueB, nonHOCTblO BbIBO,nHT KOHUbI HHTeH 1I3 Konbua CTe:>KKa
(puc. 10. 105).
V 3Tan - 3aTHmoaHHe neTJIH. HHTH OTBO,nSIT B npoTHBo-
1I0nO:>KHble CTOpOHbl no,n yrnoM He MeHee 180 0 . YKa3aTeJIbHbIMH
naJIbuaMH 3a THrnBalOT neTnlO (puc. 10.106).
C . :2 : '
r; ,.: ,.-,. """'"
, .. . .., \
" -' '\
./ e / , l"",,,/ " , ' \
11 ( 1../ ;:\ '1 ... "Jj \
It l \- "-"'-' :: y .... <-. ".
l ' '.' .............., 1(.,- iF"'
\::. , .' -.- : \ '
.:' :::""
r . fX/. ;::;;':?<i>
{ ; :, :/.1 '"{
.. ;f1 \..::..: , '--
/P r --:f
/ ....-;;" >oj;,
" -
--
Puc. 10.101 Cnoc06.1
,popMupoeaHufi CRO:J/CHOU
nemJ/U. 3axeam lIumu
PUC. 10.102 Cnoc06 1 pOpMU-
poea/lufl CRO;J/ClIOU nentllu.
tPopMupOeallue nepell:pecmu
f-N' -
A ,' '>1' ....J.(7 ... , .
, If '\ A' r'..
I, '.'/' 1 d\ \
,.- '> J
¥='
.
,
'>. -;""," -,
i n ' . f r-:-....... , ...' 11 . , " \ '
'- .....1 '., ,
'f' ' /'
..{ .;, ... '.
:".1 (;::..,...--: _. ' \ i
...;::-:,'1: ":::-_;'-..' . ,. J;.
-,£ '.'IS "-:;.- :
Puc. 10.104 Cnoc06 1 ,pOpMup06a-
HUfi CRO:J/ClIOU nentllu. M OMe/lm
6b16eaellUR lIumu U3 1I:0Rbqa cme:J/ClI:a
Puc. 10.105 Cnoc06 1 ,popMupo6aHUJl
CRO:J/CHOU nemRU. OIl:OH'JameRbllOe
ebleeoellue lIumu U3 1I:0Rbqa cme:J/ClI:a
,.\ :, : .c:;) : .
f)rt; 'j t!0,,\
f/"'V.J. -.;_.___\
i f .,{'i7'""'\ )<:..,
. j 'r.::"':;p' .
f:,. ':/
Puc. 10.100 Cnoc06 3
,popMupoeaHufi CRO:HC/lOU
nenVlu Hcxoalloe nORo:Hcellue
:"" "' .:i-:-:::"
/'. /t r',' - -, ,
. "....-<'i"
J {. :::::y"",. .' -." ' .
.'.........,'..... ,.
"' ..
I "If::
Puc. 10.103 Cnoc06 3 ,pOPMUPO-
eallUfi CRO;J/CiIOU nemRU. Ha'laJ/o
ebleeOellUfi lIumu U3 1I:0Rbqa cme:J/ClI:a
-;?' ,;'-.,
< l -
/ .
/,- \ ;/
I' . ,
. /JfJi 1,
'?" ..../
,, .
PUC. 10.106 Cnoc06 1
,popMupoeUllufi CRO:HCHOU
nemnu. 3amfizueuHue nentllu
93
rnaBa 10
cnOCOEq,OPMMPOBAHMRllETJIH EAPKOBA
I 3Tan - 4>HKcaUHH HHTen B HCXO,nHOM nOJIo»>eHHH. HlITb npoBo,nsrT no,n JIHrHpyeMbIM
cocy,nOM, nOCJIe qero ,nanbHHH ee KOHeu 3aXBaTblBaIOT npaBoH KHCTblO. HUTb y,nep:>KHBalOT Ha
OTBe,neHHOM YKa3aTenbHOM naJIbue (puc. 10.107).
II :nan - nepeKpecT HHTen. JIeBoH KHCThlO ,nBa>KlIbI HaMaTblBalOT 6nH:>KHlOlO HlITb Ha nlirlIpy-
eMbIH cocy,n H YKa3aTeJIbHbIH naJIeu npaBoH KlICTII. TaKIiM 06pa30M, 06pa3YeTCH nepeKpecr HIiTeH
Ha JIa,noHHoH nOBepxHoCTH II naJIbua npaBoH KHCTH (puc. 10.108). 3aBepiliM BTOpOH BHTOK, nepe-
Mell.{aIOT JIeBYlO KHCTb C 6JIH:>KHeH HHTblO «OT ce6H», qT06bI BTOpOH nepeKpeCT 06H3aTeJIbHO pacno-
narallCH Ha II naJIbue npOKCliMaJIbHee nepBoro (puc. 10.109).
III nan - 3a6op HHTH H npoBe,neHHe ee '1epe3 neTJIIO. 06a nepeKpeCTa HIiTeH IlJIIKCHPYlOT
II nallbueM npaBoH KlICTH (puc. 10.110). 3aTeM npaBYlO KIiCTh POTIiPYlOT npoTHB qaCOBOH CTpeJIKII.
3TO n03BOJIHT npoBeCTH ,nHCTaJIbHYlO llJaJIaHry I naJII,ua B 06a KOJIbua CTe:>KKa. EJIII:>KHlOlO HIITb
nOMell.{alOT JIeBOH KIICTblO no,n no,nYIlIeqKY ,nHCTanbHoH llJallaHrH II nanbua (puc. 10.111). POTHPYH
npaBYlO KHCTb no qaCOBOH CTpeJIKe, npoBo,nHT 6JIlI:>KHlOlO HIITb qepe3 KonbUO CTe:>KKa (puc. 10.112).
IV nan - 4>HKCaQHH npoBe)J.eHHon '1epe3 neTJIIO HHTH. IIocJIe npoBe,neHIIH qepe3 neTJIIO
C' ',----::-",), cB060,nHbIH KOHeu 6JIII:>KHeH
i tli:J:::1fj... '\ HIiTlI 3axBaTblBalOT neBoH KIIC-
. If.\ -,., 1}' , '.
")..:':_/_\;;1'1' TblO (puc.lO.113).
' -- J -' -<{.:"r' V 3Tan - 3aTHrHBaHHe
/ " : neTJIH. HIITII OTBOMT B npOTH-
/' .4 BOnOnO}KHble CTOpOHbI no,n yr-
+. <. // JIOM He MeHee 180°. YKa3aTe-
" /'....... .-....,
" )_.. "'A-'
. _\; I ...l.
--' T " <'"....1 '
I. ".'>",,::Y'" .
..... ,,,,y-, .
"" t ,.
'\;::-.......!
..... ..,,-
Puc. 10.107 Cnoc06 ,p0PMUPO-
ea1/ufl nemJ/u Eap'<oea.
Hcxoalloe nOll03ICeHue
---' ----.
'\':< ;.' < '-;-r
/ . ",,;""'7
7..<., 'i '-:, 1,
:,' .I.. . \. "
.;0 ,,::..,;;.. - <:. :..
" , .
.
Puc. /0.109 Cnoc06 ,pOpMU-
poeaHUR nem?u Eapll:Oea.
t/JopMupoeaHue nepeKpecma
r-;'-;. .,
'W',,,, ' ....-. .",
$' 7 "/ JI .. . ..... . : . '\
- :f1lr::,,: . :
"",.:.0 f\-l "->i(."';""':
"'___ ,.r.
Puc. 10.112 Cnoc06 ,popMupoea-
HUfi nemJ/u EapKoea. MOMellm
ebleei>eHufi Humu U3 ll:011blJa cme;J/CKa
94
Puc. 10.108 Cnoc06 ,popMupoea-
HWi nemJ/u EapKoea. 06MllmbieaHue
Humu eOKpyz nallblJa
nbHbIMII nanbuaMH 3anI-
rHBalOT nemlO (puc. 10.114).
7"
; . >\
",. .
:y- PA :;- ff : <.r. "
. l,It .-:- - \
.\. 1: . / '.I' . ',
.'<--!,.,! - \.
.,............, I' -"I
t\ }
-;/ . .
- f1 ' . - -
, . " /f j 1 ; .
.? \ 1([
.' I':-:.;;;:/
Puc. 10.110 Cnoc06 ,pOPMUPO-
eaHUfi nemllU EapKoea.
t/JUKCaIJUR nepeKpecma lIumeu
Puc. /0.111 Cnoc06 ,popMupoeaHufi
nem?u EapKoea. Ha'iallO MOMeHma
ebleei>eHuR lIumu U3 KOllblJa cme3ICKa
,,-' /-:.;( ..,.
." ; t- M ..
'-"". j ' r; -'"
;-/". l.; \
;./ .'
l z: ».: .
.// , --
, 4'
"-:?- .
t ". \
. "r-", :,.,}t;Pi.
'QO;;- !J'\\\,::"
,:"".,
Puc. 10. 114 Cnoc06 ,popMupoea-
HWI nemJ/u EapKoea. 3amHzuea-
Hue nemJ/u
Puc. 10.113 Cnocn6 ,popMupoew/W1
nemllU EapKoea. OKOH'IamenbHoe
ebleei>eHue Humu U3 KOJ/pllo. cme3ICKD
t ' "" _ rrtam£ 11
& ,,' ,r!fr() ObhI C;PQBLVjJit1"\i.U A.llH:SI"'"
..., ItE:'fEJI»:",
CndMd I>W IIH<;1P,;MMEHTOB;:.
. . ,,,,\; . ,; - . : ;:. <,.4I:
B xHPyprlIqeCKOH npaKTHKe 6bIBaIOT MOMeHTI>I, Kor,na
He06xo,nIIMO 3aBH3aTb Y3eJI C nOMOll.{b HHCTpYMeHTOB. TaKOH
cnoc06 1lJ0pMIIpoBaHHH Y3JIa n03BOnHeT HCnOnb30BaTb Bee npe-
HMYll.{eCTBa anO,naKTRITbHOH TeXHHKII:
- B03MO:>KHOCTb 1lJ0pMIIpomlHIIH Y3JIa Ha KOpOTKOH HIITH;
- CYlI.{eCTBeHHOe CHII:>KeHHe pliCKa HHllJlIUHpoBaHIIH H1ITII;
- 3KOHOMWI. IlIOBHOrO MaTeplialla.
B TO:>Ke BpeMH YMeHbIlIeHHe TaKTHJIbHOrO KOHTpOJIH Ha-
Tsr:>KeHlIHHnOBpe)l(,D;eHlIe HHTHHHCTpYMeHTOM cymecTBeHHO or- Puc. 11.1 Cnoc061 rjJOpMup06aHuR
paHHqHBalOT npHMeHeHHe ,naHHoro cnoc06a 3aBH3bIBaHII Y3- npocmou nem?u. lfcxoauoe nORO:JICellue
noB.
PaCCMOTpHM TexHHKY 1lJ0pMHpoBaHIIH neTeJIb nocpe,n-
CTBOM IIHCTpYMeHToB.
CIIOCOE 1.
I 3Tan - c)mKcauHH HHTen B HCXOl{HOM nOJIO)KeHHH.
nOcJIe npoBe,neHHsr HHTH qepe3 TKaHI, cB060,nHble KOHUbl He
nepeKpell.{HBaIOT H y,nep:>KHBalOT 60nee ,nJIHHHYlO 6nH:>KHlOlO
HIITb neBoH KHCTblO. ,[{aJIbHHsr HHTh cB060,nHO pacnonaraeTCH
Ha ,naJIbHeH CTopoHe onepaI.(IIOHHOrO nonH (puc. 11.1).
II 3Tan - nepeKpecT HHTen. MHcTPYMeHT nOMeIUaIOT Ha,n
HIiTblO (puc. 11.2) H JIeBOH PYKOH ,nBa)l(,D;b1 B HanpaBneHlIIi npo-
TIIB qaCOBOH cTpeJIKII HaMaTbIBalOT Ha Hero 6JIH:>KHlOlO HHTb
(puc. 11.3, 11.4).
III :nan - 3a6op HHTH H npoBe,neHHe ee 'Jepe3 neTJIIO.
Pa3.D:BHHYB 6paHllIH, 3aXBaTblBalOT IIHCTpYMemoM KOHeu ,naJIb-
HeH HIITH (puc. 11.5). 3aTeM ee npoBoMT qepe3 KOJIbUO CTe:>K-
Ka npaBoH PYKOH Ha ee6H, 1lJ0pMIIPYH, TaKHM 06pa30M, ,nBOH-
Hoe nepenJIeTeHHe HHTeH.
IV 3Tan - 3aTHrHBaHHe neTJIH. HHTH OTBOMT B npOTII-
BOnOnO:>KHbIe CTOpOHbl no,n yrnoM He MeHee 180 0 . EnlI:>KHlOlO
HIiTh nepeMeIUaIOT neBoH PYKOH «OT Ce6H», a JJ:aJIbHlOlO HIITb-
npaBOH PYKOH «Ha Ce6H» (pUC. 11.6). IIeTnIO 3aTsrmBalOT II
.........
--<
./ 4J)
J' ;:%ii
" l
Puc. 11.2 Cnoc06 1 rjJopMupOeaHUJI
npocmou nemRU. Pa3MeUjellue
UllcmpYMeHma Haa HumblO
.. .. .::: :........
:V:' .-;--... .7;;.-
'H' .
{ ';....,..,. .; , .,
; /<:' ' '.' -""
..J " ,'I
'>< ::. :;'> ,.
.
Puc. 11.3 Cnoc06 1 rjJopMupoeaHWI
npocmou nemnu. MOMeHm HaMamb/eallUJI
lIumu eOKpY2 ullcmpYMeHma
95
rnaBa 11
-..j'
IG) '
l- ';;'0
,t } l/
" ./.1
,1'..
Puc. 11.4 Cnoc06 1 ,popMupoeallufi
npocmoii nel1lJlu. J(eoUlloii eumOK HUmu
60KPYZ UHcmpYMellma
_¥.:--...-.....
.. ,
:/ .L /. > :
. .' ' '.". .I ":
:'\.N' y . -'_... .
, l_>. --.
f' " '.2::-
; I .! -
( \
Puc. 11.5 Cnoc06 1 ,popMupoeUllufi
npocmou nem.nu. 3a60p IIwnu u npoeeae-
Ilue ee '1epe3 nem?1O
/ <
I \:
'J' . . \
1/ ' 0-
1. I . _-':7 ....
, - ,
..
"
naJIbueM JIeBOH KHCTH H, HaxoAAIl(HMCH B npaBOH PYKe, HH-
crpYMeHTOM.
C nOMOll.{blO HHCTpYMeHTa npOCTbIe neTJIH 1lJ0PMH-
PyIOT, ,neml5l O,D;lm 060POT HIITII BOKpyr IIHCTpYMeHTa, a CJIO:>K-
HbIe - ,nBa 060pOTa.
,lIJIH 3aBSl:3bIBaHHH BTOpOH neTJIH ,nJIIIHHbIH KOHeu
HIITH HaMaTblBaIOT Ha HHCTpYMeHT B HanpaBJIeHHII 3a qaco-
BOH CTpeJIKOH.
IIpli 1lJ0pMHpoBaHHH neTeJIb C nOMOll.{blO HHCTPY-
MeHTOB He06xOLIHMO C06JIlO,naTb HeKoTopbIe npaBIiJIa.
1. ECJIH npli 1lJ0pMHpoBaHllH nepBoH neTJIH HlITb 06-
MaTbIBaJIaCb BOKpyr HHcTpYMeHTa B HanpaBJIeHHH no qa-
COBOH CTpeJIKe, TO MH 06pa30BaHmI BTOpOH neTnlI Tpe6y-
eTCSI: 06MaTbIBamIe HHTH B 06paTHOM HanpaBJIeHlIH - npOTIIB
qaCOBOH CTpeJIKH.
2. IIpH 1lJ0pMHpoBaHliH nepBoH neTJIH MO:>KHO HC-
nonb30BaTb 6JIH:>KHIOlO H ,nallbHIOIO HIITH. IIplIqeM, npH HC-
nOJIb30BaHHH HHTH, pacnOJIO:>KeHHOH Ha 6nH:>KHeH nonOBH-
He onepaulIoHHoro nOJISI:, IIHCTpyMeHT nOMell.{aIOT nOBepx
ee. COOTBeTCTBeHHO Ha,nanbHeH nOJIOBI1He onepaUHOHHO-
ro nom He06xo,D;lIMO nOMeCTIITh IIHCTpYMeHT no,n HlITb. IIpH
1lJ0pMIIpoBaHHH BTOpOH neTJIHIICnOJIb3YIOT 06paTHoe npa-
BRITO: HIITb, Haxo,n}lll.{yIOC}llla 6nH:>KHeH nOJIOBHHe onepa-
UIIOHHoro nom, pacnonaraIOT Ha,n IIHCTpYMeHTOM, II Ha-
060pOT.
3. ECJIH MH 1lJ0pMlIpOBaHHSI: nepBoH neTnlI 3aXBa-
TbIBalOT PYKOH H 06MaTblBalOT BOKpyr IIHCTpYMeHTa 6nlI:>K-
HlOlO HIITb, TO II npli 1lJ0pMHpoBaHHII BTOpOH neTnH He06xo-
,nHMO 06MaTbIBaTb BOKpyr IIHCTpYMeHTa TY :>Ke caMYlO
6mDKHlOIO HIITb.
4. IIocJIe 3aTHrlIBaHliH neTJIH KOHUbl HlITH lIOn:>KHbI
pacnonaraTbc}l Ha npoTlIBOnOJIO:>KHbIX, no OTHOilieHIIlO K HC-
XO,nHbIM, CTOpOHax onepaUHoHHoro nonH.
CIIOCOE 2 (Mop03aM. A.)
I 3Tan - 4>uKCaQUH HUTen B UCXOLIHOM nOJIO-
iKeHUU. CB060,nHbIH KOHeu HIITH YlIep)l(lIBalOT IV II V nallb-
uaMH JIeBOH KHCTII. B TO :>Ke BpeMSI: I H II naJIbuaMH neBoH
KllCTII y,nep:>KHBaIOT nHHueT. B npaBoH PYKe HaXOlIlITCSI: Hr-
no,nep:>KaTeJIb C IlJIIKclipOBaImOH B lime HlITbIO (puc. 11. 7).
113Tan - nepeKpecT HUTen. IIpaBoii PYKOH npOIlIH-
BalOT TKaHH Ha ce6H, He BbIBO,n}l HrJIy nonHOCTblO Ha 6nH:>K-
HlOIO nOJIOBIiHY onepaUIIOHHoro nonH (puc. 11.8). KOHeu HrnbI 3aXBaTbIBaIOT nIiHueTOM, Haxo,nH-
Il(IIMCH B neBoH PYKe. IIpaBoH PYKOH no,nBoAAT IIHCTpYMeHT no,n H1ITb. 3aTeM BpaIl(aTeJIbHbIM ,nBH-
Puc. 11.6 Cnoc06 1 ,popMupoeUllUH
npocmou nem.nu. 3amfl<ueallue nem.nu
96
:>KeHlIeM O,nHOKpaTHO HaKpYqr{BalOT Ha HerO CB060L\HbIH
KOHeUHIITH (puc. 11.9).
III naIl - 3a6op HUTH H npoBe}1eHHe ee 'Iepe3
I1eTJIIO. EpaHlliaMH HHcTpYMeHTa 3aXBaTbIBalOT KOlleu
HrTIbI, nOCJIe qero JIeBOH PYKOH, 3aXBaTblBaH nliHueTOM
HHTb, «c6paCbIBaIOT» ee C HHCTpYMeHTa (puc. 11.10).
OKOHqaTeJIbHO npOIlIIiBalOT TKaHM II nOJIHOCTblO BbIBO-
,nsrT MrJIY qepe3 KOJIbUO CTe:>KKa Ha 6JIH)!(HlOlO nOJIOBHHY
onepauHoHHoro nOJI}!. IIMHueToM, HaXOJJ:jlll.\HMCH B JIe-
BOH PYKe, 3aXBaTblBalOT 6nlI)!(HlOlO HIITb, a IIrny y,naJIH-
lOT (puc. 11.11).
IV nan - c»HKcanHH npoBe,neHHoii 'Iepe3 neT-
JIIO HHTH. IIocJIe npOBe,neHHH qepe3 neTnlO, cB060,n-
HblH KOHeu 6JIII:>KHeH HIITH IlJIIKCHpylOT (puc. 11.12).
V :nall - 3aTIlrHBaIlHe I1eUIH. HIITH OTBO,nSl:T B npOTHBOnOJIO:>KHble CTOpOHbI no,n yrJIOM He
MeHee 180 0 . EJIH:>KHlOlO HHTb nepeMell.{alOT npaBoH PYKOH «OT Ce6H», a ,naJIbHlOlO HHTb - neBoH
PYKOH «Ha Ce6H». [JeTnIO 3aTHrlIBalOT II naJIbueM JIeBOH KHCTH H I rranbueM npaBoH KHCTH
(puc.11.13).
B 3aKJIlOqeHHe MbI MO:>KeM ,naTb HeCKonbKO peKOMeH,D;aUHH:
- HCnOJIb3YHTe TOJIbKO Te cnoc06bI BH3aHliH Y3JIOB, KOTOpbIMH OBna,neJIH B cOBepIlIeHCTBe;
- HHKor,na He CneilllITe npH 3aBH3blBaHHII Y3JIa. CKOpOCTb BH3aHlIH Y3JIa He ,nOJI:>KHa nplIHO-
CHTb Bpe,na KaqeCTBY :noro Y3JIa. CneilllI MeMeHHO!;
- npli MHHIIManbHbIX COMHeHIIH B HaL\e)!(HOCTII, TonbKO qTO 3aBH3aHHoro Y3na - TOTqaC:>Ke
peilllITeJIbHO y,nallHTe ero nOJIHOCTblO. He paCCqlITbIBaHTe Ha TO, qTO Y3eJI He pa3BH:>KeTCH. 3TO
y6epe:>KeT naUHeHTa H Bac OT 6eccoHHbiX HOqeH;
- nOCTOHHHO TpeHHpYHTeCb B 3aBH3blBaHIIII Y3JIOB. BallIH PYKH BbIpa60TalOT CTepeoTlin ,D;BH-
)!(eHIIH, H Y3TIbI BO BpeMSI: onepaUHII 6y,nyT B}!3aTbCSI: 6bICTpO, KaK 6bl caMlI no ce6e.
YcnexoB BaM!
:--.:\...
u: -. _." "\,.'. - ."'.
, \... --.
/ .... ',' - ..... \
I ' _ *,7- J.,._,. . \,' ""\ ...
C ..'" :' ;% <:0.::.- "' I .; \c ,'" , .!
.' . r -' .,,'..
:! . , -" '-"c':,..i
J/ / '. f
':':. l
Puc. 11.8 Cnoc06 2 tjJopMupoeaHuR
npocmou nemJ/u. t1JUKCQljllR KO/l'lUKa U2Rbi
Puc. 11.7 Cnoc06 2 tjJopMupOea/lUR
npocmou nem u. Hcxor)/Ioe nOllO;J/Cellue
i .-.
: : -:..""-- .., .."<-
--- . ......-
," '" .,, :"
' ,. .
A , -;;i)/ \,->;\
;7"/,'1 ,....,,,. I ' ";. - 1 ')
. -'<- .-- ".' . . ," ".,'
'" - . , - ,. ,,,,.'
/ ,.,- . fJ \. -=:;;;.-. '/
"""- . '- ---. i 'it';:""-
\ "/'\1; ... " ''':':'=..-
'\ '" / .
. /'
Puc. 11.9 Cnoc06 2 tjJopMupOea/lUR
npocmou nemJ/U. MOMeHm HaJlWlI1bleaHWl
/lUfflU eOKpY2 uncmpYMe/lma
97
rJIaBa 11
Puc. 11.10 Cnoc06 2 ,popMupoeaHufl
npocmou nemJIu. 3a60p Humu u
npOeeaeHUe ee 'lepe3 nemJIlO
/J:.:-{
-- \\-r lC \'1
...' "-.(! . }
: t .... .. '!'!-...*.: . , ... \ i
,- >!,.....1" ff;::...- . '\..-. . '.. J
' I ..:,... .'. .. .
'f . ..: .... Yl
. .. ....
\ ,: ....
\;;;-./3 *.
Puc. 11.12 Cnoc06 2 ,popMupoeaHWI
npocmou nemJIu. t!>UKCaljUfl Ce060aHOZO
KOHlJa 611u;J/cueu Ilumu
98
..
.. '.
<; ::;: ",, J .._---:- ;\.:.C
....... .'.. \ - ' . ..
.' '7 '('1 \.......: \: ..'-- '.
\ .. .' (>,.1 'w.... .. ';
, .' ; !!r .:' f'
\ ' . 1) " -, ." '. j .
, I ,w . .\.
. . 4' :)
PUC. 11.11 Cnoc06 2 ,popMupoeallufl
npocmou nemllU. tPuKcaljUfl numu, npoee-
aeHHOU 'lepe3 nemJIlO
/;,
(4' \'1
c ;
1 1 . f '
+ :,
.' .
ii. II
/;;3>7 . j ::S.
f' . " "-:;1 ..
;;f 1 '1 '" '" . J
.t""O>, J.J .
""''0 .
...
.
.
:
Puc. 11./3 Cnoc06 2 ,popMupoea/lufl
npocmou nemJIu. 3amflZUBtlHUe nel1lJlu
e':':" "'.1
_,,:; /..J },.It'
w..:: 0(
e
rrraBa 12 n
...., -
CPE3AIiME M3JJllIIIKOBIiM'EEM
Ii.
IIocJIe 3aBSl:3blBaHHH Y3JIa HacTynaeT 3aKJIlOqlITeJIbHbIH :nan 1lJ0pMHpoBaHHH IlIBa - Cpe3a-
mle 1I3JIIIIlIKOB HIiTeH. OT npaBHJIbHOCTH BbmOJIHeHHH nOH MaHHnYJIHUlI1I B 60JIbiliOH CTeneHH
3aBliCliT Ha,ne)f(HOCTb Y3JIa.
CB060,nHbIe OTpe3KII HHTII, H,D;yll.{He OT Y3JIa, Ha3bIBalOT «YCHKaMH» Y3JIa. OT ,nJIHHbl «YCH-
KOB» Y3JIa 3aBHCHT ero Ha.D:e:>KHOCTb. OnTHMaJIbHaH }UIIiHa OCTaBJIHeMbIX KOHUOB HHTeH onpe.D:eJIH-
eTCSI:, C O,nHOH CTOpOHbI, xapaKTepliCTIiKaMIi npHMeHHeMoro IlIOBHoro MaTepHaJIa, c,npyroH - pac-
nOJIO:>KeHlIeM Y3JIa (Ha KO:>Ke IIJIII BHYTPII TKaneH).
TOJICTbIe HIITH Tpe6YIOT ,nOCTaTOqHO }UIIIHHbIX «YCIIKOB» Y3JIa, nOCKOJIbKY 1I3BeCTHO: qeM TOJI-
lI.{e HHTb, TeM MeHee OHa rH6KaSl: H YCTOHqlIBaH B Y3JIe. IIpH Hcnonb30BaHIIII nOJIlIllJlIJIaMeHTHbIX
HHTeH (,nJIH OCTalOlI.{lIXCH B TKaHHX IlIBOB) peKOMeH,D;YlOT OCTaBJIHTb KOHqHKH ,nJIHHOH 3 MM. Kor,na
:>Ke <}JOpMIIpYlOT Y3eJI MOHollJRITaMeHTHbIMIi HIITHMII IIJIII HIITHMH C nOJIIiMepHbIM nOKpblTHeM, }UIIiHa
«YCIIKOB» ,nOJI:>KHa COCTaBJIHTb He MeHee 5-6 MM. CaMbIe KOpOTKlIe KOHUbl (1-2 MM) cJIe,nYeT OCTaB-
JIHTb npH IICnOJIb30BaHHII MeTanJIlIqeCKOH npOBOJIOKH.
ECJIH IlIOB DJIaHlipYlOT BnOCJIe,nCTBHH y,nanHTb, TO npHMepHa51 }UIIiHa OCTaBJIHeMbIX KOHUOB
HIiTeH ,nOJI:>KHa COCTaBJIHTb 1 CM. B 3TOM CJIyqae npoue,nypa CHSl:TIISI: IlIBOB 6y,neT KOMllJopTHee H
6e30naCHee. ,[{JIIIHHble «YCHKII» Y3JIa y,n06Hee IlJIIKclipoBaTb nHHueTOM, qTO npe,nynpe)l(,D;aeT paHe-
HHe TKaHeH IIHCTpYMeHTaMH.
IIpH cpe3aHIIII H3JIlilliKOB HIiTeH B03MO:>KHbI ,nBa BH,D;a OIlIH60K. Bo-nepBbIX, MO:>KHO OCTaB-
JIHTb CJIIIIlIKOM KopOTKHe KOHUbI HlITeH, qTO qpeBaTO pa3BH3bIBaHHeM Y3JIa B nOCJIeOnepaUIIOHHOM
neplIo,ne. BnOCJIe,nCTBHH 3TO MO:>KeT npHBeCTH K cepbe3HbIM nOCJIeOnepaUIIOHHblM OCJIO:>KHeHHHM:
rpbI)f(e (npli CIllIIBaHIiH anOHeBp03a), nepHTOHIiTy (npH HanO:>KeIIIIII :>KeJIy,nOqnO-KHllieqHbIX aHaCTO-
M030B), KpOBOTeqeHMlO (npH HaJIO)f(eHHII cocy,nHCToro IllBa) H ,np. BO-BTOpbIX, MO:>KHO OCTaBHTb
CJIHiliKOM ,nJIHHHble YCHKH Y3JIa. IIpH 3TOM H3JIHIlIeK IlIOBHoro MaTepliana B paHe YBeJIlIqlIBaeT
pliCK ee HarHOeHHSI:.
I1Hor,na, no HeBHlIMaTenbHOCTH, cpe3aH KOHUbI HIiTeH, xlIpypr MO:>KeT cpe3aTb H caM Y3eJI. B
3TOM CJIyqae IllOB TOTqaC)f(e pacnYCTHTCSI:, H conOCTaBJIHeMbIe TRaHH pa30H.D:YTCSI:. McnpaBIITb 3TY
OIlIII6KY MO:>KHO nOBTopHbIM 1lJ0pMHpoBaHHeM Y3JIa. ECJIH:>Ke ODJIOiliHOCTb OCTaHeTCH He3aMeqeH-
HOH, Tor,na B paHe OCTaHeTCH pa3pe3aHHbIH IlIOB co BceMIi BbITeKalOIUHMII nOCJIe,nCTBIIHMII.
Bo H36e:>KaHlie nepeqHCJIeHHbIX OlliH60K II ODJIOiliHOCTeH, He06xo,nIIMO C06JIlo,naTb HeCKonb-
KO npoCTblX npaBRIT.
Cpe3aTb HHTH He06xo,nHMO TOJIbKO HO:>KHlIuaMH. HIIKor,na He Hcnonb3YHTe ,nJIH 3TOH ueJIH
CKanbneJIb. Bo-nepBbIX, OH nplITynJIHeTC5I, a, BO-BTOpbIX, npli 3TOM B03paCTaeT BepOHTHOCTb paHe-
HII5I OKPY:>KaIOll.{IIX TKaHeH. HalI60JIee y,n06HO HCnOJIb30BaTb H30rnYTbIe TynoKOHeqHble HO:>KHIIUbI
Kynepa.l1x Ha,no ,nep:>KaTb TaK, qT06bI B rOpH30HTanbHOH nJIOCKOCTH 6paHlliH 6bmH HanpaBneHbl
H3rII60M BBepx (puc. 12.1), a B BepTIiKanbHoH - H3m60M BnpaBO (ecJIIi IIX y,nep)f(IIBalOT npaBoH py-
99
rnaBa 12
KOH), RITII BJIeBO (npH IlJHKcaUlili HHcTpYMeHTane-
BOH PYKOH). TaKoH cnoc06 y,nep:>KllBaHliH HHCTPY-
MeHTa HaH60JIee y,n06eH. OH ,naeT B03MO:>KHOCTb
BH,D;eTb MeCTO npeJJ:nOJIaraeMOro pa3pe3a HHTH.
ECJIII HO:>KHIIUbI ,nep:>KaTb no- ,npyroMY, TO npli cpe-
3aHHH B rny6IIHe paHbI KOHqHKH 6paHilieH MOryT
OKa3aTbCSI: BHe nOJIH 3peHIIH xHpypra. 3T0 MO:>KeT
npliBeCTII K He:>KenaTeJIbHOMY nOBpe)l(,D;eHIIlO npH-
neralOlI.{IIX K Y3ny TKaHeH.
IIepe,n cpe3aHHeM HHTb, Haxo,nHIUYlOCH
Me:>K.D:Y pe:>KYlliHMH KpOMKaMH iIO:>KHIIU, CJIerKa Ha-
THrHBaIOT. EpaHiliH pa3Mell.{alOT Ha,n Y3nOM, na-
paJIJIeJIbHO nOBepXHOCTH CIlIHBaeMbIX TKaHeH (puc. 12.2). 3aTeM IIX nOBOpaqHBalOT no qaCOBOH
cTpeJIKe Ha 45° (puc. 12.3). IIpH 3TOM o,nHa 6paHllia nepeMell.{aeTCSI: KBepxy. Enaro,napH nOBopoTY
HO:>KHHU HHTb nepepe3aeTcH Ha HeKoTopoM pacCToHHlIll OT Y3JIa, qTO n03BOJIHeT npe,noxpaHHTb ero
OT cpe3aHIiH. KpoMe Toro, npH pOTaUliH HO:>KHIIU xlIpypr nonyqaeT B03MO:>KHOCTb BH,D;eTb Y3eJI, o
TaK:>Ke npe,noTBpall.{aeT Henpe,nHaMepeHHoe ero cpe3aHHe.
II6cJIe cpe3aHHH H3JIHiliKOB HHTeH 1lJ0pMHpoBaHHe IlIBa 3aKOHqeHO.
"'''-
Puc. 12.1 YiJep;J/cueanue HO;J/CHUlj npu cpe3a-
HUU U3RUUlKoe Humeu
\
' " -:",\
Puc. 12.2 PaCnORO:JICeHUe 1I0;J/CHUlj Haa Y3ROM
npu cpe3aHuu U3RUUlKoe Humeu
100
Puc. 12.3 110Ro;J/ceHue 11O:JICHUIj npu cpe3aHuu
U3RUUlKoe Humeu
,
rJIaBa 13
5>})
<:;,
./.
3AHlMBAHliE P AH KQJKIl.
CHHTME UIBOB
. ;.4': ,
IIo npHqHHe nOBpe)l(,D;eHIISI: paHbl KO:>KII ,neJIHT Ha OnepallltOHlILIe (npe,nHaMepeHHble) H
CJIY'IaifHLIe.
CnY'IaiiHble paHLI (pe3aHble, py6JIeHble, YllIII6JIeHHble, YKYllIeHHble, orHeCTpenbHbIe If ,np.)
YllIIiBalOT TonbKO rrOCJ1e TIlIaTeJIbHOH rrepBHqHOH xHpyprlIqeCKOH 06pa60TKH. rnaBHbIMIi ee 3a):(a-
qaMIi jlBJISl:lOTCSI: OCTaHOBKa KpOBOTeqeHHjI, y,naneHlIe IIHOpO,nHbIX TeJI U HeKpOTII3HpOBaHbiX TKa-
HeH, BCKpblTHe ,nonOJIHlITeJIbHblX KapMaHOB, ,npeHlIpOBaHlie H HanO:>KeHlIe IlIBOB.
B 3a 3lICIiMOCTIi OT CpOKOB HanO:>KeHHH pa3JIHqalOT:
. - nep6U'l1lblU U106 - naKlla,D.bIBalOT B nepBble 5 qaCOB C MOMeHTa nOBpe:>K1IeHIIH;
. - 6mOpU t l.1lbiU U106-;--- nplIMeHHlOT B 60JIee rr03,D;HHe CpOKH (OT 4-6 He,neJIb,no HeCKonb-
KUXneT).
BTOpH'IHbIii IUOB - 3TO C06IIpaTeJIbHOe nOHHTlIe, 06'bel!IIHHlOIUee cOBoKynHoCTb Bcex OT-
CpOqeHHblX IlIBOB, KOTopbIe HaKlla,nblBalOTCSI: Ha paHbl B pa3JIIIqHbie CpOKIi rrOCJIe rrpolI3Be,neHHoH
XlIpyprlIqeCKOH 06pa60TKII. Bbl,L{eMlOT TaKlie BH.D:bI BTOPHqHblX IlIBOB:
II: - nepBmHo oTcpOqeHHbIH JUOB HaKJIa,nblBaIOT Ha paHY ,no nOHBJIeHIIH rpaHYAAUIiH
II rrpli OTCYTCTBHH KllIIHmeCKliX nplI3HaKOB IIHllJeKUlIoHHoro BocrraneHIIH. 06bIqHO TaKlie
IlIBbI HaKlla,nblBalOT no HCTeqeH1I1I 5-6 CYTOK rrOCJIe nOBpe)l(,D;eHIIH;
II - paHHHH BTOPHqHbIH IlIOB HaKlla,nblBalOT Ha rpaHYJIlIpYIOJUYlO paHY qepe3 8-15 CyTOK
nOCJIe paHeHIIH. KpaH paHbl 06bIqHO He IICCeKalOT;
... - n03,nHIIH BTOPlIqHbIH IlIOB IIcnonb3YlOT nOCJIe TOro, KaK npoII30H,nYT py6uoBbie
H3MeHeHIIH B paHe. Ero HaKJIa,nblBalOT Ha rpaHYJIlipylOlI.{YlO paHY, npe,nBaplITeJIbHO MO-
6RITH3IIpOBaB KpaH H y,nanUB py6UOBYIO TKaHb. 06bIqHblH CpOK HanO:>KeHUH JUBOB - 20-30-
e CYTKH.
BToplI ble JUBbiliCnOJIb3YlOT TOJIbKO npli OTcyTCTBlI1I B paHe OCTpbIX BOCnanlITeJIbHblX 1I3-
MeHeHIIH II HanlIqlIlI rpaHynHUlIoHHoro nOKpoBa. He CJIe,nYeT HaKlla,nblBaTb BTOplIqHbIe IlIBbI rrplI:
- BSl:JIblX rpaHYAAUHSI:X, nOKpbITbIX 1lJ1I6p1IH03Hb1M HaneTOM;
- He OTToprnyBlliHXCSI: HeKpoTlIqeCKHX TKaHSI:X;
- OreqHbIX KpaHX paHbl;
- HanlIqlIlI BOKpyr paHbl nlIo.n:epMlIIi.
101
rJIaBa 13
a
6
.... . J1». '7JJ1
i t{;;; 1f ; ¥ t
.-'-.B..--
Puc. 13.1 t1>opMupoeallue Ulea KO:J/CU: a -
npOeeaeHUe Humu noa aHOM paHbl; 6. e -
06pa30ea/lUe «MepmeOi!O» npocmpallcmea
npu llenpaeUJIb/lOM popMupoeaHuu Ulea
k - .':
.. . ,>
.. .
'" .:;.
';;S. X S'-
....'-:- :..
,
r t
i
'-.1../: ;'J if.
",,--'.'_'.. _ , { .L.
-. ... ->
- {I''''.; ,-, .. .': . <
\
-1 .. . .7",,",
..-),.::" )
l":"\;j'C' . ';:
.....-; i...
Puc. 13.2 CxeMa npOeeaeHUJ/ /lumu npu
popMupoealluu HenpepblellOi!O ellympeHlle-
zo aaanmupylOUjezo IUBa X oJlcmeaa
102
DplICTynaH K HaJIO:>KeHlIlO lIIBa, CHaqana KO:>KY CJ1e-
,nYeTTlI.{aTeJIbHO nOMblTb H rrpo,ne3IIHIlJUIJ.HpoBaTb. <1>OpMII-
pOBaHHe IlIBa He06xo.D:IIMO npOBOl!IITb OqeHb aKKypaTHo,
TaK KaK OT 3Toro 3aBHCliT KOCMeTlIqecKuH pe3YJIbTaT JIlO-
60H onepaUHII. 3TO BO MHorOM onpe,neJIHeT aBTopHTeT XII-
Pypra y 60JIbHblX.
1II0B, HaKlla,D;bIBaeMbIH Ha paHY KO:>KH, ,nOJI)!(eH 06ec-
neqHBaTb ConpHKoCHoBeHHe KpaeB, He 06pa3YH npli 3TOM
ocraTOqHOH nOJIOCTII «<MepTBoro npocrpaHCTBID» (puc. 13.1).
B 3TOH rrOJIOCTIi MO:>KeT CKanJIIiBaTbCH paHeBoe OT,neJIHe-
Moe, IIHHUIIHPYH BOCnallmeJIbHbIH rrpouecc.1136e:>KaTb 3TO-
ro MO:>KHO .npeHlIpOBaIIUeM OCTaTOqHOH rrOJIOCTH IIJIII 3aIIlH-
BaHlieM paHbl rrOCJIOHHO (HeCKOJIbKRMIi 3Ta:>KaMII).
DOCJIe,nHIIH crroc06 60JIee paUIiOHaneH.
ECJIH paHa HerJIy60KaH, TO MH 3allIliBaHliH onepa-
UIIOHHblX paH KO:>KH KaK MeTO,n BbI60pa MO:>KHO peKOMeH-
,nOBaTb BHYTPIIKO:>KHbIH KOCMeTHqeCKHH 1lI0B C rrpHMeHeHH-
eM paccaCblBalOlI.{lIXCH MaTeplianOB (noJIHcop6, 6HOCIIH,
MOHOKpRIT, BlIKpRIT H,np.).,[{JIH ero HaJIO:>KemUI nOHa,n06IIT-
CH TaK)!(e aTpaBMaTHqeCKaSl: IIrJIa C OCTpbIM pe:>KYlI{HM TpeX-
rpaHHblM KOHqHKOM. T eJIO TaKOH IIrJIbl,non:>KHO 6blTh H30r-
HYTblM no nOJIOrOH ,nyre C TpexrpaHHOH 06pall.{eHHOH
KHYTPH pe:>KYIUeH KpOMKOH. XOpOlliaSl: KoanTaUIiH KpaeB
paHbllI MlIHHMaJIbHOe HapyuIeHHe MlIKpOUIIPKYJIsrulI1I KO:>KII
06eCrre 1 1HBaIOT HalIJIyqllIliH KOCMeTHqeCKIiH pe3YJIbTaT.
IlloB XOJICTe,na - nenpepblBllblH BHYTpellHHH
a}J.anTHpYlOllI.HH mOB. 1II0BHaSl: HnTb rrpoxo,nIIT B nJIOCKO-
CTII, napanJIeJIbHOH nOBepXHOCTIi KO:>KII. D,JISI: 06JIerqeHIISI:
npOTSl:rnBaHliH HIITH nyqllIe nonb30BaTbCSI: MOHoqJlIJIaMeH-
THblMIi MaTeplianaMIi. MO:>KHO HCnOJIb30BaTb paccaCbIBa-
1OlI{lIecSI:(61I0CIIH,MOHOKpHJI,rrOJIIICOp6,,neKCOH,BHKPHJI)
R HepaCCaCbIBalOlI.{HeCH HIITH (MOHoIlJHJIaMeHTHbIH IIonlI-
aMlI,D; II nOJIlinpOnRITeH).
I1rJIY BKanblBalOT CO CTOpOHbl 3nlI,D;epMlIca, OTCTY-
nliB 1 CM OT yrJIa paHbl. BbIKanbIBalOT - B cpe,nIIHe CJIOSl:
,nepMbl (puc. 13.2). CB060,nHbIH KOHeu HIITII IlJIIKcnpYlOT
. MapJIeBblM llIapnKoM.l1rJIY nOCJIe,nOBaTeJIbHO BKanbIBaIOT
II BblKanblBalOT Ha O,nHOH CTopoHe pa3pe3a, npoBoM ee
TOJIbKO HHTpa):(epManbHo B roplI30HTallbHOH nJIOCKOCTIi.
IIocne 3TOro nepexo,n5lT Ha ,npyrylO CTOPOHY pa3pe3a II
TaKIiM :>Ke 06pa30M 1lJ0pMIIPYlOT CJIe,nYlOlI.{IIH CTe:>KOK. C
06eRx CTOpOH B llIOB 3aXBaTbIBalOT o,nIIHaKOBoe KOJIlIqe-
CTBO ,nepMbI. llIar llIBa ,nOJI:>KeH COOTBeTCTBOBaTb KplIBH3He
IIrJIbL He06xo,nIIMO CJIel!IITb, qT06bl MeCTO YKOJIa HrJIbl Ha
O,D;HOM KpalO COBna):(ano C MeCTOM ee BblKanblBaHIISI: Ha
,npyroM. B HTOre, npH HaTHrlIBaHIiH HHTII (C6nH:>KeHIIH KpaeB
paHbl) 3TH ,nBe TOqKII ,nOJI:>KHbI COnpIiKaCaTbCSI:.
B KOHue lliBa HrJIY BbIKanblBalOT Ha KO:>Ke, OTCTynlIB OT
YrJIa paHbI 1 CM (puc. 13.3). HIITb 3aBH3bIBaIOT Ha MapJIeBOM
IlIapliKe.
IIpH Hcnonb30BaHliH nOJIlIllJRITaMeHTHbIX HepaccacblBa-
IOlI.{HXCSI: MaTepHanOB HJIII npH CIlIHBamm KpaeB MIIHHblX paH
nOCJIe Ka)l(,D;bIX 6-8 CM IlIBa He06xo,D;IIMO c,neJIaTb BblKOJI Ha
nOBepxHoCTb KO)!(H II 3allJHKcHpoBaTb HIITb Y3JIOM IIJIII Mapne-
BblM lliapliKoM (puc. 13.4).
1lI0B XoncTe a-30nTaHa - BYXpH,ZJ;HblU HenpepblBHblu
C"beMllbiU 11I0B. Ero peKoMeH,nYlOT npHMeHHTb npli BbIpa:>KeH-
HOH nO KO:>KHOH :>KlfpoBOH KllerqaTKe. IIepBblH psw. (3Ta:>K) lliBa
HaKJIa,D.blBaIOT nplI6JIII3IITeJIbHO nOCpe.D:IIHe no.ru<O:>KHOH OCHO-
Bbl, BTOpOH - BHYTPIIKO:>KHO. IIpli 3TOM paUIiOHaJIbHO IICnOnb30-
BaTb aTpaBMaTnqecKYlO IIrJIY C MOHollJRITaMeHTHoH HHTblO.
IlepBblH YKOJI nrJIbl npolI3BoMT B6nlI31I KOHua paHbI Ha
paCCTOSl:HlI1I 2 CM OT O,nHOro II3 KpaeB (puc. 13.5). BbIKaJIbIBa-
lOT Hmy nOCpe,D;IIHe TonruHHbl no.ru<O:>KHOH OCHOBbI. 3aTeM HrJIy
BKaJIbIBalOT II BbIKanbIBaIOT no O,nHOMY KpalO paHbl, npoBoM
ee TOJIbKO nocpe,nHHe TOJIlI.{lIHbI no.ru<O:>KHOH OCHOBbI B roplI-
30HTallbHOH nnOCKOCTIi. AHaJIOmqHO npOlI3BOLLHT CJIe.nyIOIUIiH
cre:>KOK Ha ,npyroM KpalO paHbI. T OqKH YKOJIa IIrJIbl Ha O,nHOH
CTopOHe pa3pe3a ,non:>KHbl 6blTb pacnOJIO:>KeHbI TOqHO Hanpo-
THB TOqeK ee BbIKaJIbIBaHliH Ha npOTIiBOnOJIO:>KHOH CTopOHe. C
06elIx CTOpOH B Ka)!(,nbIH CTe:>KOK HY)!(HO CTapaTbCH 3axBaTbI-
BaTb o,nHHaKOBoe KOnlIqeCTBO TKaHeH. .
3aKOHqHB 1lJ0pMIIpOBaHlie rny60Koro pMa llIBa, HHTb
BblBOMT Ha nOBepXHOCTb KO:>KH. 06a KOHua HIITH HaTHrHBaIOT,
C6nlI:>KaH, TaKIiM 06pa30M, KpaH pa3pe3a. ,[{O 3aBepllieHIIH
HanO:>KeHIIH nOBepXHOCTHOrO IlIBa HHTII y,nep:>KIIBalOT HaTSl:HY-
ThIMII.
,[{JIH 1lJ0pMHpoBaHHH BToporo psw.a llIBOB KOHqlIK IIrJIbl
BbIBOMT B CJIOH c06CTBeHHO ,nepMbl. IIpoBo,nH IIrJIy IIHTpa,nep-
MaJIbHO, npo,nOJI)l(aIOT llillTb TaK, qT06bl TOqKH YKOJIa II BbIKaJIbl-
BaHIISI: Hrnbl Bcer,na pacnOJIaranliCb CHMMeTpHqHO OTHOCIITeJIb-
HO JIHHHII pa3pe3a. B CTe:>KOK He06xo,nHMO 3aXBaTblBaTb
O,nIIHaKOBOe KOJIlIqeCTBO ,nepMbI.
,[{OCTlirHYB npOTHBOnOJIO:>KHoro KpaH paHbl, HIITb BbIKa-
nbIBalOT y MeCTa nepBoro YKOJIa. 3aTSl:rHBaSl: 06e HIITII, paHY
3aKpblBalOT.
HeCKonbKO COBeTOB no HaJIO:>KeHHIO Ha KO:>KY npOCToro
Y3JJOBOro I1IBa. KO:>Ka JIerqe Bcero npOKanblBaeTCH pe:>KyrueH
HrJIOH, nplIqeM CqIITaeTCH, 'ITO JIyqllie IICnOnb30BaTb IIrJIY
<<reverse cutting». IIpli IICnOnb30BaHHII TaKOH IIrnbl npOKon
.:Ii!:
Puc. /3.3 3aeepUieHue pOpMUpO-
eallu» HenpepbleHOi!O eHympeltHei!O
aaanmUPYIOUJei!O Ulea X OllCmeaa
Puc. 13.4 CxeMa npOeeaeHUR
Humu npu popMupoeaHuu
npepbleUCmOi!O eltympeltHezo
aaanmuPYloUJei!O Ulea XOllCmeaa
,/.
, _ _ 1... :
, '. '. .
'- - .. :
t.....:: . :
. ".-=--- :,,(.1' '\J < ,
" -..., - . "",.,.:....,
{_ :I 4-'- }). /, ..
."...... .- - ...
. . ,.cr. , .. 1 .;,'/'
.... d-
" J
Puc. 13.5 CxeMa npOeeaeHUR
Humu npu popMUpOnaltuu
aeyxp»allOi!O lIenpepble/IOi!O
C"beMltOi!O Ulea XOllcmeda-3011malla
103
rnaBa 13
..- - --- ,_.
npe,ACTaBJISl:eT C060H TpeyronbHIIK, OCHOBaHlie KOToporo 06-
pall.{eHO K paHe. TaKajj 1lJ0pMa npOKOJIa JIyqllIe y,nep:>KHBaeT
HlITb. KO>Ka MeHbllIe npOpe3aeTCSI:.
I1rny BKaJIbIBaIOT co CTOpOHbI :mn,.a.epMHca, OTcrynlIB 5-
8 MM OT Kpajj paHbl. 3aTeM, B no,nKO:>KHOH OCHOBe ee HanpaB-
mlOT KOCO, B rny6b, HeMHoro OT,naJIjljjCb OT KpaH pa3pe3a. HIITb
npOBO,WIT no,n,D;HOM II BbIKallbIBalOT Ha npOTIIBOnOJIO:>KHOH CTO-
pOHe (puc. 13.6).
IIpli 1lJ0pMIIpoBaHliH Y3JIa npaBHJIbHO npoBe,neuHoH
HIiTblO 1I36blTOK TKaHII, 3axBaqeHHOH y OCHOBaHIiH paHbl, Bbl-
TeCHHeT BbIllieJIe:>KaIUI1e CJIOH, TeM caMblM npenSlTCTBYSl: IIX BBO-
paIJUBallluo. WOB 06eCneIJIIBaeT conpliKOCHOBeHlIe O,nHOpO,n-
HblX TKaHeH. B npOTIIBHOM crryqae, ecrrH npOBeCTIi HIITb KOCO K
cpeWIHHOH JIlIHHII paHbl, 3aXBaTblBaH B lliOB 60nblliee KOJIlIqe-
CTBO TKaHeH 1I3 nOBepXHOCTHbIX CJIOeB, npOIICXO,D;IIT BBOpaqlI-
BaHHe KpaeB (puc. 13.7). qT06bI 3TOro He npOH30mno, He06-
XO,D;IIMO nplf,lJ.ep:>KHBaTbCSI: npliHUlma: «qeM rJIy6:>Ke Haxo,nIITCSI:
npoIlIIiBaeMbIH CJIOH, TeM «MaCCHBHee» lJ,OJI:>KeH 6blTb 3aXBaT».
P 13 6 C .> Kor,na nplIxo,nIITCSI: IIMeTb ,neJIO C 3allIliBaHlieM OqeHb
uc. . xeMa npoeeueHUJ/ HumU .
n A. Z rny60Klix paH, r,ne O,D;HIIM CTe:>KKOM 3axBaTIITb ee,D;HO HeB03MO:>K-
pu ,/-,OpMUpOtialLUU npocmo 0
Y3J/oeozo Ulea: a _ 00 3aeJ/3blealluJ/ HO , npliMeHSl:lOT 8-o6pa3HblH mOB CnaCOl YKOllKoro (puc. 13.8).
Y3J/a; 6 - nOCJle 3aeJ/3blealLUJ/ Y3Jla YKon IIrJIbI ,neJIalOT co CTOpOHbl 3nlf,lJ.epMHCa C60KY OT paHbl, a
BblKanbIBalOT nocpe,nIIHe TOJIIUHHbl no,nKO:>KHOH OCHOBbI Ha TOH
:>Ke CTopoHe. 3aTeM HIITb npoBO,D;HT OT Cpe,nIIHbl nO,D;KO:>KHOH OCHO-
Bbl npoTIiBOnOJIO:>KHOrO KpaSl:, no,n ,nHOM. BblKanbIBalOT IIrJIY Ha
KO:>Ke cHMMeTpliGHO MeCTa ee nepBoro YKOJIa.
Y3JIOBbie lliBbl HaKlla,nbIBalOT Ha paCCTOHHlI1I 1-2 CM ,npyr
OT ,npyra. YKOJIbI II BblKOJIbl Hrnbl,non:>KHbI pacnonaraTbCSI: Ha o,n-
HOH JIIIHHII, cTporo nepneH,D;HKynHpHo K JIIIHHII pa3pe3a, Ha pac-
CTOHHHII 0,5-1 CM OT ero KpaH. EOJIee qaCTble CTe:>KKII npHBO,D;HT K
HapYIlIeHI1lO KpoBOCHa6)l(eHIISI: B 30He llIBa, a 60JIee pe,nKHMII
CTe:>KKaMH TPy,D;HO TOqHO COnOCTaBIITb KpaSi paHbl.
Y3eJI 3aTHmBalOT ,no conpliKocHOBeHIISI: KpaeB paHbI. 113-
................... JII1lliHee YCHJIHe npli 3aTSl:rnBaHIIII nepBOH neTJIIi Y3JIa npHBOlJ,HT
"("I,"'
K HapYllieHlIlO TpOllJlIKII KO:>KII II 06pa30BaHHlO ypO,D;JIIiBbIX none-
peqHblX nonoc, pacnOJIaralOlI.{lIXCSI no BeeH MIiHe onepaunOHHO-
ro py6ua.
.: . Y3JIbl HY:>KHO 3aBH3bIBaTb TaK, 06b[ OHII Haxo,nRITIiCb c60-
. m
KY OT paHbI, a He Ha,n HeH. )J,JISI: KaqeCTBeHHoro conOCTaBJIeHIISI:
O,nHOpO,nHbIX TKaHeH, BO BpeMH 3aBSl:3bIBaHIiH yJnOB ,nBYMSI: XH-
Puc. 13.7 CxeMCl npOeeaelll/J/ pyprlIqeCKHMH nliHueTaMIi conOCTaBJISIlOT KpaSl: pa3pe3a
Humu npu llenpaeUJlbllOM pOpMU- ( 13 9) B
puc. . . TaKOM nOnO:>KeHIIH IIX y,nep)l(lIBalOT ,no 3aTHrIfBaIlIIH
poeallUU npocmozo Y3JlOeOZO Ulea: C 6
.> 6 nepBoli neTnlI. OnOCTaBJIeHlIe ,nOJI:>KHO npolI3Bo,nIITbCSI: e3 Ha-
a - uO 3aeJ/3bleallUJ/ Y3Jla; -
TSI:)l(eHIIH. IIpn HaCIIJIbCTBeHHOM C6JIH)l(eHIIII KpaeB pa3pe3a co
noclIe 3aeJ/3bleaHUJ/ Y3l1a
npoucxodum eeopa'lUeaHUe «paee BpeMeHeM MO:>KeT npolI30HTli npope3bIBaHHe lliBOB. Oc06eHHo
/
104
_.._--.......-......_._-
_..__.._... 0
-- .... - -
..._,_..._. -
. .................
Puc. 13.8 CxeMa npOeeaeHUJI Humu npu
popMupoeaHuu 8-06pmIl0i!0 Ulea
CnacoKYKo,,!KOlO
3TO KaCaeTCj{ CJIy'meB coe,nIIHeHIIj{ KpaeB paHbl C Heo-
,nIIHaKoBOH TOJIIUIlHOH. 1136e:>KaTb YKa3aHHOrO HeraTHB-
HOro HBneHWI MO:>KHO rryreM nOCJIOHHOrO 3alllHBaHlIj{, HC-
nOJIb3YH Y3JIOBbie a,narrTHpYlOlUlie lllBbI.
llloB MaK-lVbtJlJIalIa-,[{oHaTH - BepTUK3.JThHblii II-
06pa3I1b1" Y3JIOBoii 3JJ.anTHpYlOlQU" mOB. Ero npHMe-
HeHlIe HCKmOqaeT 06pa30BaHlie «MepTBoro npocTpaH-
CTBa» B6JIII3H ,nHa paHbl.
IIepBblH YKOJI IImbI npOlI3BO,D;Sl:T Ha pacCToHHlI1I 2
CM II 60JIee OT KPaH paHbl (puc. 13.10). Mmy npOBo,nHT
KOCO KHapY:>K1I II KaK MO:>KHO rJIy6:>Ke .D:JIH 3aXBaTa ,nHa
paHbl. ,[{oCTlirHYB ypOBHSI: OCHOBaHHSI: paHbl, limy nOBO-
paqHBalOT B HanpaBJIeHlI1I K Cpe IIIIHOH JIIIHIIII paHbllI
BblKanblBalOT B caMoll rJIy60KoH ee TOqKe. Ha rrpoTIIBo-
nOJIO:>KHOH CTopOHe HIITb npOBO,D;Sl:T CHMMeTpmHO. Mec-
Ta YKoJIa II BblKanblBaHIISI: IIrJIbl Ha KO:>Ke ,nomKHbl pacno-
JIaraTbCSI: Ha O lmaKOBOM pacCToHHlI1I OT KpaeB pa3pe3a.
3aTeM, Ha CTopOHe BbIKanbIBaHHj{, rro Xo,ny CTe:>KKaoB He-
CKOJIbKlIX MIIJIJIIiMeTpax OT KpaH paHbI HrJIY BHOBb BKa-
JIblBalOT II BbIBO,D;Sl:T B TOJIlI.{e ,nepMbl. Ha npoTHBOnOJIO:>K-
HOH cTopoHe (cTopoHe rrepBoro YKona) limy TaKHM :>Ke
06pa30M rrpOBO,D;Sl:T B 06paTHoM narrpaBJIeHHH. HIITH Ha-
THrIIBalOT II pa3BO,D;Sl:T B CropOHbl. IIpli 3TOM O,nHopO.D:Hble
TKaHH COnOCTaBJIHlOTCH. Y3eJI pacnonaralOT 6JIII)!(e K TOq-
Ke nepBoro YKOJIa.
3aBH3bIBaTb HIITH npli 3allllIBaHlIli rny60KoH paHbI
CJIe,nYeT nOCJIe HanO:>KeHIIH Bcex lllBOB - 3TO 06JIerqaeT
i I I
; ,
I ' " :'
/ ..'
"I .-
l/ ./
" /
,\\ .. ':' /
.;t / /'
<#(/'J. : . " . fe " /;;# ,
7 -"::::, . '\ . ?; ." ' . "' . .'
j , r ,,," >U
.""'.:' .. ., ...,.
........{>:.. .
. . -.. '\.-"
" .r J . .)'lA : 1 ." 'tJ .. .
__ .......¥' f .. _0 _ t
- "- -.
Puc. 13.9 ConocmaeJlellue
Kpaee pallbl KO;HCU
c
d
m _ _. _' _.____ . ______.__.____....._,_
.. ----- -_.>. <'¥.., -
a
a=b
c=d
6
Puc. 13.10 CxeMa npoeeaelluJ/ Humu npu
pop,'>/upoealluu eepmUKlUlbllOi!O 11-
06pa31l0i!0 Y3JlOeOi!0 aaanmupytoUJei!O Ulea
MaK-MuJlnaHa-poHamu: a - 00 3aeJ/3blea-
HUR Y3Jla; 6 - nocne 3aeR3bleallUR Y3Jla
105
rJIaBa 13
MaHlInynHUlI1I B rJIy6IIHe paHbl. IIpliMeHeHlIe lIIBa MaK-MIIJIJIaHa-,[{OHaTIi n03BOnHeT COnOCTaB-
nSl:Tb KpaSl: paHbI ,na:>Ke npli IIX 60JIblllOM l!lIaCTa3e.
.D:JIH nOBblilieHIISI: 3CTeTIIqeCKliX Ka<IeCTB lliBa lUror,na HHTb npOBOMT HHTpa,nepManbHO 6e3
BblKOJIa Ha nOBepXHOCTb KO)!(H C O,nHOH CTOpOHbl (mOB A.rIbmBepa) (puc. 13.11).
rIpli 60JIblllOH my6HHe paHbI paUlioHanbHo IICnOJIb30BaTb BepTHKaJIbHblU fi-06pa3HblH
Y3JIOBOU a,nanTupYIOLQUU MHomCTe KOBOU mOB CTPY'lKOBa. B OTJIlIqlIe OT lllBa MaK-MIIJIJIaHa-
,[{OHaTIi OH npe,nYCMaTpliBaeT npOlliliBaHlie KpaH pa3pe3a HeCKOJIbKIIMH CTe:>KKaMIi (puc. 13.12).
WOB ,lJ:)l(UJIJIHCa - Y3JIOBOU a,nanTHpYIOLQHU mOB. IIepBbIH YKOJI npOII3Bo,nSl:T y KpaSl: 3nlI-
,nepMlIca. HlITb npoBOMT no,n,nHOM paHbI, IlIlipOKO 3aXBaTblBaH ,nepMY II no,nKO)!(HYlO OCHOBY. Bbl-
KanblBalOT IIrJIY Ha npOTIiBOnOJIO:>KHOH CTopOHe IIHTpa):(epManbHO (pUC. 13.13). IIOWITHO, O B
MeCTax pacnOnO:>KeHIIH Y3JIOB ,n06IITbCSI: nJIOTHOrO conpIiKOCHOBeHIISI: 3nlI,D;epMHCa HeB03MO)!(HO,
qTO OrpaHlIqHBaeT npliMeHeHlIe ,naHHoro IlIBa.
KpOMe «BepTHKanbHOrO» CYll.{eCTBYIOT BaplIaHTbI «ropII30HTanbHOrO» lllBa MaK - MIIJIJIaHa-
,[{OHaTU. K npuMepy, BHYTPUKO HbIU mpH30HTaJIbHbiU II-06pa3Hblu Y3JIOBOU a.LI.anTHpYIOLQHU
mOB. Ero BbIllOJIHHlOT npH He60nbIlIlix nOBepxHoCTHbIX paHax aTpaBMaTlIqeCKOH IIrJIOH C TOHKOH
(3/0 - 510) HIiTblO.
IIepBblH YKOJI npolI3BoMT, oTCTynlIB 0,5 CM OT KpaH paHbl (puc. 13.14). BblKanblBalOT limy
B cepe,nIIHe ,nepMbl. Ha npoTIiBOnOJIO:>KHOM KpalO pa3pe3a limy npoBo,n T B 06paTHoM HanpaBJIe-
HIIII, BKanblBaH IIHTpa,nepManbHo, a BblKallblBaH Ha paCCToHH1I1I 0,5 CM OT KpaH paHbI. CJIe,nyIOIUHH
YKOJI npOII3Bo,nHT Ha TOH :>Ke CTopOHe, Ha paCCTOHHlI1I 4-6 MM OT MeCTa BblBo,na HIITII no xo.ny paHbl.
CJIe,nYlOlI.{IIH CTe:>KOK ,neJIalOT B 06paTHoM HanpaBJIeHHII.
,[{JISI: coe,nHHeHIISI: KpaeB KO:>KHOH paHbI C ycnexoM MO:>KHO npHMeHHTb cKo6KH MumeJISI,
Koropble 1I3rOTOBMlOTCSI: 1I3IIHepTHOrO MaTepnana. 3TH CK06KII 06eCne<IUBaIOT XOpOllilIH KOCMeTlI-
qeCKIiH pe3YJIbTaT, cpaBHIIMbIH C KOCMeTlIqeCKHM lliBOM. OHII npe,nCTaBJIHlOT C060H nJIaCTIIHKY,
cB060,nHble KOHUbl KOTOpOH 3aBepHyTbi B neTJIlO. PacnOJIO:>KeHHble no KpaHM CK060K 3y6<IIIKII ner-
KO npOKanbIBaIOT KO:>KY (pUc. 13.15).
CK06Ka YCTpoeHa TaKIiM 06pa30M, qTO npli HanO:>KeHHII ee cnlIHKa Haxo,nHTCH pa):( paHoH. B
nOCTonepaUHoHHoM neplIo,ne, KaK npaBRITo, 06'beM TKaHII, Coe,D;IIHeHHoH cK06KOH, YBeJIlIqIIBaeTCH.
Ho, B OTJIlIqne OT HIITH, cnlIHKa CK06KH He ,naBIiT Ha TKaHb II He Bb13blBaeT ee IIllieMHlO.
Puc. /3.11 CxeMa npOeeaeHUR
Humu npu popMupoeaHuu eepmu-
KaJlbHOZO 11-06pa3Hozo Y3J10eOZO
aaanmUPYIOUleZO Ulea AJlbZOeepa
106
Puc. 13.12 CxeMa npOeeaellUf/ Humu
npu popMUpOealluu eepmUKWlb1l0Z0
11-06pa3Hozo Y3J10eOZO aaanmUPYIOUle-
zo MHOZOCme:JICKOeoZO Ulea CmpY'IKOea
Puc. 13.13 CxeMa npOeeaeHUf/
Ilumu npu popMUpOealluu
eepmUKWlbHOZO Y3J10eOZO
aaanmUPYIOUleZO Ulea j{:JICuJlJ/uca
\J b JZ - -;.-
\ L. /,_ ....
..... . a . , /. 1-:/
.. ;;.-:-;.,. . , - , .- . ': ../-
t -: -- - :l ;'
f
. " a=b c;d
Puc. 13.14 CxeMll npOeeaeHUJ/ llU1llU npu
qJOpMupoealluu e1/ympUKO:J/CIIOi'O
i'OpU30/l/JUlJlbJIOi'0 11-06pa3Hoi'0 Y3J10eOi'0
aaanmUPYJOUJei'O Ulea
(" - - >,
: ; !
f : /y.).)
If:...,,- t, ) t .. - 'H
....,).. ,.. .
£ V ' -"
r;:::=':.: .4
7'I '
.,.r' :-:
(-:;::-'....;7 .;u
? .-
Puc. 13.15 CK060'lllbZU Uloe
,[{JISI: HanO:>KeHIISI: CK060K MlillieJIH, Kpajj paHbl npe,nBaplITeJIbHO C6nH:>KalOT C nOMOlUblO XII-
pyprnqeCKoro nliHUeTa. CK06KY IlJIIKCIiPYlOT crreUHanbHblM nliHUeTOM II pa3MeIl.{alOT nonepe o K
JIIIHlllI pa3pe3a. Crn6aSl: CK06KI1, IlJIIKClipyroT KpaH paH!>!.
CH TME IlIBOB KOJIGI
IIIBbI, pacnOJIO:>KeHHbIe Ha KO:>Ke CHHMalOT Ha 6-9-e CYTKII nOCJIe IIX HaJIO:>KeHIIH. O.D:HaKO 3TII
CpOKH MorYT BapbUpOBaTb B 3aBliCHMOCTli OT JIOKaJIII3aUHH II oc06eHHOCTeH 3mKIIBJIeHWI paHb!. B
MeCTax C XOpOlliliM KpOB006paIl.{eHUeM (Ha rOJIOBe, lllee) HeT Ha,n06HOCTH Bbl,L{ep:>KIIBaTb YKa3aH-
HblH CpOK. B 3TIIX 06JIaCTHX py6eu 06pa3YeTCSI: paHbllle - Ha 4-5-e CYTKII. B MeCTax C llJIOXliM KpOBO-
06paIlIeHHeM (Ha rOJIeHII, CTone) lllBbl CHIiMalOT n03:>Ke - 9-12-e CYTKII. KpOMe 06'beMa KpOBOCHa6-
:>KeHHSI:, npO,D;JIeHlIe CpOKOB IlJYHKUIiOHlipOBaHIISI: lllBOB orrpe,nenSl:eTCH TaK:>Ke 3HaqlITeJIbHbiM
HaTH:>KeHlIeM coe,nIIHSl:eMblX KpaeB paHbI H nOHH:>KeHHOH pereHepaUHeH TKaHeH.
ECJIII HMelOT ,neJIo C paHaMIi CJIO:>KHOH 1lJ0pMbI, HaqHHalOT y,nanHTb IlIBbI C BepllllIHbl JIOCKY-
TOB. OCTanbHble CHliMalOT qepe3 O,nUH, OTKlla,D.blBaH y,naneHlIe OC-
TanbHblX IlIBOB,nO nOJIHOrO 3a:>KHBJIeHHH paHb!.
TeXHHKa CHHTHH Y3JIOBbIX K03\HbIX IUBOB. JIHHHlO IlIBOB
npe.D:BaplITeJIbHO 06pa6aTblBalOT paCTBopOM aHTlIeemliKa (uarrplI-
Mep, crrllpTOBblM paCTBopOM Ho,na). IIocJIe TIoro Y3eJI IlJIIKCIiPYlOT
nliHUeTOM II OCTOpO:>KHO nplIno,nHIIMalOT ,no Tex nop, nOKa Ha,n KO-
:>Ken He nOHBIITCSI: qaCTb HIITII, Haxo,nIIBllia$lCH B TOJJII.{e ,nepMbI H
no,nKO:>KHOH KlleTqaTKe (pUc. 13.16). Ee JIerKO onpe,neJIIiTh rro OK-
pacKe. U,BeT CKpbITOH B TOJIII.{e TKaHeH HHTH OTJIlIqaeTCSI: OT UBeTa
HapY)I(HOH qaCTII, KOTOpajj B nocJIeorrepaI.{IIOHHOM nepHo,ne rro,ll,L{a-
eTCSI: oKpacKe aHTIIcenUI'leCKliMIi paCTBopaMH. BHyTpeHHlOlO qaCTb
HIITH Y nOBepXHOCTIi KO:>KII nepeceKalOT KOHqUKOM OCTpOKOHeqHbIX
HO:>KHIIU. HIITb, y,nep:>KHBa513a Y3eJI, H3BJIeKalOT. ,[{JISI: TIoro ee BbI-
THrlIBalOT BBepx B HanpaBJIeHlI1I JIIIHIIII lIlBa. 113BJIeKaT!> HHTb B Puc. 13.16 CIlJ/mue
npoTIiBOnOnO:>KHOM HarrpaBJIeHlI1i (B CTOPOHY OT py6ua) npocmoi'o Y3J10tlOi'0 Ulea
107
rJIaBa 13
HeJIb3H. 3TO MO:>KeT npliBeCTIi K paCXO)l(,D;eHHlO COnOCTaBJIeH-
HbIX, HO HenpOqHO CpOCIlIIIXCSI: KpaeB paHbI. JJ.nH MaKCIiManb-
HOH IIMM06RITH3aUHII KO:>KY BOKpyr HIITII MO:>KHO npII.D:ep:>KH-
BaTb pa3Be,neHHblMIi KOHqlIKaMIi 6paHlli HO:>KHHU.
He06xo.D:IIMO rrOJIllepKHYTb, O npli BbITHrHBaHlIIi HHTIl
ee qaCTb, HaXO,nHBlliaHCH CHapY)l(lI, He ,non:>KHa npOXOLlHTb qe-
pe3 rny60KHe TKaHH (paHeBOH KaHan).
IIocJIe CHHTHSI: lliBOB paHY 06pa6aTblBaIbT aHTlicerrTII-
KOM H nOKpbIBalOT CTepRITbHOH rrOBH3KOll.
TeXHHKa CHHTHH Y3JIOBbIX a,D.anTHpYIOIllHX mDOD MaK-
MHJIJIaHa-)J.OHaTH. IIocJIe 06pa60TKII paHbl Ha npOTHBono-
JIO:>KHOH OT pa3Mell.{eHII5l Y3JIOB CTopOHe IlJHKCIiPYlOT rrlIHue-
TOM TY qaCTb HIITII, KOTOpM Haxo,nIIJIaCb Ha,D. nOBepXHOCTblO
KO)l(lI (puc. /3./7). <1>IIKCHpyeMyIO HIiTh nplITIO,D;HlIMalOT ,no TeX
nop, nOKa He rrOKa)l(YTCH qaCTII, Haxo,nHBllilieCH B Tomue TKa-
HII. I1x nepeceKalOT HO:>KHHuaMIi. 3aTeM, 3aXBaTliB 3a Y3eJI,
HHTb 1I3BJIeKaIOT B HanpaBJIeHHII JIIIIlHII IlIBa.
TeXHHKa CHHTHH HenpepblBHom mDa XOJICTe}J.a. IIocJIe KllaCClIqeCKOH 06pa60TKl! paHbI,
nliHUeTOM no,nTSl:rHBalOT O,nIIH 1I3 KOHUOB HIITII ,no nOSl:BJIeHIIH Ha,n KO:>KeH BHYTpeHHeH ee qaCTIi
(puc./3./8). Ee rrepeceKalOT HO:>KHlIuaMIi. 3aXBaTliB nliHUeTOM ,npyroH KOHeu HIITII, OCTOpO:>KHO,
1I36eraH pbIBKOB, 1I3BJIeKalOT BCIO HHTb. IIpli 3TOM Ha,no CTpeMIITbC51, 'U06bI BeKTOp CRITbI HaTSI::>Ke-
HIISI: y,nanSl:eMOH HIITII CORnMan C OCblO orrepaUHOHHoro lliBa. B 3T0 BpeM5l 3a:>KaTb1M B ,npyroH pYKe
MapJIeBl:'IM lliapHKOM KO:>KY IlJIIKCHpyroT IIJIII ,na:>Ke CJIa60 OTTHrlIBalOT B npOTHBOnOnO:>KHOM HanpaB-
JIeHIIII.
IIoxo:>Ke npOII3Bo,nHT y,naneHHe ,nBYXPMHOro HenpepblBHoro lliBa XonCTe,na-30maHa
(puc. /3./9). IIpe,nBaplITeJIbHO y O,nHOro H3 KOHUOB lliBa 06pe3aIOT 06e HIITH.
TeXHHKa CHHTHH cKo6oK. ,[{JISI: CHSl:TIIH cK060K MlillierrSl: nOHa,n06HTCSI: CneUHaJIbHbrn 3a-
:>KHM RITH ,nBa nliHUeTa (3a:>KHMa Koxepa). IIpoue,nypa 1I3BJIeqeHIIH cK060K npOCTa. JJ.nH 3TOro
KPlOqKII C 06elIx CTOpOH IlJIIKCHPYlOT nliHueTOM HJIII 3a:>KIIMOM H pa3BOJJ:j{T B pa3Hble CTOpOHbI. B
3aBepllieHIIe nlIHHlO IlIBa 06pa6aTblBalOT aHTHCemIiKOM.
Puc. 13.17 CURmue eepmUKUJlbHOi!O
11-06pa3110i!0 Y3JlOeOi!0 aaanmupylO-
Ulei!O Ulea MaK-MW/J/alla-J(ollamu
JJ ,q
"" """'"'_A- ::::>
"'" - -..:.
. .
'"
Puc. 13.18 Ommue Henpepble1l0i!0 eHympeH-
Hei!O aaanmUPYIOUlei!O Ulea XOllCmeaa
108
Puc. 13.19 CHRmue aeyXPRaHOi!O HenpepblellOi!O
coeMHOZO Ulea XOllcmeaa-3011maHa
<..... -" .--
(naBa 14
CKy,nHoe KpOBOCHa6>KeHlIe TKaHeH anOHeBp03a onpe,neJIHeT ero H1I3KHe pereHepaTopHble
CBOHCTBa. B CBOlO Oqepe,nb, 3TO 06YCJIOBJIliBaeT lIe06XO IIMOCTb ,nJIHTeJIbHOrO TeCHoro conpHKOC-
HOBeHHg coe,nlmSl:eMbIX KpaeB< II03ToMy 06mHM Tpe60BaHlIeM.D:JIH Beex cnoc060B HanO:>KeHIIH lima
anOHeBp03a HBJIjleTCSI: TluaTeJIbHOCTb B conOCTaBJIeHlI1I KpaeB, HCKlllOqalOma$llIIITepn03IIUlII0 :>KHpa.
OTCYTCTBHe 06IIJIbHOH KpOBOHOCHOH ceTIi B anOHeBp03e 06YCJIOBJIliBaeT He3HaqlITeJIbHblH nOCT-
TpaBMaTlIqeCKIiH OTeK TKaHeH. II03TOMY Y3JIbi He06xo,nIIMO 3aBSl:3bmaTb Tyro, 6e3 nOCJIa6JIeHIIH
HIiTeH. II pli 3TOM 06eCneqlIBaIOTCSI: YCJIOBIIH ,nJIH 1lJ0pMHpoBaHliH npOqHOrO coe,nHHHTeJIbHO-TKaH-
HOro py6Ua, II, TeM caMblM, npe,nynpe)l(,D;aeTCSI: 06pa30BaHHe nOCJIeOnepaUIIOHHbIX rpbl:>K. )J;JI$I npe-
,nynpe)l(,D;eHIIH HapYilieHIISI: nliTaHIIH npli CllIliBaHIiH anOHeBp03a era KPM CJIe,nYeT M06IIJIII3HpOBaTb
TOJIbKO B MeCTe HanO:>KeHII$I IlIBOB. B TO:>Ke BpeMSI: OTCYTCTBlie ,nOCTaTOGHOH M06RITbHOCTli anOHeB-
pOTHqeCKHX JIIICTKOB qpeBaTO YBeJII1qenlieM HanpH:>KeHIIH KpaeB paHbl H npope3aHHeM IlIBOB. OT,ne-
JIgTb anOHeBp03 OT no,nJIe:>Kall.{HX TKaHeH JIyqllIe TynblM nYTeM. 11 TOJIbKO B TOM CJIyqae, Kor,na 3TO
He y,naeTC$I, IICnOJIb3YlOT KllaCClIqeCKyIO MeTo,nIIKY pa3,neneHIIH TKaHeH :>KeJI060BaTbIM 30H,D;OM H
CKanbneJIeM (HO:>KHlIuaMII).
Coe,nIIHIITb KpaH anOHeBp03a MO:>KHO: (puc. 14.1):
- C nOMOIUblO npoCToro Y3JIOBOrO IlIBa;
- «BHaXJIeCT»;
- C 06pa30BaHlieM ,ny6JIIIKaT)'pbI.
YqHTblBaH ,nJIHTeJIbHOCTb 1lJ0pMlIpOBaHIISI: py6ua, paHbllie.D:JISI:
npOllilIBaHHSI: anoHeBp03a IICnOJIb30BanH nepaccacbIBalOIUHeCSI: HHTII
(llieJIK, JIaBCaH, KanpoH H ,np.). B nOCJIe,D;HlIe raJJ:bI npmJ:3oIlIJIIi Cepbe3-
Hble H3MeHeHIIH B Bbl60pe lliOBHoro MaTepliana. MCnOJIb30BaHHe Tpa-
,nIIUHOHHbIX HepaccacblBalOlI.{lIXCSI: HHTeH nocreneHHO YXO,D;IIT B npo-
IlIJIoe. ,[{JIH COemmeHI1H paCCeqeHHOrO anoHeBp03a xHpyprn Bce qall.{e
npHMeHHlOT cOBpeMeHHbIe paccaCbIBalOll(HeCSI: HIITII, KOTopbIe nOJIHOC-
TblO OTBeqalOT OCHOBHblM Tpe6oBaHIIHM, npe,lJ,'bSI:BJI$leMbIM K lliBaM ano-
HCBp03a. IIonYJISl:pHbIM CTaHOBIITCSI: 6blCTpO HaKlla blBaeMblH Henpe-
pbIBHblO 06808HOO 1U08 CItHTeTH'IeCKHMO paccaCbIBalOUUIMHcH IIItTHMH
Puc. 14.1 Cnoc06bl COeaUHellWl
(noJIHcop6, 6HOCIIH, BIIKPRIT, MaKcon, PDS)..D:JIH 3TOH uenli Hcnonb3Y-
JlUCmKOe anO/leep03a: a) c
lOT HIITII C YCJIOBHbIM ,nHaMeTpOM 1 RITII 2. HeKoTopble xHpypm OTM-
lOT npe,nnOqTeHlIe .D:BOHHbIM HHTHM (loop). 3allilITb ,nBOHHOH HIiTblO He
CJIO:>KHO. IIocJIe nepBoro CTe:>KKa 1lJ0pMIIPYlOT Y3eJI. 3aTeM HaKJIa):(bl-
BalOT 06BHBHOH lliOB 06eHMI1 HHT$lMIi. B KOHue era IlJIIKClIpyIOT H cpe-
3alOT O,nHY H3 HIiTeH. OCTaBllieHCSI: HlITblO npo,nOJI:>KalOT npOllilIBaHHe
B 06paTHOM HanpaBJIeHlIH, nOCJIe qero HIITH 3aBSI:3blBalOT.
t
llIB:bI /i.fJ 0 HE J?O:1L io,
IF ... ..-
......T:
......
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o
a
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!.."
6
c:. .
B
nOMOU/blO npOl"mOZO Y3JlOeOZO
Ulea; 6) «ellllXfleCml>; e) c
06pmOea/lUeM dy6JlUKamypbl
109
rJIaBa 14
IIpoCTOH Y3JIOBOH IlI0B. Ha paCCTOSl:HlI1I 0,8-1 CM OT KpaH pa3pe3a npOH3BO,D;HT YKOJI IImbl
cHapY:>K1I BHYTpb, BblKaJIblBalOT Ha CIiMMeTplIqHOM Y<IaCTKe npoTUBOnOJIO:>KHoro KpaH (puc. 14.2).
He06xo,D;IIMO CJIe,nHTb, qT06bI 3aXBaTblBaTb B IlI0B TOJIbKO anoHeBpOTH<IeCKlie TRaHH. IlIBbI HaKJIa-
,D;blBalOT Ha paCCTOSl:HIIH 0,5-1 CM ,nPyr OT ,npyra. I1cnoJIb3YIOT aTpaBMaTlIqecKYlO Hmy, H30rnYTYlO
Ha 1/2 ,nJIIIHbI OKPY>KHOCTII, C TpexrpaHHbIM nOnepeqHblM Ce<IeHlIeM TeJIa H OCTpblM pe:>KymlIM
(TpexrpaHHbIM) oCTplieM.
lllBb paCnOnO:>KeHHble nOnepeqHO K Xo,ny anoHeBpOTH<IeCKIIX BOJIOKoHjnpH 3aTHrlIBaHHII
Y3JIOB MorYT pa3BonoKHIITb TKaHb anoHeBp03a. Bo 1I36e:>KaHlie ,naHHoro OCJIO:>KHeHIIH peKOMeHlIY-
lOT IICnOJIb30BaTb lliBbI C pa3HOH ,nmmOll CTe:>KKa HJIII :>Ke HaKJIa,D;blBaTb IIX no,n yrJIOM OTHOCHTeJIb-
HO xo,na anOHeBpOTlIqeCKHX BOJIOKOH (puc. 14.3).
Y3JIb13aBSl:3blBaIOT Tyro, He ,nonYCKaSl: nOCJIa6neHHSI: HIiTeH npH 3aBSI:3bIBaHHH BTOpOH neTnH
Y3JIa. PacnOJIaralOT IIX TaK, qT06bl OHII Haxo,nRITHCb C60KY OT KpaeB coe,D;IIHHeMblX JIIiCTOB anOHeB-
p03a.
B Tex CJIyqaHX, Kor,na nporH03lIpYeTCSI: ,D;JIIITeJIbHOe 3a:>KIIBJIeHlIe COe.D:IIHSl:eMblX TKaHeH (Ha-
npliMep, npH ,nHarHOCTHKe KaXeKCI1H, llJIaHlipyeMoM npOBe,neHHH nyqeBOH IIJIII XHMHOTepanHII
MO:>KHO BOCnOJIb30BaTbCSI: Y3J10BbIM IlIBOM anOHeBp03a HepaccaCblBalOllUIMHCH HHTHMH (nOJIII-
nponRITeH, nOJIII34JlIpbl).
IIpli ,nlIaCTa3e JIHCTKOB anOHeBp03a ,nOBOJIbHO qaCTO HaKJIa1IblBalOT n -06Pa3HblU BblBopa-
'1HBaIOLQIIU Y3JIOBOU IlI0B (puc. 14. 4). ,[{aHHbIH 1Il0B npliMemllOT npli 3Ha <IIITeJIbHOM paCXO)l(,D;eHHH
KpaeB anoHeBp03a. OH CHII:>KaeT pHCK npope3aHIISI: HIITH II o6eCne<IUBaeT YBeJIII<IeHlIe nJIOmaLJ,1I
Henocpe,ncTBeHHoro KOHTaKTa COelIl'IHSl:eMbIX TKaHeH. IIepBblH YKOJI npou3Bo,nSI:T cHapY:>K1I BHYTpb
Ha 60JIee M06RITbHOM nliCTRe anoHeBp03a, a BblKon - Ha cIIMMeTplI<IHOM yqaCTKe ,npyroro JIIICTKa.
3aTeM Ha 3TOM :>Ke Kpae, oTcTynlIB no xo,ny pa3pe3a 1,5-2 CM OT MeCTa BblKanbIBaHIiH IIrJIbl, HIITb
npoBo,n5IT B npoTIiBOnOJIO:>KHOM HanpaBJIeHHII qepe3 06a Kpa5I anOHeBp03a. ,[{JISI: nOBblllieHIISI: npoq-
Puc. 14.2 11pocmou Y3J1oeou Uloe anO/leepo-
3a
110
-
Puc. 14.3 "XaomuOJlloe» pacnoJlo:JICellue Cme:JICKOe
npocmozo Y3J1oeozo Ulea n03eOJlRem u3veJ/Camb pa3eOJlOK-
HellWl anolleep03a npu 3aeR3bleallUU Y3J10e
HOCTII II -06pa3HblX IlIBOB IIX OplIeHTHpYIOT rro,n ymoM K
HarrpaBJIeHHlO xo,na BOJIOKOH.
I1pH 3aTHrnBaHlIli Y3JIa KpaH arrOHeBp03a BblBO-
paqlIBalOTCH H COrrpHKaCaIOTCH BHYTpeHHlIMH rrOBepX-
HOCTHMII.
,[{nH HanO:>KeHHH I1-o6pa3HOrO IllBa C o6pa30-
BaHlleM ,ny6JIIIKaTypbl anOHeBp03a (pUC. 14.5) He06-
xo,nHMa 60JIblliaH M06IIJIH3aumI KpaeB arroHeBp03a.
I1rny BKaJIblBalOT cHapY:>KH BHyTpb Ha 60JIee M061IJIb-
HOM JIHCTKe paCCeqeHHOrO anoHeBp03a. IIpoTHBono-
nO:>KHbIH nocKYT npolliliBalOT KHapY:>K1I B 60KOBOM Ha-
npaBJIeHHH. ,[{aJIee HIITb rrpoBo,nHT Ha
rrpoTIiBOrrOJIO:>KHbIH KpaH, rrpollilIBM arroHeBp03 II3HYT-
pH HapY:>KY. IIpli TIOM paCCTOHHlIe Me)[{)J;Y MeCTOM BXO,na
H BbIXO,na HHTII Ha 1I3Ha qaJIbHO rrpOlliliBaeMOM nHCTKe
,nOJI:>KHO 6blTb paBHO lliHpHHe CTe:>KKa Ha ,npyroM JIHCTKe
arrOHeBp03a. IIpli 3aTHrlIBaHHH HIiTeH 60JIee M061IJIb-
HbIH nHCTOK arrOHeBp03a paCnOJIaraeTCH Ha,n MeHee MO-
6IIJIbHbIM, 06pa3YH no nHHIIH lliBa «HaXJIeCT». ECJIH M06RITbHOCTb nOCKYTa rr03BOJIHeT OCTaBIITb
nOCKYT ,nOCTaTOqHOH ,nJIIIHbI (1,5-2 CM), TO MO:>KHO cllJopMHpOBaTb ,ny6nIIKaTYPY. ,[{JIH TIoro CBO-
60,nHYlO qaCTb BepxHero JIOCKYTa CJIe,nyeT rrplIKperrHTb OT!IeJIbHbIMH Y3JIOBbIMH lliBaMIi K HII:>KHeMY
JIOCKyTY. IIpli 3TOM llJIOIua!Ib conpliKaCaHII5! JIlICTKOB arrOHeBp03a 6y,neT ,nOCTaTOqHOH MH 1lJ0PMH-
pOBaHII5! KperrKoro py6ua.
llloB lIpapa-CIIKa - OT,neJIbHbm Y3JIOBOii 1ll0B C 06pa30BaHlleM ,ny6JIIIKaTypbl anOHeB-
p03a (puc. 14.6). KpaH BepxHero (60JIee M06HJIbHoro) JIOcKYTa arroHeBp03a rrpOKallblBalOT cHapy-
:>KH BHYTPb Ha paccToHHHH 0,7-] CM OT KpaH. Ha rrpoTHBOrrOJIO:>KHOM JIHCTKe 1lJ0pMIIPYlOT CTe:>KOK
neprreH,D;HKYJIHpHO xo,ny paHbI. ,[{nsr 3Toro BKaJJbIBaIOT IIrJIY Ha HapY:>KHOH rrOBepXHOCTH HH:>KHerO
..-...........'1"'"
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c/ j)y/: . .s
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Puc. 14.5 11-06pa3I1b/u Uloe anOlleep03a
c 06pa30eallueM oy6nuKamYPb/
H ( .. ' i i'
ci ig 7 ' . -
,.;.
1/ :: . .
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Puc. 14.4 11-06pa3Ilb/u eb/eopa'lueaIO-
UJuu Uloe anOlleep03a
-- , .. (1/
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d.
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rf\ .
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.' t <->...... [1ft!1: ..'¥. ..-
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Pue. 14.6 OmOeJIbllb/U Y3noeou Uloe c 06pa30-
eallUi!M oy6nuKamypb/ (Uloe JKupapa-CuKa)
III
rnaBa 14
t . ';' 'r; "V . . .{ /
.., . "- " fR
1; . \t ' ".(\ n \ L.;;i
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6
Puc. 14.7 a, 6 - Uloe anOlleep03a e euae UlUllenbllOU CKnaaKU
nOCKYTa Ha TaKOM :>Ke paCCTOHHlI1I OT KpaH. BbIKallbIBalOT B TOM :>Ke HanpaBJIeHlI1I B npe,neJIax 1-1,5
CM OT npe,nbI.D:ymero MeCTa ee BbIKanbIBaHIiH. 3aTHrlIBaH Y3eJI, 1lJ0pMIIPYlOT ,ny6nlIKarypy anOHeB-
p03a, KOTopaH 06eCneqHBaeT ,noCTaTOqHYlO nJIOma):{b coe):{lIHeHHH ero nIICTKOB.
llloB B BlI.IJ:e IUHHeJIbHOH CKJIa):{KH (puc. 14. 7) npHMeHHlOT ,nJIH YKpenJIeHIIH nepe):{HeH
CTeHKII naXOBoro KaHaJIa, He npH6erajJ K ero BCKpbITHlO (cnoc06bI qepHH, Py). CHaqaJIa COOTBeT-
CTBeHHO Kp BH3He HrnbI ,neJIalOT CTe:>KOK B,nonb BonOKOH BepXHero nHCTKa anOHeBp03a HapY:>KHOH
KOCOH MbIIlIUbl :>KIIBOTa. OTCTynlIB 1,5-2 CM OT CTe:>KKa B TOM :>Ke HanpaBJIeHIIH npOlliliBalOT H HH:>KHIIH
nHCTOK. B rrepBbIH CTe:>KOK MO:>KHO 3aXBaTIITb BonOKHa BHYTpeHHeH KOCOH MbIlliUbI :>KIIBOTa (Py).
3aBH3blBaH Y3JIbI, 1lJ0pMHPYlOT CKJIa,nKY anOHeBp03a.
-"f'
"'.
:,3AII.U'IBAHfJE MbII11I(
.--<;--'3
;.::;.
"-
TJ1ct13a 15
U'4->"A
<.ft.-,.
::-'t<;,.
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.
KaK H3BeCTRo, MLImeqHbIe BonOKHa CKeneTHblX MbIIliU 06pa3YlOT rrapanJIeJIbHO pacrrono-
:>KeHHble nyqKH, OKYTaHHble coe,[(HHIITeJIbHO-TKaHHOH CYMKOH (nepeMH3HeM). PblXJIaH BOJIOKHHC-
Ta COe,D;IIHIITeJIbHa TKaHb, CBH3bIBalOlI.{aSl: nyqKlI, 06pa3yeT rrOnepeqHble rreperopo,nKH. BcH MbIlllua
nOKpblTa 060JIOqKOH - llJacUHeH. KaK npaBIIJIO, COCY,[(bI II HepBbl pacnOnO:>KeHbl B Mbllllue rrapan-
neJIbHO rryqKaM BonOKOH. 3TH aHaTOMHqeCKlie oc06eHHocTH ,[(OJI:>KHbl yqHTblBaTbcjJ npli 3alliHBa-
HIIH MbIlliU. He06xo,[(HMOCTb HanO:>KeHHH IlIBOB Ha MbIIlIUbI B03HIIKaeT npH IIX rrepeCeqeHlI1I B none-
pe<IHOM HarrpaBJIeHlI1I HJIH rrpH pa3'be,[(IIHeHlllI rro xo,ny BOJIOKOH.
OCHoBHble npaBIiJIa HaJIO:>KeHHH lliBOB Ha MbIlliUbI rrpOCTbI. 3alliHBaH He06xo,D;HMO:
- HaKlla,nblBaTb IlIBbI TOJIbKO nocne TIuaTeJIbHOH xHpyprlIqeCKOH 06pa60TKH (HCCeqeHHH
HeKpOTHqecKIIX TKaHeH);
- HCrrOJIb30BaTb paccaCbIBalOlI.{HeCH IlIOBHble MaTepHaJIbl;
- cTapaTbcH TOqHO corrOCTaBHTb KPaH paHbI H 3aXBaTIITb B IlIOB 06a nHCTJ<a MblIlIeqHOH
llJacUHlL 3TO rrOMO:>KeT 1I36e:>KaTb 1lJ0pMHpoBaHIIH MbillieqHOH rpbDI<H;
- (no B03MO:>KHOCTH) BOCCTaHOBIITb ueJIOCTHOCTb, npoxo)IjJlI.{ero B TOnll.{e MbliliUbI, HepBa;
- CTpeMIITbc npollIliBaTb BClO TOnll.{y MbIlliUbl. B npoTHBHOM cJIyqae B03H1IKaeT onaCHOCTb
1lJ0pMIIpoBaHliH BHYTpHMbIllieqHOH reMaTOMbI C nOCJIe,nYlOIUHM ee HarHoeHlIeM;
- yqlITblBa PbIXJIYlO CBH3b Me)l(,D;Y COCTaBJI lOmHMH MbIlllUbl nyqKaMH BonoKoH, HaKJIa,nbI-
BaTb n-IIJIII 8-06pa3Hble IlIBbI;
- He ,[(orrYCKaTb c,naBnHBaHIiH IlIBOM KpOBeHOCHbIX COCy,nOB II HepBHbIX CTBonOB, TaK KaK
BCJIe,nCTBHe 3Toro MO:>KeT pa3BIITbCH aTpollJHH H ,[(a:>Ke HeKp03 MbIIlIU;
- 06eCrreqHTb M06HJIbHOCTb MbllliUbl npli ee COKpameHIIH;
- npH 3aBjJ3bIBaHHH Y3JIOB HHTb CJIe,nyeT 3aTHrHBaTb TonbKO ,no conpHKOCHOBeHHH KpaeB
paHbl.
,[{JISI: HaJIO:>KeHlIjJ IlIBa Ha MbIllIUbl nOHa,n06HTCSI: aTpaBMa-
THqeCKaH IIrJIa C OCTpblM KOHqIIKOM. TeJIo TaKOH HrnbI ,non:>KHO
6blTb H30rHyTO Ha 5/8 ,D;JIIIHbI OKPY>KHOCTII, C KpyrJIblM IIJIII OBallb-
HbIM rrOrrepeqHblM CeqeHlIeM.
CymecTByeT HeCKonbKO BapMaHToB IlIBOB, HaKJIa,D.blBae-
MblX Ha CKeJIeTHbIe MbIlliUbl. T eXHIIKa IIX 1lJ0pMHpoBaHIIH 3aBliCIIT
OT HarrpaBJIeHIIH nOBpe)l(,D;eHlIH. B Tex CJIyqaHX, Kor,na He06xo,D;II-
MO C6JIII3IITb KpaH MbllllUbl, pa3'be,nHHeHHoH no xody 60I1OKOll,
rronb3YIOTCH npocTbIM Y3JIOBLlM IUBOM (puc. 15.1). B IlIOB 3ax-
BaTblBalOT 06a JIlICTKa MbIlIIeqHOH llJacUHH. <1>OpMIIPYlOT CTe:>KOK, Puc. 15.1 COeaUHeHUe MblUillbl,
BKanblBaH II BbIKaJIbIBaH Hrny, oTcTynlIB 1,5-2 CM OT KpaSl: paHbI. pa3beOUHellHou no xoay eOJlOKOH,
OnTIiManbHoe paCCTOSI:HHe Me)l(,D;y CTe:>KKaMH - 3- 5 CM. PaCCTOH- npocmblM y3J/oeblM UleOM
113
rnaBa 15
HlIe Me)l(,D;Y CTe:>KKaMH 3aBliCIIT OT TOJIlI.{HHbI TKaHH - qeM TOHbllie
TKaHb, TeM rYIUe CJIe,nYeT HaKJIa,nbIBaTb CTe:>KKII. llpH 3TOM He06xo-
,[(IIMO yqlITblBaTb KOnHqeCTBO rrOBpe)l(,D;aeMbIX COcy,nOB Ha e,D;IIHHUY
nJIOIUa,D;H.
HIITH 3aTHrnBaIOT JIIIIlIb,nO corrpliKocHoBeHIIH KpaeB. 3aTHrH-
BaHHe C YCRITlieM qaCTO npHBo,nHT K npope3aHlIlO MbliliUbI. Y3enHe06-
XO,nIIMO pacnonaraTb C60KY OT paHbI.
Coe,[(1IHj{j{ Kpa MbllIIUbI, pa3'be,nIIHeHHoH rro Xo,ny BonOKOH, TaK-
:>Ke MO:>KHO Hcrronb30BaTb II-06pa311LlH IlIOB (puc. 15.2). I1my npo-
BO,[(HT CKB03b MblllieqHYlO TKaHb, oTCTynHB 1-1,5 CM OT KpaH paHbI.
llpH 3TOM B IlIOB 3aXBaTbIBaIOT 06a JIHCTKa ee llJacUHH. 3aTeM, OTCTY-
rrHB 2-2,5 CM no Xo,ny BOJIOKOH, HlITb npoBo,nHT B npoTIiBOrrOJIO:>KHOM
HarrpaBJIeHlI1I CHH3Y - BBepx. Ha ,[(pyroM KpalO paHbl Ha paCCTOHHHH 1-1,5 CM OT ee Kpa rrpOIlIHBa-
lOT MbIIlIUY cBepxy - BHII3. 3aTeM, oTCTyrrHB 2-2,5 CM B CTOPOHY (rro Xo,ny BonoKoH) OT MeCTa BbIXO-
,na HrnbI, npOBo,n T HlITb B HarrpaBJIeHHII rrepBOHaqanbHOrO YKOJIa. B 3TOM cJIyqae HaKlla,nbIBaIOT
CTe:>KOK rrapanJIeJIbHO JIHHHH pa3pe3a. OnTHMaJIbHOe pacCToHHlIe Me)l(,D;y IlIBaMH - 3-4 CM.
IIpli rrpOIlIHBaHHII He60JIblliHX ,[(ellJeKTOB (,no 5-6 CM) MbllIIUbI, pa3'be,D;IIHeHHOH no Xo,ny BO-
nOKOH, MO:>KHO HCnOJIb30BaTb 8-o6pa3l1blH mOB. OTcryrraH 2 CM OT KpaH paHbI, HrJIY BKallblBalOT H
BblKanblBalOT CHaqalla Ha O,[(HOH CTopoHe. CTe:>KOK paCnOJIaraIOT B,nonb BOJIOKOH. 3aTeM rrpOlliH-
BalOT ,npyroH KpaH B TOM :>Ke HarrpaBJIeHlIH. llpH 3TOM CTe:>KOK TO:>Ke paCnOJIaralOT B,[(OJIb BonOKOH.
MeCTa BbIBe,[(eHHH HrJIbI Ha 060HX KpaHX ,nOJI:>KHbI COOTBeTCTBOBaTb ,npyr ,npyry. 06pa30BaHHbIH
TaKIiM 06pa30M IlIOB He c,naBJIIiBaeT COCy,nbl H HepBbI. llIar lliBa 1-1,5 CM. IlIlIpHHa nOnepeqHIIKa 2
CM. Ha puc. 15.3 rrOKa3aHa cxeMa TaKoro lliBa. IIpli HanO:>KeHIIH IlIBOB Ha MbIIlIUY, nepeCeqeHHYlO
nonepelJllO XO,lQ' BOJIOKOII, He06xo,D;IIMO ,n06HBaTbCH MaKCHMallbHOrO C6nlI:>KeHHH TKaHeH. C ycne-
XOM MO:>KHO Hcrronb30BaTb 8-o6pa3l1blH Y3JIOBOH mOB. ACCHCTeHT y,nep:>KHBaeT KpaH paHbI. )J;JIH
3TOH UeJIIi MO:>KHO Hcnonb30BaTb rrpeBeHTIIBHbie lliBbl-,nep:>KaJIKlI. OTCTynaH 2-2,5 CM, xHpypr BKa-
nbIBaeT II BbIKanblBaeT IIrJIY Ha O,nHOM KpalO MbIIlIU, pacrronaraH CTe:>KOK nepneH,nHKynHpHo Xo,ny
BonOKOH (puc. 15.4). 3aTeM B 06paTHoM HarrpaBJIeHHH npolliHBalOT ,npyroH eeKpaH, ,neJIaH lliOB
CHMMeTpHqHbIM. llIar lliBa 1-1,5 CM. IlIlIpHHa rrOrrepeqHIIKa IlIBa 2 CM. llpH 3aBH3bIBaHHII Y3JIa
,nJIIIHHaH rreTnH II caM Y3en 6Y,[(YT pacrrOJIaraTbCH no Xo,ny MbIIlIeqHbIX BonOKOH, He c,naBnHBaH
COCy,nbI H HepBbI. He06xo,D;IIMO CTpeMHTbCH paCrrOnO:>KHTb Y3eJI Ha MeHee M06IIJIbHOM KpaIO paHbI.
Coe,nIIH H Kpa MbIlliUbI, nepeCe'IeHHOH rreprreH,D;IIKYJIHpHO xo,ny MbIIIIeqHbIX BonOKOH C rro-
MOIUblO II-06pa3l1oro IlIBa (puc. 15.5), HHTb npoBo,[(HT rroOqepe,[(Ho qepe3 cHMMeTpHqHbIe TOqKH
Ha 060lIx KpMX. IIpH 3aTHrHBaHIIII Y3JIa Haxo,nHIUlieCH B Tomue TKaHIi HIITH TaK:>Ke pacnonaralOTcH
no xo,ny MblllieqHbIX BOJIOKOH.
Puc. 15.2 COeOUllellUe MblUltJbl,
pa3beoWlCllllOit nu xuoy
eOllOKOH 11-06pa3HblM UleOM
Puc. 15.3 COeaUHeHUe MblUltJbl,
pa3beaWlellllOii no xoay eOllOKOH
8-o6pa3HblM UleQM
114
Puc. 15.4 COeaUHeHUe MblUltJbl,
nepeCe'leHHOii nOnepe'lHO K xooy
eOllOKOH 8-06pa3HblM UleOM
f
';: 7Jr> ' t
. ,., ' i_
. t;. / ., /. t. .
f. .,' . .,.. i
''jo--' ., .., ,... :C \1
( g, ... ".
- .
Puc. 15.5 COeaUHeHUe MblUltJbl,
nepeCe'leHHOii nonepe'lIlO K xoay
eOllOKOH 11-06pa3HblM UleOM
e
e
It
.,'!IIf<'
.< .::i
"0'
rrraBa 1'6
-<Ii
\....
COE,LU1HEHME
KPOBEHOCHbIX COCY;:J,OB
. .
....
y-
j
.ZJ:nH coe,nIIHeHlIH COCy,nOB H BOCCTaHOBneHIISI: ueJIOCTHOCTIi COCy,nIICTOH CTeHKH IIcrronb3YlOT
CrreUHallbHbIH COCy,nIICTbIH liOB. CYIUeCTBYeT MHO:>Kecrno BapliaHTOB IICrrOnHeHIIH TaKOrO liBa. ::fro
CBH,D;eTeJIbCTByeT KaK 0 TPY,[(HOCTII ero HanO:>KeHHH, TaK H 0 He06xo.D:HMOCTH pa3pa60TKII qeTKHX
nOKa3aHliH II rrpOTIiBOrrOKa3aHHH K rrpliMeHeHlIlO Ka)l(,D;Oro H3 CYll.{eCTBYlOIUHX cnoc060B. MbI CO-
qJIIi HY:>KHbIM orrlIcaTb TonbKO Te COCY,[(HCTbIe IIIBbI, KOTopbIe lil1pOKO HCrrOJIb3YlOTCH H y,n06HbI B
npIiMeHeHHH.
KJIACCJ1<1>MKAU.IU[ llJBOB COCY,AOB:
II - IlIBbI, HaKJIa,nbIBaeMble Ha apTepHH;
.. - IlIBbI, HaKlla,nbIBaeMble Ha BeHbI;
. -llIBbI, HaKlla,[(bIBaeMble Ha nHMllJaTHqeCKHe COCY,[(bl;
. - liBbl Me)l(,D;Y BeHOH H nlIMllJaTlIqecKIiM COCY,[(OM.
B 3aBlfCIIMOCTli OT cnoc06a HanO:>KeHHSI: COCY,D;IICTOro liBa, pa3JIHqaIOT:
., - MeXaHHqeCKHe;
II' - pyqHbIe;
II - liBbI C npHMeHeHHeM KOHCTPYKUHH II npOTe30B.
MeXaHHqeCKlie cocy,nIICTble liBbI HaKJIa,nbIBalOT C rrOMOll.{blO cocy,nOCliHBalOlI.{erO annapa-
Ta. IIpli HanO:>KeHlIH rrpOTe3HblX IlIBOB Hcnonb3YlOT BHYTPII- RITH BHecocy,nIICTbIe BTynKIi.
WBbI c rrpliMeHeHl1eM KOHCTPYKUHH II npOTe30B B CBOlO oqepe,D;b ,[(eJISl:T Ha:
1(1 - JIIIraTypHbIe - npH 3TOM KOHUbl COCy,nOB YKpenJIHlOT Ha npOTe3e nHraTYPOH;
. - 6e3JIUraT)'pHLle, coe,nHHHlOrnHe KOHUbI nepeCe'IeHHOrO cocy,na C nOMOll.{blO
cneUHaJIbHbIX KOJIeu.
115
rJIaBa 16
Bce PyqHble crroc06bI HaJIO:>KeHIIH COCY!IHCTbIX liBOB !IeJIHT Ha:
III - KpaeBble;
III - HHBarIIHaUHoHHbIe.
K qHCJIY KpaeBbIX liBOB OTHOCHT 06BIIBIlble (KappCJIH, MOp030BOii, IIOJIHH cBa), BblBO-
paqHBalOIUlie (paHTOB HbIii, OT,nCJIbHLlii II-06pa3I1bIii, MaTpa IILlii, ,nBYX3TamHbIii), a TaK:>Ke
IlIBbl, HaKJIa,D;bIBaeMbIe Ha 3a!IHlOlO CTeHKY cocy,na - IIJBbI EJICJIOKa H MClIJaJIKHHa. I1HBarIIHaUH-
OHHble liBbl nO!Ipa3,neJIHlOT Ha IIJBbI C o,nHHapHoii (Map H, KpHB'IHKOBa) H IIJBbl C .lI.BoiiHOii
MaH:>KCTKOii (,[{aIlHC, COJIOBbcBa).
PyqHbIe KpaeBble COCY!IHCTble liBbl MorYT 6blTb KaK HcnpcpbIBHLlMH, TaK H Y3JIOBbIMH.
JJ.nH BbIlIOJIHeHIIH orrepaUHH Ha cocY!Iax He06xo,nuM CrreUlIaJIbHbIH IIHCTpYMeHTaplIll: COCY-
,nIICTble Hrnbl, COCY!IIICTble 3a:>KHMbl (rrpHMble U H30rHYTbIe), KpOBOOCTaHaBnHBalOIUHe 3a:>KHMbI
Tlirra «MOCKHT», a TaK:>Ke COCYMCTblH HrJIo,nep:>KaTeJIb, COCY,D;IICTbIH H rJIa3IlbIe nHHueTbI, rrperrapo-
BOqHbIe IUHrrUbl, TOHKlIe 3naCTIIqeCKlie pe3HHoBbie Tpy60qKII, HHCTpYMeHTblMH OT:>KaTIiH 60KOBOH
qaCTII COCy,nOB.
B KaqeCTBe liOBHoro MaTepHana ,nJIH HaJIO:>KeHIIH COCY!IHCTOrO liBa IICrrOJIb3YlOT HIITH C
TpOM60pe3HCTeHTHbIMli CBOHCTBaMH, ,naIOliHe He3HaqHTenbHYIO TKaHeBYlO peaKUHlO. 1Il0B COCY-
,nOB npOH3BO!IHT KaK paccaCblBalOIUHMHCH (61I0CIIH, MaKCOIl, PDS), TaK H HepaccaCblBalOIUIIMHCSI:
(rrOJIlIDpOIDmeH) IlHTHMII. ECJIH npe!IYCMaTpIiBaeTCH HCrrOJIb30BaHlie rrpOTe3a, rrOJIb3YlOTCH HCKJIlO-
qlITeJIbHO HepaccaCbIBalOIUHMIICH MaTepHanaMH. CJIe!IyeT npHMeHHTb aTpaBMaTHqeCKHe HrJIbl C
YCJIOBHbIM pa3MepOM HHTH 4/0-6/0.
06liee Tpe60BaHlie K liBaM, HaKJIa,nbIBaeMbIM Ha COCy,nbl, - 06eCneqeHHe ,nocTaTOqHOH
npOqHOCTIi II repMeTlIqHOCTIi aHaCTOM03a, llpH coxpaHeHHH !IHaMeTpa ero rrpOCBeTa. ,[{JIH C03!Ia-
HIIH YCJIOBIIH 06pa30BaHHH Ha,ne:>KHOrO COYCTbH He06xo!IIIMO CTpeMlITbCH corrOCTaBnHTb CliHBae-
Mble yqaCTKH BHYTpeHHHMH 060nO'IKaMH. B TO :>Ke BpeMH B rrpOCBeTe KpOBeHOCHoro COCY!Ia ,non:>KHO
Haxo,nHTbCH KaK MO:>KHO MeHbille 1IJ0BHOrO MaTeplIaJIa.
B Tex CJIY'.J:aHX, KOr!Ia HMelOT ,neJIO C He60JIbIlIHMII rrOBpe)l(,D;eHHHMH CTeHKH COCY!Ia (eCJIH
,nJIHHa rrOBpe)l(,D;eHHH He rrpeBbliliaeT TpeTIi ,nJIHHbI ero OKpY:>KHOCTII), paUIiOnaJIbHO Bocrronb30-
BaTbCH rrpOCTbIM YlilIBaHHeM !IellJeKTa CTeHKH. ,[{JIH 3TOH ueJIII rro,noil:):(eT KpaCBoii COCy,nHCTbIii
IIJOB. OH xapaKTeplI3yeTcH ,nOCTaTOqHOH Ha,ne:>KHOCTblO, TaK KaK 06eCneqlIBaeT xopolIJee conoc-
TaBJIeHlIe HHTHMbI COCY!Ia. LlJIH HanO:>KeHIIH KpaeBoro COCY!IIICTOrO IlIBa COCY!I BbI):{eJIHIOT H3 rrapa-
Ba3aJIbHOH KJIeTqaTKII. Bbllie H HH:>Ke MeCTa paHeHIIH HaKJIa!IblBalOT COCY!IHCTbIe 3a:>KHMbl. IIocJIe
HCCeqeHHH rrOBpe)l(,D;eHHbiX KpaeB paHbI HaKJIa!IbIBalOT 06BHBHOH HenpepbIBHbIH IlIOB 'Iepe3 Bce
CJIOII COCY!IHCTOH CTeHKII. ECJIH paCrrOJIO:>KHTb IIJOB B nOrrepeqHOM HanpaBJIeHHH, TO 3T0 YMeHbliHT
B03MO:>KHOCTb CY:>KeHIIH apTepliH. ,[{JIH JIHKBII!IaUHII He60nbIlIliX nOBpe)l(,D;eHHH rrpHMeHHlOT Y3JIO-
Bble II -06pa3Hble IlIBbl. II pH 06lilIpHbiX ,nellJeKTax B CTeHKe cocy,na BO H36e:>KaHHe Bblpa:>KeHHOrO
CY:>KeHHH BMeCTO KpaeBoro COCYMCToro liBa HaKlla,nblBalOT 3aIIJIaTY H3 aYTOBeHbl RITH CHHTeTHqec-
Koro MaTepHaJIa (puc. 16.1). B MeCTe rroBpe)l(,D;eHHH COCy,nbl nepeceKalOT (puc. /6.1,a). 3aTeM
npOH3BO!ISl:T 3allIIIBaHHe 3a,nHeH CTeHKH aHaCTOM03a (puc. 16.1,6). B oCTaBIlIHHcH OBaJILHbrn J!,e-
llJeKT BIlIIiBalOT 3aImaTY H3 aYToBeHbI (puc. 16.1,6).
reMoCTa3 no JIHHHH cocy,nlIcToro IlIBa rrpolI3BoJJ:j{T nplIKJIa!IbIBaHlieM TeIIJIblX BJIa:>KHblX TaM-
rrOHOB, reMOCTaTlIqeCKOH ry6K1I, HaKlla,D;blBajJ O!IIIHOqHble II-06pa3Hble IIJIH Y3JIOBble liBbl.l1Hor,na
nlIHHlO liBa YKpeDJIjlIOT Me,nIIUIIHCKIiM KJIeeM IIJIH nOCKYTOM (MaIDKeTKOH) H3 llJacUHH, BeHbl.
116
ECJIII :>Ke rrpHXO,nHTCH 3aIlIliBan 60nee 06-
IlIlIpHble nOBpe)l(,D;eHHH cocY!Ia, nOnb3YlOTCH IlUp-
KYJUlpHblM IUBOM. Ero HaKlla,nblBalOT rr03TarrHO.
CHaqana rrpOBO,D;HT M06HJIH3aUHlO COCY!IOB WIH
6e30nacHoro C6nH:>KeHII KOHUOB, a 3aTeM npo-
H3BO!IHT HenOCpe!ICTBeHHoe HaJIO:>KeHlIe lliBa H
BOCCTaHOBJIeHHe KpOBOTOKa. 3aBeplliaIOT HaJIO-
:>KeHffe lima rrpOBepKOH repMeTlIqHOCTIi COYCTbH H
npOXO.LI.HMOCTH COCY!I a .
PaCCMOTpliM Ha npliMepe COCy,nHCTOro aHa-
CTOM03a «KOHeu B KOHeu» OCHOBHble 3neMeHTbI
MeTO,nHKH BbIDonHeHlIH Ka)l(,D;OrO H3 3TanOB CIlIH-
BaHIiH.
I :nan - Mo6uJIU3allUH cocy,na. 1136e:>KaTb
rrOBpe>K.I(alOlI.{erO HaTH:>KeHIIH ClliliBaeMbIX yqaCT-
KOB rrOMO:>KeT !IOCTaTOqHaH M06IIJIII3aUliH cocy-
,nOB rrpOKCIiMaJIbHee II !IHCTanbHee MeCTa rro-
Bpe:>K!IeHIIH. PaccToHHHe Me)l(,D;y KOHuaMH
nOBpe)l(,D;eHHoro cocy,na He ,non:>KHO npeBbIlliaTb
3-4 CM. B npOTIIBHOM CJIyqae 3TO HeraTHBHO oTpa-
:>KaeTCSl Ha HX KpOBOCHa6:>KeHHII II HHHepBaUIiH.
,[(Jm a,neKBaTIIOH M06IIJIH3aUHII nplIXO,D;IIT-
CH H30nHpOBaTb COCY!I Ha paccToHHHH,nO 10 CM.
3Ta3a,naqa 06JIerqaeTCH llilipOKHM aHaTOMHqeC-
KII 060CHOBaHHbIM ,nOCTynoM K MeCTY rrOBpe)l(,D;e-
H1IH. YqaCTOK apTeplI1I IlIHpOKO 06Ha)((aIOT HenoC-
pe,nCTBeHHO qepe3 paHY IIJIH qepe3 pa3pe3 MHrKIIX
TKaHeH. C ueJIblO aHeCTe3HH, npollJHJIaKTIIKH
crra3Ma II rH,npaBJIHqeCKOH nperrapOBKII B JIO:>Ke cocy,na BBO,nsrT 10-15 MJI 0,5-1 % paCTBopa HOBO-
KaHHa. IIpOII3BO,D;HT npO!IOJIbHbIH pa3pe3 no xo,nY cocY!Ia. TynblM H30rHYTbIM 3a:>KIIMOM BbI.IIeJI IOT
rrepe,nHlOlO H 60KOBYlO rrOBepXHOCTIi cocy,na. IIo,n 06Ha:>KeHHbIM cocY!IOM rrpOBO!IHT pe3HHoBbIH
TypHHKeT. C ero nOMOll.{blO OCTaHaBJIIiBalOT KpOBOTOK B cocy,ne. )J;anbille HCrrOJIb3YH TYpHIiKeT KaK
,nep:>KanKY, Bbl)J.eJIHlOT 3a,nHlOlO cTeHKY cocy,na H OTXO,D;HlI.{lIe OT Hero BeTBIi. 3TH BeTBH rrepeBH3bIBa-
lOT H nepeceKalOT. Cne,nyeT 3aCTepeqb HaqlIHaIOIUHX xHpyproB OT YBJIe'leHIIH CJIlilliKOM IlIlipOKHM
06Ha)((eHHeM ClliHBaeMblX KOHUOB, 'iTO qpeBaTO rrOTepeH :>KH3HeCrroc06HOCTII yqaCTKa cocy,na. MeK-
BaTHOH CqHTaeTCH Ta M06RITII3aUH , npli KOTOpOH KOHUbI cocy,na Y!IaeTCH C6JIH3HTb 6e33HaqHTeJIb-
Horo HaTH:>KeHIIH.
II 3Tan - C6JIU)KeHUe KOHIlOB cocy,na. EpaHlliaMli cocy,nHCToro 3a:>KHMa 3aXBaT'bIBalOT CO-
cy,n B carliTanbHOH ImOCKOCTH Ha pacCToHHIIH 1,5-2 CM OT KpaH. TaKoH 3aXBaT 06JIer'laeT pOTaUlilO
COCy,nOB.
YqHTbIBaH qpe3BbIqaHHYlO paHHMOCTb COCY,D;IICTOH CTeHKII, He06xo,nHMO npaBHJIbHO BbI6-
paTb CTeneHb C:>KaTHSl COCy,nOB 6paHlliaMH 3a:>KHMa. IIpH IlJIIKcaUHH KOHUbI cocy,na He ,non:>KHbI
BbICKallb3blBaTb, a IIX BHYTpeHHH 060JIOqKa pa3,naBJIHBaTbcH.
III :nan - no,nroToBKa KOHIlOB cocy,na K HaJIO:>KeHIIIO IUBa. Y,naJIHlOT CryCTKH KpOBH, nooqe-
pe.LI.Ho BOCCTaHaBnHBaH KpOBOTOK rrpHOTKpbIBaHlieM 3a:>KIIMOB. PaCTBopoM aHTHKoarynHHTa npo-
8fi&; ,
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Puc. 16.1 a. 6. e Jmanbl COeaUHeHUH KpOeeHOC/lblX
cocyaoe C npllMeliellueM «3annamKUJ)
117
rJIaBa 16
MblBalOT rrpocBeT cB060,nHb1X Y'IaCTKOB cocy,na. He06xo,nIIMO Cpe3aTb H3JIIIIlIKH an:BeHTHUlianb-
HOH 060JIOqKH rro KpalO cocy,na. 3TO n03BOJIHeT rrpen:yrrpe,D;IITb ee npona6HpoBaHlie B npOCBeT
cocy,na II C03,naeT YCJIOBHH ,nJIH nyqllieH KoanTaUIiH.
IV JTan - Hcnocpc,ncTBCHHOC 1U1JI0:>KCHHC IllBa no O,D;HOH H3 BbI6paHHbix MeTo,nIIK.
V - BOCCTaHOBJICIIHC KpoBoToKa no cocy,ny, npoBcpKa rCpMCTH'IIiOCTH IllBa H npoxo,nH-
MOCTH cocy,na. IIoo'Iepe,nHo CHIiMalOT 3a)KIIMblIIJIH TypHHKeTbI C ueHTpaJIbHOrO II rrepHCpeplIqeCKO-
ro KOHUOB apTepliH. KpOBOTeqeHlIe rro JIIIHHII lliBa OCTaHaBJIlIBalOT CJIa6bIM rrpH:>KaTlieM KpOBOTO-
qaIUerO MeCTa MapJIeBbIMIi IlIapliKaMH (cMOqeHHbIMIi TenJIblM 4JH3HOJIOrHqeCKHM paCTBopoM) B
Te'leHlIe HeCKOJIbKIIX MHHYT. I1plI He06xo,nIIMOCTH naKllan:bIBalOT HeCKOJIbKO ,n06aBO'lHblX Y3JIOBblX
IlIBOB IICKJIlO'lIITeJIbHO Ha a,nBeHTHUHlO, BCKope KpOBOTe'lelme OCTaHaBJIIiBaeTCH.
06naCTb cocy,nlIcToro mBa TIUaTeJIbHO nplIKpbIBalOT TKaH5IMH C XOpolliliM KpOBOCHa6:>KeHII-
eM. PaHY nOCJIOHHO 3amHBalOT.
B TeqeHlIe BceH orrepaUHH KOHUbI cocy,na nepHo,nHqeCKH CMa'lHBalOT H30TOHHqecKHM pa-
CTBOpOM HaTpHH XJIopH.D:a.
,[{JIH ClliHBaHIiH nOnepeqHO nepepe3aHHOH apTeplI1I HaH60JIee qaCTO nplIMeHHlOT KJIaCCH-
qeCKliH UlIpKynHpHbIH COCy,nHCTbrn 1ll0B KappcJIJI. ,[{JIH 3Toro CHa'laJIa Ha 13mane HaKlla,nbIBalOT
Tpli Y3JIOBaTbiX lliBa, pa3n:eJIHlOlI.{He OKPY:>KHOCTb npOCBeTa
cocyn:a Ha Tpli paBHble qaCTH (puc. 16.2). AccliCTeHT paCTH-
rnBaeT KOHUbl3TIIX IlIBoB-,nep)((anOK II paHa apTeplI1I 06pa-
3yeT paBHocTOpOHHIIH TpeyrOJIbHIIK. Ka:>K,D;ylO CTOPOHY TIO-
ro TpeyronbHHKa 3alliliBalOT OTn:eJIbHO HerrpepbIBHbIM
06BIIBHbIM (CKOpHH)l(l{bIM) IlIBOM. TaKoe paCTHrlIBaHlie paHbI
OqeHb 06JIerqaeT 3aIlIHBarme.
II :nan - HaJIO:>KCHUC HcnpcphlBHoro 06BHBlioro
UJBa (puc. 16.3). HaqlIHalOT llilITh, oTCTynHB 1-2 MM OT KpaH
cocy,na, B03JIe o,nHoro H3 IlIBOB-,nep:>KanOK. HaKJIan:bIBalOT
KpaeBoH HerrpepbIBHbIH 06BHBHOH lliOB qepe3 Bce 060noq-
KII cocy,na. B 3aBliCliMOCTli OT TOJIll.\IIHbI COCY,D;IICTOH CTeHKH
IlIar CTe:>KKOB BapbHpyeT OT 0,5 n:o 2 MM. IIpH n:HaMeTpe
cocyn:a n:o 3 MM, lliar IlIBa II pacCToHHlIe OT KpaH paHbI
COKpall.\arOT B,nBoe. I10cJIe nepBbIx 2-3 CTe:>KKOB, HaqaJIb-
HYlO HIiTh CBH3bIBalOT C O,nHOH H3 HHTeH lliBa-,nep:>KaJIKH.
ACCIiCTeHT rro,nDlrlIBaeT rrlIHueTOM HIITb, paCnpaBJI5I-
eT II y,nep:>KIIBaeT ee, He n:orrYCKaH paCCJIa6JIeHIIH HaJIO)((eH-
HblX CTe:>KKOB. I10CJIe Toro, KaK xlIpypr HaJIO:>KHT CJIe,nylO-
lI.{HH CTe:>KOK, aCCIiCTeHT rro,nTHrlIBaeT HIiTb.
IIpolliHB TpeTb OKPY:>KHOCTH, HHTb 06BHBHoro lliBa
TaK:>Ke CBH3bIBalOT C On:HOH H3 HIiTeH lliBa-n;ep)((anKH. Ta-
KIIM :>Ke 06pa30M ClliHBaIOT OCTaJIbHble rpaHIi TpeyronbHH-
Ka, POTIIPYH ,nJIH y,n06CTBa cocy.a 3a:>KHMaMH II ,nep:>KanKa-
MH. 06BHBHOH lliOB MO:>KHO HaJIO:>KHTb O,nHOH H3 HHTeH
IlIBa-,nep:>KanKH, c,neJIaB ee 60nee MHHHOH.
I1epe,n 3aBH3bIBaHHeM nocne,nHero CTe:>KKa nplIOT-
KpblBaIOT ,D;IICTallbHO HanO:>KeHHbrn 3a:>KIIM, qT06bI KpOBb BbI-
Puc. 16.3 Kpaeeou cocyoucmblu Uloe
TeCHRITa B03,n y X, crycTKII K p OBH. 3aBH3aB rrOCJIe,nHIIH Y 3en,
KappeJl51. HaJlo:J/CeHue 06eue1lozo Ulea
Puc. 16.2 Kpaeeou cocyoucmblu Uloe
KappeJl1l. HaJlo:JICellue Uleoe-Oep:JICaJlOK
118
BHaqaJIe CHHMalOT 3a:>KIIM C nepHllJepHqeCKOrO KOHua cocy-
.n:a, a 3aTeM - c ueHTpaJIbHoro.
IIpHHUlin corrOCTaBneHIIH BHYTpeHHHX 060JIOqeK CO-
Cy,nOB «HHTIiMa K HHTHMe» C06JIlO,neH II B lUBe IIOJIHHlleBa-
HenpepbIBHoM 06BHBHOM IlIBe, HaKlla,D;blBaeMOM Me)l(,D;y Tpe-
MH I1-06pa3HbIMHiliBaMII-.n:ep:>KanKaMH (puc.16.4).
I JTan - HanO:>KeHHeM II-06pa3Hblx lliBOB-.n:ep:>KaJIOK,
pacnOJIO:>KeHHblX Ha o,nIIHaKOBOM paCCToHHlIIi ,npyr OT .D:Pyra,
npeBpaIUalOT npOCBeT cocy,na B TpeyrOJIbHIIK. I1pH 3TOM KpaH
cocy.n:a BbIBOpaqHBalOTCH H corrpHKacalOTcH BHYTpeHHIIMIi
060JIOqKaMII.
II :nan - HcnonHeHHe c06CTBeHHo HenpepbIBHoro 06-
BIIBHoro lliBa. OCTOpO:>KHO rro,nTHrHBalOT 3a lliBbI-,nep:>KallKIi
,no 06pa30BaHHSI ry60BH,D;HOrO BaJIHKa. 3TO rr03BOJIHeT xo- Puc. /6.4 Kpaeeou coCyauCmblU Uloe
pOlliO a.n:arrTlipoBaTb BHYTpeHHlOlO 060JIOQKY. 3aTeM Herrpe- 110R1l11l/eea
pbIBHblM 06BIIBHbIM lliBOM coe,nIIHHlOT KOHUbI cocy.n:a Me)l(JJ:y
lliBaMlI-.n:ep:>KaJIKaMH.
mOB MOp030Boii - HenpepbIBHbIH 06BIIBHOH lliOB, Ha-
Kna.n:blBaeMbIH Me:>K.n:y ,nBYMH lliBaMH .n:ep:>KaJIKaMIi
(puc.16.5).
I :nan - HaJIO:>KeHHe lliBOB-.n:ep:>KallOK CHaqaJIa Ha 3a,n- ,... _ , .=""..
HlOlO, a 3aTeM Ha rrepe,nHlOlO CTeHKH COe,D;IIHHeMbIX yqaCT-
KOB cocy,na. TaKoe pacrrOnO:>KeHHe lliBoB-,nep:>KaJIOK n03BO- ...".',..,k
MeT H36e:>KaTb 06pa30BaHIISl3a,D;HeH CTeHKII, KOTOpYIO TpY.D:HO
3alliHBaTb. MaHlirrynHpoBaTb Ha 06pa30BaBlliHxcH 60KO-
BbIX CTeHKax 60nee y,n06HO.
II nan - HaJIO:>KeHlIe HenpepblBHoro 06BHBHoro lliBa.
IIpli 3TOM B KaqeCTBe TpeTbeH ,nep:>KaJIKH, OTTHrHBalOIUeH
CTeHKY cocy.n:a II c03.n:alOIUeH rrpocTOp ,D;JIH MaHlIrryJIHUIIH, HC- Puc. 16.5 Kpaeeou cocyoucmblu Uloe
rrOJIb3YIOT HlITb, KOTOpOH HaKlla,nbIBalOT IlIOB. M op030eou
He,nOCTaTKII rrpe,nCTaBneHHblx IlIBOB, OCHOBOH KOTO-
pbIX HBJIHeTCSl 06BHBHOH UlIpKynHpHbIH COCy,nHCTbIH IlIOB:
- 06pa30BaHlle Herro,naTnlIBoro Konbua BOKpyr cocy,na;
- npOHHKHOBeHlIe lliOBHoro MaTepHana B rrpOCBeT cocy.n:a;
- OTCYTCTBHe KoallTaUHH HHTHMbI, QTO He 06ecneqlIBaeT ,nOCTaTOqHOH repMeTlI OCTH.
lIIoB CanomHIIKoBa - HenpepbIBHbIH paHToBH,D;HbIH lliOB, HaKJIa,nbIBaeMblH Me)l(,D;y ,nBYMSl
Y3nOBbIMH lliBaMII- ,nep:>KaJIKaMH.
I 3Tan - HallO:>KeHlIe lliBOB-.n:ep:>KaJIOK H C03,naHlie MaH:>KeTKII. 06Ha:>KalOT 06a KOHua cocy,na
Ha HeCKonbKO 60nbilleM pacCToHHHH. ClliHBaeMble oTpe3KH pacceKalOT B,nonb ,nJIHHOH 3-4 MM.
IlIBbI-,nep:>KanKIi HaKlla.n:bIBalOT y BeplliHHbl paCCeqeHHH (puc. 16.6). IIpH 3aBH3bIBaHIIII, CTeHKII
cocy.n:a rrlIHueTOM BblBOpaqUBalOT, o rrplIBo,nIIT K 06pa30BaHli1O MaH:>KeTKII (puc. 16.7).
II :nan - HaJIO:>KeHHe paHTOBH,D;HOrO lliBa. PaHTOBH,D;HbIH IlIOB HaKlla,D;bIBalOT rrpHMbIMH cocy-
,nIICTbIMIi HrJIaMII, coe.n:HHeHHbIMH O.n:HOH ,D;JIHHHOH HlITblO (puc. 16.8).
lIIOB JbITfMaHHa - HenpepbIBHblH MaTpaUHbIH lliOB, HaKJIa,nbIBaeMbIH Me)l(,D;Y TpeMH II-06-
pa3HblMH lliBaMH-.n:ep:>KaJIKaMH (puc. 16.9).
119
rJIaBa 16
, ,
.: . /; ". ,
Puc. /6.6 Kpaeeou cocyoucmblu
woe Cano:J/ClluKoea. HaJlo:J/CeHue
Uleoe-oep:J/ClIlloK
'1'-'."-
Puc. 16.9 Kpaeeou coCyaUCmblU
UloeJ]lOtllnlllIl1lI
. .);.,.. .".
Puc. 16.10 Kpaeeou cocyoucmhlu Uloe
lipualla u )J(a6Ylle
120
C\
<" l :f:' . . ,+,
.d . X j ' ,; :
):if" --'>- -t:'
Puc. /6.7 Kpaeeou cocyoucmblu
woe Cano:J/ClluKoea. C03aaHUe
.IIIlIIt;}ICemKU
Puc. 16.8 Kpaeeou cocyouc-
mblU woe CanO:J/CIlUKOe(L
HaJlo:J/Cellue plllllrlOfillollo O
Ulea
I :nan - HanO:>KeHlIe lliBOB-,[(ep:>KanoK. Ha o,nHHaKO-
BOM paCCTOjJHIIH ,npyr OT ,npyra HaKJIa,nbIBalOT Tpli II-06-
pa3HbIX IlIBa-,nep:>KanKH.
II JTan - Ha Ka:>K,D;ylO 1I3 CTOpOH 06pa30BaHHoro Tpe-
yronbHIIKa OT,neJIbHOH HIiTblO HaKJIa,D;blBalOT MaTpaUHbIH
IlIOB. HHTH, KOTOpblMH C03,[(alOT MaTpaUHblH IlIOB, CBH3bI-
BalOT C COOTBeTCTBYlOlUHMH HlITHMH IlIBOB-,nep:>KanoK.
IIpH He06xo,[(HMOCTH oc06eHHO TllIaTeJIbHOH peno-
3HUHH KpaeB COcy,nIICTOH paHbI, npli npope3bIBaHHII lllBOB
Ha 1I3MeHeHHOH COCY.LI.HCTOH CTeHKe lICnOJIb3YlOT IIJOB Epn-
aHa n lKa6y JIe - BbIBOpa'IHBalOlI.{IIH OT,nenbHbIH I1-06pa3-
HblHlliOB (puc.16.10).
I JTan - HallO:>KeHHe lllBoB-,nep:>KanoK. Ha nepe,[(HlOlO
II 3a,nHlOlO CTeHKH cocy,nOB HaKJIa,nblBalOT II-06pa3Hble
UlBbl.
II :nan - HanO:>KeHlIe OT,neJIbHblX II -06pa3HblX lliBOB
TaK, qT06bl npli HX 3aBjJ3bIBaHHH ,[(OCTHqb BblBOpaqHBa-
HlIH cocy,na H nOJIHOrO COnOCTaBJIeHlIH BHYTpeHHIIMIi 060-
nOqKaMH. War lliBa I - 1,5 MM. ,lJ,JIH rrpe,nynpe)l(,D;eHIISI:
npOllilIBaHIiH npOTHBOrrOJIO:>KHOH CTeHKH aCCIiCTem nocro-
HHHO HaTHrllBaeT HIITH npe,D;bI,D,yll.{ero lliBa.
06eCne'IIiBaH XOPOIlIYlO repMeTlIqHOCTb, BbIBopa-
qlIBalOlUHH COCY,[(HCTbIH IlIOB MO:>KeT npliBeCTH K cy:>KeHlIlO
cocy,na no MeCTY HanO:>KeHIIH llIBa.
HHBArnHAl.{I10HHbIE COCY,[{MCThIE IIIBLI
Pa3JIIIqHbIe MO,D;IIIlJIIKaUIIH HHBarlIHaUHOHHOrO IlIBa nplI-
MeHHlOT B HaCTOHIUee BpeMH npli He06xo,nIIMOCTIi COe,nIIHeHIIH
apTepliH pa3HbiX ,nlIaMeTpOB. HanpliMep, KOr,na ,D;IIaMeTp l..{eHT-
panbHorO OTpe3Ka Y:>Ke nepHllJepwleCKOrO.
WOB COJIOBbCBa - IIHBarliHaUJlOHHbIH IlIOB C ,nBOHHOH
MaH:>KeTKOH. ,[{JIH BblllonHeHIIH liIBa M06IIJIII3IIPYlOT l..{eHTpaJIb-
HbIH II neplIllJepwlecKIiH OTpe3KII CIlIIiBaeMoro cocy,na.
I :nan - HanO:>KeHlIe 4IIHBarlIHIIpYlOIUliX IlIBOB. HaqlIHa-
lOT IlIHTb Ha ueHTpanbHoM KOHue cocy,na. IIepBbIH YKOJI npolI3-
BO,nHT Ha paCCTOHHHH, COOTBeTCTBYlOIUeM 1,5 ,D;IIaMeTpa cocy,na.
Ha He60JIbiliOM yqaCTKe J];Ba)l():(bI npOliHmalOT ero Hap)':>KHYlO 060-
nOqKY. 3aTeM B HanpaBJIeHIIH cHapY:>K1I BHYTPb npoIlIlIBalOT Bce
CJIOII CTeHKII cocy,na Ha paccToHHlI1I 1 MM OT KpaH. Ha TaKOM:>Ke
paccToHHlI1I neplIllJeplIqeCKIiH oTpe30K cocy,na npoIlIIiBalOT H3-
HYTPII HapY:>KY. no OKPY:>KHOCTH cocy,na HaKna,nblBaIOT qeTblpe
TaKIIXlliBa (puc. 16.11).
n nan - 1lJ0pMIIpoBaHlie MaH:>KeTKH. HIITII-,nep:>KanKll 3ax-
BaTbmalOT 3a:>KIIMaMIi no ,nBa H, no,nTHrlIBaH B HanpaBJIeHHII ueH-
TpanbHoro OTpe3Ka, C6JIII:>KalOT KOHUbI apTeplIli. IIpH 3TOMCTeH-
KII ueHTpaJIbHOrO cocy,na BblBOpa'lIiBalOTCH II 1lJ0pMIIpyeTcH
MaH:>KeTKa (puc. 16.12). \\
111 3Tan - IIHBarlIHaUHH MaH)KeTK1f H 3aBH3bIBaHlie IlIBOB.
KOHUbl COCy,nOB C6JIlI)l(alOT. Y,nep)!(HBmr ueH1-paJIbHbIH KOHeu, ero
HHBarHHHpYlOT B neplIllJeplI'leCKIiH. ECJIII IIHBarliHaUIIH He npo-
IICXO,nIlT caMOCTOHTeJIbHO, ee npOH3Bo,nHT aHaTOMlIqeCKHM nlIH-
ueTOM, 3aBo,nH ero 6paHillY no,n MaH:>KeTKY (puc. 16.13) .I1HBam-
HaUHlO HaqlIHalOT c 3a,D.HeH nonyoKpy:>KHOCTIi cocy,n:a.
n pH BOCCTaHOBlleHlIIi KpOBOTOKa no cocy.ny 3a:>KIIM BHaqalle CHlIMalOT C ueHTpaJIbHOrO, a 3aTeM
C neplIllJeplIqeCKoro OTpe3KOB. IIpOBepHlOT repMeTH'lHOCTh IlIBa II npoxonHMOCTb cocy,na. IIpli He,no-
CTaTOqHOH repMeTHqHOCTIi HaKlla,D.bIBaIOT ,nonOJIHIITeJIbHbIe OT,neJIbHble Y3JIOBbIe IlIBbl, 3axBaTbIBaH
Bce CJIOH CTeHKII neplIllJeplI'leCKOrO II HapY:>KHYIO 060JIOqKY ueHTpanbHoro OTpe3KOB cocy,na.
IIpeHMYlUeCTBOM IlIBa COJIOBbeBa HBmeTCH ero npOCTOTa IICnOJIHeHIIH, TOqHOCTb conOCTaB-
JIeHIIH HHTHMbI, OTCYTCTBlie conpliKOCHOBeHHH IlIOBHoro MaTepliana II paHbl cocy.D:a C npOTeKalO-
IUeH no HeMy KpOBblO.
He,nOCTaTKaMH IlIBa HBJIHeTCH TO, qTO MH ero BblllonHeHIIH He06xo,nIIMa M06HJIH3aUliH CO-
cy,na Ha MIITeJIbHOM npOTH:>KeHIIII; Mlma cocy,na nOCJIe 3aIlIliBaHliH 3Ha'lHTeJIbHO YKopa qIIBaeTCH;
C03naHlie ,nBOHHOH MaH:>KeTKII 3Ha'lIITeJIbHO CY:>KHBaeT npOCBeT cocy,na; BblCOKaH KpOBonOTepH
qepe3 JIlIHlIlO IlIBa npH coe,nHHeHIIJI KOHUOB KpynHoro cocy,na.
IlIoB KpJlB'IJlKOBa. I 3Tan - C03,naHlie MaH:>KeTKlI H3 neplIllJeplIqeCKOrO oTpe3Ka cocy,na. Ha
paccToHHIIH 0,5-0,7 CM OT KpaH neplIllJepHqeCKoto oTpe3Ka cocy,na HaKJIa,D.blBalOT ,nBa II-06pa3-
HbIX IlIBa. CTeHKY neplIllJeplIqeCKOrO oTpe3Ka cocy,na BblBOpaqlIBalOT, 1lJ0PMIIPYH MaH:>KeTKY
( puc. 16. 14).
" " ()
.;;.... ! .- --...
", i,' ,
./ .r ' \
Puc. 16.11 HlIea2UlIaJ.{1l01lllblU
coCyaucmblU Uloe COlloebeea.
HallO:HCellUe UII6a2U1IUpylOU/UX Uleoe
Puc. 16.12 HHea2U1U1J.{uoHHbIU
coCyauCmblU Uloe COlloebeea.
<POpJ',tllpOeaHue Mall:HCelIIKU
121
rnaBa 16
Puc. 16.14 Hllea2WlaljUOllliblU
coCyallClllblU Uloe Kplle'lUKoea.
HO/lo:HCellue MalIlpOljl1020 Uleo
L
. {h.m
, ''':''\1- .''';''
Puc. 16.15 Hllea2UllaljUOllllblU
cocyi)ucmblu Uloe Kplle'lUK06a.
cJ>uKCaljWI Jo-taIl:HCeIllKU
Puc. 16.13 Hlleo2UlwIIUOIllIb/U
cocyc)ucmblii Uloe CO/lOebeea.
Hllea2l/1laljllH nUlIljemOM
113Tan - HanO:>KeHlIe MaTpaUHoro IlIBa. MaTpauHbIH IlIOB MO:>KHO HanO:>KlITb OJJ.HOH 1I3 HIiTeH
II-06pa3Horo IlIBa. IIepHllJepHqeCKIiH oTpe30K cocy,na npOlliliBalOT no,n MaH:>KeTKOH no JIIIHIIII ee
1I3rn6a. 1lI0B HaKlla,nbIBalOT CHa'lalla Ha 3a,D.HlOlO, a nOTOM Ha
nepe,nHlOlO nonyoKpY:>KHOCTH.
III nan - nepeBO,n MaH:>KeTKII Ha ueHTpaJIbHbIH oTpe-
30K cocy,na. IIocJIe cpe3aHlIH 1I3JIIIIlIKOB HHTeH MaTpaUHoro
IlIBa c nOMoIUblO nIiHueTOB, MaH:>KeTKY nepeBo,njjT Ha ueHT-
paJIbHbIH oTpe30K. CB060,nHbIH KpaH MaH:>KeTKII, KOTOpbrn npH-
KpblBaeT JIIIHHIO lllBa, no,nlliliBalOT oT,neJIbHbIMIi Y3JIOBbIMli
IlIBaMIi K HapY:>KHOH 060JIOqKe ueHTpaJIbHOrO OTpe3Ka cocy-
,na. IIpH 3TOM HIITb npoBo,njjT qepe3 Bce ero CJIOH (puc. 16.15).
=""'7;.'!ff. Q ' L o .>.. ,
:""...:;t:. :?if . ,)" :
,"i:. ., '. ( , . . ',
..:o>" Yb "
f<' \) ' '<
PIIC. 16.16 llJoe 1ac)lIeu CmeJIKU
cocyaa no E/le.qOKY. HO/lo:}/(;elllle
Henpepb/ell020 11-06pa31lO2o IUBa
-- t'&) ., : ....
. ? . . .H. t<=t*: .,\. . v ...'\.<,.,.,. <>'. ,
p..' ..
:: \, .>''''il\.J. '' ' .,;,i \
..,;,.' ' i . ,_,;J
Puc. 16.17 llJoe 1aalleU cmeuKu
cocyaa no E/le/lOKY. Ha/lo:HCe-
HUe Ulea Ha nepeoHlO1O cmellKY
122
IlIBbI 3A,lUIEM CTEHKI1, HAK.JIA)..I.blBAEMhlE
llPI1 HEB03MOJKH0 CTM POTAIJ.MM COCY,[{A
IlIoB EJIe.TIOKa. I3Tan - HanO:>KeHHe HenpepblBHoro II-
06pa3Horo IlIBa. lJJOB HaqHHalOT C HapY:>KHOH nOBepXHOCTH
cocy,na. Ha ,npyroM OTpe3Ke cocy,na HIITb npOBO,D;HT CO CTOpO-
HbI ero npocBeTa HapY:>KY. CJIe,nYlOIUHH CTe:>KOK npolI3Bo,nHT
Ha 3TOM :>Ke oTpe3Ke cHapY:>K1I BO BHYTPb (puc. 16.16).
Il3Tan - 3aTHrlIBaHHe IlIBa. HaTHrIIBa KOHUbl HIITII B
npoTIIBOnOJIo:>KHylO CTOpOHY, IlIOB 3aTHrlIBaIOT,n0 nOJIHOrO co-
npliKocHoBeHIIH BHYTpeHHHx 060JIOqeK CIlIHBaeMbIX oTpe3-
KOB cocy,na.
III nan - 3allllIBaHlie nepe,nHeH CTeHKII. Depe,nHlOIO
cTeHKY 3aIlIliBalOT HenpepbIBHbIM MaTpaUHbIM IlIBOM. HHTII
CBH3blBalOT Me)l(,D;y C060H (puc. 16.17).
IlIBbI C IIPMMEHEHMEM KOHCTPYKQM.M M IIPOTE30B
OCHOBOH npliMeHeHHH 6eCllIOBHOrO COe,nIIHeHHH ap-
TepliH nOCJIY:>KRITIi IICCJIe,nOBaHHH IIaHpa II <DlIpTa, KOTOpble
npeMO:>KIIJIIi COe,nIIHHTb COCy,abI C nOMOIUblO paCCaCblBalO-
lI.{HXCH Tpy60qeK II KaHlOJIb. B HaCTOHIUee BpeMH 6eCIlIOB-
HOe coe,nIIHeHlIe COCy,nOB npaKTlIqeCKIi He ynOTpe6JIHeTCH.
IlIoB l1aiipa. Inan - no,n60p npOTe3a. D.JIH 06JIer-
qeHHH IIHBarliHaUlI1i ueHTpaJIbHOrO KOHua cocy,aa B neplI-
llJeplIqeCKHH peKOMeH,nyeTC}l Bbl6paTb BTYJIKY, B KOTOpOH
BHYTpeHHHH ,nlIaMeTp HeCKOJIbKO MeHbille HapY)l{Horo ,nlIa-
MeTpa cocy,na.
II 3Tan - pa360pTOBKa ueHTpaJIbHOrO OTpe3Ka cocy-
,aa. IIocJIe Ha,neBaHIIH npOTe3a Ha ueHTpanbHblH OTpe30K
cocy,na, 3aXBaTblBalOT ero CTeHKY TpeMH 3a:>KIIMaMIi II Bbl-
BOpaqHBaIOT ee HapY:>KY BHYTpeHHeH 060JIOqKOH (pue. 16.18).
III3Tan - IIHBarliHaUIIH ueHTpallbHOrO OTpe3Ka B ne-
plIllJeplIqeCKIiH. PacTHHYB TpeMH 3a:>KIIMaMIi CTCHKY neplIllJeplIqeCKOrO oTpe3Ka cocy,na, IIHBarH-
HIiPYlOT B Hero ueHTpanbIlblH OTpe30K (pue. 16.19).
IV nan - IlJIIKcaUIiH CTeHOK cocy,na Ha npoTe3e KpellKoH JIliraTypoH (pue. 16.20).
HecoMHeHIlblMIi ,nOCTOIIHCTBaMIi 3Toro llIBa ecTb npocToTa II 6bICTpoTa ero BbIllOJIHefIlIH. K
He,nOCTaTKaM CJIe,nyeT OTHecTH HanllqlIe ,aBYX BHeIlIHIIX c,aaBJIlIBalOlI.{lIX JIliraTYP II IIHOpo,nHoro TeJIa
B npocBeTe cocy,na.
Puc. 16.19 CoeaUlIellue cocyaoe c nOA-tOU/blO
npome3a no 11aupy. Jfllea uHm/lIR 'leHmpallb-
1I0 0 ompe3Ka cocyoa e neputjlepll'leCKUU
Puc. 16.18 COeaUlIellUe cocyaoe c
nOA-IOU/b10 npome3a no 11aupy. 110a 0-
m06Ka 'lel1mpallbl1O O ompe3Ka cocyaa
PIIC. 16.20 COeaUl1el1Ue cocyaoe c nOA-tOU/bl0
npome3a no 11aupy. <PIIKcmJuR cmel10K cocyaa
l1a npome3e
CilOCOEbI HAJIO)KEHIDI IIIBOB HA P A3HOKAJIHEEPHbIE COCY,[{bI
.[(mr coe,nIIHeHlIH «KOHeu B KOHeu» COCy,nOB pa3HOrO ,nlIaMeTpa MO:>KHO ,a06IITbCH IIX a,D.anTa-
UIIII nYTeM cpe3aHliH no,n yrJIOM KOHua cocy,na C MeHbIlIHM ,nlIaMeTpOM. )J;JIH 3Toro ero He06xo-
.D:HMO XOpOllIO M06HJIlI3HpOBaTb. JIIIHeHKoH 1I3MepHlOT ,nlIaMeTp 60JIbillOro cocy,na. 3aTeM nlIHeH-
123
rJIaBa 16
. :::3 >;'" . ... J
. ,
,
. .. . I
'"
II h
Puc. 16.21 YeellUIlellue aua"tempa
COCY()ll no cnoco6y po6poeollbcKoU.
HalleceHue HacelleK
'Y
Puc. 16.22 YeellUlle1lUe aua",empa
cocyoa no cnoco6y p06poeollbcKoU.
H allO:HCellUe Ulea
"Hj
KY nplIKlla,nbIBalOT K KOHUY cocy,na C MeHbIlIIiM ,nlIaMeTpOM
H OllbITHbIM DyTeM no,n6HpalOTyroJI Cpe3a. J],JUI TIoro yron Me:>K-
Lty MIIHHHKOM cocy,na H nlIHeHKOH MeHHlOT ,no Tex nop, nOKa
MIiHa JIHHlIIi CKoca He CTaHeT paBHOH BeJIlIqlIHe 1I3MepeHHoro
,nlIaMeTpa 60JIblliOrO cocy,na. IIo Hail:.neHHoR JIIIHIIIi npOII3BO-
,nHT cpe3. J1plI 3TOM BeJIlIqHHa 06pa3YIOluerOCH OTBepCTIiH
6y,neT TOqHO COOTBeTCTBOBaTb npOCBeTY cocy,na 60JIbilierO ,n1I-
aMeTpa.
D.J1I1HY OKPY:>KHOCTII cocy,na MO:>KHO YBeJIlIqlITb nYTeM
HaHeceHIIH HaCeqeK (cnoco6 )].06pOBOJILCKOU). rrpllLtaBa
3TOMYKOHUYllJopMypacTpy6a (pue.16.21),MO:>KHOnerKOHa-
JIO:>KIITb coe,nHHHlOIUIiH IlIOB (pue. 16.22).
ECJIII eCTb B03MO:>KHOCTb YBeJIlIqlITb OKPY:>KHOCTb cocy-
,na nYTeM ero nepeceqeimH B 06JIaCTli ,neJIeHIIH Ha ,nBa CTBona
(cnoco63au,ncII6cpra-XypBHTH-KapTaHa) (pue. 16.23).
.u
A '.
f. '.
.,'-;...,:
. , .
.."",[.7
\
.'G:;' r.,
. w -:C' {, ', '\ . 'rr-'
i ::..'" . 'U fi. :' I".. .."
.Jfi,.q",,,,.,, .< .' ,. ".c:
' ..}:t
ii
Puc. 16.23 YeellUIlellue aUaMempa cocyoa no cnQC06y
3auaeu6eP2a-X ypeumu-Kapmalla
MEXAHMqECKHM CKPEIIOqHblM IlIOB
MCnOJIb30BaHlie annapaTHoro IlIBa n03BOJI eT TOqHO COnOCTaBlITb HHTIIMY CIlIlIBaeMbIX CO-
Cy,nOB, C03LtaTb npOqHbIH aHaCTOM03 H H36e:>KaTb ero cY)l{eHIIH B paCTYIUeM opraHH3Me. HecoMHeH-
HbIMIi npelIMYIUeCTBaMIi 3Toro BlI,[(a COCy,nIICThIX IlIBOB }!BJIHeTCSI: 6bICTpoTa ero HcnonHeHIIH II Pe3II-
CTeHTHOCTb K IIHllJeKUIIII. CYIUeCTBeHHblMIi He,nocTaTKaMIi MeXaHHqeCKOrO liIBa HBJIHeTCH
npoTliBonoKa3aHHe K ero IICnOJIb30BftHli1O npli CIlIHBaHHII COCy,nOB C 60nbilioH pa3HlIueH ,nlIaMeT-
pOB, B my60Klix paHax IIJIH npli OqeHb KOpOTKIIX KOHuax apTepHH
C03)..(AHME APTEPMAJThHbIXMMKPOAHACTOM030B
C MCnOJIb30BAHHEM JIA3EPHOrO H3JIyqEHHB
OueHKa pe3YJIbTaTOB onepaUIiH C IICnOJIb30BaHlieM JIa3epHOro H3JIyqeHIIH nOKa3ana, qTO
MIIKpoaHacToM03, BblllOJIHeHHblH nYTeM JIa3epHOH cBapKII, 06eCneqHBaeT 60JIee BbICOKYlO, qeM
IlIOBHbIH aHacToM03, npOqHOCTb, XOPOillYlO repMeTHqHOCTb H npoxo,nIIMOCTb, HCKlllOqaeT IIHIlJHUII-
pOBaHHe H He MeHee qeM B ,nBa pa3a COKpall.{aeT npo,non)l(lITeJIbHOCTb onepal.lHll.
124
Coe,nHHeHHe apTepHH HaqHHalOT C HaKJIa,nblBaHIIH TpeX IlIBOB no OKPY:>KHOCTH cocy,na Ha
paBHblX paCCTOHHIIHX ,npyr OT ,npyra. C nOMOIUblO TaKIiX ,nep:>KanOK Kpa51 COCy,nOB npH6JIH:>KaIOT ,no
conpIiKOCHOBeHIIH. 3aTeM Ha C6JIH:>KeHHbIH CerMeHT B03,neHCTBYIOT na3epHbIM JIyqOM B MIIJIJIIiBaT-
HOM pe:>KIIMe B TeqeHlIe HeCKonbKlIX MRITJIIiCeKYH,D;. IIpli 3TOM npOIICXO.D:IIT «CBapIIBaHHe» II coe,nlI-
HeHHe KpaeB COcy,nOB. TaKIIM:>Ke 06pa30M coe,nIIHHlOT CJIe,nYlOIUIiH cerMeHT ,n:o nOJIHOrO repMeTlIq-
Horo 06pa30BaHIIH aHaCTOM03a. TeXHIIKa na3epHoro C03,naHIiH cocy,nIICToro MIIKpoaHaCTOM03a
(apTepHII) ,nHaMeTpoM 0,6-0,7 MM no Tliny «KOHeu B KOHeu» cxo,nHa C onlIcaHHoH Bblille.
rEPMETI13AI..(MH IIIBA
Cnoco6 XeHKHHa 3aKlllOqaeTCH B ,nonOJIHII-
TeJIbHOM OKYTbIBaHliH nHHHII IlIBa MyIlJTOH. B Kaqe-
CTBe MyllJTbI Hcnonb3YlOT aYToBeHY cooTBeTcTBY-
lOlI.{ero ,nlIaMeTpa, npe,nBapHTeJIbHO
KOHcepBlipoBaHHble COCy,nbl IIJIH CHHTeTHqeCKlie
npOTe3bI. My4JTy pacceKalOT no ,D;JIIIHHIIKY H 0KYTbl-
BalOT JIIIHHIO IlIBa. 3aTeM CHaqana CIlIIiBalOT pacce-
qeHHbIe CTeHKII, a nOTOM IlJIIKCHPYlOT IIX OT,n:eJIbHbI-
MII IlIBaMIi K a,nBeHTIiUlIanbHoH 060nOqKe cocy,na
(puc.16.24).
KpliTepHHMH npaBHJIbHOrO BbIllonHeHHR
onepaUHH HanO:>KeHIIH IlIBa Ha apTeplI1I HBnHlOTCH:
- nYJIbCaUHH COCy,nOB ,nIICTanbHee npOBO.D:II-
Moro onepaTIIBHoro npHeMa;
- y,nOBJIeTBOpIITeJIbHble nOKa3aTeJIH llJIeTH3MorpallJIIH II ynbTpa3BYKoBoro IICCne,nOBaHIIH;
- HopManH3aUliH UBeTa II TeMnepaTypbI KO:>KH;
- OTcYTCTBlie OTeKa,nIICTaJIbHOrO eerMeHTa KOHe oCTH.
Puc. 16.24 repMemU3a"lUR UJea
cnoc060J,' X eHKUHa
IUBbI, HAKJIA,l],bIBAEMbIE HA BEHbI
IIpHHIJ:IIIIlIallbHble no,nxo,nbi K TeXHIIKe Coe,D;IIHeHHH apTepHH pacnpOCTpaHHIOTCH II Ha IlIBbI
BeH. TeM He MeHee, norpelliHOCTII, KOTopble MorYT 6bITb He CYll.{ecTBeHHblMIi npli BMeIlIaTeJIbCTBaX
Ha apTeplIHX, 3aqacrylO CTalOT nplIqlIHaMIi Hey,naq npH onepaUIIHX Ha BeHax.
PaCCMOTpHM HeKOTopble oc06eHHOCTH HanO:>KeHIIH IlIBOB Ha BeHbI. IIpe)l(,D;e Bcero, 06paIUa-
eM BHIIMaHlie Ha He06xo,nIIMOCTb 60JIee TIUaTenbHoro oCMoTpa ClliHBaeMblX COCy,nOB. ,1],0 HanO:>Ke-
HHSI: IlIBa Ha BeHY CJIe,nyeT y6e,nIITbcH B OTCYTCTBHII KllanaHOB B 30He 6y,nYIUero aHaCTOM03a. He-
IIpe,nHaMepeHHoe npoIlIHBaHlie CTBOpKII KllanaHa MO:>KeT npHBeCTIi K H3MeHeHII1O npocBeTa BeHbl,
HapYIlIeHHIO KpoBoToKa II CTaTb nplIqlIHOH nOCJIe,nYlOIUero Bblpa:>KeHHOrO TpoM603a. ECJIII MeCTO
aHaCTOM03a Bbl6paHo npaBHJIbI-!O, TO MeJIKHe npHCTeHOqHbie TPOM6bl, pa3MeIUeHHbie no JIIIHHH
IlIBa, He CTpaIlIHbl. IIpHCTeHOqHblH TpOM6 repMeTII3HpYeT aHacToM03, Crna:>KIIBaeT HepoBHocTH,
npe,nOTBpall.{aH Typ6yneHTHoe ,D;B1I:>KeHIIH KpOBH, II cnoc06cTByeT Haqany pereHepaUlI1I COCy,nOB.
HaH60JIee y,n06HO coe,nHHHTb BeHbl, IICnOJIb3YH HenpepblBHblH 06BIIBHOH IlIOB. B OTJIlIqHe
OT IlIBa Ha apTeplIlI, BeH03HblH 1lI0B BblllonHHlOT C MeHbIlIHM HaTH:>KeHlIeM HHTH, 60JIee peJ{KIiMIi
CTe:>KKaMli (OKOJIO 2 MM).
IIpH 1lJ0pMIIpoBaHHH COYCTbR Me)l(JJ:y IIoBepXHOCTHblMH H rny60KIIMH BeHaMH BHaqane npo-
125
rJIaBa 16
IlIIIBalOT BeHY, IIMelOIUYlO 60JIee TOJICTYlO creHKY cHapy)l(II BHYTpb, nOTOM H3HYTpH Hapy:>KY - TOHKO-
CTeHHYlO BeHY. IIpH 3TOM aTpaBMaTlIqeCKYlO IIrJIY BbI6IIpalOT COOTBeTCTBeHHO HalI60nee TOHKO-
CTeHHOMY cocy,ny.
IIIBbI HA JllIM<1>ATM CKI1E COCY,[{bI
B nOCJIe;:ume ro,nbl 06'beKTOM onepaTIIBHbIx BMernaTeJIbCTB Bce qall.{e HBJIHeTCH JIHMllJa-
TnqeCKaH CIiCTeMa. PeKoHcTPYKTIIBHbIe onepaulIlI Ha JIIIMllJaTII'leCKOH CIiCTeMe HaxOMT IlIHpoKoe
npHMeHeHlIe npli nOBpe)l(,D;eHIIHX rpy,nHoro npoToKa, penJIaHTaUlI1I KOHe'lHOCrn, nepeca,nKe
opraHoB, JIeqemm JIHMllJoCTa3a. Bce 1I3BeCTHbie B HaCTOHIUee BpeMH peKoHcTpYKTHBHble onepa-
UIIII Ha nIIMllJaTII'leCKHX nYTHx, pa3pa60TaHHble C ueJIblO BOCCTaHOBJIeHHSI: OTIOKa nHMllJbl, MorYT
6bITb pa3,Z:\eJIeHbI Ha Tpli rpynnbI:
1) coe,nlIHeHlIe Me)l(,D;Y C060H KOJIJIeKTOpHbIX JIIIMllJaTlIqeCKIiX COCy,nOB;
2) 1lJ0pMlIpOBaHHe npHMblx IICKyccTBeHHblx JIIIMllJoBeH03Hblx aHaCTOM030B;
3) C03,I:\aHlie aHaCTOM030B Me)l(,D;Y JIIIMllJaTHqeCKHMII Y3JIaMH.
TOHKOCTeHHOCTb II xpynKoCTb JIlIMllJaTlIqeCKIiX COCy,nOB He n03BOJIHeT HCnOJIb30BaTb MH HX
COe,D;IIHeHIIH MeTO,D;IIKII CIlIIIBaHHH COCy,nOB. B TO:>Ke BpeMH cnoc06HOCTb nlIMllJaTHqeCKOH CIiCTeMbI
K pereHepaUIiH 06JIerqaeT BOCCTaHOBJIeHlIe npOXO,D;IIMOCTIi nHM<paTlIqeCKOrO pYCJIa. IIpH 3TOM HeT
He06xo,nHMOCTH TIUaTenbHoro conOCTaBJIeHHSI: KpaeB nepeCeqeHHOrO cocy,Z:\a H BOCCTaHOBJIeHHH
repMeTHqHOCTIi. 3TOMY cnoc06CTByeT HeBblCOKM BepOHTHOCTb 06pa30BaHHH TpOM6a BHYTPII cocy-
,na, He60nbrnaSl: CKOpOCTb nlIMllJoToKa, HII3Koe BHYTPlicocy,nIICToe ,naBJIeHHe.
IlIBbl Ha JIIIMllJaTlIqeCKIIX cocy,nax BbmOJIHHlOT C IICnOJIb30BaHlieM npeUII3HOHHOH MIIKPOXH-
pypmqeCKOH TeXHIIKII. OnepaUlilO npOH3BOMT npli OnTlIqeCKOM YBeJIlIqeHlI1I B 8-10 pa3 CneUlIaJIb-
HbIMIi MIIKpoxlIpyprmecKIiMIi IIHCTpYMeHTaMII, IIcnonb3YH MOHollJHJIaMeHTHble HIITH C yCJIOBHbIM
,nHaMeTp"oM 8/0-10/0. Cne,I:\yeT Hcnonb30BaTb OT,neJIbHble Y3JIOBbIe IlIBbl, 3aBH3bmaH HX ano,naK-
THJIbHO. IIpli 3TOM IlIBbl He cne,nyeT CJIHiliKOM Tyro 3aTHr1IBaTb, TaK KaK 3TO Bb13bIBaeT Ha,npblBbl
CTeHKH II 06Ha:>KeHlIe cy63H,D;OTeJIlIanbHOro CJIOR, npHBOMIUHe K nplIJIHnaHlilO TPOM60UHTOB, HX
arperaulIli H TPOM603Y.
OnacaHCb BblCblxaHIiH nll.MllJaTHqeCKHX COCy,nOB, onepaulIOHHoe none nOCTOHHHO YBlla:>KHH-
lOT 1lJ1I3HOJIOrlIqeCKliM paCTBopOM. 06H3aTeJIbHbiM HBJIHeTCH npliMeHeHlIe renaplIHa MH coxpaHe-
HIIH npoxo,nIIMOCTH aHaCTOM03a.
IIIBbI ME)K)J,Y BEHOMH JllIM<1>ATH1JECKMM COCY)].OM
JIHMIlJoBeH03Hbie aHaCTOM03bl HcnonHHlOT B ,nBYX BapliaHTax: aHaCTOM030M <<KOHeu B 60K»
H aHaCTOM030M «KOHeu B KOHel{».
ECJIH ,nlIaMeTp nHMllJaTlIqeCKOrO cocy,na MeHbille 1 MM, HCnOJIb3YlOT aHaCTOM03 «KOHeU B
60K». TexHHKa HanO:>KeHIIH COYCTbH ,nOBOJIbHO npocTaH. IIpe)l(,D;e Bcero, Bbl,D;eJIHlOT BeHY II pMOM
pacnOnO:>KeHHbIH JIIIMllJarnqeCKIiH cocY,I:\, KOTOpblH npe,I:\BapHTeJIbHO nepeceKaIOT nOL{ ymoM 45°
MH YBeJIlIqeHIIH ero ,nHaMeTpa. 3aTI?M, B 60KOBOM oTBepcTIiH BeHbI OT,neJIbHbIMH Y3JIOBblMH IlIBa-
MH IlJHKCHPYIOT KOHeu cocY,I:\a. IIpHcaCbIBalOlI.{ee ,neHcTBHe BeH03Horo KpoBoToKa cnoc06CTByeT
BOCCTaHOBlleHIIIO ,nBII:>KeHIIH JIHMllJbI.
IIpe,nJIoqTHTeJIbHee HaKlla,nblBaTb aHaCTOM03 «KOHeu B KOHeu», KOTOpblH BbmOJIHSl:lOT CJIe-
,nYlOIUIiM 06pa30M: MH YBeJIlIqeHIIH ,nHaMeTpa aHaCTOM03a Bbl,D;eJIHlOT 1-2 JIlIMllJaTlIqeCKIiX cocy-
,na y MeCTa IIX Bna,D.eHIIH B JIlIMllJaTmeCKIIH Y3eJI. OTeeKaIOT IIX OT Y3JIa BMecTe C yqaCTKOM KancYJIbI.
126
3aTeM, cnoc060M HHBarHHaUIIII, 1lJ0PMVPYlOT npHMbIe JIIIMIlJoBeH03Hbie aHaCTOM03bl «KOHeu
B KOHeu». HeCKOJIbKO JIIIMllJaTlIqeCKHX COCy,nOB MO:>KHO KOMnaKTHO BHe,npHTb B npOCBeT O,nHOH
BeHbl.
MHor,na npH HanO:>KeHIIII nlIMIlJoBeH03HOrO aHaCTOM03a no Tliny «KOHeu B KOHeu» B Bbl,D;e-
neHHble H3 OKpY:>KalOIUIiX TKaHeH yqaCTKII COCy,nOB BBO,njjT KaTeTep (puc. 16. 25). HapY:>KY KaTerep
BJ>IBO,nHT qepe3 cTeHKY BeHbl. KOHUbI COCy,nOB coe,nIIHHlOT pyqHbIM COCy,nIICTbIM IlIBOM, nOCJIe 'lero
KaTeTep y.n:anHlOT.
\1 '1>\
III ,_
r.' ,_ .c"\.:\
,.: ;/.. '\,
.. .. .. 7\ ,". ,
'"'. "
.. _c_ . ;.. '';:i-.
J1J/r '
A t! i -
,. . 'J
/ :_J i
Puc. 16.25 JIUMrjloBt!no3Hblu anOi:mOM03 no mtiny «KOHel/ B KOHl!lJ»
llI1M OHO,[{YllOBEHOCTOMMR
IIepe,n BbIllOJIHeHHeM 3Toro BH,D;a COYCTbH 06H3a-
TeJThHO He06xo,nIIMO npe,nBaplITeJIbHOe npOMbIBaHlie npo-
CBerOB BeH paCTBopoM renapHHa.
,[{JIH COe,D;HHeHHH JIIIMllJarnqeCKOrO Y3JIa C BeHoH
HCnOJIb3YlOT HanO:>KeHHe aHaCTOM03a no THny «KOHeu B
60K» (puc. 16. 26). IIpe.D:BapHTeJIbHo nlIMllJaTHqeCKIiH Y3en
nepeceKaIOT no 3KBaTopy. 3aTeM, nonoBIIHY, co,nep:>KaIUYlO
npliBoMIUlie nlIMllJaTmecKlie COCy,nbl, IlJIIKCIIPYIOT K BeHe.
.ZJ:JIH 3TOH ueJIIi 06blqHO Hcnonb3YlOT BeHbl, pacnOnO:>KeH-
Hble pMOM C no,nKOJIeHHbIM HJIII naXOBblM nHMllJarnqeC-
KIIM Y3JIOM. HanO:>KeHlIe COyCTbH JIIIMllJaTII'leCKOrO Y3JIa C
BeHoH no Tliny «KOHeu B KOHeu» (puc. 16. 27) He nOJIyqRIT
IlIlipoKoro pacnpocTpaHeHIIH, TaK KaK ero BbIllOJIHeHHe
Tpe6yeT BblKlllOqeHHH 1I3 KpoBoToKa BeHbI ,nOBOJIbHO
60JIbilierO ,nlIaMeTpa, qTO MO:>KeT HeraTHBHO CKa3aTbCH Ha.
pe3YJIbTaTaX JIeqeHIIH.
MHor,na IICnOJIb3YIOT HanO:>KeHHe Kancyno-Ben03-
Horo aHaCTOM03a «60K B 60K». TexHIIKa onepaUIIII Karrcy-
nO-BeH03Horo aHaCTOM03a COCTOIiT B CJIe,nYIOlI.{eM: Me:>K-
,ny 3a:>KIIMaMIi pacceKalOT CTeHKY BeHbI, 3aTeM Ha,D.ceKalOT
Puc. 16.26 JIUMrjJoeeH03Hblu aHacmoM03
no muny «KOHeIj e 60K))
127
rnaBa 16
I;.. .. .. - .t '
?r ; .
)! '.
/1. ..;;,
' .I:. ,.j "
..
".' I
Puc. 16.27 HallO:HCeHUe coycmbR llUMqlamu-
'1eCKOZO Y311a c eel/ou no muny «KOHeil
e KOHeijJ)
Kancyny Y3na, BCKpblBaH CHHYCbl. OT,neJIbHbIMIi Y3JIOBbl-
MII IlIBaMIi COeLtHHHlOT Kancyny nlIMllJaTlIqeCKOrO Y3JIa II
CTeHKY BeHbl. HeOCnoplIMblMIi npeHMYIUeCTBaMIi :noro
BH.D:a aHaCTOM03a HBAAeTCH ero npOCTOTa BbInOJIHeHHH, OT-
CYTCTBlie CKllOHHOCTIi K TpoM6lIpOBaHlIlO, coxpaHeHHe npo-
XO,nIIMOCTIi MHTeJIbHOe BpeMH, BbInOJIHeHHe aHaCTOM03a
6e3 pa306l1.{eHIIH eCTeCTBeHHblX JIIIMllJaTWlecKIiX lJYTeH
(6e3 nepeCeqeHlIH Y3JIa C coxpaHeHHeM npHHocsrll.{lIX H Bbl-
HOCHIUIIX COCYLtOB).
)J;JIH HanO:>KeHIIH aHaCTOM030B He peKOMeH,D;yeTcH
HCnOJIb30BaTb MarlICTpanbHbIe BeHbl (B qaCTHOCTII, 6eLt-
peHHYlO), 06bl B CJIyqae B03MO:>KHOrO TpOM603a K JIIIM-
llJaTlIqeCKOH He,nOCTaTOqHOCTIi He ,n06aBAAJIaCb BeH03HaH.
_;".,. m_ "
- <. ">"..
r.iIaBaT7."""'. .
.... -
.>
v'., ,-,' "..". '-,.--' . ', -",, . ." ".".-." """r.
IllBbI nEPH(I)EPH CIGIX HEPBOB
;::.;"
TpaBMa, COnpOBO)l(,D;alOIUaHCSI: HapYIlIeHHeM ueJIOCTHOCTIi neplIllJepWlecKRX HepBHblX BOnO-
KOH, HHIIUlIHpyer B HIIX npOueCCbl,nereHepaUlllI II pereHepaUIiH. .HBJIeHHH ,n:ereHepaUHII pa3BHBa-
lOTCH maBHblM 06pa30M, B neplIllJeplIqeCKOM yqaCTKe nepepe3aHHOrO HepBa. OHH KaCalOTCH KaK
oeeBoro UIIJIHH,D;pa, KOTOpblH pacna,naeTCH Ha MeJIKlIe 3epHa, TaK Hero MHeJIIiHOBOH 060JIOqKH.
06pa3YlOIUeH paccaCblBalOIUHeCR :>KHpOBble KanJIH. CoxpaHHeTCH JIHilib 3anycTeBiliaH IlIBaHHOBC-
KaH 060JIOqKa. KOTOpaH npH pa3paCTaHIIII nepeKpblBaeT nOnepe'lHblH cpe3 HepBa C pa3BHTlieM
YTOJIIUeHHH - llioaHHOMLI. OnlIcaHHbIe npoueCCbI HaqlIHalOTCH B nepBbIe 24 qaca nOCJIe nOBpe)l(,D;e-
HIIH II 3aKaH'lIiBalOTCSI: K KOHUY l-ro MeCHua, Kor,na Y:>Ke BII,nHa nOJIHaH KapTHHa nepepo)l(,D;eHIIH
HepBa.
B UeHTpallbHOMOTpe3Ke HepBa npolIcxoMT ,nOBOJIbHO CJIO:>KHbIe npoueccbl pa3HOBeKTopHoH
HanpaBJIeHHoCTIi. C O,nHOH CTOpOHbI OH npcrepneBaeT nepHaKcoHanbHYIO ,nereHepaUlIlO, BbIpa:>KalO-
myIOCH paCna,D.oM MlIeJIIIHOBOH 060JIOqKH, C ,npyrOH - o,D;HOBpeMeHHo B03H1IKaeT npouecc ueHTporeH-
HOH pereHepaulI1I HepBa. CnyCTH HeKoTopoe BpeMH nOCJIe TpaBMbI UeHTpallbHbrn KOHeu oceBoro UII-
JIIIHL\pa 6ynaBOBH.D:HO YTOJIlI.{aeTCH H npopaCTaeT HaBCTpeqy neplIllJeplIqeCKoMY oTpe3KY. IIpH
OTCYTCTBIIII ,nHaCTa3a oceBble UIIJIHH.D:Pbl npoHIiKalOT B IlIBaHHOBCKlie 060JIOqKII neplIllJeplIqeCKOrO
KOHua HepBa. IIpOBO,nIIMOCTb no HepBY BOCCTaHaBJIIiBaeTCH. B npOTlIBHOM c qae KOCTHble 06JIOM-
KII, IIHOpo,nHbIe TeJIa, nJIOTHbIH py6eu II ,np. C03L\aIOT Henpeo,nOJIIiMble npellHTCTBIIH Ha nYTII npopac-
TaHHH aKCOHOB. Ha ueHTpanbHoM KOHue HepBa 06pa3yercH nmepnnaCTIIqeCKOe YTOJIIUeHlIe - Heopo-
Ma, HapYllialOIUaH npoBo,nIIMOCTb HepBa. I1cxo,nH H3 TIoro, CYTb onepaUlIH CIlIHBaHHH KOHUOB
nOBpe)l(,D;eHHOrO HepBa COCTOIiT B TOM, qT06bI C6JIII3HTh (npaBRITbHO conOCTaBHTb!) IIMelOlI.{lIe HOp-
ManbHYlO CTpYKTypY era ueHTpanbHbIH II nepmpeplIqeCKlIH OTpe3KH. IIpH 3TOM pacrymHe C ueHTpanb-
Horo KOHua HepBa aKCOHbI npOHlIKaIOT B 060JIO'lKIi ero nepnllJeplIqeCKOrO KOHUa.
HaRITyqIlIeH pereHepaTopHOH cnoc06HOCTbIO 06JIaAalOT nyqeBOH H MbIIlIeqHO-KO:>KHbIH He-
pBbl. HII3KaH - CBOHCTBeHHa JIOKTeBOMY, ce,nanlIlI.{HOMY H 06IUeMY MaJI06epUOBOMY HepBaM. One-
paUHH BOCCTaHOBJIeHIIH ueJIOCTHOCTIi neplIllJeplIqeCKOrO HepBa COCTOIiT H3 HeCKonbKIIX ::JTanOB:
- HeBpOJIII3;
- HCCeqeHlIe HeBpOMbI (pe3eKUIiH «OCBe:>KeHHe» nOBpe)l(,D;eHHbiX KOHUOB);
- HaJIO:>KeHHe'IlIBa.
HCOpOJIH3 - BbI.D:eJIeHlIe HepBa H3 OKpY:>KalOlI.{IIX TKaHeH, py6l{OB wm C03,naHIIH 6naronpH-
srTHbIX YCJIOBIIH ero pereHepaUlIIi II IlJYHKUHOHlipOBaHHH. B 3aBIICliMOCTH OT xapaKTepa nOBpe)l(,D;e-
HH}III BpeMeHII, npolIIe,nlIIero nOCJIe TpaBMbI, npOII3Bo,nHT HapY:>KHbIH, BHYTpeHHIIH HeBpOJIII3 IIJIII
HX KOM6IIHaUHlO. XlIpyprWlecKOH CYTbIO HapY:>KHOrO HeBpOJIH3a HBJIHeTCH M06HJIII3aUH}I HepBa,
oCB060)l(,D;eHlIe ero OT 3KCTpaHeBpaJIbHOrO Py6ua, B03HIIKiliero B pe3YJIbTaTe nOBpe)l(,D;eHIIH co-
ce,nHHX opraHoB. 3Ta npoue,nypa n03BOJIHeT yCTpaHIITb HaTH:>KeHlIe HepBa H npoII3Bo,nHTCH B 3a-
:>KIIBilieH paHe. BHYTpeHHHH HeBpOJIII3 HanpaBJIeH Ha CHHTlie aKCOHanbHOH KOMnpeCClI1I II CBO,nHT-
129
rnaBa 17
CH K HCCeqeHHlO Me:>KllJacUIIKYfi51pHOH 1lJ1I6p03HOH TKaHli. O,nHHM 1I3 maBHbIX YCJIOBIIH ycneiliHoro
pe3ynbTaTa HeBpOJIII3a TpaBMlIpoBaHHoro nepHllJepwlecKoro HepBa HBJIHeTCH a,neKBaTHblH ,nOC-
Tyn K HeMY. OH n03BOJIHeT TluaTeJIbHO OCMOTpeTb c06CTBeHHo cy6cTpaT onepauliH H KaqeCTBeHHO
npOH3BeCTIi onepaUlIoHHblH npHeM - HaJIO:>KeHlIe IlIBa. )J.JIHHY II 1lJ0PMY pa3pe3a MH ,nocTyna K
nOBpe)l(,D;eHHOMY HepBY paCCqHTblBalOT C yqeTOM He06xo,nIIMOCTH MaKCIiManbHoro 06Ha:>KeHHH He-
pBa BbIIlIe H HII:>Ke MeCTa TpaBMbl. )J;JIH 06Ha:>KeHIIH rny60Ko pacnOJIO:>KeHHbiX HepBoB, nplIKpbITblX
MbIllIl.\aMII, peKoMe yeTCH IICnOnb30BaTb npHMoH ,nocryn. ,[{JIH nO,D;Xo}:(a K CTBonaM HepBoB, 3aHII-
MalO 1IX OTHOCMTeJIbHO nOBepxHocTHoe nOJIO:>KeHlIe, paUIIoHanbHo npHMeHHTb OKOJIbHbIH ,nocryn
(BHe npoeKUIIII HepBa Ha KO:>KY). B 3TOM cnyqae CHH:>KaeTCH BepoHTHoCTb ,naBJIeHIIH nocJIeonepa-
UHOHHoro py6ua Ha HepBHblH CTBOJI. B CBe:>KeH paHe (6e3 nplI3HaKoB HHIlJHUHpoBaHIIH) IIcnonb3Y-
lOT ,nocryn, BbInOJIHeHHblH npli nepBlIqHOH xlIpyprnqeCKOH 06pa6OTKe.
06eCneqlIB ,nOCTaTOqHbIH ,noCTyn, BbI.D:eJIHlOT HepB,no HeH3MeHeHHblX TKaHeH H onpe,neJIHlOT
MaClliTa6bl HeBpOJIII3a. B CBe:>KeH paHe HaXOJJ:jlT KOHUbl nepeCeqeHHOrO HepBa. Onpe,neJIHlOT rpa-
HlIUbl He06xo,n:IIMOH pe3eKUIIII HepBa - npOTH:>KeHHOCTIi He06paTIIMbiX H3MeHeHIIH (pa3MO:>K:>KeHIIH,
KpOBOlI3JIHHHIIH II T.n.). )J;JIH YTOqHeHIIH rny6IIHbI nOBpe)l(,D;eHIIH HCnOJIb3YlOT IIHTpaonepaUHOHHYlO
3neKTpo,nHarHOCTHKY. )J.JIH 3Toro pa3,npa:>KalOT HepB BbIIlIe MeCTa nOBpe)l(,D;eHIIH. COKpa eHHe
MbIIlIU, IIHHepBlipyeMblx 3TIIM HepBOM, CBlI,D;eTeJIbCTBYeT 0 ero npoxo,nHMOCTIi. 3KCTpaHeBpanb-
HbIH py6eu IICCeKaIOT CKanbneJIeM. HepB, c,naBneHHblH KOCTHblMIi 06JIOMKaMH, OCB060)l(,D;alOT OT
KOCTHOH M030JIII }:(onOTOM.
,[{anee CJIe,nyeT 3Tan BHYTpeHHero HeBpOJIII3a. )J,JIH 06HapY:>KeHIIH nOKanH3aUHII BHYTpeH-
Hero py6ua npliMeIDIlOT HH'beKUIiH 0,25 % paCTBopa HOBOKaHHa rro,n 3nHHeBpIIH. PacTBop cB060,n:-
HO npoHIiKaeT no,n 060JIO'lKY HenOBpe)l(,D;eHHOro HepBa H OCTaHaBJIIiBaeTCH B MeCTe IIHTpaHeB-
panbHoro py61.\a. 3TO oc06eHHo qeTKO BII,nHO npli HCnOJIb30BaHIIII IIHTpaOnepaUHoHHoH
MlIKpOCKonlIli. Pe3eKUli1O nOBpe)l(,D;eHHblX KOHUOB npolI3Bo,n:Sl:T ne3BIIeM 6e30nacHoH 6plITBbi RITII
CKaJIbneJIeM. IIpli 3TOM y,nanHlOT HeBpoMY Ha ueHTpanbHoM KOHue II IlIBaHHOMY Ha nepHllJepHqeC-
KOM. llpHKlla,D;blBaH IlIapliKII C TellJIbIM IlJH31I0nOrHqeCKliM paCTBopoM, npoH3BoMT oCTaHoBKY He-
MHHYeMoro KpOBOTeqeHIIH. rJIaBHbIMH KpliTeplIHMII ,nOCTaTOqHOCTIi pe3eKUIIII (lIcCeqeHIIH) Sl:Bfi51-
lOTCH KPOBOTOqlIBOCTb COCy,nOB 3nlI-1i nepHHeBpHH, a TaK:>Ke 3epHIICTbIH co cBoeo6pa3HbIM 6necKoM
rronepeqHbIH cpe3 HepBa. llpH IIHTpaonepaUHoHHoH MlIKpocKonHII BII.D:HbI OT,neJThHble nyqKH aKCO-
HOB.
Coe,nIIHeHHH KOHUOB nOBpe)l(,D;eHHoro neplIllJeplIqeCKOrO HepBa ,nOCTHralOT Y3JIOBbiMli 3llH-
HeBpanbHblMH IlIBaMIi (puc. 17.1). OnepaUIIH 3aKlllOqaeTCH B TOqHOM COnOCTaBJIeHIIII nOnepeqHblX
Cpe30B ueHTpanbHoro II neplIllJepHqeCKOrO KOHUOB nOBpe)l(,D;eHHOrO HepBHoro CTBOJIa. IIepe,n: CIllH-
BaHlieM KOHUbl HepBa YKlla,D.blBaIOT B IIcxo,D;Hoe nOJIO:>KeHHe 6e3 nepeKpyqHBaHliH no OCH, qTO
rrpe}:(oxpaHHeT OT HeCOBna,neHHSI: BHYTPII-
CTBOJIbHbIX CTPYKTyp. )J;JIH CIlIHBaHHH HC-
nOJIb3YlOT aTpaBMaTHqeCKYlO Hrny C CHH-
TeTHqeCKIiMIi HHTRMH (1010). Bbl6HpalOT
KaK HepaccacblBaIOmHHCSI: IlIOBHblH MaTe-
plian (06'bHCHHH 3TO MeHbilieH peaKUHeH
TKaHeH), TaK H paccaCblBalO IIHCH.
B 3aBliCHMOCTH OT ,nlIaMeTpa none-
peqHlIKa HepBa HaKlla,nblBalOT 2 - 4 TOHKlIX
IlIBa. IIepBble IlIBbl HaKlla,nblBaIOT CIiMMeT-
Puc. 17.1. 3nuHeepallbHblu Uloe PHqHO no naTepallbHoMY H Me,nHanbHOMY
130
KpaHX HepBa. YKOn H BblKOn npOBO,D;HT 3ll1IHeBpanbHO B,nOJIb HepBa Ha pacCToHHlI1I 2-4 MM OT KpaH.
3TH IlIBbI BpeMeHHo CJIY:>KaT ,nep:>KanKaMII, C nOMOll.{blO KOTOpblX HepB OCTOpO:>KHO nOBOpaqlIBalOT
no OCII Ha 180 0 B CTOPOHY aCCHCTeHTa ,nJIH HanO:>KeHIIH ,nonOJIHIITeJIbHbIX lliBOB (cHaqana 3a,nHero,
3aTeM nepe,nHero). I10CJIe 3Toro xHpypr II ero aCCHCTeHT, o,nHoBpeMeHHo nOTHrIIBaJ:I HIITb, c6nlI:>Ka-
lOT KOHUbI HepBa, OCTaBJIHJ:I Me)l(,D;y HIIMl1 paCCTOJ:IHlIe B 1-2 MM. Hl1TH 3aBH3bIBalOT. EcnH lliBbl
npope3alOTCH, MO:>KHO HanO:>KIITb He npo,nonbHbIe, a I1-06pa3HbIe 3nlIHeBpanbHbIe IlIBbI Ha:>KOTTa.
O,nHaKo npH IIX BbmonHeHIIH cymecTByeT onaCHOCTb 3aXBaTIITb B IlIOB nyqKII HepBHblx BOJIOKOH.
IIpli 3aTHrlIBaHliH Y3noB coe,nIIHJ:IeMbIe KOHUbI HepBa He ,non:>KHbI c,naBJIIiBaTbCH, IICKplIB-
nHTbCH II U3rH6a TbCH.
I1IOB HaKlla,nbIBalOT B nOnO:>KeHHII KOHeqHOCTH, C03,nalOlI.{eH,nM HepBa MIIHIIManbHoe HaTH-
:>KeHHe. 3TO nOnO:>KeHHe y,nep:>KHBalOT nmCOBOH nOHreTOH 3-4 He,neJIIi nOCJIe onepaUHII. B TOM
cnyqae, eCJIH npH nepBHqHOH 06pa60TKe paHbI He 6bmo YCJIOBIIH ,nJIH HanO:>KeHIIH nepBHqHOrO IlIBa,
qepe3 3-4 He,nenli nOCJIe nOBpe:>K,neHIIH HaKJIa,nbIBalOT pann"H OTCpO'lennLlH IUOB nepBa. 3TO
KacaeTCH YIlIH6neHHblx, 3arpH3HeHHbIX H orHeCTpenbHbIX paHeHIIH. B nepBbIe ,nHII nOCJIe orHe-
crt>eJIbHOrO paHeHIIH Tpy,nHO onpe eJIIITb rpaHIiUbI He06xo,nHMOH pe3eKUIIII He06paTHMO nOBpe:>K-
,neHHbIX yqaCTKOB HepBa. HapYIlIeHIIH npOBO l1MOCTIi MorYT 6bITb 06YCJIOBJIeHbI ero COTpHceHlIeM.
I103:>Ke npOBO,D;IIMOCTb MO:>KeT caMonpOlI3BOJIbHO BOCCTaHOBIITbCH.
BTOP"'lHLlH IUOB HepBa nplIMeHHlOT B pa3JIIIqHbIe CpOKH nOCJIe nOBpe)l(,D;eHHH - OT 4-6
He,neJIb,no HeCKonbKIIX neT. CYTb BTOPlIq-
Horo IlIBa 3aKlllOqacrcH B IICCeqeHlI1I py6-
ua HepBa II CIlIHBaHHII ero «OCBe:>KeHHbIX»
KOHUOB. IIpH 3TOM Hcnonb3YlOT npelIMY-
lI.{eCTBa OTCpOqeHHOrO lliBa Ha HepBbI. Bo-
nepBbIX, ero, KaK npaBIIJIO, BbmOJIHHeT
Bpaq, IIMelOlI.{IIH OnbIT B xHpypmH neplI-
llJeplIqeCKOH HepBHOH CHCTeMbI, a, BO-BTO-
pbIX, CBO,nHTCH K MHHlIMYMY onaCHOCTb
nOCJIeOnepaUHOHHblX HHllJeKUHoHHblX OC-
nO:>KHeHIIH, TaK KaK BOCnalllITeJIbHblH npo-
uecc K 3TOMY BpeMeHH, KaK npaBRITO, y,na-
eTCH KynlIpoBaTb.
B 3a:>KIIBilieH paHe CHaqana npOBO-
,D;HT HCCeqeHlIe py6UOB H npenapOBKY CTBO-
na HepBa Bbillie H HH:>Ke MeCTa TpaBMbl B
npe,neJIax 3,nOpOBbIX TKaHeH. 3aIlJHKCHpo-
BaB BbI.D:eJIeHHbIe qaCTH HepBa Ha pe311HO-
BbIX IIJIII MapneBbIX ,nep:>KanKaX, HaqlIHa-
lOT HeBponH3. I1pOH3BO,nHT 06H3aTeJIbHOe
HCCeqeHlIe HeBpOMbI OT py6UOBbIX cpalI.{e-
HIIH. ,[(mr xnpypmqecKoH 06pa6OTKII UeHT-
panbHOH HeBpOMbI npe,nBapHTeJIbHO CHII-
MalOT 3n1IHeBpIIH, 3aBOpaqlIBaH ero BBepx
BBH,D;eMaH:>KeTKH (puc. 17.2).
IIocne OCBe:>KeHHH nepHllJepwlec-
Koro oTpe3Ka HepBa HaKlla,nbIBalOT TpH-qe-
....._.
. .... .... . ,--;
. .-
?"."' -.'
J _.
. ..- .
, . '..
. :". ;- :: .-
t
)'tf h1' t ';'
Puc. 17.2 3aeOpa'lU6aHUe 3nUHe6pWl e euae MaH:HCem-
KU npu xupypcU'IeCKOU o6pa6omKe HeepOMbl
'" .,-
---_. -.;"'.
. " , - .-
j.". <.; - ii
. , .: i I ;;' _ i: <
'<'i'.- ;l ,.
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l.k::: JH "t:: "'.. ttlI:
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.' 9.ry, "m1\!
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)- '.. XN
PUC. 17.3 COeaUHeHUe H1I06 Hep606 11-
o6pa3HblMu weaMU, npox{'oRUjUMU '1epe3
OCHoeaHue Mali:HCemKU
131
rnaBa 17
. /' 'h -".,.-' ,..1-._
. . ;t " IT";>H ... '"'' tF' .. \iTI\'
lY(!'l''','I''/' . ''''.,'' . '', .,.. 't, .l l i;' ! !'
. .. .,-,.<'
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'I! 't t.W "' >. ill>' '..dW"
.. -, I'(J ..._. ,'
PUC. 17.4 <PuKCaljWl Mall:J/CemKU.
HWlo:J/CeHue Ulea Ha nepu4JepU'leCKUU uepe
nOClle o6pa6omKU ueepOMbl
TbIpe II -06pa3HbIX Y3JIOBbIX IlIBa, KOTOpble npO-
XO,nHT qepe3 OCHOBaHlie MaH:>KeTKH (puc. 17.3).
IIpH 3aBH3bIBaHIIII HHTeH nepHllJeplIqeCKHH OT-
pe30K HepBa BXO,nIIT B MaH:>KeTKY ueHTpanbHoro
OTpe3Ka. IIpH 3TOM C03,naeTCSI: XOpOllIlIH KOHTaKT
HepBHblX BonOKOH. KpaH MaH)l(erKIi CMell.{alOT Ha
nepHllJepmecKHH KOHeu HepBa II no,nIlIIiBalOT OT-
,nenbHbIMIi Y3nOBbIMH llIBaMH K ero 31IIIHeBpHIo
(puc.17.4).
CilllITbIH HepB.D:JIH npe,nOTBpameHIIH cpa-
CTaHIIH C anoHeBp03aMII, llJacUIIHMH H KO:>KHbIMH
nOKpoBaMIi 06H3aTeJIbHO nOMell.{alOT B MbIllieq-
HbIH IlJYTmp.
e-
ee '
ee c
. ""..
rJIaBa 1'8
-.
, _:::
. .:'
'.1If ,
i:;H1BLI CYXO/KMJiJIM
0,.
,
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;: _.....
YqlITbmaH oc06eHHOCTli rnCTOJIOrlIqeCKOrO CTpoeHIIH CYXO:>KRITIIH, TeXHIIKa 1lI0BHoro coe,nH-
HeHII5I 3TIIX TKaHeH npe,nCTaBJIHeT C060H 60JIbiliHe TpY.D:HOCTII. I1pe)l(,D;e Bcero, He06xo,nHMO yqHTbl-
BaTb BOJIOKOHHYlO CTpYKTYPY CYX0:>KRITliH. Ka)l(,[(brn BOJIOKOHHbIH nYQOK OKpY:>KeH coe,nIIHHTeJIbHOH
TKaHblO (:JH OTeHOHOM), a Bce CYXO:>KHJIHe nOKpbIBaeT 60nee nJIOTHaH 060JIOqKa (nepUTeHOH).
TOHKIIH CJIOH pbIXJIOH Klle aTKII, B KOTOpOM pacnOJIaraerCH CYXO:>KRITHe C 060JIOqKaMH, Ha3blBaer-
CH napaTeHOHOM. B 06naCTH nanbueB KIICTH H CTonbl CYX0:>KIIJIHH 3aKJIlOqeHbI B CHHOBHaJIbHble
Bnaranmua, CKJIa,nKH KOToporo 06pa3YlOT CYX0:>KHJIbHYlO 6pbI:>KeHKY - Me30TeHOH. Bce 3TH 06pa-
30BaHliH HMelOT ,nOBonbHO xopOlliee KpOBOCHa6:>KeHHe. Oc06eHHO ryCTaH KpOBeHOCHaH ceTb OTMe-
qaerCH B 06JIaCTH nepHTeHOHa H Me3aTeHOHa. IIpH onepaUIIHX Ha CYXO:>KRITIIHX COCy,nbI 3TOH ceTIi
Tpe6YlOT OCTOpO:>KHOrO H IUa,nHIUero 06paIUeHIIH.
IIpouecc pereHepaulI1I nOBpe)l(,D;eHHoro CYXO:>KRITIIH ,nOBOJIbHO ,nJIlITeJIbHbIH. Ha npOTH:>Ke-
HlIIi nepBOll. He,neJIH B MeCTe coe,nIIHeHIIH CYX0:>KRITbHbIX BonOKOH 06pa3yeTcH IlJH6p06naCTHqeC-
KaH cnaHKa. OHa He B COCTOHHHII BbI.D:ep:>KaTb ,na:>Ke He3HaqlITeJIbHOrO HaTH:>KeHHH. TonbKO cnYCTH
3-4 He,neJIIi 1lJ0pMHPyeTcH ,nOBonbHO npOqHOe coe,nHHIITeJIbHOTKaHHoe coe,nHHeHHe. IIpoueccbI
nponHllJepaUHH H BacKynHplI3aUHII 06JIaCTli lliBa, npOXO.D:5IIUHe B 3TO BpeMH, n03BOJIHlOT coe,nIIHH-
TeJIbHOTKaHHbIM CTpYKTYpaM npH06peCTH HeKOTopoe CXO,nCTBO C CYXO)l(lIJIbHbIMH BonbKHaMIi. OKOH-
qaTeJIbHOe 1lJ0pMHpOBaHlie Py6ua npOHcxo,nIIT cnycnl 3-4 MeCHua nOCJIe HaJIO:>KeHHH lliBa.
I1plI npOllilIBaHlIIi pa3pymeHHblX CYXO)l(lIJIIiH MOryT 6bITb ,nOnyIUeHbI HecKonbKo BH,D;OB OllIH-
60K. Bo-nepBblX, 1IH0r,na HeonbITHble xHpyprlI 3aXBaTbIBalOT B CTe:>KOK llIBa 60nbilioe KOnlIqeCTBO
CYX0:>KRITbHblX BOJIOKOH, HapYlliaH TeM caMbIM IIX KpoBOCHa6:>KeHlIe. ECJIII 3Ta OIlIII6Ka 06HapY:>KeHa
cpa3Y, TO He06xo,nIIMO HanO:>KIITb HOBbIH lliOB. rOpa3,n0 xY:>Ke, Kor,na OIlIH6Ka OKa:>KeTCH He3aMeqeH-
HOH, qTO qpeBaTO pa3BIITHeM HarHoeHIIH H3-3a HllIeMHH IIJIH HeKp03a. Oc06eHHO 6epe:>KHO CJIe,nYeT
06paIUaTbCH C 6pbl:>KeHKOH CYXO:>KRITIIH, qepe3 KOTOpylO npOXO.wIT OCHOBHble apTeplIanbHbIe CTBO-
nbl.
BO-BTOPbIX, HanO:>KeHHble Ha KOHUbI CYXO:>KHJIIiH nliraTypbI Hepe,nKO npope3alOTCH, nHiliaH
BonOKHa ueJIOCTHOH CTpYKTypbl. KaK npaBIIJIO, 3TOT BH,D; ollIH60K CBSl:3aH C TeXHlIqeCKHMH norpeIlI-
HOCTHMH xlIpypra - CJIHIlIKOM CIIJIbHbIM 3aTHrlIBaHHeM HHTOK. I1pope3bIBaHIiH Y3JIOM y,naeTCH H3-
6e:>KaTb OCTOpO:>KHbIM 06pall.{eHIIeM C TKaHblO.
TlinlIqHOH OIlIII6KOH HBJI5IeTCH pacnOnO:>KeHHe Y3JIOB Ha nOBepXHOCTIi CYXO:>KRITIIH, qTO Hapy-
IlIaeT HX CKOJIb:>KeHHe. Oc06eHHO Ba:>KHO 6epe:>KHO OTHOCHTbCH K KOJIbueBbIM H KpeCTo06pa3HbIM
qaCTHM IlJH6p03HbIX BJIaranHIU, KOTopbIe CJIY:>KaT cBoe06pa3HbIMH HanpaBJIHlOlliHMH KaHaJIaMIi
MH CYX0:>KRITbHbIX BOnOKOH.
IIpH HanO:>KeHIIII IlIBOB Ha CYJtO:>KRITIiH CJIe,nyeT OTKa3aTbCH OT npHMeHeHIIH rpy6blX 3a:>KIIMOB
H xlIpyprlIqeCKOrO nliHUeTa. He06xo,nHMO Hcnonb30BaTb TOHKlIe npOqHbIe, apeaKTHBHble, pacca-
cblBalOIUHeCH HHTH C YCJIOBHbIM ,nHaMeTpOM 6/0-8/0 Ii aTpaBMaTlIqeCKlie HmbI Kpymoro CeqeHHH.
133
rnaBa 18
KOHqHK TaKoH IIrnbl,non:>KeH 6bITb OCTpbIM TpexrpaHHblM, a Teno H30rHYTo Ha 3/8 ,nJIHHbl
OKPY:>KHOCTH. Ha nOBepxHocTHO ne:>KalliHe CYXO:>KIIJIHH lliBbI HaKJIa,nbIBalOT C nOMOIUblO npHMoH
HI'nbL
)J;JIj{ ,nOCTII:>KeHIIH KaqeCTBeHHoro npOIlIIiBaHII5I TKaHeH CYXO:>KRITIIH oc06eHHO Ba:>KHO C03,naTb
YCJIOBHH,D;JIH xopolliero 0630pa nOBpe)l(,D;eHHblX KOHUOB. IIpli OTKpbITblX TpaBMax CYXO:>KRITIIH MbIlIIU-
pa3rlI6aTeJIeH, KpaH KOTOpblX npli nepeceqeHHII ,naneKO He pacxo,nHTCH, 3TO He TPy,nHO c,nerraTb
qepe3 paHY. lipH 3aKpbITbIX TpaBMax RITII nepeCeqeHIIH MbIIUu-crII6aTeJIeH,D;JIH 06JIerqeHIIH MaHII-
nynHUIIH HCnOJIb3YlOT ,nononHHTeJIbHble pa3pe3bI.
IIo,nbITO:>KHM OCHOBHbIe Tpe60BaHIIH, npe,n'bHBnHeMble K IlIBaM CYXO:>KRITIIH:
- yqlITblBaH 06RITbH)'IO KpOBeHOCHYlO ceTb CYX0:>KRITIIH, lliOB He ,non:>KeH CYIUeCTBeHHO Hapy-
lliaTb KpOBOCHa6:>KeHlIe;
- yqlITblBaH no,nBII:>KHOCTb CYXO:>KRITIIH, npH HanO:>KeHHH IlIBa He06xo,nllMO 06ecne b coxpa-
HeHlIe rna,D.KOH, CKOnb3HlI.{eH nOBepXHOCTIi CYXO)l(Hll1IH II OrpaHHqnTbCH npHMeHeHlIeM MIIHHMaJIb-
Horo KOnlIqeCrna HIiTeH;
- yqlITbIBaH ,nJIIITeJIbHOCTb npouecca pereHepall.HH (1-4 Mec.), lllOB ,nOJI:>KeH KpenKO y,nep)l(lI-
BaTb KOHUbl CYXO:>KIIJIHH B TeqeHlIe ,D;JIIITeJIbHOro BpeMeHH II He ,nonYCKaTb HapymeHIIH. ueJIOCTHOH
CTpYKTypbl BOJIOKOH;
- yqlITbIBaH HH3KYlO pe3IICTeHTHOCTb CHHOBlIanbHOH 060nOqKH CYXO:>KIIJIHH K IIHllJeKUHII H
6JIarOnplI5ITHble YCJIOBIIH,D;JIH pa3BHTIIH naTOrefJHOH MHKpOIlJJIOpbl B 3aMKHYTOM CHHOBHaJIbHOM
IlJYTnHpe, IlIOB ,nOJI:>KeH HaKlla,n:bIBaTbCH B YCJIOBIIHX CTpOrOM aCenTH1JHOCTIi HHepTHblMH HIITKaMIi.
COBpeMeHHaH xlIpyprlIH 06na,D.aeT HeCKOJIbKIIMH BlI,D;aMH lliBOB, y,nOBJIeTBOpHlOIUIIMH 3TII
Tpe60BaHIIH. IIplIBO,D;IIM IIX KllIIHlIqeCKYlO KJIacclIllJlIKaUHIO.
KJIaCCHlj>HKaQHH IUBOB CYXO)KHJIHH
WI IIo BpeMeHH HaJIO)KeHHH pa3nHqalOT:
- nepBHqHble IlIBbl, KOTopble HaKlla,nbIBalOT Ha npOTH:>KeHIIII 24 1JaCOB OT MOMeHTa
HapYllieHIIH uenbHOCTH CYXO:>KRITIIH npli OTCYTCTBIIII npH3HaKOB BocnaneHIIH paHbI;
- BTOpH'IHble paHHHe IlIBbI - HaKlla,nbIBaIOT Ha npOTH:>KeHIIH 2-6 He,neJIb nOCJIe no-
Bpe)l(,D;eHIIH H 3a:>KIIBneHHSI: KO:>KHOH paHbl;
- BTOplIqHble n03l1.HIIe IlIBbl - HaKJIa,nbIBalOT 1Jepe3 6-8 He,neJIb nOCJIe nOBpe)l(,D;eHHH.
B 60JIee n03,nHlle CpOKH npH6eralOT K ImaCTHKe CYXO:>KIIJIHH.
WI IIo cnoco6y HaJIO)KeHHH pa3rrHqalOT:
- lliBbl C HHTHMH H Y3JIaMH Ha nOBepXHOCTH CYXO:>KRITIIH;
- BHYTPHCTBOJIOBbIe IlIBbl C Y3JIaMH, norpY:>KeHHblMM Me)l(,D;Y KOHuaMH CYXO:>KlillIIH;
- BHYTplICTBonoBble lliBbI C Y3JIaMli II HIITHMII Ha nOBepxHoCTIi CYXO:>KlillHH;
- KOM6HHIIpoBaHHbIe JIIBbl.
III IIo MeCTY HaJIO)KeHHH pa3JIlIqalOT:
- IlIBbl CYXO:>KIIJIIIH, pacnOJIO:>KeHHbIe BHe CHHOBlIanbHblX BJIaranIIIU;
"
., IlIBbl CYXO)l(HllIIH, pacnOJIO:>KeHflbIe B CIiHOBlIanbHblX BJIaranmuax.
134
.. IIoTexHHkenpoueAeHuH HUTeiipa3JIHqatot: >y
- Y3JIOBbIe UHpKynJlpHbIe IlIBbI (nOnepeqHbIH IlIOB, IlIBbI ApKca, BIIJIMIMCa, BIITIJ:eIDI,
TIIJIJIo) ;
- nHraTypHbIe IlIBbI. B 3TOM CJIyqae JIHraTypbI Ha COe,nIIHHeMbIX KOHuaX CYXO:>KIIJIIiH
npeAOXpaHHlOT IlIOB OT npOpe3bIBaHII (iliBbI raHrOnbllJa, IlIBapua);
- I1-06pa3HbIe lliBbl (O,nHOCTe:>KKOBble II MHOrOCTe:>KKOBbIe) (iliBbI JIaHre, Manelmqa,
<l>pIIIIJa );
- KpeCT006pa3HbIe IlIBbI (lliBbI ,[{peHepa, 1lI1OCJIepa, IOCTa);
- neTJIeBbIe IlIBbI (lliBbI Ka3aKOBa, TpaHKe);
'- KOM6HHlIpOBaHHbIe IlIBbI (IliBbI J1lIpa, Xemepa).
mOB CYXO:>KHJIHM, P ACrrOJlO:IKEHHbIX BHE CMHOBI1A.JThHbIX BJIAr AJIHll{
PaCCMOTpHM oc06eHHOCTH coe,nHHeHIISI: CYXO:>KIIJIHH, pacnOnO:>KeHHbIX BHe CIIHOBHanbHblX
BllaranHlu. Tpa,nHUHoHHO HaqlIHalOT C nepBlIqHOll. xHpyprlIqeCKOH 06pa60TKH paHbl. 3aTeM, npe,n-
BHJJ:H He06xo,nHMOCTb HanO:>KeHIIH IlIBa, KOHUbl pa30pBaHHoro CYXO:>KIIJIIIH IlJIIKClipYlOT nHHueraMH.
3KOHOMHO OTceKalOT ,no nOHBJIeHIIH HopManbHoH BOJIOKHHCTOH CTPYKTypbI. Coe,nIIHHlOT TKaHH o,n-
HJIM 1I3 cnoc060B.
Cnoco6 EpaYHa (puc. 18.1). KOHUbI CYX0:>KRITIIH 3aBO.D:HT 0,n1IH 3a ,npyroH H CIlIHBalOT 60KO-
BbIMIi II-06pa3HbIMH lliBaMH. Bo H36e:>KaHlie TpaBMaTII3aUIIII CIlIIiBaeMbIX TKaHeH, ueJIeco06pa3HO
He 3aXBaTblBaTb HX nHHueTOM, a IlJHKclipoBaTb lliBaMH-,nep:>KanKaMH. IIoTHrHBaH 3a HlIX, MO:>KHO
KaqeCTBeHHO HanO:>KHTb nOCTOHHHbIe IlIBbI.
B TOM CJIyqae, eCJIH ueHTpanbHbIH OTpe30K CYXO:>KHJIIiH 60JIee TOJICTbIH, qeM nepHllJepHqeC-
KIIH, Hcnonb3YIOT cnoco6 JlH'ITMaHa (puc. 18.2). .ZJ:JIH 3TOro CHa qana ueHTpanbHbIH oTpe30K B,nonb
CYXO:>KIIJIIIH pacceKalOT nOnOJIaM. Me)l(,D;Y ,nBYMH ero nOJIOBHHaMIi pa3Mell.{alOT nepHllJepHqeCKHH
KOHeu, H HaKlla,nblBalOT OT,neJIbHbIe CKB03Hbie II -06pa3HbIe IlIBbI. CB060,D;HbIe KOHUbl ueHTpanbHo-
ro oTpe3Ka no,nIlIHBalOT K nepHllJeplIqeCKoMY oTpe3KY CYXO:>KRITIIH OT,neJIbHbIMH Y3JIOBbIMli IlIBaMIi.
!' '1JI! )9
.8;21
.' .
.-
.;::
.;;
-
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Puc. 18.1 CoeOulleHue
nepeCl!'leHHOZO CYXO:J/CWlWI
no cnoc06y EpaYHa
PUC. 18.2 COeaUHeHUe
PUC. 18.3 CoeOuHeHue
nepeCl!'leHHOZO CYXO:J/CU!lUR no
cnoc06y JJ'1mmMaHa
nepeCe'leHHOZO CYXO:J/CWlUR no
cnoc06y llYRb6epmapma
[35
rJIaBa 18
Cnoc06 IIYJIbBepTa Ta (pUc. 18.3) - npliMeHsrlOT TOJIbKO B Tex cJIyqa x, Kor,na KOHUbl cyxo-
:>KRITIIH M06RITbHbI (He HaTHHYTbI) H MOryT 6blTb COnOCTaBJIeHbI Ha npOTH:>KeHlIH 3-4 CM. B,nOJIb BQJIO-
KOH o,nHoro H3 CYXO:>KIIJIHH ,neJIalOT HeCKonbKO npo,nonbHbIX pa3pe30B. B nOJIyqeHHbIe OTBepCTWI
npOBO,D;Sl:T ,npyroH KOHeu CYXO:>KIIJIIiH. MeCTa pa3pe3a IlJIIKCnpYlOT OT,neJIbHbIMH Y3JIOBbIMH lllBaMH.
. Cnoc06 qaCTO npHMeHHlOT npH nepeca,D.KaX CYXO:>KIIJIHH.
1lI0B CYXo)KR)llfj.f, P ACnOJIO)l{EHHLIXB CHHOBI1AJILHbIX BJIAr AJIHI..QAX
1lI0B JIaHre (puc. 18.4). BHaqane npolliHBalOT nepHllJepHqeCKIiH KOHeu CYXO:>KRITHH. HIITb
npOBO,D;Sl:T B,Z:\OJIb xo,na BOJIOKOH II BblKanbIBalOT Ha Topue. 3aTeM B 06paTHoM nop .D:Ke HIITb npoBo-
,nHT Ha ueHTpaJIbHOM KOHue. I10cJIe BbIBe,neHIIH HrnbI Ha 60KOBYlO nOBepxHocTb Ha HeKoTopoM
paccToHHHII npoH3Bo,Z:\IITCH CJIe,nYlOIUHH YKOJI. IIocJIe a,nanTaUHH coe,nIIHHeMbiX KOHUOB CYXO:>KII-
JIHH, HIITH 3aBH3bIBalOT Ha nOBepxHocTIi CYX0:>KIIJIHH. O,nHaKo c03,naHHbIH yJeJI pa3MelUaeTcH Ha
nOBepXHOCTH CYXO:>KRITHH, qTO 3aTpY.D:HHeT CKOnb:>KeHlIe CYXO:>KIIJIIIH B TKaHHX.
PacnpOCTpaHeHHbIH mOB KIOHeo (puc. 18.5) nlIIlIeH 3Toro He,nOCTaTKa II OTnHqaeTCH npoq-
HOCTblO coe,nIIHeHIIH KOHUOB CYX0:>KIIJIHH - npope3aeTcH TaKoH IlIOB npH HarpY3Ke 950 r. ,[{nH ero
HanO:>KeHIIH nOHa,n06IITCH ,nJIHHHa nHraTypa C Ha,neTbIMH Ha ee KOHUbI npHMbIMH HrJIaMH. Ha
pacCToHHlIIi 2-2,5 CM B nOnepeqHOM HanpaBneHHII npolliliBalOT ueHTpanbHblH yqaCTOK nepeCeqeH-
Horo CYX0:>KRITIIH. 3aTeM KOCO OTHOClITeJIbHO xo,na BonOKOH <POpMIIPYlOT CTe:>KKH TaKIiM 06pa30M,
qT06bI OHII nepeceKanHcb. BblBO,D;Sl:T 06a KOHua HlITIi B Topue cyxmKRITIiH. TaKHM:>Ke 06pa30M ,nPY-
roH HlITblO npoIlIHBalOT nepHllJepHqeCKliH yqacTOK. KOHUbI H1ITeH, BbIBe,neHHbIX qepe3 nonepeqHOe
CeqeHlIe CYXO:>KRITHH, CBH3bIBalOT. Y3JIbI, pacnOJIO:>KeHHbIe B TOJIlI.{e CYXO:>KRITIIH, He MeilialOT ero
CKOJIb:>KeHHlO. K He,nOCTaTKaM IlIBa KlOHeo MO:>KHO OTHeCTH ero CKllOHHOCTb K pa3BOJIOKHeHHlO
CIlIIiBaeMbIX TKaHeH, oc06eHHO npH CIIJIbHOM CTHrHBaHHII HHTOK, H B03MO:>KHOCTb c,naBJIeHIIH KpO-
BeHOCHblX COCy,nOB B TOnll.{e CYXO:>KRITIIH.
)J;JIH ClliHBaHHH CYX0:>KRITHH nanbl.(eB KlICTIi IICnOnb3YlOT mOB EaHHeJIJIa (puc. 18.6) - C'beM-
..
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PUC. 18.4 COeOUlIeHUe
PUC. 18.5 COeaUHeHUe
Puc. 18.6 COeaUHeHUe
nepece eHHOZO cYXO unUR
lUeOM JI4IIze
nepece eHHOZO CYXO UJlUR
UleOM KIOHeo
nepece ellllozo CYXO UJlUR
Ul60M EaHHeJlJla
136
HbIH BHYTplICTBOJIOBOH moB. B 3TOM cnyqae B KaqeCTBe lliOBHoro MaTepHana Hcrronb3YlOT TOHKYlO
XpOM-MonII6,neHOBYlO RITII TaHTallOBYlO npOBonoKy. .ZJ:nH 06eCneqeHIIH HalI60nbIlIeH HMM06RITII3a-
UHII HaqlIHaIOT IlIIITb C npOKCHManbHOrO OTpe3Ka CYX0:>KRITIIH. IIpoBonoKY npOBOMT B nOrrepeqHOM
HanpaBneHIIII, oTcTynHB npe,nBaplITeJIbHO 2-2,5 CM OT KpaH CYXO:>KRITIIH. IIo,n 3TOT lliOB rro,nBo,nHT
BTOpylO npOBOJIOKy, C nOMOIUblO KOTOpOH rrpOH3BOMT 1I3BJIeqeHHe HHopo,nHoro MaTepHana nOCJIe
Toro, KaK rrpOqHO cpaCTYTCH ero KOHUbI. )],anee nOCJIe,nOBaTeJIbHO npOKanblBalOT HaCKB03b B KO-
COM HarrpaBneHIIH npOKCHManbHblH OTpe30K CYX0:>KRITIIH. qepe3 rrOnepeqHblH cpe3 CYX0:>KIIJIHH
npOBonOKY npOBOMT Ha nepHllJepmecKIiH ero KOHeu. IIocJIe,nHHH npoIlIHBalOT B rrpo,nonbHoM Ha-
npaBJIeHlIlf. KOHUbI npOBOJIOKH BbIBOMT 1I3 CYXO:>KRITIIH no,n OCTpblM yrnoM II IlJIIKClIpyIOT Ha KO:>Ke.
HaTHrHBalOT KOHUbl rrpOBonOKH ,no rronHOH a,narrTaUIIII cpe30B CYXO:>KRITIIR. CB060,nHble KOHUbI
npoBo,nHT qepe3 oTBepcTlie B nyroBHue II CBSl:3bIBalOT Ha HeH. IIpoBOJIOKY, C nOMOll.{blO KOTOpOH
6y,neT y,naneHa nOCJIe cpall.{eHHH CYX0:>KIIJIHH IlJHKcnpYlOIUaH ee npoBonoKa, TaK:>Ke BbIBO,nHT Ha
KO:>KY H 3aKpenJIHlOT Ha ,npyroH nyroBHUe. .ZJ:JIH CHHTHH IlIBa OTceKalOT IlJIIKCHpyIOlI.{YlO CYXO:>KIIJIlie
npOBOJIOKY rro,n nyroBHUeH H BblTHrlIBalOT ee.
CYXO)KHJIbllble IUBLI EJIoxa-EoHHe H P030Ba (puc. 18.7, 18.8) ManoTpaBMaTHqHbI (He3Ha-
'lIITeJIbHO pa3BonOKHHlOT npolliHBaeMYIO-TKaHb) H npOqHbI. OHH OTJIlfqalOTCH TeM, qTO npli rrepBoM
1I3 HIIX HlITb nOCJIe nOnepeqHOrO npOIlIHBaHHH CYXO:>KHJIHH npoBo,nHT Ha nJIOCKOCTlI ero CeqeHHH
KpeCTo06pa3Ho, a npli BTOpOM - npo,nonbHo. 06l1.{IIM He,nOCTaTKOM HBJIHeTCJ'I c,naBJIeHHe qaCTH
KpoBeHocHblX COCy,nOB B TOnll.{e CYXO:>KRITIIH.
CXeMaTlIqeCKOe H306pa:>KeHlIe ,npyrHx BH,D;OB CYXO:>KIIJIbHbIX IlIBOB npe,nCTaBneHo Ha
puc. 18.9.
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Puc. 18. 7 COeaUHeHUe nepecl!'lt!H-
HOcO CYXO:HCWlWl UleOM EJloxa U
EO/me
PUC. 18.8 COeaUHeHUe nepece-
'leHHOcO CYXO:JlCUJlUR UleOM
P030ea
137
rnaBa 18
a
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Puc. 18.9 COeaUHeHUe nepeCe'leHHOi!O CYX03ICU-
RWl UleOM: a - ApKca; 6 - BURbMca; e - BumljeJ/J/;
i! - Ta/li!ORbt/Ja; a - )J,peuepa; e - KmaKoea; 3IC -
JIupa; 3 - MaJle6U'la; u - nOnepe'lHblU Uloe;
K - TWlRo; R - TpallKa; M - TpaHKa; H - CPpUUla;
o -Xei!.nepa; n - Weaplja; p - WlOcRepa; c -
IOcma
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139
rnaBa 18
3AKOH KYWHEPA
lJJaHCbI Ha BbillOJIHeHlIe pa60TbI 06pamo nponOpUHOHaJIbHbI qHCny nHU,
no ,nonry CJIY:>K6bI 06J13aHHbIX 3TO c,neJIaTb.
\
llPllHI.JHll llqJEHqJEP A
HHKor,na He npHHIIMaHTe pellieHlIe caMH, ecJIH MO:>KHO 3aCTaBHTb pellIlITh KorO-TO ,npyroro.
AKCHOMA IYP/{A
Ha c06paHIISI:X - 3KOHOMHT MHHyTbI II TepHlOT qaCbI.
3AKOHhI YXO/{A 3A EOJIhHhIMH TEJIECHO
1. Bce TeJIeBH30pbl Haxo,nJHCH Ha ,npyroM KOHue nanaTbl.
2. TanaHT Bpaqa 06paTHo nponopUHoHaneH B03MO:>KHOCTH nonaCTb K HeMY Ha nplieM.
3. ECTb ,nBa BlI,D;a neHKOnnaCTblpB: TOT, KOTOpblH HeB03MO:>KH0 npHKlleHTb, H TOT, KOTOpblH
HHKaK He y,naeTCH CHHTb.
4. Bce Tpe6YlOT YKona o,nHOBpeMeHHO.
5. KTO He ,naBan CTaBHTb YKon B Ha3HaqeHHOe BpeMH, Tpe6yeT lIH'beKUHH, Kor,na pa3,nalOT
CHOTBopHoe.
llPABHJIOEAPAXA
AnKoronliK - 3TO TOT, KTO IIber 60nbille CBoero Bpaqa.
AKCHOMA/{EXAJI
IIpOCTYIO pa60TY OTKJIa,nblBalOT, CqIITaH, O Bcer,na HaH,neTCH BpeMH c,nenaTb ee n03:>Ke.
llEPBhIH3AKOH PEMOHTA
Henb3S1: nOqfIHHTb TO, qTO He CJIOMaHO.
/{HJIEMMA/{EBPH
ECJIH BbI o,nHOBpeMeHHO Ha:>KanH ,nBe KJIaBIIIlIH nHllIYIUeH MallilIHKH, TO OTneqaTaeTCH Ta,
KOTOpylO BbI3a,D.eJIH HeqaHHHO.
140
r--::
--....;.
d
lllBbl. KOCTll
WaBaI9
U,eJIblO IlIBa Ha KOCTH HBJIHeTCH npOqHOe IlJHKCHpOBaHHe 06JIOMKOB Ha Beeb nepHO,n HMMO-
6RITH3aUIIII KOHeqHOCTIi H KOHCOJIH,D;aUHH KOCTHOH M030JIH. BnpOqeM, KOCTII (BepHee IIX 06JIOMKII)
coe,nIIHHlOT IlIBaMH TOJIbKO npli HanlIqHH onpe,neJIeHHbIX YCJIOBIIH, a IIMeHHO:
- ,nlIarHOCTHpOBaH KOCOH nepeJIOM, nOCKOJIbKY npli HaJIHqHH nOnepeqHOrO nepeJIOMa C no-
MOll.{blO IlIBa He y,naeTCH ,nOCTlirHYTb CTa6RITbHOCTH 06JIOMKOB;
- HMelOT ,neJIO co CBe:>KHM nepeJIOM KOCTH;
- B paHe npOH3Be,neH TlI.{aTeJIbHbIH reMOCTa3;
- npOH3Be,neH IlIHpOKIiH ,nOCTyn K Mecry HaJIO:>KeHII5I IlIBa.
IIepe,n HaJIO:>KeHHeM IlIBa Ha KOCTb npe,nBapHTeJIbHO npOH3Bo,nHT 06pa60TKY 06JIOMKOB.
MM npe,nalOT KOHrpY3HT.HY1O 1lJ0PMY, a 3aTeM ,n06IIBaIOTCH TOqHOro II DJIOTHOrO COnOCTaBJIeHIIH. Bo
BpeM5I3THX npoue,nyp Tpe6yeTcH 6epe:>KHOe OTHOIlIeHHe K Ha,nKOCTHHue. Pe3YJIbTaT onepauHH Ha-
npHMYlO 3aBliCliT OT COXpaHeHHH Ha,nKOCTHIIUbl B 30He IlIBa.
IIpH coe,nIIHeHIIII KOCTeH IlIOB He06xo,nIIMO HaKJIa,D;blBaTb nocpe,nIIHe. H CTporo nepneHJJ:IIKY-
JIHpHO K JIlIHIIH nepeJIOMa. T onbKO B 3TOM cnyqae MO:>KHO ,nOCTHqb npOqHOro cpaCTaHII5I 06JIOMKOB.
)J;JIH HaJIO:>KeHII5I IlIBOB Ha KOCTII B OCHOBHOM HCnOJIb3YlOT npOBOJIOKY H3 CneuHaJIbHbIX He-
MarHIITHblX Hep:>KaBelOlI.{IIX COpTOB CTalllI (MapKII IXI8H9T, 3II-400, 3K-2, 3.HT-l), THTaHa, HlIXpO-
Ma, TaHTana ,nHaMeTpOM 0,7-0,8 MM. I1Hor,na npHMeHHlOT CllHTeTHqeCKlie HHTII (KanpOH, JIeTRITaH,
JIaBcaH) XpOMlipOBaHHbIH KeTryT TaKoro :>Ke ,nHaMeTpa. IIpHBe,neHHbIe BH,D;bl npOBOJIOKH HMelOT
,nOCTaTOqHYlO npOqHOCTb H rII6KOCTb. 3TO HeMaJIOBa:>KHO, TaK KaK npH 3aKpyqlIBaHliH npOBOJIOKH
npHxo,nmCH neJIaTb He MeHee 3-4 060pOTOB.
B OTJIlIqlIe OT npOIlIHBaHIiH HlITblO, ,D;JIH HcnOnHeHlI5I IlIBa Ha KOCTII He06xo,nHMO npOBeCTII
IlIOBHbIH MaTeplIaJI qepe3 npe,nBapHTeJIbHO npo,neJIaHHbIe OTBepCTIiH (KaHaJIbI). Mx ,neJIalOT TOH-
KHM CBepJIOM HJIII IlIapOBH,D;HblM 60pOM. BMeCTO Y3JIa, B npliBbIqHOH ero 1lJ0pMe, 1lJ0PMIIPYIOT nepe-
DJIeT KOHUOB npOBOJIOKH. 113JIIIIIlKli npOBOJIOKIi 06pe3alOT. « Y CIIKII» npOBOJIOqHOrO IlIBa 3arH6alOT
no,n yrJIOM 90° K ero DJIOCKOCTH H 3aTlipalOT HalllIJIbHIIKOM.
HalI60JIee IlIHpOKO nplIMeHHlOTcH CJIe,nYlOlI.{He Ba-
pHaHTbI IlIBa KOCTII:
KpyroBOU Y3JIOBOU IUOB Ha KOCTH. ,[{JI5I ero HCnOJI-
HeHIISI:, B nepBYlO Oqepe,nb, He06xo,nIIMO OqHCTlITb JIHHHIO
nepeJIOMa, 06pa60TaTb H CJIO:>KIITb 06JIOMKH. IIoToM npH-
CTynaIOT K BbillOJIHeHHlO nepneH,D;IIKYJIHpHO npo,neJIaHHblX
CKB03HbiX OTBepCTHH. I1x pa3Mell.{alOT Ha 1-1,5 CM JIaTe-
paJIbHee OT JIHHHH nepeJIOMa. B 06pa30BaBIlIliecH oTBep-
CTHH npoBo,nHT IlIOBHbIH MaTepHaJI II 1lJ0pMIIpYlOT neTJIlO
(puc. 19.1). He06xo,nHMO CJIe,nIITb 3a HanpaBJIeHHeM
Puc. 19.1 KpYi?oeou Y3JlOeOU Uloe Ha
Kocmu. KOHeli npOeOJlOKU, omomymblu
noa Yi?JlOM 90 0 K nJlOCKOCmU Ulea
141
rJIaBa 19
.;;_L. .
. """';' i'; ' \:kii.1 .;::. " .. ' . .
... . ,,<h".J _ _ ": i1-' i"t4 ...'
:' I
Puc. 19.2 1l-06pa3HbIU Uloe Ha Kocmu
...........
'I,
Puc. 19.3 8-06pa3Hblu Uloe Ha Kocmu
OTBepCTIiH. OTKllOHeHHe era OCH OT nHHHII nepeJIOMa MO-
:>KeT npliBeCTH K ,neBHaUIiH KOCTHbIX 06JIOMKOB.
,[{OCTOIIHCTBOM KpyroBOro Y3JIOBOro IlIBa HBJIHeT-
CH OTHOCIITeJIbHaH rrpOCTOTa H 6bICTpOTa HaJIO:>KeHIIH, a
TaK:>Ke no,nTBep)l(,D;eHHM npaKTIIKOH Ha,ne:>KHOCTb.
n-06pa3HblH IIJOB Ha KOCTH. Ha rny6IIHY nOJIO-
BlIHbl nonepeqHOrO CeqeHII5I KOCTII TOHKIIM CBepJIOM npo-
,neJIbIBalOT KaHanbI Ha 060lIX KOHuax KOCTII. PaCCTOHHHe
Me)l(,D;y OTBepCTIIHMH He nOJI:>KHO npeBblIlIaTb 2-2,5 CM. B
npo,neJIaHHble OTBepCTII5I BBO,nHT npOBOJIOKY KaK Ha
puc. 19.2.
8-o6pa3HblH IIJOB Ha KOCTH. EOpOM RITII cBepnoM
npo,nenbIBalOT CKB03Hble oTBepCTHH Ha paccToHHHH 1,5-
2 CM. 3aTeM B HIIX npOBO,D;HT IlIOBHYlO HHTb (npOBOJIOKY),
06pa3yIOIUylO nepenJIeTeHHe (puc. 19.3). IIpH CTHrIIBa-
HHH KOHUOB npOBOJIOKIi ,naBJIeHlIe Ha TKaHH pacnpe,ne-
JIHeTCH paBHoMepHo, qTO CHH:>KaeT BepOHTHOCTb pa3py-
IlIeHIIH KpaH KOCTII. 3TO BbITO,nHO OTJIlIqaeT 8-06pa3HbIH
IlIOB OT II-06pa3Horo.
_e ._ "
ee. ;. 'If ..
- ...
:'\if',."'
.,
J;'1C "".._ ..m. ............ ..
, .... rJIaBa20
. ". "' -E ".tm..;7,. .
KI1IllE'tJ:lIbIM mOB
(if
:r:
.......::: .:' .
IIOHHTlie «KIIIlIeqHbIH IlIOB» 06'be,nHHHeT Bce BH,D;bI IlIBOB, HaKlla,nbIBaeMbIX Ha CTeHKY nOJIbIX
opraHoB nHlI.{eBapHTeJIbHOrO annapaTa (nmueBo,na, )J(eJIy,nKa, KIIIlIeqHlIKa) II ,npyrHe nOJIbIe opra-
HbI, ecJIH OHII IIMelOT 6plOIlIHHHbIH nOKpoB (a.I:!BeHTHUHaJIbHYlO 060JIOqKY), MbIIlIeqHYlO 069JIOqKY,
no,nCJIII3IICTbIH CJIOH, a H3HYTpli - cnlI3HCTYIO 060JIOQKY.
KIIrneqHbIe IlIBbI npHMeHsrlOT npH:
- HapYIlIeHHH 1\eJIOCTHOCTIi CTeHKH nOJIoro opraHa, KaK co BCKpbITHeM nonOCTIi (npocBeTa
KHlliKH), TaK H npH nOBpe)l(,D;eHIIII TOJIbKO cep03HoH RITH Cep03HO-MbIIlIeqHOH 060JIOqKH;
- pe3eKUHH KHIlIKH, :>KeJIy,nKa, nmueBo,na IIJIH MOqeBOrO nY3bIPH, KecapeBoM CeqeHIIH, KOH-
cepBaTHBHOH MlIOMeKTOMIIH;
,
- HanO:>KeHIIII aHaCTOM030B Me)l(,D;y oT,neJIbHbIMH yqaCTKaMIi nmueBaplITeJIbHOrO annapaTa
HJIII coce,nHIIMH nonblMH OpraHaMH (:>KeJIqHbIM nY3bIpeM H :>KeJIqHbIMH npOTOKaMH).
)J;JIsr ycneiliHoro HanO:>KeHHH KHIlIeqHOrO IlIBa He06xo,nHMO c06mo,naTb CJIe.nyIOlI.{He YCJIO-
Bm!:
1. Coe,nIIHHeMbIe OTBepCTIIH ,nOJI:>KHbI COOTBeTCTBOBaTb .npyr ,npyry no MIiHe. B Tex cnyqaHX,
Kor,na conOCTaBnHlOT KpaH pa3HoH MIIHbI, MO:>KHO npHMeHHTb L-06pa3HbIH IlIOB.
2. HY:>KHo, qT06bI npH HaJIO:>KeHHH IlIBa BacKYJIHpH3aUliH coe,nHHHeMbiX nOBepxHocTeii: He
nOCTpa,D.ana. Cne,nOBaTeJIbHO, IlIBbl Ha 6pbI:>KeHKY KMiliKII Ha,D.O HaKlla,D.bIBaTb TaK, qT06bI 3aXBa-
TIITb KaK MO:>KHO MeHbille 6pbl)J(eeqHblX COCy,nOB. ,[{JIH 3Toro, no Mepe B03MO:>KHOCTII, HIITII npOBO-
,nsrT napanneJIbHO cocy,naM KHIlIeqHIIKa. EOJIbiliOe 3Ha qeHlIe HMeeT paCCTOSI:HHe Me)l(,D;Y CTe:>KKaMH,
KOTopoe 3aBliCliT OT TOJIlI.{HHbI CTeHOK CllIHBaeMbIX opraHOB. ,[{JIH O,nHopH,nHoro IlIBa KHiliKII, He3a-
BHCHMO OT cnoc06a YIlIIiBaHII5I, paCCTOHHlIe Me)l(JJ:y CTe:>KKaMH ,nOJI:>KHO COCTaBnHTb 3- 3,5 MM. EOJIb-
lliee paCCTOHHHe He Bcer,na 06eCneqlIBaeT COCTOHTeJIbHOCTb IlIBa, a MeHbillee (MeHee 2 MM) -
Be,neT K HapYilieHlIlO KpoBOCHa6:>KeHII5I H, KaK CJIe,nCTBlIe, K HeKp03Y CTeHKII II pa3BIITHlO HecoCTO-
HTeJIbHOCTH IlIBa. IIpH HanO:>KeHHII IlIBa Ha CTeHKY )J(eJIy,nKa RITH MaTKH pacCToHHHe Me)l(,D;y CTe:>KKa-
MII ,non:>KHO COCTaBJIsrTb 0,8-1,0 CM.
3. IIepe,n 1lJ0pMHpOBaHHeM IlIBa Hy:>KHO npe,D;BapHTeJIbHO 06eCneqHTb Ha,ne:>KHbIH reMOCTa3
coe,nHHsreMblx nOBepxHocTeH. B 06paTHoM CJIyqae B03HIIKaeT peanbHaH onaCHOCTb B03HIIKHOBe-
H1I5I BHYTpHCTeHOqHOH reMaTOMbl.
4. IIpH HanO:>KeHHH IlIBa He06xo,nIIMa qeTKaH KoanTaUIiH O,nHOpO,nHbIX (CXO,nHbIX) no cBoeH
CTpYKrype CJIOeB. Coe,nIIHeHlIe TKaHeH pa3JIHqHOH npnpO,D;bI npHBo,nIIT K 1lJ0pMHpOBaHHlO HenonHO-
1\eHHoro py6ua.
5. Ha OCHOBaHlI1I IlIHpOKOro conOCTaBJIeHHH cep03HbiX 060JIOqeK, IlIOB ,non:>K<{H 06ecneqlI-
BaTb Ha,D.e:>KHYlO 61I0JIOrHqecKYlO H IlJH3HqecKYlO repMeTlIqHOCTb nonblX opraHoB.
6. He06xo,nHMO, qT06bl HanO:>KeHlle KIIIlIeqHOrO lliBa He CY:>KIIBanO npOCBeT KHIlIKH, T.e. Hy:>K-
HO 06ecneqlITb coxpaHeHlIe Hcxo,nHoro eCTeCTBeHHoro npOCBeTa KlilliKII.
143
rnaBa 20
Bee 3TH YCJIOBIIH MOryT 6bITb BbIIIOn-
HeHbI pa3JIIIqHbIMH npHeMaMli. EOJIbiliOe
3Ha qeHlIe HMelOT xlIpyprHqeCKIiH MaTepH-
aJI (HHTH) II a,D.eKBaTHO BbI6paHHaH MeTO-
,nHKa COe,nIIHeHIIH TRaHeH. IIpH OnepaUIIHX
Ha :>KeJIy,nKe H TOHKOH KHiliKe peKOMeH.D:Y-
lOT I1CnOJIb30BaTb HlITIi YCJIOBHblM ,nlIaMeT-
pOM 3/0-4/0, npH onepaUHHX Ha TonCTOH
KIIIlIKe - HHTH ,nHaMeTpoM 4/0-510. IIpe,n-
nO HTeJIbHee IICnOJIb30BaTb paccacbIBa-
lOlI.{lIecH MaTepHaJIbI, HanplIMep, nOJIlIcop6,
.n;eKCOH, BIIKpIIJI, 6HOCIIH. B Tex cJIyqaSl:x,
Kor,na peaKUIiH TKaHeH Ha HHTH BeCbMa He-
:>KeJIaTeJIbHa, B03MO:>KHO npliMeHeHHe H He-
paCCaCbIBalOIUIIXCH MaTepHaJIOB (nonHnpo-
nRITeH). IIpH onepaUIIHx Ha TonCToH KHiliKe
II nmueBo,ne ueJIeC006pa3HO HCnOJIb30BaTb
nOJIlInpOlIlIJIeH, MaKCOH, nonII.L(HOKCaHOH,
61I0clIH.
BapliaHTOB KHllieqHoro IlIBa nplI,D;)'-
Mano MHO:>KeCTBO. IIpe.n;no eHII5I HaJ];O OT-
,naBaTb, KOHeqHO, TeM, KOTopble npoll.{e H
OCHOBaHbI Ha yqeTe oc06eHHocTeH cTpoe-
HM5I npoIlIHBaeMoro opraHa H 3a)!(HBJIeHIIH
ero nOBpe)l(,D;eHHH. He06xo,nHMO yqHTblBaTb 4JYTJIHpHbIH npHHulin cTpoeHJ1H CTeHOK nHlI.{eBapH-
TeJIbHOro TpaKTa. BblJI.eJIHlOT ,nBe ero COCTaBHbIe - HapY:>KHbIH II BHYTpeHHHH 4JYTmpbI (puc. 20.1).
HapY:>KHbIH 4JYTJIHp 06pa3YlOT cep03HaH II TeCHO CBH3aHHa5I C HeH MbIIlIeqHaH 060JIOqKH. BHYTpeH-
HHH 4JYTJISl:p 06pa3YlOT CJIH3HCTaH 060JIOqKa H no,nCJIH3'HCTbIH CJIOH. OHH TeCHO CBH3aHbi Me)l(JJ:y
C060H H aHaTOMmeCKIi COCTaBnHlOT Hepa3pbIBHOe l.\eJIoe. YqlITbIBaSl: TO, qTO MblIlIeqHaH 060JIoqKa
TeCHO CBSl:3aHa C cep03HoH (a,nBeHTIfUlIanbHoH) 060JIOqKOH H IIMeeT pblXJIYlO CBH3b C no,nCJIH3HC-
TbIM CJIOeM, BHYTpeHHlIH H HapY)!(HbIH 4JYT bI MOryT CMeIUaTbCSI: OTHOCHTeJIbHO .npyr .npyra. OMa-
KO, CTeneHb Bblpa:>KeHHOCTH no,nBH:>KHOCTIi 4JYTnHpoB B pa3nlIqHbIX OT,neJIaX nlIlI.{eBapHTeJIbHOrO
TpaKTa pa3HaH. TaK, npH paCCeqeHHH CTeHKII nHlI.{eBo,na B HaH60JIbilieH CTeneHH COKpaIUaeTCH
BHYTpeHHIIH 4JyTJIHp. CJIH3HCTaH 060noqKa C no,nCJIH3HCTblM CJIOeM yxo,nSI:T BHYTPb npOCBeTa nHIUe-
Bo,na. IIpH paCCeqeHIIH CTeHKH :>Keny,nKa npOIICXO.D:IIT Bblpa:>KeHHOe COKpall.{eHlIe HapY:>KHoro 4JYT-
mpa. Cep03HaH H MOIUHM MblIlIeqHaH 060nOqKH CRITbHO COKpaIualOTCH H BHYTpeHHlIH 4JYTJIHp (CJIII-
3HCTaH 060nOqKa C no,nCJIH3HCThlM CJIOeM) BblBOpaqlIBaeTCH Hapy:>KY. TaKOe:>Ke CMeIUeHlIe HapY:>KHoro
4JYTJIHpa B CTOPOHY OT pa3pe3a, TOJIbKO MeHee Bblpa:>KeHHOe, HaCTynaeT npH paCCeqeHIIH CTeHKH
,D;BeHa,nuaTHnepCTHoH KHiliKH. ElI.{e MeHee Bblpa)!(eHO cMeIUeHHe Hapy:>KHoro 4JYTnHpa no OTHOIlIe-
HlilO K BHYTpeHHeMY npH nOBpe)l(,D;eHlIIi CTeHOK TOll.{eH RITII no,nB3,n0IliHOH KlilliOK. He3HaqIITeJIbHOe
nepeMeIUeHHe 060lIx 4JYTmpoB Ha6nlO,naeTcH npli paHeHIIH CTeHKII TOJICTOH KIIIlIKII. 06a 4JYTJIHpa
CO,'ieraHO pacxo,nSI:TCH H OKa3blBalOTCH pacnOJIO:>KeHHbIMH Ha O,nHOM ypoBHe.
<DYTnHpHoe CTpoeHHe nlIlI.{eBapHTeJIbHOrO annapaTa onpe,neJIHeT TeXHHKY HaJIO:>KeHHSI: KH-
IlIeqHbIX IlIBOB, a TaK)!(e MeTO,D;IIKY pMa OnepaTHBHbIX BMeIlIaTeJIbCTB. TaK, npH HanO:>KeHIIII CKB03-
Horo IlIBa Ha CTeHKY nHlI.{eBo,na Hrny Ha,no BKaJIbIBan 6nH:>Ke K Kparo paHbI, a BhIKaJIblBan. - He-
a
{:
,
3
6
Puc. 10.1 <1>ymJIHpHOe cmpoeHue KUUlKU; a -
eHympeH1/Uii pynvIHp; 6 - napY:JICHblU pymJlJ/p; 1 -
CJlU3UCmUR 060JlO'lKa; 2 - nOaCJlU3UCmbiU c. ou; 3 -
MbIUle'lI/aR 060JlO'lKa; ,4 - Cep03HaR 060J10'iKa
144
CKonbKO ,nanbIlIe, HanpaBnHH HHTb KOCO-naTepaJIbHO B rny-
6HHY TRaHeH (puc. 20.2). CTeHKY :>KeJIY.D:Ka cJIe.nyeT npoKa-
nblBaTb B npoTHBOnOJIO:>KHOM HanpaBJIeHlI1I - KOCO-Me,nH-
anbHO. Mrny Ha,no BKaJIblBaTb, HeMHOrO oTcrynaH OT KpaH,
a BbIKaJIbIBaTb - Henocpe,ncTBeHHo Y KpaH pa3pe3a
(puc. 20.3). B TOM CJIyqae, eCJIH npli 06pa60TKe panbI )!(e-
ny,nKa y,naJIHlOT 1I36bITOK cnlI3HCTOH 060nOqKl!, Hmy rrpo-
BO,n»T rrepneH,D;IIKYJIsrpHo CTeHKe opraHa.
T OJICTYlO H TOHKYlO KlIllIKlI, yqlITblBa» He3HaqIITeJIb-
Hoe CMeIUeHlIe 4JYTJIHPOB, CJIe,nyeT rrpOIlIIiBaTb CTporo rrep-
neH,D;IIKYJIjlpHO (puc. 20.4).
IIpoqHOCTb KIIIUeqHoro IlIBa ,nOCTliraeTCH rny6IIHoH
3axBaTa TRaHeH, MeHee nO,D;Bep:>KeHHbIX rrpope3aHlI1O HIiTblO.
TaKHM CBOHCTBOM o6JIaL!aeT TOJIbKO pbIXJIa» no,nCJIII3HC-
TaH KlleTqaTKa. MeXaHHqeCKa» npOqHOCTb rro,nCJIII3HCTOro
CJIOH COCTaBJIHeT OKOJIO 70 % npOqHOCTH Bcex CJIOeB CTeH-
KH nlIIueBapHTeJIbHoro annapaTa.
113BecTHo, qTO npH 1I3rOTOBJIemrn KeTryTa nOCJIe 06-
pa60TI<M KlillIKH OCTaeTCH TOJIbKO TRaHb rro,nCJIII3IICTOrO CJIOH.
Eonbllia» qaCTb MblIlIeqHOH 060JIOqKH BMecre C Cep03HbIM no-
KpOBOM npli 3TOM OTMaqlIBaeTC» II CqIIIUaeTCH. IIpIIBeL!eHHbIH
npliMep ,naeT B03MO:>KHOCTb OUeHIITb npOqHOCTb 3TOH TRaHIi.
II03ToMY CJIe.nyeT no,nqepKHYTb, qTO 60nbilieH MexaHmeCKOH
npOqHOCTblO 6y.nyT OTnlIqa TbCH IlIBbl, BblllonHeHHbIe C 3aXBa-
TOM no,nCJIII3l!CTOrO CJIOH. Ka:>K,I:(bIH xlIpypr 3HaeT KaK JIerKO
npope3alOTCH npli 3aBH3blBaHliH Cep03Hbie H Cep03HO-MbIIIIeq-
HbIe IlIBbI. KpOMe MeXaHlIqeCKOH npOqHOCTIi 3aXBaTbIBaHlie B
CTe:>KOK no,nCJIH3IICTOH 060JIO 1I 06ecrreqIIBaeT XopoIlIYlO Bac-
KYJIHpH3aUHlO JIIIHIIII IlIBa. BKlllOqeHHe B CTe)!(OK rJIa.D;KIIX
MbIIIIeqHbIX BOJIOKOH 06eCneqlIBaeT 3JIaCTIIqHOCTb nlIHlIlI IlIBa
H, HCXOM H3 3Toro, HBJIjleTCH HerrpeMeHHbIM aTplI6yTOM npaK-
TlIqeCKH Bcex BH,D;OB KIIIlIeqHOrO IlIBa.
XHpyprHqeCKOH CYTblO repMeTlIqHOCTH KIIIlIeqHO-
ro IlIBa HBJIHeTCH C03,naHHe Ha,ne:>KHOrO npenHTCTBIiH ,nnH
npOHIiKHOBeHHH MHKp04JJIOpbI H3 rrpOCBeTa KlillIKl! B
6plOlliHYlO rrOJIOCTb. repMeTlIqHOCTb IlIBOB ,nOCTHraeTC»
nyTeM coe,nHHeHIIH cep03HOH 060JIOqKH II KoarrTaUIiH OC-
TaJIbHbIX cnoeB CTeHKII. B cep03HOH 060JIOqKe, Y:>Ke qe-
pe3 HeCKonbKO qaCOB nOCJIe 3alliIIBaHHH, npOHcxo,nIIT
BocnanlITeJIbHOe CJIHnaHlie CO npHKacalOIUIIXCH nOBepx-
HOCTeH. Cpa3Y nOCJIe coe,nIIHeHHH cep03HbiX JIHCTKOB H3
nOBpe:>K,neHHbIX KanlIJIJIHpOB B MeCTax nOBpe:>K,neHHH Me-
30TeJIHanbHOH BbICTHJIKH Bbllla,naeT <p1I6pIIH. IIpoHcxo-
,nHT COeL!IIHHTeJIbHO-TKaHHoe npeo6pa30BaHHe 30HbI py6-
I.\a. Y:>Ke qepe3 24-48 qaCOB cep03Hbie CJIOH npOqHO cpa-
.,.--".
t:l ; '
, "
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Puc. 20.2 Oc06ellllocmu QJOPl,4upoeaHufi
Ulea nuUjeeoaa
Puc. 20.3 Oc06eHHocmu tjJopMupoea-
lIUfI Ulea :J/CenyaKa
Puc. 20.4 OC06ellHOCmU tjJopMupoea-
HUfi Ulea KUUlKU
145
rJIaBa 20
CTalOTCH, 06eCneqlIBaH HaL!e:>KHYlO repMeTmHoCTh. Ha 3TOM 6bICTpOM cpaCTaHIiH 6plOIlIHHbI OCHO-
BaHbI H npHHUHnbI KIIIlIeqHOrO IlIBa. CKOJIbKO 6bI PMOB IlIBOB He HaKJIa,D.bIBaJIOCb, H KaKHe 6bI
Mo,nIIIlJIIKaUHH 3aIlIIIBaHHH He nplIMeHAAHCb, OpraHbl 6plOiliHOH nOJIOCTII Bcer,na He06xo,nHMO YK-
pblBaTb IlIBOM, 3aXBaTbIBalOlI.{HM cep03HbIe 060JIOqKH. IIpHqeM OH ,non:>KeH 06eCneqHTb nJIOTHOe
conpliKOCHOBeHlIe HCTbIX cep03HblX nOBepXHOCTeH KHapY:>K1I OT nOBpe)l(,D;eHII5I. War TaKoro IlIBa
He ,nOJI:>KeH npeBbIIlIaTb 3 MM.
llllITb y,n06Hee Bcero cneuHanbHblMIi Klillie bIMIi HrJIaMli. OCTpbrn KOHqlIK JIerKO npOKallbl-
BaeT 6plOIlIliHY H MbIIlIeqHYlO 060JIoqKY. TeJIo, H30rHYToe Ha 5/8 MIIHbI OKPY:>KHOCTH, 06ecneqlI-
BaeT 3aXBaT CpaBHHTeJIbHO MHoro no,nCJIH3HCTOH KlleTqaTKH, He npOHHKaH B CJIH3HCTYlO.
CYIlIeCTByeT MHO:>KeCTBO cnoc060B 3aIlIHBaHHH KHiliKII. HeCMOTpH Ha TO, qTO HeKOTopbIe
npe,nCTaBllHlOT JIIIIlIb HCTOplIqeCKYIO UeHHOCTh, MbI BCe:>Ke COq)J1I HY:>KHbIM ,naTb IIX KpaTKOe onlIca-
HlIe, TaK KaK CqnTa M, qTO 3TO nOMO:>KeT nOHHTb CYTb HaJIO)KeHIIH KHIlIeqHOrO IlIBa.
:; i: , -\!
KJIACCMcDHKAlUUI KMIlIE1ffibIXIIIBOB
no OTHOUleHHIO K npocBery KHIUKH IlIBbI .zkJIHT Ha HenpOHHKalOUUIe H npOHHKaIOI.QHe.
III HenpOIlHKalOlI.{HMH (acenTHqeCKHMH) IlIBaMIi Ha3blBalOTCH IlIBbI, npli I<OTOpbIX HHTb
He npOHHKaeT B npOCBeT KHiliKH. B 3aBliCHMOCT.ll OT 3aXBaTa B IlIOB 3neMeHTOB CTeHKH
pa3JIlIqaIOT: a) cep03flble Ul6bl - 3aXBaTbIBaeTCH TOJIbKO cep03HaH 060nOqKa (BHcuepaJIb-
HaH 6plOIlIHHa); 6) cepo311O-MbZUle'l11bZe Ul6bZ - 3aXBaTbIBaeTCH Cep03HaH H MbIIlIeqHaH 060-
JIOqKII (HapY:>KHbIH IlJYTJIHp ); B) Cep031l0-MbZUleli1l0-noiJcllU3ucmble Ul6bZ- B CTe){{OK 3aXBaTbI
BalOTTpH HapY:>KHbleo60JIoqKII 6e3 CJIII3IICTOH.
III npOUHKalOl.QHMH (HHcI>HQHpOBaHHLlMH) IlIBaMH Ha3blBalOT TaKH llI!3 I npHJ(OTg-
pblX H1ITb npoxo,nHT qepe3 CJIH3HCTYlO 060JIOqKY opraHa.
,.
Pa3JIHqalOT CJIe.nylOIUHe BH,D;bI npOHHKaIOIUHX IlIBOB: a) CK6031lbZU - IlIOB, npH KOTOpOM HHTb
npoxo,nHT qepe3 Bce CJIOH CTeHKH KHlliKH; 6) MLllUe'lHO-nOJlCJIH3HCTo-CJIH3HCTLlU; B) nOJlCJIH3HC-
TO-CJIH3HCThIU; r) UlOB CJIH3HCTOU 060JIO'lKH.
no MeTo,nHKe HaJIO eHHH IlIBbl 6blBalOT:
III - OT,neJIbHble pJIOBbIe;
III - n-06pa3HLle;
III - HenpepLlBULle (HaKlla,nblBalOT O,nHOH MIIHHOH HIiTbIQ);
III . - HenpepblBHO-Y3JIOBLle (HaKlla,l1bIBalOT ,nBYMH KOHl.\aMH O,nHOH ,nJIHHHOH HHTII, KO-
T9PYlO nocm: Ka)l(,D;oro CTe:>KKa 3aBH3bIBalOT B Y3eJI).
no conOCTaBJIeHHIO TKaHeu nOCJIe 3aTHrHBaHHH UlBa pa3JIHqalOT:
III - KpaeBblt: (B IlIBe conpHKacalOTCH KpaH pa3pe3a CTeHKHKHlliKH);
146
.. - BBOpalJUBalOlI.{Ue (IIHBepTI-!pOBaHHbIe), 06eCneqlIBalOIUlIe COnpUKOCHOBeHlIe CIlIH-
BaeMblX yqaCTKoB Cep03HbIMH 060JIOqKaMH;
1.1 -BblBOpalJUBalOlI.{Ue (3BepTHpOBaHHbIe),o6ecneqIIBalOlI.{He COnpHKOCHOBeHHe CIlIH
BaeMbIX yqaCTKOB CJIH3HCTbIMli 060JIOQt<aMH;
.kOM6uHupOBaUBbIe BbOpaQUBaroii\e-BLIBOpa'luBaroll.{UeCH.
no kOJIUqeCTBY 3TajKen (PH,JJ;OB) IlIBbI 6bIBalOT:
II - O.aHOpH,JJ;HbIe;
. - ,nByxpH,JJ;HbIe;
.. - T)JeXpH,JJ;HbIe.
no MaTepua.JIY BUTen pa3JIHqaIOT:
.. - paccaCblBalOlI.{UeCU;
. - Hepa caCLlBalOlI\ueCH.
PaCCMOTpHM TeXHIIKY HallO:>KeHIIH HeKOTopblX KlIllieqHbIX IlIBOB.
HEIIPOHMKAromMEIlIBM
t:
OCHOBHblM IlIBOM B 6plOlliHOH XHpYPrHH HBJIHerCR OT.aeJIbHbIn Y3JIOBOn cep03Ho-MbImelJ-
HbIn IllOB, npeMO:>KeHHbIH A. JIaM6epoM B 1826 r. (puc. 20.5). ,[{JIH ero HanO:>KeHHH limy BKaJIbIBa-
lOT H BbIKanblBaIOT Ha cep03HoH nOBepxHoCTH C Ka)l(,D;OH CTOpOHbI paHbI. MrJIY BBO,nHT Ha pacCToH-
HIIH 0,5-0,8 CM H BblBO,n»T Ha 0,1 CM OT KpaH paHbI KHiliKII. C .npyrOH CTOpOHbI TRaHH 3aXBaTblBalOT
B 06paTHoM nOpH.D:Ke. B IlIOB BXO,nHT cep03HaH H MbIIlIeqHaH 060JIOqKII. PaccToHHHe Me)l(JJ:y MeCTa-
MH YKOJIa H BblKanbIBaHIiH HrJIbI He ,nOJI:>KHO npeB'bllliaTb 0,5 CM. O,nHaKO npH coe,nHHeHHH TKaHeH
pa3JIHqHOH TOJIlI.{lIHbl rny6HHa 3aXBaTa 60JIee TOJICTOH CTeHKH ,nOJI:>KHa 6bITb 60JIbrneH, qeM npH
3aXBaTe 60nee TOHKOH. IIocJIe npOIlIIiBaHliH 06e-
HX CTeHOK HlITb 3aBH3bIBalOT. IIpoHcxo,D;IIT DJIOT-
Hoe conpHKOCHOBeHlIe cep03HbIX 060JIOqeK. Y3eJI
pacnOJIaralOT Ha MeHee no,nBII)!(HOM KpalO paHbI
RITH CTeHKe opraHa.
HanOMlIHaeM, o BCJIe,nCTBHe He,nOCTaTOq-
HOH MeXaHHqeCKOH npOqHOCTH cep03HOH H MbI-
IlIeqHOH 060JIOqeK npH CRITbHOM 3aTHrHBaHHH
Y3en MO:>Ker npope3aTbCH. Cep03HO-MbIIlIeqHbIe
IlIBbI JIaM6epa 06eCneqHBalOT B OCHOBHOM He Me-
xaHmeCKYlO npOqHOCTb, a repMerH3aUli1O nlIHlI1I
IlIBa, TaK KaK He 06JIa,D.alOT xopOilieH KoanTIIBHOH
Puc. 20.5 HenpoHuKalOUjuu KUUle'lHbIU
Uloe JJaM6epa
147
rJIaBa 20
Puc. 20.6 HenpoHuKaJOUjUU KUUle'lHbIU
woe llupoi!oea
Puc. 20.7 HenpOHUKGIOUjUU KUUle'lHbIU Uloe
llupo;;oea-MameUlYKa
cnoc06HOCTblO. MCXO,nH H3 3TOrO, IlIOB JIaM6epa HCnOnb3YlOT TOJIbKO B KOM6IIHaUHH C ,npyrHMH
IlIBaMIi.
mOB llupOZOBa - OT,neJIbHbIH KpaeBOH Cep03HO-MblllieqHO-no,nCJIII3IICTbIH IlIOB (puc. 20.6). B
IlIOB 3aXBaTbIBalOT cep03HYlO H MbIIlIeqHYlO 060nOqKII, a TaK:>Ke no,nCJIII3HCTbIH CJIOH, KOTOpbIH 06-
JIa,naeT HaH60JIbilieH MeXaHlIqeCKOH npOqHOCTblO. I1rJIY BKaJIbIBalOT co CTOpOHbl cep03HoH 060JIoq-
KII II BbIKanblBalOT Me)l(,D;Y no,nCJIH3IICTbIM CJIOeM II CJIH3IICTOH 060JIOqKOH. Ha .npyroM KpalO paHbI
HrJIY npOBO,WIT Me:>K.D:Y CJIII3HCTOH 060JIOqKOH H no,nCJIH3HCTbIM CJIOeM II BbIKaJIbIBalOT Ha cep03HoH
nOBepxHoCTH. WOB 06eCneq}lBaeT Ha,IIe:>KHbIH reMOCTa3, a xopolIla KoanTaUIiH KpaeB C coxpaHe-
HlieM 4JYTnHpHocTII, npe,noTBpaIUaeT 06pa30BaHlie rpy60ro py6ua H cY:>KeHIIH COYCTbH. He06xo,nlI-
MO nOMHIITb, qTO npHMeHeHlIe «4JHTRITbHblX HHTeH» ,D;JIH HaJIO:>KeHlIH 3Toro IlIBa YBeJIHqlIBaeT B03-
MO:>KHOCTb 06pa30BaHIISI: cnaeK H3-3a 60JIblliOH BepOHTHOCTH BOCnaJIIITeJIbHOrO npol.\ecca.
IlIoB IIuporoBa - MaTemYKa - OT,IJ,eJIbHbrn KpaeBOH cep03Ho- MblllIeqHO-no,nCJIII3IICTbIH BHyT-
PlIY3JIOBOH lliOB (puc. 20. 7). I1rny BKaJIbIBalOT co CTOpOHbl KpaH paHbl B no,nCJIII3HCTbIH CJIOH H
qepe3 MbllIleqHYlO H cep03HYlO 060JIOqKII H11Tb BblBO,WIT HapY:>KY O,nHOH CTOpOHbI. Ha npoTIiBono-
JIO:>KHOH CTopoHe HIITb npoBoLLSlT qepe3 cep03Ho-MblllIe 1O 060nOqKY H nO,nCJIlI3HCTbrn CJIOH. Y3JIb1
3aBH3bIBalOT co CTOpOHbl npOCBeTa KIIIlIKH.
llIoB MOM6ypra - oT,neJIbHbIH KpaeBoH cep03Ho- MbIIlIeqHO-no,nCJIH3HCTbIH BHYTPlIY3JIOBOH
1lI0B (puc. 20.8). IIpe,nCTaBJIjleT C060H KOM6HHaUHlO IlIBOB JIaM6epa H IIlIporoBa. DepBbIH CTe:>KOK
npOH3Bo,nHT co CTOpOHbI cep03HoH 060JIOqKH, OTCTYllHB 1,5 CM OT KpaH paHbI H 3aXBaTbIBaH B IlIOB
cep03HYlO, MbIIlIeqHYlO 060JIOqKH H no,ncnlI3lICTbIH CJIOH. 3aTeM Ha paccToHHHH 0,5 CM OT KpaH
paHbI npoH3Bo,nHT BTOpOH CTe:>KOK. MrJIY BKanbIBaIOT co CTOpOHbI cep03HoH 060JIOqKH, a BbIKanbI-
BalOT co CTOpOHbl Kpa paHbI Me:>K.D:Y no,nCJIII3HCTbIM CJIO-
eM H cep03HOH 060JIOqKOH. Ha ,npyrOM KpalO paHbI HHTb
npOBo,nHT CHMMeTpHqHO. I1rny BKanblBalOT co CTOpOHbI
KPM paHbI Me)l(,D;Y CJIH3HCTOH 060JIOqKOH II no,nCJIH3HC-
TbIM CJIOeM. BbIKanblBalOT ee Ha cep03HOH nOBepXHOCTH
KlillIKH, nOCJIe qero BHOBb BKaJIblBalOT H BbIKaJIbIBalOT
co CTOpOHbl cep03bI. 3aBH3bIBaH Y3en, coe,nHHHIOT ce-
p03Hbie 060JIOqKH.
,lJ,JIH HanO:>KeHHH mBa XJIonooa (puc. 20.9) nOHa-
,n06IITCH HIITb C.D:BYMH IIrnaMH Ha KOHuax. 1ll0B XnonoBa
Puc. 20.8 HenpO/lUKalOUjuu KUUle'lHbIU
Uloe MOM6ypi!a
148
OTJIlIqaeTCH OT IlIBa MOM6ypra TeM, qTO Y3eJI pacnOJlara-
eTCH B npOCBeTe KHiliKH. BHaqaJIe O,nHOH HrJIOH HaKJIa-
,nbIBalOT cep03HO-MbIIlIeqHbIH H cep03Ho-no,nCJIH3HCTbIH
CTe:>KKH Ha O,nHOM KpaIO paHbI, 3aTeM - ,npyrnM KOHUOM
HIITII HaKlla,nbIBaIOT TaKOH :>Ke cre)!(OK Ha .npyroM ee KpaIO.
CB060.D:HbIe KOHUbI HHTeH CBSl:3bIBmOT Me:>K.IJ:Y C060H.
llIoB )I()"IeHKO - OT,neJIbHbIH KpaeBOH cep03HO- M l-
llIeqHO-no,nCJIII3HCTbIH BHyTPHY3JIOBOH lliOB (puc. 20.10).
IIocJIe HaJIO:>KeHlI5I cep03Ho-MbIIlIeqHOrO CTe:>KKa Ha o,n-
HOM KpalO paHblllJOPMHPYlOT cep03Ho-MbIllieqHO-no,ncnlI-
3HCTblH Ha ,npyrOM KpalO. 3aTeM HlITb npOBO,D;Sl:T co CTOpO-
HbI pa3pe3a qepe3 no,nCJIH3IICTbIH CJIOH, MbIIlIeqHYlO H
Cep03HYlO 060JIOqKH nepBIIQHO npoIlIIiBaeMoro KpaH. 3a-
KaHqlIBalOT IlIOB HanO:>KeHHeM Cep03Ho-MblllIeqHOrO CTe:>K-
Ka Ha npOTHBOnOnO:>KHOM KpalO paHb!. <1>OpMHPYH Y3eJI,
,n061IBalOTCH llIHpOKOro conpliKoCHoBeHIIH Cep03HbiX nlIc-
TKOB.
llIo6 Eoi)"apYKa (puc. 20.11). Mmy BKaJIbIBaIOT
Ha pacCToHHlI1I 0,5 CM OT KpaH paHbI, a BbIKanbIBalOT Ha
pacCToHHIIH 1 CM, C03,naBaH CTe:>KOK cep03HO-MbllIIeqHOrO
llIBa. Ha npOTHBOnOJIO:>KHOM KpaIO paHbI Hrny BKaJIblBalOT
Ha paccToHHIIH 1 CM OT KpaH, a BbIKaJIbIBalOT Ha pacCToH-
H1IH 0,5 CM. O,nHOKpaTHO KOHl\b1 HHTII nepeKpell.{HBalOT H
IIMH HaKlla,nblBalOT KpaeBOH cep03HO-MbllIIeqHO-no,nCJIII-
3HCTbIH CTe:>KOK. IIpH 3TOM YKOJI HrJIbI npOH3Bo,nHT B MCCTe Bblxo,na HHTH 1I3 cep03HO-MbIIlIeqHOrO
CTe)!(Ka, a BbIKaJIblBalOT Me:>K,D;y no,nCJIH3HCTbIM CJIOeM H CnH3IICTOH 060nOqKOH. Y3eJI 3aBH3bIBaIOT
co CTOpOHbI npOCBeTa KlilliKII.
IlIoB KnuMeHKo - OT,neJIbHbIH KpaeBOH cep03HO-MbIllIeqHO-nO,nCJIII3HCTbrn IlIOB (puc. 20.12).
B nepBoM CTe:>KKe HIITb npoBo,nHT qepe3 cep03HylO H MbIIlIeqHylO 060JIOqKH o,nHoro KpaH. Bo BTO-
pOH CTe:>KOK 3aXBaTbIBaIOT no,nCJIII3HCTbIH CJIOH H MbllIIe lO 060JIOqKY ,npyroro KPaH paHbI. CJIe.ny-
lOJUIiH CTe:>KOK npoH3Bo,nHT.qepe3 MbIllieqHylO 060nOqKY H no,nCJIH3HCTbIH CJIOH nepBOHaqaJIbHO
npollIHBaeMoro KpaH paHbI. 3aKaHqlIBalOT IlIOB Ha npoTIIBOnOnO:>KHOM KpalO, 3aXBaTbIBaH MbIIlIeq-
Ho-cep03HbIH IlIap.
Puc. 20.9 HenpoHU1wIOUjUU
KUUle'lHbIU Uloe XJlonoea
Puc. 20.10 HenpoHuKalOUjuu
KUUle'lllbIU luoe )/(Y'IeHKO
Puc. 20.11 HenpOHUKalOIl/UU
KUUle'l/lbIU Uloe EOaHapYKa
Puc. 20.12 H enpoHuKalOUjuu
KUUle'lHbIU Uloe KJlUMeHKO
149
rJIaBa 20
IIpHMeHeHHe II-06pa3Hblx Cep03Ho-MbIIlIeqHbIX IlIBOB no-
3BOnHeT YMeHbllIHTb onaCHOCTb npope3blBaHII5I IlIBOB JIaM-
6epa. 3TO oc06eHHo aKryaJIbHO B TeX cnyqa5lX, Kor,na npIIXO-
,nIITCH coe,nIIHHTb TKaHli Pa3JIlIqHOH TonlUlIHbI, a TaK:>Ke B Tex
CJIyqa5lX, Kor,na O,D;IIH H3 COe,D;IIHHeMbIX opraHoB MeHee no,n-
BH:>KeH.
,[{JIH ,nOCTII:>KeHII5I Ha,D.e:>KHOrO coeiufHeHlIH cep03HbiX
nHCTKOB IICnOnb3YlOT II-06pa3HbIH cep03HO-MbIIlIeqHbIH
mOB JKeJIH (puc. 20.13). IIpeHMylUeCTBOM IlIBa HBJIHeTCH
TO, qTO HHTb npoxo,nIIT qepe3 cep03HYlO H MbIIlIe'mylO 060-
no napaJIJIeJIbHO OCH opraHa, qTO YMeHbiliaeT onaCHOCTb
npOpe3aHII5I. PacnOJIaraTb Y3eJI He06xo.D:HMO Ha MeHee no,n-
BH:>KHOM opraHe RITH Ha 60JIee H3MeHeHHOH CTeHKe.
,[{JIH ,nOCTII:>KeHIIH 60JIee TeCHoro conpliKOCHOBeHIIH
H3MeHeHHbiX (BocnaneHHbIX) cep03HbIX 060JIOqeK npHMe-
HHlOT mOB XOJICTe)la (puc. 20.14). 1ll0B HaqHHalOT HaKll<\.-
,nblBaTb C 60nee H3MeHeHHoH HJIH MeHee no,nBH:>KHOH CTeH-
KH KIIIlIKH. IIepneH,D;IIKYJIHpHO pa3pe3Y IlJOpMHPYlOT
cep03Ho-MbIIlIeqHbIH CTe:>KOK CHaqaJIa Ha O,nHOM Kparo
paHbI, a 3aTeM Ha CTporo cHMMeTpHqHOM yqaCTKe ,npyroro
KpaH pa . IIoCJIe TIora HrJIY nOBopa alOT H, OTCTylIIiB B
CTOpOHY 1-1,2 CM OT npe,nbI.D:YlUero CTe:>KKa, TaK :>Ke npOBO-
,nHT H1ITb B 06paTHoM HanpaBJIeHIIII.
B Tex CJIyqaHX, Kor,na He06xo,nHMO CY3HTb O,nHH H3
KpaeB paHbI, Hcnonb3YlOT mOB XOJIL,na (puc. 20.15). OH
COCTOIiT H3 Tpex CTe:>KKOB II npe,nCTaBJIHeT C060H KOM6HHa-
UHlO IlIBOB )l(eJIIi H XOJICTe,na.llIoB TaK:>Ke HaqHHalOT Ha 60-
JIee 1I3MeHeHHOM KpalO paHb!. IIepBbIH CTe:>KOK ,neJIalOT ce-
p03Ho-MbIIlIeqHbIM, pacnOJIaraH ero nepneH,D;HKynHpHo
nlIHHII pa3pe3a. Ha ,npyraM KpalO paHbI HIITb npoBo,nHT qe-
pe3 cep03HYlO H MbIIlIeqHYlO 060JIOqKH napanJIeJIbHO OCH
paHbI. Pacnonar.alOT CTe)!(OK Ha paccTosrHHH 0,5-0,6 CM OT
KpaH pa3pe3a. DOCJIe,nHHH CTe:>KOK npoH3Bo,nHT Ha nepBo-
HaqaJIbHO npOlliliBaeMOM KpaIO. B 3aBHCHMOCTII OT paccTo-
HHIIH Me)l(,D;y nepBbIM II nOCJIe,nHMM CTe:>KKaMH, npH 3aBH-
3blBaHIIH HIITII npolIcxo,nIIT YMeHbIlIeHHe MIIHbl Toro KpaH
paHbI, Ha KOTOpOM pacnOJIaraeTCH Y3eJI.
KHceTHblU mOB - HenpepbIBHbIH cep03HO-MbIllieq-
HbIH IlIOB, HaKlla,nblBaeMbIH UHPKYJIHpHO (puc. 20.16). OH
npe,D;Ha3HaqeH MH nepHToHII3aUIIII He60JIbIlIIIX paH, KYJIb TH anneH,D;lIKca H T .n. 1ll0B HaKlla,nbIBalOT
I..(IIPKYJIHpHO BOKpyr norpY:>KaeMoro 06'beKTa. HaqlIHalOT llilITb B HalI60JIee ,nOCTyIIHOM MH MaHlIny-
JIHUIIII yqaCTKe KlilliKII. B CTe:>KOK 3aXBaTblBaIOT cep03HYlO H MbIllieqHYro 060JIOqKH. OqeHb Ba:>KHO,
qT06bl CTe:>KKH IlIBa paBHHJIHCb IlIary IlIBa.l1.MaMeTp KliceTHoro lliBa ,nOJI:>KeH 6bITb ,nOCTaTOqHbIM
MH norpY:>KeHHH B Hero KYJIbTH. IIpH CJIHiliKOM 60nblliOM ,nlIaMeTpe nOCJIe norpY:>KeHHsr KYJIbTH
Me:>K.D:Y HeH H CTemOH KHIlIKII 06pa3yercH cB060,nHoe npOCTpaHCTBO, B KOTOpOM MO:>KeT CKaDJIH-
Puc. 20.13 1l-06pa3Hblu cep03HO-
MbIUle'lHbIU KUUle'lHbIU Uloe )/(enu
Puc. 20.14 1l-06pmHblu cep03HO-
MbIUle'lHblU KUUle'lHbIU Uloe Xoncmeaa
.
Puc. 20.15 1l-06pa3Hblu cep03HO-
MbIUle'lHbIU KUUle'lHblU Uloe X onbma
150
.
BaTbCH :>KH,D;KOCTb. MHIlJHUlipoBaHHe 3TOH :>KH,D;KOCTH BbI3bIBaeT
06pa30BaHHe a6cuecca. IIpH He,nOCTaTOqHOM ,D;IIaMeTpe norpy-
:>KeHHe KynbTH MOiKeT BbI3BaTb ee TpaBMaTH3aUHlO.
KynbTlO nOrpY:>KalOT B IlIOB, 3aXBaTbIBaH ee aHaTOMWleC-
KHM nliHuerOM. IIpli 3TOM HHTb lliBa nO,nTHrHBalOT. TOJIbKO y6e-
,nIIBIlIIiCb B TOM, qTO creHKH KIIIliKH nOnHOCTbIO nOKpbmalOT Kynb-
TlO, H1ITII CBH3bmalOT.
llIoo PycaHooa - S-06pa3HbIH (puc. 20.17) OTJIHqaeTCH
OT KHceTHoro IlIBa TeM, qTO nOCJIe HaJIO:>KeHHH CTe:>KKOB Ha O,nHY
nonyoKpY:>KHOCTb, HIITb nepeKH,D;bIBalOT qepe3 KYJIbTlO K MecTY
nepBOHaqanbHOrO YKona H npo,noniKalOT IlIIITb B npOTHBOnOnO:>K-
HOM HanpaBneHlI1I. TaKaH 1lJ0pMa lliBa 06nerqaeT norpY:>KeHHe
KYJIbTlI.
B cJIyqaHX He06xo,D;IIMOCTII norpY3HTb KynbTlO 60JIblliOrO
pa3Mepa npHMeIDIlOT JJ,BOHHOH nOJI)'KHceTHbIH moo (puc. 20.18) .
,nn5I ero HaJIO:>KeHlIH nOTpe6YlOTCH.D:Be HIITH. IIepBoH HaKlla,nbI-
BalOT cep03Ho-MbIIlIeqHbIe IlIBbl Ha O,nHY nonyoKpY:>KHOCTb KMlli-
KII, ,npyroH HHTblO - Ha ,npyrylO nonyoKpY:>KHOCTb. HHTH 3aBH3bI-
. BalOT OT,neJIbHO. IIpli 3TOM npOIICXO,nIIT norpY:>KeHlIe KynbTlI.
KynbTlO He60JIbillOrO pa3Mepa MO:>KHO norpY3HTb C no-
MO.mblO Z-06pa3Horo moa (puc. 20.19). OH TaK:>Ke HBJIHerCH MO-
,D;IIIlJIIKaUlieH KIiCeTHOrO IlIBa. BHa qane Ha O,nHOH CTopoHe OT no-
rpy:>KaeMoro 06'beKTa Ha O,nHOHJIHHHII nOCJIe,nOBaTeJIbHO ,neJIaIOT
2-3 CTe:>KKa cnpaBa HaJIeBO. 3aTeM nepexo,nHT Ha npOTHBono-
nO:>KHYlO CTOpOHy H npOII3Bo,nHT TaKHX :>Ke 2-3 CTe:>KKa B TOM :>Ke
HanpaBJIeHHH (cnpaBa HaneBO). MeCTa HaqaJIa CTe:>KKOB Ha 06e- B
IIX CTopOHax ,non:>KHbl pacnOnaraTbCH ,npyr npOTHB ,npyra. 7- __.,
.ZJ:nH YKPblTIIH He60JIbIlIIIX ,nellJeKToB KIIIlIKII Hcnonb3yIOT .:fl:::..-; ; r
TaK:>KemoolOoapa (P::c. 20.20). BHaqaJIeHao,nHoHcTOpoHe f,,.. '. . \.
HarrpaBJIeHIIH 6y.ny eH TOqKH norpY:>KeHlIH 1lJ0pMIIPYlOT ne!,BbIlI \t:J .c...,..:- :JoB
cep03HO-MblIlIeqHbIlI CTe:>KOK. 3aTeM Ha npOTHBOnOnO:>KHOH CTO- 51: .. .
r.-. J
pOHe napanJIeJIbHO nepBOMY CTe:>KKY npOH3Bo,nHT BTOpOH. IIo- .. '..,. . -1
Bopa qHBaIOT Hmy H Ha TOH :>Ke CTopOHe no nlIHlI1I nepBoro npo- :,-::,;. ....::: :c )
H3BO,nHT CJIe.nylOlI.{IIH cep03HO-MblllIeqHbIH CTe:>KOK. 3aBepilialOT . ,;.:..
1lJ0pMHpOBaHlie IlIBa CTe:>KKOM, pacnOnO:>KeHHbIM Ha CTopOHe Puc. 20.18 Cepo3Ho-MbIUle'l-
nepBOHaqanbHoro YKona, Ha JIlIHIIH BToporo cre:>KKa. IIpH 3aBH- HblU aeOUHOU nOJ/YKucemHblu
3bmaHHH Y3JIa H 3aTHrHBaHHH HIITH npOHCxO,D;IIT IIHBap HaUIIH KUUle'lHbIU Uloe
,nellJeKTa H IlIlipoKoe COrrpHKocHoBeHlIe cep03HblX 060nolIeK
BOKpyrpaJIbl.
CKB03HbIE Y3JIOBbIE IllBbI
X . C ' b : H '; . .. . .): '
. " ' .. ". .' --,' . II - ,. .. .. ' ... .
. : ,;:,'.1'"' -' .
.. - .
. .
J . . ,
';'. . .';.\
.\
\Yff(IW " /
,,,-,4.,-./
Puc. 20.16 Cep03HO-MbIUle'l-
HblU KucemHblU KUUle'lHbIU Uloe
Puc. 20.17 Cep031l0-MbIUle'l-
HblU KucemHblU Uloe PycaHoea
,nnH HanO:>KeHlIH Kpaeooro moa JKo6epa (puc. 20:21) limy BKaJIbIBaIOT B cep03HblH CJIOH.
OTCTyllHB OT KPM paHbI 0,8-1 CM, HHTb npOBO.D:HT KOCO, BblKallbIBaH Hmy y KPM CJIH3HCTOH 060noq-
KII. Ha npoTIiBOnOnO:>KHOM KpalO IIrJIy BKallblBaIOT y caMoro KpaH co CTOpOHbl CJIII3HCTOH 060noq-
151
rnaBa 20
KH, a BbIKaJIbIBalOT Ha pacCToHHHH 0,8-1 CM. IIpH 3aBH3bI-
BaHHII Y3JIa H36bITOK 3aXBaqeHHOH TKaHIi BbITecHHeT HII:>Ke-
ne:>Kall.{He CJIOII, cnOC06CTBYH BBOpaqHBaHIiIO. IIpoHcxo,nHT
conpHKOCHOBeHHe TKaHeH cep03HbIMH nHCTKaMH Ha 60nb-
lliOH TIJIOll.{a,D;H.
ll-06pa3HbIU IUOB JKo6epa (puc. 20.22) OTnHqaeTC5I
OT IlIBa XOnbTa TeM, qTO B CTe:>KOK, pacnOJIO:>KeHHbIH napan-
neJIbHO KpalO paHbI, 3aXBaTbIBaIOT Bce CJIOII KIIIIIeqHOH CTeH-
KII. II pH 3aBH3bIBaHliH KpaH paHbI BBopa qlIBalOTCH H cep03-
HbIe 060nOqKII conpHKacalOTCH.
IlIoB l>apHlUeBCKom-MaTelUYKa (OT,neJIbHbIH Kpae-
BOH CKB03HOH lliOB) (puc. 20.23) OTnHqaeTCH OT KpaeBoro
IlIBa )l(06epa MeCTOM pacnOnO:>KeHIIH Y3JIa. Ero y3eJI 06pa-
.meH BMYTPb, B CTOPOHY npocBeTa KIIIlIKII. HaqlIHalOT IlIOB co
CTOpOHbI CJIH3HCTOH 060nOqKH B HanpaBJIeHlI1I cep03Horo
nOKpOBa. IIpOTHBOnOnO:>KHYIO CTeHKY npoIlIIIBaIOT B 06paT-
HOM HanpaBJIeHlIIi - co CTOpOHbl cep03HoH 060nOqKII B npo-
CBeT KIIlliKII, r,ne H 3aBH3bIBalOT Y3eJI. IIpH 3TOM CTeHKH Klilli-
KH BBOpaqHBalOTCH H conpHKacalOTcH cep03HbIMH
060nOqKaMH. PacnOJIO>KeHlIe Y3JIOB B npOCBeTe KIiIlIKI1 cno-
c06CTByeT IIX 6bICTPOMY y,naJIeHHlO. 31)' oc06eHHocTb pac-
nOnO:>KeHHH y3JIa IICnOJIb3YIOT npH HanO:>KeHIIII CKB03Horo II-
06pa3Horo IUBa O'KOHHeJIa (puc. 20.24). Tpa!!HUHOHHO
HaqHHalOT IlIHTb co CTOpOHbI CJIH3HCTOH 060JI01.JKH. I1rJIY
npoBo,nHT napaJIJIeJIbHO KpalO pa3pe3a. CJIe,nYlOlI.{HH YKon
npoH3Bo,nHT Ha npOTHBOnOnO:>KHOM KpalO KIIIlIKII, IlJOpMIIPY5I
cre:>KOK co CTOpOHbl Cep03HOH 060nOqKII napaJIJIeJIbHO KpalO
paHbI. B 060lIx CJIyqaHX -lIHTb npOBO.D:HT qepe3 Bce cnOH opraHa. 3aBepilialOT IlIOB npoBe,neHHeM
HrnbI qepe3 Bce CJIOH B HanpaBJIeHHll OT cep03bl K CJIH3HCTOH 060nOqKe nepBoHa qaJIbHO npoIlIIIBa-
eMoro KpaH KlilliKH. Y3eJI 3aBH3bIBalOT co CTOpOHbI npocBeTa opraHa. B HTore KpaH pa3pe3a BBopa-
qHBalOTCH H conpliKacalOTcH Cep03HbIMli 060nOqKaMIi.
1 :,
. . ' -' . ' .. .y . .....
!\. .... ....' \.
. . ,.", .< . ,"I,
_ I' ..
.
."4f -
Puc. 20.19 Cepo31LO-MbIUl(!'l/lbIU
Z-06pa3Hblu KUWe'lHbIU woe
Puc. 20.22 CKe03Hou
1l-06pll3/lblu KUUl(!'lHbIU Uloe
;: : f.: ::
Puc. 20.23 CKe031LOu KUUle'lHbIU
Uloe 'EapbIUleecKozo-MameUlYKa
152
Puc. 20.20 1l-06pa3/lblu
cepo3Ho-MbIUle'lHblii KUUle'lHblU
Uloe lOeapa
Puc. 20.21 CKe03/loii
Kpaeeou KUUle'lllblU Uloe
)Ko6epa
llloB raM6u - CKB03HOH KpaeBOH IlIOB (puc. 20.25)
,nOBOJIbHO qaCTO IIcnonb3YlOT B xlIpyprnli npHMoH KIIIlIKII.
3TOT 1lI0B HanOMlIHaeTKO>KHbIH IlIOB MaK-MlmaHa-,[{oHaT-
TH. IIpli 3TOM nepBOHaqallbHO IIrJIY BKallbIBalOT co CTOpO-
Hhl cep03HoH 060JIOqKH Ha pacCToHHHH 0,8 - 1 CM OT KpaH.
HHTb npoBo,nHT qepe3 Bce CJIOIi. Cne,nYlOlI.{lIH YKon npolI3-
BOAAT Ha TOM :>Ke KpalO KIIIlIKII CO CTOpOHbI CJIII3IICTOH, a
BbIKon - Ha rpaHlIue no,nCJIH3IICTOrO H MbIllIeqHOrO CJIO-
eB. Ha ,npyroM KpalO paHbI HliTb npOBO,D;HT B 06paTHOM
HanpaBneHIIII, ,neJIaH IlIOB CIiMMeTpHqHbIM. 1lI0B 06ecne-
qIIBaeT COnOCTaBJIeHHe KpaeB paHbI. B T. q. II cep03HblX 060-
noqeK.
IlIoB HaKJIa,r{blBalOT B Tex aHX, Kor,na HeT onac-
HOCTII CY:>KeHIIH aHaCTOM03a.
OnHcaHHble IlIBbI OTHocmCH K rpynne HHBe lIpO-
BaHHbIX IlIBOB. B OTJIlIqlIe OT 3BepTHpoBaHHbIx, OHH xopo-
IlIO pa3pa60TaHblII 3aHlIMalOT Be,ny.mee nOnO>KeHHe B TeX-
HHKe HaJIO:>KeHHH KlillieqHOrO lliBa. IIocJIe 3aBH3bIBaHliH Y3JIa HHBeprnpoBaHHoro IlIBa npolIcxo,nIIT
conpliKocHoBeHHe cep03HbIX JIIICTKOB CIlIHBaeMbIX KpaeB. IIpli 3aB5I3bIBaHHH Y3JIa 3BepTHpoBaH-
Horo IlIBa, CIlIHBaeMbIe KpaH conpliKacalOTcH CJIII3IICTblMli 060nOqKaMIi. I1plIMepoM MO:>KeT CJIY-
:>KHTb IUOB reTueHa - CKB03HOH KpaeBoH BbIBOpa'lIIBaIOlI.{HH IlIOB (puc. 20.26). BbIllOJIH5I1OT ero
CJIe,nYlOlI.{HM 06pa30M: limy BKallblBalOT co CTOpOHbl cep03HoH 060JIOqKII 6JIH:>Ke K KpaIO pa3pe3a,
a BbIKallblBaIOT - Ha CJIH3HCTOH 060JIOqKe, OTCTYTIIiB 1,5-2 CM OT Kpa5I. B TOJI.me CTeHKH KHiliKII HIITb
npoBo,nm KOCO, 3aXBaTbIBa5I 60ITbille no,nJIe>Kall.{IIX CJIOeB. Ha ,npyroH CTeHKe 3TY:>Ke H1ITb TIpOBO-
JJ:j{T cliMMeTpHqHo. IIpH 3aBH3blBaHHH Y3JIa 3aXBaqeHHblH B IlIOB 1I36bITOK TKaHeH BHYTpeHHero
4JYTJIHpa cnoc06cTByeT BblBOpaqHBaHHIO KpaeB paHbI. B pe3YJIbTaTe - coe,nIIHHeMbIe CTeHKH KIIIlI-
KII conpliKacalOTcH CJIH3HCTbIMli 060JIOqKaMII.llIoB npHMeHHlOT pe,nKo.
Puc. 20.25 CKeo3Hou KUUle'lHbIU
UIOe raM6u
Puc. 20.24 CKeo31lOu KUUle'lUbIU
Uloe O'K01lHena
,.-.... .........._. . .
".'_.. J'
Puc. 20.26 CKeo3Hou KUUle'lHbIU
Uloe remljeHa
153
rnaBa 20
CKB03HbIEHEllPEPbffiHbIEWBbI
Puc. 20.27 HenpepbleHblu CKOpHR3/CHbIU
KUUlel.J1/bIU Uloe
PUC. 20.28 Henpepble1/blU KUUlel.JHblU Uloe
MUKYJlul.Ja
Puc. 20.29 Henpepble1/blli «(PYCCKUU»
ICUWe'lHbIU IUOII
154
CKB03HbIe HenpepbIBHbIe IlIBbI npHMeHHlOT
KaK ,D;JIH YIlIIIBaHHH pa3pe30B nOJIblX OpraHOB, TaK H
,D;JIH £tJOpMlIpOBaHIiH aHacToM030B, TeXHIIKa IIX HallO-
:>KeHII5.I npOCTa II OTJIlIqaerCH HanpaBJIeHlIeM npOXO:>K-
,neHII5.I HHTH. PaCCTOHHHe Me)l(,D;Y CTe:>KKaMH TaKoro
lliBa COCTaBnHeT B CpelJ,HeM 0,5-0,8 CM. PaCCTOHHHe
OT MeCTa YKona ,no KpaH paHbI 3aBliCliT OT Ton.mIIHbI
ClliHBaeMbIX CTeHOK. ,[{JIH KIIIlIKII OHO COCTaBJIHeT 0,7-
0,8 CM, ,nJIH :>KeJIy,nKa, MaTKII -,no 1 CM. IIpH onepa-
UHII Ha TOHKOH KIIIlIKe, :>KeJIy,nKe, MaTKe, MOqeBOM
nY3bIpe CKB03HOH HenpepbIBHbIH IlIOB HaKJIa,nbIBa-
lOT HIITHMII C YCJIOBHblM ,nlIaMeTpOM 3/0-4/0, npli
onepaUlI1I Ha TonCTOH KlilliKe - HIITj{MH ,nHaMeTpoM
4/0-5/0.
CKopHHmHLlu mOB - HenpepblBHbIH KpaeBoH
06BIIBHOH BbIBOpaqnBaIo.mIIH 1ll0B (puc. 20.27). ,[{JIIIH-
HYlO HHTb npoBo,nHT qepe3 Bce CJIOII CTeHKII nonoro
opraHa. Ha O,nHOM KpalO paHbI Hrny BKaJIbIBalOT co
CTOpOHbI cep03bl, aHa ,npyroM - co CTOpOHbI CJIH3HC-
TOH 060JIOqKII. IIocJIe BblKanblBaHIiH HrJIbl Ha cep03-
HOH 060nOqKe HHTb 3aTHrlIBalOT cHapY)l(lI. IIpH 3TOM
KpaH paHbI BblBOpaqHBalOTcj{ H IIX CJIH3HCTble 060-
nOqKHconpHKacalOTcH.
UloBreMOCTaTHqeH,o,nHaKoBblBOpaqHBaHlie
CJIII3IICTOH 060nOqKH cnoc06CTByeT HHllJlIUHpoBaHlIlO
nHHHH lllBa, B CBH31I C qeM ero nplIMeHHIOT pe,nKo.
IIIOB MUKYJIU'Ia - HenpepbIBHbIH 06BIIBHOH
BBOpaqHBalOlI.{lIHiliOB (puc. 20.28). TexHIIKaeroHa-
JIO:>KeHIIH OTJIlIqaeTCH OT BblllleonHcaHHoro TeM, qTO
nOCJIe HallO:>KeHlIH Ka)l(lJ,OrO CTe:>KKa HHTb 3aTHrlIBalOT
co CTOpOHbI npocBeTa opraHa. 3TO nplIBo,nIIT K BBO-
paqHBaHHIO KpaeB pa3pe3a H conpliKocHoBeHlI1O HX
cep03HbIX 060noqeK.
He,noCTaTKOM IlIBa HBJIHeTC5.I B03paCTalOlI.{ee no
Mepe 3allllIBaHliH Hey,n06CTBO 3aTHrlIBaHHH HIITH. IIoc-
ne,D;HHe CTe:>KKII nplIXo,nIITCH 3aTHrlIBaTb cHapY:>KH.
Pa3HOBH.D:HOCTblO HenpepbIBHoro BBOpaqHBa-
IOlI.{ero lllBa HBJIHeTCH «PYCCKUU» mOB (puc. 20.29).
B OTJIHqHe OT npe,nbI.D:Yll.{erO IlIBa, 06BIIBHYlO HIITb
npOBo,n5.lT He qepe3 Bce cnOH, a 3aXBaTblBalOT TonbKO
Cep03Hbrn CJIOH, MbIlIIe ylO H no,nCJIlI3lIcryIO 060noq-
KH, He npOHIiKaH qepe3 CJIH3IICTYlO 060nOqKY.
HIITb :3a THrlIBalOT co CTOpOHbl npOCBern
OpraHa, qeM ,nOCTHraIOT BBOpaqlIBaHIiH KpaeB
paHbI H cepO-Cep03HOrO KOHTaKTa. IIocJIe,nHHe
CTe:>KKII, KaK II B IlIBe MHKynlIqa, 3aTHrHBalOT
CHapY:>KH.
IUOB IIIMU){eHa - HenpepbIBHbIH 06BIIB-
HOH (CKB03HOH) BBOpaqHBalOlI.{HH JIIOB
(puc. 20.30). ,[{JIIIHHYlO HIITb npoBo,nHT qepe3
Bce CJIOII KIIIlIKII B O,nHOM HanpaBneHHII. YKon
IIrJIOH H Ha O,nHOH, II Ha ,nPyroH CTeHKe opraHa
npolI3BoMT co CTOpOHbI CJIII3IICTOH 060nOqKII.
IIocne npoIlIIiBaHIiH 060lIx KpaeB HIITb 3aTHrH-
BalOT C HapY:>KHOH CTOpOHbl. IIpH 3TOM npoHcxo-
,nHT BBOpaqlIBaHlie CIlIIiBaeMblX CTeHOK B npo-
CBeT opraHa H conpliKocHoBeHlIe cep03HbiX
060nOqeK. ,[{JIH yny eHII5.\ BBOpaqHBaHIIH nrny
ueJIeC006pa3Ho npOBO,nIITb B KOCOM HanpaBJIe-
HIIH, 3aXBaTbIBaH B CTe:>KOK 1I3JIlillieK TKaHeH Ha-
pY:>KHoro llJymHpa.
IUOB KOHHeJIH - CKB03HOH HenpepbIBHhIH
II -06Pa3HbIH BBOpaqlIBalOlI.{lIH IlIOB (puc. 20.31) .
HaKna,nblBalOT ,nJIIIHHOH HIiTblO, pacnonaraH
CTe:>KKH napaJIJIeJIbHO KpalO paHbI. HHTh npoBo-
,n»T qepe3 Bce cnOH CTeHKII opraHa. O,nIIH KpaH
npoIlIIiBalOT co CTOpOHbl CJIII3HCTOH 060JIOqKH, a
,npyroH - co CTOpOHbI Cep03bI. HHTh no,nTHrIIBa-
lOT II CHOBa npOIlIHBalOT Ha TOH :>Ke CTopOHe OT
cnlI3HCTOH K cep03e. 3aTeM B03Bpall.{a1OTC5.\ Ha
nepBOHaqaJIbHO npOIlIIiBaeMblH KpaH pa3pe3a
II npOBO,D;HT HIITb co CTOpOHbI cep03HOH 060noq-
KII, 3aTHrHBaH ee co CTOpOHbI npOCBeTa opraHa.
I1rny BKaJIbIBalOT H BbIKanhlBalOT Ha paCCT05.\-
HIIII 0,5 - 0,7 CM OT KpaH pa3pe3a.I.llIIpHHa CTe:>K-
Ka He ,nOJI:>KHa npeBblIlIaTb 1,2 - 1,3 CM.
MeCTo YKOJIa IIrJIbI ,nOJI:>KHO CTporo COOT-
BeTCTBOBaTb MecTY ee BbIKaJIbIBaHIiH Ha ,npyroM
KpalO. IIpli Hec06nlO,neHHH 3TOro YCJIOBIIH CTeH-
KII opraHa BBOpaqHBalOTCH DJIOXO, a JIHHHH llIBa
rollJplIpyeTcH H c06IIpaerCH B cKlla,nKH.
Bo BpeMH HanO:>KeHHH cre:>KKOB acclicreHT
nOCTOHHHO y,nep:>KIIBaeT HIITb B HaTH:>KeHlIIi.
IUOB KYIUHHI'a - HenpepbIBHhrn II-06pa3-
HbIH cep03HO-MbIIlIeqHO-no,n,CJIH3HCTbIH lliOB
(puc. 20.32). OTnlIQaeTCH OT lliBa KOHHeJIH rny-
6IIHOH 3aXBaTa TKaHeH. HHTb npOBo,nHT qepe3
Puc. 20.30 Henpepb/eHb/u KUUle'lHb/U
Uloe lliMUaella
Puc. 20.31 Henpepb/ellb/u KUUle'lHb/U UJoe
KOllllellR
Puc. 20.32 Henpepb/e/lb/u KUUle'lHb/U Uloe
KYUluHza
155
rJIaBa 20
Puc. 20.33 HenpepbleHblu KUUle'lHbIU Uloe
PeeepaeHa-A1YRbrnaHOeCKOZO
Puc. 20.34 HenpepbleHo-eo3epamHblu
KUUle'lllbIU Uloe
Puc. 20.35 HenpepbleHo-Y3Roeou
KUWe'lH/>lu woe
156
cep03HYIO, MbIIlIeqHYIO 060nOqKII II nO,nCnH3IICTbIH
cnOH, He 3aXBaTbIBa5I CJIII3IICTYlO 060JIOqKY. IIpli 3a-
THrHBaHlI1I HIITII nOCITe HaJIO:>KeHHH CTe:>KKOB Ha 06a
Kpa5I paHbI CTeHKII BBOpaqlIBalOTCH II coe,nIIH5IeMbIe
nOBepXHOCTH conpliKacalOTcH cep03HhIMH 060nOqKa-
MII.
WOB PeBep,neHa-MYJIbTaHOBCKoro - Henpe-
pbIBHblH CKB03HOH 06BIIBHOH lliOB «B3aXJIeCTKY»
(puc. 20.33). HIITb npoBoMT qepe3 06e CTeHKII KHIlI-
KII. Ka)l(,D;bIH nocne,nYIOlI.{HH CTe:>KOK npoxo,nHT qepe3
nemlO npe,nhI,D;yll.{ero. B pe3ynbTaTe - npli HaTH:>KeHIIII
HIITII 06pa3yeTcH «3aXJIeCTKa», c,naBnHBaIOlI.{aH TKa-
HII. ,[{nIiHa cre:>KKa He ,nomKHa npeBbIlIIaTb 0,6-0,8 CM.
HenpepblBHblM CKB0311blM B03BpaTHblM MaT-
paUHblM WBOM (puc. 20.34) 06bIqHO npoIlIIiBalOT TKa-
HH, IlJHKCIipOBaHHble 3a:>KIIMOM. Ha yrJIY paHbI HaKlla-
,nbIBalOT Y3JIOBOH lliOB. ,[{JIIIHHbIM KOHUOM HHTH no,n
6paHIlIaMH 3a)!(IIMa qepe3 Bce CJIOH npOlIIlIBalOT CTeH-
KII opraHa. Ka)l(,l:\hIH nOCJIe.lO'lOlI.{lIH CTe:>KOK IlJOpMIIpY-
lOT TaK, qT06bI HHTh nepexo,nRITa Ha npOTHBOnOJIO:>K-
HYIO CTOPOHY nocpe,nIIHe npe,nbI.D:YlI.{erO CTe:>KKa.
TaKHM 06pa30M, qepe.nyH HanpaBJIeHlIe CTe:>KKOB, npo-
H3BOMT 3alIIIIBaHlie paHbI Ha BceM npOTH)!(eHIIII. IIoc-
ne HanO:>KeHIIH nOCJIe,nHero CTe:>KKa HIiTh 3aBH3hIBaIOT,
a 3a)!(HM cHIiMalOT.
B cnyqae onaCHOCTH pa3PYilieHIIH H1ITII «arpec-
CIIBHbIM» KIIIlIeqHbIM co,nep:>KIIMbIM MO:>KHO Bocnonb-
30BaTbC5I HenpepbIBHO-Y3JIOBbIM WBOM (MIIJIbKOB
E.O., CWJ;OP II. n, IIoJIjlHcKIIllI1. IO.) (puc. 20.35). ,[{JIH
HanO:>KeHIIH IlIBa nOHa,n06IITCH HIITb C ,nBYM5I HrnaMIi
Ha ee KOHuax. HaqHHaIOT 1IIIITb co CTOpOHbI CnII3IIC-
TOH 060nOqKII, npoBo,nH HIITb Qepe3 Bce CJIOII KHapy-
)l(II. AHallOrnqHbIH cre:>KOK, HO Y:>Ke ,npyroH IImOH, 1lJ0p-
MHPYIOT Ha npoTHBOnOnO:>KHOM KpalO. KOHUbI HIITII
CBH3bIBalOT B Y3eJI, pa3Mell.{aH ero Ha cep03HoH 060-
nOqKe. IIocJIe 3aB5I3bIBaHliH Y3na nOCJIe,nOBaTeJIbHO
Ka)l(,D;OH HrnoH npoIlIIiBalOT 06a KpaH paHbl H3HYTpH
KHapY:>KlI, nocne qero BHOBb 3aBH3blBalOT KOHUbI HIITH.
06eCneqlIBaeTCH BBOpaqlIBaHHe KpaeB paHbllI Ha-
,ne:>KHbIH reMOCTa3. IIpH He60nbilioM llIare IlIBa pa3-
pYilieHlIe co,nep:>KIIMbIM opraHa (KIIIlIKII) OT,nenbHoro
CTe:>KKa HHTH He CKa3hlBaeTCH Ha MeXaHlIqeCKOH npoq-
HOCTH Bcero IlIBa.
,!UJYXP»,lJ,Hbrn mOB
)];ByxpMHble lliBbI - OCHOBHOH cnoc06 npOllIHBa-
HIIH CTeHKII lIHlueBOLIa, :>Keny.D:Ka. TOHKOH KlilliKII, MaTKH.
MOqeBOrO ny3blpH. ,[{JIj{ IIX C03,naHHH IICnOJIb3YIOT TOJIb-
KO o,nHOTHnHble llIBbI (TOJIbKO Y3JIOBbIe RITII TonbKO He-
npepbIBHble). B npoTIIBHOM CJIyqae, npli 06'be,nIIHeHIII1
llIBOB C pa3HblMli cBoii.cTBaMII, lIpOIICXO,nIIT HapYllIeHHe
KoalITaUMIi CIlIIiBaeMbIX CJIOeB.
IIIoB AJIb6epTa (puc. 20.36) - ,nBYXPMHbIH IlIOB,
06'be,nIIHHlOlI.{IIH KpaeBoH CKB03HOH IIHBepTlipOBaHHbIH
IlIOB II oT,neJIbHblH cep03Ho-MbIllIeqHblH lliOB JIaM6epa.
LlJOB 06eCneqlIBaeT HaLIe:>KHbIH reMOCTa3 II repMeTlIq-
HOCTb. O,nHaKO npOBe,neHlIe HIITII qepe3 Bce CJIOII KlilliKII
COnpOBO)l(,D;aeTCH pliCKOM pa3BIITMH BOCnaJIIITeJIbHOH pe-
aKUlI1I no nlIHlfH llIBa, 3aMe,nJIeHHH pereHepaUlI1I TKa-
HeH H pa3BIITliH ClIaeqHOrO npouecca.
IIIoB TYlIe (puc. 20.37) OTJIlIqaeTCH OT npe,nbIlIY-
lI.{ero IlIBa MeCTOM pacnOJIO:>KeHHH Y3JIOB nepBoro pH,na
IlIBOB. I1pH ero IICnOnHeHlI1I Y3JIbi OKa3bIBalOTCH 06pa-
lI.{eHHbIMIi B npocBeT opraHa. ,[{JIH :.JToro nepBbIii YKOJI
HrJIbI BbIllOJIHHIOT co CTOpOHbI CJIH3IICTOH 060nOqKII, a
BbIKanbIBaIOT Ha cep03HoH. II pOTIIBOnOnO:>KHYIO CTOpO-
HY npoKanbIBalOT HrnoH OT cep03HoH,nO CJIII3l1CTOH 060-
nOqKII. IIocJIe 3aBH3blBaHHH Y3JIa B npOCBeTe KUlliKH
H3JIIUIIKH HIiTeH He cpe3aIOT, a Hcnonb3YIOT B KaqeCTBe
pblqara-,nep:>KallKH. IIo,nTHrHBaH 3a HHX B CTOPOHY npo-
CBeTa opraHa, HaKllarIbIBalOT cep03HO-MbIllIeqHbIH IlIOB.
I1Ha'le KpaH KHllIKH BbIBOpaqIIBalOTCH.
IIIoB qepHH - ,nBYXpH,nHbIH cep03HO-Mb1IlIeqHbIH
IlIOB (puc. 20.38) npe,ncTaBJIHeT C060H 06'be,nIIHeHlIe OT-
,neJIbHbIX KpaeBbIx cep03HO-MblllIeqHbIX I1JIH cep03Ho-
MbIllIe 0-no,nCJIII3IICTblX lliBOB (l-H PM) H cep03Ho-Mbl-
llleqHbIX lllBOB JIaM6epa (2-H PH,n). rnaBHbIM
npelIMYIUecTBoM llIBa HBnHeTCH ero aCenTlIqHOCTb.
11. JIHTTMaHH (1981) BbIlIeJIRIT pa3JIIIqHbie KOM-
6HHaUIIII ,nBYXPMHbIX IlIBOB: a, [3, y.
a-lllOB (puc. 20.39) - HanO:>KeHHeM l-ro 'pH,na
CKB03HbIX llIBOB ,nocTHraeTcH COlIpHKocHoBeHHe KpaeB
paHbl cep03HbiMli 060JIO'lKaMII; 2-H pH,n (cep03HO-MbI-
llIeqHbIH IlIOB) ,nonOJIHlITeJIbHO repMeTl13IIpYeT nHHlIlO CO-
e,nIIHeHIIH.
-IlIOB (puc. 20.40) - HanO:>KeHHeM l-ro pH,na
CKB03HbIX IlIBOB ,nOCTHraeTCH conOCTaBJIeHlIe KpaeB
Puc. 20.36 l1eyxpJlaHblU KUUlelJHblU
Uloe Allb6epma
Puc. 20.37 PeYXPJlallblU KUUle'lHbIU
Uloe Tyne
Puc. 20.38 PeYXPJlallblU KUUle'lllbIU
Uloe lfepllu
157
rnaBa 20
paHbI CJIII3IICTbiMli 060JIOqKaMII; ,nJIH 06eCneqeHIIH Ha,ne:>KHOCTIi repMeTH3aUIIII 1lJ0pMIIPYIOT 2-H
PM cep03Ho-MbIllIeqHblX IlIBOB. BbIBOpaqHBaHlie CJIII3IICTbIX 060JIOqeK npHBo,nIIT K 06pa30BaHHlO
3aMKHYTOH HHllJlIUlipOBaHHOH nOJIOCTH. KOnHqeCTBO co,nep>KIIMOrO 3TOH nonOCTIi nporpeccHBHo
B03paCTaeT, BCJIe,nCTBlie qero HapyrrraeTCH repMeTWIHOCTb H pa3BIIBaeTcH HeCOCTOHTeJIbHOCTb IlIBa.
IIpH 1lJ0pMIIpOBaHHII Y-lliBa (puc. 20.41) npo-
HCXO,nHT conpliKocHoBeHlIe pa3JIUqHbIX TKaHeH - cnlI-
3HCTaH 060nOqKa no,nIlIHBaerCH K cep03HoH II Ha060-
pOT. KpaH paHbI, 3aIlIHTOH TaKIiM Y-iliBOM,
cpaCTalOTCH TOJIbKO BTOPlIqHbIM HaTH:>KeHlIeM.
f3 H Y-IlIBbl HBJIHlOTCH pe3ynbTaToM HerpaMOT-
HOrO nO,D;Xo,na K HanO>KeHlIlO KlIIlIeqHOrO IlIBa. IIpn BbI-
nOJIHeHlI1I BCeX MaHlInynHIJ,HH, CBH3aHHbIX C He06-
XO,nIIMOCTbIO BOCCTaHOBJIeHIIH ueJIOCTHOCTH nOJIbix
OpraHOB, He06xo,nHMO BO BCeX cnyqa X HaKlla,nblBaTb
a-lIlBbl.
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Puc. 20.41 PeYXpJlaHblU KUUle'lHbIU Y-Uloe
3Allll1BAHl1E PAHI10JIbIXOprAHOB
3aKpbITlie npocBera nOITbIX opraHOB Tpe6yeTcH npli IIX paHeHIIII, npOBe,neHHH onepaUIIOH-
HblX BMeIlIaTeJIbCTB, pa3JIHqHbIX naTOJIOrlIQeCKIiX npoueccax.
,lJ:n 3aKpbITliH paHbI KlilliKII RITII MOqeBOrO nY3bIpH HY:>KHO HaJIO)l(lITb He MeHee .D:BYX 3Ta:>KeH
IlIBOB. IIpli 3allIIIBaHHII KHIlIKII - I-H 3Ta:>K npe,nCTaBJIHeT C060H CKB03HbIe (IIHIlJHUMpOBaHHble) IlIBbl
(puc. 20.42); 2-H - HenpOHIiKalOlI.{He (cep03HO-MbIllIeqHbIe) (puc. 20,43). IIepBbIH 3Ta:>K npe,nHa3Ha-
qeH.wrSl: npOqHOrO y,nep:>KaHUH c6JIII>KeHHblX KpaeB paHbI, Ero MO:>KHO HaKlla,nblBaTb, 3axBaTbIBaH Bee
CJIOIi. BTOpOH 3Ta:>K ,nOJI:>KeH YKpbITb 3TOT IlIOB 6plOIlIHHOH II ,nononHIITb repMeTHqHOCTb 3aKpbITII c
nOMOll.{blO xopoiliero conpliKOCHOBeHHH no,norHYTblX cep03HbIX 060nOqeK. IIpH BbI60pe IlIBa MSI
nepBoro 3Ta:>Ka yqlITblBalOT BeJIlIqlIHY ,nellJeKTa CTeHKII II xapaKTep naTOJIOrlIqecKoro npouecca.
158
)];JIH BOCCTaHOBJIeHIIH ueJIOCTHOCTIi CTeHKII MOqeBOrO
ny3bIPH IlIBbI nepBOrO 3Ta:>Ka HaKllaJ];blBalOT Ha MbIllie 060-
nOqKY, He 3aXBaTblBaH CJIII3IICTOH. I1rHopnpOBaHlie :noro YC-
nOBHH MO:>KeT npHBecTIi K 06pa30BaHliIO B npOCBeTe MOqeBOrO
nY3bIpH KaMHeH (IIHKPYCTaIJ,IIH xlIpyprHqeCKIiX HIiTeH COJIHMII
MOqn).
IIpH nlIHeHHblX pa3pe3ax CTeHKII KHiliKII RITH :>KeJIy,nKa B
KaqeCTBe l-ro 3Ta:>Ka IlIBOB, KaK npaBIIJIO, Hcnonb3yIOT O,nIIH
H3CKB03HblX BBOpaqHBalOlI.{lIX lliBOB (llIMH,D;eHa, KOHtleJIH, )l{o-
6epa, IIlIporoBa, EapIIIlIeBCKoro-MaTeI1IYKa H ,np.). OH 06ecne-
qHBaeT reMOCTa3 II conpliKOCHOBeHlIe cep03HbIX 060JIOqeK.
3allIliBaHlie paHbl KIiIliKH npOII3Bo,nHT CJIe,nYlOlI.{IIM 06-
pa30M. IIpe.nnoJIO:>KIIM, qTO IIMeerCH KocaH paHa Ha TOHKOH
KIIllIKe. ECJIII TaKYIO paHY npoCTo 3allIIITb no ,D;JIIIHe, TO, OqeBH,D;-
HO, nonyqlITcH HeKOTopoe CY:>KeHHe npOCBeTa KHlliKI1, qTO BOB-
ce He :>KenaTenbHO. Bo 1I36e:>KaHHe 3Toro, npo,nonbHYIO paHY
npeBpaIIlalOT B nonepeqHYlO. )];JIH 3Toro cTemy KIIIlIKII 3aXBa-
TblBaIOT 3a:>KIIMaMH B TOqKaX, 0603HaqeHHbIX Ha plIcYHKe Kpec-
TIIKOM (puc. 20.44), II pacTHrlIBalOT paHY B nOnepeqHOM Ha-
npaBneHlI1I (puc. 20.45). 3a:>KIIMbI 3aMeHHlOT Y3JIOBaTbiMli
lliBaMIi (puc. 20.46). HaKna,D.blBaIOT my60KliH 3Ta:>K IlIBa. 3,necb
xnpypr, no cBoeMY yCMoTpeHIIIO, MO:>KeT HanO)l(HTb Y3JIOBaTblH
IIJIH HenpepblBHbIH lliOB. He cYlI.{eCTBeHHO, 6y,ner nli 3TOT 1lI0B
npoHliKaTb qepe3 CITlI3IICTYIO KIiIliKH. rnaBHoe, 'lT06bl OH 6blJI
reMOCTaTH bIM II 3aXBaTIIJI ,nOCTaTO'lHOe KOJIlIqeCTBO no,nCJIII-
3IICTOH KlleTqaTKII. I1HbIMIi CJIOBaMlI, 1lI0B ,nOJI:>KeH 6blTb Ha-
CTonbKO npOqeH, qT06bI Mor y,nep:>KIIBaTb KpaH paHbI,no Tex nop,
nOKa cep03Hbie nHCTKII, coe,nHHeHHble CJIe,nYlOlI.{HM 3Ta:>KOM
lliBOB, ycnelOTxopoIllO CJIlInHYTbcH.
IIo,noH.wr K npoTlIBonono:>KH0MY KOHUY paHbI, HenpepblB-
HbIH 1lI0B 3aKpenJIHIOT OT,neJIbHbIM Y3JIOBaTblM IlIBOM, KOHUbI
HHTeM KOToporo 3aMeHHIOT BTOpOH 3a)l(IIM. Tenepb aCCHCTeHT
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3aIlIHTaH paHa XOpOllIO npoTlipaeTcH aHTItCenTHKOM,
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xHoCTeH KllllIKII B,nOJIb 3allilITOH paHb!. KaK npaBlIJIO, HaKJIa-
,nblBaIOT Y3JIOBbie llIBbI. ,[{06HTbCH Toro, qT06bl OHI1 6blJIli ,neH-
CTBIiTenbHO cepo3Ho-cep03HbIe RITII cep03HO-MbIllIeqHbIe,
,nOBonbHO Tpy,nHO. KorLIa He 3aXBaqeHa KlleTlIaTKa, llIBbI OqeHb
nerKO npope3alOTCH. 3aBH3aTb 11X nOqTH HeB03MO:>KHO. CTeH-
Ka KItllIKII HaCTonbKO TOHKa, qTO lIlOB, 3aXBaTblBalOll.IlIH KpOMe
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:>Ke, <IeM IlIOB, 3aXBaTblBalOlI.{ItH TOJIbKO MbIllie'iHbIM CJIOH. He
nO,D;JIC:>KHT COMHeHHlO, '1TO MHorne lIlBbl, KOTopbIe C'UfTalOTCH
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IIocJIe 06pe3aHliH KOHUOB HIITOK lliOB ell.le pa3 npOTII-
palOT aHTHcenTuKOM. Y:>Ke qepe3 5-6 '!aCOB conpliKaCaIOlI.{lIe-
CH nOBepXHocTU cep03HbIX JIHCTKOB OKa3blBaIOTcH CJIUnllIIIMU-
CH. 3TO npOHcxo,nIIT BCJIe,nCTBlie 06pa30BaHHH 1lJ1I6plIH03Horo
3Kccy,naTa B 1lJ0PMe JIO>KHOH 060JIOqKH. OH He TOJIbKO CKJIeU-
BaeT paHY, HO H COBepllieHHO YKpblBaeT Y3JIbI 11 KOHUM H11TOK. C
TeqelUICM BpeMeHII 3Kccy,naT opraHH3yeTcH II npeBpaIUaeTCH
B COeLIIIHHTeJIbHYKJ TKaHb. HIITKH, KOTOpbIMH 3allIliTa KlilIlKa,
MOryT IIlI0rLIa HHKanCYJIUpOBaTbCH, HO 06bIlIHO OHH npOBa.'IH-
BalOTCH B npOCBeT KlilIlKH II BbI,lJ.eJIHIOTCH opraHH3MOM, KaK
IIHOpo,nHoe TeJIO.
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Puc. 20.46 tPW(£'al{UR Kpaee paHbl Te 1I3 HIIX, KOTopbIe npoxo,nHT HaCKB03b B npocBeT KlillIKII, B03-
MO:>KHO, BbI,neJIHlOTCH 1I3 opraHII3Ma COBepIlIeHHO TaK >Ke, KaK
II HepaCCaCblBaKJIUliecH. CKOplUI:>KHbrn IlIOB (HenpepbIBHbIH) OT-
,neJIHeTCH Tpy,nHee. 1103TOMY CJIe,nyeT 1I36eraTb HaJIO:>KeHIIH Ha KHlliKH HenpepbIBHblX IlIBOB qepe3
BClO TOJIlllY CTeHKU. IIpli 3allIIIBaHII11 paubl naKJIa,.'.{bIBaIOT IlIBbI Y3noBble.
Y:>Ke Ha 18-H ,neHb nOCJIe onepaUlI1I CKOpHHJKHbrn lIlOB, npoxo,nHll.UIH 'Iepe3 Bce CJIOII Ha :>Ke-
ny,nKe, II ,na:>Ke MeCTO ero HaJIO:>KeHHH OTbICKaTb OKa3aJIOCb O'IeHb Tpy,nHO, B qeM 6bma B03MO:>KHOCTb
y6e,nIITbCH Ha BCKpbITIIII. I1plIqeM HHKaKoro yTOJIIUeHHH B 06JIaCTli lIlBa He npoIUynbIBanOCb.
TonbKO pa3pe3 CKallbneJIeM nepe,naBan oIUYIUeHHe nepepe3aeMOH HIITKH.
ElI.{e pa3 XOTIIM HanOMHlITb, qTO y,naqHOe 3allIIIBaHHe KlillIKII ,nOCTliraercSI XOpOlliliM repMe-
TlilIeCKHM coe,nUHeHHeM paHbI H MIIHIIManbIlblM KOJIlilIeCTBOM KaqeCTBeHHO naJIO:>KeHHblX lliBOB,
3aBH3aHHbIX ,nOCTaTOqHO Tyro, HO 6e3IIllIeMliH n npOpe3aHIiH TKaHIi. ECJIII 3TH YCJIOBIIH y,naJIOCb
BblDOJIHIITb, TO Y:>Ke qepe3 ,nBa-TpIi ,nHH coe,nIIHeHlIe TKaHeH MO:>KeT 6blTb HaCTOJIbKO npOqHbIM, 'ITO
HeT OCHOBaHlIH onacaTbCH Ha3HaqeHIIH JIerKOrO CJIa6lITeJIbHoro. OnaCHOCTb nOCJIa6JIHIOIUerO 31lJ-
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H HH:>Ke nOBpe)!(j:(eHHoro MeCTa HaKJIaJ(bIBalOTO! 3a:>KJ1MbI, CllaBnHBalOIlIHe npOCBeT KlillieqHHKa.
I1cKyccTBeHHoe coe,nUHeHlIe ,nBYX yqaCTKOB nlIlueBapHTeJIbHOrO KaHana - o,nHa H3 Ha1I60-
nee pacnpOCTpaHeHHbIX onepaUHH B a6,nOMUHanbHOll xHpyprnn. l..I.eJIblO 1lJ0pMHpoBaHHH aHaCTO-
M03a HBnHeTCH BOCCTaHOBneHHe naCca:>Ka co,nep:>KUMOrO nlIlueBapHTeJIbHOrO annapaTa.
IIpH HaJJO)!(eHlIU aHaCTOM03a cne,nyeT yqHThlBaTb OCHOBHble Tpe60BaHH»:
- aHaCTOM03 He06xo,nHMO naKna,nblBaTb H30nep1iCTanbTlIqeCKH, TO eCTb BeKTOp nepHC-
TaJJbTHKH B npHBOllHllleM yqaCTKe ,non:>KeH COOTBeTCTBOBaTb TaKOBOMY B OTBo,nHweM Y'iaCTKe;
- IlIliplIHa aHaCTOM03a ,nOJI:>KHa 6bITb ,nOCTaTOqHOH.D:JIH 6ecnpenHTCTBeHHOrO npo,nBH)!(eHIIH
co,nep:>KHMOrO KHllleqlIlIKa;
- lliOB COYCTbH ,nOJI:>KeH 6bITb ,nOCTaTO O npO bIM ,nJIH Toro, 06bI 06eCneqlITb IlJH3HqeC-
KYlO H 6HOnOrHqeCKYlO repMeTlIqHOCTb.
Bce aHaCTOM03bI no THny coe,nUHeHHH npHBo,nHlI.{ero H OTBo,nHlI.{ero yqaCTKOB miweBapu-
TeJIbHOrO TpaKTa ,neJIHT Ha:
a) aHaCTOM03 «KOHeu B KOHeu» (anastomosis termino-termina1is) - KOHeu npHBo,nHll1ero
yqacTKa coe,nIIHHIOT C KOHUOM OTBOllHwero; .
6) aHaCTOM03 «60K B 60K» (anastomosis latero-Iateralis) - coe,nHHHlOT60KoBble nOBepxHoc-
TH npHBo,nHwero II OTBO.D:HlI.{erO yqaCTKOB;
B) aHaCTOM03 «KOHeu B 60K» (anastomosis termino-Iatera1is) - KOHeu npHBO.D:HwerO yqaCTKa
coe,nHHHlOT C 60KOBOH nOBepXHOCTblO OTBo,nHwero;
r) aHaCTOM03 «60K B KOHeu» (anastomosis 1atero-tenninalis) - 60KOBYlO nOBepXHOCTb nplIBo-
JJ:jIwero Y'IaCTKa coe,nUHHlOT C KOHUOM OTBOJJ:jIwero.
HaH60JIee qaCTO aHaCTOM03 cpOPMUPYlOT C nOMOiliblO
,nByxpHllHoro lliBa, KOTOpbIH CHaqaJIa HaKJIaJ(blBaIOT Ha 3a;J,-
IllOlO, a 3aTeM Ha nepe,nulOlO CTeHKII (puc. 20.47).
AllacToM03 «KOHeQ B KOlleQ» HBm!eTCH HalI60JIee IlJH-
3HOnOrlI'IHbIM, TaK KaK co,nep:>KHMOe nliweBapHTeJIbHOrO TpaK-
Ta npo,nBHraeTcH eCTeCTBeHHO. O,nHaKo He,nOCTaTKOM TaKOrO
BH,na aHaCTOM03a HBnHeTCH ero cY:>KeHHc. OHO MO:>KCT B03-
HHKHyTb KaK B palIl!eM nocJIeonepauuoHHoM neplIo,ne BCJIe,n-
CTBHe OTeKa TKaHeH, TaK H B OTllaJJeHHble CTpOKH no npU'IIiHe
06pa30BaHliH py6Ua.
BecoMocTb 3Toro He,nOCTaTKa MO:>KHO cyweCTBeHHo
CHH3HTb 3a CqeT Kocoro nepeCeqeHHH KHlliKH.
06bIqHO npH HanO:>KeHHU aI-IaCTOM03a «KOHeu B KOHeu»
CHaqana 1lJ0pMIIPYlOT ero 3a;J,HIOlO ry6y.,lJJIH 3Toro OCB060:>K-
,nalOT OT 6pbI:>KeHKII (Ha paCCTOSI:HHH 1 CM) KOHUbl KHlllKIi. I1x
conOCTaBAAlOT H CIlIIIBalOT cep03HO-MbIllie'IHbIMH Y3nOBbIMH
lliBaMU (puc. 20.48). IIOCJIe,nHlIe npH npoqlIx paBHbIx yCJIOBH-
HX npope3alOTcH pe:>Ke, qeM HenpepblBHble cep03Ho-MbIllleq-
Hble lllBb!.
HAJIOiKEHMEAHACTOM03A
...h---->O'
Puc. 20.47 CxeMa paCnOllO:>KeIlWl
Uleoe KUUle'lHOZO aflaCmO,\to3a
161
rJIaBa 20
10 ..... .,
fi ;<:;} ): \r ' - .
\ \ <, - ;: ': }J
"tK"'k'U K
1 5J
, t
Puc. 20.48 AllaCmO,\to3 KIlUlKU
«KOHe4 e KOHCq»: COeaUHeHUe
Y'laCmKOe KUUlKU cep03110-
MbIUle'lHbI.MU UlellMU JI llM6epa
Pile. 20.49 AllaCmO,\to3 KIlUlKU
«KOllell e KOlleWI: 3aUlUeGlille
3aolleu cmellKU allacmOM03a UleOM
Peeepaclla- M YJlbmalIOecK020
l .-J'
--/ t :tij:« ..; - . ,k
/(f ....
i ; . . .. 11. . . . .
, - --,;;.
. .-
Puc. 20.50 AHaCmO,\to3 KUUlKU
«KOlleq e KOlle/I»: 3aUllleallue
nepealleil cmellKU allaCmOM03G
eeopa'lUealOlljUM weOM IlIMUaella
162
Y3JIOBble lliBbI HaKJIa,nbIBaIOT Ha paCCTOHHHH 3-4 MM OT KpaH.
113JIHlliKII HIiTeH ,nBYX KpaHHHX Y3JIOB HCnOJIb3YlOT KaK ,nep:>Kan-
KH, OCTanbHble cpe3alOT.
CB060,nHbIe 'laCTH 3a,nHeH CTeHKH aHaCTOM03a ClliHBalOT
HenpepbIBHbIM 06BIIBHbIM IlIBOM qepe3 Bce CJIOH opraHa (HanpH-
Mep, lliBoMPeBe,neHa-MYJIbTaHOBcKoro) (pUc. 20.49). IIpH 3TOM
CTe>I<KH lliBa He ,nOJI:>KHbI 3aXBaTbIBaTb I-H pM cep03HO-MbIllieq-
HbIX lliBOB. OocJIe 1lJ0pMHpoBaHHH 3a,D.HeH CTeHKH aHaCTOM03a
3TOH :>Ke HHTblO npoIlIHBaIOT ero nepe,nHlOlO CTeHKY. I1CnOJIb3YlOT
O.D:IIH H3 BBOpaqlIBalOWHx lliBOB (HanpHMep, lllMH,neHa, KOHHe-
JIR), KOTopble 06eCneqHBalOT coe,nHHeHHe cep03HbIX 060JIOqeK
(puc. 20.50). IIoBepx CKB03Horo BBOpaqHBalOlI.{erO HaKna,nbIBa-
lOT OT,neJIbHbIe Y3JIOBbIe cep03HO-MbIllieqHble lliBbI JIaM6epa
(puc.20.51).
.ZJ:JIH 1lJ0pMHpoBaHHR 3a,nHeH H nepe,nHeH CTeHOK aHaCTO-
M03a B KaqeCTBe CKB03HbIX C ycnexoM MO:>KHO Hcnonb30BaTb OT-
,neJIbHbIe Y3JIOBbie lliBbl )l(06epa, IIHporoBa, EapHIlIeBcKoro-Ma-
TelliYKa. I1cnoJIb30BaHHe OT,neJIbHblX Y3noBblx IlIBOB n03BOJIHeT
YMeHbUlIITb cY:>KeHHe aHaCTOM03a.
Henocpe,ncTBeHHoe CllilIBaHHe KOHl..{OB KHiliKII cOnpOBO:>K-
,naeTCH pH,nOM Hey,n06cTB:
- HY>I<HO OqeHb TlliaTeJIbHO npRITa>I<HBaTb ClliHBaeMble KpaH,
nOCKOJIbKY HX JIerKO nepeKocHTb H IlIOB 6y,neT ne:>KaTb HepaBHo-
MepHo;
- nerKO nonyqlITb cy:>KeHHe Ha MeCTe UlBa;
- npH CIlIHBaHHH qaCTeH KHiliKH C pa3HblMH ,nHaMeTpaMH
O,nHH KpaH HY>I<HO paCTRrnBaTb, a ,npyroH cY:>KIIBaTb, "ITO He Bcer,na
BbmOJIHHMO;
- ,nJI5I HaJIO:>KeHHH TaKoro aHaCTOM03a Tpe6yeTcH MHoro
lliBOB H BpeMeHH.
rOpa3,L\0 npowe c,neJIaTb 60KOBOH aHaCTOM03, npH KOTO-
pOM He B03HHKaeT no,n06HbIX Hey,n06CTB. qawe Beero aHaCTOM03
«60K B 60K» HaKlla,D.bIBalOT B Tex CJIyqaR-X, Kor,na npOCBeTbl CIlIIIBa-
eMbIX yqaCTKOB KlIIlIKH Y3KH H cywecTByeT onaCHOCTb CY:>KeHHR
COYCTbH. KpOMe TIoro 60KOBOH aHaCTOM03 HaKJIa,D;bIBalOT npH He-
COOTBeTCTBHH ,nHaMeTpOB CIlIHBaeMbIX opraHOB (HanpHMep, npH
HanO:>KeHHH COYCTbH Me)l(,D;y :>KeJIy,nKOM H TOHKOH KHlliKOH).
OnepaUHH 3Ta ,neJIaeTCH CJIe,nYlOlI.{HM 06pa30M. CHaqana
npOH3Bo,nHT 3alliHBaHHe «Harnyxo» l..{eHTpanbHoro H nepHllJeplI-
qeCKOrO KOHUOB KIIIlIKH. 3aTeM IIX pacnOJIaralOT H30nepliCTanbTH-
qeCKH H Ha npOTR:>KeHHII 6-8 CM coe,nHHHlOT C nOMOWblO OT,neJIb-
HbIX cep03Ho-MblIlIeqHblX lliBOB JIaM6epa (puc. 20.52).
CKanbneJIeM B,nOJIb nlIHHH UlBa B npe,neJIax 0,8-1 CM BCKpbI-
BalOT npocBeT 060HX yqaCTKOB KHiliKH. BnpOqeM, ,nJIHHY pa3pe-
30B Ha 60KOBbIX creHKax Bbl6HpalOT npoH3BonbHo, nOTIOMY onac-
Hoen CY:>KeHHH npH 3TOM BlI.D:e aHaCTOM03a He3HaqlITenbHa.
Ha 3a,D.HHe ry6bI HaKlla,D;bIBaIOT CKB03HOH HenpepbIBHbIH 06-
BIIBHOH (<<B3axneCTKY») lliOB (puc. 20.53). 3aTeM 3TOH:>Ke
HIiTblO O,nHIIM 113 BBOpaqlIBalOIUIIX lliBOB (lllMlI.D:eHa, KOHHe-
nH) ClliHBalOT nepe,nHHe ry6bI. IIocJIe YlliHBaHIISI: nepe,nHeH
CTeHKH aHaCTOM03a KOHeu HHTH, KOTOpbIM BbIllOnHj{JIH lliOB
nepe,nHeH CTeHKII, CBR3bIBaIOT co CB060.D:Hb1M KOHUOM H1ITH,
OCTaBlliHMCH Ha 3a,nHeH CTeHKe. BBOpaqlIBalOIlIHH lliOB Ha
nepe,nHeH CTeHKe aHaCTOM03a HaKpbIBalOT cep03HO-MbIIlIeq-
HbIMIi UIBaMH JIaM6epa (puc.20.54). TaKHM 06pa30M, 1lJ0p-
MHPYlOT 60JIbiliOe oTBepcTHe, coe,nHHHlOIUee 06e KHIlIeqHbie Puc. 20.51 AllaCmO,\to3 KUUlKU «KouelJ e
KOlleljJ>: eep03Ito-MbIUle'llible Ulebl JJaM6e-
nemll H 06lliliToe ,nBYMH 3Ta:>KaMIi IlIBOB: rny60KI1M (npOHH- " _
pa Ha nepeulleu Cme/lKe aHacmOM03a
I<alOIUIiM qepe3 Bce CJIOII KHlIIeqHOH CTeHKH) II nOBepXHoCT-
HhIM (c6JIH:>KalOIUHM Ha,D. HHM cep03HbIH nOKpoB H npoHHKa-
lOlI.{HM TOJIbKO,nO KlleT'IaTKH Me)l(,D;Y CJIH3IICTOH H MbIllie'lHOH
060JIOqKaMH).
AHaCTOM03bl «KoHeQ B 60K» " «60K B KOHcn» 1lJ0PMII-
PYlOT npH neCOOTBeTCTBHH ,nlIaMeTpOB CIlIIiBaeMhlX opraHoB
(HanpHMep, npH pe3eKUlIH npaBOH nOJIOBHHbI TOJICTOH KHlli-
KH II HanO:>KeHHII aHaCTOM03a Me)l(,D;Y TomoH H ToncToH KlIlli-
I<OH). CTemy TOHKOH KHlliKII coe)J,HHRlOT oT,nenbHblMIi cep03-
HO-MbIIlIeqHbIMH lIIBaMIi JIaM6epa co CTeHKoH ToncTOH
KHlIIKH. 3aTeM no TeHIIH npOlIOJIbHO BCI<pblBalOT npocBeT
TOJICTOH KHIlIKlI (puc. 20.55). )J,mma pa3pe3a,nOJI:>KHa COOT-
BeTCTBOBaTb ,nHaMeTpy TOHKOH KlilliKH. 3a,nHHe ry6bI ClliH-
BalOT CKB03HbIM HenpepblBHbIM 06BlIBHbiM IlIBOM «B3axneCT-
KY» (iliOB PeBeplIeHa-MYJIbTaHOBcKoro) (puc. 20.56).
3aTeM :3TOH :>Ke HHTblO O,nHHM H3 BBOpaqHBalOIUHx
llIBOB ClliliBalOT nepe,nHHe ry6bI. IIocJIe ymHBaHHH 06enx CTe-
HOK HHTH CBH3bIBalOT. Ha nepe,nHlOlo cTeHKY aHaCTOM03a no-
Bepx BBOpaqHBalOIUero lliBa HaKlla,nblBalOT cep03HO-MbIIlIeqHbIe lliBbI JIaM6epa (puc. 20.57).
'\,. !.
, '.
Puc. 20.53 AllaCmO,\to3 KUUlKU
«60K e 60K>I: 3alUueallue 3aalleU
cmeHicu aliacmOM03a UleOM
Peeepaella- MY,7bmaHOeCKozo
Pue. 20.54 AliacmoM03 KUUlKU
«60K e 60K>I: 3aUlueaHue nepe-
aHeU cmellKU aliacmOM03a
eeOpO'lU6a10UjIIM U/eOM ll1Muoella
J /_. c
if,. ' '
A .. :.,.-o(
-::ls
i / \.
t \
.
\.
u '
- . \.
. ___.:!:.....;.r.,
,......-:::J .
. '''' )'
. ,../'" 4 ""'-'
of
"
Puc. 20.52 AIlacmOM03 KUUlKU «60K
e 60K)): COeaUliellUe Y'IaCmKOe
KUIUKU cep0311O-MbIUle'lHbIMU
UleaMU JJCLw6epa
Puc. 20.55 AliacmoMo3 KUUlKU
«KOHelj e 60K»: COeallllellUe
Y'IaemKOe KUUlKU eep031l0-MbIUle'l-
IIblMU UleaMU JJaM6epa
163
rnaBa 20
Puc. 20.56 AHacmoM03 KUUlKU «KOllelj 6 60K»:
3aWUeaHUe 3aOHeU CmellKU aHaCmOM03a UleOM
Peeepaella-M YJlbmaHOeCKOZO
Puc. 20.57 AliacmoM03 KUUlKU «KOllelj e
60K»: cep03/IO-MblUle'tllble webl JIaM6epa
Ha nepeaHeU cmeliKe aHacmOM03a
MEXAHH1IEcKIIi1 (AllllAP ATHbIM) II10B KHI.1IKH
MeXaHl1qeCKliH (arrrrapaTHbIH) lliOB KllIlIKII n03BomeT 6blCTpO
II Ha,lJ,e:>KHO 3aKpblTb npOCBeT KHlIIKH RITII :>Keny,nKa. AnnapaTbI Tlina
GlA-55, GlA-60, EndoGlA-30 llIHpOKO npHMeHHlOTCH.D:JIH HaJIO:>KeHIIH
aHaCTOM030B. .ZJ:m! HanO:>KeHml 3HTep03HTepoaHaCTOM03a «60K B
60K» IlJHKCHPYlOT OTKpbITble pe3eUHpOBaHHble nplIBo,nmuHH H OTBO-
.D:HIUIIH KOHUbI KllIlIKH.
EpaHiliH annapaTa nOMeIUalOT BHYTPb ClliHBaeMbIX I<OHUOB
(puc. 20.58). 06e CTeHKH ClIIHBalOT 4-MH pH,naMH CK060qHbIX lliBOB.
P 20 59 3 O,nHOBpeMeHHO Me)l(,D;Y cK06KaMH CTeHKa KIIIlIKH pacceKaeTcH HO-
uc. . aKall'tuea/om
HllJlO:J/Cellue aHacmOM03a 3aUlUea- :>KOM II C03,naeTCH npocBeT Me:>K,IJ,Y ClIIHTbIMIi CTeHKaMH. BTOpbIM Ha-
HueM omeepcmui1 e opzaHax nO>I<eHlIeM annapaTa YlliliBalOTCH oTBepcTIIH B opraHax (puc. 20.59).
HAJIO)KEHllE MEJKKllIIlEQHbIX AHACTOM030B
C llOMOJ..U:blO BbICOKOQACTOTHOi1
3JIEKTPOXlIPYPrMM
B03MO:>KHOCTH BblCOKOqaCTOTHOH 3JIeKTpoxnpyprHl! n03BO-
nRITH pa3pa60TaTb TeXHHKY HaJIO:>KeHlIS!. aCenTIlqeCKIIX COYCTIIH Me:>K-
,ny pa3JIHqHbIMH opraHaMIi :>KeJIy,nOqHO-KHllieqHOrO TpaKTa, B'T .q.
Me:>KKHlIIeqHOrO aHaCTOM03a. IlplIBe,neM onHcaHlie MeTo,nHKH, npe,n-
nO:>KeHHOH M.C. lllYJIbMaH C BH,D;OH3MeHeHIIS!.MH M.3. CHrllilOM.
Coe,nHHHeMbIe neTnH KHlliKH C6JIII:>KalOT ,nBYMH Y3JIOBbIMli
eHympb CUlueaeMblX opzaHoe lIIBaMH Y BepxHero H HH)l(HerO KpaeB npe,nnonaraeMoro aHaCTOMO-
3a. Me)l(,D;Y cep03HO-MbllIIe'lHbIMH CJIOHMH 3THX rreTeJIb HaKllaLlblBa-
lOT HerrpepblBHblH IlIOB. 3JIeKTpoHO:>KOM pacceKalOT cep03Ho-MbIIlIeqHbIe CJIOH 06eHx coe,nHHHeMblX
KlillieqHblX neTeJIb B,nOJIb HenpepbIBHoro lliBa. B npOMe:>KYTKax Me)l(,D;YKepKpHHroBbIMIi CKlla,nKa-
MII TKaHH no,nCJIH3HCTOro CJIOH KoaryJIHpYlOT B nOnepeqHOM HarrpaBJIeHlIH. TaK C03,nalOT OKOHqa-
Tble npo,nonbHble ,nellJeKTbI cep03Ho-MbIlIIeqHOrO CJIOS!.. IloBepx KoarynHToB HaKlla,nbIBalOT lliBbI,
norpy:>KalOIUHe KoarYJIHpOBaHHbIe nonOCbI CTeHKH KllIlIKII. IIepe,nHlOlO ry6y aHaCTOM03a repMeTH
3HpYlOT LIBYMS!. pHLIaMIi HenpepbIBHblX eep03HO-MblllieqHblX llIBOB.
IlpH ,naHHoH TeXHHKe BbIllOJIHeHH}! onepaUHH npocBeT opraHa He BCKpbIBalOT B CB060,nHYIO
6plOlliHYlO nonOCTb. EeCKpOBHOCTb II aeenTHqHOCTb }!Bn5!lOTC}! HeOCnOpHMblMIi TIpeHMymeCTBaMH
onlIcaHHoro BbIllie cTIQc06a HanO:>KeHllil aHaCTOM03a.
PUC. 20.58 )1.J1J1 HllJlO:J/CeHWI
a/laCmOM03a 6paliUlu
CUlueameJlJl /1OMeUjalOm
164
m.'t 4
rnaBa 21
3AllIHBAHME .PAH
ITAPEHXMMltT03H.bIX OPFAHOB.
" :-:\',<><
"'1i...
"
' ......... >.t .,
K napeHXHMaT03HblM opraHaM OTHOCHTCH: neqeHb, nOqKH, nerKHe, no,n:>KeJIy,nOqHaJl :>KeJIe-
3a, CeJIe3eHKa, :>KeJIe3bl BHYTpeHHeH ceKpeUIiH (WliTOBH.D:HaH :>KeJIe3a, Ha,nnOqeqHHKH). TIpH HX
nOBpe)l(,neHHH B03HIIKaeT HHTeHCHBHoe ,nH4J4JY3Hoe KpOBOTeqeHHe no BeeH nOBepXHOCTII paHbI
(napeHXHMaT03Hoe KpOBOTeqeHlIe), 06YCJIOBJIeHHOe HanHqHeM B 3THX opraHax 06IIJIbHOH ceTH
KpOBeHOCHblX cOCy,nOB. PbIXllOCTb coe,nHHeHIIH TKaHeH OCJIO)l(HReT npoue,nypy reMOCTa3a, TaK KaK
HaKJIa,nblBaeMbIe JIHraTypbI npope3alOTCR H Bb13bIBalOT ,nonOJIHHTeJIbHOe KpOBOTeqeHHe. TI03TO-
MY, npHcTynaH K HanO:>KeHlIlO lliBOB Ha napeHxnMaT03Hbie opraHbI, He06xo,D;IIMO:
- lliOB HaKlla,nblBaTb nOnepeqHO Xo,ny COCy,nOB, coe,nHHHH 06a KpaR paHbI. ECJIII paHa npoxo-
,nHT napaJJJIenbHO cocy,naM, c,nenaTb 3TO HeTpy,nHo. B npoTIIBHOM cnyqae no 06e CTOpOHbI paHbI
HaKlla;::J;bIBalOT ,nBa pMa llIBOB, nOCJIe qero HHTH, HaXOlIHIUHeCH C npoTHBOnOJIO:>KHblX KOHUOB 1lI ,
CBR3bIBalOT;
- ,nJIR HalIe:>KHOH OCTaHOBKH napeHxHMaT03Horo KpOBOTeqeHHH ueJIeC006pa3Ho npH6eI"H)'Th
K 6HOnOrHqeCKHM TaMnOHaM (CaJIbHIIK, MbilliUbI, cneUHanbHble TaMnOHbl, npHrOTOBJIeHHbIe H3 ,no-
HOpCKOH llJIa3Mbi HJIII cyxoro 4JH6plIHoreHa C ,n06aBJIeHHeM B HHX KpoBoocTanaBnlIBalOWIIX cpe,nCTB
H aHTIICenTHKoB);
- lliBbI HaKlla,D.bIBaTb TaKliM 06pa30M, 'H06bl npH 3aTHrHBaHliH HHTeH napeHXHMa opraHa
c,naBJIHBanaCb paBHoMepHo Ha DceM npOTR:>KeHHH nlIHHH lliBa H He npope3anaCb. 3aBR3bIBaTb
Y3JIbl HalIo OqeHb cJIa60, JIHllib,nO OCTaHOBKH KpOBOTeqeHIIR;
- npe,nnOqTHTeJIbHee HCnOJIb30BaTb II-06pa3HbIe RITH MaTpaUHbIe IlIBbl..ZJ:JIH npe,noTBpaIlIe-
HlIH npope3aHHH ueJIeC006pa3Ho nOJIb30BaTbCR npoKna,nKaMII, pacnOJIaraH HX Me)l(,D;y nOBepxHo-
CTblO opraHa H HIiTblO IlIBa;
-.D:JIH npoBe,neHHH HIITH Hcnonb30BaTb IIrny C 3aKpyrJIeHHblM KOHUOM, TaK KaK OHa He pa3-
pe3aeT, a pa3'be,nIIHHeT TKaHb;
'- MlIHHMII3IIpOBaTb KOnlIqeCTBO npOKonOB TKaHH. Ka)KJ\l>IH ,nonOJIHIITeJIbHbIH npOKon nOBbI-
lliaeT onaCHOCTb nOBpe)l(,neHIIH KpOBeHOCHoro cocy,na. .
YqlITbIBaH, qTO nplIHUHnLI II MeTO,D;b13alli1iBaHIIH paH nO lI 1I neqeHII OTJImalOTCR Hemaqn-
TeJIbHO, paCCMOTpHM IIX Ha npHMepe nHKBH.D:aUHH neqeHOqHblX paH.
IIIBhI KP AEBbIX P AH nEqEHII
IIocJIe nanapOTOMIIH npOBO,D;HT peBH3lIlO opraHOB 6plOllIHOH nOJIOCTII. C nOMOll.{blO BJIa:>KHO-
ro MapneBoro TaMnOHa aKKypaTllO y,nanHlOT crYCTKII CBepHYBllieHCH KpOBH, nOBpe)l(,D;eHHbIe yqac-
TKH neqeHH H HHOpO,D;IIbIe TeJIa. 06H3aTeJIbHbIM 3TanOM onepaUlIH HBJIHeTCH xnpyprmeCKaH 06pa-
60TKa paHbI neqemr. TKaHb neqeHII XOpOiliO pereHepHpyeT, n03TOMY pa3M03:>KeHHbIe KpaH TKaHli
165
rJIaBa 21
y,nanSl.lOT. BMIIMbIe KpOBOTOqawlie cocy,nbl H :>KeJIqHble npOTOKIi nepe:>KIIMaIOT 3a)l(1IMaMII H nHrH-
pYIOT.I1Hor,na KpoBOTeqeHHe OCTaHaBJIIiBalOT 6HOJIOrHqeCKOH TaMnOHa,D.OH.
)];0 HaCTOHlI.{erO BpeMeHH HanO:>KeHHe IlIBa neqeHII OCTaeTCSI. OqeHb CJIO:>KHOH np06JIeMoH.
HaH60JIee cOBpeMeHHbIM MeTo,nOM npe.nynpe)l(,D;eHHH nocJIeOnepaUHoHHoro KpOBe- H :>KeJIqeTeqe-
HIIH H3 neqeHII HBJIHeTCH ynbTpa3BYKoBaH KaBHTaUHH, 06pa60TKa neqeHOqHOH napeHXHMbI ropSl.-
qlIM B03,nYXOM, HaHeceHHe Ha TKaHb neqeHII CneUHaJIbHblX nneHOqHblX nOKpbITHH RITH IlJH6pHHOBO-
ro KlleH. TaKlie cnoc06bI coe,nHHeHIIH pa3pYllIeHHblx TKaHeH He npe,nYCMaTpHBalOT lliOB neqeHH.
O,nHaKO Ka)l(,D;blH xlIpypr llOn:>KeH Bna,D.eTb KllaCClIqeCKOH MeTo,nHKOH ee 3allIHBaHIiH. .ZJ:JISI. TIoro, B
OCHOBHOM, HCnOJIb3YlOTCSI. pa3mrqHble MO,D;IIIlJHKaUHH II - H 8-06pa3HblX llIBOB.
TIpH HanO:>KeHHII IlIBa neqeHII ueJIeC006pa3HO nOJIb30BaTbCSI. paccaCbIBalOWHMIICH lliOBHbl-
MH MaTepHanaMH (BIIKpHJI, nonlIcop6, ,neKCOH) 60nbllinx ,nlIaMeTpOB C 60JIblliHMH aTpaBMaTHqeC-
KlIMH 3aoKpyrJIeHHbIMH TynOI<OHeqHblMIi HrnaMH.
Bo H36e:>KaHlie npope3blBaHIIH, nepe,n 3aBSl.3bIBaHHeM Y3JIOB aCCHCTeHT c6JIH:>KaeT I<paH
paHbI. Y3eJI 3aTSl.rHBalOT ,no conpHKOCHOBeHHSI. paHeBbIX nOBepXHOCTeH.
)];JISI. 3alliHBaHHSI. paH neqeHH He60JIbiliOH rny6HHbI HCnOJIb3YlOT n-06pa3HLIe WBLI
(puc. 21.1). Mmy B anbIBalOT Ha paccToHHHH 1,5-2 CM OT I<paeB paHbl. HIITb npOBo,nHT no,n ,nHOM
paHbI Ha npoTIiBOnOnO:>KHYlO CTOpOHY. Bo H36e:>KaHHe nOBpe)l(,D;eHIIH KpynHblX coCy,nOB IIJIII :>KeJIq-
HblX XO,nOB, rny6IIHa npoIlIHBaHHH paHbI Ha,nlIallJparManbHoH nOBepXHOCTIi He ,nOJI:>KHa npeBbIllIaTb
2 - 2,5 CM, a Ha BHcuepanbHoH - 1,5 CM. Cne,nYlOlI.{lIH YKon HmbI ,neJIalOT JIaTepanbHee, npOBO,nH ee
B 06paTHOM HanpaBJIeHIIII.
TIpH HanO>I<eHIIH II-06pa3Hblx IlIBOB Ha rny60KHe paHbI,.D:JIj{ npe,nOTBpaweHHH OCJIO:>KHeHIIH,
l..{eJIeC006pa3HO 3aKJIa,nblBaTb Ha BClO rny6HHY 60JIblliOH CaJIbHHI< Ha nHTalOweH HO:>KKe
(pUc. 21.2, 21.3). B TaI<OM cJIyqae paHY YlliHBalOT, 3aXBaTHB B CTe:>KOI< lliBa He60JIblliHe yqaCTKH
canbHHKa. He06xo,nIIMO CTpeMHTbCSI. npollIHBaTb canbHIIK 6e3 COCy,nOB, qT06bI He HapYIlIHTb ero
KpOBOCHa6:>KeHlIe. IIpH conOCTaBneHHII I<paeB CanbHIII< Ha,ne:>KHO TaMnoHHpyeT paHY neqeHH 6e3
06pa30BaHHSI. «MepTBoro npocTpaHcTBa».l1cnoJIb30BaTb ,nJI5I TaMnOHa)J,bI H30JIHpOBaHHbIH Callb-
HlIK HeueJIeco06pa3HO.
,[{JI5I YKpenneHHSI. IlIBOB, npe,nynpe:>K)J,eHlIH npope3bIBaHHH H YBeJIHqeHHH HX nnOll.{a,nH ,naB-
JIeHIIH Ha napeHXHMY neqeHII nplIMeHHlOT npOKlla,D.KY H3 yqaCTKa OT,neJIeHHOH OT ,nHacpparMbI cep-
nOBMHOH CBSl.3KH neqeHH, nnaCTHHKY H3 llJacUHH (puc. 21. 4) HJIH paccaCbIBalOlI.{HecH HIITH
(puc. 21.5). B nOCJIe,nHeM CJIyqae CHaqana HaKlla.IJ.bIBalOT nOBepxHocTHbIH lliOB OT,neJIbHbIMIi CTe:>K-
I<aMH napaJIJIeJIbHO KpaHM pa3pe3a. 3aTeM npOBO,nSl.T OKOHqaTeJIbHOe 3aIlIIIBaHHe.
)];JIH 60JIee TeCHoro C6JIII:>KeHIIH KpaeB paHbI neqeHH H nOBblilieHIIH Ha,D.e:>KHOCTH reMOCTa3a
npIiMeHSl.IOT UIOB neTpOBa. CHaqana HaKlla,nbIBalOT TI-06pa3Hbrn IlIOB, KOTOpbIH 6e3 npliMeHeHIIH
,// 1 .1 J'er
'. . ......,. .'OJ!
./.l{ /i"
.' .... IIIt,J
.,. .'."""'
/ ,.- ....
, r
.
"jT
Puc. 21.1 3aUlueallue Kpae6blX
paH ne'leHU 1l-06pa:JHblMU
UleaMU
166
. (i: '
, .
\ .." '.
\ / . ,--,-
' . . ' ' \- j <1:1;- . ,,!:,\ . ,.
,, , \'\ ."f !-' t;J./
''-:# ' . ' <' f' ..-
r ) '11 1 . r' . Y
',L' '.1,1 (-:>'.'.l.
, (, n : r';..'1J)
I, ' { ....
Puc. 21.2 TClI>1nOHaaa
CaJlbHUKOM npu 3awueaHUU
Kpae6blx paH ne'leHU
/ . . ' ,-.
, ....- .
.?: ,
.,'
lL:
'-('. : "j'".. '-/
:.2 ,'/ - ..
PUC. 21.3 YKpelVlellue Uleoe
CWlbHUKOM npu 3aUlueaHUU
Kpaeeblx paH ne'leHU
60nbIlIoro YCRITIIR 3aBR3blBalOT (puc. 21.6). KOHUbI HHTeH He cpe-
3alOT. 3aTeM OCTaBlIIeHCH HIiTblO npOIlIHBalOT no,n,nHOM paHbI He-
nocpe,nCTBeHHO no cpe,nHHe nepBoro I1lBa (puc. 21. 7). HHTb, OKa-
3aBillYlOcR Ha ,npyrOH cTopoHe paHbl, CBH3hlBalOT C OCTaBIIIHMCH
cB060,D;Hb1M KOHUOM (puc. 21.8). TaKoH IlIOB He npope3aeT TKaHb,
TaK KaK ,naBJIeHlIe paBHOMepHO pacnpe,neJIReTCH no BceH nJIOlua-
,n1I HanO:>KeHHOrO IlIBa.
)J;JIR CHII:>KeHIIH onaCHOCTIi npope3bIBaHliH JIHraTypbI nOCJIe
HanO:>KeHHH II-06pa3Horo IlIBa cB060,nHble KOHQI>1 HHTII MO:>KHO 3a-
BR3bIBaTb CnO:>KHOH nemeH. IIpH 3TOM ,D;JIIiHa cl<pyqeHHOrO npOMe-
:>KYTKa ,non:>KHa COOTBerCTBOBaTb ,D;JIHHe nocne,nHero CTe:>KKa (mOB
A.H. I>eTaUeJIJlH) (puc. 21. 9) .
.ZJ:JIH 3alliliBaHliH rny60KIIX paH napeHXHMbl neqeHH Hcnonb-
3YlOT 8-06pa3HbIH mOB 3aMOUI:Hua (puc. 21.10). Tal< KaK o6a ero
CTe:>KKa pacnonaralOTcR B O,nHOH nnOCKOCTH, 1II0B paBHOMepHO c,naBJIIiBaeT TKaHb neqeHH H He
npope3aeTCR.
Bblllie nepeqHCneHHble lliBbI C ycnexoM MO:>KHO Hcnonb30BaTb,D;JIH 3aIlIHBaHHH pall nOqKH
(puc. 21.11 - 21.13).
/:,/ /!
. _ _ -'" "".;f.T
/::' . '" ;. ....l.' ,....,.-
p #"' ,,... ",L..'
;. } ,f;.;;:' r
&' 3'/_1/';,'
t '
'F '>', /,..... f.J
.....--= ............ "",.'"
Puc. 21.5 YKpe1llleHUe Uleoe
HumRMU npu 3aUlueallUU
Kpaeeblx pall ne'leHU
/': - D .
.f l '') , . jJf) .l , \;,' . , ' .-'..
I,. ., ,.. t .t .'
. \ J..
. -, .V'.%
:00.; -- It
.;7
Puc. 21.8 OKOH'IameJlbHbIU eua
Ulea llempoea
( . (
: fII" J l/ . ,,':
""\ "'; "
.- .
,... -- .
,':. ", .' ...:..
l's ::J..<IO"-'
'N "
Puc. 21.6 1l-06pa3HIJlu Uleoe
KaK cocmaellRIOUjaJ/ lUea
>.€ -b'
-r-rt
l_-J
.-.;. _.::c.=' ... --
Puc. 21.9 CxeMa Ulea liemaHeJlIlU
.,. ' " / / !'
I , . ' ,,"'- '..'1:........
&: J;' " '..,,' .... ..(.
. -'-"
>;:: 1.7
Puc. 21.4 YKpe1l/leHUe WI/Oil
nllacmUHKOU U3 tjJaCljuu npu
3awueaHUU KpaeeIJIX paH
ne'leHU
-.,..,."""-
(.- .. .0
( Q,. I / .
£ .o l!t. .
!t.-' ;;;, ...'.\ ,10;'
fi ,'- .>-' . .:,
i£;i7: '> ',;
Puc. 21.7 Woe llempol/a:
npoeeaellue Humu noa
1l-06pa3HblM UleOM
t1 ; »
. ----"
. ).-../ .-
t- :)
:7
Puc. 21.10 CxeMa Ul6a 3llMoUjuHa
167
rJIaBa 21
Puc. 21.11 Y3Roeou Uloe npu
3aUlUeaHUU paHbl no'tI<U
- ,,(/
i?' ,, ll', x .".
t...... \:
"'.y C"'".
A ; " 0", ,.,# ,I )
.... !
.'" .
.,. \\<. ,./
. ...."'. __::;V"
Puc. 21.12 1l-06pa3Hblu Uloe
npu 3aUlUeallUU paHbl no'tI<U
( ::.r:::2
.>"p" ' A
'f:)i:,f ¥.! I)
\r ,:,t, .-..J
? , '.f' ,..
." ..f' ".. ..:;/
Puc. 21.13 llIoe llempoea npu
3aUlUeaHUU paHbl no'tI<U
lllBbI IlPM PE3EKUMM IlEqEHM
IIpH pe3eKUHH neqeHII, yqHTbIBaH TonIUHHY npoIlIH-
BaeMoH TKaHH, HCnOJIb3YlOT IIrJIbI npRMbIe.
WOB KY3ueQoBa-IIeucKoro (puc. 21.14) cpOpMH-
PYlOT rynoH IIrJIOH C ,nBOHHOH HHTblO. I1eqeHb npoIlIIiBalOT
qepe3 BCIO TOJIlI.{Y. IIocJIe 1lJ0pMIIpoBaHHH Ka)[(,[l,OrO CTe:>KKa
O,nHY HHTb nepeeeKalOT H CBH3bIBalOT C TaKOH :>Ke HHTblO,
II.D:YIUeii OT pacnOnO:>KeHHOrO pR,nOM CTe:>KKa. CTe:>KKH rreT-
JIe06pa3HO npoxo,nRT OllHH 3a llPYrHM. B pe3YJIbTaTe TKaHb
neqeHII c,naBJIHBaeTCR no llJIOCKOCTli lliBa. 3aBH3bIBalOT Y3JIbI
no 06eHM nOBepXHOCTRM rreqeHII (puc. 21.15). OCHOBHblM
He,nOCTaTKOM lliBa HBAAeTCR TO, qTO ,nBOHHble HHTH qaCTO
3anYTbIBaIOTCH.
Won )K0pllaHo (pUc. 21.16). I1eqeHb npOKaJIbIBa-
lOT HaCKB03b HrJIOH C ,nBOHHOH HHTblO. )J;YllJIHKaTypbI HHTeH nepeceKalOT, a HHTII COCe.L\HHX CTe:>K-
KOB CBR3bIBalOT Me)l(,D;Y C060H.
WOB OnneJISI (puc. 21.17) TaK:>Ke HCrrOJIb3yeT Bce npeliMYlI.{eCTBa I1-06pa3Horo llma. Ha-
I<JIa.L\bIBaR OT,nenbHbIe I1-06pa3Hble IlIBbl, KOTopble HeMHoro 3axo,nRT .npyr 3a ,npyra, IIonyqalOT
XOpOIlIHH reMOCTa3. 1lI0B nerKO BbIllOJIHIIM, ,nOCTaTOqHO repMeTHqeH. O,nHaKo 1I3-3a 60nbilloro
KOnHqeCTBa npOKOJIOB neqeHH ero npHMeHSIlOT He qaCTO.
WOB TeJIKOBa (puc. 21.18). IIapaJIJIeJIbHo IlJIOCKOCTH pa3pe3a rreqeHII HaKJIallbIBalOT 8-
06pa3Hble IlIBbI. IIpH 3aBR3bIBaHHH IlIBa CHJIa ,naBJIeHHH pacnpe,neJIHerCR no BceH llJIOCKOCTH, co-
- _." f51
,/..".,' E
/" ...
./ .... 'r.,- fl '"
,. 'IJ f ff It '.
.,J , f f, I, '
"." , 'I j ! I
-::l- V -U
Puc. 21.14 llep6blu 3man qJOpMUpO-
eaHUJI Ulea KY311eljoea-lleHcl<02o npu
pe3eKljUU ne'teHU
'-'--'-i f
i ..J' "" J' -.,
Ol , . " , --i , ' , ". ,._ , ; , ; _
fl-£ H 11:" ...!Ii .. 'u
; !i! fa< . I I. '!I f> .
>', '.:it 'j ., ;If;i '; (
....... -1' i'i; 'fl f ii .-
",'H _ I_ i. :J t.
.}:>t u
Puc. 21.15 llIoe KY311e1jOea-
lleHc1<02o npu pe3e1<ljUu ne'teHU
168
; t!lj/,
'r1'''-' ".'-1"1'1". t/
< 1 I f I I . I H'I ,
'I. .1,It,] 111 , ' , ' , "_"
. .', J. .! I j, 'I II I I ->'
y t : : \ . j: ,
f "'.\
,
"
Puc. 21.16 llIoe )f(opoallo npu
pe3e1<lJUU ne'teHU
Puc. 21.17 llIoe OnneRJI npu
pe3e1<ljuu ne'tellu
3,naBaR XOpOlliHH reMbcTaTlIqeCI<HH 31lJ1lJeI<T 6e3 npOpe3aHlI}f
TKaHeH.
UlOB P06UHCOHa-EaT'lepa (puc. 21.19) - OTJIHqaeTCR
OT IlIBa TeJIKOBa TeM, qTO npH ero BblllOJIHeHHII HaKlla,D;blBalOT
OT,neJIhHble 8-06pa3Hble lliBb!.
UlOB l)apKoBa COqeTaeT 3neMeHTbI HenpepbIBHoro II Y3-
JIOBOrO lliBOB. I1epe,n npoIlIIiBaHlIeM TpH,D;JIHHHble HIITII CBH3bI-
BaIOT 06IUIIM Y3JIOM. 3aTeM Ha cB060,nHb1H KOHeu TpeTheH HlITIi
Ha,D.eBalOT rynylO neqeHOqHYlO IIrny. OCTallbHhIe pacnonaralOT
Ha ,nlIallJparMallbHOH H BHCUepallhHOH nOBepxHocTHX neqeHlI.
I1my npOBO,D;HT qepe3 TKaHb neqeHII co CTOpOHhI BHCuepallhHOH
nOBepxHoCTII B KOCOM HanpaBJIeHHII (puc. 21.20). BbIKallhlBa-
lOT Ha .D:Ha<pparManbHOH nOBepXHOCTH. BblBe,neHHYlO HHTb CBH-
3blBalOT C HIiTblO, pacnOnO:>KeHHOH Ha 3TOH norepXHOCTIi. 3aTeM
TaR:>Ke B KOCOM HanpaBlleHHlI BbillOJIHj{lOT CJIeJJ:YlOlL(lill: CKB03HOH
lliOB. BbIBe,neHHYlO HIITb TaR >I<e CBH3bIBalOT co CB060,nHOH H1I-
TblO, HaXO.D:HIUeHCR Ha 3TOH nOBepXHOCTH nelleHH (puc. 21.21).
PaCToHHHe Me:>K.D:Y Y3JIaMH He ,n0JI)l(H0 npeBblillaTh 2-3 CM.
CYTb ,npyrHx lliBOB, npHMeHReMblX npH pe3eKUHH neqe-
HH, MO>I<HO nOHHTb 1I3 puc. 21. 22-21. 26.
npH pe3eKIIUU nO'lKU, nOCJIe ee oCB060)l(,D;eHIIH OT IlJH6-
p03HOH Kancynbl, KllHHOBII,D;HO IIcceKalOT napeHxlIMY. IIpH 3a-
lliliBaHIiH paHbl Ha BCKphITble qallieqKII HaKlla,nbIBalOT OT,neJII,-
HhIe Y3JIOBble lliBbl (pur. 21. 27). 3aTeM OT,neJIhHblMli Y3JI9BblMH
lliBaMII, 3aXBaTbIBaR IlJH6p03HYlO Kancyny, paHY 3aKpbIBalOT
(puc. 21.28). IIpH 3aliHBaHHH paH JIOXaHKH, B03HHKalOIUHX
npH TpaBMax IIJIH nHenOTOMIIII, naKJIa,nbIBalOT Y3JIOBble liBbI,
He npOlliliBaH CJIII3IICTOH 060JIOqKH JIOXaHKH (puc. 21.29).
1lI0B rEnA TIlKOXOJIEJJ:0XA
lJJBbI :>KeJIqHbIX npoToKoB npHMeHRIOT nocne
XOJIe,nOXOTOMHH HnH nplI CJIyqaHHOM nOBpe:>K,neHHH
npoToKoB. )J;JIH 3Toro HCnOJIb3YlOT MOHoIlJHJIa-
PUC. 21.21 Woe EapKoea npu
pe3eKl/uu ne'lel/u
Puc. 21.22 Woe EpeZaa3e npu
pe3eKl/uu ne'leHU
Puc. 21.18 Woe TellKoea npu
pe3eKl/UU ne'leHU
Puc. 21.19 Woe P06uHcoHa-
Eam'lepa npu pe3eKl/UU ne'leliU
Puc. 21.20 llepeblu )man rjJOPMUPO-
eallUR wea EapKoea npu pe3eKl/uu
ne'leHU
Puc. 21.23 moe Ea6ypa npu
pe3eKl/uu ne'leIiU
169
rnaBa 21
Puc. 21.24 llIoe BapllaMO-
ea npu pe3eT<IJUU ne'leHU
PUc. 21.27 3aUlueallue
'taUle'teT< no't"u Y3ll06bIM 1U60M
PUC. 21.25 llIoe Oepe npu
pe3eT<ljuU ne'leliU
PUC. 21.26 llIoe JJa660T<a U
Oplloea npu pe3eT<ljuu ne'leHU
u'\
,", \:: :- t '.:
"
;. .
Fi .. .
t ,:'
'C", .
f ,
PUC. 21.28 3aUlueallue pallbl nO'lT<U Puc. 21.29 3awueallue
Y3ll06WJW 1U60M C 3axeamOM rjJU6P03HOU lloxaHKU nO'lT<U Y3ll0ebIM Ul60M
T<anCYJlbl
MeHTHble paccaCbIBalOlI.{HeCH HHTH (6HOCHH), C YCJIOBHblM ,nlIaMeTpoM 5/0-7/0. IIo B03MO:>KHOCTH
cne,nyeT npHMeHHTb HenpepbIBHbIH lliOB C 3aXJIeCTOM. OH 06eCneqlIBaer XOPOIlIYIO KoamaUlIlO 6e3
3axBaTa CJIH3IICTOH.
IIpH HallO:>KeHHH 6"JI"O H['eCTHBHLIX auacroMo30B peKOMeH.IJ:YlOT nonb30BaTbCR TonbKO
O,nHOpH,D;HblM HenpepbIBHbIM lliBOM. OH npoCT B npHMeHeHlI1I H ,naeT MeHblliee qHCJIO OCJIO:>KHeHIIH.
)J;JIH HallO:>KeHIIH aHaCTOM030B y,n06HO nonb30BaTbCR ,nBYMR paccaCbIBalOIUIIMHCR MOHoIlJHJIaMeH-
THbIMH IIJIlf nOJIlIllJRITaMeHTHbIMH HIITHMII. Tpa,D;llUHOHHO nepBOHaqaJIbHO 1lJ0PMIIPYIOT 3a,D;H101O ry6y
aHaCTOMb3a. HHTII C HrJIaMIi pacnonaralOTCH no 06e CTOpOHbI 6y,nYIUero aHaCTOM03a. I10CJIe :noro
nonepeMeHHO HaKJIa,nbIBalOTCR npaBaR H JIeBaH qaCTH aHaCTOM03a, ,no Tex nop, nOKa HHTH He
BCTpeTHTCR Ha nepe,nHeH ero ry6e. 3aBepIlIaIOT HaJIO)f(eHHe aHaCTOM03a CBj{3hIBaHHeM HHTeH Me:>K,D;y
c06oH.
IIIOB IIO,LVKEJIY.LJ,OQHOM )KEJIE3L1,
Bo BpeMR pe3eKUHII no,n:>KeJIy,noqHOH :>KeJIe3bI npOH3Bo,nRT y,nalleHHe HeKpOTHqeCKHX Macc,
KPOBOTOqall.{lIe COcy,nbl npOllilIBalOT OT,neJIbHbIMH nOJIHnpOnHlleHOBblMIi IlIBaMH. 3aTeM Ha naHK-
peaTHqeCKHH npOTOK HaKlla,D.bIBalOT KHeeTHblH mOB. )J;eJIO B TOM, qTO JI106ble c,naBJIHBalOlI.{He IlIBbl
Ha no,n:>KeJIy,nOqHylO :>KeJIe3Y MorYT nplIBo,nIITb K pa3BHTHlO KpaeBoro naHKpeOHeKp03a. K cpe3Y
170
:>KeJIe3bI, no B03MO:>KHOCTII, nOWIIlIBalOT CTeHKY KIIIlIKII RITII :>Keny,nKa. IIpH HallO:>KeHIIII naHKpeaTO-
3HTepoaHaCTOM03a «60K B 60K» no nOBO,ny XpOHlIqeCKOrO naHKpeaTIiTa :>KeJIe3a pacceKaeTCH ,no
naHKpeaTlIqeCKOrO npOTOKa. 3aTeM O,nHOPMHbIM HenpepblBHblM lllBOM CllilIBalOTCH CTeHKII KlIlllKII
II npOTOKa. MeTo,nIIKa HallO:>KeHIIH aHaCTOM03a Tpa,nIIUIIOHHa. CHaqana IlJOPMIIPYIOT3a,D.HlOlO ry6y,
a nOTOM nepe,nHlOlO. PeKOMeH.D:YlOT IICnOnb30BaTb 61I0CIIH, MaKCOH, PDS, nonlinpOnRITeH 2/0,
3iO. Bce nonlIllJlInaMeHTHble MaTepHanbI ,nalOT BbIpa:>KeHHYlO peaKUlIlO TKaHIi :>Kene3b!.
AHaCTOM03 «KOHel{ B 60K» HaKna,nblBaIOT npli naHKpeaTo,nyo,neHaJIbHOH pe3eKUHII. IIep-
BOHaqallbHO nOCJIe nepeCeqeHIIH :>KeJIe3bl OCTaHaBllIIBalOT KpOBOTeqeHlIe npollllIBaHlieM COCy,nOB
OT,neJIbHbIMli Y3JIOBbIMIi IlIBaMIi. 3aTeM B npoTIIB06pbI:>KeeqHOM Kpae KlIlllKIi ,nenaeTCH oTBepCTIIe,
paBHoe ,nlIaMeTpy naHKpeaTlIqeCKOrO npoToKa. AHacToM03 HaKJIa,D;blBaeTCH O,nHOpH,nHbIM Y3JIO-
BbIM lllBOM. IIpli 3TOM npo1I3Bo,nIITCH TOqHaH KoanTaUIiH npoToKa II npocBeTa KHiliKII. IIpli Bblpa-
:>KeHHOM 1lJ1I6p03e TKaHIi :>Kene3bllI pacllllIpeHHoM naHKpeaTlIqeCKOM npoToKe B03MO:>KHO npHMe-
HeHlIe O,nHopHlIHoro HenpepblBHoro IlIBa aHaCTOM03a.
AHaTOMlIqeCKlie oc06eHHoCTli cTpoeHIIH nerKoro 06YCJIOBJIIIBaIOT Tpy,nHOCTb npolllHBaHIiH
3TOH TKaHI1. TOHKaH BIiCuepallbHaH nJIeBpa, BbIpa:>KeHHOe pa3BIITlie 3nacTH4ecKoH TKaHIi II cocy,nlI-
CTOH ceTIi Ha 1lJ0He He,nOCTaTOqHO pa3BIIToro coe,nIIHIITeJIbHOTKaHHOrO KapKaca nplIBO,D;Sl:T K 1lJ0p-
MlipoBaHlIlO IlIlipoKoro paHeBoro KaHalla. IIocne npoKona TKaHIi 1I3 oKpY:>KalOlI.{eH HIITb lI.{enH
BbIXO,nIIT B03,nyx, a 1I3 pa3pYllieHHbIx cocy,nOB npOCaqlIBaerCH KpOBb. EOJIee Toro, qaCTO nOnbITKa
KpenKo 3aTHHYTb yJen Be,neT K ,nononHIITeJIbHblM nOBpe>K,L\eHIIHM 1I3-3a npope3aHHH HIITblO TKaHIi.
MCXO,nH 1I3 3Toro, lliOB ueneC006pa3HO HaKlla,nblBaTb Ha MallOpa3,nYToe RITII cnaBllleeCH JIerKoe.
)J;JIH BbInOnHeHIIH 3Toro YCJIOBIIH Tpe6YlOTcH COrJIaCOBaHHbIe ,neHCTBIiH xlIpypra II aHecre31I0nora.
B MOMeHT npoBe,neHIIH HlITH qepe3 TKaHb He06xo,nIIMO 06eCneqlITb KpaTKoBpeMeHHYlO 3a,nep:>KKY
,nblxaHIiH.
1ll0B, HallO:>KeHHbIH Ha nerKoe, nplI3BaH 06ecneqlI- "
BaTb TluaTenbHbIH reMOCTa3 II repMeTlIqHOcTb. )J;JIH ,nOCTII- ' .".
)KeHIUI reMOCTa3a IIIOB ,nOJI>KeH 3aXBaTbIBaTb BCIO r.rry6IIHY '"
paHb!. repMeTHqHOCTb IlIBa ,nocTliraeTcH nYTeM YBeJIlIqe-
HlIH nJIOlua,n1I conpliKocHoBeHIIH nlICTKOB BIiCuepallbHoi1
nJIeBpbI.
B 3alliliBaHIIII nOBepXHOCTHbIX paH nerKoro Her He-
06XO.D:HMOCTH. YqaCTOK nOBpe)l(,D;eHIIH 3aXBaTblBaIOT 3a)l(lI-
MOM, no,n KOTOpblM 3aBH3blBaIOT nHraTYPY. IIoHa,n06IITcH
TonbKO XOpOlliaH llJIeBplI3aUHH. BbIpa:>KeHHbIe pereHepaTIIB-
HbIe If peaKTIIBHbIe CBoHcTBa BIiCUepallbHOH nJIeBpbl 06ec-
neqaT Ha,D.e:>KHOe 3aKpbITlie ,nellJeKTa. Eonee rny60KYIO paHY
npOllilIBalOT 8-06pa3Hb1M lliBOM (puc. 21.30). 3allJHKclIpo-
BaB nOBpe)l(,D;eHHbIH yqaCTOK 3a:>KIIMOM n CJIerKa ero no,nTH-
HYB, IIrJIY BKallblBalOT II BblKallblBalOT Ha paCCTOHHlI1I 3-5
CM OT KpaH ,nellJeKTa. IIpH 3TOM HHTb npOBo,nHT Ha BClO rny-
6IIHY paHb!. Mcnonb3YlOT KPYTolI30rHYTYlO aTpaBMaTlIqeC-
KYlO IIrny C OCTpbIM KOHqIIKOM.
n pH YIlIIIBaHHII 60JlblliliX nlIHeHHbIX paH IIcnOJIb-
UlBbI IIPH P AHAX JIErKOrO
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3YlOT II10B TUreJIH (puc. 21.31). Bo 1I36e:>KaHlie npope3aHliH TKa-
HeH,UBe HIITH npoBo,D;HT HenoCpe,D,CTBeHHO no,n nJIeBpOH, B HeCKOJIb-
KIIX MIIJIJIIiMeTpax OT KpaeB paHbI, napaJIJIenbHO ee ,nJIHHHIIKY.
3aTeM nonepeK nlIHHII paHbl HaKllaJJ:bIBalOT OT,nenbHbIe Y3JIOBble
lliBb!.
II pli 3alllHBaHIIII He60JIbIlIIIX paH nerKoro xopoIlIlie pe3YJIb-
TaTbI,naer nneBpallbHbIH norpY:>KHOH mOB «l>pUJJ:puxa (puc. 21. 32).
IIpoIlIHBalOT CHaqalla O,nIIH KpaH paHb!. YKon IIrJIblrrpOII3BO,D;HT co
CTOpOHbI rrJIeBpbI Ha paCCToHH1I1I 5-8 MM OT KpaH, a BbIKallbIBalOT
Ha paccToHHIIII 1-3 MM. Cne.nylOIUIiH CTe:>KOK npOH3Bo,nHT Ha npo-
TIiBOnOnO:>KHOM KpalO. I1rny BKallbIBalOT B npe,nenax 1-3 MM OT
KPaH II BbIKallbIBalOT Ha paccToHHlI1I 5-8 MM. fIpH 3aBH3bIBaHliH
Y3JIa,nOCTHraerCHconpIiKOCHOBeHlIenOBepXHOCTIIBIiCuepaJIbHOH
nJIeBpbI Ha 60JIblliOH nnOIUa,nlI. OTCYTCTBlie Ha,ne:>KHOrO reMOCTa-
3a HBnHerCH He,nOCTaTKOM onlIcaHHoro IlIBa.
XOpOllllIH reMOCTa3 II ,nOCTaTOqHYlO repMeTlIqHOCTb paHbI
06eCrreqlIBaeT mOB rappe-TaJIbKa (puc. 21.33). TeXHlIqeCKIi OH
nerKO BbIIIOnHHM. KaK II B npeJJ:bI.L1YIUeM lllBe, nepBbIH CTe:>KOK npo-
1I3BO,nHT Ha O,nHOM 1I3 KpaeB paHb!. I1rJIY BBO,nHT B napeHXIIMY co
" CTOpOHbl nneBpbI Ha paccToHHlI1I 1,0 - 1,3 CM OT KpaH paHbI, a
BbIKallbIBalOT Ha paccToHHHlI 0,5 - 0,6 CM. 3aTeM HIITb npOBOJJ:HT
co CTOpOHbl nneBpbI no,n ,nHOM paHbI II BbIBO,nHT CIiMMeTplIqHO Y
npOTHBOrrOnO:>KHOrO ee KpaH. OTcrynHB OT KpaH 0,5 - 0,6 CM, CHOBa
m:rny60Ko npOKallbIBalOT nJIeBpy II nOMe:>KaIUYlO TKaHb nerKoro.
BbIBO,nHT limy Ha paccToHHlIli 1,0 - 1,3 CM OT KpaH paHb!. npli
3aBH3bIBaHlllI Y3na npOlIcxo,nIIT YBeJIlIqeHlIe rrJIOIuaM conpliKOC-
HOBeHIIH nlICTKOB BIiCuepaJIbHOH nJIeBpbI.
EcnH He06xo,nIIMO y,nalllITb OTHOCIITeJIbHO He60nblllOH
06'beM TKaHH nerKoro} no ero KpalO 06bIqHO BblUonliHIOT KJIUHO-
BU,nuylO pe3eKUUIO. ,[{nH 3Toro JIerOqHbIe 3a:>KIIMbI HaKJIa,nalOT
KHapY:>KU OT KpaeB paHbI TaK, (J:T06bI ux KOHUbI CXO,nRITIiCb II 06pa-
30BblBallII yrOJI (KJIlIH), OTKpbITblH K neplIllJeplIli (puc. 21.34). IIo-
Bpe)l(,D;eHHbIH yqaCTOK OTceKalOT. Coe,D;IIHeHlIe pa3pYllleHHblX TKa-
HeH npe,nycMaTpliBaeT HallO:>KeHHe 06BIIBHoro HenpepbIBHoro
IIlBa. ,[{JIH 3Toro 3a:>KHMbl pa3BO,D;HT TaKHM 06pa30M, qT06bI IIX KOH-
UbI 06pa30BbIBallH yrOJI npliMepHo 180 0 . 3aTeM npoH3Bo,nHT 06-
llllIBaHlie TKaHeH Ha 3a:>KIIMe HenpepbIBHbIM 06BIIBHbIM lllBOM
(puc. 21.35). no Mepe nJIaBHoro 3aTHrlIBaHHH IlIBa 3a:>KIIMbl H3-
BJIeKalOT. CrHmBaHlie (rollJp:npoBaHlIe) TKaHIi nerKoro K ueHTpy II
Ilue I1lKalleU Ha 3a:J/CUMe 3aBH3blBaHlie HlITH rrpoH3BO,D;HT OCTOpO:>KHbIMIi CXO,nmuHMIICH ,UBII-
HenpepblellblM 06euellblM UleOM :>KeHIIHMII KOHqlIKOB nallbueB (MapneBbIM IlIapIIKoM).
IIpOlue BblllonHHTb KllIIHOBIIl{HYlO pe3eKUHlO C nOMoIUblO CIlIIIBalOIUIIX annapaToB. TaKlie
pe3eKUIIII 0CYIUeCTBnHlOT HanO:>KeHlIeM Ha nerKoe,UBYX arrnapaTOB YO tYIlIHBaTeJIb opraHoB), npo-
llllIBalOIUIIX ero TaHTallOBbIMIi cK06KaMIi. K neplIllJeplIlI OT JIIIHIIH MexaHII4eCKoro lllBa, CJIe.nyH no
6paHlllaM annapaToB, OTceKalOT nOpa:>KeHHbrn yqaCTOK. IIneBpaJIbHYlO nonOCTb ,npeHHpYlOT.
Puc. 21.32 3aUlueallue pallbl
Ile2K020 UleOJlf CPpuapuxa
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pe3eKljUJl . e2K020. JIe20'lllble
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pa3pe3a. KaK npaBHJIO, 3TO npOlIcxo,nIIT cpa3Y :>Ke nOCJIe nona.uaHIiH B03,nyxa B 6plOIlIHYlO no-
JIOCTb. B TOM CJIyqae, KOr,na CallbHIIK JIHilieH M06RITbHOCTH, cYIUeCTByeT 60JIblliaH BepOHTHOCTb ero
cnaeK C 6plOlliliHOH RITII KIIIlIKaMIi. qame Bcero nplIql1HOH TaKOrO cpaIUeHHH HBJIHIOTCH rrepeHeceH-
Hbrn RITII npo,non:>KalOIUHHCH BOCnalllITenbHblH npouecc. BOCCTaHOBIITb M06IInbHOCTb CallbHIIKa
TynbIM nYTeM He Bcer,na B03MO:>KHO. EcnlI 3TO He y,naeTCH c,neJIaTb cpa3Y H nerKO, TO nyqllie ero
OTpe3aTb HO:>KHlIuaMH Ha no,nBe,neHHbIx no,n CaJIbHIIK naJIbuaXneBOH PYKII.
BepXHIIH KpaH paHbI nepepe3aHHoro CaJIbHHKa OCMaTpIIBalOT II npollIliBaroT KpoBOTOqaIUlie
apTepHH. BnpoqeM, 3TO nplIxo,nmCH ,neJIaTb ,nOBOJIbHO pe,nKO, TaK KaK B crraHKax pe,nKO BCTpeqaIOT-
CH COCy,nbl 60nbllioro ,nlIaMeTpa. B 60nbllilIHCTBe CJIyqaeB ,nOCTaTOqHO 06MeTaTb KpaH paHbl CKOp-
HH:>KHbIM IlIBOM (puc. 22.1), IIcnonb3YH,D;JIH 3TOro TOHKYlO paccacbIBalOll{YlOcH HIiTb. IJ.eneco06pa3-
HO lliOB npepBaTb B ,nByx-Tpex MeCTax.
IIocJIe TaKoro 06lliHBaHliH CallbHlIKa Ha ero cB060,nHOM Kpae OCTalOTCH YTonIUeHlIH, HO OHII
He60nbllioro pa3Mepa II C XOpOlliHM nliTaHlieM. ECJIII IIX KOJIlIqeCTBO MIIHIIMallbHO, Tor,na OHII H
BOBce He3aMeTHbI. B npoTIIBHOM cnyqae, npli nepeBH3blBaHlIli H nepepe3aHHH CallbHIIKa Me)l(,D;y
,nBYMH JIliraTypaMIi OCTaerCH 60nbllioH KOMOK TKaHeH.
K ynbTH, OCTalOIUaHCH Ha BIiCUepallbHOH 6plOlliIIHe KlIIlIKH, ,non:>KHa 6bITb MlIHlIMaJIbHa. Tor-
,na, nplipociliaH K 6plOlliHOH nonOCTIi OCTaBlliaHCH qaCTb CallbHIIKa, npOlliliBaHIiH He Tpe6yeT. 3TO
CYIUeCTBeHHO YMeHblliaeT BepOHTHOCTb nOCJIe,nYIOIUero 06pa30BaHliH cnaeK.
He06xo,nIIMOCTb M06HJIll3IIpoBaTb 60nb-
IlIOH CallbHIIK MO)!(eT B03HHKHYTb npli JIanapoc-
KODlIqeCKOM MeTo,ne npOBe,neHlIH OnepaTHBHO-
ro BMelliaTeJIbCTBa. .ZJ:nH ,nOCTII)!(eHIIH 3TOH UeJIli
MO:>KHO OT,nenHTb CallbHHK OT KIIIlIOK HJIH 6plO-
IlIIIHbI TynbIM nyTeM (no CyTlI, OTpbIBaH OT 6plO-
lliIIHbI). HalI60nee y,n06eH CJIe.nylOll{IIH nplIeM:
y6e,D;IIBlliliCb B TOM, qTO B CpameHIIH He BOBJIe-
qeHa KlilliKa, npMb CaJIbHHKa 3aXBaTbIBalOT 6H-
nonHpHbIM 3a:>KIIMOM Henocpe,nCTBeHHO y na-
plieTanbHOH 6PlOlliHHbl. 3aTeM ee KoarynHpYIOT
,no 06pa30BaHIIH cTpyna ceporo UBeTa II OTpbI-
BalOT OT 6plOllilIHbI.
CpaIueHHH 60nbIlIoro CaJIbHHl<a C KII-
llieqHHKOM HalI60nee y,n06HO pa3,neAATb OCT-
pbIM nyTeM. ECJIII y,naeTCH «BOHTH B CJIOH»,
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TO 3T0 MO:>KHO C,nenaTb 6e3 KoarymlUHII. B npOTHBHOM CJIyqae IIHOr,na MO:>KeT nOHa,n06IITbCH npe,n-
BapHlOIlIasr KOarYJIHUIiH. ECJIII IIMelOTC5I nJIOTHble Cpall.\eHIIH C Bblpa:>KeHHOH BacKynsrplI3aUlIeH,
,D;JIsr ,nOCTII:>KeHIIH Ha,ne:>KHOrO reMOCTa3a TKaHb 60nbIlIOrO CallbHlIKa Tpe6yer IIHTeHCIIBHOH Koary-
nHUIIII. B 3TOM CJIyqae He06xo,nIIMO KoarynlIpoBaTb J],O 06pa30BaHliH CTpyna qepHoro UBeTa. B TO
:>Ke BpeMH OqeHb Ba:>KHO yqlITbIBaTb B03MO:>KHOCTb pacnpe,neneHHH TenJIa Ha OKpY)KalOIUlie TKaHIi.
PaCCTOHHlIe 60nee 10 MM OT CTeHKH KlilliKII n03BOJIHer H36e:>KaTb TepMHqeCKOH TpaBMbl. IIocJIe
3neKTplIqeCKOrO B03,neHCTBIiH TKaHIi pa3,nen5l1OT OCTpblM nYTeM. JIIIHlIlO pa3pe3a npOBO,nHT qepe3
30HY KoarynHUlIoHHOrO HeKp03a no KpalO, 06pall{eHHOMY K KHlliKe.
Dpli He,D,OCTaTOqHO 31lJIlJeKTHBHOH KoarymUlI1I KpOBOTeqeHlIe, B03HHKalOIUee nOCJIe nepece-
qeHIIH TKaHli CallbHIIKa, MO:>KeT ,nOCTaBHTb MHoro XJIOnOT, a IIHor,na ,na:>Ke nOTpe60BaTb KOHBepclIli.
3TO 06YCJIOBneHO TeM, qTO KPOBOTOqaIUIiH cocy,n «TOHeT» B :>KlIpOBOH KlleTqaTKe II OKa3blBaeTCH
He,nOCHraeMbIM npli nOnblTKaX ,nonOJIHHTeJ1hHOH KoarymUHII.
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no,nenlITb Ha npe.lJ.HaMepeHHLIe (ypeTepoTOMIIH, pe3eKUliH MOqeTOWHKa IIJIII MOqeBOrO nY3bIp5l,
nepeca,nKa MOqeTOqHHKa) II CJIY'IaHHLIe (TpaBMlIpOBaHlie npH npOBe,neHIIII pa3JIIIWblX onepaTHB-
HbIX BMelliaTeJIbCTB Ha opraHax 6plOIIlHOH nonOCTH II MallOrO Ta3a).
PaHbl MOqeTOWHKa MorYT 6bITb nOnepe'IHLIMH H npo,nOJIbHblMH. IIpo,nonbHble paHeHlIH,
KaK nOKa3blBaeT npaKTIIKa II MHOrOqHCJIeHHble onblTbI Ha )l(IIBOTHbIX, OqeHb 6blCTpO 3a:>KIIBalOT
caMIi. II03TOMY, npli B03MO:>KHOCTII, IIX 3aIlIliBaTb He peKOMeH,D;YIOT, 06'bHCHHH 3TO TeM, qTO lllOB,
npoxo,nH B nOnepeqHOM HanpaBJIeHIIH, HeMIiHyeMo npHBe,ncr K 1I3MI3BJIeHII1O. B HTore nOJIyqnTCH
31IH1OIUa51 RITH nOnepeqHa51 paHa, KOTOpa51 nJIOXO 3a:>KIIBaer H OCJIO:>KH5IerCSI CBHIUaMIi. Bce, qTO
H}')KHO c,nenaTb npli 06HapY:>KeHIIII npo,nonbHOH paHbl, - 3T0 YKpenlITb ee 6plOllilIHOH. ,[{JIH 3Toro
6plOllllIHY npHKpeDJIjllOT npo,nOJIbHO pacnOJIO:>KeHHblMH llIBaMlI, 3aXBaTbiBaH B CTe:>KOK MHHlIMallb-
Hoe KOJIlIqeCTBO nOKpblBalOll{eH MOqeTOqHIIK KlleTqaTKII. npli 3aBH3bIBaHHH H1ITb CTHrlIBalOT OqeHb
cna60, TonbKO ,no conpliKOCHOBeHIIH KpaeB paHb!. Ha3HaqeHIIe TaKIiX lliBOB - nplI,nep:>KIIBaTb
Heno,nBII:>KHO 6plOIlIHHY, nORa OHa He npRITIIDHer K paHe MOqeTOqHlIKa. 06IDaTeJIbHbiM 3neMeHTOM
onepaUlI1i HBJIJleTCH ,npeHlIpOBaHlie KlleTqaTOWOro npOCTpaHCTBa.
ECJIH Bce-TaKIi npIIXo,nIITCH ymHBaTb .D:JI,HHHble npo,nonbHbIe pa3pe3bl MOqeTOqHHKa, npOlI3-
Be,neHHble, HanpHMep, npli yperepoTOMIIII, TO ,nenalOT 3TO OT,neJIbHLIMH Y3JIOBLIMH WBaMH
(puc. 23.1). I1x HaKlla,nbIBalOT B nOnepeqHOM HanpaBneHHH C lliaroM 2-3 MM. B CTe:>KOK He 3aXBa-
TblBalOT CJIH3IICTYlO 060nOqKY M5I1I36e:>KaHIiH nOCJIe,nYIOll{eH HHKpYCTaUIiH lliBOB conHMII. I1rny
BKallblBalOT II BblKanbIBalOT, oTcTynHB 1-2 MM OT KpaeB paHbI. I1cnonb3YlOT TOHKYlO (2/0-4/0)
paccaCbIBalOIUYIOcH HIITb (noJIHcop6, 61I0CIIH, ,neKCOH, MaKCOH, BIIKPRIT,
PDS) II aTpaBMaTlIqecKYIO limy.
IIepeqHCJIeHHbIe HIITH, paCCaCbIBaHCb B npouecce 6Ho,ner-
pa,naUIIII, npe,noTBpaIUalOT B03MO:>KHOCTb 06pa30BaHII5I MOqeBbIX KaM-
HeH. BnpOqeM, CJIe,nyer c OCTOpO:>KHOCTblO nplIMeHHTb MaKCOH II PDS-
MH IIX paccaCbIBaHII5I Tpe6yeTcH ,nOBOJIbHO MHTeJIbHblH CpOK.
)J;JIH npolliHBaHIiH TKaHeH MOqeBbIBo,n5lIUeH CIiCTeMbI HaH60nee
y,n06HOH 6y,neT lima C OCTpbIM KOHqlIKOM II TenOM, H30rnYTbiM Ha 5/8
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1.fT06bl He CY3HTb npOCBeT MOqeTOqHIIKa, lllBbI peKo¥eH,D;yeTcH
HaKlla,nblBaTb Ha,n BBe,neHHbIM B MOqerOqHlIK KarerepOM, KOTOpblH He-
06XO,nIIMO OCTaBHTb Ha 6-8 CYTOK.
IIonepewble paHbI nOqTII He OTnlIqalOTCH OT nOJIHoro nepepe3a-
HH5I MOqeTOqHHKa. 3anrnTb TaKYlO paHY Tpy,nHO II e.fiBa nH B03MO:>KHO.
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BOCCTaHOBneHlIeM. B CJIyqae, eCJIII MOqerOqHIIK nepepe3aH BHlI3Y RITH Ha cpe,nIIHe ero nYTII OT
linea innominata K MOqeBOMY nY3bIplO, peKOMeH.D:YlOT ,neJIaTb nepeca,nKY KOHua MOqerOqHIIKa B
nY3b1Pb. Ba:>KHo nOMHIITb, qTO M ,nOCTII:>KeHIIH nOnO:>KIITeJIbHOrO pe3ynbTaTa TaKoro onepaTIIBHO-
ro BMelliaTenbCTBa CJIe,nyeT H36eraTb HaTH:>KeHHH 3Toro npOTOKa. TIplIT5IrHBaTb He06xo,nIIMO ny-
3blpb K MOqerOqHIIKY, a He Ha060poT. Donee Toro, C06JIlO,naH 3TO YCJIOBlIe, ,nIIBepTIiKyn nY3blPH
npHllllITb HY:>KHO TaK, qT06bl OH BnOCJIeJ],CTBHII He Mor OTOHTII OT fossa iliaca II paCTHrlIBaTb MOqe-
TOqHlIK.
B Tex CJIyqa x, Kor,na KOHeu MOqeTOqHHKa B ny3bIpb BilllITb HeB03MO:>KH0, KOHUbl npHXO,D;IIT-
CH coe,nIIHHTb. rnaBHble 3aTpY.lJ.HeHHH npH cmHBaHHH KOHQOB MO'leTO'lHHKa COCTOHT B TOM, qTO:
- Y 3Toro npOTOKa MalleHbKIIH ,nlIaMeTp II TOHKlIe CTeHKH. II03TOMY npli 3allilIBaHHH ero
KOHUbI BepTHTcH II HX TPY.D:HO y,nep)l(lIBaTb;
- BO BpeM5I 3alliliBaHliH CYIUeCTByeT onaCHOCTb CY3HTb npocBer MOqerOqHIIKa.
Y CJIOBHH, Heo6xo.lJ.HMLle .lJ.JIH ycnemHoro 3amHBaHHH:
- OqeHb Ba:>KHO He:>KHOe 06paIUeHIIe C MOqeTOqHHKOM II H36e:>KaHlie ero 3aXBaTa HHcTpYMeH-
TaMH;
- He60flbllioe 'IlIcno IlIBOB, HallO:>KeHHblX IICKlllOqHTenbHO B npo,nOJIbHOM HanpaBneHHII. H
MHHIIMallbHOe KOnlIqeCTBO IlIBOB, npoHIIKalOIUIIx CKB03b Bce CJIOH 3Toro npoToKa. IIocJIe,nHee
YCJIOBlie npe,noTBpall{aeT 06pa30BaHlie KOHrnoMepaToB B npocBere MOqerOqHIIKa;
- OTcYTCTBlie BCHKoro HaTH:>KeHIIH H, B TO :>Ke BpeMH, ,nOCTaTOqHO npOqHOe CKpenJIeHlIe, qTO
n03BonHT y,nep:>KaTb KOHUbI,nO B03HHKHOBeHIIH py6ua;
- XOpOiliaH npoxo,nHMOCTb MOqerOqHI1Ka, OTCYTCTBHe BCHKOro cy:>KeHIIH €;ro npOCBera B Me-
CTe ClliIIBaHHH;
- CTpO:>Kail:IlIa aHTIiCeDTHKa.
IIpoCToe ClllHBaHlie KOHUOB MOqeTOqHlIKa ymoBaTblMlI IlIBaMH y,nOBJIeTBOpsreT TonbKO O,nHO
YCJIOBlIe: IlIBbl pacnonaralOTCH npo,nonbHO II He ,nalOT IlJHcTyn. )J;JIH 06nePleHIIH IlJHKcaUIiH KOHUOB
MOqeTOqHlIl<a npH IIX CIlIHBaHHII Ha ueHTpallbHblH II neplIllJeplIqeCKliH OTpe3KII HaKJIa,nbIBalOT II-
06pa3Hbie lliBbI- ,nep:>KallKH. Ha,n KaTeTepOM, BBe,neHHbIM B 06a KOHua MOqeTOqHIIKa, TOHKOH pac-
caCblBalOIUeHCH H1ITblO Ha KpYTOH KpyrnoH Hrne no OKPY:>KHOCTH MOqeTOqHIIKa HaKJIa,D.blBalOT OT-
,neJIbHble Y3JIQBble IlIBbl. CTapalOTCH npOBo,nIITb HIITb qepe3 a,D.BeHTHUHanbHbIH II MbIllieqHblH CJIOH
(puc. 23.2). Y3JIbl3aB 3blBaIOT CHapY)l(II TaKHM 06pa30M, qT06bl KPaH MO'IeTOqHlIKa TOJIbKO conplI-
KacanHCb.
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Puc. 23.2 y'1J10eble Ulebl npu
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176
B ,nallbHeHllieM npli HOpMallbHbIX pa3Mepax npOCBeTa MO-
qerOqHHKa B 06naCTII IlIBa MO:>KeT B03HIIKHYTb cY:>KeHlIe. nporHO-
3HPYH 3TO OCJIO:>KHeHlIe,,D;Jlj{ CIlIHBaHIiH KOHUOB MOqeTOqHIIKa «KO-
Hel.{ B KOHeu» He06xo,nIIMO nepeceKaTb ero He B nOnepeqHOM, a B
KOCOM HanpaBneHIIH no,n yrnoM 45°. 3TO ,naeT B03MO:>KHOCTb He-
MHoro YBeJIII'IlITb npocBeT MOqcrOqHIIKa B MeCTe aHaCTOM03a. .ZJ:nH
,nOCTII:>KeHlIH aHanOrnqHOH UeJIH MO:>KHO HaKlla,D.blBaTb mOB c BHe-
.lJ.peHHeM npOKCHMaJIbHOro KOHQa MO'leTO'lHHKa B .lJ.HCTaJIbHLlH.
KpOMe npoqero, TaKOH lliOB nOBbllliaer repMeTHqHOCTb coe,nHHe-
HIIH. TeXHIIKa TaKoro lliBa npOCTa. KOHeu ,nHCTaJIbHOrO OTpe3Ka
MOqerOqHIIKa pacceKalOT no nepe,nHeH ero CTeHKe B npo,nOJIbHOM
HanpaBneHIIH B npe,nenax 1 CM. IIpOKCIiMallbHblH OTpe30K MOqe-
TOqHHKa IlJIIKCIIPYIOT ll-06pa3HblMIi lliBaMII, pacnonaraH HX Ha
nepeAHeH II 3a,D.HeH CTeHKe Ha pacCToHHIIH 1-1,2 CM OT KpaH.
3aKaHqHBaIOT CKpeIIJIeHlIeKOHIXoB MO-
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UlIanbHOH 060nOqKOH ueHTpallbHOrO OTpe3Ka.
TaKIiX lliBOB HY:>KHO HallO:>KIITb He 60nee 3-4.
IIocJIe OKOHqaHII5I ClliHBaHII5I, KaK H npli ,npymx
MeTo,nax, MOqeTOqHHK (ecJIII 3TO B03MO:>KHO) ne-
peBo,nIITCH B IIHTpallHraMeHTapHoe COCTOHHlIe C
nOMOIUblO CTHrlIBaHIIH Ha,L\ HHM 6plOlIIHHbl. OT xo-
pOiliero YKpblTliH 3TOH nJIeBOH 3aBliCHT 6bICTpO-
Ta CJIlInaHHH II y,naqHbIH pe3ynbTaT.
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peHHOM MOqeTOqHIIKe BbIllOJIHIITb OqeHb TPY,n-
HO, nOTOMY qTO KOHUbl ero BepTHTCH, a CTeHKII
TOHKII, II XOpOlliO CllllITb npaKTWleCKli HeB03MO:>K-
HO. I1pH caMOM Tll{aTeJIbHOM HallO:>KeHIIII IlIBOB,
BCJIe,nCTBHe 3aTHrlIBaHliH lliBaMH, 06pa3yeTcH
YTomueHHe, KOTopoe nplIBO,D;IIT K HeMIiHYeMoMY
CY:>KeHlIlO B 3TOM MeCTe.
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HHH KOHUOB MOqeTOqHIIKa HBnHeTCH cnoco6 Ban XYKa. 0H COCTOHT B TOM, qTO HII:>KHlIH KOHeu: MOqe-
TOqHIIKa nepeBH3bIBaeTCH II no,n nHraTYPOH ,neJIaerCH npo,nonbHoe OTBepCTlIe, B KOTopoe BllilIBa-
erc5I BepXHIIH KOHeu TIoro npOTOKa. IIpli TIOM npOKCIiMallbHbIH KOHeu BTHrlIBaeTC5I B OTBepCTIIe II .
nonyqaeTCH ero norpY:>KeHlIe B H1I:>KHIIH (,nIICTallbHbrn)..ZJ:nH TIoro KOHeu npOKCIiMallbHOro OTpe3Ka
MOqeTOqHIIKa npOllilIBalOT II-06pa3HbIMH lliBaMII, He npOKallbIBaH ero HaCKB03b. CB060,nHbIMH
KOHuaMIi HIITKII npOllIlIBalOT CTeHKY ,nHCTaJIbHOro KOHua co CTOpOHbI npOCBeTa (puc. 23.4)..
Kor,na 3TOT lliOB 6y,neT 3aB5I3aH, ueHTpanbHbIH KOHeu MOqeTO HKa OKa:>KeTCH BTHHynIM B
paHY nepHllJeplIqecKoro KOHua II nonyqHTCH aHaCTOM03 «KoneQ B 6010>. OCTaHeTCH TonbKO 06lliHTb
KPaH paHbI HeCKonbKIIMH Y3JIOBbIMli IlIBaMII, He npOHIIKalOll{IIMIi HaCKB03b, II npHKpenlITb O,nHIIM
JIJIII ,nBYMH IlIBaMH nepepe3aHHbIH KOHeu HII:>KHerO OTpe3Ka K HapY:>KHOH nOBepXHOCTIi BepXHero.
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BBe,neHHe 30H.na cymeCTBeHHO 06nerqa-
eT ,nallbHeHmee 3allilIBaHHe. CB060,nHbIe KOH-
UbI HIiTeH npOBO.D:5IT qepe3 60KOBbIe CTeHKII ,n1I-
CTaJIbHOrO OTpe3Ka MOqeTOqHIIKa 1I3HYTPH
HapY:>KY. IIpli 3TOM He CYIUeCTBeHHO npOKOJIOT
nli HaCKB03b BepXHIIH (npOKCIiMallbHbIH) KOHeu.
Eonee Ba:>KHO HenpeMeHHO npOKonOTb HII:>KHlIH
(.nHCTallbHbIH) KOHeu (puc. 23.3) .llIBbI3aTsrrn-
BalOT; BHe,npHH npOKCIiMaJIbHbIH KOHeu MOqe-
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no 3.MMemu U BaH XYKY: a - UHea2UHaIjUJI npOKCU-
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177
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neperlI6 MOqerOqHIIKa B ClllHTOM MeCTe, HO CY:>KeHIIH npli 3TOM He 06pa3YeTCH.
B HaCTosrIUee BpeM5I MOqeTOqHHKOBO-MOqeTOqHIIKOBble aHaCTOM03b1 «60K BOOK» (puc. 23.5)
II «60K B KOHeQ» (puc. 23.6) npliMeIDllOTcH pe,nKo. -
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pacnOJIaralOTCH BonoKHlIcTo-xpHIUeBble nOJIYKonbua. I1x cB060,nHble 3a,UHHe KOHI.\bI coe,nIIHeHbI
KonbueBH,nHblMIi CBH3KaMli II nyqKaMIi rJIa,UKIiX MbIllieqHblX BonOKOH. IIocne,nHHe, B CBOlO oqe-
peJJ:b, BMeCTe C 3JIaCTHqHbiMli II KOJIJIareHOBblMIi BonOKHaMH 1lJ0pMHPYIOT nepenOHqaTYlO 3a,D;H101O
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TOH OCHOBe. B 6poHxax 3Ta OCHOBa Bblpa:>KeHa cJIa60, 'ITO 06'bHCHHeT ee cKlla,nqaT)'lO CTPYKryPY.
Pa3pe3 CTeHKII npli TpaXeOCTOMlIIi (6pOHXOCTOMlIII) npOII3BO,D;HT B nepenOH'laTOH qaCTII KOCO
HJIII npo,UonbHo. B03MO:>KeH ,noCTyn H qepe3 KOJIbueBH,nHYlO CBH3KY. Ho, yqlITbIBaH oc06eHHoCTH
rliCTOnOrlIqeCKOrO cTpoeHIIH, TaKaH paHa xY:>Ke 3a:>KIIBaeT.
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THBHaH cnoc06HoCTb CTPYKTYP creHOK Tpaxell II 6POHXOB, 06YCJIOBneHHaH oc06eHHocTHMII IIX rHC-
TOJIOrlIqeCKOrO cTpoeHIIH II KpoBOCHa6:>KeHIIH, - C ,npyroH, BbI,nBlIralOT K lliBaM onpe,neJIeHHble
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- 06eCneqHBaTb Ha,ne:>KHYlO repMeTlIqHOCTb nHHHH IlIBa;
- 06eCne'llIBaTb XOPOlliYlO KoanTaUlIlO KpaeB paHbI,nJIH npe,noTBpall{eHIIH 1lJ0pMIIpoBaHliH
rpy60ro py6ua II CTeH03HpoBaHIIH;
- MIIHIIMH3HpoBaTb paccTpoHcTBa KpoBo06pameHIIH no nlIHlI1I lliBa;
- coxpaHHTb ,noCTaTOqHYlO MeXaHlIqecKYlO npOqHOCTb B TeqeHlIe MIITeJIbHOrO BpeMeHH;
- COXpaHHTb 3naCTHqHOCTb TKaHeH no JIHHIIII IlIBa;
- He Bb13bIBaTb CY:>KeHlIe npOCBeTa B03,nYXOHOCHblX nYTeH.
B 3aBIICliMOCTH OT MeCTa npOlliHBaHIIH, lliBbl Tpaxell II 6POHXOB nplIHHTO pa3,UeJIHTb Ha:
. .. HrBbl6oKOB:bix nonepXHOCTeH, HaKlla,UbIBaeMbIe C uenbIO BoCCTaHOBJIeHIIH npoxo-
,nIIMOCTli ,nblXaTeJIbHbIX nYTeH. Ha.n06HOCTb B TaKHX nlBax B03H1IKaeT npli OKOHqaTOH II UlIp-
KynHpHoH pe3eKUliH Tpaxell II 6POHXOB, TpaxeOTOMHII, 6pOHXOTOMliH II .np.;
. .- lliBbI, HaKJIa,nblBaeMbIe Ha KYJIbTlO TpaXelI, 6pOHxa. fix IICnOnb3YlOT rrpH nynbMo-
H3KTOMIIH II pe3eKUIIII nerKIiX.
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HOKpRITOBble RITH cynpaMH,nHbIe HIITII (N!:! 0,1). Pe:>KYIUlie Hrnb! OCTaBnHlOT B CTeHKe oTBepcTIIH,
qepe3 KOTopbIe MO:>KeT npoHIiKaTb B03,nyx, n03TOMY BbI6IIpalOT KpyrnbIe aTpaBMaTlIqeCKlie. JJ.nH
179
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C03,naHIiH Ha.ue:>KHOH repMeTlIqHOCTH lliar IlIBa He ,non:>KeH npeBbllliaTb 3 MM.
IIoBpe)l(,D;eHIIH Tpaxell RITII 6POHXOB YllilIBalOT Y3JIOBbiMli lliBaMIi C 3aXBaTOM Bcex COCTaB-
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cepe,nIIHy,nellJeKTa HaKJIa,nblBalOT npoBH30pHbIH II -06pa3HbIH lliOB. Y,nep:>KIIBaH C ero nOMOIUblO
TKaHlI, nplicrynalOT K 3aIlIMBaHII1O nOBpe>K,L\eHIIH (puc, 24.2). CTapalOTcH 3aXBaTbIBaTb TOJIbKO Me:>K-
xpHllieBYlO qaCTb RITH :>Ke HIITb npoBo,UHT qepe3 eepe,UIIHY xpHIUeBoro Konbua. Y3JIbI3aBH3blBalOT
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PaccMoTpliM oc06eHHOCTH xlIpypmqeCKOH 06pa60TKII KYJIbTIi 6poHXa (TpaxelI). OCHOBHOH
npHHulin 06pa60TKII 3neMeHTOB KOpHH nerKoro - HaqHHaTb BMelliaTenbCTBO C 60nee ,noCTynHblx
yqaCTKOB.
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raTypbl 6pOHX npollilIBalOT (puc. 24.3). IIepHllJeplIqeCKIiH KOHeu 6poHxa IlJIIKCIIPYlOT 3a)l(IIMOM, no
6paHillaM KOToporo 6pOHX nepeceKalOT. IIpouecc 06pa60TKH 6poHXa cYIUecTBeHHo 06nerqaeT IIC-
nonb30BaHlie YWHBaTenH opraHoB. AnnapaTHoe npolliliBaHlie YHlIllJlIUlipyeT npoue.nypy.
OCTaBIlIYlOcH KYJIbTlO norpY:>KalOT B nO:>Ke y,naneHHoro eefMeHTa. EpoHXH 60JIbllierO ,D;IIaMeT-
pa YWIIBalOT nOCTeneHHO no Mepe IIX nepeCeqeHIIH. npli 3TOM cTeHKY 6poHxa Ha He60JIblliOM
npOTH:>KeHIIII pa3pe3alOT CKaJIbneJIeM. ,[{IICTanbHbIH KOHeu IlJIIKCIIPYlOT 3a:>KIIMOM lilllI 6poHxo,nep-
:>KaTemMH. Ha nepeCeqeHHbIH yqaCTOK HaKJIa.ublBalOT mOB CYUTa, npe,nCTaBnHlOIUIiH C060H OT-
,nenbHbIH Y3nOBOH mOB, 3aXBaTblBalOIUHH Bce CJIOH 6pOHXa (puc. 24.4). nOcJIe 3aBH3blBaHliH Y3-
nOB CTeHKY 6pOHxa Ha He60JIbiliOM yqaCTKe CHOBa nepeceKalOT. IIepeeeqeHHblH yqacToK YllilIBalOT.
Y3JIhI ,UOJI)I(Hhl pacnonaraTbCH Ha nepe,nHeH nOBepXHOCTIi KynbTIi. JIIIHMlO lliBOB nOKpbIBalOT Me,nlI-
aCTIiHallbHOH nJIeBpoH. He HY>K,L\aeTCH B nJIeBplI3aUliH JIlillib KynbTH neBoro rnaBHoro 6poHxa.
TaKoe nplIKpbITlie ,na:>Ke He :>KenaTeJIbHO 1I3-3a 6nlI3Koro pacnOnO:>KeHIIH 6ny)l(,D;alOll\ero HepBa.
)J;JIH 06pa60TKII KYJIbTH 6pOHxa IICnOJIb3YlOT TaK:>Ke llJOB MeTpa-Eoryma. CHaqalla 6pOHX
IlJIIKCIIPYIOT ,nBYMH 60KOBbiMli WBaMII-,nep)l(allKaMIi. IIo 6paHwaM HallO:>KeHHOrO 3a:>KIIMa 6POHXH
OTceKalOT. OqeHb y,n06HO ,nJIH YMeHbllieHIIH npY)l(lIHHIUIiX CBOHCTB npRITe:>KaIUlie xpHIUeBbIe Konbua
Ha,D.ceqb. 3aTeM HaKlla,D.blBalOT neplI6pOHXIIallhHbie lliBbl, He 3aXBaTbIBaH CJIH3IICTYlO 060nOqKY
....
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r ....,," ,
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t{: .. / !V
..
jf;; ......
Puc. 24.1 3aUluea1lue
mpaxeomoMHo2o pa3pe3a
Y3ROeblM UleOM
Puc. 24.2 3aUlueaHue He60RbUluX
O/(OH'wmblX ae,pezanoe cmeHKU mpaxeu
1l-06pa3HblM Y3ROeblM UleOM
180
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..-:. -
"1 . . . .. > ,
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.,-
. .
. . . ".. ....
-.. ' '"
Puc. 24.3 YUlueauue /(YRbmu
ceZMeHmapl/020 6poHxa
Puc. 24.4 moe Cyuma
Puc. 24.5 moe Mempa-EozYUla
6pOHxa. ,[{JIH 3Toro peKoMeH,nylOT Hcnonb30BaTb KaK II -06pa3Hble, TaK H Z-06pa3Hble lliBb!. IIpH
3aBH3blBaHIIII Y3JIOB He06xo,nIIMO CTpeMHTbcS! norpY3HTb Kpa51 KYJIbTIi 6poHxa BHYTpb era npocBera
(puc. 24.5). qT06bl nOBblClITb repMerHqHOCTb IlIBa, KYJIbTlO 6poHxa nOKpbIBalOT Me,nlIacTlIlmJIb-
HOH llJIeBpoH.
B cJIyqae He06xo,nHMOCTH HallO:>KeHUjI Me)K6pOHXHaJILHOrO aHaCTOM03a, coe,nHHS!eMble
KOHUbl npollilIBalOT Y3JIOBbIMli lliBaMIi qepe3 Bce CJIOII 6pOHXIIaJIbHOH CTeHKII. IIpH 3TOM CJIII3IIC-
TYlO 060JIOqKY cTapalOTcS! 3aXBaTblBaTb B CTe:>KKII MIIHIIMallbHO. 3TO npe,noxpaHS!eT OT HaCJIaIIBa-
HIIS! CTeHOK 6POHXOB ,npyr Ha ,npyra. OnTIiMallbHOe paccToS!HHe Me)l(,D;Y CTe:>KKaMIi IlIBa 3 MM. EOJIb-
lliee paccToS!HlIe cYIUecTBeHHo YMeHblliaeT ero repMeTlIqHOcTb. Y3JIbi 3aBS!3blBalOT cHapY:>KH,
Tpa,nIIUHOHHO YKYTblBaH IIX llJIeBpOH.
181
rJIaBa 24
TEOPHJI BhIIiOPOlfHOrO KOHTPOJIJI
.'>: :.
,, . .'
. >.....1,.". "!.
\ :. '
I1MeHHo B TOT e,D;IIHCTBeHHbIH 3a BeCb ,neHb MOMeHT, KOr,na Bbl OTKIIHY-
nHCb B Kpecne H paCCJIa6RITHCb, qepe3 KOHTOpy npOH.neT C 06XO,nOM 60cc.
llEPBhIH 3AKOHJ()J(OHCA
YqeHbrn, c,neJIaBIlIHH CYlUeCTBeHHblM BKlla,n B JI106ylO 06JIaC:Tb IICCne,nOBaHHH II npOJIOJI:>Ka-
lOlUliH pa60TaTb B HeH ,nOCTaTOqHO ,nonro, CTaHOBIITCSI 3,neCb KaMHeM npeTKHOBeHIIH nporpecca
npSlMO nponopUIiOHanbHO 3HaqlIMOCTli CBoero nepBOHaqanbHOrO BKlla,D.a.
3AKOH 3BAHCA
ECJIII Bbl coxpaHSIere ronOBY Ha lUIeqax, Kor,na Bce BOKpyr TepSllOT CBOII, 3Haq1IT, BbI npOCTO
He nOHHMaere cHryaUlIlO.
3AKOHhI (]JH3HKHJ(AHJI3llA
1. <1>aKT - 3TO oTBep,neBlliee MHeHlIe.
2. IIo,n ,neHcTBHeM BblCOKIIX TeMnepaTYP H ,naBJIeHIIH llJaKTbl pa3MHrqalOTCjI.
3. IIpaBJIa 3JIaCTlIqHa.
PEllIEHHE XAJIrPEHA
EcnH Bbl nonanli B npocaK, HanycKaHTe ryMaH.
3AKOH lfJIEHJ(A
PeilieHlIe CnO:>KHOH 3a,naqlI noPyqaHTe neHHBoMy COTpy,nHIIKY - OH HaH,neT 60JIee JIerKHH
nYTb.
A (]JOPH3M KOXP3HHA
IIonyqaH HanpaBneHHe Ha aHaJIH3, no,nYMaHTe, qTO Bbl npe,nnpHMeTe, eCJIH pe3YJIbTaT OKa-
:>KercSI: a) nOnO)l(lITeJIbHbIM; 6) oTpnuaTeJIbHbIM. ECJIH OTBeTbl cOBna,D.YT, Ha,D.06HOCTb B aHanH3e
OTna,naeT.
KOMMEHTAPHH JIOPJ(A K03HA
)J;ocTynHocTb onepaQIIH - ell{e He nOKa3aTeJIb Toro, qTO ee Ha,D.O ,nenaTb.
, . " ,
i
182
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:t: w,,>.... ;.......
.J p,.,..
;. :?
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,""
.-I<'{.,O:
,..g.."..- <'
B CJIyqae He06xo,nHMOCTH HanO:>KeHIISI IlIBOB Ha cep.nue Bce MepOnpHHTIISI: Hy:>KHO OCYIUeCTB-
nHTb MaKCHManbHO 6b1CTpO. ,[{JISI 3Toro Bbl6IIpalOT HaH60JIee npOCTble onepaTHBHble ,nocTynbI -
nepellHe60KOBYlO roplI30HTanbHYlO TopaKOTOMlIlO no qeTBepTOMY IIJIH DHTOMY Me:>Kpe6epblO OT
KpaSi rpy,nHHbl,nO 3a,D;HeH no,nMbIllieqHOH JIHHIIH. IIepHKap,n, KaK npaBRITO, BCKpblBaIOT npOllOJIbHO.
Ycnex onepaUHH HanpSlMYlO 3aBliCliT OT KaqeCTBeHHoro OCMOTpa nOBpe)l(,D;eHHOrO opraHa.
IIpH 3TOM 06H3aTeJIbHbiM S1BJISIerCH OCMOTp 3a,D;HeH ero creHKH- ,[{JISI 3Toro OCTOpO:>KHO npHnO,D;HII-
MalOT II BblBO,D;HT H3 nOJIOCTII nepHKap,na. Ba)l(HO nOMHIITb, qTO CJIIIIlIKOM :meprmHoe npHnO,D;HlIMa-
Hlie qpeBaTO ero OCTaHOBKOH 1I3-3a neperlI6a COCy,nOB.
PeBII3IISI COCTOHHIISI paHbl He06xo,nIIMa .D:JIH oueHKII 06'beMa nOBpe)l(,D;eHIIH H Bblpa60TKII
nJIaHa ee 3alliIIBaHHH, TaK KaK BCHKoe nOBpe)l(,D;eHlIe MHOKap,na Tpe6yer BOCCTaHOBneHHH aHaTO-
MlIqeCKOH UeJIOCTHOCTIi. ,[{a:>Ke 06HapY:>KHB HenpOHIIKalOll{ee nOBpe)l(,D;eHHe MHOKap,na, He conpo-
BO)l(,D;alOll{eeCSI KpOBOTeqeHlIeM, paHY Bce-TaKIi CJIellyeT 3alIIlITb. 3TO CHII:>KaeT pHCK BTOplIqHOrO
KpOBOTeqeHIIH II 06pa30BaHHSI aHeBplI3Mbl.
AnroplITM xlIpyprlIqeCKIiX MaHlInynHUHH HII B KoeM cnyqae He npe.nyCMaTpliBaer HCCeqeHlIe
KpaeB paHbl. 3m npoue,nypa, 06blqHO npHMeHHeMaSi Dpli 06pa60TKe paH B ,npyrlIx 06JIaCTSIX XIIPYP-
rnlI, npH paHeHlInx cep,nua He,nonycTIIMa!
Bblpa6aTbIBaH llJIaH 3alliliBaHliSi paHbl cep.nua, CJIe,nyeT OrpaHlIqlITbCSI MIIHIIManbHblM KO-
JIlIqeCTBOM IlIBOB. 3TO MOTIIBIiPYeTCH CJIO:>KHbIMIi IlJYHKUHOHaJIbHbIMIi II rliCTOJIOrlIqecKliMIi oco6eH-
HOCTHMII 3Toro opraHa.
HanO:>KIITb IlIBbl Ha IlJYHKUHOHHPYlOll{ee cepllue, oco-
6eHHo B ycnoBIIHX IIHTeHCIIBHoro KpOBOTeqeHIIH, TeXHlIqeC-
KII ,nOBonbHO CJIO:>KHO. II03ToMY cep,nue Ha BpeMH, He06xo-
,nIIMoe,D;JIH npoBe,neHIIH onepaTHBHoro nplieMa, IlJIIKCIIPYlOT.
,ZJ;JISI 3Toro KpaH pa3pe3a nepHKap,na y,nep:>KHBalOT 3a:>KIIMOM
H OCTOpO:>KHO no,nTHrlIBalOT Knepe,nlI. AHanOrlIQHoro 31lJ1lJeK-
Ta MO:>KHO ,nOCTII%, IlJIIKCHPYH cepllue qeTblpbMSI nanbuaMIi
neBoHPYKIICOCTopoHbI3a,nHeHcTeHKII (puc. 25.1). IIpliHe-
06XO,nHMOCTIi cB060,nHbIM 60JIblliliM nanbueM MO:>KHO OCTa-
HOBIITb KpOBOTeqeHHe, 3anlIBalOll{ee paHY. Bo BpeMH 3alliH-
BaHIIH paHbl xlIpypr npaBoH PYKOH HaKlla,D;blBaeT lliBbl, a
aCCIiCTeHT IIX 3aBSl3blBaeT.
Bbl60p lliBa 3aBHCHT OT nOKaJIH3aUliH II pa3MepOB Puc. 25.1 t!>uKcal/UR cepal/a lIemblpbMR
nOBpe)l(,D;eHIIH. TaK, npli He60nbIlIIIX pal/ax npeocepoUR npH- nallbl/llMU lleeoil PYKU co cmOpOHbl 3aaHeU
v cmeHKu, EOllbUiUM nallbl/eM M03ICHO
MeHHlOT ,nOBOJIbHO repMeTnqHbIH KlICeTHbIlI IlIOB. JIHHeHHble >
oCY/ilecmeJIRmb npu3ICamue paUbl <lJIR
paHbl npe,ncep,nHH 3aIlIIIBalOT y3JIOBbiMli lliBaMII, KOTopble .
epeMeHHOU ocmaHoeKU KpoeomellellUR
183
rJIaBa 25
npoxo,n5!T qepe3 BClO TOJIll{Y CTeHKII. OHII npocTbI, Ha,ne:>KHbl
II, qTO HeManOBa:>KHO, 6blCTpO HaKlla,nblBalOTCH. lllar IlIBa B
0,5 CM 06eCneqHBaer Ha.Qe:>KHOe conpliKocHoBeHlIe KpaeB
paHbI 6e3 pliCKa B03HIIKHOBeHHH ,nlIaCTa3a B npOMe:>KYTKax
Me)l(,D;Y CTe:>KKaMIi.
Bo BpeM5! 3aBH3bIBaHliH Y3JIa, KpOMe repMeTlIqHOC-
TII, He06xo,nIIMO ,n06IIThc5! BbIBOpaqlIBaHII5! CTeHKII npe,ncep-
,nIIH II conpliKocHoBeHIIH KpaeB paHbI BHYTpeHHIIMIi 060JIoq-
KaMIi. ll03TOMY ,nJIH 3TOH ueJIIi MO:>KHO IICnOJIb30BaTb
Puc. 25.2 llpu 3l1a'lUmellbllblX pa3MepaX 06BHBHOH BbIBOpaqlIBalOIUIiH IlIOB npeJICep,lllIH.
TexHIIKa 3aIlIIIBaHIIH paHLI )KeJIy,nO'IKa onpe,neJIHeT-
C5! 06'beMOM, 1lJ0PMOH.1I my6IIHoH nOBpe)l(,D;eHIIH. Ho B JIlO-
60M cnyqae lliOB ,nOJI:>KeH npoxo,nHTb qepe3 BClO TOJIll{Y MIIO-
Kap,na, He npOHIiKaH B nOJIOCTb cep,nua. PaHY:>KeJIy,nOqKa
YIlIHBalOT OT,neJIbHbIMH Y3JIOBbIMli IlIBaMlI, KOTopble 3aB5!-
3bIBalOT no Mepe IIX HanO:>KeHII5!. IIpOKOJI HrJIOH CTapalOTC5!
c,neJIaTb O,nHIIM ,nBII:>KeHlIeM, 3aXBaTblBa5! o,nHOBpeMeHHO
.npyroH KpaH paHb!. IIpli BbIpa:>KeHHOM KpOBOTeqeHlI1I ueJIe-
co06pa3HO HanO:>KIITb Ha paHY 1-2 II -06pa3HblX lliBa. llocJIe
3Toro IICnOJIb3YlOT OT,neJIbHble Y3JIOBble IIJIH HenpepblBHble
IlIBbl (puc.25.2).
Bo Bcex CJIyqaHX He06xo,nHMO B03,nep:>KaTbCH OT IIC-
nOJIb30BaHII5! HeMIiHyeMo npOpe3alOll{HXC5! KpeCT006pa'3-
HbIX (8-06pa3HbIx) IlIBOB.
IIpH HaJIO:>KeHlIIi IlIBOB Ha CTeHKY cepJIua B CTe:>KOK
HeJIb3H 3aXBaTbIBaTb KpynHble HenOBpe)l(I(eHHbIe BeTKII KO-
pOHapHbIx apTeplIH, TaK KaK 3TO Bbl3blBaeT HeKp03 CTeHKII
MHoKap,na. II-06pa3Hble IlIBbl C npoBe,neHlIeM HIITII no,n YKa-
3aHHbIMH cocy,naMIi nOMorYT 1I36e:>KaTb 3TOro OCJIO:>KHeHH5! (puc. 25.3).
npliMeHeHHe HepaccacbIBalOIUerOc5! llIOBHoro MaTeplIaJIa IICKlllOqaer Bep05!THOCTh paCXO:>K-
,neHIIH KpaeB paHbl,no nOJIHOrO 1lJ0pMlIpOBaHII5! npOqHOro py6ua. l1,neaJIbHbIM MeTo,nOM BOCCTa-
HOBJIeHH5! KpoBOCHa6:>KeHIISI: MlioKap,na npH nOBpe)l(,D;eHHII KopoHapHoH apTepliH IInH ee KpynHbIx
BerBeH HBJIHeTCH COCy,nIICTbIH IlIOB. I1Hor.na nepepe3aHHbIe KOHUbl COCYJIOB nepeBH3blBalOT II 1lJ0p-
M'lIPYIOT 06XO,nHOH aOpTOKOpOHapHbrn lliYHT. B KaqeCTBe npoTe3a qaIUe IICllOJIb3YIOT aYToBeHY.
rnaBHaH Tpy,nHOCTb, C KOTOpOH nplI,D;eTC5! BCTperlITbcH HeonblTHoMY xlIPYPry npli npOIlIHBa-
HHH paHbI cep.nua, - npope3bIBaHHe HaKlla,D.blBaeMbIX llIBOB. HalI60JIee qaCTO 3TO CBH3aHO C
TeXHHqeCKIiMIi norpeiliHOCTHMH - HeyMeJIbIM 3aTHrlIBaHlieM IIJIH qpe3MepHbIM HaTH:>KeHlIeM IlIBOB.
II03ToMY 3aBH3bIBaTb lliBbl HY:>KHO C 60JIbiliOH OCTOpO:>KHOCTblO, CTHrlIBaH HX nOCTeneHHO. EcnlI
npope3blBaHliH IlIBOB 1I36e:>KaTb He y,naeTC5!, - ueJIeC006pa3HO HaJIO:>KIITb II -06pa3HbIe IlIBb!. I1x
MO:>KHO YKpenlITb npOKlla,D.KaMli H3 llJacUlIII, nOCKYTaMIi nepHKap,na, MbllliUbI II ClIHTerlIqeCKOH TKa-
HII (KanpOHa, TellJJIOHa H,np.).
IIocne Toro, KaK paHa cepJIua 3alliHTa, He06xo,nHMO y6e.QIITbCH B OTCYTCTBIIII ,npyrlIx no-
Bpe:>KlIeHHH H TluaTeJIbHO OqlICTIITb nonOCTb neplIKap,na OT KpOBIi H crYCTKOB. Bo 1136e:>KaHlie
B03HHKHOBeHH5! TaMnOHa,nbl cep,nua npli Henpe,nBII,neHHbIX KpOBOTeqeHIIHX, neplIKap,n YlliHBalOT
pe,D;KHMII Y3JIOBbIMH IlIBaMII, Hcnonb3Y5! paccacblBalOll{lIeCH HHTH.
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: :i {;': S':':\'
paHbl u eblpa:JKell1lOM KpOeOme'leHUU
npI/MeHJllOm 1l-06pa3llb/e Ulebl. Me:JKay
HI/MU HaKllaiJb/ealOm OmaellbHble
Y3JWebie WlU Henpepbl6Hble Ul6bl
Puc. 25.3 Hcnollb30eaHue 1l-06pa3l1bIX
Uleoe c npoeeiJeHueM Ilumu noa KpynHblMu
HenOepe:JICaeHHblMU eemKClMU KopoHapllblx
apmepuu nOMO:JICem U36e:JICamb HeKp03a
Cn1eHKU MUOKapaa
184
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J!P ,EH W ..POBA811E
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.6PIDmHOB nOJ1:QCTH"
rJIaBHaH 3a,naqa, KOTOpylO npeCne,nyeT xlIpypr npli ,npeHlIpOBaHIiH 6plOiliHOH nOnOCTH,-
3TO BbIBeJIeHlIe H3 Hee :>KIIJIKOrO CO,nep:>KHMoro. AAA 3TOH ueJIIi IICnOnb3yIOT xnpyprnqeCKIiH ,npeHa:>K
(CneUHaJIbHble Tpy6KII, BBe,neHHble B 6plOlliHYlO nOJIOCTb) II 1lJ1I31I0JIOrHqeCKHH ,npeHa:>K (Mepbl,
HanpaBJIeHHbIe Ha YCRITeHHe BCaCblBaHHH 6plOIlIIIHOH).
<D1I31I0nOrlIqeCKIiH ,npeHa:>K BKJIlOqaeT, C O,nHOH CTOpOHbl, npliMeHeHlIe Cna6HTeJIbHblX
Cpe,nCTB, c ,npyroH - onpe,neneHHble nOnO:>KeHH}J 60JIbHOrO B nOCTeJIIi. CJIa6IITenbHbie Cpe,nCTBa,
YCRITIiBaH nepliCTaJIbTlIKY KHllIe lIKa, HHlIUHIIPyIOT YCRITeHlIe BCaCbIBaHIiH :>KIIJIKOCTH. IIpHno,nHHB
HII:>KHlOlO qaCTb TYJIOBIIll{a, y,naeTCH 06eCneqHTb paClIpe,neJIeHlIe II BCaCblBaHlie :>KlI.D:KOCTH Ha 60nb-
IlIeH llJIOll{a.D:H 6plOllilIHbI. IIepeqlICneHHble HanpaBJIeHIIH YCRITeHHH 1lJ1I31I0nOrlIqeCKOrO ,npeHlIpO-
BaHIIH, HeCOMHeHHO, OqeHb nOJIe3Hbi H ,neHcrBeHHbl. 06 3TIIX MepOnplIHTlIHX CKa3aHO JIOCTaTOqHO.
CqlITaeM ueJIeC006pa3HbiM paccMoTpeTb B HallieH KHHre npaBRITa II MeTO,D;b1 BBe,neHHSI B 6plOllI-
HYlO nonOCTb HaCTOHll{ero (xlIpyprnqeCKoro) ,npe-
Ha)l(a.
<l>yHKuHoHlipoBaHlie xnpyprnqecKOrO ,npeHa-
:>Ka ,nOCTliraeTC}J ,nBYMH ycnoBIIHMII: Bo-nepBblX,
,neHcTBHeM BHYTPlI6plOiliHoro ,naBneHIIH, 6e3 qero
:>KII.D:KOCTb He MOrJIa 6bl no,nHHMaTbCH BBepx (Ha-
npliMep, 1I3 ,[{ymacoBoro npOCTpaHCTBa), BO-BTO-
pblX, npe,nnonaraeMbIM H3MeHeHIIeM cep03HbIX
nOTOKOB B 6plOlliHHe. Y CIIJIeHHe BJIHHHlIH 060lIX
3TIIX MOMeHTOB MO:>KHO ,nOCTII% COOTBeTCTBYlOlUliM
nOJIO:>KeHHeM TYJIOBHIUa II 31lJIlJeKToM coe,nIIHeHHblX
COCy,nOB. Pa3HHua Me)l(,D;y ypOBHeM :>KII.D:KOCTII B
6plOlliHOH nOJIOCTIi II KOHUOM ,npeHa:>Ka n03BOJISIeT
eH J];BlII'aTbCH Hapy:>KY. 0 TOM, O BHYTplI6plOlliHoe
,naBneHlIe YBenlIqHBaeTCH B nonyCIIJJ:j{ll{eM nonO:>Ke-
HHII, MO:>KHO 6blII He rOBoplITb, 3TO nOHHTHO caMO
C060H.
,ZJ;aBHO no,nMeqeHO, qTO MeCTa CKOllJIeHIIH
:>KIIJIKOCTH np}JMO 3aBHCHT OT aHaTOMHqeCKHX OCO-
6eHHOCTeH npoCTpaHCTB 6plOiliHOH nonocm. B 3TIIX
npOCTpaHCTBaX :>KH,1U(OCTb MO:>KeT nerKO 3aCTaHBaTb-
CH H n03TOMY OHII ,non:>KHbl,npeHHpOBaTbCSI:.
06nacm, rJIe MO:>KeT nOTpe60BaTbCH IIcnOJIb-
30BaHlie ,npeHa:>Ka B BepXHeM OT,neJIe 6plOiliHOH
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Puc. 26.1 peHupo6llHUe 6p1Oumou
nOJlocmu npu ZHOUHOM naHKpeamume.
OCJlO3ICHeHHOM nepumoHumoM
185
rJIaBa 26
nonOCTH, - 3TO HII:>KHHH nOBepxHocTb ,nlIallJparMbl BnpaBO II BJIeBO OT 1ig. rotundum II nepe,nHHH
nOBepxHocTb :>KeJIy,nKa. B cpeJlHeM OTJIeJIe - 06e nOqeqHble Bna,nIIHbl. HaKoHeu, BHII3Y - .o6e
fossae i1iacae H nOJIOCTb MaJIoro Ta3a (puc. 26.1).
TIOHHTHO, qTO Bce BbIllie onHcaHHble ,npeHa:>K1I o,D;HOBpeMeHHo nplIMeHHlOTcSI ,nOBOJIbHO pe,n-
KO. 06blqHO IICnOJIb3YlOT JIHilib HeCKOJIbKO 1I3 HIIX. ,[{peHlIpoBaHlie BceH 6plOlliHOH nOJIOCTH JIerKO
npe,ncTaBIiTh TeOperlIqeCKH, HO Tpy,nHO oCYIUecTBIITb npaKTlIqeCKH. BCKope, ,npeHa:>K OKa3blBaeTCH
oKpY:>KeHHbiM OTrOpa:>KIIBalOIUIiMIi cpaIUeHIIHMII H JIO:>KHbIMH 060nOqKaMH, a :>KIIJIKOCTb, BbITeKaIO-
ll{aH 1I3 Hero, C06IIpaeTCH BOBce He co BceH 6plOlliHOH nOJIOCTlI, a TOJIbKO C 6mI:>Kafunlix K ,npeHa:>KY
ee OT,neJIOB IIJIII ,na:>Ke co CTeHKII ,npeHlIpyeMoro KaHana. Oc06eHHO, eCJIIi ,D;JIH ,npeHlIpOBaHIiSI He
HCnOJIb3YlOT cneUlIanbHble .npeHa:>KHble Tpy6KII. I1CnOJIb30BaHlie no,npyqHOrO MaTepliana (HanplI-
Mep, Tpy6KII OT CIiCTeMbl,D;JIH BHYTplIBeHHoro BBeJIeHIIH npenapaTOB C npo,neJIaHHblMIi HO:>KHlIuaMIi
ornepCTHHMH) (puc. 26.2) He COBceM paunOHanbHO, Y,n06HbIe,D;JIH ,npeHlIpOBaHIiH paH KO:>KII, KJIeT-
qaTKH, MbIIlIL{ II T.n., OHII He COBceM npHro,nHbl,D;JIH IICnOJIb30BaHHSI B 6plOiliHOH nOJIOCTIi. OnblT
nOKa3an, qro B OTBepCTHH TaKOrO .npeHa-
:>Ka BCKope nona,nalOT CKJIa,nKH 6plOllilI-
Hbl, CaJIbHHK H rpaHynHL{IIH, 3aKynoplI-
BaH IIX. JIO:>KHbIe 060JIOqKII II
llJIaCTHqeCKaH JIIIMllJa TO:>Ke JIerKO 06pa-
3ylOT np06KH. OHH nepeKpbIBalOT OTBep-
CTHH II nperulTCTBYlOT pa60Te .npeHa:>KHOH
CIiCTeMbI. 113BneKaH TaKOH ,npeHa:>K, cy-
ll{eCTByer onaCHOCTb nopaHIITb 6plOIlIII-
HY, TaK KaK npli 3TOM pa3pYilialOTCH CBe-
:>KlIe OTrOpa:>KIIBalOll{lIe Cpall{eHHH. B
3TOM cnyqae nOHBnHeTCSI pliCK cnpOBO-
unpOBaTb KpOBOTeqeHlIe. rJIaBHaH onac-
HOCTb KOToporo - C03JIaHlie 6JIarOnpH-
HTHOH Cpe,D;bI,D;JIH 6aKTep1iH.
IIo,n06Hble Hey,n06cTBa 3aCTaBH-
JIll OTKa3aTbCH OT IlIlipOKoro IICnOJIb30-
BaHliSI «no.npyqHOro» ,npeHa)l(a. B nocne-
,nHee BpeMH Bce qaIUe npliMeHSIlOT
.npeHa:>KHbIe Tpy6KII co cneL{lIaJIbHO no-
,n06paHHb1M ,nlIaMeTpOM OTBepCTIiH. KO-
TopbIe HII canbHIIK, HH rpaHynHUHII ne-
peKpblTb He MOryT.
Hepewo MOJIO,nbIX xnpyproB HH-
Tepecyer Bonpoc: B KaKIiX CJIyqaHX He06-
XO,nIIMO ,npeHlIpoBaTb 6plOlliHYlO no-
JIOCTb? IIonynHpHoe Kor,na -TO
Bblpa:>KeHne - «Kor,na COMHeBaellibCH,
,npeHHpYH», cero,nHH 3aMeHeHO ero aH-
TIITe30H - «Kor,na COMHeBaeIlIbCH, He ,npe-
Puc. 25.2 HCnOJlb30eallue aJlJl apeHa:JICa mpy6Ku om cucmeMbl aJlfl HIIPYH». COBepIlIeHHO OqeBIIJIHO, qTO 3Ta
6HympUBeHHozo eeeiJeHufl npenapamoe c npOaeJlaHi/blMU npoue.nypa HBnHeTCH BMeillaTenbCTBOM
HO:JICHUlJaMU omeepcmWIMu
n .
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186
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'/ 1 . '.'.:. - y /, .' I
. . : :' J:: I
Wi. >., h
.-",,"
He6e30naCHbIM. ECJIII B03MO:>KH0 - nyqIIle 060HTliCb 6e3 Hee. COBepllIeHHO rna,nKoe, RITII, KaK rOBO-
pIITCSI, acellTlIqeCKOe TeqeHlIe nOCJIeonepaUHOHHoro neplIo,na npH ,npeHa:>Ke BPM JIll B03MO:>KHO. B
TO:>Ke BpeMH, XOTHM no,nqepKHYTb: MaprlIHanbHble B3rJIH,D;b1 Ha ueneco06pa3HOCTb npliMeHeHIIH
.npeHa)l(a B xnpyprlIH He ,nonyCTIiMbI. 0,n1IH H3 caMbIX 1I3BeCTHblX XIIpyproB npOllIJIoro JIOYCOH T eil:JI
(1892 r.) 0 3HaqeHIIII ,npeHa:>Ka npli onepaUIISix Ha 6plOiliHOH nOJIOCTII rOBOpRIT TaR: «Koma KaKOH-
HlI6y,nb aBTop rOBopHT, qTO OH HIiKOrI{a He Moer 6plOlliHYlO nonOCTb II He HY:>K.D:aeTCSI B ,npeHa)lffiX, H
npIIXO:>KY K 3aKJIlOqeHHlO, qTO OH TepHeT Te cnyqalI, KOTOpble H cnacaIO, II nplInIICblBaer CBOII pe-
3YJIbTaTbi BceMoryIUIiM 3apO,D;bIIlIaM». 3T0 MHeHlIe 3HaMeHHToro B npOllIJIOM aHrnIIHCKoro XlIpyP-
ra, nO-BII,D;IIMOMY, H cero,nm He YTpaTRITO CBoeH aKTyaJIbHOCTII, XOTH npOIlIJIO Y:>Ke 60JIee ,nBYX Be-
KOB.
B HaCTOSlll{ee BpeMH, nOKa3aHliH K MHTeJIbHOMY IICnOnb30BaHlilO ,npeHa:>Ka B 6plOiliHOH
nOJIOCTII orpa eHbl:
- Kor,na eCTb COMHeHHSI B TOM, qTO OCTaHOBKa KpOBOTeqeHlISl6y,neT ycneiliHoH RITII eCJIIi eCTb
onaCHOCTb nOBTopHoro. HeCOMHeHHO, TaKlie CJIyqalI He JIOn:>KHbl HMeTb MeCTO B npaKTHKe xlIpypra
Bo06ll{e, HO, K CO:>KaneHlIlO, OHII XOTb II OqeHb pe,nKo, HO BCe:>Ke BCTpeqalOTcH. MHbIMIi CnOBaMlI, 3TO
He06xo,D;IIMO ,neJIaTb B ycnOBHSI:X, KOTOpbIX :>KeJIaTeJIbHO II B03MO:>KHO 1I36eraTb. KpaHHe Ba)l(HO TaK
:>Ke 06paTIITb BHIIMaHlie Ha TO, qTO CYll{eCTByer qpe3BblqaliHaH onaCHOCTb B03HIIKHOBeHIIH nocne-
,nYlOll{erO BocnanHTenbHoro npouecca, ,nOBonbHO qaCTO COnpOBO)l(,D;alOll{erO ,npeHIIpOBaHlie BCH-
KOro KpOBOII3JIIIHHIIH;
- ecnlI eCTb OCHOBaHIIH npe,nnOJIO)l(lITb, O 6plOIlIliHa RITH ee qaCTb Y:>Ke IIHIlJIIUlipoBaHa, II
YCTpaHIITb BJIIISlHlIe IIHllJeKunoHHoro areHTa K MOMeHTY 3aBepllieHIIH onepaUlI1I He npe,nCTaBJISleT-
CSI B03MO:>KHbIM. ClO,na OTHOCHTCH onepaTHBHble BMeIlIaTeJIbCTBa, npOBe,neHHbIe no nplIqHHe paHe-
H1IH KIIIlIeqHIIKa RITII ,npyrlIx BHYTpeHHOCTeH, 1I3JIIITliH BIIpyneHTHoro rHOH H T.n. ,[(aHHaH rpynna
nOKaJaHHH npHMO 3aBliCliT OT cy6'beKTIIBHOH oueHKII cliryaUHH xlIpyproM, era IIHTepnpeTaUHII pa3-
JIlIqHbIX ,neTaJIeH H ycnoBIIH, Ha KOTOpbIX 3TH nOKa3aHliH OCHOBaHbI.
TeXHIIKa ,npeHlIpOBaHIIH npOCTa. IIocne COOTBeTCTBYlOll{eH 06pa60TKII aHTlicenTIiKOM MeCTa
BBe,neHHH ,npeHa:>Ka Ha KO:>Ke npOII3Bo,nIITCH He60JIblliOH pa3pe3. Co CTOpOHbl 6plOlliHOH nonOCTIi
pe3KIIM ,nBII:>KeHlIeM 3a:>KIIM BblBO,nHTCH B npo,neJIaHHOe OTBepCTIIe. EpaHllili 3a)l(lIMa nOMell{aIOT B
npOCBeT ,npeHa:>KHblX Tpy60K. B COMKHYTOM COCTOHHHII 3a:>KIIM BblBO,D;HT B 06paTHOM HanpaBJIeHIIII.
,ZJ;peHa:>K pa3Mell{alOT B 06nacTII, Tpe6YlOIUeH ,npeHlIpOBaHIiH. 3aTeM paHY KO:>KII 3alliHBalOT, a KOH-
uaMIi HIITKH IlJIIKCIiPYlOT .npeHa:>KHble Tpy6KII OT Bbma,neHIIH.
ECJIH B ,npeHa:>Ke 60nbille HeT He06xo,nIIMOCTH, ero BblHHMaIOT, npe,nBapHTeJIbHO nepe:>KaB
Tpy6KH 3a:>KIIMOM. 3TO npe,noxpaHHeT OT nona,naHIIH co,nep)l(lIMOrO Tpy60K 06paTHO B 6plOlliHYlO
nOJIOCTb.
Y :>KeHll{IIH 6plOlliHYlO nonOCTb B03MO:>KHO .npeHlIpOBaTb qepe3 KonbnOTOMHbIH pa3pe3. IIoc-
ne 06Ha)l(eHIIH llieHKII MaTKII BarliHanbHbIMIi 3epKanaMII, ee IlJHKCIiPYlOT 3a 3a,D;H101O ry6y. B ueHTpe
3a,nHero CBo,na BnaranlIll{a CKanbneJIeM ,neJIalOT He60nbilioH pa3pe3, qepe3 KOTOpbIH BBO,nHT ,npe-
Ha:>KHble Tpy6KII B ,[(yrnacoBo npocTpaHcTBo. ITocne H3BJIeqeHHSI TaKoro ,npeHa)l(a paHa 3a:>KIIBaer
caMOCTOHTeJIbHO.
187
rJIaBa 26
3AKOH IlIHPJIH
EOJIbIlIIIHCTBO JIlO,neH ,nOCTOHHbI .npyr ,npyra.
\ ' -: : " :."
3AKOHhI JIIOEBH, IIPEPJIO}J(EHHhIE APTYPOM
1. JIlO,nH, K KOTOpblM Bac BneqeT, HeH3MeHHO .D;yMaIOT, o BbllIM Koro-
TO HanOMIiHaere.
2. ECJIII Bbl HaKOHeU-TO OTBa:>KRITIiCb oTnpaBHTh n1060BHoe nIICbMO, TO OHO TaK ,nonro 6y,neT
H.D:TII no nOqTe, qTO Bbl 3a 3TO BpeMH ycneeTe BblCTaBIITb ce6S1 Ha nOCMeIlIHlue.
3. POMaHTIIqeCKlie :>KeCTbl,npyrnx Ka:>KYTcH He06blqHblMH H BOJIHYlOIUIIMH. A BailllI c06CTBeH-
Hble - rnynbIMIi H HeYKJIlO)l(IIMH.
3AKOH CBApEEHhIX 3A TP AT
npO,non)l(lITeJIbHOCTb 6paKa 06paTHo nponopUHoHanbHa pacxo,naM Ha cBa,nb6y.
IIPHHI.JHII IIEPECEKAIOIlJHXCJJ 3HAKOMbIX
BepOHTHOCTb BCTpeTIITb npHHTeJIeH B03pacTaeT, ecnlI Bbl H.D:eTe C nepcoHoH, 3HaKOMCTBO C
KOTOpOH BaM He XOTenOCb 6bl a4JHllIlipoBaTb.
IIEPBbIH IIOCTYJIA T IIAPPO
Bee, qTO eCTb xopoiliero B :>K1I3HH, nlI60 He3aKOHHO, nlI60 aMopanbHo, JIII60 Be,neT K o:>KHpe-
HlIlO.
3AKOB OTHOCHTEJIbHOCTH E'3JIJI'3HCA
npO,nOJI:>KHTeJIbHOCTb MHHyTbl3aBliCIIT OT Toro, no KaKYlO CTopoHY,D;Bepli B BaHHylO KOMHa-
TY BbI Haxo,nIITeCb.
IIPABHJIOEPHTTA
BepOHTHaH npo,nOJI)l(IITeJIbHOCTh :>KII3HH KOMHaTHoro paCTeHIIH 06paTHo nponopUlioHanbHa
ero L{eHe II npSlMo nponopUHoHanbHa ero HenpHBJIeKaTenbHoMY BH.D:Y.
AKCHOMA KAHA
ECJIII HHqTO ,npyroe He nOMorae-r, npOqTIITe, HaKOHeL{, HHCTpYKl{HIO.
. .
188
e_
II
;; :":,,.'
OCHQ1J l
,,'<3 9CKOnl1qECKOH XMP prMM
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rntma 21
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.
,:"",!l
...._ .. ._.--.....-... ""...
v_
.._ .:..:.:
........._....'.. ...._:i': ., _..... .. ......M
C03.l{AHllE nHEBMonEPllTOHEYMA
HaqanbHblM 3TanOM JIanapOCKOnlIqeCKOrO BMellIaTeJIbCTBa HBJIHeTCH C03,naHHe nHeBMO-
nepliTOHeYMa. JJ.nH 3Toro no BepXHeMY KpalO nynOqHoro KOJIbua nonYOBanOM KO:>KY nepe.D:HeH
6plOllIHOH CTeHKII Ha,nceKalOT CKanbneJIeM. ,ZJ;JIHHa pa3pe3a KO:>KII (B cpe,nHeM 1 - 1,5 CM) 3aBliCliT
OT BeJIlIqlIHbl npe,nnOJIaraeMoro MaKponpenapaTa, ero 1I3MeHeHIIH (HanpIiMep, BOCnanHTeJIbHbIX),
,nlIaMeTpa HCnOJIb3yeMoro TpoaKapa H Bblpa:>KeHHOCTH no,nKO:>KHOH KJIerqaTKH. Y 60JIbHbiX C
O:>KlIpeHlIeM KO:>KY B KOHue onepaUHII npHxo,nIITCH pacceKaTb nmpe ,D;JIH cB060,nHoro ,nocTyna K
anOHeBp03Y npli ero 3alliIIBaHHH.
IIocne npe,D;BaplITeJIbHOrO nplmo,nHIIMaHIIH nepe,nHeH 6plOlliHOH CTeHKH C nOMOll{blO IIrJIbl
Bepellia RITII raHca-OCTIiHa npOII3BO,D;HT nYHKUlilO 6plOlliHOH nOJIOCTH. TeXHlIqeCKaH oc06eHHOCTb
3TIIX HrJI n03BOJIHeT c,neJIaTb :no C MIIHIIManbHblM pliCKOM TpaBMlIpOBaHHa BHYTpeHHIIX opraHOB.
IIocJIe npOKOJIa MHrKHX TKaHeH nepe,nHeH 6plOlliHOH CTeHKII, anOHeBp03a OCTpblH KOHeU, npH no-
na,naHIIII B CB060,nHYlO 6plOlliHYlO nOJIOCTb, caMonpOlI3BOJIbHO TpaHcIlJopMIIPycrCH B rynoH.
IIpH npOH3Be,neHHII nYHKUHII IIrJIy y,nep)l(lIBalOT Me:>K.D:Y 60JIbllIliM II YKa3aTeJIbHbIM nanbua-
MH. BBe,neHlIe B TKaHIi OCYll{eCTBJIHlOT IICKlllOqlITenbHO ,nBII:>KeHIIHMH 3anaCTbH B HanpaBJIeHlI1I
nepneH,D;IIKymrpHoM no OTHOllIeHHlO K anOHeBp03Y (puc. 27.1). I1plI Hec06JIlOJIeHHII 3Toro YCJIOBHH
B03MO:>KHO npoHIIKHoBeHlIe HrJIbI B npeJI6plOlliHHHoe
npoCTpaHCTBo. B ,nanbHeHIlIeM, npH HarneTaHlIIi ra3a,
3TO MO:>KeT npliBecTIi K 3MIlJ1I3eMe npe,n6plOllilIHHOH
KlleTqaTKII (puc. 27.2). Bo BpeM1I BBe,neHIIH HrJIbl MH-
3HHeu H npe,nnJIeqbe npaBoH PYKII MorYT onlipaTbcH
Ha nepe,nHlOlO 6plOiliHYlO cTeHKY, npenHTcTBYSI:
qpe3MepHo rny60KoMY npoBany B 6plOllIHYlO nOJIOCTb.
Ha nyTH IIrJIbI He06xo,D;IIMO ,D;Ba)l()U>1 nOqyBCTBoBaTh co-
npoTHBneHlIe: npli npoXO)l(,D;eHHH CKB03b anoHeBp03
II 6plOllIIIH)'.
Bo BpeMHBBe,neHHH KllanaM llrJIbI,nOJl)l(eH 6blTh OT-
KpbITbIM. 3T0 n03BOJIHT oJ:UYTllTh <<npOBaJI» npH nona,na-
HIIII ee Ko a B CB06o.D;HylO 6plOIlIH)'lO nOJIOCTh.l1Hor,na
MO:>KHO YCJIblIlIaTb ll{eJI<lOK nO,D;BlI:>KHoro MaH,D;peHa II xa-
paKTepHoe llIHlleHlIe BO:myxa, BCaCbmaeMoro B 6plOllIHYIO
Puc. 27.1 TexlIUKa nYHKlluu 6plOumou nonocmu
nOJIOCTh. TIp:wnrna3TOro HBJIeHIIH - HaJIIIlIlle B 6plOllIHOH
nOJIOCTIIHe60JIbllIOrO O1plIUaTeJIbHoro JIaBJ1eHlIH.
189
rnaBa 27
QT06bl YJIOCTOBepHThCH B npaBRITbHOCTIi npoBe,neHIIj}
npe,nBaplITeJIbHblX MaHlInYJIHUIIH, peKOMeHL\YlOT npoBecTIi
HeCKOJIbKO cneUlIanbHbIX np06.
1. lIpo6a co UmpUl(OM (puc. 27.3). K KaHlOJIe lImbl
nplIcoe,nIIHHlOT wnpliU C 4JH31I0JIOrlIqeCKHM pacTBopoM (10
MJI). IIocJIe BBe,neHIIH 3 - 5 MJI pacTBopa nopIlIeHb IlInplIua
nOWHrnBaIOT Ha ce6H. OTcYTCTBlie 06paTHOH acnHpauHH )l(II,D;-
KOCTH cBH,D:ereJIbCTByeT 0 npaBRITbHOM pacnOnO:>KeHHII lI:rnbI.
KpOBb IIJIII KIIWeqHOe co,nep:>KIIMOe B IlInplIue CBH,D:eTeJIb-
CTBYlOT 0 paHeHlI1I cocy,na RITII KIIWeqHIIKa. Bo Bcex cnyqaHX
nonyqeHIIH acnnpaTa cne.nyeT nOBTOpHO BBecTII Hrny H BHOBb
nOBTOplITb llIllpIIUeBYIO np06y.
2. Tecm na 6caCbl6aHue (puc. 27.4). IIocne BBe,neHIIH
IImbl B 6plOiliHYlO nOJIOCTb K HeH no,ncoe,nIIHHlOT IlInpHU C
4JH3HOJIOmqecKHM pacTBopoM 6e3 nopllIHH. EcnlI KOHqlIK
HrnbI Haxo,nIITCH B cB060,nHOH 6plOllIHOH nOnOCTH, TO nOCJIe
He3HaqnreJ1bHOrO nplIllO,D;HIIMaHIIH nepe,D;HeH 6plOllIHOH creH-
KII :>KII,[{KOCTb BbITeKaer 1I3 IlInplIua B :>KIIBOT. B npOTIIBHOM
cnyqae (KOHqIIK IImbI Haxo,nIITCH B 6plOiliHOH CTeHKe RITH
opraHe) ypOBeHb :>Kl!,lU<OCTIi B IlInpHue OCTaeTCH nOCTosrHHbIM.
B 3TOM CJIyqae He06xo,nIIMO 1I3MeHHTb nOnO:>KeHlIe IIJIH rny-
6IIHY BBe,neHIIH IIrnbI, a TeCT nOBTopliTb.
3. IIocne npoBe,neHIIH BblWenepeqlICneHHblx TeCTOBblX
peaKUIIH K lime nplIcoe,D;IIHHlOT IlIJIaHr ,D;JIH BBe,neHIIH B 6plOW-
HYIO nonOCTb ra3a II npoBe,neHIIHMaHPMempU'leCKOZO mecma.
IIpIIJJO,nHHB nepe,nHlOlO 6plOWHYlO CTeHKY, no,naqy raJa B 6plOiliHYlO nOJIOCTb HaqlIHalOT C MHHII-
MaJIbHOH CKOpOCTli. IIpli 3TOM nepBble nopulIlI raJa BBO.D:HT Me,D;JIeHHO, no,n KOHTpOJIeM MaHoMeTpa
IIHCY4J4JJIHTopa.
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Puc. 27.2 HanpaeReHue eeeaellW/
e 6plOUlHYlO nORocmb Ui!1!bl Bepema:
a - npaeURbHO; 6 - HenpaeURbHO
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lJ . :
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o/iJ ' l . ;:. . t;Q
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Puc. 27.3 lllnpuljeeaR npo6a:
a - KOHelj U2Rbi e 6plOUlHOU nORocmu;
6 - KOHeIl UZRbl 6 npoc6eme KUUlKU
190
Puc. 27.4 KanJleeaR npo6a. llpu noaHRmuu
6plOUlHOU cmeHKU Ka11JlR UC'le3aem U3
omeepcmW/ UZRbl
IIpli CKOpOCTII no,naqn raJa 1 nlMHH. (MlIHlIMaJIbHaSl: CKopOCTb) ,naBJIeHlIe He ,nOJI)l(HO npeBbI-
IlIaTb 5 - 10 MM pT .CT. B Haqane HHcY<PllJnSl:UHII IIpHno,nHl-lMaHMe 6plOiliHOH CTeHKH HeCKOJIbKO
YMeHbiliaeT nOKaJaTenli ,naBJIeHHH, qTO CBH,D;ereJIbCTByeT 0 npaBIIJIbHOCTH npOBe,neHIIH npe,D;BapH-
TeJIbHblX MaHHnYJISl:UIIH. IIocne BBe,neHIIH 1-1,5 n ra3a 6plOiliHYlO CTeHKY OTnYCKalOT.
IIpH npaBIIJIbHOM nOnO:>KeHHII HrJIbI ,naBJIeHHe B 6PlOiliHOH nonOCTIi HapacTaeT Me.D:JIeHHO,
:>KHBOT pa3,nYBaeTcH paBHoMepHo. JIoKanbHoe B3,nYTHe MO:>KeT CBH,D;erenbCTBOBaTb 0 BBe,neHHII
ra3a B npocBeT KIIIlIeqHIIKa HnH B canbHHK. EblcTpoe nOBbIIlIeHHe ,naBneHHH npH no,naqe nepBbIx
nopUIiH ra3a Y peJIaKCHpOBaHHoro naUHeHTa TaK :>Ke cBH,neTeJIbCTBYeT 0 HenpaBIIJIbHOM nOJIO:>Ke-
HIIII HrJIbI.
OKOHqaTeJIbHO npaBHllbHoCTb npoII3BO.D:HMbIx,neHCTBHH npli C03,naHHH DHeBMonepMToHey-
Ma no,nTBep)l(,D;aeTCSI: HCqe3HOBeHIIeM neqeHOqHOR T)'noCTII.
IIpoBe,neHlIe TaKoro 60nbilloro KOnmeCTBa np06 BeCbMa 060cHoBaHHo. BBe,neHlIe HrJIbI
Bepellia II C03,naHHe nHeBMOneplITOHeYMa BblllOnHSl:IOTCH BCJIenyIO, n03ToMy qpeBaTO cepbe3-
HblMIi OCJIO:>KHeHIIHMH Ha CaMbIX nepBblX 3Tanax onepauHII.
KaK nocryrrHTb, eCJIH npOH3Be,D;eHO HeCKonbKO Hey,naqHblX nOnbITOK DYHKTHpoBaHIIH 6p1OIlI-
HOH nonoCTII? 06bIqHO nOCJIe npoBe,neHIIH Hey,naqHOH nYHKUHII peKoMeH.D:YlOT CMeHIITb MeCTO BBe-
,neHHH HrJIb!. MHor,na DYHKUIIH 6plOlliHOH nOJIOCTIi B TOqKe MOHpO (KoHTpJIaTepanbHaH TOqKa MaK-
EYPHeH) B JIeBOH no,nB3,noiliHOH 06naCTH 6blBaeT 60nee 31lJIlJeKTIIBHOH. ,ZJ;eJIo B TOM, qTO B 3TOH
06JIaCTH :>KHBOTa KpaHHe pe,nKO nOKanH3YlOTCH HOBo06pa30BaHHH, cnaeqHble II BOCnanlITeJIbHbIe
npOueCCbI. KpOMe Toro, 3,necb nOqTII He BCTpeqaIOTCSI: BpO)l(,D;eHHbIe cnaHKII II TS[:>KII, IlJIIKCIIPYIOll{He
neTIIH KHllIeqHlIKa.
M36e:>KaTb Hey,naqHOH nODbITRII nYHKUlIH 6plOllIHOH nonOCTIi B03MO:>KH0 npH C03,naHIIII nHeB-
MonepliTOHeYMa OTKpblTblM cnoco60M RITH npH npHMOH nYHKUlIH :>KIIBOTa C nOMOI1U>1O 0,nHopa30BO-
ro TpoaKapa Surgiport CO cneUlIanbHOH 3all{IITOH. B nocne,nHeM cnyqae nocne nYHKUHII nepe,n
HHcyllJllJnSl:UlIeHraJaHeMe.D:JIeHHOBBo,nIITCHBH,D;eOKaMepa.D:JISl:BH3YaJIbHOrOKOHTponHnpaBHllb-
HOCTII BXO)l(,D;eHIIH B CB060,nHylO 6plOIlIHyIO nonoCTb.
BBE.LJ:EHME TPOAKAPOB If OE30PHAg JIAnAPOCKOnIfg
HarneTaHHe ra3a npo,non:>KaeTCH,no ypOBHH 12 - 14 MM pT. CT. 3aTeM Hrny .D:JISl HanO:>KeHIIH
DHeBMOnepHTOHeYMa H3BJJeKalOT H YCRITlieM JIIIllIb KHCTII PYKH OCTOpO:>KHO BBO,D;HT 10 MM TpoaKap.
TpoaKap 6epYT B npaBYIO PYKY, pacnonaraH YKa3aTeJIbHbIH naneu B,nOJIb rRITb3bI TpoaKapa
H ynHpaSl: llillsrDKY CTlIJIeTa B na,nOHb (pue. 27.5). OTBe,neHHbIM MII3HHueM B MOMeHT BBe,neHHH
MO:>KHO olllIpaTbCSI: Ha nepe,nHlOlO 6plOIlIHyIO
CTeHKY. 3TO 06e30nacliT OT pe3Koro npoBana
TpoaKapa B 6plOIlIHyIO nonoCTb H HTpOreHHOH
TpaBMbI.
,ZJ;onOnHlITeJIbHblH Ha,npe3 anoHeBp03a
TaK:>Ke nOMO:>Ker H36e:>KaTb nOBpe)l(,D;eHHH BHYT-
peHHHx opraHoB. B 3TOM cnyqae YCRITIIH .D:JISI:
npOKOJIa MHrKlIX TRaHeR H 6plOllIHHbI HaMHoro
MeHbille. B TO :>Ke BpeMH, pa3pe3bI KO:>KII II ano-
HeBp03a,non:>KHbI6bITb He60nbllIHMH. 3T0 06e-
30naCHT OT Bbllla,neHIIH MyIlJTbI npH MaHlIllynH-
ltHSI:X H YTe H raJa H3 6plOllIHOH nonOCTIi.
'_..
-. ..\.
F . > \ JJ @.. I
a t J. t \ ; ..' . ; I
" . . ,I. Y' : . "'''\ .; ,. "
...... A . ,< ,
"'>\.
'
Puc. 27.5 llpaeulIbHoe yaep:J/CaHue mpoaKapa
191
rJIaBa 27
M36e:>KaTb nOBpe)l(,D;eHHSI: KaKHX-JIII60 COCY,D;IICTbIX CTPYKryp BO BpeMH npOKOJIa 6plOlliHOH
creHKII nOMO:>KeT cBeTOBoH nyqOK TeJIeCKona. Ero HCnOJIb3YlOT MH OCBeIUeHIIH nepe,D;HeH 6p1OIlI-
HOH CTeHKH B MeCTax BBe,[(eHUH nOCJIe,nyIOIUlix TpoaKapOB.
Bbl60p TOqKH ,[(JI5.I BBe,neHIISI: TpoaKapoB 3aBHCHT OT TOnHqeCKOrO ,nlIarH03a npH ycnoBHII
C03,naHH5.I xopollieH ,nocTynHocTIi MH BblllonHeHIIH BMeIlIaTeJIbCTBa. O,nHaKo, He06xo,nHMO 3anOM-
HIITb 30Hbl, B KOTOpblX Henb3H BBO,nIITb TpoaKapbI, - 3TO npOeKUH5.I 3nHraCTpanbHOH apTeplIH,
06naCTII naXOBblX KaHanOB RITH pe6epHoro Kpa5.l.
KOHlIqeCKHH TpoaKap BHaqane BBO,nHT nO,D;KO:>KHO, nOqTH napaJIJIeJIbHO 6plOlliHOH CTeHKe.
Koma COnpOTHBJIeHHe BpaIlIeHlIlO CHII:>KaeTCH (qaCTHqHO npOH,neH anoHeBp03), TpoaKap npo,nBHra-
IOTB 6plOlliHYIO nonocn.
IlHpaMH,nanbHbIe TpoaKapbI 60JIee OnaCHbI. OHH pe:>KYT Ha CBoeM nYTII TKaHIi II BBO.D:HTCH
Ha,naBJIHBaHHeM. Tpe6yercSI: 60JIbllIaH OCTOpO:>KHOCTb npli HX Hcnonb30BaHHH.
IlocJIe BBe,neUHH TpoaKapa y,na.,!HIOT CTRITeT. n pH y,naneHHH CTlIJIeTa He06xo,nHMO OTKpbITb
KJIanaH TpoaKapa. Bbl,neJISl:lOIUHHC5.I ra3 YKroblBaer Ha npaBIIJIbHOe proMeIUeHHe HHCTpYMeHTa.
Cne,nYIOIlIHM 3TanOM, nocne BBe,neHHSI: TpoaKapa, HBJIHeTCSI: 3aMeHa MaH.npeHa OllTliKOH C
nplIcoe,nHHeHHOH K HeH BH,D;eOKaMepoH. 3aTeM K KaHlOne TpoaKapa no,ncoe.D:HHHlOT llIJIaHf MSI: BBe-
,neHHSI: rroa. 3THM 3aKaHqHBaeTC5.I no,nrOTOBHTeJIbHbIH 3Tan.
JIanapoCKOnHqeCKOe BMeIlIaTeJIbCTBO BO Bcex CJIyqaHX HaqlIHalOT C KOHTpOJlbHOrO OCMOT-
pa. PeBH3HIO opraHOB 6plOiliHOH nonOCTII, T.e. co6CTBeHHO 0630pHyIO nanapOCKOlllIlO, HaqlIHalOT
C BbI5.lBJIeHHH B03MO:>KHbIX nOBpe)l(,D;eHHH, HaHeceHHblX IIrnOH Bepellia IIJIII TpOaKapoM. 3TO ,nOCTII-
raeTCH nYTeM nOBopOTa TeJIeCKOna Ha 360°. TIUaTeJIbHO oCMaTpHBalOT Bce ,nocTynHbIe 06nacTli
6plOiliHOH nOJIOCTH: neqeHb, :>KeJIqHblH nY3blPb, ,nHallJparMy, nepe,D;HlOlO CTeHKY :>KeJIY,D;Ka, CeJIe3eH-
RY, KHIlIeqHIIK, qepBe06proHbrn OTpOCTOK, naplieTaJIbHYlO 6plOllIHHY B MeCTax BBeJJ:eHIISI: TpoaKa-
pOB, BHYTpeHHlIe KOJIbua naXOBblX KaHanOB, MaTKY, MaTOqHbIe Tpy6bI C HHqHHKaMH H T.,n.
JJ.nSl: 60nee TIUaTeJIbHOrO OCMOTpa OpraHOB Manoro Ta3a peKOMeH,D;YlOT nepeBeCTII naUlIeH-
TRY B nOnO:>KeHHe TpeH,D;eJIeH6ypra (npHno,nHHTb HO:>KHOH KOHeu CTOJIa Ha 10-15°). JJ.nH 0630pHOH
BH,neonanapocKolllIH 30Hbl :>KeJIqHOrO nY3blpSl: ueJIeC006proHo npHno,nHHTb ronoBHoH KOHeu CTO-
na Ha 25-30° C HaKllOHOM BneBO.
TEXHMqECKMEOCOEEHHOCTM3 OCKOIIMqECKOrO
npOlIlHBAHlUI TKAHEM
EOJIbIlIIIHCTBO npHeMoB B 3H,D;ocKOlllIqeCKOH xnpypnllI, HanpaBJIeHHblX Ha 06eCneqeHHe re-
MOCTroa H coe,nHHeHHe TKaHeH, BblllOnHSl:lOT C nOMOIUblO MeranJIHqeCKHX KJIlinC (puc. 27.6). JJ.nSl:
KJIlInHpOBaHIIH HCnOJIb3yIOT KllHnCanllJIHKaTOp (HHCTpYMeHT, no 1lJ0pMe HanOMHHaIOll{HH 3a>KIIM) II
KJIlInCbl proJIHqHOH 1lJ0PMblII proMepoB.
Ilepe,n KJIHllIIpOBaHlieM He06xo,nIIMO M06RITII3IIpOBaTb TKaHb Ha ,nOCTaTOqHOM npOTj{)l(eHHII.
Ilpli 3TOM ueneco06pa3Ho :>KenqHbIH npoToK ompenaplipoBaTb MaKCHMaJIbHO. Cocy,nbl :>Ke
npeJJ:IIOqTIITeJIbHee KlllffilipOBaTb BMeCTe C oKpy)!(alOll{HMH TKaHHMII, TaK KaK TIUaTeJIbHOe HX BbI,D;eJIe-
HHe qpeBaTO KpOBOTeqeHHeM. KpoMe Toro, HanlIqHe B KllHnce OKpY:>KalOIUeH TKaHli npe,noTBpama-
eT ee COCKanb3blBaHlie B nocJIeonepaUHoHHoM nepHo,ne.
JJ.nsr npoBe,[(eHJ!SI: 6e30nacHora KlllInlipOBaHII5.I KllHnCalIIIJIIIKaTOp (KlllInca) ,non)!(eH pacnoJIa-
rancsr nepneH,!U1KympHo K npo,nOJIbHOH OCII KJIHnHpyeMoro 06pa30BaHIIH, a KllHnca ,non:>KHa nonHO-
CTbIO OXBaTbIBaTb era. Ilpli 3TOM MH 06ecne1.J:eHHH onTIiManbHOH KOMllpeCCHH KlllInHpyeMaH CTpYK-
rypa ,non:>KHa 6blTh pacnonO:>KeHa B cpe,[(HeH TpeTIi npocBera KllHnCbI. B MOMeHT HanO:>KeHlIH KllHnCbI
He06xo,nIIMO BH3yanbHO KOHTpOJIlipOBaTb 06e 6paHillII IIHcTpYMeHTa (KlllInCanDJIHKaTOpa).
.192
)]JIH Ha,ne:>KHOrO KllHnHpOBa-
HIIH Tpy6qaTOH CTpYKTYpbI He06xo-
.D:HMbl, KaK MHHHMYM, ,nBe KJIHnCbI,
paCnOnO:>KeHHble napaJIJIeJIbHO. Ha-
nO:>KeHHe O,l.:(HOH KlllInCbl Ha .npyrylO
He YBeJIlIqlIBaeT Ha,ne:>KHOCTH II He
,non:>KHO IICnOnb30BaTbCH Bo06ll{e.
O,nHaKO, B HeKOTopbIX CJITY-
aUHSI:X nepe:>KaTHe opraHa KJIlinOM
OKa3bmaerCj{ HeJJ:OCTaTOqHbIM H3-3a
B03MO:>KHOCTH ero COCKanb3blBaHliH
C nOCJIe.nylOll{HM pa3BIITHeM OCJIO:>K-
HeHIIH. B TaKHX CJIyqaHX peKOMeH,D;YeTCSlIICnOnb30BaTb CIlIHBalOll{HH annapaT IUlH nHrnpOBaHHe
opraHa neTJIeH 1I3 HIITII C IlJIIKcaUHeH cneUliallbHbIM Y3JIOM.
ECJIII MH 06nlITepaUIIII Tpy6qaTOH CTpYKTYpbI, KaK npaBRITO, nplIMeHHlOT KlllInlipOBaHlIe, TO
Mero,q: coe,nIIHeHHH TRaHeH Heo6xo.D:HMO BbI6HpaTb B 3aBIICliMOCTII OT CJIO)l(lIBllIIIXCH 06crOHTeJThCTB.
MeXaHH'Iecl\:HH IUOB HaKJIa,nbIBalOT C nOMOll{blO CIlIIiBalOll{ero annapaTa (<<Auto Suture»
«EthicoD»). AnnapaTbl,nalOT B03MO:>KHOCTh 6blCTpO pacceKaTh II YIlIHBaTb TKaHlI, HaKlla,nblBaTb Ha-
,ne:>KHble aHaCTOM03bI Me:>K,D;y pa3JIIIqHblMH nonblMH OpraHaMli. He,noCTaTKaMIi CIlIIiBalOll{HX anna-
paTOB Sl:BJIHerCH IIX HenpHrO,D;HOCTh MH ClllHBaHHH TOHKIIX aHaTOMlIqeCKIIX CTpYKTyp (COcy,nOB, npo-
TOKOB, MOqeTOqHHKa H ,np.). HepaUlioHanbHo TaK:>Ke IICnOnb30BaTb CIlIHBalOll{He annapaTbI ,rouI
repMeTH3aUHH He60nbIlIHx OTBepCTHH, r,ne ,nOCTaTO O HanO)l(lITb HeCKonbKO Y3JIOBbIX llIBOB.
CKo6o'lHLIe IUBLI He3aMeHHMbI npH IlJHKcaUHH CeTqaTOrO TpaHCnJIaHTaTa K Ha,nKOCTHHue,
BO BpeMH repHHormaCTHKH RITH npli 3ailllIBaHHJI 6plOIlIHHbI.
3H.lJ.OJIHrarypa He06xo,nHMa MSI: nepeBH3KII KaKJIX-nH60 CTpYKTYP BHyTpIi 6plOlliHOH nono-
CTH. OHa MO:>KeT nplIMeHHTbCSI: KaK B BlI,D;e HHTII, TaK H 3apaHee cllJopMHpoBaHHOH 3H,D;OneTnH. B
nepBOM CJIyqae HHTb C HmOH (npH He06xo.D:HMOCTIi npOllilIBaHHH TKaHII) BBO,nHT B 6plOlliHYlO no-
JIOCTb, rJJ:e 06XBaTbIBalOT, nOJ],BepralOll.{)'lOCSI: JIlImpOBaHlilO CTpYKTypy JI H3BJIeKalOT Hapy:>KY. 3aTeM
3KCTpaKopnopanbHO 3aBj{3bIBalOT Y3eJI II HH3BOMT ero ,no He06xo,nHMoro ypOBHH c nOMOll{blO
TOJIKaTeJISI: (Y3JIOnepeMeCTIITeJIj{) - MHHHOH TOHKOH Tpy6KII C KOHllqeCKHM KOHltOM.
B CJIyqae Hcnonb30BaHHj{ rOTOBOH 3H,noneTnH ee HaKlI,D;bIBalOT Ha nHrlIpyeMoe 06pa30Ba-
Hlie II 3aTSl:mBalOT. MCXOM 1I3 3Toro, B 3H,D;OCKODlIqeCKOH xnpyprHII cyIUeCTBYIOT ,nBa cnoc06a 1lJ0p-
MHpOBaHHH Y3JIa - 3KCTpaKOpnOpaJILHLIH, Kor,na Y3en 3aBSl:3blBaerCH BHe 6plOiliHOH nonOCTH H
3aTeM norpY:>KaeTCj{ B Hee H 3aTHrIIBaerCSI:, H HHTpaKOpnOpaJILHbIH, Kor,na Y3eJI nOJIHOCTblO 1lJ0p-
MlIPYIOT BHyTpH Tena qeJIOBeKa HHCTpYMeHTaMH.
CaMbIM nonynSl:pHblM 3KCTpaKOpnOpallbHblM Y3JIOM Sl:BJISl:eTCH CKOJIb3S1ll{JIH Y3eJJ Penepa.
JJ:JIH ero 1lJ0pMlIpOBaHHj{ Tpe6yercj{ nHraTypa MHHOH He MeHee 70 CM H He TOHbille 2/0. O,nIIH ee
KOHe.u onYCKalOT B 6plOllIHYIO nOJIOCTb, 06BO,nHT BOKpyr nHmpyeMoH TRaHIi (HJIJI npoIlIHBalOT) II
BHOBb H3BJIeKalOT HapY:>KY (puc. 27. 7) < 3aTeM 3KCTpaKopnopanbHo 1lJ0PMlIPYIOT O,nIIHOqHOe nepe-
llJIereHlIe HIITeH (puc. 27.8). IIanbuaMH IlJHKCHPYlOT nepellJIereHHe, a KOHUOM ,nanbHeH HIITH Tpe-
MbH BIITKaMIi 06BHBalOT BOKpyr 06elIx HIiTeH HII:>Ke nepenneTeHIIH TaR, qro6bl nonyqRITacb CnlIpallb
(puc. 27.9). IlpHqeM KOHI.{bl 06elIx HHTeH ,non:>KHbI HaxO,nllTbCSI: no O,nHY CTOPOHY OT CnHpanJI
(puc.2 7.10). KOHeu HlITII, KOTOpbIM HaKpyqlIBanH CnlIpaJIb, npOBo,nsrT qepe3 KonbUO CTe:>KKa. HaTSI:-
rHBaH 06a KOHua HIITH BBepx, 1lJ0pMIIPYlOT Y3en (puc. 27.11). OTpe3alOT nlilliHHH KOHeu HJITH JI
HH3BO,nHT Y3eJI Y3JIOnepeMeCTIITeJIeM B 6plOiliHYlO nOJIOCTb (puc. 27.12). KOHeu HHTH 06pe3alOT H
(- - _. \
'N.- \\
(i('\ .. .., ) \ )) '\
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l==-.-)?// <
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6
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Puc. 27.6 3manbl KJlunupoeaHuR mpy6'lamou cmpYKmypbl
193
rnaBa 27
BblHHMalOT Y3JIOnepeMeCTIITeJIb 1I3 TpoaKapa (puc. 27.13). Ha,ne:>KHOCTb Y3JIa COCTOHT B TOM, qTO
OH nepeMeIUaeTCj{ TOnbKO B O,nHOM HanpaBJIeHHH II He ocna6eBaeT nOCJIe oTnycKaHHH HHTII.
,ZJ;pyrHM BapliaHTOM 3KCTpaKopnopanbHoro Y3JIa j{BllSl:eTCSI: Y3eJI MeJI3epa (puc. 27.14).
OH Hcnonb3yercH xnpypraMIi pe:>Ke II npaKTlIqecKli He OTnlIqaeTCH OT npe,D;bI,D;yll{ero no XapaKTeplI-
CTlIKaM H MeTO.ny HanO:>KeHIIH.
Puc. 27.7 lloa2omoeumeRbHblu
3man fjlopMupoealluR JKCmpaKOp-
nOpaJIbH020 Y3Ra Peaepa
{« - '" .
.,' " :-...'
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Puc. 27.10 3KcmpaKOpnOpaJIb-
HblU Y3eR Peaepa. llpoeeaellue
Humu 'lepe3 KORbl/O cnupaJIu
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IIblU Y3eR Peaepa. t/JopMupoea-
Hue nepeTlJlemeHUR Humeu
/ ""-:l! ,
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Puc. 27.11 3KcmpaKOpnOpaJIb-
HblU Y3eR Peaepa. 3amJI2UeallUe
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Puc. 27.12 3KcmpaKOpnOpaJIbllblU
Y3eR PeiJepa. Cpe3aHUe U3RUUlKoe
aaJIbHeU Humu
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Puc. 27.13 3KcmpaKOpnOpllJ/bHblU
Y3eJl Peaepa. Cpe3aHue U3J1UUlKOe
6J1u.J/ClIeu Humu
Puc. 27.14 3KcmpaKOpnOpllJ/bHblU
Y3eJl M eJlb3e
OCHOBbl OnepaTIIBHOH TeXHIIKII
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Puc. 27.15 3manbl rjJopMupoeaHwl
nepeou nemJlu ulImpaKOpnOpaJIbllOZO
Y3J1a:
a.6.e - rjJuKCal./UR U o6eumue Humu
eOKpyz 3a.J/CUMa
HaH60nee nerKO 3aBSl:3blBaeTCjl npoCTOH napaJIJIeJJLHLIH 3KCTpaKOpnOpaJILHLIH Y3eJI. OH
1lJ0pMIIpyeTcH TaK :>Ke, KaK II B OTKpblTOH xnpyprlIlJ: - nYTeM 06bIqHOrO nepeDJIeTeHHSI: O,nHOH HHTH
BOKpyr .npyrOH. Ha 06'beKre BMeIlIaTeJIbCTBa Y3eJI 3aTm11BaIOT. YqnTbIBM TO, O Y3JIbl norpY:>KaIOTCH
B 6plOllIHYIO nOJIOCTb «BIIJIKOID), a He PYKaMlI, ,[!,.!UI. Ha,D.e:>KHOrO nlimpOBaHlIH He06xo,nHMO HanO)l(lITb
He MeHee 4-5 Y3JIOB. 3TOT Y3eJI IIMeeT MHoro He,nOCTaTKOB, BKlllOqaH B03MO:>KHOCTb oTpblBa II
npope3blBaHHSI: TKaHIi.
IlpoBe,neHHe HHTpaKOpnOpaJiLHOrO JIHrHpOBaHHH npe,nycMaTpIiBaeT ,nOCTaTOqHO BblCO-
Klie MaHyanbHble HaBbIKH xHpypra, nocKonbKY Y3eJI 1lJ0pMIIpyeTcH B Tene naUlIeHTa.
,[{JIH npOBe,neHIIH HIITH C nrJIOH B 6plOIIIHYIO nonOCTb HCnOJIb3YeTCH My4JTa. HIITb 3axBaTblBa-
lOT IIrJIo,nep:>KaTeJIeM B 2 CM OT IIrnbI H BTHrHBalOT B My4JTy.
IIOnblTKa npOBe,neHHH HIITH C IIrnOH 6e3 MyllJTbI MO:>KeT npHBeCTIi K 3aKllHHHBaHHlO HrnbI B
KJIanaHHOM MexaHII3Me H cpe3aHHIO HIITH.
B 6plOllIHOH nonoCTII Hrny 3axBaTblBalOT HrJIo,nep:>KaTeJIeM. Ilo,n KOHTponeM MOHIITOpa npo-
BOwrr npOIlIHBaHlie TKaHeH. )J;JIH 3KOHOMHII BpeMeHH II npaBHJIbHOrO 3a'xBaTa HrnbI Heo6xo,nIIMO
nonb30BaTbCSI: .D:BYMH Hrno,nep:>KaTeJIHMH. <1>YHKUHSI: BToporo Hrno,nep:>KaTeJIH - 3aXBaTIITb HrJIY ,no
Toro, KaK OHa 6y,neT nonHOCTblO npOTSl:HYTa. 3allJIIKcHpoBaB TaKIiM 06pa30M nrny, MO:>KHO qeTKO
BblBeCTH ee H3 TRaHeH nepBblM IJTJIo,nep:>KaTeJIeM. IlocJIe 3aBeprneHHH npOIlIHBaHIISI: HrJIa cpe3a-
eTCH H 1I3BJIeKaerCH H3 6plOlliHOH nOJIOCTIi. KOHUbl HIITII IlJHKCHpyIOTOI IIrJIo,nep:>KaTeAAMIi (3a)l(lIMa-
MII), H HaqlIHaeTCH 1lJ0pMHpoBaHHe IIHTpaKopnOpallbHOrO Y3JIa O,nHIIM 1I3 Mero,nOB.
)J;JIHHa IlJHKcHpoBaHHoro HrJIo,nep}l(aTeneM KOHua ,non:>KHa 6blTb npHMepHo 2 CM. Eonee
,D;JIHHHble KOHUbI HHTH 3HaqlITeJIbHO OCJIO:>KHHIOT 3aBSl:3blBaHlie Y3JIa, nocKonbKY npH 3TOM IIHCTpy-
MeHTbl npHxo,nI1TCjl nepeMell\aTb Ha 60JIbillee paccToHHlIe JJ:pyr OT ,npyra.
XHpyprH'leCKHH HHTpaKOpnOpaJILHLIH npocToH napaJIJIeJILHLIH Y3eJJ 1lJ0pMHpyeTcH ny-
TeM ,nBoHHoro IIJIH TpoHHoro 06MaTblBaHHSI: HHTH, CBSl:3aHHOH C HrnoH, BOKpyr 3a:>KIIMa II 3aXBaTa
KOHua 3TOH HHTII ,npyrHM 3a:>KHMOM (puc. 27.15). 3aTeM 3a:>KHMOM, Ha KOTOpOM HaMOTaHa HHTb,
3axBaTblBalOT npoTHBOnOnO:>KHbIH KOHeu nlirarypbI (puc. 27.16). PaCTSl:nlBaH 3a:>KIIMbl, OKOHqa-
TeJIbHO 1lJ0pMHPYlOT Y3eJI (puc. 27.17).
195
rnaBa 27
BTOPYIO neTnlO 3aBH3bmalOT TaKHM:>Ke 06Pa30M, HO
CJIe,nsrT 3a TeM, qT06bI HanpaBJIeHHe 06MaTbIBaHIISI: 6bIJIO
npoTIiBOnOnO:>KHO npliMemIBllIeMYcj{ npH 1lJ0pMHpoBaHliH
nepBoH nerJIH (pue. 27.18). .ZJ:JIH nOBbIIlIeHHSI: Ha,ne:>KHOCTIi
Y3JIa KOJIlIqeCTBO nereJIb MO:>KHO YBeJIlIqHTb,nO qeTbIpex.
BTOpbIM cnoc060M 1lJ0pMlIpoBaHHj{ Y3JIa j{BJIHeTCSI
npOTSl:rlIBaHlie HIITII C HmoH qepe3 Y}J(e CIlJOpMlIpOBaHHYlO
3KCTpaKopnopanbHYIO nernlO (pue. 27.19).
,[{JISI: 1lJ0pMHpoBaHHH HenpepLIBHom 3HnOCKonH-
'1eCKOm IIIBa MO:>KHO Hcnonb30BaTb ,nBOHHYIO HHTb. ,[{aH-
HaH MerO.D:IIKa n03BOnSl:eT He TonbKO 6blCTpO II KaqeCTBeH-
HO 1lJ0pMHpOBaTb nepBblH Y3en (pue. 27.20), HO H
1lJ0pMIIpoBaTb BeCb IlIOB (pue. 27.21).
DocJIe HaKJIa,D;blBaHIiH HenpepblBHoro IIlBa Hrny OT-
pe3aIOT (pue. 27.22), a OMY H3 HIITCH npoTsrrHBalOT Ha3a,D;
H HCnOJIb3YlOT .D:JIH 1lJ0pMIIpoBaHHH nOCJIe,nHero Y3na
(pue.27.23).
B cJIyqae HCnOJIb30BaHliH O,nIIHOqHOH HHill npH 3a-
BepilieHlI1I HenpepblBHoro IlIBa Y3eJI 3aBSl3bIBalOT HHTpa-
KopnopanbHo (pue. 27.24).
HOBoe TeXHHqecKoe peIlIeHHe IlJHPMbl <<Auto Suture» nepeou nemJ/u UHmpaKopnopaJ/bHOZO
d . h Y3J/a. 3amJlZUeaHUe nemJ/u
(IIHCTpYMeHT En o-Stltc ) n03BOnSl:er CBeCTH BeCb npouecc
npoIlIIiBaHIIH TKaHli II nepeXBaTblBaHHSI: HI'JIbl OT o,nHoro Hmo,nep:>KaTeJIH K .npyroMY B O,nHO ,D;BH)I(e-
Hlie.
CneUHallbHaH Hrna 3a:>KHMaeTCH B OMOH H3 6paHilieH annapaTa H MO:>KeT nepe,naBaTbCH II
IlJHKclipOBaTbCH B ,npyroH 6paHllle OMIIM ,[{BII:>KeHHeM. Y3eJI 3aBSl:3blBaerCj{ TaK:>Ke B ,nBa ,nBH:>Ke-
HHSI:, nOCKonbKY eCTb B03MO:>KHOCTb nepeXBaTIITb limy ,npyroH 6paHIlIOH, npe,nBaplITeJIbHO nepe-
KpeCTliB HIITb (pue. 27.25 a,6,6,z,o,e).
9'k-(..
".il.
(
. . " . . . .. ..
.. ".
" . .-. ,
,
Puc. 27.18 (/J0pMupoeaHue
emopou ne1l1Jlu uHmpaKopno-
paJ/bHOZO Y3J/a
Puc. 27.19 (/J0pMupoeaHue
uHmpaKopnopaJ/bHoZO Y3J/a.
llpomRzueaHue lIumu 'tepe3
cfjlopMupoeaHHYIO 3KcmpaKop-
nopaJ/bHYIO ne1l1Jl1O
196
o?
". y .
. -' . ..
,> ".
1>,. , .
Puc. 27.16 3man fjlopMupOeaHUJl nepeou
ne1l1Jlu uHmpa/wpnopaJ/blloZO Y3J/a. 06pmo-
eaHue nepellJlemeuWl
- --.. .. .. .. . ,...,.. .........
. .. :::,,:.
.. 1 ... '. ....:
. / < "'.....,
Puc. 27.17 3man fjlopMupOeaHUJI
Puc. 27.20 (/J0pMupOeallue
uHmpaKopnopaJ/bHoZO Y3J/a npu
ucnOJ/b30eaHUU aeouHou Humu
\,
PUC. 27.21 llpoUlueaHue
aeoimou HumblO
'
: ;
. f ..\ ..
, ,
.".,
PUC. 27.22 t/JopMupOeallue
nOCJleaHelO Y3Jla npu npoUluea-
HUU aeoullou HUmblO. llpo1Wlzuea-
Hue U pa3pe3aHue HumU
/' .". ':/'"
'l,;c 1
/i " K J \
. .... . I
, (B }: 'A... ,,;
$ f: .. . \
;: /" a.... ;,
___ .. . :J; . 1 .. ;)'
>\...
;;, -,>" ."... .Jii /
... .... ........." J ..
I" ,"" . ." ..\
I . . .,
J' 6 '" .".';.
... .;! '.;
PUC. 27.24 a,6 t/JopMUpOeaHUe Y3Jla npu
UCnOJlb30eaHUU HenpepMBHozo tuea
oaHOU HumblO
.J't
J
', '
! »\ . Y ' 'f ""....
;. .:'" {,. . . ':: ":"'''...
, L >" "
. <. " +
,,' ' ... "
PUC. 27.23 t/JopMupoeaHue
nOCJleaHeZO Y3Jla npu npoUlu:
eaHUU aeouHou HumblO.
3aeJl3bleaHue Y3Jla-
,
' ., / t
a 6
';'f ... , . .
. ;:;:I ...
/'>0
r
r: : j ;,
-, ....
. * .,:)(
. .;, . . . ..
. ,. . ,'x'-
#'. O_h .._._._._.
,n
_.
y,j"----" "I""......
<{- .--"",: - .
' .
.'
'"" .,
B
.. .....\, .4
- . t {!'/
.......,w
i':\.: :
.,.J01t '" ,;
e
PUC. 27.25 a,6,e,z,a,e 3manbl fjlopMupOeaHUJI
Y3Jla annapamoM Endo-Stirch
197
cnMCOK JIMTEPATYPbI
1. Ee30nacHaH TeXHIIKa B JIanapOcKonlIlI./CTe6YHOB C.c., JIbl3IIKOB A.H., 3aHbKo C.H.,
JIbI3HKOB A.A. - MH.: BbIW. IlIK., 2000. - 218 c.
2. EYPbIX M.II. 06ll{lIe OCHOBbI TeXHonorlI1i xnpyprnqeCKHX onepaUHH. POCTOB HlJJ..: M3,D;-
BO «<1>eHHKc», 1999. - 544 c.
3. BOllJIeHKO B.M., Me,nemrn A.M., OMeJThqeHKO B.M. Amac onepauliH Ha 6plOlliHOH creme II
opraHax 6plOlliHOH nonocTII./Ilo,n pe,n. r .E. OCTpoBepxoBa. - M.: Me,nIIUIIHa, 1965. - 205 c.
4. rpHropbeB E.E. IIplieMbI II cnoco6bl, n03BOnHlOll{He Ha,D.e:>KHO H 6bICTpO 3aBH3blBaTb Y3JIbI
npH npoBe,neHIIII xlIpypmqecKlix onepaUIiH (COBeThl MOJIO,D;bIM xnpypraM). - CIl6.: M3,D;-BO EYKOB-
CKoro, 1996. - 143 c.
5. E:>KeB B.H., EYHHOB B.M., Y,nOTOB O.A. XIIpypmqeCKIIllllIoB. - M.: Me,nnpaKTlIKa-M, 2001.
- 110 c.
6. 30nTaH .H. Cicatrix optima. OnepaulIoHflaH TeXHHKa II YCJIOBIIH OnTHManbHOrO 3a)l(lIBne-
HIIH pallbI. - Ey,nanewT: M3,n-BO AH BeHrpHH, 1983. -175 c.
7. OnepaTIIBHaH xnpyprHH.: nep. C BeHr ./IIo,n pe,n. M. JIHTTMaHa. - Ey,naneIliT. M3,n-BO AH
BeHrplIH, 1982. - 1175 c.
8. CeMeHoB r.M., IleTpHllIHH B.JI., KOBiliOBa M.B. XIIpyprnqecKHil:WOB. -CIl6.: IIHrep, 2002.
- 251 c.
9. CJIenuoBM.B., qepHIIKoBP.A. Y3JIbIBxnpypmlI.-CIl6.: CaJIHT-Me,lU<HIIra,2000.-176c.
10. Coe,nIIHeHHe TKaHeH B xnpypmlI./MIIJIbKOB E.O., llIaMpeH r.Il., IloJISl:HCKHH II ,np. no,n
pe,n. MHJIbKOBa E.O.-q.: Pe,naKUHoHHo-H3,narenbcKIiH OT,neJI o6nnonHrpa4JH3,naTa, 1991. -112 c.
11. TapaHoB Il.C. 30nOTaHKHHra PYKoBO,D;IITeJIH. - M.: AreHTcTBo «<1>aHp», 1996. -496 c.
12. <1>e,nopoBM.B., HIIKIITIIH AT. KnHHlIqecKM3JIeKTpOxnpypnrn. - M.: DOT AP Me.D:HUHHa,
1997.- 92 c.
CO,[(EP)KAffiffi
IIPE.ZJ:MCJIOBME. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
rnaBa 1. XI1PYPrJ1qECKAH OIIEPAU,I1H: pa3'be.lUIHeHlIeTKaHeH, OCTaHOBKa
KpOBOTeqeHIIH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
XlIpyprnqeCKIiH IIHCTpYMeHTapliH . . . . . .. .................... ..7
TIpaBliJIa pa3'be,nIIHeHIIH TKaHeH . . . . . . . . . . . . . . .. . . . . . .15
IIpaBIiJIa OCTaHOBKII IIHTpaonepaUHoHHoro KpOBOTeqeHIISI: . . . . . . .21
rnaBa2. 3JIEKTPOXMPYPrMqECKOE B03,[{EMCTBME HA TKAHI1 .27
EliollJll3HqeCKlie npe,nnocbmKII 3neKTpoXlIpyprnqeCKOrO
B03,neHCTBIISI: Ha TKaHli. . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
3neKTpOTepMIIqeCKlie 31lJIlJeKTbI BbICOKOqaCTOTHOro TOKa ....... 29
rnaBa 3. IIP ABMJIA HAJIO)l(EHM.H XMPyprMqECKOrO IIIBA. . . . .35
rJIaBa 4. TEXHMKA HAJIO)l(EHM.H XMPyprMQECKI1X IIIBOB. . . . .39
rnaBa5. COBPEMEHHbIEMATEPMAJThI,MCnOJTh3YEMbIE,lJ.JUI
HAJIO)l(EHl1H XI1PYPrJ1qECKOrO IIIBA . . . . . _ _ . . . . . . . . . . . . . . . . .43
XlIpypl'lIqeCKlie HIITII. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
XIIpyprlIqeCKlie HrJIbI . . . . . . . . . . . . . . . . _ . . . . . . . . . . . 51
rnaBa6.XAPAKTEPMCTI1KAIIETEJIb,IIPI1MEHHEMbIXBXI1PYPrl1l1.55
rnaBa 7. KOHCTPYKTMBHbIEXAPAKTEPMCTMKMIIPMMEH.HEMbIX
B XMPyprMM Y3JIOB. . .. . . . . . . . . . . . . . . . . . . . . . . . . . .59
KOnHqeCTBO neTeJIb B Y3ne. . . . . . . . . . . . . . . . . . . . . . . . . . .60
KOnlIqeCTBO nepenneTeHIIH B neTnSI:X Y3JIa. . . . . . . . . . . . . . . . . .61
KOnlIqeCTBO HlITeH B Konbue CTe:>KKa. . . . . . . . . . . . . . . . . . . . .62
IIpocTpaHCTBeHHoe CTpoeHlIe neTenb B Y3JIe. . . . . . . . . . . . . . . . .62
HanpaBneHlIe 3aTSl:rIIBaHIISI: neTenb. . . . . . . . . . .. . . . . . . . . . . .63
rnaBa 8. KJIMHMQECKA.H XAP AKTEPMCTMKA I1PMMEH.HEMbIX B
XMPyprMM Y3JIOB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Y3nbI 1I3 ,nBYX neTenb. . . . . . . .. ................... .65
Y3JIbllI3 Tpex neTeJIb. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
Y 3JIbllI3 qeTblpex nereJIb. . . . . . . . . . . . . . . . . . . . . . . . . . . .71
rnaBa9.3TAIIbI<1>OPMMPOBAHM.HXMPyprI1QECKOrOY3JIA. . . .73
rnaBa 10. CIIOCOEbI <1>OPMMPOBAHM.H IIETEJIb PYKAMH.. .....77
Cnoco6bI IlJOpMlIpOBaHlISI: npoCToH neTnlI. . . . . . . . . . . . . . . . . . .77
Cnoco6bI llJopMlIpOBaHHSI: CJIO:>KHblX neTenb. . . . . . . . . . . . . . . . . .91
Cnoco6 llJopMlIpOBaHIiH nerJIIi EapKoBa. . . . . . . . . . . . . . . . . . . .94
199
rnaBa 11. CilOCOEbI <1>OPMMPOBAHIDI IIETEJIb C IIOMOI..IJ;bIO
MHCTPYMEHTOB. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . 95
rnaBa 12. CPE3AHME M3JIMIIIKOB HMTEM. . . . . . . . . . . . . . . .99
rnaBa 13. 3AIIIMBAHI1E PAH KO)l(M. CHHTME IIIBOB. . . . . . 101
CHHTlie IlIBOB KO:>KII. . . . . . . . . . . . . . . . . . . . . . . . . .107
rnaBa 14. IIIBbIAilOHEBP03A. . . . . . . . . . . . . . . . . . . . . . . 109
rnaBa 15. 3AlllMBAHME MbIIIIU,. . _ . .. . . . . . . . . . . . . . . . . 113
rnaBa 16. COEAMHEHMEKPOBEHOCHbIXCOCY,ZJ;OB. .. . . . . .115
KnacclIllJlIKaUIiH IlIBOB COCy,nOB . . . . . . . . . . . . . . . . . . .115
MHBarnHaUlIoHHbie COCYMCThIe lllBbl. . . . . . . . . . . . . . . . . .121
lllBbI 3a,D.HeH CTeHKII, HaKlla,nblBaeMble npli HeB03MO:>KHOCTII
pOTaUlIlIcocy,na. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .122
IIIBbI C npliMeHeHlIeM KOHCTpYKUIiH II npoTe30B. . . . . . . . . . . .123
Cnoco6bl HanO:>KeHIIH lllBOB Ha pa3HOKanlI6epHble cocYJJ:bl. . . . . .123
MeXaHlIqeCKIIHcKpenOqHbIlllllOB. . . . . . . . . . . . . . . . . . . . . 124
C03,naHHe apTeplIanbHblx MIIKpoaHaCToMo30B C
IICnOnb30BaHlieM na3epHOro eHIIH. . . . . . . . . . . . . . . . . .124
repMeTH3aUHSI lllBa. . . . . . . . . . . . . . . . . . . . . . . . . . . .125
IIIBbl, HaKlla,nbIBaeMble Ha BeHbl. . . . . . . . . . . . . . . . . . . . .125
lllBbl Ha nlIMllJaTlIqeCKlie COCy,nbI. . . . . . . . . . . . . . . . . . . . .126
IIIBblMe:>K.D:YBeHoHlinIIMllJamqeCKliMcocy,nOM. . . . . . . . . . . . .126
JIIIMllJoHo,nynoBeHoCToMIiH. . . . . . . . . . . . . . . . . . . . . . . . . .127
rnaBaI7.IIIBbIIIEPM<1>EPMqECKI1XHEPBOB............. .... .129
rnaBa 18.IIIBbICYXO)l(MJIMM. . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
llloB cyxo:>KRITHil:, pacnOnO:>KeHHblX BHe CHHOBlIaJIbHbIX BllaralllIll{. .135
llloB cyxO:>KRITIIH, pacnOnO:>KeHHblX B CIIHOBliallbHblX BllaranHll{ax. .136
rnaBa 19. IIIBbI KOCTH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141
rnaBa 20. KI1111EqHbIH IIIOB. . . .. . . . . . . . . . . . . . . . . . . . .143
KnacclIllJlIKaUIiH KlillIeqHblX llIBOB . . . . . . . . . . . . . . . . . 146
HenpOHIiKalOll{lIe IlIBbI. . . . ., ...................147
CKB03Hble Y3nOBbie IlIBbI. .. . . . . . . _ _ . _ . . . ... . . . . . . . .151
CKBo3Hbie HenpepbIBHble IlIBbI. . . . . . . . . . . . . . . . . . . . . . .154
,ZJ;ByxPMHbIH IlIOB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157
3allllIBaHHe paH nonbIX opraHoB. . . ., . . . . . . . . . . . . . . . . .158
HanO:>KeHlIe aHaCTOM03a. . . . . . . . . . . . . . . . . . . . . . . . . .161
MeXaHlIqeCKIiH (annapaTHbIH) lllOB KIiIliKII . . . . . . . . . . . . .164
HanO:>KeHlIe Me:>KKlIllIeqHblX aHaCTOM030B C nOMOll{blO
BblCOKOKaqeCTBeHHoH 3neKTpoxnpyprlIli . . . . . . . . . . . . . 164
rnaBa21. 3AIIII1BAHME PAHIIAPEHXI1MAT03HbIX OprAHOB. 165
lllBbl KpaeBbIx paH neqeHII. . . .. . . . . . . . . . . . . . . . . . . . .165
lllBbI npli pe3eKUIIII neqeHII. .. . . . . . . . . . . . . . . . . . . . . . .168
llloB renaTlIKoxone,noxa . . . . . . . . . . . . . . . . . . . . . . . . .169
IIIoB no,n:>Keny,nOqHOH :>Kene3bl. . . . . . . . . . . . . . . . . . . . . . .170
IIIBbI npli paHax nerKoro. . . . . . . . . . . . . . . . . . . . . . . . . . .171
200
rnaBa 22. IIIOB CAJIbHMKA. . . . . . . . . . . . . . . . . . . . . . . . . .173
rnaBa23. IIIOBMOqETOqHMKA. . . . . . . . . . . . . . . . . . . . . . .175
rnaBa24.IIIBbITPAXEMMEPOHXOB. . . . . . . . . . . . . . . . . . . .179
rnaBa25.3AIIIMBAHMEPAHbICEP,lJJJA. ................ .183
rnaBa 26. APEHMPOBAHME EPIOIIIHOM IIOJIOCTM. . . . . . . . . .185
rnaBa 27. OCHOBbI 3H)J,OCKOIIMqECKOM XMPyprMM. . . . . . . 189
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