The spread of the tumor above the anterior surface of the mouths of the pulmonary veins in the immediate vicinity of the interatrial sulcus, we consider it to be a sign of the patient’s inoperability. To solve the problem of the degree of involvement of the posterior surface of the pulmonary veins and the wall of the left atrium into the tumor process, it is necessary to try to isolate the vessels. For this purpose, parallel to the upper and lower surfaces of the walls of the pulmonary veins, dissect the posterior leaflet of the pericardium, at the level of the transitional fold, cut the serous membrane of the pericardium along the front surface of the vessels. After isolating the anterior surface of the wall of the veins, by theircircumference, gradually allocate the rear walls, in close proximity to the mouths of the veins. If thus it is not possible to isolate and circumvent the veins, they produce an audit of the posterior wall of the heart through the oblique sinus of the pericardium. For this purpose, dissect the mesentery of the inferior vena cava, the vein is pulled up and anteriorly. The incision of the posterior wall of the pericardium is supplemented, if it has not been previously performed, by dissecting it along the lower surface of the wall of the lower pulmonary vein. The dissector is placed behind the inferior vena cava in the oblique pericardial sinus along the posterior surface of the heart, directing it to the retrocaval pericardial cavity formed by the lateral wall of the superior vena cava and the upper wall of the superior pulmonary vein. In this place, the posterior pericardial wall is incised. The selection is made gradually and very carefully, holding the dissector as bottom-up,and from top to bottom. If it is possible to circumvent the posterior surface of the left atrium in this way, then gradually expanding access from the bottom, they enter the oblique pericardial sinus with a finger and produce the posterior pericardiotomy under his control. This technique allows you to significantly expand access to the left atrium. However, it is not necessary to perform posterior pericardotomy before resection of the atrium in the region of the orifices of the pulmonary veins. In most cases, it is sufficient to bypass the posterior surface of the atrium with a tool. If this is not done, then the question of the operability of the patient is decided negatively.This technique allows you to significantly expand access to the left atrium. However, it is not necessary to perform posterior pericardotomy before resection of the atrium in the region of the orifices of the pulmonary veins. In most cases, it is sufficient to bypass the posterior surface of the atrium with a tool. If this is not done, then the question of the operability of the patient is decided negatively.This technique allows you to significantly expand access to the left atrium. However, it is not necessary to perform posterior pericardotomy before resection of the atrium in the region of the orifices of the pulmonary veins. In most cases, it is sufficient to bypass the posterior surface of the atrium with a tool. If this is not done, then the question of the operability of the patient is decided negatively.

Involvement in the tumor process of the superior vena cava can be caused by damage to it as directly by the tumor itself, so that more often it has been observed,

metastasis of the tumor to the numerous lymph nodes located along it. Most often, such a lesion was detected at the place of inflow into the superior vena cava of the unpaired vein. The lymph node located here is one of the lower nodes of the right paratracheal chain and is affected quite often. In some cases, the superior vena cava appears to be located for a considerable distance surrounded by a conglomerate of enlarged lymph nodes, which cause its compression, which is sometimes clinically manifested by the development of the superior vena cava syndrome. In 23 patients operated in the clinic before the operation there were pronounced clinical manifestations of this syndrome with an increase in pressure in the system of the superior vena cava up to 300-400 mm of water. Art. (2.9 -, 9 kPa). On examination and palpation, with such a lesion, the impression of a total tumor germination of the superior vena cava and the impossibility of resection was created. However, a detailed histological study of paracancic changes accompanying the development of a tumor and its lymph node metastases showed that in most patients with an expected wide lesion of the superior vena cava tumor, the true lesion was much less in extent. Detailed preparation of the wall of the superior vena cava could be distinguished from paracancrosis inflammatory changes, the true boundaries of the tumor could be clarified and in most patients resection of a section of its wall.

The main method of the selection involved in the blastomatous process of the superior vena cava is the beginning of dissection from its unchanged sections: from above — from the confluence of the brachiocephalic veins, from below — from the right atrium. At the same time an unpaired vein is isolated and tied up on the chest wall, at the place of its formation, and — directly at the place of inflow into the superior vena cava. A vascular clamp is applied to the central end of the unpaired vein, which subsequently allows the upper vena cava to be withdrawn and somewhat raised, which considerably facilitates its preparation and the separation of metastases of the right tracheobronchial, pretracheal and preventive lymph nodes. If the ligation of the unpaired vein, directly at the place of its inflow into the superior vena cava, cannot be performed, then it is crossed forextracting from adhesions together with a conglomerate of enlarged lymph nodes. The success of the preparation of the superior vena cava is the exact definition of the anatomical layer in which it is produced. Starting from unchanged areas of the vessel, the preparation is made directly on its wall, without disturbing the integrity of the lymph node capsule. Thus it is possible to remove large conglomerates of the affected lymph nodes, the inner surface of which is an exact cast of the vessel.

In the area of ​​pericardial torsion along the superior vena cava, its germination by metastases to the lymph nodes located here is often noted. Allocation of the superior vena cava in such a situation from the right atrium is advisable to begin intrapericardially, dissecting a leaf of the pericardium on the dissector inserted between it and the vessel wall in an unchanged place and gradually removing and exfoliating the pericardium with affected lymph nodes, to release the vein wall.

The preparation should be done very carefully, literally millimeter by millimeter, only under the control of vision. In case of intimate adhesion of the tumor to the vessel wall, it is better not to perform dissection in the adventitia of the vein, as on the aorta, because its wall is very thin and easily damaged. If the area of ​​such a lesion turns out to be small in size and without significant narrowing of the lumen of the vein, it is possible to perform marginal resection, then proceed to its implementation. In other cases, to clarify the nature and size of the lesion, the possibility of resection followed by grafting of the superior vena cava, special diagnostic methods and surgical intervention are used. In the second period of the clinic for the diagnosis of involvement in the tumor process of the walls of the atria and mainly the vena cava, together with cardioch
 Irurg Professor , we have developed and apply intracardiac finger revision. Access to the heart chambers is through the ear auricles. A clip is applied to the base of the ear. Above the clamp on the ear is placed a purse string. Then, the tip of the ear is cut off with scissors and the edges of the wound are spread with vascular clamps, thereby opening access to the heart cavity. Bleeding is usually not observed, because a clip is laid on the base of the ear. Before an intracardiac revision, the surgeon takes off his gloves and handles the hands with heparin solution. After removing the clip from the base of the ear, through the hole formed, the index finger of the right hand is inserted into the atrium. In order to avoid bleeding, the assistantsqueezes the surgeon’s finger with a tightening of the pouch string . With right-hand access, this technique makes it possible to assess the state of the walls of the right atrium, mainly it concerns the interatrial septum in cases of lesions of the external wall of the left atrium, as well as the upper and lower hollow veins. With a finger inserted into the vena cava, it is possible to determine the degree of its narrowing, the presence and size of the sprouting of the vessel wall with tumor tissue. Considering that during the finger examination of the hollow veins, they develop severe hypertension, manipulations are performed repeatedly, if necessary, briefly. The indications for resection of a section of the wall of the superior vena cava, with its subsequent plastic surgery, we consider the presence of tumor growth of the vessel with a size not exceeding one third of its circumference and a length of no more than 2 cm, depending on its own size.

After the revision, the index finger is slowly removed from the atrium and the clamp is again applied to the base of the atrial appendix. When performing a resection of the wall of the superior vena cava or continuing to release it from the tumor tissue, the vein is bypassed through the same access in the ear of the atrium, which makes it possible to facilitate and secure further surgery. After removal of the shunt or end of the audit of the heart chambers, the base of the ear is sutured with a double stitch. An intracardiac revision of the right atrium and vena cava was performed in 25 patients. We did not observe any complications during the operation related to the execution of this manipulation.