Question 1. Role of N. I. Pirogof and V. N Shevkunenko in the development of topographic anatomy and operative surgery.

1) The methods of topographo-anatomic studies of N. I. Pirogoff. Pirogoff founded operative surgery and topographic anatomy as an educational discipline. He studied anatomy using the method of frozen corpses (ice anatomy). He cut corpses in 3 planes by saw and studied natural relations of topographoanatomic structures without displacement. He conducted experiments on corpses. He filled abdominal cavity with water, modelling ascitis and filled pleural cavity with water , modelling pleuritis, then studied topographic anatomy in pathology; dislocation of organs in mediastinum pathology. 2) Interrelations of the blood vessels and fasciae. Pirogoffs laws. He studied relation of neurovascular bundle with fasciae. According to Pirogoffs laws, neurovascular sheath is formed by fascia of nearby muscle. 1st law; anterior wall of neurovascular sheath is posterior wall of muscular sheath. Vice versa. 2nd law; neurovascular sheath has prismatic shape in cross section. 3rd law; apex of prismatic shape of neurovascular bundle directly or indirectly, through intermuscular septa attached to bone or capsule of joint. 3) Role of V. N. Shevkunenko in the creation and development of the type anatomy. Shevkunenko is the 2nd specialist which founded operative surgery and topographic anatomy as an educational discipline. He studied topographic anatomy of depending on body build, individual changeability of topographic anatomy, age and body type. Type anatomy means- topographic anatomy in different constitutions. 4) Two extremes forms of the body build. According to him, there are two extremes forms of body build. Brachimorphic; short, wide build is characterised by short and wideneck, short height, wide thoracic cage with big epigastric angle, long body and short lower extremities. Doligomorphic; long narrow build, long neck, tall narrow thoracic cage with small epigastric angle, short body, long lower extremities. 5) Position of the organs of thoracic and abdominal cavity depending on the type of body build. Brachimorphic: High diaphragm Heart occupies horizontal position Wide extraperitoneal field of liver]

High, oblique or horizontal position of stomach High position of caecum and appendix Doligomorphic: Low diaphragm Vertical heart Narrow extraperitoneal field of liver Low J or hook shaped stomach Low caecum and appendix.

Question 2. Exposure of the vessels and nerves of the extremities. 1. Correspond to subquestion 1 of question 1 2. Correspond to subquestion 2 of question 1 3. Straight (direct) and roundabout accesses for exposure of the vessels and nerves. Straight or direct access for expose of vessels and nerve are drawn along projection line. Roundabout / indirect axis for exposure of vessels and nerve are drawn 2 cm medially / laterally from projection line and parallel to it. 4. Advantages and shortcomings of the straight (direct) and roundabout acceses. Advantage of direct access is exposure of vessels very quickly without difficult along projection line. Disadvantage of direct access is dangerous access may damage nerves and vessels. Advantage of indirect is = safe, avoid damage of vessels and nerve. Disadvantage of indirect is = has difficulty during exposure of vessels, musculosheath and occupy more ligation than direct method. 5. Definition of the optimum level of the ligation of the arteries. The intersystemic and intrasystemic anastomoses. -Optimal level of ligation of arteries is point of arteries after ligation of it, maximum anastomosis are developed. -Anastomoses maybe inter- or intra systemic. 1. intersystemic anastomosis is communication of different arteries. E.g. Subclavian + Axillary, Subclavian + external iliac, femoral + external iliac 2. Intrasystemic anastomosis is communication of one arteries. E.g Femoral medial + Femoral Lateral, Circumflex anterior + circumflex posterior)

Question 3. Topography of the deltoid region. 1) Layers. Skin Subcutaneous tissue Superficial fascia Deep fascia Deltoid muscle Humerus Shoulder joint. Skin is innervated by superior lateral cutaneous nerve of arm which is branch of axillary nerve. 2) Interrelations of the deep fascia with deltoid muscle. i) Deep fascia of deltoid region split and surrounds deltoid muscle forming a sheath for it. ii) Deep fascia gives off septa and divides muscles into 3: - clavicular, acromial, spinal 3) Nerves and vessels. i) Through quadrilateral space, axillary nerve and posterior circumflex humeral artery pass. ii) These nerves and arteries lie on the surgical neck of humerus in the deltoid region. iii) From anterior side, anterior circumflex humeral artery passes and also lies on the surgical neck. iv) Posterior & anterior circumflex artery form intrasystemic anastomosis. v) Clinical importance of relation of nerve & surgical neck. - possible damage of nerve in fracture of surgical neck of humerus. 4) The subdeltoid fat space. Subdeltoid fat space is located between i) Laterally deltoid muscle ii) Medially humerus and shoulder joint Anteriorly, these fat spaces may reach deltopectoral sulcus. This space is not close and communicates with fat space of adjacent region. 5) Communications of the subdeltoid fat space with fat spaces of the adjacent regions. i) Along tendon of supraspinous muscle, subdeltoid fat space communicates with supraspinous bed of scapular region. ii) Along tendon of infraspinous muscle, subdeltoid fat space communicates with infraspinous bed of scapular region. iii) Along axillary nerve and posterior circumflex humeral artery through quadrilateral space, subdeltoid fat space communicates with axillary fossa fat.

Question 4. Topography of shoulder joint 1) Bones, surface landmarks, projection of articular slit Bone: head of humerus, glenoid cavity of scapula form shoulder joint Surface landmark: clavicle, coracoid process, acromion, deltoid muscle margin Projection of articular slit: anterior apex of coracoid process Lateral line connecting coracoid process with acromion end of clavicle Posterior under most protruding part of acromion 2) Intraarticular structure & ligaments Intraacrticular structure: 1. cartilage of glenoid labium, which increase the depth of small glenoid cavity 2. long head of bicep muscle: passes through capsule & attach to supragleniod cavity Ligaments: (to strengthen capsule) Shoulder joint is only strengthen by anterior & superior ligaments (inferior & posterior ligament is absent) 1. superior: coracohumeral ligament 2. anterior: glenohumeral superior, medial & inferior Medial glenohumeral ligament is inconstant. Therefore, this is an pre-anatomical condition of anterior dislocation of arm, leading to displacement of head of humerus under clavicle 3.coracoacromion ligament: between coracoid process & acromion not connected to shoulder joint capsule, but it prevent dislocation of arm upward 3) Lax places of the capsule & synovial bursae Lax places weak places, where pus spread or dislocation occur Pus spread in recesses & bursa around joint There are 3 recesses: axillary, intratubercular, subscapular Recess =protrusion of synovial membrane through fibrous capsule (hernia) In norm, recess take part in circulation of fluid during movement In pathology, pus has tendency to melt synovial layer pus spread to adjacent region. Rupture of subscalpular recessspread to subscapular bed Rupture of intertubercualr recessaccumulate in subdeltoid fat space Rupture of axillary recess spread to axillary fossa Synovial bursa surround any joint & do not take part in fluid circulation. Its important in decrease friction during movement of joint. In norm, synovial bursa synthesized synovial fluid which decrease friction during joint movement. & synovial bursa surround the joint and therefore does not take part in fluid circulation. Around subcoracoid, subacromial, subdeltoid, subscapular Bursa that communicate with capsule of joint: subcoracoid, subscapular Bursa that doesnt communicate with capsule of joint: subacromial, subdeltoid

4) Strengthening of the joint by muscles. Skeletotopy of the vessels & nerves around joint Capsule of joint is strengthen by muscles Anterior: 1. subscapula muscle 2. coracobrachial muscle 3. short head of biceps Lateral: 1. long head of biceps 2. deltoid muscle Posterior: 1. supraspinal muscle 2. infraspinal muscle 3. teres minor muscle Inferior: no ligament & muscle Therefore, dislocation of shoulder joint is always inferior & into axillary fossa axillary dislocation

Clinical importance: 1. axillary dislocation head of humerus compress on axillary nerve axillary nerve injury 2. absent of middle glenoid ligament anterior dislocation compress brachial plexus compress axillary artery compress axillary vein 5) Puncture of the shoulder joint Aim of puncture of (any) joint: to evacuate pathological fluid & injection of contrast material etc 3 point of puncture of shoulder joint: 1. anterior: under apex of coracoid process, 3-4cm backward 2. lateral: under most prominent part of acromial through deltoid muscle, obliquely & medially downward 3. posterior: most inferior of acromion process, 4-5cm forward (needle pass though tendon of supraspinous muscle & margin of deltoid muscle)

Question 6. Topography of infraclavicular region. 1) Layer. Subpectoral fat spaces. Ways of pus spreading. Layer 1. 2. 3. 4. Skin Subcutaneous fat Superficial fascia Deep fascia (split to cover pectoralis major) 5. Superficial fat space 6. Clavipectoral fascia sheath covering Pectoralis minor 7. Deep fat space 8. External intercostal muscle 9. Rib 10. Internal intercostal muscle Subpectoral fat spaces i) Superficial fat space is open Anterior deep fascia & posterior surface of pectoralis major muscle & its sheath. Posterior clavipectoral fascia & anterior layer of pectoralis minor muscle. ii) Deep fat space is close Anterior posterior surface of pectoralis minor muscle Posterior clavipectoral fascia sheath c) Ways of pus spreading i) From superficial because its open ii) Along ?????? branch, communicate with axillary fossa. Pass cephalic vein and branch of axillary artery. 2) Syntopy & skeletotopy of the main neurovascular bundle under clavicle (in clavipectoral triangle). Clinical importance.

Skeletotopy Neurovascular bundle in clavipectoral triangle is projected on middle third. Syntopy

i) ii) iii)

Medial and lateral axillary vein Lateral and superior brachial plexus In between axillary artery

Clinical importance i) 1.0 - 1.5cm below between middle third = Wilsons point for catheterization of subclavian vein ii) Between medial and lateral 1/3 = projection of brachial plexus - Local anaesthetic local block of upper arm iii) If fractured into 2 parts: i) Medial fragment pulled up by sternocleidomastoid muscle ii) Lateral fragment pulled down by deltoid muscle (can injure brachial plexus, axillary art & vein) 3) The line of the projection of the subclavian artery & the brachial plexus. If projection line from... along to - Drawn from middle point of posterior margin of sternocleidomastoid muscle through middle of the clavicle along deltopectoral sulcus (Line is only drawn when patients head to the opposite side, if not cant find & expose vein) 4) The operative accesses to the subclavian artery. Common sign of all operative accesses to subclavian artery includes cutting of the clavicle using bone saw (osteotomy) and after operation, osteosynthesis. Petrovsky incision (T-shape) Horizontal part is drawn along superior anterior surface of clavicle. Vertical part is drawn from middle of clavicle downwards 5-6cm. Arch shaped incision

1 = deltopectoral sulcus 2 = pectoralis 5) Collateral circulation in ligation of the subclavian artery. Ligation of the subclavian artery is possible only after arising of thyrocervical trunk. Internal thoracic artery

l l l

l ____ l ____ l

anterior intercostal artery axillary artery thoracoacromial artery superior thoracic artery lateral thoracic artery subscapular artery + arterial ring around scapula

Question 7. Topography of axillary region 1) Layer. Pecularity of the structure of the skin. Clinical importance. Layer Skin subcutaneous tissue superficial fascia deep fascia cavity of axillary fossa which filled by fat, lymph nodes & neurovascular bundle Pecularity Skin -very thin -fixate up by suspensory ligament of axillary which is formed by clavicopectoral fascia -contain hair follicles, sebaceous & subdoriferous glands - inflammation of 1 follicle furuncle 2 folliclescarbuncle -inflammation of sweat glands hydrodenitis (pain, intoxication & pus spread into axillary fossa 2) Walls of the axillary fossa. 4 walls: anterior, posterior, lateral & medial anterior: pectoralis major, pectoralis minor & subclavius muscle clavicopectoral fascia suspensory ligament of axilla posterior: subscapularis, latissimus dorsi, teres major muscle (from superior to inferior) medial: thorax till 4th intercostals space serratus anterior lateral: surgical neck of humerus short neck of biceps coracobrachialis 3) Intermuscular space of the posterior wall of the axillary region: triangular & quadrilateral . posterior muscle form 2 intermuscular space: triangular & quadrilateral triangular, limited superiorly by- subscapularis & teres minor inferiorly by- teres major & latissimus dorsi laterally byking head of triceps through triangular space, 2 infraspinous bed & circumflex scapular artery pass quadrilateral, limited superiorly by- subscapularis & teres minor (same as triangular) inferiorly by- teres major & latissimus dorsi (same as triangular) medially by- long head of triceps laterally by- surgical neck of humerus transmit: posterior circumflex artery & vein axillary nerve (on surgiacal neck of humerus) 4) Topography of the triangles of the anterior wall of the axillary fossa

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clavicopectoral triangle: superior- clavical inferiorsuperior border of pectoralis minor muscle baselateral border of sternum pectoralis triangle: correspond to pectoralis minor muscle subpectoral triangle: superiorinferior border of pectoralis minor muscle inferiorinferior border of perctoralis major muscle basedeltoid muscle

5) Syntopy vessles & nerves on different levels (in triangles). Lateral cord gives 2 branches: musculocutaneous nerve & lateral root of median nerve Posterior cord gives 2 branches: radial nerve & axillary nerve Medial cord: ulnar nerve medial cutaneous nerve of arm medial cutaneous of forearm medial root of median nerve which crosses artery anteriorly

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Question 8: Topographic anatomy of the anterior region of the arm 1) Topography of the layers. Layers: i) skin- thin, mobile and innervated along medial margin by medial cutaneous nerve and along lateral margin by lateral cutaneous nerve. ii) subcutaneous fat- is a loose structure and transmits superficial veins; basilic vein medially (accompanying medial cutaneous nerve of forearm) and cephalic vein laterally. iii) superficial fascia iv) deep fascia- gives of two septa; medial and lateral which attach to the humerus and form anterior compartment v) muscles vi) humerus The anterior compartment is limited by: -deep fascia anteriorly -humerus posteriorly -medial intermuscular septa medially -lateral intermuscular septa laterally It contains: -flexor muscles -neurovascular bundles 2) Syntopy of main neurovascular bundle of this region. Relation of the brachial artery and median nerve on the different level of the arm - main neurovascular bundle of anterior region of arm include brachial artery which accompany vein and median nerve - bundle is located into medial bicipital sulcus - at level upper 3rd, nerve is located laterally, and brachial artery medially - at level middle 3rd, nerve crosses artery anteriorly - at level lover 3rd, nerve lies medially and artery laterally - medial and some posteriorly to main neurovascular bundle, ulnar nerve is located

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3) Peculiarity topography of the ulnar nerve and musculocutaneous nerve. - ulnar nerve arise on medial cord, passes through anterior region of the arm at level upper and middle 3rd - at level lower 3rd, ulnar nerve penetrate medial intermuscular septa and go to posterior compartment of the arm - nerves lies medially and posteriorly to main neurovascular bundle - musculocutaneous nerve arises from lateral coracobrachial plexus - at level upper 3rd of the anterior region of arm, nerve is located between biceps anteriorly and coracobrachial posteriorly - at level middle and lower 3rd, biceps muscle anteriorly and brachial muscle posteriorly - at boundary between anterior region of arm and cubital fossa, nerves become superficial and change name to lateral cutaneous nerve of forearm which will accompany cephalic vein 4) The line of the projecton of the brachial artery and median nerve - projection line of brachial artery and median nerve is drawn from top of axillary fossa along medial bicipital sulcus to middle point between medial epicondyle and tendon of biceps muscle 5) Optimum level if the ligation of the brachial artery. Collateral circulation in ligation of the brachial artery. - optimal level of ligation of brachial artery is located below arising profunda brachial artery - collateral circulation in ligation of brachial artery is developed through network around elbow joint which is formed by collateral radial and ulnar artery and recurrent radial and ulnar artery

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Question 9: Topography of the posterior region of the arm 1)Topography of the layers - Topography of layer: ~ skin ~ subcutaneous tissue ~ superficial fascia ~ deep fascia ~ muscle of posterior compartment ~ humerus - skin is thick, less mobile and supplied by lateral inferior cutaneous nerve of the arm which is the branch of radial nerve - deep fascia posteriorly, humerus anteriorly, medially medial intermuscular septa, and laterally by lateral intermuscular septa from posterior compartment which include triceps muscle, neuromuscular bundle i.e. radial nerve, profunda brachial artery and vein 2) Walls and contents of the humeromuscular canal. Clinical importance. - Posterior compartment include topography anatomical structure a.k.a. humeromuscular canal - this canal is limited anteriorly by spiral groove or radial groove of humerus and posteriorly by triceps muscle - through this canal, radial nerve, profunda brachial artery and vein pass - nerve lies on bone - clinical importance is relation of nerve and bone, in fracture if diaphysis of humerus leading to possible damage of radial nerve 3) The line of projection of the radial nerve in the arm - from projection line of radial nerve in arm is drawm from middle part margin of deltoid muscle to lower 3rd of lateral bicipital sulcus 4) Exposure of the radial nerve in the arm - exposure of radial nerve in the arm, is made along projection line -incision is drawn through middle 3rd of projection line and succession skin, subcutaneous tissue, superficial fascia and deep fascia are cut - heads of triceps muscle are separated by blunt resection and retracted by Parabeus retractor - nerve lies on humerus 5) Surgical incisions in phlegmon of the posterior fascial compartment of the arm surgical incision orientation: - lateral and medial bicipital sulcus contains neurovascular bundle - for drainage of phlegmon, 2 parallel incisions are made i.e. medial and lateral - medial incision is drawn 2cm posteriorly and laterally to medial bicipital sulcus - lateral incision is drawn 2cm posteriorly and medially to lateral bicipital sulcus

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Question 10: The anterior elbow region 1) Superficial layers. Peculiarity of the disposition of he superficial veins. Clinical importance. - superficial layers are; skin, subcutaneous tissue, superficial fascia, deep fascia - with subcutaneous fat along medial margin, basilic vein passes along lateral margin, cephalic vein passes - these veins form anastomoses of N or M shape - clinical importance: using of these veins for intravenous injection and transfusion therapy - also cephalic vein is accompanied by lateral cutaneous nerve of forearm, which is the continuation of musculocutaneous nerve - basilica vein is accompanied by medial cutaneous nerve of forearm, which is the branch of medial cord of brachial plexus 2) Walls and floor of the cubital fossa - deeply to fascia, cubital fossa is located - fossa has wall and floor which are formed by muscles - medial wall of cubital fossa formed by pronator teres muscle - lateral wall formed by brachioradial muscle - floor of cubital fossa is formed by brachial muscle and tendon of biceps muscle

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3) Sulcuses. Neurovascular bundles - muscles of walls and floor of cubital fossa form 2 anterior cubital sulcuses i.e. medial and lateral - medial sulcus formed medially by pronator teres muscle and laterally by tendon of biceps muscle - contents of this sulcus is brachial artery and medially to artery is the median nerve - lateral sulcus is formed laterally by brachioradialis muscle and medially by brachial muscle, radial nerve and collateral radial artery - this nerve divides into 2 i.e. deep and superficial - deep nerve enter suppinator canal and go to posterior region of forearm - superficial nerve adjoins to the neck of radius and goes to anterior region of forearm 4) Syntopy of the brachial artery in cubital fossa. Clinical importance. - brachial artery located medially to tendon of biceps muscle, medially to artery with distance of 1.5-2cm, median nerve is located - order from lateral to middle: Tendon, Artery, Median nerve (TAM) - clinical importance: this area is used to measure blood pressure, used for intraarterial injection of antibiotic for purulent inflammation of hand 5) The projection of the brachial artery in cubital fossa. Exposure of the brachial artery in the cubital fossa. - projection line of brachial artery in cubital fossa is drawn along medial margin of tendon of biceps muscle - exposure of brachial artery: - incision for exposure of brachial artery in cubital fossa is made through middle 3rd of the line which is drawn - 2cm aboce medial epicondyle of humerus, going through middle of cubital fossa and then to lateral margin of forearm - line is then divided into 3 and incision is made in middle line or 2nd line of the division

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Question 11: Topograpy of the elbow joint 1) Bones, surface landmarks, projection of the articular slit - elbow joint is formed by 3 bones i.e. distal part of humerus, proximal part of radius and proximal part of ulna - surface landmark: medial epicondyle, lateral epicondyle, olecranon, tendon of biceps muscle, tendon of triceps muscle, and head of radius in lateral sulcus - projection or articular slit: located on horizontal line drawn 1cm below lateral epicondyle and 2cm below medial epicondyle 2) Places of the attachment of the articular capsule, ligaments - elbow joint consists of 3 joints with common capsule - joints are humero-ulnar, humero-radial and proximal radial ulnar joint - capsule of joint attach along articular surfaces of humerus, radius and ulna - ligaments present at 3 sites: ~ medially: collateral ulnar ligament ~ laterally: collateral radial ligament ~ anteriorly: circular ligament a.k.a. annular radial ligament 3) Lax places of the capsule. Clinical importances. Synovial bursae. - lax places of capsule divided into 2 groups i.e. pus spreading and inflammation development - pus spreading weak place are divided into 2, i.e. anteriorly and posteriorly - anterior weak place is located at proximal radioulnar joint - here synovial membrane form succiform blunt recess that lie on interosseous membrane (posterior wall of Pirogov fat space) - in rupture of this place, pus spread to Pirogovs fat space - posterior weak place are located on both side of olecranon, covered only by skin, subcutaneous tissue, superficial fascia and deep fascia - if develop inflammation, capsule protrude and leads to rupture of capsule leading to spread into posterior elbow region - synovial bursae around elbow joint are located at place of attachment tendon of triceps muscle to olecranon - this bursae are subject of chronic inflammation 4) Skeletotopy of the neurovascular bundles and possible complications in posterior dislocation of the forearm - around joint, neurovascular bundle are located - posteriorly, in medioposterior cubital sulcus which is formed medially by medial epicondyle, lateral by olecranon, ulnar nerve is located - nerve lies directly on capsule of elbos joint - anterior lateral cubital sulcus include radial nerve lying directly on capsule of elbow joint - anterior medial cubital sulcus include brachial artery and median nerve - artery and nerve are separated from capsule by brachial muscle

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- in posterior dislocation of forearm, ulnar and radius displace backward and end of humerus dislocate front or forward - this posteriorly damages ulnar nerve and anteriorly damages radial and median nerve - complete paralysis of hand may develop 5) Puncture of the elbow joint - puncture of elbow joint is made through 2 points i.e. posterior puncture and lateral puncture - lateral puncture is made through middle part between olecranon and lateral epicondyle above head of radius - this puncture is made when position of upper extremity at 90 degrees of angle - posterior puncture is made above apex of olecranon at 145 degrees of angle - needle insert above apex of olecranon through tendon of biceps muscle

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Q12) TOPOGRAPYC ANATOMY OF ANT REGION OF THE FOREARM. 1. Topography of layers. - skin, subcutaneous tissues, superficial fascia, deep fascia 4 layers of muscles, radius, ulna and interosseous membrane . - skin thin, has mobility supply medially by medial cutaneous nerves of forearm laterally by lateral cutaneous nerves of forearm. - subcutaneous fat is loose and transmit superficial veins along medial margin ~ basilic vein along lateral margin ~ cephalic vein veins accompanied by cutaneous nerves. basilic by medial cutaneous nerve of forearm. cephalic by lateral cutaneous nerve of forearm. deep fascia very strong attached to the muscles. With relation with clinical importance in septic wound air cant penetrate between fascia and muscle cause anaerobic gas gangrene.

2. Sulcuses. Piragoffs fat space. Clinical importance. Musc of ant region form 3 sulcuses: medial ulna lateral radius sulcus of median nerve. Ulnar sulcus is limited by: -medially by flexor carpi ulnaris muscle -laterally by flexor digitorum superficialis Radial sulcus limited by : -medially upper 1/3 of pronator teres -medial inferior flexor carpi radialis -laterally brachioradialis muscle. Median sulcus loc in only lower 3rd forearm and is limited : -medially by flexor carpi radialis musc. -post ly flexor digitorum profundus musc. -ant ly palmaris longus. -Piragoffs fat space is between 3rd and 4th layer of muscle and limited: ant ly : flexor digitorum profundus and flexor pollicis longus musc.

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 post ly : at lower 3rd pronator quadratus, and above it by interosseous membrane. - clinical importance: possible accumulation of pus till 250 ml from middle palmar fascia space, radial ulnar bursae and spread to posterior region of arm through foramen interosseous membrane where vessels and nerves pass. 3. The lines of the projection of the radial artery, ulnar artery and nerve and median nerve. from to ( along ) - radial artery from middle point of cubital fossa/ mid margin of biceps brachii muscle to point of pulsation located 0.5 medial to styloid process of radius. - ulnar artery and nerve: from medial epicondyle of humerus to lateral surface of pisiform bone. - medial nerve of forearm: from middle part of cubital fossa/ medial margin of tendon of biseps muscle to medial thenar-hypothenar muscle 4. Syntopy of the neurovascular bundle. Into radius sulcus: - superficial bursa of radial nerve and radial artery passes. From lateral ----------------------------- medial Radial nerve, radial artery, medial nerve, ulnar artery, ulnar nerve. In ulnar /medial sulcus: - ulnar artery and nerve passes. At lower 3rd, nerve located in median sulcus between flexor digitorum superficialis ( ant ly ) flexor digitorum profundus ( post ly ) upper 3rd, nerve located between head of pronator teres.

5. Surgical incision in phlegmons of the forearm. - 2 incision mode are made which is parallel to each other. - Medial and lateral ; orientation are bones = radius and ulnar. - 2 cm above styloid process, longitudinal line of ulnar and radius ( 8- 10 cm ).

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13) TOPOGRAPHY OF THE PALM OF THE HAND. 1. Peculiarity of the structure skin, subcutaneous tissues, palmar aponeurosis. Skin- is thick & has no mobility cos very strongly attached by fibrous septa to deep fascia and palmar aponeurosis. Skin contain sebaceous gland. Subcutaneous tissue have lobular structure cos fibrous septa connecting skin and aponeurosis & fascia divide fat into many lobular. clinical importance: - subcutaneous process on the palm have local character very painful - pus accumulate in the septa. Palmar aponeurosis arise from tendon of palmaris longus muscle - has triangle shape - apex attached to retinaculum flexorum ; base to proximal phalanx - at the level of base, fibrous of aponeurosis separated from each other in 3 commissura foramina filled by fat and digital neurovascular bundle (NVB) - palmar aponeurosis gives off 2 septa ( medial and lateral ) - medial intermuscular septa attach to 5th metacarpal bone. - Lateral to 3rd metacarpal bone.

2. The palmar fascial spaces.

deep fascia, palmar aponeurosis, medial & lateral intermuscular septa, interosseous fascia form 3 spaces: - lateral / thenar space. - Medial / hypothenar space. - Middle palmar fascia space. Thenar space limited by : - ant & lat : deep fascia.

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- Post : interosseous fascia. - Medial : intermuscular septa. this space contain thenar muscle, tendon of pollicis longus, surrounded by radial bursa, branches of median nerve and radial artery, fat. Hypothenar space limited by : - ant & med : deep fascia - lat : medial intermuscular septa. - Post : 5th metacarpal bone. this space contain hypothenar muscle, branches of ulnar artery and nerves, fat. Middle palmar limited by : - ant : palmar aponeurosis. - Post : interosseous aponeurosis. - Medial : medial intermuscular septa - Lat : lateral intermusc septa.

contain 8 tendons ( 4 flexor digitorum superficial and 4 flexor digitorum profundus, surrounded by ulnar bursa. -superficial ulnar arch, deep palmar arch, fat, branches of median and ulnar nerves. 3. Fat spaces of the palm of the hand. - located into 2 fossae subdiv into medial, lateral and middle. Lateral fat space -open into thenar -this space is closed except 1 way. Medial fat space -located into hypothenar -completely closed -pus wont spread. Middle fat space -occupies middle fascia space divided into 2 slits. -they are superficial/ subaponeurotic and deep/ subtendinous ( div by tendon or ulnar bursa.) At superficial / sub aponeurotic: -ant : palmar aponeurosis -lat and med : fibrous septa -surrounded: by ulnar bursa. -subaponeurotic fat communicate thr commisura foramina along digital neurovascular bundle : distally is clsed.

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At deep / subtendinous: -ant : ulnar bursa. -post: interosseous fascia -lat: lat intermuscular septa -med: medial intermuscular septa - it opens distally and proximally distally thr lumbrical musc, canals; deep slip communicate with subcutaneous of dorsum of finger into digital spaces. proximally thr carpal tunnel pus spread from deep slit to Piragoff space. 4. Blood supply and innervation of the hand and fingers. -divided into main and additional source of blood supply. Main: radial artery & ulnar artery from palmar arch ( superficial and deep ). Additional : ant interosseal artery, post interosseal artery, median artery accompanied with median nerve -these vessel form network around wrist joint take part in collateral artery. Innervation of the hand: PalmUM Distal RU Metacarpal: thumb to 4th finger by median nerve 4th finger to 5th finger ulnar nerve. Dorsum Rule: 1- 3rd finger radialis 3rd finger 5th finger ulnaris. Prox 3rd of thenar dangerous zone Dorsum Rule - here motor of median nerve supply thenar muscle, damage of this level can paralysis the thumb, so work is lost. 5. incision in purulent processes of the hand. Phlegmon thenar -incision 2 cm laterally parallel to distal and middle 3rd of thenar crest for drainage of phlegmon. Phlegmon hypothenar -incision longitudinally parallel to projection 5th metacarpal line on dorsum. Middle phlegmon -by 2 incision. -if absent pus spread on dorsum, 2 cm lateral parallel to 5th metacarpal bone. -if present spreading thr interdigital space between 3rd and 4th finger enter middle palm and dorsum.

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14)BLOOD SUPPLY AND INNERVATION OF THE HAND AND FINGERS. 1. Main and additional sources of the blood supply of the hand and fingers. = Question 13 (4) 2. Innervation of the skin of the hand and fingers. =Question 13 (4) 3. Innervation of the muscles of the palm of the hand. hypothenar supply by ulnar nerve. Thenar musc except adductor pollicis musc supplied by median nerve. Adductor pollicis by ulnar nerve Ulnar nerve supplies 3 muscles ( lumbrical muscles ).

4. Dangerous zone of the hand. =Question 13 (4). 5. Surgical incisions in purulent processes of the hand. - fingers: include 3 fat spaces. distal, middle and proximal. distal: -2 parallel lines. -maybe curved line like hockey stick -maybe cross lines + ( cuticular and subcut ). for pianist,, remove nail bed and drainage the pus. Middle and proximal -incision parallel to each other. -parallel lines to separate all septa so free way to drainage.

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15)TOPOGRAPHY OF THE FLEXOR SYNOVIAL SHEATHS. 1. Synovial bursae of the palm; name and topography. - synovial bursae of the palm are divided into 2: radial bursa ulnar bursa. on the palm into metacarpal radial bursa located: -in thenar space and surrounded by tendon of pollicis longus. Ulnar bursa located: -in the middle palmar fascia space and surrounded by 8 tendons. 2. communication of the synovial bursae with each other and with digital synovial sheathes. - synovial bursa communicate with synovial sheath tendons of fingers. - 12-15% of cases radial-ulnar bursae communicate with each other 3. Syntopy of synovial bursa in carpal tunnel. Clinical importance. Carpal tunnel is limited: -ant ly: by retinaculum flexorum -post ly: by carpal bones Syntopy of structure: - medially: ulnar bursa with surrounded 8 tendons. - Laterally: radial bursa by 1 tendon - between bursae is median nerve. clinical importance: -in tendon bursa, bursae enlarge but carpel tunnel is a hard structure, so compression of median nerve with carpo-tunnel syndrome. 4. Way of the pus spreadin in rupture of the proximal part of the bursae. - prox part of the radial and ulnar bursae are located along pronator quadratus which is posterior wall of Piragoff. - In rupture of the prox part, pus spread to Piragoff space. 5. U-shaped phlegmon. Surgical incision in U-shaped phlegmon of the hand. - U-shaped phlegmon for synovial struc are damaged synovial sheath of radius, radius bursa, ulnar bursa, synovial sheath of ulnar bursa. Surgical incision: - 2 parallel incision for drainage of digital synovial sheath. - incision is 2 cm lateral parallel to distal and middle 3rd of thenar crest. - 2 incision of 2 phalanx ulnar bursa into middle palm. - 2 cm lateral and parallel to 5th metacarpal bone. so 10 incision to drainage pus from Piragoff fat space.

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Question 16. Digital Tendinous Sheath. 1) Scheme of structure of the tendinous sheath (layers surrounding tendons) on cross-section through the middle phalanx of a finger. 1 = Parietal sheath 2 = Visceral sheath 3 = Tendon 4 = Mesotendinae

2) Digital synovial sheathes (walls, contents, beginning and end). i) Its divided into 2 layers: Fibrous layer & Synovial layer. ii) Fibrous layer = deep fascia of fingers + cruciate & circular ligament. iii) Distally, fibrous layer attach to the bas of distal phalanxes. iv) Together with phalanxes, it forms the osteofibrous canal. v) Tendon is located in the canal & is covered by synovial sheath. Parietal part cover inner surface of the osteofibrous canal. Visceral part cover the tendon. vi) Synovial sheath is closed on 2nd, 3rd & 4th fingers and extend from base of distal phalanx to the distal transverse crest. vii) Synovial sheath of 1st & 5th finger proximally not close and communicate with radial & ulnar bursa. 3) Blood supply and innervations of the tendon in tendinous sheathes. i) Tendons are avascular structures and have very bad blood supply. ii) Usually, blood supply of tendon passes through mesotendinae which arises from periosteum of phalanx. iii) Mesotendinae may be 1-2 maximum 3 structures (very thin threadlike) iv) Mesotendinae passes into spaces between parietal & visceral layer of synovial sheath. v) Innervate through mesotendinae. 4) Tendovaginitis (definition). Surgical incisions in tendovaginitis. i) Definition: Its the inflammation of synovial sheath of fingers (tendino-tonarisium) ii) Pus accumulates between parietal & visceral layer of synovial sheath. iii) Fibrous sheath is hard structure cant extend. So all pressure go to mesotendinae, that explains the quick development of tendon necrosis. iv) Surgical incisions to save tendon: 2nd,3rd 4th i) Incisions parallel to distal transverse crest of metacarpal.

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ii)

2 lateral on middle phalanx & 2 lateral on proximal phalanx. Incision on the distal & proximal transverse crest, - Use microligator everyday saline, antibiotics irrigation. - Disadvantage - incise at natural crest scarring. - Complete flexion may be impossible.

5) Pulp spaces of the fingers. i) Pulp spaces are soft spaces where inflammation may develop. ii) Subcutaneous fat has lobular structure because skin is connected to fibrous sheath by septa. iii) Clinical features in distal pulp spaces - Inflammation in subcutaneous fat may damage periosteum and bone osteomyelitis 1 = tendon 2 = Visceral sheath 3 = Parietal sheath 4 = Fibrous septa 5 = Subcutaneous fat (lobular structure)

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17. Topography of gluteal region. 1) The boundaries. Surface landmarks Boundariessuperior: iliac crest inferior: gluteal fold medial: median sacral crest lateral: line connecting superior anterior iliac spine & greater trochanter Surface landmarks Iliac crest, superior anterior iliac spine, greater trochanter, gluteal fold, sacral crest, anus, inguinal ligament 2) Layers. Pecularities of layers

Layers Skin subcutaneous tissues deep fascia 1st muscle layer fat space of gluteal region 2nd muscle layer 3rd muscle layer pelvic bone & ligament Pecularities of layers Skin Fix, not mobile- because skin is attached to deep fascia by fibrous septa Skin of upper part is supplied by subcostal, iliohypogastric nerve & cutaneous branches of lumbar dorsal rami (nerves of clunes superior, middle, inferior) Skin of lower part is supplied by posterior cutaneous nerve of thigh Subcutaneous fat Lobular structure- because fibrous septa connect skin & deep fascia, therefore divides fat into lobular structure. Thus, pyo-inflammation of subcutaneous fat has local character. Deep fascia 2 layers surrounding gluteus maximus & give off septa within muscle, dividing muscle into muscular bundle Thus, IM abscess us very painful

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1st muscle layer =gluteal maximus + upper part of gluteus medius 2nd muscle layer from superior to inferior: gluteus medius, piriformis, obturator internus loose fat: between 1st & 2nd muscle layers 3rd muscle layer- superior: gluteus minimus inferior: obturator externus

3) Foramina of the gluteal region, Vessels and nerves Pelvic bone has 2 notch: greater sciatic & lesser sciatic notch 2 ligaments (sacrospinous & sacrotuberous ligament) convert this notch into 2 foramens greater & lesser sciatic foramen Greater sciatic foramen transmit piriformis muscle. Piriformis muscle divide this greater sciatic foramen into 2 suprapiriformis + infrapiriformis foramen Suprapiriformis is limited- superior: inferior margin of gluteus medius muscle Inferior: superior margin of piriformis muscle Transmit- superior gluteal artery, vein & nerve (medial to lateral) Infrapiriformis is limited- superior: inferior margin of piriformis muscle Inferior: superior border of sacrospinous ligament Transmit- sciatic nerve, inferior gluteal vessels, posterior femoral cutaneous nerve, internal pudendal vessels, pudendal nerve (lateral to medial) Lesser sciatic foramen transmit tendon of obturator internus muscle and through this foramen pudendal neurovascular bundle enter ischiorectal fossa. 4) Skeletotopy of superior gluteal artery. Clinical importance. Skeletotopy Superior gluteal artery arise from internal iliac has short trunk & adventitia of this artery is attached to periosteum of pelvic bone & fascia which covered 2nd muscle layer Clinical importance Gaping artery in trauma, without contraction Thus, patient without adequate aid will die of bleeding mortal bleeding 5) Localization of fat space. The ways of pus spreading. Fat space of gluteal region is located in 1st & 2nd muscle layers In phlegmon, pus may spread: 1. through infrapiriformis foramen, along sciatic nerve along sciatic nerve, inferior gluteal vein to lateral pelvic fat space 2. along sciatic nerve to posterior compartment of thigh till popliteal fossa 3. through lesser sciatic foramen along pudendal neurovascular bundle to ischiorectal fossa 4. along anastamosis of inferior gluteal artery & obturater vessel to adductior compartment of thigh

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Question 18. Topography of the hip joint. 1) Bones, surface landmarks, projection of the articular slit Bones are: -acetabulum -head of femur and neck of femur Surface landmarks: -inguinal ligament -apex of the greater trochanter -superior anterior iliac spine -ischial tuberosity -gluteal fold Projection of the articular slit is above the apex of the greater trochanter. 2) Ligaments and places of attachment of the articular capsule, muscles. The ligaments are divided into; intra-articular: -ligament of the head of femur -transverse acetabulum ligament extra-articular:-iliofemoral ligament -pubofemoral ligament -ischiofemoral ligament Place of capsule attachment: -proximally- along the margin of the labrum acetabulum -distally- anteriorly on the intertrochanteric line covering the neck of the femur -posteriorly on the intertrochanteric crest covering two thirds of the neck. Muscles: -anteriorly; iliopsoas pectineus rectus femoris -laterally and superiorly; gluteus minimus -posteriorly; piriformis obturator internus quadratus femoris -inferiorly; obturator externus 3) Lax (weak) places of the capsule. Practical importance. These places are located between the ligaments. In purulent inflammations, the synovial membrane may protrude through these places. There are 2 weak places; a) Anterior: -location- between iliofemoral and pubofemoral ligaments. -practical importance- here, the capsule of the hip joint communicates with iliopectineal synovial bursa and pus may spread to the fat of femoral triangle, to muscle labium up along iliopsoas muscle -purulent process hour glass. b)Posterior, inferior: -location-along inferior margin of ischiofemoral ligament along tendon of obturator externus muscle. -practical importance-here, pus may spread to gluteal region and pelvic cavity.

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4) Line of Rozer-Nelaton. Practical importance. Skeletotopy of the vessels and nerves around joint. It is a diagnostic line used to diagnose dislocation of thigh at hip joint and diagnosis of fracture of neck of femur. Line is located from superior anterior iliac spine to ischial tuberosity. In normal position, apex of the greater trochanter should be here. In superior dislocation, apex of greater trochanter will be displaced upward In inferior dislocation, apex of greater trochanter will be displaced downward. In fracture, apex of greater trochanter will be displaced downward. Skeletotopy of vessels and nerves is important for estimation of complications of dislocation joint. a)In anterior superior dislocation or suprapubic dislocation; there can be damage of femoral artery which leaves through vascular lacuna lateral to femoral vein and lies on ramus of pubic bone. b)In anterior inferior dislocation; damage of obturator neurovascular bundle as it passes through obturator canal. c)In posterior (superior or inferior) dislocation; there can be damage of sciatic and inferior gluteal vessels because they occupy lateral position. 5) Puncture of the hip joint. This can be made in two points a) Anterior- at middle of the line connecting the apex of greater trochanter to the middle point of the inguinal ligament b) Lateral- above apex of greater trochanter. ( more difficult in fat patients) Posterior puncture is never made because of the position of sciatic nerve. Question 19. topography of the anterior region of the thigh. 1) layers. Skinsubcutaneous tissuesuperficial fasciadeep fasciamusclesfemur. Skin is think, mobile and supply immediate under ligament by femoral branch of genitofemoral nerve. Anterior surface is supplied by branch of femoral nerve. Superior and middle third of medial surface is supplied by femoral nerve. Lower third is supplied by obturator nerve. Lateral surface is supplied lateral cutaneous nerve. In subcutaneous tissue, medially great saphenous vein passes. Under the ligament, this vein passes saphenous opening and drain into femoral vein. Deep fascia is called fascia lata, give off lateral anterior and post septa which divide muscles of thigh into 3 compartments. Anterior 2 compartments (extensor and adductor) 2) the femoral triangle, its boundaries and floor. Femoral triangle is limited Medially: adductor longus

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Laterally: sartorius muscle Superior or base: inguinal ligament Floor: iliopsoas muscle and pectineus muscle. Muscles of floor form groove, into which neuromuscular bundle is located. Apex of triangle continue into adductor canal.

3) syntopy of main neurovascular bundle on different level of the triangle.

4) Line of projection of femoral artery. Accesses to artery. Line of projection of femoral artery is called line according to ken. This line is drawn from middle inguinal ligament to adductor tubercle of medial epicondyle of femur. In succession, skin, subcutaneous tissue, superficial fascia, fascia lata are located. Sartorius muscle is located laterally. 5) optimum level of ligation of the femoral artery. Collateral circulation. Optimal level of ligation of femoral artery is located below arising of profunda femoral artery. This point is 3-5 cm below inguinal canal. Arterial circulation is developed by anastomoses artery with anterior posterior tibial artery and with obturator artery Question 20. topography of the femoral canal. 1) muscular lacuna: walls and contents walls: - anterior superiorly: inguinal ligament - posterior and lateral: pelvic bone (ileum) - medially: iliopectineal arch contents: - iliopsoas muscle, femoral nerve and lateral cutaneous nerve of thigh muscle 2) vascular lacuna: walls, contents, and syntopy. Walls: - anterior: inguinal ligament - posterior: pectineal ligament - medially: lacuna ligament - lateral: iliopectineal arch through this lacuna, femoral vein and arterial pass. Syntopy is: vein is medially, artery laterally. 33

 Medially to vein, space is located which is called femoral ring of vascular lacuna. In norm, femoral ring is filled by fat which connect extraperitoneal fat of anterior abdominal wall with fat of femoral triangle. 3) 4) Walls of femoral canal. Femoral canal on cross section has triangle shape. Wall of femoral canal: anterior: falciform margin of fascia lata/ superficial layer of fascia lata posterior and medially: pectineal fascia lata/ deep layer of fascia lata laterally: sheath of femoral vein Deep ring of femoral canal. corona mortis(corona of death) deep ring of femoral canal is femoral ring of vascular lacuna this is limited by: anterior: inguinal ligament posterior: pectineal ligament medial: lacunar ligament laterally: sheath of femoral vein. Corona mortis (corona of death) is variant anatomy of arising obturator artery. Usually, obturator artery arises from internal iliac passes along lateral wall of pelvis and leave pelvic cavity for obturator canal. In variant anatomy, artery arises from external iliac or inferior gastric anatomy. This variant is important in strangulated femoral hernia where this ligament must be cut.

5)

Superficial ring of the femoral canal. Superficial ring of femoral canal is called salphenous opening. In pathology this opening is superficial ring or oval fossa. Superficial ring is limited by cornus superior and cornus inferior, farciform margin of fascia lata. In norm, cannot see this ring. Its surface is covered by fascia. It can only be seen when hernia protrude.

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Question 21. Anterior region of thigh. 1) layers. Skinsubcutaneous tissuesuperficial fasciadeep fasciamusclesfemur. Skin is think, mobile and supply immediate under ligament by femoral branch of genitofemoral nerve. Anterior surface is supplied by branch of femoral nerve. Superior and middle third of medial surface is supplied by femoral nerve. Lower third is supplied by obturator nerve. Lateral surface is supplied lateral cutaneous nerve. In subcutaneous tissue, medially great saphenous vein passes. Under the ligament, this vein passes saphenous opening and drain into femoral vein. Deep fascia is called fascia lata, give off lateral anterior and post septa which divide muscles of thigh into 3 compartments. Anterior 2 compartments (extensor and adductor) 2) The walls of adductor (Gunter) canal. Walls of adductor canal: a) anterior: vasta adductoria lamina b) medial: vastus medialis muscle c) lateral and posterior: adductor magnus muscle 3) The foramina of adductor canal. Superficial foramina/inlet is limited: a) anterior: vasta adductor lamina. b) Posterior: adductor magnus muscle. Through this foramina, femoral artery and vein and salphenous nerve enter the canal. Syntopy: artery medially and anteriorly vein posteriorly and laterally to artery nerve superficially and laterally to artery. Inferior outlet is formed by tendon of adductor magnus muscle. Sometimes, this foramen may be formed by tendon of adductor magnus. Through this outlet, femoral artery and vein leave canal. Artery anteriorly and medially. Vein laterally and posteriorly to artery. Immediate after leaving adductor canal, vessels change name to popliteal. Anterior outlet is located in vasta adductor foramen. Through this foramen, salphenous nerve and descending genicular artery (branch of femoral artery) leave adductor canal. 4) Vessels and nerve and their syntopy. Through canal, femoral artery, vein and salphenous nerve pass. Syntopy is: Artery anteriorly and medially

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Vein laterally and posteriorly to artery Salphenous nerve laterally to artery.

5) Connection of this canal with adjacent region. The ways of pus spreading. Adductor canal through inferior inlet foramen communicate with popliteal fossa; through anterior outlet communicate with medial aspect of knee joint. Pus spreading maybe through inlet to fat of femoral triangle to inferior outlet to fat of popliteal fossa.

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Question 22. Topography of the posterior region of the thigh. 1) layers. Skin subcutaneous tissue superficial fascia deep fascia muscles femur skin is less mobile and innervated by posterior cutaneus nerve of thigh posteriorly lateral cutaneus nerve of thigh laterally deep fascia posteriorly femur anteriorly lateral intermuscular septa laterally posterior intermuscular septa medially biceps femoris, semimembranosus, semitendinosus muscles are located in posterior region of the thigh. 2) Disposition of sciatic nerve. At level of gluteal fold, sciatic nerve is covered by skin, subcutaneous tissue, superficial fascia, deep fascia. At level of upper third of thigh, nerve is covered by long head of biceps femoris muscle. At level middle and lower third, sciatic nerve is located between biceps femoris laterally, semitendinosus and semimembranosus medially. 3) Communication fat of posterior fascial compartment with adjacent region. Sciatic nerve is surrounded by fat and this fat space supply along sciatic nerve communicate with gluteal region. Inferiorly sciatic, this fat space is communicate with fat of popliteal fossa. Anteriorly, along perforated branch of profunda femoris artery, this fat space communicate with adductor compartment of thigh. 4) Projection line of the sciatic nerve. Projection line of sciatic nerve is drawn from middle point of distance between ischial tuberosity and apex of greater trochanter to middle or popliteal fossa. 5) Exposure of the sciatic nerve in the posterior femoral region. Sciatic nerve is exposed along projection line in succession skin, subcutaneous tissue, superficial fascia, deep fascia are cut. Semitendinosus and semimembranosus muscle are retracted medially, biceps femoris laterally.

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No. 23 1) 2) -

Topography of the knee joint Bones, surface landmarks, projection of the articular slit. Bones includes femur, tibis abd patella Surf landmarks : patella, lateral and medial epicondyle of femur, tuberosity of tibia and head of fibula Projection of AS : between condyles of tibia abd femur Places of attachment of the articular capsule, ligaments, muscles. POA of articular capsule corresponse articular surf of femur, tibia abd patella ( fibula not take part ) Ligaments are subdivide into extraarticular and intra-articular Extra-articular : capsule strengthen capsule anterior, medial, posterior and lateral Anterior : capsule strengthen by ligament of patella Eg. Patella ligament medial and lateral, retinacular patella ligament Medial : capsule strengthen by collateral tibia ligament Lateral : capsule strengthen by collateral fibular ligament Posterior : capsule strengthen by arcuate lig and oblique popliteal ligament Intra-articular lig are anterior and posterior cruciate lig and transverse genus lig and meniscus femoral lig Also included intraarticular lig are medial and lateral meniscus which compensate surf tibia and femur coz these surf have no correlation with each other Usually lateral meniscus have O shape and medial meniscus have C shape Muscles :Anterior : Knee joint strengthen by tendon of quadriceps femoris Medial : Semimembranous satorius Lateral : Iliotibial tract and biceps femoris Posterior : Popliteal muscle, medial and lateral head of gastrocnemius muscle Lax places of the capsule. Synovial bursae Lax or weak places of capsule are 9; ( 5 anteriorly and 4 posteriorly ) Are recesses ( R ) or protrution of synovial capsule / fibrous Anterior : sup ant R ( unpair ), sup ant lat R, sup ant med R, inf ant lat R and inf ant med R Posterior : sup post lat R, sup post med R, inf post lat R and inf post med R Around joint, synovial bursa located anterior and posteriorly Anterior : bursi of patella eg. Suprapatellar bursa, prepatellar bursa and infrapatellar bursa ( these bursa not communicate with capsule of knee joint ) Posterior : bursa of medial head of gastrocnemius and semimembranous m ( communicate with capsule, thus pus may spread in inflammation of joint )

3) 4)

Skeletopy of the NVB and possible complications in posterior dislocation of the leg. - popliteal fossa located posteriorly to knee joint - skeletopy of NVB of popliteal fossa in frontal and sagittal plane is NEVA - N ( nerve ) , V ( wein ) , A ( artery )

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Frontal plane : from superior to deeply or post to ant Sagittal plane : from lateral to medial More superior / posterior and lateral = tibial nerve Some more deep / anterior and medial = popliteal vein Even more deeply / anterior and medial = popliteal artery Skeletopy : on the floor of popliteal fossa form by femur capsule of knee joint, popliteal artery located In posteriorly dislocation of leg, tibia is displace backward, popliteal artery may compressed; it has no adequate circulation, no optimal level for ligation; thus gangrene of foot may develop

5)

Puncture of the knee joint. - orientation of puncture is patella ( it has medial and lateral margin ) - made at following points :i) 1 -2 cm laterally from the base or apex of patella ii) 1 -2 cm medially from the base or apex of patella, which are same as - The 4 possible points :superior : medial and lateral inferior : medial and lateral - With 1.5 to 2 cm from patella, needle inserted - If inflammation occurs, size of joint increased

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No. 23 a

Posterior knee region

1) Layers. - layers : in succession; skin subcutaneous tissue, superficial fascia, deep fascia, muscle which form popliteal fossa, floor of popliteal fossa - skin : posteriorly supplied by posterior cutaneous nerve of tight medially by saphenous nerve laterally by lateral cutaneous nerve of tight - in subcutaneous tissue, lower end of post knee region, small saphenous vein passes and vein penetrate superficial fascia, deep fascia form canal for vein and drawn to popliteal vein 2) The walls and floor of the popliteal fossa - popliteal fossa has diamond shape or rhombus and limited superficial and medially by tendon of semitendinous and semimembranous - sup and lat : tendon of biceps femoris - lat and medial : medial head of gastrocnemius - inferior and lat : lateral head of gastrocnemius - floor of popliteal fossa form planum popliteum of femur, capsule of knee joint, popliteal muscle and capsule of knee joint 3) Syntopy and skeletophy of the NVB of the fossa ( in sagittal and frontal plane ) - at upper angle of popliteal fossae, sciatic nerve divided into 2 terminal branch : tibial nerve and common peroneal nerve - tibial nerve consist neurovascular bundle of popliteal fosa - connom peroneal nerve go lateral and pass under tendon of biceps femoris muscle, surround head of fibula to enter anterior region of leg - NVB of popliteal fossa include tibial nerve, popliteal vein & popliteal artery NVA 4) Projection of the popliteal artery - pls refer to No. 23 ( 4 ) 5) Accesses to popliteal artery. Collateral circulation in ligation of popliteal artery - projection line of popliteal artery. Drawn longitudinal by middle from medial of popliteal fossa - surgical excision of popliteal artery maybe longitudinal along S shape and through Joberovs fossa - longitudinal incision drawn through projection line, S shape incision - medial epicondyle of femur, pass down, turn at native crest to head of fibula - give more big surgical excision - incision through Joberovs fossa used when popliteal fossa access not possible - Joberovs fossa = medial angle of popliteal fossa - Joberovs fossa medial surface of tight and knee region - Collateral circulation in ligation of popliteal artery may develop through network around knee joint which is form by femoral perfundus, ant and post tibial artery - Network not enough to compensate in 75% cases

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No. 24

Topography of the back of the leg

1) Layers. Superficial veins ( clinical importance ) - layers are skin, suncutaneous tissue, superficial fascia, deep fascia, superficial muscle, deep layer of deep fascia, deep muscle, tibia-fibulla and anteriossous membrane - scheme : supply along medial margin by sapheneous nerve - med and lat : by med cutaneous surae nerve - lat and post : at upper half by lat cutaneous surae nerve at lower half by surae nerve - below popliteal fossa, small area supply by posterior cutaneous nerve of tight - in subcutaneous fat, superficial vein located along medial margin: great sapheneous vein lateral margin : small sapheneous vein - vein accompany by cutaneous nerve great saphebeous vein by sapheneous nerve small sapheneous vein by surae nerve - these vein have communicating vein pass thru and connect superficial and deep vein - clinical importance : in valve disturbance, retrograde flow of blood develop if varicose of vein develop 2) The superficial and deep grps muscles and fasciae - superficial group consist of 3 : gastrocnemius muscle, soleous muscle and plantaris muscle - they are united forming common tendon called calcaneal of achilles tendon - attach to calcaneal tubercle, deep layer of deep fascia - separate superficially from deep - deep grp of muscle : posterior tibia muscle, flexor hallucis longus, flexor digitorum longus 3) The cruropopliteal canal ( Guber ) - btw superficial and deep muscle group cruropopliteal canal / Guber canal form - cruropopliteal canal limited anterior : post tibial muscle posterior : soleus muscle medial : flexor digitorum longus lateral : flexor hallucis longus 4) The vessles and nerves of cruropopliteal canal. Foramina of cruropopliteal canal and their contents - cruropopliteal canal has 4 foramina, 1 inlet and 3 outlet - in leg foramen is limited anterior : by popliteal muscle posterior : by tendineal arch of soleus

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through this foramen into cruropopliteal canal enter tibial nerve, popliteal artery and vein immediately artery divided into anterior tibia and posterior tibial ant tibia leave cruropopliteal canal through foramen of interosseous membrane to enter anterior compartment of leg inferior outlet is limited medially and anterior tendon of posterior tibia muscle, calcaneum tendon Thru this foramen, cruropopliteal canal, tibial nerve, post tibial artery and vein leave 4th foramen = inferior musculocranial canal Lateral surface of Guber canal and limited Ant : fibula Post : flexor hallucis longus Through it, perineal artery and vein pass Through cruropopleteal canal, tibial nerve, post tibial artery and 2 veins and perineal artery and vein Lat and post : tibial nerve Medial and ant : post tibial artery and post tibial vein Perineal artery and vein located lateral to main NVB

5) Connection of fat of cruropopliteal region with fat of adjavent regions. Clinical importance. Accesses in phelgmon of this fat space - NVB of cruropopliteal fat, surrounded by fat - These fat along bundle communicate with adjacent region Superficial : thru inlet foramen with popliteal fossa Inferior : thru inferior outlet with maleular canal, calcaneal canal, plantal canal and middle plantal fascia space Lat : inferior musculus canal to lateral aspect of ankle Ant : thru foramen of interosseous membrane along at compartment of leg - clinical importance : in phlegmon here may stop pus spread - surgical access : drawn along lateral / medial margin of gastrocnemius muscle, possible one or 2 parallel incision ( medial / lateral )

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No, 25

Topography of the front of the leg

1) Boundaries. Layers - boundaries : superior and horizontal line drawn tuberosity of tibia inferior : horizontal line drawn from base of malleolus medial : vertical line connect medial epicondyle and medial malleolus of tibia lateral : vertical line connect lateral epicondyle of tibia, head and lateral malleolus of fibula - layers : skin, subcutaneous, superficial fascia, deep fascia, medial of anterior and lateral compartment - tibia, fibula and interosseous membrane - skin is thick, less mobile and supply medial margin by sapheneous nerve lateral margin at upper half by lateral sural nerve lateral mergin at lower half by superficial perioneum nerve - at level of tibia, skin directly attach to periosteum of tibia - important in fraction of tibia, if rupture opens - at level tibia very bad blood supply at wound ; long time healing - deep fascia, very strong attach to muscule - very important in purulent / septic wound of leg, anaerobic ( gas gangrene ) develop ( air not penetrate ) 2) Topography of vessels and nerve of the anterior fascial compartment in different part of leg - ant : deep fascia - med : tibia - lat : anterior intermuscular septa - post : interosseous membrane - contains 3 muscular and NVB - muscles are : ant tibial, external digitorum longus, external hallucis longus - NVB : anterior tibia artery and vein and deep perioneum nerve - Syntophy of NVB : upper third : nerve lies lateral, artery medially middle third : nerve cross artery anteriorly lower third : nerve lies medially, artery laterally - at upper third NVB located at medially tibial ant, laterally extensor hallucis longus - at middle and lower third, NVB located medially tibial anterior, laterally extensor longus ( carry out dorsi flexion function ) 3) The lateral compartment of the leg ant : ant intermuscular septa post : post intermuscular septa lateral : deep fascia medial : fibula

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2 muscle in this compartment : perineus longus nad brevis At upper third of compartment, superior musculoperineal canal located Limited by medially : fibula Laterally : by perineus longus muscle at this canal, terminal part of common perineal nerve and its branch superficial perineal nerve pass nerve lies on bone and adjoins to neck of fibula muscle at lateral compartment : by superficial perineal muscle, function : pronation of foot ( raise lat margin )

4) Projection line of anterior tibial artery and deep peroneal nerve - ant tibial line - medial : fr middle point, btw tuberosity of tibia and head of fibula to middle point btw medial and lateral malleolus 5) Exposure of the anterior tibial artery. The collateral circulation in ligation of the posterior artery - in succession, skin, subcutaneous tissue, superficial fascia and deep fascia are cut - ant tibial muscle is retracted medially, extensor digitorum and ??? are retracted laterally - collateral circulation in ligation of ant tibial artery is developed by network around ankle joint formed by 3 arteries - post tibila, ant tibial and peroneal - and foot plantar arch, lateral pedicles formed by dorsalis pedis artery and laterally plantar artery

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Question 26. Topography of the region of the ankle. (CHECKED WITH NOTES) 1) Boundaries. Surface landmarks. Layers. Boundaries: i) Superior horizontal line drawn through bases of lateral & medial malleolus ii) Inferior line drawn through apexes of lateral & medial malleolus through dorsum & plantar surface of foot. Surface landmarks - Lateral & medial malleolus, calcaneal tubercle, calcaneal (Achilles) tendon. Layers - Skin, subcutaneous tissue, superficial fascia, deep fascia - Deep fascia becomes thick and form retinacula : - Medial Retinaculum flexorum - Anterior Retinaculum extensor inferior - Lateral Retinaculum peroneal superior & Retinaculum peroneal inferior. 2) Anterior aspect of the ankle. i) Under retinaculum extensor inferior, which is Y-shaped, tendon of extensor muscles are located. ii) From medial to lateral : - tendons of tibialis anterior, extensor hallucis longus, extensor digitorum longus. - neurovascular bundle is located between tendons of the 2 extensors : Medially Anterior tibial artery Laterally Deep peroneal nerve iii) Below retinaculum extensor inferior, the artery changes name to dorsalis pedis artery. 3) Posterior aspect of the ankle. i) Under deep fascia, calcaneal tendon is located. It attaches to calcaneal tubercle. ii) At the place of attachment, synovial bursa is located. Inflammation may arise in this bursa aftering wearing uncomfortable shoes. iii) Above the attachment, between tendon & bone, loose fat is located. 4) Medial aspect of the ankle. Projection of the posterior tibial artery. Medial aspect of the ankle. i) Below retinaculum flexorum, malleolar canal is located Medially retinaculum flexorum Laterally medial surface of calcaneal bone ii) Through this canal, tendons of flexor muscles & neurovascular bundle passes From anterior & medial to posterior & lateral : - Posterior tibialis muscle, flexor digitorum longus, flexor hallucis longus iii) Between flexor digitorum longus & flexor hallucis longus, neurovascular bundle passes which include posterior tibial artery surrounded by 2 veins &

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tibial nerve. Syntopy : artery medial & anterior, nerve lateral & posterior. iv) At level of inferior margin of retinaculum flexorum, posterior tibial artery & nerve divide into 2 branches lateral & medial plantar artery & nerve. Projection of the posterior tibial artery. Projection of the posterior tibial artery at medial malleolus is located at middle point between medial malleolus & calcaneal (Achilles) tendon. 5) Lateral aspect of the ankle. i) Deep to retinaculum peroneal superior & inferior, 2 tendons pass & branches of peroneal artery & vein located. ii) Under retinaculum peroneal superior, these tendons are located into common peroneal sheath. iii) Under retinaculum peroneal inferior, these tendons are located into individual peroneal sheath because : tendon of peroneal longus attach to tuberosity of 1st metatarsal bone & tendon of peroneal brevis attach to tuberosity of 5th metatarsal bone.

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question 27. Topography of sole of foot 1) Pecularity og structure of skin & subcutaneous tissues of the sole. Projection of sulcus. Skin: thick, no hair, contain sebaceous gland, not mobile because skin is attached to aponeurosis by fibrous septa subcutaneous tissue: -lobular structure -during inflammation, pus is localized because pus is separated by fibous septa

2) Plantar aponeurosis Plantar aponeurosis lie on palmar surface has triangular shape apexof triangle: calcaneous base of triangle: base of proximal phalanges At the level of base, fibers of aponeurosis split to 3 commisural foramen Commissural foramen is filled by loose fat & digital neurovascualar bundle Plantar aponeurosis gives off medial & lateral septa Medial septa attached to interosseal fascia at 1st metatarsal bone Lateral septa at 5th metatarsal bone

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Deep fascia + plantar aponeurosis + lateral + medial septa + interosseous fascia form 4 fascia spaces: medial, lateral, middle & interosseal muscles spaces [palmar: 3 spaces] 3) Fascial spaces of the soles. Muscles Medial fascial space- limited: inferior & medial deep fascia lateral medial intermuscular septa superior 1st metatarsal bone contain: flexor hallucis brevis, abductor hallucis brevis, tendon of flexor hallucis longus muscle lateral fascial space- limited: inferior & lateral deep fascia medial intermuscular septa superior 5th metatarsal bone contain: opposer digiti minimi, abductor digiti minimi, flexor digiti minimi brevis middle fascial space- limited: inferior plantar aponeurosis superior interosseous fascia medial medial septa lateral lateral septa Deep layer of deep fascia divide middle fascial space into 2: superficial & deep space Superficial space- limited: inferior aponeuorosis Superiordeep layer of deep fascia Medial & lateral septa Contain:flexor digititorum brevis Deep space is limited at distal part, inferior deep layer of deep fascia Superior interosseous fascia Proximally by long plantar ligament Medial & laterally septa Contain: quadratus plantae, tendon of flexor digitorum longus with lumbrical muscles, adductor hallucis, tendon of peroneus longus 4) Sulcuses, canals, vessels & nerves 2 sulcuses: medial & lateral plantar sulcus

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medial plantar sulcus limited: medial abductor hallucis muscle lateral flexor digiti brevis content: medial plantar artery, vein, nerve pass lateral plantar sulcus limited: medial flexor digiti brevis lateral abductor digiti minimi conetent: artery, vein, nerve pass canal: Plantar & calcaneal canal communicate with each other Plantar canal located at the proximal part of deep slit of middle fascia limited- superior: long plantar ligament inferior: deep layer of deep fascia Proximally plantar canal communicate with calcaneal canal Calcaneal canal limited: medial abductor hallucis (beginning part) Lateral inframedial surface of calcaneus 5) Communication of fat. Ways of pus spreading. Fat space of sole located in 3 fat spaces: medial, lateral & middle Medial & lateral: closed, no pus spreading Middle: opened, phlegmon & pus may spread distally & proximally From superficial slit, pus may spread through commissural foramina along digital neurovascular bundle to subcutaneous fat of fingers, through perforating foramen of aponeurosis to subcutaneous of sole From deep slit, pus spread along plantar canal, calcaneal canal, maleollar canal to curalpopliteal canal Distally:- along lumbricals muscle through lumbrical canal, through dorsum of fingers & interdigital space; or, - along plantar arch which formed by lateral plantar artery & deep plantar artery, pus spread on dorsum of foot Medial & lateral: closed, no pus spreading Middle: opened, phlegmon & pus may spread distally & proximally From superficial slit, pus may spread through commissural foramina along digital neurovascular bundle to subcutaneous fat of fingers, through perforating foramen of aponeurosis to subcutaneous of sole From deep slit, pus spread along plantar canal, calcaneal canal, maleollar canal to curalpopliteal canal Distally:- along lumbricals muscle through lumbrical canal, through dorsum of fingers & interdigital space; or, - along plantar arch which formed by lateral plantar artery & deep plantar artery, pus spread on dorsum of foot

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Question 28. Operation on the vessels and nerves. 1. Suturing and suture materials Modern vascular suture was decribed by Kavyos. Kavyos suture consists of 3 stretch suture. Stretching of suture allow to carrying out of evertion of intima outside. Between stay suture, simple continue or simple interrupted suture are put. Distance between suture = 1mm. Vascular suture maybe manual and mechanical. Mechanical suture is made by special apparatus like tandal, stapler and tandal dip. Modern suture include interrupted mattress or continue mattress, suture which accept suture material into lumen of vessel. Suture material for arteries are non-absorble, while for vein are absorble. Poly or multiforamen thread and monoforamen thread is used.

2. Vascular anastomosis. - Vascular anatomosis maybe bypass or straight connect both end of vessels directly or thru prothesis. - If area of damage artery less than 4cm, possible direct connection both end of vessels. - If damage of artery more than 4cm, this fragment is resected. Artificial exogenous or autogenous venous graft can compesate this defect. - Usual type of anastomoses are 1. end to end 2. end to site 3. side to end ( Never use site to site) 3. Microvascular surgery. - Microvascular surgery is operation of vessel using operative microscope, ____ instrument, very thin suture material and special skill with the help of microscope. - Microvascular technique allows connection of vessels which diameter of 0.3mm 0.5mm. - Development of microvascular technique allows to carry out reimplantation and reattachment of extremities, transplantation of fingers, foot and hands, transplantation of organs, carry out pre-graft in plastis surgery. 4. Surgical repair of divided nerves. Result of operation of cutting of nerve depends on time, condition of wound and technique. Surgical repair of nerve include manual suture of nerve by using macrosurgical and microsurgical technique. Macrosurgical technique of suture of nerve is called epineural suture. See Pic 28.4 After tying this suture between two end of nerve, distance of 1mm must present. ( for continue growing central ) 5. Peculiarity of the suture of the nerve with using of microsurgical technique. In microsurgical technique to fix Stretching of dividing nerve of perineuron fibers. Firstly, we do suture. In this suture we never use distance of 1mm. (its called perineuron suture) See Pic 28.5.

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Question 29. Ligation of the brachial artery along the length. 1. The line of the projection of the brachial artery on the arm. -The projection line of brachial artery is drawn from top of axillary fossa along medial bicipital sulcus to middle point between tendon of biceps muscle and medial epicondyle. 2. Syntopy of the brachial artery on different level. -At level upper 3rd, brachial artery lies medially, median nerve laterally. -Middle 3rd, nerve crosses artery anteriorly. - Lower 3rd, median nerve medially. - Laterally to main neurovascular bundle along all lying musculocutaneous nerve passes. - Medially to main neurovascular bundle, ulnar nerve located. 3. Optimum level of the ligation of the brachial artery on the arm. - optimal level of ligation of brachial artery on arm is located between arising profunda brachial artery. 4. Ligation of the brachial artery in cubital fossa. Line of incision, orientation for finding artery. -Brachial artery maybe located into cubital fossa. -Projection line of cut in cubital fossa is drawn along medial margin of tendon of biceps brachial muscle. -Line for incision for exposure brachial artery is drawn from point which is located 2cm above medial epicondyle thru middle of cubital fossa to lateral margin of forearm. - Incision is made from middle 1/3 of this line. Orientation of finding brachial artery in cubital fossa is tendon of bicep muscle. 5. Collateral circulation in ligation of the brachial artery. - Brachial artery + profunda brachial artery gives collateral branches; i.e, collateral radial superior and anterior; & collateral ulnar anterior and posterior.

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Question 30. Exposure and ligation of the popliteal artery. 1. Indication to operations. i. trauma of artery ii. aneurysm of artery iii. acute and chronic occlusion of popliteal artery. 2. Access to popliteal artery. -Longitudinal along projection line thru middle of popliteal fossa. S shape incision start from medial epicondyle of tendon pass to middle of popliteal fossa to lateral margin of leg. 3. Syntopy and skeletopy of the popliteal artery. -syntopy of neurovascular bundle in popliteal fossa is NeVA (Nerve, Vein , Artery). -Popliteal artery occupy more medial and anteriorly or deep position. Vein lies at floor of popliteal fossa which is form by triangle shape of femur, capsule of the knee joint and popliteal muscle. 4. Acesses through Joberovs fossa. Walls of the Joberovs fossa. - Acceses to Joberovs fossa is used when surgical access to popliteal fossa is imposible. -Joberovs fossa correspond medial angle of popliteal fossa. Inferiorly by medial epicondyle of femur and medial head of gastronemius muscle. Superiorly, by Satorius muscles. Anteriorly, by adductor magnus. Posteriorly by semimembranous, semitendionosus muscle. - Incision is made longitudinal along medial suture of thigh along Gracilis muscle. - In succession following layer is cutted: Skin, subcutaneous tissue, superior fascia, fascia lata, abductor magnus is retracted laterally, semitendinosus are retracted posteriorly and artery is exposed. 5. Collateral circulation in ligation of the popliteal artery. -Femoral artery gives off descending genicular artery, popliteal artery gives of superior genicular lateral and medial, inferior genicular (lateral and medial) which form network around knee joint. -From anterior and posterior tibial artery, collateral artery arises which also fall part in form of network around knee joint.

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Question 31 Common principles amputation of extremities. 1. Definition of the amputation and exarticulation. -Amputation is removal of distal part of extremities thru bone. -exarticulation / disarticulation is removal of distal part of extremities thru joint. 2. indication. - 5 group. i. trauma ii. gangrene iii. malignant tumour of bone and soft tissue of extremities. iv. chronic infection resistant to treatment and endanger to life of patient. e.g osteomyelitis v. deformities (congenital or acquired). 3. Classification amputations on time criterion and in accordance with the form of incision of soft tissue. Classification of amputation i. primary ii. secondary iii. recurrent amputation. -Primary amputation is removal of distal part of extremities during 24 hour from trauma. Its the primary treatment of wound. -secondary amputation is removal of extremities after 6-7 days , (from beginning of disease/ trauma) - recurrent amputation is after primary and secondary amputation. Usually indication for pathological stunned. Classification of amputation according to incision of soft tissue include. i. circular ii. amputation using flaps iii. ellipsoid and racquet shape -Circular amputation is made perpendicular to axis of bone and is divided into 1 moment, 2 moment and 3 moment amputation. - 1 moment amputation = is called gelatin amputation ( all tissue from skin till bone are cut by it), after this, always reamputation is made. Only use in anaerobic gas gangrene. - 2 moment: i. cutting skin, subcutaneous tissue, superficial fascia. ii. muscles till bone along margin of contracting and retracting up skin. - 3 moment. i. cut skin, subcutaneous tissue, superficial fascia. ii. cut deep muscle till bone. - Amputation using flap divided into

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a. Single flap b. Double flap (divide in to 2 equal and unequal flaps) -Size of both flaps and single flap muscle equal diameter of extremities at level cutting of bone plus 3-6cm on contracting of tissue. - ellipsoid amputation and racquet shape amputation soft tissue are cut under angle of axis of bone and occupy intermediate position between circular amputation using flap. 4.Pecularity amputations in children In children bone have zone of growth connect to metastasis In children, thr. lower d upper part of ext. impass possible frm. middle 3rd exarticulation removal of joint In children presence risk of ischemia of end of cutting bone, in treatment periosteum, only subperiosteum bone is used In amputation thr. leg, surgeon must cut fibula 4-10 cm to tibia coz. fibula grow quickly than tibia 5. Amputation through the forearm May in 3 ways: Inferior 3 middle 3 upper 3 through lower 3rd , circular to moment amputation( tendoplastic) inner perpendicular got 2 moments: incision perpendicular axis, cut skin, subcutaneous tissue, superficial fascia cut muscle till bone, at level concentrating d retraction skin above end radius d ulnar, tendon after treat periosteum tendon of flexor extensor muscle stich together (tendoplasty) tendon covered by 2 row above is skin at level middle 3rd d upper 3rd amputation using 2 unequal flap (myoplastic) are used usually ant. flab is long, post. is short above ulna-radius muscle stich to each other

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32. Amputation and exarticulation of the fingers on the hand 1.Exarticulation of the phalanges.Surface marking of the joints Removal through joint- exarticulation Amputation removal of bone Before exarticulation surgeon must known projection articular slit Must know surface making Under anesthesia, max flex finger see protusion of nuckle of metacarpal bone 3mm below, 6mm, 12 mm protusion point of knuckle Or phleb divide palmar d distal, connect through phalanx for removal of phalanx both part Apart start from dorsum, surgeon take sca;pel enter in joint, by scissors cut lateral lig Cut horizontally put palmar flab-opr. Using single palmar flab on dorsum scar tissue only After removal phalanx fix bycentral, middle,lateral Then, skin cover subcutaneous tissue & fix. Medially & lateral( 3 suture: central, medial, lateral) 2.Amputation phalanx of the finger Made thr. Bone (Phreg @ forsep Lonus cutting) Opposite to exarticulation start from dorsum, amputation start from palmar Form horse-shoe flab End of flap connect to dorsum Cut bone d remove it Flab close and fixate by 3 suture Avoid digital nerve d blood vessel damage 3.Amputation of the thumb This is one of eg. Of ellipsoid incision of soft tissue, but circular & under proximal part is dorsum After ellipsoid of soft tissue, surgeon but thr. Metacarpal bone ( open) Cut capsule, lat d medial lig X cut transverse, scalpel thr. Oblique On ant. Surface of Capsule, sesamoid bone located In bone protection, X remove metacarpal, compensate f-n of 1 st finger For protection of sesamoid bone 4.Exarticulation of II and V fingers at the metacarpophalangeal joint Using single flab 2 & 5 finger 2-radial and palmar 5-ulna and palmar

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5TH: head metacarpal direct middle ulnar surface descent into interdigital surface.start from end to middle dorsum, cont. to palmar return to fist,scar on radial and dorsum 2nd: headmedial of radialpalmar surface, interdigital Flab close to dorsum Scar on ulna & dorsum

5.Exarticulation of III and IV fingers at the metacarpophalangeal joint Got 2 method: Lupet & Rachet shape Lupet: include 2 incision circular thr. Interdigital and perpendicular to metacarpal( T shape)

Will have 2 equal flap, X cut 90 angle coz. Bad circulation or maybe ischemia necrosis Rachet:

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33. Amputation through the thigh 1. Indications Same answer with 31(2) 2. Types amputation through the thigh There are 3 levels: lower third, middle third & upper third. Amputation lower third are osteoplastic according to Givanosky & tendoplastic according to calender. Amputation middle third are 3 momentum according to Piragoff. Using 2 equal flab. Amputation upper third using 2 unequal flab. At the level middle third, myoplasty (above bone, muscle stich). 3. Three- moment amputation according to Piragoff It is made through middle 3rd of thight. 1st moment include fatty skin, subcutaneous tissue & superfacial fascia. 2nd moment include superfacial muscle having no attachment to femur along the margin of contracting skin. 3rd moment include deep muscle attached to bone of femur till the bone at the level of contraction & retraction without skin & superficial muscle. After separation of extremity , connection is seen. Formation of wall by deep & superfacial muscle

4. Method of working of the periosteum There are 3 methods: aperiosteal, periosteal & subperiosteal. Aperiosteal is commonly for adults & subperiosteal commonly for children. Aperiosteal include circular cutting of periosteal by scapel according to Faraber. Periosteum is displaced in removal part of extremity (healthy part). Subperiosteal is opposite periosteum external circular, at healthy part of extremity. End of bone covered by periosteum.

5. Ligation of the vessels and cutting of the nerves

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Ligation of the vessels In trauma, tourniquet is applied. Applied without bleeding, surgeon ligate vessel. Truncal vessel according to Piragoff law (3rd law). Vein & artery ligated separately from each other. Distal & proximal by absorble maternal distal ligatura. Penetrate by suture of vessel. Great vessel by tuligatura @ hemostatic. Small vessel by turnicatura. Malignant tumour, cannot use tourniquet. Cutting of the nerves Nerve not involve in scar tissue. Use very thin blade for shaving. Then put into hemostatic forceps. Local anesthetic before shaving, to prevent shock. Quickly cut the nerve in one movement . For trunk, sciatic nerve, median nerve & tibial nerve, the distance is 5cm above from wound. Cut nerve 2cm above from margin (always cut above the wound) May cause phantom syndrome @ severe pain.

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34.Amputation of lower extremities 1. Indication for amputations Same answer with 32(2) 2. Amputation through the leg There are made in 3 levels: inferior 3rd, middle 3rd & upper 3rd. More often, middle 3rd & lower 3rd are used because in this level, protection is good. Lower 3rd : Amputation Osteoplastic Piragoff. Middle 3rd : Amputation facial plastic. Using 2 unequal flab. Anterior layer past short. Upper 3rd : Amputation 2 unequal flab. Anterior layer past short but give contraction. 3. Piragoffs amputation (osteoplastic) Made through lower 3rd of leg, above Talacrural articulation. Amputation include 2 incision connecting apexes of lateral & medial malleolus. 1st incision made through foot connecting both malleolus. 2nd incision made through dorsum connecting both apexes. After dorsal incision, open capsule of ankle joint. Then, insert amputation knive, cut capsule from inside outside laterally to prevent cut through arteries. This will cause foot drop. Take saw & cut calcaneal bone. Then, cut above tibial to cut fibula (3-4 cm) After cutting the bone, fragment of calcaneal born stick to tibia (bone closed by bone) Natural support is possible with orthopedic shoes (length is decreased 1-2 cm) 4. Osteoplastic amputation of the thigh according to Gritty-Shimanovsky Made through lower 3rd of thigh above knee joint. Amputation using 2 unequal flabs. Horse shoe incision through epicondyle (anterior). Pass tuberosity of tibia. Short posterior flab through medial of popliteal fossa. Anterior long, posterior short. Cut patellar ligament, then retract ligament up till patella. Patella end in frontal plane without open joint. After patella fragment cut, retraction with tendon of quadrisep femoris. Then femur is cut & fraction of patella fixated. 5. Advantages and shortcomings of the osteoplastic amputation Advantages Natural support in area near calcaneal bone & patella, help to use proteases.

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Shortcomings The technique is difficult. Must protect the vessel, it cut could lead to aseptic necrosis. Must fixate the bone properly, if not wont heal. 35. Topography of the frontoparietooccipital region. 1. Boundaries Ant:supraorbital margin Post:external occipital protuberance & sup. Nuchal line Lat:superior nuchal line 2. Succession of the layers and their structures Skin, subcutaneous tissue, muscular aponeurosis, subaponeurosis,, fat spaces, periosteum, subperiosteal fat space, bone , scull cap Skinthick, X mobility coz. By septa connected to muscular aponeurosis layer, contain hair follicle & sabecous gland. Muscle aponeurosis layer: got 2 muscle, frontal & occipital conn. To gallia aponeurotica Periosteum: have loss connection w Bone exepting sutures, ( strong attachment periosteum to bone) 3. Fat spaces: peculiarity of the structure, boundaries o Got 3: subcutaneous Subaponeurosis Subperiosteal o Subantaneus: have lobular str. Bcoz fib. Septa connecting skin d muscle aponeurosis divide fat to many layer, pus have local character o Subaponeurotic: contain loose fat, space is closed limited by: Ant:supraorbital margin Post:sup. Nuchal line Lat:sup. Temporal line o Subperiosteal: also contain loose fat, fat divide to attachment to periosteum to suture, o Hematoma maybe limited by frontal-occipital-R parietal-L parietal 4. The blood supply and sensory nerve supply of the scalp Blood supply d innervation frontal part supply by Supraorbital & supracostal arise. Frm. Internal carotid Parietal supply by branch external carotid Occipital part by branch of external carotid (occipital art) All artery communicate between int. & external carotid artery and R & L heart non surgical line 60

Innervation: Frontal: supply supraorbital & supratrochlear, Parietal: innervate mandibular division of trigeminal Occipital: > & occipital nerve by spinal N

5. Pecularity of the structure of the skull cap 3 layers: External compact plate Internal compact plate Bet. The diploic subs. Incl. vein Vein: got 4-frontal Ant. Temporal Post. Temporal Occipital temporal Inter compact plate= called vitrous space, cause easy rupture If got traumaX-ray Internal plate may. easy fracture External plate resist fracture

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Question 36. Topography of the temporal region. 1) Boundaries & layers. a) Boundaries Anterior, superior, posterior Superior temporal line Inferior Zygomatic arch b) Layers - Skin, subcutaneous tissue, superficial fascia, deep fascia (temporal aponeurosis), subaponeurotic fat space, temporal muscles, periosteum, bones which form temporal fossa. - Deep fascia is divided into 2 :- superficial & deep - Between layers of deep fascia interaponeurotic fat space 2) Fat spaces. a) Subcutaneous i) At area where absent here loose structure ii) At area where present here lobular structure b) Interaponeurotic - Closed & limited : i) Laterally superficial layer of temporal aponeurosis ii) Medially deep layer of temporal aponeurosis iii) Inferiorly - zygomatic arch c) Subaponeurotic - Limited : i) Medially temporal muscle ii) Laterally deep layer of temporal aponeurosis 3) Topography of vessels and nerves. - Main neurovascular bundle of temporal region is located in subcutaneous fat. These r: i) Anterior - superficial temporal artery & vein (branch of external carotid artery) ii) Post - auricular temporal nerve (branch of mandibular division of trigeminal n.) - Within temporal muscle, deep temporal artery, vein & nerve are located i) Artery (usually 2) branches of maxillary artery ii) Nerve (usually 2) branch of mandibular division of trigeminal nerve 4) Disposition of the middle meningeal artery. i) Middle meningeal artery enter cranial cavity by spinous foramen & then lies into groove on inner surface of bones which form temporal fossa. ii) At level middle of zygomatic arch, artery divides 2 branches ant & post. iii) Clinical importance bone of temporal fossa is thin. Fracture damage of artery Epidural haematoma 5) Projection of the middle meningeal artery & its branches on scheme of craniocerebral topography of Kronlein. i) Trunk of middle meningeal artery project at point of intersection of inferior horizontal line & anterior vertical line. ii) Anterior of middle meningeal artery project at point of intersection of superior horizontal line & anterior vertical line. iii) Posterior of middle meningeal artery project at point of intersection of superior horizontal line & posterior vertical line.

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question 37. The dura mater of the brain 1) septa of the dura mater & their function Dura mater is outer meninges of brain & it gives off septa At level of fornix, dura mater is loosely attached to bone At level of base, dura mater is strongly attached to bone Therefore, epidura. Septa of dura mater include: falx cerebri, tentorium cerebelli, falx cerebelli, diaphragma sellae falx cerebri- divides cerebral hemisphere into 2 falx cerebelli- divides cerebellum hemisphere into 2 diaphragma sellae- allows passage of infundibulum & hypohysis Function of dura mater: formation of inner skeleton of cranial cavity to protect brain by restricting rotatory displacement of brain 2) the cranial venous sinuses Cranial venous sinuses situated between layers of dura mater especially at place of attachement of dura mater to bone in septa of dura mater 2 types of cranial venous sinuses: sinus of fornix & sinus of base Sinus of fornix 1. superior sagittal sinus: occupies upper fixed margin of falx cerebri 2. inferior sagittal sinus: lies in free margin of falx cerebri 3. strainght sinus: lies in line of junction of flax cerebri with tentorium cerebelli 4. occipital sinus: lies in fixed margin of falx cerebelli Sinus of base-usually paired sinuses right & left ; the following succession is from anterior to posterior: 1. sphenoparietal sinus right & left 2 3. superior petrosal sinus right & left 4. inferior petrosal sinus right & left 5. transverse sinus right & left 6. sigmoid sinus right & left 7. basilar sinus right & left there may be one or more basilar venous plexus 3) communications sinuses between them & veins of the brain Superior sagittal sinus: drain into confluence sinus if confluence present Drain into right transverse sinus if confluence absent Inferior sagittal sinus: join to great cerebral vein at margin of tentorium cerebrii into straight sinus Straight sinus: drain into confluence sinus if confluence present Drain into left transverse sinus if confluence absent Right sigmoid sinus continue into right sigmoid 63

Left sigmoid sinus continue into left sigmoid Sigmoid sinus: drain into internal jugular vein Right & left sphenoparietal sinus: drain into right & left cavernous sinus Right & left cavernous sinus: communicate with each other by anterior & posterior intercavernous sinus, forming venous ring around sella turcica Right & left superior petrosal sinus: connecting cavernous sinus with transverse sinus Right & left inferior petrosal sinus: connecting cavernous sinus with sigmoid sinus, or directly drain into bulb of internal jugular vein Occipital sinus: anteriorly-communicate with margin of sinus Posteriorly- communicate with confluence of sinus with either right & left transverse sinus Sinus of fornix: communicate with sinus of base by commucating with cerebral veins Great communicating vein according to Trallal ????? Small communicating vein according to Labell ?? Tralas vein connect superior sagittal sinus with cavernous Labells vein conncet carvernous sinus with one of the transverse sinuses 4) emissary veins (true & false) Emissary veins: are direct communicating vein which connecting extracranial venous system with intracranial venous system emissary veins divided into: true ( having proper foramen into bone, varies in sizes) constant: emissary parietal, emissary mastoid, emissary occipital inconstant: emissary foramen cecum, emissary candilal false ( without proper foramen into bone) 1. emissary foramen ovale: transmit mandibular & lesser petrosal nerve 2. emissary foramen rotundum: transmit maxillary division of trigeminal nerve 3. emissary foramen spinosum: transmit middle menigeal artery 4. emissary foramen lacerum: transmit internal carotid artery 5) critical of dangerous zone of the head. Communications of the venous system of the critical zone with intercranial venous system. Practical importance. Dangerous zone: is the place of inflammation Inflammation can spread from dangerous zone into intracranial cavity leading intracranial complication Dangerous zone is divided into cerebral & facial Dangerous zone of cerebral: parietal, occipital, mastoid Dangerous zone of facial: 1. mucous membrane of nasal cavity 2. upper & lower lips 3. nasal labia triangle: nostril, septa, nasal buccal, nasal labial of fold of upper & lower lips, oral cavity especially premolar & molar communication: cerebral: on parietal area- superficial vein communicate with superior sagittal sinus through parietal emissary vein

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on occipital area- superficial vein communicate with occipital & transverse sinus through occipital emissary vein on mastoid area- superficial vein communicate with sigmoid sinus through mastoid emissary vein facial- extracranial system divided into superficial & deep superficial: including fascial vein & its distribution 1. facial vein at middle angle of eye communicating with angular vein 2. angular vein communicate with superior ophthalmic vein & drain blood into deep: trigate venous plexus communicate with cavernous sinus directly through emissary vein of foramen rotundum & ovale to cavernous sinus through inferior ophthalmic vein to cavernous sinus

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question 38. Cranial meninges. 1) The dura mater of the brain and its spaces. Dura mater is the outer meninx of the brain It consists of 2 layers and gives off septa which form the inner skeleton of the cranial cavity. Septa: -falx cerebri -tentarium cerebelli -falx cerebelli -diaphragmus sela turcica Dura mater forms spaces where hematoma can occur. Between bone of skull cap and dura mater, epidural space is formed. Epidural space is present only on fornix because of lose connection. Subdural space between dura mater and arachnoid mater. 2) The arachnoid mater. The arachnoid mater is the middle or 2nd meninx of the brain. It has no vessels and it never enters sulcuses of brain. It is separated from dura mater by subdural space and from pia mater by subarachnoid space. Arachnoid mater forms channels, by these CSF drains into venous system. 3) The subarachnoid space and cisterns. It is between arachnoid mater and pia mater Contains CSF, and the wider part of the space is called cistern. The cisterns are: -cerebellarmedullar -chiasmatic -pontine -interpeduncular Subarachnoid space of brain communicates with subarachnoid space of spinal cord. 4) The pia mater. The ventricles of the brain. Pia mater directly joins to brain. It enters sulcuses contains vessels and enters lateral ventricle of the brain. In the lateral ventricles, it forms arachnoid plexuses which produce CSF. Ventricles of brain are formed: -right and left ventricles -3rd ventricle -4th ventricle Ventricles communicate with one another. Both lateral ventricles by means of interventricular foramen communicate with 3rd ventricle. 66

3rd ventricle by aqueduct communicates with 4th ventricle. 4th ventricle communicates with central canal of spinal cord and with subarachnoid fat space.

5)Circulation of the cerebro spinal fluid. Hydrocephalus. Hydrocephalus is the abnormal accumulation of CSF in the ventricles of brain and in subarachnoid space. It may be congenital of acquired. Congenital: -usually due to increased production or damage of drainage Acquired: -after trauma-adhesions develop -in tumour- disrupt circulation

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39. Topography of the base of the skull. 1) Topography of the anterior cranial fossa: walls, floor, boundaries, vessels and nerves passing through foramina. Base of skull consists of 3 fossa. Anterior fossa- anteriorly - frontal bone - posteriorly- lesser wing and chiasmatic sulcus - floor- orbital plate of frontal bone and cribiform plate. Floor of the cranial fossa is also roof of nasal cavity, superior wall of orbital cavity and posterior wall of frontal and paranasal sinus. Vessels and nerves- foramen caecum transmit emissary vein of foramen caesum which connects venous plexus of mucous membrane of nasal cavity with superior saggital sinus. Through cribiform foramen- olfactory nerves, ethmoidal nerves and anterior& posterior vessels pass. 2)Topography of the middle cranial fossa: walls, floor, boundaries. Anteriorly - lesser wing and chiasmatic sulcus -superior margin of petrous part. Floor- right and left lateral and central part Lateral of floor- formed by squamous part of temporal and parietal bones. Central part- body of sphenoid bone on which sela turcica and hypophysis located. 3) Vessels and nerves passing through foramina of the middle cranial fossa. From anterior to posterior; Optic canal - optic nerve -ophthalmic artery Superior orbital fissures -ocolomotor nerve -trochlear nerve -abducent nerve -ophthalmic division of trigeminal nerve -superior and inferior ophthalmic veins Foramen rotundum -maximal division of trigeminal nerve Foramen ovale-mandibular division of trigeminal nerva Foramen spinosum -middle meningeal artery Foramen lacerum -internal carotid artery Trigeminal impression (in apex of pyramid)- ganglion of trigeminal nerve located. 4) Syntopy vessels and nerves with cavernous sinus. Clinical importance.

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The artery may rupture in artherosclerosis, aneurism, rupture of base of skull, cavernocarotid shunt may develop which causes compression and damage of veins. Clinical picture: i) pulsating exophthalmus ii) disturbance of eye movement. 5) Topography of the posterior cranial fossa: anatomical structures passing through foramina. Posterior cranial fossa - anteriorly- superior margin of pyramid and back of sela turcica. -posterior- squamous part of occipital bone. In central fossa -foramen magnum through which pass medulla oblongata with meninges, vertebral arteries, spinal roots of accessory nerves and vertebral venous plexuses. On lateral wall, a little anterior to foramen- hypoglossal foramen transmitting hypoglossal nerve. Lateral and anterior to foramen- jugular foramen transmitting internal jugular vein, 9th, 10th & 11th cranial nerves. On posteriorsurface of pyramid, internal acoustic pyramid transmitting facial and vestibulocochlear nerves.

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Question 40: Topography of the main intercranial structures 1) Scheme of cranio-cerebral topography according to Kronlein -scheme include 2 horizontal lines, 3 vertical lines and a sagittal line - inferior horizontal line is drawn from inferior orbital margin along zygomatic arch and superior margin of external acoustic meatus - superior horizontal line is drawn from superior orbital margin parallel to inferior horizontal line - anterior vertical line is drawn from middle of zygomatic arch - middle vertical line is drawn from temporomandibular joint - posterior vertical line is drawn from posterior point of base of mastoid process - sagittal line is drawn from base of the nose to external occipital protuberence 2) Projection of the trunk of the middle meningeal artery and its branches - projection of trunk of middle meningeal artery on scheme according to Kronlein is located at point of intersection inferior horizontal line and anterior vertical line or at middle of zygomatic arch - projection of anterior branch of middle meningeal artery on scheme is located at point of intersection superior horizontal line and anterior vertical line - projection of posterior branch of middle meningeal artery is located at point of intersection superior horizontal line with posterior vertical line 3) Projection of the superior sagittal sinus - superior sagittal sinus occupy fix mrgin of falx cerebri from crista galley to tentorium cerebelli ad is projected along sagital line from base of nose to external occipital protruberence 4) Projection of the central sulcus (Roland) - projection of central sulcus (Rolands sulcus) is located on line connecting point of intersection of posterior vertical line and point of intersection superior horizontal line with anterior vertical line - Roland sulcus occupy this line between middle vertical and posterior vertical line 5) Projection of the lateral sulcus (Silviev) and parieto-occipital sulcus - projection of lateral sulcus (Sylvii sulcus) is located on bicipator of the angle between superior horizontal line and line of projection of central sulcus - parietotemporal sulcus is projected on line which is drawn through point between superior 3rd of part of sagital line locating between superior horizontal line and projection of lateral sulcus

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Question 41: Topography of the buccal and parotid regions 1) Boundaries. Layers. - buccal region is limited: ~ superiorly: inferior orbital margin ~ inferiorly: margin of mandible ~ medially: naso-buccal and naso-labii folds ~ laterally: anterior margin of masseter muscle - boundaries of the parotid region: ~ superiorly: zygomatic arch ~ inferiorly: margin of mandible ~ medial and anterior: anterior margin of masseter muscle ~ lateral and posterior: margin of ramus of mandible, external acoustic meatus, sternocleidomastoid muscle - layers of the buccal region: ~ skin ~ subcutaneous tissue ~ superficial fat space (absent deep fascia) ~ mimic muscle around nose, upper and lower lips ~ buccinator muscle ~ between buccinator and masseter muscle, fat pad body of the cheek is located or limited by proper fascia ~ skin of buccal area is thin, elastic and easy mobile - layers of parotid region: ~ skin ~ subcutaneous tissue ~ superficial fascia ~ deep fascia ~ parotid gland ~ masseter muscle ~ ramus of mandible 2) Venous drainage of the face - venous drainage of the face consists of 2 system: ~ superficial system ~ deep system - superficial system include fascial vein and its tributaries - deep system include pterygoid venous plexus and tributaries - superficial and deep system communicate with each other via deep fascial vein - veins of face doesnt have valve and in congestion, in inflammated infiltration, possible retrograde flow of blood - fascial vein at level medial angle of eye communicate with angular vein - angular vein s tributaries of superior ophthalmic vein - superior ophthalmic vein enter cranial cavity through superior orbital fissure and drain to cavernous sinus - pterygoid venous system also communicate with cavernous sinus via 2 ways:

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~ long: through inferior orbital fissure pterygoid venous plexus inferior ophthalmic vein superior orbital fissure cavernous sinus ~ short: pterygoid venous plexus cavernous sinus via foramen ovale, foramn rotundum and foramen lacerum - dangerous zone: i) superficially is the nasal labial triangle upper and lower lids ii) deeply is the pterygoid venous plexus region where the premolar and molar teeth are located and occurs mainly due to dental karies 3) Vessels and nerves of the face - skin of face is supplied by terminal branches of trigeminal nerve which enter into face via supraorbital, infraorbital and mental foramen - this foramen are located in one vertical line - infraorbital foramen is projected 0.5cm below inferior orbital line - mimic muscle is accompanied by facial nerve - at level point of intersection anterior margin of masseter muscle with margin of mandible, on face appear facial artery - here can count pulsation - artery located anterior to vein with spiral way to medial angle of eye 4) The parotid gland. Weak places. Clinical importance - parotid gland is surrounded by deep fascia of parotid region a.k.a. parotidomasseteric fascia because this fascia form capsule of parotid gland and sheath of masseter muscle - deep fascia gives off septa within gland dividing into lobules - therefore purulent inflammation in gland will have local character - capsule of gland has 2 weak places, and clinical importance is possible pus spread to adjacent region i.e: ~ posterior superior weak place near cartilage part of external acoustic meatus ~ medial or pterygoid process on gland (i.e. pharyngeal process adjoining to pharynx) - through superior posterior weak place, pus may spread to external acoustic meatus and stimulate or lead to external acoustic otitis - in medial weak place, pus may spread to anterior part if peripharyngeal fat space - through gland following structures pass: ~ external carotid artery ~ retromandible vein ~ facial nerve ~ auricular temporal nerve - within gland, lymph node are located i.e superficial and deep - more often, source of inflammation of gland is adenophlegmon of lymph node - presence of vessels leads to erosive bleeding 5) Topography of the fascial nerve - facial nerve leave cranial cavity through stylomastoid foramen and duct downward and then from angle 90 degrees to enter parotid gland - within parotid gland, facial nerve divide into terminal branch which maybe compared with fingers of hand and these are:

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~ temporal branch = supplies frontal muscle ~ zygomatic branch = muscle around eyes ~ buccal branch = buccinator muscle and upper lip muscle ~ margin of mandible = muscle of lower lip and around oral cavity ~ cranial branch = mimic muscle of neck, platysma of neck NB: nerve of branch depend on direction

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Question 42: Topography of the infratemporal region a) Disposition of the deep region of the face - deep region of the face consists of 2 parts: ~ infratemporal fossa ~deep fat space of the face - infratemporal region is located between tuber of maxilla anteriorly and medially and ramus of mandible posteriorly and laterally - deep fat space are located around pharynx b) The contents of the infratemporal fossa - infratemporal fossa contains fats, terminal part of temporal muscle, medial pterygoid muscle, lateral temporal pterygoid muscle, pterygoid venous plexus, maxillary artery and its branches - main braches of maxilla artery; ~ middle meningeal artery ~ inferior alveolar artery ~ superior posterior alveolar artery - mandibular nerve and its branches are also present in chorda tympani c) The intermuscular spaces according to Pirogoff - Pirogov described there are 2 intermuscular space where fat, vessels, nerve and pterygoid venous plexus are located - laterally and superiorly temporo-pterygoid space is located and it is limited: ~ laterally: terminal part of temporal muscle ~ medial: lateral pterygoid muscle - medial and inferior interpterygoid space is located and limited by: ~ medially: medial pterygoid muscle ~ laterally: lateral pterygoid muscle d) The vessels and nerves - main part of pterygoid venous plexus occupy temporopterygoid space - parts of maxillary artery and branches are located into interpterygoid space - through oval foramen, here appear mandibular nerve which immediately divide into anterior and posterior branch - nerves here gives buccinator branch, peribuccal branch, superior alveolar nerve, lingual nerve - lingual nerve will accompany chorda tympani - inferior alveolar nerve enter mandible through mandibular foramen and used for block anesthesia for treatment of teeth on the mandible - middle meningeal artery enter cranial fossa through spinous foramen - deep temporal artery and nerve enter temporal muscle e) The deep fat spaces around the pharynx and their communications. The way of the pus spreading - medial to medial pterygoid muscle, around pharynx, deep fat space of the face are located - these are:

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~ peripharyngeal ~ retropharyngeal - peripharyngeal fat space is divided into two, i.e. anterior and posterior, by stylopharyngeal aponeurosis (i.e. styloid process and vocal pharynx) - anterior part of peripharyngeal fat space is limited: ~ medially: pharynx ~ laterally: medial pterygoid muscle and pterygoid nerve of parotid gland ~ posteriorly: stylopharyngeal aponeurosis ~ superiorly: base of the skull ~ inferiorly: hyoid bone - they are closed space - source of infection is the weak place if the parotid gland and palatine tonsil, leading to dysphagia and asphyxia - posterior part of peripharyngeal fat pace is limited: ~ anteriorly: stylopharyngeal aponeurosis ~ medially: pharygoprevertebral aponeurosis which separate retropharygeal fat space from peripharyngeal fat space ~ laterally: by very good capsule of parotid gland ~ posteriorly: digastric muscle, sternocleidomastoid muscle, capitis muscle - contents of space: ~ medial: internal carotid artery ~ laterally: internal jugular vein - artery is surrounded by veins - veins is surrounded by deep cervical lymph node - nerve branches which surrounds artery: ~ glossopharyngeal nerve ~ vagus nerve ~ accessory nerve ~ hypocholosum nerve ~ sympathetic trunk - this space is not closed and in phlegmon, pus may spread to base of skull and along internal carotid artery and then enters medial cranial fossa - along jugular, they enter posterior cranial fossa leading to meningitis - downward to carotid sheath of neck, and then to anterior mediastenum - retropharyngeal fat space is limited: ~ anteriorly: pharynx ~ posteriorly: prevertebral fossa ~ laterally: pharyngoprevertebral aponeurosis ~ superiorly: base of skull ~ inferiorly: located very low because below C6 this fat continue into retropharyngeal and enter into posterior mediastenum until diaphragm - therefore pus may spread here from the base of skull till diaphragm through posterior medistenum

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Question 43.Trepanation of skull 1. Classification Resection / Cranioectomy removal of bone & present defect in skull after operation Osteoplasty / Craniotomy formation of osteoperiosteal to close defect 2. Surgical instruments in cranioectomy and craniotomy Cranioectomy Craniotomy Brace, cutters & drills Brace, cutters & drills Luers bone cutting forceps Guide for Gigli saw Faraboef raspartors Gigli saw Bone file Dalgrens bone cutting forceps Meningeal scissors Meningeal scissors 3. Trepenation of the mastoid process or mastoidotomy: indications, triangle of Shipo, main principles of technique, possible complication Indication in mastoiditis which may be in mesotympanitis where pus of middle ear enters mastoid antrum Shipo triangle least dangerous zone i. Anterior line connecting suprmeatus spine with apex of mastoid process ii. Posterior mastoid crest iii. Superior horizontal line which is a continuation of zygomatic arch iv. Floor lateral wall of mastoid antrum After floor is removed, antrum is exposed Principles use of mallet & gouge, only experienced doctor may use electric drill Complications if drill penetrate one of Shipos walls o Anterior wall facial nerve damage o Posterior wall massive bleeding from sigmoid sinus o Superior wall penetrate middle ear & mid-cranial fossa 4. Decompression trepanation according to Cushing: indications, place, main principles of technique Indication inoperable tumour of brain, due to fixed skull cap brain is compressed Place right/left temporal region is used due to thinness of bone. Side is chosen based on orientation of patient. A right-handed patient nerves cross over to main control center in left hemisphere so trepanation is done on right side Principles i. Horse-shoe incision is made with apex superiorly, while cut base of aponeurotic fat is directed downwards due to vascular direction from bottom-up

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ii. Temporal muscle is cut & retracted iii. Periosteum is removed by Faraboef raspartor iv. A drill hole is made in center of exposed area & with Luers bone cutting forceps, a defect of up to 6-7 cm is made v. Dura mater is then cut in avascular areas with C-like or horseshoe shape vi. Temporal muscle is then stitched above dura mater by interrupted sutures vii. Aponeurosis id then stitched with one row of simple interrupted sutures 5. Osteoplastic trepanation of the skull: indications, aim, stop bleeding from diploic veins of the skull cap Indications operable tumour of brain, hematoma, hydrocephale, meningeal tumour Aim to remove pathology Technique i. 5 drill holes is made in a pentagon shape ii. The holes are connected by making a sulcus with Gigli saw to form a flap iii. Pathology is removed iv. Flap is replaced after stitching meninges with interrupted sutures to prevent leakage of CSF v. Periosteum is stitched with interrupted sutures vi. Skin is sutured with 2 rows. 1st through galea aponeurotica & 2nd through skin Hemostasis of diploic veins is done by applying sterile wax to bleeding spots

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Question 44 .Trepenation of skull 1. Classification Resection / Cranioectomy removal of bone & present defect in skull after operation Osteoplasty / Craniotomy formation of osteoperiosteal to close defect 2. Wounds of the scalp a. Simple wound with/without gross contamination b. Large wound with/without gross contamination c. Penetrating/ non-penetrating fracture of bone and damage of dura mater Treatment of wound Small wound one row of sutures is placed i. Remove hair around wound up to 5cm ii. Foreign bodies are removed, aseptic cleansing & antibiotics are applied iii. If contamination is absent, wound is sutured and rubber glove drain is applied iv. If contamination is present/suspected, wound is not sutured immediately but after 2-3 days Large wound two rows of suture is placed i. Head is shaved completely, wound is cleansed ii. Margin is excised 1cm from wound border iii. Wound is seldom sutured iv. After 2-3 days suture may be placed, rubber gloves drain is placed and left for 24-48 hours v. For gross contamination, a micro-irrigator is placed and antiseptic and antibiotics is flushed through 3. Methods of suturing scalp 1 layer of suture through skin & subcutaneous with interrupted suture. At forehead, subcutaneous suture may be used for cosmetic result 2 layers of suture 1st through galea aponeurotica, 2nd through skin & subcutaneous 4. Depressed fractures a. In small fracture skull is drilled at site of fracture, a depressor is inserted and defect is restored b. In large fracture osteoplasty flap is made, flap is lifted, free bone fragments is removed, depression is resolved, flap is replaced and sutured 5. Cranial defects Appears after trauma of head due to penetrating wound Defect is closed by < 2cm closed by thick tissue scar > 2cm need operation called closure of defect Source of bone used to close defect is from Autogenic structures rib bone, iliac crest

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 Artificial acrylic, plastic or titanium plates Question 45.Fasciae and fat spaces of the neck 1. The fasciae of the neck on Shevcunenco a. Superficial fascia surround neck completely, starts from clavicle & sternocleidomastoid muscle up to mandible. Forms sheath for Anterior platysma b. Superficial layer of deep fascia surround neck completely, starts from clavicle & sternocleidomastoid muscle up to mandible. Forms sheath for Anterior sternocleidomastoid muscle Posterior trapezius muscle Gives off septa to transverse processes of vertebra & 5th fascia on frontal plane separating anterior & posterior halves of the neck Gives off septa to spinous processes of vertebra on sagittal plane to separate right & left halves of the neck c. Deep layer of the deep fascia doesnt surround neck, doesnt reach mandible, limited Superiorly hyoid bone Inferiorly clavicle & sternocleidomastoid muscle Laterally omohyoid muscle Forms sheath for sternohyoid, sternothyroid, thyrohyoid, omohyoid muscles d. Endocervical fascia consists of 2 layers parietal & visceral i. Parietal joins to 3rd layer, lateral part of fascia forms carotid artery sheath ii. Visceral covers organs (trachea, larynx, pharynx, esophagus, thyroid gland e. Preveterbral fascia starts from base of skull, covers longus colli & longus capiti muscles, from the vertebral body, it forms sheath for sympathetic trunk & sheath for neurovascular bundle of lateral triangle (also known as axillary sheath). Prevertebral fascia ends at level T3 2. The fat spaces of the neck i. Bed/sheath of submandibular gland formed by 2nd fascia ii. Sheath of sternocleidomastoid muscle; fat located between posterior surface of muscle & its sheath formed by 2nd fascia iii. Suprasternal interaponeurosis formed by 2nd & 3rd fascia iv. Blind retrosternal sac/Grubers sac formed by lateral part of 2nd & 3rd fascia v. Lateral triangle fat space formed between 2nd & 5th fascia vi. Previsceral fat space (before trachea) formed by parietal & visceral fascia of 4th fascia vii. Fat of carotid sheath formed by lateral part of 4th fascia viii. Retrovisceral space formed by visceral fascia & prevertebral fascia (above C6 retropharyngeal; below C6 - retroesophageal) ix. Fat of axillary sheath formed by 5th fascia x. Prevertebral fat space formed by 5th fascia & prevertebral muscle ( usually complicated in TB of cervical vertebrae & pus) 79

3. Peculiarity of deposition of the fasciae and fat spaces of the lateral triangle Fascia of neck have different relation to lateral triangle a. Lateral triangle is absent 4th fascia plus lateral triangle by inferior belly of omohyoid muscle is divided to i. Omoclavicular triangle contains 1st, 2nd, 3rd, 5th fascia. Fat is in axillary sheath of 5th ii. Omotrapezius triangle contains 1st, 2nd, 5th fascia. Fat is between 2nd & 5th 4. Places of accumulation of the pus on the neck and ways of pus spreading a. Closed when pus accumulates i. Submandibular bed ii. Sternocleidomastoid sheath iii. Suprasternal aponeurosis iv. Blind retrosternal sac/Grubers sac b. Opened where pus spreads to adjacent regions i. Carotid sheath pus may spread upwards along NVB to posterior part of peripharyngeal fat space till base of skull, where through carotid canal may enter middle cranial fossa, from jugular vein to posterior cranial fossa. Downwards along NVB, pus spread to anterior mediastinum ii. Previsceral space pretracheal space of anterior mediastinum iii. Retrovisceral space upwards to retropharyngeal space base of skull; downwards to retroesophageal space posterior mediastinum diaphragm iv. Axillary sheath to axillary fossa v. Superficial sheath supraspinous bed & superficial fat space 5. Lines of incisions for opening of the submandibular adenophlegmon 2-3cm below margin of mandible & parallel to it to exclude damage to submandibular nerve, vein, artery & marginal branch of facial nerve

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Question 46.Topography of the suprahyoid region 1. Triangles There are 5 triangles 1 unpaired & 2 paired a) Suprahyoid i) Inferiorly horizontal line through hyoid bone ii) Superiorly margin of mandible iii) Laterally right & left sternocleidomastoid muscle b) Submental i) Superiorly chin ii) Base hyoid bone iii) Laterally right & left digastric artery c) Submandibular i) Anteriorly anterior belly of digastric muscle ii) Posteriorly posterior belly of digastric muscle iii) Base base of mandible 2. Layers of triangles a. Submental: i. Skin ii. Subcutaneous tissue iii. 1st fascia with platysma iv. 2nd fascia v. Muscles of floor of oral cavity mylohyoid, geniohyoid, genioglossus Contents of triangle submental lymph nodes, beginning of anterior jugular vein Lymph nodes here maybe 1st metastasis point & middle 1/3 of lower lip & tip of tongue b. Submandibular: i. Skin ii. Subcutaneous tissue iii. 1st fascia with platysma iv. 2nd fascia v. Submandibular gland vi. Muscles of floor of oral cavity vii. Myohyoid & hyoglossus muscles 3. Contents of bed or sheath of submandibular gland 2 layers form sheath of submandbular bed: Superficial layer margin of mandible Deep layer mylohyoid muscle Bed contains gland, loose fat, submandibular lymph nodes, facial artery & vein 4. Lines of incision for opening of the submandibular adenophlegmon

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2-3cm below margin of mandible & parallel to it to exclude damage to submandibular nerve, vein, artery & marginal branch of facial nerve 5. Triangle according to Pirogoff. Practical importance Pirogoffs triangle is limited: Superiorly hypoglossus nerve Inferiorly intermediate tendon of digastric muscle Anteriorly free margin of mylohyoid muscle Floor hyoglossus muscle where lingual artery lies under Palpate deeply to locate submandibular gland Diagnostic triangle for lingual artery ligation before major face operation/tongue operation The artery is exposed by separation of hyoglossus muscle, artery is then ligated with Dishat needle or ligature of Shonce

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question 48. Topography of infrahyoid region 1) Boundaries, layers, triangles boundary: superior-horizontal line which drawn through hyoid bone inferior- sternal notch, sternocleido joint, clavicle lateral- anterior margin of both sternocleidomastoid muscle layers: skin subcutaneous tissue 1st fascia with platysma 2nd fascia 3rd fascia with infrahyoid muscle parietal layer of 4th fascia organs of neck covering visceral layer 5th fascia 2 triangles: left & right omotracheal triangle omotracheal triangle- superior: superior belly of omohyoid muscle inferior: anterior margin of sternocleidomastoid muscle base of both triangle: midline of neck 2) Topography of larynx skeletotopy: superior- C5 inferior- C6 in open epiglottis, apex of larynx reach C3 larynx consist of muscle, cartilage & membrane 3 parts of larynx: superior vestibule, middle ventricle & inferior infraglottic cavity on sagittal section- larynx correspond the form of sand glass syntopy: anterior to larynx- layer from skin to parietal layer of 4th fascia & addition lobe of thyroid gland may present behind posterior to larynx- laryngealpharnyx lateral to larynx- lobe of thyroid gland & common carotid artery 3) Topography of trachea in the neck skeletotopy: superior- C6 inferior-T5 consist of: anterior- incomplete C-shaped rings of hyaline cartilage posterior- smooth muscle of membranous tube 2 parts: cervical & thoracic syntopy: anterior- layers: skin parietal layer of 4th fascia insthmus of thyroid additional lobe of thyroid (if present) inferior thyroid venous plexus thyroidea ima artery (which present in 12%) pretrachea fast spaces posterior- esophagus lateral- lobe of thyroid gland, common carotid artery 4) Topography of pharynx skeletotopy: superior- base of skull inferior- C6 consist of 3 parts: nasal, oral, laryngeal in neck, 3rd part located syntopy: anterior to pharynx- larynx & layers of neck posterior to pharynx- lateropharynx fat space, prevertebra fascia, prevertebra muscle, body of vertebra lateral to pharynx- lobes of thyroid gland, common carotid artery 83

5) Topography of esophagus in the neck. Surgical access to esophagus in the neck (ground) skeletotopy: superior- C6 inferior- T10 where esophagus pass through diaphragm to enter cardiac part of stomach 3 parts: cervical, thoracic, abdominal cervical esophagus: is inclined to left side forming flexure to left side syntopy: anterior to esophagus- trachea, layer of neck, left recurrent laryngeal nerve posterior to esophagus- retraesophagus fat space, prevertebra fat, prevertebra muscle, body of vertebra lateral to esophagus- lobes of thyroid gland, common carotid artery surgical access: only on left side because esophagus inclined to left side. Incision is done along lower 3rd of anterior margin of left sternocleidomastoid muscle

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49. Topography of the thyroid gland and parathyroid glands. 1) Syntopy of the thyroid gland. It consists of isthmus and 2 lateral lobes. In 10 15% , additional lobes arise from isthmus. Lobes of thyroid triangle superiorly reach middle of plate of thyroid cartiladge. Inferiorly, 4th , 5th or maximum 6th ring of trachea. By medial surface, both lobes adjoin to larynx, trachea, pharynx and oesophagus. Lateral to it, carotid sheath is located, immediately lateral is common carotid artery. Behind superior and anterior pole, parathyroid glands. Anterior- layers of neck from skin to parietal layer of 4th 2) Position of the isthmus. Variants of the structure of the isthmus. Clinical importance. In children- reaches higher, on cricoid cartiladge In elderly- lower , on 4th-5th ring of trachea. Isthmus may be narrow, wide, absent or have additional lobe. Clinical importance- in operation on thyroid gland and in tracheostomy. 3) Blood supply and venous drainage from the thyroid gland. Thyroid gland has very rich blood supply. 2 systems supply it: - external carotid -subclavian External carotid- superior thyroid arteries (right and left) Subclavian artery- inferior thyroid arteries (right and left). 4) Syntopy of the right and left recurrent nerves. Right and left recurrent laryngeal nerves arise from vagus nerve. Right recurrent laryngeal nerve- arises from vagus at level of bifurcation of brachiocephalic trunk. This nerve hooks beginning of subclavian artery and ascends up along groove between oesophagus and trachea and passes between lobe of thyroid gland gland and trachea. Left recurrent laryngeal nerve- arises from vagus at level of inferior margin of aortic arc. At level of inferior poles of both lobules, right and left recurrent laryngeal nerves crosses with inferior thyroid artery. This is very important in thyroidectomy. In ligation of inferior thyroid artery, it is possible to involve recurrent laryngeal nerve. 5) Topography of the parathyroid glands. Peculiarity of the desposition of these glands. Parathyroid glands are 4. 2superior and 2 inferior. Glands are located on posteromedial surface of both lobes of thyroid gland. Superior more constant location. Inferior less constant location. Sometimes in mediastinum. Usually part of gland located outside fascial capsule at posteromedial surface of lobe of thyroid gland. May be located between fascial capsule and fibrous capsule. May be inside fibrous capsule.

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 May be inside thyroid gland. (harder for diagnosis). Question 51. exposure of the carotid arteries. 1) indications. Aneurysm of carotid artery Obliterating diseases of carotid artery Trauma of carotid artery.

2) The line of projection of the common carotid artery. The line of projection of the common carotid artery is drawn along biceps of the able between anterior margin sternocleidomastoid muscle and superior belly of omohyoid muscle. 3) Accesses to carotid arteries. Surgical are made along anterior margin of sternocleidomastoid muscle to common carotid artery, incision drawn from level of superior margin of thyroid till sternoclavicular joint. For exposure, external carotid artery and inferior carotid artery, surgical access starts at level angle of mandible and continue downward along anterior margin of sternocleidomastoid muscle. 4) Signs of difference of the internal carotid artery from external carotid artery. External carotid artery gives off branches; internal no branches. Topography of external lies medially and superficially; internal lies laterally and deeply. Clinical difference: if one of the arteries closed by elastic tourniquet, surgeon must find pulse on facial artery. On superficial temporal and occipital artery: If pulse present internal artery is compressed If pulse absent external artery is compressed. 5) Collateral circulation in ligation of the common and external carotid arteries. ..

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Question 52. Tracheostomy. 1) Groups of indications. Asphyxia (foreign bodies, false croup, true croup, edema, intoxication, burn etc.) Prophylaxis for asphyxia (malignant tumour of pharynx etc) Prolonged artificial ventilation of lung. (made in patients need in long time artificial ventilation of lung, e.g. meningitis, encephalitis, trauma of brain, intoxication. 2) Types of tracheostomy. Criterion of classification. Superior, Middle, Inferior If incision of trachea regarding to isthmus of thyroid gland, trachea is cut superiorly to isthmus. Inferiorly tracheostomy trachea is cut inferiorly Middle tracheostomy trachea is cut behind isthmus after cutting of isthmus. 3) Technique of operation. The rules of inserting of the tracheostomy tube. in asphyxia, soft tissue are cut longitudinally. In planned operation, soft tissue are cut horizontally. In superior tracheostomy, incision is drawn from middle of thyroid cartilage downward along midline, length 5cm. In succession skin, subcutaneous tissue of neck, 1st fascia of platysma muscle, linea alba of neck and parietal variant of 4th fascia are cut. Infraparietal muscles are retracted. Above isthmus, 5th layer of isthmus is cut and isthmus become mobile. Isthmus is displaced downward. 4) Complications of the tracheostomy, connecting with position of the patient on operating table. Correct position of patient on operative table: Supine , Bolster under shoulder region. ,Head extended back and fixed to straight position. If positions wrong, complication may develop. If head turn to one side, midline of neck will be occupied by common carotic artery, in asphyxia when surgeon must works quickly, might cut the common carotid artery. If bolster is very big, lumen of trachea may decrease in size (become like slit) because trachea consists of incomplete cartilage. If bolster is too small, trachea lie very deeply, tracheostomy might be difficult, possible cause damage of vein lead to air embolism, bleeding and aspiration of blood. 5) Complications of the tracheostomy, connecting with technique of operation. in incision of trachea, two complications: a) if plate not protected by plaster or end very long, scalpel may project to posterior wall of trachea and to esophagus tracheoesophagus fistula: b) if scalpels end is too small, small end cant reach mucus membrane, and it may reach submucosal layer asphyxia increased. Size of incision of trachea depends on diameter of tube. If incision is big, possible emphysema surround tissue of

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neck. If its small, after insertion of tube, margin of cartilage compressed lead to formation of necrosis of cartilage. Question 53. tracheostomy. 1) Groups of indications. Asphyxia (foreign bodies, false croup, true croup, edema, intoxication, burn etc.) Prophylaxis for asphyxia (malignant tumour of pharynx etc) Prolonged artificial ventilation of lung. (made in patients need in long time artificial ventilation of lung, e.g. meningitis, encephalitis, trauma of brain, intoxication.

2)

Types of tracheostomy. Criterion of classification. Superior Middle Inferior If incision of trachea regarding to isthmus of thyroid gland, trachea is cut superiorly to isthmus. Inferiorly tracheostomy trachea is cut inferiorly Middle tracheostomy trachea is cut behind isthmus after cutting of isthmus. 3) Technique of operation. The rules of inserting of the tracheostomy tube. in asphyxia, soft tissue are cut longitudinally. In planned operation, soft tissue are cut horizontally. In superior tracheostomy, incision is drawn from middle of thyroid cartilage downward along midline, length 5cm. In succession skin, subcutaneous tissue of neck, 1st fascia of platysma muscle, linea alba of neck and parietal variant of 4th fascia are cut. Infraparietal muscles are retracted. Above isthmus, 5th layer of isthmus is cut and isthmus become mobile. Isthmus is displaced downward, tracheostomic point of neck fix trachea through cartilage of 4) cuspidate tracheostomy of Bjork. This technique is used for prolonged artificial ventilation of lung for which ventilation special tube is used. This tube has obturator with closed space between the trachea and the tube. So, incision of trachea is made like flap, form window of trachea. Possible complications. Correct position of patient on operative table: Supine Bolster under shoulder region. Head extended back and fixed to straight position. If positions wrong, complication may develop. 88

 If head turn to one side, midline of neck will be occupied by common carotic artery, in asphyxia when surgeon must works quickly, might cut the common carotid artery. If bolster is very big, lumen of trachea may decrease in size (become like slit) because trachea consists of incomplete cartilage. If bolster is too small, trachea lie very deeply, tracheostomy might be difficult, possible cause damage of vein lead to air embolism, bleeding and aspiration of blood. in incision of trachea, two complications: a) if plate not protected by plaster or end very long, scalpel may project to posterior wall of trachea and to esophagus tracheoesophagus fistula: b) if scalpels end is too small, small end cant reach mucus membrane, and it may reach submucosal layer asphyxia increased. Size of incision of trachea depends on diameter of tube. If incision is big, possible emphysema surround tissue of neck. If its small, after insertion of tube, margin of cartilage compressed lead to formation of necrosis of cartilage.

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54. Topography of thoracic wall 1) Boundaries, surf landmark - boundaries r : Supr antr : clavicle, sternal notch Supr postr : line connecting spinous process of C7 and acromial process Infr : costal arch, xiphoid process, line connecting free margin of 12th rib w T12 - surf landmark r : a) osteal : sternum, sternal notch, ribs, spinous process of vertebra, xiphoid process b) muscular : margin of pectoralis major muscle ( m ), latisimmus dorsi m, sheath of ext oblique m 2) The layers of thoracic cage - from supf to deep : skin subcutaneous tissue supf fascia deep fascia ( form sheath for perctoralis major m ) supf m ( pectoralis major n minor, seratus ant supr, latisimus dorsi, ext oblique m ) - thoracic cage formed by ribs, ext n int intercostals ( IC ) m, endothoracic fascia, extrapleural fat n parietal pleura - skin is supplied by IC Nv n supraclavicle Nv 3) Subpectoral spaces : walls, communications w fat of adjacent regions. Practical importance - located btwn pectoralis maj n minor - 2 region a) supf limited by Antr : postr surf of pectoralis maj m, post layer of its sheath Postr : claviclopectoral fascia, antr surf of pectoralis minor m - space is open n in phlegmon pus may spread along perforating branch of IC Nv, supr pectoral art, long cephalic Vn to axillary fossa fat b) deep limited by Antr : postr surf of pectoralis minor m Postr : postr layer of its sheath wh formed by claviclopectoral fascia - space is closed coz enclosed in sheath of pectoralis minor m 4) Blood supply, innervation n lymph drainage a) blood supply : - thoracic wall is supplied by Branches of axillary art Branch of int thoracic art Branch of thoracic aorta - at upper part, thoracic wall supplied by IC art Thoracoacromial art Supr thoracic art Lat thoracic art

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- at lower part, supplied by musculophrenic art b) innervation : - under clavicle thoracic cage supplied by supraclavicular Nv antr n lat branch of pectoral Nv ( short branch of brachial plexus ) IC Nv - other areas by IC Nv c) lymph are directed into axillary lymph node ( LN ) 5) The intercostal spaces ( ICS ) - located btwn 2 ribs n 2 m ( ext IC m n int IC m ) - lower margin of rib include grove where neurovascularbundle ( NVB ) passes - NVB include ( fr supr to infr ) : IC Vn IC art IC Nv * ext IC m n int IC m form IC canal where NVB passed

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55. The breasts or mammary gls 1) Skeletopy of the base of mammary gl - skeletopy : Supr : 2nd, 3rd rib Infr : 7th rib Medial : sternal line / margin of sternum Lat : antr axillary line 2) Layers n structure of the gls - fr supf to deep : skin subcutaneous ( S/C ) fat supf fascia mammary gl retromammary fat space deep fascia supf m thoracic cage endothoracic fascia extraperitoneal fat parietal pleura - at level of nipple n areola, S/C tissue is absent n skin attached directly to supf fascia therefore skin of mammary gl except nipple n areola r mobile ( the rest r immobile ) - supf fascia form capsule of mammary gl surrounding both side - supf fascia gives off septa into gl n divide into lobules n above gl supf fascia become thickened n attached to clavicle to form suspensory ligament ( lig ) of mammary gl - lobules r 15-20 - each lobule have duct - lobules n ducts r located in radial direction according ( acc ) nipple n areola - before opening into nipple, ducts unite forming lactiferous sinus ( sinus projects on areola ) - 8-10 ducts open on nipple 3) The lymphatic drainage of the breast. The main n additional ways of the lymphatic drainage. Pratical imp - lymphatic drainage of breast have practical imp for solving problems of absence or presence of metastasis ( mts ) or palliative or radical mastectomy - all ways of lymphatic drainage divided into a) main 60% fr mammary gl - they r : axillary LN, 1 or grp of LN acc to Sorgius wh is located at pt of intersection infr margin of pectoralis maj m w 3rd rib ( abduct hand to examine ) b) additional 40% - they r : Supraclavicle Infraclavicle Parasternal LN under pectoralis minor m LN of extraperitoneal fat n organs of supracolic compartment Contralat mammary gl here also Sorgius n axillary LN ( 1 way only ) 4) Blood supply n innervation - mammary gl is supplied by int thoracic art, branches of IC art, lat thoracic art

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- art lies very deeply n so reach mammary gl where art must penetrate layers of thoracic wall ( very imp during op ) - innervation : sensation of mammary gl received fr IC Nv, supraclavicular Nv, ant pectoralis Nv / ant thoracic Nv ( branch of brachial plexus ) - sympathetic : for lactation reach gl along vessel fr sympathetic trunk

5) Incisions in breast abscess n retromammary abscess n their anatomical ground - acc localization abscess may be located : view pict a) extramammary ( 4 ) b) intramammary subdivide into supf ( 2 ) n deep ( 1 ) c) retromammary ( 3 ) - incision in supf intramammary n extramammary r made in radial direction 2cm fr areola thru center of fluctuation to periphery of base - in retromammary n deep intramammary abscess, incision is made along submammary sulcus coz deep localization accompany retromammary abscess - to exclude contamination, deep drain thru retromammary space

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56. Topography of int thoracic vessels n IC NVB 1) Skeletopy n syntopy of the int thoracic art n IC NVB - int thoracic art arises fr concave surf of 1st part of subclavian art n when art passes along margin of sternum, at level upper : 5-8mm lat fr sternum, at lower : 1.5cm fr sternum - int thoracic art accompanied by int thoracic Vn, syntopy : art laterally n Vn medially - in lower possible 2 Vn where 1 is medial n 1 is lat - medial to Vn, parasternal LN located wh drain lymph fr mammary gl - IC NVB lies along costal grove wh is located on infr margins of rib - syntopy fr supr to infr : IC Vn IC art IC Nv 2) Branches of int thoracic art n their anastomosis - int thoracic art at level 2nd ICS gives pericardiac phrenic art wh accompanied phrenic Nv ( L n R ) 3) Puncture of the pleural cavity - may be made in hydrothorax n pneumothorax - in hydrothorax, puncture is made 6th,7th,8th ICS fr scapular to mid-axillary line along supr margin of adjacent rib - this pt explain by localization of IC Nv along infr margin of adjacent rib n costal diaphragmatic recess localization - big size recess at mid-axillary line - puncture in pneumothorax is made at 2nd,3rd ICS at mid-clavicular line - puncture acc to aim may be diagnostic n therapeutic * diagnostic aim made by syringe n long needle - for prophy pneumothorax after extraction of needle before puncture is done skin is displaced down - in therapeutic purposes, needle never connect directly w syringe but by rubber tube wh is closed by hemostatic forceps 4) Thoracocentesis n IC drainage - r used in pneumothorax n hydrothorax for connection pleural cavity w syst of aspiration - throcacentesis is made by trochar - trochar consist of stylet n tube - b4 inserting trochar surgeon must make incision of skin, S/C tissue corresponding to diameter of trochar - thru m, trochar insert like screw stylet is then removed thru cylinder thoracoscope, drainage tube n other instruments is inserted - if insert drainage tube tube, direction of tube depend on disease eg hydrothorax : direct up pneumothorax : direct down - end of tube connect w syst of aspiration wh is active or passive ( by water pump ) 5) Rib resection - is used for drainage purulent cavity or empyema of pleura - is made subperiostally

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- skin cut along supr margin of rib or on rib itself - retract skin puncture see periosteum open / separate periosteum using rib raspatory to protect NVB located in the grove stretch periosteum ( view pict ) cut rib small incision is made insert tube

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N57. Structure and topography of the diaphragm. 1. Parts of diaphragm: Tendineus and muscular a) Peripheral muscular -Sternal : body of sternum and xiphoid process -Costal : Ribs -Lumbar : From lumbar vertebrae b) Central tendineus -Dome like by the intraabdominal pressure. Projected on right side (4th rib) and left ( 5th rib). -Inferior vena cava and branches of right phrenic nerve. 2. Parts of the origin of the diaphragm -Same as subquestion N1. 3. Peculiarity of the lumbar part of the origin of the diaphragm 3 pairs of crura: med, lat and mid. Right and left medial crura crossing each other (figure of 8). By this, both crura forms ant. Esophagus (eso, right and left vagus nerve), post aortic openings (desd. Aorta, thoracic duct) -Between right med. And right mid. Crura, azygous vein, greater and lesser splanchnic nerve. (On the left: hemiazygous vein). -Between mid. And lat. Crura on the right and left the sympathetic trunk passes. 4. The weak places of the diaphragm. Clinical importance Muscular origin of diaphragm at the level of thoracic wall form slit like spaces. -Only endothoracic and endoabdominal fascia is between sternal and costal part on thbe left (Kerrys slit) and right ( Morganis slit). -Between lumbar and costal: Bohdahleks slit. These weak places are for pus spreading: Ant.slit: mediastinal fat and extrapleural fat can spread to extraperitoneal fat proper. Post. Slit: from extrapleural to retroperitoneal fat space. Seldom: protrusion of hernia in esophageal opening, caval opening, aortic opening, greater omentum, fundus of stomach, small intestine. 5. Blood supply and innervation of the diaphragm. Blood supply: Sup. Phrenic artery, inf. Phrenic artery (branch of descending aorta). -Intercostal arteries: ant: inf. Thoracic (musculophrenic, pericardiophrenic) Innervation: Phrenic nerve, peripherally by intercostals nerves

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N58. Topography of the pleura. 1. Layers, parts, and ant. And post. Boundaries. -Pleura has 2 layers: Parietal- covers walls of thoracic cavity Visceral- covers lungs Parts: -Costal Diaphragm Mediastinum Cupula/ cervical

Boundaries of media: Passing 1 surface to another Ant and. post: post costal to costal into med. Ant of right pleura: behind sternum -3rd-4th costal cartilage: reach midline then go downwards obliquely into inf. Boundaries. Left anterior:behind sternum, reach midline (3rd-4th cartilage) cross 5th-6th cartilage to inf. Boundary, cardical notch. At level of 3rd and 4th costal cartilage, right and left pleura approximate to each other forming sup (thymus and remnants). And inf (pericardium and heart). Interpleural space. Post. Boundary: Same for both pleura, along heads and ribs. 2. Inferior boundaries of the pleura or cupula and apexes of the lungs Pleura Mid-clav: 7th rib Axi: 10th Scapular: 11th Paravertebral: 12th Lung apexes: -2-3cm above mid 1/3 of clavicular. 3. Skeletotopy of the cervical pleura or cupula and apexes of the lungs. Cervical pleura: 3-4cm above mid 1/3 of clavicle Lung apexes: 2-3cm above mid 1/3 of clavicular. Left Lung: - from parasternal line, 6th rib. - Mid-clav: sup. Margin of 7th rib - Ant. Axi: Inf. Margin of 7th rib - Post. Axi: 8th rib - Scapular: 10th rib - Paravertebral: 11th rib Right lung

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-sternal line: 6th rib - Mid-clav: sup. Margin of 7th rib - Ant. Axi: Inf. Margin of 7th rib - Post. Axi: 8th rib - Scapular: 10th rib - Paravertebral: 11th rib 4. The recesses of pleura. Clinical importance. -Costodiaphragmatic: right and left and. Costo mediastinum right and left -post. Mediastinum (right and left) -phrenico-media (right and left) Importance: Costodiaphragmatic coz lung in deep inspiration never enter completely into this recess where pathological fluid can collect. -larger size: along mid-axi. Line: 8-10cm Along ribs: 8-10th ribs 5. Puncture of the pleural cavity. Indications: Hemothorax, pneumothorax Point of puncture: 4th-8th intercostals spaces from scapula to mid. Axillary line along sup. Margin of adjacent rib. (wont damage nerves). -To scapula: deep sinus. Lung in inspiration wont enter here. Complications: intrathoracic penetration of lung. Intraabdominal: right: lung; left: spleen and stomach

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N59. Topography of the lungs. 1. Boundaries of the lungs, syntopy of the lungs. Passing costal surface into mediastinodiaphragmatic -Inf: No pleura connection, located on 1 rib above 2 boundaries of pleura except mid. Axi. Line Left Lung: - from parasternal line, 6th rib. - Mid-clav: sup. Margin of 7th rib - Ant. Axi: Inf. Margin of 7th rib - Post. Axi: 8th rib - Scapular: 10th rib - Paravertebral: 11th rib Right lung -sternal line: 6th rib - Mid-clav: sup. Margin of 7th rib - Ant. Axi: Inf. Margin of 7th rib - Post. Axi: 8th rib - Scapular: 10th rib - Paravertebral: 11th rib Apex: -2-3cm above mid 1/3 of clavicular. Syntopy: costal surface adjoins to ribs of intercostals space: -Diaphramatic space to diaphragm -Medistinal space to organs of mediastinum Mediastinum of right lung anterior to root: Upper half : right phrenic nerve Right brachiocephalic vein Superior vena cava Lower half: Phrenic nerve and pericocardium Pericardim and heart Post to root: Azygous vein, esophagus, sympathetic trunk Mediastinum of left lung anterior to root Upper half: Arch of aorta Pulmonary trunk Phrenic nerve Vagus nerve Lower half: Phrenic and pericardial artery

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Pericardium and heart Post to root Descending aorta, hemiazygous vein, sympathetic trunk 2. Structure of the lungs Lobes are anatomically divided into :Right lung: 3 lobes -sup (3 segments) -mid(2) -inf (5) Left lung: 2 lobes -Sup (5) -Inf (5) Oblique fissure is projected from spinous process T3 to boundary between osteol cartilage part of 6th rib. The horizontal fissure is projected on the line connected point of attachment of 4th rib to sternum to point if intersection of oblique fissure at level. Mid.axi. line. 3. Topography (skeletotopy and syntopy) of the roots of the lungs The root of lung include bronchi, pulmonary artery, 2 pulmonary veins, bronchial artery, lumphatic vessels and nerve plexuses. Skeletotopy: Post: T5-T7 Ant: 2nd-4th intercostals spaces Syntopy: according to plane Frontal plane: sup-inf Left: ABV (artery, bronchi, vein) Right: BAV Horizontal plane: ant-post -VAB for both lungs (vein, artery, bronchi) Adjoining to root: Right: post to ant -Hooks by azygous vein Left: ant to post -Hooks arch of aorta Anterior to root on both side: right and left phrenic nerve Post to root: Right and left vagus nerve 4. The accesses to the lungs Depends on the pathological process Sup and mid lobe : ant and anterolat. Incisions Inf lobe: post and posterolat./lat incisions.

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Ant. incision: Same beginning, different finish. -From point of parasternal line level of attachment 3rd rib to sternum -Directed downwards -In females, surround base of mammary gland, 2cm below main sulcus along intercostals spaces -In males, 2 cm above nipple, 5th intercostals spaces -ascend to 4th intercostals spaces, anterior thoracothomy: ant. Axi.line Post. Thoracothomy: post. Axi.line Post. Incision: from paravertebral. Line from point located at level spinous process T4 downwards till angle of scapula (7th-8th intercostals spaces). Ascend to 5th-6th intercostals. -Continue to post. Axi. Line (post) Ant. Axi (posterolat.) Laterally along intercostals spaces from mid-clav. To post axi line. 5. Sutures on the lung (lungorraphy) Complication of lung wounds include bleeding and pnemothorax. -In wound closure, surgeon has to stop bleeding and air leakage, -2 rows of suture: 1st: all layers by absorbable material. Ligation. Above 1st row on visceral pleura: pleura-pleural suture: double layer of visceral pleura. Hemitasation. 60. ???

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61. Topography of the postr mediastinum 1) Boundaries of the postr mediastinum - boundaries : Postr : vertebral column, head of rib covered by endothoracic fascia Antr : frontal condition plane thru root of lung Lat : mediastinal pleura Infr : diaph 2) The struct of postr mediastinum - struct r : Fat LN Esophagus Descending aorta R n L vagus Nv Thoracic duct Hemiazygous n azygous Vn Sympathetic trunk Greater n lesser splanchnic Nv 3) Syntopy n skeletopy organs n NV struct of postr mediastinum - along vertebral column fr R to L following struct r located : R sympathetic trunk azygous Vn thoracic duct descending aorta hemiazygous Vn L sympathetic trunk 4) Topography of esophagus ( eso ). Constriction - skeletopy of eso : Supr : C6 Infr : T10 where eso pass thru diaph n enter cardiac part of stom - 3 parts of eso : a) cervical b) thoracic c) abdominal - in thoracic part of eso at upper of mediastinum trachea is located antr to eso - in lower : Antr to eso : pericardium n heart, L vagus Nv Postr to eso : R vagus Nv - eso formed flexure fr C6 till T4 eso inclines to the L, at T4 eso crosses vertebra n inclines to R ( T4 till T7 ), below T7 inclines to L again - eso has 3 constriction where foreign body may stop : a) pharynx pass into eso b) bifurcation of trachea opposite T5 c) passing thru diaph at T10

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5) Interrelations of descending aorta n eso above diaphragm ( diaph ) : trachea n eso, eso n pericardium. Clinical imp - above diaph, descending aorta located postr n eso anteriorly coz eso below T7 inclines to the R n cross aorta antr - in malignant tumor, foreign body w sharp margin possible trauma of aorta above diaph - at upper part of postr mediastinum trachea lies antr to eso - in malignant tumor, foreign body of eso ( eg fish bone ) penetration into trachea tracheoesophageal fistula formation - below T5 eso adjoins antr to pericardium n heart - in hypertrophy of myocardium eso may displace to R or L wh has clinical imp in diagnostic of heart disease during X-raygraphy ( Ba meal )

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62. Fascie and fat spaces of the mediastinum 1) Definition of mediastinum - mediastinum is a complex of life important organs, great vessels and Nv which are located btwn mediastinal pleura 2) Fascie of the mediastinum - 5 fascie : a) endothoracic cover inner surf of sternum, thoracic wall, vertebral column - gives off septa and form sheath for great vessels and organ of mediastinum b) retrosternal start fr post surf of fascia sheath of thymus - pass behind sternum inferiorly - attach to sternum lat to mediastinal pleura c) aponeurosis acc to Reshi continuation of 3rd fascia of the neck - occupy only upper part of ant mediastinum and attached to post surf of thymus sheath d) fascia sheath of thymus e) prevertebral fascia coat fr 5th fascia of neck till T3 3) The fat spaces of mediastinum - 5 fat spaces are : a) retrosternal fat space - located btwn sternum and pericardium of heart b) fat spaces of thymus fascia sheath c) paratracheal fat space - located around trachea - have i) pre-tracheal infr passes into pre-esophagal part ii) peri-tracheal d) paraesophageal fat space - have i) pre-esophageal ii) retroesophageal e) prevertebral fat space - continue fr fat space of neck 4) Peculiarity of retrosternal fat space - retrosternal fat space by retrosternal fascia divide into : a) ant - limited by Ant : endothoracic fascia covering sternum and costal cartilage Post : retrosternal fascia Infr : diaphragm Lat : mediastinal pleura - this fat space is not closed and along int thoracic art and terminal branch ( supr epigastric art ) thru Loger slit and Morgani slit of diaphragm communicate with extraperitoneal fat space of ant abd wall

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b) post - limited Ant : retrosternal fascia Post : Pericardium Supr : thymus sheath Infr : diaphragm Lat : mediastinal pleura - fat space is closed 5) Communications of these fat spaces with the fat of the adjacent regions - post part of resternal fat space and fat space of thymus sheath are closed fat spaces - ant part of retrosternal fat space communicate with extraperitoneal fat space of ant abd wall - pre-tracheal fat space : a) supr communicate with pre-tracheal fat space of neck b) infr with pre-esophageal fat space - retroesophageal fat space superiorly with retrovisceral fat space of neck and reach base of skull - prevertebral fat space communicate with prevertebral fat space of neck

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63. Lymph nodes of mediastinum 1) Definition of the mediastinum, Boundaries. Division of mediastinum - mediastinum is a complex of life important organs, great vessels and Nv which are located btwn mediastinal pleura - boundaries of mediastinum : Ant : thorax and costal cartilages Post : vertebral column and head of ribs Infr : diaphragm - supr boundary is absent and organ continue into neck - by conditional frontal plane wh is drawn thru root of lung, mediastinum is divided into : a) ant b) post 2) The groups of lymph nodes ( classification ) - lymph node is classified into : a) parietal ( along bone ) - subdivided into i) parasternal ii) intercostals iii) paravertebral b) visceral - subdivided into i) ant mediastinal ii) post mediastinal iii) tracheobronchial iv) tracheal v) intrapulmonary 3) The visceral lymph node of mediastinum - ant mediastinal lymph node divide into 3 chain : a) R vertical chain b) L vertical chain c) horizontal chain - post mediastinal lymph node divide into : a) paraesophagal lymph node b) intraaortal esophagal lymph node - tracheal lymph node subdivide into : a) paratracheal lymph node b) laterotracheal lymph node - tracheobronchial lymph node divide into : a) supr tracheobronchial lymph node b) infr tracheobronchial lymph node are called bifurcation lymph node wh lies ant to esophagus 4) Syntopy of L vertical chain. Clinical importance - L vertical chain is located ant to arch of aorta and pulmonary trunk

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- constant lymph node of this chain is located at infr margin at arch of aorta where L vagus Nv gives off recurrent laryngeal Nv - in enlargement of lymph node compression of recurrent laryngeal Nv husky voice develop - constant lymph node also located ant to ductus arteriosum or Batalos duct - clinical imp : this lymph node is used like orientation during ligation of ductus arteriosum 5) Syntopy of R vertical chain. Clinical importantce - R vertical chain is located along R brachiocephalic Vn and supr cava Vn - constant lymph node is located at place of connection of R and L brachiocephalic Vn - clinical imp : enlargement of lymph node supr cava Vn compression supr cava Vn syndrome

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64. Topography of pericardium and heart 1) Syntopy and skeletotopy of the walls of pericardium. Triangle of safety - pericardium consist of 2 layers : a) true epicardium b) epicardium - btwn 2 layes, cavity is located and small amt of fluid in the cavity to friction - pericardium has walls : a) ant wall adjoins to sternum and costal cartilage b) lat wall adjoins to mediastinal pleura and both lungs - btwn mediastinal pleura and pericardium, phrenic Nv ( R and L ) passes c) post wall adjoins to esophagus and descending aorta d) infr wall adjoins to diaphragm - during respiration, ant pericardium is covered by lung and pleura accepting triangle of safety - boundaries of triangle of safety : Medial : L margin of sternum Lat : margin of pleural sac Infr : diaphragm - this triangle is projected at the 6th and 7th costal cartilage 2) The pericardial sinuses. Puncture of pericardium ( pericardiocentesis ) - pericardial sinuses are 3 : a) ant infr sinus b) oblique sinus c) transverse sinus - ant infr sinus is limited by ant wall of pericardium and at infr part, apex of heart is located - fluid accumulates here and thus puncture is made - pt of puncture : at angle btwn sternal and L costal arch, needle is inserted perpendicular to skin 1stly and then under angle 45 direct needle towards cranial direction until fluid appear in syringe - oblique sinus is limited Ant : atrium Post : post wall of pericardium R infr : infr cava Vn R supr : pulmonary Vn - transverse sinus is located at base of heart where is it is impossible to accumulate fluid but this sinus is used during op of the heart - transverse sinus is limited Ant : ascending part of aorta and pulmonary trunk Post : supr cava Vn, post wall pericardium 3) Surfaces, apex of the heart. The boundaries of the heart - surface of the heart are Ant / sternocostal 108

 Lat / mediastinal ( R and L ) Infr / diaphragmatic Base of heart where great art are located - apex of heart is formed by LV and is located 2.5 cm fr L midclavicular line - boundaries of heart : R : formed by RA, R auricle, RV - passed like arch fr 3rd ICS to 5th costal cartilage 2.5cm lat to R sternal line Infr : formed by LV, RV - passes obliquely fr 5th costal cartilage till 5th ICS btwn R parasternal line and L midclavicular line L : LV, L auricle, pulmonary trunk and arch of aorta - passes up like arch 2.5cm medially fr L midclavicular line till 3rd ICS and then ascend up to 2nd ICS 4) The main sources of blood supply of the heart - main supply of the heart are :R coronary and L coronary art - these art arise fr ascending aorta above valves - R coronary art passes under R auricle and occupy atrioventricular groove together with small cardiac Vn - at level R margin it gives off marginal branch of heart - posteriorly gives off post interV art located in interV groove - L coronary art passed under L auricle and divide into 2 branch : a) ant interV occupy ant groove together with great cardiac art b) circumflex cardiac art lies in atrioV groove wh goes to the back and level of L margin and gives off marginal branch 5) Accesses to the heart. Surgical treatment of the IHD - in plan op, surgical accesses made thru sternum ( sterniotomy ) more often midline seldom transverse sterniotomy - surgical Tx of IHD depends on damage of cardina vessels : a) if present local or segmental damage of coronary vessels aorta-coronary shunt, thoraco-coronary shunt ( shunt below place of occlusion ) b) in diffuse damage of art, radical op is transplantation but it is difficult so some op are used eg i) organocardiopixy stitch other organ ( wh is rich in blood supply) to the heart to blood supply of the heart eg stitch lung to heart ii) laser transluminal angioplasty in normal state some vessels are not working so use laser to stimulate the closed vessel of myocardium to blood supply of the heart

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65. Trauma to the heart 1) Accesses to the heart in trauma - accesses to heart in trauma must be made very quickly coz ptt may die fr cardiac tamponade - usually in trauma of the heart, accesses is made along R of 5th ICS on the L side fr sternum till mid axillary line - 4th or 5th ICS depends on constitution ( dolichomorphic and brachimorphic ) 2) Definition of cardiac tamponade - cardiac tamponade = is a condition when work of heart is stopped when all vessels ( eg Infr and supr cava Vn ) wh drain blood into the heart is compressed - compression of vessels draining into the heart by fluid heart chamber is not filled heart cant pump heart stop 3) Suture materials ( to ground ) - close wound of heart by using non-absorbable suture coz heart constant work ( pump ) - if absorbable suture is used may lead to weakness of scar tissue aneurysm * non-absorbable material can be used in op of the extremities coz can rest the extremities so that sutures will not rupture or weakened by the physical activity but in the heart only absorbable suture is used coz heart cant stop working / pumping !! 4) Peculiarity of the suture of the heart - 2 opinion : ( view pict ) a) suture without penetration into endocardium - mainly used b) suture with penetration into endocardium - suture material is considered foreign body in our body ptt must take anticoagulant whole life to prevent coagulation, if forget to take thrombosis may occur 5) Peculiarity of the suture of the pericardium ( to ground ) - pericardium is stitched by seldom interrupted suture - if continuous suture is used fluid may accumulate post-op tamponade - in interrupted suture fluid can flow out fluid absorbed by surrounding tissues prophylaxis of post-op tamponade

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ABDOMINAL WALL. OPERATIONS IN HERNIAE. 66.Topography of the anterior abdominal wall. 1)Boundaries. Surface landmarks. Division by the lines. The boundaries : superiorly the costal arches and xiphoid process, inferiorly the iliac crests, inguinal folds, pubic tubercles and the superior margin of the symphysis pubis, laterally the vertical line, which connects the end of the 11 rib with the iliac crests (Lesgaft's line). This line is the continuation of the midaxillary line, and it separates the abdominal region from the lumbar region. The surface landmarks: xiphoid process, costal margin, iliac crest, pubic tubercle, symphysis pubis, inguinal ligament, superficial inguinal ring, linea alba, umbilicus, rectus abdominis muscle. Division by the lines : horizontal and vertical planes (lines) Two transverse and two vertical planes (lines) divide the anterior abdominal wall into three midline, three left, and three right regions. 1) vertical right and left lateral planes- correspond to the midclavicular planes & joining the anterior superior iliac spine and the symphysis pubis 2) subcostal plane- joins the lowest point of the costal margin on each side,(10th costal cartilage) & lies at the level of the third lumbar vertebra. interspinal plane (linea bispinalis)- joins the anterior superior iliac spine on each side. The midline regions are called the epigastric, umbilical, and hypogastric regions. The lateral regions are called the hypochondriac, the lateral and inguinal (iliac) regions. 2)Layers. Muscles. The retromuscular layers. Layers: skin subcutaneous tissues superficial fascia of superficial layer superficial fascia of deep layer muscles Muscles: The musculature of the anterior and lateral walls of the abdomen is made up of a trilaminar sheet. Thin aponeurotic tendons of the three lateral muscles form a sheath around each vertical muscle before fusing in the midline at the linea alba. trilaminar sheet are : 1) The external oblique muscle. 2) The internal oblique muscle. 3) The transversus abdominis muscle. vertically oriented: rectus abdominis muscle -lower part: pyramidalis -cremaster muscle: lower fibers of internal oblique muscle retromuscular layers: They include: the fascia transversalis, the extraperitoneal (preperitoneal) fat, the parietal peritoneum. 3)The rectus abdominis muscles. The rectus sheath. RECTUS ABDOMINIS -vertically oriented muscle -attached to above 5th, 6th, 7th costal cartilages -below: by tendinous and fleshy insertion to pubic crest and symphysis pubis -ant surface of the muscle crossed by 3 tendinous intersections: level umbilicus -they are strongly attached to ant wall of rectus sheath

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Retus sheath - rectus abdominis muscle is enclosed in a fibrous sheath formed by the aponeurotic tendons of the 3 lateral muscles. -Ant layer- external oblique - internal oblique aponeurosis -below costal margin ,contributing to anterior and posterior layers - transversus abdominis aponeurosis- passes into the posterior layer. Above umbilicus - external oblique contributes to the ant layer of sheath. - Internal oblique aponeurosis splits around muscle and goes to anterior and posterior of rectus abd muscle. - Transverse aponeurosis passes at the post of the rectus abd musc. Below umbilicus the 3 muscles pass in front / ant ly to rectus abd musc. Post ly arcuate line is formed followed by transverse fascia. 4)Nerves and vessels. a) skin: cutaneous branches of the 7th to 12th intercostal nerves and 1st lumbar nerve in the form of the iliohypogastric nerve b) subcutaneous tissues: . Cutaneous arteries- branches of the superior and inferior epigastric arteries, supply the area near the midline, - branches from the intercostal, lumbar, and deep circumflex iliac arteries supply the flanks. . venous blood- thoracoepigastric, intercostal, and superficial epigastric veins collected the venous blood and drained above into the axillary vein and below into the femoral vein via the superficial epigastric and great saphenous veins .A few small veins form an important portal-systemic venous anastomosis. a) muscle-anterior abdominal lower 6th thoracic & 1st Lumbar segmental nerves. The nerves are accompanied by branches of the musculophrenic or the first lumbar artery. -Thoracic nerves are added the iliohypogastric and ilioinguinal nerves which are derived from the first lumbar nerve. supply the lower fibers of the external oblique, internal oblique, and transversus abdominis muscles. - branches of the musculophrenic and lumbar arteries, supply the lateral muscles, superior and inferior epigastric arteries supply the rectus abdominis muscle. c) The arteries of the anterior abdominal wall are: the superior epigastric artery, the inferior epigastric artery, the deep circumflex iliac artery, the posterior intercostal arteries, the lumbar arteries. The superior epigastric, inferior epigastric, and deep circumflex iliac veins and drain into the internal thoracic and external iliac veins. The posterior intercostal veins drain into the azygos veins and the lumbar veins drain into the inferior vena cava. D) lymph vessels -cutaneous lymph vessels- drain upward into the anterior axillari lymph nodes, drain downward into the superficialis inguinal nodes.

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- deep lymph vessels follow the arteries and veins and drain into the internal thoracis, external iliac, posterior mediastinal, and paraaortic (lumbar) nodes. 5)Weak places of the abdominal wall. Clinical importance. a) linea alba- slitlike spaces. vessels, nerves and fat (which connects the extraperitonial fat with subcutaneous fat) pass through this spaces. This slits can be by the places of outlet of the herniae. It is called the hernia of the linea alba or the epigastric hernia b) umbilical ring - The urachus, umbilical vein, two umbilical arteries pass through here in the intrauterine development. Then this structures are turned into the ligaments. umbilical ring can by the place of outlet of the hernia. It is called the umbilical hernia. c) Inguinal canal- -is slit btw inguinal lig for flat muscles of abd wall where spermatic cord in male, round lig of uterus in female and illoinguinal nn are located d) Femoral canale) deep inguinal ring. These fossae are the weak places of the anterior abdominal wall. The inguinal herniae pass through these fossae.

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67.Topography of the linea alba and umbilicus. 1)Boundaries, structures of the lina alba . a)Boundaries of LA - sup : Xiphoid process - inf : symphysis pubis. - lat : fusion of lat muscles of 2 sides. The linea alba extends from the xiphoid process down to the symphysis pubis and is formed by the fusion of the lateral muscles of the two sides. Wider above the umbilicus, it narrows down below the umbilicus to be attached to the symphysis pubis. The linea alba has the through slitlike spaces. The vessels, nerves and fat (which connects the extraperitonial fat with subcutaneous fat) pass through this spaces 2)Layers in region of the linea alba. - skin, subcutaneous fat, superficial fascia, deep fascia, linea alba - no muscles here; only aponeurosis. 3)Layers of the umbilicus region. The layers of the umbilicus are: the skin with scarry tissue, the umbilical fascia (the part of the endoabdominal fascia or transverse fascia) and the parietal peritoneum. 4)The umbilical canal. The umbilical vein passes into the umbilical canal. The umbilical canal is formed by the linea alba - anteriorly and by the umbilical fascia - posteriorly. The inferior foramen of this canal is located at the superior margin of the umbilical ring. The superior foramen of this canal is located to 4-6 cm above the umbilical ring. 5)Anatomical conditions of forming of hernia of the linea alba and umbilical hernia umbilical ring - The urachus, umbilical vein, two umbilical arteries pass through here in the intrauterine development. Then this structures are turned into the ligaments. umbilical ring can by the place of outlet of the hernia. It is called the umbilical hernia. linea alba- slitlike spaces. vessels, nerves and fat (which connects the extraperitonial fat with subcutaneous fat) pass through this spaces. This slits can be by the places of outlet of the herniae. It is called the hernia of the linea alba or the epigastric hernia

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68.Topography of the inguinal canal. 1)The inguinal triangle. The boundaries of this triangle are composed: Inf- the inguinal ligament Medially- the lateral margin of the rectus abdominis muscle superiorly - horisontal line, which is drawn from the point between the lateral third and the middle third of the inguinal ligament. 2)Walls of inguinal canal. The inguinal interval. They are four: anterior, posterior, superior and inferior. a) The anterior wall of the canal (in norm) is formed by the aponeurosis of the external oblique muscle and the internal oblique muscle. In herniae, is formed by the aponeurosis of the external oblique muscle. b) The superior wall (in norm) is formed by the arching lowest fibers of the transversus abdominis muscle. In herniae, is formed by the internal oblique and transversus abdominis muscles. c) The inferior wall is formed by the inguinal ligament. d) The posterior wall of the canal is formed by the transverse fascia. Its strengthened by the inguinal falx (Genle's ligament) and interfoveolar ligament. The interval between the superior and inferior wall of the inguinal canal is called the inguinal interval. The form and sizes of the inguinal interval are various. They are the slitlike, oval, rounded and triangular. The triangular form of the inguinal is the precondition for the direct hernia. 3)The deep aspect (surface) of the anterior abdominal wall. The vessels and remnant of urachus pass under the peritoneum and transverse fascia and form folds (median, medial and lateral umbilical folds). a) median umbilical fold- contains the remains of the urachus and leads to the bladder. b) Two medial umbilical folds - followed into the pelvis and are found to approach the internal iliac artery. These folds are formed by the obliterated umbilical arteries. c) Two lateral umbilical folds can seen outside the medial folds and formed by the inferior epigastric vessels. These folds can be followed from the external iliac vessels to the arcuate line. Fossa a) supravesical fossa is located between the median umbilical fold and medial umbilical fold. b) medial inguinal fossa is located between the medial umbilical fold and the lateral umbilical fold. This fossa is the projection of the superficial inguinal ring on the posterior surface of the anterior abdominal wall. c) The lateral inguinal fossa (deep inguinal ring) is located lateral to the lateral umbilical folds. These fossae are the weak places of the anterior abdominal wall. The inguinal herniae pass through these fossae. 4)The rings of the inguinal canal. a) superficial ring - triangular-shaped defect in the aponeurosis of the external oblique muscle - base is formed by the pubic crest. - lateral side: lateral crus descends to the pubic tubercle

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- medial side: the medial crus, to the symphysis pubic. - third crus: posterior crus or reflexed liqament (Collesi). -triangular gap: is a superficial inguinal ring through which the spermatic cord in the male and the round ligament of the uterus in the female leave the inguinal canal. This space made more "ringlike" by intercrural fibers which obliterate its apex. - give origin of the external spermatic fascia. - male : spermatic cord, the ilioinguinal nerve and the genital branch of the genitofemoral nerve - female : round lig, the ilioinguinal nerve and the genital branch of the genitofemoral nerve b) deep ring - oval opening in the fascia transversalis, - lies 1,3 cm above the inguinal ligament midway between the anterior superior iliac spine and the symphysis pubis. - medially are the inferior epigastric vessels, which pass upward from the external iliac vessels. - The margins of the ring give origin to the internal spermatic fascia /round ligament of the uterus. 5)Topography of the oblique (indirect) and the direct inguinal hernia: interrelations of the hernia sac and spermatic cord. The acquired hernia in its turn are divided into the oblique (indirect) and the direct inguinal hernia. The congenital inguinal hernia always is oblique. a) indirect hernia- The hernial sac in the oblique hernia passes through the deep inguinal ring, along inguinal canal and through the superficial inguinal ring and can descend into the scrotum. It is called the inguinoscrotal hernia.(congenital) The hernial sac in the acquired oblique inguinal hernia is located lateral to the spermatic cord. b) direct hernia - The hernial sac in the direct inguinal hernia passes through the medial inguinal fossa, the inguinal internal, the superficial inguinal ring. The direct inguinal hernia never descends into the scrotum, always is acquired and has the straight way (track). The hernial sac in the direct inguinal hernia is located medial to the spermatic cord.

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69.Operations in strangulated hernia. 1)Parts of hernia. The hernia consists of three parts: the sac, the contents of the sac, and the hernial ring. -The hernial ring is a weak place through which passes the hernial sac. - The hernial sac is diverticulum of peritoneum and has a neck, a body and a fundus. The hernial sac is remains of the processus vaginalis in the congenital inguinal hernia. 2)Definition of the strangulated hernia. A hernia is said to be strangulated when the contents are constricted in such a way that interference with their blood supply results. 3)Difference of the strangulated hernia from irreducible hernia. -strangulated hernia is urgent condition accompanied by compression of vessels of contents and without emergency operation may lead to death -irreducible hernia is planned condition when hernial contents cannot return back into abd cavity in horizontal position of ptts body, cos btw contents and sac has adhesions 4)Main peculiarity of removal of the sac (1 part) and examination its contents. 1st part of herniatomy on removal of sac has pecularity in strangulated hernia. Before cutting aponeurosis of external obligue, surgeon must find hernial sac, open it & fix contents. After fixation of contents aponeurosis may be cut d surgeon during 30 min examine contents covered by gause with saline solution. Inject Novocaine into mesentery During 30 min must appear pink colour of intestine instead of blue, peristaltic of intestine, pulsation of mesenteric vessels. If these sign dont appear, sesection of part of small intestine is done d anastomosis in carried out. If these sign appear, organs are sutured back to abdominal cavity, hernial sac is closed by suture at the neck d others part of hernial sac is removed If got infection, repair is not performed coz. may develop necrosis which lead to phlegmon 5)Repair of the defect (2 part). - In strangulated hernia, direct hernia Bassini method is used. - Oblique inguinal hernia: Girar, Girar-Spasokukotsky, Girar-Spasokuusar with suture of Kimbarobsky, Martynov, Ru-Oppel is used - In femoral hernia-Bassini method is used - In umbilical hernia of adult-Mayos operation is used - In treatment of the small umbilical hernia in children (or in adults)- Leksers operation

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70.The methods of repair of the inguinal canal in oblique hernia. 1)The Girar method of repair 1 stage.- The lower borders of the internal oblique muscle and transversus abdominis muscle are drawn down in front of the cord and stitched to the deep surface of inguinal ligament. 2 stage.-The upper leaf of the external oblique aponeurosis is mobilized and drawn down and stitched to the deep surface of the inguinal ligament. 3 stage. -The lower leaf of the external oblique is stitched against the upper leaf thus overlapping it. This method has the shortcomings: 1) The inguinal ligament may split. 2) The muscles and the inguinal ligament are heterogeneous tissues, therefore weak scar tissue may be. 2)The Girar-Spasokukotsky method of repair. 1 stage.- The lower borders of the internal oblique muscle, the transversus abdominis muscle, the upper leaf of the external oblique are stitched to deep the surface of the inguinal ligament in front of the cord. 2 stage.- The lower leaf of the external oblique is stitched against the upper leaf thus overlapping it, so that a strong anterior wall to the canal is constructed. This method has the shortcoming. It is the connection of the heterogeneous tissues. 3)Suture according to Kimbarovsky and its peculiarities. -Kimbarovsky suture remove connection of heterogenous tissue healing develop: very fast and scar tissue is strong -suture passes through aponeurosis, int oblique m, transverse abd m and then came to aponeurosis of ext obliqueinguinal ligament -after filling the sutures aponeurosis: surrounds inf margin of muscle to inguinal ligament 4)The Martinov method of repair. 1 stage.- The upper leaf of the external oblique aponeurosis is mobilized and drawn down in front of the cord and stitched to the deep surface of the inguinal ligament. 2 stage.- The lower leaf of the external oblique aponeurosis is stitched against the upper leaf thus overlapping it, so that a strong anterior wall of the canal is constructed. -this method is only for children and young ptts -for elder ptts this cannot be used cos aponeurosis is very weak and splits 5)The Ru-Oppel method of repair. used in the first stage of the hernia, when the patient only has the widening superficial inguinal ring. The aponeurosis is not dessected. 1 stage. The medial crus and lateral crus of the superficial inguinal ring are stitched by 23 sutures. 2 stage. The separate sutures are put on not dessecting external oblique aponeurosis. -Main aim: is to make one size of superficial ring, to strengthen the ant abd wall

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71.Operations in direct inguinal herniae. 1)Topography of the direct inguinal hernia. direct hernia - The hernial sac in the direct inguinal hernia passes through the medial inguinal fossa, the inguinal internal, the superficial inguinal ring. The direct inguinal hernia never descends into the scrotum, always is acquired and has the straight way (track). The hernial sac in the direct inguinal hernia is located medial to the spermatic cord. 2)Peculiarities of removal of the sac. -after incision of skin, SC tissue, superficial tissue and aponeurosis of ext oblique musclesurgeon must find the sac, very carefully separate structures of spermatic cord to lateral side -hernial sac is cleared from fundus till neck, fundus is operated and contents are examined and returned back to abd cavity -if neck of hernial sac is wideclosed by purstring sutures and if it narrowtransfixation ligature is done 3)Definition of the sliding hernia. -is a condition when wall of hernial sac is formed by hollow organ that is covered by peritoneum by mesoperitoneally -it may be urinary bladder, ascending and descending colons 4)Peculiarities of removal of the sac in sliding hernia. -in sliding hernia at level of neck organ is locatedsurgeon must find end of the organ. Leave 2 cm down, apply purstring suture. -U-shaped incision on peritoneum, 2 cm below from bowel -retroperitoneal surface is covered by stitching together -gap of post wall of sac is closed by sutures -neck of it closed by Purstring sutures and rest of sac is cut away 5)The Bassini method of repair. Removal of the sac - incision is made 1 cm below and parallel to the inguinal ligament. - If the hernia is irreducible, it will swelling which emerges through the saphenous opening. - The actual sac is often suprisingly small. It is covered by the cribriform fascia, and is deeply embedded in condensed fatty tissue. - It is freed by gauze dissection up to its neck, seen to emerge through the femoral canal and is then opened at its fundus. - Any contents are returned to the abdominal cavity; omentum is often adherent and requires to be separated, but if it is free at the neck the adherent part may be removed. - The neck of the sac is drawn down so that it can be ligatured by transfixion at the highest possible point, and is cut off. Closure of the canal 1 stage. The inguinal ligament is stitched to the pectineal ligament by 2-3 sutures. 2 stage. The falciform margin of the fascia lata is stitched to the pectineal fascia.

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72.Operations in femoral hernia. 1)Structure of deep femoral ring. The femoral ring of the vascular lacuna = deep femoral ring Anteriorly Inguinal ligament Posteriorly Pectineal ligament Medially Lacunar ligament Laterally Femoral vein 2)Walls of the femoral ring. Superficial femoral ring. Walls of the femoral ring Anteriorly Falciform margin of the fascia lata (superficial layer of fascia lata) Posteriorly & Medially Pectineal fascia (deep layer of fascia lata) Laterally Sheath of femoral vein superficial femoral ring limit by falciform margin (oval fossa). It also is called the saphenous opening. The saphenous opening is filled with loose connective tissue called the cribriform fascia. 3)The femoral method of the treatment of the femoral hernia. - Its the Bassini method a) Removal of sac 1. Incision 1cm below & parallel to inguinal ligament. 2. Sac is often small; covered by cribriform fascia & deeply embedded in fatty tissue (so 1st incised & separated b4 sac can be isolated) 3. Contents return to ab cavity; omentum, often adherent, needs to be separated but if free at the neck, adherent part may be removed. b) Closure of canal 1. Deep femoral ring is closed by connection of inguinal ligament & pectineal ligament. 2. Falciform margin of fascia lata is stitched to pectineal ligament. c) Main disadvantage - Dislocation of inguinal ligament inferiorly enlargement of inguinal interval (space between inferior oblique & transverse abdominal muscles with inguinal ligament inguinal hernia. 4)The inguinal method of the treatment of the femoral hernia. Rudgi-Parlovecho-Raih is the inguinal method. - incision is similar to that used for inguinal hernia. - inguinal canal is opened by the division of the external obique aponeurosis; the cord or round ligament is displaced, and the muscles are drawn upwards. - transversalis fascia is divided in the line of the incision - Extraperitoneal fat is wiped aside by gauze stripping until the sac be seen entering the femoral canal. - bladder is sometimes adherent on the medial side, and must be carefully safquarded. - if sac not empty, adherent to its surroundings, it can withdrawn without difficulty from above, by genle traction on a pair of forceps applied to its neck. - opened at its fundus and remove the contents - Finally, the sac is removed flush the general peritoneum. Closure of the canal.

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1 stage. The inguinal ligament, the lower borders of the internal oblique muscle and transversus abdominal muscles are stitched to the pectineal ligament. 2 stage. The aponeurosis of external oblique is repaired, either by simple suture, or preferably by overlapping. 5)Peculiarities of operations in strangulated hernia. If hernia is strong, after expose sac, open sac, fixate sac & cut hernia ring. Then, examine organ. If its necrosed, remove it.

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73.Operations in the umbilical hernia and epigastric hernia or hernia of the linea alba. 1)Herniotomy according to Lekser. The hernial sac of umbilical hernia in children is very small. It is separated from the tissues, is not incised and is returned to the abdominal cavity. Obturator hernia is very uncommon. It is encountered most frequently in elderly women who have lost weight. The herniation occurs through the obturator foramen usually along the narrow canal traversed by the obturator vessels and nerve. Strangulation is therefore liable to ensue. 2)Repair of the abdominal wall on Lekser. Repair of the abdominal wall. 1 stage. The purse-string suture is put around the umbilical ring. 2 stage. The interrupted sutures are put on anterior wall of the sheath of the rectus abdominis muscle. 3)Herniotomy according to Mayo. - A transverse elliptical incision is made enclosing the umbilicus and the skin covering the hernia. - neck of the sac is free from adhesion, and should be opened first, aponeurosis is cleared until the neck of the hernia is exposed at level linea alba. - A small incision is made in the fibrous coverings of the neck - The remaining circumference of the neck of the sac is then divided with scissors, the finger used to protect the contents from injury. - These contents are carefully examined. The hernial contents are returned to the abdominal cavity. 4)Repair of the abdominal wall on Mayo. - The opening is enlarged laterally by a transverse incision so overlapping of the aponeurosis can be obtained. - first stage of the overlap a series of four or five interrupted mattress sutures is applied - These are introduced so that they will draw the free edge of one flap for a distance of 4 cm under cover of the other flap. - The overlapping is then completed by suturing the free edge of the superficial flap against the deep flap. 5)Herniotomy according to Sapeshko. Same method as Sapeshko except that incision and duplication of rectus sheath are longitudinal.

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ABDOMINAL CAVITY. 74.Structures (formations) of the peritoneum of the supracolic compartment or superior floor. 1)Division of the abdominal cavity into the compartments or floors. divided into two parts by the transverse colon and its mesocolon. They are the superior floor or the supracolic compartment and the inferior floor or the infracolic compartment. a) superior floor- liver, stomach, spleen, pancreas, superior part of the duodenum, gallbladder, omental bursa or lesser sac, pregastric bursa, right and left hepatic bursae, subhepatic spac .b) inferior floor -inferior part of the duodenum, the small intestine, the large intestine ,lateral or paracolic gutters, the mesenterial sinuses, the peritoneal pouches (superior and inferior duodenojejunal fossae, superior and inferior iliocecal fossae, retrocecal fossa, intersigmoid fossa) 2) omental bursa Ant -lesser sac behind the lesser omentum and posterior wall of stomach and lying infront of structures situated on the posterior abdominal wall. Post parietal peritoneal n post wall of pancreas Inf transverse mesocolon Left-spleen into ligament Right-omental bursa communicates with the epiploic foramen Epiploic foramen Ant-hepatodeuodenal Post-parital peritoneum n inferior vena cava Sup-caudate lobe of liver Inf-descending part of duodenum Clinical importance accumulationof pathological fluid & spread to other spaces 3) The pregastric bursa. Walls. Communications. Clinical importance. a. Wall i. Anterior parietal peritoneum of anterior wall of abdomen ii. Posterior lesser omentum & anterior wall of stomach iii. Superior left lobe of liver & diaphragm iv. Inferior transverse colon b. Communications left hepatic bursa & subhepatic bursa c. Clinical importance accumulationof pathological fluid & spread to other spaces 4)Right & left hepatic bursa. Walls. Communications. Clinical importance. a)Right wall i. Left falciform ligament ii. Right right coronary ligament & right triangular ligament iii. Superior diaphragm iv. Inferior right lobe of liver b)Left wall i. Left left coronary ligament & left triangular ligament ii. Right falciform ligament iii. Superior diaphragm iv. Inferior left lobe of liver

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c)Communications with each another & pregastric bursa d)Clinical importance accumulationof pathological fluid & spread to other spaces 5)Subhepatic space Lies between : inferior visceral surface of liver transverse colon & its mesocolon hepatoduodenal ligament

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75.Topography of the stomach and duodenum. 1)Holotopy end syntopy of the stomach and duodenum. Stomach Holotopy -The stomach is situated in the upper part of the abdomen, extending from beneath the left costal margin region into the epigastric and umbilical regions. Syntopy - Anteriorly: The anterior abdominal wall, the left costal margin, the left pleura and lung, the diaphagm, and the left lobe of liver - Posteriorly: The lesser sac, the diaphragm, the spleen, the left suprarenal gland, the upper part of the left kidney, the splenic artery, the pancreas, the transverse mesocolon, and the transverse colon. Duodenum Holotopy The duodenum is situated in the epigastric and umbilical regions. Syntopy a) First part of duodenum -Anteriorly: the quadrate lobe of liver and gall bladder -Posteriorly: the lesser sac (1st inch only), the gastroduodenal artery, the bile duct and portal vein, and the inferior vena cava. -Superiorly: The entrance into the lesser sac ( the epiploic foramen) -Inferiorly: the head of the pancreas. B) Second part of duodenum -Anteriorly: the fundus of the gallbladder and the right lobe of the liver, the transverse colon, and the coils of the small intestine. -Posteriorly: The hilum of the right kidney and the right ureter. -Laterally: The ascending colon, the right colic flexure, and the right lobe of the liver. -Medially: The head of the pancreas, the bile duct, and the main pancreatic duct. c) Third part of duodenum -Anteriorly: The root of the mesentery of the small intestine, the superior mesenteric vessel contained within it, and coils of jejunum. -Posteriorly: the right ureter, the right psoas muscle, the inferior vena cava, and the aorta. -Superiorly: The head of the pancreas -Inferiorly: Coils of jejunum d) Fourth part of duodenum -Anteriorly: The beginning of the root of the mesentery and coils of jejunum -Posteriorly: the left margin of the aorta and the medial border of the left psoas muscle. 2)Positions of the stomach depending on forms of build. - The stomach is relatively fixed at both ends but is very mobile in between. - It tend to be high and transversely arranged in the short, obese person (steer-horn stomach) = hyperstenic build. - Its elongated vertically in the tall, thin person (J-shaped stomach) = astenic build - Its shape undergoes considerable variation in the same person and depends on the volume of its contents, the position of the body, and phase of respiration.

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3)Parts of the duodenum. Is divided into 4 parts. (Superior horizontal part, Descending part, inferior horizontal part, ascending part) a) First part: Superior horizontal part, -is 2 inches (5cm) long. -Begins at the pylorus and runs upward and backward on the right side of the 1st lumbar vertebra. -It thus lies on the transpyloric plane. b)Second part: Descending part. -The 2nd part of the duodenum is 3 inches (8cm) long and runs vertically downward in front of the hilum of the right kidney on the right side of the 2nd and 3rd lumbar vertebrae. -About halfway down its medial border, the bile duct and main pancreatic duct pierce the duodenal wall. The unite to form the ampulla that opens on the summit of the major duodenal papilla. -The accessory pancreatic duct, if present, opens into the duodenum a little higher up on the minor duodenal papilla. c) Third part: Inferior horizontal part. -is 3 inches (8cm) long and runs horizontally to the left on the subcostal plane. -Passing infront of the vertebral column and following the lower margin of the head of the pancreas. d) Fourth part: ascending part -is 2 inches (5cm) long. -Run upward and to the left to the duodenojejunal flexure. -The flexure is held in position by a peritoneal fold, the ligament of Treitz, (which is attached to the right crus of the diaphragm. 4)The blood supply, innervation and lymphatic drainage of the stomach. a) Blood suppy 1)Arteries - The upper half is supplied by the superior pancreaticoduodenal artery, a branch of the gastroduodenal artery. - The lower half is supplied by the inferior pancreaticoduodenal artery, a branch of the superior mesenteric artery. 2) Veins - The Superior pancreaticoduodenal vein drains into the portal vein - The Inferior vein joins the superior mesenteric vein b) Lymph drainage The lymph vessel follow the arteries and drain . . . 1) upward via pancreaticoduodenal nodes to the gastroduodenal nodes and then to the celiac nodes and 2) downward via pancreaticodudenal nodes to the superior mesenteric nodes around the origin of the superior mesenteric artery c) Nerve supply The nerves are derived from sympathetic and parasympathetic (vagus) nerves from the celiac and superior mensenteric plexuses. 5)Vagotomy and gastric drainage procedures.

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- Vagotomy is indicated for choice of treatment of dudenal ulceration. It reduce secretion of gastric acid. - In performing truncal vagotomy, the lower oesophagus is eposed by division of the overlying peritoneum. - By gentle blunt dissection, the oesophagus, which should contain a nasogastric tube, is encircled and slung with a tape. - The posterior vagal trunk can be felt as a tight cord posteriorly and is divided between ligatures as it may be accompanied by blood vessels. - On the front of the oesophagus, the anterior vagus consists of a plexus, which is divided. - The lower 7cm of oesophagus should be completely cleared of nerve fibres to achieve an adequate vagotomy. - Most popular drainage procedure is Heineke-Mikulicz pyloroplasty. - Its involve longitudinal section of the pyloric ring. - The incision is closed transversely, usually with a single layer of interrupted sutures. - Gastrojejuostomy is the alternative drainage procedure to pyloroplasty. - This is performed thru opening the lesser sac and performing an anastomosis between the most dependent part of the antrum and the first jejunal loop.

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76.Topography of the duodenum and pancreas. 1)Duodenum: parts, relation to peritoneum; blood supply innervation and lymphatic drainage. Parts of duodenum refers to Question 75.3 Relation to peritoneum -1st cm mobile and attached to lesser omentum - remainder retroperitoneal Blood supply - duodenal and superior pancreaticoduodenal branches from the gastroduodenal branch of the hepatic artery - inferior pancreaticoduodenal branches of the superior mesenteic artery. - Venous drainage is portal and superior mesenteric veins. Lymphatic drainage - pyloric, hepatic and celiac nodes and distally to superior mesenteric nodes. Innervations: - vagus nerve and celiac plexus 2)Topography of the duodenum: holotopy, skeletotopy. - holotopy: epigstric region - skeletotopy: pass to the right of the midline to the level of the body of L1 to its termination to the lumbar at the midline at level of body of L2, descending as S-shape 3)Syntopy of parts of the duodenum. Clinical importance. Syntopy: - biliary duct and portal vein lie behind posterior part of duodenum - biliary duct join with pancreatic duct, curve to right, enter posteromedial aspect of descending part - Superior mesenteric vessels pass in front of the inferior horizontal part - Superior mesenteric artery arises from the aorta Clinical importance: - syntopy of superior horizontal part of duodenum and gall bladder ~ in chronic inflammation of the gall bladder, development of fistula is possible between gall bladder and duodenum - syntopy of descending part of duodenum and right kidney ~ in ulcers of posterior wall of descending part of duodenum possible penetration into right kidney or ureter - syntopy of inferior horizontal part of duodenum and superior mesenteric part of artery: inferior horizontal part of duodenum is compressed by the superior mesenteric artery - syntopy of pancreas and common bile duct: pancreatic part of common bile duct pass through pancreas and in the lumen of pancreas. Thus in case of pancreatitis, it leads to compression of the common bile duct causing jaundice 4)Pancreas: parts, relation to peritoneum, pancreatic duct. Blood supply, innervation, lymphatic drainage. Parts - head ~ in the curve of duodenum and lies anterior to inferior vena cava and left renal vein - body ~ extend to the left kidney and overlies the aorta, left renal vein, splenic vessels and termination at inferior mesenteric vein

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- tail ~ leaves the posterior abdominal wall in lieonorenal or pancreaticolienal ligament to end at the hilus of the spleen Relation to peritoneum - retroperitoneal -posterior surface applied to posterior abdominal wall, has no peritoneal relationship - anterior and inferior surface covered by peritoneum. Pancreatic duct - main pancreatic duct transverses the organ opening into 2nd part of duodenum in company with bile duct - accessory duct drains the upper part of head or uncinate process or may drain the upper part of head and open into duodenum above level of main duct on minor duodenal papilla - accessory duct commonly communicate with main duct Blood supply, innervation, lymphatic drainage - blood supply: head of pancreas supplied by both superior and inferior pancreaticoduodenal arteries. Remainder supplied by splenic artery. - Veins drainage of pancreas joins portal, splenic and superior mesenteric vein - lymphatic drainage: lymphatic from pancreas follows blood vessels to preaortic nodes around celiac and superior mesenteric arteries. Intermediate pancreaticosplenic nodes found around splenic artery 5)Topography of the pancreas: holotopy, skeletotopy, syntopy. Clinical importance. - holotopy: epigastric region - skeletotopy: lies on the posterior abdominal wall aligned roughly about a line drawn through the body of L1. It covers the transpyloric plane, pssing the tips of 9th costal cartilage on both sides - syntopy: lies anterior to inferior vena cava and left renal vein, through which biliary duct travels. Below, small portion of head tucked beneath superior mesenteric vein a.k.a. uncinate process, body and head connected with neck. Body extends to the left until hilus of the left kidney, overlies the aorta, left renal vein, splenic vessel, terminate in inferior mesenteric vein. Tail leaves the posterior abdominal wall in lienorenal or pancreaticolienal ligament to end at the hilus of spleen.

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77.Topography of the liver and gallbladder. 1)Holotopy, skeletotopy and syntopy of the liver. holotopy: right hypochondriac region skeletotopy: it lies entirely undercover of ribs and costal cartilage and in the epigastric region syntopy: diaphragmatic and visceral surface. Inferiorly, liver adjoins to stomach, duodenum and true organ of retroperitoneal space to apex of right kidney. Posterior to liver, inferior vena cava and abdominal aorta is located. At the inferior surface of the liver, gall bladder is attached. 2)Structure of the liver. - liver is divided into a left and right lobe by attachment of falciform ligament - right lobe is further divided into quadrate lobe and caudate lobe by presence of gall bladder, fissure of ligamentum teres, inferior vena cava - liver is subdivided into segments, like lungs where each segment contains its own branch of hepatic artery, bile duct, portal vein 3)Ligaments of the liver. Ligaments of the liver with organs of ligaments of the liver with the walls of the abdominal cavity the abdominal cavity 1. hepatoduodenal ligament 1. falciform ligament 2. hepatogastricum ligament 2. ligamentum teres 3. coronary ligament 4. right triangular ligament 5. left triangular ligament 4)Syntopy of the gallbladder. Relation to peritoneum. Variations. Projections of the fundus of the gallbladder on the anterior abdominal wall. Syntopy - superior surface of gall bladder adjoins to liver - inferior surface of gall bladder: neck and body of gall bladder adjoins to duodenum and fundus of the gall bladder adjoins to transverse colon Relation to peritoneum - body lies in contact with visceral surface of liver and directed upward, backward, and to the left - body narrows to a neck, which turns medially towards porta hepatic - neck blends with cystic duct, joining with common hepatic duct to form biliary duct Variations - mesoperitoneal: covered by peritoneum inferiorly

- intrahepatic: gall bladder is in liver with no relation to peritoneum

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- intraperitoneal: gall bladder is located in the peritoneum

*KEYS: Straight line: liver Circle: gall bladder Curved line: peritoneum 5)Suture of liver. - indication: damage of liver (wounds) and operations omn liver i.e. resection of liver - principle of Opel Suture and Kusnitskov-Penski Suture - all type of suture are interrupted mattress or mattress suture

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78. Topography of the biliary tract. 1) Hepatoduodenal ligament. Upper part of hepatoduodenal ligament (or lesser omentum) is attached to margins of lesser omentum Content: 1. right & left hepatic ducts 2. right & left brances of hepatic artery, 3. portal vein 4. sympathetic & parasympathetic nerve fibers 5. lymph nodes Function: 1.drain liver & gall bladder 2. send efferent vessels to celiac lymph noders 2) Syntopy of the structures of the hepatoduodenal ligament. From right to left: biliary duct, portal vein, hepatic artery 3) The hepatic ducts and biliary duct. HEPATIC DUCT -right & left hepatic duct joins to form the common hepatic duct. -it pass and embedded to the pancreas and reach the duodenum and it unites to the hepatopancreatic ampulla which opens into the duodenal papilla are surrounded by the circular muscle fibers, known as spincter of oddi BILIARY DUCT-4parts supraduodenal part lies in the right free edge of the lesser omentum in front of the opening into the lesser sac -Retroduodenal part situated into the 1st part of the duodenim -Pancreatic part lies on the posterior part of the head of pancreas. biles come in contact with the main pancreatic ducts. 4) Variations of the biliary tract. Cystic duct may join common hepatic duct very close to its formation at porta hepatic Cystic duct join hepatic duct close to duodenum & even cross hepatic duct to reach duodenum Right hepatic artery may pass anterior to common duct (normally artery is behind duct) Cystic artery may arise to left of common hepatic duct from right or left hepatic artery & pass either to anterior or posterior to duct (normally, cystic artery is arise from right hepatic artery after right hepatic artery pass under common hepatic duct) 5) Diagnostic triangle of Calo. Practical importance. Triangle of Calo: right-cystic duct left- common hepatic duct base(superior)-right hepatic artery Importance: to identify cystic artery in cholescystectomy. Mistake in ligation of right hepatic artery lead to necrosis of right lobe of liver.

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79. Topography of the spleen. 1) Holotopy, skeletotopy of the spleen. Halotophy: spleen is on left hypochondric region. Skeletophy: Access of spleen is projected from 9th (superior)to 11th rib(inferior) Long axis lies along the shaft of the 10 rib & its lower pole extents forward at midaxillary line & cannot be palpated. 2) Syntopy of the spleen. Posterior: L kidney & left suprarenal gland Medially: adjoin stomach d tail of pancreas Inferior : L colic flexure, L kidney & phrenicocolic ligament Lateral & ant : adjoin diaphragm 3) Blood supply and venous drainage. The spleen is supplied by the splenic artery & blood draines from it in the splenic vein. This is a tributary of the portal vein and thus, blood from the spleen is carried to the liver Spleen is supplied by system of celiac trunk which splenic artery arises & passes on sup. margin of pancreas & branches d enter the spleen Venous drainage is directed along splenic vein taking part in forming portal vein 4) Accesses to the spleen. a.left oblique subcostal b.right inversion according to federov c. right inversion according to reobisovich d.supervision midline laparotomy 5) Splenectomy: indications, technique. Indication: Access of spleen Trauma of spleen & rupture Technique: Spleen in intraperitoneal has mobility. After separation of phrenicolienal lig, the spleen is pulled up. At the hilus of spleen, only branch of splenic artery is ligated, then venous branches are ligated to communicate empty organ. Trunk is never ligated as it supplies the pancreas & pancreasnecrosis may occur. After spleen removal, drainage tube is put into succession layers. Tube is fixed to the skin.

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80. Structures (formations) of the peritoneum of the infracolic compartment or inferior floor. 1) Right lateral gutter (canal): walls, communications, variations. Walls : - Medially: ascending colon - Laterally: by peritoneum covering lateral abdominal wall Communications : with right hepatic bursa, subhepatic bursa Variations : 2) Left lateral gutter (canal): walls, communications, variations. Walls Medially: descending colon Laterally: peritoneum covering lateral abdominal wall Separated from the area around the spleen by phrenicocolic ligament, a fold or peritoneum that passes from the left colic flexure to the diaphragm, Communication Freely connected with pelvic cavity (pouch of Douglas) Variations 3) Right mesenteric sinus: walls, communications. Walls : - Right: ascending colon - Superiorly: transverse colon and mesocolon - Left: mesentery of small intestine. Communication: inferiorly by mesentery of small intestine 4) Left mesenteric sinus: walls, communications. Walls : - Superiorly: transverse colon and mesocolon - Right: by mesentery of the small intestine - Left: descending colon Communications : With pelvic cavity 5) The peritoneal pouches. Clinical importance of the formations. Superior and inferior duodenojejunal fossa Superior and inferior iliocecal fossae Retrocecal fossa Intersigmoid fossa Clinical importance: Very occasionally a piece of small intestine may become trapped in one of the pouches and form an internal hernia.

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No. 81 topography of the infracoloc compartment or the inferior floor of the abdominal cavity 1. topography of the small intestine - duodenum: situated in epigastric & umbilical region Divided into 4 parts: 1) superior horizontal part it passes posteriorly & to the right at the side of vertebral column. 2) descending part descends alongside the vertebral column 3) inferior horizontal part crosses the vertebral column at the level of L3 4) ascending part ascends to duodenojejunal junction at the level of L2 - jejunum fixed to post abd wall at duodenojejunal junction - ileum is fixed to post abd wall at ileocolic junction - btw these 2 points, intestine attached to post abd wall by an extensive mesentery of small intestine 2) Topography of the parts of the large intestine. - begins at R iliac fossa at ileocecal junction and terminates at anus Cecum: - cecum and appendix lie in R iliac fossa below the level of iliocecal junction - cecum usually completely covered with peritoneum and thus lie freely in peritoneal cavity - ant : coils of small intestine, parts of greater omentum, ant abd wall in R iliac region - post : psoas and iliacus muscle, femoral nerve, lateral cutaneous nerve of thigh - medial : appendix ; posteromedial : base of appendix Ascending colon: - covered by peritoneum mesoperitoneally, lies on the right side of abdomen, extending from the right iliac fossa to right colic flexure just below the liver. - Post : muscles of posterior abdominal wall, lower pole of right kidney - Ant : coils of small intestine, the greater omentum & ant abdominal wall - lat : lateral canal - med: mesenteric sinus Transverse colon: - extends fr right colic flexure to left colic flexure - ant : greater omentum &ant abdominal wall - post : 2nd part of duodenum & the head of pancreas - inf : coils of jejunum & ileum Descending colon: - covered by peritoneum mesoperitoneally, lies on left side of abdominal cavity - post : lower pole of left kidney - inf : quadratus lumborum, psoas, iliacus muscle, iliohypogastric, ilioinguinal nerves, lat cutaneous nerve of thigh, femoral nerve - ant : coils of amall intestine, the greater omentum, ant abdominal wall - lat : lateral canal - med: mesenteric sinus

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Sigmoid or pelvic colon: - completely covered by peritoneum, suspended by a pelvic mesocolon with a inverted V-shape attachment to the pelvic brim & post wall of pelvis. - At S3, the pelvic column is continuous with rectum - The attachment of mesocolom crosses the left common iliac vessels, left gonadal vessels & left ureter. - At the apex of V : recess of sigmoid mesocolon - Beneath the floor of the recess : left ureter 3) Anatomical difference of the parts of the intestine. - small intestine is longer and smaller but large intestine is shorter but larger in caliber - presence of tenia coli in large intestine but not in small intestine - smooth tubular appearance of small intestine but series of sac or haustra in cecum - presence of numerous intestinal villi in small intestine but absent in large intestine - presence of fat containing the protrusion of serous coat & appendices epiploicae in large intestine but not in small intestine 4) Blood supply, venous drainage and lymphatic drainage. Small intestine - branches of sup mesentery artery supply jejunum and ileum - intestinal branch arise fr L side of the artery and run in mesentery to reach gut - lower part of ileum also supplied by ileocolic artery - veins of jejunum and ileum corresponds to mesenteric vein - lymph vessels of jejunum and ileum pass thru a no. of mesenteric nodes and reach sup mesenteric node finally Large intestine - superior mesentry artery and inferior mesentery artery fr abdominal aorta supplies - at R side, sup mesentry artery divided into ileocolic artert, right colic and middle colic artery - ileocolic artery gives off ant and post cecal artery; post cecal artery supplies appendicular artery - right colic artery supplies ascending colon - middle colic artery supplies 2/3 of transverse colon and its mesocolon ( include right colic flexure ) - inf mesentery artery give off to ascending branch of L colic ar which supply remaining 1/3 of transverse colon, L colic flexure, upper descending colon - inf mesentery artery also give off descending branch of L colic ar which supply lower descending colon - sigmoid artery fr inferior mesentery ar supplies sigmoid colon - sup rectal artery = terminal branch of inferior mesentery ar supplies rectum 5) Resection of small intestine. - indication : tumour of intestine or its mesentery, necrosis of intestine at an acute intestinal obstruction, strangulated hernia, clottage of artery of a small bowel, multiple wounds

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position of the patient: on a back anesthesia: endotracheal narcosis access: median laparotomy end-to-end enteroenteroanastomosis the ligation of the vessels of a mesentery can be made doubly: or parallel to intestine at its edge at a level of direct arteries, or aphenoidal (clinoidal) with a preliminary dressing of vessels of a root of a mesentery (used at extensive resections, tumour of an intestine). i) on proximal end and distal end of removed intestine, in oblique direction under 45o rigid hemostatic clamps applied ii) having departed on 1 1.5 cm from a line of a prospective resection and laterally from the placed crushing forcepses, elastic intestinal forceps applied iii) a removal part of an intestine cut in oblique direction, parallel to crushing forcepses iv) after removal of an excised site the ends of an intestine pull together isoperistaltically v) suture of the wall by interrupted sero-muscular suture to form enteroanastamosis vi) then elastic clamps taken out and post edges ( labium ) of an anastamosis sewed by a continuous simple interrupted catgut suture and anterior edge ( labium ) by sewing suture of Shmiden vii) interrupted silk sero-muscular suture applied on the ant wall of an anastamosis viii) a opening in the mesentry is sewed by separate silk suture ix) side to side enteroenteroanastamosis

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OPERATIONS ON THE ORGANS OF THE ABDOMINAL CAVITY. 82. Puncture of the abdomen. 1) Indications. The position of the patient. Indications i) therapeutic purpose evacuation of liquid at an ascites ii) diagnostic purpose - detect organ damage in abdominal cavity, blunt trauma of abdomen, small penetrating wound iii) as one stage of laparoscopy The position of the patient i) sitting ii) edgewise seriously ill patients 2) Points for puncture. -mid point of distance btwn pubic and umbilical -lateral fr mid point of distance btwn umbilical and sup iliac spine on each side -mid point of distance btwn middle and lat 3rd of bispinal line and umbilical 3) Laparocentesis: instrument, technique. 1. By tip of a scalpel, a small incision is made, through which by a trocar other layers of an abdominal wall are pierced & its entered in an abdominal cavity. 2. The stilet is taken out 3. The liquid should be let out slowly, observing for pulse & respiration of pt. 4. Superior part of abdomen is pulled together by a sterile towel or sheet for prevention of a collapse because of fast drop of pressure in abdominal cavity. 5. At a diagnostic puncture, if blood, exudate, bile, intestinal contents follows from abdominal cavity, the organ is damaged & the operation is then stopped. 6. Otherwise the technique of a searching catheter is applied. 7. Into a tube of a trocar, a chlorvinyl catheter with apertures on the end introduced. 8. A catheter enters in the direction of a liver, lien, lateral canals, to a pelvis. 9. Thus, the external end of a catheter is connected with a syringe & aspiration is made. 10. Its possible to introduce 10ml of sterile solution (Novocainum, normal saline etc) & then to aspirate = Lavage of abdominal cavity. 11. If in a solution, the impurity of blood, intestinal contents, urine, muddy exudates is found, it proves internal organs damage. 4) Possible complications of the puncture and their prophylaxis. -(compli)damage to intestine (at presence of adhensive process) -(compli)damage to urinary bladder (prophy)empty urinary bladder before puncture -(compli)formation of ascitits,fistula (prophy) displace the skin down in area of puncture

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-(compli)infection of abdominal cavity aseptic antiseptic -(compli)collapse (prophy)put a sterile towel on upper part of abd and let fluid came out slowly and check BP and pulse 5) Notions about laparoscopic surgery. 1. Its an optic-tool visual inspection of abdominal cavity & its organs with diagnostic purpose. 2. Its indicated for detailed survey of abdominal cavity to detect organ damage, tumours & inflammatory processes, detect portal hypertension, clottage of mesenteric vessels etc. 3. Its contraindicated for an extremely ill patient, meteorism & adhesive process. 4. Trocar of a laparoscope enters the same as in laparocentesis. 5. To expand abdominal cavity, a gas (air, oxygenium, CO2) is introduced through a special cock on a trocar or through a special needle from a set of a laparoscope. 6. Then an optical tube enters to survey by a flexible light guide. To better examine the abdominal cavity, its necessary to change the position of the patient on an operating table

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83. Abdominal incisions (laparotomy). 1) Surgical accesses to organs of the abdominal cavity (classification). a) Longitudinal incisions: i) Median laparotomy -superior midline laparotomy -inferior midline laparotomy -middle midline incision ii) Paramedian incision iii) Transrectal incision iv) Pararectal incision b) Oblique incisions c) Transverse incisions d) Angular incisions e) Combined incisions f) Alternating ( grid iron, muscle splitting ) incision. 2) Longitudinal incisions. Direction of incision in superior midline laparotomy. Direction of incision in inferior midline laparotomy. -sup midline laparotomy: always start fr more dangerous zone to less dangerous zone,start fr just below xiphoid process till 2cm above umbilicus,for avoiding the damage to liver. The scaple should put perpendicular to the surface, the incision is in rectangular configuration -inf midline laparotomy: start fr supra pubic area(above pubic symphysis) and continous upward till 2cm below the umbilicus, prevent damage to urinary bladder. 3) Oblique incisions. a) Superior part of anterior abdominal wall- parallel to edge of costal arch. b) Inferior part of anterior abdominal wall- parallel to inguinal ligament, also can make oblique incision by making an angle. For access to liver, gall bladder, bile ducts, spleen, vermiform appendix, sigmoid colon 4) Technique of laparotomy: screening of the skin, opening of the peritoneum, separation of adhesion, prevention of soiling of peritoneal cavity. a) Screening of skin- shave the hair, then using antiseptic solutions such as povidonIodin, alchohol to sterile the skin (prepping). b) Opening of peritoneum Always under supervision to prevent damage of organs of abdominal cavity. The peritoneum is grasped and raised by two anatomic forceps, once comfirmed that there are no organs in the folds of peritoneum, the peritoneum is dissected and fixed to towels by Mikulics forceps. c) Separation of adhesions. d) Prevention of soiling of peritoneal cavity. Operate on emptied organs. Organ is taken from abdominal cavity and operated outside. Organ is covered with napkins in depth of wound and isolated from other organs. 5) Closure of a perforated gastric and duodenal ulcer.

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It is done if perforation has occurred for a long time and peritonitis has developed or if stomach resection is not indicated. Patient in supine position. Endotracheal narcosis. Superior median laparotomy. Stomach and duodenum are searched for perforations. Suture- transverse direction to axis of stomach or duoedenum to prevent narrowing of lumen. On edges, 2 series of seromuscular sutures applied. For more reliability, after knot at perforation is tied, a nearby omentum is fixed by the same sutures. When sewing is impossiblr, an omental tamponade is used. Abdominal cavity is drained, gastric contents and exudates removed from abdominal cavity by suction and dry napkin. Wound is sewed according to layers.

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84. Laparotomy for injury. 1) Technique of exploration. Purpose: detection of damage of organs at trauma of a abdomen, finding the source of inflammatory process at a symptoms of an acute abdomen, determine operability of malignant tumor of organs. Operation : median laparotomy 2) Injuries of the liver. Suture of liver. -sup midline laparotomy is made.anteriorly,diaphragmatic surface 0inf surface are accessible in revision -inf surface is reviewed by abducting the transverse colon and its mesocolon downward,then we exlore the gall bladder,hepatic duct,hepatoduodenal ligament -in case of exploring the ant surface right hand is entered to abd cavity and reach hypochondrium under the dome of diaphragm -for better search, falciform ligament may be cut -1. use interrupted or contiuous mattress suture

-2. suture acc to Kuznetsov-peusky

3) Injuries of the small intestine and of mesentery. -we start the exploration fr duodena jejunal flexure which is found acc to Gubarors method(by holding transverse colon and mesocolon by left hand then right hand index fingers pass to spine along the mesocolon and fr there to left side finger pass and grap the position of jejunum) -fr tat flexure carefully explore the loops and this mesenteric and free margins of it -the exploration of both sides of mesentery is done while doing it can find any wounds or gangrenous parts of jejunum well wrap it wif antiseptic and hold it by forceps -only at the end of complete exploration we will do the single purse-string suture of Lembert type, use 1,2 suture. 4) Injuries of the colon. -technique of exploration is same as for small intestine -but, a suture of large intestines less reliable, therefore, the Three-row suture is needed. - Typical operation on large intestine is suturing of wound, appendectomy. Less common, malignant tumours, polypose, ulcerative colitis etc. 5) Injuries of the stomach, duodenum and pancreas. 142

-for exploring the post wall of stomach we must cut gastro colic ligaments to enter the omental bursa (lesser sac) -post aspect of duodenum is made by cutting parietal peritoneum on right side and mobilized it -ant surface can explore directly -pancrease is explored thru cutting the gastrocolic ligaments and cutting out the omental bursa 85. Gastrostomy. 1) Indications. an obstruction of an esophagus at a nonresectable cancer of an esophagus & cardiac department of a stomach, wounds, inherent defect, esophageal stenosis after combustion. 2) Accesses. -left transrectal supraumbilical laparotomy is done,also can use left supra umbi pararectal,left para median,let para rectal -in this operation patient is in supine posture 3) Tubular fistulae (Witzel, Stamm-Kader). a. Witzel (for adult) Incision on anterior wall of stomach from mid-point of lesser & greater curvature Tube is placed towards cardiac part of stomach Tube is sutured to wall by sero-muscular sutures (6-8) sutures ending with a purse-string suture Wall in middle of the purse-string suture is incised Tube is introduced into incision & the suture is tightened 2-3 sero-muscular sutures are placed to secure the tube Incision is made on left lateral border of the rectus abdominis is incised(small) Incision is pierced by a clamp & tube is drawn through Peritoneum is secured along the canal by 4-5 interrupted sutures(gastropexy) b. Stamm-Kader (for children) On anterior wall of stomach, a purse-string suture is applied on a circle with the diameter of 5-6cm An incision is made in centre of the suture & tube with diameter 1cm is introduced The suture is then tightened & fastened Tube is receded into stomach and at every 1-1.5cm interval a pursestring suture is applied & fastened Gastropexy is made like in Witzel 4) Lip-shaped (lip like) fistula (Toprover). -Anterior wall of stomach is drawn out in a cone shape

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-2 guy sutures are placed at apex of cone 2cm apart from each other -3 purse-string suture using silk is applied with the 1st being 1.5-2cm from apex & subsequent ones 1.5 cm from each other. Sutures are not tightened -An incision is made 1cm between the 2 guy sutures & a tube is introduced The purse-string sutures are tightened serially beginning from the 1st to form a canal Wall of stomach at the level of the last purse-string suture is stitched to parietal peritoneum with interrupted sutures. Edges of incised peritoneum on other extent of wound is sewed up tightly Wall of stomach at level of 2nd purse-string suture is sewed to aponeurotic sheath of rectus abdominis muscle Wall of stomach at level of 1st purse-string suture is sewed to skin Exposed mucosa of stomach is then sewed in a lip-shape fistula and tube is withdrawn

5) Difference of principle of techique of tubular fistula on Stamm-Kader from lipshaped on Toprover. Tubular Lip-shaped Duration Temporary Permanent Nature of canal Canal of fistula is formed Canal of fistula is formed by wall by serous membrane of mucosa membrane of organ organ Closure of fistula Closes without operation, Requires operation to close simply remove tube organ (adhesion formed by scar tissues). For unoperable disease. Terminal stage

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86. Principles of resection of stomach. 1) Schemes of resection of stomach on Bilroth-II and modifications of Bilroth-II. -Biliroth I -removal of part of stomach -end to end anesthemosis of stomach and duodenum done -formula is 1,2 or hemostatic 1,2 -part of stomach closed and forms a new lesser curvature

-Biliroth II -end to side anesthemosis is done

2) Difference of principle of operations on Bilroth-I from operations on Bilroth-II. -Bilroth I -end to end anesthemosis. Duodenum is attached to the end part of stomach -can resect only at pyloroantral part of stomach. -presence of angle of sorrow -very difficult technique. When Bilroth-I impossible due to large tension in connection of stomach and duodenum due to increased distance, int his case, Bilroth-II is carried out -Bilroth II -end to side anestamosis. Jejunum attach to end part of stomach -perform at any part of stomach (resection) -absent angle of sorrow -easy technique 3) Resection of the stomach on Hofmester-Finsterer. -sup midline laparotomy is done,this is modification of Bilroth II , also can do left supraumbilical transrectal incision 145

-make incision and make the stomach mobile fr lesser and greater omentum -find the duodeno jejunum junction by gubarevs method and leave 10cm -forceps is put on duodenal part and on pyloric part of stomach is put -then cut duodenum btwn forceps after tat put the clamp to living part of pyloric region of stomach and put the forcep to removal part of stomach -then cut btwn these clamps and remove part of stomach,the resected end of duodenum is incised by 1,2 formula of suturing -then form the new lesser curvature of stomach till anesthemosis area of jejunal part -then do end to side anesthemosis 4) Advantages and shortcomings of the operation Bilroth-I. Advantages: -the mucosa of pyloric part of stomach and mucosa of duodenal is matching each others -dev of ulcerative condition less thn other method -abscent of afferent loop syndrome -disadvantages -due to strech of the anesthemosis part can dev incompetence of anastomosis -very difficult technique,duodenal is located retroperitonealy -presence of sorrow angle -this technique performed only to pyloric antral part of stomach 5) Advantages and shortcomings of the operation Bilroth-II and their modifications. - advantages: always possible to perform - disadvantages: not physiological way of passage of stomach content leading to afferent loop syndrome when content pass from stomach to duodenum causing accumulation there. Complication of insufficiency of suture on duodenum because posterior part of duodenum is not covered by peritoneum

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87. Gastroenterostomy. 1) Types of gastroenterostomy. - anterior: the anastomosis is applied with a anterior wall of stomach - posterior: anastomosis with a posterior wall of a stomach - Antecolic: the loop of a jejunum is made to stomach anterior to transverse colon - Retrocolic: the loop of jejunum is made to stomach behind transverse colon 2) Indications to operation. - in disturbances of evacuation of food from a stomach at the nonresectable cancer of a pyloric department of stomach, cicatrical narrowing of a pylorus at the sharply weakened patient, when is impossible to execute radical operation 3) Accesses. - the superior median laparotomy 4) Technique of anterior antecolic gastrostomy on Welfler. - using Gubarevs Method, duodenojejunal flexure and beginning of jejunum found - an intestinal loop make to anterior wall of stomach anterior to greater omentum and transverse colon - afferent loop fixed at lesser curvature nearby cardial department - efferent loop fixed at the greater curvature near pyloric department of stomach - at first, stomach is opened, and then small bowel - content of stomach is evacuated and lumen of intestine is drained, and then anastomosis is performed 5) Technique of posterior retrocolic gastrostomy on Hacker-Petersen. - for an anastomosis, a loop of a jejunum by length 7-10cm from duodenojejunal flexure taken - a mesentery of transverse colon dissected in a vertical direction in a nonvascular zone - by left hand posed on stomach, posterior wall of stomach puffed out through an opening in mesocolon transversum - loop of an intestine fixed to a stomach in vertical in relation to an axis of a stomach direction - an afferent loop is nearby lesser curvature , and efferent to greater curvature - the afferent loop should be sewed to wall of stomach above anastomosis. An eperon(spur) for prevention of a vicious circle is thus formed - edges of an opening in mesocolon transversum fixed to wall of stomach above anastomosis

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88. Operations on the gallbladder. 1) Surgical accesses to the liver and gallbladder. -fyodorors (liver)

-reobrauk ( liver and g.bladder)

-kochers

-sup midline laparotomy

Liver operation Main problem on liver operation is stop bleeding because liver is a parenchymous organ For temporarily stop bleeding: 1. compress liver margin using finders 2. apply elastic forcep on liver margin 3. compression of hepatoduodenal ligament 15 minutes, if 15mins will lead to collapse For permanent stop bleeding from parencyme of liver, mechanical, physical, chemical, biological methods & special hemostatic can be used More simple method is mechanical: 1. suture of liver 2. ligation of veins in wound 3. mechanical tamponade of wound Suture of liver 1. Kusnikov- Spensky suture i. simple interrupted ii. simple continuous -not use in liver -usually mattress -ligature is not strong

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-aim: approximation to each other, diaphragm & visceral surface -2 different colour thread is used -suture is continuous mattress but loop must be free -one colour on one side (diaphragm), different colour on visceral -same colour thread is ligated -advantages: absence distance between different suture all tissue are compressed ( 1 needle transmit 2 thread) 2. Opel - same principle, only interrupted mattress is used - 2nd suture is distal to the one near middle of 1st double compression of organ 3. Jardan suture - needle transmit 2 thread - thread out & both side thread is ligated Resection of liver: atypical ( wedge shape, marginal, transverse) Typical (right & left hemihepatectomy, right & left paramedian lobectomy, segmentectomy) Gall bladder operation 1. cholecystotomy 2. cholecystostomy 3. cholecystectomy 4. cholecystojejunostomy 5. cholecystogastrostomy 6. cholecystoduodenostomy 2) Cholecystostomy. Types: 1. open- i) antegrade- from fundus till neck - ii)retrograde- from neck till fundus, this method is better for removal 2. laparascopic 3. percutaneous transhepatic cholecystomy (PTC) by ultrasound control Aim: to decrease pressure in gall bladder Stages: 1. right supraumbilical laparotomy or penetrate fundus using needle & syringe 2. tubular 3. fundus: purse-string suture 4. rubber tube is inserted & tie 5. if there is stone present, remove stone using special spoon shape forceps before applying rubber tube 3) Cholecystectomy from neck (the retrograde method). Start from hepatoduodenal ligament to expose Calos triangle Ligate cystic duct & cystic artery to prevent escape & bleeding Removal of gall bladder

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Disadvantages: difficult to find Calos triangle Impossible to perform if inflammation pass into hepatoduodenal ligament because inflammation may cause changes to the syntopy of hepatoduodenal ligament. This may lead to damage of portal vein during ligation. 4) Cholecystectomy from fundus ("fundus first method"). Fundus 1st method= antegrade method Gall bladder is separated from bed from fundus till neck At neck, ligate cystic artery & cystic duct This technique is easier but there is bleeding during separation of gall bladder from bed Bleeding is continuous until ligation of arch During ligation of arch, rotate gall bladder down, medial or laterally If there is stones, stones will be pushed down to bile duct occlusion post operative jaundice 5) Laparoscopic cholecystectomy. Four puncture wounds are made in abdomen, usually umbilicus & epigastrium Stages of operation: 1. traction: to raise gall bladder to expose liver hilus & zone of triangle Calo 2. mobilization: begin from L-shape incision by cauthery tips/ electric knife, incision is made along fold of peritoneum at middle 3rd of medial surface of gall bladder 3. dissecting/ preparation of triangle Calo 4. ligation of cyctic artery 5. ligation of cystic duct 6. mobilization of gall bladder from bed of gall bladder 7. aspiration of fluid & drainage of abdominal cavity 8. extraction/ removal of gall bladder 9. end of operation after removal of gall bladder includes: -examination of abdominal cavity -aspiration of fluid -extraction under visual control instrument -removal of gas in peritoneal cavity -suture foramen of abdominal wall at place of insertion of 10mm length of trochar

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89. Resection of small intestine. 1) Indications. Tumours of an intestine @ its mesentery, necrosis of an intestine at an acute intestinal obstruction, strangulated hernia, clottage of arterias of small bowel, multiple wounds. 2) Methods of suturing of gut. I row of sutures. The posterior surfaces of the pulled together walls of an intestine sew by separate interrupted serous muscular silk sutures (I row). II row of suturese. Continous catgut, sometimes interrupted suture on internal labiums. III row of sutures. Continous screwing suture of the Shmiden @ separate interrupted sutures with knots in a lumen of an intestine. IV row of sutures. Atop interrupted sutures sero muscular sutures placed from 1 guy suture to another. 3) Types of anastomosises of gut. End to end - direct connection of hollow organs with applying of 2 @ 3 row sutures. Side to side - tightly closed 2 stumps placed isoperistaltically & bridge by an anastomosis on lateral surfaces of intestine End to side applied at connection of parts of GIT tract of a different diameter Side to end - lateral surface of more proximal organ is bridged to the end of a more distally posed organ 4) Resection with side-to-side (lateral) anastomosis. Bowel resection and formation of a stump of the afferent and efferent parts of an intestine after a resection carried out by a purse-string method of the Doyen, which consist the following stages: a. A ligation by a catgut of an intestine under a clamp on a clamped site An applying of purse-string suture having departed on 1.5 cm from a ligature c. An applying of a crushing clamp on a removed site & dissecting away of an intestine on edge of a clamp d. Plunge of a stump with a tightening of a purse-string suture. 5) Resection with end-to-end anastomosis. On the proximal & distal ends of a removed department of an ontestine in a oblique direction under an angle 45 rigid haemostatic clamps applied. Having departed on 1 1.5 cm from a line of a prospective resection & laterally from the placed crushing forcepses, elastic intestinal forcepses applied. A removal part of an intestine cut in a oblique direction, parallel to crushing forcepses. After removal of an excised site ends of an intestine pull together isoperistaltically.

b.

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Formation of enteroenteroanastomosis begin from suture of its wall by interrupted sero-muscular sutures. Then elastic clamps taken out & posterior edges (labium) of an anastomosis sewed by a continuous simple interrupted catgut suture & anterior edges (labium). Atop of a catgut suture on a anterior wall of an anastomosis interrupted silk seromuscular sutures applied. An opening in a mesentery sewed by separate silk sutures.

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90. Appendicectomy. 1) Typical positions of the ceacum. Lie in the right iliac fossa below the level of the iliocecal junction. The cecum is usually completely covered with peritoneum and thus lies free in the peritoneal cavity. 2) Different position of the appendix. McBurney's point. Lanz's point. Different position of the appendix. Vermiform of appendix: right iliac fossa below the level of iliocecal junction. The base of appendix lies at the posteromedial aspect of cecum. Lying over the pelvic brim. Tucked behind the cecum or ascending colon. Retrocolic position when it is inflamed. Mc burneys point. The surface projection of the base of the appendix which located at the junction of the lateral and middle third of a line joining the anterior superior iliac supine with umbilicus. Lanzs point Surface projection of the base of the appendix which is located between right third and middle third of the bispinal line. 3) Blood supply, venous and lymph drainage from cecum and appendix. Arterial system - supplied by superior mesenteric artery - iliocolic artery is branch of sup mesentery ar supplying 30cm of ileum, appendix, caecum and beginning of ascending colon - these ar gives off appendicular ar directly thru mesoappendix Venous system - directed to superior mesenteric vein till portal vein Lymphatic system - directed along vessels to paraaortic and preaortic lymph node 4) Indication for appendicectomy. Accesses to appendix. Indication for appendicectomy Acute appendicitis Chronic appendicitis in cold stage Malignant tumor of appendix Accesses 1) More often oblique muscle, splitting incision according to Mc Burneys point. 2) Infraumbilical right pararectal according to Lenander. 3) Inferior midline laparotomy, in diffuse peritonitis. 4) Right infraumbilical transverse muscle, splitting according to Lanz.

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5) Types and technique of appendicectomy: antegrade, retrograde and ligature. Laparoscopic appendicectomy. Antegrade: removal from apex till the base of appendix. Caecum is pulled up thru wound. Appendiz also pulled up thru wound. On apex Kohirs haemostatic forceps is put. Mobilization of appendix crush forceps is put. On curshs place ligature is put. 1.5-2cm from ligature on fundus purse string seromuscular suture is put. Above ligature forceps is put. Appendix along forceps is cut and removed. Stump is covered by iodine. Stump invaginated into caecum and purse string suture is tied. Above this sutue, z shape sure is put. Retrograde: removal from the base till the apex of appendix. Caecum pulled up thru the wound. Mobilization is made. On base crushs forceps is put. On crush place ligature, purse string suture us put on caecum. Above ligature appendix is cut. Stump covered by iodine and invaginated into the caecum. Purse string sure tied. Above this z shape suture is put. Further surgeon begins to find apex of appendix. Dissection is made till the apex. -Ligature method: -used normally in children and some adult whose have small distance btwn base of appendix and iliocecal junction -after cutting appendix stump is covered by strong antiseptic like boric acid -laparoscopic appendicectomy: -used for normal w/out complicated appendicitis -advan:quicker healing of wound -using abd puncture (laparocentesis) 1st apply illuminance to give good visual field -technique same as normal operation

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91. Operations on large intestine. 1) Peculiarities of the suture of the large intestine. - large intestine in comparison with small intestine has the following pecularities i) thin and gental wall ii) has the worst blood supply iii) post wall of ascending and descending colon isnt covered by peritoneum iv) intestinal contents contain more malignant bacteria - these pecularities make suture of large intestine less reliable thus it is rational to apply a 3-row suture instead of 2-row - 3-row suture include : i) 1 thru and thru suture ii) 2 sero-muscular suture - resection of large intestine is carried out not with primary restoration of passage ( as on small bowels ) but in 2-stage 2) Ileo-transverse anastomosis. -due to presence of inoperable tumor in ascending part of large intestine,right colic flexure,cecum -anesthemosis btwn terminal part of ileum and transverse colon is done -side to side anesthemosis is done 3) Transverso-pelvic anastomosis. -in inoperable tumor of left colic flexure and descending colon anesthemosis is apply btwn transverse and sigmoid colon -anesthemosis is side to side 4) Pelvic colostomy and "artificical anus". pelvic colostomy = sigmostomy - access : oblique muscle splitting incision in L iliac region - technique : - edges of parietal peritoneum are sewed with edges of skin to prevent infection of subC fat of abd wall - a part of sigmoid colon ~ 8cm in length is taken out and connected with parietal peritoneum by interrupted sero-musculcar silk suture - lumen of intestine is opened on 2nd-3rd day ( after adhesion of visceral and parietal peritoneum was formed ) if ptts condition allows so - is an immediate opening of intestine is required, the wall is then dissected in a longitudinal direction thru all layers and the incision edge are connected to skin by interrupted suture - for closing of a colostomy, an additional op is necessary Artificial anus - indication : non ressectable tumour if large intestine wound of rectum cicatrical narrowings of rectum tumours closing distal part of intestinal lumen

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temporary / 1st stage of double stage op ( when it is impossible to apply anastamosis owing to pathological changes in the wall of large intestine remains permenant if it is impossible to remove the affected of intestine or at the extirpation of a rectum with anus at wounds of rectum, it is used as a temporary arrangement for fecal mass evacuated and favourable condition for wound healing can be applied for large intestine more often applied on sigmoid colon the formation of double loop artificial anus differs from colostomy by creation of eperon / spur which block passage of feces in the efferent branch of intestine not closed independently thus need op for closing the artificial anus with single stoma ( or end-colostomy ) is formed after extirpation of rectum or after 1st stage of Hartmanns op when distal stump is closed

5) Principles of right and left hemicolectomy. - hemicolectomy = resection of of colon Right - include removal of cecum with terminal part of ileum, ascending colon, R colic flexure in R 1.2 of transverse colon - basic moments of op i) mobilization of R of large intestine together with terminal part of ileum ii) ligation of basic vascular trunks iii) removal of all R of large intestine with vermiform appendix with ~ 10 cm of ileum iv) formation of end to side or side to side anastamosis btw stump of small intestine and transverse colon Left - consist of removal of sigmoid, descending colon, L colic flexure and L 1.2 of transverse colon - basic stages of op same as R hemicolectomy - end to end anastamosis is applied btw transverse colon and stump of sigmoid colon or initial part of rectum

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LUMBAR REGION. RETROPERITONEAL SPACE. OPERATIONS. 92. Topography of the lumbar region. 1) Boundaries. Layers. Borders :i) Superiorly 12th rib ii) Inferiorly iliac crest iii) Medially spinous process of lumbar vertebrae iv) Laterally midaxillary line Layers :Skin, subcutaneous fat, superficial fascia, fatty layer in inferior region (lumbogluteal fatty pillow), proper fascia, thoracolumbar fascia (a deep fascia), muscles (medial & lateral). 2) Peculiarities of the structure superficial fascia and subcutaneous tissue. Superficial fascia and lumbar region is divided to the layers and forms additional layers of fat called lumbar-gluteal pillow.This fat of level iliac crest communicated with upper part of subcutaneous part of gluteal region. 3) Medial part of the lumbar region. Contains 3 muscles i) Erector spinae 1. L & R portion lie in a trough on either side of vertebral spines. 2. The trough is limited i) anteriorly transverse processes ii) in the thoracic region by ribs medial to their angles 3. The remainder of muscle is enclosed by thoracolumbar fascia. 4. Its supplied by muscular branches of dorsal rami of spinal nerves. ii) Quadratus lumborum 1. This flat muscle lies immediately laterally to upper part of psoas major. 2. Its quadrilaterally-shaped & lies along vertebral column. 3. It extends from the lower border of 12th rib & the tips of the lumbar transverse processes to the iliolumbar ligament which spans the gap between 5th lumbar transverse process & the iliac crest itself. 4. Anterior & middle sheets of thoracolumbar fascia enclose this muscle. 5. Anterior sheet of this fascia is thickened above to form the lateral arcuate ligament & below to form the iliolumbar ligament. iii) Psoas major 1. It lies in the paravertebral gutter at the side of bodies of lumbar vertebrae from T12-L5. 2. The fibers run downward & laterally & leave the abdomen to enter the thigh by passing the inguinal ligament. 3. The lateral border converges with inguinal ligament.

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4. These muscles share a common attachment to the lesser trochanter of femur. 5. Its enclosed in a fibrous sheath thats derived from lumbar fascia which is thickened above to form medial arcuate ligament. 6. These muscles are supplied by the lumbar plexus. 4) Lateral part of the lumbar region. Muscles here lie in 3 layers. a) 1st layer i) Latissimus dorsi 1. Its a large, flat muscle. 2. Origin extends from lower 6 thoracic spines, lumbar spines, sacral spines & iliac crest by thoracolumbar fascia to which its attached. 3. Supplied by thoracodorsal nerve from posterior cord of brachial plexus. ii) External oblique muscle 1. Have an oblique, free posterior border that extends from upper of 12th rib to midpoint of iliac crest. 2. The fleshy fibres fan out downward & medially over the anterior ab wall. b) 2nd layer i) Serratus posterior inferior 1. A thin, flat muscle that arises from upper lumbar & lower thoracic spines. 2. Its fibres pass upward & laterally & are inserted to the lower ribs. ii) Internal oblique muscle 1. Lies deeper than the external oblique muscle. 2. It arises from thoracolumbar fascia, the anterior 2/3 of the inguinal ligament. 3. It forms the floor of lumbar triangle & has a triangle between it & serratus posterior inferior = superior lumbar triangle Lesgaft-Grunfeld. rd c) 3 layer - Transversus abdominis muscle 1. It lies deep to internal oblique, its fibres run horizontally forward. 2. It arises from the deep surface of the costal margin, thoracolumbar fascia, anterior 2/3 of medial margin of iliac crest & outer of inguinal ligament. 3. Subcostal nerve, artery & vein pierce posterior aponeurosis of transverses abdominis muscle in triangle Lesgaft-Grunfeld & continue anteriorly between internal oblique & transverses abdominis muscle. 5) Weak places of the lumbar region and their clinical importance. Lumbar region has weak places with are characteristic for pus spread form fat of retroperitoneal space to superficial, phlegmon develops. Seldom protrude hernia. a) Lumbar triangle: iv) Laterally a free posterior border of the external oblique muscle v) Medially a free border of latissimus dorsi vi) Base of triangle iliac crest (from below) b) Superior lumbar triangle Lesgaft-Grunfeld is formed by i) Superiorly serratus posterior inferior

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ii) iii)

Inferiorly internal oblique muscle Medially erector spinal muscle

Question 93 Fasciae and fat layers of the retroperitoneal space 1) Fasciae of the retroperitoneal space. 3 types of fascia of retroperitoneal space: 1. fascia endoabdominal: transverse fascia, psoas fascia, quadratus fascia 2. retroperitoneal fascia anterior and posterior layer of the renal fascia 3. retrocolic fascia of Toldi 2) First layer of the fat of the retroperitoneal space: disposition and communications. Name: Proper retroperitoneal - immediate continuation of extraperitoneal fat Walls: ant retroperitoneal fascia Post renal fascia Post.ly transversalis fascia Sup diaphragm Inf fat layer becomes pelvis fat Communications: 1. Upwards - reach the diaphragm weak point point of the diaphragm (lumbarcostal triangle of Bohdaleck) pus pass into thoracic cavity. 2. Pus can pass through triangle Pti to lumbar region. 3. Pus can pass through triangle of Lesgaft-Grunfeld to the lumbar region under the latissimus dorsi muscle. 4. Downwards: pus can get into the pelvic fat. 5. Forward: pus can get into the extraperitoneal fat or preperitoneal fat (as it is sometimes called) 3) Peculiarities of structure, disposition and communications of the second layer (name) of the retroperitoneal space. Name: Perirenal and parauteric fat - closed fat spaces Walls: ant parietal peritoneum of post abd. Wall & retrocolic fascia of Toldi post retroperitoneal fascia & ant layer of renal fascia sup transverse mesocolon inf R- cecum; L-sigmoid mesocolon 4) Name, disposition and communication of the third layer of the fat. 5) Ways of pus (air, gas, blood, urine) spreading into retroperitoneal fat. Paranephric Vichnevsky blokade.

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Question 94 Topography of the kidneys, ureters and suprarenal glands 1) Skeletotopy of the right and left kidneys. - Both kidneys are situated on either side of the vertebral column in the lumbar region from the 11th-12th thoracic vertebra to 2nd-3rd Lumbar verteba. - Right kidney lies slightly lower than the left kidney due to bulk of right lobe of liver. 2) Syntopy of the kidneys. - The medial aspect of both upper poles is directly related to a suprarenal gland. - The hilar region of the left kidney is directly related to the pancreas and the right to the duodenum. - A substantial part of the lower pole of the right kidney is directly related to the right colic flexire and similarly a lesser part of the left to the left colic flexure. - The left lower pole is covered with peritoneum and a similar but smaller area is present over the right. These areas will be in contact with overlying small intestine. - The remainder of both kidney is also covered by peritoneum and related to the overlying liver on the right and to the stomach and spleen on the left. 3) Syntopy of the pedicle of the kidney. - consists of the vein, artery and ureter or renal pelvis (from before backwards) the sympathetic nerves and the lymph vessels. 4) Syntopy of the ureters along length. - Each ureter is a continuation of the renal pelvis and leaves the hilus of the kidney posterior to the blood vessels. - It descends over the posterior abdominal wall behind the peritoneum and on the surface of psoas major. - At the pelvic brim it crosses the common iliac artery near its bifurcation and enters the pelvis. - At the level of the ischial spine it turns medially into the bladder. 5) Constrictions of the ureters. Clinical importance. - Each ureter has three constrictions along its course: 1) where the renal pelvis joins the ureter, 2) where it crosses the pelvic brim, 3) where it pierces the bladder wall. - The ureter crosses the genitofemoral nerve before second constriction. - It can explain irradiation of the pains to external genitalia and femur in nephrolithiasis if stone stops in the second constriction. - The ureter crosses the external iliac artery just beyond the common iliac bifurcation. - The ureter is divided into two parts - abdominal and pelvic.

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Question 95 Operation on the kidneys 1) Surgical approaches to the kidney. The traditional surgical approach to the kidney is the lumbar renal or retroperitoneal approach. Lumbar nephrectomy (extirpation of kidney via retroperitoneal lumbar route) is indicated when contamination of the peritoneal cavity is possible (inflammatory renal disease, calculi). The transabdominal approach to the kidney is mainly employed for surgery of the renal vessels and kidney transplants. Other approaches are: Lumbar subcostal approach according to Fyodorov Lumbar subcostal approach (Bergman-Israel) 12th rib approach Supracostal incision (Turner Warwick,1980) Lumbotomy Thoraco-abdominal approach Nagamatsu incision Anterior approach 2) Indication to nephrectomy. Nephrectomy is indicated in: 1) Patients having renal transpleants or chronic dialysis if their own kidneys are infected or considered the cause of uncontrollablke hypertension. 2) Patients with a nonfunctioning or very poorly functioning hydronephrotic, infected, ischaemic or stone containing kidney on one side and a normal kidney on the other. 3) Patients with unilateral renal hypertension, when it is thought better to remove the kidney rather than reconstruct the artery. 4) Patients with renal tuberculosis in whom the organisms are resistant to chemotherapy. 5) Some patients with a severely traumatized kidney or renal pedicle on one side and a normal kidney on the other. 6) Patients with malignant disease of the kidney. 3) Technique of the nephrectomy. - Kidney is exposed and mobilized - By gentle dissection with scissors or gauze the pedicle is cleared on both aspects and the major vessels separately identified - Ligatures are placed in following order: 1) Put ligatures on the artery. 2) Put ligatures on the vein. - Organ becomes bloodless and can be removed. - Artery is separated from investing fat. - 2 ligatures are placed on aortic side and 1 on kidney side. * Important to look for aberrant or accessory vessels - Do the same with renal vein - Ureter is divided between ligatures at a convienient level and kidney is removed. 4) Indications to pyelolithotomy. Stone in the renal pelvis and accessible stones in renal calices.

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5) Technique of pyelolithotomy. - Kidney is exposed by a subcostal or lumbotomy incision. - The pelvis is incised transversely or longitudinally between stay sutures. - The stone is gently removed. - The pelvis incision is loosely sutured with dexon or catgut suture.

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Question 96 The osteoligamentous tela of the pelvis. Walls and floor of pelvis 1) The bony of the pelvis and ligaments. The pelvis inlet and outlet. Bony pelvis is composed of 4 bones : - 2 innominate bones/hip bones : lat. & ant. wall - Sacrum & coccyx : back wall The sacrotuberous ligament - strong and extends from the lateral part of the sacrum and coccyx and the posterior inferior iliac spine to the ischial tuberosity. The sacrospinous ligament - strong and triangular in shape. - attached by its base to the lateral part of the sacrum and coccyx and by its apex to the spine of the ischium These two ligaments convert the greater and lesser sciatic notches into foramina, the greater and lesser sciatic foramina. The pelvic inlet, or pelvic brim, is bounded posteriorly - by the sacral promontory, laterally by the iliopectineal lines, and anteriorly by the symphysis pubis. The pelvic outlet is bounded posteriorly by the coccyx, laterally by the ischial tuberosities, and anteriorly by the pubic arch. Laterally there are the sciatic notches. The sciatic notches are divided by the sacrotuberous and sacrospinous ligaments into the greater and lesser sciatic foramina. The pelvic cavity lies between the inlet and the outlet. It is a short, curved canal, with a shallow anterior wall and a much deeper posterior wall. 2) The muscles of the walls and floor of the pelvis. The piriformis muscle - arises the front of the lateral masses of the sacrum - leaves the pelvis to enter the gluteal region by passing laterally through the greater sciatic foramen - inserted into the upper border of the greater trochanter of the femur. The obturator internus muscle - arises from the pelvis surface of the obturator membrane and the adjoining part of the hip bone - muscle fibers converge to a tendon, leaving the pelvis through the lesser sciatic foramen and is inserted into the greater trochanter of the femur. The levator ani - has a linear origin from the pelvic wall - starts anteriorly on the inner aspect of the body of the pubis - extends across the surface of the oturator fascia from an overlying condensation of the pelvic fascia called the arcus tendineus - terminates at the spine of the ischium where its most posterior fibers lie parallel with the lower fibers of coccygeus - can be described in two parts according to the origin of their fibers. Those fibers arising from the pubis are known as pubococcygeus and those from the arcus tendineus and the spine of the ischium as iliococcygeus. The coccygeus muscle - small muscle that arises from the spine of the ischium - inserted into the lateral margin of the lower sacrum and

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coccyx. Obturator membrane - fibrous sheet that almost completely closes the obturator foramen, leaving a small gap, the obturator canal for the passage of the obturator nerve and vessels as they leave the pelvis to enter the thigh 3) The vessels of the pelvis. Common iliac artery - ends at the pelvic inlet in front of the sacroiliac joint by dividing into the external and internal iliac arteries. External iliac artery - runs along the medial border of the psoas muscle, following the pelvic brim - gives off the inferior epigastric and deep circumflex iliac branches - leaves the false pelvis by passing under the inguinal ligament, to became the femoral artery. The following arteries enter the pelvic cavity: 1. Internal iliac artery. 2. Superior rectal artery. 3. Ovarian artery. 4. Median sacral artery. Internal iliac artery - passes down into the pelvis to the upper margin of the greater sciatic foramen, where it divides into anterior and posterior divisions - branches of these divisions supply the pelvic viscera, the peritoneum, the pelvic walls and the buttocks. The - branches of the anterior division may be divided into parietal and visceral branches. Anterior division of the internal iliac artery Posterior division of the internal iliac artery Parietal branches visceral branches Obturator artery, superior vesical artery, iliolumbal artery Internal pudendal artery, inferior vesical artery, lateral sacral artery, artery to the ductus deferens, superior gluteal artery Inferior gluteal artery middle rectal artery, vaginal artery, uterine artery Parietal veins - accompany the parietal branches of the internal iliac arteries - drain into the internal iliac veins Visceral veins - form the venous plexuses which surround the pelvic organs. o venous plexuses o vesical venous plexuses o uterine venous plexuses o vaginal venous plexuses o prostatic venous plexuses. - The venous plexuses drain into the internal iliac veins - The pelvic venous plexuses also communicate with the external and internal vertebral plexuses

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- These communications play an important part in the spread of disease from the pelvis - Middle rectal veins communicate with the superior rectal veins which form part of the portal venous system. 4) The nerves of the pelvis. The sacral plexus - lies on the posterior pelvic wall in front of the piriformis muscle. - formed from the anterior rami of the fourth and fifth lumbar nerves and the anterior rami of the first, second, third and fourth sacral nerves. - Note that the contribution from the fourth lumbar nerve joins the fifth lumbar nerve to form the lumbosacral trunk. The lumbosacral trunk - passes down into the pelvis and joins the sacral nerves as they emerge from the anterior sacral foramina. Branches: 1. Branches to the lower limb that leave the pelvis through the greater sciatic foramen: a) the sciatic nerve (L4 and 5; S1,2 and 3) is the largest branch of the plexus and the largest nerve in the body; b) the superior gluteal nerve, which supplies the gluteus medius and minimus and the tensor fasciae latae muscles; c) the inferior gluteal nerve which suplies the gluteus maximus muscle; d) the nerve to the quadratus femoris muscle, which also supplies the inferior gemellus muscle; e) the nerve to the obturator internus muscle; f) the posterior cutaneous nerve of the thigh, which supplies the skin of the back of the thigh. 2. Branches to the pelvic muscles, pelvic viscera and perineum: a) the pudendal nerve (S2,3 and 4) which leaves the pelvis through the greater sciatic foramen and enters the perineum through the lesser sciatic foramen; b) the nerves to the piriformis muscle; c) the pelvic splanchnic nerves. These constitute the sacral part of the parasympathetic system and arise from the second, third, and fourth sacral nerves. They are distributed to the pelvic viscera. 3. The perforating cutaneous nerve, which supplies the skin of the lower medial part of the buttock. The obturator nerve - branch of the lumbar plexus emerges from the medial border of the psoas muscle in the abdomen and accompanies the lumbosacral trunk down into the pelvis. - crosses the front of the sacroiliac joint and runs forward on the lateral pelvic wall in the angle between the internal and external iliac vessels. On reaching the obturator canal (that is, the upper part of the obturator foramen, which is devoid of the obturator membrane), it splits into anterior and posterior divisions that pass through the canal to enter the adductor region of the thigh.

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The pelvic part of the sympathetic trunk - is continuous above, behind the common iliac vessels, with the abdominal part. - runs down behind the rectum on the front of the sacrum, medial to the anterior sacral foramina - has four or five segmentally arranged ganglia. Below the two trunks converge and finally unite in front of the coccyx. The pelvic splanchnic nerves - constitute the parasympathetic part of the autonomic nervous system in the pelvis. - Some of the parasympathetic fibers ascend through the hypogastric plexuses and thence via the aortic plexuses to the inferior mesenteric plexus. - The fibers are then distributed along branches of the inferior mesenteric artery to supply the large bowel from the left colic flexure to the upper half of the anal canal. The superior hypogastric plexus - is situated in front of the promotory of the sacrum. - It divides inferiorly into right and left hypogastric nerves. - formed as a continuation of the aortic plexus and from branches of the third and fourth lumbar sympathetic ganglia. - contains sympathetic and sacral parasympathetic nerve fibers and visceral afferent nerve fibers. The inferior hypogastric plexus - lies on each side of the rectum, the base of the bladder, and the vagina. - formed from a hypogastric nerve (part of the superior hypogastric plexus) and from the pelvic splanchnic nerve. - contains postganglionic sympathetic fibers, preand postganglionic parasympathetic fibers, and visceral afferent fibers. - Branches pass to the pelvic viscera via small subsidiary plexuses. 5) Lymphatic drainage in the pelvis. - The lymphatic drainage of an organ in the pelvis is closely related to that organs blood supply, whether this is from a branch of the internal iliac artery or directly from the aorta. - In the pelvis, lymphatic vessels also follow the fascial and peritoneal coverings of organs which reach the iliac fossae and hence the nodes around the external iliac vessels. - Groups of lymphatic nodes are found around the internal, external, and common iliac arteries and along the aorta. Additional nodes are found in the hollow of the sacrum. - Connections between these groups, however, allow the spread of lymph and, therefore, tumors, from one organ or group to another in an unpredictable manner.

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- It must also be realized that many pelvic structures extend into the perineum where the lymphatic drainage is largely to inguinal lymph nodes. Organs Lymph nodes Rectum Pararectal nodes Inferior mesenteric nodes Preaortic nodes Internal iliac nodes Anal canal Superficial inguinal nodes Ovary Aortic nodes External iliac nodes Uterus and uterine tubes Internal iliac nodes Superficial nodes Bladder Internal and external iliac nodes Urethra Internal iliac nodes Superficial inguinal nodes

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Question 97 Fasciae and fat spaces of the pelvis 1) The fasciae of the pelvis and plates of pelvic fascia. Aponeurosis Dennonvillier. - The pelvic fascia is the continuation of the endoabdominal fascia below the pelvic brim. - The pelvic fascia may be divided into the parietal and visceral layers. Parietal pelvic fascia - lines the walls of the pelvis. - forms arcus tendineus on boundary between the superior half and inferior half of the obturator internus muscle, from which the fibers of the levator ani arise. - forms the two ligaments between the symphysis pubis and the prostate in the male puboprostatic ligaments - and between the symphysis pubis and the urinary bladder in the female. pubovesical ligaments The visceral pelvic fascia - covers all the pelvic viscera. - forms the two sagittal plates in passage from walls to pelvic organs. - They spread between the pubic bone and the sacrum. - Thus the pelvic viscera are located into space, which is limited anteriorly - by the pubic bones, posteriorly - by the sacrum and the coccyx and laterally - by the sagittal plates. - This space is divided into two parts anterior and posterior by septum, which is located in frontal plane between the peritoneum and the urogenital diaphragm. - This septum is called the peritoneoperineal aponeurosis Dennonvillier. Aponeurosis Dennonvillier - separates the rectum from urinary bladder and the prostate in the male. - The anterior parts of space in the male contains the urinary bladder, the prostate, the seminal vesicle and ampulla of vas deferens. - The anterior part of space in the female contains the urinary bladder and vagina. - The posterior part of space contains the rectum in the male and female. - separates the rectum from the vagina - The fascial sheath of some pelvic organs were described as capsules. - The fascial sheath of the prostate is called capsule Pirogov-Retziy. - The fascial sheath of the rectum is called capsule Amuse. - The organs of the pelvic cavity are separated from the walls by the fat spaces. 2) The ligaments of the organs of the pelvis. sacrotuberous ligament - strong and extends from the lateral part of the sacrum and coccyx and the posterior inferior iliac spine to the ischial tuberosity. sacrospinous ligament - strong and triangular in shape. - attached by its base to the lateral part of the sacrum and coccyx and by its apex to the spine of the ischium. - The two ligaments convert the greater and lesser sciatic notches into foramina, the greater and lesser sciatic foramina. - obturator membrane - is a fibrous sheet that almost completely closes the obturator foramen, leaving a small gap, the obturator canal for the

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passage of the obturator nerve and vessels as they leave the pelvis to enter the thigh. 3) The parietal fat spaces of the pelvis. - All fat spaces may be divided into two parts: parietal and visceral. - The parietal fat spaces of the pelvis are the two lateral spaces, the retropubic space and the retrorectal space. - The retropubic space may be divided into two parts by the prevesical fascia. - The prevesical space is located between the pelvic fascia - anteriorly and the prevesical fascia - posteriorly. - The preperitoneal space is located between the prevesical fascia - anteriorly and the peritoneum - posteriorly. - The hematoma in fractures of the pelvis may occur in the prevesical space. - The urinary infiltration may occur here injuries of the bladder. - urinary infiltration may spread upwards along the preperitoneal (extraperitoneal) fat of the abdominal wall in damage of the prevesical fascia. - The lateral spaces are communicated with 1)retroperitoneal fat space, 2)fat of the adductor region of the thigh through the abductor canal, 3)fat of the gluteal region through the infrapiriformis foramen along the inferior gluteal vessels and nerve and the sciatic nerve. The retrorectal space is located between the ampulla of rectum and its capsula anteriorly and sacrum and pelvic fascia - posteriorly. - The levator ani muscle and its fascia are limited this space below. - Above this space is communicated with retroperitoneal fat space. 4) The visceral fat spaces of the pelvis. - The visceral fat spaces are paravesical space, the perimetric space, the paravaginal space, the perirectal space. - The perimetric space is located between the layers of the broad ligaments. - The fat of the perimetric space below reaches to pelvic diaphragm - above it is communicated with the retroperitoneal fat - laterally it is communicated with lateral space fat of the gluteal region. 5) The ways of pus spreading from the fat spaces of the pelvis. (smth else here..from other fat spaces) From perimetric fat space: 1. Upwards pus can reach the retroperitoneal fat. 2. Laterally and posteriorly pus can pass through the infrapiriformis foramen to the fat of the gluteal region. 3. Pus can pass through the inguinal canal along the round ligament to the anterior abdominal wall. 4. Pus can pass through the vessels lacuna to the fat of the femoral triangle. 5. Pus can pass through the obturator canal to the adductor region. 6. Pus can pass through the lesser sciatic along the internal pudendal vessels and pudendal nerve to the fat of the ischiorectal fossa (or through the fibers of the levator ani muscle).

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Question 98 Division of male and female pelvis into floors 1) Name and disposition of the floors of pelvis. - The pelvic cavity is divided into three parts or floors: peritoneal pelvic cavum, subperitoneal pelvic cavum and subcutaneous pelvic cavum. - First floor or peritoneal pelvic cavum - is the inferior part of the abdominal cavity - limited by plane which passes through the pelvic brim - here the organ or parts of organs of the pelvic cavity which cover by peritoneum are contained - superior and partially posterolateral and anterior walls of the urinary bladder and part of the rectum are located in the peritoneal pelvic cavity in the male. - such parts of urinary bladder and the rectum and the greater parts of the uterus and its appendages (ovaries and uterine tubes), the broad ligaments and also the most superior part of the vagina (posterior fornix of the vagina) are located in the peritoneal pelvic cavity in the female. - Second floor or subperitoneal pelvic cavum - contained between the peritoneum and the parietal layer of the pelvic fascia, which covers the superior surface of the levator ani muscle - extraperitoneal parts of the uprinary bladder and the rectum, the prostate, the seminal vesicles, the pelvic parts of the vas deferenses with their ampullas, the pelvic parts of ureters are located in the male - such parts of the ureters, urinary bladder and rectum and also the cervix of the uterus, the part of the vagina are located here in the female. - All organs located here are surrounded by the fascial sheath and the fat spaces. - apart from the organs the fat layers contain the nerves, blood vessels and lymph nodes. - Third floor or subcutaneus pelvic cavum - is located between the inferior surface of the pelvic floor and the skin - is the perineum - contains the parts of organs of the urogenital system, the final part of the rectum and the ischiorectal fossa. 2) The relation of the peritoneum to the pelvic viscera. - peritoneum forms the transverse vesical fold in passage from the anterior abdominal wall to the superior wall of the urinary bladder - further in the male the peritoneum covers part of the lateral and posterior wall of urinary bladder and the medial borders (margins) of the ampullas of vas deferenses and the apexes of the seminal vesicle - then passes on rectum, forming the recto-vesical pouch - laterally, pouch is limited by the recto-vesical folds of the peritoneum which pass in sagittal direction from the urinary bladder to the rectum - The recto-vesical pouch contains the coils of small intestine in norm, but it may contains the blood, the pus, the exudate in pathology.

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- In female, the peritoneum forms the two pouches in its passage from the urinary bladder to the uterus and from the uterus to the rectum. They are vesicouterine pouch and the rectouterine pouch. 3) Pouches of peritoneum in the male and female. Connection pouches with abdominal cavity. - Recto-vesical pouch in the male and rectouterine pouch in the female are called pouch of Douglas. - Vesicouterine pouch may contain the greater omentum in norm. - The rectouterine pouch may contain the coils of small intestine in norm, but it may contain the blood, the pus, the exudate in pathology. - This pouch may drain by means the puncture through the posterior fornix of the vagina. - Laterally, the rectouterine pouch is limited by the rectouterine folds of the peritoneum, which pass in sagittal direction from the uterus to the rectum 4) Accesses to Douglas pouch. - may be using needle or trochar. Needle: - curved forceps and long needle out into forceps leaving 3 cm of end of needle - puncture is made by needle thru centre of fluctuation - when pus appear in syringe, forceps inserted and opened to separate wall maximally - needle is removed and double lumen drainage tube is inserted Trochar: - diagnostic puncture is made after pus appear in syringe - over needle trochar is inserted - in lumen of trochar, double lumen tube is inserted 5) Diagnostic puncture of Douglas pouch in the male and in the female: anatomical grounds and indications. Male: - made in anterior wall of rectum because it forms posterior wall of Douglas pouch Female: - made in posterior fornix of vagina because it forms floor of Douglas pouch

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Question 99 Pelvic viscera in the male. 1) Topography of ureters and urinary bladder. Ureters its course is followed from the kidney over the posterior abdominal wall to pelvic brim. - Each crosses the brim beneath the peritoneum covering the bifurcation of the common iliac artery. - Each ureter then runs down the lateral wall of the pelvis in front of the internal iliac artery to the region of the ischial spine and turns forward to enter the lateral angle of the bladder. In its pelvic course the urether is crossed anteriorly (superiorly) by the ductus deferens. Urinary bladder - or vesica urinaria is a highly distensible muscular organ which, when empty, lies in the pelvis and rests on the symphysis pubis and the floor of the pelvis. - partially covered by peritoneum (mesoperitoneal) - muscular walls are of smooth muscle and it is lined by transitional epithelium; a lining layer that can adapt to the large changes in its volume. - As it is filled with urine from the ureters, it enlarges upward into the abdominal cavity stripping peritoneum off the anterior abdominal wall as it ascends. - In the infant the pelvic cavity is very flat and shallow and bladder normally occupies an intraabdominal position. - The empty bladder is pyramidal in shape, having an apex, a base, and a superior and two inferolateral surfaces, it also has a neck. - The apex of the bladder lies behind the upper margin of the symphysis pubis. - To the apex of the pyramid is attached the median umbilical ligament, a remnant of the urachus. - The base, or posterior surface of the bladder is triangular in shape. - At the two superior angles of the base, the ureters enter the bladder and at the inferior angle, the urethra leaves it. It is here that the smooth muscle of the bladder wall becomes circularly arranged the commensequent of the urethra and forms the sphincter vesicae. - The two vasa deferentia lie side by side on the posterior surface of the bladder and separate the seminal vesicles from each other. - The upper part of the posterior surface of the bladder is covered by peritoneum, which forms the anterior wall of the rectovesical pouch. - The lower part of the posterior surface is separated from the rectum by the vasa deferentia, the seminal vesicles, and the rectovesical fascia or aponeurosis of Denonvillier. - The superior surface of the bladder is complete by covered with peritoneum and is related to intraabdominal contents (usually coils of ileum or sygmoid colon). This is reflected on either side

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into the paravesical fossae and onto the upper part of the base where it forms the anterior wall of the rectovesical pouch. - The infrolateral surfaces are related in front to the retropubic pad of fat and pubic bones. More posteriorly, they lie in contact with the obturator internus muscle above and the levator ani muscle below. - The neck of the bladder lies inferiorly and rests on the upper surface of the prostate. Here, the smooth muscle fibers of the bladder wall are continuous with those of the prostate. - The neck of the bladder is held in position by the puboprostatic ligaments in the male and the pubovesical ligaments in the female. These ligaments are thickenings of the pelvic fascia. 2) The interior of the bladder. Blood supply and lymph drainage - mucous membrane of the greater part of the empty bladder is thrown into folds, but these disappear when the bladder is full. - The area of mucous membrane covering the internal surface of the base of the bladder is referred to as the trigone (Lieto). Here, the mucous membrane is always smooth, even when the viscus is empty because the mucous membrane over the trigone is firmly adherent to the underlying muscular coat. - The superior angles of the trigone correspond to the openings of the ureters and its inferior angle, to the internal urethral orifica. - The ureters pierce the bladder wall obliquely and this provides a valve-like action, which prevents a reverse flow of urine the kidneys as the bladder fills. - The trigone is limited above by a muscular ridge, which runs from the opening of one ureter to that of the other and is know as the interureteric ridge. - The uvula vesicae is a small elevation situated immediately behind the urethral orifica that is produced by the underlying median lobe of the prostate. - The muscular coat of the bladder is composed of smooth muscle and is arranged as three layers of interlacing bundles known as the detrussor muscle. - At the neck of the bladder the circular component of the muscle coat is thickened to form the sphincter vesicae. - The bladder is supplied by the superior and inferior vesical branches of the internal iliac arteries. - Veins which drain a vesical form the vesical venous plexus, which communicates below with the prostatic plexus; it is drained into the internal iliac vein. - The lymph vessels from the bladder drain into the internal and external iliac nodes. - The bladder receives both motor and sensory innervation. - The motor fibers are both parasympathetic and sympathetic. - The parasympathetic fibers are motor to the smooth muscle of the bladder wall or detrusor muscle, but inhibit the sphincter vesicae. - The sympathetic fibers on the other hand are said to be inhibitory to the detrusor muscle and motor to the sphincter vesicae. - The sensory fibers give rise to the conscious sensation of a full bladder and also pain resulting from disease.

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- The fact that these pain fibers return to both sacral and lumbar segments of the cord makes it difficult to surgically eliminate the intractable pain of terminal disease in this region. 3) Clinical importance of relation of bladder with peritoneum. - The full bladder in the adult projects up into the abdomen and may be palpated through the anterior abdominal wall above the symphysis pubis. In a patient with a full bladder, a severe blow on the lower part of the anterior abdominal wall may therefore result in infraperitoneal rupture of the bladder. - As the bladder fills, the superior wall rises out of the pelvis and peels the peritoneum off the posterior surface of the anterior abdominal wall. In cases of acute retention of urine, when catheterization has failed it is possible to pass a needle into the bladder through the anterior abdominal wall above the symphysis pubis without entering the peritoneal cavity. This is a simple method of draining off the urine in an emergency; but if the bladder is allowed to refill, leakage may occur into the extraperitoneal space through the puncture hole. - Bimanual palpation of the empty bladder with or without a general anesthetic is an important method of examining the bladder. In the male one hand is placed on the anterior abdominal wall above the symphysis pubis and the gloved index finger of the other hand is inserted into the rectum. From your knowledge of anatomy, you can see that the bladder wall can be palpated between the examining fingers. - In the female, an abdominovaginal examination can be similarly made. - In the child, the bladder is in a higher position than in the adult, due to the relatively smaller size of the pelvis. For this reason, when making a low abdominal incision, the surgeon must make sure that the child's bladder is empty. 4) The male urethra. - much longer in the male than in the female (20 cm as opposed to 4 cm). - Beginning at the neck of the bladder it passes through the prostate, the floor of the pelvis, the perineal membrane, and the penis, to the terminate as the external urethral orifice at the tip of the glans penis. - divided into prostatic, membranous, and spongy parts. - The prostatic urethra is the widest and most dilatable part of the entire urethra. - The unfilled prostatic urethra is some what semilunar in cross-section with the convexity facing forward. Its posterior wall shows an elevated central region, the urethral crest, flanked by the prostatic sinuses. - The crest becomes expanded to form the seminal colliculus. At the summit of this elevation there lies a blindly ending diverticulum, the prostatic utricle, and on either side of this open the ejaculatory ductus. - The membranous urethra lies between the apex of the prostate and the bulb of the penis & is the shortest part of the urethra - is surrounded by the sphincter urethrae and the urogenital diaphragm (membranous urethra lies within the urogenital diaphragm) - The bulbourethral glands lie on either side of it. - The rigid perineal or urogenital membrane (diaphragm) anchors this portion of the urethra to the bony pelvis and renders it liable to injury. This may brought about by faulty instrumentation or trauma. - The spongy urethra (penile urethra) is the longest portion of the urethra

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- traverses the bulb, the corpus spongiosum, and the glans of the penis. - Just before its termination at the external urethral opening, the urethra is expanded to from the navicular fossa (fossa terminalis). - The ductus of the bulbourethral glands open near its commenument and over the rest of its course, is joined by the ductus of many urethral glands which may open into small out-pouchings of the mucous membrane called lacunae. - These glands are prone to gonococcal infections which may result in scarring and stricture formation. Such strictures may be dilated by instruments known as bougies. To achieve this successfully, the course of the urethra and its narrow fixed membranous portion must be borne in mind as the instrument is introduced. 5) The male pelvic reproductive organs. - In the male pelvic cavity are found the termination of each ductus deferens, the seminal vesicles and their ductus, the ejaculatory ducts formed as the deferent ductus and the ducts of the seminal vesicles join, and finally the prostate gland in which the ejaculator ducts join the prostatic urethra. - The ductus deferens - ascends from the epididymis in the spermatic cord and enters the abdominal cavity through the inguinal canal. - On reaching the deep inguinal ring, it hooks around the inferior epigastric artery, crosses over the external iliac vessels, and enters the pelvic cavity. - Passing posteriorly beneath the peritoneum lining the wall of the cavity it now crosses over the obturator nerve and vessels and the ureter to reach the base of the bladder. - Here the terminal portion becomes dilated at the ampulla and joins with the duct of the seminal vesicle to form the ejaculatory duct. - This duct enters a cleft between the neck of the bladder and the posterior surface of the prostate and opens into the prostatic urethra on the colliculus. - The seminal vesicles - are two lobulated sacs each lying lateral to the ampulla of a ductus deferens. - The tapering lower end of each vesicle joins the ductus deferens to form the ejaculatory duct. - The seminal vesicles lies in front of the anterior wall of the rectum and, if enlarged, may be palpated through the rectum. - The prostate gland - This glandular organ, supported by firm fibromuscular connective tissue, lies inferior to the male bladder and surrounds the urethra. - measures approximately 4*3*2 cm - conical in shape and has a base applied to the bladder and a blunt apex directed inferiorly and toward the urogenital diaphragm. - The connective tissue stroma of the gland is in direct continuity with that of the bladder wall, thus intimately fusing the two structures.

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- Although not apparent on the surface, except for an indistinct posterior groove, the gland consist of a left and right lateral lobe united in front of the urethra by a fibromuscular strip called the isthmus. - A middle lobe of variable size lies above the lateral lobes and the point of entry of the ejaculatory ducts. - Enlargement of this lobe rapidly leads to urethral obstruction at the bladder neck. - The sphincter urethrae which surround the urethra immediately beyond the prostate also embrace the apex of the prostate. - Awareness of this fact is important as the preservation of these fibers in prostatic sugery leads to optimum urinary continence. - has its own connective tissue capsule and, in addition, it is surrounded by a further thick sheath derived from the pelvic fascia. - The capsule and sheath are separated by the prostatic plexus of veins. - It is supplied by the inferior vesical artery and venous blood drains to the prostatic plexus and, thence, to the vesical plexus and internal iliac veins. - The prostate is influenced by circulating male sex hormones and undergoes a rapid increase in size at puberty due to the development of secretory follicles from a preexisting duct system. - A further increase in size or hypertrophy normally occurs from the fourth decade onwards due to the formation of nodules of hyperplastic glandular and connective tissue. - These may eventually produce urinary obstruction especially if they project into the bladder around the internal meatus or compress the prostatic urethra.

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Question 100 Topography of the female pelvic reprodactive organs 1) Syntopy of the uterus, the ovaries and uterine tubes. - The female reproductive organs in the pelvic cavity include the ovaries, the uterine tubes, the uterus, and the greater part of the vagina. - Each have, to a lesser or grater extent, a peritoneal covering and therefore, a surface related to the peritoneal cavity. - The peritoneum of the pelvic cavity is thrown up in a horizontal fold over the midline uterus and the uterine tubes as these extend laterally from the upper part of the uterus toward the wall of the cavity. The anterior and posterior layers of this fold are separated by the uterus but on either side where they "hand" from the uterine tubes, they come together to form the broad ligaments of the uterus. - In this way the female pelvic cavity is divided into an anteroinferior and posterosuperior compartment, the former containing the bladder, the latter, the rectum. Ovaries. - Each ovary lies on the posterior aspect of the broad ligament near the lateral wall of the pelvis. - almond-shaped, about 3 cm long and 1.5 cm thick - long axis is aligned almost vertically - attached to the broad ligament by a fold of peritoneum called the mesovarium - upper pole is closely related to the fimbriae surrounding the abdominal opening of the uterine tube and from it extends the suspensory ligament of the ovary (an extension of the broad ligament to the lateral wall of the pelvis which carries the ovarian vessels in its upper free border) - lower pole of the ovary is attached to the uterus near its junction with the uterine tube by a fibromuscular cord called the proper ligament of the ovary lying within the layers of the broad ligament and is continuous with the round ligament of the uterus. - exposed surface of the ovary is covered by a layer of surface of the ovary is covered by a layer of cuboidal cells which becomes continuous with the surrounding peritoneum. - supplied by the ovarian arteries which descend into the pelvis from the abdominal aorta. - Veins brave the ovary as a network around the artery and this is called pampiniform plexus from which two ovarian veins are formed - left ovarian vein drains into the left renal vein and the right into the inferior vena cava. Uterine tubes - extend laterally from the junction of the fundus and body of the uterus - lie in the upper border of the broad ligament - lumen of the tube communicates with the cavity of the uterus by its most medial narrowed part called the isthmus - running laterally, it becomes more expanded as the ampula - curls posteriorly over the back of the broad ligament to end close to the superior pole of the ovary as the trumpet-like infundibulum.

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- border of the infundibulum bears finger-like processes termed fimbriae of which, one - the ovarian fimbria, is attached to the ovary. - When the ovum is shed into the peritoneal cavity, it is engulfed by the infundibulum and passed to the uterus. - Fertilization takes place in the tube. Occasionally the fertilized ovum is arrested in the tube and a tubal pregnancy result. Rupture of the tube with severe hemorrhage follows within about six weeks. - supplied by branches of both the ovarium and uterine arteries. Uterus - thick-walled, muscular structure having a narrow cavity which is continuous with the peritoneal cavity through the uterine tubes and with the perineum through the vagina. - The uterus is divided into three parts, a muscular fundus above the level of the uterine tubes, a tapering body which contains the cavity and a cervix or neck the narrowest part, which projects into the vagina. - The cavity of the uterus is continuous with the canal of the cervix through the isthmus and the external os. - The upper anterior surface, the superior surface and the posterior surface of the uterus are covered by peritoneum - Peritoneum covering the anterior and posterior surface continues into the sides of the uterus and from these is reflected laterally to the pelvic wall as the two layers of the broad ligament. - Although the lower part of the body of the uterus is firmly adherent to the base of the bladder, above this point it is mobile and free to overhang the superior surface of the empty bladder. This is the normal anteverted position. - The uterus is also slightly bent forward along its own axis, and this is known as anteflexion. - Occasionally, the uterus is found to slope backward. It is then said to be retroverted. - uterus lies above the bladder and is separated from it by the vesicouterine pouch. - middle third of the rectum lies behind the uterus and is separated from it by the rectouterine pouch. - cavity of the anterverted uterus lies at approximately 90 to the cavity of the vagina. - supported in the pelvis by the muscular pelvic diaphragm and retained in position by a number of ligament 2) The ligaments of the uterus and its adnexa. Broad ligament - uterine tubes and ovarian vessels extend from the uterus towards the pelvic brim and have peritoneum hanging down both in front and behind them like a sheet on a clothesline. In this way are formed the broad ligaments of the ovaries. - together with uterus divide the female pelvic peritoneal cavity into an anteroinferior and a posterosuperior compartment.

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- contains the next structures between layers or within the ligament: the uterine tube, the ovarian vessels, the ligament of the ovary and the round ligament. - Note also the uterine vessels and the ureter at the base of the broad ligament. Round ligaments - extend from the body of the uterus, just below the uterine tube, to the pelvic brim and thence through the inguinal canal to end in the fibrofatty tissue of the labium majus. - They are probably remnants of gubernacula comparable to those that seem to guide the testes to the scrotal sac. - on occasion, may be accompanied through the inguinal canal by a patent processus vaginalis and thus prepare the ground for the appearance of an indirect inguinal hernia. - is composed of fibrous tissue and smooth muscle fibers. Cardinal ligaments - or transverse cervical ligaments - fibromuscular thickenings of the pelvic fascia surrounding the uterine vessels in the base of the broad ligament. - attached to the side of the cervix of the uterus and the lateral fornix of the vagina. - probably play a part in stabilizing the uterus and vagina. Anterior and posterior ligaments - alternative names for the uterovesical and rectouterine folds of the peritoneum forming the margins at the vesicouterine pouch and the rectouterine pouch. o uterosacral ligaments - As they run backward from uterus to rectum, the margins of the rectouterine pouch are raised as peritonial folds. - folds contain fibromuscular thickenings which pass on either side of the rectum to become attached to the sacrum. These are the uterosacral ligaments. - ligaments mentioned act to a lesser or greater extent to stabilize the uterus in the pelvis. In addition, the uterus obtains support from its attachment to the vagina, bladder, and rectum. 3) Blood supply, venous and lymph drainage. - uterus is supplied by the uterine artery a branch of the internal iliac artery. - Leaving its parent vessel on the wall of the pelvic cavity, the uterine artery crosses the floor in the base of the broad ligament. passing over (anteriorly) the ureter, (which may be at risk when the artery is ligated) - On reaching the cervix the artery runs up the lateral wall of the uterus to end by anastomosing with the ovarian artery. - Along its course it sends branches to the vagina, the cervix and the walls of the uterus. - Blood draining from the uterus forms a venous plexus in the broad ligament which empties into the internal iliac veins. - The vagina is the terminal portion of the female genital tract and its cavity is continuous proximally with that of the uterus at the external os of the cervix. Its distal opening into the perineum is known as the vaginal orifice.

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- The long axis of the vagina lies at approximately 90 to that of the uterus. As a result, the cervix of the uterus projects into its anterior wall which is, therefore shorter than the posterior wall. - At its point of entry, the cervix is surrounded by a recess of invaginated vaginal wall called the vaginal fornix. Again, as a result of the alignment of the two organs, the posterior part of the fornix is the deepest. - Anteriorly, the vagina is related to the cervix and is separated from the bladder by loose connective tissue. - Below the bladder the vagina is firmly adherent to the urethra which lies embedded in its anterior wall. - Posteriorly, the posterior fornix is related to the rectouterine pouch and below this to the rectum. - The fact that the posterior vaginal fornix is related to the peritoneum of the rectouterine pouch, means that straight instruments inserted into the vagina for the purpose of procuring an abortion, penetrate the fornix rather than enter the cervix and may give rise to both hemorrhage and peritonitis. - It is at this site also that pelvis abscesses forming in the rectouterine pouch may rupture or be drained surgically. - Blood reaches the upper part of the vagina from the uterine arteries. - Vaginal branches of the internal iliac, inferior vesical and middle rectal areries and branches of the internal pudendal aretry supply the remainder. - Venous blood reaches the uterine and vesical plexuses. 4) Topography of pelvic part of ureter in the female. - crosses the pelvic inlet in front of the bifurcation of the common iliac artery - in its pelvic course, crosses the uterine artery two times - runs downward and backward in front of the internal iliac artery and behind the ovary (here the ureter crosses the uterine artery first time: ureter - anteriorly, the uterine artery - posteriorly), until it reaches the region of the ischial spine - then turns forward and medially beneath the base of the broad ligament, where it is crossed by the uterine artery (second time: uterine artery - anteriorly, ureter posteriorly). - ureter then runs forward, lateral to the lateral fornix of the vagina to enter the bladder. 5) Clinical importance of syntopy of the ureter with uterine artery. - it is possible to damage the ureter when the uterine artery is ligated prior to removal of the uterus during a hysterectomy

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Question 101 Topography of the rectum and urinary bladder 1) Parts of rectum. Relations of the peritoneum to the rectum. Flexures of the rectum. - begins in front of the third sacral vertebra as a continuation of the sigmoid colon - a continuation of the mobile sigmoid colon but is itself and has no mesentery - passes downward, following the curve of the sacrum (anteroposterior flexure) and coccyx (posterioanterior flexure) and ends in front of the tip of the coccyx by piercing the pelvic diaphragm and becoming continuous with the anal canal. - These flexures are located in saggital plane. - The curved course is itself sinuous in that the middle portion of the rectum or ampulla shows a bend to the left. - The flexure is located in frontal plane. - At the border of the levator ani muscle it pierces the pelvic floor to become the canal, a point referred to as the anorectal junction. - The upper one-third of the rectum is covered by peritoneum anteriorly and laterally. - The middle third is only covered anteriorly and the lower third has no peritoneal relationship. - Beneath the peritoneum the three taeniae coli typical of the large intestine fuse again into a continuous longitudinal muscle coat. - The muscular coat of the rectum as arranged in the usual outer longitudinal and inner circular layers of smooth muscle. The three taeniae coli of the sigmoid colon, however, come together, so that the longitudinal fibers form a broad band on the anterior and posterior surfaces of the rectum. The mucous membrane of the rectum, together with the circular muscle layers, form three permanent folds called the transverse folds of the rectum. These folds are semicircular; two are placed on the left rectal wall and one on the right wall. 2) Syntopy of the rectum. Posteriorly - related successively to the sacrum, the coccyx and the pelvic floor. - The sympathetic trunks, lateral sacral vessels and lymph nodes also lie posteriorly. Between the upper part of the rectum and the lateral pelvic walls - lie mobile small bowel or pelvic colon in the pararectal fossa of the pelvic parietal peritoneum. Anteriorly - in the male the rectovesical pouch containing coils of small intestine separates the rectum from the bladder. - Below this, the rectum is related to the bladder, the seminal vesicles, and the prostate without the intervention of peritoneum. - structures are embedded in visceral pelvic fascia. - In the female, the rectouterine pouch separates the upper part of the rectum from the uterus and the posterior fornix of the vagina. - Below the pouch the rectum is directly related to the vagina. - The posterior surface of the prostate in the male and in the female the posterior surface (wall) of the vagina are separated from the rectal ampulla by the aponeurosis or fascia of Denonviller (rectovesical and retrovaginal septum).

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3) Blood supply and venous drainage. Clinical importance of venous drainage. Lymph drainage. - primarily supplied by the superior rectal branch of the inferior mesenteric artery - enters the pelvis by descending in the root of the sigmoid mesocolon and divides into right and left branches. - at first lie behind the rectum and then pierce the muscular coat and supply the mucous membrane. - anastomose with one another and with the middle and inferior rectal arteries. - The middle rectal artery is a small branch of the internal iliac artery. - The inferior rectal artery is a branch of the internal pudendal artery in the perineum. - It anastomoses with the middle rectal artery at the anorectal junction. - A rectal plexus of veins is drained by the superior rectal vein, a tributary of the inferior mesenteric vein. - The rectal plexus, which extends into the anal canal, is also drained by the middle and inferior rectal veins. - longitudinally running venous channels of the rectal plexus may become dilated to form hemorrhoids or piles. This conditions is common and inconvenient. - However, hemorrhoids may also be a manifestation of portal obstructions because blood which is prevented from draining through the superior rectal vein passes through the middle and inferior rectal vein to join the systemic venous system. This is an example of a portocaval anastomosis. - The nerve supply to the rectum is the sympathetic and parasympathetic nerves from the inferior hypogastric plexuses. 4) The examination of the rectum. - The anal canal and lower rectum may be palpated by a finger inserted into the anal canal - also allows the prostate to be felt in the male - In the female, provides an alternative to vaginal examination, particularly during a delivery when the degree of dilatation of the uterine cervix may be estimated. - also may detect pathological conditions of the seminal vesicles and ovaries and other pelvic disease - The rectum can be viewed directly with the proctoscope - this examination may be extended to the sigmoid colon with the sigmoidscope - The anteroposterior flexure of the rectum, as it follows the curvature of the sacrum and coccyx, and flexure in frontal plane must be remembered when one is passing a sigmoidoscope, to avoid causing the patient unnecessary discomfort. 5) Topography, blood supply and lymph drainage of the urinary bladder. - highly distensible muscular organ which, when empty, lies in the pelvis and rests on the symphysis pubis and the floor of the pelvis. - partially covered by peritoneum (mesoperitoneal) - The upper part of the posterior surface of the bladder is covered by peritoneum, which forms the anterior wall of the rectovesical pouch. - The lower part of the posterior surface is separated from the rectum by the vasa deferentia, the seminal vesicles, and the rectovesical fascia or aponeurosis of Denonvillier.

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- The superior surface of the bladder is complete by covered with peritoneum and is related to intraabdominal contents (usually coils of ileum or sygmoid colon). This is reflected on either side into the paravesical fossae and onto the upper part of the base where it forms the anterior wall of the rectovesical pouch. - The infrolateral surfaces are related in front to the retropubic pad of fat and pubic bones. More posteriorly, they lie in contact with the obturator internus muscle above and the levator ani muscle below. - The neck of the bladder lies inferiorly and rests on the upper surface of the prostate. Here, the smooth muscle fibers of the bladder wall are continuous with those of the prostate. - The neck of the bladder is held in position by the puboprostatic ligaments in the male and the pubovesical ligaments in the female. These ligaments are thickenings of the pelvic fascia. - The bladder is supplied by the superior and inferior vesical branches of the internal iliac arteries. - Veins which drain a vesical form the vesical venous plexus, which communicates below with the prostatic plexus; it is drained into the internal iliac vein. - The lymph vessels from the bladder drain into the internal and external iliac nodes. - The bladder receives both motor and sensory innervation. - The motor fibers are both parasympathetic and sympathetic. - The parasympathetic fibers are motor to the smooth muscle of the bladder wall or detrusor muscle, but inhibit the sphincter vesicae. - The sympathetic fibers on the other hand are said to be inhibitory to the detrusor muscle and motor to the sphincter vesicae. - The sensory fibers give rise to the conscious sensation of a full bladder and also pain resulting from disease. - The fact that these pain fibers return to both sacral and lumbar segments of the cord makes it difficult to surgically eliminate the intractable pain of terminal disease in this region. (for more details refer to Question 99 sub-question 1)

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Question 102 Topography of the perineum in the male 1) Surface landmarks. The boundaries of the perineum. Parts. - bounded by the pelvic outlet that lies below the pelvic diaphragm - pelvic diaphragm forms the floor of the pelvic cavity and the roof of the perineum - floor of the pelvic cavity slopes downward and medially, and so is the roof of the perineum - Thus, the perineum will be relatively deep laterally and shallow as the midline is reached. - Furthermore, a number of structures must either pass through the pelvic floor to reach the perineum (alimentary, urinary, and genital systems) or circumnavigate it (pudendal nerves and vessels). - Most anteriorly is the arcuate pubic ligament lying below the symphysis pubis - continued laterally along the ischiopubic ramus to the ischial tuberosity - completed between the tuberosity and the coccyx by the sacrotuberous ligament - It is conventional to divide this diamond shape into an anteriorly situated urogenital triangle and a posteriorly situated anal triangle by drawing an imaginary line through the ischial tuberosities. - Although this procedure simplifies description, it should not be forgotten that the two triangles communicate freely. - boundaries of the fossa when seen from the lateral aspect: - Note how the diamond is folded about the ischial tuberosities and that the plane of the urogenital triangle forms an angle with the plane of the anal triangle. - The attachment of the roof of the perineum, i.e., the levator ani, to the lateral wall of the pelvis is also indicated in the illustration. - It can now be seen that the depth of the perineum is minimal anteriorly and posteriorly and maximal in the intermediate region. - The perineum is limited inferiorly by skin and fat-filled superficial fascia. 2) Topography of urogenital triangle. - bounded in front by pubic arch and laterally by ischial tuberosities - The layers are : skin, subcutaneous tissue, superficial fascia, deep fascia, superficial muscle, inferior fascia and urogenital diaphragm (perineal membrane), urogenital diaphragm(deep transverse perineal muscle), superior fascia and urogenital diaphragm - Superficial muscles are : ischiocavernous, pubospongiousus, superficial transverses. Superficial fascia - divided into fatty layer & membranous layer - fatty layer (fascia of Camper) - consists of relatively thick areolar tissue containing a variable amount of fat. - continuous with fat of the ischiorectal fossa and superficial fascia of the thighs - in the scrotum, it is replaced by smooth muscle (dartos muscle) - dartos muscle comtracts in response to scold & reduces the surface area of scrotal skin

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- membranous layer (Colles fascia) - attached posteriorly to the posterior border of the urogenital diaphragm & laterally to the margins of the pubic arch - anteriorly, continuous with membranous later of superficial fascia of the anterior abdominal wall (Scarpas fascia) - fascia is continued over the penis (or clitoris) as a tubular sheath - forms a distinct layer in the scrotum (or labia majora) - The extent and attachments of the membranous layer are of clinical importance because they determine the direction of the spread of urine which may leak from a rupture of the spongy urethra. - Note the posterior attachment of the fascia to the posterior border of the perineal membrane. - On each side its attachment is continued forward and upward along the ischiopubic rami and then laterally over the thigh where it fuses with the fascia lata. - Extending from these attachments, the fascia surrounds the scrotum and the penis and then becomes continuous above with the membranous layer of the superficial fascia of the anterior abdominal wall. - In this way the superficial perineal pouch is formed. Superficial perineal pouch - bounded below by membranous layer of superficial fascia and above by urogenital diaphragm. - closed behind by fusion of its upper & lower walls - laterally is closed by attachments of membranous layer of superficial fascia & urogenital diaphragm to margins of pubic arch - anteriorly, space communicates freely with potential space lying between superficial fascia of anterior abdominal wall and anterior abdominal muscles - It can now be understood that urine leaking from the urethra will not pass backward into the anal triangle or laterally into the thigh, but after distending the scrotum and penis, will pass up onto the anterior abdominal wall. Urogenital diaphragm - triangular muscolofacial diaphragm situated in the anterior part of the perineum, filling in the gap of the pubic arch - formed by the sphincter urethrae and deep transverse

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perineal muscles (a layer of striated muscle) which are enclosed between a superior and an inferior layer of fascia of urogenital diaphragm - The more superficial fascial layer is known as the inferior fascia of the urogenital diaphragm or more commonly the perineal membrane. - The deep layer or superior fascia of the urogenital diaphragm is an insubstantial layer which blends posteriorly with the perineal body and perineal membrane - lies below the anterior part of the pelvic floor and the genital hiatus between the medial margins of the levator ani muscle - anteriorly, two layers of fascia fuse leaving a small gap beneath symphysis pubis - posteriorly, two layers of fascia fuse with each other and with membranous layer of superficial fascia and perineal body - laterally, layers of fascia are attached to pubic arch - closed space contained between superficial and deep layers of fascia is known as deep perineal pouch - Through the diaphragm passes the membranous part of the urethra. 3) The male urethra. Relation urethra and prostate gland. - much longer in the male than in the female (20 cm as opposed to 4 cm) - Beginning at the neck of the bladder it passes through the prostate, the floor of the pelvis, the perineal membrane, and the penis, to the terminate as the external urethral orifice at the tip of the glans penis. - It is divided into prostatic, membranous, and spongy parts. Prostatic urethra - widest and most dilatable part of the entire urethra - some what semilunar in cross-section with the convexity facing forward - Its posterior wall shows an elevated central region, the urethral crest, flanked by the prostatic sinuses. The crest becomes expanded to form the seminal colliculus. - At the summit of this elevation there lies a blindly ending diverticulum, the prostatic utricle, and on either side of this open the ejaculatory ductus. Membranous urethra - Lie between the apex of the prostate and the bulb of the penis - shortest part of the urethra - surrounded by the sphincter urethrae and the urogenital diaphragm (i.e. membranous urethra lies within the urogenital diaphragm) - bulbourethral glands lie on either side of it

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- rigid perineal or urogenital membrane (diaphragm) anchors this portion of the urethra to the bony pelvis and renders it liable to injury. - This may brought about by faulty instrumentation or trauma. In the latter case, often as a result of an automobile accident, a full bladder may be torn from the urethra or it may be ruptured as the left and right halves of the pelvis are separated by a fracture. Spongy urethra (penile urethra) - longest portion of the urethra - traverses the bulb, the corpus spongiosum, and the glans of the penis - Just before its termination at the external urethral opening, the urethra is expanded to from the navicular fossa (fossa terminalis). - The ductus of the bulbourethral glands open near its commenument - over the rest of its course it is joined by the ductus of many urethral glands which may open into small out-pouchings of the mucous membrane called lacunae. - These glands are prone to gonococcal infections which may result in scarring and stricture formation. Such strictures may be dilated by instruments known as bougies. To achieve this successfully, the course of the urethra and its narrow fixed membranous portion must be borne in mind as the instrument is introduced. 4) Relations of urethra and deep transverse perineal muscle. Clinical importance of relations in catheterization. - through urogenital diaphragm membranosus part of urethra pass. - Around urethra the deep transverse perineal muscle forms sphinter. - On both sides of sphincter bulbourethra glands are located. - Ducts and gland open below diaphragm at level bulb and penis. - The following anatomical facts should be remembered before passing a catheter or other instrument along the male urethra: 1. The external orifice at the glans penis is the narrowest part of the entire urethra. 2. Within the glans the urethra dilates to form the fossa terminalis. 3. Near the posterior end of the fossa, a fold of mucous membrane projects into the lumen from the roof. 4. The membranous part of the urethra is narrow and fixed. 5. The prostatic part of the urethra is the widest and most dilatable part of the urethra. 6. By holding the penis upward, the S-shaped curve to the urethra is converted into a J-shaped curve (the male urethra has two flexure: subpubic and prepubic).

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If the point of the catheter will pass through the external orifice and is then directed toward the urethral floor until it has passed the mucosal fold, it should easily pass along a normal urethra into the bladder. 5) Topography of the anal triangle. - limited anteriorly : bi-ischial line Posteriorly: post-tip of coccyx Laterally : sacrotuberal ligament - contains the two ischiorectal fossae which are separated by the anal canal and adjacent connective tissue - connective tissue comprises the anococcygeal ligament posteriorly and the perineal body anteriorly - In urethra of triangle is anus. - Around anus is sphinter ani external muscle, thin muscle directly attach to skin forming ischial skin fold around anus. - Anteriorly sphincter ani external attach to perineal body and posteriorly to anococcygeal ligament. - By this sphincter ani external completely separates right and left ischiorectal fossa which are located on both sides of anus.

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Question 103 The scrotum and its contents. Operations in hydrocele 1) Layers of scrotum. - Skin - tunica haustras - external spermatic fascia - cremasteric fascia with cremasteric muscle - internal spermatic fascia - tunica vaginalis connected with 2 layers of parietal and visceral - tunica albuginea. 2) Topography of the testes and the epididymis. - Each testis with its associated epididymis lies within the scrotum at the lower end of the spermatic cord - partially invaginated into a serous sac of peritoneal origin known as the tunica vaginalis - Between the visceral layer of the sac, which clothes the front and sides of the testis and the parietal layer, there is a potential space - Following injury or disease of the test, this space may be filled with watery fluid (hydrocele) or blood (hematocele). - The almond-shaped testis is about 5 X 3 X 2.5 cm in dimension. - Its tough outer fibrous coat, called the tunica albuginea, sends many fibrous septula into the interior of the gland which divide it into small testicular lobules.These contain the seminiferous tubules. - The septa and tubules converge on the posteriorly lying mediastinum testis where the tubules form a network called the rote testis. - Further tubules, the efferent ducts, open into the head of the epididymis which is attached to the upper pole of the testis. 3) Blood supply, venous drainage and innervation. - The testis is supplied with blood by the testicular artery. - This artery is a direct branch of the abdominal aorta and arises just below the renal arteries. - It descends in the spermatic cord to the posterior aspect of the testis. From here branches embrace the testis and perforate the tunica albuginea to reach the interior. - Venous blood returns via the pampiniform plexus and testicular vein to reach the inferior vena cava (right vein) and the left renal vein (left vein). - Obstruction of the left renal vein by a renal tumor may produce a dilatation of the veins around the left testis and epididymis (a varicocele). - Lymphatics from the testis run back with the testicular artery to reach lymph nodes alongside the aorta. 4) Operations in hydrocele. Aspiration. Injection treatment. - A hydrocele is a collection of clear fluid within the tunica vaginalis. - can be classified as congenital, encysted, infantile or vaginal (idiopathic). - The vaginal or idiopathichydrocele occurs in a normally formed tunica vaginallis and is by far the commonest. 189

- The other varieties occur when the tunica is abnormal and the processus vaginalis fails to close in whole or in part. - In the congenital hydrocele the tunica communicates with the peritoneal cavity, and the fluid disappears into the abdomen when the scrotum is elevated (fluid in the hydrocele may be ascitic fluid). - The emptied congenital hydrocele forms a smooth oval swelling associated with the spermatic cord and is often mistaken for a hernia. - An infantile hydrocele extends as far as the deep inguinal ring but does not communicate with the peritoneal cavity. - In the child excision of the processus vaginalis within the inguinal canal resolves congenital hydrocele or hydrocele of the cord. ASPIRATION - The position of the testis, which usually lies posteriorly, is confirmed by palpation and transillumination. - The scrotum is grasped so that the fluid is pressed towards the lower anterior part of sac rendering it tense. - A small wheal of local anaesthetic solution is raised in an area of the scrotal skin that is free of visible vessels and well clear of the testis. - A fine trocar and cannula (or needle cannula) puncture thrust through it into the sac. - After all fluid has been evacuated and the cannula withdrawn the testis is carefully examined to ensure that it is healthy. INJECTION TREATMENT - The solution most commonly employed is made up to the following formula: Quinine hydrochloride 4 g Urethane 2 g Water for infection 30 ml. -10 ml of this solution is injected through the cannula into the cavity of the tunica vaginalis when all the hydrocele fluid has been evacuated. - Gentle massage is employed to disperse the solution throughout the cavity of the tunica and the scrotum is supported for some days with a suspensory bandage. - The procedure may be repeated at a later date if necessary using 5 ml of the solution. - An alternative solution is 2 ml sodium tetradecyl used for sclerotherapy. 5) Vinkelman's operation. Bergman's operation. - The incision is placed over the superficial inguinal ring. - A finger is passed downwards and swept around the hydrocele sac to separate it from the inside of the scrotum. - The sac together with the testis and epididymis is pushed out of the scrotum into the wound. If the sac is very large its fluid content can be aspirated before it is pushed out of the scrotum. - After the coverings have been stripped aside an opening is made into the tunica vaginalis and the testis is carefully examined. If it is healthy the hydrocele alone requires treatment. - If the hydrocele is small and the sac thin walled the Jaboulay procedure is the operation of choice. - It consists simply of turning the sac inside out reversion, so that it lies entirely

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behind the testis and inserting a few sutures to retain it in position. (Vinkelmanns operation) - These sutures must not pull the margins of the sac too tightly around the cord other wise the blood supply to the testis may be impaired. - If the hydrocele is large or the sac thick walled, the sac is better excised by cutting it off closely around its attachment to the testis. (Bergmanns operation) - The bleeding points on the small remaining fringe of sac must be secured by ligatures or a running stitch otherwise a haematoma will form. - After both these operations haemostasis is secured, and the testis is returned to the scrotum from which a drain is brought out through the wound. - As a further precaution against haematoma formation, the scrotum should be well supported with a compression bandage. - A scrotal approach can be used instead of an inguinal one for either of these two operations and is preferable. (Lords operation) - Lord's procedure is virtually bloodless, and considerably reduces the risk of a scrotal haematoma, which is, unfortunately, very common after the other operations. - The hydrocele is grasped in the left hand and the anterior scrotal skin stretched. - An incision, about 4 cm in length, is made through the skin and dartos muscle avoiding, as far as possible, the superficial vessels, which are easily seen through the stretched skin. - The tunica vaginalis is opened by an incision of the same length, but neither mobilized nor separated from the inside of the scrotum and the hydrocele fluid is evacuated. - The testis is then lifted out through the incision in the tunica vaginalis. - Five or six "gathering" stitches are now inserted into the invaginated tunica, radiating outwards from its attachment to the testis towards its cut edge. When these are tied, the tunica is plicated and forms a collar around the function of testis and epididymis. - Finally, the testis is returned to the scrotum, and the dartos muscle and skin are closed as one layer by stitches or clips.

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Question 104 Topography of the perineum in the female 1) Surface landmarks. The boundaries of the perineum. Parts. (same as in Question 102 sub-question 1 except for:- presence of vaginal canal, absence of extra-abdominal gonads, and that the urethra does not traverse the clitoris (homologous of the penis) 2) The layers of the urogenital triangle. 3) Vessels, nerves and lymph drainage. - The internal pudendal artery although smaller in the female, has a course and distribution similar to that in the male. - Posterior labial branches replace posterior scrotal branches and the three branches to the penis are represented by the artery of the bulb of the vestibule and deep and dorsal arteries of the clitoris. - Each artery is accompanied by a vein draining back to the internal pudendal veins. - There is also a single deep dorsal vein of the clitoris which passes back benath the symphysis pubis to reach the vesical plexus of veins. - The pudendal nerve is also similar to that of the male in course and distribution. - All skeletal muscle of the anal and urogenital triangles is supplied by either the inferior rectal nerve or the perineal nerve. - The dorsal nerve of the clitoris which runs deep to the perineal membrane is small. 4) Syntopy of the vagina and urethra. Clinical importance. - The vagina has been seen to pass through the pelvic floor partly surrounded by the most anterior fibers of levator ani called in the female the pubovaginalis muscle. - Below this level it lies in the urogenital triangle. - The urethra is embedded in its anterior wall and posteriorly it is separated from the anal canal by the perineal body. - Distally it opens into the vestibule at the vaginal orifice or introitus, which in the virgin is partially occluded by the hymen. - Posterior wall of urethra is connected to anterior wall of vagina very closely by urethrovaginal septa - delivery is accompanied by septure of vagina, of the anterior wall of vagina and urethra - may accompany damage of post wall of urethra and develop urethrovaginal fistula. 5) Topography of the anal triangle. (as in Question 102 sub-question 5)

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Question 105 Topography of the ischiorectal fossa 1) Disposition of this fossa or the anal triangle. - Ischiorectal fossa are located on both sides - left and right are separated by attachment.ant-sphinter ani external to perineal body and post-sphinter ani external to anococcygeal ligament. 2) The boundaries of the ischiorectal fossa and its walls. - Ischiorectal fossa has 4 boundaries and 2 walls - boundaries : anteriorly - superficial transverse perineal muscle Posteriorly - inf margin of gluteus maximums muscle Laterally - ischial tuberosity Medially - sphinter ani externus - Walls are medially -levator ani Laterally - obturator external and are covered by pelvic fascia 3) The pudendal canal. Vessels and nerve. - Pelvic fascia on obturator internal muscle split 4mm - pudendal canal containing pudendal nerve and internal pudedndal artery and vein - At the level of fossa, from this neurovascular bundle inferior rectal neurovascular bundle arises and pass to rectum in frontal fossa. 4) Connection of the fat with adjacent region. The ways of pus spreading. - Loose part of ischiorectal fossa communicate with adjacent area, lesser sciatic foramen along pudendal region, infapiriformis along pudendal neurovascular bundle to lateral space. - melting thin fascia has pus spreading with subcutaneous layer of anal triangle. - Fossa has 2 blind recesses where pus may accumulate anteriorly and posteriorly - Anterior recess is underneath superficial transverse pudendal muscle. 5) Anorectal abscesses. The situation of the various anorectal abscesses. Methods of opening (incisions) of abscesses. - 4 locations of abscess : - subcutaneous : open by a cruciate incision and any undermined edges are cut away - submucous : accessed by stretching of anal sphincter - ischiorectal : incision should be a large one (provides free drainage & ensure wound will heal from its deepest part outwards) - recommended large cruciate incision, one limb of which radiated towards anus - its deep end through skin & fascia - corners are cut away so final opening represents entire floor of abscess cavity - fibrous septa broken down with finger or by further incision & whole cavity packed with gauze - pelvi-rectal : situated above levator ani, between it and rectum - drainiage is through ischiorectal fossa

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Question 106 Operations in ectopic pregnancy 1) Clinical importance of puncture of the rectouterine pouch (Douglas). Give topographoanatomical grounds. - Douglas pouch is a frequent site for accumulation of blood in ectopic pregnancy - is the most dependent part of entire peritoneal cavity - posterior fornix of vagina is floor of Douglas pouch - In accumulation of blood or pus in Douglas pouch, puncture of posterior fornix of vagina may be made for drainage 2) Laparoscopy in ectopic pregnancy. Complications of laparoscopy (immediate and late). - Laparoscopy in ectopic pregnancy is very modern procedure and is carried out if diagnosis is kept easily before rupture of tube and bleeding. - this procedure allows to remove ovum from tube on continuation of open operation. - 3 laparocentesis are made below and at level metallic chip are put on uterine end of tube and mesosalpinx and suspensory ligament before coagulating tube is mobilized from mesosalpinx and removed. - Complications: - Immediate complications include damage of abdominal aorta,common and external iliac arteries and hollow organic - Late complication include diffuse peritonitis and pelvoperitonitis. 3) Accesses to uterus and its adnexa. - more often suprapubic, - transverse laparotomy along natural suprapubic skin fold. - In oncology inferior midline laparotomy is used. 4) Laparotomy and arrest of bleeding. - Made from lateral margin of rectus abdominis to lateral margin of another rectal abdominis to lateral margin of another rectal abdomen muscle along natural suprapubic skin fold. - Transeversely by skin, subcutaneous tissue, fascia and anterior layer of rectus sheath are anterior linea alba and peritoneum 2 cut along midline - vesicular stoppage of bleeding is made by puting 2 forceps 1st on suspensory ligament to close union of anterior abd 2nd on uterine end of tube and mesosalpinx to close branch of uterine arteries communicate take part to supply tube. 5) Removing of tube, peritonization of stumps and going out (way out) from operation. - After stop bleeding tube is mobilized from mucosalopenings and anterior mucous uterus stump of tube is ligated and peritonized by round ligament of uterus on lateral layers by sutures. - Peritoneum and linea alba along ischial line, rectus sheath, skin, subcutaneous tissue, transverse.this incison is like muscle splitting. - No postoperative hernia in primary healing of wound.

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Question 107 Operations on urinary bladder 1) Urethral catheterisation. Indications. Procedure. - May be done by nurses if is female patient - In males, cathether with any type of material other than metal maybe doen by nurse. - metal catheter insertion for males MUST be done by a doctor because procedure may be followed by dangerous complications (urethra has thin wall and may rupture or catheter may encounter a false way and rupture the wall of urethra) Indications: 1. to empty the bladder in most patients with acute and clot retention and in many with chronic retention; 2. to empty the bladder before operating on pelvic viscera like the rectum or uterus and to fill the bladder before some operations on the bladder and prostate; 3. to instil antiseptics like Noxythiolin (Noxyflex) or Chlorhexidine 1/5000 into the infected bladder or tumour inhibitors like Ethoglucid (Epodyl) into the neoplastlc bladder; 4. to measure residual urine, bladder capacity and other urodynamic parameters; 5. to carry out cysto-urethrography in the investigation of bladder, vesico-ureteric, vesico-urethral and urethral disease; 6. in patients with or liable to develop acute renal failure so that the urinary output can be measured hourly; 7. in the treatment of neuropathic bladder disorders following diseases or injuries of the nervous system and other causes of urinary incontinence; 8. as a means of draining and keeping empty the bladder after operations on the bladder, prostate and urethra and after some gynaecological and rectal operations; 9. to determine the nature and extent of urethral and bladder injuries. Procedure: - The patient is placed supine, in males, the legs are separated, in females, the knees are bent then separated with the feet together. - genitalia are cleaned with an aqueous antiseptic solution (spirit irritates the skin). - In males, the penis is held in a sterile swab, the prepuce retracted and all smegma removed - in females, the labia should be separated with one hand while the meatus is cleaned (from before backwards) and only released after the catheter has been inserted. - Sterile towels are used to prevent the catheter or operator's hands touching the skin or bedclothes. - The urethra is filled with an antiseptic anaesthetic gel (Lignocaine hydrochloride 1 or 2% with chlorhexidine 0.25%) using the nozzle supplied with the tube (both nozzle and tube are supplied sterile). - Two minutes are allowed for the local anaesthetic to become effective while the catheter is prepared. - Most catheters are now supplied sterile and are often double-wrapped. When the outer pack is carefully removed by an assistant the operator can handle the sterile inner pack.

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- This is opened to expose the distal end of the catheter which is then well lubricated. (Petroleum products like liquid paraffin dissolve latex and must not be used). - The catheter is then slowly fed into the urethra out of the inner tube elevating the penis in the male and keeping the labia separated in the female. - When the catheter reaches the bladder, urine drains through it. - If a balloon catheter is being used the catheter is advanced a little further into the bladder before the balloon is inflated. - The catheter is then connected to a drainage bag providing a closed drainage system. - The bag should have a one way valve which will prevent urine returning to the bladder if the bag is lifted or sat upon. Metal catheter: - patient lie on back with head resting on a pillow in a somewhat ascending position - lower extremity must be slightly flexed at hip & kneejoint, abduct and rotated laterally - dr standon L side with back to face of patient - technique has 3 moments: 1: - by R hand, take catheter and hold parallel to L inguinal fold of patient. - by L hand, dr hold penis behind head - catheter is inserted thru external orifice of urethra and once inserted, organ is stretched over catheter (catheter is not pushed into organ!!)till location of end of catheter is at inferior margin of symphysis pubis(may be palpated) 2: - catheter is displaced parallel to midline of body - continue to stretche penis over cathetertill sensation of resistance in R hand of dr. (catheter has reached deep transverse perineal muscle/urogenital diaphragm) 3: - by L hand, dr. estimate location of catheter in perineum - dr direct it in angle between pubic bones (dont fixate penis! Hand under scrotum & by finger direct end between ramus or pelvic bones) - by R hand, displace catheter downwards and arc of 180 in sagital plane is made (with this, end of catheter slide into membranous and prostatic part of urethra) 2) Capillary puncture of urinary bladder. Suprapubic cystostomy by the percutaneous method. - Capillary puncture of urinary bladder is made when catheterization is impossible or in contraindication in obstruction of urination - called capillary due to usage of very thin needle because UB muscles cant contract completely, thus using a thick needle may form a way of drainage - Pivot on puncture is done 2cm above symphysis pubis along midline under LA - If after puncture, obstruction is still recurrent, suprapubic cystotomy by percutaneous method is indicated.

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- method causes little discomfort to the patient and little scarring but can only be done safely if the bladder is distended. - It is the method of choice unless there are compelling reasons for exploring the bladder or for bringing the tube out at a high level. Technique: - Local anaesthetic (1 or 2% Lignocaine solution) is infected into the midline skin some 5 cm above the pubis. - As the needle is advanced, anaesthetic is infected into subcutaneous tissue, linea alba, extraperitoneal fat and bladder wall. - The position and depth of the needle tip required to enter the bladder is recognized when urine can be aspirated. - After a 5 minute interval for anaesthesia to develop, a 2 cm incision is made through skin and linea alba, and the suprapubic trochar and cannula are introduced into the bladder with a quick stabbing movement. - It is best to introduce the needle - and later the trocar, cannula and catheter - directly back wards. - To introduce them backwards and downwards is hazardous because they may pass below the bladder into the prostate. - The patient may experience momentary discomfort but should have no pain if the anaesthetic has been correctly introduced. - The trochar is withdrawn and the cannula is closed with a finger. - A well lubricated Malecot or De Fezzer catheter stretched on an introducer is inserted and the cannula and introducer removed. - The catheter is anchored to the skin margin with a stitch. - Some 10 cm of catheter is left below skin level so that it is not forced out when the bladder contracts. - One of the proprietary suprapubic cystostomy kits can be used instead of a trocar and cannula with a Malecot or De Fezzer catheter. 3) Surgical approach to the bladder . - The bladder can be approached endoscopically or openly by a suprapublc incision. - The suprapubic route is generally used for the treatment of bladder stones, diverticula, trauma and some tumours, for ureteric re-implantation or for access to the prostate gland. - The operation is entirely extraperitoneal and usually through a transverse incision - for cystectomy the approach is intraperitoneal and usually through a vertical incision. - Technique: - A transverse incision is made in a skin fold about 2.5 cm above the pubis, opening the anterior rectus sheath with a transverse or Ushaped incision and freeing it from the underlying rectus and pyramidalis muscles by sharp dissection in the midline and by blunt dissection laterally. - The lower flap of the rectus sheath can be split vertically in the midline down to the pubis to improve exposure of the retropubic space. (The U incision is useful because one or both limbs can be extended up wards to expose the lower ends of the ureters and even the lower pole of the kidney). - The recti and pyramidalis muscles are separated in the midline and retracted

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laterally although it is often better to divide the pyramidalis muscles transversely and reflect them with the rectus sheath. - The extraperitoneal fat and peritoneum are stripped upwards to expose the bladder wall which is easily recognized by its fasciculated appearance and by the many thin walled veins that course over its surface. - The bladder wall is picked up at two points with tissue forceps or with stay sutures, opened vertically or transversely and emptied by suction. 4) Suprapubic cystotomy and cystostomy by open operation. - allows correct positioning of the tube exploration of the bladder and the placement of the tube at a higher level on the abdominal wall than is possible by percutaneous methods any future operations on the bladder are thus facilitated. - After exposure of anterior abd wall, 2 stay sutures are put on the urinary bladder. - Between 2 sutures at the centre longitudinally cut 5cm. - after removal of pathological process, wound of bladder is closed by 2cm and suture completely on cystotomy - may finish by cystotomy if necessary dysfunction of urinary bladder. - Incision of bladder is covered by 2 rows of suture from inf to sup angle. - near sup angle purse-string suture is made and tube is inserted. - it may be an independent operation. - after exposure of ant wall of bladder, 2 stay sutures are put - between stay sutures, purse-strings suture is made. - incision is made within ourse-string sutures and catheter is inserted. - purse-string sutures tighten to form tubular fistula (like Stamm-Kader op. on GIT) - wound is closed in succession layers, linea alba vertically and other layer transverse. 5) Peculiarity of the suture of the urinary bladder and ureter. Suture materials. - Suture of urinary bladder consists of 2 rows. - 1st row has pecularities: - does not penetrate mucous membrane for prophylaxis of formation of stone on thread. - for this row, special suture material monofilament thread is used nd - 2 row - any type of material can be used - if wound is on extra-peritoneal part of pelvis seromuscular. - if it is intra-peritoneal fasciomuscular

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