ANSWERS 3- ABDOMEN AND PELVIS

Topographic anatomy and operative surgery of abdominal cavity

1. Topographic anatomy of front abdominal wall and its week places (white line, umbilical ring, inguinal and femoral canal).

Borders: superior includes costal arches and xiphoid process;

inferior includes iliac crests, inguinal ligaments, upper edge of

symphysis; lateral includes vertical line between end of XI rib and iliac

crest.

Regions

Two horizontal lines (upper one links lower points of tenth ribs;

lower one links anterior superior iliac spines) divide the front

abdominal wall into three regions: epigastrium, mesogastrium and

hypogastrium. Each of these regions is divided into three parts by two

vertical lines (pass by external edge of rectus muscles of the abdomen):

epigastrium includes two hypohondric and proper epigastric regions,

mesogastrium includes two lateral and umbilical regions, hypogastrium

includes two inguinal and pubic regions.

Projections of organs on the front abdominal wall

 epigastric region – stomach, left lobe of the liver, pancreas,

duodenum;

 right hypochondria – right lobe of the liver, gallbladder, right flexure

of the colon, upper pole of the right kidney;

 left hypochondria – fundus of the stomach, spleen, tail of the

pancreas, left flexure of the colon, upper pole of the left kidney;

 umbilical region – loops of the small intestine, transverse colon,

lower horizontal and ascending part of the duodenum, greater

curvature of the stomach, gates of the kidneys, ureters;

 right lateral region – ascending colon, loops of the small intestine,

lower pole of the right kidney;

 left lateral region – descending colon, loops of the small intestine,

lower pole of the left kidney;

 pubic region – urinary bladder, lower parts of the ureters, uterus,

loops of the small intestine;

 right inguinal region – cecum, terminal part of the ilium, appendix,

right ureter;

 left inguinal region – sigmoid colon, loops of the small intestine, left

ureter.

Layer-by-layer topography

Skin is thin, mobile, covered with hair in pubic region and along

white line of abdomen (in men).

Subcutaneous fat contains superficial vessels and nerves. Lower

part of the front abdominal wall is supplied by branches of the femoral

artery:

 superficial epigastric artery goes to umbilicus;

 superficial circumflex artery of iliac bone goes to iliac crest;

 external pudendal artery goes to external genital organs.

These arteries are accompanied by the same veins flowing into the

femoral vein.

Upper part of the front abdominal wall is supplied by thoracoepigastric

artery, lateral thoracic artery and anterior branches of

intercostal and lumbar arteries.

Superficial veins form a dense network in the umbilical region.

Cava-caval anastomoses are made by thoraco-epigastric (system of the

axillary vein and superior vena cava) and superficial epigastric (system

of the femoral vein and superior vena cava) veins. Portocaval

anastomoses are formed by paraumbilical veins (system of the portal

vein) located in round ligament of the liver.

Lateral cutaneous nerves (branches of intercostal nerves) pierce

internal and external oblique muscles at anterior axillary line and are

divided into anterior and posterior branches that supply skin of the lateral

parts of anterolateral abdominal wall. Anterior cutaneous nerves

(terminal branches of intercostal, iliohypogastric and ilioinguinal nerves)

pierce rectus sheath and innerve skin of unpaired regions.

Superficial fascia is thin, at the level of umbilicus is divided into

two sheets: superficial (goes to the hip) and deep (dense, attached to the

inguinal ligament). Fat tissue with superficial vessels and nerves is

located between sheets of fascia.

Proper fascia covers external oblique muscle.

Muscles of the front abdominal wall are located in three layers.

External oblique abdominal muscle begins from 5-12 ribs and is

attached to iliac crest. Direction: medial and downwards. Its aponeurosis

is involved in formation of inguinal ligament, anterior wall of rectus

sheath and white line of abdomen.

Internal oblique abdominal muscle begins from superficial leaf of

thoracolumbal fascia, iliac crest and lateral two-thirds of inguinal

ligament. Direction: medial and upwards. Near the extenal edge of rectus

muscle turns into aponeurosis. Aponeurosis takes part in formation of

white line of the abdomen; above the umbilicus it is involved in

formation of both walls of rectus sheath, below – of anterior wall.

Transversus abdominis muscle begins from the inner surface of 6-

12 ribs, of thoracolumbal fascia, iliac crest and lateral two-thirds of

inguinal ligament. Direction: transverse. Upon semilunar [spigelian] line

muscle turns into aponeurosis. Aponeurosis takes part in formation of

white line of abdomen; above the umbilicus it is involved in formation of

posterior wall of rectus sheath, below – of anterior wall.

Rectus abdominis begins from anterior surface of cartilages of 5-7

ribs and xiphoid process and is attached to superior branch of pubic

bone. 3-4 transverse tendinous intersections are in muscles which are

closely attached to the anterior wall rectus sheath. The anterior wall of its

sheath in epigastric and umbilical regions is formed by aponeurosis of

external oblique and superficial leaf of aponeurosis of internal oblique

muscles, posterior – deep leaf of aponeurosis of internal oblique and

aponeurosis of transverse abdominal muscles. Anterior wall of the rectus

sheth in pubic region is formed by aponeuroses of three abdominal

muscles. Posterior wall is formed only by transverse fascia.

Linea alba (white line of the abdomen) and transverse muscles). It

connects xiphoid process with pubic symphysis. Its length is about 30-40

cm, width is various: at the level of xiphoid process it is 0.5 cm, at the

level of umbilicus it is 2-3 cm. Thickness of white line of the abdomen

above umbilicus is 1-2 mm, below – 3-4 mm. In case of longterm

exertion of the abdominal wall tendinous fibers stretch and separate. So,

hernias of white line often reveal above umbilicus because here it is thin

and wide.

Umbilicus is a pulled-in scar at the site of umbilical ring.

Abdominal wall here consists of following layers, closely grown

together: skin, scar tissue, umbilical (transverse) fascia and parietal

peritoneum. Umbilical ring is a hole in the white line with sharp even

edges formed by aponeuroses of three pairs of abdominal muscles.

Umbilical cord passes here in the antenatal period, connecting fetus with

mother. Umbilical ring is firmed with connective scar tissue after child's

birth under structures which pass in umbilical cord (umbilical vein,

arteries and urachus). This ring is weak place for umbilical hernias.

Transverse fascia is a part of endoabdominal fascia.

Preperitoneal fat separates transverse fascia from peritoneum. It

contains deep arteries and veins:

 superior epigastric artery (branch of the internal thoracic artery)

passes into rectus sheath behind the muscle and has anastomoses

with inferior epigastric artery;

 inferior epigastric artery (branch of the external iliac artery) goes

upwards between transverse fascia and parietal peritoneum and

enters rectus sheath;

 deep circumflex artery of iliac bone (branch of the external iliac

artery) goes in parallel to inguinal ligament between peritoneum

and transverse fascia in direction to iliac crest;

 five lower intercostal arteries (branches of the thoracic aorta) are

located between internal oblique and transverse abdominal

muscles;

 four lumbar arteries (branches of the abdominal aorta) are located

between internal oblique and transverse abdominal muscles.

Deep arteries are accompanied by the same veins.

Parietal peritoneum covers anatomical structures in lower regions

of anterolateral abdominal wall forming peritoneal folds and fossae.

Peritoneal folds:

 median umbilical fold (unpaired) – passes from top of the urinary

bladder to umbilicus above obliterated urinary duct (urachus);

 medial umbilical fold (paired) – passes from lateral walls of the

urinary bladder to the umbilicus above obliterated umbilical

arteries;

 lateral umbilical fold (paired) – passes above the inferior epigastric

arteries and veins.

Between peritoneal folds there are fossae:

 supravesical fossae – between median and medial umbilical folds;

 medial inguinal fossae – between medial and lateral umbilical

folds;

 lateral inguinal fossae – externaly from lateral umbilical folds.

Femoral fossae are located lower than inguinal ligament under

medial inguinal fossae and are projected into crural ring (annulus

femoralis).

These fossae are weak places for inguinal and femoral hernias.

Inguinal canal

Inguinal canal is located in inguinal triangle which is bounded

from above by horizontal line from the point between external and

middle third of inguinal fold, medially by external edge of rectus muscle,

from below by inguinal fold.

Two rings and four walls are distinguished in the inguinal canal.

Rings of the inguinal canal:

1. superficial inguinal ring is formed by divarication (splitting)

of external oblique muscle aponeurosis onto lateral and

medial limbs;

2. deep inguinal ring is a hole in endoabdominal fascia which

corresponds to lateral inguinal fossa.

Walls of the inguinal canal:

 front – external oblique muscle aponeurosis;

 back – transverse (endoabdominal) fascia;

 upper – lower edges of internal oblique and transverse

muscles;

 lower – inguinal ligament.

Space between upper and lower walls of inguinal canal is called

inguinal interval.

Content:

 spermatic cord (in men) and round ligament of uterus (in

women);

 ilioinguinal nerve;

 genital branch of genitofemoral nerve.

Femoral canal

The femoral canal is formed during formation of femoral hernia (in

case of going out of parietal peritoneum with internal organs through

femoral fossa between superficial and deep layers of lata fascia and then

under the skin of thigh through saphenous opening).

Rings of the femoral canal:

1. Internal (deep) ring corresponds to the femoral opening

which is bounded:

 in front – by inguinal ligament;

 from back – by pectineal ligament;

 medialy – by lacunar ligament;

 lateraly – by femoral vein.

The femoral ring is covered by transverse fascia forming femoral

fossa in internal surface of the front abdominal wall.

During operative treatment of incarcerated femoral hernias surgeon

should remember that through medial wall of femoral ring in 30% of

cases obturator branch of inferior epigastric artery (“crown of death”)

can pass. Injury of this artery during section of incarcerating ring can

cause profuse internal bleeding (section of lacunar ligament is done

between two forceps with subsequent ligation of ligament).

2. Superficial ring is a saphenous opening (hiatus saphenus) is

covered by cribriform fascia.

Walls of femoral canal:

1. anterior – superficial layer of femoral (lata) fascia;

2. posterior – deep layer of femoral fascia;

3. medial – femoral vein.

 2. Hernias, factors of herniation. Classification. Hernial elements. Surgical anatomy of inguinal (oblique, direct, acquired, congenital), femoral, umbilical hernias and hernias of white line.

SURGICAL ANATOMY OF HERNIAS OF THE FRONT

ABDOMINAL WALL

Hernia is the exit of internal organs covered by parietal peritoneum

from the abdominal cavity through weak places or artificial holes in the

abdominal wall.

Hernial elements:

1. Hernial gate is a hole or defect in the abdominal wall,

through which organs go out from the abdominal cavity.

2. Hernial sack is formed by parietal peritoneum. Neck, body

and bottom are distinguished in it.

3. Hernial content includes organs which are located in the

hernial sack.

Initiating factors of herniation:

1. Predisposing is changing of the structure of the front

abdominal wall weak sites.

2. Producting is a sudden increase of intra-abdominal pressure.

Classification of hernias:

1. According to time of herniation:

 acquired;

 congenital.

2. According to complications:

 uncomplicated

 reducible;

 irreducible.

 complicated

 sliding;

 strangulated (elastic, fecal, combined; parietal,

antegrade and retrograde).

3. According to clinics:

 primary;

 recurrent – herniation in place where herniotomy was already

performed;

 postoperative – herniation due to weakeness of abdominal

wall after different operations.

4. According to localization:

 internal:

 intraperitoneal

o hernias of omental bursa;

o retrocecal hernias;

o hernias of duodenojejunal recess;

 diaphragmatic hernias.

 external

 inguinal

o oblique

o direct

 femoral

 of white line

 umbilical

 lumbar

 ischial

 obturator.

Inguinal hernias

There are congenital and acquired, oblique and direct inguinal

hernias. Lateral inguinal fossa is hernial gates for the oblique inguinal

hernia. Hernial sac goes into deep inguinal ring, passes through inguinal

canal and leaves it through superficial inguinal ring. Hernial sac is

located under external spermatic fascia. Elements of spermatic cord are

located anteriad and medially to the sac. According to the stage of

herniation there are initiating, incomplete, complete and scrotal oblique

inguinal hernias.

Plastics of hernial gates at oblique inguinal hernias is directed on

strengthening of front wall of inguinal canal as in the process of passing

through it the hernial sac stretches and thins aponeurosis of external

oblique abdominal muscle.

At direct inguinal hernial sac is covered by transverse fascia and

passes through medial inguinal fossa into inguinal canal out of the

spermatic cord elements. Direct hernias go into subcutaneous fat through

superficial inguinal ring and do not descend into scrotum (location of

muscular fascicles of cremaster muscle prevent herniation downward).

Due to the fact that internal hernial ring (medial inguinal fossa) is located

just opposite to superficial inguinal ring, hernial sac goes in straight

direction out of elements of the spermatic cord.

white line hernia

 both sides of the rectus sheath on the ventral midline are intertwined and into the abdominal white line. Abdominal visceral abdominal white line called the white line hernia of abdominal prolapse (hernia of white line). Is a rare abdominal wall hernia. Occurred in the umbilical hernia, also known as white lines on the upper abdominal hernia, occurs in the white line below the belly button called lower abdominal hernia hernia. As the white line on the wide umbilicus, narrow, solid white line below the belly button, so the white lines occur in the umbilical hernia, and the vast majority occur in the umbilicus and xiphoid, especially between the mid-point between the two are most welcome.

 3. Surgical anatomy of strangulated and sliding hernias.

Stages of operation in strangulated hernias

 Anesthesia (local anesthesia, as narcosis leads to relaxation of

muscles and spontaneous reduction of strangulated organ before its

revision).

 Approach to the hernial gates.

 Separation of the hernial sack from surrounding tissues up to the

hernial gates.

 Opening of hernial sack bottom.

 Fixing of hernial contents.

 Section of the incarcerating ring (hernial gate).

 Revision of hernial contents and its viability estimation (color,

pulsation of vessels, peristalsis). Loops of the intestine are covered

by gauze moistened with warm saline for acceleration of

restoration of organ viability. When intestine is normal it is put into

the abdominal cavity, if the loop is not viable – general anesthesia

is given to a patient, lower midline laparotomy and resection is

done within the limits of normal tissues. In case of strangulation of

greater omentum resection is done without estimation of its

viability.

 Separation of hernial sack to the hernial gates.

 Processing of hernial neck and removal of the sack.

 Plastics of hernial gates.

Operation in sliding hernias

Sliding hernia is a hernia in which one wall of hernial sac is formed

by hollow organ covered mezoperitonealy (urinary bladder, cecum).

Sliding hernia is usualy diagnosed during processing of cervics of hernial

sac.

Stages of operation

 Anesthesia.

 Approach to the hernial gates and hernial sack.

 Separation of the hernial sack from surrounding tissues up to the

hernial gates.

 The hernial sack is widely opened distally from organ.

 Hernial content is putted into abdominal cavity.

 Internal purse-string suture is put round the wall of hernial sack

along the line where visceral peritoneum goes from organ to the

hernial sack.

 Distal part of the hernial sack is cut; proximal part together with

mezoperitoneal organ is put into abdominal cavity.

 Plastics of the hernial gates.

 4. Operation of herniotomy. Stages. Features of operations at sliding and congenital hernias, strangulated inguinal and femoral hernias. Complications.

Stages of operation in strangulated hernias

 Anesthesia (local anesthesia, as narcosis leads to relaxation of

muscles and spontaneous reduction of strangulated organ before its

revision).

 Approach to the hernial gates.

 Separation of the hernial sack from surrounding tissues up to the

hernial gates.

 Opening of hernial sack bottom.

 Fixing of hernial contents.

 Section of the incarcerating ring (hernial gate).

 Revision of hernial contents and its viability estimation (color,

pulsation of vessels, peristalsis). Loops of the intestine are covered

by gauze moistened with warm saline for acceleration of

restoration of organ viability. When intestine is normal it is put into

the abdominal cavity, if the loop is not viable – general anesthesia

is given to a patient, lower midline laparotomy and resection is

done within the limits of normal tissues. In case of strangulation of

greater omentum resection is done without estimation of its

viability.

 Separation of hernial sack to the hernial gates.

 Processing of hernial neck and removal of the sack.

 Plastics of hernial gates.

Operation in sliding hernias

Sliding hernia is a hernia in which one wall of hernial sac is formed

by hollow organ covered mezoperitonealy (urinary bladder, cecum).

Sliding hernia is usualy diagnosed during processing of cervics of hernial

sac.

Stages of operation

 Anesthesia.

 Approach to the hernial gates and hernial sack.

 Separation of the hernial sack from surrounding tissues up to the

hernial gates.

 The hernial sack is widely opened distally from organ.

 Hernial content is putted into abdominal cavity.

 Internal purse-string suture is put round the wall of hernial sack

along the line where visceral peritoneum goes from organ to the

hernial sack.

 Distal part of the hernial sack is cut; proximal part together with

mezoperitoneal organ is put into abdominal cavity.

 Plastics of the hernial gates.

Operation in congenital inguinal hernias

Congenital inguinal hernia is formed in case of nonclosure of

processus vaginalis of peritoneum which is sticked out during testicular

descent. In such situation the hernial sac will be presented by processus

vaginalis of peritoneum which communicates with the abdominal cavity

and goes through deep and superficial rings of the inguinal canal

together with testis into scrotum. That is why congenital inguinal

hernias are only oblique.

Main point of operation for congenital inguinal hernia is to close

communication of sac with the abdominal cavity but not to remove it.

Stages of operation

 Anesthesia (narcosis).

 Approach to the hernial sack.

 Separation of the hernial sack from surrounding tissues up to the

hernial gates.

 Opening of the hernial sack neck, revision of hernial sack contents

and putting it into the abdominal cavity.

 Processing of the hernial neck (by internal purse-string suture).

 Section of the hernial sac till bottom, turning its tunic inside out

(serous layer must be from outside), its suturing by interrupted

catgut sutures behind testis and spermatic cord.

 Plastics of the hernial gates.

 5. Ways of plastics of the anterior wall (by Martynov, Girard, Spasocucotsky, suture of Kimbarovski) and posterior wall (by Bassiny, Postempsky) of the inguinal canal. Characteristics

Ways of plastics of the anterior wall of the inguinal canal

Way of Girard

After processing and removal of the hernial sack free edges of

internal oblique and transverse abdominal muscles are sutured to

inguinal ligament in front of spermatic cord. Then medial flap of

aponeurosis of the external oblique muscle is sutured to inguinal

ligament, lateral flap is placed over the medial by interapted sutures. The

end of index finger must pass through new formed superficial ring of the

inguinal canal.

Advantages: creation of strong musculo-aponeurotic layer of the

inguinal canal front wall.

Disadvantages:

 two rows of sutures to inguinal ligament can cause its separation;

 heterogeneity of tissues of the first row of sutures (bad healing).

Way of Spasokukotsky

Medial flap of aponeurosis of the external oblique muscle, free

edges of internal oblique and transverse muscles are sutured to inguinal

ligament in front of spermatic cord. Then lateral flap of aponeurosis of

the external oblique muscle is placed over the medial by interapted

sutures.

Advantages: there is no separation of inguinal ligament.

Disadvantages: heterogeneity of tissues.

Way of Martynov

Medial flap of aponeurosis of external oblique muscle is sutured to

inguinal ligament in front of spermatic cord. Then lateral flap of

aponeurosis of external oblique muscle is placed over the medial by

interapted sutures.

Advantages:

 suturing of similar tissues – dense scar;

 there is no traction of muscles on the inguinal ligament.

Disadvantages: inguinal interval is not changed.

Way of Kimbarovski

Medial flap of aponeurosis of external oblique muscle is taken into

suture 1-1.5 cm from its edge together with lower edges of internal

oblique and transverse muscles by silk filament which then is returned to

the edge of medial flap of aponeurosis and all these structures are moved

to the inguinal ligament. By such measures after making a knot medial

flap of aponeurosis of external oblique muscle goes to inguinal ligament

and covers edges of muscles. Then lateral flap of aponeurosis of the

external oblique muscle is placed over the medial by interapted sutures

creating dublication of aponeurosis.

Advantages:

 connection of similar tissues with formation of dense scar;

 decreasing of inguinal intermal.

Ways of plastics of the inguinal canal posterior wall

Way of Bassiny

After processing and removal of the hernial sack free edges of

internal oblique and transverse abdominal muscles are sutured to

inguinal ligament together with transverse fascia behind from spermatic

cord. By the last suture in medial angle of the wound rectus muscle is

sutured to pubic tubercle and inguinal ligament. Then two flaps of

aponeurosis of external oblique muscle are sutured.

Plastics by Liechtenstein

This way of plastics is done by meshed prosthesis from

polypropylene or teflon.

Plastics with the help of prosthesis PHS

Three-dimensional prosthesis consisting of suprafascial and

subfascial flaps and special connector are used for this way of plastics.

6. Ways of plastics of the femoral canal (by Bassiny, Rudjy, Parlavechcho). Characteristics.

Ways of plastics at femoral hernias

All ways of plastic at femoral hernias can be divided into two

groups:

1. hernioplastics from femoral approach;

2. hernioplastics from inguinal approach.

Way of Bassiny

Herniotomy is done from femoral approach.

After processing and removal of hernial sack plastics of deep ring

of femoral canal is done by suturing of inguinal and pectineal ligaments.

By such way femoral openinng is liquidated. Second row of sutures is

made between semilunar edge of saphenous opening and pectineal

fascia.

Disadvantages: inguinal ligament goes down (it leads to extension

of inguinal interval and increases probability of formation of inguinal

hernias).

Way of Rudjy

Herniotomy and hernioplastics is done from inguinal approach by

section of of anterior and posterior walls.

After hernial sack is moved into preperitoneal fat its processing

and removal is done. Femoral openinng is liquidated by suturing of

inguinal and pectineal ligaments. Inguinal canal is restored by suturing

of edges of transverse fascia and than of two flaps of aponeurosis of the

external oblique muscle.

Disadvantages: the same as at Bassiny’s way.

Way of Parlavechcho

Herniotomy is done like at Rudjy’s way (from inguinal approach).

Hernioplastics: by first row of sutures lower edges of internal oblique

and transverse muscles are moved to pectineal ligament, by second –

these muscles are sutured to inguinal ligament. Than plastics of anterior

wall of inguinal canal is performed by formation of dublication of

sected aponeurosis of external oblique muscle.

Advantages: probability of formation of inguinal hernias is

liquidated.

7. Ways of plastics of hernial gates at umbilical hernias and hernias of white line (Mayo, Sapezhko, Lexer).

Herniotomy at umbilical and white line hernias

Way of Lexer

This way is applied in children at small umbilical hernias.

 Semilunar incision of skin is directed downwards.

 Separation of the hernial sack, opening of its bottom and putting

hernial sackncontents into the abdominal cavity (if bottom of the

hernial sac is fixated to umbilicus by fibrous adhesions –

separation of hernial sack neck, its opening and putting hernial

contents into the abdominal cavity).

 Suturing and ligation of the hernial sack cervix with subsequent

excision of the sack.

 Plastics of the hernial gates (purse-string suture around the

umbilical ring on aponeurosis, its tightening and making a knot).

 3-4 interrupted sutures on the front wall of the rectus sheath over

purse-string suture.

Way of Sapezhko

This way is applied in umbilical and white line hernias.

 Skin section along the median line of the front abdominal wall.

 Separation of skin flaps up to hernial gates to the right and left.

 Separation of the hernial sack.

 Section of the hernial gates with the help of grooved probe

upwards and downwards upon the white line.

 Processing and removal of the hernial sack.

 Suturing of the right flap of aponeurosis to the back wall of left

rectus sheath.

 Suturing of the left flap of aponeurosis to the front wall of the right

rectus sheath (formation of dublication from aponeuroses in

longitudinal direction).

Way of Mayo

 Oval skin and subcutaneus fat section.

 Separation of the skin flap together with the umbilicus.

 Section of the hernial gates in transverse way with the help of

grooved probe.

 Processing and removal of the hernial sack together with the skin

flap.

 Inferior flap of aponeurosis is mooved under the superior flap with

the help of П-shaped sutures.

 superior flap is sutured to inferior flap with the help of interrupted

sutures (formation of dublication from aponeuroses in the

transverse direction).

8. Anatomico-surgical evaluation of operative approaches to organs of the abdominal cavity.

9. Topography of peritoneum. Bursas, ligaments, canals, sinuses, recesses of upper and lower floor of the abdominal cavity. Operative approaches to the cavity of omental bursa, characteristics.

Abdominal cavity is a space which is bounded by parietal

peritoneum.

Peritoneum

1. Parietal peritoneum a serous membrane which covers internal

walls of abdominal cavity.

2. Visceral peritoneum represents a serous membrane which covers

organs of abdominal cavity.

Variants of peritoneal coverage of internal organs:

 intraperitoneal – from all sides;

 mesoperitoneal – from three sides;

 extraperitoneal – from one side.

Features of peritoneum: moisture, smoothness, shine, elasticity,

bactericidal action, adhesion.

Functions of peritoneum: fixation, protection, dischargeness,

absorbation, recepting, deposition (blood).

Course of peritoneum

Peritoneum passes from the front abdominal wall to lower concave

surface of the diaphragm, then – on the upper liver surface (here it forms

two ligaments: in sagittal plane – falciform ligament of liver, in frontal

plane – coronary ligament of the liver). From upper surface peritoneum

goes to lower surface of the liver, then – to lesser curvature of the

stomach and upper part of the duodenum forming lesser omentum.

Covering stomach from all sides, peritoneum from its greater curvature

goes down and turning back comes upwards in front of transverse colon

to the body of pancreas forming the greater omentum. One leaf of

peritoneum at the level of pancreas body goes upwards forming back

wall of the upper abdominal floor, another goes to the transverse colon,

covers it from all sides, comes back forming its mesentery. Then this leaf

goes down, covers the small intestine and sigmoid colon from all sides,

forms its mesentery and descends into the pelvic cavity.

Floors of the abdominal cavity

The abdominal cavity is devided into two floors by the transverse

colon and its mesentery.

 Upper floor is located upper than the transverse colon and its

mesentery. Content: liver, spleen, stomach, bulb of duodenum;

right and left hepatic, subhepatic, pregastric and omental bursae.

 Lower floor is located lower than the transverse colon and its

mesentery. Content: loops of jejunum and ileum; large intestine;

lateral canals, mesenteric sinuses and recesses.

Root of transverse mesocolon goes from right to left from lower

third of right kidney to the middle of the left kidney and crosses on its

way middle of descending part of the duodenum, head and body of the

pancreas.

Bursae of the upper floor of the abdominal cavity

Right hepatic bursa is located between diaphragm and the right

liver lobe. It is bounded from behind by the right coronary ligament,

from the left - by the falciform ligament; from the right and below it

communicates with subhepatic bursa and right lateral canal.

Left hepatic bursa is located between diaphragm and left lobe of

the liver. It is bounded from behind by left coronary ligament, from the

right – by falciform ligament, from the left – by the left triangular

ligament; in front it communicates with pregastric bursa.

Pregastric bursa is located between the stomach and the liver left

lobe. It is bounded in front by the left lobe of the liver and front

abdominal wall, from behind – by the lesser omentum, anterior wall of

the stomach and gastrocolic ligament, from above – by the gates of the

liver; it communicates with subhepatic bursa and lower floor of the

abdominal cavity through the preepiploic space.

Subhepatic bursa is bounded in front and from above by the

lower surface of the right liver lobe, below – by the transverse colon

and its mesocolon, from the left – by gates of the liver; from the right it

goes into the right lateral canal.

Omental bursa is located behind the stomach and communicates

with subhepatic bursa theough epiploic foramen.

Epiploic [Winslow's] foramen is bounded in front by the

hepatoduodenal ligament (proper hepatic artery, common bile duct and

portal vein pass in it), from below – by the duodenorenal ligament,

from behind – by the hepatorenal ligament, from above – by the

caudate lobe of the liver.

Omental bursa is bounded in front by the lesser omentum, posterior

surface of the stomach and gastrocolic ligament, from behind – by the

parietal peritoneum which covers the pancreas, aorta and inferior vena

cava, from above – by the caudate lobe of the liver, from below – by the

transverse mesocolon, from the left – by gastrolienal and lienorenal

ligaments.

Recesses, canals, sinuses of the lower floor of the abdominal

cavity

Canals

Right lateral canal is bounded from the right by the anterolateral

abdominal wall, from the left – by the ascending colon.

Communication: upwards – with the subhepatic and right hepatic bursas,

downwards – with the pelvic cavity.

Right lateral canal is bounded from the left by anterolateral

abdominal wall, from the right – by the descending and sigmoid colon.

Communication: downwards – with the left iliac fossa and pelvic cavity,

upwards – it is limited with the phrenicocolic ligament.

Sinuses

Right mesenteric sinus is bounded from the right by the ascending

colon, from above – by the transverse colon, from the left – by the

mesentery root. Communication: with the left mesenteric sinus over the

duodenojejunal flexura.

Left mesenteric sinus is bounded from the left by the descending

colon, from below – by the sigmoid colon, from the right – by the

mesentery root. Communication: with left mesenteric sinus over the

duodenojejunal flexura and with pelvic cavity (the sigmoid colon

partialy takes part in formation of the lower border of the sinus).

Recesses

Superior duodenojejunal recess is located over the

duodenojejunal fold.

Inferior duodenojejunal recess is located below the

duodenojejunal fold.

Superior ileocecal recess is located between the mesentery,

ascending colon and ileocolic fold.

Inferior ileocecal recess is located between the mesentery, cecum

and ileocecal fold.

Retrocecal recess is located behind the cecum if it is covered

intraperitonealy.

Intersigmoidal recess is located at thу site of attachment of the

sigmoid colon mesentery.

10. Topographic anatomy of organs of the abdominal cavity (stomach, duodenum, liver, spleen, pancreas, small and large intestine).

Topographic anatomy of the stomach

Holotopy: left hypohondrium, proper epigastric region.

Skeletotopy:

 cardia – 2.5 cm to the left from the edge of breast bone at the level

of VII left rib (Th11);

 fundus – at the level of V rib on left medial clavicular line (Th9-

 pylorus – at the level of VIII right rib on median anterior line (L1).

Syntopy: from above the diaphragm and left lobe of the liver is

located, from behind and from the left there are pancreas, left kidney,

epinephros and spleen, in front the abdominal wall is located, from

below there are transverse colon and transverse mesocolon.

Ligaments:

Hepatogastric ligament is located between the liver gates and

lesser curvature of the stomach; it contains left and right gastric arteries,

veins, branches of vagus nerves, lymph vessels and nodes.

Gastrophrenic ligament is located between diaphragm and fundus

and cardia of the stomach; contains branch of the left gastric artery.

Gastrolienal ligament is located between the spleen and greater

curvature of the stomach; contains short gastric arteries and veins.

Gastrocolic ligament is located between greater curvature of the

stomach and transverse colon; contains right and left gastroepiploic

arteries.

Gastropancreatic ligament is located between upper edge of

pancreas and back wall of the body, cardia and fundus of the stomach,

contains left gastric artery.

Blood supply occurs from the celiac trunk.

 Left gastric artery is divided into ascending (esophageal) and

descending branches. The last goes along the lesser curvature and

gives anterior and posterior branches.

 Right gastric artery begins from the proper hepatic artery in

hepatoduodenal ligament. Together with the left gastric artery it

forms arterial arch along the lesser curvature.

 Left gastroepiploic artery is a branch of the splenic artery. It goes

along the greater curvature and is located in gastrolienal and

gastrocolic ligaments.

 Right gastroepiploic artery is a branch of the gastroduodenal

artery. Together with the left gastroepiploic artery it forms

arterial arch along greater curvature.

 Short gastric arteries (2-7) begin from the splenic artery, pass in

the gastrolienal ligament and supply fundus of stomach.

Veins of the stomach correspond to arteries and go into the portal

vein.

Lymphatic outflow

Lymphatic vessels from the stomach go into the first order lymph

nodes which are located in the lesser omentum, along greater curvature,

at gates of the spleen and liver, along body and tail of the pancreas,

behind pylorus of the stomach. From these nodes lymph goes into the

second order lymphatic nodes which are located near the celiac trunk.

The third order of the lymph nodes is the lumbar nodes.

Innervation

Sympathetic inervation occurs from celiac plexus branches of

which go to the stomach along extraorganic and intraorganic arteries.

Parasympathetic innervation is from right and left vagus nerves which

below diaphragm form anterior and posterior trunks. They pass along

the lesser curvature and give branches to the stomach, liver, spleen,

celiac plexus. Terminal branches of the anterior and posterior trunks of

vagus nerves are called Latargee nerves which supply anhepatic biliary

tracts and pylorus of the stomach.

Topographic anatomy of the duodenum

Holotopy: proper epigastric and umbilical regions.

Four parts are distinguished in the duodenum: upper, descendent,

horizontal and ascendant part.

Upper part (bulb of duodenum) is located between pylorus of the

stomach and superior flexure of the duodenum.

Peritoneal coverage: mesoperitoneal.

Skeletotopy – L1.

Syntopy: from above there is the gallbladder, from below the head

of pancreas is situated, in the front there is the antral part of the

stomach.

Descendent part of the duodenum is located between superior

and inferior flexures of the duodenum. Common bile duct and

pancreatic duct open in this part on major duodenal papilla. Slightly

above from the major duodenal papilla the small duodenal papilla can be

located where additional pancreatic duct opens.

Peritoneal coverage: retroperitoneal.

Skeletotopy – L1-L3.

Syntopy: from the left – head of pancreas, from behind and from

the right – right kidney, right renal vein, inferior vena cava and ureter,

in front – transverse mesocolon and loops of small intestine.

Horizontal part of duodenum is located from inferior flexure to

crossing of duodenum with superior mesenteric vessels.

Peritoneal coverage: retroperitoneal.

Skeletotopy – L3.

Syntopy: from above there is the head of pancreas, from behind

the inferior vena and abdominal aorta are located; in the front and

below there are loops of small intestine.

Ascendent part of the duodenum is located at the site of crossing

with superior mesenteric vessels to duodenojejunal flexure where it is

fixated by suspensory ligament of the duodenum.

Peritoneal coverage: retroperitoneal.

Skeletotopy – L3-L2.

Syntopy: from above there is the lower surface of the body of

pancreas, from behind the inferior vena and abdominal aorta are

located, in the front and below there are loops of the small intestine.

Ligaments

Hepatoduodenal ligament is located between the liver gates and

initial part of the duodenum. It contains proper hepatic artery (from the

left), common bile duct (from the right) and portal vein (in center of

ligament).

Hepatorenal ligament is located between external edge of the

descendal part of the duodenum and right kidney.

Blood supply is carried out from the celiac trunk and superior

mesenteric artery.

Anterior and posterior branches of the superior

pancreatoduodenal arteries come from the gastroduodenal artery.

Anterior and posterior branches of the inferior

pancreatoduodenal arteries come from the superior mesenteric artery.

Veins of the duodenum correspond to arteries and go into the

portal vein.

Lymphatic outflow

Lymphatic vessels go into first order lymph nodes – superior and

inferior pancreatoduodenal nodes.

Innervation occurs by celiac, superior mesenteric, hepatic and

pancreatic nerve plexus and branches of vagus nerves.

Topographic anatomy of the liver

Holotopy: right hypohondrium, proper epigastric region and

partially left hypohondrium.

Skeletotopy:

 upper border: upon left medial clavicular line there is V

intercostal space; upon right parasternal line there is V costal

cartilage; upon right medial clavicular line there is IV intercostal

space; upon right medial axillary line there is VIII rib; upon

prevertebral line there is XI rib.

 lower border: upon right medial axillary line there is X

intercostal space; upon median anterior line there is the middle

of the distance between the umbilicus and base of the xiphoid

process; and crosses the costal margin at the level of VI costal

cartilage.

Peritoneal coverage: mesoperitoneal organ (gates and back

surface are not covered by peritoneum).

Syntopy: from above there is the diaphragm; in front there is the

front abdominal wall and diaphragm; from behind there is X and IX

thoracic vertebras, crura of the diaphragm, esophagus, aorta, right

epinephros, inferior vena cava; from below the stomach, bulb and upper

quarter of descending part of duodenum, right flexure of colon, upper

pole of the right kidney, gallbladder.

Structure

The liver has two surfaces: upper (diaphragmatic) and lower

(visceral), and two edges. Lower edge is sharp with two incisures: the

gallbladder and round ligament impressions. Posterior edge is curved

and inverted to the back abdominal wall. Diaphragmatic surface is

convex and smooth, visceral is rough, with two longitudinal and one

transverse grooves (impressions from underlying organs). Transverse

groove corresponds to the liver gate. Right longitudinal groove is the

gallbladder and inferior vena cava impressions. Left longitudinal groove

is a deep fissure separating lobes of the liver. Round ligament of the

liver is located here. The liver consists of right and left lobes bounded

by falciform ligament on the diaphragmatic surface. Besides quadrate

(between anterior parts of longitudinal grooves) and caudate (between

posterior parts of longitudinal grooves) lobes are distinguished there.

These lobes are separated from each other by transverse groove. 5

sectors and 8 most constant segments are also distinguished in the liver.

Lobe, sector, segment are parts of the liver with their own blood supply,

innervation, bilious and lymphatic outflow.

Ligaments

Coronary ligament fixes the liver to the lower surface of the

diaphragm in the frontal plane. It passes into right and left triangular

ligaments near the right and left edges of the liver.

Falciform ligament is located in the sagital plane between the

diaphragm and upper surface of the liver on the border by its right and

left lobes.

Round ligament is located between the umbilicus and gate of the

liver in free edge of the falciform ligament. It represents partially

obliterated umbilical vein.

Hepatoduodenal, hepatogastric and hepatorenal ligaments go

from visceral surface of the liver to corresponding organs.

Blood supply

Features of liver blood supply: blood inflow by the proper

hepatic artery and portal vein.

The proper hepatic artery is a branch of common hepatic artery,

originated from the celiac trunk. It passes from the left side of the

common bile duct to the liver gate between sheats of hepatoduodenal

ligament and is divided into right and left branches. Right hepatic

artery supplies right lobe of the liver and gives cystic branch to the

gallbladder. Left hepatic artery supplies left lobe of the liver.

Through the portal vein blood passes to the liver from all

unpaired organs of the abdominal cavity. It is formed by confluence of

the superior mesenteric and splenic veins behind the head of the

pancreas. Portal vein is the only vein, which has both inflows and

branches.

The umbilical vein is located in round ligament of the liver and

runs into the left trunk of the portal vein. Near the umbilical ring it is

obliterated.

Paraumbilical veins are located in round ligament of the liver.

They flow into the portal vein and carry out blood from the anterior

abdominal wall.

Blood outflow from the liver goes into hepatic veins, which flow

into inferior vena cava.

Innervation

Nerve branches starting from celiac plexus, vagus and right

phrenic nerves take part in innervation of the liver. They form anterior

and posterior hepatic plexuses nearby the liver gate.

Lymphatic outflow goes to the lymph nodes located near the liver

gate, right and left gastric, celiac, preaortic, inferior phrenic and

lumbar nodes.

Topographic anatomy of the pancreas

The pancreas is an organ with excretory [exocrine] and incretory

[endocrine] functions. Head, body and tail are distinguished in it.

Sometimes uncinate process passes from lower edge of head of the

pancreas.

 Head is surrounded from all sides by the duodenum. It has:

 anterior surface (antral part of the stomach adjoins it upper

than the transverse mesocolon, loops of small intestine – lower

than the transverse mesocolon);

 posterior surface (right renal vessels, the common bile duct and

inferior vena cava adjoin it);

 superior and inferior edges.

 Body has:

 anterior surface (posterior wall of the stomach adjoins it);

 posterior surface (the aorta, splenic and superior mesenteric

veins adjoin it);

 inferior surface (the duodenojejunal flexure adjoins it);

 superior, inferior and anterior edges.

 Tail has:

 anterior surface (fundus of the stomach adjoins it);

 posterior surface (the left kidney and its vessels, left

epinephros adjoin it).

The pancreatic duct passes through the gland from tail to head,

together with the common bile duct or separately from it opens in the

descending part of the duodenum on the major duodenal papilla.

Sometimes accessory pancreatic [Santorini's] duct opens on minor

duodenal papilla located approximately 2 cm above from the large one.

Ligaments:

 gastropancreatic – from the superior edge of the gland to posterior

surface of the body, cardia and gastric fundus (left gastric artery

passes upon its edge);

 pyloropancreatic – from superior edge of the gland to antral part

of the stomach.

Holotopy: Proper epigastric region, left hypochondrium.

Projection is upon horizontal line through the middle point between the

xiphoid process and umbilicus.

Skeletotopy: head – L1, body – Тh12, tail – Тh11.

Peritoneal coverage: retroperitoneal organ.

Blood supply occurs from basins of the common hepatic, splenic

and superior mesenteric arteries.

Head is supplied by the superior (from gastroduodenal) and

inferior (from superior mesenteric) pancreatoduodenal arteries.

Body and tail are supplied from the splenic artery, by its 2-9

pancreatic branches.

Venous outflow occurs through the pancreatoduodenal and

splenic veins into the portal vein.

Innervation: celiac, superior mesenteric, splenic, hepatic and left

renal plexuses.

Lymphatic outflow: lymph nodes of the first order are superior

and inferior pancreatoduodenal, superior and inferior pancreatic,

splenic, retropyloric nodes; lymph nodes of the second order are celiac

nodes.

Topographic anatomy of the spleen

The spleen is unpaired lymphoid organ. Diaphragmatic and

visceral surfaces, upper and lower poles, gates are distinguished in it.

Ligaments:

 gastrolienal – from greater curvature of the stomach to splenic

gates (contains left левые gastroepiploic vessels and short gastric

arteries and veins);

 splenorenal – from lumbar part of the diaphragm and left kidney

to the splenic gate (contains splenic vessels).

Holotopy: left hypohondrium.

Skeletotopy: between IX and XI ribs from paravertebral to middle

axillary line.

Peritoneal coverage: intraperitoneal organ.

Blood supply occurs through the splenic artery which comes from

the celiac trunk. Splenic vein has a twice large diameter than the artery

and is located below it.

Innervation occurs through celiac, left diaphragmatic and

suprarenal plexuses branches of which form the splenic plexus around

the same artery.

Lymphatic outflow: lymph nodes of the first order are nodes in

the splenic gate; lymph nodes of the second order are the celiac nodes.

Topographic anatomy of the small intestine

Parts of the small intestine

 duodenum – see above;

 jejunum;

 ileum.

Localization: meso- and hypogastrium.

Peritoneal coverage: intraperitonealy.

Skeletotopy: Root of mesentery goes from the second lumbar

vertebra to the right sacroiliac joint and crosses horizontal part of the

duodenum, aorta, inferior vena cava and right ureter.

Syntopy: in the front there is the greater omentum, from the right

there is the ascending colon, from the left the descending and sigmoid

colon are situated, the parietal peritoneum is behind while the urinary

bladder, rectum, uterus and its appendages are located from below.

In 1.5-2% of cases a Meckel's diverticulum can be located (residual

umbilical [vitelline] duct) on the opposite side of the mesentery of the

ileum at a distance of 1 m from the ileocecal angle. The diverticulum

can inflame and require surgical operation.

Blood supply occurs through the jejunal and iliac arteries (12-20)

which are located in the mesentery (from superior mesenteric artery).

Venous outflow goes into the portal vein through the superior mesenteric

vein.

Features of the blood supply:

 arcade type. Branches of jejunal and iliac arteries dichotomicaly

are divided and form arterial arches (up to 5 order);

 segmental type – i.e. functionally unsufficient intraorganal

anastomoses between straight branches (go from the terminal

vessel which is formed by distally located arterial arches) which

go into the wall of the small intestine;

 There is 2 intestinal arteries per 1 vein.

Lymphatic outflow

Lymph nodes of the first order are located along the mesenteric

edge of the small intestine, at the level of intermediate arcades and along

the basic branches of the superior mesenteric artery. Lymph nodes of the

second order are located along the superior mesenteric vessels behind

the head of pancreas. Lymph nodes of the third order are paraaortic

nodes. Efferent lymphatic vessels form the intestinal trunks which flow

into the thoracic duct.

Innervation occurs by the superior mesenteric plexus.

Topographic anatomy of the large intestine

External features of the large intesine structure which distinguish it

from the small intestine during operations are:

 longitudinal muscle layer in form of three longitudinal tenias that

start from the base of the appendix and ends at the beginging of the

rectum;

 haustrae are dilatations of the large intestine which are formed due

to the fact that longitudinal muscular tenias are shorter than the

colon length and bounded by circular muscle fibers;

 epiploic appendices are not expressed on cecum, on the transverse

colon they are located in one row and are most evident on the

sigmoid colon;

 color is gray-blue (the small intestine is pink);

 larger diameter.

Cecum

Holotopy: right iliac fossa.

Peritoneal coverage: intraperitonealy.

Syntopy: in the front there is the front abdominal wall, from the

right the right lateral canal is situated, from the left there are the loops

of the ileum, from behind the right ureter and iliopsoas muscle are

situated.

Ileocecal angle is a site of transition of the small intestine into the

large intestine. It includes cecum, vermiform appendix and ileocecal

joint with ileocecal [ileocolic, Bauhin's] valve.

Vermiform appendix

Position of the appendix apex:

 descending apex of the appendix is directed downwards and to

the left, reaching the terminal line and sometimes going into the

small pelvis (most common variant of position);

 medial apex goes along terminal part of the ileum;

 lateral apex is situated in the right lateral canal;

 ascending apex passes along the anterior wall of the cecum;

 retrocecal and retroperitoneal apices are located in the

retroperitoneal space.

Depending on the position appendix can be located near the right

kidney, right ureter, urinary bladder and rectum. In women it can go up

to the right ovary, right tube and uterus.

Position (projection) of the appendix base:

 Mc Burney’s point is a point on the border between external and

middle parts of the right spinoumbilical line;

 Lance’s point is a point on the border between right external and

middle parts of the bispinal line.

The Ascending colon is located between the ileocecal angle and

right flexure of the colon.

Holotopy: right lateral region.

Peritoneal coverage: mesoperitonealy (posterior wall is covered

by retrocolic fascia).

Syntopy: from the right there is right lateral canal, from the left

there is right mesenteric sinus, from behind the iliopsoas muscle is

located as well as lumbar quadrate muscle, paracolic fat, lower part of

right kidney, right ureter.

Right flexure of the colon is located in the right hypohondrium

between the lower surface of the liver right lobe, bottom of the

gallbladder, lower pole of the right kidney and is covered intra- or

mesoperitonealy.

The transverse colon is located between right and left flexures of

the colon.

Holotopy: umbilical region.

Peritoneal coverage: intraperitonealy.

Syntopy: in the front the right lobe of the liver is situated, from

above there is a greater curvature of the stomach, from below the loops

of small intestine are located, from behind there are descending part of

the duodenum, head and body of the pancreas, left kidney.

Left flexure of the colon is located in the left hypohondrium and

covers the left kidney. The most constant ligament is the left

phrenicocolic ligament which is well defined and separates the left

lateral canal from the pregastric bursa.

The descending colon

Holotopy: left lateral region.

Peritoneal coverage: mesoperitonealy (posterior wall is covered

by the retrocolic fascia).

Syntopy: from the right there is the left mesenteric sinus, from the

left there is left lateral canal, from behind there are: iliopsoas muscle,

lumbar quadrate muscle, paracolic fat, lower part of the left kidney, left

ureter.

The sigmoid colon

Holotopy: left inguinal and partialy pubic regions.

Peritoneal coverage: intraperitoneally.

Blood supply is implemented via superior and inferior mesenteric

arteries.

Branches of the superior mesenteric artery:

 iliocolic artery gives branches to the terminal part of the ileum,

vermiform appendix, anterior and posterior cecal arteries and

ascending artery which supplies initial part of the ascending

colon;

 right colic artery is divided into descending and ascending

branches which supply the ascending colon and anastomose with

the ascending branch of the iliocolic artery and right branch of

the medial colic artery respectively;

 medial colic artery is divided into right and left branches which

supply the transverse colon and anastomose with right and left

colic arteries respectively. Anastomosis between left branch of

the medial colic artery and left colic artery combines basins of

superior and inferior colic arteries and is called Riolan's arcade.

Branches of the inferior mesenteric artery:

 the left colic artery is divided into ascending branch which supplies

the upper part of the descending colon (takes part in formation of

Riolan's arcade) and descending branch which supplies lower part

of descending colon (anastomoses with first sigmoid artery);

 sigmoid arteries (2-4) anastomoses between each other (usually

there is only one extraorganal anastomosis between the last

sigmoid artery and the superior rectal artery);

 superior rectal artery supplies the lower part of the sigmoid colon

and the upper part of the rectum. Extraorganal anastomosis

between last sigmoid artery and the superior rectal artery is called

critical Zudeck point, as ligation of the superior rectal artery above

this point in case of resection of the rectum can cause ischemia and

necrosis of the lower part of the sigmoid colon (ligation of

superior rectal artery is done below this point).

Features of blood supply. There are “critical points” in the region

of the ileocecal angle, in the region of the right flexure of the colon, in

the region of the left flexure of the colon. These parts of the large

intestine are usually resected during the colon resection due to

insufficient blood supply and lack of intraorganic anastomoses.

Venous outflow from the large intestine goes upon veins that

accompany the same arteries into the superior and inferior mesenteric

veins. In the region of formation of the superior rectal vein its branches

anastomose with branches of the medial rectal veins and form

portocaval anastomosis.

Lymphatic outflow goes into lymph nodes of the first order which

are located along the mesenteric edge of the intestine or behind its

posterior wall if it is covered mesoperitoneally. Lymph nodes of the

second order are located along the branches of superior and inferior

mesenteric arteries. Lymph nodes of the third order are paraaortic and

are located nearby the inferior vena cava.

Innervation

Sympathetic innervation occurs by superior and inferior

mesenteric, paraaortic, superior and inferior hypogastric plexuses.

Parasympathetic occurs by vagus nerves and pelvic splanchnic nerves.

 11. Revision of organs at closed and penetrating wounds of the abdominal cavity.

12. Classification of intestinal sutures. Requirements. Kinds, technique and characteristics of intestinal anastomoses.

Intestinal suture

Requirements:

1. Hermecity is achived by contact of serous layers of sutured parts

of the intestine.

2. Hemostaticity is achived by taking into suture of the submucosal

layer of a pathologic organ.

3. Layer-to-layer.

4. Strength is achived by taking into suture of submucosal layer

where great amount of elastic fibres are located.

5. Asepticity (cleanness). The mucous layer is not taken into suture

(«clean» single-layer suture or invaginating of «dirty» (infected)

suture by «clean» seromuscular suture).

Four main layers are distinguished in the hollow organs of the

abdominal cavity: mucous, submucosal, muscular and serous layers.

The serous layer has well expressed plastic properties (in 12-14

hours adhesions beging to forme between serous layers after making

sutures, after 24-48 hours – they are well expressed). Thus taking into

suture of serous layer makes intestinal suture hermetic. Frequency of

these sutures must be at least 4 per 1 cm of the length of the sutured area.

Taking into suture of the muscular layer gives them elastic features.

Submucosal layer provides mechanical strength of intestinal suture and

good vascularization of the sutured area. Mucous layer does not have

mechanical strength. Suturing of this layer provides good adaptation of

wound’s edges and protects line of sutures from infection.

Classification of intestinal sutures

1. According to the technique:

 manual;

 mechanical – is made with the help special apparatus;

 glue.

2. According to sutured layers:

 sero-serous;

 sero-muscular;

 muco-submucosal;

 sero-musculo-submucosal;

 sero-musculo-submuco-mucous («dirty»).

«Dirty» sutures are infected. Sutures wich don’t touch mucous

layer are called not infected («clean»).

3. According to rows of sutures:

 single-layer (Bir-Pirogov’s, Mateshuk’s) suture passes

through the edges of serous, muscular and submucosal

layers (without touching of mucous layer) and provides

good adaptation for layers and invagination of mucous

membrane inside intestinal lumen without its additional

traumatization;

 double-layer (Albert's) suture is a first layer suture (a

«dirty» one), which is invaginated into sero-muscular

suture;

 three-layer suture is a first layer suture (a «dirty» one)

which is invaginated into two sero-muscular sutures (on the

large intestine for better hermitization of the intestinal

content).

4. According to the way of suturing:

 interrupted;

 uninterrupted.

Technique and characteristics of intestinal anastomoses

Depending on how we connect efferent and afferent parts of the

intestine following types of anastomoses are distinguished:

 End-to-end [terminoterminal] anastomosis. The end of afferent

loop is sutured to the end of efferent one.

Technique:

 formation of the posterior wall: uninterrupted blanket

(Multanovski) suture is put on the internal lip of

anastomosis;

 formation of the anterior wall: uninterrupted Schmieden

suture is put on the external lip of anastomosis by the same

filament;

 invagination of both uninterrupted sutures into the lumen of

anastomosis by interrupted sero-muscular Lambert sutures.

Characteristics:

 physiological – natural passage of food is not changed;

 economical on use of tissues – “blind” ends are not formed as

in side-to-side anastomosis;

 leads to constriction – putting of intestinal forceps and

section of the intestine is done at the angle of 45° to

mesenteric edge of the intestine for prevention of this

complication;

 difficult to perform – sutures can tear tissues in pars nuda

(mesenteric edge of intestine not covered by peritoneum)

what can lead to not leak-proof anastomosis;

 this method can connect only identical diameters of the

intestine (small intestine with small).

 Side-to-side anastomosis. Lateral surfaces of afferent and efferent

loops of intestine are connected.

Technique:

 suturing of proximal and distal ends of the intestine;

 isoperistaltic approximation and connection of afferent and

efferent loops by the interrupted sero-muscular Lambert

sutures within 6-8 cm;

 opening of the intestinal lumen, not reaching 1 cm to the

ends of line of sero-muscular sutures;

 suturing of internal lip of formed opening by the

uninterrupted blanket (Multanovski) suture;

 suturing of the external lip of the formed opening by

uninterrupted Schmieden suture with the same filament;

 invagination of Schmieden suture into the lumen of

anastomosis by interrupted sero-muscular Lambert sutures.

Characteristics:

 there is no constriction on suture line;

 easy to perform – pars nuda is out of place of anastomosis;

 not identical diameters of the intestine can be connected

(small intestine with large);

 not economical on use of tissues: “blind” ends are formed

where intestinal contents can be accumulated (lead to

ulceration of stump of anastomosis);

 not physiological: intestinal contents don’t pass through

“blind” of anastomosis (natural passage of food is changed).

 End-to-side anastomosis – end of afferent loop is connected with

lateral surface of efferent loop. This kind of anastomosis is

usually used for connection of parts of intestine with not identical

diameters (small intestine with large). Technique of operation is

as same as in side-to-side anastomosis.

13. Resection of small intestine and different parts of large intestine. Indications, technique and features of resection. Concept about hemicolectomy.

Resection of the small intestine

Indications: extensive injuries, gangrene due to incarceration or

thrombosis of the mesenteric vessels, tumors, perforated ulcers.

Stages

1. Mobilization is ligation of vessels and section of the removed

segment mesentery. Depending on the method of mobilization

there are direct (ligation of the straight vessels when a small part is

removed) and wedge-shaped (ligation of the arcade vessels when a

large part is removed) resection of the small intestine.

2. Resection. Elastic and crushing intestinal forceps are put from

both sides of the supposed part of resection (crushing forceps –

closer to the removed part, elastic forceps – lateraly to the

crushing) and section of the small intestine is done between them.

Main rules of resection:

 within the limits of healthy tissue – in case of injuries,

gangrene resection is done 7-10 cm apart from the removed

segment in proximal and distal directions (in case of cancer

this distance is considerably longer);

 take into account the blood supply; stumps of the intestine

must be well supplied with blood;

 resection is done within the limits of the intestine which are

covered intraperitonealy (this rule is applied only to resection

of the large intestine as small intestine is covered by

peritoneum from all sides).

3. Formation of intestinal anastomosis, palpation of anastomosis on

lumen patency, suturing of mesentery.

Depending on how we connect efferent and afferent parts of the

intestine following types of anastomoses are distinguished:

 End-to-end [terminoterminal] anastomosis. The end of afferent

loop is sutured to the end of efferent one.

Technique:

 formation of the posterior wall: uninterrupted blanket

(Multanovski) suture is put on the internal lip of

anastomosis;

 formation of the anterior wall: uninterrupted Schmieden

suture is put on the external lip of anastomosis by the same

filament;

 invagination of both uninterrupted sutures into the lumen of

anastomosis by interrupted sero-muscular Lambert sutures.

Characteristics:

 physiological – natural passage of food is not changed;

 economical on use of tissues – “blind” ends are not formed as

in side-to-side anastomosis;

 leads to constriction – putting of intestinal forceps and

section of the intestine is done at the angle of 45° to

mesenteric edge of the intestine for prevention of this

complication;

 difficult to perform – sutures can tear tissues in pars nuda

(mesenteric edge of intestine not covered by peritoneum)

what can lead to not leak-proof anastomosis;

 this method can connect only identical diameters of the

intestine (small intestine with small).

 Side-to-side anastomosis. Lateral surfaces of afferent and efferent

loops of intestine are connected.

Technique:

 suturing of proximal and distal ends of the intestine;

 isoperistaltic approximation and connection of afferent and

efferent loops by the interrupted sero-muscular Lambert

sutures within 6-8 cm;

 opening of the intestinal lumen, not reaching 1 cm to the

ends of line of sero-muscular sutures;

 suturing of internal lip of formed opening by the

uninterrupted blanket (Multanovski) suture;

 suturing of the external lip of the formed opening by

uninterrupted Schmieden suture with the same filament;

 invagination of Schmieden suture into the lumen of

anastomosis by interrupted sero-muscular Lambert sutures.

Characteristics:

 there is no constriction on suture line;

 easy to perform – pars nuda is out of place of anastomosis;

 not identical diameters of the intestine can be connected

(small intestine with large);

 not economical on use of tissues: “blind” ends are formed

where intestinal contents can be accumulated (lead to

ulceration of stump of anastomosis);

 not physiological: intestinal contents don’t pass through

“blind” of anastomosis (natural passage of food is changed).

 End-to-side anastomosis – end of afferent loop is connected with

lateral surface of efferent loop. This kind of anastomosis is

usually used for connection of parts of intestine with not identical

diameters (small intestine with large). Technique of operation is

as same as in side-to-side anastomosis.

Resection of large intestine

General rules for resection of large intestine:

 mechanical cleaning of the large intestine lumen before surgical

operation;

 resection is performed only in certain areas of the large intestine

which are covered from all sides by the peritoneum;

 removal of all parts of the intestine with impaired blood

circulation;

 in case of tumors the large intestine should be removed together

with the mesentery, lymph nodes and vessels;

 after resection reestablishment of digestive tract continuity is

done with the help of anastomosis with three-layer suture.

Kinds of resection of large intestine according to localization of

pathological process:

 Right hemicolectomy is removal of terminal 10-15 cm of the ileum,

cecum, ascending, right flexure and right 1/3 of transverse colon

and performing side-to-side or end-to-side ileotransverse

anastomosis.

Indications: malignant tumors in right part of the large intestine

(cecum, ascending colon or right flexure of colon) and perforating

wounds of the ascending colon.

 Resection of the transverse colon is removal of part of the

transverse colon and performing end-to-end

transversotransversoanastomosis.

Indications: tumor or wounds of the transverse colon.

 Left hemicolectomy is removal of the left 1/3 of the transverse

colon, left flexure, descending and 1/3 of the sigmoid colon and

performing end-to-end transversosigmoanastomosis.

Indications: tumors and perforating wounds in the left flexure and

descending colon, complicated nonspecific ulcerative colitis.

 Resection of the simoid colon is removal of part of the sigmoid

colon and performing end-to-end sigmosigmoanastomosis.

Indications: tumor or extensive wounds of the sigmoid colon,

megasigmoid.

 Marginal resection of the ascending (descending) colon with 3/4

anastomosis – wedge-shaped excision of the damaged part of the

anterior wall within limits of healthy tissue at an angle of 450

(removal of 1/4 part) and putting three-layer suture between

remaining ¾ part of the intestinal wall.

Indications: extensive wounds of the anterior wall of the

ascending and descending colon (which is covered by

peritoneum).

14. Operation of gastrostomy, enterostomy, colostomy. Indications, kinds, characteristics. Concept about anus praeternaturalis.

Palliative operations on the stomach

Gastrostomy is putting of artificial gastric fistula.

Indication: for nutrition in case of wounds, fistulas, burns and

scarry strictures of esophagus, inoperable tumors of pharynx, esophagus

and cardia of the stomach.

Classification

 Tubular fistula (by Vitsel, Cader) is a temporary one, inner wall

of which is a serous layer of the stomach. After removal of a

rubber tube self closure of the stoma is observed as between

serous layers adhesions are formed.

 Lip-shaped fistula (by Toprover) is a constant one, inner wall of

which is mucous layer of the stomach. After removal of a rubber

tube fistula is not closed by itself – resection and putting of

intestinal sutures is done for this purpose.

Gastrostomy by Vitsel:

 left transrectal laparotomy from costal arch is 10-12 cm long;

 putting of a rubber tube on the anterior wall of the stomach one

the end of which is directed to the pylorus;

 invagition of a tube into seroserous canal of the anterior stomach

wall which is formed by putting of 6-8 interrupted sutures over

this tube;

 putting of purse-string suture on the pylorus, opening of the

stomach wall inside of it, insertion of a tube into lumen of the

stomach;

 making a knot of purse-string suture and putting 2-3 seromuscular

interrupted sutures over it;

 taking out of the other end of a tube through separate incision upon

external edge of the left rectus muscle;

 fixation of the stomach wall to parietal peritoneum by several

seromuscular sutures.

Gastrostomy by Cader:

 transrectal laparotomy;

 putting of three purse-string sutures nearby cardia at a distance of

1.5-2 cm from each other;

 opening of the stomach wall inside of internal purse-string suture

and insertion of a tube into lumen of the stomach;

 sequential tightening of purse-string sutures, starting from internal

one;

 taking out of other end of tube through an additional incision;

 gastropexy.

This kind of gastrostomy is made in children or in case of large

tumors of the stomach when there is not enough place on a gastric wall

to perform gastrostomy by Vitsel.

Lip-shaped gastrostomy by Toprover:

 transrectal laparotomy;

 putting of three purse-string sutures nearby cardia at a distance of

1.5-2 cm from each other;

 opening of the stomach wall inside of internal purse-string suture

and insertion of a tube into lumen of the stomach;

 sequential tightening of purse-string sutures, starting from the

external one (corrugated cylinder from the gastric wall is formed in

such a way that its inner wall represents the mucous layer);

 suturing of the gastric wall at the level of internal purse-string

suture to parietal peritoneum, at the level of the middle one – to

rectus sheath, at the level of external – to the skin;

 after operation the tube is removed and inserted again only at the

time of feeding.

Enterostomy

Indications:

 for nutrition – jejunostomy in obstruction of upper part of the

digestive tract (tumors, chemical burn of stomach);

 for intestinal contents diversion – ileostomy in obstruction of

distal part of the digestive tract.

Classification:

1. tubular fistula (by Vitsel) – inner wall of which is serous

layer of the intestine (after removal of rubber tube self

closure of stoma is observed);

2. lip-shaped fistula (by Maydel) is formed due to

connection of mucous layer of intestine with skin, i.e.

inner wall is mucous layer of intestine (resection and

putting of intestinal sutures is done for closing of this

fistula).

Colostomy

Contents of the large intestine in case of colostomy moves in two

directions: outside through the stoma and in natural way in distal

direction. It is made at any flexible part of the large intestine

(cecostomy, transversostomy, sigmostomy). As enterostomy fistulas of

the large intestine can be tubular (for cecum) and lip-shaped (for

transverse and sigmoid colon).

Indications: for intestinal contents diversion, when it is impossible

to perform anastomosis after resection (operable tumors, wounds etc.).

Technique of sigmostomy:

 layer-by-layer opening of the front abdominal wall by oblique

alternating incision in the left inguinal region;

 suturing of the parietal peritoneum to edges of the skin (to

prevent infection of subcutaneous fat);

 connection of the serous layer of the sigmoid colon with parietal

peritoneum around the the wound by interrupted sutures (to

prevent infection of the abdominal cavity);

 opening of the lumen after formation of adhesions between

visceral and parietal peritoneum (in 3-4 days);

 suturing of the mucous layer to the skin.

Performing anus praeternaturalis

After anus praeternaturalis formation intestinal contents pass only

in one direction – outside through stoma.

Indications: tumors, wounds, strictures, fistulas, malformations of

rectum.

Classification: temporary and permanent, end [terminal]

(Hartman’s operation) and double-loop (Maydel’s operation).

Technique of formation of double-loop anus praeternaturalis:

 layer-by-layer opening of the front abdominal wall by oblique

alternating incision in the left inguinal region;

 making a hole in the mesentery and putting a rubber tube into it;

 connection of the afferent and efferent loops under the tube by 3-

4 interrupted seromuscular sutures («spur» formation);

 suturing of the parietal peritoneum to edges of the skin;

 connection of the serous layer of the intestine with parietal

peritoneum around the wound by interrupted sutures;

 opening of the lumen («spur» eliminates possibility of getting

intestinal contents into efferent loop).

 15. Gastroenterostomy. Indications, kinds, characteristics. Concept about vicious circle.

Gastroenterostomy (anastomosis between the stomach and small

intestine) is done in case of disturbance of luminal patency of pylorus

(inoperable tumors, cicatrical stenosis etc.) to create additional way for

removal of gastric content into the jejunum. Depending on the position

of the intestinal loop in relation to the stomach and transverse colon

there are such kinds of gastroenterostomy:

1. anterior in front of transverse colon – a loop of the jejunum

is moved to anterior wall of the stomach in front of the

transverse colon;

2. posterior in front of transverse colon – a loop of the jejunum

is moved to posterior wall of the stomach in front of the

transverse colon;

3. anterior behind transverse colon – a loop of the jejunum is

moved to the anterior wall of the stomach behind the

transverse colon throuh incision in the mesocolon;

4. posterior behind transverse colon – a loop of the jejunum is

moved to the posterior wall of the stomach behind the

transverse colon.

First and fourth kinds of operation are used more often.

In case of anterior in front of transverse colon anastomosis loop of

the jejunum is taken 30-45 cm apart from the duodenojejunal flexura

(anastomosis on long loop). Side-to-side anastomosis between efferent

and afferent loops is formed to prevent “vicious circle”. In case of

posterior behind transverse colon anastomosis a loop of jejunum is

taken 7-10 cm apart from the duodenojejunal flexura (anastomosis on

short loop). Each of these gastroenteroanastomoses should be perfomed

isoperistalticaly for correct functioning (afferent intestinal loop is

sutured from above (near to the lesser curvature); the efferent intestinal

loop is sutured from below (near to the greater curvature).

One of the most dagerous comlications during this operation is

“vicious circle” which appears during antiperistaltic making of

anastomosis and formation of so-called spur (afferent loop twist).

Suturing of this loop 1.5-2 cm higher than place of anastomosis is done

to wall of the stomach to prevent formation of such spur. Also intestinal

Brown’s anastomosis can be performed by side-to-side technique

between afferent and efferent loops to prevent “vicious circle”.

Kinds of “vicious circle”:

1. counter-clockwise – content of the stomach (in case of incomplete

obstruction of the pylorus) enters the duodenum and goes again

to stomach through gastoenteroanastomosis;

2. clockwise – gastric content enters the afferent loop of the jejunum

in antiperistaltic direction and then – back to the stomach (due to

prevalence of motor power of the stomach);

16. Stomach resection (Bilroth 1, Bilroth 2, Bilroth 2 by Hofmeister-Finsterer modification). Indications, stages, characteristics.

Resection of the stomach

Indications: complications of gastric ulcer, benign and malignant

operable tumors of the stomach.

Classification:

 According to localization of the resected part of the organ:

1. proximal (cardiac and part of the stomach body is resected);

2. distal (antral part and part of the stomach body is resected).

 According to volume of resection:

1. economic – resection of 1/3-1/2 of the stomach;

2. extensive – resection of 2/3 of the stomach;

3. subtotal – resection of 4/5 of the stomach.

 According to form of resection:

1. wedge-shaped;

2. segmental;

3. stepped;

4. circular.

Stages of resection

1. Mobilization – section of blood vessels between ligatures

part of which is planned to remove upon lesser and greater

curvature. During this stage surgeon determines volume of

resection upon nature of disease (ulcer or cancer).

2. Resection is removal of a part of the stomach which we have

mobilized.

3. Restoration of gastrointestinal continuity (making of

gastroenteroanastomosis).

Two types of operations are most actual nowadays:

 Bilroth-1 resection is resection of 1/3 of the stomach with

end-to-end gastroduodenoanastomosis.

 Bilroth-2 resection is resection of 2/3 of the stomach with

side-to-side gastrojejunoanastomosis and closing of stump of

the duodenum.

Bilroth-1 resection has an important advantage in comparison with

Bilroth-2 method: natural passage of food from the stomach into the

duodenum is not disturbed, i.e the last is not excluded from digestive

process. This kind of resection is done in case of “small” resection of

the stomach (1/3 or antrumectomy). In all other cases, because of

anatomical features (retroperitoneal location of the larger part of the

duodenum and the fixation of gastric stump to the esophagus), it is

difficult to form gastroduodenal anastomosis (sutures can tear tissues of

anastomosis because of high tension). Also Bilroth-1 resection

inadequately reduces gastric acidity (as small portion of the stomach is

resected) that can lead to repeated ulcers.

Bilroth-2 resection is done when not less than 2/3 of the stomach

is removed. This variant of operation is not physiological as the

duodenum is excluded from the digestive process (“afferent loop

syndrome” may reveal). But Bilroth-2 method adequately reduces

gastric acidity and in place of gastrojejunal anastomosis there is no

tension (sutures don’t tear tissues of anastomosis as jejunum is covered

intraperitonealy).

Nowadays numerous modifications of Bilroth-2 method are used

and most common one is Hofmeister-Finsterer resection. End-to-side

gastrojejunoanastomosis is done after removal of not less than 2/3 of

the stomach. Afferent loop of the jejunum is sutured to the stomach

stump (“anastomotic spur” is formed) to prevent regurgitation of food

into the afferent loop and duodenum (to prevent “afferent loop

syndrome”).

In disseminated tumors of the stomach gastrectomy is performed

(removal of the stomach together with the lesser and greater omentum,

spleen, tail of pancreas and regional lymph nodes). After stomach

removal reestablishment of digestive tract continuity is performed by

gastroplasty with the help of jejunum loop or transverse colon.

17. Indications and technique of suturing of perforated ulcers of stomach and duodenum.

Suturing of stomach and duodenal perforated ulcer

Two kinds of urgent operations are possible to performe in case

of perforated ulcer of the stomach: suturing of ulcer or resection of the

stomach.

Indications for perforated ulcer suturing:

 young patients;

 when there is no ulcerous anamnesis;

 old patients exhausted by concomitant diseases (cardiovascular

collapse, diabetes etc.);

 more than 6 hours from the moment of perforation (when

peritonitis has been already revealed);

 low level of surgeon’s qualification to perform resection.

Following rules should be taken into account for suturing of

perforated ulcer:

 defect of the stomach or duodenum is closed with double-layer

seromuscular sutures;

 line of sutures should be in cross direction to longitudinal line of

the stomach to prevent stenosis formation;

 it is recommended to make peritonezation of the line of sutures by

the greater omentum.

 18. Vagotomy and draining operations on stomach. Indications, kinds, characteristics.

Vagotomy is an organopreserving operation, performed to reduce

acidoproductive function of the stomach by section of the vagus nerve or

its branches.

Indications: ulcers of the duodenum or the pylorus of the stomach.

Classification

1. Truncal [stem] vagotomy is a section of both vagus nerves

before hepatic and celiac branches. It leads to pylorostenosis

and parasympathetic denervation of the liver, gallbladder,

duodenum, small intestine and pancreas.

 supradiaphragmatic;

 subdiaphragmatic.

2. Selective vagotomy is a section of both trunks below origin of

the hepatic and celiac branches. It leads to pylorostenosis but

doesn’t cause parasympathetic denervation of the internal

organs. Usually truncal and selective vagotomy are

performed in combination with pyloroplasty or other draining

operations for prevention of gastric stasis.

3. Selective proximal vagotomy is a section of branches of the

vagus nerves that go only to the body and bottom of the

stomach. Branches which innervate the antrum and pylorus

(Laterzhe branch) are not sected. Laterzhe branch is

considered to be motor and regulates motility of pyloric

sphincter of the stomach.

Draining operations on the stomach

Indications: stenosis of the pylorus and upper part of the

duodenum.

1. Pyloroplasty is operation directed to expand the pyloric

opening with preservation or restoration of the pyloric

sphincter mechanism.

 Heineke-Mikulicz pyloroplasty is a longitudinal section

of the pylorus and initial part of the duodenum with

subsequent suturing of this wound in cross direction.

 Finney pyloroplasty is an arcuate section of the pylorus

and initial part of the duodenum with subsequent

suturing of this wound by side-to-side anastomosis

technique.

2. Gastroduodenostomy

 Jabuley gastroduodenostomy is a side-to-side

anastomosis between the stomach and duodenum. It is

performed by passing the site of obstruction.

3. Gastrojejunostomy is a classic gastroenteroanastomoses

which is done by four methods (anterior in front of transverse

colon, posterior in front of transverse colon, anterior behind

transverse colon, posterior behind transverse colon).

19. Operations on anhepatic biliary tracts (cholecystectomy, cholecystostomy, choledochotomy, choledochoduodenostomy, choledochojejunostomy). Operative approaches, indications, stages, characteristics.

Cholecystectomy is a gallbladder removal.

Indications: gallstone disease, which in most cases is accompanied

by chronic cholecystitis, empyema, gangrene of the gallbladder, benign

and malignant tumors.

Kinds:

 removal of the gallbladder from the neck (retrograde);

 removal of the gallbladder from the bottom (antegrade).

Cholecystectomy from the neck

Stages of operation:

 puncture and removal of bile from the gallbladder;

 section of the anterior wall of the hepatoduodenal ligament;

ligation of the cystic duct by two ligatures at a distance of 0.5 cm

from the common bile duct (more proximal ligation can lead to

constriction of the common bile duct, more distal – to ampullar

extension of stump of the cystic duct and stone formation);

 ligation of the cystic artery by two filaments (for its definition and

to prevent ligation of the right hepatic artery from which the cystic

artery starts it is necessary to find Kalo’s triangle which is formed

by the cystic duct, common hepatic duct and cystic artery);

 section of the peritoneum over the gallbladder on its

circumference;

 separation of the gallbladder from its bed;

 peritonization of the gallbladder bed by catgut sutures;

 drainage of the site of a cystic duct stump.

This kind of operation has more benefits as a surgeon begins

manipulation from the most important stage – separation of the cystic

duct and artery and examination of the common bile duct patency in

order to identify gallstones obstruction.

Cholecystectomy from bottom is done in cases of large adhesions

in the area of the gallbladder neck. Stages of operation are as such:

separation of the gallbladder from its bed, ligation and section of the

cystic duct and artery.

Complications of cholecystectomy:

 bleeding from a stump of the cystic artery (not proper

ligation);

 ligation of the right hepatic artery (necrosis of right lobe of

liver);

 injury of the portal vein, hepatic and common bile ducts;

 bile peritonitis (not proper ligation of cystic duct);

 penetration of a gallstone into the common bile duct;

 constriction of the common bile duct;

 gallstone formation (long stump of cystic duct).

Choledochotomy is a section of the common bile duct.

Indications: mechanical jaundice, cholangitis, concomitant

pancreatitis, stones in hepatic and common bile ducts, pathological

changes in major duodenal papilla.

Technique of surgical maneuver:

• longitudinal section of the common bile duct 1 cm in length;

• investigation of the common bile duct by probe, visually (duct

size, color, thickness of wall), by palpation and instrumental methods

(intraoperational sonography choledochoskopy, cholangiography);

• removal of gallstones and clots of bile.

Variants of finishing:

1. External drainage of the common bile duct (tube is inserted in

the common bile duct for bile diversion) – in purulent cholangitis;

2. Internal drainage of the common bile duct (making

choledochoduodenal anastomosis) – the common bile duct obstruction in

terminal department;

3. Common bile duct closure (suturing of wound of common bile

duct’s wall) – if there are no signs of cholangitis after removal of single

gallstones.

◼ CHOLEDOCHODUODENOSTOMY

Indications: gallstone disease

Step 1. Establish good mobilization of the common bile duct and duodenum

to avoid anastomotic tension. Anchor the duodenum to the common

bile duct by placing a row of 4–0 Vicryl sutures posteriorly

Step 2. Make a 1.5- to 2-cm transverse incision of the duodenum just below

the suture line and a vertical or transverse incision of the common

bile duct just above the suture line.

Step 3. Perform the anastomosis in a single layer using interrupted 4–0 Vicryl

sutures, full thickness, to the common bile duct and duodenum

Note:

✓ Alternatively, a side-to-side anastomosis can be performed.

 20. Concept about resection of liver, pancreas, spleen. Operation of splenectomy: indications, stages, characteristics.

Resection of the liver

1. Atypical resection is removal of part of the organ within the

limits of healthy tissue.

• Wedge-shaped resection is done at the edge of the liver out of

projection of the vascular-secretory pedicles.

• Marginal resection is done in case of marginal location of a

pathological formation.

• Planar resection is done in case of location of a pathological

formation on diaphragmatic surface of the liver.

• Transverse resection is usually done in lateral part of the left liver

lobe.

Atypical resection is economical in use but саn be accompanied by

profuse bleeding and necrosis due to ligation of vessels and bile ducts in

healthy segments. Before or after resection hemostatic sutures are put 1

cm aside and parallel to liver section.

1. Anatomical (typical) resection is removal of the organ part taking

into account structure of the liver.

• Left or right hemihepatectomy is removal of right or left liver

half.

• Lobectomy is removal of a liver lobe.

• Segmentectomy is removal of a liver segment.

Basic moments of anatomical resection of the liver:

1. separation and ligation of elements of the hepatic pedicle;

2. ligation of hepatic veins in the caval gate;

3. section of the liver by interlobar space;

4. wound coverage.

Pancreato-duodenal resection

Indications: operable tumors of head of the pancreas and major

duodenal papilla.

Stages of operation:

 mobilization of the duodenum and head of pancreas by Kocker,

mobilization of the pylorus and body of the pancreas up to the

place of resection;

 removal of the head, part of the pancreatic body, duodenum,

retroduodenal part of the common bile duct and pylorus of the

stomach;

 performing of gastrojejunal, pancreatojejunal, choledochojejunal

anastomoses.

Operations on the spleen

Spleenectomy

Indications: splenic rupture, malignant tumors, tuberculosis,

echinococcosis, abscesses, hemolytic jaundice, thrombocytopenic

purpura (Werlhof's disease), splenomegaly at portal hypertension.

Approach: oblique incision in the left hypochondrium in parallel to

left costal arch or upper midline laparotomy.

Stages of operation:

 mobilization:

 section and ligation of the phrenicolienal ligament with

located there vessels;

 ligation and section of elements of the vascular pedicle in

the gastrolienal ligament (zonal branches of the splenic

artery and vein are ligated near the splenic gates to prevent

disturbance of blood supply of tail of the pancreas and

stomach);

 removal of the spleen;

 peritonization of proximal stump of splenic.

In order to prevent immunity loss heterotopic autotransplantation of

the splenic tissue is sometimes done (in greater omentum).

In case of small cut wounds and limited injuries of organ-saving

operations the following operations can be done: hemostatic sutures

(splenorrhaphy) and spleen resection. But these operations are used very

seldom because of danger of postoperative bleeding (splenic capsule is

rather thin).

 21. Ways of bleeding arrest from parenchymal organs.

Ways of bleeding control from the parenchymal organs

Constant:

 mechanical (hemostatic sutures);

 physical (electrocoagulation, laser radiation);

 chemical (drugs of Ca, alpha-aminocaproic acid);

 biological (blood products, hemostatic sponge, fibrin adhesive,

tamponade by greater omentum).

In case of liver injury temporary arrest of bleeding can be done by

finger clamping of the hepatoduodenal ligament for 10-12 minutes.

Mechanical ways of constant control of bleeding include special

haemostatic suture (Kuznetsov, Pensky, Giordano, Varlamov, etc.). All

methods are based on the same principle: compression of edges of a

bleeding liver wound and ligation of large vessels. Interrupted sutures

can be put only in case of small injuries.

Plates of fasciae, falciform ligament, synthetic flaps are put under

the liver sutures around the wound perimeter in order to prevent tear of

tissues. Tamponade of the wound with greater omentum or by falciform

ligament is used for hermeticity.

22. Appendectomy: indications, approaches, kinds, technique. Ways of pus distribution at perforated form of appendicitis. Operation of removal of Meckel's diverticulum.

Appendectomy

Indications: acute and chronic appendicitis, appendix tumors and

cysts.

Kinds:

 from apex (antegrade method);

 from base (retrograde method).

Technique of antegrade appendectomy

 Oblique alternating McBurney-Volkovich-Dyakonov’s incision in

right inguinal region 9-10 cm in length (or pararectal Lennander

incision).

 section of the skin, subcutaneous fat and superficial fascia;

 incision of aponeurosis of external oblique muscle;

 disconnection of internal oblique and transverse muscles in

blunt way along their fibers;

 incision of transverse fascia and moving of preperitoneal

fat;

 section of the peritoneum.

 Putting of cecum with vermiform appendix into operative wound.

 Mobilization of appendix: putting clips on the mesentery and its

portional dissection from the appendix with subsequent ligation

under each clip.

 Putting purse-string suture on the caecum round the appendix

(don’t tighten it!). Clamping of the appendix and its ligation in this

place with catgut.

 Clamping of the appendix 0.5 cm distally from the site of ligation

and its cutting between clamp and ligature.

 Processing of the stump mucous layer by 5 % alcohol solution of

iodine and putting appendiceal stump into caecum with the help of

previously made purse-string suture.

 Putting Z-shaped sero-muscular suture over purse-string.

 Revision of ileum on presence of Meckel's diverticulum and

putting cecum into the abdominal cavity.

 Layer-by-layer wound closure.

Retrograde appendectomy

Indications: adhesions in region of the apex, retroperitoneal or

retroperitoneal position (when is not possible to move vermiform

appendix into operative wound).

Technique:

 Operative approach.

 Putting cecum with base of the vermiform appendix into the

operative wound.

 Making hole in mesentery of appendix near its base. Clamping

through this opening and ligation of appendix in this place with

catgut.

 Putting purse-string suture on the caecum round the appendix.

 Clamping of appendix 0.5 cm distally from place of ligation and

its cutting between clamp and ligature.

 Processing of the stump mucous layer by 5 % alcohol solution of

iodine and putting appendiceal stump into the caecum with the

help of previously made purse-string suture.

 Putting Z-shaped sero-muscular suture over the purse-string.

 Mobilization with sequential separation of appendix from

adhesions from base to apex.

Removal of Meckel's diverticulum

Meckel’s diverticulum discovered during surgical operation

should be removed in all cases (whether it is inflammated or not).

Variants of Meckel's diverticulum removal:

 using the same technique as with vermiform appendix (when its

base is narrow);

 clamping of diverticulum and its excision with suturing of ileum

wound by double-layer suture in transverse direction (in case of

inflammation or when base is wide);

 wedge-shaped excision of diverticulum between two clamps with

suturing of ileum wound by double-layer suture in transverse

direction – in case of inflammation or when base is wide

(previous method can lead to narrowing of intestinal lumen);

 resection of ileum part together with diverticulum and making

end-to-end anastomosis (if the intestine is involved in

inflammation).

from all sides by the peritoneum;

Topographic anatomy and operative surgery of retroperitoneal space and pelvis

 1. Topographic anatomy of lumbar region and retroperitoneal space, kidneys, ureters, vessels, vegetative plexuses, fat spaces.

TOPOGRAPHIC ANATOMY OF THE LUMBAR REGION AND

RETROPERITONEAL SPACE

The lumbar region

Borders: upper – the 12 rib, lower – iliac crest, medial – line of

spinal processes, lateral – posterior axillary line.

Layer-by-layer topography

Skin is thick, not flexible.

Subcutaneous fat forms lumbogluteal adipose tissue in

inferolateral parts of the region.

Superficial fascia is well developed. It separates subcutaneous fat

from lumbogluteal adipose tissue.

Thoracolumbar (deep) fascia forms sheaths for muscles.

The first layer of musles is presented by lattissimal dorsal and

external oblique abdominal muscles. In lower part of the region

between free edges of these muscles and iliac crest there is the lumbar

trigone or Petit's triangle bottom of which is formed by internal oblique

abdominal muscle.

The second muscular layer is presented in medial parts of the

region by erector muscle of spine and inferior posterior serratus muscle,

in lateral – by internal oblique muscle. Between XII rib from above

and lateraly, inferior posterior serratus muscle from above and medialy,

erector muscle of spine from below and medialy and internal oblique

abdominal muscle from below and lateraly lumbar quadrangle or

Lesgaft-Grunfeld’s rhomb is formed. Bottom of this quadrangle is

formed by aponeurosis of transverse muscle. Subcostal neurovascular

fascicle passes through it.

The lumbar trigone and quadrangle are weak places of the

posterolateral wall through which lumbar hernias and pyogenic

abscesses can come from the retroperitoneal space.

Third muscular layer is presented in medial part of the region by

lumbar quadrate and greater psoas muscles, in lateral – by transverse

abdominal muscle.

Endoabdominal fascia. According to muscles which are covered

by fascia several departments of it are distinguished (transverse fascia,

quadrate fascia, psoatic fascia).

Retroperitoneal space is a space located between the parietal

peritoneum from behind and endoabdominal fascia.

Layers of the retroperitoneal space

Proper retroperitoneal fat is located between endoabdominal

fascia and retrorenal fascia. Communication: below – with retrorectal

fat space, above – with posterior mediastinum (through crus of

diaphragm), in front – with preperitoneal fat. Contents: aorta,

abdominal aortic plexus, inferior vena cava, lumbar lymph nodes,

thoracic duct.

Retrorenal fascia is posterior layer of the renal fascia which starts

from place where parietal peritoneum goes from the lateral abdominal

wall into the posterior (nearby external edge of kindey it is divided into

prerenal and retrorenal fascia). Downwards the retrorenal fascia goes

into retroureteric fascia, from medial side it is attached to the fascial

compartment of the aorta and inferior vena cava.

Paranephron is located between retrorenal and prerenal fascias.

Contents: kidney, ureter, epinephron (epinephron is located in izolated

compartment which is formed by prerenal fascia).

Prerenal fascia is anterior layer of the renal fascia. From above,

from external and internal edge of the kidney it joins together with

retrorenal fascia, from below it goes into preureteric fascia. At lower

pole of the kidney prerenal and retrorenal fascia are connected by

intersections which prevent falling of the kidney.

Paracolon is bounded by prerenal and preureteric fascias from

behind, parietal peritoneum of lateral canals (right and left lateral

abdominal canals) and the retrocolic fascia in front and the renal fascia

from the lateral side.

Retrocolic fascia (Told’s fascia) is formed in case of connection of

the primmary mesentery with parietal peritoneum after rotation and

fixation of the ascending and descending colon (thin plate between the

paracolon and ascending or descending colon).

The kidney

The kidney is a bean shaped organ covered by fibrous, adipous and

fascial capsules. Upper and lower poles, lateral (convex) and medial

(concave) edges, anterior and posterior surfaces are distinguished in the

kidney. In the middle of the concave edge the kidney gate is located.

Holotopy: subcostal regions, proper epigastric region.

Skeletotopy: Тhe 12 – L1-2 (at left – up to T11). The 12th rib

divides the left kidney half-and-half (in right one – 1/3 is higher, 2/3 is

lower). The corner between longitudinal axes of kidneys is sharp and

opens downwards.

Projection of the gates: in front there is crossing of rectus

abdomen muscle edge with costal margin, from behind there is crossing

of erector muscle of spine edge with the 12th rib.

Syntopy: from behind there is the lumbar part of the diaphragm,

lumbar quadrate and greater psoas muscles (they form kidney’s bed); in

front of right kidney there is the right lobe of the liver, ascending colon

and descendent part of duodenum, in front of the left kidney there is the

stomach, tail of pancreas, left curvature of the colon, loops of the small

intestine; from above there is epinephros.

The renal pedicle (renal pelvis which passes into the ureter, renal

artery and vein, branches of renal plexus, lymphatic vessels)

surrounded with fat tissue is located in gates of the kidney. Syntopy of

the renal pedicle elements from back to front includes the renal pelvis

and ureter, renal artery and renal vein.

Fixing apparatus of the kidney: muscular bed, adipous and fascial

capsule, intraabdominal pressure, renal pedicle and ligaments

(hepatorenal, duodenorenal and splenorenal).

Blood supply occurs through the renal artery.

The renal artery is divided into anterior and posterior branches near

the gate. Before the renal gate artery gives the inferior suprarenal artery.

In 30% of cases there is additional renal artery to a pole of the kidney.

Anterior and posterior branches of the renal artery are subdivided into

segmental arteries in parenchyma of the organ and anastomose on

posterior surface 0.5-1 cm from the convex edge of the kidney and in

paralle to it (zone of natural divisibility of the kidney – Tsondec’s zone).

Five segments (superior, anterior superior, anterior inferior, inferior,

posterior) are distinguished in each kidney which are supplied by

segmental arteries (must be taken into account in kidney resection).

Venous outflow occurs through the renal vein into the inferior

vena cava). Left testicular (ovarian) and suprarenal veins go into the

left renal vein.

Innervation occurs through the renal plexus.

Lympatic outflow. From renal lymph nodes which are located in

gates of the kidney lymph goes into paraaortic nodes and nodes around

the inferior vena cava.

The ureter

Abdominal, pelvic and intramural parts are distinguished in the

ureter. Also three constrictions are in each of them: transition of renal

pelvis into the ureter, between abdominal and pelvic parts of the ureter

(at level of terminal line), between pelvic and intramural parts of the

ureter (when ureter goes into urinary bladder).

Holotopy: anteriorly, upon the external edge of the rectus, from

behind it goes along the transverse processes of the lumbar vertebrae.

Syntopy. Near the terminal line the external iliac artery crosses the

right ureter, common iliac artery (the left one); from behind of both

ureters at this level genitofemoral nerve is located. From medial side the

inferior vena cava (right ureter) and the aorta (left ureter) are situated,

from lateral side there are medial edge of the ascending colon and cecum

(right ureter), the descending colon (left ureter).

Blood supply occurs via three sources: renal artery (for upper

part), testicular or ovarian artery (for middle part) and superior vesical

artery (for lower part). Arteries of the ureter form plexus in the

paraureteric space.

Venous outflow occurs through the same veins as arteries.

Lymphatic outflow from the upper part of the ureter goes into the

nodes which are located in the kidney gates, from the middle it goes

into the paraaotic and retrocaval nodes, from the ureter lower part it

goes into the iliac nodes.

The abdominal aorta goes from the aortic hiatus to IV lumbar

and divides into right and left common iliac arteries.

Syntopy: in front there are pancreas, ascendent part of the

duodenum, root of the mesentery; from the left the left sympathetic

trunk is located; from the right there is the inferior vena cava.

Branches

 Parietal:

 right and left inferior phrenic arteries;

 lumbar arteries (4 pairs);

 median sacral artery.

 Visceral branches:

 middle suprarenal arteries;

 celiac trunk;

 superior and inferior mesenteric arteries;

 renal arteries;

 testicular (ovarian) arteries.

The inferior vena cava starts from the anterior surface of IV

lumbar vertebra by confluenve of the right and left common iliac veins.

Syntopy: from the left the aorta is located, from behind there are

lumbar and XII thoracic vertedrae, tight crus of the diaphragm, right

lumbar and renal arteries, in front there are the head of pancreas,

descendent part of the duodenum, root of the mesentery and transverse

colon, right testicular (ovarian) artery, right common iliac artery, from

the right there are rightepinephros, kidney and ureter.

Venous flow

 Visceral branches:

 right testicular (ovarian) vein;

 renal veins;

 right suprarenal vein;

 hepatic veins.

 Parietal branches:

 median sacral vein;

 lumbar veins;

 inferior phrenic veins.

Autonomic (vegetative) nerve plexuses

 Celiac (solar) plexus.

 Superior mesenteric plexus.

 Inferior mesenteric plexus.

 Renal plexus.

 Abdominal aortic plexus.

 Superior hypogastric plexus.

Greater and lesser splanchnic nerves, vagus nerves, phrenic

nerves, pelvic splanchnic nerves and sacral nerves take part in

formation of autonomic nerve plexuses. All of them are located on the

anteriolateral wall of the aorta and are connected with each other.

They innervate organs of the abdominal cavity, retroperitoneal space

and small pelvis.

2. Indications, technique, substantiation of paranephral block by Vishnevsky.

Paranephral block is introduction of anesthetic in paranephral fat

for functional blockade of autonomic nerve plexuses.

Indications: renal and biliary colic, cholecystitis, biliary

dyskinesia, pancreatitis, dynamic intestinal obstruction, obliterating

diseases of vessels of lower extremities and others.

Patient position. He/she lies on the healthy side with the swab

underneath.

Tchnique: Point of injection is located at the angle which is

formed by 12 rib and erector muscle of the spine. Direction of the needle

course is strictly perpendicular to the skin surface. Needle is moved

through all layers into the paranephral fat (after sense of resistance

(needle goes through retrorenal fascia) there is sense of penetration

(needle is paranephron)). Injection of 60-80 ml of 0.25% solution of

novocaine into the paranephral fat.

Complications:

 injury of the renal parenchyma and injection of novocaine under its

capsule;

 injury of the renal vessels;

 injury of the ascending and descending colon.

3. Anatomico-surgical evaluation of operative approaches to kidneys and ureters. Concept about operations on kidneys (nephrotomy, nephrostomy, pyelotomy, nephrectomy, nephropexy, resection of kidney).

OPERATIONS ON KIDNEYS AND URETERS

Operative approaches to kidneys and ureters

 Transperitoneal approaches:

 midline laparotomy;

 pararectal laparotomy.

Disadvantages: can lead to peritonitis as most of operations on

these organs are done in case of acute purulent processes or renal

diseases accompanied by infection of the urinary tract and

surrounding fat tissue or urinous infiltration (they are of seldom

use).

 Extra peritoneal approaches:

 vertical (Simon’s approach) – along external edge of erector

muscle of spine from XII rib to wing of ilium;

 horizontal (Pean’s approach) – in transverse direction from

the external edge of the rectus muscle to external edge of

erector muscle of the spine at the umbilicus level;

 oblique:

1. Bergmann-Israel’s approach – from the angle which is

formed by the external edge of the erector muscle of the

spine and XII rib to the middle third of the inguinal

ligament. This approach is to the kidney, ureter and

common iliac artery.

2. Fyodorov's approach – from the angle which is formed

by the external edge of the erector muscle of the spine

and XII rib in direction to the umbilicus (to external edge

of rectus muscle). This approach is done in case of

tumors, major kidney traumas and combined

intraabdominal injury.

Disadvantages: traumatic, restrict operative approach to the

epinephros and renal pedicle.

Pyelotomy is a section of the renal pelvis.

Indications: concrements of the renal pelvis.

Classification: anterior, posterior and inferior.

After longitudinal section and evacuation of stone from the renal

pelvis interrupted sutures are put without capture of mucous tunic

(prevention of stone formation) and drainage of a section site.

Nephrotomy is a kidney section.

Indications: concrements, foreign bodies (for removal) and

abscesses, purulent pyelonephritis (for drainage of kidney).

Classification:

 Greater nephrotomy:

 sectional incision – upon convex edge of the kidney;

 longitudinal incision (in Tsondec’s zone) – on posterior

surface 0.5-1 cm from convex edge of kidney and in parallel to

it;

 transverse incision.

 Lesser nephrotomy is a section of the renal tissue over stone

localization.

Wound of the kidney is closed by interrupted or П-shaped sutures

not more than 1 cm in depth (to prevent urinary fistula formation due to

injury of renal calices).

Nephrostomy

   This operation is performed for persistent drainage of the kidney and improving its functions.

a)    Indications: Renal failure, Pyelonephritis, Severe course of the calculous pyelonephrosis.

b)   Procedures:

An incision is made on the renal pelvis.

From the incision, a finger is inserted to the calyx.

Later, a small incision is made on the cortex. A probe is introduced to make contact with the finger and guided out through the pelvis incision.

The external end of the catheter is cut to form a bevel and attached to a silk stitch to the probe.

Then the probe is drawn out through the cortical incision.

Pelvic incision is closed by sutures.

Resection of the kidney is removal of a part of the kidney (poles)

in case of isolated injuries abscesses.

Kidney resection is done by a planar, transverse or wedge-shaped

section. Fibrous capsule of the kidney is used to cover wound surface or

tamponade by muscle.

Nephrectomy is a removal of the kidney.

Indications: tumors, extensive traumatic injuries, renal

tuberculosis, hydronephrosis of fourth degree, multiple nephrolithiasis.

Before operation it is necessary to be convinced about presence and

functioning of second kidney!

Patient position – on healthy side with swab under it.

Technique:

 extraperitoneal oblique approach;

 elimination of the kidney from the adipose capsule (sequence:

posterior surface, lower pole, anterior surface, upper pole (it helps

to prevent injury of possible additional arteries which can go to

lower pole of kidney and epinephros));

 processing of elements of the renal pedicle between two ligatures

or between Fyodorov's forceps and ligatures in sequence – ureter,

artery vein (ureter is sected on border between upper and middle

third as upper third is supplied from the renal artery; in case of

tumors the renal vein should be ligated and sected before the

renal artery to prevent venous dissemination of a tumor);

 removal of the kidney;

 drainage of the renal bed.

Nephropexy is fixation of the kidney at its falling of 3-4 st degree.

Methods of nephropexy:

1. by sutures which go through fibrous capsule and renal parenchyma;

2. for fibrous capsule without its suturing or with its flaps at partial

renal decortication;

3. by alloplastic materials;

4. by extrarenal tissues (paranephron, muscles) with or without

suturing of fibrous capsule.

Usually fixation of the kidney is done to XII or XI rib, muscles of

the lumbar region and diaphragm.

4. Suture of ureter. Concept about ureteroplasty.

Suture of the ureter is done after its opening in case of

urolithiasis, at trauma, resection and making of anastomosis.

Requirements:

 should not separate the ureter from paraureterium on the large

extent (disorders of blood supply);

 mucous layer is not taken in suture (prophylaxis of stone

formation);

 should not be tension (prophylaxis of eruption of sutures);

 should not be constriction (prophylaxis of disorders of urine

outflow) – suture on catheter;

 should be hermetic (prophylaxis of inflammation of paraureterium)

– peritonezation of line of sutures.

Ureteroplasty is surgery to remove the stricture. The surgery may be done through several small incisions (laparoscopy). Or it will be done through one larger incision (open surgery).

·         The narrowed portion of the ureter is cut out. If a large section is removed, tissue is used to repair the ureter. This tissue is taken from another part of the body, such as the bladder. The cut ends of the ureter are then stitched together. These stitches will dissolve over time.

·         A long, flexible tube called a stent is put into the ureter. It reaches from the kidney into the bladder. It is kept in place for 4-6 weeks after surgery to help hold the ureter open while it heals.

 5. Topographic anatomy of pelvis: compartments, fasciae, fat spaces. Genital differences. Topographic anatomy of pelvic organs. Blood supply, innervation of pelvic organs. Lymphatic outflow.

TOPOGRAPHIC ANATOMY OF THE SMALL PELVIS

The small pelvis is bones and soft tissues totality which are located

below the terminal line.

Walls of the small pelvis are presented by pelvic bones below the

terminal line, sacrum, coccyx and muscles which close greater sciatic

(piriform muscle) and obturator (obturator internus muscle) foramens

and limit the pelvic cavity in front, from behind and from sides. From

below the pelvic cavity is limited by soft tissues of perineum basis of

which is presented by urogeniatal and pelvic diaphragm.

Compartments of the pelvic cavity:

 Peritoneal compartment is located between the terminal line and

lower part of the parietal peritoneum. Contents (organs which are

covered by peritoneum): rectum, urinary bladder, uterus, lata

ligaments of the uterus, uterine tubes, ovaries and posterior vaginal

fornix. Loops of the small intestine, greater omentum and

sometimes transverse, sigmoid colon and appendix can go to

peritoneal compartment after emptying of the pelvic organs.

 Subperitoneal compartment is located between parietal peritoneum

and endopelvinal fascia which covers elevator muscle of the anus

from above. Contents: blood and lymphatic vessels, lymph nodes,

nerves, fat spaces, extraperitoneal parts of pelvic organs – rectum,

urinary bladder, pelvic part of the ureter, cervix of uterus, vagina,

prostate gland, deferent duct, seminal vesicles.

 Subcutaneous compartment is located between the skin and

endopelvinal fascia which covers elevator muscle of the anus from

above. Contents: muscles and fascias of perineum; fat, internal

pudendal vessels and pudendal nerve of ischiorectal fossa, final

department of the rectum and urethra, bulbourethral glands,

vestibule of the vagina, bulbs of the vagina vestibule.

Course of the peritoneum

In the cavity of male’s pelvis the peritoneum passes from

anterolateral abdominal wall to the anterior wall of the urinary bladder,

covers its superior, posterior and lateral walls and goes to the anterior

wall of rectum forming retrovesical pouch which is bounded from lateral

sides by rectovesical folds. Loops of the small intestine and sigmoid

colon can be located in this pouch.

In women peritoneum passes from the urinary bladder to the uterus

(covers its mezoperitoneally), to posterior vaginal fornix and anterior

wall of the rectum. Thus two pouches are formed in the cavity of

female’s pelvis: vesicouterine and rectouterine (vesicouterine and

rectouterine folds limit these pouches from lateral sides respectively).

Greater omentum can be locaded in vesicouterine pouch, loops of the

small intestine – in rectouterine pouch. Urine, pus and blood also can be

here in case of injuries and inflamations of the pelvic organs.

The pelvic fascia

Pelvic (endopelvinal) fascia is continuation of endoabdominal

fascia and consists of parietal and visceral layers.

The parietal layer of the pelvic fascia covers parietal muscles of the

pelvic cavity (piriform, obturator internus, coccygeal) and divides into

the superior fascia of urogenital and pelvic diaphragms and inferior

fascia of urogenital and pelvic diaphragms. These fascias cover from

both sides muscles of urogenital and pelvic diaphragms (deep transverse

perineal muscle of perineum and elevator muscle of anus, coccygeal

muscle).

Visceral layer of the pelvic fascia covers organs which are located

in the middle floor of the small pelvis. This layer forms fascial capsules

for organs of the small pelvic (Pirogov-Retz capsule – for prostate gland

and Amyuss capsule – for rectum). Capsules are separated by loose fat

from the pelvic organs and contain nerves, blood and lymph vessels of

these organs. Fascial capsules are separated by the frontal plane

(Denonvilliers' fascia). The urinary bladder, prostate gland, seminal

vesicles and part of deferent duct are located in front of Denonvilliers'

fascia in men, urinary bladder and uterus – in women. The rectum is

located behind of this septum.

Fat spaces

Classification:

1. Parietal (between parietal and visceral layers of pelvic fascia):

preperitoneal, prevesical, retrovesical, parametrium, retrorectal,

lateral.

2. Visceral: paravesical, pararectal, paracervix.

 Lateral fat spaces is located between parital layer of pelvic fascia

and sagittal septums of the visceral layer of pelvic fascia.

Contents: internal iliac vessels and its branches, pelvic part of

the ureter, deferent duct, branches of sacral plexus.

Ways of pus distribution:

 into the retroperitoneal space (along ureter);

 into gluteal region (along superior and inferior gluteal

neurovascular fascicles);

 into the retrovesical space (along ureter);

 into the inguinal canal (along deferent duct).

 Retropubic fat space

1. Previsical fat space is located between the pubic symphysis,

branches of the pubic bone and prevesical fascia.

2. Preperitoneal fat space is located between prevesical fascia and

visceral fascia of the urinary bladder.

Ways of pus distribution:

 into subcutaneous fat of the thigh (through femoral ring);

 into adduction bed of the hip (through obturator canal);

 into preperitoneal fat of the front abdominal wall;

 into lateral fat spases (through defects in sagittal septum of

visceral layer of pelvic fascia).

 Paravesical fat space is located between wall of the urinary

bladder and visceral fascia of the urinary bladder.

Contents: vesical venous plexus.

 Retrovesical fat space is located between visceral fascia of the

urinary bladder and Denonvilliers' fascia.

Contents: prostate gland, seminal vesicles, deferent duct and

ureters in men, vagina and ureters in women.

Ways of pus distribution:

 into the inguinal canal and scrotum (along deferent duct);

 into the retroperitoneal space (along ureters).

 Retrorectal fat space is located between visceral fascia of the

rectum and parietal fascia which covers the sacral bone.

Contents: sacral part of sympathetic trunk, sacral lymph nodes,

lateral and median sacral arteries, sacral venous plexus, superior

rectal vessels.

Ways of pus distribution (along vessels):

 into retroperitoneal space;

 lateral fat spaces of the pelvis.

 Pararectal fat space is located between visceral fascia of the

rectum and its wall.

 Parametrium is located between leafs of lata ligament of the

uterus.

Ways of pus distribution:

 laterally and below – into lateral fat spaces of the pelvis;

 medially and below – into the paracervix;

 into the retrovesical fat space.

 Paracervix is located between visceral fascia of cervix of the

uterus and its wall.

Vessels of the small pelvis

Walls and organs of the small pelvis are supplied by the internal

iliac artery which goes into the lateral fat space and divides here into

anterior and posterior branches.

Branches of anterior branch of internal iliac artery:

 umbilical artery (gives superior vesical artery);

 inferior vesical artery;

 uterine artery – in women, artery of ductus deferens – in men;

 middle rectal artery;

 internal pudendal artery.

Branches of posterior branch of internal iliac artery:

 iliolumbar artery;

 lateral sacral artery;

 obturator artery;

 inferior gluteal artery;

 superior gluteal artery.

Parietal branches of the internal iliac artery are accompanied by

same two veins. Visceral branches form venous plexuses around the

pelvic organs (vesical, prostatic, uterinу and rectal), venous plexus.

Venous blood from the rectal plexus goes by s the uperior rectal vein

into the system of portal vein, by medial and inferior rectal veins – into

the system of inferior vena cava (portocaval anastomosis). Blood from

other venous plexuses goes into system of the inferior vena cava.

Innervation of the small pelvis

Sacral plexus is formed by anterior branches of IV, V lumbar and

I, II, III sacral spinal nerves.

Branches:

 muscular branches;

 superior glutal nerve;

 inferior gluteal nerve;

 posterior cutaneous nerve of thigh;

 sciatic nerve;

 pudendal nerve.

Vegetative innervation of the pelvis

Vegetative nerve system of the small pelvis is presented by

sympathetic and parasympathetic parts.

Sympathetic nerve system of small pelvis is presented by sacral

ganglions of the right and left sympathetic trunks (they are located on

anterior surface of sacral bone medially from sacral foramens 3-4 in

number) and unpaired (coccygeal) ganglion. Right and left hypogastric

nerves which go from sacral ganglions are involved in formation of

several autonomic pelvic plexus together with parasympathetic nerves.

Relaxation of muscles of the hollow organs and increase of sphincter

tone is observed under the influence of sympathetic innervation.

Parasympathetic innervation of the small pelvis is made by pelvic

splanchnic nerves which pass from parasympathetic ganglions located in

the lateral parts of anterior horns of the spinal cord II-IV sacral

segments. The main function of parasympathetic nerves is emptying of

pelvic organs. Irritation of these nerves leads to relaxation of the internal

urethral sphincter, constriction of muscles of the uterus body and

relaxation of its cervix muscles, relaxation of the internal anal sphincter.

Autonomic plexus surround the same organs:

 inferior hypogastric plexus is located on internal iliac vessels;

 rectal plexus;

 deferential plexus;

 prostatic plexus;

 cavernous plexus;

 uterovaginal plexus;

 vesical plexus.

Lymphatic system of the small pelvis

Lymph from walls and organs of the small pelvis goes in two main

directions:

 from anterior parts of the small pelvis through internal iliac,

common iliac and subaortic lymph nodes into lumbar nodes which

are located around the aorta and inferior vena cava.

 from posterior parts of the small pelvis through sacral and

subaortic lymph nodes into the lumbar nodes.

Organs of the small pelvis

The rectum

Skeletotopy: begins from the upper edge of the second sacral

vertebra.

Syntopy: Men have the prostate gland, urinary bladder, deferent

ducts, seminal vesicles, ureters in the front of the small pelvis; women

have the posterior wall of uterine cervix and vagina in the front of the

small pelvis; on the posterior part of the small pelvis there are sacral

and coccigeal bones; ischiorectal fossae are located in the lateral parts

of the small pelvis.

Structure. Two parts are distinguished in the rectum: pelvic

(above from the diaphragm and consists of supraampullar part and

ampulla) and perineal (the anal canal). The rectum has two flexures in

sagittal plane: the upper – sacral (convexity is directed posteriorly) and

the lower – perineal (convexity is directed anteriorly).

Peritoneal coverage: the supra-ampullar part of the rectum is

covered intraperitonealy, the ampulla part is covered mesoperitonealy

(the posterior wall is not covered), the anal part is not covered by the

peritoneum.

Blood supply occurs via five rectal arteries: the superior rectal

artery (from the inferior mesenteric artery), two medial rectal arteries

(from the internal iliac artery) and two inferior rectal arteries (from the

internal pudendal artery).

Veins of the rectum go into the system of the portal vein (superior

rectal vein) and the inferior vena cava (medial and inferior rectal veins)

and form three plexes in the rectum wall: subcutaneous, submucous

and subfascial plexes. The subcutaneous venous plexus is located in

the region of the anus external sphincter muscle. The submucous

plexus (consists of glomes of veins) forms the venous ring (zona

hemorrhoidalis). The subfascial plexus is located between longitudinal

muscles and visceral fascia of the rectum.

Innervation occurs from inferior mesenteric, aortic and

hypogastric plexes (the perineal part is innervated by branches of the

pudendal nerve).

Lymphatic outflow goes from the perineal part into the inguinal

lymph nodes, from the ampulla it goes into sacral and internal iliac

nodes, from the supraampullar part it goes into the lymph nodes

located near the inferior mesenteric artery.

The urinary bladder

Structure: apex, body, bottom and cervix of the urinary bladder.

The mucous layer forms folds except the triangle of the bladder – the

smooth part of the mucous layer triangular in shape without submucous

layer. The internal opening of the urethra is located on the upper segment

of the triangle, the transverse fold separating openings of the ureters is

located in the bottom.

Syntopy: from above and from sides there are loops of the small

intestine, sigmoid colon, cecum; men have the prostate gland, ampullas

of the deferent ducts, seminal vesicles in the front of the bladder;

women have the body and cervix of the uterus and vagina behind the

urinary bladder.

Certain practical significance belongs to the transverse vesical fold

of the parietal peritoneum which is located at the site where the

peritoneum passes from the front abdominal wall internal surface to the

urinary bladder. It is located several centimeters above the pubic

symphysis in case of considerable accumulation of urine in the bladder

which allows making extraperitoneal approach to the urinary bladder.

Blood supply occurs via the superior vesical artery (from the

umbilical artery) to the upper part of the urinary bladder and inferior

vesical artery (from internal pudendal artery) to its bottom and lower

part. Venous outflow goes to the vesical plexus which has numerous

connections with the prostate and rectal plexuses.

Lymphatic outflow goes into the iliac and hypogastric nodes and

then – into the lumbar lymph nodes.

Innervation occurs through sympathetic and parasympathetic

nerves which form vesical plexus at the bottom of the organ.

The prostate gland

Structure: it consists of right and left lobes and isthmus of the

prostate. Base of the gland grows together with cervix of the urinary

bladder and urethra passes through the organ in the oblique direction.

The prostate gland is surrounded by dense fascial sheet which forms its

capsule (Pirogov-Retz) connected with the pubic bone by the

puboprostatic ligament.

Syntopy: above (the base of the gland) the gland there are the

urinary bladder, lower parts of the seminal vesicles; in the front there is

pubic symphysis; behind the gland the rectum is located (the prostate

gland is divided from it by rectovesical septum and fat).

Blood supply occurs through the inferior vesical and medial rectal

arteries. Venous outflow goes into the vesical and prostatic venous

plexuses.

Lymphatic outflow goes into the sacral lymph nodes and nodes

along the iliac arteries.

Innervation occurs through branches of the hypogastric plexus

which form the prostatic plexus.

The urethra consists of three parts: prostatic, membranous and

spongiose part. There are three constrictions (near the urinary bladder

cervix, at the site where the urethra passes through the urogenital

diaphragm and at the external urethral opening) and three dilatations

(in the prostatic part, in bulb of the penis, in the urethra terminal part).

The urethra forms an S-shaped curvature. The first curvature is

formed by the prostatic and membranous parts and its concavity is

directed anteriadly and upwards. The second curvature is formed by the

spongiose part of the urethra and its concavity is directed backwards

and downwards. These features should be taken into account when

performing catheterization of the urethra.

The scrotum is a sack containing testicles and the scrotal part of

the deferent duct. Walls of scrotum consist of: skin, dartos muscle,

external spermatic fascia, cremaster muscle, internal spermatic fascia

and vaginal tunic of testis.

Blood supply: posterior and anterior branches of internal

pudendal, perineal and external pudendal arteries.

Lymphatic outflow: into the inguinal lymph nodes.

Innervation: branches of pudendal and ilioinguinal nerves.

The testicles (right and left) are located in the corresponding half

of the scrotum and are separated from each other by the septum. The left

testicle is lower than the right one. Most part of the testis is surrounded

by the peritoneum and small amount of serous fluid is located in its

cavity. Along the posterior edge there is epididymis.

Blood supply occurs via testicular artery (from abdominal aorta).

Veins of the testicle passing in the spermatic cord form pampiniform

plexus from which blood drains into the inferior vena cava from right

testicle and into left renal vein from the left one.

Lymphatic outflow: into the lumbar lymph nodes.

Innervation: branches of the aortic and renal plexuses.

The spermatic cord is acomplex of anatomical structures including

the deferent duct, its artery and vein, testicular artery and vein,

pampiniform venous plexus, lymph vessels, branches of testicular plexus

and cremaster muscle which are covered with external and internal

spermatic fascias.

The uterus

Structure: bottom, body, isthmus and cervix. Cervix is divided

into vaginal and supravaginal parts. Longitudinal axis of uterus is

directed in front and angle formed by body and cervix is opened in the

front.

Peritoneal coverage. Peritoneum covers body and bottom of

uterus, posterior wall of cervix and small portion (about 1-1.5 cm) of

posterior vaginal wall. At its edges peritoneum forms dublication which

goes to lateral walls of pelvis – lata ligament of uterus.

In upper edge of lata ligament of uterus uterine tube is located, just

below and in front – round ligament of uterus. The uteroovarian ligament

(with blood vessels in it) begins from angle of the uterus and goes to the

uterine edge of the ovary. Ureter, uterine artery, uterovaginal venous and

nervous plexes and cardinal ligament of uterus are located at the base of

lata ligament.

Blood supply occurs through the uterine artery and auxiliary

sources (inferior hypogastric, ovarian, inferior vesical and internal

pudendal arteries). Venous outflow goes into system of the internal

iliac vein (by uterine and vaginal venous plexuses which have

anastomoses with rectal and vesical venous plexuses).

Lymphatic outflow goes into the internal iliac, sacral and inguinal

lymph nodes.

Innervation: the uterovaginal plexus which is formed by branches

of the hypogastric plexus.

The uterine [fallopian] tube connects the uterus with the

abdominal cavity in the rectouterine [Douglas'] pouch. Abdominal

opening of the fallopian tube is surrounded by fimbriae. Several

departments are distinguished in it: infundibulum, ampulla, isthmus and

intramural part. The fallopian tube goes along the upper edge of the

uterus lata ligament that forms its mesentery.

Blood supply occurs by the uterine and ovarian arteries. Venous

outflow goes into the ovarian veins and uterine venous plexus.

Lymphatic outflow occurs along the ovarian vessels into the right

and left lumbar lymph nodes which are located around the aorta and

inferior vena cava.

Innervation occurs through uterovaginal and ovarian plexes.

The ovary

Uterine extremity of the ovary is fixated by the uteroovarian

ligament to angle of thr uterus. Suspensory ligament of the ovary is

fixated to its tubal extremity.

Blood supply occurs by the ovarian artery (from the abdominal

aorta) and branch of the uterine artery. Venous outflow goes into

inferior vena cava from the right ovary and into the left renal vein from

the left ovary.

Lymphatic outflow goes into paraaortic and iliac lymp nodes.

Innervation occurs via branches of the uterovaginal plexus.

The vagina is a tube that covers the uterus cervix and opens into

the vestibule.

Syntopy: in front of the vagina there is the urethra (it grows

together with the vaginal anterior wall), behind it there is the rectum (it

is separated from the vaginal posterior wall by rectovaginal septum and

fat).

Blood supply is by vaginal (from uterine arteries), inferior vesical,

medial rectal and internal pudendal arteries.

Lymphatic outflow – into iliac and inguinal lymph nodes.

Innervation – branches of uterovaginal plexus.

6. Topographic anatomy of perineum. Genital differences.

The perineum

The perineum is a complex of soft tissue which covers output from

the pelvic cavity.

Borders: anterior – lower edge of the pubic symphysis, lateral –

lower branches of the bubic bone, branches of the ischial bone, ischial

tuberosities and sacrotuberal ligaments, posterior – the coccygeal bone.

The perineum is diveded into urogenital (anterior) and anal (posterior)

regions by the conventional line which is drawn between two ischial

tuberosities.

The anal region

Layer-by-layer topography is similar in men and women.

Skin is much thicker at periphery than at the center of the region, it

contains sudoriferous and sebaceous glands and is covered with hair. It is

pigmented at anus opening and connected with the external anal

sphincter, so it forms radial folds and passes in the mucous layer of the

rectum along the anocutaneous line.

Subcutaneous fat (contains superficial vessels and nerves):

 perineal nerves (from pudendal nerve) – innervation of central part

of the region;

 perineal branches of the thigh posterior cutaneous nerve–

innervation of lateral part of the region;

 cutaneous branches of inferior gluteal and rectal arteries (veins

form venous plexus round the anus).

External sphincter muscle of the anus is located under the skin of

central part of the region and is connected in front with tendinous center

of the perineum. Behind there is the anococcygeal ligament.

Superficial fascia is thin.

Ischiorectal fossa fat. Pudendal nerve and internal pudendal vessels

go into this fossa through lesser ischiadic foramen and give here inferior

rectal nerve and vessels.

Inferior fascia of pelvic diaphragm separates ischiorectal fossa

from above and covers elevator muscle of anus from below.

Elevator muscle of anus begins from the tendinous arch of the

pelvic fascia which is located on inner surface of the internal obtarator

muscle.

Superior fascia of the pelvic diaphragm is a part of the parietal

pelvic fascia and covers elevator muscle of the anus from above.

The urogenital region

The skin is covered with hair, contains sudoriferous and sebaceous

glands. Raphe of the penis goes upon the midline of the urethral surface

of penis in men, passes into raphe of the scrotum and then – into median

raphe of the perineum.

Subcutaneous fat contains perineal arteries, veins and nerves,

lymphatic vessels which go into the inguinal lymph nodes.

Superficial fascia is attached to the lower branch of the pubic and

branch of the ischial bones and separates superficial perineal space from

below.

Superficial perineal space contains following structures:

 Superficial perineal muscles:

 superficial transverse muscle of the perineum – between

ischial tuberosity and tendinous center of the perineum;

 ischiocavernous muscle – between ischial tuberosity and

cavernous body of the penis (of clitoris): contraction of

muscle leads to erection by compression of the venous

vessels;

 bulbospongious muscle – between tendinous center of the

perineum and tunica albuginea of the penis (clitoris). It covers

inferolateral surface of the penis bulb and grows together

with muscle from the opposite side along the midline (in

women covers bulbs of the vestibule and passes laterally from

the vaginal opening). Contraction of muscle leads to

compression of the urethra and then promotes ejection of its

contents.

 Crura of the penis (crura of clitoris) are located under the

ischiocavernous muscle and are attached to lower branches of the

bubic bone.

 Bulb of the penis (bulbs of the vestibule and greater gland of the

vestibule).

 Perineal nerves (give muscular branches and posterior scrotal

(labial) branches) and perineal artery (gives posterior scrotal

(labial) arteries).

Inferior fascia of urogenital diaphragm separates deep and

superficial spaces and covers deep transverse muscle of the perineum

from below.

Deep perineal space contains following structures:

 deep transverse muscle of the perineum is located between

branches of the pubic and ischial bones and tendinous center of the

perineum;

 sphincter muscle of the urethra is located around the membranous

part of urethra;

 bulbourethral glands in men (above the posterior part of the penis

bulb behind membranous part of the urethra) or greater glands of

the vestibule (excretory ducts open into vestibule of the vagina on

the border between posterior and middle third of small lips of the

pudendum);

 arteries and nerves of the penis (clitoris): deep and dorsal arteries

of the penis (clitoris) – from the internal pudendal artery; dorsal

nerve of the penis (clitoris) – from the pudendal nerve.

Superior fascia of the urogenital diaphragm separates deep

perineal space from above.

The urethra passes through the urogenital diaphragm in men,

vagina and the urethra – in women.

 7. Pudenda block, puncture of abdominal cavity through posterior vaginal fornix, colpotomy: indications, technique.

Pudendal block

Indications: forceps delivery, episiotomy (section of perineum in

case of vaginal birth at big fetus), suturing of episiotomic wound and

perineal ruptures.

Technique: is made from two sides.

Perineal way – point of injection is located in the middle of the line

which is drawn from the back vagina wall to the ischial tuberosity.

Transvaginal way – point of injection is located on the lateral

vagina wall (needle is moved between 2 and 3 fingers entered in the

vagina in direction to sacrospinal ligament and ischiadic spine).

Puncture of the abdominal cavity through the posterior vaginal

fornix

Indications: can be done for diagnostics on presence of blood, pus

or other fluid in the rectouterine [Douglas'] pouch or for its removal.

Patient position. Patient lies on the back, legs are bent at the hip

and knee joints, moved widely apart, highly raised and fixated in leg

holders.

Technique

 Speculums are inserted into the vagina; posterior lip of the uterus

cervix is fixated by bullet forceps and moved in direction to the

pubic symphysis.

 Puncture of the posterior vaginal fornix by a long needle on a dry

syringe.

 Aspirating of rectouterine pouch contents.

 If it is necessary to remove pus from the Douglas space after the

puncture the posterior vaginal fornix can be sected in transverse

direction on the course of a needle with following drainage of the

purulent cavity (colpotomy).

8. Operation of paracentesis of urinary bladder, cystotomy, cystostomy: indications, technique. Concept about prostatectomy.

Suprapubic capillary puncture (paracentesis) of the urinary

bladder

Indications: acute urine retention at impossibility to apply

catheterization of the urinary bladder (impacted urethral calculus,

injury of the urethra, to get urine for clinical or bacteriological tests).

Technique. Manipulation is done by a long needle 1 mm in

diameter with flexible tube on the end (to control rate of urinary

diversion). The point of paracentesis is 2 cm above the pubic symphysis

upon the midline of the previously moved skin from the puncture site

and perpendiculary to it. The skin, subcutaneous fat, superficial fascia,

linea alba, prevesical fat and bladder wall are pierced by a needle. The

needle is removed after evacuation of urine.

Cystotomy is a section of the urinary bladder.

Indications: can be done as an independent operation (to remove

foreign bodies, stones, polyps or to make urinary fistula) or as approach

to the prostate gland.

Technique

 The cystic lavage and bladder is filled with isotonic solution of

sodium chloride to raise front wall of the organ which is not

covered by the the peritoneum upper than the pubic symphysis.

 Midline abdominal incision from the mons pubis in direction to the

umbilicus is 10-12 cm in length.

 Section of the muscular layer of the urinary bladder after mooving

upwards peritoneal fold with help of swab.

 Evacuation of solution of NaCl and section of the mucous layer.

 Manipulation on the urinary bladder.

 Closing of the urinary bladder wound without taking the mucous

layer into sutures. Suturing of the sected layers of the front

abdominal wall.

Cystostomy is making of artificial urinary fistula.

Indications: chronic urinary retention at rupture of the urethra,

injury of the front urinary bladder wall, tumors of the prostate gland.

Kinds: temporary and constant.

Technique

 Cystotomy.

 Insertion of a catheter 1.5 cm in diameter or rubber tube with

lateral openings nearby its end into the bladder lumen.

 Evacuation of the opposite end of a drainage tube through the

upper corner of the abdominal wound.

 Layer-by-layer suturing of the remained part of wound.

Sometimes cystostomy can be done with help of puncture of the

front abdominal wall by trocar and insertion of a draining tube upon

this canal.

Radical prostaectomy is a removal of the prostate gland together

with capsule, seminal vesicles, prostatic part of the urethra, bladder

cervix, pelvic lymph nodes in case of cancer.

 9. Surgical approach with rupture of the bladder. Ways of pelvic fat spaces draining at traumas of pelvic organs.

Draining of pelvic fat spaces

 Through the front abdominal wall – for drainage of prevesical

and preperitoneal phlegmons:

 by suprapubic extraperitoneal incision along the white line of

the abdomen;

 through incision of the rectus muscle.

 Transvaginal way – by section of the vagina for parametritis

drainage.

 Transrectal way – by section of the rectum for paraproctitis

drainage.

 Transperineal way – by section of the perineum for drainage of

deep phlegmons and abscess located round the base of the urinary

bladder.

 Through obturator foramen (through adduction bed of the hip) – in

combined extensive injuries of the urinary bladder and rectum,

for drainage of deep phlegmons and abscess located round the

base of the urinary bladder, for drainage of lateral fat spaces.

10. Operations on rectum (at haemorrhoid and cancer).

Operations in hemorrhoid

Hemorrhoid is varix dilatation of submucous venous plexuses of

the rectum which are located on 3, 7, 11 hours of a clock dial and

accompanyed by bleeding from the inflamated and thrombosed venous

boluses.

Groups of operatin:

 ligation of hemorrhoidal boluses;

 removal of hemorrhoidal boluses;

 plastic operations.

Operative treatment of hemorrhoid is done only in case of

absence of inflamation in the region of hemorrhoidal boluses.

Milligan-Morgan operation consists in ligation and excision of

hemorrhoidal tissue, located on 3, 7, 11 hours of a clock dial.

 anal dilatation;

 clamping of hemorrhoidal boluses at symmetrical points and

pulling them upwards one by one;

 section of the mucous around the bolus neck outside-inside;

suturing, ligation and removal of the boluses;

 three cutted surfaces are not sutured (they will heal by secondary

intention).

Operations in malignant neoplasms of the rectum

Extent and method of operation depend on histological structure of

a tumor, location of the rectum, presence or absence of metastases,

general condition of a patient, his age and concomitant diseases.

Classification:

1. Palliative (in case of inoperable tumors) – artificial anus

application.

2. Radical (in case of operable tumors):

 sphincterononpreserving (extirpation) –removal of distal part

of the rectum together with sphincter and artificial anus

application (in case of tumor’s location not more than 6 cm

from anus);

 sphincteropreserving (resection) – removal of part of the

rectum and making of anastomosis between the rectum and

sigmoid colon (in case of tumor location higher than 6 cm

from the anus).

 11. Operations at hydrocele.

Operations in hydrocele

Hydrocele is accumulation of serous fluid between parietal and

visceral layers of the testicle vaginal tunic.

Kinds of operations

Vinkelman’s operation – turning out of the testicle vaginal tunic

(serous layer must be from outside) and suturing of the everting vaginal

tunic behind the testis and spermatic cord.

Bergman’s operation (in large hydrocele with sclerosing of testis

tunics) – excision of sclerosing part of vaginal tunic.

Klyap’s operation – vaginal tunic is sutured in form of roll around

testis to decrease its cavity.