PREFACE

The book is intended for the III-IV–year foreign medical students. Taking into
consideration the peculiarities of teaching surgery and the existence of the subject “Operative
surgery and topographic anatomy” in the Yerevan State Medical University after M. Heratzi, it
was decided to write a practical course on the mentioned subject.
We hope that this handout will be useful for undergraduates, postgraduates of surgical
qualification and the surgeon beginners as well, taking into account the importance of the
knowledge of “Operative surgery and topographic anatomy” for the practical surgeon.
As it’s the first experience of writing such a practical course in English, we’ll be very
grateful and thankful for all comments, wishes and suggestions.

Head of the Department, M.D PhD, Professor S. L. Orduyan

ENGLISH HANDOUT
 SURGICAL INSTRUMENTS

Surgical instruments are divided into five groups.

1. Instruments for disconnection of the tissues.
2. Instruments to arrest bleeding.
3. General instruments (fixating, accessory, retracting instruments).
4. Instruments for special prescriptions.
5. Instruments for connection of the tissues.

I. Instruments for disconnection of the tissues.

Surgical knife, scalpel, lancet.

Bellied scalpel Sharp-pointed scalpel

Scalpel consists of a handle and a blade. The blade may be removable.

We hold the surgical knife in different positions.
 “Kitchen knife” position.
 “Fiddlestick ” position.
 “Pen-grip” position.
 Holding in the fist.

Scissors
Straight

Sharp- pointed. Blunt- pointed

Curved scissors.
Angled scissors.

Trocar –is used for drainaged cavities, with cannula

and stillet. Bir’s lumbar puncture needle– is used for spinal
puncture.

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 Bone – cutting forceps.

Jansen’s – bone nibbling forceps.

Luer’s – is used to nibble the skull by the side of

the burr-hole to increase the diameter of the hole.

Dalgren’s skull–cutting forceps-is used for cutting

the skull between the two burr-holes.

Doyen’s rib-cutter
Doyen’s rib-cutter
forceps (scissors)
forceps – with –double
(scissors) Shumacher’s rib-cutterforceps
Shumacher’s rib-cutter forcepc(scissors) – with
action hinges.
with double action hines. double action hinges.
Raspatory

Faraboeuf’s straight and curved – is used to Doyen’s rib raspatory - is used to raise the
raise the periosteum off the surface of the bone. periosteum from the inner surface of the rib.

Volkmann’s spoon – is used to scrape chronic ulcers, sinuses or bony cavities.

One side. Two sides

Saw
This instrument is using for cutting the bone.

Hand type bone saw

Bow – type bone saw

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 Burrs– is used to make holes in the skull. It is used
with spade-shaped and ball-shaped burrs.
Gigli’s wire saw. Using this saw with introducer
we can cut skull.
II. Surgical instruments to arrest bleeding.
Artery forceps- is used to arrest bleeding temporary in the wound. They have sot catches (lock) on their
handles so that the vessels can be crushed and they remain with the vessels keeping them in crushed position.
They may be straight and curved.

Bilroth’s haemostatic forceps – without teeth Kocher’s forceps (clamp) – heavy artery forceps
with transverse serrations on the inner aspect of which has got teeth and socket.
the blades.

Dechamp’s needle – is used permanent arrest of

the bleeding out of the wound (to make ligature of
the principal artery of this region). It may be
right, left and straight (Cooper’s needle).

Mosquito forceps – light small variant of artery

forceps, which has got narlayers and pointed
blades.
III. General instruments.
Dissecting forceps.

Dissecting forceps without teeth (anatomical) – Dissecting forceps with teeth (surgical) – it
this instrument is mainly used for fine dissection inflicts trauma to the structures held by it. Its
where any sort of injury to the tissues is not advantages are:
allowed. There are serrations on the inner aspect a) the structure can be hold without much effort;
of the blades for better grip of the structures b) it causes less injury to the close situated
during dissection. There are also serrations in the
structures;
middle part of outer surfaces of the blades for
better grip with the fingers. c) the tissues held by it do not slip out.
Its disadvantages are:
a) it can not be used during fine dissection;
b) the tissues held by it bear the insult of
injury.

Pronged-tenaculum forceps.

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 Probe

Probe – it is a simple instrument whose one end is

blunt olive pointed. It is mainly used: Grooved probe (dissector) – one end of it is
a) to detect depth and direction of sinus
of a fistula; probe-pointed director, another end is flattened
b) to detect presence of any foreign body and carries a groove on it.
inside the sinus;
c) to push it through the fistula up to the
inner end of the track.

Kocher’s Thyroid dissector – it was primarily

designed to dissect the upper pole of the thyroid
gland.
Hook, retractor.
Retractors are used to retract the wound for better visualization in its depth.

Fritsh’s hook.

Pronged surgical retractor. They may be:

a) sharp pronged surgical retractor
b) blunt pronged surgical retractor

Faraboeuf’s C-shaped plane retractor.

Liver retractor.
Towel clip.

Abdominal retractor – is used to retract the

wound of the abdomen.

Screw – type retractor – is used to retract the

wound of the thorax.

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 Packer, dressing forceps. Surgical spatula

IV. Instruments for special prescriptions.

Instruments used during tracheotomy and tracheostomy.

Tracheostomic tube (cannula) – it Trusso’s retractor – is used for enlarged the

consists of an outer tube with its shield incision of the trachea.
and inner tube. Single hook sharp retractor – is used to hold the
trachea.
Urological instruments.

Kidney pedicle forceps – curved, crushing

Catheter – it can be metallic (different for
forceps for holding the elements of the kidney
male and female), rubber and elastoplast,
hilus. It has cress-cross serrations which helps to
which are the same for both sexes.
hold the tissue very firmly.

Instruments for abdominal surgery.

Payer’s Crushing clamp – it is a heavy

instrument and is used for crushing the mucous
Doyen’s intestinal (occlusional) clamp – This is membrane of the gut whenever required. There
a light instrument and is used to clamp the are two variants of this sort of crushing clamp –
intestine. It’s blades are very flexible. The short and long types. The short one is used for
advantages of these clamps are that they not only crushing the duodenum. It produces its crushing
occlude the lumen of the guts properly, but also effect by its double action hinges. The long one is
reduce the bleeding of the cut margins of the gut
and prevent the flow of the gastro-intestinal for crushing the stomach.
secretions into the peritoneal cavity. Thus
prevents contamination of the abdominal wound
too.
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Miculicz clamp – it is heavy, curved
Allis tissue forceps.
forceps with teeth. It is mainly used for
fixation of the cut margins of the parietal
peritoneum.

Instruments used in operations on oral cavity.

Mouth retractor
Tongue forceps – is used for holding the tongue.

Instruments used in operations on rectum.

Fenestrated Luer’s forceps

Rectal speculum
V. Instruments for suturing tissues.

Needle-holder

Mathieu’s needle holder.

Hegar’s needle holder.
Surgical needle
Straight – we hold this needle by fingers.
Curved – we hold this needle with needle-holder.
The needles may be:
a) Round bodied (pricking) – are used for suturing the peritoneum, guts and the muscles.
b) Cutting – it is triangular in cross-section with sharp edges. It is used for suturing aponeurotic layer, fascia,
skin (flexible tissues).
c) atraumatic needle – it has no eye and the suture material is fixed to the needle at its end.

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 General Rules of Disconnecting and Connecting Tissues

I. The incision must be deepened in layers.

II. It must be done parallelly to the main vessels and nerves of the given region, in the
direction of elastic fibers of the skin.
III. The length of the incision should be equal in all the layers.
IV. The length of the incision must always be more than its depth or at least equal to it.

General Rules of Connecting the Tissues

I. The wound should be sutured layer by layer.

II. Each layer should be sutured in its whole depth without leaving cavities, because, as
it is well known, the organism doesn’t like wpond cavities and always fills them with
biological liquids, such as blood, lymph.
III. The distance between the neighbouring sutures is called “suture step”. This rule is
about “suture step”: it is a constant quantity (size) for the given layer and shouldn’t be
change while suturing.
IV. The places where the needle goes in and comes out should be at an equal distance
from the edges of the wound. The line connecting those two points should be
perpendicular to the direction of the wound.

The main instrument for the incision is the surgical knife or the scalpel. We have 4 types
of holding the knife.
1. Holding the knife like fiddlestick: 4 fingers from one side and the thumb from the
other. Holding the knife in this way you can do a large superficial incision. It means
that you must hold the knife in this way to cut the skin.
2. When the patient has excessively develop subcutaneous fatty tissue, we should hold
the knife like a kitchen knife, it means that the position of the second finger – it must
press on the blade of the knife, to get adeeper incison.
3. Position of holding the knife os like a pen so cold “pen-grip” position – holding the
blade of the knife between the first three fingers as we hold a pen. We can make a
thorough small incision as writing is also scrupulous hand work.
4. Holding position is pressing the knife in a fist with its blade upward. We hold only
the amputating knife in this position. We cut the muscular layer in this position when
we perform an amputation of an extremity.

OPERATIVE SURGERY AND TOPOGRAPHIC ANATOMY OF THE HEAD

The skull is formed by a number of separate bones most of which meet each other at
linear suture-narlayers gaps filled with dense fibrous tissue. It consists of a brain-box or cranium
and a facial skeleton.

Fronto-parieto-occipital Region
(regio fronto-parieto-occipitalis)
The boundaries of the region are margo supraorbitalis, linea temporalis superior, linea
nuchae superior till protuberantia occipitalis externa.

Scalp
The scalp covers the calvaria, extending from the superior nuchal lines on the occipital
bone to the supraorbital margins of the frontal bone. The scalp consists of five layers of soft
8
tissue, the first three of which are connected intimately and move as a unit. Each letter of the
word scalp serves as a memory key for its layers: skin, connective tissue, aponeurosis
epicranialis, loose connective tissue, and pericranium.

I The skin, thin except in the occipital region, contains many sweat and sebaceous
glands and hair follicles; it has an abundant arterial supply and good venous and lymphatic
drainage. The skin is fixed to the aponeurosis by dense strands of fibrous tissue which traverse
the subcutaneous tissue and split it into a number of separate pockets filled with fat.

II The connective tissue is a thick, richly vascularized, subcutaneous layer which is

well supplied with nerves.
The connective tissue includes five neuro-vascular bunches and a separate nerve
Location of the neuro-vascular bunches
1. a.v.n. supratrochlearis ( frontalis )
2. a.v.n. supraorbitalis
Arteries are terminal branches of ophthalmic artery, a branch of internal carotid artery; veins
begin from the forehead and descend to unite at the medial angle of the eye to form the facial
vein. Nerves are the major cutaneous branches of the ophthalmic nerve (first branch of
trigeminal nerve).
3. a.v. temporalis superficialis and n.auriculo-temporalis. Artery is smaller terminal
branch of external carotid artery. The superficial temporal artery emerges on the face between
the temporomandibular joint and the ear and ends in the scalp by dividing into frontal and
parietal branches, the vein drains the forehead and scalp and receives tributaries from the veins
of the temple and face. Near the auricle, the superficial temporal vein enters the parotid gland.
The retromandibular vein, formed by the union of the superficial temporal and maxillary veins,
descends within the parotid gland, superficial to the external carotid artery and deep to the facial
nerve. The retromandibular vein is divided into an anterior branch that unites with the facial vein
and a posterior branch that joins the posterior auricular vein to form the external jugular vein.
The nerve is major cutaneous branch of the mandibular nerve, which is the third branch of
trigeminal nerve.
4. a.v.n. auricularis posterior. Artery is branch of external carotid artery; auricular
posterior nerve is branch of facial nerve.
5. a.v. occipitalis and n.occipitalis major. Artery is a branch of external carotid artery.
Vein forms external jugular vein with v. auricularis posterior. Nerve is branch of the second
cervical nerve (posterior root ).
6.n. occipitalis minor is situated between the fourth and fifth bunches. It is a branch of
cervical plexus.
These arteries and veins of the scalp make anastomoses freely with each other and with
those of the opposite side. Because of this, wounds of the scalp bleed profusely, but heal rapidly.
III The aponeurosis epicranialis is a strong stringy sheet that covers the superior
aspect of the calvaria; the aponeurosis is the membranous tendon of the fleshy bellies of the
occipitalis and frontalis muscles (whereas the frontalis pulls the scalp anteriorly, wrinkles the
forehead, and elevates the eyeblayerss, the occipitalis pulls the scalp posteriorly and wrinkles the
skin on the posterior aspect of the neck).
The aponeurosis consists of two layers. The deep layer attaches to the borders of the
region and the superficial one continues to the neibouring regions as superficial fascia.
IV The loose connective tissue is somewhat like a sponge because it has many
potential spaces that may distend with fluid that results from injury or infection; this layer allows
free movement of the scalp proper (first three layers, skin, connective tissue, and epicranial
aponeurosis).
V The pericranium, a dense layer of connective tissue, is the periosteum of the
calvaria; it attaches firmly to the cranial bones, but the pericranium can be stripped fairly easily

9
from the cranial bones of living persons, except where it is continuous with the fibrous tissue in
the cranial sutures.
VI The subperiostal connective tissue is situated between the pericranium and the
bone.
VII The bones of the head consist of three layers. The names of the external and
internal layers are lamina compacta externa et interna (or vitrea) because it can be broken very
easily. The name of the middle layer is lamina diploe, which contains diploic veins.
VIII The cranial dura mater consists of two layers. Dural venous sinuses are situated
between two layers of dura mater.

The Peculiarities of Fatty Tissue in Fronto-parieto-occipital Region

Blood or pus can gather in those layers, where we have loose connective tissue. In this
region there are three layers of this kind and in each of them haematoma or abscess has
peculiarities:
a) Subcutaneous fatty tissue- Haematomae which are located in this layer are
blocked, as they appear in separate pockets of subcutaneous tissue (between dense fibrous septa
connecting the skin with aponeurosis). These haematomae appear just in the region of the injury
by oedema of the skin as a “lump” Frontal region is an exception, where subcutaneous tissue has
connection with subcutaneous tissue of the superior eyelid. Here haematoma and oedema can
spread easily.
b) Subaponeurotic loose connective tissue- Haematomae and abscesses of this layer
can spread all over the region, but they cannot spread out of its boundaries, as the deep layer of
the aponeurosis is attached to the boundaries of the region. An exception is again frontal region,
where there is connection with the loose connective tissue of the orbits. Consequently, a black
eye can result from an injury to the scalp (a symptom of the “glasses”)
c) Subperiostal connective tissue- Haematomae of this layer can spread inside the
boundaries of a bone, as periosteum is attached to the bones in the region of the sutures.

The Peculiarities of Blood Supply in Fronto-parieto-occipital Region

Peculiarities of Arterial Supply

1. The main vessels of this region are in subcutaneous fatty tissue and extend to the bregma
from every side. Because of this superficial position they can be damaged very easily.
2. The vessels are fixed by their adventitia to the dense strands of the connective tissue and
so remain retracted when they are injured.
3. The vessels make anastomoses freely with each other and with those of the opposite side.
That’s why bleeding is from the both sides of injured vessel. So the scalp wounds bleed
profusely, but heal rapidly.
4. Here we have anastomoses between the branches of internal and external carotid arteries.

Peculiarities of the Venous Supply

The venous supply of this region consists of three levels:
1. Veins which are located in subcutaneous tissue.
2. Diploic veins.
3. Dural venous sinuses.
They are connected through the emissary veins. Emissary veins don’t have any valves and
blood can pass in two directions.
If the patient has an inflammation of scalp in area of emissary veins the infection may spread
into the cranium and if the patient has a wound of the scalp in area of emissary veins profuse

10
venous bleeding may occur. It is a negative feature. But when the patient has high intracranial
pressure we can reduce it by washing the head with hot water. If the patient has headaches due to
high intracranial pressure, this procedure will help him.

Temporal Region
(regio temporalis)

Boundaries of temporal region:

 Superiorly and posteriorly–superior temporal line.
 Anteriorly –lateral wall of the orbit.
 Inferiorly – superior border of the zygomatic arch.
Layers
1. The skin- posteriorly and superiorly is thick and hairy. Anteriorly and inferiorly – thin,
movable, without hair.
2. The subcutaneous fatty tissue is well developed.
3. The superficial fascia divides the fatty tissue into two layers. A.v. temporalis superficialis
and n. auriculotemporalis are situated in the deep layer. This bunch passes all over the region
and in fronto-parieto-occipital region is divided into two branches: frontal and parietal. One can
palpate the pulsation of this artery if he (she) puts a finger on the zygomatic arch 1cm anterior to
the tragus. The sensory nerve supply of the skin is from n. zygomatico-temporalis (maxillary
division of n. trigeminus). In this layer temporal and zygomatic branches of n. facialis are
situated.
4. Temporal fascia (aponeurosis) starts from linea temporalis superior. It covers the
temporal muscle. Near zygomatic arch it splits into superficial and deep layers, which attach to
the outer and inner borders of zygomatic arch. Fatty tissue and a. temporalis media (branch of a.
temporalis superficialis) are situated between these two layers.
5. Subaponeurotic fatty tissue connects this region under zygomatic arch with infratemporal
fossa up to inner aspect of the mandible (fissura mandibulo-mastoidea). So infection can spread
from one region to another.
6. M. temporalis begins from the linea temporalis inferior and its tendon is attached to the
processus coronarius mandibulae under the zygomatic arch. On the inner aspect of the muscle
a.v.n. temporalis profundus are situated (artery is from a. maxillaris, nerve- from n.
mandibularis).
7. Temporal bone (squama) - a. meningea media is situated on the inner surface of the bone.
The injury to this artery can cause epidural haematoma.

Mastoid Region
(regio mastoidea)

Boundaries of this region are:

 Superiorly is the line, which is the continuation of zygomatic arch.
 Anteriorly and posteriorly are the margins of mastoid process.
Layers:.
1. The skin is thin, without hair, not movable.
2. The subcutaneous fatty tissue includes: a.v.n. auricularis posterior (artery is a branch of
external carotid artery, vein with posterior branch of retromandibular vein forms the external
jugular vein, nerve is posterior branch of facial nerve), n.auricularis magnus and n.occipitalis
minor are branches of plexus cervicalis.
3. The superficial fascia.
4. The deep fascia.

11
 5. Mastoid process of the temporal bone is covered with periosteum. On the anterior
surface of mastoid process a trepanation triangle is described by Shipoult. The boundaries of this
triangle are: anteriorly - suprameatic spine, superiorly it coincides with the superior boundary of
this region, posteriorly- crista mastoidea. Mastoid air-cells (cellulae mastoideae) are situated in
the thickness of the bone inside the boundaries of above mentioned triangle. The largest cellula
of the mastoid process, antrum mastoideum, is connected with cavum tympany through aditus ad
antrum. Cavum tympany is connected with pharynx through the tuba auditiva. By this way
infection can spread from the pharynx to the cavum tympany and antrum mastoideum and acute
supurative mastoiditis may develop. During antrotomy we can hurt the following structures if we
go out of the boundaries of trepanation triangle: anterosuperiorly – brain in the middle cranial
fossa, posterosuperiorly – brain in the posterior cranial fossa, anteroinferiorly – facial nerve in its
canal, posteroinferiorly – sigmoid sinus.

Lateral Facial Region

(regio facialis lateralis)

Boundaries of this region are:

Superiorly - margo infraorbitalis and arcus zygomaticus.
Inferiorly - inferior border of the mandible.
Anteriorly - plica nasolabialis.
Posteriorly - posterior border of the vertical process of the mandible (or imaginary line
between the angle of the mandible and apex of the mastoid process).
This region is divided into superficial and deep regions. The superficial region is
subdivided into regio buccalis and regio parotideo-masseterica by the anterior margin of the
masseter muscle.

Buccal Region
(regio buccalis)

1. The skin is thin, not movable, without hair. It contains many sweat and sebaceous
glands.
2. The subcutaneous fatty tissue includes a.v.facialis (a. is a branch of external carotid
artery, v. enters into the internal jugular vein), nerves of this region are the branches of facial and
trigeminal nerves. Corpus adiposum buccae is located in this layer. It has three processes:
processus orbitalis, processus temporalis and processus pterygopalatinus. Infection can spread
to these regions by processes. Facial artery in the medial angle of the eye is called angular artery
and makes anastomosis with a. dorsalis nasi (branch of ophthalmic artery which arises from the
internal carotid artery). Due to it an anastomosis between external and internal carotid arteries is
formed. Venous blood from the angular vein may pass to the sinus cavernosus by the nasofrontal
vein – a branch of the superior ophthalmic vein. At the level of the mouth, the facial vein has an
anastomosis by v.facialis profunda with plexus venosus pterygoideus, which in its turn is
connected with sinus intercavernosus. Due to these anastomoses the infection can spread
retrogradely to the sinus cavernosus when there is thrombosis of the facial vein.
3. The superficial fascia.
4. Fascia bucco-faryngea covers m.buccinator and the lateral wall of the pharynx.
5. M. buccinator. On the inner surface muscle is covered by mucous membrane (wall of
the oral cavity). Duct of parotid gland passes through the muscle and opens at the level of the I
or II superior molars.
Parotideomasseteric Region
(regio parotideo-masseterica)

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 1. Skin is thin, is covered by hair in male. It contains many sweat and sebaceous glands.
2. Subcutaneous tissue includes superficial vessels and nerves.
3. Superficial fascia.
4. Fascia parotideo-masseterica forms capsules for the parotid gland and masseter
muscle.
Vessels and nerves pass through the parotid gland in different directions. Vertically – a.v.
temporalis superficialis, n. auriculotemporalis and v. retromandibularis. Horizontally – n.
facialis. Facial nerve forms the parotid plexus and is divided into five branches forming pes
anserinus major: r.temporalis, r. zygomaticus, r, buccalis, r. marginalis mandibulae, r. colli.
Parotid duct arises from the anterior border of the parotid gland and passes at the external surface
of the masseter muscle inferiorly to the zygomatic arch (about 1 cm), surrounds anterior margin
of the muscle.

Deep Facial Region

(regio facialis profunda)

Deep facial region, which occupies the infratemporal fossa is visible if we remove
zygomatic arch, masseter muscle and mandible. Boundaries of this region are: anteriorly – facies
infratemporalis of tuber maxillae; posteriorly – anterior margin of the parotid gland; superiorly-
inferior surface of greater wing of sphenoid bone, inferiorly-where masseter and medial pterigoid
muscles attach to mandible near its angle, laterally – ramus of mandible; medially – pterygoid
process of the sphenoid bone. Superiorly it is connected with temporal fossa, inferiorly with the
neck. Infratemporal fossa includes fat, pterygoid external and internal muscles, vessels and
nerves. There is maxillary artery which is a branch of external carotid artery. It gives off several
branches: a. temporalis profunda, a. meningea media, a. masseterica, a. buccinatoria and a.
alveolaris inferior. Last one passes with n. alveolaris inferior through the mandible canal, goes
out through the mental foramen as a. mentalis. Mandible nerve gives off four sensitive branches:
n. auriculotemporalis, n. lingualis, n. buccalis and n. alveolaris inferior; and some branches to
the muscles. Deep facial region is connected with different regions of the head through the fossa
pterygo-palatina:
Through the foramen sphenopalatinum - with nasal cavity.
Through the foramen rotundum - with cranial cavity.
Through canalis palatinus major – with oral cavity.
Through canalis pterygoideus -with the external surface of the base of the cranium.
Through the fissura orbitalis inferior- with orbital region.

Krenlein’s Diagram

This diagram is used for projecting important structures in the cranial cavity and is
necessary for exact access to them.
The following lines are used for making the diagram:
 linea sagittalis -- connects the midpoint of glabella(nasion) with protuberantia
occipitalis externa (inion).
 linea auriculoorbitalis –inferior horizontal line -- connects margo infraorbitalis with
margo superior of the porus acusticus externus.
 linea supraorbitalis- superior horizontal line -- passes parallelly to first one through
margo supraorbitalis.
Three vertical lines are made also:
1. linea zygomatica-anterior vertical line -- passes perpendicularly to horizontal lines
through the midpoint of the zygomatic arch.

13
 2. linea articulationes-middle vertical line -- passes parallelly to first one through
processus articulationes os mandibulae.
3. linea mastoidea –posterior vertical line -- is parallel to first and second and passes
through the posterior margin of the base of mastoid process.
By this diagram a. meningea media is projected.
 Main trunk is projected in the crossing point of first(anterior) vertical line with
first(inferior) horizontal line.
 Anterior branch (r. anterior s.frontalis) is projected in the cross-point of the first
vertical line with second (superior) horizontal line.
 Posterior branch (r. posterior s. parietalis)- in the cross-point of the third(posterior)
vertical and superior horizontal lines.
Sulcus centralis (Rolandi) is projected by a line connecting the cross-points of the
anterior vertical line with superior horizontal line and posterior vertical line with the sagittal one.
The length of the line is measured by a part of the line between the middle and the posterior
vertical lines.
Sulcus lateralis (Silvii) is projected by the bisector of the angle between superior horizontal
and the projectional line of the central groove (sulcus centralis) of the brain.

OPERATIONS PERFORMED ON THE HEAD

Arrest of the Haemorrhage from the Head

For operation local or general anaesthesia may be employed. Position of the patient is
usually on the side (better) or on the back.
1. Haemorrhage from the soft tissues (skin, subcutaneous connective
tissue,aponeurosis,loose connective tissue) is arrested by ligature of the vessel, diathermy
coagulation, applying forceps (Kocher’s) or sewing through all layers.
2. Haemorrhage from the fracture of the skull (lamina diploe i.e. v.v. diploicae)- wax paste
is rubbed or bone is destroyed (pressed) by Luer’s nibbling forceps.
3. Haemorrhage from the vessels of the dura mater- ligature.
4. Haemorrhage from the vessels of the brain –application of a haemostatic sponge or
tampon with warm saline. Injury to the venous sinuses of the dura mater is followed by profuse
bleeding.
Haemostasis is obtained:
a) In case of the linear trauma (injury) of the external wall--sutures are put.
b) When there is a large tear- plastic by Burdenko is performed .From the superficial layer
of the dura mater processes (for example falx cerebri) , which is closer to the injured place , a
flap is made by means of which the tear is closed and fixed by interrupted sutures.
c) If there is a large defect or transverse tear of the wall of the venous sinuses,
ligation of both ends of the sinuses is made. Ligature of sinus sagittalis superior behind sulcus
centralis causes hard unsufficiency of the blood supply of the brain with mortal exit.
d) If there is profuse bleeding, bandages are inserted between lamina compacta
interna and dura mater into both sides of the injury till the lumen of the sinus is entirely closed
(firm tamponade). The bandages are taken away in 10-14 days when they are covered by slime
(mucus).

14
 Primary Surgical Treatment of the Skull Wounds
Classification of the Skull Wounds

I Not penetrating- without the tear of the dura mater.

II Penetrating- when dura mater is torn.
Not penetrating wounds can be:
1. Injury to the soft tissues (only)
2. Injury to the soft tissues and the bones of the skull
If only skin and subcutaneous tissue are damaged, the margins of the wound aren’t opened
widely, but the bleeding is profuse. In this cases pressing bandage or interrupted sutures are put.
The wounds, where the skin, subcutaneous tissue and galea aponeurotica are hurt, are usually
large, sometimes of terrible sizes (scalped wounds). Haemorrage is also profuse. Treatment of
the scalp wound is removal of the ragged edges, walls and floor of the wound with meticulous
examination of the skull. Then the wound is sutured through all layers with drainage of the
subaponeurotic space, if necessary.
Injury to the bones can be:
a) crack of the bone—no special surgical treatment is required.
b) fracture of the inner table (lamina compacta interna) with formation of big (more than
1cm) fragments while the outer table of the skull (lamina compacta externa) isn’t damaged--a
burr-hole is made through the normal skull by the side of the fractured portion, contaminated
fragments of the bone are removed, the wound is irrigated with warm saline and dura mater is
examined. Haemostasis is achieved and the wound is sutured through all the layers.
c) depressed fracture—all the free fragments (which have lost their connection with
supplying periosteum) must be removed. The borders of the bone wound are smoothened with
nibbling forceps. Then the same manipulations are made (as in point b).
Penetrating wounds must be treated in the special neuro-surgical clinics.

Trephination (Trepanatio)

Trephination is surgical opening of the skull cavity (cavum cranii). It’s a surgical access
which allows performing of the operations on the brain and on its layers.
Types of the trephination are:
I Cranioectomic (decompressive) –the part of the skull is removed forever.
II Craniotomic (osteoplastic) – the bony part is removed only during the operation
and returned to its place at the end of the operation.

Osteoplastic Trephination

Indications: all the volumetric formations located in the skull cavity which are to be
surgically evacuated (tumors, haematomae, abscesses, cysts etc). This operation is radical,
osteoplastic and as a rule- planned. Depending upon the location of the pathological process, the
operation can be performed in different regions of the skull.
As an example of osteo-plastic trephine, we’ll discuss the operation when there is injury to
a. meningea media with formation of epi- or subdural haematoma in the temporal region. Two
methods of this operation are described which a bit differ from each other by the surgical access.
1. One flap method (Wagner- Wolf) -1 skin-bone flap is formed.
2. Two flap method (Olivecron)-2 flaps are formed:
a) cutaneo-aponeurotic
b) periosteo-osseous
Kronlein’s diagram is drawn on the scalp. In the temporal region a horse-shoe shaped
incision is made with its base dirrected inferiorly. Skin-aponeurotic flap is formed by raising it
from the periosteum. Periosteum is also incised in the horse-shoe shaped manner. The edges of

15
the periosteum are raised from the bone by raspatory 1cm. 5-7 burr-holes are made on the skull
by the trephine 3-4 cm apart one from another. Two holes at the base of the flap are placed a bit
nearer to each other than the scalp incision, but at least 5-6 cm, so that the bone flap may break
easily through the narlayers base. By means of the special guide, a Gigli saw is passed between
the adjacent holes and the intervening bone is sawn under 45o, so that there will be outward
bevel in the osteo-periosseal flap. This will prevent the flap from sinking below its normal level
when placed in its position after operation on the brain. The flap is made in such a manner, that it
is remained uncut only in the base looking inferiorly. There the bone is slightly sawn from the
inner side and broken. Care must be taken not to raise periosteum from the bone flap, so
periosteo-osseal flap is formed. Dura mater is incised in the same shape (or U-shaped incision)
1cm internally in such a manner that its base will look towards the main vessels or the sinuses of
the dura mater. Epidural (extradural) or subdural haematoma (the clot) is washed by steam of the
warm normal saline. Operation is finished by finding and ligating the ruptured ends of a.
meningea media. If the proximal end of the artery is in the bone canal, last one is filled with
bone-wax. After the operation dura mater is sutured by absorbable sutures, periosteo-osseal flap
is fixed to the periosteum by interrupted sutures; skin- aponeurotic flap is fixed by non
absorbable sutures.

Decompressive Trephination

The main indication of this operation is stable increase of intracranial pressure, dangerous
for the patient’s life, as the important centres of medulla oblongata (respiratory centre and vaso-
motor centre) can be hurt as a result of inclination of the brain into foramen occipitalis magnum.
This operation is palliative,craneoectomic and as a rule is performed urgently, having vital
indications. Trephination is performed in the temporal region by Kushing’s method.
The choice of the place of decompressive trephination is conditioned by several
factors:
 In the temporal region the bone is thin.
 There isn’t any large venous sinus.
 There is a muscle which performs the function of drainage in the
postoperative period
Position of the patient is on the side (in most cases on the left side). The choice of the
side depends whether the patient is right-handed or left-handed as in this region (in the
operculum of the inferior frontal lobe of the contralateral side) motor centre of speech (Broca’s
centre) is located. In order not to hurt this centre, in right- handed patients the operation is
performed in the right side, in left-handed patients- in the left side. If its impossible to realize
which hand prevails (unconsciousness of the patient, absence of the relatives),the operation is
performed on the right side, as right –handed people are more in number than left-handed ones.
Technique of the operation. A horse-shoe shaped incision is made in the temporal region
(regio temporalis) through the linea temporalis inferior. Vertical incision passes through
aponeurosis temporalis and m. temporalis is split along its fibers. Periosteum is incised and
removed by raspatory in 20-25 square cm. In the midpoint a trephine or burr is held, and
gradually the opening is enlarged with nibbling forceps. Dura mater is incised by criss- cross
incision. Before the incision of very much tensed dura mater, cerebro-spinal puncture is
performed. CSF is evacuated a little at a time (10-30 ml) to prevent inclination and compression
of the brain trunk in the foramen occipitalis magnum. The wound is sutured layer by layer except
dura mater.

Plastic Closure of the Skull Defects

After decompressive trephination and surgical treatment of the skull wounds with an injury
to the bones of the skull, bone defects are remained ,which can be closed by the plastic methods
(if the patient wants) not earlier than 6 months after the first operation.

16
 Different methods are used for the plastic closure of the skull defects:
 Heteroplastic method—bones of the cadavers are used (it isn’t practiced
nowadays)
 Autoplastic method—the patient’s rib or iliac crest is used (it’s practiced rarely
 Alloplastic method—organic glass is used (it’s the most widely practiced
method nowadays)

Trephination of the Mastoid Process

(Antrotomia)

Indication- suppurative mastoiditis

Position of the patient- on his back, the head is turned to healthy side.
Technique of the operation- Parallel to the fixation of the concha of the auricle, a cm
posteriorly to it an incision is made 5-6 cm long up to the bone. Periosteum is raised in the
boundaries of Shipoult’s triangle, the bone is removed with chisel and hammer and cellulae
mastoideae are opened. The pus is evacuated; all the partitions between mastoid air-cells are
destroyed. The wound is drained. The wound heals by secondary stretch.

OPERATIVE SURGERY AND TOPOGRAPHIC ANATOMY OF THE NECK

TOPOGRAPHIC ANATOMY OF THE NECK

Boundaries of the Neck

Superior boundary is the inferior border of the mandible, anterior and posterior margins
of mastoid processes of temporal bones till asterion, superior nuchal line of occipital bone.
Inferior boundary is the superior margin of manubrium sterni and clavicles, the
imaginary line between acromions and spinous process of the 7-th cervical vertebra.
The neck is divided into two regions: anterior and posterior, by means of an imaginary
frontal plane and frontal septa of the second fascia of the neck which pass anteriorly from the
trapezius muscles and attach to the transverse processes of the cervical vertebrae. Posterior
region (regio cervicis posterior) is also called nuchal region ( regio nuchae)
The frontal part of the neck (regio cervicis anterior) is bisected by sternocleidomastoid
muscle (SCM) diagonally into anterior and posterior cervical triangles. Anterior (medial) triangle
of the neck is divided into suprahyoid and infrahyoid regions by the hyoid bone and posterior
bellies of digastric muscles. In the suprahyoid region we describe submandibular and submental
triangles. The infrahyoid region is divided into carotid and omotracheal triangles by the superior
belly of omohyoid muscle. Posterior (lateral) triangle of the neck is divided into omotrapezoid
and omoclavicular triangles by the inferior belly of omohyoid muscle.

Fasciae of the Neck

Fasciae of the neck by Shevkunenko are divided into five ones. This classification of five
fasciae is more necessary for surgical intervention.
I fascia is superficial cervical fascia. It is usually a thin layer, which surrounds the neck
and contains the platysma. This fascia is continued by general superficial fascia of the whole
body. It doesn’t have any place of attachment on the neck. In PNA this fascia is not described.
II fascia is lamina superficialis fasciae colli propriae (PNA lamina superficialis fasciae
cervicalis) surrounds the structures in the neck. It contains the SCM and trapezoid muscle and
submandibular gland. II fascia begins from the spinous processes of the cervical vertebrae,

17
traverses anteriorly and includes the trapezoid muscle. From the anterior border of the trapezoid
muscle the II fascia forms transverse septa to the transverse processes of the cervical vertebrae
and divides the cervix into anterior and posterior parts.
Inferiorly, it is attached to the
 Anterior surface of the manubrium and clavicles
 Acromions and spines of the scapulae

Superiorly, the II fascia is attached to the

 Superior nuchal line of occipital bone
 Mastoid processes of temporal bones
 Inferior border of the mandible
 Hyoid bone
Superior to the hyoid bone II fascia is divided into two layers (superficial and deep),
forming a sheath for the submandibular gland (saccus hyomandibularis). The deep layer is
attached to the internal surface of the mandible; the superficial layer is attached to the external
surface and traverses superiorly till zygomatic arch as fascia parotideo-masseterica. A.v. facialis
(vein lies superficially and the artery underlies the gland), lymphatic nodes are situated here.
III fascia is lamina profunda fasciae colli propriae or aponeurosis omoclavicularis
PNA(lamina pretrachealis f. cervicalis). It is extending between omohyoid muscles and it’s
present as a layer only in the anterior part of the neck. This fascia contains the infrahyoid
muscles (omohyoid, sternohyoid, sternothyroid and thyrohyoid). II and III fasciae are attached to
each other by medial cervical line to form linea alba colli which extends from the hyoid bone
inferiorly up to 3-4 cm not reaching the incisura jugularis of manubrium.
The III fascia is attached
 Superiorly to the hyoid bone
 Inferiorly to the posterior surface of the manubrium and clavicles
IV fascia is endocervical fascia (PNA vagina carotica), which is divided into two layers
(parietal and visceral). Visceral layer surrounds the thyroid gland, trachea, pharynx and
esophagus. Parietal layer surrounds these structures only anteriorly and laterally. Laterally, it
covers carotid bundle, which includes:
anteriorly and medially - common carotid artery
posteriorly and laterally - internal jugular vein
between them and posteriorly- vagus nerve
IV fascia extends from the base of the head till superior mediastinum.
V fascia is prevertebral fascia (PNA lamina praevertebralis f. cervicalis), which forms a
tubular sheath for the vertebral column and the muscles associated with it. The prevertebral
fascia extends from the base of the skull to T3 vertebra. It covers m.m. scaleni (anterior, media et
posterior), m.levator scapulae , splenius capitis and colli., a.v.subclavia, plexus brachialis.

Interfascial Spaces and Fatty Tissue of the Neck

Interfascial spaces are divided into two groups: interfascial spaces connected with other
regions and those, which are not connected.
Not connected spaces

1. Saccus hyomandibularis lies between two layers of the II fascia and encloses the
submandibular gland, facial vessels (vein lies superficially to the gland and artery underlies it)

18
fat and a few lymph nodes which collect lymph from the oral cavity. We can palpate these nodes
when the patient has inflammations in the oral cavity.
2. Spatium sternocleidomastoideum lies between two layers of the II fascia and
encloses SCM.
3. Spatium interaponeuroticum suprasternale lies between the II and III fasciae and
encloses the jugular venous arch, fat and a few lymph nodes. The jugular venous arch is an
anastomosis between anterior jugular veins. Laterally it is connected with spatium
retrosternocleidomastoideum.
4. Spatium retrosternocleidomastoideum lies between the II and III fasciae posterior
to the SCM and encloses the inferior ends of the anterior jugular veins, fat and lymph vessels.
5. Spatium praevertebrale lies between the V fascia and the cervical and the first
three thoracic vertebrae and encloses fat and sympathetic trunk.

Connected spaces

1. The carotid sheath (spatium vasoneurorum) is formed by the parietal layer of the
IV fascia. It extends from the base of the skull to the root of the neck and contains the
 Common carotid artery
 Internal jugular vein
 Vagus nerve
Artery lies a little medially, vein is laterally, nerve lies between the artery and the vein a
little posteriorly. Except these structures, it contains deep lymph nodes, carotid sinus nerve and
sympathetic fibres. If the patient has pus or blood in this space, it can spread into the
mediastinum.
2. Spatium praeviscerale lies between parietal and visceral layers of the IV fascia. It
encloses fat, plexus venosus thyroideus impar, inferior thyroid veins. The previsceral space may
contain thyroid ima artery in 10-15 % of cases. High arterial pressure exists in the thyroid ima
artery as it begins from the arch of aorta or brachiocephalic artery. The artery supplies the
isthmus of the thyroid gland and isn’t attached to the fascia. Depending on this, when the artery
is damaged, it reduces and bleeds into the mediastinum. We don’t know about it, because
bleeding is not visible in the area of the wound and we can’t help the patient. The patient can die.
The previsceral space opens inferiorly into the superior mediastinum.
3. Spatium retroviscerale (retropharyngeale ) lies between the IV and V fasciae. It
is the largest and most important interfascial space in the neck. It is potential space consisting of
loose connective tissue which may contain pus. The retrovisceral space is limited superiorly by
the base of the skull and laterally on each side by the carotid sheath. It opens inferiorly into the
superior mediastinum and pus can spread into it.

The Superficial Veins and Nerves of the Neck

The superficial veins of the neck have very important peculiarities. If the superficial veins
of the neck are damaged, the air embolism can develop. The superficial veins have the following
peculiarities:
 The veins don’t have any valves.
 The veins are situated near the chest and heart (they have negative pressure).
 Adventitia of the veins is attached firmly to the fasciae (because of this veins cannot
constrict).
The superficial veins of the neck lie between the I and II, and the II and III fasciae. They
are external jugular veins, anterior jugular veins, jugular venous arch and median cervical vein
(it may be absent). Damages to these veins are very dangerous for patient’s life. If more than

19
10.0 cm3 of air passes into the vein, the embolism of the pulmonary artery develops, because of
which the patient can die.
The superficial nerves of the neck are the nerves of cervical plexus: lesser occipital nerve,
greater auricular nerve, transverse cervical nerve, supraclavicular (medial, intermedial and
lateral) nerves.
Submandibular Triangle
(trigonum submandibulare)

Superior border is the inferior margin of the mandible. Anterior and posterior borders are
anterior and posterior bellies of m.digastricus.
1. The skin is thin, movable with subcutaneous fat and superficial fascia. Platysma
covers the most surface of this triangle except superiolateral angle. Nerve supply of the skin is
from r.colli n. facialis and r.superior n.transversus colli, which are joined here forming arcus
cervicalis superficialis. R.marginalis mandibulae (n.facialis) is also situated in subcutaneous fat
above this arch.
2. The second fascia (after Shevkunenko) with its two layers forms a sheath for
submandibular gland covering it anteriorly and posteriorly as well. Facial vein lies superficially
and facial artery underlies the gland. At the posterior border of the triangle v.facialis joins the
retromandibular vein. Facial artery turns to the upper deep surface of the gland and passes onto
the lateral surface of the face. At the inferior border of the mandible it gives off the submental
artery which runs to submental triangle with corresponding vein and the mylohyoid nerve (the
branch of n.alveolaris inferior).
3. The next layer consists of m.mylohyoideus and m.hyoglossus. N.hypoglossus
passes to the oral cavity between these two muscles. Lingual vein is situated on and lingual
artery under the hyoglossus muscle. The submandibular lymph nodes lie on the surface of the
submandibular gland. They drain the lymph from the tongue, teeth, lips and cheek into the deep
cervical lymph nodes.
Carotid Triangle
(trigonum caroticum)

This triangle bounded by the sternocleidomastoid muscle (SCM) laterally, posterior belly
of digastric muscle superiorly and the superior belly of omohyoid muscle anterioinferiorly,
contains the vertical neurovascular bundle of the neck, mainly covered by corresponding part of
SCM.
1. The skin is thin, movable with superficial fascia and platyzma which covers this
triangle completely. R.colli n.facialis, r.superior n.transversus colli and v.jugularis anterior are
situated in the fat under platyzma.
2. II fascia by Shevkunenko is represented in one layer.
3. Under this fascia internal jugular vein, the carotid arteries, the vagus nerve are
situated covered by lamina parietalis f.endocervicalis by Shevkunenko (vagina carotica, PNA).
This fascial sheath encloses the neurovascular bundle, deep lymph nodes and fat. Carotid artery
lies medially, internal jugular vein lies laterally, n.vagus is between them and deeper.
The internal jugular vein descends vertically first with the internal then with the common
carotid artery. The facial vein enters the carotid triangle over the posterior belly of digastric
muscle. It units with the anterior branch of the retromandibular vein and enters internal jugular
vein. The lingual vein and superior thyroid vein enter either the internal jugular vein or the facial
vein.
The common carotid artery is divided at the level of the upper border of the thyroid
cartilage into internal and external branches. Usually external carotid artery is situated
superficially and medially to internal.
The internal carotid artery has no branches on the neck.
The external carotid artery gives off 7 branches in carotid triangle.

20
 1. The superior thyroid artery, which gives off superior laryngeal artery.
2. The lingual artery.
3. The facial artery, which arises above the lingual one and gives off ascending palatine
artery, which supplies the palatine tonsil.
4. The occipital artery.
5. The sternocleidomastoid artery, supplies the muscle.
6. The posterior auricular artery.
7. The ascending pharyngeal artery.
In the carotid triangle hypoglossal nerve gives off the superior root of ansa cervicalis,
which descends lying on the internal and common carotid arteries and joins the inferior root of
ansa cervicalis from cervical plexus. As a result a loop is formed called ansa cervicalis which
supplies the infrahyoid muscles (sternohyoid, sternothyroid, thyrohyoid and omohyoid).
The deep cervical lymph nodes are situated around the internal jugular vein and form the
jugular lymph trunk.

Omotracheal Triangle
(trigonum omotracheale)

This is the space under the hyoid bone bounded by the sternocleidomastoid and superior
belly of omohyoid. The median plane divides it into left and right omotracheal triangles.
1. The skin is thin, moveable with superficial fascia. Platysma covers only supero-
lateral surfaces of the triangle.
2. II fascia by Shevkunenko. Anterior jugular veins are situated under the superficial
fascia. They enter spatium interaponeuroticum suprasternale which is situated between the II
and III fasciae and form an anastomosis called jugular venous arch (arcus venosus juguli).
3. III fascia encloses the pretracheal muscles. The altitude of the spatium
interaponeuroticum suprasternale is 3-4 cm, above which the II and III fasciae combine and
form linea alba cervicis.
4. Parietal and visceral layers of the IV fascia by Shevkunenko. Between the parietal
and visceral layers of endocervical fascia the previsceral space is situated, which contains fat,
plexus venosus thyroideus impar, inferior thyroid veins and in 10-15% of cases- thyroid ima
artery. The cervical organs are situated deeper and are covered by visceral layer of endocervical
fascia (IV). Here larynx and trachea are situated, deeper- pharynx and esophagus, superficially
and laterally - thyroid lobes with parathyroid glands on their postero-medial surfaces.
5. V fascia by Shevkunenko. Retrovisceral space is situated between the
endocervical (IV) and prevertebral (V) fasciae.

Sternocleidomastoid Region
(regio sternocleidomastoideus)

Sternocleidomastoid region is located between the medial and lateral triangles of the
neck, and coincides with location of the SCM muscle.
1. The skin in superior third of the region is thick, unmovable, but in inferior two
thirds it’s thin and movable. Platysma covers only medial third of this region.
2. II fascia by Shevkunenko which forms a sheath for SCM muscle. External jugular
vein, superficial lymph nodes and branches of cervical plexus are situated on the SCM. External
jugular vein begins behind the angle of the mandible by the junction of the posterior branch of
the retromandibular vein with the posterior auricular vein. It passes vertically downwards and
pierces the II, III and V fasciae (by Shevkunenko) at the posterior border of the SCM above the
clavicle and drains into the subclavian vein. As we know adventitia of the vein is attached firmly
to the fascia, because of this, the vein cannot constrict and air embolism may develop, if it’s

21
injured. The branches of cervical plexus are n. auricularis magnus, n. transversus colli, n.
occipitalis minor, n.n. supraclavicularis medialis, intermedius et lateralis.
3. Under the inferior third of SCM, inferiorly to the omohyoid muscle saccus caecus
retrosternocleidomastoideus takes place between the II and III fascia by Shevkunenko.
4. V fascia by Shevkunenko. Deeper, under the prevertebral fascia, scaleno-vertebral
triangle is described. The base of this deep triangle is copula of pleurae - apex of the lung,
medial border is vertebral column with splenius colli, lateral border is anterior scalenus muscle.
The top of this triangle is tuberculum caroticum of the transverse process of the VI vertebra. I
part of subclavian artery, brachiocephalic veins, ganglion cervico-thoracicum (g. stellatum) and
thoracic duct (in the left side) are situated in this triangle.
The left subclavian artery arises from the arch of aorta; the right subclavian artery arises from
the brachiocephalic trunk. Each artery may be divided into three parts. First part is situated on
the cervical pleura (in the deep triangle of the neck) medial to scalenus anterior. The second part
is behind it (in spatium interscalenum) and the third part is lateral to it (in omoclavicular
triangle). It ends at the outer border of the first rib behind the midpoint of the clavicle.
The branches of the first part of subclavian artery are:
1. a. vertebralis
2. a. thoracica interna
3. truncus thyreo-cervicalis, which gives rise to;
a) a. thyroidea inferior
b) a. cervicalis ascendens
c) a. cervicalis superficialis
d) a. suprascapularis
From the second part of subclavian artery truncus costo-cervicalis arises, which gives off:
a) a. cervicalis profunda
b) a. intercostalis suprema (for I and II intercostal spaces)
From the third part of subclavian artery a. transversa colli arises.
Each brachiocephalic vein begins by a junction of internal jugular and subclavian veins which is
called venous angle.
The thoracic duct enters the posterior surface of the venous angle from the left side. The
thoracic duct is a thin-walled vessel, which collects the lymph from the whole body except the
right anterior thoracic wall, upper limb, right side of the neck and the head. The lymph from
these parts of the body is collected by the right jugular and clavicular lymph trunks which open
into the right venous angle.

Lateral Cervical Triangle

(trigonum colli laterale)

Bounderies of this region are:

anteriorly – posterior border of the SCM
posteriorly – anterior border of the trapezoid muscle
inferiorly – superior surface of the clavicle
This triangle is subdivided into two triangles by the posterior belly of the omohyoid
muscle (superiorly is omotrapezoid, inferiorly – omoclavicular triangles).
1. The skin is thin, without hair, movable with subcutaneous tissue.
2. Next layer is superficial fascia (I fascia by Shevkunenko) with platyzma.
3. II fascia by Shevkunenko is perforated by the branches of the cervical plexus at the level
of the posterior border of the SCM. There are n.auricularis magnus, n.transversus colli,
n.occipitalis minor, n.n.supraclaviculares medialis, intermedius et lateralis.
4. Next layer is V fascia by Shevkunenko in the omotrapezoid triangle. N.accessorius is
located between II and V fasciae.

22
 In omoclavicular triangle after the II fascia, the III fascia is present, then the V fascia.
There the scalenal spaces are described.
Spatium antescalenum is limited: anteriorly by the clavicle, posteriorly – m.scalenus
anterior. V.subclavia and n.phrenicus (between V fascia and scalenus anterior muscle) pass
through this space.
Spatium interscalenum is limited: anteriorly by the m.scalenus anterior, posteriorly by
the m.scalenus medius, inferiorly – anterior surface of the first rib. A.subclavia and plexus
brachialis are situated in this space.

OPERATIONS ON THE NECK

During the operations on the neck it becomes clear that the surgeon has to manipulate
with a great number of various veins injury to which causes very severe results: haemorrhage
and air embolism. As very high pressure appears in the veins while coughing and tension, the
last ones can give rise to considerable, sometimes profuse bleeding. A small, unnoticed during
the operation or badly ligatured vessel suddenly starts to bleed heavily. So one must keep to the
rules:
1. Carefully and immediately ligature every, even small vessel.
2. It’s forbidden to leave in the wound the forceps which are used for haemostasis as
the veins can rupture easily from the weight of the instrument.
3. It’s forbidden to use pricking instruments (Kocher’s forceps, dissecting forceps
with teeth etc).
Air embolism is more dangerous complication of the injury to veins. It appears as a result
of the following processes:
 during the inspiration negative pressure appear in the veins but the lumen of the big
vein remains open
 as the veins of the neck refer to the system of v. cava superior, they don’t have any
valves
 sucking power of the heart.
The main attention of the surgeon must be concentrated on embolism prevention.
The operation must be performed under complete anaesthesia as intensified inspiration
which is associated with the feeling of pain, causes decrease of pressure in the veins and
facilitates the development of air embolism. The most correct method to prevent the injury to the
veins is layer by layer incision, anatomical operation under eye control.
The operations on the neck conventionally are divided into 4 groups:
1. operations on the vessels
2. operations on the nerves
3. operations on the organs
4. operations on the purulent processes of the neck

OPERATIONS ON THE VESSELS

Peculiarities of Exposure and Ligature of the Large Arteries of the Neck

A. carotis communis with its branches ( a.a.carotis externa et interna) and a. subclavia
refer to the large arteries of the neck. From the point of view of modern surgery and with the
development of the field of surgery called angiosurgery, the ligation of the large arteries is
undesirable and is experienced in exceptional cases. But it is necessary to know the principles
and the peculiarities of such a ligature for proper usage in extreme situations.
As long standing surgical experience, gained especially during world wars, shows, the
ligature of the common carotid artery (a. carotis communis) approximately in 44-50% cases

23
brings to the development of mental disorders in the form of temporary or permanent paralyses
and disorders of speech, in 30-40% cases brings to death from the softening of the brain parts.
Complications which bring to the death of the patient, when external carotid artery (a.
carotis externa) is ligated, are rare and are mainly the result of technical mistakes. The ligature
of the internal carotid artery (a. carotis interna) brings to decompensation of the brain blood
supply on the side of the ligature with softening of the parts of the brain and 100% mortality.
The ligature of the subclavian artery (a. subclavia) above the clavicle (in the region of the
neck), is technically more difficult and more dangerous than the ligature of the same artery under
the clavicle. In all cases care must be taken to ligature the artery distally to truncus
thyreocervicalis(to provide the collateral blood circulation of the limb). During the operation on
the left side it is necessary to remember about the possibility of hurting the thoracic duct.
Indications of the exposure and ligature of the big arteries are injuries to the arteries,
arterial aneurysms, arterio-venous by-pass grafting, secondary haemorrhages(during flegmons of
the neck), trombectomy. The temporary ligation of a.a. carotis communis et externa is
experienced in some operations on the throat, face or pharynx, sometimes in the angiography of
the arteries.
Position of the patient is always on his/her back. A sand bag is put under the shoulder
blades to hyperextend the neck. The face is turned to the opposite side.

Exposure of a. carotis communis is possible on different levels:

1. between the heads of m. sternocleidomastoideus (SCM)
2. in omo-trachial triangle (trigonum omo-tracheale)
3. in carotid triangle (trigonum caroticum)
Technique: The incision of 6 cm long is made in carotid triangle along the anterior
margin of m. SCM downwards from the level of the superior border of thyroid cartilage. The
skin, the subcutaneous tissue and platysma are cut along the line of incision. The sheath of m.
SCM is opened. The muscle is divided from its sheath in a blunt way and is retracted laterally.
The posterior wall of the sheath is opened, through which m. omohyoideus is seen, crossing the
incision obliquely. The posterior wall of the sheath is incised on the probe, which carries a
groove (dissector). After it the sheath of the neuro-vascular bunch is opened. The superior
branch of the cervical loop (r. superior ansae cervicalis), which lies on the sheath and obliquely
crosses the artery, is retracted before the opening of the sheath. The above mentioned sheath is
incised on the dissector along the artery, in order not to hurt the internal jugular vein (v. jugularis
interna). The elements of the bunch are opened: a. carotis communis, v. jugularis interna, n.
vagus. Care must be taken not to hurt n.vagus while isolating the artery.

Exposure of a. carotis externa is made in carotid triangle. An incision of 6-7 cm long is

made at the medial margin of the SCM muscle downwards from the angle of the mandible. After
the incision of the superficial layers, the sheath of the neuro-vascular bunch is seen (parietal
layer of the 4th fascia). It is incised on the dissector. V. facialis with the veins draining into it is
pushed upward. If it is impossible, they are divided between ligatures (care must be taken not to
hurt v. facialis). Then, in the inferior angle of the incision, on the level of the superior margin of
the thyroid cartilage, the place of bifurcation of a. carotis communis is found. A. carotis externa
is carefully isolated. It differs from a. carotis interna not only by lying more anteriorly and
medially but also by branches extending from it. In case of hesitation, the vessel can be pressed
against the vertebral column (or by two fingers) and the pulse of a. temporalis superficialis on
the zygomatic arch- palpated. If a. carotis externa is pressed, the pulse disappears.
It is better to ligature a. carotis externa above the place where a. thyreoidea superior
extends. Ligature of the artery close to the bifurcation isn’t recommended, as the thrombus
which is formed in the place of the ligature, can spread into a. carotis interna and occlude it.
Exposure of a. subclavia is performed in the omoclavicular triangle. An incision is made
a transverse finger superiorly and parallel to the clavicle from the posterior margin of m. SCM up

24
to the anterior margin of m. trapezius. The skin, subcutaneous fatty tissue, superficial fascia and
the fibres of m. platysma are incised layer by layer. The second fascia of the neck is incised on
the dissector and Gruber’s space is opened. After ligature or retraction of the veins which pass
through this space, the third fascia is incised. Widening the incision by retractors, the fatty tissue
is loosened and the trunk of the brachial plexus and the margin of m. scalenus anterior, which
are covered by the fifth fascia, are exposed. The artery lies at the lateral margin of the muscle,
inferiorly, medially and deeper to plexus brachialis.
The technique of the ligature of all large arteries is the same. It is recommended to put 3
ligatures on the large arteries: two on the proximal end and one on the distal. The first one is put
on the proximal end loosely. It damps the power of the pulsation wave on the second (main)
ligature. The second ligature is put 0,5 cm far from the first one. The third ligature is put 1,0cm
far from the second, and between the second and the third ligatures the artery is cut in order to
release the spasm from the collaterals (desympathisation).
In order to improve the collateral circulation and level the arterial and venous streams, it
is recommended to ligature (by 2 ligatures) and as well to cut the accompanying vein after
ligature of the large artery.

OPERATIONS ON THE NERVES

Cervical Vago-Sympathetic Blocade (by Vishnevsky)

Indications:Prevention and treatment of the pleuro-pulmonal shock when there is injury
to thoracic and abdominal cavities. By the blocade it becomes possible to prevent the shock
when there is combined thoraco-abdominal injury, and also to prevent postoperative shock after
serious operations.
Position: typical
Technique of the operation: The surgeon puts the index of the left hand at the posterior
margin of m. SCM, on the level of its cross-point with v. jugularis externa. This place is pressed
trying to retract medially the vessels and palpate the anterior surface of cervical vertebrae.
Without reducing the pressure, the surgeon makes novocaine “lemon-peel” on the skin at the top
of his index. Then a long needle is inserted through the “lemon-peel” and is pushed deeper,
upward and medially towards the anterior surface of vertebral column. The insertion of the
needle is accompanied by a preceeding stream of novocaine. When the needle reaches the
vertebral column, the insertion is stopped and the needle is pulled back 3-5mm. The top of the
needle must be obligatory pulled, as the injection of the solution behind prevertebral space
causes severe pain.
Being certain, that there is no backward flow of novocaine or blood from the needle, 0,25
-0,5 % 40-60ml of sol. novocaini is injected.
Spreading in the form of crawling infiltrate, along fascia prevertebralis(spatium
retroviscerale), solution of novocaine contacts with the epineurium of n. vagus, tr. sympathicus,
sometimes- n. phrenicus.
If the blocade is performed properly, hyperaemia of the face, conjunctiva of the eye and
not expressed Clode-Bernar-Horner’s syndrome occur. The signs of this syndrome are:
 contraction of the pupil(myosis)
 lowering of the superior eyelid(ptosis)
 sinking of the eyeballs (enophthalmus)
The blocade releases the pain and the cough-reflexes, tones up the cardio-vascular
system.
The blocade of n. vagus is performed by Burdenco’s method. After exposure of the
neuro-vascular bunch n. vagus is defined and 2ml of 2% novocaine solution is injected
epineurally. If there are indications for long term blocade, a thin drainage is left close to the
nerve (not more than for 2-3days) for periodic irrigation of the nerve with novocaine.

25
 Complications: apnoea, aphonia, paresis of the intestine, in severe cases- syncope and
death.

OPERATIONS ON THE ORGANS

Tracheotomy (Tracheotomia). Tracheostomy(Tracheostomia)

Tracheotomy (opening of the trachea) with following tracheostomy is an emergency

operation which is carried out in order to provide access of the air into the lungs in those cases
when upper parts of the respiratory tract are impassable for the air.
Indication of the tracheotomy is asphyxia, which can develop because of the following
reasons:
1. injury to the neck, particularly to larynx and trachea
2. injury to the skull and brain ,and injuries to the jaw and face
3. submucous haematomae of the larynx
4. foreign bodies of the larynx and trachea
5. stenosis of the larynx and pharynx on the base of acute inflammatory oedema caused by
 burnt of the upper respiratory tracts
 military toxic agents
 infectious diseases (diphtheria, tuberculosis, syphilis)
6. long term laryngospasm (allergy, anaphylactic shock, military toxic agents)
7. paralysis of respiratory centre
8. paresis of the vocal cords
9. tumours of the pharynx, larynx, thyroid gland, etc
10. in case of necessity of long term artificial ventilation of the lungs
Most of these indications require urgent surgical intervention which must be obligatory
performed by each doctor in any circumstances.
Classification. Depending on how long the tracheostomic opening (cannula) is left,
temporary and permanent tracheostomies are distinguished.
Depending on the level of the incision of the trachea, the following tracheostomies are
distinguished:
1. high tracheostomy- the opening is made above the isthmus of the thyroid
gland(the isthmus is retracted downwards). It is performed in adults.
2. medium tracheostomy- on the level of the isthmus, after it is incised. It isn’t
performed in practice because of its traumaticy and difficulty.
3. low tracheostomy- below the isthmus. It is performed in children, as their isthmus
is higher, is fixed to the cricoid cartilage and is hardly retracted downwards.
Position of the patient is on his/her back, the head is fully extended by placing a pillow
under the shoulders. The midline must be strictly followed to prevent the displacement of the
trachea.
Anaesthesia is usually local. Sometimes general anaesthesia is administered. In urgent
cases no anaesthesia is necessary, because in such patients sensitivity is decreased as a result of
the influence of the high concentration of carbonic acid in blood (hypercapnia).
Recently tracheostomy is performed under endotracheal anaesthesia, if it’s possible (if
the narlayersing of the vocal fissure permits it). In this case the operation is performed under
normal aeration of the lungs. Besides, the trachea is incised on the endotracheal tube, which
prevents the danger of injury to the posterior wall of the trachea.
Technique of the high(superior) tracheostomy- The surgeon stands on the right side of the
patient. 5cm incision is made from the middle part of the thyroid cartilage downwards exactly in
the midline. The skin, subcutaneous fatty tissue and the first fascia are incised. V. mediana colli
is retracted to the side or divided between 2 ligatures. Then “linea alba colli” is incised on the
dissector, after which sternohyoid and sternothyroid muscles are retracted to the sides. Cricoid

26
cartilage and the thyroid isthmus lying under it are defined. The layer of the 4th fascia which was
fixing the isthmus to the cricoid cartilage in the transverse direction is incised. After it the
isthmus is separated in a blunt way and retracted inferiorly. Haemorrhage is carefully arrested,
cricoid cartilage is fixed by a sharp hook which is inserted to steady the trachea and pull the
larynx and trachea upwards. Then the trachea is incised. The surgeon fixes the top of the scalpel
1cm (by his index or adhesive plaster) directed upwards to avoid injury to other structures, by
sawing movements the 2nd- 3rd cartilages of the trachea are incised. Strong cough reflex occurs
after the air passes into the trachea and causes irritation of the mucous membrane. Slime or
flakes of diphtheritic membrane are often blown out. Apnoea follows the cough and disappears
after a while. To avoid repeated cough reflex, several drops of dicaine are dropped into the
lumen of the trachea during apnoea. Then Trusso’s tracheal delator is at once inserted into the
opening and Luer’s cannula (tube) is introduced into. The last one is performed in 3 steps:
1. the cannula is inserted installing the shield in the sagital plane
2. the cannula is turned in such a way that the shield appears in the frontal plane
3. the cannula is pushed into the depth of the trachea
Several sutures are put on the skin. A square piece of split gauze is slipped under the
shield of the tube. Two tapes attached to the shield of the tube are passed round the neck and tied
in order to fix the tracheostomic tube.
Technique of the low(inferior) tracheostomy-It is considered to be more difficult. But in
practice the low one is performed more often, as in 67% of adults the gland has such a structure
and location, that the retraction of the isthmus is impossible without the risk of damage and
profuse bleeding. Besides, the pathological process (big trauma, tumours etc) spreads on to the
lower parts of the larynx and even trachea very often, and high tracheostomy cannot provide the
desired effect. So low tracheostomy is considered to be an operation of choice.
The surgeon stands on the left side of the patient. An incision is made exactly in the
middle line from the notch of the sternum up to the cricoid cartilage. After the soft tissues are
incised, the second fascia is divided and spatium interaponeuroticum is opened, where arcus
venosus juguli is situated. After retracting or dividing it between 2 ligatures, the third fascia is
incised and the muscles (m.m. sternohyoideus, sternothyroideus) are exposed. After retracting
the muscles to the sides, the surgeon incises the parietal layer of the 4th fascia on the dissector
and enters into the spacium previscerale(sp. pretracheale), in the loose connective tissue of
which pl. thyreoideus impar, v.v. thyreoideae imae and sometimes a. thyreoidea ima(12%) are
located. The vessels are ligated and cut. Injury to a. thyreoidea ima is dangerous, as the high
blood pressure in it is nearly equal to the aortic pressure. Besides, the artery isn’t fixed to the
fascia and when it is hurt, the proximal end of it contracts and bleeding in the wound isn’t
noticed, as the blood flows into the anterior mediastinum. So the surgeon’s manipulations in this
space must be extremely careful. Particularly, the manipulations are dangerous in the lower angle
of the wound, as in children v. brachiocephalica sinistra ascends high and can be located above
the jugular notch.
The trachea is separated from the 4th fascia, and the 4th-5th cartilages (rings) of the trachea
are incised. The further phases of the operation are the same as in high tracheostomy.
The final evacuation of the cannula(decannulation) is performed when the signs of the
asphyxia disappear. The wound of the trachea heals and closes quickly.
At the permanent tracheostomy, before the cannula is inserted, mucous membrane of the
trachea is sutured with the skin, so after decannulation the wound remains open.
Mistakes and complications of tracheostomy. The mistakes which are made during the
operation, can appear as complications just during the operation and after it. Depending on it, the
complications are divided into 2 groups:
1. Intraoperative
2. Postoperative
The last ones in their turn are divided into:
 The early complications- the first 1-2 days

27
  The late complications- after 2 days

Intraoperative complications:
1. Injury to a. carotis communis and v. jugularis interna when the incision is made not in
the midline and the trachea is incised without being fixed.
2. Injury to the veins of the neck (v.v. mediana colli, arcus venosus juguli, v.v. thyreoideae
imae, pl. thyroideus impar) brings to the air embolism.
3. Injury to a. thyroidea ima can bring to the mortal haemorrhage.
4. When the mucous membrane of the trachea isn’t incised, the cannula is inserted into the
submucous layer by a mistake and thus asphyxia is deepened.
5. Aspirational asphyxia (flow of the blood into the trachea) when there is unreliable
haemostasis.
6. When there are flakes of diphteritic membrane, clots of the blood and slime lower the
level of the tracheostomic opening, the insertion of the cannula without preliminary evacuation
of them, brings to the deepening of the asphyxia.
7. Introduction of the cannula, when there is insufficient (inadequate) incision of the
trachea, can squeeze the cartilage into the lumen.

Early postoperative complications

1. Secondary bleedings
2. Obstruction (corking) of the cannula by the thick slime or clots of blood.
3. Development of subcutaneous emphysema, when the diameter of the cannula is smaller
than the tracheostomic opening. This complication doesn’t develop, if the cannula is inserted
with obturator-cuff.
4. Partial or total spontaneous decannulation
5. Phlegmon of the mediastinum develops as a result of the injury to the posterior wall of
the trachea and anterior wall of the esophagus if the top of the scalpel isn’t fixed. Later
esophago-tracheal fistula develops.

Late postoperative complications.

1. Aspirational pneumonia with its complications (pleuritis, abscess of the lung, empyema
of the pleura etc).
2. Perichondritis of the tracheal cartilages followed by their necrosis, when the
tracheostomic opening is smaller than the diameter of the tube.
3. Granulational and scar strictures after decannulation
4. Tracheitis, bronchitis as a result of the flow of the air into the trachea without entering the
upper respiratory system.

OPERATIONS OF THE PURULENT PROCESS OF THE NECK

Operations on Neck Abscesses and Phlegmons

The phlegmons of the neck can be superficial and deep. The first ones develop in the
subcutaneous tissue, the second ones frequently appear as complications of the primary
supurative inflammations of the face, the neck, the oral cavity and the pharynx or acute
infectional diseases (scarlet fever, erysipelas, typhus etc), when lymphatic nodes together with
the surrounding fatty tissue(lymphadenitis) are included into the process .
The typical places of the development of the neck abscesses and phlegmons are:
submental and submandibular regions, the sheath of m. SCM, the sheath of neuro-vascular
bunch, the previsceral, retrovisceral and retropharyngeal spaces. Besides the general
complications (sepsis, hard intoxication), the deep inflammatory processes of the neck are also
dangerous because they can spread along the fatty tissue into the anterior and posterior
mediastinum , give rise to the squeeze of the trachea and oedema of the larynx(with the

28
following asphyxia), include the walls of the large vessels into the inflammatory process
resulting in their melting and hard haemorrhages.
So the main principle of the treatment is the incision made in good time, which provides
adequate large opening of all the pockets, where the pus can accumulate.
The incision on the neck must satisfy the cosmetic requirements and provide sufficient
access to the organs. The most of these requirements are satisfied by the incisions which
coincide with the direction of the natural folds of the skin (Kocher’s collar-form incision). But
often we have to make longitudinal incisions, especially in the midline. Sometimes combined
incisions are made. The incision must be made layer by layer cutting the fascia on the dissector.
Blunt instruments must be used, if it is possible (probes, closed scissors and forceps), in order
not to hurt the blood vessels changed by the pathological process.
The operation is finished by the loose tamponade or drainage of the wound.
The phlegmons of the submandibular region are opened by an incision, which is parallel
to the margin of the mandible. After the skin, the subcutaneous fatty tissue, superficial fascia and
m. platysma are incised, the surgeon goes deeper in blunt way. Care must be taken not to hurt a.
et v. facialis.
The phlegmons of the floor of the oral cavity (angina Ludowici) in the early stages of the
disease are opened by a longitudinal incision from the chin up to the hyoid bone. The skin, the
subcutaneous tissue, the superficial fascia of the neck are incised. Then we go deeper in a blunt
way through the raphe of mylohyoid muscles. In difficult cases a large incision is made parallel
to the margin of the mandible, a transverse finger below it, from one angle of the mandible to
another.
The phlegmons of the neuro-vascular sheath are opened by an incision, which passes
along the anterior or posterior margin of the m. SCM. The separation of the tissues situated
deeper to the muscle is made with great precaution in order not to hurt the neuro-vascular bunch.
In cases when the pus flows out of the boundaries of the sheath into the regions of the lateral
cervical triangle, the incision is made above the clavicle, parallel to it, from the posterior margin
of m. SCM to the anterior margin of m. trapezius.
The phlegmons of the previsceral space are opened by a transverse (or parallel to the
jugular notch) incision through the layers and the white line of the neck. If the cartilages of the
larynx or the trachea are damaged, tracheostomy is performed obligatory.
The phlegmons of the retrovisceral space are opened in the same way as in the case of
esophagus-along the anterior or posterior margin of the left m. SCM. After the exposure of the
vascular bunch m. SCM is retracted laterally together with the vessels. The vertebral column,
trachea and esophagus are palpated by a finger. If the abscess isn’t defined it’s enough to
separate in a blunt way the fascia and the fatty tissue, for the pus to appear. One must remember
that the esophagus begins on the level of the 4th cervical vertebra. Above it the retrovisceral
space is replaced by the retropharyngeal space.
The retropharyngeal abscess is usually opened through the mouth by a scalpel the blade
of which is wrapped with adhesive plaster, except the top in order not to hurt the deeper tissues.
After the incision the patient’s head is bent anteriorly not to let the pus get into the respiratory
system.

OPERATIVE SURGERY AND TOPOGRAPHIC ANATOMY OF THE THORAX

TOPOGRAPHIC ANATOMY OF THE THORAX

The thorax extends between the neck and abdomen. The superior boundary of the thorax
is the superior margin of manubrium sterni and clavicles, an imaginary line which extends
between acromions and spinous process of the 7-th cervical vertebra. The inferior boundary is

29
the xiphoid process, costal arches (arcus costae), and free ends of the 11th and 12th ribs, inferior
margin of 12-th pair of ribs till 12-th thoracic vertebra. The thorax consists of the thoracic wall
and cavity. The thoracic cavity includes the mediastinum and pleural cavities. The wall consists
of so called movable and own layers.
We describe several imaginary lines on the thoracic wall. It is necessary for the
description of wounds and organs, which are situated in the thoracic cavity. We use the
following imaginary lines (all of these lines are parallel to each other):
1. Linea mediana anterior passes through the midline of the sternum.
2. Linea sternalis passes through the lateral margin of the sternum.
3. Linea medioclavicularis passes through the middle point of the clavicle.
4. Linea parasternalis passes through the middle point of the distance between linea
sternalis and linea medioclavicularis.
5. Linea axillaris anterior begins from the inferior border of the m. pectoralis major.
6. Linea axillaris posterior begins from the inferior border of the m. latissimus dorsi.
7. Linea axillaris media passes through the middle point of the distance between linea
axillaris anterior and linea axillaris posterior.
8. Linea scapularis passes through the inferior angle of the scapula.
9. Linea vertebralis passes through the lateral margins of the thoracic vertebrae.
10. Linea paravertebralis extends in the midpoint of the distance between linea
vertebralis and linea scapularis.
11. Linea mediana posterior passes through the spinous processes of the thoracic
vertebrae.
The thorax is divided into anterior and posterior parts by a plane, which traverses through
the middle axillary lines. By means of the sternal and vertebral lines, the thorax is divided into
the following regions:
1. Regio sternalis.
2. Regio vertebralis.
3. Regio thoracalis anterior superior and inferior. The border between these 2
regions is an imaginary line, which passes through the inferior margin of the 5th pair of ribs (or
inferior margin of m. pectoralis major).
4. Regio thoracalis posterior superior and inferior. The border between these
regions is an imaginary line, which passes through the inferior angles of the scapula.
The so-called movable layers are the same in all regions, such as the skin, fatty tissue,
fasciae and muscles with their peculiarities in each region.
The own layers include the bones of the thorax (vertebrae, sternum, ribs), the intercostal
muscles and f. endothoracica.
In topographic anatomy of the chest the anterior superior thoracic region interests us most
of all, because the breast containing mammary gland is situated here.

Anterior Superior Thoracic Region

(Regio thoracica anterior superior)

The boundaries of this region are:

Superiorly -- the clavicle
Inferiorly -- the inferior margin of the 5-th rib
Laterally -- sulcus deltoideopecoralis
Medially -- linea sternalis
1. The skin is thin and in men is covered by hair.
2. The subcutaneous connective tissue contains the superficial nerves n. n.
supraclaviculares medialis et intermedius ( branches of the cervical plexus).
3. The superficial fascia which contains the mammary gland.
4. The mammary gland

30
 5. The deep fascia is divided into two layers: the superficial- called fascia pectoralis
and the deep- called fascia clavipectoralis. Fascia pectoralis forms a sheath for m. pectoralis
major and divides the muscle into three parts by fibrous dense septa. The parts are called pars
clavicularis, pars sternocostalis and pars abdominalis. Fascia clavipectoralis forms sheaths for
m. pectoralis minor and m. subclavius. Here we describe three triangles which have very
important significance for practical medicine. A.v. axillares and plexus brachialis are situated in
the lateral side of these triangles. These triangles are called:
1. Trigonum clavipectorale which is between the clavicula and superior margin of m.
pectoralis minor.
2. Trigonum pectorale coincides with m.pectoralis minor.
3. Trigonum subpectorale which is between the inferior margins of the m. pectoralis
minor et major.
Arterial supply of the anterior superior thoracic region is derived from:
 Anterior intercostal branches of the internal thoracic artery, a branch of the subclavian
artery;
 Lateral thoracic, thoracic suprema and thoracoacromial arteries, branches of the axillary
artery;
 Posterior intercostal arteries, branches of the thoracic aorta;
 Intercostal suprema arteries, branch of the subclavian artery;

Breasts

The breasts containing mammary glands are located in the superficial fascia of the
anterior thoracic wall. The boundaries of the mammary gland are:
Superiorly -- the 3-d rib
Inferiorly -- the6- 7-th ribs
Medially -- the lateral border of the sternum
Lateral-- linea axillaris anterior.
1. The skin is thin, without hair and not movable. The gland is firmly attached to the
dermis of the overlying skin by fibrous septa called the suspensory ligaments (Cooper’s ligament
–lig. suspensorium mammarium). At the greatest prominence of the breast there is a nipple,
surrounded by a circular pigmented area called the areola.
2. The connective tissue includes a number of separate pockets filled with fat, except
the zone of areola. There is no fat.
3. The superficial fascia is divided into two layers forming a capsule for mammary
gland. It takes part in the fixation of the mammary gland to the clavicle (lig. suspensorium
Giraldes). Two layers of superficial fascia are attached to each other by fibrous dense septa
which traverse through the mammary gland and split it into up to 20 lobes. Each lobe of the
gland is drained by a lactiferous duct. Two or three neighboring lactiferous ducts are connected
with each other to form lactiferous sinus. They are situated in the subareolar zone. The
lactiferous ducts from the sinuses open on the nipple. It is very dangerous to make an incision in
this zone, because the lactiferous ducts can be damaged.
4. The next layer is the deep fascia. Between the gland and the deep fascia, there is
loose connective tissue containing little fat known as the retromammary space (bursa), which
allows the breast some degree of movement.
Arterial supply of the breast is derived from
 Anterior intercostal branches of the internal thoracic artery, a branch of the subclavian
artery
 Lateral thoracic and thoracoacromial arteries, branches of the axillary artery
 Posterior intercostal arteries, branches of the thoracic aorta
Lymphatic drainage of the breast is important due to its role in the metastasis (spread) of
cancer cells. The lymph passes to the subareolar plexus, and from it

31
  Most lymph (about 75%) drains into the axillary lymph nodes, mainly to the
pectoral group (Zorgius’ lymph node), but some lymph drains into the apical, subscapular, lateral
and central groups.
 Most of the remaining lymph drains into the infraclavicular, supraclavicular, deep
cervical, transpectoral, and parasternal (internal thoracic) lymph nodes.

Own layers

As we’ve already mentioned above, the wall of the thoracic cavity consists of so called
movable and own layers.
The own layers include the bones of the thorax (vertebrae, sternum, ribs), the intercostal
muscles, which form intercostal spaces together with the ribs, and f. endothoracica, covering the
wall internally.
The boundaries of the intercostal spaces are:
Superiorly -- the inferior border of the upper rib.
Inferiorly -- the superior border of the lower rib.
Anteriorly-- the external intercostal muscle.
Posteriorly--the internal intercostal muscle.
The intercostal spaces involve fat and a.v.n. intercostales. The anterior and posterior
intercostal arteries are situated there. The anterior intercostal artery is a branch of the internal
thoracic artery (a branch of subclavian artery), posterior one is a branch of thoracic aorta.
External intercostal muscles (m.m. intercostales externi) begin from the inferior border of
the rib above, outside to its groove (sulcus costae), pass inferiorly and anteriorly to the superior
border of the rib below. The external intercostal muscles extend from the vertebrae up to the
costochondral joint and anteriorly are replaced by the external intercostal membrane.
Internal intercostal muscles begin from the superior margin of the rib below, pass
superiorly and attach to the inferior margin of the rib above, inside the costal groove. The
direction of the muscle fibers is nearly under right angle in relation to the external intercostal
muscles. They extend from the lateral border of the sternum up to the costal angle and
posteriorly are replaced by the internal intercostal membrane. The grooves in the inferior border
of the ribs appear to be between the external and internal intercostal muscles, as a result
intercostal space is formed, which is filled with fatty tissue and neuro-vascular bundle passes:
superiorly-the vein, inferiorly to it-the artery, and more inferiorly- the nerve.
The thoracic wall is covered by f. endothoracica from the inner side.

Topographic Anatomy of the Pleura

The lungs are surrounded by a thin serous membrane-pleura,which consists of two layers
– external and internal. Internal or visceral pleura (pleura visceralis s. pulmonalis) is densely
joined with lungs. It enters into the depth of the grooves, so also covers the interlobar surfaces of
the lungs. The internal surface of the thorax is covered by the external or parietal pleura (pleura
parietalis). At the hilus of the lung it turns into the visceral pleura. The pleural cavity (cavum
pleurae) is a potential space between parietal and visceral layers of pleura, which contains a
capillary layer of serous liquid-pleural fluid, that lumbricates the pleural surfaces and allows the
layers of the pleura to slide smoothly over each other during respiration.
Two pleural cavities – right and left are situated within the thoracic cavity, and
mediastinum is located between them.
The parietal layer of pleura can be topographically subdivided into four portions: the
cupola of pleura (cupula pleurae), the costal pleura (pleura costalis), the diaphragmatic pleura
(pleura diaphragmatica) and the mediastinal pleura (pleura mediastenalis).

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 1. The cupola of pleura is formed above the apex of the lung by parietal layer of pleura. It
is located in the area of neck, and in front it is projected 2-3 cm above the clavicle; at the back it
is projected on the level of spinous process of the VII cervical vertebra.
2. The part of parietal pleura, which covers diaphragm, is called diaphragmatic pleura. It
covers the convex part of diaphragm, except the place, where pericardium is densely fastened
with diaphragm.
3. The part of parietal pleura, which borders mediastinum from sides, is named
mediastinal pleura.
4. The part of the parietal pleura, which covers the internal surface of the thoracic wall
(sternum, costal cartilages, ribs intercostal muscles, intercostal membranes and sides of thoracic
vertebrae), is called costal pleura. We distinguish the upper, lower, front and back borders of
costal pleura.
The upper border of costal pleura corresponds to the top of thoracic aperture, and above
that place it turns into the cupola of pleura.
The lower border of costal pleura corresponds to the lower margin of cartilage of VI rib
by parasternal line, to the lower margin of the cartilage of VII rib by middle clavicular line, to
the X rib by middle axillary line, to the XI rib by scapular line, to the lower margin of XII rib by
paravertebral line.
The lungs do not completely occupy the pleural cavities during inspiration and a kind of
reserve space is formed in the places of transition of one part of the parietal pleura into another
called pleural sinus (sinus pleurae). Because of the presence of pleural sinuses, the pleural cavity
is larger than the lung volume.
The following sinuses are distinguished:
1. A costodiaphragmatic sinus (sinus costodiaphragmaticus) is formed in the place
of transition of the costal pleura into the diaphragmatic one. The lower border of
costodiaphragmatic sinus is located below the lower margin of the lungs. Costodiaphragmatic
sinus is the largest one, and it reaches the greatest depth by the right axillary line (up to 9 cm).
The other pleural sinuses are smaller.
2. In front, costodiaphragmatic sinus is proceeded by the front costomediastinal
sinus (sinus costomediastinalis anterior), which is located between the ventral part of the costal
pleura and the mediastenal pleura.
3. At the back, costodiaphragmatic sinus turns into the back costomediastinal sinus
(sinus costomediastinalis posterior), which is located between the dorsal part of the costal pleura
and mediastinal pleura.
4. Mediostinodiaphragmatic sinus is a small space, which is formed in the place of
transition of the diaphragmatic pleura into the mediastinal one.

Mediastinum

The mediastinum is the central portion of the thoracic cavity between the pleural sacs.
Boundaries:
anterior boundary is the sternum covered by f. retrosternalis from inside.
posterior –thoracic vertebrae, the necks of the ribs and f. prevertebralis;
lateral--mediastinal pleura covered by f. endothoracica;
inferior-- diaphragm covered by f. diaphragmatica
superior--superior aperture of the thorax (an imaginary plane between incisura jugularis
and II thoracic vertebra).
For descriptive and surgical purposes, mediastinum is divided into four compartments.
Superior mediastinum is the space between the superior aperture of the thorax and an
imaginary plane passed through the upper border of the lung roots which extends from the
sternal angle to the intervertebral disc between the IV and V thoracic vertebrae. It contains
thymus, v.v. brachiocephalicae, v. cava superior, arcus aortae with its branches (a. carotis

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communis sinistra, a. subclavia sinistra, tr. brachiocephalicus), trachea, esophagus, ductus
thoracicus , trunci sympathici, n.n. vagi, n.n. phrenici.
Below the plane the mediastinum is subdivided into the anterior, middle and posterior
mediastinum.
Anterior mediastinum is between the sternum (f.retrosternalis) anteriorly and anterior
wall of the pericardium posteriorly. It includes fat, retrosternal lymph nodes, a.a. thoracicae
internae which pass laterally to the sternum and are covered by endothoracic fascia.
Middle mediastinum is between the anterior surface of the pericardium anteriorly and
posterior surface of the tracheal bifurcation and the posterior wall of the pericardium posteriorly.
It includes the heart with the intrapericardial parts of the large vessels which enter the heart and
those which go out of it, such as aorta ascendens, pulmonary trunk, pulmonary veins, v. cava
superior, v. cava inferior and tracheal bifurcation with the principle bronchi. N.n. phrenici, a.v.
pericardiophrenicae, fat and lymph nodes are also situated there.
Posterior mediastinum is between the posterior surface of tracheal bifurcation and
posterior wall of the pericardium anteriorly and vertebral column (bodies of the IV-XII thoracic
vertebrae) covered by f. praevertebralis posteriorly. It includes aorta descendens, v.v. azygos,
hemiazygos, tr.sympaticus, n.n. splanchnici, n.n. vagi, esophagus, ductus thoracicus, fat, lymph
nodes.

OPERATIONS ON THE THORAX

Incisions at the Suppurative Mastitis

Purulent processes in the breast can be located under the skin, between the lobules of the
gland, between the fascial capsule of the gland and the fascia pectoralis (deep retrommary
mastitis).
When there is definite abscess formation, the treatment is drainage of the pus. Respective
surgical treatment depends on the depth, location and spread of the abscess.
Mostly radial incisions are preferred taking into account the radial direction of the breast
lobules and their ducts, in order not to hurt them.
Position-The patient lies on her back.
Anaesthesia- Local or general anaesthesia.
Technique of the operation
1. When there is a superficial single abscess, the incision should be made over the area of
maximum tenderness, preserving the lactiferous duct of the lobe, without reaching the areola.
Incision passes through the skin and superficial fascia and when it reaches the breast substance,
the pus will well-up. A finger is then insinuated through the incision. All septa, forming recesses,
should be broken.
2. When the abscess cavity is quite deep, it would require a contra-incision at the most
dependent area, in the radial direction. The cavity is washed with 3% solution of hydrogen
peroxide. The wound is dried, drained by pads with hypertonic saline. In a day the pads are
replaced by a drain. A rubber drain is introduced through the 2 incisions.
3. When the abscess is in the deep layers of the inferior half of the breast or there is a
retromammary abscess, a semicircular incision is made along the submammary fold. The
mammary gland is elevated and an incision is made along the skin fold (Bardenheuer’s incision).
The incision is also called Gaillard Thomas’ submammary incision, which is as well of cosmetic
value and can be used for drainage of retromammary abscesses. In the last mentioned case (when
the abscess or flegmon is behind the gland, between it and the pectoral fascia) the pus is
evacuated, the cavity is drained. If there is a deep intraglandular abscess, the same incision is
used. The skin and the subcutaneous fatty tissue are cut, the mammary gland is elevated and its
posterior surface is exposed. The opening of the pus cavity is made from the deep surface of the

34
capsule. The pus is evacuated; the cavity is examined by a finger and drained. At this method the
lactiferous ducts are not damaged, the postoperative scar is hardly noticed and the form of the
breast isn’t changed.

Puncture of the Pleural Cavity

The puncture is performed for diagnostic purpose, as well as for treatment (drainage of
the pleural cavity when there is pathological fluid or air).
Indication. Pathological fluid (effusion, blood or pus) or air (pneumothorax) in the pleural
cavity
Position of the patient. Sitting, the head is flexed anteriorly, the hand on the side of the
puncture is elevated.
When there is pathological fluid in the pleural cavity, the puncture is made in the VII-
VIII intercostal space between the middle axillary and scapular lines. When there is air in the
pleural cavity, the puncture is made in the II-III intercostal space on the midclavicular line.
When there is saccate fluid (often pus), the puncture is made in the site of localization of the
fluid after it is defined by the “X”-rays.
Technique of the operation. The site of the puncture is infiltrated with local anaesthetic
solution(e.g. procaine or lidocaine). The skin of the intercostal space is elevated forming a fold
by the fingers of the left hand and a large needle is introduced along the superior margin of the
inferior rib to prevent injury of the intercostal nerves and vessels. A rubber tube is connected to
the large needle. The end of the tube is connected to the 20 ml injector by means of a metallic
cannula. To prevent the entrance of the air into the pleural cavity while emptying the injector, the
lumen of the rubber tube is occluded by forceps. When there is a lot of fluid, not more than 1litre
can be drained at a time, in order to prevent vasomotor collapse.
The puncture is performed in aseptic conditions and when finished, the place of puncture
is covered by a sterile bandage. If it is necessary, the puncture is repeated the next day.
Complications.
1. Artificial pneumothorax.
2. Haematoma of the intercostal space.
3. When the needle is introduced deeper, in the right side one can hurt the liver, in the
left- the spleen.
4. Pleuritis can develop, when the principles of the aseptic and antiseptic aren’t
preserved.

Puncture of the Pericardial Cavity

Puncture of the pericardial cavity by Larrey is performed for diagnostic and treating
purposes (for drainage of the cavity, when there is pathological fluid inside).The volume of the
fluid can reach 1-2 liter and seriously hurt the work of the hurt- causes its tamponade. Treatment
is surgical in form of aspiration, which is carried out by a needle introduced into the cavity.
Position of the patient: half- sitting.
Anaesthesia: infiltrating local anaesthesia .
Technique of the operation: a needle is introduced through the left costo-xiphoid angle (an
angle between the base of the xiphoid process and the place of attachment of the 7th costal
cartilage). At first the needle is introduced perpendicularly 1,5cm deep. The needle passes
through the skin, then subcutaneous tissue and medial edge of m. rectus abdominis with its
aponeurotic sheath. The direction of the needle is then changed parallel to the wall of the chest, it
pierces upwards and medially 2-3 cm more and punctures the pericard. If the pulsation is felt, it
means that the top of the heart is close to the needle. After aspiration of the effusion, the point of
the puncture is covered with aseptic bandage.

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 Treatment of the Pneumothorax

Pneumothorax is a condition when the air enters the pleural cavity. There are different
types of pneumothorax which are commonly met in surgical practice: closed, open and valvular.
Closed pneumothorax. This condition occurs when either thoracic wall or the lung
parenchyma are injured. In both cases the air enters the pleural cavity only once- at the time of
the trauma. Depending upon the amount of the air which entered the pleural cavity , either
partial or complete collapse of the lung develops. A small amount of the air is absorbed in 2-3
weeks and the lung subsequently re-expands. When the lung is pressed more than in ¼ of its
volume, the air should be evacuated from the pleural cavity by pleural puncture.
Open pneumothorax. This condition occurs when the air enters the pleural cavity through
the penetrating wound in the chest wall. During the inspiration the air freely enters the pleural
cavity and goes out during the expiration. The lung usually is completely collapsed and is out of
ventilation. Treatment of the condition is closure of the wound in the chest hermetically as soon
as possible. This may be done by an aseptic occlusion bandage put on the wound, thus
transforming the open pneumothorax into the closed one. Later the patient must be operated-the
wounds of the chest and the lung are sutured.
Valvular pneumothorax. The condition is fatal. This type of the pneumothorax occurs as a
result of an injury either to the chest wall or to the lung. In both cases a”valve ”is formed either
by the chest wall or by the lung tissue, which allows the air to pass in one direction. The air
enters the pleural cavity during inspiration, but its exit is prevented during the expiration due to
the closure of the valve (closure of the wound edges). The volume of the air in the pleural cavity
gradually increases with each inspiration, thus transforming the valvular pneumothorax into the
tension one. The lung is completely collapsed and the mediastinum shifted to the opposite
(healthy) side.
Treatment of the patient with valvular pneumothorax requires immediate intervention to
save the patient’s life. Puncture of the chest wall by a wide-bore needle is performed to
evacuation the air from the pleural cavity. Later an occlusion bandage is put (external valve) or
drainage of the pleural cavity is performed (internal valve). The drainage is made in the II-III
intercostal space through the midclavicular line.

TOPOGRAPHIC ANATOMY OF ABDOMEN

Studying abdomen, we distinguish the walls of the abdomen and its cavity or abdominal
cavity (cavitas abdominis). The abdominal wall consists of anterolateral and posterior parts. The
abdominal cavity includes the peritoneal cavity (cavitas peritonei) with internal organs, which
relate to the peritoneum in different ways (intra-, meso- and extraperitoneally) and
retroperitoneal space (spatium retroperitoneale) with retroperitoneally situated organs (organa
retroperitonealia).
Internal boundaries of the abdominal cavity don’t coincide with external ones. Superiorly,
internal boundary of the abdomen is diaphragm. Its dome deeply enters the thoracic cavity.
Inferiorly abdominal cavity is separated from the pelvic cavity by means of an imaginary plane
passing through the terminal line (linea terminalis).

Anterolateral Abdominal Wall

Boundaries:
Superior boundary is formed by the margins of the costal arches (arcus costae) and
xyphoid process
Inferior boundary is formed by the crests of the iliac bones, inguinal ligaments and pubic
symphysis

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 The lateral boundaries, which separate the anterolateral abdominal wall from the lumbar
region, are the vertical lines, which pass from the anterior ends of the XI ribs to the iliac crests.
Practically they coincide with the posterior axillary lines.
By two horizontal lines the anterolateral wall is divided into 3 regions:
1. Epigastrium
2. Mesogastrium
3. Hypogastrium
The first horizontal line is between the lower points of the 10th pair of ribs and is called
bicostal line (linea bicostarum)
The second horizontal line is between spinae iliacae anteriores superiores and is called
bispinal line (linea bispinarum)
By two vertical lines which pass through the outer borders of the rectus muscles, each of
these above mentioned regions is divided into three ones, so nine regions are formed: epigastric,
right and left hypochondric, umbilical, right and left abdominal lateral, suprapubic, right and left
inguinal.
Layers:
1. Skin is elastic, moveable, except umbilical region, is covered by hair only in the
inferomedial part.
2. Subcutaneous fatty tissue, which contains superficial vessels:
 A. circumflexa ilii superficialis
 A. epigastrica superficialis
 A. pudenda externa (sometimes there are two arteries)
All the arteries are branches of the femoral artery. The veins, which are located above the
umbilicus, drain into the superior caval vein; veins below the umbilicus drain into the inferior
caval vein. So cava-caval anastomosis is formed. The superficial veins of anterior abdominal
wall form anastomosis between the portal and the caval venous systems (porto-caval
anastomosis). Paraumbilical veins pass the blood to the portal vein through the round ligament of
the liver and they make anastomoses with the veins above and below the umbilicus surrounding
it. If the patient has portal hypertension, the veins are enlarged; this anastomosis becomes well
expressed and visible through the skin as snake-like plexus, hence this symptom is called caput
Medusae.
3. The superficial fascia over the most of the wall consists of two layers that contain a
variable amount of fat. In the inferior part of the wall, the layers of the superficial fascia pass
separately:
a.A fatty superficial layer (Camper’s fascia) is extended to other regions as a superficial
fascia of the whole body.
b. A membranous deep layer (Scarpa’s (Thomson’s) fascia) is attached to the
inguinal ligament.
4. The external oblique (m. obliquus abdominis externus) is a superficial flat muscle; its
fibers pass inferomedially and in inferior part are replaced by aponeurosis, which is attached to
the spina iliaca anterior superior and tuberculum pubicum, forming the inguinal ligament (lig.
inguinale s. Puparti). The inferior part of the aponeurosis of the external oblique muscle is
divided into two parts called crura (medial and lateral). Medial crus is attached to the symphisis
pubis and lateral one - to the tuberculum pubis. Between the medial and lateral crura the
intercrural fibres(fibrae intercrurales) are located. This kind of fibers we can find also in the
inferior part again between the pedicles. The ligament is called Colles’ ligament (lig. reflexum s.
Collesi). Medial and lateral crura, intercrural fibers and reflex ligament form the superficial
inguinal ring (annulus inguinalis externus s. subcutaneous).
5. The internal oblique (m. obliquus abdominis internus) is the intermediate flat muscle. Its
fibers have fan-like direction. They run at right angle to those of the external oblique in the upper
part. In the middle part they run horizontally. In the lower part they pass downwards and are
attached to the lateral third of the inguinal ligament.

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 6. The transversus abdominis (m. transversus abdominis) is the innermost flat muscle; its
fibers except the inferior ones, run more or less horizontally.
7. Rectus muscle of the abdomen (m. rectus abdominis) has vertical direction from the
xiphoid process and costal arch to the pubis. The muscle is interrupted by 3-4 tendinous
intersections (intersectiones tendineae) on its extent, which are located at the level of the xiphoid
process, umbilicus and halfway between these two structures. Pyramidal muscle is located
medial to the rectus muscle in the inferior part near the pubis.
All three flat muscles end medially in a strong sheetlike aponeurosis. The fibers of each
aponeurisis interlace at the linea alba abdominis with their fellows of the opposite side to form
the sheath of the rectus muscle. The rectus sheath is different above and below the umbilicus.
The anterior wall of the sheath in its superior part consists of the aponeuroses of the external
oblique and the superficial layer of the internal oblique muscles. Posterior wall consists of the
deep layer of internal oblique and transversus abdominis. The anterior wall of the inferior part
consists of aponeuroses of the external oblique, internal oblique and transversus abdominis
muscles. Inner surface of the rectus muscle is covered only by transversalis fascia. In the sheath
of the rectus muscle posterior to the muscle two arteries are located: a. epigastrica superior
(branch of a.thoracica interna), which descends and forms an anastomosis with a. epigastrica
inferior (branch of a. iliaca externa) on the level of the umbilicus. Inferior epigastral artery
begins from the external iliac artery, ascends in extraperitoneal fat, then perforates the
transversalis fascia and situates between the muscle and fascia.
Between the internal oblique and transversus abdominis muscles the deep neurovascular
bunches are situated:
 The lower 6 pairs of intercostal arteries, veins and nerves. They are situated as follows:
7th, 8th and 9th pairs supply the tissue superior to the umbilicus, 10th supplies around the
umbilicus, 11th and 12th supply inferior to the umbilicus. They pass inferoanteriorly from the
intercostal spaces to supply the abdominal skin and muscles.
 N.n. ilioinguinalis and iliohypogastricus innervate the skin inferior to the umbilicus. The
first one passes through the inguinal canal. The nerves are branches of the lumbar plexus.
8. A firm membranous sheet called the endoabdominal fascia, which covers the abdominal
wall from inside. This fascia covers the deep surface of the transversus abdominis muscle and its
aponeurosis, so here it is called transversalis fascia. Inferiorly the transversalis fascia is attached
to the inguinal ligament. An aperture is located on the transversalis fascia just superior to the
midpoint of the inguinal ligament and lateral to the inferior epigastrtic artery. The aperture is the
deep inguinal ring. It is the delicate place of the anterior abdominal wall. Oblique inguinal hernia
develops here.
9. The parietal peritoneum is internal to the endoabdominal fascia and is separated from it
by a variable amount of extraperitoneal fat called Langenbek’s fatty tissue layer. Here a.
epigastrica inferior and a.circumflexa ilii profunda (branches of external iliac artery) are located.

Inguinal Region and Inguinal Canal

The inguinal region (regio inguinalis) is paired, located in both (right and left) sides of regio
hypogastrica. The boundaries of the inguinal region are: superiorly- linea bispinalis, medially-
lateral margin of the rectus muscle, inferiorly- inguinal fold or inguinal ligament.
In the medial angle of the inguinal region we describe the inguinal space. It is bounded:
superiorly by the free fibers of internal oblique and transversus abdominis muscles, medially –
lateral margin of rectus abdominis muscle and inferiorly – inguinal ligament. Hence the inguinal
space is the weak area of the anterior abdominal wall. The inguinal hernia develops there.
The inguinal canal is located in the inguinal triangle, in the thickness of the anterior
abdominal wall. It is an oblique, inferomedially directed passage for the spermatic cord through

38
the inferior part of the anterior abdominal wall. It lies parallel and just superior to the medial 2/3
of the inguinal ligament. The contents of the inguinal canal are the spermatic cord in males, the
round ligament of the uterus in females, and the ilioinguinal nerve in both sexes.
The inguinal canal has:
 Anterior wall formed mainly by the external oblique aponeurosis
 Posterior wall formed by transversalis fascia
 Roof formed by arching fibers of the internal oblique and transversus abdominis
muscles
 Floor formed by the superior surface of the inguinal ligament
The inguinal canal has superficial and deep rings, which we have already described.

Spermatic Cord

The spermatic cord suspends the testis in the scrotum and contains structures running to
and from the testis.
The coverings of the spermatic cord are formed by three layers of fascia derived from the
anterior abdominal wall during the fetal period:
 The internal spermatic fascia from the transversalis fascia
 The cremasteric fascia from the fascia covering the internal oblique
 The external spermatic fascia from the external oblique aponeurosis
The constituents of the spermatic cord are
 Ductus deferens (vas deferens)
 Testicular artery arising from the lateral aspect of the aorta
 Artery of the ductus deferens arising from the inferior vesical artery
 Cremasteric artery arising from the inferior epigastric artery
 Pampiniform plexus, a venous network formed by the anastomosis of up to 12
veins
 Sympathetic and parasympathetic nerve fibers on the ductus deferens
 Genital branch of the genitofemoral nerve
 Lymphatic vessels

Internal Surface of Abdominal Wall

The internal surface of the abdominal wall is covered by parietal peritoneum. The
infraumbilical part of the wall exhibits several peritoneal folds, some of which contain remnants
of vessels that carried blood to and from the fetus. Five umbilical folds (two on each side and
one in the median plane) pass superiorly toward the umbilicus.
 Two lateral umbilical folds covering the inferior epigastric vessels run superomedially on
each side
 Two medial umbilical folds cover the medial umbilical ligaments, the remnants of the
fetal umbilical arteries
 One median umbilical fold extending from the apex of the urinary bladder to the
umbilicus covers the median umbilical ligament, the remnant of the urachus that joined the apex
of the fetal bladder to the umbilicus
The fossae between the umbilical folds are the:
 Supravesical fossa between the median and medial umbilical folds.
 Medial inguinal fossa between the medial and lateral umbilical folds. It’s behind
the superficial inguinal ring.
 Lateral inguinal fossa is lateral to the lateral umbilical fold. It corresponds to the
deep inguinal ring.

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 Inguinal Hernia

Abdominal hernia is a protrusion of abdominal content, viscus (organ), or part of it

covered by peritoneum through the natural or new formed opening of the abdominal wall. About
90% of herniae are located in the inguinal region. There are two types of inguinal hernia: indirect
and direct.
Oblique inguinal hernia
 Leaves the abdominal cavity laterally to the inferior epigastric vessels to enter the deep
inguinal ring
 Passes through the inguinal canal and lies in the coverings of the spermatic cord
 Exits from the superficial inguinal ring and enters the scrotum
 Has a hernial sac formed by parietal layer of the peritoneum
The oblique inguinal hernia can occur in females as well, but it is about 20 times
morecommon in males at all ages.

Direct inguinal hernia

 Leaves the abdominal cavity medially to the inferior epigastric vessels (usually passes
through the inguinal space)
 Does not enter the deep inguinal ring (protrudes through the posterior wall of the inguinal
canal) so its hernial sac is covered by transversalis fascia as well
 Exits from the superficial inguinal ring and usually doesn’t enter scrotum
 Has a hernial sac formed by parietal peritoneum, which lies outside the coverings of the
spermatic cord
In the area of the inguinal space (Hesselbach’s triangle), internal oblique and transversus
muscles are absent; here are only transversalis fascia and aponeurosis of the external oblique
muscle. Direct inguinal hernias are much less common than indirect inguinal hernias, and they
usually occur in middle-aged and elderly men symmetrically from both sides. Direct inguinal
hernias are uncommon in women.

LAPAROTOMIC INCISIONS

The term “laparotomy” means opening of the abdominal cavity in surgical purpose. It
serves as an access for surgical operations as well as for examination of the abdominal cavity.
While making accesses to the organs of the abdominal cavity, one must keep to the
general rules of disconnecting the tissues.
All abdominal incisions are divided into 5 groups:
1. Longitudinal
2. Transverse
3. Oblique
4. Combined
5. Changing

1. Longitudinal incisions
 The median incision is made through the midline. We can start from the xyphoid
process up to the umbilicus which is passed by from left side (superior). If it’s necessary, the
incision may be continued downwards up to the pubic symphysis (inferior).
 Paramedian incision is made parallel to the midline at a distance of about 2 cm
lateral to it. The skin, subcutaneous tissue, superficial fascia and anterior rectus muscle sheath
are incised along the line of the incision. The rectus muscle is retracted laterally, then the
posterior rectus muscle sheath, the transversalis fascia and the parietal peritoneum are incised.

40
  Transrectal incision is made about 3-4 cm lateral and parallel to the midline. The
anterior rectus sheath is divided along the line of the incision, while rectus musle is split
longitudinally along the muscle fibers direction. The incision is made in the medial third of the
muscle. In long incisions the medial portion of the divided rectus muscle becomes derived of
nerves and hence loses its strength. But in practice it does provide a strong scar and isn’t
dangerous for postoperative herniae. Such an incision is made superior to the umbilicus in the
left side during gastrostomies.
 Pararectal incision is mostly made on the lower abdomen over the lateral part of
the rectus muscle 1-2 cm medial to its lateral border. Anterior rectus sheath is divided, then the
muscle is retracted medially by a blunt hook, then the posterior rectus sheath, transversalis
fascia, Langenbeck’s fatty tissue and the parietal peritoneum are incised along the line of the
skin incision. The peritoneum, transversalis fascia and the posterior rectus sheath are closed in
one layer; the muscle is allowed to fall on this suture line. The anterior rectus sheath is sutured
and the superficial layers are closed. Such an incision is made below the umbilicus in
appendectomy (Lenander’s incision).

2. Transverse incisions have definite advantages, though they aren’t widely practiced.
These incisions can be made on the upper abdomen as well as on the lower abdomen.
 Upper transverse laparotomy is made in the medial part of the distance between
the xyphoid process of the sternum and umbilicus.The skin, the subcutaneous tissue, superficial
fascia, anterior and posterior rectus sheath, rectus muscle are incised transversely; round
ligament of the liver (lig. teres hepatis) is ligatured and cut. One must remember, that superior
epigastric artery with its veins is situated between the posterior surface of the rectus muscle and
posterior rectus sheath.
 Inferior transverse laparotomy is made the middle part of the distance between the
umbilicus and the pubic symphysis. It can be made totally or in one side as well. While making
this incision, one must remember, that inferior epigastric artery (with accompanying veins)
passes behind the posterior rectus sheath in Langenbeck’s fatty tissue.

3. Oblique incision. Kocher’s incision is one of such incision, which is made parallel to
the right costal arch, 2 cm below it. This incision provides good access to the liver, gall bladder
and bile ducts. The similar left side incision makes an access to the spleen.

4. Combined incisions are made by combination of 2 incisions chosen from 3 above

mentioned ones. Feodorov’s incision is one of such kind. It begins from the xyphoid process,
descends longitudinally in the midline, and then is continued parallel to the right costal arch
(midline + right subcostal incision). This incision can be made for an access to the liver, gall
bladder and bile ducts.

5. Changing incisions. The directions of the separation of the tissues in different layers
don’t coincide with each other. The muscles are not cut but split. Multilayer closure forms a
rough postoperative scar, which is firmer and prevents the appearance of hernias. It’s the
advantage of these incisions.
 Pfanenshtile’s incision
Inferior changing laparotomy is made 3-4 cm above pubic symphysis, through the skin
fold, between the lateral margins of the rectus muscles. Anterior rectus sheath is cut along the
same incision. Both rectus muscles are retracted laterally. The transversal fascia and parietal
peritoneum are cut longitudinally, opening the abdominal cavity.
 McBurney’s incision

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 Inferior lateral changing incision passes through McBurney’s point, i.e. the point between
lateral and middle thirds of the line connecting right anterior superior iliac spine with the
umbilicus. The incision passes perpendicular to the spino- umbilical line 1/3 of which is above
the line and 2/3- below the same line. The skin, subcutaneous fatty tissue, the superficial fascia
are incised. One must be careful not to injure n. iliohypogastricus, which passes 1-2cm lateral to
this incision. However if it is injured, the posterior wall of the inguinal canal weakens and makes
possibility for the formation of hernia.
The external oblique aponeurosis is incised along its fibres, then internal oblique and transversus
muscles are split along the direction of their muscle fibers. It is commonly used for
appendicectomy.

OPERATIONS FOR INGUINAL HERNIAE

More than 200-s of methods are discribed for surgical treatment of the inguinal herniae.
They differ from each other only by the last phase, i.e. by the repair method of the inguinal
canal.
So the discription of the first phases will be represented in generalized form, taking as an
example the operation of reducible hernia (hernia reponibilis) in males.
Position of the patient – On his back.
Anaesthesia – Local, general or spinal anaesthesia may be performed.
Technique – The skin incision is made 2cm medial and parallel to the inguinal ligament,
from the superior anterior iliac spine up to the pubic symphysis. The skin, subcutaneous fatty
tissue, two layers of the superficial fascia are incised, superficial epigasric artery is divided
between two artery forceps and is ligated along the line of the incision. The aponeurosis of the
external oblique muscle is well exposed, separated bluntly from the subcutaneous fatty tissue and
incised on the grooved probe, inserting it through the external opening of the inguinal canal. So
the inguinal canal is opened. The inferior layer of the aponeurosis is bluntly separated from the
spermatic cord, thus exposing the inguinal ligament along its whole length.
In oblique inguinal hernia the sac containing the intrabdominal viscera is in the thickness
of the spermatic cord, so m. cremaster must be split to expose the sac which has characteristic
whitish shade. One must remember, that n. ilioinguinalis passes in front of m. cremaster. When
the nerve is hurt, pain and decrease of sensitivity occur in the region of the postoperative scar.
The sac wall is clipped with pairs of artery forceps (Bilrot’s forceps) and being sure that
there isn’t any content in that region, the sac is incised. One must be carefull in sliding herniae
(herniae labentes), when one of the walls of the hernia is formed by a hollow organ, which may
be incised instead of the sac, what is, of course, not desirable. The margins of the opened sac are
clipped by Mickulich’s forceps. The content of the sac (if it exists) is reduced (pushed back) into
the abdominal cavity by an anatomical dissector. The hernial sac now is separated from
surrounding tissues in blunt and sharp ways. The sac must be separated very carefully, under eye
control, because it’s often adherent to the spermatic cord and to its elements. Injection of
novocaine solution between the sac and the cord or so called hydraulic split, facilitates the
harmless separation of the tissues. All the parts of the sac (the bottom, the body and the neck)
must be separated.
In direct inguinal herniae the sac is situated medial to the spermatic cord and isn’t firmly
connected with it, so it is separated up to the neck easily.
After the separation of the sac, the neck is sutured in two ways, depending upon its width.
In case of narlayers neck, a transfixing suture is put, which passes through two opposite walls
and then is tied from both sides of the neck. A purse-string suture is put in case of the sac with
wide neck or sliding hernia. The ends of the suture are held with a pair of the artery forceps and
aren’t tied until the surgeon is sure that there is no content in that part. Then the sac is incised
and removed. It’s a fragrant technical mistake when a long stump is left.

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 After the incision of the sac, sutures are put (interrupted or continuous) on the transverse
fascia, which repair the normal size of the deep inguinal ring of the inguinal canal.
Then plastic repair of the inguinal canal is performed. All the herniotomic methods differ
from each other by this phase of the operation.
Generally all the operations may be divided into two big groups:
 Anterior wall repair methods
 Posterior wall repair methods
If the tissues, which form the walls of the inguinal canal are sutured in front of the
spermatic cord, they refer to the first group, and if the tissues are sutured behind the cord- to the
second group.

Anterior Wall Repair Methods of Herniorrhaphy

Girard’s method (1894)
The lower margins of the muscles (internal oblique and transversus) are sutured by the
first layers sutures to the inguinal ligament along the whole length of the inguinal canal. Then the
superior (or medial) flap of the external oblique aponeurosis is sutured to the inguinal ligament
by the second layers sutures. The repair is finished by duplication (doubling) of the aponeurosis,
which is performed by suturing the inferior (lateral) flap to the superior one. While putting the
sutures in the middle angle of the wound, in the region of pubic symphisis, care must be taken
not to hurt the spermatic cord by the new formed external opening of the inguinal canal. So
before tensing the suture, the surgeon checks the size of the opening. It must let the end of digiti
minimi pass besides the cord. The disadvantage of this method is the split of the inguinal
ligament, when two layers sutures are put on the 0,8-1, 2 cm wide ligament. It may bring to the
recurrence of the hernia in case of suture failure (insufficiency).

Spasocucotski’s method (1902)

It’s a modification of the previous method. Using the same tissues, a single layers suture
is put. The disadvantage of the method is that no similar (no homogenous) tissues are attached to
each other: muscles from one side and ligament- from the other.

Kimbarovski’s method (1929)

The principle of connection of the homogenous tissues is performed in this method,
changing the turn of including the layers in the suture. Kimbarovski’s suture begins 1.0- 1,5 cm
above the superior flap margin of external oblique aponeurosis. Passing with a needle through
the thickness of the internal oblique and transversus muscles, we turn and pierce the same flap
from the internal to the external side, but now close to the margin, and then these tissues are
sutured to the inguinal ligament in front of the spermatic cord.
While suturing the muscular layer, one must pay attention not to include n.
iliohypogastricus, which passes along the free margins of the muscles. 6-8 sutures of this kind
are put along the whole length, which are tied one after another. As a result, the superior
aponeurotic flap, curving and covering the muscles, attaches to the inguinal ligament by its
internal surface. The repair is finished, as in the previous method, by doubling aponeurosis.

Martinov’s method
It’s simple and effective in non-complicated cases. The superior flap of external oblique
aponeurosis is sutured to the inguinal ligament in front of the spermatic cord, then duplication of
the aponeurosis is performed. The principle of connection of the homogenous tissues is realized.
As internal oblique and transverse muscles aren’t involved in the suture, it decreases
considerably the tension of the tissues and as a result, inguinal ligament doesn’t split and a firm
scar is formed. Besides, the muscles which aren’t pressed in the suture, don’t atrophy and during

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the doubling of the aponeurosis, due to the loose connection between the layers of the abdominal
wall, they are gently pulled downwards. As a result, the hight of the inguinal distance is reduced,
closing the internal (deep ring of the inguinal canal).

Posterior Wall Repair Methods of Herniorrhaphy

Bassini’s method (1887)

It’s the basic method of posterior wall repair, which has many transformations.
First of all, the spermatic cord must be separated from the posterior wall of the inguinal
canal and must be rised upwards by rubber or cotton bandages. 1-2 sutures are put near the
inferior angle of the operative wound between the lateral margin of the rectus sheath and the
periosteum of the pubic symphysis. Then, continuing upwards, sutures are applied between the
free margins of internal oblique and transverse muscles and inguinal ligament including
obligatory the transverse fascia in the suture. After 5-6 sutures of this kind are applied, the
inguinal canal disappears. The spermatic cord is located on the posterior wall of newly formed
inguinal canal. The margins of external oblique aponeurosis are sutured in front of the spermatic
cord.
This method is technically difficult and traumatic, but is widely practiced abroad, as it
provides good clinical results. However, while performing this method, heterogenous tissues are
sutured to each other, and the anterior wall of the inguinal canal remains weak. To liquidate the
mentioned imperfections, different modifications were offered by Nigus, Mc Vey, Scholidis,
Kirshner, Kukujanov.
In operations for complex hernia, sometimes it’s impossible to close the hernial hillum by
own tissues. In these cases biological tissues as well as synthetic materials may be used. The
usage of own tissues (skin, fascia, aponeurosis) is preferred, as these tissues are of great vitality.,
but the additional injury, which is done to the patient just to take them, limits the usage of this
method. Tension free methods are widely practiced in modern herniology. Alloplastic materials
are used in these methods.

Peculiarities of Inguinal Herniotomy in Strangulated Herniae

Urgent operations are performed in strangulated hernia as the main purpose of the
operation is not the repair of the inguinal canal, but liquidation of the strangulation and its
complications. So the turn of the operative phases is changed a bit, and if their is necrosis of the
hernial content, another phase is added – so called abdominal phase.
Anaesthesia is general or local or a combination of both methods.
Operative access is typical as a rule. Opposite to other herniae, the strangulation in
inguinal herniae is in the region of external ring, so before its incision, it’s necessary to open the
hernial sac and fixate the strangulated content, and only then liquidate the strangulation by
cutting external oblique aponeurosis with external ring. Then the vitality of the hernial content is
examined. If it’s viable, it should be pushed into the peritoneal cavity and the hernial sac should
be removed. Then herniorrhaphy is performed by any method, prefering technically easy
methods (Martinov’s, Spasocucotski’s, Kimborovski’s etc.).
When the hernial content is non-viable (gangrenous), it is resected in the region of
healthy tissues. In order to widen the operative access, herniolaparotomy can be performed by
incising the posterior wall of the inguinal canal outwards or medially upwards. Sometimes we
need to perform additional middle midline incision for resection of intestinal bowel. It’s
performed when there is expressed adhesive process in the abdominal cavity which makes
difficult to take out from the main incision the bowel which is to be resected. It’s performed
when the final part of ileum is to be resected and is finished with ileo-transverso-anastomosis.

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 In exceptional cases, in patients with symptoms of hernial flegmon or peritonitis, the
operation is started by middle midline laparotomy. Abdominal phase (resection of non- viable
bowel) of the operation is performed through this incision, then typical herniotomy.

PERITONEUM AND PERITONEAL CAVITY

The peritoneum is a transparent, continuous serous membrane that consists of two sheets:
 Ventral peritoneum
 Dorsal peritoneum
Each of them consists of two layers: parietal layer, lining the abdominal wall and visceral
one, covering the viscera (stomach, intestine etc).
As the fetal organs assume their final positions, the peritoneal cavity is divided into two
peritoneal sacs called the greater and lesser sacs (omental bursa).
The peritoneal cavity is the space between the layers of peritoneum, but in normal
condition it’s a potential space, because the organs are packed very closely. It contains a few
amount of fluid, which lubricates the peritoneal surfaces of the viscera, enabling them to move
over each other without friction. The peritoneal cavity is closed in males, but there is a
communication in females with the exterior of the body through the uterine tubes, uterus and
vagina.
The peritoneum and all viscera are within the abdominal cavity. The relationship of the
viscera to the peritoneum is as follows:
 Intraperitoneal organs (e.g., stomach) are viscera that are covered with visceral
peritoneum from all the sides
 Mesoperitoneal organs (e.g., ascending and descending colons) are viscera that are
covered with visceral peritoneum from three sides
 Extraperitoneal (retroperitoneal) organs (e.g., pancreas, lower 1/3 part of rectum) are
viscera that are covered with visceral peritoneum only from one side.
An omentum is a double-layered extension of visceral peritoneum that passes from the
stomach and the proximal part of the duodenum to another organ or structure.
• The lesser omentum connects the lesser curvature of the stomach and the proximal part
of the duodenum to the liver.
• The greater omentum, large and fat-laden, arises from the greater curvature of the
stomach and the inferior border of the proximal half of the superior (first) part of the duodenum;
it descends and then folds back to attach to the transverse colon, so the inferior recess of the
omental bursa is between the layers of the greater omentum; it consists of four layers. Usually
the anterior descending layer fuses with the posterior ascending layer, obliterating most of the
inferior recess of the bursa.
The greater omentum prevents the visceral peritoneum from adhering to the parietal
peritoneum lining the abdominal wall. It has considerable mobility and can migrate throughout
the peritoneal cavity and wrap itself around an inflamed organ such as the appendix; i.e. it "walls
off" and protects other viscera from the infected organ.
Peritoneal ligaments also consist of two layers of peritoneum.
A mesentery is a double layer of peritoneum that begins as an extension of the visceral
peritoneum covering an organ. A mesentery connects the organ to the body wall (e.g., mesentery
of the small intestine). Mesenteries have a core of connective tissue containing blood and
lymphatic vessels, nerves, fat, and lymph nodes. Viscera with a mesentery are mobile; the degree
of mobility depends on the length of the mesentery.
A surgical incision through the anterior abdominal wall enters the greater peritoneal sac.
The transverse colon with its mesentery divides the greater sac into two compartments:
 Superior (supracolic) compartment containing the stomach, liver, gallbladder and
spleen

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  Inferior (infracolic) compartment containing the small and large intestine
The supracolic compartment includes the right and left subdiaphragmatic spaces, right
subhepatic space and the omental bursa.
The right subdiaphragmatic space (subphrenic recess) is limited by:
 Superiorly - the inferior surface of the diaphragm
 Inferiorly - the superior (diaphragmatic) surface of the right lobe of the liver
 Medially - lig. falciforme
 Posteriorly - the right part of lig. coronarium hepatis and lig. triangulare dextrum
 Laterally and inferiorly it communicates with the right abdominal canal
The right subhepatic space (bursa subhepatica) is limited by:
 Superiorly and anteriorly -the visceral surface of the right lobe of the liver
 Inferiorly- the right part of the transverse colon and superior horizontal part of the
duodenum
 Posteriorly- the hilus of the liver
 To the left- the round ligament of the liver
The deepest right part of this space is called the hepato-renal recess.
This space communicates with the right abdominal canal through the right edge of the
liver and right colic flexure.
Gallbladder and superior horizontal part of the duodenum are situated in this space,
which can be the source of the inflammatory fluid in the peritoneal cavity (destructive
cholecystitis, perforative ulcer of the duodenum).
As the left lobe of the liver is thinner, than the right one, it doesn’t form isolated spaces
below it.
The left subdiaphragmatic space (subphrenic recess) can be divided into 3 spaces, which
freely communicate with each other.
1. Bursa hepatica sinistra
2. Bursa praegastrica
3. Saccus caecus lienis

1.Bursa hepatica sinistra is limited:

 superiorly -the left part of the diaphragm,
 inferiorly- the superior surface of the left lobe of the liver
 from the right side- lig. falciforme
 posteriorly- left part of lig. coronarium hepatis and lig. triangulare sinistrum
2.Bursa praegastrica is limited by:
 Superiorly - the visceral surface of the left lobe of the liver and left part of the dome
of the diaphragm
 Inferiorly - the transverse colon
 Posteriorly - the lesser omentum and anterior surface of the stomach
 Anteriorly - the anterior abdominal wall
 To the right from the right subhepatic space it is limited by the falciform and round
ligaments of the liver
 To the left it is communicated with so called saccus caecus lienis
3.Saccus caecus lienis is the most isolated part of the left subdiaphragmatic space and is
limited by the visceral surface of the spleen, lig. phrenicolienale and lig. gastrolienale. It’s
disconnected from the left abdominal canal by lig. phrenicocolicum.

The omental bursa (bursa omentalis) is limited by:

 Superiorly - visceral surface of the liver (lobus caudatus)
 Inferiorly - transverse colon and mesocolon transversum

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  Posteriorly –the parietal peritoneum, which covers the anterior surface of the
pancreas and other structures of the posterior abdominal wall
 Anteriorly - lesser omentum, posterior surface of the stomach and lig.
gastrocolicum
 To the left - the hilus of the spleen
 To the right it communicates with the greater peritoneal sac through Winslow’s
aperture (foramen epiploicum), which is limited by: anteriorly – lig.
hepatoduodenale, posteriorly – lig. hepatorenale and the parietal peritoneum,
covering here v. cava inferior, inferiorly – lig. duodenorenale and pars superior
duodeni, superiorly -lobus caudatus of the liver.

The inferior compartment of the peritoneal cavity includes two abdominal canals (the
right and the left), two mesenteric sinuses and 6 recesses. The abdominal canals are formed
between the right and the left abdominal walls and ascending and descending colons
(respectively). The right canal is connected to the superior compartment; the left canal is
communicated with the pelvic cavity.
The mesenteric sinuses are situated to the right and left from the root of the small
intestine mesentery.
The right mesenteric sinus is situated between the ascending colon from the right, transverse
colon superiorly and the root of mesentery inferiomedially.
The left mesenteric sinus is situated between the transverse colon superiorly, descending
colon from the left, sigmoid colon inferiorly and the root of the mesentery medially. The right
sinus communicates with the left and the last one- with the pelvic cavity.

ORGANS OF THE PERITONEAL CAVITY

ORGANS OF THE SUPERIOR (SUPRACOLIC) COMPARTMENT

Liver

The liver is the largest gland in the body. The liver has diaphragmatic and visceral
(posteroinferior) surfaces that are separated by its inferior border. The diaphragmatic surface is
smooth and dome-shaped where it conforms to the concavity of the inferior surface of the
diaphragm, but it is largely separated from the diaphragm by the subphrenic recesses of the
peritoneal cavity. The liver is covered with peritoneum except posteriorly in the bare area, the
gallbladder and porta hepatis. Under the serous coat of the liver there is a thin fibrous coat
(tunica fibrosa). The right and left lobes and coronary, right and left triangular and falciform
ligaments are distinguished on the diaphragmatic surface of the liver.
The visceral surface of the liver is related to the:
• Right side of the stomach (gastric area)
• Superior part of the duodenum (duodenal area)
• Lesser omentum
• Gallbladder
• Right colic flexure (colic area)
• Right kidney and suprarenal gland (renal area)
On the diaphragmatic surface the right lobe of the liver is demarcated from the left lobe
by the falciform ligament. On the visceral surface the liver is divided into four lobes by H-
shaped groove (two longitudinal and one horisontal grooves): the right, the left, the quadrate and
the caudate. On the visceral surface the following ligaments: hepatogastric and hepatoduodenal

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(together they form lesser omentum), teres hepatis (it is the obliterated remains of the umbilical
vein), ductus venosum (it is remnant of the fetal ductus venosus that shunted blood from the
umbilical vein to the IVC, short-circuiting the liver) are distinguished. The free edge of the lesser
omentum encloses the portal triad (portal vein, common bile duct and proper hepatic artery), a
few lymph nodes and lymphatic vessels, and the hepatic plexus of nerves.
Vessels of Liver.
The liver receives blood from two sources: the hepatic artery (30%) and portal vein
(70%).
The hepatic artery (common hepatic artery) carries oxygenated blood from the aorta, and
the portal vein carries poorly oxygenated blood from the gastrointestinal tract, except the inferior
part of the anal canal. At the porta hepatis, the proper hepatic artery and portal vein terminate by
dividing into right and left branches to supply the right and left lobes of the liver, respectively.
These lobes function separately. Within each lobe the primary branches of the portal vein and
hepatic artery are consistent enough to describe vascular segments.
The hepatic veins (three in number as a rule), formed by the union of the central veins of
the liver, open into the IVC just inferior to the diaphragm. The attachment of these veins to the
IVC helps to hold the liver in position.

Billiary Ducts and Gallbladder

Bile is secreted by hepatic cells into bile canaliculi that drain into small interlobular
billiary ducts which join to form the right and left hepatic ducts. The right hepatic duct drains the
right lobe of the liver, and the left hepatic duct drains the left lobe, including the caudate lobe
and most of the quadrate lobe. Shortly after leaving the porta hepatis, the hepatic ducts unite to
form the common hepatic duct. This duct is joined on the right side by the cystic duct from the
gallbladder to form the common bile duct (ductus choledochus), which conveys bile to the
duodenum.
The bile duct (common bile duct) begins in the free edge of the lesser omentum by the
union of the cystic and common hepatic ducts. Four parts of common bile duct are distinguished:
 pars supraduodenalis
 pars retroduodenalis
 pars pancreatica
 pars intramuralis
On the left side of the descending part of the duodenum, the bile duct comes into contact
with the pancreatic duct. The two of them run obliquely through the wall of this part of the
duodenum, where they unite to form the hepatopancreatic ampulla. The distal end of the ampulla
opens into the duodenum through the major duodenal papilla (papilla Vateri).The muscle around
the distal end of the bile duct is thickened to form the choledochal sphincter (Oddi’s sphincter).
When this sphincter contracts, bile cannot enter the duodenum; hence bile backs up and passes
along the cystic duct to the gallbladder for concentration and storage.
The gallbladder (7 — 10 cm long) lies in the gall bladder fossa on the visceral surface of
the liver. The posterior surface of the pear-shaped gallbladder is covered by visceral peritoneum,
and its anterior surface adheres to the liver. Peritoneum completely surrounds its fundus and
binds its body and neck to the liver.
There are three parts of the gallbladder:
• The fundus is the wide end that projects from the inferior border of the liver and is
usually located at the tip of the right ninth costal cartilage in the midclavicular line
• The body contacts visceral surface of the liver, the transverse colon, and the superior
part of the duodenum
• The neck is narlayers, tapered, and directed toward the porta hepatis

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The neck of the gallbladder makes an S-shaped bend and joins the cystic duct. The mucosa of the
neck is shaped into a spiral fold called the spiral valve that keeps the cystic duct open so that (a)
bile can easily be diverted into the gallbladder when the distal end of the bile duct is closed by
the choledochal sphincter and/or the hepatopancreatic sphincter or (b) bile can pass to the
duodenum as the gallbladder contracts.
The cystic artery supplies the gallbladder and cystic duct. The artery commonly (72%)
arises from the right hepatic artery in the angle between the common hepatic duct and the cystic
duct. Here Calout’s triangle is described which is limited by common hepatic duct (from the left
side), cystic duct (from the right side) and the superior edge or the base of the triangle is formed
by the cystic artery. This triangle has practical importance in duct-first cholecystectomy.

Stomach

The stomach has a:

 Lesser curvature forming its concave border
 Greater curvature forming its longer convex border
 Sharp indentation about two-thirds of the distance along the lesser curvature called the
angular notch, which indicates the junction of the body and pyloric part
 Cardia around the opening of the esophagus
 Fundus, its dilated superior part that is related to the left dome of the diaphragm
 Body that lies between the fundus and pyloric antrum
 Pyloric part, its funnel-shaped part; its wide portion, the pyloric antrum, leads into the
pyloric canal, its narlayers portion
 Pylorus, the distal sphincteric region, that is thickened to form the pyloric sphincter,
which controls discharge of the stomach contents through the pyloric orifice into the
duodenum

Relations of Stomach
The stomach is covered by peritoneum, except where blood vessels run along its
curvatures and in a small area posterior to the cardiac orifice. The two layers of the lesser
omentum extend around the stomach and leave its greater curvature as the greater omentum. The
anterior surface of the stomach is in contact with the
• Diaphragm
• Left lobe of the liver
• Anterior abdominal wall
• Diaphragm
. • Transverse colon, transverse mesocolon, pancreas, spleen, and celiac trunk and its three
branches
• Left suprarenal (adrenal) gland and superior part of the left kidney
The stomach has superficial and deep ligaments. The superficial ligaments are:
o Lig. hepatogastricum
o Lig. phrenicogastricum
o Lig. gastrolienale
o Lig. gastrocolicum
Deep ligaments (or folds) are:
o Lig. gastropancreaticum
o Lig. pyloropancreaticum
Vessels of the Stomach
The gastric arteries arise from the celiac trunk and its branches:
 Left gastric artery arises from the celiac trunk and runs in the lesser omentum to the
cardia and then turns abruptly to course along the lesser curvature to anastomose with the
right gastric artery

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  Right gastric artery arises from the hepatic artery (proper hepatic artery) and runs to the
left along the lesser curvature to anastomose with the left gastric artery
 Right gastroomental (gastroepiploic) artery arises from the gastroduodenal artery and
runs to the left along the greater curvature to anastomose with the left gastroomental
artery
 Left gastroomental (gastroepiploic) artery arises from the splenic artery and anastomoses
with the right gastroomental artery
 Short gastric arteries arise from the distal end of the splenic artery and pass to the fundus
The gastric veins are parallel to the arteries in position and course. The left and the right
gastric veins form a vein called v. coronaria ventriculi, which drains into the portal vein, and
short gastric veins and the left gastroomental (gastroepiploic) vein drain into the splenic vein,
which joins the superior mesenteric vein to form the portal vein. The right gastroomental vein
empties in the superior mesenteric vein.

Duodenum

The duodenum is the shortest, widest, and most fixed part of the small intestine. It
pursues a C-shaped course around the head of the pancreas. The duodenum begins at the pylorus
on the right side and ends at the duodenojejunal junction on the left side. For descriptive
purposes the duodenum is divided into four parts:
• The superior (first) part is short (5 cm) and lies anterolaterally to the body of L1
vertebra
• The descending (second) part is longer (7 — 10cm) and descends along the right sides
of Ll —L3 vertebrae
• The horizontal (third) part is 6 — 8 cm long and crosses L3 vertebra
• The ascending (fourth) part is short (5 cm) and begins to the left of L3 vertebra and rises
superiorly as far as the superior border of L2 vertebra
The first 2 cm of the duodenum has a mesentery and is mobile. Radiologists refer to this
free part as the duodenal cap (bulbus). The distal 3 cm of the superior part is mesoperitoneal and
the other three parts of the duodenum have no mesentery and are immobile because they are
retroperitoneal. The descending part of the duodenum runs inferiorly, initially to the right and
parallel to the IVC. The bile and pancreatic ducts enter its posteromedial wall on the level of
middle and inferior thirds of it. These ducts usually unite to form the hepatopancreatic ampulla,
which opens on the summit of the major duodenal papilla. The minor duodenal рарillа is located
a little superiorly to the first one, here is opened the accessory pancreatic duct. The horizontal
part of the duodenum is crossed by the superior mesenteric vessels and the root of the mesentery
of the jejunum and ileum. The ascending part of the duodenum runs superiorly on the left side of
the aorta to reach the inferior border of the pancreas. Here it curves anteriorly to join the jejunum
at the duodenojejunal flexure. This curvature is supported by a fibromuscular band called the
suspensory muscle of the duodenum (ligament of Treitz). Contraction of this muscle also widens
the angle of the flexure, facilitating movement of its contents. The duodenum also has
hepatoduodenal ligament which contents portal triad.
The duodenal arteries arise from the celiac trunk and superior mesenteric artery. The
celiac trunk, via the gastroduodenal artery and its branch, the superior pancreaticoduodenal
artery, supplies the duodenum proximal to the entry of the bile duct. The superior mesenteric
artery, via its branch, the inferior pancreatoduodenal artery, supplies the duodenum distal to the
entry of the bile duct.
The duodenal veins follow the arteries and drain into the portal vein; some drain directly
and others indirectly via the superior mesenteric and splenic veins.

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 Spleen

The spleen is the largest of the lymphatic organs and is located in the left upper quadrant.
It varies considerably in size and shape but is usually about 12 cm long and 7 cm wide. It has
diaphragmatic and visceral surfaces, anterior and posterior margins (borders), superior and
inferior poles (borders). Its diaphragmatic surface is convexly curved to fit the concavity of the
diaphragm.
The anterior and superior borders of the spleen are sharp and often notched, whereas its
posterior and inferior borders are rounded. Except at the hilum, the spleen is completely enclosed
by peritoneum, where the branches of the splenic artery (branch of celiac trunk) enter and the
tributaries of the splenic vein leave. The spleen normally contains a large amount of blood that is
expelled periodically into the circulation by the action of the smooth muscle in its capsule and
trabeculae. The spleen contacts the posterior wall of the stomach and is connected to its greater
curvature by the gastrosplenic ligament. It also contacts the diaphragm and pancreas by the
diaphragmosplenic and pancreatosplenic ligaments.
The splenic artery, the largest branch of the celiac trunk, follows a tortuous course
posterior to the omental bursa, anterior to the left kidney, and along the superior border of the
pancreas. Between the layers of the pancreatosplenic ligament, the splenic artery is divided into
five or more branches that enter the hilum of the spleen. The splenic vein is formed by several
tributaries that emerge from the hilum of the spleen. It is joined by the inferior mesenteric vein
and runs posterior to the body and tail of the pancreas throughout most of its course. The splenic
vein unites with the superior mesenteric vein posterior to the neck of the pancreas to form the
portal vein.

Pancreas

The pancreas is an elongated digestive gland that lies transversely across the posterior
abdominal wall, posterior to the stomach. The transverse mesocolon extends to its anterior
margin. The pancreas produces
• An exocrine secretion (pancreatic juice) that enters the duodenum via the pancreatic
duct
• Endocrine secretions (glucagon and insulin) that enter the blood
The head of the pancreas is in the curve of the duodenum. It has a prolongation called the
uncinate process that extends superiorly and to the left and lies posteriorly to the superior
mesenteric vessels. The head rests posteriorly on the IVC, the right renal artery and vein, and the
left renal vein. The bile duct, on its way to the duodenum, lies in а groove on the posterosuperior
surface of the head.
The neck of the pancreas is grooved posteriorly by the superior mesenteric vessels. Its
anterior surface is covered with peritoneum and is adjacent to the pylorus. The superior
mesenteric vein joins the splenic vein posterior to the neck of the pancreas to form the portal
vein.
The body of the pancreas extends to the left across the aorta and L2 vertebra, posterior to
the omental bursa. The body is intimately related to the splenic vessels. The anterior surface of
the pancreas is covered with peritoneum and forms part of the bed of the stomach. Its posterior
surface is devoid of peritoneum where it is in contact with the aorta, superior mesenteric artery,
left suprarenal gland, and the left kidney and its vessels. The tail of the pancreas passes between
the layers of the pancreatosplenic ligament with the splenic vessels. Тhe tip of the tail usually
contacts thе hilum of the spleen.
The pancreatic duct begins in the tail of the pancreas and runs through the substance of
the gland to the head, where it turns inferiorly and comes into close relationship with the bile
duct. Usually the pancreatic and bile ducts unite to form а short, dilated hepatopancreatic

51
ampulla, which opens by а common duct into the duodenum at the summit of the major duodenal
papilla. There is а sphincter around the terminal part of the main duct called the pancreatic duct
sphincter. There is also one around the hepatopancreatic ampulla called the hepatopancreatic
sphincter (of Oddi). These sphincters control the flow of bile and pancreatic juice into the
duodenum. The accessory pancreatic duct drains the uncinate process and the inferior part of the
head of the pancreas. Usually this duct communicates with the main pancreatic duct, but in about
30% of people it is а separate duct. Typically it opens into the duodenum at the minor duodenal
рарillа which is situated a little superiorly to the major.
The pancreatic arteries are derived from the splenic and pancreaticoduodenal arteries. Up
to 10 branches of the splenic artery supply the body and tail. The anterior and posterior superior
pancreaticoduodenal arteries, branches of the gastroduodenal artery, and anterior and posterior
inferior pancreaticoduodenal arteries, branches of superior mesenteric artery, supply the head of
pancreas.

PORTAL VEIN AND PORTAL-SYSTEMIC ANASTOMOSES

The portal vein is the main channel of the portal system of veins. It collects blood from
the abdominal part of the gastrointestinal tract, gallbladder, pancreas, and spleen, and carries it to
the liver. There it branches to end in expanded capillaries known as sinusoids.
The portal venous system communicates with the systemic venous system in the following
locations:
• Between esophageal veins draining into either the azygos vein (systemic) or the left
gastric vein (portal); when dilated these are esophageal varices
• Between the inferior and middle rectal veins, draining into the IVC (systemic) and the
superior rectal vein continuing as the inferior mesenteric vein (portal); when dilated these are
hemorrhoids
•Paraumbilical veins (portal) anastomosing with small epigastric veins of the anterior
abdominal wall (systemic); when dilated these veins produce "caput medusae," so named
because of their resemblance to the serpents on the head of Medusa, а character in Greek
mythology
•Twigs of colic veins (portal) anastomosing with systemic retroperitoneal veins

ORGANS OF INFERIOR (INFRACOLIC) COMPARTMENT

Small Intestine

The small intestine extends from the pylorus to the ileocecal junction, where it joins the
large intestine. The pylorus empties the contents of the stomach into the duodenum, the first part
of the small intestine; its other two parts are the jejunum and ileum.

Jejunum and Ileum

The jejunum begins at the duodenojejunal junction, and the ileum ends at the ileocecal
junction, the union of the ileum with the cecum. Together the jejunum and ileum are 6-7 m long
in cadaver; the jejunum constitutes about two-fifths and the ileum the remainder. Most of the
jejunum lies in the umbilical region, whereas most of the ileum is in the suprapubic and right
inguinal regions. The terminal part of the ileum is usually in the pelvis from which it ascends to
end in the medial aspect of the cecum. Although there is no outer line of demarcation between
the jejunum and ileum, they have distinctive characteristics that are of surgical importance. The
mesentery attaches most of the small intestine to the posterior abdominal wall. The root of the

52
mesentery (about 15 cm long) is directed obliquely, inferiorly, and to the right from the left side
of L2 vertebra to the right sacroiliac joint.
The superior mesenteric artery supplies the jejunum and ileum. It runs between the layers
of the mesentery and from it left side it sends 15 — 18 branches to the intestine. The arteries
unite to form loops or arches called arterial arcades, from which straight arteries called vasa
recta arise. The superior mesenteric vein drains the jejunum and ileum. It lies anteriorly and to
the right of the superior mesenteric artery in the root of the mesentery.

Large Intestine

The large intestine consists of the cecum, vermiform appendix, colon, rectum, and anal
canal. The large intestine can be distinguished from the small intestine by
• Three thickened bands of longitudinally directed muscles called teniae coli
• Sacculations between the teniae called haustrae
• Small pouches of omentum filled with fat called omental (epiploic) appendages
• Colour (grey colour, small intestine has pink color)
• Thickness of the walls (the wall of the large intestine is thinner)
• Lumen of the large intestine is more in diameter, than the lumen of the small intestine

Cecum

The cecum is the first part of the large intestine and is continuous with the ascending
colon. The cecum is located in the right lower quadrant, where it lies in the iliac fossa. Usually it
is almost entirely enveloped by peritoneum and can be lifted freely, but the cecum does not have
a mesentery. The ileum enters the cecum obliquely and partly invaginates into it, forming folds
(lips) superiorly and inferiorly to the ileocecal orifice. These folds form the ileocecal valve.

Vermiform Appendix

The vermiform appendix is a worm-shaped blind tube that joins the cecum inferior to the
ileocecal junction. It has a short triangular mesentery called the mesoappendix that suspends it
from the mesentery of the terminal ileum. The position of the appendix is variable, medial,
lateral, ascending, descending, retrocecal and retroperitoneal. The base of the appendix lies on
the inferomedial surface of the dome of the cecum where the three teniae are connected.
The cecum is supplied by the ileocolic artery, a branch of the superior mesenteric artery,
and the appendix is supplied by the appendicular artery, a branch of the ileocolic artery.

Colon

The ascending colon passes superiorly from the cecum. The border between this two
parts passes at the superior margin of the ileocolic junction.On the right side of the abdominal
cavity to the liver, where it turns to the left as the right colic flexure. The ascending colon lies
mesoperitoneally along the right side of the posterior abdominal wall, it is covered by
peritoneum anteriorly and on its sides. On the medial and lateral sides of the ascending colon, the
peritoneum forms paracolic gutters. The ascending colon is usually separated from the anterior
abdominal wall by coils of small intestine and the greater omentum. Arterial supply to the
ascending colon and right colic flexure is through the ileocolic and right colic arteries, branches
of the superior mesenteric artery.
The transverse colon is the largest and most mobile part of the large intestine. It crosses
the abdomen from the right colic flexure to the left colic flexure, where it bends inferiorly to
become the descending colon. The left colic flexure lies on the inferior part of the left kidney and

53
is attached to the diaphragm by the phrenicocolic ligament. The transverse mesocolon is mobile
mesentery of the transverse colon. The root of this mesentery is located along the inferior border
of the pancreas and becomes continuous with the parietal peritoneum posteriorly. Because it is
freely movable, the transverse colon is variable in position. It usually hangs down to the level of
the umbilicus. In tall, thin people the transverse colon may reach the level of the pelvis. Arterial
supply right 2/3 of the transverse colon is mainly from the middle colic artery, a branch of the
superior mesenteric artery, the left 1/3 receives blood from the right and left colic (a branch of
the inferior mesenteric artery) arteries.
The descending colon passes mesoperitoneally from the left colic flexure into the left
iliac fossa, where it is continuous with the sigmoid colon. The peritoneum covers the colon
anteriorly and laterally and binds it to the posterior abdominal wall. As it descends, the colon
passes anterior to the lateral border of the left kidney. As with the ascending colon, there are
paracolic gutters on the medial and lateral sides of the descending colon. Arterial supply from
the left colic artery.
The sigmoid colon, an S-shaped loop that is variable in length, links the descending
colon and rectum. The sigmoid colon extends from. the pelvic brim to the third segment of the
sacrum where it joins the rectum. The termination of the teniae coli indicates the . beginning of
the rectum. The rectosigmoid junction is about 15 cm from the anus. The sigmoid colon usually
has a long mesentery (sigmoid mesocolon) and therefore has considerable freedom of movement.
The root of this mesentery has a V-shaped attachment, superiorly along the external iliac vessels
and inferiorly from the bifurcation of the common iliac vessels to the anterior aspect of the
sacrum. The sigmoid arteries, branches (2-4) of the inferior mesenteric artery, descend obliquely
to the left where they divide into ascending and descending brunches that supply the sigmoid
colon. The middle colic artery and left colic artery anastomose to each other (here is formed
anstomosis between superior and inferior mesenteric arteries which is colled Riolani’s arch).

Rectum

The rectum is continuous proximally with the sigmoid colon and distally with the anal
canal. The rectum begins anterior to the level of S3 vertebra, follows the curve of the sacrum and
coccyx, and ends anteroinferior to the tip of the coccyx by turning posteroinferiorly and
becoming the anal canal. The dilated terminal part of the rectum is the rectal ampulla, which
supports and holds the fecal mass before it is expelled during defecation.
Peritoneum covers the anterior and lateral iurfaces of the superior third of the rectum,
only the anterior surface of the middle third, and no surface of the inferior third. In males the
ieritoneum reflects from the rectum to the posterior wall of the bladder where it forms the floor
of the rectovesical pouch. In females the peritoneum reflects from the rectum to the posterior
fornix of the vagina where it forms he floor of the rectouterine pouch.
The superior rectal artery, the continuation of the inferior mesenteric artery, supplies the
proximal part of the rectum. The middle rectal artery supply middle third and inferior rectal
artery supply inferior third of the rectum (middle rectal artery is a branch of internal iliac artrey,
inferior is a brunch of internal pudental artery from internal iliac artery).

OPERATIONS ON THE ORGANS OF THE ABDOMINAL CAVITY

All the operations performed on the abdominal cavity may be divided into 5 groups:
1. Opening of the lumen of the hollow organ- tomia (-tomy), with following closure of the
wound. This operation may be performed either for diagnostic purpose (e.g. when an ulcer or

54
tumour are detected) or for the treatment purpose (e.g. removal of a foreign body, ligature of the
bleeding vessel etc).
2. The connection of the hollow organ with the external environment- stomia (-stomy). It
means that a fistula is performed on a hollow organ (e.g. colostomy, enterostomy etc).
3. The formation of an anastomosis between the different parts of gastro-intestinal tract (e.g.
gastroenteroanastomosis).
4. Removal of a part of the organ- resectio (resection, e.g. resection of the small intestine,
stomach etc).
5. Removal of the whole organ- ectomia (ectomy, e.g. gastrectomy).

All the operations on the organs of the abdominal cavity are based on the intestinal
suture. By the term “intestinal suture” we mean all kinds of sutures, which are applied on the
wall of a hollow organ of the digestive system for restoration of its lumen and natural isolation
from the free abdominal cavity. Success of any cavity operation greatly depends upon the quality
and correct application of the intestinal suture.
The main principles of the intestinal suture are:
 Hermetism
 Mechanical strength (durability)
 Preservation of the sufficient lumen of the intestinal tube
 Preservation of the blood supply of the parts, which are connected
For these purposes:
a) the parts, which are to be sutured, must be of equal sizes
b) the sutures should not be tensed
c) the bleeding from the edges of the wound must be thoroughly arrested by stitches
d) similar structures must be apposed by sutures
e) fine round-bodied atraumatic needles with suturing material are used
As we know, the wall of the intestine tube consists of 4 layers:
1)mucous membrane
2)submucous layer
3)muscular layer
4)serous membrane
However, in practice, it’s suitable to divide the wall into 2 layers: an inner infected layer
including the mucous and submucous coats, and an outer non infected layer, including muscular
and serous coats.
Two types of sutures we distinguish, depending upon the layers of the intestinal wall,
which are included into the suture:
 An inner all coats through-and-through suture
 An outer seromuscular suture (Lembert’s suture)
The marginal (through-and-through) suture passes through all the layers of the intestinal
wall, i. e. includes both inner and outer layers. As a rule, it’s applied by a continuous suture and
provides good adaptation of the margins, mechanical durability of the suture and haemostasis.
However this kind of suture has its considerable disadvantage. As it touches the infected mucous
membrane of the intestinal tube, it’s an infected suture and may be a conductor of the infection
from the lumen of the hollow organ into the free abdominal cavity. To prevent this formidable
complication, through-and-through sutures are covered by non-infected layers of the intestinal
wall and thus, invaginating the mucous membrane (covering the infected sutures), restore the
natural relationship between the infected and non-infected layers of the intestinal wall.
So, the classic (traditional) intestinal suture is applied in 2 layers (lines): an inner
through-and-through and an outer seromuscular sutures. It’s important to record, that a single-
layer or three-layer intestinal sutures are also used in surgery. A single-layer intestinal suture is
applied by interrupted sutures and, what’s important, the serous membrane, the muscular layer

55
and the submucous layer (very close to the mucous layer) are included into it. If the knot is
applied from the side of the mucous membrane, it’s called Mateshuk’s suture, if from the side of
the serous membrane- Pirogov’s suture.
The single-layer suture has its advantages:
1. well apposes the margins of the wound
2. minimally narlayerss the lumen of the intestine
3. minimally disturbs the blood supply of the wound edges
4. provides enough hermetism, haemostasis and mechanical durability
But we must pay attention to the fact, that the 4th mentioned advantage is gained only
thanks to a perfect (faultless) technical performance. This is the main factor, which limits the
broad usage of the single-layer suture.
The 3-layers suture is recommended to be put on those parts of the intestinal tube, which
don’t have serous membrane or there is a virulent infection in their lumen. (e.g. esophagus, the
large intestine). The specificity of such a suture is, that an additional seromuscular suture covers
the 2-layers suture for more reliability.
It must be mentioned, that 2-layers and especially 3-layers suture considerably narlayerss
the lumen of the intestine, disturb the blood supply of the wound margins and form micro-
cavities between the suture lines (layerss), which may cause abscesses.

Types of Gastro-Intestinal Anastomoses

The gastro- intestinal anastomoses may be performed by the following methods:

 End-to-end
 Side-to-side
 End-to-side
 Side-to-end
End-to-end anastomosis is a direct connection of the ends of the hollow organs applied
by 2-layer or 3-layer sutures. It’s more physiological and that’s why is widely used in different
operations. In order not to narrow the lumen of the intestine at the place of the anastomosis, the
bowel is divided obliquely, removing it more along the free margin. If a gross disproportion in
the size of the bowels is present (large and small intestine), the end-to-end anastomosis may be
difficult.
Side-to-side anastomosis – The two firmly closed stumps are placed isoperistalticly and
are connected along the side surfaces of the intestinal bowels or stomach and intestine. There is
no chance of narrowing the lumen at the suture line in this type of anastomosis, as the width of
the anastomosis is not limited here by the diameter of the intestine and may be freely controlled.
End-to-side anastomosis is used to connect the parts of the gastro-intestinal tract, when
there is disparity between the parts, e.g. in resection of the stomach, when the stomach stump is
sutured to the wall of the jejunum; when the small intestine is sutured to the large one, suturing
the end of the small intestine to the side surface of the large intestine.
Side-to-end anastomosis – The side surface of the more proximally situated organ is
connected to the end of the distal one. This type is used rarely (gastroenteroanastomosis by Ru,
iliotransversoanastomosis).
When we want to name the anastomosis, at first we always mention the proximally
situated organ, then the distally situated one (e.g. iliotransversoanastomosis end to side- the end
of the ileum is sutured to the side surface of the transverse colon; iliotransversoanastomosis side
to end- an anastomosis is formed between the side surface of the ilium and the end of the
transverse colon).
Technique of the operation
As these anastomoses may be performed as independent operations or be a phase of a
larger operation (e.g. resection of the stomach with performing one of the methods of gastro-

56
intestinal anastomosis), the accesses (laparotomic incisions) respectively may be different. As an
example of the gastro-intestinal anastomosis we’ll discuss the resection of the small intestine
with applying the intestinal anastomosis either by end-to-end or side-to-side method.
Removal of a portion of the small intestine (enterectomy) is often required in surgical
practice. The portion of the bowel to be resected is drawn out of the abdomen and isolated from
the general peritoneal cavity by packing with mops. This portion of the bowel to be resected is
held against the light, so that the main vessels in the mesentery are seen. They are secured by
ligatures and the mesentery is divided in V-shaped manner, the apex of the V lying towards the
root of the mesentery. Two pairs of crushing clamps are applied one on each side of the bowel to
be resected. These clamps are placed obliquely on the bowel, so that more of the antimesenteric
border is included in the excision. Now two pairs of occlusion clamps are applied one on each
side, 2cm away from the crushing clamps. The portion of the intestine held by the crushing
clamps on both sides is removed. The continuity of the intestine is maintained by anastomosing
the two ends of the bowel either by end-to-end or side-to-side method.
End-to-end anastomosis. At first the posterior layer of sero-muscular sutures (Lembert’s
suture) is applied between the afferent and the efferent bowels 5mm apart from the ends. Then
by through and through continuous suture at first the posterior and then the anterior margins of
the anastomosing bowels are sutured. The anastomosis is completed by applying the anterior
layer of the sero-muscular sutures.
Side-to-side anastomosis. The ends of the resected bowel are firmly closed, and the
bowels are placed isoperistalticly so as to touch each other by their side surfaces. 8-10cm long
layer of sero-muscular sutures is applied. The lumina of the bowels are opened 5-6cm long 0,5-
0,75 cm apart from the suture line. By through and through continuous stitches at first posterior
and then the anterior margins of the incised bowels are sutured. The anastomosis is completed by
the second layer (row) of the sero-muscular sutures between the anterior surfaces.

Operations on the Stomach and Duodenum

Gastrotomy

Indications: removal of the foreign body, the polyp, exploration and arrest of the
bleeding.
Access: superior midline laparatomy
Technique of the operation
After the opening and the observation of the abdominal cavity the operative field is
limited by means of napkins (mops). The stomach is approached to the operative wound and two
holding are applied to an avascular area of the anterior wall. The stomach is incised between the
holders in the longitudinal direction. The mucous membrane of the stomach is explored in all its
parts. The main purpose of the operation is performed. The operation is finished by suturing the
stomach by means of two-layers sutures. A tube is left in the stomach, which is inserted through
the esophagus for decompression. The wound of the abdominal wall is sutured layer by layer.

Gastrostomy

Indications: tumours of the esophagus, cardial part of the stomach, bringing to stenosis
(obstruction), scar narlayersing of the esophagus after burnt, cardiospasm.
The purpose of the operation is to perform a gastric fistula to feed the patient.
The operation is performed in several methods:
1. the formation of a temporary stomach fistula (Kader- Stamm’s and Witzel’s operations).
2. the formation of a permanent stomach fistula (Toprover’s operation)

57
 Witzel’s operation

Access: left transrectal 8-10cm long laparotomy.

Technique of the operation
The anterior wall of the stomach is brought to the wound. A 1cm diameter a rubber tube is
put in the middle part of the anterior wall of the stomach, directed to the cardial part along the
longitudinal axis. The tube is buried down by 5-7 seromuscular sutures. Thus, a canal is formed,
the end of the tube is left free. A purse string stitch is applied at the fundal part of the stomach,
proximally to the last suture. The wall of the stomach is incised inside that suture, and the end of
the rubber tube is pushed through this opening 5cm deep into the stomach. The purse string
suture is tightened. Now 2 or3 similar seromuscular sutures are made on the the first one to
invaginate it. The free end of the tube is taken out through the contra-aperture by the lateral
margin of the left rectus muscle. The stomach wall is fixed to the parietal peritoneum by 3 or 4
interrupted seromuscular sutures around the place where the rubber tube exits (gastropexia).
Thus, the stomach is isolated from the general peritoneal cavity in the place, where the tube
opens out. The tube is fixed to the skin. The wound of the abdominal wall is sutured firmly, layer
by layer.

Stamm-Kader’s method

Access: left transrectal 8-10cm long laparotomy

Technique of the operation
The anterior wall of the stomach is brought out to the wound to form a cone. Two holders
are applied at the top of the cone. The stomach is pulled by means of holders and below them
two (Stamm’s method) or three (Kader’s method) purse string sutures are applied 1,5-2cm apart
from one another. A hole is made between the two holders in the superior part of the cone in the
wall of the stomach. A 1cm diameter rubber tube is pushed 5cm deep. The superior purse string
suture is tied above the tube, and slightly invaginating the tube into the stomach cavity, the
second suture is tied, then the third one. So, the rubber tube appears in the canal, which is formed
by the anterior wall of the stomach. The canal is covered from inside by the serous membrane of
the stomach (as in Witzel’s operation), i.e. a tube-form temporary fistula is formed. The free end
of the rubber tube is taken out through the contra-aperture opened along the lateral margin of the
left rectus muscle. The following steps are the same as those of the Witzel’s operation.
After the tube is removed, no additional steps are required, as the opening of the fistula is
spontaneously closed after a while.

Toprover’s method

Access left transrectal 8-10cm long laparotomy

Technique of the operation
The preliminary steps are the same as in the previous method, only in this method, the
gastrostomy tube is fixed in a different way: after the tube is pushed inside, 3 purse string sutures
are tied one after another and so a canal is formed from the wall of the stomach around the tube,
which is covered by the mucous membrane of the stomach (lip-form fistula). The formed canal is
placed in the laparotomic wound and the levels of the purse string sutures are fixed one after one
to the peritoneum, the posterior wall of the rectus muscle sheat and the skin. The laparotomic
wound is sutured around the stoma layer by layer. The rubber tube may be removed in 3-4 days
after the fistula is formed.
This permanent gastrostomy cannot be closed spontaneously.

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 Gastroenteroanastomosis
(Gastrojejunostomy)

Indications: gastric carcinoma with pyloric obstruction, pyloric stenosis in a very weak
patient.
The purpose of the operation is to provide the entrance of the food into the intestine,
when there is non-removable obstruction of the pyloric part of the stomach or duodenum. An
anastomosis is made between the stomach and the jejunum by passing the pylorus and thus the
emptying process of the stomach is eased (or becomes possible). The anastomosis is performed
in several methods, two of which are widely practiced:
1. Anterior antecolic gastroenteroanastomosis (Gastroenteroanastomosis antecolica
anterior , Wolfler 1881)
2. Posterior retrocolic gastroenteroanastomosis (Gastroenteroanastomosis retrocolica
posterior Hacker 1885 , Peterson)

Anterior Antecolic Gastroenteroanastomosis

Access: superior midline laparotomy

Technique of operation
The greater omentum and the transverse colon are brought out of the wound and turned
upward. The first loop of the jejunum is searched and found to the left from the midpoint of the
transverse mesocolon, close to the duodeno-jejunal fold (Treitz’s ligament, which leads to the
duodeno-jejunal flexure, also serves as a guide). A loop, the afferent end of which is 30-50cm
apart from the duodeno-jejunal junction, is chosen for anastomosis. The loop is approached to
the anterior wall of the stomach in front of the transverse colon and placed in an isoperistaltic
direction. The stomach and the intestine are sutured by sero-muscular sutures at a distance of
10cm, applying the line of the sutures obliquely to the longitudinal axis of the stomach, i.e. from
the left and superior part of the lesser curvature to the right and inferior part of the greater
curvature. The anastomosis is carried out in “side to side” type, 5-6cm apart from the palpative
borders of the tumour. After isolating the operative field by napkins, the lumina of the stomach
and the intestine are incised 4-5cm long in the middle part of the sutured intestine. Now the
internal line of the sutures is applied. At first the posterior, then the anterior margins of the
anastomosis are sutured. A continuous through-and- through stitch taking all the layers of the
stomach and the jejunum, is applied. Then, after the preparation of the hands and the change of
the instruments, the second layers of the sero-muscular sutures is applied on the anterior lip of
the anastomosis. To prevent the formation of a vicious circle, the anterior
gastroenteroanastomosis must be added by jejuno-jejunal anastomosis between the afferent and
the efferent loops of the jejunum (Brawn’s anastomosis). The last one is performed in “side to
side” type 3-4cm apart from the duodeno-jejunal fold with a width equal to the lumen of the
intestine or a bit wider. The operation is completed by leaving a tube in the stomach through the
esophagus. The wound of the abdominal wall is closed layer by layer.

Posterior Retrocolic Gastroenteroanastomosis

Access: superior midline laparotomy

Technique of operation
The greater omentum and the transverse colon are brought out of the wound and turned
upward. A 10cm long loop of the jejunum is chosen for anastomosis 7-10cm apart from the
duodeno-jejunal flexure. In an avascular area of the transverse mesocolon nearly 10cm long hole
is made. By the left hand, which is placed on the anterior wall of the stomach, the posterior wall
of the stomach is brought to the opening in the transverse mesocolon. The loop of the jejunum,
which is kept very close to the posterior wall of the stomach, should be such, that the afferent

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(proximal) portion of the jejunum will be lying near the lesser curvature of the stomach, the
efferent (distal) portion- near the greater curvature. Anastomosis, as in the anterior one, is
performed by means of double-layers suture by “side to side” method. The margins of the
transverse mesocolon are fixed to the stomach by several interrupted sutures above the
anastomosis. As a result, the anastomosis appears in the inferior storey of the abdominal cavity.
A tube is left in the stomach. The wound of the abdominal wall is sutured in layers.

Resection of the Stomach

(Resectio gastrici)

Indications: the complicated ulcers of the stomach and duodenum, (bleeding, penetrating,
callous ulcers, pyloric stenosis), benign tumours (polyps, adenomas), carcinoma of the stomach.
The main purpose of the operation in ulcerative disease of the stomach and the duodenum
is the removal of the more than distal 2/3 of the stomach for elimination of the humoral zone,
which produces gastrin, it means to provide the decrease of the secretion. Besides, the above
mentioned portion is more sensitive to the ulcer formation.
In carcinoma of the stomach the size of the removed portion depends on its situation and
spread. Distal and proximal resections are distinguished. The total removal is called gastrectomy.
The resection of the stomach depending upon the size of the removal is subdivided into:
 Resection of the pyloro-antral portion of the stomach- antrectomy
 Resection of the 2/3 or 3/4 of the stomach-partial gastrectomy
 Subtotal resection, when only the base and the cardia are left
Depending upon the method of restoration of continuity of the intestinal tract after the removal
of the affected portion of the stomach, two main types of operations are distinguished: Billroth I
and Billroth II with their modifications.
Access: superior midline laparotomy
Technique of the operation
It consists of the following phases:
1. mobilization of the stomach
2. resection of the stomach and preparation of the stumps (stomach and duodenum)
3. formation of the gastro-intestinal anastomosis
Mobilization of the stomach is started from the greater curvature. The stomach and the
transverse colon are brought out of the wound; the gastrocolic ligament is tensed and incised in
an avascular area. The branches of the gastro-epiploic arteries are to be ligated and divided
between the ligatures. All the branches of the right gastro-epiploic artery are ligated up to the
pylorus in the distal direction. The branches of the arteries are ligated and divided between the
ligatures in the proximal direction up to the line of the resection in the same manner. Gradually
the gastrocolic ligament is detached along the greater curvature. Then the surgeon starts to
mobilize the lesser curvature by ligating the left, then the right gastric arteries. After completing
the mobilization, the very resection is carried out. Two clamps (Kocher’s or occlusion) are
applied side by side above and below the pylorus. The stomach is incised along the inferior
clamp at the level of the duodenum. The both stumps are prepared by iodine solution and
covered by mops (napkins). Another two clamps are applied at the stomach on the proximal
border of the resection. One of them is applied from the side of the lesser curvature including the
wall of the stomach 2-3cm long, the other one-from the side of the greater curvature in the same
direction faced to the first one, including the wall of the stomach no less than 4-5cm, which is
equal to the size of the future anastomosis. Payer’s crushing clamp is now applied to the stomach
between these two clamps. The stomach is divided below the crushing clamp and removed. The
stump of the stomach is sutured by a haemostatic over-and-over suture, including the clamp.
Then the clamp is taken out gently and the suture is tightened. After the removal of Payer’s
clamp and Kocher’s clamp from the side of the lesser curvature, the sutured stump of the
stomach is now invaginated by sero-muscular sutures.

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 Formation of the anastomosis in Billroth I method
A direct anastomosis is performed between the stomach stump from the side of the
greater curvature and the duodenal stump by means of 2-layers intestinal sutures. Particular
attention must be paid on the tightening of the suture line of the anastomosis from the side of the
lesser curvature. For this purpose 2-3 interrupted sutures are applied, each of which includes the
serous and muscular layers of the anterior wall of the stomach, the posterior wall of the stomach
and the wall of the duodenum. These sutures tighten the most dangerous place of the
anastomosis- the junction of the 3 sutures.
Formation of the anastomosis in Billroth II method in Hofmeister –Finsterer’s
modification
In this method the stump of the duodenum is closed firmly and a vertical anastomosis is
performed between the stomach stump (from the side of the greater curvature) and the first loop
of the jejunum, moved behind the transverse colon, by the “end to side” method. The stump of
the duodenum is sutured at first by through-and-through suture, and then after the thread is tied,
the stump is invaginated by one or two (applied one after another) sero-muscular purse string
sutures.
In order to perform the gastro-jejunal anastomosis, the transverse colon is brought out of
the abdominal cavity and pulled to sides. The initial portion of the jejunum is identified. A 5-
6cm long opening is made in the transverse mesocolon in an avascular area to the left of the
middle colic vessels, above the duodeno-jejunal fold. The initial portion of the jejunum is moved
through the opening in the transverse mesocolon to the superior storey of the abdominal cavity
and 2-layers anastomosis is carried out with the stomach stump from the side of the greater
curvature. After completing the anastomosis, the afferent loop of the jejunum is sutured by 2-3
sero-muscular stitches to the stomach stump, thus covering the weak place of the anastomosis-
the junction of the three sutures and giving a vertical position to the anastomosis.
Completing the operation, the anastomosis is moved to the inferior storey of the
abdominal cavity through the opening in the transverse mesocolon and fixed to the margins of
the “window”. A tube is pushed into the stomach. The subhepatic space is drained. The wound is
sutured in layers as usual.
Advantages of Billroth I gastrectomy
1. The anatomo-physiological way of the food is preserved
2. the stomach stump performs its reservoir function
3. there doesn’t exist a direct contact between the mucous membrane of the stomach and the
mucous membrane of the jejunum, which completely excludes the formation of the peptic ulcer.
4. this method is performed technically easier and faster
The disadvantages of this method are:
1. possibility of over distension of the tissues in the place of the anastomosis between the
gastric and the duodenal stumps
2. presence of the 3 sutures junction in the superior part of the anastomosis
The both moments can bring to the rupture of the sutures (blow out) and cause
unreliability of the anastomosis.
The advantage of Billroth II gastrectomy is that the imperfections of the Billroth I method
are eliminated. But at the same time the duodenum is taken out of the digestive process, which is
physiologically wrong. There is a real danger of unreliability of the duodenal stump.

Cholecystektomy

Indications: chronic recurrent cholecystitis (calculous and non calculous), flegmon,

gangrene, perforation and cancer of the gallbladder.
Access: right oblique incision parallel to the right costal arch (Feodoroff’s or Kocher’s
incision).

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 After preliminary exploration and taking the decision that the gallbladder has to be
removed, the surgeon will now proceed to perform cholecystectomy.
There are two principle methods, which can be adopted to remove the gallbladder. One is
the “duct-first” method, i.e. the cystic duct and the artery are dissected first and divided, after
which the gallbladder is removed. Another method is “fundus-first” method, in which the
dissection is started from the fundus of the gallbladder and gradually proceeded towards the
cystic duct which is divided last of all. But the first method is popular because of the fact, that
there is less chance of injury to the common bile duct or to the right hepatic artery, as the
dissection of the junction of the cystic duct and common bile duct is done first before soiling of
the part with exudate, haemorrhage or biliary leakage.
The “duct-first” method
After preliminary observation and palpation of the gallbladder and the elements of the
hepato-duodenal ligament (bile ducts, portal vein and hepatic artery), the peritoneum, which
covers anteriorly the hepatoduodenal ligament, is opened.
If the gallbladder is very much distended to prevent a good dissection at its neck and
cystic duct, it’s better to aspirate the gallbladder first and then to clamp the aspirating point so as
to prevent the biliary leakage. A sponge holding forceps is applied to the infundibulum of the
gallbladder and is used to retract the gallbladder to the right so that the cystic duct is made taut.
The junction of the cystic and and the common bile duct is now displayed by snipping the
overlying peritoneum and then by gause dissection with forceps. If a stone is felt at the cystic
duct, it is pushed towards the gallbladder. If the stone remains impacted, it is removed through a
small nick on the cystic duct. The dissection at the junction of the cystic, common hepatic and
common bile duct must be very clear. These three ducts must be shown to the assistant so that
not only the surgeon but also the assistant is satisfied with the exposure.
This step is very important and always prevents the damage to the common bile duct, the
common hepatic duct and the right hepatic artery. A. cystica , which extends from the right
hepatic artery, is defined in Calout’s triangle, formed by the junction of the cystic and the
common hepatic ducts, in the base of the triangle. It’s ligated with two ligatures and divided.
The cholecystectomy forceps is passed deep to the cystic duct to bring the thread. The
ligature is now divided to make two strands of ligature. One strand is tightened on the cystic duct
about 1cm distal to its junction with the common bile duct. The other strand is very loosely
tightened on the cystic duct at its junction with the common bile duct. The bile duct isn’t tied just
close to its entrance into the common bile duct as it can lead to the narlayersing of last one. To
leave a long stump isn’t recommended also, as it may lead to the distention and formation of new
stones.
“Fundus-first” method
This method is only applied when the dissection at the region of the junction of the cystic
duct, common hepatic duct and common bile duct becomes difficult due to lots of adhesions and
inflammatory exudates. This operation of the gallbladder is commenced from the fundus. The
peritoneal sheath is divided with scissors on each side of the gallbladder. When the gallbladder is
completely freed from the liver, the cystic duct and the artery are defined as much as practicable.
These are divided between ligatures. The danger remains of injuring the common bile
duct and the right hepatic artery.
Both methods are completed by draining the subhepatic space. The wound is sutured in layers as
usual.

Appendectomy

Indications: acute appendicitis, recurrent or chronic appendicitis, tumours of the appendix

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 Access: McBurney’s incision is mostly made for this operation or Lenander’s right
pararectal incision. If the case is not clear enough or there are clinical signs of peritonitis- a
midline incision is made.
Technique of the operation
After opening the peritoneal cavity, the caecum, which is relatively whitish, which has
got taenia coli and no omentum and mesocolon, is taken out of the abdomen with the aid of
anatomical dissectors or fingers. Now the anterior taenia coli is followed downwards to reach the
vermiform appendix. Sometimes it is very easy to find out the appendix, when it’s more or less
exposed as soon as the peritoneum is incised. In other cases it may be very difficult to find the
appendix out which may be fixed in the retroperitoneal tissue behind the caecum. A pair of tissue
forceps is applied to the tip of the mesoappendix. The appendix is lifted up with this tissue
forceps. 0,5% or 0,25% -15-20ml Novocaine solution is injected into the mesoappendix. The
mesoappendix is pierced at its base with a mosquito artery forceps and the appendicular artery is
secured with a ligature through this hole. The mesoappendix is now divided close to the
appendix till the caecum is reached. If the appendix is kinked with firm adhesions, this division
of the mesoappendix is performed in segments.
The base of the appendix is crushed with a strong artery forceps. A ligature is tied around
the crushed area. A sero-muscular purse- string suture is inserted in the caecal wall around the
base of the appendix. A pair of artery forceps is applied to the appendix 5mm distal to the
ligature. Appendix is removed with a knife between the ligature at its base and the artery forceps.
The stump is cauterized with iodine solution and is invaginated while the purse-string suture is
tightened, which is further reinforced by Z-form sero-muscular suture.
The ligature to mesoappendix is re-examed and make sure that it is not oozing. Thus
completing the operation, abdominal wound is sutured in layers as usual.
Retrograde appendectomy- Sometimes the tip of the appendix is not accessible as a long
retrocaecal appendix may be inflamed and tucked into the retroperitoneal connective tissue. In
that case the base of the appendix is well identified from the caecum and divided in usual
manner. The mesoappendix is then ligated and divided in segments and gradually proceeded
towards the tip. Thus the appendix is removed from the base towards the tip and is popularly
known as retrograde appendectomy.

LUMBAR REGION AND RETROPERITONEAL SPACE

(Regio lumbalis et spatium retroperitoneale)

Boundaries:
superiorly-the XII costae
inferiorly- crests of the iliac bones and sacrum
laterally- posterior axillary lines
Posterior median line (the line of the spinous processes) divides the region into two
symmetric parts where we distinguish medial lumbar region (regio lumbalis medialis s.
vertebralis) and lateral lumbar region (regio lumbalis lateralis).
The layers of the lumbar region are the layers of the posterior abdominal wall. The
retroperitoneal space is situated in the depth of the abdominal cavity between f. endoabdominalis
(posteriorly and laterally) and parietal peritoneum of the posterior wall of the abdominal cavity
(anteriorly). Superiorly the retroperitoneal space is bounded by the lumbar and costal parts of the
diaphragm, inferiorly by an imaginary line which passes in the retroperitoneal fatty tissue
through the terminal line (linea terminalis).
This space contains retroperitoneally situated internal organs, vessels, fatty tissue and
fasciae.

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 Lumbar Region
(Regio lumbalis)

Layers: The skin is thick, hardly movable. The subcutaneous fatty tissue is hardly
developed. The superficial fascia is developed and gives off a deep fascial spur, which divides
the subcutaneous fatty tissue into 2 layers.
Proper fascia of the region –f. thoracolumbalis, forms capsules for the muscles of the
lumbar region: m.m. latissimus dorsi, obliquus externus et internus abdominis, serratus posterior
inferior, erector spinae, transversus abdominis.
The first muscular layer consists of 2 muscles: the largest muscle of the spine (m.
latissimus dorsi) and external oblique muscle of the abdomen (m. obliquus abdominis externus).
M. latissimus dorsi begins from the spinous processes of the 6 inferior thoracic vertebrae, all the
lumbar vertebrae, posterior surface of the sacrum and iliac crest and attaches to the crest of the
lesser tubercle of the humerus (crista tuberculi minoris humeri). Muscular bundles pass upwards
and forwards.
M. obliquus abdominis externus passes downwards and forwards. Its posterior bundles
attach to the iliac crest in the anterior 2 thirds and don’t approach the border of m. latissimus
dorsi. As a result a triangular space is formed between the borders of above mentioned muscles
and the iliac crest (inferiorly), which is called lumbar triangle (trigonum lumbale). M. obliquus
internus forms its floor. This triangle is a weak place of the region, where abscesses of the
retroperitoneal space, rarely herniae of the abdominal region can pass.
The second layer consists of m. erector spinae - medially, m. serratus posterior inferior -
laterally and superiorly, m. obliquus internus abdominis –inferiorly. M. erector spinae lies in the
capsule formed by the superficial and deep layers of the thoracolumbar fascia, the superior layer
of which is attached to the spinous, and the deep layer- to the transverse processes of the
vertebrae. The superficial layer is strengthened by the aponeurosis of m.m. latissimus dorsi,
obliquus externus abdominis, trapezius. The closed capsule of the erector spinae muscle in its
lateral border is the place, where the fascial capsules of the broad muscles of the abdomen are
attached.
The borders of 2 muscles – m. obliquus internus abdominis and m. serratus posterior
inferior are turned to each other, but don’t touch each other, so between them a quadriangular or
triangular space is left, which is known as lumbar or Lesgaft-Grunfeld’s rhomb (tetragonum
lumbale). The sides of this rhomb are: superiorly- inferior border of the inferior serratus muscle;
inferiorly – posterior (free) edge of the internal oblique muscle, medially- lateral edge of the
erector spinae, laterally and superiorly- the XII rib. The floor is formed by the aponeurosis of m.
transversus abdominis. Abscesses of the retroperitoneal fatty tissue can spread through this
rhomb to the lumbar region.
The third layer is formed by m. transversus abdominis, the deep (anterior) surface of
which is covered by f. transversa, which medially forms capsules for m.m. quadratus lumborum,
psoas major et minor and is called f. quadrata and f. psoatis, respectively. In the superior part of
the region they form 2 ligaments, which are known as arcus lumbocostalis medialis et lateralis.
By the anterior surface of the quadratus lumborum muscle, under the fascia which covers
it anteriorly, n.n. subcostalis, iliohypogastricus, ilioinguinalis pass in the oblique direction ( from
medial to lateral side and from superior to inferior side). N. genitofemoralis lies on the anterior
surface of the psoas major muscle.

Retroperitoneal Space
(Spatium retroperitoneale)

Boundaries: it is situated between posterior abdominal wall covered by endoabdominal

fascia and parietal layer of peritoneum.

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 F.retroperitonealis is the next fascia of this space. It begins from f. endoabdominalis and
parietal peritoneum on the level of posterior axillary line, where peritoneum passes from the
lateral walls onto the posterior wall of the abdominal cavity. The junction of the two fasciae
fused with peritoneum forms a firm fascial knot. F. retroperitonealis extends from here medially
and at the lateral border of the kidneys divides into two fascial layers which cover each kidney
anteriorly and posteriorly. They are called f. praerenalis and f. retrorenalis, respectively.
F. praerenalis passes as a common sheet in front of the fatty tissue which covers the
kidney anteriorly, superiorly forms a fascial sheath for suprarenal glands and blends with the
similar part of f. retrorenalis. F. praerenalis turns into the fascia of the opposite side without
interruption below the place where a. mesenterica inferior starts.
Below the inferior poles of the kidneys prerenal fascia descends in front of the ureters as
f. praeureterica up to the pelvic cavity. On the level of the III-IV lumbar vertebrae f. praerenalis
becomes thinner and firmly fuses with peritoneum.
F. retrorenalis is also well developed on the level of the kidneys. It fuses with the
prerenal fascia above the suprarens and inferiorly it descends behind the ureters and is called f.
retroureterica.
F. retrocolica (f. Toldti) passes behind the ascending and descending colons covering
their extraperitoneal parts. It’s a remnant of the primary mesenterium, which was lost in the
process of ontogenesis as a result of the transfer of the parts of the colon. F. retrocolica of the
ascending colon medially is connected by many strands with fascia covering the root of the small
intestine, and f. retrocolica of the descending colon disappears in the fatty tissue of the medial
border. Laterally f. retrocolica is fused with the parietal peritoneum in the left and right sides.
Three layers of the fatty tissue are distinguished between above mentioned fasciae:
 textus cellulosus retroperitonealis
 paranephron
 paracolon

Textus cellulosus retroperitonealis is the first layer of the retroperitoneal fatty tissue. The
anterior wall of it is formed by f. retrorenalis, posterior one- by f. endoabdominalis. Superiorly it
is bounded by the fusion of the fascia with the diaphragm on the level of the XII rib; inferiorly it
turns freely into the fatty tissue of the pelvic cavity; medially it is bounded by the fusion of f.
retrorenalis with the fascial capsules of aorta abdominalis, inferior vena cava and iliopsoas
muscle. Laterally it doesn’t turn directly into preperitoneal fatty tissue, as parietal peritoneum
fuses with f. endoabdominalis and f. retroperitonealis in the posterior axillary line by many
fascial strands.
Paranephron. The second layer of the fatty tissue surrounds the kidney lying between f.
retrorenalis and f. praerenalis, forming a fatty capsule for the kidney called paranephron or
capsula adiposa renis. It’s divided into 3 parts: superior fascial- the fatty tissue of the supraren;
middle- proper fatty capsule of the kidney; inferior fascial- fatty capsule of the ureter. The first
part is isolated, whereas two others (middle and inferior) are connected with each other.
Paranephron consists of loose fatty tissue, which surrounds the kidney from all sides. Its
thickness is individually various. It is more developed in the hilus and in inferior pole. Here f.
praerenalis and f. retrorenalis are connected with each other by connective tissue bundles, which
strengthen the capsule inferiorly, and with the renal vessels and ureter hold the kidney in its
position
Paracolon. Third layer lies behind the ascending and descending colons and is called
paracolon. It is situated between Toldt’s fascia (f. retrocolica) and parietal peritoneum of the
lateral canals anteriorly, f. praerenalis and f. praeureterica- posteriorly. The thickness of this
layer depends on the state of the nourishment and can reach 1-2cm. Superiorly paracolon finishes
near the root of mesocolon transversum, inferiorly in the right side – near colon caecum, in the
left side- near the root of mesocolon sigmoideum. Specifities of the structure of retroperitoneal
space, which is divided by fasciae into above mentioned layers, is used for performing a number

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of diagnostic and treating measures such as pneumoretroperitoneum and paranephral novocaine
blockade.

TOPOGRAPHIC ANATOMY OF PELVIS

The pelvis is the region of the trunk situated inferoposteriorly to the abdomen , in the
area of transition from the trunk to the lower limbs. Bony, ligamentous and muscular walls
enclose it. The outlet of the pelvis is covered by perineum.
The bony pelvis is formed by sacrum and coccyx and 2 hipbones, each of which is
composed of three bones (ilium, ischium and pubis). The hipbones are joined anteriorly by
symphysis pubica. Iliac bones form sacro-iliac articulation with the sacrum. Two strong
ligaments, extending from the sacrum, are attached to the iliac spine (lig. sacrospinale) and tuber
ischiadicum (lig. sacrotuberale). They close the greater and the lesser sciatic notches forming the
openings of the same name (foramen ischiadicum major and foramen ischiadicum minor).
By terminal line (linea terminalis) the skeleton of the pelvis is divided into 2 parts:
greater or false pelvis (pelvis major) and lesser or true pelvis (pelvis minor). Greater pelvis is
formed posteriorly by sacrum, laterally- by the wings of the ilium.
Lesser pelvis is a cavity bounded by the pelvic surfaces of the hipbones, sacrum and
coccyx. It is located between the superior pelvic aperture (pelvic inlet) and the inferior pelvic
aperture (pelvic outlet). Superior pelvic aperture appears as a terminal line, which passes through
the superior margin of the pubic symphysis, posterior border of the pubic crest, pecten of the
pubis, arcuate line of the ilium, anterior border of the winglike ala of the sacrum and promontory
of the sacrum. The inferior pelvic aperture is bounded anteriorly by the inferior margin of the
pubic symphisis; anterolaterally on each side – by the inferior roots of the pubis and ischiadic
tuberosities; posterolaterally on each side by the sacrotuberous ligament; posteriorly- by the tip
of the coccyx.
The following muscles cover the pelvic walls: m.m. iliopsoas, piriformis, obturatorius
internus, coccygeus. The floor of the pelvic cavity is formed by the muscles and fasciae of
perineum. It consists of the pelvic diaphragm (diaphragma pelvis) and urogenital diaphragm
(diaphragma urogenitalis). Pelvic diaphragm is formed by the muscle elevating anus (m. levator
ani). Urogenital diaphragm is formed by the deep transverse muscle of the perineum (m.
transversus perinei profundus), which is in the angle between inferior branches of the pubic and
the ischial bones.

Pelvic Fasciae

Pelvic fascia is the continuation of endoabdominal fascia and comprises the visceral and
parietal pelvic fasciae. F.pelvis parietalis covers the muscles of the walls of the pelvic cavity:
m.m. piriformis, obturatorius internus, coccygeus and the muscles of the pelvic floor: m.m.
levator ani, transversus perinei profundus.
Parietal fascia, which covers m. levator ani superiorly, is called superior fascia of the
pelvic diaphragm (f. diaphragmatis pelvis superior) and parietal fascia which covers the muscle
inferiorly- inferior fascia of the pelvic diaphragm (f. diaphragmatis pelvis inferior).Both fasciae
are connected and fused with arcus tendineus fasciae pelvis.
Parietal pelvic fascia, which covers the deep transverse perineus muscle superiorly, is
called f.diaphragmatis urogenitalis superior, and the parietal fascia, covering the same muscle
inferiorly- f. diaphragmatis urogenitalis inferior.
F. pelvis visceralis forms capsules for the organs of the true pelvis, which are separated
from the organs by a layer of loose connective tissue, through which blood and lymph. vessels
and nerves pass. The organs of the true pelvis occupy middle position and are separated from the
wall by a layer of fatty tissue.

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 It is accepted to divide the pelvic cavity into 3 parts (storeys):
1. peritoneal (cavum pelvis peritoneale)
2. subperitoneal (cavum pelvis subperitoneale)
3. subcutaneous (cavum pelvis subcutaneum)

I. Cavum pelvis peritoneale

Peritoneum passes from the anterior abdominal wall onto the superior, partly posterior
and lateral walls of the urinary bladder, forming plica vesicalis transversa. When the urinary
bladder is filled, the fold is straightened and the peritoneum is elevated upwards. This peculiarity
is used for puncture of the urinary bladder and extraabdominal operations with the access
through the abdominal wall.
In males peritoneum, descending from the posterior wall of the urinary bladder, covers
the medial edges of the ampullae of ductus deferens, tops of the seminal vesicles and then
traverses onto the anterior surface of the rectum, forming recto-vesical pouch (excavatio recto-
vesicalis). This depression (pouch) is bounded laterally by the recto-vesical folds of the
peritoneum. The bottom of the pouch, which is the lowest point of the peritoneal cavity, is fixed
to the tendinous centre of the perineum by peritoneo-perineal aponeurosis (Denonwilli’s
ligament). The inflammatory fluid (exudate) may accumulate in this pouch in acute appendicitis,
perforative ulcers, and blood- in the injuries of liver or spleen. Here abscesses may be formed
being isolated from the free abdominal cavity by adhesions.
The peritoneum covers only narlayers part of the rectum, then ascending, on the level of
the III sacral vertebra; it covers the intestine from all sides, forming mesentery for it. This level
is considered to be the border between the rectum and sigmoid colon.
In females the relations of the peritoneum with the organs of the pelvis are different
because between the urinary bladder and the rectum appears the uterus which is also covered by
peritoneum. As a result in the female pelvis two peritoneal pouches are formed: the peritoneum
passes from the posterior surface of the urinary bladder onto the anterior surface of the uterus on
the level of the isthmus, forming not deep pouch- excavatio vesico-uterina. Anteriorly the neck
of the uterus and the vagina are remained extraperitonealy. Covering the bottom, body and the
neck of the uterus posteriorly, the peritoneum descends lower the level of the neck, covers
posterior fornix of the vagina and passes onto the rectum, forming the deep recto- uterine pouch
or Duglas’ space (excavatio recto-uterina).
The knowledge of Duglas’ space has practical importance, as we can make diagnosis of
the presence of the fluids (blood, pus, ascidic fluid) by palpating through the posterior fornix of
the vagina. Puncture of Duglas’ space by a long needle helps the doctor to define the character of
the fluid and sometimes evacuate it by an access (incision) through the posterior fornix of the
vagina (colpotomia). This excavatio is bounded laterally by the folds-plicae recto- uterinae,
which continue up to the anterior surface of the sacrum. The folds cover the excavatio also
superiorly, thus isolating it partly from the whole pelvic cavity.

II. Cavum pelvis subperitoneale

It’s between the peritoneum and parietal fascia. It contains parts of the organs not
covered by peritoneum, vessels, nerves, lymph nodes and fatty tissue surrounding them. Here the
organs are covered by the visceral fascia and spaces between the organs and fasciae are formed:
pararectal, parametral, paraprostatic spaces etc.
In the subperitoneal storey of the pelvic cavity two processes of the fascia pass in the
sagital plane: anteriorly they are attached to the medial border of the obturator foramen, then
they pass posteriorly, fusing with the fasciae of the urinary bladder, rectum, then they attach to
the anterior surface of the sacrum close to the ilio-sacral joint. Visceral branches of the vessels
and nerves for pelvic organs are situated in each process.

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 In the frontal plane, between urinary bladder, prostate and rectum in males , between the
vagina and the rectum in females, peritoneo-perineal aponeurosis passes, which reaching sagittal
processes, fuses with them and reaches the anterior surface of the sacrum. As a result following
parietal fatty tissue spaces are formed: prevesical, retrovesical, retrorectal and two lateral. All of
them have practical importance as places, where flegmons of the true pelvis can locate.
Prevesical space (Spatium praevesicale s. retropubicum). It is between the visceral fascia
of the urinary bladder, which is called f. praevesicalis and parietal fascia. The bottom of the
space is formed by the anterior part of the pelvic diaphragm. Loose fatty tissue, vesical and
prostatic venous plexuses and arteries of the bladder are situated here.
The pus can spread from this space in the following directions:
1. to the thigh through the femoral and obturator canals;
2. to the lateral parietal spaces;
3. to the paravesical visceral space;
4. into the free abdominal cavity;
5. into the sheaths of the rectus abdominis muscles, umbilical region, under the skin.
Suprapubic incision of the urinary bladder (sectio alta) is performed through this space.
Retrovesical space (Spatium retrovesicale). It is between the posterior wall of the urinary
bladder, covered by the visceral fascia and peritoneo-perineal aponeurosis. Laterally it is
bounded by the sagittal fascial processes. The bottom of the space is formed by the urogenital
perineum. The prostate covered by a firm capsule, terminal parts of the ureters, ductus deferens
with their ampullae, seminal vesicles, fatty tissue and prostatic venous plexus are situated here.
The pus from this space can spread to:
1. posterior part of the paravesical visceral space;
2. inguinal canal along the ductus deferens;
3. retroperitoneal fatty tissue space along the ureter;
4. urethra two peritoneal pouches, rectum.
Retrorectal space (Spatium retrorectale). It is located between the rectum with its
fascialcapsule anteriorly and the sacrum posteriorly. From the lateral parietal spaces it is
separated by the sagittal fascial processes. The bottom is formed by the coccygeal muscles. A.
rectalis superior, a. sacralis mediana and the branches of a.a. sacrales laterales, sacral part of the
sympathetic trunk and nerves extending from it ( n.n. splanchnici sacrales, plexus hypogastricus
superior), n.n. splanchnici pelvini from the parasympathetic centers of the sacral part of the
spinal cord, nodi lymphatici sacrales.
The pus can spread to:
1. retroperitoneal space (textus cellulosus retroperitonealis);
2. lateral parietal spaces ;
3. visceral space of the rectum –pararectal space .
Lateral spaces (spatia lateralia dextrum et sinistrum). The boundaries of the space are: medially-
the sagittal fascial processes, laterally- parietal layers of the pelvic fascia, anteriorly- fusion of
the urinary fasciae with the fascial processes, posteriorly- the sagittal processes which border
with the retrorectal space. The bottom is formed by the parietal fasciae, which cover the pelvic
diaphragm.
The blood vessels (the common and internal iliac arteries and veins), lymphatic vessels
and nodes, visceral nerve trunk, nerve trunks of the sacral plexus, ureters, ductus deferentes are
situated in these spaces.
The pus can spread to:
 textus cellulosus retroperitonealis (along the vessels and nerves)
 gluteal region (through the suprapiriformis and infrapiriformis foramina)
 retrorectal space
 previsceral space
 region of the adductor muscles of the thigh through the obturator canal
 visceral spaces of the internal organs of the true pelvis along the vessels of the organs.

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 III. Cavum pelvis subcutaneum s. fossa ischio-rectalis

They are paired spaces of triangular shape situated laterally to the perineal part of the
rectum.
Boundaries of the ischio-rectal fossa are:
 Medially- m. sphincter ani externus
 Laterally-tuber ischii
 Anteriorly- m. transversus perinei superficialis
 Posteriorly-inferior border of m. gluteus maximus
The walls of the fossa are formed laterally by the inferior 2/3 –s of m. obturatorius
internus, covered by the dense parietal pelvic fascia, which splits here, forming a canal for the
genital neuro-vascular bundle. This canal is called Alcock’s canal (canalis pudendalis). The
pudendal bunch (a.v. pudenda interna, n. pudendus) passes through the infrapiriform foramen,
then it lies on the sacrospinal ligament, passes through the lesser sciatic opening under the
sacrotuberal ligament to the internal surface of the sciatic tuber. Superiorly and medially the
walls are formed by the pelvic diaphragm, i.e. the inferior surface of m. levator ani covered by
the inferior fascia of the pelvic diaphragm (f.diaphragmatis pelvis inferior). The muscle passes
from the superior to inferior part, from the lateral to the medial side, forming an inferiorly
opened angle with the lateral wall of the fossa.
The depth of the fossa is 5-7,5 cm from the surface of the skin up to the angle of the
fossa. Gradually it decreases anteriorly reaching 2,5cm.
Pus can accumulate in the ischio-rectal fossa (paraproctitis). Sometimes it’s necessary to
open flegmons of the subperitoneal cavity through this fossa.
The pudendal neuro-vascular bunch passes in the pudendal canal 4-5 cm above the
inferior margin of tuber ischiadicum. This projectional point is used for pudendal nerve blockade
in anaesthesia of confinement.

OPERATIVE SURGERY AND TOPOGRAPHIC ANATOMY OF THE LIMBS

The following operations are performed on the limbs:

1. Operations on blood vessels are performed (in the wound and along the course of the
artery) to arrest bleeding in arterial damage.
2. Operations on nerves
3. Operations on tendons
4. Operations on the limbs in case of abscesses and carbuncles
5. Amputations
The skills of performing above mentioned operations depend on the knowledge of
topographic anatomy of the limbs.
Specifities of the Topographic Anatomy of the Limbs
All the operations on the limbs are made in the fascial compartments which contain
elements to be operated .These compartments are formed by the sheets of deep fascia (fascia
propria). Intermuscular septa extend from the deep fascia. Proper fascia together with
intermuscular septa, bones and interosseous membrane makes osteo-fascial spaces
(compartments). Interfascial spaces are formed between two layers of fascia.
It’s important to mention the following specifities:
 In the region of the arm on the upper limb and in the region of the thigh on the
lower limb both osteo-fascial and interfascial spaces are formed while in the other regions –only
osteo-fascial spaces.
 Knowledge of projectional (surface) anatomy, as the knowledge of the projection
of the arteries and nerves is particularly important during the operations on the limbs.

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 TOPOGRAPHIC ANATOMY OF THE UPPER LIMB

Boundaries: it is divided from the trunk by an imaginary line which passes anteriorly
through the sulcus deltoido-pectoralis, posteriorly by a line which connects lower borders of the
pectoralis major and latissimus dorsi muscles.Upper limb consists of shoulder girdle and free
upper limb.
Shoulder girdle consists of four regions:
 Regio axillaris
 Regio deltoidea
 Regio scapularies
 Regio infraclavicularies
The last 2 regions are on the chest, but as they are related to the axilla -make its anterior
and posterior walls- we study them in this chapter. Free upper limb consists of :
 Regg. brachii anterior et posterior
 Regg. cubiti anterior et posterior
 Regg. antebrachii anterior et posterior
 Reg. palmae manus
 Reg. dorsi manus
 Regg. digiti (palmaris/dorsalis)

Axillary Region( Regio axillaris)

It is at the junction of the chest and the arm when the upper limb is abducted. Boundaries:
anteriorly- lower border of pectoralis major muscle, posteriorly-lower border of latissimus dorsi
muscle, laterally- an imaginary line which connects lower borders of the above mentioned
muscles on the arm, medially- the same line on the chest.
Layers.
1. The skin is covered with hair, has a great number of sweat and sebaceous glands.
2. In the subcutaneous fatty tissue there are 5-6 superficial lymphatic nodes and
intercostobrachial nerves (n .n. intercostobrachiales –from plexus brachialis and n.n.
intercostales).
3. Superficial fascia is hardly developed.
4. Proper fascia is fine in the centre and is pierced by the arteries and nerves. After
taking away proper fascia a cavity called axilla (fossa axillaris) appears. It has a shape of
truncated pyramid, the shape and size of which vary, depending on the position of the arm.
Apex of the axilla lies between the first rib, the clavicle and the superior edge of the
subscapularis muscle. It is directed superiorly and medially. Base of the axilla (armpit) is
directed inferiorly and laterally.
Axillary fossa has 4 walls:
 Anterior wall of the axilla is formed mainly by the pectoralis major and minor muscles.
Here we distinguish 3 triangles: clavipectoral, pectoral and subpectoral.
 Posterior wall is formed chiefly by the scapula, subcapularis, teres major and minor,
latissimus dorsi muscles.
 Lateral wall is the humerus covered by the coracobrachial muscle and short head of the
biceps brachii muscle.
 Medial wall is formed by the first to fourth ribs, intercostal muscles and the overlying
serratus anterior muscle.
Axillary fossa is filled with loose fatty tissue where we can find arteries, veins, lymphatics
and nerves. They pass through the apex to reach the arm. The topography of the above
mentioned elements is described in each of 3 above mentioned triangles separately.
I. The sides of the clavipectoral triangle (trigonum clavipectorale) are: superiorly-the
clavicle, inferiorly- upper border of the pectoralis minor muscle. In the boundaries of this
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triangle vein lies medially to axillary artery. The brachial plexus is formed by the union of the
ventral rami of C5-C8, T1 nerves. As they enter the neck they unite to form three (superior,
middle and inferior) trunks, which form divisions posterior to the clavicle. Here the brachial
plexus lies superiorly and laterally to the artery .Two branches extend from the artery: a.
thoracica suprema and a. thoracoacromialis. Fascia clavipectoralis encloses the pectoralis minor
and subclavicularis muscles and then attaches to the clavicle.Because the inferior part of the
clavipectoral fascia supports the axillary fascia this part of the fascia is referred to as the
suspensory ligament of the axilla (ligamentum suspensorium axillae).
II. In the pectoral triangle (trigonum pectorale) which coincides with pectoralis minor
muscle a branch called a. thoracica lateralis extends from a. axillaris. It is followed by n.
thoracicus longus. Brachial plexus passes by 3 cords (fasciculi): medial, lateral and posterior
(according to their relationship to the second part of the axillary artery). Vein again is medial to
the artery.
III. Subpectoral triangle (trigonum subpectorale) is between inferior borders of both
pectoral muscles. Here a.axillaris gives off 3 branches: a. circumflexa humeri anterior, a.
circumflexa humeri posterior and a. subscapularis. The last one is divided into a. circumflexa
scapulae and a. thoracodorsalis. First 2 branches curve around the surgical neck of the humerus
and make anastomosis with each other.
Terminal branches start from the cords of the brachial plexus: n. medianus is formed by
the medial and lateral cords and passes in front of the artery; n. musculocutaneus starts from the
lateral cord, n. ulnaris, n. cutaneus brachii medialis and n. cutaneus antebrachii medialis start
from the medial cord, n. radialis and n. axillaris start from the posterior cord. As a matter of fact
these nerves surround the artery from all the sides.
Posterior wall is made by scapular region where we describe two openings: quadrilateral
and trilateral. Between teres minor and subscapularis muscles above, teres major and latissimus
dorsi muscles below and humerus laterally there is left a space, which is crossed by the long
head of triceps brachii muscle. As a result foramen trilaterum is formed medially and foramen
quadrilaterum –laterally. A. circumflexa scapulae (a branch of a. subscapularis), followed by
veins ,passes through trilateral opening from axillary to scapular region. A. circumflexa humeri
posterior and n. axillaris pass through foramen quadrilaterum.
A.axillaris is the main artery, branches of which make anastamoses with the branches of
subclavian and brachial arteries.
There are many lymph nodes in the fibrofatty connective tissue of the axilla, which are
arranged in 5 principle groups. Four of them (lateral, central, medial and subscapular) lie
inferiorly and deep to pectoralis minor muscle and one (apical) lies superiorly to it.
1. Nodi lymphatici axillares mediales (pectorales) - lymph is collected from anterior
superior surface of the thorax and abdomen (above umbilicus) and mammary gland. A lymph
node (or nodes) called Zorgues’ node is most common site of metastases from cancer of the
breast.
2. Nodi lymphatici axillares laterales (brachiales) - collect lymph from the upper
limb.
3. Nodi lymphatici axillares centrales- the lymphatics of the region drain into them.
4. Nodi lymphatici axillares subscapulares (posteriores) - collect lymph from the
superior part of the trunk and posterior surface of the neck.
5. Nodi lymphatici axillares apicales (infraclaviculares) -get lymph from lower
lymph nodes and superior pole of the breast.
Projection of a. axillaris has practical importance. According to Pirogov it is projected
through the anterior border of the hair covering of the axilla. According to Langenbek it is
projected by the continuation of the sulcus bicipitalis medialis in the axillary fossa.

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 Deltoid Region
(Regio deltoidea)

Boundaries: This region coincides with the position of the deltoid muscle.
Layers.
1. The skin is thick. It is innervated by the branches of the lateral cutaneous nerve of the
brachium (n. cutaneus brachii lateralis superior) and supraclavicular nerve (n. supraclavicularis
lateralis) - from plexus cervicalis.
2. Subcutaneous fat is developed well.
3. The superfitial fascia is fused with the proper fascia in the region of the acromion.
4. Proper fascia forms a sheath for the deltoid muscle which starts from the clavicle,the
acromial process and the spine of the scapula and is attached to the deltoid tuberosity of the
humerus.
5. There is a space filled with loose fatty tissue where tendons of the muscles,synovial
bursae,vessels and nerves pass.Synovial bursae are the followings:bursa subdeltoidea, bursa
subacromialis and bursa subtendinea m. subscapularis. The last one communicates with the joint
cavity.
The region is innervated by axillary nerve (n. axillaris) which passes through the
quadrangular space from the axillary region together with the posterior circumflex artery of the
humerus (a. circumflexa humeri posterior). The last one anastomoses with the anterior
circumflex artery arround the surgical neck of humerus. Anterior and posterior circumflex
arteries make anastomoses with the branches of a. thoracoacromialis: r.acromialis and r.
deltoideus. Subdeltoid space communicates with fibrofatty connective tissue of the axilla and the
supraspinatus and infraspinatus fossae of the scapula. These are the ways through which
infection can spread.
From the practical point of view it’s important to know the projection of n. axillaris: it’s
a vertical line descending from the acromion, which intersects with the posterior margin of the
deltoid muscle (approximately 6cm below the acromion). The loss of the function and the
atrophy of the deltoid occur when the axillary nerve is severely damaged (e.g. when the surgical
neck of the humerus is fractured). To test the strength of the deltoid muscle clinically the
person’s arm is fully abducted and held in that position against resistance. Inability to do this
indicates that n. axillaris is injured.

Infraclavicular Region
(Regio infraclavicularis)

Boundaries: superiorly is the clavicle, inferiorly –a horizontal line which passes through
the 3rd rib in men and through the upper border of the breast in women; medially- outer border of
the sternum; laterally- anterior border of the deltoid muscle.
Layers.
1. The skin is fine.
2. Subcutaneous fatty tissue is especially developed in women. N.n.
supraclaviculares from the cervical plexus pass just under the clavicle. Anterior and lateral
branches of the intercostal nerves innervate other parts.
3. Superficial fascia is loosely connected with the proper one from the clavicle up to
the upper border of the breast and is called lig. suspensorium mammae.
4. Proper fascia which is called here fascia pectoralis forms a sheath for the
pectoralis major muscle, gives off septa into the thickness of the muscle dividing it into 3 parts:
clavicular, sternocostal and abdominal. Between pectoralis major and deltoid muscles a groove is
formed (sulcus deltoido-pectoralis) which increases superiorly in width, becoming a fossa( fossa
Morenheimi). V. cephalica passes through this groove .Ascending, it pierces proper fascia and
drains into v. axillaris or v. subclavia in the subpectoral space. Anterior wall of this space is

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formed by the deep layer of the proper fascia and pectoralis major muscle, posterior wall is
fascia clavipectoralis(deep fascia). A.v. thoracoacromiales, n.n. pectorales medialis et lateralis
pass through the subpectoral space. A. thoracoacromiales passes here from the axillary region
and gives off 3 branches: r. pectoralis, r. deltoidus and r. acromialis which supply corresponding
muscles and regions.

Scapular Region
(Regio scapularis)

Boundaries: superior border passes through a line connecting acromion with the spinous
process of the 7th cervical vertebra; lower border is a horizontal line passing through the angle of
the scapula; medially- medial border of the scapula, laterally- a vertical descending line from the
acromion.
Layers .The skin is thick, hardly movable. Superficial fascia is dense and consists of
several layers. Several fibrous strands pass through the subcutaneous fatty tissue, fixing it to the
skin and proper fascia, which explanes limited movements of the superficial layers.
Proper fascia appears as a badly developed plate .The muscles are arranged in 2 layers:
superficially are m.m. latissimus dorsi and trapezius, deeper- proper muscles of the scapula: m.
supraspinatus, m. infraspinatus, m. teres minor, m. teres major. They are covered by the deep
fascia, which forms osteo-fascial compartments for the muscles.
Branches of a. axillaris make anastomosis with the branches of a. subclavia. Collateral
circulation is possible due to anastamoses between a. circumflexa scapulae (branch of a.
axillaris) and r. descendens a. transversa colli (branch of the third part of a. subclavia) and a.
suprascapularis (branch of thyrocervical trunk- from the first part of a. subclavia). The clinical
importance of the collateral (accessory) circulation that is possible due to these anastomoses,
becomes apparent when the main arterial pathway to the upper limb is disturbed. For example, if
the axillary artery is obstructed between thyrocervical trunk (subclavian artery) and the
subscapular artery (axillary artery), the direction of bloodflow in the subscapular artery is
reversed, enabling blood to reach the distal part of the axillary artery.
The Arm
(Brachium)

Boundaries: upper border is a circular line which connects inferior margins of the
pectoralis and latissimus dorsi muscles; lower border is a circular line which passes 4cm above
the epicondyles of the humerus.Two vertical lines, which pass through the epicondyles and
practically coincide with sulcus bicipitalis medialis and lateralis, divide the arm into 2 regions:
anterior and posterior.

Anterior Region of the Arm

(Regio brachii anterior)

Layers. In lateral parts the skin is thicker than in medial parts. Subcutaneous fatty tissue
is loose. Superficial fascia is a thin layer, which forms sheaths for superficial veins and
cutaneous nerves. Laterally we can see v. cephalica, which superiorly passes into sulcus
deltoidopectoralis. V. basilica passes through the medial edge of the biceps brachii muscle. On
the border of the inferior and the middle thirds of the arm it pierces proper fascia and enters
Pirogov’s canal, which is formed by the splitting of the proper fascia. In the superior third v.
basilica drains into v. brachialis or v. axillaris. The skin is innervated by medial cutaneous nerves
of the arm ( n.n. cutanei brachii medialis and n. intercostobrachialis.).
Topographic anatomy of the arm is studied on the transverse sections which are made on
different levels: superior, middle and inferior one thirds of the arm. On the transsection made on

73
the level of the middle third of the arm anterior and posterior osteofascial compartments are
distinguished.
From the inner surface of the proper fascia 2 intermuscular septa (septa intermusculare
mediale et laterale) extend to the humerus and attaching to it, form 2 osteofascial capsules:
anterior and posterior. Boundaries of the anterior compartment are: anteriorly- proper fascia,
medially and laterally- intermuscular septa, posteriorly- humerus.This compartment contains the
muscles of the anterior group, which are arranged in 2 layers: superficial (m. biceps brachii) and
deep ( m. coracobrachialis in the upper third , m. brachialis in the middle and lower thirds and
m. brachioradialis in the lower third of the brachium). All of them are flexors. Deep fascia of the
arm (f. brachii profunda) passes between m. brachialis and biceps brachii. N. musculocutaneus
lies under this fascia. It innervates all the muscles of the anterior group, then emerges into the
inferior lateral border of the region as lateral skin nerve of the forearm (n. cutaneus antebrachii
lateralis).
Septum intermusculare mediale splits into two sheets and an interfascial space is formed,
where the main neuro-vascular bundle of the arm lies: a. brachialis (superior 1/3-medially),
v.v.brachiales, n. medianus (laterally). N. ulnaris lies medially. The last one is accompanied by
the superior collateral ulnar vessels.
A. brachialis provides the principle arterial supply to the arm. It is the continuation of the
axillary artery, begins at the inferior border of the teres major and ends opposite the neck of the
radius in the cubital fossa. In the upper one third of the artery a. profunda brachii extends from a
brachialis and, together with n. radialis, pierces medial intermuscular septum and enters
posterior muscular compartment (posterior osteo-fascial compartment). In the middle third n.
medianus lies anteriorly to a. brachialis, so it isn’t comfortable to expose the artery on this level
through direct entrance because n. medianus can be hurt. So it is performed (exposure of the
artery) through the sheath of the biceps brachii muscle, a little laterally from the projectional line
of the artery.
Besides a. profunda brachii 2 other branches extend from a. brachialis: a. collateralis
ulnaris superior in the middle third of the arm, which joins n. ulnaris and pierces medial
intermuscular septum in the middle third and enters posterior osteo-fascial compartment. In the
inferior third (in the inferior border with cubital region) another branch -a. collateralis ulnaris
inferior extends, which descends to anterior cubital region. Here n. medianus lies medially to a.
brachialis.

Posterior Region of the Arm

(Regio brachii posterior)

Layers. The skin is thick and is firmly blended with the subcutaneous tissue. Superficial
fascia is a thin layer. In the subcutaneous tissue we can find n.n. cutanei brachii laterales
superior et inferior(branches of n. axillaris), n. cutaneus antebrachii posterior and n. cutaneus
brachii posterior(n. radialis), which pierce the fascia and lie in the sulcus bicipitalis lateralis.
Posterior osteofacial compartment is bounded: posteriorly by the proper fascia, anteriorly by
humerus, from both sides- by medial and lateral intermuscular septa.
An extensor muscle- m. triceps brachii- lies in this compartment, in the middle third of
which, from proper fascia septa pass into the thickness of the muscle, dividing the heads from
each other. N. radialis innervates this muscle. It descends obliquely and laterally with a. v.
brachialis profunda in the spiral canal (canalis spiralis s. humeromuscularis). The last one is
formed by the groove of the radial nerve (sulcus n. radialis)of the humerus and triceps muscle of
the arm. In the middle part of the arm deep brachial artery ramifies, becoming a. collateralis
media and a. collateralis radialis. The last one follows n. radialis, pierces lateral intermuscular
septum in the inferior region, again appearing in the anterior compartment (lateral interfascial
space).

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 From the practical point of view it’s important to know the main projectional lines of the
arteries and the nerves of the arm. The main neurovascular bundle is projected by a line, which
connects the point between anterior and middle thirds of the axilla with the midpoint of the
cubital fold. Practically this line coincides with the sulcus bicipitalis medialis.To stop the
bleeding temporarly we can press a. brachialis to the humerus in this groove .In the inferior third
of the arm n. medianus is projected a cm medially from a. brachialis.N. radialis is projected by a
spiral line which connects midpoint of the posterior border of the deltoid muscle with the
inferior end of the sulcus bicipitalis lateralis. Injury to the radial nerve proximal the origin of the
triceps results in paralysis of the triceps, brachioradialis, supinator and extensor muscles of the
wrist and the digits. The characteristic sign of the radial nerve injury is wrist-drop (inability to
extend the wrist and the digits). Projection of the ulnar nerve (n. ulnaris) on the arm in the
upper parts coincides with the projection of the main bandle, but from the middle third it is
projected by a line, which connects the midpoint of the sulcus bicipitalis medialis with the
medial epicondyle.
Injury to the n.musculocutaneus results in paralysis of the coracobrachialis, biceps and
brachialis muscles. As a result the flexion of the elbow joint and supination of the forearm are
greatly weakened. There may also be loss of sensation on the lateral surface of the forearm
supplied by the lateral antebrachial cutaneus nerve.

Cubital Region
(Regio cubiti)

Boundaries: proximal and distal boundaries are formed by two circular lines 4cm above
and below the epicondyles of the arm. By two vertical lines, which pass through the medial and
lateral epicondyles, this region is divided into anterior and posterior regions.

Anterior Cubital Region /Cubital Fossa

(Regio cubiti anterior/ Fossa cubiti)

Layers.The skin is thin. Subcutaneous tissue has a plated structure.Superficial veins and
nerves pass in it: laterally- v. cephalica and n. cutaneus antebrachii lateralis, medially- v.
basilica and n. cutaneus antebrachii medialis. Veins are connected with each other by v.
mediana cubiti forming shapes of letters “N”and “И”.Sometimes this anastomosis has an
appearance of the letter “M”, which appears as a result of connection v. mediana cephalica with
v. mediana basilica which are formed from v. mediana antebrachii. By a branch, which pierces
proper fascia, v. mediana cubiti is connected with the deep veins of the forearm. There are 2-3
lymphatic nodes in the subcutaneous tissue.
Proper fascia is thickened medially due to the tenden fibers of the biceps muscle
(aponeuroses m.bicipitis brachii), which is called also” lacertus fibrosus” or Pirogov’s fascia.
Under the proper fascia muscles are arranged in 3 groups: medial, middle and lateral. The lateral
group consists of m.m. brachioradialis et supinator, middle group- m.m. biceps et brachialis,
medial group-m.m. pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris et
flexor digitorum superficialis. Between them 2 grooves are formed: sulci cubitales anteriores
medialis et lateralis. N. radialis lies in the lateral cubital groove with a. collateralis radialis.
Here the nerve is divided into 2 branches: superficial and deep. R. superficialis n. radialis then
continues its way on the forearm in the radial groove, when as r. profundus n. radialis passes to
the dorsal region of the forearm and is called also n. interosseus posterior. A. brachialis with
veins and n. medianus lies in the medial groove.
Below Pirogov’s fascia a. brachialis is divided into 2 branches: a. radialis and a.
ulnaris.A. radialis gives off a branch-a.reccurens radialis-which anastamoses with a. collateralis
radialis –branch of a. brachialis profunda. From a. ulnaris a branch extends- a. interossea
communis which then is divided into 2 branches: anterior and posterior. Posterior branch gives

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off a. interossea reccurens which anastamoses with a. collateralis media-branch of a. brachialis
profunda. A. ulnaris also gives off a branch- a. reccurens ulnaris which is divided into anterior
and posterior branches. R. anterior a. reccurens ulnaris anastamoses with a. collateralis ulnaris
inferior whereas r. posterior a. reccurens ulnaris anastamoses with a. collateralis ulnaris
superior. The last two collateral arteries are branches of a. brachialis. Due to all these
anastamoses rete articulare cubiti is formed,which not only supplies with blood cubilal region
and elbow joint,but also performs the collateral (accessory) circulation in the cubital region.

Posterior Cubital Region

(Regio cubiti posterior)

Layers. The skin is thick, movable. Subcutaneous bursa (bursa subcutanea olecrani) is
situated under the skin on the level of the olecranon.
Proper fascia is thick and has an appearance of the aponeuroses. Two grooves are formed
in both sides of the process of the ulna (olecranon): posterior medial and lateral grooves. In
sulcus cubitalis posterior medialis n. ulnaris lies. It passes between medial epicondyle and
olecranon in the osteo-fibrous canal formed by proper fascia. Superficial position of the ulnar
nerve is the cause of its frequent injury N. ulnaris then continues its way on the forearm passing
between the heads of m. flexor carpi ulnaris. Sulcus cubitalis posterior lateralis is between
lateral epicondyle and olecranon. Here the head of the radius is palpated and the puncture of the
elbow joint is made here. In children a fossa is formed in place of groove which is called
marvelous fossa (fossa pulchritudinis).

The Forearm
(Antebrachium)

Boundaries: superior border is a circular line which passes 4-6cm below the epycondyles;
inferior border is a line which passes 2 cm above styloid process of radius. By 2 vertical lines,
which connect epycondyles with styloid processes, the forearm is divided into anterior and
posterior regions.

Anterior Region of the Forearm

(Regio antebrachii anterior)

Layers. The skin is thin, through which v. cephalica and v. basilica are visible.
Superficial fascia is hardly developed.
In the subcutaneous tissue near the medial border of the brachioradialis muscle v.
cephalica is accompanied by lateral skin nerve of the forearm (n. cutaneus antebrachii lateralis),
medially v. cephalica is accompanied by medial skin nerve of the forearm (n. cutaneus
antebrachii medialis). By the midline v. mediana antebrachii passes.
Proper fascia is thick and shiny in the proximal part. By two intermuscular septa which
extend from the proper fascia and are attached to the radius (septa intermusculare radiale
anterior et posterior), the forearm is divided into 3 osteofascial compartments: anterior, posterior
and lateral. It is better seen on the transsection of the forearm in the middle third of it.In
difference to arm, there are no interfascial spaces for the vessels and nerves, so neurovascular
bundles pass through the muscular fissures in the osteo-fascial capsules. Anterior compartment is
bounded by the proper fascia anteriorly, radius, ulna and the interosseous membrane posteriorly
and anterior radial intermuscular septum laterally. Medially proper fascia is fused with posterior
margin of the ulna. Lateral compartment is formed by 2 intermuscular septa (anterior and
posterior), radius and proper fascia laterally.

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 In the anterior region of the forearm the muscles are arranged in 4 layers: first layer
consists of (beginning from lateral border) m.m. brachioradialis, pronator teres, flexor carpi
radialis, palmaris longus and flexor carpi ulnaris; second layer-m. flexor digitorum superficialis;
third layer-m.m. flexor digitorum profundus et flexor pollicis longus; fourth layer-m. pronator
quadratus( only in the inferior third of the forearm).A space is left between the third and fourth
layers which is called Pirogovs space, filled with loose connective tissue.
Four neurovascular bundles are located in the anterior region of the forearm. Three of
them are lying in the grooves, which are formed between the muscles of the anterior region. A.
radialis with accompanying veins and r. superficialis n. radialis lies in the radial groove. This
groove (sulcus radialis) is formed between brachioradial muscle laterally and pronator teres in
the superior parts, and flexor carpi radialis in the middle and inferior parts. At the inferior
boundary of the region a. radialis passes to the dorsal surface of the hand- into the anatomical
snuff -box. A common place for measuring the pulse rate is where the radial artery lies on the
anterior surface of the distal end of the radius, lateral to the tendon of the flexor carpi
radialis.Here the artery can be compressed against the distal end of the radius where it lies
between the tendons of the flexor carpi radialis and abductor pollicis longus. Radial pulse, like
other palpable pulses of the body,is a peripheral reflection of the cardiac action.
A.ulnaris with accompanying veins and nerve lies in the ulnar groove. Last one is formed
between m. flexor carpi ulnaris medially and m.flexor digitorum superficialis laterally.Nerve is
located medially.The ulnar artery and nerve pass into the palm lateral to the pisiform. The ulnar
pulse is usually difficult to palpate.
Median neurovascular bundle consists of the median nerve, artery and veins. N. medianus
lies in the median groove (sulcus medianus) only in the inferior third of the forearm. This
groove is formed between m. flexor digitorum superficialis medially and m. flexor carpi radialis
laterally. In the superior parts of the forearm nerve passes between the heads of m. pronator
teres, then between two-superficial and deep flexors of the digits.A. mediana (its also called a.
comitans n. mediani) is the branch of a. interossea anterior.
Fourth bundle consists of the anterior interosseous artery, veins and nerve (vasa
interossea anterior and n. interosseus anterior). N. interosseus anterior is the branch of the
medianus nerve and a. interossea anterior-branch of the common interosseous artery.The last
one pierces the interosseous membrane through the superior margin of the pronator quadratus
muscle and passes into the posterior osteo-fascial compartment.

Posterior Region of the Forearm

(Regio antebrachii posterior)

Layers. The skin is thick, hardly movable. There is a little amount of fat in the
subcutaneous tissue. The skin is innervated by n. cutaneus antebrachii posterior which is the
branch of n. radialis.
Proper fascia is thick, dense and forms posterior osteo-fascial compartment. It is
bounded anteriorly by the bones of the forearm and interosseous membrane, posteriorly by the
proper fascia, laterally-by the posterior intermuscular septum and medially- by the proper fascia
which is attached to the posterior border of the ulna.In the posterior region the muscles are
arranged in two layers:superficial, which contains five extensors: m.m. extensor carpi radialis
longus et brevis, m. extensor digitorum, m. extensor digiti minimi and m. extensor carpi ulnaris;
deep layer contains also 5 muscles: m. supinator, m. abductor pollicis longus, m.m. extensor
pollicis longus et brevis , m. extensor indicis.
There is a deep fascia between these two layers. There is a fatty tissue space on the deep
fascia, where the neurovascular bunch lies. It consists of r. profundus n. radialis, vasa
interosseae posterior. The posterior interosseous nerve is the continuation of the deep branch of

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the radial nerve (r. profundus n. radialis). A. interossea posterior is the branch of a. interossea
communis.
Clinically it is important to know the projection of the radial artery which is made by
connecting the midpoint of the cubital fold with the medial border of the styloid process of the
radius( it coincides with the radial groove). N. ulnaris is projected by a line which connects
medial epicondyle of the humerus with the sesamoid bone. A. ulnaris is projected by this line
only in the middle and inferior thirds.In the superior third it moves laterally to the midpoint of
the elbow fold. N. medianus is projected by a line which connects the midpoint of the line
between lacertus fibrosus and medial epycondyle with the midpoint of the line connecting the
styloid processes.

The Hand
(Manus)

Boundaries: it’s divided from the forearm by a line which passes 2cm above the styloid
process of the radius. It consists of the wrist (carpus), metacarpus and the fingers. By the radial
and the ulnar borders the hand is divided into anterior (palma manus) and posterior (dorsum
manus) regions.

Region of the Palm

(Regio palmae manus)

There are 2 eminences on the palm, which are formed by the muscles of the first and fifth
fingers and are called thenar and hypothenar eminences. Middle part has an appearance of a
fossa and coincides with the aponeurosis of the palm.
Layers. The skin on the palm is thick and richly supplied by the sweat glands, but it
contains no hair or sebaceous glands. The skin has longitudinal and transverse flexion creases
where the skin is firmly bound to the deep fascia. The distal wrist crease indicates the proximal
border of the flexor retinaculum. The thenar is divided from the palmar fossa by the radial
longitudinal crease, which deepens when the thumb is opposed. Proximal third of this crease is
called “Kanavel’s forbidden zone”. Here a motor branch extends from the median nerve to the
muscles of the thumb, so incisions here are forbidden.
In the anterior region of the wrist the fascia is represented by the thickened distal part of
the forearm fascia (lig. carpi volare). Thickening of the fascia near the pisiform bone forms
canalis carpi ulnaris, where ulnar neurovascular bunch lies. The thickest and strongest ligament
of the hand is retinaculum flexorum. It consists of dense transverse fibres, which connect the
bony margins of the palmar surface of the wrist. Retinaculum flexorum with the bones forms
canalis carpi through which the flexors of the fingers and median nerve pass.
Vertical dense fibrous bands pass through the subcutaneous tissue and connect the skin
with the palmar aponeurosis. The last one is formed by the middle thickened part of the proper
fascia. Aponeurosis of the m. palmaris longus blends with it. The palmar aponeurosis, a strong
well - defined part of the deep fascia of the hand, covers the soft tissues and overlies the long
flexor tendons. The proximal end of the palmar aponeurosis is continued by flexor retinaculum
and palmaris longus tendon. The distal end divides into four longitudinal digital bands that attach
to the bases of the proximal phalanges and fuse with the fibrous digital sheaths. A fibrous medial
septum extends deeply from the medial border of the palmar aponeurosis to the fifth metacarpal.
Similarly a lateral septum extends deeply from the lateral border of the palmar aponeurosis to the
first metacarpal. By means of these septa the palm is divided into medial or hypothenar
compartment containing the hypothenar muscles, and lateral or thenar compartment containing
the thenar muscles. Between the hypothenar and thenar compartments is the central compartment
containing the flexor tendons and their sheaths, the lumbricals and the digital vessels and nerves.

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 The superficial palmar arch (arcus palmaris superficialis) lies just under the palmar
aponeurosis. It’s formed mainly by the ulnar artery which makes anastamosis with the superficial
branch of the radial artery (r. superficialis a. radialis). It gives rise to three common palmar
digital arteries (a.a. digitales palmares communes) that anastamose with the palmar metacarpal
arteries from the deep palmar arch. Each common palmar digital artery is divided into a pair of
proper palmar digital arteries (a.a. digitales palmares proprii) that run along the sides of the
second to fourth digits. The deep palmar arch (arcus palmaris profundus), formed mainly by the
radial artery, which enters palm through the first interosseous space from the anatomical snuff-
box, and the deep branch of the ulnar artery (r. profundus a. ulnaris), lies across the metacarpals
just distal to their bases. The deep arch gives rise to three metacarpal arteries (a.a. metacarpeae
palmares), which run distally and join the common palmar digital arteries from the superficial
palmar arch. The deep arch is located more proximally than the superficial one. Because of
numerous arteries in the hand, bleeding is usually profuse when the palmar arches are lacerated.
In laceracions of the palmar arches, it may be useless to ligate one forearm artery, because these
arteries have many communications in the forearm and the hand. To obtain a bloodless operating
field in the hand for treating complicating injuries, it may be necessary to compress the brachial
artery and its branches proximal to the elbow (e.g. using a pneumatic tourniquet). This procedure
prevents blood from reaching the arteries of the forearm and hand through the anastamoses
around the elbow.
The superficial and deep arterial arches are accompanied by superficial and deep palmar
venous arches, respectively.
The nerves of the hand are n.n. medianus, ulnaris and radialis. The median nerve passes
deep to the flexor retinaculum and through the carpal tunnel where it lies superficial to the long
flexor tendons. Its branches lie under the superficial palmar arch together with the superficial
branch of the ulnar nerve. N.n. digitales palmares communes are formed by these branches
which then become proper nerves of the fingers (n.n. digitales palmares proprii). N. medianus
innervates three fingers beginning from the first finger and the radial surface of the fourth one,
and n. ulnaris innervates fifth finger and ulnar surface of the fourth one.
The tendons of the superficial flexor of the fingers (m. flexor digitorum superficialis) are
splitted into two bands on the level of the heads of the proximal phalanges and are attached to
the margins of the middle phalanges. The tendons of the deep flexor (m. flexor digitorum
profundus), after passing through the split in the deep flexor tendon, are attached to the base of
the distal phalanges.
The tendons of the superficial and deep flexors of the digits enter the common flexor
synovial sheath (vag. synovialis communis m.m. flexorum) deep to the flexor retinaculum. This
sheath is also called ulnar synovial sheath. The tendons enter the central compartment of the
hand and then fan out to enter their respective digital synovial sheaths. The radial sheath contains
the tendons of m. flexor pollicis longus (vag. tendinis m. flexoris pollicis longi). These sheaths
enable the tendons to slide freely over each other during the movements of the digits. The fibrous
digital sheaths are strong coverings of the flexor tendons and their synovial sheaths. The fibrous
digital sheaths extend from the heads of the metacarpals to the bases of the distal phalanges and
prevent the tendons from pulling away from the digits. These sheaths combine with the bones to
form osteo-fibrous tunnels through which the tendons pass to reach the digits. The tendons of the
second, third and fourth fingers are covered by the synovial sheaths beginning blindly on the
level of the heads of the metacarpal bones and finish on the base of the distal phalanges.
Synovial sheaths of the first and fifth fingers are continued up to the wrist and proximal blind
ends of them are in Pirogov’s space, 2cm above retinaculum flexorum. In 10% ulnar and redial
synovial sheaths are connected with each other which cause development of the “U” shaped
flegmon when one of the sheaths is inflammated (tenosynovitis). Synovial sheath consists of two
layers which pass one to the other: parietal-peritenon (peritendineum), which covers fibrous
sheath from inside, and visceral (epitenon) which closely covers the tendon except a small part
behind which small blood vessels pass to the tendon from the periosteum. This part is called the

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mesenterium of the tendon-mesotenon (mesotendineum). During the suppurative inflammation
the exudate fills the cavity of the synovial sheath, presses the vessels in the mesotendineum, as a
result necrosis of the tendon occurs.

The Dorsal Region of the Hand

(Dorsum manus, regio dorsi manus)

Layers.The skin is thin and movable.

Subcutaneous tissue is loose. Many veins pass in it forming the dorsal venous network
(rete venosum dorsale manus). Superficial to the metacarpus, this network is prolonged
proximally on the lateral side as the cephalic vein. On the medial side of the hand the dorsal
venous network is continuous proximally with the basilic vein.
Superficial branch of the radial nerve (r. superficialis n. radialis) and dorsal branch of the
ulnar nerve( r. dorsalis n. ulnaris) innervate the skin of this region. Ten dorsal digital nerves are
formed by these branches. The radial nerve supplies no hand muscles but its superficial branch
supplies the skin of the two fingers beginning from the first finger and radial surface of the third
one. Ulnar nerve innervates the rest two and half fingers.
The dorsal aponeurosis covers the tendons of the extensors and forms retinaculum
extensorum, which prevents bowstringing of the tendons when the hand is hyperextended at the
wrist joint. Six osteo-fibrous tunnels are formed by the fascial septa, which extend from
retinaculum extensorum and are attached to the bones of the carpus. The tendons of the extensors
of the carpus and digits pass through these canals. The four flat tendons of the extensor
digitorum muscle and the tendon of extensor indicis muscle pass deep to the extensor
retinaculum in the canal, which occupies middle position, in the synovial sheath of triangular
shape. This synovial sheath finishes blindly in the middle part of carpal bones. Medially are
located the canals of m. extensor digiti minimi and m. extensor carpi ulnaris. Laterally to the
canal of the common extensor of the digits the canal of the extensor pollicis longus lies. The
osteofibrous canal of the radial extensors of the carpus lies deeper and more laterally than the
last mentioned canal.The most laterally lies the canal of m. abductor pollicis longus and m.
extensor pollicis brevis. They are in the common synovial sheath. On the distal ends of the
metacarpals and on the phalanges, the extensor tendons flatten to form extensor expansions.
Each expansion is wrapped around the dorsum and sides of a head of the metacarpal and
proximal phalanx. The dorsal expansion divides into a median band that passes to the base of the
distal phalanx.
The tendons of the abductor pollicis longus and extensor pollicis brevis muscles indicate
the anterior border of the anatomical snuffbox, and the tendon of extensor pollicis longus
indicates its posterior border. A. radialis passes through the snuff-box where its pulse may be
palpated. The scaphoid and trapezium bones lie in the floor of the snuff-box. When bleeding
occurs, a. radialis is pressed to the bones.
Ulnar nerve injury brings to difficulty making a fist because of paralyses of most
interosseous muscles which are innervated by this nerve. In addition they cannot flex their fourth
and fifth digits at the distal interphalangeal joints when they try to straighten their fingers.This
results in characteristic appearance known as “clawhand”.

THE TOPOGRAPHIC ANATOMY OF THE LOWER LIMB

Lower limb (Membrum inferius, extremitas inferior) is divided from the trunk by an
imaginary line which passes anteriorly through the skin inguinal fold (plica inguinalis),
posteriorly through the crest of the iliac bone( crista iliaca). The lower limb is divided into the
following regions:
 Regio glutea
 Regg. femoris anterior et posterior

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  Regg. genu anterior et posterior
 Regg. cruris anterior et posterior
 Regg. articulationis talocruralis anterior, posterior, lateralis et medialis
 Regio dorsi pedis
 Regio plantae pedis

Gluteal Region
(Regio glutea)

Boundaries: superiorly is the crest of the iliac bone, inferiorly-gluteal fold, laterally- a
vertical line descending from anterior superior iliac spine up to the major trochanter of the
femur, medially- sacrum and coccyx in the depth of the natal cleft.
Projection of a. glutea superior is on the border of superior and middle thirds of the line
connecting superior posterior iliac spine with the top of the greater trochanter.
Projection of a. glutea inferior is a little lateral and inferior from the midpoint of the
line between superior posterior iliac spine and sciatic tuber.

Layers. The skin is thick, movable, near the intergluteal fold it’s covered by hair and is
richly supplied by sweat and sebaceous glands. It is connected with proper fascia by many
fibrous septa which pass through the subcutaneous tissue.The last mentioned tissue is divided
into two layers (superficial and deep) by the superficial fascia. The deep layer passes to the
lumbar region and is called massa adiposa lumboglutealis. The region is innervated by n.n.
clunium superiores medii et inferiores. N.n. clunium superiores are branches of r.r. dorsales n.n.
lumbalium; n.n. clunium medii are branches of r.r. dorsales n.n. sacrales; n.n. clunium inferiores
– branches of n. cutaneus femoris posterior from plexus sacralis. The branches of the superior
and inferior gluteal arteries and veins are also situated in the subcutaneous layer.
Proper fascia is attached to the iliac crest and sacrum and anteriorly and inferiorly it turns
into the broad fascia of the thigh (fascia lata). It forms a capsule for the gluteus maximus
muscle. Muscles of this region are arranged in 3 layers: superficial, middle and deep.The
superficial layer consists of m. gluteus maximus.The middle layer consists of m. gluteus medius,
m. piriformis, m. obturatorius internus, mm. gemelii superior et inferior and m. quadratus
femoris. In the deep layer there are 2 muscles: m.m. gluteus minimus et obturatorius externus.
The largest fatty tissue space is under the gluteus maximus muscle and is separated from
the lumbar region by the attachment of the proper fascia to the iliac crest. This space is
communicated with the pelvic cavity through the suprapiriform and infrapiriform openings. They
are formed by the piriform muscle, fibers of which pass through the greater schiatic opening up
to the top of the great trochanter. M. piriformis divides sciatic opening into two openings:
suprapiriform and infrapiriform (foramen suprapiriforme et foramen infrapiriforme). The above
mentioned fatty tissue space is connected with other regions too: along a. v. pudendae internae it
communicates with fossa ischiorectalis; along n. ischiadicus- with posterior femoral region;
under f. lata –with lateral and anterior parts of the thigh.
The superior and inferior gluteal arteries (branches of a. iliaca interna) leave the greater
sciatic foramen and pass superiorly and inferiorly to piriformis, respectively. They are followed
by veins and nerves of the same name. Pudental internal vessels (a. iliaca interna), pudental and
sciatic nerve and posterior skin nerve of the thigh also pass through the infrapiriform foramen
(all the nerves are from the sacral plexus). The branches of the superior gluteal artery (a. glutea
superior) pass through the thickness of the piriform muscle where they make anastamoses with
the branches of the inferior gluteal artery. The trunk of the superior gluteal artery lies just on the
periosteum of the greater sciatic foramen, so here we must ligature it when it’s bleeding. The
inferior gluteal artery is 2-3 times thinner than the superior one. This neurovascular bunch (a.v.n.
glutea inferiores), after leaving the infrapiriform foramen, first pierces the fascia and then passes
into the thickness of the gluteus maximus muscle.

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 Pudental bunch (a.v. pudendae internae and n. pudendus) pass through the infrapiriform
foramen more medially. Then it lies on the sacrospinal ligament, passes through the lesser sciatic
opening under the sacrotuberal ligament to the internal surface of the sciatic tuber. It passes
through the canal which is formed by the split of the internal obturator muscle fascia (so called
Alkok’s canal).
Sciatic nerve (n. ischiadicus) passes more laterally through the infrapiriform opening.
Along it’s medial border posterior cutaneous nerve of the thigh (n. cutaneus femoris posterior)
passes and the artery which accompanies the sciatic nerve(a. comitans n. ischiadici)- a branch of
the gluteal inferior artery.At the inferior border of the gluteus maximus the sciatic nerve lies
superficially, covered only by broad fascia. Here it can be anaesthetized in its projectional point
which is in the midpoint of the line between the medial border of the sciatic tuber and the top of
the greater trochanter.

Thigh
(Femur)

Anterior Femoral Region

(Regio femoris anterior)

Boundaries: superiorly is the inguinal ligament which extends from the superior anterior
iliac spine to the pubic tubercle; laterally-the line between the above mentioned spine and the
lateral epicondyle of the femur; medially- the line from the pubic symphysis to the medial
epicondyle of the femur; inferiorly- a circular line which passes 6cm above the patella. The
following structures are distinguished in the anterior region of the thigh which are important
from the practical point of view: femoral (scarpian) triangle, femoral canal, obturator and
adductor canals.
Projection of the femoral artery on the thigh is made by a line which passes from the
midpoint of the inguinal ligament to the medial epycondyle of the femur, while the thigh is
flexed in the knee joint and is abducted laterally.
Layers. The skin is thin and fine, movable. There are blood vessels, lymph nodes and skin
nerves in subcutaneous tissue. The superficial arteries extend from the femoral artery and pass
through the hiatus saphenus. The superficial epygastric artery (a. epigastrica superficialis)
passes from the midpoint of the inguinal ligament to the umbilicus. A. circumflexa ilii
superficialis passes to the superior anterior iliac spine parallel to the inguinal ligament. A.a.
pudendae externae (two in number), pass medially and lie anteriorly to the femoral vein and
sometimes inferiorly to the point where v. saphena drains into it.The skin is innervated by the
femoral branch of the genitofemoral nerve (r. femoralis n. genitofemoralis- from plexus
lumbalis). The lateral skin nerve of the thigh (n. cutaneus femoris lateralis) emerges below the
anterior superior iliac spine and innervates the skin of the lateral surface of the thigh where it
passes first in the thickness of the broad fascia, then inferiorly in the subcutaneous tissue. The
skin branch of the obturator nerve (r. cutaneus n. obturatorii) which lies on the lateral wall of the
true pelvis, passing through the internal surface of the thigh, innervates the inferomedial surface
of the thigh and reaches the patella. That is why sometimes pain appears in the knee joint when
there is inflammation of the hip joint or of the uterine tubes (salpingitis). All the above
mentioned nerves are from the lumbar plexus.
The superficial lymph nodes are arranged into superior (superolateral and superomedial)
and inferior groups.They collect lymph from anterior abdominal wall, inferior to umbilicus, from
the external genital organs, from the fundus of the uterus, from the skin of the lower limb.
Lymph vessels from the superficial lymph nodes pass to the deep lymph nodes which lie along
the femoral artery. Then lymph drains into external iliac lymph nodes (nodi lymphatici iliaci
externi).

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 Broad fascia (fascia lata) is thick enough on the lateral surface of the thigh where it
forms iliotibial tract ( tractus iliotibialis). On the transverse section of the middle 1/3 of the thigh
we can see the following: the proper fascia gives off 3 intermuscular septa (septa intermusculare
femoris laterale, posterius et mediale), which are attached to the medial and lateral lips of the
linea aspera of the femur. Together with the proper fascia these septa divide the entire thigh into
3 osteofascial compartments: anterior, where extensors lie; posterior-for the flexors of the leg;
and medial, where adductors of the thigh are located. The anterior compartment is occupied by
m. quadriceps femoris which consists of 4 parts: m. rectus femoris, m.m. vastus medialis,
lateralis et intermedius. In the medial compartment m. pectineus, adductor longus, adductor
brevis, m. adductor magnus lie. The main neuro-vascular bundle of the thigh is in the medial
interfascial space. Three muscular sheaths are also formed for the superficial muscles: m.m.
sartorius, tensor fasciae latae and gracilis.

Femoral Triangle
(Trigonum femorale)

It is a triangular space in the superomedial third of the thigh. It appears as a depression

inferior to the inguinal ligament when the thigh is flexed, abducted and laterally rotated.
Boundaries: superiorly is the inguinal ligament, medially- m.adductor longus, laterally -
m. sartorius. The muscular floor is formed by the iliopsoas and pectineus muscles, which form
the walls of the fossa iliopectinea. The hight of the triangle is 15-20 cm, the base is formed by
the inguinal ligament, and the top is the point where the border of the sartorius crosses with the
border of the adductor longus.
In the region of the femoral triangle, at the medial border of the sartorius, fascia lata
splits into 2 sheets: superficial and deep.The deep layer passes behind the femoral vessels and
blends with the fasciae of the iliopsoas and pectineus muscles. The superficial layer passes in
front of the femoral vessels and fuses whith the inguinal ligament superiorly. It is dense laterally,
covering the femoral artery and forms falciform margin (margo falciformis), and is loose and
cribriform on the femoral vein (fascia cribrosa). Two horns are distinguished in the falciformis
margin: superior and inferior (cornua superius et inferius) which form subcutaneous ring of the
femoral canal (hiatus saphenus). V. saphena magna drains into the femoral vein passing over the
inferior horn. The main contents of the interfascial space of the femoral triangle are the femoral
artery laterally and the femoral vein medially.The femoral nerve is lateral to the femoral vessels
and is separated from them by the iliopectineal arch and the fascia of the iliopsoas muscle.A.
femoralis enters the femoral triangle a little medially from the midpoint of the inguinal ligament.
Here it can be pressed to the bone for the temporary arrest of bleeding.The femoral vein which
lies medially to the artery, gradually passes back and on the top of the triangle it is hidden behind
the artery. Very soon n. femoralis is divided into branches.Some of them pierce the broad fascia
becoming anterior skin branches .The deep branches innervate m.m. quadriceps, sartorius and
pectineus. The longest skin branch –n. saphenus, continues its way inferiorly with the vessels.
The deep artery of the thigh (a. profunda femoris) usually extends from the posterior
surface of the femoral artery 1-6cm below the inguinal ligament. First it passes along the
posterior wall, then laterally to the femoral artery. A branch extends from the deep femoral
artery-a. circumflexa femoris medialis,which runs in the transverse direction medially behind the
femoral vessels. At the medial margin of the iliopsoas muscle it is divided into superficial and
deep branches. The superficial branch supplies with blood m. gracilis. The deep branch is
continuation of the artery and is divided into ascending and descending branches. The ascending
branch passes to the gluteal region and anastomoses with the gluteal arteries.The descending one
appears on the posterior surface of the thigh and anastamoses with the branches of the obturator
and perforating arteries. A. circumflexa femoris lateralis is thicker and extends from the deep
femoral artery 1.5-2 cm below its origin or from the femoral artery.It is also divided into

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ascending and descending branches. R. ascendens makes anastomoses with the superior gluteal
artery in the trochanteric network (rete trochanterica), whereas r. descendens extends inferiorly,
, reaches the knee region and makes anastomosis with the branches of the popliteal artery, taking
part in the network of the knee joint (rete articulare genus).
Inferiorly the vessels pass from the femoral triangle into the femoral groove(sulcus
femoris anterior), which is located between adductor longus and vastus medialis muscles.In this
groove the deep femoral artery is covered by the femoral vessels and sartorius muscle.Here 2-4
perforating branches of the deep femoral artery (r.r. perforantes) extend.Through the openings in
the tendon of the adductor muscles with the edges of which adventicia of the vessels is fused,
these arteries appear on the posterior surface of the thigh.The lumen of perforating artery doesn’t
constrict when it is incised which explanes the development of the increasing haematoma when
the femur is fractured in its middle part.

Femoral Canal
(Canalis femoralis)

Muscular and vessel lacunae(lacunae musculorum et vasorum) are formed under the
inguinal ligament which are separated from each other by iliopectineal arch(arcus iliopectineus)
.It is the thickened medial part of the iliac fascia which descends and passes from the inguinal
ligament to the eminencia iliopectinea of the pubic bone. M. iliopsoas, n. femoralis and n.
cutaneus femoris lateralis pass through the lacuna musculorum. Lacuna vasorum is bounded
anteriorly and superiorly by the inguinal ligament, laterally – by iliopectineal arc, medially- by
the lacunar ligament (lig. lacunare s. Gimbernati), inferiorly and posteriorly- by pectineal
ligament (lig. pubicum Cooperi) which is the thickened part of the periosteum of the pubic bone.
Femoral artery and vein pass through lacuna vasorum, but the vessels don’t occupy the whole
lacuna and between femoral vein and lacunar ligament a fissure is left which is filled with loose
connective tissue, lymph vessels and nodes (Pirogov-Rosenmuller’s lymph node). Here also
femoral hernias can pass which form the femoral canal. It means that in normal conditions this
canal doesn’t exist. It appears as a trilateral pyramid with anteriorly directed base. It is formed
between 2 layers of the broad fascia and femoral vein. The anterior wall is the superficial layer
of the broad fascia, and its superior horn (cornu superius), posteriorly- deep layer of the broad
fascia, covering m. pectineus, laterally-femoral vein with the sheath covering it (vagina vasorum
femoralium). It has two rings: superficial and deep. The deep ring (annulus femoralis profundus)
opens into the pelvic cavity and is bounded anteriorly by lig. inguinale, posteriorly-lig.
pectineale, medially- lig. lacunare and laterally- by the femoral vein. It occupies the medial
angle of the lacuna vasorum. From the internal surface this ring is covered by transverse fascia
which here has an appearance of a cribriform sheet and is called septum femorale. Subcutaneous
or superficial ring of the femoral canal is hiatus saphenus. The last one is also covered by a
cribriform sheet of fascia lata (fascia cribrosa ).The length of the canal is 1-3cm .It is widened at
its abdominal end-the deep femoral ring, and extends distally to the level of the proximal edge of
the saphenous opening.
In about 20-28% of people an inlarged pubic branch of the inferior epigastric artery takes
the place of the obturator artery or forms an accessory obturator artery. This artery runs close to
or across the femoral ring to reach the obturator foramen. Here it is closely related to the free
margin of the lacunar ligament and the neck of the femoral hernia. Consequently, this artery
could be involved in a strangulated femoral hernia. The deep femoral ring in such cases is
surrounded by anomalous obturator artery superiomedialy, by femoral vein- laterally and pubic
branch of the epigastric inferior artery- medially. The arterial anastamoses around the deep
femoral ring have got a name of “clayersn of death”(corona mortis) as the blindly performed
incision of this ring by herniotom in the case of strangulated femoral hernia in old times
frequently were finished by mortal bleeding from injured vessels.

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 Obturator Canal
(Canalis obturatorius)

The canal is situated in the deep layers of the femoral triangle. Obturator foramen is
covered by a membrane which splits into two sheets at the superior margin and attaches to both
sides of a groove on the inferior surface of the pubic bone (sulcus obturatorius). M. obturatorius
internus begins from the internal surface of the membrane, m. obturatorius externus- from the
external surface. A narlayers fissure between the obturator groove and the sheets of the
membrane is called an obturator canal.It is an oblique canal, directed from the superiolateral to
inferio medial side. A.v. obturatoriae et n. obturatorius pass through this canal from the pelvic
cavity to the deep layers of the thigh. In the canal the artery is divided into two branches (r.r.
anterior et posterior),which supply adductor muscles with blood and make anastomosis with a.
circumflexa femoris medialis, a. glutea inferior and r.r. perforantes a. profundae femoris. The
nerve is also divided into anterior and posterior branches, which innervate adductor muscles,
pectineal muscle and gives off a skin branch to the medial surface of the thigh.

Adductors’ Canal
(Canalis adductoriusi)

Bounderies: in the inferior 1/3 of the thigh femoral groove is continued by a groove
between adductor magnus and vastus medialis. An aponeurotic sheet passes between them
(lamina vastoadductoria) which transforms the groove into a canal (canalis vastoadductorius s.
canalis femoropopliteus, s. Hunteri).Anteriorly the canal is covered by sartorius muscle.It has an
entrance and 2 exits. Through the entrance which is formed laterally by vastus medialis, medially
by adductor magnus and anteriorly by superior margin of lamina vasto-adductoria, femoral
artery, vein and saphenus nerve enter the canal. Inferior opening is a fissure between the tendon
of the adductor magnus medially and femur laterally (hiatus tendineus adductorius), through
which vessels pass into popliteal fossa. The anterior opening is in lamina vastoadductoria,
through which descending artery and vein of the knee (a.v. genu descendens) and n. saphenus
exit. It is 5-6 cm long. It has communications with iliopectineal fossa, with popliteal fossa and
with medial surface of the knee region and leg along the vessels. Fascial capsule of the femoral
vessels is tightly fused with the superior margin of the lamina vasto-adductoria. In the canal the
artery lies anteriorly, the vein –posteriorly and laterally.

Posterior Femoral Region

(Regio femoris posterior)

Boundaries: superiorly is the transverse gluteal fold (plica glutea), inferiorly-continuation

of the circular line 6cm above patella, medially- connecting line of pubic symphisis with the
medial epicondyle of the femur, laterally- connecting line of anterior superior iliac spine with
lateral epicondyle of the femur.
N. ischiadicus is projected by a line which passes from the midpoint the distance
between sciatic tuberosity and greater trochanter to the midpoint of the popliteal fossa.
Layers. The skin is thick and blended with the subcutaneous connective tissue, it is
covered by hair. N.cutaneus femoris lateralis runs laterally and n. cutaneus femoris posterior
appears in the middle third of the thigh. Here we find the branches of v. saphena magna.
Proper fascia gives off 2 intermuscular septa (septa intermusculare laterale et posterius)
and with them forms posterior osteo-fascial compartment. Connective tissue space
communicates with gluteal region and with popliteal fossa along the sciatic nerve; with anterior
femoral compartment through the perforating arteries and a. circumflexa femoris medialis. All
the muscles of the posterior osteo-fascial compartment begin from tuber ischiadicum. Laterally

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extends m. biceps femoris which is distally attached to the head of the fibula. Medially m.m.
semitendinosus, semimembranosus are attached to the tibial tuberosity and together with m.m.
gracilis and sartorius form pes anserinus.The muscles in the posterior compartment are called
hamstrings: semitendinosus, semimembranosus, biceps femoris.They span the hip and knee
joints hence they are extensors of the thigh at the hip joint and flexors of the leg at the knee joint.
Pulled hamstrings are common in sportsmen who run very hard (baseball and soccer players).
Hamstring injuries often result from inadequate warming up before competition.
The sciatic nerve descends from the gluteal region into the posterior region of the thigh.
Usually it is separated into tibial and peroneal nerves in the inferior third of the thigh, but
sometimes this division occurs at the level of the infrapiriformis fossa. It supplies branches to the
hip joint and muscular branches to the hamstrings. An artery which accompanies sciatic nerve is
called a. commitans n. ischiadici. The nerve and the accompanying vessels are inclosed in a
fascial sheath which is connected with the capsules of the neigbouring muscles. In the superior
third of the thigh it lies just under the broad fascia, in the middle third it is covered by the long
head of biceps femoris muscle, and in the inferior third- between biceps femoris and
semimembranosus muscles.

Knee
(Genu)
Boundaries: superiorly is a circular line 6 cm above patella, inferiorly- a circular line
on the level of the tibial tuberosity ; medially and laterally- vertical lines, which pass through the
posterior margins of the condyles of the femur, divide this region into two-anterior and posterior
regions:
Anterior Genicular Region
(Regio genus anterior)

Layers.The skin is dense and movable, patella is palpated through it. The vessels and
branches of the skin nerves pass in the subcutaneous tissue. Several synovial bursae lie under the
skin between the layers of the superficial fascia:
 bursa prepatellaris subcutanea- in front of patella
 bursa infrapatellaris- in front of tuberositas tibiae
 bursa m. semimembranosi- coincides with medial epicondyle
Under the proper fascia two bursae lie:
 bursa prepatellaris subfascialis
 bursa prepatellaris subtendinea
Under the tendon of the quadriceps femoris lies
 bursa suprapatellaris-communicates with the knee joint
Proper fascia is the continuation of the broad fascia. The tendon of the quadriceps muscle
encloses patella and is attached to the tuberositas tibiae. Along the sides of the patella, in the
tendon of the quadriceps muscle fibrous thickenings are formed: retinaculum patellae mediale,
which is attached to the infraglenoidal margin of the tibia; and retinaculum patellae laterallae,
which is attached to Gerdy’s tuberosity.
An arterial network appears on the anterior and posterior surfaces of the region under the
proper fascia (rete articulare genus) . The following arteries take part in the formation of this
network:a. genus descendens- from the femoral artery; r. descendens a. circumflexa femoris
lateralis- from the deep femoral artery; a.a. genus superiores medialis et lateralis, a.a. genus
inferiores medialis et lateralis and a. genus media –last five arteries are from the popliteal
artery; a.a.reccurentes tibiales anterior et posterior-branches of the anterior tibial artery; and r.
circumflexus fibulae- branch of the posterior tibial artery.

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 Posterior Genicular Region. Popliteal Fossa
(Regio genus posterior. Fossa poplitea)

Projection of the popliteal artery (and the whole neurovascular bunch) is made by a
vertical line which passes from the superior angle by the midline to the inferior one.
The skin is thin, movable. In the subcutaneous tissue sometimes v. saphena parva
ascends, which drains into v. poplitea. Superficial lymph nodes lie here. N. saphenus, n. cutaneus
surae lateralis (n. peroneus communis) and branches of n. cutaneus femoris posterior innervate
the skin. Fascia poplitea is the continuation of the broad fascia and has an appearance of
aponeurosis.
The diamond shaped popliteal fossa is on the posterior aspect of the knee. It is formed
superolaterally by the biceps femoris, superomedially-by the semimembranosus and
semitendinosus, inferolaterally and inferomedially by the lateral and the medial heads of
gastrocnemius , respectively; posteriorly (roof) –by fascia; anteriorly (floor) –by the popliteal
surface of the femur, the oblique popliteal ligament and the fascia over the popliteus muscle. The
main contents of the popliteal fossa are neuro-vascular bunch, lymph nodes and vessels. Deep
fascia (f. poplitea) forms a strong protective sheet for the elements passing from the thigh
through the fossa to the leg. A. poplitea is the continuation of the femoral artery and is called this
way after emerging from Hunter’s canal through the adductor tendineus hiatus. It passes through
the fossa and at the inferior border of it ends by dividing into the anterior and posterior tibial
arteries. Popliteal artery lies close to the articular capsule of the knee joint and hence is the
deepest structure. The vein passes superficially to and laterally in the same fibrous sheath with
the popliteal artery. The schiatic nerve usually ends at the superior angle of the popliteal fossa by
dividing into the tibial and common fibular (peroneal) nerves. The tibial nerve (n. tibialis), the
medial larger terminal branch of the sciatic nerve, is the most superficial and lateral of the three
structures (n.v.a.).
Five genicular branches of the popliteal artery supply the knee joint and anastomose to
form the network around the knee (see above). The common fibular nerve (n. peroneus
communis) is the lateral, smaller branch of the sciatic nerve. Beginning at the superior angle of
the popliteal fossa, it passes by the medial border of the biceps femoris muscle and tendon, and
leaves the fossa by passing superficially to the lateral superior boundary. Then it passes over the
posterior aspect of the head of the fibula before winding around its neck.
Because the popliteal artery lies deeply, it may be difficult to feel the popliteal pulse. Its
palpation is usually performed by placing the patient in the prone position with the leg flexed to
relax popliteal fascia and hamstrings. When the femoral artery is obstructed, an obvious sign is
the weakening or the loss of the popliteal pulse. The operative access to the popliteal artery
sometimes is made through Jober’s fossa, which is in the medial side of the popliteal fossa.
Boundaries of Jober’s fossa are: inferiorly- medial condyle of the femur and medial head of the
gastrocnemius; superiorly-border of the sartorius; anteriorly- the tendon of the adductor magnus
muscle; posteriorly-the tendons of the semitendinosus, semimembranosus and gracilis muscles.
Fibrofatty tissue of the popliteal fossa communicates with the posterior region of the
thigh and with the space under the gluteus maximus along the sciatic nerve. Along the femoral
vessels it communicates with the adductors’ canal and femoral triangle, along the popliteal
vessels and tibial nerve- with the deep space of the posterior region of the leg. Popliteal flegmons
tend to spread superiorly and inferiorly because of this communications and toughness of the
popliteal fascia.

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 Leg
(Crus)

Boundaries: superior border is a circular line on the level of the tibial tuberosity, inferior-
a circular line through the basis of the medial and lateral malleoli. By two vertical lines first of
which connects the medial malleolus with the medial condyle of the tibia and the other- lateral
malleolus with the head of the fibula, the leg is divided into 2 regions: anterior and posterior

Anterior Region of the Leg

(Regio cruris anterior)

Projection of the neurovascular bundle is made by an imaginary line from the midpoint
of the line connecting tibial tuberosity and the head of the fibula (or Jerdy’s tuberosity) with the
midpoint of the intermalleolar distance.
Layers. The skin is thinner than in other regions. In subcutaneous tissue the branches of v.
saphena parva and n. cutaneus surae lateralis pass laterally. Anteromedially passes v. saphena
magna with n.saphenus. N. peroneus superficialis appears on the border of middle and inferior
thirds laterally.
Proper fascia of the leg has an aponeurotic structure. It is tightly fused with the
periosteum of the anteriomedial surface of the tibia. Two intermuscular septa extend from the
fascia and are attached to the borders of the fibula. Septum intermusculare anterius cruris is
attached to the anterior border and septum intermusculare posterius cruris- to the posterior
border of the fibula. In the anterior region of the leg two osteo-fascial compartments are
distinguished: anterior and lateral. The anterior compartment is bounded anteriorly by proper
fascia, posteriorly-by the interosseous membrane and the bones, laterally-by the anterior
intermuscular membrane, and medially-by the lateral surface of the tibia. Extensors lie in the
anterior compartment: medially lies anterior tibial, laterally to it- extensor digitorum longus and
between them, beginning from the middle third, extensor hallucis longus.The lateral osteofascial
compartment is formed by the proper fascia laterally, anterior and posterior intermuscular fascia-
anteriorly and posteriorly, respectively, and fibula-medially. Long and short peroneal muscles
lie in the lateral compartment.
The main neuro-vascular bandle of the region consists of a. v. tibialis anterior and n.
peroneus profundus. The artery is the branch of the popliteal artery, which appears on the
anterior surface of the leg through the foramen in the membrana interossea, 4-5 cm below the
head of the fibula, near its medial margin. Superiorly the bundle lies on the interosseus
membrane between tibialis anterior and extensor digitorum longus muscles, inferiorly-between
tibialis anterior and extensor hallucis longus muscles. N. peroneus profundus pierces anterior
intermuscular septum and lies in the anterior compartment laterally to the vessels, then in the
inferior third -anteriorly and medially to them.
N. peroneus communis lies in the canalis musculoperoneus superior which is formed
between the parts of the long peroneal muscle and fibula. Then the nerve is divided into two
branches: superficial and deep. The deep branch (n.peroneus profundus) continues its way
accompanying anterior tibial vessels (see above). The superficial one(n. peroneus superficialis),
after emerging from the fissure between the parts of the long peroneal muscle, descends along
the anterior intermuscular septum in the lateral osteofascial compartment up to the inferior third
of the leg, where it pierces the fascia and passes to the subcutaneous tissue. It innervates the
distal part of the anterior surface of the leg.
The common fibular nerve is the most commonly injured nerve in the lower limb, mainly
because it winds superficially around the neck of the fibula. This nerve may be severed during
fracture of the neck of the fibula or severely stretched when the knee joint is injured. Injury
results in paralysis of all the dorsi flexor muscles of the ankle and causes the foot to hang down,
a condition known as foot-drop. The patient has a high stepping gait in which the foot is raised

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higher than it is necessary so the toes do not hit the ground. In addition, the foot is brought down
suddenly producing a distinctive “clop”.
A. reccurens tibialis posterior extends from a. tibialis anterior in the popliteal fossa. The
artery forms anastomoses with a. genus descendens and a. genus inferior medialis. A.a.
malleolares anteriores medialis et lateralis extend from a. tibialis anterior in the inferior third of
the leg.

Posterior Region of the Leg

(Regio cruris posterior)

Projection of the posterior tibial artery and tibial nerve is a line which passes 2cm
medially from the medial margin of the tibia superiorly to the midpoint of the distance between
medial malleolus and calcaneous tendon.
Layers. The skin is thin. In subcutaneous tissue the trunk of v. saphena parva is formed
which ascends curving around the lateral malleolus. In the middle part of the leg it pierces the
proper fascia lying between its sheets (Pirogov’s canal), enters the space between two heads of
the gastrocnemius. Here it lies under the fascia with the medial skin nerve of the leg (n. cutaneus
surae medialis), which is the skin branch of the tibial nerve. Then v. saphena parva drains into v.
poplitea. N peroneus communis gives off a skin branch (n. cutaneus surae lateralis), which
descends in the subcutaneous tissue, and in the inferior part of the leg it forms n. suralis, after
connecting with n. cutaneus surae medialis. N. saphenus innervates a narlayers part in the
posteromedial region of the leg.
Posterior osteo-fascial compartment is formed anteriorly by two bones of the leg and
interosseous membrane, posteriorly and medially- by proper fascia, and laterally-posterior
intermuscular septum of the leg. Muscles of the posterior compartment are arranged into two
groups: superficial and deep. They are separated from each other by the deep layer of the proper
fascia, which is also known as transverse fascia of the leg. Three muscles lie in the superficial
capsule: m.m. gastrocnemius, soleus et plantaris. The two –headed gastrocnemius and soleus
form together m.triceps surae.It has a common tendon of insertion into the calcaneus called the
calcaneal or Achilles tendon (tendo calcaneus s. Achillis). This muscle plantarflexes the ancle
joint. M. plantaris is usually small and may be absent. Three muscles comprise the deep group in
the posterior compartment of the leg: m.m, flexor hallucis longus, flexor digitorum longus,
tibialis posterior.
The main neuro-vascular bundle passes between m. popliteus and arcus tendineus of m.
soleus from the popliteal fossa to the posterior region of the leg. Then it lies in the muscular
canal which is called Gruber’s cruropopliteal canal (canalis cruropopliteus Gruberi).The walls
of the canal are: anteriorly-m. tibialis posterior; posteriorly- m. soleus and the deep layer of the
proper fascia, covering it; laterally- m. flexor hallucis longus; medially- m. flexor digitorum
longus. It has three openings: the entrance of the canal is the fissure described above.
A. poplitea with n. tibialis enter and v. poplitea exits. A. poplitea is divided into tibialis
posterior, which descends in the canal, and tibialis anterior, which pierces interosseous
membrane above m. tibialis posterior and passes to the anterior surface of the leg. This opening
is anterior opening (exit) of the canal. The second exit from the canal (inferior one) is situated
between the tendon of the posterior tibial muscle and calcaneal tendon. Posterior tibial vessels
and tibial nerve pass through it posteriorly to the medial malleolus. The posterior tibial artery
provides the main blood supply to the foot. It is the larger terminal branch of the popliteal
artery.In the superior half of the canal, laterally to the nerve the second large artery- a. peronea
lies, which extends from the posterior tibial artery and passes laterally through a canal formed by
muscles and fibula (canalis musculoperoneus inferior). The walls of the canal are: anteriorly-m.
tibialis posterior; posteriorly- m. flexor hallucis longus; laterally-fibula. A.v. peroneae pass
through this canal and emerge from it under the inferolateral border of the m. flexor hallucis

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longus and pass along the lateral border of the calcaneal tendon.On the level of the malleolus a
communicating branch extends from the peroneal artery (r. communicans posterior) which forms
an anastomosis with posterior tibial artery. The fibular artery gives muscular branches to the
popliteus and other muscles in the posterior and lateral compartments of the leg. It also supplies
a nutrient artery to the fibula. The fibular artery usually pierces the interosseous membrane (r.
perforans), passes to the dorsum of the foot, where it makes anastomosis with the arcuate artery
branch of the dorsalis pedis artery. The nutrient artery of the tibia, the largest nutrient artery in
the body, arises from the posterior tibial artery near its origin.
The calcaneal arteries are the branches of the posterior tibial artery, which supply the
heel. A malleolar branch joins the network of vessels in the region of the medial malleolus. A.
peronea gives off malleolar branches to the lateral malleolus and calcaneal branches which take
part in the formation of rete malleolare laterale et rete calcaneum.
All the muscles of the posterior osteo-fascial compartment of the leg are innervated by
the tibial nerve. It descends in the medial plane of the calf, deep to the soleus. Posteroinferior to
the malleolus the tibial nerve is divided into medial and lateral plantar nerves. Articular branches
of the tibial nerve supply the knee joint, and medial calcaneal branches- the skin of the heel.

The Region of the Ankle Joint

(Regio articulationis talocruralis)

Boundaries: superiorly is a circular line through the bases of the both malleoli, inferiorly-
a circular line on the level of the tops of the malleoli through the sole and the dorsum of the foot.
This region is divided into 4 parts: anterior, posterior, medial and lateral.

Anterior Region of the Ankle Joint

(Regio articulationis talocruralis anterior)

It is situated between two malleoli. Between them the tendons of the extensors pass
which are clearly noticed, when the foot is dorsally flexed. .
Projection of a. dorsalis pedis is made by a line which passes from the midway between
the malleoli to the first interdigital space.
Layers.The skin is thin, movable. Subcutaneous tissue is hardly developed. On the
anterior surface of the medial malleolus v.saphena magna is seen accompanied by n.saphenus .
The branches of n. peroneus superficialis pass in the thickness of the superficial fascia anteriorly
to the lateral malleolus.
Proper fascia of the region is thickened and has an appearance of ligaments: the superior
extensor retinaculum (retinaculum m.m. extensorum superius ) is a strong broad band of deep
fascia, passing from the fibula to the tibia, proximally to the malleoli. It binds down the tendons
of muscles in the anterior compartment, preventing them from bow-stringing anteriorly during
the dorsiflexion of the ankle joint.
The inferior extensor retinaculum (retinaculum m.m. extensorum inferiores), a lying “Y”-
shaped band of deep fascia, is attached laterally to the anteriosuperior surface of the calcaneus,
medially with a part to the medial malleolus, with another part –to the tuberosity of the navicular
bone. It forms a strong loop around the tendons of the extensors. Vertical septa pass from the
retinaculum extensorum superius to the tibia and to the articular capsule, forming 3 osteo-fibrous
canals. The tendons pass through these canals in the synovial sheaths: medially- m. tibialis
anterior, laterally- m. extensor digitorum longus, and between them- m. extensor hallucis longus.
A. dorsalis pedis which is the continuation of a. tibialis anterior, accompanied with veins
and n. peroneus profundus, passes in the canal of the m. extensor hallucis longus

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 Posterior Region of the Ankle Joint
(Regio articulationis talocruralis posterior)

The region is formed by the Achilles tendon and grooves passing in both sides of it.
Layers. The skin is thick, formes transverse folds which are expressed during the plantar flexion
of the foot. Subcutaneous tissue is hardly developed. The calcaneal arterial network lies in the
subcutaneous tissue and on the fascia.
By two sheets deep fascia forms a capsule for calcaneal tendon. Bursa tendinis calcanei
is formed between the tendon and posterior surface of the calcaneus above the place of
attachment to the tuberosity of calcaneus.

Medial Malleolar Region

(Regio malleolaris medialis)

It is bounded between the medial malleolus anteriorly and calcaneus posteriorly.

Neurovascular bundle is projected in the midway between medial malleolus and
calcaneus.
Layers. The skin is thin, hardly movable. Transversly the sources of v. saphena magna,
arterial and nerve malleolar branches pass in the subcutaneous tissue.
Proper fascia streches between medial malleolus and calcaneus, forming retinaculum
musculorum flexorum (lig. laciniatum).The space between calcaneus and the above mentioned
retinaculum is called canalis malleolaris. The tendons of the deep muscles of the posterior region
of the leg and neurovascular bundle pass through it. The tendons are surrounded by synovial
sheaths. The tendon of the tibialis posterior lies just behind the medial malleolus, then –the
tendon of the long flexor of the toes, behind it- a. tibialis posterior with two veins, next to it- n.
tibialis, and deeper –the tendon of the flexor hallucis longus.
The artery and the nerve are divided into medial and lateral plantar branches (a.a. et n.n.
plantares mediales et laterales), which together with the tendons of the long flexors of the toes
and hallux pass to the plantar surface of the foot into the canalis calcaneus. The last one is
formed by the abductor of the hallux (m. abductor hallucis) and calcaneus.
The pulse of the posterior tibial artery is not always easy to palpate; it is absent in about
15% of people. The posterior tibial pulse can usually be palpated between the posterior surface
of the medial malleolus and the medial border of the calcaneal tendon. It is usually easier to
palpate when the foot is relaxed and not bearing weight. It is essential for examining patients
with occlusive peripheral artery disease. Intermittent claudication is characterised by leg cramps
that develop during walking and disappear soon after rest. This painful condition results from
ischemia of the leg muscles caused by narlayersing or occlusion of the leg arteries.

Lateral Malleolar Region

(Regio malleolaris lateralis)

It’s bounded between the lateral malleolus and calcaneus.

Layers. The skin is thin. Subcutaneous tissue is loose, not developed. V. saphena parva
and n. suralis pass in this tissue curving posteriorly the lateral malleolus. The proper fascia is
fused with the periosteum of malleolus and calcaneus, is thickened in two places forming
ligaments: superior and inferior retinacula of the fibular muscles (retinacula musculorum
peroneorum superius et inferius). The tendons of the long and short fibular muscles pass under
the superior retinaculum in the common synovial sheath which ascends 4-5 cm above the
ligament. Under the inferior retinaculum the tendons are in separate sheaths, which are separated
by trochlea peronealis of the calcaneus.

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 Foot
(Pes)

It consists of two regions: the dorsal region and the plantar region. The boundary between
them is laterally a line which passes from the midheight of the calcaneus to the midpoint of the
head of the fifth metatarsal bone; medially- a line which passes from the same point of the
calcaneus to the midpoint of the head of the first metatarsal bone. When the axis of the foot is
inclined laterally, it is called pes valgum, medially- pes varum.

Dorsal Region of the Foot

(Regio dorsalis pedis)

Projection of the main neurovascular bundle is made by a line passing from the
midpoint of the intermalleolar distance to the first interosseous space.
Layers.The skin is thin and movable. The loose subcutaneous tissue is poor in fat. The
liquid is gathered here easily.Dorsal venous network is formed in the subcutaneous tissue, which
is connected with the dorsal venous arch (arcus venosus dorsalis pedis) by means of
anastomosis. This network is a source for v. saphena parva passing through the lateral border of
the foot and for v. saphena magna passing through the anterior surface of the medial malleolus.
We must remember about this while performing venepuncture or venesection of that vein. Skin
nerves lie in the thickness of the subcutaneous tissue: n. saphenus lies medially, laterally-
branches of n. suralis, 2-3 branches of n. peroneus superficialis pass between the above
mentioned two nerves: n. cutaneus dorsalis medialis, n. cutaneus dorsalis intermedius, n.
cutaneus dorsalis lateralis. The branches of n. peroneus profundus pass through the first
interdigital space. All these skin nerves innervate the dorsal surfaces of the toes.
The proper fascia is the continuation of fascia cruris.The tendons of long extensors and
anterior tibial muscle are bounded between the sheets of proper fascia. The short extensors (m.m.
extensores hallucis brevis et digitorum brevis) lie under the fascia. When there is the third fibular
muscle (m. peroneus tertius), its tendon is attached to the base of the fifth metatarsal bone.
Neurovascular bundle consists of a.v.dorsalis pedis and n. peroneus profundus. A.
dorsalis pedis is the continuation of a. tibialis anterior. A. arcuata extends from A.dorsalis
pedis before it reaches first intermetatarsal space. A.a. metatarseae dorsales (second, third and
fourth) extend from it. These vessels run to the clefts of the toes where each of them is divided
into two dorsal digital arteries for the sides of adjoining toes. The main trunk of a. dorsalis pedis
is continued by first dorsal metatarseal artery. The second terminal branch is r. plantaris
profundus which, passing through the first interosseous space, gets into the plantar region and
makes anastmosis with the lateral plantar artery (a. plantaris lateralis), a branch of a. tibialis
posterior.
N. peroneus profundus innervates short extensors of the digits and the skin of the first
interdigital space.
The palpation of the dorsalis pedis pulse is usually easy because the artery is situated
superficially. It can be felt on the dorsum of the foot, where the artery passes over the navicular
and cuneiform bones just lateral to the extensor hallucis longus tendon. It may also be felt
distally to this at the proximal end of the first interosseous space. But a. dorsalis pedis has a
great variety of location: it can pass through the center of the dorsum and even through the
lateral border. It must be taken into consideration while palpating the pulse. A diminished or
absent pulse suggests arterial unsufficiency caused by vascular obstructive diseases of the lower
limb.

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 The Plantar Region of the Foot
(Regio plantaris pedis)

The lateral neurovascular bunch of the sole is projected by a line which passes from the
centre of the width of the sole (or from the midpoint of the line connecting the tops of the
malleoli) with the fouth interdigital space. The medial neurovascular bunch is projected by a
line which passes from the centre of the medial half of the width of the sole to the first
interdigital space.
Layers. The skin is hardly movable, thickened especially on the tuberosity of calcaneus
and heads of the metatarsal bones, is tightly connected with the plantar aponeurosis by fibrous
septa. Dense subcutaneous tissue is lobular and is developed disproportionally.
The deep fascia of the sole (proper fascia) is thick in the central part and forms a strong
plantar aponeurosis of the foot. It consists of a thick central part and weaker and thinner medial
and lateral portions. This aponeurosis, consisting of longitudinally arranged bands of dense
fibrous connective tissue, helps to support the longitudinal arches of the foot and to hold the
parts of the foot together. It arises posteriorly from the calcaneus and divides into five bands that
split to enclose the digital tendons that attach to the margins of the fibrous digital sheaths and to
the sesaamoid bones of the great toe. Distally these bands are connected by the transverse
bundles (fasciculi transversi), bounding the commissural openings. The last ones are filled with
fatty tissue, lumbrical muscles lie here, vessels and nerves of the toes pass through them. From
the margins of the central part of the aponeurosis, vertical septa extend deeply: the medial and
lateral fascial intermuscular septa which separate subaponeurotic space of the sole into three
osteo-fascial compartments .Medial intermuscular septum is attached to the calcaneus, navicular,
medial cuneiform and the first metatarsal bones. The lateral one is attached to the tendon of the
peroneus longus and the fifth metatarsal bone. Medial osteo-fascial compartment contains
abductor hallucis, flexor hallucis brevis muscles and the tendon of the long flexor of the hallux.
Medial neurovascular bundle lies between the splitted sheets of the medial intermuscular septum.
The lateral fascial compartment of the sole is separated from the middle one by the fascial
septum and contains the muscles of the small toe: m.abductor digiti minimi et m. flexor digiti
minimi brevis. The middle osteo-fascial compartment contains flexor digitorum brevis, flexor
digitorum longus, quadratus plantae, lumbricals, proximal part of tendon flexor hallucis
longus.The superficial and deep connective tissue spaces of the sole lie in the middle osteo-
fascial compartment. This compartment is communicated with the subfascial space of the
dorsum pedis by the anastomoses between the dorsal and lateral plantar arteries of the foot.It also
communicates with the loose connective tissue of the interdigital spaces and the dorsal surface of
the toes; with the subcutaneous tissue of the sole through the plantar metatarsal and plantar
digital vessels, passing through the commissural openings; with the medial compartment of the
sole through the tendon of the m. flexor hallucis longus; with the lateral compartment through
the lateral plantar vessels; with the deep space of the leg through the neurovascular bundle
passing through the malleolar canal.
The arteries of the sole are derived from the posterior tibial artery which is divided to
form medial and lateral plantar arteries in the groove on the medial side of the calcaneus.The
vessels close n. tibialis which also are divided into the plantar branches.
Medial plantar vessels and nerve pass to the medial plantar groove(sulcus plantaris
medialis) which is formed between m. flexor digitorum brevis and muscles of the great toe.
Lateral plantar vessels and nerve lie in the lateral plantar groove (sulcus plantaris lateralis)
formed between the short flexor of the digits and the muscles of the small toe. At the level of the
heads of the metatarsal bones lateral plantar artery makes anastomosis with the deep branch of
the dorsal artery of the foot (r. profundus a. dorsalis pedis) forming the plantar arch (arcus
plantaris). A.a. metatarseae plantares extend from this arch. Then they give off common digital
plantar arteries (a.a. digitales plantares communes), and perforating branches (r.r. perforantes).

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The last ones make anastomosis with the arteries of the dorsal surface of the foot. The common
digital arteries divide into proper ones (a.a. digitales plantares propriae).
Plantar nerves innervate the muscles of the sole and the skin of the toes. Medial plantar
nerve (n. plantaris medialis) innervates the muscles of the first toe, short flexor of the digits, two
medial lumbrical muscles and gives off skin branches (n.n. digitales plantares propriae) to three
and half toes ,beginning from the hallux ( first, second, third and medial surface of the fourth
toe).
Lateral plantar nerve (n. plantaris lateralis) innervates the muscles of the fifth toe,
adductor of the hallux, quadrate muscle of the sole, two lateral lumbrical and all the interosseous
muscles. It also innervates the skin of the fifth toe and the lateral surface of the fourth one. The
innervation of the toes in the plantar region looks like the innervation of the palmar region of the
hand by median and ulnar nerves.

AMPUTATION

Amputation of the limb is the removal of the peripheral part of the limb on the level of
the bone. Amputation on the level of the joint is called exarticulation.
Amputations are classified by their indications:
 Amputations with primary indications are performed in urgent surgical treatment before the
clinical signs of infection are developed.
 Secondary amputations are performed when the conservative and surgical treatments were
not effective. It’s performed in any period of the treatment, when complications, dangerous for
the patient’s life, appear.
 Repeated amputations or reamputations are performed after insufficient results of the
previous operation, when vicious stump is formed.
The main indications for primary and secondary amputations are:
1. Traumatic (injuries, burnts, frostbites)
2. Inflammatory (acute osteomyelitis, diabetic cellulites, septic arthritis etc)
3. Vascular insufficiency (e.g. atherosclerosis)
4. Malignant tumors (osteosarcoma, fibrosarcoma, chondrosarcoma)
5. Diabetes (diabetic angiopathies, which cause gangrene)
6. Congenital (supernumerary digits- polydactylia)
Pathology of the stump, which is the indication for the reamputation is defined by the
length, the form and the state of the soft tissues of the stump.
What does the term “ideal stump” mean?
 The stump should be of optimum length
 The end of the stump should be smoothly rounded
 The stump should be firm
 The opposing groups of muscles should be sutured together over the end of the bone: they
will be converted into fibrous tissue and will serve as an effective cushion, which will protect the
skin.
 The vascularity of the flaps should be normal
 There should be no projecting spur of bone
 The stump should neither be redundant nor be under tension
 The position of the scar should be such, as to avoid pressure
 The resulting scar should be fully mobile and should be neither adherent, nor enfolded. In
case of the upper limb, the scar may be terminal, but in case of the lower limb, a posterior scar is
desirable to avoid the pressure of weight on the artificial limb.

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 Technique of the amputation
Most of the major amputations should be performed under bloodless condition by
application of a tourniquet. At first the limb is held elevated for a few minutes to drain out the
blood. A towel bandage may be wound at the place of the application. The tourniquet is tied by a
simple knot.
Technique of the amputation consists of several phases:
1. Incision of the soft tissues or shaping of the flaps
2. Incision of the periosteum and sawing of the bone
3. Processing of the stump and closure of the wound
According to the first phase there are two main types of amputation: circular type and flap type.
Circular amputations are divided into one-, two- and three –moment types depending
on the moments of the incision. In a single-moment method the skin and the subcutaneous tissue
are retracted proximally and then incised. A special type of one-moment amputation is Guillotine
type, when all the structures of the limb, including the bone, are divided at the same level and the
wound is left open. Though it is the most primitive type of amputation, yet it is used nowadays in
case of gas- gangrene.
The principle of the two- or three-moment incision of the soft tissues in circular
amputations is suggested by Pirogov.

Cone-circular Amputation by Pirogov

It’s used in amputations of the thigh and the arm, were we have a single bone. At first the
skin, the subcutaneous tissue and the superficial fascia are incised (I moment). Then through the
margin of the shortened skin superficially situated muscles with their own capsules are cut (II
moment). Finally the soft tissues are retracted by a retractor and the deep muscles, which are
attached to the bone and cannot constrict in a long distance, are incised (III moment). The bone
is sawn on the same level. This method gives an opportunity to hide the edge of the divided bone
in the depth of the cone formed by the soft tissues.
Flap methods of amputation nowadays are performed mainly in amputations of the leg
and the forearm. Single or double flaps are formed. Two flaps may be of either equal or unequal
sizes. When two unequal flaps are formed, one of them is long and the other- short. In single-flap
method the length of the flap should be 1/3 of the perimetrium (or the length of the long flap is
2/3 diameter, short flap-1/3d) of the limb on the level of the section, keeping a provision for
certain amount of the elastic shortening of the skin (2-5 cm). In two-flap method, if the flaps are
of equal sizes, the length of the flaps should be 1/6 perimetrium of the limb plus the index of the
skin shortening.
The amputations are classified into fascioplastic, myoplastic or osteoplastic, depending
upon the tissues, which are included into the flap.
The amputations are classified as well, depending upon the method of processing
(cutting) the periosteum and the bone:
 Aperiostal processing, when the periosteum is separated 3-5mm above the level of the
amputation and removed in a ring-form.
 Subperiostal processing, when the periosteum is separated 3-4cm below the level of the
amputation, then it’s turned back as a cuff, the bone is sawn and the edge is covered by the
periosteum.
 Osteoplastic processing, when the periosteum is cut on the same level as the bone.
Processing of the nerves and vessels
After the bone is sawn, the vessels of the stump are ligated and the nerves-incised. The
large vessels are found topographically and are ligated by two ligatures. The bleeding from other
(small) vessels is arrested after the tourniquet is released by applying arterial forceps.
All large nerve trunks should be slightly pulled down and divided, so that the ends are
retracted upwards and are not involved in the scar. If they are involved in the scar tissue,

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continuous pain or pain during movement of the limb will be intolerable for to the patient. The
methods of processing the nerves are so important, that Burdenko called amputation a
neurosurgical operation. Often absolute spirit or other sclerosis making medicine is injected into
the nerve trunk. The nerve is cut by a single touch with a sharp blade.
Closure of the wound
The wound isn’t closed only in the case of anaerobe infection (gas gangrene). In other
cases it is a good practice to provide a drain, which should preferably be a suction drainage. The
wound is closed layer by layer.

Supracondylar Osteoplastic Amputation of the Thigh by Gritti-Stokes (Shimanovsky)

The tongue-shaped anterior flap extends down from the level -2 cm above the medial and
the lateral epicondyles to the tibial tubercle, and the posterior flap is ½ as long as the anterior
one. The lig. patellae is divided near its insertion. Posteriorly, the tendons of the hamstrings are
divided and the popliteal vessels and the sciatic nerve are dealt properly. The femur is divided
across at the level of the adductor tubercle and the articular surface of the patella is removed.
The lig. patellae is now sutured to the tendons of the hamstrings in such a manner, that the
articular surface of the patella is apposed to the cut end of the femur. Interrupted sutures are
applied on the skin.

Osteoplastic Amputation of the Leg by Bier

A cutaneo-fascial flap is shaped from the anteromedial surface of the leg and is turned
back upwards. A thin plate of bone (2mm thick and 6cm long) is sawn from the medial surface
of the tibia and broken on its base. As a matter of fact two types of flaps are formed: the first is
the cutaneo-fascial flap, the length of which is calculated by above mentioned method, the
second one is the periosteo-osseal flap. The bony plate remains connected to the proximal end of
the bone by a periosteal pedicle (bridge). Laterally and posteriorly the skin is cut circularly. The
muscles are cut and the bone is sawn on the level of the flap base. The bony plate of the tibia
covers the sawn surfaces of the bones. The stump is closed by interrupted sutures.

Osteoplastic Amputation of the Inferior 1/3 of the Leg by Pirogov

It’s the modification of Lisfrank’s, Chopart’s and Syme’s amputations. This amputation
almost doesn’t shorten the limb. The foot touches the ground, so the patient can do without an
artificial limb.
A stirrup-shaped incision of the skin is made from the medial malleolus to the lateral one.
The soft tissues are incised in two planes: at first- in horizontal till the calcaneum, then in
frontal- from the plantar side. The anterior capsule of the ankle joint is incised and the foot is
forcibly plantar flexed. The calcaneum is sawn in the frontal plane so, that its tuberosity is left in
the heel flap and is made to unite with the divided end of the tibia (by this phase Pirogov’s
amputation differs from Syme’s one, where calcaneum is entirely removed). The distal ends of
the tibia and the fibula are sawn on the level of the base of the malleoli in horizontal plane. The
posterior flap is sutured to the leg, the tendons and the periosteum are sutured by catgut, the skin-
by silk (interrupted sutures). In this case the synovial bursa of the calcaneum appears under the
stump and, being always under the weight of the body, brings to bursitis and restriction of the
movements. So to avoid this complication, an oblique direction of sawing the bones (both
calcaneum and the bones of the legs) is used. To avoid the necrosis of the calcaneum, a. tibialis
posterior is ligated below the place, where a. calcanea extends. A. tibialis anterior and the plantar
arteries are ligated with stitching. Peroneal and plantar nerves are cut.

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 TENDON SUTURE (TENORAPHIA)

Usually an indication for tenoraphia is the trauma with the injury of the tendon.
Depending on the time when the operation is performed, are distinguished:
 primary suture
 secondary suture
The primary tendon suture is performed within 6 hours of the injury.
The secondary tendon suture is performed after 2-3 weeks.
The specificities of such sutures are to provide:
 durability (mechanical straight)
 blood supply of the sutured ends
 sliding of the tendon in its synovial sheath
 the fiber structure of the tendon (not to destroy it)

The divided ends of the tendon are first identified. There is every chance that the
proximal end will be pulled up. After it the frayed ends of the tendon are cut transversely with a
sharp knife, so that clear healthy tendons on both sides face each other. In order not to destroy
the longitudinal bundles of the fibrous structure of the tendon, the sutures must be put on not
longitudinally but transversely and curved in different directions. Care must be taken also to bury
as much suture material as possible within the tendon to reduce the formation of adhesions with
the surrounding structures, first of all with synovial sheath.
The knot should not be exposed but should lie in between the ends of the tendon.
Atraumatic monofilament non absorbable less irritant suture materials are used (e.g. prolene, ti-
cron, stainless steel etc.). In postoperative period the limb should be immobilized in a splint (or
Paris bandage) for three weeks in a position so as to keep the tendon, just repaired, fully relaxed.
Different types of sutures are suggested by Langae, Kuneo, Bonnae, Rozov, Kozakov and
others.

MANAGEMENT OF NERVE INJURIES (NEURORAPHIA)

Primary nerve repair and secondary nerve repair are distinguished.

The primary nerve repair is only considered in case of very recent, clean-cut wound, as
for example, occurred after a cut by a piece of glass. It can also be performed in case of children
when the result of this primary suture is a good one. First of all the surgeon needs to find the cut
ends of the nerve as they can be retracted. After that, a small portion of the nerve is resected
from both ends with a scalpel or razor and never with the scissors as it may cause crushing of the
nerve ends. The ends should be excised till the healthy clean cut ends are seen.
Non-absorbable, non-irritant monofilament suturing material on an atraumatic needle is
used. 2-4 interrupted sutures are inserted through the epineurium. One should not be inclined to
apply more sutures as this will simply encourage fibrosis and will stand on the way of good
results.
The sutured ends of the nerve should not be very close. It is recommended to leave 1-
2mm distance between the ends.
The sutured nerve should not be allowed to lie on scar tissue.
A new path is constructed by opening a muscle sheath and embedding the nerve within
the muscle fibers.
Sometimes to minimize the tension on the suture line transposition of the nerve is
performed. After suturing the wound the limb is immobilized in a splint to prevent any strain on
the sutured nerve. It should be kept for no less than three weeks.
The secondary nerve repair is performed when the wound has already primarily healed.
The nerve ends are generally buried in scar tissues. The dissection starts from the normal tissues

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lying proximally and distally to the scar tissues and gradually the nerve ends are released. It’s
called neurolysis. The end-bulb should be excised. Anastomosis should be performed.
The time required for recovery, varies according to the level of the lesion. Down
glayersing axons proceed distally at the rate of about 1mm a day till they reach their endings.
Nearly 3 weeks pass before the end organs become fully activated.

VESSEL REPAIR

The repair of injured arteries is performed to maintain usual flow of the blood through
them. For this purpose a special type of suture is applied which is called vessel suture.
This specifities of such sutures are to provide:
 hermetism
 durability
 prevention of the occlusion of the vessel after suturing. For these purposes care must be
taken not to decrease the lumen of the vessel, keep the elasticity of the sutured part and avoid
leaving any foreign structure (e.g. thread) inside the vessel.
Before suturing, the lumen of the artery must be closed with the arterial clamps (Blelock
clamps) which are applied above and below the injured place to arrest the bleeding. If the artery
is damaged in less than 1/3 of its lumen, interrupted sutures are put.
Non-absorbable, non-irritant monofilament suturing material on an atraumatic needle is
used.
The distance between the neibouring sutures, the so called suture step, is 1.5-2.0mm. The
distance from the edge of the arterial wound is 0.7-1.0mm.
If the artery is damaged completely or more than 1/3 of its lumen is hurt, we perform a
circular anastomosis. For this purpose first of all the injured ends of the artery should be excised
transversely. After that, 3 interrupted sutures are put between the ends which connect them and
divide the lumen into 3 equal parts (segments). When we pull the sutures, the circular opening of
the vessel is transformed into a triangular form. Then the edges of the triangle are sutured by
continuous suture. The ends of the thread are tied with interrupted sutures. Before tying the last
suture, the clamp from the distal end is removed in order to fill the anastomosed part with blood
and thus push out the air in it. After that, the last suture is tied and the arterial clamp from the
proximal end is also removed. Then control of the bleeding from the suture line is done, and, if
necessary, an additional suture is put in the place of bleeding.
Some surgeons prefer the interrupted suture to the continuous one.
To avoid leaving a foreign structure inside the vessel, another type of anastomosis is
performed- invaginating type.
In this method the end of the proximal part of the artery is turned back externally by its
intima as a culf and is inserted into the distal end of the artery. This invaginating anastomosis is
formed by several circularly applied interrupted sutures. Each of them passes through the whole
thickness of the wall of the distal end and the turned-back part of the proximal end in the region
of the anastomosis of the artery. Finally it’s fixed to the adventitia of the proximal end.

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