KHARKIV NATIONAL MEDICAL UNIVERSITY

Department of operative surgery and topographic anatomy

Lecture #1

INTRODUCTION IN TOPOGRAPHIC ANATOMY

AND OPERATIVE SURGERY. TOPOGRAPHIC
ANATOMY OF THE HEAD

Lecturer: Associate Professor, Ph.D., Vdovichenko Viacheslav Iurievich

Kharkiv, 2016
 Plan of lecture
 Three approaches to the study of the
human structure.
 Topographic Anatomy: definition.
 History of Clinical Anatomy in personals.
 Wounds: definition, classification.
 The operation: definition, classification.
 Surgical technique.
 Topographic anatomy of the head.

1
Three approaches to the study of
the human structure.

1. Systematical;
2. Regional;
3. Topographical.

2
Systematical approach to study of
the Human Structure.

3
Regional approach to study of the
Human Structure.

4
Topographical approach to study of
the Human Structure.

5
 "The Clinical Anatomy" –
what does it mean?
The term originates from gr.: klinikos that
means pertaining to a bed. The clinic is
an establishment where patients are
admitted for special study and treatment
by a group of physicians practicing
medicine together.

6
 "The Clinical Anatomy" (H.Ellis, 1960-1994;
K.L.Moore, 1985; R. Snell, 2000 et all.)

 is an integrative science which

comprises topographic, regional,
radiological, surgical and others
approaches to the study of the Human
Structure in application to clinics.

7
 Subdivisions of clinical anatomy:

Regional anatomy;
Topographic anatomy;
Surgical anatomy.

8
 Methods to the study
of the human structure.

1. Syntopy;
2. Skeletotopy;
3. Holotopy.

9
 Methods to the study
of the human structure.

 syntopy (from gr.\ syn with, together + topos

place) – the position of organ with others in any
cavity;
 skeletotopy (from skeleton + topos place) –
the position of organ with skeleton;
 holotopy (from gr.: holos whole, entire + topos
place) - the position of organ to the skin surface.

10
 Topographic Anatomy
 Topographic Anatomy studies the structures of
the Human Body on cross-sections in application
to clinical diagnostic: ultrasound images (USI),
computed tomography (CT) and magnetic
resonance (MR). These are tomographic (two-
dimensional) slice images. Imaging technologies
using X-ray, USI, CT, MR and radioisotopes can
give precise anatomic delineation (M. Burykh,
1990) and as well as function.

11
 Surgical Anatomy
 Surgical Anatomy studies structures of
the Human Body from the surgical point of
view, that is their importance to the
performance of incisions and operative
methods (-tomy, -stomy, -ectomy,
resection and so on). This also means a
study of anatomical variations in
preparation for structural differences
encountered at the operating table.
12
History of Anatomy in personals.
Prof. NIKOLAY PIROGOV (1801-1881)

Main works:

"Is the ligation (vinculum) of abdominal aorta

easy and nondangerous operation of inguinal
aneurysms?" (Derpt, 1832);

"Surgical Anatomy of Vascular Trunks and

Fascia" (1837);

"Complete Course of Applied Anatomy" (1844);

"Atlas of topographic Anatomy in cross-

sections through frozen cadavers" (1853-1859).

13
History of Anatomy in personals.
Prof. VICTOR SCHEVKUNENKO (1872-1952)

Main works:

"Theory of individual anatomical variability";

"Age and typological Anatomy" (1925);

"Course of Operative Surgery and Topographic

Anatomy" (1932-1952);

"Atlas of Peripheral Nervous and Venous

Systems" (1949).

14
History of the department of Topographical Anatomy and
Operative Surgery of Kharkiv National Medical University
in personals.
Prof. ALEXANDER DUDUKALOV (1884-1889)

Prof. SERGEY DELITZIN (1900-1903)

Prof. JULIAN PENSKI (1905-1909)

15
History of the department of Topographical Anatomy and
Operative Surgery of Kharkiv National Medical University
in personals.

Prof. BRONISLAV PRGEWALSKY (1909-1915)

Prof. VALENTINA ZYNCHENKO- GLADKICH

(1974-1990)

Prof. MICHAEL BURYKH (1990-2007)

16
 WOUNDS
WOUND is a simply disruption of the
normal continuity of tissue. When tissue
has been disrupted so severely that it
cannot heal naturally (without
complications or possible disfiguration) it
must be repaired by a skilled surgeon.

17
 Classification of wounds according
to the mode of damage
1. An incised wound is caused by a sharp instrument; if
there is associated tissue tearing, the wound is said to
be lacerated;
2. An abrasion results from friction damage to the body
surface, and is characterized by superficial bruising
and loss of varying thickness of skin and underlying
tissues;
3. Crush injuries are due to severe pressure. The skin
may not be breached even if massive tissue
destruction is present. Oedema, characteristic of this
type of injury, can make wound closure impossible
and, by increasing pressure within fascial
compartments, may cause ischaemic necrosis of
muscle and other structures.;

18
Classification of wounds according
to the mode of damage
4. Degloving injury occurs as a result of shearing forces
which cause parallel tissue planes to move against each
other. Large areas of apparently intact skin may be
deprived of their blood supply from rupture of feeding
vessels.
5. Gunshot wounds may be from shotgun pellets or bullets.
Bullets fired from high-velocity rifles cause massive
tissue destruction.
6. Burns are caused by heat, cold, electricity, irradiation or
chemicals. They form a distinct variety of wound
requiring special consideration.

19
 Operative wounds
1. Clean wounds. They are closed by primary union and are not
usually drained. No break in aseptic technique occurs during this
procedure. Here the surgeon does not enter the oropharyngeal
cavity or the respiratory, or alimentary or genitourinary tracts.
2. Clean-contaminated wounds. These operative wounds
have usual normal flora without unusual contamination.
3. Contaminated wounds. These include fresh traumatic
injuries such as soft tissue laceration, open fractures and
penetrating wounds. Microorganisms multiply so rapidly that within
six hours a contaminated wounds can become infected.
4. Dirty and infected wounds. These wounds have been
heavily contaminated or clinically infected prior to the operation.
They included perforated viscera, abscesses or old traumatic
wounds in which devitalized tissue or foreign material have been
retained.

20
 THE OPERATION
 THE OPERATION is a therapeutic
procedure with instruments to repair
damage or arrest disease in a living body;
or any act performed with instruments or
by the hands of a surgeon with the aim of
diagnostic or treatment.

21
Clinical classification of operations:
1. The radical operation (lat.: radix, root) is
an operation which is directed to the
cause or directed to the root or source of
a morbid process;
2. The palliative operation (lat.: palliates,
cloaked) is an operation which affords
relief but not cure.

22
 Surgical operation
The surgical operation is a technological
process which includes following components:
1) the knowledge of Clinical Anatomy (in
application to surgical clinic Surgical Anatomy);
2) an operating room, general and special surgical
instruments and apparatus;
3) an operating room and patient management
(aseptic procedures; anesthesia);
4) surgical technique (operative approach, operative
method and wound closure).

23
GENERAL PRINCIPLES OF
SURGICAL TECHNIQUE

 Dissection technique.
 Arrest of haemorrhage.
 Tissue handling.

24
 SURGICAL TECHNIQUE
A large operation consists of three parts:

1. operative approach (lat.: operativus,

pertaining to an operation): exposure of organs
with instruments or incision (lat.: in + cedere,
to cut, to open through);
2. operative method: surgical acts performed
with instruments, based on strong precedence
rules;
3. wound closure (absorbable and
nonabsorbable sutures and aseptic bandage):
holding tissues in proximity with means.
25
 Operative approaches (incisions)

Abdominal operative approaches: 1 - upper middle laparotomy; 2 - McBurney

approach for appendectomy; 3 - Phannenstiel's approach for ceasarian section.
26
 Operative approaches (incisions)
 The incision should give optimal exposure for the most
difficult part of the operation and should allow for
extension in the event of a greater than expected
procedure being required;
 all skin incisions should be carefully planned so as to
give a good view of the deeper parts and at the same
time to avoid important structures;
 in general, when an incision has to be made in the
neighborhood of large vessels or nerves, it should be
made parallel to, and not across, their long axis;
 an incision of adequate length should always be made;
 for cosmetic reasons, however, incision on the face or
neck should be placed in a natural crease, for not only
will the scar be less visible, but there will be less
likelihood of keloid formation.
27
 Operative methods
There are the following surgical actions:
 ~ tomy (gr.: tome, a cutting);
 ~ stomy (gr.: stomoun, to provide with an
opening, or mouth);
 ~ ectomy (gr.: ectome, removing);
 ~ plasty (gr.: plassein, to form);

28
 Operative methods
There are the following surgical methods :
 resection (lat.: resecare, to cut off);
 amputation (lat.: amputare, to cut off);
 exarticulation (lat.: ex-, from or outside +
articulus, joint or articulation);
 implantation or transplantation (lat.: in,
trans, through + plan- tare, crop or plant).

29
 Wound closure
 The surgeon's goal. — Whether a patient has
elected to have surgery or is undergoing an
emergency procedure, the surgeon's ultimate
goal upon closing is the same:
to hold severed tissue in opposition (that is, to
hold them together in proximity with means) until
the wound has healed enough to withstand
stress without mechanical support.

30
 Types of surgical sutures:

A - continuous overhead suture; B - continues blanket suture;

C - ordinary interrupted suture; D - eversion interrupted suture. 31
Cerebral part of the Head

32
 Borders of the head
 ledge of the chin
(protuberantio mentalis),
 foundation of the jaw
(basis mandibulae) and its
Branch (ramus mandibulae),
 external acoustic duct,
 mastoid process,
 linea nuchea superior,
 external occipital ledge
(protuberantia oссipilalis externa)
or the most prominent point of
this ledge - the Inion.
33
 Borders of the cerebral part of
the head
The cerebral part of the
head is separated from the
facial part by following
structures:
- glabella
- superior edge of the orbit
- upper edge of zygomatic
arc
34
 Regions of the cerebral part
of the head

1. Frontal-parietal-occipital (regio
fronto-parieto-occipitalis);
2. Temporal region (regio temporalis)

3. Mastoid region (regio mastoidea)

35
Regions of the cerebral part of
the head

36
Frontal-parietal-occipital region
 Frontal-parietal-occipital region is
limited from the front side by superior edge
of the orbit and glabella, posteriorly - by
the upper occipital line (linea nuchae
superior), from sides - by the upper
temporal line (linea temporalis superior).

37
Layers of the frontal-parietal-occipital region

S - skin
C - connective tissue
A - aponeurosis
L - loose fatty tissue
P - pericranium

38
 Temporal region
 Temporal region corresponds to the limits
of the temporal muscle. It is limited from
the front side by the frontal process of
zygomatic bone; below - zygomatic arc,
above and behind – upper temporal line
(linea temporalis superior).

39
Layers of temporal region, frontal section :

40
 Mastoid region
Mastoid region is limited by mastoid
process of the temporal bone.
Types of mastoid process:
- pneumatic (many cells occupies all process)
- sclerotic (cells are not present or they are
poorly developed)
Among these cells a large one is
distinguished, its name is mastoid cavity (antrum
mastoideum).

41
Shipot’s triangle (for antrotomy)
Borders of the triangle:
- upper - the horizontal line which is the
continuation of the zygomatic arc;
- anterior - the line from the back edge of
the external acoustic duct to the top of the
mastoid process
- posterior - crista mastoidea

42
Mastoid process
1- external acoustic duct
2- facial nerve
3-cellulae mastoideae
4-crista mastoidea
5-foramen mastoideum
6- sigmoideus sinus

43
Arteries of the cerebral part of a
head

44
 Borders of the Facial part of the
Head
 ledge of the chin
(protuberantio mentalis);
 foundation of the jaw (basis
mandibulae) and its branch
(ramus mandibulae);
 upper edge of zygomatic arc
(or trago-orbital line);
 superior edge of the orbit;
 glabella.

45
Facial part of the head: Regions
1. Lateral part of the face consists of four regions:
- cheek (regio buccalis),
- parotidomasseteric (regio parotideomasseterica)
- infraorbital region (regio infraorbitalis)
- zygomatic region (regio zygomatica)

2. Anterior part of the face consists of following

regions:
- orbital (regio orbitalis),
- nasal (regio nasalis),
- oral (regio oralis),
- mental (regio mentalis).

3. Deep region of the face (regio facialis profunda)

Regions of the Head.
Regions of the Head
1 – Frontal region
2 – Parietal region
3 – Occopital region
4 – Temporal region
5 – Auricular region
6 – Mastoid region
Facial region:
7 – Orbital region
8 – Infraorbital region
9 – Buccal region
10 – Parotidomasseteric region
11 – Zygomatic region
12 – Nasal region
13 – Oral region
14 – Mental region
 Borders of Lateral Region of the Face

 Inferior margin of orbita

 Trago-orbital line
 Temporo-mandibular joint
 Posterior surface of ramus
mandibulae
 Angle of Mandibula
 Inferior margin of Mandibula
 Mental process
 Nasoorbital, nasooral and
oromental folds
Buccal region: Borders

Superior — horisontal line

which pass through inferior
point of the nose
Inferior — inferior margin of
mandibula
Anterior — m. orbicularis oris
Posterior — anterior margin of
m. masseter.
Buccal region: Layers

1. Skin
2. Subcutaneous tissue
3. Mimic muscles
4. The fatty body of cheek
(Bichat’s fat pad)
5. A.&v. Facialis
6. Fascia buccopharingea
7. M.buccalis
8. Submucosa of vestibulum
oris
9. Mucosa of vestibulum oris
Processes of the fatty body of cheek

a – Temporal

b – Pterigo-
palatine
a b c
c – Orbital
 Regio parotidomasseterica

Borders:
- Inferior margin of the zygomatic arc
- Anterior margin of the masseteric muscle
- Inferior margin of the mandibula
- Anterior margin of the
m.sternocleidomastoideus and mastoid
process
- Temporo-mandibular joint
Regio parotidomasseterica
 Regio parotidomasseterica: Layers

 Skin
 Subcutaneous cellulose
 Superficial fascia
 Capsula parotidea (external sheet)
 Glandula parotidea
 Capsula parotidea (internal sheet)
 M.masseter
 Periosteum
Glandula parotidea

1 – a.&v. transversa facii

2 – a.&v. facialis
3 – a.&v. temporalis superficialis
4 – n. facialis
5 – v.retromandibularis
6 – glandula parotidea
7 – a. carotis externa
8 – ductus of the parotid gland
9 – r.temporalis n. faciales
10 – r.zygomaticus n. faciales
11 – r.buccalis n. faciales
12 – r.marginalis mandibulae
n.faciales
13 – r. cervicalis n. faciales
Glandula parotidea: ductus
Musculus masseter

The Masseter is a
thick,
somewhat quadrilateral
muscle,
consisting of two
portions,
superficial and deep,
fix to zygomatic arc
and inferior margin of
mandibula.
Deep region of the Face
 Deep region of the Face

Adipose spaces:

 temporopterygoid,
 interpterygoid,
 pterygopalatinal.
Arteries of the head
 Parts of the maxillary artery
1. Mandibular part: - a. auricularia profunda
- a. tympanica anterior
- a. alveolaris inferior
- a. meningea media

2. Pterigoid part: - a. masseterica

- a. pterigoidea lateralis
- a. pterigoidea medialis
- a. temporalis profunda
- a. temporalis media
- a. buccalis
- a. alveolaris superior
posterior

3. Pterigopalatinal part: - a. infraorbitalis

- a. palatina
descendens
- a. sphenopalatina
Topography of the maxillary artery
Arteria et vena facialis
Facial Venous Drainage
 Thank u 4
attention!

Have a nice day! ;)

65