THEREPUBLICOFKAZAKHSTAN MINISTRYOF HEALTH
KARAGANDASTATEMEDICALACADEMY
F.K.KOPOBAYEV, K.K.KAPENOVA,
K.K KAIYRBEKOVA
THE LECTURES
ON TOPOGRAPHICAL ANATOMY AND
OPERATIVE SURGERY
(MANUAL AID)
Karaganda – 2008
УДК 617. 9
ББК 54. 54 я 7
К 74
Reviewer:
- Igimbayev T.K., c.m.s., assistant professor of Surgical Diseases and Urology department №2 of
KSMA.
2.Baigulakov A. T., the teacher of Normal Anatomy department of KSMA
3.Sisabekov K. E., d.m.s. head of the Normal Anatomy with course of operative surgery department of SouthKazakhstanStateMedicalAcademy
Kopobayev F. K., Kapenova K. K., Kaiyrbekova K. K.The lectures on topographical anatomy and operative surgery–manual aid. Karaganda 2008. – page 118
Annotation: The lectures on topographical anatomy and operative surgery
in school text-book are presented and intended for students who studies in English. Here described the topographical anatomy of regions of human body regions and organs, the principles of basic operative interventions are described here.
Discussed and approved on meeting of KSMAMethodical council
Protocol №_7______
«_12____» ___03______2008_y.
Reccomended to edition by decision of KSMALearned council
Protocol №__8_____
«__28___» _____03_____2008_y
Abbreviations
a - artery
aa - arterias
cm - centimetre
CNS – central nervous system
m - muscle
ml – millilitre
mm – millimetre
n - nerve
v – vein
vv - veins
LECTURE 1.PURPOSES AND TASKS OF TOPOGRAPHICAL ANATOMY ANDOPERATIVESURGERY. CLINICAL ANATOMY OF FASCIAS AND CELLULAR SPACES OF THE LIMBS. BASIC PRINCIPLES OF OPERATIVE INTERVENTIONS AT PHLEGMONS
Dear students! This year you start to study thetopographical anatomy, operative surgery. This subject is exclusive important in that system which prepares a doctor. It creates the base for a student to come over to practical work from theoretical program with clinical knowledge.
The aim of theteaching topographical anatomy, operative surgery is the anatomo-surgical training of the students, it gives knowledge which is needed in surgical case and in independent work of the doctor.
To achieve this aim, you should decide the following tasks:
1.To study of topographical anatomy of all regions and organs of the human body, anatomo-
physiological ground of methods and technique of basic operative interventions.
2.To master general operative technique and typical surgical operations.
3.To apply received knowledge of the understanding of the pathological process and to
decide the situation tasks.
In main parts of the lectures information of the anatomical individual variability, the collateral blood circulation, the fascias, the structure of peripherical nervous and lymphatic systems is given
In summary of teaching of the surgical operations general surgical technique or notion of operations on the organs and anatomical formations and also about the surgical tools and apparates will be given.
The topographical anatomy of the region and operation that organ will be discussed in the special part of the lecture, for example: "Topographical anatomy and operations of the head".
The name "topographical anatomy and operative surgery" is a unite of two disciplines which unite the topographical anatomy and operative surgery. The scientific discoveries of one are the succession of the second subject.
The word "topographical" is made up of two Greek words: "topos" - place and "grapho" - to write, i. e. the describing of a place. Topographical anatomy deals with studying of structure of tissue and organs in a region; it also studies the anatomical connections of one organ with neighboring as well as far away organs and tissues. The task of practical classes in topographical anatomy is to describe a region with insections. In topographical anatomy a region is the part of a body which is limited from other parts by natural or conductional lines (f.e., the lateral region of a face, frontal region of thigh). Natural boundary means leather pleat, bone formations etc. Topographical anatomy like normal anatomy studies the structure of human body in their normal condition. But the methods of studying are different in these disciplines. The Normal Anatomy describes the human body by systems (digestion, reparative, blood vascular, nervous system, etc). But the topographical anatomy describes the mutual location of organs and systems by regions.
Topographical anatomy is an applied science needed in every clinical discipline and for every doctor of all professions. We prepared methodical directions to control knowledge on topographical anatomy in which the orientation scheme is described which helps the student to study the typical questions for understanding of topography of a region. This scheme contains questions:
1.Boundary of region
2.External points
3.Location of layer step by step from surface to depth. Specific structure of every layer.
a)Skin
b)Subcutaneous adipous 1ayer
c)Fascies (superficial, proper), their branches, fascial, bone-fascial compartments
Muscles (their division in groups, layers, furrows, channels)
d)Bones, joints, their topography and structure
e)The presence of vessels and nerves in every layer
f)Arrangement, structure, topography of the basic vessels. Nervous bindle and their
projection on the body's surface
g)The lymphatic ways and nodes
h)Individual, sexual, anatomical differences
The methodical guidance also contains scheme which helps in studying of topographical anatomy of an organ, scheme has the following points:
1.Position of organ, systematic relation and function
2.Anatomical structure: form, size, parts and internal structure
3.Topography:
a)Skeletotopy - relation of organs with skeleton
b)Sintopy - relation of organs with each other, i. e. with neighboring organ, vessels,
nerves and other anatomical formations
c)Golotopy - relation of organs with body, region
d)Projection of organ on the skin
4.Blood supply
5.Lymphatic ways
6.Innervation
7.Vices of development
8.Individual anatomical differences
Therefore, topographical anatomy gives possibility to understand the relation of organs with each other what doctor uses in diagnosis of surgical cases. So it's proof that without the knowledge of topographical anatomy, it's impossible to make surgical job and to know the organs diseases.
Operative surgery is a science which deals with the studying of surgical operations, their
methods, principles, technique of surgical operation.
Operation is the mechanical action on the tissue and organs of patient for the purpose of treatment and diagnosis.
Operations are divided into:
1.Radical - full removal of struck organ, f.e. removal of mammary gland in cancer
2.Palliative - directed to relieve the condition of patient when impossible to remove the
struck organ (f. e. at an inoperable cancer of esophagus with it impassability, forming a
fistula on stomach for feeding the patient and prevention hungry death)
Operations can be divided to terms:
1.Emergency - are carried out after establishment of the diagnosis (f. e.,
tracheotomy)
2.Urgent be made in during 2 hours after hospitalization
3.Planned carried out on convenient time for doctor and the patient
The operations also divided into:
1.Trial - at not clear diagnosis
2.Methodical, diagnostical
Each surgical operation has 3 main moments:
1.Access - lawyerly level cut of tissues laying on a way to the centre of defeat
2.Operative action - surgical intervention on the struck organ or tissues, technique of
performing the operation
3.Restoration of integrity of tissues (anatomical and functional)
For carrying out any operation following conditions should be kept:
-The diagnosis.
-Indication to operation
-The plan of the operation
Access - is a part of operation providing an exposure of organ on which surgical intervention is planned. It is possibily to make a cut explosive, without damaging of the important systems or tissues. For this it must be provided with the nearest access, executed through the planned cut, guided according to projections on body's surface. Demands to access - anatomical basis, technical possibility, physiological character and sufficiency for achieving the aim.
Surgical method is manipulation on the organ or tissue, technique of carrying out of given operation to restore or to reconstruct the organ after operation. There are systematic recommendations in the plan of right understanding of aims and problems of operative surgery, where are approximate schemes of basis action on technique of surgical operations:
1.Definition and essence of operation
2.Indication
3.Aim, plan of operation
4.Position of patient on the operating table, arrangement of participants of operation
5.Methods of anesthesia
6.Tools
7.An operative access, basis of it
8.Operative methods. Principal stages
9.Consistency in closing operating wound kind of seam
From the moral point of view surgeons make many operations on the experimental animals and then they transfer results on patients. Studying of topographical anatomy and experiments on animals confirms the scientific basis of the most important problems of medicine such as establishment of limit of possibility of surgical intervention on organs or systems, using anatomical resources of patient's organism with the purpose of reconstruction of the system or organ, (which sufferes from trauma or disease). Necessity of knowledge of topographical anatomy is also important for physicians, pediatrics, neuropathologists, neurosurgeons et cetera).
In 1815 the famous Russian scientist, surgeon E. O. Muhin (H.I. Pirogov's teacher) confirmed that the doctor who didn't know anatomy was not only useless, but harmful, and 100 years later the prominent surgeon - A. P. Zubarev wrote: "There are no surgeon, no physician without knowledge of topographical anatomy, but there are only signs and prejudices»ю N. J. Pirogov, A. V. Vishnevskiy, N. J. Burdenko, P. A. Kupriyanov dedicated half of their activity to study Topographical Anatomy and consequently they brought in clinical surgery big investment.
It is important to study Topographical Anatomy for constructing anatomo-physiological substrate of diagnosis, understanding dynamics of development of many diseases. F. e.:" why can panaricium of the first finger pass to the fifth finger?" Anatomical basis of this phenomenon is indirect contact of synovial vaginas of tendons of fingers in the area of radial-wrist joint, to where infection can spread. Detailed knowledge of topographical anatomy helps to understand correctly peculiarity of organ's structure in different ages.
At last, the intraorganical topographical anatomy takes important place on the basis of principles of sparing operations. F. e., these principles allow to remove only part instead of the whole organ. On the basis of topographo-anatomical of conformity to natural laws of situation of blood vessels reconstructive operations for restoration of circulation of blood in large vessels, methods of angiography with the help of introduction of catheter in aorta, methods of introduction into blood medicines and contrast substances, sounding of heart's cavities, lymphadenography are claphorated.
Development's history of topographical anatomy, operative surgery
In 1706, on empirer Peter's the I order there was built the military hospital in Moscow. It was built by N. Bidloo was the cradle of Russian medicine. National basic personas were prepared there. In 1735 there were built 3 schools in Saint-Petersburg. At the beginning of the 18-th century the famous surgeons of the country usually were professor of anatomy simultaneously. Topographical anatomy got its progress as an independent discipline more later than normal anatomy.
Topographical Anatomy was called surgical (practical). Appearance of works in surgical anatomy have come the answer to needs of practical doctors and surgeons who were in need of information, which could help them in practical activity. M. J. Shein - founder of anatomical atlas in Russia and Russian anatomical terms. E. O. Muhin created an original textbook of anatomy in Moscow. Then at the department of Anatomy began to pick out independent teacher but preparations and operations on the cadaver didn't make.
At 1825 professor I. F. Bush organized an independent course of Topographical Anatomy attached to his surgical faculty of Military War-Medical academy at Saint-Petersburg, which was read by famous surgeon H. H. Solomon.
I.V. Buyalskiy, the greatest surgeon published "Anatomical-surgical tables which explained execution of operations of cutting out and breaking urine stones" at 1852. More than 2000 operations were made by him.
Real founder of topographical anatomy and operative surgery is N. I. Pirogov (1810 - 1881). He made a great number of descriptions of structure of human body, which were not studied before him. He corrected inexact and sometimes totally wrong notions about interrelations of organs and tissues; systematized uncoordinated facts and knowledge to the whole and he began for the first time joint teaching of topographical anatomy and operative surgery. There are Pirogov's merits:
1.Found teaching about relations vessels and fascies.
2.Laid basis of topographical anatomy as a science. At first time wide applied method of
showing into pieces of frozen cadavers, anatomical sculpture and experiment on the
cadaver.
3.Showed importance of topographо-anatomical researches for studying organ's
function
4.Determined changes in topography of series of regions, which join with different
functional conditions of organs or progress of pathological process in it.
5.Gave the beginning of study about individual anatomical modification of form and
position of organs.
6.First time determined relations between different sections of CNS and defined
precisely topography of periphery nerves and connections between them.
7.Offered topographo-anatomical description of synovial vaginas of hand
and fingers, cellular spaces of limbs, face, neck, detailed topography of joints,
cavity of nose and mouth, thoracic chest and abdominal cavities, fascies and organs of pelvis.
8.Used facts of topographо-anatomical researches to explain of mechanism of the
origin series of pathological conditions and to elaborate rational operative access and
methods.
9.Studied the action of ether's steam.
10.Worked out the first in the world bone-plastic amputation.
Contemporary of N. I. Pirogov was F. I. Inozemtsev - the first head of the faculty in surgical clinic of MoscowUniversity. He is a founder of teaching about aneurysm. He considered organism as a whole.
Тhe first faculty of operative surgery with topographical anatomy was founded at Petersburg medical-surgical academy in 1867. In 1869 the same faculty was founded at medical faculty of MoscowUniversity.
A.A. Bobrov had been leading at the faculty of operative surgery and topographical anatomy of MoscowUniversity since 1885 till 1892. He has published "The leadership to surgical anatomy", the book on operative surgery. He propagandized persistently the view that "the way to the surgical clinic should be through anatomical theatre and surgeon, who didn't study anatomical school couldn't be at the height of his vocation".
P. I. Diakonov had been leading at the faculty of operative surgery and topographical anatomy of the MoscowUniversity since 1892 till 1902. Together F. A. Rein, N. K. Lisenkov, N. I. Napalkov published leadership "Lectures of topographical anatomy and operative surgery" which consisted of two volumes. He was organizer and editor of magazine "Surgery".
E. S. Salishev brought valuable contribution to topographical anatomy surgical science. He has worked at war-medical academy at the Petersburg, then at the Tomsk (father of Siberia surgery). He wrote the work about bandaging of carotid artery and topographical anatomy of
male perinea.
S. N. Delitsin had been leading at the faculty of operative surgery and topographical anatomy at war-medical academy since 1902 till 1913. He wrote short course of operative surgery and topographical anatomy, "Operations at cadaver". He used widely the experiment at cadaver and method of sawing of frozen cadaver. The prominent scientists had been leading at the faculties of operative surgery and topographical anatomy at different time: Rasumovskiy V. I. - at Kazan, Spasokukotskiy S. I. - at Saratov, Shevkunenko V.N. - founder of the big topographo-anatomical school of the Soviet period. He was editor writting of the series of the famous textbooks:
1.The atlas of periphery nervous system.
2.The short course of operative surgery with topographical anatomy.
3.Basis of topographical anatomy.
He founded study about individual changeability of organism, about age able differences in form and positions of organs.
Since 1947 professor Kovanov V.V. has been leading at the faculty of operative surgery and topographical anatomy at the first Moscow medical institute, who offered to study the fascies and cellular spaces, microsurgery, reconstructive-plastic operations on heart , vessels and others.
The methods of study
1. To study surface of cadaver . & alive and to define the boundary of each region, bones - muscular composition, fibers. To find out a proper place on skin for the projection of.
2. In layers investigation of cadaver with the help of scalpel & forceps. Access to
tissues, organs, vessels in layers which need in the practical work of a surgeon. For
knowing how to cut.
3.The method to saw into pieces the different parts of organs (on cadaver) into three
mutually perpendicular directions: horizontal, sagittal & frontal. This method is valuable
& very important because when we cut the body we can see all organs & their relations to
the other organs & also we can see that the organ is located surfacely or deeply.
4.For the study of the topography of abdominal cavity frontal saw is not much confirmed ,
therefore Pirogov used the method of sculptry-to work in a tissue with chisel, hammer &
hot water.
5.Macromicroscopical method of Vorobyev - to maximize a thing with the help of a special
apparatus & to use acid, light, drop of water in this process.
6.X-ra method
R-scopy – onscreen
R-graphy - on photograph
7.Injective method: for study of blood vessels (even small), lymphatic vessels, lymphatic
nodes, for fascia, interfascial, intermuscular space with the help of
hardened solutions, mixture, contrastive substance & then take the R-graphy.
8.Corrozionic method - it helps to define the relation between vessels. First of all I. V.
Buyalsky used this method. In this method fill the vessels with the help of syringe of
cannula of the different hardened masses color, or hot, then corrozoid the organ (separate,
destruct the organic tissue) in strong solution of acetic acid. In the result of process
parenchyma organ destruct & remove substance which have mould vessels.
9.Method of enlightenment: organ with inject able vessels (after fixation formalin &
deaquations in absolute spirit) mix with solution (benzol, benzenebenzonale, glycerin etc)
which does not destruct the tissue but make it to enlight.
10.Experiment on cadaver (operation).
11. Experiment on animal (operation).
12. Experimental modulation of disease, disease of organs.
13. Instrumental method of investigation - endoscopy, ultra sound, c. t. scan.
14.Clinical methods of investigation - observer the pathological process in patient.
15.Histological.
16.Electronic microscopy it "through sight", - definition in which tissue, vessels, nerve of the
organ may be damaged with the help of needle find out the damaged place on line.
The knowledge of topographical anatomy & practice of case help you to define in operation the point of disease also help you to make a plan of operation & warn the difficulty.
In operative surgery you study many apparatus which decrease the duration of operation & help in the joining of tissue qualitatively (f.e. apparatus for stitching of vessels, apparatus for the intestinal anasthomosis, laser and plasmic scalpel). Also work in the preparation of artificial organs & interchange of organ & tissues: kidney, liver, pancreas, heart, heart-lung complex etc.