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Home , Appendicular artery, Femoral triangle, Gastrophrenic ligament, Hepatorenal ligament, Hypogastrium, Iliac fascia

Operative surgery & topographical of the . Surgical anatomy of the and . Surgical anatomy of the inguinal canal and spermatic cord. Topographical peculiarities of the inguinal hernias.The descendense of the testicle, formation of scrotal layers.

Boundaries: Superior boundary is formed by the margins of the costal arches (arcus costae) and xyphoid process Inferior boundary is formed by the inguinal folds, which are coincide with inguinal and The lateral boundaries are the middle axillary (Lesgaft’s) lines. By two horizontal lines the anterior wall is divided into 3 regions: 1. 2. Mesogastrium 3. 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 from the lower points of the 10th pair of ribs to the pubic tubercles the mesogastrium and hypogastrium are divided into three regions . The mesogastrium – into umbilical, right and left abdominal lateral regions, the hypogastrium – into pubic, right and left inguinal regions. So there are formed seven regions. If there will be drawn two vertical lines which coincide with the midclavicular lines to the pubic tubercles the epigastrium also can divided into three regions – the epigastric, right and left hypochondric regions. So nine regions are formed. Layers of anterior : 1. Skin is thin, elastic, moveable, except , is covered by only in the pubic and inguinal parts, with sebaceous and sweat glands. In lateral parts rich with elastic fibres, which run from up to down, from lateral to medial sides. This fact is considered in abdominal surgery. 2. Subcutaneous fatty tissue (panniculus adiposus), is well developed. In inferior part of anterior abdominal wall it is much expressed, especially for fatty persons, but in umbilical ring it is absent. Below the umbilicus subcutaneous fatty tissue by the superficial is divided into superficial and deep layers, the superficial fatty tissue has cellular structure, the deep one is continuous fat (acellular). 3. The superficial fascia is the continuation of the general superficial fascia of the body, in the inferior part 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 are superficial and deep: 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 (Thomson’s fascia) is started from the level of umbilical ring and attached to the inguinal . From the pubic symphisis it continuous to the scrotum and as superficial fascia. The well developed proper fascia in anterior abdominal wall is absent, but the thin connective tissue membrane is covered the each muscle of this region. In the margin between the muscular fibres and aponeurosis it fuses with the last one. The musculoaponeurotic layers accomplish the tonus of the and intraabdominal pressure. 4. The external oblique (m. obliquus abdominis externus) is a superficial flat muscle; starts from the lower 8 ribs (5-12 ribs), the fibres are intercrossed with the fibres of the latissimus dorsi muscle and anterior serrate muscle, with which it covers the inferior parts of the . Then it descends to the abdominal lateral and anterior parts. The muscular fibres are directed from up to down, from lateral to medial. At the lateral margin of the the external oblique muscle fibres are replaced by aponeurosis, which participate in formation of the sheath of rectus abdominis muscle. In the lateral margin of the inguinal region the inferior part of aponeurosis is thickened and form the (lig. inguinale s. Puparti), its fibers pass inferomedially and attached to the spina iliaca anterior superior and tuberculum pubicum. The length of inguinal ligament is 12-16 cm. In the inferior angle of inguinal region the aponeurosis of the external oblique muscle is divided into two parts called crura (superior and inferior). Superior crus is attached to the symphisis and inferior one - to the tuberculum pubis. Between the superior and inferior 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). Superior and inferior crura, intercrural fibers and reflex ligament form the superficial inguinal ring (annulus inguinalis externus s. subcutaneous). Inferiorly the external oblique muscle fibres are attached to the anterior 2/3 of the . 5. The internal oblique (m. obliquus abdominis internus) is the intermediate flat muscle. Its fibers have fan-like direction. They run at right angle (from down to up, from lateral to medial) to those of the external oblique in the upper part. In the middle part they run horizontally. In the lower part they pass downwards (same as external oblique muscle fibres) and are attached to the anterior part of the iliac crest and to the lateral half of the inguinal ligament. Posteriorly it starts from the thoracodorsal (thoracolumbar) fascia. Superiorly it begins from the lower parts of the costal arch. Medially the muscular fibres are replaced by aponeurosis, which subdivided into two lamins. Anterior lamina participate in formation of anterior wall of rectus muscle sheath, while the posterior lamina – in posterior wall of rectus muscle sheath. In 2-5 cm below the umbilicus the aponeurosis without subdivision runs in front of rectus muscle and participate in formation of anterior wall of rectus muscle sheath. In inguinal region the muscular fibres do not reach the inferior margin and freely hang in some distance. 6. The transversus abdominis (m. transversus abdominis) is the innermost flat muscle; its fibers except the inferior ones, run more or less horizontally. Superiorly it starts from posterior surfaces of lower 6 ribs, where it interlace with the diaphragm. Posteriorly it continuous from the anterior lamina of thoracodorsal fascia. Medially the muscular fibres are replaced by aponeurosis. Till the level of 2-5 cm below the umbilicus the aponeurosis runs posteriorly from the rectus muscle, below this level it goes anteriorly from the rectus muscle and participate in formation of rectus muscle sheath. In the inferior margin of inguinal region the muscular fibres remains freely hang in some distance. Inferiorly laterally the transversus abdominis muscle attached to the iliac crest. 7. Rectus muscle of the abdomen (m. rectus abdominis) has vertical direction to two sides from the midline. Starts from the xiphoid process and external surfaces of 5-7 rib cartilages and costal arch to the pubic symphisis. Pyramidal muscle is located medial to the rectus muscle in the inferior part and starts from the superior margin of the pubic bone to the , which can absent in 16-17 %. The muscle is interrupted by 3 tendinous intersections (intersectiones tendineae) on its extent, which are located at the level of the xiphoid process, umbilicus and halfway between these two structures. All three flat muscles end medially in a strong sheet like 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 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 anterior layer of the internal oblique muscles. Posterior wall consists of the posterior layer of internal oblique and transversus abdominis aponeuroses. The anterior wall of the inferior part (2-5 cm below umbilicus) consists of aponeuroses of the external oblique, internal oblique and transversus abdominis muscles. Posteriorly from the rectus muscle 2-5 cm below umbilicus remains the linea arcuata s.Duglas’s line. Inner surface of the rectus muscle is covered only by . At level of the costal arches anteriorly from the rectus muscle is the aponeurosis of the external oblique muscle and posteriorly it attaches to the 5-7 rib cartilages. Laterally from the rectus muscle, at the place, where muscular fibres of three flat muscles are continuous by aponeurosis is formed the semilunar line, linea semilunaris s. Shpigel’s line, one of the delicate places of the anteriorabdominal wall. linea alba abdominis continuous from the xyphoid process till the pubic symphisis, by length 30-40 cm. Above umbilicus it is broad (1-2 cm width) and flat, while below umbilicus it become thicker and narrower. Above umbilicus linea alba is formed by fusion of anterior and posterior walls of rectus muscle sheath, that’s why the vaginas of rectus muscles are not communicated each other, and besides the single part of one vagina of rectus muscle does not communicate with neighbor parts because the tendinous intersections are fused with the wall of rectus muscle sheath. It is important for localized purulent process. 2-5 cm below the umbilicus linea alba is formed by fusion of anterior walls of rectus muscle sheath (aponeurosis of oblique external, internal and transverse muscles), so the right and left vaginas of rectus muscles are communicated each other. Superiorly in the sheath of the rectus muscle posterior to the muscle two are located: a. epigastrica superior (branch of a.thoracica interna) with double . 8. A firm membranous sheet fascia transversalis is the part of 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 it continuous to the , then on the posterior abdominal wall to the diaphragm. 9. An extraperitoneal fat called Langenbek’s fatty tissue layer is between the parietal and endoabdominal fascia. In some cases can allows the extraperitoneal entrances to the abdominal organs. 10. The parietal peritoneum is the part of the ventral peritoneum, which covers the anterior abdominal wall from inside. The arteries and nerves of the anterior abdominal wall Between two layers of the superficial fascia or in subcutaneous fatty tissue are located the 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 with the veins, which are accompanied them are continuous from the oval opening of the antero-medial surface of the ascend to the hypogastrium. The deep neurovascular bunches are situated: • The lower 6 pairs of intercostal arteries, veins and nerves, directed from up to down from lateral to medial, situated between the internal oblique and transversus abdominis muscles. They are situated as follows: 7th, 8th and 9th pairs supply the tissue superior to the umbilicus, 10th supplies around the umbilicus, 11 and 12 supply inferior to the umbilicus. They pass inferoanteriorly from the intercostal spaces to supply the abdominal skin and muscles. The rectus muscle is innervated by 6 intercostal nerves. • A. epigastrica superior (branch of a.thoracica interna) with double veins situated in the sheath of the rectus muscle posterior to the muscle and in front of the sheath wall. • A. epigastrica inferior (branch of external iliac artery) ascends in extraperitoneal fat, then at the Duglas’s line perforates the transversalis fascia and situates between the rectus muscle and fascia. On the level of the umbilicus forms an anastomosis with a. epigastrica superior. • A. circumflexa ilii profunda (branch of external iliac artery) anastomosis with a.lumbalis. • N.n. ilioinguinalis and iliohypogastricus innervate the skin inferior to the umbilicus (hypogastrium). The first one passes through the inguinal canal, situated on anterior surface of the spermatic cord or round ligament of the . The nerves are branches of the . • A. lumbales, four in each sides , branches of the abdominal . The superficial veins form a network. The veins, which are located above the umbilicus, drain into the axillary by the thoracoepigastric veins; veins below the umbilicus drain into the . Deeply located veins v.epigastrica superior drains into the superior caval vein, and v.epigastrica inferior drains into the inferior caval vein. So cava-caval anastomosis is formed. The superficial veins of umbilical region by the 4-5 paraumbilical veins pass the blood to the portal vein through the round ligament of the . During constriction diseases of the portal and the inferior caval venous systems, 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. The lymphatic vessels above the umbilicus, drain into the axillary and thoracic lymphnodes, below the umbilicus drain into the inguinal lymphnodes. The lymphatic vessels of the deep layers of anterior abdominal wall accompaned the arterio-venous vessels drain into the intercostals and lumbar lymphnodes.

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- oblique vertical lines which pass from the lower points of the 10th pair of ribs to the pubic tubercles, laterally- inguinal fold or inguinal ligament. In the medial angle of the inguinal region we describe the inguinal space and inguinal triangle. The inguinal triangle is bounded: laterally- the inferior and middle 1/3 of the inguinal ligament, medially- lateral margin of the rectus muscle, superiorly- the perpendicular line, which is drowning from the point between upper and middle 1/3 of the inguinal ligament to the lateral margin of the rectus muscle. The inguinal canal is located in the inguinal triangle (one of the weak areas), in the thickness of the anterior abdominal wall. The inguinal space is located between superiorly- the free fibers of internal oblique and transversus abdominis muscles, and inferiorly – the inguinal ligament. It has shape of oval or triangle. For female and brachiomorphus male the inguinal space has a shape of oval and during increasing of the intraabdominal pressure, by contraction of the abdominal muscles the space is become smaller, so is prevented formation of the indirect hernia. For dolychomorphus male the inguinal space has a shape of triangle and during increasing of the intraabdominal pressure, contraction of the abdominal muscles can’t affected to the changing of triangular space, because the muscular fibers of oblique internal muscle directed horizontally. In these situations can develop the indirect hernia. The inguinal canal is an oblique, running from up to down, from lateral to medial, from back to front passage for the spermatic cord through 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.

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 transversalis fascia • The cremasteric muscle • The cremasteric fascia In front of spermatic cord is the ilioinguinal nerve. The constituents of the spermatic cord are • Ductus deferens (vas deferens) • arising from the lateral aspect of the aorta • A. et v. ductus deferentialis • 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 of the ductus deferens and testes • Genital branch of the • Lymphatic vessels • Remnant of the vaginal process

The content of the inguinal canal in women: the round ligament of the uterus; the ilioinguinal nerve; the genital branch of the genitofemoral nerve; the remnant of the vaginal process.

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 between the median and medial umbilical folds.  between the medial and lateral umbilical folds. It’s behind the superficial inguinal ring.  is lateral to the . It corresponds to the deep inguinal ring. 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. Descendens of the testis It goes three stages: I STAGE till 3-4 months of fetal life. 1.Formation of the testis at the level of the upper lumbar vertebras in retroperitoneal space; 2. Formation of the peritoneal processus vaginalis; 3. Protrusion of the layers of anterior abdominal wall. II STAGE 5-7 months of fetal life. 1.Descendens of the testis and passing of it through the inguinal canal with the help of the gubernaculum. Gubernaculum is formed by fusion of two ligaments: a)From the lower extremitas of the testis starts the embrional connective tissue, the ligamentum testis. b)From the free margin of the vaginal process starts the connective tissue cord, the ligamentum scroti. III STAGE 8-9 months of fetal life. 1.Final situation of the testis inside of the scrotal layers. The layers of the scrotum: the skin, tunica dartos, superficial fascia (Tomson’s fascia)( fascia spermatica externa), cremasteric fascia, cremasteric muscle, fascia spermatica interna (f.transversalis), tunica propria testes (peritoneum).

Oblique (indirect) inguinal hernia Direct inguinal hernia 1.Can be hereditary, or acquired 1.Always acquired throughout life throughout life 2. Hernial sac according to the spermatic 2. Hernial sac according to the spermatic cord elements has lateral situation cord elements has medial situation 3. Hernial content lies in the coverings of 3.Hernial content lies outside the coverings the spermatic cord of the spermatic cord

4.Cough symptom is present at the top of 4. Cough symptom is present to the side of the finger the finger 5. Inferior epigastric vessels remain 5. Inferior epigastric vessels remain medially from the hernia laterally from the hernia

6. Frecuently can compressed by hernial 6. Rarely can compressed by hernial ring ring 7. Hernial sac is covered by f.spermatica 7. Hernial sac is covered by f.spermatica interna, m.cremaster, f.cremasterica interna 8. Enters the scrotum 8. Usually doesn’t enter the scrotum 9. Passes through the lateral inguinal fossa 9. Passes through the medial inguinal fossa 10. Usually the delicate place is the 10. Usually the delicate place is the anterior wall of the inguinal canal. posterior wall of the inguinal canal. Hereditary oblique inguinal hernia Acquired oblique inguinal hernia 1. Develops unimomently 1. Develops by hernial stages 2. Develops after birth 2. Develops at the second period of the life 3. At the floor of the scrotum is fixed the 3. Hernial sac is completely extracted testis that’s why hernial sac is not extracted

Operative surgery & topographical anatomy of the abdominal cavity. Proceedings of the peritoneum. Compartment of , its connections & way of spreading pathological fluid.

The liver is the largest gland in the body. It situated under the diaphragm, in upper storey of the peritoneal cavity, is projected in the right and epigastric proper regions. It’s ¾ part is located to the right of the midline and ¼ part to the left of midline. Skeletotopia. In upright posture during inhalation the liver is descend a bit, but in horizontal position during exhalation the liver is ascend. At the stage of deep exhalation the highest point of the right lobe of liver is projected in the IV intercostal space by right mammary line, the same point of the left lobe is projected in the V intercostal space by left parasternal line. Under the rib cartilages normaly the liver is not palpable, only palpable for kids till 5 years old and during ventropetal position of the liver, when by horizontal plane the upper surface of the liver is directed forward, but lower surface – to the back. The superior margin of the liver is projected in the right sternal line by V rib cartilage, in the mammilar line by VI rib, in middle axillary line – VIII rib, in vertebral line – XI rib. The liver has diaphragmatic and visceral (posteroinferior) surfaces that are separated by its inferior border, which is normaly sharp. The liver has posterior margin, which is because of it’s wideness can be considered as a surface. 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. On the diaphragmatic surface of the liver are distinguished the right and left lobes and between them, which is located sagittaly. Frontaly is located the coronary or suspensory ligament, which accomplish the fixation of the liver. This ligament continuous to the sides as the right and left triangular ligaments. 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 lobes. The horisontal groove is the porta hepatis. On the anterior part of the right longitudinal groove is situated the gall bladder in it’s fossa (fossa vesicae felleae), posteriorly – the sulcus for vena cava inferioris. On the anterior part of the left longitudinal groove is situated the round ligament of the liver - ligamentum teres hepatis(it is the obliterated remains of the umbilical vein), posteriorly – the sulcus for ductus venosum(it is remnant of the fetal ductus venosus that shunted blood from the umbilical vein to the IVC). Between the right and left anterior parts of the longitudinal grooves is situated the quadrate lobe of the liver, between the right and left posterior parts of the longitudinal grooves is situated the caudate lobe of the liver. The border between these lobes is the porta hepatis. The syntopia. The diaphragmatic surface of the liver is faced to the diaphragm and anterior abdominal wall. The posterior margin is faced to the XI-XII thoracic vertebras, cruras of the diaphragm, abdominal parts of the esophagus, aorta. The visceral surface of the liver is related to the: Right side of the from the lesser curvature to it’s anterior surface(gastric area) Esophageal area Superior horizontal part of the duodenum (duodenal area) Lesser omentum Gallbladder Right colic flexure (colic area) Right and suprarenal gland (renal area) Relation to the peritoneum. The liver is covered mesoperitonealy. Devoid of the peritoneum the posterior free surface (in the bare area), fossa for gall bladder and porta hepatis. Under the serous coat of the liver there is a thin fibrous coat (tunica fibrosa). On the diaphragmatic surface of the liver the peritoneum is formed the ligaments: 1. the falciform ligament, is continuation of the teres ligament of the liver. 2. the - from the inferior surface of the diaphragm continuous to the diaphragmatic surface of the liver frontally, between two layers of the peritoneum thus forming the free area on the diaphragmatic surface of the liver. 3. the right and left triangular ligaments. On the visceral surface the following ligaments: 1. the . 2. the . These two ligaments with the together they form lesser omentum, which connect the liver with the superior horizontal part of the duodenum, the lesser curvature and the cardial part of the stomach. 3. the . 4. the teres ligament of the liver, it is the obliterated remains of the umbilical vein, passes from the umbilicus to the liver, contains the paraumbilical veins, is continuation of the falciform ligament. 5. the , it is remnant of the fetal ductus venosus that shunted blood from the umbilical vein to the IVC. The free edge of the lesser omentum in the hepatoduodenal ligament enclosed the portal triad (common bile duct to the right, proper hepatic artery to the left and portal vein between them to the back), a few lymph nodes and lymphatic vessels, and the hepatic plexus of nerves. The gastrophrenic ligament passes from the diaphragm to the cardial part of the stomach and contains the connective fatty tissue. The hepatogastric ligament passes from the liver to the lesser curvature of the stomach and contains the left gastric artery, which form the arterious arch between right and left gastric arteries. Vessels of Liver. The liver receives blood from two sources: the hepatic proper artery (30%) and portal vein (70%). The hepatic proper artery (common hepatic artery) carries oxygenated blood from the aorta by the truncus coeliacus, and the portal vein carries the venous blood (poorly oxygenated blood) from the gastrointestinal tract (unpaired organs), 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. Innervation of the liver. The parasympathetic innervation liver receives from the vagus, the symphathetic innervations – from the celiac plexus.

Gallbladder and Billiary Ducts

Holotopia. The gallbladder (8 — 12 cm long, 3-5 cm width, 30-50 ml volume) lies in the gall bladder fossa on the visceral surface of the liver, in anterior part of the right sagital (longitudinal) groove. The cystic duct, common hepatic duct and common bile duct are located in the hepatoduodenal ligament. Syntopia, skeletotopia. There are three parts of the gallbladder: • The fundus is the wide end that projects from the inferior border of the liver in 3 cm, faced to the anterior abdominal wall, inferiorly faced to the right colic flexure and transverse colon and is usually located at the tip of the right tenth costal cartilage in the parasternal line. Sometimes the fundus is located under the liver or into the thickness of it. • The body contacts visceral surface of the liver, the right colic flexure, and the superior part of the duodenum. • The is narlayers, tapered, and directed toward the porta hepatis. 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. Peritoneum. The gallbladder is covered by visceral peritoneum mesoperitoneally, between the and gallbladder wall there is the loose connective tissue present, which allows the subserous extraction of the organ. During chronical cholecystitis this connective tissue can hardly fixed the organ to the liver and disturbe the process of extraction. Peritoneum completely surrounds its fundus and binds its body and neck to the liver. Vessels. The 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. The cystic artery can be the branch of the hepatic proper artery also. Innervation. The parasympathetic innervation it receives from the vagus, the symphathetic innervations – from the celiac plexus. 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 right and left 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(duodenalis) On the left side and in the middle 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 hepatopancreatic ampulla is thickened to form the 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.

Stomach

The stomach has a: • Lesser curvature forming its concave border • Greater curvature forming its longer convex border • Cardia around the opening of the esophagus and pars cardiaca, surrounding it. • 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 Holotopia. Stomach is located in the epigastric proper region and left hypochondrial region. Skeletotopia. Cardia is located at the level of the VII rib cartilage by vertical line, which is drown 2,5cm to the left from sternum, it corresponds to the XI thoracic vertebra posteriorly. The fundus is projected at the level of the V rib by left midclavicular line. The pylorus is projected at the level of the VIII rib cartilage by midline or 1,5-2cm to the right from it. The lesser curvature of the stomach is projected by the bisector of the angle, which form with right costal arch and bicostal line, and the greater curvature of the stomach is projected by the bicostal line. Syntopia and relations of stomach. The stomach is covered by peritoneum from whole sides, except where blood vessels run along its curvatures and in a small area posterior to the cardiac orifice (pars nuda). In the lesser curvature the free part is larger 3-5cm, then in greater curvature it is narrower 1-2cm. The stomach has superficial and deep ligaments. The superficial ligaments are in frontal plane: o Lig. hepatogastricum o Lig. gastrophrenicum o Lig. gastrolienale o Lig. gastrocolicum Deep ligaments (or folds) are visible only after section of the and lifting the stomach. Deep ligaments are in horizontal plane: o Lig. gastropancreaticum o Lig. pyloropancreaticum The anterior surface of the stomach is in contact with the • Diaphragm – in front from the fundus; • Left lobe of the liver – from the lesser curvature; • Anterior abdominal wall. Transverse colon, transverse mesocolon, – are faced to the greater curvature. Left suprarenal (adrenal) gland and superior part of the left kidney – are behind of the greater curvature. Pancreas and celiac plexus – are behind from the posterior surface of the stomach. 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 hepatogastric ligament to the cardia and then turns to course along the lesser curvature to anastomose with the right gastric artery • Right gastric artery arises from the proper hepatic artery and runs to the left in the hepatoduodenal ligament 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 and inferior mesenteric vein to form the portal vein. The right gastroomental vein empties in the superior mesenteric vein. At the border between the body and pyloric part of the stomach there is the pyloric vein (Meo), which drain into the portal vein through the coronar vein. At the cardia the gastric veins anastomosis with the esophageal veins, which drain into the system of the VCS. So is forming the portocaval anastomosis. Innervation. The parasympathetic innervation it receives from the vagus, the symphathetic innervations – from the celiac plexus.

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. Holotopia. Duodenum is located in the epigastric proper region and umbilical region. Syntopia and skeletotopia. For descriptive purposes the duodenum is divided into four parts: • The superior horizontal(first) part is short (5 cm) and lies anterolaterally to the body of L1 vertebra, runs from left to the right, back and up. Superiorly it faces to the quadrate lobe of the liver, anteriorly – to the gallbladder, posteriorly – to the common bile duct, portal vein, inferiorly – the pancreatic head. • The descending (second) part is longer (7 — 10cm) and descends along the right sides of Ll —L3 vertebrae. The descending part of the duodenum runs inferiorly, initially to the right and parallel to the IVC. Anteriorly it faces to the liver and transverse colon with mesocolon; posteriorly – to the VCI and the right kidney; laterally – to the ascending colon and right colic flexure; medialy – to the pancreatic head. • The inferior 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. Syntopia of these parts: Superiorly – to the pancreatic head and body; anteriorly – to the transverse colon, loops of the small intestine, radix mesenteriale, superior mesenteric vessels; posteriorly – to the , VCI. 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. The duodenum forms three flexures: Flexura duodeni superior; Flexura duodeni inferior; Flexura duodenojejunalis. The bile and pancreatic ducts enter its posteromedial wall on the level of middle and inferior thirds of descending part of the duodenum. These ducts usually unite to form the hepatopancreatic ampulla, which opens on the summit of the major duodenal papilla on the longitudinal fold of the mucosa. The minor duodenal рарillа is located a little superiorly to the first one, here is opened the accessory pancreatic duct. Peritoneum. The first 2 cm of the duodenum is intraperitoneally, has a and is mobile. Radiologists refer to this free part as the duodenal cap (bulbus). The distal 3 cm of the superior horizontal part is mesoperitoneal and the other three parts of the duodenum have no mesentery and are immobile because they are extraperitoneal. The ligaments. The duodenum has hepatoduodenal ligament which contents portal triad and right gastric artery. It stretches from the liver porta to the bulbus duodeni, forms the anterior wall of the epiploic foramen. The duodenorenal ligament – from the duodenum to the anterior surface of the right kidney, forms inferior wall of the epiploic foramen. Ligament of Treitz the suspensory ligament of the duodenum. The duodenojejunal flexure 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 muscular fibres begins from the circular layer of the duodenal wall and continuous behind of the pancreas to the left crus of the diaphragm. Vessels. 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.

Spleen

The spleen is the largest of the lymphatic organs and is located in the left hypochondriac region, at the level of the 9-11 ribs by middle axillary line. 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 costal part of diaphragm. It is faced to the greater curvature of the stomach and connects with it by gastrolienal ligament, inferiorly - faced to the left colic flexure, medially – to the tail of the pancreas, posteriorly – to the left , left kidney and lumbar part of the diaphragm. The anterior and posterior borders of the spleen are sharp and often notched. Except at the hilum, the spleen is completely enclosed by peritoneum, where the branches of the splenic artery (branch of celiac trunk) and nerves enter and the tributaries of the splenic vein and lymph vessels leave. The ligaments. From the lumbar part of the diaphragm to the hilum of the spleen stretches the phrenicolienale ligament. From the greater curvature and fundus of the stomach stretches the gastrolienal ligament, which contains the short gastric vessels and left gastroepiploic vessels. From the pancreas stretches the pancreatolienal ligament. The , which stretches from the diaphragm to the left colic flexure has an important role in fixation of the spleen and formation of the lineal sac (saccus lienale). 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. Vessels. The splenic artery, the largest branch of the celiac trunk, follows a tortuous course posterior to the omental bursa, 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 short gastric branches and left gastroepiploic branches enter the gastrolienal ligament. The splenic vein is formed by several tributaries that emerge from the hilum of the spleen. It 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 head of the pancreas to form the portal vein. In the splenic vein drain short gastric veins, left gastroepiploic vein, pancreatic veins (of tail and body), inferior mesenteric vein. Lymph vessels drain into the pancreatosplenic lymph nodes. The sympathetic and parasympathetic nerves come from the celiac, adrenal left diaphragmatic plexuses.

Pancreas

The pancreas is an elongated digestive gland that lies transversely across the posterior abdominal wall, in the upper storey of the abdominal cavity, in the epigastric proper region and left hypochondrial region, in the retroperitoneal space. It is projected by the connecting of the 7-8 ribs or by horizontal line, which stretches at the midpoint of distance from the xyphoid process to the umbilicus. This level corresponds to the L1 lumbar vertebra. The head of the pancreas is located to the right from L1,L2 vertebraas, body - across with aorta, posterior from the omental bursa is located at the level of the L1 vertebra, the tail goes to the left at the level of the 11,12 ribs. 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 transverse mesocolon extends to its anterior margin. The head has non equal quadrate shape. The body has a prism shape structure with anterior, posterior, inferior surfaces. On anterior surface is present the omental tubercle. Respectively pancreas has the upper, lower, anterior margins. The length of the gland 16-17cm, head width 5cm, body – 3,5cm, tail – 0,3-0,4cm. 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 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. In about 30% of people this duct communicates with the main pancreatic duct, but usually 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. Syntopia. To the head of the pancreas attaches transverse mesocolon, where superiorly from it the head is faced to the pylorus and inferiorly from the transverse mesocolon are loops of small intestine remain. The anterior surface of the pancreas body is covered with peritoneum and from the stomach is separated by the omental bursa. The body anteriorly is intimately related to the duodenojejunal flexure. Тhe tip of the tail usually contacts thе hilum of the spleen and left colic flexure. Posterior surface is devoid of peritoneum and faces to the IVC, the part of portal vein, the common bile duct, the superior mesenteric vessels, the aorta, inferior mesenteric vein, left suprarenal gland, and the left kidney. The pancreas from frontaly located organs is separated by parietal peritoneum, which is the posterior wall of the omental bursa, it’s tail completely is covered by peritoneum. The tail of the pancreas passes between the layers of the pancreatosplenic ligament with the splenic vessels. The pancreatic arteries are derived from the splenic and pancreaticoduodenal superior and inferior arteries. Up to 10 branches of the splenic artery supply the body and tail (rr.pancreatici). The superior pancreaticoduodenal arteries, branches of the gastroduodenal artery, and inferior pancreaticoduodenal arteries, branches of superior mesenteric artery, supply the head of pancreas. The ligaments: lig. gastropancreaticum; lig. pyloropancreaticum; lig. pancreatolienale. Small Intestine

The small intestine extends from the pylorus to the ileocecal junction, where it joins the large intestine. Clinicaly the intraperitoneal part is called the small 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 .

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 . 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 horizontally and to the left from midline, whereas most of the ileum vertically and to the right from the midline. It is located in the mesogastrium and hypogastrium. The terminal part of the ileum is usually in the 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 mesentery (about 15 cm long) is directed obliquely, inferiorly, and to the right from the left side of L2 vertebra to the right sacroiliac . The root of the mesentery is projected by oblique line from the apex of the left axillary cavity to the midpoint of the right inguinal ligament. Anteriorly the small intestine faces to the and anterior abdominal wall, posteriorly – to the VCI, abdominal aorta, kidneys, part of the duodenum, superiorly – to the transverse mesocolon, inferiorly posteriorly – for both sexes is situated the sigmoid colon and rectum, inferiorly anteriorly for males – the urinary bladder, for females – the urinary bladder and uterus. The length of the root of mesentery at the beginning and ending is 1-2cm, at the central part is 20-25cm. By point of attachment of the mesenterium in clinic can be found the proximal and distal ends of the intestine.

The superior mesenteric artery (arise at L1 level from aorta) 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 (till 5th order), 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. The superior mesenteric vein drains into the portal vein.

Large Intestine

The large intestine consists of the cecum, ascending, transverse, descending, sigmoid colons, rectum. The large intestine can be distinguished from the small intestine by • Three thickened bands of longitudinally directed muscles called teniae coli (libera, mesocolica, omentalis) • 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) • Lumen of the large intestine is more in diameter, than the lumen of the small intestine On the rectum these featers are absent. 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 and is projected in the right inguinal region. Usually it is almost entirely enveloped by peritoneum and can be lifted freely, but the cecum does not have a mesentery, the has mesoappendix, where is located the . 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. The appendix begins from the point of connection of the tenias and it’s base is projected by McBurney’s point, which is located at the border between the lateral and middle thirds of the projectional line from anterior, superior iliac spine to the umbilicus.

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. Concern with it’s long mesoappendix can be following positions: Descending or pelvic position – to the true pelvic cavity. Mobile appendix – during which the ascending colon has also an intraperitoneal situation as in fetal life and appendix can situated under the liver, in the mesogastrium, even in the left iliac fossa. If the mesoappendix is shorter the positions of the vermiform process are follows: Anterior (antecaecal) Medial – when appendix is in the lower ileocaecal recessus, Lateral – when appendix is in the right abdominal canal, Retrocecal and retroperitoneal - when appendix is in the retrocecal recessus. The base of the appendix lies on the inferomedial surface of the dome of the cecum where the three teniae are connected (at the end of the tenia libera) or in the lower ileocaecal recessus.

Colon

The ascending colon 18-20cm passes superiorly from the cecum in the lateral right abdominal region, close to the midline, then the descending colon. It is projected by the transverse processes of the lumbar vertebras.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, posteriorly is covered by Toldi’s fascia (remnant of the fetal peritoneum). Same structure has the descending colon. 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 (anteriorly). Posteriorly from it is the paracolon and part of the right kidney. The transverse colon 23-25cm 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 right colic flexure is in the right hypochondriac region, the left colic flexure is in the left hypochondriac region, the transverse colon is in the umbilical region. The transverse colon is projected by the bicostal line. The left colic flexure lies on the inferior part of the left kidney and 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. The right colic flexure is faced to the visceral surface of the liver, gallbladder fundus and posteriorly to the right kidney. The transverse colon is faced from right to left superiorly to the liver, gallbladder, greater curvature of the stomach, spleen; Inferiorly to the small intestine; Anteriorly to the anterior abdominal wall; Posteriorly to the duodenum, pancreatic head, which are separated by the mesocolon and parietal peritoneum. The left colic flexure is faced to the spleen, posteriorly to the left kidney, which is separated by the parietal peritoneum and connective tissue. The descending colon 20-23cm in the lateral left abdominal region, 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, posteriorly is covered by Toldi’s fascia (remnant of the fetal peritoneum). 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. Anteriorly is faced to the anterior abdominal wall and coils of small intestine. Posteriorly from it is the paracolon and part of the left kidney. The sigmoid colon, an S-shaped loop that is variable in length, links the descending colon and rectum. It is in the left inguinal region, can enter the pubic region. 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, crosses the left iliac vessels, testicular (ovaric) artery, left ureter. The sigmoid colon is faced to the m. and left external iliac vessels posteriorly. Anteriorly if it is empty – to the small intestine, when expanded – to the anterior abdominal wall.

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. It has pelvic and perineal parts. Superiorly from the pelvic diaphragm the pelvic part is delated to form the ampulla and supraampular part. The dilated rectal ampulla supports and holds the fecal mass before it is expelled during defecation. Peritoneum covers the sides of the superior third of the rectum intraperitonealy, the mesoperitonealy in the middle third, and extraperitonealy in the inferior third at the level of S4-5 vertebra. The extraperitoneal part of it is covered by the visceral fascia. In males the rectum faced to the posterior wall of the bladder, seminal vesicles, ampull of the ductus deferens, prostate, ureters. In females the rectum faced to the posterior wall of the vagina and uterus. Posteriorly from the rectum is the sacrum and coccyx and retreorectal space, where the medial and lateral sacral arteries are present, venous plexus, sympathetic nerves, sacral lymph nodes. Vessels. The colon is supplied by the superior and inferior mesenteric artery. Arteries run in the retroperitoneal space. The superior mesenteric artery gives off: The ; The ; The . The caecum, the appendix (appendicular artery) and end part of the ileum are supplied by the ileocolic artery. The right colic artery supply to the ascending colon and right colic flexure, subdivided into the ascending and descending branches, which anastomosis with the ileocolic artery and middle colic artery. The middle colic artery supply right the ascending colon and 2/3 of the transverse colon, the left 1/3 receives blood from the left colic (a branch of the inferior mesenteric artery) arteries. The middle colic artery subdivided into the right branch anastomosis with the ascending branch of the right colic artery and left branch anastomosis with the ascending branch of the . Here is formed anstomosis between superior and inferior mesenteric arteries which is colled Riolani’s arch. The inferior mesenteric artery gives off: The left colic artery; The sigmoid artery; The superior rectal artery. The left colic artery to the descending colon and transverse colon, subdivided into the ascending and descending branches, which anastomosis with the middle colic artery and sigmoid artery. The sigmoid arteries, (2-4) descend obliquely to the left where they divide into ascending and descending branches that supply the sigmoid colon and anastomosis with left colic artery and superior rectal artery. The superior rectal artery, the continuation of the inferior mesenteric artery, supplies the proximal part of the rectum. The 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 branch of internal pudental artery from ). In the wall thickness are formed the submucosal, subfascial and subcutaneal venous plexuses. The submucosal veins drain into the subfascial venous plexus, from which form the superior and middle rectal veins. Superior rectal vein drain into the portal system through the inferior mesenteric vein, middle rectal veins drain into the internal iliac vein, so is present the porto-caval anastomosis. From the subcutaneal venous plexus blood flows into the inferior rectal vein, into the internal pudental vein. The superior mesenteric vein drain the veins of the jejunum and ileum, the gastroepiploic right vein, inferior pancreatoduodenal vein. Corresponding veins form the inferior mesenteric vein. Innervation is the vegetative by the superior and inferior mesenteric plexuses. Surgical anatomy of the retroperitoneal space. Fatty tissues, its connections & way of spreading pathological fluid. Boundaries: it is situated between posterior abdominal wall covered by endoabdominal fascia and parietal layer of peritoneum. 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 and retroperitonealis, 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 (lateral cellular tissue of the pelvis); 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 – so called paraureteron. The first part is isolated, whereas two others (middle and inferior) are connected with each other and with fatty tissues of pelvic cavity. 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, f. praeureterica and retroperitonealis- 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 of diagnostic and treating measures such as paranephral novocaine blockade.

Surgical anatomy of the pelvis. Fasciae and cellular spaces.

Boundaries: Superiorly- Inferiorly-skin of perineum Laterally-hip bones, muscles and ligaments of the pelvis Pelvic cavity is divided into 3 floors 1. Cavum Pelvis Peritoneale-the region, which is situated below the linea terminalis (limited superiorly) covered by the peritoneum (limited inferiorly).Parts of the rectum, uterus uterine appendages, prostate, seminal vesicles, urinary bladder which are covered by peritoneum, are situated here. In this region we describe Vesicorectal excavation in men. (the lowest point of the abdominal cavity) Rectouterine excavation in women(fossa of Douglas) and vesicouterine excavation. Vesicorectal excavation in men and rectouterine excavation in women are the lowest points of the abdominal cavity , where the pathologic liquid can be accumulated. 2. Cavum pelvis subperitoneale-the region which is situated between the peritoneum superiorly and pelvic fascia inferiorly (covers pelvic diaphragm).Here, in this region we describe the parts of pelvic organs, which are not covered by the peritoneum. Here pelvic fascia is described which is the continuation of endoabdominal fascia. Pelvic fascia has visceral and parietal layers. The visceral layer covers the organs, the parietal-the walls of the pelvis.Between these two layers the loose tissue is located, which surrounds the organs.In the thickness of the loose connective tissue pass vessels and nerves. Along the course of the vessels and nerves the pathologic processes can spread into different regions, both to pelvic organs and to adjacent regions such as retroperitoneal space, gluteal region, anterior and medial regions of the thigh.Although the loose connective tissue surrounds the organs from all the sides, the are places, where the connective tissue is well developed and can be the place of accumulatig of pathologic liquid.According to this statement the following spaces are distinguished

1.Spatium retropubicum or prevesicale-situated between the anterior wall of the urinary bladder and pubic symphysis. Pathologic processes along the course of the ureter can spread into the retroperitoneal space and onto the anterior abdominal wall till the navel(umbilicus) along the pelvic fascia. 2. Parametrium- pathologic processes spread along the course of the vessels and ligaments of the uterus and its appendages into the retroperitoneal space, gluteal region, up until the anterior abdominal wall. ( through the inguinal canal). 3.Spatium retrorectale- bounded by the capsule of the rectum anteriorly and by the anterior surface of th sacrum posteriorly. 4. Spatium lateralia dextrum et sinistrum. 3. Cavum pelvis subcutanea (fossa ischiorectalis) –bordered superiorly by the pelvic fascia (covers pelvic diaphragm), inferiorly- by the skin of perineum.

Operative surgery & topographical anatomy of the lower extremity. The structural peculiarities of the different regions of the lower limb in cross section

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 subinguinalis • Regio glutea • Regg. femoris anterior et posterior • Regg. genu anterior et posterior • Regg. cruris anterior et posterior • Regg. articulationis talocruralis anterior, posterior, lateralis et medialis • Regio dorsi pedis • Regio plantae pedis

The subinguinal region Is bounded by the inguinal ligament, the superior pubic branch and iliac wing (ala osis ilii). Muscular and vessel lacunae (lacunae musculorum et vasorum) are formed under the inguinal ligament which are separated from each other by (arcus iliopectineus) .It is the thickened medial part of the 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 (lig. lacunare s. Gimbernati), inferiorly and posteriorly- by (lig. pectineale Cooperi) which is the thickened part of the periosteum of the pubic bone. and vein, femoral branch of genitofemoral nerve 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 ). Femoral artery and vein are covered by the sheath (vagina vasorum femoralium). Here also femoral hernias can pass which form the . It is the deep ring of the femoral canal. 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 (fascia cribrosa interna BNA). Innerly from which is located the preperitoneal fatty tissue(Langenbeck’s) and parietal peritoneum. These three will be the layers of the annulus femoralis profundus. Femoral Canal (Canalis femoralis) 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 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 with 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 externa). 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. Cornu superius fuses with the lig.lacunare, cornu inferius fuses with the lig.pectineale. The anterior wall is the superficial layer of the broad fascia, 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. Deep ring was described. Subcutaneous or superficial ring of the femoral canal is hiatus saphenus. The last one is also covered by a cribriform sheet of (fascia cribrosa externa ).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. The hernial sac is covered by the skin, subcutaneous fat, fascia cribrosa externa, loose connective tissue, fascia cribrosa interna (f.transversa), preperitoneal fatty tissue and the sac is fomed by parietal peritoneum. In about 20-28% of people an inlarged pubic branch of the inferior epigastric artery takes the place of the 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 medialy, by femoral vein- laterally and the epigastric inferior artery- superiorly. 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.

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 , 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 . 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 superficial 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 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 and posterior skin nerve of the thigh also pass through the infrapiriform foramen (all the nerves are from the ). The branches of the (a. glutea superior) pass through the thickness of the piriform muscle where they make anastamoses with the branches of the . 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. 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; posteriorly – gluteal fold, laterally-the line between the above mentioned spine and the major trochanter. By 2 lines the thigh is separated into anterior and posterior regions; 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 2 transverse fingers 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, anterior femoral groove 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 joint and is abducted laterally ( the Quain’s line). By the same line but in normal anatomical position of limb is projected the v.saphena magna. Layers. The skin is thin and fine, movable medialy, thicker lateraly. The superficial fascia is subdivided the subcutaneous fat into superficial and deep layers. There are blood vessels, lymph nodes and skin nerves are in deep 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 magna drains into it.The skin is innervated by the femoral branch of the genitofemoral nerve (r. femoralis n. genitofemoralis), n. ilioinguinalis, n.iliohypogastricus (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 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. 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. Lateraly from v. saphena magna there are branches of the , medialy from the vein - branches of the obturator nerve. The superficial lymph nodes are arranged into superior (inguinal) and inferior (subinguinal) groups.The inguinal group collect lymph from anterior abdominal wall, inferior to umbilicus, from the external genital organs, perineum, from the gluteal region, lumbar region. The subinguinal group collect lymph from lower limb, which lie along the femoral vein. Then lymph drains into external iliac lymph nodes (nodi lymphatici iliaci externi). Broad fascia (fascia lata) is thick enough on the lateral surface of the thigh where it forms iliotibial tract ( tractus iliotibialis) with tendons of the m.tensor fascia lata and m.gluteus maximus. It stretches from the anterior superior iliac spine to the Gerdy’s tuberosity of the lateral tibial epicondile. On the transverse section 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; the posterius intermusculare septa does not attach to 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 in whole length, which consists of 4 parts: m. rectus femoris, m.m. vastus medialis, lateralis et intermedius; and only in superior 1/3 m.iliopsoas. The anterior compartment is bounded by the femur, proper fascia, septa intermusculare femoris laterale et mediale. In the medial compartment m. pectineus, adductor longus, adductor brevis, m. adductor magnus,m. gracilis lie; m. pectineus only in superior 1/3 present, in inferior 1/3 the m. adductor brevis is absent. The medial compartment is bounded by the femur, proper fascia, septa intermusculare femoris posterior et mediale. The posterior compartment is occupied by the flexors of the leg and is bounded by the femur, proper fascia, septa intermusculare femoris posterior et laterale. There are medial, lateral, posterior interfascial spaces on the thigh. The main neuro-vascular bundle of the thigh is in the medial interfascial space. In the lateral, posterior interfascial spaces there are the fatty tissues. Two muscular sheaths (interfascial spaces) are also formed for the superficial muscles: m.m. sartorius, tensor fasciae latae. The medial interfascial space is presented in the superior 1/3 by the , medial 1/3 – by the anterior femoral sulcus, inferior 1/3 – by the . The anterior, medial osteofascial compartments, medial, lateral interfascial spaces, muscular sheath of m. sartorius are in the anterior thigh region; the posterior osteofascial compartment and posterior interfascial space are in the posterior thigh region. An obturator canal is an oblique canal, directed from the superiolateral to infero- 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. 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. 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 . The superficial layer passes in front of the femoral vessels with skin, subcutaneous fat, superficial fascia and superiorly fuses with the inguinal ligament. 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 externa). 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 septum femorale s. Gloquet of the proper fascia. 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. The longest skin branch –n. saphenus, continues its way inferiorly with the femoral 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, at the apex of femoral triangle it passes back from femoral vein. 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 inferior arteries. The descending one anastamoses with the branches of the obturator arteries. A. circumflexa femoris lateralis is thicker and extends from the deep femoral artery 1.5-2 cm below its origin. It is also divided into ascending and descending branches. R. ascendens makes anastomoses with the gluteal arteries in the trochanteric network (rete trochanterica), whereas r. descendens extends inferiorly to the rete genu. In the medial 1/3 the deep femoral artery gives off 2-4 perforating branches (r.r. perforantes). The femoral anterior sulcus It is the medial interfascial space in the middle 1/3 of thigh. Inferiorly the vessels pass from the femoral triangle into the femoral groove (sulcus femoris anterior), which is located between adductor longus medialy and vastus medialis muscles lateraly. The stretches from the apex of triangle till the entrance of adductor canal. In this groove the deep femoral artery is covered by the femoral vessels and . 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.

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). It is musculo- fibrous canal, 5-6 cm length. 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 longus 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 . The anterior opening is in lamina vastoadductoria, through which descending artery and vein of the knee (a.v. genu descendens) and n. saphenus exit in anteromedial region of knee. 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 from it, n.saphenus – in front and laterally from artery. Posterior Femoral Region (Regio femoris posterior) Boundaries: superiorly is the transverse gluteal fold (plica glutea), inferiorly-continuation of the circular line 2 transverse fingers 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 tuber and greater trochanter to the superior angle of the popliteal fossa. Layers. The skin is thick and blended with the subcutaneous connective tissue, it is covered by hair. N.cutaneus femoris posterior appears in the connective tissue of the thigh. 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, pelvic cavity and with popliteal fossa along the sciatic nerve; with anterior femoral compartment through the and a. circumflexa femoris medialis. All the muscles of the posterior osteo-fascial compartment begin from tuber ischiadicum. Laterally 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 : semitendinosus, semimembranosus, biceps femoris. They span the hip and knee 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). injuries often result from inadequate warming up before competition. In the superior and middle thirds the muscles pass closely, in inferior 1/3 they separate and are bounded the superior angle of popliteal fossa. The sciatic nerve descends from the gluteal region into the posterior region of the thigh. Usually it is separated into tibial and peroneal common nerves in the superior angle of the popliteal fossa, 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, from a.glutea inferior. 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, laterally from the m.biceps femoris tendon, in the middle third it is covered by the long head of , and in the inferior third- between biceps femoris and semimembranosus muscles in the groove (sulcus femoralis posterior).

Knee (Genu) Boundaries: superiorly is a circular line 2 transverse fingers 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: • bursa prepatellaris subcutanea- in front of patella • bursa infrapatellaris subcutanea - in front of tuberositas tibiae • bursa m. semimembranosi- coincides with medial condyle of femur, on the tendon of m. semimembranosi ( ”rider’s” bursa). Superficial fascia is a thin layer. Under the proper fascia and tendon bursae lie: • bursa prepatellaris subfascialis • bursa prepatellaris subtendinea, between the tendon and patella. • bursa suprapatellaris-communicates with the knee joint, under the tendon of the quadriceps femoris lies. • bursa infrapatellaris profunda - between the lig.patellae and tuberosity of , does not communicate with the knee joint.

Proper fascia is the continuation of the broad fascia. It is straightened by the tractus iliotibialis and by the pes anserinus major. The tendon of the quadriceps muscle encloses patella and is attached to the tuberositas tibiae by the lig. patellae. 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. In anterior knee region there are the tendons of the quadriceps, sartorius, gracilis, semimembranosus, semitendinosus muscles. Under the retinaculum patellae mediale there are the tendons of the sartorius, gracilis, semimembranosus, semitendinosus muscles, which form the pes anserinus major and attach to the tibial tuberosity. Under the retinaculum patellae laterallae there is the tendon of the bicers muscle. An arterial network appears on the anterior surface 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 – five arteries are from the ; a.a.reccurentes tibiales anterior et posterior-branches of the anterior tibial artery; a. circumflexus fibulae- branch of the .

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 v. saphena parva ascends, which drains into v. poplitea, v.saphena magna medialy. Superficial lymph nodes lie here. N. saphenus, n. cutaneus surae lateralis (n. peroneus communis) and branches of n. cutaneus femoris posterior innervate the skin.The thin superficial fascia. 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 are bounded superior and inferior triangles of the popliteal fossa; posteriorly (roof) –by fascia; anteriorly (floor) –by the popliteal surface of the femur (planum popliteum), the oblique popliteal ligament and the . 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 angle 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 (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 under the biceps femoris tendon and 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 (anterior region of thigh), along the popliteal vessels and tibial nerve- with the deep space of the posterior region of the leg, cruropopliteal canal. Popliteal flegmons tend to spread superiorly and inferiorly because of this communications and toughness of the popliteal fascia.

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 margin of the tibia and the other- lateral malleolus with the head of the fibula (by groove between peroneus and soleus muscles), 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 inferior third laterally. Subcutaneous tissue poorly present. The thin superficial fascia. 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. In the superior third only long peroneal muscle is present, where the canalis musculoperoneus superior is formed. 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 osteofascial compartment laterally to the vessels, then in the inferior third -anteriorly and medially to them and continuous to the dorsal surface of the foot. 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, before that gives off the n.cutaneus surae lateralis to the lateral skin of leg. 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 lateral 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 (extensors of leg) 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 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 anterior, posterior extends from a. tibialis anterior. The artery forms anastomoses with above mention knee arteries. A.a. malleolares anteriores medialis et lateralis extend from a. tibialis anterior in the inferior third of the leg anastomoses with a. malleolares from a. tibialis posterior and a.peronea.

Posterior Region of the Leg (Regio cruris posterior) Projection of the posterior tibial artery is a line which passes from inferior angle of rhomboid fossa superiorly to the midpoint of the distance between medial malleolus and Achilles tendon. Layers. The skin is thick. In subcutaneous tissue the trunk of v. saphena parva is formed which ascends curving around the lateral malleolus in inferior third of leg. In the middle third of the leg it pierces the proper fascia lying between its sheets (Pirogov’s canal), then in superior third enters the space between two heads of the gastrocnemius. Here it lies under the fascia. 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 third of the leg it forms n. suralis, after connecting with n. cutaneus surae medialis, from n.tibialis. N. suralis is accompanied the v. saphena parva in inferior third of leg. The superficial fascia is thin layer. 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 fibrous capsule: m.m. gastrocnemius, soleus et plantaris. They form a common tendon in inferior third of leg for insertion into the calcaneus called the calcaneal or Achilles tendon (tendo calcaneus s. Achillis). Between the calcaneus and tendon there is a bursa Achilii. The two –headed gastrocnemius and soleus form together m.triceps surae. This muscle plantar flexes the ancle joint. M. plantaris is usually small and may be absent. Three muscles comprise the deep group in the posterior osteofibrous compartment of the leg: m.m, flexor hallucis longus, flexor digitorum longus, tibialis posterior. The tendons of three muscles pass through the maleollar canal. 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 vessels and n.tibialis appear from the medial margin of m.soleus, then lie between the m. flexor hallucis longus and m. flexor digitorum longus. 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 in the maleolar canal, where separated into terminal medial and lateral plantar branches. 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 longus and pass along the lateral border of the calcaneal tendon.On the level of the malleolus a communicating branch (r.maleolaris) extends from the peroneal artery 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. 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 in the maleolar canal 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 cruropopliteal canal communicats with popliteal fossa, the anterior osteofibrous compartment and maleolar canal.

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 anteriorly to the lateral malleolus, where it separated into the nn.cutaneus dorsalis pedis medialis et intermedius. The superficial fascia is thin. 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 and medial cuneiform 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. tibialis anterior, accompanied with veins and n. peroneus profundus, passes in the canal of the m. extensor hallucis longus 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 proper fascia and is formed by branches of posterior tibial and peroneal arteries. 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. The superficial fascia is thin. Proper fascia stretches between medial malleolus and calcaneus, forming retinaculum musculorum flexorum (lig. lacinatum). The space between calcaneus, medial malleolus and the above mentioned retinaculum is called canalis malleolaris. By fibrous septas the space is separated into three canals. 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). A. tibialis posterior with two veins, n. tibialis together pass between the tendons of the long flexors of the toes and hallux to the plantar surface of the foot. The canalis malleolaris communicats with the cruropopliteal canal and middle connective plantar space of foot. 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 superficial fascia is thin. 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. A.peronea is posteriorly from the muscles tendons, gives off the rr.calcanei, perforantes, malleolaris, then anastomosis with the a.dorsalis pedis and participates in formation of the dorsal arterial network of foot. Also forming the lateral maleolar and calcaneal network.