TOPIC № 1. THE SUBJECT OPERATIVE SURGERY. THE MAIN PRINCIPLES OF OPERATIONS. THE STAGES, NAMES AND CLASSIFICATION OF OPERATIONS.

- The subject operative surgery. Operative surgery is a science about general principles and technical of operations. The goals of this subject are: • To learn the principles of surgical treatment in dependence of the pathology and the disorders of the function. • To master operative technique and at the first the methods of disconnection and connection of the different tissues, temporary and finally hemostasis. • To master of the technical of the typical, especially urgent operations. • To understand the causes of the possible complications due to mistakes committed during patients’ management and stem operative treatment. The surgical operation is technical/instrumental intervention on the patient’s organs/ tissues, which is carried out by doctor in order to treatment, diagnostic or reconstruction of the organ function. It is carried out mainly by incision and different methods of the connection of the tissues. - The main operation principles. The surgeon carried out the operation must aim at patient’s life preservation and be influenced by following main points: 1. Anatomical accession 2. Technical possibility 3. Physiological permission Anatomical accession. Non each organ or formation can be easy accessible for carrying out of operation. Anatomical accession may be different. There are easy accessible organs (stomach, liver, bowel) and difficult accessible organs (esophagus, posterior mediastinum). Sometimes the operation may be non carried out due to impossibility for penetrating to the organ (base of the skull).

Technical possibility. The many operations become possible there, where earlier were impossible. Due to developing of the science the hard operations of the heart and magisterial vessels excluding of the heart from blood circulation become possible. Using of the different equipment (heart-lung apparatus, US-generators, monitors, ect.) enlarges the diapason of the surgical interventions.

Physiological permission. So that the first aim of the operation is the preservation of patient’s life, in some cases the organ function must be kept. For example, the operations on the pancreas are anatomically accessible, technically easy, but it must be solely carried out spared, in order to preservation its functional ability. This rule may be taken to other organs, from which patient’s health and life depend. Technically carrying out total pancreatectomy is not difficult, but patient’s surviving in this case is impossible. The main principle of these cases is radical removing of the pathologic hearth and maximally to keep of organ function.

Stages of operation: 1. Operative access (start of operation) 2. Operative way (operative technique) 3. Going out from operation Operative access is first stage of the surgical intervention, which provides maximal mobilization of the operated organ. It must be rational so as provide maximal mobilization and visualization of the organ, which allows surgeon to carry out operative technique and minimally to damage that organs and tissues, from which operative access is carried out. Operative access is not specific for each operation. Through same access different surgical interventions are possible to carry out. For example, through middle-line laparotomy we can operate on stomach, duodenum, liver, gallbladder, small and large bowel. It is very important to choice the most rational access, because technical possibility of the operation and its result depend from it. Approximately 500 accesses were proposed for laparotomy; however the surgeons usually use 10-12 typical incisions, sometimes with its some modifications. Besides free possibility to operate on the organ, the surgeon has to remember about negative consequences, which may develop due to major traumatic incisions (postoperative hernias may be more suffering than the primary pathology). Incorrect operative access may develop such complications as rupture or incarceration of the nerves or vessels, atrophy of the muscles, incorrect adhesion of the ribs. Thus, the demands to operative access are small traumatism and maximal accession to the object. The operative access naturally may not be same for every case. Pathologic condition, size, localization and form of the organ in considerable degree have influence on the kind of the access and the size of the incision. Patient’s age, constitution, peculiarity of the region when operative intervention is carried out have essential meaning too. Marked above demands surgeon to analyze and learn used operative accesses. Sometimes the access may be changed during operation in dependence on character and extension of the pathologic process, which was determined after revision of operative field. Operative way or technique is a second stage of the surgical intervention, which is specific for given operation and determines the details of the operative intervention (cholecystectomy, partial gastrectomy, appendectomy ect.). The same operation may be carried out by different accesses. For example, cholecystectomy may be carried out by middle-line laparotomy, oblique incision by Kocher, or laparoscopy. The operative way depends on patient’s general condition, kind of the disease and surgical anatomy of the affected organs and tissues. Going out from operation is a third stage of the surgical intervention, during which the surgeon must restore the completeness of the tissues disturbed by operative access. Going out may include either complete (hermetically) restoration of the tissue completeness with operative region drainage or seldom tamponage by dressing materials. - The title of the operation. For term formation marked the title of the operation two components are used. The first is organ which must be operated, and second is operative way technique (partial gastrectomy, appendectomy, resection of thyroid gland, thoracotomy ect.). In the medical, especially surgical literature the Greek or Latin terms are usually used. The most common terms are: tomy – opening, stomy – fistula formation, ectomy – complete removing, resection – partial removing, amputation – removing of the peripheral part of the limb or organ ect (tracheostomy – formation of the fistula on trachea; appendectomy – removing of appendix; partial gastrectomy – removing of the part of the stomach).

Classification of operations. Classification of surgical operations depends on character, aim and other factors may be put in its basis. I. The whole surgical operations are divided into two big groups: bloody and non-bloody. Second group includes comparison of the bony splinters in case of fracture with ostectopy, setting a bone, urinary bladder catheterization, laryngoscopy. All other operations belong to the first group. II. In dependence of developing of the possible complications carrying out the operations of the first group are divided into two groups: major and minor. The major are these operations, during which the complications, including mortal result, may develop. The minor operations have minimal risk of complications and named ambulatory. III. In dependence of the aim the operations may be curative and diagnostic. IV. In dependence of the character of carried out operations they may be radical and palliative. If during operation complete removing or liquidation of pathologic process don’t turn out, and patient’s suffering only is relieved or the life is saved, these operations are named palliative. V. By time of carrying out and indications the operations are divided into urgent, pressing and planned. Between the time of urgent operation and possibility of developing of the complications (including mortal result) the direct proportional communication presents. Differently, as the time lost before operation bigger, then the developing of the complications is more possible. In case of planned operations the developing of the complications doesn’t depend on the time of its carrying out, so that the operation may be carried out at any time. Pressing is the right urgent operations put off on short time, which is necessary for patient’s pre-operative management (6-24 hours). VI. The surgical interventions may be primary and recurring. The primaries are theese operations, which are carried out in case of establishment of the diagnosis. The operations, which are carried out repeatedly due to continuation of the principal disease of developed complication, are named recurring (for example, laparotomy/relaparotomy with the patient with continued peritonitis after appendectomy). VII. Those operations which aim is reconstruction of the lost function or anatomy of this or another organ are named plastic or reconstructive. This group includes also organ transplantation. VIII. Operations which demands special optic equipment are named microsurgical. IX. If the second stage of operation - the operative technics, follows directly the first stage (operative access), operation is called as single-step and if between operative access and a method there is a certain time, the operation is called as double-step. Can be three, four …and many-steps operations. X. Operations which are carried out by special endoscopes (laparo-, thoraco-, arthro- scopes) are named endoscopic.

TOPIC № 2. BASIC PRINCIPLES OF CONNECTING AND DISCONNECTING TISSUES. Ligature and Suture Materials. Surgical Sutures.

The first phase of the surgical operation, the surgical approach or access consists of disconnecting tissues for the mobilization of the organ which is aimed at performing the second phase of the operation, the operative procedure. Thus, one of the most important components of the surgical operation is the disconnection of tissues. The size of the incision performed for the disconnection of tissues, its depth and direction are conditioned by the character and localization of pathological process and its prevalence. In spite of it there are a number of general principles which are permanent and obligatory during the disconnection of tissues performed during operations. The general principles (requirements) of disconnecting tissues are the following: 1. Tissues must be strongly disconnected layer by layer. 2. The length of the incision must be the same in all the layers. 3. The direction of the incision of each layer is, as a rule, dictated by the location and direction of the main vessels and nerves of the given region. 4. The size (length) of the incision must follow the principle of “necessary sufficiency”. 5. The form of the incision must be as a rule maximally simple and its edges must be strictly linear. 6. The length of the incision must be more than its depth.

General Principles of Connecting Tissues. When connecting tissues certain rules must be followed. The general principles (requirements) of disconnecting tissues are the following: 1. Tissues must be connected layer by layer. 2. Only homogeneous tissues can be connected to each other. 3. The connection of tissues must be firm and strong. 4. When suturing the wound the ''suture step'' must be of the same constant size for the given layer. 5. The points where the needle goes in and comes out should be at an equal distance from the edges of the wound. 6. The line connecting the points of the needle must be perpendicular to the direction of the wound.

Surgical Sutures. Ligature and Suture Materials. Every surgical procedure has a stage of repairing (re-approximating) the tissues. The most widely used method of repairing the tissues nowadays is suturing (sewing) with suture materials. Suture materials are foreign bodies that are required to keep the wound edges together, until they hold sufficiently well by themselves by natural fibres (collagen), to form a strong scar. Any suture material should correspond to strict specific requirements, such as very little reactivity (inertness), ability of biological degradation (absorption), minimal traumaticity, and tensile strength. Very little reactivity (biological compatibility, inertness) means that reaction of tissues of the organism to suture material is minimal. The best suture material results in less reaction in tissues, and also has non-toxic, non-allergenic, non-oncogenic properties. Non-absorbable, monofilament sutures are more inert, than absorbable, braided sutures. Ability to be absorbed and terms of absorption of suture material are important – suture material should be absorbed much later, than scar has been formed. If scar of the fascia is formed on 21st day, but the suture material is absorbed on 14th day, edges of the wound may detach (the wound may break open) after absorption of the suture. Less traumaticity means absence of damage of the tissues when the suture passes through the tissues, or is lodged within the tissues. Less traumatic or non-traumatic sutures are elastic, best handling, and flexible materials with smooth surface, with non- traumatic needles. Tensile strength of a thread defines the diameter of the thread that should be used to obtain a strong scar after wound closure. It should be remembered that suture material loses about 10-50% of its tensile strength at the knot. Classification of suture materials: 1.Absorbable sutures 2.Non-absorbable suture 3.Monofilament sutures 4.Polyfilament sutures Surgical sutures are basic method of connection of the tissues. The are some important principles of the suturing: careful tissue handling, suturing together only tissues of the same type, good approximation of the layers. Suture types 1. Interrupted suture. It can be used for the skin suturing, and it is the oldest type of skin suture. A cutting needle is used for the skin. The distance between the wound edge and the thread should be about 0.5-1 cm, perpendicular to direction of the wound. The distance between stitches is 1.5-2 cm. o tight and closely placed sutures result in ischemia and delay healing, rare stitches prevent adaptation of wound margins. Knots are located laterally from the wound edges. Stitches are removed in 5-7 days. It is very important to prevent dead space formation in any wound and collection of fluid there. In presence of dead space in a wound drainage is used. 2, Continuous sutures, for example cosmetic subcuticular continuous suture (running suture) is often used, it provides good cosmetic effect due to proper adaptation of wound margins and less impede of blood supply. It is a continuous suture picking up alternate sides of the wound just beneath the surface. In cosmetic continuous suture preferable is use of monofilament materials. Commonly used are absorbable sutures Biosin, Monocryl, Polysorb, Dexon, Vikryl, non-absorbable sutures Nylon and Polypropylene.

Surgical knots. Setting of knots is one of the basic elements of any operation. The principal views of knots are: 1,Simple female knot 2.The sea knot 3.The double surgical knot

Topographical anatomy & operative surgery of the head. Topographical pecularities of regions of the head and its practical importance. Main principles of surgical treatments

The boundaries and divisions. The border between the head and a neck carried out (conditionally) to the inferior margin of mandible, angle of mandible, posterior margin of the vertical process of the mandible; the anterior and posterior edges of the mastoid process, superior nuchal line (linea nuchae superior), external occipital protuberance (protuberantia occipitalis externa). Then it passes symmetrically to the opposite side. On the head distinguish cerebral and facial departments, according to the cerebral and facial skull. The border between these departments passes by supraorbital margin, superior margin of the zygomatic arch to the porus acusticus externus. All that is down and anterior to this border belongs to the facial department, which is upward and backward, refers to the cerebral department. The cerebral department is divided into calvaria (fornix cranii) and bases of skull (basis cranii). The boundary between the base of scull and calvaria is mainly passes by the horizontal plane which joins the nasion to the inion (an imaginary line that passes along the supraorbital margin - margo supraorbitalis, superior margin of the zygomatic arch - arcus zigomaticus, base of the mastoid process - processus mastoideus, upper nuchal line - linea nuchae superior to inion). The parts of the skull located above this plane belong to the calvaria; located below - to the base of skull. Calvaria areas. 1) fronto-parietal-occipital region - regio frontoparietooccipitalis; 2) Temporal region - regio temporalis.

Fronto-parieto-occipital region (regio fronto-parieto-occipitalis) The boundaries of the region are margo supraorbitalis, linea temporalis superior, linea nuchae superior till protuberantia occipitalis externa. Scalp The scalp covers the calvaria, extending from the superior nuchal lines on the occipital bone to the supraorbital margins of the frontal bone. The scalp consists of five layers of soft tissues, the first three of which are connected intimately and move as a unit. Each letter of the word scalp serves as a memory key for its layers: skin, connective tissue, aponeurosis epicranialis, loose connective tissue, and pericranium. I The skin, thick especially in the occipital region, contains many sweat and sebaceous glands and hair follicles; it has an abundant arterial supply and good venous and lymphatic drainage. The skin is fixed to the aponeurosis by dense strands of fibrous tissue which traverse the subcutaneous tissue and split it into a number of separate pockets filled with fat. II The connective tissue is a thick, richly vascularized, subcutaneous layer which is well supplied with nerves. The connective tissue includes five neuro-vascular bunches and a separate nerve Location of the neuro-vascular bunches 1. a.v.n. supratrochlearis ( frontalis ) 2. a.v.n. supraorbitalis Arteries are terminal branches of ophthalmic artery, a branch of internal carotid artery; veins begin from the forehead and descend to unite at the medial angle of the eye to form the facial vein. Veins have connection with ophthalmic vein, which drains into sinus cavernosus. Nerves are the major cutaneous branches of the ophthalmic nerve (first branch of trigeminal nerve). 3. a.v. temporalis superficialis and n.auriculo-temporalis. Artery is smaller terminal branch of external carotid artery. The superficial temporal artery emerges on the face between the temporomandibular joint and the ear and ends in the scalp by dividing into frontal and parietal branches, the vein drains the forehead and scalp and receives tributaries from the veins of the temple and face. Near the auricle, the superficial temporal vein enters the parotid gland. The retromandibular vein, formed by the union of the superficial temporal and maxillary veins, descends within the parotid gland, superficial to the external carotid artery and deep to the facial nerve. The retromandibular vein is divided into an anterior branch that unites with the facial vein and a posterior branch that joins the posterior auricular vein to form the external jugular vein. The nerve is major cutaneous branch of the mandibular nerve, which is the third branch of trigeminal nerve. 4. a.v.n. auricularis posterior. Artery is branch of external carotid artery; auricular posterior nerve is branch of facial nerve. 5. a.v. occipitalis and n.occipitalis major. Artery is a branch of external carotid artery. Vein forms external jugular vein with v. auricularis posterior. Nerve is branch of the second cervical nerve (posterior root ). 6.n. occipitalis minor is situated between the fourth and fifth bunches. It is a branch of cervical plexus. These arteries and veins of the scalp make anastomoses freely with each other and with those of the opposite side. Because of this, wounds of the scalp bleed profusely, but heal rapidly. III The aponeurosis epicranialis is a strong stringy sheet that covers the superior aspect of the calvaria; the aponeurosis is the membranous tendon of the fleshy bellies of the occipitalis and frontalis muscles (whereas the frontalis pulls the scalp anteriorly, wrinkles the forehead, and elevates the eyeblayerss, the occipitalis pulls the scalp posteriorly and wrinkles the skin on the posterior aspect of the neck). The aponeurosis consists of two layers. The deep layer attaches to the borders of the region and the superficial one continues to the neibouring regions as superficial fascia. IV The loose connective tissue is somewhat like a sponge because it has many potential spaces that may distend with fluid that results from injury or infection; this layer allows free movement of the scalp proper (first three layers, skin, connective tissue, and epicranial aponeurosis). V The pericranium, a dense layer of connective tissue, is the periosteum of the calvaria; it attaches firmly to the cranial bones, but the pericranium can be stripped fairly easily from the cranial bones of living persons, except where it is continuous with the fibrous tissue in the cranial sutures. VI The subperiostal connective tissue is situated between the pericranium and the bone. VII The bones of the head consist of three layers. The names of the external and internal layers are lamina compacta externa et interna (or vitrea) because it can be broken very easily. The name of the middle layer is lamina diploe, which contains diploic veins. VIII The cranial dura mater consists of two layers. Dural venous sinuses are situated between two layers of dura mater.

Projections of the main neurovascular bundles of the fronto-parietal-occipital region.

1. A.v. n. supratrochlearis - projected on the crosspoint between vertical line drawn through the medial angle of the orbit and supraorbital line. 2. A. v. n. supraorbitalis - projected on the border between middle and medial thirds of supraorbital line. 3. A. v. temporalis superficialis, n. auriculotemporalis - projected one transverse finger in front to the tragus of the ear on the zygomatic arch. 4. A. v. n. auricularis posterior - projected by the middle of the distancesbetween the external auditory meatus and the tip of the mastoid.process 5. A. v. occipitalis, n. occipitalis major - projected on the midpoint of the distances between the tip of the mastoid process and inion. 6. N. occipitalis minor - is projected on the tip of the mastoid process

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

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

Peculiarities of the Venous Supply The venous supply of this region consists of three levels: 1. Veins which are located in subcutaneous tissue. 2. Diploic veins. 3. Dural venous sinuses. They are connected through the emissary veins. Emissary veins don’t have any valves and blood can pass in two directions. The permanent emissary veins are: - Parietal (in fronto-parieto-occipital region, single) - Mastoid (in mastoid region, double) - Occipital (in fronto-parieto-occipital region, double) If the patient has an inflammation of scalp in area of emissary veins the infection may spread into the cranium and if the patient has a wound of the scalp in area of emissary veins profuse venous bleeding may occur. It is a negative feature. But when the patient has high intracranial pressure we can reduce it by washing the head with hot water. If the patient has headaches due to high intracranial pressure, this procedure will help him.

THE DURA MATER The cerebral dura mater (dura mater encephali), or pachymeninx, a thick whitish connective-tissue membrane, it is a outermost tunic of brain. Its external surface is in direct contact with the cranial bones for which it serves as the periosteum; this is the main feature distinguishing it from the spinal dura mater. The inner surface facing the brain is lined with endothelium and is therefore smooth and shiny. Between it and the cerebral arachnoid mater is a narrow slit-like subdural space (cavum subdurale) filled with a small amount of fluid. At places the dura mater is separated into two layers, namely, in the region of the venous sinuses (see below) and in the region of the fossa at the apex of the pyramid of the temporal bone (to form the cavum trigeminale) where the trigeminal nerve ganglion is located. The dura mater gives off several processes from its inner surface, which penetrate between the parts of the brain and separate one part from another. The falx cerebri, a large sickle-shaped process, lies sagittally between both cerebral hemispheres. On the midline of the calvaria it is attached to the margins of the sulcus sinus sagittalis superioris, its anterior narrow end grows into the crista galli, while the wide posterior end blends with the superior surface of the tentorium cerebelli. The tentorium cerebelli is a horizontally stretched plate slightly convex upward like a roof with two sloping surfaces. It is attached to the margins of the sinus sulcus transversi of the occipital bone and along the anterior side of the pyramid of the temporal bone on both sides, up to the posterior clinoid process of the sphenoid bone. The tentorium cerebelli separates the cerebral occipital lobes from the cerebellum lying below them. The falx cerebelli, a small sickle-shaped process, lies, like the falx cerebri, on the midline along the crista occipitalis interna and stretches to the foramen magnum whose sides it embraces with two limbs; this small process projects into the posterior cerebellar notch. The diaphragma sellae is a plate forming the roof over the fossa in which the hypophysis cerebri is lodged on the floor of the sella turcica. The dura mater contains several reservoirs collecting blood from the brain; these are the sinuses at the dura mater (sinus durae materis). The sinuses are venous canals (triangular on transverse section) devoid of valves and located in the thickness of the dura mater at the attachment of its processes to the skull; they differ from veins in the structure of their walls which are composed of tightly stretched layers of the dura mater and consequently do not collapse when cut and gape on being injured. The inflexibility of the walls of the venous sinuses provides free drainage of venous blood in changes of intracranial pressure; this is important for uninterrupted activity of the brain, which explains why such venous sinuses are present only in the skull. The sinuses are as follows. - The transverse sinus (sinus transversus), the largest and widest sinus which runs along the posterior margin of the tentorium cerebelli in the sulcus sinus transversi of the occipital bone. From here it descends into the sulcus sinus sigmoidei under the name of the sigmoid sinus (sinus sigmoideus), and at the jugular foramen is continuous with the orifice of the internal jugular vein. As a result, the transverse and sigmoid sinuses form the main receptacle for all the venous blood of the cranial cavity. All the other sinuses drain into it either directly or indirectly. It is projected by direction of the superior nucal line. Sigmoid sinus projected by direction of posterior margin of the mastoid process. The following sinuses drain directly into transverse sinus: - The superior sagittal sinus (sinus sagittalis superior) runs on the upper margin of falx cerebri for the whole length of sulcus sinus sagittalis superioris from crista galli to the internal occipital protuberance. It is projected by the line, which connect nasion with inion. -The inferior sagittal sinus (sinus sagittalis superior) runs on the lower margin of falx cerebri. It is projected by direction of the superior temporal line. -The occipital sinus (sinus occipitalis) is a continuation, as it were, of the superior sagittal sinus along the attachment of falx cerebelli to the internal occipital crest and then (after bifurcating) along both margins of the foramen magnum of the occipital bone. -The straight sinus (sinus rectus) runs on the line of attachment of falx cerebri to tentorium cerebelli. It receives anteriorly the inferior sagittal sinus (sinus sagittalis inferior) stretching on the free lower margin of falx cerebri and vena cerebri magna (Galeni) carrying blood from the deep parts of the brain. At the confluence of these sinuses (transverse, superior sagittal, straight, and occipital) a common expansion forms; it is called the confluence of the sinuses (confluens sinuum), or torcula herophili. -The cavernous sinus (sinus cavernosus) is located on the base of the skull lateral to the sella turcica. It has the apperance of either a venous plexus or a wide lacuna surrounding the internal carotid artery. It is connected with a similar sinus on the other side by means of two transverse communications, intercavernous sinuses (sinus intercavernosus), passing in front of and behind the hypophyseal fossa as a consequence of which a venous circle forms in the region of the sella turcica. According to certain data, the cavernous sinus is an intricate anatomical complex whose components, in addition to the sinus itself, are the internal carotid artery, the nerves and the connective tissue surrounding them. All these structures compose, as it were, a special instrument which plays an important role in regulation of the intracranial flow of venous blood. The cavernous sinus receives anteriorly the superior ophthalmic vein passing through the superior orbital fissure, as well as the inferior end of the sphenoparietal sinus (sinus sphenoparietalis) running on the margin of the ala parva. The cavernous sinus is drained of blood by two sinuses located behind it, namely the inferior and superior petrosal sinuses (sirtus petrosus superior and inferior) located in the superior and inferior petrosal sulci. Both inferior petrosal sinuses communicate by means of several venous canals which lie within the dura mater on the basal part of the occipital bone and are united under the term plexus basilaris. This plexus is connected with the venous plexuses of the vertebral canal, into which blood from the cranial cavity flows. Blood drains from the sinuses mainly into the internal jugular veins, but the sinuses are also connected with the veins of the outer surface of the skull through emissary veins (venae emissariae) transmitted through openings in the skull bones (foramen parietale, foramen mastoideum, canalis condylaris). Emissary veins are parietal, mastoid and occipital. Unpaired parietal vein connects with superior saggital sinus, mastoid veins with sigmoid sinus, occipital veins with transverse sinus. Small veins leaving the skull together with nerves through foramen ovale, foramen rotundum and canalis hypoglossi play a similar role. The diploic veins and the veins of the spongy substance of the cranial bones also drain into the sinuses of the dura mater, while their other end may be connected with the veins on the external surface of the head. The diploic veins (venae diploicae) are canals anastomosing with one another and lined by a layer of endothelium; they pass in the spongy substance of the flat cranial bones. Temporal Region (regio temporalis)

Boundaries of temporal region: • Superiorly and posteriorly–superior temporal line. • Anteriorly –superior, lateral margin of the orbit. • Inferiorly – superior border of the zygomatic arch. Layers 1. The skin- posteriorly and superiorly is thick and hairy. Anteriorly and inferiorly – thin, movable, without hair. 2. The subcutaneous fatty tissue is not well developed. 3. The superficial fascia divides the fatty tissue into two layers. A.v. temporalis superficialis and n. auriculotemporalis are situated in the deep layer. This bunch passes all over the region and is divided into two branches: frontal and parietal. One can palpate the pulsation of this artery if he (she) puts a finger on the zygomatic arch 1cm anterior to the tragus. The auriculotemporal nerve is major cutaneous branch of the mandibular nerve, which is the third branch of trigeminal nerve. The sensory nerve supply of the skin is from n. zygomatico-temporalis (maxillary division of n. trigeminus). In this layer temporal and zygomatic branches of n. facialis are situated. 4. Temporal fascia (aponeurosis) starts from linea temporalis superior. It covers the temporal muscle. Near zygomatic arch it splits into superficial and deep layers, which attach to the outer and inner borders of zygomatic arch. Fatty tissue and a.v. temporalis media (branch of a.v. temporalis superficialis) are situated between these two layers. 5. Subaponeurotic fatty tissue connects this region under zygomatic arch with infratemporal fossa in the deep facial region. So infection can spread from one region to another. Subaponeurotic fatty tissue, m. temporalis and a.v.n.temporalis profundus are situated in the temporal fossa. 6. M. temporalis begins from the linea temporalis inferior and its tendon is attached to the processus coronoideus mandibulae under the zygomatic arch. On the inner aspect of the muscle a.v.n. temporalis profundus are situated (artery is from a. maxillaris, nerve- from n. mandibularis). 7. Temporal bone (squama) – thin, diploetic layer is non well developed, the periosteum is attached to the bone, the subperiostal fat is absent, bone is fragile. a. meningea media is situated on the inner surface of the bone or in the canal inside of bone. The injury to this artery can cause epidural haematoma.

Mastoid Region (regio mastoidea)

Boundaries of this region are: • Superiorly is the line, which is the continuation of zygomatic arch. • Anteriorly and posteriorly are the margins of mastoid process.

Layers: 1. The skin is thin, without hair, not movable. 2. The subcutaneous fatty tissue includes: a.v.n. auricularis posterior (artery is a branch of external carotid artery, vein with posterior branch of retromandibular vein and occipital vein forms the external jugular vein, nerve is branch of facial nerve), n.auricularis magnus and n.occipitalis minor are branches of plexus cervicalis. 3. The superficial fascia. 4. The proper deep fascia. 5. Mastoid process of the temporal bone is covered with periosteum. Crista mastoidea is divided the region into anterior and posterior parts. In the posterior part which is called tuberositas mastoidea the tendons of the muscles are attached here – m.sternocleidomastoideus, m.splenius coli, the posterior belly of digastrics muscle. On the anterior surface of mastoid process the periosteum is not strongly attached to the bone and the trepanation triangle is described by Shipoult. The boundaries of this triangle are: anteriorly - suprameatic spine or the posterior margin of the auricle, superiorly it coincides with the superior boundary of this region, posteriorly- crista mastoidea. Mastoid air-cells (cellulae mastoideae) are situated in the thickness of the bone inside the boundaries of above mentioned triangle. The largest cellula of the mastoid process, antrum mastoideum, is connected with cavum tympany through aditus ad antrum. Cavum tympany is connected with nasopharynx through the tuba auditiva. By this way infection can spread from the pharynx to the cavum tympany and antrum mastoideum and acute supurative mastoiditis may develop. During antrotomy we can hurt the following structures if we go out of the boundaries of trepanation triangle: superiorly – brain in the middle cranial fossa, anteroirly – facial nerve in its canal, posteroirly – sigmoid sinus. The auditive tube is shorter, wider and has a horizontal direction for children, for adults it has an oblique, vertical position. This has a greater importance for spreading infection from the nasophanynx to the middle ear.

Krenlein’s Diagram This diagram is used for projecting important structures in the cranial cavity and is necessary for exact access to them. The following lines are used for making the diagram: • linea sagittalis -- connects the midpoint of glabella(nasion) with protuberantia occipitalis externa (inion). • linea auriculoorbitalis –inferior horizontal line -- connects margo infraorbitalis with margo superior of the porus acusticus externus. • linea supraorbitalis- superior horizontal line -- passes parallelly to first one through margo supraorbitalis. Three vertical lines are made also: 1. linea zygomatica-anterior vertical line -- passes perpendicularly to horizontal lines through the midpoint of the zygomatic arch. 2. linea articulationes-middle vertical line -- passes parallelly to first one through processus articulationes os mandibulae. 3. linea mastoidea –posterior vertical line -- is parallel to first and second and passes through the posterior margin of the base of mastoid process. By this diagram a. meningea media is projected. • Main trunk is projected in the crossing point of first(anterior) vertical line with first(inferior) horizontal line. • Anterior branch (r. anterior s.frontalis) is projected in the cross-point of the first vertical line with second (superior) horizontal line. • Posterior branch (r. posterior s. parietalis)- in the cross-point of the third(posterior) vertical and superior horizontal lines. Sulcus centralis (Rolandi) is projected by a line connecting the cross-points of the anterior vertical line with superior horizontal line and posterior vertical line with the sagittal one. The length of the line is measured by a part of the line between the middle and the posterior vertical lines. Sulcus lateralis (Silvii) is projected by the bisector of the angle between superior horizontal and the projectional line of the central groove (sulcus centralis) of the brain.

Facial Region Facial region is subdivided into medial and lateral parts. Medial region is included orbits, nasal part, oral part and mental part. The lateral region consists from deep and superficial regions and the last one includes the buccal and parotideomasseteric regions. Lateral Facial Region (regio facialis lateralis) Boundaries of this region are: Superiorly - margo infraorbitalis and arcus zygomaticus. Inferiorly - inferior border of the mandible. Anteriorly - plica nasobuccalis and buccolabialis. Posteriorly - posterior border of the vertical process of the mandible (or imaginary line between the angle of the mandible and apex of the mastoid process because of situation here of parotid gland). This region is divided into superficial and deep regions. The superficial region is subdivided into regio buccalis and regio parotideo-masseterica by the anterior margin of the masseter muscle.

Buccal Region (regio buccalis)

1. The skin is thin, movable and elastic, without hair. It contains many sweat and sebaceous glands. The elasticity of this region is used in reconstruction surgery practice for liquidation of local skin defects. 2. The subcutaneous fatty tissue is well developed and contains the arteriovenous bunches. Corpus adiposum buccae or Bichat’s adipose body is located in this layer and is well developed for women and kids. It is surrounded by the capsule, which is formed by superficial fascia, that’s why can be separated from other subcutaneous fatty tissue, masseteric and facial expression muscles. It has three processes: processus orbitalis, processus temporalis and processus pterygopalatinus. Infection can spread to the temporal, orbital and deep facial regions by processes. In subcutaneous fatty tissue also described the facial expression muscles with two layers: superficial and deep. In superficial layer are situated m.orbicularis oculi, mm. zygomatici major et minor, m.levator labii superior. In deep layer is present m.buccinator, which attaches to the maxilla and mandible with one end and with another interlace with m.orbicularis oris. Fascia bucco-pharyngea covers m.buccinator and the lateral wall of the pharynx. On the inner surface muscle is covered by mucous membrane (wall of the oral cavity). Duct of parotid gland passes through the corpus adiposum buccae, fascia bucco-pharyngea, buccinator muscle and the mucous membrane of the oral cavity opens at the level of the I or II superior molars. The superficial fascia is after subcutaneous fatty tissue. The subcutaneous fatty tissue also includes a.v.facialis (a. is a branch of external carotid artery, v. enters into the internal jugular vein), nerves of this region are the branches of facial and trigeminal nerves. The facial artery is projected by the line from the midpoint of mandibular horizontal branch or from anterior margin of masseter muscle to the medial angle of the orbit. At first it situated superficially but then goes under the facial expression muscles. Facial artery in the medial angle of the eye is called angular artery and makes anastomosis with a. dorsalis nasi (branch of ophthalmic artery which arises from the internal carotid artery). Due to it an anastomosis between external and internal carotid arteries is formed. The angular artery is projected by the nasobuccal fold. The facial artery makes anastomosis with a.transversa faciei, a.buccinatoria, a.infraorbitalis, a.mentalis. As a result of such a wide anastomosis in subcutaneous fatty tissue there is: bleeding is from both ends of the wounds, vasomotor reactions are well developed, wounds are infected rare, wounds heal rapidly, autodermoplastic reconstructive surgery practice is possible here. The facial vein, which form the facial common vein begins from the angular vein. It anastomosis with the nasofrontal vein, by which venous blood through v.ophthalmica superior, then v. ophthalmica goes to the cavernous sinus. At the level of the mouth angle, the superficial veins have an anastomosis with sinus cavernosus. Due to these anastomoses the infection can spread retrogradely to the sinus cavernosus when there is thrombosis of the facial vein. Between two buccolabial folds the region is called “corona mortis”, because of widely anastomoses and connection with the intracranial sinuses. At the level of the nasal wings, the facial vein has an anastomosis by v.facialis profunda with plexus venosus pterygoideus of the deep facial region. The arterial supply and innervations of the buccal region : a.v.n.infraorbitalis – come from the same foramen, the artery is the branch of maxillary artery in the pterygopalatine fossa, the nerve is from second division of trigeminal nerve, continuation of maxillary nerve, which form the pes anserinus minor. n.buccalis, sensory branch of the mandibular nerve, n.buccalis, motor branch of the facial nerve, a.v.buccinatoria, branch of maxillary artery and vein, a.v.transversa faciei, branch of temporal superficial artery and vein, a.v.n.mentalis, artery is the branch of the inferior alveolar artery (a.maxillaris), nerve from n.alveolaris inferior (n.mandibularis). Parotideomasseteric Region (regio parotideo-masseterica)

1. Skin is thin, is covered by hair in male. Does not form the folds because of connective tissue’s strands connect the skin with the underlying fascia. 2. Subcutaneous tissue includes superficial vessels and nerves, superficial parotid lymph nodes. 3. Superficial fascia is thin layer. 4. Fascia parotideo-masseterica is the continuation of the superficial lamine of the proper neck fascia (by Shevkunenko) on the lateral facial region. It forms capsules for the parotid gland and masseter muscle. The large part of the parotid gland is situated in the retromandibular fossa, which is bounded by Anteriorly – the ramus of the mandible and the medial pterygoid muscle; Posteriorly – the tendons of the m.sternocleidomastoideus and posterior belly of m.digastricus; Superiorly – inferior wall of the external acoustic meatus. It has a shape of the pyramid with the apex directed medialy and back. From the capsule to inside the gland continues the connective septa, which subdivide the gland into the lobes. That’s why the inflammation process will be in located manner, it does not spread through whole gland. From anterior aspect the capsule is thicker, from superior posterior sides it is thinner and this fact allows infection continues to the parapharyngeal connective tissue and to the up to external acoustic meatus. Inside from the capsule are situated the deep parotid lymph nodes, fatty pad and arteriovenous bunches: 1. Facial nerve after leaving the facial canal through the stylomastoid foramen gives off the auricular posterior nerve, then enters the parotid gland, where separate into it’s superior and inferior branches. The superior branch gives off to the r.temporalis, r. zygomaticus, r, buccalis and the inferior branch gives off the r. marginalis mandibulae, r. colli. Inside the gland from these branches go widely communicating branches to each other and form the plexus parotideus. Damaging of this branches leads to real cosmetic defects. For not to damaging the branches incisor lines should be parallel to them and from the posterior surfaces of the facial expression muscles. If the palm of the hand will put on the gland area, the fingers will show the branches projections: First finger to the middle of the zygomatic arch - r.temporalis; Second finger to the upper, lateral angle of the orbit - r. zygomaticus; Third finger to the upper lip (parallel to the zygomatic arch) – r. buccalis; Fourth finger to the margin of mandible or 1-1,5cm down - r. marginalis mandibulae; Fifth finger vertically down - r. colli. 2. V. retromandibularis is situated superficially from the external carotid artery. It forms by connection of several veins: v.temporalis superficialis v.temporalis media v.temporalis profundus anterior, posterior v.transversa faciei v.maxillaris After leaving the gland V. retromandibularis separated into it’s anterior and posterior branches. The anterior one join to the facial vein and form the common facial vein, which drains into the internal jugular vein. The posterior one with v.occipitalis and v.auricularis posterior form the external jugular vein. 3. External carotid artery at the level of mandibular articular head is subdivided into the a.maxillaris and a.temporalis superficialis. The last one gives off the a.transversa faciei while inside the gland. The maxillary artery pierces the posterior wall of capsule, surrounds the mandibular head and goes to the deep facial region. 4. N.auriculotemporalis is inside the gland. Parotid duct arises from the anterior border of the parotid gland and passes (with a.v.transversa faciei and r.buccalis of the facial nerve) at the external surface of the masseter muscle inferiorly to the zygomatic arch (about 1 cm), surrounds anterior margin of the muscle. Deep Facial Region (regio facialis profunda)

Deep facial region, which occupies the infratemporal fossa is visible if we remove zygomatic arch, masseter muscle and ramus of mandible. Boundaries of this region are: anteriorly – tuber maxillae and the base of the zygomatic arch; posteriorly – anterior margin of the parotid gland; medially – pterygoid process of the sphenoid bone and lateral wall of the pharynx. laterally – masseter muscle with it’s fascia. Infratemporal fossa includes fat, pterygoid medial and lateral muscles, vessels and nerves. There is maxillary artery which is a branch of external carotid artery. It gives off several branches in it’s first part at the level of : a. alveolaris inferior a. meningea media. In it’s second part in infratemporal fossa it gives off: a. masseterica, a. temporalis profunda anterior and posterior, a. buccinatoria, a.pterygoidei to the corresponding muscles. In it’s third part in pterygopalatine fossa it gives off: a.sphenopalatina supplies the nasal cavity, a.palatina descendens, which by the greater palatine canal goes to the oral cavity, a.alveolaris superior posterior, a.infraorbitalis, which gives off the a.alveolaris superior media et anterior. In deep facial region is situated the plexus pterygoideus, which communicats with cavernous sinus through the inferior ophthalmic vein, emisar veins at the foramen ovale and foramen lacerum. The plexus pterygoideus by the v.facialis profunda connects with the facial vein at the level of the nasal wings. In deep facial region also located the mandibular nerve, which leaves the skull through foramen ovale and gives off: n. auriculotemporalis, n. lingualis, n. buccalis, n. alveolaris inferior, n masseter, nn.temporalis profunda anterior et posterior, nn.pterygoidei medialis et lateralis. The connective tissue space of the deep facial region is connected with different regions of the head: Superiorly – to the temporal fossa, Medially – to the parapharyngeal connective tissue, Through the pterygopalatine process of the adipose body – to the buccal region, Through the a.sphenopalatina - with nasal cavity. Through a.palatina descendens – with oral cavity.

TOPOGRAPHICAL ANATOMY & OPERATIVE SURGERY OF THE NECK. TOPOGRAPHICAL PECULARITIES OF THE REGIONS (TREUNGLES) OF THE NECK AND ITS PRACTICAL IMPORTANCE. MAIN PRINCIPLES OF SURGICAL TREATMENTS

Boundaries of the Neck Superior boundary is the inferior border of the mandible, anterior and posterior margins of mastoid processes of temporal bones till asterion, superior nuchal line of occipital bone. Inferior boundary is the superior margin of manubrium sterni and clavicles, the imaginary line between acromions and spinous process of the 7-th cervical vertebra. The neck is divided into two regions: anterior and posterior, by means of an imaginary frontal plane and frontal septa of the second fascia of the neck which pass anteriorly from the trapezius muscles and attach to the transverse processes of the cervical vertebrae. Posterior region (regio cervicis posterior) is also called nuchal region ( regio nuchae) The frontal part of the neck (regio cervicis anterior) is bisected by sternocleidomastoid muscle (SCM) diagonally into anterior and posterior cervical triangles. Anterior (medial) triangle of the neck is divided into suprahyoid and infrahyoid regions by the hyoid bone and posterior bellies of digastric muscles. In the suprahyoid region we describe submandibular and submental triangles. The infrahyoid region is divided into carotid and omotracheal triangles by the superior belly of omohyoid muscle. Posterior (lateral) triangle of the neck is divided into omotrapezoid and omoclavicular triangles by the inferior belly of omohyoid muscle. Fasciae of the Neck Fasciae of the neck by Shevkunenko are divided into five ones. This classification of five fasciae is more necessary for surgical intervention. I fascia is superficial cervical fascia. It is usually a thin layer, which surrounds the neck and contains the platysma. This fascia is continued by general superficial fascia of the whole body. It doesn’t have any place of attachment on the neck. In PNA this fascia is not described. II fascia is lamina superficialis fasciae colli propriae (PNA lamina superficialis fasciae cervicalis) surrounds the structures in the neck. It contains the SCM and trapezoid muscle and submandibular gland. II fascia begins from the spinous processes of the cervical vertebrae, traverses anteriorly and includes the trapezoid muscle. From the anterior border of the trapezoid muscle the II fascia forms transverse septa to the transverse processes of the cervical vertebrae and divides the cervix into anterior and posterior parts. Inferiorly, it is attached to the • Anterior surface of the manubrium and clavicles • Acromions and spines of the scapulae Superiorly, the II fascia is attached to the • Superior nuchal line of occipital bone • Mastoid processes of temporal bones • Inferior border of the mandible • Hyoid bone Superior to the hyoid bone II fascia is divided into two layers (superficial and deep), forming a sheath for the submandibular gland (saccus hyomandibularis). The deep layer is attached to the internal surface of the mandible; the superficial layer is attached to the external surface and traverses superiorly till zygomatic arch as fascia parotideo-masseterica. A.v. facialis (vein lies superficially and the artery underlies the gland), lymphatic nodes are situated here. III fascia is lamina profunda fasciae colli propriae or aponeurosis omoclavicularis PNA(lamina pretrachealis f. cervicalis). It is extending between omohyoid muscles and it’s present as a layer only in the anterior part of the neck. This fascia contains the infrahyoid muscles (omohyoid, sternohyoid, sternothyroid and thyrohyoid). II and III fasciae are attached to each other by medial cervical line to form linea alba colli which extends from the hyoid bone inferiorly up to 3-4 cm not reaching the incisura jugularis of manubrium. The III fascia is attached • Superiorly to the hyoid bone • Inferiorly to the posterior surface of the manubrium and clavicles IV fascia is endocervical fascia (PNA vagina carotica), which is divided into two layers (parietal and visceral). Visceral layer surrounds the thyroid gland, trachea, pharynx and esophagus. Parietal layer surrounds these structures only anteriorly and laterally. Laterally, it covers carotid bundle, which includes: anteriorly and medially - common carotid artery posteriorly and laterally - internal jugular vein between them and posteriorly- vagus nerve IV fascia extends from the base of the head till superior mediastinum. V fascia is prevertebral fascia (PNA lamina praevertebralis f. cervicalis), which forms a tubular sheath for the vertebral column and the muscles associated with it. The prevertebral fascia extends from the base of the skull to T3 vertebra. It covers m.m. scaleni (anterior, media et posterior), m.levator scapulae , splenius capitis and colli., a.v.subclavia, plexus brachialis.

Interfascial Spaces and Fatty Tissue of the Neck Interfascial spaces are divided into two groups: interfascial spaces connected with other regions and those, which are not connected. Not connected spaces 1. Saccus hyomandibularis lies between two layers of the II fascia and encloses the submandibular gland, facial vessels (vein lies superficially to the gland and artery underlies it) fat and a few lymph nodes which collect lymph from the oral cavity. We can palpate these nodes when the patient has inflammations in the oral cavity. 2. Spatium sternocleidomastoideum lies between two layers of the II fascia and encloses SCM. From inner side it pierces by vessels and nerves. 3. Spatium interaponeuroticum suprasternale lies between the II and III fasciae and encloses the jugular venous arch, fat and a few lymph nodes. The jugular venous arch is an anastomosis between anterior jugular veins. Laterally it is connected with spatium retrosternocleidomastoideum. 4. Spatium retrosternocleidomastoideum lies between the II and III fasciae posterior to the SCM and encloses the inferior ends of the anterior jugular veins, fat and lymph vessels. 5. Spatium interaponeuroticum supraclaviculare lies between the II and III fasciae and continuous superiorly till the omohyoid muscle. 3, 4 and 5 spaces are connected each other and during inflammation is discribed the inflammation collar. Connected spaces 1. The carotid sheath (spatium vasoneurorum) is formed by the parietal layer of the IV fascia. It extends from the base of the skull to the root of the neck and contains the • Common carotid artery • Internal jugular vein • Vagus nerve Artery lies a little medially, vein is laterally, nerve lies between the artery and the vein a little posteriorly. Except these structures, it contains deep lymph nodes, carotid sinus nerve and sympathetic fibres. If the patient has pus or blood in this space, it can spread into the superior mediastinum. 2. Spatium praeviscerale lies between parietal and visceral layers of the IV fascia. It encloses fat, plexus venosus thyroideus impar, inferior thyroid veins. The previsceral space may contain thyroid ima artery in 10-12 % of cases. High arterial pressure exists in the thyroid ima artery as it begins from the arch of aorta or brachiocephalic artery. The artery supplies the isthmus of the thyroid gland and isn’t attached to the fascia. Depending on this, when the artery is damaged, it reduces and bleeds into the superior mediastinum. We don’t know about it, because bleeding is not visible in the area of the wound and we can’t help the patient. The patient can die. The previsceral space opens inferiorly into the superior mediastinum. 3. Spatium retroviscerale lies between the IV and V fasciae. It is the largest and most important interfascial space in the neck. It is potential space consisting of loose connective tissue which may contain pus. The retrovisceral space is limited superiorly by the base of the skull and laterally on each side by the carotid sheath. It opens inferiorly into the superior mediastinum and superiorly to the retropharyngeale space and pus can spread into them. The Superficial Veins and Nerves of the Neck The superficial veins of the neck have very important peculiarities. If the superficial veins of the neck are damaged, the air embolism can develop. The superficial veins have the following peculiarities: • The veins don’t have any valves. • The veins are situated near the chest and heart (they have negative pressure). • Adventitia of the veins is attached firmly to the superficial fasciae (because of this veins cannot constrict). The superficial veins of the neck lie between the I and II, and the II and III fasciae. They are external jugular veins, anterior jugular veins, jugular venous arch and median cervical vein (it may be absent). Damages to these veins are very dangerous for patient’s life. If more than 10.0 cm3 of air passes into the vein, the embolism of the pulmonary artery develops, because of which the patient can die. 1. The external jugular vein is projected by line from the angle of mandible to the midpoint of clavicle, is situated between the I and II fascias. 2. The anterior jugular vein is situated between the I and II fascias and is projected by the anterior margin of SCM. The right and left vein connect and form arcus venosus juguli between the II and III fasciae. 3. The median cervical vein if it is one it is projected by the midline of the neck, if two – to the sides of the midline The superficial nerves of the neck are the nerves of cervical plexus C1-C4: lesser occipital nerve, greater auricular nerve, transverse cervical nerve, supraclavicular (medial, intermedial and lateral) nerves. The lesser occipital nerve is projected by line from the midpoint of the posterior margin of the SCM to the apex of mastoid process. The greater auricular nerve is projected by line from the midpoint of the posterior margin of the SCM to the angle of the mandible. The transverse cervical nerve is projected from the midpoint of the posterior margin of the SCM horizontally forward, then subdivided into the superior branch, which with the r.colli n. facialis are formed arcus cervicalis superficialis and inferior branch – to the jugular incisures. The supraclavicular (medial, intermedial) are projected by line from the midpoint of the posterior margin of the SCM to the medial 1/3 of the clavicle and the supraclavicular lateral nerves from the same point to the acromeon. Submandibular Triangle (trigonum submandibulare) Superior border is the inferior margin of the mandible. Anterior and posterior borders are anterior and posterior bellies of m.digastricus. 1. The skin is thin, movable. 2. The subcutaneous fat well developed and sometimes formed the second chin in fat persons. Nerve supply of the skin is from r.colli n. facialis and r.superior n.transversus colli, which are joined here forming arcus cervicalis superficialis. R.marginalis mandibulae (n.facialis) is also situated in subcutaneous fat above this arch. 3. The superficial fascia forms the vagina for m.platysma. Platysma covers the most surface of this triangle except superiolateral angle. 4. The second fascia (after Shevkunenko) with its two layers forms a saccus caecus hyomandibularis for submandibular gland covering it anteriorly and posteriorly as well. It communicates with the oral cavity by the submandibular duct. The septas inside of the gland are absent and it can be separates from the gland easily. Facial vein lies superficially and facial artery underlies the gland. At the posterior border of the triangle v.facialis joins the retromandibular vein and form the common facial vein. Facial artery turns to the upper deep surface of the gland and passes onto the lateral surface of the face. At the inferior border of the mandible it gives off the submental artery which runs to submental triangle with corresponding vein and the mylohyoid nerve (the branch of n.alveolaris inferior). 5. The muscular layer is presented by two layer: The superficial – m.digastricus, m.stylohyoideus The deep layer - m.mylohyoideus and m.hyoglossus. N.hypoglossus passes to the oral cavity between these two muscles. Lingual vein is situated on and lingual artery under the hyoglossus muscle. The submandibular lymph nodes lie on the surface of the submandibular gland(anterior, posterior, inferior). They drain the lymph from the nose, medial angle of the eyelids, tongue, teeth, lips and cheek into the deep cervical lymph nodes. The Pirogov’s triangle is described in the submandibular triangle and is bounded anteriorly by the posterior margin of the m.mylohyoideus, posteriorly by the posterior belly of the m.digastricus, superiorly by the n.hypoglossus and the v.lingualis. The floor is formed by the m.hyoglossus under which the a.lingualis is situated.

Carotid Triangle (trigonum caroticum) This triangle bounded by the sternocleidomastoid muscle (SCM) laterally, posterior belly of digastric muscle superiorly and the superior belly of omohyoid muscle inferiorly. 1. The skin is thin, movable with superficial fascia and platyzma, with which it fuses. Platyzma covers this triangle completely. Under the platyzma and on the II fascia r.colli n.facialis, r.superior n.transversus colli and v.jugularis anterior are situated in the fat. 2. II fascia by Shevkunenko is represented in one layer. 3. Under this fascia the neurovascular bundle of the medial triangle of the neck is situated. Internal jugular vein, the carotid arteries with it’s branches, the vagus nerve with it’s n.laryngeus superior (the last one gives off n. thyroideus superior) are situated covered by lamina parietalis f.endocervicalis by Shevkunenko, IV fascia(vagina carotica, PNA). This fascial sheath encloses the neurovascular bundle, deep lymph nodes, which accompany the internal jugular vein and fat. Carotid artery lies medially, internal jugular vein lies laterally, n.vagus is between them and posteriorly. Carotid common artery is projected by bisector of the angle between the SCM and m.omohyoideus. The common carotid artery is divided at the level of the upper border of the thyroid cartilage or greater horn of hyoid bone into internal and external branches. Usually external carotid artery is situated superficially and medially to internal. The internal carotid artery has no branches on the neck in this triangle. The external carotid artery gives off 7 branches in carotid triangle. 1. The superior thyroid artery, which gives off superior laryngeal artery. 2. The lingual artery. 3. The facial artery, which arises above the lingual one and gives off ascending palatine artery, which supplies the palatine tonsil. 4. The occipital artery. 5. The sternocleidomastoid artery. 6. The posterior auricular artery. 7. The ascending pharyngeal artery. In the carotid triangle hypoglossal nerve gives off the superior root of ansa cervicalis, which descends lying on the internal and common carotid arteries and joins the inferior root from cervical plexus. As a result a loop is formed called ansa cervicalis which supplies the infrahyoid muscles (sternohyoid, sternothyroid, thyrohyoid and omohyoid). The deep cervical lymph nodes are situated around the internal jugular vein and form the jugular lymph trunk. The facial vein enters the carotid triangle over the posterior belly of digastric muscle. The internal jugular vein descends vertically first with the internal then with the common carotid artery. In front from the common carotid bifurcation in internal jugular vein drains the common facial vein, which form by connection of: v.facialis v.thyroidea superior v.laryngea superior v.lingualis r.anterior v.retromandibularis At the place of common carotid bifurcation is located the sinocarotic reflex zone, which forms vagus, glossopharyngeus nerves and sympatethic branches. From the zone arises the sinocarotic nerve, which goes to the brain as component of the glossopharyngeus nerves. The baroreceptors of this zone regulate the arterial blood pressure. Behind the common carotid bifurcation is situated the glomus caroticus, which contain the chemoreceptors. They are sensitive to the hyperoxygenation and hypercarbodioxygenation of blood. 4. After vagina carotica is coming the V facsia, which is covered the cervical part of the sympathetic trunk. The common carotid artery is projected by line, which connects the midpoint of mandibular angle and mastoid process with the sternoclavicular joint to the right and with the midpoint of SCM muscle both legs (cruras).

Omotracheal Triangle (trigonum omotracheale) This is the space under the hyoid bone bounded by the sternocleidomastoid laterally and superiorly by superior belly of omohyoid. The median plane divides it into left and right omotracheal triangles. 1. The skin is thin, moveable. 2. The subcutaneous tissue is loose connective tissue. 3. Superficial fascia with platysma. Platysma covers only supero-lateral surfaces of the triangle, in the midline it is absent. Under this fascia is situated the transverse coli nerve with it’s branches and anterior jugular vein. The vein pierces the II fascia and form the anastomosis. 4. II fascia by Shevkunenko, superiorly attaches to the hyoid bone, inferiorly to the anterior margin of jugular notch. With III fascia in the upper half of this distant it forms the linea alba. In lower half spatium interaponeuroticum suprasternale which is situated between the II and III fasciae and where located an anterior jugular veins anastomosis called jugular venous arch (arcus venosus juguli). 5. III fascia encloses the infrahyoid muscles. The altitude of the spatium interaponeuroticum suprasternale is 3-4 cm, above which the II and III fasciae combine and form linea alba cervicis. 6. Parietal and visceral layers of the IV fascia by Shevkunenko. Between the parietal and visceral layers of endocervical fascia the previsceral space is situated, which contains fat, lymph nodes, plexus venosus thyroideus impar, inferior thyroid veins and in 10-12% of cases- thyroid ima artery. The cervical organs are situated deeper and are covered by visceral layer of endocervical fascia (IV). Here larynx and trachea are situated, deeper- pharynx and esophagus, superficially and laterally - thyroid lobes with parathyroid glands on their postero-medial surfaces. 7. V fascia by Shevkunenko covered the anterior surfaces of the vertebral bodies. Retrovisceral space is situated between the endocervical (IV) and prevertebral (V) fasciae. The thyroid gland. The isthmus of thyroid gland is situated at the level of 2-4 tracheal cartilages. In front from lobes are situated the sternothyroid, sternohyoid, omohyoid muscles. Laterally and posteriorly to the lobes are faced common carotid arteries and internal jugular veins. The gland is surrounded the trachea and pharynx, from the left also esophagus. Besides the visceral layer of the IV fascia the gland also directly is covered (by Kornig) by fibrous capsule. Between this two coats posteromedialy from the lobes the parathyroid glands are present. The fascial coat of gland is formed two ligaments for fixation the gland. The middle one stretches from the isthmus of the gland till cricoid cartilage, the lateral ones from the lobes to the cricoid and thyroid cartilages. The isthmus become movable only after cutting these ligaments. The gland is supplied by superior and inferior thyroid arteries and in 10-12% also by thyroid ima artery to the isthmus. The veins form the plexus, from which arises the inferior and superior thyroid veins. The superior thyroid vein participates in formation of the common facial vein, the inferior thyroid vein drains into the brachiocephalic veins (innominate veins). From the plexus thyroideus impar blood goes to the left innominate vein. Sympathetic innervation is from the upper cervical ganglion of the sympathetic trunk. Parasympathetic innervation is from the n.thyroideus superior and n.laryngeus reccurens (n.vagus). At the inferior margin of thyroid gland in front from n.laryngeus reccurens runs the inferior thyroid artery. During non complete (subtotal) strumectomia the n.laryngeus reccurens can be incorrectly ligatured, which can lead to dysphonia. The trachea. The trachea is located by midline. Cervical part of the trachea is presented by 6-8 semicircular cartilaginous rings, which posteriorly are replaced connective tissue layer and smooth musculature. Inside is covered by ciliary epithelium. The cervical part of trachea starts from the C6 vertebra and continuous till Th2-3 vertebra. Laterally and superiorly trachea is faced to the lobes of thyroid gland, inferiorly – to the common carotid arteries. The isthmus of thyroid gland is situated at the level of 2-4 tracheal cartilages. Posteriorly from the trachea - is esophagus. To the external surface of the body the trachea is located in different depth. It’s beginning in 1,5-2 cm deeply from the skin surface, at the level of jugular notch – 4cm, at the level of bifurcation - 6-7 cm. This fact has a clinical importance. Inferior thyroid artery supplies the cervical part of the trachea. Sympathetic innervations – from sympathetic trunk. Parasympathetic innervations - is from recurrent laryngeal nerve of the vagus. The esophagus. Cervical part of the esophagus 4-6 cm. It situated posteriorly and to the left from the trachea. The cervical part of it starts from the C6 vertebra and continuous till Th2-3 vertebra. In front from the esophagus is the trachea (between them is connective tissue), laterally in the groove there is the recurrent laryngeal nerve and common carotid arteries. Behind the esophagus is the vertebral column with m.longus colli and capitis. Left carotid artery is in distance 0,3-0,5 cm from the esophagus, the right one – 1 -1,5 cm. The esophagus has 2 physiological constriction on the neck. Superior or pharyngeal constriction at it’s beginning and the aortic constriction (it is related with aorta). Inferior thyroid artery supplies the cervical part of the esophagus. Sympathetic innervations – from sympathetic trunk. Parasympathetic innervations - is from recurrent laryngeal nerve of the vagus. Sternocleidomastoid Region (regio sternocleidomastoideus) Sternocleidomastoid region is located between the medial and lateral triangles of the neck, and coincides with location of the SCM muscle. 1. The skin in superior third of the region is thick, unmovable, but in inferior two thirds it’s thin and movable. Platysma covers only medial third of this region. 2. II fascia by Shevkunenko which forms a sheath for SCM muscle. External jugular vein, superficial lymph nodes and branches of cervical plexus are situated on the SCM. External jugular vein begins behind the angle of the mandible by the junction of the posterior branch of the retromandibular vein with the posterior auricular vein. It passes vertically downwards and pierces the II, III and V fasciae (by Shevkunenko) at the posterior border of the SCM above the clavicle and drains into the subclavian vein. As we know adventitia of the vein is attached firmly to the fascia, because of this, the vein cannot constrict and air embolism may develop, if it’s injured. The branches of cervical plexus are n. auricularis magnus, n. transversus colli, n. occipitalis minor, n.n. supraclavicularis medialis, intermedius et lateralis. 3. Under the inferior third of SCM, inferiorly to the omohyoid muscle saccus caecus retrosternocleidomastoideus takes place between the II and III fascia by Shevkunenko. 4. V fascia by Shevkunenko. Deeper, under the prevertebral fascia, scaleno-vertebral triangle is described. The base of this deep triangle is copula of pleurae - apex of the lung, medial border is vertebral column with longus colli, lateral border is anterior scalenus muscle. The top of this triangle is tuberculum caroticum of the transverse process of the VI vertebra. I part of subclavian artery, brachiocephalic veins, ganglion cervico- thoracicum (g. stellatum) and thoracic duct (in the left side) or right lymphatetic duct are situated in this triangle. The left subclavian artery arises from the arch of aorta; the right subclavian artery arises from the brachiocephalic trunk. Each artery may be divided into three parts. First part is situated on the cervical pleura (in the scaleno-vertebral triangle) medial to scalenus anterior. The second part is behind it (in spatium interscalenum) and the third part is lateral to it (in omoclavicular triangle). It ends at the outer border of the first rib behind the midpoint of the clavicle. The branches of the first part of subclavian artery are: 1. a. vertebralis 2. a. thoracica interna 3. truncus thyreo-cervicalis, which gives rise to; a) a. thyroidea inferior b) a. cervicalis ascendens c) a. cervicalis superficialis d) a. suprascapularis From the second part of subclavian artery truncus costo-cervicalis arises, which gives off: a) a. cervicalis profunda b) a. intercostalis suprema (for I and II intercostal spaces) From the third part of subclavian artery a. transversa colli arises. Each brachiocephalic vein begins by a junction of internal jugular and subclavian veins which is called venous angle. The thoracic duct enters the posterior surface of the venous angle from the left side. The thoracic duct is a thin-walled vessel, which collects the lymph from the whole body except the right anterior thoracic wall, upper limb, right side of the neck and the head. The lymph from these parts of the body is collected by the right jugular and clavicular lymph trunks which open into the right venous angle.

Lateral Cervical Triangle (trigonum colli laterale) Bounderies of this region are: anteriorly – posterior border of the SCM posteriorly – anterior border of the trapezoid muscle inferiorly – superior surface of the clavicle This triangle is subdivided into two triangles by the posterior belly of the omohyoid muscle (superiorly is omotrapezoid, inferiorly – omoclavicular triangles). 1. The skin is thin, without hair, movable with subcutaneous tissue. 2. Next layer is superficial fascia (I fascia by Shevkunenko) with platyzma. 3. II fascia by Shevkunenko is perforated by the branches of the cervical plexus at the level of the posterior border of the SCM. There are n.auricularis magnus, n.transversus colli, n.occipitalis minor, n.n.supraclaviculares medialis, intermedius et lateralis. 4. Next layer is V fascia by Shevkunenko in the omotrapezoid triangle. N.accessorius is located between II and V fasciae. In omoclavicular triangle after the II fascia, the III fascia is present, then the V fascia. There the scalenal spaces are described. Spatium antescalenum is limited: anteriorly by the clavicle, posteriorly – m.scalenus anterior. V.subclavia and n.phrenicus (between V fascia and scalenus anterior muscle) pass through this space. Spatium interscalenum is limited: anteriorly by the m.scalenus anterior, posteriorly by the m.scalenus medius, inferiorly – anterior surface of the first rib. A.subclavia and plexus brachialis are situated in this space.

TOPOGRAPHICAL ANATOMY & OPERATIVE SURGERY OF THE THORAX. TOPOGRAPHICAL PECULARITIES OF THE REGIONS OF THE THORAX AND ITS PRACTICAL IMPORTANCE. MAIN PRINCIPLES OF SURGICAL TREATMENTS

TOPOGRAPHIC ANATOMY OF THE THORAX

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

Anterior Superior Thoracic Region (Regio thoracica anterior superior) The boundaries of this region are: Superiorly -- the clavicle Inferiorly -- the inferior margin of the 5-th rib Laterally -- sulcus deltoideopecoralis Medially -- linea sternalis Inferiorly from the clavicle is described the infraclavicular fossa, which is bounded superiorly by clavicle, inferiorly – 3rd rib, laterally – anterior margin of deltoid muscle, medially – sternal line. 1. The skin is thin and in men is covered by hair. 2. The subcutaneous connective tissue contains the superficial nerves n. n. supraclaviculares medialis et intermedius ( branches of the cervical plexus) and superficial veins. 3. The superficial fascia which superiorly contains the platysma muscle, then is divided into two layers forming a capsule for mammary gland. It takes part in the fixation of the mammary gland to the clavicle (lig. suspensorium Giraldes). 4. The proper fascia is called fascia pectoralis. Fascia pectoralis forms a sheath for m. pectoralis major and divides the muscle into three parts by fibrous dense septa. The parts are called pars clavicularis, pars sternocostalis and pars abdominalis. In sulcus deltoideopectoralis is situated the v.cephalica, which is pierced the proper fascia in the Morenheim’s fossa and drained into the v. axillaris. Under the pectoral muscle is situated the subpectoral connective tissue (spatium subpectorale), which is bounded posteriorly by the fascia clavipectoralis. In this space are located the a.vv.thoracoacromealis, n.n. pectorales mediales and laterals. A.thoracoacromealis is the branch of the axillary artery and gives off the r.pectoralis, r.deltoideus and r.acromealis. 5. Fascia clavipectoralis forms sheaths for m. pectoralis minor and m. subclavius. This fascia attaches superiorly to the coracoid process, clavicle and ribs. Fascia clavipectoralis with the axillar fascia is formed the lig. suspensorium axillae (Gaerdy’s ligament). Under the lesser pectoral muscle is situated the deep connective tissue (deep space). After m.pectoralis minor is coming the own layers of thoracic wall.

Here we describe three triangles which have very important significance for practical medicine. A.v. axillares and plexus brachialis are situated in the lateral side of these triangles. These triangles are called: 1. Trigonum clavipectorale which is between the clavicula and superior margin of m. pectoralis minor. 2. Trigonum pectorale coincides with m.pectoralis minor. 3. Trigonum subpectorale which is between the inferior margins of the m. pectoralis minor et major. Arterial supply of the anterior superior thoracic region is derived from: • Anterior intercostal branches of the internal thoracic artery, a branch of the subclavian artery; • Lateral thoracic, thoracic suprema and thoracoacromial arteries, branches of the axillary artery; • Posterior intercostal arteries, branches of the thoracic aorta; • Intercostal suprema arteries, branch of the subclavian artery;

The nerve supply is from: n.n. intercostales, from the thoracic segments; n.n. pectorals mediales and laterals, from the plexus brachialis; n. thoracicus longus, from the plexus brachialis.

Breasts The breasts containing mammary glands are located in the superficial fascia of the anterior thoracic wall. The boundaries of the mammary gland are: Superiorly -- the 3-d rib Inferiorly – the 6- 7-th ribs Medially -- the parasternal lines Lateral-- linea axillaris anterior. 1. The skin is thin, without hair and not movable. The gland is firmly attached to the dermis of the overlying skin by fibrous septa called the suspensory ligaments (Cooper’s ligament –lig. suspensorium mammarium). At the greatest prominence of the breast there is a nipple, surrounded by a circular pigmented area called the areola. 2. The connective tissue Includes a number of separate pockets filled with fat, except the zone of areola. There is no fat. The venous plexus and superficial nerves are there. 3. The superficial fascia is divided into two layers forming a capsule for mammary gland. It takes part in the fixation of the mammary gland to the clavicle (lig. suspensorium Giraldes). Two layers of superficial fascia are attached to each other by fibrous dense septa which traverse through the mammary gland and split it into up to 18-20 lobes. Each lobe of the gland is drained by a lactiferous duct. Two or three neighboring lactiferous ducts are connected with each other to form lactiferous sinus. They are situated in the subareolar zone. The lactiferous ducts form the sinuses open on the nipple by 8-15 porus lactiferi. It is very dangerous to make an incision in this zone, because the lactiferous ducts can be damaged. In the nipple the superficial fascia is absent also. 4. The next layer is the deep fascia (fascia pectoralis). Between the gland and the deep fascia, there is loose connective tissue containing little fat known as the retromammary space (bursa), which allows the breast some degree of movement. Arterial supply of the breast is derived from • Anterior intercostal branches of the internal thoracic artery, a branch of the subclavian artery • Lateral thoracic, branch of the axillary artery • Posterior intercostal arteries, branches of the thoracic aorta • Mammarian branches from the thoracic internal arteries

Innervation is provide by the intercostal nerves and supraclavicular medial and intermedial nerves. Lymphatic drainage of the breast is important due to its role in the metastasis (spread) of cancer cells. The lymph drainage can be separated into superficial (extraorganic) and intraorganic systems. The superficial lymph drains into the axillary anterior lymph nodes. The intraorganic system is subdivided into the four quadrants. From the lateral (upper and lower) quadrants lymph drains into the axillary anterior lymph nodes mainly to the pectoral group (Zorgius’ lymph node by III rib, below the inferior margin of the pectoral major muscle) totally about 75%. From the upper quadrants (medial and lateral) lymph drains into the infraclavicular, supraclavicular lymph nodes (along v.axillaris and v.subclavia). From the medial (upper and lower) quadrants lymph drains into the mediastinal (internal thoracic) lymph nodes. From the upper medial quadrant lymph drains into the opposite gland (transmammar drainage). From the lower medial quadrant lymph drains into the portal lymph nodes of the liver.

Own layers As we’ve already mentioned above, the wall of the thoracic cavity consists of so called movable and own layers. The own layers include the bones of the thorax (vertebrae, sternum, ribs), the intercostal muscles, which form intercostal spaces together with the ribs, the thoracic transverse muscle and f. endothoracica, covering the wall internally. The boundaries of the intercostal spaces are: Superiorly -- the inferior border of the upper rib. Inferiorly -- the superior border of the lower rib. Anteriorly-- the external intercostal muscle. Posteriorly--the internal intercostal muscle. The intercostal spaces involve fat and a.v.n. intercostales. The anterior and posterior intercostal arteries are situated there. The anterior intercostal artery is a branch of the internal thoracic artery (a branch of subclavian artery), posterior one is a branch of thoracic aorta. External intercostal muscles (m.m. intercostales externi) begin from the inferior border of the rib above, outside to its groove (sulcus costae), pass inferiorly and anteriorly to the superior border of the rib below. The direction of the muscle fibers is from up to down, from lateral to medial, nearly under right angle in relation to the internal intercostal muscles. They extend from the border of the costovertebral joins up to the costal cartilages and anteriorly are replaced by the external intercostal membrane. Internal intercostal muscles begin from the superior margin of the rib below, pass superiorly and attach to the inferior margin of the rib above, inside the costal groove. The direction of the muscle fibers is from down to up, from lateral to medial, nearly under right angle in relation to the external intercostal muscles. They extend from the lateral border of the sternum up to the costal angle and posteriorly are replaced by the internal intercostal membrane. The grooves in the inferior border of the ribs appear to be between the external and internal intercostal muscles, as a result intercostal space is formed, which is filled with fatty tissue and neuro-vascular bundle passes: superiorly-the vein, inferiorly to it-the artery, and more inferiorly- the nerve. Vena azygos (v. azygos) and vena hemiazygos (v. hemiazygos) form in the abdominal cavity out of ascending lumbar veins which connect the lumbar veins longitudinally. They pass upward behind m. psoas major and make their way into the thoracic cavity between the muscular bundles of the diaphragm's crus: v. azygos together with the right n. splanchnicus, v. hemiazygos with the left n. splanchnicus or the sympathetic trunk. In the thoracic cavity v. azygos rises along the right lateral side of the spinal column, closely adhering to the posterior wall of the oesophagus. At the level of the fourth or the fifth vertebra, it departs from the spine and, bending over the root of the right lung, drains into the vena cava superior. Besides the branches carrying blood from the organs of the mediastinum, nine right inferior intercostal veins and, through them, the veins of vertebral plexuses also drain into the unpaired vein. Near the place where the unpaired vein bends over the root of the right lung, it receives blood from the v. intercostalis superior dextra created by the merger of three right superior intercostal veins. V. hemiazygos lies on the left lateral surface of the vertebral bodies behind the descending thoracic aorta. It ascends only up to the seventh or eighth thoracic vertebra, then turns right and, passing obliquely upward over the anterior surface of the vertebral column behind the thoracic aorta and ductus thoracicus, drains into v. azygos. It receives branches from the organs of the mediastinum and the lower left intercostal veins, as well as veins of the vertebral plexuses. The upper left intercostal veins drain into v. hemiazygos accessoria, which runs from top to bottom, arranging itself, just as v. hemiazygos, on the left lateral surface of the vertebral bodies, and drains either into v. hemiazygos or directly into v. azygos, bending to the right over the anterior surface of the seventh thoracic vertebral body. The damaging of the anterior and posterior intercostals arteries is characterized by: -Because of anastomosis bleeding two ends of the arteries -Inside of arteries is the high arterial pressure -Vasomotor reaction is absent because of fusion of the adventitia to the intecostal muscles fascia. Intercostal nerves contain the sympathetic fibers from the sympathetic trunk. Intercostal neuro-vascular bundle passes in the costal groove till the middle axillary lines, after which it goes obliquely to the anterior abdominal wall (7-12). Posteriorly from the costal angles the parietal pleura is separated from the intercostal nerves by the internal intercostal membrane and endothoracic fascia, that’s why during pleuritis the nerves can be involved into the inflammation process. The transverse thoracic muscle starts from the lower half of the sternum and obliquely attaches 2-6 costochondral joints (from medial to lateral, from down to up). The thoracic cavity does not correspond to the margins of the thorax, it is smaller: -diaphragm is inside the thoracic cavity; -vertebral bodies are inside the thoracic cavity; -the apex of the lungs are appears in 3-4 cm above the first rib. The upper margin of the thoracic cavity is jugular notch of the sternum, first rib, body of the first thoracic vertebra. The lower margin is the xyphoid process of the sternum, costal arches, 11 and 12 free ends of the ribs, body of the 12 thoracic vertebra. The thoracic wall is covered by f. endothoracica from the inner side.

Topographic Anatomy of the Pleura The lungs are surrounded by a thin serous membrane-pleura,which consists of two layers – external and internal. Internal or visceral pleura (pleura visceralis s. pulmonalis) is densely joined with lungs. It enters into the depth of the grooves, so also covers the interlobar surfaces of the lungs. The internal surface of the thorax is covered by the external or parietal pleura (pleura parietalis). At the hilus of the lung it turns into the visceral pleura. The pleural cavity (cavum pleurae) is a potential space between parietal and visceral layers of pleura, which contains a capillary layer of serous liquid-pleural fluid, that lumbricates the pleural surfaces and allows the layers of the pleura to slide smoothly over each other during respiration. Two pleural cavities – right and left are situated within the thoracic cavity, and mediastinum is located between them. The parietal layer of pleura can be topographically subdivided into four portions: the cupola of pleura (cupula pleurae), the costal pleura (pleura costalis), the diaphragmatic pleura (pleura diaphragmatica) and the mediastinal pleura (pleura mediastenalis). 1. The cupola of pleura is formed above the apex of the lung by parietal layer of pleura. It is located in the area of neck, and in front it is projected 2-3 cm above the clavicle; at the back it is projected on the level of spinous process of the VII cervical vertebra. 2. The part of parietal pleura, which covers diaphragm, is called diaphragmatic pleura. It covers the convex part of diaphragm, except the place, where pericardium is densely fastened with diaphragm. 3. The part of parietal pleura, which borders mediastinum from sides, is named mediastinal pleura. 4. The part of the parietal pleura, which covers the internal surface of the thoracic wall (sternum, costal cartilages, ribs intercostal muscles, intercostal membranes and sides of thoracic vertebrae), is called costal pleura. We distinguish the upper, lower, front and back borders of costal pleura. The upper border of costal pleura corresponds to the top of thoracic aperture, to the sternoclavicular joint, and above that place it turns into the cupola of pleura. Posteriorly from right side costal pleura continuous to mediastinal pleura by level of costovertebral joints, from left side – by anterolateral surfaces of the thoracic vertebras. Anteriorly from the sternoclavicular joint right costal pleura goes to the left, left one – to the right, till the II rib cartilages and form area interpleurica superior or area thymica. Posteriorly from the sternal body they continuous together till the IV rib cartilage, from where left costal pleura crosses down the V rib cartilage and reaches the VI rib cartilage by parasternal line. The right one does not change it’s direction till the VI rib cartilage by parasternal line. The lower border of costal pleura corresponds to the lower margin of cartilage of VI rib by parasternal line, to the lower margin of the cartilage of VII rib by middle clavicular line, to the X rib by middle axillary line, to the XI rib by scapular line, to the lower margin of XII rib by paravertebral line. The lungs do not completely occupy the pleural cavities during inspiration and a kind of reserve space is formed in the places of transition of one part of the parietal pleura into another called pleural sinus (sinus pleurae). Because of the presence of pleural sinuses, the pleural cavity is larger than the lung volume. The following sinuses are distinguished: 1. A costodiaphragmatic sinus (sinus costodiaphragmaticus) is formed in the place of transition of the costal pleura into the diaphragmatic one. The lower border of costodiaphragmatic sinus is located below the lower margin of the lungs. Costodiaphragmatic sinus is the largest one, and it reaches the greatest depth by the right middle axillary line (up to 9 cm). The other pleural sinuses are smaller. 2. In front, costodiaphragmatic sinus is proceeded by the front costomediastinal sinus (sinus costomediastinalis anterior), which is located between the ventral part of the costal pleura and the mediastenal pleura. 3. At the back, costodiaphragmatic sinus turns into the back costomediastinal sinus (sinus costomediastinalis posterior), which is located between the dorsal part of the costal pleura and mediastinal pleura. 4. Mediostinodiaphragmatic sinus is a small space, which is formed in the place of transition of the diaphragmatic pleura into the mediastinal one. In 2,3,4 sinuses the lung parenchyma is entered during breathing. The parietal pleura is supplied by intercostal arteries (thoracica interna, thoracic aorta) and mediastinal arteries from thoracic aorta, and intercostal nerves. The visceral pleura is supplied by bronchial arteries and pulmonal veins and innervated by pulmonal plexuses.

Mediastinum The mediastinum is the central portion of the thoracic cavity between the pleural sacs. Boundaries: anterior boundary is the sternum covered by f. retrosternalis from inside. posterior –thoracic vertebrae, the necks of the ribs and f. prevertebralis; lateral--mediastinal pleura covered by f. endothoracica; inferior-- diaphragm covered by f. diaphragmatica superior--superior aperture of the thorax (an imaginary plane between incisura jugularis and II thoracic vertebra). For descriptive and surgical purposes, mediastinum is divided into four compartments. Superior mediastinum is the space between the superior aperture of the thorax and an imaginary plane passed through the upper border of the lung roots which extends from the sternal angle to the intervertebral disc between the IV and V thoracic vertebrae. It contains thymus, v.v. brachiocephalicae, v. cava superior, arcus aortae with its branches (a. carotis communis sinistra, a. subclavia sinistra, tr. brachiocephalicus), trachea, esophagus, ductus thoracicus , trunci sympathici, n.n. vagi, n.n. phrenici. Below the plane the mediastinum is subdivided into the anterior, middle and posterior mediastinum. Anterior mediastinum is between the sternum (f.retrosternalis) anteriorly and anterior wall of the pericardium posteriorly. It includes fat, retrosternal lymph nodes. Middle mediastinum is between the anterior surface of the pericardium anteriorly and posterior surface of the tracheal bifurcation and the posterior wall of the pericardium posteriorly. It includes the heart with the intrapericardial parts of the large vessels which enter the heart and those which go out of it, such as aorta ascendens, pulmonary trunk, pulmonary veins, v. cava superior and tracheal bifurcation with the principle bronchi. N.n. phrenici, a.v. pericardiophrenicae, fat and lymph nodes are also situated there. Posterior mediastinum is between the posterior surface of tracheal bifurcation and posterior wall of the pericardium anteriorly and vertebral column (bodies of the IV-XII thoracic vertebrae) covered by f. praevertebralis posteriorly. It includes aorta descendens, v. cava inferior, v.v. azygos, hemiazygos, tr.sympaticus, n.n. splanchnici, n.n. vagi, esophagus, ductus thoracicus, fat, lymph nodes.

TOPOGRAPHICAL ANATOMY & OPERATIVE SURGERY OF THE UPPER LIMB. TOPOGRAPHICAL PECULARITIES OF THE REGIONS OF THE UPPER LIMB AND ITS PRACTICAL IMPORTANCE. MAIN PRINCIPLES OF SURGICAL TREATMENTS TOPOGRAPHIC ANATOMY OF THE UPPER LIMB

Boundaries: it is divided from the trunk by an imaginary line which passes anteriorly through the sulcus deltoido-pectoralis, posteriorly by a line which connects lower borders of the pectoralis major and latissimus dorsi muscles.Upper limb consists of shoulder girdle and free upper limb. Shoulder girdle consists of four regions: • Regio axillaris • Regio deltoidea • Regio scapularies • Regio infraclavicularies The last 2 regions are on the chest, but as they are related to the axilla -make its anterior and posterior walls- we study them in this chapter. Free upper limb consists of : • Regg. brachii anterior et posterior • Regg. cubiti anterior et posterior • Regg. antebrachii anterior et posterior • Reg. palmae manus • Reg. dorsi manus • Regg. digiti (palmaris/dorsalis) Axillary Region( Regio axillaris) It is at the junction of the chest and the arm when the upper limb is abducted. Boundaries: anteriorly- lower border of pectoralis major muscle, posteriorly-lower border of latissimus dorsi muscle, laterally- an imaginary line which connects lower borders of the above mentioned muscles on the arm, medially- the same line on the chest. Layers. 1. The skin is covered with hair, has a great number of sweat and sebaceous glands. 2. In the subcutaneous fatty tissue there are 5-6 superficial lymphatic nodes and intercostobrachial nerves (n .n. intercostobrachiales –from plexus brachialis and n.n. intercostales). 3. Superficial fascia is hardly developed. 4. Proper fascia is fine in the centre and is pierced by the arteries and nerves. After taking away proper fascia a cavity called axilla (fossa axillaris) appears. It has a shape of truncated pyramid, the shape and size of which vary, depending on the position of the arm. Apex of the axilla lies between the first rib, the clavicle and the superior edge of the subclavius muscle. It is directed superiorly and medially. Base of the axilla (armpit) is directed inferiorly and laterally. Axillary fossa has 4 walls:  Anterior wall of the axilla is formed mainly by the pectoralis major and minor muscles. Here we distinguish 3 triangles: clavipectoral, pectoral and subpectoral.  Posterior wall is formed chiefly by the subcapularis, teres major, teres minor, latissimus dorsi muscles.  Lateral wall is the humerus covered by the coracobrachial muscle and short head of the biceps brachii muscle.  Medial wall is formed by the first to fourth ribs and the overlying serratus anterior muscle. Axillary fossa is filled with loose fatty tissue where we can find arteries, veins, lymphatics and nerves. They pass through the apex to reach the arm. The topography of the above mentioned elements is described in each of 3 above mentioned triangles separately. I. The sides of the clavipectoral triangle (trigonum clavipectorale) are: superiorly-the clavicle, inferiorly- upper border of the pectoralis minor muscle. In the boundaries of this triangle vein lies medially to axillary artery. The brachial plexus is formed by the union of the ventral rami of C5-C8, T1 nerves. As they enter the neck they unite to form three (superior, middle and inferior) trunks, which form divisions posterior to the clavicle. Here the brachial plexus lies superiorly and laterally to the artery .Two branches extend from the artery: a. thoracica suprema and a. thoracoacromialis. Fascia clavipectoralis encloses the pectoralis minor and subclavicularis muscles and then attaches to the clavicle.Because the inferior part of the clavipectoral fascia supports the axillary fascia this part of the fascia is referred to as the suspensory ligament of the axilla (ligamentum suspensorium axillae). II. In the pectoral triangle (trigonum pectorale) which coincides with pectoralis minor muscle a branch called a. thoracica lateralis extends from a. axillaris. It is followed by n. thoracicus longus. Brachial plexus passes by 3 cords (fasciculi): medial, lateral and posterior (according to their relationship to the second part of the axillary artery). Vein again is medial to the artery. III. Subpectoral triangle (trigonum subpectorale) is between inferior borders of both pectoral muscles. Here a.axillaris gives off 3 branches: a. circumflexa humeri anterior, a. circumflexa humeri posterior and a. subscapularis. The last one is divided into a. circumflexa scapulae and a. thoracodorsalis. First 2 branches curve around the surgical neck of the humerus and make anastomosis with each other. Terminal branches start from the cords of the brachial plexus: n. medianus is formed by the medial and lateral cords and passes in front of the artery; n. musculocutaneus starts from the lateral cord, n. ulnaris, n. cutaneus brachii medialis and n. cutaneus antebrachii medialis start from the medial cord, n. radialis and n. axillaris start from the posterior cord. As a matter of fact these nerves surround the artery from all the sides. Posterior wall is made by scapular region where we describe two openings: quadrilateral and trilateral. Between teres minor and subscapularis muscles above, teres major and latissimus dorsi muscles below and humerus laterally there is left a space, which is crossed by the long head of triceps brachii muscle. As a result foramen trilaterum is formed medially and foramen quadrilaterum –laterally. A. circumflexa scapulae (a branch of a. subscapularis), followed by veins ,passes through trilateral opening from axillary to scapular region. A. circumflexa humeri posterior and n. axillaris pass through foramen quadrilaterum. A.axillaris is the main artery, branches of which make anastamoses with the branches of subclavian and brachial arteries. There are many lymph nodes in the fibrofatty connective tissue of the axilla, which are arranged in 5 principle groups. Four of them (lateral, central, medial and subscapular) lie inferiorly and deep to pectoralis minor muscle and one (apical) lies superiorly to it. 1. Nodi lymphatici axillares mediales (pectorales) - lymph is collected from anterior superior surface of the thorax and abdomen (above umbilicus) and mammary gland. A lymph node (or nodes) called Zorgues’ node is most common site of metastases from cancer of the breast. 2. Nodi lymphatici axillares laterales (brachiales) - collect lymph from the upper limb. 3. Nodi lymphatici axillares centrales- the lymphatics of the region drain into them. 4. Nodi lymphatici axillares subscapulares (posteriores) - collect lymph from the superior part of the trunk and posterior surface of the neck. 5. Nodi lymphatici axillares apicales (infraclaviculares) -get lymph from superior pole of the breast. Projection of a. axillaris has practical importance. According to Pirogov it is projected through the anterior border of the hair covering of the axilla. According to Langenbek it is projected by the continuation of the sulcus bicipitalis medialis in the axillary fossa. Deltoid Region (Regio deltoidea) Boundaries: This region coincides with the position of the deltoid muscle. Layers. 1. The skin is thick. It is innervated by the branches of the lateral cutaneous nerve of the brachium (n. cutaneus brachii lateralis superior) and supraclavicular nerve (n. supraclavicularis lateralis) - from plexus cervicalis. 2. Subcutaneous fat is developed well. 3. The superfitial fascia is fused with the proper fascia in the region of the acromion. 4. Proper fascia forms a sheath for the deltoid muscle which starts from the clavicle,the acromial process and the spine of the scapula and is attached to the deltoid tuberosity of the humerus. 5. There is a space filled with loose fatty tissue where tendons of the muscles,synovial bursae,vessels and nerves pass. Synovial bursae are the followings: bursa subdeltoidea, bursa subacromialis and bursa subtendinea m. subscapularis. The last one communicates with the joint cavity. The region is innervated by axillary nerve (n. axillaris) which passes through the quadrangular space from the axillary region together with the posterior circumflex artery of the humerus (a. circumflexa humeri posterior). The last one anastomoses with the anterior circumflex artery arround the surgical neck of humerus. Anterior and posterior circumflex arteries make anastomoses with the branches of a. thoracoacromialis: r.acromialis and r. deltoideus. Subdeltoid space communicates with fibrofatty connective tissue of the axilla and the supraspinatus and infraspinatus fossae of the scapula. These are the ways through which infection can spread. From the practical point of view it’s important to know the projection of n. axillaris: it’s a vertical line descending from the acromion, which intersects with the posterior margin of the deltoid muscle (approximately 6cm below the acromion). The loss of the function and the atrophy of the deltoid occur when the axillary nerve is severely damaged (e.g. when the surgical neck of the humerus is fractured). To test the strength of the deltoid muscle clinically the person’s arm is fully abducted and held in that position against resistance. Inability to do this indicates that n. axillaris is injured. The Arm (Brachium) Boundaries: upper border is a circular line which connects inferior margins of the pectoralis and latissimus dorsi muscles; lower border is a circular line which passes 4cm above the epicondyles of the humerus. Two vertical lines, which pass through the epicondyles and practically coincide with sulcus bicipitalis medialis and lateralis, divide the arm into 2 regions: anterior and posterior. Anterior Region of the Arm (Regio brachii anterior) Layers. In lateral parts the skin is thicker than in medial parts. Subcutaneous fatty tissue is loose. Superficial fascia is a thin layer, which forms sheaths for superficial veins and cutaneous nerves. Laterally we can see v. cephalica, which superiorly passes into sulcus deltoidopectoralis. V. basilica passes through the medial bicipital groove in the lower and middle thirds. In the middle third of the arm it pierces proper fascia and enters Pirogov’s canal, which is formed by the splitting of the proper fascia. V. basilica drains into v. brachialis. The skin is innervated by medial cutaneous nerves of the arm ( n.n. cutanei brachii medialis n.n. cutanei antebrachii medialis.). N.n. cutanei brachii medialis is in the superior and middle thirds, but n.n. cutanei antebrachii medialis is in the middle third enters Pirogov’s canal and lower third under the skin . Topographic anatomy of the arm is studied on the transverse sections which are made on different levels: superior, middle and inferior one thirds of the arm. On the transsection made on the every level of the arm anterior and posterior osteofascial compartments are distinguished. From the inner surface of the proper fascia 2 intermuscular septa (septa intermusculare mediale et laterale) extend to the humerus and attaching to it, form 2 osteofascial capsules: anterior and posterior. Boundaries of the anterior compartment are: anteriorly- proper fascia, medially and laterally- intermuscular septa, posteriorly- humerus. This compartment contains the muscles of the anterior group, which are arranged in 2 layers: superficial (m. biceps brachii) and deep ( m. coracobrachialis in the upper third , m. brachialis in the middle and lower thirds and m. brachioradialis in the lower third of the brachium). All of them are flexors. Deep fascia of the arm (f. brachii profunda) passes between m. brachialis and biceps brachii. N. musculocutaneus lies under this fascia between these muscles in the middle and lower thirds. It innervates all the muscles of the anterior group, then emerges into the inferior lateral border of the region under the biceps margin as lateral skin nerve of the forearm (n. cutaneus antebrachii lateralis). Septum intermusculare mediale splits into two sheets and an interfascial space is formed, where the main neuro-vascular bundle of the arm lies: a. brachialis (superior 1/3-medially), v.v.brachiales, n. medianus and n.musculocutaneus (laterally). N. ulnaris, n.n. cutanei antebrachii medialis lie medially. N.radialis is posteriorly from the artery. A. brachialis provides the principle arterial supply to the arm. It is the continuation of the axillary artery, begins at the inferior border of the teres major and ends opposite the neck of the radius in the cubital fossa. In the upper one third of the artery a. profunda brachii extends from a brachialis and, together with n. radialis, pierces medial intermuscular septum and enters posterior muscular compartment (posterior osteo-fascial compartment). In the middle third n. medianus lies anteriorly to a. brachialis, so it isn’t comfortable to expose the artery on this level through direct entrance because n. medianus can be hurt. So it is performed (exposure of the artery) through the sheath of the biceps brachii muscle, a little laterally from the projectional line of the artery. N. ulnaris lies posteriorly from the a. brachialis. Besides a. profunda brachii 2 other branches extend from a. brachialis: a. collateralis ulnaris superior in the middle third of the arm, which joins n. ulnaris and pierces medial intermuscular septum in the middle third and enters posterior osteo-fascial compartment in the inferior third. In the inferior third (in the inferior border with cubital region) another branch -a. collateralis ulnaris inferior extends, which descends to anterior osteo-fascial compartment, then anterior cubital region. Here n. medianus lies medially to a. brachialis in the medial interfascial space in the lower third. Posterior Region of the Arm (Regio brachii posterior) Layers. The skin is thick and is firmly blended with the subcutaneous tissue. Superficial fascia is a thin layer. In the subcutaneous tissue we can find n.n. cutanei brachii laterales superior et inferior(branches of n. axillaris, n.radialis), and n. cutaneus brachii posterior(n. radialis), which pierce the fascia and lie in the all subcutaneous space posteriorly and laterally of the arm. Posterior osteofacial compartment is bounded: posteriorly by the proper fascia, anteriorly by humerus, from both sides- by medial and lateral intermuscular septa. An extensor muscle- m. triceps brachii- lies in this compartment, in the middle third of which, from proper fascia septa pass into the thickness of the muscle, dividing the heads from each other. N. radialis innervates this muscle. It descends obliquely and laterally with a. v. brachialis profunda in the spiral canal (canalis spiralis s. humeromuscularis). The last one is formed by the groove of the radial nerve (sulcus n. radialis) of the humerus and triceps muscle of the arm. In the middle part of the arm deep brachial artery ramifies, becoming a. collateralis media and a. collateralis radialis. The last one follows n. radialis, pierces lateral intermuscular septum in the inferior region, again appearing in the lateral interfascial space. A. collateralis media in the inferior third descends in the posterior osteofacial compartment From the practical point of view it’s important to know the main projectional lines of the arteries and the nerves of the arm. The main neurovascular bundle is projected by a line, which connects the point between anterior (medial) and middle thirds of the axilla with the midpoint of the cubital fold. Practically this line coincides with the sulcus bicipitalis medialis.To stop the bleeding temporarly we can press a. brachialis to the humerus in this groove .In the inferior third of the arm n. medianus is projected 1 cm medially from a. brachialis. N. radialis is projected by a spiral line which connects midpoint of the posterior border of the deltoid muscle with the inferior end of the sulcus bicipitalis lateralis. Injury to the radial nerve proximal the origin of the triceps results in paralysis of the triceps, brachioradialis, supinator and extensor muscles of the wrist and the digits. The characteristic sign of the radial nerve injury is wrist-drop (inability to extend the wrist and the digits). Projection of the ulnar nerve (n. ulnaris) on the arm in the upper parts coincides with the projection of the main bandle, but from the middle third it is projected by a line, which connects the midpoint of the sulcus bicipitalis medialis with the medial epicondyle. Injury to the n.musculocutaneus results in paralysis of the coracobrachialis, biceps and brachialis muscles. As a result the flexion of the elbow joint and supination of the forearm are greatly weakened. There may also be loss of sensation on the lateral surface of the forearm supplied by the lateral antebrachial cutaneus nerve. N.musculocutaneus is projected by a line which connects midpoint of the clavicle (apex of the axilla) with the inferior end of the sulcus bicipitalis lateralis.

Cubital Region (Regio cubiti) Boundaries: proximal and distal boundaries are formed by two circular lines two transverse fingers (4cm) above and below the epicondyles of the arm. By two vertical lines, which pass through the medial and lateral epicondyles, this region is divided into anterior and posterior regions. Anterior Cubital Region /Cubital Fossa (Regio cubiti anterior/ Fossa cubiti) Layers. The skin is thin, movable. Subcutaneous tissue has a plated structure.Superficial veins and nerves pass in it: laterally- v. cephalica and n. cutaneus antebrachii lateralis, medially- v. basilica and n. cutaneus antebrachii medialis. Veins are connected with each other by v. mediana cubiti forming shapes of letters “N”and “И”.Sometimes this anastomosis has an appearance of the letter “M”, which appears as a result of connection v. mediana cephalica with v. mediana basilica which are formed from v. mediana antebrachii. V. mediana cubiti forms the connection in shape of letters “N”and “И”. By a branch, which pierces proper fascia, v. mediana cubiti is connected with the deep veins of the forearm. There are 2-3 lymphatic nodes in the subcutaneous tissue. Superficial fascia is the thin, transparent membran. Proper fascia - the continuation of the brachial fascia, is thickened medially due to the tenden fibers of the biceps muscle (aponeuroses m.bicipitis brachii), which is called also” lacertus fibrosus” or Pirogov’s fascia. Under the proper fascia muscles are arranged in 3 groups: medial, middle and lateral. The lateral group consists of m.m. brachioradialis and tendons of the extensor muscles, middle group- m.m. biceps et brachialis, medial group-m.m. pronator teres and tendons of the flexor muscles . Between them 2 grooves are formed: sulci cubitales anteriores medialis et lateralis. N. radialis lies in the lateral cubital groove with a.v. collateralis radialis. Here the nerve is divided into 2 branches: superficial and deep. R. superficialis n. radialis then continues its way on the forearm in the radial groove, when as r. profundus n. radialis passes to the dorsal region of the forearm and is called also n. interosseus posterior. A. brachialis with veins and n. medianus lies in the medial groove, under the lacertus fibrosus, the nerve is 0,5-1cm medialy from the artery. Below Pirogov’s fascia a. brachialis is divided into 2 branches: a. radialis and a. ulnaris, which is projected one transverse finger below the midpoint of the distance between the two epicondyles. A. radialis gives off a branch- a.reccurens radialis-which anastamoses with a. collateralis radialis –branch of a. brachialis profunda. From a. ulnaris a branch extends- a. interossea communis which then is divided into 2 branches: anterior and posterior. Posterior branch gives off a. interossea reccurens which anastamoses with a. collateralis media-branch of a. brachialis profunda. A. ulnaris also gives off a branch- a. reccurens ulnaris which is divided into anterior and posterior branches. R. anterior a. reccurens ulnaris anastamoses with a. collateralis ulnaris inferior whereas r. posterior a. reccurens ulnaris anastamoses with a. collateralis ulnaris superior. The last two collateral arteries are branches of a. brachialis. Due to all these anastamoses rete articulare cubiti is formed,which not only supplies with blood cubilal region and elbow joint,but also performs the collateral (accessory) circulation in the cubital region. N. radialis in the upper margin of the cubital region lies between the m.m. brachialis and brachioradialis, then at the level of the lateral epicondyle is situated on the articular capsule, between the m.m. brachioradialis and supinator. Here the nerve is divided into 2 branches: superficial and deep. Posterior Cubital Region (Regio cubiti posterior) Layers. The skin is thick, movable. Subcutaneous tissue is not well developed. Subcutaneous bursa (bursa subcutanea olecrani) is situated under the skin on the level of the olecranon. Superficial fascia is the thin, transparent membran.

Proper fascia is thick and has an appearance of the aponeuroses, under which m.anconeus is located. To the olecranon attaches the tendon of the triceps muscle, under which the mucos bursa is present. One groove is formed in medial sides of the process of the ulna (olecranon): posterior medial grooves. In sulcus cubitalis posterior medialis n. ulnaris lies. It passes between medial epicondyle and olecranon in the osteo-fibrous canal formed by proper fascia with the collateral ulnar superior artery. Superficial position of the ulnar nerve is the cause of its frequent injury. N. ulnaris then continues its way on the forearm passing between the heads of m. flexor carpi ulnaris. Between lateral epicondyle and olecranon here the head of the radius is palpated and the puncture of the elbow joint is made here. In children a fossa is formed in place of groove which is called marvelous fossa (fossa pulchritudinis). The Forearm (Antebrachium) Boundaries: superior border is a circular line which passes two transverse fingers (4-6cm) below the epycondyles; inferior border is a line which passes 1 cm above the base of styloid processes. By 2 vertical lines, which connect epycondyles with styloid processes, the forearm is divided into anterior and posterior regions. Anterior Region of the Forearm (Regio antebrachii anterior) Layers. The skin is thin, movable through which v. cephalica and v. basilica are visible. Superficial fascia is hardly developed. In the subcutaneous tissue near the medial border of the brachioradialis muscle v. cephalica is accompanied by lateral skin nerve of the forearm (n. cutaneus antebrachii lateralis), medially v. cephalica is accompanied by medial skin nerve of the forearm (n. cutaneus antebrachii medialis). By the midline v. mediana antebrachii passes. Proper fascia is thick and shiny in the proximal part. By two intermuscular septa which extend from the proper fascia and are attached to the radius (septa intermusculare radiale anterior et posterior), the forearm is divided into 3 osteofascial compartments: anterior, posterior and lateral. It is better seen on the transsection of the forearm in the middle third of it.In difference to arm, there are no interfascial spaces for the vessels and nerves, so neurovascular bundles pass through the muscular fissures in the osteo-fascial capsules. Anterior compartment is bounded by the proper fascia anteriorly, radius, ulna and the interosseous membrane posteriorly and anterior radial intermuscular septum laterally, where flexors and pronators are located. Medially proper fascia is fused with posterior margin of the ulna. Lateral compartment is formed by 2 intermuscular septa (anterior and posterior), radius and proper fascia laterally, where m.m. brachioradialis and supinator only in upper 1/3 are located. Anterior and lateral compartments are in the anterior region of the forearm. In the anterior region of the forearm the muscles are arranged in 4 layers: first layer consists of (beginning from lateral border) m.m. brachioradialis, pronator teres, flexor carpi radialis, palmaris longus and flexor carpi ulnaris; second layer-m. flexor digitorum superficialis; third layer-m.m. flexor digitorum profundus et flexor pollicis longus; fourth layer-m. pronator quadratus( only in the inferior third of the forearm). Between the second and third layers there is the deep layer of the proper fascia, which subdivided the muscular layers into the superficial and deep. A space is left between the third and fourth layers which is called Pirogovs space, filled with loose connective tissue and connected with the ulnal and radial synovial bursas of the hand. Four neurovascular bundles are located in the anterior region of the forearm. Three of them are lying in the grooves, which are formed between the muscles of the anterior region. A. radialis with accompanying veins and r. superficialis n. radialis lies in the radial groove. This groove (sulcus radialis) is formed between brachioradial muscle laterally and pronator teres in the superior parts, and flexor carpi radialis in the middle and inferior parts. R. superficialis n. radialis lying laterally from the artery, accompanied the artery till the margin between the middle and inferior thirds, then pierces the fascia goes to the subcutaneous tissue of the dorsal surface of the forearm. At the inferior boundary of the region, 2cm above the base of the styloid process a. radialis passes to the dorsal surface of the hand- into the anatomical snuff -box. A common place for measuring the pulse rate is where the radial artery lies on the anterior surface of the distal end of the radius, lateral to the tendon of the flexor carpi radialis. Here the artery can be compressed against the distal end of the radius where it lies between the tendons of the flexor carpi radialis and abductor pollicis longus. Radial pulse, like other palpable pulses of the body, is a peripheral reflection of the cardiac action. In the superior third a. radialis gives off a.recurrens radialis. A. radialis is projected by line which passes from the midpoint of the cubital fold to the lateral styloid process. A.ulnaris with accompanying veins and nerve lies in the ulnar groove. Last one is formed between m. flexor carpi ulnaris medially and m.flexor digitorum superficialis laterally.Nerve is located medially and it accompanies the artery in middle and inferior thirds of the ulnar groove. The a.ulnaris in the upper third of forearm is located under the m.pronator teres and m.flexor digitorum superficialis. The ulnar nerve in the upper third of forearm passes between heads of the m. flexor carpi ulnaris. So the ulnar nerve is in the ulnar groove in it’s whole length, but the artery only in middle and inferior thirds. The ulnar nerve in the border between middle and inferior thirds gives off the r.dorsalis to the subcutaneous space of the wrist’s dorsal surface. N. ulnaris is projected by a line which connects medial epicondyle of the humerus with the sesamoid pisiform bone. A. ulnaris is projected by this line only in the middle and inferior thirds. In the superior third it moves laterally to the midpoint of the elbow fold. The ulnar artery and nerve pass into the palm lateral to the pisiform. The ulnar pulse is usually difficult to palpate. Median neurovascular bundle consists of the median nerve, artery and veins. N. medianus lies in the median groove (sulcus medianus) only in the inferior third of the forearm. This groove is formed between m. flexor digitorum superficialis medially and m. flexor carpi radialis laterally. In the superior third of the forearm nerve passes between the heads of m. pronator teres, then crosses the ulnar artery anteriorly and in the middle third passes between two- superficial and deep flexors of the digits. A.mediana (its also called a. comitans n. mediani) is the branch of a. interossea anterior. N. medianus is projected by a line which connects the point located 1cm medialy from the midpoint of the cubital fold with the midpoint of the line connecting the styloid processes. In the superior third of forearm the ulnar artery gives off the common interosseus artery, which subdivided into anterior and posterior interosseus arteries. Fourth bundle consists of the anterior interosseous artery, veins and nerve (vasa interossea anterior and n. interosseus), and located on the anterior surface of the interosseus membran. N. interosseus is the branch of the medianus nerve and a. interossea anterior-branch of the common interosseous artery.The last one pierces the interosseous membrane through the superior margin of the pronator quadratus muscle and passes into the posterior osteo-fascial compartment and participate into the rete carpi dorsale.

Posterior Region of the Forearm (Regio antebrachii posterior) Layers. The skin is thick, hardly movable, covered by haires. There is a little amount of fat in the subcutaneous tissue. The skin is innervated by n. cutaneus antebrachii posterior which is the branch of n. radialis. Superficial fascia is the thin layer. Proper fascia is thick, dense and forms posterior osteo-fascial compartment. It is bounded anteriorly by the bones of the forearm and interosseous membrane, posteriorly by the proper fascia, laterally-by the posterior intermuscular septum and medially- by the proper fascia which is attached to the posterior border of the ulna. In the posterior osteo-fascial compartment are located the extensors and supinator muscles. In the posterior region the muscles are arranged in two layers: superficial, which contains five extensors: m.m. extensor carpi radialis longus et brevis, m. extensor digitorum, m. extensor digiti minimi and m. extensor carpi ulnaris; deep layer contains also 5 muscles: m. supinator, m. abductor pollicis longus, m.m. extensor pollicis longus et brevis , m. extensor indicis. There is a deep fascia between these two layers. There is a fatty tissue space on the deep fascia, where the neurovascular bunch lies. It consists of r. profundus n. radialis, vasa interosseae posterior. The posterior interosseous nerve is the continuation of the deep branch of the radial nerve (r. profundus n. radialis) comes from the supinator canal. Nerve is the laterally from the artery. A. interossea posterior is the branch of a. interossea communis passes to the posterior region through the opening in the interosseus membrane. In the middle and inferior thirds the neurovascular bunch lies on the posterior surface of the interosseus membran. Clinically it is important to know the projection of the radial artery which is made by connecting the midpoint of the cubital fold with the medial border of the styloid process of the radius( it coincides with the radial groove). N. ulnaris is projected by a line which connects medial epicondyle of the humerus with the sesamoid pisiform bone. A. ulnaris is projected by this line only in the middle and inferior thirds.In the superior third it moves laterally to the midpoint of the elbow fold. N. medianus is projected by a line which connects the point located 1cm medialy from the midpoint of the cubital fold with the midpoint of the line connecting the styloid processes.

Operative surgery & topographical anatomy of the abdomen. Surgical anatomy of the inguinal canal and spermatic cord. 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 ligaments and pubic symphysis The lateral boundaries are the middle axillary (Lesgaft’s) lines. By two horizontal lines the anterior wall is divided into 3 regions: 1. Epigastrium 2. Mesogastrium 3. Hypogastrium The first horizontal line is between the lower points of the 10th pair of ribs and is called bicostal line (linea bicostarum) The second horizontal line is between spinae iliacae anteriores superiores and is called bispinal line (linea bispinarum) By two vertical lines which pass 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 abdominal wall: 1. Skin is thin, elastic, moveable, except umbilical region, is covered by hair 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 fascia 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 ligament. From the pubic symphisis it continuous to the scrotum and perineum 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 abdominal cavity 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 thorax. 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 rectus abdominis muscle 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 inguinal ligament (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 pubis 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 iliac crest. 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 linea alba, 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 rectus sheath is different above and below the umbilicus. The anterior wall of the sheath in its superior part consists of the aponeuroses of the external oblique and the 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 transversalis fascia. 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 arteries are located: a. epigastrica superior (branch of a.thoracica interna) with double veins. 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 pelvic cavity, then on the posterior abdominal wall to the diaphragm. 9. An extraperitoneal fat called Langenbek’s fatty tissue layer is between the parietal peritoneum 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 artery with the veins, which are accompanied them are continuous from the oval opening of the antero-medial surface of the thigh 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 uterus. The nerves are branches of the lumbar plexus. • A. lumbales, four in each sides , branches of the abdominal aorta. The superficial veins form a network. The veins, which are located above the umbilicus, drain into the axillary vein by the thoracoepigastric veins; veins below the umbilicus drain into the femoral vein. 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 liver. 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) • Testicular artery 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 genitofemoral nerve • 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 fossa between the median and medial umbilical folds.  Medial inguinal fossa between the medial and lateral umbilical folds. It’s behind the superficial inguinal ring.  Lateral inguinal fossa is lateral to the lateral umbilical fold. It corresponds to the deep inguinal ring. Inguinal Hernia Abdominal hernia is a protrusion of abdominal content, viscus (organ), or part of it covered by peritoneum through the natural or new formed opening of the abdominal wall. About 90% of herniae are located in the inguinal region. There are two types of inguinal hernia: indirect and direct. 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 peritoneal cavity, 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 hypochondrium 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 falciform ligament 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 stomach 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 kidney 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 coronary ligament - 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 hepatogastric ligament. 2. the hepatoduodenal ligament. These two ligaments with the gastrophrenic ligament 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 hepatorenal ligament. 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 ligamentum venosum, 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 neck 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 serous membrane 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 cystic artery supplies the gallbladder and cystic duct. The artery commonly (72%) arises from the right hepatic artery in the angle between the common hepatic duct and the cystic duct. Here Calout’s triangle is described which is limited by common hepatic duct (from the left side), cystic duct (from the right side) and the superior edge or the base of the triangle is formed by the cystic artery. This triangle has practical importance in duct-first cholecystectomy. 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 gastrocolic ligament 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, spleen – 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 abdominal aorta, 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 mesentery 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 adrenal gland, 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 phrenicocolic ligament, 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 ileum.

Jejunum and Ileum

The jejunum begins at the duodenojejunal junction, and the ileum ends at the ileocecal junction, the union of the ileum with the cecum. Together the jejunum and ileum are 6-7 m long in cadaver; the jejunum constitutes about two-fifths and the ileum the remainder. Most of the jejunum lies 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 pelvis from which it ascends to end in the medial aspect of the cecum. Although there is no outer line of demarcation between the jejunum and ileum, they have distinctive characteristics that are of surgical importance. The mesentery attaches most of the small intestine to the posterior abdominal wall. The root of the mesentery (about 15 cm long) is directed obliquely, inferiorly, and to the right from the left side of L2 vertebra to the right sacroiliac joint. The 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 greater omentum 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 appendix has mesoappendix, where is located the appendicular artery. 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.iliopsoas 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 ileocolic artery; The right colic artery; The middle colic artery. 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 left colic artery. 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 middle rectal artery supply middle third and inferior rectal artery supply inferior third of the rectum (middle rectal artery is a branch of internal iliac artrey, inferior is a branch of internal pudental artery from internal iliac artery). 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-linea terminalis 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 iliopectineal arch(arcus iliopectineus) .It is the thickened medial part of the iliac fascia which descends and passes from the inguinal ligament to the eminencia iliopectinea of the pubic bone. M. iliopsoas, n. femoralis and n. cutaneus femoris lateralis pass through the lacuna musculorum. Lacuna vasorum is bounded anteriorly and superiorly by the inguinal ligament, laterally – by iliopectineal arc, medially- by the lacunar ligament (lig. lacunare s. Gimbernati), inferiorly and posteriorly- by pectineal ligament (lig. pectineale Cooperi) which is the thickened part of the periosteum of the pubic bone. Femoral artery 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 lymph node). Femoral artery and vein are covered by the sheath (vagina vasorum femoralium). Here also femoral hernias can pass which form the femoral canal. 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 lata (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 obturator artery or forms an accessory obturator artery. This artery runs close to or across the femoral ring to reach the obturator foramen. Here it is closely related to the free margin of the lacunar ligament and the neck of the femoral hernia. Consequently, this artery could be involved in a strangulated femoral hernia. The deep femoral ring in such cases is surrounded by anomalous obturator artery 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 femur, medially- sacrum and coccyx in the depth of the natal cleft. Projection of a. glutea superior is on the border of superior and middle thirds of the line connecting superior posterior iliac spine with the top of the greater trochanter. Projection of a. glutea inferior is a little lateral and inferior from the midpoint of the line between superior posterior iliac spine and sciatic tuber. Layers. The skin is thick, movable, near the intergluteal fold it’s covered by hair and is richly supplied by sweat and sebaceous glands. It is connected with 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 gluteus maximus muscle. Muscles of this region are arranged in 3 layers: superficial, middle and deep.The superficial layer consists of m. gluteus maximus.The middle layer consists of m. gluteus medius, m. piriformis, m. obturatorius internus, mm. gemelii superior et inferior and m. quadratus femoris. In the deep layer there are 2 muscles: m.m. gluteus minimus et obturatorius externus. The largest fatty tissue space is under the gluteus maximus muscle and is separated from the lumbar region by the attachment of the proper fascia to the iliac crest. This space is communicated with the pelvic cavity through the suprapiriform and infrapiriform openings. They are formed by the piriform muscle, fibers of which pass through the greater schiatic opening up to the top of the great trochanter. M. piriformis divides sciatic opening into two openings: suprapiriform and infrapiriform (foramen suprapiriforme et foramen infrapiriforme). The above mentioned fatty tissue space is connected with other regions too: along a. v. pudendae internae it communicates with fossa ischiorectalis; along n. ischiadicus- with posterior femoral region; under f. lata –with lateral and anterior parts of the thigh. The superior and inferior gluteal arteries (branches of a. iliaca interna) leave the greater sciatic foramen and pass superiorly and inferiorly to piriformis, respectively. They are followed by veins and nerves of the same name. Pudental internal vessels (a. iliaca interna), pudental and sciatic nerve and posterior skin nerve of the thigh also pass through the infrapiriform foramen (all the nerves are from the sacral plexus). The branches of the superior gluteal artery (a. glutea superior) pass through the thickness of the piriform muscle where they make anastamoses with the branches of the inferior gluteal artery. The trunk of the superior gluteal artery lies just on the periosteum of the greater sciatic foramen, so here we must ligature it when it’s bleeding. The inferior gluteal artery is 2-3 times thinner than the superior one. This neurovascular bunch (a.v.n. glutea inferiores), after leaving the infrapiriform foramen, first pierces the fascia and then passes into the thickness of the gluteus maximus muscle. 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 knee 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 femoral nerve, 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 femoral triangle, medial 1/3 – by the anterior femoral sulcus, inferior 1/3 – by the adductor canal. 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 pectineus muscle. 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 sartorius muscle. Here 2-4 perforating branches of the deep femoral artery (r.r. perforantes) extend. Through the openings in the tendon of the adductor muscles with the edges of which adventicia of the vessels is fused, these arteries appear on the posterior surface of the thigh.The lumen of perforating artery doesn’t constrict when it is incised which explanes the development of the increasing haematoma when the femur is fractured in its middle part.

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 popliteal fossa. The anterior opening is in lamina vastoadductoria, through which descending artery and vein of the knee (a.v. genu descendens) and n. saphenus exit 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 perforating arteries 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 hamstrings: semitendinosus, semimembranosus, biceps femoris. They span the hip and knee joints hence they are extensors of the thigh at the hip joint and flexors of the leg at the knee joint. Pulled hamstrings are common in sportsmen who run very hard (baseball and soccer players). Hamstring injuries often result from inadequate warming up before competition. 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 biceps femoris muscle, 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 tibia, 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 popliteal artery; a.a.reccurentes tibiales anterior et posterior-branches of the anterior tibial artery; a. circumflexus fibulae- branch of the posterior tibial artery.

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 popliteus muscle. The main contents of the popliteal fossa are neuro-vascular bunch, lymph nodes and vessels. Deep fascia (f. poplitea) forms a strong protective sheet for the elements passing from the thigh through the fossa to the leg. A. poplitea is the continuation of the femoral artery and is called this way after emerging from Hunter’s canal through the adductor tendineus hiatus. It passes through the fossa and at the inferior 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 tibial nerve (n. tibialis), the medial larger terminal branch of the sciatic nerve, is the most superficial and lateral of the three structures (n.v.a.). Five genicular branches of the popliteal artery supply the knee joint and anastomose to form the network around the knee (see above). The common fibular nerve (n. peroneus communis) is the lateral, smaller branch of the sciatic nerve. Beginning at the superior angle of the popliteal fossa, it passes 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.