Pirogov's laws on the structure of fascial structures. Topographic anatomy
Great scientific discoveries
Secrets of the living
Topographic anatomy
The great Russian surgeon and scientist Pirogov is considered to be the founder of topographic anatomy.
Nikolai Ivanovich Pirogov (1810-1881) was born in Moscow. When Nikolai was fourteen years old, he entered the medical faculty of Moscow University. To do this, he had to add two years to himself, but he passed the exams no worse than his older comrades.
After graduating from the university, Pirogov went to prepare for a professorship at the University of Dorpat. At that time, this university was considered the best in Russia. Here, in the surgical clinic, Pirogov worked for five years, brilliantly defended his doctoral dissertation, and at the age of twenty-six became a professor of surgery.
The subject of his thesis, he chose the ligation of the abdominal aorta, performed until that time - and then with a fatal outcome - only once by the English surgeon Astley Cooper. The conclusions of the Pirogov dissertation were equally important for both theory and practice. When Pirogov, after five years in Dept, went to Berlin to study, the famous surgeons, to whom he went with a respectfully bowed head, read his dissertation, hastily translated into German. A teacher who, more than others, combined everything that Pirogov was looking for in a surgeon, he found in Göttingen, in the person of Professor Langenbeck. The Göttingen professor taught him the purity of surgical techniques.
Returning home, Pirogov fell seriously ill and was left for treatment in Riga. As soon as Pirogov got up from the hospital bed, he undertook to operate. The city had heard rumors before about the promising young surgeon. Now it was necessary to confirm the good reputation that ran far ahead.
He began with rhinoplasty: he carved out a new nose for a noseless barber. Then he recalled that it was the best nose he had ever made in his life. Plastic surgery was followed by the inevitable lithotomies, amputations, removal of tumors. In Riga, he operated for the first time as a teacher. From Riga, Pirogov went to a clinic in Dorpat.
Here, in 1837, one of Pirogov's most significant works, Surgical Anatomy of Arterial Trunks and Fascia, was born. It was the result of eight years of work, a work of classical breadth and completeness.
There may be a different approach to information about the structure of the human body, and Pirogov writes about this: “... A surgeon should deal with anatomy, but not in the same way as an anatomist ... The department of surgical anatomy should belong to a professor not of anatomy, but of surgery ... Only in the hands of a practical physician, applied anatomy can be instructive to listeners. Let the anatomist study the human corpse to the smallest detail, and yet he will never be able to draw the attention of students to those points of anatomy that are extremely important for the surgeon, but for him may have absolutely no significance.
The reason for the failure of most of the "anatomical and surgical treatises" compiled by Pirogov's predecessors is the underestimation of the applied value of anatomy, in avoiding the "private goal" - to serve as a guide for the surgeon. Meanwhile, everything must be subordinated to this “private goal”, only to it.
Pirogov, of course, was well acquainted with the works of his predecessors - the prominent French scientists Velpeau and Blandin. I carefully examined the famous atlas of Buyalsky. He asks himself the question: “Can a young surgeon be guided in his operational exercises on a corpse, not to mention operations on the living, by drawings of arterial trunks in the best works on surgical anatomy, what are the works of Velpeau and Blunden?”
And the answer is emphatically: no!
“The usual method of preparation adopted by anatomists ... is not suitable for our applied purposes: a lot of connective tissue is removed that holds the various parts in their relative position, as a result of which their normal relations change. Muscles, veins, nerves are removed in the drawings from each other and from the artery to a much greater distance than it actually exists.
Pirogov criticized Buyalsky’s atlas: “... You see, for example, that in one of the drawings depicting the ligation of the subclavian artery, the author removed the collarbone: thus, he deprived this area of \u200b\u200bthe main, natural border and completely confused the surgeon’s idea of the relative position of the arteries and nerves to the clavicle, which serves as the main guiding thread during the operation, and about the distance of the parts located here from each other.
Brilliant for their time, the attempts of Velpo and Buyalsky faded before the new word of Pirogov.
In his essay, a whole science, surgical anatomy, Pirogov develops and approves on the basis of a very specific and at first glance not very voluminous doctrine of fascia. Before Pirogov, they almost did not deal with fascia. They knew that there were such membranes, plates, surrounding groups of muscles or individual muscles, saw them on a corpse, stumbled upon them during operations, cut them - and did not attach any importance to them, treated them as some kind of "anatomical inevitability".
Pirogov's basic idea is quite specific: to study the course of fascial membranes. He gets to the smallest details and already here he finds a lot of new things. Having thoroughly studied the particular - the course of each fascia - he goes to the general: he deduces certain patterns of the relationship of fascial membranes with blood vessels and surrounding tissues. That is, it opens up new anatomical laws. But he needs all this not in itself, but in order to find rational methods for performing operations, “to find the right way to ligate this or that artery,” as he himself says.
“Finding a vessel is sometimes not easy,” writes V.I. Porudominsky. - The human body is complex - much more complex than it seems to a non-specialist who learned about it from posters-diagrams of a school anatomy course. In order not to get lost, you need to know the landmarks.
Pirogov again scolds (does not get tired!) "scientists who do not want to be convinced of the benefits of surgical anatomy", "famous professors" in "enlightened Germany", "who speak from the department about the uselessness of anatomical knowledge for the surgeon", professors whose "method of finding of one or another arterial trunk is reduced exclusively to touch: “you should feel the beating of the artery and bandage everything from where the blood spurts” - this is their teaching !!” If the head "does not balance" the hand with extensive anatomical knowledge, the surgeon's knife, even an experienced one, wanders like a child in the forest. The most experienced Grefe fiddled around for three quarters of an hour until he found the brachial artery. Pirogov explains: “The operation became difficult because Grefe did not get into the arterial vagina, but into a fibrous bag.” Here, in order to prevent this from happening, Pirogov studied the fascia in detail, looking for their relationship to blood vessels and nearby tissues. He pointed out the most detailed landmarks to traveling surgeons, set milestones, - according to the apt definition of the professor of surgery Lev Levshin, he developed “excellent rules on how to go with a knife from the surface of the body to the depths in order to easily and quickly tie up the various arteries of the human body.”
In each section of his work, Pirogov, firstly, outlines the boundaries of the area within which the operation is performed; secondly, he lists the layers that the surgeon goes through, making his way deeper; thirdly, it gives the most accurate operational remarks.
"Surgical anatomy of the arterial trunks and fascia" is a text and over fifty tables. Pirogov always treated illustrations with particular captiousness. He wrote that "a good anatomical-surgical drawing should serve the surgeon for what a guide map serves the traveler: it should represent the topography of the area in a slightly different way than an ordinary geographical map, which can be compared with a purely anatomical drawing."
Pirogov illustrated each operation mentioned in the book with two or three drawings. No discounts, the greatest subtlety and accuracy of drawings, reflecting the subtlety and accuracy of Pirogov preparations - the proportions are not violated, every branch, every knot, jumper is preserved and reproduced. According to such a map, the surgeon will go unmistakably.
Among those who admired the "Surgical Anatomy of the Arterial Trunks and Fascia" was the famous Parisian professor Alfred Armand Louis Marie Velpeau.
But Nikolai Ivanovich did not calm down on this. The usual method of preparation satisfied those who studied the structure of organs. Pirogov brought topography to the fore. He wanted the human body to be transparent to the surgeon. So that the surgeon mentally imagines the position of all parts in a section drawn in any direction through any point of the body.
To find out how different parts of the body are located, anatomists opened cavities and destroyed connective tissue. The air, breaking into the cavities, distorted the position of the organs, their shape.
However, it was impossible to achieve an accurate cut in the usual way. The location of the parts, their ratios, already distorted during the opening of the cavities, finally changed under the anatomist's knife. There was a situation sometimes encountered in science: the experiment itself interfered with obtaining the exact results for which it was carried out. It was necessary to find a new way.
There is a legend that connects a random episode from the life of Pirogov with an idea that turned the whole of anatomical science onto a new path. “We, ordinary people,” writes one of Pirogov’s adherents, “pass by without attention the subject that gives rise to a creative thought in the head of a man of genius; So Nikolai Ivanovich, driving along Sennaya Square, where in winter frozen pork carcasses, cut across, were usually placed, paid special attention to them and began to apply what he had noticed to the case.
And indeed, there is a connection between the sawn carcasses on Sennaya Square and a new direction in anatomical research. But the idea came to Nikolai Ivanovich much earlier. Recounting his disputes with Amusse in Paris, the surgeon-scientist writes: "I told him about the result of my research into the direction of the urinary canal on frozen corpses." But Pirogov went to Paris as a Dorpat professor!
Around the same years, Buyalsky made an interesting experiment at the academy: on a frozen corpse, which was given a beautiful pose, he exposed muscles; the sculptors made a mold and cast a bronze figure - future artists used it to study the muscles of the body. Consequently, the idea of using cold in anatomical studies appeared long before traveling around Sennaya Square. It is difficult to assume that Pirogov, with his craving for everything new, with his scope, lived in ignorance. Apparently, Sennaya Square again suggested a method, a technique, and did not give birth to an idea.
“What path did Pirogov take in order to obtain accurate data on the topography of the human body? - asks V.I. Porudominsky and answers. - He kept the corpse for two or three days in the cold and brought it "to the density of solid wood." And then he "could treat it in exactly the same way as with a tree", without fear "neither the entry of air after opening the cavities, nor the compression of parts, nor their disintegration."
Like a tree! Pirogov sawed frozen corpses into thin parallel plates.
He made cuts in three directions - transverse, longitudinal and anteroposterior. It turned out a whole series of records - "discs". Combining them, comparing with each other, it was possible to get a complete picture of the location of various parts and organs. Starting the operation, the surgeon mentally saw transverse, longitudinal, anteroposterior incisions made through one or another point - the body became transparent.
A simple hand saw was not suitable for this purpose. Pirogov adapted another, brought from the carpentry factory - there, with its help, they cut red, walnut and rosewood wood. The saw was huge - it occupied an entire room in the anatomical theater.
The room was as cold as outside. Pirogov froze so that the corpses would not thaw. The work went on for hours. It would lose its meaning if each plate of the cut could not be preserved forever, made the property of all. Pirogov compiled an atlas of sections. The atlas was called: "Illustrated topographical anatomy of cuts made in three directions through the frozen human body." Right there in the cold room, the frozen cut plates were covered with glass lined into squares and exactly redrawn in full size on paper covered with the same grid.
Pirogov struggled with "ice anatomy" for about ten years. During this time, he discovered another way to "apply cold" to his research - he came up with "sculptural anatomy". Now there are no cuts. The corpse was frozen even more - "to the density of the stone." And then, on a frozen corpse, with the help of a chisel and a hammer, the parts and organs needed for study were exposed from the icy layers. “When, with considerable effort, it is possible to take away the frozen walls, thin layers should be thawed with a sponge soaked in hot water until, finally, the organ under study is opened in its unchanged position.”
If each anatomical atlas of Pirogov is a step in the knowledge of the human body, then "Ice Anatomy" is the top. New patterns have been revealed - very important and very simple. For example, it became known that, with the exception of three small cavities (pharynx, nose and ear drum) and two channels (respiratory and intestinal), empty space is never found in any part of the body in the normal state. The walls of all other cavities fit snugly against the walls of the organs enclosed in them.
Pirogov froze corpses in different poses - then on cuts he showed how the shape and ratio of organs change when the position of the body changes. He studied deviations caused by various diseases, age and individual characteristics. I had to make dozens of cuts to find one worthy of reproduction in the atlas. In total, there are a thousand drawings in the "ice anatomy"!
Pirogov's anatomical atlas has become an indispensable guide for surgeons. Now they have the opportunity to operate, causing minimal injury to the patient. This atlas and the technique proposed by Pirogov became the basis for the entire subsequent development of operative surgery.
Tasks of operative surgery and topographic anatomy. The definition of the subject, the unity of the two components of the discipline, the place among the surgical departments, the significance for the clinic.
Operative surgery (the science of surgical operations) studies the technique of surgical interventions. Topographic (surgical) anatomy - the science of the relationship of organs and tissues in various areas of the human body, studies their projection on the surface of the human body; the ratio of these organs to non-displaced bone formations; changes in the shape, position and size of organs depending on body type, age, sex, disease; vascularization and innervation of organs, lymphatic drainage from them. Based on modern achievements in anatomy and physiology, operative surgery develops methods for the rational exposure of organs and the implementation of certain influences on them. Topographic anatomy describes the layered location and relationship of organs by region, which allows you to determine the affected organ, choose the most rational operational access and reception.
Tasks topographic anatomy: holotopia - areas of location of nerves, blood vessels, etc.; layered structure of the area; skeletopia - the ratio of organs, nerves, blood vessels to the bones of the skeleton; siletopia - the relationship of blood vessels and nerves, muscles and bones, organs.
Tasks operative chir: adequate accesses and opera techniques corresponding to the rationality and expediency of the operation.
The history of the development of the subject of operative surgery and topographic anatomy, the main directions of development in different periods, the significance for the clinic.
The first work on operational and topographic anatomy was written by the Italian surgeon and anatomist B. Jeng in 1672. The founder of topographic anatomy as a science is the brilliant Russian scientist, anatomist and surgeon N. I. Pirogov. For the first time the department of operative surgery and topographic anatomy appeared on his initiative at the St. Petersburg Military Academy in 1867, the first head of the department was Professor E. I. Bogdanovsky. Topographic anatomy and operative surgery have received special development in our country in the works of V. N. Shevkunenko, V. V. Kovanov, A. V. Melnikov, A. V. Vishnevsky and others
I period: 1764-1835 1764 - opening of the medical faculty of Moscow University. Mukhin - head of the department of anatomy, surgery and midwifery. Buyalsky - published anatomical and surgical tables - director of the medical and instrumental plant (Buyalsky's spatula). Pirogov is the founder of operative surgery and topographic anatomy. Years of life - 1810-1881 At the age of 14 he entered Moscow University. Then he studied in Dorpat with Moyer (the topic of his doctoral dissertation - "Ligation of the abdominal aorta in inguinal aneurysms" - defended at the age of 22). In 1837 - the atlas "Surgical anatomy of arterial trunks" and ... received the Demidov Prize. 1836 - Pirogov - professor of surgery at Dorpat University. 1841 - Pirogov returned to St. Petersburg to the Medical and Surgical Academy at the Department of Hospital Surgery. Founded 1 anatomical institute.
New techniques invented by Pirogov: layer-by-layer dissection of a corpse; method of transverse, frozen cuts; ice sculpture method.
The cuts were made taking into account the function of the joints - in a bent and unbent state.
Pirogov is the creator of the Complete Course of Applied Anatomy. 1851 - atlas of 900 pages.
II period: 1835-1863 Separate departments of surgery and topographic anatomy are distinguished.
III period People: 1863-present: Bobrov, Salishchev, Shevkunenko (typical anatomy), Spasokukotsky and Razumovsky - founders of the Department of Topographic Anatomy; Klopov, Lopukhin.
The role of N.I. Pirogov in the development of operative surgery and topographic anatomy. The main stages of the life and work of N.I. Pirogov. Pirogov's laws on the relationship of vessels and fascia.
the founder of military field surgery in Russia and the anatomical and experimental direction in surgery. Pirogov developed a number of completely new techniques, thanks to which he managed more often than other surgeons to avoid amputation of limbs. One of these techniques is still called the “Pirogov operation.” In search of an effective teaching method, Pirogov decided to apply anatomical studies on frozen corpses. Pirogov himself called this "ice anatomy". Thus was born a new medical discipline - topographic anatomy. After several years of such study of anatomy, Pirogov published the first anatomical atlas entitled "Topographic anatomy, illustrated by cuts made through the frozen human body in three directions", which became an indispensable guide for surgeons. From that moment on, surgeons were able to operate with minimal trauma to the patient. This atlas and the technique proposed by Pirogov became the basis for the entire subsequent development of operative surgery. Pirogov is considered the founder of a special direction in surgery, known as military field surgery.
Before N.I. Pirogov did not attach importance to the study of fascia. For the first time, Nikolai Ivanovich carefully and in detail describes each fascia with all its septa, processes, splits, and junction points. Based on these data, he formulated certain regularities in the relationship of fascial membranes with blood vessels and surrounding tissues, that is, new anatomical laws that make it possible to justify rational operational access to blood vessels. The anatomical relationships of the neurovascular bundles with the surrounding fascia and muscles are shown in the drawings from the Topographic Anatomy illustrated by cuts made through the frozen human body in three directions by N.I. Pirogov.
The basic first law is; that all vascular sheaths are formed by the fascia of the muscles located near the vessels, that is, the posterior wall of the fascial sheath of the muscle is, as a rule, the anterior wall of the sheath of the neurovascular bundle located next to the muscle
The second law concerns the shape of the vascular sheath when stretching the walls of the muscular sheaths related to the vessels. The shape of the arterial sheaths will be prismatic in cross section - triangular, in the form of a trihedral prism. one face is facing anteriorly, and the other two - medially and laterally from the vessels. The edge of the prism N.I. Pirogov calls the top, and the face facing forward - the base.
The third law on the relation of the vascular sheaths to the deep layers of the region.
Further: the development of the teachings of N.I. Pirogov about the relationship of blood vessels and fascia was: the provision on the sheath structure of the fascial-muscular system of the limbs. Each department of the limb shoulder, forearm, thigh, lower leg is a set of fascial bags, or cases, located in a certain order around one or two bones.
Theory of N.I. Pirogov about the sheath structure of the limbs is of great importance for substantiating the spread of purulent streaks, hematomas, etc. In addition, this theory forms the basis of the doctrine of local anesthesia using the creeping infiltrate method developed by A.V. Vishnevsky on the limbs, this method is called case anesthesia.
Proceedings:"Surgical anatomy of arterial trunks and fascia" - the basis of topographic anatomy as a science;
"Full course of applied anatomy of the human body with drawings. Descriptive-physiological and surgical anatomy";
"Topographic anatomy illustrated by cuts through the human body in 3 directions". The main rule is observed: preservation of organs in their natural position;
Using the method of cuts to study not only the morphology, but also the function of organs, as well as differences in their topography, associated with a change in the position of certain parts of the body and the state of neighboring organs;
Used the method of cuts to develop the question of the most appropriate access to various organs and rational operational methods;
Osteoplastic amputation of the lower leg;
Animal experiments (ligation of the abdominal aorta);
Studying the action of ether vapors;
For the first time he taught topographic anatomy of operative surgery.
The doctrine of extreme forms of variability of organs and systems. The basic principles for the selection of extreme forms according to V.N. Shevkunenko, concepts: norm, anomaly, malformation. Applied value of the doctrine of the patterns of individual variability.
The most complete scientific theoretical substantiation and resolution of the problem of individual anatomical variability was found in the doctrine of extreme forms of variability of organs and systems of the human body, created by Academician V.N. Shevkunenko. The works laid the foundation for the creation of a new direction in applied anatomy - the study of not individual options, but the definition of a scientific approach to identifying patterns of individual variability. It was possible to prove that anatomical variants are not accidental, they are based on the law of development of the organism. The identification of extreme forms of variability was aimed at giving the practitioner an idea of the boundaries within which, for example, the level of an organ or its structure can fluctuate (variate).
1) all human organs and systems without exception are subject to individual variability.
2) application of the principles of variation statistics to the study of individual variability, the use of a variation series for the analysis of both the range of variability and the frequency of occurrence of individual variants.
3) individual anatomical differences are not the sum of chances, they are basically determined by the laws of ontogenesis and phylogenesis and are formed in the process of complex interactions of a developing organism with environmental factors.
The norm, therefore, should be considered as a varying set of morphological features, a range of observed anatomical differences, the boundaries of which are extreme forms of variability. an anomaly as an anatomical fact is the result of a disturbed, “perverted” developmental process while maintaining functions.
A malformation is such congenital disorders of the anatomical structure (or position) of organs that entail greater or lesser dysfunction (for example, cleft arterial duct between the aorta and pulmonary artery, cleft of the interventricular septum, atresia of the digestive tract in newborns, etc.) .
5. Types and classifications of operations: planned, urgent and emergency, radical and palliative, choice and need. The concept of simultaneous operations.
Operation types
Emergency (urgent, urgent) - are made according to vital indications immediately.
Urgent operations are operations that can be postponed for a short time (24-48 hours) in order to make minimal preparation of the patient or try to cope with the situation without surgery. Example. A person enters the surgical department and is diagnosed with acute calculous cholecystitis. Immediately after the diagnosis is established, the patient, as a rule, is not operated on. First, they try to stop the attack of pain with conservative measures, while simultaneously correcting the patient's condition and preparing for a possible operation. And only when no improvement is observed after 24-48 hours, the patient is operated on. in this situation, there is no immediate danger to the patient's life, and there is a chance to cope with the situation with conservative methods, and to carry out the necessary operation later, in a planned manner. Carefully examining and preparing the patient for it.
Planned - are made after examining the patient, establishing an accurate diagnosis, long-term preparation. Elective surgeries pose less danger to the patient and less risk to the surgeon than emergency surgeries.
Radical - completely eliminate the cause of the disease (pathological focus).
Palliative surgery does not eliminate the cause of the disease, but only provides temporary relief to the patient.
The operation of choice is the best operation that can be performed for a given disease and which gives the best treatment result at the current level of medical science.
Necessity operations are the best possible option in this situation; depends on the qualifications of the surgeon, the equipment of the operating room, the condition of the patient, etc.
Also, operations can be single-stage, two-stage or multi-stage (one-, two- or multi-stage). One-stage operations are operations in which, during one stage, all the necessary measures are performed to eliminate the cause of the disease. Two-stage operations are performed in cases where the patient's state of health or the risk of complications do not allow to complete the surgical intervention in one stage, or, if necessary, prepare the patient for a long-term dysfunction of any organ after the operation. Multi-stage operations are widely practiced in plastic and reconstructive surgery, and in oncology.
6. The structure of the surgical operation. Elements and stages of surgical intervention. Methods and rules for joining tissues.
A surgical operation is a complex of mechanical instrumental effects on the patient's body, performed with a therapeutic purpose and in compliance with certain rules. a surgical operation is defined as a complex of mechanical influences. this is the effect of the surgeon's hand, armed with an appropriate surgical instrument. It is expressed in the form of various cuts, removals, connections, replacements. With a therapeutic purpose, a surgical operation is a method of treatment and can be undertaken for a diagnostic purpose as part of the treatment process. Subject to certain rules, i.e. strict sequence and uniformity of performance of all actions of the surgeon. In this case, there may be different ways of performing operations of the same type. surgical treatment - contains the preoperative period, the performance of the surgical operation itself and the postoperative period. A surgical operation consists of three main stages: operative access (exposure of an organ or pathological focus), operative reception (surgical manipulations on an organ or pathological focus), and operative exit (a set of measures to restore the integrity of tissues damaged during the implementation of operative access).
Tissue connection: bloodless (Michel's staples, sticky patch) and bloody (suture). Suture is the most common option. superimposed with the help of needles and needle holders and tweezers. The sutures for different tissues are also different: nodal, surgical, continuous sutures.
Surgical instrument: classification, requirements. Electrosurgical instrument.
Heer tools - scoop of tools, devices, devices designed to perform surgical operations. Titanium alloy is usually used (low weight and high corrosion resistance), as well as silver, platinum.
Classification: according to the principle of.
anatomist research (anatomical hammer, brain knife)
diagnostics (neurol hammer)
operative interventions (general surgical instruments, neurosurgery, ophthalmol oper)
Auxiliary tools, accessories, fixtures. (screwdrivers, wrenches)
According to the main fnom value:
stabbing (needles, trocars)
Cutting, drilling, scraping. (knives, scalpels, chisels, saws, drills)
Pushing back (creating access - early expander, mirrors, hooks)
clamping (forceps, tweezers, tongs, needle holders, clamps)
probing, bougienage (treatment, diagnostics) - catheters, cannulas
mechanized (connecting tissues with staples)
Auxiliary (not soprik with shopping mall org-ma, but needed for operas) - syringes, hammers, screwdrivers
In practical medicine:
- operas on soft tissue (general) 1) tools and devices for the introduction and removal of liquid - syringes, cannulas, catheters 2) tools for sectioning the tissue - scalpels, scissors 3) for connecting tissue needles, needle holder
for operas on the abdomen and floor (with the release of gastric, intestinal, operas on the biliary tract)
bone (on the skull (trepanation), and see the canal)
instrument for operas on the ends
on a chest cage
in the urinary tract
in the rectum
special tool (gynecology, ophthalmia, otorino)
Requirements for surgical instruments:
· Simplicity of a design that not only facilitates manufacturing technology, but also simplifies use of it.
· Possibility of cleaning and sterilization after completion of work, for this purpose the toolkit has a smooth and even surface.
· Ease.
· Durability, ability to resist mechanical influences, resistance to chemical and thermal influences in the course of sterilization.
Comfort and convenience of use in the course of work.
Electrosurgical instruments
Electrosurgical instruments - intended for surgical interventions using high frequency currents. The main part of the electrosurgical instrumentation is the UDL-350 or UDL-200 electron tube generator, to which a special set is attached: operating or active electrodes, an insulating handle-holder for electrodes, cords going from the electrode handle to the diathermy apparatus, passive or indifferent electrode. To prevent accidents, it is necessary to carefully comply with all operating conditions of the equipment.
All manipulations on tissues are performed using active electrodes, which have a variety of shapes and sizes that determine their purpose. Pointed electrodes in the form of a blade and a needle are used to cut tissue.
Electrodes with larger surfaces in the form of a cylinder, ball, disk are used for tissue coagulation - in order to stop bleeding and destroy small tumors. Electrodes in the form of a loop allow you to remove tumors and other pathological formations from the bladder, larynx, rectum.
Depending on the designs, mono- and bi-active (one- and two-pole) electrosurgical methods are distinguished. With monoactive methods, only the small electrode is active, having a variety of shapes described above. The second, passive (indifferent) electrode, large in size, in the form of a lead plate, is bandaged to the patient's skin away from the surgical field (on the thigh, lower back, lower leg). The passive electrode should fit snugly against the skin. To ensure good contact with the skin, a napkin moistened with saline is placed under the electrode. In the absence of good contact, not only skin burns under the indifferent electrode are possible, but also the formation of coagulation foci in deep tissues on the current path from the active electrode to the passive one. With the biactive method, two active electrodes of a small area (no more than 1 cm2) are used. They are superimposed on the fabric close to each other. The set of biactive electrodes includes tweezers, electrodes for coagulation of the mucous membrane of tubular organs, and an electroknife.
Brought up on the best traditions of the Russian medical school, Nikolai Ivanovich Pirogov (1810-1881) launched a broad creative scientific activity that lasted over 45 years. The works of N. I. Pirogov in the field of topographic and surgical anatomy indicate that he is the founder of this science.
N. I. Pirogov (1810-1881).
The outstanding Soviet surgeon N. N. Burdenko wrote that N. I. Pirogov “created new research methods in the study of anatomy, new methods in clinical medicine, and military field surgery was also created. In these works, in the philosophical and scientific part, he gave a method, approved the dominance of the method and showed an example of the use of this method. In this, Pirogov found his fame ”(N. N. Burdenko, On the historical description of the academic activities of N. I. Pirogov (1836-1854), No. 2, p. 8, 1937).
In scientific research, N. I. Pirogov attached great importance to the method. He said: “In special studies, method and direction are the main thing” (N. I. Pirogov, Regarding the studies of Russian scientists abroad, the newspaper “Voice”, No. 281, 1863).
Even at the dawn of his scientific activity, N. I. Pirogov, developing a dissertation topic on ligation of the abdominal aorta, showed that when using the method of simultaneous ligation of the abdominal aorta, most of the animals die, while gradual compression of the abdominal aorta usually saves the life of animals and prevents development those severe complications that are caused by one-stage dressing. A number of original and highly fruitful research methods were used by N. I. Pirogov in the study of topographic anatomy.
Topographic anatomy existed before Pirogov. Known, for example, are manuals on topographic (surgical) anatomy by French surgeons Velpo, Blandin, Malgenya, and others (similar courses published before the appearance of Pirogov's works in other countries were, in essence, copies of French ones). All of these guides are surprisingly similar to one another both in title and content. And if at one time they played a certain role as reference books, in which information useful to surgeons was collected, grouped according to areas of the human body, then the scientific value of these guidelines was relatively small for a number of reasons.
Firstly, the materials given in the manuals were largely deprived of scientific accuracy, since the exact methods of topographic and anatomical research did not yet exist at that time; this led to the fact that gross errors were made in the manuals, not to mention the fact that they lacked a truly scientific direction that satisfies the demands of practice. Secondly, in a number of cases, the most important requirement for a truly topographic study of areas, which is important for the purposes of surgical practice, was not fulfilled. In the manufacture of preparations aimed at showing the most important topographic and anatomical relationships of various organs, the cellular and fascial elements holding the neurovascular bundles were removed, or landmarks were ignored.
In “The Surgical Anatomy of the Arterial Trunks and” N. I. Pirogov wrote: “... Worst of all, the authors do not explain the artificiality ... the position of the parts and thus give students inaccurate, false ideas about the topography of a particular area. Take a look, for example, at the 2nd, 3rd and 4th tables of Velpo's anatomy and you will see that it is extremely difficult to judge from it the true position and distance of nerves, veins and muscles from the carotid, subclavian and axillary arteries ... Nobody of ... the authors does not give us a complete surgical anatomy of the arteries: neither Velpo nor Blunden has drawings of the brachial and femoral arteries ... None of the authors gives drawings from fascia preparations that cover the brachial and femoral arteries and which should be carefully open and cut when ligating the artery. The atlases of Tiedemann, Scarpa and Manek have nothing to do with the surgical anatomy of the arteries ”(N. I. Pirogov, Surgical anatomy of arterial trunks and fascia, St. Petersburg, p. VI, 1881).
The works of N. I. Pirogov made a complete revolution in the ideas of how topographic anatomy should be studied, and brought him world fame. The Academy of Sciences in St. Petersburg awarded Pirogov the Demidov Prize for each of his three outstanding works related to the field of topographic anatomy: 1) "Anatomy chirurgica truncorum arterialium atque fasciarum fibrosarum" (1837) ("Surgical anatomy of arterial trunks and fascia"); 2) “Full course of applied anatomy of the human body with drawings. Descriptive-physiological and surgical anatomy” (only a few issues devoted to limbs were published, 1843-1845); 3) "Anatome topographica sectionibus per corpus humanum congelatum triplici directione ductis illustrata" ("Topographic anatomy illustrated by cuts made through the frozen human body in three directions") (1852-1859).
Already in the first of these works, N. I. Pirogov elucidated the tasks of surgical anatomy in a completely new way; in it for the first time found an unusually complete expression of a new direction in surgery - anatomical. N. I. Pirogov established the most important for surgical practice laws of relationships and fascia, which form the basis of topographic anatomy as a science (see Chapter 3).
"Anatome topographica" is a large atlas containing 970 drawings that depict cuts of various areas of the frozen human body. The atlas is accompanied by explanations in Latin, amounting to 796 pages of small text. The creation of the atlas of cuts, which completed the gigantic work of N.I. Pirogov, was the triumph of Russian medical science: nothing equal to this atlas had been created before him in terms of idea and its implementation. The relationships of organs are presented in this atlas with such exhaustive completeness and clarity that Pirogov's data will always serve as a starting point for research in this area.
None of the methods of topographic and anatomical research that existed before N. I. Pirogov can be considered truly scientific, because they did not comply with the main requirement for conducting such a study: the preservation of organs in their natural, undisturbed position. Only the method of sawing a frozen corpse gives the most accurate idea of the actual relationship of organs (it goes without saying that the modern X-ray method for studying topographic and anatomical relationships is the greatest achievement of medical science).
The greatest merit of N. I. Pirogov is that, both in Applied Anatomy and Topographic Anatomy, he gave his research an anatomical and physiological direction. At first glance, it may seem that, by studying the topography of organs on cuts, we cannot understand anything but the static position of the organs. However, this view is clearly misleading. Pirogov's brilliant idea is that he used his method of cuts to study not only morphological statics, but also the function of organs (for example, joints), as well as differences in their topography associated with changes in the position of certain parts of the body and the state of neighboring organs (see chapter 2).
N. I. Pirogov also used the method of cuts to develop the question of the most appropriate access to various organs and rational operational methods. So, having proposed a new way of exposing the common and external iliac arteries, Pirogov made a series of cuts in directions corresponding to skin incisions during these operations. Pirogov's cuts clearly show the significant advantages of both of his methods compared to the methods of Cooper, Abernathy and others.
It is important to note that in developing his methods for exposing the iliac arteries, Pirogov tested them several hundred times on corpses, and then ligated these vessels 14 times on patients.
The second original way of studying the topography of internal organs, proposed and implemented by N. I. Pirogov, is called anatomical sculpture by him. This method is not inferior in its accuracy to the study of topography on sections of frozen corpses (for details, see Chapter 2).
Thus, the great merits of N. I. Pirogov in the field of topographic anatomy are that he:
1) created the doctrine of the relationship of blood vessels and fascia;
2) laid the foundations of topographic anatomy as a science, for the first time widely using the method of sawing frozen corpses, anatomical sculpture and experiment on a corpse; 3) showed the importance of topographic and anatomical studies for studying the function of organs;
4) established changes in the topography of a number of areas associated with a different functional state of organs or the development of pathological processes in them;
5) laid the foundation for the doctrine of individual variability in the form and position of organs;
6) for the first time established the relationship between various parts of the central nervous system and specified the topography of the peripheral nerves and the connections between them, drawing attention to the significance of these data for practice; for the first time presented a topographic and anatomical description of the hand and fingers, cellular spaces of the limbs, face, neck, outlined a detailed topography of the joints, nasal and oral cavity, chest and abdominal cavity, fascia and pelvic organs;
7) used the data of topographic and anatomical studies to explain the mechanism of occurrence of a number of pathological conditions and to develop rational operational approaches and techniques.
From all that has been said, it undoubtedly follows that N. I. Pirogov is the founder of topographic anatomy as a science. His works have had and continue to have a huge impact on the development of all topographic anatomy.
However, it was not only Pirogov's widely used experiment on a corpse that contributed to the development of surgical knowledge. N. I. Pirogov carried out experiments on animals on a large scale, and Pirogov's experimental and surgical activities constitute a significant part of his scientific work. Already in Pirogov's dissertation on ligation of the abdominal aorta, his enormous talent was revealed both in setting up experiments and in interpreting their results. N. I. Pirogov has priority in a number of issues of circulatory pathology. His experiments with Achilles transection and the results of his study of the healing process of tendon wounds have not lost their scientific value so far. So, Pirogov's installations were confirmed in modern studies of the outstanding Soviet biologist O. B. Lepeshinskaya. Pirogov's experiments on studying the action of ether vapors are recognized as classic.
N. I. Pirogov, as it were, foresaw what he expressed and so brilliantly carried out in his activity, unprecedented in scope and results, our brilliant compatriot, who owns the wonderful words: “Only after passing through the fire of experiment, all medicine will become what it should be , i.e., conscious, and therefore, always and quite expediently acting.
Knowledge of connective tissue formations - fascia, the laws of their structure is of great practical importance, as it allows you to determine the places of possible accumulation of pus, blood, the spread of anesthetics during local anesthesia, methods of amputation of limbs, methods of operations on blood vessels, skin and tissue.
The history of the study of fascial sheaths of muscles, vessels and nerves begins with the work of the brilliant Russian surgeon and topographic anatomist Nikolai Ivanovich Pirogov, who, based on the study of cuts of frozen corpses, revealed the topographic and anatomical patterns of the structure of vascular fascial sheaths, reduced by him to three laws:
1) all major vessels and nerves have connective tissue sheaths formed by muscle fascia located near the vessel.
First Law states that all major arteries with accompanying veins and nerves are enclosed in fascial sheaths or sheaths. Vascular sheaths are formed by "fibrous" (according to N.I. Pirogov), that is, a dense connective tissue and represent a doubling of the wall (often the back) of the muscle sheaths. For example, the sheath for the neurovascular bundle of the shoulder is formed by the posterior wall of the sheath of the biceps brachii muscle, the sheath of the neurovascular bundle of the thigh is formed by the posterior wall of the sartorius muscle, etc.
2) on the transverse section of the limb, these sheaths have the shape of a trihedral prism, one of the walls of which is simultaneously the posterior wall of the fascial sheath of the muscle.
Second Law- the walls of these cases are formed by their own fascia, covering the adjacent muscles. In cross section, the connective tissue sheath has a triangular ("prismatic") shape, which determines the special strength and rigidity of its design.
third law emphasizes the fixation of the vascular sheaths to the bones of the extremities. According to the description of N.I. Pirogov, the top of the vagina, as a rule, "is in a mediocre or direct connection with the nearby bones." So, for example, a spur of the connective tissue case connects the sheath of the shoulder vessels with the humerus. The vagina of the common carotid artery is connected with the transverse processes of the cervical vertebrae, etc.
The practical significance of these laws:
The presence of a vascular fascial sheath should be taken into account during surgery when the vessels are exposed along their projection. When ligating a vessel, it is impossible to apply a ligature until its fascial case is opened.
The presence of an adjacent wall between the muscular and vascular fascial sheaths should be taken into account when conducting extra-projective access to the limb vessels.
When a vessel is injured, the edges of its fascial sheath, turning inward, can contribute to the spontaneous stop of bleeding.
Continuing to develop the foundations of topographic anatomy laid by N.I. Pirogov, Academician V.N. Shevkunenko gave a detailed analysis of the embryological aspects of the structure of the fascia and cellular spaces. VF Voyno-Yasenetsky studied the ways of the spread of purulent-inflammatory diseases in the deep cellular spaces of the face. For the purpose of anatomical substantiation of the method of sheath local anesthesia, the surgeon academician A.V. Vishnevsky studied the fascial sheaths of muscles and cellular spaces. The study of fascia, fascial cases, cellular spaces, fascial nodes was carried out by the Department of Topographic Anatomy of the 1st Moscow Medical Institute under the guidance of Academician V.V. Kovanov.
Adipose tissue, fascia, aponeuroses are different types of connective tissue. The accumulation of fatty tissue leads to the development of additional sheets of superficial fascia (gluteal region, lower abdominal wall). Compaction of the own fascia of muscle groups leads to the formation of aponeuroses (aponeurosis of the forearm). The structure of the fascia is closely related to the function of the muscles, holding them in position, maintaining lateral resistance, and increasing muscle support and strength. P.F. Lesgaft wrote that "the aponeurosis is as independent an organ as the bone is independent, which makes up a solid and strong stand of the human body, and its flexible continuation is fascia."
Fascial formations should be considered as a soft, flexible frame of the human body, complementing the bone frame, which plays a supporting role. Therefore, it was called the soft skeleton of the human body. Fascias are soft translucent connective tissue membranes covering some organs, muscles, vessels or located in the subcutaneous tissue (aortic fascia, fascial sheaths of muscles, superficial fascia).
Fascia differ from each other in structural and functional features, which are a reflection of the development process. In accordance with the teachings of V.N. Shevkunenko, depending on the source of origin, the main groups of fascia are distinguished: connective tissue, muscle, coelomic and paraangial.
Connective tissue fasciae can develop through seals connective tissue membranes around moving muscle groups and individual muscles.
Paraangial fasciae are a derivative of loose fiber, which gradually thickens around pulsating vessels and forms fascial sheaths for large neurovascular bundles.
Muscular fasciae are formed:
1) at the expense rebirth end sections of the muscles that are constantly under the influence of force tension into dense connective tissue plates-tensions (palmar aponeurosis, plantar aponeurosis, aponeurosis of the external oblique muscle of the abdomen, etc.); 2) due to full or partial reduction muscles and their replacement with connective tissue (scapuloclavicular fascia of the neck).
Fascia development coelomic origin is associated with the formation of the primary embryonic cavity. They, in turn, are divided into two subgroups:
1) fascia primary- of coelomic origin, arising in the early stages of embryogenesis and later forming connective tissue membranes of cavities (intracervical, intrathoracic and intra-abdominal fascia); 2) fascia secondarily- of coelomic origin, arising from the transformation of primary coelomic sheets (posterior colonic, prerenal fascia).
aponeuroses- dense opaque connective tissue plates, also limiting the anatomical formations, often a continuation of the muscles (palmar aponeurosis, plantar aponeurosis, aponeurosis of the broad abdominal muscles, etc.).
There are the following types of soft skeleton elements:
1. Fascial bed or fascial space;
2. Fascial vagina;
3. Cellular space;
4. Cellular gaps;
5. Fascial nodes.
1) Fascial bed called a space bounded by its own fascia and spurs extending from them, which includes muscles, tendons, blood vessels, nerves. In the fascial bed, walls and contents are distinguished. The spur of its own fascia, which makes up the wall of the fascial bed and goes to the bones, separating one fascial bed from another, is called the intermuscular septum.
2) The anatomical formations that make up the contents of the fascial bed may have their own fascial cases or fascial sheaths. Fascial sheaths around muscles are called muscle sheaths, around vessels - vascular sheaths, around tendons - tendon sheaths.
3) The fascial bed containing a large amount of fatty tissue is called cellular space.
4) Part of the cellular space enclosed between the walls of the fascial bed and its contents or between the elements of the contents itself is called cellular gap. In the cellular space there may be one or more cellular fissures: muscular-fascial fissure, interfascial fissures, musculoskeletal fissure, paravasal fissures, paraneural fissures.
5) Under fascial knot(V.V. Kovanov, 1968 ) understand the junction of fascia connected directly or indirectly with the bone and with nearby motor or other anatomical formations (vessels, nerves).
Meaning fascial nodes:
Supporting role (foot; hand, face, etc.);
The function of communication of various anatomical formations with each other;
Role in maintaining fascia tone;
A conductor of pus from the bones to the superficial layers, to soft tissues (with osteomyelitis).
B -11 ) The founder of the top. Anatomy Russian scientist I. I. Pirogov , the works of his works revolutionized anatomy. He established the laws of the relationship between blood vessels and fascia, created an extensive atlas of cuts, proposed methods for transverse, sagittal, and frontal cuts of frozen corpses. He investigated anatomically and functionally: that is, he made cuts in various positions of course. After freezing, he filled the stomach, MP with water, intestines with air. He proposed skin-plastic amputations of the lower leg. From that moment on, a department was created in Moscow. Univ. - Bobrov, Dyukonov, Saratov - Spasokukotsky, Kazan. Shevkunenko is the creator of the school for the study of individual variability in the shape and position of organs. Investigate differences in the insertion of arteries and veins, nerve trunks. Differences in shape and position associated with age. Operative technology intervene. Chir surgery is a mechanical effect on the tissues, organs of the patient, performed by a doctor for the purpose of treatment or Ds-ki.
2) Fronto-parieto-occipital region . Borders in front - the upper edge of the orbit, behind - the external occipital protuberance and top. protruding line, side - top. temporal line of the parietal bone. Layers: skin, subcutaneous tissue, vessels pass over the aponeurosis, their walls are tightly connected with fibrous bridges. Lymph. vessels flow into the region. knots and arr. 3 gr.:
1 - superficial parotid. 2 - behind the ear. 3 - occipital. On the vault of the skull limf. no nodes. The muscular-aponeurotic layer, consisting of the frontal muscle in front, the occipital muscle in the back, a layer of loose fiber separates the muscle from the periosteum. The periosteum is connected to the skull bone also through loose fiber. The bones of the water of the skull consist of outer and inner plates between which there is a spongy in-in. Due to the presence of connections between the m / y of the extracranial and intracranial venous system, it is possible to transfer information from the integument of the skull to the brain. membranes with the subsequent development of meningitis and other diseases.
3) Bladder ( cystotomy and resection technique): MP nah-Xia behind the pubic fusion. Distinguish: top, body, bottom, neck. Int. the submucosal layer forms folds. In the region the bottom has a section of the mucus-th triangular shape where there is no submucosal layer. It is firmly fused with the muscle layer. Involuntary sphincter at the beginning of the urethra, arbitrary sphincter - in the membranous mouth of the urethra. The symphysis adjoins in front, to the bottom - the body of the prostate, the seed. vesicles, vas deferens. From above and from the sides - loops of the small intestine, sigmoid colon. Behind: in women - the body and bottom of the uterus, in men - the rectum. Kr\supply - from vnutr. iliac arteries. The veins form plexuses and outflow into the internal. lift the vein. Lymph. vessels - in the nar and internal iliac nodes. Innervation - hypogastric plexus. Cystotomy- incision along the midline from the symphysis to the navel. Dissect the skin, fat. checker, aponeurosis, white line of the abdomen. They push the muscles apart, stupidly push back the transverse fascia, fiber, expose the roses. Art. bubbles, cut lengthwise. Liquid is released, a special catheter 1.5 cm obliquely cut and rounded end is inserted into the opened bladder, the cut wall above and below the tube is tightly sutured with interrupted catgut sutures, drainage is brought out at the upper corner of the wound, the wound is sutured in layers. Resection- the bladder is isolated from the apex, exfoliated from the peritoneum and cross the ligament of the urinary duct, the pelvic part of the ureter is isolated and crossed 3 cm from the place where it flows into the bladder. The bladder is replaced by a segment of the intestine, or the ureter is brought to the anterior abdominal wall.
B-3
1.Hir. opera.- is called a mechanical effect on the tissues and organs of the patient, produced by a doctor for the purpose of treating, diagnosing or restoring the function of an org-ma and performed mainly with the help of incisions and various methods of connecting tissues. In most surgical operations, it is customary to distinguish between two main elements - operational access and operational reception.
^ online access call the part of the operation that provides the surgeon with exposure of the organ on which the performance of one or another surgical intervention is scheduled.
^ Operational reception they call the main part of surgery. intervention on the affected organ, the chosen method for eliminating the pathological focus, the features of the technique of this operation.
^ Oper.consists of successive elements:
Preparing the patient for surgery, anesthesia and performing the surgical intervention itself.
Surgical intervention includes: 1) tissue incision to expose the affected organ; 2) performing an operation on the organ itself; 3) the connection of tissues disturbed during the operation.
According to the nature and goals of opera.hir. interventions can be divided into 2 groups : radical and palliative.
radical called chir intervene, in which they seek to completely eliminate the pathological focus.
palliative called surgical interventions, which are aimed at alleviating the patient's condition (if it is impossible to remove the affected organ) and at eliminating life-threatening symptoms.
Operations can be one-shot, two-shot or multi-shot.
Most operations are carried out in one stage, during which all the necessary measures are taken to eliminate the cause of the disease, these are one-stage operations. Double moment opera. produced in cases where the patient's state of health or the risk of complications does not allow to complete the surgical intervention in one stage. If hir. intervention is performed several times for the same disease, then such operations are called repeated.
^ By urgency performance distinguish emergency, urgent and planned operations.
emergency require immediate implementation. For example, stopping bleeding, opening the windpipe (tracheotomy), Urgent are considered, the implementation of which can be postponed for a short time, necessary to clarify the diagnosis and prepare the patient for surgery. Planned called hir. interventions performed after a systematic examination of the patient and preparation for surgery.
All operations according to their target orientation are divided into 2 groups: medical and diagnostic.
Therapeutic aims to remove the focus of the disease or restore the impaired function of organs.
K diagnostician. include biopsy, angiography, in some cases - trial laparotomy, thoracotomy, and other interventions aimed at clarifying the diagnosis.
^ 2. Axillary area (REGIO AXILLARIS) The area contains soft tissues located m / at the shoulder joint and chest. Borders: Front- the lower edge of the pectoralis major muscle; rear- the lower edge of the broad muscle of the back and the large round; internal line(conditional), connecting the edges of these muscles on the chest; outdoor- a line connecting the same edges on the inner surface of the shoulder. With an abducted limb, the area looks like a fossa (or hollow) fossa axillaris, which, upon removal of the skin, fascia, fiber, vessels and nerves, turns into a cavity (cavum, s. spatium axilare).
LAYERS. Leather contains a large number of apocrine and sebaceous glands.
^ Superficial FasciaProper Fascia (fascia axillaris)
After removing your own fascia, the muscles that limit the axillary cavity are exposed. The latter has the shape of a truncated quadrangular pyramid with the base turned downwards. Walls armpit anterior- mm. pectoralis major and minor; back - mm. subscapularis, 1atissimus dorsi and teres major; internal- the lateral part of the chest (up to and including the IV rib), covered with m. serratus anterior; outdoor- the medial surface of the humerus with the t. coracobrachialis covering it and the short head of the t. biceps.
In the back wall of the armpit, two openings are formed between the muscles, through which the vessels and nerves pass.
medial-trilateral(foramen trilaterum). It is limited: from above - mm. subscapularis and teres minor, below m.teres major, laterally long head m. triceps. Vasa circumflexa scapulae pass through it.
Lateral-quadrilateral(foramen quadrilaterum). It is limited: from above - mm.
Subscapularis and teres minor, below m. teres major, medially long head m. triceps, laterally - the surgical neck of the humerus. N passes through it. axillaris and vasa circumf1exa humeri posteriora.
^ The contents of the armpit are: 1) loose fatty tissue; 2) lymph nodes; 3) a. axillaris with its branches; 4) v. axilaris with its tributaries; 5) plexus brachialis with nerves extending from it; 6) skin branches II and (often) II intercostal nerve involved in the formation of n. intercostobrachia1is, which connects with n. cutaneus brachii medialis.
^ The fiber of the axillary region is concentrated:
1) in the walls and between the walls of the axillary cavity;
2) under the axillary fascia, in the subfascial space;
3) in the vagina of the neurovascular bundle.
The lymph nodes armpits make up five interconnected groups.
1. Nodes lying at the lateral wall 2. Nodes lying on the medial wall 3. Knots lying on the back wall of the cavity 4. Nodes located in the center of the fat accumulation of the axillary cavity
5. Nodes lying in trigonum c1avipectora1e, near v. achillaris, - apical. Lymph nodes of the axillary region are often the source of abscesses formed here, when the infection is transmitted through the lymphatic pathways in case of injuries and diseases of the hand and fingers. This leads to the formation of adenophlegmon.
^ 3. SMALL INTESTINE (Gejunum) And ileum occupy most of the lower floor of the abdominal cavity. The loops of the jejunum lie mainly to the left of the midline, the loops of the ileum lie mainly to the right of the midline. Part of the loops, the small intestine, is placed in the pelvis.
The small intestine is separated from the anterior abdominal wall by the greater omentum.
Behind, lie, organs that are located on the back. abdominal wall and separated from the small intestine by the parietal peritoneum: kidneys (partially), the lower part of the duodenum, large blood vessels (inferior vena cava, abdominal aorta and their branches). From above, the small intestine is in contact with the transverse colon and its mesentery. From below, the loops of the intestine, descending into the pelvic cavity, lie in men with the large intestine (sigmoid and rectum) behind and the bladder in front; in women, the uterus is located anterior to the loops of the small intestine. On the sides: the small intestine is in contact with the cecum and ascending colon on the right side, with the descending and sigmoid colon on the left.
^ The small intestine is attached to the mesentery ; starting from flexura duodenojejunalis to the transition to the large intestine, it is covered with peritoneum on all sides, with the exception of a narrow strip; where the sheets of the mesentery are attached. Due to the presence of the mesentery, the mobility of the small intestine is very significant, but the length (height) of the mesentery throughout the intestine is different, and therefore its mobility is not the same everywhere. The least mobile small intestine is in two places: near the beginning of the jejunum, at the flexura duodenojejunalis, and at the end of the ileum, in the area of the ileocecal angle. The root of the mesentery of the small intestine (radix mesenterii) has an oblique direction, going from top left to bottom and right: from the left half of the body of the II lumbar vertebra to the right sacroiliac joint. The length of the root of the mesentery is 15-18 cm.
^ Blood supply to the small intestine It is carried out by the superior mesenteric artery, which gives numerous branches to the small intestine, as well as a number of branches to the right half of the colon. The nerves of the small intestine accompany the branches of the superior mesenteric artery; they are branches of the superior mesenteric plexus.
diverters lymphatic vessels jejunum and ileum converge at the root of their mesentery, but are interrupted along the way by numerous mesenteric lymph nodes(nodi lymphatici mesenterici), the number of which reaches 180-200. They are located, according to Zhdanov, in 4 rows. The central nodes through which lymph passes from the entire small intestine (with the exception of the duodenum) are considered to be 2-3 lymph nodes lying on the trunks of the superior mesenteric vessels in the place where they are covered by the pancreas.
^B–5
1) Temporal region. Layers: skin, fiber, superficial fascia, temporal aponeurosis, inter-aponeurosis and sub-aponeurotic tissue, temporal muscle, temporal bone. Vessels and nerves are arranged in a radial direction in relation to the crown. Superficial temporal arteries and branches of the facial nerve in the dermal fatty tissue, deep temporal arteries in the thickness of the temporal muscle, media. shell art. - under the bone in the epidural space. Opening of the phlegmon of the temporal region - Cellulose, space of the temporal region, boundaries - superior and posterior temporal lines, inferior zygomatic arch, in front of the zygomatic process, frontal bones.
^ 2) Resection of the small intestine – Indications: tumors, gangrene, strangulated hernias, thrombosis, gunshot wounds. Narcosis, local anesthesia. Technique: incision along the midline of the abdomen, 2-3 cm from the pubis, + above the navel. A section of the small intestine is taken out into the wound and isolated with gauze napkins. Outline the boundaries of resection within healthy tissue. The resected area is separated from the mesentery by ligating the vessels. On both ends of the removed part of the intestine, spreading is applied. with a clamp, at the ends along an elastic pulp, then at one end the intestine is cut off by spreading the pulp and a stump is made, suturing its lumen with a simple through seam from the inside. This is Sheniden's furry stitch, m / b and a blanket stitch. Above the nodes is a serous-muscular suture. After removal of the resected intestine, a 2nd stump is formed and a lateral anastomosis is started. The wall of the intestine and loops for 8 cm connected. etc. with a number of knots of small serous-muscular sutures according to Lashber (clean) at a distance of 0.5 cm in the middle of the stretch of the suture line, 0.75 cm from them, they cut the intestinal stack parallel to the suture line. Having also opened the lumen of 2 quilt loops, they begin to stitch the inner edges with a rough continuous twisting catgut suture through all layers. The outer lips are joined with a Schmideny suture (2nd dirty suture), a number of Evil serous-muscular sutures (clean) are applied to the mucosa. The blind ends of the stump are fixed with several sutures to the intestinal wall to avoid their invagination.
^ 3) Basic healing tools : 1-tools separating tissues (knives); 2- tools to stop bleeding (clamps, ligatures); 3- Auxiliary tools (tweezers, hooks) 4- tools for connecting tissues (needle holders)
Rules for using the tool in good condition: - use it for its intended purpose (the scalpel cannot be placed on the bone); - hold tools easily and confidently; - carry out manipulations smoothly; - be attentive to living tissues. The scalpel is the main tool, to hold - a pen, a table knife, a bow. Scissors: straight, blunt, curved (Cooper), straight pointed, needle holders, tweezers (anatomical, khir-e, pawled)
B - 6
3) Operations outside the pancreas Access: upper median laparotomy. The pancreas can be approached in 2 ways: 1) through the gastrocolic ligament, it is dissected, drooped into the lesser omentum, the stomach is pushed up, and the colon down. 2) through the lesser omentum by dissecting the transverse gastric ligament. 3) through the mesentery of the transverse colon (for drainage of pancreatic cysts) For acute pancreatitis . Goals: 1) stop the activation of enzymes and further destruction of the gland by creating a good outflow for the secret. 2) creation of a wide channel for the discharge of sequestered sections of the pancreas. 3) elimination of the inflammatory process in the pancreas. Access: Upper middle laparotomy with a transition, if necessary, to the right hypochondrium, a wide tamponade of the omental sac is performed, drainage of the omental sac is performed: the gastrocolic ligament is dissected (before that, 0.25% solution of novocaine is injected into it), without dissecting the capsules of the pancreas into the adjacent the space is injected with 0.25% solution of novocaine and 50 thousand units of trasilol. To the pancreas, 5-5 tampons are loosely injected into the stuffing bag and held, the gastrocolic ligament is sutured with separate sutures to the tampons and drainage and sutured to the parietal part of the peritoneum. Operations for pancreatic tumors In case of cancer of the head, ampullar part of the common bile duct and large duodenal nipple, pancreatoduodenal resection is a radical operation. 1) Mobilization of the head of the pancreas, duodenum and the distal part of the stomach along the lesser and greater curvature. 2) intersection of the common bile duct and duodenum. 3) Removal in one block of the head of the pancreas, part of the stomach and the initial part of the duodenum. 4) the imposition of an anastomosis m / y with the common bile duct, the stump of the pancreas and jejunum, the remaining part of the stomach. And the jejunum (the imposition of an interintestinal anastomosis),
^ 1) Connection and separation of tissues . Separation is carried out using cutting tools. Electrotomy - performed with special electro-surgical instruments (using high-frequency current) - no bleeding. Principle: strictly consistent with the incision, must correspond to the course of large blood vessels and nerves, in order to avoid their damage, taking into account the location of the Lascher line - mesh layer II. Technique: 1) fixed with 2 fingers 2) the skin and subcutaneous tissue (up to the corresponding fascia) are dissected immediately in one movement 3) lift it with 2 tweezers, make a small hole in the fascia and insert a grooved probe into it, through which the facies sac is cut with a scalpel, connective tissue: 1) bloody (suture) - the cleanest way (silk, catgut, nylon) 2) not bloody (plaster)
2) Breast - the part of the body that is located between the neck and abdomen. Borders: upper - passes along the upper edges of the sternum and clavicle, behind along a horizontal line drawn through the spinous process of the 7th cervical vertebra, lower - passes from the xiphoid process of the sternum obliquely down the costal arches, behind in a straight line drawn from the distal end of the 12th rib to the spinous process of the 12th thoracic vertebra. Chest muscles: superficial pectoral muscle (functionally refers to the muscles of the shoulder girdle), deep or intrinsic chest muscles - external / internal intercostal muscles, transverse chest muscle, diaphragm, tendons of the center of the diaphragm, muscular part of the diaphragm: chest - starts from the inner surface of the xiphoid process. Costal - starting from 7-12 ribs, lumbar - starting at the level of 10 g of the vertebra, layers: skin, saphenous veins, cutaneous nerves, own fascia, muscles. Topography of the intercostal spaces: filled with intercostal muscles, vessels, nerves, lymphatics and nodes., which pass in the intermuscular gaps, costal canals. The costal fissure is bounded from above by the costal groove, outside and inside by the costal mm, deeper than the outer costal muscles are the vascular nerve bundles. The lower 6 costal nerves innervate the anterior lateral cyanotic wall inflammation of the pleura and lungs abdominal pain. Deep m\costal vessels and nerves - m\redernye mm, and costal cartilages, from the inside lined with intrathoracic fascia, deeper - a layer of loose fiber, which separates it from the soaring pleura throughout.
^ B -71) V. N. Shevkunenko - his work made it possible to establish differences in the structure of the topography of organs and to identify changes in the signs that determine these differences with the shape of the physique. This facilitates the diagnosis of diseases, clarifies the pathogenesis and course of some pathological processes, explains the complications of non-operational operations, and contributes to the development of rational operational approaches and techniques. Published "Atlas of the Peripheral Nervous and Venous System".
^ 2) Shoulder joint. Formed by: the head of the humerus and the surface of the scapula. Above the joint hangs a vault, the image of the acramion and the coracoid process. Shoulder puncture: can be performed from the front and back. - in order to make a puncture of the joint, the coracoid process of the scapula is probed in front, and an injection is made directly under it, the needle is advanced backwards, between the coracoid process and the head of the humerus to a depth of 3-4 cm; process, in the fossa formed by the posterior edge of the deltoid muscle and the lower edge of the musc supraspinatus, the needle is passed anteriorly towards the coracoid process to a depth of 4-5 cm. and from the inside, the joint is covered by the musk subscapularis, musk corocobrochialis, and the head of the musk biceps, outside the joint is covered by the deltoid muscle, near the articular synovial bag. On top of the large tubercle of the humerus and the tendon of the supraspinatus muscle - bursa subdeltoidea, bursa subacromialis (it is higher) communicates with it. These bags do not communicate with the joint cavity. Bursa m. The subscapularis communicates with the joint cavity and connects with the bursa subcorocoidea (at the base of the coracoid process), the joint is reattached to the anatomical neck of the humerus. The ligament lig corocohumerale strengthens the bag. 1) above - lig gienohumorale 2) lig gienohumorale medium - from the inside 3) lig gienohumorale inferios - from below. In the absence of media ligaments - dislocation in the shoulder joint. The cavity of the shoulder joint is expanded due to 3 inversions: subscapular, axillary and intertubercular. Subshovel at the level of the anterior upper section of the neck of the scapula (synovial bag of the substrate of the muscle). Between the tubercles is formed due to the protrusion of the synovial region. in the tubercles groove along the tendon of the long head of the biceps muscle.
^ 3) Indications Key words: kidney rupture, crush injury, nephrolithiasis. Position on a healthy side with a roller placed under it. Hier access during kidney operations. Subdivided into transabdoninal and extraperitoneal. Transabdominal approaches include median and pararectal laparotomy. All extraperitoneal accesses are divided into vertical (Simon's incision), horizontal (Pean's incision), and oblique Fedorov, Bergman-Israel incisions. The most optimal is the Fedorov access. Nephrectomy (standard). One of the extraperitoneal accesses exposes the kidney and dissects the posterior leaf of its outer capsule. Having isolated the kidney from the fatty capsule from all sides, it is taken out into the surgical wound. The aliments of the renal pedicle, vein, artery, posterior wall of the pelvis, and ureter are sequentially exposed. 2 ligatures are applied to the ureter and I cross it between it at the border of its upper and middle thirds. With the help of a Deschamp needle, 2 silk ligatures are brought under each of the vessels at a distance of 1 cm from one another. The ligatures are cut off, the kidney is removed, a drain is brought in, which is removed through the posterior corner of the wound (removed within 5 days). Resection: with tuberculosis, echinococcus, closed injury, gunshot. This is an organ-preserving operation. Access according to Fedorov exposes the kidney, the leg of the kidney is clamped with an elastic sphincter. With a knife - wedge-shaped notches within healthy tissue. Nephropathy : with a foreign body, blind penetrating wounds, stones. The kidney is exposed with an oblique abdominal incision and brought out. Dissect the capsule, dilute the tissues, remove with a clamp. Nephrostomy: through the holes in the kidney, rubber drainage is introduced into the pelvis (if outflow from the ureter is difficult) Nphropexy : wandering drooping kidney.
B-8.
^ 1. Teaching about fascia.
Fascia- This is a connective tissue sheath of various structure and severity, covering mainly the muscles. As well as other anatomical formations. 2 types of fascia: superficial and own. superficial- a sheet of varying degrees of thickness, lining the inside of the subcutaneous fatty tissue, making the surface layer mobile in relation to its own fascia. Forms cases for the anatomist. formations located in the subcutaneous fatty tissue (veins, arteries, nerves, lymph nodes, facial muscles, internal organs). Own- usually associated with bones, forms cases, septum sheets, aponeuroses. Shown in several sheets. Own fascia grows together with flat tendons, makes up a single anatomist structure with them. Cellular space (fascial) space filled with fiber between the fascia sheets or between the fascia sheet and the anatomist formation. Ego frequent cases are cellular gaps, channels and bone fibrous beds. The cellular gap is the space located between the organ and the fascia covering it. Channels - usually formed not only by fascia, but also by other dense connections - TC formations (ligaments and bones, etc.), sometimes muscles. Bone - fibrous beds (fascial, muscle beds) spread in the region of the limbs. They are usually limited to their own fascia, its septa to the bone and bone. Interfascial fatty tissue fills the cellular space between the fascial cases of anat formations. It is also m / b located between the fascia cases of anat formations and the parietal fascia.
Borders: upper - line 4 cm above the epicondyles of the shoulder; the bottom line is 4 cm. below the epicondyle; internal - vertical through the medial epicondyle; external - vertical through the lateral epicondyle. Layers: the skin is thin, the subcutaneous tissue has a lamellar structure, superficial fascia, own fascia: 2 septa extend from f, cubiti, which continue from the shoulder, thickened in the center due to aponeurosis m. Bicipitalis brachii, muscles: 3 groups each in 2 layers: a) m. Brachioradialis, m. supinator - laterally; b) biceps brachii, m. brachialis - in the center, above the elbow; c) mm. pronator teres, flexor carpi radialis, palmaris longus, flexor carpii ulnaris, deeper and medially m.flexor digitorum superficialis. Walls: tendons m. biceps brachii, m. brachi radialis, sul. cubitalis anterioses lat. et .medial, epicondyles of the humerus of the saphenous vein, elbow bend. Contents of the cubital fossa: vessels and nerves . Vascular-nerve bundles: a. collateralis radialis. n. radialis lie on the joint capsule in the gap between mm. brachioradialis et supinator at the level of the lateral epicondyle, the nerve is divided into 2 branches: deep (goes to the back region of the forearm in the canalis supinatorius) and superficial (goes to the anterior region of the forearm), a.vv. brachiales lie at the inner edge of the m.biceps brachii tendon, are divided into aa. radialis et ulnaris under aponeurosis m. bicipitis brachii. n medianus passes 0.5-1 cm inside from a. brachialis, leaves the area between the heads of m.pronator teres.
^ 3. Purulent mastitis. Localization of abscesses: subcutaneous, vnr lobules of the gland, between the fascial capsule of the gland and fascia pectoralis. Op reception: depending on localization. 1) Subcutaneous: open with linear incisions directed radially with respect to the nipple, the opened cavity is emptied of pus, drained and packed with antiseptics, the wounds are not sutured. 2) With deep abscesses and phlegmon, radial incisions are made from the edge of the pigment. spots around the nipple for 5-6 cm, deep. But an arcuate incision along the skin fold under the mammary gland or parallel to it is better. 3) Retromammary phlegmons (located behind the mammary gland - between it and the thoracic fascia) are opened in the same way, see above. The final stage: the opened cavities are emptied of pus and necr masses, drained with loose swabs with an antiseptic solution.
Ticket number 10
1) TRANSPLANTOLOGY
A branch of surgery dealing with tissue and organ transplantation and studying the compatibility of TC. and conservation of tissues and organs.
Types of transplant: * autogenous - donor and recipient - the same person
1) isogenic - ovarian twins
2) syngeneic - related. 1st degree
3) allogeneic - transplantation from a person to a person
4) xenogenic - transplantation from living to human
5) prosthetics org. - in and so on. with the use of - m synthetic materials, and other inorg. thing-tv.
Types of tissue transplant: free: transplan - moving from one part of the body to another or from one organism to another.
Replantation - affected mc. and the organs are transplanted back to their original place.
Implantation - transferred to the nearby region.
Not free: connected or plastic on the supply leg, provides for the connection of the cut shopping mall. flap with the original bed until the moved part grows into a new place.
Skin plastic.
More often, skin autoplasty is used, its free or non-free version.
Free: cn - b Yatsenko - Reverden; cn - b Tirsha; cn - b Lawson - Krause.
Not free: provides for the formation of a flap of skin and skin cells, maintaining a connection with the maternal tissue through the feeding leg.
MUSCLE PLASTY: used for filling bone cavities in patients with osteomyelitis and bronchial fistulas. Regional plasty for closing defects of the abdominal st. hernia of the white line of the abdomen, etc.
PLASTY OF TENDONS AND FASCIUM: for east.
Lost f limbs, as well as gr.parali-
Called muscles. Fascia to strengthen the joint capsule. TV defect replacement. brain. obol, the formation of art - the first sphincter of the pr. intestine.
BONE PLASTY: for restoring the lost f and cosmetic form of the organ, eliminating the defect of the cranial vault or jaw.
NERVE PLASTY: convergence of its ends and elimination of the causes hindering regeneration. Operation options 1st, 2nd suture, nerve transplantation, neurolysis.
VASCULAR PLASTY: using - t autotransp - you (veins, arteries), synthetic prostheses (dacron, teflon, etc.). in the recipient within 7–10 days of subtransplantation and is aimed at rejection of the transp-ta. In RTI, the basis of T-killers, macrophages and T-lim-you realize. In order to increase the efficiency - ti transp. - and non-specific are carried out. immunosuppression.
Blockade of the recipient's immunocompetent system with antimitotic agents, GCs, antilymphocyte sera. with one-time stimulation of the activity of T-suppressor cells.
Formed: shoulder, radial and ulnar os. consists of 3 joints and one cavity and a common capsule. The articular gap is projected in front along the transverse line 1 cm below the later. And 2 cm below the medial epicondyle of the shoulder. The joint capsule is fixed in front of the humerus above the radius and coronary fossa, behind the cubital fossa, to the bones of the forearm along the edge of the articular cartilage. Innervation: n ulnares, radialis
Blood supply: a. brachial is, a collateral's radialis et ulnaris sup. V. cephalica, v. basilica, v. intermedia cubiti The weak point is the reccessus sacciformis, which is directed to the deep layers of the forearm.
^ 3) COLON OPERATIONS:* COLON RESECTION
* APPLICATION OF FEcal FISTULA - COLOSTOMY
* ART OVERLAY ANUS
Operations on the large intestine are different from operations on the small intestine. Thinness and tenderness of art., its worst nutrition, the presence of a zone not covered by the peritoneum, more infected. Intestinal contents make the seam less reliable. Instead of a 2-row seam, a 3-row one is used: 1n inner. and two serous-muscular, 3rd row m.b. replaced by fixation to the line of the serous-muscular suture of fat suspensions. ^ RESECTION OF THE COLON:
POK - I: cancer, torsion and intussusception, accompanied by necrosis, megasigma - a giant sigmoid colon, extensive intestinal injuries - ka, fistulas, ulcerative colitis.
ANEZBOL - E: anesthesia or places. anesthesia.
^ RESECTION OF THE RIGHT HALF OF THE RIM-TH INTESTINE:
Removal of the blind with the terminal section of the ileum, rim (up) and the right section of the transverse colon. Mobilize the right half of the P. - O intestine, cut it off and remove it together with the posterior colon and terminal ileum. Impose an anastomosis m \ they (side to side anti-peristaltic).
SIMULTANEOUS RESECTION OF THE SIGMOID COUNT: The abdominal cavity is opened with a lower median incision. The sigmoid colon is removed into the wound, approximately in the area patol. process. The first moment of the operation is a wedge-shaped excision of the mesentery, corresponding to the removed section of the intestine. After suppression of the mesentery, the abdominal cavity is carefully isolated with gauze pads. The sections of the intestine, which are supposed to be connected by anastomosis, are applied to each other along the edges, they are sutured with serous-muscular knots with sutures - holders that fix them in this position. The intestine is crossed alternately at one and the other end in the transverse direction, the affected area is removed and the gaps are connected end to end.
TWO-STAGE RESECTION OF THE SIGMOID COUNT ACCORDING TO GREKOV: The abdominal cavity is opened with the lower median incision and connected side by side with an anastomosis. Make a second oblique incision in the left iliac region. the area with the pathological process is removed, the median incision is sutured. For several days, the vessels are tied up and the mesentery is dissected. The affected area is cut off outside the abdominal cavity and the resulting intestinal lumens are closed with a 3-row suture.
