Operative Surgery and Topographic Anatomy - 2016

Content Module No. 3. Topographic Anatomy and Operative Surgery of the Abdominal Regions and Organs

Topic 14. Topographic Anatomy of the Abdominal Cavity. Topography of the Stomach, Liver, Gallbladder, and Biliary Tract. Blood Supply, Innervation, and Lymphatic Drainage

1. Relevance of the topic: diseases and INJURIES OF THE Stomach, Liver, and extrahepatic biliary tract (especially cholecystitis) are frequent pathologies that require Surgical Treatment. Timely Diagnosis and successful surgical intervention are ensured by a detailed knowledge of the topography of these upper abdominal Organs.

2. Specific objectives:

1. Explain the Topographic anatomy of Blood supply, innervation, and lymphatic drainage Pathways of the stomach, liver, Gallbladder, and extrahepatic biliary tract.

2. Analyze the topographic rationale for surgeries performed on The Stomach, liver, and extrahepatic biliary tract.

3. Tasks for independent work during preparation for the Class.

3.1. List of key terms, parameters, and characteristics that the student must master when preparing for the class:

3.2. Theoretical questions for the class:

1. Structure OF THE stomach, its skeletotopy and syntopy.

2. General structure of the liver, its syntopy.

3. Ligamentous apparatus of the liver.

4. Lobes and segments of the liver, and their practical significance.

5. How is the Blood supply to the liver carried out, along with its venous and lymphatic drainage?

6. How is the portal vein formed? Specifics of its Location relative to other elements of the hepatoduodenal ligament.

7. How is Calot's triangle formed, and what is its practical significance?

8. Which ducts comprise the extrahepatic biliary tract? Segments of the common Bile duct.

9. How can Hemorrhage from the hepatic parenchyma be temporarily arrested?

3.3. Practical skills to be acquired during the class:

1. Layer-by-layer dissection of the stomach wall, liver ligaments, porta hepatis, and extrahepatic biliary tract.

2. Temporary cessation of bleeding in liver trauma by clamping the elements of the hepatoduodenal ligament.

3. Isolation and ligation of the cystic artery within Calot's triangle.

4. Isolation of the common bile duct along its entire length.

5. Isolation of the elements of the hepatoduodenal ligament.

4. Topic Outline

The stomach. The greater part of the organ is located in the left hypochondrium. The stomach comprises the cardia (the entrance), the fundus (or vault of the stomach), and the body. Further along lies the pyloric part, which is subdivided into the pyloric antrum and the pyloric canal. The latter includes the pylorus and its opening. When filled, the stomach abuts against the Diaphragm and the left lobe of the liver; posteriorly and to the left, it is related to the Pancreas, the left Kidney and suprarenal gland, and the Spleen; anteriorly, it relates to the abdominal wall; and inferiorly, to the transverse colon and its mesentery. The capacity of the stomach ranges from one to several liters. An empty stomach contracts and shifts upwards and posteriorly. The stomach is a typical intraperitoneal organ, meaning it is surrounded by Peritoneum on all sides and features a well-developed ligamentous apparatus. The following ligaments must be examined: the gastrophrenic, hepatogastric, gastrosplenic, gastrocolic, and gastropancreatic ligaments.

The blood supply to the stomach is derived from Branches of the celiac trunk. The left gastric artery runs along the lesser curvature of the stomach. It anastomoses with the right gastric artery, which arises from the proper hepatic artery; together, they form the arterial arch of the lesser curvature. The left and right gastro-omental (gastroepiploic) Arteries are located along the greater curvature of the stomach. The former originates from the splenic artery, while the latter springs from the gastroduodenal artery. The blood supply is additionally supplemented by 2–7 branches arising from the splenic artery which course within the gastrosplenic ligament to reach the greater curvature and Cytology/practical/108.html">Fundus of the stomach.

The Veins OF THE stomach correspond to the arteries and run alongside them, ultimately draining into the portal vein. The veins of the abdominal part of the Esophagus (draining into the SUPERIOR VENA CAVA) widely anastomose with the veins of the cardiac part of the stomach (draining into the portal vein). These constitute the so-called portosystemic anastomoses, which become markedly engorged in liver cirrhosis. Controlling hemorrhage from these varices is extremely challenging, with a mortality rate of 30–40% for the initial bleed.

The Lymphatic vessels of the stomach drain into regional Lymph Nodes situated along the lesser and greater curvatures.

The Innervation of the stomach is provided by sympathetic and parasympathetic nerves. The bulk of sympathetic nerve fibers reach the stomach from the celiac plexus. Parasympathetic innervation is supplied by the right and left vagal trunks, branches of which also innervate other abdominal viscera.

Branches are more numerous on the anterior wall of the stomach than on the posterior wall. A thorough knowledge of gastric innervation is essential for performing conservative operations such as vagotomy.

The liver presents two lobes, right and left, which are separated on the diaphragmatic surface by the falciform ligament of the liver, and on the visceral surface by the left longitudinal fissure (the anterior part of which lodges the round ligament of the liver, while the posterior part contains the ligamentum venosum). Parallel to the left fissure lies the right fissure, housing the gallbladder in its anterior part and the INFERIOR VENA CAVA in its posterior part. A deep transverse fissure, the porta hepatis, is situated between the two longitudinal fissures. Consequently, the visceral surface features two additional lobes: the anterior quadrate lobe and the posterior caudate lobe. The liver occupies a mesoperitoneal position relative to the peritoneum, lacking peritoneal covering on its posterior area where it abuts the diaphragm. The serous coat of the liver is underlain by its fibrous capsule (Glisson's capsule).

Today, owing to advancements in hepatic surgery, the segmental Anatomy of the liver is widely recognized. A bipartite division of the liver has been proposed corresponding to the perfusion Zones of the right and left hepatic arteries, which are further subdivided into 8 segments according to Couinaud.

A unique feature of the liver's Vascular System is its dual blood supply via two vessels: the proper hepatic artery and the portal vein. Venous drainage is accomplished via a system of hepatic veins (typically 3–4 in number) that empty into the inferior vena cava.

Innervation of the liver is derived from nerve branches originating from the celiac plexus, vagus nerves, and the right phrenic nerve, which form anterior and posterior nerve plexuses at the porta hepatis. Lymphatic drainage is directed to the gastric, celiac, lumbar, aortic, and diaphragmatic lymph nodes.

The gallbladder is located on the visceral surface of the liver. It consists of a fundus, body, and neck, which transitions into the cystic duct. The blood supply to the gallbladder is provided by the cystic artery—most commonly a branch of the right branch of the proper hepatic artery—located within Calot's triangle (bounded by the common hepatic duct, the cystic duct, and the right branch of the proper hepatic artery).

The Extrahepatic bile ducts include the common hepatic duct, cystic duct, and common bile duct. The length of the common hepatic duct is 3–4 cm, and the cystic duct reaches up to 3 cm. Their union forms the common bile duct, which averages 5–8 cm in length and is conventionally divided into 4 parts: supraduodenal, retroduodenal, retropancreatic,

and intraduodenal.

The latter part passes obliquely through the posterior wall of the duodenum and opens at the major duodenal papilla. In 80% of cases, the terminal portions of the common bile duct and the pancreatic duct merge to form the hepatopancreatic ampulla, surrounded by smooth Muscle fibers that constitute the ampullary sphincter (sphincter of Oddi).

During Operations on the stomach and duodenum, the supra- and retroduodenal segments of the common bile duct are most frequently injured.

5. Self-Assessment Materials

A. Self-Assessment Tasks

Test No. 1

In Gastric Cancer, hematogenous metastasis occurred via the portal vein. Which organ will be affected by the metastasis?

а. Left lung

в. Right lung

c. Spleen

d. Liver

e. The kidney

Test No. 2

During a partial gastrectomy, the surgeon mobilized the stomach along its greater curvature. Which ligament must the surgeon transect in this situation?

a. Hepatoduodenal

в. Gastrophrenic

c. Gastrosplenic

d. Hepatogastric

e. Gastrocolic

Test No. 3

To temporarily control hepatic hemorrhage, the surgeon inserted the index finger into the omental foramen. Posterior to which ligament is this foramen located?

а. Hepatorenal

в. Hepatogastric

c. Gastrocolic

d. Gastrosplenic

e. Hepatoduodenal

Test No. 4

During abdominal exploration, the surgeon separated the supracolic compartment from the infracolic compartment using an Anatomical Structure that covers the loops of the Small Intestine anteriorly, originates from the greater curvature of the stomach, and fuses with the anterior wall of the transverse colon. Which of the following structures was utilized by the surgeon in this case?

а. Transverse mesocolon

в. Lesser omentum

c. Greater omentum

d. Gastrocolic ligament

e. Mesentery of the small intestine

Test No. 5

A worker sought medical assistance at a hospital following an abdominal trauma. During surgery, the physician discovered a laceration on the posterior wall of the stomach. Through which opening of the omental bursa did the doctor examine the posterior wall of the stomach?

а. Omental foramen

b. Hepatic

c. Pancreatic

d. Celiac

e. Mesenteric

Test No. 6

During surgery for gallstones, the surgeon needs to locate the common hepatic duct. Between the layers of which ligament is it located?

a. Hepatoduodenal

b. Hepatogastric

c. Hepatorenal

d. Round ligament of the liver

e. Ligamentum venosum

B. Self-Assessment Tasks

Task 1. A 48-year-old patient undergoing surgery for intra-abdominal hemorrhage was found to have a wound on the diaphragmatic surface of the right lobe of the liver. What technique should the surgeon use to temporarily stop the bleeding?

Task 2. A female patient was admitted to the clinic with acute pancreatitis. Complex conservative therapy yielded no effect, and a decision was made to operate. Exploration revealed pancreatic edema. The common bile duct is markedly dilated. The gallbladder is tense and does not empty. What is the cause of this symptom complex? What should be the surgeon's strategy?

Task 3. A patient with liver cirrhosis was admitted. The spleen is markedly enlarged with venous congestion and plethora. What pathway can be used to ensure venous outflow from the spleen?

References

Core

1. Operative Surgery and Topographic Anatomy; ed. by M.S. Skrypnykov. — K.: Vyshcha Shkola, 2000. — P. 294-312.

2. Operative Surgery and Topographic Anatomy; ed. by M.P. Kovalsky. — K.: Medytsyna, 2010. — p. 198-222.

Supplementary:

1. Kovanov V.V. Operative Surgery and Topographic Anatomy / V.V. Kovanov. — M., 2001. — P. 151-179.

2. Operative Surgery and Topographic Anatomy; ed. by M.S. Skrypnykov. — Poltava, 2001. — P. 104-115.

3. Operative Surgery and Topographic Anatomy; ed. by K.I. Kulchytsky. — K., 1994. — P. 176-192.

4. Elizarovsky S.I. Operative Surgery and Topographic Anatomy / S.I. Elizarovsky, R.N. Kalashnikov. — M., 1979.

5. Matyushin I.F. Introduction to the Course of Operative Surgery and Topographic Anatomy / I.F. Matyushin. — Gorky, 1976.

6. Tomashuk, I.P. Rukovodstvo po operativnoy tekhnike dlya nachinayushchikh khirurgov [Guide to Surgical Technique for Beginner Surgeons] / I.P. Tomashuk, I.I. Tomashuk. — Kyiv: European University Press, 2001. — 860 p.

7. Frauchi, V.Kh. Kurs topograficheskoy anatomii i operativnoy khirurgii [Course of Topographic Anatomy and Operative Surgery] / V.Kh. Frauchi. — Moscow, 1976.