Operative Surgery and Topographic Anatomy - 2016

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

Topic 15. Topographic Anatomy of the Abdominal Cavity. Topographic Anatomy of the Small and Large Intestines, Pancreas, and Spleen. Syntopy, Blood Supply, Innervation, and Lymphatic Drainage of These Organs

1. Relevance of the topic: acute and Chronic Pancreatitis, congenital and acquired Diseases of the small and large intestines, Hirschsprung's disease, atresias, mega- and dolichocolon, congenital and acquired intestinal obstruction, ileal diverticulum (Meckel's diverticulum), acute appendicitis, etc., as well as trauma and neoplasms of abdominal Organs, are common pathologies requiring surgical intervention. Diagnosis and Treatment require the physician to have a precise understanding of the structural and topographic features of these organs.

2. Specific objectives:

1. Explain the Topography of the duodenum, jejunum, and ileum, cecum, Appendix, as well as the topography of the ascending, transverse, descending, and sigmoid colons, and the Pancreas.

2. Analyze the topographic rationale for surgeries on the intestines and pancreas.

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

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

3.2. Theoretical questions for the class:

1. How is the Peritoneum positioned relative to the PARTS OF THE duodenum, and what is their skeletotopy?

2. How to perform an exploration of the pancreas?

3. What are the differences between the small and large intestines and the peritoneal arrangement relative to them?

4. How to identify the initial and terminal segments of the small intestine?

5. How to locate the vermiform appendix?

6. How to determine the afferent and efferent segments of a small intestinal loop?

7. Which parts of the Large Intestine are used for colostomy creation and why?

8. How is the ROOT of the mesentery of the small intestine positioned?

9. Meckel's diverticulum. Its practical significance.

10. How is the Blood supply to the small and large intestines organized? What features of their blood supply are of great practical significance? Venous drainage from the small and large intestines.

11. Topography of the Spleen and its ligamentous apparatus.

12. Blood supply and Innervation of the spleen.

13. Into which vein does venous blood drainage from the spleen occur?

3.3. Practical skills acquired during the class:

1. Inspection and exploration of the pancreas.

2. Inspection and exploration of the organs in the lower floor of the abdominal cavity.

3. Identifying the initial segment of the small intestine.

4. Identifying the terminal segment of the small intestine.

5. Identifying the afferent and efferent segments of a small bowel loop.

6. Mastering the technique for locating the vermiform appendix.

7. Delivering the cecum and vermiform appendix into the surgical wound.

4. Topic Content

Study the BOUNDARIES OF THE lower floor of the ABDOMINAL CAVITY AND the topography of the duodenum. Through inspection and Palpation, identify its parts, paying attention to the transition site from The Stomach to the duodenum, the Location OF THE pylorus, and the potential position of the prepyloric vein. Examine the peritoneal reflections relative to the parts of the intestine, its skeletotopy, and THE POSITION OF the descending part relative to the transverse mesocolon.

Demonstrate the Ligamentous apparatus of the duodenum and the positioning of its parts relative to the elements of the hepatoduodenal ligament. Review the syntopy of the intestine, The Relationship of its parts to the HEAD of the pancreas, and the sites where the common Bile duct and pancreatic duct(s) empty into the duodenum. Determine the feasibility of mobilizing the duodenum by incising the peritoneum along its lateral border, and examine the pancreaticoduodenal Arteries, their origins, and their distribution along the inner circumference of the intestine. Pay attention to the venous and lymphatic drainage, as well as the innervation of the duodenum.

Next, study the topography of the pancreas. During inspection and palpation of the gland, note the transverse orientation of its body, the position of the head within the duodenal C-loop, and the tail directed toward the spleen. Examine the skeletotopy of the gland and its spatial relations to the stomach, duodenum, transverse mesocolon, upper pole of the left Kidney, left Adrenal gland, and major Blood Vessels. Determine the peritoneal reflection relative to the gland and introduce METABOLISM/2.html">THE CONCEPT OF the "pancreatic capsule." Locate the splenic artery along the upper border of the gland, noting the risk of injury and Hemorrhage when the gland is displaced downward.

Following mobilization of the gland along its inferior border, displace the gland upward to expose the superior mesenteric artery and superior mesenteric vein. Examine the position of the gland relative to the Water/144.html">Origin of the portal vein, which lies posterior to the head of the pancreas. Surgeons must account for this anatomical feature in cases of pancreatic head tumors, as compression of the portal vein can lead to subhepatic portal Hypertension and consequent ascites. Review the venous and lymphatic drainage of the gland, as well as its innervation.

Subsequently, examine the ligaments and peritoneal recesses at the duodenojejunal junction, determining their significance during the exploration of the lower floor of the abdominal cavity and The Role of the duodenojejunal recess in The formation of internal hernias. Determine the direction of the root of the mesentery of the small intestine, its attachment site to the posterior abdominal wall, and its relation to the spine. Study the topography of the mesenteric vessels and vascular arcades, highlighting Structure/19.html">The Importance of the terminal arcade when utilizing a small bowel loop as an autograft for esophageal reconstruction or to replace defects in other organs. Study the venous drainage into the superior mesenteric vein, lymphatic drainage, and innervation of the small intestine.

Demonstrate techniques for locating the initial segment of the jejunum without exteriorizing the intestine from the abdominal cavity. The first fixed loop of the small intestine is located to the left of the spine, near the base of the transverse mesocolon, at the level of the second lumbar vertebra on the left (Gubarev's maneuver).

Demonstrate the terminal segments of the small intestine and its junction with the cecum (clarifying the role of the ileocecal valve). The mesenteric sinuses are located on either side of the small intestine's mesentery; determine their role, boundaries, and pathways for the spread of purulent processes.

Study the subdivisions of the small and large intestines, noting the anatomical differences between them and their respective segments. Examine the peritoneal coverage of the cecum, ascending, transverse, descending, and sigmoid colons, along with its practical significance.

When studying the topography of the ileocecal region, pay attention to the peritoneal fossae and recesses and their clinical significance. Note the varying degrees of mobility of the cecum depending on its peritoneal investment. Examine the position of the vermiform appendix, its mesentery, and the blood vessels contained within it. Review the anatomical Variants of the appendix's position and the projection of its base onto the anterior abdominal wall. Study the specifics of lymphatic drainage and innervation.

Study the skeletotopy and syntopy of the descending and ascending colons, noting the potential for bowel injury during extraperitoneal approaches to the retroperitoneal organs.

Examine the right and left paracolic gutters and their connections with other compartments of the abdominal cavity.

When studying the transverse colon, specify the attachment site of the transverse mesocolon, and pay attention to the right and left colic flexures, the avascular Zones of the mesentery, and their practical significance.

Examine the topography of the sigmoid colon depending on the length of its mesentery, the recesses of the latter, and their practical significance. Study the blood supply to the segments of the large intestine, identify anastomoses between the superior and inferior mesenteric arteries, and highlight the "critical points" of colonic blood supply and their significance during surgical interventions. Review the formation site of the portal vein, the topography of its branches, lymphatic drainage, and the innervation of the large intestine.

Next, students study the spleen. The Diaphragm relates to the spleen superiorly, laterally, and posteriorly, while the left kidney and left adrenal gland lie posteriorly. Inferiorly, the spleen is adjacent to the tail of the pancreas and the splenic flexure of the colon, and its medial surface reaches the gastric fundus. The spleen is completely covered by peritoneum and is a mobile organ.

The blood supply to the spleen is provided by the splenic artery, which branches off the celiac trunk. The splenic vein has twice the diameter and joins the superior mesenteric vein posterior to the head of the pancreas to form the portal vein. The celiac plexus, left phrenic plexus, and left suprarenal plexus participate in the innervation of the spleen. The regional Lymph Nodes are the splenic nodes, located near the hilum of the organ.

5. Self-Assessment Materials

A. Self-Assessment Tasks

Test No. 1

During an appendectomy, the surgeon exteriorized a segment of the intestine that was grayish-blue in color, featuring taeniae coli and a poorly defined mesentery, lacking epiploic appendages. Which part of the intestine was exteriorized by the surgeon?

a. Cecum

в. Ascending colon

c. Transverse colon

d. Descending colon

e. Sigmoid colon

Test No. 2

During an appendectomy in a child, the vermiform appendix was found in the right hypochondrium. Which anatomical feature of the child's digestive tract caused such a high position of this organ?

a. Short ascending colon

в. Retrocecal position of the appendix

c. Large size of the Liver

d. Presence of the cecal mesentery

e. Short mesentery of the small intestine

Test No. 3

A 50-year-old patient is undergoing resection of the tail of the pancreas for pancreatitis. It should be kept in mind that the pancreas is located relative to the peritoneum:

а. Extraperitoneally

в. Mesoperitoneally

c. Intraperitoneally

d. Parenterally

e. Intramurally

Test No. 4

A 50-year-old patient was hospitalized with suspected Gallbladder inflammation. He was scheduled for esophagogastroduodenoscopy with mandatory examination of the major duodenal papilla. In which part of the duodenum should the physician look for this papilla?

а. Descending

в. Ascending

c. Lower horizontal

d. Upper horizontal

e. Ampulla

Test № 5

During a microscopic examination of the intestinal mucosa, the surgeon found accumulations of lymphoid follicles (Peyer's patches). Which part of the intestine is this?

a. Ileum

b. Jejunum

c. Cecum

d. Duodenum

e. Rectum

Test № 6

In small intestine Cancer, metastasis occurred via the hematogenous route. Into which vein does the venous drainage from this intestine occur?

a. INFERIOR VENA CAVA

b. SUPERIOR VENA CAVA

c. Umbilical vein

d. Hepatic vein

e. Portal vein

Test № 7

During surgery for phlegmonous pancreatitis, purulent exudate was found in the omental bursa cavity. It is known that the pancreas forms one of the walls of this bursa. Which one?

a. Posterior

b. Anterior

c. Lateral

d. Superior

e. Inferior

Test № 8

During surgery for an incarcerated umbilical hernia, an intestinal loop with Appendices epiploicae containing adipose tissue was found within the hernia sac. Which part of the intestine was incarcerated?

a. Transverse colon

b. Duodenum

c. Jejunum

d. Ileum

e. Cecum

B. Self-Assessment Tasks

Task 1. During surgery on a patient with clinical presentations typical of acute appendicitis, the vermiform appendix was not found. How should the surgeon proceed in this situation?

Task 2. At the end of an appendectomy for acute appendicitis, the ligature slipped off the appendicular mesentery. It was not possible to reapply a clamp to the mesentery. What must the surgeon do to stop the bleeding?

Task 3. A patient who underwent surgery 5 days ago for destructive appendicitis complained of pain in the right upper quadrant, which worsens on inspiration. The liver extends 6 cm below the costal margin. What complication should be suspected? What is the appropriate surgical strategy?

Task 4. On the second day after surgery for acute phlegmonous appendicitis, a 61-year-old patient experienced a deterioration in general condition. Fever developed (Temperature rose to 39.6 °C), along with pain in the right upper quadrant. Palpation revealed hepatomegaly and liver tenderness. Over the next 2 days, the fever persisted, accompanied by jaundice of the sclerae. Radiological examination revealed no abnormalities in the thoracic and abdominal cavities. What complication has occurred in the patient? What is its Etiology?

Task 5. A patient underwent a splenectomy. On the 5th postoperative day, symptoms of acute pancreatitis appeared. Which Anatomical Features of the spleen's topography caused this complication?

References

Essential

1. Operativna khirurhiia i topohrafichna anatomiia; ed. by M.S. Skrypnikov. — K.: Vyshcha shkola, 2000. — P. 294-312.

2. Operativna khirurhiia i topohrafichna anatomiia; ed. by M.P. Kovalsky. — K.: Medytsyna, 2010. — P. 198-222.

Supplementary

1. Kovanov, V.V. Operativnaya khirurgiya i topograficheskaya anatomiya / V.V. Kovanov. — M., 2001. — P. 151-179.

2. Operativnaya khirurgiya i topograficheskaya anatomiya; ed. by M.S. Skrypnikov. — Poltava, 2001. — P. 104-115.

3. Operativnaya khirurgiya i topograficheskaya anatomiya; ed. by K.I. Kulchitsky. — K., 1994. — P. 176-192.

4. Elizarovsky, S.I. Operativnaya khirurgiya i topograficheskaya anatomiya / S.I. Elizarovsky, R.N. Kalashnikov. — M., 1979.

5. Matyushin, I.F. Vvedenie v kurs operativnoy khirurgii i topograficheskoy anatomii / I.F. Matyushin. — Gorky, 1976.

6. Tomashuk, I.P. Rukovodstvo po operativnoy tekhnike dlya nachinayushchikh khirurgov / I.P. Tomashuk, I.I. Tomashuk. — K.: Iz-vo Evropeyskogo universiteta, 2001. — 860 p.

7. Frauhi, V.Kh. Kurs topograficheskoy anatomii i operativnoy khirurgii / V.Kh. Frauhi. — M., 1976.