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Ministry of Health of Ukraine

Bukovinian State Medical University


on methodical meeting of the Department of Anatomy, Topographical anatomy and Operative Surgery

…………………………….2008 р. (Protocol №……….)

The chief of department

professor ……………………….……Yu.T.Achtemiichuk

…………………………….2008 р.


for the 2d-year foreign students of English-spoken groups of the Medical Faculty

(speciality “General medicine”)

for independent work during the preparation to practical studies

the Theme of studies

The surgical instrumentation and usage rules”

Module 1

Topographical Anatomy and Operative Surgery

of the Head, Neck, Thorax and Abdomen

Semantic module

Topographical Anatomy and Operative Surgery of the Head and Neck

Chernivtsi – 2008

1. Actuality of theme:

The topographical anatomy and operative surgery are very importance, because without the knowledge about peculiarities and variants of structure, form, location and mutual location of their anatomical structures, their age-specific it is impossible to diagnose in a proper time and correctly and to prescribe a necessary treatment to the patient. Surgeons usually pay much attention to the usage rules of surgical instruments.

^ 2. Duration of studies: 2 working hours.

3. Objectives (concrete purposes):

To know the definition of topographical anatomy and operative surgery, surgical operation.

To know classification of surgical instrumentation.

To know surgical instrumentation and usage rules.

To be able to define the surgical instrumentation.

^ 4. Basic knowledges, abilities, skills, that necessary for the study themes (interdisciplinary integration):

The names of previous disciplines

The got skills

1. Normal anatomy

2. Physiology

3. Biophysics

To describe the structure and function of the different organs of the human body, to determine projectors and landmarks of the anatomical structures. To understand the basic physical principles of using medical equipment and instruments.

5. Advices to the student.

5.1. Table of contents of the theme:


The surgeon realizes the mechanical influence on organs and tissues by his surgical instruments. There are a few classifications. According to the gov­ernment standard 19126-79E (“Metal medical instru­ments. General technical conditions”) they are divided by character of mechanical action:

  1. Piercing

  2. Cutting

  3. Pressing

  4. Clumps (multisurface action)

  5. Probing

  6. Bougienaging

  7. Traumatologic (connecting tissues of organ­ism and acting on them).

The classification by function is more comfortable for surgeons:

I. General surgical instruments:

  1. Instruments for parting tissue.

  2. Instruments to arrest bleeding.

  3. Instruments for suturing tissue.

  4. Fixation instruments. Accessory instruments.

II. Special surgical instruments (neuro-surgical, traumatologic, stomatologic, ophthalmologic and other).

The structure of surgical instrument. An in­strument consists of working portion (blade of an in­strument), which is acted on patient tissues and handle kept by a surgeon. The construction of instrument is conditioned by character of its mechanical acting on tissues. The greater part of instruments (clamps, scis­sors and others) consist of two parts – branches, con­nected by a lock. The blade of an instrument can have grinds, windows, incisions, teeth on its tips, and oth­ers. For the firm keeping of instrument in hand the handles should have rings, incisions or lugs. For fixing of branches in the clamped position on handles can be rack gear. For the firm keeping in a hand an instru­ment should have three points of fixing. For example, clamps, needle-holders, scissors kept by 1st, 2nd and 4th fingers.

The surgical instruments applied in pediatric sur­gery have less sizes and weight, fine tips of an instru­ments (for example, less length and width of grips of clamps).

^ 1. The Instruments for the Parting of Tissue

For disconnection of soft tissues the scalpels, operating knives, scissors are utilized. For bone tis­sue – the surgical saws, chisels are utilized. In addi­tion, the properties of electric current, laser and radia­tion emanation, ultrasonic waves.

^ A scalpel is an instrument of piercing and cut­ting action. For realization of mainly cutting action ab­dominal scalpels are utilized, for piercing – spoking (sharp-pointed) ones. There are also other configurations of cutting edge, conditioned by the features of form of organs and tissues to dissect.

There are entire-stamped, non-permanent and with a removable blade scalpels. There are certain receptions of using a scalpel. The position of “writing pen” provides exact, dosated cuts of precise length and depth. The position of bow provides long and superficial cuts of soft tissues, the position of table-knife – deep cuts. For realizing a skin cut a scalpel is set almost at the beginning of future cut vertically, and then it is inclined and cuts a skin and hypodermic cel­lular tissue. At the end of cut a scalpel is again trans­ferred in a vertical position.

^ The scissors are the instruments of crushing and cutting action. It is not recommended to cut a skin, vessels, nerves and internal organs by scissors be­cause of their excessive injuring. The fascias, apo-neurosis, suture material are cut by scissors. By the form of branches the scissors may be straight and curved (Richter scissors – by plane, Cooper scissors – by axis). By the form of form ends may be blunt-pointed, sharp-pointed and button-type scissors (scis­sors of Lister for the bandages removal). The scissors are hold in a hand with help of 1st, 2nd and 4th fingers.

The special type of scissors is laparotomy scis­sors of Metzenbaum, or dissector. They are arcuated by plane, have rounded surfaces, narrow blunt ends, long handles. They are applied for cutting off of suture material, dissecting of connections in the body cavities, and also for blunt disconnection of tissues by separation of branches or piercing of non-vascular areas of copulas and frills by closed ends (e.g. during organ’s mobiliza­tion).

The ends of the bound are cut away by scissors by certain rules: 1) having strained threads by a left arm, the separated scissors’ tips carefully approached to the tied knot; 2) after stopping in the knot the branches are turned on 90° and cut away the threads excess. Such mode provides necessary minimum length of knot ends – approximately 3 millimetres.

^ The resection knives have the wide back of blade, allowing to make additional effort for discon­nection of dense tissues.

The catling (small, middle and large) is utilized for the single-stage dissection of soft tissues during amputations. For this purpose the surgeon holds the knife blade up and edge toward himself.

^ The surgical saws disconnect bone tissues: flat bones – by the saws of Jeegly and Olivecrone, tubular bones – by dissecting blade, knife, arched and circu­lar saws. For the bones dissection is used also cutters of Liston, Lyuer, Dalgran, Schtille and others.

During operations on bones the surgical chisels is used (straight and grooved). Before a bones dis­section a periosteum is detached layer by a layer by raspatories (straight and arcuated).

For the dissection of skull cavity (trepanation) is used a trepan with the set of pinned and spherical milling cutters, for the dissection of tubular bones cavity – the osteotome.

^ The principles of soft tissues disconnection

During the disconnection of tissues a surgeon must provide:

  1. Minimum cosmetic defect, favourable condi­tions of tissues regeneration, in other words: the skin cut direction must coincide with elastic fibres (fissure-lines of Langer), connective tissue and muscular fi­bres, vessels and nerves one; a dissection section is done by one motion of scalpel (wound edges must be even); to be consistent with the principle of instrumen­tality – all of manipulations in wound must be done with instruments.

  2. The layer-by-layer access provides: every next layer of tissues is dissected only after a complete (at length of wound) dissection section of previous; du­ring the access the direction of next tissue layer dis­secting can be changed in relation to previous based on direction of aponeurosis, muscles, vessels and nerves fibres; for dissecting of fascias, aponeurosis, parietal serous tunic the grooved probe is used.

  3. The hemostasis, that is: every next layer is dis­sected after the arrest of bleeding from previous vessels.

  4. Asepsis and antisepsis (blastics and antiblastics for oncosurgery), that is: for prevention of infect­ing during access the every layer of tissues is limited from the other one with surgical garb (linen); change instruments and gloves, use antiseptics on suspicion of contamination.

  5. The due notice of possible complications and fight against them, that is: to size up clearly, in which anatomic layer manipulation is realized; constantly get information about the general state of patient (contact with a patient, anaesthetist, dresser, analysis of infor­mation of monitoring, colour of blood, intension of mus­cles and other); give instructions to junior medical staff operating-room in advance about preparation to the use of certain medical equipment and instrumentation.

^ 2. The Instruments for the Arrest of Bleeding

Among these are vascular and hemostatic for­ceps (clamps).

The arteries and veins of middle and large gauge are pinched by vascular clamps to prevent hemorrhage during operations on vessels and organs (heart, lungs, kidneys, gallbladder and others). Among these are the vascular clamps of Satinsky, Hophner, Pyrogov, Mayo, Negus, Well and others.

The final hemostasis is carried out by hemostatic forceps. They are used for cross-clamping of vessels of small gauge, damaged during access or separation of organ from surrounding tissues. Such clamps are different by a construction, but they can be divided to two groups: 1) clamps with teeth on the ends of work­ing portion (Kocher’s clamps); 2) clamps without teeth (Billroth’s, “mosquito”, Pean’s clamps and others).

^ The Technique for the Arrest of Bleeding by Kocher’s Clamps

The straight clamp with teeth on the tip Kocher firstly applied for vessels’ pinching of thyroid gland. The hemostasis is carried out by damaged vessel cross-clamping together with surrounding tissues by blade of instrument (except teeth). The teeth do not permit the instrument to slip off. Under a clamp is got the thread or piercing ligature. After making the first knot a clamp is carefully taken off, not breaking off to tighten the first knot and making the second one.

^ The Technique of Arrest of Bleeding by the Billroth’s Clamp

The clamp is applied for haemostasis of the dam­aged hypodermic vessels. The bleeding vessel’s open­ing (without surrounding tissues) is pinched by clamp’s tips. The ends of grips are carefully turned inside out to let them appear in the assistant’s field of vision putting the thread under ends. During tightening the first knot a clamp is carefully taken off then the second knot is tied.

For arrest of bleeding the blunt-pointed ligature needle of Deschamp is applied. It has an eye on a tip. An eyed thread is put by an instrument under the pre­pared segment of vessel. The Deschamp’s needle is delivered from a wound, and a thread is fixed and cut on two parts by which the ligatures are put.

With a purpose of arrest of bleeding surgical dia­thermy (thermal effect of electric current) is applied. The electric current with certain characteristics is put to the vessel through a metallic instrument (clamp, for­ceps). The electric field at this moment is closed. The arising thermal effect at passing of current through bio­logical tissues with a little electric resistance causes coagulation and hemostasis.

^ 3. The Instruments for the Suturing of Tissue

The tissues connection is carried out suture ma­terial by medical needles, needle-holders and also by Michel’s cramps put by special forceps, staplers and by the mechanical sutures devices.

The suture material is classified after high-quality and quantitative characteristic of elemental fibres. By the structure of fibre the suture material is divided on monofilament and polyfilament (twisted and wattled).

The main destination of suture material is to ap­proach, adapt and fix biological tissues which are to be connected on a term necessary for formation of adhesion (seam, scar).

The general requirements regarding suture ma­terial:

  • Biological compatibility (inactivity).

  • Durability.

  • Monofilament properties (absence of wick prop­erties).

  • Atraumatic properties (elasticity, flexibility, smooth surface).

  • Expectant biodegeneration (dissolving and remov­ing from an organism during a necessary term).

  • Possibility of sterilization.

- Cheapness of raw material and production.

The elastic suture material is conducted through

tissues for their connection by surgical needles. The needles are held up by the needle-holders of different constructions (Hegar, Troyanov and Mathieu).

The needles are classified by their different cha­racteristics. There are straight, circle and steep needles by a form. The surgeon choice of needle of necessary form is determined by angle of operative action. At large angle (up to 180°) it is comfortable to use a straight needle, for example, for creation of anastomosis be­tween the intestinal loops, and at small angle (to 30°) a steep needle is better, for example, for the plastic surgery of femoral canal.

The needles are made with the various form of cross-section (flat, round, triangular and multangular), but the widest distribution have round (piercing) and triangular (cutting) surgical needles. Piercing needles pull apart the fibres of biological tissue and provide impermeability of tubular structures sutures; that is why they are applied for connection of muscles, intestine walls, vessels. The cuttings needles conduct suture material through a skin.

By the method of suture material fixing the needles are divided into traumatic and atraumatic. The traumatic needle has an eye (round, automatic, heli­cal and others). The atraumatic, or swagged, needle is as though the continuation of suture material. The absence of eye and double thread determines the mini­mum injuring of tissues at putting of cosmetic suture.

There is the special place for its fixing of needle-holder on a needle, which is located nearer to the eye.

The needle-holder of Hegar is most widespread (small, middle and large). It should be remembered that this needle-holder is expected to act during 600 work cycles (600 reliable, without motions and fixings of needle), that is why it would be bad to leave an in­strument lying idle with the clamped needle.

For conducting of suture material through paren-chymal organs the sharp-pointed Deschamp’s needle also is utilized.

After stitching up the wound edges are drawn together, compared and fixed by tying a knot with thre­ads ends.

During the tying of surgical knot it is necessary to provide permanent moderate intension of suture material. A minimum of knots – 2, but, depending on properties of suture material, there are can be more knots to prevent of untying and rupture of wound edges.

The most reliable is square knot (reef knot, sailor’s knot). A surgeon’s knot (surgical knot, friction knot) al­lows comparing and fixing the wound edges now at the first tying, but for bandaging of vessels of small diameter this knot isn’t worth utilizing.

There are a lot of methods of knot’s tying. The best method is that by which the surgeon wields perfectly.

The basic moments of knot’s tying (a right arm – “handle”, a left one – “working”):

  1. The ends of threads are hitched by fingers and the intersection is done. An upper thread is held by working hand as reins, to set free the thumb and forefin­ger. The threads all of time must be moderately strained.

  2. The threads intersection is fixed between 1st and 2nd (3rd) fingers of working hand.

  3. The end of thread held by working hand is set free and pushed between intersection and wound.

  4. The end of thread is hitched again by right arm and threads are moved closer to knot’s tying.

In microsurgery, ophthalmology, pediatric surgery the instrumental methods of knots tying are often ap­plied, so to say without a touch by fingers but only by instruments to prevent the possible infecting of suture material.

The Principles of Tissues Connection

For providing favourable conditions for regenera­tion, minimum cosmetic defects and violations of phy­siologic functions of organs and tissues a surgeon fol­lows the certain rules of biological tissues connection. A surgeon must provide:

1. Anatomic and physiologic continuity of tissues, that is:

  • to confront tissues exactly in such order which they were disconnected in;

  • to connect only allied tissues (muscular – with a muscle, fibrous connective tissue – with the same fibrous connective tissue and others like that);

2. Prophylaxis of festering and septic complica­tions, that is:

  • aseptic conditions are during tissues connec­tion (treatment of edges of wound before and after su­turing, frequent replacement of instruments, treatment of gloves by antiseptic);

  • do not leave cavities during tissues connection;

  • extraction of ichors and exudation from a wo­und and cavities (wound drainage, irrigation aspira­tion, insertion of rubber tapes – turundas);

3. Reliable hemostasis and prophylaxis of bleed­ing after an operation, that is:

  • control of hemostasis during suturing;

  • the microirrigator is left in a wound to oppor­tune reveal of internal hemorrhage.

4. Optimum conditions for wound regeneration and healing by initial intension, prophylaxis of tissues necrosis, that is:

  • nonviable and chipped edges of non-operative wound it is necessary to plane sharply (to convert it in a cut);

  • to delete nonviable tissues from an non-ope­rative wound;

  • to put the non-operative wound into long-oval shape;

  • the sutures by which the edges of wound are compared and fixed and their intension must not cause ischemia of biological tissues.

^ 4. The Accessory Surgical Instruments

These are designed for holding, fixing and push­ing back (retract) of tissues and surgical garb. Among these are retractors, flat hooks of Farabeuf, hepatic mirrors, pincers (anatomical, surgical, gripping, fenes-trated), dressing forceps, pumps, hooks for surgical garb, clamp of Miculicz and others. By these instru­ments is provided the important general surgical prin­ciple – the instrumentality – for the minimum injuring of biological tissues and preventing of their infecting by the surgeon hands.

^ The Special Surgical Instruments

This is the most numerous group of various sur­gical instruments by construction, which are utilized in gynaecology, urology, neurosurgery, otolaryngology and other spheres of medicine.

The ophthalmologic, neurosurgical, cardiac and pediatric surgery’ instruments are differing by small sizes and weight. The form of microsurgical instruments is adapted to the operative conditions.

The operations for children’s require application of atraumatic needles and modern synthetic suture material. During an operation the special exactness and delicacy of manipulations is necessary: the tis­sues are disconnect mainly sharply, avoiding compres­sion, crushing and exfoliation. The electric coagula­tion and using of electric knife must be limited and applied with a maximal carefulness, because the im­possibility of the exact adjusting of influence intensity on tender tissues can bring to burn and injury of nearby organs and structures.

The careful control on loss of blood and its sup­plying is obligatory to during an operation (but not af­ter it’s finishing). In surgery of newborns is especially justified the aspiration to the rational acceleration of operation, however without a loss for its delicacy and atraumatic measures.

The general principles of pediatric surgery:

  • taking into account of age-specific, topographi­cal, anatomic and physiologic features of child’s or­ganism;

  • the operations are carried out by the most ex­perienced surgeon;

  • during the choice of operation method on or­gans and growing tissues, the preference is shown for operations of organ’s conservation;

  • application of the special instruments;

  • providing of comfort conditions for an operated child, which includes rational preoperative preparation, warming during an operation, adequate anaesthetizing, infusion intraoperative therapy and so on;

  • correct choice of strategy and tactic of surgical treatment, determination of optimum method of surgi­cal operation;

  • achievement of necessary result by a maximally simple and atraumatic mode, to divide an operation into a few stages or carry out palliative operation as may be necessary.


- Absorbable:

Plain Catgut

Plain catgut is not commonly used in modern surgery. Although its rapidity of absorption might seem to be an advantage, this rapidity is the result of an intense inflammatory reaction that produces enzymes for the digestion of the organic material. Plain catgut is acceptable for ligating bleeding points in the subcuta­neous tissues and not for very much else.

^ Chromic Catgut

Chromic catgut has the advantage of a smooth surface, which permits it to be drawn through delicate tissues with minimal friction. It may be depended upon to last for about a week and is suitable only when such rapid absorption is desirable. It is completely contraindicated in the vicinity of the pancreas, where proteolytic enzymes produce premature absorption, and in the closure of abdominal incisions and hernia repair, where it does not hold the tissues long enough for adequate healing to occur. Chromic catgut is useful for the ap­proximation of the mucosal layer in a two-layer anas­tomosis of the bowel. For this purpose, size 4-0 is suit­able. Bear in mind that wound infection will increase the rapidity of catgut digestion.

^ Polyglycolic Synthetics

Polyglycolic synthetic sutures (PG), such as Dexon or Vicryl, are far superior to catgut because the rate at which they are absorbed is much slower. Even after 15 days, about 20% of the tensile strength re­mains. Digestion of the polyglycolic sutures is by hy­drolysis. Consequently, the proteolytic enzymes in an area of infection have no effect on the rate of absorp­tion of the polyglycolics. Also, the inflammatory reac­tion they incite is mild as compared with catgut. Their chief drawback is that their surface is somewhat rougher than catgut, which may traumatize tissues slightly when the PG suture material is drawn through the wall of the intestine. This characteristic also makes the tying of secure knots somewhat more difficult than with catgut. However, these appear to be minor disad­vantages, and these products have for many purposes made catgut an obsolete suture material.

- Nonabsorbable:

Natural Nonabsorbables

Natural nonabsorbable sutures, such as silk and cotton, have enjoyed a long period of popularity among surgeons the world over. They have the advantage of easy handling and secure knot tying. Once the knots are set, slippage is rare. On the other hand, they pro­duce more inflammatory reaction in tissue than do the monofilament materials (stainless steel, Prolene) or even the braided synthetics. Silk and cotton, although classified as nonabsorbable, do indeed disintegrate in the tissues over a long period of time, whereas the synthetic materials appear to be truly nonabsorbable. In spite of these disadvantages, silk and cotton have maintained worldwide popularity mainly because of their ease of handling and surgeons’ long familiarity with them. Because there are no clear-cut data at this time demonstrating that anastomoses performed with synthetic suture material have fewer complications than those performed with silk or cotton, it is not yet neces­sary for the surgeon to abandon the natural nonabsor-bables if he or she can handle them with greater skill. With the exception of the monofilaments, a major dis­advantage of nonabsorbable sutures is the formation of chronic draining sinuses and suture granulomas. This is especially marked when material larger than size 3-0 is used in the anterior abdominal fascia or in the subcutaneous tissue.

^ Synthetic Nonabsorbable Braids

Synthetic braided sutures include those made of Dacron polyester, such as Mersilene, Ticron (Dacron coated with silicone), Tevdek (Dacron coated with Teflon), and Ethibond (Dacron with butilated coating). Braided nylon (Surgilon or Nurolon) is popular – in the United Kingdom. All these braided synthetic materials require four or five knots for secure closure, compared to the three required of silk and cotton.

^ Synthetic Nonabsorbable Monofilaments

Monofilament synthetics like nylon and Prolene are so slippery that as many as 6-7 knots may be required. They and monofilament stainless steel are the least reactive of all the products available. For this rea­son, 2-0 or 0 Prolene has been used by some sur­geons for the abdominal closure in the hope of elimi­nating suture sinuses. Because of the large number of knots, this hope has not been realized, but the sinuses have turned out to be fewer than when nonabsorbable braided materials are used. Prolene size 4-0 on atrau-matic needles has been used for the seromuscular layer of intestinal anastomoses. Both Prolene and vari­ous braided polyester sutures have achieved great popularity in vascular surgery.

^ Monofilament Stainless

Steel Wire

Monofilament stainless steel wire has many char­acteristics of the ideal suture material; however, it is difficult to tie. Also, when it has been used for closure of the abdominal wall, patients occasionally have com­plained of pain at the site of a knot or of a broken su­ture. True suture sinuses and suture granulomas have been extremely rare when monofilament stainless steel has been used – no more than 1 in 300 cases. Size 5-0 monofilament wire has been used for one-layer eso-phagogastric anastomoses and for colon anasto­moses. Three square throws are adequate for a se­cure knot in tying this material. If steel wire in the form of a braid is used, the incidence of suture sinuses is not less than experienced with braided silk.

^ Modern Suture Material

Dermalon – monofilament nylon.

Ethibond – braided Dacron polyester with buti-lated coating.

Ethilon – monofilament nylon.

Mersilene – braided Dacron polyester.

Nurolon – braided nylon.

PDS – Polydiaxanone, synthetic monofilament absorbable suture; slowest rate of absorption of cur-rendy available suture materials.

PG – polyglycolic acid, Dexon, polyglactin, Vicryl.

Prolene – monofilament polypropylene.

Surgilene – monofilament polypropylene.

Surgilon – braided nylon coated with silicone.

Tevdek – braided Dacron polyester coated with Teflon polytetrafluorethylene.

Thumbtack – titanium hemorrhagic occluder pin with applicator.

Ticron – braided Dacron polyester coated with silicon.

Vicryl – Polyglactin, synthetic absorbable suture material.

^ Size of Suture Material

As there mustn’t ever be any tension on an anas­tomosis in the gastrointestinal tract, it is not necessary to use suture material heavier than 4-0. Failure of heal­ing is often due to tearing of a stitch through the tissue and almost never to a broken suture. When two layers of sutures are used for an anastomosis in the gast­rointestinal tract, the inner layer should be 5-0 Vicryl. This layer provides immediate and accurate approxi­mation of the mucosa and, in some instances, hemostasis. Therefore, this layer of suture material doesn’t need persist more than 4-6 days before it is absorbed. In esophagogastric anastomoses, interrupted 4-0 PG should be used for the inner layer, which has the addi­tional function of contributing strength to the anasto­mosis. For this purpose, slower absorption is desirable. When taking large bites of tissue that has consider­able tensile strength, such as in the closure of the ab­dominal wall, heavier suture material is indicated. Here, 1-0 PDS is suitable. Obviously, the size of the suture material must be proportional to the strength of the tissues into which it is inserted and to the strain it has to sustain.

^ 5.2. Theoretical questions to studies:

  1. Put the definishen of the operative surgery.

  2. Classification of the surgical instruments.

  3. General surgical instruments.

  4. The usage rules of general surgical instruments.

  5. Special surgical instruments.

  6. The usage rules of special surgical instruments.

  7. Classification of the suture material.

  8. The kinds of absorbable suture.

  9. The kinds of nonabsorbable suture.

  10. Methods of making a surgical knots.

^ 5.3. Practical tasks which are executed on studies:

1. Give a demonstration of correct using of surgical instruments for the parting of tissue.

2. Give a demonstration of correct using of surgical instruments for the arrest of bleeding.

3. Give a demonstration of correct using of surgical instruments for the suturing of tissue.

4. Give a demonstration of correct using of the accessery surgical instruments.

5. Give a demonstration of knots tying.


1. Snell R.S. Clinical Anatomy for medical students. – Lippincott Williams & Wilkins, 2000. – 898 p.

2. Skandalakis J.E., Skandalakis P.N., Skandalakis L.J. Surgical Anatomy and Technique. – Springer, 1995. – 674 p.

3. Netter F.H. Atlas of human anatomy. – Ciba-Geigy Co., 1994. – 514 p.

4. Ellis H. Clinical Anatomy Arevision and applied anatomy for clinical students. – Blackwell publishing, 2006. – 439 p.


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