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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 2nd-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

Topographical anatomy of the anterolateral abdominal wall.

The methods of laparotomy


Topographical Anatomy and Operative Surgery

of the Head, Neck, Thorax and Abdomen

Semantic module 3

Topographical Anatomy and Operative Surgery of the Abdomen”

Chernivtsi – 2008

1. Actuality of theme:

The topographical anatomy and operative surgery of the abdomen are very importance, because without the knowledge about peculiarities and variants of structure, form, location and mutual location of abdominal 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 topographo-anatomic basis of surgical operations on the abdomen.

^ 2. Duration of studies: 2 working hours.

3. Objectives (concrete purposes):

To know the definition of regions of the abdomen.

To know classification of surgical operations on the abdomen.

To know the topographical anatomy and operative surgery of the organs of the abdomenal cavity.

^ 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 Abdominal Wall

The abdominal wall extends from the osteocartilaginous thoracic cage to the pelvis. Its major part is muscular.

Subdivisions of the Abdominal Wall. Although the abdominal wall is continuous, it is helpful for descriptive purposes to subdivide it into: (1) the anterior abdominal wall; (2) the right and left lateral walls (flanks); and (3) the posterior abdominal wall (lumbar region). The combined term anterolateral wall is often used because some structures (e.g., the external oblique muscle and cutaneous nerves) are located in both the anterior and lateral walls.

^ Layers of the Abdominal Wall. The abdominal wall consists of skin, subcutaneous tissue (superficial fascia and fat), investing fascia, muscles, transversalis fascia (endoabdominalis fascia), extraperitoneal (subserous) fat, parietal peritoneum.

The Anterolateral Abdominal Wall

When the abdomen is surgically operated on, it is usually the anterolateral abdominal wall that is incised. Most of this wall consists of three muscular layers, each of which has its fibers arranged in a different direction.

Boundaries of the anterolateral abdominal wall. The anterolateral abdominal wall is limited superiorly by the right and left costal margins; inferiorly by a line connecting each anterior superior iliac spine to the pubic symphysis; and on each side by a vertical line through the ends of 11th ribs to the iliac crests.

^ Surface Anatomy and Anatomical Landmark of the Abdominal Wall

The umbilicus (navel, "belly-button") is the puckered scar represents the former site of attachment of the umbilical cord. In physically fit people, the umbilicus lies at the level of the intervertebral disc between L3 and L4 vertebrae. This is about midway between the xiphoid process of the sternum and the pubic symphysis.

A line joining the xiphoid process to the pubic symphysis indicates the position of the linea alba (L. alba, white), a median fibrous white line or band. This line divides the anterior abdominal wall into right and left halves. The position of the linea alba is indicated by a vertical skin groove in the anterior median line.

The linea semilunaris is a curved line or groove (convex laterally) that extends from the 9th costal cartilage to the pubic tubercle. This semilunar line indicates the lateral border of the rectus abdominis muscle, which is located 5 to 8 cm from the median plane. In such persons, three or more transverse grooves are also visible in the skin overlying the tendinous intersections of the rectus abdominis muscles. The site of the inguinal ligament is indicated by the inguinal groove. It also indicates the division between the anterior abdominal wall and the thigh. A fold of skin, called the inguinal fold, is visible just superior to the inguinal groove. The inguinal ligament may be felt along its entire length.

^ Regions of the Abdomen

The abdomen is divided by four planes (subcostal, transtubercular and two sagittal through the lateral edges of the rectus abdominis muscle) into the nine regions (epigastric; subcostal left and right; umbilical; lateral, or flank, left and right; suprapubic; inguinal left and right).

For the simple four-quadrant topographical pattern a horizontal transumbilical plane passes through the umbilicus and the intervertebral disc between vertebrae LIII and LIV and intersects with the vertical median plane to form four quadrants-the right upper, left upper, right lower, and left lower quadrants.

^ Layer-by-layer structure of the anterolateral abdominal wall

1. Skin

The natural lines of cleavage in the skin are constant and run almost horizontally around the trunk. This is important clinically because an incision along a cleavage line will heal as a narrow scar, whereas one that crosses the lines will heal as a wide or heaped-up scar.

^ 2. Subcutaneous fat, or superficial layer (Camper's fascia), contains of a variable amount of fat, superficial nerves and vessels.

Nerve Supply

The cutaneous nerve supply to the anterior abdominal wall is derived from the anterior rami of the lower six thoracic and first lumbar nerves. The thoracic nerves are the lower five intercostal and the subcostal nerves, and the first lumbar nerve is represented by the iliohypogastric and ilioinguinal nerves, branches of the lumbar plexus. The dermatome of T7 is located in the epigastrium over the xiphoid process; that of T10 includes the umbilicus; and that of LI lies just above the inguinal ligament and the symphysis pubis.

^ Blood Supply

The skin near the midline is supplied by branches of the superior epigastric artery (a branch of the internal thoracic artery) and the inferior epigastric artery (a branch of the external iliac artery). The skin of the flanks is supplied by branches from the intercostal, lumbar, and deep circumflex iliac arteries.

The venous blood is collected into a network of veins that radiate from the umbilicus. The network is drained above into the axillary vein via the lateral thoracic vein and below into the femoral vein via the superficial epigastric and great saphenous veins. A few small veins, the paraumbilical veins, connect the network through the umbilicus and along the ligamentum teres to the portal vein. They form a clinically important portal-systemic venous anastomosis.

^ Lymph Drainage

The cutaneous lymph vessels above the level of the umbilicus drain upward into the anterior axillary lymph nodes. The vessels below this level drain downward into the superficial inguinal nodes.

The superficial fascia, or membranous deep layer (Scarpa's fascia) containing fibrous tissue and very little fat. It is continuous with the deep fascia of the thigh, called the fascia lata, and with the superficial fascia of the perineum (Colles' fascia) and with that investing the scrotum and penis and the labia majora. The membranous deep layer of superficial fascia fuses with the deep fascia of the abdomen.

^ The deep, or investing, fascia. It is a very thin, strong layer over the superficial muscles and cannot be separated easily from them. Between the deep layer of superficial fascia and the deep fascia of the abdomen, there is a potential space in which fluid may accumulate.

Muscles of the Anterior Abdominal Wall

Most of the abdominal wall is muscular and extends between the thoracic cage and the bony pelvis. There are four important paired muscles in the anterior abdominal wall: three flat muscles (external oblique, internal oblique, and transversus abdominis) and one rectus abdominis.

The combination of muscles and aponeuroses (sheetlike tendons) in the anterior abdominal wall affords considerable protection to the abdominal viscera, especially when the muscles are in good physical condition. The flat muscles cross each other in such a way (similar to a three-ply corset) that strengthens the abdominal wall and diminishes the risk of protrusion of viscera (herniation) between the muscle bundles. In about 80% of people there is an insignificant, small triangular abdominal muscle, called the pyramidalis, which is located anterior to the inferior part of the rectus abdominis. It tenses the linea alba.

The anterior abdominal wall may be the site of congenital hernias. Most of them occur in the umbilical and inguinal regions. Umbilical hernias are usually small (1 to 5 cm) and congenital (present at birth). They result from incomplete closure of the anterior abdominal wall after the umbilical cord is ligated at birth. Herniation occurs through the defect created by the degenerating umbilical vessels. Hernias may also occur through defects in the linea alba; these are median hernias. Extraperitoneal fat and/or omentum (a peritoneal fold) protrude through these defects. If the hernia occurs in the epigastric region, it is called an epigastric hernia. This type tends to occur after 40 years of age and is often associated with obesity.

The External Oblique Muscle. This is the largest and most superficial of the three flat abdominal muscles. It is located in the anterolateral part of the abdominal wall. Its fleshy part forms the anterolateral portion and its aponeurosis (sheet of tendon fibers) forms the anterior part. Its fibers run inferoanteriorly and medially in the same direction as do the extended digits (fingers) when they are in one's side pockets. The attachments, nerve supply, and main actions of the external oblique are given in Table 2-1. As the fibers of this muscle pass medially, they become aponeurotic.

This aponeurosis ends medially in the linea alba. Inferiorly it folds back on itself to form the inguinal ligament between the anterior superior iliac spine and the pubic tubercle. Medial to the pubic tubercle the external oblique aponeurosis is attached to the pubic crest. Some fibers of the inguinal ligament cross the linea alba and attach to the opposite pubic crest. These fibers form the reflex inguinal ligament. The medial part of the inguinal ligament is reflected horizontally back and is attached to the pecten pubis as the lacunar ligament. Just superior to the medial part of the inguinal ligament, there is an opening in the aponeurosis called the superficial inguinal ring. This clinically important ring is discussed with the inguinal region.

^ The Internal Oblique Muscle. This is the intermediate of the three flat abdominal muscles. Its attachments, nerve supply, and main actions are given in Table 2-1. The fibers of the internal oblique muscle run superoanteriorly. at right angles to those of the external oblique. Its fibers also become aponeurotic and the aponeurosis splits to form a sheath for the rectus abdominis muscle. The inferior fibers of the aponeurosis arch over the spermatic cord as it lies in the inguinal canal. They then descend posterior to the superficial inguinal ring to attach to the pubic crest and pecten pubis. The most inferior tendinous fibers of the internal oblique muscle join with aponeurotic fibers of the transverses abdominis muscle to form the conjoint tendon, which turns inferiorly to insert into the pubic crest and pecten pubis.

^ The Transversus Abdominis Muscle. This is the innermost of the three flat abdominal muscles. Its attachments, nerve supply, and main actions are given in Table 2-1. Its fibers run more or less horizontally, except for the most inferior ones, which pass inferiorly and run parallel to those of the internal oblique muscle. Muscle fibers of the transversus abdominis end in an aponeurosis which contributes to the formation of the rectus sheath.

^ Actions of the Three Flat Abdominal Muscles (Table 2-1). The anterolateral abdominal wall is unsupported and unprotected by bone. However, the three-ply structure of its flat muscles and their extensive aponeuroses form a strong expandable support, which provides considerable protection for the abdominal viscera. Normally, quiet rhythmic movements of the anterolateral abdominal wall accompany respirations. When the diaphragm contracts during inspiration, its domes flatten and descend, increasing the vertical dimension of the thorax. To make room for the viscera {e.g., the stomach and intestine), the anterolateral abdominal wall expands as its muscles relax. When the thoracic cage and diaphragm relax during expiration, the anterolateral abdominal wall passively sinks in. However, in the forced expiration that occurs during coughing, sneezing, vomiting, and straining, all the anterior abdominal muscles act strongly in compressing the abdominal contents.

^ Acting together, the flat abdominal muscles increase the intraabdominal pressure. When the ribs and diaphragm are fixed, compression of the viscera by the anterior abdominal muscles occurs, which raises the intra-abdominal pressure. This action produces the force required for defecation (bowel movement), micturition (urination), and parturition (childbirth). Acting separately, the flat abdominal muscles move the trunk. If the pelvis is fixed, both external oblique muscles can flex the trunk. Acting separately, one external oblique muscle can laterally flex the trunk and rotate it to the opposite side. If the thorax is fixed, both external oblique muscles tilt the anterior part of the pelvis superiorly and flex the trunk. Similarly, when the pelvis is fixed, one internal oblique muscle can flex the trunk and rotate it to the same side. If the thorax is fixed, one internal oblique muscle can laterally flex the trunk and rotate the pelvis to the opposite side. See Chap. 4 for a further discussion of these movements of the vertebral column and trunk.

The Rectus Abdominis Muscle. This long, broad, strap muscle is the principal vertical muscle of the anterior abdominal wall. The two muscles are separated by the linea alba and lie close together inferiorly. The rectus abdominis is three times as wide superiorly as inferiorly; it is narrow and thick inferiorly and broad and thin superiorly. The lateral border of the rectus muscle and its sheath are convex and form a clinically important surface marking known as the linea semilunaris. Most of the rectus abdominis muscle is enclosed in the rectus sheath, formed by the aponeuroses of the three flat abdominal muscles. The anterior layer of the rectus sheath is firmly attached to the rectus muscle at three or more tendinous intersections. When this muscle is tensed in muscular persons, each stretch of muscle between the tendinous intersections bulges outward. The location of the tendinous intersections is indicated by grooves in the skin between the muscle bulges. They are usually located at the level of the xiphoid process, umbilicus, and halfway between these structures.

Actions of the Rectus Abdominis Muscles. In addition to helping the other abdominal muscles to compress the abdominal viscera (e.g., during coughing, vomiting, and defecating), these muscles depress the ribs and stabilize the pelvis during walking. This fixation of the pelvis enables the thigh muscles to act effectively. Similarly, during lower limb lifts from the supine position, the rectus abdominis muscles contract to prevent tilting of the pelvis by the weight of the limbs.

The Linea Alba and Rectus Sheath. These structures have been mentioned several times and have been briefly described; however, owing to their clinical importance, a more detailed description and summary of the rectus sheath and its relationship to the linea alba follows. The rectus sheath is the strong, incomplete fibrous compartment of the rectus abdominis muscle. It forms by the fusion an separation of the aponeuroses of the flat abdominal muscles. At its lateral margin, the internal oblique aponeurosis split: into two layers, one passing anterior to the rectus muscle an the other passing posterior to it. The anterior layer joins with the aponeurosis of the external oblique to form the anterior wall of the rectus sheath. The posterior layer joins with the aponeurosis of the transversus abdominis muscle to form the posterior wall of the rectus sheath. The fibers of the anterior and posterior walls of the sheath interlace in the anterior median line to form a complex tendinous raphe, called the linea alba, which is an intermixture of the aponeurotic fibers of this oblique and transverse abdominal muscles. It is narrow inferior to the umbilicus, but is wide superior to it A groove is visible in the skin superficial to it in thin muscular persons. The linea alba lies between the two parts of the rectus abdominis muscle; the umbilicus is located just inferior to its midpoint. Superior to the costal margin, the posterior wall of the rectus sheath is deficient because the transversus abdominis muscles passes internal to the costal cartilages and the internal obliqus muscle is attached to the costal margin. Hence, superior to the costal margin, the rectus muscle lies directly on the thoracic wall. The inferior one-fourth of the rectus sheath is also deficient because the internal oblique aponeurosis does not split here to enclose the rectus muscle. The inferior limit of the posterior wall of the rectus sheath is marked by a crescentic border called the arcuate line. The position of this line is usually midway between the umbilicus and the pubic crest. Inferior to the arcuate line, the aponeuroses of this three flat muscles pass anterior to the rectus muscle to form this anterior layer of the rectus sheath.

^ Important structures in the rectus sheath, in addition to this rectus abdominis muscle, are the superior and inferior epigastrh vessels, and the terminal parts of the inferior five intercostal and subcostal vessels and nerves.

The Transversalis Fascia

This somewhat transparent internal investing layer lines most of the abdominal wall; posteriorly it fuses with the anterior lamina of the thoracolumbar fascia. The transversalis fascia (fascia transversalis) covers the deep surface of the transversus abdominis muscle and its aponeurosis and is continuous from side to side, deep to the linea alba. Each part of the transversalis fascia is named according to the structures it covers. It is called the diaphragmatic fascia on the diaphragm; the iliac fascia on the iliacus muscle; the psoas fascia on the psoas major muscle; and the pelvic fascia in the pelvis. The transversalis fascia also extends into the thigh with the iliac fascia to form the femoral sheath. It also passes through the inguinal canal to form the internal spermatic fascia, part of the covering of the spermatic cord. Internal to the transversalis fascia is the peritoneum, the extensive serous membrane that lines the abdominal and pelvic cavities. The transversalis fascia is separated from the peritoneum by a variable amount of subperitoneal fat, referred to as extraperitoneal fat.

^ Nerves of the Anterior Abdominal Wall

The skin and muscles of the anterior abdominal wall are supplied mainly by the ventral rami of the inferior six thoracic nerves (i.e., the continuation of the inferior intercostal nerves, T7 to T11) and the subcostal nerves (T12). The inferior part of the anterior wall is supplied by two branches of the ventral ramus of the first lumbar nerve via the iliohypogastric and ilioinguinal nerves. The iliohypogastric nerve supplies the skin over the inguinal region (groin). The ilioinguinal nerve runs anteroinferiorly, just superior to the iliac crest. to the superficial inguinal ring. Here it emerges to supply the skin on the superomedial aspect of the thigh. The main trunks of the intercostal nerves pass anteriorly from the intercostal spaces and run between the internal oblique and transversus abdominis muscles. The plane between these muscles, known as the neurovascular plane, corresponds with a similar plane in the intercostal spaces. The nerves in this plane are accompanied by the inferior intercostal, subcostal, and lumbar arteries. The common nerve supply of the skin and muscles of the anterolateral abdominal wall explains why palpating the abdomen with cold hands causes contraction of the abdominal muscles. All these nerves pass between or through muscles to reach the rectus sheath. They supply the three flat abdominal muscles, as well as the rectus abdominis.

The anterior cutaneous nerves pierce the rectus sheath a short distance from the median plane. The branches of T7 to T9 nerves supply the skin superior to the umbilicus; T10 innervates the skin around the umbilicus; and T i l , T12, and LI supply the skin inferior to the umbilicus.

^ Arterial Supply of the Anterior Abdominal Wall

Small arteries arise from anterior and collateral branches of the posterior intercostal arteries in the 10th and 11th intercostal spaces and from anterior branches of the subcostal arteries to supply the anterior abdominal wall. They anastomose with the superior epigastric arteries, the superior lumbar arteries, and with each other.

The main arteries of the anterior abdominal wall are the inferior epigastric and deep circumflex iliac arteries, which are branches of the external iliac artery, and the superior epigastric artery, which is a terminal branch of the internal thoracic artery. The inferior epigastric artery runs superiorly in the transversalis fascia to reach the arcuate line; there it enters the rectus sheath. The deep circumflex iliac artery runs on the deep aspect of the anterior abdominal wall, parallel to the inguinal ligament, and along the iliac crest between the transversus abdominis and internal oblique muscles. The superior epigastric artery enters the rectus sheath superiorly, just inferior to the seventh costal cartilage.

^ Venous and Lymphatic Drainage of the Anterior Abdominal Wall

The superficial epigastric vein and the lateral thoracic vein anastomose, thereby uniting the veins of the superior and inferior halves of the body. The three superficial inguinal veins end in the great saphenous vein of the lower limb.

The superficial lymph vessels of the anterolateral abdominal wall, superior to the umbilicus, pass to the axillary lymph nodes, whereas those inferior to the umbilicus drain into the superficial inguinal lymph nodes. However, lymph from the anterior abdominal wall, in general, drains to the lumbar lymph nodes and to the common and external iliac lymph nodes.

Internal Surface of the Anterior Abdominal Wall

The internal or deep surface of this wall is covered with parietal peritoneum. It exhibits several peritoneal folds, some of which contain remnants "of fetal vessels that carried blood to and from the placenta before birth. A peritoneal fold is an elevation of peritoneum with a free edge, which is usually raised by an underlying blood vessel or its ligamentous remains. There are hollows or fossae between adjacent folds. Superior to the umbilicus there is a large median fold called the falciform ligament. It passes from the deep surface of the superior half of the anterior abdominal wall to the liver and the diaphragm. The free edge of this ligament contains the ligamentum teres, the remnant of the umbilical vein. Before birth the umbilical vein carried oxygenated blood from the placenta to the fetus. This vein is patent for some time after birth and may be used for exchange transfusions during early infancy (e.g., in infants with erythroblastosis fetalis or hemolytic disease of the fetus. Although reference is often made to the "obliterated" umbilical vein, it is usually patent to some extent. It often becomes very dilated if there is portal hypertension (raised pressure in the portal system, such as that caused by cirrhosis of the liver. Inferior to the umbilicus, five umbilical folds (two on each side and one in the median plane) pass superiorly toward the umbilicus. The lateral umbilical folds, formed by elevations of peritoneum covering the inferior epigastric arteries, run superomedially on each side. The medial umbilical folds are formed by elevations of peritoneum covering the medial umbilical ligaments, the obliterated parts of the fetal umbilical arteries. These vessels carried blood from the fetus to the placenta for oxygenation before birth. They ascend obliquely from the lateral walls of the pelvis to the umbilicus. The median umbilical fold is formed by an elevation of peritoneum covering the median umbilical ligament, the fibrous remnant of the urachus that joined the fetal bladder to the umbilicus. The median umbilical ligament and fold pass from the deep aspect of the umbilicus to the apex of the urinary bladder. Of the five folds inferior to the umbilicus, only the lateral umbilical folds contain vessels that carry blood.

^ 5.2. Theoretical questions to studies:

  1. The regional structure of the abdominal wall.

  2. The regions of the antero-lateral abdominal wall.

  3. The nerve and blood supplay of the antero-lateral abdominal wall.

  4. The layer structure of the antero-lateral abdominal wall.

  5. Muscles of the antero-lateral abdominal wall.

  6. Fascias of the antero-lateral abdominal wall.

  7. Surgical anatomy of the congenital disease and congenital anomalies of antero-lateral abdominal wall. Principles of surgical treatment.

  8. The methods of laparotomies.

^ 5.3. Materials for self-control:

  1. Diffuse pain referred to the epigastric region and radiating circumferentially around the chest is the result of afferent fibers that travel via which of the following nerves?

  1. Greater splanchnic

  2. Intercostal

  3. Phrenic

  4. Vagus

  5. None of the above

  1. In the patient described, the subsequent localization of the pain in the right hypochondriac region is the result of inflammatory stimulation of fibers that are extensions of which of the following nerves?

  1. Greater splanchnic

  2. Intercostal

  3. Phrenic

  4. Vagus

  5. None of the above

  1. The patient receives a general anesthetic in preparation for a cholecystectomy. A right subcostal incision is made, which begins near the xiphoid process, runs along and immediately beneath the costal margin to the anterior axillary line, and transects the rectus abdominis muscle and rectus sheath.
    At the level of the transpyloric plane, the anterior wall of the sheath of the rectus abdominis muscle receives contributions from the

  1. aponeuroses of the internal and external oblique muscles

  2. aponeuroses of the transversus abdominis and internal oblique muscles

  3. aponeuroses of the transversus abdominis and internal and external oblique muscles

  4. transversalis fascia

  5. transversalis fascia and aponeu-rosis of the transversus abdominis muscle

  1. At this level of incision, liga-tion of the superior epigastric artery probably will result in little, if any, necrosis of the rectus abdominis muscle because the superior epigastric artery anastomoses with the

  1. deep circumflex iliac artery

  2. inferior epigastric artery

  3. intercostal arteries

  4. internal thoracic artery

  5. musculophrenic artery

  1. Exploration of the peritoneal cavity disclosed a distended gallbladder. It is located

  1. between the left and caudate lobes of the liver

  2. between the right and quadrate lobes of the liver

  3. in the falciform ligament

  4. in the lesser omentum

  5. in the right anterior leaf of the coronary ligament

  1. Numerous stones could be palpated. A finger was inserted into the omental foramen (of Winslow), and the common bile duct was palpated for stones. Structures that bound the omental foramen include all the following EXCEPT the

  1. caudate lobe of the liver

  2. common bile duct

  3. hepatic vein

  4. inferior vena cava

  5. superior part of the duodenum

  1. Before closure of the incision, it is felt that a drain should be left in place in the abdominal cavity so that any leakage of bile from the sutured stump or from inadvertent injury to the duct system can be detected. This drain would most advantageously be located in the

  1. omental bursa

  2. pelvic cavity

  3. pouch of Morison

  4. right paracolic gutter

  5. right subphrenic recess


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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