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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

…………………………….2007 р. (Protocol №……….)

The chief of department

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

…………………………….2007 р.


for the 3d-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


Module 2

“Topographical anatomy and operative surgery of the regions and organs of the lumbar region, pelvis and extremities”

Semantic module

“Topographical anatomy and operative surgery of the walls and organs of lumbar region and pelvis”

Chernivtsi – 2007

^ 1. Actuality of theme:

The topographical anatomy and operative surgery of pelvis 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 and sexual properties it is impossible to diagnose in a proper time and correctly and to prescribe a necessary treatment to the patient. Surgeons of the different specialization usually pay much attention to the topographic anatomy of the small pelvis organs. Topography of the bladder, urethra and ureter is important for urologist, womb and adnexa for obstetrics and gynecologists, rectum for proctologists. Small measures of the true pelvis, availability a number of the organs, nerves and vessels causes the certain difficulties for surgical interventions for clinical and topical diagnosis.

^ 2. Duration of studies: 2 working hours.

3. Educational purpose (concrete purposes):

To know peculiarities and variants of structure, form, location and mutual location of the pelvis and pelvic organs.

To be able to define the borders, skeletotopy and projectors of the pelvis.

To master practical skills to make the approaches to the pelvic organs.

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

The names of previous disciplines

The got skills

1. Normal anatomy

2. Physiology

To describe the structure and function of the different organs of the human body, to determine projectors and landmarks of the anatomical structures.

^ 5. Advices to the student.

5.1. Table of contents of the theme:

Surgeons of the different specialization usually pay much attention to the topographic anatomy of the small pelvis organs. Topography of the bladder and ureter is important for urologist, womb and adnexa for obstetrics and gynecologists, rectum for proctologists. Small measures of the true pelvis, availability a number of the organs, nerves and vessels causes the certain difficulties for surgical interventions for clinical and topical diagnosis.

There are large vessels and nervous plexes in the cellular spaces of the small pelvis that causes a great lethality on account of traumatic shock and loss of blood. The infectiosity of the organs' contents leads to the development of phlegmons and their increasing.

The small pelvis is a part of a human body, which is bordered by two hipbones, sacrum, coccygeal bone the 5 lumbar vertebra and ligaments.

The skin, soft tissues, which cover hipbones, belong to other anatomo-topographical regions.

The hipbone consists of three bones these are iliac, sciatic, pubic bones and are divided by the cartilage. The neonate may pass through the maternal passages because measures and pelvis configuration may vary.

The three bones form a hipbone by union at the acetabular region. This let us to carry great loading.

The bones union reflects the change of the function during phylo­genesis. The pelvis of the four-footed can't carry on a large loading because their horizontal posture.

The humans have a vertical posture and pelvis is a support for the internal organs and a place of transferring of the load from corpus to legs, separate bones connected by the cartilage forms one bone, and a synchondrosis becomes a synosthosis. All the pelvic bones are sturdy fixed. There are connected by three joints two sacroiliac joints, pubic symphysis and sacrococcygeal symphysis. The pubic symphysis connects the pubic bones by means of fibrous cartilage. The superior pubic ligament passes along the superior edge of the joint. The arcuate pubic ligament passes along the inferior edge of the sumphysis. It forms the urogenital diaphragm (the triangular ligament).

The pubic symphysis may be disjoined in obstetrics practice to broader the maternal passages. The operation is called the symphysotomia. The sacroiliac articulation is paired, form by jointing of the auricular surfaces of the sacrum and iliac bones. It is strengthened with ventral sacroiliac ligaments from the front, with interosseal and dorsal sacroiliac ligaments from behind. The obstetricians call this articulation "a key of pelvis". A rupture of these ligaments while delivery is attended by the discrepancy of the pelvic ring. Women after labor can't walk for a long time with such a complication.

The mobility in the sacroiliac articulation play an important role in delivery, the apex of the coccygeal bone back for 2cm while fetus passes through the maternal passages. On account of this fact conjugate of the pelvic outlet increases from 9sm to 11 cm. If the coccygeal bone in immobile because of fusing with the sacrum, there will be a stage, called a clinically contracted pelvis.

The fixative apparatus of the pelvis consists of the ligament, between the backbone and the upper flaring portion of the iliac bone. Two powerful ligaments link the sacrum (on both sides) with iliac and ischiadic bones. There is sacrotuberous ligament and sacrospinous ligament. Both ligaments the sciatic spine and two notches of the innominate bone form the greater sciatic foramen and the lesser sciatic foramen. Muscles, vessels and nerves pass through these foramens.

The inguinal ligament and membrane obturatoria are the false ligaments of the pelvic. Small measures of the ligaments and their tightness limit the mobility in pelvic joints. Their physiological importance is to amortize sudden strikes and pushes and reduce the strength of the hits while movements. The rupture one of the joints is attended with affection of the others. That's why when the rupture of the pubic symphysis is having place; the removal of the pubic bones is possible just with a slight tear at the sacroiliac articulation.

The walls of the pelvic bound are rather elastic, on account of the coordinated actions of the joints. That's why the fractures occur seldom just because of a great straight power affection. The joints of the bones influent the form of the fractures. The weakest places are situated on the anterior and posterior bonewalls of the pelvis because these places have the spongious structure. Sacral and obturatorium foramens are available and that's the place of union of three pelvic bones. These facts explain us the localization of the most typical fractures. These fractures are double direct fracture, when the posterior and anterior (straight) walls of the pelvis are fractured.

The fracture line goes through the foramen obturatorium from the front across the place if ischiopubic symphysis and through the sacrum near the sacral foramens from behind. The bone basement of the pelvis is divided into 2 parts: large (false) pelvis and small pelvis. The terminal line that passes through the promontorium, arcuate line of the iliac bone, spine of the pubic bone and a superior edge of the symphysis border them. The large pelvis belongs to the inferior portion of the abdominal cavity. There are genitourinary system and the terminal portion of the digestive system in the small pelvis.

The conjugate of the inlet and outlet are important in obstetrics.

The gynecoid pelvis has such measures of the inlet the anterior-posterior diameter of the pelvic inlet (from the promontorium to the pubic symphysis) is 11 cm, the transversal diameter (the line between the farthest points of the terminal line) is 13 cm, oblique diameter (from the pubic tuber to sacroiliac articulation is 12 cm.

The obstetric conjugate or the outlet (the distance from the coccygeal bone to the subpubic angle) is 11 cm; the transversal diameter (the distance between the tubes of the ischiadic bone) is 11 cm.

The small measures of the bone pelvic ring mean the contracted pelvis. There may occur pelvis justo minor, generally contracted flat pelvis, in obstetrician pathology. An operative intervention is necessary than.

An axes of the pelvis is the line that passes in the middle of the conjugates of the inlet and outlet, and goes through the center of the pelvis.

Pelvis is leaned to the front that is the physiologic posture. The angle between the surface of the inlet and horizontal surface is 54-55° in women one is called the angle of inclination.

Different diseases (rickets, pathologic curvature of the vertebral column, congenital dislocations and inflammations in hip joint) influent the form, measures and axis of the true pelvis.

Pelvic ring differs in men and women. Masculine pelvis is narrower and longer, gynecoid pelvis is wider and shorter. The inlet is heart-spared in men and oval in women. The subpubic angle is 70-75° in men and 80-100° in women.

The muscles that cover walls and bottom of the true pelv is are parietal and visceral. The piriformis muscle starts from the sacrum, goes through the greater obturatorium foramen and fixates to the greater trochanter. The parietal muscles are the next.

The piriformis muscle while passing through the greater obturatorium foramen forms two slits: foramen suprapiriformis and infrapiriformis. Ves­sels and nerves bounds pass there. The second parietal muscle is the internal obtutatorium muscle. It starts from fixes to the fosse intertrochanterica.

There is ma fissure in a lesser sciatic foramen. The pudendal neuro­vascular bound goes through the fissure into the ischiorectal fosse. Those three foramens connect the pelvic cavity with the ischiac region.

The pelvic outlet covered with the visceral muscles those are forming the diaphragm of the pelvis. These muscles are:

1) The levator ani muscle. It consists of the two portions (the pubococcygeal and iliococcygeal muscle) those muscles start from the pubic bone and the tendinous arch formed by the strengthened pelvic fascia that goes around the rectum. It fastens to the coccygeal bone.

  1. The coccygeal muscles those pass from the coccygeal bone to the sciatic spine.

  1. The external sphincter of anus.

The pelvic cavity is divided into three portions (stores).

  1. The peritoneal portion. That is the inferior part of the peritoneal cavity that is limited by the horizontal surface that passes across the pelvic inlet and contain the pelvic organs those are covered by the peritoneum.

  2. The subperitoneal portion. That is a space between the peritoneum and levator ani muscle.

  3. The subcutaneous portion. That is a space between the diaphragm of the pelvis and skin. The portion belongs to the perineum and contains the ischiorectal fosse.

The peritoneum goes from the anterior abdominal wall and covers the lateral parts and the posterior wall o the bladder, the internal edges of the deferens duct and apexes of the seminal vesicles at the first portion of the pelvic cavity in man.

There are two recesses in women' anatomy. The peritoneum goes from the bladder on to the uterine and forms the vesicouterine pouch. It passes then from the uterine on to the rectum and is forming the rectourine) pouch (Douglas' pouch). That is the most inferior point of the abdominal cavity. The pathologic fluid accumulates there while there is an inflam­mation in the abdominal cavity or blood (while the oviduct breaks because of the extrauterine pregnancy).

There will be a sharp pain if a doctor presses at the posterior vault of the vagina and takes away his hand suddenly. The symptom is called the Douglas' scream. One can have a fluid while puncture of the posterior vault of the vagina. That helps to precise the diagnosis.

The walls and organs of the true pelvis are covered with the pelvic fascia. The parietal layer covers the pelvic walls and the visceral one is fused with the organs.

The parietal layer goes down to the border of the superior and inferior portions of the internal obturator muscle and forms the enlargement that is called the tendinous arch. The levator ani muscle starts from it.

The pelvic fascia covers that muscle, piriformis muscle, it reaches then the pelvic organs and goes upwards and becomes the visceral fascia.

The pelvic organs are inside the space that is bordered by the pubic bones from the front, by sacrum from the behind and sagital plates of the visceral fascia from sides.

The peritoneperineal aponeurosis (Salyshcheva-Denonvilley), which is formed from the primary peritoneal duplicature, divides the space into the anterior and posterior portions.

There are urogenital organs at the anterior portion and rectum at the posterior portion. So all the pelvic organs have the fascial sheathes (coverings). The prostatic sheath is called Pyrogov-Reticiy' sheath and the rectal sheath is the Amus's sheath. The fascia is much like ligaments at the places of the organs fastening to the pelvis.

There are muscular fascicles as well as collagenic and elastic fascicles. Those are the pubovesical ligament and the puboprostatic ligament in men and the pubouterine and sacrouterine ligaments in women.

The spaces between the fascial layers are filled with the pelvic fat.

The space between the pubic symphysis and bladder.

The triangle fascial plate (the antevesical fascia) is strained between the obliterated umbilical arteries and ring and divides the space into two portions. These are the antevesical fat (between the transversal and antevesical fascias and anteperitoneal space (between the antervesical fascia and peritoneum). The antervesical fat goes to the paravesical fat from sides where the internal ilium vessels are passing.

The retrovesical space is between the posterior wall of the bladder and peritoneoperineal aponeurosis. It borders with the sagittal parts of the visceral fascia from sides.

The recto rectal space is between rectum and sacrum. The fat that lies around the rectum is called the pararectal fat.

The parametric fat is around the neck of the womb. It is of a great importance.

The lateral space is bordered by fascias of the obturator and piriformis muscles from sides by ligaments those are straitened between the pubic bones and sacrum from medial. The internal ilium vessels pass there. The fascia of the piriformis muscle gives a segment that separates the parietal space from the lateral one. There are branches of the sacral plexus and the great sciatic nerve there.

The internal iliac artery is the main artery at the lateral space. It goes more medial than transverse muscle and divides into the anterior and posterior trunks. The anterior trunk goes super­ficially and gives visceral and parietal branches. These are the umbilical artery, superior uterine artery (or the deferens duct in men), inferior vesicle artery, middle rectal artery, obturator artery and internal pudenda artery from which the inferior rectal artery starts away. The posterior parietal trunk lies more profoundly. The lateral sacral, iliolumbar, and inferior sciatic arteries go from it.

Nerves start from the sacral plexus that is formed by 4-5 lumbar and 1-3 sacral nerves. The sacral plexus lies on the anterior surface of the piriformis muscle and gives branches. These are the superior and anterior nerves of the sciatic part, the greater sciatic, posterior femoral cutaneus, obturator and pudendal nerves.

The ligature of the ilium artery is performed when the parietal branches of the internal ilium artery are damaged and bleeding can't be stopped. An access is performed according to Shevkunenko.The skin, fat and fascia should be cut along the line, which starts from the edge of the 12 rib above the anterior superior ilium spine and turns to the external body of the rectus abdominal muscle. An access according to Pirogov is performed above the Poupart's ligament higher 2-3 cm and in parallels to this ligament. Then the abdominal muscles and transverse fascia are cut. The peritoneum with the attached urethra on it should be exfoliated by the gauze tourunde. The internal ilium artery may be ligatured on the psoas muscle.

The blood supply of the pelvic organs the opposite side artery will supply.

The suppurative processes of the perineal spaces.

The suppuration may spread in different ways. The pus spread along the vessels into the visceral spaces from the lateral space; into the ischiac fat through the suprapiriformis foramens; into the medial surface of the hip through the obturator foramen.

The pus spreads hip and into the anterior abdominal wall through the obturator and femoral canals from the antervesical space. The pus spreads into the retroperitoneal space along the urethra from the paravesical space or from the retrovesical space.

The pus spreads from the parauterine space by two ways:

1) Along the round ligament of the uterus through the internal inguinal ring to the anterior abdominal wall.

2) To the inguinal fosse and to the retroperitoneal space then. There are such accesses for the abscesses draining:

  1. The antevesical space is drained from the Cooprianov's access. The inferior median cut is performed; the packer passes between the bladder and the levator ani muscle. Urogenital diaphragm and run through the skin under the inferior border of the pubic.

  2. The Buyalskiy-Mack-Woters' access is put into practice for antervesical space draining. The skin should be cut at the anterior surface of the hip 4-cm Jower than the femoralperineal fold, the packer passes through the abductor muscles to the obturator membrane and breaks it in its lower portions, (there is a neurovascular canal in its upper portion).

  3. The Pyrogov's access is applied for the operations at the ureter (its lower 1/3) and for the antervesical space draining. The incision goes in parallels to the Poupart's ligament. The purulent parametritis may be drained from the same access. If the process spreads towards the vagina the posterior vault of the vagina would be drained. The semilunar incision between the anal orifice and the sacrum is performed to access the retrorectal space.

The abscess should be evacuated in the rectum opening by its wall incision if it lies directly near the rectum.

^ The urinary bladder.

It is situated in the true pelvis cavity. It borders with the posterior surface of the pubic symphysis in men. The seminal vesicles, ampulles of the deferent duct and rectum lay from the behind. The prostata and the perineal muscles are lower. The bladder borders with the uterine and the superior portion of the vagine in women. The levators ani muscles are from sides. The bladder lies higher than symphysis in infants.

There are apex, corpus, fundus and cervix that prolongs to the uterine in the bladder. The peritoneum goes from the abdominal wall on to the anterior wall of the bladder, forms the transversal fold and covers its superior, posterior and partially lateral wall. The peritoneum is attached to the bladder with a loose connective tissue, so slips lightly, accept the apex where it is jointed tightly with the muscular layer. The full bladder juts out the symphysis. Its anterior wall isn't covered with the peritoneum. In this case that gives a possibility to punctate the bladder without injuring the peritoneum.

The fixative apparatus of the bladder is rather important in surgery. It is attached to the pubic symphysis with the pubovesical and puboprostatic ligaments from the front; the rectovesical ligaments are from the behind. The urethra is fastened to prostata from below. The apex is attached to the navel by the obliterated cystic duct. There are the vesicouterine ligaments in women instead of the prostatical component. There are 4 layers in the bladder. These are the connective tissue, muscular, submucous and mucous layer.

There are external longitudinal, medial, circular and internal transverse oblique layers in the muscle layer of the bladder. The circular layer is the most powerful and forms the internal vesicle sphincter at the cervix of the bladder. The main sphincter of the bladder is the external sphincter that is formed by the striated muscle around the membranous part of the urethra. The mucous layer slips on the submucous base and forms in the empty bladder accept the Letto triangle where the submocus base is absent and there are no folds. The base of the triangle are the interureter fold. Its apex is the cervix of the bladder with the internal opening of the ureter. The triangle is the orientative point for finding of the ureter openings while the chromocystscopiy.

The blood supplying is providing by the superior (a portion of the umbilic artery) and inferior vesical arteries (those are the branches of the internal ilium artery). The additional blood supply is providing from the medial rectal and uterine arteries. The venous outflow is providing by the vesical plexus that is attached with the antevesical and rectal plexuses.

The sensitive innervating and voluntary regulation of the external sphincter goes from the sacral plexus by the pudenda nerve. The para-sympathic splanchnic nerves (2-4 sacral segments) innervate the involun­tary muscles of the walls and internal sphincter.

There is bladder's constriction and sphincter's relaxation while those nerves irritation. The sympathic innervating goes from the sympathic trunk. and nerves of the hypogastric plexus. There is a bladder relaxation and sphincter constriction while those nerves irritation.

he lymph flows off the into the ilium and hypogastrical lymphatic nodes those are along the iliac artery and aorta.


It is situated between the bladder and urogenital diaphragm. It is cone shaped. Its width is 4 cm, its length is 2 cm, height is 4 cm, and weight is 20 gr. The sulcus divides it into right and left parts on its posterior surface. The prostata borders with the levator ani muscle from sides, rectum that is separated by the fascia from behind. That's why it may be palpated through the rectum. It is smooth and elastic in normal, with its sulcus and parts. The prostata is the conglomerate of the alveoli-tubular glands in the musculous-connective tissue stroma.

The urethra passes oblique through it. The urination is difficult while prostata enlargening.

Its blood supply is providing by the inferior vesical, medial rectal and internal pudendal arteries. These arteries form the organic plexus (Santorini plexus) that is injuring easily while adenectomia and may be a cause of the pulmonal artery's thrombembolism.

^ The paracentesis of the bladder.

The intervention is performing while the acute parauria and the cathetrization is impossible. The stippling is carrying out on 2 cm higher the pubic symphysis perpendicularly to the abdomen strictly on the median line. When gap feeling appears and the urine starts to drop from the end of the cannula the bladder will empty. The needle must be quickly brought out after the procedure.

^ The high incision of the urine bladder.

The incision is carrying out to extract stones, foreign objects, tumors, and adenoma by means of the catheter. The bladder should be filled with a sterile physiologic salt solution to lift the bladder apex above the symphysis.

An access is a suprapubic median longitudinal incision. The bladder walls are fixating with 2 ligatures through its muscular layer. The bladder empties by means of the catheter and the surgeon incises its wall between the ligatures. The wall of the vesicle should be sutured hermetically after the manipulation. The first interrupted suture involves the adventicia, muscular and the submucous layers. There is no reason to suture the mucous layer because salt may crystallize on the threads. The external suture involves just the adventitia and muscular layer.

^ The uterine.

It is the muscular cavitary organ that is situated between the bladder and rectum. It consists of the corpus, fundus and cervix. There are orifices of the oviduct at the borders of the fundus (base). The end of the uterine cavity has it opening in the canal of the cervix. The isthmus of the uterine is between the corpus and cervix. The obstetricians call it the superior segment of the uterine. The inferior part o the cervix is in the vagine and may be palpated. That's why the cervix is divided into the supravaginal and vaginal J parts. The wall of the uterine consists of 3 layers. These are serosal (perimetrium) with the subserosal basement, muscular (myometrium) and mucous layers (endometrium) (without the submucouse basement).

The peritoneum covers the uterine mostly. The lateral borders have no covering. There is a layer of fat between the anterior and posterior layers of the peritoneum where the vessels and nerves pass.

The pelvic fundus is a fixative apparatus more important as the ligaments are.

The ligaments are:

  1. The broad ligament of the uterine. It is the peritoneal duplicature that passes from the lateral borders of the uterine (uterine ribs to the lateral pelvic walls). There is the uterine tube in it from above.

  2. The cardinal ligaments. These are the fibrous muscular bands those are passing at the inferior parts of the broad ligaments.

  3. The round ligament. It is the anologic to the Hunter's gubernaculum. It starts from the angles of the uterine and goes to the deep inguinal ring. It may pull the peritoneum into the inguinal canal like the vaginal process in men. It is called Nukke's diverticulum and may be the pace of the cystogenesis. The ligament diverges to Emlakh bunch in the large pudendal lip after the leaving of the inguinal canal.

  1. The sacrouterine ligaments. They go in the lateral folds of the peritoneum from the sacrum to the uterine. There are muscular fascicles in it sometimes.

  2. The vesicouterine ligament. It is the extension of pubovesical ligament and is formed by the bulge of the sagital plate of the visceral layer of the pelvic fascia.

The main blood supply is providing by the uterine artery, which is the branch of the internal artery. The uterine artery crosses with the ureter for two times. The ureter passes from the front of the uterine artery at start. The artery passes from the front of the ureter at the middle of the uterine artery level. The artery turns around the ureter semicirculary. They are equal at the diameter. There is a danger of the ureter incision or dressing instead of the artery. The pulsation may help differ them.

The uterine artery goes within the broad ligament and comes to the uterine ribs and divides into the ascending and descending branches there. The branches go in parallels to the uterine axe. The terminal arteries come horizontally directly to the uterine from these branches.

The isthmus has lesser vessels than the corpus. The isthmus portion ought to be incised while the Caesarian section according to the archite­cture of the vessels net. There would be the lesser traumatisation and bleeding.

The ovarian artery provides the additional blood supply. It starts from the aorta and forms the anasthomose with the uterine artery.

The uterine arteries are straight in infants. They become sinuous in pubertates that gives a reserve for the uterine enlarging while pregnancy. The arteries are the most sinuous after the delivery. The uterine involution is of a great meaning in this process after the delivery. That is the symptom of labor in past of a women at the medicolegal investigation.

The venous outlet is providing by the uterovaginal plexus and ovarian veins partially. The ovarian veins confluent into the inferior Cava vein from right side and renal vein from the left.

The parasympathic innervation is providing by the pelvic nerves those form the uterovaginal plexus (Frankengeiser's plexus). The sympathic innervation is providing by the hypogastrical plexus.

The corpus has sympathic innervation dominant, the cervix has the parasympathic innervation dominant. That explains the chronic contraction of the corpus and relaxation of the cervix while delivery. The nervous plexuses are mostly in the parametriums from sides that should be mentioned while the novocaine anesthesia.

^ The ovary.

It is lying in the fosse between the internal and external ilium arteries on the internal obturator muscle. It is covered with a germinal epithelium

that makes a mat surface.

There is a residue of the peritoneum like a thin border that is called

Farae-Waldeyer's ring.

The ligamentous apparatus.

  1. The infundibulopelvic ligament is a suspensory ligament of the ovary. The ovarian vessels pass there.

  2. The own ligament. It goes from the lateral angle of the uterine to the uterine end of the ovary.

3) The mesoovarium. It goes from the broad ligament of the uterine to its posterior layer.

The blood supply is providing by ovary and uterine arteries.

The surgery interventions are carrying out because of the cysts, tumors or breakups of the ovary. An access is the inferior median laparotomy. When the cyst is too large it should be punctate and empty previously.

There is performing the exposure of cyst. There are two forceps on its peduncle between them the dicision is carrying out. The sero-serous suture is applied. The abdominal cavity must be closed in layers. There is the uterine tube along the superior border of the broad ligament of the uterine. There are the interstitial tube, tubal isthmus, ampullar tube and infundibulum. There are fimbriae on the infundibulum those embrace the ovary.

Mesosalpinx is the part of the broad ligament of the uterine between the uterine tube and mesovarium. The operations are carrying out while the extrauterine pregnancy.

Four accesses may be applied.

  1. The inferior median laparotomy from the umbilic to pubic.

  1. Pfanenstile's access. This is the arched incision along the suprapubic fold. The blunt dissection of the straight abdominal muscles is applied after white line section.

  2. Cherny's access. This is a transverse incision 5-6 cm higher than pubic symphysis. All the layers are dissected. The access is applying when the pelvic and abdominal organs revision is necessary.

4) The oblique incisions are in parallels to the Poupart's ligament. There are such moments of the operation because of the interrupted tubal pregnancy.

  1. The lips of the wound are pulled away with the retractor.

  2. The exposure of the tube with the ooblast.

  3. The dissection of the tubal part after the mesosalpinx clipping by Bilrot’s clamp and dressing of it catgut suturing of the angle of the uterine.

  4. The peritonization.

  5. Clots of blood exposure from the abdominal cavity.

  6. The revision of the pelvic organs.

  7. The suturing of the wound.

The rectum intestine.

It is the terminal portion of the large intestine. It starts at the level of the third sacral vertebra. It looses its mesentery there. There is a longitudinal layer of the smooth muscle along the rectum in contrast to other intestines. The pelvic part of the rectum is higher than the pelvic diaphragm. The lower portion is called the perineal part.

There is the ampoule and supraampullar portion in the pelvic part. Rectum turns for two times in a sagital plane

The first curvature is from the behind and responds to the curvature of the sacrococcygeal symphysis. The second curvature is from the front, where the ampoule of the rectum goes onto anus. These curvatures are of a great meaning while rectoromanoscvopia and endoscopia. When they are not mentioned there is a risk of trauma.

The rectum curves to the left in the frontal plane. That's why the patient lies on his left side while administration of the enema. The length of the rectum grows for 5-6 cm after straightening. That's why the mobilization of the rectum is possible while the intestinal obstruction.

The supraampular parts are covered by the peritoneum wholly. The posterior side looses lower the peritoneal cover and then the lateral sides loose it. The inferior part of the ampoule lies retroperitonealy.

There is the mesorectum at the supraampoular part sometimes. These patients have the rectal prolapse more often.

There is prostata in front of the rectum in men or uterus in women. The sacrum and coccygeum are from behind. There are ischiorectal fosses from sides.

The mucous layer forms the circular folds in the pelvic part and longitudinal folds in the perineal part. The longitudinal folds (Morgany's columns) end with the tubercles with the semilunaris valves. They form sinuses. The circular space between the sinuses and anus is called the hemorrhoid zone. The structure of the mucous layer plays role in the pathogenesis of the rectal diseases. Every rectal abscess and fistula grows from the anal crypts. The infection spreads into the anal submucous glands from there and goes into the rounding tissues through the glands' wall.

The muscular layer consists of the longitudinal and circular fascicles. The longitudinal muscles are distributed evenly.

The circular muscles form sphincters those are the constrictive system of the rectum. Its damage means the failure of the main rectal function.

The external sphincter is around the anus. The subcutaneous part is the most superficial. The superficial part of the external muscular sphincter starts from the coccygeal bone. The most powerful part of the anus is its deep part of the striated muscles. The pudendal nerve gives the voluntary innervation.

The smooth muscles thicken 3-4 cm higher than anus and form the internal sphincter. The third sphincter (or Hepher's muscle) is 10 cm higher than anus. There is the vegetative innervation. The both sphincters are involuntary.

The sympathic innervation goes from the mesenteric and aortal plexuses; the parasympathic innervation goes from the pelvic nerves. The mucous and muscular layers are connected by means of vessels. The separation of the mucous layer is possible after the complete dicision of the vessels. But the mucous layer is rather mobile. The prolapse of the mucous layer may occur if the vessels are too long.

The blood supply is providing by:

  1. the superior rectal artery that goes from the inferior mesenteric artery

  2. Twinned medial rectal artery that goes from the internal ilium artery.

  3. Twinned inferior rectal artery that goes from the internal pudendal artery (the brunch of the internal ilium artery).

When the superior and medial arteries are too long they may be the factor of the rectal prolapse.

The venous outflow is providing by the subcutaneous, submucous and subfascial plexes. The subcutaneous plexus is situated around the external rectal sphincter. The submucuos plexus is the mostly developed. The subfascial plexus is between the longitudinal muscular layer and rectal fascia.

The venous blood flows out into the rectal veins. The superior one is the start of the inferior mesenteric vein and belongs to the portal vein system. The inferior and medial veins belong to the inferior Cava vein system. The medial veins flows into the internal ilium veins. The inferior veins flows into, the internal pudendal veins. That is the way of the portacaval anastomoses formation. These anasthomoses may enlarge and imitate the hemorrhoid while the portal system block.

That is rather possible because there are no valves in the hemorrhoid veins.

The submucous plexus is rather special. Its structure is much like the cavernous corpuses that means a lot of anasthomoses with arteries and arterioles. The bleeding will be with a bright red color of the blood because of a high containing of the arterial blood. The hemorrhoid bleeding may be significant and leads to anemia. That fact ought to be mentioned while the differential diagnosis of the intestinal bleeding.

There are 3 zones of the lymph outflow. These are the inferior, medial and superior zones. The lymph flows into the inguinal lymphatic nodes from the perineal part; into the sacral and internal ilium lymphatic nodes from the ampoule and into the inferior mesenteric lymphatic nodes from the supraampular part.

The sensitiveness of the rectum differs in various parts. The pelvic part is of law sensitiveness. The anus is of a great pain sensitiveness because of the various innervation. The pelvic part has the sympathic and parasympathic innervation; the anus is innervated by the spinal nerves. That should be mentioned while anesthesia.

The sacrum should be dicised lower than the third sacral foramen while the access to the rectum. The 3rd, 4th and sometimes the 5th sacral nerves may innervate the rectum. Don't let these nerves to damage. That leads to the functional break of the rectum, anal sphincter and other pelvic organs.

There are three accesses for the operative interventions at the rectum. These are the perineal, abdominal and perineo-abdominal a sacral access.

The perineal access is applied when low localization of the tumor. But a great trauma is possible if there is a need to broaden the wound by means of the coccygeal bone or even the part of the sacrum extraction, (the operation by Kraske).

The combined perineoabdominal access is much better. The rectum is extracted both with the tumor through the laparotomy incision.

The operative treatment of the hemorrhoids.

There are 3 groups of the operations

  1. the dressing of hemorrhoids

  2. Cutting off the piles.

  3. Cutting off the mucous layer and piles by Widenhead.

  4. The method has been founded by Hippocrates. The local type of the anesthesia is applied. When the sphincter is rasped the fenestrated Luer's forceps should be placed on the piles. Then the mucous layer is dissected. The hemorrhoid dressing is performing with silk ligatures on both sides. The residue-free diet should be prescribed. The knots necrotize and falloff at the 6-7 day.

  1. The operation by Rockytsky.

  1. The local type of the anesthesia is employed. The piles are exposed with Luers forceps; the denticulate Rockytsky forceps are applied lower. The piles are cutting off and interrupted catgut suture is placed. The mucous layer is sewed with between the denticles of forceps.

  2. The operation by Meligane-Morgan. The idea is that the piles are situated according the 3, 7 and 11 figures of the clock-face.

  1. The operation by Widehead. It is the dicision of the mucous layer together with the hemorrhoids as a cylinder of 5 cm height. The mucous layer is pulling down and sewing to the skin.

  2. The constriction of the anal canal may occur as a complication.

The perineum.

This is a system of the soft tissues that closes the pelvic outlet. It is bordered by the pubic and sciatic bones in front, by sciatic tubers from sides and by the sacrum from the behind. It is a diamond-shaped.

The obstetrical perineum is the tissue between the posterior comissure and anus. The perineum divides into urogenital and anal triangles by the arch line between the sciatic tubers.

There is a suture on the skin in man. It is the prolongation of the scrotal suture. There are branches of the pudendal nerves and internal pudendal vessels in the subcutaneous fat.

The superficial fascia covers the superficial muscles of the perineum. These are the superficial transverse perineal muscle, ischiocavernosus and bulbospongious muscles. The profound layers of the urogenital triangle are called the urogenital diaphragm. It consists of the inferior fascia of the urugenital diaphragm that covers the deep transverse perineal muscle and arcuate pubic ligament from the side of the pelvic surface.

The diaphragm is stretched between the arcuate pubic ligament and transverse perineal ligament.

The urethra passes through the urogenital diaphragm. The vagine passes through it in women.

The muscular fascicles those are strengthening the sphincter of the urethra are starting off the deep transverse muscle.

There are three parts in the urethra in men. These are the prostatic, membranous and spongious parts. The urethra turns twice. The first retropubic flexure is formed by the spongious part and curves to the behind and down. The membranous part is fixed the best. These facts have to be mentioned while the cathetrization of the bladder.

The skin, subcutaneous fat and superficial perineal fascia are the layers of the anal triangle. The profound layers are the ischiorectal fossa that is filled with the fat tissue. It is located around the rectum and anus. The internal obturator muscle with its fascia borders from the exterior ad the levator ani muscle borders it from the middle.

It is bordered from the perineal side too. The inferior end of the great ischiadic muscle is from the behind, the sciatic tubers are from the exterior and the external anal sphincter is from the middle, the superficial perineal muscle is from the front.

The levator ani muscle is covered with the inferior pelvic fascia from the surface of the ischiorectal fossa.

The pudendal nerve and internal pudendal vessels pass from the ischiac region through the minor obturator foramen. The nerve and vessels are lying on the internal obturator muscle. The end of the fascia forms a canal for them. (Olkock's canal).

The inflammation of the ischiorectal fat is called the paraproctitis.

There are the subcutaneous, submucosal ischiorecal and pelvirectal paraproctitis.

  1. The semilunar incisions arc applied while the subcutaneous parapro­ ctitis. The radial incisions are atraumatic for the branches of the pudendal nerve those converge radial to the externa! anal sphincter. But the incisions concur with the anal folds. That's why the incisions collapse soon. The semilunar incisions are expanded that lets the deep access. But the damage of the pudendal nerve is rather possible. That's why just the skin is incised semilunary. The blunt dissection of the deeper tissues is employed.

  2. The submucosal paraproctitis is incised through the mucous layer and drained through the anus.

  3. The ischiorectal paraproctitis is incised in the middle between the external sphincter and sciatic tuber to avoid the damage of the sphincter and neurovascular bound.

4) The pelvirectal paraproctitis is incised semilunary between the coccygeus and anus. The blunt dissection of the tissues is employed then between the levator ani muscle and the coccygeal muscle.

^ The operative anatomy of the testicles.

The embryogenesis o the testicle goes at the 4th month both with the primary ren retroperitoneally. It descends to the internal inguinal ring at the 7th month of the embryogenesis. It passes through all the layers of the abdominal wall and forms all the coverings (sheathes) with itself. The testicle has own albugineal envelope. The testicles are intime attached to the peritoneum and pull into the scrotum like a vaginal process that obliterate to the moment of birth. The serous envelope of the testis forms just to the moment of birth too. Th internal spermatic fascia is formed of the transverse abdominal fascia. The cremaster muscle is formed by the oblique and straight abdominal muscles. The external spermatic fascia is formed by Tompson's plate; tunica dartos is formed by the subcutaneous fat.

The testicular arteries provide blood supply. The venous blood outflows from the right testicle into the inferior Cava vein and from the left one to the left renal vein. That explains more frequent dilatation of the veins of the left testicle and spermatic cord.

The operation by Ivanisevich is performed then. That is the dressing of the left testicular vein or both vein and artery (operation by Yerohin).

Hydrocele occurs frequently. This is the accumulation of the fluid in the serous envelope while the inflammatory, posttraumatic fluid production dominates its absorbtion.

The parietal layer of the own envelope is incised and the fluid has to flow to the tunica dartos.

  1. The operation by Wincelmann (the incision and turning inside out of the envelope).

  2. The operation by Bergmans-Israel (cutting off the segment of the parietal layer).

  3. The operation by Alferov (fenestration).

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