Knowing the structure and location of internal organs is extremely important. Even if you do not study this issue thoroughly, then at least a superficial understanding of where and how this or that organ is located will help you quickly navigate when pain occurs and at the same time react correctly. Among the internal organs, there are both organs of the chest and pelvic cavity, and organs of the abdominal cavity of a person. Their location, diagrams and general information are presented in this article.

Organs

The human body is a complex mechanism, consisting of a huge number of cells that form tissues. From their separate groups, organs are obtained, which are commonly called internal, since the location of organs in humans is inside.

Many of them are known to almost everyone. And in most cases, until somewhere it hurts, people, as a rule, do not think about what is inside them. Nevertheless, even if the layout of human organs is only superficially familiar, in the event of a disease, this knowledge will greatly simplify the explanation to the doctor. Also, the recommendations of the latter will become more understandable.

Organ system and apparatus

The concept of a system refers to a specific group of organs that has anatomical and embryological kinship and also performs a single function.

In turn, the apparatus, whose organs are closely interconnected, has no kinship inherent in the system.

Splanchnology

The study and location of organs in humans are considered by anatomy in a special section called splanchnology, the study of the insides. We are talking about the structures that are in the body cavities.

First of all, these are the organs of the human abdominal cavity involved in digestion, the location of which is as follows.

Next comes the genitourinary, urinary and reproductive systems. The section also studies the endocrine glands located next to these systems.

The internal organs also include the brain. In the cranium is the head, and in the spinal canal - the dorsal. But within the limits of the section under consideration, these structures are not studied.

All organs appear as systems functioning in full interaction with the whole organism. There are respiratory, urinary, digestive, endocrine, reproductive, nervous and other systems.

Location of organs in humans

They are in several specific cavities.

So, in the chest, located within the boundaries of the chest and the upper diaphragm, there are three others. This is a pelicard with a heart and two pleurals on both sides with lungs.

The abdominal cavity contains the kidneys, stomach, most of the intestines, liver, pancreas and other organs. It is a body located below the diaphragm. It includes the abdominal and pelvic cavities.

The abdomen is divided into the retroperitoneal space and the peritoneal cavity. The pelvis contains the excretory and reproductive systems.

To understand in more detail the location of human organs, the photo below serves as an addition to the above. On one side, it depicts cavities, and on the other, the main organs that are located in them.

The structure and layout of human organs

The first in their tubes have several layers, which are also called shells. The inside is lined with a mucous membrane, which plays mainly a protective function. Most organs on it have folds with outgrowths and depressions. But there are also completely smooth mucous membranes.

In addition to them, there is a muscular membrane with circular and longitudinal layers separated by connective tissue.

On the human body there are smooth and striated muscles. Smooth - prevail in the respiratory tube, urinary organs. In the digestive tube, striated muscles are located in the upper and lower sections.

In some groups of organs there is another shell, where the vessels and nerves pass.

All components of the digestive system and lungs have a serous membrane, which is formed by connective tissue. It is smooth, thanks to which there is an easy sliding of the insides against each other.

Parenchymal organs, unlike the previous ones, do not have a cavity. They contain functional (parenchyma) and connective (stroma) tissues. The cells that perform the main tasks form the parenchyma, and the soft framework of the organ is formed by the stroma.

Male and female organs

With the exception of the sex organs, the arrangement of human organs - both men and women - is the same. In the female body, for example, are the vagina, uterus and ovaries. In the male - the prostate gland, seminal vesicles and so on.

In addition, male organs tend to be larger than female organs and therefore weigh more. Although, of course, it also occurs vice versa, when women have large forms, and men are small.

Dimensions and functions

As the location of human organs has its own characteristics, so does their size. Of the small ones, for example, the adrenal glands stand out, and of the large ones, the intestines.

As is known from anatomy and shows the location of human organs in the photo above, the total weight of the viscera can be about twenty percent of the total body weight.

In the presence of various diseases, the size and weight can both decrease and increase.

The functions of the organs are different, but they are closely interconnected with each other. They can be compared to musicians playing their instruments under the control of a conductor - the brain. There are no unnecessary musicians in an orchestra. Also, however, in the human body there is not a single superfluous structure and system.

For example, due to respiration, the digestive and excretory systems, the exchange between the external environment and the body is realized. The reproductive organs provide reproduction.

All of these systems are vital.

Systems and Apparatus

Consider the common features of individual systems.

The skeleton is the musculoskeletal system, which includes all the bones, tendons, joints and somatic muscles. Both the proportion of the body and the movement and locomotion depend on it.

The location of organs in a person of the cardiovascular system ensures the movement of blood through the veins and arteries, saturating the cells with oxygen and nutrients, on the one hand, and removing carbon dioxide with other waste substances from the body, on the other. The main organ here is the heart, which constantly pumps blood through the vessels.

The lymphatic system consists of vessels, capillaries, ducts, trunks and nodes. Under slight pressure, the lymph moves through the tubes, ensuring the removal of waste products.

All internal organs of a person, the layout of which is given below, are regulated by the nervous system, which consists of a central and peripheral sections. The main part includes the spinal cord and brain. Peripheral consists of nerves, plexuses, roots, ganglia and nerve endings.

The functions of the system are vegetative (responsible for the transmission of impulses) and somatic (connecting the brain with the skin and ODP).

The sensory system plays the main role in fixing the reaction to external stimuli and changes. It includes the nose, tongue, ears, eyes and skin. Its occurrence is the result of the work of the nervous system.

The endocrine system, together with the nervous system, regulates internal reactions and sensations of the environment. Emotions, mental activity, development, growth, puberty depend on her work.

The main organs in it are the thyroid and pancreas, testicles or ovaries, adrenal glands, pineal gland, pituitary gland and thymus.

The reproductive system is responsible for reproduction.

The urinary system is located entirely in the pelvic cavity. It, like the previous one, differs depending on gender. The need for the system is to remove toxic and foreign compounds, an excess of various substances through the urine. The urinary system consists of the kidneys, urethra, ureters, and bladder.

The digestive system is the human internal organs located in the abdominal cavity. Their layout is as follows:

Its function, logically coming from the name, is to extract and deliver nutrients to cells. The location of the human abdominal organs gives a general idea of ​​the process of digestion. It consists of mechanical and chemical processing of food, absorption, breakdown and excretion of waste products from the body.

The respiratory system consists of the upper (nasopharynx) and lower (larynx, bronchi and trachea) sections.

The immune system is the body's defense against tumors and pathogens. It consists of thymus, lymphoid tissue, spleen and lymph nodes.

The skin protects the body from temperature extremes, drying out, damage and the penetration of pathogens and toxins into it. It consists of skin, nails, hair, sebaceous and sweat glands.

Internal organs - the basis of life

The photo shows the location of the internal organs of a person with a description.

We can say that they are the basis of life. It is difficult to live without lower or upper limbs, but still possible. But without a heart or a liver, a person cannot live at all.

Thus, there are organs that are vital, and there are those without which life is difficult, nevertheless possible.

At the same time, some of the first components have a paired structure, and without one of them, the entire function passes to the remaining part (for example, the kidneys).

Some structures are able to regenerate (this applies to the liver).

Nature has endowed the human body with the most complex system, to which it must be attentive and protect what is given to it in the allotted time.

Many people neglect the most elementary things that can keep the body in order. Because of this, it becomes unusable ahead of time. Diseases appear and a person passes away when he has not yet done all the things that he should have done.

After the invention of diagnostics using an ultrasound device, many unsolved mysteries of the human body were revealed to physicians. Doctors began to see the internal organs, their condition and inflammatory processes, so this study is now the most used for making accurate diagnoses. So they examine the entire retroperitoneal space, the intestines, the reproductive system in women, the prostate in men. If ultrasound is carried out as planned, then there is a high probability of preventing any disease at an early stage.

Indications for an abdominal ultrasound

Ultrasound is not a painful procedure, so patients always easily agree to it. Ultrasound allows you to accurately determine the shape, structure, size and localization of the abdominal organs, ducts and vessels. Indications for the appointment of an ultrasound doctor are the following symptoms:

Heaviness in the right hypochondrium.

1. Bitterness in the mouth.
2. Abdominal pain of any kind.
3. Drawing or bursting pains after eating.
4. Increased gas formation in the stomach or intestines.
5. Abdominal injuries.
6. Assessment of inflammatory lesions of the genitourinary system.
7. Search for primary tumors and metastases.
8. Pregnancy.
9. Clinical symptoms (jaundice, blood in the urine, etc.).

What organs are checked with abdominal ultrasound

The abdominal cavity is bounded from above by the diaphragm, and from behind by the spinal column, fiber, and back muscles. The inner surface of the abdomen is covered with peritoneum (a thin membrane with nerve endings). Abdominal organs examined by ultrasound include:

Completely covered by the peritoneum: stomach, pancreas, gallbladder, spleen, liver.

1. Partially covered with peritoneum: large and small intestines, duodenum.
2. Retroperitoneal space: inferior vena cava and its tributaries, abdominal aorta and its branches, ureters, adrenal glands, kidneys.
3. Preperitoneal space: bladder, uterus, prostate.

How to Prepare for an Ultrasound

Abdominal ultrasound is a procedure that should be prepared in advance in order to obtain accurate examination results. For example, if a woman on the eve of the examination consumed foods that caused flatulence, then after an ultrasound this fact will cause difficulties in visualizing the spleen, pancreas, liver or biliary structure. Or if the patient is taking medication, then you must refuse them or warn the specialist who will conduct the ultrasound examination about this.

It is especially necessary to take the diagnosis of the small pelvis seriously: before undergoing an ultrasound scan, it is necessary to cleanse the intestines, and in a few days start drinking herbs and drugs that improve digestion and reduce gas formation: tea from lemon balm, mint, chamomile, ginger. If a study is required for a child, it is also advisable to put him on a diet on the eve of the ultrasound. A couple of days before the scheduled date, give him enzymes (festal, activated charcoal) to avoid flatulence during the ultrasound examination.

How many days in advance do you need to start a diet?

Patients are always interested in whether it is possible to eat before an abdominal ultrasound? Yes, but doctors warn that a special diet of balanced nutrition must be followed for three days before the procedure. It is advisable to eat every three to four hours, and there should be at least 4 meals. The use of low-fat cheese, meat, fish is recommended. Cereal cereals must be present in the daily diet: buckwheat, oatmeal, barley. Harmoniously complement the diet 1 boiled egg per day.

What not to eat before the study

On the eve of ultrasound, a diet is prescribed so that the conclusions of the studies are correct, because ultrasonic waves cannot pass through the air in the stomach. Before undergoing the procedure, you should avoid any products that promote gas formation: dairy and sour-milk, muffins, raw vegetables, sweets, carbonated drinks. You also need to give up too salty, spicy and fatty foods, and immediately before the procedure - from alcohol, smoking, chewing gum, lollipops, so as not to provoke stomach cramps.

How much can you eat on the day of the ultrasound

The cleaner the body on the day of the ultrasound, the more accurate the decoding of the diagnosis will be, and, as a result, the more effective the treatment, the faster the recovery. A short-term diet before an abdominal ultrasound will help improve the condition of the whole body, which is important for both men and women. The day before the procedure, you need to have dinner no later than 19 hours, and on the day of the ultrasound, you can’t eat anything.

Do I need to drink before an abdominal ultrasound

During the diet, 2-3 days before the ultrasound, doctors recommend drinking herbal infusions, weak tea or non-carbonated water, but not more than 1.5 liters per day. On the day of the ultrasound, you can not drink anything. It is recommended not to drink for several hours before the procedure so that the digestive system is completely empty. But this does not create much inconvenience for patients, since most doctors prescribe an ultrasound scan in the morning, and after the studies, you are allowed to drink and eat as much as you want.

If an ultrasound of the kidneys or bladder is planned, then the preparation for the procedure includes the use of water for the acoustic window, so the patient is instructed to drink plenty of fluids. But it must be taken into account that you need to drink non-carbonated drinks slowly, without swallowing a lot of air, so that during the examination it does not form a space in the stomach that will not allow the device to correctly read the information.

How it goes and what gives an ultrasound of the abdominal cavity

The algorithm for conducting an ultrasound examination is as follows: the patient undresses in the diagnostic room, exposes the abdominal cavity, and lies down on the couch, which is located next to the device. Sometimes during the diagnosis, a person needs to lie on his side or stomach when the adrenal glands and kidneys are viewed, because they are better visualized from several angles.

Then the doctor applies a special conductive gel to the sensor head and the patient's skin, which excludes the reflection of ultrasonic waves from the body surface. During the procedure, the doctor gives commands regarding the depth of breathing, using a sensor to scan the abdominal organs. The ultrasonic signal goes from the sensor to the organ under study, and, reflected, returns to the monitor, where the specialist fixes it. The procedure lasts, depending on the diagnosed organs, from 5 to 60 minutes.

In the first moments after applying the gel, the patient may feel cold in the examination area, feel light pressure from the sensor. Ultrasound does not bring any more discomfort. But if an ultrasound is performed to determine internal damage, then the patient may experience mild pain when the doctor passes the probe over the body. The ultrasonic waves themselves are neither felt nor heard.

The diagnostic value of abdominal ultrasound is very high, this study examines in detail most of the vital human organs. Modern ultrasound devices will reveal the most insignificant changes in the body, assess the rate of development of any disease, and allow the doctor to make an accurate diagnosis. Key research parameters include:

the size and location of the abdominal organs;

• the presence and structure of additional formations;
• violations, deformation of organs;
• chronic diseases.

Deciphering the ultrasound will show any deviations from the norm, which will allow you to start treatment on time and avoid unpleasant consequences. Ultrasound of the abdominal cavity 100% determines the diseases of the following nature:

rupture of the gallbladder;

• cirrhosis of the liver;
• all inflammatory processes;
• the presence of stones;
• tissue damage;
• the condition of the appendages and uterus in women;
• accumulation of unbound liquid;
• prostate tumors in men.

Video

The presence of contrast agents in the intestines or stomach can affect the results of an ultrasound examination. The device may distort the results if the patient was not immobile during the procedure or if a bandage or an open wound got into the scanning area. The extreme degree of obesity also affects the accuracy of the results.

If you go for the procedure, you need to take with you a disposable diaper, which is sold in any pharmacy, napkins to remove the remnants of the gel after the examination, and shoe covers so as not to take off your shoes at the doctor. Although in a private clinic, as a rule, all these things are provided. Watch the video below, in which the specialist will tell you in more detail what preparation is needed for an ultrasound of the abdominal organs.

Attention! The information provided in the article is for informational purposes only. The materials of the article do not call for self-treatment. Only a qualified doctor can make a diagnosis and give recommendations for treatment, based on the individual characteristics of a particular patient.

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What is included in an abdominal ultrasound

Peritoneum, - a thin serous membrane with a smooth, shiny, homogeneous surface, covers the walls of the abdominal cavity, cavitas abdominis, and partly of the small pelvis, located in this cavity of organs. The surface of the peritoneum is about 20,400 cm 2 and is almost equal to the area of ​​the skin. The peritoneum is formed by its own plate, lamina propria, of the serous membrane and the single-layer squamous epithelium covering it - mesothelium, mesothelium.

lining the walls of the abdomen is called the parietal peritoneum, peritoneum parietale; the peritoneum covering the organs is the visceral peritoneum, peritoneum viscerale. Passing from the walls of the abdominal cavity to the organs and from one organ to another, the peritoneum forms ligaments, ligamenta, folds, plicae, mesentery, mesenterii.

Due to the fact that the visceral peritoneum, covering one or another organ, passes into the parietal peritoneum, most organs are fixed to the walls of the abdominal cavity. The visceral peritoneum covers the organs in different ways: from all sides (intraperitoneally), from three sides (mesoperitoneally) or from one side (retro- or extraperitoneally). The organs covered with peritoneum on three sides, located mesoperitoneally, include the partially ascending and descending sections, the middle part.

Extraperitoneally located organs include (except for its initial section), the pancreas, adrenal glands,.

Organs located intraperitoneally have a mesentery that connects them with the parietal.

Mesentery is a plate consisting of two connected sheets of the peritoneum of the duplication. One - free - the edge of the mesentery covers the organ (intestine), as if hanging it, and the other edge goes to the abdominal wall, where its sheets diverge in different directions in the form of a parietal peritoneum. Usually, between the sheets of the mesentery (or ligament), blood, lymphatic vessels and nerves approach the organ. The place of the beginning of the mesentery on the abdominal wall is called the root of the mesentery, radix mesenterii; approaching an organ (for example, the intestine), its leaves diverge on both sides, leaving a narrow strip at the point of attachment - the extraperitoneal field, area nuda.

The serous cover, or serous membrane, tunica serosa, is not directly adjacent to the organ or abdominal wall, but is separated from them by a layer of connective tissue subserous base, tela subserosa, which, depending on the location, has a different degree of development. So, the subserous base under the serous membrane of the liver, diaphragm, upper section of the anterior abdominal wall is poorly developed and, conversely, it is significantly developed under the parietal peritoneum lining the posterior wall of the abdominal cavity; for example, in the region of the kidneys, etc., where the peritoneum is very movably connected to the underlying organs or parts of them.

The peritoneal cavity, or peritoneal cavity, cavitas peritonealis, is closed in men, and in women through the fallopian tubes, uterus and communicates with the external environment. The peritoneal cavity is a slit-like space of complex shape, filled with a small amount of serous fluid, liquor peritonei, moisturizing the surface of organs.

The parietal peritoneum of the posterior wall of the abdominal cavity delimits the peritoneal cavity from the retroperitoneal space, spatium retroperitoneale, in which the retroperitoneal organs, organa retroperitonealia, lie. In the retroperitoneal space, behind the parietal peritoneum, is the retroperitoneal fascia, fascia retroperitonealis.

The extraperitoneal space, spatium extraperitoneale, is also the retropubic space, spatium retropubicum.

Peritoneum and peritonealfolds. The anterior parietal peritoneum, peritoneum parietale anterius, forms a series of folds on the anterior wall of the abdomen. Along the midline is the median umbilical fold, plica umbilicalis mediana, which stretches from the umbilical ring to the apex; in this fold, a connective tissue cord is laid, which is an obliterated urinary duct, urachus. From the umbilical ring to the side walls of the bladder are the medial umbilical folds, plicae umbilicales mediales, in which strands of the empty anterior sections of the umbilical arteries are laid. Outside of these folds are the lateral umbilical folds, plicae umbilicales laterales. They stretch from the middle of the inguinal ligament obliquely upward and medially, to the back. These folds contain the lower epigastric arteries, aa. epigastricae inferiores, which feed the rectus abdominis muscles.

At the base of these folds, pits are formed. On both sides of the median umbilical fold, between it and the medial umbilical fold, above the upper edge of the bladder, there are supravesical fossae, fossae supravesicales. Between the medial and lateral umbilical folds are medial inguinal fossae, fossae inguinales mediates; outward from the lateral umbilical folds lie the lateral inguinal fossae, fossae inguinales laterales; these pits are located against the deep inguinal rings.

The triangular section of the peritoneum, located above the medial inguinal fossa and limited on the medial side by the edge of the rectus abdominis muscle, with the lateral - lateral umbilical fold and below - the inner part of the inguinal ligament, is called the inguinal triangle, trigonum inguinale.

The parietal peritoneum, covering the anterior abdomen above the umbilical ring and the diaphragm, passing to the diaphragmatic surface of the liver, forms a sickle-shaped (suspending) ligament of the liver, lig. falciforme hepatis, consisting of two sheets of peritoneum (duplication), located in the sagittal plane. In the free lower edge of the falciform ligament, there is a strand of the round ligament of the liver, lig, teres hepatis. Leaves of the falciform ligament posteriorly pass into the anterior leaf of the coronary ligament of the liver, lig. coronarium hepatis. It represents the transition of the visceral peritoneum of the diaphragmatic surface of the liver into the parietal peritoneum of the diaphragm. The posterior leaf of this ligament passes to the diaphragm from the visceral surface of the liver. Both sheets of the coronary ligament converge at their lateral ends and form the right and left triangular ligaments, lig. triangulare dextrum et lig. triangular sinistrum.

The visceral peritoneum, peritoneum visceralis, of the liver covers the gallbladder from the underside.

From the visceral peritoneum of the liver, the peritoneal ligament is directed to the lesser curvature of the stomach and the upper part of the duodenum. It is a duplication of the peritoneal sheet, starting from the edges of the gate (transverse groove) and from the edges of the gap of the venous ligament, and is located in the frontal plane. The left side of this ligament (from the gap of the venous ligament) goes to the lesser curvature of the stomach - this is the hepatogastric ligament, lig, hepatogastricum. It has the appearance of a thin cobweb plate. Between the sheets of the hepatogastric ligament, along the lesser curvature of the stomach, arteries and veins of the stomach pass, a. et v. gastricae, nerves; here are the regional lymph nodes. The right part of the ligament, more dense, goes from the gate of the liver to the upper edge of the pylorus and duodenum, this section is called the hepatoduodenal ligament, lig. hepatoduodenale, and includes the common bile duct, the common hepatic artery and its branches, the portal vein, lymphatic vessels, nodes and nerves. On the right, the hepatoduodenal ligament forms the anterior edge of the omental opening, foramen epiploicum (omentale). Approaching the edge of the stomach and duodenum, the sheets of the ligament diverge and cover the anterior and posterior walls of these organs.

Both ligaments: hepatic-gastric and hepatic-duodenal - make up the lesser omentum, omentum minus. An inconstant continuation of the lesser omentum is the hepatic-colic ligament, lig. hepatocolicum, connecting the gallbladder with and the right bend of the colon. The falciform ligament and the lesser omentum are ontogenetically the anterior, ventral, mesentery of the stomach.

The parietal peritoneum departs from the left side of the dome of the diaphragm, passing to the cardiac notch and the right half of the fornix of the stomach, forming a small gastro-diaphragmatic ligament, lig. gastrophrenicum.

Between the lower edge of the right lobe of the liver and the upper end of the right kidney adjacent here, the peritoneum forms a transitional fold - the hepatic-renal ligament, lig. hepatorenale.

The sheets of the visceral peritoneum of the anterior and posterior surfaces of the stomach along its greater curvature continue down in the form of a greater omentum. The greater omentum, omentum majus, in the form of a wide plate ("apron") follows down to the level of the upper aperture of the small pelvis. Here, the two leaves that form it tuck and return, heading up behind the descending two leaves. These return sheets are fused to the front sheets. At the level of the transverse colon, all four leaves of the greater omentum adhere to the omental band located on the anterior surface of the intestine. Then the posterior (recurrent) sheets of the omentum depart from the anterior ones, connect with the mesentery of the transverse colon, mesocolon transversum, and go together dorsally to the line of attachment of the mesentery along the posterior abdominal wall in the region of the anterior edge of the body of the pancreas.

Thus, a pocket is formed between the anterior and posterior sheets of the omentum at the level of the transverse colon. Approaching the anterior edge of the body of the pancreas, the two posterior sheets of the omentum diverge: the upper sheet passes into the posterior wall of the omental sac (on the surface of the pancreas) in the form of a parietal sheet of the peritoneum, the lower sheet passes into the upper sheet of the mesentery of the transverse colon.

The area of ​​the greater omentum between the greater curvature of the stomach and the transverse colon is called the gastrocolic ligament, lig. gastrocolicum; this ligament fixes the transverse colon to the greater curvature of the stomach. Between the sheets of the gastrocolic ligament, along the greater curvature, the right and left gastroepiploic arteries and veins pass, regional lymph nodes lie.

The greater omentum covers the front of the large and small intestines. A narrow gap is formed between the omentum and the anterior abdominal wall - the preomental space. The greater omentum is a distended dorsal mesentery of the stomach. Its continuation to the left is the gastro-splenic ligament, lig. gastrolienale, and diaphragmatic-splenic ligament, lig. phrenicolienale, which pass one into another.

Of the two sheets of the peritoneum of the gastrosplenic ligament, the anterior one passes to the spleen, surrounds it from all sides, returns back to the gates of the organ in the form of a sheet of the diaphragmatic-splenic ligament. The posterior leaf of the gastrosplenic ligament, having reached the hilum of the spleen, turns directly to the posterior abdominal wall in the form of the second leaf of the diaphragmatic-splenic ligament. As a result, the spleen is, as it were, included from the side in a ligament connecting the greater curvature of the stomach with the diaphragm.

The mesentery of the colon, mesocolon, in different parts of the colon has unequal sizes, and sometimes is absent. So, the caecum, which has the shape of a bag, is covered with peritoneum on all sides, but it does not have a mesentery. At the same time, the appendix extending from the caecum, which is also surrounded on all sides by the peritoneum (intraperitoneal position), has a mesentery of the appendix, mesoappendix, reaching considerable sizes. At the place of transition of the caecum to the ascending colon, there is sometimes a slight mesentery of the ascending colon, mesocolon ascendens.

Thus, the serous membrane covers the ascending colon from three sides, leaving the posterior wall free (mesoperitoneal position).

The mesentery of the transverse colon begins on the posterior abdominal wall at the level of the descending part of the duodenum, the head and body of the pancreas, and the left kidney; approaching the intestine at the mesenteric tape, two sheets of the mesentery diverge and cover the intestine in a circle (intraperitoneally). Throughout the mesentery from the root to the place of attachment to the intestine, its greatest width is 10-15 cm and decreases towards the bends, where it passes into the parietal leaf.

The descending colon, as well as the ascending colon, is covered with a serous membrane on three sides (mesoperitoneally), and only in the area of ​​transition to the sigmoid colon does a short mesentery of the descending colon, mesocolon descendens, sometimes form. Only a small portion of the posterior wall of the middle third of the descending colon is covered by the peritoneum.

The mesentery of the sigmoid colon, mesocolon sigmoideum, has a width of 12-14 cm, which varies considerably throughout the intestine. The root of the mesentery crosses the bottom of the iliac fossa obliquely to the left and from top to bottom and to the right, the iliac and lumbar muscles, as well as the left common iliac vessels and the left ureter located along the borderline; having rounded the boundary line, the mesentery crosses the region of the left sacroiliac joint and passes to the anterior surface of the upper sacral vertebrae. At level III of the sacral vertebrae, the mesentery of the sigmoid colon ends at the beginning of the very short mesentery of the rectum. The length of the mesentery root varies greatly; the steepness and size of the loop of the sigmoid colon depend on it.

The ratio of the rectum to the pelvic peritoneum at its various levels varies. The pelvic part is to some extent covered with a serous membrane. The perineal part is devoid of peritoneal cover. The uppermost (supraampullary) part, starting at the level of the III sacral vertebra, is completely surrounded by a serous cover and has a short and narrow mesentery.

The left bend of the colon is connected to the diaphragm by a horizontally located peritoneal diaphragmatic-colic fold (sometimes referred to as the diaphragmatic-colic ligament, lig. phrenicocolicum).

For a more convenient study of the topography of the peritoneum and organs of the abdominal cavity, a number of topographic and anatomical definitions are used that are used in the clinic and do not have either Latin terms or their Russian equivalents.

The peritoneal folds, ligaments, mesentery, and organs create relatively isolated recesses, pockets, bursae, and sinuses in the peritoneal cavity.

Based on this, the peritoneal cavity can be divided into an upper floor and a lower floor.

The upper floor is separated from the lower by a horizontal mesentery of the transverse colon (at the level of the II lumbar vertebra). The mesentery is the lower border of the upper floor, the diaphragm is the upper one, and the lateral walls of the abdominal cavity limit it on the sides.

The lower floor of the peritoneal cavity is bounded from above by the transverse colon and its mesentery, on the sides by the lateral walls of the abdominal cavity, and below by the peritoneum covering the pelvic organs.

In the upper floor of the peritoneal cavity, there are subdiaphragmatic recesses, recessus subphrenici, subhepatic recesses, recessus subhepatici, and stuffing bag, bursa omentalis.

The subdiaphragmatic recess is divided by the falciform ligament into right and left parts. The right part of the subdiaphragmatic recess is a gap in the peritoneal cavity between the diaphragmatic surface of the right lobe of the liver and the diaphragm. Behind it is limited by the right part of the coronary ligament and the right triangular ligament of the liver, on the left by the falciform ligament of the liver. This recess communicates with the right subhepatic space located below, the right paracolic sulcus, then with the iliac fossa and through it with the small pelvis. The space under the left dome of the diaphragm between the left lobe of the liver (diaphragmatic surface) and the diaphragm is the left subdiaphragmatic depression.

On the right it is limited by the falciform ligament, behind - the left part of the coronary and left triangular ligaments. This recess communicates with the lower left subhepatic recess.

The space under the visceral surface of the liver can be conditionally divided into two sections - the right and left, the boundary between which can be considered the falciform and round ligaments of the liver. The right subhepatic recess is located between the visceral surface of the right lobe of the liver and the transverse colon and its mesentery. Behind this recess is limited by the parietal peritoneum (hepatic-renal ligament, lig. hepatorenale). Laterally, the right subhepatic depression communicates with the right paracolic-intestinal sulcus, in depth through the omental opening - with the omental bag. The department of the subhepatic space, located in the depths at the posterior edge of the liver, to the right of the spinal column, is called the hepatic-renal recess, recessus hepatorenalis.

The left subhepatic recess is a gap between the lesser omentum and stomach on one side and the visceral surface of the left lobe of the liver on the other. Part of this space, located outside and somewhat posterior to the greater curvature of the stomach, reaches the lower edge of the spleen.

Thus, the right subdiaphragmatic and right subhepatic recesses surround the right lobe of the liver and gallbladder (the outer surface of the duodenum faces here). In topographic anatomy, they are combined under the name "liver bag". The left lobe of the liver, the lesser omentum, and the anterior surface of the stomach are located in the left subdiaphragmatic and left subhepatic recesses. In topographic anatomy, this department is called the pancreatic sac. Stuffing bag, bursa omentalis, is located behind the stomach. To the right, it extends to the omental opening, to the left - to the gates of the spleen. The anterior wall of the omental sac is the lesser omentum, the posterior wall of the stomach, the gastrocolic ligament, and sometimes the upper section of the greater omentum, if the descending and ascending leaves of the greater omentum are not fused and there is a gap between them, which is considered as a continuation of the omental sac down.

The posterior wall of the omental sac is the parietal peritoneum, which covers the organs located on the posterior wall of the abdominal cavity: the inferior vena cava, the abdominal aorta, the left adrenal gland, the upper end of the left kidney, the splenic vessels and, below, the body of the pancreas, which occupies the largest space of the posterior wall of the omental sac.

The upper wall of the omental bag is the caudate lobe of the liver, the lower wall is the transverse colon and its mesentery. The left wall is the gastrosplenic and diaphragmatic-splenic ligaments. The entrance to the bag is the omental opening, foramen epiploicum (omentale), located on the right side of the bag behind the hepatoduodenal ligament. This hole allows 1-2 fingers through. Its anterior wall is the hepatoduodenal ligament with the vessels located in it and the common bile duct. The posterior wall is the hepato-renal ligament, behind which are the inferior vena cava and the upper end of the right kidney. The lower wall is formed by the peritoneum, passing from the kidney to the duodenum, the upper one is the caudate lobe of the liver. The narrow section of the bag closest to the opening is called the vestibule of the stuffing bag, vestibulum bursae omentalis; it is bounded by the caudate lobe of the liver above and the upper part of the duodenum below.

Behind the caudate lobe of the liver, between it and the medial pedicle of the diaphragm covered with the parietal peritoneum, there is a pocket - the upper omental recess, recessus superior omentalis, which is open below towards the vestibule. Down from the vestibule, between the posterior wall of the stomach and the gastrocolic ligament in front and the pancreas covered with the parietal peritoneum and the mesentery of the transverse colon, behind is the lower omental recess, recessus inferior omentalis. To the left of the vestibule, the cavity of the omental bag is narrowed by the gastropancreatic fold of the peritoneum, plica gastropancreatica, running from the upper edge of the omental tubercle of the pancreas upward and to the left, to the lesser curvature of the stomach (it contains the left gastric artery, a. gastrica sinistra). The continuation of the lower recess to the left is the sinus, located between the gastrosplenic ligament (in front) and the diaphragmatic-splenic ligament (behind), which is called the splenic recess, recessus lienalis.

In the lower floor of the peritoneal cavity, on its back wall, there are two large mesenteric sinuses and two paracolic sulci. Here, the lower sheet of the mesentery of the transverse colon, downward from the root, passes into the parietal sheet of the peritoneum, lining the posterior wall of the mesenteric sinuses.

The peritoneum, covering the back wall of the abdomen in the lower floor, passing to the small intestine, surrounds it from all sides (except the duodenum) and forms the mesentery of the small intestine, mesenterium. The mesentery of the small intestine is a double sheet of peritoneum. The root of the mesentery, radix mesenterii, goes obliquely from top to bottom from level II of the lumbar vertebra on the left to the sacroiliac joint on the right (the place where the ileum flows into the blind). The length of the root is 16-18 cm, the width of the mesentery is 15-17 cm, however, the latter increases in the areas of the small intestine most distant from the posterior wall of the abdomen. In its course, the root of the mesentery crosses the ascending part of the duodenum at the top, then the abdominal aorta at the level of the IV lumbar vertebra, the inferior vena cava and the right ureter. Along the root of the mesentery go, following from top to left down and to the right, the upper mesenteric vessels; mesenteric vessels give intestinal branches between the sheets of the mesentery to the intestinal wall. In addition, lymphatic vessels, nerves and regional lymph nodes are located between the sheets of the mesentery. All this largely determines that the duplication plate of the mesentery of the small intestine becomes dense, thickened.

The mesentery of the small intestine divides the peritoneal cavity of the lower floor into two sections: the right and left mesenteric sinuses.

The right mesenteric sinus is bounded from above by the mesentery of the transverse colon, to the right by the ascending colon, and to the left and below by the mesentery of the small intestine. Thus, the right mesenteric sinus has the shape of a triangle, and is closed on all sides. Through the parietal peritoneum lining it, the lower end of the right kidney (to the right) is contoured and translucent at the top under the mesentery of the colon; adjacent to it is the lower part of the duodenum and the lower part of the pancreatic head surrounded by it. Below in the right sinus, the descending right ureter and the iliococolic artery with a vein are visible.

Below, at the place where the ileum flows into the blind, an ileocecal fold, plica ileocecalis, is formed. It is located between the medial wall of the cecum, the anterior wall of the ileum and the parietal peritoneum, and also connects the medial wall of the caecum to the lower wall of the ileum above and to the base of the appendix below. In front of the ileocecal angle there is a fold of the peritoneum - the vascular cecal fold, plica cecalis vascularis, in the thickness of which the anterior cecal artery passes. The fold departs from the anterior surface of the mesentery of the small intestine and approaches the anterior surface of the caecum. Between the upper edge of the appendix, the ileum and the wall of the medial portion of the bottom of the caecum is the mesentery of the appendix (appendix), mesoappendix. Feeding vessels pass through the mesentery, a. et v. appendiculares, and regional lymph nodes and nerves. Between the lateral edge of the bottom of the caecum and the parietal peritoneum of the iliac fossa are the caecal folds, plicae cecales.

Under the ileocecal fold lie pockets located above and below the ileum: upper and lower ileocecal recesses, recessus ileocecalis superior, recessus ileocecalis inferior. Sometimes under the bottom of the caecum there is a retroceiling recess, recessus retrocecalis.

To the right of the ascending colon is the right paracolonic sulcus. It is limited outside by the parietal peritoneum of the lateral wall of the abdomen, on the left - by the ascending colon; downwards it communicates with the iliac fossa and the peritoneal cavity of the small pelvis. At the top, the groove communicates with the right subhepatic and subdiaphragmatic recesses. Along the furrow, the parietal peritoneum forms transversely located folds connecting the upper right bend of the colon with the lateral wall of the abdomen and the right phrenic-colic ligament, usually weakly expressed, sometimes absent.

The left mesenteric sinus is bounded from above by the mesentery of the transverse colon, to the left by the descending colon, and to the right by the mesentery of the small intestine. From top to bottom, the left mesenteric sinus communicates with the peritoneal cavity of the small pelvis. The sinus has an irregular quadrangular shape and is open downwards. Through the parietal peritoneum of the left mesenteric sinus, the lower half of the left kidney is translucent and contoured above, below and medially in front of the spine - the abdominal aorta and to the right - the inferior vena cava and the initial segments of the common iliac vessels. To the left of the spine, the left testicular artery (ovary), the left ureter, and branches of the inferior mesenteric artery and vein are visible. In the upper medial corner, around the beginning of the jejunum, the parietal peritoneum forms a fold that borders the intestine from above and to the left - this is the upper duodenal fold (duodenal-jejunal fold), plica duodenalis superior (duodenojejunalis). To the left of it is the paraduodenal fold, plica paraduodenalis, which is a semilunar fold of the peritoneum, located at the level of the ascending part of the duodenum and covering the left colon artery. This fold limits the front of the unstable paraduodenal recess, recessus paraduodenalis, the back wall of which is the parietal peritoneum, and the lower duodenal fold (duodeno-mesenteric fold), plica duodenalis inferior (plica duodenomesocolica), which is a triangular fold of the parietal peritoneum, passing on the ascending part of the duodenum.

To the left of the root of the mesentery of the small intestine, behind the ascending part of the duodenum, there is a peritoneal fossa - a retroduodenal recess, recessus retroduodenalis, the depth of which can vary. To the left of the descending colon is the left paracolic sulcus; it is limited to the left (laterally) by the parietal peritoneum lining the lateral wall of the abdomen. From top to bottom, the furrow passes into the iliac fossa and further into the cavity of the small pelvis. Above, at the level of the left bend of the colon, the groove is crossed by a constant and well-defined diaphragmatic-colon fold of the peritoneum.

Below, between the bends of the mesentery of the sigmoid colon, there is a peritoneal intersigmoid depression, recessus intersigmoideus.

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15.1. BORDERS, AREAS AND SECTIONS OF THE ABDOMINAL

From above, the abdomen is limited by the costal arches, from below - by the iliac crests, inguinal ligaments and the upper edge of the pubic fusion. The lateral border of the abdomen runs along vertical lines connecting the ends of the XI ribs with the anterior superior spines (Fig. 15.1).

The abdomen is divided into three sections by two horizontal lines: the epigastrium (epigastrium), the womb (mesogastrium) and the hypogastrium (hypogastrium). The outer edges of the rectus abdominis go from top to bottom and divide each section into three areas.

It should be borne in mind that the boundaries of the abdominal cavity do not correspond to the boundaries of the anterior abdominal wall. The abdominal cavity is a space covered with intra-abdominal fascia, bounded from above by the diaphragm, from below - by the boundary line that separates the abdominal cavity from the pelvic cavity.

Rice. 15.1.The division of the abdomen into departments and regions:

1 - projection of the dome of the diaphragm;

2 - linea costarum; 3 - linea spmarum; a - epigastrium; b - womb; in - hypogastrium; I - the actual epigastric region; II and III - right and left hypochondria; V - umbilical region; IV and VI - right and left side areas; VIII - suprapubic region; VII and IX - ilioinguinal regions

15.2. ANTERELATERAL ABDOMINAL WALL

The anterolateral abdominal wall is a complex of soft tissues located within the boundaries of the abdomen and covering the abdominal cavity.

15.2.1. Projection of organs on the anterolateral abdominal wall

The liver (right lobe), part of the gallbladder, hepatic flexure of the colon, right adrenal gland, part of the right kidney are projected into the right hypochondrium (Fig. 15.2).

The left lobe of the liver, part of the gallbladder, part of the body and the pyloric part of the stomach, the upper half of the duodenum, the duodeno-jejunal junction (bend), the pancreas, parts of the right and left kidneys, the aorta with the celiac trunk, the celiac plexus, are projected into the epigastric region proper. a small section of the pericardium, inferior vena cava.

The bottom, cardia and part of the body of the stomach, spleen, tail of the pancreas, part of the left kidney and part of the left lobe of the liver are projected into the left hypochondrium.

The ascending colon, part of the ileum, part of the right kidney and the right ureter are projected into the right lateral region of the abdomen.

Part of the stomach (greater curvature), transverse colon, loops of the jejunum and ileum, part of the right kidney, aorta, and inferior vena cava are projected into the umbilical region.

The descending colon, loops of the jejunum, and the left ureter are projected into the left lateral region of the abdomen.

The caecum with the appendix and the terminal ileum are projected into the right ilio-inguinal region.

Loops of the jejunum and ileum are projected into the suprapubic region, the bladder is in a full state, part of the sigmoid colon (transition to the straight line).

The sigmoid colon and loops of the jejunum and ileum are projected into the left ilio-inguinal region.

The uterus normally does not protrude beyond the upper edge of the pubic symphysis, but during pregnancy, depending on the period, it can be projected into the suprapubic, umbilical or epigastric region.

Rice. 15.2.Projection of organs on the anterior abdominal wall (from: Zolotko Yu.L., 1967):

1 - anterior border of the pleura; 2 - sternum; 3 - esophagus; 4 - heart; 5 - left lobe of the liver; 6 - cardia of the stomach; 7 - the bottom of the stomach; 8 - intercostal space; 9 - XII rib; 10 - common bile duct; 11 - spleen; 12 - the body of the stomach; 13 - left bend of the colon; 14 - costal arch; 15 - duodenal-jejunal bend; 16 - jejunum; 17 - descending colon; 18 - sigmoid colon; 19 - wing of the ileum; 20 - anterior upper spine of the ileum; 21 - V lumbar vertebra; 22 - fallopian tube; 23 - ampulla of the rectum; 24 - vagina; 25 - uterus; 26 - rectum; 27 - appendix; 28 - ileum; 29 - caecum; 30 - the mouth of the ileocecal valve; 31 - ascending colon; 32 - duodenum;

33 - right bend of the colon; 34 - pyloric stomach; 35 - gallbladder; 36 - cystic duct; 37 - common hepatic duct; 38 - lobar hepatic ducts; 39 - liver; 40 - diaphragm; 41 - easy

15.2.2. Topography of layers and weaknesses of the anterolateral abdominal wall

Leatherthe area is mobile, elastic, which allows it to be used for plastic purposes in the plastic surgery of facial defects (the Filatov stem method). The hairline is well developed.

Subcutaneous adipose tissue divided by superficial fascia into two layers, the degree of its development may be different in different people. In the umbilical region, fiber is practically absent, along the white line it is poorly developed.

superficial fascia consists of two sheets - superficial and deep (Thompson's fascia). The deep leaf is much stronger and denser than the superficial one and is attached to the inguinal ligament.

own fascia covers the abdominal muscles and fuses with the inguinal ligament.

The most superficial external oblique muscle of the abdomen. It consists of two parts: muscular, located more laterally, and aponeurotic, lying anterior to the rectus abdominis muscle and participating in the formation of the rectus sheath. The lower edge of the aponeurosis thickens, turns down and inward and forms the inguinal ligament.

More deeply located internal oblique muscle of the abdomen. It also consists of a muscular and aponeurotic part, but the aponeurotic part has a more complex structure. The aponeurosis has a longitudinal fissure located about 2 cm below the navel (Douglas line, or arcuate). Above this line, the aponeurosis consists of two sheets, one of which is located anterior to the rectus abdominis muscle, and the other is posterior to it. Below the Douglas line, both sheets merge with each other and are located anterior to the rectus muscle (Fig. 15.4).

rectus abdominis located in the middle part of the abdomen. Its fibers are directed from top to bottom. The muscle is divided by 3-6 tendon bridges and lies in its own vagina, formed by aponeuroses of the internal and external oblique and transverse abdominal muscles. The anterior wall of the vagina is represented by an aponeurosis

external oblique and partially internal oblique abdominal muscles. It is loosely separated from the rectus muscle, but fuses with it in the area of ​​the tendon bridges. The posterior wall is formed by the aponeurosis of the internal oblique (partially), transverse abdominal muscles and intra-abdominal fascia and does not fuse with the muscle anywhere, forming

Rice. 15.3.Layers of the anterolateral abdominal wall (from: Voilenko V.N. and others,

1965):

1 - rectus abdominis; 2 - external oblique muscle of the abdomen; 3 - jumper between the segments of the rectus muscle; 4 - aponeurosis of the external oblique muscle of the abdomen; 5 - pyramidal muscle; 6 - spermatic cord; 7 - ilio-inguinal nerve; 8 - anterior and lateral cutaneous branches of the iliac-hypogastric nerve; 9, 12 - anterior cutaneous branches of the intercostal nerves; 10 - lateral cutaneous branches of the intercostal nerves; 11 - anterior wall of the sheath of the rectus abdominis muscle

cellular space in which the upper and lower epigastric vessels pass. In this case, the corresponding veins in the navel are connected to each other and form a deep venous network. In some cases, the rectus abdominis is reinforced from below by the pyramidal muscle (Fig. 15.3).

Rice. 15.4.Deep blood vessels of the anterolateral abdominal wall (from: Voilenko V.N. et al., 1965):

I - superior epigastric artery and vein; 2, 13 - posterior wall of the sheath of the rectus abdominis muscle; 3 - intercostal arteries, veins and nerves; 4 - transverse abdominal muscle; 5 - iliac-hypogastric nerve; 6 - dagoobraznaya line; 7 - lower epigastric artery and vein; 8 - rectus abdominis; 9 - ilioinguinal nerve; 10 - internal oblique muscle of the abdomen;

II - aponeurosis of the internal oblique muscle of the abdomen; 12 - anterior wall of the sheath of the rectus abdominis muscle

transverse abdominis muscle lies deeper than all the others. It also consists of muscular and aponeurotic parts. Its fibers are located transversely, while the aponeurotic part is much wider than the muscular one, as a result of which there are small slit-like spaces at the place of their transition. The transition of the muscular part into the tendon has the form of a semicircular line, called the lunate, or Spiegel's line.

According to the Douglas line, the aponeurosis of the transverse abdominis muscle also splits: above this line it passes under the rectus abdominis muscle and participates in the formation of the posterior wall of the vagina of the rectus muscle, and below the line it participates in the formation of the anterior wall of the vagina.

Under the transverse muscle is the intra-abdominal fascia, which in the area under consideration is called transverse (along the muscle on which it lies) (Fig. 15.4).

It should be noted that the aponeuroses of the left and right oblique and transverse abdominal muscles fuse with each other along the midline, forming the linea alba. Given the relative paucity of blood vessels, the presence of a connection between all layers and sufficient strength, it is the white line of the abdomen that is the site of the fastest surgical access for interventions on the internal organs of the abdomen.

On the inner surface of the abdominal wall, a number of folds and depressions (pits) can be identified.

Directly along the midline is located vertically the median umbilical fold, which is the remainder of the urinary duct of the fetus, subsequently overgrown. In an oblique direction from the navel to the lateral surfaces of the bladder, there are internal, or medial, right and left umbilical folds. They are remnants of obliterated umbilical arteries covered with peritoneum. Finally, from the navel to the middle of the inguinal ligament, lateral, or external, umbilical folds stretch, formed by the peritoneum covering the lower epigastric vessels.

Between these folds are the supravesical, medial inguinal and lateral inguinal fossae.

Under the concept of "weak spots of the abdominal wall" unite such parts of it that weakly restrain intra-abdominal pressure and, when it increases, can be places for hernias to exit.

These places include all the above fossae, the inguinal canal, the white line of the abdomen, the lunate and arcuate lines.

Rice. 15.5.Topography of the inner surface of the anterior-lateral abdominal wall:

1 - rectus abdominis; 2 - transverse fascia; 3 - median fold; 4 - internal umbilical fold; 5 - external umbilical fold; 6 - lateral inguinal fossa; 7 - medial inguinal fossa; 8 - supravesical fossa; 9 - femoral fossa; 10 - lacunar ligament; 11 - deep femoral ring; 12 - external iliac vein; 13 - external iliac artery; 14 - spermatic cord, 15 - deep ring of the inguinal canal; 16 - lower epigastric vessels; 17 - umbilical artery; 18 - parietal peritoneum

15.2.3. Topography of the inguinal canal

The inguinal canal (canalis inguinalis) is located above the inguinal ligament and is a slit-like space between it and the broad abdominal muscles. In the inguinal canal, 4 walls are distinguished: anterior, upper, lower and posterior, and 2 openings: internal and external (Fig. 15.6).

Anterior wall of the inguinal canal is the aponeurosis of the external oblique muscle of the abdomen, which thickens in its lower part and tucks backwards, forming the inguinal ligament. The latter is inferior wall of the inguinal canal. In this area, the edges of the internal oblique and transverse muscles are located slightly above the inguinal ligament, and thus the upper wall of the inguinal canal is formed. Back wall represented by the transverse fascia.

outside hole, or superficial inguinal ring (annulus inguinalis superficialis), formed by two legs of the aponeurosis of the external oblique muscle of the abdomen, which diverge to the sides and attach to the pubic symphysis and pubic tubercle. At the same time, from the outside, the legs are strengthened by the so-called interpeduncular ligament, and from the inside, by a bent ligament.

inner hole, or deep inguinal ring (annulus inguinalis profundus), is a defect in the transverse fascia, located at the level of the lateral inguinal fossa.

The contents of the inguinal canal in men are the ilioinguinal nerve, the genital branch of the femoral-genital nerve and the spermatic cord. The latter is a collection of anatomical formations connected by loose fiber and covered with a vaginal membrane and a muscle that lifts the testicle. In the spermatic cord behind the vas deferens with a. cremasterica and veins, anterior to them are the testicular artery and the pampiniform venous plexus.

The contents of the inguinal canal in women are the ilioinguinal nerve, the genital branch of the femoral-genital nerve, the vaginal process of the peritoneum and the round ligament of the uterus.

It should be borne in mind that the inguinal canal is the exit point of two types of hernias: direct and oblique. In the event that the course of the hernial canal corresponds to the location of the inguinal canal, i.e. the mouth of the hernial sac is located in the lateral fossa, the hernia is called oblique. If the hernia comes out in the area of ​​the medial fossa, then it is called direct. It is also possible the formation of congenital hernias of the inguinal canal.

Rice. 15.6. inguinal canal:

1 - anterior wall of the inguinal canal (aponeurosis of the external oblique muscle of the abdomen); 2 - upper wall of the inguinal canal (lower edges of the internal oblique and transverse abdominal muscles; 3 - posterior wall of the inguinal canal (transverse fascia); 4 - lower wall of the inguinal canal (inguinal ligament); 5 - aponeurosis of the external oblique abdominal muscle; 6 - inguinal ligament ; 7 - internal oblique muscle of the abdomen; 8 - transverse abdominal muscle; 9 - transverse fascia; 10 - ilioinguinal nerve; 11 - genital branch of the femoral-genital nerve; 12 - spermatic cord; 13 - muscle that lifts the testicle; 14 - seed - efferent duct; 15 - external seminal fascia

15.2.4. Topography of blood vessels and nerves of the anterolateral abdominal wall

The blood vessels of the anterolateral abdominal wall are arranged in several layers. The branches of the femoral artery pass most superficially in the subcutaneous fatty tissue of the hypogastrium: the external pudendal, superficial epigastric and superficial arteries enveloping the ilium. Arteries accompany one or two veins of the same name. In the subcutaneous fatty tissue of the epigastrium, the thoracic vein (v. thoracoepigastrica) passes from top to bottom, which stretches to the umbilical region, where it merges with the superficial paraumbilical venous network. Thus, in the region of the navel, an anastomosis is formed between the system of the inferior vena cava (due to the superficial epigastric veins) and the superior vena cava (due to the thoracic vein).

Between the transverse and internal oblique muscles of the abdomen, there are intercostal arteries and veins belonging to 7-12 intercostal spaces.

Along the posterior wall of the sheath of the rectus abdominis muscle lie the inferior epigastric artery and vein (below the navel) and the superior epigastric vessels (above the navel). The former are branches of the external iliac arteries and veins, the latter are a direct continuation of the internal mammary arteries and veins. As a result of the connection of these veins in the navel, another anastomosis is formed between the system of the inferior vena cava (due to the inferior epigastric veins) and the superior vena cava (due to the superior epigastric veins).

In the umbilical region, from the inside, a round ligament of the liver is attached to the anterolateral abdominal wall, in the thickness of which there are paraumbilical veins that have a connection with the portal vein. As a result, so-called porto-caval anastomoses are formed in the umbilical region between the umbilical veins and the lower and superior epigastric veins (deep) and superficial epigastric veins (superficial). Of greater clinical importance is the superficial anastomosis: with portal hypertension, the saphenous veins increase sharply in size, this symptom is called the “jellyfish head”.

The innervation of the anterolateral abdominal wall is carried out by the lower 6 intercostal nerves. The trunks of the nerves are located between the transverse and internal oblique muscles, while the epigastrium is innervated by the 7th, 8th and 9th intercostal nerves, the stomach by 10th and 11th, the hypogastrium by the 12th intercostal nerve, which is called the hypochondrium.

15.3. DIAPHRAGM

The diaphragm is a domed septum that separates the chest cavity from the abdominal cavity. From the side of the chest cavity, it is covered with intrathoracic fascia and parietal pleura, from the side of the abdominal cavity - by intra-abdominal fascia and parietal peritoneum. Anatomical characteristic

Allocate tendon and muscle sections of the diaphragm. In the muscular section, three parts are distinguished according to the places of attachment of the diaphragm: sternal, costal and lumbar.

Rice. 15.7.Lower surface of the diaphragm:

1 - tendon part; 2 - sternal part; 3 - costal part; 4 - lumbar part; 5 - sternocostal triangle; 6 - lumbocostal triangle; 7 - opening of the inferior vena cava; 8 - esophageal opening; 9 - aortic opening; 10 - medial interpeduncular fissure; 11 - lateral interpeduncular fissure; 12 - aorta; 13 - esophagus; 14 - right vagus nerve; 15 - aorta; 16 - thoracic lymphatic duct; 17 - sympathetic trunk; 18 - unpaired vein; 19 - splanchnic nerves

Topography of apertures and diaphragm triangles

The sternocostal triangles are located in front between the sternum and costal parts, and the lumbocostal triangles are located behind. In these triangles, there are no muscle fibers and the sheets of the intra-abdominal and intra-thoracic fascia are in contact.

The lumbar part of the diaphragm forms three paired legs: medial, middle and lateral. The medial legs cross each other, as a result of which two openings are formed between them - the aortic (behind) and the esophageal (front). In this case, the muscle fibers surrounding the esophageal opening form the esophageal sphincter. The content of the remaining holes is shown in fig. 15.7.

15.4. OVERVIEW TOPOGRAPHY OF THE TOP FLOOR

ABDOMINAL CAVITY

The upper floor of the abdominal cavity is located from the diaphragm to the root of the mesentery of the transverse colon, the projection of which more or less coincides with the bicostal line.

Internal organs

In the upper floor of the abdominal cavity are the liver, gallbladder, stomach, spleen and part of the duodenum. Despite the fact that the pancreas lies in the retroperitoneal tissue, due to its topographical, clinical and functional proximity to the listed organs, it is also referred to as the organs of the upper floor of the abdominal cavity.

Peritoneal bags and ligaments

The peritoneum of the upper floor, covering the internal organs, forms three bags: hepatic, pregastric and omental. At the same time, depending on the degree of peritoneal coverage, intraperitoneal or intraperitoneal (on all sides), mesoperitoneally (on three sides) and retroperitoneally (on one side) located organs are isolated (Fig. 15.8).

The liver bag is limited medially by the falciform and round ligaments of the liver and consists of three sections. The suprahepatic region, or right subdiaphragmatic space, lies between the diaphragm and the liver, is the highest place in the abdominal cavity.

Rice. 15.8.Scheme of the sagittal cut of the abdomen:

1 - anterolateral abdominal wall; 2 - subphrenic space; 3 - liver; 4 - hepato-gastric ligament; 5 - subhepatic space; 6 - stomach; 7 - gastrocolic ligament; 8 - gland hole; 9 - pancreas; 10 - stuffing bag; 11 - mesentery of the transverse colon; 12 - transverse colon; 13 - a large gland; 14 - parietal peritoneum; 15 - loops of the small intestine and the mesentery of the small intestine

cavities. Air accumulates in this space when the internal organs are perforated. In front, it passes into the prehepatic fissure, which lies between the liver and the anterolateral wall of the abdomen. The prehepatic fissure from below passes into the subhepatic space located between the visceral surface of the liver and the underlying organs - part of the duodenum and the hepatic flexure of the colon. On the lateral side, the subhepatic space communicates with the right lateral canal. In the posteromedial part of the subhepatic space between the hepatoduodenal and hepatorenal ligaments, there is a slit-like gap - the omental, or Winslow, opening connecting the hepatic sac with the omental sac.

The stuffing bag occupies a rear-left position. Behind, it is limited by the parietal peritoneum, in front and laterally - by the stomach with its ligaments, medially - by the walls of the omental opening. This is a slit-like space that, apart from the omental opening, has no connection with the abdominal cavity. This fact explains the possibility of a long, asymptomatic course of an abscess located in the omental sac.

The pancreatic sac occupies an anterior-left position. Behind, it is limited by the stomach with its ligaments and partly by the spleen, in front - by the anterolateral wall of the abdomen. The upper part of the pancreatic sac is called the left subdiaphragmatic space. On the lateral side, the bag communicates with the left lateral canal.

Blood vessels

blood supplyorgans of the upper floor of the abdominal cavity (Fig. 15.9) is provided by the abdominal part of the descending aorta. At the level of the lower edge of the XII thoracic vertebrae, the celiac trunk departs from it, which almost immediately divides into its final branches: the left gastric, common hepatic and splenic arteries. The left gastric artery goes to the cardia of the stomach and then is located on the left half of the lesser curvature. The common hepatic artery gives off branches: to the duodenum - the gastroduodenal artery, to the stomach - the right gastric artery and then passes into its own hepatic artery, which supplies blood to the liver, gallbladder and bile ducts. The splenic artery runs almost horizontally to the left to the spleen, giving short branches to the stomach along the way.

Venous blood from the organs of the upper floor of the abdominal cavity flows into the portal vein (from all unpaired organs except the liver), which is directed to the portal of the liver, located in the hepatoduodenal ligament. Blood flows from the liver into the inferior vena cava.

Nerves and nerve plexuses

innervationthe upper floor of the abdominal cavity is carried out by the vagus nerves, the sympathetic trunk and celiac nerves. Along the entire course of the abdominal aorta is the abdominal aortic plexus, formed by sympathetic and parasympathetic branches. At the point of departure from the aorta of the celiac trunk, the celiac plexus is formed, which gives off branches,

Rice. 15.9.The upper floor of the abdominal cavity (from: Voilenko V.N. et al., 1965):

I - common hepatic artery; 2 - splenic artery; 3 - celiac trunk; 4 - left gastric artery and vein; 5 - spleen; 6 - stomach; 7 - left gastrocolic artery and vein; 8 - a large gland; 9 - right gastrocolic artery and vein; 10 - duodenum;

II - right gastric artery and vein; 12 - gastroduodenal artery and vein; 13 - common bile duct; 14 - inferior vena cava; 15 - portal vein; 16 - own hepatic artery; 17 - liver; 18 - gallbladder

spreading along with the branches of the celiac trunk. As a result, organ nerve plexuses (hepatic, splenic, renal) are formed near the organs, providing innervation of the corresponding organs. At the place of origin of the superior mesenteric artery is the superior mesenteric plexus, which is involved in the innervation of the stomach.

Groups of lymph nodes

lymphatic system the upper floor of the abdominal cavity is represented by lymphatic collectors that form the thoracic lymphatic duct, lymphatic vessels and nodes. It is possible to distinguish regional groups of lymph nodes that collect lymph from individual organs (right and left gastric, hepatic, splenic), and collectors that receive lymph from several organs. These include the celiac and aortic lymph nodes. From them, the lymph flows into the thoracic lymphatic duct, which is formed by the fusion of two lumbar lymphatic trunks.

15.5. CLINICAL ANATOMY OF THE STOMACH

Anatomical characteristic

The stomach is a hollow muscular organ in which the cardial part, fundus, body, and pyloric part are isolated. The wall of the stomach consists of 4 layers: mucous membrane, submucosa, muscular layer and peritoneum. The layers are interconnected in pairs, which allows them to be combined into cases: mucosubmucosal and serous-muscular (Fig. 15.10).

Topography of the stomach

Holotopia.The stomach is located in the left hypochondrium, partly in the epigastrium.

Skeletotopiastomach is extremely unstable and differs in the filled and emptied state. The entrance to the stomach is projected onto the point of connection with the sternum of the VI or VII costal cartilages. The pylorus is projected 2 cm to the right of the midline at the level of the VIII rib.

Syntopy.The anterior wall of the stomach is adjacent to the anterolateral abdominal wall. The greater curvature is in contact with the transverse

colon, small - with the left lobe of the liver. The back wall is in close contact with the pancreas and somewhat looser with the left kidney and adrenal gland.

Connective device. There are deep and superficial ligaments. Superficial ligaments are attached along the greater and lesser curvatures and are located in the frontal plane. These include the greater curvature of the gastroesophageal ligament, gastrodiaphragmatic ligament, gastrosplenic ligament, gastrocolic ligament. Along the lesser curvature are the hepatic-duodenal and hepatic-gastric ligaments, which, together with the gastro-phrenic ligament, are called the lesser omentum. Deep ligaments are attached to the back wall of the stomach. These are the gastro-pancreatic ligament and the pyloric-pancreatic ligament.

Rice. 15.10.Sections of the stomach and duodenum. Stomach: 1 - cardiac part; 2 - bottom; 3 - body; 4 - antral part; 5 - gatekeeper;

6 - gastroduodenal junction. Duodenum;

7 - upper horizontal part;

8 - descending part; 9 - lower horizontal part; 10 - ascending part

Blood supply and venous return

Blood supply.There are 5 sources of blood supply to the stomach. The right and left gastroepiploic arteries are located along the greater curvature, and the right and left gastric arteries are located along the lesser curvature. In addition, part of the cardia and the posterior wall of the body are powered by short gastric arteries (Fig. 15.11).

Venous bedThe stomach is divided into intraorganic and extraorganic parts. The intraorgan venous network is located in layers corresponding to the layers of the stomach wall. The extraorganic part basically corresponds to the arterial bed. Venous blood from the stomach

flows into the portal vein, but it should be remembered that in the region of the cardia there are anastomoses with the veins of the esophagus. Thus, a porto-caval venous anastomosis is formed in the region of the cardia of the stomach.

innervation

innervationThe stomach is carried out by branches of the vagus nerves (parasympathetic) and the celiac plexus.

Rice. 15.11.Arteries of the liver and stomach (from: Big Medical Encyclopedia. - T. 10. - 1959):

1 - cystic duct; 2 - common hepatic duct; 3 - own hepatic artery; 4 - gastroduodenal artery; 5 - common hepatic artery; 6 - lower phrenic artery; 7 - celiac trunk; 8 - posterior vagus nerve; 9 - left gastric artery; 10 - anterior vagus nerve; 11 - aorta; 12, 24 - splenic artery; 13 - spleen; 14 - pancreas; 15, 16 - left gastroepiploic artery and vein; 17 - lymph nodes of the gastroepiploic ligament; 18, 19 - right gastroepiploic vein and artery; 20 - a large gland; 21 - right gastric vein; 22 - liver; 23 - splenic vein; 25 - common bile duct; 26 - right gastric artery; 27 - portal vein

Lymph drainage. Similarly to the venous bed, the lymphatic system is also divided into intraorganic (along the layers of the wall) and extraorganic parts, corresponding to the course of the veins of the stomach. Regional lymph nodes for the stomach are the nodes of the lesser and greater omentum, as well as the nodes located at the gates of the spleen and along the celiac trunk (Fig. 15.12).

Rice. 15.12.Groups of lymph nodes of the upper floor of the abdominal cavity: 1 - hepatic nodes; 2 - celiac nodes; 3 - diaphragmatic nodes; 4 - left gastric nodes; 5 - splenic nodes; 6 - left gastro-omental nodes; 7 - right gastro-omental nodes; 8 - right gastric nodes; 9 - pyloric nodes; 10 - pancreatoduodenal nodes

15.6. CLINICAL ANATOMY OF THE LIVER AND BILE TRACT

Anatomical characteristic

Liveris a large parenchymal organ of a wedge-shaped or triangular flattened shape. It has two surfaces: the upper, or diaphragmatic, and the lower, or visceral. The liver is divided into right, left, quadrate and caudate lobes.

Topography of the liver

Tolotopia.The liver is located in the right hypochondrium, partly in the epigastrium and partly in the left hypochondrium.

Skeletotopia.The upper border of the projection of the liver on the abdominal wall corresponds to the height of the dome of the diaphragm on the right, while the lower one is extremely individual and can correspond to the edge of the costal arch or be higher or lower.

Syntopy.The diaphragmatic surface of the liver is closely adjacent to the diaphragm, through which it comes into contact with the right lung and partly with the heart. The junction of the diaphragmatic surface of the liver with the visceral posterior is called the posterior margin. It is devoid of a peritoneal cover, which makes it possible to speak of a non-peritoneal surface of the liver, or pars nuda. In this area, the aorta and especially the inferior vena cava closely adjoin the liver, which sometimes turns out to be immersed in the parenchyma of the organ. The visceral surface of the liver has a number of grooves and depressions, or impressions, the location of which is extremely individual and is laid down even in embryogenesis, the grooves are formed by passing vascular and ductal formations, and the depressions are formed by the underlying organs that press the liver up. There are right and left longitudinal furrows and a transverse furrow. The right longitudinal sulcus contains the gallbladder and the inferior vena cava, the left longitudinal contains the round and venous ligaments of the liver, the transverse sulcus is called the gates of the liver and is the site of penetration into the organ of the branches of the portal vein, the proper hepatic artery and the exit of the hepatic ducts (right and left). On the left lobe, you can find an impression from the stomach and esophagus, on the right - from the duodenum, stomach, colon and right kidney with the adrenal gland.

Ligament apparatus represented by places of transition of the peritoneum from the liver to other organs and anatomical formations. On the diaphragmatic surface, the hepaphrenic ligament is isolated,

consisting of longitudinal (crescent ligament) and transverse (coronary ligament with right and left triangular ligaments) parts. This ligament is one of the main elements of liver fixation. On the visceral surface are the hepatoduodenal and hepatogastric ligaments, which are duplications of the peritoneum with vessels, nerve plexuses and fiber located inside. These two ligaments, along with the gastrophrenic ligament, make up the lesser omentum.

Blood enters the liver through two vessels - the portal vein and its own hepatic artery. The portal vein is formed by the confluence of the superior and inferior mesenteric veins with the splenic vein. As a result, the portal vein carries blood from the unpaired organs of the abdominal cavity - the small and large intestines, stomach, and spleen. The proper hepatic artery is one of the terminal branches of the common hepatic artery (the first branch of the celiac trunk). The portal vein and own hepatic artery are located in the thickness of the hepatoduodenal ligament, while the vein occupies an intermediate position between the arterial trunk and the common bile duct.

Not far from the gates of the liver, these vessels are each divided into two of their final branches - the right and left, which penetrate the liver and are divided into smaller branches. The bile ducts are located parallel to the vessels in the liver parenchyma. The proximity and parallelism of these vessels and ducts made it possible to distinguish them into a functional group, the so-called Glisson triad, the branches of which ensure the functioning of a strictly defined section of the liver parenchyma, isolated from others, called a segment. Liver segment - a section of the liver parenchyma in which the segmental branch of the portal vein branches, as well as the corresponding branch of its own hepatic artery and segmental bile duct. Currently, the division of the liver according to Couinaud is accepted, according to which 8 segments are distinguished (Fig. 15.13).

Venous outflowfrom the liver is carried out through the system of hepatic veins, the course of which does not correspond to the location of the elements of the Glisson triad. The features of the hepatic veins are the absence of valves and a strong connection with the connective tissue stroma of the organ, as a result of which these veins do not collapse when damaged. In the amount of 2-5, these veins open with mouths into the inferior vena cava passing behind the liver.

Rice. 15.13.Ligaments and segments of the liver: 1 - right triangular ligament; 2 - right coronary ligament; 3 - left coronary ligament; 4 - triangular ligament; 5 - crescent ligament; 6 - round ligament of the liver; 7 - gate of the liver; 8 - hepatoduodenal ligament; 9 - venous ligament. I-VIII - liver segments

Topography of the gallbladder

gallbladderis a hollow muscular organ in which the bottom, body and neck are isolated, through which the bladder is connected through the cystic duct with the rest of the bile duct components.

Tolotopia.The gallbladder is located in the right hypochondrium.

Skeletotopia.The projection of the bottom of the gallbladder corresponds to the point of intersection of the costal arch and the outer edge of the rectus abdominis muscle.

Syntopy.The upper wall of the gallbladder is closely adjacent to the visceral surface of the liver, in which a cystic fossa of the appropriate size is formed. Sometimes the gallbladder is, as it were, embedded in the parenchyma. Much more often, the lower wall of the gallbladder is in contact with the transverse colon (sometimes with the duodenum and stomach).

blood supplygallbladder is carried out by the cystic artery, which, as a rule, is a branch of the right hepatic artery. Given that its course is very variable, in practice, Callot's triangle is used to detect the cystic artery. The walls of this triangle are

Rice. 15.14.Extrahepatic bile ducts: 1 - right hepatic duct; 2 - left hepatic duct; 3 - common hepatic duct; 4 - cystic duct; 5 - common bile duct; 6 - supraduodenal part of the common bile duct; 7 - retroduodenal part of the common bile duct; 8 - pancreatic part of the common bile duct; 9 - intramural part of the common bile duct

cystic duct, common bile duct and cystic artery. The blood from the bladder flows through the cystic vein into the right branch of the portal vein.

Topography of the bile ducts

bile ductsare hollow tubular organs that provide the passage of bile from the liver into the duodenum. Directly at the gates of the liver are the right and left hepatic ducts, which, merging, form the common hepatic duct. Merging with the cystic duct, the latter forms the common bile duct, which, located in the thickness of the hepatoduodenal ligament, opens into the lumen of the duodenum with a large papilla. Topographically, the following parts of the common bile duct are distinguished (Fig. 15.14): supraduodenal (the duct is located in the hepatoduodenal ligament, occupying the extreme right position in relation to the portal vein and hepatic artery), retroduodenal (the duct is located behind the upper horizontal part of the duodenum), pancreatic (the duct is located behind the head of the pancreas, sometimes it turns out to be embedded in the parenchyma of the gland) and intramural (the duct passes through the wall of the duodenum and opens in the papilla). In the latter part, the common bile duct usually joins with the common pancreatic duct.

15.7. CLINICAL ANATOMY OF THE PANCREAS

Anatomical characteristic

The pancreas is a parenchymal organ of an elongated shape, in which the head, body and tail are isolated.

(Fig. 15.15).

Tolotopia.The pancreas is projected onto the epigastric and partially left hypochondrium.

Skeletotopia.The body of the gland is usually located at the level of the second lumbar vertebra. The head lies lower, and the tail is 1 vertebra higher.

Syntopy.The head of the gland from above, below and on the right is closely adjacent to the bend of the duodenum. Behind the head are the aorta and the inferior vena cava, and on top of the back surface -

the beginning of the portal vein. Anterior to the gland, separated from it by a stuffing box, lies the stomach. The back wall of the stomach adjoins the gland quite tightly, and if ulcers or tumors appear on it, the pathological process often passes to the pancreas (in these cases, one speaks of ulcer penetration or tumor germination into the gland). The tail of the pancreas comes very close to the hilum of the spleen and may be damaged when the spleen is removed.

Rice. 15.15.Topography of the pancreas (from: Sinelnikov R.D., 1979): 1 - spleen; 2 - gastro-splenic ligament; 3 - tail of the pancreas; 4 - jejunum; 5 - ascending duodenum; 6 - head of the pancreas; 7 - left common colic artery; 8 - left common colonic vein; 9 - horizontal part of the duodenum; 10 - lower bend of the duodenum; 11 - root of the mesentery; 12 - descending part of the duodenum; 13 - upper pancreatoduodenal artery; 14 - upper part of the duodenum; 15 - portal vein; 16 - own hepatic artery; 17 - inferior vena cava; 18 - aorta; 19 - celiac trunk; 20 - splenic artery

Blood supply and venous outflow. Three sources take part in the blood supply of the gland: the celiac trunk (through the gastroduodenal artery) and the superior mesenteric artery mainly provide blood supply to the head and body of the gland; the body and tail of the gland receive blood from the short pancreatic branches of the splenic artery. Venous blood is drained into the splenic and superior mesenteric veins (Fig. 15.16).

Rice. 15.16.Arteries of the pancreas, duodenum and spleen (from: Sinelnikov R.D., 1979):

I - inferior vena cava vein; 2 - common hepatic artery; 3 - splenic artery; 4 - left gastric artery; 5 - left gastroepiploic artery; 6 - short gastric arteries; 7 - aorta; 8 - splenic artery; 9 - splenic vein; 10 - upper pancreatoduodenal artery;

II - gastroduodenal artery; 12 - portal vein; 13 - right gastric artery; 14 - own hepatic artery; 15 - right gastroepiploic artery

15.8. REVIEW TOPOGRAPHY OF THE LOWER FLOOR OF THE ABDOMINAL CAVITY

Internal organs

The lower floor of the abdominal cavity is located from the root of the mesentery of the transverse colon to the borderline, i.e. entrance to the pelvic cavity. The small and large intestines lie on this floor, while the peritoneum covers them differently, as a result of which a number of depressions - canals, sinuses, pockets - are formed at the transition points of the visceral peritoneum to the parietal and when the peritoneum passes from organ to organ. The practical significance of these recesses is the possibility of spreading (channels) or, conversely, delimitation (sinuses, pockets) of a purulent pathological process, as well as the possibility of forming internal hernias (pockets) (Fig. 15.17).

The root of the mesentery of the small intestine is a duplication of the peritoneum with cellular tissue, vessels and nerves located inside. It is located obliquely: from top to bottom, from left to right, starting at the level of the left half of the II lumbar vertebra and ending in the right iliac fossa. On its way, it crosses the duodenum (final section), abdominal aorta, inferior vena cava, right ureter. In its thickness passes the superior mesenteric artery with its branches and the superior mesenteric vein.

Peritoneal sinuses and pockets

Right mesenteric sinus it is bounded from above by the mesentery of the transverse colon, to the left and below by the root of the mesentery of the small intestine, to the right by the inner wall of the ascending colon.

Left mesenteric sinus bounded above by the root of the mesentery of the small intestine, below - by the terminal line, on the left - by the inner wall of the descending colon.

Rice. 15.17.Channels and sinuses of the lower floor of the abdominal cavity: 1 - right side channel; 2 - left side channel; 3 - right mesenteric sinus; 4 - left mesenteric sinus

Right side channel located between the ascending colon and the anterolateral wall of the abdomen. Through this channel, communication between the hepatic sac and the right iliac fossa is possible, i.e. between the upper and lower abdomen.

Left side channel lies between the anterolateral wall of the abdomen and the descending colon. In the upper part of the canal there is a diaphragmatic-colic ligament, which closes the canal from above in 25% of people. Through this channel, communication is possible (if the ligament is not expressed) between the left iliac fossa and the pregastric sac.

Peritoneal pockets. In the region of the duodenal-jejunal flexure, there is Treitz's pouch, or recessus duodenojejunalis. Its clinical significance lies in the possibility of true internal hernias occurring here.

In the region of the ileocecal junction, three pockets can be found: the upper and lower ileocecal pockets, located above and below the junction, respectively, and the retrocecal pocket, which lies behind the caecum. These pockets require special attention from the surgeon when performing an appendectomy.

Between the loops of the sigmoid colon is the intersigmoid pocket (recessus intersigmoideus). Internal hernias may also occur in this pocket.

Blood vessels (Fig. 15.18). At the level of the body of the first lumbar vertebra, the superior mesenteric artery departs from the abdominal aorta. It enters the root of the mesentery of the small intestine and branches into its own

Rice. 15.18.Branches of the superior and inferior mesenteric arteries: 1 - superior mesenteric artery; 2 - middle colon artery; 3 - right colon artery; 4 - ileocecal artery; 5 - artery of the appendix; 6 - jejunal arteries; 7 - ileal arteries; 8 - inferior mesenteric artery; 9 - left colic artery; 10 - sigmoid arteries; 11 - superior rectal artery

Rice. 15.19.The portal vein and its tributaries (from: Sinelnikov R.D., 1979).

I - esophageal veins; 2 - left branch of the portal vein; 3 - left gastric vein; 4 - right gastric vein; 5 - short gastric veins; 6 - splenic vein; 7 - left gastroepiploic vein; 8 - veins of the omentum; 9 - left renal vein; 10 - place of anastomosis of the middle and left colonic veins;

II - left colonic vein; 12 - inferior mesenteric vein; 13 - jejunal veins; 14, 23 - common iliac veins; 15 - sigmoid vein; 16 - superior rectal vein; 17 - internal iliac vein; 18 - external iliac vein; 19 - middle rectal vein; 20 - lower rectal vein; 21 - rectal venous plexus; 22 - vein of the appendix; 24 - iliac-colic vein; 25 - right colonic vein; 26 - middle colic vein; 27 - superior mesenteric vein; 28 - pancreatoduodenal vein; 29 - right gastroepiploic vein; 30 - paraumbilical veins; 31 - portal vein; 32 - right branch of the portal vein; 33 - venous capillaries of the liver; 34 - hepatic veins

end branches. At the level of the lower edge of the body of the III lumbar vertebra, the inferior mesenteric artery departs from the aorta. It is located retroperitoneally and gives branches to the descending colon, sigmoid and rectum.

Venous blood from the organs of the lower floor flows into the superior and inferior mesenteric veins, which, merging with the splenic vein, form the portal vein (Fig. 15.19).

Nerve plexuses

Nerve plexuses the lower floor is represented by parts of the aortic plexus: at the level of the origin of the superior mesenteric artery, the superior mesenteric plexus is located, at the level of the origin of the inferior mesenteric, the inferior mesenteric plexus, between which lies the intermesenteric plexus. Above the entrance to the small pelvis, the lower mesenteric plexus passes into the upper hypogastric plexus. These plexuses provide innervation of the small and large intestine.

Groups of lymph nodes

lymphatic system The small intestine is similar to the arterial one and is represented by several rows of lymph nodes. The first row is located along the marginal artery, the second - next to the intermediate arcades. The third group of lymph nodes lies along the superior mesenteric artery and is common to the small and part of the large intestine. The lymphatic system of the large intestine also consists of several rows, the first lying along the mesenteric edge of the intestine. In this row, groups of lymph nodes of the blind, ascending, transverse colon, descending colon and sigmoid colon are distinguished. At the level of the arcades lies the second row of lymph nodes. Finally, along the trunk of the inferior mesenteric artery lies the third row of lymph nodes. At level II of the lumbar vertebrae, the formation of the thoracic lymphatic duct occurs.

15.9. CLINICAL ANATOMY OF THE FINE

AND COLON

The large and small intestines are hollow muscular tubular organs, the wall of which consists of 4 layers: mucous membrane, submucosa, muscular and serous membranes. Layers

combined into cases similar to the structure of the stomach wall. The small intestine is divided into three sections: the duodenum, jejunum, and ileum. The large intestine is divided into 4 parts: the caecum, colon, sigmoid colon and rectum.

During abdominal surgery, it is often necessary to distinguish the small intestine from the large intestine. Allocate the main and additional features that allow you to distinguish one gut from another.

The main features: in the wall of the colon, the longitudinal layer of muscle fibers is located unevenly, it is combined into three longitudinal ribbons; between the ribbons, the wall of the intestine protrudes outward; between the protrusions of the wall there are constrictions, which cause the unevenness of the colon wall. Additional signs: the large intestine normally has a larger diameter than the small intestine; the wall of the large intestine has a grayish-green color, the wall of the small intestine is pink; arteries and veins of the large intestine rarely form a developed network of arcades, in contrast to the arteries of the small intestine.

15.9.1 Duodenum

The duodenum is a hollow muscular organ with 4 sections: upper horizontal, descending, lower horizontal and ascending.

Tolotopia.The duodenum is located mainly in the epigastric and partly in the umbilical region.

Skeletotopia.The shape and length of the intestine can be different, its upper edge is located at the level of the upper edge of the 1st lumbar vertebra, the lower one - at the level of the middle of the 4th lumbar vertebra.

Syntopy.The root of the mesentery of the transverse colon passes horizontally through the middle of the descending part of the duodenum. The inner-left surface of the duodenum is closely connected with the pancreas, the Vater nipple is also located there - the place where the common bile and pancreatic ducts flow into the intestine. The outer right wall of the intestine is adjacent to the right kidney. The upper wall of the intestinal ampulla forms a corresponding impression on the visceral surface of the liver.

Connective device. Most of the intestine is fixed to the back wall of the abdomen, however, the initial and final sections lie freely and are held by ligaments. The ampoule is supported by the hepatoduodenal and duodenal ligaments. Finite

department, or flexura duodenojejunal,fixed with the Treitz ligament, which, unlike other ligaments, has a muscle in its thickness - m. suspensorius duodeni.

blood supplyThe duodenum is provided by two arterial arches - anterior and posterior. The upper part of these arches is formed by the branches of the gastroduodenal artery, and the lower part by the branches of the superior mesenteric artery. Venous vessels are arranged similarly to arteries.

innervationThe duodenum is carried out mainly by the vagus nerves and the celiac plexus.

Lymph drainage.The main lymphatic vessels are located along with the blood vessels. Regional lymph nodes are nodes located in the gates of the liver and in the root of the mesentery of the small intestine.

15.9.2. The jejunum and ileum

Tolotopia.The jejunum and ileum can be found in the mesogastric and hypogastric regions.

Skeletotopia.The small intestine is unstable in its position, only its beginning and end are fixed, the projection of which corresponds to the projection of the beginning and end of the root of the mesentery of the small intestine.

Syntopy.In the lower floor of the abdominal cavity, the jejunum and ileum are located in the central part. Behind them lie the organs of the retroperitoneal space, in front - a large omentum. On the right are the ascending colon, cecum and appendix, on top is the transverse colon, on the left is the descending colon, which passes into the sigmoid colon from below.

blood supplyjejunum and ileum is carried out at the expense of the superior mesenteric artery, which gives rise to the jejunal and ileo-intestinal arteries (total number 11-16). Each of these arteries divides according to the type of bifurcation, and the resulting branches merge with each other, forming a system of collaterals called arcades. The last row of arcades is located next to the wall of the small intestine and is called a parallel or marginal vessel. Direct arteries run from it to the intestinal wall, each of which supplies blood to a certain part of the small intestine. Venous vessels are located similarly to arterial ones. Venous blood flows into the superior mesenteric vein.

innervationThe small intestine is carried by the superior mesenteric plexus.

Lymph drainagefrom the jejunum and ileum goes to the mesenteric lymph nodes, then to the lymph nodes along the aorta and the inferior vena cava. Part of the lymphatic vessels opens directly into the thoracic lymphatic duct.

15.9.3. Cecum

The caecum is located in the right iliac fossa. In the lower part of the intestine lies the appendix, or appendix.

Tolotopia.The caecum and appendix, as a rule, are projected onto the right ilio-inguinal region, however, the appendix can have a very different position and direction - from the suprapubic to the right lateral or even subcostal region. During the operation, muscle bands of the caecum are used to search for the appendix - the mouth of the appendix is ​​located at the junction of all three bands with each other.

Skeletotopiathe cecum, as well as the colon, is individual. As a rule, the caecum is located in the right iliac fossa.

Syntopy.On the inside, the terminal ileum is adjacent to the caecum. At the point of transition of the ileum into the blind is the so-called ileocecal valve, or valve. In the upper part of the caecum passes into the ascending colon.

blood supplyThe cecum, as well as the appendix, is carried out due to the last branch of the superior mesenteric artery - the ileocolic artery, which, in turn, approaching the ileocecal junction, is divided into the ascending branch, the anterior and posterior caecal arteries and the artery of the appendix. Venous vessels are located similarly to arterial ones (Fig. 15.20).

innervationcaecum and appendix is ​​carried out due to the mesenteric plexus.

Lymph drainage.The regional lymph nodes for the caecum and appendix are those located along the superior mesenteric vessels.

Rice. 15.20.Parts and blood vessels of the ileocecal angle: 1 - ileum; 2 - appendix; 3 - caecum; 4 - ascending colon; 5 - upper ileo-caecal pocket of the peritoneum; 6 - lower ileo-caecal pocket of the peritoneum; 7 - mesentery of the appendix; 8 - anterior band of the colon; 9 - upper cusp of the ileocecal valve; 10 - lower sash; 11 - superior mesenteric artery and vein; 12 - artery and vein of the appendix

15.9.4. Colon

The ascending, transverse, descending and sigmoid colons are distinguished. The transverse colon is covered with peritoneum on all sides, has a mesentery and is located on the border of the upper and lower floors. The ascending and descending colon is covered by the peritoneum mesoperitoneally and is rigidly fixed in the abdominal cavity. The sigmoid colon is located in the left iliac fossa, covered with peritoneum on all sides and has a mesentery. Behind the mesentery is the intersigmoid pocket.

blood supplyThe colon is carried out by the superior and inferior mesenteric arteries.

innervationthe colon is provided by branches of the mesenteric plexus.

Lymph drainageis carried out in the nodes located along the mesenteric vessels, aorta and inferior vena cava.

15.10. OVERVIEW TOPOGRAPHY OF THE RETROPERITONEAL

SPACES

Retroperitoneal space - a cellular space with organs, vessels and nerves located in it, constituting the posterior part of the abdominal cavity, bounded in front by the parietal peritoneum, behind - by the intra-abdominal fascia covering the spinal column and muscles of the lumbar regions, extending from top to bottom from the diaphragm to the entrance to the small pelvis. On the sides, the retroperitoneal space passes into the preperitoneal tissue. In the retroperitoneal space, a median section and two lateral ones are distinguished. In the lateral part of the retroperitoneal space are the adrenal glands, kidneys, ureters. In the middle part, the abdominal aorta, the inferior vena cava pass, and the nerve plexuses are located.

Fascia and cellular spaces

The retroperitoneal fascia divides the retroperitoneal space into cellular layers, the first of which is the retroperitoneal tissue itself, which is limited by the intra-abdominal fascia at the back and the retroperitoneal fascia at the front (Fig. 15.21, 15.22). This layer is a continuation of the preperitoneal tissue, upward it passes into the tissue of the subdiaphragmatic space, downward into the tissue of the small pelvis.

At the outer edge of the kidney, the retroperitoneal fascia divides into two sheets, which are called the prerenal and retrorenal fascia. These leaves between themselves limit the next cellular layer - perirenal fiber. The fatty tissue of this layer surrounds the kidneys on all sides, extends upward, covering the adrenal gland, and downwards passes into the periureteral tissue and then connects to the tissue of the small pelvis.

In the medial direction, the retrorenal fascia grows together with the intra-abdominal fascia, as well as with the periosteum of the XI-XII ribs, thus, the retroperitoneal cellular layer itself becomes thinner and disappears. The prerenal fascia runs behind

duodenum and pancreas and connects to the same fascia of the opposite side. Between these organs and the prerenal fascia, slit-like spaces remain, containing loose, unformed connective tissue.

Behind the ascending and descending sections of the colon there is a retrocolic fascia (Toldt's fascia), which limits the third cellular layer in front - the pericolonic cellulose. Posteriorly, the paracolic tissue is limited by the prerenal fascia.

These cellular spaces are the place of origin and distribution of purulent processes. Due to the presence of nerve plexuses in the cellular spaces, local blockades for pain relief play an important clinical role.

Rice. 15.21.Scheme of the retroperitoneal space in a horizontal section: 1 - skin; 2 - subcutaneous fatty tissue; 3 - superficial fascia; 4 - own fascia; 5 - tendon of the latissimus dorsi muscle; 6 - the latissimus dorsi muscle; 7 - muscle that straightens the spine; 8 - external oblique, internal oblique and transverse abdominal muscles; 9 - square muscle; 10 - large lumbar muscle; 11 - intra-abdominal fascia; 12 - retroperitoneal fascia; 13 - preperitoneal fiber; 14 - left kidney; 15 - perirenal fiber; 16 - paracolic tissue; 17 - ascending and descending colon; 18 - aorta; 19 - inferior vena cava; 20 - parietal peritoneum

Rice. 15.22.Scheme of the retroperitoneal space on the sagittal section: - intra-abdominal fascia; 2 - own retroperitoneal cellular layer; 3 - retrorenal fascia; 4 - perirenal cellular layer; 5 - prerenal fascia; 6 - kidney; 7 - ureter; 8 - periureteral cellular layer; 9 - paracolic cellular layer; 10 - ascending colon; 11 - visceral peritoneum

15.11. CLINICAL ANATOMY OF THE KIDNEYS

Anatomical characteristic

External building. The kidneys are located in the lateral part of the retroperitoneal space on the sides of the spinal column. They distinguish the anterior and posterior surfaces, the outer convex and inner concave edges. On the inner edge there is a gate of the kidney, which includes the renal pedicle. The renal pedicle consists of the renal artery, renal vein, pelvis, renal plexus and lymphatic vessels, which are interrupted in the renal lymph nodes. The topography of the elements of the renal pedicle is as follows: the renal vein occupies the anterior position, the renal artery is posterior to it, and the renal pelvis follows the artery. The kidney parenchyma is divided into segments.

segmental structure. The anatomical basis for dividing the kidney into segments is the branching of the renal artery. The most common variant is the division into 5 segments: 1st - upper, 2nd - anterior superior, 3rd - anteroinferior, 4th - inferior and 5th - posterior. Between the first 4 segments and the 5th segment there is a line of natural divisibility of the kidney. The kidneys are surrounded by three membranes. The first, fibrous capsule of the kidney, is adjacent to the parenchyma, with which it is loosely connected, which makes it possible to separate it in a blunt way. Second capsule

Adipose - formed by perirenal adipose tissue. Third capsule - fascial

It is formed by sheets of pre- and retrorenal fascia. In addition to these three capsules, the renal stalk, muscle bed and intra-abdominal pressure are referred to the fixing apparatus of the kidneys.

Topography of the kidneys

Skeletotopia(Fig. 15.23). Skeletotopically, the kidneys are projected at the level of the XI thoracic to the I lumbar vertebrae on the left and at the level of the XII thoracic - II lumbar vertebrae on the right. XII rib crosses the left

Rice. 15.23.Skeletotopia of the kidneys (front view)

kidney in the middle, and the right kidney - at the level of the upper and middle thirds. On the anterior abdominal wall, the kidneys are projected into the epigastric region proper, hypochondrium and lateral regions. The hilum of the kidney is projected from the front to the intersection of the outer edge of the rectus abdominis muscle with the line connecting the ends of the XI ribs. Behind the gate are projected in the corner between the extensor of the back and the XII rib.

Syntopy.Syntopy of the kidneys is complex, while the kidneys are in contact with the surrounding organs through their membranes and adjacent fiber. So, the right kidney from above borders on the liver and the right adrenal gland, on the left - on the descending section of the duodenum and the inferior vena cava, in front - on the ascending section of the colon and loops of the small intestine. The left kidney is in contact with the adrenal gland from above, in front - with the tail of the pancreas, the descending colon, on the right - with the abdominal aorta. Behind both kidneys lie in a bed formed by the muscles of the lumbar region.

Holotopia.The longitudinal axes of the kidneys form an angle open downwards, in addition, in the horizontal plane, the kidneys form an angle open anteriorly. Thus, the gates of the kidneys are directed downward and anteriorly.

Blood supply and venous return

The kidneys are supplied with blood by the renal arteries, which are branches of the abdominal aorta. The right renal artery is shorter than the left and passes behind the inferior vena cava and the descending duodenum. The left renal artery runs behind the tail of the pancreas. Before entering the kidney, the inferior adrenal arteries depart from the arteries. At the gates of the kidneys, the arteries are divided into anterior and posterior branches, the anterior, in turn, is divided into 4 segmental branches. In 20% of cases, the kidneys receive additional blood supply from additional branches that extend either from the abdominal aorta itself or from its branches. Accessory arteries most often enter the parenchyma at the poles. Venous outflow occurs through the renal veins into the inferior vena cava. On its way, the testicular (ovarian) vein flows into the left renal vein.

The kidneys are innervated by the renal plexus, which is localized along the course of the renal artery.

The lymphatic vessels of the kidneys flow into the lymph nodes of the renal gate, and then into the nodes along the aorta and inferior vena cava.

15.12. URETER

The ureters start from the pelvis and end with the flow into the bladder. They are a hollow muscular organ with a typical wall structure. The length of the ureter is 28-32 cm, the diameter is 0.4-1 cm. There are two sections of the ureter: abdominal and pelvic, the boundary between them is the boundary line. There are three constrictions along the ureter. The first constriction is located at the junction of the pelvis with the ureter, the second at the level of the borderline, and the third at the confluence of the ureter with the bladder.

The projection of the ureters on the anterior abdominal wall corresponds to the outer edge of the rectus abdominis muscle. The syntopic relations of the ureters, as well as those of the kidneys, are mediated by the fatty tissue surrounding them. The inferior vena cava passes medially from the right ureter, and the ascending colon passes laterally. The abdominal aorta passes medially from the left ureter, and the descending colon passes outwards. Both ureters are crossed anteriorly by the gonadal vessels. In the cavity of the small pelvis, the internal iliac artery is adjacent to the ureters behind the ureters. In addition, in women, the ureters posteriorly cross the uterine appendages.

The ureters are supplied with blood in the upper part by the branches of the renal artery, in the middle third by the testicular or ovarian artery, in the lower third by the vesical arteries. Innervation is carried out from the renal, lumbar and cystic plexuses.

15.13. ADRENAL

The adrenal glands are paired endocrine glands located in the upper part of the retroperitoneal space. The adrenal glands can be crescent-shaped, U-shaped, oval, and hat-shaped. The right adrenal gland is located between the liver and the lumbar part of the diaphragm, while between the gland and the upper pole of the right kidney there is a layer of fatty tissue up to 3 cm thick. The position of the left adrenal gland is more variable: it can be located above the upper pole of the left kidney, it can move closer to its lateral edge , as well as descend on the renal pedicle. The blood supply to the adrenal glands comes from three main sources: the superior adrenal artery (a branch of the inferior phrenic artery), the middle

adrenal artery (branch of the abdominal aorta) and inferior adrenal artery (branch of the renal artery). Venous outflow goes to the central vein of the adrenal gland and then to the inferior vena cava. The glands are innervated by the adrenal plexus. The glands consist of a cortical and medulla and produce a number of hormones. The cortex produces glucocorticoids, mineralocorticoids, and androgens, and adrenaline and norepinephrine are synthesized in the medulla.

15.14. LAPAROTOMY

Laparotomy is an operative access to the organs of the abdominal cavity, carried out by layer-by-layer dissection of the anterolateral abdominal wall and opening the peritoneal cavity.

There are different types of laparotomy: longitudinal, transverse, oblique, combined, thoracolaparotomy (Fig. 15.24). When choosing an access, they are guided by the requirements for incisions of the abdominal wall, which must correspond to the projection of the organ, it is enough to expose the organ, be less traumatic and form a strong postoperative scar.

Longitudinal incisions include median incisions (upper median, middle median and lower median laparotomy), transrectal, pararectal, longitudinal lateral. The most commonly used median incisions in the clinic are characterized by minimal tissue trauma, mild bleeding, no muscle damage, and wide

Rice. 15.24.Types of laparotomic incisions:

1 - upper median laparotomy;

2 - incision in the right hypochondrium according to Fedorov; 3 - pararectal incision; 4 - according to Volkovich-Dyakonov; 5 - lower median laparotomy

access to the abdominal organs. But in a number of clinical cases, longitudinal median approaches cannot provide a full operational review. Then they resort to others, including more traumatic combined accesses. When performing pararectal, oblique, transverse and combined approaches, the surgeon necessarily crosses the muscles of the anterolateral abdominal wall, which can lead to their partial atrophy and, as a result, the occurrence of postoperative complications, such as postoperative hernias.

15.15. HERNISECTION

A hernia is a protrusion of the abdominal organs covered with the peritoneum through a congenital or acquired defect in the muscular-aponeurotic layers of the abdominal wall. The components of a hernia are the hernial orifice, hernial sac and hernial contents. Hernial orifice is understood as a natural or pathological opening in the muscular-aponeurotic layer of the abdominal wall, through which the hernial protrusion emerges. The hernial sac is a part of the parietal peritoneum that protrudes through the hernial orifice. Organs, parts of organs and tissues located in the cavity of the hernial sac are called hernial contents.

Rice. 15.25.Stages of isolation of the hernial sac in oblique inguinal hernia: a - the aponeurosis of the external oblique muscle of the abdomen is exposed; b - the hernial sac is highlighted; 1 - aponeurosis of the external oblique muscle of the abdomen; 2 - spermatic cord; 3 - hernial sac

In clinical practice, the most common are inguinal, femoral, and umbilical hernias.

With inguinal hernias, under the action of a hernial protrusion, the walls of the inguinal canal are destroyed, and the hernial sac with the contents comes out under the skin above the inguinal ligament. Hernial contents, as a rule, are loops of the small intestine or a large omentum. Allocate direct and oblique inguinal hernia. If the posterior wall of the inguinal canal is destroyed, then the hernial sac follows the shortest path, and the hernial ring is located in the medial inguinal fossa. Such a hernia is called direct. With an oblique inguinal hernia, the gate is located in the lateral inguinal fossa, the hernial sac enters through the deep inguinal ring, passes through the entire canal and, destroying its front wall, exits through the superficial ring under the skin. Depending on the nature of the hernia - direct or oblique - there are various methods of its surgical treatment. With a direct inguinal hernia, it is advisable to strengthen the posterior wall, with an oblique one, the anterior wall of the inguinal canal.

With a femoral hernia, its gates are located under the inguinal ligament, and the hernial sac goes under the skin through a muscular or vascular lacuna.

An umbilical hernia is characterized by the appearance of a protrusion in the umbilical region; usually purchased.

15.16. OPERATIONS ON THE STOMACH

Gastrotomy- the operation of opening the lumen of the stomach with the subsequent closure of this incision.

Indications for surgery: difficulty in diagnosis and clarification of the diagnosis, solitary polyps of the stomach, infringement in the pyloric zone of the gastric mucosa, foreign bodies, bleeding ulcers in debilitated patients.

Operation technique. Access is carried out by upper median laparotomy. At the border of the middle and lower thirds on the anterior wall, an incision is made in the stomach wall through all layers 5-6 cm long, parallel to the longitudinal axis of the organ. The edges of the wound are bred with hooks, the contents of the stomach are sucked off, and its mucous membrane is examined. If a pathology (polyp, ulcer, bleeding) is detected, the necessary manipulations are performed. After that, the gastrotomy wound is sutured with a two-row suture.

gastrostomy- an operation to create an external fistula of the stomach for the purpose of artificial feeding of the patient.

Indications for surgery: cicatricial, tumor stenosis of the esophagus, severe traumatic brain injury, bulbar disorders requiring long-term artificial nutrition of the patient.

Operation technique. The entrance to the abdominal cavity is carried out by a left-sided transrectal laparotomy. The anterior wall of the stomach is brought out into the wound, and in the middle of the distance between the greater and lesser curvature along the longitudinal axis of the stomach, a rubber tube is applied to the stomach wall, the end of which should be directed to the cardial part. Folds are formed around the tube from the wall of the stomach, which are fixed with several serous-muscular sutures. A purse-string suture is applied at the last suture, an incision is made in the center and the end of the probe is inserted into the stomach. The purse-string suture is tightened, and the folds of the wall are sewn over the tube. The proximal end of the tube is brought out through the surgical wound, and the stomach wall is sutured to the parietal peritoneum with interrupted gray-serous sutures. The surgical wound is sutured in layers.

Gastroenterostomy - operation on imposing of an anastomosis between a stomach and a small bowel.

Indications for surgery: inoperable cancer of the antrum of the stomach, cicatricial stenosis of the pylorus and duodenum.

Operation technique. Creating an anastomosis of the stomach with the small intestine can be performed in various ways: behind or in front of the colon, and also depending on which wall of the stomach - anterior or posterior - the small intestine is sutured. The most commonly used are the anterior precolic and posterior retrocolic variants.

Anterior precolon gastroenterostomy (according to Welfler) is performed from the upper median laparotomy. After opening the abdominal cavity, a duodeno-jejunal flexure is found and a loop of jejunum is taken at a distance of 20-25 cm from it, which is placed next to the stomach above the transverse colon and greater omentum. The bowel loop should be located isoperistaltically with the stomach. Next, an anastomosis is applied between them according to the side-to-side type with a two-row suture. To improve the passage of food between the afferent and efferent loops of the small intestine, a second side-to-side anastomosis is applied according to Brown. The operation is completed by layer-by-layer suturing of the abdominal cavity tightly.

Posterior retrocolic gastroenterostomy. The access is similar. When opening the abdominal cavity, the greater omentum and the transverse colon are raised at the top and a cut of about 10 cm is made in the mesentery of the transverse colon (mesocolon) in the avascular area. The back wall of the stomach is brought into this hole, on which a vertical fold is formed. Departing from the duodenal-jejunal bend, a loop of the jejunum is isolated and an anastomosis is applied between it and the fold on the posterior wall of the stomach in a side-to-side manner with a two-row suture. The location of the anastomosis can be transverse or longitudinal. Further, the edges of the opening in the mesentery of the transverse colon are sutured with gray-serous sutures to the posterior wall of the stomach in order to avoid slippage and infringement of the loop of the small intestine. The abdominal cavity is sutured tightly in layers.

Resection of the stomach - an operation to remove part of the stomach with the formation of a gastrointestinal anastomosis.

Indications for surgery: chronic ulcers, extensive wounds, benign and malignant neoplasms of the stomach.

Depending on the section of the stomach to be removed, there are proximal (removal of the cardiac section, bottom and body), pyloric antral (removal of the pyloric section and part of the body) and partial (removal of only the affected part of the stomach) resection. According to the volume of the removed part, one can distinguish resection of one third, two thirds, half of the stomach, subtotal (removal of the entire stomach, except for its cardia and fornix), total (or gastrectomy).

Operation technique. There are many options for gastric resection, of which Billroth-I and Billroth-II operations and their modifications are most often used (Fig. 15.26). Access to the stomach is performed by upper median laparotomy. Operational guidance consists of several stages. Initially, after access, the stomach is mobilized. The next step is the resection of the part of the stomach prepared for removal, while the remaining proximal and distal stumps are sutured. Further, a necessary and mandatory step is the restoration of the continuity of the digestive tract, which is carried out in two ways: according to Billroth-I and Billroth-II. The operation in both cases ends with the sanitation of the abdominal cavity and its layer-by-layer suturing.

Gastrectomy- complete removal of the stomach with the imposition of an anastomosis between the esophagus and the jejunum. Indications and main steps

Rice. 15.26.Schemes of resection of the stomach: a - resection boundaries: 1-2 - pyloric antral; 1-3 - subtotal; b - scheme of resection according to Billroth-I; c - resection scheme according to Billroth-II

operations are similar to those of resection of the stomach. After removal of the stomach, the continuity of the gastrointestinal tract is restored by connecting the esophagus to the small intestine (formation of an esophagojejunostomy).

Gastroplasty- autoplastic surgery to replace the stomach with a segment of the small or large intestine. It is performed after a gastrectomy, which greatly upsets the digestive function. As an autograft, a section of the small intestine 15-20 cm long is used, which is inserted between the esophagus and the duodenum, the transverse or descending colon.

Pyloroplasty according to Heineke-Mikulich - operation of longitudinal dissection of the pyloric sphincter without opening the mucous membrane with subsequent stitching of the wall in the transverse direction. It is used for chronic and complicated duodenal ulcer.

Vagotomy- the operation of the intersection of the vagus nerves or their individual branches. It is not used on its own, it is used as an additional measure in operations for gastric and duodenal ulcers.

There are stem and selective vagotomy. With stem vagotomy, the trunks of the vagus nerves are crossed under the diaphragm until they branch, with selective - the gastric branches of the vagus nerve with the preservation of branches to the liver and celiac plexus.

15.17. OPERATIONS ON THE LIVER AND BILE TRACKS

Liver resection- surgery to remove part of the liver.

Resections are divided into two groups: anatomical (typical) and atypical resections. Anatomical resections include: segmental resections; left hemihepatectomy; right hemihepatectomy; left lateral lobectomy; right lateral lobectomy. Atypical resections include wedge-shaped; marginal and transverse resection.

Indications for resection are injuries, benign and malignant tumors and other pathological processes that have a limited prevalence.

Access to the liver is different depending on the location of the pathological focus. Laparotomic incisions are most commonly used, but there may be combined approaches. The stages of anatomical resection begin with the isolation of a segmental branch of the hepatic artery, a segmental branch of the portal vein, and a segmental bile duct in the hilum of the liver. After ligation of the segmental branch of the hepatic artery, the area of ​​the liver parenchyma changes color. A segment of the liver is cut along this border and the hepatic vein is found, which drains venous blood from this area, it is tied up and crossed. Next, the wound surface of the liver is sutured using straight atraumatic needles with capture into the suture of the liver capsule.

In atypical resections, the first step is to cut the parenchyma, and then ligate the crossed vessels and bile ducts. The last step is suturing the wound surface of the liver.

Operations for portal hypertension are distinguished into a special group of operations on the liver. Of the many proposed operations to create fistulas between the portal and inferior vena cava systems, the operation of choice is splenorenal anastomosis, which is currently recommended to be performed using microsurgical techniques.

Operations on the biliary tract can be divided into operations on the gallbladder, operations on the common bile duct, operations on the major duodenal papilla, reconstructive operations on the biliary tract.

The main accesses to the extrahepatic biliary tract are oblique incisions according to Fedorov, Kocher, upper median laparotomy, less often other types of laparotomy. Anesthesia: anesthesia, the position of the patient - lying on his back with a padded roller.

Operations on the gallbladder

Cholecystotomy- surgery to cut the wall of the gallbladder to remove stones from its cavity, followed by suturing the wall of the gallbladder.

Cholecystostomy - Operation of the imposition of the external fistula of the gallbladder. It is performed in debilitated patients to eliminate the phenomena of obstructive jaundice.

Cholecystectomy - surgery to remove the gallbladder.

Technically, it is performed in two modifications: with the release of a bubble from the neck or bottom. It is performed for acute or chronic inflammation of the gallbladder. In modern conditions, the technique of laparoscopic bladder removal is increasingly being used.

Operations on the common bile duct

Choledochotomy- the operation of opening the lumen of the common bile duct by dissecting its wall, followed by suturing or drainage. Depending on the place of opening of the lumen, supraduodenal, retroduodenal, transduodenal choledochotomy is distinguished. External drainage of the common bile duct is called choledochostomy.

Operations on the major duodenal papilla

Stenosis of the major duodenal papilla and wedging of a stone at its mouth are the main indications for the following operations.

Papillotomy- dissection of the wall of the major duodenal papilla.

Papilloplasty - dissection of the wall of the major duodenal papilla, followed by suturing.

Papillosphincterotomy - dissection of the wall and sphincter of the major duodenal papilla.

Papillosphincteroplasty - dissection of the wall and sphincter of the major duodenal papilla, followed by suturing the cut edges.

Papillotomy and papillosphincterotomy can be performed endoscopically, i.e. without opening the lumen of the duodenum. Papillosphincteroplasty is performed with opening of the abdominal cavity and duodenum.

Reconstructive operations include biliodigestive anastomoses. Indications: stenosis of the extrahepatic biliary tract

of various origins, iatrogenic injuries of the biliary tract, etc.

Cholecystoduodenostomy - an anastomosis operation between the gallbladder and the duodenum.

Cholecystojejunostomy - operation of anastomosis between the gallbladder and the jejunum.

Choledochoduodenostomy - anastomosis between the common bile duct and the duodenum.

Choledochojejunostomy - the operation of imposing an anastomosis between the common bile duct and the loop of the jejunum.

Hepaticoduodenostomy - the operation of imposing an anastomosis between the common hepatic duct and the jejunum.

Currently, biliodigestive anastomoses must necessarily have areflux and sphincter properties, which is achieved using microsurgical techniques.

15.18. OPERATIONS ON THE PANCREAS

Operations on the pancreas are complex surgical interventions. Access to the gland can be either extraperitoneal (to the posterior surface of the gland) or transperitoneal, with dissection of the gastrocolic ligament or mesentery of the transverse colon.

necrectomy- a sparing operation to remove necrotic areas of the pancreas. It is performed with pancreatic necrosis, purulent pancreatitis against the background of a serious condition of the patient.

Cystoenterostomy - the operation of imposing a message between the pancreatic cyst and the lumen of the small intestine.

Indication for surgery: pancreatic cyst with well-formed walls.

Operation technique. After opening the abdominal cavity, an incision is made in the cyst wall, its contents are evacuated, the partitions in it are destroyed to form a single cavity. Next, an anastomosis is placed between the cyst wall and the small intestine. The operation is completed with drainage and layer-by-layer suturing of the surgical wound.

Left side pancreatic resection - removal of the tail and part of the body of the pancreas.

Indications for surgery: trauma to the tail of the gland, pancreatic necrosis of this area, tumor lesions. Access to the gland is described above.

The main conditions for a successful operation: maintaining a full-fledged outflow of pancreatic secretion along the main duct, full peritonization of the pancreatic stump. After surgery, the patient's insulin levels must be carefully monitored.

Pancreatoduodenal resection - an operation to remove the head of the pancreas along with a part of the duodenum, followed by the imposition of gastrojejuno-, choledochojejuno- and pancreatojejunoanastomosis to restore the passage of gastric contents, bile and pancreatic juice. The operation is one of the most difficult surgical interventions due to significant organ trauma.

Indications for surgery: tumors, necrosis of the head of the pancreas.

Operation technique. Access - laparotomy. Initially, the duodenum, pancreas, stomach, and choledochus are mobilized. Next, these organs are cut off with careful cover of the pancreatic stump to avoid leakage of pancreatic juice. At this stage, all manipulations with adjacent vessels require great care. The next is the reconstructive stage, during which the pancreatojejuno-, gastrojejuno- and choledochojejunoanastomosis is sequentially applied. The operation is completed by washing, draining and suturing the abdominal cavity.

15.19. OPERATIONS ON THE SMALL AND COLON INTESTINE

Intestinal suture - a suture used for suturing all hollow tubular organs, the walls of which have a sheath structure, i.e. consist of 4 membranes: mucous, submucosal, muscular and serous (or adventitial), combined into two loosely interconnected cases: muco-submucosal and muscular-serous.

The intestinal suture must meet several requirements: it must be airtight to prevent leakage of the contents of the hollow organ and mechanically strong, in addition, when making the suture, its hemostaticity must be ensured. Another requirement is the asepticity of the intestinal suture, i.e. the needle should not penetrate the mucosa into the lumen of the organ, the inner shell should remain intact.

Enterostomy- the operation of imposing an external fistula on the jejunum (jejunostomy) or ileum (ileostomy) intestine.

Indications for surgery: for drainage of the common bile duct, parenteral nutrition, decompression of the intestinal tube, cancer of the caecum.

Operation technique. Access - laparotomy. A loop of the small intestine is sutured with interrupted sutures to the parietal peritoneum. The intestine is opened immediately or after 2-3 days. The edges of the intestinal wall are sutured to the skin.

Colostomy- the operation of imposing an external fistula on the large intestine. Through the superimposed colostomy, only part of the stool is excreted, the rest goes its usual way.

Indications for colostomy: necrosis or perforation of a section of the colon if its resection is impossible, tumors of the colon. Depending on the localization, a cecostomy, a sigmoideostomy and a transversostomy are distinguished. The most commonly performed cecostomy is the operation of applying an external fistula to the caecum. The technique of cecostomy is as follows. The incision is made in the right iliac region through McBurney's point. The caecum is brought out into the wound and sutured to the parietal peritoneum. The intestine is not opened, an aseptic bandage is applied to the wound. Within 1-2 days, the visceral peritoneum is soldered along the entire circumference of the suture with the parietal. After that, you can open the lumen of the intestine. For a while, a drainage tube can be inserted into the intestine. Currently, specially designed colostomy bags are used.

The technique of sigmoideostomy and transversostomy is similar.

Unnatural anus - an external fistula of the large intestine, artificially created by a surgical operation, through which its fecal contents are completely excreted.

Indications for surgery: tumors of the underlying colon, wounds of the rectum, perforation of ulcers and diverticula.

Operation technique. The operation is performed only on free areas of the colon - transverse colon or sigmoid. Access - oblique incision in the left iliac region. The parietal peritoneum is sutured to the skin. The adductor and efferent loops of the sigmoid colon are brought into the wound, their mesenteric edges are sutured with gray-serous interrupted sutures to form a "double-barreled". The visceral peritoneum of the intestine is sutured to the parietal to isolate the peritoneal cavity from the external environment. Intestinal wall

open a few days later with a transverse incision, thus opening the gaps of both the afferent and efferent loops, which prevents the passage of feces into the distal loop. A superimposed artificial anus requires careful care.

Resection of the small intestine - an operation to remove a part of the jejunum or ileum with the formation of an enteroanastomosis of the end-to-end or side-to-side type.

Indications for surgery: tumors of the small intestine, necrosis of the small intestine with thrombosis of the mesenteric vessels, intestinal obstruction, strangulated hernia.

Operation technique. Access - laparotomy. After opening the abdominal cavity, the section of the intestine to be resected is taken out into the wound and separated with gauze napkins. Further, in this area, all vessels of the mesentery are ligated, after which it is separated from the intestinal wall. Next, resection of the intestine is performed and stumps are formed at the remaining ends. The stumps are applied to each other isoperistaltically and enteroenteroanastomosis is applied side to side to restore the patency of the digestive tube. Some surgeons perform an end-to-end anastomosis, which is more physiological. The laparotomic wound is sutured in layers.

Resection of the transverse colon - an operation to remove a part of the transverse colon with the imposition of anastomosis between the parts according to the end-to-end type.

Indications for surgery: necrosis of parts of the intestine, its tumors, intussusceptions.

The technique of the operation is similar to the resection of the small intestine. After removal of part of the intestine, the patency is restored by end-to-end anastomosis. Given the significant bacterial contamination of the colon, when applying an anastomosis, a three-row suture is used or the anastomosis is applied in a delayed manner.

Right hemicolectomy - operation of removal of the caecum with the terminal section of the ileum, ascending colon and the right section of the transverse colon with the imposition of an anastomosis between the ileum and the transverse colon of the end-to-side or side-to-side type.

Indications for surgery: necrosis, invagination, tumors.

Operation technique. Perform a laparotomy. After opening the abdominal cavity, the ileum is isolated, bandaged

the vessels of her mesentery, after which the mesentery is cut off. The ileum is transected at the required site. The next step is to isolate the caecum and ascending colon and tie up the vessels that feed them. The removed part of the colon is cut off, and its stump is sutured with a three-row suture. To restore intestinal patency at the final stage of the operation, an ileotransverse anastomosis is applied. The wound is drained and sutured in layers.

Left hemicolectomy - an operation to remove the left section of the transverse, descending colon and most of the sigmoid colon with the imposition of anastomosis between the transverse colon and the stump of the sigmoid colon or the initial part of the rectum, end-to-end. Indication for surgery: tumor process in the left half of the colon.

15.20. APPENDECTOMY

Appendectomy is an operation to remove the appendix. This operation is one of the most frequently performed in abdominal surgery.

The indication for appendectomy is catarrhal, phlegmonous or putrefactive inflammation of the appendix.

Operation technique. In the right iliac region, a variable incision of the anterior abdominal wall is made according to Volkovich-Dyakonov parallel to the inguinal ligament through the McBurney point, which is located on the border of the outer and middle third of the line connecting the navel and the superior anterior iliac spine (Fig. 15.27). First, the skin, subcutaneous fatty tissue, superficial fascia and aponeurosis of the external oblique muscle of the abdomen are dissected with a scalpel. Then, along the fibers, the internal oblique and transverse abdominal muscles are bred in a blunt way (the muscles cannot be crossed with a scalpel due to the subsequent violation of the blood supply to them). Next, the transverse fascia of the abdomen, the parietal peritoneum are cut with a scalpel and enter the abdominal cavity. The dome of the caecum is brought into the wound along with the appendix. A distinctive feature of the caecum from the ileum is the presence of fatty processes, swellings and longitudinal muscle bands, while it must be remembered that all three bands converge at the base of the appendix, which can serve as a guide for its detection. The assistant fixes the caecum, the surgeon near the end of the process

Rice. 15.27.Oblique incision for appendectomy:

1 - external oblique muscle of the abdomen; 2 - internal oblique muscle of the abdomen; 3 - transverse abdominal muscle; 4 - peritoneum

puts a clamp on his mesentery and lifts him up. Next, a hemostatic clamp is applied to the mesentery, and it is cut off. Under the clamps bandage the stump of the mesentery of the appendix. The cutting and ligation of the mesentery must be carefully performed to avoid severe bleeding from the mesenteric stump.

The next step is manipulation on the process itself. Holding it by the remainder of the mesentery in the region of the tip, a purse-string seromuscular suture is applied to the caecum around the base of the process. When applying it, it is necessary to ensure that the needle shines through the serous membrane all the time in order to avoid damage to the wall of the caecum. The purse-string suture is not temporarily tightened. Next, on the base of the appendix impose

a clamp under which the appendix is ​​tightly tied with a ligature. Then the process is cut off, and its stump is treated with iodine. Holding the stump with anatomical tweezers, the surgeon immerses it in the direction of the caecum, at the same time completely tightening the purse-string suture. After tying it, the stump should be completely immersed in it. A Z-shaped serous-muscular suture is applied over the purse-string suture for strengthening.

Then the abdominal cavity is thoroughly drained, and hemostasis is monitored. If necessary, drains are installed. The surgical wound is sutured in layers with catgut: first, the peritoneum, then the muscle layers, then the aponeurosis of the external oblique muscle of the abdomen and subcutaneous fatty tissue. The last row of sutures is applied to the skin using silk.

15.21. KIDNEY OPERATIONS

Operations on the organs of the urinary system are diverse and are singled out as a separate branch of medicine - urology. Distinctive features of operations on the organs of the retroperitoneal space are the presence of special surgical instruments, the use of mainly extraperitoneal accesses, and, more recently, the use of high-tech methods of operation. Modern technologies make it possible to use minimally invasive approaches, microsurgical techniques, endovideosurgical and retroperitoneoscopic methods in urology.

Nephrotomy- dissection of the kidney.

Indications for surgery are foreign bodies of the kidney, blind wound canals, kidney stones if they cannot be removed through the pelvis.

Operation technique (Fig. 15.28). One of the accesses exposes the kidney, takes it into the wound. Next, the kidney is fixed and the fibrous capsule and parenchyma are dissected. After removing the foreign body, sutures are placed on the kidney so that they do not damage the pelvicalyceal system.

Nephrostomy- the imposition of an artificial fistula between the lumen of the pelvis and the external environment.

Indication for surgery: mechanical obstructions at the level of the ureter that cannot be removed in any other way.

The technique of the operation consists in exposing the kidney, performing a nephrotomy, dissecting the pelvis. Next, the drainage tube is fixed with a purse-string suture and brought out.

Kidney resection- removal of part of the kidney. Kidney resection refers to organ-preserving operations, therefore testimony for it are processes that capture part of the organ, for example, tuberculosis, the initial stage of a kidney tumor, echinococcus, kidney injury, and more.

According to the technique of performing resections, they are divided into anatomical (removal of a segment, two segments) and non-anatomical (wedge-shaped, marginal, etc.). The steps for performing the operation are as follows. After the kidney is exposed, the renal pedicle is clamped, then the affected area is excised within healthy tissues. The wound surface is sutured by suturing or plasty with a flap on a vascular pedicle. The renal bed is drained and the surgical wound is sutured in layers.

Rice. 15.28.Right-sided nephrectomy: stage of ligation and transection of the renal pedicle

Nephrectomy- kidney removal. Indications for nephrectomy are a malignant tumor, crushing of the kidney, hydronephrosis, etc. Special attention should be paid to the functional state of the second kidney; without her examination, the operation is not carried out.

Operation technique (Fig. 15.28). One of the accesses exposes the kidney, dislocates it into the wound. Next, a key stage of the operation is carried out: the treatment of the renal pedicle. Initially, the ureter is treated, tying it between two ligatures, the stump is cauterized with an antiseptic solution. Then proceed to the ligation of the renal artery and renal vein. After making sure that the ligatures are reliable, the vessels are crossed and the kidney is removed. The wound is drained and sutured in layers.

Nephropexy- fixation of the kidney when it is lowered. The indication for nephropexy is the omission of the kidney, in which there is an inflection of the vascular pedicle and a violation of its blood supply. Currently, many ways of fixing the kidney have been described. For example, the kidney is fixed to the overlying rib with ligatures, there are methods for cutting out a fascial and muscle flap, with which the organ is fixed in the muscle bed. Unfortunately, all these methods often lead to relapses.

15.22. TESTS

15.1. The anterolateral wall of the abdomen is separated by horizontal and vertical lines:

1. For 8 areas.

2. For 9 regions.

3. For 10 areas.

4. For 11 regions.

5. For 12 areas.

15.2. Performing a median laparotomy in the epigastrium, the surgeon sequentially dissects the layers of the anterior abdominal wall. Determine the sequence of cutting layers:

1. White line of the abdomen.

2. Skin with subcutaneous fat.

3. Parietal peritoneum.

4. Superficial fascia.

5. Transverse fascia.

6. Preperitoneal tissue.

7. Own fascia.

15.3. The median vesico-umbilical fold formed as a result of fetal development is:

1. Obliterated umbilical artery.

2. Obliterated umbilical vein.

3. Obliterated urinary duct.

4. Deferent duct.

15.4. In the right hypochondrium, 3 of the listed organs or their parts are usually projected:

1. Part of the right lobe of the liver.

2. Spleen.

3. Part of the right kidney.

4. Tail of the pancreas.

5. Right flexure of the colon.

6. Gallbladder.

15.5. The duodenum is projected onto the anterolateral abdominal wall in the following areas:

1. In the right and left side.

2. In the umbilical and proper epigastric.

3. In the proper epigastric and left lateral.

4. In the proper epigastric right lateral.

5. In the umbilical and right lateral.

15.6. In the inguinal canal can be distinguished:

1. 3 walls and 3 holes.

2. 4 walls and 4 holes.

3. 4 walls and 2 holes.

4. 2 walls and 4 holes.

5. 4 walls and 3 holes.

15.7. The lower wall of the inguinal canal is formed by:

1. The lower edges of the internal oblique and transverse muscles.

2. Inguinal ligament.

3. Comb fascia.

4. Parietal peritoneum.

5. Aponeurosis of the external oblique muscle of the abdomen.

15.8. When plastic surgery of the inguinal canal in a patient with an oblique inguinal hernia, the surgeon's actions are aimed at strengthening:

15.9. When plastic surgery of the inguinal canal in a patient with a direct inguinal hernia, the actions of the surgeon are aimed at strengthening:

1. The upper wall of the inguinal canal.

2. Anterior wall of the inguinal canal.

3. Posterior wall of the inguinal canal.

4. The lower wall of the inguinal canal.

15.10. When performing a median laparotomy:

1. The navel is bypassed on the right.

2. The navel is bypassed on the left.

3. The navel is dissected along.

4. The navel is cut across.

5. The choice of side does not matter.

15.11. One of the symptoms observed in a number of diseases accompanied by stagnation in the portal vein system is the expansion of the saphenous veins in the umbilical region of the anterior abdominal wall. This is due to the presence here:

1. Arteriovenous shunts.

2. Cavo-caval anastomoses.

3. Lymphatic venous anastomoses.

4. Portocaval anastomoses.

15.12. The superior and inferior epigastric arteries with their accompanying veins of the same name are located:

1. In the subcutaneous adipose tissue.

2. In the vagina of the rectus abdominis muscles in front of the muscles.

3. In the vagina of the rectus abdominis muscles behind the muscles.

4. In the preperitoneal tissue.

15.13. The upper and lower floors of the abdominal cavity are separated by:

1. Big omentum.

2. Gastrocolic ligament.

3. Mesentery of the transverse colon.

4. Mesentery of the small intestine.

15.14. The organs of the upper floor of the abdominal cavity include 4 of the following:

2. Stomach.

4. Liver with gallbladder.

5. Pancreas.

6. Spleen.

8. Sigmoid colon.

15.15. The organs of the lower floor of the abdominal cavity include 5 of the following:

1. Ascending colon.

2. Stomach.

3. Descending colon.

4. Liver with gallbladder.

5. Pancreas.

6. Spleen.

7. Caecum with appendix.

8. Sigmoid colon.

9. Skinny and ileum.

15.16. Set the boundaries of the liver bag.

1. Top.

2. Front.

3. Behind.

4. Bottom.

5. Right.

6. Left.

A. Lateral wall of the abdomen. B. Coronary ligament of the liver.

B. Anterior abdominal wall.

D. Transverse colon. D. The right dome of the diaphragm. E. Costal arch. G. Falciform ligament of the liver.

15.17. Establish the boundaries of the pancreatic sac.

1. Top.

2. Bottom.

3. Front.

4. Behind.

5. Right.

6. Left.

A. Lateral wall of the abdomen. B. The left dome of the diaphragm.

B. Stomach.

G. Small omentum. D. Anterior abdominal wall. E. Transverse colon. G. Falciform ligament of the liver.

15.18. The small omentum consists of 3 ligaments of the following:

1. Diaphragmatic-gastric ligament.

2. Gastro-splenic ligament.

3. Gastrocolic ligament.

4. Hepatoduodenal ligament.

5. Hepatogastric ligament.

15.19. Install the stuffing box walls:

1. Top.

2. Bottom.

3. Front.

4. Back.

A. Mesentery of the transverse colon. B. Stomach.

B. Gastrocolic ligament. G. Small omentum.

D. Posterior leaf of the parietal peritoneum. E. Transverse colon. G. Caudate lobe of the liver.

15.20. Of the 4 peritoneal formations of the lower floor of the abdominal cavity, they freely communicate with the peritoneal bags of the upper floor:

1. Left mesenteric sinus.

2. Left side channel.

3. Right mesenteric sinus.

4. Right side channel.

15.21. The stomach is supplied with blood by arteries that branch off:

1. Only from the celiac trunk.

2. From the celiac trunk and superior mesenteric artery.

3. Only from the superior mesenteric artery.

15.22. Gastrostomy is:

1. Introduction of the probe into the lumen of the stomach.

2. The imposition of an artificial external fistula on the stomach.

3. Formation of the gastrointestinal anastomosis.

4. Dissection of the stomach wall to remove a foreign body, followed by suturing the wound.

5. Removal of part of the stomach.

15.23. Gastropexy is:

1. Stitching sections of the stomach wall around the tube during gastrostomy.

2. There is no such term.

3. This is the name of the dissection of the wall of the stomach.

4. Fixation of the stomach to the parietal peritoneum with several sutures to isolate the peritoneal cavity from the contents of the stomach.

5. Dissection of the muscle sphincter in the region of the pylorus.

15.24. Total vagotomy involves:

1. Crossing the trunk of the left vagus nerve above the diaphragm.

2. The intersection of the trunks of the left and right vagus nerves immediately below the diaphragm.

3. Crossing the trunk of the left vagus nerve immediately below the diaphragm.

4. Crossing the trunk of the left vagus nerve below the origin of its hepatic branch.

5. The intersection of the branches of the left vagus nerve, extending to the body of the stomach.

15.25. Selective vagotomy involves:

1. Crossing the trunk of the left vagus nerve below the origin of its hepatic branch.

2. The intersection of the branches of the left vagus nerve, extending to the body of the stomach.

3. Crossing the branches of the left vagus nerve, extending to the bottom and body of the stomach.

4. Crossing the trunk of the left vagus nerve above the origin of its hepatic branch.

5. None of the options.

15.26. In the liver secrete:

1. 7 segments.

2. 8 segments.

3. 9 segments.

4. 10 segments.

15.27. During cholecystectomy, the cystic artery is determined at the base of the Calot triangle, the lateral sides of which are two anatomical formations from the following:

1. Common bile duct.

2. Common hepatic duct.

3. Right hepatic duct.

4. Cystic duct.

5. Own hepatic artery.

15.28. Determine the sequence of parts of the common bile duct:

1. Duodenal part.

2. Supraduodenal part.

3. Pancreatic part.

4. Retroduodenal part.

15.29. The relative position in the hepatoduodenal ligament of the common bile duct, own hepatic artery and portal vein is as follows:

1. Artery along the free edge of the ligament, duct to the left, vein between them and posteriorly.

2. The duct along the free edge of the ligament, the artery to the left, the vein between them and posteriorly.

3. Vein along the free edge of the ligament, artery to the left, duct between them and posteriorly.

4. The duct along the free edge of the ligament, the vein to the left, the artery between them and backwards.

15.30. The celiac trunk is usually divided into:

1. Left gastric artery.

2. Superior mesenteric artery.

3. Inferior mesenteric artery.

4. Splenic artery.

5. Common hepatic artery.

6. Gallbladder artery.

15.31. Venous blood flows into the portal vein from 5 of the following organs:

1. Stomach.

2. Adrenals.

3. Colon.

4. Liver.

5. Pancreas.

6. Kidneys.

7. Spleen.

8. Small intestine.

15.32. Venous blood flows into the inferior vena cava from 3 of the following organs:

1. Stomach.

2. Adrenals.

3. Colon.

4. Liver.

5. Pancreas.

6. Kidneys.

7. Spleen.

8. Small intestine.

15.33. Of the 4 external differences between the large intestine and the small intestine, the most reliable sign is:

1. The location of the longitudinal muscles of the large intestine in the form of three ribbons.

2. The presence of gaustra and circular furrows in the colon.

3. The presence of fatty appendages in the colon.

4. Greyish-blue color of the large intestine and light pink color of the small intestine.

15.34. The blood supply of the caecum is carried out from the pool of the artery:

1. Superior mesenteric.

2. Inferior mesenteric.

3. External iliac.

4. Internal iliac.

5. General hepatic.

15.35. Venous outflow from the caecum is carried out into the vein system:

1. Bottom hollow.

2. Top hollow.

3. Bottom and top hollow.

4. Gate.

5. Gate and bottom hollow.

15.36. Features that determine the differences between operations on the large intestine from operations on the small intestine are that:

1. The large intestine has a thicker wall than the small intestine.

2. The large intestine has a thinner wall than the small intestine.

3. The small intestine has more infected contents than the large intestine.

4. The large intestine has more infected contents than the small intestine.

5. Unevenly distributed muscle fibers in the wall of the colon.

15.37. In the retroperitoneal space between the intra-abdominal and retroperitoneal fascia are:

1. Retroperitoneal cellular layer.

2. Colonic fiber.

3. Perirenal fiber.

15.38. The pericolic tissue is located between:

1. Ascending or descending colon and posterior colon fascia.

2. Posterior colonic and anterior renal fascia.

3. Posterior colonic and intra-abdominal fascia.

15.39. Perirenal tissue is located around the kidney:

1. Under the fibrous capsule of the kidney.

2. Between the fibrous and fascial capsule.

3. Over the fascial capsule of the kidney.

15.40. The renal arteries arise from the abdominal aorta at the level of:

15.41. Determine the order of the three kidney capsules, starting from its parenchyma:

1. Fat capsule.

2. Fascial capsule.

3. Fibrous capsule.

15.42. In relation to the spine, the left kidney is located at the level of:

15.43. In relation to the spine, the right kidney is located at the level of:

15.44. In front of the left kidney are 4 organs of the following:

1. Liver.

2. Stomach.

3. Pancreas.

4. Duodenum.

5. Loops of the small intestine.

7. Splenic flexure of the colon.

15.45. In front of the right kidney are 3 of the following organs:

1. Liver.

2. Stomach.

3. Pancreas.

4. Duodenum.

5. Loops of the small intestine.

6. Ascending colon.

15.46. The elements of the renal pedicle are located in the direction from front to back in the following sequence:

1. Renal artery, renal vein, pelvis.

2. Renal vein, renal artery, pelvis.

3. Lohanka, renal vein, renal artery.

4. Lohanka, renal artery, renal vein.

15.47. The basis for the allocation of segments of the kidney are:

1. Branching of the renal artery.

2. Formation of the renal vein.

3. Location of small and large renal calyces.

4. Location of the renal pyramids.

15.48. The ureter along its course has:

1. One constriction.

2. Two restrictions.

3. Three restrictions.

4. Four restrictions.

15.49. The anterior and posterior boundaries of the retroperitoneal space are:

1. Parietal peritoneum.

2. Fascia endoabdominalis.