Operative Surgery and Clinical

Anatomy
 Topographical Anatomy

is a science about spatial position and mutual relations between the

organs and tissues in different regions of the human body.
According to the purpose of studying there are the follow parts of
the topographical anatomy:
• applied anatomy ( anatomy for art, painting, space,
manufacturing);
• clinical one with task to define the coordinates of the anatomic
formations for diagnose and treatment.
• to give explanation to clinical symptoms and syndromes, zones of
anatomical risk, changing of anatomy in different pathological
processes.
One part of the clinical anatomy is a surgical anatomy which
1) establishes correct mutual correlations between organs in three-
dimensional space;
2) helps to provide precise manipulations within the surgical
wound.
 Regional Approach
To study the topography is
used a regional approach.
All human body can be
divided into several regions
with strictly defined
borders. The most
prominent bone points are
used to mark the borders of
these areas.
 Borders of the Fossa Axillaris
More rare some
muscular folds, grooves or even
imaginary lines help to separate
one region from another one.

The fossa axillaris is

bounded by the folds from the
inferior edge of the pectoralis
major anteriorly and latissimus
dorsi posteriorly. Imaginary
lines between these muscles in
the chest and upper arm are
the medial and lateral borders.
Regional Approach
Usually the shape of
these examined regions is
rectangular.

This method gives a

complete presentation on
spatial relations of all
anatomic formations in
each strictly determined
part of the body.
 The Main Methods of Studying of the
Topography Include:

1.Description of the regional relief (relief’s anatomy)

2.Stratigraphic examination, or sequence and
properties of layers in strictly definite region
3.Plan geometric examination, that is a finding of the
coordinates of any organ in two-dimensional space
4.Stereometrical examination, that is a position of the
organ in three-dimensional space.
 1. Description of Regional Relief.
The relief’s signs can be devided into dynamic and
static and vary because of sex, age, expression of
muscles et so on.
Dynamic Signs
Dynamic features

depends on the ability

of muscles to retract.
Swelling of the III Finger in Pus
Collection Presence
Normal static relief’ signs
can be changed
because of soft tissue
swelling, hematomas
formation, pus collections.
They can result from not only
superficial, but deep
pathological processes too.
Thus some depressions can
disappear, muscular grooves
can be smoothed down, or
some new elevations are
found
 2. Stratigraphic Examination
To study the topography a method of
«dissection from separate windows» is carried
out. What is it? The investigator dissects the
skin like a small rectangular flap and move it
aside. Then he consequently studies all
anatomical layers and structures within the
borders of this flap, like follows: the skin,
subcutaneous fat with its superficial vessels and
nerves, superficial and deep fascias, muscles,
the main neurovascular bundles.
Therefore this stratigraphic examination allows
- to establish the most constant and well
determined landmarks, which allow to find all
necessary anatomic elements;
- to characterize the properties of the layers of
the examined area;
- to create more simple model for studying of
the topographical anatomy (e.g., virtual
computers' programs);
- to think over the precise plan of operation and
surgical dissection.
 Stratigraphic Examination of the Anterior Wall
of the Fossa Axillaris
Layers of the anterior wall
of the fossa axillaris:
the skin, subcutaneous fat,
superficial fascia, fascia
pectoralis which encloses
the m.pectoralis major,
subpectoral fat space,
fascia clavipectoralis,
m.pectoralis minor, fascial
sheath of the axillary
neurovascular bundle.
Stratigraphic Examination of the Floor
of the Fossa Axillaris

Layers of the floor of the

fossa axillaris are the
follow:
the skin, subcutaneous
fat, superficial fascia, deep
fascia is said the fascia
axillaris, fatty tissue which
surrounds the axillary
neurovascular bundle.
 3. Plan Geometric Anatomy
is a studying of mutual relationships between
organs in two-dimensional space. It is possible by
means of follow special methods, such as:
1) traditional dissections and cross sections through
the human body;
2) diagnostic equipment usage, like X-ray
examination and modern methods like ultrasound
imaging, nuclear imaging, computed tomography,
emission computer assisted tomography etc.
 N.I. Pirogoff (1810 – 1881)
•N.I. Pirogoff is a great russian scientist who
developed topographic anatomy at the base
of cross sections of the human body,
anatomical experiments upon the corpses
and animals, models of pathological
processes. As a result he published 3 main
books about surgical anatomy of arterial
trunks and fascias, topographical anatomy
with incisions of the human body in three
directions and course of applied anatomy of
the human body with pictures, descriptions
and physiology for surgeons.
•In 1846 he created the first course of
topographical anatomy and operative surgery
in Medico-Surgical Academy and first
department was opened there in 1865. From
this time this discipline was developed in all
russian medical universities together N.I. Pirogoff on the
including dissections upon the corpses and market with peace of
experiments upon the animals.
meat
 Cross Section (transverse plan) and Longitudinal
Section through Upper 1/3 of the Thigh
•N.I. Pirogoff did cross sections through
separate parts of the frozen human body
in 3 directions at a distance of 0,5, 1 and
2cm. Then he puts this sections on the
glass or paper and draw position, view
and details of construction of organs
upon this paper. At last he joined all
pictures into atlas “Anatomia topografica,
subsections, per corpus humanum
congelatum triplice directione ductis,
illustrata” (1852-1859) which contains 4
books, 224 tablets, pictures of 970 cross
sections with explanations.
Cross Section through the Head and Computed
Tomography Scan of the Same Region

Studding of cross sections of the human bodies

helps to understand x-ray films, computer and
magnetic resonance scans and to understand
them correctly.
Ultrasound Image, CT Image and
Angiogram of the Aneurysm
 4. Three-dimensional Examination:
A. The Qualitative Estimation of Definition of the
Position of the Organ
is made according to various bone points. They are
prominent, well expressed and constant. At last, it is
important to know the relationships with the adjacent organs,
for example, from which side of muscle does the
neurovascular bundle pass.
Thus, set of the topographo-anatomic items of information
about any object can be shown as a description of 3 main
characteristics, such as:
1) holotopy is a definition of a position of an object in relation
to a human body as a single whole;
2) sceletotopy is a definition of an object’s position according
to the bone landmarks;
3) sintopy is a definition of the relations between adjacent
anatomic formations.
 Human body is always considered as standing erect,
facing ahead, the arms by the sides and the palms of
the hands facing forwards with the fingers extended.
2. Sceletotopy
is carried out by projection of
borders of any organ on the
bone landmarks. For example,
boundaries of the heart can
be determined by means of
percussion concerning the
ribs, intercostal spaces and
vertical lines. More precisely
sceletotopy is revealed by X-
ray examination.
 3.For sintopy definition of an organ are used
the follow well known concepts:

1) The terms anterior-posterior

(ventral-dorsal) refer to
structures facing the front and
back of the body respectively.
2) Structures in the antero-
posterior midline are said to be
median, those close to the
midline medial, and those
further away lateral.
3) Formations above are referred to
as superior (cephalic); structures
below as inferior (caudal).
Proximal means nearer to the
origin of a structure, distal is the
opposite. Superficial means
nearer the skin, deep is the
opposite.
Syntopy of the axillary neurovascular
bundle
The axillary
neurovascular bundle
contains the
a.axillaris, v.axillaris
and the plexus
brachialis.
Triangles on the Anterior Wall of the Fossa
Axillaris
•There are 3 triangles on the
anterior wall of the fossa axillaris,
they are the trigonum
clavipectorale, trigonum pectorale,
trigonum subpectorale.
•Trigonum clavipectorale is bounded
by the clavicle and anterior edge of
the pectoralis minor.
•Trigonum pectorale is bounded by
the anterior and posterior edges of
the m.pectoralis minor.
•Trigonum subpectorale is bounded
by the inferior edges of the
pectoralis major and minor.
Syntopy of the Axillary Neurovascular
Bundle
Within the borders of
the trigonum
clavipectorale the
v.axillaris occupies the
most anterior and medial
position.
The a.axillaris is
posteriorly and laterally
from the vein.
The plexus brachialis
is the most posterior and
lateral.
 Syntopy of the Axillary Neurovascular Bundle

•In the trigonum pectorale

the v.axillaris is the most
anterior and medial,
a.axillaris is posteriorly and
laterally, the plexus brachialis
divides into 3 cords:
fasciculus medialis, lateralis
and posterior according to
their position around the
artery.
 Syntopy of the Axillary Neurovascular Bundle
Within the trigonum
subpectorale positions of the
artery and vein are the same, but
every cord of the plexus
brachialis divides into separate
nerves.
Fasciclus medialis gives off
the nn.cutanei brachii and
antebrachii mediales, n.ulnaris
and radix medialis n.mediani.
Fasciculus lateralis divides
into the n.musculocutaneus and
radix lateralis n.mediani.
Nn.axillaris and radialis
arise from the fasciculus
posterior.
 4. Three-dimensional Examination:
The quantitative criterions of
definition of position of an organ can
be found by means of modern
techniques. For quantitative
approach the investigator has to
define the direction of a plane of
cross section (vertical, horizontal, at
different angles) and initial point.
One of the most simple methods is
definition of co-ordinates in
horizontal plane with the 0-point at
the centre of the vertebral body.
Investigator can change the visual
angle with special computer’s
programs, so it become possible to Aorto-femoral Grafting. Anastomotic
study the organ’s topography from Pseudoaneurysms.a- 3D reconstruction; b –
all sides like a single object. multiplanar image; c, d – axial image at the
levels of proximal and distal anastomosis
 For quantative delimitation of the organs is used the system like a
geographical co-ordinate network. Various areas are the revolving
(rotation) ovals with central line which is formed by the cross section
between sagittal and frontal planes.
In the head, neck and trunk vertical
The main planes of the head: axis extends from the top of the head till
1- sagittal , 2- frontal, 3 - the perineal center;
horizontal 1.Medial sagittal plane passes through the
vertical axis forms the initial (0-) meridian;
2.At last frontal plane runs through the
revolving axis.
Combination of frontal and sagittal
planes allows to define the anterior and
posterior quadrants with auxiliary
meridians which pass through every 300.
3. Another plane is horizontal one which
passes through the margo infraorbitalis
and porus acusticus externus in the head
and at the level of the cartilago crycoidea
in the neck
 Stereotactic Examination and Surgery

This approach allows: The atlas developed by Ganser and

1.to define co-ordinates of an coworkers proposes a non rigid
object at the surface of the registration method to fit the brain
human body; MRI geometry of a given patient
2.to measure the distance
between the skin and object;
3.to carry out three-dimensional
operations after quantitative
co-ordinates definition;
4.to apply computer's programs
for surgical distant
manipulators and automatic
systems.
The Riechert–Mundinger System Mounted on
Skull: Anterior and Lateral Views
Dr J L Barcia-Salorio Placing the Stereotactic
Frame for a Radiosurgical Treatment
 Base Directions of the Topographical Anatomy
Development
1. Development of the doctrine about constitution.
2. Studying of topographical features of people:
- of different age
- in pathological processes development
- microanatomic norm.
3. Definition of anatomic, anthropologic and local topographic
correlations for modern diagnostic procedures and
their further development
4. Detail description of the topography for open and closed
surgical accesses
5. Explanation of clinical symptoms and syndromes
6. Studying of the topography in pathology.
 1. Development of the Doctrine about Constitution.
Constitution is a complex of individual physiological and
morphological features, related to the given individual only and
formed under definite social and natural conditions and are displayed
in the organism's reaction to different influences. Constitutional
sings are manifested morphologically by the deposit of the fat, the
musculature development, which define the shape of the chest,
abdomen, and back. So all people can be conjoined into 3
constitutional types according to morphological stand point.
1. Dolichomorphic person has a body that is long or of above average
height, a relatively short trunk, a small chest circumference, narrow
or moderate wide shoulders, long lower limbs, slight tilting of the
pelvis (S.Crowford, Naomi Campbell, Goldie Hawn and many other
top models and famous actresses).
2. Brachymorphic person is characterized by moderate or shorter than
average height, a relatively long trunk, a large chest circumference,
relatively wide shoulders, short lower limbs, and marked inclination
of the pelvis (Denny de Vito).
3. Mesomorphic person has an average body built, intermediate
between the two described above (Sylvester Stallone).
 Shape of the Thoracic Cage and Blood Supply of the
Sternum, Position of the Heart in Brachymorphic and
Dolichomorphic Patients
 Norm
•Norm is a complex of morphological
and functional attributes which takes
place within the limits of define sign
and is bounded by the marginal
values.
•Norm is diverse and represented by
many structural variants which
together constitute the organism's
variability. This individual variability
does not disturb the established
equilibrium with the environment.
• Function of the organs within this
range is normal and provides their
ability to live. The norm is a result of
correct development.
 Anomaly is a deviation from the norm; it is manifested to different
degrees. Anomalies also have variations, some of which result from
improper development but do not disturb the established equilibrium
between the organism and the environment and therefore have no
effect on function.
Anomaly of the Bowel Absence of the Gallbladder – 1%
Development
Some anomalies are attended by impaired function of the organism or
some systems. They disturb the equilibrium between the organism and
the environment or are even incompatible with life. Such gross
disturbances of development are said a monstrosity, or a
malformation, or a teratism.

Malformation of the
cloacal membrane and
urogenital fold
А- obliteration of the rectum
and anus
В- atresia of the anus and
fistula rectovaginalis
С- obliteration of the anus
Д- atresia of the anus and
fistula rectovesicalis
 Doctrine about individual variability of organs and systems
of a body was developed by V.N. Shevkunenko and his
pupils. The basic rules are the follows:
1. All organs and systems are the subjects of individual
variability without any exception.
2. Individual differences are determined by the laws of
phylogenesis and ontogenesis and are the results of complex
interactions with the factors of an environment
(manifestation of the palatinum durum and upper lip
cleavage depends on unfavorable environment).
3. Range of normality can be presented as a
variation series which are limited by the marginal
values. They are the most distinguished values of this
sign.

Position of the Gallbladder according to the Peritoneum

The doctrine about individual variability of organs and
systems of a body was developed by V.N. Shevkunenko
and his pupils. The basic rules are the follows:
1. All organs and systems are the subjects of individual
variability without any exception.
2. Individual differences are determined by the laws of
phylogenesis and ontogenesis and result from complex
interactions with the factors of an environment (f.e,
manifestation of the palatinum durum and upper lip
cleavage depends on unfavorable environment).
3. Range of normality can be presented as a variation
series which are limited by the marginal values. They
are the most distinguished values of this sign.
II. Operative Surgery consists of two parts:
1 – is a doctrine about surgical operation and
2 - it studies technique of bloody surgical treatment.
The main method is an independent
work on a corpse. The goal of discipline
is to approximate conditions in the
wound of corpse to real operation
wound. So it is possible to use method of
dissection from the «windows», which
simulates an extended operation wound.
It allows to establish a relationships
between organs and tissues more widely
than from real surgical incision and helps
to identify anatomic formations
according to their specific local signs
(depth, relation to well known objects,
direction of muscular fibers etc).
Dissection through the Knee Joint from
the Window and Exposure of the Same
Joint by Textor’ Incision
 Operative Surgery
•However work on the corpse does not allow to
stop real bleeding, which always accompanies any
operation, therefore operations on corpses are
supplemented by the operations upon the alive
models.
•These interventions are carried out with general
anesthesia in aseptic conditions. They allow to
receive manual skills on alive tissues, to study rules
of control of bleeding, to take possession of
elementary manuals.
Major Operative Theatre
 1. Surgical instruments
• Surgical instruments are the specially
designed tools or devices which help to
perform specific actions during surgical
operation or manipulation.
•Some instruments are designed for
general use in surgery and they are said the
general instruments. Other instruments are
used in specific procedures only and are
said special ones.
•Accordingly, the nomenclature of surgical
instruments follow certain patterns, such
as
a)a description of the actions it performs
(needleholder),
b)the name of its inventor (Halstead
c)a compound specific name related to the
type of surgery (tracheotomic tubes).
 There are Follow Requirements to Surgical Instruments:
1. The simplicity of construction, without special preparation for usage.
2. Opportunity of scrubbing and sterilization after usage.
3. The instruments should be convenient for long manipulations within the wound, so
must be easy, their handles have to be empty,
their long axis should be like a continuation of the hand of the surgeon.
4.Instruments should be strong, e.g.
- to be capable to resist mechanical, chemical and temperature influences at
sterilization;
- they should not be deformed by mechanical loading;
- parts of the broken instruments must be visible and large to remove them from the
wound.
5. Surface of the instruments should be smooth and flat. These properties provide
good sterilization and safety of surgical gloves during the operation.
6. Instrumental surface should be lusterless (mat) to except any patch of light.
7. Construction of the instrument should allow to divide it to separate parts and to
connect them together without any effort.
8. They should not narrow the operative field.
9. Instrument must serve for a long time, therefore it should be easy to replace
their several parts.
10. Instrument should be safe in application.
11. It must be possible to change, modernize and utilize the instrument with low price
 Construction of Surgical Instruments.
There are follow elements of instruments,
such as:
• Working tips, which provide main
actions;
• Auxiliary parts, f.e., handles, locks etc.

Construction can be of
- 1 element only (scalpel, probe, tissue
retractor – superior picture by
Farabeouf);
- several elements, connected by various
methods ( by hinge or opened locks with
fluent (smooth, flowing) movements of
instrumental parts). On middle picture
are bone nibblers by Luer and Liston;
- combine parts from different materials,
f.e., single action scalpel with plastic
handle and steel blade.
 Closed Locks
Closed locks (cremalers)
provide fixation of working tips in
given position. They can be of follow
types:
toothed; spiral; with ratchet
latch mechanism.
Usual toothed cremalers has a
single teeth from one side and several
tooth from the opposite one with the
same orientation, or several tooth
from both sides. When handles move
towards each other all teeth become
in partial or full contact and provide
good fixation. This closed lock may be
at the end of the instrument too,
therefore it can damage the surgical
gloves and even hands of the surgeon.
 Classification of Surgical Instruments according to
Their Function
• General instruments for
- sharp dissection of tissue: scalpels, scissors
(sharp-sharp, sharp-blunt, blunt-blunt)
- blunt dissection of tissue: probes (stick, gutter,
Kocher’s)
- tissue grasping forceps: anatomical, surgical,
toothed by Ott
- tissue retraction: retractors by Volkmann and
Farabeuf
• Special instruments for
- control of bleeding (hemostats): artery forceps by
Kocher, Billroth, Halstead, Adson, Pean
- tissue connection: needle holders by Hegar,
Mathieu
- surgical needles and suture materials
- instruments for grasping and clamping other
tissues and textile: towel clamps by Backhaus,
Schaedel