Download 9.Pelvis

LECTURE 9
THE ANATOMIC AND PHYSIOLOGIC
BASEMENT OF THE SURGICAL INTERVENTIONS
ON THE SMALL PELVIS ORGANS
Surgeons of the different specialization usually pay much attention to
the topographic anatomy of the small pelvis organs. Topography of the bladder
and ureter is important for urologist, womb and adnexa for obstetrics and
gynecologists, rectum for proctologists. Small measures of the true pelvis,
availability a number of the organs, nerves and vessels causes the certain
difficulties for surgical interventions for clinical and topical diagnosis.
There are large vessels and nervous plexes in the cellular spaces of the
small pelvis that causes a great lethality on account of traumatic shock and loss
of blood. The infectiosity of the organs' contents leads to the development of
phlegmons and their increasing.
The small pelvis is a part of a human body, which is bordered by two
hipbones, sacrum, coccygeal bone the 5 lumbar vertebra and ligaments.
The skin, soft tissues, which cover hipbones, belong to other anatomotopographical regions.
The hipbone consists of three bones these are iliac, sciatic, pubic bones
and are divided by the cartilage. The neonate may pass through the maternal
passages because measures and pelvis configuration may vary.
The three bones form a hipbone by union at the acetabular region. This
let us to carry great loading.
The bones union reflects the change of the function during phylogenesis.
The pelvis of the four-footed can’t carry on a large loading because their
horizontal posture.
The humans have a vertical posture and pelvis is a support for the
internal organs and a place of transferring of the load from corpus to legs,
separate bones connected by the cartilage forms one bone, and a synchondrosis
becomes a synosthosis. All the pelvic bones are sturdy fixed. There are
connected by three joints two sacroiliac joints, pubic symphysis and
sacrococcygeal symphysis. The pubic symphysis connects the pubic bones by
means of fibrous cartilage. The superior pubic ligament passes along the
superior edge of the joint. The arcuate pubic ligament passes along the inferior
edge of the sumphysis. It forms the urogenital diaphragm (the triangular
ligament).
The pubic symphysis may be disjoined in obstetrics practice to broader
the maternal passages. The operation is called the symphysotomia. The
sacroiliac articulation is paired, form by jointing of the auricular surfaces of the
sacrum and iliac bones. It is strengthened with ventral sacroiliac ligaments from
the front, with interosseal and dorsal sacroiliac ligaments from behind. The
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obstetricians call this articulation “a key of pelvis”. A rupture of these ligaments
while delivery is attended by the discrepancy of the pelvic ring. Women after
labor can’t walk for a long time with such a complication.
The mobility in the sacroiliac articulation play an important role in
delivery, the apex of the coccygeal bone back for 2cm while fetus passes
through the maternal passages. On account of this fact conjugate of the pelvic
outlet increases from 9sm to 11sm. If the coccygeal bone in immobile because
of fusing with the sacrum, there will be a stage, called a clinically contracted
pelvis.
The fixative apparatus of the pelvis consists of the ligament, between
the backbone and the upper flaring portion of the iliac bone. Two powerful
ligaments link the sacrum (on both sides) with iliac and ischiadic bones. There
is sacrotuberous ligament and sacrospinous ligament. Both ligaments the sciatic
spine and two notches of the innominate bone form the greater sciatic foramen
and the lesser sciatic foramen. Muscles, vessels and nerves pass through these
foramens.
The inguinal ligament and membrane obturatoria are the false ligaments
of the pelvic. Small measures of the ligaments and their tightness limit the
mobility in pelvic joints. Their physiological importance is to amortize sudden
strikes and pushes and reduce the strength of the hits while movements. The
rupture one of the joints is attended with affection of the others. That’s why
when the rupture of the pubic symphysis is having place; the removal of the
pubic bones is possible just with a slight tear at the sacroiliac articulation.
The walls of the pelvic bound are rather elastic, on account of the
coordinated actions of the joints. That’s why the fractures occur seldom just
because of a great straight power affection. The joints of the bones influent the
form of the fractures. The weakest places are situated on the anterior and
posterior bonewalls of the pelvis because these places have the spongious
structure. Sacral and obturatorium foramens are available and that’s the place of
union of three pelvic bones. These facts explain us the localization of the most
typical fractures. These fractures are double direct fracture, when the posterior
and anterior (straight) walls of the pelvis are fractured.
The fracture line goes through the foramen obturatorium from the front
across the place if ischiopubic symphysis and through the sacrum near the
sacral foramens from behind. The bone basement of the pelvis is divided into 2
parts: large (false) pelvis and small pelvis. The terminal line that passes through
the promontorium, arcuate line of the iliac bone, spine of the pubic bone and a
superior edge of the symphysis border them. The large pelvis belongs to the
inferior portion of the abdominal cavity. There are genitourinary system and the
terminal portion of the digestive system in the small pelvis.
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The conjugate of the inlet and outlet are important in obstetrics.
The gynecoid pelvis has such measures of the inlet the anterior-posterior
diameter of the pelvic inlet (from the promontorium to the pubic symphysis) is
11sm, the transversal diameter (the line between the farthest points of the
terminal line) is 13sm, oblique diameter (from the pubic tuber to sacroiliac
articulation0 is 12sm.
The obstetric conjugate or the outlet (the distance from the coccygeal
bone to the subpubic angle) is 11sm; the transversal diameter (the distance
between the tubes of the ischiadic bone) is 11sm.
The small measures of the bone pelvic ring mean the contracted pelvis.
There may occur pelvis justo minor, generally contracted flat pelvis, in
obstetrician pathology. An operative intervention is necessary than.
An axes of the pelvis is the line that passes in the middle of the
conjugates of the inlet and outlet, and goes through the center of the pelvis.
Pelvis is leaned to the front that is the physiologic posture. The angle
between the surface of the inlet and horizontal surface is 54-55 in women one
is called the angle of inclination.
Different diseases (rickets, pathologic curvature of the vertebral column,
congenital dislocations and inflammations in hip joint) influent the form,
measures and axis of the true pelvis.
Pelvic ring differs in men and women. Masculine pelvis is narrower and
longer, gynecoid pelvis is wider and shorter. The inlet is heart-spared in men
and oval in women. The subpubic angle is 70-75 in men and 80-100 in
women.
The muscles that cover walls and bottom of the true pelvis are parietal
and visceral. The piriformis muscle starts from the sacrum, goes through the
greater obturatorium foramen and fixates to the greater trochanter. The parietal
muscles are the next.
The piriformis muscle while passing through the greater obturatorium
foramen forms two slits: foramen suprapiriformis and infrapiriformis. Vessels
and nerves bounds pass there. The second parietal muscle is the internal
obtutatorium muscle. It starts from fixes to the fosse intertrochanterica.
There is ma fissure in a lesser sciatic foramen. The pudendal
neurovascular bound goes through the fissure into the ischiorectal fosse. Those
three foramens connect the pelvic cavity with the ischiac region.
The pelvic outlet covered with the visceral muscles those are forming
the diaphragm of the pelvis. These muscles are:
1) The levator ani muscle. It consists of the two portions (the pubococcygeal
and iliococcygeal muscle) those muscles start from the pubic bone and the
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tendinous arch formed by the strengthened pelvic fascia that goes around the
rectum. It fastens to the coccygeal bone.
2) The coccygeal muscles those pass from the coccygeal bone to the sciatic
spine.
3) The external sphincter of anus.
The pelvic cavity is divided into three portions (stores).
1) The peritoneal portion. That is the inferior part of the peritoneal cavity that is
limited by the horizontal surface that passes across the pelvic inlet and
contain the pelvic organs those are covered by the peritoneum.
2) The subperitoneal portion. That is a space between the peritoneum and
levator ani muscle.
3) The subcutaneous portion. That is a space between the diaphragm of the
pelvis and skin. The portion belongs to the perineum and contains the
ischiorectal fosse.
The peritoneum goes from the anterior abdominal wall and covers the
lateral parts and the posterior wall o the bladder, the internal edges of the
deferens duct and apexes of the seminal vesicles at the first portion of the pelvic
cavity in man.
There are two recesses in women’ anatomy. The peritoneum goes from
the bladder on to the uterine and forms the vesicouterine pouch. It passes then
from the uterine on to the rectum and is forming the rectourine) pouch
(Douglas’ pouch). That is the most inferior point of the abdominal cavity. The
pathologic fluid accumulates there while there is an inflammation in the
abdominal cavity or blood (while the oviduct breaks because of the extrauterine
pregnancy).
There will be a sharp pain if a doctor presses at the posterior vault of the
vagina and takes away his hand suddenly. The symptom is called the Douglas’
scream. One can have a fluid while puncture of the posterior vault of the vagina.
That helps to precise the diagnosis.
The walls and organs of the true pelvis are covered with the pelvic
fascia. The parietal layer covers the pelvic walls and the visceral one is fused
with the organs.
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The parietal layer goes down to the border of the superior and inferior
portions of the internal obturator muscle and forms the enlargement that is
called the tendinous arch. The levator ani muscle starts from it.
The pelvic fascia covers that muscle, piriformis muscle, it reaches then
the pelvic organs and goes upwards and becomes the visceral fascia.
The pelvic organs are inside the space that is bordered by the pubic
bones from the front, by sacrum from the behind and sagital plates of the
visceral fascia from sides.
The peritoneperineal aponeurosis (Salyshcheva-Denonvilley), which is
formed from the primary peritoneal duplicature, divides the space into the
anterior and posterior portions.
There are urogenital organs at the anterior portion and rectum at the
posterior portion. So all the pelvic organs have the fascial sheathes (coverings).
The prostatic sheath is called Pyrogov-Reticiy’ sheath and the rectal sheath is
the Amus’s sheath. The fascia is much like ligaments at the places of the organs
fastening to the pelvis.
There are muscular fascicles as well as collagenic and elastic fascicles.
Those are the pubovesical ligament and the puboprostatic ligament in men and
the pubouterine and sacrouterine ligaments in women.
The spaces between the fascial layers are filled with the pelvic fat.
The space between the pubic symphysis and bladder.
The triangle fascial plate (the antevesical fascia) is strained between the
obliterated umbilical arteries and ring and divides the space into two portions.
These are the antevesical fat (between the transversal and antevesical fascias
and anteperitoneal space (between the antervesical fascia and peritoneum). The
antervesical fat goes to the paravesical fat from sides where the internal ilium
vessels are passing.
The retrovesical space is between the posterior wall of the bladder and
peritoneoperineal aponeurosis. It borders with the sagital parts of the visceral
fascia from sides.
The recto rectal space is between rectum and sacrum. The fat that lies
around the rectum is called the pararectal fat.
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The parametric fat is around the neck of the womb. It is of a great
importance.
The lateral space is bordered by fascias of the obturator and piriformis
muscles from sides by ligaments those are straitened between the pubic bones
and sacrum from medial. The internal ilium vessels pass there. The fascia of the
piriformis muscle gives a segment that separates the parietal space from the
lateral one. There are branches of the sacral plexus and the great sciatic nerve
there.
The internal iliac artery is the main artery at the lateral space. It goes
more medial than transverse muscle and divides into the anterior and posterior
trunks. The anterior trunk goes superficially and gives visceral and parietal
branches. These are the umbilical artery, superior uterine artery (or the deferens
duct in men), inferior vesicle artery, middle rectal artery, obturator artery and
internal pudenda artery from which the inferior rectal artery starts away. The
posterior parietal trunk lies more profoundly. The lateral sacral, iliolumbar, and
inferior sciatic arteries go from it.
Nerves start from the sacral plexus that is formed by 4-5 lumbar and 1-3
sacral nerves. The sacral plexus lies on the anterior surface of the piriformis
muscle and gives branches. These are the superior and anterior nerves of the
sciatic part, the greater sciatic, posterior femoral cutaneus, obturator and
pudendal nerves.
The ligature of the ilium artery is performed when the parietal branches
of the internal ilium artery are damaged and bleeding can’t be stopped. An
access is performed according to Shevkunenko.The skin, fat and fascia should
be cut along the line, which starts from the edge of the 12 rib above the anterior
superior ilium spine and turns to the external body of the rectus abdominal
muscle. An access according to Pirogov is performed above the Poupart’s
ligament higher 2-3 cm and in parallels to this ligament. Then the abdominal
muscles and transverse fascia are cut. The peritoneum with the attached urethra
on it should be exfoliated by the gauze tourunde. The internal ilium artery may
be ligatured on the psoas muscle.
The blood supply of the pelvic organs the opposite side artery will
supply.
The suppurative processes of the perineal spaces.
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The suppuration may spread in different ways. The pus spread along the
vessels into the visceral spaces from the lateral space; into the ischiac fat
through the suprapiriformis foramens; into the medial surface of the hip through
the obturator foramen.
The pus spreads hip and into the anterior abdominal wall through the
obturator and femoral canals from the antervesical space. The pus spreads into
the retroperitoneal space along the urethra from the paravesical space or from
the retrovesical space.
The pus spreads from the parauterine space by two ways:
1) Along the round ligament of the uterus through the internal inguinal ring to
the anterior abdominal wall.
2) To the inguinal fosse and to the retroperitoneal space then.
There are such accesses for the abscesses draining:
1) The antevesical space is drained from the Cooprianov’s access. The inferior
median cut is performed; the packer passes between the bladder and the
levator ani muscle. Urogenital diaphragm and run through the skin under the
inferior border of the pubic.
2) The Buyalskiy-Mack-Woters’ access is put into practice for antervesical
space draining. The skin should be cut at the anterior surface of the hip 4-cm
lower than the femoralperineal fold. the packer passes through the abductor
muscles to the obturator membrane and breaks it in its lower portions. (there
is a neurovascular canal in its upper portion).
3) The Pyrogov’s access is applied for the operations at the ureter (its lower 1/3)
and for the antervesical space draining. The incision goes in parallels to the
Poupart’s ligament. The purulent parametritis may be drained from the same
access. If the process spreads towards the vagina the posterior vault of the
vagina would be drained. The semilunar incision between the anal orifice and
the sacrum is performed to access the retrorectal space.
The abscess should be evacuated in the rectum opening by its wall
incision if it lies directly near the rectum.
The urinary bladder.
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It is situated in the true pelvis cavity. It borders with the posterior
surface of the pubic symphysis in men. The seminal vesicles, ampulles of the
deferent duct and rectum lay from the behind. The prostata and the perineal
muscles are lower. The bladder borders with the uterine and the superior portion
of the vagine in women. The levators ani muscles are from sides. The bladder
lies higher than symphysis in infants.
There are apex, corpus, fundus and cervix that prolongs to the uterine in
the bladder. The peritoneum goes from the abdominal wall on to the anterior
wall of the bladder, forms the transversal fold and covers its superior, posterior
and partially lateral wall. The peritoneum is attached to the bladder with a loose
connective tissue, so slips lightly, accept the apex where it is jointed tightly
with the muscular layer. The full bladder juts out the symphysis. Its anterior
wall isn’t covered with the peritoneum. In this case that gives a possibility to
punctate the bladder without injuring the peritoneum.
The fixative apparatus of the bladder is rather important in surgery. It is
attached to the pubic symphysis with the pubovesical and puboprostatic
ligaments from the front; the rectovesical ligaments are from the behind. The
urethra is fastened to prostata from below. The apex is attached to the navel by
the obliterated cystic duct. There are the vesicouterine ligaments in women
instead of the prostatical component. There are 4 layers in the bladder. These
are the connective tissue, muscular, submucous and mucous layer.
There are external longitudinal, medial, circular and internal transverse
oblique layers in the muscle layer of the bladder. The circular layer is the most
powerful and forms the internal vesicle sphincter at the cervix of the bladder.
The main sphincter of the bladder is the external sphincter that is formed by the
striated muscle around the membranous part of the urethra. The mucous layer
slips on the submucous base and forms in the empty bladder accept the Letto
triangle where the submocus base is absent and there are no folds. The base of
the triangle are the interureter fold. Its apex is the cervix of the bladder with the
internal opening of the ureter. The triangle is the orientative point for finding of
the ureter openings while the chromocystscopiy.
The blood supplying is providing by the superior (a portion of the
umbilic artery) and inferior vesical arteries (those are the branches of the
internal ilium artery). The additional blood supply is providing from the medial
rectal and uterine arteries. The venous outflow is providing by the vesical
plexus that is attached with the antevesical and rectal plexuses.
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The sensitive innervating and voluntary regulation of the external
sphincter goes from the sacral plexus by the pudenda nerve. The parasympathic
splanchnic nerves (2-4 sacral segments) innervate the involuntary muscles of
the walls and internal sphincter.
There is bladder’s constriction and sphincter’s relaxation while those
nerves irritation. The sympathic innervating goes from the sympathic trunk. and
nerves of the hypogastric plexus. There is a bladder relaxation and sphincter
constriction while those nerves irritation.
The lymph flows off the into the ilium and hypogastrical lymphatic
nodes those are along the iliac artery and aorta.
Prostata.
It is situated between the bladder and urogenital diaphragm. It is cone
shaped. Its width is 4 cm, its length is 2 cm, height is 4 cm, and weight is 20 gr.
The sulcus divides it into right and left parts on its posterior surface. The
prostata borders with the levator ani muscle from sides, rectum that is separated
by the fascia from behind. That’s why it may be palpated through the rectum. It
is smooth and elastic in normal, with its sulcus and parts. The prostata is the
conglomerate of the alveoli-tubular glands in the musculous-connective tissue
stroma.
The urethra passes oblique through it. The urination is difficult while
prostata enlargening.
Its blood supply is providing by the inferior vesical, medial rectal and
internal pudendal arteries. These arteries form the organic plexus (Santorini
plexus) that is injuring easily while adenectomia and may be a cause of the
pulmonal artery’s thrombembolism.
The paracentesis of the bladder.
The intervention is performing while the acute parauria and the
cathetrization is impossible. The stippling is carrying out on 2 cm higher the
pubic symphysis perpendicularly to the abdomen strictly on the median line.
When gap feeling appears and the urine starts to drop from the end of the
cannula the bladder will empty. The needle must be quickly brought out after
the procedure.
The high incision of the urine bladder.
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The incision is carrying out to extract stones, foreign objects, tumors,
and adenoma by means of the catheter. The bladder should be filled with a
sterile physiologic salt solution to lift the bladder apex above the symphysis.
An access is a suprapubic median longitudinal incision. The bladder
walls are fixating with 2 ligatures through its muscular layer. The bladder
empties by means of the catheter and the surgeon incises its wall between the
ligatures. The wall of the vesicle should be sutured hermetically after the
manipulation. The first interrupted suture involves the adventicia, muscular and
the submucous layers. There is no reason to suture the mucous layer because
salt may crystallize on the threads. The external suture involves just the
adventitia and muscular layer.
The uterine.
It is the muscular cavitary organ that is situated between the bladder and
rectum. It consists of the corpus, fundus and cervix. There are orifices of the
oviduct at the borders of the fundus (base). The end of the uterine cavity has it
opening in the canal of the cervix. The isthmus of the uterine is between the
corpus and cervix. The obstetricians call it the superior segment of the uterine.
The inferior part o the cervix is in the vagine and may be palpated. That’s why
the cervix is divided into the supravaginal and vaginal parts. The wall of the
uterine consists of 3 layers. These are serosal (perimetrium) with the subserosal
basement, muscular (myometrium) and mucous layers (endometrium) (without
the submucouse basement).
The peritoneum covers the uterine mostly. The lateral borders have no
covering. There is a layer of fat between the anterior and posterior layers of the
peritoneum where the vessels and nerves pass.
The pelvic fundus is a fixative apparatus more important as the
ligaments are.
The ligaments are:
1) The broad ligament of the uterine. It is the peritoneal duplicature that passes
from the lateral borders of the uterine (uterine ribs to the lateral pelvic walls).
There is the uterine tube in it from above.
2) The cardinal ligaments. These are the fibrous muscular bands those are
passing at the inferior parts of the broad ligaments.
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3) The round ligament. It is the anologic to the Hunter’s gubernaculum. It starts
from the angles of the uterine and goes to the deep inguinal ring. It may pull
the peritoneum into the inguinal canal like the vaginal process in men. It is
called Nukke’s diverticulum and may be the pace of the cystogenesis. The
ligament diverges to Emlakh bunch in the large pudendal lip after the leaving
of the inguinal canal.
4) The sacrouterine ligaments. They go in the lateral folds of the peritoneum
from the sacrum to the uterine. There are muscular fascicles in it sometimes.
5) The vesicouterine ligament. It is the extension of pubovesical ligament and
is formed by the bulge of the sagital plate of the visceral layer of the pelvic
fascia.
The main blood supply is providing by the uterine artery, which is the
branch of the internal artery. The uterine artery crosses with the ureter for two
times. The ureter passes from the front of the uterine artery at start. The artery
passes from the front of the ureter at the middle of the uterine artery level. The
artery turns around the ureter semicirculary. They are equal at the diameter.
There is a danger of the ureter incision or dressing instead of the artery. The
pulsation may help differ them.
The uterine artery goes within the broad ligament and comes to the
uterine ribs and divides into the ascending and descending branches there. The
branches go in parallels to the uterine axe. The terminal arteries come
horizontally directly to the uterine from these branches.
The isthmus has lesser vessels than the corpus. The isthmus portion
ought to be incised while the Caesarian section according to the architecture of
the vessels net. There would be the lesser traumatisation and bleeding.
The ovarian artery provides the additional blood supply. It starts from
the aorta and forms the anasthomose with the uterine artery.
The uterine arteries are straight in infants. They become sinuous in
pubertates that gives a reserve for the uterine enlarging while pregnancy. The
arteries are the most sinuous after the delivery. The uterine involution is of a
great meaning in this process after the delivery. That is the symptom of labor in
past of a women at the medicolegal investigation.
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The venous outlet is providing by the uterovaginal plexus and ovarian
veins partially. The ovarian veins confluent into the inferior Cava vein from
right side and renal vein from the left.
The parasympathic innervation is providing by the pelvic nerves those
form the uterovaginal plexus (Frankengeiser’s plexus). The sympathic
innervation is providing by the hypogastrical plexus.
The corpus has sympathic innervation dominant, the cervix has the
parasympathic innervation dominant. That explains the chronic contraction of
the corpus and relaxation of the cervix while delivery. The nervous plexuses are
mostly in the parametriums from sides that should be mentioned while the
novocaine anesthesia.
The ovary.
It is lying in the fosse between the internal and external ilium arteries on
the internal obturator muscle. It is covered with a germinal epithelium that
makes a mat surface.
There is a residue of the peritoneum like a thin border that is called
Farae-Waldeyer’s ring.
The ligamentous apparatus.
1) The infundibulopelvic ligament is a suspensory ligament of the ovary. The
ovarian vessels pass there.
2) The own ligament. It goes from the lateral angle of the uterine to the uterine
end of the ovary.
3) The mesoovarium. It goes from the broad ligament of the uterine to its
posterior layer.
The blood supply is providing by ovary and uterine arteries.
The surgery interventions are carrying out because of the cysts, tumors
or breakups of the ovary. An access is the inferior median laparotomy. When
the cyst is too large it should be punctate and empty previously.
There is performing the exposure of cyst. There are two forceps on its
peduncle between them the dicision is carrying out. The seroserous suture is
applied. The abdominal cavity must be closed in layers. There is the uterine
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tube along the superior border of the broad ligament of the uterine. There are
the interstitial tube, tubal isthmus, ampullar tube and infundibulum. There are
fimbrias on the infundibulum those embrace the ovary.
Mesosalpinx is the part of the broad ligament of the uterine between the
uterine tube and mesovarium. The operations are carrying out while the
extrauterine pregnancy.
Four accesses may be applied.
1) The inferior median laparotomy from the umbilic to pubic.
2) Pfanenstile’s access. This is the arched incision along the suprapubic fold.
The blunt dissection of the straight abdominal muscles is applied after white
line section.
3) Cherny’s access. This is a transverse incision 5-6 cm higher than pubic
symphysis. All the layers are dissected. The access is applying when the
pelvic and abdominal organs revision is necessary.
4) The oblique incisions are in parallels to the Poupart’s ligament.
There are such moments of the operation because of the interrupted
tubal pregnancy.
1) The lips of the wound are pulled away with the retractor.
2) The exposure of the tube with the ooblast.
3) The dissection of the tubal part after the mesosalpinx clipping by Bilrote
clamp and dressing of it catgut suturing of the angle of the uterine.
4) The peritonization.
5) Clots of blood exposure from the abdominal cavity.
6) The revision of the pelvic organs.
7) The suturing of the wound.
The rectum intestine.
It is the terminal portion of the large intestine. It starts at the level of the
third sacral vertebra. It looses its mesentery there. There is a longitudinal layer
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of the smooth muscle along the rectum in contrast to other intestines. The pelvic
part of the rectum is higher than the pelvic diaphragm. The lower portion is
called the perineal part.
There is the ampoule and supraampullar portion in the pelvic part.
Rectum turns for two times in a sagital plane
The first curvature is from the behind and responds to the curvature of
the sacrococcygeal symphysis. The second curvature is from the front, where
the ampoule of the rectum goes onto anus. These curvatures are of a great
meaning while rectoromanoscvopia and endoscopia. When they are not
mentioned there is a risk of trauma.
The rectum curves to the left in the frontal plane. That’s why the patient
lies on his left side while administration of the enema. The length of the rectum
grows for 5-6 cm after straightening. That’s why the mobilization of the rectum
is possible while the intestinal obstruction.
The supraampular parts are covered by the peritoneum wholly. The
posterior side looses lower the peritoneal cover and then the lateral sides loose
it. The inferior part of the ampoule lies retroperitonealy.
There is the mesorectum at the supraampoular part sometimes. These
patients have the rectal prolapse more often.
There is prostata in front of the rectum in men or uterus in women. The
sacrum and coccygeum are from behind. There are ischiorectal fosses from
sides.
The mucous layer forms the circular folds in the pelvic part and
longitudinal folds in the perineal part. The longitudinal folds (Morgany’s
columns) end with the tubercles with the semilunaris valves. They form sinuses.
The circular space between the sinuses and anus is called the hemorrhoid zone.
The structure of the mucous layer plays role in the pathogenesis of the rectal
diseases. Every rectal abscess and fistula grows from the anal crypts. The
infection spreads into the anal submucous glands from there and goes into the
rounding tissues through the glands' wall.
The muscular layer consists of the longitudinal and circular fascicles.
The longitudinal muscles are distributed evenly.
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The circular muscles form sphincters those are the constrictive system
of the rectum. Its damage means the failure of the main rectal function.
The external sphincter is around the anus. The subcutaneous part is the
most superficial. The superficial part of the external muscular sphincter starts
from the coccygeal bone. The most powerful part of the anus is its deep part of
the striated muscles. The pudendal nerve gives the voluntary innervation.
The smooth muscles thicken 3-4 cm higher than anus and form the
internal sphincter. The third sphincter (or Hepher’s muscle) is 10 cm higher
than anus. There is the vegetative innervation. The both sphincters are
involuntary.
The sympathic innervation goes from the mesenteric and aortal
plexuses; the parasympathic innervation goes from the pelvic nerves. The
mucous and muscular layers are connected by means of vessels. The separation
of the mucous layer is possible after the complete dicision of the vessels. But
the mucous layer is rather mobile. The prolapse of the mucous layer may occur
if the vessels are too long.
The blood supply is providing by:
1) the superior rectal artery that goes from the inferior mesenteric artery
2) Twinned medial rectal artery that goes from the internal ilium artery.
3) Twinned inferior rectal artery that goes from the internal pudendal artery (the
brunch of the internal ilium artery).
When the superior and medial arteries are too long they may be the
factor of the rectal prolapse.
The venous outflow is providing by the subcutaneous, submucous and
subfascial plexes. The subcutaneous plexus is situated around the external rectal
sphincter. The submucuos plexus is the mostly developed. The subfascial
plexus is between the longitudinal muscular layer and rectal fascia.
The venous blood flows out into the rectal veins. The superior one is the
start of the inferior mesenteric vein and belongs to the portal vein system. The
inferior and medial veins belong to the inferior Cava vein system. The medial
veins flows into the internal ilium veins. The inferior veins flows into the
internal pudendal veins. That is the way of the portocaval anasthomoses
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formation. These anasthomoses may enlarge and imitate the hemorrhoid while
the portal system block.
That is rather possible because there are no valves in the hemorrhoid
veins.
The submucous plexus is rather special. Its structure is much like the
cavernous corpuses that means a lot of anasthomoses with arteries and
arterioles. The bleeding will be with a bright red color of the blood because of a
high containing of the arterial blood. The hemorrhoid bleeding may be
significant and leads to anemia. That fact ought to be mentioned while the
differential diagnosis of the intestinal bleeding.
There are 3 zones of the lymph outflow. These are the inferior, medial
and superior zones. The lymph flows into the inguinal lymphatic nodes from the
perineal part; into the sacral and internal ilium lymphatic nodes from the
ampoule and into the inferior mesenteric lymphatic nodes from the
supraampular part.
The sensitiveness of the rectum differs in various parts. The pelvic part
is of law sensitiveness. The anus is of a great pain sensitiveness because of the
various innervation. The pelvic part has the sympathic and parasympathic
innervation; the anus is innervated by the spinal nerves. That should be
mentioned while anesthesia.
The sacrum should be dicised lower than the third sacral foramen while
the access to the rectum. The 3rd, 4th and sometimes the 5th sacral nerves may
innervate the rectum. Don’t let these nerves to damage. That leads to the
functional break of the rectum, anal sphincter and other pelvic organs.
There are three accesses for the operative interventions at the rectum.
These are the perineal, abdominal and perineo-abdominal a sacral access.
The perineal access is applied when low localization of the tumor. But a
great trauma is possible if there is a need to broaden the wound by means of the
coccygeal bone or even the part of the sacrum extraction. (the operation by
Kraske).
The combined perineoabdominal access is much better. The rectum is
extracted both with the tumor through the laparotomy incision.
The operative treatment of the hemorrhoids.
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There are 3 groups of the operations
1) the dressing of hemorrhoids
2) Cutting off the piles.
3) Cutting off the mucous layer and piles by Widenhead.
1) The method has been founded by Hippocrates. The local type of the
anesthesia is applied. When the sphincter is rasped the fenestrated Luer’s
forceps should be placed on the piles. Then the mucous layer is dissected.
The hemorrhoid dressing is performing with silk ligatures on both sides. The
residue-free diet should be prescribed. The knots necrotize and falloff at the
6-7 day.
2) The operation by Rockytsky.
a) The local type of the anesthesia is employed. The piles are exposed
with Luers forceps; the denticulate Rockytsky forceps are applied lower. The
piles are cutting off and interrupted catgut suture is placed. The mucous layer is
sewed with between the denticles of forceps.
b) The operation by Meligane-Morgan. The idea is that the piles are
situated according the 3, 7 and 11 figures of the clock-face.
3) The operation by Widehead. It is the dicision of the mucous layer together
with the hemorrhoids as a cylinder of 5 c height. The mucous layer is pulling
down and sewing to the skin.
4) The constriction of the anal canal may occur as a complication.
The perineum.
This is a system of the soft tissues that closes the pelvic outlet. It is
bordered by the pubic and sciatic bones in front, by sciatic tubers from sides
and by the sacrum from the behind. It is a diamond-shaped.
The obstetrical perineum is the tissue between the posterior comissure
and anus. The perineum divides into urogenital and anal triangles by the arch
line between the sciatic tubers.
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There is a suture on the skin in man. It is the prolongation of the scrotal
suture. There are branches of the pudendal nerves and internal pudendal vessels
in the subcutaneous fat.
The superficial fascia covers the superficial muscles of the perineum.
These are the superficial transverse perineal muscle, ischiocavernosus and
bulbospongious muscles. The profound layers of the urogenital triangle are
called the urogenital diaphragm. It consists of the inferior fascia of the
urugenital diaphragm that covers the deep transverse perineal muscle and
arcuate pubic ligament from the side of the pelvic surface.
The diaphragm is stretched between the arcuate pubic ligament and
transverse perineal ligament.
The urethra passes through the urogenital diaphragm. The vagine passes
through it in women.
The muscular fascicles those are strengthening the sphincter of the
urethra are starting off the deep transverse muscle.
There are three parts in the urethra in men. These are the prostatic,
membranous and spongious parts. The urethra turns twice. The first retropubic
flexure is formed by the spongious part and curves to the behind and down. The
membranous part is fixed the best. These facts have to be mentioned while the
cathetrization of the bladder.
The skin, subcutaneous fat and superficial perineal fascia are the layers
of the anal triangle. The profound layers are the ischiorectal fossa that is filled
with the fat tissue. It is located around the rectum and anus. The internal
obturator muscle with its fascia borders from the exterior ad the levator ani
muscle borders it from the middle.
It is bordered from the perineal side too. The inferior end of the great
ischiadic muscle is from the behind, the sciatic tubers are from the exterior and
the external anal sphincter is from the middle, the superficial perineal muscle is
from the front.
The levator ani muscle is covered with the inferior pelvic fascia from
the surface of the ischiorectal fossa.
The pudendal nerve and internal pudendal vessels pass from the ischiac
region through the minor obturator foramen. The nerve and vessels are lying on
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the internal obturator muscle. The end of the fascia forms a canal for them.
(Olkock’s canal).
The inflammation of the ischiorectal fat is called the paraproctitis.
There are the subcutaneous, submucosal ischiorecal and pelvirectal
paraproctitis.
1) The semilunar incisions are applied while the subcutaneous paraproctitis. The
radial incisions are atraumatic for the branches of the pudendal nerve those
converge radial to the external anal sphincter. But the incisions concur with
the anal folds. That’s why the incisions collapse soon. The semilunar
incisions are expanded that lets the deep access. But the damage of the
pudendal nerve is rather possible. That’s why just the skin is incised
semilunary. The blunt dissection of the deeper tissues is employed.
2) The submucosal paraproctitis is incised through the mucous layer and
drained through the anus.
3) The ischiorectal paraproctitis is incised in the middle between the external
sphincter and sciatic tuber to avoid the damage of the sphincter and
neurovascular bound.
4) The pelvirectal paraproctitis is incised semilunary between the coccygeus and
anus. The blunt dissection of the tissues is employed then between the levator
ani muscle and the coccygeal muscle.
The operative anatomy of the testicles.
The embryogenesis o the testicle goes at the 4 th month both with the
primary ren retroperitoneally. It descends to the internal inguinal ring at the 7 th
month of the embryogenesis. It passes through all the layers of the abdominal
wall and forms all the coverings (sheathes) with itself. The testicle has own
albugineal envelope. The testicles are intime attached to the peritoneum and
pull into the scrotum like a vaginal process that obliterate to the moment of
birth. The serous envelope of the testis forms just to the moment of birth too. Th
internal spermatic fascia is formed of the transverse abdominal fascia. The
cremaster muscle is formed by the oblique and straight abdominal muscles. The
external spermatic fascia is formed by Tompson’s plate; tunica dartos is formed
by the subcutaneous fat.
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The testicular arteries provide blood supply. The venous blood outflows
from the right testicle into the inferior Cava vein and from the left one to the left
renal vein. That explains more frequent dilatation of the veins of the left testicle
and spermatic cord.
The operation by Ivanisevich is performed then. That is the dressing of
the left testicular vein or both vein and artery (operation by Yerohin).
Hydrocele occurs frequently. This is the accumulation of the fluid in the
serous envelope while the inflammatory, posttraumatic fluid production
dominates its absorbtion.
The parietal layer of the own envelope is incised and the fluid has to
flow to the tunica dartos.
1) The operation by Wincelmann (the incision and turning inside out of the
envelope).
2) The operation by Bergmans-Israel (cutting off the segment of the parietal
layer).
3) The operation by Alferov (fenestration).