The upper floor

1. Bashkir State Medical University
Department of Topographic Anatomy and Operative Surgery
TOPOGRAPHICAL ANATOMY AND
OPERATIONAL SURGERY OF THE UPPER
ABDOMINAL CAVITY
Reviewer: Associate Professor V.D. Zakharchenko
Lecturer: Candidate of Medical Sciences,
Associate Professor I.M.Nasibullin

2. abdominal cavity (abdominalcavity)- the inner space of the
abdomen, linedtransverse fascia (intra-abdominal
fascia)andlimited:
abovediaphragm;
front - the back wall of the aponeurotic sheath of the rectus
abdominis muscles and transverse muscles;
By sides- these muscles and wings of the iliacbones;
behind - lumbar spine, psoas major, quadratus lumborum,
latissimus dorsi back;
from below- the plane of entry into the small pelvis.
Includes:
Abdomen(peritoneal cavity,peritonealcavity)- a set of slit-like
spaces between the sheets of the peritoneum (parietal and
visceral), covering the organs and walls of the abdominal cavity;
contains a small amount of serousliquids (25-30ml).
Retroperitoneal space- between the parietal peritoneum of the
posterior abdominal wall and the transverse fascia.
ABDOMEN

3. Upper abdominal cavity
- the department of the abdominal cavity, located above
the transverse colon and its mesentery;
containsstomach, liver with gallbladder, spleen,
abdominal esophagus, early duodenum.

4. Peritoneum-thin translucent serous membrane,coversinternal walls of the
abdominal cavity and the surface of internal organs.It hassmooth shiny surface,
formed by two sheets - visceral (covering organs) andparietal, both sheets are a
direct continuation of one another and form ligaments at their place of transition.
Intra peritoneally (organ covered with peritoneum on all sides):
stomach,
spleen,
jejunum,
iliac,
cecum,
appendix,
transverse colon,
Sigmoid colon
Meso peritoneally(organ covered with peritoneum on three sides):
liver,
gallbladder,
ascending colon,
descending colon
Extra peritoneally (organ covered peritoneum on one side):
pancreas,
duodenum,
bud, ureter
PERITONEUM. ATTITUDE of ORGANS TO THE PERIODIN

5. PERITONEUM
Distinguish: ligaments, omentums and mesentery.
With peritoneal tying-peritoneal transitionfrom one organ to
anotherorfrom the organ to the abdominal wall.
Lesser sac-duplication peritoneumcontainingbetween
themsignificant amountfatty tissue.
Mesentery-duplication peritoneum, with the help of which the
intestine, on the one hand, is fixed to the posterior wall of the
abdominal cavity, and on the other hand, mobility is
providedintestines in whichNumerous blood and lymphatic
vessels, nerves and lymph nodes are enclosed.
Parietalthe sheet of peritoneum covers the anterolateral
abdominal wall from the inside and at the top passes to the lower
concave surface of the diaphragm and then to the diaphragmatic
surface of the liver, forming twobundles:
insagittal plane -crescent;
infrontal plane -coronal, which is at the edgescalled rightandleft
triangular ligament.
rearsurface of the liver adjacent todiaphragmnot covered by
peritoneum. Furtherthe peritoneum passes to the visceral surface
of the liver, approaching the gates of the liver, goes to the lesser
curvature of the stomach, formingsmall omentum.
Sagittal section of the abdomen. (J.V. Roen,
1998):
one- liver; 2 - stomach; 3 - transverse colon; 4 -
a large gland; 5 - small intestine; 6 - uterus; 7-
vesico uterine deepening; 8 - bladder; 9 -
urethra; 10 - small gland; 11 - gland hole; 12 -
stuffing bag; 13 - duodenum; 14 - the root of the
mesentery of the small intestine; 15 - rectum; 16
- rectal-uterine depression; 17 - the vaginal part
of the cervix; 18 - vagina; 19 - anal canal.

6. - Formed of three links which go from one to another.
Left part presented-diaphragmatic-gastric ligament (goesfrom diaphragm
tocardiastomach,contains onlyfiber);
Medium -hepatogastric(connectshilum of the liver and lesser
curvaturestomach),contains anastomosisleft and right gastric arteries, as well as
branches of the vagustrunks;
Right -hepatoduodenal ligament (from the liverto the duodenumintestine),
contains:gatevein, common and proper hepatic arteries, right gastric
artery,gastro-duodenal artery andcommon bileduct.
On theThe lesser curvature of the stomach divides the peritoneum into two
layerscovering front and backwall of the stomach. At the level of the greater
curvature of the stomach, both layers of the peritoneum form gastrocolic
bundle (betweens tomach and transverse colongut),which further freely
descends to the small pelvis in the form greater omentum.
Greater omentum consists of four sheets of peritoneum - two of them
continuation gastrocolic ligament, descend topelvis, tucking backto the
transverse colon. The posterior two sheets of the omentum cover the transverse
colon and, forming its mesentery, go to the posterior wall of the abdominal
cavity, where they again diverge into two sheets. One goes up and lines the back
wall of the stuffing bag (Fig..), the other is sentdown and lines the posterior wall
of the lower floor of the abdominal cavity, covering the duodenum, ascending
and descending colons. In the lower abdomen, the peritoneum covers the small
and sigmoid colon, forming a mesentery for each of them, and then descends
into the small pelvis, lines its walls and organs..
Small, big omentum

7. On the top floor are:
Right liver bag-between the diaphragm and the right lobe of the liver:
Behind- right coronary ligament;
Left- crescent ligament;
Bottom right- opens atprehepaticbag and right side channel;
Bottom- freely communicates with the lower floor;
It forms subphrenic abscesses (complications of purulent appendicitis,
cholecystitis, perforated ulcers of the stomach, duodenum, etc.). It
communicates through the right lateral canal with the right iliac fossa, and
along the outer edge of the liver – with subhepatic space;
Left liver bag-between diaphragm andleftlobe of the liver:
Behind- leftcoronalbundle
On right-falciform ligament
Left- left triangular ligament
front- communicated withpregastricbag
Pregastrica bag- between the stomach and the left lobe of the liver:
front- lower surface of the left lobe of the liver
Behind- lesser omentum, anterior wall of the stomach
Above- gates of the liver
Bottom- freely communicated with the lower floor
Abscesses of the left subphrenic spaces can spread into the lower floor of the abdominal cavity through a gap in front of the
greater omentum and on the left - into the blind sac of the spleen.
Sub hepatica bag:
Anterior - lower surface of the right lobe of the liver
Bottom - transverse colon with mesentery
On the left - the portal of the liver and the omental opening
Right - opens into the right side channel
Abscesses of the left subphrenic spaces can spread into the lower floor of the abdominal cavity through a gap in front of the
greater omentum and on the left - into the blind sac of the spleen.

8. Lesser Sac (bursa omentalis)
slit-like cavity, behind the stomach
above- caudate lobe of the liver;front—
small seal, rear wallstomach
andgastrocolic ligament;
behind —parietal peritoneum,covering
the pancreasgland;
from below —transverse colon with
mesentery;
left —gatesspleen,diaphragmatic-splenic
and gastro-splenic ligaments;on right -
stuffing boxhole.

9. Lesser Sac(forum epiploicum;Vinslovo hole)—
reports slesser omentum with abdominal cavity
above- caudate lobe liver,
front- hepatoduodenal ligament
behind- hepato-renal ligament,
from below—renal-duodenal ligament;
Small gland (omentum minus)—duplication
peritoneum,from the lower surface of the liver
to the lesser curvature of the stomach and the
initial part of the duodenum;
Submitted by:
diaphragmatic-gastric,
hepatogastric
hepatoduodenal ligaments

10. Top stuffing box(recessus superior
omentalis;syn.:stuffing box upper) - part of the
stuffing bag adjacent to the caudate lobe of
the liver.
Omental lower recess (recessus inferior
omentalis;syn.:lesser sac) - part of the stuffing
bag, located between the pyloric part of the
stomach and the pancreas.

11. COMPOSITION OF THE HEPATIC-DUODENAL LINK
General hepaticduct (4)
Cysticduct
common bileduct (1)
Own hepaticartery (3)
gatevein (2)
Hepatic lymph nodes
Lymphatic vessels
hepatic nerve plexus
Loose fiber
liver segment (segmentum hepatis)- a section
of the liver in which the segmental branch of the
portal vein branches,relevanther branch of her
own hepatic artery and segmental bile duct;
Distinguish8 segments of the liver.

12. EXTRAHEPATIC BILE TRACTS
Right hepaticduct (1)
Left hepaticduct (1)
General hepaticduct (2)
biliousbubble (10)
Cysticduct (3)
common bileduct (4)
Supraduodenal part
Posterior duodenalpart
pancreatic part
Intra-wall part
Ampoule of common bileduct
Major duodenal papilla(7)

13. Projection on the anterior abdominal wall:
Cardiac part- the border of the chest and abdominal walls is 2-3
cm to the left of the attachment siteVI-VIIleft costal cartilages to
the sternum.
Bottom– projection onto the anterior chest wall within the range
betweenV-VIIIleft costal cartilages. The top dot matches the
bottom edgeVribs in the midclavicular line. LevelXthoracic
vertebra.
Body of the stomach- in the left hypochondrium and epigastric
regions.
Pyloric part- the right section of the epigastric region itself.
Entrance to the stomach-VI-VIIrib cartilage 2-4 cm to the left of the
sternum line.
Place of transition to the duodenum- the middle of the distance
between the xiphoid process andnavel,levelI lumbar vertebra.
Lesser curvature- at the xiphoid process, less often 5-7 cm below
it.
Greater curvature- in the middle distance between xiphoid
process and umbilicus.
Stomach

14. Ligaments of the stomach:
Surface (a)
1.Diaphragmatic-esophageal-between the diaphragm, esophagus and cardia of
the stomach; contains a branch of the left gastric artery.
2. Gastro-diaphragmatic -It is formed as a result of the transition of the parietal
peritoneum from the diaphragm to the anterior wall of the bottom and partially to
the cardial part of the stomach.
3.Gastro-splenic-between the spleen and the greater curvature of the stomach;
contains short arteries and veins of the stomach.
4.Gastrocolic-between the greater curvature of the stomach and the transverse
colon; contains the right and left gastroepiploic arteries.
5.Hepato-pyloric-between the gates of the liver and the lesser curvature of the
stomach;
6. Hepatogastric-between the gates of the liver and the lesser curvature of the
stomach; contains the left and right gastric arteries, veins, branches of the vagus
trunks, lymphatic vessels andnodes, on the right passes into the hepatoduodenal,
forming a lesser omentum.
Deep (b)
1. Gastro-pancreas bundle-with the upper edge of the pancreas on the back
wall of the body,cardia and bottom of the stomach; contains the left gastric
artery
2. Pyloric-pancreas –with upper border of the pancreas to the pylorus.

15. Holotopia
- Left hypochondrium,
Actually epigastric areas.
syntopia:
up - diaphragm and left lobe of the
liver
behind and left- pancreas, left
kidney, adrenal gland andspleen
front - abdominal wall
down below - transverse colon and
its mesentery.

16. From the celiac trunk(Haller's tripod)trancus coeliacus (from aortaat
the level of the XII thoracic or I lumbar vertebra at the upper edge of the
pancreatic glands),and its branches: a.gastrica sinistra, a.hepatica
communis, a.splenica(lienalis).
Lesser curvature -left and right gastric arteries:
Left gastricartery- from celiac trunk, goes under gastro pancreatic
crease reaches lesser curvature at cardio esophageal branches, next runs
from left to right between the leaves of the lesser omentum giving front
and rear branches to walls of stomach. Final artery branches anastomose
with the right gastric artery, formin ganastomotic arc.
Right gastricartery-from own hepatic artery, less often from
gastroduodenal or general hepatic artery, between leaflets hepatogastric
bundles anastomoses with the left gastric artery.
Alonggreater curvature - leftand right gastro-omental arteries forming
anastomotic arc:
Left gastroepiploic artery -moving away from splenic artery in the
splenic-gastric ligament, goes left to right along the greater curvature in
gastrocolic giving back to the bunchomental branches and posterior
gastric artery.
Right gastroepiploicartery- from gastro duodenal artery behind the
duodenum and runs from right to left in the gastrocolic ligament along
the greater curvature stomach, giving anterior and posterior branches to
the stomach and several lesser sac branches.
Bottomstomach -short arteries stomach (from 1 to 6 branches),from
splenic arteries located in splenic-gastric link, at walls of the stomach
anastomose with other arteries of the stomach.
Blood supply to the stomach

17. Venous drainage from the stomach. Veins of the stomach
Venous drainage from the stomach carried outinto
the systemportal vein.
Left gastricvein-most often falls directly to the portic
vein.
Right gastricvein- flows intointo the portal vein or its
left branch in the hepatoduodenal ligament.
Right gastroepiploicvein - flows into the superior
mesenteric vein.
On theanterior surface of the pylorus,passes
v.prepylorica-internal landmark border between the
pylorus and the duodenum.
Left gastroepiploicvein- and short veins of the
stomach fall into the splenic vein.
There are anastomoses between leftgastric vein (portal
vein system)with esophageal veins (top hollow
system),falling into an unpaired vein.
With portal hypertension anastomoses varicose
expanding – syndrome Mallory-Weiss -superficial
lacerations of the abdominal mucosa esophagusand
cardiac department stomach with recurrent vomiting,
accompanied bleeding.

18. Lymph drainage - through the lymphatics nodes of the first and second
order.
First order regional nodes:
Rightsand left gastric- inlesser omentum.
Rightsand leftgastro-omental - inligaments of the greater omentum.
Gastro-pancreas-in the gastro-pancreatic ligament.
Second order regional nodes: - celiac The lymph nodes.
Innervation of the stomach - vagus nerves and branches of the celiac
plexus.
Sympathetic fibers reach the stomach from celiac plexus through the
superior and inferior gastric, hepatic, splenic, and superior mesenteric
plexuses.
Para sympa thetic fibers are included left and right vagus trunks.
Anterior (left) vagus trunk –lies on the anterior surface of the abdominal
esophagus. At the stomach, it gives off the anterior gastric branches,the
most significant is the front small branch curvature(front nerve Latarjet)
going to pyloro anthral. Also depart hepatic and pyloric branches.
Rear (right) vagus trunk- lies between the posterior surface of the
esophagus and the abdominal aorta, gives posterior gastric branches with
posterior nerve small curvature(rear nerve Latarjet),and branchto the
celiac plexus.
Lymph drainage and innervationstomach

19. Topography of the duodenum
Departments:
one. Upper part (bulb)- betweenthe pylorus of the stomach and the superior flexure of the
duodenum.
intraperitoneally in primary,mesoperitoneallyin the middle parts.
Skeletotopia -L1-L3.
Syntopy:gallbladder above, head below pancreas,front antral part of the stomach.
2. Descending part-forms a bendto the right and goes from the upper to the lower bends.
ATit opens common bile duct and pancreatic duct on the major duodenal papilla.
Above - fickleminor duodenal papilla, on which the accessory pancreatic duct opens.
Retroperitoneally.Skeletotopia – L1-L3.
Syntopy:on the left is the head of the pancreas, behind and on the right is the right kidney,
right renal vein, inferior vena cava and ureter, in front of the mesentery of the transverse colon
and loops of the small intestine.
3. Horizontal part of the duodenum- from inferior flexure to intersection with the superior
mesenteric vessels.
Retroperitoneally.
Skeletotopia – L3.
Syntopy:from above the head of the pancreas, behind the inferior vena cava and abdominal
aorta, in front and below the loop of the small intestine.
4. Ascending part of the duodenum- fromintersection with the superior mesenteric vessels
to the left and up to the duodeno-jejunal flexure and is fixed by the suspensory ligament of the
duodenum.
Mesoperitoneally.
Skeletotopia– L3-L2.
Syntopy:from above the lower surface of the body of the pancreas, behind the inferior vena
cava and abdominal aorta, in front and below the loop of the small intestine.

20. Ligaments of the duodenum
Hepatoduodenal ligament- between the gates of the liver and the initial
section of the duodenumintestines, containsown hepaticartery (left)common
bileduct (right), between them and behind portal vein.
Duodenal-renalbundle- with masonry the peritoneum is stretched
between the outer edge of the descending part of the intestine and the right
kidney.
Lymph drainage
Diverting lymphatic vessels drain into the lymph nodes of the first order –
upper and lower pancreaticoduodenal nodes.
innervation
Implemented from the celiac, superior mesenteric, hepatic and pancreatic
plexuses,and branches both vagus nerves.

21. Blood supply from the system of
the celiac trunk and superior
mesenteric artery.
Posterior and anterior superior
pancreaticoduodenal arteries
depart from the gastroduodenal
artery.
Posterior and anterior inferior
pancreaticoduodenal arteries
depart from the superior
mesenteric artery, go towards the
two upper ones and connect with
them.
Blood supply to the duodenum

22. Veins of the duodenum repeat
the course of the arteries of
the same name, divert blood
into the portal vein system.
Venous outflow

23. LIVER
Holotopia
Right hypochondrium, epigastric region proper,
partially left hypochondrium
Skeletotopia:
Upperborder:
onleft midclavicular line
V intercostal space;
On right parasternal—
V costal cartilage;
On right midclavicular line
IV intercostal space;
On right mid-axillary
VIII edge;
At spine - XI rib.
Lowerborder:
On right mid-axillary line
X intercostal space;
On midline - the middle of the distance between
the navel and the base of the xiphoid process,
goes under the left costal arch at the level of the
VI costal cartilage

24. Age features
-in a newborn, the liver is large and occupies more than half of the
volume of the abdominal cavity.
Weight liver of a newborn 135 g (4-4.5% of body weight), in an adult
(2-3% of body weight).
In the postnatal period, the liver continues to grow, but more slowly
than body weight.
The liver parenchyma is poorly differentiated, the lobular structure is
revealed only by the end of the first year of life.
Left the lobe of the liver is equal to or greater than the right. In a
newborn, the lower edge of the liver along the right mid-clavicular line
protrudes from under the costal arch by 2.5-4 cm, and along the
anterior midline, 3.5-4 cm below the xiphoid process.
At in children 3-7 years old, the lower edge of the liver is 1.5 cm-2 cm
below the costal arch.
After 7 years the lower edge of the liver from under the costal arch is
not coming out (not palpable).
By the age of 8, the morphological and histological structure of the liver
is the same as in adults.
Atin children, the liver is very mobile and its position changes easily
with a change in body position.

25. Syntopy:
above - diaphragm;
front - anterior abdominal wall and diaphragm;
behind - X and IX thoracic vertebrae, crura of the diaphragm,
esophagus, aorta, right adrenal gland, inferior vena cava;from
below- stomach, bulb, superior flexure and upper quarter of the
descending duodenum, right flexure of the colon, upper pole of
the right kidney, gallbladder.
Ligament apparatus
Crown bundle-fixesliver to the lower surface of the diaphragm
in the frontal plane. At the right and left edges of the liver, it
passes into right and left triangular ligaments.
Crescent bundle-insagittal plane between the diaphragm and
the convex diaphragmatic surface of the liver on the border of
its right and left lobes.
Round ligament (partially obliterated umbilical vein)-
between umbilicus and hilum of the liver in the free edge of the
falciform ligaments.
Hepatic-gastric, hepatic-duodenal and hepatic-renal
bundles- from visceral surface of the liver to the corresponding
authorities

26. There are two surfaces on the liver:
- diaphragmatic,facies diaphragmatica, convex and smooth, facing the
diaphragm and in contact with its lowersurface
- visceral,facies visceralis, facing down and back and in contact with
a number of abdominal organs.
Upper and lower surfaces in front are separated from each other by a
sharp edge,margo inferior, on which there is a notch of the round
ligament,Incisura lig.teretis. On the sides, both surfaces converge at an
acute angle. On the visceral surface of the liver there are two
longitudinal (going from front to back) and one transverse groove,
resembling the letter H. The left longitudinal groove serves as the
border between the right (larger) and left lobes of the liver on its lower
surface. The anterior part of the left sulcus, occupied by the round
ligament of the liver, is called fissura lig.teretis. Rear end,fissura
lig.venosi, contains a fibrous cord, which is a continuation of the round
ligament and represents the remainder of the overgrown venous duct
(lig.venosum|Arantius]), which connects the umbilical vein with the
inferior vena cava in the prenatal period. Parallel to the left
longitudinal groove on the lower surface of the liver is the right
groove. In its front part lies the gallbladder, so this part of the furrow is
called fossa vesicae biliaris (felleae). Rear, deeper sulcus v.cavae
occupied by the inferior vena cava. rear ends fissura lig.teretis and
fossa vesicae biliaris(felleae) are connected by a transverse groove.
Longitudinal depressions and a transverse groove on the lower surface
of the right lobe of the liver distinguish two more lobes: square in
front,lobus quadratus, and tailed behind, lobus caudatus

27. Portal of liver
Transverse the sulcus corresponds to the hilum of the liver, porta hepatis.
Anterior border of the hilum of the liver- formsposterior edge of the square lobe,
right- right lobe
back- caudate lobe and partially right,
left- left lobe.
Transversegate size - 3-6 cm, anteroposterior - 1-3 cm. The leaves of the
visceral peritoneum, forming duplicate- hepatoduodenal ligament. Inside this
ligament, the right and left branches of the proper hepatic artery and the right
and left branches of the portal vein enter the liver through the gate.
From The right and left hepatic ducts leave the liver gate, inside the ligament
connecting to the common hepatic duct. The liver parenchyma is covered with a
fibrous membrane,tunica fibrosa,Glisson capsule [Glisson], which is especially
developed in the gates of the liver, where it forms the sheaths of blood vessels
and nerves and penetrates with them into the thickness parenchyma.

28. blood supply
Peculiarity - blood is delivered by two vessels: own hepatic artery and portal
vein.
Hepatic artery- branch of the common hepatic arterylongfrom 0.5 to 3cm,
diameter -2-4 mmbeing branch of the celiac trunk. Goes to the left of the
common bile duct to the gates of the liver, is divided into the right and left
branches. The right branch supplies the right lobe and partially the caudate,
gives the cystic branch to the gallbladder, the left branch - left lobe, square and
partiallytailed, its length is 2-3cm, diameter -2-3 cm.
Portal veincarries venous blood to the liver from all unpaired organs of the
abdominal cavity. Its trunk is formed behind the head of the pancreas from the
splenic and superior and inferior mesenteric veins.
umbilical vein- in the round ligament of the liver, flows into the left trunk of
the portal vein;obliteratednear the umbilical ring.
Paraumbilical veins- in the round ligament of the liver, flow into the portal
vein; carry blood from the anterior abdominal wall.
Venous drainage from the liver - 3-4 hepatic veins, flow into the inferior vena
cava, closely adjacent to the posterior surface of the liver.

29. innervation
- from celiac plexus;
-From vagus and right phrenic nerves.
At port of the liver from them are formed anterior and posterior
hepatic plexuses located between the sheets of the
hepatoduodenal ligament of the liver around the hepatic arteries.
Lymph drainage
carried outto the lymph nodes located:
- at the gate of the liver;
- inright or leftgastric;
- celiac;
- pre-aortic,
- Lower diaphragmatic and lumbar nodes.

30. Spleen
Holotopy: left hypochondrium.
Skeletotopia: between the IX and XI ribs fromparavertebralto the mid-
axillary line.
Relation to the peritoneum: intra peritoneal organ.
Bundles:
Gastro-splenic - from the greater curvature of the stomach to the hilum of
the spleen (contains the left gastroepiploic vessels and short gastric arteries
and veins);
splenic-renal - from the lumbar part of the diaphragm and the left kidney to
the hilum of the spleen (contains the splenic vessels).
blood supply-splenic artery from the celiac trunk.
The splenic vein is 2 times larger in diameter than the artery, located below,
participates in the formation of the portal vein.
innervation- carry outceliac, left diaphragmatic, left adrenal plexus. Arising
from these sources twigs form splenic plexus around artery of the same
name.
Lymph drainage- in the regional lymph nodes of the first order at the gates of
the spleen. In the celiac lymph nodes - nodes of the second order.

31. Pancreas
Holotopy:the epigastric region proper and the left hypochondrium.
Projected along a horizontal line through middle the distance between the
xiphoid process and the umbilicus.
Skeletotopia:head - L1, body - T12, tail - T11.
Located in oblique position,longitudinal axis directed from right to left and
bottom up.
Relation to the peritoneum:retroperitoneally.
blood supply – from common basins hepatic, splenic and superior
mesenteric arteries.
Bundles
gastrointestinal- transition of the peritoneum from the upper edge of the
gland to the posterior surface of the body, cardia and bottom stomach(the
left gastric artery passes along its edge);
porta gastric- transition of the peritoneum from the upper edge of the body
of the gland toantralpart of the stomach

32. Abdominal puncture (syn.: abdominal puncture, laparocentesis)-
puncture of the abdominal wall using a trocar, produced to extract
pathological contents from the abdominal cavity or introduce
laparoscope.
Laparotomy(syn.: incision)- operational access to the abdominal
organs, carried out by layer-by-layer dissection of the anterolateral
abdominal wall and opening the peritoneal cavity.
Thoraco laparotomy - operative access, which consists in the
simultaneous opening of the chest and abdominal cavities from one
incision; It is used in operations in hard-to-reach areas in the lower
part of the chest and upper part of the abdominal cavity.
OPERATIVE ACCESS TO THE ABDOMINAL ORGANS

33. Longitudinal sections
upper median
central median
lower median
paramedian
transrectal
Pararectal on Lenander-Dobrotvorsky
Oblique cuts
oblique along Kocher,
oblique according to Fedorov,
oblique according to Cherni–Keru,
oblique by macBurney,
Oblique section according to Volkovich–
Dyakonov
TYPES AND METHODS OF LAPAROTOMY

34. Transverse incisions
transverse in epigastrium
transverse in mesogastrium
transverse in hypogastrium
Combined cuts
angle cut
Angular incision along Rio Branco
Incision on Keru
Bayonet incision
anchor-shaped incision
Thoracoabdominal incisions(thoracolaparotomy)

35. REQUIREMENTS FOR LAPAROTOMIC SECTIONS
Compliance of the incision with the projection of the organ on the
abdominal wall
Sufficient organ exposure
Malaya injury
Receipt durable surgical scar

36. OPERATIONS ON THE STOMACH
TYPES OF OPERATIONS ONSTOMACH
Gastrotomy
Pylorotomy
gastrostomy
Gastroenterostomy
Resection of the stomach
Gastrectomy
Gastroplasty

37. Gastrotomy—operation opening of the stomach
cavity.
gastrostomy - an operation to create an external
fistula of the stomach for the purpose of artificial
feeding of the patient.
By Witzel - withusing a rubber tube sewn into the
anterior wall of the stomach to form a channel, at the
end of which the tube is inserted into the stomach
cavity; the other end of the tube is brought out, the
stomach is sutured to the anterior abdominal wall.
By Kaderu - introduction of a rubber tube into the
stomach cavity perpendicular to the anterior wall and
fixing it to the wall of the stomach with two or three
concentrically applied purse-string sutures, creating
a channel around the tube, lined with the serous
membrane of the stomach.
By Topprover - the anterior wall of the stomach is
brought into the wound in the form of a cone, several
purse-string sutures are placed on it and they are
tightened around the rubber tube inserted into the
stomach through the opened top of the cone, the
edges of the wound of the stomach are sutured to
the skin, the tube is removed.

38. Gastroenterostomy
—anastomosis surgery between the stomach and small
intestine.
The purpose of the operation is to create a bypass route
for food in case of obstruction of the gastric outlet.
There are 4 types of gastroenterostomy:
- Front anterior colic anastomosis(Welfler),
-Rear anterior colic anastomosis(Monastyrsky),
-Front retro colic anastomosis(Billroth),
-Rear retro colic anastomosis(Gakker-Petersen).

39. TYPES OF RESECTION STOMACH
Pyloro anthral resection
Resection of 2/3 of the stomach
Resection 3/4 stomach
Subtotal resection

40. Resection of the stomach- an
operation to remove part of the
stomach with the formation of a
gastrointestinal anastomosis.
By Billroth I –anastomosis
between the stump of the stomach
and the duodenum in an end-to-
end fashion.
onBillroth II – stumps the
stomach and duodenum are
sutured tightly,gastrointestinalthe
anastomosis is imposed on the
anterior wall of the stomach with a
loop of the small intestine of the
"side to side" type.

41. By Chamberlain–Finsterer – modification Billroth II,
sutured2/3 of the stomach stump from the lesser
curvature, the latter is immersed in the lumen of the
stomach, the rest of the stumpanastomoseaccording to
the "end to side" type with a short loop of the jejunum, the
leading segment of which is fixed to the sutured part of
the stomach stump.
By Moynihan – by Billroth II,anastomose the entire
lumen of the stomach stump to the side of the loop of the
jejunum, held in front of the transverse colon and sutured
to the stomach with the location of the afferent loop at the
greater curvature, and the outlet loop at the lesser
curvature.
By RU— suturing proximal end duadenum, dissection of
the jejunum with the formation of an anastomosis
between the stump of the stomach and the distal end of
the jejunum. Proximal end of the jejunum (with
duadenum) connects ("end-to-side"") with the wall of the
jejunum below the place gastro jejunal anastomosis -
provides prevention duodeno gastric reflux

42. Resection pylor anthral – deletion pyloric parts stomach.
Resection subtotal- leave only cardiac part and bottom.
Vagotomy - operation of the intersection of the vagus nerves or their
individual branches (treatment ulcerative disease).
Vagotomy stem – cross trunks of the vagus nerves above the
diaphragm before their branching.
Vagotomy selective – cross gastric branches of the vagus nerve
while maintaining branches to the liver and celiac plexus.
Vagotomy selective proximal – intersect branches of the vagus
nerve only to the upper parts of the stomach.

43. Gastrectomy- the operation of the complete removal of the
stomach with the imposition of an anastomosis between the
esophagus and the jejunum.
Gastroplasty —autoplasticsurgery to replace the stomach with
a segment of the small or large intestine.
Pylorotomy according to Freda Ramstedt (extramucosal
pyloroplasty) - the operation of a longitudinal dissection of the
sero-muscular layer of the pylorus without incision of the mucous
membrane.
Pyloroplasty by Heinecke–Mikulich - operation of longitudinal
dissection of the pyloric sphincter without opening the mucous
membrane with subsequent suturing of the serous membrane
into transverse direction.

44. OPERATIONS ON THE LIVER AND BILIARY TRACT
TYPES OF LIVER RESECTION
Typical (anatomical) resections
-are carried out along the anatomical boundaries of the segments of the liver, having
previously bandaged the portal triad in accordance with the segmental structure of the
organ:
Segmental(syn.:segmentectomy) is an operation to remove a segment of the liver.
left-sided hemi hepatectomy - surgery to remove segments I, II, III and IV of the liver.
right side hemi hepatectomy - surgery to remove segments V, VI, VII and VIII of the liver.
Lateral left lobectomy - surgery to remove segments II and III of the liver.
Lateral right lobectomy - surgery to remove segments VI and VII of the liver.

45. Atypical resection
-carried out along the boundaries of the
pathological formation, performed after
preliminary application hemostatic
stitches on the area of the liver to be
removed:
- wedge-shaped (a),
- planar (b),
- edge (in),
- transverse (d).

46. Seams of the
liver

47. Operations on the gallbladder and biliary tract
Cholecystotomy - an operation to cut the wall of the gall bladder
to remove stones from its cavity, followed by suturing bubble
walls.
Cholecystostomy - operation of the imposition of the external
fistula of the gallbladder.
Cholangiotomy - operation of opening the lumen of the common
hepatic (hepaticotomy) or common bile (choledochotomy) duct by
dissecting its wall, followed by suturing the wall of the duct or its
drainage.
Papillotomy- operation of dissection of the anterior wall of the
major duodenal papilla after opening the lumen of the duodenum

48. Cholecystectomy
-surgery to remove the gallbladder.
Distinguish:
-removal of the gallbladder from the neck (retrograde)-
more difficult, but preferable (they ligate the cystic duct at the
beginning of the operation - it prevents the movement of small
stones from the gallbladder and cystic duct into the common
bile duct during the intervention. Ligation of the cystic artery at
the beginning of the operation - the gallbladder is removed
almost bloodlessly).
-removal of the gallbladder from the bottom (antegrade)-
when the selection of the gallbladder from the neck is not
possible due to anatomical features or inflammatory changes
in the neck of the gallbladder.
-laparoscopic cholecystectomy – surgery using endoscopic instruments. Can be done as an
isolatedcholecystectomy, andintraoperative cholangiography, choledochotomy and overlay bilio
digestive anastomoses.
Advantages:
a. Reduces injury surgical aid
b. reduces the duration of surgery
in. provides a great cosmetic effect
d. reduces the duration of inpatient and outpatient treatment

49. RECONSTRUCTIVE SURGERY ON THE BILE TRACT
Biliodigestiveanastomoses
Cholecystogastrostomy-anastomosis between the
gallbladder andstomach
Cholecystoduodenostomy-anastomosis surgery
between the gallbladder and duodenum ;
Choledochogastrostomy -anastomosis between the
common bile duct and stomach
Cholecystojejunostomy-anastomosis surgery between
the common bile duct and the jejunum ;
Plastic surgery and prosthetics of the common
gallbladderduct-surgery to replace a duct defect with a
tubular biological graft or drainage tube;

50. Porto-caval anastomoses:
AT abdominal wall esophagus, in the area cardiac stomach-through esophageal
branches (rr.oesophageales) (tributaries unpaired and paired veins from the superior vena
cava system) and the left gastric vein (portal vein system).SyndromeMallory-Weiss.
In the wall of the rectum-through hmiddle rectal vein (v.rectales mediae) (inflow of the
internal iliac vein from the inferior vena cava system) together with the inferior rectal vein
(inflow of the internal pudendal vein from the inferior vena cava system) and the superior
rectal vein (inflow of the inferior mesenteric veinveins (v. mesenterica superior) from the
portal vein system). Haemorrhoids.
AT anterior abdominal wall cavities – through lower epigastric vein (v.epigastrica inferior)
(inflow of the internal iliac vein from the system of the inferior vena cava) and
paraumbilicalveins (v.paraumbilicales) (portal vein system). Head of Medusa.
AT back wall of abdominal cavity- anastomoses between the renal, adrenal veins (inferior
vena cava systems) with superior and inferior mesenteric veins(portal vein system);Renal
hypertension.

51. Surgical interventions on the pancreas
access to stuffing box:
- through the gastrocolic ligament
- through a small omentum,
- through the mesentery of the transverse colon.
In acute destructive pancreatitis, the following surgical procedures are performed
interventions:
- drainage and tamponade stuffing bag- introduce drainage tubes into the opening of the
hepatogastric or gastrocolic ligament and lay them on the anterior wall of the pancreas without
dissection or with the dissection of the capsule;
- laparotomy and omento pancreatopexy - cut out two flaps of the omentum on a wide
feeding leg and cover them with the anterior surface of the pancreas;
- laparotomy and omentoburso pacreatostomy - the dissected gastrocolic ligament and
omentum are sutured to the stomach at the lesser curvature and to the root of the mesentery of
the transverse colon and temporarily drained.
- resection of the pancreas - in case of damage to the tail or body of the pancreas, a partial
resection is performed, in case of damage to the head of the gland or total pancreatic necrosis-
pancreato duodenal resection.
-Pancreato duodenal resection- an operation to remove the head of the pancreas along with a
part of the duodenum, followed by the imposition n gastrojejuno-,choledochojejuno- and
pancreato jejuno anastomoses to restore the passage of gastric contents, bile and pancreatic
juice.

52. SURGERY ON THE SPLEEN
Splenectomy- surgery to remove the spleen, a simple and radical method to
stop bleeding.
In n.v. Increasingly, various types of organ-preserving operations are used:
- in the presence of single cracks in the parenchyma - tamponade with an
omentum on the feeding leg and stitching the spleen catgut sutures, be sure to
pass the threads under the bottom of the wound.
- when the pole of the spleen is torn off - resection of the organ with wrapping the
wound surface with an omentum and applying hemostatic seams (U-shaped
seams and seams of the type Kuznetsov-Pensky).
Auto transplantation of the spleen into the greater omentum preserve the
immune function of the spleen (especially in childhood). Several pieces of the
spleen (separated from the capsule) are isolated, washed in saline and, using a
purse-string suture, are immersed in the upper left corner of the greater
omentum.

53. I.Inter vascular anastomoses:
-Splenorenal anastomosis
—the imposition of an anastomosis between the splenic and
left renal vein according to the "end to side" type; combined
withsplenectomy.
-Mesenteric-caval anastomosis
—anastomosis between the superior mesenteric and inferior
vena cava in an end-to-side manner.
-Straight portocaval anastomosis
—direct fistula between the portal and inferior vena cava in a
side-to-side fashion.
TYPES OF OPERATIONS FOR PORTAL HYPERTENSION

54. II.Palliative operations:
-ligation of the branches of the celiac trunk,
-splenectomy,
-organ anastomoses
-esophagocardial resection andgastrectomy
-operations that drain the abdominal cavity
-surgery for ongoing bleeding from the veins of the esophagus.
-Omento renopexy - the operation of suturing the greater omentum to the
kidney in order to form adhesions between them and develop venous
anastomoses between the portal and inferior vena cava systems.
-Omento hepato diaphragmopexy - the operation of suturing the greater
omentum to the upper surface of the liver and the lower surface of the
diaphragm in order to form adhesions between them and develop venous
anastomoses between the systems of the portal and caval veins.

55. Thanks You for Attention!