20131116-151758

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PRACTICAL LESSON 1

Theme of lesson:

Table of contents, tasks and methods of study of the topographical anatomy and operative surgery. History of discipline. Surgical tool.

Aim of lesson:

To familiarize with the content, history and method of study of topographical anatomy and operative surgery. To learn governed and to capture the technical receptions of using the basic surgical instruments of the different setting.

Educational tasks:

To know:

1. Table of contents, history and method of study of topographical anatomy and operative surgery.

2. Student's duties and work order in the department.

3. Basic principles of classification and requirement to the surgical instruments, stitch material.

4. Structure and special purpose setting of operating block apartments.

To know:

1. Setting and technique of application of general and special surgical instruments.

2. Positions and rules of using a scalpel.

3. Rules of stitch priming material and needle.

4. Ways of the handling the instruments during the operations.

5. Types of surgical knots and their application.

To be able:

1. To distinguish basic surgical instruments in accordance with their setting.

2. To be able to use pincers, hooks, styptic clamps correctly.

3. To tuck in the stitch material in the needle.

4. To tuck in the needle in a needleholder.

5. To tie up woman, surgical and marine knots.

Contents of the lesson:

Definition of topographical anatomy as the science which studies the structure, form and coarrangement of organs and fabrics in the different areas of human body, and also bonemuscular centers of certain areas, projection of organs and vascular-nervous formations on the surface of human body, location of organs, their location according to a skeleton and difficult anatomic formations (syntopy) depending on a sex, age and body structure. Forms of individual anatomic changeability. Studies of V.M. Shovkunenko and his school about the extreme forms of individual anatomic changeability of body structure.

Definition of operative surgery as the science about the surgical operations, methods of surgical interferences, essence of which consists in the mechanical operation in organs and fabrics with a medical, restoration and diagnostic purpose. Operative accesses and operative appliances. Anatomic access, technical feasibility and physiology allowance of operation are the principles formed by the prominent surgeon M.H. Burdenko.

Application of two groups of research methods in a topographical anatomy and operative surgery: research of living man and research of dead body.

Study of body surface of living human, definition of bone-muscular centers, direction of surgical cuts, implementation of the anthropometric measuring.

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Methods of scientific researches: rentgenoscopy, sciagraphy, rentgenostereography, computer tomography, antiography, radionuclear scintigraphy, thermography with registration of infrared and tomography by nuclear-magnetic resonance, endoscopic methods of research — gastro-, cardio-, broncho- rectometer, method of experimental modeling.

Methods of research of dead body: topographo-anatomic preparing, sawing up the frozen dead bodies after M.I. Purohov, sculptural method; injections methods of research of the vascular system, corrosive method, radiography method of the fabrics.

Types of operations: radical and palliative; primary, second and repeated; one-, two- and multymoments; urgent and planned. Operations after the types of interferences: dissecting

(tomia), imposition of stomia, complete deletion (ectomia), partial deletion (resectio), deletion of peripheral part of organ (amputatio).

Acquaintance with a surgical tool. Classification and standardization of surgical instruments.

General rules and technical appliances of the use of different setting instruments.

Time division:

Acquaintance with composition of group - 10%

Theoretical interviews about history and task of discipline - 10%

Study of instruments with a teacher - 50%

Independent mustering of educational material - 20%

Control of final knowledge level and conclusions - 10%

Task for the final knowledge level control

1. What instrument is used for dissociating of periosteum from flat bones at the operative interference?

A. raspator of Farabef

B. raspator of Duaen

C. costal raspator

D. retractor

E. spoon chisel of Kornev

2. What instrument is used for dissociating of periosteum from the internal surface of ribs at operative interference?

A. raspator of Farabef

B. raspator of Duaen

C. T-like raspator

D. retractor

E. spoon chisel of Kornev

3. By the presence of what structural elements do the surgical pincers differ from the anatomic ones?

A. by the presence of lumbar notches on the ends of branch

B. by the presence of sharp denticles on the ends of branch

C. by the presence of pawls with chips on the ends of branch

D. by the presence of all the indicated elements on the ends of branch

E. by the presence of lumbar notches and sharp denticles on the ends of branch

4. What are the pegs for Meyo linen used for ?

A. for fixing the surgical linen

B. for supporting the instruments (drainages, tubes and others)

C. for supporting the organs ( tongue, rib, seedy rope and others)

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D. for fixing the surgical linen, for support of drainages, tubes, for support of organs

(tongue, rib, seedy rope and others)

E. for fixing the surgical linen, for supporting the instruments (drainages, tubes and others)

5. What name does a styptic clamp have with straight or arcuated cheeks and denticles on their ends?

A. a clamp of Kocher

B. a clamp of Bilrot

C. a clamp of Pean

D. a «mosquito»clamp

E. a clamp of Langenbeck

6. How does a styptic clamp «mosquito» differ from the clamp of Bilrot?

A. by smaller size

B. by less mass

C. by sharp cheeks

D. by a presence of shallow notch

E. by all the all indicated features

7. Which from the suggested fabrics are taken by surgical pincers?

A. fascias

B. muscles

C. the internals

D. vessels

E. nervous barrels


A, aponeurosises

B. muscles

C. the internals

D. vessels

E. nervous barrels


A. skin

B. muscles

C. the internals

D. vessels

E. nervous barrels

10. Which from the suggested fabrics are fixed by sharp surgical hooks?

A. fascias

B. muscles

C. the internals

D. vessels

E. nervous barrels


A. aponeurosises

B. muscles

C. the internals

D. vessels

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E. nervous barrels


A. skin

B. muscles

C. internals

D. vessels

E. nervous barrels

13. By the presence of what structural elements do anatomic pincers differ from surgical?

A. by a presence of lumbar notches on the ends of brache

B. by a presence of sharp denticles on the ends of brache

C. by a presence of pawls with chips on the ends of brache

D. by a presence of all the indicated elements on the ends of brache

E. by a presence of lumbar notches and sharp denticles on the ends of brache

14. What name does a styptic clamp have with straight or arcuated cheeks and transversal notches on their ends?



C. a clamp of Pean


E. clamp of Langenbeck

15.How does a styptic clamp«mosquito» differ from the clamp of Kocher ?

A. by smaller size

B. by less mass

C. by sharp cheeks without denticles

D. by the presence of shallow notch

E. by all the indicated features

16. Which from the suggested instruments are recommended to stop bleeding from the vessels of the internals?



C. a clamp of Allis

D. a clamp Laine

E. a clamp of Bebcock

17. Who of managers of operative surgery and topographical anatomy department of Kiev

University medical faculty (Medical institute. National medical university) was awarded rank of the honoured citizen of Kiev?

A. A.Yu. Shymakovsky

B. V.O. Karavaev

C. M.I. Pyrohov

D. I.V. Stutzynsky

Ê. D.I. Kultchytsky

Confirmed at the department meeting «____» _____________ Protocol № _______

Head of department prof. Kostyuk G.Y.

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Theme of Lesson:

Initial forms of surgical technique

Aim of Lesson:

To be able to disconnect and connect fabrics on a dead body, to stop bleeding. To master method and technique of surgical of the wounds, venesection.


To know:

1. Classification of operative interferences.

2. Basic stages of operative interferences.

3. Descriptions of operative access.

4. Dentological approaches of work with a dead body.

5. Basic functional duties of an operating brigade members .

To know:

1. Basic principles of disconnection and connection of fabrics.

2. Types of stitches for connection of soft fabrics.

3. Types of local anaesthetizing.

4. Technique of venesection.

5. General principles of surgical cleansing of the surface wounds.

To be able to do:

1. The section of surface layers by different positions of scalpel

2. The section of fascias by the groovy probe.

3. The section of muscles by blunt way.

4. The imposition of the knot and continuous stitches on a skin and cellulose, muscles.

5. The imposition of a styptic clamp.

6. The ligating of vessels.

Contents of the lesson:

Concept about the operation, types of operations. Types of the local anaesthetizing. Surgical stitches and knots. Basic methods of temporal and final stop of bleeding. Basic rules of disconnection and connection of fabrics. Surgical cleansing of wounds. Venesection and venepuncture.

Division of time:

Control of final knowledge level- 20%

Theoretical options and interviews - 10%

Practical work (section of fabrics, imposition of clamp, imposition of stitches, venesection) -

60%

Control of eventual level of knowledge and conclusion - 10%

Task for the final level knowledge control

Test

1. How many and what classic positions of scalpel are used during operative interference?

A. three: table-knife, writing peer, in a fist

B. three: table-knife, bow, in a fist

C. three: writing peer, bow, in a fist

D. three: table-knife, writing peer, bow

E. four: table-knife, writing peer, bow, in a fist

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2. What values of corner of operating action are considered most optimum for the procedure of operation?

A. 45

B. 60

C. 90

D. 120

E. 180

3. What values of angle slope of axis of operating action are considered most optimum for the procedure of operation?

A. 45

B. 60

C. 90

D. 120

E. 180

4. At stringing of surgical ligature knot twisting of filament is conducted. At the use of what reception will a surgical knot appear?

A. the single twisting of filament on the first knot

B. the double twisting of filament on the first knot and single twisting of filament on the second knot

C. the double twisting of filament on the first knot and double twisting of filament on the second knot

D. the single twisting of filament on the first knot and double twisting of filament on the second knot

E. the double twisting of filament on the second knot

5. At stringing of simple (woman) ligature knot twisting a filament is conducted. At the use of what reception will a simple knot appear?

A. the double twisting of filament on the first knot

B. the double twisting of filament on the first knot and single twisting of filament on the second knot

C. the double twisting of filament on the first knot and double twisting of filament on the second knot

D. the single twisting of filament on the first knot and single twisting of filament on the second knot

E. the double twisting of filament on the second knot

6. What basic criteria after M.N. Burdenko must a surgeon follow at the implementation of operative interferences?

A. by anatomic availability, technical possibility and settled physiology

B. by anatomic availability, technical possibility and state of patient

C. by own surgical experience, technical possibility and settled physiology

D. by anatomic availability, consent of patient and settled physiology

Ä. by anatomic availability, technical possibility and settled physiology, consent of patient

7. By which of the suggested instruments is it recommended to stop bleeding from the vessels of serosas?

A. clamp of Kocher

B. clamp of Bilrot

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C. clamp of Allis

D. a clamp Line

E. clamp of Bebcock

8. What is the name of an operation which is directed on the complete delete of pathological hearth?

A. palliative

B. radical

C. urgent

D. planned

E. multi moment

9. What styptic clamp is it recommended to use for the stop to bleeding from the vessels of hypoderm?



C. a clamp of Pean


E. clamp of Langenbeck

10. What surgical needles are used for sewing skin together?

A. non-traumatic

B. cuttings (trihedral)

C. prickly (round)

D. Deshan's

E. mixed

11. What surgical needles are used for sewing hypoderm together?

A. non-traumatic


C. prickly (round)

D. Deshan's

E. mixed

12. What surgical needles are used for sewing muscles together?

A. Michele metallic clips


C. prickly (round)

D. Deshan's

E. mixed

13. What surgical needles are used for sewing bones together?

A. non-traumatic


C. prickly (round)

D. Deshan's

E. mixed

14. What surgical needles are used for sewing fabrics of internals together?

A. Michele metallic clips


C. prickly (round)

D. Deshan's

E. mixed

15. What surgical needles are used for sewing vessels together?

A.Michele metallic clips


C. non-traumatic

D. Deshan's

E. prickly (round)

16. What surgical needles are used for sewing nervous barrels together?

A.Michele metallic clips


C. non-traumatic

D. Deshan's

E. mixed

Task for the final level knowledge control

Test

1. Which of the suggested methods of stop of bleeding is temporal?

A. pressing bandage

B. tamponade

C. electro-coagulation

D. ligating in a wound

E. ligating by draft


A. pinning in a wound

B. tamponade





A. pinning in places projection of vessels

B. tamponade





A. plait

B. tamponade





A. appendix of hemostatic sponge

B. tamponade c. electro-coagulation


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6. Which of the suggested methods of stop of bleeding is final?

A. plait

B. pressing bandage

C. pinning in a wound

D. tamponade

E. appendix of hemostatic sponge


A. plait

B. pressing bandage


D. electro-coagulation



A. plait

B. pressing bandage





A. plait

B. pressing bandage


D. ligating by draft


10. Which of the suggested methods of fabrics connection is considered bloody?

A. stitches

B. clips of Michelle

C. sticky plaster

D. biological glue

E. sewing together apparatus

11. Which of the suggested requirements must answer the skin section?

A. to the direction of skin wrinkles

B. accordance of section to motion of large vessels

C. accordance of section to the Langer lines of skin

D. accordance of section to motion of large nervous barrels

E. to all the indicated requirements

12. Which of the suggested technical receptions must be executed at the skin section?

A. prick athwart of skin surface

B. inclination to the scalpel under the corner of 45

C. identical depth during all section

D. output athwart of skin surface

E. all are indicated appliances

13. What is a principle of skin disconnection?

A. severe layer

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B. accordance of section to projection of organ to which is done an access

C. accordance of section to the Langer's lines of skin

D. accordance of section to the projection of vessels and nerves of organ to which an access is done

E. to all the indicated requirements

14. Which of the suggested methods of stop bleeding is not effective at гемостазі from the vessels of hypoderm?

A. dactylar clamping

B. clamping by a serviette

C. ligating

D. tamponing by a hemostatic sponge

E. imposition of styptic clamps



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Topographical anatomy of cerebral department of head. Surgical cleansing of wounds of skull. Antropotomy. Topography of shells of cerebrum and venous sines of hard shell of cerebrum. Chart of Krenlein - Brusova. Trepanation of skull.

Aim of lesson:

On the basis of knowledge of anatomic-physiological features of soft fabrics the frontalparietal-back of head, temple, papillary areas structure, to be able to conduct the surgical cleansing of wounds of cerebral department of the head on a dead body, correctly to expose haematomas, abscesses, phlegmons. On the basis of the detailed knowledges of topography of basic furrows and rollups of cerebrum, determined by the chart of cranial cerebral topography, knowledge of technique of comducting of operative interferences.

To be able to conduct on a dead body the delete of еpі-, subdural and subarachnoiditiss haematomas, to execute bone-plastic and decompressive trepanations of skull.


To know:

1. Age-old features of papillary sprout.

2. Difference of layer structure of regions of skull vault.

3. Connection of the venous systems of person and skull.

4. Possibility of distribution of haematomas of skull vault

5. Possible complication at the traumas of temporal area.

6. Localization of intracraneal haematomas.

7. Practical value of triangle of Shypo.

8. Modern methods of stop bleeding of vessels of different layers of vault of skull.

9. Stop bleeding from the sines of hard brain-tunic.

10. Stop bleeding from the veins of sponge.

11. About the individual features of location of vessels of hard brain-membrane

12. Topography of spider web shell of cerebrum

13. Topography of soft shell of cerebrum

14. Description of breaks of basis cranii

15. Topography of cisterns of cerebrum

16. Value of effluence of neurolymph at the traumas of ear, nose

17. Topographical anatomy and some clinical descriptions inwardly cranial haematomas

18. Localization inwardly of cranial haematomas

19. Bloodsupply of cerebrum — Vilizeev circle

To know:

1. Borders of cerebral and facial departments of head.

2. Areas of skull vault and their border.

3. Layers of frontal-parietal-cervical area.

4. Vessels and nerves of frontal-parietal-cervical area.

5. Layers of temple area.

6. Vessels and nerves of temple area.

7. Checked spaces of temple area.

8. Layers of temporal area.

9. Borders of trepanation triangle of Shypo and his value at implementation of antrotomy.

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10. Walls of antrum mastoideum.

11. Connections of the venous system of vault of skull with the sines of hard brain-tunic.

12. Anaesthetizing at the operations on the craniocerebral department of head

13. A surgical tool for implementation of operations in the area of skull

14. Basic methods of stop - bleeding from the vessels of canopies of head and bones of skull vault

15. Basic methods of stop-bleeding from the sines of hard shell of cerebrum and vessels of brain

16. Operations of trepanation of skull

17. Demonstration to implementation of osteoplastic trepanation of skull

18. Technique of execution of osteoplastic trepanation of skull

19. Demonstration to implementation of osteoplastic trepanation of skull.

20. Technique of execution of decompressive trepanation of skull.

21. Posible errors at the trepanation of skull

To be able:

1. To show on preparation (a dead body is fixed) layers of the frontal-parietal-back of head, temporal areas and papillary sprout.

2. To select the scopes of trepanation triangle of Shipo and to explain possibility of complications during the trepanation.

3. To execute trepanation of papillary sprout on a dead body.

4. To take apart on preparation the possible ways of distribution of festerings processes from the layers of temporal area.

5. To conduct the surgical wounds processing of skull vault .

6. To draw the chart of Kreilen-Brusova.

7. To project a middle thecal artery and its branches after the chart of Kreilen-Brusova.

8. To project after the chart of Kreilen-Brusova. central and латеральну furrows of cerebrum.

9. To project the basic arteries of cerebrum after the chart of Kreilen-Brusova.

10. To execute osteoplastic trepanation of skull on a dead body

11. To be able to stop bleeding from a meningeal artery and sine of hard shell of cerebrum.

12. To execute decompressive trepanation of skull on a dead body.

Contents of lesson:

Scopes of head, facial and cerebral departments of skull. Basis and vault of skull. Sizes of head. Children's peculiarities. Dividing principles by areas. Layer structure of blood supply, innervation, lymph flow-out. Connection of the venous system of superficial veins with the sines of hard brain-membrane. Surgical wounds processing of skull. Features of stopbleeding. Antripotomy is a technique of operation, complication during operation.


Control of final knowledge's level - 10%


Practical work - 50%

Control of final knowledge's level- 15%

Task for the final control of knowledge level

Test

1. To name the mesial border of trepanation triangle of Shipo.

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A. Vertical line conducted on the back edge of the external auditory opening.

B. Vertical line conducted through the middle of temple arc.

C. Vertical line conducted through the apex of papillary sprout.

D. Vertical line conducted through the cutting edge of the external auditory opening.

E. Line conducted for cricta mastoidea.

2. To name the back border of trepanation triangle of Shipo

À. Vertical line conducted on the back edge of the external auditory opening.

B. Vertical line conducted through the middle of temple arc.

C. Vertical line conducted through the apex of papillary sprout.

D. Vertical line

E. Betweenaponeurosis cellulose

F. Underosseous cellulose.

G. Muscular layer.

9. What vessel adjoins from inside to the temporal bone?

A. A. temporalis profunda.

B A. cerebri media.

C. a.meningia media.

D. a.cerebri anterior.

E. sinus sigmoideus.

10. To what formation does the back wall of papillary sprout adjoin?

A. canalis n.facialis

B sinus sigmoideus.

C. sinus cavernosus.

D. drum cavity.

E. sinus transverrus.

11. In what layer of skull vault is a conelike haematoma localized?

A. In a hypoderm.

B In a underneurotic cellulose.

C. In a underosseus cellulose.

D. Endermic.

E. In the middle of bone.

12. In what layer of skull vault (regio fronto-paricto-occipitalis) has haematoma a poured out characte?

A. In a hypoderm.



D. Endermic.


13. In what layer of regio - fronto-paricto-occipitalis is haematoma, that has the scopes of bone, localized?

A. In a hypoderm.



D. Endermic.


14. To name the constituents of internal basis of skull.

A. fossa cranii anterior, fossa cranii media, fossa cranii posterior

B. fossa gutturalis, underoot fossula.

C. recessus epitympanicus, fossa gutturalis.

D. tossa orbitalis, cavum nasi.

E. recessus epitympanicus, fossa orbitalis.

15. To name the constituents of middle craniocerebral fossula.

A. prolate brain, cerebellum.

B. temporal particles of cerebrum, hypophysis, cavernous bosoms.

C. frontal particles of cerebrum, prolate brain.

D. sigmalike sinuses, hypophysis.

Ä. cerebellum, frontal particles of cerebrum.

16. To name the constituents of back cranial fossula.

A. Bridge and prolate brain, cerebellum, cervical particles of brain.

B. Temple particles of brain and cerebellum.

C. Frontal particles of brain, hypophysis.

D. Hypophysis, temporal particles of brain, cervical particles of brain.

E. Cavernous sinuses, bridge, hypophysis.

17. To specify the elements of cerebrum, which form sines.

A. Pia membrane.

B. arachnoid membrane.

C. hard brain-membrane.

D. subarachnodial space.

E. epidural space.

18. To name the place of finding of lower sagital sine.

A. On the lower edge of falx cerebri.

B. On the edge falx cerebelli

C. On sulcus transversi of cervical bone.

D. On crista occipitalis interna.

E. On the upper edge of falx cerebri.

19. To name the place of finding of sinus rectus.

A. On the edge of falx cerebelli.

B. On the upper edge of falx cerebri.

C. Place of connection of falx cerebri and tentorium cerebelli

D. On crista occipitalis interna.

E. On sulcus transversi of cervical bone.

20. To name the place of localization of sinus transversus.

A. Place of attachment of tentorium cerebelli to the furrow of occipitalis.

B. In a furrow between the hemispheres of cerebellum.

C. On the sides of the Turkish saddle

D. On front of the Turkish saddle.

E. In basis of pyramid of temporal bone.

21. To name a sine which takes blood from the cavity of skull to the veins of neck

A. Overhead sagital.

B. Transversal.

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C. Back of head.

D. Sigmalike

E. Direct.

22. To name the sine of hard brain-membrane, that directly connected with the venous system of person.

À. Uper stony

B. Sigmalike

C. Cavernous.

D. Direct

E. Across sine.

23. To name an arterial vessel which passes inside cavernous sine.

A. External carotid

B. Middle thecal artery

C. Front cerebral artery

D. Middle cerebral artery

E. Ineer sleepy carotid.

24. In what place after the chart of Kronlein a back branch and.meningea media is placed ?

A. crossing of lower horizontal line and front vertical line

B. crossing of upper horizontal line and front vertical line

C. crossing of upper horizontal line and back vertical line

D. crossing of lower horizontal line and middle vertical line

E. crossing of lower horizontal line and back vertical line

25.In what place after the chart of Kronlein-Brusova a.cerebri media is placed?

A. projection of sylvia furrow

B. middle vertical line between upper and lower horizontal lines

C. upper horizontal line between middle and back vertical line

D. crossing of upper horizontal line and front vertical line

E. line of Brusova

26. In what place after the chart of Kronlein-Brusova and.cerebri posterior is placed ?

A. crossing of upper horizontal line and front vertical line

B. middle vertical line between upper and lower lines c. upper horizontal line between a middle and back vertical line

Ã. crossing of upper horizontal line and middle vertical line

27. What name has trepanation of skull, at which a skin-aponeurotic shred is separately cut out with wide basis with its further scalping and sawing of separate periosteum-bone shred on a leg?

A. bone-plastic trepanation after the method of Vagner-Volf

B. bone-plastic trepanation after the method of Kushig

B. bone-plastic trepanation after the method of Oliverkron

Ã. decompressive trepanation after the method of Vagner-Volf

Ä. decompressive trepanation after the method of Oliverkron .

28. To name the sequence of layers of skull vault , which an extraneous body passed at the opened nonpenetraiting wound of frontal department of parietofrontal-cervical area ?

A. skin, tendiuos helmet, underaponeurotic cellulose, periosteum, frontal bone.

B. skin, hypoderm, tendiuos helmet, periosteum, subperiosteum cellulose, frontal bone.

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C. skin, hypoderm, tendiuos helmet, underaponeurotic cellulose, periosteum, subperiosteum cellulose, frontal bone.

D. skin, hypoderm, tendiuos helmet, underaponeurotic cellulose, periosteum, subperiosteum cellulose.

E. skin, hypoderm, superficial fascia, tendiuos helmet, underaponeurotic cellulose, periosteum

Task for the eventual knowledge level control

Test

1. At birth of a full-term newborn is set the unclosed front (large) top of head. What its forms and sizes specify on full-term and normal development of child?

A. oval, diameter 1x1,5 cm

B. diamond-shaped, 2x2,5 cm

C. three-cornered, 1x1x1 cm

D. three-cornered, 2x2x2 cm

E. diamond-shaped, 3x5 cm

2. A patient with the opened nonpenetraiting wound of head is marked with the scalped wound of frontal area without the damage of bones. What layers of skull vault are the elements of the scalped shred?

A. skin, hypoderm, sinew aponeurosis

B. periosteum, subperiosteum cellulose, bone

C. sinew aponeurosis , underneurotic cellulose

D. hypoderm, aponeurosis, aponeurotic cellulose

E. bone, hard brain-tunic

3. In an adult patient under a pressing bandage a strong bleeding of the chopped wound of parietal area is marked. What from the suggested topographic-anatomic features of area predetermine bleeding which is not stopped independently?

A. connections of vessels of vault with the vessels of other areas of head and neck

B. the walls of bloods vessels are related to the fibrotic membranes

C. relatively with large diameter of vessels of this area

D. by plenty of arteriovenous anastomosis

E. connections of vessels of vault with the sinus of hard shell

4. The posttraumatic underneurotic haematoma of the left temporal area festered for 3 days after a trauma and a phlegmon spread on a person. Name the cellular space of person, which is connected with underaponeurotic space of temporal area, where a phlegmon spread?

A. cellulose of cheek area

B. underaponeurotic cellulose of frontal department of skull vault

C. retropharungeal cellulose

D. cellulose of parotid retraction

E. prepharungeal cellulose

5. In an adult patient from the chopped wound of frontal area the strong arterial bleeding from the wall of wound is marked. Specify in what point it is necessary temporally to pin a basic artery in, that supplies blood to this area of the skull vault ?

A. a.supratrochlearis - along the lateral edge of eye socket

B. a.temporalis superficiatis -on the front edge of the chewing muscle

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C. a.supratrochlearis - 2 sm from glabella

D. a.supratrochlearis - near the mesial edge of eye socket

E. a.temporalis superficialis - on 2-3 sm in the front from the corner of jaw

6. Injury of what nerve, the branches of which are n.temporalis profundi, will result in violation of innervation temporal of the muscle?

A. n.occipitalis major

B. n.mandibularis

C. n.facialis

D. n.maxillaris

E. n.occipitalis minor

7. What complication of trepanation of papillary sprout can arise up in a postoperation period, if during the operation the front border of trepanation triangle of Shipo was broken?

A. peripheral paralysis of n.facialis on the side of operation

B. central paralysis of n.facialis on the side opposed to the operation

C. infection in the cavity of skull

D. damage of internal ear

E. damage of sigmalike sinus and its bleeding

8. What complication of trepanation of papillary sprout can arise in a postoperation period, if during the operation the high bound of trepanation triangle of Shipo was broken?

A. central paralysis of n.facialis on the side of operation

B. peripheral paralysis of n.facialis on the side of operation

C. central paralysis of n.facialis on the side opposed to the operation

D. infection in the cavity of skull

E. damage of sigmalike sinus and its bleeding

9. What complication of trepanation of papillary sprout can arise in a postoperation period, if during the operation the back border of trepanation triangle of Shipo was broken?

A. peripheral paralysis of n.facialis on the side of operation

B. damage of sigmalike sinus and its bleeding

C. central paralysis of n.facialis on the side opposed to the operation

D. infection in the cavity of skull

E. damage of internal ear

10. A patient is delivered with complaints about head pain, slight swelling of the skull vault, which arose after falling. At a check up is a soft, fluctuating swelling limited in the front by the edge of eye socket, behind - upper nuchal line, on each side - upper temporal line. In what layer of the skull vault is probably a hemorrhage?

A. underaponeurotic cellulose

B. sinew aponeurosis

C. epidural space

D. hypoderm

E. subperiosteum cellulose

11. What from the suggested methods of stop-bleeding is used in case of stopping bleeding from the vessels of hypoderm of the skull vault?

A. moistening by a 3% solution of peroxigen

B. embrocation of beeswax

C. by styptic clamps

18

D. tamponade by a hemostatic sponge

E. tamponade by a shred of muscle

12. An adult patient has a diagnosis - nonpenetraiting wound of the skull vault with the damage of cervical bone. During the surgical processing the considerable defect of bone is set. What from the suggested plastic materials can be used for the plastic surgery of skull vault bone?

A. xenotranspantat

B autotransplantat from ribs

C. alotransplantat is lyophilized

D. autotransplantat from fascia

E. autotransplantat from muscles

13. Which from the suggested methods of stop-bleeding is used in case of stop- bleeding from the vessels of bones and emisar veins?

A. sewing ligatures

B. tamponade by a gauze

C. embrocation of beeswax

D. clipping of vessels

E. tamponade by a hank to the catgut

14. What from the suggested methods of stop-bleeding are used in case of stopping the bleeding from the vessels of brain?

A. clipping of vessels

B. by styptic clamps

C. sewing ligatures


E. tamponade by a gauze

15. In what interthecal spacious cavities of the skull passes a.meningea media and what intracraneal haematomas are more frequent to appear at its defeat or damage?

A. subdural space and epidural haematomas

B. epidural space and subdural haematomas

C. subdural space and subdural haematomas

D. epidural space and epidural haematomas

E. subdural space and subarachnoiditiss haematomas

16. What from the suggested methods of stop-bleeding is used in case of stopping the bleeding from pacchionian granulations?

A. tamponade by a hemostatic sponge

B. by styptic clamps

C. sewing ligatures

D. tamponade by a hank to the catgut

E. electro-coagulation

17. What from the suggested methods of stop-bleeding is used in case of stopping the bleeding from a.meningea media?

A. tamponade by a gauze

B. bandaging higher and below places of trauma


D. tamponade by a hemostatic sponge

19

E. irrigation by a 3% solution of peroxigen

18. What from the suggested operative receptions is used at the treatment of wounds of venous sinuses of hard brain-membrane?

A. vascular stitch

B. tamponade by a gauze



E. tamponade by a hemostatic sponge

19. What from the suggested operative receptions is used at the treatment of wounds of venous sinuses of hard brain-membrane ?

A. clipping

B. patch from a hard brain-tunic after Burdenko



E. tamponade by a hemostatic sponge

20. In what part of cavity of skull does a hard brain-membrane slightly adjoin the bones of the skull and where is the formation of epidural haematomas possible?

A. basis to the skull

B. pyramid of temporal bone

C. along stitches

D. vault of skull e. along the lower sagital sinus

21. What materials are used for closing the defect of hard brain-membrane during the surgical processing of penetrable wounds of skull vault?

A. alotransplantat from a hard brain-membrane

B. explant from synthetic fabric

C. explant from fiber tape

D. autotransplantat from the muscle

E. autotransplantat from a hard brain-membrane



20

PRACTICAL Lesson 4


Topographical anatomy of facial department of head. Lateral area of person. Parotid masticatory area. Deep area of face. The operations are on priornasal sinuses. Sections at the phlegmons of person and behindgullet abscesses. Surgical processing of face wounds.

Aim of lesson:

On the basis of knowledge of anatomo-physiological features of facial department of head

To be able to execute on a dead body the sections at festerings parotits, phlegmons and abscesses of lateral area of face.

Educational tasks: To know:

1. Age-old features of face

2. Sources of arterial blood supply of person

3. Anatomic ground of dividing into areas

4. Function of trifacial.

5. Function of facial nerve.

6. Possibility of retrograde of blood current in the area of face

7. Presence of connection of face veins with the sines of hard brain-membrane

8. Classification of muscles of face, their functional features

9. Features of topography of mimic muscles.

10. Features of bone basis of face, forming of sinuses, their copula.

To know:

1. division of face into areas.

2. layer topography of parotid-masticatory area

3. extracranial department of facial nerve, its topography

4. parotid salivary gland. Capsule. Weak points

5. topography of channel of parotid salivary gland. Projection

6. deep (interjaw area of face, cellular spaces, their connections.

7. nearpharyngeal and beyondpharyngeal cellular spaces. Connection with the cellular spaces of face.

8. Surgical processing of face wounds

9. Typical cuts on the face

10. Opening of frontal and supramaxillary sinuses

To be able:

1. Reparate lateral area of face.

2. To design the branches of facial nerve and channel of parotid salivary gland on a face.

3. To execute the section on face at festerings paratitises.

4. To execute trepanation of frontal sinus on a dead body.

5. To execute trepanation of genyantrum on a dead body.

Table of contents of lesson:

Borders of viscerocranium.Division into areas. Topographical anatomy. Parotid-masticatory area. Topography of parotid gland, weak points of capsule, practical value. Ways of distribution of festerings processes of gland. Projection of channel. Topographical anatomy of cheek area of face. Topographical anatomy of deep area- temple-winglike and intrawinklike celllular spaces after Pyrohov. Table of contents. Nearpharyngeal and beyondpharyngeal cellular spaces. Surgical processing of face wounds. Features. The

21 operations are on nearnasal sunuses. Section at the phlegmons of face and beyondpharyngeal processes.


Control of final level of knowledges - 10%



Control of final level of knowledges - 20%


Test

1. In what place on face is it possible to palpate pulse of facial artery?

A. on the frontal edge of m.masseter

B. at chin projection of lower jaw

C. in the middle of temple arc

D. on the middle of line which connects the wing of nose and corner of lower jaw

E. on the middle of tragoorbital line

2. By what vein can a blood clot from a facial vein get to the system of intracraneal sinuses and veins?

A. v.jugularis interna

B. v.angularis

C. v.jugularis externa

D. v.nasalis externa

E .v.transversa faciei

3. Trauma of which nerve can result in a paralysis or plegia of mimic muscles?

A. triple nerve

B. wandering nerve

C. frontal nerve

D. facial nerve

E. underorbital nerve

4. What from the suggested factors promotes the rapid distribution of festerings processes from the areas of face into a cavity of skull?

A. high-rate of blood circulationin the veins of face

B. winding motion of avalvular facial vein

C. rich bloodsupply of face

D. presence of two floors of venous outflow

E. presence of numerous inosculations of avalvular veins of person with the higher piesis with veins and bosoms of cavity to the skull

5. Where on the face is it possible to set the pulsation of superficial temporal artery?

A. 1,5 cm ahead from trestle of auricle b. in the middle of temple arc c. in the middle of line which connects trestle with the lateral corner of eye d. on the frontal edge of m.masseter e. on the middle of tragoorbital line

6. In what cellular space is the distribution of inflammatory process possible in a patient with the hypodermic phlegmon of cheek area?

A. in nearpharyngeal cellular space

22

B. in the cellulose of deep area of face

C. in the beyondpharyngeal cellular space

D. in underaponeurotic cellular space of temporal area

E. in intraponeurotic cellular space of temporal area

7. What branch comes from a.maxillaris in its 1 department?

A. aa.alveolares superior posterior

B. a.alveolaris inferior

C. a.infraorbitalis

D. a.palatina descendens

E. a.alveolaris superior anterior

8. What branch comes from a. maxillaris in its 2 departments?

A. a.temporalis superficialis b. a.infraorbitalis

C. a.alveolaris superior posterior

D. a.meningea media

E. a.alveolaris inferior

9. What branch comes from a.maxillaris in its 3 departments?

A. a.temporalis superficialis

B. a.infraorbitalis

C. a.alveolaris superior posterior

D. a.meningea media

E a.alveolaris inferior

10. What branch does a facial nerve give to the output on basis of skull?

A. n.intermedius

B. chorda timpani

C. n.pterigopalatinus

D. n.auricularis posterior

E. n.petrosus minor

11. What vascular-nervous formations which are located in the layer of parotid salivary gland can be damaged at traumas in the area of gland or at operative interferences with this organ?

A. and.carotis externa et v.retromandibularis

B. internal carotid and glossopharyngeal nerve

C. facial artery and supramaxillary nerve

D. barrel triple to the nerve and external jugular vein

E. internal jugular vein and supramaxillary nerve

12. On what surface of gland is the «weak» point of capsule of parotid salivary gland located, through which inflammatory processes can pass into nearpharyngeal space?

A. on the mesial surface of gland

B. on the front surface of gland

C. on the back surface of gland

D. on the lower surface of gland

E. on the external surface of gland

13. What of the suggested nerves originates from the 2nd branch of triple nerve?

A. n.ethmoidalis

23

B. n.infraorbitalis

C. n.infraorbitalis

D. n.hypoglossus

E. n.buccalis

14. What of the suggested nerves originates from the 3rd branch of triple nerve?

A. n.ethmoidalis

B. nn.alveolares superior posterior

C. n.infraorbitalis

D. n.hypoglossus

E. n.auriculotemporalis

15. At the damage of which nerve can be lost specific taste sensitiveness of the front 2/3 of tongue?

A. chorda timpani

B. n.lingualis

C. n.glossopharingeus

D. n.hypoglossuss

E. n.stapedius

16. At the damage of which nerve can be lost specific taste sensitiveness of the front 1/3 of tongue?

A. n.lingualis

B. n.glossopharingeus

C. chorda timpani

D. n.hypoglossuss

E. n.stapedius

17. At the check up of lower nasal passage of a patient there are marked purulent discharges from openings. What sinuses are opened in this nasal passage?

A. sinus sphenoidalis

B. cellelae ethmoidales posterior

C. tearnasal channel

D. sinus cavernosus

E. sinus sigmoideus


Test

1. In what maximal terms from the moment of injury is possible the imposition of deaf stitches on face?

A. to 6 hours

B. to 48 hours

C. to 12 hours

D. to 24 hours

E. to 18 hours

2. What vessels must be bandaged at the surgical wound processing of tongue which is accompanied by the massive arterial bleeding from the left half of tongue?

A. left tongue artery

B. left and right internal carotids

C. left and right external carotids

24

D. left and right external jugular veins

E. left and right tongues arteries

3. Where is the section of hypodermic phlegmon of cheek area conducted ?

A. along a line from the middle of temple arc to the corner of lower jaw

B. along a line from to the temple-lower jaw joint to tuber mentale

C. along a line from an ear-lobe to the corner of mouth crack

D. along a line on 1 cm. below the edge of lower jaw at the level of its corner

E. along a front edge of chewing muscle

4. Where is the section of submucous phlegmon of cheek area conducted?

A. in the cavity of mouth between the branch of lower jaw and lig. pterigomandibulare

B. in a mouth groove along a cheek

C. in a mouth groove transitional fold of supramaxilla

D. in a mouth groove along transitional fold of lower jaw

E. in the cavity of mouth along arcus palatoglossus

5. In what cellular space the distribution of inflammatory process is possible in a patient with the phlegmon of bed of parotid gland

A. in the nearpharyngeal cellular space

B. in the cellulose of deep area of face

C. in the beyondpharyngealcellular space

D. in underaponeurotic cellular space of temporal area

E. in betweenaponeurotic cellular space of temporal area

6. Name the veins through which thrombotic clot in a patient with the phlegmon of cheek area can get from the angular vein of person in a cavernous venous bosom?

A. v.emissaria

B. vv.cerebri media

C. v.meningea media

D. vv.ophthalmicae

E. v.jugularis interna

7. At the damage of which nerve and on what level is the paralysis of mimic muscles?

A. facial after an exit from the skull

B. facial in the layer of parotid gland

C. facial to the exit from the skull

D. facial at any level

E. mandibular after an exit from the skull

8. On what anatomic formations at the surgical wounds processing of face the deaf stitches are always imposed?

A. fascias of deep area of person

B. mucus shell of mouth cavity

C capsule of parotid salivary gland

D. skin of nose

E. skin of cheek area

9. Where is the section of intermaxillary phlegmon conducted ?

A. along a back edge of the chewing muscle

B. 1cm behind the back edge of branch of lower jaw

C. along a front edge of the chewing muscle

25

D. 1cm below the edge of lower jaw at the level of its corner

E.

1cm below the lower edge of temple arc

10. Where is the section of phlegmon of parotid-masticatory area conducted?

A. along motion of fibres temporal to the muscle

B. along the lower-lateral edge of eye socket

C. along a frontal edge chewing muscle

D. 1cm below the edge of the lower jaw at the level of its corner and along the lower edge of temple arc

E. 1cm below the lower edge of temple arc

11. Where the section of near pharyngeal phlegmon by mouth method is conducted?

A. along the fibres motion of temporal muscle

B. along the lower-lateral edge of eye socket

C. along a frontal edge of chewing muscle


E. 1cm below the lower edge of temple arc

12. Where the section of near-pharyngeal phlegmon by an inwardly-mouth method is conducted?

A. in the cavity of mouth between the branch of lower jaw and lig.pterigomandibulare

B. in the groove of mouth along the gingival edge of supramaxilla

C. at a groove mouth along the transitional fold of supramaxilla

D. at a groove mouth along the transitional fold of lower jaw

E. in the cavity of mouth along arcus palatoglossus

13. Where the section of mandibular adenophlegmon by extraoral method is conducted?

A. by 1cm below the edge of lower jaw

B. along the lower-lateral edge of m.sternohyoideus

C. along the frontal edge of chewing muscle


E. 1cm below lower edge of temporal arc

14. At the damage of what nerve the tongue motion is disorganized?

A. n.glossopharingeus

B. n.hypoglossus

C. n.mandibularis

D. n.abducens

E. chorda tympani

15. One of elements of initial surgical management of wound of anterolateral area of face is the revision of excretory canal of parotid salivary gland. Along what lines is the projection of canal located along?

A. from an ear-lobe to the corner of mouth crack

B. from an ear-lobe to tuber mentale

C. from the middle of temporal arc to the corner of lower jaw

D. from to the hinge temporal mandibular joint to tuber mentale

E. from external auditory motion to the corner of mouth crack.



26



Topographical anatomy of neck. Operative interferences on vessels and nerves. Cysts and abscesses of neck.

Aim of lesson:

On the base of knowledges of topographical features of neck, surgical anatomy of fascias, cellular spaces

To be able to substantiate and execute on a dead body the sections for draining of phlegmons of neck. To give the topographic-anatomic ground of vagosympathetic blockade after O.V.

Vyshnevskyi. To be able to execute on a dead body operative interferences on vascularnervous formations of neck.


To know:

1. Classification of neck fascias.

2. Age features of neck topography .

3. Individual features of topography of neck.

4. Divisions of neck into areas.

5. List of basic operative interferences with different areas of neck.

6. Possibility of bandaging of carotid branches on a neck.

7. Bandaging of vessels on a neck at the operations and wounds in other areas of body.

8. Co-arrangement of neck organs .

9. Possibility of connections of the cellular spaces of neck with the cellulose of other areas of body.

10. Possibility of accesses to the large neuroplexes and barrels with the purpose of implementation of blockades.

To know:

1. Scopes of neck, division into areas.

2. Triangles of neck.

3. Fascias of neck.

4. Cellular spaces of neck.

5. Lower-jaw triangle.

6. Triangle of M.I.Pyrohov

7. Sleepy triangle.

8. Topography of basic vascular-nervous bunch of neck.

9. Difference between external and internal carotids.

10. Branches of external carotid in a sleepy triangle

11. Demonstration of conduction of vagosympathetic blockades on a neck. Indexes of the right conducted vagosympathetic blockade.

12. Rational cuts are accesses for the section of festerings processes

To be able:

1. To know layers and neck fascias at cuts.

2. To be able to distinguish an external carotid from internal.

3. To bare an internal jugular vein, external and general carotid.

4. To find external orientations for implementation of vagosympathetic blockade after

Vyshnevsky and Burdenko.

27

5. To conduct a vagosympathetic blockade after Vyshnevsky and Burdenko.

6. To give the anatomic substantiation of the rational cuts at phlegmons and abscesses of neck.

Table of contents of employment:

General review. Borders of neck. Division into areas. Fascias and interfascial spaces. Mesial triangle of neck. suprahyoid area, submandibular and chin triangle. Submandibular salivary gland. Triangle of Pyrohov. Sublingual area. Area of sleepy triangle. Vessels and nerves.

Area of sternal-clavicular-papillary muscle. Cuts at a phlegmon. Baring of internal jugular vein, external and general carotid. Vagosympathetic blockade after O.M. Vyshnevsky and

M.N. Burdenko. Cysts and festerings of neck. Operative treatment.


Control of entrance level of knowledge - 5 %


Practical work - 65 %

Control of eventual level of knowledge – 10%


Test

1. By what differentiating feature during access to the arterial vessels of neck does the external sleepy arteries differ from internal in a sleepy triangle?

A. a pulsation on a.temporalis at stopping up a.carotis externa disappears

B. branches go from a.carotis interna

C. disappears a pulsation on a.temporalis at stopping up a.carotis interna

D. a.carotis externa lies lateral

E. a.carotis externa has more winding motion

2. At registration of hospital chart a doctor marked, that a pathological process was localized in tr. omoclaviculare necks. Which of suggested anatomic landmarks limits this area of body?

A. m.sternocleidomastoideus

B. hyoid

C. edge of lower jaw

D. m.trapecius

E. middle line of neck

3. By making access to the trachea it is necessary to pass through the «white line of neck».

What is this anatomic object formed by?

A. by second and fourth neck fascias

B. by first, second and third neck fascias

C. by second and fifth neck fascias

D. by first and third neck fascias

E. by second and third neck fascias

4. A patient is with set diagnosis – interaponeurotic suprasternal phlegmon. What is this phlegmon limited by?





28


5. During a strumectomy bandaging of numerous vessels of thyroid gland is conducted with which parathyroid glands lie together. In what layer are parathyroid glands located?

A. between the visceral sheet of fourth neck fascia and own capsule

B. between visceral and parietal sheets of fourth neck fascia

C. in previsceral spacious

D. in retrovisceral spacious

E. under own capsule

6. In a patient with the phlegmon of the cellular space of external neck triangle the festering melting of anatomic objects is possible in this cellular spacious. What is located in this neck area, where does this phlegmon lie?

A. tr.brachiocephalicus

B. pl.brachialis

C. arcus venosus juguli

D. a.carotis communis

E. pl.thyreoidea impar

7. During a strumectomy, a bandaging of numerous vessels of thyroid gland is conducted. In what layer are the veniplexs of gland located?

A. between the visceral sheet of fourth neck fascia and own capsule

B. between visceral and parietal sheets of fourth neck fascia



E. under own capsule

8. Where does a projection line a.carotis communis pass?

A. along the cutting edge of m.sternocleidomastoideus

B. bisectricess of corner between m.genioglossus and m.styloglossus

C. along the back edge of m.sternocleidomastoideus between m.styloglossus and m.mylohyoideus

D. bisectricess of corner between mm.sternocleidomastoideus et omohyoideus

E. bisectricess of corner between m.stylogiossus and m.sternocleidomastoideus

9. Name from the suggested features, the one which distinguishes tr.sympaticus from n.vagus?

A. lies above V neck fascia

B. it is easily moved

C. laterally lies a.carotis communis

D. mesially lies a.carotis communis

E. consists of separate knots

10. Which of the suggested symptoms indicates the proper implementation of vagosympathetic blockade?

A. exophthalmos

B. hyperemia of face and scleroticas

C. mydriasis

D. cross-eye

E. tachycardia

29

11. Which of the suggested symptoms indicates the proper implementation of vagosympathetic blockade?

A. exophthalmos

B. Ptimalum

C. mydriasis

D. cross-eye

E. tachycardia

12. A patient has a diagnosis- interaponurotic suprasternal phlegmon. What is spatium interaponeuroticum suprasternale limited by ?






13. A patient has a diagnosis previsceral phlegmon of neck. What is spatium previscerale

(pretracheale) limited by ?

A. by two sheets of fourth neck fascia





14. A patient has a diagnosis retropharyngeal phlegmon of neck. What is spatium retroviscerale limited by ?

A. by two sheets of fourth neck fascia


C. by fourth and fifth neck fascias



15. In a patient with the phlegmon of external triangle of neck clinically is a limitation of this process. What is the cellular space of external triangle of neck limited by, where does this phlegmon lie?

A. parietal sheet of fourth neck fascia


C. by fourth and fifth neck fascias

D. visceral sheet of fourth neck fascia

E. by second and fifth neck fascias

16. At registration of hospital chart of an injured a doctor marked, that the ingate of wound was in a maxillary triangle. Which of suggested anatomic landmark limits this area of body?

A. edge of lower jaw

B. m.sternocleidomastoideus

C. m.omohyoideus

D. middle line of neck

E. m.trapecius

30

Task for the eventual control of knowledge level

Test

1. In what area and carotis externa is it necessary to conduct bandaging of artery?

A. between overhead by thyroid and tongue arteries

B. from bifurcations and carotis communis to overhead thyroid

C. from a tongue to the facial artery

D. higher facial artery

E. below overhead thyroid artery

2. In a patient with the phlegmon of spatium retroviscerale is observed expansion of inflammatory process in the neighbouring cellular spaces. In which from the suggested spaces the distribution of festering process is possible ?

A. anterior mediastinum

B. saccus caecus sternocleidomastoideus of Gruberi

C. postmediastinum

D. cellulose of armpit cavity

E. supraspinal cellular space of shovel area

3. In what place a cut at the section of maxillary phlegmon of neck is conducted?

A. along the edge of lower jaw

B. along the white line of neck

C. along the overhead edge of collar-bone

D. along the back edge of m sternocleidomastoideus

E. along the frontal edge of m sternocleidomastoideus

4. Specify what type of operative maneuver is used at surgical treatment of flebectazia of external superficial vein of neck?

А. the extended area retires

В. alotransplantat is imposed on the extended area

C. spiral extransplantat is imposed on the extended area

D. the sclerosing substance is injected in the extended area

E. an extended vein is secured

5. Specify what type of operative maneuver is used at surgical treatment of phlebitis of internal jugular vein of neck?

A. the extended area is extracted

B. alotransplantat is imposed on the extended area

C. input and output vessels are ligatured


E. an extended vein is ligated

6. Why on the front surface of neck the horizontal skin wounds gape and are inverted, and vertical – not?

A. a skin is related to own fascia

B. a skin is tied-up from m.platisma

C. a skin is related to the outer fascia

D. a skin is related to the saphenas

E. a skin is related to the suction action of pectoral cavity

7. In what place at the section of phlegmon of previsceral space of neck is the section conducted?

31

A. along the stitch of bottom of mouth cavity


C. along the upper edge of collar-bone

D. along the edge of lower jaw

E. along the frontal edge of m.sternocleidomastoideus

8. A patient with the phlegmon of spatium retroviscerale the expansion of inflammatory process in the neighbouring cellular spaces is observed. In which from the suggested spaces the distribution of festering process is possible ?

A. anterior mediastinum


C. postpharyngeal space


E. supraspinal cellular space of shovel area

9. In a patient with the phlegmon of the cellular space of external triangle of neck there is an expansion of inflammatory process in the neighbouring cellular spaces. In which from the suggested spaces the distribution of festering process is possible ?

A. back department of space parapharyngeal


C. postmediastinum


E. retropharyngeal space

10. In what place at the section of phlegmon of vascular crack is the section conducted?





E. along the frontal edge of m. sternocleidomastoideus

11. In a patient with the phlegmon of spatium interaponeuroticum neck the festering melting of anatomic objects in this cellular spacious is possible. What is located in that spacious of neck, where this phlegmon lies?

A. pl.thyreoidea impar

B. arcus venosus juguli

C. v.thyreoidea ima

D. tr.brachiocephalicus

E. v.jugularis interna

12. In a patient with the phlegmon of the cellular space of external neck triangle the festering melting of anatomic objects in this cellular spacious is possible. What is located in this spacious of neck, where this phlegmon lies?

A. tr.brachiocephalicus

B. a.subclavia

C. arcus venosus juguli

D. a.carotis communis

E. pl.thyreoidea impar

32

13. At the processing of tongue wounds, which are accompanied by large bleeding, a.lingualis bandaging is showed after a classic method in a triangle of Pyrohov, where lies v.lingualis, but a.iingualis is not visible. Where is this artery located?

A. under m.hyoglossus

B. under m.geniohyoideus

C. under m.genioglossus

D. under m.styloglossus

E. under m.sternocleidomastoideus

14. A patient with adenophlegmon of the cellular space of submaxillary triangle of neck has the expansion of inflammatory process in the cellulose of bottom of mouth cavity along the excretory duct of submandibular gland. What muscles of bottom of mouth cavity does this duct pass between?

A. between m.geniohyoideus and m.styloglossus

B. between m.genioglossus and m.styloglossus

C. between m.styloglossus and m.mylohyoideus

D. between m.hyoglossus and m.mylohyoideus

E. between m.styloglossus and m.sternocleidomastoideus

15. What place of neck is the characteristic place of localization of abscess when patient has the middle cyst of neck?

A. on each side from the frenulum of tongue

B. in a submaxillary area

C. below the hyoid externally from the middle line of Ductus thymopharingeus and lateral cysts

D. higher the hyoid on a middle line

E. below the hyoid on a middle line



33



Topographical anatomy of neck. Organs of neck. The operations on the organs of neck.

Aim of lesson:

On the basis of exact knowledge of topographic-anatomic correlations of formations and organs of neck. To be able to execute on a dead body accesses and operations on a trachea, thyroid, gullet.


To know:

1. Individual and age-old features of position of organs of neck.

2. Possibility of congenital and acquired phlebitis of jugular veins.

3. The necessity of operative interferences on the lymphatic knots of neck at the malignant tumours of front face divisions.

4. Congenital torticollis

5. The features of anaesthetizing at operative interferences on the organs of neck.

6. Description of wounds of neck. Features of wounds. Pathological processes of thyroid gland, which require operative interferences

To know:

1. Topography of trachea.

2. Topography of neck part of gullet.

3. Branches of cerviciplex.

4. Scopes of lateral triangle of neck, division of it on scapular-trapezoid and the scapularclavicular triangles.

5. Layers of lateral triangle of neck

6. Cellular space of lateral triangle of neck.

7. Topography of neck part of diaphragmatic nerve.

8. Technique of tracheostomy.

9. Errors and complications at tracheostomy.

10. Features of operative access to neck part of gullet

11. The operations are on a thyroid gland.

To be able:

1. To reparate lateral triangle of neck.

2. To execute overhead tracheostomy

3. To execute lower tracheostomy .

4. To execute access to the lower part of gullet.

5. To take apart the technique of punction of suclavian vein on preparation .

6. To explain the errors and complications at intubation


Neck part of trachea and gullet, providing of blood supply and innervation. Branches of cerviciplex. Pre-stair, interstair and stair-vertebral the cellular spaces. Table of contents.

Tracheostomy. Complication and errors at tracheostomy. Intubation. The operations on neck part of gullet. Subtotal subfascial resection of thyroid gland after O.V. Nikolaev. Operation of Vanakh. Operation of Krael.

34


Control of initial level of knowledge - 5%



Control of eventual level of knowledge - 15%

Task for the initial control of level of knowledge

Test

1. During a strumectomy, bandaging of numerous vessels of thyroid gland is conducted. In what layer are the veniplexs of gland located?

A. between the visceral sheet of fourth fascia of neck and own capsule

B. between visceral and parietal sheets of fourth fascia of neck



E. under an own capsule

2. During a strumectomy, bandaging of numerous vessels of thyroid gland, is conducted, with which parathyroid glands lie together. In what layer are parathyroid glands located?






3. A patient has deformation of larynx through the very-large-scale increase of organ or fabrics located from one side from a larynx. Which of the suggested anatomic objects lies laterally from a larynx?

A. lateral particles of thyroid gland

B. m.sternothyreoidei

C. pharynx

D. m.longus capitis

E. rn.sternohyoideus

4. In what place is tracheostomy conducted?

A. higher of isthmus of thyroid gland

B. higher of hyoid

C. higher of the undercuts of breastbone

D. higher of arcus venosus juguli

E. higher of the middles of neck part of trachea

5. In what place is lower tracheostomy conducted?

A. below isthmus of thyroid gland

B. below hyoid

C. below undercuts of breastbone

D. below arcus venosus juguli

E. below middles of neck part of trachea

6. Damage of which nerve brings to paresis of vocal cords and disorder of phonation?

A. n.laryngeus superior (n.vagus)

B. n.laryngeus inferior (n.laryngeus reccurens)

C. n.abducens

35

D. n.mandibularis

E. n.glossopharingeus

7. Damage of which nerve results in the esthesioneurosis middle division of larynx?



C. n.abducens

D. n.mandibularis


8. Damage of which nerve results in the esthesioneurosis of upper division of larynx?



C. n.abducens

D. n.mandibularis


9. Where is the operative access to the neck department of gullet done?

A. along the frontal edge of left m.sternocleidomastoideus

B. along the back edge of left m.sternocleidomastoideus

C. along the frontal edge of right m.sternocleidomastoideus

D. along the back edge of right m.sternocleidomastoideus

E. along the frontal edge of left m. omohyoideus

10. What is the fascial capsule of thyroid gland formed by?

A. visceral sheet of fourth fascia of neck

B. parietal sheet of fourth fascia of neck

C. internal appendix of fifth fascia of neck

E. visceral sheet of third fascia of neck

D. thin joint cellular capsule

11. Where the bandaging of bloods vessels of thyroid gland at the subtotal subfascial resection of gland after O.V.Nikolaev is conducted?






12. In what place is the section conducted at the section of retropharyngeal phlegmon by poostmouth way?





E. along the back edge of m.sternocleidomastoideus


Test

1. Specify what type of operative maneuver is used at surgical treatment of phlebitis of external superficial vein of neck?

A. the extended area retires

36


C. spiral exnplantat is imposed on the extended area



2. Specify what type of operative reception is used at surgical treatment of phlebitis of internal jugular vein of neck?

A. the extended area is extracted


C. input and output vessels are ligated

D. in extended area the sclerosing substance is injected


3. How gaping veins and danger of air embolism wounds of neck can be explained?

A. the superficial veins of neck are related to own fascia of neck

B. the superficial veins of neck are related to m.platisma

C. by suction action of pectoral cavity

D. in the superficial veins of neck there is a negative pressure

E. the valves of superficial veins of neck do not let the veins to be saved

4. Which of the suggested reasons compels surgeons to do at children more dangerous lower tracheostomy?

A. the isthmus of thyroid gland is highly located

B. presence of large vessels higher isthmus of thyroid gland

C. higher probability of embolism of veins of thyroid gland

D. higher probability of emphysema of mediastinum

E. danger of development of laryngospasm


A. the danger of necrosis of cartilages of tracheas which collect blood from vessels to the isthmus





6. What complications can arise up in a postsurgical period after the procedure of tracheostomy in case of the insufficient stop-bleeding during the operation?

A. emphysema of neck and mediastinum

B. aspiration pneumonia

C. pneumothorax

D. necrosis of rings of trachea

E. tracheosesophageal abscess

7. What complications can be developed at one-sided trauma of n.laryngeus inferior (n. laryngeus reccurens) during the operation on a thyroid?

A. asphyxia and death

B. paresis of glottis (aphonia)

C. disorder of swallowing

D. disorder of coughing reflex

37

E. hypoparathyroidism

8. What complications can arise in post-surgical period after the procedure of tracheostomy at the wound of back wall of trachea during the operation?


B. air embolism

C. pneumothorax



9. Tracheostomy at a patient with the traumatic break of larynx is executed, but an asphyxia grows, there is a growth of edema of soft fabrics of neck, a crepitus appeared at palpation of neck. Which of the suggested errors is the most credible reason of development of emphysema and severe post-surgical condition?

A. the section of trachea is bigger than the diameter of tracheotomy tube, a skin is densely sewn up

B. a tracheotomy tube is brought into the submucous layer of trachea

C. damaged a. thyreoidea ima

D. a tracheotomy tube is closed by a blood or mucus clot

E. the section is eccentric – irritation of n.vagus

10. Tracheostomy at a patient with the traumatic break of larynx is executed, but an asphyxia grows, there is growth of edema of soft fabrics of neck, crepitus at palpation of neck appeared - a pneumoderma grows. Which of the suggested operative maneuvers is it necessary to carry out for the improvement of the state of patient?

A. to take out the stitches from a skin

B. to impose additional stitches on a skin

C. to take out the stitches from a trachea

D. to conduct the additional section of trachea

E. to conduct a vagosympathetic blockade

11. What type of treatment must be applied at a child of 2-3 years with congenital torticollis?

A. myotomy of legs of m.sternocleidomastoideus after Mykulich

B. the plastic of m.sternocleidomastoideus

C. staging gipseous bandage

D. scull traction

E. the plastic of own neck fascia

12. Tracheostomy at a patient with the traumatic break of larynx is executed, but an asphyxia grows quickly. Which of the suggested conditions is the most credible reason of unsuccessful operation?

A. the diameter of tracheotomy tube is bigger than the section of trachea

B. the diameter of tracheotomy tube is bigger than the diameter of trachea

C. the diameter of tracheotomy tube is less than the section of trachea.

D. a tracheotomy tube is brought into a submucous layer

E. damaged a.thyreoidea ima

13. What complications can be developed at the bilateral trauma of n.laryngeus inferior

(n.laryngeus reccurens) during the operation on a thyroid?



38


D. disorder of coughingreflex


14. Tracheostomy in the patient with the traumatic break of larynx is executed, but an asphyxia grows quickly. What is the most credible reason of unsuccessful operation?



C. the diameter of tracheotomy tube is less than the section of trachea

D. a tracheotomy tube is closed by mucus or blood clot




39



Class in the operating room. The operations on the trachea. Tracheostomy.

Aim of lesson:

On the basis of exact knowledge of topographic-anatomic correlations of formations and organs of neck. To be able to execute on a dead body accesses and operations on a trachea, thyroid gland.


To know:

1. Individual and age-old features of position of organs of neck.

2. Possibility of congenital and acquired phlebitis of jugular veins.

3. The features of anaesthetizing at operative interferences on the organs of neck.

4. Description of wounds of neck. Features of wounds. Pathological processes of thyroid gland, which require operative interferences

To know:

1. Topography of trachea.

2. Layers of medial triangle of neck

3. Cellular space of medial triangle of neck.

4. Technique of tracheostomy.

5. Errors and complications at tracheostomy.

To be able:

1. To reparate medial triangle of neck.

2. To execute overhead tracheostomy

3. To execute lower tracheostomy .


Neck part of trachea, providing of blood supply and innervation. Tracheostomy.

Complication and errors at tracheostomy. Intubation.


Control of initial level of knowledge - 5%



Control of eventual level of knowledge - 15%


Test

1. In what place is tracheostomy conducted?

A. higher of isthmus of thyroid gland

B. higher of hyoid

C. higher of the undercuts of breastbone

D. higher of arcus venosus juguli

E. higher of the middles of neck part of trachea

2. In what place is lower tracheostomy conducted?

A. below isthmus of thyroid gland

B. below hyoid

C. below undercuts of breastbone

40

D. below arcus venosus juguli

E. below middles of neck part of trachea

3. Damage of which nerve brings to paresis of vocal cords and disorder of phonation?



C. n.abducens

D. n.mandibularis



Test


A. the isthmus of thyroid gland is highly located






A. the danger of necrosis of cartilages of tracheas which collect blood from vessels to the isthmus





3. What complications can arise up in a postsurgical period after the procedure of tracheostomy in case of the insufficient stop-bleeding during the operation?


B. aspiration pneumonia

C. pneumothorax



4. What complications can be developed at one-sided trauma of n.laryngeus inferior (n. laryngeus reccurens) during the operation on a thyroid?




D. disorder of coughing reflex


5. What complications can arise in post-surgical period after the procedure of tracheostomy at the wound of back wall of trachea during the operation?


B. air embolism

C. pneumothorax


41


6. Tracheostomy at a patient with the traumatic break of larynx is executed, but an asphyxia grows, there is a growth of edema of soft fabrics of neck, a crepitus appeared at palpation of neck. Which of the suggested errors is the most credible reason of development of emphysema and severe post-surgical condition?

A. the section of trachea is bigger than the diameter of tracheotomy tube, a skin is densely sewn up

B. a tracheotomy tube is brought into the submucous layer of trachea

C. damaged a. thyreoidea ima

D. a tracheotomy tube is closed by a blood or mucus clot

E. the section is eccentric – irritation of n.vagus

7. Tracheostomy at a patient with the traumatic break of larynx is executed, but an asphyxia grows, there is growth of edema of soft fabrics of neck, crepitus at palpation of neck appeared - a pneumoderma grows. Which of the suggested operative maneuvers is it necessary to carry out for the improvement of the state of patient?

A. to take out the stitches from a skin

B. to impose additional stitches on a skin

C. to take out the stitches from a trachea

D. to conduct the additional section of trachea

E. to conduct a vagosympathetic blockade

8. Tracheostomy at a patient with the traumatic break of larynx is executed, but an asphyxia grows quickly. Which of the suggested conditions is the most credible reason of unsuccessful operation?



C. the diameter of tracheotomy tube is less than the section of trachea.

D. a tracheotomy tube is brought into a submucous layer


9. What complications can be developed at the bilateral trauma of n.laryngeus inferior

(n.laryngeus reccurens) during the operation on a thyroid?




D. disorder of coughingreflex


14. Tracheostomy in the patient with the traumatic break of larynx is executed, but an asphyxia grows quickly. What is the most credible reason of unsuccessful operation?



C. the diameter of tracheotomy tube is less than the section of trachea

D. a tracheotomy tube is closed by mucus or blood clot




42



Topographical anatomy of chest wall. Layers. Mammary [lactiferous] gland. The operations on mammary [lactiferous] gland. Pleurocentesis (thoracocentesis). Closing of pneumothorax.

The anatomico-physiological features of breast in infancy (childhood).

Aim of lesson:

On the basis of knowledge of topographical anatomy of thorax, to study different surgical approaches and maneuvers (ways).

To be able to ground and execute on a dead body the most rational sections at mastitis, resection of rib (costotomy), pleurocentesis (thoracocentesis).


To know (to have an overview):

1. Forms of thorax;

2. Birth defects of thorax;

3. Individual features of location of thorax vessels;

4. Age features of thorax;

5. The surgical correction of birth defects of thorax.

To know:

1. Thorax borders, fragmentation.

2. Relative borders for determination of projection of thoracic cavity organs.

3 Anterosuperior area of thorax.

4. Topography of mammary gland and ways of lymph outflow, its blood supply and innervation.

5. Topography of intercostal spaces.

6. Pleura borders.

7. Pleural sinuses and their topography.

8. Sections at mastitis. Radical mastectomy.

9. Function of pleura.

10. Resection of rib (costotomy).

11. Methods of closing of open pneumothorax.

To be able:

1. To conduct section at intramammary mastitis.

2. To conduct section at retromammary mastitis.

3. To conduct section at subareolar mastitis.

4. To conduct the sector resection of mammary gland on a dead body.

5. To conduct pleurocentesis (thoracocentesis) on a dead body.

6. To conduct the resection of rib (costotomy).

7. To conduct closing of pneumothorax.

Lesson contents:

Topographical anatomy of chest wall of diaphragm. Layers of soft tissues. Mammary gland, blood supply, innervation, lymph outflow. Intercostal space (arteries, veins, nerves). Pleural sinus. The operations on a suckling gland: sections at mastitis, resection of suckling glands, mastectomy (Peti’s, Halsted's - Mayer mastectomy). Pleurocentesis (thoracocentesis).

Resection of rib (costotomy). Closing of open pneumothorax.

43

Distribution of time:

Control of initial level standard of knowledge - 10%

Theoretical guidelines and interview - 10%


Control of ultimate level/ standard of knowledge - 15%

Task for the initial control of level/standard of knowledge

Tests.

1. At the examination of patients the borders of heart, lungs, pleura are set according to conditional vertical and horizontal lines. Specify, what anatomic formations does lin.mediana anterior pass on a thorax?

A. from the jugular incisure through an umbilicus to symphysis

B. by the edge of breastbone

C. middle between sternal and medial clavicular lines

D. middle of clavicle/ collar-bone

E. along the costal cartilages of the I-VI ribs

2. At the examination of patients of borders of heart, lungs, pleura are set according to conditional vertical and horizontal lines. Specify, behind what anatomic formations does lin. sternalis pass on the chest?






3. At the examination of patients of borders of heart, lungs, pleura are set according to conditional vertical and horizontal lines. Specify, behind what anatomic formations does lin. parasternalis pass on the chest?






4. At the examination of patients of borders of heart, lungs, pleura are set according to conditional vertical and horizontal lines. Specify, behind what anatomic formations does lin. medioclavicularis pass on the chest?






5. At the examination of patients of borders of heart, lungs, pleura are set according to conditional vertical and horizontal lines. Specify, behind what anatomic formations does lin. axillaris ant. pass on the chest?

A. front edge/ side of axillary crease

B. acromion process

C. the deepest part of axillary crease

44

D. shoulder joint, humeral articulation

E. lateral edge of small pectoral muscle

6. At the examination of patients of borders of heart, lungs, pleura are set according to conditional vertical and horizontal lines. Specify, behind what anatomic formations does lin. axillaris media pass on the chest?

A. front edge/ side of axillary crease

B. acromion process

C. the deepest part of axillary crease

D. shoulder joint, humeral articulation

E. lateral edge of small pectoral muscle

7. At the examination of patients of borders of heart, lungs, pleura are set according to conditional vertical and horizontal lines. Specify, behind what anatomic formations does lin. mediana post. pass on the chest?

A. transverse processes of vertebra

B. acromion process

C. spinous processes of vertebra

D. intervertebral foramens

E. articular process of vertebra

8. What fascia forms the capsule of mammary [lactiferous] gland?

A. superficial pectoral fascia

B. external plate of fascia of greater pectoral muscle

C. external plate of proper pectoral fascia

D. inner/ internal plate of proper pectoral fascia

E. external plate of fascia of small pectoral muscle

9. What fascia forms the supporting ligament of mammary [lactiferous] gland?

A. superficial pectoral fascia

B. external plate of fascia of greater pectoral muscle

C. external plate of proper pectoral fascia

D. inner/ internal plate of proper pectoral fascia

E. external plate of fascia of small pectoral muscle

10. How are intercostal veins and nerves located top-down in an intercostal space?

A. v.intercostatis, a.intercostalis, n.intercostalis

B. a.intercostalis, v.intercostalis, n.intercostalis

C. v.intercostalis, n.intercostalis, a.intercostalis

D. n.intercostalis, v.intercostalis, a.intercostalis

E. n.intercostalis, a.intercostalis, v.intercostalis

11. Specify a vein, where do the intercostal veins of right side flaw into?

A. v.intercostalis

B. v.azygos

C. v.hemiazygos

D. v.cava inferior

E. v.cava superior

12. Specify a vein, where does v.azygos flaw into?

A. v.intercostalis

B. v.azygos

45

C. v.subclavia

D. v.cava inferior

E. v.cava superior

13. Thrombosis or the wound of which of the following arteries will result in circulatory arrest at a.thoracica interna?

А. a.subclavia

B. a.axillaris

C. a.carotis communis

D. a.pericardiacophrenica

E. a.bronchialis

14. At the examination of a female patient with mammary [breast] tumor for staging procedure it is necessary to determine the state/ condition of regional lymphatic nodes.

Specify the regional lymphatic nodes of a 1 order for the lateral sectors of mammary gland?

A. Zorgius’ node

B. nodi lymphatici supraclavicularis

C. nodi lymphatici sternalis

D. nodi lymphatici cervicalis profunda

E. nodi lymphatici mediastinalis

15. At the examination of a female patient with mammary tumor for staging procedure it is necessary to determine the state condition of regional lymphatic nodes. Specify the regional lymphatic nodes of a 1 order for the upper sectors of mammary gland?

A. nodi lymphatici axillaris anterior et profunda





Task for the control of ultimate level/ standard of knowledge

Tests.

1. At the examination of a female patient with mammary tumor for staging procedure it is necessary to determine the state condition of regional lymphatic nodes. Specify the regional lymphatic nodes of a 1 order for the upper sectors of mammary gland?

A. Zorgius’ node





2. What, besides esophagus, passes in hiatus esophagius of diaphragm?

А. nn.vagi

B. ductus thoracicus

C. v.cava inferior

D. nn.splanchnici

E. v.azygos

3. What passes in Larrey’s hiatus of diaphragm (trigonum sternocostale sinistra)?

A. nn.splanchnici, v.azygos, v.hemiazygos

Б. aorta, ductus thoracicus

46

B. стравохід, nn.vagi

Г. v.cava inferior

Д. vasa thoracica interna

4. At the examination of a patient with auscultation and percussion ( auscultatory percussion ) there was determined the presence of liquid in the pleural cavity. In what place of thorax is it recommended to conduct trial paracentesis in this case?

A. VII-VIII intercostal space between lin.axillaris post. et scapularis

B. II intercostal space along lin. medioclavicularis (in sitting position/posture)

C. V-VII intercostal space between lin.axillaris post. et scapularis

D. Х-Х1 intercostal space between lin.axillaris post. et scapularis

E. VIII-X intercostal space between lin.axillaris post. et scapularis

5. At the examination of a patient with auscultation and percussion ( auscultatory percussion ) there was determined the presence of air in the pleural cavity. In what place of thorax is it recommended to conduct trial paracentesis in this case?

A. VII-VIII intercostal space between lin.axillaris post. et scapularis

B. II intercostal space along lin. medioclavicularis (in sitting position/posture)

C. V-VII intercostal space between lin.axillaris post. et scapularis

D. Х-Х1 intercostal space between lin.axillaris post. et scapularis

E. VIII-X intercostal space between lin.axillaris post. et scapularis

6. What should be diagnosed a female patient with the inflammatory process of mammary

[breast] gland, if the nidus of suppurative inflammation is located between the lobes of gland and skin?

A. subareolar mastitis

B. intramammary mastitis

C. premammary mastitis

D. retromammary [submammary] mastitis

E. subpectoral phlegmon

7. What should be diagnosed a female patient with the inflammatory process of mammary

[breast] gland, if the nidus of suppurative inflammation is located between superficial and own fascia of the gland?

A. subareolar mastitis

B. intramammary mastitis

C. premammary mastitis

D. retromammary [submammary] mastitis

E. subpectoral phlegmon

8. A female patient was diagnosed intramammary mastitis. What sections should be applied at surgical treatment of this form of mastitis?

A. radial, beginning within 2 – 3 sm. from the edge of the pigmentary area/field of nipple

B. radial, beginning directly from a nipple

C. radial, directly above nidus of inflammation

D. radial, beginning from the edge of the pigmentary area/field of nipple

E. oval section under a gland

9. A female patient was diagnosed subareolar mastitis. What sections should be applied at surgical treatment of this form of mastitis?


47




E. oval section under a gland

10. A female patient was diagnosed retromammary [submammary] mastitis. What sections should be applied at surgical treatment of this form of mastitis?





E. moon-shaped section under a gland

11. On a female patient with the tumour of mammary [breast] gland was performed the incomplete/partial ablation of gland. What name does the executed surgical procedure have?

A. partial mastectomy

B. conservative radical mastectomy

C. radical [Halsted's] mastectomy

D. simple [total] mastectomy

E. extended [enlarged] radical mastectomy

12. On a female patient with mammary [breast] tumor was performed ablation of gland, fascia of greater pectoral muscle, cellular tissue of axillary crease. What name does the executed surgical procedure have?






13. On a female patient with mammary tumor was performed en bloc resection of gland with subcutaneous cellular tissue, greater and small pectoral muscles, cellular tissue of axillary crease, and infraclavicular and infrascapular regions with the parasternal lymphatic nodes ablation. What name does the executed surgical procedure have?






14. What should be diagnosed the patient with pneumothorax, if air got in the pleural cavity during the closed injury of lungs?

A. external closed pneumothorax

B. internal open pneumothorax

C. internal closed pneumothorax

D. external open pneumothorax

E. external valvular pneumothorax

15. What should be diagnosed the patient with the injury of thorax, at which air gets in a pleural cavity through a wound in a thorax, and doesn’t come out?

A. external closed pneumothorax

48

B. internal valvular pneumothorax

C. internal closed pneumothorax

D. external open pneumothorax

E. external valvular pneumothorax

Confirmed at the department meeting «____» _____________ Protocol № _______ prof. Kostyuk G.Y. Head of department

49



Topographical anatomy of thoracic cavity: Pleura, innervation, blood supply, lymph outflow. Lungs. Anterior and posterior mediastinum. Approaches to lungs, modern surgical procedures on lungs (pneumonectomy, resection of lungs, segmental resection/ectomy).

Aim of lesson:

On the basis of the detailed knowledge of topography of thoracic cavity organs, to be able to execute on a dead body approaches to lungs, to close the wound of lungs, to close the wound of esophagus.

To know the ways of distribution of inflammatory exudate and haematomas in the posterior mediastinum.



1. Surgical anatomy of birth defects of esophagus.

2. Modern possibilities of esophagoplasty.

3. Modern possibilities of surgical treatment at birth defects of esophagus.

4. Modern possibilities of drainage of thoracic lymphatic duct.

5. Modern possibilities of surgical treatment at birth defects of lungs.

6. Surgical methods of treatment at staphylococcal destruction of lungs.

To know:

1. Surgical anatomy of lungs.

2. Anatomic features of division of lungs into parts and segments.

3. The notions of the hilus and root of lungs. The surgical anatomy of root of lungs.

4. To define the notion of "mediastinum", division of mediastinum into superior, lower, anterior, posterior, and middle. Organs placed in all parts of mediastinum.

5. Surgical anatomy of thymus (gland), superior vena cava, phrenic nerves.

6. Surgical anatomy of thoracal part of esophagus. The grounds of approaches to esophagus at different levels. Opening of esophagus.

7. Surgical anatomy of thoracic duct, azygos and hemiazygos veins, sympathetic trunk, forming of splanchnic nerves.

8. Anatomic and physiological grounds of surgical approaches to lungs, esophagus.

9. Ground states of pulmonectomy.

10. Basic stages of resection of lungs.

To be able:

1. To conduct on a dead body anterolateral approach to lungs.

2. To conduct on a dead body posterolateral approach to lungs.

3. To close the wound of lungs.

4. To close the wound of esophagus.

5. To conduct a segmental resection of lungs.

6. To be able to dissect elements of root of lungs.

7. To be able to execute the costectomy.


Topographical anatomy of thoracic cavity organs. Pleura and its parts. Topography and segmental structure of lungs. Topography of anterior and posterior mediastinum. Surgical anatomy of thoracic duct, azygos and hemiazygos veins, sympathetic trunk, forming of

50 splanchnic nerves. The operations on the organs of thoracic cavity. Examination of operative approaches to lungs and technique of pneumonectomy. Examination of basic operations on the thoracal part of esophagus.


Control of initial level/ standard of knowledge - 10%





Tests.

1. In what intercostal spaces is a thoracic cavity dissected at anterolateral approach to the root of lungs?

A. IV-V intercostal space

B. ІІІ-IV intercostal space

C. V-VI intercostal space

D. VII intercostal space

E. VIII intercostal space

2. In what intercostal spaces is a thoracic cavity dissected at posterolateral approach to the root of lungs?






3. What layers of soft tissues should be taken in the first row of stitches at closure of penetrating wound of thorax with the wound of parietal pleura?

A. pleura, endothoracic fascia, intercostal muscles

B. endothoracic fascia, intercostal muscles, small pectoral muscle

C. intercostal muscles, periosteum of ribs, small pectoral muscle

D. small pectoral muscle, greater pectoral muscle, own fascia

E. superficial fascia, subcutaneous cellular tissue, skin

4. What layers of soft tissues should be taken in the third row of stitches at closure of penetrating wound of thorax with the wound of parietal pleura?






5. At radiological examination of patient dilatation of root of lungs is set. Specify the indexes/rates of skeletopy of root of lungs which are considered normal for the healthy adult?

A. at the level of 7-8 thoracic vertebrae

B at the level of 5-7 thoracic vertebrae

C at the level of 3-4 thoracic vertebrae

D at the level of 3-5 thoracic vertebrae

51

E at the level of 4-6 thoracic vertebrae

6. At radiological examination of patient dilatation of root of lungs is set. Specify in what order top-down are the elements of root of left lung located?

A. bronchus, artery, vein

B. artery, bronchus, vein

C. artery, vein, bronchus

D. bronchus, vein, artery

E. vein, artery, bronchus

7. At radiological examination of patient dilatation of root of lungs is set. Specify in what order are the elements of root of the right lung located in a sagittal plane from front to back?






8. At radiological examination of patient dilatation of root of lungs is set. Specify in what order are the elements of root of the left lung located in a sagittal plane from front to back?






9. The bronchus of what order ventilates a pulmonary segment?

A. primary bronchus

B. bronchus of the first order

C. bronchus of the second order

D. bronchus of the third order

E. bronchus of the fourth order.

10. What nerve passes in anterior mediastinum in front of the root of lungs?

A. n.vagus

B. n.phrenicus

C. n.laryngeus reccurens

D. n.splanchnicus

E. tr.sympathicus

11. At the examination of patient it was set that the height of standing of cervical pleura at the front corresponds to normal indexes. Specify the height of standing of cervical pleura behind, that is considered normal for the healthy adult?

A. level of the 6 th cervical vertebra

B. level of the 5 th cervical vertebra

C. level of the 7 th cervical vertebra

D. level of the head of the 1 st rib

E. level of the head of the 2 nd rib

12. With what cellular space of neck does the cellular tissue of anterior mediastinum join?

A. prevertebral

B. Grubber’s blind recess

52

C. retrovisceral

D. previsceral

E. interfascial compartment

13. Along what area of intercostal space is neurovascular fascicle covered by the lower edge of the upper rib?

A. between lin.paravertebralis and lin.scapularis

B. between lin.paravertebralis

C. between lin.scapularis and lin.axillaris media

D. between lin.axillaris ant. and lin.axillaris post.

E. between lin.axillaris post. and lin.medioclavicularis

14. At the examination of patient it was set, that lower lungs border corresponds to normal indexes or near normal indexes. Specify the index of lower lungs border for lin.parasternalis, which is considered normal for the healthy adult?

A. costal cartilage of the VI rib

B. costal cartilage of the V rib

C. VII rib

D. IX rib

E. XI rib

15. At the examination of patient it was set, that lower lungs border corresponds to normal indexes or near normal indexes. Specify the index of lower lungs border for lin.medioclavicularis, which is considered normal for the healthy adult?



C. VII rib

D. IX rib

E. XI rib


Tests.

1. Specify at the damage of what layer of chest wall a wound of the chest is considered to be penetrating in thoracic cavity?

A. ribs and intercostal muscles

B. parietal pleura

C. visceral [pulmonary] pleura

D. endothoracic fascia

E. parietal pleura or pericardium

2. In what order are the elements of root of lungs separated and ligated at pulmonectomy at a patient with chronic pneumonia?






3. In what order are the elements of root of lungs separated and ligated at pulmonectomy at a patient with a malignant tumour of lung?


53





4. By what suture material are pulmonary arteries ligated and sewn at pulmonectomy?

A. catgut

B. silk

C. lavsan

D. kapron

E. cotton

5. In what intercostal spaces is anterolateral approach to the root of lungs conducted?






6. In what intercostal spaces is posterolateral approach to the root of lungs conducted?






7. In what intercostal spaces is lateral approach to the root of lungs conducted?






8. In what place of thorax does anterolateral approach to lungs begin?

A. on the level of the II rib along lin.parasternalis

B. on the level of the III rib along lin.medioclavicularis

C. on the level of the II rib along lin.medioclavicularis

D. on the level of the III rib along lin.parasternalis

E. on the level of the IV rib along lin.parasternalis

9. Specify advantages of anterolateral surgical approach to lungs over posterolateral approach.

A. less traumatic and more convenient approach to the root of lungs

B. less traumatic, convenient conducting of artificial pulmonary ventilation and convenient position of patient on a surgical [operating] table

C. convenient approach to the root of lungs and convenience of encapsulating of root’s stump

D. convenient approach to the root of lungs and possibility of dilatation of approach

E. the best possibility of extrapleural treatment of elements of root of lungs

54

10. At the examination of patient it was set, that lower lungs border corresponds to normal indexes or near normal indexes. Specify the index of lower lungs border for lin.paravertebralis, which is considered normal for the healthy adult?



C. VII rib

D. IX rib

E. XI rib

Confirmed at the department meeting «____» _____________ Protocol № _______ prof. Kostyuk G.Y. Head of department

55



Topographical anatomy of heart and pericardium. Surgical approaches to heart. Karyolysis.

Operations on the heart because of its wound. Mitral commissurotomy. The congenital heart diseases and acquired valvular diseases and their surgical treatment. Surgical treatment of cardiac ischemia.

Aim of lesson:

On the basis of the detailed knowledge of topography of heart and study of surgical approaches and techniques at operations on the heart and great vessels, to master the art of the technique of mitral commissurotomy, to be able to execute on a dead body longitudinal median [midline] sternotomy and longitudinal transverse sternotomy, to close [to repair] a wound of heart.



1. Surgical anatomy of congenital heart diseases.

2. Surgical anatomy of the acquired valvular diseases.

3. Modern possibilities at the congenital heart diseases and great vessels.

4. Modern possibilities at the acquired valvular diseases.

5. The modern views on heart transplantation.

6. Modern possibilities of shunting of great vessels.

To know :

1. Surgical anatomy of heart (skeletopy, syntopy, blood supply, innervation, ways of venous and lymphatic outflow).

2. The congenital heart diseases.

3. The acquired valvular diseases.

4. Surgical anatomy of aorta and its branches.

5. Surgical anatomy of pulmonary trunk and pulmonary arteries.

6. Anatomical and physiological grounds of surgical approaches to the heart.

7. Pericardiocentesis. Closure of wound of heart.

8. Mitral commissurotomy.

9. Coronary artery bypass grafting.

10. Stenting of coronal arteries.

11. Principles of heart transplantation.

To be able:

1. To conduct on the dead body longitudinal median [midline] sternotomy.

2. To conduct on the dead body longitudinal transverse sternotomy.

3. To close [to repair] a wound of heart.

4. To conduct a mitral commissurotomy.


Chambers of heart, cardiac openings, cardiac valves, coronary arteries, cardiac veins. Aorta, its parts and branches, brachiocephalic trunk, arch of aorta. Defects of heart and great vessels. Wounds of heart. Heart transplantation. Basic surgical procedures on the heart and vessels coronary artery bypass grafting, operations at congenital heart diseases, operations at mitral stenosis. Sutures on vessels, operations at aneurism and coarctation of vessels.

56


Control of initial level/ standard of knowledge - 10%





Tests.

1. In what intercostal spaces is a thoracic cavity dissected at anterolateral approach to the root of lungs?






2. In what intercostal spaces is a thoracic cavity dissected at posterolateral approach to the root of lungs?






3. What layers of soft tissues should be taken in the first row of stitches at closure of penetrating wound of thorax with the wound of parietal pleura?






4. What layers of soft tissues should be taken in the third row of stitches at closure of penetrating wound of thorax with the wound of parietal pleura?






5. At radiological examination of patient dilatation of root of lungs is set. Specify the indexes/rates of skeletopy of root of lungs which are considered normal for the healthy adult?

A. at the level of 7-8 thoracic [dorsal] vertebrae

B at the level of 5-7 thoracic [dorsal] vertebrae

C at the level of 3-4 thoracic [dorsal] vertebrae

D at the level of 3-5 thoracic [dorsal] vertebrae

E at the level of 4-6 thoracic [dorsal] vertebrae

6. At radiological examination of patient dilatation of root of lungs is set. Specify in what order top-down are the elements of root of left lung located?

57






7. At radiological examination of patient dilatation of root of lungs is set. Specify in what order are the elements of root of the right lung located in a sagittal plane from front to back?






8. At radiological examination of patient dilatation of root of lungs is set. Specify in what order are the elements of root of the left lung located in a sagittal plane from front to back?






9. The bronchus of what order ventilates a pulmonary segment?

A. primary bronchus

B. bronchus of the first order

C. bronchus of the second order

D. bronchus of the third order

E. bronchus of the fourth order.

10. At the examination of patient it was set, that lower lungs border corresponds to normal indexes or near normal indexes. Specify the index of lower lungs border for lin.paravertebralis, which is considered normal for the healthy adult?



C. VII rib

D. IX rib

E. XI rib


Tests.

1. Specify at the damage of what layer of chest wall a wound of the chest is considered to be penetrating in thoracic cavity?

A. ribs and intercostal muscles

B. parietal pleura

C. visceral [pulmonary] pleura

D. endothoracic fascia

E. parietal pleura or pericardium

2. In what order are the elements of root of lungs separated and ligated at pulmonectomy at a patient with chronic pneumonia?


58





3. In what order are the elements of root of lungs separated and ligated at pulmonectomy at a patient with a malignant tumour of lung?






4. At female patient with cardiac ischemia omentocardiopexy was conducted. Explain the essence of this operation.

A. anchoring visceral [pulmonary] pleura to pericardium

B. anchoring diaphragm to myocardium

C. anchoring greater [gastrocolic] omentum to myocardium

D anchoring parietal pleura to the pericardium

E anchoring parietal pleura to myocardium

5. At female patient with cardiac ischemia the operation of autogenous venous coronary artery bypass grafting was conducted. Explain the essence of this operation.

A. anastomosis of healthy areas of coronary arteries above the place of occlusion

B. intra-arterial introduction of bougie to the narrowed part of coronary artery

C. anastomosis of healthy areas of coronary arteries with an internal thoracic artery

D. removing of pathological changes in the inner coat of coronary arteries

E. inseaming of autogenous venous vein graft between healthy parts of coronary arteries above the place of occlusion

6. At female patient with cardiac ischemia the operation of endarterectomy of coronary arteries is conducted. Explain the essence of this operation.






7. At female patient with cardiac ischemia the operation of intra-arterial coronaroplasty is conducted. Explain the essence of this operation.






8. At sick with ischemic heart trouble the operation of the mammary coronary artery bypass grafting is conducted. Explain the essence of this operation.


59





9. Specify where according to skeletopy the border of the left ventricle of heart of an adult is normally projected?

A. costal cartilage of II rib on the left

B. costal cartilage of II-IV ribs, 1, 5-2sm inwards from lin. mediocla-vicularis sinistra

C. V intercostal space, 1, 5-2sm inwards from lin. mediocla-vicularis sinistra

D. costal cartilage of III-IV ribs, 2sm to the right of the right edge of breast-bone

E. retrosternally on the level of the III intercostal space

10. Specify where according to skeletopy the border of the right auricle of heart of an adult is normally projected?

A. costal cartilage of II rib on the left

B. costal cartilage of II-IV ribs, 1, 5-2sm inwards from lin. mediocla-vicularis sinistra

C. V intercostal space, 1, 5-2sm inwards from lin. mediocla-vicularis sinistra

D. costal cartilage of III-IV ribs, 2sm to the right of the right edge of breast-bone

E. retrosternally on the level of the III intercostal space



60



Topographical anatomy of abdominal wall. Division into parts. Projection of organs of abdominal cavity on a front wall. Layered sectional structure of the front abdominal wall.

Blood supply, innervation, lymph outflow. Surgical approaches to the organs of abdominal cavity

Aim of lesson:

To learn the topographical anatomy of the front abdominal wall, division into parts, layered/sectional structure, blood supply, innervation, lymph outflow. To master the technique of execution of some approaches to the organs of abdominal cavity.

For the correct understanding of pathological processes and grounding the rational approaches to the internal the most important in the training of doctor is the knowledge of anatomic and physiological, age and sexual structural peculiarities of the front-lateral abdominal wall.



1. The age and sexual structure peculiarities of studied area.

2. The birth development defects related to anatomic formations of front-lateral abdominal wall (pathology of urachus, omphalocele and methods of their treatment).

3. The classification of sections of front-lateral abdominal wall.

To know:

1. Division of front-lateral abdominal wall into parts.

2. Projections of internal on the front-lateral abdominal wall.

3. Structure of front layer of front-lateral abdominal wall.

4. Structure of middle layer of front-lateral abdominal wall, forming sheath of rectus muscle.

5. Topographical anatomy of deep layer, fossa and fold of posterior surface of front-lateral abdominal wall.

6. Weak points of front-lateral abdominal wall (white [Hunter's] line, umbilical ring).

7. Blood supply, innervation, lymph outflow of front-lateral abdominal wall.

8. Classification of sections of front-lateral abdominal wall.

9. Grounds of the use of rational approaches.

10. Layered/sectioned description of vertical [lengthwise, longitudinal] incision and

Volkovich-Diakonov’s oblique incision.

To be able:

1. To execute middle midline laparotomy.

2. Paramedian incision

3. Transrectal incision

4. Lenander’s incision

5. Volkovich-Diakonov’s incision


External landmarks of front-lateral abdominal wall. Layered topography. White [Hunter's] line. Structural features of umbilical ring. Surgical approaches to the organs of abdominal cavity. Techniques of midline [median], paramedian, transrectal, pararectal, oblique,

61 transverse and combined incision. Volkovich-Diakonov’s oblique incision (through

McBurney's point), its physiology.


Control of initial level/ standard of knowledge — 10%

Theoretical guidelines and interview — 30%

Practical work — 40%

Control of ultimate level/ standard of knowledge — 20%


Tests.

1. How do the upper, lower, and lateral boundaries of abdomen pass?

2. Name the parts of abdomen.

3. Where are the projections of vermiform appendix, gall-bladder, pyloric and cardial parts of stomach, spleen, liver, small and large intestine loops, urinary bladder situated?

4. What are the peculiarities of structure of navel, white [Hunter's] line?

5. What are the peculiarities of structure of sheath of rectus muscle of abdomen on different levels (higher and below umbilical ring)?

6. Where are the nerves of muscles of front-lateral abdominal wall situated?

7. How do nerves and vessels pass to rectus muscle of abdomen?

8. What operative approach through sheath of rectus muscle of abdomen is most rational?

9. What are advantages and disadvantages of surgical approaches to vermiform appendix?

Evaluate Volkovich-Diakonov’s incision and Lenander’s incision [pararectal incision].

10. Give comparative description of longitudinal and transverse incisions.


Tests.

1. What layers form the front-lateral abdominal wall in the middle of umbilical ring?

A. skin, umbilical (internal) fascia, parietal peritoneum

B. skin, subcutaneous cellular tissue, umbilical (internal) fascia, parietal peritoneum

C. skin, umbilical (internal) fascia, abdominoanterior cellular tissue, peritoneum

D. skin, subcutaneous cellular tissue, umbilical (internal) fascia, abdominoanterior cellular tissue, parietal peritoneum

E. skin, subcutaneous cellular tissue, white [Hunter's] line, umbilical (internal) fascia, parietal peritoneum

2. What anatomic objects form plica umbilicalis mediana?

A. imperforated urinary duct

B. obliterated umbilical arteries

C. inferior epigastric arteries

D. inferior epigastric arteries and inferior epigastric veins

E. obliterated umbilical arteries and obliterated umbilical veins

3. What anatomic objects form plica umbilicalis medialis?






4. What anatomic objects form plica umbilicalis lateralis?

62






5. Aponeurosis of what muscles forms the front wall of sheath of rectus muscle of abdomen higher Douglas’s line?

А. m.obliqus abdominis externus, m.obliqus abdominis internus

B. m.transversus, m.obliqus abdominis internus

C. m.obliqus abdominis externus, m.rectus abdominis

D. m.obliqus abdominis externus

E. m.obliqus abdominis internus

6. Aponeurosis of what muscles forms the back wall of vagina of rectus muscle of abdomen higher Douglas’s line?

А. m.obliqus abdominis externus, m.obliqus abdominis internus

B. m.transversus, m.obliqus abdominis internus


D. m.obliqus abdominis externus


7. What is the back wall of vagina of rectus muscle of abdomen formed by below Douglas’s line?

A. m.obliqus abdominis externus, m.obliqus abdominis internus

B. m.transversus, m.obiiqus abdominis internus


D. f. endoabdominalis


8. What anatomic object separates a supracystic fossa from the medial axillary cavity on the internal surface of anterolateral abdominal wall?

A. plica umbilicalis mediana (imperforated urinary duct)

B. plica umbilicalis mediana (obliterated umbilical arteries)

C. plica umbilicalis medialis (obliterated umbilical arteries)

D. plica umbilicalis medialis (inferior epigastric arteries and veins)

E. plica umbilicalis lateralis (inferior epigastric arteries and veins)

9. What anatomic object separates the medial axillary cavity from the lateral axillary cavity on the internal surface of anterolateral abdominal wall?

A. plica umbilicalis mediana (imperforated urinary duct)

B. plica umbilicalis mediana (obliterated umbilical arteries)

C. plica umbilicalis medialis (obliterated umbilical arteries)

D. plica umbilicalis medialis (inferior epigastric arteries and veins)

E. plica umbilicalis lateralis (inferior epigastric arteries and veins)

10. What surgical approach to the organs of abdominal cavity which is conducted through

McBurney's point (border of external and middle third of distances between navel and spina iliaca anterior superior) almost parallel to the axillary ligament?

A. Volkovich-Diakonov’s oblique variable approach

B. Lenander’s pararectal approach

63

C. Pfanienstiel’s transversal approach

D. Petropvsky’s combined approach

E. paramedian approach

11. What surgical approach to the organs of abdominal cavity which is conducted on the external edge of rectus muscle of abdomen?






12. What surgical approach to the organs of abdominal cavity which is conducted on the internal edge of rectus muscle of abdomen?






13. How is surgical approach to the organs of abdominal and thoracic cavity named?






14. Which from the named surgical approaches to the organs of abdominal cavity is

“Volkovich-Diakonov’s approach”?

A. oblique variable approach

B. pararectal approach

C. transversal access

D. combined access


15. Which from the named surgical approaches to the organs of abdominal cavity is

“Lenander’s approach”?

A. oblique variable approach

B. pararectal approach

C. transversal access

D. combined access




64



Topographical anatomy of inguinal canal. Inguinal region. Notion of hernia. Operations at inguinal [groin] hernia. Girard's-Spasokukotsky’s, Bassini’s, Martinov’s methods of the plasty. Femoral canal. Operations at femoral, umbilical, midline [epigastric] hernias.

Aim of lesson:

To study the inguinal region (borders, external landmarks, layered topography; to define the inguinal region as weak point of muscular-aponeurotic layer; to define the surgical anatomy of oblique and direct hernias; to learn the technique of the most widespread methods of herniotomy and the plasty of inguinal canal).

To be able to execute on a dead body the Girard's-Spasokukotsky’s, Martinov’s plasty of walls of inguinal canal.



- age and sexual features of studied area;

- notions of hernia and its classification;

- methods of treatment of congenital inguinal hernia;

- age and sexual features of anatomic structure of studied area;

- classification of hernia;

- internal hernia and places of their formation;

- sliding [slip(ped), extrasaccular] hernia and peculiarities of its surgical treatment;

- diaphragmatic hernia;

- omphalocele;

- parietal [Richter's] hernia and retrograde strangulation;

- conservative methods of treatment of umbilical hernia at children of early age;

- peculiarities of surgical treatment of the strangulated femoral hernia;

- peculiarities of surgical treatment of congenital inguinal hernia.

To know:

- Walls and openings/foramens of inguinal canal;

- Content of inguinal canal;

- Surgical anatomy of oblique and direct inguinal hernias;

- Femoral canal and crural ring;

- Definition of concept of hernia and elements of its surgical anatomy (hernial gate, hernial sack, hernial content);

- Origin of congenital inguinal hernia;

- Surgical methods of the plasty of inguinal canal (Girard's-Spasokukotsky’s, Bassini’s,

Martinov’s).

- Surgical treatment of femoral hernia (Bassini’s, Ruggi-Parlaveccio’s).

- Surgical treatment of umbilical hernia (Meyo’s, Sapezhko’s, Lexer’s);

- Peculiarities of treatment of inguinal hernia at children of early age (Roux’s,

Krasnobayev’s).

To be able:

- To define the boundaries of inguinal region, external and internal landmarks and projections;

65

- To execute the layered section of front wall of abdomen parallel to inguinal [Poupart's] ligament;

- To prepare inguinal canal with determination of its walls and openings;

- To execute the Girard's-Spasokukotsky’s, Martinov’s plasty of walls of inguinal canal;

- To define walls and ring of inguinal canal.


Boundaries of inguinal region, external landmarks, projection of inguinal trigone, inguinal canal, its external [superficial] and deep [internal] rings. Structure of spermatic cord. Forms of inguinal region. Features of the topography of ilioinguinal nerve. Elements of surgical anatomy of hernia: hernia gate, coats of hernia sack, hernia content. Variety of inguinal hernia: direct, oblique, congenital, acquired, sliding and strangulated. Description of direct and oblique inguinal hernia. Congenital inguinal hernia. Operations concerning hernia.

Stages of operative maneuvers: treatment/processing of hernia sack and Girard's-

Spasokukotsky’s, Martinov’s, Bassini’s plasty of hernia gate. The contribution of prominent surgeons to the study of hernia (Spasokukotsky, Bobrov, Krymov, Martynov, Kymbarovsky,

Kukudzanov).

Operations of herniotomy without the cut of spermatic cord. Initial forms of hernia at children — Roux’s, Opel’s, Krasnobaev’s methods.







Tests.

1. What is inguinal trigone and inguinal region?

2. How are external [superficial] and deep [internal] rings projected?

3. What are folds and fossas on the internal surface of anterolateral wall of abdomen formed by?

4. How is spermatic cord disposed in relation to a hernia sack at direct and oblique inguinal hernias?

5. What anatomic object does spermatic cord consist from?

6. What inguinal hernia is more frequent at children?

7. How is the Girard's-Spasokukotsky’s, Martinov’s, Bassini’s, Kymbarovsky’s plasty of inguinal canal executed?

8. Is it possible to operate hernia at a child, without the section of inguinal canal? With the help of what methods?

9. When are the methods of the plasty of back wall of inguinal canal needed?

10. How to distinguish inguinal hernia from femoral hernia?


Tests.

1. At examination of back wall of inguinal canal of a patient with oblique inguinal hernia the pulsation of what artery will be determined medially from a hernia gate?

A. a.epigastrica superior

B. a.epigastrica inferior

66

C. a.epigastrica superficialis

D. a.circumflexa ilium profunda

E. a.cremasterica

2. At examination of back wall of inguinal canal of a patient with direct inguinal hernia the pulsation of what artery will be determined laterally from a hernia gate?

A. a.epigastrica superior

B. a.epigastrica inferior

C. a.epigastrica superficialis

D. a.circumfiexa ilium profunda

E. a.cremasterica

3. What is the anatomic cause of formation congenital inguinal hernia?

A. non-closed vaginal process of peritoneum (canal of Nuck, Nuck's diverticulum)

B. enlarged inguinal region

C. dilation of deep [internal] rings of inguinal canal

D. dilation of external [superficial] of inguinal canal

E. enlarged spermatic cord

4. What muscle forms inguinal [Poupart's] ligament?

A. m.obliqus abdominis externus

B. m.obliqusabdominis internus

C. m.transversus

D. m.rectus abdominis

E. m.pyramidalis

5. What ligament passes in the inguinal canal of women?

A. wide ligament of uterus

B. main ligament of uterus

C. round ligament of uterus

D. intestinal-uterine ligament

E. pubofemoral ligament

6. What is anatomic basis of formation congenital inguinal hernia?

A. non-closed vaginal process of peritoneum (canal of Nuck, Nuck's diverticulum)

B. enlarged inguinal region

C. varicose veins of spermatic cord

D. dilation of external [superficial] ring of inguinal canal

E. descent of testis retention

7. What fossa of anterior abdominal wall does oblique inguinal hernia pass through?

A. medial inguinal

B. supracystic

C. lateral inguinal

D. femoral

E. obturator

8. What fossa of anterior abdominal wall does direct inguinal hernia pass through?

A. medial inguinal

B. supracystic

C. lateral inguinal

D. femoral

67

E.

obturator

9. What differentiates the medial inguinal fossa on the internal surface of antero-lateral abdominal wall from a femoral fossa?

A. a.epigastrica inferior

B. lacunar [Gimbernat's] ligament

C. v.femoralis

D. pectineal ligament

E. inguinal ligament

10. What element of inguinal or femoral canals does the inguinal lateral fossa corresponds to?

A. to external [superficial] inguinal ring

B. to deep [internal] inguinal ring

C. to deep [internal] ring of femoral canal

D. to external [superficial] ring of femoral canal

E. to femoral fossa

11. What wall of inguinal canal is strengthened at Martinov’s operative [surgical] intervention?

A. upper

B. lower

C. anterior

D. posterior

E. anterior and lower

12. Where is spermatic cord located comparatively to a hernia sack at direct inguinal hernia?

A. laterally

B. medially

C. hernia sack passes into the coat of spermatic cord

D. spermatic cord is located in hernia sack

E. behind

13. Where is spermatic cord located comparatively to a hernia sack at oblique inguinal hernia?

A. laterally

B. medially

C. hernia sack passes into the coat of spermatic cord

D. spermatic cord is located in hernia sack

E. behind

14. Who offered the method of herniotomy at inguinal hernia, at which edges of internal oblique and transversal muscles, transversal fascia, sheath and edge of direct muscle are anchored to inguinal ligament behind spermatic cord, and aponeurosis of external oblique muscle of abdomen are sutured edge to edge/end to end without duplication?

А. Bassini’s

B. Kukudzanov

C. Girard - Spasokukotsky

D. Bobrov

E. Girard - Kymbarovsky

15. What vessel is the external wall of femoral canal at formation of femoral hernia?

68

A. v.femoralis

B. a.femoralis

C. a.profunda femoris

D. v.profunda femoris

E. v.saphena magna



69



Topographical anatomy of abdominal cavity. Peritoneum, its connection with the organs of abdomen. Bursas, canals, nooks of peritoneum. Topography of stomach, liver, gall-bladder.

Aim of lesson:

For exact and complete diagnostics of pathological changes of peritoneum and organs of peritoneal cavity it is necessary to be well-informed in anatomical and physiological features both of peritoneum and organs of peritoneal cavity.

To be able to conduct the systematic revision of organs of abdominal cavity at the penetrating wounds of abdomen, to execute surgical d-bridement of wounds with the damage of abdominal organs.



- difference between notions "abdominal cavity" that "peritoneal cavity";

- peritoneal track its connection with the organs of peritoneum;

- formation of peritoneum in the upper floor of peritoneal cavity;

- formation of peritoneum in the lower floor of peritoneal cavity;

- ways of spreading of pyoinflammatory processes within peritoneal cavity;

- spreading of metastatic processes at malignant neoplasms of stomach;

- forms of stomach and age features/peculiarities;

- fixating mechanism of liver;

- sphincteric mechanism of extrahepatic/anhepatic bile [biliary, gall] ducts;

- mechanism of filling and emptying of bile of gall-bladder.

To know:

- boundaries of peritoneal cavity;

- topography of omental bursa and epiploic [Winslow's] foramen;

- topographical anatomy of ligamentous apparatus of stomach;

- features/peculiarities of arterial blood supply and venous outflow from a stomach;

- innervation of stomach (nerve plexus of stomach);

- outflow of lymph from a stomach (superficial and deep lymphatic collectors);

- blood supply of liver and its venous mechanism;

- forming of intrahepatic and extrahepatic/anhepatic bile [biliary, gall] ducts;

- blood supply of gall-bladder;

- topography of triangle of Kallo.

To be able:

1. To show on preparation (fixed dead body) formations of peritoneum in the upper and lower floors.

2. On a dead body (or preparation), to find and show the parts of stomach, arteries and veins of stomach.

3. To show the nervous mechanism of stomach.

4. On preparation of liver to find and show hepatic ligaments, topography of hepatic hilus.

5. On preparation to show the separation of elements of hepatoduodenal ligament.


Boundaries of gastric cavity and peritoneal cavity. Connection of peritoneum with the organs of peritoneal cavity. Formations of peritoneum in peritoneal cavity (upper and lower

70 floor): bursas, canals, nooks. Topographical anatomy of stomach, its blood supply, venous outflow, innervation, lymphatic system. Topographical anatomy of liver with intrahepatic and extrahepatic/anhepatic bile [biliary, gall] ducts.

The possible ways of distribution of pus at peritonitis, places of its accumulation with formation of local pyogenic [hot] abscess. The most rational methods of drainage of peritoneal cavity. The topography of gall-bladder, spleen, its position in peritoneal cavity, projection, skeletopy, interrelation with neighbouring organs.







Tests.

1. Name the front wall of omental bursa

A. caudate [spigelian] lobe of liver;

B. mesocolon transversum;

C. lesser [gastrohepatic] omentum;

D. duodenum;

E. back surface of stomach and gastrocolic ligament

2. What formation is the back wall of bursa hepatica sinistra?

A. muscular part of diaphragm;

B. left coronary ligament of liver;

C. falciform ligament of liver;

D. left trigonal ligament of liver;

E. lesser [gastrohepatic] omentum.

3. Name the left border of sinus mesenterscus dexter

A. mesocolon transversum;

B. сolon transum;

C. root of mesentery;

D. ascending colon;

E. descending colon.

4. Name the anterior border of epiploic [Winslow's] foramen.

A. lig.hepatorenale;

B. lobus caudatus;

C. lig.duodenorenale;

D. lig.hepatoduodenale

E. lig.gastrocolicum

6. In the elements of what ligament is a. gastrica sinistra lokated?

A. lig. hepatopyloricum;

B. lig. gastrophrenicma;

C. lig. hepatogastricum;

D. lig. gastropancreaticum;

E. lig. pyloropancreaticum.

7. From what artery does a.gastrica sinistra begin?

A. aorta;

B. А. mesenterica superior;

C. а. gastroduodenalis;

D. а. lienalis;

E. truncus coeliacus.

8. What arteries of stomach form lesser arterial circle of stomach?

A. а. gastroepiploica sinistra;

B. а. gastroepiploica dextra;

C. а. gastrica dextra;

D. а. lienalis;

E. а. gastrica sinistra

9. A branch of what artery is a. gastrica dextra?

A. a.hepatica proprira;

B. а. gastrica sinistra;

C. a.mesenterica superior;

D. a.colica media;

E. a.gastroepiploica dextra

10. Which from the named veins is located in the elements of lig. gastropancreaticum?

A. v.mesenterica superior;

B. v.pylorica;

C. v.lienalis;

D. v.coronaria ventriculi;

E v.gastroepiploica sinisrta

11. How many groups of visceral lymphatic nodes of stomach are there?

A. 5;

B. 6;

C. 9;

D. 12;

E. 10.

12. Name the middle border of caudate [spigelian] lobe of liver.

A. porta hepatis;

Б. sulci saqittales;

B. right lobe of liver;

Г. нижня порожниста вена;

Д. gall-bladder

13. Which from the mentioned nerves forms the front nerve plexus of stomach?

A. right vagus [X cranial] nerve;

Б. left vagus [X cranial] nerve;

B. branches of hepatic plexus

Г. n.splauchnicus major;

Д. n.splauchnicus minor.

14. The branch of what artery is a.cystica?

A. hepatica propria;

B. a.gastrica dextra;

C. а. hepatica communis;

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D. a.gastroduodenalis;

E. a.mesenterica superior.

15. What part of ductus choledochus is placed in the elements of lig. hepatoduodenale?

A. first part;

B. second part;

C. third part;

D. fourth part;

E. is not placed in lig.hepatoduodenale


Tests.

1. What is the name of organ covered from all sides by peritoneum?

A. intraperitoneal;

B. retroperitonal;

C. mesoperitonal;

D. extraperitoneal;

E. anperitoneal.

2. At drainage of omental bursa cavity a surgeon set rubber drainage through epiploic

[Winslow's] foramen. There was venous bleeding on the third day. In which wall of omental bursa are the nearest main venous vessels located?

A. anterior;

B. posterior;

C. lateral;

D. medial;

E. upper.

3. On the 5 th day after the appendectomy at a patient was found temperature rise, hiccup, pains in right hypochondrium. A doctor diagnosed subdiaphragmatic [subphrenic] abscess.

How did an infection from an ileocecal corner get in subdiaphragmatic [subphrenic] space?

A. Through the right lateral canal of peritoneum

B. Through epiploic [Winslow's] foramen

C. Through a right mesenteric sinus

D. Through the left mesenteric sinus

E. Through greater [gastrocolic] omentum cavity

4. In what position is the back chord of vagus nerve concerning stomach?

A. On the front wall of stomach

B. On the back wall of stomach

C. Near lesser curvature

D. Near greater curvature

E. On fornix of ventricle

5. Which from the named organs has mesoperitoneal relation with peritoneum?

A. Small intestine

B. Sigmoid colon

C. Pancreas

D. Liver

E. Transverse colon

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6. A surgeon makes a revision of abdominal cavity at pyoinflammatory process in the left mesenteric sinus. What tendency does spread of pus have?

A. Localization at place.

B. Spread in a small pelvis

C. Spread in the left subdiaphragmatic space

D. Transfer to the right mesenteric sinus

E. Spread in the right subdiaphragmatic space

7. During the surgical operation, tightening tourniquet round hepatoduodenal ligament a surgeon defined its elements. Which from them is located behind?

A. Portal vein

B. Hepatic artery

C. Choledoch

D. Hepatic vein

E. pancreatic [Wirsung's] duct

8. What arterial vessels does gastrocolic ligament contain?

A. proper hepatic artery

B. Left and right gastric arteries

C. Left and right gastroepiploic arteries

D. Splenic [lienal] artery

E. Celiac trunk

9. Do left and right mesenteric sinuses have connection between them, if so, what type of connection?

A. Yes, lower the place of attachment of root of mesentery

B. Yes, higher the place of attachment of root of mesentery

C. Yes, through the opening in root of mesentery

D. No

E. They have connection along their whole length

10. How does the upper part (pars superior) of duodenum concern/relate to the peritoneum?

A. Retroperitoneally

B. Mesoperitoneally

C. Intraperitoneally

D. Extraperitoneally

E. In other way

11. During the surgical operation on a liver there was a necessity to stop temporarily blood flow to the liver. What formation of peritoneum enables to impose tourniquet on vessels which carry blood to the liver?

A. Duodenal-gastric ligament

B. Duodenal-portal ligament

C. Hepatorenal ligament

D. Epiploic [Winslow's] foramen

E. Mitral orifice

12. What is the medial wall of hepatic bursa?

A. Coronary ligament of liver

B. Falciform ligament of liver

C. Hepatogastric ligament

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D. Gastrocolic ligament

E. Diaphragm



75



Intestinal sutures. Resection of intestines. Enteroanastomotic techniques “end-to-end”, “sideto-side”, and “end-to-side”.

Aim of lesson:

To master the methods of placing intestinal sutures; to be able to close [to repair] a wound of intestine; conduct enterectomy; enteroanastomotic technique “end-to-end”, “side-to-side”.



- layered structure of intestinal wall and wall of stomach;

- difference between the structure of wall of stomach, of small and large intestines;

- seroserosal and seromuscular sutures;

- uninterrupted suture, blanket suture and interrupted suture;

- indication for resection of intestines;

- substantiation of using one or another method of enteroanastomosis;

- advantages of certain method of enteroanastomosis, disadvantages of other;

- closure of wounds of small intestine;

- application of intestinal fistula.

To know:

1. Albert's suture and (interrupted) Lembert suture. Their techniques.

2. Through intestinal suture and blanket uninterrupted suture. Their techniques.

3. Technique of resection of intestines.

4. Anastomotic technique “end-to-end”, “side-to-side”.

5. Complications at enterostomies.

6. Advantages and disadvantages of some intestinal sutures in comparison.

7. Technique of closure of intestinal wounds.

8. Judin’s enterostomy.

To be able:

1. To show on preparation the layers of small intestine, stomach.

2. To show on preparation passages of parietal and mesenteric vessels of intestines.

3. To execute on preparation anastomotic technique “side-to-side”.

4. To execute on the segments of intestine enteroanastomotic technique “end-to-end”.

5. Through palpation to define a size and patency/ permeability of anastomosis.


Technique of intestinal suture. Varieties of intestinal sutures. Theoretical aspects of enteroanastomosis. Enteroanastomotic techniques “end-to-end”, “side-to-side”, and “end-toside”. Advantages and disadvantages of these techniques. Closure of wounds of intestines.

Judin’s enterostomy.





Control of ultimate level/ standard of knowledge — 15 %


Tests

1. What layers of intestine determine strength of intestinal suture?

A. Serous

B. Serous and muscular

C. Serous, muscular, submucous

D. Mucous

E. Submucous

2. What intestinal suture are the external lips of entero-enteroanastomosis united by?

A. (interrupted) Lembert suture

B. Albert's suture

C. Schmieden suture

D. Czerny's suture

E. Pirohov’s suture

3. What operation is included in the notion of enterography?

A. Dissecting of space of small intestine.

B. Application of small intestine fistula.

C. Enterectomy.

D. Suture of small intestine

E. Plication of small intestine.

4. What intestinal sutures are placed in the second row of anastomosis?

A. Schmieden suture

B. Connel’s suture

C. Albert's suture

D. Pribram suture

E. Czerny's suture

5. What is the indication for resection of part of small intestine?

A. Stab [punctured] wound of intestine

B. Linear wound of intestine up to 1-1,5sm

C. Several stab [punctured] wounds on different distances

D. Thrombosis of part of intestine with necrosis

E. Unserous part of intestine

6. What intestine suture is used for closing stab [punctured] wounds of wall of intestine?

A. Schmieden suture


C. Purse-string suture

D. Z -shaped stitch

E. Purse-string suture and Z -shaped stitch

7. What basic advantages of entero-enteroanastomosis “end-to-end”?

A. Physiology of anastomosis

B. Possibility of regulating the width of anastomosis

C. Simplicity of anastomotic technique

D. Absence of critical points of anastomosis

E. Chaotic blood supply of anastomosis

8. In which cases is anastomosis “end-to-side” used?

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A. At resection of area of small intestine

B. At linear wound of small intestine

C. At inconsistency between diameters at places of joint

D. At combined wounds of small intestine

E. At formation of anastomosis between the areas of large intestine

9. Which from the mentioned instruments is used for forming entero-enteroanastomosis?

A. Hegar's dilator

B. Doyen's elastic press

C. press of Payr

D. Kocher's probe

E. cutting needles

10. With what suture material are continuous mass sutures placed?

A. Silk

B. Lavsan

C. Catgut

D. Kapron

E. Teflon


Tests.

1. After laparotomy at the revision of small intestine there was found out the defect of intestine up to 2mm. What tactics should surgeon use?

A. Closure of the defect by the part of omentum

B. Resection of part of intestine

C. To place single seroserosal sutures

D. To place purse-string suture

E. To place purse-string suture and Z- shaped stitch

2. At the revision of organs of peritoneal cavity at a patient was found out the defect of small intestine – a linear wound up to 2sm length. What tactics should surgeon use?

A. To place purse-string suture

B. To place Z- shaped stitch

C. Resection of part of intestine

D. To place combination of purse-string suture and Z- shaped stitch

E. To use two-layer intestinal technique

3. On operating table at the revision of organs of the lower floor of peritoneal cavity there was found out the combined wounds of part of intestine 10-15sm length. What tactics should surgeon use?

A. To place purse-string suture on each of wounds

B. To place Z- shaped stitch on the wounds

C To place the combined stitches on the wounds

D. To use two-layer intestinal technique

E. To do resection of part of intestine

4. At laparotomy there was found out the thrombosis of mesenteric vessels of part of small intestine, and peritonitis. What tactics should surgeon use?

A. Resection of intestine with anastomosis “end-to-end”

B. Resection of intestine with anastomosis “side-to-side”

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C. Drainage of peritoneal cavity

D. To bring omentum to the damaged part

E. Enterostomy

5. The planned operation is executed on account of non-malignant growth of small intestine.

What method of anasomosis would surgeon give preference to?

A. “End-to-end”

B. “End-to-side”

C. “Side-to-side”

D. Combined resection of intestine

E. Enterostomy

6. At strangulated hernia a young surgeon found out the part of small intestine with the signs of necrosis of this area. What tactics should surgeon use?

A. Laparotomy with the resection of intestine and anastomosis “end-to-end”

B. Laparotomy with the resection of intestine and anastomosis “side-to-side”

C. Resection of intestine without laparotomy

D. Drainage of initial [original] postoperative wound

E. Enterostomy

7. In what cases is the resection of part of small intestine used with anastomosis “side-toside”?

A. Inconsistency between diameters of joined organs

B. Lineal wounds of small intestine

C. Combined wounds of small intestine

D. New growth at initial parts of small intestine

E. New growth at middle parts of large intestine

8. What intestinal suture is the suture of choice in intestinal surgery?

A. Czerny's suture

B. (interrupted) Lembert suture

C. Kirpatovsky suture

D. Albert's suture

E. Schmieden suture

9. What intestinal sutures from the named are “clean”?

A. Schmieden suture

B. Pribram suture

C. Blanket suture

D. (interrupted) Lembert suture

E. Interrupted through suture

10. A patient had right hemicolectomy. What type of anastomosis is the choice of surgeon?

A. “End-to-end“



D. Combined anastomosis

E. “End-to-side” with formation of artificial valve



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Topographical anatomy of stomach, liver, gall-bladder.

Aim of lesson:

For exact and complete diagnostics of pathological changes of peritoneum and stomach, liver, gall-bladder it is necessary to be well-informed in anatomical and physiological features.

To be able to conduct the systematic revision stomach, liver, gall-bladder at the penetrating wounds of abdomen, to execute surgical d-bridement of wounds with the damage of stomach, liver, gall-bladder.



- spreading of metastatic processes at malignant neoplasms of stomach;

- forms of stomach and age features/peculiarities;

- fixating mechanism of liver;

- sphincteric mechanism of extrahepatic/anhepatic bile [biliary, gall] ducts;

- mechanism of filling and emptying of bile of gall-bladder.

To know:

- topographical anatomy of ligamentous apparatus of stomach;

- features/peculiarities of arterial blood supply and venous outflow from a stomach;

- innervation of stomach (nerve plexus of stomach);

- outflow of lymph from a stomach (superficial and deep lymphatic collectors);

- blood supply of liver and its venous mechanism;

- forming of intrahepatic and extrahepatic/anhepatic bile [biliary, gall] ducts;

- blood supply of gall-bladder;

- topography of triangle of Kallo.

To be able:

1. To show on preparation (fixed dead body) formations of peritoneum in the upper and lower floors.

2. On a dead body (or preparation), to find and show the parts of stomach, arteries and veins of stomach.

3. To show the nervous mechanism of stomach.

4. On preparation of liver to find and show hepatic ligaments, topography of hepatic hilus.

5. On preparation to show the separation of elements of hepatoduodenal ligament.


Topographical anatomy of stomach, its blood supply, venous outflow, innervation, lymphatic system. Topographical anatomy of liver with intrahepatic and extrahepatic/anhepatic bile [biliary, gall] ducts.

The topography of gall-bladder, spleen, its position in peritoneal cavity, projection, skeletopy, interrelation with neighbouring organs.







Tests.

1. What formation is the back wall of bursa hepatica sinistra?

A. muscular part of diaphragm;

B. left coronary ligament of liver;

C. falciform ligament of liver;

D. left trigonal ligament of liver;

E. lesser [gastrohepatic] omentum.

2. In the elements of what ligament is a. gastrica sinistra lokated?

A. lig. hepatopyloricum;

B. lig. gastrophrenicma;

C. lig. hepatogastricum;

D. lig. gastropancreaticum;

E. lig. pyloropancreaticum.

3. From what artery does a.gastrica sinistra begin?

A. aorta;

B. А. mesenterica superior;

C. а. gastroduodenalis;

D. а. lienalis;

E. truncus coeliacus.

4. What arteries of stomach form lesser arterial circle of stomach?

A. а. gastroepiploica sinistra;

B. а. gastroepiploica dextra;

C. а. gastrica dextra;

D. а. lienalis;

E. а. gastrica sinistra

5. A branch of what artery is a. gastrica dextra?

A. a.hepatica proprira;

B. а. gastrica sinistra;

C. a.mesenterica superior;

D. a.colica media;

E. a.gastroepiploica dextra

6. Which from the named veins is located in the elements of lig. gastropancreaticum?

A. v.mesenterica superior;

B. v.pylorica;

C. v.lienalis;

D. v.coronaria ventriculi;

E v.gastroepiploica sinisrta

7. How many groups of visceral lymphatic nodes of stomach are there?

A. 5;

B. 6;

C. 9;

D. 12;

E. 10.

8. Name the middle border of caudate [spigelian] lobe of liver.

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A. porta hepatis;

Б. sulci saqittales;

B. right lobe of liver;

Г. v. cava inferior;

Д. gall-bladder

9. Which from the mentioned nerves forms the front nerve plexus of stomach?

A. right vagus [X cranial] nerve;

Б. left vagus [X cranial] nerve;

B. branches of hepatic plexus

Г. n.splauchnicus major;

Д. n.splauchnicus minor.

10. The branch of what artery is a.cystica?

A. hepatica propria;

B. a.gastrica dextra;

C. а. hepatica communis;

D. a.gastroduodenalis;

E. a.mesenterica superior.

11. What part of ductus choledochus is placed in the elements of lig. hepatoduodenale?

A. first part;

B. second part;

C. third part;

D. fourth part;

E. is not placed in lig.hepatoduodenale


Tests.

1. In what position is the back chord of vagus nerve concerning stomach?

A. On the front wall of stomach

B. On the back wall of stomach

C. Near lesser curvature

D. Near greater curvature

E. On fornix of ventricle

2. During the surgical operation, tightening tourniquet round hepatoduodenal ligament a surgeon defined its elements. Which from them is located behind?

A. Portal vein

B. Hepatic artery

C. Choledoch

D. Hepatic vein

E. pancreatic [Wirsung's] duct

3. What arterial vessels does gastrocolic ligament contain?

A. proper hepatic artery

B. Left and right gastric arteries

C. Left and right gastroepiploic arteries

D. Splenic [lienal] artery

E. Celiac trunk

4. How does the upper part (pars superior) of duodenum concern/relate to the peritoneum?

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A. Retroperitoneally

B. Mesoperitoneally

C. Intraperitoneally

D. Extraperitoneally

E. In other way

5. During the surgical operation on a liver there was a necessity to stop temporarily blood flow to the liver. What formation of peritoneum enables to impose tourniquet on vessels which carry blood to the liver?

A. Duodenal-gastric ligament

B. Duodenal-portal ligament

C. Hepatorenal ligament

D. Epiploic [Winslow's] foramen

E. Mitral orifice

6. What is the medial wall of hepatic bursa?

A. Coronary ligament of liver

B. Falciform ligament of liver

C. Hepatogastric ligament

D. Gastrocolic ligament

E. Diaphragm



83



The operations on stomach. Dissection, suture, abscess of stomach. Gastroenterostomy.

Organ-preserving operations. Principles of stomach [gastric] resection.

Aim of lesson:

On the basis of distinct knowledge of topography, methods of surgical operations and surgical approaches on stomach.

To be able to execute on a dead body the basic stages of gastrostomy, stomach [gastric] resection. To know basic stages of radical and palliative operations in patients with stomach ulcer and tumours of stomach.



- contribution of our surgeons in development of gastric surgery

- indication for operations of gastrotomy

- commons rules of execution of gastrotomy

- indication for and technique of gastrotomy

- complications at gastrotomy

- types of gastroenteroanastomosis, basic principles of operations

- technique of gastroenteroanastomosis

- stomach [gastric] resection: classification and operative intervention regimen

- organ-preserving operations on stomach, classification and technique of vagotomy

- drainage operations on stomach at stomach ulcer.

To know:

1. Technique of gastrotomy. Complications during this operation.

2. Technique of Witzel's gastrostomy, gastrotomy by the methods of Stamm-Senn-Kader,

Toprover, Beck-Giane, Dekosh-Ganavey.

3. Technique of gastroenteroanastomosis by Volfler, Hapker-Netersen, Monastyrsky.

4. Technique of Brown’s interintestinal enteroanastomosis

5. Reasons of formation of incorrect circle.

6. Stomach [gastric] resection by the I method of Bilrot. Technique of operation.

7. Stomach [gastric] resection by the II method of Bilrot. Technique of operation and basic postoperative complications.

8. Basic modifications of operations of stomach [gastric] resection by the I and II method of

Bilrot.

9. Organ-preserving operations. Basic stages of vagotomy. Postoperative complications.

10. Drainage operations. Technique of operations by Heineke-Mikulicz, Finney, Zabulet.

To be able:

1. Sections of stomach in middle third of body

2. Forming of Witzel's gastrostomy, gastrotomy by Stamm-Senn-Kader, Toprover and by

Beck-Giane.

3. Gastroenteroanastomosis by Volfler and Hapker-Netersen.

4. Technique of basic stages of stomach [gastric] resection after Bilrot I, II

5. Basic stages of vagotomy and drainage operations after Heineke-Mikulicz, Finney,

Zabulet.

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Technique of gastrostomy. Concept of tubular and liplike abscess, and liplike — on more distant term of time. Approaches for gastrostomy. Gastrostomy by Stamm-Senn-Kader,

Toprover, Beck-Giane. Order and technique of placing sutures. Brown’s interintestinal enteroanastomosis. Possible errors and complications (formation of spur, incorrect circle, etc.) Principles of stomach [gastric] resection — Bilrot I and Bilrot II. Modifications of

Hofmeister-Finsterer. Basic methods of closure of duodenal stump. Method of Moynihen.

Organ-preserving operations, selective and combined vagotomy, in combination with a pyloroplasty or antrectomy. Heineke-Mikulicz, Finney pyloroplasty. Gastroduodenostomy by Zabulet/


Control of initial level/ standard of knowledge —10%





Tests

1. Where is made section of anterior wall of stomach at gastrostomy?

A. cardial part

B. pyloroantral part

C. on lesser curvature of stomach

D. between greater and lesser curvature of stomach

E. on greater curvature of stomach

2. What is purpose of dissecting Treitz ligament at Roux’s stomach [gastric] resection?

A. For prophylaxis of small bowel obstruction

B. For improvement of intestinal motility

C. For bringing down of duodenojejunal flexure, I and prophylaxis of stagnation of intestinal contents

3. What is purpose at stomach [gastric] resection by Більрот II to fix esophagogastric anastomosis or jejunum in the window of mesocolon?

A. For prophylaxis of possible inflammatory complications of anastomosis passing to the ground floor

B. For prophylaxis of small bowel obstruction

C. For prophylaxis of failure of gastroenterostomy

4. What’s the danger of ligation of gastroduodenal artery at the operation of stomach

[gastric] resection?

A. Necrosis of gastric stump

B. Necrosis of duodenal stump

C. Necrosis of greater [gastrocolic] omentum

5. A patient, 40 is hospitalized with a diagnosis of sarcoma of stomach. What surgical operation should be executed at the patient?

A. proximal stomach [gastric] resection

B. subtotal gastrectomy with ablation of both epiploons

C. subtotal resection of stomach with ablation of greater [gastrocolic] omentum

D. gastrectomy with ablation of both epiploons

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E. gastroenterostomy

6. What defect of stomach is the most often?

A. diverticulum,

B. gastric duplication

C. pylorostenosis

D. agastria

E. Sent’s triad

7. What is the content hepatogastric ligament?

A. celiac trunk

B. gastroduodenal artery

C. left gastric artery

D. esophageal branch of the left gastric artery

E. common hepatic artery

F. left gastric vein

G. lymphatic vessels, nodes

H. artery of caudate lobe of liver

8. The injury of what anatomic formation can be observed at associated wounds of anterior wall of stomach on the level of its bottom?

A. inferior [lower] lobe of left lung

B. left lobe of liver

C. Pancreas

D. inferior [lower] lobe of left lung

9. What ligaments near the place of their attachment is retroperitoneal area gastrica limited by?

A. hepatogastric ligament

B. hepatoduodenal ligament

C. gastrolienal ligament

D. gastrophrenic ligament

E. coronary ligament

F. gastropancreatic ligament

10. What arteries are placed in phrenico-esophageal ligament?

A. inferior phrenic artery

B. esophageal branches of the left gastric artery

C. left gastric artery

D. pancreatic branches of splenic artery

E. short gastric arteries


Tests.

1. Patient, 25 is hospitalized with diagnosis of extraneous object in gastric cavity (from anamnesis – a needle). There is no gastrofibroscope in the hospital. What surgical operation must be executed at the patient?

A. Gastroenterostomy

B. gastrotomy

C. gastropexy

D. gastrostomy

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E. duodenotomy

2. Patient, 70 is diagnosed malignant neoplasm of inferior third of esophagus, IV stage. Only liquid passes esophagus at swallowing. What operative interventions does a patient need?

A. gastrotomy

B. vagotomy

C. gastric resection

D. gastrostomy

E. gastropexy

3. During operation of gastrostomy surgeon made a section in the area of lesser curvature of stomach. There was considerable bleeding. In what area of stomach is it correctly to make the section of anterior wall of stomach?

A. greater curvature of stomach

B. lesser curvature of stomach

C. axis of stomach between lesser and greater curvatures of stomach

D. cardial part

E. pyloric part

4. At child, 4 was executed Kader's gastrostomy. There were the symptoms of peritonitis on the second day. What technical mistake did a surgeon make?

A. incompletely tightened I purse-string suture

B. tube was freely in a channel

C. incomplete gastropexy

D. large diameter of tube

E. occasional sutures on a skin

5. A patient, 17 after the chemical burn of esophagus the operation of Witzel's gastrostomy is executed. How correctly is the method of operation chosen? What operation must be executed?

A. resection of inferior third of esophagus

B. Toprover’s gastrostomy

C. Resection of cardial part of stomach

D. esophageal fistula

E. gastropexy

6. A patient, 55 is operated on account of obstruction of pyloric part of stomach of cancer aetiology. During the operation the presence of the nearest and remote metastases is discovered in lymph nodes, invasion of tumour in retroperitoneal space. What tactics should surgeon use?

A. explorative laparotomy

B. Більрот-І gastric resection

C. Front gastroenterostomy

D. subtotal gastric resection

E. gastrectomy

7. At patient, 70 was executed the palliative operation: back gastroenterostomy on the account of chronic penetrating ulcer of initial part of stomach with stenosis of IV degree. In a week there were pains in the area of anastomosis, and diarrhea. In excrement there were present mucus, undigested parts of food, and blood. What mistake did a surgeon make?

A. antiperistaltic [aperistaltic] anastomosis was made

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B. gastroenteroanastomosis on a long loop with Braun’s anastomosis was made

C. anastomosis of stomach and the terminal part of ileum was made

D. high gastroenteroanastomosis was made

E. inadequate diameter of gastroenteroanastomosis

8. At patient, 35 the stomach [gastric] resection after Bilrot I was made on account of duodenal ulcer. In 2 days after the operation there was sharp pain in the area of anastomosis and in the right part of abdomen. What technical mistake was made by a surgeon?

A. Small diameter of anastomosis

B. marked tension between duodenal stump and stomach

C. a probe was not inserted in the abdominal cavity

D. seromuscular suture was made with lavsan ligatures/threads

E. inadequate mobilization of stomach from the side of greater curvature of stomach

9. At patient, 46 the stomach [gastric] resection after Bilrot ІІ in modification of

Hofmeister-Finsterer was made. In 4 days after the operation a patient had the clinical picture of bowel [intestinal] obstruction. At the check roentgenogram of gastric stump, the evacuation of barium is satisfactory. What mistake did a surgeon make at operative intervention?

A. broad/wide gastroenteroanastomosis

B. short adducting intestinal loop

C. insufficient fixing of anastomosis from the side of mesocolon transversum

D. not closed opening of mesocolon trartsversum

E. inadequate sutures of duodenal stump

10. During the operation at patient on the account of malignant tumour of ascending part of stomach there were discovered no visible metastases and enlarged lymph nodes. What operation should surgeon execute?

A. gastroenterostomy

B. gastrostomy

C. proximal selective vagotomy

D. stomach [gastric] resection after Bilrot -ІІ in modification of Hofmeister-Finsterer

E. gastrectomy

11. A patient, 20 is hospitalized in surgical hospital with a diagnosis ulcerous bleeding.

From anamnesis, this is the first case of bleeding. Endoscopic findings - ulcer is 1sm diameter on the back wall of pyloros. What operative intervention should be executed by surgeon?

A. Gastroenterostomy

B. stomach [gastric] resection of 2/3 after Bilrot -ІІ in modification of Hofmeister-Finsterer

C. stomach [gastric] resection after Bilrot -І

D. gastrotomy with suturing of ulcer

E. gastrotomy with coagulation of ulcer

12. During the operation, at a patient an ulcer with localization in the initial part of descending part of duodenum was found. The decision is made to execute stomach [gastric] resection after Bilrot -ІІ in modification of Hofmeister-Finsterer. By what method should a surgeon suture and peritonize duodenal stump?

A. After Duane

B. to place purse-string suture

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C. to place two half purse-string sutures

D. to form Judin’s “shell”

E. to place interrupted suture

13. A patient, 65 suffers from chronic cardiac insufficiency. Stenosis of the IV stage of ulcerous etiology is diagnosed. What operation should surgeon execute?

A. Gastrotomy

B. stomach [gastric] resection after Bilrot І

C. stomach [gastric] resection after Bilrot -ІІ

D. front gastroenterostomy on a long loop with Braun’s anastomosis

E. front gastroenteroanastomosis on a short loop

14. At gastrofibroscopy a patient has a "low" gastro-duodenal ulcer. Patient is from the group of "increased risk". Evident periprocess. What operative intervention should a surgeon execute?

A. Gastrotomy

B. stomach [gastric] resection after Bilrot -І

C. stomach [gastric] resection after Bilrot -ІІ

D. stem [truncal] vagotomy

E. proximal selective vagotomy with the Heineke-Mikulicz drainage

15. A patient has the clinical picture of perforating gastric ulcer. During the operation on the anterior abdominal wall there was found ulcer of 1,5sm in its lower third. Infiltrated edges, pudgy. What method should a surgeon close an ulcer by?

A. purse-string suture

B. interrupted suture

C. Z-shaped stitch

D. tamponade of perforation opening by omentum on limb

E. blanket suture

Situational tasks

1. Operative intervention on the account of perforating gastric ulcer is going on. A surgeon sutured the perforation on a front wall in a pyloric part. To avoid mirror ulcer on a back wall it is necessary to examine it, how to do it?

2. At a patient, 22 who did not have in anamnesis ulcerous illness, the perforation of ulcer in the pyloric part of stomach appeared. At the revision there was found perforative opening

0,5*0,5sm of round shape. How to close the perforation?



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Liver operations, gall-bladder operations, biliary tract operations. Pancreas operations.

Spleen excision.

Aim of lesson:

- to explain the peculiarities of pathosises and their complications on the basis of knowledge of anatomy-physiological peculiarities of liver’s, gall-bladder’s, biliary tract’s, pancreas’s and spleen’s structures;

- to execute a surgical approach to liver, extrahepatic biliary tract, pancreas, spleen, as well as to make a liver wound closure, to ligate a gall-bladder artery and neck of gallbladder, to separate a gall-bladder from its bed, to carry out the dissection of general bile duct, to ligate the vessels of spleen’s gate, and to separate the spleen out on a corpse.


Students should have an idea about:

- Topographic-anatomic basis of operative interventions on a liver and extrahepatic ducts;

- Indications and contra-indication for the operation of cholecystectomy, cholecystotomy, draining of extrahepatic bile ducts;

- Hepatography. Basic methods of putting in of hepatic stitches in cases of traumatic defeats of liver and its resection;

- Surgical approach to liver and extrahepatic bilious ducts;

- Surgical approaches to spleen;

- Surgical approaches to pancreas;

- Basic methods of gall-bladder excision;

- Basic methods of section and draining of extrahepatic bilious ducts;

- Approaches to spleen’s gate with the subsequent ligation of splenic vessels;

- Operative pancreas interventions

Students should know:

1. Overhead-middle laparotomy — as a basic approach to liver, gall-bladder and extrahepatic bilious ducts.

2. Hepatography. Kuznetsov-Penskiy’s liver stitch.

3. Technique of cholecystectomy execution from a neck and from a bottom.

4. Basic method of draining of general bilious duct.

5. Approach to spleen during splenectomy.

6. Basic methods of spleen excision.

7. Approaches to pancreas through an omental bursa.

8. Approaches to pancreas through a lumbar area in case of purulent destructive processes in pancreas.

9. Draining of an omental bursa in cases of acute pancreatitis.

10. Technique of omental bursa revision through the mesentery of transverse colon bowel.

Students should be able:

1. To execute surgical approach to liver, to extrahepatic bilious ducts, pancreas, spleen.

2. To make a liver wound closure.

3. To ligate a gall-bladder artery and neck of gall bladder, to separate a gall bladder from its bed.

4. To execute the dissection of general bilious duct.

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5. To ligate the vessels of spleen’s gate and to separate the spleen out.


Approaches to liver. Debridement of liver wound. Arrest liver wounds bleeding. Liver resection. Kuznetsov-Penskiy’s liver stitch. Gall-bladder excision, section of general bile duct. Revision of large duodenal papilla. Spleen excision. Approaches to pancreas.

Time regulation:

Control of entrance level of knowledge — 10%

Theoretical options and interviews — 25%


Control of eventual level of knowledge — 15%


Tests

1. During the operation of cholecystectomy a surgeon has defined a.cystica by means of

Kalo’s triangle. What is Kalo’s triangle formed by?

A. General bile duct, cholecyst duct, right branch of own hepatic artery

B. Cholecyst duct, right hepatic duct, general hepatic artery

C. General bile duct, portal vein, general hepatic artery

D. Hepatic duct, general bile duct, right branch of own hepatic artery

E. Hepatic duct, cholecyst duct, right branch of own hepatic artery

2. What is the most optimum approach to liver and extrahepatic ducts?

A. Superior-middle laparotomy

B. Kokher’s oblique approach

C. Pararectal approach

D. Roi-Branko’s approach

E. Transrectal approach

3. What’s surgeon tactics in a case of diagnosis of traumatic break of liver?

A. Putting in of a nodal stitch on liver

B. Putting in of a blanket suture

C. Tamponade by an omental bursa

D. Putting in of hepatic Kuznetsov-Penskiy’s stitches

E. Putting in hepatic stitches with a tamponade by an omental bursa

4. What must the surgeon do in case of damage of considerable areas of liver?

A. To put in nodal stitches

B. To put in a blanket stitch

C. To put in a hepatic stitch

D. To carry out a biological tamponade of the damaged part of liver.

E. To carry out a resection of a part of liver.

5. What must surgeon do in case of marginal traumatic breaks of liver?

A. To carry out a marginal resection

B. To carry out a tamponade

C. To put in blanket suture

D. To put in nodal stitches

E. To carry out draining of alvus without putting in hepatic stitches

6. What are indications to the operation of cholecystectomy?

A. Chronic gastritis

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B. Pericholecystitis

C. Gastroduenitis

D. Calculous cholecystitis

E. Dyskinesia of extrahepatic bile ducts

7. In what cases is cholecystectomy executed in a form "from a bottom" (antegrade cholecystitis)?

A. in cases of periprocesses

B. in case of an acute period of illness

C. in cases of chronic forms of illness

D. Evident commissure

E. In case of calculous cholecystitis

8. What length should the section of general bile duct be in case of its revision?

A. 0,3-0,5 cm

B. 1,0 cm

C. 1-1,5 cm

D. 1,5-2 cm

E. 2-2,5 cm

9. What ligament does a surgeon dissect in order to approach the vessels of spleen?

A. splenic-diaphragmatic ligament

B. gastro-splenic ligament

C. gastro-pancreas ligament

D. hepatogastric ligament

E. gastro-diaphragmatic ligament

10. What approach for the revision of pancreas is optimum?

A. through a hepatogastric ligament

B. through a mesentry of transverse colon bowel

C. through a gastro-transverse-colon ligament

D. through an omental bursa opening

E. through a lumbar area

Task for the eventual control of level of knowledge

Tests

1. A patient, 25, is brought to the surgical unit with suspicion on the traumatic damage of liver, internal bleeding. What approach should a surgeon execute laparotomy by?

A. Fedorov’s approach

B. superior medium laparotomy

C. Petrovskiy-Pochuchev’s laparotomy

D. Kerr’s approach

E. medium-medium laparotomy

2. A patient, 30, is hospitalized in the surgical unit with a damage of liver, internal bleeding.

There was a marginal damage of liver caused by laparotomy. What’s of surgeon’s action?

A. cuneate resection of liver

B. single nodal stitches

C. sewing up an omental bursa

D. blanket suture

E. draining of alvus only

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3. During the laparotomy the revision of organs of alvus a surgeon diagnosed a considerable internal bleeding, as a result of numerous cuts of right part of liver. What’s the tactic of surgeon?

A. putting in of a blanket suture

B. single nodal stitches

C. sewing up of an omental bursa

D. resection of a part of liver

E. draining of alvus only

4. For a patient, 65, a cholecystectomy operation is planned to be executed. What surgical approach will be the best?

A. superior medium laparotomy

B. Fedorov’s approach

C. inferior medium laparotomy

D. right Pararectal section

E. right transrectal approach

5. During the cholecystectomy operation a surgeon has found a considerable commissure process within the limits of overhead level of alvus cavity. What should the surgeon do next?

A. to execute a cholecystotomy “from a bottom”

B. to execute a cholecystectomy “from a neck”

C. to execute a cholecystotomy

D. to execute a cholecystoenterostomy

E. to execute a cholecystoduodenotomy

6. During the operation there was a necessity to find the place of gate vein formation. Where is it located?

A. in a hepatic-duodenal ligament

B. on the back wall of omental bursa

C. behind the duodenum

D. behind the body of pancreas

E. behind the head of pancreas

7. During the cholecystectomy operation “from a neck” there was a necessity to define the topography of general bile duct. By confluence of what ducts is general bile duct formed?

A. left hepatic and general hepatic ducts

B. left and right hepatic ducts

C. general hepatic and cholecyst ducts

D. general hepatic and right hepatic ducts

E. left hepatic and cholecyst ducts

8. During the cholecystectomy operation "from a neck" a surgeon determines the artery of gall bladder. From what artery does a.cystica depart?

A. a.hepatica propria

B. a.hepatica dextra

C. a.mesenterica superior

D. a.hepatica sinistra

E. a.gastrodyodenalis

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9. A patient, 65, has an obturative icterus. During the cholecystectomy operation in the cavity of gall-bladder a surgeon establishes a large number of concrements. What else should a surgeon execute except the gall-bladder excision?

A. to conduct the revision of the right hepatic duct

B. to conduct the revision of the left hepatic duct

C. to conduct the revision of general bile duct

D. duodenotomy

E. gastrotomy

10. A patient, 64, with an obstructive jaundice is operated with suspicion on the concrement of general bile duct. During the operation it was get known that at the patient had a malignant tumour of major duodenal papilla with infiltration of general bile duct. What operation is executed in this case?

A. cholecystectomy

B. cholecustotomy

C. cholecystojejunostomy

D. cholecystoduodenostomy

E. cholecystogastrostomy

11. A patient, 35, was delivered into the surgical unit with the symptoms of splenic laceration. Operative intervention is needed. What approach to spleen must a surgeon choose?

A. left parallel

B. left transmural

C. superior medium laparotomy

D. left oblique approach

E. middle middle laparotomy

12. A patient has a lot of blood in the superior level of alvus after laparotomy. Bleeding proceeds from the body of the damaged spleen. What ligament should be dissected to get an approach to the gate of spleen?

A. Diaphragmatic-splenic

B. gastrosplenic

C. gastrophrenic

D. splenic transversal colon

E. gastro pancreas

13. In what order does a surgeon put ligatures in on the elements of vascular leg of spleen during its excision?

A. on an artery

B. on a vein

C. single-staged on an artery and vein

D. first on a vein, then on an artery

E. first on an artery, then on a vein

14. A patient, 50, with symptoms of acute pancreatitis is on an operating table. A considerable commissure process is found during laparotomy. It is necessary to execute the revision of pancreas. What is the most optimum approach in this case?

A. through mesocolon transversus

B. through omental bursa

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C. through lig.hepatogastricum

D. through lig.gastrocolicum

E. through the cut in a lumbar area.

15. A patient has a sharp destructive pancreatitis with symptoms of phlegmon of extraperitoneal cellular. What approach of the draining of pancreas should be held?

A. lig.gastrocolicum

B. lig.hepatogastricum

C. mesocolon transversus

D through an omental bursa opening

E. through the section in a lumbar area



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Large intestine operations. Appendectomy

Aim of lesson:

Students should be able to execute the following operations: appendectomy, colostomy, and colopexostomy.



1. Contribution of home surgeons to the development of colon surgery.

2. Peculiarities of resections on colon.

3. Peculiarities of colopexostomy.

4. Indication and technique of bilateral resection of sigmoid colon using Grekov’s 2 nd method.

5. Svenson-Grekov operation’s technique.

6. Complications after the colon operations.

7. The essence of ileocoplastics.


1. Indications to appendectomy operations.

2. Complications caused by appendectomy.

3. Right hemicolectomy operation technique.

4. Left hemicolectomy operation technique.

5. Anal orifice imposition operation technique.

6. Tubular cecostomy operation technique.

7. Labial colostomy operation technique.

8. Single-stage resection of sigmoid transverse colon operation technique.

9. Colon wounds closure making technique.


1. To give a scientific ground of peculiarities determination of vermix projection on the front abdominal wall.

2. To execute the appendectomy operation.

3. To execute the retrograde appendectomy.

4. To execute the appendectomy operation in case of extraperitoneal location of vermix.

5. To execute the debribement of “кукса” of vermix.


The topographic-anatomic grounds of colon operations. Points of projection of appendical on the front side of abdominal wall. Variants of appendical sprout position. Appendectomy.

Types of appendectomy. Colostomy. Tubular and labial colostomy technique.

Colopexostomy. Colon wounds closure making. Resection of colon. Resection of sigmoid colon using Grekov’s 2 nd method.







Tests

1. Who offered a pararectal approach to the vermix?

A. Kokher

B. Fyodorov

C. Pirogov

D. Vishnevskiy

E. Lenander

2. What is it needed during the separption of retrocecally extraperitoneally placed vermix?

A. to lead blind intestine laterally as much as possible

B. to lead blind intestine medially as much as possible

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C. to conduct a mobilization of blind intestine

D. to conduct a resection of blind intestine

E. to conduct a section of blind intestine

3. Is the mobilization of vermix during appendectomy carried out?

A. it is not carried out

B. it is carried out in a way of successive ligament of mesentry with the help of ligature needle or styptic clamps and ligament of mesentry

C. it is conducted in a way of ligament of vermix together with mesentry by one ligature

D. it is conducted in a way of blunt separating of vermix from a mesentry

E. it is conducted in a way of ligament of vermix only

4. What types of appendectomy do you know?

A. using left approach

B. using inferior-medium laparotomy

C. ordinary appendectomy

D. retrograde appendectomy

5. What are the peculiarities which stipulate the differences of colon operations from small intestine operations?

A. a colon has more thick wall, than small intestine

B. a colon has more thin wall, than small intestine

C. a small intestine has more infectious content, than a colon

D. a colon has more infectious content, than a small intestine

E. irregular distribution of muscular fibers in the colon wall

6. What section is conducted during the Maidel’s colopexostomy?

A. an oblique variable approach 2-3 cm higher than inguinal ligament and parallel

B. an oblique approach 3-4 cm higher than inguinal ligament and parallel

C. inferior-medium laparotomy

D. ectatic medium laparotomy

E. approach choice depends on the projection of sigmoid colon

7. During the colopexostomy a parietal peritoneum is binded with a skin. What’s the purpose of this stage of the operation?

A. to insulate the cavity of peritoneum

B. to insulate the layers of hypoderm from infecting

C. for fixation

D. in order to wash the peritoneum cavity

E. to prevent the development of spike disease

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8. Are the operations of colostomy and colopexostomy distinguished?

A. they are distinguished by the indications and execution techniques

B. they are synonyms

C. they are distinguished by the indications but not by execution techniques

D. they have the same indications but are distinguished by execution techniques

E. divergences are not substantial

9. What are the operations of colostomy and colopexostomy differentiated by?

A. by the fact that an unnatural anus is imposed on a sigmoid colon only

B. during the colostomy operation the opening on an abdominal wall is double-barrelled, and during colopexostomy it is single-barrelled?

C. colostomy can be executed in any part of colon

D. the existence of the so called “spure” while colopexostomy which hinders to the output of excrements into the rectum

E. all the variants mentioned above are right

10. While colopexostomy a pariental peritoneum is connected with a serosal canopy of a sigmoid colon. What is the purpose of this stage of operation?

A. to prevent the development of excrement phlegmon

B. to prevent the development of spike disease

C. in order to fix a sigmoid colon

D. to prevent the infecting of peritoneum cavity

E. all the variants mentioned above are right

11. In what time after colopexostomy is it possible to cut the wall of sigmoid colon?

A. in 12 hours

B. in 24 hours

C. in 2-3 days

E. in 4-6 days

F. the cut is done if patient wants

12. What of colon shells has the most mechanical stability?

A. serosal

B. muscle

C. submucous

D. mucous

13. During what time colon serosas solidation after sewing together?

A. in 12 hours

B. in 24 hours

C. in 2-3 days

D. in 4-6 days

E. in 7 days

14. What case of colon provides impermeability?

A. serosal-muscle

B. mucous-submucous


Tests

1. What are the indications to the retrograde appendectomy?

A. pelvic position of vermix

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B. the length of vermix is more than 10 cm

C. in case of fixation of vermix by connections to the back wall of peritoneum

D. when the vermix is very short

E. the choice of the method depends on the patient’s desire

2. Choose the section for approach to the vermix:

A. Kokher’s section

B. Pfannenstil’s section

C. Lenander’s section

D. Mak-Burney-Volkovich-D’yakonov’s section

E. Fyodorov’s section

3. Name the recessions on the part of blind intestine, where an inflammatory exsudate accumulates in case of diseases of vermix:

A. paraduodenal recession

B. intersigmoidal recess

C. superior ileocecal recess

D. sulci paracolic

E. hepatorenal recess

F. bottom ileocecal recess

G. subphrenic recess

H. post blind-intestinal recess

4. While Debridement of vermix’s “кукса” after an appendectomy it is important to take into account the distance between the vermix and the place inflow of small intestine into a colon. What is the standard distance?

A. 0,5-1,0 cm

B. 1,0-1,5 cm

C. 1,5-2,0 cm

D. 2,0-2,5 cm

E. 2,5-3,0 cm

5. Locate possible positions of vermix in respect to a blind intestine from most frequently to most rare. Choose the right answer.

A. descending, lateral, medium, front, back (retrocecal)

B. descending, lateral, medium, back (retrocecal), front

C. lateral, medial, front, back (retrocecal), descending

D. medial, front, back (retrocecal), descending, lateral

E. front, back (retrocecal), descending, lateral, medium

F. back (retrocecal), front, descending, lateral, medium

G. front, back (retrocecal), descending, medium, lateral

6. Choose the most frequent localizations of abscesses on case of descending position of vermix:

A. superior ileocecal recess

B. sulci paracolic

C. inferior ileocecal recess

D. subphrenic recess

E. pose blind-intestinal recess

F. ovarian fossa

G. rectouterine pouch

H. bladder-uterine pouch

I. rectobladder recess

J. subhepatic recess

K. lateral inguinal recess

L. paracystic recess

7. Choose the most frequent localizations of abscesses in case of lateral position of vermix:


B. sulci paracolic

C. lower (bottom) ileocal recess

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E. post blind-intestinal recess

F. ovarian fossa







3. Choose the most frequent localizations of abscesses in a medium position of vermix:


B. sulci paracolic




F. ovarian fossa







9. Choose the most frequent localizations of abscesses in a front position of vermix:


B. sulci paracolic




F. ovarian fossa







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10. Choose the most frequent localizations of abscesses at back (retrocecal) position of vermix:


B. sulci paracolic




F. ovarian fossa







11. What place of anastomosizing of what arteries which take part in blood supply of sigmoid colon is named as a "critical point"?

A. Rights colon artery

B. medium colon artery

C. left colon artery

D. left colon artery

E. sigmoid artery

F. superior rectal artery

G. inferior rectal artery

12. On what level relatively to a "critical point" does not ligament of superior rectal artery worsen the blood supply of rectum?

A. superior

B. inferior

C. on equal level

13. What line is drawn preliminary in order to calculate the size of Mak-Burney-Volkovich-

D’yakonov’s section during the appendectomy operation?

A. line which connects the ends of costal arches

B. line which connects front iliac spine

C. line which connects a belly-button and middle of inguinal ligament

D. line which connects a belly-button and right superior front iliac spine

E. line made 3-4 cm higher relatively to inguinal ligament

14. Why is Mak-Burney-Volkovich’s approach is named variable?

A. because of alteration of sharp and blunt methods of fabrics disconnection

B. because of discrepancy of skin section and line of muscles section

C. because of discrepancy of skin section line and peritoneum section

D. because of sequence of muscles section with different fibers direction using a blunt method



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Class in the operating room. Intestinal sutures. Surgical approaches to the organs of abdominal cavity. Enteroanastomotic techniques “end-to-end”, “side-to-side”, and “end-toside”.

Aim of lesson:

To master the methods of placing intestinal sutures; to be able to close [to repair] a wound of intestine; conduct enterectomy; enteroanastomotic technique “end-to-end”, “side-to-side”.



- layered structure of intestinal wall and wall of stomach;

- difference between the structure of wall of stomach, of small and large intestines;

- seroserosal and seromuscular sutures;

- uninterrupted suture, blanket suture and interrupted suture;

- indication for resection of intestines;

- substantiation of using one or another method of enteroanastomosis;

- advantages of certain method of enteroanastomosis, disadvantages of other;

- closure of wounds of small intestine;

- application of intestinal fistula.

To know:

1. Albert's suture and (interrupted) Lembert suture. Their techniques.

2. Through intestinal suture and blanket uninterrupted suture. Their techniques.

3. Technique of resection of intestines.

4. Anastomotic technique “end-to-end”, “side-to-side”.

5. Complications at enterostomies.

6. Advantages and disadvantages of some intestinal sutures in comparison.

7. Technique of closure of intestinal wounds.

8. Judin’s enterostomy.

To be able:

1. To show on preparation the layers of small intestine, stomach.

2. To show on preparation passages of parietal and mesenteric vessels of intestines.

3. To execute on preparation anastomotic technique “side-to-side”.

4. To execute on the segments of intestine enteroanastomotic technique “end-to-end”.

5. Through palpation to define a size and patency/ permeability of anastomosis.


Technique of intestinal suture. Varieties of intestinal sutures. Theoretical aspects of enteroanastomosis. Enteroanastomotic techniques “end-to-end”, “side-to-side”, and “end-toside”. Advantages and disadvantages of these techniques. Closure of wounds of intestines.

Judin’s enterostomy.







Tests

1. What layers of intestine determine strength of intestinal suture?

A. Serous

B. Serous and muscular

C. Serous, muscular, submucous

D. Mucous

E. Submucous

2. What intestinal suture are the external lips of entero-enteroanastomosis united by?

A. (interrupted) Lembert suture

B. Albert's suture

C. Schmieden suture

D. Czerny's suture

E. Pirohov’s suture

3. What operation is included in the notion of enterography?

A. Dissecting of space of small intestine.

B. Application of small intestine fistula.

C. Enterectomy.

D. Suture of small intestine

E. Plication of small intestine.

4. What intestinal sutures are placed in the second row of anastomosis?

A. Schmieden suture


C. Albert's suture

D. Pribram suture

E. Czerny's suture

5. What is the indication for resection of part of small intestine?

A. Stab [punctured] wound of intestine

B. Linear wound of intestine up to 1-1,5sm

C. Several stab [punctured] wounds on different distances

D. Thrombosis of part of intestine with necrosis

E. Unserous part of intestine

6. What intestine suture is used for closing stab [punctured] wounds of wall of intestine?

A. Schmieden suture


C. Purse-string suture

D. Z -shaped stitch

E. Purse-string suture and Z -shaped stitch

7. What basic advantages of entero-enteroanastomosis “end-to-end”?

A. Physiology of anastomosis

B. Possibility of regulating the width of anastomosis

C. Simplicity of anastomotic technique

D. Absence of critical points of anastomosis

E. Chaotic blood supply of anastomosis

8. In which cases is anastomosis “end-to-side” used?

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A. At resection of area of small intestine

B. At linear wound of small intestine

C. At inconsistency between diameters at places of joint

D. At combined wounds of small intestine

E. At formation of anastomosis between the areas of large intestine

9. Which from the mentioned instruments is used for forming entero-enteroanastomosis?

A. Hegar's dilator

B. Doyen's elastic press

C. press of Payr

D. Kocher's probe

E. cutting needles

10. With what suture material are continuous mass sutures placed?

A. Silk

B. Lavsan

C. Catgut

D. Kapron

E. Teflon


Tests.

1. After laparotomy at the revision of small intestine there was found out the defect of intestine up to 2mm. What tactics should surgeon use?

A. Closure of the defect by the part of omentum

B. Resection of part of intestine

C. To place single seroserosal sutures

D. To place purse-string suture

E. To place purse-string suture and Z- shaped stitch

2. At the revision of organs of peritoneal cavity at a patient was found out the defect of small intestine – a linear wound up to 2sm length. What tactics should surgeon use?

A. To place purse-string suture

B. To place Z- shaped stitch

C. Resection of part of intestine

D. To place combination of purse-string suture and Z- shaped stitch

E. To use two-layer intestinal technique

3. On operating table at the revision of organs of the lower floor of peritoneal cavity there was found out the combined wounds of part of intestine 10-15sm length. What tactics should surgeon use?

A. To place purse-string suture on each of wounds

B. To place Z- shaped stitch on the wounds

C To place the combined stitches on the wounds

D. To use two-layer intestinal technique

E. To do resection of part of intestine

4. At laparotomy there was found out the thrombosis of mesenteric vessels of part of small intestine, and peritonitis. What tactics should surgeon use?

A. Resection of intestine with anastomosis “end-to-end”

B. Resection of intestine with anastomosis “side-to-side”

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C. Drainage of peritoneal cavity

D. To bring omentum to the damaged part

E. Enterostomy

5. The planned operation is executed on account of non-malignant growth of small intestine.

What method of anasomosis would surgeon give preference to?

A. “End-to-end”



D. Combined resection of intestine

E. Enterostomy

6. At strangulated hernia a young surgeon found out the part of small intestine with the signs of necrosis of this area. What tactics should surgeon use?

A. Laparotomy with the resection of intestine and anastomosis “end-to-end”

B. Laparotomy with the resection of intestine and anastomosis “side-to-side”

C. Resection of intestine without laparotomy

D. Drainage of initial [original] postoperative wound

E. Enterostomy

7. In what cases is the resection of part of small intestine used with anastomosis “side-toside”?

A. Inconsistency between diameters of joined organs

B. Lineal wounds of small intestine

C. Combined wounds of small intestine

D. New growth at initial parts of small intestine

E. New growth at middle parts of large intestine

8. What intestinal suture is the suture of choice in intestinal surgery?

A. Czerny's suture

B. (interrupted) Lembert suture

C. Kirpatovsky suture

D. Albert's suture

E. Schmieden suture

9. What intestinal sutures from the named are “clean”?

A. Schmieden suture

B. Pribram suture

C. Blanket suture

D. (interrupted) Lembert suture

E. Interrupted through suture

10. A patient had right hemicolectomy. What type of anastomosis is the choice of surgeon?

A. “End-to-end“



D. Combined anastomosis

E. “End-to-side” with formation of artificial valve



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CONCLUDING SESSION 20


Concluding session of the part “Topographical anatomy and operative surgery of head, neck, thorax, and abdominal cavity”

Aim of lesson:

Control and correction of level of professional knowledge, abilities and skills of the part

“Topographical anatomy and operative surgery of head, neck and thorax”. To find out accuracy, depth, plenitude of theoretical knowledge of students by means of the tests of the

3 rd level and tasks of the 2 nd level. To show the skill of implementation of the offered operative interferences on a dead body.


To write the tests of written programmed control

To accomplish situational tasks of the 2 nd level

To be able:

1. To show on a specimen (a fixed dead body) layers the frontal, parietal, occipital, and temporal regions of head and mastoid.

2. To select the borders of Chipault’s trephine triangle and explain the possibility of complications at trepanation.

3. To execute trepanation of papillary sprout on a dead body.

4. To conduct the primary surgical d-bridement of wound of calvarium.

5. To draw the scheme of Kreunlane-Brusova.

6. To execute bony-lamellar trepanation of the skull on a dead body.

7. To stop meningeal arterial hemorrhage and venous sinus of durae matris hemorrhage.

8. To execute decompressive trepanation of the skull on a dead body.

9. To prepare lateral area of face.

10. To execute the section on face at suppurative parotitis

11. To execute trepanation of frontal sinus on a dead body.

12. To execute trepanation of maxillary sinus on a dead body.

13. To be oriented in layers and fascia of neck at sections.

14. To be able to distinguish an external carotid artery from internal carotid artery.

15. To bare/uncover an internal jugular vein, external carotid artery and common carotid artery.

16. To find external landmarks for implementation of vagosympathetic Vishnevskiy's and

Burdenko’s block.

17. To conduct vagosympathetic Vishnevskiy's and Burdenko’s block.

18. To ground anatomically the rational sections at phlegmon and abscess of neck.

19. To prepare lateral trigone of neck.

20. To execute upper tracheostomy.

21. To execute lower tracheostomy.

22. To execute approach to the lower part of esophagus.

23. To conduct sections at intramammary mastitis.

24. To conduct sections at retromammary mastitis.

25. To conduct sections at subareolar mastitis.

26. To conduct the partial mastectomy on a dead body.

27. To conduct pleurocentesis , on a dead body.

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28. To conduct costotomy.

29. To conduct closing of pneumothorax.

30. To conduct on a dead body anterolateral approach to lungs.

31. To conduct on a dead body posterolateral approach to lungs.

32. To close [to repair] a wound of lungs.

33. To close [to repair] a wound of esophagus.

34. To conduct a segmental resection of lung.

35. To prepare elements of root of lungs.

36. To conduct on the dead body longitudinal median [midline] sternotomy.

37. To conduct on the dead body longitudinal transverse sternotomy.

38. To close [to repair] a wound of heart.

39. To execute medium medium laparotomy

40. Paramedial section

41. Transrectal section

42. Lenander’s section

43. Volkovich-D’yakonov’s section

44. To execute the layer section of front wall of stomach parallel to inguinal ligament

45. To make a preparation of abdominal canal with determination of its walls and openings

46. To execute Zhyrar-Spasokukotskiy-Martynov’s abdominal canal plasty

47. To show formations of peritoneum in the superior and inferior floors on the autopsied specimen (a fixed corpse)

50. On a corpse (or autopsied specimen) to find and point the portions of stomach, arteries and veins of stomach

51. To find and point liver ligament of liver, topography of gate of liver on an autopsied specimen

52. On preparation to point the selection of elements of hepato-doudenal legiment on an autopsied specimen

53. To point the methods of finding small intestine on an autopsied specimen (Gubarev’s and Monks’s methods)

54. To find arteries and veins, that deliver blood to large intestine on an autopsied specimen

55. Through lig.gastrocolicum to enter an omental bursa and point a pancreas on an autopsied specimen

56. To take apart the topography of spleen gate and its ligaments on an autopsied specimen

57. To point the layers of small intestine and stomach on an autopsied specimen

58. To show the ways of pariental and mesentry vessels of a bowel on an autopsied specimen

59. To execute an imposition of anastomosis "side sdws" on an autopsied specimen

60. On the segments of bowel to execute an enteroanastomoses "end in an end"

61. In a palpable way to define a size and patency of the imposed anastomoses

62. Section of stomach in middle 1/3 of body

63. To form Vittsel’s, Toprover’s, Schtamm-Senn-Kader’s and Beckon-Jean’s gastrosomy

64. To execute a surgical approach to the liver, parahepatic bile ducts, pancreas, spleen

65. To make a closure of liver wound

66. To ligate a cystic artery and neck of gall-bladder, to select a gall-bladder from its bed

67. To execute dissecting of general bile duct

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68. To ligate the vessels of spleen gate and select it

69. To explain the features of determination of projection of vermix on a front abdominal wall

70. To execute an appendectomy operation

71. To execute a retrograde appendectomy

72. To execute an appendectomy in case of extraperitoneal location of vermix

73. To execute the debridement of vermix stump.


Writing programmed control, Accomplishing situational tasks of the 2 nd level, practical work on the preparation using surgical operations from this part.


Writing programmed control - 50 %

Accomplishing situational tasks of the 2 nd level - 10 %

Practical work on preparation - 25 %

Theoretical guidelines and interview - 15 %



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PRACTICAL LESSON 1(21)


Topographical anatomy of spine and spinal cord. Tunics of spinal cord. Spinal cord and roots of spinal nerves. Lumbar puncture. Topographical anatomy of lumbar area. Layers.

Fascias. Cellular spaces. Lumbar triangle. Topography of organs extraperitoneal space.

Kidneys, glands, ureters.

Aim of lesson:

To study the features of structure and placing of spine and spinal cord. To master the technique of lumbar puncture, and opening of vertebral canal. To study the topographical anatomy of lumbar area and extraperitoneal. To study the topographical anatomy of lumbar area and extraperitoneal. To study common rules and principles of operative interventions on the organs of extraperitoneal space.

To be able to use these knowledge in order to decide practical questions. To study common rules and principles of operative interventions on the organs of extraperitoneal space.



1. Topography of spine.

2. Division on parts and external orientation point.

3. A topography layer in the spine area.

4. Rachis and ligamentary apparatus.

5. Vertebral canal and its maintenance.

6. Tunics of spinal cord and spaces between them. Maintenance of these spaces and connection with the skull cavity.

7. Topography of spinal cord and roots of spinal nerves.

8. Place of lumbar puncture for adults and children.

9. Possible errors and complications.

10. Bone’s landmarks;

11. features of the topography of muscles of lateral and medial parts of lumbar area;

11. Layers of extraperitoneal space;

12. Sides and bottom of Petit’s triangle;

13. Sides and bottom of Lesgaft-Grunfeld’s rhombus;

14. Sections of lumbar area;

15. Kidney topographical anatomy;

16. Pecial surgical instruments;


1. To define the conducting level of diagnostic lumbar puncture for adults and children.

2. To execute a diagnostic lumbar puncture on an autonised specimen.

3. To define the line of rachitomy section.

4. Practical implementation of rachitomy

5. To prepare a lumbar area;

6. To execute independently operative approach to kidney and ureter;

7. To be able to tell about blood supply, lymph outflow of organs of extraperitoneal space;


Topographic-anatomic peculiarities of rachis, spinal cord and its tunics.

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Theoretical options and interviews — 25% ¿




Tests

1. What space is the anaesthetic matter introduced into during the peridual anaesthesia?

A. subarachnoid

B. subdural

C. epidural

D. into the dura mater of brain

E. into a yellow ligament

2. What space is the anaesthetic matter introduced into during the rachianesthesia?

A. subarachnoid

B. subdural

C. epidural

D. into the dura mater of brain

E. into a yellow ligament

3. A patient has a pathological bend of spine. What of the following bends is pathological?

A. cervical lordosis

B. pectoral lordosis

C. lumbar lordosis

D. sacrum cyphosis

E. pectoral cyphosis



B. cervical cyphosis

C. lumbar lordosis

D. sacrum cyphosis




B. lumbar cyphosis

C. lumbar lordosis

D. sacrum cyphosis


6. A patient has a pathological bend of spine is set. What of the following bends is pathological?


B. sacrum lordosis

C. lumbar lordosis

D. sacrum cyphosis


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7. A patient has a pathological bend of spine is set. What of the following bends is pathological?


B. lumbar cyphoscoliosis

C. lumbar lordosis

D. sacrum cyphosis

8. On what level a diagnostic rachicentesis for adults is conducted?

A. Th11-Th12

B. L4 —L5

C. Th12-L1

D. L1—L2

E. L2-L3

9. On what level a diagnostic rachicentesis for little children is conducted?

A. Th11— Th12

B. L4 —L5

C. Th12-L1

D. L1—L2

E. L2-L3

10. A patient has a dislocation of vertebrae — spondylolisthesis. Among sources of this pathological process is a damage of ligaments, which are located on the front and back surface of vertebrae. What are these ligaments?

A. anterior longitudinal and yellow ligaments

B. posterior longitudinal and supraspinal ligaments

C. anterior and posterior longitudinal ligaments

D. anterior longitudinal and supraspinal ligaments

E. posterior longitudinal and supraspinal ligaments


Tests

1. What is spine pathology, which causes appearance of bifidae between vertebral body and arch?

A. spondylolysis

B. spina bifida

C. spondylolisthesis

D. spondylosintesis

E. spinal funios

2. What is spine pathology, which causes appearance of bifidae between two parts of vertebra and arch?

A. asomia

B. spina bifida

C. spondylosis

D. hemisomia

E. spinal funios

3. What is spine pathology, which there is a complete absence of vertebral body?

A. asomia

B. spina bifida

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C. spondylolysis

D. hemisomy

D. spinal funios

4. What is spine pathology, when there is absence of number of vertebral bodies?

A. asomia

B. spina bifida

C. spondylolysis

D. hemisomy

E. spinal funios

5. What pressure (in mm of mercury column) is considered to be normal during the spinal puncture when patient is in lying position?

A. 100-120

B. 80-100

C. 250-300

D. 100-180

E. 70-90

6. What pressure (in mm of mercury column) is considered to be normal during the spinal puncture when patient is in a sitting position?

A. 100-120

B. 80-100

C. 250-300

D. 100-180

E. 70-90

7. At a patient in a result of increase of pressure has got the damage of vessels of pia mater of spinal cord and blood got into Virkhov-Roben’s space. Will this patient have blood in a neurolymph and between what tunics of spinal cord this space is located?

A. yes, in layer of pia mater

B. no, in layer of pia mater

C. no, between arachnoid of brain and pia mater of spinal cord

D. yes, between arachnoid of brain and pia mater of spinal cord

E. yes, between the sheets of dura mater of spinal cord

8. A patient has got a spinal hernia — meningocele. What anatomic objects formed such a hernia?

A. tunics of spinal cord

B. roots and tunics of spinal cord

C. deformed spinal cord and its tunics

D. expansion of central canal of spinal cord

E. all the mentioned defects

9. A patient has got a spinal hernia — meningoradiculocele. What anatomic objects formed such a hernia?






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10. A patient has got a spinal hernia — mielomeningocele. What anatomic objects formed such a hernia?






11. A patient has got a spinal hernia — mielocystocele. What anatomic objects formed such a hernia?






12. A patient has got a herina - meningoradiokulomielocystocele. What anatomic objects formed such a hernia?






13. What is the operation during which a spine canal is exposed with the help of resection of spinous processes and arches of vertebrae?

A. rachitomy

B. anterior spondylothesis

C. dyskektomia

D. posterior epodylothesis

E. spondylolisthesis

14. What is the operation during which spinous processes and arches of vertebrae are fixed with the help of transplants?

A. rachitomy

B. anterior spondylothesis

C. dyskektomia

D. posterior epodylothesis

E. spondylolisthesis



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PRACTICAL LESSONS 2(22)


Operations on organs of extraperitoneal space. Surgical approaches to kidneys. Kidney dissecting. Kidney resection. Kidney excision. Opening of renal pelvis. Paranephric blockade (indications, technique). Ureter operations. Surgical treatment of pancreatitis

Aim of lesson:

To master the methods, techniques of the most frequent operative approaches and maneuvers.




- approach to kidney;

- nephrotomy technique;

- kidney resection technique;

- renal decapsulation technique;

- nephrectomy technique;

- ureter stitch technique.


- to execute a nephrectomy independently;

- to execute kidney resection independently;

- to execute renal decapsulation independently;

- to execute ureter stitch independently;

- to execute a paranephric blockade independently.


Definition of extraperitoneal space. Structure and maintenance of extraperitoneal space.

Cellular spaces. Ways of purulent processes and haematomas spread. Structure, form and position of kidneys. Blood supply of kidney, venous outflow. Ways of lymph outflow. Renal plexus, its formation, topography, variants of structure. Adrenal glands - topography, variants of form and structure. Ureters. Fyuodorov’s, Bergman-Israel’s approaches to kidneys. Pirogov’s approach to the inferior third of ureter. Nephrectomy. Renal resection.

Renal decapsulation. Ureter stitch. Paranephric blockade.



Theoretical options and interviews -20%

Practical work 60%



Tests:

1. To name bounds and external oriental points of lumbar area.

2. To describe the projection of organs of extraperitoneal space on a posterior abdominal wall.

3. To describe the layer topography of lumbar area

4. To define the weak points of lumbar area.

5. To describe the topography of lumbar nerve plexus and its nerves.

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6. To describe the layer structure of extraperitoneal space, ways of distribution of purulent processes and urinary leakages.

7. To describe the topographical anatomy of kidney and ureters.

8 To describe the topographical anatomy of abdominal aorta, postcava, pectoral lymphatic canal, azygos vein and hemiazygos vein.

9. To describe the technique of paranephric blockade.

10. To describe possible complications at implementation of paranephric blockade.

11. To describe the nephrectomy technique.

12. To describe the technique ureter stitch.

13. To describe draining operations of kidney and ureters.

14. To name general and special surgical instruments which are necessary for the operations on kidneys and ureters.

Tests:

1. A patient with phlegmon of extraperitoneal space has got an edema within Lesgaft-

Grunfeld’s rhombus. What is the superior-medial border of weak point through which a phlegmon went out formed by?

A. m.serratus posterior inferior

B. m.obliquus abdominis externus

C. m.obliquus abdominis internus

D. m.latissimus dorsi

E. m.erector spinae


Grunfeld’s rhombus. What is the inferior-lateral border of weak point through which a phlegmon went out formed by?



C. m.obiiquus abdominis internus


E. m.erectorspinae


Grunfeld’s Rhombus. What is the superior-lateral border of weak point through which a phlegmon went out formed by?




D. m.latissimusdorsi

E. m.erector spinae


Grunfeld’s rhombus. What is the bottom of weak point, which a phlegmon went out through, formed by?



C. m.obliquus abdominisinternus

D. m.transversus

E. m.erector spinae

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5. A patient with a phlegmon of extraperitoneal space has got an edema within Lesgaft-

Grunfeld’s rhombus. What a weak point through which a phlegmon went out is covered with?

A. m.serratus posterior tnferior



D. m.iatissimus dorsi

E. m.erector spinae

6. A patient with phlegmon of extraperitoneal space has got an edema within Petit’s triangle.

What the medial border of weak point through which a phlegmon went out through is formed by?





E. m.erector spinae

7. A patient with phlegmon of extraperitoneal space has got an edema within Petit’s triangle.

What the lateral border of weak point through which a phlegmon went out is formed by?





E. m.erector spinae

8. A patient with a phlegmon of extraperitoneal space has got an edema within Petit’s triangle. What the low bound of weak point through which a phlegmon went out is formed by?

A. glomerular crest




E. m.erector spinae

9. A patient with a phlegmon of extraperitoneal space has got an edema within Petit’s triangle. What the bottom of weak point through which a phlegmon went out is formed by?





E. m.erector spinae

10. A patient’s posttraumatic haematoma of extraperitoneal space was complicated by a phlegmon that is penetrated downwards. In what cellular space of pelvis such a distribution of purulent process is probably to spread into?

A. prevesical

B. posterior vesical

C. posterior rectum

D. peiuterine

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E. lateral

11. A patient’s posttraumatic haematoma of extraperitoneal space was complicated by a phlegmon that is spread upwards. In what cellular space and through what openings of diaphragm such a distribution of purulent process is probably to spread into?

A. front mediastinum

B. mediastinum into a gap between the cura of diaphragm

C. postmediastinum through hiatus esophageus

D. postmediastinum through hiatus aorticus

E. front mediastinum into a gap between the cura of diaphragm

12. The patient’s diagnosis is a posttraumatic haematoma of right pericolon cellular space.

What level will haematoma achieve from above?

A. mesentery of transversal colon bowel

B. accretion of extraperitoneal fascia with a parietal peritoneum (fascial knot)

C. mesostenium root

D. blind intstine

E. root of sigmoid colon of mesentry

13. The patient’s diagnosis is posttraumatic haematoma of right pericolon of the cellular space. What level will haematoma achieve from below?



C. mesostenium root

D. blind intstine

E. root of sigmoid colon of mesentry

14. The patient’s diagnosis is posttraumatic haematoma of right pericolon of the cellular space. What level will haematoma achieve medially?



C. mesostenium root

D. level of aorta

E. root of sigmoid colon mesentery


1. The patient’s diagnosis is a posttraumatic haematoma of left pericolon of the cellular space. What level will a haematoma achieve from below?

A. mesentery of transversal colon


C. mesostenium root

D. blind intestine

E. root of sigmoid colon mesentery

2. During the inspection of patient with suspicion on the nephroptosis it is set that the overhead end of the left kidney achieves the XIIth rib, and the right – the XIth intercost.

Specify normal skeletotopy of the overhead pole of the left kidney.

A. XIth rib

B. XIth intercost

C. Xth intercost

D. Xth rib

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E. XIIth rib

3. During the inspection of patient with suspicion on the nephroptosis it is set that the overhead end of the left kidney achieves the XIIth rib, and the right – the XIth intercost.


A. XIth rib

B. XIth intercost

C. Xth intercost

D. Xth rib

E. XIIth rib

4. During the inspection of patient with suspicion on the nephropotosis it is set that the overhead end of the left kidney achieves the XIIth rib, and the right – the XIth intercost.


A. XIth rib

B. XIth intercost

C. Xth intercost

D. Xth rib

E. XIIth rib

5. During a nephrectomy the selection and mobilization of elements of renal crus is conducted. What is the position of a renal vein in the right renal crus?

A. behind mostly

B. higher and ahead from a renal artery

C. below and ahead from a renal artery

D. higher and behind from a renal artery

E. below and behind from a renal artery

6. During a nephrectomy the selection and mobilization of elements of renal crus is conducted. What is the position of a renal vein in the left renal crus?

A. behind mostly



D. higher and behind from a renal artery


7. During a nephrectomy the selection and mobilization of elements of renal crus is conducted. What is the position of a renal artery in the left renal crus?

A. behind mostly

B. higher and ahead from a renal vein

C. below and ahead from a renal vein

D. higher and behind from a renal vein

E. below and behind from a renal vein

8. During a nephrectomy the selection and mobilization of elements of renal crus is conducted. What is the position of a renal artery in the right renal crus?

A. behind mostly

B. higher and ahead from a renal vein

C. below and ahead from a renal vein


E. below and behind from a renal vein

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9. During a nephrectomy the selection and mobilization of elements of renal crus is conducted. What is the position of a renal pelvis and ureter in the right renal crus?

A. below and ahead from a renal vein





10. During a nephrectomy the selection and mobilization of elements of renal crus is conducted. What is the position of a renal pelvis and ureter in the left renal crus?

A. below and ahead from a renal vein





11. What layer will be the following after the section of m.transversus during Bergman-

Israel’s operative approach?


B. extraperitoneal fascia

C. pericolon cellular space

D. intra-abdominal fascia

E. extraperitoneal cellular

12. What layer will be the following after the section of intra-abdominal fascia during

Bergman-Israel’s operative approach?




D. m.transversus

E. extraperitoneal cellular

13. What layer will be the following after the section of extraperitoneal cellular during

Bergman-Israel’s operative approach?




D. intra-abdominal fascia

E. m.transversus



119



Topographical anatomy of pelvis. Ostoligamentary apparatus. Parietal and visceral muscles of pelvis. Fascias and cellular spaces of pelvis. Vessels, nerves, lymph outflow.

Topographical anatomy of organs of pelvis. Topographical anatomy of masculine and feminine pelvis (topography of urinary bladder, predstate gland and seminal vesicles, uterus and its appendages, rectum).

Aim of lesson: to learn the topographical anatomy of osteal matrix, muscles, fascias, cellular spaces, organs of pelvis, ways of distribution of purulent processes.



- about the variant of pelvis structure;

- pathological forms of pelvis;

- the inborn pelvis defects.


- pelvis bones;

- osteal matrix of pelvis;

- parietal and visceral muscles of pelvis;

- fascias of pelvis;

- cellular spaces (pericystic, periuterine, lateral, perirectal);

- cellular spaces of pelvis stuff;

- ways of distribution of purulent processes;

- meatus of peritoneum in pelvis;

- topographical anatomy of perineum.


- to execute section in cases of purulent processes;

- to point the topographic-anatomic elements of pelvis on autopsied specimens and tables;

- to prepare the cellular spaces of pelvis on complex and corpse.


External oriental points, walls and pelvis floor (diaphragm of pelvis). Dividing by floors

(peritoneal, subperitoneal, hypodermic). Meatus of masculine and feminine peritoneum.

Pelvic fascia (parietal and visceral). Cellular spaces. Topography of masculine and feminine organs of pelvis. Arterial blood supply, nerve plexus and ways of lymph outflow.

Nerveplexuses (sacral and subperitoneal). Topography of urogenital region, external masculine and feminine genitals, urogenital diaphragm.

Topography of sheets of pelvic fascias, location of pelvic and urogenital diaphragm, ligamentary apparatus of pelvis, capsule of pelvic organs, fascias of myogenous, mesenchymous origin, residues of primary peritoneum - Salishchev-Denonvil’ye’s aponeurosis.

Structure of perineum, its border, parts, layers of anal region, wall and maintenance of ischoriorectal fossa, Olkock’s canal. Layers of urogenital region, structure of urogenital diaphragm.



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Question for oral analysis

1. Osteal basis of pelvis. Sizes of pelvis.

2. Joints of pelvis.

3. Ligaments of pelvis.

4. Parietal fascia of pelvis.

5. Visceral fascia of pelvis.

6. Pericystic cellular space.

7. Perirectal cellular spaces.

8. Central cellular space of masculine pelvis.

9. Periuterine cellular space.

10. Lateral cellular space.

11. Topographical anatomy of Olkock’s canal.

12. Topographical anatomy of perineum.

13. Pelvic diaphragm and urogenital diaphragm.

Tests

1. In what way does the direct size of entrance into a small pelvis is defined (true konjugate)?

A. from the most prominent point of internal surface of symphysis to the promontory

B. from the middle of superior edge of symphysis to the sacral bone

C. from the middle of back surface of symphysis to the place of connection of S1-S2

D. from the lower edge of symphysis to sacroccygeal connection

E. from the lower edge of symphysis to the promontory

2. In what way does the direct size of wide part of small pelvis is defined?






3. In what way the direct size of narrow part of small pelvis is defined?






4. In what way diagonal konjugate of small pelvis is defined?

A. from the most salient point of prominent surface of symphysis to the promontory





5. In what way the direct size of outlet from a small pelvis is defined?

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A. from the lower edge of symphysis to the tag of promontory




E. from the lower edge of symphysis to the tag of the coccyx

6. What minimum values are considered normal for the direct size of entrance into a small pelvis?

A. 11 cm

B. 12 cm

C. 9,5 cm

D. 11.5 cm

E. 12.5 cm

7. What minimum values are considered normal for the direct size of wide part of small pelvis?

A. 11 cm

B. 10 cm

C. 9 cm

D. 11.5 cm

E. 12.5 cm

8. What minimum values are considered normal for the direct size of narrow part of small pelvis?

A. 11 cm

B. 10 cm

C. 9 cm

D. 11.5 cm

E. 12.5 cm

9. What minimum values are considered normal for the direct size of outlet from a small pelvis?

A. 11 cm

B. 12 cm

C. 9,5 cm

D. 11.5 cm

E. 12.5 cm

10. What minimum values are considered normal for diagonal konjugate of small pelvis?

A. 11 cm

B. 12 cm

C. 9,5 cm

D. 11.5 cm

E. 12.5 cm

11. What minimum values are considered normal for the transversal size of entrance into a small pelvis?

A. 11 cm

B. 12 cm

C. 13 cm

D. 11.5 cm

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E. 12.5 cm

12. What minimum values are considered normal for the transversal size of outlet from a small pelvis?

A. 11 cm

B. 12 cm

C. 13 cm

D. 11.5 cm

E. 12.5 cm

13. What minimum values are considered normal for the oblique size of entrance to the small pelvis?

A. 11 cm

B. 12 cm

C. 13 cm

D. 11.5 cm

E. 12.5 cm

14. What minimum values are considered normal for the external direct size of small pelvis?

A. 11-12 cm

B. 20-21 cm

C. 10-13 cm

D. 9.5 cm

E. 12.5 cm

15. In what way the external direct size of small pelvis is defined?




D. from the symphysis to the deepening between last lumbar and first sacrum vertebrae



Tests

1. One of the reasons of rectal prolapse is the weakening of diaphragm. What the diaphragm of pelvis is formed by?

A. by muscles (mm.levator ani,sphincter ani, coccygeus) and internal pelvis fascia

B. by muscles (mm.levator ani,sphincter ani) and internal pelvic fascia

C. by muscles (mm. levator ani, coccygeus) and internal pelvis fascia

D. by muscles (mm.transversus perinei prof., levator ani, sphincter ani) and internal pelvic fascia

E. by muscles (mm.transversus perinei prof.) and internal pelvic fascia

2. One of the reasons of prolapse of uterus is the weakening of urogenital diaphragm. What the urogenital diaphragm is formed by?

A. by muscles (mm.levator ani,sphincter ani, coccygeus) and internal pelvic fascia

B. by muscles (mm.levator ani,sphincter ani) and internal pelvic fascia

C. by muscles (mm.levator ani, coccygeus) and internal pelvic fascia

D. by muscles (mm.transversus perinei prof., levator ani, sphincter ani) and by internal pelvic fascia

E. by muscles (mm.transversus perinei prof.) and internal pelvic fascia

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3. In what part of ureter through a narrow lumen do urinary stones stick more frequent?

A. in a paracystic part

B. in an intramural part

C. in the mouth of ureter (intramucous part)

4. In what distance from the neck of uterus is there crossing of ureter with an uterine artery situated?

A. 0,5-0,7 cm

B. 1-3 cm

C. 4-5 cm

D. 5-6 cm

E. an ureter densely joins to the neck of uterus

5. What level is an internal iliac artery formed on?

A. on the level of entrance in an obturator canal

B. on the level of superior edge of the obtural opening

C. on the level of lower edge of the obtural opening

D. on the level of sacroccygeal joint

E. on the level of superior edge of the small sciatic opening

6. Where can the compression of sciatic nerve happen in its transition from the cavity of pelvis into a sciatic area?

A. between the superior edge of the large sciatic opening and piriform muscle

B. between a piriform muscle and dense sacrospinal ligament

C. between a piriform muscle and dense sacrotuberal ligament

D. at passing through Alkock’s canal

E. at passing through a obtural canal

7. In what plane wide ligaments are oriented?

A. in a horizontal plane

B. in a sagital plane

C. in a frontal plane

D. the orientation is not defined

E. in front-back direction under the corner of 45 degrees to the wall of pelvis

8. What channel does the round ligament of uterus pass through?

A. obtural

B. femoral

C. inguinal

D. Alkock’s

9. What part of the obtural opening does hernia go out through?

A. medial

B. lateral

C. superior

D. inferior

E. there is no clear localization of hernia

10. What shell lies directly on the parenchyma of testicle?

A. muscle fascia, that erects the testicle

B. skin

C. internal seminal fascia

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D. dartos muscle

E. vaginal tunic

F. tunica albuginea

11. In what part of masculine urinoexcretory channel external sphincter is placed to?

A. in a periosteal

B. in a predstate

C. in a membraneus

D. bulbous

E. hanging

12. Name the layers of salpinx?

A. Serosal

B. subserosal

C. muscle

D. submuscle

E. smooth and muscular fibres

F. mucus

G. submucous



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The operations on the organs of pelvis.

Aim of lesson: to study the topographical anatomy of organs of pelvis, their form, skeletopy and syntopy, relation toward a peritoneum, blood supply and innervation, veniplexs round them, venous and lymphatic outflow.



- about the variant structure of organs of pelvis:

- pathological forms of organs of pelvis;

- inborn defects of organs of pelvis.


- topographical anatomy of urinary bladder;

- topographical anatomy of predstate gland and its appendages;

- topographical anatomy of uterus and its appendages;

- topographical anatomy of perineum;

- topographical anatomy of rectum.

- topographical anatomy of testicle.


- to execute sections in cases of purulent processes;

- to point the topographic-anatomic elements of organs of pelvis on an autopsied specimen and tables;

- to prepare on corpse the ovary and uterine vessels.


Topography of urinary bladder, peculiarities of his form, skeletopy and syntopy, relation toward a peritoneum, blood supply and innervation, its veniplexs, venous and lymph outflow.

Topography of predstate gland, seminal vesicles, deferent ducts.

Topography of rectum, peculiarities of form, parts, bends, skeletopy and syntopy, relation toward a peritoneum and pelvic fascia, innervation, ways of lymph outflow, the ways of possible tumours innidiation.

Topography of uterus, its ligament apparatus, blood supply, venous outflow, innervation, ways of lymph outflow. Possible ways of innidiation in case of new malignant formations.

Topography of salpinxs, ovaries, peculiarities of their structure.

Topography of masculine and feminine urines. Topography of scrotum, its stuff. Anomalies of descent of testicle into a scrotum.







Question for oral analysis

1. Topographical anatomy of urinary bladder.

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2. Topographical anatomy of predstate gland and its appendages.

3. Topographical anatomy of uterus and its appendages

4. Topographical anatomy of rectum.

5. Topographical anatomy of testicle.

Tests


7. In what plane are wide ligaments of uterus oriented?

A. in a horizontal plane

B. in a sagital plane

C. in a frontal plane

D. the orientation is not defined

E. in front-back direction at an angle of 45



to the wall of pelvis

8. What channel does the round ligament of uterus pass through?

A. obtural

B. femoral

C. inguinal

D. Alkock’s

10. What shell lies directly on the parenchyma of testicle?

A. muscle’s fascia which erects a testicle

B. skin

C. internal seminal fascia

D. dartos muscle

E. vaginal tunic

F. tunica abliginea

11. What part of masculine urinary tract is external sphincter placed in?

A. in a periosteal

B. in a predstate

C. in a membraneous

D. bulbous

E. hanging

12. Specify the layers of salpinx?

A. Serosal

B. subserosal

C. muscle

D. submuscle

E. smooth and muscular fibres

F. mucus

G. submucous



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PRACTICAL LESSON 5 (25)


Topographical anatomy of superior departments of lower limb. Operations on the superior departments of lower limb.

Aim of lesson:

To learn the topographical anatomy of overhead departments of lower limb, peculiarities of collateral circulation of blood.


Indications and methodology of imposition of nerve stitch, to master the technique of baring of main vessels and nerves. To know the ways of distribution of purulent processes.



1. Topographical anatomy of hip and knee joints.

2. The topographic-anatomic ground of possible dislocations in a hip joint.

3. Formation of lumbar and sacrum neuroplexs.

4. Areas of denervation in case of defeat of basic neuroplexs of lower limb.

5. Ways of possible reinnervation of lower limb in case of defeat of nerves of lumbar-sacral plexus.

6. Ways of distribution of purulent processes in cluneal area.

7. Ways of distribution of purulent processes from a popliteal space on front and back surfaces of femur.

8. Inguinal lymph node.

9. Features of venous outflow of lower limb.


1. Bounds of cluteal and femoral area.

2. Cellular spaces of cluteal area.

3. Basic vascular-nervous bundle of front area of thigh, its projection.

4. Projection line of popliteal vascular-nervous bundle.

5. Operative approaches to hip joint.

6. Operative approaches to knee joint.

7. Femoral trigone, vascular-nervous bundle in basis of trigone.

8. Vascular-nervous bundle in apex of femoral trigone.

9. Adductor canal, vascular-nervous bundle.

10. Zhober’s fossula, approaches to the popliteal vascular-nervous bundle.


1. To conduct operative approaches to the femoral artery at different levels of thigh.

2. To execute operative approaches to the vascular-nervous bundles of cluteal area.

3. To execute operative approaches to the popliteal vascular-nervous bundle (through popliteal and Zhober’s fossula).

4. To execute sections in cases of purulent processes of cluteal area.

5. To execute operative approaches to the vascular-nervous bundle of back area of thigh.

6. To execute sections in case of phlegmons of front area of thigh.


Bounds of lower limb, division by areas. Bounds of femoral, cluteal areas. Areas of knee.

Topographical anatomy of hip and knee joints. Basic vascular-nervous bundles of cluteal area.

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Blood supply and innervation of thigh. Vascular-nervous bundle of popliteal space. Lymph outflow of superior departments of lower limb. Operative approaches to the vascular-nervous bundles of cluteal area, area of thigh, popliteal space. Sections in cases of purulent processes of cluteal area, areas of thigh, popliteal spaces.




Practical work — 65 %

Control of eventual level of knowledge —10%

Task for the initial control of level of knowledge:

Tests

1. How is the vascular-nervous bundle of thigh located in a femoral trigone on its basis

(medially-laterally)?

A. artery, vein, nerve

B. nerve, vein, artery

C. vein, nerve, artery

D. artery, nerve, vein

E. vein, artery, nerve

2. What Skrapov’s (thigh) triangle is formed by?

A. lig.inguinale, m.sartorius, m.adductor longus

B. m.sartorius, m.adductor magnus, m.vastus medialis

C. lig.inguinale, m.sartorius, m.adductor magnus

D. m.sartorius, m.vastus medialis, m.vastus lateralis

E. lig.inguinale, m.pectneus, m.sartorius

3. What muscles form the bottom of Skrapov’s (thigh) triangle?

A. m.gracilis, m.psoas mayor

B. m.vastus medialis, m.vastus lateralis

C. m.vastus rectus, m.sartorius

D. m.pectineus, m.ileopsoas

E. m.gracilis, m.sartorius

4. An injured has got the damage of muscles of back surface of thigh. What are these muscles?

A. m.gracilis, m.adductor longus, m.semitendinosus

B. m.semitendinosus, m.vastus lateralis, m.pectineus

C. m. biceps femoris, m.pectineus, m.semitendinosus

D. m.biceps femoris, m.semitendinosus, m.semimembranosus

E. m.gracilis, biceps femoris, m.pectineus

5. What is the source of blood supply of muscles of medial group of thigh great adductor muscle?

A. a.obturatoria

B. a.pudenda externa

C. a.profunda femoris

D. a.perforantes

E. a.femoralis

6. What is the source of innervation of muscles of medial group of thigh great adductor muscle?

A. n.saphenus

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B. n.ichiadicus

C. n.sacralis

D. n.obturatorius

E. n.femoralis

7. What of the formations mentioned below are named as great adductor muscle canal?

A. canalis of crurupopliteus

B. canalis of femoropopliteus

C. canalis of spiralis

D. canalis of musculoperonealis

E. canalis of pudendalis

8. In what quadrant of cluteal area the intramuscular injections are executed?

A. in superior medial

B. in superior lateral

C. in any

D. in inferior lateral

E. in inferior medial

9. A patient’s previous diagnosis is arthritis of hip joint. What is the orientation point for lateral puncture of the hip joint?

A. cluteal tuber

B. large acetabular

C. small acetabular

D. inguinal ligament

E. inferior superior iliac spine

10. Where the biggest cellular space of cluteal area is located?

A. Under a large cluteal muscle

B. under a small cluteal muscle

C. under a mesogluteus

D. under a piriform muscle

E. quadrate muscle of thigh

11. During the inspection of the hip joint of a child a surgeon defined that the apex of large acetabular was at the level of Rosen-Nelaton’s line. How is this line drawn?

A. from a large acetabular to the symphysis

B. from the heads of thigh to the cluteal tuber

C. from posterior superior iliac spine to the head of thigh

D. from posterior superior iliac spine to the perineal ligament

E. from posterior superior iliac spine to the cluteal tuber

12. A patient has got hermarthrosis of knee joint. Which of the arteries is its source?

A. a.genus superior medialis

B. a.genus superior lateralis

C. a.genus media

D. a.genus inferior medialis

E. a.genus inferior lateralis

13. A patient has got a hermarthrosis of knee joint. Which of torsions of knee joint can be punctured in this case?

A. superior medial

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B. superior lateral

C. inferior medial

D. inferior lateral

E. superior anterior

14. How is the vascular-nervous bundle of popliteal space (from backwards forwards)?



C. vein, nerve, artery



15. During the approach to the vascular-nervous bundle of thigh in the middle third a surgeon used Ken’s line. In what canal are there vessels at this level?

A. canalis of crurupopliteus

B. canalis of femoropopliteus

C. canalis of spiralis

D. canalis of musculoperonealis

E. canalis of pudendalis


Tests

1. A surgeon conducts the ligament of femoral artery in the area of apex of femoral trigone. In what way are the elements of femoral vascular-nervous bundle located (from forwards backwards)?



C. nerve, artery, vein



2. During debriding of missle wound in the area of femoral trigone there was made up a decision to ligature a femoral artery. What branch of femoral artery is it needed to try to leave higher the place of ligature for the maintainance of collateral blood stream of lower limb?

A. a.epigastica superficialis

B. a.profunda femoris

C. a.pudenda externa

D. a.circumflexa femoris lateralis

E. a.circumflexa femoris medialis

3. During debriding of missle wound in the area of femoral trigone there was made up a decision to ligature a femoral artery. For the maintainance of collateral blood stream of lower limb it is necessary to save the deep artery of thigh. At what level below the inguinal ligament does it run?

A. 1-2 cm lower

B. 3 cm lower

C. 4-6 cm lower

D. just under the inguinal ligament

E. on the apex of trigone

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4. During debriding of missle wound in the area of femoral triangle there was made up a decision to ligature a femoral artery. For the maintainance of collateral blood stream of lower limb it is needed to save the deep artery of thigh. What surface of femoral artery does it run from?

A. from superior

B. from inferior

C. from lateral

D. from medial

E. from superior lateral

5. During the approach to the femoral vascular-nervous bundle in middle third of thigh a surgeon has found a long nervous branch in a hypoderm. What is this nerve?

A. n.saphenus

B. n.ichiadicus

C. n.sartorius

D. n.obturatorius

E. n.femoralis

6. For baring of a cluteal nerve on a thigh a surgeon has defined a projection line. In what way is it conducted?

A. from the middle of distance between cluteal tuber and large acetabular to the middle of popliteal space

B. from the middle distance between a cluteal tuber and large acetabular to the medial epicondyle of thigh

C. from a cluteal tuber to the lateral epicondyle of thigh

D. from a large acetabular to tuberculum adductorium

E. from the middle of distance between a large acetabular and head of thigh to the middle of popliteal spaces

7. For baring of femoral artery a surgeon has defined Ken’s projection line. In what way is it conducted?

A. from the middle of inguinal ligament to the middle of patella

B. from the middle of inguinal ligament to the medial epicondyle of thigh

C. from a point on verge of 2/5 lateral and 3/5 medial lengths of inguinal ligament to the middle of patella

D. from point on verge of 2/5 lateral and 3/5 medial lengths of inguinal ligament to tuberculum adductorium

E. from tuberculum pubicum to tuberositas tibiae

8. Thanks to what arteries mentioned below the blood supply of hip joint takes place?

A. a.profunda femoris

B. a.iliàñà interna

C. a.pudenda interna

D. a.acetabuli

E. a.gluteae inferior

F. a.circumflexae femoris medialis

G. a.circumflexae femoris lateralis

9. In what direction is a distal fragment displaced in case of break of thigh-bone in the suerior third?

132

A. forwards

B. backwards

C. medially

D. laterally

10. In what direction is proximal fragment displaced in case of break of thigh-bone in the superior third?

A. forwards

B. backwards

C. medially

D. laterally

11 For baring of femoral artery a surgeon has defined Ken’s projection line. In what position of lower limb does it corresponds to artery?

A. erect

B. flexed in a hip joint and knee joint

C. flexed in a knee joint

D. flexed in a hip joint and knee joint and rotated outwards

E. flexed in a hip joint and knee joint and rotated inwards

12. During the approach to the vascular-nervous bundle of thigh in the middle third a surgeon used Ken’s line. In superficial layers a vascular-nervous bundle is not found. What anatomic formation should be cut, to get to the vessels?

A. m.vastus medialis

B. m.vastus lateralis

C. fascia pectinea

D. lamina of vastoadductoria

E. lata fascia

13. What anatomic formations are more frequently damaged in cases of supracondylar breaks of thigh?

A. femoral artery

B. femoral vein

C. artery which accompanies cluteal nerve

D. popliteal artery

E. cluteal nerve

F. subdermal nerve

14. What muscles stipulate the displacement of fragments in cases of break of thigh-bone in the superior third?

A. large cluteal muscle

B. middle cluteal muscle

C. small cluteal muscle

D. glomerular-lumbar muscle

E. adductor muscles

F. obturator internus muscle

G. muscle of calf



133

PRACTICAL LESSON № 6(26)

Theme of the lesson:

Topographical anatomy of the shin and the foot. Entries to the vessels and nerves, sections at the purulent diseases.

Aim of lesson:

To learn the topographical anatomy of front and back surface of the shin and on the basis of knowledge to be able to bare on a dead body from the most rational entries of the vessel and nerves, to conduct bandaging of the vessel, do the sections concerning purulent processes on the shin and foot.

Educational task:

To have an idea about:

1. Forming of vaginas of the vascular-nervous bundles of the shin and the foot;

2. Popliteal channel for Shin;

3. Facial-muscular beds of the front area of shin;

4. Blood supply of the shin and the foot. Peculiarities of the venous outflow;

5. Areas of denervation at the defeat of shinbone, fibular nerves;

6. Topographical anatomy of the ankle joint;

7. Joints of foot (transverse joint of articulation, articulation cuneonavicularis, articulations tarsometatarseae);

8. Muscle-fascial beds of foot;

9. Operations at the phlebeurysm of the limbs;

10. Collateral circulation of blood at bandaging of the front and back a. tibialis

To know:

1. Bounds of the shin, talocrural area of the foot.

2. Channels of the shin and the foot.

3. Cellular spaces of the shin and the foot.

4. Composition of the vascular-nervous bundles of the shin and the foot.

5. Projections lines of the vascular-nervous bundles of the shin and the foot.

6. Operative entries to the ankle joint.

To be able:

1. To conduct operative entries to the front vascular-nervous bundle of the shin at different levels.

2. To conduct operative entries to the back vascular-nervous bundle of the shin at different levels.

3. To conduct the baring of the vascular-nervous bundle in a medial drupaceous channel.

4. To execute sections at the phlegmons of the shin.

5. To execute sections at the підапоневротичних phlegmons of foot.

The contents of the lesson:

The bounds of the areas of the shin and the foot. The basic vascular-nervous bundles of the shin and the foot. The lymph-outflow of the limbs. The peculiarities of the venous outflow of the limbs. The operative entries to the vascular-nervous bundles of the shin and the foot.

The sections at the purulent processes of the shin and the foot.


Control of the entrance level of knowledge — 5%

Theoretical instructions and interviews — 20%

134


Control of the ultimate level of knowledge — 10%

The task for the initial control of the knowledge level. Test.

1. In what channel passes n.peroneus communis?

A. Canalis of cruropopliteus

B. Canalis of malleolaris

C. Canalis musculoperonealis superior

D. Canalis of musculoperonealis inferior

E. Canalis of femuropoliteus

2. With the purposes of baring a.tibialis anterior and n.peroneus a profundus the surgeon determines the projection line of the vascular-nervous bundle. How is it conducted?

A. From tuberositas tibiae to the medial bone

B. From the head of os peronea to the medial bone

C. From the middle of the distance between tuberositas tibiae and caput fibulae to the middle of the distance between the bones

D. From tuberositas tibiae to the middle of the distance between bones

E. From the head of os peronea to the middle of the distance between bones

3. The surgeon conducts the baring a.tibialis anterior and n.peroneus profundus. What muscles does a vessel-nervous bundle lie between in the overhead third of the shin?

A. M.tibialis anterior and m.extensor digitorum longus

B. M.tibialis anterior and m.extensor hallucis longus

C. M.extensor hallucis lorigus and m.extensor digitorum longus

D. M.extensor hallucis longus and m.peroneus longus

E. M.extensor digitorum longus and m.peroneus longus

4. The surgeon conducts baring a.tibialis anterior and n.peroneus profundus. What muscles does a vessel-nervous bundle lie between in the lower third of the shin?

A. M.tibialis anterior and m.extensor digitorum longus

B. M.tibialis anterior and m.extensor hallucis longus

C. M.extensor hallucis longus and m.extensor digitorum longus

D. M.extensor hallucis longus and m.peroneus longus

E. M.extensordigitorum longus and m.peroneus longus

5. In what channel does a.tibialis posterior and n.tibialis pass?

A. Canalis of cruropopliteus


C. Canalis of musculoperonealis superior



6. In what channel does a.peronea pass?

A. Canaliscruropopliteus


C. Canalis of musculoperonealis superior



7. The tendons junction of what muscles does a heelstring form?

A. M.flexor digitorum iongus, m.gastrocnemius, m.soleus

135

B. M.flexor digitorum longus, m.gastrocnemius, m.plantaris

C. M.flexor hallucis longus, m.gastrocnemius, m.soleus

D. M.flexor hallucis longus, m.gastronemius, m.plantaris

E. M.gastronemius, m.soleus, m.plantaris

8. There is a necessity in baring and.tibialis posterir and n.tibialis in the overhead third of the shin. How will a projection line be conducted?

A. From the middle of popliteal fossa down

B. From tuberositas tibiae to the medial bone

C. From tuberositas tibiae to the middle of the distance between the medial bone and heelstring

D In 1 centimetre from the medial edge of os tibiae to the middle of the distance between the medial bone and heelstring

E. From the head of perone to the lateral bone

9. There is a necessity in baring a.tibialis poslerior and n.tibialis in the middle third of the shin. How will a projection line be conducted?

A. From the middle of popliteal fossa down


C. From tuberositas tibiae to the middle of the distance between a medial bone

and a heelstring

D. In 1 centimetre from the medial edge of os tibiae to the middle of the distance between a medial bone and a heelstring

E. From the head' of perone to the lateral bone

10. There is a necessity in baring a.tibialis posterior and n.tibialis in the lower third of the shin, under a bone. How will a projection line be conducted?

A. From the middle of popliteal fossa vertical down


C. From tuberositas tibiae to the middle of the distance between a medial bone and a heelstring


E. From the head' of perone to the lateral bone

11. What formation is the back artery of the foot placed between?

A. Tendon of the front shinbone muscle

B. Dorsal interosseous muscles

C. Tendon of a long pollex extensus

D. Flexor hallucis brevis

E. Extensor digitorum brevis

12. Indicate the most thin and not fastened by the connections department of articulatio talocruralis

A. Front

B. Back

C. Lateral

D. Medial

13. What artery passes in metatarsus bone-muscular slit?

A. Back metatarsus arteries

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B. aa. digitales plantares communes

C. a. plantaris profundus

D. пронизна гілка

14. With what cellular spaces are the superficial and deep fascial-cellular spaces of middle fascial bed connected?

A. Internal fascial bed

B. External fascial bed

C. Heel channel

D. Plantar channel

E. Interdigital cellulose

Task for the ultimate control of knowledge level

Test.

1. There is a necessity in the baring a.tibialis anterior on the foot. How will a projection line be conducted?

A. From the middle of popliteal fossa vertical down


C. From tuberositas tibiae to the middle of the distance between a medial bone and a heelstring


E. From the middle of the distance between stone to the 1th interdigital interval

2. A child is diagnosed to have an innate clubfoot. What setting of the foot takes place?

A. Pes of eqinovarus adducta

B. Pes of eqinovalgus adducta

C. Pes of eqinovarus abducta

D. Peseqinovalgus of abducta

E. Pes of valgus abducta

3. A patient has a diagnosis of підапоневротична phlegmon of the foot. The sections are conducted in projections of the lateral and medial intermuscular membranes of the sole by

Delorm. How is a lateral intermuscular membrane designed?

A. From tuber calcanei to the 2th interdigital interval

B. From the middle of the vertical line which connects stone to the 1th interdigital interval

C. From tuber calcanei to the 4th interdigital interval

D. From tuber calcanei to the 1th interdigital interval

E. From the middle of the vertical line which connects stone to the 3th interdigital interval

4. A patient has a diagnosis of підапоневротична phlegmon of the foot. The sections are conducted in projections of the lateral and medial intermuscular membranes of the sole by

Delorm. How is the medial intermuscular membrane designed?

A. From tuber calcanei to the 2th interdigital interval

B. From the middlesof the vertical line which connects stone to 1th interdigital interval

C. From the middle of the medial half of the vertical line which connects stone to the 1th interdigital interval

D. From tuber calcanei to the 1th interdigital interval

E From the middle of the vertical line which connects stone to 3th interdigital interval

5. To what anatomic formations does a.tibialis anterior in lower third of the shin belong?

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A. m. tibialis anterior

B. m. tibialis posterior

C. m. extensor digitorum longus

D. m. extensor hallucis longus

E. m. flexor hallucis brevis

F. m. flexor hallucis longus

G. Medial edge of fibula

H. Lateral edge of fibula

I. Interbone membrane of the shin

J. tibia

6. To what anatomic formations does a. tibialis anterior in overhead third of shin belong?

A. m. tibialis anterior

B. m. tibialis posterior

C. m. extensor digitorum longus

D. m. extensor hallucis longus

E. m. flexor hallucis brevis

F. m. flexor hallucis longus

G. Medial edge of fibula

H. Lateral edge of fibula

I. Interbone membrane of the shin

J. tibia

7. Indicate the projection line of hypodermic nerve on the area of the medial bone?

A. On the line which passes on the term of the front and middle third of the excavation formed by a bone and Achilles tendon

B. On the line which passes on the lower edge of the bone

C. On the line which passes from the middle of the excavation formed by a bone and

Achilles tendon to the tuberosity of the V metatarsal bone

D. On the line which passes from the top of the bone to the tuberosity of I metatarsal bone

E On the front edge of premiddle bone

8. What muscles and tendons does an internal fascial bed contain?

A. m. abductor digity minimi

B. m. flexor digity minimi brevis

C. m. flexor digitorum brevis

D. m. adductor hallucis

E. m. abductor hallucis

F. m. flexor hallucis brevis

G. m. flexor hallucis longus

9. What muscles and tendons do an external fascial bed contain?

A. m. abductor digity minimi

B. m. flexor digity minimi brevis

C. m. adductor hallucis

E. m. abductor hallucis

F. .m. flexor hallucis brevis

G. m. flexor hallucis longus

H. m. flexor digitorum longus

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10. In the capsule of what joint are two sesamoid bone included?

A. I metatarsophalangeal

B. II metatarsophalangeal

C. III metatarsophalangeal

D. IV metatarsophalangeal

E. V metatarsophalangeal

F. Lisfrank’s joint

11. What is a heel channel limited by?

A. calcaneus

B. os. naviculare

C. os. cuboideum

D. m. abductor hallucis

E. m. abductor digity minimi

F. m. adductor hallucis

12. From what side is it expedient to conduct the спицкгв tuberositas tibiae at skeletal strain, in order not to injure a general fibular nerve?

A. In front

B. From a lateral side

C. From a medial side

D. At the back

E. The choice of the point is not important and is determined by the qualification of the surgeon

13. What materials are applied for the connection of the bones?

A. Thick catgut

B. Nickel-plated spokes

C. Steel pins

D. Cartilaginous autotransplants

E. Wire loops

14. Оsteosynthesis with the help of Ilizarov’s apparatus includes the followings stages of the apparatus assembling:

A. Dismantling of the proximal and distal debris of the bones

B. Conduction of the spokes through the proximal and distal debris of the bones

C. Fixing of the spokes in the rings

D. Assembling of the rings

E. The setting of the shaft which connect tissue



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Topographical anatomy of the upper arm, armpit, shoulder, elbow fossula, area of the elbow joint. Topographical anatomy of humeral and elbow joints. Entries to the armpit, subclavian, humeral arteries. Enyries to the nerves. Interference on the joints of the upper limbs.

Aim of lesson:

To learn the topographical anatomy of the upper arm, shoulder and elbow fossula. To master the technique of the baring of the vessels and nerves of subclavian area, armpit, shoulder and elbow fossula.



- purulent processes of articulatio humeri;

- purulent processes of articulation cubiti;

- innate dislocations of the shoulder;

- clinic of the damage of the main vessels;

- clinic of the damage of the nerves of the upper limbs;

- clinic of phlegmons of the shoulder and upper arm;

- blocking of nerve;

- neurolysis;

- stitch of the nerve;

- neurotomy;

- the plasty and moving of the nerves;

- stitches of the tendons.

To know:

- Topographical anatomy: armpit, subclavian area, shoulder-blade area, дельтоподібної area, front and back area of shoulder, elbow fossula;

- collateral arterial circulation of blood is in the areas of shoulder-blade, articulatio humeri, articulation cubiti;

- projections lines of the main vessels and nerves, technique of baring of the main vessels and nerves;

- technique of the fulfillment of the front synosteotomy of articulatio humeri;

- ways of the spread of the purulent processes.

To be able: to execute the baring of the armpit artery, humeral artery in the upper, middle, lower third of the shoulder and elbow fossula, n. radialis.


The limits of the upper arm, shoulder and elbow fossula, muscular-bone references, the lines of the fulfilment of the sections for the entries to the vessels, nerves, joints. Cellular spaces.

Subdeltoid cellular space and his connection with the armpit and shoulder-blade areas.

Topography of the quadrilateral opening, in relation to the operation of the back synosteotomy. Articulatio humeri. The forms of the joint, the scope of motions. Capsule, arthral bags, connections, tendons of muscles which strengthen a joint. The armpit area.

Cellulose which fills the armpit. Conventional dividing of the armpit is on three triangles

(tr.clavipectorale, tr.pectorale, tr.subpectorale). Topography of vascular-nervous bundles in these triangles. The front and the back departments of the shoulder, muscles, vessels and

140 nerves. The topography of n. radialis in a humeros-muscular channel and n. radialis in the lower third of shoulder. The baring of the armpit and humeral arteries. The operations on the restitution of the vessels passage - a vascular stitch, hand or mechanical, imposition of vascular inosculations, prosthesis of the vessels. The elbow area. The front elbow area.

Vascular-nervous bundle of the elbow bend. The back elbow area, tendons of the muscles, topography of the elbow nerve. Articulation cubiti.






Task for the initial control of the knowledge level

The questions for the consideration on the lesson:

1. Dividing of the upper limbs by areas, their limits

2. External references

3. Dividing of the armpit area into triangles

4. The topographical anatomy of the vascular-nervous bundle in the different triangles of the armpit fossula. Trilateral and three-plus-oneextraneous openings of the armpit fossula

5. Collateral circulation of blood at the level of the shoulder-blade

6. The ways of spread of the purulent processes are on the upper limbs

7. Topographical anatomy of articulatio humeri

8. Topography of the basic vascular-nervous bundle of the shoulder

9. Topographical anatomy of the channel of n. radialis

10. Projections lines of the arteries and nerves

Test

1. Which one from the mentioned areas of the upper limbs does to the humeral belt (upper arm) belong?

A. Front area of the shoulder

B. Back area of the shoulder

C. m. deltoideus

D. Back area of the forearm

E. Front area of the forearm

2. Which one from the mentioned areas of the upper limbs does to membri superioris liberi belong?

A. Subclavian area

B. Back area of the shoulder

C. m. deltoideus

D. Armpit area

E. Shoulder-blade area

3. Who from the prominent scientists did the general acts of the structure of the vascular system on extremities formulate?

A. Spasokukotsky

B. Pirohov

C. Karavaev

D. Shymanovsky

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E. Lesgaft

4. Who from the prominent scientists did the general acts of the structure of the vascular sheath on extremities formulate?

A. Spasokukotsky

B. Pirohov

C. Karavaev

D. Shymanovsky

E. Lesgaft

5. With the purposes of baring and bandaging of v.cephalica a surgeon defined tr.deltoideopectorale. What is it formed by?

A. By a collar-bone, by small and large pectoral muscles

B. By small and large pectoral muscles and m. deltoideus

C. By a collar-bone, by a large pectoral muscle and f.clavipectoralis

D. By a collar-bone, large pectoral and m. deltoideus

E. By a small pectoral muscle, f.clavipectoralis and m. deltoideus

6. At the patient’s examination who fell from the bicycle a surgeon set the diagnosis of the fracture of the collar-bone in the middle third. In what side is the central fragment of the collar-bone displaced?

A. Down

B. Forward

C. Backward

D. Upward

E. It is not displaced

7. At the patient’s examination who fell from the bicycle a surgeon set the diagnosis of the fracture of the collar-bone in the middle third. In what side is the peripheral fragment of the collar-bone displaced?

A. down

B. forward

C. backward

D. upward

E. it is not displaced

8. At the patient’s examination who fell from the bicycle a surgeon set the diagnosis of the closed fracture of the collar-bone in the middle third. Thus there are the signs of the massive internal bleeding. The damage of what vessel is the most possible?

A. General carotid

B. v. subcluva

C. v. jugularis externa

D. a. subclavia

E. a. vertebralis

9. During the operation concerning the purulent process of subclavian area a surgeon consistently cut a skin, fascia pectoralis, divided muscular bundles of the large thoracal muscle, but did not reveal the pus. The pus appeared only after dissecting of the next layer of the tissues. What was the next layer of the tissues presented by?

A. By m. serratus anterior

B. By m. serratus posterior

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C. F.clavipectoralis

D. By fascia pectoralis

E. By m. pectoralis minor

10. During the operation concerning the purulent process of subclavian area a surgeon consistently cut a skin, fascia pectoralis, divided muscular bundles of the large thoracal muscle, but did not reveal the pus. The pus appeared only after dissecting of the next layer of the tissues. The phlegmon of what cellular space took place?

A. Superficial subpectoral space

B. Deep subpectoral space

C. Armpit

D. Lateral cellular space of the neck

E. Hypodermic cellulose

11. How many triangles is subclavian area divided into topographically?

A. Into 3

B. Into 2

C. Into 4

D. It is not divided

E. It consists of one triangle

12. During the operation a surgeon defined the wound of the artery which went away from a. subcluvia in it’s first department up to the top. What artery is it?

A. Truncus of brachicephalicus

B. A.vertebralis

C. A.thoracica lateralis

D. Truncus of costocervicalis

E. A.axillaris

13. During the operation concerning a. subcluvia wound in 2 department a surgeon made decision about its bandaging. What branch must the surgeon for the saving of the collateral blood supply of the upper extremity try to save?

A. A.vertebraÿlis

B. A.thoracica lateralis

C. Truncus of costocervicalis

D. A.transversa coli

E. A.thoracoacromialis

14. At the wound of the subclavian artery in the second department a surgeon chooses an operative entry to a.subclavia. What is the best entry?

A. Supraclavicular

B. Subclavian

C. By Petrovsky

D. By Dzhanelidze

E. By Pirohov

15.What is tr.clavipectorele limited by?

A. Collar-bone, the upper edge of the large pectoral muscle

B. Collar-bone, the upper edge of the small pectoral muscle

C. The upper edge of the large pectoral muscle and the lower edge of the small pectoral muscle

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D. The lower edge of the large pectoral muscle and the lower edge of small pectoral muscle

E. The lower edge of the large pectoral muscle and the upper edge of the small pectoral muscle

16. What is tr.pectorele limited by?

A. The upper and the lower edges of the small pectoral muscle



D. The lower edge of the large pectoral muscle and the lower edge of the small pectoral muscle


17. What is tr.subpectorele limited by?

A. Collar-bone, the upper edge of the large pectoral muscle



D. The lower edge of the large pectoral muscle and the lower edge of the small pectoral muscle


18. During the operation in subcluvian space a surgeon selects the elements of the vascularnervous bundle. In what order are they located from the front backwards?

A. Artery, vein, nerves

B. Vein, artery, nerves

C. Nerves, artery, vein

D. Artery, nerves, vein

E. Vein, nerves, artery

19. In which topographical cellular space does v.subclavia pass?

A. In sp.interscalenum

B. In sp.scalenovertebrale

C. In sp.interaponeuroticum suprasternale

D. In sp.retrosternodidomastoideum

E. In sp.antescalenum

Task for the ultimate control of the knowledge level

Test

1. In which topographical cellular space does v.subclavia pass?

A. sp.interscalenum

B. sp.scalenovertebrale

C. sp.interaponeuroticum suprasternaie

D. sp.retrosternoclidomastoideum

E. sp.antescalenum

2. At the wound of subcluvian artery its bandaging is executed in a pectoral triangle. What arteries will collateral blood supply of the upper limbs be carried out through?

A. A.supiascapularis, a.drcumflexa scapulae, a.transversa coli

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B. A. thoracica lateralis, a.thoracodorsalis,a.brachialis

C. A.vertebralis, a.circumfiexa humeri posterior

D. A.thoracodorsalis, tr.costocervicatis

E. Tr.thireocervicalis, a.thoracoacromialis

3. In the case of the wound of the armpit artery in the place of its passing into the humeral artery a surgeon made decision about its bandaging. Where is the «critical» area of the collateral circulation of blood, in which to impose a ligature is undesirably?

A. Between the entrance a.circumflexa humeri posterior and a.transversa coli

B. Between the entrance a.circurnflexa humeri posterior and a.subscpularis

C. Between the entrance a.profunda brachii and a.colateralis ulnariss

D. Between the entrance a.circumflexa humeri anterior and a.thoracoacromialis

E. Between the entrance a.profunda brachhii and a.subscapuiaris

4. At the dislocations of the shoulder the displacement of the head of the shoulder up to the top never takes place. The vault (fornix) of the shoulder hinders it. What is it formed by?

A. Coracoid process of the shoulder-blade and its glenoid cavity

B. Acromion process of the shoulder-blade and its glenoid cavity

С. Acromion process of the shoulder-blade, coracoid process and coracohumeral ligament.

D. Acromion process of the shoulder-blade, coracoid process and coracoacrominal ligament

E. Corcoid process of the shoulder-blade, аcrominal extremity of the collar-bone and coracoacrominal ligament

5. While fulfilling the entry to the humeral artery in middle third of the shoulder a surgeon sets the line of the section of the skin. How must it pass?

A. On sulcus bicipitalis medialis

B. On sulcus bicipitalis lateralis

C. .In 1 centimetre more lateral sulcus bicipitalis medialis

D. In 1 centimetre more medial sulcus bicipitalis medialis

E. In 1 centimetre more medial sulcus bicipitalis lateralis

6. A surgeon determines the possibilities of the spread of the purulent process from an armpit fossula. Through which from the mentioned formations is the cellular space of the armpit fossula united with the subdelta-shaped space?

A. Sulcus of bicipitalis medialis

B. Sulcus of bicipitalis lateralis

C. Foramen of trilaterum

D. Foramen of quadniaterum

E. Sulcus of deltoideopectoralis

7. At the fracture of shoulder there was the paralysis of the extensors of the hand in the middle third. What nerve is damaged during a trauma?

A. N.medianus

A. N.radialis

B. N.musculocutaneus

C. N.ulnaris

D. N.axillaris

8. At the baring of the armpit artery a surgeon conducted its projection line on the front border of the growth of hairs. What method is a projection line conducted by?

A. By Pyrohov

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B. By Lisfrank

C. By Langenbeck

D. By Dzhanelidze

E. By Petrovsky

9. At the baring of the armpit artery a surgeon conducted its projection line for the boundaryline of the front and the middle third of width of the armpit fossula. What method is a projection line conducted by?

A. By Pyrohov

B. By Lisfrank

C. By Langenbeck

D. By Dzhanelidze

E. By Petrovsky

10. At the baring of the armpit artery a surgeon conducted its projection line as the continuation of sulcus bicipitalis medialis. What method is a projection line conducted by?

A. By Pyohov

B. By Lisfrank

C. By Langenbeck

D. By Dzhanelidze

E. By Petrovsky

11. At the baring of the armpit artery a surgeon defined the nerve which engulfs the artery as the letter Y as the reference. What nerve is it?

A. N.medianus

B. N.radialis

C. N.musculocutaneus

D. N.ulnaris

E. N.axillaris

12. During the opened replicon of the fracture of the surgical neck of the shoulder there was a necessity to check up the integrity of the armpit nerve. What is the opening this nerve passes in limited by?

A. M.teres minor, m.teres major, m.biceps brachii, m.deltoideus

B. M.triceps brachii, m.teres minor,m.teres major, m.deltoideus

C. M.triceps brachii, m.teres minor, m.teres major, os scapulae

D. M.triceps brachii, m.teres minor, m.teres major, os humerus

E. M.biceps brachii, m.teres minor, m.teres rnajor, os humerus

13. After the fracture of the surgical neck of the shoulder, which was treated conservatively, a gipseous bandage was taken off in 6 weeks. On the side of the fracture the active taking of the shoulder is absent. What nerve is damaged?

A. N.medianus

B. N.radialis


D. N.ulnaris

E. N.axillaris

14. At the bandaging of the armpit artery a surgeon defined the branch of the artery, which passes in the three-cornered opening. What is the three-cornered opening limited by?

A. M.teres minor,m. teres major, m.biceps brachii

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B. M.triceps brachii, m.teres minor, m.teres major

C. M.triceps brachii, m.teres major, os scapulae

D. M.triceps brachii, m.teres minor, os humerus

E. M.biceps brachii, m.teres major, os humerus

15. A patient has the previous diagnosis of the arthritis of the humeral joint. A surgeon chose the front way of the puncture of the joint. What is a reference for the prick of the needle?

A. Glenoid cavity of the shoulder-blade

B. Acrominal extremity of the collar-bone

C. Acrominal process of the shoulder-blade

D. Coracoid process of the shoulder-blade

E. The head of the humeral bone

16. A patient has the previous diagnosis of the arthritis of the humeral joint. A surgeon chose the side way of the puncture of the joint. What is a reference for the prick of the needle?

A. Glenoid cavity of the shoulder-blade

B. Acrominal extremity of the collar-bone

C. Acrominal process of the shoulder-blade

D. Coracoid process of the shoulder-blade

E. The head of the humeral bone

17. While measuring arteriotony a doctor feels the pulse on a.cubitalis. Where is a pulse point?

A. In the middle of the line which connects the epicondyles of the humeral bone

B. On the lateral edge of the tendon of m.biceps brachii

C. On the medial edge of the tendon of m.biceps brachii

D. On the lateral edge of the tendon of m.triceps brachii

E. On the medial edge of the tendon of m.triceps brachii

18. What formations are in the lateral furrow of the elbow fossula?

A. N.ulnaris,a.collateralis ulnaris

B. N.medianus,a.cubitalis

B. N.musculocutaneus,a.cubitalis

C. N.radialis, a.collateralis radialis

D. N.radialis,a.collateralis ulnaris

19. What formations are in the medial furrow of the elbow fossula?

A. N.ulnaris,a.collateralis ulnaris

B. N.medianus,a.cubitalis

C. N.musculocutaneus,a.cubitalis

D. N.radialis.a.collateralis radialis

E. N.radialis,a.collateralis.ulnaris



147



Topographical anatomy of the forearm and the hand. The fascia and fascial cases. Cellular spaces. Ways of the spread of the purulent processes. The entries to the a.ulnaris, a.brachialis on the forearm and the hand. The sections at whitlow, paronychia, the phlegmons of the hand. The amputations and the exarticulations of the phalanxes and the fingers of the hand.

The stitch of the tendons.

Aim of the lesson:

To learn the topographical anatomy of the forearm and the hand, the ways of the spread of the purulent processes in these areas and their operative treatment. To master the technique of the baring of the main vessels and nerves.

To be able to execute operative interferences at the different forms of the whitlow, tendovaginities and the phlegmons of the hand.


To have an idea about: about: osteomyelitis, phlegmon, peripheral, nerve palsy, contracture, acampsia of the joints.

To know:

1. Fascial cases of the forearm

2. The sulcus of the forearm and their composition

3. The layer structure of the forearm

4. The projections lines of the vessels and the nerves

5. The cellular spaces of the forearm and the palm

6. The ways of the spread of the purulent processes

7. The blood supply and the innervation of the areas

8. Ways of the collateral circulation of blood

9. Whitlow: classification, clinic, operative treatment

10. The operative treatment of phlegmons of the hand and the forearm

11. The amputations and exarticulations of the fingers

12. The methods of imposition of the tendinous stitches, the clinical displays of the damage of the forearm nerves

To be able:

1. To define the external landmarks of the forearm and the hand on a dead body

2. To demonstrate the layer structure of the forearm and the hand

3. To demonstrate the cellular spaces of the forearm and the hand

4. To expose the sulcus of the forearm, and bare the vascular-nervous bundles

5. To define every element of the vascular-nervous bundle

6. To execute cuts at hypodermic and tendinous whitlows

7. To demonstrate the restricted areas for the cuts of the forearm


The external landmarks, bounds and layer topography of the front area of forearm. Muscular beds: external, front and back. Topography of the sulcus — radial, middle and cubital.

Projections lines of the vascular-nervous bundles. The Pyrohov’s deep cellular space. Layer topography of the palmar surface of the hand.

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The palmar aponeurosis. The fascial beds. The carpal channel. The Pirohov’s space. The technique of the entries to the radial and cubital artery, the middle nerve and superficial palmar arc.


Control of the entrance knowledge level — 10%



Control of the ultimate knowledge level — 20%

Task for the initial control of the knowledge level

The external landmarks of the forearm:

1. The layer structure of the areas of the forearm

2. The layer structure of the hand

3. The muscle-fascial cases of the forearm

4. The sulcus of the forearm

5. The collateral circulation of blood of the hand

6. The cellular spaces of the forearm and the hand

7. The ways of the spread of the purulent processes of the hand and the forearm

8. The projections lines of the vessels and nerves of the forearm

9. The surgical entries to the vessels and nerves

10. The surgical treatment of the phlegmons of the forearm

11. The whitlow, its kinds

12. The surgical treatment to the whitlow

13. The forbidden areas for the cuts on a hand

14. The methods of amputations and exarticulations of the fingers

Test

1.There is the necessity of the baring of the cubital artery. What muscles is it between?

A. Between m.pronator teres and m.flexor carpi radialis

B. Between m.flexor carpi uinaris and m.flexor carpi radialis

C. Between m.flexor carpi ulnaris and m.flexor digitorum superficialis

D. Between m.pronator teres and m.flexor digitorum superficialis

E. Between m.brachioradialis and m.flexor digitorum superficialis

2. There is the necessity of the baring of the cubital artery. How does its projection line pass?

A. From the middle of the fossa olecrani to os pisiforme

B. From the middle of fossa olecrani to processus coronoideus

C. From the middle of fossa olecrani to the middle of the distance between the processus coronoideus and processus styloideus

D. From the lateral epicondyle of humerus to os pisiforme

E. From the medial epicondyle of humerus to os pisiforme

3.There is the necessity of the baring of the radial artery. What muscles is it between?

A. Between m.brachioradialis and m.flexorcarpi radialis

B. Between m.flexor carpi ulnaris and m.flexor carpi radialis

C. Between m.flexor carpi ulnaris and m.flexor digitorum superficialis

D. Between m.pronator teres and m.fiexor digitorum superficialis

E. Between m.brachioradialis and m.flexor digitorum superficialis

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4. There is the necessity of the baring of the radial artery. How does its projection line pass?

A. From the middle of fossa olecrani to the os pisiforme

B. From the middle of fossa olecrani to processus styloideus



E. From the medial epicondyle of humerus to os pisiforme

5. There is the necessity of the baring of n.medianus. What muscles is it between?

A. Between m.pronator teres and m.flexor carpi radialis

B. Between m.flexor сагрі ulnaris and m.flexor carpi radialis

C. Between m.flexordigitorum profundus and m.flexor digitorum superficialis

D. Between m.pronator teres and m.flexor digitorum superficialis

E. Between m.brachioraialis

and m.flexor digitorum superficialis

6. There is the necessity of the baring of n.medianus .How does its projection line pass?

A. From the middle of the fossa olecrani to os pisiforme

B. From the middle of the fossa olecrani to processus coronoideus



E. From the medial epicondyle of humerus to os pisiforme bones

7. A patient has the paralysis of m.extensor digitorum. What nerve does the motive innervation of these muscles provide?

A. N.medianus

B. N.radialis


D. N.ulnaris

E. N.axillaris

8. What anatomic formations are in canalis carpi radialis located?

A. A.radialis

B. N.radialis

C. M.extensor policis longus

D. M.flexor carpi radialis

E. Ramus profundus a.radialis

9. What anatomic formations are in canalis carpi ulnaris located?

A. A.ulnaris, n.ulnaris

B. N of medianus

C. M.extensor digiti minimi

D. M.flexor carpi ulnaris

E. Ramus of profundus and.ulnaris

10. What of these anatomic formations are in canalis carpi located?

A. A.radialis

B. N of radialis

C. M.extensor policis longus

D. M.flexor carpi radialis

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E. N.medianus

11. For the baring of the superficial palmar arterial arc a surgeon defined its projection line.

How does it pass?

A. Over the edge the ball of thumb

B. Over the edge the ball of minimus

C. From the middle of the distance between processus to the basis of the third finger

D. From os pisiforme to the second interdigital interval

E. From os pisiforme to the fourth interdigital interval

12. At the expense of the tendon of which muscle is palmar aponeurosis formed?

A. M.fiexor digitorum superficialis

B. M.flexordigitorum profundus

C. M.palmares brevis

D. M.palmares longus

E. M.flexorcarpi radialis

13. A patient has the phlegmon of the muscular bed of pollex section is set to conduct on a skinning sulcus which limits thenar. In what part of this sulcus is not recommended to conduct the section?

A. In the distal third

B. In the proximal third

C. In the middle third

D. It is not recommended

E. Can be conducted in any part

14. A patient has the phlegmon of the muscular bed of pollex. Section is conducted on a skinning sulcus which limits thenar. After the operation, contrasting and lead of the pollex are absent. What nerve is damaged during the operation?

A. N medianus

B. N radialis

C. N musculocutaneus

D N ulnaris

E N.axillans

Task for the ultimate control of knowledge level

Test

1. The removal of the pollex is indicated to a patient. What method is it executed by?

A. Luppy

B. Pharabef

C. Method of racket

D. Malgen

E. Кlapp

2. The removal of the third finger is indicated to a patient. What method is it executed by?

A. Luppy

B. Pharabef

C. Pyrohov

D. Malgen

E. Кlapp

3. The removal of the fifth finger is indicated to a patient What method is it executed after?

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A. Luppy

B. Pharabef

C. Method of racket

D. Malgen

E. Кlapp

4. The removal of the fourth finger is indicated to the patient. What method is it executed by?

A. Luppy

B. Pharabef

C. Pyrohov

D. Malgen

E. Кlapp

5. The removal of the second finger is indicated to the patient. What method is it executed by?

A. Luppy

B. Pharabef

C. Method of racket

D. Malgen

E. Кlapp

6. What is the sequestrotomy?

A. The removal of the part of the bone

B. The section bone

C. The removal of the eliminated bone fabric from a sequestral box

D. The removal of the pus from a bone-cerebral channel

E. The removal of the unviable fabrics

7. Where is a point for puncture of articulation radiocarpea?

A. On a crossing of the line which connects processus styloideus, with a line which is the continuation of the fourth metacarpal bone.

B. On a crossing of the line which connects processus styloideus, with a line which is the continuation of the third metacarpal bone.

C. On a crossing of the line which connects processus styloideus, with a line which is the continuation of the second metacarpal bone

D. In the middle of the distance between processus styloideus.

E. In the external third of the distance between processus styloideus.

8. From what surfaces of the forearm are the shreds for implementation of double graft amputation of the forearm in the middle third cut out?

A. On the front and back surface.

B. On the medial and lateral surface.

C. On the front lateral and back medial surfaces.

D. On the back lateral and front medial surfaces.

E. On any surface

9. With what speed does the growth of the central end of the nerve after the damage pass?

A. 1-1,5 мilimetre in a day.

B. 2-3 мilimetre in a day.

C. 5-10 мilimetre in a day

152

D. 11-15 мilimetre in a day.

E. 16-20 мilimetre in a day.

10. From what side is it necessary to lead a ligature needle at the bandaging of a.ulnaris?

A. From any side.

B. From the side of n.ulnaris.

C. From the lateral side.

D. «from yourself».

E. «on yourself».

11. What will take place at the damage of the «restricted area» in the proximal part of thenor?

A. The damage of the tendons of m.flexor digitorum.

B. The damage of the tendons of m.flexor pollicis longus.

C. The damage of the motor part of n.medialis with the disorder of the contrasting of the pollex of the hand.

D. The damage of the arterial palmar arc.

E. The damage of the muscles of thenora.

12. What does in the radial channel of the wrist pass?

A. A.radialis

B. The superficial branch of n.radialis.

C. The tendon of the radial extensor of the wrist

D. N.medialis.

E. A.medialis.

13. What is V-form phlegmon?

A. The purulent tendovaginitis of the I and V fingers

B. The purulent tendovaginitis of the II and IV fingers

C. The purulent tendovaginitis of the II and III fingers

D. The purulent damage of the intermuscular intervals of the ball of the I and the V fingers

E. All above-stated elements

14 Where is it necessary to do the sections at the purulent tendovaginitis of the tendons of the extensors of the fingers?

A. On a palmar surface

B. On a back surface

C. On a lateral surfaces

D. On the area of the ungual phalanx

E. On the front lateral surfaces from outside between the phalanx joints.



153



The principles of the amputations and exarticulations of the upper and lower extremity.

Aim of the lesson:

To learn the general principles of the amputations and exarticulations of the extremities and master the basic methods of these operations. To aquaint with principles of еxtra- and іntramedullary osteosynthesis.



1. Modifications of the basic methods of the amputations and exarticulations.

2. The complication at amputations.

3. Approaches to the amputations at children.

4. Prosthetis.

5. Reamputation.

To know:

1. Determination of amputation and exarticulation.

2. Classifications of amputations.

3. Methods of treatment of soft tissues.

4. Methods of treatment of vessels, nerves, bones.

5. Methods of amputations and exarticulations of fingers of brush.

6. Amputation of forearm with a cuff.

7. The patchwork method of amputation of shoulder is in the middle third.

8. Exarticulation of fingers of foot after Garanjo.

9. Amputation of metatarsal bones after Sharp.

10. Exarticulation in a retrometatarsus-metatarsal joint after Lisfrank.

11. Bone-plastic amputation of shin after Pyrohov.

12. Amputation of shin in the middle third.

13. Bone-plastic amputation of thigh after Gritti-Shymanovsky.

14. Conical-circular amputation of thigh after Pyrohov.

15. The patchworks methods of amputation of thigh are in the overhead and middle third.

16. Exarticulation of thigh in a stump joint.

17. Types of painful stump.

To be able:

1. To tell the technique of execution of basic methods of amputation and exarticulation.

2. To be able to tell the technique of treatment of soft tissues and bone at amputations.

3. To execute the exarticulations of fingers of brush on a dead body.

4. To tell the structure of amputation stump of upper and lower limb at different levels.

Table of contents of employment:

Basic types of amputations. Primary, second, the repeated is amputations. Methods and methods of amputations are in dependence on the form of dissecting of soft tissues, level of dissecting of soft tissues, type of tissues which close sawing of bones. A testimony, anaesthetizing and essence of operations of exarticulation and amputation, on a foot and shin.

Methods of treatment of soft tissues. Methods of treatment of vessels, nerves, bones.

Methods of amputations and exarticulations of fingers of hand. Amputation of forearm with

154 a cuff. The patchwork method of amputation of shoulder in the middle third. Amputations and exarticulations of phalanxes of fingers of hand. Local anaesthesia after Lukashevich-

Оberst. Explorer anaesthesia after Brawn-Usoltseva.

Bone-plastic amputation after M.Ì.Pyrohov, errors and complications are possible

Amputation of shin in the middle third. Bone-plastic supracondylar amputation of thigh after

Gritti-Shymanovsky, Sabaneev, Albrecht. Amputation of thigh in the middle and upper third. Conical-circular stage amputation of thigh after M.Ì.Pyrohov.

Exarticulation of fingers of foot after Garanjo. Amputation of metatarsal bones after Sharp

Exarticulation in a retrometatarsus-metatarsal joint after Lisfrank. The disarticulation in interphalangeal joints. Types of painful stump.


Control of entrance knowledge level — 10%



Control of eventual knowledge level — 15%

Task for the initial knowledge level control

Test

1. The patient must undergo exarticulation of thumb. What method should be applied?

A. after Luppi

B. after Pharabef

C. after the method of racket

D. after Malgenem

E. after Klapp

2. The patient must undergo the exarticulation of the 3-rd finger. What method should be applied?

A. after Luppi

B. after Pharabef

C. after Pyrohov

D. after Malgenem

E. after Кlapp

3. The patient must undergo the exarticulation of the 5-th finger. What method is to be executed?

A. after Luppi

B. after Pharabef


D. after Malgenem

E. after Klapp

4. The patient must undergo the exarticulation of the 4-th finger. What method is to be executed ?

A. after Luppi

B. after Pharabef

C. after Pyrohov

D. after Malgenem

E. after Кlapp

155

5. The patient must undergo the exarticulation of the 2-nd finger. What method is to be executed ?

A. after Luppi

B. after Pharabef


D. after Malgenem

E. after Klapp

6. The man with a heavy transport trauma of shin underwent amputation after 10 hours from the moment of trauma. What kind of amputation was it due to the time of implementation?

A. Second early

B. Second late

C. Primary

D Reamputation

E. Necrectomy

7. The man with a heavy transport trauma of shin underwent amputation after 48 hours from the moment of trauma. What kind of amputation was it due to the time of implementation?

A. Second early

B. Second late

C. Primary

D Reamputation

E. Necrectomy

8. The man with a heavy transport trauma of shin underwent amputation after 10 days from the moment of trauma. What kind of amputation was it due to the time of implementation?

A. Second early

B. Second late

C. Primary

D Reamputation

E. Necrectomy

9. The man with frost-bitten feet underwent the delete of areas of feet within the limits of nonviable fabrics. What kind of amputation was it due to the time of execution?

A. Second early

B. Second late

C. Primary

D Reamputation

E. Necrectomy

10. A surgeon executes an exarticulation in a retrometatrsal -metatarsus joint after Lisfrank method. What copula is the key to the joint?

A. Lig.bifurcatum

B. Lig deltoideum

C. Lig.cuneometetarseum mterosseum mediale

D. Lig.cuneometetarseum interosseum laterale

E. Lig.talocalcaneum

11. A surgeon executes an exarticulation in Shaparov joint. What copula is the key to the joint?

A. Lig.bifurcatum

156

B. Lig .deltoideum

C. Lig.cuneometetarseum mterosseum mediale

D. Lig.cuneometetarseum mterosseum laterale

E. Lig.talocalcaneum

12. A surgeon executes amputation of thigh in the middle third after M.I. Pyrohov. Is this… amputatio?

A. Mioplastic

B. Fasciaplastic

C. Тendoplastic

D. Osseousplastic

E. Cutisplastic

13. A surgeon executes amputation of shin in middle third part with the use of front long flap. Is this …amputatio?

A. Mioplastic

B. Fasciaplastic

C. Тendoplastic

D. Osseousplastic

E. Cutisplastic

14. A surgeon executes amputation of shin in the middle third, with the use of back long flap. Is this…. amputation ?

A. Mioplastic

B. Fasciaplastic

C. Тendoplastic

D. Osseousplastic

E. Cutisplastic

15. Does a surgeon execute the operation of amputation of thigh in the middle third after

Pyrohov method? Which is this method ?

A. Guillotine

B. Circular

C. Conical-circular

D. Patch

E. Bipatch

16. A surgeon executes the operation of amputation of thigh in the lower third. Amputation after Shymanovsky is…?

A. Mioplastic

B. Fasciaplastic

C. Тendoplastic

D. Osseousplastic

E. Cutisplastic

17. A patient with the anaerobic infection of wounded thigh undergoes amputation by a guillotine method. This method foresees…?

A. Cirtcular amputation

B. Conical-circular amputation

C. onepatch

D. collar

157

E. bipatch


1. Patient underwent supracondylar amputation of thigh in the lower third after Gritti-

Shymanovsky. This operation is…?

A. circular

B. conical-circular

C. mioplastic

D. Osteoplastic

E. fasciaplastic

2. Patient underwent supracondylar amputation of thigh in the lower third after Gritti-

Shymanovsky. This operation is…?

A. circular

B. conical-circular

C. onepatch

D. collar

E. bipatch

3. At the amputations of thigh after Pyrohov method the first moment of operation is…?

A. Dissection of skin, hypoderm, superficial fascia

B. Dissection of skin, hypoderm, own fascia, muscles

C. Dissection of muscles on the edge of brief skin

D. Dissection of muscles on the edge of the drawn aside skin

E. Dissection of all layers to the bone

4. At the amputations of thigh after Pyrohov method the second moment of operation is…?

A. Dissection of skin, hypoderm, superficial fascias

B. Dissection of skin, hypoderm, own fascias, muscles

C. Dissection of muscles on the edge of contracted skin



5. During amputation of thigh after Pyrohov method the third moment of operation is:?

A. Dissection of bone

B. Dissection of skin, hypoderm, own fascias of muscles

C. Dissection of muscles on the edge of contracted skin



6. At the execution of amputation at a child a surgeon elects the method of periosteum preparation . What method should be applied?

A. Аpperiostal

B. Subperiostal

C. Sub-apperiosatl

D. Skin-plastic

E. Tenoplastic

7. Which of the surgeons was the first to offer the bone-plastic operations?

A. Birr

B. Shimanovsky

C. Gritti

158

D. Kallender

E. Pyrohov

8. Which of the surgeons was the first to offer classification of аmputations due to the time of their execution?

A. Zur-Vert

B. Àlcock

C. Pyrohov

D. Priorov

E. Brown

9. The patient must undergo amputation of thigh in the lower third. A surgeon chose the method of Каllender. Is this method:?

A. Fasciaplastic

B. Skinplastic

C. Mioplastic

D. Tenoplastic

E. Boneplastic

10. A surgeon executes amputation of thigh by a biflap method. What is the length of long flap?

A. 1/3 diameters of limb in the place of amputation

B. 2/3 diameters of limb in the place of amputation'

C. 1/3 lengths of circle of limb in the place of amputation

D. 2/3 lengths of circle of limb in the place of amputation

E. a diameter of limb in the place of amputation

11. A surgeon executes amputation of thigh by a biflap method. Why is length of short flap?

A. 1/3 diameter of limb in the place of amputation

B. 2/3 diameter of limb in the place of amputation

C. 1/3 length of circle of limb in the place of amputation

D. 2/3 length of circle of limb in the place of amputation


12. A surgeon executes amputation of thigh by a biflap method. What is total length of flaps

A. 1/3 diameter of limb in the place of amputation

B. 2/3 diameter of limb in the place of amputation

C. 1/3 length of circle of limb in the place of amputation

D. 2/3 length of circle of limb in the place of amputation


13. A surgeon executes amputation of thigh by a biflap method. How much is necessary to be added to the length of flap taking into account reduction of fabrics?

A. To add none

B. To add 1-2cm.

C. To add 2-4 cm.

D. To add 6-8 cm.

E. To add 10-12 cm.

14. A surgeon executes osteoplastic periosseous amputation of shin in the lower thirds after

Pyrohov method. How is the skinning section conducted?

A. From the ends of bones in a vertical and horizontal (to the front) plane

159

B. From the ends of bone in a vertical plane

C. From the ends of bone in the horizontal plane to the front

D. From the heel hump to the line which combines humps of 1-st and 5-th of metatarsus bones

E. From the ends of bones in the horizontal plane backwards

15. The patient must undergo the foot amputation on the level of tarsometatarsus joint. A surgeon chose the method of exarticulation-amputation. Which of metatarsi bones must be amputated?

A. 1st

B. 2nd

C. 3rd

D. 4th

E. 5th

16. A patient after amputation of shin had phantom pains in absent part of limb. What is their reason?

A. nonresistant stump

B. purulent complication of stump

C. Dystrophy of muscles

D. neuroma

E. osteomyelitis



160

CONCLUDING LESSON 10(30)


Concluding lesson from a section the ” The topographical anatomy and operative surgery of lumbar area, spine, extraperitoneal space and small pelvis Topographical anatomy and operative surgery of upper and lower limbs".

Aim of lesson:

Control and correction of level of professional knowledge, abilities and skills within the limits of section the ”Topographical anatomy and operative surgery of upper and lower limbs". To find out exactness, depth, plenitude of theoretical knowledge of students by the tests of 3 levels and tasks of 2 levels. To perform ability of execution of the offered operative interferences on a dead body.


To write the tests of writing programmed control

To decide the situational tasks of 2 levels

To be able:

1. to prepare a lumbar area;

2. to execute operative approach to the kidneys and ureter;

3. to execute nephrectomy;

4. to execute the resection of kidney;

5. to execute the decapsulation of kidney;

6. to execute the stitch of ureter;

7. to execute a paranephric block;

8. to execute sections in case of purulent processes;

9. to point the topographic anatomic elements of pelvis on preparations and tables;

10. to prepare the cellular spaces of pelvis on a complex and corpse;

11. to execute suprapubic puncture of urinary bladder;

12. to execute the resection of salpinx;

13. to execute epicystostomy;

14. to execute a hemorrhoidectomy;

15. to define the level of a diagnostic rachicentesis for adults and children;

16. to execute a diagnostic rachicentesis on preparation;

17. to define the line of laminectomy section;

18. practical implementation of laminectomy.

19. To conduct operative accesses to the femoral artery at different levels of thigh.

20. To execute operative accesses to the vascular-nervous bunches of buttock area.

21. To execute operative accesses to the popliteal vascular-nervous bunch (through popliteal and Zhoberov fossula).

22. To execute cuts at the festering processes of buttock area.

23. To execute operative accesses to the vascular-nervous bunch of back area of thigh.

24. To execute cuts at the phlegmons of front area of thigh.

25. To conduct operative accesses to the front vascular-nervous bunch of shin at different levels.

26. To conduct operative accesses to the back vascular-nervous bunch of shin at different levels.

27. To conduct baring of vascular-nervous bunch in a medial drupaceous channel.

161

28. To execute cuts at the phlegmons of shin.

29. To execute cuts at the underaponeurotic phlegmons of foot.

30. To execute baring of armpit artery, humeral artery in upper, middle, lower third of shoulder and elbow fossula, radial nerve.

31. To show the layer structure of forearm and hand.

32. To show the checked spaces of forearm and hand

33. To expose the furrows of forearm, and bare vascular-nervous bunches

34. To define every element of vascular-nervous bunch of limb

35. To execute cuts at hypodermic and tendinous panaritiums

36. To show the restricted areas for the cuts of forearm

37. To be able to conduct treatment of soft fabrics and bone at amputations.

38. To execute the exarticulations of fingers of hand on a dead body.


The conduct written programmed control, decision of situational tasks of 2 levels, practical work on preparation of implementation of operative interventions from this section.


Writing programmed control — 50%

Decision of situational tasks of 2 levels — 10%

Practical work on preparation — 25%




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