Ministry of Health of Ukraine
BUKOVINIAN STATE MEDICAL UNIVERSITY
“APPROVED”
on methodical meeting of the Department of
Anatomy, Topographical anatomy and Operative
Surgery
“………”…………………….2008 р. (Protocol №……….)
The chief of department
professor ……………………….……Yu.T.Achtemiichuk
“………”…………………….2008 р.
METHODICAL GUIDELINES
for the 2d-year foreign students of English-spoken groups of the Medical Faculty
(speciality “General medicine”)
for independent work during the preparation to practical studies
THE THEME OF STUDIES
“The surgical instrumentation and usage rules”
Module 1
“Topographical Anatomy and Operative Surgery
of the Head, Neck, Thorax and Abdomen”
Semantic module
“Topographical Anatomy and Operative Surgery of the Head and Neck”
Chernivtsi – 2008
1. Actuality of theme:
The topographical anatomy and operative surgery are very importance, because
without the knowledge about peculiarities and variants of structure, form, location
and mutual location of their anatomical structures, their age-specific it is impossible
to diagnose in a proper time and correctly and to prescribe a necessary treatment to
the patient. Surgeons usually pay much attention to the usage rules of surgical
instruments.
2. Duration of studies: 2 working hours.
3. Objectives (concrete purposes):
To know the definition of topographical anatomy and operative surgery,
surgical operation.
To know classification of surgical instrumentation.
To know surgical instrumentation and usage rules.
To be able to define the surgical instrumentation.
4. Basic knowledges, abilities, skills, that necessary for the study themes
(interdisciplinary integration):
The names of previous disciplines
1. Normal anatomy
2. Physiology
3. Biophysics
The got skills
To describe the structure and function of
the different organs of the human body, to
determine projectors and landmarks of
the anatomical structures. To understand
the basic physical principles of using
medical equipment and instruments.
5. Advices to the student.
5.1. Table of contents of the theme:
THE SURGICAL INSTRUMENTS AND RULES OF THEIR USE
The surgeon realizes the mechanical influence on organs and tissues by his surgical
instruments. There are a few classifications. According to the government standard 19126-79E
(“Metal medical instruments. General technical conditions”) they are divided by character of
mechanical action:
1. Piercing
2. Cutting
3. Pressing
4. Clumps (multisurface action)
5. Probing
6. Bougienaging
7. Traumatologic (connecting tissues of organism and acting on them).
The classification by function is more comfortable for surgeons:
I. General surgical instruments:
1. Instruments for parting tissue.
2. Instruments to arrest bleeding.
3. Instruments for suturing tissue.
4. Fixation instruments. Accessory instruments.
II. Special surgical instruments (neuro-surgical, traumatologic, stomatologic,
ophthalmologic and other).
The structure of surgical instrument. An instrument consists of working portion (blade of
an instrument), which is acted on patient tissues and handle kept by a surgeon. The construction of
instrument is conditioned by character of its mechanical acting on tissues. The greater part of
instruments (clamps, scissors and others) consist of two parts – branches, connected by a lock. The
blade of an instrument can have grinds, windows, incisions, teeth on its tips, and others. For the firm
keeping of instrument in hand the handles should have rings, incisions or lugs. For fixing of branches
in the clamped position on handles can be rack gear. For the firm keeping in a hand an instrument
should have three points of fixing. For example, clamps, needle-holders, scissors kept by 1st, 2nd and
4th fingers.
The surgical instruments applied in pediatric surgery have less sizes and weight, fine tips of an
instruments (for example, less length and width of grips of clamps).
1. The Instruments for the Parting of Tissue
For disconnection of soft tissues the scalpels, operating knives, scissors are utilized. For
bone tissue – the surgical saws, chisels are utilized. In addition, the properties of electric current,
laser and radiation emanation, ultrasonic waves.
A scalpel is an instrument of piercing and cutting action. For realization of mainly cutting
action abdominal scalpels are utilized, for piercing – spoking (sharp-pointed) ones. There are also
other configurations of cutting edge, conditioned by the features of form of organs and tissues to
dissect.
There are entire-stamped, non-permanent and with a removable blade scalpels. There are
certain receptions of using a scalpel. The position of “writing pen” provides exact, dosated cuts of
precise length and depth. The position of bow provides long and superficial cuts of soft tissues, the
position of table-knife – deep cuts. For realizing a skin cut a scalpel is set almost at the beginning of
future cut vertically, and then it is inclined and cuts a skin and hypodermic cellular tissue. At the end
of cut a scalpel is again transferred in a vertical position.
The scissors are the instruments of crushing and cutting action. It is not recommended to cut a
skin, vessels, nerves and internal organs by scissors because of their excessive injuring. The fascias,
apo-neurosis, suture material are cut by scissors. By the form of branches the scissors may be
straight and curved (Richter scissors – by plane, Cooper scissors – by axis). By the form of form
ends may be blunt-pointed, sharp-pointed and button-type scissors (scissors of Lister for the bandages
removal). The scissors are hold in a hand with help of 1st, 2nd and 4th fingers.
The special type of scissors is laparotomy scissors of Metzenbaum, or dissector. They are
arcuated by plane, have rounded surfaces, narrow blunt ends, long handles. They are applied for
cutting off of suture material, dissecting of connections in the body cavities, and also for blunt
disconnection of tissues by separation of branches or piercing of non-vascular areas of copulas and frills
by closed ends (e.g. during organ’s mobilization).
The ends of the bound are cut away by scissors by certain rules: 1) having strained threads by
a left arm, the separated scissors’ tips carefully approached to the tied knot; 2) after stopping in the
knot the branches are turned on 90° and cut away the threads excess. Such mode provides necessary
minimum length of knot ends – approximately 3 millimetres.
The resection knives have the wide back of blade, allowing to make additional effort for
disconnection of dense tissues.
The catling (small, middle and large) is utilized for the single-stage dissection of soft tissues
during amputations. For this purpose the surgeon holds the knife blade up and edge toward himself.
The surgical saws disconnect bone tissues: flat bones – by the saws of Jeegly and Olivecrone,
tubular bones – by dissecting blade, knife, arched and circular saws. For the bones dissection is used
also cutters of Liston, Lyuer, Dalgran, Schtille and others.
During operations on bones the surgical chisels is used (straight and grooved). Before a bones
dissection a periosteum is detached layer by a layer by raspatories (straight and arcuated).
For the dissection of skull cavity (trepanation) is used a trepan with the set of pinned and
spherical milling cutters, for the dissection of tubular bones cavity – the osteotome.
The principles of soft tissues disconnection
During the disconnection of tissues a surgeon must provide:
1.Minimum cosmetic defect, favourable conditions of tissues regeneration, in other words:
the skin cut direction must coincide with elastic fibres (fissure-lines of Langer), connective tissue
and muscular fibres, vessels and nerves one; a dissection section is done by one motion of scalpel
(wound edges must be even); to be consistent with the principle of instrumentality – all of
manipulations in wound must be done with instruments.
2. The layer-by-layer access provides: every next layer of tissues is dissected only after a
complete (at length of wound) dissection section of previous; during the access the direction of next
tissue layer dissecting can be changed in relation to previous based on direction of aponeurosis,
muscles, vessels and nerves fibres; for dissecting of fascias, aponeurosis, parietal serous tunic the
grooved probe is used.
3. The hemostasis, that is: every next layer is dissected after the arrest of bleeding from previous
vessels.
4.Asepsis and antisepsis (blastics and antiblastics for oncosurgery), that is: for prevention of
infecting during access the every layer of tissues is limited from the other one with surgical garb
(linen); change instruments and gloves, use antiseptics on suspicion of contamination.
5.The due notice of possible complications and fight against them, that is: to size up clearly,
in which anatomic layer manipulation is realized; constantly get information about the general state of
patient (contact with a patient, anaesthetist, dresser, analysis of information of monitoring, colour of
blood, intension of muscles and other); give instructions to junior medical staff operating-room in
advance about preparation to the use of certain medical equipment and instrumentation.
2. The Instruments for the Arrest of Bleeding
Among these are vascular and hemostatic forceps (clamps).
The arteries and veins of middle and large gauge are pinched by vascular clamps to prevent
hemorrhage during operations on vessels and organs (heart, lungs, kidneys, gallbladder and others).
Among these are the vascular clamps of Satinsky, Hophner, Pyrogov, Mayo, Negus, Well and others.
The final hemostasis is carried out by hemostatic forceps. They are used for cross-clamping of
vessels of small gauge, damaged during access or separation of organ from surrounding tissues. Such
clamps are different by a construction, but they can be divided to two groups: 1) clamps with teeth on
the ends of working portion (Kocher’s clamps); 2) clamps without teeth (Billroth’s, “mosquito”,
Pean’s clamps and others).
The Technique for the Arrest of Bleeding by Kocher’s Clamps
The straight clamp with teeth on the tip Kocher firstly applied for vessels’ pinching of
thyroid gland. The hemostasis is carried out by damaged vessel cross-clamping together with
surrounding tissues by blade of instrument (except teeth). The teeth do not permit the instrument to
slip off. Under a clamp is got the thread or piercing ligature. After making the first knot a clamp is
carefully taken off, not breaking off to tighten the first knot and making the second one.
The Technique of Arrest of Bleeding by the Billroth’s Clamp
The clamp is applied for haemostasis of the damaged hypodermic vessels. The bleeding vessel’s
opening (without surrounding tissues) is pinched by clamp’s tips. The ends of grips are carefully turned
inside out to let them appear in the assistant’s field of vision putting the thread under ends. During
tightening the first knot a clamp is carefully taken off then the second knot is tied.
For arrest of bleeding the blunt-pointed ligature needle of Deschamp is applied. It has an eye
on a tip. An eyed thread is put by an instrument under the prepared segment of vessel. The
Deschamp’s needle is delivered from a wound, and a thread is fixed and cut on two parts by which
the ligatures are put.
With a purpose of arrest of bleeding surgical diathermy (thermal effect of electric current) is
applied. The electric current with certain characteristics is put to the vessel through a metallic
instrument (clamp, forceps). The electric field at this moment is closed. The arising thermal effect at
passing of current through biological tissues with a little electric resistance causes coagulation and
hemostasis.
3. The Instruments for the Suturing of Tissue
The tissues connection is carried out suture material by medical needles, needle-holders and
also by Michel’s cramps put by special forceps, staplers and by the mechanical sutures devices.
The suture material is classified after high-quality and quantitative characteristic of elemental
fibres. By the structure of fibre the suture material is divided on monofilament and polyfilament
(twisted and wattled).
The main destination of suture material is to approach, adapt and fix biological tissues which
are to be connected on a term necessary for formation of adhesion (seam, scar).
The general requirements regarding suture material:
- Biological compatibility (inactivity).
- Durability.
- Monofilament properties (absence of wick properties).
- Atraumatic properties (elasticity, flexibility, smooth surface).
- Expectant biodegeneration (dissolving and removing from an organism during a necessary
term).
- Possibility of sterilization.
- Cheapness of raw material and production.
The elastic suture material is conducted through
tissues for their connection by surgical needles. The needles are held up by the needleholders of different constructions (Hegar, Troyanov and Mathieu).
The needles are classified by their different characteristics. There are straight, circle and steep
needles by a form. The surgeon choice of needle of necessary form is determined by angle of operative
action. At large angle (up to 180°) it is comfortable to use a straight needle, for example, for creation
of anastomosis between the intestinal loops, and at small angle (to 30°) a steep needle is better, for
example, for the plastic surgery of femoral canal.
The needles are made with the various form of cross-section (flat, round, triangular and
multangular), but the widest distribution have round (piercing) and triangular (cutting) surgical
needles. Piercing needles pull apart the fibres of biological tissue and provide impermeability of
tubular structures sutures; that is why they are applied for connection of muscles, intestine walls,
vessels. The cuttings needles conduct suture material through a skin.
By the method of suture material fixing the needles are divided into traumatic and atraumatic.
The traumatic needle has an eye (round, automatic, helical and others). The atraumatic, or swagged,
needle is as though the continuation of suture material. The absence of eye and double thread
determines the minimum injuring of tissues at putting of cosmetic suture.
There is the special place for its fixing of needle-holder on a needle, which is located nearer to
the eye.
The needle-holder of Hegar is most widespread (small, middle and large). It should be
remembered that this needle-holder is expected to act during 600 work cycles (600 reliable, without
motions and fixings of needle), that is why it would be bad to leave an instrument lying idle with the
clamped needle.
For conducting of suture material through paren-chymal organs the sharp-pointed Deschamp’s
needle also is utilized.
After stitching up the wound edges are drawn together, compared and fixed by tying a knot
with threads ends.
During the tying of surgical knot it is necessary to provide permanent moderate intension of
suture material. A minimum of knots – 2, but, depending on properties of suture material, there are
can be more knots to prevent of untying and rupture of wound edges.
The most reliable is square knot (reef knot, sailor’s knot). A surgeon’s knot (surgical knot,
friction knot) allows comparing and fixing the wound edges now at the first tying, but for bandaging
of vessels of small diameter this knot isn’t worth utilizing.
There are a lot of methods of knot’s tying. The best method is that by which the surgeon wields
perfectly.
The basic moments of knot’s tying (a right arm – “handle”, a left one – “working”):
1. The ends of threads are hitched by fingers and the intersection is done. An upper thread is
held by working hand as reins, to set free the thumb and forefinger. The threads all of time must be
moderately strained.
2. The threads intersection is fixed between 1st and 2nd (3rd) fingers of working hand.
3. The end of thread held by working hand is set free and pushed between intersection and
wound.
4. The end of thread is hitched again by right arm and threads are moved closer to knot’s tying.
In microsurgery, ophthalmology, pediatric surgery the instrumental methods of knots tying are
often applied, so to say without a touch by fingers but only by instruments to prevent the possible
infecting of suture material.
The Principles of Tissues Connection
For providing favourable conditions for regeneration, minimum cosmetic defects and
violations of physiologic functions of organs and tissues a surgeon follows the certain rules of
biological tissues connection. A surgeon must provide:
1.
Anatomic and physiologic continuity of tissues, that is:
- to confront tissues exactly in such order which they were disconnected in;
- to connect only allied tissues (muscular – with a muscle, fibrous connective tissue – with
the same fibrous connective tissue and others like that);
2.
Prophylaxis of festering and septic complications, that is:
- aseptic conditions are during tissues connection (treatment of edges of wound before and
after suturing, frequent replacement of instruments, treatment of gloves by antiseptic);
- do not leave cavities during tissues connection;
- extraction of ichors and exudation from a wound and cavities (wound drainage, irrigation
aspiration, insertion of rubber tapes – turundas);
3.
Reliable hemostasis and prophylaxis of bleeding after an operation, that is:
- control of hemostasis during suturing;
- the microirrigator is left in a wound to opportune reveal of internal hemorrhage.
4.
Optimum conditions for wound regeneration and healing by initial intension,
prophylaxis of tissues necrosis, that is:
- nonviable and chipped edges of non-operative wound it is necessary to plane sharply (to
convert it in a cut);
- to delete nonviable tissues from an non-operative wound;
- to put the non-operative wound into long-oval shape;
- the sutures by which the edges of wound are compared and fixed and their intension must not
cause ischemia of biological tissues.
4. The Accessory Surgical Instruments
These are designed for holding, fixing and pushing back (retract) of tissues and surgical garb.
Among these are retractors, flat hooks of Farabeuf, hepatic mirrors, pincers (anatomical, surgical,
gripping, fenes-trated), dressing forceps, pumps, hooks for surgical garb, clamp of Miculicz and
others. By these instruments is provided the important general surgical principle – the
instrumentality – for the minimum injuring of biological tissues and preventing of their infecting by
the surgeon hands.
The Special Surgical Instruments
This is the most numerous group of various surgical instruments by construction, which are
utilized in gynaecology, urology, neurosurgery, otolaryngology and other spheres of medicine.
The ophthalmologic, neurosurgical, cardiac and pediatric surgery’ instruments are differing
by small sizes and weight. The form of microsurgical instruments is adapted to the operative
conditions.
The operations for children’s require application of atraumatic needles and modern synthetic
suture material. During an operation the special exactness and delicacy of manipulations is
necessary: the tissues are disconnect mainly sharply, avoiding compression, crushing and exfoliation.
The electric coagulation and using of electric knife must be limited and applied with a maximal
carefulness, because the impossibility of the exact adjusting of influence intensity on tender tissues
can bring to burn and injury of nearby organs and structures.
The careful control on loss of blood and its supplying is obligatory to during an operation
(but not after it’s finishing). In surgery of newborns is especially justified the aspiration to the
rational acceleration of operation, however without a loss for its delicacy and atraumatic measures.
The general principles of pediatric surgery:
- taking into account of age-specific, topographical, anatomic and physiologic features of
child’s organism;
- the operations are carried out by the most experienced surgeon;
- during the choice of operation method on organs and growing tissues, the preference is
shown for operations of organ’s conservation;
- application of the special instruments;
- providing of comfort conditions for an operated child, which includes rational preoperative
preparation, warming during an operation, adequate anaesthetizing, infusion intraoperative therapy and
so on;
- correct choice of strategy and tactic of surgical treatment, determination of optimum method
of surgical operation;
- achievement of necessary result by a maximally simple and atraumatic mode, to divide an
operation into a few stages or carry out palliative operation as may be necessary.
TYPES OF SUTURE MATERIAL
Absorbable:
Plain Catgut
Plain catgut is not commonly used in modern surgery. Although its rapidity of absorption
might seem to be an advantage, this rapidity is the result of an intense inflammatory reaction that
produces enzymes for the digestion of the organic material. Plain catgut is acceptable for ligating
bleeding points in the subcutaneous tissues and not for very much else.
Chromic Catgut
Chromic catgut has the advantage of a smooth surface, which permits it to be drawn through
delicate tissues with minimal friction. It may be depended upon to last for about a week and is suitable
only when such rapid absorption is desirable. It is completely contraindicated in the vicinity of the
pancreas, where proteolytic enzymes produce premature absorption, and in the closure of abdominal
incisions and hernia repair, where it does not hold the tissues long enough for adequate healing to
occur. Chromic catgut is useful for the approximation of the mucosal layer in a two-layer anastomosis of the bowel. For this purpose, size 4-0 is suitable. Bear in mind that wound infection will
increase the rapidity of catgut digestion.
Polyglycolic Synthetics
Polyglycolic synthetic sutures (PG), such as Dexon or Vicryl, are far superior to catgut
because the rate at which they are absorbed is much slower. Even after 15 days, about 20% of the
tensile strength remains. Digestion of the polyglycolic sutures is by hydrolysis. Consequently, the
proteolytic enzymes in an area of infection have no effect on the rate of absorption of the
polyglycolics. Also, the inflammatory reaction they incite is mild as compared with catgut. Their
chief drawback is that their surface is somewhat rougher than catgut, which may traumatize tissues
slightly when the PG suture material is drawn through the wall of the intestine. This characteristic also
makes the tying of secure knots somewhat more difficult than with catgut. However, these appear to
be minor disadvantages, and these products have for many purposes made catgut an obsolete suture
material.
- Nonabsorbable:
Natural Nonabsorbables
Natural nonabsorbable sutures, such as silk and cotton, have enjoyed a long period of
popularity among surgeons the world over. They have the advantage of easy handling and secure knot
tying. Once the knots are set, slippage is rare. On the other hand, they produce more inflammatory
reaction in tissue than do the monofilament materials (stainless steel, Prolene) or even the braided
synthetics. Silk and cotton, although classified as nonabsorbable, do indeed disintegrate in the tissues
over a long period of time, whereas the synthetic materials appear to be truly nonabsorbable. In spite
of these disadvantages, silk and cotton have maintained worldwide popularity mainly because of
their ease of handling and surgeons’ long familiarity with them. Because there are no clear-cut data
at this time demonstrating that anastomoses performed with synthetic suture material have fewer
complications than those performed with silk or cotton, it is not yet necessary for the surgeon to
abandon the natural nonabsor-bables if he or she can handle them with greater skill. With the
exception of the monofilaments, a major disadvantage of nonabsorbable sutures is the formation of
chronic draining sinuses and suture granulomas. This is especially marked when material larger
than size 3-0 is used in the anterior abdominal fascia or in the subcutaneous tissue.
Synthetic Nonabsorbable Braids
Synthetic braided sutures include those made of Dacron polyester, such as Mersilene, Ticron
(Dacron coated with silicone), Tevdek (Dacron coated with Teflon), and Ethibond (Dacron with
butilated coating). Braided nylon (Surgilon or Nurolon) is popular – in the United Kingdom. All these
braided synthetic materials require four or five knots for secure closure, compared to the three
required of silk and cotton.
Synthetic Nonabsorbable Monofilaments
Monofilament synthetics like nylon and Prolene are so slippery that as many as 6-7 knots
may be required. They and monofilament stainless steel are the least reactive of all the products
available. For this reason, 2-0 or 0 Prolene has been used by some surgeons for the abdominal
closure in the hope of eliminating suture sinuses. Because of the large number of knots, this hope has
not been realized, but the sinuses have turned out to be fewer than when nonabsorbable braided
materials are used. Prolene size 4-0 on atrau-matic needles has been used for the seromuscular layer
of intestinal anastomoses. Both Prolene and various braided polyester sutures have achieved great
popularity in vascular surgery.
Monofilament Stainless
Steel Wire
Monofilament stainless steel wire has many characteristics of the ideal suture material;
however, it is difficult to tie. Also, when it has been used for closure of the abdominal wall, patients
occasionally have complained of pain at the site of a knot or of a broken suture. True suture sinuses
and suture granulomas have been extremely rare when monofilament stainless steel has been used – no
more than 1 in 300 cases. Size 5-0 monofilament wire has been used for one-layer eso-phagogastric
anastomoses and for colon anastomoses. Three square throws are adequate for a secure knot in tying
this material. If steel wire in the form of a braid is used, the incidence of suture sinuses is not less
than experienced with braided silk.
Modern Suture Material
Dermalon – monofilament nylon.
Ethibond – braided Dacron polyester with buti-lated coating.
Ethilon – monofilament nylon.
Mersilene – braided Dacron polyester.
Nurolon – braided nylon.
PDS – Polydiaxanone, synthetic monofilament absorbable suture; slowest rate of absorption
of cur-rendy available suture materials.
PG – polyglycolic acid, Dexon, polyglactin, Vicryl.
Prolene – monofilament polypropylene.
Surgilene – monofilament polypropylene.
Surgilon – braided nylon coated with silicone.
Tevdek – braided Dacron polyester coated with Teflon polytetrafluorethylene.
Thumbtack – titanium hemorrhagic occluder pin with applicator.
Ticron – braided Dacron polyester coated with silicon.
Vicryl – Polyglactin, synthetic absorbable suture material.
Size of Suture Material
As there mustn’t ever be any tension on an anastomosis in the gastrointestinal tract, it is not
necessary to use suture material heavier than 4-0. Failure of healing is often due to tearing of a stitch
through the tissue and almost never to a broken suture. When two layers of sutures are used for an
anastomosis in the gastrointestinal tract, the inner layer should be 5-0 Vicryl. This layer provides
immediate and accurate approximation of the mucosa and, in some instances, hemostasis. Therefore,
this layer of suture material doesn’t need persist more than 4-6 days before it is absorbed. In
esophagogastric anastomoses, interrupted 4-0 PG should be used for the inner layer, which has the
additional function of contributing strength to the anastomosis. For this purpose, slower absorption is
desirable. When taking large bites of tissue that has considerable tensile strength, such as in the
closure of the abdominal wall, heavier suture material is indicated. Here, 1-0 PDS is suitable.
Obviously, the size of the suture material must be proportional to the strength of the tissues into
which it is inserted and to the strain it has to sustain.
5.2. Theoretical questions to studies:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Put the definishen of the operative surgery.
Classification of the surgical instruments.
General surgical instruments.
The usage rules of general surgical instruments.
Special surgical instruments.
The usage rules of special surgical instruments.
Classification of the suture material.
The kinds of absorbable suture.
The kinds of nonabsorbable suture.
Methods of making a surgical knots.
5.3. Practical tasks which are executed on studies:
1. Give a demonstration of correct using of surgical instruments for the parting of
tissue.
2. Give a demonstration of correct using of surgical instruments for the arrest of
bleeding.
3. Give a demonstration of correct using of surgical instruments for the suturing of
tissue.
4. Give a demonstration of correct using of the accessery surgical instruments.
5. Give a demonstration of knots tying.
Literature
1. Snell R.S. Clinical Anatomy for medical students. – Lippincott Williams &
Wilkins, 2000. – 898 p.
2. Skandalakis J.E., Skandalakis P.N., Skandalakis L.J. Surgical Anatomy and
Technique. – Springer, 1995. – 674 p.
3. Netter F.H. Atlas of human anatomy. – Ciba-Geigy Co., 1994. – 514 p.
4. Ellis H. Clinical Anatomy Arevision and applied anatomy for clinical
students. – Blackwell publishing, 2006. – 439 p.