LECTURE 6
TOPOGRAPHY OF THE PERITONEUM. ABDOMINAL CAVITI
AND ORGANS INSPECTING. MAIN PRINCIPLES OF THE
OPERATIVE INTERVENTIONS ON THE CAVAL ORGANS
In surgical clinic of regional hospital by the machine of the first help the delivered
patient with the complaints on a pain in the bottom of a stomach, giddiness, general
weakness. The hour therefore, working on construction, has stumbled and has run on a
wooden beam. For want of it the impact was came on forward peritomeal a wall. For want
of inspection lossed
By the next surgeon, is installed: often filariform pulse (100 pulse beate for a
minute), arterial pressure on the brahialis arteria lowest from norm (100/60 mm. Of
hydrargyrum column). The peritonealis wall is intense, is sharp painfull for want of
palpationis on all stretch. A symptom of Chotkin-Blumberg sharply positive. For want of
further observation little place further decrease of pressure of blood, increase of symptoms
of an irritation of peritoneum, decrease of an amount of erythrocyte, hemoglobine, colour
parameter.
The surgeon has determined the diagnosis: 1) closed trauma of a stomach 2) has
dug of a cavitas organ, general peritonitis; 3) bleeding in abdominalis hollow. In thouse
cases it is necessary of fulfilment laparotomia, to conduct auditing organs of abdominalis
hollow and to make operation on the damaged organs. However, before to conduct
operating interference, should stay on topographical anatomy of peritoneal.
Peritoneal – is serous envelope, which tectorius a wall of abdominalis hollow and
organs placed in this large serous hollow of a human skew field. A part of peritoneal,
which covers walls of abdominalis hollow is named of parietalis chart, the second part,
which covers organs, is named visceral chart. The square of peritoneum reaches 1600020000 sq. see. Space between parietalis and visceralis peritoneum name as a hollow of
abdomine. In the men it closed, and in the women through uterine pipe, uterus and vagine,
the abdominalis hollow incorporates with an external medium. For want of transition
peritoneum from an organ on an organ or from a back wall on the parenhimatosus organ, is
2
organized duplication, which has a title ligamentum coronaris connection of a liver,
hepato-duodenalis, hepato-gastric and another). Through last frequently pass important
anatomic derivate. And in addition ligamentums will play a role of a fixing means.
Under pruritu understand duplicationis, which is organized owing to transition of
abdominalis
back wall of a stomach on
an cavitas organ (pruritus small intestine,
transversal colon, sigmoideum colon). That it is better to understand a structure
of
abdominalis hollow, it be necessary to consider it a course on transversal and sagitalis slits
of a skew field.
Transversal slit of a stomach at a level IV lumbalis vertebrae. Parіetalis peritoneum,
which covers forward abdominalis wall, is smooth. But it is lower umbilicus organizes
middle (in thickness with which passes urinaris a passage and residuals alantois of a fetus),
umbilicalis a tuck, which connects umbilicus with urinary bladder, medialis— in thincless
with which passes partially obliteration umbilicalis arteria and lateralis, that covers lowest
epigastricus vessels. The last tuck stretched between umbilicus and arteria iliacus external .
From forward of abdominalis wall, peritoneum pas ses to a back wall, and is
farther, as the visceral leaf covers ascending and descending intestinalis. In area of aortae
and lower venae cavae of parietalis peritoneum passes in pruritus , small intestin.
Transversal slit of a stomach at a level XII vertebrae thoracica. Parietalis
peritoneum, covering forward abdominalis wall, organizes a tuck as a sickle —
ligamentum sickleformias of a liver, which connects a forward surface of a liver to the
diaphragm and forward abdominalis wall. It located slightly for a righte from of a middle
line. On a free edge ligamentums two leaves of a peritoneum рin and wrap up venae
umbilicalis, form round ligament of a liver. Last disposition from umbilicus to a clipping
between square and left parts of a liver.
Visceral peritoneum covers splen, reach it of a gate, passes to a large curvature
of a stumac as a forward leaf ligamentum gastro-lienalis . Further visceral peritoneum wrap
up a forward surface of a stumac also organizes a forward wall small omentalis. Last on
the right has a dense edge here again peritoneum wrap up a common bilious passage,
3
arteria hepatica and venae vorticosae. In the whole free part small omentalis, namely
ligamentum hepato-duodenalis together with the contents creates a forward wall of an
omentalis orifice.
The second leaf of parietalis peritoneum with and back wall of a stomach passes in
visceral covers a back wall of a stumac, creating for want of it a forward wall omentalis
bags. On great ї й to a curvature of a stumac peritoneum abandons it and as the back leaf
ligamentum gastro-lienalis passes on a spleen and goes on back abdominalis wall, form
the forward leaf lig. lienorenalis. In the given time peritoneum covers forward facies of
glandulae subgastricae, aortae and lower cavae venae, and in final passes on forward
abdominalis wall.
A sagitalis a slit of a stomach and basin. Parietalis peritoneum, which covers
forward abdominalis wall, goes up to the left of lig.sickleformes and grows together with
a bottom face of the diaphragm. From here it is lowered on the upper surface of a liver, as
the forward leaf left triangular ligamentum. The visceral leaf wrap up forward and lower
surfaces of a liver down to it of a gate. From here peritoneum is thrown to a small
curvature of a stumac, as the forward leaf small omentalis. Having covered a forward
surface of a stumac, peritoneum is covers a large curvature and creates the forward leaf
large omentalis. Having reached(achieved) the lower edge, peritoneum is lifted up, creating
for want of it a back wall large further omentalis, proceeds in the back leaf covers
transversal colon intestin further. The course,(during,) following it, is directed to a forward
edge glandulae subgastricae, lower horizontal part duodenal intestin. From here
peritoneum abandons back abdominalis wall as a forward leaf pruritus small intestin. The
visceral peritoneum covers ansaes of small intestine organizes the back leaf it
mesenterium. Having returned on back abdovinalis wall, peritoneum is lowered in a basin,
where she covers a forward surface of a part rectum intestine. From here in the women she
passes to a back surface of a top vagine and uterus, forme the important direct – intestinuterus recess — space of the Douglas (low point of abdominalis hollow). Further in the
women peritoneum covers the upper surface of uterus and from its forward surface is
4
thrown on a urine bubble, and from here on forward abdominalis wall. In the men
peritoneum from rectum intestin throw on the upper surface of a urine bubble, forme for
want of it bubble rectalis recess.
Thus, all organs of abdominalis
hollow differ by the attitude(relation) to the
peritoneum, and behind this indication them divide on three groups: intraperitoneal covered by the peritoneum from all parties; mesoperitoneal — wrapped up by the visceral
peritoneum from three parties, and extraperitoneal organs, which have only one surface
covered by the peritoneum or they lie retroperitoneal.
Intraperitoneal placed
those organs: a stomach, top duodenal intestin, small
intestin, transversal colon, sygmoidal intestin, spleen. For organs placed intraperitoneal,
characteristic is large movement, which enables during operation them to introduce from
abdominalis hollow and to conduct operating interference.
Mesoperitoneal placed an ascending part of duodenal intestin , a bend ascending
and descendens departments colon intestin, ampoule of rectum intestin, liver, bilious
bubble. A displacement of mesoperitoneal organs minor. The operating interferences on
them require(demand) diligent isolation them in to abdominal hollow by sterile napkins.
Extraperitoneal
are descendens and horizontal part of duodenal intestin, pancreas and
final department of rectum intestin. And in addition to back of parietalis peritoneum the
placed organs also derivate, that do not enter into structure of a digestiv system. In
particular, these kidneys with subkidneys glandulas,ureters,abdominalis departments of
aortae and lower venae cavae, nervous textures.
The abdominalis hollow conditionally divide into two floors: upper and lower, the
oundary between which passes through the radical transversal mesentery. Both floors
incorporate among themselves only ahead, through foramen preomentalis The organs of
abdominalis hollow, limit them ligamentum ,mesenterium,omentalis in to abdominal
hollow of recess, sines, bag. In the upper floor the placed reserve spaces, which are
referred to as bags: hepatis,omentalis,pancreatis. Bags: 1) The hepatis bag — imagines by
itself foramen intraperitoneal between the right destiny of a liver and diaphragm. She
5
limited: from above - by the diaphragm, from below - to cookies, to back - by a right
member lig. coronaris of a liver, at the left - lig. sickleformes of a liver. This bag still name
in surgery right as subdiafragmail space.
For want of position of the person on a spin, right back department of this bags
between average and dorsum і inguen by lines most deep. A pathological liquid here can
concetrated..
2)A pancreatis bag — space of abdominalis hollow, which is limited to back—
small omentalis and forward wall of a stomach, ahead and from above — to cookies,
diaphragm, forward by abdominalis wall, on the right - round and lig. sickleformes of a
liver, at the left — the expressed boundary has no.
For want of position on a spin deep department foramen pregastrical placed under
the left destiny of a liver.
3) The omentalis bag — is to back from small omentalis, stomach and lig.gastrocolon. This most isolated part upper floor of abdeominalis hollow. The input(entrance) in
a omentalis bag — omentalis an orifice is placed for lig hepato-duodenalis below from
caudalis of destiny of a liver. To back it is limited lig.hepato-renalis.Lower from above of
abdominalis hollow the space from mesenterium to a small basin takes.
The mesernterium of small intestine , ascending and descendens of rims intestin
divide lower from above of abdominal hollow on four departments: right and left side
channels, right and left sinus. The right side channel — is placed between a side wall of a
stomach and right department small intestin. Above channel passes in a back department of
subdiafragmail space. Below — it passes in right fovea iliaca. For want of level attitude of
the person by most deep there is a top of the channel. For want of such position the liquid
from the side channel will be free to become numb in right subdiafragmail space. That is
why after operating interferences to the patient it is expedient and to give a sitdown
position.
6
The left side channel — is limited to the left side wall of abdominalis hollow and
left department small intestin. Below — the left side channel passes in left fowea iliaca.
The liquid from this channel through fowea iliaca is freely selected in a small basin.
Right mesenterium sine — is bounded above mesocolon, on the right — ascending
colon, at the left and from below — mesenterium of small intestin. This sine appears
largely limited from other departments of abdominalis hollow. The liquid from it can be
distributed only ahead, being poured through ansa of small itestin.Left mesenterium sine
— behind volume is much more right. Bounded above mesocolon, at the left —
descendens colon and mesenterium of sigmoideal intestin, on the right — mesenterium of
small intestin, from below — it freely incorporates with a hollow to a small basin.
Left and right mesenterium sines are separated by one from one mesenterium of
small intestin. Above sines incorporate through narrow foramen between initial: by a part
empty intestin and mesocolon. Except for reserve spaces in to abdominalis hollow select
recesses. Last are mainly located in places of transition peritoneum from walls
of
abdominalis hollow on organs or from one organ on second.The duodenal recess is
organized in a place of duodenal-cavum bend. The upper pocket is placed between the
upper wall of a final part of iliaca intestin and by a medial wall of cecus intestin. The lower
pocket is between the lower wall of a final department of iliaca intestin by an internal edge
of cecus — the places where iliaca intestin grows in cecus intestin are lower. Behind of
itself the cecus intestin recess can be seen between a back wall of abdominal hollow and
mobile part of cecus intestin.
Innervationes:
The visceral leaf of peritoneum has no sensing innervation it is innervation by the
same nerves, which and organs of abdominal cavity (sympaticus nervous textures and
wandering nervus).
Taking into account differenty sources of innervationes — the response about lefs
on diverse stimuluses is not identical. So parietalis peritoneum reacts of an mechanical and
thermal stimulus (puncture, recompression), while visceral peritoneum more; reacts .more
7
to stretching. This most can explain not hospital ward of small children for want of
meteorism shock for want of operating interferences on organs of abdominalis hollow in
case surgeon has entered a unsufficient amount novocaini in mesenterium for blocking of
nerwosus impulses.
You already were in operational and the patients restless in that moment have
noticed probably, still for want of appendectomia, when the surgeon searches removes
appendicitis in an operational wound and, on the contrary. Therefore for want of operating
interferences on organs of abdominalis caviti, to general anastesia it is necessary to
concern very seriously.
Peritoneum, which covers walls of a stomach, consists from somemany is
functional and morfological of various layers: 1) mesotelium, 2) the diaphragm, 3) surface
filamentary
a kolagenicus layer, 4) surface diffuse elastic is boundary and basalis; a grid,
5) deep longus elastic grid.
Besides in peritoneum there is a texture reticularis fibraes , around of circulatory
vessels, fatty part and thick kolagenalis fibraes.
Circulatory and lymphaticy vessels of peritoneum are placed in it deep ethmoidokolagenalis layer. Even more capillary tubes do not pass through deep longus an elastic
grid (5-th layer of peritoneum). By such: by a grade first five layers of peritoneum do not
contain in usual conditions neither circulatorys, nor lymphaticys vessels.
The structure and functional features of peritoneum, which covers various organs
and various plots of abdominalis wall, is unequal . So, in peritoneum of liver most well
developed plexiform of bundles fibraes kolagenicus. In peritoneum of spleen, which
volume is sharply changed, predominate elastic fibraes. In peritoneum of small intestine
bundles elastic and of fibrae kolagenicus incorporate in a spiral, which wrapped up a wall
of an organ in opposite directions. Such form piexiform fibrosus a fundamentals of
peritoneum on
intestine to a wall ensures to it exclusive elasticity. In parietalis
peritoneum deep lattice a kolageno-elasticus layer in particular thick. It makes more strong
subward peritoneum.
8
The excellent feature of a structure of peritoneum the diaphragm is availability in
it are thin of plots, which cover 'so-called' absorption manholes ". In these places –the end
of the pin, deep of a kolageno-elasticus layer рin and organize cavity of the oval form.
Above them are only very much thin a membrane with mesoteliy, is boundary diaphragms
and surface filamentary of a kolagenic layer.
The cells of mesoteliy are very small and between them are organized much little
of an orifice, which can considerably be increased some places of peritoneum.Through
these orifices can pass a liquid and small parts. During respiratory traffic of the diaphragm
thick end of the pin deep of kolageno-elasticus a layer chanche рin . For want of it the
gleam of "manholes" is changed, that ensures them absorption during operation. The
respiratory movements assist transition of a liquid on to lymphatici vessels. In an outcome
of ages modifications the amount of "manholes" decreases, and the possibility from
convexity of abdominalis hollow is accordingly changed also. The vessels system of
various sites of peritoneum also has some impotant of a feature. In one — she characterizes
considerably developed and lies superficialis by grids of circulatorys vessels,
In other — more developed much higher lie of a lymphaticys grid. From here and
diverse function in various plots of peritoneum . So disting uish transsudate liquids of a
site of peritoneum. In transsudate plots of small intestine, broad of uterus communication
predominate circularys vessels. Absorption departments of peritoneum (the diaphragmes,
cecus intestine) have, opposite(on the contrary), exceeding development of limphaticus
vessels. Residual of a site of peritoneum(stomach, parietalis) have such parity of a grid of
circularis vessels and limphaticus vessels, whichtranssudate of a liquid counterbalanced.
The peritoneal liquid has pale yellow colour, where this ligamentum and contains
leycocytis. It is secretion by the peritoneum also ensures a free sliding of organs one
concerning other. In an outcome mowementsі of the diaphragm and muscule of abdomine
together with peristaltic movements of a gastro-intestinalis tract, is observed movement
peritoneal liquids. Experimental was shown, that the pus, which was entered in lower part
of a stomach, very fast for want of horizontal; a position achieves the diaphragm. Here
9
goes heavily absorptions of pus. The picture {of intoxication and peritonitis accrues.
Therefore in afteroperation period expedient a halflie position of a skew field. On the one
hand, in an outcome of hydrostatic pressure of a liquid, it will be directed in lower surface
of abdominalis hollow, where absorption is slowed down. Knowing properties absorption
of liquoris in the peritoneal hollow can explain sharp aggravation of a condition and
development of peritonitis for want of perforation to a ulcer of a stomach through 3 — 4
hours and slow course of peritonitis for want of pair - metritis.
Secondly, the attachment mesocolon and mesenterium of small intesyine to back
of abdominalis wall ensures present a peritonealis barrier, which can prevent movement
of a infectiosness peritoneum liquid with lower floor in upper, as well as on the contrary.
And in addition concetrated
of infectiosness peritonealis
liquid in one from
subdiaphragmail spaces frequently accompanies by treatment adjacent of a pleuralis
hollow. There is nothing strange, if in the patient with subdiaphragmail abscess it is
possible to find located empiema. It is considered, that infections is distributed from
peritoneum on the pleurae through the diaphragmail lymphaticus vessels and knots.The
extremely important significance in surgery of organs of abdominalis hollow have the
plastic properties peritoneum
(After mechanical, natural or chimical danger of
peritoneum). Combustible process of a zymotic origin, on a surface of peritoneum is
accumulated sticky fibrosus exudate. It results in a pasting together leafs of peritoneum,
which touch; one to another, in a plot it a defeat.
The fast pasting together leafs of peritoneum seals an interface seams for want of
operations on organs
of abdominalis hollow, conducts to formation of spikes round
drainages, which in it are tampons and another. These properties of peritoneum are widely
applied in surgery. Nevertheless in many cases after operation in to abdominalis hollow of
formation of comissures in particular widespread is undesirablis. In some cases the
increased ability of peritoneum to formation of comissuress (comissures illness) is
observed. Adhesion of organs among themselves and walls of abdominalis hollow on
large stretch sharply infringe activity of cavity organs cause diverse intestinai obstruction.
10
That is why it resistibility іs weakening .But in adults they protective role is
grows.Before acute appendicite inflammatory exudate reaches omnemum. In reply for this
it wropped up infectious organ. As the outcome, frequently infection is located on small
square abdomіnalіs hollow, rescueing the patient from serious diffuse perіtonіtіs . It is
necessary to add, that the liquid and large omentum contains much antіbodіes, which also
will play the important protective role. Excessive accumulation of perіtoneal liquid name
ascіtes.For fіnd out it is necessary at least 1,500 ml, and in compact of the subjects it
should be much more.
Knowing a topography peritoneal, it blood supply, innervatіon, and also functional
properties, we can with you approach to the analysis of operating interference in lossed,
engineering of its fulfilment. When the diagnosis vague, execute average medіal
laparatomy. That is a slit of a forward perіtoneal wall execute on a white line of a stomach
from a point, which is on a middle of a distance between xіphoіd proces and umbіlіcus ,to
a point on a middle of an interval between umbіlіcus and symphysіs, for want of it
umbіlіcus bypass at the left. The vesels hemostasіs of soft tіsue realize by superposition
of clips with their consequent bandaging.
On all stretch of a slit dissect a white line of a stomach. By two anatomic tweezers
seize perіtoneals whis subperitoneals fat, lift it, dissect by scalpel. In a derivated orifice
enter scissors and under monitoring of sight and pins cut peritoneal on all gap of lengths of
a wound of a skin.Peritoneal in accordance with a cutting apart seize by clips Mykulycha
and fix to sterile napkins. By this most isolate from contamination subcutaneous fat by
infectionals contents from peritoneal of a hollow.
It is necessary to pay attention to the general provisions laparotomy.
1. Severe sequence of each operation, not infringing
asepsis
2. Whenever possible it is necessary to conduct operating interference outside of peritoneal
hollow, draw out organs from it. It is rather difficult for making with organs, which
placed by mesoperytoneal.
11
3.The peritoneal hollow is necessary diligently for isolating(insulating). It is done(made)
from two reasons: at first, to protect it from contents of organs (stomach,intestine), on
which carry out operating interference;
Secondly, to notify contaminations of a wound forward of a perytoneal wall from possible
infectious exudate of aperitoneal hollow.
4. Pathological exudate, blood, bile is necessary dro out from of a perytoneal hollow. It is
necessary to be convinced in reliable hemostasis .
5. All places with damaged by a serous cover it is necessary diligently peritonisal.
6. During operation it is necessary is minimum to injure organs (that is instead of intestine
of clips to use ligature-keeping).
On the hollow organs of a digestive tract execute such operations: 1) cutting apart
of an organ for dro out strange of skew fields, tomia; superposition fistula — junction of a
hollow of an organ with an external medium — stomia; junction among themselves of two
organs — anastomosis. Besides depending on volume dro out of an organ carry out
(conduct) resektion — partial dro out of an organ, and also full it dro out — ektomy .
After laparotomy begin auditing organs of a peritoneal hollow. The principle of
auditing consists in the review of organs from clean to dirty, from less dirty to more dirty .
That is why auditing begin with upper flour, as for want of wounds of holow organs it
always will be less infectious in a comparison with the lower floor of a peritoneal hollow.
At first examine a hepatic
bag, then pancreatic, and is farther, after a slit
gastrointestinal ligamentum, go in a omental bag. If in the upper floor is not revealed
damages, then it is necessary to examine organs lower flour.
For a clearing of a condition thin intestinal and determination of a plot changed
owing to a trauma or and pathological proces, carry out a methodical inspection it. For
want of it it is necessary is cautious to examine all intestinal loops, keap them from
contamination, drying and cooling. The auditing intestinal should be executed in the
certain sequence, from a beginning it to plase to transfer in thick intestine. For revealing a
beginning thin intestine use a reception Gubareva:
12
а) By the left hand the surgeon lifts large omentum together with transversal ободовою intestine;
b) By the right hand along the radical omentum transversal – colon intestine the
surgeon goes to vertebra to a pole at the left (reference point aorta);
c) turning, hand on 90 Ё, it slip є by a hand on to a backbone downwards on 5 —
6sm to first ansa, which has hitted pins;
d) Having seized a closed loop by pins, the surgeon draw of of closed loops smole
intestine and for want of availability duodenal-cavity ligamentum (lig.of Treits), is
convinced of the beginning small intestine, and Is farther
Carries out the review of all of closed Loops thin and of departments of small
intestine —
From cecus to rectum intestine.
Nevertheless, if for want of slit of abdominalis hollow at once contents of intestine are
visible and the odor stool mass is determined. That to the surgeon is not necessary to catch
in upper from above, as all pathology is located in the lower floor. From other party, if
after a slit are determined bloody clots, which resemble with upper floor, irrespective of a
rupture of closed loops of small intestine, the surgeon should liquidate first of all — a
bleeding. The stop of a bleeding always because of the vital indications, is by first and
main problem of surgeon.
Frequently for want of obtuse traumas a source of a bleeding can be parenchimatous
organs. For a stop of a bleeding with last use omentalis for tamponade of a place a defeat
of an organ, diverse gemostatic of substance, and sometimes a seam KuznetsovaPenskogo. A principle of this seam based on use thick thread in gew of liver or spleen. For
want of delay mattress or of П-formes seams takes place cutting of parenchime and
delivery strom. It also reaches(achieved) a stop of a bleeding. You will be acquainted with
engineering of fulfilment of a seam in details on practical occupations.
If for want of auditings of abdominalis hollow expose of a wound of an hollow organ,
certainly, that is damages it is necessary to sew up, to restore permeability and
of
13
germetic organ. For want of gewing of wounds of a hollow organ use twoo line intestinal
seam.
Intestinal seam — this concept harvest also can not be referred only to mending by one of
intestinal wall.
Operating on diverse departments digestive tract, the surgeons connect, intestinal by a
seam intestine with stomach, intestine with esophagus etc. It is possible, that in such cases
it would be correct to speak about a gastro-intestinalis seam , esophago-intestinalis seam
more ", nevertheless surgeons seldom use a similar nomenclature.
The history of intestinal seams reaches in depth ages. Being acquainted with the literature
on this problem, test surprise of variety all a method? In and offers, to which the surgeons
for want of to development of a technique superposition of a seam managed. In India after
some centuries to AD there were attempts to connect edges of intestinal wound with the
help of formic jaw. For this purpose formic presented to an edge of a wound and, after it
stuck of a jaw, a trunk of an insect separated. A jaw remained in fabrics and kept edges of a
wound a divergence (intestinal seam).
In China in the famouse surgeon Hian-Tuo, which the Hahn lived for want of dynasties,
conducted resection of intestine with consequent superposition anastomosis. Nevertheless
technique, used a Nim of a seam remained unknown.
In the beginning XIX of century there was a widespread technique, which has received a
title " of a seam of four foremans ", and the Essence it was reduced to that the artificial
limb was entered into a gleam intestine, above which sewed together edges of a wound.
Successful development of gastro-intestinal surgery began after introduction in surgery
asepsis, antisepsis, that is from 2 half XIX century (1881). So there was an offered seam
Cherny (1880), Albert (1881). For today there is a plenty of updatings of intestinal seams.
About it is in details stated in the monography І. О. Kirpatovsky.
Distinguish boundary and sinking seams. Separately they are not applied. The boundary
seams pass through all thikness of an organ. They rather strong, but not hermetic. The
tightness can supply to a серозно-muscle or seroso-serosus seam. But
14
In itself sinking seam very weak. That the use of twoo line seam optimally will supply
restoring an integrity functions of an organ to.
What requests to intestinal seam. Last should supply: 1) capasity of a wall, 2) hemostasis in
intestinal to a wound, 3) tightness of a sewed up place of an organ, 4) to not infringe or to
save function of an organ.:
From all layer of a wall of intestine by most strong is submucosal (from 60 up to 90 % by
all mechanical of capasity; a seam, which will penetrate through). On residual of layers it is
necessary about 30 % by all capasity. Therefore in twoo line intestinal seam capasity to
him ensures the first number of seams, which passes through all layers. Nevertheless it not
hermetic, seaming material capable to wick pour distribution through him of infectionius
contents. Therefore impose always second number of seams—seroso-muscularis or serososerousis, as assists tightness.
To understand process germetisationis, should address with you to performance of a course
an inflammation. Still for want of study of a rate of pathological physiology it is known,
for an inflammation of a plot or organ characteristic е — tumor,dolor,rubor. Increase of
temperature, violation of function of an organ (tumor,dolor,rubor,calor,functio lesa). For a
course healing of any wound of nintestine (has dug, slit, puncture) characteristic е an
inflammation (asepsis,sepsis). Tumor of edges of a wound is accompanied exudate of a
liquid in a wound, rich on fibrine. The drop - out fibrine on serosus to an envelope
conducts to a pasting together of a wound (through and hours after mending) — primary
germetism. All this conducts to formation comissure and assistance of tightness.
Together both seams (open and seroso-muscularis) ensure compasity and germetism. But
not always they can supply hemostasis. For a solution of this problem a boundary seam, as
a rule, impose not knotty, but continuous. This direct to squeezing of vessels in a plot of a
seam and (gemostasis of a wound. For formed of hemostasis, it is possible to use and nodal
seams. But then it is necessary to tie up each vessel separately, which conducts to loss of
time, magnification of a duration of operation.
The first number of seams impose catgut, second - silk. But when the first row formed by
15
nodal seams, then use only silk material.
At last important it is necessary to save function of an organ. In the given moment we
speak about small intestine. For safety of permeability intestine, warning of a contraction it
of a gleam, wound sew up perpendicularly to its stake. For this purpose a favourite wound
transfer in transversal and only then it sew up.
What destiny
Intestinal of a seam: Experiment of І. O. Kirpakovskogo (1964) have shown, that
all wounds after superposition two line of a seam are healed by a secondary tension and for
want of it is determined certain stagition.
І. At onse after superposition of a seam the stage boundary (2 — 3 days) is observed
swilling of fabrics, necrosis of edges of a wound, hematomas.
Some times boundary necrosis seizes not only mucous, and but also edge submucosus and
muscular globe.
II. In an outcome regection of necrotisous fabrics on a line of anastomosis there is broad
ulcerous defect — a stage regestion and boundary diastasis (4 — 5 dais). The most
responsible moment of the patient life and surgion.
In further boundary defect is execute by fibroblastes and submucosal fabric. Is organized
cicatrix. This period name III as a stage. She(it) changes from 5 till 9 days
At last on cicatrix from the party unchange mucous approaches prolipheration eritrositis,
which completely close hours effect. This period name as a stage epitelisation.It lasts from
1 up to 6 months (depending on magnitude of defect). For want of stritching of two lines
seam on organs of digestion, mainly apply internal open and external aseptis seroserous
seams. Opening seams: Rounding continuous seam (seam of Dgolli) impose by piercing all
layers of a wall of hollow organ, for want of it the filament is carried out(conducted) on
one partyfrom from serosus to a mucous envelope, on the opposite party on the contrary,
troubles mucous to serosus.
The seam of Shmiden, also is by a continuous seam through all layers of a wall of an
organ. In difference from previous, an injection by niddle and on one, and on the second
16
party carry out(conduct) from a mucous envelope with out knidle on serosus of a surface.
For want of delay of such seam of an edge of both walls enter in a of hollow organ,
touching by serosus envelopes. Open seams, as winding, such glovers. Immerse yes
serososerosus or seromuscularis by a seam.
In hepato-intestinal surgery most widespread there is a continuous seam, as for
want of it it is possible to reach ideal hermetic of an intestinal wound and stop of a
bleeding from submucosal of a layer. At the same time continuous seam worsens blood
supply of edges of a wound owing to squeezing of bloody vessels by an open filament
along all to a perimeter of a wound. It can be refered and to glovers seam by Shmiden for
want of enteroanastomosis, mending of back and forward wall gastroenteroanastomosis for
want of resections of stomach.
Updating of intestinal seams. Pursesting seam — it seroso-muscular seam, which
use frequently for peritonisation of small wounds, peaces of intestinal, apendisitis. A seam
impose to cirkulates around boundary or ligature. For want of sqiueesing of a seam peases
or desorisonis on a plot of a hall organ are immersed in a gleam of a seam. The z-formed
seam also is by updating serosomuscular seam. Mainly it apply as additional to pursesting
one. A seam impose by such grade,that at first on one side from the future point of
immersing do(make) on one line two seams from the right to the left and further pass to the
opposite party and execute same two seams from the right to the left, on a line is parallel
by the first.
The seam of Albert imagines by itself an internal open boundary continuous seam,
which put in on a back wall of organs. The filament passes throse all layers from mucous
to serosis to an envelope on one party and through serosis and all layers with an output of
an extremity through a mucous envelope of the opposite party. Further this seam immerse
sterile grey - серозним by a seam (a seam of Lambera) in hollow of an organ. The seam of
Mykulych— a simple continuous seam with stretching of a filament from within. Seams
impose such: pierce mucous, muscularis and serosis envelope on the one hand, and is
farther serosis, muscularis and mucous envelope from the second party — the filament
17
tighten from the parties of a gleam, for want of it serosus of a surface are levied to absolute
comparison. Further such seam immerse by seroserosis seams.
The seam of Pribram — continuous matrasing seam with delay of a filament out. A
corse of separate seams such: one party is pierced neddle from serosis envelopes to
mucous, after that a filament tighten from mucous to serosusis.From the second party again
make an injection from the party serosis envelopes to mucous, and further tighten a
filament from mucous to serosis. From above impose pushing seroserosis seam.
Uniserial seam. The inclining of the surgeons in high plastic properties
peritoneal(serosis envelope) of intestine has reduced in the substantiation!? Propagation of
a uniserial seam, which and in addition is characterized small traumatising. But does one
lines seam guarantes sufficient hermetisation, kind adaptation of edges of a wound? The
majority of the surgeons puts it under a doupt: uniserial intestinal seam without gewing.
Uniserial seam more often use as interrupted seam. A filament begin to conduct
from the party of hollow of an organ. Pierce through all layers to serosis on one party,
after that from serosis to mucous on the opposite party. A seam fasten high school.
Mechanical seam impose with the help of special meanses, by gew`s material in which is
tantalum seams. The use of meanses reduces time of operation, ensures I paint asepsis.
Thus primal problem of the surgeon for want of operations on hepato-intestinal
tract is reduced to throw out patologikal to a fire of damage, restoring of an integrity of
digestive tract after operation and g hermetisation of afteroperational wound of a stomach
or intestinal with the purpose of warning an output(exit) them of infektional contents;
peritoneal hollow. The second and most important problem of the surgeon for want of such
operations is reproduction of the most physiological conditions of restoring of a continuity
of
digestive tract, saving as much as possible of
motorosokretional function of
operationalis organs and uniform passing of digestive masses. The basis of a solution of
such problems is knowledge of anatomico-physiological features of digestive tract and
correct fulfilment of two technical operating receptions: of intestinal seam and creation
appropriate anastomose for restoring a continuity ofdigestive tract. As to of intestinal seam,
18
we with you have taken apart engineering of its superposition in details enough. That
affects creation anastomosis between organs after them resectione, we shall consider them
on the next lectures.
19
Література:
1. Кульчицький К.І., Ковальський М.П., Дітковський А.П. та ін. Оперативна хірургія
і топографічна анатомія. Київ: “Вища школа”, 1994.- 464 С.
2. Максименков О.М. (ред.) Хірургічна анатомія живота. Л., 1972.
3. Кирпатовський І.Д. Кишечний шов. М., 1964.
4. Ісаков Ю.Ф. і співавт. Оперативна хірургія і топографічна анатомія дитячого віку.
М., 1977.