Surgical anatomy

Vermiform appendix and Meckel`s diverticulum

Tracheostomia

Puncture of subclavian vein

Tunnel syndromes 

Flat foot 

Stop bleeding from the common carotid artery

Vertebral artery syndrome

 

Vermiform appendix and Meckel`s diverticulum

The most common cause of abdominal pain is appendicitis (inflammation of the vermiform process). So now we pay our attention to the anatomy of the caecum and vermiform process.
The caecum is the first part of the large intestine, is continuation of the ileum; it lies in the right inguinal fossa (picture 1). Its length is 6-12 cm. It is completely corvered by the peritoneum. The three caecal taeniae (mesocolica, libera and omentalis) arise from the orifice of appendix, situated on the caecal protrusion, the cupula (picture 2, 3).
Thus the caecum has two orifices: appendicular and ileocaecal. The second one is bounded by the two folds: superior, ileocolic lip, and inferior, ileocaecal lip. Together these lips form the ileocaecal valve regulating the passage of food masses from the ileum.

In embryo, the caecum and appendix primarily have equal diameter but further the appendix lags behind in growth. After birth the lateral caecal wall grows faster than medial thus, the appendix displaces and opens into the caecum a little below the ileocaecal orifice.
Like a hollow organ, the appendix has mucosa, muscle and serous layer (so most commonly it has an intraperitoneal position and has a mesentery but sometimes it is devoid of serous layer and covered by adventitia,having a retroperitoneal position). The submucous layer contains lymphatic follicles (about 1500 in number).
The length of the appendix ranges from 1 to 15 cm (can reach 25 cm), diameter is 4-5 mm.
The surface projection of the appendix (in its usual position behind and below the end of the ileum) is the point of Mac Burney (at the junction of the external and middle thirds of a line connecting the anterior superior iliac spine with the umbilicus), the point of Monro (the middle of the noted line) or the point of Lanz (the external border of the rectus abdominis on the line connecting the two anterior superior iliac spines) (picture 3.1).

 

The position of the appendix is variable. It can be:
1. Pelvic position ( the appendix descends into the pelvic cavity);
2. Medial position (the appendix is parallel to the ileum):
3. Lateral position (the appendix is in the right lateral canal, lateral to the ascending colon);
4. Subhepatic position (the appendix ascends towards the liver);
5. Retrocaecal position (the appendix is behind the caecum);
6. Anterior position (the appendix lies on the anterior surface of the caecum)

If the appendix has the retroperitoneal position, it can adjoin the femoral nerve or the left renal facial sheath. Thus, during appendicitis, pain can irradiate to the thigh or lumbar region.
The position of the appendix determines the way of pus spreading during purulent inflammation of the appendix. So, it can spread into the pelvic cavity, subphrenic space, retroperitoneal fat.
A doctor has to differentiate appendicitis with the following diseases: diseases of the uterus and ovaries; acute cholecystitis, perforated ulcer of the stomach or duodenum, acute pancreatitis, acute diverticulitis, intestinalobstruction, stone of the ureter, pyelonephritis.
To see the appendix in the abdominal cavity, a doctor should pull the caecum laterally and up to find its cupula where the three taeniae converge with each other. This point is a constant landmark for searching of the appendix.

This video demonstartes the operation the removal of appendix

One more disease, with which appendicitis should be differentiated, is Meckel`s diverticulum. This is congenital small intestine anomaly associated with the failure of reverse development of yolk stalk (omphalomesenteric duct), when its proximal part stays opened.
During first weeks of embryonic life, yolk stalk provides feeding of embryo connecting the intestine with yolk sac. During 3-5 months of prenatal life yolk stalk in norm undergoes reverse development, turning into a ligament.
So, Meckel`s diverticulum is protrusion of intestinal wall, having all the intestinal layers (picture 4, 5). Its length ranges from 1 to 26 cm (in average 2-3 cm); its diameter is like that of a finger, or it can be narrow like the appendix. Meckel`s diverticulum is located on the free border of the ileum, usually within 60–100 cm of the ileocaecal valve (picture 6).

Usually Meckel`s diverticulum is found accidentally, during other operations in the abdominal cavity because uncomplicated diverticulum (95% of cases) is asymptomatic.
Its complications are inflammation (diverticulitis); ulcer with possible hemorrhage and perforation; intestinal obstruction; herniation; tumors; umbilical fistula.
So, symptoms of diverticulitis are similar to those of appendicitis. Thus, if during operation intact appendix is found, a doctor must do revision of the ileum throughout 1 m from the ileocaecal angle (picture 7).

 

Tracheostomia

During sudden laryngeal stenosis, acute respiratory failure or absence of spontaneous breathing, urgent tracheostomia must be done.
Tracheostomia can be done under local or general anesthesia. Usually, the cut (4-6 cm long) of skin, subcutaneous tissue, superficial cervical fascia, platysma and superficial layer of the proper cervical fascia is done from the lower edge of the thyroid cartilage to the sternal jugular notch along the linea alba. Then a doctor should move apart the sternohyoids and sternothyroids and then cut the endocervical facia to expose the tracheal cartilage. If it is necessary, the thyroid gland`s isthmus can be cut. Then a doctor cut the tracheal cartilage (II-III, IV-V or VI-VII) and put a tracheostomy tube into the trachea.
This video shows tracheostomia

 

Puncture of subclavian vein

The subclavian vein is a direct continuation of the axillary vein; it is continuous into the latter at the level of the external border of the I rib. It arches the first rib and lies between the posterior surface of the clavicle and the anterior surface of the anterior scalene (so called spatium antescalenum which is bounded by the anterior scalene posteriorly; the sternohyoid and sternothyroid anteromedially; and the sternocleidomastoid anterolaterally) (picture 1). The first rib separates the subclavian vein from the pleural cupula.
The subclavian vein can be divided into supraclavicular (2-3 cm long) andinfraclavicular parts (picture 2).

The borders of the supraclavicular zone are: medially a point situated 2-3 cm lateral to the sternoclavicular joint; laterally a point situated 1-2 cm medial to the junction between the medial and middle clavicular thirds.
The puncture of this zone is done in a point of Joffe (picture 3) situated 0,5-0,8 cm upward to the clavicle`s superior border (between the lateral border of the sternocleidomastoid and the clavicule`s superior border). The needle is directed at the angle of 45o relatively to the clavicle and at the angle of 15-25o relatively to the anterior surface of the neck.
The infraclavicular zone is bounded superiorly by the inferior border of the clavicle from its middle point (point 1 in the picture 4) to a point, 2 cm before the sternal end of the clavicle (point 2 in the picture 4); laterally by a vertical line descending 2 cm down from the point 1; medially by a vertical line descending 1 cm down from the point 2; inferiorly by a line connecting the lower ends of the noted lines.

The puncture of the infraclavicular zone can be done at three points:
1- point of Aubiniac situated 1 cm below the junction of the medial and middle clavicular thirds;
2- point of Wilson situated 1 cm below the center of the clavicle;
3- point of Jiles situated 1 cm below the clavicle and 2 cm lateral to the sternum
The needle is inserted at the angle of 30-45o relativelyto the body surface.
The position of a patient is horizontal with a roller 10-15 cm in height under the shoulder girdle and with the feet higher than the head by 15-30 degrees (the Trendelenburg position). The arm on the side of the puncture is adducted to the trunk, the shoulder is lowered; the head is turned to the opposite side.
The position of a doctor is standing on the side of the puncture. The right side is desirable for the puncture.

 

Tunnel syndromes

As known, the muscles together with the bones bound different canals and openings that transmit the vessels and nerves. In the diseases which lead to the increase of surrounding tissues or to the muscle spasm, the nerves and vessels passing through some canal can be compressed. Thus, the tunnel syndrome is a compression of the nerves or vessels in the pathologically changed osseous, osseo-fibrous or osseo-muscular canals. The tunnel syndromes can occur in such situations as traumas, physical overload, hormonal-endocrine and metabolic disorders (pregnancy, hypothyroidism, acromegaly, diabetes etc), osteochondrosis.
The tunnel neuropathies are divided into the neuropathies of the cranial nerves, the neuropathies in the cervical region and shoulder girdle, the neuropathies of the arms, pelvic girdle and legs. Today we will talk only about the names of the tunnel syndromes, i.e. their potential places; they are known for you by now. When we reach the topics about peripheral nervous system and vessels, we will discuss the clinical symptoms of these tunnel syndromes.

So now:
1) the compression of the facial nerve in the facial canal (in the temporal bone`s pyramid);
2) the compression of the trigeminal nerve branches in the infraorbital canal or in the mandibular canal;
3) the compression of the glossopharyneal nerve because of the hypertrophy of the temporal bone`s styloid process;
4) scalenus syndrome is a compression of the brachial plexus`s trunks and subclavian artery between the anterior and middle scaleni.
5) the syndrome of the vertebral artery: the compression of the vertebral artery in the canal formed by the transverse foramina of the cervical vertebrae (from VI to I);
6) the compression of the suprascapular nerve in the opening formed by the scapular notch and superior transverse scapular ligament;
7) the compression of the axillary nerve in the foramen quadrilaterum;
8) the costoclavicular syndrome (of Falconner-Waddel): compression of the brachial plexus and subclavian vessels; it develops in case of abnormally high position of the I rib or as a result of the trauma of the I rib or clavicle;
9) the pectoralis minor syndrome (of Wright): the compression of the brachial plexus and axillary vessels by a pathologically increased pectoralis minor;
10) the compression of the median nerve in the upper third of the forearm between the heads of the pronator teres;
11) the carpal tunnel syndrome: the compression of the median nerve in the carpal canal (between the flexor retinaculum and carpal bones) which transmits together with the median nerve the tendons of flexor pollicis longus, flexor digitorum superficialis and profundus; the median nerve supplies some muscles of the hand (mainly the muscles of the thenar) and the skin of the radial side of the palm and palmar surface of three and half fingers (I, II, III and half of IV);

12) compression of the ulnar nerve can occur in three places: under the ulnar collateral ligament at the upper attachment of the muscle; between the fibres of the supinator muscle; and in the Guyon`s canal, between the pisiform bone, hook of the hamate bone, palmar carpal ligament and palmaris brevis.
The compressions of the median and ulnar nerves usually occur after lengthy overload of the arms (in violinists, pianists, some sportsmen, during the work at the computer (position of the hand on the mouse)).
13) the compression of the lateral cutaneous nerve of thigh between the inguinal ligament and anterior superior iliac spine;
14) the piriformis syndrome: the compression of the sciatic nerve in the foramen infrapiriforme;
15) the compression of the common peroneal nerve in the canalis musculoperoneus superior after long staying in squat position;
16) the compression of the tibial nerve in the calcaneal canal (of Rishe) consisting of two parts: the superior part is between the medial malleolus` posterior edge and posterior tibiotalar ligament; the inferior part is between the calcaneus (externally) and the adductor hallucis (internally);
17) the compression of the IV digital plantar nerve between the heads of the III and IV metatarsals and the deep transverse metatarsal ligament.
Thus, you see how many potential places where the vessels or nerves can be compressed exist. This is one more point of application of the knowledge about muscles (also about bones and ligaments). 

 

Flat foot

The human foot is built on the principle of an elastic arch. In normal the pressure during walking falls only onto several points: calcaneus and five metatarsals. Due to an arch-shaped structure the foot can do the following:
1) to spread the body weight during movements;
2) to establish the equilibrium and adapt the foot to various terrain
3) to thrusts us forward to the next step
4) to amortize steps
In classic anatomy five longitudinal arches (corresponding to the five metatarsals) and one transverse arch (passing through the metatarsal heads) are recognized. Functionally one transverse arch and just two longitudinal arches are distinguished: inner and outer. The inner arch encompasses the calcaneus, the talus, the navicular, the first three cuneiforms, and the first three metatarsals. The outer arch is the calcaneus, the cuboid, and the fourth and fifth metatarsals. The arches are held by strong short ligaments (they form the passive arch) and by the muscles of the foot and leg (they form the active arch). Of the foot ligaments the long plantar ligament plays a chief role in the support of the longitudinal arches. The transverse arch is held by short transverse plantar ligaments. Which muscles maintain the longitudinal and transverse arches? The peroneus longus and brevis (lateral crural muscles); flexor digitorum longus, flexor hallucis longus, tibialis posterior (deep posterior crural muscles) support the longitudinal arches. The tibialis anterior, peroneus longus and brevis hold the transverse arch. The muscles of the foot also maintain its arches.
Thus, flat foot is fallen arches, is a condition when the arches are flattened (only longitudinal, onle transverse or both).
Flat foot is caused by weakness of the muscular and ligamental apparatus of the foot or wrong development or destruction of the bones.

Thus, flat feet deformity can be divided according to etiology into posttraumatic, paralytic, rachitic and static.
Flat foot can be congenital and acquired.
Posttraumatic flat foot is caused by injury of the synovial joints, ligaments, muscles; fractures of the leg bones.
Paralytic flat foot occurs because of the disorder of muscle innervation (congenital or acquired).
Rachitic flat foot is acquired, occurs because of wrong development of the bones.
Static flat foot is most common:
— congenital flat foot which occurs in congenital weakness of connective tissue;
— a sedentary lifestyle, standing work, aging process which weaken the muscles;
— overweight;
— uncomfortable shoes
The information about the degrees of flat feet you may find here: http://www.osteopathy.net.ua/…/ploskostopie-i-bolevye-sin…/…
The treatment of flat feet includes massage, physiotherapy, therapeutic exercises and rare surgical operations. We focus our attention on therapeutic exercises. Here you will find full complex:
https://youtu.be/vVgCKqxgA1U

Pay attention what muscles we should develop first of all to prevent and to treat flat feet. At first, these are the muscles of the foot. And of course the muscles of the leg: the extensors of the foot (anterior crural muscles); the flexors of the foot (posterior crural muscles); the supinators of the foot (lateral crural muscles, tibialis anterior, tibialis posterior) (see the training of sural muscles).

Stop bleeding from the common carotid artery

The injury of the large arteries is dangerous for life. The rate of blood loss may reach 200 ml per a minute therefore, it is very important to know the topography of the arteries and algorithm of the stop bleeding. For the temporary stop bleeding from the common carotids (see the arteries of the head and neck) we have to do the following:
1) to press the artery below the place of its injury by the fingers (picture 1);
2) to impose a pressure tourniquet (picture 2, 3) and notice the time (usually it may stay during1-2 hours);
3) to lay an aseptic bandage;
4) immediate transportation to a hospital

Фото Anna Kurtseva.Фото Anna Kurtseva.Фото Anna Kurtseva.

 

Vertebral artery syndrome 

The vertebral artery syndrome (VAS) may be caused by: 1) Congenital anomalies of the vertebral artery: pathological tortuosity, abnormal course, bends; 2) Vascular diseases that decrease the arterial lumen: atherosclerosis, arteritis, throbosis, embolism; 3) Compressions of the VA from the outside: osteochondrosis, osseous anomalies, traumas, scoliosis (vertebrogenic causes); tumors of the cervical tissues, scar changes, spasm of the cervical muscles (non-vertebrogenic causes).
It should be noted that during the external compression the VA can be compressed directly or because of the reflex spasm in response to the compression of the sympathetic plexus formed by the vertebral nerve branches.
To understand more completely the VAS symptoms let`s name the organs supplied by the vertebral artery branches (see the course of the vertebral artery in the arteries of the head and neck). They are the spinal cord and meninges, deep cervical muscles, cerebellum, medulla oblongata, pons, internal ear, midbrain colliculi, posterior thalamus, medial geniculate body, pineal body, tela choroidea of the III and IV ventricles, temporal and occipital lobes (picture 1 shows only the regions supplied by the cerebral branches of the VA; they are marked with green lines).

The symptoms of the VAS in the case of the direct VA compression:
1) headache (because of haemodynamic disorders) and paresthesia in one half of the head (because of the damage to the trigeminal nerve nuclei situated in the brain-stem);
2) in vertebrogenic causes the symptoms of the injury of the cervical spine: pain in the cervical spine, symptoms of the spinal nerve compressions, muscle tension;
3) cochleovestibular disorders (because of the disturbance of the blood flow in the labyrinthine artery, damage to the brain-stem vestibular nuclei);
4) visual disorders (the narrowing of visual fields, scotomas) (as a result of the disorder of the blood supply in the occipital lobe, superior colliculi, thalamic nuclei);
5) drop attacks (sudden fall without loss of consciousness because of transient vertebrobasilar insufficiency);
6) mental disorders (asthenic, anxious-hypochondriacal and hysterical state) probably because of changes of the blood supply in the limbico-reticular structures

The main symptoms of the VA syndrome in case of the reflex spasm are:
1) headache;
2) the changes of the arterial pressure;
3) Wallenberg syndrome because of the damage to the vagus, trigeminal, glossopharyngeal nerve nuclei and to the conduction tracts in the brain stem. It is characterized by sensory deficits affecting the trunk and extremities on the opposite side of the damaged artery and sensory deficits affecting the face and cranial nerves on the same side. Specifically, there is a loss of pain and temperature sensation on the contralateral (opposite) side of the body and ipsilateral (same) side of the face. On the same side paralysis of the palatine and pharyngeal muscles and Horner’s syndrome are observed. Also cerebellar ataxia and nystagmus are typical.
4) cochleovestibular disorders;
5) visual disorders (scotomas, photophobia, lacrimation);
6) laryngeo-pharyngeal symptoms (cough, dysphagia, taste perversion, pain)

All this symptoms may be observed in different combinations because the VA and sympathetic plexus are often compressed together.
It is the most important for us to understand the interrelation between the anatomy of the VA and clinical manifestation of its damage.

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