Introduction to the

topographical anatomy
and operative surgery

by
Kavan vyas
Crimean federal university
What is topographical anatomy :
topographic anatomy - the study of anatomy bas
ed on regions
divisions of the body and emphasizing relations bet
ween
various structures (muscles and nerves and arterie
s etc.) in that region.
Topographic Anatomy studies the structures of
the Human Body on cross-sections in application to
clinical diagnostic: ultrasound images (USI),
computed tomography (CT) and magnetic
resonance (MR). These are tomographic (two-
dimensional) slice images. Imaging technologies
using X-ray, USI, CT, MR and radioisotopes can give
precise anatomic delineation (M. Burykh, 1990)
and as well as function.
Methods to the study of the human structure.
Syntopy
Skeletotopy
Holotopy

Methods to the study of the human

structure.

syntopy (from gr.\ syn with, together +

topos place) the position of organ with
others in any cavity;
 skeletotopy (from skeleton + topos place)
the position of organ with skeleton;
holotopy (from gr.: holos whole, entire +
topos place) - the position of organ to the
skin surface.

Surgical Anatomy
Surgical Anatomy studies structures
of the Human Body from the surgical point of
view, that is their importance to the
performance of incisions and operative
methods (-tomy, -stomy, -ectomy, resection
and so on). This also means a study of
anatomical variations in preparation for
structural differences encountered at the
operating table.

History of Anatomy in personals.

Prof. NIKOLAY PIROGOV (1801-1881)
Main works:
"Is the ligation (vinculum) of abdominal
aorta easy and nondangerous operation of
inguinal aneurysms?" (Derpt, 1832);
"Surgical Anatomy of Vascular Trunks and
Fascia" (1837);
 "Complete Course of Applied Anatomy"
(1844);
"Atlas of topographic Anatomy in cross-
sections through frozen cadavers" (1853-
1859).

Prof. VICTOR SCHEVKUNENKO (1872-

1952)
Main works:
"Theory of individual anatomical variability";
"Age and typological Anatomy" (1925);
"Course of Operative Surgery and
Topographic Anatomy" (1932-1952)
"Atlas of Peripheral Nervous and Venous
Systems" (1949).

What is operative surgery

The operative surgery is a science about
surgical operations, methods of surgical
operations, the essence of which comes to
mechanical action upon the organs and
tissues with diagnostic, medical or
reconstructive purpose.
Operative approach means to make the
wound for the exposure of the organ to be
operated on.
Operative method the main part of the
operation, performing the action contained in
the name of the operation
Classification of operations
Emergency
Urgent
Planned
Bloodless
Bloody
Radical
Palliative
Single stage
WOUNDS
WOUND is a simply disruption of the
normal continuity of tissue. When tissue has
been disrupted so severely that it cannot
heal naturally (without complications or
possible disfiguration) it must be repaired by
a skilled surgeon.
Classification of wounds according to
the mode of damage
1. An incised wound is caused by a sharp
instrument; if there is associated tissue
tearing, the wound is said to be lacerated;
2. An abrasion results from friction damage to the
body surface, and is characterized by
superficial bruising and loss of varying
thickness of skin and underlying tissues;
3. Crush injuries are due to severe pressure. The
skin may not be breached even if massive
tissue destruction is present. Oedema,
characteristic of this type of injury, can make
wound closure impossible and, by increasing
pressure within fascial compartments, may
cause ischaemic necrosis of muscle and
other structures.;
4 Degloving injury occurs as a result of shearing
forces which cause parallel tissue planes to move
against each other. Large areas of apparently
intact skin may be deprived of their blood supply
from rupture of feeding vessels.
5 Gunshot wounds may be from shotgun pellets or
bullets. Bullets fired from high-velocity rifles
cause massive tissue destruction.
6 Burns are caused by heat, cold, electricity,
irradiation or chemicals. They form a distinct
variety of wound requiring special consideration.
Operative wounds

1 Clean wounds. They are closed by primary union

and are not usually drained. No break in
aseptic technique occurs during this
procedure. Here the surgeon does not enter
the oropharyngeal cavity or the respiratory, or
alimentary or genitourinary tracts.
2. Clean-contaminated wounds. These operative
wounds have usual normal flora without
unusual contamination.
3. Contaminated wounds. These include fresh
traumatic injuries such as soft tissue
laceration, open fractures and penetrating
wounds. Microorganisms multiply so rapidly
that within six hours a contaminated wounds
can become infected.
4. Dirty and infected wounds. These wounds have
been heavily contaminated or clinically
infected prior to the operation. They included
perforated viscera, abscesses or old traumatic
wounds in which devitalized tissue or foreign
material have been retained.
THE OPERATION
THE OPERATION is a therapeutic procedure
with instruments to repair damage or arrest
disease in a living body; or any act performed
with instruments or by the hands of a
surgeon with the aim of diagnostic or
treatment.

Clinical classification of operations:

1. The radical operation (lat.: radix, root) is an
operation which is directed to the cause or
directed to the root or source of a morbid
process;
2. The palliative operation (lat.: palliates,
cloaked) is an operation which affords relief
but not cure.

Surgical operation
The surgical operation is a technological process
which includes following components:
1) the knowledge of Clinical Anatomy (in
application to surgical clinic Surgical
Anatomy);
2) an operating room, general and special
surgical instruments and apparatus;
3) an operating room and patient management
(aseptic procedures; anesthesia);
4) surgical technique (operative approach, operative
method and wound closure).

GENERAL PRINCIPLES OF SURGICAL

TECHNIQUE

Dissection technique.
Arrest of haemorrhage.
Tissue handling.

SURGICAL TECHNIQUE

1. operative approach (lat.: operativus,

pertaining to an operation): exposure of
organs with instruments or incision (lat.: in +
cedere, to cut, to open through);
2. operative method: surgical acts performed
with instruments, based on strong
precedence rules;
3. wound closure (absorbable and
nonabsorbable sutures and aseptic
bandage): holding tissues in proximity with
means.

Operative approaches (incisions)

The incision should give optimal exposure for
the most difficult part of the operation and
should allow for extension in the event of a
greater than expected procedure being
required;
all skin incisions should be carefully planned
so as to give a good view of the deeper parts
and at the same time to avoid important
structures;
in general, when an incision has to be made
in the neighborhood of large vessels or
 nerves, it should be made parallel to, and not
across, their long axis;
an incision of adequate length should always
be made;
for cosmetic reasons, however, incision on
the face or neck should be placed in a natural
crease, for not only will the scar be less
visible, but there will be less likelihood of
keloid formation.

Operative methods
There are the following surgical actions:

centesis puncture to aspirate

desis fusion
ectomy surgical excision of
lysis freeing of
orrhaphy repair of
oscopy examination of an organ by viewing
ostomy the creation of an artificial or new
opening through the wall of an organ
otomy cutting into an organ or tissue
pexy to fix or suture in place
plasty restoration of a lost part or piece of tissue
Prefixes
a or an without or not
ante before, forwards
anti against, opposite
circum around, about
dys bad, difficult
extra outside, beyond, in addition
hemi half
hyper above, over, excessive
hypo below, under
infra underneath, below
inter between, among
intra within, on the inside
peri around, about
post after, behind, during
pre before
retro behind, backwards
semi half
sub under, beneath
super above, over
supra on the upper side, above
trans across, beyond
ultra beyond, over
gland neuro nerve
arthro joint oophor ovary
blepharo eyelids ophthalm eye
cardi heart orchio testicle
chole gall os bone
cholecyst gallbladder ot ear
col colon pharyng throat
colpo vagina phleb vein
cranio brain pneumo lung
urinary
cysto procto rectum
bladder
dent tooth prostate prostatic
 gland
pelvis of
dermat skin pyelo
kidney
entero intestines rhino nose
fallopian
gastro stomach salping
tube
hepato liver spermato semen
hystero uterus splanchno viscera
second part
jejun teno tendon
of intestine
posterior
lamin thoraco chest
vertebral arch
neck or
mast breast trachelo necklike
structure
myo muscle ureter kidney tube
vessel or
nephro kidney vas
duct

resection (lat.: resecare, to cut off);

amputation (lat.: amputare, to cut off);
exarticulation (lat.: ex-, from or outside +
articulus, joint or articulation);
implantation or transplantation (lat.: in,
trans, through + plan- tare, crop or plant).

Wound closure
 The surgeon's goal. Whether a patient
has elected to have surgery or is undergoing
an emergency procedure, the surgeon's
ultimate goal upon closing is the same:
to hold severed tissue in opposition (that is, to
hold them together in proximity with means)
until the wound has healed enough to
withstand stress without mechanical support.

Type of sutures
1 simple
2 inturrupted
3 blanket
4 Surgical
Suture material
Absorbable
- Plain catgut
- Chromic catgut
- Polyglycolic synthetics
Nonabsorbable

- Natural (silk, cotton)

- Synthetic braids (Ticron, Tevdek, Ethibond)

- Synthetic monofilament ( nylon, Prolen)
- Monofilament stainless
- Steel wire
Suturing Techniques

General Principles

Many varieties of suture material and needles are

available. The choice of sutures and needles is
determined by the location of the lesion, the thickness of
the skin in that location, and the amount of tension
exerted on the wound. Regardless of the specific suture
and needle chosen, the basic techniques of needle
holding, needle driving, and knot placement remain the
same.

Suture placement
A needle holder is used to grasp the needle at the distal
portion of the body, one half to three quarters of the
distance from the tip of the needle, depending on the
surgeons preference. The needle holder is tightened by
squeezing it until the first ratchet catches. The needle
holder should not be tightened excessively, because
damage to both the needle and the needle holder may
result. The needle is held vertically and longitudinally
perpendicular to the needle holder
Incorrect placement of the needle in the needle holder
may result in a bent needle, difficult penetration of the
skin, or an undesirable angle of entry into the tissue.
The needle holder is held by placing the thumb and the
fourth finger into the loops and placing the index finger
on the fulcrum of the needle holder to provide stability
Alternatively, the needle holder may be held in the palm
to increase dexterity
The tissue must be stabilized to allow suture placement.
Depending on the surgeons preference, toothed or
untoothed forceps or skin hooks may be used to grasp
the tissue gently. Excessive trauma to the tissue being
sutured should be avoided to reduce the possibility of
tissue strangulation and necrosis.

Forceps are necessary for grasping the needle as it

exits the tissue after a pass. Before removal of the
needle holder, grasping and stabilizing the needle is
important. This maneuver decreases the risk of losing
the needle in the dermis or subcutaneous fat, and it is
especially important if small needles are used in areas
such as the back, where large needle bites are
necessary for proper tissue approximation.

The needle should always penetrate the skin at a 90

angle, which minimizes the size of the entry wound and
promotes eversion of the skin edges. The needle should
be inserted 1-3 mm from the wound edge, depending on
skin thickness. The depth and angle of the suture
depends on the particular suturing technique. In general,
the two sides of the suture should become mirror
images, and the needle should also exit the skin
perpendicular to the skin surface.

Knot tying
Once the suture is satisfactorily placed, it must be
secured with a knot. The instrument tie is used most
commonly in cutaneous surgery. The square knot is
traditionally used.
First, the tip of the needle holder is rotated clockwise
around the long end of the suture for two complete turns
The tip of the needle holder is used to grasp the short
end of the suture. The short end of the suture is pulled
through the loops of the long end by crossing the hands,
so that the two ends of the suture are on opposite sides
of the suture line. The needle holder is rotated
counterclockwise once around the long end of the
suture. The short end is then grasped with the needle
holder tip and pulled through the loop again.
The suture should be tightened sufficiently to
approximate the wound edges without constricting the
tissue. Sometimes, leaving a small loop of suture after
the second throw is helpful. This reserve loop allows the
stitch to expand slightly and is helpful in preventing the
strangulation of tissue because the tension exerted on
the suture increases with increased wound edema.
Depending on the surgeons preference, one or two
additional throws may be added.

Properly squaring successive ties is important. In other

words, each tie must be laid down perfectly parallel to
the previous tie. This procedure is important in
preventing the creation of a granny knot, which tends to
slip and is inherently weaker than a properly squared
knot. When the desired number of throws is completed,
the suture material may be cut (if interrupted stitches are
used), or the next suture may be placed
Surgical instruments can be generally divided into
five classes by function. These classes are:
1.Cutting instruments and dissecting: scalpels,
scissors, saws.
2.Grasping or holding instruments: smooth
[anatomical] and toothed [surgical] forceps, towel
clamps, vascular clamps, and organ holders.
3.Haemostatic instruments: Kochers and Billroths
clamps, hemostatic mosquito forceps, atraumatic
hemostatic forceps, Deschamps needle, Hpfners
hemostatic forceps.
4.Retractors:Farabefs C-shaped laminar hook, blunt-
toothed hook, sharp-toothed hook, grooved probe,
tamp forceps.

5.tissue unifying instruments and materials:

needle holders, surgical needles, staplers,
clips, adhesive tapes.

Instrument class Image Uses Specific instruments

Articulator Galotti articulator

 Instrument class Image Uses Specific instruments

Cutting
Bone chisel
instrument

Cottle cartilage crusher

Bone cutter To cut the bone

Clamps and
Bone distractor
distractors

Accessories
Ilizarov apparatus
and implants

Intramedullary kinetic Clamps and

bone distractor distractors

To drill inside
Bone drill
the bone

Accessories
Bone lever
and implants

Bone mallet Accessories

 Instrument class Image Uses Specific instruments

Cutting
Bone rasp
instruments

Cutting
Bone saw
instruments

Bone skid

Bone splint

Bone button

Accessories
Caliper Castroviejo caliper
and implants

Accessories
Cannula Spackmann Cannula
and implants

Accessories
Cautery
and implants

for scraping or
debriding
biological
tissue or debris
in a biopsy,
Curette
excision, or
cleaning
procedure
Cutting
instrument
 Instrument class Image Uses Specific instruments

Depressor

Accessories
Dilator
and implants

cutting
Dissecting knife
instrument

Grasping/holdin
surgical Pinzette
g

cutting
Dermatome
instrument

Grasping/holdin
Forceps, Dissecting Adson
g
 Instrument class Image Uses Specific instruments

Grasping/holdin
Forceps, Tissue Allis Babcock
g

Forceps (Other) Sponge Forceps

Acanthulus or Acanthabol
Thorn removal
os

Grasping/holdin
Bone forceps
g

haemostatic
Carmalt forceps kalabasa
forceps

grasping/holdin Non-toothed dissecting

Cushing forceps
g forceps

haemostatic
Dandy forceps
forceps

Non-toothed dissecting
grasping/holdin
DeBakey forceps forceps designed for use on
g
blood vessels

Non-crushing clamp
clamps and
Doyen intestinal clamp designed for use on the
distractors
intestines
 Instrument class Image Uses Specific instruments

Epilation forceps

haemostatic
Halstead forceps
forceps

haemostatic
Kelly forceps
forceps

haemostatic
Kocher forceps
forceps

haemostatic
Mosquito forceps
forceps

Hook retractor

Nerve hook retractor

Obstetrical hook retractor

Skin hook retractor

 Instrument class Image Uses Specific instruments

Lancet (scalpel) cutting

Luxator

Lythotome

Lythotript

Mallet

Partsch mallet

Mammotome

grasping/holdin Castroviejo Crilewood Mayo-

Needle holder
g Hegar Olsen-Hegar
 Instrument class Image Uses Specific instruments

Occluder

Osteotome cutting

Epker osteotome cutting

Periosteal elevator cutting

Joseph elevator cutting

Molt periosteal elevator cutting

Obweg periosteal
cutting
elevator

Septum elevator cutting

Tessier periosteal
cutting
elevator

Probe
 Instrument class Image Uses Specific instruments

Retractor retractor

Deaver retractor retractor

Gelpi retractor retractor

Weitlaner retractor retractor

USA-Army/Navy retractor retractor

O'Connor-O'Sullivan retractor

Mathieu Retractor retractor

Jackson Tracheal Hook retractor

Crile Retractor retractor

Meyerding Finger
retractor
Retractor

Little Retractor retractor

Love Nerve Retractor retractor

 Instrument class Image Uses Specific instruments

Green Retractor retractor

Goelet Retractor retractor

Cushing Vein Retractor retractor

Langenbeck Retractor retractor

Richardson Retractor retractor

Richardson-Eastmann
retractor
Retractor

Kelly Retractor retractor

Parker Retractor retractor

Parker-Mott Retractor retractor

Roux Retractor retractor

Mayo-Collins Retractor retractor

Ribbon Retractor retractor

Alm Retractor retractor

West, Travers and Norfolk &

Self Retaining Retractors
Norwich

Weitlaner Retractor
 Instrument class Image Uses Specific instruments

Beckman-Weitlaner
Retractor

Beckman-Eaton Retractor

Beckman Retractor

Adson Retractor

Rib spreader

cutting
Rongeur
instrument

Ultrasonic scalpel cutting

Laser scalpel cutting

Scissors cutting
 Instrument class Image Uses Specific instruments

Iris scissors cutting

Kiene scissors cutting

To dissect soft
Metzenbaum scissors cutting
tissue, etc.

To cut suture,
Mayo scissors cutting
etc.

Tenotomy scissors cutting

Spatula

Speculum retractor

Mouth speculum retractor

 Instrument class Image Uses Specific instruments

Rectal speculum retractor

Sim's vaginal speculum retractor

Cusco's vaginal speculum retractor

accessories
Sponge bowl
and implants

accessories
Sterilization tray
and implants

Sternal saw cutting

accessories
Suction tube
and implants

Surgical elevator

Surgical hook retractor

 Instrument class Image Uses Specific instruments

Surgical knife

accessories
Surgical mesh
and implants

accessories
Surgical needle
and implants

Surgical snare

Surgical sponge

Surgical spoon

accessories
Surgical stapler
and implants

Surgical tray
 Instrument class Image Uses Specific instruments

Suture

Tongue depressor

Tonsillotome

Towel clamp clamp

Towel forceps clamp

Backhaus towel forceps

Lorna towel forceps

Tracheotome

Tissue expander accessories

 Instrument class Image Uses Specific instruments

and implant

Subcutaneous inflatable accessories

balloon expander and implants

cutting
Trephine
instrument

cutting
Trocar
instrument

surgical device
using low
frequency
ultrasound
Ultrasonic cavitation
energy to
device
dissect or
fragment
tissues with low
fiber conten

Image based surgical anatomy

layers of abdominal wall

types of surgical sutures

A - continuous overhead suture; B - continues blanket
suture;
C - ordinary interrupted suture; D - eversion interrupted
suture.
knots

Topographical approach to study of

the Human Structure.
Types of wound

Retractors
Needles

Correct position of holding a needle

holder
Main lines of incision for opration
Connections

Surgical screwing in human bones

( type of connection)
Types of bandages and bandaging
Thank you
for your

kind attention