Surgical approaches

Theoretical framework: anatomy and surgery

Operative surgery is the study of surgical operations. It provides the specialist with the necessary methodology and techniques for performing interventions. In turn, topographic anatomy serves as an applied science that charts the correct course for these actions. Unlike normal (systematic) anatomy, which examines body systems in isolation, anatomia topographica studies tissues and organs collectively within a specific region of the body.

Prominent physicians of the past emphasized the absolute necessity of this knowledge. A.P. Gubarev noted that without knowledge of topographic anatomy, neither a surgeon nor a therapist could practice, leaving only symptoms and prejudices in their work. V.F. Voyno-Yasenetsky pointed out that this discipline serves as the crucial foundation for diagnosing purulent diseases and formulating a surgical treatment plan. Without understanding topography, it is impossible even to establish the exact localization of a pathological process.

Principles underlying the surgical incision

Any surgical operation inevitably involves tissue destruction. Therefore, the primary requirement for an approach is an anatomically substantiated incision. To plan it, the physician must study in detail:

• The layer-by-layer structure of human body regions (stratigraphia).
• The projection of internal organs, vessels, and nerves onto the body surface (holotopia, skeletotopia).
• The relationship of organs to fixed bony structures, such as the spine, ribs, and pelvic bones.
• The mutual relationships among organs (syntopia).
• The specific features of vascularization, innervation, and lymph drainage.

In addition, the surgeon must account for individual variability. The shape, position, and size of organs can change significantly depending on the patient's sex, age, and body type, as well as under the influence of pathological processes (which is the subject of surgical anatomy).

Physiological permissibility and new challenges

When performing an intervention, topographic and anatomical data alone are not enough. Knowledge of physiology plays a huge role, allowing the surgeon to understand and anticipate functional disorders both during and after the operation. The study of functional features is critically important for choosing the correct method of restoring functions in diseases or trauma.

N.N. Burdenko formulated three fundamental principles that a surgeon must follow:

1. Anatomical accessibility — the ability to safely reach the target area.
2. Technical feasibility — the availability of means and skills to perform the maneuver.
3. Physiological permissibility — the patient's ability to withstand the intervention.

The higher the level of medical development, the broader the range of operations and the more complex the technique. For example, the development of thoracic surgery required a thorough study of the mediastinum to devise approaches to lung segments, heart chambers, the aorta, and the esophagus. Advances in physiology made it possible to sustain a patient's vital functions during highly complex surgeries (congenital heart defects, brain tumors), where managing respiratory and cardiac disorders is no less difficult than the intervention itself.

Examples of approaches: laparoscopy in gynecology

Modern operative surgery actively utilizes minimally invasive approaches, such as laparoscopy. In operations on the uterine appendages, this approach allows for detailed visualization of structures and the safe execution of surgical maneuvers (procedures applied to exposed organs):

• Tubectomy (removal of the uterine tube — tuba uterina). Viewed from behind and to the left, the surgeon identifies the tube, grasps the tissues of the mesosalpinx (mesosalpinx), coagulates, and transects them.
• Adnexectomy (removal of the appendages). Viewed from behind, the removal of the uterine tube along with the ovary is visualized. The key maneuver is placing an instrument on and transecting the proper ovarian ligament (ligamentum ovarii proprium), which connects the uterine pole of the ovary to the uterine horn.

Class and exam questions

What else to study on this topic

• Individual variability in organ shape and position
• Organ topography in pathological changes (surgical anatomy)
• Specific features of approaches to mediastinal organs (heart, lungs, esophagus)
• Vascularization, innervation, and lymph drainage in surgical practice

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.