Sergodeev I.V.

Applicant,

Chelyabinsk State University

MYTHOPOETICAL SPACE OF JAMES DOUGLAS MORRISON (INTEXTUAL AND HYPERTEXTUAL RELATIONS)

annotation

The article considers the features of the implementation of the category of intertextuality in the mythopoetic space of J. Morrison. Two types of intertextuality are considered: inteksuality and hypertextuality. Some archetypes of J. Morrison's works are analyzed.

Keywords: myth, intextuality, hypertextuality.

Sergodeev I. V.

Chelyabinsk State University

MYTHOPOETIC SPACE OF JAMES DOUGLAS MORRISON (INTEXTUAL AND HYPERTEXTUAL LINKS)

Abstract

The articles considers special aspects of intertextual category implementation in J. Morrison’s mythopoetic space. Two types of intertextuality are under consideration: intextuality and hypertextuality. Some archetypes of J. Morrison's works are analyzed.

keywords: myth, intextuality, hypertextuality.

Myth allows a person to look at himself not as a product of history, but as a product of mythical events that took place outside of time. Myth also presupposes the existence of primitive experience, or, in other words, a return "to the origins." This attitude is inherent in the American poet J. Morrison. All his work is saturated with images of death and catastrophes, which correlate with the plots of eschatological myths. The mythopoetics of J. Morrison refers to the world of thoughts and feelings of the author, and at the same time immediately to a whole layer of world mythology, which creates some difficulties in the perception of his text.

The category of intertextuality is the textual category that will facilitate the perception of the poetic text of the author and allow organizing the mythopoetic space of J. Morrison into something whole. Speaking about the category of intertextuality, we will rely on the classification of various types of intertextual relations in postmodern literature developed by N. S. Olizko. According to this classification, the typology of intertextuality is built in two planes: horizontal (hypertextuality, metatextuality) and vertical (architeksuality, intextuality).

For a more complete understanding of J. Morrison's mythopoetics, it is necessary to turn to primary sources, that is, to myths. To do this, let's analyze the means of expressing intextuality in the mythopoetic space of J. Morrison. "Intextuality is a text inclusion that introduces into this text information about various precedent phenomena and reflects the "citation of postmodern thinking" - the saturation of the works of postmodernism with various kinds of reminiscences" .

Ride the snake, ride the snake

To the lake, the ancient lake, baby

The snake is long, seven miles

Ride the snake…he's old, and his skin is cold… (The End)

Intextuality in this passage is realized through references to mythological precedent phenomena, which are embodied in specific allusions: the image of the Serpent or the Lizard often appears in the poetry of J. Morrison. This is an allusion to Native American mythology, in particular to the "Snake Song" of the Navajo Indians:

He's comin' to us

He's comin' to us

His body is white

He's comin' to us

With a black stripe

It is known that the poet is fond of Indian culture and mythology, reads a lot of literature, spends a lot of time in the desert with the Indians. However, in the texts of J. Morrison there is no fully formed complex of mythology of Indian tribes, since the mythology of each individual tribe often differs from the mythology of any other. Different tribes have different cult images and clan totems, among which there is not always a place for the Serpent, which plays an important role in the poet's work. Therefore, the Serpent is not fully an allusion to Indian mythology, but has more ancient roots. According to A. Golan, the appearance of the image of the Morrison Serpent refers to the mythology of the Neolithic and to the Nostratic proto-language. J. Morrison collects the mythologemes of various cults that date back to the early agricultural culture, and combines them into the Serpent, and later into the Lizard: “I've always liked reptiles. I used to see the universe as a mammoth snake…” (Jim Morrison) In Neolithic mythology, the image of the snake is the source of evil, the image of the black god, the god of the underworld, the god of the earth, the god of thunder. In Egyptian mythology, the god of the underworld is called Serapis, in the Jewish tradition the word seraph (serpent) means "burn, burn"; in the Hittite rituals there is a moment of worship of the mountain, the home of the fiery serpent; in Indian mythology, Indra kills a dragon located on a mountain; in Slavic mythology, there is a serpent Gorynych, who lives on a mountain; in the American tradition, to which J. Morrison belongs, the serpent lives in a hole, that is, in the context of mythology, in the underworld.

Well, I'm the Crawlin' King Snake

And I rule my den (Crawling King Snake, folk song, 1920s)

The primitive idea gives the Serpent the functions of a destroyer and a creator, and the underworld is located both under the earth and in the sky. The ring in which the serpent coils symbolizes the cycle of life and death. In the mythopoetic space of J. Morrison, this plays a very important role. The shaman enters a trance through the rite of initiation, "dies" and acquires a new quality. J. Morrison tries to do the same in his work: “Why the desire for death. Desire for Perfect Life.” (Jim Morrison)

Ride the snake, ride the snake

to the lake, the ancient lake, baby (The End)

The image of water is also one of the central images of the poet. In mythology, water is associated with both death and life: there is another world beyond the sea, and life arises from water. “There is an internal conditioning of such descriptions, which indicates a connection with archetypes; the meeting of sea and land can be regarded as an important experience of experiencing the border, the threshold between the infinite and the finite.

Let's swim to the moon

Let's climb to the tide

Penetrate the evening that the

City sleeps to hide (Moonlight Drive)

In mythology, the image of the moon can act as a symbol of the world of the dead and as one of the forms of the black god or Morrison's Serpent. The poet wants to cross the sea to join him. Thus, J. Morrison "dies" in order to be transformed. The poet's work is eschatological in nature: it is not death itself that is important, but absolute repetition, which leads to cosmogony. “The cosmogonic myth can be reproduced on the occasion of death, for this is the new situation that can be correctly perceived in order to make it creative” .

This statement can be proved through intertextual relations, namely through hypertextuality. "Hypertextuality is a kind of intertextuality, which allows us to consider each work of an individual author, on the one hand, as a link in one narrative chain, on the other hand, as a hypertext that serves as an effective means of implementing intertextual relations within the framework of the work of a particular writer" .

J. Morrison writes a number of poems in which he identifies himself with the ancient god:

I'm a guide to the Labyrinth

Monarch of the protean towers

on this cool stone patio (The Opening of the Trunk)

In this passage, the labyrinth is an image of the change of day and night, obeying the black god. In many traditions, the home of the sun is the underworld, which is similar to the underground lake among the Indians and the River Styx, which is also located in the afterlife, among the Greeks. The sun appears in the sky by the will of the black god, that is, it is a symbol of the Serpent, an integral attribute of which is also a stone. The poet puts together a mosaic of his mythopoetic space and complements the chain of narration traced in his texts by asserting that he is the guide in the Labyrinth, the monarch of stone palaces. Comparing this passage with the previous ones, hypertextual connections are seen especially clearly - there is a qualitative transition of J. Morrison from a poet who describes the reality surrounding him, to a poet who himself is the creator of this reality. This process is clearly traced in the poetic development of J. Morrison from his early works to his later ones. For a more vivid illustration, let's turn to another poem by J. Morrison, where he directly declares his divine nature:

'I'm the Lizard King

I can do anything…”(Celebration of the Lizard)

Thus, in his mythopoetic space, the poet J. Morrison resorts to primitive experience and "resurrects" ancient myths, the synthesis of which serves as the foundation of his work. He, as it were, creates his own universe and, like a shaman, transforms in it, he himself takes the place of the Creator Serpent, doomed to an endless series of transformations, which is expressed in the most endless process of creation.

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The hepatic mass fills the right dome of the diaphragm and extends to the left of the midline of the body below the heart (Fig. 1A). The most typical form of the anterior surface of the liver, namely, its decreasing volume to the left of the falciform ligament, is very convenient for laparoscopic access to extrahepatic biliary structures. The apex of the lateral segment of the left lobe of the liver may have the form of a fibrous continuation, which is an embryonic remnant (Fig. 1B). Less common is downward enlargement of the right lobe of the liver, which may cause additional difficulties (Fig. 1B). The edge of the liver has a direction to the left from above and to the right from top to bottom, leaving open a part of the anterior wall of the stomach and the pylorus on the left and the proximal section of the transverse colon on the right. Between the large intestine and the lower edge of the liver, the tip of the unchanged gallbladder may protrude.

Studying the anatomy of the liver in three projections, one must always correlate it with the anatomy of neighboring organs. The relationship between the liver and the diaphragm is determined by the commonality of their embryonic origin - the transverse septum (Fig. 2 A). The areas of the liver not covered by the peritoneum are the result of the transition of the parietal peritoneum from the lower surface of the diaphragm to the liver. This feature of the distribution of the peritoneum forms a diamond-shaped crown above the liver, called the coronary ligament.

The boundary of attachment of the "ligaments" is located on the upper surface of the liver far above and posteriorly, forming a deep suprahepatic pocket on the right. In the center of this area is the confluence of the inferior vena cava with the main hepatic veins. Anteriorly, the coronary ligament passes into the falciform ligament, the head section of the ventral mesentery. Along the edges, on the left and right, the anterior and posterior surfaces of the coronary ligament converge at an acute angle and form triangular ligaments.

When the surgeon cuts the left triangular ligament to mobilize the lateral segment of the left hepatic lobe, he must be aware of the proximity of the hepatic veins and the inferior vena cava. Access to these vessels, in case of damage, will be extremely difficult due to deep localization. Small veins running from the posterior surface of the liver directly to the inferior vena cava reflect the peculiarity of the evolutionary development of the vena cava from the dorsal part of the venous plexus of the liver. Note the location of the inferior left phrenic vein, which runs along the anterior semicircle of the esophageal opening of the diaphragm. This is a very common variant of anatomy.

The organs of the upper floor of the abdominal cavity, when viewed on a section of a computed tomograph, are located in the shape of a kidney or bean (Fig. 2 B). The spine and large vessels fill the cavity, and the organs themselves are located behind and on the sides, in the diaphragmatic recesses. The most rear position is occupied by the kidneys.

In the sagittal section (Fig. 3), the abdominal cavity has a wedge-shaped shape due to the slope of the lumbar spine and adjacent psoas muscles. Hepatorenal torsion of the peritoneum (Morrison's pouch) is the most distant space of the abdominal cavity. On the right and behind, the lower surface of the liver goes around the kidney with perirenal fiber, and in front of it is the hepatic angle of the large intestine.

On the sagittal section of the right upper quadrant of the abdominal cavity (Fig. 4), it can be seen that the inferior vena cava is located in the center of the abdominal cavity, and the hepatoduodenal ligament with the portal vein passes immediately in front of it. On a frontal cholangiogram, the common bile duct usually runs along the right edge of the lumbar vertebrae. In order to see fine details in it without overlaying the image of the underlying structures, the patient should be turned slightly to the right (Fig. 5).

If the liver is lifted, the hepatogastric omentum becomes visible, another derivative of the ventral mesentery, which extends from the lesser curvature of the stomach to the groove of the ligamentum venosus and the hilum of the liver (Fig. 6). The free edge of the omentum surrounds the bile ducts and forms the hepatoduodenal ligament. You can also see the place of contact of the anterior surface of the fundus of the stomach and the lower surface of the lateral segment of the left lobe of the liver. The initial section of the duodenum, previously closed by the edge of the liver, is available for review, and the relative position of the intestine and the lower surface of the square lobe, as well as the gallbladder, is visible. And, finally, on the right, the relative position of the hepatic angle of the large intestine, the right lobe of the liver and the gallbladder is open.

When the stomach and duodenum are retracted, the root of the mesentery of the transverse colon and the borders of the omental sac behind the lesser omentum become visible (Fig. 7). In the upper part of the bag, the caudate lobe of the liver is visible, which usually has a significant size. The peritoneal fold between the liver and the pancreas looks like a ridge formed by the hepatic artery, which passes in the retroperitoneal space of the omental sac and turns into the hepatoduodenal ligament.

When diluting the posterior leaf of the parietal peritoneum, the anatomical structures of the hilum of the liver and their relationship with the pancreas are exposed (Fig. 8). The trunk of the celiac artery, as a rule, divides into three branches, giving rise to the left artery of the stomach, hepatic and splenic arteries.

And we will complete the review of the organs of the upper abdominal cavity with a rear view (Fig. 9). The right lobe of the liver extends posteriorly over the superior pole of the right kidney, so that the right adrenal gland is enclosed between the kidney, liver, and inferior vena cava. The inferior vena cava, for a greater or lesser extent, is located in the fossa separating the right and left lobes of the liver. To the left of the vena cava lies the caudate lobe of the liver.

The gastrohepatic omentum extends from the lesser curvature of the stomach to the hilum of the spleen and the groove of the venous ligament. The esophagus is located immediately to the left of the square lobe, between the lower thoracic aorta posteriorly (behind the crura of the diaphragm) and the lateral segment of the left lobe of the liver in front. The cone-shaped edge of the left lobe protrudes above the cardia of the stomach, reaching the anterior border of the spleen. The fourth section of the duodenum goes obliquely upward between the body of the pancreas in front (removed) and the aorta (removed) behind.

On the lower surface of the liver there is a deep central transverse groove formed by its gate (Fig. 10). The common bile duct, hepatic artery and portal vein - the main anatomical structures of the gate - are adjacent to the right side of the sulcus, and their branches go to the left side, located for a considerable distance outside the hepatic tissue. The plane drawn along the bed of the gallbladder and the inferior vena cava mainly separates the left and right lobes of the liver (the caudate lobe comes on both sides).

Near the end of the portal sulcus on the left side in a small depression is a round ligament of the liver (the remainder of the umbilical vein). The extrahepatic portion of the teres ligament below the umbilical notch lies along the free margin of the falciform ligament. From the left end of the gate obliquely posteriorly stretches the groove of the venous ligament, which runs from the left branch of the portal vein to the inferior vena cava near the diaphragm. The hepatogastric omentum departs from the same gutter, continuing to the gates of the liver and surrounding the main portal structures in the form of a hepatoduodenal ligament.

Between the omentum and the inferior vena cava is the caudate lobe of the liver. The caudate and right lobes are connected by a narrow isthmus - the caudate process, which lies between the gate and the vena cava. It is the roof of the omental opening connecting the omental sac and the abdominal cavity. The anterior margin of this opening is the hepatoduodenal ligament, and the posterior margin is the vena cava. The inferior volvulus of the parietal peritoneum onto the liver crosses the inferior vena cava immediately below the liver and partly follows an impression from the right adrenal gland on the inferior surface of the right lobe.

It is important for the laparoscopist surgeon to know the segmental structure of the liver (shown in an oblique caudal plane, Fig. 11). Knowledge of the normal anatomy of the bile ducts (which occurs in 70% of cases) is necessary to recognize possible anomalies, to identify ductal branches that are not visualized on cholangiograms (due to damage or obstruction), and to be more careful about anatomical formations adjacent to the gallbladder bed. Each bile segment contains a bile duct, a branch of the portal vein, and a branch of the hepatic artery. The hepatic veins run between the segments.

The right and left lobes of the liver are separated by a plane passing through the gallbladder bed and the fossa of the inferior vena cava, and each lobe is divided into two segments. The median hepatic vein is located where both lobes meet. The right lobe is divided by an oblique transverse plane, running, respectively, to the right hepatic vein, into the anterior and posterior segments. The left hepatic vein divides the left lobe into medial and lateral segments. Each of these large segments consists of an upper and lower section.

The caudate lobe, located behind the upper part of the medial segment, contacts both lobes to varying degrees. The terminal sections of the hepatic artery and portal vein anastomose with the initial sections of the hepatic vein at the level of the hepatic lobules. Portal vessels and ducts enter each segment from the side of the centrally located gate. The gallbladder bed is formed by the inferior surfaces of the right anterior and left medial segments, and the ducts and vessels passing through these segments are at risk of injury during cholecystectomy.

The cholangiogram shows the usual structure of the biliary system (Fig. 12 A). The right and left hepatic ducts join at the hilum of the liver into the common bile duct (outside the liver itself in 90% of cases). The right hepatic duct is formed by the confluence of the anterior and posterior segmental ducts, which occurs near (~1 cm) from the junction of the right and left hepatic ducts.

The right anterior segmental duct is shorter and located below the posterior segmental duct. The frontal cholangiogram shows that the site of bifurcation of the anterior duct is more medial than the posterior one. In about a third of individuals, there is a subcystic duct that runs near the gallbladder bed and empties into the right anterior duct. Unlike other bile ducts, it is not accompanied by a branch of the portal vein. It is not associated with the gallbladder, but may be damaged during cholecystectomy.

The left lateral superior and inferior ducts usually join at or slightly to the right of the left segmental sulcus. Bile flows from the top of the left lobe into the long and thin upper duct, which passes into the fibrous process. In a small number of people (=5%), bile ducts in this process may persist and be a source of bile leakage when the process is severed to mobilize the left triangular ligament of the liver.

From the upper and lower sections of the medial segment of the left lobe, bile flows into four small ducts. When connecting the medial and lateral segmental ducts near the gates of the liver, the left hepatic duct is formed. Bile from the caudal part of the medial segment goes in three directions. From the most right section, bile usually flows into the right ductal system, from the most left - to the left, and from the intermediate section, with approximately equal frequency, to one of the sides.

There are several options for the location of the bile ducts inside the liver. Typically, the main left and right bile ducts join at the center of the hilum of the liver (in 10% of cases, within the hepatic parenchyma). In about 22% of individuals, the posterior right segmental duct may cross the interlobar sulcus and empty into the left hepatic duct (Fig. 12B).

In 6% of cases, the right anterior segmental duct passes to the left side (Fig. 12B). With a separate location of the right segmental ducts, they may be damaged during cholecystectomy. These ducts are more properly termed aberrant than accessory ducts because they collect bile from normal areas of the liver and are not accessory. On the left side, in a quarter of cases, the duct of the medial segment flows into the lower branch of the duct of the lateral segment (Fig. 12D).

Of the peripheral ducts, the right posterior superior duct has the most constant location. The remaining subsegmental ducts in 22% of cases have alternative confluence options.

The course of the trunks of the portal vein, when viewed from below, corresponds to the segmental structure of the liver (Fig. 13). The portal vein divides outside the liver, near the right side of the gate, and the longer left trunk crosses the portal sulcus. The right trunk runs close behind the infundibular gallbladder and is most often damaged at this point. The right trunk of the portal vein usually divides into anterior and posterior branches, leading to the two main segments of the right lobe in anterior-superior and posterior-inferior directions, respectively. Sometimes this division occurs at the site of the main bifurcation of the portal vein, which thus becomes a trifurcation. During cholecystectomy, the right trunk of the portal vein may be damaged near the portal of the liver.

The left trunk of the portal vein curves anteriorly and enters the liver parenchyma at the groove of the round ligament. It then divides into two branches going to the medial and lateral segments of the left lobe. Each segmental branch feeds the upper and lower sections of its segment. Proximal branches from the main right and left trunks of the portal vein depart to the caudate lobe. Venous outflow from the gallbladder in some volume goes to the right portal trunk, but the main amount of blood flows directly into the hepatic bed of the bladder.

Wind G. J.
Applied laparoscopic anatomy: abdomen and pelvis

Examinations of the abdominal cavity and its organs are carried out using real-time devices equipped with linear, convex, sector and special probes with a scanning frequency of 2.6, 3.5, 5 and 7.5 MHz.

Currently, there are four types of ultrasound:

• outdoor,
• through the perineum
• intracavitary,
• intraoperative.

Due to the lack of special probes for endocavitary and intraoperative examinations in the basic device, in practice, the external examination technique is most often used, which we will discuss in more detail.

There are various approaches to the method of external echographic examination of the abdominal cavity and its organs, however, in any case, certain methodological rules should be observed that allow you to get as close as possible to the desired result: a general survey of the abdominal cavity allows you to assess the condition of the subcutaneous fatty tissue, identify hernias and muscle discrepancies the anterior abdominal wall, the condition of the parietal peritoneum and the presence of free fluid in the abdominal cavity; a targeted study of individual abdominal organs allows you to assess the position of the organ, its topographic and anatomical relationship to neighboring organs, mobility, shape, contours, size, condition, ducts, walls, as well as the state of echogenicity of the organ tissue in the form of focal or diffuse changes; a detailed targeted examination allows the study of painful areas, palpable formations and examination of organs with a suspected disease.

The peritoneum as a whole is normally not located. Sometimes at the level of the anterior wall of the abdomen, it is possible to differentiate the parietal peritoneum in the form of a narrow echogenic strip. With large ascites in the form of the same echogenic strip, the location of the visceral peritoneum of the intestinal loops is possible.

Pathology

Peritoneal injury

Self-injuries to the peritoneum are rare. Of sonographic interest is the combination with a wound or trauma of internal organs to determine the nature of the damage, the presence of internal bleeding, peritonitis, etc.

Bleeding in the abdomen

It can be detected with closed injuries of internal organs, most often with ruptures of the intestine with the mesentery, and spleen, as well as with ovarian apoplexy and rupture of tubal pregnancy.

In the first hours after injury, liquid blood is found in the abdominal cavity in the form of anechoic accumulations, which, depending on the change in body position, can change their place and shape. After 24-48 hours, with the onset of the reorganization process, the outflowing blood changes its shape and echogenicity. Echogenic floating or fixed formations (clots) of different sizes are located.

Hematoma

Fresh (post-traumatic or resulting from a violation of the coagulation system) hematoma is located as an anechoic formation of different sizes, indefinite shape and indistinct contours. The aging process can proceed in two phases: a weakly echogenic capsule is formed on the periphery, and in the middle a rounded anechoicity is a false cyst, which in some cases suppurates and turns into an abscess. The second phase is characterized by a decrease in hematoma in size and an increase in its echogenicity with the appearance of elements of calcification.

Diseases

Ascites

This is the accumulation of a large amount of fluid in the abdominal cavity. Common causes of ascites are: pericardial, kidney, alimentary dystrophy in its edematous form, stagnation in the portal vein system due to cirrhosis of the liver or acute hepatitis, peritoneal cancer, ovarian carcinoma, etc.

It should be noted that there is normally a small amount of fluid in the abdominal cavity, in particular, in the retrouterine space and periovarian before menstruation.

Pure uninfected ascitic fluid is located in the form of anechoic zones, in the supine position it accumulates primarily around and in the gates of the liver, in the gallbladder bed. With an increase in volume, the fluid spreads to the lateral parts of the abdomen, the small pelvis and Morrison's space. To detect small amounts of fluid, the study is carried out in different positions of the body and standing. Against the background of a large amount of ascitic fluid, even a small liver, a floating gallbladder with thickened double contours, intestinal loops with their peristalsis, appendicular process, uterus, tubes and ovaries are well located. Often, floating echoes (fibrin) can be seen against the background of the liquid. When infected, the fluid changes its echogenicity upwards, and against its background, an accumulation of small and larger echogenic floating signals (pus) is located.

Due attention should be paid to a good adjustment (contrast and light) of the device, the selection of an adequate probe scan site, because it is possible to artificially create the illusion of the presence or absence of fluid in the abdominal cavity.

Ascites should be differentiated from a number of fluid formations, such as large ovarian cysts, giant myxomas, intestinal echinococcal cysts, mesentery, lipomatosis, and others, which can sometimes occupy the entire abdominal cavity, not allowing you to see the internal organs, and, unfortunately, often such patients attributed decompensated. True, with the help of echography it is always possible to correct this error. For differentiation, the patient should be examined in the prone position through the lumbar region and lateral intercostal spaces. In this case, it is always possible to detect internal organs and some specific features of formations taken for ascites.

Recently, with the help of echography, attempts have been made to distinguish between benign and malignant ascites, especially when it is impossible to identify the site of a cancerous lesion. It is believed that if with benign (cirrhosis) ascites the wall of the gallbladder is always thickened (up to 4 mm or more), with a double contour and the presence of cholesterol stones or sediment (although this may depend on the duration of ascites), then with malignant formations in 97% the wall of the bladder is single, its thickness does not exceed 3 mm, it is absent or is a finding of cholestasis in the gallbladder. With cancerous ascites, intestinal loops are dilated, rigid, without visible peristalsis.

However, these data need to be verified on a large clinical basis.

These assumptions can be confirmed by cytological and laboratory examination of ascitic fluid.

Inflammation of the peritoneum (peritonitis)

Inflammation of the peritoneum can be acute or chronic. According to the nature of the spread of the inflammatory process on the surface of the peritoneum, there are: peritonitis delimited and diffuse (diffuse).

Diffuse peritonitis

Diffuse peritonitis can be local if it occupies one anatomical region of the abdomen and is located in close proximity to the source of infection (acute destructive appendicitis, acute cholecystitis, pancreatitis, perforation of the stomach and duodenal ulcer, intestinal trauma), and widespread if it occupies several anatomical regions of the abdomen i.e. when there are multiple infectious sources. The defeat of the entire peritoneum is called general peritonitis. In clinical practice, there are also peritonitis of unclear etiology, when the focus of infection is not detected on the operating table.

The echographic picture of diffuse peritonitis (local or widespread) depends on the degree of involvement of the peritoneum in the inflammatory process. At the initial stage, the peritoneum is finely compacted, has a whitish tint, and there is a symptom of echo reflection from the compacted wall of the peritoneum, which makes it difficult to visualize the internal organs. In different parts of the abdominal cavity, fluid (transudate or pus) is detected, differentiation is difficult.

Delimited peritonitis (abscesses)

Sonographic diagnosis of delimited accumulations of fluid in the abdominal cavity presents significant difficulties and requires a great skill from a specialist in determining the localization and correct interpretation of the identified pathology. To do this, you must follow certain rules:

• It is good to know the topographic anatomy of the abdominal floors, peritoneal and retroperitoneal spaces - places where accumulations of fluid can most often be detected.
• In the study, all possible positions of the human body should be used, as far as the state of his health allows.
• To improve visualization, it is necessary to use physiological windows (liver, spleen, bladder, etc.).
• For orientation, it is necessary to use anatomical structures adjacent to the focus (liver, gallbladder, pancreas, large vessels, intestinal loops, spleen, bladder, uterus, etc.).

• For the correct echographic interpretation of the detected accumulation of fluid, a comparison should be made with the clinical data of the patient on the day of the study.

Despite certain difficulties, if the researcher has the skill, echography is the only method that allows you to easily diagnose abdominal abscesses. The right half of the abdominal cavity and the left lower quadrant are better visualized. Diagnosis of abscesses in the left upper quadrant is somewhat difficult, the transverse colon and stomach interfere, especially if there is content, as well as the spleen if it is enlarged.

Delimited abscesses of the abdominal cavity are divided according to the clinical course into acute and chronic; by location on the subdiaphragmatic and subhepatic - located in the upper floor of the abdominal cavity; interintestinal - their localization can be very different; small pelvis - are localized: in men in the rectovesical, in women - in the recto-uterine depressions (Douglas space).

The echographic picture is polymorphic and largely depends on the cause leading to the development of an abscess and its evolutionary stage.

Acute abscess

Regardless of the localization, it is an oval-elongated echo-negative formation with irregular angles, with a poorly defined periphery (contours) and a less echogenic middle. Sometimes it is possible to locate floating small-point echogenic inclusions (pus). An acute abscess can end in complete resorption or go into a chronic stage.

chronic abscess

In the process of evolution, echogenicity changes upward. A thick echogenic capsule is formed, the contents are polyechoic, that is, there are foci of high and low echogenicity, and sometimes calcifications.

Right subphrenic abscess

In the classic version, it is located between the echogenic strip of the diaphragm and the liver capsule.

should be differentiated:

- from an abscess located in the liver directly under the capsule. At the same time, the unevenness of the contours of the capsule is located; when the position of the body changes, it does not change its shape, only sometimes you can notice the movement of purulent contents;

- from the presence of fluid in the sinus of the pleural cavity. The latter, when changing the position of the body, especially in the standing position of the patient, changes its shape and position;

- from uncomplicated simple or echinococcal cysts - there is no acute clinic;

- from tumors located on the diaphragmatic surface of the liver, etc.

Left subphrenic abscess

It is very rare and presents great diagnostic difficulties.

Various scanning options are used for research. More often it is possible to detect with intercostal scanning.

should be differentiated:

- from the stomach with the presence of small contents. After applying a water load (2 glasses of water), the contents of the stomach are set in motion, while the abscess does not change its position and shape;

- from dilated intestinal loops with high obstruction, especially when there is no peristalsis;

- from cysts and diverticulum of the intestine;

- from highly located cysts of the left ovary in the absence of the spleen.

In all cases, information about the possible cause of infection and an acute clinic help.

Interintestinal abscesses

Sonographic diagnosis of interintestinal abscesses is sometimes very difficult due to the presence of a number of factors (a large number of intertwined loops of the small intestine, intestinal paresis leading to uneven expansion of the loops, echo reflection from gas and intestinal walls, etc.).

Sometimes with active pressure, you can find a painful localization of the abscess. The examination should be carried out in different positions of the body and using different scanning methods. The best results are obtained with the use of a multihertz probe and repeated studies.

Abscess of the recto-uterine cavity (Douglas space)

It occurs quite often, the causes are destructive forms of acute appendicitis, purulent gynecological diseases and transferred purulent diffuse peritonitis. Sonography is considered a highly effective method for identifying and differentiating purulent foci in this area.

And, despite this, the question arises of differentiation from conditions similar to an abscess, such as:

- tubal rupture during ectopic pregnancy,

- rupture of the follicular cyst,

- cyst infection

- ovarian apoplexy,

- pyosalpinx,

- ureterocele, true and false bladder diverticula,

- the presence of a small amount of blood after an injury,

- the presence of a small amount of fluid before menstruation and other conditions.

Each of these conditions has a specific clinical picture, and their echocardiography is described in the relevant sections.

Echography is a highly informative method for diagnosing most postoperative liquid (abscesses) and solid (infiltrates) formations of the abdominal cavity, it makes it possible to determine their localization, monitor the dynamics of their development, exercise control, including puncture biopsy, help the surgeon in choosing the right treatment tactics (conservative or surgical ).

SURGICAL ANATOMY OF THE LIVER AND BILIC TRACKS

prof. G.E. Ostroverkhov, V.F. Zabrodskaya

Chapter V from the capital work, compiled under the editorship of Academician of the USSR Academy of Medical Sciences A.N. Maksimenkov "Surgical anatomy of the abdomen", 1972.

The liver (hepar - Greek) is one of the largest organs of the human body. It is located in the upper floor of the abdominal cavity, occupying the right subdiaphragmatic space, the epigastric region and partially the left hypochondrium.

Approximately, the projection of the liver onto the chest wall is determined by the following features: the highest point of the upper border of the liver reaches the level of the VI costal cartilage along the nipple line - on the left, the V costal cartilage - on the right, and the anterior-lower edge of the liver is determined in greater parts at the level of the tenth intercostal space along the first axillary line.

The liver tissue is quite dense, but easily traumatized, even with a slight impact on this organ. The peritoneal cover of the liver provides little protection from external influences; after damage to it, the loose tissue of the liver is easily destroyed in any direction, which explains the relatively frequent ruptures of the liver with a closed abdominal injury.

The color of the liver varies depending on the age and pathological conditions of the organ. So, in children it is bright red, in the elderly - cherry with a brownish tint; the anemic liver has a pale gray color, with obstructive jaundice it is yellow-brown, with cirrhosis it is gray with a red tint.

The weight of the liver is subject to large fluctuations - in the range of 1200-1800 g for an adult. The relative sizes of a liver and its weight considerably change depending on age. A. Fisher (1961) indicates that the range of fluctuations in the weight of the liver can reach 20-60 g per kilogram of body weight, and in some diseases, such as hypertrophic cirrhosis, the weight and volume of the liver increases by 3-4 times compared with the average norm (1500 g). During the first months of life after birth, the liver undergoes the greatest changes in both size and shape of the organ. So, for example, the liver of newborns and children of the first month of life occupies 1/2 or 1/3 of the abdominal cavity, averaging 1/18 of body weight, while in adults the weight of the liver decreases to 1/36 - 2.3% ( Yu.E. Vitkind, 1940).

Unlike adults, the size of the left lobe of the liver in newborns is the same as the right, and sometimes more than it (B. G. Kuznetsov, 1957; V. S. Shapkin, 1964, etc.). This fact is explained in the best blood supply to the left lobe of the liver in the embryonic period (AV Melnikov, 1922; Elias a. Petty, 1952). But already by the age of three, the liver acquires almost the same ratio with the organs of the abdominal cavity as in adults, although its lower border in children protrudes lower in relation to the costal arch due to the short chest of the child.

Liver function.

The liver is of great importance in the process of digestion and in inter-duck metabolism.

In carbohydrate metabolism, the role of the liver is to retain the sugar that comes with the blood from the intestines. The bulk of the carbohydrates brought to the liver by the blood of the portal vein is processed here into glycogen, which can be stored in the liver for a long time and automatically regulate the level of sugar in the peripheral blood in accordance with the needs of the body.

The role of the liver in the detoxification of decay products that appear in the process of metabolism and absorption is great, as an organ located on the path of blood flow from the intestines to the general circulatory system (neutralization of intestinal toxins, toxic drugs, etc.) .

On this path there are two filters for products entering the blood through the intestines: the first is the capillaries of the intestinal wall and the second is the capillaries of the liver parenchyma with a complex structure of cells with specific functions.

The liver and kidneys are organs that are functionally related to each other. The antitoxic function of the liver is complemented by the excretory function of the kidneys. The liver destroys poisons, the kidneys secrete less poisonous products resulting from the neutralizing activity of the liver. Therefore, these two organs are often affected simultaneously or sequentially in a particular disease. Acute liver and kidney failure is sometimes the main cause of death after operations on the liver and biliary tract.

Equally important is the role of the liver in protein metabolism. It processes amino acids, synthesizes urea, hippuric acid and plasma proteins. Further, prothrombin is produced in the liver, which plays a decisive role in the process of blood coagulation.

The liver also takes part in fat and lipid metabolism (synthesis of cholesterol and lecithin), in the production of bile pigments and in the circulation of urobilin (liver - bile - intestines - portal blood - liver - bile, according to A. L. Myasnikov, 1956).

Hepatic cells are known to have bilateral secretion properties. Some of the substances that enter the liver from the blood are secreted into the bile capillaries in the form of bile, and all the rest (urea, etc.) return back to the blood. In case of blockage of the bile ducts, the bile accumulating in the lobules penetrates the membranes of the blood vessels and enters the bloodstream, causing jaundice.

The role of the liver in vitamin balance (vitamins A, B, D, K) and in salt metabolism is important.

The liver, in addition to metabolic and protective functions in the body, plays an important role in lymphatic separation and lymph circulation. Lymph circulation and bile circulation in the liver are interconnected with each other. So, in the experiment after ligation of the common bile duct, the content of free and bound bilirubin in the lymph increases, bile acids and bilirubin can be detected in the hepatic lymph even earlier than in the blood. When draining the thoracic lymphatic duct in an experiment with ligation of the common bile duct, as well as in patients with obstructive jaundice, the level of bilirubin in the blood and lymph decreases. V. F. Zabrodskaya (1962), S. I. Yupatov (1966), A. Z. Aliev (1967) injected the lymphatic vessels of the liver of living animals and human corpses through the common bile duct. At the same time, the injection mass stained not only the bile ducts, but also the lymphatic vessels of the liver: 3-5 minutes after the start of the injection, the lymphatic vessels that emerged from the gates of the liver became visible. In the liver, the mass filled the bile ducts, interlobular and intralobular bile ducts; in large quantities was in the Kupffer cells that form the walls of the venous sinuses, as well as in the spaces of Disse (between the liver cells and the venous sinuses). There was a communication of mass-filled spaces of Disse with perilobular lymphatic fissures, which are located on the border between the hepatic parenchyma and interlobular connective tissue. Mascara was also found in the interlobular lymphatic vessels.

Thus, in conditions of obstructive jaundice, bile can enter the bloodstream not only through the system of hepatic veins and the inferior vena cava, but also through the lymphatic vessels of the liver into the lymphatic collectors of the retroperitoneal space, the thoracic lymphatic duct and through the superior vena cava. This circumstance should be taken into account when performing operations on the extrahepatic biliary tract in patients with obstructive jaundice. Damage to the lymphatic vessels in the hepatoduodenal ligament in such cases can be accompanied not only by lymphorrhea, but also by the flow of bile into the abdominal cavity.

Blood is supplied to the liver through the portal vein and the hepatic artery. The portal vein collects blood from almost the entire intestine, stomach, spleen and pancreas. The blood entering the liver through this vein is rich in chemical products, which form the basis of synthesis in the process of digestion. The volume of blood entering the liver through the portal vein reaches two thirds of the circulating blood in the organ, and only one third of the blood passes through the hepatic artery.

Nevertheless, the importance of the hepatic artery for the life of the liver is great, since the blood brought by this vessel is rich in oxygen. From this, the complications arising from the ligation of the hepatic artery become clear.

The liver tissues receive a huge amount of blood (84 mg of blood per minute passes through 100 g of the liver); at the same time, the blood flow in the organ is slowed down, which contributes to the most complete exchange between blood and liver cells.

The slowdown in blood flow in the liver is explained by the presence in the organ of a huge network of capillaries, which has a large cross-sectional area approaching 400 m 2, as well as the presence in the hepatic vessels, especially in the hepatic veins, of sphincters that regulate the movement of blood, depending on the nature substances contained in the blood passing through the liver.

The presence of sphincters in the hepatic veins explains such a violation of hemodynamics, when an outflow block occurs, which leads to a dangerous overflow of the liver with blood.

The hemodynamics of the portal blood supply is a complex and at the same time simple system that provides a gradual drop in high blood pressure in the mesenteric arteries to the lowest levels in the hepatic veins. The blood of the mesenteric arteries under pressure of 120-100 mm Hg. Art. enters the network of capillaries of the intestine, stomach, pancreas; pressure in the capillaries of this network averages 10-15 mm Hg. Art. From this network, blood enters the venules and veins that form the portal vein, where blood pressure normally does not exceed 5-10 mm Hg. Art. From the portal vein, blood is directed to the interlobular capillaries, from there the blood enters the hepatic vein system and passes into the inferior vena cava. The pressure in the hepatic veins ranges from 5-0 mm Hg. Art. (Fig. 168).

Rice. 168. Scheme of the structure of the portal channel and the difference in blood pressure.

1 - aorta; 2 - hepatic artery; 3 - mesenteric arteries; 4 - the first network of capillaries of the portal channel; 5 - portal vein; 6 - the second (intrahepatic) network of capillaries of the portal bed; 7 - hepatic veins; 8 - inferior vena cava (according to V. V. Parin and F. Z. Meyerson)

“Thus, the pressure difference between the beginning and end of the portal bed, which ensures the forward flow of blood in the portal system, is 90-100 mm Hg. Art. " (V. V. Parin, F. Z. Meyerson, 1960). In total, an average of 1.5 liters of blood per minute flows through the portal channel in a person, which is almost 1/3 of the minute total blood volume of the human body. As experimental studies and clinical observations have shown, liver function in some cases is preserved when the portal vein is turned off or when the hepatic artery is ligated at a certain level. This fact can be explained by the presence of portacaval, porta-arterial and arterial anastomoses, as well as the existence of accessory liver arteries. According to V. V. Larin and F. 3. Meyerson, it is also necessary to take into account the fact that after the portal blood flow is turned off, the hepatic artery compensates for the blood supply to the liver.

The hepatic veins, together with the portal vein system, are a huge blood depot, which is important in hemodynamics both under normal and pathological conditions. In the vessels of the liver, more than 20% of the total blood volume can simultaneously fit.

The significance of the blood deposition function in the norm lies in the fact that it ensures the timely supply of a sufficient amount of blood to the most intensively functioning organs and tissues. So, during physical work, a large amount of liver blood is quickly released, which increases blood flow to the heart and working muscles. With large blood loss, against the background of a reduced blood flow to the liver, there is an active expulsion of blood from the depot into the general circulation. In the occurrence of this reaction, both during physical exertion and during massive blood excitation plays an important role in lossessympathetic nervous system and adre nalinemia.

Under pathological conditions, the ability of the portal bed to deposit blood reaches dangerous proportions. This is observed, in particular, in severe forms of shock, when there is an overflow of blood vessels in the abdominal cavity. As a result, 60-70% of the entire blood of the body can accumulate in the portal channel (“bleeding into the vessels of the abdominal cavity”), and a sharp anemia of the heart and brain occurs.

V. A. Bets back in 1863 gave a very original interpretation of the mechanism of intrahepatic circulation. It boils down to the fact that the speed of blood movement in the hepatic artery is two times less than in the portal vein system; as a result of a decrease in pressure in the portal vein, an increased arterial blood flow occurs, and vice versa.

With cirrhosis of the liver, intrahepatic circulation is completely rebuilt due to the presence of fibrosis, leading to the death of sinusoids and the development of functioning arteriovenous fistulas. The latter, depending on the specific situation, are able to conduct arterial blood both in the direction of the extrahepatic network of the portal vein, which determines the occurrence of vicious hepatofugal circulation, and in the direction of the hepatic veins.

Hepatofugal circulation occurs in the direction of such outflow tracts, where the pressure is less and the lumen of the veins is wider.

According to D. G. Mamatavrishvili (1966), the purpose of arteriovenous anastomoses that develop in cirrhosis of the liver in various organs of the epigastrium is to ensure a roundabout movement of blood to the heart. By the presence of arterio-venous anastomoses, he also explains the paradoxical phenomenon that after the operation of a port-caval shunt, high pressure in the portal vein system decreases.

Regeneration of liver tissue.

An important problem in practical surgery is the issue of establishing the limits of liver removal that are compatible with the life of the patient, and the potential properties of the liver tissue for regeneration after removal of a part of the organ during surgery. According to Mallet-Guy (1956) and other authors, the liver has rich regenerative abilities, and in a short time after extensive resections, its volume can be completely restored (AM Dykhno, 1955).

In experiments, it was found that dogs satisfactorily tolerate the removal of 3/4 of the liver. After a few weeks, the liver regenerates and reaches 4/5 of its original size B. P. Solopaev (1962), Z. A. Ryabinina and A. B. Ustina (1963) in experiments on young monkeys (rhesus monkeys) found that after the removal of 1/4 of the liver within two weeks, there is a complete restoration of the initial weight of the liver.

The newly formed hepatic tissue differs from normal only in some structural atypism. VS Surpina (1963) reported a case of removal of 2/3 of the liver in a young man after an injury. Despite the severe postoperative course, the patient recovered by the 50th day and subsequently became healthy.

The good regenerative capacity of the liver served as the basis for the emergence of a surgical method for the treatment of cirrhosis by resection of sections of this organ.

The studies of B. P. Solopaev, Yu. P. Butnev and G. G. Kuznetsov (1961, 1963) proved that the normalization of a cirrhotic liver in animals is significantly accelerated after resection of its site, the removed part of the liver is restored according to the type of compensatory hyper- trophies, although after 10-12 months the regenerated area was again subjected to cirrhotic degeneration.

Embryogenesis of the liver and bile ducts

The laying of the liver occurs in the third week of embryonic development. The endodermal epithelium of the ventral wall of the middle intestine near its beginning forms a saccular protrusion, which is called the hepatic bay or hepatic diverticulum.

In the process of differentiation of the midgut into sections, the hepatic diverticulum is included in the ventral wall of the emerging duodenum. At the same time, the ventrocranial wall of the hepatic bay begins to grow in the form of a labyrinth of branching and anastomosing cell strands with each other. Thus, the hepatic bay turns out to be subdivided into two parts: ventrocranial (branched) and dorsocaudal (smooth-walled). The ventrocranial part of the hepatic bay is the laying of the hepatic ducts and the glandular tissue of the liver; the dorsocaudal part of the hepatic bay constitutes the anlage of the bile duct and the primary gallbladder (Fig. 169). The ventrocranial part of the hepatic bay is located between the sheets of the ventral mesentery of the midgut in the form of numerous outgrowths of glandular cells, from which hepatic beams are subsequently formed. It grows especially fast. At the same time, a labyrinth of wide capillaries, the so-called sinusoids, develops between the hepatic beams.

Rice. 169. Development of liver anlages and pancreas.

1 - pharyngeal pocket; 2 - trachea; 3 - pulmonary kidney; 4 — septum transversum ; 5 - hepatic beams; 6 - hepatic ducts; 7 -gallbladder; 8 - ventral pancreas; 9 - two-duodenal ulcer; 10 - dorsal pancreas;11 - esophagus.

The dorsocaudal part of the hepatic bay differentiates much more slowly. Its ventrocranial wall is initially the site of the confluence of the hepatic ducts, while the dorsocaudal wall, gradually protruding in the form of a sac, is the anlage of the primary gallbladder.

The growth of the primary gallbladder in the ventrocaudal direction causes the differentiation of this rudiment into two sections: the definitive gallbladder and the cystic duct. Violation of the laying and growth process of the primary gallbladder can explain the anomalies and structural variants of the definitive gallbladder and cystic duct. Thus, the absence or incomplete laying of the primary gallbladder is accompanied by agenesis or various variants of underdevelopment of the definitive gallbladder with rare cases in the postnatal period of the confluence of the hepatic ducts directly into the cranial wall of the gallbladder or its duct, as well as bifurcation of the cystic duct.

Approximately in 0.003% of cases (Boyden, 1940) there is a laying of not one, but two primary gallbladders, which leads to the development of two definitive gallbladders with two cystic ducts, and if two protrusions develop only in the area of ​​the bottom of the primary gallbladder, then two definitive gallbladders with one cystic duct are formed.

In the process of development, there may be some deviation in the direction of growth of the primary gallbladder, which in turn determines the whole variety of forms of the external structure and position of the definitive gallbladder. For example, the growth of the primary gallbladder only in the caudal direction leads to its introduction into the cavity of the coelom and the formation of the mesentery (vagrant gallbladder), growth in the cranial direction - to the intrahepatic location, and, finally, to the sides - to the transverse position. bubble.

As the liver tissue develops, the latter is introduced between two sheets of splanchnopleura, which forms a ventral mesentery at this level of the intestine. In the process of growth, the peritoneal cover of the liver develops from the splanchnopleura. At the same time, from the cells of the mesenchyme surrounding the yolk vein, a connective tissue capsule of the liver is formed, from which interlobular processes develop, dividing the liver into separate lobes. Mesenchymal cells are also the structural basis for the formation of smooth muscles of the intrahepatic bile ducts.

Development of blood vessels in the liver. The yolk-mesenteric veins of the early stages of embryos pass from the yolk sac to the heart through the site where the liver develops. Growing strands of hepatic cells divide these veins into plexuses consisting of small vessels (sinusoids) that branch out between the hepatic beams. This is how the laying of the intraorgan system of the portal vein occurs.

After the regression of the yolk sac, the paired yolk-mesenteric veins, when approaching the liver, are connected to each other by jumpers, as a result of which these veins partially become empty, which leads to the formation of an unpaired portal vein (Fig. 170).

At the fifth week of development, lateral branches arise from the sections of the umbilical veins adjacent to the liver, which, growing into the liver, come into contact with the vitelline-mesenteric veins of the corresponding side. Thanks to this, blood from the umbilical veins begins to flow to the liver and here it mixes with the blood of the yolk veins. Since this process is continuously growing, the cranial sections of both umbilical veins, located between the Cuvier ducts and the liver, gradually become empty and atrophy. Thus, at the sixth week of development, all blood entering through the umbilical veins, before entering the common vascular bed of the embryo, mixes with the blood of the yolk veins and is filtered through the liver.

At the sixth week of development, asymmetry in the structure of the umbilical veins is outlined; the right umbilical vein is gradually obliterated. Placental blood increasingly begins to flow to the liver through the left umbilical vein. As you know, in adults, one left umbilical vein remains, which flows into the left trunk of the portal vein.

With an increase in the volume of the liver, a large vessel is formed that passes through the parenchyma of this organ, the so-called venous duct (ductus venosus - Arantia duct), which connects to the hepatic veins and the inferior vena cava (see Fig. 170). This explains the presence in rare cases of congenital malformations in the form of non-closure of the Arantzian duct in the postnatal period, as a result of which the portal vein communicates with the inferior vena cava.

A functional feature of the blood circulation of the embryo is that nutrients enter the portal system of the liver not from the intestine, but from the placenta. Placental blood, rich in nutrients, enters the liver through the umbilical vein and mixes with the blood of the portal system.

Rice. 170. Embryology of liver vessels (Netter scheme).

a: 1 - venous sinus; 2 - intestine; 3 - common cardinal veins; 4 - umbilical veins; 5 - liver; 6 - yolk veins; 7 - gut;

b: 1 - venous sinus; 2 - umbilical veins; 3 - proximal anastomosis of the vitelline veins; 4,8 - right and left anastomoses of the umbilical veins with sinusoids of the liver; 5 — an average anastomosis of vitelline veins; b - distal anastomosis of the vitelline veins; 7 - intestines;

in: 1 - obliterated umbilical veins; 2 - ductus venosus; 3 - non-blistering area of ​​the left umbilical vein, passing into the venous duct;

g: 1 - diaphragm; 2 - hepatic veins; 3 - ductus venosus; 4 - left umbilical vein; 5 - portal vein; 6 - splenic and mesenteric veins; 7 — the right part of the obliterated vitelline vein.

It should be noted that neither the embryo nor the adult has a separate venous outflow of the blood that enters through the hepatic artery. Arterial blood, after it passes through the small vessels of the stroma of the liver, enters the sinusoids, from which the blood leaves along with the portal blood, passes into the central veins, following further through the sublobular veins into the inferior vena cava.

It must be emphasized that in a person during his development, three different circulatory systems are observed: yolk, placental and pulmonary, successively replacing one another. The yolk system functions for a very short time and is replaced by placental circulation, which persists until the end of uterine life.

The ratio of the liver to the ventral mesentery (mesogastrium ventrale) changes in different periods of the embryonic life of the fetus: the latter gradually loses its mass and turns from a thick layer into a thin duplication of the peritoneum. The initial sagittal position of the ventral mesentery is completely preserved in the sector between the liver and the anterior wall of the abdomen in the form of a falciform ligament (lig. falcirarme).

As for the section of the ventral mesentery between the intestines and the liver, due to the rotation of the stomach, it partially assumes a frontal position, forming the hepatoduodenal ligament, partially retains the sagittal position, forming the hepatogastric ligament. This is confirmed by the fact that the hepatoduodenal ligament is attached to the transverse sulcus of the liver, the hepatogastric ligament - to the back of the left sagittal sulcus.

After the blood supply pathways of the liver bookmark are formed, the latter grows especially actively and fills almost the entire abdominal cavity. Due to the rapid increase in the volume of the liver, the loops of the intestinal tube of the embryo, formed from the umbilical loop, protrude from the abdominal cavity into the umbilical cord. As a result, in the second month of uterine life, a physiological umbilical hernia is obtained.

Later, the growth rate of the liver decreases, while the abdominal wall grows rapidly. As a result, in the third month of uterine life, the umbilical loop of the intestine returns from the umbilical cord to the abdominal cavity, making a turn around its axis.

In a six-week-old embryo, the liver already reaches a considerable size, maintaining a connection with the stomach in the form of a lig. hepatogastricum and with the anterior wall of the body using the crescent ligament (Fig. 171).

Ryas, 171. The relationship of the liver of a 6-week-old embryo with the leaves of the ventral mesentery.

1 - dorsal mesentery; 2 - spleen; 3 - truncus coeliacus; 4 - pancreas; 5-a. mesenterica superior; 6 - intestinal loop; 7-lig. teres hepatis; 8-lig. hepatoduodenale; 9-liver; 10-lig. falciforme; 11-lig. hepatogastricum; 12 - stomach.

Anatomical characteristics of the liver

Shape of the liver. The liver has a wedge-shaped shape with smoothed edges. The base of the wedge belongs to the right half; its thickness gradually decreases towards the left lobe. The shape and size of the liver is not constant. In adults, the length of the liver reaches an average of 25-30 cm, width - 15-20 cm and height - 9-14 cm. The shape of the liver depends on the age, physique of the person and a number of other reasons. Pathological conditions are also reflected in the shape of the organ.

Individual differences in the shape of the liver. B. G. Kuznetsov, according to the outlines of the lower surface of the organ, distinguishes: oval, rectangular, irregular and triangular shape of the liver. V. S. Shapkin offers a more objective classification of liver forms. He distinguishes: 1) the liver is wide, when its longitudinal size is almost equal to or slightly exceeds the transverse one; 2) an oblong liver, when the length of the organ is 1/3 or more greater than its transverse size; 3) triangular-shaped liver; 4) an irregularly shaped liver, when there are large constrictions between the lobes, significant protrusion or, conversely, retraction of some lobes or segments (Fig. 172).

Rice. 172. Individual differences in the shape of the liver.

a - a wide liver with a small left lobe and impressions from the ribs on the right lobe;

b - a long liver of a "saddle-shaped" shape, which has a relatively large left lobe;

in — a liver which right share has a tongue-like form a shoot;

g - a long liver, on the diaphragmatic surface of the right lobe of which there are grooves.

Often, with various forms of the liver, significant deviations from the usual sizes of the liver lobes are noted. Most often, there is a small left “classic” in volume.

A decrease in the size of the lobe may be the result of true hypoplasia, as well as atrophy caused by the pathological process. In cases of true hypoplasia, the structure of the liver tissue is not disturbed, with pathological hypoplasia associated with impaired blood circulation, bile secretion, cirrhosis of the liver, not only a decrease in the proportion, but also a violation of the structure of the liver tissue occurs.

There are cases of additional lobes of the liver, which, as a rule, are ectopic and are located in various places: under the left dome of the diaphragm (V. S. Zhdanov, 1957), retroperitoneally under the duodenum, sometimes penetrate into the chest cavity through a defect diaphragms.

surface of the liver.

The liver has two surfaces: visceral (fades visceralis) and diaphragmatic (facies diaphragmatica). On the diaphragmatic surface of the liver, the upper, anterior, right and posterior parts are distinguished. The anterior edge of the liver is always sharp, while the posterior and inferior ones are more or less rounded. On the front edge of the liver there is a notch (incisura lig. teretis), through which a round ligament passes. The diaphragmatic surface of the liver has a generally uniform bulge corresponding to the shape of the diaphragm (Fig. 173).

Rice. 173. View of the liver from the diaphragmatic and visceral surface.

a - diaphragmatic surface of the liver: 1 - right triangular ligament; 2 - diaphragm; 3 - coronary ligament; 4 - left triangular ligament; 5 - left share; 6 - crescent ligament; 7 - round ligament; 8-umbilical notch; 9 - gallbladder; 10—right share;

b - visceral surface of the liver: 1 - fibrous process; 2 - esophageal depression; 3 - fossa venous duct; 4 - caudate lobe; 5 - inferior vena cava; 6 - renal depression; 7—right share; 8 - impression from the duodenum; 9 - depression from the transverse membrane; 10 - gallbladder; 11 - square share; 12 - round connected; 13 - crescent ligament; 14 - groove of the umbilical vein; 15 - impression from the stomach; 16 - left lobe.

The relief of the visceral surface of the liver (see Fig. 173) is uneven, it is crossed by grooves, there are impressions from the internal organs adjacent to the bottom. On this surface of the liver there are two longitudinal grooves and one transverse, which, by their location, resemble the letter H. The transverse groove corresponds to the portal of the liver (porta hepatis). Here vessels and nerves enter, bile ducts and lymphatic vessels leave the liver. The right longitudinal groove in its anterior part contains the fossa of the gallbladder, and in the posterior part - sulcus venae cavae. The left longitudinal groove is a narrow, rather deep gap that separates the left lobe of the liver from the right. In the posterior half of the left sagittal sulcus, there is the remainder of the venous duct (ductus venosus, s. ductus Arantii), which connects the left branch of the portal vein with the inferior vena cava in fetal life. The anterior part of this groove contains a round ligament of the liver (lig. teres hepatis), in which the umbilical vein mainly lies. According to the Parisian nomenclature, the left sagittal sulcus in the anterior section is called fissura lig. teretis or sulcus v. umbilicalis, and in the back - fissura lig. venosi or fossa ducius venosi.

The size and shape of the left sagittal sulcus is individually variable. The furrow may look like a very narrow slit, the bottom of which does not exceed 2-3 mm; in other cases, the width of its base is 2.0-2.5 cm. Above the groove and the round ligament, very often (in 11% of cases - according to V. S. Shapkin), there is a bridge from the hepatic parenchyma or peritoneal duplication, connecting between a square and left lobes of the liver. In some cases, the square lobe almost completely merges with the left lobe, a fissura lig. teretis in this case is weakly expressed or completely absent, and the round ligament of the liver passes in the canal formed by the liver tissue. In the presence of a parenchymal bridge over the left sagittal sulcus, the border between the left and square lobes is smoothed out. However, sometimes (13.3% of cases - according to B.V. Ognev and A.N. Syzganov, 1957), the left sagittal sulcus is through for a significant part of its path, causing a pronounced separation from each other of the square and left lobes.

Lobes of the liver.

The liver is subdivided into unequal right and left lobes. The border between them is the crescent ligament located on the diaphragmatic surface of the liver (lig. falciforme hepatis). On the visceral surface, the liver is distinctly divided into right and left lobes by fissura sagittalis sin.

In addition, the square and tail lobes are distinguished, which are usually attributed to the right lobe. The square lobe, enclosed by the anterior sections of the two longitudinal grooves, has a quadrangular shape. Between the posterior sections of the longitudinal furrows is the tail lobe of the liver. The square lobe of the liver is separated from the caudate transverse groove corresponding to the gates of the liver.

The division of the liver into lobes based on external morphological features is currently being revised in connection with the latest anatomical and clinical data regarding the architectonics of the intrahepatic vessels and bile ducts. Similar to the doctrine of the segmental structure of the lungs, new classifications of the lobar and segmental structure of the liver have arisen (Couinaud, 1957; Healey, Schroy, 1953). According to modern research, the anatomical units of the liver (segments, sectors and lobes) are separated from each other by small vascular grooves (gaps).

The gates of the liver (porta hepatis) are located on its visceral surface in the region of the transverse groove. At present, the term “gate” of the liver is commonly understood to mean not only the transverse sulcus, but also the left longitudinal sulcus, into which large branches of its vessels and bile ducts extend (B. V. Shmelev, 1961; V. S. Shapkin , 1964; V. F. Zabrodskaya, 1965; A. I. Krakovsky, 1966). The anterior border of the gate of the liver forms the posterior edge of the square lobe, the right - the right lobe. The posterior border of the gate is formed by the tail-thai and partially the right lobe. On the left, the gate of the liver is limited by the right edge of the left lobe. The transverse size of the gate ranges from 2.7 to 6.5 cm, the anterior-posterior size of the transverse slit varies from 0.6 to 3 cm, the depth is from 1.0 to 2.6 cm (M. D. Anikhanov , 1963). The gates of the liver are a zone where the vessels and ducts are located superficially, outside the liver parenchyma and are relatively easily accessible to surgical treatment. Vessels and bile ducts in the left half of the gates of the liver are more accessible to processing than in other parts of them.

Individual differences in the forms of the gates of the liver can be reduced to three types: closed, open and intermediate. With the gate open, the wide transverse sulcus communicates freely with the left sagittal and accessory sulci. (The anterior-right corner of the hilum of the liver often continues into the parenchyma of the right lobe in the form of a rather deep notch, from a few millimeters to 2 cm). This form of the gate creates favorable conditions for access not only to the share, but also to the segmental vessels and ducts. When the hilum is closed, there is no communication with the left sagittal sulcus. The dimensions of the gates are reduced due to the presence of a parenchymal bridge connecting the square lobe with the “classic” left lobe of the liver. Other additional furrows of the gate are absent. With a closed form of the gate, the isolation of segmental vessels and ducts in the gates of the liver without dissection of the parenchyma is impossible. The portal of the liver of an open form is observed in 20-50% of the preparations. V. B. Sverdlov (1966), in the study of 202 isolated organs, established an open form in 61.4% of cases.

The location of the gates of the liver in relation to its anterior and posterior edges is also of practical importance in surgery. A liver is distinguished with a gate located in the middle, with a gate shifted backwards, and with a gate shifted anteriorly. When the gate is displaced posteriorly, more difficult conditions are created for prompt access to the vessels and ducts of the portal system when performing liver resections and operations on the biliary tract.

Peritoneum and ligaments of the liver.

The liver is covered with peritoneum on all sides, with the exception of the gate and the dorsal part of the diaphragmatic surface. Thus, the liver belongs to the group of mesoperitoneal organs. The peritoneal cover during the transition from the liver to the diaphragm, the abdominal wall and adjacent organs forms its ligamentous apparatus. Ligaments of the liver in ontogenesis arise from the ventral mesentery (see Fig. 171, 173).

The following ligaments are distinguished: crescent ligament - lig. falciforme hepatis - stretched almost in the sagittal plane between the diaphragm and the convex surface of the liver. Its length from the coronary ligament to the anterior edge of the liver reaches 8-15 cm, on average it is 10 cm, its width is 4-7 cm, on average 5 cm. In the posterior section, it is located corresponding to the midline of the body; at the level of the anterior edge of the liver, it deviates 4-9 cm to the right of it.

The round ligament of the liver, with which the anterior end of the falciform merges, first lies in the groove of the umbilical vein (sulcus v. umbilicalis) on the lower surface of the liver, and then, heading forward and down, ends in the navel. The umbilical vein is located in the round ligament of the liver. During fetal development, the umbilical vein connects the placenta (brings arterial blood from it) with the left branch of the portal vein. After birth, this vein does not become empty, but is in a collapsed state. In practical surgery, the umbilical vein is used to contrast the portal vein system and to administer drugs for liver diseases (G. E. Ostro-top, T. A. Suvorova, A. D. Nikolsky, 1964).

Coronary ligament of the liver - lig. coronarium hepatis - goes from the lower surface of the posterior diaphragm to the border between the upper and posterior parts of the diaphragmatic surface of the liver. The coronary ligament is located in the frontal plane. It runs to the right and left of the falciform ligament. While the leaves of the coronary ligament to the left of the lig. falciforme hepatis closely adjacent to each other, the peritoneal sheets of the coronary ligament, located to the right of the falciform ligament, diverge at a great distance. In this regard, the upper sheet of the coronary ligament, which runs from the diaphragm to the liver, is also called the hepatic-phrenic ligament, and the lower one, passing from the liver to the kidney, is called the hepato-renal ligament. In the medial part of the hepato-renal ligament, the inferior vena cava passes, v. cava inferior. Between the hepato-diaphragmatic and hepato-renal ligaments, or rather, between the sheets of the coronary ligament, there is a surface of the liver not covered by the peritoneum, directly fused with the diaphragm. Length lig. coronarium hepatis fluctuates within 5-20 cm, reaching an average of 15 cm. The most terminal parts of the coronary ligament (near the right and left edges of the liver) pass into triangular ligaments.

Left triangular ligament - lig. triangulare sinistrum - stretched between the lower surface of the diaphragm and the convex surface of the left lobe of the liver. It is clearly visible if the left lobe of the liver is pulled down and to the right, and the costal arch is slightly raised upwards. This ligament is located in the frontal direction, 3-4 cm anterior to the abdominal esophagus (VM Omelchenko, 1965); on the right, it passes into the coronary ligament of the liver, and on the left it ends with a free edge, the length of which is on average 5 cm. On the convex surface of the left lobe, the ligament extends for 5 cm.

Right triangular ligament - lig. triangulare dextrum - located between the diaphragm and the right lobe of the liver. It is less developed than the left triangular ligament.

The hepatic-gastric ligament (lig. hepatogastricum), hepatic-duodenal ligament (lig. hepatoduodenale), hepato-renal ligament (lig. hepatorenale) and in some cases lig. hepatocolicum.

Lig. hepatoduodenale, lig. hepatogastricum and lig. gastrophrenicum, connecting the duodenum, the cardial part of the stomach and its lesser curvature with the diaphragm and the liver, constitute the lesser omentum (omentum minus).

The lesser omentum as a whole is a (approximately) frontally located duplication of the peritoneum, which stretches from the lesser curvature of the stomach and upper part of the duodenum to the liver. Both sheets of the peritoneum of the lesser omentum recede (depart) from each other in the region of the gate of the liver, where they continue into the peritoneal cover of this organ. The anterior plate of the lesser omentum passes here to the left lobe of the liver, and the posterior plate to the caudate lobe.

In the structure of the lesser omentum, the hepatoduodenal ligament is important. To the left, the hepatoduodenal ligament continues into the hepatogastric ligament, to the right, it ends with a free edge. The length and width of the ligament varies on average within 4-6 cm. The ligament is located to the right of the midline of the body, at a depth of 7-12 cm from the anterior abdominal wall. Anteriorly, the hepatoduodenal ligament is covered by the square lobe of the liver and partly by the gallbladder. Behind it is the stuffing hole. The hepatoduodenal ligament becomes clearly visible if the upper horizontal part of the duodenum is pulled down and slightly to the left, and the liver and gallbladder are lifted up. Between the sheets of the hepatoduodenal ligament are the blood and lymphatic vessels, bile ducts and nerves of the liver. On the left is a. hepatica, on the right - ductus choledochus, between them and behind - v. portae (Fig. 174).

Rice. 174. Hepatoduodenal ligament.

a - blood and bile ductslig. hepatoduodenale: 1 - gallbladder; 2 - square lobe of the liver; 3 - tailed lobe; 4 - round ligament; 5 - left share; 6 - places of attachment of the hepatogastric ligament; 7 - lesser curvature of the stomach; 8 - pylorus; 9 - common hepatic artery; 10 — top smssntstrialnye vessels; 11 - pancreatic-duodenal artery; 12 - head of the pancreas; 13 - duodenum; 14-a. hepaticapropria; 15 - common bile duct; 16 - portal vein; 17 - cystic duct; 18 - hepatic duct; 19 - cystic artery; 20 — the right branch of own hepatic artery; 21 - hepatoduodenal ligament;

b- arteries of the biliary tract (scheme): 1 - a. hepatica propria; 2-a. gastroduodenalis; 3 - a. pancreaticoduodenalis sup.; 4 - a. mesenterica sup.; 5 a. cystica

In addition, in the thickness of the hepatoduodenal ligament are the hepatic and cystic ducts, which form the common bile duct, branches of the hepatic artery, lymphatic vessels and several lymph nodes, one of which almost always lies at the confluence of the cystic and hepatic ducts, and the other is at the free edge of the ligament. The hepatic artery is surrounded by the plexus hepaticus anterior, and between the portal vein and the bile duct is the plexus hepaticus posterior. In the lowest part of the ligament, the right gastric (a. et v. gastricae dextrae) and gastroduodenal (a. et v. gastroduodenalis) vessels also pass.

In case of bleeding from the liver, you can quickly squeeze the blood vessels passing in the hepatoduodenal ligament with two fingers.

The stuffing bag - bursa omentalis (see Fig. 48), otherwise called the small peritoneal sac, limits the slit-like space under the liver, located mainly behind the stomach and hepatogastric ligament. The bag communicates with a large peritoneal sac through the omental opening - foramen epiploicum (Winslowi). This hole is located near the gates of the liver and is bounded in front by the hepatoduodenal ligament, behind - by the inferior vena cava, covered by the posterior leaf of the peritoneum (lig. hepatorenale), from above - by the caudate lobe of the liver, from below - by the initial section of the duodenum. The stuffing hole has an average diameter of 3-4 cm; during inflammatory processes, the hole can be closed by adhesions.

During operations on the liver and biliary tract, the common bile duct and the head of the pancreas are palpated through the omental opening. The walls of the stuffing bag are: in front - the posterior wall of the stomach, the lesser omentum and lig. gastrocolicum; behind - a sheet of the parietal peritoneum, behind which lies the pancreas, left kidney, aorta, inferior vena cava; below - the left side of the mesentery of the transverse colon, on the left - the spleen with its ligaments. At the top, the cavity reaches the diaphragm and the caudate lobe of the liver, on the right it extends to the duodenum.