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Thiel· Photographic Atlas of Practical Anatomy I
Springer Berlin Heidelberg New York Barcelona Budapest Hong Kong London Milan Paris Santa Clara Singapore Tokyo
WALTER THIEL
Photographic Atlas of Practical Anatomy I
Companion Volume Including Nomina Anatomica and Index
Translated by Terry C. Telger With the Assistance of Udo Schumacher
With 207 Figures
Springer
IV
Prof. Dr. Walter Thiel Anatomisches Institut University of Graz Harrachgasse 21 8010 Grazl Austria
German edition © Springer-Verlag Berlin Heidelberg 1996
Spanish edition
Translators:
Terry C. Telger Translations for Health Sciences 6112 Waco Way Fort Worth, TX 76133/USA
Prof. Dr. Udo Schumacher Head of Human Morphology Bassett Crescent East University of Southampton Southampton S016 7PX/UK
© Springer-Verlag Iberica, S. A. Barcelona 1996
Cataloging-in-Publication Data applied for Die Deutsche Bibliothek - CIP-Einheitsaufnahme
Thiel, Walter: Photographic atlas of practical anatomy / Walter Thiel. Transl. by Terry Telger. - Berlin; Heidelberg; New York; Barcelona; Budapest; Hong Kong; London; Milan; Paris; Santa Clara; Singapore; Tokyo: Springer
Dt. Ausg. u. d. T.: Thiel, Walter: Photographischer Atlas der praktischen Anatomie ISBN-13: 978-3-642-64406-1 e-ISBN-13: 978-3-642-60435-5 DOl: 10.1007/978-3-642-60435-5
1. [Hauptbd.l.Abdomen, lower limb. - 1997 Companion Vol. Including Nomina Anatomica and Index. -1997
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law.
© Springer-Verlag Berlin Heidelberg 1997
Softcover reprint of the hardcover 1 st edition 1997
The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.
Product liability: The publishers cannot guarantee the accuracy of any information about the application of operative techniques and medications contained in this book. In every individual case the user must check such information by consulting the relevant literature.
Cover design: Erich Kirchner, Heidelberg Reproduction of the figures: Reproteam, Graz Typesetting: Data conversion by Appl, Wemding
SPIN 10537952 15/3135-543210 Printed on acid-free paper
Table of Contents
Figure Page
1 Subcutaneous Fat of the Anterolateral Abdominal Wall 2-3
2
3
4
5-6
7-8
9
10
11
12
13-16
17
18-26
27-28
29-30
31-35
36-39
40-41
42
43-44
45-46
47
Subcutaneous Fascia and Abdominal Regions
Anterior Wall of the Rectus Sheath
in the Midabdominal Region ............. .
Superficial Layer of the Anterolateral Abdominal Wall
Middle Layer of the Anterolateral Abdominal Wall
Deep Layer of the Anterolateral Abdominal Wall
Inguinal Region in the Male
Inguinal Region in the Female ..... .
Exposure of the Superficial Inguinal Ring
Examination of the Superficial Inguinal Ring
Structure of the Spermatic Cord
Deep Inguinal Ring ...... .
Inguinal Hernia
Incision for Abdominal Dissection
Opening of the Peritoneal Cavity
Position of the Viscera
Relative to the Abdominal Incision
Approach to the Gallbladder
and Hepatoduodenal Ligament
Stomach and Omental Bursa
Vestibule of the Omental Bursa
Omental Bursa ........ .
Large and Small Intestine .. .
Attachment of the Jejunum and Ileum
48 Position of the Duodenojejunal Flexure
49
50-54
55
56-57
58
and the Mesenteric Roots ... .
Cecum and Ascending Colon .. .
Cecum and Vermiform Appendix
Omenta and Vessels of the Stomach
Vessels of the Upper Abdominal Organs
Nerves of the Upper Abdominal Organs
and the Extrahepatic Biliary Tract
59 Gastroduodenal Artery and Right Gastroepiploic Artery
60 Duodenum and Head of Pancreas
4-5
6-7
8-9
10-13
14-17
18-19
18-19
20-21
22-23
24-31
32-33
34-51
52-55
56-59
60-69
70-77
78-81
82-83
84-87
88-91
92-93
94-95
96-97
98-107
108-109
110-113
114-115
116-117
118-119
V
VI
Figure
61-63
64
65
66
67
68
69
70-71
72-77
78-86
87
88-91
92-94
95-99
100-104
105-108
109
110
111
112
113
114
115-118
119-124
Pancreas, Duodenum, and their Adjacent Vessels
Elevation of the Duodenum ....... .
Vessels of the Mesenteric Pedicle ..... .
Nerves and Vessels of the Mesenteric Pedicle
Ileocolic Artery and the Mesenteries ....
Vessels of the Vermiform Appendix
Distribution of the Superior Mesenteric Artery
Vascular Supply of the Large Intestine .....
Retroperitoneal Space
Perineal Region in the Male, Anal Region, Urogenital Region
Pudendal Region in the Male .,
Perineal Region in the Female
Urogenital Region in the Female
Perineal Region in the Female . .
Subinguinal Region
Anterior Femoral Region, Superficial Layer
Lacunae and Fascia Lata
Femoral Triangle
Anterior Femoral Region, Femoral Nerve
Anterior Femoral Region, Circumflex Arteries
Anterior Femoral Region, Obturator Nerve
Anterior Femoral Region, Femoral Artery
Adductor Canal ............ .
Posterior Femoral Region ....... .
125-134 Gluteal Region, Infrapiriform Foramen,
Suprapiriform Foramen, Lumbar Region
135-143
144-149
150-154
155
156
157-162
163-168
169-176
177-184
185
186-198
199-207
Lateral Approach to the Hip Joint
Posterior Region of the Knee
Posterior Crural Region .....
Medial Aspect of the Knee and Lower Leg
Medial Retromalleolar Region
Anterior Crural Region
Dorsum of the Foot
Sole of the Foot
Hip Joint and Puncture Sites
Position of the Greater Trochanter
The Knee Joint and Puncture Sites.
Joints of the Foot, Puncture Sites, and Tendons
Index ..................... .
Page
120-125
126-127
128-129
130-131
132-133
134-135
136-137
138-141
142-153
154-171
172-173
174-181
182-187
188-197
198-207
208-215
216-217
218-219
220-221
222-223
224-225
226-227
228-235
236-247
248-267
268-285
286-297
298-307
308-309
310-311
312-323
324-335
336-351
352-367
368-369
370-395
396-413
415-427
Figure
1
2
3
4
5-6
7-8
9
Table of Contents
Subcutaneous Fat of the Anterolateral Abdominal Wall ...
Subcutaneous Fascia and Abdominal Regions
Anterior Wall of the Rectus Sheath
in the Midabdominal Region ............. .
Superficial Layer of the Anterolateral Abdominal Wall
Middle Layer of the Anterolateral Abdominal Wall
Deep Layer of the Anterolateral Abdominal Wall
Inguinal Region in the Male
10 Inguinal Region in the Female
11
12
13-16
17
18-26
27-28
29-30
Exposure of the Superficial Inguinal Ring
Examination of the Superficial Inguinal Ring
Structure of the Spermatic Cord
Deep Inguinal Ring
Inguinal Hernia
Incision for Abdominal Dissection
Opening of the Peritoneal Cavity
31-35 Position of the Viscera
Relative to the Abdominal Incision
36-39 Approach to the Gallbladder
and Hepatoduodenal Ligament
40-41 Stomach and Omental Bursa
42 Vestibule of the Omental Bursa
43-44 Omental Bursa ............ .
45-46 Large and Small Intestine ...... .
47 Attachment of the Jejunum and Ileum
48 Position of the Duodenojejunal Flexure
49
50-54
55
56-57
58
and the Mesenteric Roots .... .
Cecum and Ascending Colon .. .
Cecum and Vermiform Appendix
Omenta and Vessels of the Stomach
Vessels of the Upper Abdominal Organs
Nerves of the Upper Abdominal Organs
and the Extrahepatic Biliary Tract
59 Gastroduodenal Artery and Right Gastroepiploic Artery
60 Duodenum and Head of Pancreas
Page
2-3
4-5
6-7
8-9
10-13
14-17
18-19
18-19
20-21
22-23
24-31
32-33
34-51
52-55
56-59
60-69
70-77
78-81
82-83
84-87
88-91
92-93
94-95
96-97
98-107
108-109
110-113
114-115
116-117
118-119
VII
VIII
Figure
61-63
64
65
66
67
68
69
70-71
72-77
78-86
87
88-91
92-94
95-99
100-104
105-108
109
110
111
112
113
114
115-118
119-124
125-134
135-143
144-149 150-154
155 156
157-162
163-168
169-176
177-184
185
186-198
199-207
Pancreas, Duodenum, and their Adjacent Vessels
Elevation of the Duodenum ....... .
Vessels of the Mesenteric Pedicle ..... .
Nerves and Vessels of the Mesenteric Pedicle
Ileocolic Artery and the Mesenteries ....
Vessels of the Vermiform Appendix
Distribution of the Superior Mesenteric Artery
Vascular Supply of the Large Intestine .....
Retroperitoneal Space
Perineal Region in the Male, Anal Region, Urogenital Region
Pudendal Region in the Male ..
Perineal Region in the Female
Urogenital Region in the Female
Perineal Region in the Female . .
Subinguinal Region
Anterior Femoral Region, Superficial Layer
Lacunae and Fascia Lata
Femoral Triangle
Anterior Femoral Region, Femoral Nerve
Anterior Femoral Region, Circumflex Arteries
Anterior Femoral Region, Obturator Nerve
Anterior Femoral Region, Femoral Artery
Adductor Canal ............ .
Posterior Femoral Region ....... .
Gluteal Region, Infrapiriform Foramen,
Suprapiriform Foramen, Lumbar Region
Lateral Approach to the Hip Joint
Posterior Region of the Knee
Posterior Crural Region .....
Medial Aspect of the Knee and Lower Leg
Medial Retromalleolar Region
Anterior Crural Region
Dorsum of the Foot
Sole of the Foot
Hip Joint and Puncture Sites
Position of the Greater Trochanter
The Knee Joint and Puncture Sites.
Joints of the Foot, Puncture Sites, and Tendons
Bibliography and Proper Names
Page
120-125
126-127
128-129
130-131
132-133
134-135
136-137
138-141
142-153
154-171
172-173
174-181
182-187
188-197
198-207 208-215
216-217
218-219
220-221
222-223
224-225
226-227
228-235
236-247
248-267
268-285
286-297 298-307 308-309 310-311 312-323
324-335
336-351
352-367
368-369
370-395
396-413
415-427
Introduction
The Subcutaneous Tissue
All pathways into the interior of the body lead through the subcutaneous tissue (tela
subcutanea). This layer, which includes a variable thickness of subcutaneous fat, has a
variegated internal structure that is appropriate for the mechanical requirements of its
vessels and nerves.
If vessels and nerves, in coursing from deeper to more superficial levels, were to pass
through a simple hole or oblong slit in a superficial fascial covering, as the descriptions
and illustrations in most textbooks would suggest, even ordinary forces acting on the
abdominal wall could easily damage or disrupt these structures at numerous sites in
the skin.
Dissections in well preserved, non-emaciated cadavers can readily demonstrate that
the superficial fascia and the sites where it is pierced by neurovascular structures have
a very specialized form. There is no single, superficial investing fascial layer of relative
ly uniform thickness that bears openings for the passage of nerves and blood vessels,
and consequently this layer cannot be demonstrated by dissection without obscuring
key anatomic features.
The Superficial Fascia
To better understand the structure of the superficial fascia as it is encountered in dis
sections, it is helpful to start with a thin layer of connective tissue that borders deeply
on the subcutaneous fat. LESSHAFT calls this layer in the perineal region the deep layer
of the stratum subcutaneum (lamina profunda strati subcutanei).
This connective tissue layer may blend with superficial muscle fascia to form a super
ficial fascia, or it may be loosely connected to the abdominal wall as exemplified by
SCARPA'S fascia over the aponeurosis of the external oblique muscle. It occurs in the
perineal region as the superficial perineal fascia (LESSHAFT, DELBET), where it is also
known as COLLES' fascia.
The deep layer of the stratum subcutaneum may also overlie large fat pads, as illustrated
in the axillary region by the superficial axillary fascia. Vessels and nerves emerging
IX
from the fat pad and passing through the fascia carry with them fibrous sheaths that lat
er blend with layers of connective tissue, as in the flat tunnels described below. Remov
ing these sheaths leaves perforations in the fascia, which then has the appearance of a
cribriform plate. Fascia overlying a fat pad is sometimes greatly rarefied, as in the area
of the ischioanal fossa, where this boundary of the subcutaneous tissue is often absent.
The Entry of Vessels and Nerves into the Subcutaneous Tissue
At sites where nerves and vessels pass to the surface of the body from deeper levels, it
is misleading to regard the superficial fascial covering as a two-dimensional structure.
Rather, the connective tissue acquires three-dimensional features from its tendency to
follow the structures that traverse the layer.
At the level where the vessels and nerves lose their relationship to deeper tissues, the
deep layer of the stratum subcutaneum separates from the superficial muscle fascia
along a circumscribed interfascial plane that we call a flat tunnel, the muscle fascia
forming only the thin basal plate of the tunnel at that location. This plate becomes pro
gressively thinner toward the start of the tunnel, and its termination, which is not al
ways clearly defined, borders the entrance to the tunnel itself. Except in cases of severe
emaciation, fatty tissue normally occurs alongside the emerging nerves and vessels
within the spindle-shaped cross section of the tunnel.
The deep layer of the stratum subcutaneum, which initially covers the emerging
nerves and vessels superficially, invests these structures toward the end of the tunnel,
which can range to many centimeters in length, and in this way conveys them into the
subcutaneous fat. There they are further enclosed by strands of connective tissue that
arise as a continuation of the deep layer of the stratum subcutaneum. Still finer strands
of connective tissue accompany the smaller neurovascular branches to the skin, effec
tively protecting these important, vulnerable structures from tensile stresses all along
their route through the subcutaneous tissue.
Dissection of the Superficial Fascia
It follows from this description that there is no ubiquitous connective tissue system
that runs strictly parallel to the body surface, nor is there a single, encasing layer of
superficial fascia. If the subcutaneous fat is removed down to the lamina profunda,
there are still sites at which deposits of fatty tissue will be encountered. These do not
represent deep tissue, because there is still a thin, superficial fascial layer separating
the fat from deeper structures. Removing this fat, which is contained within the flat
tunnels, along with the subcutaneous fat exposes a superficial fascia that presents a
very nonuniform thickness and whose cut edge shows differentiation into layers.
x
Thus, the fatty tissue in the flat tunnels cannot be characterized as deep fat, nor can it
be assigned to the subcutaneous tissue. This "tunnel fat" is, rather, a type of intermedi
ate fat that is analogous to the large fat pads of the axilla or ischioanal fossa. Only in
very thin cadavers that are almost devoid of fat do we find that the deep layer of the
stratum subcutaneum is adherent to the true superficial fascia at these locations. In
this case the vessels and nerves normally embedded in fatty tissue at these sites are
easily exposed in isolation, unaccompanied by lateral strands of fat, by splitting the
overlying layer of connective tissue. They can be demonstrated as far as the site where
the deep layer of the stratum subcutaneum is consistently adherent to the true superfi
cial fascia to form a relatively thick, uniform connective tissue layer separating the
deep structures from the subcutaneous tissue. A hiatus, commonly shown in drawings
and included in the anatomic nomenclature, can be produced artificially at the margin
of this attachment.
The usual representations of the superficial fascia are based on this special situation.
The absence of fat in the otherwise very fatty layer of the subcutis causes the connec
tive tissue in this area to form a thin, amorphous layer that, during dissection, provides
a "fill-in" at sites where the nonhomogeneity of the superficial fascia present\S a prob
lem. This representation is not valid in cadavers that have a normal or greater-than
normal quantity of body fat.
When one considers that, on average, the subcutaneous fat accounts for up to one-fifth
of the total body weight, there is no reasonable justification for applying the term
"superficial fascia" to the whole of the tela subcutanea or specifically to CAMPER'S fas
cia in the abdomen, because this tissue is not essentially fascial in nature.
The term superficial fascia as used in this book refers to the fascial sheet that directly
invests the surfaces of muscles. It is fused with the deep layer of the stratum subcuta
neum in some places and is entirely separate from it in others. In some areas it is apo
neurotic in structure and is concerned in the attachment of muscular tissues, func
tioning as a supplement to the skeletal origins of the muscles. We do not follow the
common practice of referring to this structure as the deep fascia, because this implies
an incorrect meaning for "superficial fascia" and because the term "deep fascia" is
needed for fasciae that occur at deeper levels.
The Attachment of the Common Integument
Besides the connective tissue complex that protects the nerves and vessels from tensile
stresses, the subcutaneous tissue also contains connective tissue whose exclusive func
tion is to anchor the skin. Thus, the connective tissue permeating the fat may be great
ly thickened at the palm, fingertips, and sole of the foot to bind down the corium while
XI
outlining small pads of fatty tissue. Thick bands of tough connective tissue called the
retinaculata cutis pass from the bone and the palmar or plantar aponeurosis to the ad
jacent corium and serve to prevent excessive elevation of the skin.
These connective tissue structures, which serve mainly to anchor the integument, are
sporadically traversed by fine nerves and blood vessels, just as the connective tissue
complex that protects the nerves and vessels from tensile stresses also helps to anchor
the integument.
Besides the transverse and oblique connective tissue bands permeating the fat, the
deep layer of the stratum subcutaneum shows various linear or patchy sites of attach
ment to soft tissues and bony prominences that contribute to the fixation of the integ
ument. The subcutaneous fasciae, which are most fully developed in the deeper subcu
taneous layers of the abdomen and are roughly parallel to the body surface, have at
tachments to surrounding structures that contribute to the stability of the soft fatty
tissues.
The structures described above form the basis for the surgical mobility of the skin.
They account for the "rolling veins" phenomenon in flat tunnels that can hamper the
drawing of blood in fat -depleted patients. Their importance is more than purely theo
retical, therefore.
XII