3 курс / Топографическая анатомия и оперативная хирургия / ТАиОХ брюшная полость
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Ƚɪɚɧɢɰɚ ɧɢɠɧɟɝɨ ɤɪɚɹ ɩɟɱɟɧɢ ɦɨɠɟɬ ɫɢɥɶɧɨ ɦɟɧɹɬɶɫɹ ɨɫɨɛɟɧɧɨ ɩɪɢ ɩɚɬɨɥɨɝɢɱɟɫɤɢɯ ɫɨɫɬɨɹɧɢɹɯ ɨɪɝɚɧɚ ȼ ɧɨɪɦɟ ɧɢɠɧɢɣ ɤɪɚɣ ɩɟɱɟɧɢ ɫɩɪɚɜɚ ɩɨ ɫɪɟɞɧɟɣ ɩɨɞɦɵɲɟɱɧɨɣ ɥɢɧɢɢ ɫɨɨɬɜɟɬɫɬɜɭɟɬ ɞɟɫɹɬɨɦɭ ɦɟɠɪɟ ɛɟɪɶɸ ɡɚɬɟɦ ɩɪɨɯɨɞɢɬ ɩɨ ɤɪɚɸ ɪɟɛɟɪɧɨɣ ɞɭɝɢ ɭ ɩɪɚɜɨɣ ɫɪɟɞɧɟɤɥɸɱɢɱ ɧɨɢ ɥɢɧɢɢ ɜɵɯɨɞɢɬ ɢɡ-ɩɨɞ ɧɟɟ ɢ ɢɞɟɬ ɤɨɫɨ ɜɥɟɜɨ ɢ ɜɜɟɪɯ ɩɪɨɟɰɢɪɭɹɫɶ ɩɨ ɫɪɟɞɢɧɧɨɣ ɥɢɧɢɢ ɬɟɥɚ ɧɚ ɫɟɪɟɞɢɧɟ ɪɚɫɫɬɨɹɧɢɹ ɦɟɠɞɭ ɩɭɩɤɨɦ ɢ ɨɫ ɧɨɜɚɧɢɟɦ ɦɟɱɟɜɢɞɧɨɝɨ ɨɬɪɨɫɬɤɚ
Ʌɟɜɭɸ ɱɚɫɬɶ ɪɟɛɟɪɧɨɣ ɞɭɝɢ ɧɢɠɧɢɣ ɤɪɚɣ ɩɟɱɟɧɢ ɩɟɪɟɫɟɤɚɟɬ ɩɪɢɦɟɪɧɨ ɧɚ ɭɪɨɜɧɟ ɯɪɹɳɚ VI ɪɟɛɪɚ
Ƚɪɚɧɢɰɵ ɩɟɱɟɧɢ ɡɚɜɢɫɹɬ ɨɬ ɟɟ ɪɚɡɦɟɪɨɜ ɮɨɪɦɵ ɢ ɩɨɥɨɠɟɧɢɹ Ʉɪɨɦɟ ɨɩɢɫɚɧɧɵɯ ɝɪɚɧɢɰ ɜɫɬɪɟɱɚɸɬɫɹ ɤɪɚɣɧɢɟ ɮɨɪɦɵ ɢɡɦɟɧɱɢɜɨɫɬɢ ɜ ɟɟ ɩɨɥɨɠɟ ɧɢɢ ɞɨɪɡɨɩɟɬɚɥɶɧɨɟ ± ɤɨɝɞɚ ɩɟɱɟɧɶ ɧɚɤɥɨɧɟɧɚ ɤɡɚɞɢ ɜ ɬɚɤɢɯ ɫɥɭɱɚɹɯ ɯɨɪɨɲɨ ɜɢɞɧɚ ɟɟ ɧɢɠɧɹɹ ɩɨɜɟɪɯɧɨɫɬɶ ɢ ɥɟɝɤɨ ɞɨɫɬɭɩɟɧ ɠɟɥɱɧɵɣ ɩɭɡɵɪɶ ɜɟɧɬɪɨɩɟ ɬɚɥɶɧɨɟ ± ɩɟɱɟɧɶ ɧɚɤɥɨɧɟɧɚ ɤɩɟɪɟɞɢ ɜ ɬɚɤɢɯ ɫɥɭɱɚɹɯ ɞɨɫɬɭɩ ɤ ɧɢɠɧɟɣ ɟɟ ɩɨ ɜɟɪɯɧɨɫɬɢ ɜɟɫɶɦɚ ɡɚɬɪɭɞɧɟɧ ȼɫɬɪɟɱɚɸɬɫɹ ɬɚɤɠɟ ɮɪɨɧɬɚɥɶɧɵɟ ɫɦɟɳɟɧɢɹ ɩɟ ɱɟɧɢ ɉɪɢ ɫɦɟɳɟɧɢɢ ɜɩɪɚɜɨ dextropositio ɤɪɚɣ ɩɟɱɟɧɢ ɦɨɠɟɬ ɞɨɫɬɢɝɚɬɶ ɝɪɟɛɧɹ ɩɨɞɡɜɞɨɲɧɨɣ ɤɨɫɬɢ ɩɪɢ ɫɦɟɳɟɧɢɢ ɜɥɟɜɨ sinistropositio) ± ɦɨɠɟɬ ɫɦɟɳɚɬɶɫɹ ɤɧɚɪɭɠɢ ɨɬ ɥɟɜɨɣ ɫɪɟɞɧɟɤɥɸɱɢɱɧɨɣ ɥɢɧɢɢ
ȼ ɩɟɱɟɧɢ ɪɚɡɥɢɱɚɸɬ ɞɢɚɮɪɚɝɦɚɥɶɧɭɸ ɢ ɜɢɫɰɟɪɚɥɶɧɭɸ ɩɨɜɟɪɯɧɨɫɬɢ ɇɚ ɜɟɪɯɧɟɣ ɱɚɫɬɢ ɞɢɚɮɪɚɝɦɚɥɶɧɨɣ ɩɨɜɟɪɯɧɨɫɬɢ ɜ ɫɚɝɢɬɬɚɥɶɧɨɦ ɧɚɩɪɚɜɥɟɧɢɢ ɩɪɨɯɨɞɢɬ ɫɟɪɩɨɜɢɞɧɚɹ ɫɜɹɡɤɚ ȼ ɡɚɞɧɟɣ ɱɚɫɬɢ ɩɟɱɟɧɶ ɥɢɲɟɧɚ ɛɪɸɲɢɧɧɨɝɨ ɩɨɤɪɨɜɚ ɫɪɚɳɟɧɚ ɫ ɞɢɚɮɪɚɝɦɨɣ Ɂɞɟɫɶ ɢɦɟɟɬɫɹ ɛɨɪɨɡɞɚ ɧɢɠɧɟɣ ɩɨɥɨɣ ɜɟɧɵ (sulcus v. cavae inferior ɇɚ ɜɢɫɰɟɪɚɥɶɧɨɣ ɩɨɜɟɪɯɧɨɫɬɢ ɩɟɱɟɧɢ ɪɚɫɩɨɥɚɝɚɸɬɫɹ ɫɩɪɚɜɚ ɜ ɩɟɪɟɞɧɟɣ ɱɚɫɬɢ ± ɹɦɤɚ ɠɟɥɱɧɨɝɨ ɩɭɡɵɪɹ fossa vesicae felleae ɫɥɟɜɚ
± ɳɟɥɶ ɤɪɭɝɥɨɣ ɫɜɹɡɤɢ lig. teres hepatis ɚ ɫɡɚɞɢ ± ɨɛɥɢɬɟɪɢɪɨɜɚɧɧɵɣ ɜɟɧɨɡɧɵɣ ɩɪɨɬɨɤ ductus venosus ± Arantii). Ɇɟɠɞɭ ɹɦɤɨɣ ɠɟɥɱɧɨɝɨ ɩɭɡɵɪɹ ɢ ɳɟɥɶɸ ɤɪɭɝɥɨɣ ɫɜɹɡɤɢ ɧɚɯɨɞɹɬɫɹ ɜɨɪɨɬɚ ɩɟɱɟɧɢ portae hepatis) ± ɦɟɫɬɨ ɜɯɨɞɚ ɜ ɩɟɱɟɧɶ ɤɪɭɩɧɵɯ ɫɨɫɭɞɨɜ ɢ ɜɵɯɨɞɚ ɩɟɱɟɧɨɱɧɵɯ ɠɟɥɱɧɵɯ ɩɪɨɬɨɤɨɜ
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Ɋɢɫ.1.24. Ƚɨɥɨɬɨɩɢɹ ɩɟɱɟɧɢ.
1 ² linea medioclavicularis; 2 ² linea parasternalis; 3 ² hepar; 4 ² gaster; 5 ² vesica biliaris; 6 ² colon transversum; 7 ² linea bicostarum; 8 ² umbilicus; 9 ² arcus costalis; 10 ² processus xiphoideus; 11 ² diaphragma.
ȼ ɩɟɱɟɧɢ ɪɚɡɥɢɱɚɸɬ ɞɜɟ ɞɨɥɢ ɩɪɚɜɚɹ ɢ ɥɟɜɚɹ ɩɹɬɶ ɫɟɤɬɨɪɨɜ ɢ ɫɟɝɦɟɧ ɬɨɜ Ƚɪɚɧɢɰɟɣ ɦɟɠɞɭ ɩɪɚɜɨɣ ɢ ɥɟɜɨɣ ɞɨɥɹɦɢ ɹɜɥɹɟɬɫɹ ɩɥɨɫɤɨɫɬɶ ɩɪɨɜɟɞɟɧ ɧɚɹ ɱɟɪɟɡ ɹɦɤɭ ɠɟɥɱɧɨɝɨ ɩɭɡɵɪɹ ɍɱɢɬɵɜɚɹ ɚɪɯɢɬɟɤɬɨɧɢɤɭ ɜɧɭɬɪɢɩɟɱɟɧɨɱ ɧɵɯ ɫɨɫɭɞɨɜ ɢ ɠɟɥɱɧɵɯ ɩɪɨɬɨɤɨɜ ɤɚɠɞɚɹ ɞɨɥɹ ɜ ɫɜɨɸ ɨɱɟɪɟɞɶ ɞɟɥɢɬɫɹ ɧɚ ɫɟɝɦɟɧɬɚ ɥɟɜɚɹ ɞɨɥɹ ɫɨɫɬɨɢɬ ɢɡ ɥɟɜɨɝɨ ɩɚɪɚɦɟɞɢɚɥɶɧɨɝɨ ɫɟɤɬɨɪɚ III ɢ IV ɫɟɝɦɟɧɬɵ ɥɟɜɨɝɨ ɥɚɬɟɪɚɥɶɧɨɝɨ ɫɟɤɬɨɪɚ II ɫɟɝɦɟɧɬ ɢ ɥɟɜɨɝɨ ɞɨɪɡɚɥɶɧɨɝɨ ɫɟɤɬɨɪɚ I ɫɟɝɦɟɧɬ
ɉɪɚɜɚɹ ɞɨɥɹ ɜɤɥɸɱɚɟɬ ɩɪɚɜɵɣ ɩɚɪɚɦɟɞɢɚɥɶɧɵɣ ɫɟɤɬɨɪ V ɢ VIII ɫɟɝɦɟɧ ɬɵ ɢ ɩɪɚɜɵɣ ɥɚɬɟɪɚɥɶɧɵɣ ɫɟɤɬɨɪ VI ɢ VII ɫɟɝɦɟɧɬɵ ɪɢɫ .
ɉɟɱɟɧɶ ɩɨɤɪɵɬɚ ɛɪɸɲɢɧɨɣ ɫ ɬɪɟɯ ɫɬɨɪɨɧ ɡɚ ɢɫɤɥɸɱɟɧɢɟɦ ɜɧɟɛɪɸɲɢɧ ɧɨɝɨ ɩɨɥɹ ɞɢɚɮɪɚɝɦɚɥɶɧɨɣ ɩɨɜɟɪɯɧɨɫɬɢ ɉɚɪɢɟɬɚɥɶɧɚɹ ɛɪɸɲɢɧɚ ɩɟɪɟɯɨɞɹ ɫ ɩɟɪɟɞɧɟɣ ɫɬɟɧɤɢ ɠɢɜɨɬɚ ɧɚ ɞɢɚɮɪɚɝɦɭ ɚ ɡɚɬɟɦ ɧɚ ɩɟɱɟɧɶ ɨɛɪɚɡɭɟɬ ɫɟɪɩɨɜɢɞ ɧɭɸ ɫɜɹɡɤɭ lig. falciforme hepatis).
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Ɋɢɫ ɋɟɝɦɟɧɬɵ ɩɟɱɟɧɢ
ȼ ɡɚɞɧɟɣ ɱɚɫɬɢ ɞɢɚɮɪɚɝɦɚɥɶɧɨɣ ɩɨɜɟɪɯɧɨɫɬɢ ɩɟɱɟɧɢ ɫɟɪɩɨɜɢɞɧɚɹ ɫɜɹɡ ɤɚ ɜɟɟɪɨɨɛɪɚɡɧɨ ɪɚɡɞɟɥɢɜɲɢɫɶ ɩɟɪɟɯɨɞɢɬ ɜ ɜɟɧɟɱɧɭɸ lig. coronarium ɪɚɫ ɩɨɥɨɠɟɧɧɭɸ ɜɨ ɮɪɨɧɬɚɥɶɧɨɣ ɩɥɨɫɤɨɫɬɢ ɋɩɪɚɜɚ ɢ ɫɥɟɜɚ ɜɟɧɟɱɧɚɹ ɫɜɹɡɤɚ ɩɟ ɪɟɯɨɞɢɬ ɜ ɬɪɟɭɝɨɥɶɧɭɸ lig. triangulare dextra et sinistra) ɪɢɫ 6) ɉɪɢ ɩɟɪɟ ɯɨɞɟ ɜɢɫɰɟɪɚɥɶɧɨɣ ɛɪɸɲɢɧɵ ɫ ɩɟɱɟɧɢ ɧɚ ɫɨɫɟɞɧɢɟ ɨɪɝɚɧɵ ɨɛɪɚɡɭɸɬɫɹ ɩɟɱɟ ɧɨɱɧɨ-ɠɟɥɭɞɨɱɧɚɹ ɢ ɩɟɱɟɧɨɱɧɨ-ɞɭɨɞɟɧɚɥɶɧɚɹ ɫɜɹɡɤɢ ɚ ɬɚɤɠɟ ɩɟɱɟɧɨɱɧɨɩɨɱɟɱɧɚɹ ɫɜɹɡɤɚ lig. hepatorenale ɪɚɫɩɨɥɨɠɟɧɧɚɹ ɦɟɠɞɭ ɧɢɠɧɟɣ ɩɨɜɟɪɯɧɨ ɫɬɶɸ ɩɟɱɟɧɢ ɢ ɩɪɚɜɨɣ ɩɨɱɤɨɣ.
Ɋɢɫ 1.26. Ʌɨɠɟ ɩɟɱɟɧɢ ɩɨ ɇɟɬɬɟɪɭ ɫ ɢɡɦɟɧɟɧɢɹɦɢ
1 ² lig. coronarium; 2 ² area nuda; 3 ² v. cava inferior; 4 ² gl. suprarenalis; 5 ² lig. triangulare dextrum; 6 ² ren; 7 ² duodenum; 8 ² colon transversum; 9 ² recessus superior; 10 ² bursa omentalis; 11 ² gaster; 12 ² diaphragma; 13 ² lig. triangulare sinistrum.
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ȼ ɬɨɥɳɟ ɩɟɱɟɧɨɱɧɨ-ɞɭɨɞɟɧɚɥɶɧɨɣ ɫɜɹɡɤɢ ɩɪɨɯɨɞɹɬ ɫɨɛɫɬɜɟɧɧɚɹ ɩɟɱɟ ɧɨɱɧɚɹ ɚɪɬɟɪɢɹ ɫɥɟɜɚ ɨɛɳɢɣ ɠɟɥɱɧɵɣ ɩɪɨɬɨɤ ɫɩɪɚɜɚ ɢ ɜɨɪɨɬɧɚɹ ɜɟɧɚ ɦɟɠɞɭ ɧɢɦɢ ɢ ɫɡɚɞɢ
ɉɟɱɟɧɶ ɮɢɤɫɢɪɭɟɬɫɹ ɛɥɚɝɨɞɚɪɹ ɫɪɚɳɟɧɢɸ ɜɟɪɯɧɟɡɚɞɧɟɣ ɟɟ ɩɨɜɟɪɯɧɨɫɬɢ ɫ ɞɢɚɮɪɚɝɦɨɣ ɫɜɹɡɤɚɦɢ ɫɪɚɳɟɧɢɟɦ ɫ ɧɢɠɧɟɣ ɩɨɥɨɣ ɜɟɧɨɣ ɢ ɜɧɭɬɪɢɛɪɸɲɧɵɦ ɞɚɜɥɟɧɢɟɦ
Ʉɪɨɜɨɫɧɚɛɠɟɧɢɟ ɩɟɱɟɧɶ ɩɨɥɭɱɚɟɬ ɢɡ ɞɜɭɯ ɢɫɬɨɱɧɢɤɨɜ ɫɨɛɫɬɜɟɧɧɨ ɩɟɱɟ ɧɨɱɧɨɣ ɚɪɬɟɪɢɢ ɢ ɜɨɪɨɬɧɨɣ ɜɟɧɵ ɋɨɛɫɬɜɟɧɧɚɹ ɩɟɱɟɧɨɱɧɚɹ ɚɪɬɟɪɢɹ a. hepatica propria ɨɬɯɨɞɢɬ ɨɬ ɨɛɳɟɣ ɩɟɱɟɧɨɱɧɨɣ ɚɪɬɟɪɢɢ ɹɜɥɹɸɳɟɣɫɹ ɨɞɧɨɣ ɢɡ ɜɟɬ ɜɟɣ ɱɪɟɜɧɨɝɨ ɫɬɜɨɥɚ ɪɢɫ ɋɨɛɫɬɜɟɧɧɨ ɩɟɱɟɧɨɱɧɚɹ ɚɪɬɟɪɢɹ ɜɧɚɱɚɥɟ ɢɞɟɬ ɫɥɟɜɚ ɡɚɬɟɦ ɫɩɟɪɟɞɢ ɜɨɪɨɬɧɨɣ ɜɟɧɵ ɢ ɭ ɜɨɪɨɬ ɩɟɱɟɧɢ ɞɟɥɢɬɫɹ ɧɚ ɩɪɚɜɭɸ ɢ ɥɟɜɭɸ ɩɟɱɟɧɨɱɧɵɟ ɜɟɬɜɢ ɢɞɭɳɢɟ ɤ ɫɨɨɬɜɟɬɫɬɜɭɸɳɢɦ ɟɟ ɞɨɥɹɦ Ɉɬ ɩɪɚɜɨɣ ɩɟɱɟɧɨɱɧɨɣ ɜɟɬɜɢ ɨɬɯɨɞɢɬ ɠɟɥɱɧɨɩɭɡɵɪɧɚɹ ɚɪɬɟɪɢɹ a. cystica ɨɬ ɫɨɛɫɬɜɟɧ ɧɨ ɩɟɱɟɧɨɱɧɨɣ ± ɩɪɢɜɪɚɬɧɢɤɨɜɚɹ ɚɪɬɟɪɢɹ a. pylorica).
Ɋɢɫ 7. ɋɨɫɭɞɵ ɩɟɱɟɧɢ ɩɨ ɇɟɬɬɟɪɭ ɫ ɢɡɦɟɧɟɧɢɹɦɢ
1 ² ramus dexter a. hepaticae propriae; 2 ² a. cystica; 3 ² ductus hepaticus communis;
4 ² trigonum Callot; 5 ² ductus cysticus; 6 ² ductus choledochus; 7 ² v. portae; 8 ² a. hepatica propria et a. gastrica dextra; 9 ² a. supraduodenalis; 10 ² a. gastroduodenalis; 11 ² a. pancreaticoduodenalis inferior; 12 ² caput pancreatis; 13 ² a. pancreaticoduodenalis inferior (ramus anterior); 14 ² v. mesenterica superior; 15 ² a. mesenterica superior; 16 ² a. colica media;
17 ² a. pancreatica dorsalis; 18 ² pancreas; 19 ² a. splenica; 20 ² a. hepatica communis; 21 ² truncus coeliacus; 22 ² splen; 23 ² a. gastrica sinistra; 24 ² gaster.
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ȼɨɪɨɬɧɚɹ ɜɟɧɚ v. portae) ɩɪɟɞɫɬɚɜɥɹɟɬ ɫɨɛɨɣ ɤɨɥɥɟɤɬɨɪ ɜɟɧ ɨɬɯɨɞɹɳɢɯ ɨɬ ɧɟɩɚɪɧɵɯ ɨɪɝɚɧɨɜ ɛɪɸɲɧɨɣ ɩɨɥɨɫɬɢ ɢ ɧɟɫɭɳɢɯ ɤɪɨɜɶ ɛɨɝɚɬɭɸ ɩɪɨɞɭɤɬɚ ɦɢ ɪɚɫɩɚɞɚ ɢ ɬɨɤɫɢɱɟɫɤɢɦɢ ɜɟɳɟɫɬɜɚɦɢ ȼɨɪɨɬɧɚɹ ɜɟɧɚ ɨɛɪɚɡɭɟɬɫɹ ɩɨɡɚɞɢ ɝɨɥɨɜɤɢ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ ɡɚ ɫɱɟɬ ɫɥɢɹɧɢɹ ɫɟɥɟɡɟɧɨɱɧɨɣ ɢ ɜɟɪɯɧɟɣ ɛɪɵɠɟɟɱɧɨɣ ɜɟɧ ɪɢɫ 8) ȼ ɦɟɫɬɨ ɫɥɢɹɧɢɹ ɷɬɢɯ ɜɟɧ ɪɟɠɟ ɜ ɫɟɥɟɡɟɧɨɱɧɭɸ ɜɩɚɞɚɟɬ ɜɟɧɟɱɧɚɹ ɜɟɧɚ ɠɟɥɭɞɤɚ v. coronaria ventriculi ɟɟ ɨɛɪɚɡɭɸɬ ɩɪɚɜɚɹ ɢ ɥɟɜɚɹ ɠɟɥɭɞɨɱɧɵɟ ɜɟɧɵ Ʉɪɨɦɟ ɬɨɝɨ ɜ ɜɟɪɯɧɸɸ ɛɪɵɠɟɟɱɧɭɸ ɢɥɢ ɫɟɥɟɡɟɧɨɱ ɧɭɸ ɜɩɚɞɚɟɬ ɧɢɠɧɹɹ ɛɪɵɠɟɟɱɧɚɹ ɜɟɧɚ v. mesenterica inferior Ɉɛɟɡɜɪɟɠɟɧ ɧɚɹ ɤɪɨɜɶ ɢɡ ɩɟɱɟɧɢ ɩɨ ɩɟɱɟɧɨɱɧɵɦ ɜɟɧɚɦ vv. hepaticae ɨɬɬɟɤɚɟɬ ɜ ɧɢɠɧɸɸ ɩɨɥɭɸ ɜɟɧɭ
Ʌɢɦɮɚɬɢɱɟɫɤɢɟ ɫɨɫɭɞɵ ɩɟɱɟɧɢ ɫɨɫɬɨɹɬ ɢɡ ɩɨɜɟɪɯɧɨɫɬɧɵɯ ɢ ɝɥɭɛɨɤɢɯ ɉɨɜɟɪɯɧɨɫɬɧɵɟ ɥɢɦɮɚɬɢɱɟɫɤɢɟ ɫɨɫɭɞɵ ɜɵɯɨɞɹ ɢɡ ɞɢɚɮɪɚɝɦɚɥɶɧɨɣ ɩɨɜɟɪɯ ɧɨɫɬɢ ɩɟɱɟɧɢ ɜɩɚɞɚɸɬ ɜ ɫɨɫɭɞɵ ɢ ɭɡɥɵ ɪɚɫɩɨɥɨɠɟɧɧɵɟ ɜɨɡɥɟ ɦɟɫɬɚ ɩɪɨ ɯɨɠɞɟɧɢɹ ɧɢɠɧɟɣ ɩɨɥɨɣ ɜɟɧɵ ɢ ɛɪɸɲɧɨɣ ɱɚɫɬɢ ɩɢɳɟɜɨɞɚ ɱɟɪɟɡ ɞɢɚɮɪɚɝɦɭ Ʌɢɦɮɚɬɢɱɟɫɤɢɟ ɫɨɫɭɞɵ ɜɵɯɨɞɹɳɢɟ ɢɡ ɞɢɚɮɪɚɝɦɚɥɶɧɨɣ ɩɨɜɟɪɯɧɨɫɬɢ ɥɟɜɨɣ ɞɨɥɢ ɩɟɱɟɧɢ ɜɩɚɞɚɸɬ ɜ ɫɨɫɭɞɵ ɤɨɥɶɰɚ ɤɚɪɞɢɢ annulus lymphaticus cardiae ɭ ɧɢɠɧɟɣ ɩɨɜɟɪɯɧɨɫɬɢ ɞɢɚɮɪɚɝɦɵ Ƚɥɭɛɨɤɢɟ ɥɢɦɮɚɬɢɱɟɫɤɢɟ ɫɨɫɭɞɵ ɪɚɫɩɨɥɚ ɝɚɸɬɫɹ ɩɨ ɯɨɞɭ ɤɪɨɜɟɧɨɫɧɵɯ ɫɨɫɭɞɨɜ ɜɩɚɞɚɹ ɜ ɫɨɫɭɞɵ ɢ ɭɡɥɵ ɜ ɨɛɥɚɫɬɢ ɜɨ ɪɨɬ ɩɟɱɟɧɢ ɬɚɤɠɟ ɜɨɡɥɟ ɱɪɟɜɧɨɝɨ ɫɬɜɨɥɚ Ɍ ɤ ɥɢɦɮɚɬɢɱɟɫɤɢɟ ɭɡɥɵ ɪɚɫɩɨɥɨ ɠɟɧɧɵɟ ɜ ɜɨɪɨɬɚɯ ɩɟɱɟɧɢ ɢɧɬɢɦɧɨ ɩɪɢɥɟɝɚɸɬ ɤ ɤɪɨɜɟɧɨɫɧɵɦ ɫɨɫɭɞɚɦ ɢ ɨɛ ɳɟɦɭ ɠɟɥɱɧɨɦɭ ɩɪɨɬɨɤɭ ɬɨ ɜ ɫɥɭɱɚɟ ɢɯ ɭɜɟɥɢɱɟɧɢɹ ɜɨɡɦɨɠɧɵ ɪɚɫɫɬɪɨɣɫɬɜɚ ɠɟɥɱɟɜɵɞɟɥɟɧɢɹ ɢ ɩɟɱɟɧɨɱɧɨɝɨ ɤɪɨɜɨɨɛɪɚɳɟɧɢɹ
ɂɧɧɟɪɜɚɰɢɹ ɩɟɱɟɧɢ ɨɫɭɳɟɫɬɜɥɹɟɬɫɹ ɫɢɦɩɚɬɢɱɟɫɤɢɦɢ ɩɚɪɚɫɢɦɩɚɬɢɱɟ ɫɤɢɦɢ ɢ ɱɭɜɫɬɜɢɬɟɥɶɧɵɦɢ ɜɨɥɨɤɧɚɦɢ ɩɟɱɟɧɨɱɧɨɝɨ ɫɩɥɟɬɟɧɢɹ, ɩɪɨɢɡɜɨɞɧɨɝɨ ɱɪɟɜɧɨɝɨ ɫɩɥɟɬɟɧɢɹ ɇɟɪɜɵ ɤ ɜɨɪɨɬɚɦ ɩɟɱɟɧɢ ɩɪɨɯɨɞɹɬ ɜɞɨɥɶ ɩɟɱɟɧɨɱɧɨɣ ɚɪ ɬɟɪɢɢ ɜɨɪɨɬɧɨɣ ɜɟɧɵ ɢ ɨɛɳɟɝɨ ɠɟɥɱɧɨɝɨ ɩɪɨɬɨɤɚ
ɀɟɥɱɧɵɣ ɩɭɡɵɪɶ (vesica fellea)
ɉɪɟɞɫɬɚɜɥɹɟɬ ɫɨɛɨɣ ɩɨɥɵɣ ɨɪɝɚɧ ɜɦɟɫɬɢɦɨɫɬɶɸ - ɦɥ ɫɥɭɠɢɬ ɪɟɡɟɪ ɜɭɚɪɨɦ ɞɥɹ ɠɟɥɱɢ Ⱦɥɢɧɚ ɟɝɨ - ɫɦ Ɉɛɵɱɧɨ ɢɦɟɟɬ ɝɪɭɲɟɜɢɞɧɭɸ ɢɥɢ ɜɟɪɟ ɬɟɧɨɨɛɪɚɡɧɭɸ ɮɨɪɦɭ ɢ ɪɚɫɩɨɥɨɠɟɧ ɧɚ ɜɢɫɰɟɪɚɥɶɧɨɣ ɩɨɜɟɪɯɧɨɫɬɢ ɩɟɱɟɧɢ ɜ ɹɦɤɟ ɠɟɥɱɧɨɝɨ ɩɭɡɵɪɹ Ⱥɧɚɬɨɦɢɱɟɫɤɢ ɠɟɥɱɧɵɣ ɩɭɡɵɪɶ ɞɟɥɢɬɫɹ ɧɚ ɞɧɨ fundus vesicae felleae ɬɟɥɨ corpus vesicae fellea ɜɨɪɨɧɤɨɨɛɪɚɡɧɭɸ ɫɭɠɢɜɚɸ ɳɭɸɫɹ ɱɚɫɬɶ infundibulus ɢ ɜɵɯɨɞɧɭɸ ɱɚɫɬɶ ± ɲɟɣɤɭ collum vesicae felleae).
ȼ ɠɟɥɱɧɨɦ ɩɭɡɵɪɟ ɪɚɡɥɢɱɚɸɬ ɞɜɟ ɫɬɟɧɤɢ ɜɟɪɯɧɸɸ ɩɪɢɥɟɝɚɸɳɭɸ ɤ ɩɚ ɪɟɧɯɢɦɟ ɩɟɱɟɧɢ ɢ ɧɢɠɧɸɸ ɫɜɨɛɨɞɧɭɸ ɩɨɤɪɵɬɭɸ ɜɢɫɰɟɪɚɥɶɧɵɦ ɥɢɫɬɤɨɦ ɛɪɸɲɢɧɵ ɋɬɟɧɤɚ ɠɟɥɱɧɨɝɨ ɩɭɡɵɪɹ ɫɨɫɬɨɢɬ ɢɡ ɫɟɪɨɡɧɨɣ ɨɛɨɥɨɱɤɢ ɩɨɞɫɟɪɨɡ ɧɨɣ ɨɫɧɨɜɵ ɬɨɧɤɨɣ ɦɵɲɟɱɧɨɣ ɢ ɫɥɢɡɢɫɬɨɣ ɨɛɨɥɨɱɟɤ
ɋɜɨɟɣ ɜɟɪɯɧɟɩɟɪɟɞɧɟɣ ɩɨɜɟɪɯɧɨɫɬɶɸ ɠɟɥɱɧɵɣ ɩɭɡɵɪɶ ɩɨɫɪɟɞɫɬɜɨɦ ɤɥɟɬɱɚɬɤɢ ɢ ɤɪɨɜɟɧɨɫɧɵɯ ɫɨɫɭɞɨɜ ɪɵɯɥɨ ɫɜɹɡɚɧ ɫ ɬɤɚɧɶɸ ɩɟɱɟɧɢ ɇɢɠɧɟɛɨ ɤɨɜɵɟ ɢ ɡɚɞɧɹɹ ɩɨɜɟɪɯɧɨɫɬɢ ɩɭɡɵɪɹ ɩɨɤɪɵɬɵ ɜɢɫɰɟɪɚɥɶɧɨɣ ɛɪɸɲɢɧɨɣ ɦɟɡ ɨɩɟɪɢɬɨɧɟɚɥɶɧɨ ȼɡɚɢɦɧɨɟ ɪɚɫɩɨɥɨɠɟɧɢɟ ɛɪɸɲɢɧɵ ɢ ɠɟɥɱɧɨɝɨ ɩɭɡɵɪɹ ɜɫɬɪɟɱɚɟɬɫɹ ɧɚɢɛɨɥɟɟ ɱɚɫɬɨ
45
ȼɟɫɶ ɠɟɥɱɧɵɣ ɩɭɡɵɪɶ ɩɨɤɪɵɬ ɛɪɸɲɢɧɨɣ ɬɨɥɶɤɨ ɫɧɢɡɭ ɷɤɫɬɪɚɩɟɪɢɬɨɧɟ ɚɥɶɧɨ ȼ ɬɚɤɢɯ ɫɥɭɱɚɹɯ ɩɭɡɵɪɶ ɛɨɥɶɲɟɣ ɫɜɨɟɣ ɱɚɫɬɶɸ ɝɥɭɛɨɤɨ ɡɚɥɟɝɚɟɬ ɜ ɩɚ ɪɟɧɯɢɦɟ ɩɟɱɟɧɢ ɱɬɨ ɡɧɚɱɢɬɟɥɶɧɨ ɡɚɬɪɭɞɧɹɟɬ ɟɝɨ ɭɞɚɥɟɧɢɟ ȼ ɧɟɤɨɬɨɪɵɯ ɫɥɭ ɱɚɹɯ ɛɪɸɲɢɧɚ ɩɨɤɪɵɜɚɟɬ ɠɟɥɱɧɵɣ ɩɭɡɵɪɶ ɫɨ ɜɫɟɯ ɫɬɨɪɨɧ ɢɧɬɪɚɩɟɪɢɬɨɧɟ ɚɥɶɧɨ ɫ ɨɛɪɚɡɨɜɚɧɢɟɦ ɛɪɵɠɟɣɤɢ ɢɥɢ ɛɟɡ ɧɟɟ ɉɪɢ ɬɚɤɨɦ ɜɚɪɢɚɧɬɟ ɠɟɥɱɧɵɣ ɩɭɡɵɪɶ ɜɟɫɶɦɚ ɩɨɞɜɢɠɟɧ ɢ ɜɨɡɦɨɠɟɧ ɟɝɨ ɡɚɜɨɪɨɬ
Ɋɢɫ 1.28. Ɏɨɪɦɢɪɨɜɚɧɢɟ ɜɨɪɨɬɧɨɣ ɜɟɧɵ ɩɨ ɒɩɚɥɶɬɟɯɨɥɴɰɭ ɫ ɢɡɦɟɧɟɧɢɹɦɢ
1 ² hepar; 2 ² a. gastroduodenalis; 3 ² v. portae; 4 ² v. hepatica; 5 ² v. cava inferior; 6 ² v. pylorica; 7 ² truncus coeliacus; 8 ² a. splenica; 9 ² v. splenica; 10 ² v. gastrica brevis; 11 ² splen;
12 ² v. gastroomentalis sinistra; 13 ² pancreas; 14 ² colon descendens; 15 ² v. colica sinistra; 16 ² v. mesenterica inferior; 17 ² a. mesenterica superior; 18 ² v. mesenterica superior;
19 ² v. gastroomentalis dextra; 20 ² v. pancreaticoduodenalis; 21 ² duodenum.
Ⱦɧɨ ɩɭɡɵɪɹ ɪɚɫɩɨɥɨɠɟɧɨ ɭ ɩɟɪɟɞɧɟɝɨ ɤɪɚɹ ɩɟɱɟɧɢ ɢ ɩɪɨɟɰɢɪɭɟɬɫɹ ɧɚ ɩɟ ɪɟɞɧɟɣ ɫɬɟɧɤɟ ɠɢɜɨɬɚ ɜ ɭɝɥɭ ɨɛɪɚɡɨɜɚɧɧɨɦ ɩɪɚɜɨɣ ɪɟɛɟɪɧɨɣ ɞɭɝɨɣ ɢ ɧɚɪɭɠ ɧɵɦ ɤɪɚɟɦ ɩɪɹɦɨɣ ɦɵɲɰɵ ɠɢɜɨɬɚ
ɒɟɣɤɚ ɩɭɡɵɪɹ ɩɟɪɟɯɨɞɢɬ ɜ ɩɭɡɵɪɧɵɣ ɩɪɨɬɨɤ ductus cysticus ɉɨɫɥɟɞ ɧɢɣ ɜ ɨɛɥɚɫɬɢ ɜɨɪɨɬ ɩɟɱɟɧɢ ɫɨɟɞɢɧɹɟɬɫɹ ɫ ɨɛɳɢɦ ɩɟɱɟɧɨɱɧɵɦ ɩɪɨɬɨɤɨɦ
46
(ductus hepaticus communis ɨɛɪɚɡɭɹ ɨɛɳɢɣ ɠɟɥɱɧɵɣ ɩɪɨɬɨɤ ductus choledochus Ɉɛɳɢɣ ɩɟɱɟɧɨɱɧɵɣ ɩɪɨɬɨɤ ɨɛɪɚɡɭɟɬɫɹ ɡɚ ɫɱɟɬ ɫɥɢɹɧɢɹ ɩɪɚɜɨɝɨ ɢ ɥɟ ɜɨɝɨ ɩɟɱɟɧɨɱɧɵɯ ɩɪɨɬɨɤɨɜ ɫɨɨɬɜɟɬɫɬɜɭɸɳɢɯ ɩɪɚɜɨɣ ɢ ɥɟɜɨɣ ɞɨɥɹɦ ɩɟɱɟɧɢ Ɉɛɳɢɣ ɠɟɥɱɧɵɣ ɩɪɨɬɨɤ ɦɨɠɧɨ ɪɚɡɞɟɥɢɬɶ ɧɚ ɱɟɬɵɪɟ ɱɚɫɬɢ ɧɚɞɞɜɟɧɚɞɰɚɬɢ ɩɟɪɫɬɧɚɹ pars supraduodenalis ɩɪɨɬɹɠɟɧɧɨɫɬɶɸ ɨɬ ɧɚɱɚɥɚ ɩɪɨɬɨɤɚ ɞɨ ɜɟɪɯ ɧɟɝɨ ɤɪɚɹ -ɩɟɪɫɬɧɨɣ ɤɢɲɤɢ ± ɧɚɢɛɨɥɟɟ ɞɥɢɧɧɚɹ ɞɨɫɬɭɩɧɚɹ ɞɥɹ ɢɫɫɥɟɞɨɜɚ ɧɢɹ ɢ ɨɩɟɪɚɬɢɜɧɨɝɨ ɜɦɟɲɚɬɟɥɶɫɬɜɚ ɩɨɡɚɞɢɞɜɟɧɚɞɰɚɬɢɩɟɪɫɬɧɚɹ pars retroduodenalis ɪɚɫɩɨɥɨɠɟɧɧɚɹ ɩɨɡɚɞɢ ɜɟɪɯɧɟɝɨ ɝɨɪɢɡɨɧɬɚɥɶɧɨɝɨ ɨɬɞɟɥɚ - ɩɟɪɫɬɧɨɣ ɤɢɲɤɢ ɩɚɧɤɪɟɚɬɢɱɟɫɤɚɹ pars pancreatica ɩɪɨɯɨɞɹɳɚɹ ɜ ɬɨɥɳɟ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ ɜɧɭɬɪɢɫɬɟɧɨɱɧɚɹ pars intramuralis ɥɟɠɚɳɚɹ ɜ ɬɨɥ ɳɟ ɫɬɟɧɤɢ -ɩɟɪɫɬɧɨɣ ɤɢɲɤɢ ɢ ɨɬɤɪɵɜɚɸɳɚɹɫɹ ɜ ɩɪɨɫɜɟɬ ɟɟ ɧɚ ɜɟɪɲɢɧɟ ɛɨɥɶɲɨɝɨ ɫɨɫɨɱɤɚ papilla duodeni major, p. Fateri BNA) ɫɚɦɨɫɬɨɹɬɟɥɶɧɨ ɢɥɢ ɫɥɢɜɚɹɫɶ ɫ ɩɪɨɬɨɤɨɦ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ
ɉɟɪɟɞ ɜɩɚɞɟɧɢɟɦ ɨɛɳɟɝɨ ɠɟɥɱɧɨɝɨ ɩɪɨɬɨɤɚ ɜ ɞɜɟɧɚɞɰɚɬɢɩɟɪɫɬɧɭɸ ɤɢɲ ɤɭ ɨɛɪɚɡɭɟɬɫɹ ɪɚɫɲɢɪɟɧɢɟ ɩɟɱɺɧɨɱɧɨ-ɩɨɞɠɟɥɭɞɨɱɧɚɹ ɚɦɩɭɥɚ (ampula hepatopancreatica ɡɚɦɵɤɚɸɳɟɟɫɹ ɦɵɲɟɱɧɵɦ ɠɨɦɨɦ ɤɨɬɨɪɵɣ ɪɟɝɭɥɢɪɭɟɬ ɩɨɫɬɭɩ ɥɟɧɢɟ ɠɟɥɱɢ ɜ ɤɢɲɤɭ
Ʉɪɨɜɨɫɧɚɛɠɟɧɢɟ ɠɟɥɱɧɵɣ ɩɭɡɵɪɶ ɩɨɥɭɱɚɟɬ ɨɬ ɠɟɥɱɧɨɩɭɡɵɪɧɨɣ ɚɪɬɟɪɢɢ (a. cystica ɨɬɯɨɞɹɳɟɣ ɨɬ ɩɪɚɜɨɣ ɜɟɬɜɢ ɫɨɛɫɬɜɟɧɧɨɣ ɩɟɱɟɧɨɱɧɨɣ ɚɪɬɟɪɢɢ ɍ ɲɟɣɤɢ ɩɭɡɵɪɹ ɠɟɥɱɧɨɩɭɡɵɪɧɚɹ ɚɪɬɟɪɢɹ ɞɟɥɢɬɫɹ ɧɚ ɞɜɟ ɜɟɬɤɢ ɨɞɧɚ ɩɪɨɯɨɞɢɬ ɩɨ ɜɟɪɯɧɟɣ ɩɨɜɟɪɯɧɨɫɬɢ ɩɭɡɵɪɹ ɞɪɭɝɚɹ ɧɚɢɛɨɥɟɟ ɤɪɭɩɧɚɹ ɩɨ ɧɢɠɧɟɣ ɩɨ ɜɟɪɯɧɨɫɬɢ ɩɨɤɪɵɬɨɣ ɛɪɸɲɢɧɨɣ ɉɪɢ ɭɞɚɥɟɧɢɢ ɠɟɥɱɧɨɝɨ ɩɭɡɵɪɹ cholecystectomia ɤɚɤ ɩɪɚɜɢɥɨ ɩɟɪɟɜɹɡɵɜɚɟɬɫɹ ɠɟɥɱɧɨɩɭɡɵɪɧɚɹ ɚɪɬɟɪɢɹ Ⱦɥɹ ɟɟ ɨɛ ɧɚɪɭɠɟɧɢɹ ɩɨɥɶɡɭɸɬɫɹ ɨɩɨɡɧɚɜɚɬɟɥɶɧɵɦ ɬɪɟɭɝɨɥɶɧɢɤɨɦ Ʉɚɥɥɨ Calot ɞɜɭɦɹ ɫɬɨɪɨɧɚɦɢ ɤɨɬɨɪɨɝɨ ɹɜɥɹɸɬɫɹ ɫɩɪɚɜɚ ɩɭɡɵɪɧɵɣ ɢ ɫɥɟɜɚ ɨɛɳɢɣ ɩɟɱɟɧɨɱɧɵɣ ɩɪɨɬɨɤ ɢ ɫɜɟɪɯɭ ɨɛɪɚɡɭɳɚɹ ɨɫɧɨɜɚɧɢɟ ɬɪɟɭɝɨɥɶɧɢɤɚ ɠɟɥɱɟɩɭɡɵɪɧɚɹ ɚɪɬɟɪɢɹɪɢɫ .
ȼɟɧɵ ɩɭɡɵɪɹ ɨɛɪɚɡɭɸɬ ɲɢɪɨɤɭɸ ɫɟɬɶ ɚɧɚɫɬɨɦɨɡɨɜ ɫ ɜɧɭɬɪɢɩɟɱɟɧɨɱɧɵɦɢ ɜɟɬɜɹɦɢ ɜɨɪɨɬɧɨɣ ɜɟɧɵ ȼɟɧɨɡɧɵɣ ɨɬɬɨɤ ɨɫɭɳɟɫɬɜɥɹɟɬɫɹ ɜ ɩɪɚɜɭɸ ɜɟɬɜɶ ɜɨ ɪɨɬɧɨɣ ɜɟɧɵ ɱɟɪɟɡ ɠɟɥɱɧɨɩɭɡɵɪɧɭɸ ɜɟɧɭ
Ʌɢɦɮɚɬɢɱɟɫɤɢɟ ɫɨɫɭɞɵ ɠɟɥɱɧɨɝɨ ɩɤɡɵɪɹ ɜɩɚɞɚɸɸɬ ɜ ɥɢɦɮɚɬɢɱɟɫɤɢɟ ɭɡɥɵ ɪɚɫɩɨɥɨɠɟɧɧɵɟ ɜɨɡɥɟ ɟɝɨ ɲɟɣɤɢ ɑɚɫɬɶ ɥɢɦɮɚɬɢɱɟɫɤɢɯ ɫɨɫɭɞɨɜ ɦɢɧɭɹ ɷɬɢ ɭɡɥɵ ɜɩɚɞɚɟɬ ɜ ɩɟɱɟɧɨɱɧɵɟ ɥɢɦɮɚɬɢɱɟɫɤɢɟ ɭɡɥɵ ɜ ɨɛɥɚɫɬɢ ɩɟɱɟɧɨɱɧɨɞɭɨɞɟɧɚɥɶɧɨɣ ɫɜɹɡɤɢ ɇɟɤɨɬɨɪɵɟ ɥɢɦɮɚɬɢɱɟɫɤɢɟ ɩɪɨɬɨɤɢ ɜɩɚɞɚɸɬ ɜ ɩɚɧɤɪɟ ɚɬɨɞɭɨɞɟɧɚɥɶɧɵɟ ɥɢɦɮɚɬɢɱɟɫɤɢɟ ɭɡɥɵ
ɂɧɧɟɪɜɢɪɭɸɬ ɠɟɥɱɧɵɣ ɩɭɡɵɪɶ ɛɥɭɠɞɚɸɳɢɣ ɫɢɦɩɚɬɢɱɟɫɤɢɣ ɜɧɭɬɪɟɧ ɧɨɫɬɧɵɣ ɚ ɬɚɤɠɟ ɞɢɚɮɪɚɝɦɚɥɶɧɵɣ ɧɟɪɜɵ
47
Ɋɢɫ 1.29 ɉɟɱɟɧɨɱɧɨ-ɞɭɨɞɟɧɚɥɶɧɚɹ ɫɜɹɡɤɚ ɢ ɬɪɟɭɝɨɥɶɧɢɤ Ʉɚɥɨ ɩɨ ɇɟɬɬɟɪɭ ɫ ɢɡɦɟɧɟɧɢɹɦɢ
1 ² lobus dexter hepatis; 2 ² a. cystica; 3 ² trigonum Callot; 4 ² ductus cysticus;
5 ² foramen omentale; 6 ² ren dexter (ɪɟɬɪɨɩɟɪɢɬɨɧɟɚɥɶɧɨ); 7 ² duodenum; 8 ² fiexura coli dextra; 9 ² omentum majus; 10 ² flexura coli sinistra; 11 ² lig. gastrocolicum; 12 ² gaster; 13 ² splen; 14 ² omentum minus; 15 ² v. portae; 16 ² ductus choledochus; 17 ² a. hepatica propria; 18 ² ductus hepaticus; 19 ² lobus sinister hepatis; 20 ² lig. teres hepatis;
21 ² lobus quadratus hepatis; 22 ² vesica biliaris.
ɉɨɞɠɟɥɭɞɨɱɧɚɹ ɠɟɥɟɡɚ (pancreas)
Ɋɚɫɩɨɥɚɝɚɟɬɫɹ ɡɚɛɪɸɲɢɧɧɨ ɧɚ ɭɪɨɜɧɟ I-II ɩɨɹɫɧɢɱɧɵɯ ɩɨɡɜɨɧɤɨɜ ɩɨɱɬɢ ɩɨɩɟɪɟɤ ɡɚɞɧɟɣ ɫɬɟɧɤɢ ɛɪɸɲɧɨɣ ɩɨɥɨɫɬɢ ɩɪɨɫɬɢɪɚɹɫɶ ɨɬ -ɩɟɪɫɬɧɨɣ ɤɢɲɤɢ ɞɨ ɜɨɪɨɬ ɫɟɥɟɡɟɧɤɢ
ȼ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɟ ɪɚɡɥɢɱɚɸɬ ɬɪɢ ɨɬɞɟɥɚ ɝɨɥɨɜɤɭ ɬɟɥɨ ɢ ɯɜɨɫɬ Ƚɨɥɨɜɤɚ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ caput pancreatis ɪɚɫɩɨɥɚɝɚɟɬɫɹ ɜ ɞɭɝɟ - ɩɟɪɫɬɧɨɣ ɤɢɲɤɢ ɬɟɫɧɨ ɫɨɟɞɢɧɹɹɫɶ ɫ ɟɟ ɧɢɫɯɨɞɹɳɟɣ ɱɚɫɬɶɸ ɇɚ ɫɟɪɟɞɢɧɟ ɧɢɫɯɨɞɹɳɟɝɨ ɨɬɞɟɥɚ -ɩɟɪɫɬɧɨɣ ɤɢɲɤɢ ɜ ɨɛɥɚɫɬɢ ɟɟ ɦɟɞɢɚɥɶɧɨɣ ɫɬɟɧɤɢ ɜɩɚɞɚɟɬ ɩɪɨɬɨɤ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ ductus pancreaticus s. Wirsungianus ɜ ɛɨɥɶɲɢɧɫɬɜɟ ɫɥɭɱɚɟɜ ɩɪɟɞɜɚɪɢɬɟɥɶɧɨ ɫɨɟɞɢɧɢɜɲɢɫɶ ɫ ɨɛɳɢɦ ɠɟɥɱɧɵɦ ɩɪɨ ɬɨɤɨɦ Ɇɟɠɞɭ ɝɨɥɨɜɤɨɣ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ ɢ ɧɢɠɧɟɣ ɝɨɪɢɡɨɧɬɚɥɶɧɨɣ ɱɚɫɬɶɸ -ɩɟɪɫɬɧɨɣ ɤɢɲɤɢ ɨɛɪɚɡɭɟɬɫɹ ɳɟɥɶ ɱɟɪɟɡ ɤɨɬɨɪɭɸ ɩɪɨɧɢɤɚɟɬ ɜɟɪɯ ɧɹɹ ɛɪɵɠɟɟɱɧɚɹ ɚɪɬɟɪɢɹ ɉɨɡɚɞɢ ɝɨɥɨɜɤɢ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ ɪɚɫɩɨɥɚɝɚ ɸɬɫɹ ɧɢɠɧɹɹ ɩɨɥɚɹ ɩɪɚɜɚɹ ɩɨɱɟɱɧɚɹ ɜɟɧɵ ɧɚɱɚɥɶɧɚɹ ɱɚɫɬɶ ɜɨɪɨɬɧɨɣ ɜɟɧɵ
48
Ɍɟɥɨ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ corpus pancreatis ɢɦɟɟɬ ɮɨɪɦɭ ɬɪɟɯɝɪɚɧ ɧɨɣ ɩɪɢɡɦɵ ɜɫɥɟɞɫɬɜɢɟ ɱɟɝɨ ɜ ɧɟɣ ɪɚɡɥɢɱɚɸɬ ɬɪɢ ɩɨɜɟɪɯɧɨɫɬɢ ɉɟɪɟɞɧɹɹ ɨɛ ɪɚɳɟɧɚ ɤ ɡɚɞɧɟɣ ɩɨɜɟɪɯɧɨɫɬɢ ɠɟɥɭɞɤɚ Ɂɚɞɧɹɹ ɩɨɜɟɪɯɧɨɫɬɶ ɫɨɩɪɢɤɚɫɚɟɬɫɹ ɫ ɡɚɛɪɸɲɢɧɧɨɣ ɤɥɟɬɱɚɬɤɨɣ ɜɟɪɯɧɢɦ ɤɨɧɰɨɦ ɥɟɜɨɣ ɩɨɱɤɢ ɢ ɧɚɞɩɨɱɟɱɧɢɤɨɦ ɚ ɬɚɤɠɟ ɫ ɬɟɥɚɦɢ I ɢ II ɩɨɹɫɧɢɱɧɵɯ ɩɨɡɜɨɧɤɨɜ Ɇɟɠɞɭ ɩɨɡɜɨɧɨɱɧɢɤɨɦ ɢ ɩɨɞ ɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɨɣ ɥɟɠɚɬ ɛɪɸɲɧɚɹ ɚɨɪɬɚ ɢ ɱɪɟɜɧɨɟ ɫɩɥɟɬɟɧɢɟ ɇɢɠɧɹɹ ɩɨ ɜɟɪɯɧɨɫɬɶ ɞɨɜɨɥɶɧɨ ɭɡɤɚɹ ɫɨɩɪɢɤɚɫɚɟɬɫɹ ɫ ɧɢɠɧɟɣ ɝɨɪɢɡɨɧɬɚɥɶɧɨɣ ɱɚɫɬɶɸ 12-ɩɟɪɫɬɧɨɣ ɤɢɲɤɢ ɏɜɨɫɬ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ cauda pancreatis ɨɛɵɱɧɨ ɭɡɤɢɣ ɞɨɫɬɢɝɚɟɬ ɜɨɪɨɬ ɫɟɥɟɡɟɧɤɢ ɉɨɡɚɞɢ ɧɟɝɨ ɪɚɫɩɨɥɚɝɚɸɬɫɹ ɫɟɥɟɡɟɧɨɱɧɵɟ ɜɟɧɵ ɢ ɚɪɬɟɪɢɹ ɚ ɬɚɤɠɟ ɩɟɪɟɞɧɹɹ ɩɨɜɟɪɯɧɨɫɬɶ ɥɟɜɨɣ ɩɨɱɤɢ
Ʉɪɨɜɨɫɧɚɛɠɟɧɢɟ. ɉɢɬɚɟɬ ɩɨɞɠɟɥɭɞɨɱɧɭɸ ɠɟɥɟɡɭ ɜɟɪɯɧɹɹ ɩɚɧɤɪɟɚɬɨ ɞɭɨɞɟɧɚɥɶɧɚɹ ɚɪɬɟɪɢɹ ɜɟɬɜɶ ɝɚɫɬɪɨɞɭɨɞɟɧɚɥɶɧɨɣ ɚɪɬɟɪɢɢ ɢɡ ɫɢɫɬɟɦɵ ɱɪɟɜ ɧɨɝɨ ɫɬɜɨɥɚ ɧɢɠɧɹɹ ɩɚɧɤɪɟɚɬɨɞɭɨɞɟɧɚɥɶɧɚɹ ɚɪɬɟɪɢɹ ɢɡ ɜɟɪɯɧɟɣ ɛɪɵɠɟɟɱ ɧɨɣ ɚɪɬɟɪɢɢ ɢ ɜɟɬɜɢ ɨɬɯɨɞɹɳɢɟ ɨɬ ɫɟɥɟɡɟɧɨɱɧɨɣ ɚɪɬɟɪɢɢ ɪɢɫ 30, 1.31).
ȼɟɧɵ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ ɜɩɚɞɚɸɬ ɜ ɫɟɥɟɡɟɧɨɱɧɭɸ ɢ ɜɟɪɯɧɸɸ ɛɪɵ ɠɟɟɱɧɭɸ ɜɟɧɵ
Ʌɢɦɮɚɬɢɱɟɫɤɢɟ ɫɨɫɭɞɵ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ ɜɩɚɞɚɸɬ ɜ ɜɟɪɯɧɢɟ ɢ ɧɢɠɧɢɟ ɩɚɧɤɪɟɚɬɢɱɟɫɤɢɟ ɜɟɪɯɧɢɟ ɢ ɧɢɠɧɢɟ ɩɚɧɤɪɟɚɬɨɞɭɨɞɟɧɚɥɶɧɵɟ ɥɢɦɮɚ ɬɢɱɟɫɤɢɟ ɫɨɫɭɞɵ ɢ ɭɡɥɵ Ʌɢɦɮɚɬɢɱɟɫɤɚɹ ɫɢɫɬɟɦɚ ɠɟɥɟɡɵ ɬɟɫɧɨ ɫɜɹɡɚɧɚ ɫ ɥɢɦɮɚɬɢɱɟɫɤɨɣ ɫɢɫɬɟɦɨɣ -ɩɟɪɫɬɧɨɣ ɤɢɲɤɢ ɠɟɥɱɧɨɝɨ ɩɭɡɵɪɹ ɢ ɠɟɥɱɧɵɯ ɯɨɞɨɜ
ȼ ɢɧɧɟɪɜɚɰɢɢ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ ɩɪɢɧɢɦɚɸɬ ɭɱɚɫɬɢɟ ɛɥɭɠɞɚɸɳɢɟ ɢ ɫɢɦɩɚɬɢɱɟɫɤɢɟ ɧɟɪɜɵ ɉɨɞɠɟɥɭɞɨɱɧɚɹ ɠɟɥɟɡɚ ɩɨɥɭɱɚɟɬ ɜɟɬɜɢ ɨɬ ɱɪɟɜɧɨɝɨ ɩɟɱɟɧɨɱɧɨɝɨ ɫɟɥɟɡɟɧɨɱɧɨɝɨ ɩɨɱɟɱɧɨɝɨ ɢ ɜɟɪɯɧɟɝɨ ɛɪɵɠɟɟɱɧɨɝɨ ɫɩɥɟɬɟɧɢɣ.
ɋɟɥɟɡɟɧɤɚ lien, ɝɪɟɱ. splen)
ɉɨ ɮɨɪɦɟ ɧɚɩɨɦɢɧɚɟɬ ɤɨɮɟɣɧɨɟ ɡɟɪɧɨ ɇɚ ɧɟɣ ɢɦɟɸɬɫɹ ɞɜɟ ɩɨɜɟɪɯɧɨɫɬɢ ɞɢɚɮɪɚɝɦɚɥɶɧɚɹ facies diaphragmatica ɢ ɜɢɫɰɟɪɚɥɶɧɚɹ (facies visceralis ɧɚ ɤɨɬɨɪɨɣ ɜ ɫɜɨɸ ɨɱɟɪɟɞɶ ɪɚɡɥɢɱɚɸɬ ɩɨɜɟɪɯɧɨɫɬɢ ɩɨɱɟɱɧɭɸ facies renalis), ɠɟɥɭɞɨɱɧɭɸ facies gastrica ɨɛɨɞɨɱɧɭɸ facies colica ɋɟɥɟɡɟɧɤɚ ɢɦɟɟɬ ɩɟ ɪɟɞɧɢɣ ɢ ɡɚɞɧɢɣ ɤɨɧɰɵ ɜɟɪɯɧɢɣ ɢ ɧɢɠɧɢɣ ɤɪɚɹ Ɋɚɫɩɨɥɨɠɟɧɚ ɨɧɚ ɜ ɥɟɜɨɦ ɩɨɞɪɟɛɟɪɶɟ ɦɟɠɞɭ IX-XI ɪɟɛɪɚɦɢ
ɋɧɚɪɭɠɢ ɢ ɫɡɚɞɢ ɫɟɥɟɡɟɧɤɚ ɫɨɩɪɢɤɚɫɚɟɬɫɹ ɫ ɞɢɚɮɪɚɝɦɨɣ ɫɩɟɪɟɞɢ ɢ ɢɡ ɧɭɬɪɢ ɩɪɢɥɟɠɢɬ ɤ ɠɟɥɭɞɤɭ ɢ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɟ ɫɡɚɞɢ ± ɤ ɥɟɜɨɣ ɩɨɱɤɟ ɢ ɧɚɞɩɨɱɟɱɧɢɤɭ ɋɧɢɡɭ ɨɧɚ ɫɨɩɪɢɤɚɫɚɟɬɫɹ ɫ ɩɨɩɟɪɟɱɧɨ-ɨɛɨɞɨɱɧɨɣ ɤɢɲɤɨɣ ɢ ɞɢɚɮɪɚɝɦɚɥɶɧɨ-ɫɟɥɟɡɟɧɨɱɧɨɣ ɫɜɹɡɤɨɣ Ȼɪɸɲɢɧɚ ɩɨɤɪɵɜɚɟɬ ɫɟɥɟɡɟɧɤɭ ɫɨ ɜɫɟɯ ɫɬɨɪɨɧ ɡɚ ɢɫɤɥɸɱɟɧɢɟɦ ɜɨɪɨɬ ɉɟɪɟɯɨɞɹ ɫ ɫɟɥɟɡɟɧɤɢ ɧɚ ɠɟɥɭɞɨɤ ɛɪɸɲɢɧɚ ɨɛɪɚɡɭɟɬ ɠɟɥɭɞɨɱɧɨ-ɫɟɥɟɡɟɧɨɱɧɭɸ ɫɜɹɡɤɭ ɜ ɤɨɬɨɪɨɣ ɩɪɨɯɨɞɹɬ ɤɨɪɨɬɤɢɟ ɠɟ ɥɭɞɨɱɧɵɟ ɚɪɬɟɪɢɢ ɢ ɜɟɧɵ aa. et vv. gastricae breves ɢ ɡɚɥɟɝɚɸɬ ɥɢɦɮɚɬɢɱɟ ɫɤɢɟ ɭɡɥɵ ɞɧɚ ɠɟɥɭɞɤɚ Ɉɬ ɜɨɪɨɬ ɫɟɥɟɡɟɧɤɢ ɢ ɱɚɫɬɢɱɧɨ ɨɬ ɟɟ ɜɟɪɯɧɟɝɨ ɤɪɚɹ ɤ ɞɢɚɮɪɚɝɦɟ ɧɚɬɹɧɭɬɚ ɞɢɚɮɪɚɝɦɚɥɶɧɨ-ɫɟɥɟɡɟɧɨɱɧɚɹ ɫɜɹɡɤɚ ɚ ɜ ɬɨɥɳɟ ɟɟ ɩɪɨɯɨ ɞɹɬ ɫɟɥɟɡɟɧɨɱɧɵɟ ɚɪɬɟɪɢɹ ɢ ɜɟɧɵ ɧɟɪɜɵ ɥɢɦɮɚɬɢɱɟɫɤɢɟ ɫɨɫɭɞɵ ɢ ɭɡɥɵ ɫɟɥɟ ɡɟɧɤɢ Ʉɪɨɦɟ ɩɟɪɟɱɢɫɥɟɧɧɵɯ ɫɜɹɡɨɤ ɜ ɮɢɤɫɚɰɢɢ ɫɟɥɟɡɟɧɤɢ ɛɨɥɶɲɨɟ ɡɧɚɱɟɧɢɟ ɢɦɟɸɬ ɜɧɭɬɪɢɛɪɸɲɧɨɟ ɞɚɜɥɟɧɢɟ ɢ ɞɢɚɮɪɚɝɦɚɥɶɧɨ-ɨɛɨɞɨɱɧɚɹ ɫɜɹɡɤɚ ɪɚɫɩɨ
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ɥɨɠɟɧɧɚɹ ɦɟɠɞɭ ɥɟɜɵɦ ɢɡɝɢɛɨɦ ɨɛɨɞɨɱɧɨɣ ɤɢɲɤɢ ɢ ɞɢɚɮɪɚɝɦɨɣ ɉɨɫɥɟɞɧɹɹ ɨɛɪɚɡɭɟɬ ɤɚɤ ɛɵ ɤɚɪɦɚɧ ɜ ɤɨɬɨɪɨɦ ɪɚɫɩɨɥɚɝɚɟɬɫɹ ɫɟɥɟɡɟɧɤɚ
Ɋɢɫ. 1.30 ɉɨɞɠɟɥɭɞɨɱɧɚɹ ɠɟɥɟɡɚ ɛɪɸɲɢɧɚ ɱɚɫɬɢɱɧɨ ɭɞɚɥɟɧɚ ɜɵɞɟɥɟɧ ɩɪɨɬɨɤ ɩɨɞɠɟɥɭɞɨɱɧɨɣ ɠɟɥɟɡɵ ɞɜɟɧɚɞɰɚɬɢɩɟɪɫɬɧɚɹ ɤɢɲɤɚ ɜɫɤɪɵɬɚ
1 ² gl. suprarenalis dextra; 2 ² ren dexter; 3 ² a. et v. pancreaticoduodenalis superior; 4 ² duodenum; 5 ² papilla duodeni minor; 6 ² ductus pancreaticus accessorius; 7 ² ductus choledochus; 8 ² papilla duodeni major; 9 ² a. et v. pancreaticoduodenalis inferior; 10 ² v. mesenterica superior; 11 ² a. mesenterica superior et plexus mesentericus superior; 12 ² ductus pancreaticus; 13 ² ren sinister; 14 ² ramus pancreaticus (a. splenica); 15 ²splen; 16 ²nodi lymphoideipancreaticosplenicum; 17² gl. suprarenalis sinistra; 18 ² a. splenica et plexus splenicus; 19 ² nodi lymphoidei coeliaci; 20 ² truncus coeliacus; 21 ² plexus coeliacus; 22 ² a. gastroduodenalis; 23 ² a. hepatica propria; 24 ² v. portae; 25 ² ductus choledochus.
Ʉ ɫɨɫɭɞɚɦ ɫɟɥɟɡɟɧɤɢ ɨɬɧɨɫɹɬɫɹ ɫɟɥɟɡɟɧɨɱɧɚɹ ɚɪɬɟɪɢɹ ɢ ɜɟɧɚ ɩɪɨɯɨɞɹɳɢɟ ɜ ɬɨɥɳɟ ɞɢɚɮɪɚɝɦɚɥɶɧɨ-ɫɟɥɟɡɟɧɨɱɧɨɣ ɫɜɹɡɤɢ ɪɢɫ
Ʌɢɦɮɚɬɢɱɟɫɤɢɟ ɫɨɫɭɞɵ ɩɪɨɯɨɞɹɬ ɫɟɥɟɡɟɧɨɱɧɵɟ ɥɢɦɮɚɬɢɱɟɫɤɢɟ ɭɡɥɵ (nodi lymphatici lienalis ɪɚɫɩɨɥɨɠɟɧɧɵɟ ɜ ɨɛɥɚɫɬɢ ɜɨɪɨɬ ɫɟɥɟɡɟɧɤɢ ɨɬɤɭɞɚ ɥɢɦɮɚ ɨɬɬɟɤɚɟɬ ɱɟɪɟɡ ɱɪɟɜɧɵɟ ɥɢɦɮɚɬɢɱɟɫɤɢɟ ɭɡɥɵ nodi lymphatici coeliaci) ɜ ɝɪɭɞɧɨɣ ɩɪɨɬɨɤ.
ɂɧɧɟɪɜɚɰɢɹ ɫɟɥɟɡɟɧɤɢ ɨɫɭɳɟɫɬɜɥɹɟɬɫɹ ɢɡ ɫɟɥɟɡɟɧɨɱɧɨɝɨ ɫɩɥɟɬɟɧɢɹ (plexus lienalis), ɪɚɫɩɨɥɨɠɟɧɧɨɝɨ ɩɨ ɯɨɞɭ ɨɞɧɨɢɦɟɧɧɵɯ ɫɨɫɭɞɨɜ
Ɉɪɝɚɧɵ ɧɢɠɧɟɝɨ ɷɬɚɠɚ ɛɪɸɲɧɨɣ ɩɨɥɨɫɬɢ
ȼ ɧɢɠɧɟɦ ɷɬɚɠɟ ɛɪɸɲɧɨɣ ɩɨɥɨɫɬɢ ɪɚɫɩɨɥɨɠɟɧɵ ɬɨɧɤɚɹ ɢ ɬɨɥɫɬɚɹ ɤɢɲ
ɤɢ
Ɍɨɧɤɚɹ ɤɢɲɤɚ (intestinum tenue, ɝɪɟɱ.enteron)
Ⱦɟɥɢɬɫɹ ɧɚ ɬɪɢ ɨɬɞɟɥɚ -ɩɟɪɫɬɧɭɸ duodenum ɬɨɳɭɸ intestinum jejunum ɢ ɩɨɞɜɡɞɨɲɧɭɸ intestinum ileum ɤɢɲɤɢ
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