Abdominal wall (PDF) by bahar19852010

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									part of the trunk that lies
between the thorax and
pelvis
        located between diaphragm and pelvic
        brim
        diaphragm forms the roof
        no floor, continuous with pelvic cavity


• 5 lumbar vertebrae
• intervertebral discs
• lower ribs
• iliac bone
• muscles                organs of digestive system
                         parts of urogenital system
                         spleen
                         suprarenal glands
                         part of autonomic plexuses
                         peritoneum
extent
  from osteocartilagenous
  thoracic cage to the pelvis
  form lumbar vertebra to linea
  alba

subdivisions
  anterio-lateral abdominal
  wall
  posterior abdominal wall
    Posterior abdominal wall:
-     Composed of 5 lumbar vertebrae & IV discs, muscles, fascia, lumbar plexus, fat, nerves, LN & lymphatic vessels
-     lumbar vertebrae is central prominence in posterior wall, creating paravertebral gutters (narrow groove)
-    Most posterior (kidney & surrounding fat) vertebral column (lumbar) lower abdominal aorta               anterior structure (superior
    mesenteric artery, duodenum, pancreas & left renal vein) anterior abdominal wall
       Fascia: 2 layers of endoabdominal fascias (lie between parietal peritoneum & muscle) cover post. abdominal wall; these fascia
    are continuous with transversalis fascia that lines transverse abdominal muscle
    1) psoas fascia
    - covers psoas major, attached medially to lumbar vertebrae & pelvic brim
    -thickens superiorly to form MEDIAL arcuate ligament
    -fuses laterally with quadratus lumborum(QL) & thoracolumbar fascia
    -continous with iliac fascia covering iliacus and fascia covering QL
    2) thoracolumbar fascia
    - extensive fascia attached to vertebral column medially( thin )
    -have anterior , middle & posterior layers with muscles enclosed between them
    - not attached to external oblique; but atteched to latissimus dorsi, internal oblique and transverse abdominis
    -posterior, middle layers( thicker becoz in the lumbar region) enclose deep back muscles (erector spinae) and have bony support
    than rectus sheath
    -anterior layer( thin bcoz not in lumbar region) quadratus lumborum fascia that continues laterally with aponeurotic origin of
    transverse abdominal muscle, thickens superiorly to form LATERAL arcuate ligaments sand adherent inferiorly to iliolumbar
    ligament
      muscles: major muscles are psoas major (inf + lat); iliacus (lying along lateral sides of inferior part of psoas major); quadratus
    lumborum (lying adjacent to transverse processes of lumbar vertebrae & lateral to superior part of psoas major)
    clinical application: iliopsoas are related to kidney, ureter, cecum, appendix, sigmoid colon, pancreas, lumbar LN and
    nerves of POST abdominal wall. Thus, when these structure are disease (adenocarcinoma of pancreas, appendicitis),
    movement of iliopsoas causes pain. Do iliopsoas test :1)lie on unaffected part & extend thigh on affected side against
    examiner’s hand positive sign when pain is elicited( right psoas sign indicates inflamed appendix)
        nerves: subcostal( ext oblique, skin of anterolateral wall); lumbar plexus, L1-L4( femoral, obturator, lumboacral trunk,
    ilioinguinal & iliohypogastric, genitofemoral nerve, lateral cut n of thigh, accessory obturator nerve-10%)
                       Branches of ABD aorta:
                      Vascular    class         Distribution
                      plane
                      Anterior    Unpaired      Alimentary tract
                 1    midline     visceral      (branch to SMA-
                                                L1, IMA- L3,
Vessels of POST                                 celiac artery-T12)
abd wall
abdominal aorta 2     lateral     Paired        Urogenital &
                                  visceral      endocrine organ
(begins in aortic                               (branch to
hiatus in                                       suprarenal- L1,
diaphragm at T12                                renal- L1,
and ends at L4                                  testicular/ovarian
by divide into rt                               artery-L2)
& lt common           POST +      Paired        Diaphragm (
iliac artey)      3   lateral     parietal      subcostal-L2,
                                  (segmental)   inferior phrenic-
                                                T12, lumbar-L1
                                                to L4)
boundaries
    Rt.& Lt.costal margin,
    xiphoid process
    iliac crest,
    ASIS,
    symphysis pubis
    vertical line through ASIS




     surface anatomy
   median vertical fibrous line joining
                                           curved line,
xiphoid process to symphysis pubis
( wider above the umbilicus )           convex laterally extending from
                                        9th costal cartilage to pubic tubercle,
                                        indicating lateral boarder of rectus
                                        abdominis muscle
                    xiphoid process


                                    Umbilicus
                                    • site of attachment of umbilical cord
linea alba                          • location variable, between L 3 – L4
                                    • mid way between xiphoid process
                                      and symphysis pubis
                                    • dermatone distribution – T 10

                               linea semilunaris

                                   symphysis pubis

                                                surface anatomy
To describe
      location of the viscera (in general)
      location of pain, swelling, incisions
      etc

divide the abdomen into 9 regions by
pairs of vertical and horizontal planes

   vertical planes
      connecting midclavicular
      and midinguinal points ***

   horizontal planes
      transpyloric plane / subcostal plane
      transtubercular plane ***
  midway between suprasternal notch & symphysis pubis
  midway between umbilicus & xyphoid process

Generally passes through
• the tip of 9thcostal cartilage
• fundus of the gall bladder
• pylorus of the stomach
• portal vein
• neck of the pancreas
• DJ junction
• 1st lumbar vertebra
• SMA
• hila of the kidneys
• at this point linea semilunaris crosses
  the costal margin
others
  alternate method of dividing
  abdomen
    two lines / four regions

 other planes in the abdomen
    intercristal plane
regions of abdomen

  RHC
    liver , gall bladder

  epigastrium
    stomach, pancreas, left lobe of liver

  LHC
    spleen, tail of pancreas, fundus of
    stomach
Rt. lumbar
  right kidney, ascending colon

umbilical
  coils of small intestine

Lt. lumbar
  left kidney, descending colon
SPA
  Bladder

RIF
  caecum, appendix

LIF
  sigmoid colon
LIVER                                   5th rib
                                                  5th ICS
• most of the bulk lies on right side

• under cover of lower ribs
• RHC, epigastrium, LHC
• dome 5th. rib Rt. / 5th. ICS Lt.
• not palpable
GALL BLADDER
fundus
tip of the 9th. right costal
cartilage on trans-pyloric
plane
SPLEEN
LHC
• related to 9, 10, 11 ribs
      ( long axis - 10 th rib )

• characteristic notch
      ( anterior border )
PANCREAS
related to transpyloric plane
• Head   - to the right and below
• Neck - on the plane
• Body and tail - to the Lt. and above
              *
KIDNEYS
• right kidney lies lower than left


• trans-pyloric plane passes
through both hila
STOMACH
• epigastrium, LHC, umbilical
region
• fixed at 2 points
   • OG junction
         left to the XS joint ( T- 11 )
   • pyloroduodenal junction
         right to the midline (L- 1)
CAECUM & APPENDIX ( in RIF )
McBurney’s point
base of the appendix
                   umbilicus




 ASIS
surface anatomy

layers of abdominal wall
  Skin
  Fascia
  Muscles of the anterior
  abdominal wall
    the rectus sheath
  Fascia transversalis
  Extraperitoneal fat
  Peritoneum
thinner skin compared to the back
natural lines of cleavage
  run almost horizontally around the trunk
  incision along the cleavage line will heal with a
  narrow scar
cutaneous nerve supply
   derived from anterior rami of the 7th through the 12th
   thoracic nerve and first lumbar nerve

Dermatone
   “area of skin supplied by a single spinal nerve”
   epigastrium      T 7
   umbilicus        T 10
   symphysis pubic         L1
ASIS




DERMATONE DISTRIBUTION OF ANTERIOR ABDOMINAL WALL
superficial fascia
deep fascia ( very thin )
superficial fascia - divided into two layers
     fatty layer ( Camper’s fascia )
        merge with subcutaneous tissue of the body
     membranous layer ( fascia Scarpa )
        continuous with perineal fascia ( Colle’s fascia)
Superficial veins
superficial network of venous
plexus radiate out from the
umbilicus

above umbilicus,
     - drain into axillary vein via
lateral thoracic vein

below umbilicus,
     - drain into femoral vein via
superficial epigastric vein
membranous layer ( fascia Scarpa )
    - more prominent in lower half of abdomen
    - fuse with fascia Lata of thigh below the inguinal
    ligament
    - continuous with superficial fascia of perineum           (
    Colle’s fascia ), fascia investing penis, scrotum and labia
    majora
    - in the perineum, attached to the perineal body,
    posterior margin of perineal membrane and laterally to
    the rami of pubis and ischium
Scarpa’s fascia


                  P




                      bulbous urethra
clinical application

  - rupture of the bulbous
  urethra

  - extravasated urine is
  collected deep to Scarpa’s
  fascia
external oblique muscle
internal oblique muscle
transversus abdominis muscle
rectus abdominis muscle
   muscle                    origin                           insertion

external      lower 8 ribs                     xiphoid process, linea alba,
oblique                                        pubic crest, pubic tubercle, iliac
                                               crest
internal      lumbar fascia, iliac crest,      lower 3 ribs and costal cartilages,
oblique       lateral                          xiphoid process, linea alba,
              two third of inguinal ligament   symphysis pubis
transversus   lower 6 costal cartilages,       xiphoid process, linea alba,
abdominis     lumbar fascia, iliac crest,      symphysis pubis
              lateral third of inguinal
              ligament
rectus        symphysis pubis, iliac crest     5th, 6th, 7th costal cartilages, xiphoid
abdominis                                      process
pyramidalis   anterior part of pubis           linea alba
External oblique muscle
      ( free posterior boarder )


 * inguinal ligament
 * external inguinal ring
      ( superficial inguinal ring )
 * external spermatic fascia
Internal oblique muscle
 free boarder – arch over spermatic cord

 form conjoint tendon
 together with
 similar fibres of transversus abdominis
 muscle.
Transversus abdominis muscle


•   free boarder – arch over spermatic cord

• form conjoint tendon
• together with similar fibres of internal
    oblique muscle

• cremasteric muscle
Neurovascular plane
 the plane between internal oblique and transverse
 abdominis muscle
 lower 5 intercostal nerves, subcostal nerve and first lumbar
 nerve and vessels run in neurovascular plane
 lateral and anterior cutaneous branches pierce through the
 muscle
 enter the rectus sheath by piercing its posterior wall
rectus abdominis muscle

  long strap muscle extending from
  xiphoid process to symphysis pubis
  broader above
  linea alba separates the two rectus
  muscles

muscle is
 enclosed in rectus sheath
 adherent to rectus sheath anteriorly,
  3 constant tendinous intersections are formed
      at the tip of the xiphoid process
      at umbilicus and
      mid -way between 1 & 2
  completely free behind ( not adherent to rectus sheath posteriorly)
rectus sheath

 tendonous sheath ( in which rectus muscle lies )
 formed by aponeurosis of lateral abdominal muscles
 fused in mid line ( linea alba )
  posterior rectus sheath & its relations
                                • xiphoid process and
                                • costal cartilages




                                   • posterior layer of internal oblique aponeurosis
                                   • aponeurosis of transversus abdominis muscle
• fascia transversalis
• extra peritoneal pad of fat
• parietal peritoneum




                                     no posterior rectus sheath
free curved lower boarder of
posterior wall of the rectus
sheath                       “
arcuate line of Douglas ”

where inferior epigastric
vessels enter the rectus
sheath
to support the viscera
to compress the abdomen
to assist respiration ( expiration )
to move the trunk
  combination of muscles and aponeurosis in anterior
  abdominal wall give protection to the abdominal viscera
  muscles cross each other in such a way that it strengthen
  the abdominal wall
Superior epigastric artery
Inferior epigastric artery
Deep circumflex iliac
artery
Superficial circumflex
iliac artery
Posteior intercostal
artery
Lumbar arteries
Superior epigastric vein - internal thoracic
Inferior epigatric vein &
Deep circumflex vein - external iliac
Posterior intercostal veins - azygos
Lumbar veins - IVC
anterior rami of lower 6
thoracic and first lumbar
nerves
passes forward in plane
between internal oblique and
transversus abdominis muscle
( neurovascular plane )
supply skin, muscles and
parietal peritoneum
first lumbar nerve supply skin
over inguinal ligament &
symphysis pubis
Neurovascular plane
    segmental nerve supply
      referred pain *
      intercostal nerve blocks
      collection of pus
superficial veins
    dilatation of superficial veins in
    anterior abdominal wall
       site ( abdomen / thorax )
       direction of blood flow
    clinical conditions
       portal venous obstruction -dilated
       veins radiating out from the
       umbilicus
       vena cava obstruction
       “caput Medusae ”



In portal venous obstruction,
superficial veins of the abdominal wall
around the umbilicus are dilated and
tortuous as blood from the portal vein
flow back through paraumbilical veins
into superficial veins of the anterior
abdominal wall.
Vena caval obstruction




     SVC obstruction
Vena caval obstruction




                         IVC obstruction
incisions


 aim at leaving abdominal wall
 as strong as possible after the operation,
 otherwise there exist a very real danger of bad
 weak scar and ventral hernia
Principles

 Good access, direct access to the area of operation
 Allow extension if required
 No nerves must be divided
 Split the muscle in the direction of the fibres, rather than
 cut across
 Rectus abdominis muscle may be cut transversely without
 serious weakening
 Close the wound with no tension
Incisions
 Mid line incisions
 Paramedian incisions
 Transverse incisions
 Kocher’s incision
 Incision through linea
 semilunaris

 * structures under your knife
?
inguinal region

Surface markings

 Iliac crest

 ASIS

 Symphysis pubis & pubic
 tubercle
Note

 mid-inguinal point

 mid point of inguinal ligament
mid inguinal point

 mid point of a line drawn between ASIS and
 symphysis pubis

 femoral artery lie deep to this point
    arterial puncture
mid point of inguinal ligament

 mid point of a line drawn between ASIS and pubic
 tubercle

 deep inguinal ring lies 1.5 cm above this point
     ( important landmark to identify the deep inguinal ring )
inguinal ligament

• formed by free edge of aponeurosis of external
    oblique muscle
•   extending from ASIS to pubic tubercle
•   edge is rolled inwards and form a gutter
•   provide origin for internal oblique & transversus
    abdominis muscles
•   fascia lata is attached to inguinal ligament
         mid point of inguinal ligament
 midinguinal point
                           linea semilunaris



                                          IEA
                  ASIS



                                    IR


               inguinal ligament

F Lata
                               pubic tubercle   SyP
parts of inguinal ligament

 Lacunar ligament
    triangular in shape, apex lies at the pubic tubercle, base
    is concave, free and laterally related to femoral canal
 Pectinate part
oblique canal ( intermuscular slit ) in the inguinal
region formed as a result of descent of testis through
the abdominal wall
1.5 - 2 inches / 4 - 6 cm long
lying downward and medially
extending from internal to external inguinal ring
above and parallel to medial half of inguinal
ligament

            ASIS
                          IEA
                     IR


 inguinal ligament
                                ER
                                     PT

                            SyP
External inguinal ring

    triangular opening
    in external oblique aponeurosis
    above and medial to the pubic tubercle
    as the cord traverses the opening, it carries “external
    spermatic fascia ” from the ring margin
Internal inguinal ring

    opening in the transversalis fascia
    transversalis fascia forms “ internal spermatic fascia ”
    and is attached to the margins of internal ring
    the ring lies lateral to inferior epigastric vessels
anterior relation
   skin, sup fascia, external oblique, internal oblique
posterior relation
   IEV, fascia transversalis, conjoint tendon medially
foor
   inguinal ligament
roof
   arching fibres of internal oblique & transversus abdominis
   muscle
spermatic cord ( round ligament of uterus )
ilio-inguinal nerve
genital branch of genito-femoral nerve
spermatic cord
  3 layers of fascia
     external spermatic fascia ( from ext. oblique m )
     cremasteric muscle ( from internal oblique m )
     internal spermatic fascia ( from fascia transversalis )
  3 arteries
     testicular A – from abdominal aorta
     cremasteric A – from inferior epigastric artery
     artery to the vas – from inferior vesical artery
3 nerves
  nerve to cremaster – from genitofemoral N
  sympathetic fibres
  ilio-inguinal nerve
3 other structures
  vas deferens
  pampiniform plexus of veins
  lymphatics
Clinical application

 Hernia , the most commonly seen problem in daily
 clinical practice

 Hydrocoele

 Torsion of the testis
disposition of deep and superficial rings
inguinal canal is oblique
shutter mechanism of internal oblique and
transversus abdominis muscles
intra-abdominal pressure
guy-rope action of inferior epigastric artery
cremasteric muscle
anterior abdominal wall hernias
inguinal swelling / inguino-scrotal swelling

 Inguinal hernia
  hernia passing through the inguinal canal
    direct
    indirect

 Femoral hernia
  hernia passing through the femoral canal
        indirect                    direct

in a preformed sac          no preformed sac
through internal ring,      not through deep
inguinal canal, external    inguinal ring – but
ring                        through Hesselbach’s
neck of hernia is lateral   triangle
to IEV                      neck of hernia is medial
                            to IEV
   inguinal hernia
                                femoral hernia
inguinal canal
above and medial to     femoral canal
pubic tubercle          below and lateral to
into the scrotum        pubic tubercle
                        groin swelling growing
                        downward then upwards


           clinical tests
                            Revisit femoral triangle !!!
Hydrocoele
         Accumulation of fluid in tunica albugenia

                         No inguinal swelling.




 Varicocoele !
Torsion of the testis

                    predisposing factors ???

								
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