1 ANA4 - Abdomen in General 2015B

8/3/2019 1 ANA4 - Abdomen in General 2015B

1/10

ANATOMY Abdomen in Generalby Dra. Zulueta UERMedicine2015B

OBJECTIVESGENERAL OBJECTIVEUnderstand the gross anatomy of the anterior and posteriorabdominal wall including the inguinal region

SPECIFIC OBJECTIVESANTERIOR ABDOMINAL WALL

1. Identify anatomical landmarks (skeleton,cadaver, living subject) used in the study of thesurface anatomy of the abdomen.2. Describe how abdomen is divided intoquadrants and regions and the clinical application ofsuch.3. Name and define extent of layers/musculature from outwards to inwards.4. Describe the formation of the rectus sheathat various levels.5. Name the contents of the rectus sheath.6. Describe the innervations.7. Describe the internal aspect.8. Describe the disposition of the peritoneum.9. Name the corresponding layers of musculature in the scrotum.

INGUINAL REGION1. Define the deep fascia in the inguinalregion.

2. State the extent and boundaries of theinguinal canal.3. Locate the superficial and deep inguinalring.4. Differentiate the types of inguinal hernia.5. Describe other forms of hernia in theabdomen.

POSTERIOR ABDOMINAL WALL1. Name the musculature of the posteriorabdominal wall.

THE ABDOMEN

Figure 1. Overview of Thoracic and Abdominal Viscera

Abdomen a.k.a. abdominopelvic cavity.

There is no exact delineation between the abdomenand the pelvis

Part of the trunk bet. the thorax andpelvis

Designed to enclose & protect its contents

Abdominal viscera organs inside the cavity

Peritoneum

Glistening, transparent serous membrane

2 continuous layers: Parietal and visceralperitoneum (both are lined by mesothelium simple squamous epithelium)

-Parietal peritoneum: continuous withparietal peritoneum lining the pelvis: Sensitive to pressure, pain andtemperature; pain at inferior surface ofdiaphragm can be referred to the C3-C5dermatomes on shoulder

-Visceral peritoneum: covers visceral organs

: Insensitive to pressure, pain andtemperature; sensitive to stretch andchemical irritation

Peritoneal cavity

Space between visceral and parietalperitoneum

Contains no organs but approximately50 ml of peritoneal fluid (water, electrolytes,

leukocytes and antibodies) for lubrication andmovement without friction

Closed cavity in males, but has exteriorcommunication in females thru vagina, uterus,and uterine tube.

THE ABDOMINAL CAVITY

The major part of the abdominopelvic cavity.

Located between the diaphragm and the pelvic inlet.

Separated from the thoracic cavity by the thoracicdiaphragm.

Continuous inferiorly with the pelvic cavity.

Under cover of the thoracic cage superiorly

Supported and partially protected inferiorly by thegreater pelvis.

Enclosed anterolaterally by multi-layered,musculoaponeurotic, abdominal walls.

The location of most digestive organs, parts of theurogenital system (kidneys and most of the ureters),and the spleen.

Through voluntary or reflexive contraction itsmuscular roof, anterolateral walls, and floor can raiseinternal pressure to aid expulsion from theabdominopelvic cavity from the adjacent thoraciccavity, expulsion of air from the thoracic cavity(lungs and bronchi) or of fluid, flatus, feces, or

fetuses from the abdominopelvic cavity

ANTERIOR ABDOMINAL WALL

ABDOMINAL PLANES

Figure 2. Abdominal Regions, Reference Planes andQuadrants

Rey, Miggy, Gab, Lara, Sarah, Elene, Ronna 11042011 - 1st Lecture (4th LE )

Page 1 of10


2/10


Used to locate abdominal organs, pains orpathologies

Subcostal plane- Horizontal plane at the inferior level of the 10th

rib or L3; lower border of 10th costal cartilage

Transtubercular plane

- Horizontal plane that crosses over the iliac tubercles5cm posterior to the ASIS at the lower border of L5

Transpyloric plane- Horizontal broken line running from the tip of the

9th costal cartilage to the fundus of thegallbladder, pylorus of the stomach,duodenojejunal junction, lower body of L1, neckof the pancreas to the hila of the kidneys; root oftransverse mesocolon and origin of superiormesenteric a. and portal vein.

- At the junction of the linea semilunaris and costalmargin

Transumbilical plane- Transects the umbilicus ( L3-L4)

The abdomen is divided into quadrants. In order todivide, you need:

- Vertical line / Median plane: vertical line passingthrough the medial line; starting fromepigastrium

- Horizontal / Transumbilical plane: transverseline passed through the umbilicus between theIV disc of L3-L4 level (umbilical region)

4 quadrants: Right Upper (RU), Left Upper (LU), LeftLower (LL), Right Lower (RL)

1. Right Upper Quadrant (RUQ) contains:

Liver (right lobe)

Gallbladder

Pylorus (stomach)

Duodenum (1st 3rd parts)

Head of Pancreas

Right Suprarenal Gland Right Kidney

Right colic/hepatic flexure

Ascending Colon (superior part)

Transverse Colon (right half)2. Left Upper Quadrant (LUQ) contains:

Liver (left lobe)

Pancreas (body and tail)

Spleen

Stomach

Jejunum (proximal to ileum)

Left Suprarenal Gland

Left Kidney

Left Colic/Splenic flexure

Descending Colon ( superior part)

Transverse Colon (left half)3. Right Lower Quadrant (RLQ) contains:

Most of Ileum

Cecum

Appendix

Ascending colon (inferior part)

Right Ovary

Right Uterine tube

Right Ureter (abdominal part)

Right Spermatic cord (abdominal part)

Uterus (only when enlarged)

Urinary Bladder (only when full)

4. Left Lower Quadrant (LLQ) contains: Sigmoid Colon

Descending Colon (inferior part)

Left Ovary

Left Uterine tube

Left Ureter (abdominal part)

Left Spermatic cord (abdominal part)

Uterus (only when enlarged)

Urinary bladder (if very full)

What distends the abdomen?- The Fs: Food, Fluid, Flatus, Feces, Fetus.

9 Regions of the Abdomen

1. Epigastric (E)2. Umbilical (U)3. Pubic region (P)4. Right Hypochondriac (RH)5. Left Hypochondriac (LH)6. Right Inguinal (RI)

7. Left Inguinal (LI)8. Right Lumbar / Right Flank (RL)9. Left Lumbar / Left Flank (LL)

2 vertical sagittal planes- 2 lines that passes through the midclavicular line to

midinguinal points- Right and Left Midclavicular Lines

2 transverse planes

- Subcostal plane - lower border of 10th costal cartilageat each side

- Transtubercular plane - passes through the iliactubercle

Clinical significance of regions location of organs,

pain, etc.Examples:

o Appendicitis pain at the Right Inguinal or

Right Lower Quadranto Ulcer pain at Epigastric region = Right or

Left Upper Quadrant

o if you palpate an enlargement at the right

upper region it is the liverTRANSPYLORIC PLANE

Extrapolated midway between the superior bordersof the manubrium of the sternum and the pubicsymphysis (typically the L1 vertebral level)

Commonly transects pylorus (distal, tubular part ofstomach) when patient is recumbent or supine.

Landmark for:- The fundus of the Gallbladder

- Neck of the Pancreas

- Origin of the Superior Mesenteric Artery (SMA)- Origin of portal vein,

- Root of the transverse Mesocolon

- Duodenojejunal junction

- Hila of the Kidneys

Figure 3. Regions and Planes of Abdomen

Interspinous plane- Passes through the easily palpated anterior

superior iliac spine of each side.

OTHER LANDMARKS


Page 2 of10


3/10


Figure 4. Surgical incisions made in the abdominal area

McBurney Point - For open surgery; not for surgerywith scopes

Langers Line or Lines of Cleavage

- Incision with most cosmetic effect Bikini Cut(incision at the surface of the abdomen;Suprapubic/Pfannenstiel (made at the pubichairline) incision done in most ob-gynprocedures)

SUBDIVISIONS

Figure 5. Abdominal Wall subdivisions

2 abdominal walls:(1) Anterolateral - no delineation between the

anterior and the lateral part (thewall is oblique which extendslaterally and anteriorly)

(2) Posterior

LAYERS OF ANTEROLATERAL ABDOMINAL WALL

Figure 6. Layers of the anterolateral abdominal wall

1. Skin

- Loosely attached to the underlying structuresexcept at the umbilicus

2. Superficial fascia (also called subcutaneoustissue/ Tela Subcutanea)

a. Campers fascia- Fatty layer

-Continuous with superficial fat over the restof the body; vary with nutritional status of

individual- Thick fascia in obese individuals- From the thorax to the lowerextremities

-Equivalent to the Dartos Muscle of theperineum/scrotum

b. Scarpas fascia-Deep membranous layer-With continuity at the perineal area asColles fascia

- In the midline, it is not attached to the pubisbut instead forms tubercular sheath for thepenis or clitoris

-Thickening at the base and sides of the

penis forms the fundiform ligament3. Deep (investing) fascia-Continues to become Bucks fascia or deep

penile fascia-Potential spaces: between superficial and deep

fascia or between Colles fascia and deep fascia- Thickens to form the suspensory ligamentthat

anchors the root of the penis to the symphysispubis and arcuate line

- Site of urine extravasation when there is penilefracture

4. MusclesFlat muscles:

a. External obliqueb. Internal obliquec. Transversus abdominis

Vertical muscles:

a. Rectus abdominisb. Pyramidalis

5. Transversalis fascia (part of endoabdominalfascia)

6. Extra/preperitoneal fat7. Parietal peritoneum

SUBCUTANEOUS TISSUE & FASCIAL LAYER

Variable amount of fat

Males susceptible to fat accumulation

Superficial fatty layer - Campers fascia

Deep membranous layer (Scarpas fascia)

Panniculus (plural: panniculi) sagging fold orbilbil

Superficial, intermediate and deep layers of theinvesting fascia cover the external aspects of the 3muscle layers of the anterolateral abdominal walland their aponeurosis and cannot be easilyseparated from them.

The internal aspect of the abdominal wall is linedwith a membranous sheet of varying thickness calledendoabdominal fascia.

The lining of the abdominal cavity, the parietalperitoneum, is internal to the transversalis fasciaand is separated from it by a variable amount of

extraperitoneal fat.

INTERNAL ASPECT


Page 3 of10


4/10


Figure 7. Internal view of the anterior abdominalwall

5 umbilical folds

o 1 Median umbilical fold - from the apex of the

bladder, covers median umbilicalligament(remnant of uracus)

o 2 Medial umbilical folds - lateral to median

umbilical fold, cover medial umbilical ligaments(obliterated umbilical artery)

o 2 Lateral umbilical folds - lateral to medial

umbilical folds, cover the inferior epigastricvessels. Clinical significance due to the fact thatwhen you cut the fold, vessels are hit, patientmay have perfused bleeding.

PERITONEAL FOSSAE

Supravesical fossae between median and themedial umbilical folds

Medial inguinal fossae

- Between medial and lateral umbilical folds alsocalled inguinal triangles(Hesselbachtriangles)

- Potential sites of direct hernia- Boundaries of the inguinal triangle:

o Linea semilunariso Inguinal Ligament

o Lateral Umbilical Fold

Lateral inguinal fossae

- Lateral to the lateral umbilical fold- Include the deep inguinal ring- Site of indirect hernia

MUSCLES OF ANTERIOR ABDOMINAL WALL

Form a strong expandable support for theanterolateral abdominal wall.

Protect the abdominal viscera from injury.

Compress the abdominal contents to maintain orincrease the intra-abdominal pressure (to expelfeces, for normal delivery, and to strengthen back)and, in so doing, oppose the diaphragm (increased

intra-abdominal pressure facilitates expulsion). Move the trunk and help maintain posture.

Figure 8. Anterolateral abdominal wall

Three flat muscles1. External oblique2. Internal oblique3. Transversus abdominis

Two vertical muscles1. Rectus abdominis2. Pyramidalis

Figure 9. Muscles of the anterolateral abdominal wall

EXTERNAL OBLIQUE

Largest and most superficial

is aponeurotic, fleshy

Does not originate posteriorly from thethoracolumbar fascia

Posteriormost fibers are free edged spanningbetween costal margin and iliac crest

Fleshy fibers run inferomedially*Note: Inferomedially its like putting your handsinside your own pocket

It becomes aponeurotic in the MCL in its inferiormargin.

Thickens into Poupart/inguinal ligament in itsinferior part(extends from ASIS to pubic tubercle)

Continues as external spermatic fascia that coversspermatic cord

Forms a digastrics muscle w/ internal oblique (2-

bellied muscle sharing a common tendon andworking as a unit)

Superficial inguinal ring- triangular shaped defectin the external oblique aponeuroses above theinguinal ligament

INTERNAL OBLIQUE

Thin muscular sheet

Fleshy fibers run superomedially (at right angles withthe fibers of the external oblique muscle )

*Note: Superomedially its like putting your righthand on your right chest or your left hand on your


Page 4 of10


5/10


left chest. Direction of fibers is similar to thedirection of the fingers

Have 3 origins: lumbar fascia, ant. 2/3 of iliac crest,lateral 2/3 of inguinal ligament

Fibers from the ASIS and lateral inguinal ligament runtransversely

Lower tendinous fibers with transversus abdominisform the conjoint tendon, attach medially to linea

alba but has lateral free border The aponeurosis of the internal and ext oblique acts

as a digastric muscle

The aponeurosis of the external oblique of the rightside will interweave of the aponeurosis of the internaloblique on the other side forming a cross.

Thus, you can do torsional movement of thetrunk( eg. bending of right shoulder to the directionof the left hip)

TRANSVERSUS ABDOMINIS

Innermost

From 7th to 12th costal cartilages

Inserted into the linea alba, xiphoid process and

symphysis pubis Like IOM, attach to posterior border via lumbar fascia

For visceral support and ipsilateral rotation of thevertebral column

Run more or less transversally

Orientation is ideal for compressing abdominalcontents

The transverse circumferential orientation is ideal forcompressing the abdominal contents, increasingintra-abdominal pressure.

Neurovascular plane (VAN) is located in between theinternal oblique and the transversus abdominis. Theylie in subcutaneous tissue.

RECTUS ABDOMINIS Long, broad and strap like muscle

Principal vertical muscle

3X as wide superiorly than inferiorly

Broad and thin superiorly but narrow and thickinferiorly

Antagonistic partners of the deep (extensor) musclesof the back. Balance in the development and tonus ofthese partners affects posture.

Linea alba separates the 2 rectus muscles.

Umbilical ring: significant in the fetal circulationbecause this is where the fetal umbilical vessels arelocated and passed from the umbilical cord to theplacenta. So thats why if there is protrusion of small

intestine within this defect you have the so calledumbilical hernia.

*Note: All muscles EXCEPT Rectus Abdominis areattached to linea alba

TENDINOUS INTERSECTIONS

Produced by the attachment of the rectus muscleto the ant layer of rectus sheath

When tensed in muscular people, stretches ofmuscle bulge outward

The intersections, indicated by grooves in the skinbetween the muscular bulges, usually occur at thelevel of the xiphoid process, umbilicus, andhalfway between these structures.

PYRAMIDALIS

Small triangular muscle

Absent in 20% of people

Lies anterior to the inferior part of rectus abdominis

Ends in the linea alba

Tenses the linea alba

Used as a landmark for accurate median umbilicalincision during surgery

*Note: You are pretty sure you are staying in themiddle if you are passing between the 2 pyramidalis

muscles.

Table 1. Origin, Insertion and Action of Anterior AbdominalWall Muscles

Muscle Origin Insertion ActionExternaloblique

Lower eightribs (5th-

12th ribs)

Xiphoidprocess,

linea alba,pubic crest,pubictubercle,iliac crest

Supportsand

compressesabdominalcontents;Assists inflexing androtationoftrunk;Assists inforcedexpiration,micturition,defecation,parturitionandvomiting

Internaloblique

Thoraco-lumbarfascia, iliaccrest,lateral 2/3of iliaccrest,lateral ofinguinal

ligament

Lower 3ribs andcostalcartilages,xiphoidprocess,linea alba,symphysispubis

Transversusabdominis

Lower 6costalcartilages,thoraco-lumbarfascia, iliaccrest,lateral thirdof inguinalligament

Xiphoidprocess,linea alba,symphysispubis

Compresses andsupportsabdominalcontents

Rectusabdomini

s

Symphysispubis and

pubic crest

5th, 6th,and 7th

costalcartilagesand xiphoidprocess

Compresses

abdominalcontentsand flexesvertebralcolumn;accessorymuscle ofExpiration

Pyramidalis (ifpresent)

Anteriorsurface ofpubis

Linea alba Tenses thelinea alba

CORRESPONDING SCROTAL LAYER/COVERING

Figure 10. Layers of the anterior abdominal wall withcorresponding layers of the scrotum

What causes wrinkling of the scrotum?- It is more wrinkled when it is cold. This is causedby the Dartos muscle and fascia.

- The testis needs cold temperature as comparedto the temperature when inside the abdomenwhich is hotter. Sperm production is better whenits cold.


Page 5 of10


6/10


Initially testis is located inside the abdomen. Moreoften than not, you can wait until 2 years old for thetestis to descend. If still undescended, male is proneto testicular cancer.

Cremasteric Reflex stroke the inner aspect of thethigh in males the expected result is the elevation ofthe scrotum on the same side where the thigh wasstroked.

Table 2. Corresponding Layers of anterior abdominal wall,scrotum and spermatic cord.

Layers of theAnteriorAbdominalWall

Scrotum andCovering ofthe Testis

Coverings ofthe SpermaticCord

Skin Skin Skin continuouswith scrotum(and scrotalseptum

Subcutaneoustissue(fatty/membranous)

Subcutaneoustissue (dartosfascia) anddartos muscle

--

External obliquems.

ExternalSpermaticFascia

Externalspermatic fascia

Internal obliquems.

Cremaster ms. Cremaster ms.

Fascia of bothsuperficial anddeep surfaces ofthe internaloblique ms.

Cremastericfascia

Cremastericfascia

Transversusabdominis ms.

-- --

Transversalisfascia

Internalspermatic

fascia

Internalspermatic fascia

Peritoneum Tunica vaginalis(parietal andvisceral layers)

Vestige of processusvaginalis

RECTUS SHEATH

Strong and incomplete fibrous compartment of therectus abdominis and pyramidalis ms.

The sheath is formed by the decussation andinterweaving of the aponeurosis of the flat abdominalmuscles.

FORMATION OF RECTUS SHEATH

Figure 11. Rectus Sheath Composition

Arcuate line divides the rectus sheath into 4 quarters

Superior

o Anterior: contains aponeurosis of EO, ant. Lamina

of IO

o Posterior: contains posterior lamina of IO and TA

Inferior (below the umbilicus near the pubis)

o Anterior: contains aponeurosis of EO, IO, TA

o Posterior: lies directly in Transversalis Fascia

ARCUATE LINE

Demarcates the transition between theaponeurotic posterior wall of the sheath coveringthe superior three quarters of the rectus and thetransversalis fascia covering the inferior quarter.

CONTENTS OF THE RECTUS SHEATH

Rectus abdominis

Pyramidalis

Anterior rami of T7-T12 spinal nerves

Superior & inferior epigastric vessels

Lymph vessels

INNERVATION: ANTERIOR ABDOMINAL WALL

Figure 12. Dermatomes and nerves of anterolateralabdominal wall.

Thoracoabdominal nerves: the distal,abdominal parts of the anterior rami of the inferiorsix thoracic spinal nerves (T7-T11)

Lateral (thoracic) cutaneous branches ofthe thoracic spinal nerves T7,T9 or T10.

Subcostal nerve: the large anterior ramus ofspinal nerve T12.

Iliohypogastric and ilioinguinal nerves:terminal branches of the anterior ramus of spinalnerve L1

T7-T9 supply the skin superior to the umbilicus

T10 innervates the skin around the umbilicus

T11, plus the cutaneous branches of the subcostal

(T12), iliohypogastric, and ilioinguinal (L1), supplythe skin inferior to the umbilicus.Parietal peritoneum: innervated by the somatic

nerves (lower 6 thoracic nerves, and 1stlumbar nerves)Sensitive to pain, temperature, touch andpressure

Visceral peritoneum: innervated by the ANSSensitive only to stretch and tearing

BLOOD SUPPLY


Page 6 of10


7/10


Figure 13.Arterial supply of the abdomen

NOTE: The internal mammary or internal thoracicarteryis a branch of the 1st part of subclavian artery.Its terminal branches are the superior epigastric a.and the musculophrenic a.

Superior epigastric artery

- Direct continuation of the internal thoracicartery

- Enters the rectus sheath superiorly through itsposterior layer

- Supplies the superior part of the rectusabdominis and anastomoses with the inferiorepigastric artery approximately in the umbilical

region Inferior epigastric artery

- Arises from the external iliac arteryjust superiorto the inguinal ligament

- Runs superiorly in the transversalis fascia toenter the rectus sheath below the arcuate line

- Enters the lower rectus abdominis andanastomoses with the superior epigastric artery.

- Superficial circumflex iliac and superficialepigastric vessels from the femoral artery andgreater saphenous vein, respectively.

- Posterior intercostal vessels of the 11thintercostal space and anterior branches ofsubcostal vessels.

Deep Circumflex artery- Branch ofexternal iliac a.- Supplies lower part of the lateral abdominal wall

Lower 2 Posterior Intercostal arteries- Branch ofdescending aorta(thoracic)- Supply lateral part of abdominal wall

Lumbar arteries- Branch ofabdominal aorta- Supply the lateral part of the abdominal wall- The 5th pair of lumbar a. ill rise from medialsacral artery not from abdominal aorta

NOTE: Abdominal aorta will begin at the aortic

hiatus at T12 and ends at the level of L4 (Supracristalplane), which will branch into Right and Left CommonIliac Artery that is further divided into External andInternal Iliac A. at the medial border of Psoas musclesto pelvic brim

Branches of Abdominal aorta will be divided into 3vascular planes

(1) Anterior: unpaired visceral for Alimentarytract

Celiac a.

Superior mesenteric a.

Inferior mesenteric a.

(2) Lateral: paired visceral for urogenital andendocrine organs

Suprarenal

Renal

Gonadal(3)Postero-lateral: paired parietal for diaphragm andbody wall

Subcostal

Inferior phrenic Lumbar

VENOUS DRAINAGE

Figure 14. Lymphatics and superficial veins of anterolateralabdominal wall.

A. SUPERFICIAL VEINS- The abdomen is enriched with a lot ofsubcutaneous tissue = intricate venous plexuses,which drain:

Superiorly medially to internal thoracicvein

Laterally to the lateral thoracic vein whichdrains to the axillary vein

Inferiorly to the superficial epigastric veinand inferior epigastric vein

- A collateral anastomosis may sometimes formbetween the lateral thoracic vein (a tributary ofaxillary vein) and superficial epigastric vein(thoracoepogastric vein)

- A lot of cutaneous vein surrounding the umbilicus drains to paraumbilical vein

NOTE: In cases of obstruction of inferior cava orobstruction in the portal circulation (in the case of livercirrhosis), vessels may be dilated (dilatedthoracoepigastric vein and dilated paraumbilical veins= Caput Medusi)

Retrograde Flow Due To SVV Or IVC Obstruction

IVC subclavian v. axillary lateral thoracic

thoracoepigastric superficial epigastric

femoralexternal iliac -> common iliacback tothe IVC

* NOTE: Commonly seen in liver cirrhosis

B. DEEP VEINS- Venae comites or venae comitantes (follow the

arteries of the same name)

LYMPHATIC DRAINAGE

Courses along the veins


Page 7 of10


8/10


A. SUPERFICIAL LYMPHATIC VESSELS

- Accompany the subcutaneous veins- Superior to the transumbilical plane drain mainly

to the axillary lymph nodes few to theparasternal lymph nodes.

- Inferior to the transumbilical plane drain to thesuperficial inguinal lymph nodes.

B. DEEP LYMPHATIC VESSELS

- Accompany the deep veins of the abdominal wall- Drain to the external iliac, common iliac, and

right and left lumbar (caval and aortic) lymphnodes.

Clinical importance:

Infection in the subcutaneous area above theumbilicus - enlarged lymph node either in theaxillary region or near the sternum

Infection in the subcutaneous area below theumbilicus- enlarged lymph node in the inguinalregion

INGUINAL REGION

Extends between the ASIS (anterior superior iliacspine)& pubic tubercle

Anatomically important: region where structuresexit and enter the abdominal cavity

Clinically important: pathways of exit and entranceare potential sites of herniation

Hernias occur in both sexes, but most inguinalhernias occur in males because of the passage ofthe spermatic cord through the inguinal canal.

INGUINAL LIGAMENT

Figure 15. Formations of the inguinal region

Extends from the ASIS to the pubic tubercle

Also known as Pouparts ligament

Thickened inferolateral most portions of theexternal oblique aponeurosis

Lacunar ligament(Gimbernat): deeper fibers thatattach posteriorly to the superior pubic ramus;forms the medial boundary of the subinguinal space

Pectineal ligament(Cooper): lateral fibers thatcontinue to run along the pecten pubis

Some of the more superior fibers fan upward,bypassing the pubic tubercle and crossing the lineaalba to blend with the lower fibers of thecontralateral external oblique aponeurosis. Thesefibers form the reflected inguinal ligament.

The iliopubic tract is the thickened inferior margin ofthe transversalis fascia, which appears as a fibrousband running parallel and posterior to the inguinalligament. It also reinforces the posterior wall andfloor of the inguinal canal as it bridges thestructures traversing the subinguinal space.

INGUINAL CANAL

An oblique passage approximately 4 cm longdirected inferomedially through the inferior part ofthe anterolateral abdominal wall

Main occupant: spermatic cord(males)/roundligament of the uterus(females)

Openings:

Entrance: Superficial Inguinal Ring

Exit: Deep inguinal ring

BOUNDARIES OF THE INGUINAL CANAL

Anterior wall: external oblique aponeurosis & ms.Fibers of internal oblique

Posterior wall: transversalis fascia

Roof: transversalis fascia, internal oblique andtransversus abdominis, medial crus of ext. oblique

Floor: iliotibial tract, inguinal ligament, lacunarligament

SUPERFICIAL AND DEEP INGUINAL RING

Figure 16. Inguinal Canal and spermatic cord. The layers ofthe abdominal wall and the coverings of the spermatic cordand testis. B. Sagittal Section of the anterior abdominal walland inguinal canal with respect to A. Top Right. arcades of

inguinal canal

Deep inguinal ring- Entrance to inguinal canal- Superior to middle of inguinal ligament- Lateral to inferior epigastric artery- Has an opening where the vas deferens and

testicular vessels in males or round ligament of theuterus in females pass to enter the inguinal canal.

Superficial inguinal ring

- Exit by which the spermatic cord or roundligament emerges from the inguinal canal

- A diagonal split

- Lateral (attaches to the pubic tubercle) and

medial (attaches to pubic crest) crus.- Fibers of the superficial layer of the deep fascia

overlying the external oblique muscle andaponeurosis, running perpendicular to thefibers of the aponeurosis, pass from one crus tothe other across the superolateral part of thering. These intercrural fibers help prevent crurafrom spreading apart.

- The most inferior, medial tendinous fibers ofthe internal oblique merge with aponeuroticfibers of the transverse abdominal muscle hereto form the inguinal falx (conjoint tendon).


Page 8 of10


9/10


INGUINAL HERNIA: DIRECT & INDIRECT

Table 3. Characteristics of Direct and Indirect Hernias

Indirect hernia lateral to inferior epigastricarteryDirect hernia medial to inferior epigastric artery(at the area of inguinal triangle or Hesselbachtriangle)

OTHER FORMS OF ABDOMINAL HERNIA

Figure 17. Locations of other types of hernias

Spigelian a hernia along the linea semilunaris (orsemilunar line)Relative to the scrotum:

Indirect hernia- within the scrotumDirect hernia above the area of scrotum

PERITONEUM

Parietal peritoneum- Lines the glisteningstructure , the internal aspect of the abdominal wall

Visceral peritoneum - Extension to the organs

CLASSIFICATION OF ORGANSIntraperitoneal Organs

- More or less completely (or almost completely)covered by peritoneum

- Ex: stomach, small intestinesExtraperitoneal (or retroperitoneal) Organs

- Is partially covered by peritoneum

PERITONEAL FORMATIONS (Mesentery)- Concerning the abdominal cavity*Mesentery

- Connects an intraperitoneal organ to the body wall- Is a double layer of peritoneum that occurs as a

result of the invagination of the peritoneum by an

organ and constitutes a continuity of the visceraland parietal peritoneum\

- Provides a means for neurovascularcommunication between the organ and the bodywall

1. Mesentery Proper- Double layer of peritoneum that is attached to the

small intestine- Connects an intraperitoneal organ to the body wall

usually the posterior abdominal wall2. Other forms of Mesentery

- Transverse mesocolon attached to transversecolon

- Sigmoid mesocolon attached to the sigmoidcolon

NOTE: When pinned in the exam and you see the takeoff or have seen it connected to the dorsal or posteriorbody wall mesentery proper

PERITONEAL FORMATIONS (Omentum)

Omentum always related to the stomach

A double-layered extension or fold of peritoneumthat passes from the stomach and proximal part ofthe duodenum to adjacent organs in the abdominalcavity

1. Greater Omentum

- Attaches from the greater curvature of thestomach

- FUNCTIONS:a. Isolates fluid, pus or inflammation and preventsother organs from being infected, thus calledPoliceman of the abdominal cavity.b. Prevents visceral peritoneum from adhering toparietal peritoneumc. Organ cushioningd. Insulation against loss of body heat

2. Lesser Omentum- Attaches from the lesser curvature of the stomach

PERITONEAL FORMATIONS (Ligaments)

Figure 18. Peritoneal formations

- Ligaments can also form the omentum or theycan arise from the omentum

1. Ligaments from the greater omentum

- Double layers of the peritoneum that attaches oneorgan to another organ

- Examples:

Gastro-phrenic ligament from the stomach tothe diaphragm

Gastro-splenic ligament from the stomach tothe spleen


Page 9 of10


10/10


Gastro-colic ligament from the stomach tothe large intestines

2. Ligaments from the lesser omentum- Examples:

Hepato-duodenal ligament part of the liverto the duodenum

Hepato-gastric ligament part of the liver to

the part of the stomach

Falciform ligament- connects liver to anteriorabdominal wall

POSTERIOR ABDOMINAL WALL

Five lumbar vertebrae and associated IV discs(centrally).

Posterior abdominal wall muscles, including thepsoas, quadratus lumborum, iliacus, transverseabdominal and oblique muscles (laterally).

Diaphragm, which contributes to the superior part ofthe posterior wall.

Fascia, including the thoracolumbar fascia.

Lumbar plexus composed of the anterior rami oflumbar spinal nerves.

Fat, nerves, vessels (e.g., aorta and IVC), and lymphnodes.

Table 4. Origin, Insertion, and Action of Posterior AbdominalWall Muscles

muscle origin insertion action

PsoasMajor

transverseprocesses,bodies, andIV discs of

12ththoracic & 5

lumbarvert.

lessertrochanterof femur

flexes thighon trunk; if

thigh isflexed,

flexes trunkon thigh, asin sitting upfrom lying

Iliacus iliac fossaQuadratusLumboru

m

iliolumbarligament,iliac crest,

tips oftransverse

processesof lowerlumbar

vertebrae

12th rib fixes 12thrib during

inspiration;depresses12th rib

duringforcedexpiration;

laterallyflexes

vertebralcolumn

same sideTransvers

usabdominis

Lower 6costal

cartilages,thoraco-lumbar

Xiphoidprocess,

linea alba,symphysis

pubis

Compresses and

supportsabdominalcontents

fascia, iliaccrest,

lateral thirdof inguinalligament

Dagdag lang :))

"Ang pag-ibig parang imburnal...nakakatakotmahulog...at kapag nahulogka, it's either by accidentor talagang tanga ka .."

"Kung nagmahal ka ng taong di dapat at nasaktan ka,wag mong sisihin ang puso mo. Tumitibok lang yanpara mag-supply ng dugo sa katawan mo. Ngayon,kung magaling ka sa anatomy at ang sisisihin monaman ay ang hypothalamus mo nakumokontrol ngemotions mo, mali ka pa rin! Bakit? Utang na loob!Wag mong isisi sa body organs mo ang mgasamangloob mo sa buhay! Tandaan mo: magiging Masaya kalang kung matututo kang tanggapin na hindi ang puso,utak, atay o bituka mo ang may kasalanan sa lahat ngnangyari sayo, kundi IKAW mismo!"

"Huwag magmadali sa babae o lalaki. Tatlo, lima,sampung taon, mag-iiba ang pamantayan mo atmaiisip mong hindi pala tama ng pumili ng kaparehadahil lang maganda o nakakalibog ito. Totoong masmahalaga ang kalooban ng tao higit sa anuman. Sa

paglipas ng panahon, maging ang mga crush ng bayannagmumukha ding pandesal, maniwala ka."

"I wish true love is like a boy playing chess whos afraidof losing his queen and a girl whos risking everythingjust to protect her king."

Hindi lahat ng lokohan walang magandangpatutunguhan, minsan sa lokohan, inuumpisahan, paramagkatuluyan.

-Bob Ong


1 ANA4 - Abdomen in General 2015B

Documents

Transcript of 1 ANA4 - Abdomen in General 2015B