Lidia IonescuIonescuCl.III chirurgie

Abdomen

Region of the trunk, between the diaphragm and the inlet of the pelvis.

AbdomenDiaphragm=primary muscle of respiration, dome-

shaped: right dome-upper border 5th rib, left dome-lower border 5th rib.

Openings:aorta opening, esophageal opening, caval opening

Pelvic inlet: sacral promontory, ileopectineal lines and symphysis pubis.

xiphoid process X costal cartilages (ribs 7-10) tips of ribs 11 and 12 vertebrae L1-L5 iliac crests IC tubercle of the crest TC anterior superior iliac spine

ASIS anterior inferior iliac spine

AIIS inguinal ligament IL pubic tubercle PT pubic crest PC pubic symphysis PS the separation of the

abdomen from the pelvis, the pelvic brim PB

Rectus sheath Is a covering envelope over the rectus abdominis m.(RA) created by the

aponeurosis of the other three musc.Above arcuate line – ant.- RA has aponeurosis of EO, and ant half of IO

aponeurosis . - behind it, is the post half of IO aponeurosis, TA.

aponeurosis  and TF.Below  arcuate line - all musc aponeurosis run in front of RA m., leaving only

transversalis fascia behind it. The idea is that - to keep the tension of the ant wall of abdomen.

Where the hell is the Arcuate line?  About 1/3 of the way between the umbilicus and the pubic crest. 

Surface landmarksXiphoid processCostal marginIliac crestSymphysis pubisInguinal ligamentSuperficial inguinal ringLinea albaUmbilicusRectus abdominisLinea semilunaris

NORMAL ABDOMEN

NORMAL ABDOMEN

Use your knowledge to project the anatomy onto the surface of the abdomen.

You will want to be able to visualize the relative positions of abdominal organs as they lie within the abdomen.

By subdividing the surface into regions, one person can tell another person exactly where to look for possible problems

Layers of the abdominal wall

- skin - superficial fascia - deep fascia - muscle - subserous fascia - peritoneum

These regions are formed by two vertical planes and two horizontal planes.

The two vertical planes are the lateral lines LLL and RLL.

These lines are dropped from a point half way between the jugular notch and the acromion process.

The two horizontal planes are the transpyloric plane TPP and the transtubercular plane TTP.

The tubercles are the tubercles of the iliac crests.

As you examine the abdomen in thin subjects, you may be able to see the superficial veins that drain the abdominal wall.

These veins drain into one of two major veins: subclavian and femoral (F)

and also into a minor, but important vein, the paraumbilical vein PU.

The paraumbilical vein drains into the portal vein and then through the liver. This is an important clinical connection.

The lower abdominal wall is drained by way of the superficial epigastric SE and superficial circumflex iliac SCI veins into the femoral vein.

The upper abdominal wall is drained by way of the thoracoepigastric TE and lateral thoracic LT veins into the subclavian.

The most superficial layer of anterolateral muscles are the: external abdominal obliques EAO

The cutaneous nerves to the

abdomen are mainly continuations of the lower intercostal nerves (T7 - T12).

The lowermost part of the abdominal wall is supplied by a branch of L1, the iliohypogastric IH nerve. Its other branch is the ilioinguinal II nerve.

Linea alba LA. is where the aponeuroses of the external abdominal oblique, internal abdominal oblique, and transverse abdominis muscles converge at the midsagittal part of the abdominal wall.

In the image, the left external abdominal oblique has been cut away at the white dotted line and removed in order to show the internal abdominal oblique IAO.

You can also see lower cut edge of the external abdominal oblique at the inguinal ligament IL

The anterior wall of the rectus sheath RS has also been removed on the right side in order to see the underlying right rectus abdominis RA muscle.

Note that the rectus abdominis muscle is subdivided into small sections by so called tendinous inscriptions TI.

You may also see a small muscle

overlying the inferior end of the rectus abdominis muscle, the pyramidalis muscle PY. This small muscles tenses the lower part of the linea alba.

The rectus abdominis muscle, internal abdominal oblique and anterior rectus sheath have been removed. You can identify the posterior rectus sheath and its lower free margin, the arcuate line AL.

What you see below this line is the transversalis fascia and running in the fascia is the inferior epigastric artery IEA, a branch of the external iliac artery. This artery enters the rectus sheath posterior to the rectus abdominis muscle and supplies the anterior abdominal wall. Extending from the top, is a branch of the internal thoracic (or mammary) artery, the superior epigastric artery.

Also note that the cutaneous nerves are found to lie between the internal abdominal oblique and the transversus abdominis muscles.

Good abdominal examination

Good lightRelaxed patientFull exposure of the abdo. from xiphoid

process to the SP.The groin should be visible although the

genitalia should be kept draped

Inspection

Note the shape of the abdomenLook for scars, sinuses, fistulaeLook for distended veinsLook for visible peristalsis- Bowel obstruction

InspectionInspection is always

an important first step in any physical examination. Look at the abdominal contour and note any asymmetry. Record the location of scars, rashes, or other lesions.

ABDOMEN DRAPING

ASCITES

CAPUT MEDUSA

HEPATOMEGALY

OBESITY

ASSYMETRIC ABDOMEN

UMBILICAL HERNIA

AuscultationUnlike other regions of

the body, auscultation comes before percussion and palpation (the sounds may change after manipulation). Record bowel sounds as being present, increased, decreased, or absent.

Auscultation

Bowel sounds- gurgling noises if it contains a mixture of fluid and gas

Normal bowel sounds- low-pitched gurglesNo bowel sounds- silent abdomenHigh-pitched bowel sounds- “tinkling sounds”-

mechanical bowel obstructionSystolic bruits over the aorta and iliac arteries

ABDOMINAL ASCULTATION

BruitsIn addition to bowel

sounds, abdominal bruits are sometimes heard. Listen over the aorta, renal, and iliac arteries. Bruits confined to systole do not necessarily indicate disease. Don't be fooled by a heart murmur transmitted to the abdomen.

Palpation

Begin by feeling the area that you might otherwise forget:Feel the supraclavicular fossa for lymph nodesFeel the hernial orifices at rest and when the

patient coughs.Feel the femoral pulsesExamine the external genitalia

PALPATION

Light palpationBegin with light

palpation. At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient's facial expression.

Deep palpation

Proceed to deep palpation after surveying the abdomen lightly.

Try to identify abdominal masses or areas of deep tenderness.

Palpation of the liverTo palpate the liver

edge, place your fingers just below the costal margin and press firmly.

Ask the patient to take a deep breath. You may feel the edge of the liver press against or slide under your hand. A normal liver is not tender.

Alternate method for liver palpationAn alternate method

for palpating the liver uses hands "hooked" around the costal margin from above.

The patient should be instructed to breath deeply to force the liver down toward your fingers.

Palpation of the aortaThe aorta is easily

palpable on most individuals.

You should feel it pulsating with deep palpation of the central abdomen.

An enlarged aorta may be a sign of an aortic aneurysm.

Palpation of the spleenPress down just below

the left costal margin with your right hand while asking the patient to take a deep breath.

It may help to use your left hand to lift the lower rib cage and flank. The spleen is not normally palpable on most individuals.

Palpation

Tenderness

Guarding

Rigidity

Palpate for massesSiteShapeSizeSurfaceEdgeConsistenceMobilityTenderness

Percussion

Shifting dullness- ascitis

Tympanism- hyperresonance- bowel distension

Measure the height of the liver dullness

PercussionTympany is normally

present over most of the abdomen in the supine position.

Unusual dullness may be a clue to an underlying abdominal mass.

Liver spanMeasure the liver

span by percussing hepatic dullness from above (lung) and below (bowel).

A normal liver span is 6 to 12 cm in the midclavicular line.

Splenic enlargementTo detect an

enlarged spleen, percuss the lowest interspace in the left anterior axillary line.

Ask the patient to take a deep breath and repeat. A change from tympany to dullness suggests splenic enlargement

Rebound tendernessThis is a test for

peritoneal irritation. Palpate deeply and then quickly release pressure.

If it hurts more when you release, the patient has rebound tenderness.

Costo vertebral angle tenderness

CVA tenderness is often associated with renal disease.

Use the heel of your closed fist to strike the patient firmly over the costovertebral angles.

Shifting dullness

If dullness on percussion shifts when the patient is rolled on the side, peritoneal fluid (ascites) may be present.

Abdominal pain

The significance of the site of abdominal pain:Upper abdominal painCentral abdominal painLower abdominal pain

Acute appendicitisThe position of the

appendix is highly variable. In addition to its "normal"

position it can be found against the abdominal wall (anterior), below the pelvic brim (pelvic), behind the cecum (retrocecal), or behind the terminal ilium (retroilial).

The pain associated with appendicitis varies with the anatomy.

Appendicular point

The picture on the left shows a swollen appendix attached to the cecum. Note the stress on the blood vessels caused by the swelling. The picture on the right is a cross section through the appendix showing an appendicolith blocking the lumen. Blockage of the lumen is one of the most common causes of acute appendicitis.

Acute cholecystitis

Localized or diffuse RUQ pain

Radiation to right scapula

Vomitting and constipation

Fever

Acute renal colic

Severe flank pain Radiation to groin Vomitting and

urinary symptoms Blood in the urine

Things to rememberConsider inguinal/rectal examination in males.

Consider pelvic/rectal examination in females.

Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine the chest when evaluating an abdominal complaint

Anorectal examination

PreparationEnsure adequate privacyUncover the patient from the waist to the kneeLeft lateral position, hips flexed to 90º , knees

flexed less than 90º

Anorectal examination

EquipmentGloveLubricating jellyGood light

Position for PR

Position of the finger

Digital rectal examination- PRIndications: for the diagnosis of rectal

tumors and other forms of cancer;

in males, for the diagnosis of prostatic disorders, notably tumors and benign prostatic hyperplasia;

for the diagnosis of appendicitis or other examples of an acute abdomen (i.e. acute abdominal symptoms indicating a serious underlying disease);

Digital rectal examinationIndications: for the estimation of the tonicity of

the anal sphincter, which may be useful in case of fecal incontinence or neurologic diseases, including traumatic spinal cord injuries;

in females, for gynecological palpations of internal organs

for examination of the hardness and color of the feces (ie. in cases of constipation, and fecal impaction);

prior to a colonoscopy or proctoscopy.

to evaluate haemorrhoids

Do not do like that

Anorectal examinationInspection:perianal skin:

Skin rashesFecal soiling, blood,mucusScars or fistula openingsPolyps, papillomata, prolapsed pilesUlcers, fissures

Palpation:The anal canalThe rectum

Perianal abscess The anus and rectum (which form

the back passage) are common sites of abscess formation.

Anorectal abscesses are more common in men and often develop from anorectal fistulas or sexually transmitted infections.

They present as painful, tender swellings and are easily accessible for surgical treatment. The image below shows a magnified view of a perianal abscess on the skin surrounding the anal opening.

This should be picked up by your doctor on careful examination of the anus and rectum.

Perianal inspection

Extensive perianal condyloma acuminata (arrow).

This condition is generally caused by infection with human papillomavirus .

Perianal condiloma acuminata Patients are often unaware that condylomata can arise around the

anal area . In a sexually active population, the prevalence of the human

papillomavirus (HPV, or "wart virus") is around 50 percent. Once infected with HPV, the entire anogenital tract is involved. The majority of patients with perianal condylomata have not

engaged in anal intercourse. Infection is believed to occur due to pooling of secretions in the

anal area. Condylomata can reach substantial size, and multiple lesions are common.

If one lesion is present, a complete genital and anorectal examination is indicated to detect additional growths.

Acute fissure Anterior and posterior fissures are most

common. If fissures are located laterally, other

etiologies must be considered. Fissures can often be identified by

merely spreading the glutei but generally require anoscopy.

A fissure is a small cut or split in the anoderm . It may be induced by a hard bowel movement or straining at stool. Fissures are most commonly located anterior or posterior to the anus.

When fissures are found laterally, syphilis, tuberculosis, occult abscesses, leukemic infiltrates, carcinoma, herpes, acquired immunodeficiency syndrome (AIDS) or inflammatory bowel disease should be considered as causes.

Acute fissure

Sphincter tone is markedly increased, and digital examination produces extreme pain.

Most fissures can be observed with gentle lateral retraction around the anus.

If the patient can tolerate anoscopic examination, a tear may be seen in the mucosa, and frequently there is bleeding.

Chronic fissure-anoscopyChronic fissures may

present as an external perianal tag, or sentinal tag (black arrow).

The proximal end may also have granulation tissue that appears as an anal polyp (white arrow).

When the condition is this advanced, a lateral sphincterotomy is usually required.

External site of perianal fistula The most common cause of anal

fistula is cryptoglandular infection. Infections that begin in the anal

glands can evolve and present as either abscesses or fistulas.

Fistulas are common in patients with Crohn's disease.

The track of anal fistulas can be extensive . Flexible sigmoidoscopic examination is indicated to evaluate the mucosa of the distal colon for signs of inflammatory bowel disease. The index of suspicion for Crohn's disease is increased by a history of episodes of diarrhea, abdominal cramping and weight loss, and the appearance, location and multiplicity of the fistulas

Probing of perianal fistula

When anoscopy revealed no anal pathology, closer inspection allowed the physician to identify this papular area.

The wooden end of a cotton-tipped applicator was inserted 3 cm. confirming a fistula, and the patient was referred for surgery.

Perianal abscesses

Thrombosed external hemorrhoids and perianal tags from "old" disease

Anal polyp Anal polyps require

removal and, if they are confirmed to be adenomatous (tubular, tubular-villous or villous), colonoscopy is required to rule out the existence of proximal lesions.

Anal cancerThis anal cancer had been

treated for three months with steroid suppositories although the patient had never had a physical examination.

Simple inspection of the external anal area allowed the physician to identify this aggressive tumor.

Case report A case of a man with uncommon, but

surgically significant cause of abdominal pain is presented

Case reportA 22-year-old man came to our ED with a chief

complaint of lower abdominal pain with a history of 8 hours.

Physical examination showed tenderness sharply localized to the left lower quadrant, and marked rebound tenderness in an area corresponding to McBurney's point but on the left side.

His temperature was 37°C.

Case report

Laboratory examinations showed a white blood cell count of 14.7x103/µl with 91.3% neutrophils.

A chest radiograph demonstrated dextrocardia without other abnormalities

Abdominal ultrasonography showed a left-sided liver and gallbladder, and a right-sided spleen.

The appendix was not visualized.

DEXTROCARDIA

Case reportAn emergency operation was performed within 4

hours from his admission to the ED. At operation, a left paramedian incision was

made, and an acutely inflamed appendix was removed from the caecum located in the left iliac fossa.

A quick exploration revealed the liver to be on the left side and the viscera to be completely transposed.

Recovery was uneventful

AppendicitisAppendicitis, including both right-sided and left-

sided, has an annual incidence of 1:1,000 population.

The classical presentation includes the gradual onset of vague peri-umblical abdominal pain localizing to the right lower quadrant over approximately 24 h, associated with nausea, vomiting, anorexia, and diarrhea.

This typical presentation occurs only in about 60% of patients.

Case report

Situs inversus totalis is a rare anatomic anomaly with an estimated incidence of 1:20,000 in the general population and an autosomal recessive mode of inheritance.

Visceral situs inversus can occur with or without dextrocardia.

Situs inversus is caused by a clockwise rotation of the viscera during early embryonic life, resulting in a “mirror image” of the normal bowel

Case reportThe diagnosis of acute appendicitis in situs inversus totalis

can be difficult because of abnormal pain localization.Malrotation of the intraabdominal viscera is not

accompanied by corresponding changes in the nervous system; and in about 31% of the patients the first signs of acute left-sided appendicitis are pain and rebound tenderness in the right lower quadrant of the abdomen.

This led to an incorrect incision in 45% of these cases; in 1/3 a second correct incision had to be made.

Case reportElectrocardiogram, Radiographic studies, Computed tomography (CT) scan with oral and

intravenous contrast, Ultrasound, and Barium studies can help to diagnose situs

inversus.In this case, we diagnosed it by a chest

radiograph and an abdominal ultrasonography.

Case report 2 A twelve-year-old male presented to the ED with a 36-hour history

of periumbilical and right lower quadrant (RLQ) abdominal pain and anorexia.

The patient's white blood count (WBC) and differential were within normal limits and his abdominal films were unremarkable.

The physical exam was significant for guarding and rebound tenderness in the RLQ.

The patient was taken to the operating room for diagnostic laparoscopy and laparoscopic appendectomy. At that time, two cecal appendices were noted, both of which showed signs of inflammation without evidence of perforation or abscess. Laparoscopic appendectomies were performed without difficulty.

The final pathology report revealed acute appendicitis for both appendices.

Acute appendicities

Acute appendicitis

Although rare, anomalies of the appendix do occur and may have serious clinical and medicolegal implications.

Fewer than 100 cases have been reported in the literature

Acute appendicitis

Appendiceal anomalies include: agenesis, duplication, triplication, anomalous location of a single appendix