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Figure 3. Pelvis
Part of the Abdominopelvic cavity, which ranges from Abdomen divided into 4 quadrants - done by drawing
the diaphragm to pelvic floor 2 imaginary lines:
The abdominal cavity is separated from the pelvic o Median plane or median line separates the
cavity by the pelvic brim, which is composed of: body into right and left halves
Anterior margin of sacral o Transumbilical plane or line divides the
promontory
body into upper and lower halves
Arcuate line
Pecten pubis (pectineal line) These 2 planes or lines bisect each other at the
Pubic crest umbilicus
Pubic symphysis End result: right upper quadrant (RUQ), left upper
quadrant (LUQ), right lower quadrant (RLQ) and
left lower quadrant (LLQ)
Note: (See Netter Plate 244 for a more detailed partitioning) Derivative of the deep fascia of the
anterior abdominal wall
To divide the abdomen into nine regions, variations in the o Also attached to the fascia lata of the thigh,
pairing with the transverse and horizontal lines are made to such that there is a potential space between
delineate the boundaries the deep fascia and scarpas fascia
R and L Midclavicular lines paired with If there is a penile fracture and
Transpyloric plane and
there is a break in the Bucks
Transtubercular/Intertubercular plane
o Transtubercular/Interubercular plane fascia expect blood and urine to
passes through the iliac tubercles collect in the scrotum and in the
Alternatively, R and L Lateral Rectus Plane area of the lower abdominal wall.
(semilunar line) paired with Subcostal and Blood and urine cannot collect at
Interspinous planes the area of the lower limbs because
o Subcostal plane: Line passing through the scarpas fascia and deep fascia
th
the lower margin of the 10 rib attach to the fascia lata of the thigh
o Interspinous plane: Line passing through If the fundiform ligament is cut, the
the ASIS suspensory ligament of the penis
will be exposed
F. Anterolateral Abdominal Wall Derivative of deep fascia
Extends from the thoracic cage to the pelvis and and suspends the penis to
th th
bounded superiorly by the 7 to 10 costal the symphysis pubis and
cartilages and xiphoid process; inferiorly by the the arcuate ligament of the
inguinal ligament and the pubic bones pubic bone
Transversalis fascia (of endoabdominal fascia)
Layers (See Moore Figures 2.4 to 2.6) o Endothoracic fascia continuous with
Skin endoabdominal fascia
Superficial fascia o Transversalis fascia covers the transversus
o Campers (superficial fatty layer) abdominis muscle
Extends all the way up to the area
Extra/pre-peritoneal fat
of the thorax and down to the area
Parietal peritoneum
of the lower limbs
o Innermost layer
In the area of the perineum (area
between anus and scrotum/vulva), it Panniculi protuberance of the abdomen
forms the superficial perineal 5 common causes (5Fs): Fat, Feces, Fetus, Flatus,
fascia and Fluid
At the area of the scrotum, it forms
the Dartos muscle and fascia G. Anterolateral Abdominal Wall Muscles
Area of the ischiorectal fossa, it
forms the ischiorectal fat 3 Flat Muscles (strong sheet like aponeuroses)
o Scarpas (deep membranous layer) 1. External Oblique
o Becomes the Colles fascia at the area o From the external surfaces of ribs 5 to 12
of the urogenital triangle o Direction of muscle fibers: inferomedially
o Extends one finger-breath under the o Ends in an aponeurosis that attaches to
inguinal ligament to attach to the fascia the linea alba, pubic tubercle, and iliac
lata crest (cannot attach to the inguinal
o Fundiform Ligament derivative of ligament because the inguinal ligament is
Scarpas fascia; suspends the penis formed from the thickening of the
dorsally from its dorsum and from its lowermost fibers of the aponeurosis of the
side external oblique)
Investing (deep) fascia o Inguinal ligament extends from the ASIS
o Very thin and very difficult to separate from up to the area of the pubic tubercle
the fascia that individually encloses the 2. Internal Oblique
anterolateral abdominal muscles o Comes from the thoraco-lumbar fascia
o Becomes the Bucks fascia at the area of (deep back), iliac crest, inguinal
the penis ligament
o Muscle fibers: go towards ribs 10-12, The pyramidalis keeps the linea alba taut during the
aponeurosis attach to the linea alba to process flexion and rotation of the trunk
the pectin pubis through conjoint All muscles EXCEPT the pyramidalis muscle
tendon (formed by the lowermost fibers compress and support the viscera
of the internal oblique and transverse
abdominis muscle before they insert to Example: Valsalva maneuver compressing the abdominal
the pubic crest) viscera that happens during vaginal delivery, defecation, and
o Direction: urination
Fibers arising above the iliac
crest are directed
superomedially
Fibers arising below the iliac
crest are directed transversely
3. Transversus Abdominis
o Arises from the internal surfaces of ribs
7-12, thoracolumbar fascia, iliac crest,
and inguinal ligament
o Inserts to the linea alba, pubic crest, and
pubic tubercle/pectin pubis via conjoint
tendon
o As they insert the linea alba, they form
the rectus sheath (within are the rectus
abdominis muscle and pyramidalis
to the paraumbilical veins and to the Superficial lymphatic vessels accompany the
subcutaneous veins around the area of the subcutaneous veins
umbilicus Superior to the transumbilical plane drain mainly to
o This produces the so-called Caput the axillary lymph nodes; few to the parasternal
Medusae. This condition is more commonly lymph nodes
seen in patients with alcoholic cirrhosis of Inferior to the transumbilical plane drain to the
the liver superficial inguinal lymph nodes
2. Iliopubic Tract
Thickened inferior margin of the transversalis fascia
Counterpart of inguinal ligament
Appears as a fibrous band running parallel and
posterior (deep) to the inguinal ligament
3. Inguinal Canal
An oblique passage, approximately 4cm long, directed
Figure 10. Abdominal Incisions Internal View inferomedially through the inferior part of the
anterolateral abdominal wall, and lies parallel and
McBurneys Point: superior to the medial half of the inguinal ligament
o Used for appendectomy Main occupant: spermatic cord in males, the round
o Location: drawing an imaginary line from the ligament of the uterus in females, and blood and
umbilicus to the ASIS, and divide the line into lymphatic vessels and the ilioinguinal nerve in both
3 portions, the junction of between the sexes
middle third and lateral third is the From deep inguinal ring to superficial inguinal ring
McBurneys Point
o Ruptured appendicitis: McBurneys C. Openings
Incision (blue) Deep (Internal) Inguinal Ring
o Ruptured with washing of abdominal o Entrance to the inguinal canal
cavity: Median or midline incision o Located superior to the middle of the inguinal
ligament and lateral to the inferior epigastric
artery
o Through this opening, the extraperitoneal
II. INGUINAL REGION ductus (vas deferens) and testicular vessels
in males or round ligament of the uterus in
A. Inguinal Region (See Appendix) females pass to enter the inguinal canal
-
Extends between the ASIS and pubic tubercle o Defect in the transversalis fascia that forms
-
Anatomical importance: it is a region where structures an oval opening like the entrance to a cave
exit and enter the abdominal cavity o Transversalis fascia continues into the canal,
-
Clinical importance: the pathways of exit and entrance forming the innermost covering (internal
are potential sites of herniation fascia) of the structures traversing the canal
-
The inguinal ligament and iliopubic tract, extending Retroinguinal Space/Space of Bogros
from the ASIS to the pubic tubercle, constitute a o Space between the transversalis fascia and
bilaminar anterior (flexor) retinaculum of the hip joint parietal peritoneum
-
The retinaculum spans the subinguinal space, through o Where prosthetic mesh is overlaid in hernia
which the flexors of the hip and neurovascular repairs
structures serving much of the lower limb pass Superficial (External) Inguinal Ring
-
The fibrous bands are the thickened inferolateral-most o A diagonal split of EOM
portions of the external oblique and aponeurosis and o Exit by which the spermatic cord in males, or
the inferior margin of the transversalis fascia the round ligament in females, emerges from
the inguinal canal
o Split that occurs in the diagonal, otherwise
parallel fibers of the external oblique
aponeurosis just superolateral to the pubic
tubercle
D. Boundaries
During incision:
1. Remove the flap of the external oblique (usually just a
tendon)
2. Be careful not to damage the ilioinguinal nerve when
cutting the internal oblique
3. Underneath to that, the joint tendon of both the internal
oblique and transverses abdomens muscle are seen
followed by the deep inguinal ring Figure 14. Layers of inguinal region and covering of spermatic cord
The spermatic cord contains structures running to and from H. Types of Hernias
the testis and suspends the testis in the scrotum.
- Begins at the deep inguinal ring lateral to the inferior Two Types of Inguinal Hernia:
Indirect Hernia crosses through the inguinal canal;
epigastric vessels, passes through the inguinal canal,
outside inguinal triangle
exits at the superficial inguinal ring, and ends in the Direct Pointing towards position of inguinal triangle
scrotum at the posterior border of the testis
- Provides the floor and sometimes the anterior wall of Other Types of Abdominal Hernias:
the inguinal canal Epigastric Epigastric area
- Fascial coverings derived from the anterolateral Umbilical At umbilicus
abdominal wall during prenatal development surround Incisional Post-operative problems due to opening of
the spermatic cord investing fascia during surgery
Femoral Occurs in femoral canal
Clinical Correlation:
Ascending lumbar veins also anastomose with epidural
venous sinuses at subdural space. Their interconnections
mean that if theres infection/cancer/thrombi, easy to
spread to spine and to brain, or to lungs.
Branches:
Paired visceral branches
Figure 16. IVC and its tributaries
o Right suprarenal vein
o Right and left renal veins
E. Lymph Vessels and Lymph Nodes
o Right gonadal vein
o Left suprarenal and left gonadal veins drain Lie along the aorta, IVC and iliac vessels
indirectly into IVC tributaries of left renal vein
Paired parietal branches 1. Intestinal lymphatic trunks
o Inferior phrenic veins a. Common iliac lymph nodes
o L3 and L4 lumbar veins o Receive lymph from external and internal
rd th
Only 3 and 4 pairs of lumbar iliac lymph nodes
veins drain to IVC o Lymph will pass to right and left lumbar
st
1 pair: renal v. lymph nodes
nd rd
2 pair drains into 3 pair
Lumbar vs R and L ascending b. Pre-aortic lymph nodes (celiac and superior and
lumbar v.s*. subcostal vein inferior mesenteric nodes)
azygos on R and hemiazygos on L o Lymph from alimentary tract, liver, spleen
SVC and pancreas pass along celiac and superior
o Common iliac veins and inferior mesenteric arteries to this area
Veins to unpaired visceral branches of aorta are
tributaries of the hepatic portal vein 2. Lumbar lymphatic trunks
a. Right and left lumbar (caval and aortic) lymph
nodes
o Lie on both sides of the IVC and aorta
o Receive lymph directly from posterior
abdominal wall, kidneys, ureters, testes or
ovaries, uterus, uterine tubes, descending
colon, pelvis, and lower limbs through inferior
mesenteric and common iliac lymph nodes
3. Peritoneal fluid
Lubricates the peritoneal surfaces, enabling the
viscera to move over each other without friction and
allowing movements of digestion
Contains leukocytes and antibodies that resist
infection
Absorbed by lymphatic vessels, particularly on the
inferior surface of the constantly active diaphragm
4. Peritoneal Formations
A. Mesentery
Double layer of peritoneum that occurs as a result
of the invagination of the peritoneum by an organ
Originates at the level of L2
Around to 20cm
Continuity of the visceral and parietal peritoneum
Provides means of neurovascular communications
between the organ and the body wall
Goes downward obliquely to reach the sacroiliac
joint and iliocolic junction
As it crosses the midline, it passes through the
Figure 17. Sagittal section showing adult mesenteries ascending and horizontal portion of the duodenum
Structures being traversed by intestinal mesentery
4 Omental bursa boundaries: 1. abdominal aorta
Superiorly - diaphragm 2. inferior vena cava
Posteriorly - coronary ligament of the liver 3. psoas major
Inferiorly - between the inferior layers of the 4. right ureter
greater omentum
5. testicular vessels
a. Superior recess Connects an intraperitoneal organ to the body
Limited superiorly by the diaphragm and wall- usually the posterior abdominal wall
posterior layers of the coronary ligament of the Have a core of connective tissue containing blood
liver and lymphatic vessels, nerves, lymph nodes, and
fat
b. Inferior recess Examples: Mesentery (small bowel),
Found between the superior parts of the layers Mesoesophagus, Transverse and sigmoid
of the greater omentum mesocolons (large bowel), Mesogastrium,
Most become sealed off from the main part Mesoappendix
posterior to the stomach after adhesion of the
anterior and posterior layers of the greater
omentum
D. Peritoneal Recess/Fossa
Pouch of peritoneum formed by peritoneal fold
o Supravesical fossa bet. median and the
medial umbilical folds
o Medial inguinal fossae bet. medial &
lateral umbilical folds, also called inguinal
triangles (Hesselbach triangles), potential
sites of direct hernia
o Lateral inguinal fossae lateral to the
lateral umbilical fold, include the deep
inguinal ring, site of indirect hernia
F. Pathologies 4
QUIZ
Pneumoperitoneum Presence of air inside the
peritoneal cavity (Moore, Dalley, & Agur, 2014)
1. True or False. The Pouparts ligament forms the
Symptoms include drawing in of abdomen
medial boundary of the subinguinal space
as chest expands (also known as
2. True or False. The superior part of the posterior
paradoxical abdominothoracic rhythm), and
abdominal wall contains the 5 lumbar vertebrae and
muscle rigidity
its associated IV disc.
Can be due to perforation of viscera
3. True or False. The hepatic portal vein, bile duct, and
Counterpart in the thorax is pneumothorax hepatic artery forms the bile duct.
Different from gastric bubble, which is
normal and can be seen in the fundus of
the stomach
REFERENCES:
1. Lecture Notes
2. Dr. Elevazos presentation
3. 2019As trans
4. 2018As trans
5. Moore, K.L. & A.F. Dalley. (1999). Clinically Oriented
Anatomy. Philadelphia: Lippincott Williams & Wilkins.
th
6. Netter, F.H. (2011). Atlas of Human Anatomy. 6 ed.
Philadelphia: Elsevier.
Answers: F, F, T