ANATOMY Abdomen in General by Dra.

Zulueta 2015B
OBJECTIVES
GENERAL OBJECTIVE Understand the gross anatomy of the anterior and posterior abdominal wall including the inguinal region SPECIFIC OBJECTIVES ANTERIOR ABDOMINAL WALL Identify anatomical landmarks (skeleton, cadaver, living subject) used in the study of the surface anatomy of the abdomen. 2. Describe how abdomen is divided into quadrants and regions and the clinical application of such. 3. Name and define extent of layers/musculature from outwards to inwards. 4. Describe the formation of the rectus sheath at 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 REGION 1. Define the deep fascia in the inguinal region. 2. State the extent and boundaries of the inguinal canal. 3. Locate the superficial and deep inguinal ring. 4. Differentiate the types of inguinal hernia. 5. Describe other forms of hernia in the abdomen. POSTERIOR ABDOMINAL WALL 1. Name the musculature of the posterior abdominal wall.

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and and

: Insensitive to pressure, pain temperature; sensitive to stretch chemical irritation Peritoneal cavity

1.

Space between visceral and parietal peritoneum Contains no organs but approximately 50 ml of peritoneal fluid (water, electrolytes, leukocytes and antibodies) for lubrication and movement without friction

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

THE ABDOMEN

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 thoracic diaphragm. Continuous inferiorly with the pelvic cavity. Under cover of the thoracic cage superiorly Supported and partially protected inferiorly by the greater pelvis. Enclosed anterolaterally by multi-layered, musculoaponeurotic, abdominal walls. The location of most digestive organs, parts of the urogenital system (kidneys and most of the ureters), and the spleen. Through voluntary or reflexive contraction its muscular roof, anterolateral walls, and floor can raise internal pressure to aid expulsion from the abdominopelvic cavity from the adjacent thoracic cavity, 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 1. Overview of Thoracic and Abdominal Viscera

Abdomen a.k.a. abdominopelvic cavity. There is no exact delineation between the abdomen and the pelvis Part of the trunk bet. the thorax and pelvis Designed to enclose & protect its contents

Abdominal viscera organs inside the cavity

Peritoneum Glistening, transparent serous membrane 2 continuous layers: Parietal and visceral peritoneum (both are lined by mesothelium simple squamous epithelium) -Parietal peritoneum: continuous with parietal peritoneum lining the pelvis : Sensitive to pressure, pain and temperature; pain at inferior surface of diaphragm can be referred to the C3-C5 dermatomes on shoulder -Visceral peritoneum: covers visceral organs
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Figure 2. Abdominal Regions, Reference Planes and Quadrants

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Used to locate abdominal organs, pains or pathologies 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 tubercles 5cm 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 the gallbladder, pylorus of the stomach, duodenojejunal junction, lower body of L1, neck of the pancreas to the hila of the kidneys; root of transverse mesocolon and origin of superior mesenteric a. and portal vein. - At the junction of the linea semilunaris and costal margin Transumbilical plane - Transects the umbilicus ( L3-L4) The abdomen is divided into quadrants. In order to divide, you need: - Vertical line / Median plane: vertical line passing through the medial line; starting from epigastrium - Horizontal / Transumbilical plane: transverse line passed through the umbilicus between the IV disc of L3-L4 level (umbilical region) 4 quadrants: Right Upper (RU), Left Upper (LU), Left Lower (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.
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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 cartilage at each side - Transtubercular plane - passes through the iliac tubercle Clinical significance of regions location of organs, pain, etc. Examples: o Appendicitis pain at the Right Inguinal or Right Lower Quadrant o Ulcer pain at Epigastric region = Right or Left Upper Quadrant o if you palpate an enlargement at the right upper region it is the liver TRANSPYLORIC PLANE Extrapolated midway between the superior borders of the manubrium of the sternum and the pubic symphysis (typically the L1 vertebral level) Commonly transects pylorus (distal, tubular part of stomach) 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

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Figure 4. Surgical incisions made in the abdominal area

McBurney Point - For open surgery; not for surgery

with 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 pubic hairline) incision done in most ob-gyn procedures)

SUBDIVISIONS

Loosely attached to the underlying structures except at the umbilicus 2. Superficial fascia (also called subcutaneous tissue/ Tela Subcutanea) a. Campers fascia - Fatty layer - Continuous with superficial fat over the rest of the body; vary with nutritional status of individual - Thick fascia in obese individuals - From the thorax to the lower extremities - Equivalent to the Dartos Muscle of the perineum/scrotum b. Scarpas fascia - Deep membranous layer - With continuity at the perineal area as Colles fascia - In the midline, it is not attached to the pubis but instead forms tubercular sheath for the penis or clitoris - Thickening at the base and sides of the penis forms the fundiform ligament 3. 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 ligament that anchors the root of the penis to the symphysis pubis and arcuate line - Site of urine extravasation when there is penile fracture 4. Muscles Flat muscles: a. External oblique b. Internal oblique c. Transversus abdominis Vertical muscles: a. Rectus abdominis b. Pyramidalis 5. Transversalis fascia (part of endoabdominal fascia) 6. Extra/preperitoneal fat 7. Parietal peritoneum SUBCUTANEOUS TISSUE & FASCIAL LAYER Variable amount of fat Males susceptible to fat accumulation Superficial fatty layer - Campers fascia

Figure 5. Abdominal Wall subdivisions

Deep membranous layer (Scarpas fascia) Panniculus (plural: panniculi) sagging fold or

2 abdominal walls: (1) Anterolateral - no delineation between the anterior and the lateral part (the wall is oblique which extends laterally and anteriorly) (2) Posterior LAYERS OF ANTEROLATERAL ABDOMINAL WALL

bilbil Superficial, intermediate and deep layers of the investing fascia cover the external aspects of the 3 muscle layers of the anterolateral abdominal wall and their aponeurosis and cannot be easily separated from them. The internal aspect of the abdominal wall is lined with a membranous sheet of varying thickness called endoabdominal fascia. The lining of the abdominal cavity, the parietal peritoneum, is internal to the transversalis fascia and is separated from it by a variable amount of extraperitoneal fat. INTERNAL ASPECT

Figure 6. Layers of the anterolateral abdominal wall

1. Skin
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Figure 8. Anterolateral abdominal wall

Figure 7. Internal view of the anterior abdominal wall

Three flat muscles 1. External oblique 2. Internal oblique 3. Transversus abdominis Two vertical muscles 1. Rectus abdominis 2. Pyramidalis

5 umbilical folds o 1 Median umbilical fold - from the apex of the bladder, covers median umbilical ligament(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 epigastric vessels. Clinical significance due to the fact that when you cut the fold, vessels are hit, patient may have perfused bleeding. PERITONEAL FOSSAE

Supravesical fossae between median and the

medial umbilical folds

Medial inguinal fossae - Between medial and lateral umbilical folds also
called inguinal triangles(Hesselbach triangles) - Potential sites of direct hernia - Boundaries of the inguinal triangle: o Linea semilunaris o 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 the anterolateral abdominal wall. Protect the abdominal viscera from injury. Compress the abdominal contents to maintain or increase the intra-abdominal pressure (to expel feces, 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 9. Muscles of the anterolateral abdominal wall

EXTERNAL OBLIQUE Largest and most superficial is aponeurotic, fleshy Does not originate posteriorly from the thoracolumbar fascia Posteriormost fibers are free edged spanning between costal margin and iliac crest Fleshy fibers run inferomedially *Note: Inferomedially its like putting your hands inside your own pocket It becomes aponeurotic in the MCL in its inferior margin. Thickens into Poupart/inguinal ligament in its inferior part(extends from ASIS to pubic tubercle) Continues as external spermatic fascia that covers spermatic cord Forms a digastrics muscle w/ internal oblique (2bellied muscle sharing a common tendon and working as a unit) Superficial inguinal ring - triangular shaped defect in the external oblique aponeuroses above the inguinal ligament INTERNAL OBLIQUE Thin muscular sheet Fleshy fibers run superomedially (at right angles with the fibers of the external oblique muscle ) *Note: Superomedially its like putting your right hand on your right chest or your left hand on your

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left chest. Direction of fibers is similar to the direction 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 run transversely Lower tendinous fibers with transversus abdominis form 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 right side will interweave of the aponeurosis of the internal oblique on the other side forming a cross. Thus, you can do torsional movement of the trunk( eg. bending of right shoulder to the direction of the left hip)

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*Note: You are pretty sure you are staying in the middle if you are passing between the 2 pyramidalis muscles.
Table 1. Origin, Insertion and Action of Anterior Abdominal Wall Muscles

Muscle External oblique

Origin Lower eight ribs (5th12th ribs)

Internal oblique

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 the vertebral column Run more or less transversally Orientation is ideal for compressing abdominal contents The transverse circumferential orientation is ideal for compressing the abdominal contents, increasing intra-abdominal pressure. Neurovascular plane (VAN) is located in between the internal oblique and the transversus abdominis. They lie 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 thick inferiorly Antagonistic partners of the deep (extensor) muscles of the back. Balance in the development and tonus of these partners affects posture. Linea alba separates the 2 rectus muscles. Umbilical ring: significant in the fetal circulation because this is where the fetal umbilical vessels are located and passed from the umbilical cord to the placenta. So thats why if there is protrusion of small intestine within this defect you have the so called umbilical hernia. *Note: All muscles EXCEPT Rectus Abdominis are attached to linea alba TENDINOUS INTERSECTIONS Produced by the attachment of the rectus muscle to the ant layer of rectus sheath When tensed in muscular people, stretches of muscle bulge outward The intersections, indicated by grooves in the skin between the muscular bulges, usually occur at the level of the xiphoid process, umbilicus, and halfway 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 umbilical incision during surgery

Thoracolumbar fascia, iliac crest, lateral 2/3 of iliac crest, lateral of inguinal ligament Lower 6 costal cartilages, thoracolumbar fascia, iliac crest, lateral third of inguinal ligament Symphysis pubis and pubic crest

Insertion Xiphoid process, linea alba, pubic crest, pubic tubercle, iliac crest Lower 3 ribs and costal cartilages, xiphoid process, linea alba, symphysis pubis

Action Supports and compresse s abdominal contents; Assists in flexing and rotationof trunk; Assists in forced expiration, micturition, defecation, parturition and vomiting Compress es and supports abdominal contents

Transver sus abdomini s

Xiphoid process, linea alba, symphysis pubis

Rectus abdomini s

5th, 6th, and 7th costal cartilages and xiphoid process

Pyramida lis (if present)

Anterior surface of pubis

Linea alba

Compress es abdominal contents and flexes vertebral column; accessory muscle of Expiration Tenses the linea alba

CORRESPONDING SCROTAL LAYER/COVERING

Figure 10. Layers of the anterior abdominal wall with corresponding layers of the scrotum

What causes wrinkling of the scrotum? - It is more wrinkled when it is cold. This is caused by the Dartos muscle and fascia. - The testis needs cold temperature as compared to the temperature when inside the abdomen which is hotter. Sperm production is better when its cold.
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Initially testis is located inside the abdomen. More often than not, you can wait until 2 years old for the testis to descend. If still undescended, male is prone to testicular cancer. Cremasteric Reflex stroke the inner aspect of the thigh in males the expected result is the elevation of the scrotum on the same side where the thigh was stroked.
Table 2. Corresponding Layers of anterior abdominal wall, scrotum and spermatic cord.

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o o

Anterior: contains aponeurosis of EO, IO, TA Posterior: lies directly in Transversalis Fascia

ARCUATE LINE Demarcates the transition between the aponeurotic posterior wall of the sheath covering the superior three quarters of the rectus and the transversalis 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

Layers of the Anterior Abdominal Wall Skin

Scrotum and Covering of the Testis Skin

Coverings of the Spermatic Cord Skin continuous with scrotum (and scrotal septum --

Subcutaneous tissue (fatty/membran ous) External oblique ms. Internal oblique ms. Fascia of both superficial and deep surfaces of the internal oblique ms. Transversus abdominis ms. Transversalis fascia Peritoneum

Subcutaneous tissue (dartos fascia) and dartos muscle External Spermatic Fascia Cremaster ms. Cremasteric fascia

External spermatic fascia Cremaster ms. Cremasteric fascia

-Internal spermatic fascia Tunica vaginalis (parietal and visceral layers)

-Internal spermatic fascia Vestige processus vaginalis of

Figure 12. Dermatomes and nerves of anterolateral abdominal wall.

RECTUS SHEATH Strong and incomplete fibrous compartment of the rectus abdominis and pyramidalis ms. The sheath is formed by the decussation and interweaving of the aponeurosis of the flat abdominal muscles. FORMATION OF RECTUS SHEATH

T10 innervates the skin around the umbilicus T11, plus the cutaneous branches of the subcostal

Thoracoabdominal nerves: the distal, abdominal parts of the anterior rami of the inferior six thoracic spinal nerves (T7-T11) Lateral (thoracic) cutaneous branches of the thoracic spinal nerves T7,T9 or T10. Subcostal nerve: the large anterior ramus of spinal nerve T12. Iliohypogastric and ilioinguinal nerves: terminal branches of the anterior ramus of spinal nerve L1 T7-T9 supply the skin superior to the umbilicus

(T12), iliohypogastric, and ilioinguinal (L1), supply the skin inferior to the umbilicus. Parietal peritoneum: innervated by the somatic nerves (lower 6 thoracic nerves, and 1st lumbar nerves) Sensitive to pain, temperature, touch and pressure Visceral peritoneum: innervated by the ANS Sensitive only to stretch and tearing BLOOD SUPPLY

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)

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(2) Lateral: paired visceral for urogenital and endocrine organs Suprarenal Renal Gonadal (3)Postero-lateral: paired parietal for diaphragm and body wall Subcostal Inferior phrenic Lumbar VENOUS DRAINAGE

Figure 13. Arterial supply of the abdomen

NOTE: The internal mammary or internal thoracic artery is 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 thoracic artery - Enters the rectus sheath superiorly through its posterior layer - Supplies the superior part of the rectus abdominis and anastomoses with the inferior epigastric artery approximately in the umbilical region Inferior epigastric artery - Arises from the external iliac artery just superior to the inguinal ligament - Runs superiorly in the transversalis fascia to enter the rectus sheath below the arcuate line - Enters the lower rectus abdominis and anastomoses with the superior epigastric artery. - Superficial circumflex iliac and superficial epigastric vessels from the femoral artery and greater saphenous vein, respectively. - Posterior intercostal vessels of the 11th intercostal space and anterior branches of subcostal vessels.

Figure 14. Lymphatics and superficial veins of anterolateral abdominal wall.

Deep Circumflex artery - Branch of external iliac a. - Supplies lower part of the lateral abdominal wall Lower 2 Posterior Intercostal arteries - Branch of descending aorta(thoracic) - Supply lateral part of abdominal wall Lumbar arteries - Branch of abdominal aorta - Supply the lateral part of the abdominal wall - The 5th pair of lumbar a. ill rise from medial sacral artery not from abdominal aorta NOTE: Abdominal aorta will begin at the aortic hiatus at T12 and ends at the level of L4 (Supracristal plane), which will branch into Right and Left Common Iliac Artery that is further divided into External and Internal Iliac A. at the medial border of Psoas muscles to pelvic brim Branches of Abdominal aorta will be divided into 3 vascular planes (1) Anterior: unpaired visceral for Alimentary tract Celiac a. Superior mesenteric a. Inferior mesenteric a.
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A. SUPERFICIAL VEINS - The abdomen is enriched with a lot of subcutaneous tissue = intricate venous plexuses, which drain: Superiorly medially to internal thoracic vein Laterally to the lateral thoracic vein which drains to the axillary vein Inferiorly to the superficial epigastric vein and inferior epigastric vein - A collateral anastomosis may sometimes form between the lateral thoracic vein (a tributary of axillary 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 or obstruction in the portal circulation (in the case of liver cirrhosis), vessels may be dilated (dilated thoracoepigastric vein and dilated paraumbilical veins = Caput Medusi) Retrograde Flow Due To SVV Or IVC Obstruction IVC subclavian v. axillary lateral thoracic thoracoepigastric superficial epigastric femoral external iliac -> common iliac back to the 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

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A. SUPERFICIAL LYMPHATIC VESSELS - Accompany the subcutaneous veins - Superior to the transumbilical plane drain mainly to the axillary lymph nodes few to the parasternal lymph nodes. - Inferior to the transumbilical plane drain to the superficial 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) lymph nodes. Clinical importance: Infection in the subcutaneous area above the umbilicus - enlarged lymph node either in the axillary region or near the sternum Infection in the subcutaneous area below the umbilicus- enlarged lymph node in the inguinal region INGUINAL REGION

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INGUINAL CANAL An oblique passage approximately 4 cm long directed inferomedially through the inferior part of the anterolateral abdominal wall Main occupant: spermatic cord(males)/round ligament 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 and
ligament

transversus abdominis, medial crus of ext. oblique

Floor: iliotibial tract, inguinal ligament, lacunar

SUPERFICIAL AND DEEP INGUINAL RING

Extends between the ASIS (anterior superior iliac

spine)& pubic tubercle Anatomically important: region where structures exit and enter the abdominal cavity Clinically important: pathways of exit and entrance are potential sites of herniation Hernias occur in both sexes, but most inguinal hernias occur in males because of the passage of the spermatic cord through the inguinal canal. INGUINAL LIGAMENT

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

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 the external oblique aponeurosis Lacunar ligament(Gimbernat): deeper fibers that attach posteriorly to the superior pubic ramus; forms the medial boundary of the subinguinal space Pectineal ligament(Cooper): lateral fibers that continue to run along the pecten pubis Some of the more superior fibers fan upward, bypassing the pubic tubercle and crossing the linea alba to blend with the lower fibers of the contralateral external oblique aponeurosis. These fibers form the reflected inguinal ligament. The iliopubic tract is the thickened inferior margin of the transversalis fascia, which appears as a fibrous band running parallel and posterior to the inguinal ligament. It also reinforces the posterior wall and floor of the inguinal canal as it bridges the structures traversing the subinguinal space.

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 the uterus in females pass to enter the inguinal canal. Superficial inguinal ring Exit by which the spermatic cord or round ligament 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 and aponeurosis, running perpendicular to the fibers of the aponeurosis, pass from one crus to the other across the superolateral part of the ring. These intercrural fibers help prevent crura from spreading apart. The most inferior, medial tendinous fibers of the internal oblique merge with aponeurotic fibers of the transverse abdominal muscle here to form the inguinal falx (conjoint tendon).
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organ and constitutes a continuity of the visceral and parietal peritoneum\ Provides a means for neurovascular communication between the organ and the body wall

INGUINAL HERNIA: DIRECT & INDIRECT

Table 3. Characteristics of Direct and Indirect Hernias

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 wall 2. Other forms of Mesentery - Transverse mesocolon attached to transverse colon - Sigmoid mesocolon attached to the sigmoid colon NOTE: When pinned in the exam and you see the take off or have seen it connected to the dorsal or posterior body wall mesentery proper PERITONEAL FORMATIONS (Omentum) Omentum always related to the stomach A double-layered extension or fold of peritoneum that passes from the stomach and proximal part of the duodenum to adjacent organs in the abdominal cavity

1. Indirect hernia lateral to inferior epigastric artery Direct hernia medial to inferior epigastric artery (at the area of inguinal triangle or Hesselbach triangle) OTHER FORMS OF ABDOMINAL HERNIA

- Attaches from the greater curvature of the

stomach - FUNCTIONS: a. Isolates fluid, pus or inflammation and prevents other organs from being infected, thus called Policeman of the abdominal cavity. b. Prevents visceral peritoneum from adhering to parietal peritoneum c. Organ cushioning d. Insulation against loss of body heat

Greater Omentum

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

PERITONEAL FORMATIONS (Ligaments)

Figure 17. Locations of other types of hernias

Spigelian a hernia along the linea semilunaris (or semilunar line) Relative to the scrotum: Indirect hernia- within the scrotum Direct hernia above the area of scrotum

Parietal

PERITONEUM peritoneumLines the glistening structure , the internal aspect of the abdominal wall Visceral peritoneum - Extension to the organs
Figure 18. Peritoneal formations

CLASSIFICATION OF ORGANS Intraperitoneal Organs More or less completely (or almost completely) covered by peritoneum Ex: stomach, small intestines Extraperitoneal (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
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Ligaments can also form the omentum or they can arise from the omentum 1. Ligaments from the greater omentum - Double layers of the peritoneum that attaches one organ to another organ - Examples:

Gastro-phrenic ligament from the stomach to

the diaphragm the spleen

Gastro-splenic ligament from the stomach to

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Gastro-colic ligament from the stomach to
the large intestines 2. Ligaments from the lesser omentum - Examples: Hepato-duodenal ligament part of the liver to the duodenum Hepato-gastric ligament part of the liver to the part of the stomach fascia, iliac crest, lateral third of inguinal ligament

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Falciform
abdominal

ligament- connects liver to anterior wall

POSTERIOR ABDOMINAL WALL

Dagdag lang :)) "Ang pag-ibig parang imburnal...nakakatakot mahulog...at kapag nahulogka, it's either by accident or talagang tanga ka .." Five lumbar vertebrae and associated IV discs (centrally). Posterior abdominal wall muscles, including the psoas, quadratus lumborum, iliacus, transverse abdominal and oblique muscles (laterally). Diaphragm, which contributes to the superior part of the posterior wall. Fascia, including the thoracolumbar fascia. Lumbar plexus composed of the anterior rami of lumbar spinal nerves. Fat, nerves, vessels (e.g., aorta and IVC), and lymph nodes. "Kung nagmahal ka ng taong di dapat at nasaktan ka, wag mong sisihin ang puso mo. Tumitibok lang yan para mag-supply ng dugo sa katawan mo. Ngayon, kung magaling ka sa anatomy at ang sisisihin mo naman ay ang hypothalamus mo nakumokontrol ng emotions mo, mali ka pa rin! Bakit? Utang na loob! Wag mong isisi sa body organs mo ang mgasamang loob mo sa buhay! Tandaan mo: magiging Masaya ka lang kung matututo kang tanggapin na hindi ang puso, utak, atay o bituka mo ang may kasalanan sa lahat ng nangyari sayo, kundi IKAW mismo!" "Huwag magmadali sa babae o lalaki. Tatlo, lima, sampung taon, mag-iiba ang pamantayan mo at maiisip mong hindi pala tama ng pumili ng kapareha dahil lang maganda o nakakalibog ito. Totoong mas mahalaga ang kalooban ng tao higit sa anuman. Sa paglipas ng panahon, maging ang mga crush ng bayan nagmumukha ding pandesal, maniwala ka." "I wish true love is like a boy playing chess whos afraid of losing his queen and a girl whos risking everything just to protect her king." Hindi lahat ng lokohan walang magandang patutunguhan, minsan sa lokohan, inuumpisahan, para magkatuluyan. -Bob Ong

Table 4. Origin, Insertion, and Action of Posterior Abdominal Wall Muscles

muscle Psoas Major

Iliacus Quadratus Lumboru m

origin transverse processes, bodies, and IV discs of 12th thoracic & 5 lumbar vert. iliac fossa iliolumbar ligament, iliac crest, tips of transverse processes of lower lumbar vertebrae

insertion lesser trochanter of femur

action flexes thigh on trunk; if thigh is flexed, flexes trunk on thigh, as in sitting up from lying fixes 12th rib during inspiration; depresses 12th rib during forced expiration; laterally flexes vertebral column same side Compress es and supports abdominal contents

12th rib

Transvers us abdominis

Lower 6 costal cartilages, thoracolumbar

Xiphoid process, linea alba, symphysis pubis

Rey, Miggy, Gab, Lara, Sarah, Elene, Ronna Page 10 of 10

11042011 - 1st Lecture (4th LE )