4 - Abdominal Wall and Hernias

Question 1

What is the gastrocolic ligament?

Answer 1

Ligament between greater curve of the stomach and the transverse colon. Part of the greater omentum

Question 2

How do the greater and lesser sacs communicate?

Answer 2

Foramen of Winslow (Eploic foramen)

Question 3

What is visceral pain and how does it present in general?

Answer 3

• Pain from visceral stretching, inflammation or ischaemia
• Diffuse, poorly defined, midline (even if organ to one side)
• Nausea, vomiting, sweating
• Difficult to diagnose as vague

Question 4

What is the innervation to the gut that percieves pain?

Answer 4

• Sympathetic T5-L2

Question 5

Why is pain of the viscera referred?

Answer 5

• Afferent sensory fibres run back along same path as motor fibres so when impulse gets to ganglia will split along all contributing spinal nerves
• e.g stomach T5-T9 innervation so these dermatomes affected so epigastric pain. Bilateral stimuli and brain can’t decide which is more so midline

Question 6

What would be the pain pattern if a caecal volvulus were to occur?

Answer 6

Midgut - periumbilical pain

Hindgut - suprapubic pain

Question 7

What is a hernia and what are the signs and symptoms?

Answer 7

• Protrusion of part of the abdominal contents beyond the normal confines of it’s containing cavity (abdoinal wall)

Question 8

What are the 3 parts of a hernia?

Answer 8

Sac is pouch of peritoneum

Coverings is abdominal wall layers

Question 9

Where do hernias occur, and what can increase your risk of developing a hernia?

Answer 9

- Congenitally related areas (e.g processus vaginalis)

- Post surgery non healed areas (incisional hernia)

- Points of weakness (femoral, inguinal, umbilical)

Question 10

What is the inguinal canal?

Answer 10

Oblique passage through lower abdominal wall

Males: abdomen - testes

Females: uterus to labia majora

Question 11

What are the boundaries of the inguinal canal?

Answer 11

A: External oblique aponeurosis

P: Transversalis fascia and cojoint tendon

Floor: Inguinal ligament and lacunar ligament medially

Roof: arching fibres of internal oblique and transversus abdominis

(deep ring in posterior wall, superficial ring in anterior wall)

Question 12

What are the two locations of inguinal hernias in the male testes that can occur, and what leaves certain men susceptible to these?

Answer 12

Hernia can only go as far as processus vaginalis, if through superficial ring then scrotal hernia

Question 13

What is the inguinal ligament made of?

Answer 13

The rolling tendon of extrnal oblique

Question 14

What are the two types of inguinal hernia?

Answer 14

- Direct: straight through abdominal wall through Hesselbach’s triangle and maybe superficial ring

- Indirect: through inguinal canal and deep inguinal ring

Indirect is more common and these occur in males more

Question 15

What are the most to least common abdominal hernias?

Answer 15

Question 16

What is the relationship of inguinal hernias to the inferior epigastric vessels?

Answer 16

Question 17

What are the boundaries of Hesselbachs triangle? (direct on picture correlates to anatomical area of this triangle)

Answer 17

Area of potential weakness, hernias follow path of least resistance. This hernia will take one more layer with it. Superficial ring in lowest corner

Medial: lateral border of rectus abdominis

Lateral: Inferior epigastric vessels

Inferior: Inguinal ligament

Question 18

What is the basis of femoral hernias?

Answer 18

• More common in females
• Passes through femoral ring to femoral canal
• At risk of incarceration as such small opening, can lead to strangulation and therefore tissue necrosis

Question 19

What are the borders of the femoral canal?

Answer 19

Question 20

What is an omphalocele?

Answer 20

- Failure of midgut to return to abdomen during development so viscera grow in umbilical ring

• Viscera covered in peritoneum but may not grow to correct size
• Mortality is high as associated with other genetic problems

Question 21

What is gastroschisis?

Answer 21

- Defect in ventral abdominal wall, viscera not covered by peritoneum so could be damaged by amniotic fluid

• Gut problems like intestinal atresia
• Issue with feeding unlike omphalocele
• Slow retreat back into abdomen, higher survival rate than omphalocoele as less genetic issues

Question 22

What is an umbilical hernia and how is it treated?

Answer 22

• Common in infants
• Bulge at umbilicus and not often painful
• Most close by themselves by age of 3 so no intervention

Question 23

What is an umbilical hernia actually called in an adult?

Answer 23

• Paraumbilical hernia
• Goes through linea albea near umbilicus
• Greater risk in females and if obese
• Risks of strangulation as so small

Question 24

Why is there a risk of sepsis with a hernia?

Answer 24

• Strangulation can cause the organs to break down leading to necrosis and break down of the viscera
• This is why may feel nauseous and vomit when have a hernia

Question 25

What is a diverticulum?

Answer 25

• Mainly in the colon
• Outpouching of epithelium into the muscular layer in weakened areas, e.g later parts of colon where faeces is hard
• Faeces can get in the pouches and cause diverticulitis

Question 26

Where is Vitamin B12 absorbed?

Answer 26

Ileum

Question 27

Where are some areas in the male peritoneal cavity that abnormal gastric fluid can collect?

Answer 27

• Paracolic gutters
• Rectovesical pouch

Question 28

What parts of the gut do each of the splanchnic nerves supply?

Answer 28

Enter the abdomen via the diaphragm and synapse at celiac ganglia

Question 29

What are the two parts of the enteric nervous system, where are they found and what do they do?

Answer 29

- Submucosa: in submucosa, blood flow and secretions

- Myenteric: between two muscle layers, motility

Question 30

How does the autonomic system communicate with the enteric nerves system?

Answer 30

Question 31

Where can peptic ulcers form?

Answer 31

Stomach and D1