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GI Term 4 > 6.1- The Abdominal Wall > Flashcards

6.1- The Abdominal Wall Flashcards

1
Q

Describe the components of the abdominal wall.

A
  • partly of bone, mainly muscle
  • extends from thoracic cage to pelvis (inguinal ligament)
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2
Q

What are the components of the Posterior abdominal wall?

A

lateral to vertebral bodies

  • quadratus lumborum
  • iliacus and psoas major ie iliopsoas

​distal attachment on lesser trochanter of femur because powerful hip flexor

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3
Q

What are the components of the Anterior Abdominal Wall?

A

Lateral Flank Muscles:

  • transverse abdominus
  • internal oblique
  • external oblique
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4
Q

What are the abdominal wall layers?

A
  • Skin
  • Superficial Fascia
  1. Fatty Layer; Camper’s Fascia
  2. Membranous Layer; Scarpa’s Fascia
  • 3 MUSCLES
  • Transversalis fascia
  • extraperitoneal fascia
  • parietal peritoneum
  • visceral peritoneum
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5
Q

What are the functions of the:

a) Camper’s fasia

b) Scarpa’s fascia

A
  • Camper’s fascia: superficial fatty layers on abdomen+ covers anterior abdomen and back
  • Scarpa’s fascia: tough fasia, can be used for anchoring sutures
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6
Q

Describe the functions of:

a) The parietal peritoneum

b) The visceral peritoneum

A
  • mesentery sits between visceral peritoneum and parietal peritoneum
  • blood vessels, nerves, SNS chain, LN’s

a) Parietal Peritoneum:

  • fatty tissue curtain that suspends intraperitoneal organs in the peritoneal cavity
  • more superficial
  • somatic innervation ie perception of point pain
  • lines abdominal cavity

b) Visceral Peritoneum:

  • ​intermittently surrounds organ viscera
  • visceral innervation; has stretch receptors
  • Visceral Type Innervation is REFFERED PAIN PATTERNS
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7
Q

What are the 3 muscle layers of the abdominal wall?

Describe their function

A

From out to in

  • External Oblique
  • Internal Oblique
  • Transverse Abdominis
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8
Q

What happens if abdominal wall muscles get compromised?

A

weaking of the abdominal wall

protrusion of abdominal viscera through that particular weakness ie hernias

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9
Q

What is the structure of the External Oblique?

A

Aponeurosis:

  • coverts anterior part of abdominal wall to the midline
  • continues off of the external oblique muscle and covers rectus abdominis anteriorly and medially

at midline`: fibres intwine and are interconnected and form a dense connective tissue called:

LINEA ALBA:

  • Extends from xyphoid process ( inferior part of sternum) to pubic symphysis
  • long strong aponeurosis of dense connective tissue
  • good location and integrity for anchoring sutures in place

SUPERFICIAL INGUINAL RING:

deficit in inferior fibres of external oblique muscles esp its aponeurotic sheath

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10
Q

What direction do the muscle fibres of external oblique travel in?

A
  • immediately deep to Scarpa’s Fascia ie membranous
  • pass in an inferior and medial direction
  • designed to go in different directions to increase strength and function
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11
Q

How is the inguinal ligament formed?

A
  • stretches from ASIS to pubic tubercle
  • formed from inferior fibres of external oblique muscle
  • lower border of external oblique aponeurosis forms the INGUINAL LIGAMENT on each side.
  • Thickened, reinforced free edge of external oblique muscle can be palpated; along w ASIS and pubic tubercle ie inguinal ligament is between them
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12
Q

How is inguinal canal formed?

A

fibres underneath the inguinal ligament curl underneath itself and form a trough or tunnel

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13
Q

Which structures support superficial inguinal ring?

A

inguinal ligament

lacunar ligament

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14
Q

Describe the direction of the internal oblique musle fibres

A

deep to external obique

  • its middle fibres go TRANSVERSE
  • ie go down from a superior to medial direction ( bottom)
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15
Q

What is the internal oblique muscle?

A
  • smaller and thinner muscle than the external oblique
  • central muscular components and anteriorly as an aponeurosis that blends into the linea alba ie contribute to linea alba
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16
Q

What is the conjoint tendon?

A
  • strengthens the abdominal wall, medial and behind where the superficial inguinal ring is
  • internal abdominal oblique contributes to the conjoint tendon BUT
  • transverse abdominis also contributes to the conjoint tendon
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17
Q

What is the transversus abdominis?

A

thin sheet of muscle whose fibres run transversversely anteriorly perpendicularly to linea alba

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18
Q

What is the function of the deep inguinal ring?

A
  • sits at inferior border of transverse abdominus
  • structures exit abdominal cavity through deep inguinal ring
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19
Q

What is deep to the three muscle layers?

A

TRANSVERSALIS FASCIA

  • a continous layer of deep fascia that lines the abdominal cavity and continues into pelvic cavity
  • portion that lines the deep surface of the transverse abdominal muscles and that muscle’s aponeurosis
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20
Q

What is HESSELBACH’S TRIANGLE? ( or inguinal triangle)

A
  • can get direct inguinal hernias which protrude through the abdominal wall

BORDERS: RIP and MLI

  • Rectus Sheath - Medial Border
  • Inferior epigastric artery - Lateral Border
  • Poupart’s/ Inguinal ligament- Inferior Border
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21
Q

What is the arcuate line?

A

above this line, the muscle layers that are posterior to the rectus abdominus are different from the muscles below the arcuate line

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22
Q

Describe the positioning of the deep inguinal ring

A
  • deficit in transversus abdomnis
  • intrinsic to inguinal canal
  • located (lateral) to inferior epigastric Artery and vein
23
Q

Describe the structure of the rectus abdominis?

A

Linea alba: midline CT merging all 3 abdominal wall muscles ie aponeurosis of all 3 muscles

Arcuate Line: belly button level

  • demarkates the lower limit of the posterior layer of the rectus sheath
  • where the inferior epigastric vessels perforate/ pierce the rectus abdominis into the muscle’s belly

Rectus sheath: covers the entire rectus abdominis muscle

24
Q

Describe the organization of the rectus sheath

A
  • The aponeurosis of all 3 abdominal muscles ( external oblique, internal oblique, transversus abdominis) come together medially and surround the rectus abdominis, form the RECTUS SHEATH
  • therefore we have a much denser rectus sheath anterior to RA htan posterior ( has an impact on repair)
25
Q

What is the importance of the arcuate line?

A

ABOVE arcuate line: all the way to the xyphoid process to the ribcage; it is inverted intermittently and either side of the interal oblique ) encloses around RA above arcuate line)

BELOW Arcuate line: Rectus abdominis dives deep and back

  • all external and internal obliques’ aponeuroses become ANTERIOR to RA same with Transverse abdominis
26
Q

How does the linea alba change above and below the arcuate line?

A

ABOVE: the linea alba is thick and de-markated

BELOW: less thick below the arcuate line because all the muscles’ aponeuroses have gone anterior to/in front of the rectus abdominus

27
Q

What is a rectus sheath haematoma?

A
  • common if on blood thinners
  • bleed within rectus sheath
  • the sheath has tight fascia so if you bleed into it, there is no place to expand
  • very painful, blood accumulates and pours into rectus abdominis space
28
Q

Find the rectus sheath haematoma in the imaging and describe it-

A

LEFT: blood has accumulated and poured into rectus space

RIGHT: lower density blood bc it is a clot ie will cause a bruise on the abdomen

29
Q

Why do lateral flank muscles have such high innervation?

A
30
Q

What is the importance of the floor of the inguinal canal?

A
  • oblique passage
  • in descent of the gonads, the the testes decend from retroperitoneal position on the posterior abdominal wall through the abdominal cavity, into the scrotum. During their descent, the testes picls up a layer of
  1. External abdominal oblique (superficially) becomes a layer; EXTERNAL SPERMATIC FASCIA
  2. one layer deeper it picks up the internal oblique; becomes CREMASTER FASCIA

BUT the gonads do not pick up the transverse abdominis

  1. picks up Transveralis Fascia and becomes INTERNAL SPERMATIC FASCIA
31
Q

What are the inguinal canal contents?

A

MALES:

  • Vas deferens ie spermatic cord
  • Ilioinguinal nerve; somatic innervation to mons pubis

FEMALES:

  • round ligament of the uterus; exits inguinal canal and goes to labia majora
  • ilioinguinal nerve; also innervates mons pubis ie external genitalia
32
Q

Formation of inguinal ligament??

A
  • incurled margin of external oblique aponeurosis forms inguinal ligament
  • stretches from ASIS to PUBIC TUBERCLE
33
Q

What is the inguinal region?

A

a structure that passes obliquely through abdominal wall, just above inguinal ligament

FEMALE: round ligament of the uterus

MALE: spermatic cord ie vas deferens

34
Q

Name 5 types of hernias (IUFEI)

A
  1. Inguinal
  2. Umbilical
  3. Femoral
  4. Epigastric
  5. Incisional
35
Q

How do umbilical hernias form?

A

through umbilical ring, which is a gap in the linea alba

36
Q

How do femoral hernias protrude?

A

through the femoral canal

37
Q

How do incisional hernias form?

A

protrusion of abdominal viscera through surgical incision if it does not heal correctly

38
Q

What is an inguinal hernia?

A

portion of intestine protrudes throgh weak spot in the inguinal canal or inguinal triangle

39
Q

Differentiate between indirect and direct inguinal hernias?

A

INDIRECT HERNIAS: ​

  • more common in M>F ( bc of patent processus vaginalis)
  • through deep inguinal ring through inguinal canal to scrotum to superficial inguinal canal

or

F- go through labia majora (looks like a swelling)

DIRECT HERNIAS:

directly through posterior wall of the inguinal canal

40
Q

Which type of hernia is a surgical emergency?

A

INDIRECT

because it passes LATERAL to inferior epigastric vessels

41
Q

What are the borders of the inguinal triangle?

A

LATERAL BORDER: Inferior epigastric vessels

MEDIAL BORDER: lateral edge of rectus abdominis

INFERIOR BORDER: inferior aponeuoris of external oblique ie INGUINAL LIGAMENT

42
Q

What route is taken by indirect inguinal hernias?

A
  • PROCESSUS VAGINALIS: part of parietal peritoneum that helps gubernaculum and testes in their descent ( becomes TUNICA VAGINALIS)
  • potential WEAK SPOT
43
Q

What route does a direct inguinal hernia take?

A

goes directly through;

  • Hasselbach’s triangle
  • medial to inferior epigastric vessels
  • through superficial inguinal ring
44
Q

What innervates the skin, muscle and parietal peritoneum of the anterolateral abdominal wall?

A

Mainly T7-T12 and L1 spinal nerves that give off lateral cutaneous branches on the way

  • mainly intercostal (T7-T11)
  • *-Subcostal N:** T12 below ribcage/ thoracic cage
  • *L1 Branches:
  • Iliohypogastric N:** terminates on mons pubis/upper groin and innervates them
  • *-Ilioinguinal N:** sensation to external genitalia (external surface of labia majora and scrotum)

found in ilioinguinal canal and goes from ilium of pubis to inguinal canal

45
Q

Which arteries supply the lateral wall flank muscles?

A
  • *Lateral flank muscles: 1. Intercostal arteries
    2. Lumbar arteries
  1. Epigastric’s: anastomose behind rectus abdominis
    * *Superior epigastri    c - superior part of rectus abdominis, branches off internal thoracic artery and SUPPLIES RECTUS ABDOMINIS
    * *Inferior epigastric** - inferior parts of rectus abdominis, branches off external iliac

SUPPLIES RECTUS ABDOMINIS

46
Q

What is the significance of the “watershed” line?

A

T10 Umbilicus

where the arcuate line is

  • Above this: ALL drainage is to axillary lymph nodes
  • Below this: ALL drainage is to superficial inguinal lymph nodes
47
Q

Which lymph nodes are involved in the deep lymphatic drainage of the abdomen?

A

follows the deep arteries back to:

  1. Parasternal nodes
  2. Pre-Aortic lymph nodes (CSI)
  • Celiac
  • Superior Mesenteric
  • Inferior Mesenteric
  1. External iliac nodes: go along the external iliac artery
48
Q

What are the criteria in choosing which abdominal incision to make?

A
  1. Pre-op diagnosis
  2. Speed at which operation must be perfomed
  3. Status of patient
  4. Previous abdominal operations
  5. Potential placements of stomas

should be CLOSEST to area to be operated to provide long-lasted STRENGTH

better healing if incisions are made parallel to LANGER LINES ie natural tension lines

49
Q

Where is appendix found?

A

McBurney’s Point; ie 1/3 along thw way between umbilicus and the ASIS

for appendectomies, the gridiron approach of muscle splitting is used :)

50
Q

Which direction should an incision ideally be made?

A

in direction of the LANGER LINES ie lines of cleavage in skin so a hairline scar results

ie parallel to langer lines

better healing and less scarring

51
Q

Advantages of a midline/ paramedian incision?

( through linea alba aponeurosis)

A
  • almost bloodless
  • no muscle fibres divided
  • nerves at lower risk of injury
  • very quick
52
Q

What are the 2 types of Transverse Abdominal Incisions?

A

A: Kocher Incision

  • Of value in obese patients
  • Exposes gall bladder and biliary tract
  • Cholecystectomy

E: Pfannenstiel Incision
Often used for C-section

suprapubic incision

risks injury to HYPOGASTRIC N; sensory deficit in babies if damaged

53
Q

What incision is made in a cholecystectomy?

A
  • gall bladder removal
  • KOCHER’S INCISION
  • now done laparoscopically
54
Q

What is the gridiron approach?

A

A decision to ‘split’ muscle (spread them apart to access the abdomen), often chosen in appendectomies

  • does not cut muscle layers but spreads them apart to maintain strength and integrity of the muscle time
  • has a shorter healing time

GI Term 4 (7 decks)

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