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3002 > 7 Abdominal wall, neuromuscular hernias 2 and incisions > Flashcards

7 Abdominal wall, neuromuscular hernias 2 and incisions Flashcards

1
Q

Name the 3 muscles of the posterior abdominal wall

A
  1. Quadratus lumborum
  2. Psoas major, possibly with poses minor overlying it
  3. Iliacus

(Diaphragm contributes to the upper, posterior abdominal wall)

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2
Q

Function of the posterior abdominal wall muscles

A
  • Quadratus lumborum stabilises the 12th rib for diaphragmatic movement in respiration
  • Psoas major and iliac pass to the lesser trochanter together and are powerful hip flexors
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3
Q 
Diaphragm:
Loop?
Made up of?
Function?
Nerve supply?
A
  1. Loop forming a sling around the oesophagus - functional sphincter preventing reflux of stomach contents into the oesophagus during inspiration
  2. Sheet of muscle & tendon (i.e. central tendon)
  3. Functions
    • Separates the thoracic &
    abdominal cavities
    • Responsible for inspiration at rest
  4. Nerve supply:
    • C3, C4 and C5 (phrenic nerve)
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4
Q

What is the position of the iliolumbar ligament?

A

From transverse process of L5 –> posterior superior iliac spine and adjacent iliac crest

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5
Q

Quadratus lumborum:
Attachments?
Nerve supply?

A 
1. Attachments:
• Iliac crest
• Iliolumbar ligament 
• 12th rib (inf. border)
• L1-4 transverse processes
  1. Nerve supply:
    • T12 and L1 -4
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6
Q

Psoas major:
Attachment?
Nerve supply?

A
  1. Attachments:
    • Transverse processes of L1 to L5, bodies & intervertebral discs from T12 to L5
    • To lesser trochanter of femur (with Iliacus)
  2. Nerve supply:
    • L1 to 3
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7
Q

Psoas minor:
Attachments?
Nerve supply?

A
  1. Attachments:
    • T12 & L1 bodies
    • To pectineal line & iliopectineal eminence on pelvic bone
  2. Nerve supply:
    • L1

(Absent in 50%)

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8
Q

Iliacus:
Attachments?
Nerve supply?

A
  1. Attachments:
    • Iliac fossa
    • To lesser trochanter of femur (with psoas)
  2. Nerve supply:
    • Femoral nerve L2, 3, 4
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9
Q

What are the contents of the femoral sheath?

A
  • Femoral artery
  • Femoral vein
  • Femoral canal (lymphatics e.g. Cloquet’s lymph node that receives directly from the glans of penis or clitoris)
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10
Q

Where is the site of a femoral hernia?

A
  • Femoral sheath, below and lateral to the pubic tubercle

* This is an extension of the abdominal transversals fascia

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11
Q

What are the boundaries of the femoral canal?

Medial, lateral, posterior, anterior

A
  • Medial: Lacunar ligament
  • Lateral: Femoral vein
  • Posterior: Pectineus or pectineal ligament for ring
  • Anterior: Inguinal ligament
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12
Q 
Where do spinal nerves arise from? 
Emerge as? 
Combine as? 
Pass through? 
Divide into?
A
  • Arise from segments of the spinal cord
  • Emerge as dorsal (posterior) sensory roots & ventral (anterior) motor roots
  • They combine to form a mixed spinal nerve that passes through an intervertebral foramen & divides into a dorsal & a ventral ramus
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13
Q

What is a dermatome?

A

Region or strip of skin supplied by a specific spinal nerve

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14
Q

How is each spinal nerve named?

A

In relation to the intervertebral foramen from which it emerges

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15
Q

What is a myotome?

A

Muscle or group of muscles supplied by a specific spinal nerve

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16
Q

Which nerves supply the skin and muscle of the abdominal wall?

A

Supplied in segments by ventral rami of the spinal nerves T7-12 and L1 (iliohypogastric and ilio-inguinal nerves)

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17
Q

What is the subcostal nerve?

A

T12

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18
Q

What is the epigastric dermatome? Where does the referred pain go to?

A
  • Epigastric: T7

* Referred pain: Stomach and oesophagus

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19
Q

Where is the umbilical dermatome? Where is it’s referred pain?

A
  • Umbilical: T10

* Referred pain: Appendix, gonad, small intestine

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20
Q

What is the suprapubic dermatome? Where is it’s referred pain?

A
  • Suprapubic: T12 (L1 laterally, superior to inguinal ligament)
  • Referred pain: Lower colon, bladder, uterus
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21
Q

Where does shingles (herpes zoster) occur?

A

Painful skin rash in T10

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22
Q

In the abdominal wall muscle, nerves pass between which 2 muscle?

A
  • Internal oblique and transverses abdominis

* Pass forwards and medially

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23
Q

What must be done when splitting rectus abdominis surgically to avoid denervation?

A

The fibres must be pushed laterally towards the nerves

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24
Q

What muscles do the nerves which pierce the posterior wall of the rectus sheath supply?

A
  • Rectus abdominis muscle (T7 - T12)

* Pyramidalis (T12 only)

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25
Q

How do the nerves terminate in the abdominal wall muscle and what do they supply?

A
  • Terminate by piercing the anterior wall of the sheath

* Supplying the overlying skin (anterior cutaneous branches)

26
Q

Where does the iliohypogastric nerve (L1) pierce the external oblique aponeurosis?

A

Above superficial inguinal ring

27
Q

What nerve emerges through the superficial ring?

A

Ilioinguinal nerve (L1)

28
Q

What 2 nerves supply the skin just above the inguinal ligament? And the fibres of internal oblique and transverse abdominis?

A
  1. Iliohypogastric (L1)

2. Ilioinguinal (L1)

29
Q

What are the consequences of nerve injury to iliophypogastric and ilioinguinal nerves (L1)?

A
  • Weaken internal oblique and transverse abdominis muscles and hence conjoint tendon (iliohypogastric nerve)
  • Predispose to inguinal hernias
30
Q

What are the branches of the lumbar plexus and which nerve fibres do they carry?

A
  • Iliohypogastric (L1)
  • Ilioinguinal (L1)
  • Genitofemoral (L1,2)
  • Lateral femoral cutaneous (L2,3) - (Lateral cutaneous nerve of thigh)
  • Obturator (L2,3,4)
  • Femoral (L2,3,4)
  • Muscular branches
31
Q

Which muscle is the lumbosacral plexus formed in?

A

Psoas major

32
Q

Which vessels provide the arterial supply to the abdominal wall?

A
  • Superior, inferior and superficial epigastrics

* Superficial and deep circumflex iliacs

33
Q

Superior epigastric artery:
Pathway?
Supplies which muscles?

A

• Branch of the internal thoracic (mammary) artery entering the upper part of the rectus sheath between the sternal & costal origins of the diaphragm
• Descends behind the rectus abdominis
- supplying the upper central part of the anterior abdominal wall
-anastomoses with the inferior epigastric artery (may form a collateral circulation for an obstructed aorta)

34
Q

What artery supplies the upper lateral abdominal wall?

A

Branches from the musculophrenic branch of the internal thoracic artery

35
Q

What artery supplies the upper central part of anterior abdominal wall?

A

Superior epigastric artery

36
Q

Inferior epigastric artery:
Branch of which vessel?
Pathway?
Supplies?

A
  • Branch of the external iliac
  • It runs upward & medially along the medial side of the deep inguinal ring & pierces the transversalis fascia to enter the rectus sheath anterior to the arcuate line
  • It ascends behind the rectus muscle supplying the lower central part of the anterior abdominal wall & anastomoses with the superior epigastric artery
37
Q

What artery supplies the lower central part of the anterior abdominal wall?

A

Inferior epigastric artery

38
Q

Deep circumflex iliac artery:
Branch from which vessel?
Pathway?
Supplies what?

A
  • Branch of external iliac just above the inguinal ligament
  • Runs upward & laterally toward the anterior superior iliac spine & then continues along the iliac crest
  • Supplies lower lateral part of the abdominal wall
39
Q

What artery supplies the lower lateral part of the abdominal wall?

A

Deep circumflex artery

40
Q

Superficial epigastric and superficial circumflex iliac arteries:
Branch of which vessel?
Supply what?

A

• Arise from the femoral just below the
inguinal ligament
• Supply the lower abdominal wall

41
Q

Which arteries supply the lower abdominal wall?

A
  • Superficial epigastric

* Superficial circumflex iliac

42
Q

Which vessels pass forwards between the muscle layers and supply the lateral abdominal wall?

A
  • Lower 2 posterior intercostal arteries (i.e. branches of the descending thoracic aorta)
  • 4 lumbar arteries (i.e. branches of the abdominal aorta)
43
Q

What is the structure of the abdominal wall venous drainage system?

A
  • Superficial epigastric & superficial circumflex iliac veins drain into the proximal end of the great (long) saphenous vein along with the superficial & deep external pudendal veins
  • These 4 veins are important in varicose vein surgery
44
Q

What direction do the arteries and veins run in the abdominal wall in relation to umbilicus?

A
  • Arteries converge towards the umbilicus

* Veins radiate out from umbilicus

45
Q

Veins radiate out from the umbilicus, which eventually drain into the femoral & external iliac veins inferiorly &
the internal thoracic & axillary veins superiorly:
• What vessel forms the portosystemic venous anastomosis?
• What is the result of obstruction of this vessel?

A
  • Para-umbilical veins connect the system through the umbilicus to the portal veins of the liver
  • Obstruction of the portal vein may cause venous back pressure into the veins of the abdominal wall => Caput Medusae
46
Q

What is the superficial lymphatic drainage of the abdominal wall? (anterior, posterior)

A
  1. Anterior:
    • Above umbilicus to anterior axillary nodes
    • Below umbilicus to superficial inguinal nodes
  2. Posterior
    • Above iliac crests to posterior axillary nodes
    • Below iliac crests to superficial inguinal nodes
47
Q

Where do the axillary nodes empty into?

A

Subclavian lymph trunk

48
Q

The anterior/ pectoral group of axillary lymph nodes are the lymph drainage for which area?

A

Anterior superficial abdominal wall above umbilicus

49
Q

The posterior/ subscapular group of axillary lymph nodes are the lymph drainage for which area?

A

Posterior superficial abdominal wall above iliac crests

50
Q

The superficial inguinal nodes are the lymph drainage for which area? Where does it extend to?

A
  • Below inguinal ligament
  • Extending inferiorly along the great (long) saphenous vein for anterior & posterior lower superficial abdominal wall (below umbilicus & below iliac crests)
51
Q

Where do the superficial inguinal nodes drain into?

A

Deep inguinal nodes (in the femoral canal) that drain into the external iliac & then the para-aortic nodes

52
Q

What is the deep lymph drainage of the abdominal wall?

A

Drains in parallel to the epigastrics:

• Inferiorly to the
external iliac & then the para-aortic nodes
• Superiorly to the parasternal nodes alongside the internal thoracic artery & then mediastinal nodes

53
Q

List the main surgical incisions? (6)

A
  1. Kocher’s - right subcostal
  2. Thoraco-abdominal
  3. Midline
  4. Muscle splitting/ Gridiron
  5. Pfannenstiel
  6. Paramedian
54
Q

What is Kocher’s surgical incision used for?

A
  • Right subcostal

* For removal of gallbladder

55
Q

What is thoraco-abdominal surgical incision used for?

A

For accessing oesophagus

56
Q

What is midline surgical incision used for?

A

For rapid access through the almost avascular line alba but has poor healing

57
Q

What is muscle splitting/ Gridiron surgical incision used for?

A

For appendicectomy with muscles split in the direction of their fibres rather than incised with good strong healing

58
Q

What is pfannenstiel surgical incision used for?

A

For gynaecological and other pelvic procedures (no posterior rectus sheath)

59
Q

What is paramedical surgical incision used for?

A

Similar to midline, but avoiding the lines alba for better healing with the fibres of rectus abdominis split or reflected laterally towards their nerve supply

60
Q

Where is McBurney’s point?
What does it overlie?
What surgical incision is made here?

A
  • 1/3 of distance from right ASIS to umbilicus
  • Typically overlies the base of vermiform appendix as this attaches to the caecum
  • Appendicectomy incisions are made here
61
Q

Extending the appendicectomy incision laterally may put what nerves at risk?

A

Iliohypogastric and ilioinguuinal nerves

- possibile consequence of weakening the muscles supplied (inguinal hernia)

62
Q

How do skin flaps work?

A
  • It is possible to remove a piece of abdominal wall skin & close the wound behind it while moving this skin flap to replace an area of lost skin
  • Essential to maintain the vascular pedicle both arterial & venous

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