7. Abdominal wall, neurovascular, hernias 2 and incisions .pptx

Question 1

Name the 3 muscles of the posterior abdominal wall

Answer 1

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

(Diaphragm contribute to the upper, posterior abdominal wall)

Question 2

Function of the posterior abdominal wall muscles

Answer 2

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

Question 3

What is the position of the iliolumbar ligament?

Answer 3

From the transverse process of L5 to the posterior superior iliac spine and adjacent iliac crest

Question 4

Quadratus lumborum:
Attachments?
Nerve supply?

Answer 4

Attachment:
From iliac crest, iliolumbar ligament and L5 LP
To 12th rib and L1-4 TPs

Nerve supply: T12 to L1-4

Question 5

Psoas major:
Attachment?
Nerve supply?

Answer 5

Attachments:
From transverse processes, bodies, and intervertebral discs of 12th thoracic and five lumbar vertebrae;
To lesser trochanter of femur (with Iliacus)

Nerve supply: L1 to 3

Question 6

Psoas minor:
Attachments?
Nerve supply?

Answer 6

Attachments:
From T12/L1 vertebral bodies
To pectineal line and iliopectineal eminence on pelvic bone

Nerve supply: L1

(Absent in 50%)

Question 7

Iliacus:
Attachments?
Nerve supply?

Answer 7

Attachments:
From Iliac fossa
To lesser trochanter of femur (with psoas)

Nerve supply: Femoral nerve L2, 3, 4

Question 8

What are the contents of the femoral sheath?

Answer 8

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

Question 9

Where is the site of a femoral hernia?

Answer 9

Femoral sheath, below and lateral to the pubic tubercle.

This is an extension of the abdominal transversals fascia

Question 10

What are the boundaries of the femoral canal?

Medial, lateral, posterior, anterior

Answer 10

Medial: Lacunar ligament
Lateral: Femoral vein
Posterior: Ligament for ring
Anterior: Inguinal ligament

Question 11

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

Answer 11

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

Question 12

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

Answer 12

Epigastric: T7

Referred pain: Stomach and oesophagus

Question 13

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

Answer 13

Umbilical: T10

Referred pain: Appendix, gonad, small intestine

Question 14

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

Answer 14

Suprapubic: T12

Referred pain: Lower colon, bladder, uterus

Question 15

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

Answer 15

The fibres must be pushed laterally towards the nerves

Question 16

What is the pathways of the nerves that supply the abdominal muscles?

Answer 16

Anterior rami of T7-12 and L1 pass between internal oblique and transversus abdominis
Enter rectus sheath to supply rectus abdominis, from lateral to medial. T12 only supplies pyramidalis
Terminates by peircing the ant wall of the sheath and supplying the overlying skin.

Iliohypogastric nerve pierces the external oblique aponeurosis above superficial inguinal ring
Ilio-inguinal nerve emerges through superficial ring.
End by supplying the skin above the inguinal ligament

Question 17

What does the iliohypogastric nerve supply?

Result of injury?

Answer 17

Internal oblique and Transverse abdominis fibres that form the conjoint tendon.
Injury: Weakens the conjoint tendon and pre disposal to hernia

Question 18

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

Answer 18

Iliohypogastric (L1) 
Ilio-inguinal (L1) 
Genitofemoral (L1, 2) 
Lateral Femoral Cutaneous (L2, 3) 
Obturator (L2, 3, 4) 
Femoral (L2, 3, 4)

Question 19

Which muscle is the lumbosacral plexus formed in?

Answer 19

Psoas

Question 20

What is McBurney’s point?

Answer 20

1/3 of the way up that line from the ASIS to the umbilicus

Note: Point of appendicectomy incisions

Question 21

Which vessels provide the arterial supply to the abdominal wall?

Answer 21

Lower 2 posterior Intercostal arteries
4 Lumbar arteries
Sup, inf and superficial epigastric artery
Deep circumflex iliac artery
Superficial epigastric 
Superficial circumflex iliac artery

Question 22

Superior epigastric artery:
Pathway?
Supplies which muscles?

Answer 22

Is a branch of the internal thoracic (mammary) artery, and enters the upper part of the rectus sheath between the sternal and costal origins of the diaphragm
It descends behind the rectus muscle, SUPPLYING the upper
central part of the anterior
abdominal wall, and anastomoses
with the inferior epigastric artery

Branches from the musculophrenic branch of the internal thoracic artery SUPPLY the upper, lateral abdominal wall

Question 23

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

Answer 23

The inferior epigastric artery is a branch of the external iliac

It runs upward and medially along the medial side of the deep inguinal ring and pierces the transversalis fascia to enter the rectus sheath anterior to the arcuate line.

Supplies:
-Lower central part of the anterior abdominal wall
Anastomoses with sup epigastric artery

Question 24

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

Answer 24

Branch of external iliac just above the inguinal ligament

Pathway: Runs upwards and laterally towards the ASIS, then along iliac crest

Supplies: Lower, lateral part of the abdominal wall

Question 25

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

Answer 25

Branch from femoral just below inguinal ligament

Supply: Lower abdominal wall

Question 26

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

Answer 26

Lower 2 posterior intercostal arteries

The 4 lumbar arteries

Question 27

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

Answer 27

The veins radiate out from the umbilicus to drain into the femoral and external iliac veins inferiorly and the internal thoracic and axillary veins superiorly.
Para-umbilical veins connect the system through the umbilicus to the portal veins of the liver
The superficial epigastric and superficial circumflex iliac veins drain in to the proximal end of the great (long) saphenous vein along with the superficial and deep external pudendal veins; these 4 veins are important in varicose vein surgery

Question 28

What vessel forms the portosystemic venous anastomosis?

What is the result of obstruction of this vessel?

Answer 28

Para-umbilical veins connect the system through the umbilicus to the portal veins of the liver
If obstructed, resulting in Caput Medusae

Question 29

What is the superficial lymphatic drainage of the abdominal wall?

Answer 29

Anteriorly:
Above umbilicus –> Axillary nodes (Anterior/pectoral group)
Below umbilicus –> Superficial inguinal nodes

Posteriorly:
Above iliac crest –> Axillary nodes (Posterior/ subscapular group)
Below iliac crest –> Superficial inguinal nodes

Question 30

What is the lymph drainage pathway after the superficial inguinal nodes?

Answer 30

The superficial nodes drain to the deep inguinal nodes (in the femoral canal), which drain to external iliac and then para-aortic nodes

Question 31

What is the lymph drainage of the deep abdominal wall?

Answer 31

Inferiorly: To external iliac and then para-aortic nodes

Superiorly: To parasternal nodes alongside the internal thoracic artery and then mediastinal nodes

Question 32

Which parts of the contractile tissue of GIT ISN’T smooth muscle?

Answer 32

Pharynx
Upper third of oesophagus
External sphincter