Abd and peritoneum Flashcards
Site of inguinal hernia
above inguinal ligament
also site for passage of spermatic cord in males and round ligament of uterus in female
Site of femoral hernia
below inguinal ligament
also the site for passage of femoral artery, vein, nerve, etc
External abdominal oblique m. - origins
Superficial aspects of lower 8 ribs
Iliac crest, linea alba, pubic tubercle
Internal abdominal oblique m - origins
- Thoracolumbar fascia, iliac crest, inguinal ligament
- Costal cartilages of last 3-4 ribs, linea alba, pubic crest, pecten pubis
Transversus abdominis - origins
- Internal aspects of lower 6 costa cartilages, thoracolumbar fascia, iliac crest and inguinal ligament
- Linea alba, pubic crest, pecten pubis
Rectus abdominis m. - origins
- Pubic symphysis, pubic crest
- Anterior aspect of xiphoid process, ant aspects of costal cartilages 5-7
Tendinous intersections
Separations in the Rectus abdominis m.
Arcuate Line
Above: Posterior rectus sheath (transversus abdominis and Internal abdominal oblique tendons)
Below: No posterior rectus sheath!; just transversalis fascia. All 3 tendons jump on front of muscle (with external abdominal oblique).
“Little Pilot”
Gubernaculum; aids in the descent of the gonads.
-becomes round ligament of uterus in females
Spermatic cord covering - layers
- Extermal spermatic fascia (continuation of external abdominal oblique fascia)
- Cremaster muscle & fascia (from internal abdominal oblique fascia)
- Internal spermatic fascia (transversalis fascia)
- Tunica vaginalis (peritoneum)
Transversus abdominis doesn’t contribute.
75% of Anterior Abdominal Hernias
Superficial Inguinal ring
Direct Inguinal Hernia
- Pass directly through superficial ring
- Medial to inferior epigastric artery
- 25% of all hernias (1/3 of inguinal hernias)
Indirect Inguinal Hernia
- Passes through deep ring, inguinal canal, superficial ring
- Lateral to inferior epigastric artery
- 50% of all hernias; 7x more likely in males
- Can be congenital
Horizontal planes
a. Subcostal - L3
b. Transtubercular (between two tubercles on iliac crest) - L5
Vertical planes
c. Midclavicular/midinguinal (linea semilunaris)
What lies in the peritoneal cavity?
Nothing! (except serous fluid.
visceral peritoneum in contact with organs, parietal layer towards body wall.
Mesentery
Double layer of peritoneum
- often called “ligaments”
- Carry arteries, veins, nerves and/or lymphatics
Omentum
Double layer of peritoneum joining two viscera (usually associated with stomach and duodenum)
Intraperitoneal structure
Abdominal structure suspended by a mesentery.
They do NOT lie inside the peritoneal cavity
Ex: stomach, spleen, jejunum, ileum, transverse colon
Retroperitoneal structure
Abdominal structure not suspended by a mesentery - behind peritoneum.
Primary was not suspended by a mesentery earlier in development.
Secondary Retroperitoneal Structure
An abdominal structure suspended by a mesentery earlier in development
Ex: pancrease, ascending and descending colon.
Peritoneal Sacs
Lesser = behind stomach & liver, lesser omentum, greater omentum Greater = everywhere else
Connected by epiploic foramen (Foramen of Winslow)
Esophageal Constriction -Junction of Pharynx & esophagus (Cervical)
Vertebral Level = C6
Structures assoc = Cricopharyngeus m., clinically: upper esophageal sphincter
Esophageal Constriction - Aortic Arch
Vertebral Level = T5
Structures assoc = Sternal angle
Esophageal Constriction - Left Main Bronchus
Vert Level = T5-T6
Structures assoc = Tracheal bifurcation
Esophageal Constriction - Left atrium
Vert Level = T6-T7
Struct assoc = Heart
Esophageal Constriction - Hiatus
Vert Level = T10
Structures Assoc = Diaphragm: Lower esoph sphincter, phrenicoesophageal ligament, z line
Hiatal Hernia
Protrusion of stomach into mediastinum via esophageal hiatus.
Caused by weakened muscular part of diaphragm, widening of hiatus
Paraesophageal Hernia
- Less common
- Cardia remains in position
- NO REGURGITATION
Sliding Hiatal Hernia
- MOST COMMON!
- Abdominal part of esophagus, cardia, and parts of fundus slide superiorly
- Regurgitation: claming of right crus.
Upper Esophagus
A: Inferior Thyroid A.
V: Inferior Thyroid V.
L: Cervical and Jugular Trunks
Middle Esophagus
A: Descending Aorta
V: Azygos System (SYSTEMIC system)
L: Bronchomediastinal Trunks
Lower Esophagus
A: Left gastric & Left inferior phrenic A.
V: Left gastric V. (PORTAL system)
L: Superior diaphragmatic nodes, left gastric & celiac
Esophageal Innervation
-Anterior & Posterior Vagal Trunks - GVE to smooth muscle fibers
-Thoracic Sympathetic Trunks - Greater Splanchnic N: T5-T9 ; GVA (pain)
Celiac ganglion
GERD
Incompetent lower esophageal sphincter
Achalasia
Smooth m. sphincter fails to relax; difficulty swallowing
- similar to “Hirschsprung’s Disease” - absence of terminal parasymp. ganglia
Regions of the Stomach
Cardia, Cardial notch/orifice, Fundus, Body, Pyloric Area (pyloric antrum, pyloric canal), lesser curvature, greater curvature
Z-line
Change esophageal to gastric mucosa
-esophagogastric junction: T11
Lesser Omentum
- lesser curvature
- Gastrohepatic Ligament
- Hepatoduodenal Ligament
- Gastric Arteries (Left from celiac trunk and RIght from common hepatic)
Greater Omentum
- Greater Curvature
- Gastrophrenic Ligament
- Gastrosplenic Ligament
- Gastrocolic Ligament
- Gastro-omental arteries (Left from splenic, right from gastroduodenal), short gastric (From splenic)
Branches of Celiac Trunk (T12)
- Left gastric a.
- Splenic `a.
- Common hepatic a.
Stomach - Venous Drainage
- R&L Gastric veins: from hepatic portal vein (left gastric anastomoses w/ esophageal)
- Short Gastric & Left Gastro-omental Veins (from Splenic V)
- Right Gastro-omental (superior mesenteric V)
Hepatic Portal Vein
= Splenic Vein + Superior Mesenteric Vein
Stomach Nerves - Sympathetic
- T6-T9
- Via Greater Splanchnic Nerve
- -Celiac plexus: inhibit gastric juices/ decrease motility, contract pyloric sphincter
- GVA (visceral sensory: pain)
Stomach Nerves - Parasympathetic
-Anterior & Posterior Vagal Trunk
Spleen - borders
Anterior: Stomach
Posterior: Diaphragm
Inferior: Splenic flexus (L. colic)
Medial: Left kidney
At rib levels: T9-T11
Spleen - Irrigation
- Splenic artery
- tributary v –> splenic vein + IMV + SMV –> portal vein
Spleen - Innervation
Celiac plexus (Sympathetic): vasomotor
Spleen - Lymphatic
Splenic (LN hilum) –> pancreaticosplenic LN –> celiac t
Subphrenic Recess
Between diaphragm and anterior & superior aspects of diaphragmatic surface of liver
Hepatorenal Recess
- Morison’s Pouch
- Between liver and kidney + adrenal gland
- communicates anteriorly with subphrenic recess
- Potential space for infections hiding; esp if gallbladder bursts
Portal Triad: Porta Hepatis
- Hepatic artery (ant L)
- Bile duct (ant R)
- Portal vein (post)
- -> Hepatoduodenal Ligament - from liver to first 2cm of 1st part of duodenum
- in Lesser Omentum (sac)
Functional (Portal) Lobes
- Caudate Lobe (Seg I)
- Left Lobe (Seg II-IV)
- Right Lobe (Seg V-VIII)
each segment is supplied by 3ry branches of hepatic vessels and ducts - can remove one and still have functioning liver
Liver - Irrigation
- Hepatic artery (blood from aorta)
- Celiac trunk (T12-L1); common hepatic a, proper hepatic a, R&L hepatic a.
Portal Vein (splenic, SMV)
Liver - Innervation
Hepatic Nerve Plexus
- Celiac plexus (sympathetic fibers; GVE, GVA)
- Vagal trunks (parasympathetic)
Gallbladder - Irrigation
Cystic A
Portal V
Cystohepatic Triangle (Calot’s)
Borders:
- Liver
- Cystic duct
- Common hepatic duct
Gallbladder - Innervation
- Celiac plexus (sympathetic; visc afferent/pain)
- Vagus (parasympathetic)
- Right Phrenic N (somatic afferent/sensory fibers)
Penetrating Ulcer/Erosion
Arterial erosion:
- posterior stomach wall: splenic artery
- lesser curvature: L gastric a.
- wall of 1st part duodenum: gastroduodenal a
Subphrenic abscesses
- Localized
- Ruptured appendices
- perforated duodenal ulcers
Hepatomegaly
- A rise in central venous pressure directly impacts the liver: enlarges and engorges
- Causes: CHF, bacterial disease, viral disease, tumors
