Abdomen Flashcards
Liposuction
Remove subcutaneous fat with a percutaneously placed suction tube and high vacuum pressures
Tubes inserted subdermally through small skin incisions
Closing abdominal skin incisions inferior to the umbilicus
Include membranous layer of subcutaneous tissue when suture bc of strength
What is between the membranous layer of subcutaneous tissue and the deep fascia covering the rictus abdominis and external oblique muscles
Potential space where fluid may accumulate (urine from ruptured urethra)
Where can fluid spread from between the membranous layer of subcutaneous tissue and deep fascia covering rictus abdominis and external oblique
Can spread superiorly
Can’t spread inferiorly into thigh bc the deep membranous later of subcutaneous tissues fuse with the deep fascia of the thigh along a line approximately 5.5cm inferior and parallel to the inguinal ligament
Why is the endoabdominal fascia of importance in surgery
Provides a plane that can be opened , enabling the surgeon to approach structures on or in the anterior aspect of the posterior abdominal wall , such as kidneys or bodies of lumbar vertebrae without entering the membranous peritoneal space between the transversalis fascia and the parietal peritoneum is used for placement of prostheses when repairing inguinal hernias
Space of bogros and what is it used for
Between the transversalis fascia and the parietal peritoneum
Placing prostheses when repairing inguinal hernias
Why is. a prominent abdomen normal in infants and young children
Abdomen contains a lot of air and anterolateral abdominal cavities are enlarging an their abdominal muscles gaining strength
What are the six common causes of abdominal protrusion
6F
Food, Fluid, Fat, Feces, Flatus, Fetus
What is inversion of the umbilicus a sign of
Increased intra abdominal pressure usually ascites or large mass , organometallic
Most obesity fat is what
Subcutaneous
But can be extraperitoneal
What happens when anterior abdominal muscles are underdeveloped or atrophy from aging or insufficient exercise
Insufficient tonus to resist the increased weight of a protuberant abdomen on the anterior pelvis. The pelvis tilts anteriorly at the hip joints when standing producing excessive lordosis of the lumbar spine
Where do anterolateral abdominal wall hernias occur
Places where something (vessels, spermatic cord) pierce the abdominal wall creating a potential weakness
Where do most hernias occur
Inguinal, umbilical, epigastric
Umbilical hernia
Think neonates (esp low birth weight) bc the anterior abdominal wall is weak in the umbilical reign, which had failed to close normally, causing a protrusion of the umbilicus
Sooo what causes umbilical hernia in baby
Increased abdominal pressure in the presence of weakness and incomplete closure of the anterior abdominal wall after ligation of the umbilical cord at birth
Acquired umbilical hernia
Most commonly in women and obese people
Extraperitoneal fat and,or peritoneum protrude into the hernial sac
Lines along which the fibers of the abdominal aponeurosis interlace are also potential sites of herniation(can have gaps where these fiber exchanges occur)
What is a common site of gaps where fiber exchange occurs
Midline or in the transition from aponeurosis to rectus sheath
What causes these gaps that hernias can happen at
Congenital, obesity stress, aging, surgical or traumatic wounds
Epigastric hernia
Through linea alba at midline between diploid process and the umbilicus
Usually just lobules of fat
Are epigastric hernias painful
YES especially when a nerve is compressed
Spigelian hernias
Along semilunar lines
Who gets spigelian hernias
People over 40 that are obese
In spigelian hernia what is in the sac
The hernial sac is composed of peritoneum and covered with only skin and fatty subcutaneous tissue, but may occur deep to muscle
Why are warm hands important when palpating the abdominal wall
Cold hands cause guarding
Is guarding voluntary of involuntary
Involuntary
What is guarding a sign of
Acute abdomen
-inflamed organ
Why do these spasms occur
Common nerve supply of the skin and muscles of the wall explain it
Protect viscera
What position is patient when palpating abdominal wall ..why
Supine with legs flexed slightly
To relax anterolateral abdominal wall
Hands at side with pillow under head
If legs are fully extended why is the anterolateral abdominal wal not relaxed
Deep fascia if the thighs pulls on the membranous layer of abdominal subcutaneous tissue, tensing the abdominal wall
Some people place their hands being their head when lying supine-is this ok for abdominal wall examination
No tightens the muscles and makes the examination difficult
How do you elicit the superficial abdominal reflex
Quickly stroking horizontally, lateral to medial, toward the umbilicus
Get contraction of the abdominal muscles
Who may not have a felt superficial abdominal reflex
Obese people
What is the superficial abdominal reflex in people with abdominal skin injury
Rapid reflex contraction of the abdominal muscles
What nerves approach the abdominal musculature separately to provide the multisegmental innervates of the abdominal muscles
Inferior thoracic spinal nerves (t7-t12)
Iliohypogastric and ilioinguinal nerves(L1)
What is the course of the inferior thoracic spinal nerves and iliohypogastric and ilioinguinal nerves on the abdomen
Across the anterolateral abdominal wall where they run oblique but mostly horizontal courses
Where and when are the inferior thoracic spinal nerves and iliohypogastric and ilioinguinal nerves susceptible to injury
Surgery or trauma at any even of the abdominal wall
What happens if get injury of the anterolateral abdominal wall
Weakening of the muscles.
What is a risk of an oblique subcostal incision used for liver ,pancreas surgery
Enervation of part of the abdominal wall if the nerves are not carefully identified and spared
What does weakness in the inguinal region cause
Predisposition of inguinal hernia
When making abdominal incisions, what is the ideal direction and spot
Follow cleavage lines in the skin
Take into account location of nerves and aponeurosis
Would a surgeon rather transact or split a muscle
Split in direction of fibers
What muscle can be safely transected
Its muscle fibers run short distances between tendinitis intersections and the segmental nerves supplying it enter the lateral part of the rectus sheath where they can be located and preserved
Are muscles and viscera retracted towards or away from their neuromuscular supply
Toward
Why may one or two small branches be cut without a noticeable loss of motor supply
Overlapping areas of interaction between nerves
What are two longitudinal incisions and when are they performed
Median and paramedian
Exploratory operations bc they offer good exposure of and access to the viscera and can be extended as necessary with minimal complication
Median incisions, made on linea alba from diploid to pubic symphysis. What is benefit
Can be made rapidly without cutting muscle, major blood vessels or nerves
Bad about median incision
Some people may have abundant and well vascularized fat
Poor blood supply so may undergo necrosis and subsequent degeneration after incision if edges not aligned properly during closure
Paramedian incision
Sagittarius plane and may extend front he costal margin to the pubic hairline
After incision passses through the anterior layer of the rectus sheath, the muscle is retracted laterallly without sectioning to prevent tension and injury to the vessels and nerves ….the posterior layer of the rectus sheath and the peritoneum are then incised to enter the peritoneal cavity
Gridiron(muscle splitting) incisions are used for what
Appendectomy
Describe the gridiron mcburney incision
At mcburney point 2.5 cm superomedial to the ASIS not he spinoumbilical line
The external oblique aponeurosis is incised inferomedially in the direction of its fibers and retracted
The musculocutaneous-aponeurotic fibers of the internal oblique and trans versus abdominis are then split int he line of their fibers and retracted
During appendectomy the __ nerve is identified and preserved
Iliohypogastric
During appendectomy, there should be no cut of musculo-aponeurosis fibers. Why is this important
When incision is closed the muscle fibers move together and the abdominal wall is as strong after the operation as before
Suprapubic incision are made where
Pubic hair Line
Why do a suprapubic incision
Gyno
And obstetrical operations (c section)
How do a suprapubic incision
Linea alba and anterior layers of the rectus heaths are transected and respected superiorly and the rectus muscles are retracted laterally or divided through their tendinitis parts allowing reattachment without muscle fiber injury
What nerves need to be identified and preserved in suprapubic incision
Iliohypogastric and ilioinguinal
___ incisions through the anterior layer of the rectus sheath and rectus abdominis provide good access and cause the least possible damage to the nerve supply of the rectus abdominis
Transverse incision
Why may the recut abdominis be cut transversely without damage
New transverse band forms when the msucle segments are rejoined.
Transverse segments are not made through the tendinous intersections why
Cutaneous nerves and branches of their superior epigastric vessels pierce these fibrous regions of the msucle
What do we use subcostal incisions for
Gallbladder and biliary duct on the right and spleen on the left
Describe subcostal incision
Paralelll but 2.5 cm inferior to the costal margin to avoid the 7th and 8th thoracic spinal nerves
What are high risk incisions
Pararectus and inguinal incisions
What is a pararectal incision
Along the lateral border of the rectus sheath
Why is a pararectal incision risky
Maycut nerve supply to rectus abdominis
What are inguinal incisions for and why are they risky
Repairing hernias
May injure the ilioinguinal nerve
Incisional hernia
Protrusion of omentum( a fold of peritoneum) or an organ through a surgical incision
What causes incisional hernia
Muscular and aponeurotic layers of the abdomen do not heal properly
Laparascope
For minimally invasive surgery
Tiny perforations of the abdominal wall allow the entry of the instruments operated externally, replacing the larger conventional incisions
What does minimally invasive surgery minimize
Hernia, nerve injury, contamination, time to heal
If the superior or inferior vena cava is obstructed what happens
Anastomoses between the tributaries of these systemic veins such as the thoraco-epigastric vein, may provide collateral pathways by which the obstruction may be bypassed allowing blood to return to the heart
When inferior or superior vena cava obstructed, what two veins can you see cutaneously from increased flow
Superficial epigastric vein
Thoraco epigastric vein
Cryptorchid
Undescended testis
Cryptorchid is in _ % of full term infants and _% of preterm
3
30
95% of undescended testes are ___
Unilateral
Where is the undescended teste
Along the normal path of its prenatal descent, commonly in the inguinal canal
People with cryptorchid said are at increased risk of what
Malignancy in undescended testis bc it is not palpable and not detected until cancer has progressed
And
Infertility-needs cooler environment
How correct cryptorchid
Surgery corrected in childhood
What does the umbilical vein become after birth
Round ligament of the liver
The umbilical vein is patent for some time after birth. What is this used for
Umbilical vein catheteriation for exchange transfusion during early infancy
Why may we do exchange transfusion through umbilical vein in infant
Erythroblastosis fetealis or hemolytic anemia disease of the neonate
In metastese of the uterus, the veins and lymph vessels mostly drain via ____ routes
Deep
However some lymphatic vessels from uterus follow the course of what
Round ligament through the inguinal canal
So where do uterine cancers metastecize
Deep more often
Or TO THE LABIUM MAJUS and from there to the superficial inguinal nodes which receive lymph from the skin of the perineum (and labia)
Where are the majority of abdominal hernias
Inguinal hernias 75%
Are inguinal hernias more common in males or females
Males bc of the passage of the spermatic cord through the inguinal canal
What is an inguinal hernia
Protrusion of parietal peritoneum and viscera, such as the small intestine through a normal or abnormal opening from the cavity in which they belong
Two types of inguinal hernia
Direct and indirect
Are most hernias direct or indirect
Indirect
Indirect (congenital ) hernia predisposing factors
Patency of processus vaginalis (complete of at least superior part) in younger persons, the great majority which are males
Indirect (congenital) frequency
2/3 of inguinal hernias
Indirect (congenital) exit from abdominal cavity
Peritoneum of persistent processus vaginalis plus all three fascial coverings of cord/round ligament
Indirect (congenital) course
Traverse inguinal canal (entire canal if it is of sufficient size)
Indirect (congenital) exit from anterior abdominal wall
Via superficial ring inside cord, commonly passing into scrotum/labium majus
Direct (acquired) hernia predisposing factors
Weakness of anterior abdominal walll in inguinal triangle (eg owing to distended superficial ring, narrow inguinal falx, or attenuation of aponeurosis in males>40 )
Direct (acquired) hernia frequency
1/3
Direct (acquired) exit from abdominal cavity
Peritoneum plus transversalis fascia (lies outside inner one or two fascial coverings of cord)
Direct (acquired) hernia course
Passes through or around the inguinal canal, usually transversing only medial third of canal , external and parallel to vestige of processus vaginalis
Direct (acquired) exit from anterior abdominal wall
Via superficial ring, lateral cord ; rarely enter scrotum
Normally, most of the processus vaginalis obliterates before birth, except what part
Distal part that forms the tunica vaginalis of the testis
The peritoneal part of the hernial sac of an indirect hernia is formed by the persisting ___ ___
Processus vaginalis
What happens if entire stalk of the processus vaginalis persists
Hernia extends into the scrotum superior to the testis forming a complete indirect inguinal hernia
Where is the superficial inguinal ring palpable
Superolateral to the pubic tubercle by invaginating the skin of the upper scrotum with the index finger . The examiners finger follows the spermatic cord superolateral to the superficial inguinal ring.
Is the finger able to go into the superficial inguinal ring
If it is dilated
While palpating the superficial inguinal ring, how can you tell if a hernia is present
Ask patient to cough and a hernia is present if feel a sudden impulse felt against either the tip or pad of the examining finger when the patient is asked to cough
Does feeling an impulse at the superficial inguinal ring mean a direct or indirect hernia
Both types go through superficial inguinal ring…cant discriminate
How can you feel the deep inguinal ring
With palmar surface of the finger against the anterior abdominal wall, the deep inguinal ring may be felt as a skin depression superior to the inguinal ligament 2-4 cm superolateral to the pubic tubercle.
What indicates an indirect hernia
Detection of impulse at superficial ring and a mass at the site of the deep ring
Cremasteric reflex
Contraction of the cremaster muscle is elicited by lightly stroking the skin on the medial aspect of the superior part of the thigh with an applicator stick or tongue depressor
What nerve supplies the skin of the superior part of the thigh
Ilioinguinal nerve
The cremasteric reflex is extremely active in ___
Kids
Hyperactive cremasteric reflexes mat stimulate ___ ___
Undescended testes
How can you abolish hyperactive reflex in kid
Sit cross legged , squatting position
Why would you want to abolish a hyperactive cremasteric reflex in kid
If the testes are descended can then palpate them int he scrotum
Indirect inguinal hernias are 20x more common in __
Men
What happens if processus vaginalis is patent in females
May form a small peritoneal pouch (canal of nuck) in the inguinal canal that may extend to the labium majus
Clinical picture of patent processus vaginalis in females
Can enlarge and form cysts in the inguinal canal
Cyst may produce a bulge in the anterior part of the labium majus and have the potential to develop into an indirect inguinal hernia
Hydrocele
Presence of excess fluid in a persistent processus vaginalis
What is a hydrocele associated with
Indirect hernia
What is the fluid from in a hydrocele
Secretion of an abnormal amount of serous fluid from the visceral layer of the tunica vaginalis
The hydrocele of the testis is confined to the ___ and distended the tunica vaginalis
Scrotum
The hydrocele of the spermatic cord is confined to the ___ ___ and distended the persistent part of the stalk of the processus vaginalis
Spermatic cord
A congenital hydrocele of the cord and testis may communicate with the ___ ___
Peritoneal cavity
How do you detect hydrocele
Transillumination ….bright light applied to scrotum in darkened room
If have hydrocele what color does scrotum glow …indicating excess serous fluid
Red
Newborn male infants often have residual peritoneal fluid in their tunica vaginalis. However it is absorbed in the _ year
1st
What may cause hydrocele in adults
Certain pathological conditions, such as injury and/or inflammation of the epididymis
Hematocele of testis
Collection of blood in the tunica vaginalis
What causes hematocele of the testis
Trauma may produce a scrotal and/or testicular hematoma (accumulation of blood)
Transillumination of hematocele
Does not transilluminate
A hematocele of the testis may be associated with a scrotal hematocele resulting from effusion of blood into he scrotal tissues
Yup
Torsion of the spermatic cord
Surgical emergency bc of necrosis
Why get necrosis with torsion of spermatic cord
Blocks the venous drainage with resultant edema and hemorrhage and subsequent arterial obstruction
Where is the twisting in torsion spermatic cord
Just above the upper pole of the testis
Clinical prevention of torsion of spermatic cord
Testis seem to lie transversely
See with ultrasound to confirm
How prevent recurrence of spermatic cord torsion
Both testes are surgically fixed to the scrotal septum
The anterolateral surface of the scrotum is supplied by the __ __ and the posteroinferior aspect is supplied by the __ ___
Lumbar plexus (mainly L1 fibers via ilioinguinal nerve)
Sacral plexus (primarily s3 fibers via pudendal nerve)
A spinal anesthetic agent must be injected more ___ to anesthetize the anterolateral surface of the scrotum than is necessary to anesthetize its postero-inferior surface
Superiorly
Spermatocele
Retention cyst in the epididymis usually near its head
What is in a spermatocele
Milky fluid and generally asymptomatic
What is an epididymal cyst
Collection of fluid anywhere in the epididymis
When the tunica vaginalis is open what is seen
Rudimentary structures may be observed at the superior aspects of the testes and epididymis —-small remnants of genital ducts in the embryo-rarely observed unless pathological changes occur
Appendix of the testis
Vesicular remnant of the cranial end of the paramesonephric duct (mullerian) the embryonic genital duct that in the female forms half of the uterus . It is attached to the upper pole of the testis
Appendix of the epididymis
Remnants of the cranial end of the mesonephric duct (wolffian), the embryonic genital duct that in the male forms part of the ductus deferens. The appendices are attached to the head of the epididymis
Varicocele
Vine like pampiniform plexus of veins may become dilated (varicose) and tortuous, producing varicocele
When is varicocele visible when is it not visible
When man is standing or straining when lying down alllowing gravity to empty veins
What does palpating a varicocele feel like
Bag of worms
What amuses varicocele
Defective valves in the testicular vein, but kidney or renal vein problems can also result in distension of the pampiniform veins
Which side does varicocele happen on. Why
Left
Acute angle at which the right vein enters the IVC is more favorable to flow than the nearly 90 degree angle at which the left testicular vein enters the left renal vein, making it more susceptible to obstruction or reversal of flow
___ metastasis is common to all testicular tumors
Lymphogenous
Bc the testes relocate from the posterior abdominal wall to the scrotum during fetal development, their lymphatic drainage differed from that of the scrotum which is an outpouching of anterolateral abdominal skin.
Ya
How does cancer of the testes spread
Metastasizes initially to the retroperitoneal lumbar lymph nodes, which lie just inferior to the renal veins . Subsequent spread may be to mediastinal and supraclavicular nodes
How does cancer of the scrotum spread
Metasticize to the superficial inguinal lymph nodes, which lie in the subcutaneous tissue inferior to the inguinal ligament and along the terminal part of the great saphenups vein
How do surgeons approach testicular tumors
Through an inguinal incision so that vessels and lymphatics can be controlled early.
Why is a classic pitfall of approaching a testicular tumor going through a scrotal incision , why would u do this
Think its a hydrocele (use ultrasound to check )
Metastasis of testicular cancer hematogenous spread
To lungs liver brain and bone
How does the body limit spread of organisms from uterine tubes to peritoneal cavity
Mucus plug-blocks external os of uterus to most things, except sperm
How do we test latency of uterine tubes —hysterosalpingography
Air or radioopaque dye is injected into the uterine cavity from which it normally flows through the uterine tubes into the peritoneal cavity
Tests whether Fallopian tubes are blocked (important for fertility)
Why do patients undergoing abdominal surgery experience more pain with large invasive open incisions of the peritoneal mood than with small laparoscopic incisions
Peritoneum is well innervated
Reperitonealization
The visceral peritoneal (serosal)covering makes it easy to achieve a water tight anastomoses of intraperitoneal organs
Can surgeons easily achieve a water tight anastomoses or extraperitoneal organs
No harder if have adventitia, like the thoracic esophagus
Complications of opening the peritoneal cavity , how can we prevent
Peritonitis
Adhesions
Even in surgeries where open peritoneal cavity-try to remain outside..lets limit contamination of the cavity
How get peritonitis
Bacterial contamination during laparotomy or when gut traumatically Penetrated or ruptured as a result of infection or inflammation, allowing gas fecal matter and bacteria to enter peritoneal cavity
What does peritonitis cause
Exudation of serum, fibrin, cells and pus into the peritoneal cavity accompanied by pain in overlying skin and increase in tone of the anterolateral abdominal muscles
Why is generalized(widespread) peritonitis dangerous
Extent of peritoneal surface and rapid absorption
Signs of generalized peritonitis
Severe abdominal pain, vomiting, fever, constipation
How can an ulcer ofthe stomach or duodenum cause general peritonitis
Perforate the wall of stomach of duodenum , spilling acidic contents into peritoneal cavity
Ascetic fluid
Extra fluid in peritoneal cavity
What causes ascites
Mechanical injury , portal hypertension, widespread metastasis, starvation (plasma protein fall)
What is the normal rhythmic movement of the anterolateral abdominal wall normally accompanying respiration’s
Abdomen drawn in and chest deflates
Abdomen drawn out and chest expands
What rhythmic movement of the anterlateral abdominal wall is present if there is peritonitis or pneumonitis
Paradoxical
Abdomen drawn in and chest expands
How do patients lay when they have peritonitis and why
With knees plexus to relax their anterolateral abdominal muscles
Bc of pain
How do patients breathe when they have peritonitis
Slowly and more rapidly to minimize intrabadominal pressure and pain
The suction effect of the diaphragm during respiration draws fluid into what space. Why is this a problem with peritonitis
Subphrenic space
Subphrenic recess is a frequent complication of peritonitis
If the peritoneum is damaged, the peritoneal surface becomes inflamed, making them sticky with ___
Fibrin
When the peritoneum heals from a wound, the fibrin may be replaced by what. Why is this a problem
Fibrous tissue, forming abnormal attachments between the visceral peritoneum of adjacent viscera or between the visceral peritoneum of an organ and the parietal peritoneum of the adjacent abdominal wall
Adhesion
Scar tissue form after an abdominal operation and limit normal movement of the viscera
Clinical issue of adhesions
Limit movement of viscera
Chronic pain
Intestinal obstruction when the intestinal becomes twisted around an adhesion
Volvulus
Intestinal obstruction when the intestine becomes twisted around an adhesion
Adhesiolysis
Surgical separation of adhesions
Most cases of peritonitis are secondary, what does this mean
Have a surgical cause
Ascites can result from __ of the liver or in association with malignancy
Cirrhosis
How may one get primary peritonitis
People with chronic ascites, such as in cirrhosis, in which the ascites become infected without surgical cause
How treat generalized peritonitis
Removal of the ascitic fluid and diagnosis(culture)—-ANTIBIOTICS
Paraccentesis
Surgical puncture of the peritoneal cavity for the aspiration or drainage of the fluid
In paracentesis, where is the needle and cannula inserted
Anterolateral abdominal wall through linea alba superior to the empty urinary bladder in a location that avoids the inferior epigastric artery
Why is fluid that is injected into the peritoneal cavity absorbed rapidly
The peritoneum is a semipermeable membrane with an extensive surface area, much of which overlies blood and lymphatic capillary beds
In __ failure, waste products such as urea accumulate in the blood and tissues and may reach fatal levels
Renal
Peritoneal dialysis
Soluble substances and excess water are removed from the system by transfer across the peritoneum, using a dilute sterile solution that is introduced into the peritoneal cavity on one side then drained from the other side . Diffusable solutes and water are transferred between the blood and peritoneal cavity as a result of concentration gradients between the two fluid compartments.
Lon term peritoneal dialysis?
Prefer to go through blood using renal dialysis machine
What is the greater omentum. What does it do
Large and fat laden double layer of peritoneum that attaches stomach to another viscous. It hangs from the greater curvature of the stomach.
It prevents the visceral peritoneum from adhering to the parietal peritoneum.
Why is the greater omentumcalled the “policeman if the abdomen”
Goes to the site of trouble. Forms adhesions adjacent to inflamed organ such as appendix , sometimes walling it off and protecting other viscera from it
When doing surgery is it common to find the omentum displaced
Yup
What else does the greater omentum do
Cushions abdominal organs and forms insulation against loss of body heat
Lesser omentum
Attaches the lesser curvature of the stomach to the liver superiorly
Perforation of the duodenal ulcer, rupture of the gallbladder, or perforation of the appendix may lead to the formation of an ____ in the __ ___
Abscess in the subphrenic recess
An abscess in the subphrenic recess may be walled inferiorly by adhesions of the __ __
Greater omentum
What determines the extent and direction of spread of fluids that may enter the peritoneal cavity
Peritoneal recesses
What are paracolic gutters
Spaces between colon and abdominal wall
Why are paracolic gutters of clinical importance
Provide pathways for the flow of ascitic fluid and the spread of intraperitoneal infections
Purluent material in the abdomen can be transported along the paracolic gutters into the _____, especially when the person is ___
Pelvis
Upright
Why would someone with peritonitis be placed in the sitting position
To facilitate flow of exudate into the pelvic cavity where absorption of toxins is easy to drain
Infections of the pelvis may extend superiorly to the ___ ___ situated under the diaphragm especially when they are ___
Subphrenic recess
Supine
Paracolic gutters and spread of cancer?
YES
Pathway for spread of cancer cells that have sloughed from the ulcerated surface of a tumor and entered the peritoneal cavity
Perforation of the posterior wall of the stomach results in passage of its fluid into the __ __
Omental bursa
What is the omental bursa
The lesser sac
Cavity in abdomen formed by the lesser and greater omentum
What connects the lesser sac to the greater sac
Omental foremen (foramen of Winslow)
An inflamed or injured pancreas can also result in the passage of the pancreatic fluid into the bursa forming a ___ ___
Pancreatic pseudocyst
Can any boundaries of the omental foramen be incised
No all contain vessels
Sometimes a loop of small intestine may pass through the omental foramen….how fix this if cant cut any of the walls
Swollen intestine must be decompressed using a needle so it can be returned to the greater sac of the peritoneal cavity through the omental foramen
What is the greater sac
Inside the peritoneum but outside the lesser sac (the general cavity)
The __ artery must be lighted or clamped during cholecystectomy
Cystic
What is a cholecystectomy
Removal of gallbladder
What do if accidentally sever the cystic artery
Control bleeding by compressing hepatic artery as it transverse the hepatoduodenal ligament
Place index finger in omental foramen and thumb on anterior wall
Alternating compression and relaxation allows surgeon to identify bleeding artery and clamp it.
Pringle manuever
Alternate compression and release of pressure on the hepatic artery allows the surgeon to identify the bleeding artery and clamp it….. sometimes to provide temporary control during cases of severe trauma to the liver or associated structures
Because the submucosal veins of the inferior esophagus drain to both the __ and ___ venous systems, they constitute what
Portal
Systemis
Portosystemic anastomsis
Describe portal hypertension
Increased blood pressure in the portal venous system
Blood is unable to pass through the liver vie the hepatic portal vein, causing a reversal of flow in the esophageal tributary
What does the large volume of blood causes the submucosal veins to enlarge markedly. What is this
Esophageal varices
Concern with esophageal varices
Distended collateral channels may rupture and cause severe hemorrhage that is life threatening and difficult to control surgically
What population commonly gets esophageal varices
Alcoholic cirrhosis
Pyrosis
Heart burn
Pyrosis in abdominal part of esophagus is result of what
GERD
Pyrosis may also be associated with __ hernia
Hiatal
Pyrosisis is commonly perceived as what
Chest sensation
Why do bariatric surgery
Morbidly obese people to achieve weight loss
Restrictive bariatric surgery
Reducing stomach volume
Malabsorptive bariatric procedures
Reducing nutrient absorptive area
Rerouting of the connection of the stomach with the small intestine and,or variable portions of the small intestine
Mixed bariatric procedure
Combination
Gastric bypass
Banding
Fixed or adjustable bands externally to the stomach
Fundoplication
Resectioning of the stomach creating a small pouch or tubular sleeve or folding of the stomach on itself
Bariatric surgery benefits
Weight loss
Reduce diabetes and sleep apnea
Do you have to eat healthy after bariatric surgery
YES important factor for success
Complications of bariatric surgery
Common
Why may the stomach be displaced anteriorly
Pancreatic pseudocysts and abscesses in the omental bursa may push the stomach anteriorly
Following pancreatitis, the posterior wall of the stomach may adhere to the part of the posterior wall of the __ ___ that covers the pancreas
Omental bursa
Hiatal hernia
Protrusion of part of the stomach into the mediastinum through the esophageal hiatus of the diaphragm
Who gets haital hernias and why
After middle age bc of weakening of muscular part of the diaphragm and widening of the esophageal hiatus
Two main types of hiatal hernia
Paraesophageal and sliding
Which hiatal hernia is more common
Sliding
Paraesophageal hernia
Cardia remains in its normal position
However, a pouch of peritoneum, often containing part of the fungus of the stomach( phreno-esophageal ligament), extends through the esophageal hiatus anterior to the esophagus.
Is there regurgitation of gastric contental in para esophageal hernia
No bc cardinal orifice is in its normal position
Sliding hiatal hernia
Abdominal part of the esophagus, the cardia, and parts of the fungus of the stomach slide superiorly through the esophageal hiatus into the thorax, especially when the person lies down or bends over
Is there regurgitation of stomach contents into the esophagus with a sliding hiatal hernia
Ya
Bc clamping action of the right crus of the diaphragm on the inferior end of the esophagus is weak
Pylorospasm
Spasmodic contraction of the pyloric occurring in infants 2-12 weeks
Characterization of pylorospasm
Failure of the smooth muscle fibers encircling the pyloric canal to relax normally so food can not pass easily from stomach into duodenum and stomach becomes overly full—-discomfort and vomiting
Congenital hypertrophic pyloric stenosis
Thickening of the smooth muscle in the pylorus that affects 1/150 male infants and 1/750 female infants
Normally the gastric peristalsis pushes chyme through the pyloric canal and orifice into the small intestine at irregular intervals. What about in neonates with pyloric stenosis
Elongated overgrown pyloric canal is narrow resisting gastric emptying . Proximally the stomach may become secondarily dilated
Genetic congenital hypertrophic pyloric stenosis
Yea bc common in monozygotic twins
Pyloromyotomy
Pyloric stenosis surgery in which cut through hypertrophied circular muscle layer of the pylorus allowing free passage
Can you palpate a stomach tumor
Yea sometimes
Gastroscope
Can look at mucosa and take biopsies
Surgical issue with stomach cancer
Extensive lymphatic drainage of the stomach and the impossibility of removing all the lymph nodes
How excise nodes along splenic vessels
Remove spleen , gastrosplenic, and splenorenal ligaments and body and tail of pancreas
How remove gastro-omental nodes
Respecting the greater omentum however hard to remove aortic and celiac nodes and those around head of pancreas
Most gastric cancers are detected too late for surgical control
:(
Total gastrectomy
Total removal of stomach
Partial gastrectomy
Remove region involved in carcinoma
Why is it ok to legate one or more arteries during partial gastrectomy
Because the anastomoses of the arteries supplying the stomach provide good collateral circulation, without seriously affecting the blood supply
Removing pyloric antrum
Cut greater omentum parallel and inferior to the right gastro-omental artery requiring ligation of the omental branches of the artery
But omentum doesn’t degenerates bc of anastomoses such as the omental branches of left gastro-omental arteries
If dealing with cancer important to remove lymph nodes. What lymph nodes drain pyloric region need to be removed
Pyloric lymph nodes and gastro-omental nodes
As stomach cancer becomes more advanced, the malignant cells spread to the ___ nodes, to which all gastric nodes drain
Celiac
Most ulcers of the stomach and duodenum are associated with ______
H pylori
People with extreme emotions chronic ___ are at risk for peptic ulcer
Anxiety
Why are anxious people prone to peptic ulcers
High gastric acid secretion rates that are markedly higher than normal between meals
Overwhelms bicarbonate
And reduces effectiveness of mucous lining , leaving it vulnerable to h pylori
What does h pylori do
Bacteria erode the protective mucous lining of the stomach , inflaming the mucosa and making it vulnerable to the effects of the gastric acid and digestive enzymes (pepsin) produced by the stomach
What happens if the ulcer erodes into the gastric arteries
Can cause life threatening bleeding
How can we reduce production of acid
Vagotomy
Vagotomy
Surgical section of vagus nerves-bc the vagus nerves control secretion of acid by parietal cells of the stomach
Treatment for h pylori
Vagotomy maybe with resection of an ulcerated area to reduce acid secretion
Truncal vagotomy
Surgical section of vagaries trunk
Rarely done bc innervates other abdominal structures
Selective proximal vagotomy
Denervate even more specifically the area in which the parietal cells are located, hoping to affect the acid producing cells while sparing other gastric function (motility) stimulated by the vagus nerve
Posterior gastric ulcer may erode through the stomach wall into the ____, resulting in referred pain to the ___
Pancreas
Back
What artery is of concern with posterior gastric ulcer erosion and why
Splenic artery may cause severe hemorrhage into peritoneal cavity
Pain impulses from the stomach are carried by visceral afferent fibers that accompany ____ nerves . How know this
Sympathetic
Pain in recurrent peptic ulcer sometimes persisted after complete vagotomy, whereas patients who had bilateral sympathectomy could have perforated peptic ulcer with no pain
Organic pain
From organ
Varies from dull to severe
Poorly localized
Radiates to the dermatologist level which receives visceral afferent fibers from the organ concerned
Visceral referred pain from gastric ulcer
Referred to the epigastric region bc the stomach is supplied by pain afferent that reach the T7 and T8 spinal sensory ganglia and spinal cord segments through the greater splanchnic nerve
Pain from the parietal peritoneum is ____ and usually severe and the site of origin can be ___
Somatic
Site of origin can be localized
Why can parietal peritoneum pain be localized
Parietal peritoneum is supplied by somatic sensory fibers through thoracic nerves, whereas a viscous such as the appendix is supplied by visceral afferent fibers in theesser splanchnic nerve
Rebound tenderness
Finger into the anterolateral abdominal wall over inflammation the parietal peritoneum is stretched when remove finger feel extreme localized pain
Duodenal ulcer (peptic)
Inflammatory erosions of the duodenal mucosa
Most duodenal ulcers occur where
Posterior wall of the superior part of the duodenum within 3 cm of the pylorus
If duodenal ulcer (especially anterior) perforated the duodenal wall we get
Peritonitis
Since the liver, gallbladder, and pancreas are close to the duodenum, what happens if the duodenum is inflamed
Structures may become adherent
Ulcerated as the lesion continues to erode the tissue that surrounds it
Why may get severe hemorrhage from duodenal ulcer
Intraluminal bleeding
Or erosion of the gastroduodenal artery (posterior relation) by a perforating ulcer results in severe hemorrhage into the peritoneal cavity (hemoperitoneum)
During the early fetal period, the entire duodenum has a ____: however, most of it fuses with the posterior abdominal walll because of pressure from the overlying transverse colon
Mesentery
The attachment of the mesoduodenum is ___ why
Secondary
It occurred through formation of a fusion fascia
Secondary attachment allows the duodenum and pancreas to be __ during surgery
Separated from the retroperitoneal viscera without endangering the blood supply to the kidney or the ureter
Paraduodenal fold and fossa
Large and lie to the left of the ascending part of the duodenum. If a loop of intestine enters this fossa it may strangulate
Paraduodenal hernia repair what vein and artery must be avoided
Care taken to not injure the branches of the inferior mesenteric artery and vein or the ascending branches of the left colic artery
Primordial foregut comprises the __, ___ and ___
Foregut, midgut and hindgut
Pain arising from foregut derivatives, esophagus, stomach, pancreas, duodenum, liver, and biliary ducts, cause pain where
Epigastric region
Pain arising from midgut derivatives, small intestine distal to the bile duct, cecum, appendix, ascending colon, and most of transverse colon, localized where
Periumbilical region
Pain arising from hind gut derivatives, distal part of transverse colon, descending colon, sigmoid colon, and rectum, localized where
Hypogastric region
For 4 weeks, the rapidly growing midgut, supplied by the SMA, is physiologically herniated through the proximal part of the __ ___
Umbilical cord
It is attached to the umbilical vehicle by the __ __ _
Omphalo-enteric duct (yolk stalk)
As the relative size of liver and kidney decrease, the midgut returns to the abdominal cavity bc space is available
Woo
As the parts of the intestine reach their definitive positions their mesenteric attachments undergo modification. Some shorten, others disappear. As what organs become secondarily retroperitoneal
Duodenum, pancreas, ascending and descending colons
What are consequences of normal rotation of the midgut
-duodenum passes posterior to the SMA
-transverse colon and mesocolon are transversely oriented, pass anterior to the SMA and divide the peritoneal cavity into Supra and infracoloc compartments
-the ascending and descending colons lie on right and left sides and are RETROPERITONEAL
-most of the ileum occupies the left superolateral part of the infracolic compartment
-momost of the ileum, cecum, and appendix occupy the right inferolateral part of the infraacolic compartment
Malrotation of the midgut(intestine)
Several congenital anomalies such as volvulus of intestine
When doing surgery how feel which direction of intestine u are following (road or caudad)
Follow mesentary with finger to roots
Occlusion of vasa recta by emboli or atherosclerotic occlusion results in ___
Ischemia
If ischemia is severe
Necrosis of involved segment and ileus (bstruction of intestine) of the paralytic type
Ileus symptoms
Severe colicky pain with abdominal dissension, vomiting, and often fever and dehydration.
Emboli from the heart sent inferiorly via the descending aorta tend to lodge in the ___ or its branches . Why
SMA
Arises at a less acute angle than aorta
Ideal diverticula (meckel diverticulum)
Congenital anomaly that occurs in 1-2% of the population
What is the ideal diverticulum
Remnant of the proximal part of the embryonic omphalo-enteric duct (yolk stalk)
How does ideal diverticulum appear
Finger like pouch ALWAYS at the site of attachment of the omphalo-enteric duct on the antimesenteric border of the ileum
The diverticulum is usually 30-60cm from the ileocecal junction in ___ and 50 cm in ___
Infants adults
Is the ideal diverticulum more commonly free or attached to the umbilicus
Free
The mucosa of the ideal diverticulum is mostly ideal, but what else may be included
Acid producing gastric tissue, pancreatic tissue, or jejunal or colonic mucosa
What happens if ideal diverticulum becomes inflamed
Pain that mimics appendicitis
Retrocecal appendix
Extends superiorly toward the right colic flexor and is usually freely mobile
What happens if appendix if beneath the peritoneal covering of the Cecum. What is the problem
Fuse
If inflamed more difficult to remove
The appendix may also project inferiorly
Ok
Why do we care about anatomical position of appendix
Surgery
Also determines symptoms and side of muscular spasm and tenderness when the appendix is inflamed
Where is mcburney point
One third from ASIS to umbilicus ………careful if have a subhepatic cecum
Appendicitis
Acute inflammation of the appendix …common cause of acute abdomen
What usually causes appendicitis in young people
Hyperplasia of lymphatic follicles in the appendix that concludes the lumen obstruct the appendix
What causes appendicitis in older people
Obstruction from fecalith (coprolith) a concretion that forms around a center of fecal matter ..
What happens when the appendix is occluded
Secretions cant escape
The appendix swells
Stretching the visceral peritoneum
Initial pain of appendicitis
Vague pain in the periumbilical region because affferent pain fibers enter the spinal cord at T10
Later pain of appendicitis
Severe pain in the right lower quadrant from irritation of the parietal peritoneum liningthe posterior abdominal wall (usually formed by the peso as and iliacus muscles in the region of the appendix) so extending the thigh and hip may cause pain
Acute infection of the appendix may result in thrombosis in the ____ artery, which often results in ischemia, gangrene, and perforation of an inflamed appendix
Appendicular
Rupture of the appendix
Peritonitis
Abdominal pain
Nausea
Vomiting
Abdominal RIGIDITY
With appendicitis, why does flexion in the right thigh ameliorate pain
Relaxes the right spots muscle, a flexor of the thigh
How do an appendectomy
Gridiron incision perpendicular to the spino-umbilical line, but a transverse incision is also common
Laparoscopic (peritoneal cavity inflated with CO2)
During an appendectomy, what is the surgeon cant find the base of the appendix or appendix itself
Look for convergence of the three tenaie on the surface of the cecum after finding ileocecal valve
Why may the appendix not be in the lower right quadrant
Malrotation of the intestine
Failure of descent of the cecum
Where is the appendix when you have a high (subhepatic) cecum
Upper right hypochondriac region and pain localized there not the LRQ
What is appendicitis in late pregnancy
Will be displaced cephalad by the enlarging uterus
What happens when the inferior part of the ascending colon has mesentery
The cecum and proximal part of the colon are abnormally mobile
How many people have mobile ascending colon
11%
Mobile ascending colon may cause cecal bascule or cecal volvulus what are these
Cecal bascule-folding of the mobile cecum
Cecal volvulus-roll twist of mobile cecum
What is bad about cecal bascule or cecal volvulus
May obstruct the intestine
Cecopexy
Fixation
To avoid volvulus and possible obstruction of the colon
Tenia coli of the cecum and proximal ascending colon is sutured to the abdominal wall
Chrons and ulcerative cholitis
Chronic inflammation of the colon characterized by severe inflammation and ulceration of the colon and rectum
Colonectomy to my for chronic inflammation of colon
Terminal ileum and colon, and rectum and anal canal removed.
Ileostomy
Constructed to eestablish a stoma , an artificial opening of the ileum through the skin of the anterolateral abdominal wall
The terminating ileum is delivered through and sutured to the periphery of an opening int he anterolateral abdominal wall, allowing the egress of its contents
Following partial colonectomy
Colostomy or sigmoidoscomy is performed to create an artificial cutaneous opening for the terminal part of the colon
What does temporary or permanent ostomy prevent
Fecal contents from going through the anastomsis , thus if the anastomsis has a small imperfection causing a leak, the result is not catastrophic peritonitis
Colonoscope
For colonoscopy
Sigmoidoscope
Shorter endoscope can go into sigmoid and take samples or do surgery
Most tumors of the large intestine occur in the _____
Sigmoid colon and rectum (near rectosigmoid junction_ or ascending colon
Tumors of ascending colon
Most common among women and older patients
Rectosigmoidal tumors
Men and younger patients
Diverticulosis
Multiple false diverticula develop along the intestine
Where is diverticulosis commonly found
Sigmoid colon , ending where the teniae expand and converge at the colorectal junction
Who gets diverticulosis
Middle aged and elderly people
Are colonic diverticula true diverticulum? Why
No, they are formed from protrusions of mucous membrane only, evaginated through weak points developed between muscle fibers rather than involving the whole wall of the colon
Where are colonic diverticula
On mesenteric side of the two nonmenenteric teniae coli, where nutrient arteries perforate the msucle coat to reach submucosa
Diverticulitis
Infection or rupture of diverticula which can distort and erode the nutrient arteries leading to hemorrhage
What kind of diet is beneficial for reducing diverticulosis
High fiber
Volvulus of sigmoid colon
Rotation and twisting of the mobile loop of sigmoid colon and mesocolon
Problem with volvulus of the sigmoid colon
Obstruction of the lumen of the descending loon and any part of the sigmoid colon proximal to the twisted segment
What happens if obstruction of the lumen
Obstipation (cant fart or poop)
Ischemia
What to do if see volvulus
ACUTE EMERGENCY….. necrosis and tissue death if untreated
What is the most frequently injured organ of the abdomen
Spleen
What ribs is the spleen protected by
Ribs 9-12
How injure spleen
Blunt trauma to the left side or to other regions of the abdomen cause sudden increase in intra abdominal pressure can cause the thin fibrous capsule and overlying peritoneum of the spleen to rupture
Or when break ribs ..can rupture or lacerate
What happens if rupture spleen
Profuse bleeding (intraperitoneal hemorrhage) and shock
Treat ruptured spleen
Splenectomy
Subtotal splenectomy
Done when possible, get rapid regeneration after.
Consequences of total splenectomy
Not bad functions assumed by other reticuloendothelial organs (liver, bone marrow)
Greater susceptibility to certain bacterial infections
Diseased spleen from granulocytic leukemia
Splenomegaly (10x normal size) and hypertension
Is the spleen palpable in the adult
No
What is you can palpate the spleen
Enlarged about 3 times normal
Hemolytic or granulocytic anemia
Splenomegaly
Do splenectomy
One or more small accessory spleens may develop prenatal near the ___ __
Splenic hilum ….may be embedded partly or wholly in the tail of the pancreas between the layers of the gastrosplenic ligament in the infracolic compartment , in the mesentery, in in close proximity to an ovary or testis
Accessory spleen may resemble a __ __
Lymph node
Why should you be aware of the presence of a possible accessory spleen
If not removed during splenectomy, the symptoms (splenic anemia) that indicated removal may persist
Splenosis
Generalized auto implantation of a topic splenic tissue into the peritoneum, omentum, or mesenteries….sometimes follows splenic rupture
What is the relationship of the costodiaphragmatic recess do the pleural cavity to the spleen important
Potential space descends tot he level of the 10th rib in the mid axillary line. Its existence must be kept in mind when doing a splenic needle biopsy , or when injecting radioopaque material into the splanchnic for visualization of the hepatic portal vein
Splenoportography
Injecting radio opaque material into the spleen for visualization of the hepatic portal vein
If inject material into the costodiaphragmatic recess while doing splenoportography
May enter pleural cavity causing pleuritis
The main pancreatic duct joint the bile duct to form the ___ ____ and pierces the duodenal wall
Hepatopancreatic ampulla
A gallstone passing along the extrahepatic bile passing along the extrahepatic bile passages where it opens at the summit of the ___ ___ ___
Major duodenal papilla
What is blocked if a gallstone is lodged at the distal end of ampulla
Biliary and pancreatic duct systems and neither bile of pancreatic juice can enter the duodenum
Why does a blocked hepatopancreatic ampulla cause pancreatitis
Bile may back up and enter the pancreatic duct, causing ancreatitis
Normally the __ of the pancreatic duct prevents reflux of bile into the pancreatic duct. However is obstructed it may be unable to prevent the pressure
Sphincter
Accessory pancreatic duct and blockage of hepatopancreatic ampulla
May compensate for obstructed main pancreatic duct or spasm of the hepatopancreatic sphincter
Magnetic resonance cholangiopancreatography (MRCP)
MRI for diagnosis of pancreatic and biliary disease.
Can look at hepatobiliary and pancreatic systems including the liver, gallbladder, bile ducts, pancreas, and pancreatic duct.
Endoscopic retrograde cholangiopancreatography (ERCP)
Used when interventions are required.
Fiber optic endoscope through mouth to duodenum is entered and a cannula inserted into major duodenal papilla and advanced under fluoroscopic control into the duct of choice for injection of radiographic contract. Can also do intervention
Where does ectopic accessory pancreatic tissue typically develop
Stomach, duodenum, ileum, ileal diverticulum
What does ectopic accessory pancreatic tissue do
Contain pancreatic islet cells that produce glucagon and insulin
Is the pancreas palpable
No…it is well protected
Most exocrine pancreatic problems are secondary to ___ problems
Biliary
How may pancreas be directly damaged
Forceful and sudden compression of the abdomen , such as the force of impalement on a steering wheel in an automobile accident . Bc the pancreas lies transversely, the vertebral column acts as an anvil, and the traumatic force may rupture the friable pancreas
What happens if rupture pancreas
Tears the duct system allowing pancreatic juice to enter the parenchyma of the gland and to invade adjacent tissue. ….this is very painful due to digestion of tissues by pancreatic juice
When is pancreatectomy performed
Tumors are detected
Susbtotal or partial pancreatectomy
Remove ruptured portions of the pancreas and for the treatment of chronic pancreatitis after nonsurgical options fail
What happens when pancreatic enzymes activated before they are released into the small intestine
Damage. Begin to digest and attack pancreas
Subtotal pancretomy reduces pancreatic secretion how
Reducing size of the pancreas
Its easy to remove the body and tail of the pancreas. Tell me about head removal
Blood supply, bile duct, and duodenum, make it impossible to remove the entire head of the pancreas without removing the duodenum and terminal bile duct
What do we do to prevent removal of duodenum in pancreatectomy
Rim of pancreas is retained along the medial border of the duodenum to preserve the duodenal blood supply
What causes most cases of extrahepatic obstruction of the biliary duct
Cancer of the pancreatic head
What does cancer of the head of the pancreas obstruct
The bile duct and/or the hepatopancreatic ampulla
What happens if bile duct obstructed
Bile pigment retention, enlargement of the gallbladder, and obstructive jaundice.
Most common pancreatic cancer
Ductular adenocarcinoma
Where do people with pancreatic cancer have pain
Back
Why may cancer of the neck and body of the pancreas may cause hepatic portal vein or inferior vena canal obstruction why
Bc the pancreas ever lies these veins
Why is pancreatic cancer difficult to resect and hard to detect early
Extensive drainage to relatively inaccessible lymph nodes and the fact that pancreatic cancer typically metasticize to the liver early via the hepatic portal vein
Whipple procedure
For cancer of pancreas and biliary tract
(Pancreatoduodenectomy)
Remove head of pancrea, part of duodenum, and gallbladder
Tumor on body and tail of pancreas
Removed by subtotal procedure called distal pancreatectomy
Is the liver palpable. Why
In supine bc of the inferior movement of the diaphragm and liver that accompanies deep inspiration
How do you palpate the liver
Left hand behind lower rib cage and put right hand on RUq lateral to the rectus abdominis and inferior to the costal margin
Take deep breath and press posterosuperiorly and pull anteriorly
What is a common site for abscess in peritonitis and on what side
Subphernic recess on the right
Why are subphrenic recesses more common on the right
Frequency of ruptured appendices and perforated duodenal ulcers
Why may pus from the subphrenic recess spread to the hepatorenal recess
They are continuous
How do you drain a subphrenic recess
Incision in bed of 12th rib so don’t have to make incision into pleura or peritoneum
Drain anterior subphrenic recess
Through subcostal incision located inferior and parallel to the right costal margin.
Hepatic lobectomies
Can do! Right and left hepatic Arteries and ducts and branches of right and left hepatic portal veins do not communicate
Don’t get excessive bleeding
Hepatic segmentectomies
Remove only those segments that have tumor,
What is the portal triad
Hepatic portal vein, hepatic artery, bile duct
Hepatic veins
Left intermediate and right
Umbilical fissure
Left hepatic vein
Main portal fissure
Intermediate hepatic vein
Right sagittal fissure
Right hepatic vein
Why is the liver easily injured
Large, fixed in position, friable
What happens with liver laceration (rib)
Hemorrhage in URQ and pain there
Excessive vasculature
How manage injured liver
Remove foreign material and packing or embolization (deliberate blocking of blood vessels to control bleeding)
Resection of the liver is a last resort. Why?
Lobectomy or segmentectomy
Aberrant right hepatic artery source
SMA
Aberrant left hepatic artery source
Left gastric artery
In most people the right hepatic artery crosses __ to the hepatic portal vein
Anterior
In some people, the right hepatic artery passes posterior to the hepatic portal vein
Ok
In most people the right hepatic artery runs ___ to the common hepatic duct
Posterior
In some individuals the right hepatic artery crosses anterior to the common hepatic duct or the right hepatic artery arises from the SMA and so does not cross the common hepatic duct at all
Ok
Both the IVC and hepatic veins lack __
Valves
Any rise in central venous pressure is directly transmitted to the __, which enlarges as a results
Liver
What does hepatomegaly cause when temporary
Pain around lower ribs particularly right hypochondriac
Runners stitch
Engorgement of liver in conjunction with increased or sustained diaphragmatic activity
What is an important disease that produces hpatic engorgement
CHF, bacterial and viral disease, hepatitis,
Can you feel an enlarged liver
Readily palpable and may even go down to pelvic brim
Do tumors enlarge the liver
Yup
The liver is a common site of ____ carcinoma
Metastatic ….secondary cancers spreading from organs drained by the portal system
Why may cancer from the right breast spread to the liver
Communications between thoracic lymph nodes and the lymphatic vessels draining the bare area of the liver .
Histology of metastatic liver tumors
Hard, rounded nodules within the hepatic parenchyma
The ___ is the primary site for detoxification of substances absorbed by the GI tract. What does this imply
Liver
Vulnerable to damage and scarring accompanied by regenerative nodules
There is progressive destruction of ___ in hepatic cirrhosis and replacement of these cells by __
Hepatocytes
Fat and fibrous tissue
Causes of cirrhosis
Alcoholism
Carbon tetrachloride
Alcoholic cirrhosis causes __ hypertension
Portal
Characterization of alcoholic cirrhosis
Portal HTN
Hepatomegaly
Hobnail liver appearance
Fatty changes and fibrosis
In cirrhosis why is metabolic evidence of liver failure late
Great functional reserve
In cirrhosis, fibrous tissue surrounds the intra hepatic blood vessels and biliary ducts. What does this cause
Liver becomes firm and impedes the circulation of blood through it (HTN portal)
Treatment liver cirrhosis
Transplant
Portosystemic or portocaval shunt which anastomsing the portal and systemic venous systems
How get liver biopsy
Needle 10th intercostal space in mid axillary line HODL BREATH IN FULL EXPIRATION to reduce costodiaphragmatic recess and lessen the possibility of damaging the lung and contaminating the pleural cavity
Is the gallbladder fixed
Usually closely attached to the fossa for gallbladder on liver surface
In 4% of people the gallbladder is mobile…
Suspended from the liver by a short mesentery increasing its mobility
Proble with mobile gallbladder
Vascular torsion and infarction (sudden insuffiency of arterial or venous blood supply)
There are a ton of variations in cystic and hepatic ducts. Why is this important
Surgeons when they ligate the cystic duct during cholecystectomy
Are accessory hepatic ducts common
Yes
In what surgery are accessory hepatic ducts vulnerable
Cholecystectomy
What is an accessory hepatic duct
Normal segmental. Duct that joins the biliary system outside the liver instead of within it
What happens if accessory hepatic duct is cut during surgery
Leak bile
What is a gallstone (cholelithiasis)
Connection in the gallbladder, cystic duct, or bile duct composed chiefly of cholesterol crystals
Gallstones more common in males or females and old or young
Females older
50% of people gallstones are __
Silent
When does a gallstone cause symptoms
Size sufficient to produce mechanical injury to the gallbladder or obstruction of the biliary tree
What is common site of gall bladder impaction
Distal end of the common bile duct is narrow part of the biliary passages
What does a stone lodged in the cystic duct cause
Biliary colic….when gallbladder relaxes it may move back to the gallbladder
Cholecystitis
Cholecystitis
Stone block cystic duct
Inflammation of the gallbladder
Bile accumulation causing enlargement
Sacculation(Hartman pouch)
Common site of gallstone impaction
Junction of the neck of gallbladder and cystic duct
What happens when Hartman pouch is large
Cystic duct arises from its upper left aspect, not from what appears to be the apex of the gallbladder….gallstones collect int he pouch
If a peptic duodenal ulcer ruptures, a false passage may form between the pouch and the superior part of the duodenum….allowing what
Pouch and superior part of duodenum connection
Allowing gallstones to enter duodenum
Where do you get pain from impaction of the gallbladder
Epigastric region and later shifts to the right hypochondriac region at the junction of the 9th costal cartilage and the lateral border of the rectus sheath.
Inflammation of the gallbladder may cause pain in the posterior thoracic wall or right shoulder owing to irritation of the ___
Diaphragm
If bile cant leave the gallbladder and enters the blood it may cause ____
Jaundice
What technique is used to detect stones
Ultrasound and CT
A dilated and enlarged gallbladder may adhere to adjacent viscera…may result. In cholecysto-enteric fistula. What areas are most likely to get this fistula
Duodenum and transverse colon
What happens if get cholecysto-enteric fistula
Gallstone too large to pass through the cystic duct will enter the IGI
If a gallstone enters the GI, where may it get trapped
Ileocecal valve producing a bowel obstruction (gallstone ileus)
A cholecysto-enteric fistula also permits GI stuff to enter the gallbladder , providing what
Diagnostic radiographic sign
Cholecystectomy
If have extreme biliary colic
The cystic artery most commonly rises from the ___ artery int he cystohepatic triangle
Right hepatic
Boundaries of the cystohepatic artery
Inferior-cystic duct
Medially-common hepatic duct
Superiorly-inferior surface of the liver
Why must we carefully dissect the cystohepatic triangle when doing a cholecystectomy
Safeguard the structures should there be anatomical variation
Why are there common errors in gallbladder surgery
Failure to appreciate variation in anatomy of biliary system , especially the blood supply
Before removing the gallbladder what must a surgeon identify
Three biliary ducts, cystic and hepatic arteries
The __ ___ artery is in danger during gallbladder surgery and must be located before lighting the ___ artery
Right hepatic
Cystic
Portal hypertension
When scarring and fibrosis from cirrhosis obstruct the hepatic portal vein in th liver, pressure rises in the vein and its tributaries
The large volume of blood flowing from the portal system to the systemic system at the sites of portal-systemic anastomoses may produce __ ___
Varicocele veins
Problem with varicose veins
Walls may rupture-hemorrhage
Esophageal varicose
Dilated veins at distal end of esophagus …severe, fatal if bleeding
In severe portal obstruction, the veins of the anterior abdominal wall (normally caval tributaries) that anastomoses with the para umbilical veins(portal tributaries0 may become varicose and look somewhat like small snakes radiating under the skin around the umbilicus. What is this called
Caput medusae
How reduce portal hypertension
Divert blood from the portal venous system to the systemic venous system
How do we create communication between hepatic portal vein and systemic venous system
Communicate hepatic portal vein and a IVC
Connect usually where they lie close to each other posterior to the liver
What is this called
Portocaval anastomoses or portosystemic shunts
After splenectomy, how could we reduce portal htn
Connect splenic vein to the left renal vein (splenorenal anastomesis or shunt)
Are these anastomses common now?
No replaced by liver transplant
Transjugular intrahepatic portosystemic shunt (TIPS)
By interventional radiologist
Introducing a catheter tipped with an unexpanded stent into the right internal jugular vein and directing it under fluoroscopic guidance into one of the major hepatic veins via the right brachiocephalic vein, superior vena cava, right atrium, and inferior vena cava. Once in the hepatic vein, the unopened stent is pushed through the parenchyma of the liver into the portal vein. The stent is expanded setting it in place and providing the portosystemic shunt.
How palpate the kidney
Can’t really
In thin -right kidney is palpable by bimanual examination as round mass that descends with inspiration
Why can we palpate right kidney
It is 1-2 cm inferior from left
Where can u feel the right kidney
Between 11 and 12 ribs and iliac crest from behind and feel anteriorly at costal margin
Why would the left kidney be palpable
If enlarged or retroperitoneal mass has displaced it inferiorly
What determines the path of extension of the perinephric abscess
Attachments of the perinephric fascia
Fascia at the renal hilum attaches to the renal vessels and ureter, usually representing spread where
To the contralateral side
How can pus get from perinephric abscess to the pelvis
Between the loosely attached anterior and posterior layers of the renal fascia
Nephroptosis
Dropped kidney
Why do kidneys drop
Layers of renal fascia do not fuse firmly inferiorly to offer resistance, abnormally mobile kidneys may descend more than the normal 3 cm when erect body
When the kidneys descend, what happens to suprarenal glands
They stay up bc in separate fascial compartment and are firmly attached to the diaphragm
How distinguish nephroptosis from ectopic kidney
Ureter of normal length that has loose coiling or kinks bc the distance to bladder has been reduced
Symptom of dropped kidney
Intermittent pain in the renal region received by lying down bc of traction on renal vessels
Why are transplanted kidneys placed in the iliac fossa
Lack of inferior support for the kidneys in th lumbar region
Availability of major blood vessels and convenient access to the nearby bladder
Renal transplant
For chronic renal failure
Don’t damage suprarenal gland bc of weak septum of renal fascia that separates them
Transplant to iliac fossa of greater pelvis -site supports so no traction
Renal artery and vein are joined ot the external iliac artery and vein and ureter is sutured into bladder
Adult polycystic disease of the kidneys
Can cause renal failure
Inherited AD
Kidneys enlarged by cysts
If inflammation of pararenal areas, why extension of hip painful
Close relationship between kidney and psoas major
These muscles flex thigh at hip
During their ascent to their final state, the embryonic kidneys receive their blood supply and venous drainage from successively more __ vessels
Superior
Usually the vessels degenerate, what if they don’t
Accessory renal arteries and veins
Can have polar or inferior
Polar arteries- cross ureter and may obstruct
Superior-poles of kidney
Renal vein entrapment syndrome mesoaortic compression of the left renal vein
Also known as nutcracker syndrome
In crossing the midline to reach the IVC, the longer _ renal vein transverse an acute angle between the SMA anteriorly and the abdominal aorta posteriorly
Left
What does downward traction on the SMA cause
Compress the left renal vein resulting in renal vein entrapment syndrome
Why is renal vein entrapment syndrome also called nutcracker syndrome
Based on appearance of the vein in the acute arterial angle in a sagittal view
Symptoms of renal vein entrapment syndrome
He matures
Proteinuria
Left flak abdominal pain
Nausea and vomiting
Left testicular pain in men
Maybe left sided varicocele
Bifid renal pelvis and ureter
Common .. from division of the ureteric bud (metanephric diverticulum), the primordium of the renal pelvic and ureter
Bifid renal pelvis may be unilateral or bilateral, but separate openings into the bladder are ___
Uncommon
What causes bifid ureter
Incomplete division of the ureteric bud
What causes supernumerary kidney
Complete division of ureteric bud
Retrocaval ureter
Leaves the kidney and passes posterior to the ivc
Horseshoe kidney
1/600 fetus the inferior poles of kidneys fuse for make U shape
Where does a horseshoe kidney lie
L3-L5 bc the root of the inferior mesenteric artery prevented normal relocation of the kidneys
Symptoms of horseshoe kidney
Not really….may obstruct ureter
Ectopic pelvic kidney
Embryonic kidney on one or both sides fails to enter the abdomen and lies anterior to the sacrum
Why need to know about ectopic kidneys
Don’t want to confuse for a pelvic tumor and remove it
Can also cause obstruction during childbirth
Where do pelvic kidneys usually receive their blood supply from
The aortic bifurcation or a common iliac artery
Calculi
Composed of salts of inorganic or organic acids or other materials
Form and becomes located in the calices of the kidneys, ureters, or urinary bladder
Renal calculus(kidney stone)
May pass from kidney into renal pelvis and then into ureter
What does a calculi in ureter cause
Excessive distension of this muscular tube , the ureteric calculus will cause severe intermittent pain (ureteric colic) as it if forced down the ureter by waves of contraction
Does a calculus cause complete or intermittent obstruction of urinary flow
Can cause both
How observe and remove ureteric calculi
Nephroscope an instrument inserted through a small incision
Lithotripsy-focuses on shockwave through the body that breaks the calculus into small fragments that pass with the urine
The pan from ureteric calculi is referred to the cutaneous areas innervated by spinal cord segments and sensory ganglia which also receive visceral afferent from the ureter, mainly ______
T11-L2
The pain passes inferno-anteriorly from “ ____ _ ___” as stone passes through ureter
Loin to groin
The pain from ureteric calculi may extend into the proximal anterior aspect of the thigh by projection through the ____ nerve (-), the scrotum in males and the labia majora in females
Genitofemoral
L1, L2
The extreme pain may be accompanied by what in ureteric colliculus
Digestive upset, generalized sympathetic response that may to various degrees mask the more specific symptoms
Hiccups
Involuntary spasmodic contractions of the diaphragm, causing sudden inhalation’s that are rapidly interrupted by spasmodic closure of the glottis that checks the inflow of air and produces the sound
What hiccups result from
Irritation of afferent or efferent nerve endings or of medullary centers in the brainstem that control the muscles of respiration, particularly the diaphragm
What causes hiccups
Indigestion, diaphragm irritation, alcoholism, cerebral lesions, thoracic and abdominal lesions, which all disturb phrenic nerves
Section of the phrenic nerve causes what
Complete paralysis and eventual atrophy of the muscular part of the corresponding Half of the diaphragm, except if have accessory phrenic nerve
“Paralysis of hemidiaphragm” seen radiographically
Where is referred pain from the diaphragmatic pleura or diaphragmatic peritoneum
Shoulder region ..area of skin supplied by c3-c5
Where is pain from irritation of the peripheral regions of the diaphragm
Innervated by the inferior intercostal nerves more localized..being referred to the skin over the costal margins of the anterolateral abdominal wall
What may cause rupture of the diaphragm and herniation of viscera
Sudden large increase in either intrathoracic or intra-abdominal pressure
Severe trauma to the thorax or abdomen during a MVA
Why are most diaphragmentic ruptures on the left side
Bc substantial mass of the liver, intimately associated with the diaphragm on the right side provides a physical barrier
Where is the lumbocostal triangle
Between the costal and lumbar parts of the diaphragm
Nonmuscular
Normally formed only by fusion of the superior and inferior fascial of the diaphragm
When a traumatic diaphragmatic hernia occurs, the stomach, small intestine, and mesentery, transverse colon, and spleen may herniate through what
The lumbocostal triangle into the thorax
What is a hiatal hernia
Protrusion of part of stomach into the thorax through the esophageal hiatus
What structures pass through the esophageal hiatus
Vagal trunks, left inferior phrenic vessels, esophageal branches of the left gastric vessels
Careful may be injured in surgical procedures not he esophageal hiatus
Congenital diaphragmatic hernia
Part of the stomach and intestine herniate through a large posterolateral defect (foramen of bochdalek) in the region of the lumbocostal trigone of the diaphragm
Why does congenital diaphragmatic hernia almost always occur on the left
Presence of the liver on the right
Why get a congenital diaphragmatic hernia
Posterolateral defect of the diaphragm is the only relatively common congenital anomaly of the diaphragm 1/2000
With abdominal viscera int he limited space of the prenatal pulmonary cavity, one lung (usually left lung) does not have room to develop normally or to inflate after birth…bc of the pulmonary hypoplasia the mortality rate in these infants is high
There is currently a resurgence of TB, especially where
Africa, asia….owing to aids and drug resistance
TB of the vertebral colum is common. How may is spread
Through blood to the vertebrae particularly in young children
An abscess of TB in the lumbar region tends to spread from the vertebrae into the ___ __ , producing what
Psoas fascia
Psoas abscess
What happens with a psoas abscess
Fascia thickens
To form a strong stocking like tube
Where may pus from a psoas abscess spread
Inferiorly along the psoas muscles within the fascia tube over the pelvic brim and deep into the inguinal ligament
The pus usually surfaces in the superior part of the thigh
Pus can also reach the psoas fascia by passing from the posterior mediastinum when the thoracic vertebrae are diseased
The inferior part of the iliac fascia is often tense and raises a fold that passes to the internal aspect of the iliac crest. The superior part of this fascia is loose and may do what
Form a pocket m the iliacosubfascial fossa, posterior to the above mentioned fold.
Clinical concern of the iliacosubfascial fossa
Part of the large intestine such as the cecum and or appendix on the right side of the sigmoid colon on the left side may become trapped in this fossa, causing considerable pain
The iliopsoas muscle has extensive clinically important relations to what
Kidney, ureteric, cecum, appendix, sigmoid colon, pancreas, lumbar lymph nodes and nerves of the posterior abdominal wall.
When any of the structures associated with the iliopsoas are diseased what happens
Movement of the iliopsoas causes pain
When is the iliopsoas test performed
Intra abdominal inflammation is suspected
Bc the psoas lies along the vertebral column and the iliacus crosses the sacro-iliac joint, disease of the intervertebral and sacro-iliac joints may cause what
Spasm of the iliopsoas, a protective reflex
Adenocarcinoma of the pancreas in advanced stages invades the muscles and nerves of what
Posterior abdominal wall , producing excruciating pain because of the close relationship of the pancreas to the posterior abdominal wall
Partial lumbar sympathectomy
Surgical removal of two or more lumbar sympathetic ganglia by division of their rami communicates ….to treat disease of the lower limbs
How get access to the sympathetic trunk
Through lateral extraperitoneal approach because the sympathetic trunks lie retroperitoneally in the extraperitoneal fatty tissue
The surgeon splits the muscles of the anterior abdominal wall and moves. The peritoneum medially and anteriorly to expose the medial edge of the psoas major along which the sympathetic trunk lies
The sympathetic trunk is covered by the IVC. The intimate relationship of the sympthetic trunk to the aorta and ivc also makes these large vessels vulnerable to injury during lumbar sympathectomy . Consequently the surgeon carefully retracts them to expose the sympathetic trunks that usually lie in the groove between the psoas major laterally and the lumbar vertebral bodies medially. Those trunks are often obscured by fat and lymphatic tissue. Knowing that identification of the sympthetic trunk is not easy, great care is taken not to remove inadvertently part of the genitofemoral nerve, lumbar lymphatics or ureter
Because the aorta lies posterior to the pancreas and stomach , a tumor of these regions may cause what
Pulsation of the aorta that could be mistaken for an abdominal aortic aneurysm(a localized enlargement of the aorta)
How tell if its an aneurysm
Can be palpate midabdomen to the left of midline (the pulsating mass can be moved easily from side to side), which usually results from a congenital weakness of the arterial wall
Acute rupture of abdominal aortic aneurysm
Severs pain in abdomen or back
90% death rate due to blood loss
How can surgeons repair an aneurysm
Opening it and inserting a prosthetic graft and sewing the wall of the aneurysm aorta over the graft to protect it
Now using catheterization procedures
How may we control bleeding in the pelvis or lower limbs
Compress inferior part of abdominal aorta against the body of L4 by putting firm pressure on the anterior abdominal wall over the umbilicus
What are the three routes, formed by valveless veins of the trunk that are available for venous blood to return to the heart when the IVC is obstructed or lighted
Superior and inferior epigastric veins
Thoracoepigastric vein
Epidural venous plexus
Where is the epidural venous plexus
Inside the vertebral column
What does the epidural venous plexus communicate with
Lumbar veins of the inferior canal system and the tributaries of the azygos system of veins which is part of the superior canal system
Why are inferior vena cava anomalies common , most occurring inferior to the renal veins, like persistent left IVC)
The inferior part of the IVC has a complicated development bc it forms from parts of three sets of embryonic veins
What do anomalies of the inferior vena cava result from
Persistence of embryonic veins on the left side which normally disappear ….if a left IVC is present, it may cross to the right side at the level of the kidney
