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The Abdomen > Abdominal Wall > Flashcards

Abdominal Wall Flashcards

1
Q

Superior bounds of anterolateral abdominal wall

A
  • Xiphoid process

- Cartilage of ribs 7-10

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2
Q

Inferior bounds of anterolateral abdominal wall

A
  • Inguinal ligament

- Superior pelvic girdle

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3
Q

Superficial fatty layer of fascia inferior to umbilicus

A

Camper’s fascia

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4
Q

Deep membranous layer (superficial) fascia

A

Scarpa’s fascia

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5
Q

Colle’s Fascia

A

Perineal continuation of Scarpa’s fascia

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6
Q

Incisional layers of abdominal wall inferior to umbilicus

A
  1. Skin
  2. Camper’s fascia
  3. Scarpa’s fascia
  4. Muscles (dependent on incision)
  5. Transversalis fascia
  6. Extraperitoneal fat
  7. Peritoneum
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7
Q

Limit of ectopic testes descent

A

Point of Colle’s fascia inserting into deep fascia of thigh 2.5cm below inguinal ligament

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8
Q

Site of urine tracking in bulbous urethral rupture

A

Scrotum, perineum, penis, abdominal wall deep to Scarpa’s fascia

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9
Q

External Oblique (OIIA)

A

O - External surface of ribs 5-12
I - Linea alba, pubic tubercle, anterior half of iliac crest
I - Thoracoabdominal nerves
A - Compresses and supports abdominal viscera, flexes/rotates trunk

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10
Q

Anterolateral abdominal wall neurovascular plane

A

Between internal oblique and transversus abdominis

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11
Q

Internal Oblique (OIIA)

A

O - Thoracolumbar fascia, anterior 2/3rd of iliac crest, connective tissue deep to lateral 1/3rd of inguinal ligament
I - Inferior borders of ribs 10-12, linea alba, pectin pubis
I - Thoracoabdominal nerves
A - compresses and supports abdominal viscera, flexes and rotates trunk

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12
Q

Transversus Abdominis (OIIA)

A

O - Internal surfaces of 7th-12th costal cartilages, thoracolumbar fascia, iliac crest, connective tissue deep to lateral 1/3rd inguinal ligament
I - linea alba with aponeurosis of internal oblique, pubic crest, pectin pubis
I - Thoracoabdominal nerves
O - compresses and supports abdominal viscera

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13
Q

Rectus Abdominis (OIIA)

A

O - pubic symphysis and pubic crest
I - xiphoid process and 5-7th costal cartilage
I - Thoracoabdominal nerves
O - flexes trunk, compresses viscera, stabilises pelvis

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14
Q

Components of anterior rectus sheath

A
  1. External oblique aponeurosis

2. Part of internal oblique aponeurosis

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15
Q

Components of posterior rectus sheath

A
  1. Part of internal oblique aponeurosis

2. Transversus abdominis aponeurosis

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16
Q

Rectus abdominis blood supply

A

Superior and inferior epigastric artery

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17
Q

Outline structure of rectus sheath

A
  1. Above costal margin anterior rectus is external oblique aponeurosis only (no posterior sheath)
  2. From costal margin to just below umbilicus there is anterior and posterior rectus sheath
  3. Below arcuate line - posterior recuts passes anterior to rectus abdominis (rectus abdominis lies directly on transversals fascia)
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18
Q

Contents of rectus sheath

A
  • Rectus abdominis
  • Pyramidalis
  • Segmental nerves
  • Segmental vessels from T7-12
  • Superior and inferior epigastric vessels
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19
Q

Course of iliohypogastric nerve (L1)

A
  • Originates from lumbar plexus (L1)
  • Pierces transversus abdominis muscle to course between IO and TA, branches pierce external oblique aponeurosis of most inferior abdominal wall
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20
Q

Course of ilioinguinal nerve (L1)

A

Passes between IO and TA; then traverses inguinal canal

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21
Q

Distribution of ilioinguinal nerve (L1)

A

Skin of lower inguinal region, mons pubis, anterior scrotum or labium majus, adjacent medial thigh, inferior most IO and TA

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22
Q

Outline lymphatic drainage of the anterolateral abdominal wall

A
  • Above umbilicus = drains to axillary lymph nodes with a few to the parasternal lymph nodes
  • Inferior umbilicus = drains to superficial inguinal lymph nodes
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23
Q

Course and distribution of superior epigastric artery

A
  1. Originates from internal thoracic artery
  2. Descends in rectus sheath deep to rectus abdominis
  3. Supplies rectus abdominis, superficial and deep wall of epigastrium and upper abdomen
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24
Q

Course and distribution of inferior epigastric artery

A
  1. Originates from external iliac artery
  2. Runs superiorly to enter rectus sheath; runs deep to rectus abdominis
  3. Supplies rectus abdominis, deep abdominal wall of pubic and inferior umbilical regions
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25
Q

Describe the internal surface of anterolateral abdominal wall

A

Covered with transversals fascia, a variable amount of extraperitoneal fat, and parietal peritoneum

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26
Q

Describe the median umbilical fold

A
  • Infraumbilical
  • Extends from apex of bladder. to the umbilicus
  • Covers the median umbilical ligament (obliterated urachus)
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27
Q

Describe the medial umbilical folds

A
  • Infraumbilical
  • Bilateral
  • Cover medial umbilical ligaments (obliterated umbilical artery)
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28
Q

Describe the lateral umbilical folds

A

Cover the inferior epigastric vessels (bleed if cut - from the inferior epigastric artery)

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29
Q

Describe the deep inguinal ring

A
  • Defect in transversals fascia
  • 1cm above midpoint of inguinal ligament
  • Immediately lateral to inferior epigastric vessels
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30
Q

Describe the superficial inguinal ring

A
  • V-Shaped defect in inguinal ligament

- Lies above and medial to pubic tubercle

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31
Q

Composition of inguinal ligament

A

External oblique aponeurosis running from ASIS to pubic tubercle

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32
Q

Lacunar ligament

A

Deep fibres of the inguinal ligament attach to the superior pubic ramus

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33
Q

Pectineal ligament

A
  • Lateral fibres of inguinal ligament attach to pectineal line (pectin pubis)
  • Forms posterior border of femoral canal
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34
Q

Define the iliopubic tract

A

Thickened inferior margin of transversalis fascia that reinforces posterior floor of inguinal canal

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35
Q

Anterior relations of inguinal canal

A
  • Skin
  • Camper’s and Scarpa’s
  • External oblique aponeurosis
  • Internal oblique in lateral 1/3rd of canal
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36
Q

Posterior relations of inguinal canal

A
  • Medial = conjoint tendon

- Lateral = transversalis fascia

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37
Q

Roof of inguinal canal

A
  • Internal oblique

- Transversus abdominis

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38
Q

Floor of inguinal canal

A

Inguinal ligament (external oblique aponeurosis)

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39
Q

Contents of inguinal canal (men vs women)

A
  • Men = spermatic cord and ilioinguinal nerve

- Women = round ligament and ilioinguinal nerve

40
Q

Gallbladder surface marker

A

Tip of 9th costal cartilage where linea semilunaris intersects the costal margin (lateral edge of rectus)

41
Q

Spleen surface marker

A

Under ribs 9-11 on the left (long axis lies under rib 10)

42
Q

Pancreas surface marker

A

Lies along the transpyloric plane (L1)

43
Q

Kidney surface marker

A

From T12-L3. Hilum lies at the level of the transpyloric plane (L1)

44
Q

Appendix surface marker

A

McBurney’s point - 1/3rd distance between ASIS and umbilicus

45
Q

Aortic bifurcation surface marker

A

Level of L4 to the LEFT of the midline

46
Q

External iliac artery surface marker

A

Palpable between midinguinal point halfway between ASIS and symphysis pubis

47
Q

Mid-point of inguinal ligament

A

Half way between pubic tubercle and ASIS

48
Q

Mid-inguinal point

A

Half way between ASIS and pubic symphysis

49
Q

Define a hernia

A

Protrusion of all or part of a viscus through the wall of the cavity in which it is usually contained

50
Q

Most common side of groin hernias

A

RIGHT sided (due to later descent of testes or appendicectomy)

51
Q

Define indirect inguinal hernia

A

Indirect hernia sac (remains of processes vaginalis) extends through the deep ring, inguinal canal, and superficial ring into the scrotum

52
Q

Embryological cause of indirect inguinal hernia

A

Failure of processus vaginalis to close

53
Q

Outline risk factors for indirect inguinal hernias

A
  • Male - bigger processus vaginalis
  • Prematurity - processus vaginalis not closed
  • Africans - low pelvic arch
  • Right sided - slower testicular descent
  • Testicular feminisation syndrome
  • Increased intraperitoneal fluid
54
Q

Define direct inguinal hernia

A

Acquired weakness in the abdominal wall causing hernia sac to pass directly forwards through defect in transversalis fascia (posterior wall of inguinal canal)

55
Q

Site of inguinal hernia

A

Above and medial to pubic tubercle

56
Q

Describe the femoral sheath

A
  • Downward protrusion into the thigh of the fascial envelope lining the abdominal wall (transversalis fascia and psoas fascia)
  • Surrounds the femoral vessels until 2.5cm below the inguinal ligament
57
Q

Outline the compartments of the femoral sheath

A
  1. Medial = femoral canal
  2. Intermediate = contains femoral vein
  3. Lateral = contains femoral artery
58
Q

Function of femoral sheath

A

Provides freedom of vessel movement during hip motion

59
Q

Describe the femoral canal

A

1.3cm long medial compartment of the femoral sheath containing lymphatics with an UPPER opening called the femoral ring

60
Q

Contents of the femoral canal

A
  • Connective tissue
  • Efferent lymph vessels from deep inguinal nodes
  • Deep inguinal node of Cloquet (drain penis/clitoris)
61
Q

Outline the boundaries of the femoral ring

A
  • Anterior = inguinal ligament
  • Posterior = superior ramus of pubis and pectineal ligament
  • Medial = lacunar ligament or iliopubic tract
  • Lateral = femoral vein
62
Q

Describe femoral hernia

A
  • Enter femoral canal via femoral ring
  • Hernia arrives in thigh next to saphenous opening
  • Hernia enlarges upwards and medially
  • Lies between superficial external pudendal and superficial epigastric veins
63
Q

How do femoral veins compromise lower limb venous drainage

A

Compress saphenous vein as it emerges through saphenous opening

64
Q

Why and to what extent are femoral hernias more common in women

A
  • 2.5x
  • Inguinal ligament makes a wider angle with the pubis
  • Fat in femoral canal stretches the canal
  • Pregnancy increases pressure
65
Q

Site of femoral hernias

A

Below and lateral to pubic tubercle

66
Q

Emergency indications for hernia repair

A

Painful irreducible hernias

67
Q

Which hernias should be electively repaired

A
  • Indirect

- Symptomatic direct

68
Q

Which hernias should be repaired urgently

A
  • All femoral hernias

- 50% strangulate within 1 month

69
Q

Which hernias should be repaired promptly

A
  • Irreducible inguinal hernia

- History <4 weeks (greater risk of strangulation within first 3 months of appearance)

70
Q

Operation for primary unilateral inguinal hernia

A

Mesh repair (Lichtenstein or endoscopic)

71
Q

Operation for primary bilateral inguinal hernia

A

Mesh repair

72
Q

Operation for recurrent inguinal hernia

A
  • If previously anterior = open preperitoneal mesh of endoscopic
  • If previously posterior = Lichtenstein’s totally extraperitoneal (TEP)
73
Q

Outline the principles of hernia repair

A
  1. Reduce hernia contents
  2. Remove hernia sac
  3. Repair defect
74
Q

How does herniotomy in children differ from that in adults

A

No need to repair the posterior wall of the inguinal canal as there is no defect

75
Q

Contraindications to mesh repair

A

Presence of pus or bowel contents in emergencies

76
Q

What operation should be performed if mesh repair is contraindicated

A

Shouldice repair (transversalis flap is created)

77
Q

Outline the closure of mesh and Shouldice repairs

A
  1. Inspect for potential femoral hernias
  2. Close external oblique aponeurosis with continuous absorbable suture (e.g. PDS) over the cord
  3. Close Scarpa’s fascia with interrupted vicryl
  4. Close skin with subcuticular monocryl
78
Q

Intraoperative hazards of hernia repair

A
  • Damage to ilioinguinal nerve (sensory loss in lower groin and anterior scrotum)
  • Damage to cord structures
  • Orchidectomy
79
Q

What is the standard approach to elective femoral hernia repair

A

High inguinal (Lotheissen) approach (except in thin females where a low crural approach is acceptable)

80
Q

Approach for complex, recurrent, or obstructed femoral hernias

A

High extraperitoneal approach (McEvedy’s)

81
Q

Describe Spigellian hernia

A

Protrusion of the peritoneum through bands of the internal oblique muscle as the muscle enters the semilunar line

82
Q

What is the Spigellian line

A

A.K.A. Linea semilunaris
Bilateral vertical curved line in the anterior abdominal wall where the layers of the rectus sheath fuse lateral to the rectus muscle and medial to the oblique muscles

83
Q

Describe Richter’s Hernia

A
  • Partial enterocele
  • One anti-mesenteric margin of the gut is strangulated in the sac
  • Obstruction may be incomplete
  • Will be a tender, irreducible hernia
84
Q

Describe Madyl’s hernia

A
  • W-shaped loop of small gut lies in hernia sac
  • Intervening loop is strangulated in the abdominal cavity
  • Seen in very large hernias
85
Q

Describe Sliding hernia (Hernia en glissade)

A
  • Sac wall is composed in part by a RETROPERITONEAL viscus

- The bowel forms part of the hernia but is anatomically outside of the sac

86
Q

Main risk when operating on sliding hernias

A

Opening the bowel due to mistaking it for the sac (bowel lies outside the sac in these hernias)

87
Q

Describe Littre’s hernia

A

Hernia sac containing a strangulated Meckel’s diverticulum

88
Q

Outline the pathophysiology of hernia strangulation

A
  1. Venous outflow obstruction
  2. Leads to oedema
  3. Arterial obstruction
  4. Ischaemia
  5. Necrosis of mucosal layer
  6. Luminal toxins and bacteria enter portal venous circulation causing sepsis
  7. Transudation of toxins and bacteria into peritoneal cavity causes peritonitis
89
Q

Site of obstruction in indirect hernias

A

Deep or superficial inguinal rings

90
Q

Site of obstruction in direct hernias

A

Defect in transversalis fascia

91
Q

Site of obstruction in femoral hernias

A

Fibrosis of peritoneum of the neck

92
Q

Site of obstruction in umbilical hernias

A

Rigid aponeurotic margins around the sac

93
Q

Describe sublay method of incisional hernia repair

A

Mesh inserted between the abdominal muscles and the peritoneum

94
Q

Describe the covering layers of an umbilical hernia

A

Skin, superficial fascia, rectus sheath, transversalis fascia, sac

95
Q

How can the superficial inguinal ring be identified

A

Presence of crural fibres

The Abdomen (8 decks)

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