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Abdominal wall Flashcards

1
Q

What are the divisions of the abdominal wall

A

Anterolateral

Posterior

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2
Q

What is the superior border of the anterolateral abdominal wall

A

Cartilages of ribs 7-10

Xiphoid process

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3
Q

What is the inferior border of the anterolateral abdominal wall

A

Inguinal ligament

Superior margins of anterolateral aspects of the pelvic girdle

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4
Q

What does the anterolateral abdominal wall consist of from superficial to deep

A

Skin
Superficial fatty subcutaneous tissue (camper fascia)
Scarpa fascia
External oblique, internal oblique and transversus abdominis separated by deep fascia (superficial, intermediate and deep)
Endoabdominal fascia
Extra peritoneal fat
Parietal peritoneum

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5
Q

What spinal level is the umbilicus at

A

L3

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6
Q

What is the epigastric fossa

A

Depression in the epigastric region just inferior to the xiphoid process

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7
Q

What is the linea alba

A

Aponeuroses of abdominal muscles that separates the left and right rectus abdominis

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8
Q

What is divarication of recti and what increases its likelihood

A

When the rectus abdominis contract the muscles spread apart if the linea alba is lax
More likely in elderly and in women who have had lots of children (pregnancy stretches Linea Alba)

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9
Q

What is the inguinal groove

A

Skin crease parallel and inferior to the inguinal ligament that separates the thigh and abdominal wall

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10
Q

What are the semilunar lines

A

Curved tendinous lines either side of the rectus abdominis

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11
Q

Where is the arcuate line (Douglas’ line)

A

Inferior limit of the posterior layer of the rectus sheath

1/3 way from umbilicus to the pubic crest

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12
Q

What are the flat muscles in the anterolateral abdominal wall

A

External oblique
Internal oblique
Transversus abdominis

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13
Q

What are the vertical muscles of the anterolateral abdominal wall

A

Rectus abdominis

Pyramidalis

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14
Q

What are the orientations of the anterolateral abdominal wall muscle fibres

A

External oblique - inferomedial
Internal oblique - superomedial
(Perpendicular)
Transversus abdominis - medial

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15
Q

Origin of external oblique muscle

A

Ribs 5-12 (external)

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16
Q

Insertion of external oblique muscle

A

Linea alba
Pubic tubercle
Anterior half of iliac crest

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17
Q

Origin of internal oblique muscle

A

Thoracolumbar fascia
Anterior 2/3 of iliac crest
CT deep to lateral 1/3 of inguinal ligament

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18
Q

Insertion of internal oblique muscle

A

Inferior borders of ribs 10-12
Linea alba
Pectin pubis via the conjoint tendon

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19
Q

Origin of transversus abdominis muscle

A

Costal cartilage of ribs 7-12 (internal)
Thoracolumbar fascia
Iliac crest
CT deep to lateral 1/3 of inguinal ligament

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20
Q

Insertion of transversus abdominis

A

Linea alba
Pubic crest
Pectin pubis via conjoint tendon

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21
Q

What is the rectus sheath

A

Tendinous sheath between the midclavicular line and the midline
Made up of the aponeuroses which are the anterior continuations of the flat muscles
It encloses the rectus abdominis

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22
Q

How is the linea alba formed

A

Aponeuroses interweave with the aponeuroses of the opposite side
(There is also interweaving between layers on the same side)

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23
Q

Where does the linea alba run from and to

A

Xiphoid process to pubic symphysis

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24
Q

What is an ideal incision

Why can’t we sew muscles together

A

Can close and provide long lasting strength to reduce chance of incisional herniae
Sutures in a muscle will ‘cut out’ (like sewing butter)

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25
Q

What’s a midline incision

A

Surgeons suture the linea Alba together

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26
Q

What’s a transverse incision

A

Surgeons suture the external oblique aponeuroses together

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27
Q

Where is the incision for an appendicectomy

A

McBurney’s point

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28
Q

Where is McBurney’s point

A

2/3 distance from umbilicus to the ASIS

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29
Q

What is a gridiron incision

A

Put scissors in and open and close them to separate out the muscle fibres
3 stages because 3 layers of muscle (3 different fibre directions)

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30
Q

What is somatic referred pain

A

Pain caused by a noxious stimulus to the proximal part of a somatic nerve that is perceived in the distal dermatome of the nerve
E.g herpes zoster

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31
Q

What is visceral referred pain

A

Pain caused by ischaemia, abnormally strong muscle contraction, inflammation or stretch
It is referred to dermatomes of the spinal ganglia providing the sensory fibres

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32
Q

What is the course of visceral afferent pain fibres in the thorax and abdomen

A

Follow sympathetic fibres back to the same segment of the spinal cord that give rise to the preganglionic sympathetic fibres

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33
Q

Where is foregut pain felt

A

Epigastric region

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34
Q

Where is midgut pain felt

A

Periumbilical region

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35
Q

Where is hindgut pain felt

A

Suprapubic region

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36
Q

Where is early appendicitis pain felt

A

Umbilicus

Innervation of the appendix enters the spine at T10

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37
Q

Where is late appendicitis pain felt

A

Right lower quadrant

Becomes more inflamed and and irritates the surrounding bowel wall

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38
Q

What causes referred diaphragmatic irritation

A

Ruptured spleen
Ectopic pregnancy
Perforated ulcer

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39
Q

Describe referred diaphragmatic irritation

A

Blood pools in pelvis giving pain
Loss of blood makes patient faint so lies down causing blood to rush up to the diaphragm (C3-5)
This leads to referred pain in the left shoulder
No pain in right shoulder because the liver is in the way of the blood at the right diaphragm

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40
Q

What is the peritoneal cavity

A

A potential space of capillary thinness between the parietal and visceral layers of peritoneum containing a thin film of peritoneal fluid

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41
Q

What absorbs peritoneal fluid

A

Lymphatic vessels

Particularly on the interior surface of the diaphragm

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42
Q

What difference is there between males and females in the peritoneal cavity

A

Males - completely closed
Females - there’s a communication with the exterior of the body through uterine tubes, the uterus and vagina (infection from exterior)

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43
Q

What is the peritoneum

A

Continuous 2 layers membrane:
Parietal - lines the internal surface at the abdominal wall
Visceral - invests viscera

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44
Q

What separates parietal peritoneum from the abdominal muscles

A

Extraperitoneal connective tissue

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45
Q

What attaches the parietal peritoneum to the anterior abdominal and pelvis walls
Why is this

A

Loose CT

Allows bladder and rectum to enlarge

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46
Q

Describe how the extraperitoneal tissue differs depending on location

A

Behind the linea alba and on the inferior surface of the diaphragm it is denser and more firmly adherent

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47
Q

What’s the blood, lymphatic and somatic nerve supply of the parietal peritoneum

A

Same as the region of the wall it lines

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48
Q

What’s the blood, lymphatic and visceral nerve supply of the visceral peritoneum

A

Same as the organ it covers

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49
Q

What sensations is parietal peritoneum sensitive to

A

Pressure
Pain
Heat
Laceration

50
Q

Is pain of parietal peritoneum well or poorly localised

What’s the exception

A

Well

Diaphragm (referred pain to shoulder)

51
Q

What innervated the diaphragm

A

Phrenic nerve

52
Q

What sensations is visceral peritoneum sensitive to

A

Stretching

Chemical irritation

53
Q

Is pain of visceral peritoneum well or poorly localised

A

Poorly

54
Q

What is mesentery

A

Double layer of peritoneum occurring as a result invagination of the peritoneum by an organ
It connects intraperitoneal organs to the body wall

55
Q

What’s a peritoneal ligament

A

Double layer of peritoneum that connects an organ with another organ/to the abdominal wall

56
Q

What peritoneal ligaments are attached to the liver

A

Falciform ligament (liver to anterior abdominal wall)
Hepatogastric ligament
Hepatoduodenal ligament

57
Q

What peritoneal ligaments are attached to the stomach

A 
Gastrosplenic ligament
Gastrophrenic ligament (stomach to inferior surface of diaphragm)
Gastrocolic ligament (stomach to transverse colon)
58
Q

What are bare areas

A

They allow entrance and exit of neurovascular structures in organs

59
Q

What are intraperitoneal organs

A

Organs completely covered by peritoneum

60
Q

What are retroperitoneal organs

A

Organs outside of the peritoneal cavity and so are only covered partially by parietal peritoneum

61
Q

What are subperitoneal organs

A

Organs beneath the peritoneum in the subperitoneal space

E.g bladder and lower third of the rectum

62
Q

What lines are used to divide the abdomen

A

Vertically - midclavicular lines

Horizontally - subcostal line and transtubercular line

63
Q

What are the 9 regions of the abdomen from left to right (superior to inferior)

A 
Left hypochondriac
Epigastric
Right hypochondriac 
Left lumbar
Umbilical
Right lumbar
Left iliac 
Hypogastric
Right iliac
64
Q

What does the transverse mesocolon divide the abdominal cavity into

A

Supracolic

Infracolic

65
Q

What does the supracolic compartment contain

A

Stomach
Liver
Spleen

66
Q

What does the infracolic compartment contain

A

Small intestine
Ascending colon
Descending colon

67
Q

Where does the infracolic compartment lie

A

Posterior to the greater omentum

68
Q

How is the infracolic compartment divided

A

Left and right infracolic spaces by the mesentery of the small intestine

69
Q

How do the supracolic and infracolic compartments communicate

A

Paracolic gutters

70
Q

Where are the paracolic gutters

A

Grooves between the lateral aspect of the ascending or descending colon and the posterolateral abdominal wall

71
Q

What is the greater peritoneal sac made up of

A

Supracolic and infracolic compartments

72
Q

Other name for the lesser peritoneal sac

A

Omental bursa

73
Q

What limits the superior recess of the lesser sac

A

Diaphragm

Posterior layers of the coronary ligament of the liver

74
Q

Where is the inferior recess of the lesser sac

A

Between the superior parts of the layers of the greater omentum

75
Q

How does the inferior recess of the lesser sac change with age

A

Most of the inferior recess becomes sealed off from the main part (part posterior to stomach) after adhesion of the anterior and posterior layers of the greater omentum

76
Q

What does the lesser sac permit

A

Free movement of the stomach on the structures anterior and posterior to it

77
Q

How do the greater and lesser sacs communicate

A

Through the omental/epiploic foramen

78
Q

How is the omental foramen located

A

Running a finger along the gall bladder to free the edge of the lesser omentum (hepatoduodenal ligament)
The opening admits 2 fingers

79
Q

Where is the right subphrenic space

A

Between the diaphragm and anterior, superior and right lateral surfaces of the right lobe of the liver

80
Q

How is the right subphrenic space bound on the left side

A

By the falciform ligament

81
Q

How is the right subphrenic space bound on the posterior side

A

By the upper layer of the coronary ligament

82
Q

Where does fluid usually collect after right sided abdominal inflammation

A

In the right subphrenic space

83
Q

Where is the left subphrenic space

A

Between the diaphragm, the anterior and superior surfaces of the left lobe of the liver, the anterosuperior surface of the stomach and the diaphragmatic surface of the spleen

84
Q

How is the left subphrenic space bound on the right side

A

By the falciform ligament

85
Q

How is the left subphrenic space bound on the posterior side

A

By the anterior layer of the left triangular ligament

86
Q

Where does fluid usually collect after a splenectomy

A

Left subphrenic space

87
Q

Which subphrenic space is larger

A

Left (because liver is on the right)

88
Q

Describe the recto-uterine pouch (of Douglas)

A

Pouch created between the rectum and uterus by a peritoneal fold
The recto-uterine fold of peritoneum passes from the rectum to the posterior vaginal fornix and back to the uterine cervix and body

89
Q

Describe the vesico-uterine pouch

A

Shallow pouch created between the uterus and the bladder by a peritoneal fold
The peritoneum passes from the uterine fundus to the junction of the uterine body and cervix. Then it is reflected to the upper surface of the bladder

90
Q

Describe the recto-vesicle pouch

A

Pouch created between the rectum and bladder by a peritoneal fold
The peritoneum passes from the junction of the middle and lower thirds of the rectum to the super aspect of the bladder

91
Q

What does the mesentery of the small intestine connect

A

Jejunum and ileum to the posterior abdominal wall

92
Q

What’s between the layers of peritoneum of the mesentery of the small intestine

A

Blood vessels, lymph vessels and nerves

93
Q

What is the root of mesentery of the small intestine

A

Attached parietal border
Starts 15cm from the duodenojejunal flexure at the level of L2
Ends at the ileoceacal junction

94
Q

What does the root of mesentery of the small intestine cross

A 
2nd and 3rd parts of the duodenum
Abdominal aorta
Inferior vena cava
Right ureter
Right psoas major
Right gonadal artery
95
Q

What does the sigmoid mesocolon connect

A

Sigmoid colon to the pelvic wall

96
Q

Where is the apex of the (inverted V-shaped) root of the sigmoid mesocolon

A

Superior to the division of the left common iliac artery

97
Q

Where does the lateral/left limb of sigmoid mesocolon descend

A

Medial to left psoas major

98
Q

Where does the medial/right limb of sigmoid mesocolon pass

A

Into the pelvis and ends in the midline at S3

99
Q

What runs between the layers of the sigmoid mesocolon

A

Sigmoid and superior rectal vessels

100
Q

What descends posterior to the apex of the root of sigmoid mesocolon

A

Left ureter

101
Q

What does peritoneal fluid consist of

A

Water
Electrolytes
Leukocytes
Antibodies

102
Q

Functions of peritoneal fluid

A

Acts as a lubricant to allow free movement of abdominal viscera
Antibodies fight infection

103
Q

What is ascites

A

Accumulation of excess fluid in the peritoneal cavity

104
Q

Why is peritonitis resulting from infections of the vagina, uterus and uterine tubes rare

A

Presence of a mucous plug in the external opening of the uterus

105
Q

What does the mucous plug in he external uterus opening do

A

Prevents passage of pathogens but allows passage of sperm

106
Q

What is culdocentesis

A

Extraction of fluid from the recto uterine pouch through a needle inserted through the posterior fornix of the vagina

107
Q

What is paracentesis

A

Drainage of fluid from the peritoneal cavity through a needle inserted through the anterolateral abdominal wall
Used to drain ascitic fluid, diagnosis of cause of ascites, check for cancers which metastasise via the peritoneum

108
Q

Most common cause of ascites

A

Portal hypertension secondary to cirrhosis of the liver

109
Q

Less common causes of ascites

A

Malignancies of GI tract,
Malnutrition,
Peritonitis,
Internal bleeding

110
Q

How does ascites present

A

Distended abdomen
Discomfort
Nausea
Dyspnea (SOB)

111
Q

Why are patients with ascites positioned in a sitting position (at least 45 degree angle)

A

Encourages ascitic fluid to flow into pelvis instead of through paracolic gutters
In the pelvis toxins are absorbed much slower

112
Q

Causes of peritonitis

A

Bacterial contamination:
during a laparotomy (open surgical incision of peritoneum)
Secondary to an infection in the GI tract e.g burst appendix, acute pancreatitis

113
Q

Presentation of peritonitis

A 
Pain and tenderness of overlying skin 
Anterolateral abdominal muscles contract to protect viscera (guarding) - patients may flex knees in an attempt to relax the anterolateral abdominal muscles 
Fever
Nausea
Vomiting
Constipation
114
Q

Major risk of generalised peritonitis

A

Sepsis

115
Q

Purpose of tendinous intersections of rectus abdominis

A

To make rectus abdominis more efficient (very long muscle)

116
Q

How does the greater omentum have a function in infection

A

Walls off infection from the rest of the body so an abscess is formed in the peritoneum

117
Q

Difference of the rectus sheath above and below arcuate line

A

Below arcuate line there is no posterior part of the rectus sheath (rectus abdominis is not enclosed in sheath)

118
Q

Signs of a rectus sheath haematoma

A

Bruising on the abdomen

Severe pain when using rectus abdominis muscles

119
Q

Where are the loins

A

Junction of ribs and paravertebral muscles

120
Q

Why is shingles often mistaken for appendicitis

A

Pain in supra public region (T12) occurs before rash forms

GI (19 decks)

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