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DMH Part 1 > Abdominal Wall and Inguinal Region > Flashcards

Abdominal Wall and Inguinal Region Flashcards

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Sliding Hiatal Hernia

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  • Gastro-esophageal junction slips upward
  • Associated with gastric reflux
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9
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Paraesophageal Hiatal Hernia

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  • Gastro-esophageal junction position normal
  • Fundus of stomach herniates; no reflux
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  1. Arises from the 5th to 12th ribs
  2. Attaches to the anterior portion of the iliac crest, the xiphoid process, the linea alba, pubic symphysis and pectineal line
  3. On its inferior edge it turns under and forms the inguinal ligament, which extends between the anterior superior iliac spine and the pubic tubercle.
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20
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  1. Arises from thoracolumbar fascia, the iliac crest, and the inguinal ligament.
  2. Insertions form a “fan” Upper fibers to ribs 7-12 Middle fibers to linea alba Inferior fibers to pubic crest and pectineal line
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  1. Arises from the costal cartilage along the costal arch, the thoracolumbar fascia, the iliac crest, and the inguinal ligament.
  2. Inserts along the midline from the xyphoid process to the pubic crest and pectineal line.
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30
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Inguinal Canal

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The area between the anterior superior iliac spine and the pubic tubercle is defined as the inguinal region. The muscles of the anterior abdominal wall converge in this area to form the inguinal canal. The inguinal canal has two “openings” at each end – the deep inguinal ring and the superficial inguinal ring. The rings are staggered thus creating the canal and helping to reinforce the wall to prevent herniation; of course this is not foolproof.

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32
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Types of Hernias

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  • Hiatal hernia
  • Umbilical hernia
  • Femoral hernia
  • Indirect inguinal hernia
  • Direct inguinal hernia
33
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Femoral Hernia

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  • hernia sac passes directly thru femoral ring/canal into the thigh
  • more common in females (middle aged to elderly; esp. if parous)
34
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Indirect Inguinal Hernia

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  • hernia sac enters deep inguinal ring (passes to outside world indirectly by traversing the canal; may pass completely thru canal to scrotum/labia majora
  • lateral to the inferior epigastric artery
  • more common in males due to patency of processus vaginalis -most common as a congenital condition; though may be acquired later in life
35
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Hesselbach’s Triangle

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36
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Direct Inguinal Hernia

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  • hernia sac passes directly thru abdominal wall, usually thru Hesselbach’s triangle
  • medial to the inferior epigastric artery -more common in adults (middle aged to elderly though this demographic may also acquire hernia lateral to inf. epigastric which is defined as an indirect hernia)
37
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Diaphragm

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The diaphragm is a dome-shaped, musculofibrous sheet that separates the thoracic and abdominal cavities. The diaphragm has multiple sites of origin which insert into the central tendon

38
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Sites of Origin of Diaphragm

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  1. Sternal Part
  2. Costal Part
  3. Lumbar Part
39
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Diaphragm Site of Origin - Sternal Part

A

•posterior portion of xiphoid process

40
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Diaphragm Site of Origin - Costal Part

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a. from the inner surface of the 7th, 8th, and 9th ribs and ends of 10th, 11th and 12th ribs.
b. from the arcuate ligaments
1. lateral arcuate ligament - from 12th rib, across quadratus lumborum to the transverse process of L1.
2. medial arcuate ligament - from transverse process of L1 across the psoas major to the side of L1 and L2.

41
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Diaphragm Site of Origin - Lumbar Part

A

a. Right and left crus
1. From bodies of L1-L4
2. Unite over the front of the aortic hiatus to form the median arcuate ligament.
3. The fibers of the right crus pass on either side of the esophageal hiatus.

42
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Blood Supply of the Diaphragm - Arteries

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The abdominal aorta gives off the inferior phrenic arteries whereas the thoracic aorta gives off the superior phrenic arteries. In addition, the internal thoracic artery gives rise to the musculophrenic artery

43
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Blood Supply of the Diaphragm - Veins

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The right inferior phrenic vein empties into the inferior vena cava and the left inferior phrenic vein drains into the left suprarenal or left renal vein.

44
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Innervation of the Diaphragm

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Motor innervation is derived from the phrenic n. (C3-C5) Sensory innervation is derived from two sources.

The phrenic nerve supplies the middle portion of diaphragm, but the intercostal nerves supply the periphery of the diaphragm. Pain from the diaphragm is often referred to the shoulder.

45
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Passages through the Diaphragm

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  1. Aortic Hiatus
  2. Esophageal Hiatus
  3. Vena Cava Hiatus
46
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Passages through the Diaphragm - Aortic Hiatus

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T12

a. aorta
b. thoracic duct
c. (azygous v.)

47
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Passages through the Diaphragm - Esophageal Hiatus

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T10

a. esophagus
b. vagal trunks
c. esophageal branches of the left gastric vessels. Enlargement of the esophageal hiatus can result in hiatal hernia in which the stomach can protrude into the thoracic cavity.

48
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Passages through the Diaphragm - Vena Cava Hiatus

A

aka “foramen for the IVC”

T8

a. inferior vena cava
b. branches of rt phrenic n.

49
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Muscles of the Posterior Abdominal Wall

A
  1. Quadratus Lumborum
  2. Psoas Major
  3. Iliacus
  4. Psoas Minor
50
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Quadratus Lumborum

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a. Superior attachment: Medial half of inferior border of the 12th rib and tips of lumbar transverse processes.
b. Inferior attachment: iliolumbar ligament and internal lip of iliac crest.
c. action: depression and stabilization of the 12th rib, lateral bending of trunk d. innervation: ventral rami T12, L1-4

51
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Psoas Major

A

(medial component of the iliopsoas)

a. Superior attachment:
1. lumbar transverse processes
2. sides of bodies of T12-L5 vertebrae and intervertebral disks
b. Inferior attachment:
1. lesser trochanter of the femur
c. action: (with the iliacus) flexion of thigh, flexion of the hip
d. innervation: ventral rami L1-L3

52
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Iliacus

A

a. Superior attachment:
1. iliac fossa
2. ala of sacrum
3. anterior sacroiliac ligaments
b. Inferior attachment:
1. with the psoas major
c. action: same as psoas major
d. innervation:
1. branches of femoral n. (L2,3)

53
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Psoas Minor

A

The psoas minor is found on the ventral surface of the psoas major. It is present in only 50% of the population.

54
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Blood Supply of the Kidneys

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The kidneys receive 1/6 of the cardiac output, second only to the brain.

Arteries: The right and left renal arteries branch from the abdominal aorta and form anterior and posterior branches that enter the kidneys

Veins: The left and right renal veins empty into the inferior vena cava

55
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Blood Supply of the Ureters

A

Arteries: The blood supply of the ureters can come from many sources, but mainly from the:

a. renal a.
b. aorta
c. common iliac a.
d. testicular or ovarian a.

These arteries often form an anastomosing network; therefore, ligation of one artery will not necessarily compromise the blood flow to the area supplied.

Veins: The venous drainage is into the ovarian or testicular veins

56
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Innervation of Kidneys and Ureters

A

Sympathetic T10-L1

Via the renal plexus from the lesser and lowest splanchnic nerves

Parasympathetic

  1. Vagus n.
  2. S2-S3

Afferents T10-L1(2)

Pain from renal calculi (stones) that enter the ureter is usually felt on the side that the stone is descending. The ureter is supplied by T11 to L2, and the pain is referred to the cutaneous areas supplied by those segments. The pain is characterized as a sharp, stabbing pain and passes inferoanteriorly from the loin to the groin.

57
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Suprarenal (Adrenal) Glands

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The suprarenal glands are located on the superior pole of the kidneys embedded in fat.

  1. Cortex- secretes corticosteroids
  2. Medulla- secretes catecholamines
58
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Blood Supply of Suprarenal Glands

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Arteries. The arterial supply of the suprarenals is extensive and may have up to 30 branches. Inferior phrenic artery gives off the superior suprarenal arteries whereas the middle suprarenal arteries arise from the abdominal aorta. In addition, the renal artery gives off the inferior suprarenal arteries

Veins The right suprarenal vein empties into the inferior vena cava and the left suprarenal vein empties into the left renal vein.

59
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Innervation of Suprarenal Glands

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Medulla The medulla of the suprarenal glands is innervated predominantly from fibers from the splanchnic nerves and the celiac plexus. These nerves are preganglionic sympathetic fibers that terminate directly on the cells of the medulla. Other postsynaptic fibers supply the blood vessels.

Cortex Other than blood vessels, the cortex of the suprarenal gland is not innervated

60
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Abdominal Aorta

A

The abdominal aorta is a continuation of the thoracic aorta that becomes the abdominal aorta when it passes through the diaphragm. It ends with the bifurcation into the common iliac arteries. The branches of the abdominal aorta can be grouped as follows:

  1. Ventral
  2. Lateral
  3. Dorsal
61
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Ventral Branches of the Abdominal Aorta

A

(unpaired visceral)

This group is comprised of unpaired branches that supply the abdominal viscera.

  1. Celiac Trunk
  2. Superior Mesenteric Artery
  3. Inferior Mesenteric Artery
62
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Lateral Branches of the Abdominal Aorta

A

(paired visceral)

These arteries supply retroperitoneal structures along the lateral body wall.

  1. Inferior phrenic arteries
  2. Middle suprarenal arteries
  3. Renal arteries
  4. Testicular or Ovarian arteries
63
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Dorsal Branches of the Abdominal Aorta

A

These arteries supply the posterior abdominal wall.

  1. Lumbar arteries
  2. Median sacral artery
64
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Inferior Vena Cava

A

Conveys blood to the right atrium from all of the body below the diaphragm. It starts at the union of the paired common iliac veins, ascends up the posterior abdominal wall, pierces the diaphragm and enters the right atrium. It receives the following contributions.

  1. Lumbar veins
  2. Ovarian or Testicular veins Left to left renal vein
  3. Renal veins
  4. Suprarenal veins Left to left renal vein
  5. Inferior phrenic veins
  6. Hepatic Veins
65
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Retroperitoneal portal-caval anastomoses

A

Veins that drain the posterior abdominal wall communicate with veins that drain the abdominal viscera. This can provide an alternative route back to the IVC or the hepatic portal vein.

66
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Lumbar Plexus

A

Like the brachial plexus, the lumbar plexus is comprised of the ventral rami of several spinal nerves, L1-L5.

  1. Iliohypogastric (L1)
  2. Ilioinguinal (L1)
  3. Genitofemoral (L1, 2)
  4. Lateral cutaneous nerve of the thigh (L2, 3)
  5. Femoral (L2-4)
  6. Obturator (L2-4)
  7. Lumbosacral trunk (L4,5)
67
Q

Recctus Abdominis

A
  1. Arises on the pubic crest
  2. Inserts onto the 5th through 7th ribs
  3. Central connective tissue that runs from the xiphoid process to the pubic symphysis is the linea alba
68
Q

External Oblique Muscle

A
  1. Arises from the 5th to 12th ribs
  2. Interdigitates with the serratus anterior and latissimus dorsi muscles
  3. Attaches to the anterior portion of the iliac crest, the xiphoid process, the linea alba, pubic symphysis and pectineal line
  4. On its inferior edge it turns under and forms the inguinal ligament, which extends between the anterior superior iliac spine and the pubic tubercle.
69
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Internal Oblique Muscle

A
  1. Arises from thoracolumbar fascia, the iliac crest, and the inguinal ligament.
  2. It is fan shaped
    a. Upper fibers to ribs 7-12
    b. Middle fibers to linea alba
    c. Inferior fibers to pubic crest and pectineal line

The fibers of the internal oblique fuse with the muscles of the transversus abdominis to form the conjoint tendon.

70
Q

Transversus Abdominis Muscle

A
  1. Lies deep to the internal and external oblique muscles.
  2. Arises from the costal cartilage along the costal arch, the thoracolumbar fascia, the iliac crest, and the inguinal ligament.
  3. Inserts along the midline from the xyphoid process to the pubic crest and pectineal line.
71
Q

The Rectus Sheath

A

The three abdominal muscles contribute to a fascial covering of the rectus abdominis. Anterior to the rectus abdominis the sheath is continuous. However, from a point midway between the umbilicus and the pubic symphysis the posterior sheath is incomplete. The line is called the arcuate line.

72
Q

Arteries of the Anterior Abdominal Wall

A
  1. The superior epigastric arteries
  2. The inferior epigastric arteries
  3. The deep circumflex iliac arteries
  4. The superficial circumflex iliac arteries
  5. The superficial epigastric arteries
73
Q

Veins of the Anterior Abdominal Wall

A

Venous drainage of the anterior wall is through an extensive venous plexus. It drains superiorly to the internal thoracic vein, laterally to the lateral thoracic vein and inferiorly to the superficial and inferior epigastric veins. These veins anastomose with the paraumbilical veins which are tributaries of the hepatic portal vein. Because of these portal:systemic anastomoses, portal hypertension can result in the formation of the “caput medusa” on the anterior abdominal wall.

74
Q

Nerves of the Anterior Abdominal Wall

A
  1. The majority of the innervation of the anterior abdominal wall is through the intercostal and subcostal nerves.
  2. The inguinal region also receives innervation from:
    a. The subcostal nerve (T12)
    b. The iliohypogastric nerve (L1)
    c. The ilioinguinal nerve (L1)
    d. The genitofemoral nerve (L1, L2)
75
Q

The Inguinal Canal

A

The inguinal canal is a passageway between the abdominal cavity and the scrotum (males) and labia majora (females). In the males, this allows the descent of the testes into the scrotum. The inguinal canal is formed by the staggered openings of the muscles of the anterior abdominal wall.

76
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Ligaments of the Inguinal Canal

A
  1. Inguinal ligament – formed from the inferior edge of the external oblique muscle. Extends from the anterior superior iliac spine to the pubic tubercle.
  2. Lacunar ligament – connects the inguinal ligament to the pectineal ligament. Crescent shaped extension of the inguinal ligament that attaches to the pectineal line.
  3. Pectineal ligament – thickening of the periosteum of the pectineal line of the pubis
  4. Conjoint tendon – common aponeurosis of the internal oblique and the transversus abdominis. Attaches to the pubic tubercle and pectineal line.
77
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Walls of the Inguinal Canal

A
  1. Anterior wall External oblique aponeurosis together with originating fibers of the internal oblique
  2. Posterior wall Conjoint tendon and transversalis fascia
  3. Roof

Arching fibers of the internal oblique and transversus abdominis muscles

  1. Floor Inguinal ligament and lacunar ligament

The organization of these fibers creates the deep inguinal ring and the superficial inguinal ring.

DMH Part 1 (35 decks)

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