Abdominal Wall/ Inguinal Region Flashcards
liposuction
surgical method for removing unwanted subQ fat using percutaneously placed suction tube and high vacuum pressure
why will fluid accumulated in the potential space b/w Scarpa’s fascia and deep fascia not spread inferiorly down into thigh?
fascia lata (deep fascia of thigh) fuses with Scarpa’s fascia along a line 2.5 cm inferior and parallel to inguinal ligament
significance of transversalis fascia in surgery
-provides a plane to access structures on or in anterior aspect of the posterior abdominal wall w/o entering membranous peritoneal sac - minimizes risk of contamination
space of Bogros
anterolateral part of potential space b/w transversalis fascia and parietal peritoneum used for placing prostheses when repairing inguinal hernias
why is a prominent abdomen normal in infants/young children?
- their GI tracts contain a large amount of air
- anterolateral abdominal cavities enlarging
- ab muscles gaining strength
- relatively large liver
six common causes of abdominal protrusion
- food
- fluid
- fat
- feces
- flatus
- fetus
ascites
abnormal accumulation of serous fluid in the peritoneal cavity
what is eversion of umbilicus a sign of?
increased intra-abdominal pressure - from ascites or large mass
site of abdominal hernias
anterolateral abdominal wall
what patients are umbilical hernias common in?
neonates - herniation through umbilical ring
what patients acquired umbilical hernias most common in?
women and obese people
epigastric hernia
hernia in the epigastric region through the linea alba - occurs in midline b/w the xiphoid process and umbilicus
spigelian hernias
hernias occuring along semilunar lines
who usually experiences spigelian hernias?
people older than 40 and obese people
why are warm hands important in palpating abdominal wall?
cold hands make the anterolateral abdominal muscles tense, producing involuntary spasms of muscles (guarding)
what is a clinical sign of acute abdomen?
intense guarding that cannot be willfully repressed
best position to palpate abdominal wall
patient in supine position w/ thighs and knees semiflexed and upper limbs placed at sides
superficial abdominal reflex
quickly stroking horizontally, lateral to medial, towards the umbilicus - usually feel contraction of abdominal muscles
when are the nerves of the abdominal wall at risk of injury?
surgical incisions or trauma at any level of the abdominal wall
injury to nerves of anterolateral abdominal wall
may result in weakening of muscles - if in inguinal region, can predispose patient to inguinal hernia
how do surgeons choose where to make abdominal incisions?
try to follow Langer’s lines - aim for incision that allows adequate exposure, best cosmetic effect, and minimizes injury
when are longitudinal incisions preferred?
for exploratory operations - offer good exposure of and access to viscera and can be extended w/ minimal complication
what incisions can be made rapidly without cutting muscle, major blood vessels, or nerves?
median or midline incisions
where can median/midline incisions be made?
alone any part or length of the linea alba from the xiphoid process to pubic symphysis
where are paramedian incisions made?
in sagittal plane, may extend from costal margin to pubic hairline
what are gridiron (muscle-splitting) incisions used for?
appendectomy
McBurney incision
made at McBurney point - 2.5 cm superomedial to the ASIS on the spino-umbilical line
where are suprapubic/ Pfannenstiel incisions made and what are they used for ?
bikini line - used for most gynecological and obstetrical operations
where are transverse incisions made and why?
muscle belly of rectus abdominis - a new transverse band forms when the muscle segments are rejoined
what are subcostal incisions used for?
R side: access to gallbladder and biliary ducts
L side: access to spleen
where are subcostal incisions made?
parallel but at least 2.5 cm inferior to costal margin to avoid 7th and 8th thoracic spinal nerves
what are high-risk incisions?
pararectus and inguinal incisions
where are pararectus incisions made and why high risk?
along lateral border of the rectus sheath - high risk b/c may cut the nerve supply to rectus abdominis
what are inguinal incisions made for and why high risk?
repair of hernias - may injure the ilio-inguinal nerve
incisional hernia
protrusion of omentum or organ through a surgical incision when the muscular and aponeurotic layers do not heal properly
benefit of endoscopic surgery
- minimize potential for nerve injury, incisional hernia, comtamination through open wound
- minimize healing time
reversal of venous flow and collateral pathways of superficial abdominal veins
when SVC or IVC blocked, anastamoses b/w tributaries (thoraco-epigastric) provide collateral pathways to return blood to heart
cryptorchidism
condition where testes are undescended or are not retractable - greatly increases risk of malignancy that is not palpable
where do you find undescended testis?
somewhere along normal path of prenatal descent - usually in inguinal canal
external supravesical hernia
hernia that leaves peritoneal cavity through the supravesical fossa medial to that of a direct inguinal hernia
what nerve may be damaged in repair of external supravesical hernia?
iliohypogastric nerve
umbilical vein catheterization
done through the round ligament of the liver (remnant of umbilical vein) for exchange transfusion during early infancy
where does lymphogenous metastasis of cancer most commonly occur?
along lymphatic pathways that parallel the venous drainage of the primary tumor organ
where can metastatic uterine cancer cells spread?
labium majus
most common type of abdominal hernia
inguinal hernia - 75% of abdominal hernias
in what sex do most inguinal hernias occur?
male b/c passage of spermatic cord through inguinal canal
inguinal hernia
protrusion of parietal peritoneum and viscera through a normal or abnormal opening from the cavity in which they belong
which type of inguinal hernia is more common?
indirect - more than 2/3 of them
direct inguinal hernia
hernia through Hesselbach’s triangle
indirect inguinal hernia
hernia through the processus vaginalis
how do you palpate the superficial inguinal ring?
invaginate skin of upper scrotum with index finger - follow spermatic cord with finger to superficial inguinal ring
how do you determine if there is a hernia at the superficial inguinal ring?
while palpating ring, ask patient to cough - if pressure on finger, hernia present - DOES NOT DISTINGUISH WHICH TYPE OF HERNIA
how do you palpate the deep inguinal ring?
felt as a skin depression superior to the inguinal ligament
what palpations indicate indirect hernia?
impulse at the superficial ring and mass at site of the deep ring
how do you palpate a direct inguinal hernia?
put finger on Hesselbach’s triangle and ask patient to cough - pressure indicates hernia
cremasteric reflex
lightly stroke skin on medial aspect of superior part of thigh -> rapid elevation of the testis on the same side (contraction of cremaster muscle)
canal of Nuck
small peritoneal pouch formed by a persistent processus vaginalis in females - can get cysts here
hydrocele
presence of excess fluid in a persistent processus vaginalis
hydrocele of testis
hydrocele confined to the scrotum - distends the tunica vaginalis
hydrocele of spermatic cord
hydrocele confined to the spermatic cord - distends the persistent part of the stalk of the processus vaginalis
how do you detect a hydrocele?
transillumination - red glow indicates excess serous fluid
hematocele of testis
collection of blood in the tunica vaginalis that results from rupture of branches of the testicular artery by trauma to testis
how do you differentiate b/w a hydrocele and hematocele?
hematocele and hematoma do not transilluminate
hematoma
accumulation of blood, usually clotted, in any extravascular location
scrotal hematocele
effusion of blood into the scrotal tissues
torsion of the spermatic cord
twisting obstructs venous drainage, resulting in edema, hemorrhage, and subsequent arterial obstruction - medical emergency
where does torsion of spermatic cord usually occur?
just above the upper pole of the testis
how is recurrent torsion of spermatic cord prevented?
surgical fixation of both testes to the scrotal septum
where do you inject spinal anesthetic agent to anesthetize the anterolateral surface vs. posteroinferior surface of scrotum?
inject more superiorly for anterolateral surface than for posteroinferior surface - anterolateral supplied by lumbar plexus (mostly L1 - ilio-inguinal nerve); posteroinferior supplied by sacral plexus (mostly S3 - pudendal nerve)
spermatocele
retention cyst in the epididymis, usually near the head, containing milky fluid - asymptomatic
epididymal cyst
collection of fluid anywhere in epididymis
appendix of testis
vesicular remnant of the cranial end of the paramesonephric (mullerian) duct attached to upper pole of testis- forms half of uterus in female
appendices of epididymis
remnants of the cranial end of the mesonephric (wolffian) duct attached to head of epididymis - forms part of ductus deferens in male
varicocele
dilated and tortuous pampiniform plexus of veins, usually only visible when standing or straining - feels like bag of worms
where do varicoceles predominantly occur?
left side
what causes varicoceles?
defective valves of testicular vein, kidney or renal vein problems
how do all testicular tumors metastasize?
lymphogenous metastasis - testicular may also metastasize by hematogenous to lungs, liver, brain, bone
metastasis of testis cancer
initially to retroperitoneal lumbar lymph nodes -> mediastinal and supraclavicular nodes
metastasis of scrotum cancer
to superficial inguinal lymph nodes
