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lss 2:anatomy of the abdomen, pelvis & perineum > Abdominal Wall, Inguinal Region & Hernias > Flashcards

Abdominal Wall, Inguinal Region & Hernias Flashcards

1
Q

what is the abdominal pelvic cavity split into?

A
  1. abdominal cavity

2. pelvic cavity

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2
Q

Describe the abdominopelvic cavity?

A

Abdominal and pelvic cavities are continuous

Diaphragm separates the thoracic and abdominal cavities.

Upper part of the abdominal cavity extends beneath the thoracic cage

Pelvic inlet (pelvic brim) arbitrarily separates the abdominal from the pelvic cavity

The abdomen is a large cylinder extending from the superior margin of the pelvis to the inferior margin of the thorax
The inferior thoracic aperture (hole at the bottom of the ribcage) forms the superior opening of the abdomen
Closed by the diaphragm

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3
Q

what are the visceral structures?

A

Stomach, duodenum, small and large intestines

Liver, pancreas & spleen

Kidneys, ureters and urinary bladder

Reproductive organs

Abdominal vessels

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4
Q

what are the 9 regions of the abdomen ?

A

-Epigastric region

Right/Left hypochondrium

-Umbilical
Right flank, Left Lumbar region

  • Hypogastric/Supra pubic region

Right groin and Left iliac region

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5
Q

what are the lines that separate the 9 regions?

Describe another plane

A

2 midclavicular plane
Subcostal plane—- at L3

Intertubercular plane—-L5
Between the lower edges of the 10th costal cartilages

Transpyloric plane passes through L1

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6
Q

what are the pains from the different regions of the abdomen and what does it consist of ?

A

Epigastric region
-referred pain from the foregut.
The foregut starts at the point the oesophagus pierces the diaphragm
Ends just after the major duodenal papilla (second part of the duodenum)

Umbilical
-referred pain from the midgut
The midgut begins just inferior to the major duodenal papilla
Ends two-thirds of the way through the transverse colon

Pubic region
-referred pain from the hindgut
The hindgut two-thirds of the way through the transverse colon
Ends mid-way through the anal canal

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7
Q

what are the 4 quadrant of the abdomen, and how is this divided and what organs can you find?

A

Sagittal plane and transumbilical plane

Right upper quadrant
-Liver and gallbladder

Left upper quadrant
-Spleen and stomach

Right Lower quadrant
-Appendix, ascending colon and caecum

Left lower quadrant
-Descending colon, sigmoid colon

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8
Q

how can you find Mcburney’s point?

Where is the iliac tubercle

A

It is in the right lower quadrant

McBurney’s point – 1/3 from ASIS to umbilicus is a marking of where an incision for an appendicectomy would be made.
In appendicitis pain can first manifest in the periumbilical area (referred from midgut) and once inflammation invades the subcutaneous tissues it moves to the R inguinal region

Relevant for acute appendicitis

The iliac tubercle is located 5cm posterior to the ASIS on the iliac crest

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9
Q

how is the rectus abdominas positioned?

A

Rectus abdominas muscle:
On the anterior wall on either side.
Semilunar lines.

A long, flat muscle
Paired muscle
Separated by the linea alba: A linear, fibrous structure which is formed from the aponeurosis of the lateral abdominal muscles.

Intersected three of four times by tendinous intersections (just some fibrous tissue)
easily visible

Origins
-Pubic crest 
-Pubic tubercle 
-Pubic symphysis 
(all the pubic stuff)

Insertion :

  • Costal cartilages of ribs 5 to 7
  • Xiphoid process
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10
Q

Describe the layers of the abdomen

what are the abdominal wall muscles and what is made of those

A

Skin, Superficial fascia - fatty layer, Superficial fascia- membranous fatty, Parietal peritoneum, Extraperitoneal fascia, Transversalis fascia, Transversus abdominus muscle, Internal olique, external olique

Anterior wall
-Paired vertical rectus abdominis muscles within rectus sheath

Lateral wall - 3 flat sheet muscles

  • External oblique
  • Internal oblique
  • Transversus abdominis

Posterior wall
Post vertebral muscles –erector spinae group
-Psoas, quadratus lumborum and iliacus muscles

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11
Q

what are the 3 flank sheet muscles and how are the muscle fibres orientated and describe where they are?

A

Obliques – external and internal
Transversus abdominis.

External: inferiormedially
At the midline, the large aponeuroses combine to form the linea alba which extends form the xiphoid process to the pubic symphysis

Origin: The outer surfaces of the lower eight ribs (so from ribs 5 to 12)
Insertion: Later lip of the iliac crest

Internal: superiormedially
Origin: Thoracolumbar fascia
Iliac crest
Lateral 2/3s of the inguinal ligament

Insertion:
Inferior border of the lower three or four ribs
Xiphoid process
Aponeurosis ends at linea alba
Also attached to pubic crest (just medial to the pubic tubercle)

Transverse abdominas: horizontally fibres
Origin:Thoracolumbar fascia
Iliac crest
Lateral 1/3 of inguinal ligament
Costal cartilages of the lower six ribs (so ribs 7 to 12)

Insertion: Aponeurosis ends in linea alba
Pubic crest

The three muscles are separate in the flanks and have fascia in between each layer.

The three flat muscle fibres continue anteriorly as aponeurotic sheets and contribute to the rectus sheath (encloses the rectus abdominas muscle)

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12
Q

what are the function of the flank muscles

A
  • Compress the abdomen and increase the intra-abdominal pressure to aid expiration, and evacuation of urine, faeces, parturition, heavy lifting
  • Supports viscera – “guarding” mainly the intestines
  • Flex and rotate the trunk
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13
Q

Desscribe how the anterior and posterior link?

A

Link via the external, internal and transverse abdominas. Each have a layer of fascia in between.

Aponeurosis of three anterolateral muscles form rectus sheath and form around the abdominal muscles.
-Fibrous sheath.

External internal and transverse abdominas doesnt run all along to the rectus abdominus. The muscle stops. This is the semilunar lines.

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14
Q

describe the external oblique attachments and what does it form at the pubic tubercle

A

Muscle fibres are directed down ward and forward.

Attached to:
External surface of lower 8 ribs
Free posterior border
Fans out to attach to xiphoid process, linea alba, pubic crest and tubercle, anterior half of iliac crest.

The lower border of the aponeurosis of the external oblique forms the inguinal ligament
The inguinal ligament runs from the ASIS to the pubic tubercle

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15
Q

what is apneurosis, ligament and tendon?

A

Apneurosis: flat tendon of the muscles

Ligament: muscles to bone

Tendon: muscles to tendon to bone (generally stronger muscles e.g. biceps)

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16
Q

what happens to the aponeurosis and what happens to the lower aponeurotic edge?

A

The aponeurosis fuses medially with the rectus sheath

Lower aponeurotic edge is rolled inwards and forms the inguinal ligament. ASIS to pubic tubercle.

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17
Q

what are the attachments of the internal olique?

A

Muscle fibres are directed downward and backward

Lateral:
Thoracolumbar fascia
Iliac crest - anterior 2/3rd
Inguinal ligament - lateral half

Medial: 
Lower 3 ribs and costal cartilages
Xiphoid process, 
Rectus sheath, 
Conjoint tendon
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18
Q

what is the attachment of the transversus abdominus?

A

Muscle fibres are directed horizontally

Lateral: 
Lower 6 costal cartilages
Thoracolumbar fascia
Iliac crest – anterior 2/3rd 
Inguinal ligament –lateral 1/3rd
Medial: 
Xiphoid process
Linea alba (rectus sheath)
Symphysis pubis
Conjoint tendon

The neurovascular plane (blood supply to these muscles and nerve supply to the skin) lies between the internal oblique and transversus abdominis muscle layers

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19
Q

what is the arrangement of the rectus abdominas?

A

Long strap muscle of the anterior abdominal wall enclosed in rectus sheath

Rectus sheath Two heads
Superior attachment
5-7 costal cartilages
Xiphoid process

Inferior attachment
Symphysis pubis
Pubic crest
n

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20
Q

what is the rectus abdominas muscle divided into?

A

The muscle is divided into segments by tendinous intersections (3/4 on each side) which are attached to the anterior wall of the rectus sheath.

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21
Q

describe the rectus sheath above and below?

What is directly behind the transverses abdominis?

A

The rectus sheath is a tendinous region formed by the aponeuroses of the three lateral muscles

In the upper ¾ of this sheath, the rectus abdominis muscles are completely surrounded by aponeuroses

The entire aponeurosis of the external oblique joins with half of the aponeurosis of the internal oblique to form the anterior wall of the sheath
The other half of the aponeurosis of the internal oblique joins with the aponeurosis of the transversus abdominis to form the posterior wall:

At a point midway between the umbilicus and pubic symphysis (bottom ¼ of the rectus sheath), all of the aponeurosis randomly move to the front only
Therefore all aponeuroses are anterior to the rectus abdominis

The transversalis fascia
The rectus abdominis muscle is in direct contact with the transversalis fascia. The point of transition is called the arcuate line.

22
Q

describe the formation and features of the rectus sheath?

A
  1. Rectus sheath is formed by the aponeuroses of external & internal obliques, and transversus abdominis muscles.
  2. Rectus sheaths meet in the midline - linea alba
  3. The anterior wall of the sheath is complete from the xiphoid process and costal cartilages to pubic symphysis and crest.
  4. Posterior wall of the sheath is incomplete, stops short below the umbilicus at the arcuate line.
  5. Below arcuate line, the rectus abdominis muscle is in contact with the transversalis fascia.
23
Q

what is the most powerful flexor?

A

Rectus abdominis is the most powerful flexor of the vertebral column (lower thoracic & lumbar)

External and internal obliques of both sides are important partners in this action.

24
Q

what muscles are in the posterior abdominal wall muscles?

A

Iliacus muscle: makes the hip joint flex.

Transversus abdominis

Quadratus lumborum: (attachment: lower border of 12th rib and transverse process of 5th lumbar vertebra and adjacent iliac crest)
stabilises the 12th rib and a lateral flexor of the trunk

Psoas major: (attachment: bodies and discs of all 5 lumbar vertebrae and lesser trochanter of femur)

is a flexor of hip and trunk

25
Q

describe the blood supply of the rectus muscle?

A
  1. Superior epigastric artery- terminal branch of internal thoracic
  2. Inferior epigastric artery- branch of external iliac

These two vessels enters the rectus sheath and anastomose forming a potential by-pass to abdominal aorta.

26
Q

blood supply of the flank muscles?

A 
Flank muscles are segmentally supplied
Intercostal arteries 7-11 
Subcostal artery
Lumbar arteries
Deep circumflex iliac arteries
27
Q

describe the innervation of the anterior abdominal wall?

A

Xiphesternum: T6
T7 – epigastrium
T10 – umbilicus
L1 – inguinal ligament

28
Q

describe the innervation of the peritoneum, skin and peritoneum

A

Parietal peritoneum: Same segmental nerves of the body wall provide somatic sensory supply to the underlying parietal peritoneum.

Visceral peritoneum has NO somatic sensory innervation, therefore pain localisation is more difficult

29
Q

describe the motor nerves innervation

A

The skin, muscles and parietal peritoneum are supplied by T7 to T12 and L1 spinal nerves

External oblique – Anterior rami of lower six thoracic spinal nerves (T7 to T12)

Internal oblique & Transversus –Anterior rami of lower size thoracic spinal nerves (T7 to T12) and L1

Rectus – Anterior rami of lower six thoracic spinal nerves (T7 to T12)

The “source” is the anterior rami of these spinal nerves. The anterior rami pass around the body, giving off lateral cutaneous branches (on the left of the diagram) which end as anterior cutaneous branches (right of the diagram)

30
Q

Describe the innervation of the posterior abdominal muscles

A
  • Subcostal N. T12
  • Iliohypogastric N. L1
  • Ilio-inguinal N. L1 supply the antero-lateral abdominal wall.

Motor supply to:
Quadratus lumborum- T12 & L1-L4

Psoas major- L2-L4

Iliacus – femoral n. L2–L4

Lumbar plexus (L1 - L4)
Motor and sensory, mainly for the lower limb.  
Sensory branches to the parietal peritoneum of the posterior abdominal wall
31
Q

How many lymph nodes in the abdominal wall

A

None

32
Q

Describe the lymphatic drainage of the abdominal wall

A

There is superficial and deep drainage.

Superficial tissues:

Above the umbilicus lymph goes up to axillary nodes
Below the umbilicus lymph goes down to the superficial inguinal nodes

Deeper tissues:
Above the umbilicus goes up to parasternal (next to sternum) nodes
Below the umbilicus goes down to para-aortic (next to aorta) and external iliac nodes (harder to remember)

33
Q

where is the inguinal region?

A

It is the Junction between the anterior abdominal wall and the thigh
This area is between the ASIS and the pubic tubercle

The anterior abdominal wall is weakened in the inguinal region ( the muscles are not directly linked to the bone, it is via a ligament which is weak)

34
Q

why is the groin clinically and anatomically important?

A

It is clinically important because it is a potential site where most of the abdominal hernias occur.
It is anatomically important because structures exit and enter the abdominal cavity (e.g. spermatic cord, round ligament, vessels

35
Q

what is the inguinal canal and what is inside it?

A

Just above and parallel to the inguinal ligament
Begins at the deep inguinal ring
Continues for roughly 4cm
Ends at the superficial inguinal ring

Contents of the inguinal canal include:
The ilio-inguinal nerve (does not run in spermatic cord!)
Spermatic cord in men
Round ligament of the uterus in women
The testis and spermatic cord descend from the abdomen into the scrotum via the developing inguinal canal
In females the round ligament descends through the developing inguinal canal

Testes originally form on the posterior abdominal wall, then it descend to the outside, it has to pierce through the abdominal wall: and here a canal forms called the INGUINAL canal: there is anterior, posterior, superior and inferior.

inguinal canal
End up in the superficial inguinal ring (this where the testes has come out)

presence of this causes weakness. Intestine can come out if canal becomes too big

36
Q

what goes through the femoral canal?

A

lymphatics

37
Q

which sex is affected more by hernia

A

Males

38
Q

Two Areas of Inherent Weakness in the Groin

A
  1. Inguinal canal – The testis and spermatic cord descend from the abdomen into the scrotum via the developing inguinal canal. in the female the uterine round ligament descends through the developing inguinal canal. (testicular descent starts after 7th wk of IUL and enter the inguinal canal around 28 wks of IUL and enters the scrotum by 32-36 wks of IUL.)
  2. Femoral canal – Another canal below the inguinal ligament through which femoral artery and vein pass
39
Q

define hernia

A

A hernia* is a condition in which part or whole of an organ or tissue abnormally protrude through the wall of the structure containing the organ or tissue.

*Plural: hernias or herniae

40
Q

what type of hernia can you have

A
  1. Weakness/defect/hole on the wall through which the hernia protrudes
  2. Hernial Sac – e.g. peritoneum with neck, body and fundus
  3. Contents of the hernial sac - e.g. bowel, bladder
41
Q

what are the clinical sign and symptoms of hernia

A

A lump or protrusion in the groin

Appears intermittently or present all the time

Painless/painful and uncomfortable

Hernia may be reducible or irreducible

May be strangulated with tissue death- and associated with vomiting, constipation, intestinal obstruction – this is an emergency situation

42
Q

what are the types of hernia?

A
  1. Inguinal Hernia
    Indirect inguinal hernia
    Direct inguinal hernia

2.Femoral Hernia

43
Q

arrangement and landmark of inguinal canal

A

Oblique passageway in the lower part of the anterior abdominal wall
Present in both males and females, 4 cm long in adults
Lies above the medial half of the inguinal ligament
Extends from deep inguinal ring (a hole in transversalis facia) to superficial inguinal ring (a hole in external oblique aponeurosis)
Deep ring is about 1.5 cm above the midpoint of inguinal ligament
Superficial ring immediately above and medial to pubic tubercle
In males- Contents: spermatic cord, genital branch of genito-femoral nerve and ilioinguinal nerve

In females- Contents: round ligament, genital branch of genito-femoral nerve and ilioinguinal nerve

44
Q

what are the wall of the inguinal canal

A

Anterior wall
External oblique aponeurosis (whole length)
Internal oblique muscle reinforces the lateral 3rd of the canal
Floor
Rolled inferior edge (gutter like) of the external oblique aponeurosis - this is the inguinal ligament (stretches between ASIS and pubic tubercle)

Roof
Arching fibres of the internal oblique muscle and transverse abdominis muscle (whole length)
Medially conjoint tendon*

Posterior wall
Transversalis fascia
Medially conjoint tendon

45
Q

what is conjoint tendon

A

Conjoint tendon = lowest fibres of the internal oblique aponeurosis and similar fibres of the transversus abdominis aponeurosis join to form the conjoint tendon. Conjoint tendon is attached medially to linea alba.

46
Q

what is direct and indirect hernia

A

Direct (acquired) inguinal hernia

A direct hernial defect tends to go through Hesselbach’s Triangle (inguinal traingle) which is always MEDIAL to the inferior epigastric vessels.
-Older age group
Older age group

Acquired defect in posterior wall of the inguinal canal

Associated with chronic straining

Associated with weak musculature

The hernia’s path is straight through the posterior wall of the inguinal canal

Defect is in the posterior wall of the inguinal canal medial to the Inferior epigastric vessels

Indirect (congenital) inguinal hernia

An Indirect hernial defect is always the internal ring which is always LATERAL to the inferior epigastric vessels

Most common type
Tend to be in younger adults and children
The hernia takes an indirect path through the abdominal wall
The defect is a dilated deep ring
The hernia enters the deep ring then passes through the inguinal canal, external inguinal ring and into the scrotum

47
Q

what is femoral hernias?

A

On examination:
Hernia through the femoral canal

Not as common as inguinal hernias

Commoner in elderly and females

Have a high incidence of obstruction and strangulation

Femoral hernias tend to be irreducible, and hot and painful if they are strangulated. They have become so large it wont move back.

They can be distinguished from inguinal hernias because they appear below and lateral to the pubic tubercle

Inguinal hernias are above and medial to the pubic tubercle

Superior – Inguinal ligament
Inferior – Pectineus fascia
Medial – Lacunar ligament
Lateral – Femoral vein

48
Q

what is the mid-inguinal point and the midpoint of the inguinal ligament?

A

Mid-inguinal point–halfway between the pubic symphysis and the anterior superior iliac spine. The femoral pulse can be palpated here.

Midpoint of the inguinal ligament– halfway between the pubic tubercle and the anterior superior iliac spine (the two attachments of the inguinal ligament). The deep inguinal ring is located just above this point.

49
Q

what is the deep inguinal ring?

A

The deep inguinal ring is a hole in the transversalis fascia and is 1.5cm above the midpoint between the anterior superior iliac spine and the pubic symphysis (this is the mid-inguinal point)
At the deep inguinal ring, part of the transversalis fascia can form part of the spermatic cord/round ligament of the uterus
The superficial inguinal ring is the end of the inguinal canal and is superior to the pubic tubercle.
It is a triangular opening in the aponeurosis of the external oblique (diagram)
At the deep inguinal ring, part of the transversalis fascia forms one of the covering for the spermatic cord (called the internal spermatic fascia). In women the transversalis fascia is involved in forming the round ligament of the uterus.

As with the deep inguinal ring, the superficial inguinal ring is actually the beginning of the tubular evagination of the aponeurosis of the external oblique onto the structures traversing the inguinal canal and emerging from the superficial inguinal ring. This continuation of tissue over the spermatic cord is theexternal spermatic fascia.

50
Q

what are the boundaries of the inguinal canal?

A

Roof – 2 Muscles

  • Internal oblique muscle
  • Transverse abdominis muscle

Anterior wall – 2 Aponeurosis
-External oblique aponeurosis (whole length)
-Internal oblique aponeurosis
reinforces the lateral 3rd of the canal*

Floor – 2 Ligaments

  • Inguinal ligament
  • Lacunar ligament

Posterior wall – 2 T’s

  • Transversalis fascia
  • Conjoint tendon
  • Conjoint tendon = lowest fibres of the internal oblique aponeurosis and similar fibres of the transversus abdominis aponeurosis join to form the conjoint tendon. Conjoint tendon is attached medially to linea alba

lss 2:anatomy of the abdomen, pelvis & perineum (7 decks)

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