Anatomy - Hernias and Peritoneal Cavity Flashcards
What is a hernia?
When an organ or structure protrudes through a wall that normally confines it
What are the 2 types of inguinal hernias? Describe their respective relationships with the inguinal canal.
Direct: Bowel is not travelling through the inguinal canal
Indirect: Bowel enters the inguinal canal
What are the borders of Hesselbach’s triangle?
Medial border
Superolateral border
Inferior border
Medial border: Lateral margin of rectus abdominis
Superolateral border: Inferior epigastric vessels
Inferior border: Inguinal ligament
Which type of inguinal hernia occurs WITHIN Hesselbach’s triangle?
Direct inguinal hernias
Which type of inguinal hernia occurs outside of the Hesselbach’s triangle?
Indirect inguinal hernias (protrude through the abdominal wall ABOVE the epigastric vessels)
Superficial inguinal ring is…
a) on the inside of the abdomen
b) on the outside of the abdomen
b) on the outside of the abdomen
What about the abdominal wall region defined by Hesselbach’s triangle is special?
The Hesselbach’s triangle marks a weakness in the abdominal wall, where there is a deficiency in the strong muscle layers of the abdominal wall because this is where the inguinal canal is coursing.
In terms of the inferior epigastric artery, where do direct vs indirect inguinal hernias occur?
Direct: Occurs MEDIAL to the inferior epigastric artery, i.e. within Hesselbach’s triangle
Indirect: Occurs LATERAL to the inferior epigastric, i.e. outside Hesselbach’s triangle
Which type of inguinal hernia is usually present in adults? Which is more common in children?
Adults: direct hernia
Children: indirect hernia
What is the most common inguinal hernia (in both males and females)
Indirect inguinal hernia
What is the main reason for developing a direct inguinal hernia?
It usually results from a weakening in the conjoint tendon and/or transversalis fascia.
What is the main reason for developing an indirect inguinal hernia?
It is facilitated by a patent processus vaginalis.
What is a distinctive feature of direct inguinal hernias?
Usually reduces when a patient lies down.
What is a distinctive feature of indirect inguinal hernias?
Passes THROUGH the deep inguinal ring and into the canal. May extend far enough to emerge from the superficial inguinal ring.
Which type of inguinal hernia tends to be acquired? Which one tends to be congenital?
Acquired: direct
Congenital: indirect
The processus vaginalis is a temporary process formed when the testes drag down layers of the abdominal wall during embryological development.
Normally, what happens to the processus vaginalis after birth?
It normally obliterates shortly after birth.
Before the processus vaginalis obliterates, it allows communication between…
the scrotal region and the abdominal cavity.
What can happen if the processus vaginalis DOES NOT obliterate (i.e. remains patent)?
The scrotal region and abdominal cavity remain connected and can communicate with one another.
This patent processus vaginalis can then allow a loop of bowel to go through it and enter the inguinal canal.
This is how an indirect inguinal hernia occurs!
A 3rd type of groin hernia, unrelated to the inguinal canal.
Femoral hernia
Where do femoral hernias occur?
Just inferior to the inguinal ligament.
What abdominal wall weakness can result in femoral hernias?
In the case of femoral hernias, abdominal contents can pass through a natural weakness in the anterior abdominal wall called the FEMORAL CANAL.
How frequent are femoral hernias in men vs women?
Men: very rare
Women: account for ~25% of groin hernias
What is the femoral ring?
An opening through which the femoral artery and vein exit the abdominal cavity to reach the thigh (creates a weakness in the abdominal wall below the inguinal ligament).
What is an aberrant obturator artery?
Normally, the obturator artery (in the thigh region) branches off of the internal iliac artery.
However, sometimes, it may branch off of the epigastric artery.
What is the risk of having an aberrant obturator artery in the context of a femoral hernia?
It is at risk of ligation during femoral hernia repair (surgery) - this can lead to downstream problems.
Overall, groin hernias are more common in…
a) men
b) women
a) men (80:20 ratio)
True or false: The processus vaginalis only develops in males.
FALSE: Processus vaginalis develops both in males and females.
Compare the incidence of femoral, direct and indirect hernias in men vs women.
Men:
* Most hernias are indirect
* ~33% are direct
* Femoral are very rare
Women:
* Most (~50%) hernias are indirect
* ~25% femoral
* ~25% direct
Most common type of groin hernia (both for men and women)
Indirect hernias
What is a common cause of anterior abdominal wall hernias?
Weaknesses in the anterior abdominal wall caused by past surgical procedures (postoperative, incisional).
The peritoneal cavity shares common origin with… (2)
pleural cavity (lungs)
pericardial cavity (heart)
Note: The peritoneal space is a potential space that is normally empty (free air), but could be penetrated and filled with xyz.
What is the mesentery?
It is a fold of the peritoneum that suspend certain organs in the abdominal cavity.
Note: Mesentery is a double sheet of peritoneal membrane.
Intraperitoneal organs are … by the visceral peritoneum
Nearly entirely covered by the visceral peritoneum.
They move around freely in the abdomen
What are retroperitoneal organs?
Organs that only have peritoneum on their anterior surface and cannot move freely in the abdomen.
What are the 2 types of retroperitoneal organs? Define these two types.
Primarily retroperitoneal:
Structures that were retroperitoneal during the entirety of development
Secondarily retroperitoneal:
Structures that were originally suspended within the abdominal cavity by mesentery, but during development migrated posterior to become retroperitoneal.
Name the 6 primarily retroperitoneal organs
- adrenal glands
- kidneys
- ureters
- bladder
- aorta
- inferior vena cava
Name 4 secondarily retroperitoneal organs
- ascending colon
- descending colon
- duodenum (2nd and 3rd parts)
- pancreas (except tail)
Which regions of the duodenum are intraperitoneal? Which regions are retroperitoneal?
Intraperitoneal: 1st and 4th part
Retroperitoneal: 2nd and 3rd part
What is the greater Omentum?
It is a peritoneal fold that hangs down from the greater (inferior) curvature of the stomach and covers the small intestine, like an apron.
The greater omentum hangs down from the stomach and reflects back onto…
the transverse colon
What is the Mesentery proper?
Fold of the peritoneum that suspends the jejunum and ileum (regions of the small intestine)
Other than securing the SI to the posterior abdominal wall, what is another importance of the Mesentery proper?
The blood supply to the intestines travels through this structure!
What is the lesser Omentum?
Peritoneal fold that stabilizes the stomach and provides a route for neurovasculature to reach the liver
What is the transverse mesocolon?
A peritoneal fold that supports the transverse colon, extending from the pancreas on the posterior wall of the abdomen
What is the sigmoid mesocolon?
A peritoneal fold that supports the sigmoid colon
The greater sac and lesser sac are both regions of the peritoneal cavity. They are connected by a thin recess called…
epiploic foramen
What is the Pringle Maneuver?
When you clamp down the portal triad, allowing your finger into the lesser sac of the peritoneal cavity.
2 ligaments of the lesser omentum
Hepatogastric ligament (liver to lesser curvature of the stomach)
Hepatoduodenal ligament (liver to duodenum)
What is the name of the ligament (part of the greater omentum) that connects the the greater curvature of the stomach to the transverse colon?
Gastrocolic ligament
Gastrocolic ligament
Part of the greater omentum
Connects the greater curvature of the stomach to the transverse colon
The lesser omentum (specifically the hepatoduodenal lig.) contains….
the portal triad (bile duct, hepatic artery, portal vein)
vasculature runs through the omenta, allowing the organs to be supplied with blood despite being suspended in the cavity
The spleen and stomach are connected by..
gastrosplenic ligament
The spleen and kidney are connected by…
splenorenal ligament
Falciform ligament
Ligament that attaches the liver to the anterior body wall (broad and thin peritoneal fold)
Coronary ligament
Connect the liver to the diaphragm
Triangular ligaments
continuous with coronary ligament, help attach the liver to the diaphragm
The round ligament is a fetal remnant of…
fetal umbilical vein (contained within falciform ligament)
What is the “bare area” of the liver
A region of the liver (on the posterior side) that is not covered by peritoneum, but is in direct contact with the diaphragm.
This is where the blood vessels can access the liver
What do we call peritoneal recesses that lie lateral to the ascending and descending colon?
Right and left paracolic gutter
The right paracolic gutter may facilitate…
the spread of infection
The 9 abdominal regions are delineated by 3 lines/planes…
- Midclavicular line
- Subcostal plane
- Intertubercular plane
Which abdominal quadrant encompasses the following organs:
* Liver
* Gallbladder
* Duodenum
* Pancreas
* Kidney
* Ascending colon
* Transverse colon
Right upper quadrant
Which abdominal quadrant encompasses the following organs:
* Stomach
* Spleen
* Liver
* Pancreas
* Kidney
* Transverse colon
* Descending colon
Left upper quadrant
Which abdominal quadrant encompasses the following organs:
* Descending colon
* Sigmoid colon
* Reproductive organs
Left lower quadrant
Which abdominal quadrant encompasses the following organs:
* Cecum
* Appendix
* Ascending colon
* Reproductive organs
Right lower quadrant
Name the 8 abdominal regions, going from top-to-bottom and right-to-left
- Right hypochondriac
- Right lumbar
- Right iliac (inguinal)
- Epigastric
- Umbilical
- Hypogastric
- Left hypochondriac
- Left lumbar
- Left iliac (inguinal)
