Anesthesia care for Abdominal Procedures Flashcards
Describe anesthetic considerations, Identify appropriate management plans, Discuss alternative anesthetic techniques, Summarize anesthetic implications and management and Summarize the potential surgical anesthetic risks/complications for abdominal surgery.
Name the Intraperitoneal Abdominal Organs
SDS JILT S = Stomach D = (Bulb of) Duodenum S = Spleen J = Jejunum I = Ileum L = Liver T = Transverse colon, and sigmoid colon
Name the Retroperitoneal Abdominal Organs
SAD PUCKER S = Suprarenal (adrenal) glands. A = Aorta/Inferior Vena Cava. D = Duodenum (second and third segments) P = Pancreas. U = Ureters. C = Colon (ascending and descending only) K = Kidneys. E = Esophagus. R = Rectum (sigmoid)
What are the Functions of the Abdominal Wall?
-Form firm flexible wall keep viscera in abdominal cavity
-Protect viscera from injury & maintain integrity of wall
-Maintain anatomical position against gravity
-Assist in respiration, forceful ventilation
-Involved in any action increasing abdominal pressure (cough)
assist with respiration and control the expulsive efforts of urination, defecation, coughing, and parturition. They also work with the back muscles to flex and extend the trunk at the hips, rotate the trunk at the waist, and protect viscera by becoming rigid.
What are the 9 Layers of the Abdominal Wall?
- Skin
- Subcutaneous tissue
- Superficial fascia
- External oblique muscle
- Internal oblique muscle
- Transversus abdominis muscle
- Transversalis fascia
- Preperitoneal adipose & areolar tissue
- Peritoneum
Nerves, blood vessels, and lymphatics are present throughout.
Describe the Superficial Fascia.
- Fatty connective tissue
- Above umbilicus is a single fascial sheet
- Below umbilicus are 2 fascial sheets
- Superficial vessels, lymph nodes & nerves in between
- Important Features of Superficial Fascia:
- Superficial fascia is most distinct in the lower part of the anterior abdominal wall, perineum, and the limbs.
- Superficial fascia shows stratification (into two layers) in the lower part of anterior abdominal wall, perineum, and uppermost parts of thighs.
Describe & Name Flat Muscles of Abdominal Wall.
How many are there?
3 Flat Muscles of Abdominal Wall are:
External Oblique
Internal Oblique
Transversus Abdominis
These muscles are located laterally in the abdominal wall, stacked upon one another. Running in different directions & crossing each other strengthening the wall, and decreasing the risk of herniation.
Each flat muscle forms an aponeurosis (a broad, flat tendon) which covers the vertical rectus abdominis muscle. The aponeuroses of all the flat muscles become entwined in the midline, forming the linea alba.
What is the Linea Alba?
The white line (Latin: linea alba) is a fibrous structure that runs down the midline of the abdomen in humans and other vertebrates. In humans linea alba runs from the xiphoid process to the pubic symphysis.
It is formed by the fusion of the aponeuroses of the abdominal muscles & it separates the left and right rectus abdominis muscles. In muscular individuals its presence can be seen on the skin, forming the depression between the left and right halves of a “six pack”.
Because it consists of mostly connective tissue, and does not contain any primary nerves or blood vessels, a median incision through the linea alba is a common surgical approach.
Discuss the flat muscle: External Oblique.
Originates from Ribs 5-12
Inserts into Iliac Crest and pubic tubercle
Contralateral rotation torso.
Innervation: Thoracoabdominal nerves (T7-T11) and subcostal nerve (T12).
External oblique important functions:
- major role in maintenance of abdominal tone.
- It helps in completion of micturition, parturition and defecation & vomiting by compressing the abdominal contents.
- assists in flexing and rotating the trunk.
- assists in forced expiration.
Discuss the flat muscle: Internal Oblique:
Originates from Inguinal ligament, iliac crest and lumbodorsal fascia,
Inserts into ribs 10-12
Bilateral contraction compresses the abdomen, while unilateral contraction ipsilaterally rotates the torso.
Innervation: Thoracoabdominal nerves (T6-T11), subcostal nerve (T12) and branches of the lumbar plexus.
Internal Oblique important functions:
- Supports the abdominal wall.
- Assists in forced respiration.
- Aids in raising pressure in the abdominal area.
- Rotates and turns the trunk with help from other muscles.
Discuss the flat muscle: Transversus Abdominis:
Originates from Inguinal ligament, costal cartilages 7-12, the iliac crest and thoracolumbar fascia
Inserts into the conjoint tendon, xiphoid process, linea alba and the pubic crest.
Compression of abdominal contents.
Innervation: Thoracoabdominal nerves (T6-T11), subcostal nerve (T12) and branches of the lumbar plexus.
Vertical Muscles–Rectus Abdominis
The rectus abdominis is long, paired muscle, found either side of the midline in the abdominal wall. It is split into two by the linea alba.
At several places, the muscle is intersected by fibrous strips, known as tendinous intersections. The tendinous intersections and the linea alba give rise to the ‘six pack’ seen in individuals with a well-developed rectus abdominis.
Attachments: Originates from the crest of the pubis, before inserting into the xiphoid process of the sternum and the costal cartilage of ribs 5-7.
Functions: As well as assisting the flat muscles in compressing the abdominal viscera, the rectus abdominis also stabilizes the pelvis during walking, and depresses the ribs.
Innervation: Thoracoabdominal nerves (T7-T11).
Vertical muscles–Pyramidalis
This is a small triangular muscle, found superficially to the rectus abdominis. It is located inferiorly, with its base on the pubis bone, and the apex of the triangle attached to the linea alba.
Attachments: Originates from the pubic crest and pubic symphysis before inserting into the linea alba.
Functions: It acts to tense the linea alba.
Innervation: Subcostal nerve (T12).
What structures/organs are perfused by the inferior mesenteric artery (IMA)?
Perfusion of abdominal structures: IMA
The inferior mesenteric artery (IMA) supplies arterial blood to the organs of the hindgut – the distal 1/3 of the transverse colon, splenic flexure, descending colon, sigmoid colon and rectum.
What are 3 major branches from the IMA?
left colic artery,
sigmoid artery
superior rectal artery.
What structure does the IMA branch from?
The inferior mesenteric artery (IMA) is a major branch of the abdominal aorta.
What structures/organs are perfused by the superior mesenteric artery (SMA)?
The SMA supplies the intestine from the lower part of the duodenum through two-thirds of the transverse colon, as well as the pancreas.
What structure does the SMA branch from?
The superior mesenteric artery (SMA) arises from the anterior surface of the abdominal aorta, just inferior to the origin of the celiac trunk,
Perfusion abdominal structures: Superior Mesenteric Artery (SMA)
Branch: inferior pancreaticoduodenal artery
Supplies: head of the pancreas and to the ascending and inferior parts of the duodenum
Branch: intestinal arteries
Supplies: branches to ileum, branches to jejunum
Branch: ileocolic artery
Supplies: supplies last part of ileum, cecum, and appendix
Branch: right colic artery
Supplies: to ascending colon
Branch: middle colic artery
Supplies: to the transverse colon
What are the two systems responsible for venous drainage of abdominal structures?
Two venous systems drain abdominal structures:
Portal system transports venous blood to liver for processing via Portal Vein.
Systemic venous system returns deoxygenated blood to right atrium of the heart via the Inferior Vena Cava (IVC).
What are the Portal Veins (PV) functions?
Carries venous blood to liver for processing. Portal Vein (PV) drains spleen, pancreas, gallbladder, abdominal part of GI tract. Portal Vein is formed by the union of the splenic vein & the superior mesenteric vein, posterior to the neck of the pancreas, at the level of L2.
What Tributaries does the Portal Vein receive?
PV receives additional tributaries from: R&L Gastric, Cystic (Gb), Para-umbilical
Immediately before entering the liver, the portal vein divides into R&L branches which then enter the parenchyma of the liver separately.
What is the Role of the Inferior Vena Cava (IVC)?
Systemic venous system returns blood to right atrium of the heart.
Transports de-oxygenated blood to Right Atrium
The Inferior Vena Cava—Posterior Abdominal Wall (anterior Vertebral Column & Right of Aorta) responsible for venous drainage of all structures below the diaphragm. IVC receives tributaries from common iliac, lumbar, renal (drains kidneys-left adrenal-left testes/ovaries), right suprarenal, right testicular/ovarian, inferior phrenic & hepatic veins
Explain Langer’s lines:
Ideally an incision should provide easy access to desired structures, be aesthetically pleasing & heal quickly w minimal scarring.
Also known as skin cleavage or tension lines.
Considered to affect scarring and outcome, Langers Lines are suggestions for incisional sites.
What is the Clinical Relevance of the Vertical Abdominal Incision– Median?
Median
An incision that is made through the linea alba. It can be extended the whole length of the abdomen, by curving around the umbilicus. The linea alba is poorly vascularized, so blood loss is minimal, and major nerves are avoided. All can be used in any procedure that requires access to the abdominal cavity.
What is the Clinical Relevance of the Vertical Abdominal Incision– Paramedian?
Paramedian
Similar to the median incision, but is performed laterally to the linea alba, providing access to more lateral structures (kidney, spleen and adrenals). This method ligates the blood and nerve supply to muscles medial to the incision, resulting in their atrophy.
What is the Clinical Relevance of the Transverse Abdominal Incision– Suprapubic (Pfannenstiel)?
Suprapubic (Pfannenstiel)
are made 5cm superior to the pubis symphysis.
used when access to the pelvic organs is needed.
care must be taken not the perforate the bladder as the fascia thins around the bladder area.
What is the Clinical Relevance of the Transverse Abdominal Incision– Subcostal?
Subcostal
starts inferior to the xiphoid process, and extends inferior parallel to the costal margin.
mainly used on the right side to operate on the gall bladder and on the left to operate on the spleen.
What is the Clinical Relevance of the Transverse Abdominal Incision– McBurney?
McBurney
a ‘grid iron’ incision (consists of two perpendicular lines, splitting the fibres of the muscles without cutting them) – this allows for excellent healing.
performed at McBurney’s point (1/3 of the distance between the ASIS {anterior superior iliac spine and the umbilicus).
mostly used in appendectomies.
