General Questions Flashcards
- The abdomen is the region between the ___ and ____ .
Thorax and pelvis
- The separation between the thorax and the abdomen is the _____ diaphragm
Respiratory
- When separating the abdomen into four quadrants, the ____ is the midpoint.
Umbilicus
Name the four quadrants of the abdomen
We have a right upper quadrant, right lower quadrant, left upper quadrant, and left lower quadrant for the abdomen.
When we talk about the anterolateral abdominal wall, we are talking about the ____ margin that is approximately from rib _ to rib _ and the ___ process on each side
subcostal, rib 10 to rib 7, xiphoid
What are the four muscles that makeup the anterolateral abdominal wall?
The rectus abdominis, the external oblique, the internal oblique, and the transverse abdominis
What are the muscles from superficial to deep in the anterolateral abdominal wall ?
The rectus abdominis, the external oblique, the internal oblique, and the transverse abdominis
The rectus abdominis is encased in a tendinous sheath or aponeurosis of the other (__) anterolateral abdominal wall muscles.
Three
The 3 aponeurosis’ are fused along the midline at what is called the ____ and they are fused at what is called the ____ . They split again. They surround the rectus abdominis and reattach and refuse at the linea alba.
linea alba; semi lunar line
As the external oblique runs down in an inferomedial direction, the outer layer of the sheath definitely (does not have/has) external oblique aponeurosis in it, but we can’t say for sure how much of the internal oblique aponeurosis and how much of the transverse abdominis aponeurosis is in it.
Has
The (external oblique/rectus abdominis) is a vertically oriented muscle that runs from the subcostal margin to the superior ramus and body of the pubic bone
rectus abdominis
There are transverse intersections of tendon on the (rectus abdominis/internal oblique) and what this does is it separates the muscle into variably distinct segments and that allows for a change in pull of the muscle as it contracts at each segment.
rectus abdominis
The (internal oblique/external oblique) has an inferomedial fiber orientation.
External oblique
The (rectus abdominis/external oblique) has multiple attachment sites and it is covering the entire anterolateral abdominal wall. It is the most external component.
External oblique
The (rectus abdominis/internal oblique) has a superomedial fiber orientation and almost a 90-degree change in orientation from the fibers of the external oblique.
Internal oblique
The internal oblique is attached to part of the inguinal ligament (not distally), but as it comes through the inferior portion of the abdomen, it joins with the transverse abdominis tendon and creates what is called the ____ tendon.
Conjoint
The internal oblique covers (the entire/ half of the) anterolateral abdominal wall.
The entire
The internal oblique runs further (anteriorly/posteriorly) than the external oblique and it attaches to the thoracolumbar fascia.
Posteriorly
The thoracolumbar fascia has this combined connection with what two muscles in the anterolateral abdominal wall?
Those two muscles will surround the quadratus lumborum with its anterior layer and middle layer, so there is a connection with these two muscles to lumbar stability. When it contracts it will pull on the thoracolumbar fascia and that is going to effect spinal stability.
The internal oblique and transverse abdominis
If we go with standing position (up right anatomic position) and I draw a line of pull. If the internal oblique contracts, the moving component is the (pelvis/thorax) and the line of pull is (contralateral/ipsilateral).
thorax; ipsilateral
So, when we are in anatomical neutral with feet on the ground and we contract our left internal oblique, it is going to contract to the (right/left)
Left
If the thorax is the moving component, the right external oblique when contracted will pull the thorax to the (right/left).
Left
The left internal oblique and the right external oblique can work (against each other/synergistically) together to turn the trunk.
synergistically
In anatomic neutral with our feet on the ground, using the trunk as the moving component, the external obliques when it contracts will turn the trunk (contralaterally/ipsilaterally).
Contralaterally
In anatomic neutral with our feet on the ground, using the trunk as the moving component, the internal obliques when it contracts will turn the trunk (contralaterally/ipsilaterally).
ipsilaterally
In anatomic neutral with our feet on the ground, using the pelvis as the moving component, the internal obliques when it contracts will turn the trunk (contralaterally/ipsilaterally).
Contralaterally
If the internal oblique and external oblique on the same side contract, you are going to get a (rotation/side bend) versus gravity.
Side bend
A synergistic action between the internal and external obliques will go in the direction of the (external/internal) oblique if the thorax is the moving component.
Internal
The transverse abdominus along with the internal oblique join with the thoracolumbar fascia (anteriorly/posteriorly). (Anteriorly/posteriorly) they join together at the conjoint tendon.
posteriorly; anteriorly
The conjoint tendon can be found (inferior/superior) to the superficial ring of the inguinal canal and you are going to find it (superficial/deep) to the external oblique aponeurosis and (medial/lateral) to the rectus abdominis.
superior; deep; lateral
The nerves and blood vessels of the anterolateral abdominal wall will run in-between what two muscles?
The internal oblique and transverse abdominis
The ventral rami that are coming around anteriorly from T7-T11 are known as ___ nerves because they run around the ribs. But when they enter the abdomen as they continue along their path and enter the abdomen, they become the ___ nerves.
intercostal; thoraco-abdominal
The T12 intercostal nerve is called the ____ nerve and it continues to the posterior abdominal wall and helps supply the anterolateral abdominal wall muscles.
Subcostal
The subcostal artery is at the level of T__
12
Anything that has the name SUBcostal means that it is below the level of T__
12
The lumbar portion of the lumbosacral plexus (lumbar plexus) originates inside the ____ muscle .
Psoas major
The psoas major and quadratus lumborum aid in lumbar (mobility/stability).
Stability
The inguinal ligament runs from the ____ to the _____
ASIS to the pubic tubercle
The inguinal canal is located (superior/inferior) to the inguinal ligament
Superior
The midpoint of the inguinal ligament is the location of the (superficial/deep) inguinal ring
Deep
From the midpoint of the inguinal ligament, just lateral to the pubic tubercle (4-5 cm long, sloping inferomedially) is the ____ canal.
Inguinal
The inguinal canal is (on top of/under) the inguinal ligament and the inguinal ligament is a part of the inguinal canal. The inguinal canal is not the full length of the inguinal ligament.
On top of
The inguinal ligament is part of the (internal/external) oblique aponeurosis. It is a thickening of the most inferior portion of the (internal/external) oblique to create that inguinal ligament.
external; external
At the transversalis fascia is where you are going to find the (superficial/deep) inguinal ring.
Deep
The deep inguinal ring is found more (medial/lateral) to the superficial inguinal ring.
Lateral
The superficial ring of the inguinal canal comes out through the (internal/external) oblique aponeurosis.
External
What makes up the floor of the inguinal canal ?
The inguinal ligament
What makes up the roof of the inguinal canal?
The internal oblique and the transverse abdominis
What makes up the anterior wall of the inguinal canal?
The external oblique aponeurosis
What makes up the posterior wall of the inguinal canal?
The transversalis fascia, the inferior fibers of the internal oblique, and the conjoint tendon
The (superficial/deep) ring of the inguinal canal is a defect (there is a hole and it is not perfectly covered like it is supposed to be) of the external oblique aponeurosis and it’s an actual ring.
Superficial
The (superficial/deep) inguinal ring is a depression more than a hole.
Deep
The superficial inguinal ring and deep inguinal ring (do not overlap/ overlap) and that’s important because if they overlap and you increase your abdominal pressure, a lot of stuff would come right out of the hole, so this is a way of keeping stuff in the pelvic cavity versus letting it shoot outside.
Do not overlap
As we contract our (internal/external) oblique muscle, we are compressing the superficial ring against the posterior abdominal wall.
External
The idea of the ___ canal is to get certain things out of the pelvic cavity to the external environment, but not allow things that aren’t supposed to come out slide out.
inguinal
The ___ cord exits the superficial ring and this cord contains the ductus deferens and associated blood vessels and lymph nodes
Spermatic
You will find the spermatic cord and a branch of the ilioinguinal nerve coming out of the superficial ring of the inguinal canal for a biological (male/female).
Male
You will find the round ligament of the uterus and the branch of the ilioinguinal nerve coming out of the superficial ring of the inguinal canal for a biological (male/female).
Female
In an (direct/indirect) inguinal hernia, what is coming out, is coming through that canal.
Indirect
In a (direct/indirect) inguinal hernia, what is coming out, is coming out next to the canal.
Direct
The (direct/indirect) inguinal hernia is the more common hernia and the hernia they used to perform in sports physicals.
Indirect
A (direct/indirect) inguinal hernia is where there is a weakness in the abdominal wall muscles and it pushes through them and exits through the superficial inguinal ring in the process.
Direct
An (direct/indirect) inguinal hernia can be formed if pressure builds up in the abdomen and if there is any opening in the deep inguinal ring it is going to get pushed into the canal and as the pressure keeps building up it can work its way down the canal.
Indirect
A (direct/indirect) inguinal hernia means you tore something in the abdomen wall or you had a defect there that no one knew about and the increased intrabdominal pressure pushed it out.
Direct
For athletic pubalgia (sports hernia), what we know for sure is that there is a weakness or deficit of some sort in the ___ region but there’s no actual herniation of the tissue. There are no intestines coming out.
Inguinal
In athletic pubalgia there are many tendons and ligaments coming together and they are all pulling on each other, and when there’s weakness in one it is going to lead to (increased/decreased) tension on the other and that is when patients end up with athletic pubalgia.
Increased
The spleen is in the (right/left) (upper/lower) quadrant of the abdominal viscera
Left upper
Half of the descending colon is in the (right/left) upper quadrant and (right/left) lower quadrant of the abdominal viscera
left; left
The kidneys are found in the right and left posterior abdominal wall and found in the right and left (upper/lower) quadrants of the abdominal viscera
Upper
The stomach is found in the (right/left) (upper/lower) quadrant of the abdominal viscera
Left upper
The liver is found in the (right/lower) (upper/lower) quadrant of the abdominal viscera
Right upper
The ascending colon is in the (right/left) upper and lower quadrant of the abdominal viscera
Right
The duodenum is in the (right/left) (upper/lower) quadrant of the abdominal viscera
Right upper
The abdominal aortic artery runs right down the midline of your vertebral bodies (T__ - L_).
T12-L4
You will find the uterus in the (abdominal/pelvic) cavity for biological females.
Pelvic
You will find the urinary bladder in the (abdominal/pelvic) cavity for both biological males and females.
Pelvic
The greater ___ is part of the (parietal/ visceral) peritoneum that makes up the surrounding lining or internal surface of the abdominal pelvic wall.
omentum; visceral
The (parietal/visceral) peritoneum is very large and covers the whole area on the inner wall
Parietal
The (parietal/visceral) peritoneum is smaller than the parietal peritoneum and covers each individual organ.
Visceral
The (parietal/visceral) peritoneum lines the internal abdominal pelvic wall and the (parietal/visceral) peritoneum lines the actual viscera themselves, so it is two layers.
parietal; visceral
To get to the spleen you have to move the ___
Stomach
The kidneys are retroperitoneal, they sit (in front of/behind) the (parietal/visceral) peritoneum in the right and left quadrants of the abdominal viscera.
behind; parietal
At L__the abdominal aorta splits into common iliac arteries.
4
You will find the fallopian tube (uterine tube) in the (abdominal/pelvic) cavity for biological females.
Pelvic
What is the origin of external oblique?
It arises just lateral to the anterior extremities of the lower eight ribs. The Upper four interdigitate with serratus anterior and the Lower four interdigitate with lat dorsi.
Describe the insertion of external oblique
It inserts into the outer half of the iliac crest, inguinal ligament, pubic tubercle, the aponeurosis of the rectus sheath and linea alba, and xiphisternum
Borders of external oblique
It has Three borders: a posterior muscular, and an upper and lower aponeurotic. The first two lie free. The latter is rolled.
Arterial supply of external oblique
Branches of superior and inferior epigastric, superficial epigastric, the lumbar and deep circumflex arteries, superficial circumflex iliac arteries, ascending branch of deep circumflex artery
Borders of lumbar triangle of petit
Anterior border is the posterior margin of external oblique
Posterior border is the anterior margin of lat dorsi
Base is the iliac crest
Floor is the internal oblique
What artery is at risk in a gridiron incision?
The ascending branch of the deep circumflex iliac artery
What planes divide the abdomen into nine regions?
Left and right midclavicular lines: extend down to midinguinal points
Intertubercular plane: runs between the tubercles of the iliac crests
Transpyloric plane: found midway between the jugular notch and the top of the pubic symphysis. (Some clinicians use the supcostal plane, a little lower).
Name the nine abdominal regions
Three rows from superior to inferior:
Left and right hypochondral and epigastric
Left and right lumbar and umbilical
Left and right iliac and hypogastric or suprapubic
Innervation of external oblique
Lateral cutaneous branches of the lower intercostal and subcostal nerves (T7-12)
What are the attachments and significance of the upper border of the external oblique aponeurosis
Runs free from the fifth rib to the xiphisternum. Is the only structure in the anterior rectus sheath above the costal margin.
Describe the Innervation of internal oblique
Lower intercostal and subcostal nerves (T7-12) and iliohypogastric and ilioinguinal nerves (L1). The lowest fibres are innervated by L1 which is hence responsible for the integrity of the inguinal canal
Innervation of transversus abdomens
Lower intercostal and subcostal nerves (T7-12) and iliohypogastric and ilioinguinal nerves (L1). The lowest fibres are innervated by L1 which is hence responsible for the integrity of the inguinal canal
Innervation of pyrimidalis
Subcostal nerve T12
Origin and insertion of the inguinal ligament of Poupart
ASIS to pubic tubercle
What happens to the inguinal ligament when the thigh is extended?
The fascia lata pulls the ligament downward in a gentle convexity
What abdominal muscles arise from which part of the inguinal ligament?
The edge of the ligament is inrolled. The internal oblique and transverses muscles arise from the lateral part of this gutter
Describe the relations of the superficial inguinal ring
V shaped gap above and lateral to the pubic tubercle. The gap extends down to the pubic crest, medial to the tubercle. The aponeurosis is attached to the medial part of the pubic crest, beside the pubic symphysis.
Describe the relations and give the eponym of the lacunar ligament
Gimbernat
Arises from the medial end of the inguianl ligament and extends backwards to the pectineal line
What are the intercrural fibres?
Found at the apex of the superficial inguinal ring, fibres running at right angles to those of the aponeurosis. These blend and prevent the crura from separating.
Where does the reflected part of the inguinal ligament run?
From the pubic tubercle, fibres running upwards and medially behind the spermatic cord to interdigitate in the linea alba
The linea alba is (vascular/avascular)
Avascular
Origin of internal oblique muscle
Lumbar fascia, anterior two thirds of iliac crest and lateral two thirds of inguinal ligament
Insertion of internal oblique muscle
Costal margin, aponeurosis of rectus sheath (both ant and post), conjoint tendon to pubic crest and pectineal line.
The anterior configuration changes at the conjoint tendon
A free lower border arches over the spermatic cord - laterally in front of the cord, medially behind the cord
Origin of transverse abdominis
Costal margin (from inside each costal cartilage, interdigitating with the costal origins of the diaphragm), lumbar fascia of quadrates lumborum,internal lip of iliac crest, the fascia over iliacus, and the lateral half of inguinal ligament deep to OM
Insertion of transverses abdominus
Aponeurosis of post rectus sheath above arcuate line, and ant rectus sheath below arcuate line, fusing behind Internal Oblique Muscle fibres then together forming the conjoint tendon to pubic crest and pectineal line
Origin of rectus abdominus
Two heads per belly; medial from pubic crest and lateral from pubic symphysis.
Insertion of rectus abdominus
Most to 5th, 6th, 7th costal cartilages (= EOM), some to medial inferior costal margin (i.e. lower border of 7th costal cartilage = IOM, and the xiphisternal fibres of the diaphragm = int oblique)
IOM= internal oblique muscle
EOM= external oblique muscle
Insertion of rectus abdominus
Most to 5th, 6th, 7th costal cartilages (= EOM), some to medial inferior costal margin (i.e. lower border of 7th costal cartilage = IOM, and the xiphisternal fibres of the diaphragm = int oblique)
IOM= internal oblique muscle
EOM= external oblique muscle
Action of rectus abdominus
Flexes trunk, aids forced expiration and increases Intra abdominal pressure
Action of external and internal oblique muscles
Support, expiration, raises intra abdominal pressure (IAP) and with muscles of opposite side abducts and rotates trunk
Action of transversus abdominus
Support, expiration, conjoint tendon supports inguinal canal
Action of pyrimidalis
Reinforces rectus sheath
Origin of pyrimidalis
Pubic crest, anterior to origin of rectus abdominus, but posterior to RA’s sheath.
Insertion of pyrimidalis
Lower linea alba, approx 4cm or 1.5inch above its origin
Describe the body of rectus abdominus
The two bellies lie edge to edge below the arcuate line. Separated by the linea alba above the arcuate line. Three tendinous intersections - umbilicus, xiphisternum, and one between these two. Sometimes also found below the umbilicus. Intersections are superficial only - do not involve the posterior sheath.
Linea alba origin and insertion
From xiphoid process to pubic symphysis. Lower portion very narrow. Broadens from just below the umbilicus.
Which muscles form what parts of the rectus sheath?
EOM anterior, TAM posterior, IOM splits around. Below the arcuate line all pass anteriorly. Here TAM and IOM fuse completely, EOM only fuses in the midline.
EOM= External oblique muscle
TAM= transverse abdominis muscle
IOM= internal oblique muscle
What is the semilunar line?
A shallow and bloodless groove running from the pubic tubercle to the costal margin (at the transpyloric plane), formed by the splitting of Internal oblique muscle aponeurosis around Rectus abdominis
Describe the nerve supply to rectus abdominis and its sheath
Posterior intercostal nerves T7-11 pass between TAM and IOM and enter the sheath and enter the midline of the rectus by piercing the posterior layer of IO aponeurosis.. They pass through the anterior sheath to become the anterior cutaneous nerves.
T7 runs up, T8 transverse, the rest obliquely downwards
How do cutaneous nerves to the lateral abdominal wall arise?
Posterior intercostal nerves T7-11 run between IOM and TAM. Before reaching the sheath they give off lateral cutaneous branches which pierce IOM and EOM to the skin and supply EOM also.
What does the subcostal nerve supply?
T12 subcostal supplies Ant abdominal Wall, Rectus abdominis muscle , Pyramidalis muscle , and has a lateral cutaneous branch to the buttock
Describe the vascular supply to the anterior abdominal wall
Superior epigastric artery passes through the diaphragm to anastomose with inf epigastric artery within rectus abdominus. Inferior epigastric arises from the external iliac artery at the inguinal ligament, passes behind the conjoint tendon and enters RA via the arcuate line. The deep circumflex iliac artery arises from ext iliac, runs laterally to ASIS between TAM and iliac fascia, and anastomoses with iliolumbar and gluteal arteries. At the ASIS it gives off an ascending branch which enters the NV plan to anastomose with IEA and lumbar arteries.
Lumbar arteries supply the anterolatereal abdominal wall but do not reach the rectus sheath.
Describe the venous drainage of the anterior abdominal wall
Veins accompany arteries
Describe the lymphatic drainage of the abdominal wall
Superficial lymph drainage in quadrants to the pectoral group of axillary nodes above and the superficial inguinal below. Deep is into extra peritoneal tissue then above to mediastinal and below to external iliac and para-aortic
What are the four actions of the abdominal muscles?
Move the trunk - ant and wall is the flexor of the vertebral column but not TAM
Depress the ribs for expiration - recti and obliques, not TAM
Compress the abdomen EOM, IOM, and aided strongly by TAM
Support the viscera
EOM and IOM but not transversus are abductors and rotators of the trunk - L) EOM works with R) IOM and vice versa. Needed for one armed movements e.g. tennis.
What are the contents of the rectus sheath?
Rectus abdominus
Pyramidalis
The ends of the lower six thoracic nerves and their accompanying posterior intercostal vessels
How else may the arcuate line be known?
The semicircular line of Douglas :)
How does the diaphragm overcome being weaker than the abdominal wall?
Closure of the glottis =/- closure of the mouth and nasopharynx
How do you test the anterior abdominal wall muscles?
Test Rectus abdominis by lying on back and raising head without using the arms. No specific tests for the others.
What layers does a midline incision go through?
Skin, subcutaneous tissue, line alba, transversalis fascia, extra peritoneal fat and peritoneum. No major vessels or nerves involved.
Describe a paramedian incision
3cm from the midline, sheath split <1cm from the midline, and posterior wall incised.
What incision is 3cm parallel to and below the R) costal margin?
Kocher incision or R) subcostal.
Double Kocher = rooftop = good access to upper abdomen
What is a gridiron incision?
A transverse muscle splitting technique
What lower abdominal transverse incision is used for pelvic access?
Pfannenstiel incision.
What is a lumbar incision used for?
An extra peritoneal approach to the kidney and upper ureter.
