Lecture 10 (abdomen) pt 2 Flashcards
There’s a small amt of peritoneal fluid in abdominal cavity; abnormal accumulation is called what?
Ascites
Visceral pain tends to be with _____________ of GI tract
distention
Describe the associated organs of the abdominal cavity
1) Liver: produces bile which helps digest fats
2) Pancreas: secretes pancreatic enzymes to help with digestion via exocrine process
3) Spleen: immune and hematological functions, can add RBCs
What makes the suprarenal (adrenal) glands unique?
Act as postganglionic synapse for the sympathetic system, which stimulates release of epinephrine and cortisol
Superficial to the pelvic diaphragm and deep to the skin is the ________________.
perineum
The superior pelvic aperture is also called what?
Pelvic inlet
What does the sacrum have joints with?
1) L5 (lumbar-sacral joint)
2) Either side of the hip (hip joint; SI joint)
What muscle does the linea alba divide in half? What else does this muscle do?
Rectus abdominus; appears as the “six pack”
1) What part of the abdominal wall do we try to cut through instead of muscle? Why?
2) What parts of the abdomen heal easily?
1) Through fascia covering the muscle rather than the muscle itself; has holding power and heals easier.
2) Peritoneum and pleura
List the 4 dermatomes of the abdomen. Where are they, and what does each innervate?
1) Thoracoabdominal: T7-11
-Lateral and anterior branches (of intercostal segmental nerves)
2) Subcostal: T12
-Lateral and anterior branches
3) Iliohypogastric: L1
-Skin over iliac crest, upper inguinal and hypogastric region
4) Ilioinguinal: L1
-Skin of scrotum or labia majorus, mons, adjacent medial aspect of thigh (afferent for cremaster reflex)
What artery is the superficial epigastric artery medial to?
Superficial circumflex iliac artery (both come from internal thoracic a)
Infection below umbilicus will infect ___________ nodes first, chest infection will affect the ______________ lymph nodes
inguinal; axillary
What vein runs up the lateral side of the abdomen? What does it come from and turn into?
Thoraco-epigastric vein from superficial epigastric (from femoral) turns into lateral thoracic vein
There’s an umbilical divide for ________ drainage
lymph
What is the significance of the Thoracoepigastric veins?
Anastomose bt femoral/superficial epigastric veins and lateral thoracic/axillary veins
-act as a back door if IVC obstructed
1) Where does the inguinal ligament run from?
2) What forms the inguinal ligament?
1) ASIS to PUBIC tubercle
2) Inferior margin of EO
1) What does the inguinal canal do?
2) What is responsible for much of the structural features of the inguinal canal/ region
1) Allows structures to travel between abdominal cavity and scrotum
2) Descent of testis from abdomen into perineum during development; “vascular and nerve follow the bouncing ball”
What structures are inferior (not to be confused w deep) to the inguinal ligament? What can one of them cause?
1) Lateral cutaneous nerve of the thigh (compression can cause meralgia parasthetica)
2) Femoral canal with: femoral n., fem art, fem vein (VAN)
1) Where does the inguinal canal run between?
2) What is the inguinal falx and what forms it?
3) What is the iliopubic tract? What is it a landmark for?
1) Runs between EO and IO
2) Forms posterior wall of canal; IO and TO combine to form it
3) Thickening of transversalis fascia; is the internal surgical landmark corresponding to the inguinal ligament
1) The internal surgical landmark corresponding to the inguinal ligament is the ____________________
2) What does the EO form?
3) Which is important to surface anatomy, inguinal ligament and iliopubic tract?
1) Iliopubic tract
2) Inguinal ligament
3) Inguinal ligament
1) What is the inguinal ligament and what does it form?
2) ASIS to (mostly) insert on what?
3) What type of anatomy is it important for?
1) Most inferior part of external oblique aponeurosis; forms “gutter” floor of the inguinal canal
2) Pubic tubercle
3) Surface anatomy
1) What is the clinical application of the iliopubic tract?
2) What is it the inferior margin of?
3) Where does it run from and to?
4) Where is it in relation to the inguinal ligament?
1) Surgical landmark (seen in place of inguinal ligament)
2) Transversalis fascia
3) ASIS (anterior superior iliac spine) to pubic tubercle
4) Runs parallel and deep to inguinal ligament
1) What is seen in place of the inguinal ligament via endoscope?
2) What does this structure do?
1) Iliopubic tract (why it’s a surgical landmark)
2) Reinforces the posterior wall and floor of the inguinal canal as it bridges the structures traversing the retroinguinal space
Iliopubic tract is posterior/internal view of inguinal ligament when viewed from endoscope, reinforces the ______________________________________ as it traverses the vessels and hip flexors.
posterior and floor of canal
VANs are __________to inguinal ligament, and inferior epigastric nerves are _____________ to deep ring
inferior; lateral
1) What makes up the inguinal triangle? (3 things)
2) A direct hernia pushed through triangle medially to what?
1) Rectus, inguinal ligament, inferior epigastric vessels
2) Inferior epigastric vessels
What is the clinical application of the fact that the ligament follows spermatic cord from internal ring?
Direct hernias don’t go all the way into scrotum usually, but indirect hernias that follow the spermatic cord can go into the testicles
What type of hernias do women usually have?
Direct hernias
What’s the difference between a direct and indirect hernia?
1) Direct hernia: hernia sac pushes MEDIAL to inferior epigastrics thru peritoneum, transversalis fascia and inguinal triangle, parallels spermatic cord, weakness in anterior abd wall, usually > 40 y/o
2) Indirect hernia: hernia sac inside spermatic cord, younger men, patency of processus vaginalis
Inferior epigastric vessels follow what?
Arcuate line
What arteries (3), veins (1), muscles (1), nerves (2) and other structures (3) contribute to the spermatic cord?
1) Other: Ductus deferens (Vas deferens), lymphatic vessels, vestige of processes vaginalis
2) Arteries: Testicular artery, artery of the vas deferens, and cremaster artery
3) Muscles: Cremaster muscle
4) Veins: Pampiniform venous plexus (pathology = varicocele)
5) Nerves: Sympathetic nerve fibers for arteries; Genital branch of the genitofemoral nerve to cremaster m.
1) What provides innervation to the cremaster muscle?
2) Where do the veins and arteries of the spermatic cord originate?
1) Genitofemoral nerve’s genital branch
2) Veins drain back to left renal vein
-Arteries come from renal vein or aorta at about the level of the kidneys (bc that’s about where testicles start)
1) What is a hydrocele? What side is it more common on?
2) What is a varicocele? What side is a pampiniform plexus varicocele usually on?
1) Buildup of fluid in scrotum; equally common bilaterally
2) Varicose vein in scrotum; benign usually on left side because the right comes out of IVC at a different angle.
1) What is the cremaster muscle a continuation of?
2) What does its contraction do?
3) What innervates it?
4) What reflex is it involved in? Explain this reflex.
1) IO muscle
2) Raises the testicle
3) Genital branch of the genitofemoral nerve
4) Cremaster reflex: reflex is elicited (very active in kids) by stroking the inner thigh, afferent via ilio-inguinal n., efferent genitofemoral n.
What is the Dartos muscle and what does it do?
1) Smooth muscle in the wall of the scrotum (gentofemoral nerve innervates?)
2) Contraction of skin of scrotum; wrinkles
What veins are involved in testicular temperature regulation?
Pampiniform venous plexus
What muscles (2) and veins (1) help keep the testicle close to body in cold temps?
1) Cremaster muscle and dartos muscle
2) Pampiniform venous plexus
What do the parietal and visceral layers of the tunica vaginalis make up?
1) Parietal: Cavity of the tunica vaginalis
2) Visceral: Testis
What do the testicular arteries arise from?
Abdominal aorta (L2)
-What do the left and right testicular veins empty into?
-In which testicular vein are varicoceles more common. Where are they concerning?
1) Left testicular vein empties into left renal vein
-Varicocele more common
2) Right testicular vein empties into IVC
-Varicocele concerning for IVC mass; renal cell carcinoma
Describe the lymphatic drainage of the testis
Lymphatic drainage follows the arteries and veins (differs from scrotum)
1) What are the parts of the epididymis?
2) What structure does it contain? What is the clinical application of this?
3) What is its function?
1) Head and body of epididymis; duct; tail
2) Ductus deferens (Vas Deferens); vasectomy
3) Capacitation of sperm
What are the endocrine and exocrine functions of the testes?
1) Endocrine function: Testosterone
2) Exocrine function: Sperm
1) What is vasectomy?
2) What happens to accomplish this?
3) What two things are still produced?
1) Bilateral ligation of ductus deferens
2) Sperm passage interrupted; degenerate in epididymis or proximal end of ductus
3) Seminal fluid still ejaculated; testosterone is still produced and secreted into testicular vessels
Where is fluid located in the scrotum?
Tunica vaginalis
1) What has pigmented skin?
2) What fascia is found here? Describe it
3) Is its innervation complex or simple?
1) Scrotum
2) Dartos fascia: Fat free fascia layer including dartos smooth muscle
3) Complex
List the nerves of the scrotum and what each innervates
1) Genital br. of the genitofemoral n: to anterolateral surface
2) Ilioinguinal n: to anterior surface
3) Perineal br of Pudendal nerve: to posterior surface
4) Perineal br of posterior cutaneous nerve: of the thigh
1) Where does vascular supply and drainage of the scrotum come from?
2) Where do the scrotal lymphatics drain? How is this different from testicular lymphatics?
1) Pudendal vessels
2) To superficial inguinal nodes
-Testicular lymphatic drainage: goes to midline (pre-aortic) nodes
1) What does the cremaster muscle act on?
2) What is the Dartos muscle made of? What innervates it and what does it act on?
1) Testis
2) Smooth muscle, is innervated by sympathetic nerves, and acts on skin of scrotum
What provide the afferent and efferent parts of the Cremaster reflex?
1) Afferent: ilio-inguinal nerve
2) Efferent: genital br. of the genitofemoral nerve
1) What innervates the cremaster muscle?
2) What does the Ilio-inguinal nerve innervate?
1) Genital branch of the genital femoral nerve
2) Skin of the scrotum and inner thigh
What do the Dartos muscle and Cremaster muscle work together to do? What else contributes to this?
Regulate temperature of the testicle; along with pampiniform plexus for optimal fertility
1) Where does lymph from the scrotum drain?
2) Where does lymph from the testes drain?
3) What does this explain?
1) To the inguinal lymph nodes and veins
2) To the pre-aortic lymph nodes
3) Difference in area at risk from cancer and infection of testes vs. scrotum
1) What makes up the abdominopelvic cavity?
2) What makes up the thoracic cavity?
1) Peritoneum and viscera
2) Pleura, mediastinum, viscera
What makes up the peritoneum?
2 continuous layers (think pleura & pericardium)
What are the two layers of the peritoneum? What does each line?
1) Parietal peritoneum: lines internal surface of the abdominopelvic wall
2) Visceral peritoneum: covers viscera; retro peritoneal and intraperitoneal visceral
slide 46
1) What is the peritoneal cavity (space)?
2) What does it contain?
3) Is it closed or open in men and women?
1) Potential space between the parietal and visceral peritoneum
2) Thin fluid; peritoneal fluid, but NO ORGANS in this cavity??
3) Closed in males; open in females (fallopian tubes into uterus, cervix and vagina to exterior)
1) What covers the intraperitoneal viscera? Give examples
2) Where are the retroperitoneal (extraperitoneal, sub-peritoneal) organs?
1) Intraperitoneal viscera: covered with visceral peritoneum (e.g., stomach, spleen, transverse colon, appendix)
2) Outside peritoneal cavity, usually behind or posterior or inferior to peritoneum
Describe the coverage of the retroperitoneal organs and give examples
Viscera covered only on one surface by peritoneum (e.g., pancreas, most of duodenum, ascending and descending colon, kidneys, etc)
Intraperitoneal organs are _______________ into peritoneum (fist into balloon)
invaginated
1) What is the mesentery? Describe it.
2) What type of communication does it provide the means for?
3) What property does it provide?
1) Double layer of peritoneum, occurs from invagination of peritoneum by organ, continuity of parietal and visceral peritoneum
2) Means for neurovascular communication between organ and body wall
3) Mobility (also allows torsion)
1) What is the peritoneal ligament?
2) What is the omentum? Where does it go from and to?
1) Double layer of peritoneum that connects organs or organ to body wall (falciform ligament connecting liver to anterior abdominal wall)
2) Double layered extension of peritoneum from STOMACH or proximal DUODENUM to adjacent organs
1) What are bare areas?
2) What are peritoneal folds?
3) What are peritoneal recesses or fossas?
1) Areas devoid of visceral peritoneum to allow access by N-V structures
2) Reflections of peritoneum, usually by vessel, ducts, etc.
3) Pouch or recess formed by peritoneal folds (inferior recess of omental bursa)
1) What organs are retroperitoneal?
2) What organs are intraperitoneal?
1) Retroperitoneal: kidneys, aorta, IVC
2) Intraperitoneal: stomach and spleen
Where is the lesser omentum? What is deep to it?
Lateral to the curve of the stomach, continues behind greater omentum to portal triad; lesser sac
Where is the bare area without peritoneum?
The liver where it attaches to diaphragm
What 3 ligaments make up the greater omentum?
Gastrophrenic ligament
Gastrosplenic ligament
Gastrocolic ligament
What are the two ligaments that form the lesser omentum? What does one contain?
1) Gastrohepatic ligament
2) Hepatoduodenal ligament: contains portal triad: Portal vein, hepatic artery,& bile duct
1) What is the portal triad?
2) What does the lesser omentum’s omental foramen open into?
1) Portal vein, hepatic artery, & bile duct
2) Into omental bursa (lesser sac of peritoneal cavity)
1) What divide the greater sac?
2) What two compartments does this form?
1) Greater omentum (gastrocolic ligament) and transverse mesocolon (mesentery of transverse colon)
2) Supracolic and infracolic compartments
What do the supracolic and infracolic compartments contain?
1) Supracolic compartment – stomach, liver, spleen
2) Infracolic compartment – small intestines, colon
1) Where is the infracolic compartment?
2) What spaces are in this compartment?
3) What allows for free communication between the infracolic and supracolic compartments?
1) Lies posterior to Gr Omentum
2) Right and left infracolic spaces
3) Right and left Paracolic gutters
1) What is an omental bursa hernia (internal hernia) of the peritoneal cavity?
2) What can it cause?
1) Abdominal contents from infracolic region cause internal herniation; where a piece of omentum or small intestine goes through the bursa to the lesser sac
2) Can cause strangulation of herniated tissue.
1) Why are the gutters clinically important?
2) Give an example
3) List 3 other potential conditions that can affect the gutters
1) They allow a passage for infectious fluids from different compartments of the abdomen.
2) For example; fluid from a ruptured appendix can track up the rightparacolic gutterto the hepatorenal recess.
3) Peritonitis, ascites, abdominal paracentesis
Fluid from a ruptured appendix can do what?
Go up right paracolic gutter up into hepatorenal recess, subphrenic recess, or subhepatic space
1) What supplies the midgut? Be specific about the boundaries of this area
2) What supplies the hindgut? Be specific
1) Superior mesenteric
-second part of duodenum to splenic flexure of colon (transition point)
2) Inferior mesenteric
-splenic flexure of colon to the sigmoid colon & superior rectal aa
1) What supplies the thoracic esophagus with blood?
2) What supplies the foregut? Be specific about the boundaries of this area
1) Esophageal arteries
2) Celiac trunk
-Abdominal esophagus to the descending (2nd part) of duodenum where bile duct enters (transition point)
Where does the aorta bifurcate?
About L4-5; sacral plane (iliac crests); 2-3 cm inferior and to the left of the umbilicus
What drains the abdomen’s blood? List its 4 parts
A portal system:
1) Hepatic portal vein
2) Gastric vein
3) Splenic vein + inferior mesenteric vein
4) Superior mesenteric vein
What does the azygous venous system drain blood from?
Esophagus
Describe the sympathetic innervation of the visceral nervous system (4 parts)
1) Intermediolateral cell column (horn) give rise to presynaptic fibers
2) Thoracolumbar sympathetic trunk (paravertebral ganglia)
3) Abdominopelvic splanchnic nerves: synapse in celiac, aorticorenal, superior mesenteric and inferior mesenteric ganglia.
4) Postsynaptic fibers innervate smooth muscle of corresponding gut
Describe the parasympathetic innervation of the visceral nervous system
1) Presynaptic fibers from CN X, Vagus nerve synapse locally in smooth muscle of foregut and mid gut.
2) Via sacral spinal cord segments, presynaptic fibers from intermediolateral horn form pelvic splanchnic n and plexus, synapse locally in hind gut viscera.
1) Pain from foregut structures radiateto the ______________ region
2) Pain from viscus such as stomach is poorly localized and radiates where?
1) Epigastric region
2) To dermatome level that receives afferents from the organ concerned
1) Describe the initial pain of appendicitis
2) Describe the later pain of appendicitis
1) It’s periumbilical: ~T10 dermatome - visceral afferent pain fibers accompany sympathetic visceral motor fibers along splanchnic nerves to sympathetic trunk
2) Localized to RLQ when the inflamed appendix touches peritoneal wall: McBurney point
