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BLOCK 2 - Anatomy (Grace) > The Abdomen I > Flashcards

The Abdomen I Flashcards

1
Q

Abdomen = part of the trunk between the thorax + pelvis.

What are its superior, inferior, anterolateral borders?

A

superior = diaphragm

inferior = muscles of the pelvis

anterolaterally = musculoaponeurotic walls

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2
Q

What are 2 principle functions of the abdomen?

A

**protect **+ enclose abdominal contents

**flexibility **= for respiration, posture, locomotion

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3
Q

Name the 2 transverse planes + 2 sagittal planes of the abdomen

A

Transverse:

  • subcostal plane (most superior)
  • transtubercular plane (most inferior)

Sagittal:

  • midclavicular lines (x2)
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4
Q

Name the 9 regions of the abdomin, as numbered in this figure.

A
  1. Right hypochondriac
  2. Right lumbar
  3. Right inguinal
  4. Epigaastric
  5. Umbilical
  6. Hypogastric
  7. Left hypochondriac
  8. Left lumbar
  9. Left inguinal
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5
Q

What are the superior and inferior landmarks for the 2 sagittal planes ?

A

Superior = midclavicular planes; pass approximately 9 cm from the midline

inferior = midinguinal points; midway between the anterior superior iliac spine and the superior edge of the pubic symphysis on each side

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6
Q

What are the landmarks for the 2 transverse abdominal planes?

A

subcostal plane = passes through inferior border of the 10th costal cartilage on each side

transtubercular plane = passes through the iliac tubercles (approx. 5 cm posterior to anterior superior iliac spine) + body of L5

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7
Q

Where is the transpyloric plane located?

A

approximate midpoint between:

superior border of manubrium + superior border of pubic symphysis

(L1 vertebral level)

  • comonly transects the pylorus (distal part of stomach)
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8
Q

What other important structures are transected by the transpyloric plane?

A
  • fundus of gallbladdar
  • neck of pancreas
  • origins of superior mesenteric artery & portal vein
  • root of transverse mesocolon
  • duodenojejunal junction
  • hila of kidneys
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9
Q

Where does the interspinous plane pass through

A

anterior superior iliac spine on each side

(easily palpated)

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10
Q

Which part of the abdominal wall is NOT musculoaponeurotic?

A

posterior abdominal wall

(includes lumbar vertebral column)

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11
Q

The anterolateral abdominal wall extends

from__________ to ___________?

A

thoracic cage to the pelvis

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12
Q

What are the superior and inferior boundaries of the anterolateral abdominal wall?

A

superior = 7th - 10th rib cartilages + xiphoid process

inferior = inguinal ligament + superior margins of the anterolateral aspects of the pelvic girdle (iliac crests, pubic crests, + pubic symphysis).

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13
Q

Identify the numbered muscles of the anterior abdominal wall:

A
  1. external oblique
  2. internal oblique
  3. transverse abdominis
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14
Q

Identify the fascia in the anterior abdominal wall:

A
  1. Camper fascia (superficial, fatty, subcutaneous)
  2. Scarpa fasca (deep, membranous, subcutaneous)
  3. a) Superficial Investing (deep) fascia
  4. b) Intermediate Investing (deep) fascia
  5. c) Deep Investing (deep) fascia
  6. Endoabdominal (transversalis) fascia
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15
Q

Identify these anterior abdominal wall structures:

A
  1. skin (cut edge)
  2. extraperitoneal fat
  3. parietal peritoneum
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16
Q

In what area is the skin firmly attached to the subcutaneous tissue (in the anterior abdominal wall) ?

A

at the unbilicus

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17
Q

Why is it structurally significant that the muscle fibers of the abdominal walls go in 3 different directions?

A

b/c the abdomin is a positive pressure area

  • higher chance of herniation so intersecting fibers = added strength
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18
Q

The subcutaneous tissue over most of the abdominal walls is a major storage site for what?

What happens if there is too much of this substance stored here?

A

FAT

too much fat** = obesity;** can cause sagging folds “panniculi” (apron)

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19
Q

There are some areas of the body that maintain fat storage even during starvation. These areas include…?

A
  • face
  • bottocks

*fun facts from Dr. Ray :)*

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20
Q
  1. Inferior to the umbilicus, the deepest part of the subcutaneous tissue is reinforced by which types of fibers?
  2. What are the two layers of subcutaneous tissue here?
A
  1. many elastic and collagen fibers
    • Camper fascia = superficial fatty layer
      - Scarpa fascia = deep membranous layer
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21
Q

The membranous layer (Scarpa fascia) continues inferiorly into the ___________.

A

perineal region as the superficial perineal fascia (Colles fascia)

*NOT into the thighs (fascia lata)*

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22
Q

What is the clinical significance of the membranous Scarpa fascia being sufficiently complete ?

A

Significant because:

fluids** escaping from a ruptured vessel or urethra (blood and/or urine) may **accumulate deep to it

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23
Q

The superficial, intermediate, and deep layers of investing fascia cover____________ ?

A

the external aspects of the three muscle layers of the anterolateral abdominal wall + their aponeuroses (flat expanded tendons)

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24
Q

The endoabdominal fascia (membranous sheet of varying thickness) lines the __________?

A

the internal aspect of the abdominal wall

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25
Q

The portion of fascia lining the deep surface of the transverse abdominal muscle and its aponeurosis is called…?

A

“transversalis fascia”

(relatively firm)

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26
Q

The portion of fascia lining the abdominal cavity is called…?

A

“parietal peritoneum”

(internal to transversalis fascia; separated by extraperitoneal fat)

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27
Q

What is the clinical significance of fascia and fascial spaces of abdominal wall?

A

1. potential space b/t membranous layer of subcutaneous tissue + deep fascia (covering rectus abdominis + external oblique m.)

** fluid may accumulate**

  • cannot spread inferiorly into the thigh because the membranous layer fuses with the deep fascia of the thigh (fascia lata)
    2. helps **protect against contamination **therefore, during surgeries, entry into the periotoneal cavity is aoided as much as possible.
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28
Q

Why is the potential (or fat-filled) space b/t the endoabdominal fascia of special importance in surgery?

A

it can be opened during surgery

  • access structures on/in anterior aspect of posterior abdominal wall without entering the peritoneal sac
  • minimize risk of contamination
  • Space of Bogros = b/t transversalis fascia + parietal peritoneum; anterolateral part of potential space used for placing prostheses (ex. when repairing inguinal hernias);
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29
Q

How many bilaterally paired muscles are there in the anterolateral abdominal wall?

A

5 muscles

  • 3 flat (external oblique, internal oblique, and transverse abdominal)
  • 2 verticle (rectus abdominis, pyrimidalis)
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30
Q

The fibers of which 3 abdominal muscles are blended together for increased strength?

A

external oblique

internal oblique

transverse abdominal

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31
Q

External Obliques

A

origin: External surfaces of 5th - 12th ribs

insertion: Linea alba, pubic tubercle + anterior half of iliac crest

innervation: Thoracoabdominal nerves (T7 - T11) + subcostal nerve

    • largest, most superficial*
    • run inferomedially*
    • left superficial become right deep; Right superficial become left deep @ linea alba*
    • continued anteromedially as aponeurosis*
32
Q

The 3 flat muscles continue anteromedially as….?

A

aponeuroses

(strong, sheet-like)

33
Q

At what point do the aponeuroses form the tough, aponeurotic, tendinous rectus sheath?

A
  • between the midclavicular line and the midline (medially)
  • at the spinoumbilical line; running from umbilicus to anterior superior iliac spine (inferiorly)
  • most become continuous with tendinous fibers of the contralateral internal oblique*
34
Q

Linea alba

A
  • interweaved aponeuroses form a midline raphe
  • extends from xiphoid process to the pubic symphysis
35
Q
  1. Which aponeuroses interweave together to form the linea alba?
  2. What is this sheath called?
  3. Which anterior abdominal muscles are enclosed in this sheath?
A
  1. aponeurosis fibers interweave from:
    - right + left sides
    - superficial + intermediate; intermediate + deep layers
  2. “rectus sheath”
  3. contains the rectus abdominis + pyramidalis
36
Q

External Oblique Aponeurosis

A

Inferior attachment = pubic crest (medial to pubic tubercle)

inferior margin = inguinal ligament (thickened fibrous band; free posterior edge spanning b/t anterior superior iliac spine + pubic tubercle)

37
Q

Inguinal Ligament

A
  • continuous inferiorly w. deep fascia of thigh
  • acts as a retinaculum (retaining band) for structures passing deep to it

(iliopsoas muscle + femoral vessels + nerve)

*most herniations happen here = weak area*

38
Q

Internal Oblique Muscle

A

Origin: Thoracolumbar fascia, anterior two-thirds of iliac crest + lateral half of inguinal ligament

Insertion: Inferior borders of 10th - 12th ribs, linea alba + pecten pubis via conjoint tendon

Innervation: Thoracoabdominal nerves (anterior rami of T7-T12 nerves) + first lumbar nerves

Main action: Compress + support abdominal viscera; flex + rotate trunk

    • deep to extrenal; superficial to transversus*
    • run anterosuperiorly*
39
Q

Transversus Abdominis muscles

A

Origin: Internal surfaces of 7th - 12th costal cartilages, thoracolumbar fascia, iliac crest + lateral third of inguinal ligament

Insertion: Linea alba w. aponeurosis of internal oblique, pubic crest + pecten pubis via conjoint tendon

Innervation: Thoracoabdominal nerves (anterior rami of T7-T12 nerves) first lumbar nerves

Main action: Compresses + supports abdominal viscera

    • run transverly*
    • deep to internal obliques*
40
Q

Rectus Abdominis (characteristics)

A
  • long, broad, strap-like muscle

(broad + thin superiorly; narrow + thick inferiorly)

  • principal vertical muscle of anterior abdominal wall
  • paired rectus muscles; separated by the linea alba; lie close together inferiorly
  • Most of rectus abdominis is enclosed in rectus sheath
  • anchored transversely by attach. to anterior layer of the rectus sheath (three or more tendinous intersections)
  • sometimes herniation may occur; connection not strong
41
Q

The connecting inersection of the rectus abdominis usually occur at which locations?

A
  • level of xiphoid process
  • umbilicus
  • halfway between these two
42
Q

Rectus Abdominis Muscle

A

Origin: Pubic symphysis and pubic crest

Insertion: Xiphoid process and 5th - 7th costal cartilages

Innervation: Thoracoabdominal nerves (anterior rami of T7-T12 nerves)

Main action: Flexes trunk (lumbar vertebrae) + compresses abdominal viscera; stabilizes and controls tilt of pelvis (balancing pelvis)

43
Q

Pyramidalis muscle

A

- absent in approximately 20% of people

  • small, triangular muscle
  • lies anterior to inferior rectus abdominis
  • attaches to anterior surface of pubis + anterior pubic ligament
  • ends in linea alba
  • tenses linea alba (when present)
44
Q

Rectus Sheath

A
  • strong, incomplete fibrous compartment of rectus abdominis + pyramidalis muscles
  • formed by decussation + interweaving of aponeuroses of flat ab. muscles
45
Q

Rectus Sheath: Layers + make-up

A
  • external oblique aponeurosis contributes to anterior wall of sheath throughout its length
  • superior 2/3 of internal oblique aponeurosis splits into 2 layers (laminae) at the lateral border of rectus abdominis; one passes anterior, the other passes posterior
  • anterior lamina joins aponeurosis of external oblique = anterior layer of sheath
  • posterior lamina joins aponeurosis of the transverse abdominal = posterior layer of sheath
  • approx. 1/3 of distance fr. umbilicus to pubic crest –> aponeuroses of 3 flat muscles pass anterior to rectus abdominis = anterior layer of sheath
  • *(fibers of anterior + posterior layers of sheath interlace @ anterior median line = linea alba)*
  • **(only thin transversalis fascia left to cover rectus abdominis posteriorly)*
46
Q

Why is the posterior layer of the rectus sheath deficient superior to the costal margin?

A

because the transverse abdominal muscle pass internal to the costal cartilages and the internal oblique attaches to the costal margin…

…rectus abdominis lies directly on the thoracic wall

47
Q

What are the major functions & actions of the anterolateral abdominal muscles?

A

→Form a strong expandable support for the anterolateral abdominal wall.

→Protect the abdominal viscera from injury.

→Compress the abdominal contents to maintain or increase the intra-abdominal pressure and, in so doing, oppose the diaphragm (increased intra-abdominal pressure facilitates expulsion).

→Move the trunk and help maintain posture.

48
Q

What is important to consider when palpating the anterolateral abdominal walls?

A
  • use warm hands (cold hands=anterolateral ab. muscles tense=guarding)
  • guarding: reflexive muscular rigidity that cannot be willfully suppressed

–> sign of abdominal organ inflammation

–> involuntary muscular spasms attempt to protect viscera fr. pressure (painful when abdominal infection is present)

49
Q

Palpation of abdominal viscera is performed with the patient in what position?

Why?

A

1. supine position with thighs and knees semiflexed

  • adequate relaxation of the anterolateral abdominal wall
    2. upper limbs at the sides +** **putting a **pillow under the knees **
  • relax the anterolateral abdominal muscles
50
Q

With a patient is supine with ab. muscles relaxed, what motion stimulates the superficial abdominal reflex?

A

** quickly stroking horizontally** (lateral to medial) toward the umbilicus

    • Usually, contraction of the abdominal muscles is felt*
    • injury to the abdominal skin results in a rapid reflex contraction of the abdominal muscles.*
51
Q

What underlies the linea alba at the umbilicus?

What was the function of this structure?

A

umbilical ring

  • fetal umbilical vessels passed to/from umbilical cord and placenta
  • All layers of anterolateral abdominal wall fuse at the umbilicus.*
  • (Cannot distinguish b/t different fibers)*
52
Q

Why is a prominent abdomen normal in infants and young children?

A
  • their gastrointestinal tracts contain considerable amounts of air
  • their anterolateral abdominal cavities are enlarging and their abdominal muscles are gaining strength
  • have a **relatively large liver **
53
Q

What may be a sign of increased intra-abdominal pressure?

A

Eversion of the umbilicus

*- usually resulting from ascites (serous fluid accumulation) or a large mass (tumor; enlarged organ) *

54
Q

Tumors and organomegaly can produce…?

A

abdominal enlargement

55
Q

What is the clinical significance of being able to palpate the spleen?

A

it means it is already pathology (3x larger than normal)

*cannot palpate a normal spleen*

56
Q

Most abdominal hernias occur in what areas?

A

inguinal region

umbilical region

epigastric region

57
Q

What type of hernia is common in newborns?

What causes this?

A

**Umbilical hernias **

(Herniation occurs through the umbilical ring)

  • anterior abdominal wall is relatively weak in umbilical ring
    (esp. in low-birth-weight infants)
58
Q

Who will be most likely to experience aquired umbilical hernias?

What occurs in this type of hernia?

A

women + obese people

  • extraperitoneal fat and/or peritoneum protrude into the hernial sac
59
Q

Which parts of the abdominal muscles are more likely to herniate?

A

_- the lines where abdominal aponeuroses interlace _

(ocassionally have gaps; ex. midline, transition fr. aponeurosis to r.sheath)

  • gaps can be congenital due to stresses of obisity + aging

OR

consequences of surgery or trauma

60
Q

epigastric hernia

A

occurs in midline b/t xiphoid process + umbilicus (through linea alba)

(usually problems with muscle fibers at this site = hernia)

61
Q

Spigelian hernias

A

occur along semilunar lines

  • hernial sac = (peritoneum) covered w. skin + fatty subcutaneous tissue
  • usually people more than 40 years
  • usually associated with obesity
62
Q

What parts of the Thoracoabdominal nerves supply the anterior abdominal wall?

A

distal, abdominal parts of the anterior rami of T7 - T11

63
Q

Which lateral (thoracic) cutaneous branches supply the anterior abdominal wall?

A

from the thoracic spinal nerves T7 - T9 or T10

64
Q

Subcostal nerve

A

large anterior ramus of spinal nerve T12

65
Q

Iliohypogastric and ilioinguinal nerves

A

terminal branches of the anterior ramus of spinal nerve L1

66
Q

Which nerves approach the abdominal musculature separately to provide the multi-segmental innervation of the abdominal muscles?

A

inferior thoracic spinal nerves (T7 - T12)

+

iliohypogastric and ilioinguinal nerves (L1)

67
Q

Inferior thoracic spinal nerves (T7 - T12) + the iliohypogastric and ilioinguinal nerves (L1) run oblique but mostly horizontal. What are they susceptable to?

A

injury in surgical incisions or from trauma at any level of the abdominal wall

68
Q

Injury to the inferior thoracic or iliohypogastric and ilioinguinal nerves may result in what?

What does this predispose a person to if it occurs in the inguinal region?

A
  • weakening of the muscles
  • predisposed to inguinal hernia
69
Q

When it is possible, how are abdominal inscisions made?

What 2 things are considered in these incisions?

A

Made to follow the cleavage lines (Langer lines) in the skin

insicions chosen for:

  1. adequate exposure
  2. best possibly cosmetic effect
70
Q

The location of an incision in abdominal surgery depends on…?

What is considered to accomodate these desired outcomes?

A
  • the type of operation
  • location of the organ(s) the surgeon wants to reach
  • bony or cartilaginous boundaries
  • avoidance of (especially motor) nerves
  • maintenance of blood supply
  • minimizing injury to muscles + fascia of the wall
  • aiming for favorable healing

surgeon must consider direction of the muscle fibers + location of aponeuroses and nerves

71
Q

What are 2 types of high-risk incisions?

A

pararectus and inguinal incisions

72
Q

Pararectus incisions

A

**along the lateral border of the rectus sheath **

  • undesirable b/c likely to cut the nerve supply to the rectus abdominis
  • blood supply from inferior epigastric artery also may be compromised
73
Q

Inguinal incisions

A

for repairing hernias

  • may injure the ilioinguinal nerve directly; may be inadvertently included in the suture during closure of the incision
74
Q

Incisional Hernia

A

protrusion of omentum (a fold of peritoneum) or an organ through a surgical incision

  • can result if muscular + aponeurotic layers of abdomen do not heal properly
75
Q

What factors can predispose a patient to an incisional hernia?

A
  • advanced age
  • debility of patient
  • obesity
  • post-op. wound infection
76
Q

Endoscopic (Minimally Invasive) Surgery

A

tiny perforations of the abdominal wall allow the entry of remotely operated instruments

  • replaces larger conventional incisions
  • many abdominopelvic surgical procedures can be done this way
  • potential for nerve injury, incisional hernia, or contamination through the open wound + the time required for healing are minimized
  • * surgeons should know both methods, as resources might not be available**

BLOCK 2 - Anatomy (Grace) (16 decks)

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