Week 1- Introduction to the abdomen Flashcards
Where does the abdominal cavity go to + from?
Abdominal cavity extends from the diaphragm to the pelvic girdle
What are the four quadrants?
- RUQ
- RLQ
- LUQ
- LLQ
What abdominal organs sit in the RUQ?
- Colon (hepatic flexure, ascending)
- Duodenum (parts 1-3)
- Gallbladder
- Liver
- Biliary tree
- IVC
- Pancreas
- Pylorus
- Right Kidney
- Right ureter
- Right adrenal gland
What abdominal organs sit in the LUQ?
- Colon (splenic flexure, descending)
- Duodenum (4 part)
- L Kidney
- L ureter
- L adrenal gland
- Pancreas (body, tail)
- Spleen
- Stomach
- Jujunum
- Ileum
What abdominal organs sit in the RLQ?
- Colon (caecum, appendix, ascending)
- IVC
- R ductus deferens
- Ovary
- R Uterine tubbe
- R ureter
- Ileum
What abdominal organs sit in the LLQ?
- Colon (descending, sigmoid)
- Left ductus deferens
- Left ovary
- Left uterine tube
- Left ureter
- Jejunum
- Ileum
What are the abdominal planes?
- Transpyloric (L1)
- Subcostal (L3)
- Supracristal (L4)
- Transtubercular (L5)
What are the 9 regions?
Which planes divide these?
- R + L Hypercondrium
- R + L Flank/Lumbar
- R + L Iliac Fossa
- Epigastric
- Umbilical
- Pubic
Above Subcostal is hypercondrium
Below Transtubercular is iliac fossa
What organs are in each of the 9 regions?
R Hypercondrium:
- Liver
- Hepatic flexure of colon
- Diaphragm
- Costodiaphragmatic recess
L Hypercondrium:
- Stomach
- Spleen
- Pancreatic tail
- Splenic flexure of colon
- Diaphragm
- Costodiaphragmatic recess
Epigastric:
- Liver
- Stomach
- Gallbladder
- Transverse colon
- Lesser sac
- Abdominal aorta
- Duodenum
- Pancreas
- Kidneys
- Supradrenal glands
- Origin + plexus of CT and SMA
Right F/L:
- Ascending colon
- Small intestine
Left F/L:
- Descending colon
- Small intestine
Umbilical:
- Small intestine
- Root of mesentery
- Abdominal aorta
- IMA + plexus
R IF:
- Cecum
- Appendix
L IF:
- Sigmoid colon
Pubic:
- Small intestine
- Sigmoid colon
- Upper rectum
- Ovary
- Uterine tube
- Distended bladder
- Enlarged uterus
- Common iliac arteries
Where does foregut, midgut + hindgut pain usually refer to?
Foregut= Epigastric
Midgut= Umbilical
Hindgut= Pubic
What pain may refer to the R Hypercondrium?
- Liver abcess
- Hepatitis
- Gall bladder
- Biliary tree
- Choleocystitis
- Choleolithiasis
What pain may refer to the left hypercondrium?
- Constipation
- Splenic infarct
- Abcess
- Colitis
- Diverticulitis
- Pyelonephritis
What pain may refer to the Epigastrium?
- Foregut pain
- Aortic aneurysm
- Pancreatitis
- Ulcer
- Gastritis
- Reflux
- MI
- Pericarditis
What pain may refer to the Right Flank/Lumbar
- Ascending colitis
- Nephrolithiasis
- Pyelonephritis
What pain may refer to the left flank lumbar?
- Descending colitis
- Nephroliothiasis
- Pyelonephritis
What pain may refer to the umbilical region?
- Midgut pain
- Enteritis
- Intestinal obstruction
- Mesenteric occlusion
What pain may refer to the Right Iliac Fossa?
- Appendicitis
- Gonadal pathology
- Gastroenteritis
- Inguinal hernia
What pain may refer to the left iliac fossa?
- Diverticulitis
- Colitis
- Gonadal pathology
- Inguinal hernia
- Ulcerative colitis
What pain may refer to the pubic region?
- Hindgut pain
- Uterine pathology
- UTI/ UT obstruction
- Endometriosis
- Pelvic Inflammatory disease
Define Hernia
Protrusion of tissue / organ through a retaining tissue
What may predispose a person to hernia?
- Surgery
- Pregnancy
- Congenital defects
- Lifting
- Obesity
- Family history
- Chronic coughing
How do you find the:
a) Transpyloric plane
b) Subcostal plance
c) Supracristal plane
d) Transtubercular?
a) Halfway between jugular notch + pubic symphsis. Passes through tips 9th CC
b) Immediately inferior to 10th CC. At lowest anterior point of costal margin
c) Highest point of Iliac crest
d) Tubrcles of iliac crest. (Palpable 5-7cm posterior to ASIS)
What features occurs at T8?
Xiphisternal plane + joint
T8 vertebral body
Central tendon of diaphragm
Diaphragmatic surface of heart
Superior hepatic border
What features occur at the Transpyloric plane?
L1 Vertebral body
Pylorus
Duodenum part 1
Attachement of transverse mesocolon
SMA
Fundus gallbladder
Portal vein formation
Pancreatic neck
Kidney hila
Renal arteries + veins
What features occur at the subcostal plane?
L3 vertebral body
Duodenum 3rd part
IMA
What features occur at the supracristal plane?
L4 vertebral body
Aortic birfurcation
Landmarking L4 spinous process for LP
What features occur at the transtubercular plane?
L5 vertebral body
IVC formation close to midline
What are the layers from skin to parietal peritoneun?
- Skin
- Superficial fascia (Campers/ Scarpers below umbilicus)
- Rectus Abdominus (if in centre)
- External obliques
- Internal obliques
- Transversus abdominus
- Transversalis fascia
- Parietal peritoneum
What are the layers of the abdominal wall muscles?
Superifical –> Deep
- Rectus Abdominus (depending on where you are)
- External obliques
- Internal obliques
- Transversus abdominus
What is superficial fasica?
What are the types + demarcation point?
a) Connective tissue
b) Above umbilicus: Single layer, continous with superficial fascia in other body regions
* Below umbilicus:*
Campers: Fatty superifical layer
Scarpers: Membranous deep layer
What is the collective function of the anterolateral abdominal muscles?
What might be the consequence of a weakness of part of the abdominal wall musculature?
- Keep abdominal viscera in abdominal cavity
- Protect viscera from injury
- Maintain position of viscera in erect postion from gravity
Contraction aids:
- Quiet/forced expiration (by pushing viscera upwards which pushing relaxed diaphragm into thoracic cavity)
- Coughing/ Vomiting
Also:
- Increases intrabdominal pressure: childbirth, micturition, defecation
b) Hernination
Name the flat abdominal muscles?
- External obliques
- Internal obliques
- Tranversus abdominus
What is the
a) loaction + muscle fibre direction
b) function
c) innervation
External obliques?
a) Immediately deep to superficial fascia
Laterally placed muscle
Fibres inferomedial direction
- Origin:* Outter surfaces ribs 5-12
- Insertion:* Lateral lip iliac crest
Large aponeurotic compnent covers anterior abdo wall as aproaches midline formes linea alba
b) Compress abdominal contents
Flex trunk
Each muscle bend trunk to same side turning anterior part of abdomen to opposite side
c) Anterior rami T7-T12
What are the attachments of the lineaalba?
Does the linea alba have a good blood supply? Why is this useful to know for surgery?
1) Rectus Abdominus
External obliques
Internal obliques
Transversus abdominus
2) Poor blood supply therefore may not heal well
What is the
a) loaction + muscle fibre direction
b) function
c) innervation
* INTERNAL OBLIQUES?*
a) Deep to internal obliques
Superomedial direction
- Origin*: Thoracolumbar fascia, iliac creset between origins of external + transversus. Lateral 2/3 inguinal ligament
- Insertion:* Boarder lower 3/4 ribs (ribs 8-9)
Aponeurosis ending in linea alba anteriorly
Pubic crest + pectineal line
b) Compress abdo contents
Flex trunk
Each muscle bends trunk + turns anterior part of abdomen to same side
c) Anterior rami of T7-L1
What is the
a) loaction + muscle fibre direction
b) function
c) innervation
Transversus abdominus?
a) Deep to internal obliques
Transverse running fibres
Origin: Thorocolumbar fascia
Medial lip iliac crest
Lateral 1/3 inguinal ligament
CC ribs 8-12
Insertion: Aponeurosis ending in linea alba
Pubic crest + Pectineal line
b) Compress abdominal contents
c) Anterior rami T7-L1
What is the
a) loaction + muscle fibre direction
b) function
c) innervation
Rectus Abdominus?
a) Origin = Pubic: crest, tubercle + symphesis
* Insertion:* CC ribs 5-7
Xiphoid process
Extends length anterior abdo wall separated by linea alba @ midline
Intersected by tendinous intersection
b) Compress abdominal contents
Flex vertebral column
Tense abdominal wall
c) Anterior rami T7-T12
What is the rectus sheath?
What happens to the position of rectus abdominis during pregnancy?
What else does it contain?
a) Encloses rectus abdominus
Formed by aponeuroses of flat abdo wall muscles
Above arcuate line (midway between umbilicus + pubis symphysis): sheath completely encloses RA
Anteriorly–> EO apn + 1/2 IO apn
Posteriorly –> 1/2 IOapn + TA apn
Below arcuate line: All aponeuroses move to anterior wall rectus sheath
RA in contact with transversalis fascia posterially
b) Stretches + moves apart from linea alba
c) Inferior epigastric artery + vein
What is the layer underneath the traversalis fascia?
What is its innervation + therefore sensitive to?
Parietal Peritoneum
Somatic sensroy therefore localised pain
Sensitive to: pain, pressure, laceration, temperature
How does the anterior abdominal wall get is NV supply?
What are the dermatomal regions?
Name the 2 important arteries, where they meet + their role
b) Travels around the abdominal wall from the vertebral column toward the anterior midline
* T7- L1 spinal nerves:* supply skin, muscle + parietal peritoneum of anterior abdo wall
Anterior rami pass around body posterior to anterior in an inferomedial direction. Give off lateral cutaneous branches + end as anterior cutaneous branches- which pass through rectus abdominus muscle + anterior wall of rectus sheath to supply the skin
- Intercostal nerves T7-T11:* leave intercostal spaces continue onto anterolateral abdominal wall between internal obliques + transversus abdominus muscle. Enter rectus sheath + pass posterior to lateral aspect of RA muscle
c) T7-T9: Xiphoid process –> just above umbilicus
T10: Umbilicus
T11-L1: Below umbilicus including pubic region
d) Superior + inferior epigastric arteries anastmoses in rectus sheath
Unite subclavian + external iliac artery providing arterial shunt if aorta narrowed
How does knowing where the NV supply to abdomen guide surgical placement of incisions?
Surgical incisions/endoscopy ports take into account the position and course of arteries and nerves in order to minimise iatrogenic damage
Name + draw location of the 5 incisions.
1) Median/ Midline
2) Paramedian
3) Gridiron (muscle splitting) @ McBurney Point
4) Pfannenstiel (suprapubic)
5) Subcostal (Kocher)
With a midline incision:
What is incised + is it a problem
What does it allow entry into?
a) Linea alba
Relatively avascular therefore long healing time
Also aneural
b) Peritoneum
With a Paramedian incision:
What is incised?
What muscle is diplaced + why?
a) Rectus sheath
b) Rectus abdominus divided/displaced laterally towards its nerve supply so not to damage the nerves
Gridiron incision @ McBurney’s point:
Where McBurney’s point?
What does it allow access to?
Which nerve is at risk + what are the consequences?
a) 1/3 way from ASIS to umbilicus
b) Ceacum + Appendix
c) Ilioinguinal + Iliohypogastric nerve (Branch L1): at risk of hernia formation
What is a Pfannestiel cut used for?
What nerves are at risk?
a) Cesarean + Pelvic organ access
b) Ilioinguinal nerve
What is at risk with a Subcostal (Kocher) incision?
T9 nerve
Superior epigastric artery
Thoracoabdominal nerves (7th-11th intercostal nerve. They run between the layers of abdominal muscles to innervate the muscles of the anterolateral abdominal wall. Anterior and lateral and cutaneous branches provide nerve supply to the skin.)
Where does lymphatic drainage of the abdominal wall go to?
b) What is it relavent to?
Above umbilicus: Axillary nodes
Below umbilicus: Superficial inguinal nodes
The lymphatic drainage of more superficial tissues and the skin is regional
b) To spread of infection/cancers
What is lymphatic fluid?
What are lymph nodes?
a) Tissue fluid not returned at the venous end of capillary which contains: plasma proteins, lymphocytes +/- cell bacteria/ debris. It is transported along lymph vessels + returned to the bloodstream near the heart
b) Small swelllings in the lymphatic system where lymph is filtered + lymphocytes formed
The gut tube is located within the _____ _____ and is surrounded by a layer of tissue called _____
The gut tube is located within the peritoneal cavity, and is surrounded by a layer of tissue called peritoneum
Define:
a) Intra peritoneal
b) Retro-peritoneal
c) Mesentery
d) Secondary retropetitoneal
a) Structure covered in peritoneum
b) Structure behind the peritoneum
c) Fold of peritoneum suspending an organ from the abdo wall
d) Intraperitoneal structure that leter becomes retroperitoneal
Embryology:
From the trilaminar disc what layer once folded forms the gut tube?
What way does the tub fold to form the gut tube?
Endoderm
b) Laterally (side-side)
What is the role of the parietal + visceral peritoneum?
Label the diagram
Line future abdominal wall and surround and support the organs
The gut tube blood supply arises from 3 main arteries which branch off abdominal aorta.
Name these arteries, the vertebral level of artery origin, the region it suppies, the boundaries, the visceral/sympathetic nerves that travel alongside the blood supply
Coelia Trunk:
- T12
- Foregut
- Lower oesophagus –> Major duodenal papilla (proximal 1/2 2nd part duodenum)
- T5-T9
Superior Mesenteric Artery:
- L1
- Midgut
- Major duodenal papilla –> Proximal 2/3 Transverse Colon
- T10-T11
Inferior Mesenteric Artery:
- L3
- Hindgut
- Distal 2/3 Transverse Colon –> Upper anal canal
- T12-L1
What is visceral peritoneum sensitive + insensitive to?
Describe visceral pain
Sensitive: Stretch, hypoxia, chemical + environmental changes
Insensitivie: Cutting/ burning/ thermal stimuli
Visceral (organ) pain is a vague, diffuse, and poorly defined/located sensation
What is a dermatone?
An area of skin innervated by a single spinal nerve
Visceral Pain: Referral
Describe what happens
Visceral (organ) & somatic sensory (afferent) nerves enter the spinal cord together and travel in the same spinal tracts
Brain confuses origin of signal + assumes pain is of dermatomal origin
