Applied Anatomy Edited 25 08 07-1

8/19/2019 Applied Anatomy Edited 25 08 07-1

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Dr. S. M. AL SALAMAH B.Sc, MBBS, FRCS

Associate Prof. & Consultant General

Surgeon

Dept of Surgery, College of Medicne, KSU.

nterior

nterior

bdominal Wallbdominal Wall

pplied natom y

pplied natomy


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Abdominal wall dividedAbdominal wall divided

into:-into:-

Anteriolateral abdominalAnteriolateral abdominal

wallwall Anterior wallAnterior wall

Right lateral wall (Right Flank)Right lateral wall (Right Flank)

Left lateral wall (Left Flank)Left lateral wall (Left Flank)

Posterior abdominal wallPosterior abdominal wall


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ntrolateral bdominal


Wallall

This extended from the thoracic cage to This extended from the thoracic cage tothe pelvis and bounded :the pelvis and bounded : uperiorl!uperiorl!

""thth through #$through #$thth costal cartilages and and xiphoid processcostal cartilages and and xiphoid process

%nferiorl!%nferiorl! %nguinal ligaments and the pelvic bones&%nguinal ligaments and the pelvic bones&

The wall consists of skin' subcutaneous The wall consists of skin' subcutaneoustissues (fat)' muscles' deep fascia andtissues (fat)' muscles' deep fascia andparietal peritoneum&parietal peritoneum&


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Wall

all

Fascia & Subcutaneous Tissues

ascia & Subcutaneous Tissues

The subcutaneous tissues over most of The subcutaneous tissues over most ofthe wall consists of la!er of connectivethe wall consists of la!er of connectivetissues that contains a variable amounttissues that contains a variable amount

of fat&of fat&

%n the inferior part of the wall ' the%n the inferior part of the wall ' thesubcutaneous tissue is composed of twosubcutaneous tissue is composed of two

la!ersla!ers

Fatt! supercial la!er (amper*s fascia)Fatt! supercial la!er (amper*s fascia) +embranous deep la!er (carpa*s+embranous deep la!er (carpa*s fascia)fascia)


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Wall

all

Muscles

uscles

3 Flat Muscles with strong sheet like3 Flat Muscles with strong sheet like

aponeurosesaponeuroses

,xternal -bli.ue,xternal -bli.ue %nternal -bli.ue%nternal -bli.ue

Transversus Abdominus Transversus Abdominus

2 Vertical Muscles2 Vertical Muscles Rectus AbdomiusRectus Abdomius

/!ramidalis/!ramidalis


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Wall

all

Nerves

erves

T" 0 T## T" 0 T## Thoracoabdominal 1erves Thoracoabdominal 1erves

T#2 T#2 ub3costal nerveub3costal nerve

L#L# %lio3h!pogastric 1erve%lio3h!pogastric 1erve

%lio inguinal 1erves%lio inguinal 1erves


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Wall

all

rteries

rteries

Internal Thoracic ArteryInternal Thoracic Artery uperior ,pigastric Arter!uperior ,pigastric Arter!

External Iliac ArteryExternal Iliac Artery %nferior ,pigastric Arter!%nferior ,pigastric Arter!

4eep ircum5ex %liac Arter!4eep ircum5ex %liac Arter!

Femoral ArteryFemoral Artery uperfecial ,pigastric Arter!uperfecial ,pigastric Arter!

uperfecial ircum5ex Arter!uperfecial ircum5ex Arter!


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pplied natomy

pplied natomy

Abdomen is diided into ! regions ia

"our planes#

Two hori$ontal %sub&costal '()th* and transtubercules plane+ ',-*.

Two ertical 'midclaicular planes*.

They help in locali$ation o" abdominal

signs and symptoms


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nterior bdominal Wall

nterior bdominal Wall

Functions

unctions

Form strong expandable support&Form strong expandable support& /rotect the abdominal viscera from/rotect the abdominal viscera from

in6ur! such as low below in boxingin6ur! such as low below in boxing ompress the abdominal contentompress the abdominal content

7elps to maintain or increase the7elps to maintain or increase theintraabdominal pressure&intraabdominal pressure& +ove the trunk and help to maintain+ove the trunk and help to maintain

posture&posture&


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/rotuberance of the abdomen& The/rotuberance of the abdomen& The

ve common causesve common causes (8F)(8F)

Fat' Faeces' Fetus' Flatus And FluidFat' Faeces' Fetus' Flatus And Fluid

Abdominal 7erniasAbdominal 7ernias

Anteriolateral abdominal wall ma! beAnteriolateral abdominal wall ma! bethe site of herniasthe site of hernias

%nguinal' umbilical and epigastric regions%nguinal' umbilical and epigastric regions


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Posterior bdominal

osterior bdominal

Wallall

Lumbar vertebrae and %9 discs&Lumbar vertebrae and %9 discs& +uscles+uscles

/soas' .uadratus lumborum' iliacus' transverse'/soas' .uadratus lumborum' iliacus' transverse'

abdominal wall obli.ue muscles&abdominal wall obli.ue muscles& Lumbar plexusLumbar plexus

9entral rami of lumbar spinal nerves&9entral rami of lumbar spinal nerves&

FasciaFascia

4iaphragm4iaphragm ontributing to the superior part of the posterior wallontributing to the superior part of the posterior wall Fat' nerves' vessels (%9' aorta) andFat' nerves' vessels (%9' aorta) and

l!mph nodes&l!mph nodes&


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Posterior bdominal

osterior bdominal

Wallall

Fascia

ascia

Between the parital peritoneumBetween the parital peritoneum

and the musclesand the muscles

The psoas fascia or psoas sheath.The psoas fascia or psoas sheath.

The quadratus lumborum fascia.The quadratus lumborum fascia.

The thoracolumbar fascia.The thoracolumbar fascia.


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Posterior bdominal

osterior bdominal

Wall

all

Muscles

uscles

Three paired musclesThree paired muscles

/soas ma0or /soas ma0or

IliacusIliacus

1uadratus1uadratus

,umborum,umborum


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Posterior bdominal

osterior bdominal

Wall

all

Nerves

erves

Somatic nervesSomatic nerves

The sub costal nervesThe sub costal nerves

The lumbar nervesThe lumbar nerves

The lumbar plexus of nerves branchusThe lumbar plexus of nerves branchusare:are:

(a(a The obturator nerves (!The obturator nerves (!"" # !# !$$ (b(b The femoral nerves (!The femoral nerves (!"" # throu%h !# throu%h !$$

(c(c &lio in%uinal and ilio h'po%astric nerves (! &lio in%uinal and ilio h'po%astric nerves (!

(d(d )entio femoral (! # !")entio femoral (! # !"

(e(e !ateral femoral cutaneous nerves (!" # !* !ateral femoral cutaneous nerves (!" # !*


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Posterior bdominal

osterior bdominal

Wall

all

Nerves

erves

Autonomic nervesAutonomic nerves

+ne cranial nerve (the va%us+ne cranial nerve (the va%us Several di,erent splanchnicSeveral di,erent splanchnic

nerves that deliver pres'napticnerves that deliver pres'naptic

s'mpathier ands'mpathier andparas'mpathetic bers to theparas'mpathetic bers to the

plexus and s'mpathetic %an%lia.plexus and s'mpathetic %an%lia.


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Posterior bdominal

osterior bdominal

Wall

all

Nerves

erves

S'mpathetic /ervesS'mpathetic /erves

Abdomino-pelvic splanchic /. from the thoracicAbdomino-pelvic splanchic /. from the thoracicand abdominal s'mpathetic trun0sand abdominal s'mpathetic trun0s

Prevertebral s'mpathetic %an%liaPrevertebral s'mpathetic %an%lia

Periarterial plexusPeriarterial plexus Abdominal autonomic plexusAbdominal autonomic plexus

1eliac plexus1eliac plexus

Superior mensentric plexusSuperior mensentric plexus

&nferior mensentric plexus.&nferior mensentric plexus.

1eliac plexus1eliac plexus Superior h'po%astric plexusSuperior h'po%astric plexus

&nferior h'po%astric plexus&nferior h'po%astric plexus


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Posterior bdominal

osterior bdominal

Wall

all

Blood Vessels

lood Vessels

Aorta and its branches Aorta and its branches

IV and its tributeriesIV and its tributeries


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pplied natomy

pplied natomy

Posterior abdominal pain:Posterior abdominal pain:

&lio-psoas has relationship to 0idne'2 ureters2&lio-psoas has relationship to 0idne'2 ureters2

caecum2 appendix2 colon2 pancreas3.etc.caecum2 appendix2 colon2 pancreas3.etc.

4hen an' of these structures is diseased4hen an' of these structures is diseased

movement of the ilio psoas usuall' causesmovement of the ilio psoas usuall' causespain.pain.

4hen intra abdominal in5ammation is suspected4hen intra abdominal in5ammation is suspectedthethe &lio Psoas Test&lio Psoas Test performed b' movin%performed b' movin%ileopsoas muscle and if positive if it causesileopsoas muscle and if positive if it causespain.pain.


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Psoas bscess

soas bscess

6emato%enous6emato%enousspread to thespread to thelumbar vertebraelumbar vertebrae

ma' form anma' form anabscess whichabscess whichma' spread fromma' spread fromthe vertebraethe vertebrae

into the Psoasinto the Psoassheath producin%sheath producin%a Psoas abscess.a Psoas abscess.


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Partial Lumbar

artial Lumbar

Sympethectomy

ympethectomy

Some patients with arterialSome patients with arterial

disease in the lower limbsdisease in the lower limbs(ischaemia ma' include partial(ischaemia ma' include partial

lumbar s'mpathectom' b'lumbar s'mpathectom' b'

removal of two or more lumbarremoval of two or more lumbars'mpathetic %an%lias'mpathetic %an%lia


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V! "bstruction

V! "bstruction

Three collateral routs formed b'Three collateral routs formed b'

valveless veins of the trun0 arevalveless veins of the trun0 are

available for venus blood to return toavailable for venus blood to return to

the heart.the heart.

inferior epigastric veininferior epigastric vein

superficial epigastric veinsuperficial epigastric vein

epidural venous plexus inside theepidural venous plexus inside thevertebral column.vertebral column.


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bdominal ncisions

bdominal ncisions

7enition:7enition: incision dened as cutincision dened as cut

made with 0nife for sur%icalmade with 0nife for sur%ical

purposes.purposes.


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Types o# ncisions

ypes o# ncisions

The vertical incisions:The vertical incisions: 8idline incision8idline incision

Para medianPara median

The transverse abdominal incisions:The transverse abdominal incisions: 9pper and lower transverse incision9pper and lower transverse incision Pfannenstiel incisionPfannenstiel incision

!A/ incision (appendectom'!A/ incision (appendectom'

The oblique abdominal incisionsThe oblique abdominal incisions The subcostal or ;ocher


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pplied natomy

pplied natomy

The correct dia%nosis will enable theThe correct dia%nosis will enable the

sur%eon to choose the correct incision.sur%eon to choose the correct incision.

ButBut laparotom'laparotom' for undia%nosedfor undia%nosed

abdominal disease is most usefull'abdominal disease is most usefull'

approached throu%h vertical incisionapproached throu%h vertical incision

equidistant above and below theequidistant above and below theumbilicusumbilicus +nce the dia%nosis conrmed2 the incision ma'+nce the dia%nosis conrmed2 the incision ma'

be enlar%ed in an upward or downward direction.be enlar%ed in an upward or downward direction.


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!hoosin$ the ncision

hoosin$ the ncision

1hoice of incision depends on man' factors1hoice of incision depends on man' factorsthese includes:-these includes:-

The or%ans to be investi%atedThe or%ans to be investi%ated

The t'pe of sur%er' to beThe t'pe of sur%er' to bepreformedpreformed 4hether speed is an essential4hether speed is an essential

considerationconsideration

The build of the patientThe build of the patient The de%ree of obesit'The de%ree of obesit' The presence of previousThe presence of previous

abdominalabdominal incisionsincisions


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!losin$ the ncision

losin$ the ncision

The ideal method of abdominal wound The ideal method of abdominal woundclosure has not been discovered&closure has not been discovered&

7owever it should be free from7owever it should be free fromcomplications such as:3complications such as:3 Burst abdomenBurst abdomen

&ncisional hernia&ncisional hernia

Persistent sinusesPersistent sinuses &t should be comfortable to the patient&t should be comfortable to the patient

Should leave reasonabl' %ood scarShould leave reasonabl' %ood scar


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ncisional %ernia

ncisional %ernia

It is a protrusion of omentum or organIt is a protrusion of omentum or organthrough surgical incision.through surgical incision.

If the muscles and aponeurotic layersIf the muscles and aponeurotic layersof the abdomen doesn’t heal properlyof the abdomen doesn’t heal properlyan incisional hernia can resultan incisional hernia can result

Prredisposing factors includePrredisposing factors include InfectionInfection bowel obstructionbowel obstruction obesityobesity


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bdominal %ernia

bdominal %ernia

"ri#ices

ri#ices

6ernia is dened as the protrusion of an or%an throu%h6ernia is dened as the protrusion of an or%an throu%hit


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!ommon Sites

ommon Sites

&n%uinal 6ernia&n%uinal 6ernia

9mbilical 6ernia9mbilical 6ernia

>emoral 6ernia>emoral 6ernia

&ncisional 6ernia&ncisional 6ernia

!ess common 6ernia!ess common 6ernia ?pi%astric 6ernia?pi%astric 6ernia

=ecurrent 6ernia=ecurrent 6ernia


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!ommon !linical

ommon !linical

Features

eatures

The features of all hernias are:The features of all hernias are:

They occur at weak spotThey occur at weak spot They reduce on lying down or withThey reduce on lying down or with

direct pressuredirect pressure

They have an expansile coughThey have an expansile cough

impulseimpulse


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%istory

istory

%istory is very important&%istory is very important&

AgeAge -ccurs at all ages: ma! be present at-ccurs at all ages: ma! be present at birth orbirth orappear suddenl! at an! age&appear suddenl! at an! age&

-ccupation-ccupation

Local s!mptomsLocal s!mptoms 4iscomfort and pain the commonest4iscomfort and pain the commonest

!stemic s!mptoms!stemic s!mptoms

%f the hernia obstructing the patient%f the hernia obstructing the patient has cardinalhas cardinals!mptoms of intestinals!mptoms of intestinal obstructions (colick! abdominalobstructions (colick! abdominalpain'pain' vomiting' abdominal distension' constipation)vomiting' abdominal distension' constipation)


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'(amination

(amination

As) the patient toAs) the patient to stand up andstand up and

loo) to the site o# the Lumploo) to the site o# the Lump

*inspection+ and as) the patient*inspection+ and as) the patient toto

cou$h loo) #or cou$hcou$h loo) #or cou$h impulse, i#impulse, i#

positive orpositive or ne$ative-ne$ative-

ThenThen palpitate thepalpitate the lump andlump and.hether.hether it/sit/s reducible or not-reducible or not-


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!omplications

omplications

0ntreated hernia may develop0ntreated hernia may develop

#ollo.in$ complicationsollo.in$ complications&

(a(a intestinal obstructionintestinal obstruction

(b(b stran%ulationstran%ulation

(c(c incarcerationincarceration


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Perop or Post op

erop or Post op

!omplications

omplications

(a(a 6aemorrha%e6aemorrha%e

haematomahaematomaformationformation

(b(b Bowel in@uriesBowel in@uries

(c(c 4ound infections4ound infections

(d(d =ecurrent of 6ernia=ecurrent of 6ernia


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n$uinal %ernia

n$uinal %ernia

Anatom! of inguinal regionAnatom! of inguinal region

%nguinal canal with boundaries'%nguinal canal with boundaries'contents and oricescontents and orices

T!pes T!pes

Treatment Treatment

linical aspectlinical aspect


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&ndirect in%uinal hernia&ndirect in%uinal hernia pass via deep in%uinalpass via deep in%uinalrin% alon% the canal then if lar%e enou%hrin% alon% the canal then if lar%e enou%hemer%es throu%h the external rin% and descendsemer%es throu%h the external rin% and descendsinto scrotum.into scrotum.

7irect hernia pushes7irect hernia pushes throu%h the posterior wallthrou%h the posterior wallof the in%uinal canal via 6esselbech


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Documents

Applied Anatomy Edited 25 08 07-1