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Lecture given on 12 Oct 2010 by Dr Vooght and Dr Banigo to Surgical Scousers.
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Anatomy of Abdomen- GI tract
Adonye Banigo & Abigail Vooght, Oct 2010
Plan- Lecture 1 Abdo Wall
Surface markings Regions Layers Inguinal canal & hernias Incisions
Abdo cavity Whistlestop tour of GI tract Viscera + peritoneum + embryology Peritoneal cavity
Surface markings Abdominal wall
surgical incisions Inguinal canal
hernias Whistle stop tour of gut (mouth > anus) incl. landmarks Embryology of gut
Foregut/ midgut/ hindgut principles
Peritoneum and mesenteries
Referred pain
Plan- Lecture 2
Key features of each organ The GI adnexae- liver, gallbladder, pancreas,
spleen Not including the bony pelvis, genitourinary
system, or histology of the gut
The Abdominal Wall
Role of Abdo Wall
• Moving the trunk• Depressing the ribs• Compressing the abdomen• Supporting and protecting organs
Surface Markings
Linea Alba
Linea semilunaris
Tendinous intersections (3)
Landmarks
Xiphisternum T9
Iliac crest
Costal Margin
Umbilicus L3/4
Midclavicular line
9 regions
Midclavicular line
Transpyloric plane (L1)
Transtubercular plane (L4/5)
9 regions
Umbilical
Suprapubic
Epigastric
9 regions
Lumbar
Iliac Fossae
Hypochondrium
9 regions
Layers of Abdo Wall- Laterally
Skin Superficial fascia
Camper’s (soft & spongy fat!) Scarpa’s (membranous)
External Oblique (Aponeurosis) Internal Oblique Transversus Abdominis Transversalis Fascia Extraperitoneal fat Peritoneum
Layers of Abdo Wall- Medially
Skin Superficial fascia
Camper’s (soft & spongy fat!) Scarpa’s (membranous)
Rectus Abdominis and Rectus Sheath Transversalis Fascia Extraperitoneal fat Peritoneum
Abdo wall- Layers Medially
Arcuate line (of Douglas)
Costal Margin
Inguinal canal
Passage for spermatic cord ♀// round ligament ♂ 4cm long Deep (internal) ring to superficial (external) ring Boundaries:
Anteriorly- E-O aponeurosis + I-O lateral 1/3 Posteriorly- transversalis fascia + conjoint tendon medially Above- arching fibres of internal oblique + transversalis Below- inguinal ligament (infolded gutter of E-O)
1) External oblique aponeurosis, 2) Internal oblique muscle, 3) Transversus abdominis muscle, 4) Endo abdominal fascia, 5) Internal inguinal ring, 6) Iliopubic tract, 7) Inguinal ligament, 8) Pubic symphisis, 9) Spermatic cord, 10) Interparietal connective tissue (cremasteric fascia), 11) cremasteric muscle, 12) Aponeurotic layer of posterior inguinal wall, 13) Fascial layer of posterior inguinal wall
Extenal Oblique Aponeurosis
Transversalis fascia
AS
IS
Pu
bic
Tu
bercle
Posterior
Anterior
Inguinal Canal- conceptual- from above
Conjoint Tendon
Internal Oblique
Deep and Superficial Rings
Deep Ring: Transversalis fascia evagination into canal as
internal spermatic fascia ½ inch above midpoint of inguinal ligament Transmits spermatic cord or round ligament
Superficial Ring: V-shaped defect in E-O aponeurosis Transmits spermatic cord + ilioinguinal nerve
Spermatic Cord: 3 coverings,6 constituents Coverings
External spermatic Fascia (from E-O apo) Cremastic muscle + fascia (?I-O, TA) Internal spermatic Fascia (transversalis fascia)
Constituents Ductus Deferens Arteries: Testicular artery, artery to ductus Veins: Pampiniform plexus Lymphatics Nerves: Genital br of genitofemoral n + sympathetic twigs Processus Vaginalis
Indirect Inguinal Hernia
• Generally congenital• Lax deep ring• Repair by excising hernia sac and mesh to
reinforce ring
Direct Inguinal Hernia
• Generally weakness in EO aponeurosis• Repair by reinforcing external ring, suturing
mesh to conjoint tendon
PRINCIPLES OF INCISIONS• Adequate exposure of the organ• Follow cleavage lines in skin
(Langer’s lines)• Avoid neurovascular structures• Consider direction of muscles
fibres and location of aponeuroses
Abdo wall nerve supply
78
9
101112-s/cL1-i/hL1-i/i
Abdo Wall Arterial Supply
Principles of Abdominal Incisions Adequate exposure of the organ Follow cleavage lines in skin (Langer’s lines) Avoid neurovascular structures Consider direction of muscle fibres and
location of aponeurosis
Midline
Paramedian
Pfannenstiel
Subcostal (Kochers)
Gridiron
Muscle split
Abdominal Incisions- access vs healing
The Abdominal Cavity
Viscera + peritoneum
Peritoneal Cavity
Viscera
• Urinary- kidneys, ureters• Endocrine- adrenal glands
Develop on post. Abdo wall (1° retroperitoneal)
Arterial supply from corresponding side of aorta
Nerve supply bilateral, true to level of origin
Referred pain to corresponding side
Digestive- GI tract, liver & biliary tract, pancreas
Haemopoietic- Spleen Develop on a mesentery
(which some lose to become 2° retroperitoneal)
Arterial supply from front of aorta
Nerve supply bilateral Referred pain to midline
Paired Unpaired
Intro: the Peritoneum
Serous membrane (latin =thin skin) 2 layers- visceral + parietal Parietal
Lines interior of body wall Nerve & vascular supply from body wall (somatic)
Visceral Covers viscera (!) Visceral supply
Mesenteries
Double layer of serous membrane (peritoneum), suspends all intraperitoneal viscera
Intermediary structure between parietal and visceral peritoneum
Function Provide mobile attachment for viscus Contains supply lines (sandwiched between 3
layers) All unpaired viscera develop on a mesentery
Whistlestop tour of gut
Stomach
Duodenum
Jejenum
Ileum
Caecum
Large Bowel
Rectum & Anus
Embryology of gut- 6/40
Midgut
Foregut
Hindgut
Posterior abdo wall
Mesentery (ventral)
Mesentery (dorsal)
Foregut Oropharynx to D2 (precisely opening of bile duct) Includes
Outgrowths: biliary tract Glands: liver & pancreas Spleen
Artery: Coeliac Nerve supply: T6- T9 spinal segments Rotation (on vertical axis of gut)- 90º left
Spleen from posterior (dorsal mesogastrium) to left Liver from anterior (ventral mesogastrium) to right
Retroperitoneal: 2nd part duodenum, spleen, most of pancreas
Rotation of foregut
Midgut
Foregut
Hindgut
Mesentery (ventral)
Mesentery (dorsal)
liver
Sp
leen
Foregut rotation 2
Greater sac
Lesser sac
Midgut
D2 to mid-transverse colon Artery: SMA Nerve supply: spinal segments T9, T10 Rotation:
On axis of SMA 270° anticlockwise 6- 10/40 gestation Via physiological hernia
Retroperitoneal: duodenum, ascending colon
Midgut rotation 6-10/40
Rotation occurs around the axis of the SMA on a single mesentery, “the mesentery”
Hindgut
Mid-transverse colon- upper anal canal Artery: IMA Nerve supply: T11 -S4 Mesenteries:
transverse mesocolon (shared with midgut) sigmoid mesocolon
Rotation: swings to left vertical axis of dorsal mesentery
Retroperitoneal: L colon (line of Toldt), rectum
Peritoneal Attachments
Bare area of liver
Lesser sac
Epiploic foramen
Greater sac
Abdominal Viscera
Next time!
Any Questions?
?