APPLIED ANATOMY

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3. 3 Applied Anatomy of:- Abdominal wall Abdominal incisions The hernial orifices Abdominal wall divided into:- ? Anteriolateral abdominal wall ? Posterior abdominal wall

4. 4 it is subdivided into: ? anterior wall ? right lateral wall ? left lateral wall This extended from the thoracic cage to the pelvis and bounded by: ? superiorly by the cartilages of the 7th through 10th ribs and xiphoid process of the sternum. ? inferiorly by the inguinal ligaments and the pelvic bones. The wall consists of skin, subcutaneous tissues (fat), muscles, deep fascia and parietal peritoneum.

5. 5 ? The subcutaneous tissues over most of the wall consists of layer of connective tissues that contains a variable amount of fat. ? In the inferior part of the wall , the subcutaneous tissue is composed of two layers:- ? a fatty superficial layer (Camper�s fascia) ? a membranous deep layer (Scarpa�s fascia)

6. 6 There are five muscles, three flat muscles and two vertical muscles The three flat muscles are; � External oblique muscles � Internal oblique muscles � Transverse abdominal muscles All the three flat muscles end anteriorly in strong sheet like aponeurosis. (the rectus sheath) The two vertical muscles are; � Rectus abdominis muscles � Pyramidalis muscles

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10. 10 The skin and muscles of the anteriolateral abdominal wall are supplied by:- ? Thoracoabdominal nerves [inferior intercostal (T7 � T11)] ? Sub-costal nerves (T12) ? Ilio-hypogastric and Ilio inguinal nerves (L1)

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13. 13 ? Physical examination of the abdominal wall. Physicians perform the part of physical examination with patient in the supine position with thighs and knees semi-flexed. (inspection, palpations, perussion and auscultation) ? Functions and actions of the anterio lateral abdominal muscles are:- ? form strong expandable support. ? protect the abdominal viscera from injury such as low below in boxing. ? compress the abdominal content.

14. 14 ? helps to maintain or increase the intra abdominal pressure. ? move the trunk and help to maintain posture. ? Protuberance of the abdomen. The five common causes of abdominal protuberance are begins with (5F) (fat, faeces, fetus, flatus and fluid). ? abdominal hernias: the anteriolateral abdominal wall may be the site of hernias. Most hernias occur in the inguinal, umbilical and epigastric regions.

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17. 17 The posterior abdominal wall is mainly composed: ? Five lumbar vertebrae and associated IV discs. ? Post abdominal wall muscles � psoas, quadratus lumborum, iliacus, transverse, abdominal wall oblique muscles. ? Lumbar plexus, composed of the ventral rami of lumbar spinal nerves. ? Fascia including thoracolumbar fascia. ? Diaphragm contributing to the superior part of the posterior wall ? Fat, nerves, vessels (IVC, aorta) and lymph nodes.

18. 18 The fascia lies between the parital peritoneum and the muscles: it is customizing to name the fascia according to the structure it covers. ? the psoas fascia or psoas sheath. ? the quadratus lumborum fascia. ? the thoracolumbar fascia.

19. 19 The main paired muscles in the posterior abdominal wall are:- ? Psoas major ? Iliacus ? Quadratus lumborum

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21. 21 There are somatic and autonomic nerves in the posterior abdominal wall. Somatic nerves of the posterior abdominal wall:- ?The sub costal nerves ?The lumbar nerves ?The lumbar plexus of nerves branchus are: (a) The obturator nerves (L2 � L4) (b) The femoral nerves (L2 � through L4) (c) Ilio inguinal and ilio hypogastric nerves (L1)

22. 22 (d) Gentio femoral (L1 � L2) (e) Lateral femoral cutaneous nerves (L2 � L3) Autonomic nerves of the posterior abdominal wall: The autonomic nerves of the abdomen consists of one cranial nerve (the vagus) and several different splanchnic nerves that deliver presynaptic sympathizer and parasympathetic fibers to the plexus and sympathetic ganglia.

23. 23 The sympathetic part of the autonomic nervous system in the abdomen consists of the: ? Abdomino-pelvic splanchic N. from the thoracic and abdominal sympathetic trunks ? Prevertebral sympathetic ganglia ? Periarterial plexus ? Abdominal autonomic plexus ? Celiac plexus ? Superior mensentric plexus ? Inferior mensentric plexus. ? Celiac plexus ? Superior hypogastric plexus ? Inferior hypogastric plexus

24. 24 ARTERIES of the posterior abdominal wall: abdominal aorta and branches VEINS of the posterior abdominal wall: the veins of the posterior abdominal wall are triturates of the I.V.C CLINICAL ASPECTS of the posterior abdominal wall ? Posterior abdominal pain: The ilio-psoas has extensive and clinically important relations to kidney, ureters, caecum, appendix, colon, pancreas�.etc. When any of these structures is diseased

25. 25 movement of the ilio psoas usually causes pain. When intra abdominal inflammation is suspected the ilio psoas test performed. ? Psoas abscess: tuberculosis has been greatly reduced the infection may spread through the blood to the vertebrae (Hematogenous spread) in abscess resulting from TB in the lumbar region tends to spread from the vertebrae into the psoas sheath,where it produces psoas abscess. ? Partial lumbar sympathectomy: the TR of some patients with arterial disease in the lower limbs (ischaemia) may include partial lumbar sympathectomy by removal of

26. 26 two or more lumbar sympathetic ganglia. ? Pulsations of the aorta and abdominal aortic aneurysm. ? When IVC obstructed or ligated: Three collateral routs formed by valveless veins of the trunk are available for venus blood to return to the heart. ? inferior epigastric vein ? superficial epigastric vein ? epidural venous plexus inside the vertebral column.

27. 27 Psoas Abscess

28. 28 Definition: incision defined as cut made with knife for surgical purposes. Types of abdominal incision: The abdominal incisions are classified into:- ? Vertical abdominal incision ? Transverse abdominal incision ? Oblique abdominal incision ? Abdomino thoracic incision

29. 29 The vertical incisions: ? Midline incision ? Para median The transverse abdominal incisions: ? Upper and lower transverse incision ? Pfannenstiel incision ? LANZ incision for appendicectomy The oblique abdominal incisions ? The subcostal or Kocher�s incision ? Rutherford Morison incision ? McBurney incision for appendicectomy

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32. 32 ? The abdominal cavity can be approached through numerous incisions but only the correct diagnosis will enable the surgeon to choose the correct incision. ? When the pre-operative diagnosis is reasonably certain the incision may be chosen with confidence. But laparotomy for undiagnosed abdominal disease is most usefully approached through vertical incision equidistant above and below the umbilicus and once the diagnosis confirmed. The incision may be enlarged in an upward or downward direction.

33. 33 ? Choice of incision depends on many factors these includes:- ? The organs to be investigated ? The type of surgery to be preformed ? Whether speed is an essential consideration ? The build of the patient ? The degree of obesity ? The presence of previous abdominal incisions ? Closure of the abdominal incision:- The ideal method of abdominal wound closure has not been discovered. However it should be free from complications such as:-

34. 34 ? Burst abdomen ? Incisional hernia ? Persistent sinuses ? It should be comfortable to the patient ? Should leave reasonably good scar ? Incisional Hernia:- defined as protrusion of omentum or organ through surgical incision. However if the muscles and aponeurotic layers of the abdomen doesn�t heal properly an incisional hernia can result, infection, bowel obstruction and obesity are predisposing factors to incisional hernia

35. 35 Hernia defined as the protrusion of an organ through it�s containing wall. However before an organ can herniate they must be weakness in the wall, this may be: (a) normal weakness found in everyone and related to anatomy of the area e.g., place where vessel or viscus enters or leaves the abdomen. (b) abnormal weakness caused by congenital abnormality or acquired as result of trauma or diseases.

36. 36 ? Inguinal Hernia ? Umbilical Hernia ? Femoral Hernia ? Incisional Hernia Less common Hernia ? Epigastric Hernia ? Recurrent Hernia

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38. 38 The features of all hernias are: ? They occur at weak spot ? They reduce on lying down or with direct pressure ? They have an expansile cough impulse

39. 39 The Causes of Abdominal Hernia: ? An anatomical weakness where: a. Structures pass through the abdominal wall b. Muscles fail to overlap c. There are no muscles only scar tissue (e.g. umbilical) ? An acquire weakness following trauma ? High intraabdominal pressure from: a. Coughing b. Strains c. Abdominal distention

40. 40 ? Anatomy of inguinal region ? Inguinal canal with boundaries, contents and orifices ? Types ? Treatment ? Clinical aspect

41. 41 ? Umbilical hernia ? Femoral hernia ? Incisional hernia ? Epigastric hernia ? Recurrent hernia

42. 42 History very important: ? age it occur at all ages they may be present at birth or appear suddenly at any age. ? occupation ? local symptoms the commonest symptoms are discomfort and pain. ? systemic symptoms; if the hernia obstructing the patient complaints one or more of the following cardinal symptoms of intestinal obstructions.

43. 43 � colicky abdominal pain � vomiting � abdominal distension � constipation During examination of the patient, ask the patient to stand up and look to the site of the Lump (inspection) and ask the patient to cough look for cough impulse, if positive or negative. Then palpitate the lump and whether it�s reducible or not.

44. 44 If the Hernia not treated. One or more of these complication may occurs. (a) intestinal obstruction (b) strangulation (c) incarceration

45. 45 Local complications may occur during or after surgery for any Hernia repair:- (a) Haemorrhage haematoma formation (b) Bowel injuries (c) Wound infections (d) Recurrent of Hernia

46. 46 Clinical features of inguinal Hernia:- (a) Indirect inguinal hernia pass via deep inguinal ring along the canal then if large enough emerges through the external ring and descends into scrotum.

47. 47 (b) Direct hernia pushes its way directly forward through the posterior wall of the inguinal canal Via Hesselbech�s triangle, which is boundary base inguinal ligament medial border midline laterally by inferior epigastric vessels. However, the inferior epigastric vessels demarcate the indirect hernia sac pass lateral and direct hernia medial to these vessel.

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