Anatomy of Abdomen and Pelvis

Areas/Organs Abdominal wall – anterior Inguinal region Abdominal wall - posterior Bowel Biliary system Genital tract Liver Pancreas Peritoneum Pelvis Pelvic bones Perineum Sacrum Spleen Suprarenal (adrenal) glands Urinary tract

Anatomy of Abdomen and Pelvis Surface anatomy Surface marking Xiphoid Iliac crest Pubic tubercle Vas deference

Anatomy of Abdomen and Pelvis Vertebral Levels T9 __ The xiphoid L1 __ Transpyloric plane of addison L3 __ The subcostal plane L4 __ The plane of iliac crest The Umbilicus __ at the junction between L3 __ L4

Anatomy of Abdomen and Pelvis Nerve supply of the abdominal wall Abdominal Muscles Overlaying Skin From T7 __ L1 The Umiblicus T10 The Groin and Scrotum L1

Anatomy of Abdomen and Pelvis Surface Marking Abdominal Vescera are inconstant in their position Liver Spleen Gallbladder Pancrease Aorta Kidneys In thin people (women) you may palpate caecum sigmoid colon

Anatomy of Abdomen and Pelvis The fascia and muscles of the abdominal wall No deep Fascia Super fecial Fascia Camper __ Faty layer Scarpas __ fibrous Colles __ Extinction of scarpas to the perineum

Anatomy of Abdomen and Pelvis The muscles of the anterior abdominal wall of considerable practical importance. The Rectus abdominis (origin) arises- Horizontal line from the 5th, 6th, and 7th costal cartilage. Insertion____ into the crest of pubis Transverse tendinous intersections 3 or 4

Abdominal wall muscle

Anatomy of Abdomen and Pelvis Rectus sheath- aponeurotic expansion of lateral abdominal muscles. Above the costal margin From the costal margin to a point half way between the umbilicus and the pubis Below the previous point The arcuate line of douglas

Anatomy of Abdomen and Pelvis The oblique Externus abdominis (External oblique) Origin: Anterior surface of lower 8th ribs. Insertion: xiphoid, pubic crest and pubic tubercle and anterior part of iliac crest. Inguinal ligament of poupart’s from pubic tubercle to the anterior superior iliac spine Fibers: downwards, forwards, mediall Posterior wall – Free

Anatomy of Abdomen and Pelvis The oblique internus abdominis ( internal oblique) Origin – lumber fascia, Anterior two third of iliac crest, and lateral two third of inguinal ligament. Insertion: lower 6th costal cartilage linea alba and pubic crest. Fibers: upwards, forwords Posterior wall – arise from lumber fascia

Anatomy of Abdomen and Pelvis The transversus abdominis: Origin: lumber fascia, lower 6th costal cartilage, anterior two third of iliac crest and the lateral two third of inguinal ligament. Insertion: linea alba – pubic crest Fibers: transversely Posterior border – arise from lumber fascia.

Anatomy of Abdomen and Pelvis The anatomy of abdominal incisions Midline incision Through linea alba Wide fibrous structure above the umbilicus Narrow hair line below the umbilicus Bloodless line Through it the abdomen can be opened rapidly Gives wide exposure.

Anatomy of Abdomen and Pelvis Paramedian incisions: 1in {2.5cm -1.5in (4cm)} parallel to ML Anterior rectus sheath opened Rectus muscle retracted Posterior rectus sheath and peritoneum opened Posterior rectus sheath and peritoneum become thin and fatty below a point half way between umbilicus and pubis

Anatomy of Abdomen and Pelvis Transrectus incision: Best avoided The rectus muscle is split in the line of paramedian incision The nerve supply of rectus muscle lies laterally The medial part of the muscle become atrophic Pararectal incision (Battle) Rectus sheath opened Rectus muscle retracted medially Extending of this incision may damage the segmental nerve supply to the rectus muscle

Anatomy of Abdomen and Pelvis Subcostal incision (Kocher) Right side ___ used in Biliary Surgery Left side ___ to expose the spleen Starts at midline and extends parallel to and 1in (2.5cm) below costal margin Anterior rectus sheath is opened Rectus muscle is cut Posterior rectus sheath and peritonerm is incised The 8th 9th intercostal nerves might be injured Is valuable in wide costal angle’s patient.

Anatomy of Abdomen and Pelvis Gridiron Incision ( muscle splitting to the appendix) Centered at Mac Burney's point ( two third of the way laterally along the line from the umbilicus to the anterior superior iliac spine Transverse incision ( to the appendix) Skin crease forwards from, and 1in (2.5cm) above the anterior spine

Anatomy of Abdomen and Pelvis Transverse and oblique incisions Cutting incisions through the lateral abdominal muscles Do not damage their nerve supply Used to expose lower abdominal intraperitoneal and extra peritoneal structure. ie sigmoid colon, caecum, ureter, blood vessels

Anatomy of Abdomen and Pelvis Throco abdominal Incision Upper Para median or oblique abdominal incision through 8th and 9th inter costal space. Used to expose upper stomach, lower esophagus, right lobe & liver

Anatomy of Abdomen and Pelvis Paracentesis abdominis To evacuate intraperitoneal abdominal fluid Through a cannula inserted through abdominal wall Through linea alba (mid lines) Lateral to Mac Burney's point

Anatomy of Abdomen and Pelvis The inguinal canal Is 1.5in (4cm) long Passes downwards medially from external to internal inguinal ring Parallel to and immediately above the inguinal ligament Relations Anteriorly skin, superficial fascia, external oblique, internal oblique Posteriorly, conjoind tendon, fascia transversalis

Anatomy of Abdomen and Pelvis Above – internal oblique and transversus abdominis Below – The inguinal ligament Deep ring (internal ring) – the point at which the spermatic cord pushes through the T.F. External Ring ( superficial ring) – A defect in external oblique The I.C. Transmit – spermatic cord and ilioinguinal nerve – in male Round ligament and ilioinguinal nerve in female

Anatomy of Abdomen and Pelvis The spermatic cord 3 layers of fascia – E.S.F., I.S.F.C.F 3 arteries – T.A., C.A. and artery to Vas. 3 nerves – G.N.,S.F.I.I.N. 3 other structure: Pampiniform plexus of veins draining the right testis (R.T) to inferior vena ceva ( I.V.C.) and the left testis (Lt) to the renal vein (R.v.) Vas deferens Lymphatics drain the testis to Aortic lymph nods (L.N.)

Anatomy of Abdomen and Pelvis Indirect inguinal Hernia passes through Internal ring – along the inguinal canal – external ring – scrotum If reducible controlled by direct pressure on the internal ring The internal ring: lies 0.5in (12mm) above the midian point of inguinal ligament above the pulsation of femoral artery

Anatomy of Abdomen and Pelvis Direct inguinal hernia Pushes directly the posterior wall of the inguinal canal ( I.C.) Lies medial to inferior epigastric artery May protrude through the external inguinal ring (E.I.R.) Notice The diagnosis of inguinal hernia wither direct or indirect sometimes is difficult and can only made during surgery

Anatomy of Abdomen and Pelvis Inguinal Hernia – is felt to lie above and medial to pubic tubercle (p.T.) The femoral hernia – is felt to lie below and lateral to the P.T. The inferior epigastric vessels ( I.E.V.) demarcate the medial border of the internal ring so An indirect hernia sac – lies lateral to IEV A direct hernia sac – lies medial to IEV Pantaloons hernia - both direct and indirect hernia coexist and bulge through on each side of the IEV