Abdominal wall, umbilicus, omenteum Sabiston 769-781

Abdominal wall Musculoaponeurotic structure Attachments Defects: congenital, acquired,iatrogenic

Anterior abdominal wall Protect viscera Respiratory function Urination defecation

Anatomy 1. Skin 2. SubQ 3. Scarpa fascia 4. Ext. Abd. Oblique M 5. Int Abd. Oblique M 6. Transversus abd. 7. Transversalis fascia: hernia 8. Extraperitoneal fat 9. Parietal peritoneum

Lymphatics Above umb: Below umb: ipsilateral axillary LN ipsilateral superficial inguinal LN

Blood supply Superior epigastric A Inferior epigastric A from int. thx. A Inferior epigastric A from ext. iliac A Lower intercostal Iliac circumflex arteries

Congenital abnormalities Diastasis recti: most common Weakness of linea alba No treatment Omphalocele Gastroschisis

Case Neonate with protrusion in the umbilicus

Exomphalos and gastroschisis Two different congenital anomalies Differ markedly in their clinical appearance Overall incidence is approximately 1: 3000 live births Usually diagnosed prenatally on ultrasound

Exomphalos Sac contains intestinal loops, liver, spleen and bladder Often associated with other major congenital anomalies Prognosis depends on theses associated anomalies Mortality is approximately 40%

Exomphalos Often associated with other major congenital anomalies Prognosis depends on theses associated anomalies Mortality is approximately 40%

Gastroschisis A gastroschisis never has a sac Umbilical cord arises from normal place in abdominal wall Usually to the left of the abdominal wall defect Evisceration usually only contains intestinal loops Rarely associated with major congenital anomalies

Exomphalos Rx Treatment depends on the size of the lesion Aims of treatment are to reduce contents into small abdominal cavity If bowel is covered there is no urgency to do this

Gastroschisis Infants have better prognosis than those with an omphalocele Mortality is approximately 10%

Rx usually direct full-layer closure of abdominal wall May be associated with postoperative gut dysfunction Usually require postoperative nutritional and ventilatory support

Granuloma: silver nitrate

Omphalomesenteric duct Midgut-yolk sac Polyp: excision Sinus: sinogram, excision Persistent omphalomesenteric duct Cyst: volvulus Meckel’s diverticulum

Urachus Umb/bladder May become infected Diverticula of bladder

Omentum Double endothelium Vessels Lymphatics Nerves Fat

Omentum Large in obese Can be removed Policeman of the abdomen Movement by intestine Can adhere firmly

Omentum Torsion Cysts Solid Tumors Vascular pedicle flap: neck/knee -Wrap anastomosis, lymphedema, liver for hemostasis, biliary leak, chest wall reconstruction