ABDOMEN

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ABDOMEN

• Lu Xiaoli
• Regional Anatomy Operative Surgery
• China Medical University

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BOUNDARIES
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• Abdominopelvic Cavity
• Abdominal Cavity
• Pelvic Cavity

P242-fig.4.21
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DIVISIONS
P242-fig.4.22
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P243-fig.4.23
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P243-fig.4.23
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• Which one of the following is not one of the 9
  regions of the abdomen?
• Right hypochondriac
• Left inguinal or iliac
• Epigastric
• Right upper
• Left lumbar

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• Which of the following is NOT true concerning the
  peritoneal cavity?
• The peritoneal cavity is a potential space.
• The peritoneal cavity contains organs inside of
  it.
• The peritoneal cavity is filled with fluid that
  lubricates its contents.
• The parietal and visceral peritoneum are linings
  of the peritoneal cavity.

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• The usual location for an appendectomy incision
  is the
• left lower quadrant
• left upper quadrant
• right lower quadrant
• right upper quadrant

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• You were asked to assist in a surgical operation
  on a young patient to treat an ulcer in the first
  part of the duodenum. You would expect that the
  surgeon will approach the ulcer by doing an
  anterior abdominal wall incision in the following
  region

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1. Epigastric
2. Left inguinal
3. Left lumbar
4. Right hypochondrial
5. Hypogastric

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ABDOMINAL WALL
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Abdominal wall

• Anterolateral abdominal wall

Posterior abdominal wall
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LAYERS

• Skin
• Superficial fascia
• Deep fascia
• Muscles

• Transversalis fascia
• Extraperitoneal fascia
• Peritoneum

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Superficial fascia

• Campers fascia
• Scarpa's fascia

P245-fig.4.254.26
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SUPERFICIAL ARTERIES

• Lateral
• Posterior intercostal a.
• Subcostal a.
• Lumbar a.
• Median
• Epigastric a.
• hypogastric a.
• Inferior
• Superficial epigastric a.
• Superficial iliac a.

P255-fig.4.39
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Superficial veins
lateral thoracic
subclavian
thoracoepigastric
portal
paraumbilical
S epigastric
femoral
S circumflex iliac
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Caput Medusae(Medusa Head )
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INNERVATIONS

• Intercostal Nerve
• T7-T12
• 10th Intercostal Nerve

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MUSCLES
Anterior Group
Lateral Group

• External Oblique
• Internal Oblique
• Transversus

• Rectus Abdominis
• Pyramidalis

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RECTUS ABDOMINIS

• Tendinous Intersection (3)
• Linea Semilunaris

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Rectus Sheath
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Arcuate line
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PYRAMIDALIS
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LINEA ALBA
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External Oblique Abdominis
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Oblique Internal Abdominis
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Transversus Abdominis
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Arteries

• 5 intercostal arteries
• subcostal arteries
• 4 lumbar arteries
• Superior epigastric arteryinternal thoracic
  artery
• Inferior epigastric artery -external iliac artery
• Deep iliac circumflex artery- external iliac
  artery

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Inferior epigastric artery
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Lymphatic Drainage
Anterior ? Intercostal Lymphatic Nodes Parasternal Lymphatic Nodes
Middle ? Lumbar Lymphatic Nodes
Lower ? External Iliac Lymphatic Nodes
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Innervations

• Intercostal n.
• Anterior cutaneous branch
• Lateral cutaneous branch

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• T7-12 thoracic n.
• Iliohypogastric n.
• Ilioinguinal n.
• Genitofemoral n.

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Transversalis Fascia
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Extraperitoneal Fascia
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Parietal Peritoneum
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Umbilical Folds

• Median
• -- median umbilical lig.
• Medial
• -- chorda arteriae umbilicalis
• Lateral
• -- inferior epigastric a. v.

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INCISIONS

• Longitudinal
• Midline
• Paramedian
• Transrectal
• Oblique
• Subcostal
• McBurneys
• Transverse
• Pfannenstiel
• Combined
• Thoracal-abdominal

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• The inferior border of the rectus sheath
  posteriorly is called the
• Falx inguinalis
• Inguinal ligament
• Internal inguinal ring
• Arcuate line
• Linea alba

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• Following an emergency appendectomy your patient
  complained of having paresthesia (numbness) of
  the skin at the pubic region. The most likely
  nerve that has been injured during the operation
  is
• Genitofemoral
• Iliohypogastric
• Subcostal
• Spinal nerve T10
• Spinal nerve T9

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• An obstetrician decides to do a Caesarean section
  on a 25-year-old pregnant woman. A transverse
  suprapubic incision is chosen for that purpose.
  All of the following abdominal wall layers will
  be encountered during the incision EXCEPT the

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1. Anterior rectus sheath
2. Posterior rectus sheath
3. Rectus abdominis muscle
4. Skin and subcutaneous tissue
5. Transversalis fascia, extraperitoneal fat, and
   peritoneum

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• Surgical approaches to the abdomen sometimes
  necessitate a midline incision between the two
  rectus sheaths, i.e., through the
• Linea aspera
• Arcuate line
• Semilunar line
• Iliopectineal line
• Linea alba

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• The internal thoracic artery is sometimes
  surgically cut near the caudal end of the sternum
  and used to supply blood to a region of the
  heart. In these cases, maintenance of adequate
  blood flow to the rectus abdominis may be
  dependent on increased flow through which artery?

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1. Superficial epigastric
2. Inferior epigastric
3. Umbilical
4. Superficial circumflex iliac
5. Deep circumflex iliac

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INGUINAL REGION
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Boundaries
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LAYERS

• Skin
• Superficial layer
• Campers
• Scarpas

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External Oblique Abdominis
Inguinal Lig. Lacunar Lig. Pectineal Lig.
(coopers Lig.)
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Reflected Ligament
Intercrural Fibers
Lateral Crus
Superficial Inguinal Ring
Medial Crus
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• Internal oblique abdominis
• transverse abdominis

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Cremaster
Conjoint Tendon
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Cremaster

• Conjoint Tendon

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Transverse Abdominal Fascia
abdominal inguinal ring (deep inguinal ring)
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• Extraperitoneal fascia
• Parietal peritoneum
• Medial inguinal fossa
• lateral inguinal fossa

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Descent Of Testis
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4 lunar month
11 weeks
8 lunar month
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Inguinal Canal

• Roof
• internal oblique abdominis
• transversus abdominis
• Floor
• inguinal ligament
• lacunar ligament
• anterior wall
• external abdominal oblique aponeurosis
• internal abdominal oblique aponeurosis
• posterior wall
• transversalis fascia
• conjoint tendon (falx inguinalis)

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Contents (male)

• spermatic cord
• arteries testicular artery, deferential artery,
  cremasteric artery
• nerves genital branch of the genitofemoral
  nerve, nerve to cremaster, sympathetic nerves
• vas deferens
• pampiniform plexus
• lymphatic vessels
• ilioinguinal nerve

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Contents (female)

• round ligament of the uterus
• ilioinguinal nerve

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Spermatic Fascia

• Internal spermatic fascia
• Transversalis fascia
• Middle
• cremaster
• External
• aponeurosis of external oblique abdominis

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HERNIA

• Inguinal hernia
• Indirect
• Direct

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Inguinal Triangle (Hesselbach's triangle )

• Direct Hernia

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• A medical student was asked by her preceptor to
  palpate the margin of the superficial inguinal
  ring of a healthy male patient. After passing her
  finger down the edge of the medial crus of the
  superficial inguinal ring, she felt a bony
  protuberance deep to the lateral edge of the
  spermatic cord, which she correctly identified as
  the

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1. pecten pubis
2. pubic symphysis
3. pubic tubercle
4. iliopubic eminence
5. iliopectineal line

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• In order to reduce a hernia (return it to the
  abdominal cavity), a surgeon finds it necessary
  to ligate an artery in the extraperitoneal
  connective tissue (preperitoneal fat) running
  vertically just medial to the bowel as the bowel
  passes through the abdominal wall. This artery is
  the

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1. Deep circumflex iliac
2. Inferior epigastric
3. Superficial circumflex iliac
4. Superficial epigastric
5. Superficial external pudendal

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• During a laparoscopic examination of the deep
  surface of the lower anterior abdominal wall
  (using a lighted scope on a thin tube inserted
  through the wall), the attending physician noted
  something of interest and asked the young
  resident to look at the medial inguinal fossa. To
  do so, the young doctor would have to look at the
  area between the

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1. inferior epigastric artery and urachus
2. medial umbilical ligament and urachus
3. inferior epigastric artery and lateral umbilical
   fold
4. medial umbilical ligament and inferior
   epigastric artery
5. median umbilical ligament and medial umbilical
   ligament

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• If one were to make an incision parallel to and 2
  inches above the inguinal ligament, one would
  find the inferior epigastric vessels between
  which layers of the abdominal wall?

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1. Camper's and Scarpa's fascias
2. External abdominal oblique and internal
   abdominal oblique muscles
3. Internal abdominal oblique and transversus
   abdominis muscles
4. Skin and deep fascia of the abdominal wall
5. Tranversus abdominis muscle and peritoneum

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• Which structure passes through the deep inguinal
  ring?
• Iliohypogastric nerve
• Ilioinguinal nerve
• Inferior epigastric artery
• Medial umbilical ligament
• Round ligament of the uterus

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• A loop of bowel protrudes through the abdominal
  wall to form a direct inguinal hernia viewed
  from the abdominal side, the hernial sac would be
  found in which region?

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1. Deep inguinal ring
2. Lateral inguinal fossa
3. Medial inguinal fossa
4. Superficial inguinal ring
5. Supravesical fossa

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• In a female with an indirect inguinal hernia, the
  herniated mass lies along side of which structure
  as it traverses the inguinal canal?
• Iliohypogastric nerve
• Inferior epigastric artery
• Ovarian artery and vein
• Pectineal ligament
• Round ligament of the uterus

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• The skin of the mons pubis is supplied by which
  nerve?
• Anterior scrotal
• Anterior labial
• Femoral branch of the genitofemoral
• Iliohypogastric nerve
• Subcostal nerve

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• During your peer presentation of the inguinal
  region dissection, you would indicate the
  position of the deep inguinal ring to be
• Above the anterior superior iliac spine
• Above the midpoint of the inguinal ligament
• Above the pubic tubercle
• In the supravesical fossa
• Medial to the inferior epigastric artery

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• A 45-year-old porter develops a direct inguinal
  hernia. If the hernia extended through the
  superficial inguinal ring, it would be surrounded
  by all of the abdominal wall layers EXCEPT the

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1. External spermatic fascia
2. Internal spermatic fascia
3. Peritoneum and extraperitoneal connective tissue
4. Weak fascia of the transversus abdominis muscle
   lateral to the falx

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• The boundaries of the inguinal triangle include
  all except
• Arcuate line
• Inferior epigastric vessels
• Inguinal ligament
• Lateral border of rectus abdominus muscle

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• The superficial inguinal ring is an opening in
  which structure?
• External abdominal oblique aponeurosis
• Falx inguinalis
• Internal abdominal oblique muscle
• Scarpa's fascia
• Transversalis fascia

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• Which nerve passes through the superficial
  inguinal ring and may therefore be endangered
  during inguinal hernia repair?
• Femoral branch of the genitofemoral
• Ilioinguinal
• Iliohypogastric
• Obturator
• Subcostal

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• During exploratory surgery of the abdomen, an
  incidental finding was a herniation of bowel
  between the lateral edge of the rectus abdominis
  muscle, the inguinal ligament and the inferior
  epigastric vessels. These boundaries defined the
  hernia as a(n)

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1. Congenital inguinal hernia
2. Direct inguinal hernia
3. Femoral hernia
4. Indirect inguinal hernia
5. Umbilical hernia

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Anterolateral abdominal wall Superficial layers Skin Superficial skin
Anterolateral abdominal wall Deep layers Muscles Transversalis fascia Subperitoneal fascia Parietal peritoneum
Inguinal region Inguinal canal triangle 4 walls 2 openings Contens