Abdominal wall

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Abdominal wall

• ??????? ?????
• ???

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Anterior wall

• Layers ( from superficial to deep)
• Skin
• Superficial fascia
• Anterolateral muscles
• Transversalis fascia ????
• Extraperitoneal fascia ?????
• Parietal peritoneum ???

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• Superficial fascia-divisions below umbilicus
• Superficial fatty layer (Campers)
• Membranous layer (Scarpas)

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Muscles of abdomen

• Anterolateral group
• Obliquus externus absominis ????
• Oblequus enternus abdominis????
• Transversus abdominis???
• Rectus abdominis ???

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• Posterior group
• Quadiatus lumborum ???
• Psoas major ???

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Obliquus externus absominis ????

• General direction of fibers downward, forward
  and medially (run down and inward)
• Structures
• Inguinal ligament ?????
• Lacunar ligament ????
• Superficial inguinal ring ?????
  -triangular-shaped defect in aponeurosis of
  obliquus externus abdominis above pubic tubercle

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Obliquus internus abdominis ????

• Deep to obliquus externus abdominis
• General direction of fibres upwards, forwards
  and medially

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Transversels abdominis ???

• Deep to obliquus internus

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• Inguinal falx ???? arch over spermatic cord,
  inserted with transverses abdominis fiber into
  medial part of pecten of pubis
• Cremaster ??? around the spermatic cord and
  testis

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Rectus abdominis ???

• Position lie on to either of midline
• Origin pubic crest and symphysis
• Insertion xiphoid and 5th-7th costal cartilages
• Has 3-4 tendinous intersections ??
• linea semiluaris ???

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Similar functions for above four pairs of muscles

• Support and compress the abdominal viscera
• Increase intra-abdominal pressure, aid in
  expulsive efforts-vomiting, coughing, sneezing,
  defecation, urination and childbirth.
• Depress ribs, assist in (the act of
  force(4)expiration.
• Flex, lateral flex, and rotate vertebral column

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Sheath of rectus abdominis ????

• Ant layer-formed by fusion of aponeurosis of
  obliquus externus abdominis and anterior leaf of
  aponeurosis of obliquus internus abdominis
• Post layer
• Formed by fusion of posterion leaf of aponeurosis
  of obliquus internus abdominis and aponeurosis of
  transverses abdominis
• Absent in about 4-5cm below the umbilicus, where
  aponeuroses of all three muscles form anterior
  layer the lower free border named arcuate line
• Below this line rectus abdominis in contact with
  transverse fascia

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Linea alba ?? -tendinous raphe between right and
left recti from xiphoid to pubic symphysis.
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Inguinal region ????

• Boundaries
• Inguinal ligament
• Lateral margin of rectus abdominis
• A horizontal line stretching from anterior iliac
  spine to laeral margin of rectus abdominis

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Descent of testes
Seven-week embryo showing the testis before its
descent from the dorsal abdominal wall
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Fetus at 28 week the testis passing through the
inguinal canal
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Newborn
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Inguinal canal ????

• Position oblique passage, 4cm long, located
  1.5cm above medial half of inguinal lig.

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• Boundaries
• Ant wall
• Aponeurosis of obliquus externus abdominis
• Obliquus internus abdominis (lateral third of
  wall)

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• Post wall
• Transverse fascia
• Inguinal flax medially
• Roof-arched lower fibers of obliquus internus and
  transversua abdominis
• Floor-inguinal lig.

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• Two openings
• Superficial inguinal ring ?????
• Deep inguinal ring ????? -defect in transverse
  fascia 1.5cm above midpoint of inguinal ligament

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• Structures passing through the inguinal canal
• Spermatic cord ?? and ilioinguinal nerve?????? in
  males
• Round ligament of uterus ?????and ilioinguinal
  nerve?????? in females

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Inguinal Triangle (of Hesselbach) ?????

• Boundaries
• Inguinal ligament inferiorly
• Lateral border of rectus abdominis medially
• Inferior epigastric artery laterally

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Indirect inguinal heinia and direcet inguinal
heinia
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Superficial vessels and cutaneous nerves

• Arteries
• Superficial epigastric a.
• Superficial iliac circumflex a.
• Veins
• Thoracoepigastric v.
• Superficial epigastric v.
• Cutaneous nerves
• Anterior and lateral cutaneous n. of lower six
  thoracic
• Iliohypogastric n. (first lumb nerves)

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Deep vessels and nerves

• Arteres
• Superior and inferior epigastric arteris
• Lower posterior intercostal a.
• Subcostal a.
• Four lumbar a.

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• Nerves
• Iliohypogastric n. ?????
• Arises from lubar plexus
• Passes forward in the interval between obliquus
  internus and tranversus abdominis
• Pieces obliquus internus abdominis 2.5 cm medial
  to anterior superior iliac spine
• Pieces aponeurosis of obliquus externus
  abdominisabout 2.5 cm above superficial inguinal
  ring
• Ilioinguinal n. ??????
• Runs parallel with iliohypogastric n. at a lower
  level
• Enters inguinal canal and emerges through
  superficial inguinal ring
• Genitofemoral n. ?????

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Layer ?
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Abdomen 2

• ??????? ?????
• ???

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Abdominal aorta ????

• Continuation of thoracic aorta at aortic hiatus
  of diaphragm in front of T12
• Terminates at lower border of L4 vertebra by
  dividing into right and left common iliac
  arteries

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• Parietal branches
• Inferior phrenic a. ????(one pair)
• Lumbar a. ???(four pairs of arteries that supply
  the posterior abdominal wall)
• Median sacral a. ?????

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• Visceral branches
• Paired branches
• Middle suprarenal artery ??????
• Renal artery ???
• Testicular (ovarian) artery ??(??)??

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• Unpaired branches
• Celiac trunk ??? -a short thick vessel that
  arises from the front of aorta, at the level of
  T12
• Superior mesenteric a. ??????-arises from the
  front of aorta, at the level of L2
• Inferior mesenteric a. ?????? -arises from the
  front of aorta, at level of L3

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Celiac trunk

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Celiac trunk
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Colic marginal artery
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• Relations of abdominal aorta
• Anteriorly (from above downward)
• Pancreas
• Ascending part of duodenum
• Radix of mesentery
• Posteriorly
• Upper four lumber vertebrae
• On its right
• Inferior vena cava
• On its left
• Left sympathetic trunk

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Veins of abdomen and pelvis

• Internal iliac vein ????
• Parietal tributaries accompany with arteries
• Visceral tributaries
• ?superior rectal vein?inferior
  mesenteric v.
• ?Rectal venous plexus ?inferior rectal
  vein?internal iliac v.
• ????? ?anal vein?internal pudendal v.
• ?Vesical venous plexus ??????vesical v.
• ?Uterine venous plexus ??????uterine v.

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• External iliac vein ???? accompany the
  artery
• Common iliac vein ???? formed by union of
  internal and external iliac veins in front of
  sacroiliac joint, end upon L4L5 by uniting each
  other to form inferior vena cava

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Inferior vena cava ????

• Formed by union of two common iliac veins
  anterior to and just to the right of L4L5
• Ascends on the right side of aorta, pierces vena
  cava foramen of diaphragm opposite the T8 and
  drains into the right atrium
• Conveys blood from the whole body below the
  diaphragm to the right atrium

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• Chief tributaries
• Parietal
• Paired inferior phrenic v. ????
• paired lumbar v. ??? (four)
• Visceral
• Right and left renal veins ??????
• Right suprarenal vein ?????? (left drain
  into left renal vein)
• Right testicular or ovarian v???(??)??. (left
  drain into left renal vein)
• Hepatic veins ??? right, left and intermediate

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• Relations of inferior vena cava
• Anteriorly (cranially to caudally)
• Liver
• Head of pancreas
• Horizontal part of duodenum
• Right testicular (or ovarian) a.
• Radix of mesentery
• Posteriorly
• Right crus of diaphragm
• Upper four lumber vertebrae
• Left sympathetic trunk
• Parietal branches of abdominal aorta
• On its right
• Psoas major
• Right kidney
• Right suprarenal gland
• On its left
• Abdominal aorta

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Hepatic portal vein ????

• General features
• Formed behind the neck of pancreas by the union
  of superior mesenteric vein and splenic vein
• Ascends upwards and to the right, posterior to
  the first part of duodenum and then enters the
  lesser omentum to the porta hepatis, where it
  divides into right and left branches
• There are no functioning valves in hepatic portal
  system
• Drains blood from gastrointestinal tract from the
  lower end of oesophagus to the upper end of anal
  canal, pancreas, gall bladder, bile ducts and
  spleen

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Variation and anomalies of hepatic portal vein
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• Tributaries of hepatic portal vein
• 1. Superior mesenteric v. ??????
• 2. Inferior mesenteric v. ??????
• 3. Splenic v. ???
• 4. Left gastric v. ????
• 5. Right gastric v.????
• 6. Cystic v. ????
• 7. Paraumbilical v. ????

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• Portal-systemic anastomoses
• 1. At the lower end of the oesophagus
• Hepatic portal vein ? left gastric vein ?
  esophageal
• venous plexus ? esophageal vein ? azygos vein
• ? superiorvena cava
• 2. At rectal venous plexus
• Hepatic portal vein ? splenic vein ? inferior
  mesenteric
• vein ? superior rectal vein ? rectal venous
  plexus ?
• inferior rectal and anal veins ? internal iliac
  vein ?
• inferior vena cava
• 3. At periumbilical venous plexus
• Hepatic portal vein?paraumbilical
  vein?periumbilical
• venous plexus?
• thoracoepigastric and superior epigastric vein ?
  superiorvena cava
• superficial epigastric and inferior epigastric
  veins ? inferior vena cava

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• 4. Portal-retroperitoneal anastomosis
• Between the retroperitoneal branches of the
  colic veins and the lumbar veins,
  pancreaticoduodenal veins with the renal veins
  and the subcapsular veins of the liver with the
  phrenic veins twigs of colic veins (portal)
  anastomosing with systemic retroperitoneal veins

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The lymphatic drainage of abdomen

• Lymphatic drainage of abdominal wall
• To axillary lymph node from region above
  umbilicus
• To superficial inguinal lymph node from region
  below umbilicus
• To lumbar lymph node from post wall of abdomen

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• Lymphatic drainage of abdominal viscera
• Lumbar lymph nodes ????
• Lie on posterior abdominal wall, along the
  abdominal aorta and inferior vena cava
• Receive lymph from kidneys, suprarenal glands,
  testes, ovarirs, fundus of uterus, ovary, and
  common iliac nodes
• Right and left lumbar trunks formed by efferent
  vessel
• Paired viscera-drain to the lumbar lymph nodes

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• Celiac lymph nodes ?????
  -situated around the celiac
  trunk
• Superior mesenteric lymph node ???????
  -situated around superior mesenteric a.
• Inferior mesenteric lymph node ???????
  -situated around inferior mesenteric a.
• Intestinal trunk ??? -formed by
  efferent vessel of celiac, superior and inferior
  lymph nodes

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• Thoracic duct ???
• Begins in front of L1 as a dilated sac, the
  cisterna chyli, which formed by joining of left
  and right lumbar trunks and intestinal trunk
• Enter thoracic cavity by passing through the
  aortic hiatus of the diaphragm and ascends along
  on the front of the vertebral column, between
  thoracic aorta and azygos vein
• Travels upward, veering to the left at the level
  of T5
• At the roof of the neck, it turns laterally and
  arches forwards and descends to enter the left
  venous angle
• Just before termination, it receives the left
  jugular, subclavian and bronchomediastinal trunks
• Drains lymph from lower limbs, pelvic cavity,
  abdominal cavity, left side of thorax, and left
  side of the head, neck and left upper limb

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Spleen ?

• Location lies in the left hypochondriac region
  (between stomach and diaphragm) deep to the 9th
  to 11th rib, its long axis corresponds roughly to
  the 10th rib
• Shape-reddish in colour

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• Two surfaces
• Diaphragmatic smooth, convex
• Visceral concave, hilum of spleen
• Two extremities
• Anterior-wider
• Posterior-rounder
• Two border
• Superior-has 2-3 splenic notch ???, which serve
  as a landmark on palpation when it is enlarge
  normally it is not palpable
• Inferior-rounder
• Functions the spleen is considered to be
  important in
• Formation of lymphocytes and monocyte
• Phagocytosis of bacteria, inert particles and
  white blood cells and platelets
• Destroying effete or abnormal red blood cells
• Making antibodies

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• Ralationships of spleen
• Diaphragmatic surface-diaphragm
• Visceral surface
• Anteriorly-fundus of stomach
• Posteriorly-left suprarenal gland and kidney
• Inferiorly-tail of pancreas and left colic
  flexure

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Nervers of abdomen

• Lumbar plexus ??
• Formation formed by anterior rami of L1-L3, a
  part of anterior rami of T12and L4
• Position lies within substance of psoas major

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• Branches
• Iliohypogastric n. ?????Supplies lower part of
  anterior abdominal wall
• Ilioinguinal n. ??????Passes through inguinal
  canal to supply skin of the groin and scrotum
• Lateral femoral cutaneous ??????
• Femoral n. ???
• Obturator n. ????
• Genitofemoral n. ?????

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Lumbar sympathetic trunk ????

• Made up of paired chains with four to five lumbar
  ganglia anterolateral to vertebral column
• Enters abdomen via the diaphragm and as a
  continuation of he thoracic part
• Passes inferiorly behind common iliac vessels and
  terminations by joining to form unpaired ganglion
  impar, anterior to sacrum

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Abdomen 3

• ??????? ?????
• ???

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Relationships of abdominal viscera

• First layer-live, gallbladder, stomach
• Second layer-duodenum, pancreas, spleen
• Third layer-suprarenal gland, kidney, ureter,
  inferior vena cava, abdominal aorta, nerves and
  lymphatics

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Relationships of the stomach

• Anterior
• Live (right part)
• Diaphragm (left upper part)
• Anterior abdominal wall (left lower part)
• Posterior-separated by peritonum of lesser sac
  from the following (stumach-bed)
• Pancreas
• Left suprarenal gland
• Left kidney
• Spleen
• Transverse colon and transvers mesoclon

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Arteries of stomach

• Left and right gastric arteries arise from celiac
  trunk and proper hepatic artery, repectively.
  These two vessels run in lesser omentum along
  lesser curvature , and anastomose end-to-end.

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• Right and left gastroepiploic arteries arise from
  the gastroduodenal and splenic artery,
  repectively. These two vessels pass into the
  greater omentum, run parallel to the greater
  curvature, and anastomose end-to-end.
• Short gastric arteries, branches of splenic
  artery, course through the gastrosplenic ligament
  and supply the fundus of stomach.
• Posterior gastric artery (72) arise from the
  splenic artery, course through the gastrophrenic
  ligament and supply the posterior wall of fundus
  of stomach.

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• Venous drainage
• Right and left gastric veins empty directly into
  hepatic portal vein.
• Left gastroepiploic and short gastric veins drain
  into hepatic portal vein via the splenic vein.
• Right gastroepiploic vein join either superior
  mesenteric vein.

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• Lymphatics of stomach
• Right and left gastric ln. lie along the same
  vessels and finally to the celiac ln.
• Right and left gastroomental ln. lie along the
  same vessels, the former drain into subpyloric
  ln., the latter drain into splinic ln.
• Supra- and subpyloric ln. receive lymphatics from
  pyloric part and finally to the celiac ln.
• Splenic ln. receive lymphatics from fundus and
  left third of stomach, and finally to the celiac
  ln.

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• Nerve supply
• Parasympathetic innervation by anterior (left)
  and posterior (right) vagal trunks
• The anterior trunk divides into anterior gastric
  and hepatic branches
• The posterior trunk divides into posterior
  gastric and celiac branches
• The anterior and posterior gastric branches
  descend on the anterior and posterior surfaces of
  the stomach as a rule about 1 to 2 cm from the
  lesser curvature and parallel to it in the lesser
  omentum as far as thr pyloric antrum to fan out
  into branches called crows foot to supply the
  pyloric part
• Sympathetic innervation
• Mainly from celiac ganglia
• Affent and effent fibers derives from thoracic
  segments (T5 -L1

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The duodenum

• Relationships of superior part
• Anteriorly
• Quadrate lobe of live
• Gallbladder
• Posteriorly
• Commom bile duct
• Gastroduodenal a.
• Hepatic portal v.
• Inferior vena cava
• Superioely
• Omental foramen
• Inferiorly
• Head of pancreas

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• Relationships of descending part
• Anteriorly
• Live
• Transverse colon and mesocolon
• Loops of small intestine
• Posteriorly
• Right renal hilum and ureter
• Right renal vessels
• Medially
• Head of pancreas
• Common bile duct and pancreatic duct
• Laterally
• Right colic flexure

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• Relationships of horizontal part
• Superiorly
• Head of pancreas
• Inferiorly
• Loops of small intestine
• Anteriorly
• Radix of mesentery
• Superior mesenteric a. and v.
• Posteriorly
• Right ureter
• Inferior vena cava
• Abdominal aorta

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• Relationships of ascending part
• Right
• Head of pancreas and abdominal aorta
• Left
• Left kidney and ureter

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Relationships of liver

• Diaphragmatic surface-separated by diaphragm from
  the following
• Right costodiaphramatic recess and lung
• Cardiac base
• Visceral surface
• Left lobe is related to the stomach and abdominal
  part of esophagus
• Right lobe is related to the right colic flexure
  anteroly, gallbladder and superior duodenal
  flexure medially, right kidney, superarenal gland
  posteriorly

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• Blood supply
• Arteries
• Superior pancreaticoduodenal a.
• Inferior pancreaticoduodenal a.
• Veins-follow arteries, draining directly into
  superior mesenteric and hepatic portal veins

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Divisions and relations of common bile duct

• Supraduodenal segment
• Descends along the right margin of hepatoduodenal
  lig.
• To the right of proper hepatic a.
• Anterior to hepatic portal v.
• Retroduodenal segment
• Behind the superior part of duodenum
• Anterior to the vena cava
• To the right of the hepatic portal v.

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• Pancreatic segment
• Lies in a groove between posterior surface of
  head of pancreas and duodenum
• Intraduodenal segment
• Enters the wall of descending part of duodenum
  obliquely where jions the pancreatic duct to form
  the hepatopancreatic ampulla
• opens at the major duodenal papilla

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Divisions and relations of pancreas

• Head of pancreas
• Located in C-shapes curvature of doudenum
• Anteriorly
• Transverse mesocolon
• Posteriorly
• Inferior vena cava
• Right renal vessels
• Common bile duct
• Neck of pancreas
• Anteriorly-pylorus
• Posteriorly-commencement pf hepatic portal v.
  (formed by union of splenic and superior
  mesenteric veins

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• Body of pancreas
• Anteriorly
• Separated from stomach by omental bursa
• Posteriorly
• Abdominal aorta
• Left suprarenal gland
• Left kidney
• Left renal vessels
• Spleen vein
• Superiorly
• Celiac trunk
• Celiac plexus
• Splenic a.

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• Tail of pancreeas
• Runs in spleicorenal ligament to reach hilum of
  spleen
• Accompanies with splenic vessels

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Relationships of spleen

• Diaphragmatic surface-diaphragm
• Visceral surface
• Anteriorly-fundus of stomach
• Posteriorly-left suprarenal gland and kidney
• Inferiorly-tail of pancreas and left colic
  flexure

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Celiac trunk

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