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Anterior Abdominal Wall Applied Anatomy

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Anterior Abdominal
Wall
Applied Anatomy
Dr. S. M. AL SALAMAH B.Sc, MBBS, FRCS
Associate Prof. & Consultant General Surgeon
Dept of Surgery, College of Medicne, KSU.
Abdominal wall divided into:-
пЃ† Anteriolateral abdominal wall
 Anterior wall
 Right lateral wall (Right Flank)
 Left lateral wall (Left Flank)
пЃ† Posterior abdominal wall
Antrolateral Abdominal
Wall
This extended from the thoracic cage
to the pelvis and bounded :
 Superiorly
 7th through 10th costal cartilages and and xiphoid process
 Inferiorly
 Inguinal ligaments and the pelvic bones.
The wall consists of skin, subcutaneous
tissues (fat), muscles, deep fascia and
parietal peritoneum.
Antrolateral Abdominal Wall
Fascia & Subcutaneous Tissues
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
 Fatty superficial layer (Camper’s fascia)
 Membranous deep layer (Scarpa’s
fascia)
Antrolateral Abdominal Wall
Muscles
 3 Flat Muscles with strong sheet like
aponeuroses
 External Oblique
 Internal Oblique
 Transversus Abdominus
 2 Vertical Muscles
 Rectus Abdomius
 Pyramidalis
Antrolateral Abdominal Wall
Nerves
 T7 – T11
Nerves
Thoracoabdominal
 T12
Sub-costal nerve
 L1
Nerve
Ilio-hypogastric
Ilio inguinal Nerves
Antrolateral Abdominal Wall
Arteries
 Internal Thoracic Artery
 Superior Epigastric Artery
 External Iliac Artery
 Inferior Epigastric Artery
 Deep Circumflex Iliac Artery
 Femoral Artery
 Superfecial Epigastric Artery
 Superfecial Circumflex Artery
Applied Anatomy
 Abdomen is divided into 9 regions via
four planes:
 Two horizontal [sub-costal (10th) and trans
tubercules plane] (L5).
 Two vertical (midclavicular planes).
 They help in localization of abdominal
signs and symptoms
Anterior Abdominal Wall
Functions
 Form strong expandable support.
 Protect the abdominal viscera from
injury such as low below in boxing
 Compress the abdominal content
 Helps to maintain or increase the
intraabdominal pressure.
 Move the trunk and help to maintain
posture.
 Protuberance of the abdomen. The
five common causes (5F)
 Fat, Faeces, Fetus, Flatus And Fluid
 Abdominal Hernias
 Anteriolateral abdominal wall may be the
site of hernias
 Inguinal, umbilical and epigastric regions
Posterior Abdominal Wall
 Lumbar vertebrae and IV discs.
 Muscles
 Psoas, quadratus lumborum, iliacus, transverse, abdominal
wall oblique muscles.
 Lumbar plexus
 Ventral rami of lumbar spinal nerves.
 Fascia
 Diaphragm
 Contributing to the superior part of the posterior wall
 Fat, nerves, vessels (IVC, aorta) and lymph
nodes.
Posterior Abdominal Wall
Fascia
Between the parital peritoneum and
the muscles
 The psoas fascia or psoas sheath.
 The quadratus lumborum fascia.
 The thoracolumbar fascia.
Posterior Abdominal Wall
Muscles
Three paired muscles
 Psoas major
 Iliacus
 Quadratus
Lumborum
Posterior Abdominal Wall
Nerves
Somatic nerves
пЂёThe sub costal nerves
пЂёThe lumbar nerves
пЂёThe 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)
(d) Gentio femoral (L1 – L2)
(e) Lateral femoral cutaneous nerves (L2 – L3)
Posterior Abdominal Wall
Nerves
Autonomic nerves
 One cranial nerve (the vagus)
 Several different splanchnic nerves that
deliver presynaptic sympathizer and
parasympathetic fibers to the plexus
and sympathetic ganglia.
Posterior Abdominal Wall
Nerves
пЃ”
пЃ”
пЃ”
пЃ”
Sympathetic Nerves
Abdomino-pelvic splanchic N. from the thoracic
abdominal sympathetic trunks
Prevertebral sympathetic ganglia
Periarterial plexus
Abdominal autonomic plexus
п‚ Celiac plexus
п‚ Superior mensentric plexus
п‚ Inferior mensentric plexus.
п‚ Celiac plexus
п‚ Superior hypogastric plexus
п‚ Inferior hypogastric plexus
and
Posterior Abdominal Wall
Blood Vessels
 Aorta and its branches
 IVC and its tributeries
Applied Anatomy
Posterior abdominal pain:
Ilio-psoas has relationship to kidney, ureters,
caecum, appendix, colon, pancreas….etc.
When any of these structures is diseased
movement of the ilio psoas usually causes pain.
When intra abdominal inflammation is suspected the
Ilio Psoas Test performed by moving ileopsoas
muscle and if positive if it causes pain.
Psoas Abscess
Hematogenous
spread to the
lumbar vertebrae
may form an
abscess which may
spread from the
vertebrae into the
Psoas sheath
producing a Psoas
abscess.
Partial Lumbar
Sympethectomy
Some patients with arterial disease in
the lower limbs (ischaemia) may
include partial lumbar
sympathectomy by removal of two or
more lumbar sympathetic ganglia
IVC Obstruction
Three collateral routs formed by valveless
veins of the trunk are available for venus
blood to return to the heart.
пѓ� inferior epigastric vein
пѓ� superficial epigastric vein
пѓ� epidural venous plexus inside the
vertebral column.
Abdominal Incisions
Definition: incision defined as cut made with
knife for surgical purposes.
Types of Incisions
The
п‚­
п‚­
The
п‚­
п‚­
п‚­
The
п‚­
п‚­
п‚­
The
vertical incisions:
Midline incision
Para median
transverse abdominal incisions:
Upper and lower transverse incision
Pfannenstiel incision
LANZ incision (appendectomy)
oblique abdominal incisions
The subcostal or Kocher’s incision
Rutherford Morison incision
McBurney incision (appendicectomy)
thoracolumbar incisions
Applied Anatomy
The correct diagnosis will enable the
surgeon to choose the correct incision.
But laparotomy for undiagnosed abdominal
disease is most usefully approached
through vertical incision equidistant
above and below the umbilicus
 Once the diagnosis confirmed, the incision may be
enlarged in an upward or downward direction.
Choosing the Incision
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



Closing the Incision
The ideal method of abdominal wound
closure has not been discovered.
However it should be free from
complications such as:




Burst abdomen
Incisional hernia
Persistent sinuses
It should be comfortable to the patient
Should leave reasonably good scar
Incisional Hernia
 It is a protrusion of omentum or organ through
surgical incision.
 If the muscles and aponeurotic layers of the
abdomen doesn’t heal properly an incisional
hernia can result
 Prredisposing factors include
 Infection
 bowel obstruction
 obesity
Abdominal Hernia Orifices
 Hernia is defined as the protrusion of an organ through
it’s containing wall. It can occur because of
 Normal weakness found in everyone and
related to anatomy of
the area e.g., place where vessel or viscus enters or leaves the
abdomen, muscles fail to overlap or there is only scar tissue
(Umbilicus)
 Abnormal weakness caused by congenital
acquired as result of trauma or diseases.
abnormality or
 High intraabdominal pressure from Coughing / Strains /
Abdominal distention
Common Sites
п‚Њ
п‚Ќ
п‚Ћ
п‚Џ
Inguinal Hernia
Umbilical Hernia
Femoral Hernia
Incisional Hernia
Less common Hernia
п‚І
п‚І
Epigastric Hernia
Recurrent Hernia
Common Clinical Features
The features of all hernias are:
пѓ¬ They occur at weak spot
пѓ¬ They reduce on lying down or with
direct pressure
пѓ¬ They have an expansile cough
impulse
History
History is very important:
 Age
Occurs at all ages: may be present at
birth or appear suddenly at any age.
 Occupation
 Local symptoms
Discomfort and pain the commonest
 Systemic symptoms;
constipation)
If the hernia obstructing the patient
has cardinal symptoms of intestinal
obstructions (colicky abdominal pain,
vomiting, abdominal distension,
Examination
 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.
Complications
Untreated hernia may develop
following complications:
(a) intestinal obstruction
(b) strangulation
(c) incarceration
Perop or Post op
Complications
(a) Haemorrhage haematoma
formation
(b) Bowel injuries
(c) Wound infections
(d) Recurrent of Hernia
Inguinal Hernia
Anatomy of inguinal region
Inguinal canal with boundaries,
contents and orifices
Types
Treatment
Clinical aspect
 Indirect inguinal hernia pass via deep inguinal ring along
the canal then if large enough emerges through the
external ring and descends into scrotum.
 Direct hernia pushes 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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