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 п‚§ Anterior wall п‚§ Right lateral wall (Right Flank) п‚§ Left lateral wall (Left Flank) пЃ† Posterior abdominal wall Antrolateral Abdominal Wall This extended from the thoracic cage to the pelvis and bounded : п‚§ Superiorly п‚§ 7th through 10th costal cartilages and and xiphoid process п‚§ Inferiorly п‚§ 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 п‚§ Fatty superficial layer (CamperвЂ™s fascia) п‚§ Membranous deep layer (ScarpaвЂ™s fascia) Antrolateral Abdominal Wall Muscles п‚§ 3 Flat Muscles with strong sheet like aponeuroses п‚§ External Oblique п‚§ Internal Oblique п‚§ Transversus Abdominus п‚§ 2 Vertical Muscles п‚§ Rectus Abdomius п‚§ Pyramidalis Antrolateral Abdominal Wall Nerves п‚§ T7 вЂ“ T11 Nerves Thoracoabdominal п‚§ T12 Sub-costal nerve п‚§ L1 Nerve Ilio-hypogastric Ilio inguinal Nerves Antrolateral Abdominal Wall Arteries п‚§ Internal Thoracic Artery п‚§ Superior Epigastric Artery п‚§ External Iliac Artery п‚§ Inferior Epigastric Artery п‚§ Deep Circumflex Iliac Artery п‚§ Femoral Artery п‚§ Superfecial Epigastric Artery п‚§ Superfecial Circumflex Artery Applied Anatomy п‚§ Abdomen is divided into 9 regions via four planes: п‚§ Two horizontal [sub-costal (10th) and trans tubercules plane] (L5). п‚§ Two vertical (midclavicular planes). п‚§ They help in localization of abdominal signs and symptoms Anterior Abdominal Wall Functions п‚§ Form strong expandable support. п‚§ Protect the abdominal viscera from injury such as low below in boxing п‚§ Compress the abdominal content п‚§ Helps to maintain or increase the intraabdominal pressure. п‚§ Move the trunk and help to maintain posture. п‚§ Protuberance of the abdomen. The five common causes (5F) п‚§ Fat, Faeces, Fetus, Flatus And Fluid п‚§ Abdominal Hernias п‚§ Anteriolateral abdominal wall may be the site of hernias п‚§ Inguinal, umbilical and epigastric regions Posterior Abdominal Wall п‚§ Lumbar vertebrae and IV discs. п‚§ Muscles п‚§ Psoas, quadratus lumborum, iliacus, transverse, abdominal wall oblique muscles. п‚§ Lumbar plexus п‚§ Ventral rami of lumbar spinal nerves. п‚§ Fascia п‚§ Diaphragm п‚§ Contributing to the superior part of the posterior wall п‚§ Fat, nerves, vessels (IVC, aorta) and lymph nodes. Posterior Abdominal Wall Fascia Between the parital peritoneum and the muscles п‚§ The psoas fascia or psoas sheath. п‚§ The quadratus lumborum fascia. п‚§ The thoracolumbar fascia. Posterior Abdominal Wall Muscles Three paired muscles п‚§ Psoas major п‚§ Iliacus п‚§ 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 вЂ“ L4) (b) The femoral nerves (L2 вЂ“ through L4) (c) Ilio inguinal and ilio hypogastric nerves (L1) (d) Gentio femoral (L1 вЂ“ L2) (e) Lateral femoral cutaneous nerves (L2 вЂ“ L3) Posterior Abdominal Wall Nerves Autonomic nerves п‚§ One cranial nerve (the vagus) п‚§ 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 п‚§ Aorta and its branches п‚§ IVC and its tributeries Applied Anatomy Posterior abdominal pain: Ilio-psoas has relationship to kidney, ureters, caecum, appendix, colon, pancreasвЂ¦.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 KocherвЂ™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 п‚§ 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 п‚§ The build of the patient п‚§ The degree of obesity п‚§ The presence of previous abdominal incisions п‚§ п‚§ п‚§ Closing the Incision The ideal method of abdominal wound closure has not been discovered. However it should be free from complications such as:п‚§ п‚§ п‚§ п‚§ п‚§ Burst abdomen Incisional hernia Persistent sinuses It should be comfortable to the patient Should leave reasonably good scar Incisional Hernia п‚§ It is a protrusion of omentum or organ through surgical incision. п‚§ If the muscles and aponeurotic layers of the abdomen doesnвЂ™t heal properly an incisional hernia can result п‚§ Prredisposing factors include п‚§ Infection п‚§ bowel obstruction п‚§ obesity Abdominal Hernia Orifices п‚§ Hernia is defined as the protrusion of an organ through itвЂ™s containing wall. It can occur because of п‚§ 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) п‚§ Abnormal weakness caused by congenital acquired as result of trauma or diseases. abnormality or п‚§ 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: п‚§ Age Occurs at all ages: may be present at birth or appear suddenly at any age. п‚§ Occupation п‚§ Local symptoms Discomfort and pain the commonest п‚§ Systemic symptoms; constipation) If the hernia obstructing the patient has cardinal symptoms of intestinal obstructions (colicky abdominal pain, vomiting, abdominal distension, Examination п‚§ 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. п‚§ Then palpitate the lump and whether itвЂ™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 п‚§ Indirect inguinal hernia pass via deep inguinal ring along the canal then if large enough emerges through the external ring and descends into scrotum. п‚§ Direct hernia pushes through the posterior wall of the inguinal canal via HesselbechвЂ™s triangle, which is boundary base inguinal ligament medial border midline laterally by inferior epigastric vessels. п‚§ However, the inferior epigastric vessels demarcate the indirect hernia sac pass lateral and direct hernia medial to these vessel.