Anatomy test 3.4

bones of abdominal wall

5 lumbar vertebrae and IV discs

Superior, expanded part of pelvic bones (greater pelvis)

12th rib

Anterior portion of 11th rib

Xiphoid process

posterior muscles of abdominal wall

quadratus lumborum

psoas major

iliacus

anterolaterally muscles of abdominal wall

transversus abdominis

internal oblique

external oblique

rectus abdominis

transpyloric plane at L1

superior mesenteric artery

subcostal plane at L3

inferior mesenteric artery

supracristal plane at L4

bifurcation of aorta

transtubercular at L5

formation of inferior vena cava

look at slide 11 anterolateral abdominal wall

McBurney's point

1/3rd of way up along line from right anterior superior iliac spine to umbilicus

epigastric region is located

above L3 vertebrae

umbilical region is located between

L3 and L5

pubic region is below

L5

layers for abdomen

skin

superficial fascia (2 layers)

Flat muscles

transversalis fascia

extraperitoneal fascia

peritoneum

2 layers of superficial fascia

fatty layer- campers fascia

membranous layer- scarpas fascia

Flat muscles

external oblique

internal oblique

transversus abdominis

the deep membranous fascia (scarpas fascia) gives rise to what ligament

fundiform ligament of penis

thoraco-epigastric vein can allow blood to return to the heart from

lower limb if the inferior vena cava is blocked

caput medusae

blockage of portal drainage, like hypertension, caused by end stage liver disease and will cause distension of the superficial veins of the anterolateral abdominal wall

the membranous layer of the superficial fascia (scarpas) is continuous with

Colles fascia in the perineum, the tunica Dartos of the scrotum and superficial penile fascia

the superficial fascia is tightly adherent to

fascia lata below the inguinal ligament

urinary or blood extravasation

fluid gets in potential space between scarpas fascia and fascia over external oblique muscle. This blood cannot enter the thigh bc of the tight adherence to fascia lata

the functions for muscles in the anterolateral wall

support and protect abdominal viscera

regulate intra-abdominal pressure

serve as core muscles

origin and insertion of external oblique muscle

O: outer surface of ribs 6-12

I: linea alba, pubic tubercle

anterior 1/2 of iliac crest

origin and insertion for internal oblique muscle

O: thoracolumbar fascia, anterior 2/3 of iliac crest, lateral 1/2 of inguinal ligament

I: inferior borders 10-12 ribs, linea alba, pecten pubis via conjoint tendon

what gives rise to cremaster muscle in spermatic cord

internal oblique

origin and insertion of transversus abdominis

Origin: internal surfaces of 7-12 costal cartialges, thoracolumbar fascia, iliac crest, lateral third of inguinal ligament

Insertion: linea alba with aponeurosis of internal oblique pubic crest, pectin pubis via conjoint tendon

transversalis fascia

helps form posterior wall of rectus sheath above arcuate line

forms posterior wall of rectus sheath below arcuate line

continues over spermatic cord to form internal spermatic fascia

diastasis recti

most common in pregnant women but it is lateral splitting of the rectus abdominis

referred pain

pain associated with visceral disease is referred to abdominal wall bc visceral afferents enter spinal cord with somatic afferents and synapse on same second order neuron

falciform ligament

remnant of ventral mesentery

liagmentum teres hepatis (round ligament of liver)

remnant of left umbilical vein

median umbilical fold

peritoneum over urachus, which is a fibrous cord remnant of the allantois

if the allantois doesn't fully obliterated a cyst can exist between the bladder and umbilicus

medial umbilical fold

perineum over obliterated umbilical artery

lateral umbilical fold

peritoneum over inferior epigastric vessels

the femoral artery is consistently located at the

mid-inguinal point

the inguinal ring location

the deep inguinal ring is about 1.0cm medial to the femoral artery and 1.0cm superior to the inguinal ligament

inguinal canal relation to inguinal ligament

it is parallel and superior to inguinal ligament

what passes through inguinal canal in males and females

M: spermatic cord

F: round ligament of the uterus

the deep ring lies

superior to inguinal ligament

medial to femoral artery

lateral to inferior epigastric vessels

the superficial ring lies superior to

pubic tubercle

conjoint tendon aka flax inguinalis is formed by the

joined insertions of the internal oblique and the transversus abdominis muscles into the pubic crest and pectinate line

it forms the medial 1/3rd of posterior wall of inguinal canal

nerves that can be injured during hernia repair

anterior cutaneous branch of iliohypogastric nerve

femoral and genital branches of genitofemoral nerve

anterior scrotal branch of ilioinguinal nerve (most often)

the ilioinguinal nerve enters the inguinal canal at its

midpoint by passing between the transversus abdominis and internal oblique muscles

this nerve carries sensation from skin of lower inguinal region, mons pubis, anterior scrotum and medial thigh

the genitofemoral nerve (L1,L2) passes through

psoas major muscle and divides into a genital branch and a femoral branch

the genital branch of genitofemoral nerve enters the

deep ring and innervates the cremasteric muscle, a derivative of the internal oblique

gubernaculum AKA cuadal genital ligament

proximal end attaches to gonads, testis or ovary

distal end attaches to the anterolateral body wall (labioscrotal swellings) where the inguinal canal forms

it guides descent of gonads

male remnant of gubernaculum

short testicular ligament

female remnant of gubernaculum

the ligament of the ovary

round ligament of the uterus

deep inguinal ring

beginning of inguinal canal

located midway between the ASIS and the pubic symphysis about 1/2 inch above the inguinal ligament

beginning of a tubular evagination of the transversalis fascia

superficial inguinal ring

end of inguinal canal

superior to the pubic tubercle

beginning of a tubular evagination of the aponeurosis of the external oblique muscle

floor of inguinal canal

medial 1/2 of inguinal ligament and lacunar ligament

roof of inguinal ligament

formed by the arching fibers of the transversus abdominis and internal oblique muscles on their way to form the conjoint tendon

anterior wall of inguinal canal

external oblique aponeurosis through the length of the canal and reinforced laterally by the internal oblique

posterior wall of inguinal canal

transversalis fascia which is reinforced medaily by the conjoint tendon

the testis descend behind

the peritoneum along the posterior abdominal wall

internal spermatic fascia of spermatic cord

as it passes through the deep inguinal ring it gets this fascia which is derived from transversalis fascia

as the spermatic cord passes beneath the conjoint tendon it takes on a layer

from the internal oblique (the cremasteric fascia) which contains skeletal muscle

as the spermatic cord passes through the superficial ring it takes on a layer from the

aponeurosis of the external oblique muscle, the external spermatic fascia

cremasteric reflex

stroke upper thigh which is innervated by the ilioinguinal nerve (L1) and muscle contracts

usually younger kids

tests L1 and L2

the tunica vaginalis a remnant of the

processus vaginalis

it has a visceral layer which covers the testis except where the testis attach to the epididymis and spermatic cord

parietal layer is adjacent to spermatic fascia

testisicular innervation is

vagal para-sympathetics and visceral afferent and sympathetics form T10-T11 spinal cord segments

testicular cancer travels to

lumbar nodes

scrotal cancer travels to

superficial inguinal nodes

hydrocele

fluid in tunica vaginalis

can shine flashlight to check

varicocele

feels like bag of worms

two types of inguinal hernias

direct and indirect

indirect inguinal hernias

passes through processus vaginalis

most common

Lateral to inferior epigastric vessels

sac protrudes through the inguinal ring anterior and medial to cord structures

direct inguinal hernia

pushes through hasselbachs triangle

due to weakness

medial to inferior epigastric vessels

sac protrudes through the posterior wall of inguinal canal

lower risk of incarceration but higher risk of recurrence

ratio of males to females for hernias

12:1

25% of males vs 2% of females

which hernia usually occurs in older people

direct

what side predominates for indirect hernia

right side

inguinal triangle is site of

direct hernia which occurs medial to inferior epigastric vessels and lateral to rectus abdominis muscle

indirect hernias enter the

the deep ring and occur lateral to inferior epigastric vessels

coverings of direct and indirect hernias

direct- peritoneum

Indirect- peritoneum and coverings of spermatic cord

physical examination for inguinal hernia

place finger into scrotal sac and advance into inguinal canal

if hernia comes from superolateral to inferomedial and strikes distal tip of finger most likely indirect

if it strikes pad of finger form superficial to deep more likely direct hernia

indirect hernia for females

if processus vaginalis remains patent in a female it can form a peritoneal pouch that extends from deep inguinal ring through the inguinal canal to the labium majus

what is the pouch called for female indirect hernia

canal of nuck

it usually closes during first year of life

reducible inguinal hernias

contents of the hernia can be manipulated back into its original

position through the defect from which it emerges

incarcerated hernia

he hernia is compressed by the defect causing

it to be irreducible (cannot be pushed back into its original position)

obstructed hernia

refers mainly to hernias containing bowel, where the contents

of the hernia are compressed to the extent that the bowel lumen is no longer patent and causes bowel obstruction

strangulated hernias

the compression around the hernia prevents blood flow into

the hernial contents causing ischemia of the bowel and subsequent bowel necrosis

femoral hernias

appear below inguinal ligament

passes into the femoral canal into medial thigh

acquired not congenital

happen mostly in middle aged or older women

4:1 in women bc they have wider pelvisis and smaller inguinal canals and rings

hernia sac of femoral hernia may contains

omentum. bowel, ovary and or oviduct or rarely appendix