limb limb
Lower Lower
------
-+- A A Introduction to abdomen comprising of extending from the lesser pelvis diaphragm to the base of the pelvis, abdomen proper & Cylindrical chamber • Abdomen proper & lesser pelvis communicate with each other at the plane of inlet into lesser pelvis (upper border of pubic symphysis,pubic crests, arcuate line of innominate bones,sacral promontary)
pelvis
Pelvic inlet
Inguinal ligament • Contents of Abdomen proper:- Most of the digestive tube, Liver, pancreas, spleen, kidneys, ureters (in part), supra renal gland & various blood &lymph vessels lymph nodes &nerves • Contents of lesser pelvis:- Terminal parts of ureters, urinary bladders, the sigmoid colon, rectum some coils of ileum, internal genitalia, blood & lymph vesels, lymph nodes & nerves cage
Rib Functions Houses & protects major viscera • Assists in breathing
of Relaxation of diaphragm diaphragm
Relaxationof abdominal muscles Contraction of abdominal muscles
Expiration Inspiration
Defecation Defecation
_..l,....._ _..l,....._
I I
n n
i
of of
wal wal
·ition ·ition
ion ion birth birth
pressure pressure
ncrease ncrease
erd erd
1 i i
Child Child
Mictu Mictu
os
1 1
·
abdominal abdominal
Cr0ntrac Cr0ntrac
c
abdominal abdominal
Laryngea Laryngea -
Changes in
cav'ity cav'ity intra the intra abdominal pressure Component parts ony Frame,vork of Abdomen • Wall- Skeletal elements Muscles fascia
peritoneum
E Parietal Transversalis Visceral yer la [= (Scarpa's) fascia Membranous Superficial ll. ayer l y wa Fatt (Camper's) abdominal the of ayers l the showing section Transverse ~.34 Muscles: - Anteriorly a segmented muscle Rectus abdominis Anterolateraly External oblique, internal oblique & trasversus abdominis • • • Po~ t ei·i 01· .--\. lJcl0111in a] \,-a]] • Posteriorly- Quadratus lumborum, psoas major & iliacus Abdominal regions Subcostalplane Midclavicular planes ,7 I I Left lowe ( I. _ quadr;mt Transumbilical plane Median plane Transtubercular plane Regions on anterior abdominal wall vertic~I plane Left ve rti cal p,lane ' Hypochond riac Hypochondriac L / ' / ' ,/ '' / ' ✓ ' Subcostal plane ,-.;;'-~_,,:;.....,,,___ --i------~+-----'_ ...... ;;_..,,___. Lateral Umbilical Lateral, 0 Transtubercu lar 1c-~------+------;------,1 plane , I \ I \ \ I I / / \ \ Jnguinaf Pubic nguinal f 1 "\' ~ ,.I "\ ' ,.I "\ , ' ' , ,. / ' / ' ' ,,,/ ' ' I I pattern. pattern. planes planes organizational organizational Midclavicular Midclavicular plane plane region region - Nine plane plane Fig.4.23 Fig.4.23 Transtubercular Transtubercular Subcostal Subcostal TH lower border 1 midway between suprasternal notch & symphysis pubis, cuts the tip of ninth costal cartilage, vertebral level L Passes from 5 Transpyloric plane- Transpyloric Lumber vertebra near its upper border Trans tubercular plane- Trans • • Transpyloric plane Pyloric orifice between stomach and duodenum margin Jugular notch ·I • ,. LI (transpyloric Right - --+-- --' ,kidney plane Position of umbilicus Pubic symphysis pattern. pattern. planes planes organizational organizational Midclavicular Midclavicular plane plane Nine-region Nine-region plane plane Fig.4.23 Fig.4.23 Transtubercular Transtubercular Subcostal Subcostal 3 th Some other lines and planes Lower margin of rib Lower margin of cage, passes thru upper border of L joins the highest point of iliac crest, passes thru body of L5 Subcostal plane- Subcostal plane- Supracristal • • pattern. pattern. planes planes organizational organizational Midclavicular Midclavicular plane plane Nine-region Nine-region plane plane 4.23 4.23 . . Fig Transtubercular Transtubercular Subcostal Subcostal Vertical planes Midline Midclavicular line: passes thru the midpoint of the clavicle, crosses the costal margin just lateral to the tip of ninth costal a passes thru cartilage & point midway between the anterior superior iliac the pubic spine & symphysis • • Abdominal cavity • Cavity is lined by Peritoneum- Parietal peritoneum Visceral peritoneum Abdominal viscera can be Intraperitoneal structures Retroperitoneal structures fascia fascia toneum s i i peritoneum per Extraperitoneal Parietal Transversal Visceral layer s) ' (Scarpa fasci? Membranous layer wall. Fatty (Camper's) abdominal the of layers the showing section Transverse U4 Anterior abdominal wall superficial fascia, muscles , fascia transversalis, extra peritoneal connective tissue & parietal layer of peritoneum front and side of the wall up of the skin, Made Includes both the • • • Skin- highly strechable, show following feature • A midline verticle furrow • Umbilicus • Linea semilunaris • Three transverse furrows Umbilicus • Normal scar • Normally lies at the junction between the third & fourth vertebra • Supplied by T10 segment • Marks the water shed line of the body • Important site of portocaval anastomosis • Meeting point of four folds in embryo • Meeting point of three systems Superficial fascia • A layer of fatty connective tissue • Single layer up to umbilicus • Below umbilicus splits in to superficial fatty layer deep membranous layer thigh of of s i oblique ligament l lata Inguina external Aponeuros -Fascia ~ fascia Dartos Scrotum - symphysis Skin layer layer fascia fascia)- s fascia) Pubic Fatty fascia. Scarpa's ( Camper's ( Membranou uperficial Superficial layer Contains fat & varies in & fat Contains thickness inguinal over Continues superficial ligament with the thigh fascia of In men continues over penis, with deeper & fuses looses fat layer & forms dartos fascia of scrotam In women, it retains fat & labia of becomes content majora • • • • • • Deep membranous layer • Contains fat • continues into thigh • In men in midline forms fundiform ligament of penis • continues inferiorly with superficial fascia of perineum. The line of attachment pass over holden’s line, pubic tubercle, body of pubis, margins of pubic arch & posterior border of perineal membrane ______...______Membranous layer of superficial fascia External oblique muscle (Scarpa's fascia) and aponeurosis ontinuity with superficial ~ - - ---,-+-- Attachment to fascia lata penile fascia Attachment to ______,______;-;------__,_...... -__ Superficial perinea! ischiopubic rami fascia (Colles 1 fascia) Continuity with dartos fascia .4.26 Continuity of membranous layer of superficial fascia into other areas. Cutaneous nerves • Lower six thoracic & first lumbar nerves Anterior cutaneous branches T7 to T1 2 Lateral cutaneous branchesT7 to T12 External oblique muscle and aponeurosis Innervation of the anterolateral abdominal wall. Cutaneous vessels of ~-\.nterior ~-\.bdon1ina] ,,·a11 • Anterior cutaneous art are branches of Superior & inferior epigastric artery • Lateral cutaneous art are branches of posterior intercostal artery • Below umbilicus supply is from three suprficial branches of femoral artery Superficial epigastric Superficial external pudendal Superficial circumflex iliac Cutaneous veins eios of Anterior Abdominal \\l"'all • Accompany arteries • Below the umbilicus they drain in to great saphenous vein, eventually into inferior vena cava • Above umbilicus they pass to axilla & in to superior vena cava • Both group anastomose thru small veins, which open up in case of obstruction in liver, giving a appearance called caput medusae • Lymphatics also respect water shed line m u um fascia e e l fascia on s t i l a periton peri ransvers Extraperitonea Parietal T Visceral -- -- '-- --- layer 1-- s) ' Scarpa ( fascia Membranous al i c i s) ' l. layer wal l a Camper Fatty ( in abdom the of layers the neuroses uscle m showing Apo on i sect oblique ternal x E Transverse U4 Anterolateral muscles Three flat muscles whose fiber flat Three are begin posterolaterally, replaced anteriorly by an continue they aponeurosis as towards midline. These are external oblique, internal transversus oblique & abdominis muscle muscles, vertical Two enclosed within tendinous sheath, rectus abdominis & Pyramidalis • 5muscles • • External oblique muscle------ ..-.------+--+-- ---Arcuate line ---,,..;...:;..- --~ --\------Transversalis fascia :m--- 'll"---'-~ "'--""',-:A,,------11------Linea alba Pyramidalis muscle --- - -1---- ..J:,.J,.,~ ~~~ 1,.- O Fig. 4.32 Rectus abdominis and pyramidal is muscles. the of - an : hysis below) . inserted rest lig tubercle -c - -symp of (See Pubic Linea alba process crest xiphoid Through Insertion aponeurosis into: are attachments ower __ l -- abdomen. iliac the a Inguinal is aponeurosis border fibres . the . : into show of to ribs : surface border) Posterior directly muscle trunk from 12th l to the que li lower of ob (external & Origin 5th view external teral La 39.7. Fig. ABDOMINIS view Oblique) (External EXTERNUS External oblique (EO) Trunk-lateral OBLIQUUS • Nerve supply – lower 6 thoracic nerves • Has three free Anterior cutaneous branches T? to T12 La teral cutaneous borders. Inferior branches T? to T12 free border forms inguinal ligament • Has one opening External oblique muscle and aponeurosis superficial inguinal ring nnervation of the anterolateral abdominal wall. -, -, - ligament ligament - - ligament ligament ligament ligament -- Lacunar Lacunar Inguinal Inguinal spine spine Pectineal Pectineal iliac iliac region. region. superior superior inguinal inguinal the the of of Anterior Anterior symphysis symphysis tubercle tubercle Pubic Pubic Pubic Pubic line line Ligaments Ligaments 4.29 4.29 Pectineal Pectineal Fig. Fig. Inguinal ligament TA from its superior surface Lower border of external oblique aponeurosis which is rolled backwards on itself attached inferiorly to give it convexity origin Gives to IO & Fascia lata is Fascia • • • nt nt e gament gament li gament gament li ligam --~--~ --~--~ Lacunar Lacunar Inguinal Inguinal . . spine spine Pectineal Pectineal iliac iliac region superior superior inguinal inguinal the the of of Anterior Anterior symphysis symphysis tubercle tubercle Pubic Pubic Pubic Pubic line line Ligaments Ligaments 4.29 4.29 Pectineal Pectineal Fig. Fig. surface in medial half forms inguinal canal Upper grooved Upper • ~ ~ ligament ligament ligament ligament ligament ligament --~-- Lacunar Lacunar Inguinal Inguinal . . spine spine Pectineal Pectineal ac ac li i region superior superior inguinal inguinal the the of of Anterior Anterior symphysis symphysis tubercle tubercle Pubic Pubic Pubic Pubic line line Ligaments Ligaments 4.29 4.29 Pectineal Pectineal Fig. Fig. Lacunar ligament ligament or Pectineal ligament of cooper part of Reflected inguinal ligament Extensions of inguinal ligament • • • : : from fascia fascia lumbar in in Thoraco crest crest Iliac )rig OMINIS OMINIS view view ABD ABD Oblique) Oblique) (Internal (Internal Internal oblique (IO) INTERNUS INTERNUS Trunk-lateral Trunk-lateral OBLIQUUS OBLIQUUS • Nerve supply- Lower 6 thoracic nerve & first I nguinal Region Dis.section -· Anterior Vie lumbar nerve • Conjoint tendon is formed by the fusion of Lowest aponeurotic fibers of the IO& TA & is attached to pubic crest & median part of pecten pubis. Guards the week point of superficial inguinal ring of of of of to to rsus rsus . . pubis pubis e tbe tbe view view alba alba ----, ----, 39.10. 39.10. tendon tendon : crest crest trunk trunk . . muscle transv show show abdominis abdominis Fig pecten pecten the the linea linea Through Through Through Through Lateral Lateral attachments attachments the the pubic pubic into into nto nto (b) (b) & & conjoint conjoint i Insertion (a) (a) aponeurosis aponeurosis \ \ . . - - - - .. .. 1 - --.. --.. · - -· -· . . - ...... - . - · . - -_.' -_.' .. .. . - . . . .. .. - .. . . : : .. ---,-----, ---,-----, Femur Femur --- - . . the the the the into into 113rd 113rd lig chiefly chiefly : : of of margin margin costal costal form form 6 6 from part part to to inserted inserted Thoracolumbar Thoracolumbar crest crest Iliac Lateral Lateral inguinal inguinal Costal Costal s s i c) c) b) b) wer wer rtilages) rtilages) ascia ascia st st inserted inserted Je Je ·igin ·igin ' . d) d) ) ) ,f ,f , : : Transversus Abdominis (TA) thoracic nerve & first lumbar nerve Nerve supply-Lower 6 Nerve • the the : : side} side} of of line) line) s s the the of of the the i 7th 7th into . . & & is is end end a a cartilages cartilages that that 6th 6th opposite opposite of of Note Note upper upper muscle muscle insertion Pyramida/ Insertion Insertion Tendinous Tendinous ( ( 5th, 5th, intersection intersection costal costal (along (along Umbilicus Umbilicus transverse transverse attachments attachments the the _ _ • • , , 1 1 . . abdominis abdominis . . . . j' j' \ \ .. .. . ..,,_ ..,,_ ...... ...... show show i i j j .__ .__ I I __ __ _,,___ _,,___ i i ...... •-.:. •-.:. -... -... . I I 1 1 1 1 .. .. .., .., ., ;- to to I I I I :- : : I . ...... ...... •-"◄• •-"◄• ,,,• _ _ ! ! ...... · · ••• ••• rectus rectus ...... t t " 1/1 ...... ,!_ ,!_ _ the the , , ~- Scheme Scheme . . : : crest crest 39.16 from . . Fig. Fig. pubic pubic Pubic Pubic Origin Origin symphysis symphysis & & view view Rectus abdominis (RA) Trunk-anterior Trunk-anterior s s , aretry iliac artery artery circumflex epigastric Musculophrenic Deep Inferior es. ri arte epigastric inferior and r Superio 4.40 Fig. sheath Crossed Part Is Upper With 3 Tendinous Intersection 7 thoracic nerves in rectus Enclosed Nerve supply-Nerve lower 6 or • • • Pyramidalis Note that the upper end of the muscle is the • Small triangular ) insertion. rudimentary muscle Insertion into: ... 5th, 6th & 7th ... costal cartilages (along a • Nerve supply – sub transverse line) I I \ t•l.- .. ◄1... "" • I _ Tendinous costal nerve(T12) .....••"'\ : -.-■,••- l intersection II I 1 11 Umbilicus ~ ' '-·•·• ~ ... , ... 4 l ....,...... \... ·i1 Ii from: I . Pubic symphysis & pubic crest I 1 \ l , Pyramidalis , \ 1 1· ,,,,...,,,,..,-(of opposite side) ~/~ Fig. 39.16. Scheme to show the attachments of the rectus abdominis view view CREMASTER CREMASTER Trunk-anterior Trunk-anterior Cremaster branch of Genitofemoral nerve Nerve supply-Nerve Genital • Action of muscles • Support of abdominal viscera • Movement of trunk • Help in forcefuful respiration • Expulsive acts • Pyramidalis tenses the linea alba • Cremaster helps to suspend the testis. Plugs superficial inguinal ring when intra abdominal pressure rises ) L1 ( nerve nerve 12 lliohypogastric T -- -- _____, ~ l. wal l na i abdom ateral l antero the innervating nerves the by taken Path 4.37 Fig. wall Deep nerves of anterior abdominal & first lumbar Lower Six thoracic Lower Six • aretry iliac artery artery gastric i circumflex ep Deep Musculophrenic nferior I ies. r arte epigastric ior r infe and ior r e p Su 40 . 4 Fig. wall artery artery circumflex Deep artery Inferior epigastric Superior epigastric Superior artery Musculophrenic Deep arteries of anterior abdominal • • • • Rectus sheath • Aponeurotic sheath formed Lineaalba Rectusabdominis A by aponeurosis of EO, IO Externaloblique &TO. • Checks Bowing Of rectus Transversalisfascia muscle during contraction Parietalperitoneum Transversusabdominis • Maintains the strength of the Lineaalba Rectusabdominis anterior abdominal wall B Externaloblique • Anterior wall of sheath is ..., complete , covering RA, I Pyramidalis from end to end ~ Transveisahsfascia Parietalperitoneum • Firmly Adherent To Transversusabdominis Tendinous Intersections Of ,4.33Organization ofthe rectus sheath. A.Transverse section through the upper three-quarters ofthe rectus sheath. B.Transverse ionthrough thelower one -quarterofthe rectus sheath. RA • Posterior wall above the costal margin- deficient, RA lies directly on costal alba Rectusabdominis A cartilages Externalobli que • Midway between umbilicus & pubic Transversalisfascia Parietalperitoneum Transversusabdominis symphysis posterior wall Lineaalba Rectusabdominis ends in a curved margin B Externaloblique known as Arcuate line • Below the Arcuate line- Transversalisfascia posterior wall is Parietalperitoneum Transversusabdominis deficient. RA lies directly .4.ll Organizationofthe rectus sheath. A.Transverse section through the upper three -quartersofthe rectus sheath. B.Transverse on fascia transversalis ionthrough thelower one-quarter ofthe rectus sheath. Skin Anterior wall formed by: Aponeurosis of external oblique m. Costal · · cartilage .:: '" .. , ...... , , _ .. Diaphragm Pectoralis major ... .,,, ..._.- - - Skin RECTUS - ~ B ABD0MINIS Ext oblique . , Diaphragm _ :--,; Aponeuros1s RECTUS of external Fas. transversalis - ABDOMINIS Posterior lamina Peritoneum --- oblique m Posterior wall formed by: of aponeurosis Costa! cartilages & of internal oblique m . ' lntercostal muscles Anterior f Aponeurosis of lamina of ' transversus aponeurosis abdominis m. of internal oblique m . ANTERIOR ·1- POSTERIOR Anterior wall formed by: ASPECT ASPECT Aponeurosis of ext. oblique !I Ant. lamina of aponeurosis of .1'~ 1-~ internal oblique ; ;J ...,,,H!'IL.IJ__ Tendinous Umbilicus intersection ....,Y ·-- .,,.... - --:--~ ~ --- ~ - . J ,r ' .....,,, '"-'-- ... __,.. --- :;· ~ Skin - ._,.,,, ~ - C Ext. oblique Int. oblique Post erior wall formed by: Transversus Post. lamina of aponeurosis A abdominis of internal oblique m. Aponeurosis of transversus abdominis m. Peritoneum Anterior wall Fascia transversalis for med by: Aponeurosis of external oblique Ant. & post. laminae of aponeurosis / of internal oblique Aponeurosis Arcuate Aponeurosis of transversus abdominis of external line oblique m . Ant. & post. laminae of ... aponeurosis D of internal Skin oblique m . Ext. oblique Aponeurosis Int. oblique of transversus RECTUS abdominis m . ABDOMINIS Transversus abdominis Peritoneum Posterior wall formed by: Fascia transversalis Pubis Contents of rectus sheath Abdominal \\l"'all • Rectus abdominis & Deep Dissection Pyramidalis • Superior epigastric &inferior epigastric arteries • Superior epigastric &inferior epigastric veins • Lower Six Thoracic Nerves Applied anatomy of Rectus sheath Diverication of recti Epigastric hernia Planning of incision on anterior abdominal wall Fascia transversalis • Fascia deep to transversus abdominis muscle • Main arteries lie inside but nerves lie outside the fascia • Continue above with the fascia under diaphragm • Inferiorly continue with the endopelvic fascia • Posteriorly cover muscle of posterior abdominal wall • Anteriorly joins the fascia of the other side • Deep inguinal ring is an oval opening in fascia • Prolongation over the femoral Vessel in to the thigh forms anterior wall of femoral sheath • At the deep inguinal ring, fascia forms internal spermatic fascia over spermatic cord Inguinal canal Region • Slit like passage, which Dts sectio n - .Anterior Vie'tv extends downward & medially, just above & parallel to lower half of inguinal ligament • Begins at deep inguinal ring • About 4 cm long • Ends at superficial inguinal ring 1 r-ansversaris fascia Anterio i- superior r Inferior e ilinc sp n r I I ' . "'· .I .~·r• Ir r j I; :,-- .. -L.~~~r. I I : ..... -~······"". " ":,, J f ~-- . \ ; ' / ~-,: . ~- I ~:1.. ..•.. ·. I l Sped· T C>O Fc~m c>r;:1.I .:~1r1 rv' artd vc-:-in I • Internal oblique muscle ---!--4-.--- Aponeurosis of internal oblique Anterior superior iliac spine ---~ External oblique muscle __-!--1,,,,,...__ Aponeurosis of external oblique Anter iorsuperior iliac spine --~ \ Spermatic cord Boundaries of inguinal canal • Anterior wall- EO aponeurosis, reinforced in its lateral part by fleshy fibers of IO • Posterior wall- Transversalis fascia, reinforced in medial 1/3by conjoint tendon, reflected part of inguinal ligament support at the medial end • Roof- Arched fibers of IO & TA • Floor- Medial half of inguinal ligament, Lacunar ligament reinforces the medial part Contents • Spermatic cord in men • Round ligament of uterus in women • Ilioinguinal nerve Spermatic cord • Ductus deferens • Artery to Ductus deference • Testicular artery • Pampiniform plexus of veins • Cremasteric artery & vein • Genital branch of genitofemoral nerve • Sympathetic plexus around the artery • Lymphatics • Remnants of processus vaginalis Fascial coverings of spermatic cord • External Spermatic Fascia- EO aponeurosis • Cremasteric fascia- IO muscle, contains Cremasteric muscle • Internal spermatic fascia- Transversalis fascia Inguinal hernias • Protrusion or passage of a peritoneal sac, with or without abdominal contents thru a weekend part of the abdominal wall in the inguinal region. • Indirecrt inguinal hernia • Direct inguinal hernia Indirect inguinal hernia, Direct inguinal hernia Inferior epigastric vessels Inferior epigastric vessels Deep inguinal ring Extraperitoneal fascia • Deep inguinal Extra peritoneal fascia Parietal peritoneum Parietal peritoneum Conjoint tendon Superficial inguinal ring --- Superficial inguinal ring A Inferior epigastric vessels Deep inguinal ring Transversus abdominis muscle Anterior superior iliac spine Testicular vessels External iliac artery Inguinal triang le ------External iliac vein Superficial inguinal ring Lacunar ligament - • The weakness in the anterior abdominal wall is compensated by the following factor • Obliquity of canal • Deep inguinal ring is guarded from ant side by IO • Superficial ring is guarded by conjoint tendon &reflected part of ligament • IO forms ant post wall &roof • Cremaster plugs the suprficial ring when intra abdominal pressure increases • Contraction of EO result in closure of two crura of superficial ring Development of inguinal canal Extraperitoneal fascia • Gonads develop in Transversalis fascia inguinal region Internal oblique muscle • They descend in to scrotum during intra ,------Processus vaginalis uterine life Gubernaculum • Inguinal canal represent passage of gubernaculum through the abdominal wall • Gubernaculum extends from caudal end of developing gonad to labioscrotal swelling .41 Descent of the testis from week 7 (postfertilization) to birth.