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Abdominal Terminology

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Abdominal Terminology Abdominal Terminology Background In the July 2019 release SNOMED International took the stance that the meaning of the concept identified by the concept id 113345001 should be made more explicit as Abdominopelvic structure (body structure) but retain the ‘synonyms’ of Abdomen and ​ ​ ​ Abdominal structure based on the most common usage. However, feedback has ​ highlighted that users of DICOM used “abdomen” to mean abdomen including the ​ back and excluding the entire false and true pelvic region for cross-sectional imaging ​ such as CT (Computed tomography) and MRI (Magnetic resonance imaging). The purpose of this document is to explicitly describe and define concepts relating to regional anatomy of the abdomen and pelvis. This work has been stimulated by a SNOMED International initiative to improve the quality of SNOMED CT anatomy using the key resources of FMA (Foundation Model of Anatomy), Gray’s anatomy1, Terminologia Anatomica, other medical terminologies, classifications, and literature publications. The ‘abdomen’ in natural language can be used to refer to, but not limited to, the following concepts: ● Abdominopelvic cavity ● Abdominopelvic cavity excluding the true pelvic cavity (Abdomen proper ​ cavity) ● Abdominopelvic cavity and/or content (Intra-abdominopelvic structure) ​ ● Intra-abdominopelvic structure excluding intra-pelvic structure of true pelvis ● Intra-abdominopelvic structure and/or anterior abdominal wall ● Intra-abdominopelvic structure and/or anterior abdominal wall, excluding intra-pelvic structure of true pelvis (Abdomen proper) ​ ● Abdominal segment of trunk ● Abdominal cross-sectional segment of trunk and possibly additional concepts if they are needed for clinical practice: ● Intra-abdominopelvic structure and/or wall of abdominopelvic cavity 1 Standring, S. ed., 2015. Gray's anatomy e-book: The anatomical basis of clinical practice. Elsevier ​ ​ ​ Health Sciences. Copyright© 2019 International Health Terminology Standards Development Organisation Page 1 Abdomen Terminology in SNOMED CT (2019-09-03) Trunk Structure The purpose of this section is to achieve a consensus of the description of the subdivisions of ‘trunk structure’ and perspectives of the anatomical structures comprising the trunk. It attempts to define clinically relevant walls, cavities, segments and regions of the trunk so that users of SNOMED CT have confidence in the semantics of the concept chosen. In addition, it relates these concepts to morphological anatomical boundaries and structures in a multiple-hierarchical structure. These concepts can then be employed as values to model disorders and procedures to infer relationships between these clinical concepts. Anatomical boundaries and planes of the trunk The following diagram illustrates a number of recognised anatomical morphological planes and boundaries. Figure 1. Main boundaries and planes of the trunk region ​ Some key planes can be identified: ​ ​ ● Thoracic inlet - this is an artificial boundary, also known as the superior ​ ​ ​ thoracic aperture) bounded by T1; the first pair of ribs laterally; and anteriorly ​ ​ ​ the costal cartilage of the first ribs continuous with the superior border of the manubrium and the chest wall; ● Diaphragm (thoracic); ​ ● False pelvis upper border - is an artificial plane from the symphysis pubis to ​ ​ the superior iliac crests; in front it is incomplete, presenting a wide interval ​ ​ between the anterior borders of the ilia; Copyright© 2019 International Health Terminology Standards Development Organisation Page 2 Abdomen Terminology in SNOMED CT (2019-09-03) ● Superior pelvic aperture - is an artificial oblique plane passing through the ​ sacral promontory posteriorly and the lineae terminales elsewhere. Each linea terminalis includes the iliac arcuate line, pectineal line (pecten pubis) and pubic crest. It is also known as pelvic inlet or pelvic brim. This is the plane that ​ ​ ​ ​ separates the abdomen proper cavity from the true or minor pelvis; and ​ ​ ● Inferior aperture of true pelvis - The boundaries of this trapezoidal shaped ​ inferior aperture of true (minor) pelvis are formed by the symphysis pubis in front, the coccyx behind, on each side the inferior pubic ramus and the ramus of the ischium, the ischial tuberosity and the sacrotuberous ligament. An imaginary line drawn transversely in front of the ischial tuberosities divides the region into two triangular parts. The posterior part contains the anus and is known as ‘the anal triangle’, while the anterior part is the ‘urogenital triangle’ containing the external urogenital organs. The pelvic floor spans the inferior 2 opening. Cavity of trunk The planes above form significant boundaries of the following anatomical volumes of the trunk whose cavity can be divided into the: ● Thoracic cavity: bounded by the diaphragm inferiorly; superiorly the thoracic ​ inlet, (or superior thoracic aperture); and bounded but excluding the chest wall ​ ​ [shown in orange in Figure 2]; and ● Abdominopelvic cavity: bounded superiorly by, but excluding, the ​ diaphragm; the pelvic diaphragm, inferiorly; and wall of abdominopelvic cavity. ○ False (major or greater) pelvic cavity - is the expanded portion of ​ ​ the bony pelvis above and in front of the superior pelvic aperture (or ​ pelvic brim)3. It lies between the false pelvis upper border and the ​ ​ ​ superior pelvic aperture and is bounded on either side by the ilium; ​ ​ in front it is incomplete, presenting a wide interval between the anterior ​ ​ borders of the ilia; behind is a deep notch on either side between the ilium and the base of the sacrum. It supports the intestines, and transmits part of their weight to the anterior wall of the abdomen.4; and ○ True (minor or lesser) pelvic cavity - is a bowl-shaped volume ​ bounded superiorly by the superior pelvic aperture and inferiorly by the ​ ​ inferior aperture of true pelvis and pelvic diaphragm. ​ ​ ​ ○ Peritoneal space: lies between the parietal peritoneum (the ​ peritoneum lines the abdominal wall) and visceral peritoneum (the peritoneum that surrounds the internal organs) ○ Extraperitoneal space: lies outside the peritoneum and can be ​ divided into: ■ Retroperitoneal space: situated posteriorly to the peritoneum ■ Preperitoneal space: situated anteriorly to the peritoneum 2 Key, J., 2010. Back Pain-A Movement Problem E-Book: A clinical approach incorporating relevant ​ ​ research and practice. Elsevier Health Sciences. ​ 3 Chung, K.W. and Chung, H.M., 2008. Gross anatomy. Lippincott Williams & Wilkins. ​ ​ ​ 4 https://theodora.com/anatomy/the_pelvis.html ​ Copyright© 2019 International Health Terminology Standards Development Organisation Page 3 Abdomen Terminology in SNOMED CT (2019-09-03) Thus a key morphological plane with respect to the abdominopelvic cavity is the superior pelvic aperture which divides this volume into: ​ ​ ● True pelvic cavity [shown in blue in Figure 2 below]; and ​ ● Abdomen proper cavity - more explicitly the Abdominopelvic cavity excluding ​ ​ the true pelvic cavity [shown in yellow in Figure 2 below]. ​ Figure 2. Cavities of the trunk ​ Wall of trunk From the description above it is apparent that the boundaries of an anatomical volume can be virtual e.g. thoracic inlet, or structural e.g. thoracic diaphragm: and when an anatomical structure forms the boundary this is often described as a ‘wall’. The FMA defines the body wall, as a ‘Subdivision of trunk that consists of those ​ ​ organs that separate the body cavity from the body's exterior; together with the body cavity and its contents, the body wall constitutes the trunk (one of the principal body parts).‘ The FMA also considers the wall as a constitutional part of the ‘compartment’ (along ​ ​ ​ ​ ​ with the space and content): The approach in SNOMED CT has been subtly different by using the ‘compartment’ to describe the space and content only (but not the wall). ​ ​ In order to avoid confusion it is proposed to use the term ‘intra’ to describe the combination of space and contents, as illustrated in the following amended hierarchy in the SNOMED CT anatomy: Structure of X Wall of X Intra-X structure Space of X Content of X Copyright© 2019 International Health Terminology Standards Development Organisation Page 4 Abdomen Terminology in SNOMED CT (2019-09-03) The constituent layers of the trunk wall vary between and within different cavities: The inner wall boundary is consistent but the extent to which more superficial layers are included as ‘part of the wall’ is dependent on the area considered. A general rule derived from the FMA approach is where the trunk wall is entirely comprised of a skeletal framework e.g. rib cage, this wall structure excludes the overlying ​ ​ integument. To consider this aspect further the walls of the three main volumes are considered below. Wall of thorax (Thoracic wall) The Wall of thorax is defined in FMA as a ‘Heterogeneous cluster which surrounds ​ ​ the thoracic cavity and its content; and which includes the ribcage, muscle group of thoracic wall and costal pleura’: thus the thoracic wall is entirely comprised of a ​ ​ skeletal frame, and excludes the overlying integument. ​ ​ However, the chest wall ‘includes all the structures from the skin to [and including] ​ ​ ​ ​ ​ the costal pleura (FMA) i.e. the wall of thorax, the superficial chest wall, lateral chest wall and anterior chest wall, which includes the integument. Wall of abdomen The wall of the abdominopelvic cavity is complicated by having two regional parts: ​ ​ the wall of abdomen proper cavity, and
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