Denver F. Sapo, MD Regions and Quadrants Quadrants • Transumbilical plane • Median plane

• Duodenum lies above the umbilicus Umbilicus • Vertebral level—L4

• Bifurcation of the aorta

• Iliac crest • Dermatomal level—T10 • Weeks AOG—20 weeks Regions • Midclavicular plane • Subcostal plane—L3

• 3rd part of the duodenum

• Origin of IMA • Transtubercular plane—L5 Transpyloric plane • xxx ANTERIOR ABDOMINA L WALL Fascial layers • Superficial fascia

• Camper fascia

• outer fatty layer

• Scarpa fascia • inner membranous layer

• continuos with the... • Dartos fascia (scrotum) • Colles fascia (superficial perineal fascia) External oblique • Inguinal (Poupart) • External/superficial inguinal ring • External spermatic fascia Internal oblique • Splits • Conjoint tendon • Middle (Cremaster) spermatic fascia and muscle Transversus abdominis • Conjoint tendon Transversalis fascia • Internal spermatic fascia • Internal/deep inguinal ring (defect) • Strongest layer Paracentesis (Clinical correlation) • Flank approach

• Skin

• Superficial fascia

• Camper fascia • Scarpa fascia

• External oblique

• Internal oblique

• Transversus abdominis

• Transversalis fascia

• Preperitoneal fat

• (parietal) • Midline approach

• Skin

• Superficial fascia • Camper fascia

• Scarpa fascia

• Linea alba

• Transversalis fascia

• Preperitoneal fat

• Peritoneum (parietal)

Paracentesis (Clinical correlation) Extravasation of urine (Clinical correlation) • Where will the fluid accumulate? Covering of the testes and scrotum

Rectus sheath • Contents

• Rectus abdominis

• Pyramidalis

• Anterior rami of the lower six thoracic nerves

• Superior and inferior epigastric vessels • Linea alba • Linea semilunaris Rectus sheath • Between xiphoid process and ASIS Rectus sheath • Between ASIS and pubis Rectus sheath • Arcuate line (of Douglas)

• What covers the rectus abdominis posteriorly muscle below the arcuate line? Rectus sheath hematoma (Clinical correlation) • MCC is trauma • MC on the right side, below the umbilicus • Inferior epigastric VEIN Rectus sheath hematoma (Clinical correlation) • Fothergill sign (Classic)

• palpable abdominal mass that remains unchanged with contraction • Dx: CT • Will the hematoma cross the midline? INGUINAL Region Inguinal canal • Connection between the superficial and deep inguinal rings • Contents

• Spermatic cord (male)

• Round ligament of (female)

• Ilioinguinal nerve Inguinal canal • Boundaries: “M-A-L-T”

• Roof • internal oblique Muscle

• transversus abdominis Muscle • Anterior wall • Aponeurosis of external oblique

• Aponeurosis of internal oblique

• Floor • inguinal Ligament·

• lacunar Ligament

• Posterior wall • Transversalis fascia

• conjoint Tendon Spermatic fasciae • External oblique fascia External spermatic fascia • Internal oblique fasciaCremaster fascia/muscle • Transversalis fascia Internal spermatic fascia Varicocele (Clinical correlation) • MC on the left side • Examine the left kidney for malignancy • “bag of worms” Descent of testis • Parietal peritoneum tunica vaginalis • Gubernaculum Bell clapper deformity (Clinical correlation) • Poor gubernacular fixation torsion • Homologue of gubernaculum in females? Persistent processus vaginalis (Clinical correlation) • Females? • Associations

• hydrocele

• What type of hernia? Hesselbach triangle • Inguinal triangle • Boundaries

• Inferior epigastric vessels

• Rectus abdominis muscle

• Inguinal ligament • Relationship of the deep inguinal ring to the inferior epigastric vessels? Inguinal hernia (Clinical correlation)

• Most common type of hernia? • Most common in males? • Most common in females? • More prone to obstruction/strangulation?

Indirect inguinal hernia (Clinical correlation) Direct inguinal hernia (Clinical correlation) Epididymitis (Clinical correlation) • Differentiate between epididymitis versus testicular torsion • What maneuver to differentiate?

• A positive sign means pain relief = epididymitis Femoral hernia • Femoral triangle? • Femoral sheath? • Femoral canal? • Femoral ring? Femoral sheath • Continuous with the transversalis fascia • Three compartments

• Medial = femoral canal • Lymphatic vessels

• Middle

• Femoral vein

• Lateral • Femoral artery

• In which compartment is the femoral nerve situated? Femoral ring • Upper opening of the femoral canal • Relationships

• Anterior—inguinal ligament

• Posterior—pectineal ligament

• Medial—lacunar ligament • Lateral—femoral vein Inguinal hernia vs femoral hernia(Clinical correlation) • Most common in females? • More common in FEMales? PERITONEU M AND PERITONEA L CAVITY Peritoneum • Lining epithelium? Parietal peritoneum Patent urachus (Clinical correlation) • Reveals when urethral obstruction is present • Congenital urethral obstruction

• Prostate enlargement Visceral peritoneum • Viscera

• Peritoneal • Have

• Mobile

• Retroperitoneal • Immobile or fixed Peritoneal organs • Peritoneal cavity

• Is it an open or closed cavity?

• Peritoneal fluid: 50 mL (Moore) • Greater sac • Lesser (Omental) sac Epiploic foramen (of Winslow) • Connection between the greater and lesser sac • Relationships

• Anteriorly • • Hepatic artery • Hepatic vein • Portal vein

• Posteriorly • IVC Pringle maneuver (Clinical correlation) • Compressed? Morrison pouch (Clinical correlation) • Hepatorenal recess • Most dependent portion of the in the supine position Douglas pouch (Clinical correlation) • Rectouterine pouch

• Most dependent area in the upright position • Posterior fornix??? Gastrointes tinal VISCERA Derivatives of the developing gut Pharynx • Compartments

• Nasopharynx

• Oropharynx

• Laryngopharynx • Function? Zenker diverticulum (Clinical correlation) • Most common esophageal diverticulum • Between the transverse and oblique fibers • Pseudodiverticula

• Traction diverticula? • Pulsion diverticula? Esophagus (Histology) • Lining epithelium? • No serosa Esophagus • 10 inches • C6 →cardia • Parts

• Cervical

• Thoracic

• Abdominal • Course in the mediastinum? Esophagus • Blood supply

• Cervical esophagus

• Inferior thyroid artery

• Thoracic esophagus • Bronchial arteries

• Aorta

• Abdominal esophagus • Left gastric artery

• Inferior phrenic artery Esophagus • Constrictions

• Anatomic

• Cervical constriction (UES) • Cricoid cartilage?

• Bronchoaortic constriction • Diaphragmatic constriction

• Physiologic

• LES!!! Bird’s beak sign (Clinical correlation) • Diagnosis? • Pathology? Esophageal hernia (Clinical correlation)

• What type will produce reflux? GERD (Clinical correlation) • 24-hour pH monitoring is the gold standard in the diagnosis Stomach • Openings • Curvatures • Notches Stomach (Histology) • Cardia

• Mucus • Fundus and Body

• Parietal cell→IF and HCl

• Chief cells→ pepsin • Pyloric region

• Pyloric antrum • G cells →Gastrin

• Pyloric canal Stomach • Innervation • THINK—LARP

• Left/anterior vagus nerve • Hepatic branch

• Nerves of Laterjet (anterior)

• Right/posterior vagus nerve • Celiac branch

• Nerves of Laterjet (posterior)

• Criminal nerve of Grassi (50%) Stomach • Innervation

• Nerves of Laterjet

• Fundus and Body

• Crow’s foot • Antrum Vagotomy (Clinical correlation) Peptic ulcer disease (Clinical correlation) • Modified Johnson Classification

• THINK • One is one

• Two is two • Three is pre

• Four is door • Type 5--NSAIDs Upright CXR (Clinical correlation) • “gastric bubble” = fundus of the stomach Upright CXR (Clinical correlation) • Diagnosis? Upright CXR (Clinical correlation) • Diagnosis Duodenum • 10 inches!!! • Portions

• First part—duodenal cap/bulb

• Posterior—GDA • L1 vertebra • Second part-descending • Duodenal papillae

• Third part—horizontal

• Anterior—superior mesenteric vessels • L3 vertebra

• Forth part • Which is intraperitoneal? • Vertebral level of duodenojejunal flexure? UGIB and LGIB (Clinical correlation) • Ligament of Treitz/Suspensory ligament of the duodenum • MCC of UGIB? • MCC of LGIB?

• Pediatric? • Adult? • UGIB or LGIB?

• Melena

• Hematochezia Mesenteric small bowel Jejunum versus ileum • L’s of the iLeum

• Less in everything else

• Lymphoid tissue (Peyer’s patches)

• Loops (Arcades)

• Longer (3/5th)

• Lipid (more fat in the mesentery) Double bubble sign (Radiologic sign) • Diagnosis? Colon • Unique features

• Taenia coli

• Rectosigmoid junction

• Appendices epiploicae

• Haustra • What segments are intraperitoneal? Colon • Cecum

• Most dilated portion • Ascending colon • Transverse colon • Descending colon • Sigmoid colon

• MC site of volvulus

• MC site of diverticulosis • Rectum Colon • Blood supply

• SMA

• Cecum → splenic flexure

• IMA • Descending colon → upper rectum • Marginal artery (of Drummond) • Arc of Riolan

• “meandering mesenteric artery”

• Middle colic artery and left colic artery Apple core deformity (Clinical correlation) • Diagnosis? • Most common site? Coffee bean sign (Radiologic sign) • Bent inner tube sign • Kidney bean sign • Diagnosis? • Intraperitoneal or retroperitoneal? Intussusception (Clinical correlation) • Most common type? • Intraperitoneal or retroperitoneal? Vermiform appendix • Blood supply

• Ileocolic artery-->posterior cecal artery-->appendicular artery • Most common location? Appendicitis (Clinical correlation) • First manifestation? • Migration of pain?

• Dermatomal level? • McBurney's point? • How can the base of the appendix be identified? • Left-sided? Small intestine versus colon • Anatomic division

• • Physiologic division

• Cantlie line Liver—Anatomic division • Right lobe

• Caudate lobe

• Quadrate lobe • Left lobe Liver—Physiologic division • Right lobe • Left lobe

• Caudate lobe

• Quadrate lobe • Couinaud segments

• Planes • Right hepatic vein

• Middle hepatic vein • Left hepatic vein

• Right and left portal veins Couinaud segments Liver • Blood supply

• Hepatic artery (75%)

• Postal vein (25%) Biliary Tree • Cystic duct

• Valves of Heister • Right and left hepatic ducts • CBD • Ampulla of Vater • Drainage

• Posteromedial wall of the 2nd part of the duodenum Gallbladder • Parts • Function Mercedes-Benz sign • gallstones Pancreas • Parts

• Head

• Uncinate process

• Body

• Neck

• Tail Embryology • Ventral pancreas

• Head, inferior

• Uncinate process

• Major pancreatic duct • Dorsal pancreas

• Head, superior

• Neck

• Body

• Tail

• Minor pancreatic duct Pancreas • Ducts

• Main pancreatic duct (Wirsung) major duodena papilla

• Accessory pancreatic duct (Santorini) minor duodenal papilla Necrotizing pancreatitis (Clinical correlation) • Grey-Turner sign

• Flank Double duct sign • Pancreatic head mass Inverted-3 sign • Diagnosis? Whipple procedure (Clinical correlation) Spleen • THINK—“Spleen is a very odd organ”

• 1, 3, 5, 7, 9, 11

• Spleen size is 1” x 3” x 5” • Spleen is 7 oz

• Between ribs 9 to 11 Accessory spleen (Clinical correlation) • Splenorenal ligament

• Splenic vessels

• Tail of the pancreas •

• Short gastric vessels

• Greater or lesser omentum? Posterior

Kidneys • T12-L3 • Hilum (anterior to posterior)

• Renal vein

• Renal artery

• Ureter Kidneys • Coverings

• Renal capsule

• Perirenal fat

• Renal (Gerota) fascia

• Encapsulates the adrenal glands and kidneys

• Pararenal fat Kidneys (Histology)

• Cortex

• Glomeruli • PCT

• DCT

• Renal column • Medulla (10-18)

• Loop of Henle

• Collecting duct • Drainage? Kidney stones (Clinical correlation) • 90% seen on AXR • Unseen = Uric acid Left renal vein • Left renal vein

• Left adrenal vein • Left gonadal vein

• Longer? Varicocele (Clinical correlation) • Left renal tumor • Dilation of what venous plexus? • Description? Ureter • Constriction

• Ureteropelvic junction

• External iliac artery and/or pelvic brim

• Bladder wall-most common site* Adrenal glands (Histology) • Cortex • Medulla

• chromaffin cells

• Embryologic origin

• cortex?

• medulla? Adrenal glands • Blood supply?

• Superior adrenal artery

• Middle adrenal artery

• Inferior adrenal artery • Venous drainage? Ureter • Blood supply?

• Upper—Renal artery

• Middle—Gonadal artery • Lower—Superior vesical artery Suprapubic aspiration (Clinical correlation) • Retropubic (Retzius) space VASCULATU RE Abdominal aorta • First branch of the abdominal aorta? Nutcracker syndrome (Clinical correlation) • renal vein entrapment syndrome Superior mesenteric artery (Clinical correlation) • compression of the third part of the duodenum Inferior vena cava • Formed at L5 Abdominal aortic aneurysm (Clinical correlation) • MC site of aneurysm? • Most important risk factor? Hepatic portal system • Portal vein = SMV + Splenic vein • Behind the neck of the pancreas

• Vertebral level? • Drain lower 1/3 of esophagus to upper 1/2 of anal canal

• Tributaries of the splenic vein

• short gastric vein

• left gastroepiploic vein* • Inferior mesenteric vein

• pancreatic vein Sites of anastomoses between portal and caval systems