Univerzita Karlova v Praze – 1. lékař ská fakulta DiaphragmDiaphragm andand itsits developmentdevelopment BackBack musclesmuscles OperativeOperative approachesapproaches Institute of Anatomy Author: Petr Valášek [email protected] Muscles of the chest • thoraco-humeral m. pectoralis major et minor m. subclavius, m. serratus anterior • thoracic mm. intercostales externi, interni, intimi, mm. subcostales, m. transversus thoracis • diaphragm uddiyana bandha http://users.telenet.be/ananda/images/thumbnails/ub.htm Hemidiaphragm domes right – 4. intercostal, left – 5. intercostal http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/cxr/atlas/cxratlas_f.htm Sternal, costal, and lumbar part; centrum tendineum Foramen venae cavae, hiatus oesophageus, hiatus aorticus Right and left crus Medial arcuate ligament (psoatic arcade) Lateral arcuate ligament (over quadratus lumborum) Phrenic nerve – C4 Lumbocostal and sternocostal triangle Diaphragmatic surface of the heart Phrenic nerve C4, directly above forelimb limbbud… then differential growth of neck… Mouse embryo stained for neurofilaments (=axons) and Sonic Hedgehog (notochord and endoderm) Craniocaudal direction of development. Sacral parasymp. Red=autofluorescence of blood in the heart. Descent and initial innervation of developing diaphragm. Greer J J et al. J Appl Physiol 1999;86:779-786 ©1999 by American Physiological Society Development of the diaphragm 3-layered embryonic disc ‚folding ‘ or rather relative differential growth of the embryo around the umbilicus Descent - relative growth of neck and heart towards the umbilicus Transverse septum - central tendon beneath the heart pleuroperitoneal folds add from dorsal and lateral aspects (these were inhabited by myogenic cells from cervical somites C4) in final caudal position, the material of internal thoracic wall will join (plus material around oesophagus) Defects - diaphragmatic hernias (do not mix with hiatus hernia) not covered by hernial sac (false hernia) prevalence 1:3000, mortality 25% 80 % of all congenital lung anomalies 95 % on left (Bochdalek’s hernia – lumbosacral) 5 % on right (Morgagni hernia – sternocostal) Correlation between the extent of phrenic nerve intramuscular branching and myotube formation. Greer J J et al. J Appl Physiol 1999;86:779-786 ©1999 by American Physiological Society autochthonous heterochthonous epaxial hypaxial 1. layer - 2. layer - dorsal rami of spinal nerves 4. layer – back muscles 3. layer – levator scap, rhomboidei latissimus dorsi trapezius neck) (from spinohumeral spinohumeral spinocostal muscles muscles muscles n. XI brachial pl. intercostal nn. brachial pl. Rami dorsales of spinal nerve 1. & 2. layer spinohumeral Name Origin Insertion Function Innervation 1. & 2. layer spinohumeral Auscultation triangle 1. & 2. layer spinohumeral Function of m. trapezius and latissimus dorsi 1. & 2. layer spinohumeral M. levator scapulae M. rhomboideus minor M. rhomboideus major 3. layer spinocostal Name Origin Insertion Function Innervation 3. layer spinocostal Musculi levatores costarum (auxilliary inspiratory) 4. layer-group Deep back muscles aka. M. erector trunci Four layers total – different course of fibers and function Spi – Tr Spi – Spi Tr – Spi 4. layer-group - ST Name Origin Insertion Function Innervation 4. layer-group - SS Name Origin Insertion Function Innervation 4. layer-group - TS Name Origin 4. layer-group - sacrospinal Name Origin Insertion Deep muscles of the neck Innervation: dorsal primary rami Trigonum suboccipitale: a. vertebralis + r.dorsalis C1 Draw it yourself Spinotransversal: m.iliocostalis , m.longissimus, m.splenius –ipsilateral rotation Spinospinal: m.spinalis - extension Transversospinální m.semispinalis, mm.rotatores, m multifidus – contralateral rotation M.latissimus M.serratus dorsi post. sup. M.trapezius Summary of function M. quadratus lumborum Spatium tendineum Trigonum lumbale (Petiti) lumbale-tetragon Krausei th crista iliaca 12 rib m. obliquus externus abd. m. seratus post. Inf. m. latissimus dorsi m. sacrospinalis m. obliquus abd. internus - hernias (rare) Fascia thoracolumbalis Povrchový a hluboký list Chirurgický přístup k ledvině (donora) Common abdominal surgical incisions Midline laparotomy upper lower Transrectal Pararectal Mc Burneyho (Lanz=transv) subcostal Midline laparotomy Pararectal incision Pfanenstiel (bladder, Caesarian) Laparoscopic operation Veress needle capnoperitoneum - CO2 Space for manouvre CO2 gets absorbed in embolisation and mainly - does not burn Complications Damage of epigastric blood vessels, and gut Puncture of aorta = can be lethal Equipment for laparoscopic surgery Advantages of laparoscopy Early Less pain, faster healing, collaboration in rehabilitaton Long-term Preserves integrity of abdominal wall, less scarring, adhesions, hernias in scar Robotic surgery http://www.indiaroboticsurgery.com/icrs-news-details?cname=7/ http://medical-dictionary.thefreedictionary.com/dermatome Head’s zones of referred pain (1898) diaphragm, gallbladder Innervation: nn. intercostales 5.-12. pl. lumbalis: n. subcostalis stomach n. iliohypogastricus liver, gallbladder n. ilioinguinalis small intestine large intestine urinary bladder kidney, testicle Vessels of the abdominal wall (superficial) v. thoracoepigastrica vv. paraumbilicales v. epigastrica superficialis v. circumflexa ilium superficialis => cavo-caval anastomoses! internal thoracic a. aa. intercostales V - XII superior epigastric inferior epigastric Vessels of the abdominal wall (deep) Abdominal wall blood vessels - view from inside => cavo-caval anastomoses http://blog.yogasynergy.com/2012/09/spinal-movement-sequence-part-21-uddiyana-bandha-mueller-manouvre-with-mula-bandha-including- external-obliques-on-exhalation-retention/ Reference Čihák: Anatomie 1, 3 Sobotta: Atlas of anatomy Grim M, Druga R et al.: Základy anatomie 1. Pohybový systém Netter F: Atlas of Human Anatomy, 4th ed., Saunders, 2006.