CaseCase •• MaleMale patientpatient broughtbrought toto thethe EDED •• ChiefChief complaintcomplaint •• AbdominalAbdominal crampingcramping •• Body-wrackingBody-wracking chillschills •• SymptomsSymptoms •• DullDull painpain inin thethe upperupper rightright quadrantquadrant ofof thethe abdomenabdomen •• VomitingVomiting andand diarrheadiarrhea forfor 3-43-4 hourshours AbdomenAbdomen -- ConceptualConceptual OverviewOverview -- •• FunctionsFunctions •• HousesHouses andand protectsprotects majormajor visceraviscera •• ChangesChanges inin intra-abdominalintra-abdominal pressurepressure •• BreathingBreathing •• UrinationUrination •• DefecationDefecation •• ParturitionParturition AnteriorAnterior AbdominalAbdominal WallWall -- SurfaceSurface LandmarksLandmarks -- •• XiphoidXiphoid processprocess •• CostalCostal marginmargin •• 9th9th costalcostal cartilagecartilage •• IliacIliac crestcrest •• PubicPubic tubercletubercle •• UmbilicusUmbilicus AnteriorAnterior AbdominalAbdominal WallWall -- SurfaceSurface LandmarksLandmarks -- Unit II, p 3 VermiformVermiform AppendixAppendix -- SurfaceSurface LandmarksLandmarks -- •• McBurney'sMcBurney's pointpoint •• SuperficialSuperficial landmarklandmark forfor thethe vermiformvermiform appendixappendix •• DiagonalDiagonal lineline fromfrom thethe umbilicusumbilicus toto thethe anterioranterior superiorsuperior iliaciliac spinespine •• PointPoint locatedlocated ~2/3~2/3 fromfrom thethe umbilicusumbilicus Unit II, p 3 SubdividingSubdividing thethe AbdomenAbdomen -- PlanesPlanes (Lines)(Lines) -- •• HorizontalHorizontal (4)(4) •• TranspyloricTranspyloric (L1)(L1) •• TransumbilicalTransumbilical Unit II, p 4 VertebralVertebral LevelsLevels andand AssociatedAssociated LandmarksLandmarks •• T9T9 -- XiphoidXiphoid processprocess •• L1L1 -- TranspyloricTranspyloric planeplane (pylorus,(pylorus, pancreaticpancreatic neck,neck, duodeno-jejunalduodeno-jejunal flexure,flexure, hilahila ofof kidneys)kidneys) •• L3L3 -- SubcostalSubcostal planeplane •• L3/4L3/4 –– UmbilicusUmbilicus •• L4L4 -- IliacIliac crestcrest planeplane Unit II, p 4 SubdividingSubdividing thethe AbdomenAbdomen -- PlanesPlanes (Lines)(Lines) -- •• HorizontalHorizontal •• SubcostalSubcostal •• TranstubercularTranstubercular Unit II, p 4 SubdividingSubdividing thethe AbdomenAbdomen -- PlanesPlanes (Lines)(Lines) -- •• VerticalVertical (2)(2) •• MidclavicularMidclavicular •• ZonesZones (9)(9) •• 44 horizontalhorizontal planesplanes •• 22 verticalvertical planesplanes Unit II, p 4 SubdividingSubdividing thethe AbdomenAbdomen -- QuadrantsQuadrants -- Unit II, p 4 AnteriorAnterior AbdominalAbdominal WallWall -- StructureStructure (Layers)(Layers) -- Unit II, p 4 AnteriorAnterior AbdominalAbdominal WallWall -- SuperficialSuperficial FasciaFascia -- •• TwoTwo (2)(2) layerslayers •• SuperficialSuperficial layerlayer ofof thethe superficialsuperficial fasciafascia •• FattyFatty layerlayer == Camper'sCamper's fasciafascia •• DeepDeep layerlayer ofof thethe superficialsuperficial fasciafascia •• MembranousMembranous layerlayer == Scarpa'sScarpa's fasciafascia •• ContiguousContiguous withwith thethe membranousmembranous fasciafascia ofof thethe perineumperineum (Colles(Colles’’ fascia)fascia) AnteriorAnterior AbdominalAbdominal WallWall -- SuperficialSuperficial FasciaFascia -- BloodBlood SupplySupply Unit II, p 5 AnteriorAnterior AbdominalAbdominal WallWall -- BloodBlood SupplySupply -- Unit II, p 5 AnteriorAnterior AbdominalAbdominal WallWall -- NervesNerves -- (Subcostal n) Unit II, p 6 AnteriorAnterior AbdominalAbdominal WallWall -- MusclesMuscles -- •• ExternalExternal abdominalabdominal obliqueoblique •• InternalInternal abdominalabdominal obliqueoblique •• TransverseTransverse abdominalabdominal •• RectusRectus abdominisabdominis •• PyramidalisPyramidalis •• FunctionsFunctions •• CompressCompress andand supportsupport visceraviscera •• FlexFlex andand rotaterotate thethe trunktrunk AnteriorAnterior AbdominalAbdominal WallWall -- MusclesMuscles -- Unit II, p 7 AnteriorAnterior AbdominalAbdominal WallWall -- MusclesMuscles -- Unit II, p 7 RectusRectus SheathSheath Above the arcuate line Below the arcuate line Unit II, p 7 InguinalInguinal LigamentLigament -- SurfaceSurface LandmarksLandmarks -- •• AnteriorAnterior superiorsuperior iliaciliac spinespine •• PubicPubic tubercletubercle •• InguinalInguinal ligamentligament •• AponeurosisAponeurosis ofof thethe externalexternal abdominalabdominal obliqueoblique musclemuscle InguinalInguinal LigamentLigament Unit II, p 8 Internal Abdominal Oblique and Transverse Abdominal mm External Abdominal Oblique m Unit II, p 8 InguinalInguinal CanalCanal -- WallsWalls ~4 cm long Unit II, p 8 DeepDeep InguinalInguinal RingRing Unit II, p 8 DeepDeep InguinalInguinal RingRing andand thethe InguinalInguinal TriangleTriangle Inguinal triangle Unit II, p 9 InguinalInguinal CanalCanal -- ContentsContents Male Female Inguinal nerve Inguinal nerve Spermatic cord Round ligament of the uterus Ductus deferens Artery of the ductus Testicular artery and vein (pampiniform plexus of veins) Lymphatics Autonomic nerves CremastericCremasteric ReflexReflex -- TestingTesting SpinalSpinal CordCord FunctionFunction atat L1L1 -- •• SensorySensory limblimb -- IlioinguinalIlioinguinal nervenerve (L1;(L1; medialmedial sideside ofof thethe thigh)thigh) •• MotorMotor limblimb -- GenitalGenital branchbranch ofof thethe genitofemoralgenitofemoral nervenerve (L1)(L1) •• ReflexReflex -- ContractionContraction ofof cremastericcremasteric musclemuscle (extension(extension ofof internalinternal abdominalabdominal obliqueoblique muscle)muscle) •• TestisTestis isis retractedretracted (raised)(raised) InguinalInguinal HerniasHernias -- DirectDirect vsvs IndirectIndirect -- •• KeyKey structurestructure •• InferiorInferior epigastricepigastric arteryartery •• IsIs thethe herniahernia medialmedial (direct)(direct) oror laterallateral (indirect)(indirect) toto thethe inferiorinferior epigastricepigastric artery?artery? InguinalInguinal HerniasHernias -- DirectDirect vsvs IndirectIndirect -- PeruPeru ’’0606 AmazonAmazon JungleJungle KristiKristi Rose,Rose, MDMD (2008)(2008) Dr.Dr. BallsackBallsack’’ss 44th SubjectSubject PeruPeru ’’0606 AmazonAmazon JungleJungle .