Abdomen

Xiphoid process (Rib 6)

Costal margin (Rib 6 - Rib 10 laterally)

Umbilicus (T6)

Linea alba

Linea semilunaris

Location

> lower abdomen, anterior below umbilicus

Structure

> Camper's fascia

> Dartos fascia

= Men: continuous over penis, having smooth muscle

= Women: labia major, fat

2. External, internal obliques, transversus abdominis

3. Rectus abdominis, Pyramidalis

4. externat obliques

1. External oblique

2. Internal oblique, transverses abdominal (the external oblique forms it)

Superficial

> superior: internal thoracic artery

= Musuclophrenic A.

> inferior: femoral A

= Superficial epigastric A. (medial)

= Superficial circumflex iliac A. (lateral)

Deep

> superficial: internal thoracic artery

= Superior epigastric A., medial

= 10, 11th ICA, subcostal, lateral

> external iliac artery

= inferior epigastric A. (medial)

= deep circumflex iliac artery.

The superior epigastric and inferior epigastric both enter rectus sheath, posterior to rectus abdomens muscle throughout their course and anastomose with each other.

Posterior rectus abdominis muscle throughout course when they enter rectus sheath.

Anastomose with each other

Superior lymphatics above umbilicus: axillary nodes

Drainage below umbilicus: superficial inguinal nodes

Deep lymphatic drainage: parasternal

fat, feces, fetus, flatus, fluids (+tumors)

gallbladder: inserseciton semilunar line, 9th coastal cartilage

spleen: under 9th-11th ribs left side, midaxillary

kidneys: scapular line, superior lobes at 11th ribs

= left more superior than right

intersection semilunar line, 9th costal cartilage

referred pain:

> referred pain right side, 9th-11th midaxillary

Under 9th-11th ribs left side at midaxillary line

referred pain:

> 6-7th rib left side midaxillary

located along scapular line 11th ribs, left more superior than right,

Superior lobes at level 11th ribs

referred pain:

> back lower left abdominal

Xiphoid process: T6

Umbilicus: T10

Inguinal ligament; T1

L1-L2 nerve test

Method

> stroke medial aspect upper thigh, stimulate

ilioinguinal nerve

Result: contraction cremaster (genital branch genitofemoral nerve), retraction testes

1. The cremate should contract (genital branch genitofemoral nerve), resulting in retraction testes.

This is the cremaster reflex that is intended to test L1-L2 s/c levels.

1. para-aortic nodes (lumbar)

2. superficial inguinal nodes

3. parasternal nodes

Inflammation testes

Result: inflammation peritoneum (parietal peritoneum)

Cause:

> infections, perforated ulcers, appendititis, diverticulitis, cancer, cirrhosis

Cause: fusion parietal, visceral alyers, inflammation or trauma (surgery)

Dx: Peritoneal adhesion

Cause: trauma (surgery)

band of fibrous C/T, abdominal wall muscles attach to, running from:

> xiphoid process - pubis symphysis, between the 2 rectus abdomens muscles

xiphoid process, costal margin, diaphragm

domed structure w/ organs under:

> kidney, spleen

span

> between ASIS, pubic tubercle

Part of the tendon of the external oblique muscle , bottom edge of ligament rolled on itself

development

> external oblique creates passage way for spermatic cord, part of the reason the abdominal wall forms covering of spermatic cut + scrotum, both testes, ovaries, kidneys, and they move down

Structure

> inguinalcana, A/V/N

Liver: ribs 8, 9, 10

Spleen: lt midaxillary ribs 9-11

Gallbladder: Rt 9th RIB - semilunar line

kidney: scapular line, rib 11 (leftkiney more superior right kidney)

skin, campers fascia, scarpa's fascia, muscles (externa, internal oblqiues, transverses abdominis), transversalis fascia, endoabdominal fascia (extraperitoneal), parietal peritoneum

Structure:

> Streaks from internal oblique that extend down into the spermatic cord, cremaster fascia

Cremaster reflex:

> Irritate thigh, muscle pulls testicle up, cremaster muscle pulled up

Sensory part: ilioinguinal

Genitlofemoral nerve: inenrvates cremaster muscle

Tests: L1 spinal cord level

1. ileiinguinal nerve

2. genitofemoral nerve

3. Touch internal thigh

> Iliac crest (L4)

Anterior superior iliac spine (ASIS), L4-L5

Pubic tubercle: one on each sid epubic symphysis

Inguinal ligament

> between ASIS + pubic tubercle

> part of the tendon of the external oblique muscle

External spermatic fascia (external oblique aponeuroses)

Cermasteric fascia (internal oblique aponeuroses)

Internal spermatic fascia (transversalis fascia)

xiphoid process - pubic symphysis

between 2rectus abdomens muscles

QIP

Quadratus lumborus

Ileacus

Psoas

==> All of these are the lateral vertebral abdominal muscles

Ileacis

Psoasis

> Specifically distal ends of posts major and ilacus muscles pass into thigh and are major flexors of th ship joint

inferior thoracic wall - pelvis

passage via anterior abdominal wall created by processes vaginalis

Tubular extension of layers of abdominal wall into scrotum that contain all structures passing between testis and abdomen

> external scrotal fascia(external oblique fascia)

> cremaster (internal oblique fascia)

> internal scrotal fascia (transversus fascia)

2 lines

> vertical: umbilicus (T10) - pubic symphysis

> horizontal: IVD L3-L4

All have parts SI

RUQ: superior ascending colon, poyloris stomach, majority live

LUQ: left transverse colon, body stomach, minor part liver

RLQ: inferior ascending colon

LLQ:

Superficial fascia

= camper's fascia (superficial fatty layer of superficial fascia)

Deep fascia (Scarpa's fascia)

= colles' fascia (superficial perineal fascia)

= fascia lata (continues into thigh, below inguinal ligament, fusing w/ deep fascia thigh)

Superior

> internal thoracic

= musculophrenic (anterior)

= superior epigastric (posterior)

Inferior (external iliac artery > femoral artery)

> femoral artery

> anterior: superficial epigastric artery, superficial circumflex iliac artery

> posterior: inferior epigastric artery, lateral deep circumflex iliac arteries

Deep lateral: A from 10th, 11TH ICA, Subcostal artery

span

> junction between anterior abdominal wall and thigh

significance

> weakened from changes that occur during development

= can create inguinal hernia, most common in men

spans

> deep inguinal ring - superficial inguinal ring

around

= deep inguinal ring: midst between Anterior superior iliac spine + Pubic symphysis

> parallel to inguinal ligament

contents

> genital branch genitofemoral nerve

> spermatic cord men, round ligament women

> ilio-inginal nerve (exiting superficial inguinal ring)

location

> Midpoint Anterior superior iliac spine - pubic symphysis

significance

> forms one of the covering: interior spermatic fascia

Location

> end inguinal canal, superior pubic tubercle

significance

> forms external spermatic fascia

T7-L2

> T7-T11

T12: subcostal

L1: iliohypogastric

L2: ilioinguinal

**

Dermatomes

> T6: Xiphoid process

> T10: Umbilicus

> L1: Inguinal ligament

Compress abdominal viscera

Assist in respiration

Movement

External oblique, internal oblique, transverses abdominal, rectus abdominal, pyramidalis

QIP

Top Left: Quadratus lubrosums

Middle left: Iliacis

RIght: Psoas

Median umbilical ligament

> Supravesical fossa

Medial umbilical ligament

> Medial inguinal fossa

Lateral umbilical ligament

> Lateral inguinal fossa

superficial inguinal ring

deep inguinal ring

Conjoin tendon

opening external oblique muscle

opening in transversals fascia

internal oblique and transversus abdominis

structure

> internal oblique

innervation

> genital branch of genitofemoral nerve

Black arrow: Ileohypogastric nerve (L1)

Blue arrow: Ileoinguinal nerve (L1) Green arrow: genital branch of genitofemoral nerve

> innervates cremaster muscle

Red arrow: Deep ring of inguinal canal

green arrow: deep ring of deep ring inguinal canal

blue arrow: genital branch of genitofemoral nerve

pink arrow: femoral branch, genitofemoral nerve

lateral border: inferior epigastric artery

medial border: rectus abdominis

base: inguinal ligament

1. transversus abdominis muscle

2. external oblique muscle

> Transverse anterior abdominal wall

> Medial inferior epigastric vessel

> pass directly through Hasselbach's triangle

= Lateral: inferior epigastric artery

= Medial rectus abdominis

= Base inguinal ligament

> covered parietal peritoneum, transversals fascia

> does not transverse entire inguinal canal

> outside spermatic cord

> emerges from superficial ring

> can go into the scrotum

> Direct inguinal hernias traverse anterior abdominal indirectly, through inguinal canal

> most common type inguinal hernia

> leave abdominal cavity lateral epigastric vessels via congenitally patent deep ring

> traversese entire inguinal canal

> same coverings of spermatic cord

> common enter scrotum

Indirect b/c inside, in inguinal canal

Indirect b/c inside inguinal canal

Direct inguinal hernia: medial inferior epigastric A

indirect inguinal hernia: lateral inferior epigastric A

Femoral hernia: inferior inguinal ligament

Femoral hernia

> inferior inguinal ligament

Arteries

> from abdominal aorta

Venous

> right testicular veins: IVC

> left testicular veins: left renal vein

Direct henia * (most common since older male)

Hematocele

Hematocele

> if intestine must be clear fluid (peritoneal fluid)

Cause:

> deep inguinal ring that doe snot close, from that cavity leaking fluid into scrotum

1. Skin, Campers fascia, Sarcos fascia, External spermatic fascia, cremaster, internal spermatic fascia

2. Testicular artery, ilioinguinal artery, genital branch: genitofemoral nerve

3. Superficial inguinal node (since scrotum)

Gallbladder

Neck

Body

Fundus

left: hepatic

right: phrenic

lower: epigastric

Splenic

Renal, Adrenal

Pancreatic

Colomesocolic surface

Hepatic surface (bottom right)

Span

> lesser curvature stomach - 1st part duodenum - inferior surface liver

Components

> medial hepatogastric ligament

> lateral hepatoduodenal ligament

= end laterally as free margin,s erving as anterior border of mental foramen

> enclosed in free edge, hepatic artery proper, bile duct portal vein, right and left gastric vessel between layer lesser momentum near lesser curvature stomach

= haas portal triad

= artery, vein, bilary systme (bile duct)

Divisions: Foregut, Midgut, Hindgut

Foregut

> Inferior esophagus, stomach, liver, spleen, proximal duodenum

= Blood supply: Celiac artery, division abdominal aorta

Midgut

> Distal 2/3 duodenum, Jejunum, Ileum, Ascending, transverse colons, appendix

= Blood supply: Superior mesenteric artery, division abdominal aorta

Foregut

> Descending colon, Sigmoid colon, rectum

= Blood supply: Inferior mesenteric artery, division, abdominal aorta

Inguinal ligament

1. external oblique aponeuroses

2. The lowest part of the external oblique aponeuroses is the inguinal ligament.

Anterior superior iliac spine

(distal part of the inguinal ligament)

Pubic symphysis *

(medial part of inguinal ligament)

inguinal ligament

Rectus muscles:

> rectus abdominis, pyramidalis

The rectus sheath encloses rectus muscles

Formaiton rectus sheath (via fascia of flat muscles)

> aponeuroses of external oblique muscles, internal oblique muscles, transversals muscles

Line demarcates transition between aponeurotic posterior wall rectus sheath and transversals fascia

span

> XP - Pubic symphysis

structure

> anterior + posterior layers of the rectus sheath

= Rectus sheath: anterior layer: aponeuroses of all 3 muscle layers

lateral umbilical ligament

SMV + Splenic vein (POSTERIOR NECK PANCREAS) > Hepatic portal vein

> sinusoids liver > IVC

Posterior neck pancreas

Tail pancreas

Hilum spleen

Superior part kidney

T12, L1

Subcostal nerve

Iliohypogastric nerve

Ilioinguinal nerve

Anterior:

> ureter

> genitofemoral nerve

1. Bifurcation of common iliac artery into external and internal iliac arteries (see diagram drawn)

2. Pelvo-uretetic junction (see diagram drawn)

3. Entrance to bladder

Fundus gallbladder at level pylorus stomach

Top to bottom:

Iliac crest, Tubercle of iliac crest, Anterior superior iliac spine (ASIS)

Iliac crest: L4

ASIS: first part of inguinal ligament

Tubercle of iliac crest (L5): Forms the inter tubercular plane (lower horizontal plane of the 9 box designation)

ASIS

(Below Tubercle iliac crest, L5)

tubercle of iliac crest

(location transtubercular plane)

L5 vertebra

Horseshoe kidney

constrictions, stones

> renal pelvis

> crossing over by genital vessels (testicular, ovarian)

Formed by aponeuroses of 3 Flat muscles

1. medial umbilical ligament

2. lateral umbilical ligament

3. lateral inguinal fossa

Span

> 12 rib - TP 1st 3 Lumbar vertebrae, inserted iliac crest, TP L5

Function

> lateral flexion lumbar spine

Span

> TP, VB, IVD T12-L5

Function

>

Span

> 5,6,7 costal cartilages - pubic crest

Span:

> Rib 5 - Rib 12

Span

> thoracolumbar + iliac crest + superior inguinal ligament - upwards

2. SMA (ileal arteries, ileac branch ileocolic artery)

SMA:

> Jejuneal arteries

> Ileal arteries

> Ileocolic artery

= Ileal branch

= Cecal artery (to colon)

> right colic A (to ascending colon)

> middle colic A (to transverse colon)

IMA:

> left colic A (to descending colon)

> sigmoidal A

> superior rectal A

Superior rectal A (from inferior mesenteric A)

1. Colic artery of ileocolic artery (of SMA)

2. Appendicular artery of ileocolic A (of SMA)

McBurney's point

Lateral and middle 1/3 of line from ASIS to umbilicus

Ascending, descending colon

> (secondarily) retroperitoneal

Transverse, sigmoid colon

> intraperitoneal

junction ascending and transverse colon

(inferior to the right lobe of the liver)

junction transverse, descending colon

(inferior spleen)

Higher and more posterior to right colic, attached to diaphragm by phrenjicocolic ligament

Formation/loocation

> depressions are formed between the lateral margins of the ascending and descending colon and the posterolateral abdominal wall

Significance

> Materials can pass from 1 region of the peritoneal cavity to another

diaphragmatic surface: anterior, psoterior, superior

visceral surface: inferior direction

diaphragmatic recesses

> subphrenic: separates diaphragmmatic surface liver from diaphragm, divided by falciform ligament

> hepatorenal recess: part peritoneal cavity on right side between liver and right kidney and right suprarenal gland

separated diaphragmatic surfaece of the liver from he diaphragm

divided into right and left areas by the falciform ligament

part of peritoneal cavity on right side between liver and right kidney and right suprarenal gland

fossa gallbladder

porta hepatitis

bare area liver (small area liver against diaphragm)

additional folds peritoneum connect liver to:

> stomach (hepatogastric ligament)

> duodenum (hepatoduodenal ligament)

> diaphragm (right and left triangular ligaments and anterior and posterior coronary ligaments)

= triangular ligaments are when coronary ligaments come together laterally

left and right lobe divided via falciform ligament (anteriorly and posteriorly)

caudate lobe

> between fissure for ligamentum venosum (left) + IVC (right)

> functionally separated from both lobes liver (right and liver)

quadrate lobe

> between fissure for ligamentum teres (left) and gallbladder fossa (right)

> functionally related to the left lobe liver

right and left hepatic artery propers

(from common hepatic artery, from celiac branch abdominal aorta)

Cystic A(from right hepatic artery, from hepatic A proper, from common hepatic artery, from celiac trunk of abdominal aorta)

1. fundus (of gallbladder)

2. neck (of gallbladder)

3. body (of gallbladder)

Orientation:

> lies mostly posterior to stomach

extends across the posterior abdominal wall from the duodenum on the right and spleen on the left

R/P

> (secondarily) retroperitoneal

ducts:

pancreatic duct in tail pancreas > enters pancreas goes inferior > joining bile duct to form > hepatopancreatic ampulla (ampulla of Vater) > enters descending part duodenum at major duodenal papilla (surrounding ampulla is sphincter of ampulla, smooth muscle)Accessory pancreatic duct> empties into duodenum above major duodenal paipilla at minor duodenal papilla

gastroduodenal A from common hepatic artery (brac of celiac trunk), after branching forms hepatic artery proper

sx:

> non specific sx:

= upper abdominal pain, loss appetite, weight loss

= obstructive jaundice (obstruction of bile duct)

Patho

> most frequent within head and neck

bulbous region neck on gall bladder

gallstones impact the region of Hartmann’spouch, which is a bulbous region of the neck of the gallbladder causing severe pain

sx

> pain RUQ (Right hypochondriac), right shoulder

patho

> if inflammation involves parietal peritoneum, pain may not only be RUQ but also right shoulder b/c referred pain due to innervation o visceral peritoneum of diaphragm by spinal cord levels: C3-C5 that also innervate skin of the right shoulder

Thus one somatic sensory region of low sensory output (diaphragm) related to another somatic sensory region of high sensory output (dermatomes)

Cause

> left lower rib fractures

> blunt abdominal injury

> localized trauma to LUQ

Result:

> profuse bleeding into peritoneal cavity b/c spleen highly vasucular

explanation: Because the spleen has such a extremely thin capsule, susceptible to injury even when there is no damage to surrounding structures and evacuees the spleen is highly vascular when ruptured, spleens profusely into peritoneal cavity

right hepatic artery

hepatic artery proper divides into left and right hepatic arteries near the port hepatis

porta hepatis

Supply

> supplies transverse colon

Mech

> enters transverse mesocolon dividing into right and left branches

= right branch anastomoses w/ right colic A,

= left branch middle colic artery anastomoses with left colic artery (branch Inferior mesenteric artery)

> 2 common iliac veins

> lumbar veins

= become important collateral channels between lower and upper parts of body if IVC become blocked

= types lumbar veins

- 1st, 2nd lumbar veins: empty into ascending lumbar veins

- 3rd, 4th lumbar veins: drain into IVC

- 5th lumbar vein: drains into iliolumbar vein, tributary of common iliac vein

> right (genital) testicular or ovarian vein

> right renal vein

> right suprarenal vein

> inferior phrenic vein

> hepatic veins

This shows the lumbar plexus, L1-L3, Most L4, Parts T12

Anterior psoas major:

> L2 Genitofemoral nerve

Lateral psoas major (from superior to inferior):

> subcostal nerve, T12

> L1, iliohypogastric nerve

> L1, ilioinguinal nerve

> lateral cutaneous nerve of thigh, L2-L3

> femoral nerve, L2-L4

Medial to psoas major: Obturator nerve, L4

5 Fs for abdominal distentions:

> fat

> flatus

> fluid

> feces

> fetus

Gallbladder

> Between semilunar line and 9th costal cartilage

Spleen

> Midaxillary line between 9-11th ribs

Kidney

> Scapular line, superior poles 11th rib

> right kidney lower than left kidney due to presence liver

Xiphoid process: T6

Umbilicus: T10

Inguinal ligament: L1

level

> L1 of lumbar plexus

location

> lateral posts major muscle

innervation

> penis, labia majora

testing (L1-L2 testing)

> stroke medial upper thigh to stimulate ilioinguinal nerve (Cremaster reflex, cutaneous abdominal reflex)

> should result in contraction of cremaster muscle via genital branch of genitofemoral nerve (L1-L2) and cause testes retraction

Direct/indirect inguinal hernia:

> most common older males w/ weak abdominal muscles, rare females, children / children (99%), females (70%), males (50%)

> herniating bowel exits abdominal cavity medial inferior epigastric vessels via Hesselbach's traingle (bound rectus abd laterally, base inguinal ligament, inferior epigastric vessel medially) / leaves abdominal cavity lateral inferior epigastric vessel via deep inguinal ring

> covered by parietal peritoneum + transversals fascia, external spermatic fascia / same covers as spermatic cord (internal spermatic fascia, cremaster, external spermatic fascia)

> does not traverse entire inguinal canal, leaving superficial inguinal ring / traverses entire inguinal canal, deep inguinal ring - superficial inguinal ring

> nothing said about entering scrotum / commonly enters scrotum

> both difficult to diagnose via assessment

> direct hernias diagnosed 75%~ intraoperatively

Torsion of the testes

Factors

Infants < 1 year

Cause/Patho

Rotation/twisting of spermatic cord

Deficient anchoring testicle to tunica vaginalis via gubernaculum

> free rotation of testicle in the scrotum

Result

Sudden testicular enlargement and pain

N&V

Abnormal cremaster reflex (L1-L2 damaged?)

Abnormal positioning of the epididymis , Head of epididymis to testicle instead of nromally, posterior + lateral

1. Not torsion of testis, b/cepididyis is normal, anterolateral

2 None

1. Torsion of the testis, since epid. is anterior abnormally when it should be psoterolateral

2. Absent cremaster reflex (no scrotal retraction)(innervated by genital branch genitofemoral nerve, L1-L2 of lumbar plexus)

Sudden testicular enlargement and pain

N&V

Abnormal epididymis position, anterior instead of normal psoterolateral

3. Deficient anchoring of testicle to tunica vaginalis via gubernaculum resulting in free rotation of testicle ins crotum, also rotation/twisting of spermatic cord

patho

> accumulation fluid in the tunica vaginalis

cause

> can be congenital

= communication between tunica vaginalis and processes vaginalis

Dx

> transillumination of the scrotum

Patho

> accumulation of blood in the tunica Vaginalis

Cause

> Trauma

1. torsion testes

2. hematocele

3. hydrocele

4. tunica vaginalis (after tunica albuginea)

1. Torsion of testes,

Testis: lumbar (para aortic nodes)

scrotum: superficial inguinal node

1. Varicocele

2. Varicose vein of the pampiniform plexus due to vertical entry of left testicular vein into left renal vein (congestion) and or entrapment of left renal vein by SMA. (more commonly on the left side)

4. Hematuria, flank pain, varicocele

1. Varicoceles

2. Left renal vein

3. SMA

4. Flank pain, hematuria, varicocele

Phrenicolic ligament:

> tethers the splenic flexure of the colon to the body wall, restricting the flow of ascites in the abdominal cavity

Pain from appendicitis, ulcers, tumor or ectopic pregnancy resulting in guarding

Flexive contraction of abdominal wall musculature to protect inflamed organs

Guarding (CS 20)

Area

> Peritoneal folds that attach viscera to posterior abdominal wall

Proeprties

> allow movement (CS) and provide a conduit for vessels, nerve, and lymphatics

Patho

> although allow movement, prone to volvulus, twisting of the organ that block flow of intestinal contents (obstruction) ,resulting in reduced blood flow and ischemia

Description

> twisting of the organ that block flow of intestinal contents (obstruction) ,resulting in reduced blood flow and ischemia

Organ

> commonly those in mesenteries (SI)

Description

> accumulation sserous fluid within peritoneum

Tx

> Paracentesis

Clinical uses

> paracentesis

> intraperitoneal delivery of drugs (peritoneum large S/A), permitting rapid absorption fluids within peritoneal cavity

> peritoneal dialysis: used in renal failure, large surface area of peritoneum allows ut to be used as a dialysis membrane

> ventriculoperitoneal shunt: through proper placement of catheter, excessive CSF can be absorbed via peritoneum

> pneumoperioteum: gas can be introduced into peritoneal cavity for laparoscopic procedures

pneumoperiotneum: gas can be introduced into peritoneal cavity for laparoscopic procedures

ventriculoperitoneal shunt: through proper placement of catheter, excessive CSF can be absorbed via peritoneum

Peritoneal dialysis.

used in renal failure, large surface area of peritoneum allows ut to be used as a dialysis membrane

peritoneal dialysis: used in renal failure, large surface area of peritoneum allows ut to be used as a dialysis membrane

intraperitoneal delivery of drugs (peritoneum large S/A), permitting rapid absorption fluids within peritoneal cavity

Sensation of esophagus

> via vagus nerve

Sx

> heartburn (pyrosis), dysphagia and or sore throat

Protection against

> LES

> folds of gastric mucosa folding seal

> angle of the cardiac orifice

> diaphragm - right crus

Patho:

Barrett’s esophagus

Cause:Chronic reflex

Patho:

> Replacement of the esophageal epithelium w/ gastric epithelium from chronic reflex

Consid:

> Patietnts w/ BE have significantly increased risk of developing esophageal carcinoma.

1. GERD

2. Barretts esophagus

Barretts esophagus

> significantly increased risk esophageal cancer

Patho

> Erosion of stomach lining, eroding via walls + damage adjacent structures

> Erosion of major artery can result in significant blood loss + death

Result

Tx

> Surgical sectioning of branch from vagal trunks

surgical sectioning of branch from vagal trunks

1. liver

2. duodenum, pancreas

Spread locally to impact the duodenum, pancreas, posterior body walls

Mech:

> via lymph channels: celiac nods

= supraclavicular nodes (Virchow's node)

= periumbilical nodes (sister mary joseph nodule, ovarian cancer also)

> via venous chanenls: To liver f

= anterior axillary node (irish node)

Sx: intraperitoneal air

Dx: Some sort of perforation

Expl: Any perforation (i.e: ulcer) involvign stomach, sI, LI can result in intraperitoneal air which can be identified o the radiography as 'free sub diaphragmatic air'

Sx: intraperitoneal air

Dx: Some sort of perforation

Expl: Any perforation (i.e: ulcer) involvign stomach, sI, LI can result in intraperitoneal air which can be identified o the radiography as 'free sub diaphragmatic air'

(Wilkie's) Superior mesenteric artery syndrome

> Common in young anorexic women w/ little intraabdominal fat

Patho

> Compression of the 3rd part of the duodenum between SMA and Abdominal aorta

Sx: N&V, abdominal pain, malnutrition

(Wilkie's)

Superior mesenteric artery syndrome

> Common in young anorexic women w/ little intraabdominal fat

Patho

> Compression of the 3rd or 4th parts duodenum between SMA and Abdominal aorta

Sx: N&V, abdominal pain, malnutrition

Wilkie's syndrome

C) Superior mesenteric artery syndrome.

Patho

> About 2 feet from the ileocecal valve there exists in 2 % of the population an ideal diverticulum (Meckel’s diverticulum), representing a persistent vitelline duct.

Rules of 2

> 2% population, 2 feet proximal ileocecal valve, 2 inches length, 2 types of common ectopic tissue (gastric and pancreatic), 2 years most common age at clinical presentation, 2:1 male : female ratio

Sx

> Majority people asymptomatic (silent Mecke’s diverticulum)

> Painless rectal bleeding: melena like black offensive stools

> followed by intestinal obstructionfeatures acute appendicitis

> Pain epigastric, umbilical regions

Meckel's diverticulum (ileal diverticulum)

About 2 feet from the ileocecal valve there exists in 2 % of the population an ideal diverticulum (Meckel’s diverticulum), representing a persistent vitelline duct.

Meckel's diverticulum (ileal diverticulum)

About 2 feet from the ileocecal valve there exists in 2 % of the population an ideal diverticulum (Meckel’s diverticulum), representing a persistent vitelline duct.

Description

> Chronic inflammatory condiiton of the intestine (most one the ileum) that typically leads to fibrosis and obstructive symptoms

Sx

> Abdominal pain, diarrhea, Often complicated by fistulas and obstructions

Ischemia of the intestine

> Despite good collateral circulation, a blood clot may deprive a small segment of intestine, resulting in encores

Sx

> Visceral painIleus (blockage because of paralysis)

1. ischemia of the intestine

2. wilkie's syndrome (or SMA syndrome)

3. Meckel's diverticulum

4. crohn's disease

5. perforated duodenal ulcer

6. significantly increased risk esophageal cancer (Barrett's esophagus)

Predisposition to appendix to infection

> reason: since the appendix is a long thin tube, it can easily collect fecal material

As a result, the thin long tube can get blocked with fecal material and be infected

Structure

> significant lymphoid tissue

Appendicular artery

> does not form significant anastomoses, thus inflammation of appendix can compress surrounding appendicular artery leading to neroiss/gangrene/perforation

Appendicitis (most common cause acute abdomen)

> pain begins as vague 'visceral' (GVA) around the umbilicus (referred pain*)

> then irritation of the parietal peritoneum results in a well-localized, somatic pain (GSA), right lower quadrant or right flank region

= pain GSA commonly located at McBurney's point: 1/3 between ASIS and the umbilicus, used to approximate the appendix region)

Appendicitis (most common cause acute abdomen)

> pain begins as vague 'visceral' (GVA) around the umbilicus (referred pain*)

> then irritation of the parietal peritoneum results in a well-localized, somatic pain (GSA), right lower quadrant or right flank region

= pain GSA commonly located at McBurney's point: 1/3 between ASIS and the umbilicus, used to approximate the appendix region)

1. bowel osbtruction

2. ulcerative colitis

3. colorectal cancer

4. intussusception

5. diverticular disease

6. appendicitis

Sx:

> may be asymptomatic but as tumor growths: bloody stool, weight loss, changes in stool (decreased caliber, diarrhea) and malaise

Spread:

> local growth: peritoneum, pelvic organs

> lymph

> veins: Caval system, Batson's plexus (brain), vertebrae, lungs (caval system), liver (portal system)

> Telescoping of a proximal gut segment into the lumen of an adjacent segment)

Sx

> Ischemia, necrosis (most commonly ileocolic region)

Male

> bladder, segminal vesicles, ductus deferens, prostate, perineal body, bulb penis

Female

> vagina, cervix, perineal body

Epididymis rest are shown on CS

Need

> Diseases affecting the LI

= Colon cancer

= Diverticulitis

Procedure

> When it is necessary to let a distal portion of th ecolon heal, the proximal portion o the colon is sutured to an opening, stoma along the anterior abdominal wall, via the rectus abdomens muscle where waste products are expelled

Rectal prolapse:

> protrusion of the rectal wall into the anal canal or via the anal opening

Characterization

> protrusion of a reddish, mucosal mass into the anal canal (most commonly related to longstanding hemorrhoids), associated with constipation, malnutrition and prior rectal trauma

> protrusion of the rectal wall into the anal canal or via the anal openingCharacterization> protrusion of a reddish, mucosal mass into the anal canal (most commonly related to longstanding hemorrhoids), associated with constipation, malnutrition and prior rectal trauma

1. rectal prolapse

2. colorectal carcinoma

3. bowel obstruction

4. Diverticular disease

5. wilkie's syndrome (Superior mesenteric artery syndrome)

1. Ischemic colitis (pain, bloody stools)

2.

3. rectal prolapse

Sx

> hematemesis (vomiting blood)

> black tarry stool (melon)

Cause

> upper GI bleeding (stomach, duodenum)

Due to:

> stomach cancer

> ulcers

> gastritis

> esophageal varices

Sx

> hematochezia (red or maroon colored stool)

Causes

> Low GI bleed

= diverticular disease

= polyps

= hemorrhoids

= anal fissures

= cancer

= IBD

Patho

> weakness in puborectalis, pubovaginalis muscles resulting in bulging of the rectal wall into the posterior vaginal wall

Sx

> painful intercourse or bowel movements

> constipation

> sense of fullness

> can lead to rectal prolapse

Poor blood flow (atherosclerosis, hypovolemia, hypo perfusion, Sickle CA) > poor blood flow, especially in important watershed/susceptible areas:

= Griffith's point (Splenic flexure) : middle colic > let colic

= sudeck's point (rectos-sigmoidal junction) : last sigmoidal > superior rectal

Sx:

> pain, blood stool

Location

> Midaxillary between 9th-11th ribs

Pathologies

Splenic rupture:

Patho:

prone rupturing, since:

= thin outer capsule, contact w/ ribs 9-11 on left side)

= soft

Sx

> Left shoulder pain (ruptured spleen), due to irritation diaphragm/peritoneum (Kehr's sign)

Splenomegaly

Patho: enlarged in numerous inflammatory or degenerative conditions

Sx

> enlarged spleen palpable below the left costal margin and displace the splenic flexure from the colon

Trauma

> in living, liver soft and covered by a thin capsule, thus lacerations or puncture wounds to the liver will often result in hemorrhage

Hematomegaly

> caused by: CHF, Cancer, alcoholic cirrhosis

Variations

> there are significant variations in the origin of the hepatic arteries, they may arise from the left gastric artery or aberrant hepatic arteries penetrating the left lobe directly

Significance portal lobes

> knowledge of the functional segmentation of the liver permits removal of diseased vascular segments

> Hepatic artery property

> Left gastric artery (*CS 54, there are many variations in the blood supply to the liver)

left gastric artery

(*CS 54, there are many variations in the blood supply to the liver, the left gastric artery is one possible method blood supply to the liver )

amount lymph

> liver is a major lymph producing organ, about 50% of the lymph in the thoracic duct arises from the liver

Lymph drainag of the liver

> lymph from most liver > hepatic node > celiac node

> lymph from bare area liver > phrenic node > posterior mediastinal node

> lymph from falciform ligament > parasternal nodes

> lymph from round ligament > umbilical nodes

Most common metastatic origin of the liver

> right breast, since the liver has so much lymphatics

right breast

> right breast, since the liver has so much lymphatics

1. parasternal nodes

2. nodes around umbilicus (and anterior abdominal wall )

3. phrenic nodes > posterior mediastinal nodes

4. hepatic nodes > celiac nodes

1. hepatic nodes, mode liver

2. phrenic nodes, bare area liver

3. nodes around umbilicus and anterior abdominal wall

1. parasternal nodes

2. phrenic nodes > posterior mediastinal nodes

3. nodes around umbilicus

There is significant variation in the branching of: > hepatic ducts

> cystic ducts

> bile duct

> as well as location major duodenal papilla

Boundaries

> bound by

= cystic duct

= common hepatic duct

= base liver

Contents

> cystic artery, vein

> lymph nodes

> autonomic nerve fibers

> any anomalous ducts

Contents

> hepatic artery proper

> hepatic portal vein

> common bile duct

> lymphatics

> CN X (Vagus nerve)

Pringle's maneuver

> during bleeding during hepatic procedures, clamping vessels of the portal triad

= locaiton at tfree edge of the lesser momentum, the hepatoduodenal ligament

Types

> prehepatic: excessive breakdown RBC

> hepatic: disruption liver functino (i.e: cirrhosis)

> obstructive jaundice: if bile can not escape the gallbladder or biliary tree (b/c of gall stones), it enters blood and causes jaundice

Causes:

> liver cirrhosis

Patho

> atty and or fibrous C/T impedes blood flow through the liver

sx

> hepatomegaly, ascites, edema, jaundice, splenomegaly, and portal hypertension

Portal vein / caval vessel / presentation:

left gastric veins / esophageal veins / esophageal varices

superior rectal veins / middle and inferior rectal veins / hemorrhoids

paraumbilical veins / superior epigastric veins // caput medusae

veins along bare area of the liver / inferior phrenic veins / bleeding risk

Right lobe

> receives venous drainage from mid gut (intestines)

Left lobe

> receives venous drainage from stomach, spleen

stomach cancer

> will impact the left lobe of the liver since stomach venous flow tends to drain into the left lobe of the liver

Risk factors

> Fs: fat, fertile, female over 40 (obese, multiparous, female > 40)

Patho

> areas common gall stones

= fundus: may result in air within the biliary tract, may form a cholecysto-colonic fistula

= bile duct (common bile duct): block hepatic secretions

= hepatopancreatic ampulla (ampulla) of vater: block hepatic and pancreatic secretions

1. ampulla of vater (hepatopancreatic ampulla)

2. bile duct

3. fundus

Patho

> inflammation of the gallbladder via gallstones blocking the cystic duct, resulting in inflammation of the gallbladder

sx

> pain in epigastric, shifting to right hypochondriac region at junction 9th costal cartilage and line semilunaris

> right shoulder (b/c gallbladder irritates diaphragm, which receives C3-C5 phrenic innervation),

Patho: inflammation of the pancreas (often sequela of gallstones, retrograde flow bile into pancreatic duct)

Result: block pancreatic ducts

B/c gland at crossroads of foregut and midgut, pancreas drains into both: celiac and superior mesenteric nodes

Pancreatic cancer

> often spreads into para aortic (lumbar nodes)

Patho

> pancreatic cancer causes obstruction of the bile and pancreatic ducts

Sx

> weight loss, abdominal /back pain, obstructive jaundice (retention bile pigments), painless, palpable gallbladder, jaundice

1. pancreatic cancer

2. cholecystitis

3. esophageal varices

4. liver cancer (especially right breast)

5. Spleen pain, left shoulder pain associated w/ irritation diaphragm, peritoneum

1. torsion of the testis

2. ischemic colitis

> (griffith point or splenic flexure) from middle colic A > left colic A affected

Sx:pain, bloody stool

3. varicocele

LUQ

Span

> pyloric stomach - neck Gallbladder

Anterior

> Bile duct, gastroduodenal artery, Portal vein, IVC

Posterior

> SMA, SMV

Anterior

> IVC, Aorta, vertebral column

Lateralaorta

ligament of Treitz

Duodenojeunal flexure

Jejunal: LUQ (left hypochondrium)

Ileum: RLQ

jejunum

perforation stomach or dudodenal uclers

Intraperitoneal b/c of its mobility not b/c of its suspension by a mesentery (Greys 32)

aNTERIOR CECAL, POSTERIOR CECA AND APPENDICULAR ARTERIES FROM THE ILEOCOLIC a. (FROM sma)

Ascending, descending colon: retroperitoneal

Transverse, sigmoid colon: intraperitoneal

Anterior:

> Superior mesenteric vessels (SMA, SMV)

> Splenic vein

= SMV, Splenic vein join to form portal vein

Location

connecteed to:

> stomach via gastrospleno ligament

> left kidney via splenorenal ligament

==> both above ligaments part of the greater momentum

> lateral at splenic hilum: neck pancreas

Covering

> covering with visceral peritoneum except at splenic hilum

A

> splenic artery (from celiac trunk of SMA)

Posterior stomach

> Takes a tortuous path to the Left along superior border pancreas

Function

> tRAVELS IN SPLENORENAL LIGAMENT DIVIDING INTO NUMEROUS BRANCHES WHICH ENTER HILUM SPLEEN.

Result

> obstruct bile + pancreatic ducts

= weight loss, abdominal/back pain, obstructive jaundice, painless, palpable gallbladder ('Courvoisier sign') and jaundice

> obstruction of portal vein + IVC (See diagram, notes for visualization)

> metastasis via:

= regional spread to adjacent organs

= any peritoneal surface, local nodes

= liver

liver

expl: These are sx of pancreatic cancer, enlarged GB with no pain (Conservier sign)

Pancreatic cancer is most likely to metastasize to the liver (regional spread to adjacent organs, any peritoneal surface, local nodes as well )

CS 68

> Removal of spleen endangers the pancreatic tail

> If the pancreatic tail is damaged, digestive enzymes can be released into the abdominal cavity

Cause

> Congenital or acquired dilation of the wall of the abdominal aorta

Sx

> palpable abdominal aorta left of the midline

> pulsatile non tender mass below the umbilicus)

> fatal if ruptured

> Sx

= Compression of adjacent structures

(anterior: vertebrae)

(posterior: left renal vein, pylori stomach, superior and inferior duodenum)

Abdominal aortic aneurysm

Cause

> tear in the intimal inner layer of the aorta and hemorrhage between layers o the vessel

Sx

> acute onset back/chest pain, lower extremity ischemia, neuropathy, pulse deficits in lower extremities

Aortic dissection

Aortic dissection

Patho

> gradual buildup of plaque in the abdominal aorta, at the bifurcation of the abdominal aorta (L4), Lerich syndrome

Sx

> leg pain (claudication), impotence

Result

> aorta to aorta anastomoses since the gradual nature of this condition permits significant collateral circulation to develop

= SMA > middle/inferior rectals > internal iliac

= intercostals, subcostal, lumbar > iliolumbar, sup. gluteal > intenral ileac

= intercostal, subcostal lumbar > circumflex iliac > external iliac

= subclavian > internal thoraci c> superior epigastric > inferior epigastric > external iliac

3 sets of tributaries permit venous return from lower extremity (caval-caval anastomoses > IVC to SVC)

> inferior to superior epigastric

> superficial epigastric to lateral thoracic (th oracoepigastric)

> vertebria/lumbar veins + Batson's plexus to azygous system

recurring blood clots arising form the veins in the lower extremity can be treated by placing a filter / screen in the IVC (below level o renal veins), clot buildup can present as naval obstruction

> Psoas major muscle is covered by a stocking like covering of investing fascia

> Attachment to psoas major

= Lateral surface bodies T12 + L1 - L5- Lesser trochanter of femur

Innervation

> AR L1-L2

Blends with:

> medial arcuate ligament, fascia of quadrates lumborum and iliacus

Function

> flexion of thigh at hip

Tests

>

> thomas test

Posts major test/sign

> Patho: Inflamed retrocecal appendix can impact function o the right posts major

> Test

= Passively extend patient's hip, asking him to actively flex the thigh at hip

( Abdominal pain indicates + test)

Thomas test

> Patho: Dysfunction/contracture of psoas major muscle

> Test: Patient lays on back, examiner flexes patients hip.

= Dysfunction of the psoas major muscle is indicated when the test reveals flexion of the contralateral hip without knee extension

1. psoas muscle

2. contralateral flexion of the psoas muscle without knee extension after the examiner flexes the patient's hip

1. (right) psoas muscle

2. Performed to detect inflamed retrocecal appendix

Active flexion of thigh at hip after passively extending patient's hip and + abdominal pain is + for inflamed retrocecal appendix

Abdominal ureter

> medial side

Pelvic ureter

> lateral side

==> This should be considered in retraction of the ureter during surgery

Cause

> stones, tumors, prostatic hypertrophy

> kidney stones (nephrolithisias) or uremic calculus

Result:

> hydronephrosis, enlargement o the ureter, renal pelvis and or/calyces, renal failure

Sx renal stones

> pain (renal colic, anywhere form flank to groin), depending on location (renal pelvis, ureter, bladder)

> N&V, hematuria

XP (T6), T6 dermatome

Umbilicus, T8, T8 dermatomes

Costal margin, T10

Linea alba (XP -Pubic symphysis between 2 rectus abdomens muscles)

Linea semilunaris (pubic tubercle - 9th rib)

> separating rectus abdominis muscles

Iliac crest (L4)

ASIS (L4-L5)

Pubic tubercle (ASIS - pubic tubercle)

> 1 on each side pubic syphysis

Inguinal ligament

spermatic cord

skin, campers fascia, dartos fascia, external spermatic fascia (derived from external oblique aponeuroses), cremaster fascia (derived from internal oblique aponeuroses), internal spermatic fascia (derived from transversals fascia)

> pampiniform plexus (venous system cooling venous blood before reaching testis)

Diaphragm

> Right: 5th rib, Left: 5th Intercostal space

Gallbladder

> Crosses body surface, in contact diaphragm

> Rt. 9th rib - semiliunar line

Spleen

> Lt (midaxillary in contact ribs 9, 10, 11)

liver *

> ribs 8, 9, 10

Kidney

> scapular line, superior lobes at rib 11

fascia of the Lower anterior abdomen divided into 2 areas in abdomen + thigh layers fascia:

> adipose - Camper’s fascia

> scarpa’s fascia, fibrous tissue (allow skin move easily over muscle) (deeper part superficial campers fascia), blends into perineum

Conversions (same layers, different name)

= Dartos: over scrotum

= fascia lata: thighColles (Superficial perineal fascia): between legs

= Fundiform ligament (both genders)proeprtiesmore prominent males location

- malesextensions of deeper membranous layer of superficial fascia attached to pubic symphysis pass inferiorly onto the dorm and lateral parts of penis forming fungiform ligament of the penis

- femalescontinues into labia majora and anterior part perineum functionsuspends penis to body wall

innervation: T7-L2, Intercostal nerves all the way to T12, then pick up L1, L2T7-T12

properties

> Approaching midline, anterior cutaneous branch passes via rectus abdominis muscle + anteiror wall of rectus sheath to supply the skin (add flashcard)

T7T8T9

T10: Umbilicus

T11T12 SubcostalFunction

T7-T12,

L1 branches to anterolateral abdomianl wall and parietal peritoneum

T7-T9: skin from xiphoid process to above umbilicus

T10: skin around umbilicus

T11-L1: below umbilicus - and including pubic region L1 (ilioinguinal nerve)anterior surface scrotum/labia major, small cutaneous branch to the thigh

1. Superior sacral (ck name)

2. L1 both, Femoral (AR L2-L4), Obturator nerve (AR L2-L4)

3. Genitofemoral nerve (AR L2)

4. lateral cutaneous (AR L2-L3)

1. femoral nerve (AR L2-L4)

2. femoral branch genitofemoral nerve

3. ilioinguinal nerve

4. obturator nerve (AR L2-L4)

5. iliohypogastric nerve

6. ilioinguinal nerve

7. genital branch genitofemoral nerve

Skin, Campers fascia, dartos fascia, external oblique muscle, internal oblique muscle, transversals fascia/muscle, endoabdominal fascia, parietal peritoneum

Arcuate line: > horizontal line that demarcates lower limit of posteriorregion of rectus sheath= at a pt midway between umbilicus and pubic symphysis,corresponding beginning lower 1/4 of rectus abdomens,all aponeuroses move anterior to rectus muscle, from this point inferior, rectus abdomens muscle in directcontact w/ transversalis fascia, making arcuate line. > where inferior epigastric vessels perorate rectus abdominis

1. internal oblique

2. rectus abdominis

3. external oblique

medial umbilical ligament

Borders

> base: inguinal ligament

> medial: rectus abdominis

> lateral: inferior epigastric artery

structure

> fibromuscular canal formed by the layers comprising anterior abdominal wall

components

> superficial inguinal ring: opening in external oblique muscle

> deep inguinal ring: opening in transversals fascia

> conjoin tendon: internal oblique and tranversalis abdominis

opening in external oblique muscle

opening in transversalis fascia

internat oblique and trasnversalis

Structure

> the cremaster is an extension of the fibers of the internal oblique muscle

Innervation

> genitoemoral nerve

1. internal oblique muscle

2. external oblique muscle

3. transversalis fascia

> properties

= traverse anterior abdominal wall medial to inferior epigastric vessels, passing directly via Hesselbach's triangle

= covered parital peritoneum, transversals fascia= does not traverse entire inguinal canal, b/c usually does not enter deepinguinal ring, but emerges from superficial ring

= outside spermatic cord

= can go into scrotum