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Gastrointestinal Module Anterior Abdominal Wall, Peritoneal Cavity, Diaphragm OUTLINE I. Introduction II. Abdominal Cavity A. Surface Anatomy B. Abdominal Wall C. Faschia D. Muscles E. Nerves and Vessels F. Internal Surface G. Inguinal Region III. Peritoneum and Peritoneal Cavity A. Vessels and Nerves B. Terminology C. Greater Sac and Omental Bursa IV. Diaphragm A. Diaphragmatic Apertures B. Actions of Diaphragm 16 November 2009 Dr. Jose Anthony Jocson Extends to 4th intercostal space of thoracic cage Continuous with pelvic cavity 9 Regions of Abdominal Cavity - Right and left hypochondriac - Right and left lumbar - Right and left inguinal - Epigastric - Umbilical - Hypogastric I. Introduction Abdomen – between thorax and pelvis - Musculotendinous walls except posteriorly - Abdominal wall encloses abdominal cavity – encloses peritoneal cavity and viscera II. Abdominal Cavity 4 Quadrants of the Abdominal Cavity - Right and left upper quadrant - Right and left lower quadrant A. Surface Anatomy Umbilicus Linea alba – centrally, it represents the muscular aponeurosis Xiphoid process Pubic symphysis Iliac crest Anterior superior iliac spine Semilunar lines – represent the lateral-most border of rectus abdominus - Tendinous intersections – represent points wherein rectus abdominis is inserting - Inguinal ligament - Abdominal Wall - Boundaries: abdominal walls, diaphragm, pelvis - Features Surrounded by abdominal wall Diaphragm separates it from thoracic cage Peritoneal lining Group 2 Anterolateral Abdominal Wall - Mostly musculo-aponeurotic - Indistinct boundaries between anterior and lateral part C. Faschia Layers of Anterolateral Wall - Skin - Camper’s faschia – fatty, superficial, subcutaneous tissue Where instrument is inserted in liposuction - Scarpa’s faschia – membranous, deep, subcutaneous tissue - Deep faschia / muscle layer - Endoabdominal faschia / fat - Parietal peritoneum Aguila. Arano. Angeles. Balictar. Escobillo. Pena. Ronquillo. Tagalog. Uy. Yeo. Yu Page 1 of 4 BATCH 2014 Anterior Abdominal Wall, Peritoneal Cavity, Diaphragm * Muscles in anterolateral wall are quite thin that is why people have died from liposuction (the machine/probe penetrates into abdominal cavity and damages structures) D. Muscle Layers External oblique Internal oblique Transverse abdominal Superficial, inferomedially directed fibers (trouser pockets) Intermediate layer, fibers are at right angles to external oblique (vest pockets) Innermost, horizontal fibers Vertical muscle, mostly enclosed by rectus sheath, running vertically between tendinous intersections (forms the ‘6-pack’) Triangular muscle in rectus sheath, inferiorly Rectus abdominis Pyramidal Posterior layer Crescentic/ Arcuate line Nerves of Anterolateral Abdominal Wall - Thoracoabdominal nerves (T7-T11) T7-T9 supply skin superior to umbilicus T10 supplies skin around umbilicus T11, T12, L1 supply skin inferior to umbilicus - Subcostal nerves (T12) - Iliohypogastric/ilioinguinal nerves Vessels - A means of collateral circulation If there is blockage of aorta, the blood can pass through superior epigastric to inferior epigastric to iliacs - Superior epigastic artery Continuation of the internal thoracic artery Supplies upper rectus abdominis Supplies sensation to level of umbilicus Anastomoses with inferior epigastric artery - Inferior epigastric artery From external iliac artery Anastomoses with the superior epigastric artery with the umbilical region - Superficial circumflex iliacs - Superficial epigastrics - Anterior and collateral branches of the posterior intercostals vessels Surgical Incisions - Midline incisions – usually in exploratory laparotomy (opening up abdomen to visualize the contents of the cavity) - Left paramedian - Gridiron – for appendectomies - Transverse - Pfannensteil (supra pubic) – ‘bikini’ – for caesarean section - Subcostal – for stones in gallbladder Rectus Sheath Anterior layer E. Nerves and Vessels In upper ¾; aponeurosis of external oblique and internal oblique Fused aponeurosis of internal oblique and transversalis Demarcates the lower limit of wall Rectus Sheath Contents - Rectus abdominis - Pyramidalis - Superior/inferior epigastric vessels - Lymphatics - Terminal portions of anterior rami of spinal nerves T7-T12 F. Internal Surface of Anterolateral Abdominal Wall - Covered with parietal peritoneum - Peritoneal folds – in infraumbilical surface - Contains remnants of fetal vessels 5 Umbilical Folds From apex of urinary bladder to umbilicus; covers Median fold medial umbilical ligament (remnant of urachus) Cover medial umbilical ligaments (remnants of fetal 2 Medial folds umbilical arteries) 2 Lateral Cover the inferior epigastric vessels umbilical folds Functions of Abdominal Muscles - Strong, flexible support - Protects viscera - Increases abdominal pressure to assist in elimination of gas, liquid, and solid - Moves the trunk, maintains posture - In patients with abdominal pain, the abdominal muscles provide balance Group 2 Aguila. Arano. Angeles. Balictar. Escobillo. Pena. Ronquillo. Tagalog. Uy. Yeo. Yu Page 2 of 4 BATCH 2014 Anterior Abdominal Wall, Peritoneal Cavity, Diaphragm III. Peritoneum and Peritoneal Cavity Peritoneum - Continuous, glistening, transparent serous membrane - Innermost Parietal - lines the internal surface of the abdominopelvic wall Visceral- invests the viscera (eg. spleen, stomach) Abdominal Cavity Peritoneal Fossae - Depressions lateral to the umbilical folds - Potential site for hernias - Lateral inguinal G. Inguinal Region - In the inferior part of wall - Area of weakness in males, due to passage of spermatic cord through the inguinal canal Inguinal Canal - Oblique, inferomedially directed passage (between superficial and deep inguinal rings) - Parallel and superior to medial half of inguinal ligament Inguinal Canal Contents - Spermatic cord in males - Round ligament of the uterus in females - Blood/lymphatic vessels - Ilioinguinal nerve Inguinal Canal Openings - Deep (internal) ring Entrance Outpouching of transversalis faschia Lateral to inferior epigastric vessels - Superficial (external) ring Exit Opening between fibers of external oblique Inguinal Canal - Anterior wall – external oblique aponeurosis, with contributions from internal oblique in lateral part - Posterior wall – transversalis faschia Group 2 Peritoneal Cavity - Potential space between the parietal and visceral layers of the peritoneum - Thin layer of peritoneal fluid keeps layers moist - Fluids keeps viscera to move without friction, especially during movements of digestion - In males, completely closed - In females, potential communication to exterior via uterine tubes, uterine cavity, vagina Peritoneal Fluid - Contains leucocytes, antibodies Intraperitoneal Organs - Almost completely covered with visceral peritoneum - Stomach Extraperitoneal/Retroperitoneal Organs - External/posterior to the parietal peritoneum Peritoneal Vessels and Nerves - Parietal peritoneum - Supplied from abdominal wall vessels - Somatic nerve innervated - Lymphatics from abdominal wall Peritonitis - Inflammation of peritoneum - Causes pain, increased muscles tone of abdominal muscles - Muscle guarding - Acute abdomen - Involuntary contraction Aguila. Arano. Angeles. Balictar. Escobillo. Pena. Ronquillo. Tagalog. Uy. Yeo. Yu Page 3 of 4 BATCH 2014 Anterior Abdominal Wall, Peritoneal Cavity, Diaphragm Parts of Peritoneum Double layer of peritoneum reflecting from abdominal Mesentery wall to enclose all/part of viscera; continuity of visceral/parietal peritoneum Peritoneal Double layer of peritoneum (more limited than, or a…) ligament Double-layered sheet of peritoneum from stomach to Omentum another abdominal organ; Greater omentum (gastrocolic ligament) IV. Diaphragm Thoracic Diaphragm - Dome-shaped, musculotendinous partition - Separates the thoracic cavity from the abdominal cavity - Descends during inspiration, but only central part moves - Right and left dome – right dome is higher due to larger right lobe of liver - Central tendon – trifoliate structure situated immediately below the pericardium with which it is partially blended - Sternal part – attaches to xiphoid process - Costal part – forms the right and left domes arises from the inner surfaces of the lower costal cartilages and ribs and interdigitate with the transversus abdominis - Aortic hiatus Posterior opening Aorta, azygos vein, thoracic duct - Superior surface Pericardiocophrenic/musculocophrenic arteries from internal thoracic Superior phrenic arteries from thoracic aorta - Inferior surface Inferior phrenic artery – usually 1st branch of abdominal aorta B. Actions of Diaphragm - Contraction causes dome to move inferiorly - Abdominal viscera also move inferiorly A. Diaphragmatic Apertures - Cava opening – passage of IVC, right phrenic nerve, lymphatics - Esophageal hiatus For esophagus T10 level Anterior/posterior vagal trunks, left gastric vessels, lymphatics Group 2 Aguila. Arano. Angeles. Balictar. Escobillo. Pena. Ronquillo. Tagalog. Uy. Yeo. Yu Page 4 of 4