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THEABDOMEN • ABDOMINALCAVITY • ANTEROLATERALANDPOSTERIORABDOMINALWALL • INGUINALCANAL THEABDOMINALCAVITY THEABDOMINALCAVITY: •formsthesuperiorandmajorpartoftheabdominopelvic cavity,thatextendsbetweenthethoracicdiaphragmandpelvic diaphragm •hasnofloorofitsownbecauseitisconOnuouswiththepelvic cavity •extendssuperiorlyintotheosseocarOlaginousthoraciccagetothe 4thintercostalspace •isthelocaOonofmostdigesDveorgans,partsoftheurogenital system THEABDOMINALCAVITY Nineregionsoftheabdominalcavityareusedtodescribethe locaOonofabdominalorgans,pains,orpathologies. Theregionsaredelineatedbyfourplanes: • twosagiGal(verOcal) • twotransverse(horizontal)planes. THEABDOMINALCAVITY ThetwoSAGITTALPLANESareusuallythemidclavicularplanes: • fromthemidpointoftheclavicles • tothemidinguinalpoints-midpointsofthelinesjoiningthe anteriorsuperioriliacspine(ASIS)andthepubictuberclesoneach side. TheTRANSVERSEPLANESare: • thesubcostalplane,passingthroughtheinferiorborderofthe 10thcostalcarOlageoneachside • thetranstubercularplane,passingthroughtheiliactubercles (approximately5cmposteriortotheASISoneachside)andthe bodyoftheL5vertebra. THEABDOMINALCAVITY Thetranspyloricplane,extrapolatedmidwaybetween: • thesuperiorbordersofthemanubriumofthesternumand • thepubicsymphysis-typicallytheL1vertebrallevel,commonly transectsthepylorus TheinterspinousplanepassesthroughtheeasilypalpatedASISon eachside. FormoregeneralclinicaldescripOons,fourquadrantsofthe abdominalcavityaredefinedby: • thetransversetransumbilicalplane,passingthroughtheumbilicus (L3-L4level) • theverOcalmedianplane THEABDOMINALCAVITY THEABDOMEN • ABDOMINALCAVITY • ANTEROLATERALANDPOSTERIORABDOMINALWALL • INGUINALCANAL THEANTEROLATERALABDOMINALWALL Thewallismusculo-aponeuroOc,exceptfortheposteriorwall,which includesthelumbarregionofthevertebralcolumn. Theboundariesoftheanterolateralabdominalwall: • superiorlybythecarOlagesofthe7th–10thribsandthexiphoid processofthesternum • inferiorlybytheinguinalligamentandthesuperiormarginsofthe anterolateralaspectsofthepelvicgirdle Theanterolateralabdominalwallconsistsof: • skin • subcutaneousOssue(superficialfascia)composedmainly offat, • musclesandtheiraponeuroses, • deepfascia, • extraperitonealfat, • parietalperitoneum THEANTEROLATERALABDOMINALWALL FasciaoftheAnterolateralAbdominalWall ThesubcutaneousDssuehastwolayers: • thesuperficialfabylayerCAMPERFASCIA • thedeepmembranouslayerSCARPAFASCIA ThemembranouslayerconOnuesinferiorlyintotheperinealregionas thesuperficialperinealfascia-COLLESFASCIA Superficial,intermediate,anddeeplayersofinvesOngfascia covertheexternalaspectsofthethreemusclelayersofthe anterolateralabdominalwallandtheiraponeuroses Theinternalaspectoftheabdominalwallislinedwithmembranous andareolarsheetsofvaryingthicknessconsOtuOngendoabdominal fascia. THEANTEROLATERALABDOMINALWALL FasciaoftheAnterolateralAbdominalWall Theparietalperitoneumisinternaltothetransversalisfasciaandis separatedfromitbyavariableamountofextraperitonealfat. Theparietalperitoneumisformedbyasinglelayerofepithelialcells andsupporOngconnecOveOssue. THEMUSCLES OFANTEROLATERALABDOMINALWALL THEMUSCLESOFTHEABDOMINALWALL Therearefive(bilaterallypaired)musclesintheanterolateral abdominalwall:threeflatmusclesandtwoverOcalmuscles. Thethreeflatmusclesarethe: externaloblique,internaloblique,transversusabdominis. AllthreeflatmusclesareconOnuedanteriorlyandmediallyasstrong, sheet-likeaponeuroses Betweenthemidclavicularline(MCL)andthemidline,the aponeurosesformthetough,aponeuroOc,tendinousrectussheath enclosingtherectusabdominismuscle. THEMUSCLESOFTHEABDOMINALWALL Theaponeurosestheninterweavewiththeirfellowsoftheopposite side,formingamidlineraphe-thelineaalba Thelineaalbaextendsfromthexiphoidprocesstothepubic symphysis. ThetwoverDcalmuscles oftheanterolateral abdominalwall, containedwithinthe rectussheath,are thelargerectus abdominis and thesmallpyramidalis THEMUSCLESOFTHEABDOMINALWALL Themusclesofanteriorabdominalwall: • EXTERNALOBLIQUEMUSCLE • INTERNALOBLIQUEMUSCLE • TRANSVERSUSABDOMINISMUSCLE • RECTUSABDOMINISMUSCLE • PYRAMIDALIS THEMUSCLESOFTHEABDOMINALWALL Theexternalobliquemuscleisthelargestandmost superficialofthethreeflatanterolateralabdominalmuscles. Theinferiormarginoftheexternalobliqueaponeurosisisthickened andspansbetweentheASISandthepubictubercle astheinguinalligament. Theintermediateofthethreeflatabdominalmuscles,theinternal obliqueisathinmuscularsheetthatfansoutanteromedially. Thefibersofthetransversusabdominis,theinnermostofthethree flatabdominalmuscles THEMUSCLESOFTHEABDOMINALWALL Betweentheinternalobliqueandthetransversusabdominis musclesisaneurovascularplane-containsthenervesandarteries supplyingtheanterolateralabdominalwall. TherectusabdominisistheprincipalverOcalmuscleofthe anteriorabdominalwall.It’sbroadsuperiorly,narrowinferiorly. Mostoftherectusabdominisisenclosedintherectussheath. Therectusmuscleisanchoredtransverselybyabachment totheanteriorlayeroftherectussheathatthreeormore tendinousintersecDons. THEMUSCLESOFTHEABDOMINALWALL Thepyramidalisisasmall,insignificanttriangularmuscle thatisabsentinapproximately20%ofpeople. Therectussheathisthestrong,incompletefibrouscompartmentof therectusabdominisandpyramidalismuscles THENERVESOFTHEABDOMINALWALL NERVESOFANTEROLATERALABDOMINALWALL: • Thoraco-abdominalnerves thesenerves • Lateral(thoracic)cutaneousbranches communicatewitheach • Subcostalnerve other • Iliohypogastricandilio-inguinalnerves T10suppliestheskin aroundtheumbilicus THEVESSELSOFTHEABDOMINALWALL Theprimarybloodvessels(arteriesandveins): • Superiorepigastricvesselsandbranchesofthemusculophrenic vesselsfromtheinternalthoracicvessels. • Inferiorepigastricanddeepcircumflexiliacvesselsfromthe externaliliacvessels. • Superficialcircumflexiliacandsuperficialepigastricvesselsfrom thefemoralarteryandgreatersaphenousvein,respecOvely. • Posteriorintercostalvesselsofthe11thintercostalspaceandthe anteriorbranchesofsubcostalvessels. THEANTERIORABDOMINALWALL LYMPHATICSINTHEREGIONABOVETHEUMBILICUS • drainintotheaxillarylymphnodes. LYMPHATICSINTHEREGIONBELOWTHEUMBILICUS • drainintothesuperficialinguinalnodes. SUPERFICIALINGUINALLYMPHNODES • receivelymphfromthelowerabdominalwall,bubocks,penis, scrotum,labiummajus,andthelowerpartsofthevaginaandanal canal.Theirefferentvesselsprimarilyentertheexternaliliacnodes and,ulOmately,thelumbar(aorOc)nodes. THEPOSTERIORABDOMINALWALL POSTERIORABDOMINALWALL THEPOSTERIORABDOMINALWALL Theposteriorabdominalwall: • Fivelumbarvertebrae • Posteriorabdominalwallmuscles • Diaphragm • Fascia • Lumbarplexus • Fat,nerves,vessels(e.g.,aortaandIVC),andlymphnodes. THEPOSTERIORABDOMINALWALL Theposteriorabdominalwalliscoveredwiththelayerof endoabdominalfasciathatliesbetweentheparietalperitoneumand themuscles. Thethoracolumbarfasciaisanfascialcomplexabachedtothe vertebralcolumnmediallyandhasposterior,middle,andanterior layerswithmusclesenclosedbetweenthem. THEPOSTERIORABDOMINALWALL Themusclesoftheposteriorabdominalwall: • Psoasmajor:passinginferolaterally. • Iliacus:lyingalongthelateralsidesoftheinferiorpartofthepsoas major. • Quadratuslumborum:lyingadjacenttothetransverseprocesses ofthelumbarvertebraeandlateraltosuperiorpartsofthepsoas major. THEPOSTERIORABDOMINALWALL PSOASMAJOR • lieslateraltothelumbarvertebrae • passesinferolaterally • deeptotheinguinalligament • lumbarplexusisembeddedintheposteriorpartofthepsoas major ILIACUS • liesalongthelateralsideoftheinferiorpartofthepsoasmajor • psoasminorandiliacusmusclesmergeinferiorly;collecOvelyform iliopsoasmuscle QUADRATUSLUMBORUM • thequadrilateralquadratuslumborumformsathickmuscular sheet THEPOSTERIORABDOMINALWALL VESSELSOFPOSTERIORABDOMINALWALL THEPOSTERIORABDOMINALWALL ABDOMINALAORTA: • beginsattheaorDchiatusinthediaphragmattheleveloftheT12 vertebra • endsattheleveloftheL4vertebrabydividingintotherightand le\commoniliacarteries ItdescendsanteriortothebodiesoftheT12–L4vertebrae Thecommoniliacarteriesdivergeandruninferolaterally,following themedialborderofthepsoasmusclestothepelvicbrim-divide intotheinternalandexternaliliacarteries. • Theinternaliliacarteryentersthepelvis. • Theexternaliliacarteryfollowstheiliopsoasmuscle,givesriseto theinferiorepigastricanddeepcircumflexiliacarteries THEPOSTERIORABDOMINALWALL RELATIONSOFABDOMINALAORTA: •Celiacplexusandganglion •Bodyofthepancreasandsplenicvein •Lejrenalvein •Horizontalpartoftheduodenum •CoilsofsmallintesOne RELATIONSOFABDOMINALAORTA: Ontheright,theaortaisrelatedtotheazygosvein,cisternachyi, thoracicduct,rightcrusofthediaphragm,andrightceliac ganglion. Onthele\,theaortaisrelatedtothelejcrusofthediaphragmand thelejceliacganglion. THEPOSTERIORABDOMINALWALL BRANCHESOFTHEABDOMINALAORTA THEPOSTERIORABDOMINALWALL VEINSOFPOSTERIORABDOMINALWALL TheveinsoftheposteriorabdominalwallaretributariesoftheIVC, exceptforthele\tesDcularorovarianvein,whichentersthelej renalveininsteadofenteringtheIVC TheIVCreturnsbloodfromthe: • lowerlimbs, • mostoftheback, • abdominalwalls, • abdominopelvicviscera. THEPOSTERIORABDOMINALWALL Bloodfromtheabdominalviscerapassesthroughtheportalvenous systemandtheliverbeforeenteringtheIVCviathehepaDcveins. Theinferiorvenacava(IVC)beginsanteriortotheL5vertebrabythe unionofthecommoniliacveins. TheIVCleavestheabdomenbypassingthrough thecavalopeninginthediaphragmandentersthethoraxattheT8 vertebrallevel. THEPOSTERIORABDOMINALWALL TheIVCcollectsbloodfromthelowerlimbsandnon-portalblood fromtheabdomenandpelvis. ThetributariesoftheIVCcorrespondtothepairedvisceraland parietalbranchesoftheabdominalaorta. AllthebloodfromthegastrointesDnaltractiscollectedbythe hepaOcportalsystemandpassesthroughthehepaOcveinstotheIVC. Theveinsthatcorrespondtotheunpairedvisceralbranchesof theaortaareinsteadtributariesofthehepaAcportalvein. THEPOSTERIORABDOMINALWALL Thebranchescorrespondingtothepairedvisceralbranchesofthe abdominalaortaincludethe: • rightsuprarenalvein, • rightandlejrenalveins, • rightgonadal(tesOcularorovarian)vein. TheleBsuprarenalandgonadalveinsdrainindirectlyintotheIVC becausetheyaretributariesoftheleBrenalvein. THEPOSTERIORABDOMINALWALL LYMPHATICVESSELS LymphaOcvesselsandlymphnodesliealongtheaorta,IVC,andiliac vessels. CISTERNACHYLI Isthelowerdilatedendofthethoracicductandliesjusttotheright andposteriortotheaorta,usuallybetweentwocruraofthe diaphragm. IsformedbytheintesOnalandlumbarlymphtrunks. ThethoracicductascendsthroughtheaorOchiatusinthediaphragm intotheposteriormediasOnum,whereitcollectsmoreparietaland visceraldrainage,parOcularlyfromthelejupperquadrantofthebody. THEPOSTERIORABDOMINALWALL LYMPHNODESRELATEDTOTHEAORTA 1.PreaorDcNodes Includetheceliac,superiormesenteric,andinferiormesentericnodes; drainthelymphfromtheGItract,spleen,pancreas,gallbladder,and liver;andtheirefferentvesselsformtheintesOnaltrunk. 2.ParaaorDc,Lumbar,orLateralAorDcLymphNodes Drainlymphfromthekidneys,suprarenalglands,testesorovaries, uterus,anduterinetubes;receivelymphfromthecommon,internal, orexternaliliac;andtheirefferentvesselsformtherightandlej lumbartrunks. THEABDOMEN • ABDOMINALCAVITY • ANTEROLATERALANDPOSTERIORABDOMINALWALL • INGUINALCANAL THEINGUINALREGION INGUINALREGION Theinguinalregion(groin)extendsbetweentheASISandpubic tubercle.Itisimportant: • structuresexitandentertheabdominalcavity • pathwaysofexitandentrancearepotenOalsitesofherniaOon INGUINAL(HESSELBACH’S)TRIANGLE Isboundedmediallybythelineasemilunaris(lateraledgeofthe rectusabdominis),laterallybytheinferiorepigastricvessels,and interiorlybytheinguinalligament. INGUINAL(HESSELBACH’S)TRIANGLE IsanareaofpotenOalweaknessandhenceisacommonsiteofa directinguinalhernia. THEINGUINALREGION INGUINALREGION TheinguinalligamentisadensebandconsOtuOngtheinferiormost partoftheexternalobliqueaponeurosis. Theiliopubictractisthethickenedinferiormarginofthetransversalis fascia,whichappearsasafibrousbandrunning parallelandposterior(deep)totheinguinalligament. Theinguinalligamentandiliopubictractspananareaofinnate weaknessinthebodywallintheinguinalregioncalledthe myopecDnealorifice THEINGUINALREGION INGUINALCANAL TheinguinalcanalisformedinrelaOontotherelocaOonofthetesOs duringfetaldevelopment.Itliesparallelandsuperiortothemedial halfoftheinguinalligament-approximately4cmlong. ThemainoccupantoftheinguinalcanalisthespermaDccordin malesandtheroundligamentoftheuterusinfemales. TheinguinalcanalalsocontainsbloodandlymphaOcvesselsandthe ilio-inguinalnerveinbothsexes. THEINGUINALREGION Theinguinalcanalhasanopeningateachend: • thedeep(internal)inguinalringistheentrancetotheinguinal canal.Itislocatedsuperiortothemiddleoftheinguinalligament andlateraltotheinferiorepigastricartery • thesuperficial(external)inguinalringistheexitbywhichthe spermaOccordinmales,ortheroundligamentinfemales,emerges fromtheinguinalcanal Thelateralcrusabachestothepubictubercle,andthemedialcrus abachestothepubiccrest. THEINGUINALREGION Theinguinalcanalhastwowalls(anteriorandposterior), aroof,andafloor. ANTERIORWALL: formedbytheexternal obliqueaponeurosis throughoutthelengthofthe canal;itslateralpartis reinforcedbymusclefibersof theinternaloblique. POSTERIORWALL:formedbythe transversalisfascia.Its medialpartisreinforcedbypubic abachmentsoftheinternaloblique andtransversusabdominis aponeuroses-inguinalfalx. THEINGUINALREGION ROOF:formedlaterallybythe transversalisfascia,centrally bymusculo-aponeuroOcarches oftheinternalobliqueand transversusabdominis,and mediallybythemedialcrusof theexternalobliqueaponeurosis. FLOOR:formedlaterallybythe iliopubictract,centrallybyguber formedbytheinfoldedinguinal ligament,andmediallybythe lacunarligament. THEINGUINALREGION 1.Anteriorwall:aponeurosesoftheexternalobliqueandinternal obliquemuscles. 2.Posteriorwall:aponeurosisofthetransverseabdominalmuscle andtransversalisfascia. 3.Superiorwall(roof):archingfibersoftheinternalobliqueand transversemuscles. 4.Inferiorwall(floor):inguinalandlacunarligaments. THEINGUINALREGION Mostgroinhernias: • inmalespasssuperiortotheiliopubictract(inguinalhernias), • whereasmostpassinferiortoitinfemales(femoralhernias). Aninguinalherniaisaprotrusionofparietalperitoneumandviscera, suchasthesmallintesOne,throughanormalorabnormalopening fromthecavityinwhichtheybelong. Themajorityofabdominalherniasoccurintheinguinalregion. Inguinalherniasaccountfor75%ofabdominalhernias. THEINGUINALREGION Thetwotypesofinguinalherniaaredirectandindirectinguinal hernias.Morethantwothirdsareindirecthernias. Indirectinguinalherniasdevelopattheinternalinguinalringandare lateraltotheinferiorepigastricartery.