Abdomen Dokter Indri 1.pdf

Abdominal Wall and Cavity

Irwan Indri Seta Septadina

Content:

Surface Anatomy ► Muscular Wall ► Review vascularisation and innervation ► Inguinal region ► Peritoneum and Peritoneal Cavity ►

Surface Anatomy 1. Planum transpyloricum Garis transversal antara incissura jugularis dan symphisis pubis. Setinggi cartilago costae IX (anterior) dan bagian bawah vertebrae lumbalis I (posterior)

Surface Anatomy (2) Planum transtubercular Garis transversal setinggi tuberculum iliaca (anterior) dan vertebrae lumbalis V (posterior)

Surface Anatomy 4 quadrants of abdomen: • upper left quadrant ULQ • lower left quadrant LLQ • upper right quadrant URQ • lower right quadrant LRQ

9 regions of abdomen

Abdominal Regions Hipocondrium

dextra

Hepar Hipocondrium sinistra Gaster, pankreas

Epigastrium

Hepar, gaster, pankreas

Lumbalis

Right contains ascending colon. Left contains descending colon. Ren

Abdominal Regions  Umbilicalis

Intestinum tenue dan colon transversum  Inguinalis Right  ileocecal junction, appendix. Left  colon sigmoideum  Hypogastrium Intestinum tenue, vesica urinaria, uterus

Bony Landmarks around Abdomen        

   

xiphoid process X costal cartilages (ribs 7-10) tips of ribs 11 and 12 vertebrae L1-L5 iliac crests IC tubercle of the crest TC anterior superior iliac spine ASIS anterior inferior iliac spine AIIS inguinal ligament IL pubic tubercle PT pubic crest PC pubic symphysis PS

Abdominal Wall from surface Rectus

abdominis Linea alba Linea arcuata Linea semilunaris Iliac crest Lig.inguinale

Abdominal Wall from surface Linea Alba  Berada

di garis tengah  Terbentang dari proc. Xyphoideus sampai ke symphisi pubis  Memisahkan m. rectus abdominus  Gabungan dari = aponeuroses of transversus abdominus, internal oblique, and external oblique muscle

Abdominal Wall from surface  Linea

semilunaris: Sepanjang lateral dari M. rectus abdominis.

 Linea

arcuata bagian bawah dari lamina posterior terletak di antara umbilicus dan pubis

Abdominal Wall from surface Inguinal

ligament:

Batas bawah dari apponeurosis M. obliquus externus yg menebal Mulai dari anterior superior iliac spine sampai ke pubic tubercle.

Abdominal wall divided into: 1. Anteriolateral abdominal wall  Anterior wall  Right lateral wall (Right Flank)  Left lateral wall (Left Flank) 2. Posterior abdominal wall

1. Anteriolateral Abdominal Wall

This extended from the thoracic cage to the pelvis and bounded : Superiorly 7th through 10th costal cartilages and and xiphoid process Inferiorly Inguinal ligaments and the pelvic bones. The wall consists of skin, subcutaneous tissues (fat), muscles, deep fascia and parietal peritoneum.

LAYERS OF ABDOMINAL WALL 

The layers of the abdominal wall vary, depending on where it is you are looking. For instance, it is somewhat different along the lateral sides of the abdomen than it is at the anterior side. It is also somewhat different at its lower regions.

LATERAL  skin  superficial

fascia  deep fascia  muscle  subserous fascia  peritoneum

ANTERIOR WALL  superficial

fascia  deep fascia (in this case a thickened area of deep fascia called the linea alba)  subserous fascia  peritoneum

Wall inferior (umbilicus) 1. Lapisan lemak superficial yg akan berlanjut dengan lapisan tubuh lain (Camper's fascia) 2. Lapisan membranosa yg akan berlanjut ke bawah menuju perineum utk melapisi penis dan scrotum (Scarpa's fascia) Superficial perineal fascia = Colle’s

1. Anteriolateral Abdominal Wall MusclesFig. 4 & Fig. 5

3 Flat Muscles with strong sheet like aponeuroses External Oblique (“hands-in-pocket”) Internal Oblique (fibers perpendicular to

external) Transversus Abdominis (wraps around) 2 Vertical Muscles Rectus Abdominis - vertical midline Pyramidalis --

Pyramidalis arises from the pubic crest and inserts into the linea alba. Its function is to

External obliquus muscle 

External oblique is the most superficial of the three flat muscles.  It arises from the middle and lower 5th – 12th ribs and passes inferomedially to insert into the linea alba, pubic tubercle and the iliac crest.

Internal Oblique muscle 

Internal oblique has fibres arising from the inguinal ligament and iliac crest that fan out from the anterior superior iliac spine to insert into the linea alba, conjoint tendon and the lower 3 ribs. It is innervated by the thoracoabdominal and lumbar nerves.

Transversus abdominis 

Transversalis is the deepest of the flat abdominal muscles that arises from the costal cartilages, iliac crest and inguinal ligament. The fibres run transversomedially to insert into the linea alba, pubic crest and conjoint tendon

Rectus Abdominis 

Rectus abdominus arises from the pubic symphysis and pubic crest, and inserts into the xiphoid process and costal cartilages.

Pyramidalis muscle 

Pyramidalis arises from the pubic crest and inserts into the linea alba. Its function is to tense the linea alba.

Rectus sheath: Encloses rectus abdominis. Formed by fusion of fascia of other three layers of abdominal muscles. Anterior and posterior laminae. (layers)

Anteriolateral Abdominal Wall Functions  Melindungi viscera abdomen dari trauma  Menekan isi dari cavum abdomen  Menjaga tekanan intraabdomen  Menggerakkan batang tubuh dan memberi bentuk tubuh

Posterior Abdominal Wall • • • • •

Lumbar vertebrae and IV discs. Muscles • Psoas, quadratus lumborum, iliacus Lumbar plexus • Ventral rami of lumbar spinal nerves. Fascia Diaphragm •

•

Contributing to the superior part of the posterior wall

Fat, nerves, vessels (IVC, aorta) and lymph nodes.

Posterior Abdominal Wall Between the parietal peritoneum and the muscles (retroperitoneal space) Fig. 6 • The psoas fascia or psoas sheath. •

The quadratus lumborum fascia.

•

The thoracolumbar fascia.

Posterior Abdominal Wall Muscles Three paired muscles  Psoas

major

 Iliacus  Quadratus

Lumborum

Applied Anatomy Posterior abdominal pain:  Ilio-psoas

has relationship to kidney, ureters, caecum, appendix, colon, pancreas….etc.

 When

any of these structures is diseased movement of the ilio psoas usually causes pain.

 When

intra abdominal inflammation is suspected the Ilio Psoas Test performed by moving ileopsoas muscle and if positive if it causes pain.

Psoas Abscess Hematogenous spread to the lumbar vertebrae may form an abscess which may spread from the vertebrae into the Psoas sheath producing a Psoas abscess.

 To

be continue

Inguinal Region Inguinal Canal: Oblique passage through lower abdominal wall. Site of potential weakness. Transmits: Spermatic cord in males. Round ligament of uterus in females. Extends between superficial and deep inguinal rings.

Inguinal Canal Its boundaries are: 1) Anterior wall – aponeurosis of external oblique 2) Posterior wall – transversalis fascia 3) Roof – internal oblique and transverse abdominus 4) Floor – inguinal ligament (superior surface)

Inguinal Region The two openings of inguinal canal are : 1. Superficial inguinal ring:

Superficial opening of the inguinal canal. Lies above and lateral to pubic tubercle. Larger in males: Transmits spermatic cord in males. Transmits round ligament of uterus in females.

Inguinal Region 2. Deep inguinal ring: Opening of the evagination of the transversalis fascia. Lies above inguinal ligament between anterior iliac spine pubic tubercle.

midway and

Inguinal Region Inguinal Canal: * Male: spermatic cord: Vas deferens. Ilioinguinal nerve. Genital branch of genitofemoral nerve. Testicular arteries and veins. Pampiniform plexus Lymph vessels. Cremaster muscle.

Inguinal Region Inguinal Canal: * Female: Round ligament. Ilioinguinal nerve. Lymph vessels.

Inguinal Region Inguinal Canal: * Female: Round ligament. Ilioinguinal nerve. Lymph vessels.

Hesselbach’s Triangle Hesselbach’s (Inguinal) Triangle is an important structure as it is the site for direct hernias. The triangle has the following borders: 1) Medial border of rectus abdominus 2) Inguinal ligament (inferiorly) 3) Inferior epigastric vessels

Abdominal Hernia Orifices Hernia is defined as the protrusion of an organ

through it’s containing wall. It can occur because of

Normal weakness found in everyone and related to anatomy of the area e.g., place where vessel or viscus enters or leaves the abdomen, muscles fail to overlap or there is only scar tissue (Umbilicus) Abnormal weakness caused by congenital abnormality or acquired as result of trauma or diseases. High intraabdominal pressure from Coughing / Abdominal distention

Common Sites Fig. 7 1.

2. 3. 4.

Inguinal Hernia Umbilical Hernia Femoral Hernia Incisional Hernia Less common Hernia

 Epigastric

Hernia  Recurrent Hernia

 PERITONEUM

LIAT DI DIKTAT

Peritoneal Lining of the Abdominal Walls

The walls of the abdomen are lined with parietal peritoneum.Fig. 9 This is a thin serous membrane consisting of a layer of mesothelium resting on connective tissue. It is continuous below with the parietal peritoneum lining the pelvis.

Peritoneal Lining of the Abdominal Walls The peritoneum can be regarded as a balloon. The parietal peritoneum lines the walls of the abdominal and pelvic cavities, and the visceral peritoneum covers the organs. The potential space between the parietal and visceral layers is called the peritoneal cavity. In males, this is a closed cavity, but in females, there is communication with the exterior through the uterine tubes, the uterus, and the vagina.

Peritoneal Lining of the Abdominal Walls Between the parietal peritoneum and the fascial lining of the abdominal and pelvic walls is a layer of connective tissue called the extraperitoneal tissue; in the area of the kidneys this tissue contains a large amount of fat, which supports the kidneys

Peritoneal Lining of the Abdominal Walls Between the parietal peritoneum and the fascial lining of the abdominal and pelvic walls is a layer of connective tissue called the extraperitoneal tissue; in the area of the kidneys this tissue contains a large amount of fat, which supports the kidneys

Peritoneal Lining of the Abdominal Walls The peritoneal cavity is the largest cavity in the body and is divided into two parts: the greater sac and the lesser sac.

The greater and lesser sacs are in free communication with one another through an oval window called the opening of the lesser sac, or the epiploic foramen. The peritoneum secretes a small amount of serous fluid, the peritoneal fluid, which lubricates the surfaces of the peritoneum and allows free movement between the viscera.

Peritoneal Lining of the Abdominal Walls Intraperitoneal and Retroperitoneal Relationships. Intraperitoneal when it is almost totally covered with visceral peritoneum. Retroperitoneal organs lie behind the peritoneum and are only partially covered with visceral peritoneum. Pancreas The ascending and descending parts of the colon

Peritoneal Lining of the Abdominal Walls Peritoneal Ligaments Peritoneal ligaments are two-layered folds of peritoneum that connect solid viscera to the abdominal walls. The liver, for example, is connected to the diaphragm by the falciform ligament, the coronary ligament, and the right and left triangular ligaments.

Peritoneal Lining of the Abdominal Walls Omenta are two-layered folds of peritoneum that connect the stomach to another viscus. The greater omentum connects the greater curvature of the stomach to the transverse colon. The lesser omentum suspends the lesser curvature of the stomach from the fissure of the ligamentum venosum and the porta hepatis on the undersurface of the liver

Peritoneal Lining of the Abdominal Walls Mesenteries are two-layered folds of peritoneum connecting parts of the intestines to the posterior abdominal wall, for example, the mesentery of the small intestine, the transverse mesocolon, and the sigmoid mesocolon. The peritoneal ligaments, omenta, and mesenteries permit blood, lymph vessels, and nerves to reach the viscera.

Peritoneal Pouches, Recesses, Spaces, and Gutters. The lesser sac lies behind the stomach and the lesser omentum. The opening into the lesser sac (epiploic foramen). Duodenal Recesses Close to the duodenojejunal junction, there may be four small pocketlike pouches of peritoneum called the superior duodenal, inferior duodenal, paraduodenal, and retroduodenal recesses

Peritoneal Pouches, Recesses, Spaces, and Gutters.

Cecal Recesses

Folds of peritoneum close to the cecum produce three peritoneal recesses called the superior ileocecal, the inferior ileocecal, and the retrocecal recesses.

Intersigmoid Recess The intersigmoid recess is situated at the apex of the inverted, V-shaped root of the sigmoid mesocolon.

Peritoneal Pouches, Recesses, Spaces, and Gutters.  Subphrenic Spaces  The right and left anterior subphrenic spaces lie between the diaphragm and the liver, on each side of the falciform ligament.  The right posterior subphrenic space lies between the right lobe of the liver, the right kidney, and the right colic flexure.  The right extraperitoneal space lies between the layers of the coronary ligament and is therefore situated between the liver and the diaphragm

Peritoneal Pouches, Recesses, Spaces, and Gutters. Paracolic Gutters  The paracolic gutters lie on the lateral and medial sides of the ascending and descending colons. The subphrenic spaces and the paracolic gutters are clinically important because they may be sites for the collection and movement of infected peritoneal fluid

Peritoneum Nerve Supply of the Peritoneum Parietal peritoneum is sensitive to pain, temperature, touch, and pressure. Visceral peritoneum is sensitive only to stretch and tearing and is not sensitive to touch, pressure, or temperature.

Peritoneum Nerve Supply of the Peritoneum Parietal peritoneum is sensitive to pain, temperature, touch, and pressure. Visceral peritoneum is sensitive only to stretch and tearing and is not sensitive to touch, pressure, or temperature.

Functions of the Peritoneum  

Peritoneal fluid ensures that the mobile viscera glide easily on one another. The peritoneal coverings of the intestine tend to stick together in the presence of infection. In this manner, many of the intraperitoneal infections are sealed off and remain localized. greater omentum is often referred abdominal policeman.

Functions of the Peritoneum 



The peritoneal folds play an important part in suspending the various organs within the peritoneal cavity and serve as a means of conveying the blood vessels, lymphatics, and nerves to these organs. Large amounts of fat are stored in the peritoneal ligaments and mesenteries, and especially large

amounts can be found in the greater omentum.

Applied Anatomy Some important skin areas involved in referred visceral pain.

Created by: dr. Irwan dr. Indri Seta Septadina, M.Kes. Bagian Anatomi FK Unsri Palembang

Fig. 1 Regio abdomen

Fig. 2 Nerves

Fig. 3 Thoracoabdominal nerve

Fig. 4 Anterolateral abdominal muscles

Fig. 5 Anterolateral abdominal muscles

Fig. 6 posterior abdominal muscles

Fig. 7 Site of hernia

Fig. 8

Fig. 9 Sagittal section of the abdomen