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ABDOMINAL WALL

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Objectives

To define boundaries, quadrant and regions of abdomen

To describe the abdominal wall

To define layers of anterior abdominal wall

To define organization of the muscles

To describe innervation and vascularisation of the abdominal wall

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Superior Diaphragm

Inferior Pelvic inlet

Anterior and lateral Muscles

Posterior Lumbal vertebra Muscles

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Skin

Fat / Camper’s fasc

Scarpa’s fasc

M. OAE

M. OAI

M. Transversus abdominis

Transversal Fascia

Peritoneum parietale

Layers of abdominal wall

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Muscles of anterior abdominal wall EOM:

4th –12th riblinea alba IOM:

Inquinale lig, crista iliaca, fasc. Thoracolumbal 9th-12th ribs, linea alba, os pubis, linea pectinea

Transversus abdominis Inquinale lig, crista iliaca, fasc. Thoracolumbal

linea alba, os pubis, linea pectinea Rectus abdominis

Os pubis, interpubic lig cartilago 5th-7th ribs, proc. xiphoideus

Pyramidalis Os pubis, ant pubic lig linea alba

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Function Compress abdominal contents Protect abdominal injury Increase intra-abdominal

pressure Support respiration Flexion the trunk Rotate the trunk

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Muscles of post abdominal wall Iliopsoas mayor

Psoas head : Proc. Transversus VT12- L4 trochanter

minor femur Iliac head : illiac fossa trochanter minor

femur

Diaphragm Costal margin VL1-L4 central tendon

Quadratus lumborum Iliolumbar lig, crista iliaca posterior 12th rib,

proc transversus VL1-4

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Action M. quadratus lumborum:

Abduction coll vert Fixation 12th rib during inspiration Depression 12th rib during forced

expiration

M. iliopsoas: Flexion coll vert, the thigh when the leg

is not planted, flexion hip joint when the leg is planted

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Iliopsoas mayor Diaphragm Quadratus

lumborum

External Obligus Abdominis Internal Obligus Abdominis Transversus abdominis Rectus abdominis Pyramidalis

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Blood supply of abdominal wall

Epigastric arteries A. epigastrica superior (thoracica interna) A. epigastrica inferior (iliaca externa)

Intercostal arteries (aorta thoracalis) Deep circumflex iliac artery (iliaca

externa) Superficial epigastric artery (femoral)

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Blood supply

a. epigastrica sup

a. epigastrica inf

a. epigastrica superf

a. circumflexa iliaca profundus

a. circumflexa iliaca superfc

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VeinsDeep drainage

Paralel to the arterial supply

Superficial drainage Superior and inferior epigastric

veins Axillary vein Femoral vein Hepatic portal vein

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Nerves of abdominal wall

Rami ventralis N. spinalis Nn. Intercostalis inferior (T7 - T12)

Lateral cutaneous branch Anterior cutaneous branch

Plexus lumbalis (L1-L2) Anterior division

N. iliohypogastricus N. ilioinquinalis N. genitofemoralis

Posterior division Lateral femoral cutaneous

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DIGESTIVE SYSTEM

DIGESTIVE SYSTEM

Mouth Pharynx Esophagus Stomach Small intestine : duodenum, jejenum, ileum Cecum and appendix Large intestine: colon ascendens, transversus,

descendens Sigmoid, Rectum, Anal canal, Anus Accessory organ: Liver, Pancreas, Spleen

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Localized the part of the abdomen

Describe the location of pain Indicating the location of viscera

General localisation (quadrant) Specific localisation (regio)

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Quadrant

RUQ (Right upper quadrant) Right lobe of liver, gallbladder, pylorus, duodenum,

pancreas, right supraren, right kidney

LUQ (Left upper quadrant) Left lobe of liver, spleen, stomach, jejenum and

ileum, pancreas, left supraren, left colic, transverse colon, descending colon

RLQ (Right lower quadrant) Cecum, appendix, ileum, ascending colon, r-ovary, r-

uterine tube, r-ureter, uterus, urinary bladder, r-spermatic cord

LLQ (Left lower quadrant) Sigmoid colon, descending colon, l-ovary, l-uterine

tube, l-ureter, l-spermatic cord, urinary bladder, uterine

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PlanePlaneVertical : Median planeVertical : Median planeHorizontal: Horizontal: Transumbilical planeTransumbilical plane

QuadrantQuadrantUpper leftUpper leftUpper rightUpper rightLower leftLower leftLower rightLower right

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Regions

For specific localisation of a finding, abdomen is devided into 9 regions

Epigastric/epigastrium RH : right hypochondriaca LH : left hypochondriaca Umbilical RL : right lumbar LL : left lumbar Hypogastric/hypogastrium RI : right inquinal LI : left inquinal

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Plane of the Regions

VerticalVerticalRight Right

midclavicularmidclavicularLeft Left

midclavicularmidclavicular

Horizontal:Horizontal:SubcostalSubcostal

TranstubercularTranstubercular

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Length 25 cm, diameter 2 cm

Behind the trachea Passes through

diaphragm at VT X Continue as cardia of

the stomach Has cardiac sphincter Function: transport of

food

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Position: left hypochondriaca - epigastric

Structure of gaster

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• • greater curvature• lesser curvature,• cardiac sphincter,• fundus, • corpus, • anthrum pyloricum• pyloric sphincter• rugae, gastric sulci,• gastric glands

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Length: 25 cm Secondary retroperitoneal C shape

Division Superior (L1), Descending (L2-L3), Transverse (L3) Ascending (L3-L2)

Location: umbilical region

Length : 2.4 m diameter : 2-4cm Thicker wall Vasa recta tall Arcades fewer Plica circularis tall Peyer patches few

Location : hypogastric region

Length: 3.6 m diameter: 2-3cm Thiner wall Vasa recta short Arcades many Plica circularis short Peyer patches many

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Blind pouch Location:

below ileocecal junctionright iliac fossa, above inq lig.

Ileocecal junction Ileal papilla:projection at

the point of entry Ileocecal valve:border

ileocecal ostium

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Retrocecal fossa: 65%

Iliac fossa: 31%

Right paracolic recess: 2%

Sup iliocolic fossa: 1%

Inf iliocolic fossa: 1%

Length : 8-9 cm Position: 2-3 cm Intraperitoneal, supported by mesoappendix

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Blood supply of esophagus

Arteries A. thyreoidea inferior A. esophageal A. bronchialis A. gastrica sinistra

Veins Azygos and hemiazygos vein Left gastric vein portal vein Esophageal venous

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Arteries Right gastric a : pylorus Gastroduodenal a : pylorus, corpus Left gastric a : fundus, cardi, corpus Short gastric a: fundus, corpus Gastroepiploic a: left corpus

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VASCULATURE Superior mesenteric

a. Inferior

Pancreaticoduodenal

Right gastric a. Gastroduodenal a.

Supraduodenal a. Retroduodenal a. Superior

pancreaticoduodenal a.

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Innervations of GI tract Parasymphatetic

Vagus Celiac plexus

Symphatetic Greater splanchnic nn. Celiac ganglia Celiac plexus

Afferent Sensory Referred pain

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Innervation

Parasymphatis: left and right vagus esophageal plexus

Symphatis : thoracic splanchnic n

Afferent Sensory thoracic and greater

splanchnic nerves

Referred pain epigastria region

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Clinical problems

Esophagitis gastric contents reflux into esophagus

heartburn Esophageal varices

portal hypertension Hiatus hernia

herniation of stomach through esophageal hiatus at diaphragm

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Clinical problems

Gastritis: excessive HCl Peptic ulcer

Location : Duodenum Complication: bleeding, peritonitis,

hematemesis Treatment: antacid, selective vagotomy

Malignant metastases

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Abdominal pain Gastritis

Epigastric pain Appendicitis

A generalized pain epigastric region umbilicus Right Lumbar quadrant

Peritoneitis Inflammation of the peritoneum Severe pain everywhere