Abdominal wall and inguinal region anatomy.pptx

Abdominal wall and inguinal region anatomy.pptx

1. Abdominal wall and inguinal region anatomy Moderator: Dr. Abebe.A(general ,hepatobiliary surgeon) Presenter: Moses lukolo (SR1) 10/10/2023 1

2. Introduction Layers of abdominal wall Blood supply , inervation and lymphatic drainage of abdominal wall Inguinofemoral region anatomy refrences Outline 10/10/2023 2

3. The abdomen is the region that is bounded by inferior costal margin & T12 vertebra above and symphysis pubis & the right & left inguinal ligaments below Thoracic diaphragm separates the abdominal cavity from the thoracic cavity. Classified Anterolateral Posterior Anatomy of abdominal wall 10/10/2023 3

4. Anterolateral abdominal wall 10/10/2023 4 Musculoaponeurotic layer Boundaries superiorly- cartilage of 7-10 th ribs and xiphoid process Inferiorly – inguinal ligaments and superior margin of the anterolateral aspect of pelvic girdle(iliac crest, pubic crest and pubic symphysis )

5. It is mesodermal in origin and develops as bilateral migrating sheets, which originate in the paravertebral region and envelop the future abdominal area. The leading edges of these structures develop into the rectus abdominis muscles, which eventually meet in the anterior midline 10/10/2023 5 E mbryology

6. I ntroduction Houses and protects major viscera Assists breathing Increase intra-abdominal pressure thus aiding in expulsion of contents of bladder, uterus and rectum. Distends to accommodate intra abdominal expansion due to different physiologic and pathologic conditions Way to get access to surgical abdomen Aid in the movement of the trunk and maintain posture Function of abdominal wall 10/10/2023 6

7. 10/10/2023 7 SURFACE ANATOMY

8. 10/10/2023 8 SURFACE ANATOMY

9. skin superficial fascia, Deep fascia Muscles Transversalis fascia, Preperitoneal adipose and areolar tissue, and Peritoneum 10/10/2023 9 Layers of abdominal wall

10. 10/10/2023 10 Layers of abdominal wall

11. two layers Fatty layer or camper’s fascia(superficial layer) Its continuous with superficial fat over the rest of the body. and may be extremely thick in obese patients Superficial fascia 10/10/2023 11

12. Deep membranous layer ( scarpa’s fascia ) Superiorly, it is continuous with the superficial fascia over the remainder of the trunk In the midline ,it is adherent to the linea alba and pubic symphysis Inferiorly, it fuses with iliac crest ,and fascia lata at the inguinal flexure. It extends on to the scrotum It become continuous with the membranuos layer of the perineum ( colles ’ fascia) Superficial fascia con… 10/10/2023 12

13. In the male ,it extends on to the dorsum of the penis to form the fundiform ligament of penis 10/10/2023 13 Scarpa’s fascia con….

14. Scarp’as fascia cont … 10/10/2023 14

15. 5 muscles 3 flat muscle _external oblique _internal oblique _ transversus abdominis 2 vertical muscles _rectus abdominis _ pyramidalis Muscle of anterior abdominal wall 10/10/2023 15

16. External oblique muscle Origin Muscular slips from the outer surfaces of the lower eight ribs(8 to 12) Insertion Lateral lip of iliac crest;aponeurosis ending in midline raphe ( linea alba) Innervation Anterior rami of lower six thoracic spinal nerves(T7 to T12) Function Maintenance of abdominal tone,increasing intra-abdominal prressure,and lateral flexion of trunk aganst resistance 10/10/2023 16

17. Internal oblique muscle Origin Thoracolumber fascia;iliac crest between origin of external and transversus ;lateral 2 third of inguinal ligament Insertion Inferior border of lower 3 or 4 ribs;aponeurosis ending in linea alba ;pubic crest Innervation Anterior rami of lower six thoracic spinal nerves(T7 to T12 ) and L1 Function Maintenance of abdominal tone,increasing intra-abdominal prressure,and lateral flexion of trunk aganst resistance 10/10/2023 17

18. Transversus abdominis muscle Origin Thoracolumber fascia; medial lips of iliac crest ;lateral one third of inguinal ligament ;costal cartilages of lower 6 ribs(7 to 12 ribs) Insertion aponeurosis ending in linea alba ;pubic crest and pectineal line Innervation Anterior rami of lower six thoracic spinal nerves(T7 to T12 ) and L1 Function Maintenance of abdominal tone, increasing intra-abdominal pressure . 10/10/2023 18

19. Rectus abdominis muscle Origin Pubic crest,pubic tubercle,and pubic symphysis Insertion Costal cartilages of ribs 5 to 7;xiphoid process Innervation Anterior rami of lower seven thoracic spinal nerves(T7 to T12) Function Flexion of the trunk and the maintenance of abdominal wall tone 10/10/2023 19

20. pyramidalis muscle Origin Front of pubis and pubic symphysis Insertion Into linea alba Innervation Anterior ramus of T12 Function Tensing the lower linea alba 10/10/2023 20

21. Strong fibrious compartment of rectus abdominis muscle(enclosing anteriorly and posteriorly) Formed by aponeurosis ( bilaminar ) of the three flat muscles Anterior layer- EOA and anterior lamina of IOA Posterior layer – posterior lamina of IOA and transverse abdominis aponeurosis Posterior layer is deficient below arcuate line or semicircular line(at about 1/3 rd from umbilicus to pubis,roughly at level ASIS). All the aponeurosis form the anterior sheath. Rectus sheath 10/10/2023 21

22. 10/10/2023 22 Rectus sheath

23. 10/10/2023 23 Arcuate line

24. The linea alba is a tendinuos raph extending from xiphoid process to the pubic symphysis and crest Lie between two recti muscles Completely avascular – prefered location for incision and intra-abdominal access 10/10/2023 24 Linea alba

25. Thin layer of connective tissue laying between the deep surface of transversus abdominis and extraperitoneal fat Posteriorly ,it fuses with the thoracolumber fascia Transversalis fascia is prolonged as the internal spermatic fascia Transversalis fascia 10/10/2023 25

26. 10/10/2023 26 Transversalis fascia

27. The peritoneum lining the walls is the parietal peritoneum The peritoneum covering the viscera is visceral peritoneum peritoneum 10/10/2023 27

28. 10/10/2023 28 Blood supply

29. 10/10/2023 29 Venous and lymphatic drainage

30. 10/10/2023 30 dermatome

31. Abdominal incisions can be divided roughly into three general types: (1) vertical incisions (2) transverse incisions (3) Oblique incision. 10/10/2023 31 Abdominal incisions

32. 10/10/2023 32 Abdominal incision

33. Inguinal ligament Acts as flexor retinaculum at hip joint Inferior most part of external oblique aponeurosis Extends from ASIS and fibers insert into pubic tubercle(most) and superior pubic ramus lateral to pubic tubercle(forms lacunar ligament). Lacunar ligament Triangular extension of the inguinal ligament before its insertion Inserted at pecten pubis and lateral ends meet proximal end pectineal ligament Forms medial border of femoral ring Anatomy of Inguinofemoral region 10/10/2023 33

34. 10/10/2023 34 Cont …

35. Iliopubic tract (Thompsons ligament ) Thickened inferior margin of transversalis fascia(part of deep layer) Run parallel and posterior to inguinal ligament. Lower marigins are attached to the inferior edge of inguinal ligament and to the pectineal ligament 10/10/2023 35 Cont …

36. Pectineal ligament (cooper’s ligament) Cooper’s ligament is the lateral portion of the lacunar ligament that is fused to the periosteum of the pubic tubercle It can be seen only in the preperitoneal space and is the first landmark that should be identified during a TEP(totally extraperitoneal ) repair 10/10/2023 36 Cont …

37. 10/10/2023 37 Cont..

38. Conjoined tendon the fusion of lower fibers of the internal oblique aponeurosis with similar fibers from the aponeurosis of the transversus abdominis where they insert on the pubic tubercle and superior ramus of the pubis( pectineal line) 10/10/2023 38 Cont …

39. 10/10/2023 39 Cont …

40. Is an oblique passage through the anterior abdominal wall. Differs in infants and adults. formed in relation to descent of gonads. It is approximately 4 -6cm long. It lies parallel and superior to the medial half of the inguinal ligament . 10/10/2023 40 Inguinal canal

41. Anterior: External oblique aponeurosis and reinforced laterally by the origin of the internal oblique from the inguinal ligament Superior : Arched fibers of the conjoined tendon. Inferior: Inguinal ligament, Lacunar ligament and Iliopubic tract. Posterior : Transversalis fascia and Conjoint tendon medialy . 10/10/2023 41 Cont..

42. Deep (internal) inguinal ring is the entrance for spermatic cord in males, or the round ligament in females in to the inguinal canal. Located superior to the middle of the inguinal ligament and lateral to the inferior epigastric artery 1 cm above the femoral artery pulse or Midway between the ASIS and pubic tubercle. 10/10/2023 42 Cont …

43. Superficial (external) inguinal ring:- Slit like opening between diagonal fibers of external oblique aponeurosis . is the exit by which the spermatic cord in males, or the round ligament in females, emerges from the inguinal canal. Lies immediately above and medial to pubic tubercle. 10/10/2023 43 Cont …

44. Spermatic cord /round ligament genital branch of the genitofemoral nerve ilioinguinal nerve Spermatic Cord contains structures running to and from the testis . Suspends the testis in the scrotum. Fascial coverings derived from the anterolateral abdominal wall. 10/10/2023 44 Contents of inguinal canal

45. Spermatic cord and its covering. Three fasciae:  External spermatic (from external oblique fascia)    Cremasteric (from internal oblique muscle and fascia)   Internal spermatic (from transversalis fascia) Three arteries:   Testicular artery    Cremasteric artery   Deferential artery 10/10/2023 45 Contents of spermatic cord

46. Three veins: Pampiniform plexus and testicular vein   Cremasteric vein   Deferential vein Three nerves:  Genital branch of genitofemoral nerve   Ilioinguinal nerve  Sympathetic nerves (testicular plexus) Lymphatics 10/10/2023 46 Cont …

47. 10/10/2023 47 Cont …

48. is bounded: laterally by the inferior epigastric artery; medially by the rectus abdominis muscle; inferiorly by the inguinal ligament. 10/10/2023 48 Inguinal triangle ( Hesselbach's triangle) ,

49. Femoral sheath an extension of the transversalis fascia of the abdomen envelops the femoral artery, the femoral vein, and the femoral canal Femoral canal most medial of the three compartments of the sheath. where a femoral hernia may pass. conical, approximately 1.9 to 2.5 cm in length Contains areolar connective tissue,lymph nodes and lymphatic channels. It has two important roles: to permit the passage of the efferent lymph vessels from the deep inguinal lymph nodes to the abdomen, and to permit expansion of the femoral vein when the venous pressure of the lower extremity is elevated 10/10/2023 49 Femoral canal

50. 10/10/2023 50 Femoral canal

51. 10/10/2023 51 51 Cont …

52. Potential site for various hernia Boundaries Upper part :Arches of IO & trasversus abdominal muscle Laterally : Iliopsoas muscle Medially :Lateral edges of rectus muscle Below : Coopers ligament 10/10/2023 52 Myopectineal orifice of fruchauds (MPO)

53. 10/10/2023 53 MPO

54. 10/10/2023 54 Triangle of doom, triangle of pain and circle of death

55. 10/10/2023 55 CONT..

56. 10/10/2023 56

57. THANKS!! 10/10/2023 57