ANATOMY OF RECTUS in OBST AND GYNAE.pptx

Obs and gynae

1. Presented by – Dr. Hafizur Rahman [3 rd year PGT, OBG FAAMCH] Moderated by – Dr. Sanghamitra Das, Asst prof, OBG FAAMCH ANATOMY OF RECTUS ABDOMINIS MUSCLE AND SHEATH WITH VARIOUS ABDOMINAL INCISIONS

2. RECTUS ABDOMINIS MUSCLE Anatomy of rectus abdominis muscle It is a segmental muscle Segmentation is due to tendinous intersectiontion of rectus sheath Rectus abdominal muscle is anteriorly completely covered by anterior wall of rectus sheath Posteriorly it is partially covered by posterior wall of rectus sheath Tendenious intersection prevent bow Stringing of rectus abdominis muscle

3. Origin – as it has two head so one head is from pubic symphysis and another from pubic crest. Insertion –xiphoid process and anterior aspect of 5, 6, 7th costal cartilage.

4. Action- Rectus abdominis flexes the trunk. The rectus muscle are the most powerfull flexors of vertebral column when rising head from supine position. Maintain abdominal tone & increases intraabdominal pressure.

5. Blood Supply Via Superior and Inferior epigastric artery

6. Nerve Supply Innervated segmentally by thoraco-abdominal nerves (T7 to T11) and subcostal (T12)

7. Surgical importance of rectus abdominis muscle An abnormal wide separation of rectus abdominis muscle during operation later may lead to ventral hernia.

8. RECTUS SHEATH Anatomy of Rectus Sheath It is a aponeurotic sheath Formed by external oblique, internal oblique and transverse abdominalis muscle Has 2 walls- anterior wall (complete) and posterior wall ( incomplete)

9. Anterior wall: It is complete. Covers the rectus abdominis muscle end to end. Firmly adherent to tendinous intersection of rectus muscle. Posterior wall: It is incomplete. Deficient above costal margin and below arcuate line. Free from rectus muscle.

10. Formation of Rectus Sheath (above costal cartilage) Antetriorly by external oblique aponeurosis. Posteriorly it is deficit Rectus muscle directly rest on costal cartilage 5,6,7.

11. Formation of Rectus Sheath(below costal cartilage and above arcuate line) Anteriorly: [1]external oblique aponeurosis, [2] internal oblique aponeurosis ( anterior lamina) Posteriorly: [1]internal oblique aponeurosis ( posterior lamina) [2] transversus abdominis aponeurosis

12. Formation of Rectus Sheath(below the arcuate line) Anterior wall: external oblique aponeurosis, internal oblique aponeurosis and transverse abdominis aponeurosis. Posterior wall: deficient, rectus muscle rests on fascia transversalis.

13. ARCUATE LINE The arcuate line is located about midway between the umbilicus and pubic symphysis and represents the inferior portion of the posterior rectus sheath. Therefore, below the arcuate line, only an anterior layer of the rectus sheath exists, and there is no posterior layer of the rectus sheath. So, anterior abdominal wall is weak below arcuate line. SURGICAL IMPORTANCE OF ARCUATE LINE Any incision given below arcuate line there is high chance of incisional hernia. Inferior epigastric artery penetrate at the level of arcuate line in rectus sheath & supply the muscle of anterior abdominal wall.

14. VARIOUS ABDOMINAL INCISION

15. Various abdominal incision for open abdominal surgery

16. Transverse Incision Pfannensteil Incision Joel Cohen Incision Misgav Ladach Incision Cherney incision Maylard incision Transverse Muscle Dividing

17. Oblique Incision Rutherford Morrison Incision

18. TRANSVERSE INCISION

19. INCISION USED IN CAESAREAN SECTION VERTICAL INCISION A. INFRA-UMBILICAL PARAMEDIAN INCISION TRANSVERSE INCISON: A. PFANNENSTIEL INCISION B. JOEL COHEN INCISION C. MISGAV LADACH INCISION

20. Pfannenstiel incision : Introduced by Pfannenstiel in 1900, this curved incision is approximately 10–15 cm long and 2 cm above the pubic symphysis . Joel-Cohen incision: Professor Joel-Cohen introduced this incision for abdominal hysterectomy in 1954 and obstetricians have since used this widely to perform caesarean sections.6 This is a straight transverse incision through the skin, 3 cm below the level of the anterior superior iliac spines.

21. Advatange :- 1. less blood loss 2. Less post operative pain 3. Shorter hospital stay 4. Avoid large incison 5. Minimal risk of incisional hernia Complecations :- 1. Injury to abdominal organ 2. Bladder injury 3. Blood vessel injury 4.Pneumo peritonium related complication.

22. CONTRAINDICATION OF LAPROSCOPY 1. Generalised peritonitis 2. Extreme body weight. 3.Multiple previous abdominal procedure. 4. Uterus size more than 12 weeks

23. USE OF LAPROSSCOPY: DIAGONOSTIC: 1. Infertility 2. Endometriosis 3 PID 4. Ectopic Pregnancy OPERATIVE: 1. Sterlization 2. Tubal Anastomosis 3.Ectopic Pregnancy 4.Hystrectomy