Abdomen

Surface anatomy Anterior abdominal wall Dr P S Aithala Prof & Unit Head Dept of surgery FMMC

!erminologies in surgical practice

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Anatomical Directions
Anterior "#entral$ % toward front of body Posterior "dorsal$ % toward bac& of body Medial % toward midline of body Lateral % toward side of body Proximal % nearer to reference point Distal % farther from reference point
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'ody (egions
)maginarily di#ided into * regions Midline sections+
, -pigastric % abo#e stomach , Umbilical % umbilicus or na#el , Hypogastric % below the stomach

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'ody (egions "con.t$

Lateral sections:
, (ight and left hypochondriac , Positioned near ribs/ specifically cartilages

Right and left lumbar

, Positioned near small of bac& "lumbar region$

Right and left iliac

, 0amed for upper bone of hip "ilium$ , Also called inguinal region "referring to groin$
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'ody Positions
Anatomical
, Standing erect/ facing forward/ arms at sides/ palms forward/ toes pointed forward

Prone
, 1ying face down

Supine
, 1ying face up
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23434 Surface anatomy

)dentify and name the bony landmar&s of the abdomen which are palpable on abdominal e5amination Schematically illustrate and discuss the nine abdominal regions and list which organs lie appro5imately in each region

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23434 Surface Anatomy

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(ight Hypochondrium
1i#er 6all bladder Subphrenic space Duodenum Hepatic fle5ure of the colon 7idney "right$ Suprarenal head of pancreas
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-pigastrium
1i#er Subphrenic space 1esser sac Stomach and duodenum 6reater and lesser omentum Pancreas !rans#erse colon 1ymph nodes retroperitoneal tissues
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1eft hypochondrium
Spleen 1i#er "left lobe$ subphrenic space Stomach 1esser sac Splenic fle5ure of the colon !ail of the pancreas 7idney "left$
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(ight lumbar
Ascending colon 7idney "right$ Paracolic gutter "right$ -5tension from the neighbouring structures 1i#er 6all bladder Appendi5
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Umbilical
Stomach Duodenum !rans#erse colon and mesocolon 8mentum Small intestine and its mesentery Pancreas 1ymph nodes Aorta 7idneys (etroperitoneal tissues Horse9shoe &idney Urachus
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1eft lumbar
Descending colon 7idney "left$ Paracolic gutter "left$ -5tension of the neighbouring structures9spleen

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(ight iliac fossa

Appendi5 Caecum 1ymph nodes )liac artery (etroperitoneal tissues )lium
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Hypogastrium
Urinary bladder Small intestine Sigmoid colon Ureters Fallopian tube 8#ary
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1eft iliac fossa

Sigmoid colon Small intestinal loops 1ymph nodes )liac artery

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(elated anatomy
Thoraco-abdomen+ Upper border% nipple "anterior$/ scapular tip "posterior$ 1ower border% inferior costal margin

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(elated anatomy
Anterior abdomen+ Upper border%anterior costal margin 1ower border%inguinal crease 1ateral border%anterior a5illary:s line
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(elated anatomy
Back+ Upper border%scapular tip 1ower border%iliac crest 1ateral border% posterior a5illary line

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23434 Surface anatomy

)dentify and name in which of the nine surface anatomical regions you would e5pect to feel tenderness in appendicitis/ cholecystitis/ gastritis and cystitis )dentify other surface anatomy lines e3g3 transpyloric line/ transumbilical line/ linea alba and linea semilunaris3 ;ou should be able to say how these lines are formed and to discuss the intra9abdominal e#ents occurring on the transpyloric line
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23434 Surface Anatomy

!ranspyloric plane
, Hilum of the &idneys , Pylorus of the stomach , 'ody of pancreas , Fundus of the gall bladder

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23434 Surface Anatomy

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232 Anterior abdominal wall

23234 23232 2323< 2323= 2323> 2323? 2323@ S&in and superficial fascia Muscles !rans#ersalis fascia Peritoneum (ectus sheath )nguinal area 8steology
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23234 S&in and superficial fascia

)dentify the fatty superficial layer "Camper:s fascia$ )dentify and shortly discuss the membranous superficial layer "Scarpa:s fascia$ according to its distribution and borders3 State what this fascia is called inferior to the superficial inguinal ring
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23232 Muscles
)dentify and discuss the three maAor abdominal muscles as follows+
, MaAor attachments to the following points+ 1inea alba/ crista iliaca and inguinal ligament where applicable/ , Direction of fibres/ , 0er#e supply and , Function

)dentify the neuro#ascular plane )dentify the ilio9inguinal and iliohypogastric ner#es3 Also state their origin and area of www.similima.com supply

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23232 Muscles

-5ternal obliBue
Origin
Muscular slips from the outer surfaces of the lower eight ribs "ribs >942$

Insertion

Innervation Function
Compress abdominal contentsC both muscles fle5 trun&C each muscle bends trun& to same side/ turning anterior part of abdomen to opposite side28

1ateral lip of Anterior rami of iliac crestC lower si5 thoracic aponeurosis spinal ner#es "!@ Table ending in to !42$ midline raphe "linea alba$

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23232 Muscles

)nternal obliBue
Origin
!horacolumbar fasciaC iliac crest between origins of e5ternal and trans#ersusC lateral two9 thirds of inguinal ligament

Insertion
)nferior border of the lower three or four ribsC aponeurosis ending in linea albaC pubic crest and pectineal line

Innervation
Anterior rami of lower si5 thoracic spinal ner#es "!@ to !42$ and 14

Function
See -5ternal 8bliBue

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23232 Muscles

!rans#erse abdominis
Origin
!horacolumbar fasciaC medial lip of iliac crestC lateral one9third of inguinal ligamentC costal cartilages lower si5 ribs "ribs @9 42$

Insertion
Aponeurosis ending in linea albaC pubic crest and pectineal line

Innervation
Anterior rami of lower si5 thoracic spinal ner#es "!@ to !42$ and 14

Function
Compress abdominal contents

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23232 Muscles

0euro#ascular plane
Ant Post

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2323< !rans#ersalis fascia

)dentify the trans#ersalis fascia

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2323= Peritoneum
)dentify the folds and associated underlying structures of the peritoneum on the posterior aspect of the anterior abdominal wall+ D23<3<E
, Plica umbilicalis mediana/ , Plica umbilicalis medialis/ , Plica umbilicalis lateralis/ , Falciform ligament
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2323> (ectus sheath

)dentify the rectus sheath and how it is formed on the following le#els+
, Superior to the arcuate line , )nferior to the arcuate lineF

)dentify and briefly discuss rectus abdominis as follows+

, maAor attachments/ , ner#e supply and , function

0ame and identify the structures on the posterior wall of www.similima.com the rectus sheath

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2323> (ectus sheath

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2323> (ectus sheath

(ectus abdominis
Origin
Pubic crest/ pubic tubercle/ and pubic symphysis

Insertion
Costal cartilages of ribs >9@C 5iphoid process

Innervation
Anterior rami of lower se#en thoracic spinal ner#es "!@ to !42$

Function
Compress abdominal contentsC fle5 #ertebral columnC tense abdominal wall

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2323? )nguinal area

)dentify and briefly discuss the inguinal canal as follows+
, Surface anatomy/ , 'orders/ , 8penings

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)nguinal canal Surface anatomy

2323? )nguinal area

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2323? )nguinal area

)ndirect inguinal hernia

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)nguinal canal 'orders

2323? )nguinal area

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=*49G

2323? )nguinal area

7now the positions of the superficial and deep inguinal rings and femoral canal3 )dentify the inguinal ligament and the structures posterior to it from lateral to medial3

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2323? )nguinal area

Femoral canal
Ant

Post

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2323? )nguinal area

Femoral hernia

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2323? )nguinal area

03A3H3-31
Contents 03A3H3-31 "lat3 9 med3$
, , , , Femoral ner#e Femoral artery Femoral #ein -mpty space "femoral canal$ , 1acunar ligament

AH

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2323? )nguinal area

1ist the contents of the spermatic cord3 Compare the content in males and females )dentify the inferior epigastric artery and its relation to the deep inguinal ring )dentify and list the borders of the inguinal triangle "Hesselbach:s triangle$ 0ame and identify the inguinal fal5 "conAoint tendon$
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2323? )nguinal area

Spermatic cord
< Fascia layers
, -5ternal spermatic fascia , Cremasteric fascia , )nternal speratic fascia

< Arteries
, !esticular artery , Cremasteric artery , Artery to ductus deferens

< 0er#es
, 6enito9femoral ner#e , )lio9inguinal ner#e , Sympathetic autonomic ple5us

< 8ther structures

, 1ymphatic #essels , Ductus deferens 50 , Pampiniform #enous ple5us

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2323? )nguinal area

Spermatic cord

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2323? )nguinal area

Hesselbach.s triangle

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2323@ 8steology
)dentify the following bony points of the os co5a+
, Anterior superior iliac spine "AS)S$ , Anterior inferior iliac spine "A))S$ , Crista iliaca , Posterior superior iliac spine "P))S$ , Pubic tubercle , Pubic crest , Symphysis pubis
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2323@ 8steology

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Appendi5
Mc 'urneys point Aunction between the medial two third and the lateral one third on the line Aoining the AS)S and umbilicus

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ANATO ! OF T"# BR#A$T

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M)17 S!(-A7

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1;MPHA!)C D(A)0A6-

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A(!-()A1 SUPP1;

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Section 3 Thyroid Gland !nctional "natomy lar#est endocrine #lands in the body$ wei#htin# abo!t 20 % 25#.

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composed of large numbers of closed follicles filled with colloid and lined with a layer of cuboidal epithelioid cells3 !he thyroid hormones are synthesiIed and secreted by the epithelioid cells but stored in colloid

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II% &roduction of Th'roid "ormones

)odide ")9$ acti#ely transported into the follicle and secreted into the colloid3 85idiIed to iodine ")o$3

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)odine attached to tyrosine within thyroglobulin chain3

, Attachment of 4 iodine produces monoiodotyrosine "M)!$3 , Attachment of 2 iodines produces diiodotyrosine "D)!$3

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Jithin the colloid/ enIymes modify the structure of M)! and D)! and couple them together3 Jhen two D)! molecules are coupled together/ a molecule of tetraiodothyronine/ !=/ or thyro5ine/ is produced3 !he combination of one M)! with one D)! forms triiodythyronine/ !<
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Th'roid "ormone $'nthesis

DIT + DIT = THYROXINE (T4) 3, 5, 3, 5TETRAIODOTHYRONINE MIT + DIT = TRIIODOTHYRONINE (T3) 3, 5, 3-TRIIODOTHYRONINE
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)))3 'iological Actions of !hyroid Hormones !< and != "Almost all is deiodinated by one iodide ion/ forming !<$ bind with nuclear receptor/ acti#ate and initiate genetic transcription3 9999 m(0A protein synthesis in cytoplasmic ribosomes 9999 general increase in functional acti#ity throughout the body3

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8n Metabolism Calorigenic action of thyroid hormones !hyroid hormones increase 82 consumption of most tissues in the body/ increasing heat production and 'M(3 !he mechanism of calorigenic effect of thyroid hormones may be+ A+ -nhances 0aK97K A!Pase acti#ity '+ Causes the cell membrane of most cells to become lea&y to 0aK ions/ which farther acti#ates sodium pump and increases heat production3
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&2' ())ect on metabolism o) *rotein$ carbohydrate and )at 1' +n ,rotein -etabolism. .ormally$ T4 and T3 stim!lates synthesis o) *roteins and en/ymes$ increasin# anabolism o) *rotein and ca!sin# *ositi0e balance o) nitro#en. 1n *atient with hyperthyroi i!"$ catabolism o) *rotein increases$ es*ecially m!sc!lar *rotein$ which leads wei#h2loss and m!scle wea3ness.
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1n *atients with hypothyroi i!", my4edema de0elo*s beca!se o) de*osition o) m!co*rotein bindin# with *ositi0e ions and water molec!les in the interstitial s*aces while *rotein synthesis decreases.

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2' +n carbohydrate metabolism "5 1ncrease absor*tion o) #l!cose )rom the #astrointestinal tract (5 (nhance #lyco#enolysis$ and e0en enhanced diabeto#enic e))ect o) #l!ca#on$ cortisol and #rowth hormone. 65 (nhancement o) #l!cose !tili/ation o) *eri*heral tiss!es.

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3' +n )at metabolism Thyroid hormones accelerate the o4idation o) )ree )atty acids by cells and increase the e))ect o) catecholamine on decom*osition o) )at. Thyroid hormones not only *romote synthesis o) cholesterol b!t also increase decom*osition o) cholesterol by li0er cells. The net e))ect o) T3 and T4 is to decrease *lasma cholesterol concentration beca!se the rate o) synthesis is less than that o) decom*osition.
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2. ())ect o) Thyroid 7ormones on Growth and 8e0elo*ment

Thyroid hormone is essential )or normal #rowth and de0elo*ment es*ecially s3eletal #rowth and de0elo*ment. Thyroid hormones stim!late )ormation o) dendrites$ a4ons$ myelin and ne!ro#lia. " child witho!t a thyroid #land will s!))er )rom #riti$i!"$ which is characteri/ed by %ro&th and "e$t'( retardation. 9itho!t s*eci)ic thyroid thera*y within three months a)ter birth$ the child with cretinism will remain mentally de)icient thro!#ho!t li)e.
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3. ())ects o) Thyroid 7ormone on .er0o!s System Thyroid hormones increase e4citability o) central ner0o!s system. 1n hy*erthyroidism$ the *atient is li3ely to ha0e e4treme ner0o!sness$ many *sychone!rotic tendencies incl!din# '$)iety #o"p(e)e!$ e)tre"e &orry and p'r'$oi'$ and "*!#(e tre"or.
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1n addition$ thyroid hormones can also stim!late the sym*athetic ner0o!s system.

The hy*othyroid indi0id!al is to ha0e )ati#!e$ e4treme somnolence$ *oor memory and slow mentation.
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4. +ther ())ects o) Thyroid 7ormone &1'())ect on cardio0asc!lar system Thyroid hormones ha0e a si#ni)icant e))ect on cardiac o!t*!t beca!se o) increase in heart rate and stro3e 0ol!me$ &may thro!#h enhance calci!m release )rom sarco*lasmic retic!l!m'.

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&2' ())ect on #astrointestinal tract Thyroid hormones increase the a**etite and )ood inta3e by metabolic rate increased. Thyroid hormones increase both the rate o) secretion o) the di#esti0e :!ices and the motility o) the #astrointestinal tract. ;ac3 o) thyroid hormone can ca!se consti*ation.

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)H (egulation of !hyroid Hormone Secretion

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Metabolic response to inAury

)ncrease energy e5penditure )ncreased o5ygen demand and consumption )ncreased acti#ity of sympathetic ner#ous system )ncrease le#el of catecholamines in circulation )ncrease le#el of cortisol /6H / AC!H
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1ipolysis , fats are principal source of energy following inAury Hyperglycemia Proteolysis , there is increase in the urinary e5cretion of urea and nitrogen

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Fluid and electrolyte management of the surgical patient

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Hyponatremia
1ow serum sodium le#els occurs when there is an e5cess of e5tracellular water relati#e to sodium3 )t can be due to 0a depletion/ 0a dilution or e#en in a normal #olume status 0ormal , 4<>9 4=> meB L1
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Causes of Hyponatremia
Dilution+ increased fluid inta&e Moral or i3#N Drugs+ antipsychotics / tricyclic antidepressants / AC- inhibitors Post operati#e ADH secretion Sodium depletion+ Decreased inta&e 63)3! loss M #omiting / prolonged nasogastric suctioning / diarrheaN (enal loss M diuretics / primary renal diseaseN
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Due to e5cess solute relati#e to free water HyperglycemiaM for e#ery 4OOmgLdl increment of glucose the 0a should decrease by 43?m-BLlN )ncreased lipids or proteins S)ADH

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Clinical features
C0S + headache / confusion/ seiIures / coma / Musculos&eletal + wea&ness / cramps / fatigue/ twitching 6)! + anore5ia / nausea / CHS + hypertension and bradycardia Mdue to increase in intra cranial pressureN !issue + lacrimation sali#ation www.similima.com 88 (enal+ oliguria

!reatment
)dentification of the cause Correction of the 0a deficit with oral or i3# 0acl

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Hypernatremia
Causes )atrogenic + gi#ing i3# fluids with 0a )ncreased mineral corticoids M Cushing:s syndrome / hyper aldosteronism N Jater loss Mdiabetes insipidus / 6)! or s&in loss of fluidsN Symptoms when the S30a more than 4?O m-BLl
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Clinical features of hypernatremia

C0S + restlessness/ lethargy / ata5ia / delirium /seiIures / coma Muscular+ pain in the muscles CHS+tachycardia/ hypotension / syncope !issue+ dry s&in red swollen tongue / decreased sali#a and tears (enal + oliguria www.similima.com Metabolic+ fe#er

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!reat the water deficit Jater deficitD1E%serum 0a 94=OP 4=O Qtotal body weight -stimate !'J is >OR lean body mass in men and =O R in women

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Hypo&alemia
CAUS-S )nadeBuate inta&e -5cessi#e loss Hyperaldosteronism DrugsMamphotericin / aminoglycosides / cisplatin N 1oss through the 6)! or the &idneys
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CLF
6)!+ ileus / constipation 0euromuscular+ decreased refle5 / fatigue / wea&ness / paralysis CHS+ cardiac arrest -C6+U wa#es / ! wa#e flattening S! segment changes / arrhythmias3

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!reatment
Find the cause and treat it 8ral correction i3# correction

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Hyper&alemia
)0C(-AS-D )0!A7-+ Potassium supplements 'lood transfusion Hemolysis / rhabdomyolysis / crush inAury / 6)! hemorrhage

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)0C(-AS-D (-1-AS-+ Acidosis/ hyperglycemia )MPA)(-D -SC(-!)80+ Potassium sparing diuretics (enal insufficiency
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CLF
6)!+ nausea / #omiting / colic&y pain Muscular+ wea&ness / paralysis respiratory failure CHS + arrthymias / arrest

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!reatment
)nhalation of a beta agonist MsalmetrolN i3# Ca gluconate 4O ml / 4O R / gi#en slowly o#er 4O min 7aye5alate orally 4OO ml of 2>R de5trose with 4O units plain insulin

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!ypes of fluids for replacement therapy

(inger lactate O3* R sodium chloride >R de5trose with O3=>R of sodium chloride >R de5trose <R sodium chloride
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A1!-(0A!)H(-SUSC)!A!)H- F1U)DS
Hypertonic saline@3>R >R albumin 2>R albumin De5tran =O De5tran @O He5tand Hetastarch
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-lectrolyte abnormalities in specific surgical patients

0-U(8186)C PA!)-0!S Syndrome of inappropriate secretion of anti diuretic hormone Diabetes insipidus

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CA0C-( PA!)-0!S+ Hyponatremia due to hypo#olemia Hypernatremia due to diabetes insipidus Hypo&alemia due to 6)! loss of 7 due to diarrhea post radiation / post chemotherapy / due to #illous adenomas of the colon !umor lysis syndrome
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Hypocalcemia after surgery Hungry bone syndrome Hypercalcemia in malignancy

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