Surface anatomy Anterior abdominal wall

Terminologies in surgical practice
Anatomical Directions

• Anterior (ventral) = toward front of body
• Posterior (dorsal) = toward back of body
• Medial = toward midline of body
• Lateral = toward side of body
• Proximal = nearer to reference point
• Distal = farther from reference point

Body Regions

• Imaginarily divided into 9 regions
• Midline sections:
• Epigastric = above stomach
• Umbilical = umbilicus or navel
• Hypogastric = below the stomach

Lateral sections:

• Right and left hypochondriac
• Positioned near ribs, specifically cartilages

Right and left lumbar
Positioned near small of back (lumbar region)

Right and left iliac

• Named for upper bone of hip (ilium)
• Also called inguinal region (referring to groin)

Body Positions

• Anatomical –Standing erect, facing forward, arms at sides, palms forward, toes pointed forward
• Prone –Lying face down
• Supine –Lying face up 

2.1.1 Surface anatomy

Identify and name the bony landmarks of the abdomen which are palpable on abdominal examination

Schematically illustrate and discuss the nine abdominal regions and list which organs lie approximately in each region

Right Hypochondrium

• Liver
• Gall bladder
• Subphrenic space
• Duodenum
• Hepatic flexure of the colon
• Kidney (right)
• Suprarenal head of pancreas

Epigastrium

• Liver
• Subphrenic space
• Lesser sac
• Stomach and duodenum
• Greater and lesser omentum
• Pancreas
• Transverse colon
• Lymph nodes retroperitoneal tissues

Left hypochondrium

• Spleen
• Liver (left lobe) subphrenic space
• Stomach
• Lesser sac
• Splenic flexure of the colon
• Tail of the pancreas
• Kidney (left)

Right lumbar

• Ascending colon
• Kidney (right)
• Paracolic gutter (right)
• Extension from the neighbouring structures
• Liver
• Gall bladder
• Appendix

Umbilical

• Stomach
• Duodenum
• Transverse colon and mesocolon
• Omentum
• Small intestine and its mesentery
• Pancreas
• Lymph nodes
• Aorta
• Kidneys
• Retroperitoneal tissues
• Horse-shoe kidney
• Urachus

Left lumbar

• Descending colon
• Kidney (left)
• Paracolic gutter (left)
• Extension of the neighbouring structures-spleen

Right iliac fossa

• Appendix
• Caecum
• Lymph nodes
• Iliac artery
• Retroperitoneal tissues
• Ilium

Hypogastrium

• Urinary bladder
• Small intestine
• Sigmoid colon
• Ureters
• Fallopian tube
• Ovary

Left iliac fossa

• Sigmoid colon
• Small intestinal loops
• Lymph nodes
• Iliac artery

Related anatomy

Thoraco-abdomen:

• Upper border= nipple (anterior), scapular tip (posterior)
• Lower border= inferior costal margin

Anterior abdomen:

• Upper border=anterior costal margin
• Lower border=inguinal crease
• Lateral border=anterior axillary’s line
• Related anatomy

Back:

• Upper border=scapular tip
• Lower border=iliac crest
• Lateral border= posterior axillary line

2.1.1 Surface anatomy

Identify and name in which of the nine surface anatomical regions you would expect to feel tenderness in appendicitis, cholecystitis, gastritis and cystitis

Identify other surface anatomy lines e.g. transpyloric line, transumbilical line, linea alba and linea semilunaris.  You should be able to say how these lines are formed and to discuss the intra-abdominal events occurring on the transpyloric line

Transpyloric plane

• –Hilum of the kidneys
• –Pylorus of the stomach
• –Body of pancreas
• –Fundus of the gall bladder

2.2 Anterior abdominal wall

•        Skin and superficial fascia
•        Muscles
•       Transversalis fascia
•       Peritoneum
•       Rectus sheath
•       Inguinal area
•       Osteology

2.2.1 Skin and superficial fascia

• Identify the fatty superficial layer (Camper’s fascia)
• Identify and shortly discuss the membranous superficial layer (Scarpa’s fascia) according to its distribution and borders. State what this fascia is called inferior to the superficial inguinal ring

2.2.2 Muscles

Identify and discuss the three major abdominal muscles as follows:

–Major attachments to the following points: Linea alba, crista iliaca and inguinal ligament where applicable,

–Direction of fibres,

–Nerve supply and

–Function

• Identify the neurovascular plane
• Identify the ilio-inguinal and iliohypogastric nerves. Also state their origin and area of supply
• External oblique
• Internal oblique
• Transverse abdominis
• Neurovascular plane

2.2.3 Transversalis fascia -Identify the transversalis fascia

2.2.4 Peritoneum

Identify the folds and associated underlying structures of the peritoneum on the posterior aspect of the anterior abdominal wall: [2.3.3]

• –Plica umbilicalis mediana,
• –Plica umbilicalis medialis,
• –Plica umbilicalis lateralis,
• –Falciform ligament

2.2.5 Rectus sheath

Identify the rectus sheath and how it is formed on the following levels:

• –Superior to the arcuate line
• –Inferior to the arcuate line
• Identify and briefly discuss rectus abdominis as follows:
• –major attachments,
• –nerve supply and
• –function

Name and identify the structures on the posterior wall of the rectus sheath

2.2.6 Inguinal area

Identify and briefly discuss the inguinal canal as follows:

• –Surface anatomy,
• –Borders,
• –Openings

Inguinal canal
Surface anatomy

Indirect inguinal hernia
Inguinal canal

Borders

2.2.6 Inguinal area

• Know the positions of the superficial and deep inguinal rings and femoral canal.
• Identify the inguinal ligament and the structures posterior to it from lateral to medial.
• Femoral canal
• Femoral hernia
• N.A.V.E.L

2.2.6 Inguinal area

• List the contents of the spermatic cord.  Compare the content in males and females
• Identify the inferior epigastric artery and its relation to the deep inguinal ring
• Identify and list the borders of the inguinal triangle (Hesselbach’s triangle)
• Name and identify the inguinal falx (conjoint tendon)

Spermatic cord

3 Fascia layers

• –External spermatic fascia
• –Cremasteric fascia
• –Internal speratic fascia

3 Arteries

• –Testicular artery
• –Cremasteric artery
• –Artery to ductus deferens

3 Nerves

• –Genito-femoral nerve
• –Ilio-inguinal nerve
• –Sympathetic autonomic plexus

•3 Other structures

• –Lymphatic vessels
• –Ductus deferens
• –Pampiniform venous plexus

Spermatic cord

Hesselbach’s triangle

2.2.7 Osteology

•Identify the following bony points of the os coxa:

• –Anterior superior iliac spine (ASIS)
• –Anterior inferior iliac spine (AIIS)
• –Crista iliaca
• –Posterior superior iliac spine (PIIS)
• –Pubic tubercle
• –Pubic crest
• –Symphysis pubis

Appendix

• Mc Burneys point
• Junction between the medial two third and the lateral one third  on the line joining the ASIS and umbilicus

II. Production of Thyroid Hormones

•Iodide (I-) actively transported into the follicle and secreted into the colloid.

•Oxidized to iodine (Io).

Iodine attached to tyrosine within thyroglobulin chain.

• –Attachment of 1 iodine produces monoiodotyrosine (MIT).
• –Attachment of 2 iodines produces diiodotyrosine (DIT).

Within the colloid, enzymes modify the structure of MIT and DIT and couple them together.

When two DIT molecules are coupled together, a molecule of tetraiodothyronine, T4, or thyroxine, is produced.

The combination of one MIT with one DIT forms triiodythyronine, T3

Types of fluids for replacement therapy

• Ringer lactate
• 0.9 % sodium chloride
• 5% dextrose with 0.45% of sodium chloride
• 5% dextrose
• 3% sodium chlorid

ALTERNATIVE RESUSCITATIVE FLUIDS

• Hypertonic saline7.5%
• 5% albumin
• 25% albumin
• Dextran 40
• Dextran 70
• Hextand
• Hetastarch

Electrolyte abnormalities in specific surgical patients

NEUROLOGIC PATIENTS

• Syndrome of inappropriate secretion of anti diuretic hormone
• Diabetes insipidus

CANCER PATIENTS:

• Hyponatremia due to hypovolemia
• Hypernatremia due to diabetes insipidus
• Hypokalemia due to GIT loss of K due to diarrhea post radiation , post chemotherapy , due to villous adenomas of the colon
• Tumor lysis syndrome
• Hypocalcemia after surgery
• Hungry bone syndrome
• Hypercalcemia in malignancy