The document discusses the anatomy, physiology, and surgical pathology of the abdominal wall and umbilicus. It describes the layers of the abdominal wall, muscles, fascia, nerves and blood vessels. It also discusses the inguinal canal, femoral canal, spermatic cord, and umbilicus. It covers the functions of the abdominal wall and pathological conditions like hernias and issues related to the umbilicus.
The document discusses the anatomy, physiology, and surgical pathology of the abdominal wall and umbilicus. It describes the layers of the abdominal wall, muscles, fascia, nerves and blood vessels. It also discusses the inguinal canal, femoral canal, spermatic cord, and umbilicus. It covers the functions of the abdominal wall and pathological conditions like hernias and issues related to the umbilicus.
The document discusses the anatomy, physiology, and surgical pathology of the abdominal wall and umbilicus. It describes the layers of the abdominal wall, muscles, fascia, nerves and blood vessels. It also discusses the inguinal canal, femoral canal, spermatic cord, and umbilicus. It covers the functions of the abdominal wall and pathological conditions like hernias and issues related to the umbilicus.
The document discusses the anatomy, physiology, and surgical pathology of the abdominal wall and umbilicus. It describes the layers of the abdominal wall, muscles, fascia, nerves and blood vessels. It also discusses the inguinal canal, femoral canal, spermatic cord, and umbilicus. It covers the functions of the abdominal wall and pathological conditions like hernias and issues related to the umbilicus.
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DR KYAING THWIN MIN
PG-1 (UROLOGY)
ANATOMY, PHYSIOLOGY & SURGICAL
PATHOLOGY OF ABDOMINAL WALL & UMBILICUS
1 SYNOPSIS
Anatomy of abdominal wall
Physiological importance Surgical pathology
2 ANATOMY
3 LAYERS OF ABDOMINAL WALL
1. Skin 2. Subcutaneous tissue 3. Superficial fascia 4. External oblique muscle 5. Internal oblique muscle 6. Transversus abdominis muscle 7. Transversalis fascia 8. Preperitoneal adipose and areolar tissue 9. Peritoneum 4 FASCIA
No deep fascia over the trunk
In lower abdomen Superficial fatty (Camper fascia) continuous with the superficial fat of the rest of the body Deeper fibrous (Scapa fascia) bends with the deep fascia of the upper thigh Extends into penis, scrotum, perineum (Colles)
5 Colles’ fascia
Attached behind to the perineal body & posterior margin of the perineal membrane
Laterally to the rami of the pubis & ischium
6 MUSCLES
Rectus abdominis Origin – 3in (7.5cm) horizontal line from 5th, 6th & 7th costal cartilage Insertion – 1in (2.5cm) into pubic crest Transverse tendinous intersections (3 constant) • At the tip of xiphoid • At umbilicus • Halfway between the two • Below umbilicus (sometimes 4th)
7 Tendinous intersections adhere to the anterior rectus sheath Rectus muscle is completely free behind At each intersection, vessels from superior epigastric artery & vein pierce the rectus
8 External oblique aponeurosis Origin – outer surfaces of lower 8th ribs Insertion – fans out into xiphoid, linea alba, pubic crest, pubic tubercle, anterior half of iliac crest From pubic tubercle to anterior superior iliac spine – lower border forms the aponeurotic inguinal ligament of Poupart Fibers run downwards & forwards
9 Internal oblique aponeurosis Origin – from lumbar fascia, anterior two-thirds of iliac crest & lateral two-thirds of inguinal ligament Insertion – the lowest 6 costal cartilages, linea alba, pubic crest Fibers run upwards & forwards Right angle to external oblique
10 Transversus abdominis Origin – from lowest 6 costal cartilages (interdigitating with diaphragm), lumbar fascia, anterior two- thirds of iliac crest & lateral one-third of inguinal ligament Insertion – linea alba, pubic crest (via conjoint tendon) Fibers run transversely
11 12 13 14 NERVE SUPPLY
Segmental nerve supply (abdominal muscles & overlying skin – from T7 to L1
• Rectus & ext; oblique – by lower 6 thoracic nerves • Int; oblique & transversus – by lower 6 thoracic nerves + iliohypogastric + ilioinguinal nerves Umbilicus – supplied by T10 Groin & scrotum – by L1
15 INGUINAL CANAL
Oblique passage in lower abdominal wall
From deep to superficial inguinal ring ~4cm long Transmits the spermatic cord & ilioinguinal nerve in male Transmits the round ligament & ilioinguinal nerve in female
Camper’s fascia Scarpa’s fascia Above External oblique aponeurosis Lower arching fibers of internal oblique & transversus
Internal oblique in lateral third of canal
Below Lower recurved edge of external oblique i.e. inguinal ligament 17 Superficial inguinal ring • V-shaped defect in inguinal ligament • Lies above & medial to pubic tubercle
Deep inguinal ring
• Defect in transversalis fascia • 1 cm above midpoint of inguinal ligament • Immediately lateral to inferior epigastric v/s
18 SPERMATIC CORD
3 layers of fascia External spermatic – from external oblique Cremasteric – from internal oblique Internal spermatic – from transversalis fascia
3 arteries Testicular – from aorta Cremasteric – from IEA Artery of the vas – from inferior vesical artery
19 3 veins Pampiniform plexus of veins – drain Rt testis into IVC, Leftestis into Left renal vein) Cremasteric vein – accompany the artery Vein of the vas – accompany the artery
3 nerves Nerve to the cremaster – from genitofemoral nerve Sympathetic fibers (T10-11) Ilioinguinal nerve
20 3 other structures Vas deferens Lymphatics of the testis Processus vaginalis
21 FEMORAL CANAL
Lies medial to femoral vein within femoral sheath
Upper (abdominal) opening of the femoral canal is the femoral ring Contains loose areolar t/s & L/N of Cloquet
Functions Dead space for expansion of femoral vein Pathway for lymphatics of lower limb to external iliac nodes
23 PHYSIOLOGY
24 FUNCTIONS
Abdominal wall is a complex structure primarily of muscle, bone & fascia
Major To protect the enclosed organs of GIT & UT Secondary Mobility – able to flex, extend & rotate Flexibility requires elasticity & stretch (which compromise abdominal m/s wall strength)
25 ABDOMINAL PRESSURE
Positive pressure Drains (to allow intra-abdominal fluids & contents outwards down the pressure gradient) Abdominal hernia (forced outwards through muscle wall defects / pressure gradient)
Bulging of part of the contents of the abdominal cavity through a weakness in the abdominal wall Natural weakness – lumbar triangles & posterior wall of inguinal canal Many structures pass in & out the abdominal cavity making hernia formation Failure of normal development weakness of abdominal wall Inguinal hernia – development failure of processus level Diaphragmatic hernia Umbilical hernia Epigastric hernia
28 Abdominal muscles weakness by sharp trauma • Abdominal surgery, stabbing Surgical scar with perfect wound healing – 70% of initial m/s strength Herniation in at least 10% of surgical incisions Muscle damage by blunt trauma or abdominal m/s tear (rare) Primary m/s pathology & neurological conditions muscle weakness
29 30 PATHOPHYSIOLOGY OF HERNIA
Normal abdominal has sufficient strength to resist high abdominal pressure
Herniation due to high pressure (constipation, excessive cough, obesity, . .) Hernia is a “collagen disease” • Due to an inherited collagen imbalance Hernia – more common in pregnancy • Due to hormonally induced laxity of pelvic ligaments
More common in smoker Less common in obesity • Hernia risk is negatively related to BMI
32 COMMON PRINCIPLES IN ABDOMINAL HERNIA
Two essential components
1. Defect in the wall
2. Content The weakness – the narrowest part of the hernia expands outside the muscle The defect varies in size Nature of the defect is important for hernia complication Small defect, rigid wall contents can’t freely move complications
33 COMMON PRINCIPLES (CONT.)
Contents may be tissues from extraperitoneal space
Fat within epigastric hernia Urinary bladder in direct hernia Hernia enlarged pulled the peritoneum into hernia secondarily with intraperitoneal structure Mostly, intraperitoneal organs can move freely in & out ‘reducible’ hernia Adhesions or small defect trapped ‘irreducible’ hernia The narrow neck constriction ring impending venous return & pressure in hernia Pain & tenderness
34 Hernia contains bowel “obstructed” partially of totally If pressure arterial blood can’t enter the hernia ischemic & infarct “strangulated” Bowel wall perforates & release infected, toxic contents into tissue & back to peritoneum
Passes through the internal (deep) ring, along the canal
Emerges through the external (superficial) ring Remain within inguinal canal – bubonocoele Protrude through the superficial ring – funicular Extend into the scrotum – complete or scrotal Occasionally, hernia between m/s of abdominal wall – interstitial hernia
37 DIRECT INGUINAL HERNIA
Due to weakness of abdominal wall & precipitated by intraabdominal pressure
Passes through a weakness in the transversalis fascia in the Hesselbach’s triangle area
Hernia occasionally bulges through superficial ring
But transversalis fascia cannot stretch sufficiently to descend into scrotum
Severe pain in the groin area, extending into scrotum & upper thigh
Young men who played football & rugby
O/E – tenderness in the region of inguinal canal
Usually no hernia can be felt
Can be d/t muscle tearing (Gilmore’s groin) or stretching of the posterior wall of inguinal canal
42 FEMORAL HERNIA
Less common than inguinal hernia
Female > male Femoral ring is narrow & lacunar ligament forms a ‘sharp’ medial border Easily missed on examination Irreducibility & strangulation are more common
Appears within a few weeks of birth Symptomless, but size increase with crying Most resolve spontaneously In adults, cause stretching & thinning of midline raphae (linea alba) The defect is rounded with well defined fibrous margin Small umbilical hernia contains extraperitoneal fat or omentum Large hernia contains small or large bowels The neck of sac is narrow irreducible, obstructed & strangulated
46 EPIGASTRIC HERNIA
Arise through the midline raphe (linea alba) between the xiphoid & umbilicus Close to the umbilicus --- supraumbilical hernia Variable, up to large defects Most frequently contains only pre-peritoneal fat Moderate risk of strangulation
47 INCISIONAL HERNIA
Through a defect in the musculofascial layers of abdominal wall
In the region of post operative scar Incidence 10-15% after surgery Due to patient, wound & surgeon factors Wide variation in size Obstruction is common but strangulation is rare Classic sign of wound disruption is serosanguineous discharge Open & laparoscopic repairs possible
48 SPIGELIAN HERNIA
Uncommon Most common in elderly Defect in the spigelian fascia Mostly appear below the level of umbilicus near the edge of the rectus sheath Often misdiagnosed High risk of complications
49 LUMBAR HERNIA
Primary lumbar hernia occur through the inferior lumbar triangle of Petit Less commonly, through the superior lumbar triangle Primary lumbar hernias are rare Mimicked by incisional hernia (renal operations, bone grafts harvested from iliac crest)
50 PARASTOMAL HERNIA
>50% rate of parastomal hernia
51 TRAUMATIC HERNIA
Non-anatomical defects caused by injury
3 types Hernia through abdominal stab wd sites Hernia protruding splits or tears in abdominal muscles a/f blunt injury Secondary to m/s atrophy(nerve injury / traumatic denervation)
54 Abdominal compartment syndrome Due to harmful effect of high intra-abdominal pressures
High pressure leads to reduced blood flow & ischemia multiorgan failure
Tension releasing incision / fasciotomy is suggested
Laparostomy
55 NEOPLASM OF THE ABDOMINAL WALL
Desmoid tumour Hamatoma More common in women Fibroma possibly the result of repeated trauma Reported in FAP
Fibrosarcoma Occur anywhere in the body Highly malignant, poorly respond to both RT & chemo Wide excision + plastic surgery 56 UMBILICAL PATHOLOGIES
Chronic infection Poor hygiene Obese people Paraumbilical hernia Due to a plug of keratin causing chronic irritation Bacteria + fungi involved
57 Chronic fistula Present with persistent discharge from umbilical area
d/t superficial infection or infected epidermoid cyst within umbilicus
Fistulous connection to deeper structures
Complication of umbilical hernia repair (chronic infection of mesh or around non-absorbable suture)
58 Patent urachus Connection between urinary bladder & umbilicus d/t increased pressure in the bladder (obstruction by BPH)
Malignancy at the umbilicus
Primary squamous carcinoma may occur If tumour at umbilicus, most probably d/t spread from internal organs along the ligament Sister Joseph’s nodule Indicates very advanced malignant disease
