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-inguinal hernia repair operation
-2nd most common surgery on an infant
-Anterior Superior Iliac Spine
-easily palpable
Pubic Symphysis
-body of pubis resides in midline
-upper part of body forms a crest which is easily palpable
Pubic Crest
-structures attach to the tubercle and crest
Division of Abdomen into Quadrants
-draw median and transumbilical planes
1. Right upper Quadrant = liver
2. Left upper quadrant = spleen
3. Right lower quadrant = appendix
4. Left lower quadrant
Division of the Abdomen into 9 Regions
-draw 4 lines (Subcostal, transtubercular, midclavicular X2)
1. Umbilical region
2. Epigastric-superior to umbilical
3. Hypogastrium-hypogastric/internal iliac artery lies deep here
4. Left Hypochondriac-below/deep to costal cartilages
5. Right Hypochondriac
6. Lumbar Left
7. Lumbar Right
8. Left Inguinal/Iliac
9. Right Inguinal/Iliac
McBurney's Point
-diagonal line between umbilicus and ASIS
-half way along this line from ASIS is where vermiform appendis lies deep
Vermiform Appendix
-diverticulum from cecum
Linea Semilunaris
-lateral border of rectus sheath
-can be hernias along this semi-lunar line
Linea Transversa
-formed by tendinous inscriptions of the rectus abdominis muscle and depicts its segmentation
-responsible for "six pack"
-upper part of rectus abdominis attaches to xiphoid process and costal cartilages
Linea Alba
-bloodless line running through midline of abdomen
-subcutaneous fibrous band extending from xiphoid process to pubic symphysis
Inguinal Ligament
-inferior border of EAO aponeurosis
-extends from anterior superior iliac spine (ASIS) to pubic tubercle
-build up of fluid in peritoneum
Camper's/Fatty Fascia
-outer layer of superficial fascia of anterior abdominal wall
-present about inferior 1/4 of anterior abdominal wall
Scarpa's Layer/Membranous Layer
-inner layer of superficial fascia of anterior abdominal wall
-present about inferior 1/4 of anterior abdominal wall
What do the 3 intercostal muscles correspond to in the abdominal wall?
Fundiform Ligament
-vertically condensed part of Scarpa's fascia
-in male loops under penis
Transversalis Fascia
-deep to transversus abdominis muscle
-if you cut this open, you will encounter the peritoneum
x-tra Peritoneal Fatty Tissue
-fibrous tissue external to peritoneum
-also called Preperitoneal fat
External Abdominal Oblique
-tendon is unusual in that it is a flat, thinned out portion called an aponeurosis
-arises from the outer surface of the lower 8 ribs
-most of it is fibrous and forms a component of rectus sheath
-other fibers form the inguinal ligament which runs between the ASIS and pubic tubercle
-vertical fibers descend from the origin (lower 8 ribs) and attach to the anterior 1/2 of iliac crest
Internal Abdominal Oblique
-has wide origin
-arises from thoracolumbar fascia posteriorly and from lateral 2/3 of iliac crest
-most of its fibers pass medially to form a component of the rectus sheath
-other fibers ascend to attach to the lower 3 or 4 costal cartilages
-some fibers of the IAO arise from the lateral 2/3 of the inguinal ligament. this is not a bony origin but a ligamentous one. The fibers arch over and form a covering or roof of inguinal canal
Cremaster Muscle
- a continuation of the IAO as it covers the spermatic cord
Transversus Abdominis
-wide origin from ribs, thoracolumbar fascia, inguinal ligament
-most of the fibers form part of the rectus sheath
-other fibers arise from inguinal ligament
Semi-Lunar Lines
-demarcate the lateral borders of the rectus abdominis and rectus sheath
-extend from inferior costal margin near 9th costal cartilages to pubic tubercles
Acruate Line
-often demarcates the transition between the posterior rectus sheath covering the superior 3/4 of the rectus abdominis proximally and the transversalis fascia covering the inferior 1/4
-small triangular muscle lying in rectus sheath anterior to inferior part of rectus abdominis
-absent in 20% people
-ends in the linea alba and tenses it
Subcostal Plane
-passes through inferior border of 10th costal cartilage on each side
Transtubercular Plane
-passes through iliac tubercles and body of L5 vertebra
Midclavicular Planes
-pass from midpoints of clavicles to midinguinal points
Midinguinal Points
-midpoints of lines joining the anterior superior iliac spines and the superior edge of the pubic symphysis
Transumbilical Plane
-passes through umbilicus and IV disc between L3 and L4 vertebrae
Median Plane
-passes longitudinally through the body dividing it into right and left halves
Rectus Abdominis
-extends from pubic crest all the way to xiphoid process and lower 5ht-7th costal cartilages
-extends superiorly
Anterior Layer of Rectus Sheath
-formed by aponeurosis of EAO, IAO, and TA
-located in upper 3/4 of anterior abdominal wall
Median Umbilical Fold
-covers the median umbilical ligament
-essentially the Urachus
-covered w/ peritoneum
-attaches to apex of bladder and runs to umbilicus
-usually closes to form median umbilical ligament
Patent Urachus
will have urine running from umbilicus
Medial Umbilical Fold
-medial umbilical ligament lies deep to this (remnant of obliterated umbilical artery)
Lateral Umbilical Fold
-represents the fold of peritoneum covering the inferior epigastric vessels
Internal thoracic artery
-divides into musculophrenic artery and superior epigastric artery
-follows costal margin
Deep circumflex ilium artery
-anastamoses with intercostal and musculophrenic arteries
Musculophrenic artery
-branch of internal thoracic
-descends along costal margin
-supplies abdominal wall of hypochondriac region, anterolateral, diaphragm
Superior Epigastric artery
-branch of internal thoracic a.
-descends in rectus sheath deep to rectus abdominis
-supplies rectus abdominis and superior part of anterolateral abdominal wall
-anastamoses with inferior epigastric artery
Deep circumflex iliac
-runs on deep aspect of anterior abdominal wall, parallel to inguinal ligament
-supplies iliacus and inferior part of anterolateral abdominal wall
Inferior epigastric artery
-arises from external iliac artery just superior to inguinal ligament
-runs superiorly in transversalis fascia to enter rectus sheath inferior to acruate line
-branches enter lower rectus abdominis and anastamose w/ superior epigastric artery
Venous supply of anterior abdominal wall
-inferior epigastric vein
-superior epigastric vein
-paraumbilical veins
-thoracoepigastric vein
-lateral thoracic vein
(all tributaries to IVC of heart
Thoracoepigastric vein
-lies in middle between superficial epigastric vein and lateral thoracic vein
Watershed of Abdominal Wall
-one line across umbilicus
-superior to this line drains to axillary nodes
-inferior to the line drains to superficial inguinal lymph nodes, just inferior to inguinal ligament
Which thoracic ventral rami supply muscles of the anterior abdominal wall?
-lower 6
L1 ventral ramus
-divides into two nerves:
1. iliohypogastric
2. ilioinguinal
-these are the only two nerves that lie between EAO and IAO
What is a potential clinical correlation of cutting the L1 ventral ramus?
-the patient will lose sensation in the muscles in the inguinal region that provide protection to that region
-can result in direct inguinal hernia
Processus Vaginalis
-outpocketing or envagination of anterior abdominal wall that forms an indirect passageway through the anterior abdominal wall in the inguinal region beginning internally at the peritoneum and protruding it and the other layers of hte anterior abdominal wall in front of it
-end result is a cutaneous pouch, the walls of which are continuous with the abdominal walls
-forms the scrotum
Inguinal Canal
-region lying in between the internal ring and external ring
-initial 5 cm processus vaginalis
Obliterated processus vaginalis
-what is left after the peritoneum's two layers close off, approach one another, and obliterate in inguinal canal after descent of testes
Vaginal Tunic
-pinched off portion of peritoneal cavity after processus vaginalis is obliterated
Layers penetrated by processus vaginalis from superficial to deep
-transversalis fascia
Patent processus vaginalis
-when processus vaginalis doesn't close off like it is supposed to
-allows loops of intestines to extend down also and results inhernia
What percent of full term male babies have at least one undescended testis? premature male babies?
When does the peritoneum start to descend and the processus vaginalis start to form in the embryo?
-8th week
What level do the testes orgiginate from?
-T10-L1 spinal cord levels
-this is important--lance armstrong
What three layers of the anterior abdominal wall are extruded to form the three layers of the spermatic fascia?
-transversalis fascia
Layers of Processus Vaginalis and Scrotum
3. Transversalis fascia becomes INTERNAL SPERMATIC FASCIA
True or false: the transversalis muscle protrudes down into the scrotum
-the processus vaginalis occurs inferior to the transversus abdominus but the transversalis fascia is carried w/ processus vaginalis
Between which two layers do the testes lie?
-peritoneum and transversalis fascia in the extraperitoneal fatty tissue
Approximately when does the testicle drop into the scrotum?
~32 weeks
What causes the testes to descend?
-sex hormones
Gubernaculum testis
-fibromuscular cord that acts as a pilot and drags the testicle to where it is attaches
-if the gubernaculum attaches to somewhere besides the scrotum, the testicle will follow it to that other location
tunica vaginalis
-parietal layer internally lines the outer covering of the testis (parietal layer of original peritoneum)
-visceral layer covers the epididymis and testis (visceral layer of original peritoneum)
-visceral layer is transparent
Tunica Albuginea
-"white coat"
-white covering of testis that is seen through clear visceral layer of visceral tunica vaginalis
-sends connective tissue partitions down into testis to divide testis into lobules
seminiferous tubules
-lie in the lobules formed by tunica albuginea
-spermatozoa are produced and grow here
Mediastinal testis/rete testis
-coalescing of seminiferous tubules
-comma shaped structure
-has a head, tail, and body
-tail is confluent w/ vas deferens
-ducts from rete testis carry sperm here
-21 feet long, plenty of time to store and mature spermatozoa
Spermatic Cord
-represents those structures that are dragged by the testis during its descent
-has 3 arteries, veins, nerves, lymphatics, and duct
Ductus/Vas Deferens
-most posterior structure of spermatic cord
-what is cut to sterilize male
Pampiform Plexus of Veins
-venous plexus that eventually forms testicular vein
Testicular artery
-usually lies in middle of pampiform plexus of veins
-if disrupted, will result in necrosis of testicle
Genital branch of genitofemoral nerve
-supplies cremaster muscle
Where does lymph from the scrotum drain to?
-superficial inguinal lymph nodes
Where does lymph from the testicle drain to?
-paraaortic lymph nodes
Nerve supply to SKIN of scrotum
-spinal nerves coming from S2-S4
Nerve supply to TESTICLE
-around T11
Clinical correlation to innervation of testicle
-if there is a lesion between these two portions, you can pinprick the scrotum to determine where the lesion is
-if you pinprick the scrotum and it is not felt but pushing deeply on the scrotum causes pain in the testicle, the lesion lies between T11 and S2
-collection of fluid in testicle
-can be caused by an accident
-tunica vaginalis filled w/ fluid
Layers you have to go through to tap a hydrocele
1. skin
2. superficial (dartos) fascia which contains smooth muscle (dartos muscle)
3. continuation of Scarpa's layer
4. EAO continuation (external spermatic fascia)
5. cremasteric fascia
6. IAO continuation (internal spermatic fascia)
7. parietal layer of tunica vaginalis
Lateral crus
-part of inguinal canal that lies lateral to spermatic cord
-specialization of EAO aponeurosis
Medial crus
-lies medial to spermatic cord
-attaches to pubic symphysis and crest
Intercrural fibers
-fibers that connect the lateral and medial crura
-if these are cut then the inguinal ring is enlarged and there will be a larger incicence of hernia
Pyramidalis Muscle
-present in 80%
-small muscle in inferior part of rectus abdominis sheath
-supposed to be well developed in belly dancers
Where do the inferior epigastric muscles lie in relation to deep ring?
-the vessels are medial to the deep ring
What nerve passes through superficial inguinal ring?
Ilioinguinal nerve
Where does the iliohypogastric nerve end?
-in suprapubic skin
Ilioinguinal nerve
-passes through superficial inguinal ring
-branch of L1
-passes through inguinal canal and comes out to supply part of anterior scrotum and anterior labia
Conjoint Tendon
-where IAO and transverses abdominis muscle come together and form part of the posterior wall of the inguinal canal
Posterior wall of inguinal canal
-formed in part by conjoint tendon
What marks the beginning of the inguinal canal?
-deep inguinal ring
Lacunar Ligament
-the portion of the inguinal ligament that attach to the pectineal line posteriolateral to the tubercle
-helps form part of the floor of the inguinal canal
IAO arching fibers
-form roof of inguinal canal
-arise partioally from inguinal ligament
-when the arching fibers attach posteriorly they help form part of the posterior wall
Borders of Inguinal Canal
1. Floor = EAO aponeurosis (inguinal ligament)
2. Anterior wall = EAO aponeurosis
3. Posterior wall = transversalis fascia, reinforced medially by conjoint tendon
4. Roof = arching fibers of IAO and transversus abdominis
What feature of the inguinal canal is especially strong in females?
-conjoint tendon
Pectineal Ligament
-represents the lacunar ligament extended laterally along pectineal line
Hasselbach's Triangle
-area where DIRECT inguinal hernia occurs
1. Lateral = inferior epigastric
2. Inferior = inguinal ligament
3. Medial = lateral part of rectus abdominis
Where does an INDIRECT inguinal hernia occur?
-processus vaginalis or inguinal canal
What structure lies between the area where an direct inguinal hernia can occur and where an indirect inguinal hernia can occur?
-inferior epigastric vessels
-protrusion of a structure from where it normally belongs
-can be intestines or just fatty tissue
In an inguinal hernia what is the hernial sack made of?
What is a hernia that can be pushed back to where it's supposed to go described as?
-a REDUCIBLE hernia
What is a hernia that can't be reduced but blood vessels are not cut off described as?
What is an incarcerated hernia that has an impinged blood supply described as?
What does the processus vaginalis form in females?
-labia major

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