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contents of inguinal canal
- spermatic cord or round ligament
- ilioinguinal nerve
-
inguinal canal borders
- inferiorly: inguinal ligament
- anteriorly: external oblique aponeurosis
- posteriorly: transversalis fascia
- superiorly: arching fibres of internal oblique and tranversus abdominis
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deep inguinal ring
- tubular evagination of transversalis fascia
- where spermatic cord or round ligament emerge from abdomen
- midway between ASIS and pubic tubercle, lateral to inferior epigastric vessels
-
superficial inguinal ring
- triangular opening in aponeurosis of external oblique muscle above and lateral to pubic tubercle
- folds of external oblique aponeurosis form external spermatic fascia which covers spermatic cord
-
femoral canal borders
- superiorly: inguinal ligament
- medially: lacunar ligament
- laterally: femoral vessels (NAVY) so femoral vein
- inferiorly: pubic ramus
-
what forms the conjoint tendon and what is it continuous with?
- formed by fusion of aponeuroses of internal oblique and transversus abdominis
- continuous with cremasteric fascia
-
continuation of transversalis fascia in the scrotum?
internal spermatic fascia
-
continuation of extraperitoneal fat in scrotum?
areolar connective tissue
-
layers covering testicles and their abdominal equivalents)
- tunica albuginea
- tunica vaginalis (parietal peritoneum)
- areolar connective tissue (extraperitoneal fat)
- internal spermatic fascia (transversalis fascia)
- cremasteric muscle (internal oblique and transversus abdominis aponeuroses/conjoint tendon)
- external spermatic fascia (external oblique aponeurosis)
- dartos muscle (membraneous Scarpa's fascia)
- skin (skin)
-
direct inguinal hernia
- herniation of bowel through weak point in lower abdominal wall fascia: inguinal triangle
- medial to inferior epigastric artery
- most common in elderly men
-
indirect inguinal hernia
- herniation of bowel through inguinal canal vai deep inguinal ring and out through superficial inguinal ring
- lateral to inferior epigastric artery
- most common in males because the inguinal canal is more prominent than in women
-
femoral hernia
- herniation of bowel through femoral canal
- more common in women than men because women have wider hips
- prone to strangulation due to narrow opening
-
congenital hernia
persistence of processus vaginalis between peritoneum and tunica vaginalis
-
pantaloon hernia
simultaneous direct and indirect hernias forming a pantaloon like shape due to inferior epigastric artery separating them
-
omentocoel
hernia of the omentum
-
clinical test to differentiate direct and indirect hernias
- gently press on deep inguinal ring (midway between ASIS and pubic symphysis) and ask patient to stand and cough to increase intraabdominal pressure
- if indirect: will not bulge out
- if direct: will still bulge medial to deep inguinal ring
-
indirect hernia treatment
- usually laparascopic or inguinal incision access to peritoneal cavity
- return bowel to peritoneal cavity and close off the deep inguinal ring
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contents of spermatic cord
- ductus deferens
- testicular artery
- pampiniform plexus of veins
- genital branch of genitofemoral nerve
- sympathetic nerves
- cremaster muscle
- lymphatics
-
drainage of gonadal (testicular and ovarian) veins
- R to IVC
- L to L renal vein
-
gonadal sensory afferents
- postganglionic sympathetic nerves travel with gonadal arteries from preaortic plexus
- cell bodies of sensory afferents travelling with these fibres are in the DRG at T10 level
- umbilical area referred pain e.g. mittelschmertz
-
vasectomy incision and procedure
- bilateral longitudinal incisions at neck of scrotum to gain entry into spermatic cord
- tie ductus deferens
-
ligaments of anterior abdominal wall
- median umbilical ligament: contains urachus, the fibrous remnant of allantois (fold of endoderm/yolk sac)
- medial umbilical ligament: contains fibrous remnant of umbilical arteries
- lateral umbilical ligament: contains inferior epigastric vessels
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anatomical factors preventing gastroesophageal reflux
- LAMP
- LES: formed by thickening of esophageal circular muscle and R crus of diaphragm contracts with inspiration and increased intraabdominal pressure closing the lower esophagus off from the stomach
- angle: at which the esophagus enters the stomach
- mucosa: mucosal folds at the cardia
- pressure: intraabdominal component of esophagus is under increased
- pressure when there is increase in intraabdominal pressure, tending to close it
-
surface anatomy of liver
- between ribs 7-11 MAL
- inferior margin palpable 1-2cm below costal margin on inspiration
- upper border reaches 5th rib MCL on expiration
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retroperitoneal organs of the abdominal cavity
distal 3/4 of duodenum, pancreas, ascending colon (excluding cecum, appendix), descending colon, rectum, kidneys, suprarenal glands
-
crc commonest sites and associated symptoms
- 1. ascending colon (30%): occult bleeding, anemia
- 2. sigmoid (25%): obstruction, overt bleeding
- 3. rectum (20%): tenesmus, pain, bleeding
-
borders of epiploic foramen
- anteriorly: hepatoduodenal ligament (portal triad)
- posteriorly: IVC
- superiorly: liver (caudate)
- inferiorly: duodenum
-
components of lesser omentum
- hepatoduodenal ligament (contains portal triad)
- hepatogastric ligament
- gastrosplenic ligament
- splenorenal ligament
-
pathway of bile storage and release
- hepatocytes
- bile canaliculi
- biliary ducts
- R/L hepatic ducts
- common hepatic duct (within portal triad)
- cystic duct
- gallbladder (storage)
- cystic duct
- common bile duct
- hepatopancreatic ampulla (w sphincter of oddi around major duodenal papilla)
- duodenum
-
celiac trunk level and branches
- T12
- left gastric
- common hepatic
- splenic
-
left gastric artery
- branch of celiac trunk
- forms anastomoses with right gastric artery (branch of common hepatic artery)
- gives off lower esophageal branches to intraabdominal esophagus
-
common hepatic artery
- branch of celiac trunk with four main branches
- right gastroduodenal artery: branches further into right gastroepiploic artery which anastomoses with left gastroepiploic artery, branch of splenic artery; and suprerior pancreaticoduodenal artery
- right gastric artery: anastomoses with left gastric artery
- hepatic artery proper: enters liver as part of portal triad and forms terminal branches of common hepatic artery, the R/L hepatic arteries
- cystic artery: branch of right hepatic artery
-
splenic artery
- branch of celiac trunk which has two main branches
- left gastoepiploic artery: anastomoses with right gastroepiploic artery, branch of common hepatic artery
- short gastric arteries: to the fundus
-
hepatobiliary triangle borders
- cystic duct
- common hepatic duct
- inferior surface of liver
-
hepatic artery variation
usually arises from common hepatic artery of celiac trunk but in 15% of population arises from SMA
-
gastric arteries
anatomoses of left and right gastric arteries on the lesser curvature of stomach
-
gastroepiploic arteries
anastomoses of left and right gastroepiploic arteries on the greater curvature of stomach
-
celiac trunk supplies
foregut: intraabdominal esophagus to major duodenal papilla
-
SMA supplies
midgut: major duodenal papilla to proximal 2/3 transverse colon
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IMA supplies
hindgut: distal 1/3 transverse colon to anal canal
-
duodenal ulceration site and cause
- site: superior (first) part of duodenum most common
- cause: H pylori infection or NSAID use
-
complications of duodenal ulceration
- perforation
- anteriorly: acute peritonitis
- posteriorly: erosion of gastroduodenal artery leading to hematemesis or melena
-
venous drainage of GIT
SMV drains into splenic vein which drains into IMV to form the portal vein
-
portosystemic anastomoses sites
- risk of haemorrhage in portal hypertension
- esophagus: esophageal varices and haematemesis
- rectum: haemorrhoids
- paraumbilical: caput medusae
-
esophageal portosystemic anastomosis
upper esophagus is drained by azygos vein which has anastomoses with left gastric vein which drains the lower esophagus
-
DDx enlarged spleen
- portal HTN
- haematological disorder
- infection
- malignancy
-
-
vertebral level renal and gonadal arteries
L2
-
-
vertebral level aortic bifurcation
L4
-
commonest appendix positions
- retrocecal
- pelvic
- others include preileal, postileal and subcecal
-
differences between jejunum and ileum
- wall thickness: thinner distally
- blood supply: distally, shorter vasa recta (smaller boxes) and more arcades (anastomoses) to increase redundancy in high strangulation risk area
- plicae circularis: more proximally, in jejunum
- mesenteric fat: more distally, in ileum
- lymphoid tissue: more distally, in ileum (Peyers patches)
-
features of colon
- taenia coli: longitudinal muscular band
- haustra: sacculations
- appendices epiploicae: fatty tags
-
lymphatic drainage of GIT
- follows arterial supply central pre aortic nodes around the arterial branch
- foregut: celiac central nodes
- midgut: superior mesenteric central nodes
- hindgut: inferior mesenteric central nodes
- all drain into intestinal trunk which collects into cisterna chyli (T12/L1), thoracic duct, L subclavian vein
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visceral nerve plexuses of abdomen
- celiac: supply foregut (T6-9, referred pain to epigastrium)
- SM: supply midgut (T8-T10, referred pain to umbilicus)
- aorticorenal: around the paired parietal branches renal and gonadal, supplying suprarenal glands, kidneys, gonads (T10-L2)
- IM: supply hindgut (T11-S4, referred pain to suprapubic area)
-
visceral nerve plexus components
- sympathetic and parasympathetic visceral motor fibres
- sympathetic ganglia
- visceral afferent sensory fibres
-
visceral nerve inputs
- vagus nerve parasympathetic innervation (major)
- thoracolumbar paravertebral ganglia of sympathetic trunk
- thoracic sympathetic greater, lesser, least splanchnic nerves
- some pelvic parasympathetic splanchnic nerves
-
visceral sensory fibres
- conscious: run with sympathetic fibres via dorsal root, DRG, dorsal horn, afferent pathway (spinothalamic tract)
- unconscious: run with parasympathetic fibres
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