Anatomy 4.

Nov 22, 2011

Dr. Zorba Bnn Bautista

Surgical Correlation-Abdomen
OUTLINE
I. Abdomen
II. Case 1
III. Case 2
IV. Meckels Diverticulum
V. Case 3
VI. Case 4

I. ABDOMEN
a temple of surprises because a patient can come to you with
many complaints and could cause tons of sickness
4 Quadrants of the Abdomen

MOST COMMON COMPLAINT IN THE ABDOMINAL AREA

Pain
o P Point of maximal pain.
o Q Quality (stabbing, burning, squeezing)
o R Radiation( steady in one area? Or a shooting pain in other
parts of the body?)
o S Severity (starts the way it is now, starts with less pain,
slowly increasing)
o T Timing (occur spontaneously, after eating, etc)
Fullness/ Enlargement

Feces
Flatus
Fetus
Fatal Masses

Tae
Tot
Tao
Tumor

Masses
o Size
o Location

Blood supply
o Upper viscera (stomach, liver, pancreas, spleen): Celiac
Trunk
o Small and large intestines: Superior Mesenteric Artery
o More distal portion of large intestine: Inferior Mesenteric
Artery
The lymphatics follow the course of the arteries.
Figure 1. Specific organs found at the 4 quadrants of the abdomen

o Most common manner of describing abdominal areas clinically

o Areas point to specific organs or organ systems, aiding in
narrowing down the diagnosis or working impression
o Ex. Right lower quadrant pain
Young individual- appendicitis
Ureters- symptom/ stone in ureters
Right ovaries
9 Regions of the Abdomen
o Less commonly used
o Frequent among Surgeons/ Ob-Gyns
o Further narrows down involved organ systems
o Ex. Sinisikmura ako, Doc- epigastric area;
Masakit puson ko- neither the left or right lower quadrant
but in the hypogastric area

ESSENTIALS OF CLINICAL DIAGNOSIS

Understanding the main complaint
Complete history of the condition
o Onset Course Aggravating Factors
o Past History/ Other medical conditions
o Family history
o Menstrual history (Important in Women)
Physical Examination
APPLICATION OF KNOWLEDGE OF ANATOMY & PHYSIOLOGY
Group 3| Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo

o Consistency (hard, soft, w/ or w/o fluid)

Stony hard like your knuckle: stone, malignant tumor
firm benign tumor
o Tenderness signs of infection or abscess formation
Ballotment is it movable? if you palpate the abdomen, and it
bounces back to your fingers- its movable- meaning its attach or
not fixed to anything underneath.

II. CASE # 1
PATIENT HISTORY
MT/ 16y/o F
CC: Abdominal Pain
HPI:
o 12 Hrs PTA
Epigastric Pain
No Vomiting/ Fever
o 8 Hrs PTA
Localized to RLQ area
Past Med Hx & Family Hx unremarkable
Menstrual Hx:
st
o Presently menstruating (1 day)
o Menarche: 12y/o
o Regular menses
o Denies any Hx of sexual contact

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PERTINENT PE FINDINGS
BP= 100/80 (normal); CR=110bpm (increased); afebrile
Pale palpebral conjunctivae
Abdomen: Flat, soft but with voluntary guarding
o (+) direct & rebound tenderness over ALL quadrants
o tenderness: when direct pressure is applied, there is pain
o rebound: when the pressure is released, the internal organs will
return to their original position
o rebound tenderness indicates peritoneal irritation
(+) R pararectal tenderness
o when a finger is inserted inside the rectum, and tenderness is felt
inside
Pulses thready
o pulses that can be compressed;
a scarcely perceptible and commonly rapid pulse that feels like a
fine mobile thread under a palpating finger

IMPRESSIONS
Acute Appendicitis
acute inflammation of the appendix usually caused by hyperplasia
of lymphatic follicles (in young people) that occlude the lumen or
obstruction resulting from a fecalith (in older people), a
concretion that forms around a center of fecal matter. (Moore)
probably ruptured because there is tenderness in all quadrants
if is not ruptured, then there should only be pain in the right
upper quadrant

Structures you will pass as you make an incision: (1) skin, (2)
subcutaneous: Campers fascia (Fatty layer), Scarpas fascia
(membranous layer), (3) external oblique aponeurosis
(inferomedial) (4) internal oblique, (5) preperitoneal fat
(sometimes present, sometimes not), (6) peritoneum
Incision should be done along the orientation of the muscle fibers
so as not to weaken the muscle.
PERITONEUM: needs to be sutured so small and large intestines
will not adhere to the muscles above it.
INTERNAL OBLIQUE: do not suture because you will strangulate
the muscle and it will hurt as the patient moves post-op; the
muscle fibers will co-uptake by themselves
EXTERNAL OBLIQUE: completely suture, should be tightened just
enough for the muscle fibers to co-uptake
SUBCUTANEOUS TISSUE: it depends whether the patient has many
fats or not, nevertheless,
*Dr. Zorba sutures all patients, whether fat or thin usually in the
Scarpas. (HAHA! Infrnez, kuhang kuha!)
DO NOT go to the root of the appendicial artery because the
ileocolic valve might be injured.

PLAN
Exploratory Laparotomy
Midline incision: less infection and less probability of the wound to
open
Appendectomy
surgical removal of the appendix through a transverse incision
along the McBurney point. (site of maximal pain and tenderness
indicates actual location)
Laparoscopic appendectomy
o standard procedure to remove appendix.
o Peritoneal cavity is first inflated with carbon dioxide to distend
abdominal wall laparoscope is passed through small incision
in the anterolateral abdominal wall 2 small incisions required
for surgical instrument to pass through to access the appendix
and related vessels
Other possible incisions:
Rocky Davis (vertical incision)
-can hide scar under the strap of panties
McBurneys Incision
o McBurneys Point -line drawn from the ASIS to the umbilicus.
-serve as a guide as to where you will
make an incision.

Figure 2. Appendectomy Procedure

CLASSICAL APPENDECTOMY INCISION

Appendectomy Procedure
Find the taenia. Then, follow the taenia proximally, this will lead
you to the appendix.
Appendix is completely covered with longitudinal muscle where
the 3 taenia converge, normally less than a centimeter in
thickness, same color with small bowel
Mesoappendix: mesentery of the appendix, The short mesentery
of the appendix lying behind the terminal ileum, blood vessel are
present
Group 3|Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo

Figure 3. Port Placement for Laparoscopy Apparatus

*no need to cut a muscle layer, you just simply go through them
(only split open the layers)
*bipolar coagulated instrument- closes blood vessels; creates heat
and electric current that could injure the ileocolic.
Note: Appendicial arteries carry a lot of pressure

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FINDINGS

FINDINGS

400ml sero- sanguinous peritoneal fluid; non-foul (not

contaminated with intestinal bacteria)
Dilated bowel loops w/ areas of gangrene
Constricting band noted at distal ileum adherent to posterior wall
3.5cm long Meckels Diverticulum w/ 1.5cm base noted 50cm
proximal to ileo-cecal valve
Firm congested appendix with fecalith near base
2 landmaks in measuring lesions In the small intestines: (1)
ileocecal valve, (2) ligament of Trietz

RUPTURED ECTOPIC PREGNANCY

1.5 Liters of Blood and blood clots
Slightly inflamed appendix
R fallopian tube w/ rupture at midpoint; (+) areas of necrosis and
persistent bleeding

PROCEDURE DONE

Exploratory Laparotomy
Evacuation of hemoperitoneum
R Salphingo-oophorectomy
Appendectomy

III. CASE # 2

OPERATION PERFORMED
Exploratory laparotomy;
Segmental ileal resectioning with EEA
Appendectomy

PATIENT HISTORY
G.S. 23M from Pasig City
CC: Abdominal Pain
History of the Present Illness
o 6 days PTA

Abdominal pain

Self-Med: Novaluzid
o 4 days PTA

Persistent Vomiting

Cx: UTI

Rx: Co-Trimoxazole
o 2 days PTA

Vomiting

Abdominal Distension

Admitted

Dx: Ileus
o AM PTA

Transferred to PCGH

ADMITTED
ROS : Unremarkable
FAMILY HISTORY: Unremarkable
PAST MEDICAL HISTORY: Unremarkable

PERTINENT PE FINDINGS
BP: 110/70 (normal)
CR:112 (increased)
RR: 24 (increased due to the distended stomach; the patients
breathing is shallow, short and thus he needs to increase the
frequency)
T: 38.2C (febrile)
Pinkish Conjunctivae, Anicteric Sclerae
Clear and equal breath sounds
Tachycardic; distinct heart sounds
Abd: Distended; Absent BS; Firm but w/o guarding; (+) Direct and
Rebound tenderness all quadrants
No deformities, full and equal pulses
Admitting Impression
Acute Abdomen prob.2 to Acute Appendicitis, probably ruptured
(neglected?)

PLAN
Exploratory Laparotomy
Possible Appendectomy

Group 3|Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo

IV. MECKELS DIVERTICULUM/ILEAL DIVERTICULUM

a remnant of the proximal part of the embryonic omphaloenteric
duct (yolk stalk), the diverticulum usually appears as a finger-like
pouch (Moore)
An inflamed ileal diverticulum may produce pain similar to that
produced by appendicitis (Moore)
True diverticulum has all three layers of bowel: muscularis,
mucosa, submucosa; outpouchings of the mucosa through a
weakness in the muscularis
False diverticulum outpouchings in the mucosa thru the
weaknessof the muscularis; has only two layers: mucosa and
serosa

EPIDEMIOLOGY

Most common congenital GI anomaly

2% of general Population
3:2 male to female ratio
True diverticulum
Within 100cm of ICV
60% contain heterotopic mucosa
60% Gastric mucosa

CLINICALLY PRESENTATION

Usualy asymptomatic
4% complication rate
More than half are < 10 years old
Common Presentations
Bleeding (>50%) - pediatric
Intestinal obstruction - adult
Diverticulitis ( 20%)

PATHOPHYSIOLOGY
Results from failure of complete obliteration of Omphalomesenteric (Vitelline) duct
May or may not have a fibrous band to the umbilicus(Vitelline
duct) or to the root of the mesentery (L Vitelline Artery)
Bleeeding
o Heterotopic Gastric Mucosa
o Ulceration of adjacent ileal mucosa
Intestinal Obstruction:
o Volvulus of the intestine around a fibrous band to the umbilicus
o Entrapment by mesodiverticular band
o Intussusception

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o Stricture formation of a chronic diverticulitis

Diverticulitis:
o Obstruction of a narrow-based Meckels diverticulum
o Diagnosis:
o Largely clinical
Imaging:
o Enteroclysis (75% yield)
o CT scan very low yield
o Radionuclide scans detect ectopic gastric mucosa
o Angiography may show extravasation into small intestine

TREATMENT

Figure 4. Laparoscopic and Open Cholecystectomies

Surgical
Segmental ileal resection
Wedge resection/ Diverticulectomy
Incidental resection controversial
Pros presence of bands narrow base

V. CASE # 3
PATIENT HISTORY
NS; 43y/o F
CC: RUQ pain
HPI: Intermittent crampy RUQ pain occurring within an hour after
meals. Waxes and wanes within a 2 hour period then resolves.
Symptoms started 2wks ago.

Figure 5. Types of Incisions: (1.)classical cholecystectomy), (2) laparoscopic

cholecystectomy, (3) single incision laparoscopic surgery

PERTINENT PE FINDINGS
Abdomen: flabby, NABS, soft
(+) direct ROQ tenderness
No Murphys Sign
Murphys Sign -performed by asking the patient to breathe out
and then gently placing the hand below the costal margin on the
right side at the mid-clavicular line (the approximate location of
the gallbladder). The patient is then instructed to breathe in.
Normally, during inspiration, the abdominal contents are pushed
downward as the diaphragm moves down. If the patient stops
breathing in (as the gallbladder is tender and, in moving
downward, comes in contact with the examiner's fingers) and
winces with a 'catch' in breath, the test is considered positive.
Abdominal Ultrasound: Distended GB; Non-thickened wall;
Multiple High-level echoes w/ posterior acoustic shadows (seen as
the soundwaves during an ultrasound comes in contact with hard,
solid structures, as in gall stones or cholelithiasis, and kidney
stones; if the soundwaves comes in contact with soft tissues only,
what is seen in the ultrasound are static projections)

VI. CASE # 4
PATIENT HISTORY

IMPRESSION AND PLAN

Impression: Chronic Calculous Cholecystitis (Inflammation of the
gallbladder)
Plan: Cholecystectomy - removal of the gallbladder (right hepatic
st
artery must be located 1 before ligation of the cystic artery)

Group 3|Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo

EA, 38M, Pasig City

CHIEF COMPLAINT: HEMATOCHEZIA (fresh blood in the stool)
HISTORY OF THE PRESENT ILLNESS:
1 DAY PTA
o Bloody stools (2 episodes)
Day of admission
o 1 episode
o Hematochezia
o Sudden weakness
ADMITTED
On Admission:
o BP: 70/50 (increased)
o CR: 120s (increased)
o RR: 20
o Afebrile
o Abd: non surgical, no masses
o Double line
o NGT, FC
o Blood works
o Hgb: 86 (decreased)
o Hct: .25 (decreased)
o Had an episode of hematocheia (fresh blood in stool) on
admission
o VS the same
o Transfusion of 3 units PRBC
o 5 liters of crystalloids in 24h
o Kept on NPO w antacids
nd
2 HD
o No hematochezia

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o BP: 100/60
o CR: 90s
RR: 20s
o Pale conjunctivae and skin
o Repeat Hgb: 97
o Hct: .28
o Abd: flabby, soft, Hyperactive BS, soft, Non-tender, no masses
o DRE: tight sphincter; (+) tarry material on tactating finger
rd
3 HD
o No hematochezia in am; stable VS
o Maintained on conservative management
o 8pm: hematochezia ~ 350 ml
o NO abdominal pain
o VS: 80/50
o CR: 112/min
o RR: 20
o Hgb: 84
o Hct: . 24
o Resuscitation w crystalloids and blood requested
th
4 HD
o Emergency Colonoscopy done
o Fresh Blood and Clots noted from rectum to mid transverse;
rectum cleared of bleeders
o Proximal transverse to Cecum Normal; terminal Ileum Normal
o Bleeding point not visualized due to persistent bleeding
o Patient Referred to Surgery

PERTINENT PE FINDINGS

BP: 80/50
CR: 122/min
Thready pulses
Pale conjunctivae and membranes
Clear Breath Sounds; distinct heart sounds
Abd: slightly globular, hyperactive BS; soft, non-tender. No masses
DRE: fresh blood on tactating finger
Resuscitation continued w whole blood and crystalloids

PLAN
Immediate Ex-Lap
Probable Left Hemicolectomy
Colitis
-Chronic inflammation of the colon (Moore)
-Severe inflammation and ulceration of the colon and rectum
(Moore)
Colectomy
-terminal ileum and colon, as well as rectum and anal canal are
removed (Moore)

FINDINGS
Colonic polyp that is highly vascular and found at the distal
transverse colon
Collapsed small bowel
Large bowel with blood clots from proximal transverse to rectum
Proceeded w Left Hemicolectomy; Hartmanns Procedure
Transfused 4 units of PRBC and 4 units of FFP intra-op
Large Bowel Lesions: at right hepatic flexure: complete dissection
Note: Marginal artery of Drummond: interconnects the iliocolic,
right, left and median colic, sigmoid rectal

Group 3|Mark Angeles, Jubelle Aquino, Chen Arellano, Mia Arevalo

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