#5

Anatomy

12/11/2015

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Anatomy lecture #5
DIGESTIVE SYSTEM
12th /Nov/2015
The last lecture was mainly about the muscles of the abdominal wall & the rectus
sheath.
We said that the rectus sheath forms in the developmental stages during the 6 th and the
7th weeks (at the emporyological stage ) because of this kind of developing one of its
specific characteristics is that its missed inferiorly at the level of the anterio-superior
iliac spine. We also talked about the contents of the rectus sheath: two muscles, four
blood Vessels (Sup. & Inf. epigastric arteries, Sup. & Inf. epigastric veins), six nerves
This lecture cover the slides (18-33) in the Antero-Lateral Abdominal Wall file
& introduction to the ingunal canal. Slides are NOT included.

Blood Vessels of Abdominal Wall

The doctor explained the blood vessels
depending on the origin of the blood vessel. The
internal thoracic artery is the artery that
descend externally downward (parastrunal)
beside the sternum and provide the anterior
intercostals artery to the level of the sixth
intercostals space where it branch into two
arteries :
- The musculophrenic artery : which will go to
the abdomen.
- The superior epigastric artery.

Note:
The abdominal wall term refer
to the antero-lateral abdominal
part NOT just the rectus
sheath. For example in the
rectus sheath there are two
arteries and two veins (four
blood vessels), while in the
antero-lateral abdominal wall
in general there are more than
four vessels and one of the
most important arteries is the
superior epigastric artery

In the anterolateral abdominal wall region the Superior epigastric artery

is the continuation of the internal thoracic artery .once it gets into the
abdominal wall it enters the rectus sheath (pass through the posterior sheath
and the rectus abdominal muscles.) Because its located behind the rectus
sheath it provide will the blood supply to mainly the Transversalis Fascia,
the posterior rectus sheath and rectus abdominal muscle ,so all in all it

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provides the blood supply to the deep superior structures of the abdominal
wall even to the umbilical level.
The decending thoracic aorta ( which is the largest artery in the
body) gives the last three thoracic arteries which are the 10th and the 11th
posterior intercostel arteries and the subcostal artery. As they descend
they will provide blood supply along with other four lumber arteries
which also branches from the descending thoracic aorta.
As these 7 blood vessels
descend they will pass between the
two deepest muscles layers the
internal oblique and the transverses
abdominal muscles, at the same
time they give branches to the
superficial structures.
The other thoracic arteries provide
the superficial anterior abdominal
wall.
In the last lecture the external
iliac artery was mentioned as the
artery that will descend at the level of the Inguinal ligament to give the
femoral artery. Another important branch of the external iliac artery is the
inferior epigastric artery.
Above the Inguinal ligament the inferior epigastric artery will arise
from the medial aspect of the external iliac artery , as it pass from the
medial aspect it will move medially to the deep Inguinal ring ( which is the
entrance or the deep opening to the Inguinal canal) when it reach the deep
abdominal cavity it will penetrate the transverse fascia to get into the antero
lateral abdominal wall, then it will ascend between the transversalis fascia
and the rectus abdominas until the level of the arcuate line. At the arcuate
line it will enter within the rectus sheath and will bind to it (posteriorly to
the rectus sheath, anteriorly to the rectus abdominals). At the level of the
umbilical it will anastomosis with the superior epigastric artery.
The superior and the inferior epigastric arteries are the main arteries in the
antero lateral abdominal wall.
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In addition to these arteries there are several other arteries for

example the deep circumflex iliac artery that also branch from the
external iliac artery, the importance of this artery is that it provide blood
supply to the deep structures in the inguinal region in the abdominal wall.
Notice that all the branches from the external iliac artery are deep branches
like the inferior epigastric artery and the deep circumflex artery

The other branches are from the femoral artery that we mentioned in the last lecture and
early in this lecture its located below the Inguinal region, its branches are
superficial not deep like the external iliac artery.
The femoral artery will give the superficial epigastric artery which will
go to the superficial structures in the anterior wall below the level of the
umbilical.
So in the lower part of the anterior wall the blood supply to the deep
structures ( rectus abdominas and posterior sheath) is by the inferior
epigastric however the blood supply to the skin and the superficial fascia is
by the superficial epigastric artery.
Another artery that provide the superficial structures is the superficial
circumflex iliac artery, by this you can notice, there are two circumflex
iliac artery to the inguinal region:
1. The deep one arising from the external iliac artery and it provide
blood supply to the deep structure in the inguinal region.
2. The superficial one which arise from the femoral and provides blood
to the superficial structures in the inguinal region ( the skin and the
superficial fascia).

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The innervations of the abdominal wall

We discussed the six thoracic nerves in the rectus sheaths last lecture
we mentioned a nerve that does not enter the rectus sheath because its a
lower level which is the first lumber spinal nerve (L1), this nerve is the
innervations for the anterio-lateral abdominal region.
The first lumber spinal nerve will divide into upper and lower branches
which are: (there names start with illio because they come from the iliac region)
1. Illiohypogastric nerve: (the upper branch) named
hypogastric because it goes to the hypogastric area.
2. Illioinguinal nerve (the lower branceh)
The picture :
The borders of the antero lateral
abdominal wall :
Superiorly : the costal margins
Superiorly at the middle: the
xiphoid process
Inferiorly: the inguinal ligament
at the middle: the umbilicus
the midline: the lena alba

there are seven nerves in the antero-lateral abdominal wall

The first nerve from the lower 6 thoracic nerves, provide
T7
innervations to the upper part, comes from the most common
medial part of the costal cartilage.
Provide innervations for the umbilical region, comes from the
lower end of the costal margin/ at the lower rib of costal margin.
Cover the sensationally the area between the xiphoid process and
T8,T9
the umbilical region.
T11,T12 Branch in an arcuate manner.
As this nerve pass between the transverses abdomens and the
L1:
internal oblique muscles it divide into two branches:
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Ingiohypogastric nerve: provide the iliohypogastric

region and the ilioinguinal region superiorly.
Ilioinguinal nerve : this branch will pass through the
superficial inguinal ring which is the medial
triangular shaped opening and it split into the
aponeurosis external oblique. Provide the lower
inguinal region and the pubic sympghysis area.
clinically when there is a disease or an injury or rupture in one of the
abdominal organ or viscera you will not feel pain from this, the pain will go
with the anatomical innervations from the diseased organ passing with
splanchnic nerve up to the center nervous system then this pain will be
referred down with the sensory spinal nerves into the abdominal wall, this
is what we call the referred pain.
The main areas from referred pain
Its a pain in your abdominal wall but it's actually originating from a
visceral source or organ, we consider it as indication for the diseased
organ.
The diseased organ
Where the pain is felt

the stomach

pain in the epigastric region,

this area in innervated by T7

the small intestine and the

pain in the umbilical region,

cecum and the appendix
innervated by T10

the large intestines

pain in the iliohypogastric

area, innervated by T10 & L1

the bladder

pain in the pubic symphysis

area, innervated by ilioingunal nerve
This is important in the early discovery of the Appendicitis in early stages
to detect this inflammation as early as possible before the burst of the
appendix. In appendicitis at the early stages the pain will be a referred pain
in the umbilical region when the appendix enlarge it will start irritating the
parietal peritoneum this will shift the pain to down into lower right inguinal
region, it will become a real pain not referred.
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Surface Anatomy
There are several classifications to divide the antero-lateral abdominal wall
the general clinicians decided to divide the abdominal wall to make it easier
to distinguish the organ the patient complain from.
General clinicians use general classification which is to divide the wall into
four abdominal quarters (this is the division that you will be using here) in
this division we have two lines ( horizontal line and vertical line) and will
divide the wall into four quarters (upper right, upper left, lower right, lower
left).
These two lines are:
- the midsagittal line or medial line which
divide the abdominal wall into left and right
parts.
- The horizontal line which we call it transumbilical plane (pass through the umbilicus,
located at the level of intervertebral disks
between L3 & L4) despite the fact that the
area of umbilicus varies sometimes between
individuals, it is still within the same limits.
By learning this you will be able to distinguish the
defected organ so when a patient is complaining
from this region and there is pain during palpation
in the upper quarter for example you will know that
the problem might be in the liver or any organ in this region.
However the more common is the division to
nine regions by two vertical lines and two
horizontal planes:
The vertical lines are the midclavicular
planes pass from the middle of the clavicle
to the med point of the inguinal ligament
The horizontal planes the sup costal one
at the lowest margin of the costal
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cartilages of T10 its located at the level of the third lumbar vertebrae
L3, the another line is the trans-tubercular plane passes through the
tubercles of the iliac crest which are the elevations located at the top
area of the iliac bone laterally remember these tubercles are important
because they are the insertion area for the illiotebial tract. this plane is
at the level of L5.
These four lines will divide the abdominal wall into nine regions.
We can't say that this classification is not used we use it for example: The
right area is called the right hypochondria ( below cartilage which refer to
the costal cartilage here) is the area where we will find the gallbladder to be
specific at the tip of the 9th costal cartilage is the fungus of the gallbladder.
Notice the right lumber and the right lingual area (named Inguinal because
its close to the ingunal ligament) in the meddle we have epigastric/stomack
area below the sup costal plane in the middle there is the umbilical region
(in the umbilical region you can find the small intestines mainly the
jejunum and the ilium, notice also the pubic/hypogastric below the stomach
and below the trans-tubercular plane.
On the left notice the left hypochondilic , left lumber and left Inguinal
region.
beside these divisions, there is a very important plane you have to know
about because of its clinical importance which is the transpyloric plane.
physicians use this plane as a landmark. Its named transpyloric plane
because it pass through the pylorus of stomach.
its located at the level of L1 vertebrae and usually from the tip of the ninth
costal cartilage to the other 9th costal cartilages so to find it just follow the
costal margin of the 9th costal cartilage if you find this difficult you can
distinguish it by the linea semilunaris, where the linea semilunaris is
crossing this is the area of the ninth costal cartilages.
Because this plane is a horizontal line and pass through several important
structures and easy to palpate over it and demarcate.

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What are the structures that can be identified by the transpiorenic plane?
(From right to left)
Put your fingers on the costalcartilage and ask the patient to take a deep
breath the first thing you can palpate at the tip of the 9th costal cartilage is
the fungus of the gallbladder, if the patient
Note:
feels a deep pain because we are pressuring
The hilum means the entrance /
over this area this means the patient is
where the roots of the organ enter
having an inflamed gallbladder. This is how
or leave . in the kidney we have
you palpate to do a cholecystectomy.
medial hilum where the roots
pass(the roots here are the renal
Secondly it will pass pylorus of stomach.
arteries, renal veins, the uretar) so
Thirdly it will pass by the neck of the
in any organ you will have a hilum
pancreases ( any pain in this area indicate
and a root.
mostly pancreases tumors).
Then it will pass through the duodenum jejunum junction.
Finally it will pass through the hilum of the kidney .

Abdominal Surgical Incisions

Surgeons use various incisions to gain access to abdominal cavity, the
surgical incisions are not much used nowadays, but they are still important
during the exploratory operations
The most common replacement these days is the laparoscopic surgery
(using a laparoscope) in this kind of surgery we do three small openings.
What is the difference between the laparoscopies surgery and the
endoscopic surgery?
The laparoscopic we make artificial three small openings
In endoscopic surgery we enter through a natural opening in the body (nasal
opening, oral opening,..)

The basic principles and roles to follow during the Surgical

Incisions:
1. Provide adequate exposure: to gain a proper access you have to
provide an adequate exposure in the proper location, in some surgeries you
will have to work in an area of inflammation or tumors it doesnt make any
sense to open small opening of 1 cm, for example if you are working on the
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liver you should open an adequate opening in the left side in the left
hypochondria.
2. Avoid damage to major vital structures : open as much as you can as
long as you are not harming other structures or vital structures which are
the VAN structures ( Veins, Arteries, Nerves). By now you already know
that the nerves goes more or less horizontally so cutting the anterior and
antero-lateral abdominal wall vertically is not allowed (because by this you
will cut the whole innervations) except in the midline because in the
midline at the linea alba there are only fibrous tissue no innervations . so all
in all always pay attention to how the orientation or the direction of the
VAN to avoid damage them.
3.provide the best possible cosmetic effect: you have to follow the
dermatome to provide a scar healing which is easy sometimes. Sometimes
because of the severity of the disease the surgeon has to do more effort.

Common surgical incisions:

The common surgical incisions are divided into two types:
1) The vertical incisions: not the common, they are three in number but
only two are used
the midline or the median incisions
2) The transverse or oblique incisions:
Kochers (Sub costal) Incision
McBurneys Incision

Median (Midline) Incisions

common to use, it for exploratory operations when you want a large abscess
for a sever tumor or sever infection in one organ and you want to remove it
like the removal or transplantation of the liver. Why is this incision used?
Because at the midline (at the linea aspera) there is less blood supply and its
easy to cut and stretch the linea aspera.

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However the risk here is that if the surgeondont line the edges of the
linea aspera probably because of the pour blood supply an ischemic
necrosis might develop after the surgery.
The medial incisions are three types :
1- The upper median incision : from the xiphoid to the umbilical
2- The lower median incision : from the umbilical to the pubic
symphysis
3- The complete median incision : used mainly for the exploratory
operations and transplantation of large organs.

Paramedian Incision:
Usually 2-5 cm lateral to the midline. Usually for small organ
transplantations that happen on the left side for example working on the
spleen or the kidney.
How we use this incision for the kidney transplantation?

First We open a lower paramedian incision then we put the transplanted

kidney (the healthy kidney) in the iliac fossa over the iliac muscles, the
surgeon cut the ureter and stitch it to it the surgeon do not remove the
diseased kidney we always leave it as it is also the surgeon do not interfere
with the renal arteries and renal veins he put tubes from the healthy kidney
to the external iliac directly.
When the surgeon wants to do a paramedian incision he does not cut the
whole abdominal wall. First he cut the skin then the superficial fascia then
the deep fascia (anterior rectus sheath) he continues the cutting until he
reaches the rectus abdominas because if he continues the cutting he will cut
the rectus abdominal longitudinally which will lead to cut the nerves and
the medial side of the muscle will undergo necrosis because by this he will
cut the blood supply to the medial part of the rectus abdominal and the
innervations ( thoracic spinal nerve).

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What the surgeon do instead of cutting

The surgeon do a paramedical cut until he reach the rectus abdominas

muscle he dont cut it he use a retractor to reflect the rectus abdominas
laterally with the anterior rectus sheath.
After that he continuo cutting posteriorly the rectus sheath to get into the
extra paretonuim fat.

Note:
There is an incision called pararectus incision or the semilunar
incision, its very risky and not operated any more.

Kochers (Subcostal) Incision:

Its an incision in the right side usually to a 0.5 cm below the costal margin.
Used in cholecystectomy Even though laparoscopic surgery are used a lot
these days they cannot by used if the gallbladder is
severely pain or bursted so we use open surgery
using kocher's incision.
This incision is 2.5 cm below the costal margin and
its not straight the surgeon follow the costal margin.
Kocher is referring to Emil Theodor Kocher its very
important to know about this scientist specially in
the surgery. He wasnt only the first Swiss citizen to
win the noble prize he was also the first surgeon to win the Nobile prize. He
won the Nobel prize for his procedure on the thyroid gland and for
developing an antiseptic method by this method he reduced the risk of
surgical infections for less than 1% in his surgery (the antibiotics was not
used yet).
He is famous for one of the surgical instruments he used the "homeostatic
forceps" or "kocher's forceps" still used nowadays in surgery rooms the new instruments
like the electrocautery procedure have reduced the use of these old
instruments.
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The kocher's forceps is a serrated adages forceps with interdigitating

teeth at the tips, its used to ligate the blood vessels during the operation so
if you want to cut an artery first you have to put the kocher's forceps one
before and one after to completely close the arterial blood movement in the
artery by this you can close between them.
McBurneys Incision
It is an oblique incision on the spino- umbilical line, the other scientific
name is gridiron incision. For open appendectomy.
What is the spino- umbilical line?

Spino- umbilical is a straight line connect between the anterior superior

iliac spine with the umbilical so in the spinoumbilical line if you go one third from the spine
and two third from the umbilical and do a cut you
are at this point at the base of the appendix ( we
need the base of the appendix not the apex to do a
cut in the appendix, in this kind of surgery we
remove all the appendix and dont leave anything
unlike the kidney transplantation) so this area is
called McBurney's bond.
the McBurney's incision was described by the American surgeon Charles
Heber McBurney.
We call the incision At McBurney's bond the McBurney's incision and the
gridiron incision but you can do the gridiron incision at any region in the
body.
what is Gridiron incision?

This term can be used in different regions in the body.

Gridiron incision is what is called in surgery the muscle splitting incision
when you have muscle fibers directed in different orientation like in the
costal muscles (external intercostals muscles and internal intercostals
muscles and the transverses thoracic muscles).
Another example is the muscles in the abdomen (external oblique and
internal oblique and transverse abdominal).

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this name come from the Gridiron frame thats used in fixing or repairing
the ships once they put the ship in this thing it will has horizontal and
longitudinal and vertical frames around the ship these frames run
perpendicular to each other.
this is similar to the orientation of the muscles fibers in the Gridiron
incision. We use this incision to prevent losing the muscles like the oblique
muscles if you cut the area horizontally you will cut the fibers of the
muscles so we lose the muscle.
In this incision if we want to remove the appendix, we cut the oblique
muscles following the orientation of the fibers then we retract the muscle ,
then we will cut the internal oblique muscles the second incision should be
perpendicular to the first incision, then we retract the internal oblique
muscles then we cut the transverse muscles horizontally the third incision
should be perpendicular to the second incision, we produce the gridiron
incision by producing perpendicular incisions. then you will get into the
abdominal cavity then you reflect the cecum (because appendix is most of
the time retrocecul -behind the cecum)then you remove the appendix.
(please check for it in other sources because it wasnt clear from the
record).

Pfannenstiel (Suprapubic) Incision:

-The smile incision / c-shaped incision / funnel steal incision.
-it is Transversed but slightly curved incision & 5
cm above the pubic.
-Its the most commonly used incision because its
used in common surgeries like the Caesarean
section (in delivery) ,c-section surgeries, its also
used in hysterectomy in some cases of tumors and
when we want to remove the uterus , we use it in
urinary bladder diseases and in prostate surgery in
males.
The describer of this incision Hermann Johannes Pfannenstiel while he was
performing his incision for a woman that have an ovarian abscess he
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injured his finger and because the antibiotics wasnt discovered yet he died
from septicemia, he was only 47.

Inguinal Region
the second abdominal wall PowerPoint presentation

In the last lecture the doctor explained the formation of the Inguinal canal,
he explained also the three openings, the superficial ring in the external
oblique and the tearing in the aponeurosis, the arching fibers of the internal
oblique and the higher arching fibers of the transverses abdomenas
muscles.
Then when the testes descend within its structure they will pull the
transeversalis facsia with it. It will pass behind the transversus abdominis
(which origin is the lateral 3rd of the inguinal ligament), then it will pass
through the internal oblique (which is from lateral half to lateral two
3rds),this will make the lowest fibers of internal oblique in touch with the
transversalis fascia,
all in all, transversalis fascia which is covering the testes will also touch the
internal oblique fibers and take them because this is during the
embryological development, so as the fibers form to become the cremaster
muscle, and lastly it will pass through the triangular split, but it's not yet
complete so when the testis pass it will take the remaining fibers and matrix
with it and this is how the spermatic fascia forms .
When speaking about the structure of the inguinal ligament remember
the word "MALT" (from up to down):
-M: the roof is Muscles (the lower arching fibers of transversus abdominis
and the lower arching fibers of internal oblique).
-A: anteriorly is the Aponeurosis of external oblique.
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-L: below is the inguinal Ligament.

-T: posteriorly is the Transversalis fascia.

There are two important structures related to this:

The conjoint tendon: when the two fibers coming into the pubic
symphysis which is too small, so the fibers interdigitate with each other and
insert into the pubic symphysis by this they become the conjoint tendon.
Note : these fibers will not became aponeurosis because aponeurosis
is thin flat tendon.
The lacunar ligament which is producing a lacunae.
The doctor explained

is a small part of the inguinal ligament fibers that reflect

this ligament at min
47.5 using a papers I
from the pubic tubercle and attach to the pubic ramus
couldnt explain it
superiorly. Its important because as its reflected it will
here
provide a canal or opening called the femoral ring,
demarcated laterally by the femoral vein, medially by the lacunar ligament,
anteriorly by the inguinal ligament, and posteriorly by the pubic ramus.
Through this femoral ring, the lymphatics (superficial inguinal lymph
nodes) will pass up from the thigh into the external iliac lymph nodes in the
abdominal cavity, so its a lymphatic passage. However, the lymphatic
vessels are very small on diameter, so mostly the
canal is empty.
Now the fascia of the abdominal wall like
transversalis and iliacus fascia, once lymphatics
expand down into the thigh, they will take it with
them so they will produce something called
femoral canal which extends just 1 cm, and the
upper opening of it is the femoral ring which is
the opening into a small tube of fascia.
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Its very important during hernia, if theres an increased strain in the

abdomen, during defecation or parturition in female, a small part of the
intestine can pass through the femoral ring downwards as the abdominal
pressure is increasing. We call This hernia femoral hernia, and it is more
common in females because the ring is wider, because of the wider pelvis.
this femoral ring is very rigid since its surrounded by tough structures
(laterally the femoral ring, medially the lacunar ligament, anteriorly the
Inguinal ligament, posteriorly bones) , so once the intestine passes through
it, most of the time it cannot get back, this is why its called irreducible
hernia.
If the hernia was above the inguinal ligament through the superficial
inguinal ring, its called inguinal hernia, while the femoral hernia is below
the inguinal ligament, this is distinguished clinically by palpation all the
way over to reach the pubic tubercle which is bony prominence, if the neck
of the hernial sack was above and medial to the pubic tubercle its inguinal
hernia, if it was below and lateral its femoral hernia.

Good luck
Majd Nabil Mo'adi

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