Post on 27-Jun-2015
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Abdomen Clinical Anatomy
Dr.Deepak N.Khedekar;M.B.B.S,M.D.
Asst. professor
Dept of AnatomyLTMMC,SION,MUMBAI.
Feb 2012
Clinical anatomy…
• Congenital• Truama• Infection• Inflammation• Tumour• Procedure: 1.Therapeutic• 2.Diagnostic
Abdominal wall…
Abdominal surgical incision…
• Incisions should be made (if possible) at lines of cleavage.
• Collagen fibers in dermis are parallel.• More narrow scar .• Incision away from nerves.• Muscle atrophy if nerve cut.• Shorter healing time.
Mc Burney incision...
Palpation of the abdomen…
• Soft and pliable • Inward and outward excursion with respiration. • From right inguinal region to left hypochondriac
region. • Contour of abdominal wall depends on tone
and fat.• Findings: lumps,enlarged organs, such as
liver,spleen,dilated veins,skin discolouration.
Palpation of the superficial inguinal ring…
• Looking for indirect hernia .• Male: Palpate spermatic cord in upper part of
the scrotum.• Firm cordlike structure (posterior part) is vas
deference.• Patient coughs to increase intra-abdominal
pressure.• Female: smaller and difficult to palpate.• Transmits round ligament
Umbilicus…
• Meeting point of CVS,GUS,GIS. during development. Hotbed of embryology
• Skin around umbilicus supplied by T10 spinal segment.
• Surgical incision should never be crossed umbilicus.
• Congenital defects include Omphalocele,hernia,fistula
Omphalocele…
Hernia…I
• Classified as …External • …Internal• Inguinal hernia can be classified as ….Direct ….Indirect Indirect further classified as …. Complete ….incomplete.
External hernia…
Layers of hernial sac
Hydrocele…
Hydrocele…
• Congenital-Persistent processus vaginalis (congenital)
• Fluid-filled sac tunica vaginalis surrounds testicle.• 1 in 10 male infants at birth.• Typically not painful or harmful• Other causes- infection,truama,tumour.• Differential diagnosis is hematocele,pyocele.
Varicocele…
Varicocele…
• Pampiniform plexus (testicles) becomes dilated ,tortuous,thickened,lengthening.
• On inspection -bag filled with worms • Common in adolescents.• Mostly left side due to connection with
renal vein vs. right side, which joins with IVC.• Could be caused by primary kidney disease.• Pt Presents with infertility (plexus not cooling)
Testicular cancer …
• Spreads upward via lumbar lymph to L1 .• Later spreads locally to superficial inguinal
lymph
Torsion of the Testicle…
• Rotation around spermatic cord.• Often associated with excessively large tunica
vaginalis.• Active young men and children.• severe pain, could lead to testicular necrosis.
Torsion of testis…
Abdominal quadrants and regions…
Peritonitis…
• Inflamed parietal peritoneum is extremely sensitive to stretching .
• Pressure applied to abdominal wall with one finger.
• Rebound tenderness
Ascites…
Ascites and Paracentesis…
• Excessive accumulation of inflammatory peritoneal fluid.
• 1.5L before clinically recognizable.• Local anesthesia, needle through abdominal wallEither
through linea alba.lateral to Mc burneys point.• Skin, superficial fascia, deep fascia (very thin),
aponeurosis or muscle of external oblique, internal oblique muscle, transversus abdominis muscle,fascia transversalis, extraperitoneal connective tissue (fatty) ,parietal peritoneum
Peritoneal adhesions…
• Associated with peritonitis .• Post-surgical (gynecological and general
abdominal) as well.• Adhesion occur >90% of the patients following
major abdominal surgery and in 55-100% of the women undergoing pelvic surgery.
• Small-bowel obstruction, infertility, chronic abdominal and pelvic pain, and difficult re- operative surgery are the most common consequence
Peritoneal Dialysis…
Volvulus…
Stomach…
• Gastric ulcer commonly seen on lesser curvature.
• Gastric carcinoma commonly occurs at pyloric antrum,greater curvature
• Zollinger ellison syndrome.• Vagotomy• Gastrin-bearing somach mucosa(Antral
gastrecomy)
Ulcer, Gasrtectomy…
Peptic ulcer…
Duodenal (Peptic) ulcers…
• An ulcer of the posterior wall of the first part of the duodenum may penetrate the wall and erode the relatively large gastroduodenal artery causing severe haemorrhage.
• As the stomach empties its contents into the duodenum, the acid chyme is squirted against the anterolateral wall of the first part of the duodenum.
Peptic ulcer…
Appendicitis…
• Afferent pain fibers enter the spinal cord at the level of the T10c segment, and a vague referred pain is felt in the region of the umbilicus .
• Later, the pain shifts to where the inflamed appendix irritates the parietal peritoneum. Here the pain is precise, severe, and localized
Appendicitis…
Portal hypertension…
• Cirrhosis of liver: Hepatocytes undergoes necrosis caused by
the infection,inflammation.Dead hepatocytes are then replaced by the fibrous tissue.
Cirrhosis liver IVC compression Portal hypertension.
Portal Hypertension
Colitis…
• Pain, tenderness in the abdomen, fever, swelling of the colon tissue, bleeding, erythema (redness) of the surface of the colon, rectal bleeding, and ulcerations of the colon .
• Associated with Crohn’s disease(Ulcerative colitis)
• Cancer of the large bowel.• Minimally invasive laparoscopic surgery.• Lymph vessels and nodes removed•
Colostomy…
Ileostomy…
• Small intestine brought out to skin; collected in pouch.
• Usually done in groin on right side.• Ulcerative colitis; Hirschprung's disease.
Colonoscopy…
• Colorectal cancer is a leading cause of death in the Western world b.
• Bowels washed, patient sedated, tube inserted.
•
Rupture of spleen…
• Associated with truama, mononucleosis.• Requires immediate medical and surgical
attention.• Severe blood loss (shocK)• Left side, T9-T11.• Removed rather than repaired• Sx-Total splenectomy
Pancreatic cancer .
• Near Head of bile duct; obstructive jaundice (yellow skin tint)
• Whipple procedure (pancreatoduodenectom• Stents could do well.
Impaction of gallstones.
• Usually asymptomatic .• Sometimes very painful.• Eating fatty foods contracts gallbladder
against stones.• May result in infected bile into the pancreatic
duct leading to pancreatitis.• Sx.-cholecystectomy.
Cirrhosis of liver …
• Scarring of liver tissue as hepatocytes die off. • Associated with chronic alcoholism and
hepatitis.• Portal hypertension develops.
Portal hypertension…
• Anastomotic backup of surrounding veins- (Gastroesophogeal, Anorectal, Paraumbilical,
Retroperitoneal)• leads ascities,caput medusae,spider naevi• Rx-Can insert a shunt from the portal vein
back to IVC.• Blood flow through sinusoids impeded
Renal and Ureteric calculi (stones)…
• Consolidation of dissolved minerals in urine.• Episodic flank pain and hematuria.• Pain -loin to groin radiating pain• Most pass with timed.• Surgical navigation removal.• Non Sx- Extracorporeal Shock
Wave Lithotripsy.(ESWL)
Abdominal aortic aneurysm…
• Localized enlargement of the aorta as a result of congenital or acquired weakness.
• can be detected left of midline.• Common site is just above the bifurcation
of the aorta to common iliac arteries.• Unrecognized rupture of an aneurysm has a
90% mortality rate.