Anterior Abdominal Wall

The boundaries of the anterior abdominal wall are:

superiorly – the costal arches and xiphoid process,
inferiorly -- the iliac crests, inguinal folds (projection of the inguinal
ligaments), pubic tubercles and the superior margin of the symphysis pubis,
laterally - the vertical line, which connects the end of the 11 rib with the iliac
crests (Lesgaft's line). This line is the continuation of the midaxillary line, and it
separates the abdominal region from the lumbar region.

The surface landmarks

are the following: xiphoid process, costal margin, iliac
crest, pubic tubercle, symphysis pubis, inguinal ligament, superficial
inguinal ring, linea alba, umbilicus, rectus abdominis muscle.
The anterior abdominal wall can be divided by horizontal and vertical planes
(lines) into a number of regions which are of use to the clinician when
describing the site of pain felt by a patient or of abdominal physical sings such
as areas of tenderness or tumors.
Two transverse and two vertical planes (lines) divide the anterior abdominal
wall into three midline, three left, and three right regions.
The vertical right and left lateral planes almost correspond to the midclavicular
planes of the thorax and pass through the midpoint of a line joining the anterior
superior iliac spine and the symphysis pubis (the midinguinal point).
The subcostal plane joins the lowest point of the costal margin on each side,
that is the tenth costal cartilage. The subcostal plane lies at the level of the
third lumbar vertebra. The interspinal plane (linea bispinalis) joins the anterior
superior iliac spine on each side. The midline regions are called the epigastric,
umbilical, and hypogastric regions. The lateral regions are called the upper
right, upper left, lower right, lower left and right inguinal (iliac) region, left
inguinal (iliac) regions.

Layers.
Skin. The natural lines of cleavage in the skin are constant and run
almost horizontally around the trunk. This is important clinically, since an
incision along a cleavage line will heal as a narrow scar, whereas one that
crosses the lines will heal as a wide or heaped-up scar. The skin is supplied by
the cutaneous branches of the seventh the twelfth intercostal nerves and by the
first lumbar nerve in the form the iliohypogastric nerve. A pleurisy involving
the lower costal parietal pleura will cause pain in the overlying skin that may
radiate down into the abdomen. Although it is unlikely to cause rigidity of the
abdominal muscle, it may cause confusion in making a diagnosis unless these
anatomical facts are remembered.
Beneath the skin is located the subcutaneous tissue. The layer of adipose
tissue is very variable thickness. Cutaneous arteries, which are branches of
the superior and inferior epigastric arteries, supply the area near the midline,
and branches from the intercostal, lumbar, and deep circumflex iliac arteries
supply the flanks.
The venous blood is collected into a network of veins that radiates out from
the umbilicus (thoracoepigastric, intercostal, and superficial epigastric veins).
The network is drained above into the axillary vein via the lateral thoracic
vein and below into the femoral vein via the superficial epigastric and great
saphenous veins. A few small veins, the paraumbilical veins, connect the
network through the umbilicus and along the teres ligament to the portal vein.
They form an important portal-systemic venous anastomosis.
The superficial veins around the umbilicus and the paraumbilical veins
connecting them to the portal vein may become grossly distended in cases of
portal vein obstruction. The distended subcutaneous veins radiate out from the
umbilicus, producing the clinical picture referred to as caput Medusae. If there
is obstruction in the superior vena or inferior vena cava, the venous blood
causes distention of the veins running from the anterior chest wall the thigh.

The superficial fascia is divided into a superficial and deep layer. The
superficial layer of the superficial fascia is continuous with a superficial fascia
of the thigh. The deep layer of the superficial fascia (Tomson's plate) or
membranous layer is attached to the inguinal ligament and from similar layer
in the perineum. It is important clinically, since beneath it there is a potential
closed space that does not open into the thigh, but is continuous with the
superficial perineal pouch via the penis and scrotum. Rupture of the penile
urethra may be followed by extravasation of urine into the scrotum, perineum
and penis and then up into the lower part of the anterior abdominal wall deep
to the membranous layer of the superficial fascia. The urine is excluded from
the thigh because of the attachment of the Tomson's plate to the inguinal
ligament.
In the anterior abdominal wall, the proper or deep fascia is merely a thin layer
covering the muscles.

The muscles.
The musculature of the anterior and lateral walls of the abdomen
is made up of a trilaminar sheet on either side of a pair of vertically oriented
muscles. The thin aponeurotic tendons of the three lateral muscles form a sheath
around each vertical muscle before fusing in the midline at the linea
alba. The trilaminar sheet is composed of the external oblique muscle, the
internal oblique muscle, the transversus abdominis muscle.
The vertically oriented muscles are the rectus abdominis muscles. In the lower
part of the rectus sheath there may be present a small muscle called the
pyramidalis.
The cremaster muscle, which is derived from the lower fibers of
the internal oblique, passes inferiorly as a covering of the spermatic cord and
the scrotum.
The external oblique muscle arises as digitations from the outer surfaces of the
lower eight ribs. The fleshy fibers fan out downward and medially over the
anterior abdominal wall. There is a free posterior margin to the muscle where
its most posterior fibers run from the twelfth rib to the anterior half of the
outer margin of the iliac crest. The remaining more obliquely running fibers
become an aponeurotic sheet which contributes to the anterior sheath of the
rectus muscle before fusing with its fellow at the linea alba in the midline.
The lower free margin of the aponeurosis extends from the anterior superior
iliac spine to the pubic tubercle is called the inguinal ligament. From the
medial end of the ligament the lacunar ligament extends backward and upward
to the pectineal line on the superior ramus of the pubis. Its sharp, free
crescentic edge forms the medial margin of the femoral ring. On reaching the
pectineal line, the lacunar ligament becomes continuous with a thickening of
the periosteum called the pectineal ligament. To the inferior rounded border of
the inguinal ligament is attached the deep fascia of the thigh-the fascia lata.
A triangular-shaped defect in the external oblique aponeurosis lies
immediately above and medial to the pubic tubercle. This is known as the
superficial inguinal ring. The spermatic cord (or round ligament of
the uterus) passes through this opening and carries the external spermatic
fascia (or the external covering of the round ligament of the uterus) from the
margins of the ring.
The internal oblique muscle arises from the thoracolumbar fascia, the anterior
two-thirds of the iliac crest-deep to the attachment of the external oblique, and
from the lateral two-thirds of the inguinal ligament. The fibers fan out from
this origin. The uppermost run upward and medially to become attached to the
costal margin. The intermediate fibers become aponeurotic and help in the
formation of the rectus sheath before joining the linea alba. The lowermost are
attached by a flattened tendon to the pectineal line on the superior pubic
ramus.
The fibers of transversus abdominis muscle arise from a long origin which
extends from the deep surface of the costal margin, the thoracolumbar fascia,
the anterior two-thirds of the medial margin of the iliac crest, and the outer
half of the inguinal ligament. Running approximately transversely across the
abdominal wall, the fibers also become aponeurotic and contribute to the
rectus sheath before joining the linea alba. The muscular fibers from the linea
semilunaris (Spigelii) in the passage to the aponeurosis. This line extends from
the inguinal ligament to the sternum.
The two rectus abdominis muscles form the vertical component of the
anterior abdominal musculature and lie on either side of the linea alba. The
muscles are broad
superiorly and narrow inferiorly.
Each is attached to the fifth, sixth, and seventh costal cartilages above and
below by tendinous and fleshy insertions to the pubic crest and the symphysis
pubis. The anterior surface of the muscle is crossed by three tendinous
intersections. One of these lies at the level of the umbilicus and two are above.
These intersections are strongly attached to the anterior wall of the rectus
sheath. The rectus abdominis is enclosed between the aponeuroses of the
external oblique, the internal oblique, and the transversus, which from the
rectus sheath.
The piramidalis muscle is often absent. It arises by its base from the anterior
surface of the pubis and is inserted into the linea alba. It lies in front of the
lower part of the rectus abdominis.
The rectus sheath. Each rectus abdominis muscle is enclosed in a fibrous
sheath formed by the aponeurotic tendons of the three lateral muscles. The
external oblique contributes to the anterior layer the sheath over its whole
extent. Below the costal margin the internal oblique aponeurosis splits around
the muscle contributing to anterior and posterior layers and the aponeurosis of
the transversus abdominis passes into the posterior layer.
Midway between the umbilicus and the symphysis pubis, the posterior wall of
the sheath becomes deficient since all aponeuroses pass anterior to the rectus
abdominis. At the level at which the aponeuroses of all three lateral muscles
fuse to form only the anterior layer of the sheath, the posterior sheath
terminates at a free margin called the arcuate line (Douglasi line). It is here
that the inferior epigastric artery enters the sheath to run superiorly on the
deep surface of the rectus abdominis muscle. The artery anastomoses with the
superior epigastric artery, which has entered the sheath from above by passing
deep to the costal margin. Below the level of the arcuate line the rectus
abdominis lies on the transverse fascia. The muscles of the anterior abdominal
wall are supplied by the lower six thoracic and first lumbar segmental nerves.
The thoracic nerves emerge beneath the costal margin and run downward and
forward the abdominal wall between the internal oblique and transversus
abdominis muscles. The nerves are accompanied by branches of the
musculophrenic or the first lumbar artery. To thoracic (intercostal) nerves are
added the iliohypogastric and ilioinguinal nerves which are derived from the
first lumbar nerve. These supply the lower fibers of the external oblique,
internal oblique, and transversus abdominis muscles. In addition to branches
of the musculophrenic and lumbar arteries, which supply the lateral muscles,
the superior and inferior epigastric arteries supply the rectus abdominis
muscle.
The retromuscular layers. They include the fascia transversalis, the
extraperitoneal (preperitoneal) fat, the parietal peritoneum.
The fascia transversalis is a thin layer of fascia that lines the transversus
abdominis muscle and is continuous with a similar layer lining the diaphragm
and the iliacus muscle. It is important to understand that the fascia
transversalis, the diaphragmatic fascia, the iliacus fascia, and the pelvic fascia
form one continuous lining to the abdominal and pelvic cavities. The
extraperitoneal fat is a thin layer of connective tissue that contains a variable
amount of fat and lies between the fascia transversalis and the parietal
peritoneum.
The walls of the abdomen are lined with parietal peritoneum. This is a thin
serous membrane and is continuous below with the parietal peritoneum lining
the pelvic. The parietal peritoneum lining the anterior abdominal wall is
supplied segmentally by intercostal and lumbar nerves, which also supply the
overlying muscles and skin.

The linea alba extends from the xiphoid process down to the symphysis pubis
and is formed by the fusion of the lateral muscles of the two sides. Wider
above the umbilicus, it narrows down below the umbilicus to be attached to
the symphysis pubis. The linea alba has the through slitlike spaces. The
vessels, nerves and fat (which connects the extraperitoneal fat with
subcutaneous fat) pass through this spaces. This slits can be by the places of
outlet of the herniae. It is called the hernia of the linea alba or the epigastric
hernia. The linea alba is a weak place of the anterior abdominal wall.
The umbilicus is located in the middle of the line which connects the apex of
the xiphoid process with the superior margin of the symphysis pubis. The
umbilicus is drawn in scar which is formed in place of the umbilical ring.
The umbilical ring is the foramen which is limited by the aponeurotic fibers of
the linea alba. The urachus, umbilical vein, two umbilical arteries pass through
the umbilical ring in the intrauterine development. Then these structures are
turned into the ligaments.
The urachus is turned into the median umbilical ligament.
The umbilical vein is turned into the ligament teres of the liver.
The umbilical arteries are turned into medial umbilical ligaments.
The layers of the umbilicus are the skin with scarry tissue, the umbilical fascia
(the part of the
endoabdominal fascia or transverse fascia) and the parietal peritoneum.

The umbilicus
is located in the middle of the line which connects the apex of the
xiphoid process with the superior margin of the symphysis pubis. The umbilicus
is drawn in scar which is formed in place of the umbilical ring.
The umbilical ring is the foramen which is limited by the aponeurotic fibers of
the linea alba.
The urachus, umbilical vein, two umbilical arteries pass through the umbilical
ring in the intrauterine development. Then this structures are turned into the
ligaments.
The urachus is turned into the median umbilical ligament.
The umbilical vein is turned into the ligament teres of the liver.
The umbilical arteries are turned into medial umbilical ligaments.

The layers of the umbilicus

are the skin with scarry tissue, the umbilical fascia (the
part of the endoabdominal fascia or transverse fascia) and the parietal
peritoneum.
The umbilical vein passes into the umbilical cannal. The umbilical canal is
formed
by the linea alba-anteriorly and by the umbilical fascia-posteriorly.
The inferior foramen of this canal is located at the superior margin of the
umbilical
ring.
The superior foramen of this canal is located to 4-6cm above the umbilical ring.
The umbilicus is a weak place of the anterior abdominal wall. The umbilical
ring can by the place of outlet of the hernia. It is called the umbilical hernia.

The arteries of the anterior abdominal wall are:

The superior epigastric artery, the
inferior epigastric artery, the deep circumflex iliac artery, the posterior
intercostal arteries, the lumbar arteries
The superior epigastric, inferior epigastric, and deep circumflex iliac veins
follow
the arteries of the same name and drain into the internal thoracic and external
iliac
veins. The posterior intercostal veins drain into the azygos veins and the lumbar
veins drain into the inferior vena cava.
The cutaneous lymph vessels above the level of the umbilicus drain upward into
the anterior axillary lymph nodes. The vessels below the level drain downward
into
the superficialis inguinal nodes. The deep lymph vessels follow the arteries and
veins and drain into the internal thoracic, external iliac, posterior mediastinal,
and
paraaortic (lumbar) nodes.
The inguinal canal
The inguinal canal is an oblique passage through the lower part of the anterior
abdominal wall and Present in both sexes. It is between the muscles and the
inguinal ligament. It allows structures to pass And from the testis to the
abdomen
in the male. In the female it permits the passage of the round ligand Of the
uterus
from the uterus to the labium majus. It transmits the ilioinguinal nerve in both
sexes. The inguinal canal lies above and parallel to the inguinal ligament. It
extends medially for about 4 cm From the deep to the superficial inguinal ring.
The inguinal triangle is the part of the Inguinal (iliac) region, where the
inguinal canal is located.
The boundaries of this triangle are composed:
the inguinal ligament – inferiorly, the Lateral margin of the rectus abdominis
muscle –Medially and superiorly-horizontal line, which is Drawn from the point
between the lateral third and the middle third of the inguinal ligament.

The walls of the inguinal canal.

They are
Four anterior, posterior, superior and inferior.
-The anterior wall of the canal is formed by
The aponeurosis of the external oblique muscle.
-The posterior wall of the canal is formed by
The transverse fascia.
-The superior wall is formed by the internal
Oblique and transversus abdominis muscles.
-The inferior wall is formed by the inguinal
Ligament.
The interval between the superior and The interval between the superior and
inferior wall of the inguinal canal is called the inguinal interval. It is of great
importance for pathogenesis of the inguinal hernia. The form and sizes of the
inguinal interval are various. They are the slitike, oval, rounded and triangular.
The
triangular form of the inguinal is the precondition for the direct hernia.
The posterior wall of the inguinal canal is strengthened by the inguinal (Genle’s
ligament) and Interfoveolar ligament. The inguinal falx is the conjoint tendon of
the internal oblique muscles. It is situated at the medial border of the inguinal
interval and anterior to the transverse fascia. The interfoveolar ligament is
situated
between the medial inguinal fovea and lateral inguinal fovea which are located
on
the deep aspect (surface of the anterior abdominal wall.
The rings of the inguinal canal. The superficial ring is a triangular-shaped defect
in
the aponeurosis of the external oblique muscle and the base is formed by the
pubic
crest. The lateral side of the triangle called the lateral crus descends to the pubic
tubercle and the medial side, the medial crus, to the symphysis pubic.
The third crus may occur. It is called posterior crus or reflexed ligament
(Collest).
This triangular gap is the superficial inguinal ring through which the spermatic
cord in the male and the round ligament of the uterus in the female leave the
inguinal canal. This triangular space is commonly made more “ring-like” by
intercrural fibers which obliterate its apex.
The deep inguinal ring an oval opening in the fascia transversalis, lies about 1,3
cm
above the inguinal ligament midway between the anterior superior iliac spine
and
the symphysis pubic. Related to it medially are the inferior epigastric vessels,
which pass upward from the external iliac vessels. The margins of thering give
origin to the internal spermatic fascia (or the internal covering of the round
ligament of the uterus).
The margins of the superficial inguinal ring give origin to the external spermatic
fascia.
The spermatic cord, the ilioinguinal nerve and the genital branch of the
genitofemoral nerve are the contents of the inguinal canal in the male.
The round ligament of the uterus, the ilioinguinal nerve and the genial branch of
the genitofemoral nerve are the contents of the inguinal canal in the female.
The spermatic cord consists of the vax (ductus) deferens, the testicular artery,
the
testicular veins (the pampiniform plexus), the testicular lymph vessels, the
autonomic nerves, the processus vaginalis, the cemasteric artery, the artery of
the
vas (ductus) deferens.
The spermatic cord is a collection of structures that transverse the inguinal canal
and pass to and from the testis. It is covered with three concentric layers of
fascia
derived from layers of the anterior abdominal wall. It begins at the deep
inguinal
ring lateral to the inferior epigstric artery and ends at the testis. Between the
testis
and the superficial inguinal ring the testicular veins form a plexus around the
cord.
This is known as the pampiniform plexus. The plexus condenses to three four
vessels which ascend through the inguinal canal to the inferior vena cava on the
right side and the left renal vein on the left.

The ductus deferens is a firm muscular tube which can be easily palpated in the
living spermatic cord. Continuous with the epididymis it ascends on its medial
side
to become incorporated into the spermatic cord above the testis.
In order that the surgical anatomy of the inguinal region, spermatic cord, and
testis
may in due course be understand, a brief account of the descent of the testis and
the
manner in which normal development may fail is now given.
The testis develops on the posterior abdominal wall of the embryon. However it
subsequently migrates downward and leaves the abdominal cavity through the
inguinal canal to reach the scrotum at about the time of birth. The course of this
migration seems to be determined by the presence of the gubernaculum testis, a
fibromuscular cord extending from the lower pole of the testis to the developing
scrotal swellings. It also seems that the slightly lower temperature prevailing in
the
scrotum is necessary for the normal maturation of spermatozoa.
As it descends, the testis is preceded by a sac of peritoneum which lines the
scrotum. This sac is known as the processes vaginalis. On reaching the scrotum,
the testis invaginates this sac from behind and in this way becomes partially
clothed by a visceral and parietal layer of peritoneum. Communication of the
sac
with the main peritoneal cavity becomes obliterated and that portion left around
the
testis forms the tunica vaginalis. This communication between the peritoneal
cavity
and the tunica vaginalis surrounding the testis is normally completely
obliterated.
Partial failure of this process at some point along the course of the processus
vaginalis may lead to the development of a fluid-filled sac called a hydrocele of
the
cord. If the processus vaginalis remains totally patent, a pathway exist through
which abdominal structures can pass into the scrotum. This is called a
congenital
hernia.
The ovary descends only to the pelvic and does not transverse the canal.
However,
the gubernaculum Is retained in the form of the round ligament. This extends
from
the uterus, along the inguinal canal, and is anchored in the fibrofatty tissue that
makes up the labium majus. Not only is the gubernaculum retained, but in fetal
life
a processus vaginalis is formed and normally obliterated. For this reason
congenital indirect herniae do occur in women, although much less frequently
than
in men. As in the male, as isolated portion of the processus may form a
hydrocele
known by gynecologists as a hydrocele of the canal of Nuck.
The deep aspect of the anterior abdominal wall. The features of the structure of
the
peritoneum which forms posterior surface in lower part of the anterior
abdominal wall are necessary for the understating of the mechanism of the
origin of the
inguinal hernia. Here, the vessels and remnant of urachus pass under the
peritoneum and transverse fascia and form folds (median, medial and lateral
umbilical folds).
A median umbilical fold contains the remains of the urachus and leads to the
bladder. On either side 2 medial umbilicus folds can also be followed into the
pelvis and are found to approach the internal iliac artery . These folds are
formed
by the obliterated umbilical arteries.
Two lateral umbilical folds can be seen outside the medial folds and they are
formed by the inferior epigastric vessels. These folds can be followed from the
external iliac vessels to the arcuate line. At this point the posterior sheath of the
rectus abdominis becomes deficient and the vessels can pass superiorly on the
deep
surface of the muscle.
The fossae are formed between these folds. The supravesical fossa is located
between the median umbilical fold and medial umbilical fold. The medial
inguinal
fossa is located between the medial umbilical fold and the lateral umbilical fold.
This fossa is the projection of the superficial inguinal ring on the posterior
surface
of the anterior abdominal wall. The lateral inguinal fossa is located lateral to the
lateral umbilical folds.
The lateral inguinal fossa is called the deep inguinal ring. These fossas are the
weak places of the anterior abdominal wall. The inguinal herniae pass through
these fossas.
Hernia involve the passage of a peritoneal sac with or without abdominal
contents
through a site of congenital or acquired weakness in the abdominal wall.
Common
sites of hernia are at the umbilicus, the inguinal region and the femoral canal.
Less
commonly, they are found in the linea alba. The hernia of the linea semilunaris
(Spigelii) may occur but very seldom. The hernia consists of three parts: the sac,
the contents of the sac, and the hernial ring. The hernial ring is a weak place
through which passes the hernial sac. The hernial sac is diverticulum of
peritoneum
and has a neck, a body and a fundus. The hernial sac is remains of the processus
vaginalis in the congenital inguinal hernia.

The inguinal hernia can be divided into the congetinal and the acquired hernia.
The acquired hernia in its turn are divided into the oblique (indirect) and the
direct
inguinal hernia. The congenital inguinal hernia is always oblique.

The hernial contents may consist of any structure found within the abdominal
cavity and may vary from a small of piece of omentum to a large viscus such as
the
kidney.
The hernial sac in the oblique hernia passes through the deep inguinal ring,
along
inguinal canal and through the superficial inguinal ring and can descend into the
scrotum. It is called the inguinoscrotal hernia.
The congenital inguinal hernia always is inguinoscrotal hernia.
The hemia sac in the acquired oblique inguinal hernia is located lateral to the
spermatic cord.
The hernial sac in the direct inguinal hernia passes through the medial inguinal
fossa, the inguinal interval, the superficial inguinal ring.
The direct inguinal hernia never descends into the scrotum, always is acquired
and
has the straight way (track). The hernial sac in the direct inguinal hernia is
located
medial to the spermatic cord.
The supravesical hernia passes through the supravesical fossa, the inguinal
interval, the superficial inguinal ring. This hernia is very seldom. An inguinal
hernia is more common in men than in women. A femoral hernia is more
common
in women than in men (possibally due to a wider pelvis and femoral canal). An
inguinal hernia may be distinguished from a femoral hernia by the fact that the
sac,
as in emerges through the superficial inguinal ring, lies above the inguinal
ligament, while that of a femoral hernia lies below the inguinal ligament.
#3

ABDOMINAL CAVITY
Borders
●Superiorly – diaphragm
●Anteriorly – anterior abdominal wall
●Posteriorly – posterior abdominal wall
●Inferiorly – pelvic brim (linea terminalis)

Peritoneum
– thin serous membrane lining the walls of the abdominal and
pelvic cavity and covering abdominal and pelvic viscera.
●Parietal – walls of the abdominal and pelvic
●Visceral – covers the organs
Space between them – peritoneal cavity. ( In males it is a closed cavity but for
females it communicates with uterine tubes, uterus & vagina)
Intraperitoneal – Organs which are surrounded by peritoneum in all its sides
and they have large mobility
Mesoparitoneal
– organs surrounded by peritoneum on the 3 sides
Retroperitoneal
– organs surrounded by peritoneum on 1 side ( pancreas, large
part of the duodenum, kidneys, ureters)
THEY LIE BEHIND THE PERITONEAL CAVITY which means only the
front part is covered by the peritoneum

Abdominal cavity is divided

Abdominal cavity is divided into 2 by tranverse colon and its mesocolon
1.Sup. Floor of the supracolic compartment ( liver, stomach, spleen,
pancreas, sup.part of the duodenum, gallbladder)
1.Inf. Floor of the infracolic compartment. ( inf.part of the duodenum,
small intestine, large intestine)
Peritoneum forms bursa, fossas, spaces, gutters and sinuses
Superior Floor
●Omental bursa
●Pregastric bursa
●Right + Left hepatic bursa
●Sub hepatic space
Inferior Floor
●Lat / Procolic gutters
●Mesenterial sinuses
●Peritoneal pouches ( sup.+inf. duodenojejunal fossa, sup.+inf. Iliocecal
fossa, retrocecal fossa, intersigmoid fossa )

SUPRACOLIC FLOOR
Omental bursa / Lesser sac
●Located behind the lesser omentum and stomach
●In front of structures in post. abdominal wall
●Projects upwards till the diaphragm and downwards till the greater
omentum.
●Lower part is formed by the adherence of the ant. Layers of the greater
omentum to the post.layers.
●Left margin – spleen
●Below – limited by the left part of the transverse mesocolon
●Ant.wall - Lesser omentum, post.wall of the stomach and gastro colic
ligaments.
●Right margin- open into the greater sac through the
“epiploic foramen”
Anteriorly – hepatoduodenal ligament
Posteriorly – inf. Vena cava
Superiorly – caudate lobe of the liver
Inferiorly – 1st part of the duodenum.
Right hepatic bursa / right subphrenic space
●Superiorly – diaphragm
●Inferiorly – right lobe of the liver
●Left side – falciform ligaments
●Post. wall – right coronary and right triangular ligament
Left hepatic bursa
●Superiorly – diaphragm
●Inferiorly – left lobe of the liver
●Post wall – left coronary and left triangular ligament
Communicates with the pregastric bursa

Pregastric bursa
●Superiorly – left lobe of the liver+diaphragm
●Posteriorly – lesser omentum + ant.wall of the stomach
●Anteriorly – parietal peritoneum of ant. abdominal wall
●Inferiorly – transverse colon
Left hepatic bursa + pregastric bursa compose left subphrenic space
Sub hepatic space – lies between the inf.visceral space of the liver and
transverse colon and its mesocolon
Folds of peritoneum associated with the ascending part of the duodenum +
duodenal junction forms :
1.Superior duodenojejunal fossa
2.Inferior duodenojejunal fossa
Folds of peritoneum associated with cecum forms :
1. Superior iliocecal fossa 2.
Inferior Iliocecal fossa
3. Retrocecal fossa.
Intersigmoid fossa – lies at the apex of the sigmoid mesocolon.

INFRACOLIC FLOOR
There are 4 paracolic gutters and they lie on the lateral and medial sides of the
ascending and descending colons respectively.
Gutters which lie on the lat. side – lateral canals
Gutters on the med. side – mesenterial sinuses (triangular shaped)
Right Lateral Canal
●Medially – ascending colon
●Laterally – lat. abdominal wall
Communicated with the right hepatic space, subhepatic space
Left lateral canal
●Medially – descending colon
●Laterally – lat. abdominal wall
Communicated with the pelvic cavity
Right mesenterial sinus
●Right – ascending colon
●Superiorly – transverse colon and mesocolon
●Left – small intestine
Left mesenterial sinus
●Left – descending colon
●Superiorly – transverse colon and mesocolon
●Right – small intestine
Right mesentery sinus is closed off from the pelvic cavity inferiorly by the
mesentery of the small intestine.

ABDOMINAL PART OF THE ESOPHAGUS

Passes through the muscular part of the diaphragm with ant. + post. vagal
trunks at the level of the 10th thoracic vertebra.
Enters the stomach on the right side.
Covered
●Anteriorly – left lobe of the liver
●Posteriorly – left crus of the diaphragm
Left and right vagi lie on ant.+post surface respectively
Right margin – passes in the lesser curvature
Left margin – forms cardiac noth/ gliss angle with fundus of the stomach.
Blood supply
Blood supply – branch of the left gastric a. + left gastric v.
Nerve supply
Nerve supply – 2 vagus n. ( parasympathetic) + splachnic n. (sympathetic)

STOMACH
Mobile , muscular organ lying between esophagus and duodenum
Lies in the upper part of the abdomen, beneath the left costal margin region
into the epigastric and umbilical regions.
Has :
2 openings
●Cardiac orifices
●pyloric orifices

2 curvatures
●Greater
●Lesser( reflected onto greater and lesser ometa)
2 surfaces – anterior and posterior ( covered by peritoneum)
Stomach is divided into
1. Undus
●Dome shaped, projects upwards to the left of the cardiac orifice.
●Full of gas

2. Body
● Extends from the cardiac orifice to insicura angularis

3. Pyloric part
●Funnel shaped
●Begins at the insicura and divided into pyloric antrum and pyloric canal.

Lesser curvature
●forms the right border of the stomach
●extends from the cardiac orifice to the pylorus

Lesser omentum
●extends from the lesser curvature to the liver
●Consists of 3 ligaments – phrenicogastricum, hepatogastricum and
hepatoduodenal.

Greater curvature
●longer than the lesser curvature
●Extends from the left of the cardiac orifice to the inf. Part of the pylorus.
Gastrosplenic ligament – extends from the upper part of the greater curvature
to the spleen

Greater omentum
●extends from the lower part of the greater curvature to the transverse
colon

Boundaries
●Anteriorly – abdominal wall, left costal margin, diaphragm, left pleura,
lung, left lobe of the liver.
Left – spleen
Posteriorly – diaphragm, suprarenal gland, left kidney, pancreas, left
colic flexure. ( these structures with spleen form the bed of the
stomach)
●Inferiorly – transverse colon
Blood supply
Blood supply
●left + right gastric a.
●short gastric a.
●left+right gastroepiploic a.
Veins which accompany these arteries drain into portal v. and its tributaries.
Left gastric artery
●passes upwards and left and descends along the lesser curvature.
●Supplies lower 3rd of the esophagus and upper right part of the stomach.
Right gastric artery
●Arises from the hepatic a. at the upper border of the pylorus and runs left
along the lesser curvature.
●Supplies the lower right part of the stomach.
Short gastric a.
●Arise from the splenic artery at the hilus of the spleen
●Pass forward in the gastrosplenic ligament to supply the fundus.
Left gastroepiploic a.
●Arise from the splenic a. at the hilus of the spleen
●Passes forward in the gastrosplenic ligament to supply the stomach along
the upper part of the greater curvature.
Right gastroepiploic a.
●Arises from the gastroduodenal branch of the hepatic a.
●Passes to the left and supplies the stomach along the lower part of the
greater curvature.
Nerve supply
●Sympathetic n. – celiac plexus ● Parasympathetic n. – vagus n.
After emerging through the esophageal hiatus both ant. + post vagus give off
hepato – biliary fibres and continue as ‘nerves of Latarjet ’( supply the body of
the stomach and innervates the mesenteric plexus of the antrum)
Ant. vagal trunk
●Formed in the thorax by the right vagus n.
●Enters the abdomen on the ant.surface of the esophagus , then divides
into branches and supply the ant.surface of the stomach.
A large hepatic branch passes to the liver and from this a pyloric branch
passes to the pylorus.
Post.vagal trunk
●Formed in the thorax by the right vagus n.
●Enter the abdomen on the post.surface of the stomach, then divides into
branches that supply the post.surface of the stomach
Pyloric sphincter
●Divides stomach from duodenum
●Regulates rate of delivery of chime into the duodenum ● Prevents
duodenogastric reflux.

LIGAMENTS OF THE STOMACH

Superficial ligaments
●Gastrocolic
●Gastrosplenic
Phrenicogastricum
Hepatogastricum

Deep ligaments
●Gastropancreatic
●Pyloropancreatic
LYMPHATIC DRAINAGE
Lymph vessels that drain along the :
●Left gastric vessels – pass to celiac nodes
●Right gastric vessels – pass to nodes along the hepatic a. and then to
celiac nodes
●Short gastric arteries, left gastroepiploic a. , then drain into lymph nodes
at the hilus of the spleen- they pass to pancreaticosplenic nodes along the
splenic a. and drain into celiac nodes.
●Right gastroepiploic nodes , which lie along the lower part of the greater
curvature of the stomach.
Efferent lymph vessels join nodes along gastroduodenal a. and then drain into
celiac.

LIVER
Occupies the upper part of the abdominal cavity. Lies under the ribs and costal
cartilages in the epigastric region. Diaphragm seperates it from the pleura,
lungs, pericardium and heart. Anterior, posterior, superior and lateral forms
“diaphragmatic surface” Liver is divided into right and left lobes by falciform
ligament.

Right lobe is divided

1.Quadrate lobe
2.Caudate lobe
Except the bare surface and beneath the gallbladder, liver is covered by
visceral peritoneum.
Falciform ligament – ascends from the umbilicus and contains the ligamentum
teres.
 Ligament teres passes into a fissure on the visceral surface of the liver
and joins the left branch of the portal v. in the porta hepatitis.
 Lesser omentum arises from the porta hepatitis and passes down to the
lesser curvature of the stomach.
 Falciform ligament splits into 2 layers and forms coronary ligament.
 Right + Left extremities of the coronary ligaments - “left and right
triangular ligament”
Ligaments can divide into 2 groups
Ligaments of the liver with organs of the abdominal cavity
●Hepatoduodenal
●Hepatogastricum
Ligaments of the liver with the walls of the abdominal cavity
●Falciform
●Ligamentum teres
●Coronary
●Right + Left triangular
 Liver can be subdivided into segments. Each contains its own branch of
hepatic artery, bile duct and portal v.
 Porta hepatic/ hilus of the liver – found on the postero – inf. Surface and
lies between the caudate and quadrate lobes.
  Hilus of liver is found on postero-inferior surface and lies between
caudate and quadrate lobes.

Hepatoduodenal ligament
 Hepatoduodenal ligament is attached to its margin (inside it lies right
and left hepatic ducts, right and left branches of hepatic artery, portal
vein, sympathetic and parasympathetic nerve fibers)
 Venous blood leaves liver by portal veins that join inferior vena cava.
 Lymphatics from liver pass to mediastinal nodes in thorax by vessels
accompanying inferior vena cava
Blood supply hepatic artery
(branch of celiac trunk) divides to L & R hepatic
arteries to feed L & R hepatic lobes, it has a cystic branch that feeds gall
bladder, liver also receives blood by portal vein.

Gall bladder
Part of excretory apparatus of liver , and a temporary bile reservoir , when
stimulated , bile is released to duodenum .

It has 3 parts ,1-fundus (rounded and lies opposite to costal arch(right costal
cartilage of 9th rib)), 2-body (contacts visceral surface of liver and directed
upwards , backwards and to the left) 3- neck (attaches to cystic duct that join
common hepatic duct and forms biliary duct).

Blood supply cystic artery (branch of right hepatic artery), veins draining pass
to liver forming porta hepatica, lymphatics pass to hepatic nodes .
Gall bladder subject to acute and chronic inflammations (chronic usually
associated with formation of gall stones that cause obstruction of bile flow and
acute pain that can further cause jaundice)

L&R hepatic ducts form common hepatic duct, cystic duct and hepatic duct
form biliary duct passes to duodenum and is embedded in head of pancreas ,
joins pancreatic duct in hepatopancreatic ampulla that opens to duodenum at
ampulla of Vater .
Variations of Biliary Tract
Cholecystectomy: removal of gall bladder.
Diagnostic triangle of Galo: used to find cystic artery in cholecystectomy, it
is formed on the right (cystic duct), left (common hepatic duct),
superiorly (right hepatic artery)
Biliary duct has 4 parts, supraduodenal (lies in free right edge of lesser
omentum) , retroduodenal (behind first part of duodenum) , pancreatic part
(groove on posterior surface of head of pancreas), duodenal part (medial wall
of second part of duodenum)
Gall bladder is usually covered by peritoneum mesoperitoneal, but variants
may occur (intra/extra-peritoneal)

Duodenum
Located in epigastric and umbilical region , forms first part of small intestines
, it’s continuous with the stomach , first cm is attached to lesser omentum , rest
is retroperitoneal and attached to posterior abdominal wall.
Duodenum has 4 parts
1-superior horizontal part : passes posterior and right to vertebral column
2-descending part : descends along vertebral column
3-inferior horizontal part : crosses vertebral column at level of third lumbar
vertebra
4- ascending part : ascends to duodenojejunal junction at level of second
lumbar vertebra
The biliary duct and the portal vein lie behind the posterior part of the
duodenum.
The biliary duct after joining with the pancreatic duct curves to the right to enter
the posteromedial aspect of the descending part. More deeply the superior
horizontal part is separated from the inferior vena cava by the epiploic
foramen and the inferior horizontal part crosses both the inferior vena cava and
the aorta.
The superior mesenteric vessels, however, pass in front of the inferior
horizontal part.
The superior mesenteric artery may arise from the aorta under very acute
angle. It may lead to compression of the inferior horizontal part of the
duodenum and to anteriomesenterial ileus.
Also crossing the descending part from right to left is the attachment of the
transverse mesocolon.
Overhanging the duodenum anteriorly is the visceral surface of the liver and the
attached gallbladder.

Blood supply.
The duodenum is supplied by duodenal and superior
pancreaticoduodenal branches from the gastroduodenal branch of the hepatic
artery
and by inferior pancreaticoduodenal branches of the superior mesenteric artery.
Venous drainage
is to the portal and superior mesenteric veins. Lymph from the
duodenum passes proximally to pyloric, hepatic and celiac nodes and distally to
superior mesenteric nodes.

PANCREAS
The pancreas is both exocrine and an endocrine gland.
Exocrine portion of the gland produces a secretion that contains enzyme capable
of hydrolyzing proteins,fats and carbohydrates.
Endocrine portion of the gland , the islets of Langerhans , produces the hormone
insulin and glucagon , play a key role in carbohydrate metabolism.
Pancreas is a soft lobulated elongated organ that lies on the posterior abdominal
wall behind the peritoneum . it crosses transpyloric plane
The posterior surface is applied to the posterior abdominal wall has no
peritoneal relationship . the pancreas is therefore said to be retroperitoneal.
The anterior and inferior surfaces are covered by peritoneum , but at the border
where these surfaces join the peritoneum is reflected off each to form the fused
peritoneal layers of the posterior wall of the lesser sac and the transverse
mesocolon. This is the point that middle colic artery pass between the two
layers to reach the transverse mesocolon. As a result of this arrangement of the
mesentery the superior surface of the pancreas lies posterior to the lesser sac
Inferior surface faces the infracolic compartment of the greater sac
The pancreas has a head it is situated in the curve of the duodeneum and lies
anterior to the inferior vena cava and the left renal vein and through which
travels the biliary duct.
A small portion of the head is tucked beneath the superior mesenteric vein and
is known as unicinate process.

The head is joined to the body by the neck which overlies the mesenteric vessels
and the portal vein
The body extends to the left as far as the hilus of the left kidney and overlies the
aorta , the left renal vein , the splenic vessels and termination of the the inferior
mesenteric vein . anteriorly attachment of the transverse mesocolon
The tail of the pancreas passes forward in splenicorenal ligament and comes in
contact with the hilum of the spleen .
The mail pancreatic duct transverse the organ to open into the second part of
duodenum in company with the bile duct. The accessory duct drain the lower
part of the head or uncinate process or may drain the upper part of the head and
open into the duodenum ,above the level of mail duct on minor duodenal papila
. The accessory duct frequently communicates with the main duct .
Blood Supply,
the head of the pancreas is supplied by both superior and inferior
pancreaticoduodenal arteries. The remainder is supplied by many branches of
splenic artery .
Veins drainage of the pancreas join the portal, splenic and
superior mesenteric veins. Lymphatic from the pancreas follow the course of its
blood vessels to preaortic nodes.

SPLEEN
The spleen forms part of the recticuloendothelial system and is concerned with
hematopoesis in fetal life and in the adult with the reutilisation of iron from the
hemoglobin of destroyed rbc.
It is oval in shape and lies beneth the left half of the diaphragm close to 9th,10th
and 11th ribs.The plural cavity separates spleen and diaphragm from the rib. A
border which is notched anteriorly separated this surface from a somewhat
concave visceral surface. Here is found the hilus,where the vessels enter and
leave the organ. The visceral surface is related to the left kidney, stomach and
splenic flexure of colon. Each surface is covered with visceral peritonium
which
is reflected as double layer onto the left kidney as the splenicorenal ligament
(in
which lied the tail of pancreas) and onto the stomach as the gastrosplenic
ligament
BLOOD SUPPLY
– the spleen is supplied with blood by the splenic artery and
blood drains from the splenic vein , this is a tributary of the portal vein and thus
blood from the spleen is carried to the liver

Lymphatic drainage is to nodes at the hilus and hence to celiac nodes

The normal spleen is not palpable . however in a number of conditions
enlargement occurs and in due course its tips becomes palpable immediately
beneath the anterior abdominal wall at the left costal margin , further
enlargement occurs in a diagonal direction towards the right iliac region
.bleeding is very difficult to control

CELIAC TRUNK AND ITS DISTRIBUTION

The abdominopelvic position of the intestinal canal is supplied by 3 large
midline branches of the abdominal aorta .
First of these celiac trunk
Celiac trunk is short wide midline vessels arising from the anterior aspect of the
abdominal aorta at the level of the 12 th thoracic vertebra ,here it is closely
invested by the celiac plexus of autonomic nerves and lies behind the cavity of
lesser sac
It is divided into 3 branches – these are splenic , left gastric and common
hepatic arteries
The splenic artery follows a sinuous course across the posterior abdominal wall
at the upper border of the the pancreas . Reaching the splenicorenal ligament it
is carried in this to the spleen, it gives off short arteries and the left
gastroepiploic artery also gives off many pancreatic branches
The left gastric artery ascends to the left across the posterior abdominal wall to
reach the gastroesophageal junction close to the diaphragm . after giving off
esophageal branches it descends the lesser curvature of the stomach to supply it
and anastomosis with the right gastric artery
The common hepatic artery is slightly more complex , it descents to the right
across the posterior abdominal wall until it lies above the retroperitoneal first
part of duodenum. It gives of the right gastric and gastroduodenal arteries , from
the duodenum the artery is now called the proper hepatic artery and it is carried
to the liver. At the liver the artery divides into left and right hepatic branch .
The cystic artery supplying the gall bladder is usually given of by right hepatic
artery . The left branch of hepatic artery supplies not only the left lobe but also
the region of caudate and quadrate lobes. The right branch supplies the region to
the right of the plane passing through the gall bladder and groove for inferior
venacava.
Arising from the common hepatic artery at the first part of duodenum , the
gastroduodenal artery passes behind the duodenum and divides into right
gastroepiploic artery and superior pancreaticoduodenal artery . In addition it
supplies branches to pyloric, stomach and the duodenam.
CLINICAL NOTES
The peritonial fluid circulates around the peritonial cavity and quickly finds its
way into the lymphatics of the diaphragm . It is generally accepted that
absorbtion of toxins from under the diaphragm is most rapid, therefore to delay
the absorption of toxins from infraperitonial infection the nurse practice to sit a
patient up in the bed with the back at an angle of 45 degree (supine position) .
In this position the infected peritonial fluid gravitates downward into the pelvic
cavity , where the rate of toxin absorption is slow.
Collection of infected peritoneal fluid in one of the suphrenic spaces is often
accompanied by infection of adjoining pleural cavity . a patien with subphrenic
abscess often complains of pain over the shoulder . the skinof the shoulder is
supllied by supraclavicular nerves C3 AND C4 which supplies to peritoneum
and centre of diaphragm .
The greater omentum is often reffered to by the surgeons as the” abdominal
policeman “ . the infection is often localised to a small area of the peritoneal
cavity thus saving the patient from serious diffuse peritonitis . the greater
omentum has also been found to plug the neck of hernial sac and prevent the
entrance of coils of small intestine. The greater omentum may undergo torsion
and bloodsupply to this part may be cut off causing necrosis
Fractures of lower rib or penetrating wounds of the thorax or upper abdomen
are common cause liver injury . blunt traumatic injuries from automobile
accidents are also common and severe and may tear the organ
The majority of amebic abscesses in the liver are located in the upper part of the
right lobe . diaphragmatic irritation may cause pain over shoulder since the
impulse Ascend in the phrenic nerves C3,C4 AND C5 and supraclavicular
nerves C3 and C4 supply the skin in this area.

Liver biopsy is common diagnostic procedure where the patient holding his or
her breath in full expiration to reduce the size of costodiaphragmatic recess and
reduce damage of lung the needle is inserted through the right 8th or 9 th
intercoastal space
Obstruction of the biliary ducts with gallstones or by compression by tumor of
the pancreas result in backup of bile in the duct and development of jaundice .
Gallstones present in the gallbladder have known to ulcerate through the walls
into the transverse colon or into the duodenum
Anatomically the pancreas is deeply placed within the abdomen and protected
Inflammation or damage to the pancreas may result in effusion of peritoneal
fluid into this space .
Pseudocysts of the pancreas due to cystic accumulation of fluid in the lesser sac
Cancer of head of pancreas often causes obstructive jaundice .

SMALL INTESTINE
Consists of Duodenum, Jejunum and ileum. 20 feet or more of Jejunum are
mobile and
fill any space in Abdominopelvic cavity. This portion is found in Hernial Sac.
Jejunum fixed to posterior Abdominal wall at duodeno jejunal junction when
it begins.
Ileum is fixed to post Abd wall at ileocecal junction when it ends. B/w these 2
points intestine is attached to post Abdominal wall
by extensive mesentery of small intestine.
Long free edge of fold covers mobile Intestine. Short rool of fold is
continuous with Parietal peritoneum of post Abd wall along a line that extends
downward right
from 2nd lumbar Vertebra to right sacroiliac
joint. Root of messentery permits entrance and exit of branches of sup
mesenteric Art, vein, lymph vessels & nerves. Jejunum is of Greater caliber,
has thicker wall, Its lymphoid tissue is diffuse and jejunal arteries are packed
& united. Ileum has thinner wall, wall marked aggregation of lymphoid tissue
at Antimesentric border ( peyers patch). ileal art are linked by multiple
archades.

Blood Supply
- Supply for Jejunum and lleum is from branches of sup mesenteric artery.
Intestine branch arise from Left side of artery & run in mesentery to reach Gut.
They Anastomose to form Arcades.
- lleum also supplied by ileocolic art.
- Veins of Jejunums & ileum are branches sup Mesenteric art and drain into sup
mesenteric Vein.
lymph vessels Pass through Large
number of mesenteric nodes and reach
Sup mesenteric nodes which are present
around sup mesenteric art nerves are derived from sup Mesenteric
plexus.

LARGE INTESTINE
divided into ceum, Apendix, Ascending colon, Transverse colon, Descending
colon, Sigmoid Colon and rectum.
• larger in Caliber, Shorter in length than small intestine. Begins in Right iliac
fossa at iliocecal junction and terminates at Anus. Wall of cecum and colon
shows sacs or haustra.
• Hussstra are present because outer longitudinal coat of muscle fibre is
concentrated into 3 bands called taeniae colli.
Function: Absorption of Water &. electrolytes, storage of undigested material
until it can be expelled from body as feces.

CECUM AND VERMIFORM APPENDIX

lies in right iliac fossa below level of iliocecal junction.
Cecum is completely covered with Peritoneum and lies free in
Peritoneal cavity. No mesentery, Appearance of large Intestine.

Base of Appendix lies at posteromedial aspect of cecum.

Narrow organ, muscular tube containing aggregation of lymphoid tissue in wall.
Suspended from terminal ileum by mesoappendix.
This allows movement of appendix over pelvic brim or behind cecum or
ascending colon.
When inflamed Retrocolic position. inflammation makes difficult finding
base of appendix. This is solved by Taenia colli because all 3 meet at this
point.
Base of appendix
-lying at Junction of lateral & middle 3rd of a line joining Ant sup iliac spine
with Umblicus. This is known as Mc Burnet point.
• Surface projection at base of appendix is found in lance's point.
located between right 3rd and
middle 3rd of bispinal line.
Patients with acute appendicitis describe
pain close to these points and this is Guide for appendectomy Incision.
At ilececal Junction a slit like valve
with lips pointing cecum is present.
Movments of tip of Appendix :-
1. hanging down into pelvic against right Pelvic wall.
2. coiled up behind cecum in retrocecal fossa
3. Projecting upward along Lateral side of ceum
4. In front or behind terminal part of ileum.
1 and 2 are Common
Relations of cecumcoils
of small intestine, part of Greater
Omentum and Ant Abdominal wall in right
iliac regions. Psoas, iliacus muscle, femoral
nerves and Lateral cutaneous nerve are
located posteriorly. Appendix arise from
cecum on medial side.
Ascending Colon.
covered by peritoneum mesoperitoneally. lies on right side of Abdomen
extending
from right iliac fossa to right colic Flexure
below liver. Post surf related to muscles,
of post Abd wall lower pole of right kidney
Ant surf related to coils of small intestine,
Greater omentum, Ant Abd wall. Bends
towards left at right colic flexure.
Transverse colons:
Extends from right colic flexure to left colic flexure. lies at higher level on left
side of abdomen. occupies umbilical and hypogastric regions.
Hangs from Transverse mesocolon and descends towards pelvic.
ant surf Related to Greater omentum and
Ant Abdominal wall. post surf Related to 2nd part of duodenum and the head
of Pancreas. Inf surf related to coils of jejunum and ileum.
Descending colon
Begins at left colic flexure tethered to
diaphragm by perinocolic ligament.
covered by mesoperitonium on Left
side of Abd cavity.
Post Sulf Related Lower pole of left
kidney below to Quadratus lumborum,
psoas, iliacus muscle, ilio hypogastric and ilioinguinal nerve, lateral
cutaneous n and
femoral n.
Ant surf related to coils of small intestine, Greater Omentum & ant Abd wall.
Ends near
brim of lesser pelvic and becomes continuous with sigmoid or pelvic colon.
laterally from Ascending and Descending colon is situated lateral canals
medially from Ascending and Descending colon is situated mesenteric
sinuses.
Blood supply of Large Intestines,
Sup and inf Mesenteric art are branches of abd aorta.
Territory of Sup M. A extends of distal half of duodenum to Latter 3rd of
transverse colon. from this point to upper part of the
anal canal supplied by inf mesenteric art.

from right side of Sup mesenteric art arise

ileocolic, right colic,middle colic Art
1. ileocolic
Gives Ant and post cecal art.
branches that supply appendix
2 Right colic and ilecolic cross post Abd wall behind peritoneum to reach
colon
3 Middle colic crossed by root of transverse
mesocolon distributed to transverse colon
inf Mesen Art supplies upper part of
anal canal
- Left colic
supply last part of transvene
colon, left colic flexure upper Descending
colon a descending branch of Left colic
art supplies remaining descending
colon.
Sigmoid Art Supplies sigmoid colon.
combination of inf mesenteric art and
Sup renal artery - into 2 or 3 branches
to supoply rectum. Marginal branch of middle colic art
forms Riolan's Arch in transverse
mesocolon.
Venous drainage of intestine
Veins correspond to Arteries. hepatic portal systems, consists of portal veins
and its tributaries - splenic, Sup mesen and inf mesenteric Vein, left & Right
Gastric veins and cystic vein
epiploic foramen seperates portal
vein from inf Vena lava on post wall.
Blood from lower end of esophagus,
stomach, gall bladder drains into
portal vein through Left and right gastric and cystic Vein.
Splenic vein is formed by hilus of spleen
by union of tributaries, joined by inf mesenteric veins.
• Sup mesen unites with splenic to form
portal vein.
inf mesen joins splenic vein

The splenic vein

The splenic vein is formed at the hills of the spleen by the union of a number of
splenic tributaries and veins from the greater curvature of the stomach. (Behind
the
upper border of the pancreas it receives many small tributaries from that organ).
Splenic vein is then joined by the inferior mesenteric vein.

Superior mesenteric vein

Superior mesenteric vein is formed by tributaries which correspond to the many
branches of the superior mesenteric artery. It unites with the splenic vein to
form
the portal vein.
The inferior mesenteric vein drains an area similar to that supplied by the
inferior
mesenteric artery. The vein, however, leaves the artery to ascend over the left
side
of the posterior abdominal wall and slip beneath the lower border of the
pancreas
where it joins the splenic vein.

OPERATIONS ON THE ABDOMEN

Herniotomy
Operation consists of the following stages: 1) Removal of the sac, 2) Repair
of the
defect.
Anesthesia: Local or general anesthesia may be used depending on the needs of
the
patients and availability of the necessary skills.
Inguinal hemiotomy prior to reconstruction
Superficial epigastric and superficial external pudendal vessels are secured. The
incision is deepened until the aponeurousisi of external oblique is exposed, and
the
superficial inguinal ring, through which the cord emerges is identified. The
external oblique aponeurosis is divided in the line of its fibers, the incision
being
placed so that it opens into the ring in its upper medial part if a satisfactory
overlapping is to be achieved later in the operation. Forceps are applied to the
two
cut edges: the upper leaf is retracted to expose the muscles arching over the
cord,
and the lower to expose the upper surface of the inguinal ligament. The
ilioinguinal
and iiohypogastric nerves are identified and safeguarded.

The cord, with which is included the hernial sac, is lifted up from the medial
part
of the incision and is spread on the finger. Its covering are incised
longitudinally,
and are further separated by blunt dissection, carefully is taken to avoid injuring
the spermatic veins. If the hernia is recent and is completely reducibly,
recognition
of the sac may be a matter of some difficulty. It appears as pearly-white
structure.
Further separation of the sac may be a matter of some gauze stripping. When
separation is complete the sac is opened at some distance from its neck or at
fungus, and a finger is introduced into its inferior to ensure that it is empty of
contents.
Adherent contents are freed from the sac and returned to the abdomen.
The sac is now drown strongly downwards, and a transfixion ligature is applied
immediately above the neck. When the neck is wide, the purse-string suture is
applied. The sac is amputated 1 cm below the ligature prior to cutting the
ligature
so that there is adequate control of the stump in the event of bleeding.

RECONSTRUCTIVE PROCEDURES
The Bassini method of repair is used for treatment of the direct hernia. This
classical operation was 1st described by Bassini in 1888. It consists essentially
in
strengthening the posterior wall of the inguinal canal in its lateral part, by
stitching
the lower border of the muscles to the inguinal ligament behind the cord.
After the sac has been removed, the cord together with the ilioinguinal nerve, is
held out of the way be drawing the lower part of the external oblique
aponeurosis
downwards superficial to it. The lower border of the muscles and the upper
surface of the inguinal ligament are carefully cleared of fat and areolar tissue.
The muscles
are lifted forwards with dissecting forceps and five or six stitches are inserted at
about 1cm intervals between them and the inguinal ligament.
The most lateral suture is inserted first, picking up tissue at the margins of the
deep
ring and the ring around the emerging cord.
All stitches should be introduced at different depths into the inguinal ligament,
in
order that they may not cause splitting of the ligament along the line of sutures.
It
is particularly important that the stitches should not be tied too tightly or they
will
cause strangulation of the muscular fibers, which included in any suture. The
muscles should lie snugly around the cord in the lateral part of the wound, thus
giving support to the deep inguinal ring. The cord is allowed to fall back on the
strengthened posterior wall of the canal. The aponeurosis of external oblique is
repaired either by simple suture or preferably by overlapping. The reconstituted
superficial ring should fit snugly around the cord, but it must not be too tight or
atrophy of the testis may result, it should admit the tip od the little finger
without
difficulty, in addition to the cord. After careful homeostasis the wound is closed
by suture of the superficial fascia and skin.

The methods of repair of the inguinal canal in oblique hernia are: Girar,
Girar-Spasokukotsky, Girar-Spasokukotsky with suture of Kimbarobsky,
Martynov, Ru-Oppel. They consist essentially in strengthening the anterior
wall of the inguinal
canal by stitching the lower border of the muscles to the inguinal ligament in
front
of the cord.

The Girar method of repair:

+ 1 stage. The lower borders of the internal oblique muscle and transversus
abdominis muscle are drawn down in front of the cord and stitched to the deep
surface of inguinal ligament.
+ 2 stage. The upper leaf of the external oblique aponeurosis is mobilized and
drawn down and stitched to the deep surface of the inguinal ligament.
+ 3 stage. The lower leaf of the external oblique is stitched against the upper
leaf
thus overlapping it.
This method has the shortcomings: The inguinal ligament may split. The
muscles
and the inguinal ligament are heterogenous tissues, therefore weak scar tissue
may
be occurred.

#1
The umbilical hernia
The Mayo's operation is method of the treatment of the umbilical hernia in
adults.
The Lekser's operation is method of the treatment of the small umbilical
hernia in children (or in adults).
The Mayo's operation.
A transverse elliptical incision is made enclosing the
umbilicus and the skin covering the hernia. The neck of the sac is generally free
from adgesion, and should
always be opened first. To enable this to be done the aponeurosis is cleared
centrally from all
directions until the neck of the hernia is exposed at level where it emerges
through
the linea
alba. A small incision is made in the fibrous coverings of the neck at any
convenient point on its circumference, and is carefully deepened until the sac
itself
has been opened.
The remaining circumference of the neck of the sac is then divided with
scissors,
the finger being used to protect the contents from injury. The central 'island"
comprising the attached
ellipse of skins and fat is now joined to the abdomen only by the contents
passing
into the sac.
These contents are carefully examined. The hernial contents are returned to the
abdominal cavity.
Repair of the abdominal wall.
The opening is enlarged laterally on each side by a transverse incision so that
comfortable overlapping of the aponeurosis can be obtained. For the first stage
of
the overlap a series of
four or five interrupted mattress sutures is employed. These are introduced so
that
they will draw the free edge of one flap for a distance of 4 cm under of the other
flap.
The overlapping is then completed by suturing the free edge of the superficial
flap
against the deep flap.

The Lekser's operation:

The hernial sac of umbilical hernia in children is very small. It is separated
from the tissues, is not incised and is returned to the
abdominal cavity.
Repair of the abdominal wall.
1 stage. The purse-string suture is put around the umbilical ring.
2 stage. The interrupted sutures are put on anterior wall of the sheath of the
rectus abdominis muscle. Obturator hernia is very uncommon. it is
encountered most frequently in elderly
women who have lost we
The herniation occurs through the obturator foramen usually along the narrow
canal traversed by the obturator vessels and nerve. Strangulation is therefore
liable
to ensue.
Puncture of an Abdominal Cavity
Puncture of an abdominal cavity or laparocentesis puncture of an anterior
abdominal wall by a troacar.
is carried out with the therapeutic purpose ; evacuation of a liquid at an ascites
with the diagnostic purpose for detection of damage of organs of an abdominal
cavity at a blunt trauma of art abdomen, small penetrating wound, and also as
one of stages of a laparoscopy
The laparocentesis is counterindicated for the patient with a abdominal
distention,
multiple postoperative scars on a anterior abdominal wall, as the probability of
damage of internal organs is very high.
At a diagnostic puncture, if the blood, exudate, bile, intestinal contents follows
from an abdominal cavity, means-the organ is damaged. At this time the
operation is stopped.
Otherwise the technique of a "searching" catheter is applied. Into a tube of a
troacar a chiorvinyl catheter with apertures on the end introduced. A catheter
entered in the direction of a Iiver, la era canals, to a pelvis. Thus the external
end of a catheter is connected with a syringe and the aspiration is made. It is
possible to
introduce into abdominal cavity 10 mi of a sterile solution (Novocainum,
normal
saline solution etc.), and then it to as irate. This method names as layage of
abdominal cavity. If in a solution the impurity of a blood, in estinal contents,
urine,
muddy exudate are found out, it proves damage of internal organs.
Complications: damages of an intestine (at presence of adhesive process),
formation of an ascetic fistula, infection of an abdominal cavity
Laparoscopy
-optic-tool visual inspection of an abdominal cavity and its organs in
the cluicrcirurposp.. It is indicated for detailed survey of an abdominal cavity
with
the purpose of detection of damages of organs, to and inflammatory processes,
detection of a portal
hypertension, clottage of mesenteric vessels etc. It is counterindicatied for the
extremely serious patient, at the phenomena of a meteorism and adhesive
process
in an abdominal cavity. Troacar of a laparoscope are entered same as at a
laparocentesis. For expansion of an abdominal cavity into it a gas (air,
Oxygeniurn,
carbon dioxide) introduced through the special cock on a trocar or through a
special needle from a set of a laparoscope. For introduction of gas usually use
the
special apparatus allowing it to sterilize. Then an optical tube entered for
survey.
Illumination of an abdominal cavity make by the lighter paired to an optical
tube
by
means of a flexible light guide. That it is good to examine an abdominal cavity,
it
is necessary to Jr change a position of the patient on an operating table.
The Surgical Accesses
The requirements to surgical incisions. the cut for an access to organs of an
abdomen should satisfy to the following requirements: the incision should be in
a
projection of an organ and provide the most brief way to it; the size of a section
should provide an easy approach to an operated organ; the incision should
minimally traumatize soft tissues, vessels and nerves to provide formation of
strong postoperative scar; the incision should provide good cosmetic result
Longitudinal incisions
The median. laparotomy (midline incision) is carried out on a linea alba of an
abdomen.
Depending on a position of a incision in relation to a umbilicus are
distinguished
the superior, medial and inferior median laparotomy.

At the superior midline laparotomy the incision is carried out between a xiphoid
process and umbilicus a direction of a incision from a xiphoid process to the
umbilicus to not damage a liver)
The inferior midline laparotomy is carried out from a pubis up to a umbilicus
(direction of a incision-from a pubis to not damage a urinary bladder).
The middle midline laparotomy is carried out with round of a umbilicus at the
left
(so that the manipulations in an abdominal cavity were not prevented by a round
ligament of a liver).
The midline laparotomy has received the greatest application, as gives the
following advantages:
quickness of performance;
a wide access to the majority of organs of an abdominal cavity;
does not damage a muscle, vessels and nerve;
an insignificant bleeding;
in case of necessity can be prolonged both up, and from top to bottom;
the incision can be easily closed.

Disadvantages of an incision: that the postoperative scar has a strong tension (as
is a
place of connection of three pairs wide muscles) and the median initially is the
badly
strengthened and poorly blood supplied part of a anterior abdominal wall —
therefore postoperative hernias may occur.
A paramedian incision carry out according to internal edge of a rectus
abdominis
muscle, the anterior leaf of its sheeth is dissectied together with a parietal
peritoneum.
The advantage of this incision consists in formation of strong postoperative
scar, as
the
rectus muscle is displaced and also incisions of anterior and posterior layers of a
sheeth of rectus muscle do not coincide.
A dis advantage is the restriction of length.

Transrectal incision. Anterior and posterior walls of a sheeth of a rectus

muscle are
dissectied, and muscle stratify on a course of fibers. The advantage is same as at
paramedian incision — the muscular tissue rich vessels, quickly grows together
and strong scar formed. However, at wide incisions the nervous branches going
to
medial departments of a muscle are
damaged. Development of an antrophy of medial departments of a muscle and
occurrence of a postoperative hernia subsequently is possible. A disadvantage is
the restriction of length.
A pararectal incision. An example — the Lenander incision — made parallel
to
lateral edge of a rectus muscle laterally and below umbilicus. Anterior wall of a
sheeth of a rectus muscle a
Disected, edge of the muscle allocate medially, and then posterior wall cut
together with a parietal peritoneum.
The advantages and disadvantages are same as at transrectal incision
The oblique incisions. This cuts usually made in the superior part of a anterior
abdominal wall —parallel to edge of a costal arch; in the inferior part —
parallel to
inguinal ligament and little
above it or under an angle to it.They used mainly for accesses to a liver,
gallbladder, bile ducts, vermiform appendix ,sigmoid colon, etc.
The transverse umbilicus. They provide a wide access to organs of an
abdominal
cavity, strong postoperative scar. However they applied less often others in
view of
the greater difficulty of their performance and suture (in comparison with a
median
laparotomy)sions made with crossing of one or two rectus muscles above or
below
The angular incisions made if necessary prolongations or enlargement of the
before
made incision in the other direction under angle (for example, at the superior
median laparotomy as access to a liver the incision may prolonged
perpendicular to
left costal arch).
The combined incisions are the incisions at which open two cavities —
abdominal
and thoracic (thoracoabdominal accesses). They are applied, if necessary of
wide
access to organs of an abdominal cavity (at a gastrectomy, splenectomy,
resection
of a liver and other operations), at a simultaneous operations on organs of both
cavities (for example, at thoracoabdominal wounds, when the organs of a
abdomen and thorax are injured), at operations on organ posed in both cavities
(for example,
at an esophagoplasty).
The alternating (gridiron, muscle-splitiing) incision — incision at which
direction
separations of tissues in different layers is changed on a course of performance
of
cut. In each
layer the direction of a section of tissues depended from a direction of muscular
or
aponeurotic fibers, i.e. incision is made on a course of muscular or aponeurotic
fibers.
The advantage of this incision — muscles do not cut and due to discrepancy of
lines of separation of muscles, the abdominal wall keeps after operation the
durability,
Example: McBurne -Volkovitch incision for appendectomy, Pfannenstiel
incision
for operation in gynaecology.
Disadvantage of alternating incision — small access.
The basic rules, which are necessary for keeping at all laparotomies and
operations on organs of an abdominal cavity
At operations on organs of an abdominal cavity it is necessary to keep a
sequence
in performance of stages of operation and certain rules of a laparotomy:
The incision of a anterior abdominal wall should be made according to
layers and
according to layers to sew up (sequence of dissected layers depends on a kind of
a
incision — see above).
For preservation from pollution of an abdominal wall by contents of an
abdominal cavity a wound covered by towels.
Most responsible stage of a laparotomy — opening of a peritoneum, A
peritoneum open always under the control of an eye in order to prevent casual
of
organs of an abdominal cavity. The peritoneum is grasped and rises by two
anatomic forcepses. Having convinced, that in the formed thus fold of a
peritoneum there are no organs, the peritoneum is dissected and fixed to towels
by Mikulicz forcepses.
A wound of an abdominal wall stretch by laminar hooks or retractors. It is
necessary to keep up, that under branches of hooks the loops of an intestine,
omentum and
other organs should do not traumatize. In an abdominal cavity work only by
anatomical forcepses.
The revision of an abdominal cavity should be carried out strictly
methodically and in the certain sequence depending on its purposes.
The infringement of an integrity of a serousa of a organ should be welltimed
is noticed and is liquidated (sew).
It is desirable to operate on the emptied organ of an abdominal cavity. To
facilitate
performance of operation and to prophylactic of infection of an abdominal cavity
For preservation from a desiccation the taken organ covered by wet
napkins.
After applying internal infected series of an intestinal sutures closing a
lumen of a organ, it is necessary to change covering towels and instruments;
the operating
brigade processes (washes) gloves by a disinfectant solution or changes them.
Upon termination of operation reliability of a hemostasis is checked,
whether the napkins, gauze globules, instruments are left in it. The abdominal
cavity is carefully
drained from a blood, exudate.
If it is necessary to put in an abdominal cavity a drainage or gauze
tampons, they are recommended to prevent a divergence of sutures make this
not through an
operational wound, and through a contraperture — an additional incision away
from basic.
Revision (exploration) of organs of an abdominal cavity
It is made with the purpose of detection of damage of organs at trauma of a
abdomen, finding out of a source of inflammatory process at a symptoms of an
acute
abdomen and
decision of a question on an operability of malignant tumours of organs of an
abdominal cavity.
Operation will carry out from a median laparotomy sequencely and
methodically.
At detection in an abdominal cavity of a blood first of all parenchymatous
organs are
examined: a liver, spleen, pancreas. During revision of a liver for survey are
accessible its
anterior and inferior surface. The inferior surface becomes best outstanding
after abduction of a
transversal colon inferiorly. Visually a condition (integrity or damage) of
gallbladder and
hepatoduodenal ligament are determined. A diaphragmatic surface of a liver
palpated by an
hand entered in the right hypochondrium, under a dome of a diaphragm. In
some cases for the
best review it is necessary to dissect a falciform ligament of a liver.
For survey of a spleen, a stomach is displaced to the right, and left colic
flexure — to bottom.
It allows to find out damages of the inferior pole of spleen. By a hand entered
in the left
hypochoncirium, by palpation presence of damages of its other departments
determined.
To find out damage of a pancreas is possible only after opening ()mental
bursa, i.e. section
of a gastrocolic ligament. The accesses to a pancreas at its revision through an
Lesser omentum
and mesentery of a transversal colon do riot give the wide review of a organ.
If in an abdominal cavity after its opening find out contents of a stomach or
intestine without obvious attributes of a bleeding, first of all carry out survey of
hollow organs.
The survey of hollow organs also should be made in a strict sequence. In the
beginning are
an abdominal part of an esophagus, anterior wall of a stomach, its pyloric
department, superior
horizontal part of a duodenum are examined.
For survey of a posterior wall of a stomach it is necessary to open an epiploic
bursa, i.e. to
dissect a gastrocolic ligament.
For detection of a damage of a posterior wall of descending part of duodenum
it is mobilized
by cut the parietal peritoneum.
Intestinal Sutures
in a basis of majority of operations on gastrointestinal tract the intestinal
suture lies.
Term Intestinal suture" means all kinds of sutures placed on a wall of a hollow
organ of a digestive tube (an esophagus, stomach, intestine).
The common requirements to applying intestinal sutures:
♣Keeping of an asepsis, careful
hemostasis and the minimal
traumatizing of tissues, is especial on mucosa and submucosal layer;
The reliable tightness by
maintenance of wide contact of serous surfaces and adaptation of other
layers of a wall, is especial at operations on a colon and bile-excreting ways;
Application of a absorbable material (catgut) at applying of throughand-
through or plunging sutures inverted in lumen of gastrointestinal tract,
and not absorbable at applying serous-muscular sutures;
In connection with peristaltic
movements of an intestine the sutures from an absorbable suture material are
better for performance as continuous, and from not absorbable — as
interrupted;
The intestinal suture is made by the help of round (pricking) needles
(direct or bent).
in a wall of a digestive tube are distinguished four basic layers: mucosa,
submucosal layer, muscular, serous (on an esophagus — adventitious).
In a basis of an intestinal suture lays the

MODIFICATIONS OF AN INTESTINAL SUTURE

One-row through-and-through suture. The walls of sewed departments of
gastrointestinal tract connected by separate interrupted sutures, when the
ligature passes through all layers from within externally and outside inside or
“mucous—serous, serous—mucous”, and knot tied inside of mucous, i.e.., it is
inverted in a lumen of an intestine.
The one-row sutures form thin scar. The suture is faster carried out, does not
make conditions for intraparietal microabscesses. But the one-row suture is
less tight, from here necessity for more often sutures, that breaks a blood
supply of anastomosis. At an one-row suture the hemostasis is less reliable,
and before applying of this suture it is necessary to make a dressing of blood
vessels in a submucosal layer.

Two-row suture-the walls of sewed organs of gastrointestinal tract are

connected by two series of sutures: Internal—through all layers and outside
(external)— sero-muscular.
Three-row sutures include the first series of through sutures and in addition
two series of serous-muscular sutures. Two and the three-row sutures frame
reliable tightness, good hemostasis.

Two-row suture now is most widely used, at which the first (internal) series of
sutures pass through all layers of the dissected wall of organ, and second
(external) - through an outside layers (serous and muscular).
The internal suture taking place through in all layers of the intestinal wall will
be infected. Hence, atop of an internal suture one more is necessary—outside
(external) suture, which would not penetrate into a lumen of gastrointestinal
tract, and passed only through an outside (external) layers (serous and
muscular).
From here all intestinal sutures can be divided on internal (through, infected)
and outside (external, sero-muscular,aseptic). Thus, any modification of a
two-row intestinal suture consists of through (internal) and aseptic
(outside,external)sutures.
Internal through-and-through sutures
—Through sutures can be manual or
mechanical. From manual sutures the following most wide-spread: interrupted
suture with knots inside of a lumen, interrupted mattress sutures. Continuous
sutures: simple continuous suture— the thread will be carried out through
edges of sewed walls by a principle “mucous—serous, serosa—mucous”, i.e.,
from within externally, outside inside. The screwing “glovers” (furrier´s)
suture of the Shmiden— thread goes from within outside, i.e “mucous—
serous, mucous— serous”. The thread thus is tightened after each stitch,
therefore walls are inverted, adjoining by the serous surfaces.
Hemostatic sutures.
They have for an object a reliable hemostasis of vessels of
the cut wall of gastroinstestinal tract. Winding round (blanket) suture of the
Reverden- Multanovsky. At applying of regional marginal suture after
realization of a glitch a thread pass into a loop and lighten.
“Stitch” suture
(Often apply at a closure of a stomach stump during a
resection), it is performed as follow, by the direct or bent round needle with a
long catgut thread pierce a stump of a stomach in front back through two walls
immediately under a clamp on the part of the greater curvature.
“Mechanical suture”
— First series of through sutures can be executed with the
help of mechanical suture apparatuses, which recently find more and more
wide application at operations on gastrointestinal tract: at a resection of a
stomach and the intestines applying of a gastroenteroanastomosis
(Suture material in such devices are tantalic brackets. tHE MECHANICAL
APPARATUSES CAN BE DIVIDED ON TWO GROUPS: APPARATUSES
for suturing a lumen of a organ, apparatuses for formation of an anastomosis.
External aseptic sutures
— Serous-muscular suture consists that stick of a
needle in each stitch make through serous and muscular layers. These sutures,
as a rule, are interrupted, for their applying the not absorbable suture material
is used. Versions: interrupted seromuscular suture, interrupted mattress suture.
+ Purse-string suture- serous-muscular suture by stitches on a circle. Is used
for immersing a stump of a vermiform appendix, duodenum, small intestine,
and also for suturing small punctured wounds of a stomach or intestine.
After a stitching the ends of a thread pull together and fasten, the stump or
wound thus is immersed in depth of a call of an organ.
+ Z-shaped suture is additional to purse-string and is imposed a top of it. At
this kind of a suture are made sticks of a needle as though on 4 angles of an
imagined quadrangle on depth of a serous— muscular layer. In final result
the suture as the letter Z turns out.

PRINCIPLES OF APPLYING GASTROINTESTINAL AND

INTERINTESTINAL ANASTOMOSES

Dissecting away of a mesentery from an intestine can be made doubly: parallel

to intestine at its side at a level of direct arteries, sphenoidally (clinoid) —
with a preliminary ligation of vessels near a root of a mesentery (extensive
resections, tumor of an intestine)
Mesentery is pierced in a nonvascular zone from two sides from a vessel,
which can be defined on a light. A curved homeostatic clamp introduced into
the formed aperture. The branches of a clamp are divided, enlarging this
aperture in a mesentery. The second clamp is introduced towards and pinch
this site of a mesentery together with vessels. The same site of a mesentery is
crossed. A removed site is ligated. A mesenteric site ligated with a preliminary
under running (suturing).
Types of intestinal anastomoses
— There are distinguished 4 types of
intestinal anastomoses: end-to-end, side-to-side, end-to-side and side-to-end.
The end-to-end anastomosis — direct connection of hollow organs with
applying of two or three-row narrowing a lumen of an intestine in a place of
applying of an anastomosis, the intestine should be crossed in a oblique
direction, deleting it is more on free edge. The ends of intestine of a different
diameter this kind of an anastomosis to bridge is not recommended.
The anastomosis side-to-side — the tightly closed two stumps placed
isoperistaltically and bridge by an anastomosis on lateral surfaces of intestinal
loops or stomach and intestine. he danger of narrowing at this kind of an
anastomosis is not present, as width of an anastomosis here is not limited by a
diameter of sewed intestines and can freely be adjusted.

Anastomosis end-to-side is applied at connection of parts of gastrointestinal

tract of a different diameter: at a resection of a stomach, when its stump sew to
a lateral wall of a small bowel; at connection of a small bowel with large
intestine, when the end of a small bowel sew to a lateral wall of a colon.

The anastomosis side-to-end —lateral surface of more proximal organ is

bridged to the end of emote distally posed organ. Is applied less often others
(gastroenteroanastomosis, ileotransverseanastomosis).
Technique of applying of an anastomosis:
- I row of sutures. Sero-muscular sutures.
Blocked by clamps after a resection of a site of an intestine the proximal and
distal ends approach with each other by posterior surfaces. Having receded
from a clamp 0.7 - 1cm, the posterior surfaces of the pulled together walls of
an intestine sew by separate interrupted serous
—Muscular silk sutures (1row). Distance between sutures 0.5cm. The extreme
(lateral)ligatures leave as guy sutures, others cut away.
- opening of lumen of intestine.
Operations on a Stomach
Gastrotomy
Gastrotomy - opening of a lumen of a stomach
specification
therapeutic purpose - as a stage of operation - for removal o foreign bodies,
polyps,
stopping of a profuse gastric bleeding etc.
Suturing of a ruptured ulcer of a stomach and duodenum.. Position of the patient
on
a back. An anesthesia - endotracheal narcosis
The stomach and duodenum are looked round.
The suturing is made in transversal direction
For greater reliability after a tie of knots to a place of perforation the nearby site
of
an omentum is fixed by the same sutures.
Drainage of an abdominal cavity. Gastric contents and exudate should be
carefully
removed from an abdominal cavity by an electro-suction machine and dry
napkins.
Mistakes and complications narrowing of a lumen of a stomach or duodenum.
suture of a wall of a St0MaCh Of duodenum, sewing of a gastric tube: an
incompetence insufficincy of sutures
Gastrostomny
The operation of formation of an artificial outside fistula of a hollow organ is
made for feeding (nutrition) of the patient, realizations of necessary therapeutic
arrangements, abductions y contents A an obstruction of distal departments, for
temporary shutdown of function of distal departments of gastrointestinal tract
and. hence, creations A rnore favorable conditions for a healing of wounds.
ulcers etc. On localization of fistulas are distinguished gastric fistulas
(gastrostomy, fistulas of a small dowel Oejunostomy and ileostomy) and colon
(colostomy). The fistulas of a colon according to its different departments are
subdivided into a cecoston, colostomy ascending. transversal. descending
oolone and also sigrnoidostomy. On a structure of the canal the fistulas are
divided on tubular (temporary) and lipform
N. (permanent). The tubular fistula is made by immersing (plunge) A a rubber
tube in the canal
formed from a anterior wall of an organ (a stornach. intestine). The internal
surface
A a fistula is inAd by a serous membrane,
Technique of the most wide spread gastrostomies for applying a tubular fistula
on a
stomach the greatest diffusion gave recived a witzel method and stamm kader
method
Indications n types
: an obstruction of an esophagus at a nonresectable cancer of an
esophagus and cardial department of a stomach, wounds, inherent defects.
Position of the patient: laying on a back.
Anesthesia: an endotracheal narcosis.

Access: a transrectal left-hand laparotomy by length 10 cm from costal arch

Downwards
Gastrostomy by witzel method
now majority of the surgeons applies more perfect technique of the witzel
mthod
when the end of a tube is introduced into a lumen of a stomach in the field of a
caridal department
The stomach is taken out in an operational wound. To an anterior wall of a
stomach,
on middle of distance between lesser and greater curvature, along its long axis a
rubber tube is put so that its end is located in the field of a cardial department of
a stomach. Above a tube 6 — 8 serous-muscular sutures are applied. After a tie
of these sutures tube becomes covered by folds of a stomach wall
The free end of a tube is introduced into a lumen of a stomach. A purse-string
suture tighten. A top of it 2 — 3 serous — muscular sutures are applied. By the
scalpel a small skin incision made on lateral edge of a rectus abdominis muscle
under the control of the left hand, entered in an abdominal cavity.

Gastrostomy by the Stamm — Kader method.

On an anterior wall of a stomach a pursestring suture are applied on a circle by a
diameter 5 — 6 cm. In center of a suture an opening is made and into a stomach
a rubber tube by a diameter 1 cm is introduced. A pursestring suture is tighten
and
fasten. Having receded on 1 — 1,5 cm to periphery from it consistently two
pursestring
sutures are applied immersing an earlier placed suture. Then a gastropexy
made as at a witzel method
Gastrostomy by the toprover method
an operational wound as a cone an anterior wall of an stomach is taken out on
an
apex of the cone two silk guy sutures are applied on distance 2 cm one from
another
below guy sutures on the extended wall of a stomach three concetric -St sutures
are
Placed: the first Suture — on distance 1,5 — 2 cm from guy sutures, 2nd and
third —
on distance 1,5 cm one from aanother
Wall of a stomach at a level of the bottom purse-string suture are sewed by
interrupted sutures to a parietal peritoneum. The edges of an incision of a
Panetal peritoneum on other extent of a wound are sewed up tightly. At a level
of the second
purse-string suture a wall of a stomach is sewed to an aponeurotic sheeth of a
rectus
muscle. The wall of a stomach is sewed to a skin by the third series of sutures so
that
the puffed out mucosa of a stomach was applied on a skin and could be sewed
to it
for formation of a permanent lip-form fistula. A skin wound on other extent are
sewed up. A tube is taken from a stomach.

Gastroenterostomy
Gastroenterostomy anastomosis between a stomach and initial part of an small
intestine (jejunum).There
There are distinguished the following gastroenterostomies:
anterior - the anastomosis is applied with an anterior wall of a stomach,
posterior - anastomosis is applied with a posterior wall of a stomach;
Antecolic - the loop of a jejunum is made to a stomach anterior to a transverse
colon,
retrocolic - the loop of a jejunum is made to a stomach behind of a transverse
colon.
4 variants of a gastroenterostomy are possible. In practice most frequently are
used
two: a anterior antecolic and posterior retrocolic gastroenteroanastomosis.
The indications: disturbance of evacuation of food from a stomach at the
nonresectable cancer of a pyloric department of a stomach, cicatrical narrowing
of a
pylorus at the sharply weakened patient, when is irnpossible to execute radical
operation. Position of the patient: laying on a back.
Anesthesia: an endotracheal narcosis.
Access: the superior rnedian laparotomy.
Anterior antecolic gastroenteroanastomosis (by Velfler-Nicoladony)
Using of the Gubarev method a duodenojejunal flexure and beginning of a
jejunum
found.
From a beginning of an intestine a part of length 50 cm is measured. An
intestinal
loop is made to a anterior wall of a stomach anterior to the greater omentum and
transverse colon. Afferent loop (small, lesser loop) e fixed by a silk sutures at
lesser
(small) curvature nearby a cordial department. Efferent loop (large. greater
loop) -
greater (large) curvature, is near a pyloric department of a stomach.
After that posterior series of serous muscular sutures are placed the threads are
cut
aaway except two extreme which are used as a guy suture
Posterior retrocolic gastroenteroanastomosis (by Hacker-Peterson)
For an anastomosis a loop of jejunum by length 7 -10 cm from duocienojejunal
flexure is taken. A mesentery of a transverse colon is dissected in a vertical
direction
in a nonvascular zone. By the left hand posed on a stomach, a posterior wail of a
stomach puffed out through an opening in rnesocolon transversum
Resection of a stomach
The indications: the complicated ulcers of a stomach and duodenum
(bleeding,
penetrating, callous, poor, stenosis). benign tumours (polyps, adenoma),
carcinoma of the stomach_ Position of the patient on a back.
An anesthesia - endotracheal narcosis.
Access: the superior median laparotomy.
The essence of operation consists of removal of a part of a stomach. Depending
on
IOCaluation of a deleted department are distinguished a pyloroantral, proximal
and
partial reset:ben of a stomach.

resection of a stomach - Bilroth-I and Bilroth-II.

At a resection of a stomach on a Bilroth-I method an anastomosis is applied
between
a II.MP Of a stomach and duodenum by a type end-to-end anastomousis.
Advantages of a resection of a stomach on this method are the following: The
anatomicophysiological way of food is kept - food partially passes in a
duodenum:
There is no direct contact of a mucosa of a stomach to a mucosa of a jejunum,
that
completely excludes formation of ulcers of an anastomosis: This method is
technically easier than others and is faster carried out, gives less complications.
Disadvantages of this method of operation are: an opportunity of a tension of
tissues
in the field of an anastomosis of a stump of a stomach and duodenum; presence
in the superior part of a gastroenteroanastomosis of a joint of three sutures. Both
moments can result in an eruption of sutures and cause an incompetence of an
anastomosis. However, at keeping correct technique of operation it is possible
to
avoid these adverse factors.

Techunique of a resection of a stomach by BlIroth-1 method.

Mobilization of a stomach.
Stomach and transverse colon taken out At a ligation of the right gastric artery
the clamps are applied in a direction from hepatoduodenal ligament for
prevention damage of a common bile dot. Hepatic artery and Pc. Vein
dissecting away of a stomach begin from the proximal end. With this purpose at
a level of a planned resection on the part of the greater curvature CereendicuAr
to axes of a stomach a damp is applied on width of an anastomosis. By the
second clamp grasped other part of a diameter of a stomach on the part of lesser
curvature. More distally than these damps on a removed part of a stomach a
crushing clamp of the Per or long Kocher's forceps are applied. On edge of a
Pean clamp a stomach is cut On an initial part of a duodenum intestinal
forcepses or 2 Kocher's forcepses are placed. Between which duodenum it cut
and resected part of a stomach deleted. The edges of a stump d a stomach and
duodenal intestine process by a solution of iodum.

Technique of a resection of a stomach by Bilrot ,ster-Finsterer.

Mobilization of a stomach and duodenum preparation of a jejunum for applying
an anastomosis. An initial department of a jejunum (duodenojejunal flexural
found ,ii.wascular zone of a mesentery of a transversal colon by a vertical by an
aorpe'nmlnrs'irnaind: ._,ough which initial loop of a jejunum (on 7 - 10 cm from
duodenojejunal flexural elevate in the. ,,,rtor floor of an abdominal cavity and
attached to a stomach.
Processing of a stump of a duodenum.
Stump of a duodenum is sewed by a continuous simple interrupted suture.
The further rnmersing (plunge) of a stump of a duodenum is made by Z-shaped
andcircular purse-string srlk sutures, or by two half-purse-string with additional
applying of interrupted silk sero-serous Mures.After applying sero-serous
sutures an additional peritonization of a stump of a duodenal intestine is made.
sewing it to a capsule of a pancreas. The suturing of a stump of a duodenal
intestine can be executed by a mechanical suture.

Operations on a Small intestine

Resection of a small intestine
The indications: tumors of an intestine or its mesentery, necrosis of an intestine
at an acute intestinal obstruction, strangulated hernia, clottage of arteries of a
small bowel, multiple wounds.
Position of the patient on a back
An anesthesia – endotracheal narcosis
An access – median laparotomy
Vessels of a mesentery: parallel to intestine at its edge at a level of direct
arteries or sphenoidal with a preliminary dressing of vessels of a root of a
mesentery.

Bowel resection.
On the proximal and distal ends of a removed departments of an
intestine in an oblique direction under a 40-degree rigid hemostatic clamps are
applied, so on the side opposite to mesentery the removed part would be more.
Enteroenteronanastomosis begin from suture of its wall by interrupted
seromuscular sutures. Careful stitches are placed at the edge on the intestine.
Then, elastic clamps taken out and posterior edges are sewed by catgut suture
and
anterior edges by screwing sutures of shmiden.
An opening in a mesentery is sewed by separate silk sutures.
A side-to-side enteroenteroanastomosis: (purse-string method of the Doyen)
A ligation by a catgut of an intestine under a clamp on a clamped site.
An applying of purse-string suture having departed on 1.5 cm from a ligature
An applying of a crushing clamp on a removed site and dissecting away of an
intestine on edge of a clamp.
Applying of enteroenteroanastomosis:
The sewed intestinal stumps are put one to another, avoiding rotation.
The walls in intestinal loops during 8-cm are connected by interrupted
seromuscular sutures.
A wall of one on intestinal loops in dissected. Cavity is drained.
Suture is applied on posterior edges of an anastomosis through all layers of an
intestinal wall. The anterior edges of an anastomosis are sewed by a thread.
Then, sero-muscular sutures are applied. The blind ends of a stump in order to
prevent their invagination are fixed by
several silk sutures to a wall on an intestine. Permeability of an anastomosis is
checked.

Operation on the large intestine

Peculiarities of the suture of the large intestine.
The large intestine compared with small saw the followings: thin and gentle
wall,
worse blood supply, posterior wall of ascending and descending colon is not
covered by peritoneum, intestinal contents contain more bacteria.
Large intestinal= less reliable, three-row sutures (1 internal series suture and 2
sero-muscle sutures)
2 types of operations on large intestine: Palliative operations and Radical
operations.
Palliative operations: does not eliminate the cause of disease, only restore
passage
on intestinal content, applying of a fecal fistula, creation of an artificial anus,
forming of a collateral anastomosis.
The radical operation: eliminates the cause of the disease and restore passage of
intestinal contents. The radical operations can be one-stage (removal or tumor
and
restore the integrity of an intestinal tube) or double-stage (1; removal of tumor
and creation of fistula. 2; performance of an anastomosis between sites of a
resected
intestine).
Appendectomy
Indications: acute or chronic inflammation of an appendix, a tumor appendix.
Acute appendix: operation should be made urgent.
Chronic appendix: in the “cold” periods.
Position of the patients on a back. an anesthesia- local or endotracheal narcosis.
Accesses – oblique muscle-splitting incision in the right iliac region.
In unknown cases, the inferior midline laparotomy is applied.
Opening of an abdominal cavity by a McBurney - Volkovitch incision
Oblique in (8 - 10cm) pass through a point posed between middle and lateral
third of line connecting anterior superior iliac spine with an umbilicus.
The incision goes perpendicularly spinoumbilical line.
Skin and subcutaneous fat are dissected, the branches of superficial epigastric
artery are crossed and ligated.
The aponeurosis of an external oblique muscle is cut along a course of fibers on
all distance of a skin incision.
Internal oblique and then transverse muscle are bluntly moved apart parallel to
fibers and stretched by Farebeufs laminar hooks.
The transversal fascia is dissected and wound covered by gauze napkins. The
parietal peritoneum raised by two anatomic forcepses is dissected under the
control of vision and fixed to edges of napkins by Mikulicz forcepses.
Identification and withdrawn of a cecum
The cecum differs from a small bowel by its gray color, presence of taeniae
coli, and from transverse and sigmoid colon - by absence on a dome of a cecum
of epiploic appendices.

The dome of a cecum is grasped by fingers or anatomic forceps and with the
help of a gauze napkin is tightened outside together with an appendix.
The further moments of operation are desirable for carrying out outside of an
abdominal cavity.
Dissecting away of a mesentery of an appendix.
On the apex of the appendix the haemostatic clamp is applied with which help
the appendix is hold. In a mesentery of an appendix 15 - 20 ml of 0.5% or
0.25% Novocainum solution is introduced.
On a mesentery of an appendix the haemostatic clamps are applied and ligated.
It is necessary to keep up the sufficient length of a stump of a mesentery. Else
ligature can slip off and a bleeding will occur.
Removal of an appendix.
The basis of the appendix are crashed by haemostatic forceps.
On the formed sulcus the appendix is ligated by thin catgut.
Around the base of the appendix on distance 1,5 cm by thin silk or capronum
the sero-muscular purse-string suture is applied, but it is not tightened.
Above ligature laying on the basis of the appendix the haemostatic forceps is
placed and between forceps and ligature the appendix is cut by a scalpel. The
appendix take away from a operational field.
Plunging (invagination) of a stump of an appendix.
The stump of the appendix is processed by iodum and by forceps is introduced
(invaginated) into the earlier made pursestring suture.
The purse-string suture is tied above a stump of the appendix. Atop of it the
Zshaped suture is applied.
The dome of a cecum comes back in an abdominal cavity. The presence of a
blood in an abdominal cavity is controlled by a swab entered into the right
lateral canal and in the pelvic cavity.
Suturing of an operational wound.
The peritoneum is sewed up by a continuous catgut suture.

On muscles the interrupted catgut sutures are applied until contact the edges of
muscles
The aponeurosis of an external oblique muscle is sewed by silk interrupted
sutures. The skin is sewd up by separate interrupted silk sutures.
Retrograde removal of an appendix.
If the appendix is connected by adhesion with a posterior surface of an
abdominal wall or with organs of a pelvic cavity and to take out in a wound is
impossible, the retrograde appendectomy is made.
For this purpose in a mesentery the base of an appendix the opening is made
and base of the appendix at this level dresses by a catgut ligature.
Around of the base of the appendix a purse-string suture is applied.
The appendix is clamped by a forceps on distance 0,5 cm from a ligature and is
cut between a forceps and ligature.
The stump of the appendix is closed by purse-string and the by Z-figurative
suture.
Cecum is allocated and the mesentery of the appendix is crossed between
clamps gradually from the base to the apex, stitched and ligated.
The vermiform appendix removed from an abdominal cavity. The cecum is
plunged in an abdominal cavity. The wound of an abdominal wall is sewed up
according to layers.
"Ligature" method of appendectomy.
The removal of the appendix is made by a standard method, but the stump of the
appendix is not closed by purse-string suture but only ligated.
This method is offered to avoid formation of the closed space around of a
stump closed by a pursestring suture.
In this place an infection can developed and chronic inflammation (appendicitis
without an appendix) or even an periappendicular abscess may be formed
.At a ligature method the danger of an infection of a peritoneum by the stump is
eliminated by destruction of a mucosa of a stump and processing its by
antiseptics.

For the majority of the surgeons a ligature method are not considered safe and it
is not recommended.
The ligature method is indicated when the applying of a purse-string suture
impossible owing to inflammation and infiltration of a wall of the cecum or can
result in complications owing to deformation of a cecum and ileocecal junction
(if base of the appendix located near it).
Operations at injuries of the colon
The parts of the damage serous membrane and the small subserous hematomas
are closed by interrupted or purse-string serous-muscular silk sutures.
The small wounds of a large intestine are sewed in a transversal direction by a
three-row suture.
At extensive damages of an intestine, at presence of several close posed
wounds, at disturbance of the blood supply the intestine is mobilized and its
resection is made.
The mentioned above operations are admitted at early terms of an intervention
(in first 6 hours after the moment of a trauma) and at a clean" abdominal cavity.
In later terms and at pollution of an abdominal cavity by a blood and intestinal
contents the part of the damaged large intestine is mobilized and resected with
applying of an artificial anus.
At impossibility to mobilize and to perform a resection of damaged intestine it
is necessary to sew a wound, to isolate a zone of damage by tampons and to
drain it by a wide tube. More proximally of the damages it is necessary the
colostomy or artificial anus to apply.
Colostomy
*Colostomy - fistula of any part of large intestine
.At colostomy intestinal contents can leave not only through the made opening,
but also to pass in a distally posed department of an intestine.
The indications. An acute intestinal obstruction (as result of a benign or
malignant tumour, strangulation, ileus etc.), ulcerative colitis, wounds of a large
intestine.

At an intestinal obstruction the urgent operation is carried out for evacuation

of intestinal contents in a case, when the radical operation for elimination of
the cause of an obstruction at the given moment is impossible. Further, if
possible, after a control of an intestinal obstruction (or peritonitis etc.) the
radical operation can be performed with the subsequent closing of a
colostomy.
At a ulcerative colitis, wounds of a large intestine the colostomy is carried out
for decrease of passage of fecal masses on distal departments of an intestine
and (or) Introduction of medicine in them
Position of the patient on a back. Anesthesia. A general anaesthesia Technique
of operation.
The colostomy is carried out on a sigmoid intestine (at diseases of its inferior
department and rectum) or on a transverse colon (at diseases of a descending
colon or left colic flexure)
Technique of sigmostomy (or pelvic colostomy). An access -oblique
musclesplitting
incision in the left iliac region.
The edges of a parietal peritoneum for protection of a subcutaneous fat of an
abdominal wall against an infection are sewed with edges of a skin
In a wound a part of a sigmoid colon of length 8 cm taken out and is
connected by interrupted serous-muscular silk sutures with a parietal
peritoneum.
If the condition of the patient allows, the lumen of an intestine is opened
through 2-3 day. after the adhesion of a visceral and parietal peritoneum was
formed.
If the immediate opening of an intestine is required, its wall is dissected
through all layers in a longitudinal direction and the edges of a incision
connected by interrupted sutures to a skin.
For a closing of a colostomy the performance of additional operation is
necessary.

Topographic Anatomy of the Anterior Abdominal Wall

The boundaries of the anterior abdominal wall are:
superiorly – the costal
arches and xiphoid process,
inferiorly, the iliac crests, inguinal folds (projection of the inguinal ligaments),
pubic tubercles and the superior margin of the symphysis pubis, laterally - the
vertical line, which
connects the end of the 11 rib with the iliac crests (Lesgaft's line). This line is
the continuation of the midaxillary line, and it separates the abdominal region
from the lumbar region.
The surface landmarks are the following:
xiphoid process, costal margin, iliac
crest, pubic tubercle, symphysis pubis, inguinal ligament, superficial inguinal
ring, linea alba, umbilicus, rectus abdominis muscle.
The anterior abdominal wall can be divided by horizontal and vertical planes
(lines) into a number of regions which are of use to the clinician when
describing the site of pain felt by a patient or of abdominal physical sings such
as areas of tenderness or tumors. Two transverse and two vertical planes
(lines) divide the anterior abdominal wall into three midline, three left, and
three right regions. The vertical right and left lateral planes almost correspond
to the midclavicular planes of the thorax and pass through the midpoint of a
line joining the anterior superior iliac spine and the symphysis pubis (the
midinguinal point).
The subcostal plane joins the lowest point of the costal margin on each side,
that is the tenth costal cartilage. The subcostal plane lies at the level of the
third lumbar vertebra. The interspinal plane (linea bispinalis) joins the anterior
superior iliac spine on each side. The midline regions are called the epigastric,
umbilical, and hypogastric regions. The lateral regions are called the upper
right, upper left, lower right, lower left and right inguinal (iliac) region, left
inguinal (iliac) regions.
Layers.
Skin. The natural lines of cleavage in the skin are constant and run
almost horizontally around the trunk. This is important clinically, since an
incision along a cleavage line will heal as a narrow scar, whereas one that
crosses the lines will heal as a wide or heaped-up scar. The skin is supplied by
the cutaneous branches of the seventh the twelfth intercostal nerves and by the
first lumbar nerve in the form the iliohypogastric nerve. A pleurisy involving
the lower costal parietal pleura will cause pain in the overlying skin that may
radiate down into the abdomen. Although it is unlikely to cause rigidity of the
abdominal muscle, it may cause confusion in making a diagnosis unless these
anatomical facts are remembered.

Beneath the skin is located the subcutaneous tissue. The layer of adipose
tissue is very variable thickness. Cutaneous arteries, which are branches of the
superior and inferior epigastric arteries, supply the area near the midline, and
branches from the intercostal, lumbar, and deep circumflex iliac arteries
supply the flanks.
The venous blood is collected into a network of veins that radiates out from
the umbilicus (thoracoepigastric, intercostal, and superficial epigastric veins).
The network is drained above into the axillary vein via the lateral thoracic
vein and below into the femoral vein via the superficial epigastric and great
saphenous veins. A few small veins, the paraumbilical veins, connect the
network through the umbilicus and along the teres ligament to the portal vein.
They form an important portal-systemic venous anastomosis.
The superficial veins around the umbilicus and the paraumbilical veins
connecting them to the portal vein may become grossly distended in cases of
portal vein obstruction. The distended subcutaneous veins radiate out from the
umbilicus, producing the clinical picture referred to as caput Medusae. If there
is obstruction in the superior vena or inferior vena cava, the venous blood
causes distention of the veins running from the anterior chest wall the thigh.
The superficial fascia is divided into a superficial and deep layer. The
superficial layer of the superficial fascia is continuous with a superficial fascia
of the thigh. The deep layer of the superficial fascia (Tomson's plate) or
membranous layer is attached to the inguinal ligament and from similar layer
in the perineum. It is important clinically, since beneath it there is a potential
closed space that does not open into the thigh, but is continuous with the
superficial perineal pouch via the penis and scrotum. Rupture of the penile
urethra may be followed by extravasation of urine into the scrotum, perineum
and penis and then up into the lower part of the anterior abdominal wall deep
to the membranous layer of the superficial fascia. The urine is excluded from
the thigh because of the attachment of the Tomson's plate to the inguinal
ligament.
In the anterior abdominal wall, the proper or deep fascia is merely a thin layer
covering the muscles.
The muscles.
The musculature of the anterior and lateral walls of the abdomen
is made up of a trilaminar sheet on either side of a pair of vertically oriented
muscles. The thin aponeurotic tendons of the three lateral muscles form a sheath
around each vertical muscle before fusing in the midline at the linea
alba. The trilaminar sheet is composed of the external oblique muscle, the
internal oblique muscle, the transversus abdominis muscle.
The vertically oriented muscles are the rectus abdominis muscles. In the lower
part of the rectus sheath there may be present a small muscle called the
pyramidalis. The cremaster muscle, which is derived from the lower fibers of
the internal oblique, passes inferiorly as a covering of the spermatic cord and
the scrotum.
The external oblique muscle arises as digitations from the outer surfaces of the
lower eight ribs. The fleshy fibers fan out downward and medially over the
anterior abdominal wall. There is a free posterior margin to the muscle where
its most posterior fibers run from the twelfth rib to the anterior half of the
outer margin of the iliac crest. The remaining more obliquely running fibers
become an aponeurotic sheet which contributes to the anterior sheath of the
rectus muscle before fusing with its fellow at the linea alba in the midline.
The lower free margin of the aponeurosis extends from the anterior superior
iliac spine to the pubic tubercle is called the inguinal ligament. From the
medial end of the ligament the lacunar ligament extends backward and upward
to the pectineal line on the superior ramus of the pubis. Its sharp, free
crescentic edge forms the medial margin of the femoral ring. On reaching the
pectineal line, the lacunar ligament becomes continuous with a thickening of
the periosteum called the pectineal ligament. To the inferior rounded border of
the inguinal ligament is attached the deep fascia of the thigh-the fascia lata.
A triangular-shaped defect in the external oblique aponeurosis lies
immediately above and medial to the pubic tubercle. This is known as the
superficial inguinal ring. The spermatic cord (or round ligament of
the uterus) passes through this opening and carries the external spermatic
fascia (or the external covering of the round ligament of the uterus) from the
margins of the ring.
The internal oblique muscle arises from the thoracolumbar fascia, the anterior
two-thirds of the iliac crest-deep to the attachment of the external oblique, and
from the lateral two-thirds of the inguinal ligament. The fibers fan out from
this origin. The uppermost run upward and medially to become attached to the
costal margin. The intermediate fibers become aponeurotic and help in the
formation of the rectus sheath before joining the linea alba. The lowermost are
attached by a flattened tendon to the pectineal line on the superior pubic
ramus.
The fibers of transversus abdominis muscle arise from a long origin which
extends from the deep surface of the costal margin, the thoracolumbar fascia,
the anterior two-thirds of the medial margin of the iliac crest, and the outer
half of the inguinal ligament. Running approximately transversely across the
abdominal wall, the fibers also become aponeurotic and contribute to the
rectus sheath before joining the linea alba. The muscular fibers from the linea
semilunaris (Spigelii) in the passage to the aponeurosis. This line extends from
the inguinal ligament to the sternum.
The two rectus abdominis muscles form the vertical component of the anterior
abdominal
musculature and lie on either side of the linea alba. The muscles are broad
superiorly and narrow inferiorly.
Each is attached to the fifth, sixth, and seventh costal cartilages above and
below by tendinous and fleshy insertions to the pubic crest and the symphysis
pubis. The anterior surface of the muscle is crossed by three tendinous
intersections. One of these lies at the level of the umbilicus and two are above.
These intersections are strongly attached to the anterior wall of the rectus
sheath. The rectus abdominis is enclosed between the aponeuroses of the
external oblique, the internal oblique, and the transversus, which from the
rectus sheath.
The piramidalis muscle
is often absent. It arises by its base from the anterior
surface of the pubis and is inserted into the linea alba. It lies in front of the
lower part of the rectus abdominis.
The rectus sheath.
Each rectus abdominis muscle is enclosed in a fibrous
sheath formed by the aponeurotic tendons of the three lateral muscles. The
external oblique contributes to the anterior layer the sheath over its whole
extent. Below the costal margin the internal oblique aponeurosis splits around
the muscle contributing to anterior and posterior layers and the aponeurosis of
the transversus abdominis passes into the posterior layer.
Midway between the umbilicus and the symphysis pubis, the posterior wall of
the sheath becomes deficient since all aponeuroses pass anterior to the rectus
abdominis. At the level at which the aponeuroses of all three lateral muscles
fuse to form only the anterior layer of the sheath, the posterior sheath
terminates at a free margin called the arcuate line (Douglasi line). It is here
that the inferior epigastric artery enters the sheath to run superiorly on the
deep surface of the rectus abdominis muscle. The artery anastomoses with the
superior epigastric artery, which has entered the sheath from above by passing
deep to the costal margin. Below the level of the arcuate line the rectus
abdominis lies on the transverse fascia. The muscles of the anterior abdominal
wall are supplied by the lower six thoracic and first lumbar segmental nerves.
The thoracic nerves emerge beneath the costal margin and run downward and
forward the abdominal wall between the internal oblique and transversus
abdominis muscles. The nerves are accompanied by branches of the
musculophrenic or the first lumbar artery. To thoracic (intercostal) nerves are
added the iliohypogastric and ilioinguinal nerves which are derived from the
first lumbar nerve. These supply the lower fibers of the external oblique,
internal oblique, and transversus abdominis muscles. In addition to branches
of the musculophrenic and lumbar arteries, which supply the lateral muscles,
the superior and inferior epigastric arteries supply the rectus abdominis
muscle.
The retromuscular layers.
They include the fascia transversalis, the
extraperitoneal (preperitoneal) fat, the parietal peritoneum.
The fascia transversalis is a thin layer of fascia that lines the transversus
abdominis muscle and is continuous with a similar layer lining the diaphragm
and the iliacus muscle. It is important to understand that the fascia
transversalis, the diaphragmatic fascia, the iliacus fascia, and the pelvic fascia
form one continuous lining to the abdominal and pelvic cavities. The
extraperitoneal fat is a thin layer of connective tissue that contains a variable
amount of fat and lies between the fascia transversalis and the parietal
peritoneum.
The walls of the abdomen are lined with parietal peritoneum. This is a thin
serous membrane and is continuous below with the parietal peritoneum lining
the pelvic. The parietal peritoneum lining the anterior abdominal wall is
supplied segmentally by intercostal and lumbar nerves, which also supply the
overlying muscles and skin.
The linea alba extends from the xiphoid process down to the symphysis pubis
and is formed by the fusion of the lateral muscles of the two sides. Wider
above the umbilicus, it narrows down below the umbilicus to be attached to
the symphysis pubis. The linea alba has the through slitlike spaces. The
vessels, nerves and fat (which connects the extraperitoneal fat with
subcutaneous fat) pass through this spaces. This slits can be by the places of
outlet of the herniae. It is called the hernia of the linea alba or the epigastric
hernia. The linea alba is a weak place of the anterior abdominal wall.
The umbilicus is located in the middle of the line which connects the apex of
the xiphoid process with the superior margin of the symphysis pubis. The
umbilicus is drawn in scar which is formed in place of the umbilical ring.
The umbilical ring is the foramen which is limited by the aponeurotic fibers of
the linea alba. The urachus, umbilical vein, two umbilical arteries pass through
the umbilical ring in the intrauterine development. Then these structures are
turned into the ligaments.
The urachus is turned into the median umbilical ligament.
The umbilical vein is turned into the ligament teres of the liver.
The umbilical arteries are turned into medial umbilical ligaments.
The layers of the umbilicus are the skin with scarry tissue, the umbilical fascia
(the part of the
endoabdominal fascia or transverse fascia) and the parietal peritoneum.
The umbilicus
is located in the middle of the line which connects the apex of the
xiphoid process with the superior margin of the symphysis pubis. The umbilicus
is
drawn in scar which is formed in place of the umbilical ring.
The umbilical ring is the foramen which is limited by the aponeurotic fibers of
the
linea alba.
The urachus, umbilical vein, two umbilical arteries pass through the umbilical
ring
in the intrauterine development. Then this structures are turned into the
ligaments.
The urachus is turned into the median umbilical ligament.
The umbilical vein is turned into the ligament teres of the liver.

The umbilical arteries are turned into medial umbilical ligaments.

The layers of the umbilicus
are the skin with scarry tissue, the umbilical fascia (the
part of the endoabdominal fascia or transverse fascia) and the parietal
peritoneum.
The umbilical vein passes into the umbilical cannal. The umbilical canal is
formed
by the linea alba-anteriorly and by the umbilical fascia-posteriorly.
The inferior foramen of this canal is located at the superior margin of the
umbilical
ring.
The superior foramen of this canal is located to 4-6cm above the umbilical ring.
The umbilicus is a weak place of the anterior abdominal wall. The umbilical
ring
can by the place of outlet of the hernia. It is called the umbilical hernia.
The arteries of the anterior abdominal wall are:
The superior epigastric artery, the
inferior epigastric artery, the deep circumflex iliac artery, the posterior
intercostal
arteries, the lumbar arteries
The superior epigastric, inferior epigastric , and deep circumflex iliac veins
follow
the arteries of the same name and drian into the internal thoracic and external
iliac
veins. The posterior intercostal veins drain into the azygos veins and the lumbar
veins drain into the inferior vena cava.
The cutaneous lymph vessels above the level of the umbilicus drain upward into
the anterior axillary lymph nodes. The vessels below the level drain downward
into
the superficialis inguinal nodes. The deep lymph vessels follow the arteries and
veins and drain into the internal thoracic, external iliac, posterior mediastinal,
and
paraaortic (lumbar) nodes.
The inguinal canal
The inguinal canal is an oblique passage through the lower part of the anterior
abdominal wall and Present in both sexes. It is between the muscles and the
inguinal ligament. It allows structures to pass And from the testis to the
abdomen
in the male. In the female it permits the passage of the round ligand Of the
uterus
from the uterus to the labium majus. It transmits the ilioinguinal nerve in both
sexes. The inguinal canal lies above and parallel to the inguinal ligament. It
extends medially for about 4 cm From the deep to the superficial inguinal ring.
The
inguinal triangle is the part of the Inguinal (iliac) region, where the inguinal
canal
Is located. The boundaries of this triangle are composed: the inguinal ligament –
inferiorly, the Lateral margin of the rectus abdominis muscle –Medially and
superiorly-horizontal line, which is Drawn from the point between the lateral
third
and the middle third of the inguinal ligament.
The walls of the inguinal canal. They are
Four anterior, posterior, superior and inferior.
-The anterior wall of the canal is formed by
The aponeurosis of the external oblique muscle.
-The posterior wall of the canal is formed by
The transverse fascia.
-The superior wall is formed by the internal
Oblique and transversus abdominis muscles.
-The inferior wall is formed by the inguinal
Ligament.
The interval between the superior and The interval between the superior and
inferior wall of the inguinal canal is called the inguinal interval. It is of great
importance for pathogenesis of the inguinal hernia. The form and sizes of the
inguinal interval are various. They are the slitike, oval, rounded and triangular.
The
triangular form of the inguinal is the precondition for the direct hernia.
The posterior wall of the inguinal canal is strengthened by the inguinal (Genle’s
ligament) and Interfoveolar ligament. The inguinal falx is the conjoint tendon of
the internal oblique muscles. It is situated at the medial border of the inguinal
interval and anterior to the transverse fascia. The interfoveolar ligament is
situated
between the medial inguinal fovea and lateral inguinal fovea which are located
on
the deep aspect (surface of the anterior abdominal wall.

The rings of the inguinal canal.

The superficial ring is a triangular-shaped defect in
the aponeurosis of the external oblique muscle and the base is formed by the
pubic
crest. The lateral side of the triangle called the lateral crus descends to the pubic
tubercle and the medial side, the medial crus, to the symphysis pubic.
The third crus may occur. It is called posterior crus or reflexed ligament
(Collest).
This triangular gap is the superficial inguinal ring through which the spermatic
cord in the male and the round ligament of the uterus in the female leave the
inguinal canal. This triangular space is commonly made more “ring-like” by
intercrural fibers which obliterate its apex.
The deep inguinal ring an oval opening in the fascia transversalis, lies about 1,3
cm
above the inguinal ligament midway between the anterior superior iliac spine
and
the symphysis pubic. Related to it medially are the inferior epigastric vessels,
which pass upward from the external iliac vessels. The margins of thering give
origin to the internal spermatic fascia (or the internal covering of the round
ligament of the uterus).
The margins of the superficial inguinal ring give origin to the external spermatic
fascia.
The spermatic cord,
the ilioinguinal nerve and the genital branch of the
genitofemoral nerve are the contents of the inguinal canal in the male.
The round ligament of the uterus, the ilioinguinal nerve and the genial branch of
the genitofemoral nerve are the contents of the inguinal canal in the female.
The spermatic cord consists of the vax (ductus) deferens, the testicular artery,
the
testicular veins (the pampiniform plexus), the testicular lymph vessels, the
autonomic nerves, the processus vaginalis, the cemasteric artery, the artery of
the
vas (ductus) deferens.
The spermatic cord is a collection of structures that transverse the inguinal canal
and pass to and from the testis. It is covered with three concentric layers of
fascia
derived from layers of the anterior abdominal wall. It begins at the deep
inguinal
ring lateral to the inferior epigstric artery and ends at the testis. Between the
testis
and the superficial inguinal ring the testicular veins form a plexus around the
cord.
This is known as the pampiniform plexus. The plexus condenses to three four
vessels which ascend through the inguinal canal to the inferior vena cava on the
right side and the left renal vein on the left.

The ductus deferens is a firm muscular tube which can be easily palpated in the
living spermatic cord. Continuous with the epididymis it ascends on its medial
side
to become incorporated into the spermatic cord above the testis.
In order that the surgical anatomy of the inguinal region, spermatic cord, and
testis
may in due course be understand, a brief account of the descent of the testis and
the
manner in which normal development may fail is now given.
The testis develops on the posterior abdominal wall of the embryon. However it
subsequently migrates downward and leaves the abdominal cavity through the
inguinal canal to reach the scrotum at about the time of birth. The course of this
migration seems to be determined by the presence of the gubernaculum testis, a
fibromuscular cord extending from the lower pole of the testis to the developing
scrotal swellings. It also seems that the slightly lower temperature prevailing in
the
scrotum is necessary for the normal maturation of spermatozoa.
As it descends, the testis is preceded by a sac of peritoneum which lines the
scrotum. This sac is known as the processes vaginalis. On reaching the scrotum,
the testis invaginates this sac from behind and in this way becomes partially
clothed by a visceral and parietal layer of peritoneum. Communication of the
sac
with the main peritoneal cavity becomes obliterated and that portion left around
the
testis forms the tunica vaginalis. This communication between the peritoneal
cavity
and the tunica vaginalis surrounding the testis is normally completely
obliterated.
Partial failure of this process at some point along the course of the processus
vaginalis may lead to the development of a fluid-filled sac called a hydrocele of
the
cord. If the processus vaginalis remains totally patent, a pathway exist through
which abdominal structures can pass into the scrotum. This is called a
congenital
hernia.
The ovary descends only to the pelvic and does not transverse the canal.
However,
the gubernaculum Is retained in the form of the round ligament. This extends
from
the uterus, along the inguinal canal, and is anchored in the fibrofatty tissue that
makes up the labium majus. Not only is the gubernaculum retained, but in fetal
life
a processus vaginalis is formed and normally obliterated. For this reason
congenital indirect herniae do occur in women, although much less frequently
than
in men. As in the male, as isolated portion of the processus may form a
hydrocele
known by gynecologists as a hydrocele of the canal of Nuck.
The deep aspect of the anterior abdominal wall. The features of the structure of
the
peritoneum which forms posterior surface in lower part of the anterior
abdominal wall are necessary for the understating of the mechanism of the
origin of the
inguinal hernia. Here, the vessels and remnant of urachus pass under the
peritoneum and transverse fascia and form folds (median, medial and lateral
umbilical folds).
A median umbilical fold contains the remains of the urachus and leads to the
bladder. On either side 2 medial umbilicus folds can also be followed into the
pelvis and are found to approach the internal iliac artery . These folds are
formed
by the obliterated umbilical arteries.
Two lateral umbilical folds can be seen outside the medial folds and they are
formed by the inferior epigastric vessels. These folds can be followed from the
external iliac vessels to the arcuate line. At this point the posterior sheath of the
rectus abdominis becomes deficient and the vessels can pass superiorly on the
deep
surface of the muscle.
The fossae are formed between these folds. The supravesical fossa is located
between the median umbilical fold and medial umbilical fold. The medial
inguinal
fossa is located between the medial umbilical fold and the lateral umbilical fold.
This fossa is the projection of the superficial inguinal ring on the posterior
surface
of the anterior abdominal wall. The lateral inguinal fossa is located lateral to the
lateral umbilical folds.
The lateral inguinal fossa is called the deep inguinal ring. These fossas are the
weak places of the anterior abdominal wall. The inguinal herniae pass through
these fossas.
Hernia involve the passage of a peritoneal sac with or without abdominal
contents
through a site of congenital or acquired weakness in the abdominal wall.
Common
sites of hernia are at the umbilicus, the inguinal region and the femoral canal.
Less
commonly, they are found in the linea alba. The hernia of the linea semilunaris
(Spigelii) may occur but very seldom. The hernia consists of three parts: the sac,
the contents of the sac, and the hernial ring. The hernial ring is a weak place
through which passes the hernial sac. The hernial sac is diverticulum of
peritoneum
and has a neck, a body and a fundus. The hernial sac is remains of the processus
vaginalis in the congenital inguinal hernia.
The inguinal hernia can be divided into the congetinal and the acquired hernia.
The acquired hernia in its turn are divided into the oblique (indirect) and the
direct
inguinal hernia. The congenital inguinal hernia is always oblique.

The hernial contents may consist of any structure found within the abdominal
cavity and may vary from a small of piece of omentum to a large viscus such as
the
kidney.
The hernial sac in the oblique hernia passes through the deep inguinal ring,
along
inguinal canal and through the superficial inguinal ring and can descend into the
scrotum. It is called the inguinoscrotal hernia.
The congenital inguinal hernia always is inguinoscrotal hernia.
The hemia sac in the acquired oblique inguinal hernia is located lateral to the
spermatic cord.
The hernial sac in the direct inguinal hernia passes through the medial inguinal
fossa, the inguinal interval, the superficial inguinal ring.
The direct inguinal hernia never descends into the scrotum, always is acquired
and
has the straight way (track). The hernial sac in the direct inguinal hernia is
located
medial to the spermatic cord.
The supravesical hernia passes through the supravesical fossa, the inguinal
interval, the superficial inguinal ring. This hernia is very seldom. An inguinal
hernia is more common in men than in women. A femoral hernia is more
common
in women than in men (possibally due to a wider pelvis and femoral canal). An
inguinal hernia may be distinguished from a femoral hernia by the fact that the
sac,
as in emerges through the superficial inguinal ring, lies above the inguinal
ligament, while that of a femoral hernia lies below the inguinal ligament.