T.

H.I
mpor
tantCl
i
nical
sofAbdomen&Pel
vi
s

Ant
eri
orAbdomi
nal
wal
l&I
ngui
nal
Regi
on

 Li
posuct
ionisasurgi
calmethodforr
emov i
ngunwantedsubcutaneousfatusingapercut
aneousl
yplaced
suct
iontubeandhi
ghvacuum pr
essure.Anant
erol
ater
alpartofpotent
ialspacebet
weent het
ransver
sali
sf asci
a
andthepari
etal
per
it
oneum (
spaceofBogros)i
susedf orpl
acingprost
heseswhenr epair
ingi
nguinalher
nias.
 Anext ernal supr avesi
cal hernial eav est heper i
tonealcav i
tythr
ought hesupr avesi
calfossa.Itismedi alt
odi rect
i
ngui nalher nia.Il
iohypogast ri
cner v
ei spr eserveddur i
ngsur gery.
 Umbi li
cal her niamayoccurduet ofailureoft hemi dguttoreturntot heabdomenear l
yinfetal l
ife,andi toccur s
asapr otrusionoft hebowel throught henat uralweakspotordef ectattheumbi li
cus.Iti
smor ecommoni ngi r
ls
andi npr emat urebabies.Acqui redumbi li
cal herniasoccurmostcommonl yi nwomenandobesepeopl e.
Extraperitoneal fatand/orper itoneum pr otrudei ntothehernialsac.
 Epigast r
icher ni
ai saprotrusionofext raperitoneal f
atorasmal lpieceofgr eateroment um throughadef ectin
thelineaal bab/ wt heumbi licus&xi phoi dpr ocess.Spigeli
anher niasar ethoseoccur ri
ngal ongt hesemi l
unar
l
ines.
 Inguinalher niai sacondi ti
oni nwhi chapor ti
onofi ntesti
nepr ot
rudest hroughaweakspoti nt hei nguinalcanal or
i
nt heingui nal t
riangl
e.Reduci bleher niai saher niainwhi chthecont entsoft heher ni
alsaccanber et
urnedt o
theirnormal posi ti
on.Incarcer atedher niaisani rreducibl
eher ni
ai nwhicht hecont entsoftheher nialsacar e
entrappedorst ucki nthegr oin.St r
angul atedher niaisani r
reducibleherniainwhi chtheintestinebecomest ightl
y
trappedort wi sted.

Femor
alHer
nia I
ngui
nal
Her
nia

I
tismor
ecommoni
nfemal
es. I
tismor
ecommoni
nmal
es.

I
tli
esi
nfer
ior&l
ater
alt
opubi
ctuber
cle. I
tli
essuper
ior&medi
alt
opubi
ctuber
cle.

 Thesuper fici
alingui nal r
ingi spal pabl esuper olateraltot hepubi ct uber clebyi nvaginatingt heski noftheupper
scrotum wi ththei ndexf inger .
Shoul daher niabepr esent , asuddeni mpul sei sf el
tagai nstthet i
poff i
ngerwhen
thepat ienti saskedt ocough.Howev er,becausebot hingui nal her niat ypesexi tthesuper fi
cial ri
ng, pal
pati
onof
animpul seatt hissi tedoesnotdi scr i
mi natety pe.
 Wi t
ht hepal marsur faceoft hef i
ngeragai nstt heant eriorabdomi nal wal l,thedeepi nguinal ri
ngmaybef eltasa
skindepr essionsuper iort ot heingui nal l
igament ,
2–4cm super olat eral tot hepubi ct ubercle.Det ect
ionofan
impulseatt hesuper ficial ri
ngandamassatt hesi teoft hedeepr ingsuggest sani ndirecther nia(Ri
ngf i
nger
test).
Di rectherniacanbei denti
fi
edbypl acingt humbi ni ngui nal tri
angl e.
 Super fi
ci alabdomi nal reflexi selicitedbyqui cklystrokinghor izont all
y,lat eral t
omedi al,towar dt heumbi l
i
cus.
Usually ,cont r
actionoft heabdomi nal muscl esi sfelt
.Cremast ericr efl
exi sadr awingupoft het estisby
contract ionoft hecr emast ermuscl ewhent heski nont heuppermedi al sideoft het highisst roked.Theef ferent
li
mboft her efl
exar cist hegeni tal branchoft hegeni tof emor alner ve.
Dir
ect(acquired)Her nia Indi rect(congeni t al)Hernia
Lesscommon Mor ecommon
Commom i nel derpeopl e Most lyiny oungerpeopl e
Iti
sduet oWeaknessofant eriorabdomi nal wall. Duet oper sistantofpr ocessusv aginalis.
Peri
toneum pl ust ransversal isf asciaexitf rom abdomi nal Per itoneum ofper sistentpr ocessusv agi nali
splusallthree
cavi
ty. fasci alcov er i
ngsofcor d.
I
tpassest hroughposteri
orwallofingui
nalcanal(
dir
ect
) I
tpassesthroughdeepinguinalr
ing(
indi
rect
ly)
I
tliesexternalandparal
l
eltovesti
geofpr ocessus I
tli
eswithi
npr ocessusv
aginali
s
vaginal
is
Viasuperfici
alri
ng;i
texi
tsfrom abdominalwall Vi
asuper
fici
alr
ing;
itexi
tsfr
om abdomi
nal
wal
l
Rarelyentersscrot
um Commonlypassesint
oscrot
um

 Theinci sionsfollowt hecleav ageli

nes( Langerli
nes).
Insteadoft r
ansect i
ngmuscl es, causingirr
ev ersi
ble
necrosis( death)ofmuscl ef ibers,thesurgeonsplit
st hem inthedirecti
onoft heirfi bers.Ther ectusabdomi ni
s
i
sanexcept i
on; i
tcanbet r
ansect edbecausei t
smuscl efi
bersrunshor tdistancesbet weent endinous
i
ntersect i
ons,canr egenerateeasi l
yandt hesegment alnervessupply i
ngwher etheycanbel ocatedandpr eserved.
Muscl esandv isceraareretractedtowar d,notawayf r
om, thei
rneurov ascularsupply .I
njurytoner vesoft he
anterolateralabdomi nalwall (
duringincisi
on)mayr esultinweakeningoft hemuscl es. Ani ncisi
onal herniaisa
protr
usi onofoment um (af oldofper i
toneum)oranor ganthroughasur gical i
ncision( whenmuscl esdon' theal
properly).

Longi
tudi
nal
Inci
sions(
medi
an&par
amedi
ani
nci
sions)

Medianormi dl
i
neincisi
onscanbemadeal ongl engt
hofthelineaalbafrom t
hexi
phoidprocesstopubi
csymphy si
s.
Becausetheli
neaalbat r
ansmit
sonlysmall
v esselsandnerv
est otheskin,amidl
i
neincisi
onisrel
ati
vel
ybloodl
ess,and
avoi
dsmaj ornerv
es.Bcauseofit
srel
ati
vel
ypoorbl oodsupply,
thelineaalbamayundergonecrosi
sanddegenerat
ion
aft
erinci
sion.

Paramedianinci
sions(l
ateralt
othemedi anplane)ar
emadei nasagitt
alpl
aneandmayextendfr
om thecostalmar
gin
tothepubichair
li
ne.Aft
ertheinci
sionpassesthroughtheanter
iorl
ayeroft
herect
ussheat
h,themusclei
sfreedand
ret
ract
edlateral
l
yt opr
eventtensi
onandi nj
urytothevessel
sandnerves.

Gri
diron( muscl e-spli
tti
ng)incisi
onsar eoftenusedforappendect omy .Theobl i
queMcBur neyincisi
onismadeatt he
McBur neypoi nt
, 2.5cm super omedialtotheASISont hespino-umbi l
icall
ine.Theexternalobli
queaponeur osi
sis
i
ncisedi nf
eromedi all
yinthedirecti
onofitsfiber
sandr et
racted.I
nternalobliqueandt r
ansv er
susabdomi nisarethen
spl
itinthelineoft hei
rfiber
sandr etract
ed.Thei l
iohy
pogastricnerve,runningdeeptot heinternalobli
que,isi
dentif
ied
andpr eserved.I
tcut snomuscul oaponeuroticfi
bers.
Abdomi nalwallisasst rongaft
ert heoperationasitwasbef or
e.

Suprapubic( Pfannensti
el)inci
sions(“biki
ni”i
ncisions)ar
emadeatt hepubichairl
i
ne.Theseare—horizontal
witha
sl
ightconv exi
ty—areusedf ormostgy necologi
cal andobstet
ri
caloper
ati
ons(e.g.,
forcesareansect
ion).Theli
neaal
ba
andanteri
orl ayersoftherectussheathsaret r
ansectedandresectedsuper
iorl
y,andtherectusmusclesareretr
act
ed
l
ateral
ly.
Il
ioinguinal&il
iohypogastr
icarepreserved.

Transver
seincisi
onsthroughtheanter
iorl
ayeroftherect
ussheat
handrectusabdomi ni
sprovi
degoodaccessand
causetheleastpossi
bledamaget ot
hener v
esupply(astheyar
eparal
l
eltonerves)
.Transver
seinci
sionsarenotmade
throught
het endi
nousint
ersect
ionsbecausecutaneousnerv
esandsuperi
orepigastr
icvessel
spier
cet hem.

Subcost
ali
nci
sionsprov
ideaccesstothegal
lbl
adderandbil
iaryductsonther
ightsi
deandt
hespleenontheleft
.The
i
ncisi
onismadeparal
l
elbutatleast2.
5cm i
nfer
iortothecostalmargint
oavoi
dt he7t
hand8tht
horaci
cspinalnerv
es

High-
riski
nci
sionsincl
udeparar
ectusandi
ngui
nal
incisi
ons.Par
arect
usinci
sionsal
ongthel
ater
alborderofther ectus
sheathareundesi
rabl
ebecausetheymaycutt
henervesupplyt
otherect
usabdomini
s.Ingui
nali
nci
sionsf orrepairi
ng
herni
asmayi nj
urethei
li
o-i
ngui
nalnerv
e.

 Warm handsarei
mport
antwhenpalpat
ingtheabdomi
nal
wallbecausecoldhandsmaketheant
erol
ater
al
abdominalmuscl
est
ense,pr
oduci
nginvol
untar
yspasmsoft
hemuscl es,
knownasguar di
ng.
 Ut
eri
necancercanspr
eadt
olabi
amaj
orusv
iar
oundl
i
gament
.
Test
is&Scr
otum

 Hy dr ocel ei sanaccumul ationoff l

ui di nt hecav i
tyoft het uni cav agi nalisoft het estisoral ongt hesper mat ic
cordduet oani nf ectionori njurytot het estis.Hemat ocel ei sahemor rhagei nt ot hecav i
tyoft het unicav agi nal
is
duet oi njuryt ot hesper mat icvessel s.
 Det ect ionofahy drocel er equi r
est ransi l
lumi nation,apr ocedur edur i
ngwhi chabr ightlighti sappl iedt ot hesi de
oft hescr otal enl argementi nadar kenedr oom.Thet ransmi ssionofl ightasar edgl owi ndicat esexcessser ousf l
uidi nt hescr ot um.Bl ooddoesnott ransi l
lumi nate.
 Var icocel ei sanenl argementoft hepampi niformv enouspl exusoft hesper mat iccor dt hatappear sli
kea“ bag
ofwor ms”i nt hescr otum.Av ar i
cocel emaycausedr aggi ng- l
ikepai n,at rophyoft het estisand/ orinfer t
ili
ty.Itis
mor ecommonont hel eftsideandcanbet reatedsur gical l
ybyr emov ingt hev ar i
cosev eins.
 Test icul artor sioni st wi stingofat est i
sast hesper mat iccor dbecomest wi sted( duet ospasm oft hecr emast er
muscl e,)
obst ruct ingbl oodsuppl ytot het estis,andcausi ngsuddenpai nandswel li
ngoft hescr otum ornausea
andv omi ti
ng.
 Orchi t i
si sinfl ammat ionoft het est i
sandi smar kedbypai n, swel l
ing, andaf eel i
ngofheav inessi nt het estis.It
maybecausedbyt hemumps, gonor rhea, sy phili
s, ort uber cul osi s.
 Test icul arcancerdev elopscommonl yf rom t hesper mat ogeni ccel l
s( semi nomaorger m cel l tumor ).Leydi gcells,
(Ley di gcell tumor ),andSer tolicell
s( Ser tolicelltumor ).Signsandsy mpt omsi ncludeapai nlessmassorl ump,
testicul arswel ling, har dness, andaf eel i
ngofheav inessorachi ngi nt hescr otum orl owerabdomen.Themaj or
ri
skf act orsar ecr yptor chidism andKl inefelter’ssy ndr ome, semi nifer
oust ubul edy sgenesi s,gy necomast ia..
 Canceroft hescr otum met astasizest othesuper f icial ingui nal l
ymphnodes. Met astasisoft est i
cul arcancer
mayal sooccurbyhemat ogenousspr eadofcancercel ls( viat hebl ood)t ot hel ungs, li
ver,br ain, andbone. Cancer
oft het esti
smet ast asizet ol umbarl ymphnodes,medi astinal andsupr aclav icularnodes.
 Cry ptor chidism i sacongeni t
alcondi ti
oni nwhi cht het est i
sf ailst odescendi ntot hescr otum dur i
ngf etal
dev elopment .Undescendedt estesar eassoci atedwi thr educedf ertil
ity& i ncreasedr i
skoft est icularcancer .
 A sper matocel ei sar et entioncy st( collect i
onoff l uid)i nt heepi didymi susual lyneari t
shead.Sper mat ocel es
cont ai nami lkyf luidandar egener allyasy mpt omat ic.Anepi didy mal cysti sacol lect i
onoff luidany wher ei nthe
epidi dy mis.

Per
it
oneum

 Peri
toni
tisisinflammationandinfecti
onoft heper
it
oneum ;r
esult
sfrom abur
stappendixthatl
eaksfecesi
nto
theperi
toneal cavi
ty,
from apenetrati
ngwoundt otheabdomen,from aper
for
ati
ngulcerthatl
eaksstomach
content
si nt
ot heperit
onealcavi
ty(lessersac),
orfr
om poorster
il
etechni
queduri
ngabdomi nalsur
gery.
 Asci
tesi
sexcessf l
uidinperi
tonealcavi
tyduetospi
l
lingaci
dcont
entbecauseoful
cer
.I
tmayoccurduet
o
mechani
cali
njur
y,portalhy
pertensi
on,cancer&st
arvati
on.
 I
ft heabdomeni sdr awninast hechestexpands(par
adoxicalabdominot
horaci
crhyt
hm)andmusclerigidi
tyi
s
present,ei
therperi
tonit
isorpneumoni ti
smaybepr esent.Peoplewit
hperit
onit
iscommonlyl
i
ewiththeirknees
fl
ex edtorelaxt
heiranterolat
eralabdominalmuscl
es.Theyalsobreathshal
lowl
y(andhencemor
er api
dly),
reducingtheintr
a-abdomi nalpressur
eandpain.
 Afterabdominal
inci
sions;
fibr
oustissueorscarmayfor
m at
tachmentbetweenv i
scer
alperi
toneum ofadj
acent
organsorbetweenperit
al&v i
scer
al per
it
oneum,i
tiscal
l
edAdhesions.Adhesi
otomyrefer
stoi t
ssurgi
cal
separati
on.
 I
nfect
ioncaneasi
lyspr
eadt ofemaleperi
tonel
cav
ityv
iaut
eri
net
ubes.
Iti
spr
event
edbymucouspl
ugwhi
ch
bl
ocksexter
nalostopathogens;butnott
osperms.
 Peri
toneum i swelli
nnerv
ated;
sol aparot
omycausespai n.
Duri
ngoperation,eff
ortsaremadet oremainoutsi
de
theperitonealcavi
tytoavoi
dperit
oniti
s,adhesions.I
ntr
aperi
tonealor
gansar eeasyt oachiev
eduet oserosa
(cover
ingofper it
oneum)thatmakeswat ertightendtoendanast omosis.Howev er
;itismoredif
ficul
ttoachiev
e
water-
tightanastomosesofextraperi
tonealstruct
uresthathaveanouteradv enti
ti
allayer
.
 Per
it
oneum i
sasemi
per
meabl
emembr
anewi
thanext
ensi
vesur
facear
ea,
itov
erl
i
esbl
oodandl
ymphat
ic
 capi
ll
arybeds.Therefor
e,f
lui
dinject
edint
otheperi
tonealcavi
tyisabsorbedrapi
dly
.So,anest
heticagents,
(sol
uti
onsofbarbit
uratecompounds,)maybeinj
ectedint
ot heperi
tonealcav
itybyint
raperi
toneal(I.
P.)inj
ect
ion.
Inrenalf
ail
ure,Perit
onealdial
ysismaybeperfor
med.
 Greateromemtum isknownaspoli
cemant ipas1)preventsspreadofi
nfecti
onbyf or
mingadhesi
onwi t
h
i
nflammedor gansuchasappendi
xit
.2)itcushi
onstheor gans&f or
minsulat
ions.3)i
tpr
event
sv i
scer
al
perit
oneum t
oadherewi t
hpar
iet
alperi
toneum.4)i ti
smobi le.
 Peri
tonealrecessesdet
ermi
nethedir
ecti
onofspreadofpus.Par
acol
icgut
ter
sprov
idepathway
sforf
lowof
asci
ticfl
uid,cancer&spr
eadofinf
ect
ion.I
nfect
ioncanspr
eadtopelv
is&subphr
enicr
ecess.
 Paracent esis(abdomi nal t
ap)i sapr ocedur einwhichaneedl ei
sinser
ted1t o2i n.t
hrought heabdomi nalwal
l
i
ntot heper it
oneal cav i
tytoobt ainsampl eordr ai
nf l
uidwhil
ethepati
ent’
sbodyi selevatedata45-degreeangle.
Thepunct uresiteismi dli
ne( l
ineaalba)atappr oxi
mat el
y2cm belowtheumbi l
i
cusorl ater
al t
oMcBur ney’
spoint
,
avoidingt heinferi
orepi gastr
icv essels.
 Ani nflamedori njuredpancr eascanal soresultinthepassageofpancreati
cflui
di nt
ooment albur
sa, f
orminga
pancr eati
cpseudo- cy st.
 Al oopofsmal li
ntestinemaypasst hrought heoment alf
oramenintotheoment albursaandbest rangulat
ed.
 Ifcysticar t
eryissev eredduringchol ecystectomy ,
hepaticart
eryi
scompr essedinhepat odudenall
igamentby
puttingindexf i
ngeri noment al foramen&t humboni t
santeri
orwall
.

St
omach
 Pept icul ceri ser osi oni nt hel i
ni ngoft hest omachorduodenum whuchi scausedbyani nfect ionwi th
Helicobact erpy l
or i buti sal socausedbyst ress, acid, andpepsi n.Itoccur smor ecommonl yinment hani n
womenandhassi mi larsy mpt omsandt r eatmentr egar dl essofl ocat ion.Pept icul cerhassy mpt omsofepi gast r
ic
pain( bur ning, crampi ng, orachi ng) ;
abdomi nal i
ndi gest ion, nausea, vomi ti
ng, l
ossofappet ite,wei ghtl oss, and
fati
gue.I tmaybet reat edwi t
hant ibioticsorsur gical inter vent i
on, i
ncl udingapar ti
al gast rect omyandv agot omy .
 Pept i
cul ceroccur si nt hepy loricr egionoft hest omach( gast ri
cul cer )ort hef i
rstpar toft heduodenum
(duodenal ulcer )andl essf requent lyint hedi stal esophagus. Gast ricul cersmayper for atei ntot hel essersacand
erodet hepancr easandt hespl eni car tery,causi ngf atal hemor rhage.Duodenal ul cer smayer ode
gast roduodenal ar ter y, causi ngbur ningandcr ampi ngepi gast ri
cpai n, andar et hreet imesmor ecommont han
gast ri
cul cer s.
 Gast ricul cer soccurt y pical l
yal ongl essercur vat ureas1. mucosai snotf reelymov abl e; 2. Epithel i
um i st hin;
3.Abundantner v esuppl y;4. l
essbl oodsuppl y;5. gast riccanal ispr esent ;6. cont ract ionst ay sl onger
 Acidsecr eretioni scont r oll
edbyv agusner v e; hencev agot omyi sdonet ot reatul cer s.Tr uncal v agot omy
(surgical sect i
onoft hev agal trunks)i sr arelyper for medbecauseofdener vationofot herabdomi nal struct ures.In
select i
v egast ricv agot omy ,t hest omachi sdener v atedbutt hev agal branchest ot hepy l
or us, l
iv erandbi li
ar y
duct s,intest ines, andcel iacpl exusar epr eser v ed.Insel ect ivepr oximal v
agot omyat tempt sar emadet o
dener vat eev enmor especi ficallyt hear eai nwhi cht hepar ietal cel l
sar epr esent .
 Ifaloopofi ntest i
neent erspar aduodenal f
ol dandf ossa(l iet ot hel eftoft heascendi ngpar toft heduodenum
fossa)i tmayst rangul at e.Dur ingr epai rofapar aduodenal her nia,t hei nfer iormesent er i
car tery&v einandl eft
colicar ter yar epr eser ved.
 A hi atal (hiatus)her niai sapr ot rusionofpar toft hest omachi ntot hemedi ast i
num t hr ought heesophageal
hiatusoft hedi aphr agm. Inpar a-esophageal hi atal her nia,t hecar diar emai nsi nitsnor mal posi tionbutt he
fundusoft hest omach, extendst hrought heesophageal hi atus. Int hecommonsl idi nghi atal her nia,t he
abdomi nal par toft heesophagus, thecar dia, andpar tsoft hef undusoft hest omachsl i
desuper i
or l
yt hr ought he
esophageal hiat us.
 Congeni t
al hy per trophi cpy loricst enosi si samar kedt hi ckeni ngoft hesmoot hmuscl e( hy per t
rophy )i nt he
pylorus.I tr esist sgast ricempt y i
ng.St omachmaybecomedi l
at ed.
 Whent hebodyorpy loricpar toft hest omachcont ainsamal ignantt umor ,themassmaybepal pabl e.Thenodes
alongt hespl eni cv essel scanbeexci sedbyr emov ingt hespl een, gast rospl enic,spl enor enal l
igament s, andt he
bodyandt ailoft hepancr eas&gr eat eroment um. i.e; Cancerofpy l
or i
cr egi oni nv olv esr emov al ofpy loric&r ight
gast ro-oment al lymphnode. Cel i
acl y
mphnodes( towhi chgast ricnodesdr ain)canal sober emov ed. Tot al
 gastrectomy(remov aloftheent i
restomach)i suncommon.Par ti
algastr
ectomy( remov alofpar
toft he
stomach)maybeper formedt oremov ear egi
onoft hest omachi nvolv
edbyacar cinoma.
 Spasmodi ccontr
actionoft hepylorussomet imesoccur sininfants,usual
lybetween2and12weeksofage.
Pylorospasm ischaracter
izedbyf ail
ureofthesmoot hmusclef ibersencircl
i
ngthepy lor
iccanaltorelax
normal l
y.
 Gastroesophagealrefl
uxdiseasei sadi gesti
vedisordercausedbyal oweresophageal sphinct
erdysfuncti
on
(r
elaxati
onorweakness)andhi atalhernia,
causingrefluxofstomachcont ent
sintlesophagus.Thisdiseasehas
sympt omsofheartburnoraci dindigesti
on,painf
ulswal l
owing,burping,andfeel
ingoff ul
lnessint
hechest .

SmallIntestine
 I nfl
ammat orybowel diseasei nvolvest hesmal lorl argei ntest
ineorbot handal soi ncludesCr ohn’ sdi seaseand
ulcerati
v ecol i
tis.
Cr ohn’ sdi seaseisi nflammat orybowl diseaseoccur sint hei leum (maybecal l
edi leiti
sor
enterit
is),buti tcanaf fectanypar toft hedigest i
v etract.Sy mpt omsi ncludedi arrhea,rectalbleedi ng, anemia,
weightl oss, andf ev er.Ul cerativecoliti
si nvolvest hecol onandv i
rtuall
yal way sinvolvest herectum.I tis
character i
zedbyashal lowi nfl
ammat ionoft helar geintest i
nalmucosa, mai nlyinther ectum, andpat i
entswith
prolongedul cerativecol itisar eatincreasedr iskf ordev elopingcoloncancer .
 Meckel ’sdiv erti
culum i sanout pouchi ng( fi
nger -
li
kepouch)oft heileum whi chi sper sistentportionsoft he
embr yonicy ol
kst alk( vitell
ineoromphal omesent er i
cduct )andi slocated2f tproximal totheil
eocecal j
unction
ont heant imesent ericsi de; i
tisappr oxi mately2i n.long, occur sinappr oximat ely2%oft hepopul ati
on, may
contain2t ypesofect opict issues( gast ri
candpancr eatic),presentsint hefirst2decadesofl i
feandmor eoften
i
nt hef i
rst2y ears, andi sf ound2t imesasf requent l
yinboy sasi ngirls.andmaybef reeorconnect edt othe
umbi li
cusv iaaf ibrouscor doraf istula.Thedi v
er ti
culum i scli
nicall
yi mpor tantbecausedi vert
icul i
tis,ulcer
ation,
bleeding, perforation, andobst r
ucti
onar ecompl icationsr equiri
ngsur gical i
nterventionandf r
equent lymi micking
thesy mpt omsofacut eappendi ci
ti
s.
 Occlusionofthev
asarect
abyembol iresul
tsi
nischemiaoftheintesti
ne.I
fthei schemiaissev
ere,necr
osis
(t
issuedeath)oft
heinvol
vedsegmentresul
tsandil
eus(obstr
uctionoftheintestine)oft
heparaly
tict
ypeoccur
s.
I
leusisaccompaniedbyaseverecol
ickypai
n,al
ongwithabdominaldist
ensi
on, vomi t
ing,
andoftenfev
erand
dehydrati
on.
Lar
geI
ntest
ine
 Diver
ticul
iti
sisinf
lammati
onofdivert
icul
a(out
pocket
ings)oftheint
esti
nalwal
l,commonl yfoundinthecol
on,
especiall
ythesigmoidcol
on,andthediver
ti
cul
adevel
opasar esul
tofhi
ghpressurewithinthecol
on.Symptoms
areabdomi nalpai
ninthel
eftlowerabdomen(butcanbeany where)
.Di
etshi
ghinf i
ber
sr educethechancesof
diver
ti
culum.
 Si
gmoidvolvul
usisat wi
sti
ngoft hesigmoidcol
onarounditsmesentery(whenthesigmoidcolonandit
s
mesenter
yareabnormall
ylong)creat
ingacoloni
cobstructi
onandmaycausei ntest
inali
schemiathatmay
pr
ogresstoconst
ipat
ion,
ischemia,necrosi
s,f
ecali
mpaction,per
it
oni
tis,andabdominaldi
stensi
on.
 Megacol
on(Hi
rschsprung’
sdisease)iscausedbyt
heabsenceofenter
icpl
exusi
nthel
owerpar
toft
hecol
on,
whi
chleadst
odilat
ionofthecolonproxi
mal t
othei
nact
ivesegment
.
 Acuteappendicit
isisanacut einf
lammat i
onoft heappendi
x,usuall
yr esult
ingfrom bact
eriaorvirusesresulti
ng
fr
om entrapmentoffeces. I
tiscommonbecause1.Ly mphati
cf ol
li
clesar epresentini
t;2.appendiculararter
yis
endartery;3.
it
slumeni ssmal l
.Symptomsincludereboundtenderness, per
iumbi l
i
calpai
nwhi chmaymov etothe
ri
ghtil
iacfossaonMcBur ney’
spoint
,accompani edbylossofappetite,nausea,vomiti
ng,fever
,diarrhea,and
consti
pati
on.Itsrupt
uremaycauseper i
toni
ti
s,leadi
ngtosepticemiaandev entual
lydeat
h, i
funtr
eat ed.
Appendicit
iscanbetreatedbyappendect omy.
 Appendectomymaybeper formedt hroughatr
ansverseorgridironincisi
oncent er
edattheMcBur ney.
Gridi
ron
i
ncisioni
smadeper pendiculartothespino-
umbili
calli
ne,butat ransverseinci
sionisal
soused.Thesi t
eof
maximalpai nandtendernessi ndi
catestheact
ual l
ocati
on.Lapar oscopicappendectomyhasbecomeast andard
procedur
ef orremovingtheappendi x.Theperi
tonealcavi
tyisf i
rstinflat
edwi t
hcarbondioxidegas,di
stending
theabdominal wall
,toprovidev i
ewingandworkingspace.Thel apar oscopeispassedthroughasmal li
ncisioni
n
theanter
olateral
abdomi nal wall
.Oneort woothersmalli
ncisions( “
por t
als”
)arerequi
redforsurgi
cal(i
nstrument)
 accesst
otheappendi
xandr
elat
edv
essel
s.
 Colonoscopyi sanint
ernalexaminationofthecol
on,usi
ngacolonoscopewi thasmal lcameral ooki
ngf
or
bleedi
ng,ul
cers,div
ert
icul
it
is,poly
ps, col
oncancer
,andinfl
ammat or
ybowel diseases.Tissuebiopsymaybe
taken.Thecolonmustbecompl etel
yempt y
, t
hepati
entl
iesonhisorherleftside,andthecolonoscopei
s
i
nser t
edthroughtheanusandgent l
yadvancedtotheter
minalsmalli
ntesti
ne.
 Ulcerativecoli
ti
s(crohndi sease)ischr oni
culcerat
ion&sev er
einflammationoft hecolonandr ectum wi t
h
crampi ngabdomi nalpain,rectalbleedi
ng, di
arr
hea, andloosedischargeofpusandmucuswi t
hscant yfecal
part.
Col ect
omyi sper f
or med, whichisremov alofthet er
minali
leum, col
on,rectum andanalcanal .
Ani leostomy
i
st henconst ruct
edt oestablishast oma,anar ti
fi
cialopeningthroughwhichi l
eum isconnectedt otheper ipher
y
ofanopeni ngintheanterolateralabdomi nalwall
.Followingapartialcol
ectomy ,col
ostomyorsi gmoi dostomy
i
sper formedt oconnectcol ont osur gi
call
ycreatedhol e.
 Rectalordigi
tal(
fi
nger )exami nati
onisperfor
medbyinserti
ngagl oved, l
ubricaatedf
ingerint
ot herectum;usi
ng
theotherhandtopr essont helowerabdo-menorpelvi
carea;andpal patingforlumps,tumors,enlargements,
ti
ssuehardening,hemor rhoids,rect
alcar
cinoma,pr
ostatecancer,
semi nalvesicl
e,ampullaoftheduct us
deferens,
bladder,uter
us, cervi
x,ovari
es,
anorect
alabscesses,pol
y ps,chronicconsti
pation.
 Rect alcancerdev el
opsi ntheepit
helial
cel l
sli
ningthelumenoft herectum.Cancercanbedet ectedby
colonoscopyRect alcancermayspr eadal onglymphat i
cvessel sandthroughthev enoussystem.Thesuper i
or
rectalveinisat r
ibutaryoftheportalvei
n, andthus,rectalcancermaymet ast
asizetotheli
ver.Rectalcancermay
penet r
atepost er
iorlytherect
alwal l
andi nvadethesacr alplexus,pr
oducingsciati
ca,andinvadelater
all
ythe
ureterandant eri
or l
ythev agi
na,uterus,
bladder,prostate,
orsemi nalvesicl
es.
 Ischi
o-analabscesses(pus)arepai
nful.I
nfecti
onsmayreacht heischi
o-anal
fossaei
nsev
eral
ways:•Af
ter
crypt
it
is( i
nfl
ammat i
onofanalsi
nuses).•Extensi
onfrom apelvir
ectal
abscess.•Aft
erat
eari
ntheanal
mucousmembr ane.•From apenet
rati
ngwoundi ntheanalregion.
Hemor
rhoi
dsar
edi
l
atedi
nter
nal
andext
ernal
venouspl
exusesar
oundt
her
ect
um andanal
canal
.
I
nter
nal
Hemor
rhoi
ds Ext
ernal
Hemor
rhoi
ds
Di
l
atedi
nter
nal
rect
alv
enouspl
exus Di
l
atedext
ernal
rect
alv
enouspl
exus.
Theyar
esi
tuat
edabov
ethepect
inat
eli
ne. Theyar
esi
tuat
edbel
owt
hepect
inat
eli
ne.
Theyar
ecov
eredbymucousmembr
ane; Theyar
ecov
eredbyski
n,
thei
rpai
nfiber
sar ecar
ri
edbyGVAf
iber
soft
he Theyaremor epai
nfult
hanint
ernal
hemorrhoi
dsbecause
sympat
heti
cnerves. thei
rpainfiber
sarecarr
iedbyGSAfiber
softheinf
eri
or
rect
alnerv
es.

 Superi
ormesent er
icart
eryobstruct
ioniscausedbyat hrombus,anembolus,atheroscl
er osis,anaort
ic
aneurysm,atumorintheuncinateprocessofthepancreas,compressi
onbythet hi
rdpar toft heduodenum,
or
surgi
calscarti
ssue.Theobstructi
onleadst
osmal landlargeint
esti
nali
schemia,result
ingi nnecrosi
s.

Li
ver

 Livercir
rhosi
si sacondit
ioninwhichlivercel
lsareprogressi
velydestroy
edandr epl
acedbyfatt
yandf ibr
ous
ti
ssuet hatsurr
oundstheintr
ahepaticbloodvesselsandbili
aryradi
cles,i
mpedi ngthecir
cul
ati
onofbl oodthrough
theliv
er.Iti
scausedbychr oni
calcoholabuse; hepati
ti
sB, C,andD;andi ngesti
onofpoisons.Alcoholi
ccirr
hosis
i
schar acteri
zedby"hobnail
"appearanceofliv
er.Li
vercir
rhosi
scausespor talhypert
ensi
on(duet oshunti
ngof
bloodfrom hepati
cportalvei
n)resulti
ng
1)esophageal
var
ices(
dil
atedv
einsi
nlowerpar
toft
heesophagus)
2)hemorr
hoids(
dil
atedv
einsar
oundtheanal
canal)
3)
caputmedusa(di
l
atedvei
nsaroundt
heumbili
cus)
.
4)spi
dernev
iorspi
derangi
oma(
smal
l
,red,
spi
der
-l
ikear
ter
iol
esi
nthecheeks,
neck,
andshoul
der
).
5)
asci
tes(
accumul
ati
onoff
lui
dint
heper
it
oneal
cav
ity
).6)edemai
nthel
eg. 7)j
aundi
ce.
8)hepat
icencephal
opat
hy(
shunt
edbl
oodby
passi
ngt
hel
i
vercont
ainst
oxi
nst
hatr
eacht
hebr
ain)
.
 9)spl
enomegal
y(t
hatleadtot hrombocyt
openia,
alowpl
atel
etcount,
andeasybrui
sing)
.10)hepat
omegal
y.
11)pal
mareryt
hema(persi
stentrednessofthepal
ms).
12)t
esti
cularat
rophy
,gynecomasti
a,and
13)
.pect
oral
alopeci
a(l
ossofhai
r)
.Ital
sohassy
mpt
omsoff
ati
gue(
ti
redness)
,weakness,
nausea,
indi
gest
ion,
l
ossofappet
it
e,wei
ghtl
oss,
andf
ever
.
 Por t
al hypertensi
oncanbet r
eatedbydi vert
ingbloodfrom t
heportaltot hecavalsystem bythepor t
acavalshunt
1)bycr eati
ngacommuni cat
ionbet weentheportalvei
nandt heI
VCast heyl i
eclosetogetherbelowtheliv
e.2)by
thespl enorenal(Warr
en)shuntaccompl ishedbyanastomosingthespl eni
cveintotheleftrenalv
ein.3)by
transj
ugul arintr
ahepat
icportosystemicshunt(TIPS),i
nwhichacat heterisplacedintother i
ghtint
ernalj
ugul
ar
veinthr oughwhi chanint
rahepaticshuntiscreat
edbet weenahepat i
cv einandabr anchoft heport
alveinwit
hin
theliver.
 Budd–Chiar
iorChi
ari
syndromei sanoccl
usi
onofthehepaticvei
nsandresul
tsi
nhighpressur
einthevei
ns,
causi
nghepatomegal
y,upperr
ightabdomi
nalpai
n,asci
tes,
mi l
djaundi
ce,
andevent
uall
yportal
hypert
ensi
onand
l
iverf
ail
ure.
 Inhepatomegaly
,inf
eri
oredgeofliv
erispal
pabl
e.Li
veri
scommonsit
eofcarci
nomaf r
om organsdrai
nedby
port
alveinsorduetoconnect
ionoflymphnode.
Cancercanspr
eadt
oli
verf
rom thor
ax(ri
ghtbreast
)becauseof
connect
ionoflymphati
cvessels.
 Subphreni
cabscessesr esul
tfr
om peri
toni
ti
s.Theyaremor
ecommonont
her
ightsi
debecauseoft
hef
requency
ofrupt
uredappendicesandperfor
atedduodenalulcer
s.
 Becauseofthei
rindependentbloodsuppl
y,hepat
icl
obectomiescanbedonewi
thoutbl
eedi
ng.
Inhepat
ic
segmentect
omy ;segmentinfectedwi
thtumororinj
uryi
sresected.
 Afract
uredri
bthatper
for
atest
hediaphr
agm t
earst
hel
iver.Becauseoftheli
ver’
sgr
eatv
ascul
ari
ty,
li
ver
l
acerat
ionsoft
encauseconsi
derabl
ehemor
rhageandr
ightupperquadrantpain.
 Engor
gementofl
i
verwi
thbl
oodduet
oincr
easedorsust
aineddi
aphr
agmat
icact
ivi
tyi
scal
l
ed“
runner
’sst
it
ch,
”
 Liv
erbi opsyi sperformedbyneedl epunct ure,
whichgoest hrought her i
ght8thor9th( perhaps7t hto10th)
i
ntercost alspaceint heri
ghtmi daxil
laryli
neunderult
ra-soundor( CT)scangui dance.Whi letakingthebiopsy,
thepatienti saskedt oholdhisorherbr eathinful
lexpir
ationt oreducet hecostodiaphragmat i
cr ecessandt o
l
essent hepossibil
ityofdamagi ngthel ungandcausingpneumot horax.Transj
ugularli
verbiopsyi salso
accompl i
shedbyi nserti
ngacat heterintotheri
ghtint
ernal j
ugularv einandguidingitthrought hesuperi
orv ena
cava,IVC, andrighthepaticvein.

 Pri
ngl
e’
smaneuveri
sat empor
arycr
oss-
clampingoft
hehepat
oduodenall
i
gamentcontai
ningpor
tal
tri
adsatt
he
for
amenofWinsl
owforcont
rol
ofhepat
icbleedi
ngdur
ingl
iv
ersur
geryforl
ivi
ngl
i
vertr
ansplant
ati
on.

Gal
l
bladder

 Gall
stones(chol
eli
thsorchol
eli
thi
asi
s)arefor
medbysolidif
icati
onofbi l
econ-
sti
tuentsandcomposedof
chol
esterol
crystal
s,wit
hbil
epigmentsandcalci
um.Gal
lstonespr esentcommonlyinfat,
fer
ti
le(
multi
par
ous)
femaleswhoar eoldert
hanfor
ty(40)year
s(4-Fi
ndi
vi
duals).Stonesmaybecomel odgedint
he
(
a)f
undusoft
hegal
l
bladder
,wher
etheymayul
cer
atei
ntot
het
ransv
ersecol
onori
ntot
heduodenum becauseof
t
hei
rpr
oxi
mal
i
ty(
int
hef
ormercase,
theyar
epassednat
ural
l
ytot
her
ect
um,
buti
nthel
att
ercase,
theymaybe
heldupattheil
eocecalj
uncti
on, producingani nt
est
inalobst
ruct
ion)
;
(
b)bil
educt,wheretheyobstr
uctbi l
ef l
owt otheduodenum, l
eadi
ngtojaundi
ce;
(
c)cysti
cduct;heretheycausechol ecysti
ti
s.
(
d)hartmanpouch;from wheretheycanl odget odoudenum.
(
e)hepato-
pancr
eati
campul l
a( constri
ctedpart)wheretheybl
ockboththebil
i
aryandt
hepancr
eat
icductsy
stems.
I
nthi
scase,
bil
emayent
ert
hepancr
eat
icductsy
stem,
causi
ngpancr
eat
it
is.
 Cholecy
sti
ti
sisaninf
lammationofthegall
bladder,
causedbyobst
ructi
onofthecyst
icductbygal
l
stones.The
pat
ientcomplai
nsofpainov
errighthypochondri
um radi
ati
ngt
oinf
eriorangl
eofri
ghtscapul
aorri
ghtshoulder
.
Murphy'
ssi
gn;
Whenf i
ngeri
splacedbel
owcostal
mar
gin(
att
ipof9t
hcar
ti
lage)
,pat
ientf
eel
sshar
ppai
non
i
nspir
ati
on.
Hewinceswithacatchi
nhisbr
eat
h.
 Cholecy stect
omy(surgicalr
emov alofthegall
bladder)r
esul
ti
ngfr
om i
nfl
ammat i
onorpresenceofgal
l
stonesin
thegallbladder.
Thegallbl
adderi
ssep- arat
edfrom theli
ver
,andt
hecyst
icductandcyst
icarter
y(i
ncal
ottri
angl
e)
aredissect edandl
igated.Ri
ghthepati
car t
eryi
si ndanger.
 Courv
oiser
'sl
aw:Dil
ati
onofgall
bladderoccur
sinextr
insi
cobstr
uct
ionofbi
leduct(i
.e;car
cinomaofheadof
pancr
eas).
Int
ri
nsi
cobstruct
ionbystonesdon'
tcauseanydil
ati
onbecauseofassoci
atedfibrosi
s.
Pancr
eas
 Pancr
eati
ti
sisaninfl
ammati
onofthepancreasandiscausedbygall
stones(gal
l
stonesinhepatoduodenal
ampull
adiver
tbi
l
educttowar
dspancreas)andalcoholconsumpt
ion.Symptomsincludeupperabdominalpai
n
(whi
chmaybesev er
eandconst
antandreachtotheback).
 Pancr
eat
iccancerfr
equentl
ycausesseverebackpain,hast hepotential
toi
nvadeintotheadjacentorgans,&
maybetreat
edbyasurgical
resecti
oncal
ledapancr eat
icoduodenect omyorWhi ppl
e’sprocedure.Cancerofthe
pancr
eat
icheadoft
encompr essesandobstructst
hebil
educt ,causingobst
ructi
vejaundi
ce.Canceroft he
pancr
eat
icneckandbodymaycausepor talorIVCobstr
uctionbecauset hepancreasover
liestheselargevei
ns.
 Dur
ingpancr
eat
ect
omy
,headofpancr
easi
spr
eser
vedt
oret
ainbl
oodsuppl
yofduodenum.
 Annul
arpancr
easoccur
swhent
hev
ent
ral
anddor
sal
pancr
eat
icbudsf
orm ar
ingar
oundt
heduodenum,
ther
eby
obst
ruct
ingi
t.
Spl
een
 Splenomegalyiscausedbyvenouscongestionr
esul
ti
ngfrom thr
ombosi softhespl
enicv ei
norport
al
hypertensi
on,whichcausest
hrombocytopenia(
alowplat
eletcount)andeasybrui
sing.Ithassymptomsof,
bonepai n,
weightloss,
andni
ghtsweats.Spl
enomegal
ymayr esultf
rom granul
ocyt
icleukemia,&hemoly
ticor
granulocyt
icanemia.
 Ruptureoft hespl een(mostv ul
nerableorgan)occursfrequentl
ybyfr
acturedribs(10-12)orsevereblowstot
he
l
efthy pochondr ium andcausespr ofusebleedi
ng.Therupt ur
edspl
eenisdiffi
culttorepair
;consequently
,
splenectomyi sperformedtopr eventthepersonfrom bleedi
ngtodeath(profusebleeding).Thespleenmaybe
remov edsur gicall
ywithminimal eff
ectonbodyf uncti
onbecauseitsfunct
ionsar eassumedbyot her
ret
iculoendot heli
alorgans.
 Dur
ingspl
eenneedl
ebi
opsy
,cost
odi
aphr
agmat
icr
ecessi
skepti
nmi
nd(
whi
chext
endst
o10t
hri
b).
 Kehr'
ssi
gn;Smal
lerbranchesofspleni
car
ter
yar
eendar
ter
ies.Thei
robst
ruct
ioncausespl
eni
cinf
arct
ionwhi
ch
causesr
efer
edpaininlef
tshoulder
.

Ki
dney
 Pelv
icki
dneyi sanectopicki
dneythatoccur
swhenki dney
sfai
ltoascendandthusremaininthepel
vi
s.Two
pel
vicki
dneysmayf usetofor
m asoli
dlobedorganbecauseoff
usionoftherenal
anlagen,
call
edacake( r
osett
e)
ki
dney.Horseshoeki
dneydev el
opsasaresul
toff usi
onofthel
owerpolesoftwokidneysandmayobst r
uctthe
uri
naryt
ractbyitsi
mpingementontheureter
s.
 Leftrenalveintr
av er
sesbetweent heSMAant erior
lyandt heabdominalaort
aposteri
orly
.Downwardtract
ionon
theSMAmaycompr essthel ef
trenal
v ei
n( maycompr ess3r dpartofduodenum)resulti
ngi
nar enalvei
n
entrapmentsy ndromeal soknownas“ nutcrackersyndrome”basedont heappearanceoftheveinint
heacute
art
er i
alangleinasagitt
al v
iew.Thesy ndromemayi ncludehemat uri
aorprotei
nur
ia,abdominal
(lef
tfl
ank)
pain,vomit
ing(duet ocompr essi
onofduodenum)andl efttest
icul
arpai
ninmen.
 Peri
nephr
icabscess:Fasci
aattherenalhil
um att
achestotherenalvessel
sandur eter
,preventi
ngt
hespreadof
pustothecontr
alat
eralsi
de.However,pusfrom anabscess(orbloodfrom aninjuredkidney)mayf
orcei
tsway
i
ntothepelv
isbetweentheloosel
yattachedanteri
orandposteri
orlayer
soft herenal f
ascia.
 Thesitefort
ranspl
anti
ngakidneyisintheili
acfossaofthegr eat
erpelvi
s(asmaj orbl
oodv essel
s&bladderare
closeandtherei
snoinferi
orsupporti
nlumbarr egi
on).
Kidneyi sr
emov edfrom donorwithoutdamagingadrenal
gland.
Thi
ssitesupport
sthetranspl
antedkidneysothattracti
onisnotplacedont hesurgicall
yanast
omosed
vessel
s.Therenalar
teryandveinar
ejoinedtotheexternalil
i
acar t
eryandv ei
n.
 Thecloserel
ationshipoftheki
dney
stothepsoasmajormusclesexpl
ainswhyext
ensi
onoft
hehi
pjoi
ntsmay
i
ncreasepainresult
ingfrom i
nfl
ammat
ioninthepar
arenal
areas.
 Nephroptosisi sdownwarddi
splacementofthekidney
,droppedkidney,orf
loat
ingkidneycausedbyl
ossof
support
ingf at.Theki
dneymovesf r
eel
yintheabdomenandev enintothepelvi
s.Itmaycauseakinki
ntheur
eter
orcompr essionoftheuret
erbyanaberranti
nfer
iorpol
arart
ery,
result
inginhydr
onephrosi
s.
 Poly
cyst
icki
dneydiseasei
sageneti
cdi
sordercharacter
izedbynumerouscystsf
il
ledwit
hflui
dintheki
dney;t
he
cyst
scanslowl
yreplacemuchofnor
malki
dneytissues,reduci
ngki
dneyfunct
ionandleadi
ngtokidneyf
ail
ure.
 Kidneyst
one(r
enalcal
cul
usornephr
oli
th)isfor
medbycombinat
ionofahighl
evelofcalci
um wit
hoxal
ate,
phosphat
e,ur
ea,ur
icaci
d,andcy
sti
ne.Cryst
alsar
ecol
l
ectedi
ncalycesoft
hekidneyorintheuret
er.
 Obst ructi
onoft heur etercausedbyr enalcalcul
ioccursatt hei t
sthreeconstri
cti
ons. Thepai npasses
i
nf eroanteriorly“from thelointothegroin”asthestoneprogr essesthroughtheur eter.(Thel oinisthelumbar
region,andt hegr oinistheinguinalr
egion.)Thepai
nmayext endi nt
ot heproximal anterioraspectoft hethi
ghby
projectionthr ought hegeni tof
emoralnerve(L1,L2)
,thescrot um inmalesandt hel abiamaj orai n
femal es.Uretericcalculicanbeobser vedandr emovedwithanephr oscope,ani nstrumentt hatisinsert
ed
throughasmal l
incision.
Lithotr
ipsy
,focusesashockwav et hr oughthebodyt hatbr eakst hecalculusintosmal
l
fragment st hatpasswi ththeur i
ne.
 Hy dronephr
osisisaf l
uidfil
ledenlar
gementoft her enal
pelvi
sandcal ycesasar esultofobstr
uct
ionoft he
ureter.I
tisduetoanobst ructi
onofur i
neflowbyki dneystonesintheureter,bycompressionontheureterby
abnor malbloodvessel
s,orbyt hedevelopingf
etusatt hepelvi
cbr i
m.Ithassy mptomsofnauseaandv omi t
ing,
uri
nar ytr
actinf
ecti
on,fever,dysur
ia(painf
ulordifcultur
inati
on),uri
naryfrequency
,andurinar
yurgency.
 Renal
angleist
heanglebetweenl
owerbor
derof12t
hrib&out
erangl
eoferect
orspi
nae(ov
erl
i
esl
owerpar
tof
ki
dney)
.Tender
nessi
nkidneyisel
i
cit
edbyappl
yi
ngpressur
ebythumboveri
t.
Post
eri
orMedi
ast
inal
Wal
l
 Anabscessresulti
ngf r
om t uber
cul
osisi
nthelumbarregiont
endstospreadfrom t
hev er
tebraeint
othepsoas
fasci
a(ev
enf r
om medi astinum),wherei
tproducesapsoasabscess.Asaconsequence, thepsoasfasci
a
thi
ckenstoform astrongst ocki
ng-
li
ketube.Pusfrom t
hepsoasabscesspassesinf
erior
lyalongthepsoas
musclewithi
nthisfascialtubeovert
hepelvicbri
m anddeeptothei
nguinal
li
gament .Thepususuallysur
facesi
n
thesuper
iorpartofthet hi
gh.
 Thepersonisaskedtol i
eontheunaffectedsideandext endthet hi
ghont heaffect
edsi
deagainstther
esistance
oft
heexami ner’
shand.Theelici
tat
ionofpai nwiththi
smaneuv erisaposi t
ivepsoassi
gn.
Iti
ndicat
esdiseaseof
ki
dney,
ur et
er,
cecum,appendi
x,si
gmoidcol on&pancr eas(thesest r
uct
uresarerelat
edtoil
i
opsoas).
Anacut el
y
i
nfl
amedappendi xwillpr
oduceapositiverightpsoassign.
 Threecoll
ater
alrout
esareavai
l
ableforvenousbloodretur
nt ot
heheartwhentheI
VCisobst
ruct
edorli
gated.
Fi
rstinvol
vesthesuper
iorandi
nfer
iorepi
gastr
icv ei
ns,
andanotherinvol
vest
hethor
aco-
epi
gastr
icv
ein.Thethi
rd
col
later
alrout
einvol
vestheepidur
alvenousplexusinsi
det hever
tebr
alcol
umn.
Pel
vi
cGi
rdl
e
 Thegy necoidpelvi
s(nor malf
emaletype);
it
spel v
icinl
ethasar oundedov alshapeandawi detransverse
diameter.Anandr oi
d( masculi
neorfunnel-
shaped)pel vi
sinawomanmaypr esenthazardstosuccessful
vaginaldel
iveryofafetus.Pel
vi
sinwhichanteri
opost er
iordi
ameterisgreaterthantransv
ersediameteriscall
ed
Anthropoidpelvi
s.Pelv
isinwhichanter
ioposter
iordiameteri
slessthantransversediameteriscal
ledplatt
ypl
oid.
 Thesizeoft helesserpelvisi
si mportanti
nobst et
ricsbecausei ti
sthebonycanal t
hr oughwhicht hefetus
passesduringnor malchildbir
th.Ant
eroposteri
or(AP)diamet erofthel
esserpelvi
s,true(obstet
rical)conjugate
from t
hemi ddleofthesacr alpromontoryt
ot hepost er
osuperiormargi
n(closestpoint)ofthepubicsy mphy si
sis
thenarrowestf i
xeddi stance(l
essthan11cm)t hroughwhi chthebaby’
sheadmustpassi nav aginaldeli
very
.It
cannotbemeasur eddirectl
y.
 Diagonalconjugate(
11cm)ismeasuredbypal pati
ngthesacr
alpromont
orywiththet
ipoft
hemi ddlefi
nger,
usingtheotherhandtomar kt
helev
el ofthei
nf er
iormargi
nofthepubi
csymphy si
sontheexami
ninghand.
I
schialspinesextendtowar
deachother,andthei nter
spi
nousdist
ancebetweenthem i
snormal
l
yt henarr
owest
 partofthepel
vi
ccanal(thepassagewayt
hrought
hepel
vi
cinl
et,
lesserpel
vi
s,andpel
vi
cout
let
)thr
oughwhi
cha
baby’sheadmustpassatbi
rt
h.
 Weakareasofthepelvi
s,wheref r
actur
esof t
enoccur,
arethepubicrami,theacetabula,t
heregi
onoft hesacr
o-
i
li
acjoi
nts,andtheal
aeoft heil
i
um.Fr actur
esinthepuboobtur
atorareaarerelati
vel
ycommonandar eoft
en
compli
catedbecauseoftheirr
elati
onshiptotheuri
nar
ybladderandur et
hra,whichmayber upt
ured.
 I
ncreasedlev
elsofsexhormonesandt hepr
esenceofthehormonerelaxi
ncausethepelv
icli
gamentstorelax
duri
ngthelat
terhal
fofpregnancy,all
owingi
ncreasedmovementatthepelvi
cjoi
nts.Rel
axati
onofthesacro-i
l
iac
j
oint
sandpubi csymphysi
spermi t
sasmuchasa10–15%i ncr
easeindiameter
s(mostlyt
ransver
se&
i
nterspi
nousdiameter
)tr
ueobst et
ricaldi
ameterr
emainsunaff
ected.

Pel
vi
cCav
ity
 Dur
ingchi
l
dbir
th,
thefetalheadmaycompresst
henerv
esoft
hemot
her
’ssacr
alpl
exus,
produci
ngpai
nint
he
l
owerli
mbs.Theobturatorner
veisvul
ner
ablet
oinj
ury.
 Bl
addercancerusual
l
yori
ginat
esincel
lsli
ningt
heinsi
deoft
hebladder(
epit
hel
i
alcel
l
s).Themostcommon
sy
mptom isbloodi
ntheur
ine(hematur
ia)& pai
nuponuri
nat
ion(
dysuri
a).
 Tenesmusi saconstantf
eeli
ngofthedesir
etoemptythebladderorbowel
,accompani
edbypain,cr
amping,
and
str
ainingduetoaspasm oft
heurogeni
taldi
aphr
agm.Inter
stit
ial
cysti
ti
sisachroni
cinf
lammatorycondi
ti
onof
thebladdert
hatcausesfr
equent
,ur
gent,andpai
nful
uri
nati
on.
 Bloodsuppl
ytotheabdominalsegmentoftheuret
erapproachesf
rom amedialdi
rect
ion,t
hatoft
hepel
vi
c
segmentapproachesf
rom alat
eraldi
rect
ion,
theuret
ersshouldberet
ract
edaccordi
ngly.
 Cystocel
e:Lossofbladdersupporti
nfemalesbydamaget othepelv
icfl
oorduri
ngchi
ldbir
thcanresul
tin
col
lapseofthebladderontotheanteri
orvaginalwall
.Whenintr
aabdominalpr
essur
eincreases,t
heanteri
orwal
l
ofthevaginamaypr ot
rudethroughthevaginalori
fi
ceint
othevesti
bule.
 Uri
narycalcul
i,
forei
gnbodies,andsmallt
umor smayal
sober
emov
edf
rom t
hebl
addert
hroughasupr
apubi
c
ext
raperi
toneali
ncisi
on(partofbl
addersuper
iort
opubi
s).
 Thef emaleuret
hraisdi st
ensibl
ebecausei tcontai
nsel ast
ictissue,aswellassmoot hmuscle.Itcanbeeasi
ly
dil
atedwithouti
njury;consequentl
y,thepassageofcat hetersorcy stoscopesiseasi
eri
nfemal esthaninmales.
Inf
ect i
onsoftheurethra,andespeciall
ythebladder,aremor ecommoni nwomenbecauset hefemal eur
ethr
ais
short,moredist
ensible,andisopent otheexteri
orthrought hev est
ibuleofthevagi
na.
Per
ineum
 Ext
rav
asat edurinemayresul
tfr
om ruptureofthebulbouspor t
ionofthespongyuret
hrabel
owtheurogeni
tal
di
aphragm; 1)t
heurinemaypassint
ot hesuperfici
alper
inealspaceandspreadinf
eri
orl
yint
othescr
otum,
ant
eri
orlyaroundthepenis,
andsuperi
orlyint
ot helowerpartoftheabdominalwal
l.
2)
Theur
inecannotspr
eadl
ater
all
yint
othet
highbecauset
heper
ineal
membr
aneandt
hesuper
fi
cial
fasci
a
oft
heper
ineum ar
efi
rml
yat
tachedt
othei
schi
opubi
crami
andar
econnect
edwi
tht
hedeepf
asci
aoft
het
high.
3)
Itcannotspr
eadpost
eri
orl
yint
otheanal
regi
on(
ischi
orect
alf
ossa)becauset
heper
ineal
membr
aneand
Col
l
es’
sfasci
aar
econt
inuouswi
theachot
herar
oundt
hesuper
fici
alt
ransv
erseper
ineal
muscl
es.
 Ift
hemembranouspartoft
heuret
hraisr
upt
ured,
uri
neescapesi
ntothedeepperi
nealspaceandcan
ext
rav
asat
eupwardaroundthepr
ostat
eandbl
adderordownwardint
othesuperf
icial
perineal
space.
 Theper i
neum, l
ev atorani,andl i
gament softhepelvi
cf asciamaybei nj
uredduringchi l
dbirt
h.The
pubococcy geusandpubor ectali
s,arethemuscl estornmostof ten.Thesemuscl ear eencircl
eandsupportthe
uret
hra,vagina, andanal canal.Weakeningoft helevat
orani andpel v
icfascia(e.g.,
teari
ngoft hepar
acolpi
um)
fr
om stretchingort eari
ngdur i
ngchi l
dbirt
h,maydecr easesuppor tforthev agi
na, bl
adder,uter
us,orr
ectum,or
al
tertheposi ti
onoft heneckoft hebladderandt heurethra.Thesechangesmaycauseur inarystr
ess
i
ncontinence, char acter
izedbydr ibbl
ingofurinewheni ntra-abdomi nalpressur
ei sraised.
 Prenataltr
aini
ng(Lamazeclass)aimsattr
aini
ngwomentol
earnhowtorel
axvol
untar
il
ythemuscl
esofthe
pelvi
cfloorwhil
esimult
aneouslyincr
easi
ngint
ra-
abdomi
nal
pressur
ethr
oughcont
ract
ionoft
hediaphr
agm and
 abdominalmuscles.
Theai
m oft
hismethodi
stofaci
li
tat
epassageoft
hef
etust
hrought
hebi
rt
hcanal
,act
ivel
y
pushi
ng(“bear
ingdown”)t
oaidtheut
eri
necont
racti
ons.
 Dur
inghyst
erect
omy,whent
heuter
ineart
eryi
sli
gat
ed;
uret
eri
sindangerofbei
ngt
ransect
edasur
eterpasses
i
mmediat
elyi
nferi
ort
otheut
eri
neart
ery.
 Culdocentesi
sisaspirati
onoff
luidfr
om thecul-de-
sacofDouglas(rectout
eri
nepouch)byaneedlepunct
ureof
theposteri
orvagi
nalforni
xnearthemi dl
i
nebetweent heut
erosacral
ligaments;becauset
her
ectouter
inepouch
i
st helowestport
ionoftheperi
tonealcavi
ty,
itcancoll
ectf
lui
d.

Mal
eRepr
oduct
iveSy
stem
 Epispadi
asi sacongenitalmalf
ormat i
oninwhicht hespongyurethr
aopensasagrooveonthedorsum oft
he
penis,f
requentl
yassociatedwit
ht hebladderexstrophy.Hypospadiasi
sacongenit
almalf
ormati
oninwhichthe
urethr
aopensont heundersi
deoft hepenisbecauseofaf ai
lur
eofthetwouret
hral
foldst
ofusecompletel
y.I
tis
fr
equentlyassociatedwit
hchor dee,whichisavent r
alcur
vatur
eofthepeni
s.
 Circumcisi
oni st
her emovalofthef oreski
n(pr
epuce)thatcov
ersthegl
ansofthepeni
s.Itisperf
ormedasa
therapeuti
cmedicalprocedur
ef orpathologi
cphimosis,chr
oni
cinf
l ammat
ionsofthepenis,andpeni
l
ecancer
.It
i
sal soperfor
medf orcult
ural
,reli
gious,andmedicalr
easons.
 Phi
mosisisacondit
ioninwhi chthef or
eski
n(prepuce)cannotbeful
l
yr et
ract
edtorevealtheglansduet oa
nar
rowopeningoft
hepr epuce.Av eryti
ghtf
oreskinmayi nter
fer
ewithuri
nati
onorsexualf unct
ion.
Par
aphi
mosisi sapainf
ul const
ri
ctionoftheglanspeniscausedbyatightbandofconstr
ictedandr et
racted
phi
moti
cforeski
nbehindthecorona.
 Vasect
omyissurgi
cal
exci
sionofaport
ionoftheduct
usdef
er-
enst
hroughthescr
otum.Itst
opsthepassageof
sper
matozoa(
hencenofer
ti
li
zat
ion)butnei
therr
educest
heamountofej
aculat
egreat
lynordi
mini
shessexual
desi
re.
 Seminalvesi
clesproducetheal kal
ineconst
it
uentoftheseminalfl
uid,whichcontai
nsfr
uctoseandchol
i
ne.
Fruct
oseprovi
desaf orensicdet er
minati
onforoccur
renceofrape,whereaschol
inecry
stal
sprovi
dethebasi
sfor
thedeter
minationofthepres-enceofsemen( Fl
orence’
stest
).
 Abscessi
nsemi
nal
glandsmayr
upt
ureal
l
owi
ngpust
oent
erper
it
oneal
cav
ity
.
 Hyper t
rophyofthepr ostatei
sabeni gnenl
argementoft heprost
atethataf fectsol
dermenandoccur smost
oft
eni nthemiddlelobe, obst
ructi
ngt hei
nternal
urethr
alorif
iceandt husleadi ngt
onocturi
a(excessi
veuri
nat
ion
atnight),dy
suriaandur gency(suddendesiretouri
nate)
.Transur
ethr
al resectionofthepr
ostat
e( TURP)i
s
surgicalr
emov alofthepr ost
atebymeansofacy st
oscopepassedt hrought heurethr
a.Prost
ati
tisi
sinf
l
ammat i
onofthepr ostate.
 Prostatecanceri saslow-growi ngcancerthatoccurspart
icul
arl
yinthepost
eri
orlobe.Prost
atecancerspr eads
tothebonypel vi
s,pel
vicl
y mphnodes, ver
tebralcol
umn,andskullvi
athevert
ebralvenousplexus,
producingpain
i
nt hepelvis,thelowerback, andt hebones.Thiscanceral
somet as-
tasi
zestotheheartandlungsthrought he
prostati
cv enousplexus,i
nter nali
liacvei
ns,andintothei
nferi
orvenacava.I
tcanbedet ect
edbydi gi
talr
ect al
exami nat
ion,ultr
asoundimagi ngwi t
hadev i
ceinsert
edintotherect
um,orPSAt est
.
 Prostatectomyissurgicalr
emov al
ofapar toralloft
heprostategl
and.Peri
nealpr
ostat
ec-t
omyi sremovaloft
he
prostatethroughanincisi
onintheperineum.Radicalpr
ostatect
omyisremov al
oftheprost
atewithseminal
vesicl
es,ductusdeferens,somepelvicfasci
ae,andpelv
iclymphnodest hr
oughtheretr
opubicortheperi
neal
route.Transuret
hralprost
atect
omyi sresect
ionoftheprostatebymeansofacy st
oscopepassedt hr
oughthe
urethra.
 Erect
il
edysf
uncti
on(ED)mayoccuri ntheabsenceofanervei
nsul
tduetoCent
ralner
voussystem (
hypot
hal
ami
c)
andendocri
ne(pi
tui
tar
yortest
icu-
lar)di
sorders.
Tlachi
eveaner
ect
ion,
asurgi
cal
lyimplant
ed,semir
igi
dpeni
l
e
prost
hesi
smayassumet herol
eoft heerecti
lebodies.
Femal
eRepr
oduct
ivesy
stem
 Pudendal
nervebl
ockisperf
ormedbyinj
ecti
ngalocalanest
heti
cneart
hepudendalner
ve.Iti
saccompl
i
shedby
i
nsert
inganeedl
ethr
oughthepost
erol
ater
alvagi
nalwall
,beneatht
hepelv
icdi
aphragm andtowar
dthei
schi
al
 spi
ne.
 Mediolat
eralepisiotomyi sasur gicali
nci
siont hrought hepost erol
ateral vaginalwall,j
ustl
ateraltotheper i
neal
body,t
oenl arget hebirt
hcanal .Themediolat eralepisiotomyal l
owsgr eaterexpansionoft hebirthcanalint
ot he
i
schior
ectal f
ossa.Howev er ,t
heincisi
onismor edifficul
ttocloselay erbyl ayer,andthereisani ncreasedriskof
i
nfecti
onbecauseofcont ami nati
onoftheischi orectalfossa.Inamedi anepi siotomy,theinci
sioniscar r
ied
poster
ior
lyint hemi dli
net hroughtheposteriorv aginalwallandt hecent raltendon( peri
nealbody )
.Themedi an
epi
siot
omyi srelativ
elybloodlessandpai nless, butthisinci
sionpr ovidesal imitedexpansionoft hebirthcanal
wit
hasl i
ghtpossi bi
li
tyoft eari
ngtheanalsphi ncters.
 Womenchooser egi
onal
anesthesi
a(t
or educepaindur
ingchi
l
dbi
rt
h)suchasaspi
nal
(L3-
L4)
,pudendal
ner
ve
(S2-
S4)
,orcaudalepi
dur
albl
ockinsacralcanal(
S2-S4)
.
 Ov ari
ancancerdevel
opsfrom germ cel
ls,
str
omal cell
s,andepi
thel
ialcel
lsthatcovert
heout ersurfaceofthe
ovary.It
ssymptomsincl
udeaf eel
ingofpressurei
nt hepelvi
sorchangesinbowel orbladderhabits.Somegerm
cellcancer
srel
easecert
ainprotei
nmar ker
s,suchashumanchor ionicgonadotropi
nand- fet
oprotein,int
othe
blood.
 Uteri
neprolapsei
st hepr
otrusi
onofthecer
vixoftheuterusintothelowerpartofthevagi
naandcausesa
beari
ng-downsensat i
oni
nt hewombandani ncr
easedf requencyofburningsensati
ononuri
nat
ion.Theprolapse
occursasar esul
tofadvancingageandmenopauseandr esul
tsfrom weaknessofthemuscl
es,li
gaments,and
fasci
aeofthepelvicfl
oor.
Treatmenti
ncl
udeskegelexercise.
 Fi
bromyomaorl eiomy
omai st
hemostcommonbeni gnneoplasm oft
hefemal egeni
talt
ractder
ivedf
rom
smoothmuscle.Itmaycauseuri
nar
yfr
equency,dys-
menorr
hea,abort
ion,orobst
ruct
edlabor.Afi
broi
disa
beni
gnuter
inetumormadeofsmoot hmusclecell
sandfibr
ousconnectiv
et i
ssueinthewalloft
heuterus.
 Endometri
osi
sisabenigndi
sorderi
nwhichamassofendometrial
tissue(
str
omaandgl ands)occur
saber
rant
ly
i
nv ar
iousl
ocati
ons,
incl
udi
ngtheuteri
newal
l,
ovar
ies,
orotherextr
aendometri
alsi
tes.
 Endomet r
ial canceri
st hemostcommont ype( approximatel
y90%)ofuter
inecanceranddev el
-opsfr
om the
endomet r
ium oft heuterususuall
yf r
om theut eri
negl ands.I
tsmainsy
mpt om i
svaginalbleedi
ng,whichal
lows
forear
lydet ecti
on;othersymptomsar eclearvaginaldischar
ge,l
owerabdominalpain,andpelvi
ccramping.Ri
sk
fact
orsincludeobesity, nul
l
ipar
it
y,infer
ti
li
ty,earlymenar che&lat
emenopause.
 Cervi
calcanceri sasl ow-
growingcancerthatdevelopsfrom theepit
heli
um cover
ingt hecervi
x.Themajorr i
sk
fact
orfordev elopmentofcervicalcanceri
shumanpapi ll
omav i
rusi
nfecti
on.Cancercel l
sgrowupwar dt othe
endometrialcav i
ty,downwardtothev agi
na,andlateral
l
yt othepelv
icwall,
invadi
ngt hebladderandrectum
dir
ectl
y.
APapani colaou(Pap)smearorcer vi
calsmeart esti
seffec-
tiv
eindetecti
ngcer vi
calcancerearl
y.This
cancermet astasizestoextr
apelvi
clymphnodes, li
ver,l
ung,andboneandcanbet reatedbysurgicalr
emov alof
thecervi
xorbyhy st
erect
omy .
 Hyster
ectomyi
ssurgi
calremovaloft
heuter
us,perf
ormedei
therthroughtheabdominal
wallorthroughthe
vagi
na.Itmayr
esul
tininj
uryt
ot heur
eter
,whi
chliesint
hetr
ansversecardinal
li
gamentbeneat
ht heuter
ine
art
ery.
 Vaginal examinationisanexami nati
onofpel vi
cst ruct
uresthroughthevagina:(a)i nspecti
onwi t
haspecul um
all
owsobser vati
onoft hev aginal wall
s,thepost eri
orforni
xast hesit
eofcul docent esis,
theuteri
necervi
x, andt he
cervicalos;(b)digit
al exami national l
owspal pationoftheur et
hraandbladdert hr
ought heanteri
orforni
xoft he
vagina; theperi
neal body ,rec-
tum, coccyx,andsacr um thr
ought hepost
eriorfornix; andtheov ar
ies,
uteri
net ubes,
ureters,andischialspinest hr
ought helater
al f
ornices;and(c)bimanualexami nationi sperf
ormedbypl acingt he
fingersofonehandi nt hev aginaandexer t
ingpr essur
eont helowerabdomenwi t ht heotherhandtodet ermine
thesi ze,shape,andposi t
ionoft heut erus,topalpatetheov ari
esanduteri
net ubes, andt odetectpelvi
cinfl
ammat ionorneopl asms.
 Vagi
nismusisapainfulspasm oft
hev
agi
nar
esul
ti
ngf
rom i
nvol
unt
arycont
ract
ionoft
hev
agi
-nal
muscul
atur
e,
pr
eventi
ngsexual
intercourse.
 Vaginacanbemarkedl
ydistended,par
ti
cul
arl
yintheregi
onoft
hepost
eri
orpar
toft
hef
orni
x.Thedi
stensi
on
accommodatest
heerectpenis&f et
usduri
ngpar-
turi
ti
on.
Wr
it
tenby
Tay
yabHasnai
n(KEMU)
(
03127351055)