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limbs. .The pelvic cavity contains the rectum, the urinary bladder, and the internal genitalia. The perineum is the region of the trunk that is located between the thighs. The pelvic diaphragm separates the pelvic cavity from the perineum . The perineum contains the anal canal, the urethrq and the external genitalia (penis and scrotum in the male, vulva in the

 


Orioin:

. At the aortic opening in the diaphragm opposite the lower border of T12 in the

median plane behind the median arcuate ligament & between the Rt. & Lt. crura.

. lt is a continuation of the thoracic aorta.

. Aortic pulsation can be felt just to the left of the umbilicus.

Termination

. At L4 vertebra slightly to the left by dividing into 2 terminal branches (2 common

iliac arteries).

Relations:

.Posterior: {F it lies directly anterior to L1 - L4.

.Structures cross anterior to aorta include:

> Left renalvein.

F Root of mesentery.

> 3'd part of duodenum.

.On its left side: ls closely related to the Lt sympathetic trunk.

.On its right side: lVC, cisterna chyli.

ABDOMEN I

Branches

Hlght

exbrnal

llhc arhrf

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3 sinqle branches to GIT viscera

F Celiac trunk ) Starts at upper border of L1.

) Superior mesenteric a.) Starts at lower border of L1.

F lnferior mesenteric a.) Starts at L3.

3 paired branches to the qland

F Middle suprarenal a.

} Renal artery a. (L2).

) Gonadal (testis or ovarian) lower border of L2.

3 terminal branches

) Rt. common iliac a.

) Lt. common iliac a.

D Median sacral a,

5 paired branches to the walls

) Phrenic a. (to the diaphragm): one pair.

) Lumbar arteries (to abdominalwall & spinal cord): 4 pairs.

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Gonadal srbdfrl

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llhc ffirI

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I ABDOMEN

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@ tf lumbar arteries are abstructed ) paraplegia due to spinat cord infarction.

Exoosu re:

. hg!gig!6 The abdominal aorta is exposed by a long midline incision

from the xiphoid process to the pubis.

. j.pgl!E!!g!!: The most common indication is for aneurysm which lies

level of the renal arteries in 95% of cases.

. PIS@I9:

1)The peritoneum in Lt. para-colic gutter is incised laterally to the Lt. colon &

extended above to the diaphragm & below to the pelvic brim.

2) Left colon, left kidney, spleen, body & tail of pancreas & fundus of the

stomach are retracted upwards and to the right in the relatively avascular

retroperitoneal plane,

Surface anatomv:

plane in anterior median line.

1 cm below & to the Lt. of the

umbilicus.

Draw 2 parallel lines 2 cm

apart by joining the previous

points.

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extending

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ABDOMEN I

O f iq in : one of the 2 terminal branches of abdominal aorta at lower border of L4.

CO U f Sg: it descends downwards & laterally along the medial side of psoas major

muscle.

End: opposite to sacro-iliac joint by dividing into external & internal iliac arteries.

lmlrm

O f iO i n : at the sacroiliac joint as the larger of the two terminal branches of the

common iliac artery.

EndS: at mid inguinal point where it continues as the femoral artery in the thigh.

Bra n ch es:

a. Deep Circumflex lliac arterv:

It runs between internal oblique & transversus abdominis, so it can be injured

during widening the incision of appendectomy (it anastomoses with

musclophrenic A.).

b. I nferior Eoiaastri c arterv

- Passes upwards close to the medial margin of deep inguinal ring.

- Then it pierces fascia transversalis (posterior wall of rectus sheath) to enter the

sheath where it anastomoses with superior epigastric artery.

I ABDOMEN

- Branches:-

o Pubic branch: anastomose with pubic branch of obturator A.

o Cremaseric branch: anastomose with testicular A.

- lt ascends close to the medial margin of the deep ring, then enter the posterior

wall of rectus sheath to anastomose with superior epigastric A. at the level of

the umbilicus.

Surqical Imoortance of inferior epioastric artery:

1. lt forms the lateral border of Hasselbach's triangle.

2. Lies between direct & indirect inguinal hernias (direct medially & indirect

laterally).

3. Lies between the two limbs of pantaloon hernia.

4. lt marks the neck of hernial sac during herniotomy.

5.ln Orchiopexy, if additional length is needed, this artery is cut and anastomosed

with testicular artery giving more length for the spermatic cord.

6. ln sometimes give an abnormal obturator artery (large pubic branch):

.Present in 30% of population.

.2A%o in safe site.

.1A%o in dangerous sife.

fifi[ enArging the femoral ring medially to relieve strangulation of femoral

hernia sometimes ) severe hemorrhage due to tear of abnormal obturator a.

7. lt gives the cremasteric artery.

8. There is an anastomosis between subclavian & external iliac arteries, in

which the inf. epigastric a. participates (important in LERICH syndrome)

Exoosure of iliac vessels

' These vessels can be approached extra-peritoneally by an oblique incision such

as the one used for the ureter.

. The incision runs obliquely fonryards from the loin in the direction of the

symphysis pubis up to the lateral border of the rectus abdominis.

. This incision exposes the whole length of iliac vessels, including the aortic

bifurcation, but the exposure afforded to the opposite iliac vessels is poor.

Tedkdrrreelc

ABDOMEN I

suface anatomv of common iliac & external iliac afteries

- 1 cm below & to the Lt. of the umbilicus.

- Midinguinal point.

common iliac A. while the lower 2i3 represent the external iliac A.

the

4. Renalvein.

5. Rt. gonadalvein. (testicular or ovarian)

6. Pairs of lumbar veins.

BeO inS: at the lower border of L5 by union of the 2 common iliac veins behind the

Rt. common iliac artery.

Course:

. lt ascends on the right side of the abdominal aorta.

. lt is closely related to the Rt. sympathetic trunk.

End: it pierces the central tendon of the diaphragm to open into the right atrium.

Tributaries:

- The 2 common iliac veins.

- Median sacral vein

1, Phrenic vein.

2. Hepatic veins.

3. Rt. suprarenalvein.

ITF

ABDOMEN

Development of the Diaphraom:

The diaphragm, pericardium & heart are formed in the neck, and thus obtain their

nerve supply from there. They migrate to their final sites carrying their nerve supply

with them.

Seotum transversum:

It separates pericardial development (ventrally) from developing gut (dorsally). lt

moves to lie caudal to pericardial cavity. lt descends from neck to form the central

tendon of the diaphragm.

Bodv wall (transverce laver) and pleura-oeritoneal membranes:

Both grow inwards to fuse with septum transversum and give the diaphragm.

Dorsal mesentry of the esophaous:

Completes the diaphragm posteriorly.

Despite this complex development, few defects occur in the diaphragm.

Perhaps the severer ones are incompatible with life.

The important sites of hernia:

hcOriqin: {f

a- Sternal: back of xiphoid process.

Costal: lower 6 costal cartilages.

Vertebral:

2 crura

, Rt. crus from front of upper 3 lumbar vertebrae.

' Lt. crus from front of upper 2 lumbar vertebrae.

5 arcuate ligaments

. 2 lateral ) bridges over quadrates lumborum muscle

. 2 medial ) bridges over psoas major muscle

. 1 median

Insertion: centrat tendon *

ABDOMEN I

in the di

The three large openings in the diaphragm are shown in table

Oi*fnldr

l*rn

Nerve Suoply of the DiaPhraom{F

i-phrenic nerve (C4) is the motor nerve to the diaphragm and is also sensory to

the central region. This explains referred pain from diaphragm to the shoulderZ-The peripheral region of the diaphragm which develops from the body ',t'all

receives sensory nerves from the lower six or seven intercostal nerves.

ABDOMEN

Action: {F - It is the chief (involuntary) muscle of inspiration (contraction ) central tendon

descends & intra-thoracic pressure decreases).

- lt can also be used voluntarily to increase pressure in the abdomen.

- Contraction of diaphragm assists in venous return to the heart.

- Contraction of Rt. crus helps in preventing regurgitation of food from stomach into

the esophagus (pinch-cock mechanism).

Relations:

o Relations of the Upper Surface:

- PIeura & lung on both sides.

- Base of pericardium in the middle.

. Relations of the Lower Surface:

- Liver, kidney & suprarenal gland (on both sides).

- Spleen & stomach (on the left).

Points of Surqical Imoortance:

Foramen of Morgagni or Magendi:

- Between the sternal & costal origins of the diaphragm through which parasternal (anterior) diaphragmatic hernia may develop.

Foramen of Bochdalek:

- Due to: persistent pleura-peritoneal canal.

- Sife. It is a triangular gap between the lat rib & the diaphragm.

- Posterior diaphragmatic hernia may develop through it.

ABDOMEN

{Fof the transverse processes of all lumbar vertebrae.

2) By 5 digitations, each of which arises from the sides of the bodies of each 2

adjacent lumbar vertebrae and the inter-vertebral discs in between.

3) From tendinous arches attached to the sides of the lumbar vertebrae. These

arches bridge over the lumbar arteries.

Insertion: -*filf

- The muscle descends medial to iliacus muscle & continues downwards to enter

the front of the thigh behind inguinal ligament above superior pubic ramus.

- lts tendon receives fibers of the iliacus muscle and is inserted into the lesser

trochanter of femur.

Nerve SuOplv: branches from the lumbar plexus (L 1, 2, 3).

Action:

..r.-1) lt flexes the thigh and rotates it medially. But in fracture of the neck of femur, the

*' muscle rotates-the thigh laterally. ' 2)Acting from below, the muscle bends the trunk fonrvards.

Psoas fascia

I'he Psoas Majon is enveloped by the psoas fascia, whieh is thickened ln tts upper

part to form the medial arcuate ligament.

I ABDOMEN

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Anteriorlv:

Common for Lt. and Rt. muscles

1) Kidney and its renal vessels.

2) Ureter and renal pelvis.

3)Gonadal vessels.

4) Genito-femoral nerve.

5) Psoas minor (in G0% of population).

6) End of the ileum (on the right) and descending coton (on the left).

7) lnguinal ligament.

Specific for Lt. muscle:

4th part of duodenum,

Specific for Rt. muscle:

lVC, 2nd and 3rd parts of duodenum.

Posteriorlv:

1. Transverse processes of lumbar vertebrae.

2. Superior pubic rami.

Laterallv:

1. Quadratus lumborum (above).

2. lliacus (below).

3. llio-hypogastric nerve.

4. llio-inguinal nerve.

5. Lateral cutaneous nerve of thigh.

6. Femoral nerve (the lower most).

I

Mediallv:

1)Sympathetic trunk (along its medial margin).

2) External iliac vessels (at the brim of the pelvis).

3)2 nerves: obturator nerve and lumbosacraltrunk.

root of mesentery and superior mesenteric vessels.

Points of Surqical Importance:

a. Psoas sign:

- ln acute appendicitis, there.is spasm of psoas major ms. ) flexion deformity.

- Hyperextension of the rib leads to abdominal pain (psoas sign).

h. Psoas Abscess:

- Produces cross fluctuation (DD: mass in the Rt. iliac fossa & mass in the

femoral triangle).

E. Obliterated Psoas Shadow in X-Ray film:

- Rupture spleen.

- Peri-nephric abscess.

d. In fracture neck of the femur the muscle rotates the thigh laterally (not

medially).

It is formed by ventral rami of L1, 2,3 & greater part of L4 (nervus furcalis).

It is lies within the posterior part of Psoas major muscle.

ls connected to sacral plexus by lumbo-sacral trunk

o

a

a

Branches: (Muscutar) {F

) To quadratus lumborum (T12, L1, L2, L3).

) To psoas minor (Ll).

) To psoas major (L2, L3, L4).

) To iliacus (12, L3).

) llio-inguinal (11).

) llio-hypogastric (11 ).

) Genito-femoral (L1, L2).

) Lateral cutaneous nerve of the thigh (L2, L3).

) Femoral (dorsal division of L2, L3, L4).

) Obturator (venteral division of L2, L3, L4).

) Accessory obturator (venteral division of L3, L4).

FnsooMENl

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ABDOMEN I

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C.

The pelvis is the area of transition

between the trunk and the lower

limbs. The bony pelvis serves as the

foundation for the pelvic region and it

provides strong support for the

vertebral column upon the lower

limbs. .The pelvic cavity contains the

rectum, the urinary bladder, and the

internal genitalia. The perineum is the

region of the trunk that is located

between the thighs. The pelvic

diaphragm separates the pelvic cavity

from the perineum . The perineum

contains the anal canal, the urethrq

and the external genitalia (penis and

scrotum in the male, vulva in the

female).

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Upper or pelvic

surface: from 4th

sacral nerve

Lower or perineal

surface: from the

inferior rectal

nerve

Back of the body

of pubis (in front)

lnner surface of

the ischeal spine

(behind)

Tendinous arch of

obturator fascia

(white line)

- Anterior fibers:

perineal body

- lntermediate fibers:

. At anorectal

junction, it continues

with its fellow

behind the rectum

(U-shaped)

o This part of the

muscle is thickened

& blends with the

wall of the rectum &

is called

puborectalis

- Posterior fibers: last

2 segments of the

Both muscles

acting together: f

intraabdominal

pressure

Puborectalis:

supports the

external anal

sphincter

Anterior fibers:

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