9A

Protrusion of an organ through the wall of the cavity that normally contains it

hernia

omphalocele

herniation at the umbilicus (a part of the intestine protrudes through the abdominal wall at birth)

incarcerated hernia

A hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated.

Umbilical hernias

A very common hernia in infancy, this is a ventral hernia located near or at the umbilicus.

epigastric hernia

An __________ is a ventral hernia that occurs through the linea alba at the midline between the umbilicus and the xiphoid process.

incisional hernia

An artificial hernia that occurs at the original surgical incision, a drain site, or a trocar site in the case of laparoscopy is called an __________.

Deep (internal) inguinal ring: - beginning of the inguinal canal and is at a point midway between the anterior superior iliac spine and the pubic symphysis. - It is just above the inguinal ligament and immediately lateral to the inferior epigastric vessels. - it is made from a hole or opening in the transversalis fascia (deep) that forms one of the coverings of the spermatic fascia of the spermatic cord Superficial (external) inguinal ring: - end of the inguinal canal and is superior to the pubic tubercle - triangular opening in the aponeurosis of the external oblique through which the spermatic cord exits

Deep (internal) inguinal ring and superficial (external) inguinal ring

an example of an eventration (thinning & bulging), not a hernia (hole thru which viscera can slide / be incarcerated). --> thinning and widening of the linea alba and so when they contract rectus mm. in sit-up, it's looks like a hernia (smooth midline protrusion) but the transversalis fascia is intact, and hence not a hernia.

Diastasis recti

the internal inguinal ring is bounded by the fibers of the transversus abdominis laterally and superiorly and inferiorly by the epigastric artery and vein medial

How is the internal inguinal ring bounded?

Formed by the lower border of the external oblique aponeurosis; passes between the ASIS laterally and the pubic tubercle medially A- external oblique aponeurosis B- external oblique m.

Inguinal ligament

Yellow- arcuate line: marks the end of the posterior rectus sheath, the lower 1/4 is only anterior rectus comprised of EO (same as before) AND IO and TA from crossing over Green- linea alba: entwining and fusion of all the abdominal muscle fascia: the EO, IO, and TA fascias all come together forming the linea alba extending from the xiphoid process to the pubic symphysis Blue- linea semilunaris: lateral border of the rectus sheath and is formed by the aponeurosis of the internal oblique, reinforced anteriorly the external oblique and internally by the transversus abdominis.

Label the colored lines and explain the fascial changes that occur at each.

Purple- external oblique Blue- internal oblique Green- transversus abdominis Orange- transversalis fascia Black- peritoneum Top: anterior 3/4 Bottom: posterior 1/4 (where there isn't a posterior rectal sheath) A- linea alba

Label the colors. Top and bottom pictures represent what? What does the letter 'A' signify here?

1. Epigastric hernia- ventral hernia that occurs through the linea alba at the midline between the umbilicus and the xiphoid process. 2. Umbilical hernia- ventral hernia located near or at the umbilicus 3. Incisional hernia- occurs at the original surgical incision 4. Spiegelian hernia- passes upward through the arcuate line into the lateral border at the lower part of the posterior rectus sheath. 5. Inguinal hernial- appears through the superficial inguinal ring above the pubic tubercle and crest through a weakened part of the abdominal wall in the groin or along spermatic cord. 6. Femoral hernia- passes through the femoral canal and into the medial aspect of the anterior thigh.

List and describe the possible hernia locations.

1. Inguinal 2. Umbilical Rest are more rare.

Most common hernias.

blood supply to the bowel is cut off at the neck of the hernial sac, rendering the bowel ischemic and susceptible to perforation; A hernia becomes strangulated when the blood supply of its contents is seriously impaired. - signs include: pain or tenderness at the site, vomiting,

Strangulated hernia

inguinal canal; inguinal canal; external; spermatic cord (males); round ligament

The __________ is a natural passageway between the muscle layers of the anterior abdominal wall in the region of the groin. Its size and form vary with age, and although it is present in both sexes, it is best developed in the male. The canal is an oblique tunnel, with deep (__________) and superficial (__________) openings or rings. It transmits the __________ in males, the __________ of the uterus in females, and the ilioinguinal nerve in both sexes.

external oblique aponeurosis (A); spermatic cord (male)/round ligament (female)

The external inguinal ring and inguinal ligament is formed from __________ with which the __________ exits.

external oblique aponeurosis; anterior rectus sheath; external inguinal ring; external spermatic fascia

The external oblique muscle turns into __________ which covers most of the abdomen and that is going to form part of the _________ but in the groin it's going to have a hole-- that's the __________ and then part of that is going to continue as a filmy __________

creemaster m. A- internal oblique m. B- iliohypogastric n. C- ilioinguinal n. D- creemaster m. E- spermatic cord / round ligament

The lowermost part of the internal oblique muscle continues as the __________ muscle down along the surface of the spermatic cord just underneath that external spermatic fascia.

Inguinal hernia; inguinal canal either: 1. indirectly, through the deep inguinal ring (can feel with tip of finger), or 2. directly, through the posterior wall of the inguinal canal (side or pad of finger).

The protrusion or passage of a peritoneal sac, with or without abdominal contents, through a weakened part of the abdominal wall in the groin is known as an __________. These occur because the peritoneal sac enters the __________ either:

rectus sheath; the external and internal oblique, and transversus abdominis muscles

The rectus abdominis and pyramidalis muscles are enclosed in an aponeurotic tendinous sheath (the __________) formed by a unique layering of the aponeuroses of what muscles?

completely encloses; anterior surface The upper 3/4 is totally enclosed, anteriorly and posteriorly. ANTERIORLY: 1. external oblique (EO) aponeurosis, 2. internal oblique (IO) aponeurosis (1/2) POSTERIORLY: 1. IO aponeurosis (1/2) 2. transversus abdominis (TA) aponeurosis. The arcuate line marks the point of the lower 1/4, covered only anteriorly. ANTERIORLY: at the arcuate line, all of the aponeuroses cross to cover the abdomen anteriorly which includes: 1. EO aponeurosis 2. IO aponeurosis 3. TA aponeurosis POSTERIORLY: None. From this point inferiorly, the posterior surface of the rectus abdominis muscle is only in direct contact with the anterior surface of the transversalis fascia--no rectus sheath posteriorly

The rectus sheath __________ the upper 3/4 of the rectus abdominis and covers the __________ of the lower one-quarter of the muscle. Describe the layering of the rectus sheath.

splits; inferior epigastric vessels; spermatic cord; internal inguinal ring

The transversus abdominis __________ and where it does so laterally is the __________ and medially of this origin is the __________ where everything comes together and starts to form the tube. The hole through which it is transmitted is known as the __________.

obstructed hernia

This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel.

femoral hernia

This type of hernia is susceptible to bowel strangulation from passage through its narrow neck.

1. Internal spermatic fascia- deepest layer, arises from the transversalis fascia and is attached to the margins of the deep inguinal ring) 2. Cremasteric fascia- with the associated cremasteric muscle, which is the middle fascial layer, arises from the internal oblique muscle. 3. External spermatic fascia, which is the most superficial covering of the spermatic cord, arises from the aponeurosis of the external oblique muscle and is attached to the margins of the superficial inguinal ring

Three fascias enclose the contents of the spermatic cord:

prolonged as the internal spermatic fascia over the structures that pass through the internal inguinal ring (the testicular vessels and vas (ductus) deferens in the male and the round ligament of the uterus in the female).

Transversalis fascia

- acquired or congenital - most common in babies and pregnancy - Rx: if < 2cm, observe; > 2 cm, get repaired; wait out most umbilical hernias in babies - outies, a classic type of umbilical hernia

Umbilical hernias

1- R. hypochondriac 2- Epigastric 3- L. hypochondriac 4- R. lumbar 5- Umbilical 6- L. lumbar 7- R. inguinal 8- hypogastric 9- L. inguinal

What are these abdominal regions?

1. RUQ 2. LUQ 3. RLQ 4. LLQ

What are these abdominal regions?

1- rectus abdominis m.- flexion of torso, primarily in situps. 2- external oblique m. 3- internal oblique m. 4- transversus abdominis m. 2-4 fxn: isometric contraction to hold guts in and withstand increased pressure when the diaphragm contracts

What are these abdominal wall muscles? Function?

the arcuate line (also called the linea semicircularis); marks the bottom of the posterior rectus sheath and delineates the point inferiorly where the rectus sheath is only anterior (i.e. EO, IO and TA aponeuroses are all anterior)

What is highlighted here? This marks the...

Pyrimidalis- trivial m. with not a lot of function

What is this additional abdominal wall m.?

a striated voluntary (after puberty, not really voluntary) skeletal muscle that wraps around the spermatic cord and raises testicles in response to warmth/cold-- temperature regulation of the testes; particularly a problem in newborn babies because one of the things you might check for is an undescended testicle-- if you don't feel a testicle in scrotum in a newborn you need to stick your finger up palpate in the area of that external inguinal ring and see if you feel a testicle up there; baby might just be cold and testicles are pulled up high

What's the function of the creemaster m? Possible implications?

Hernia repair; nearly 1/4 of all men will have a hernia repair

__________ is the most common procedure. Men?

external oblique; creemaster m.; internal spermatic (spermatic cord or round ligament); the ductus deferens and its vessels, the testicular vessels (pampiniform vv. and testicular aa.), the genital branch of the genitofemoral n., the cremasteric vessels, and lymphatics and remnants of the processus vaginalis

__________ → external spermatic fascia. and then you've got - internal oblique → __________ - transversus abdominis splits and transversalis fascia → __________ and - inside spermatic cord or round ligament → __________.

an opening or area of weakness in the abdominal wall through which abdominal contents can protrude.

abdominal hernias

Muscle contracts but there is no movement--holds position = like our abdominal mm.

isometric contraction