Abdomen Blue Boxes

Pancreatectomy

The anatomical relationships and blood supply of the head of the pancreas, bile duct, and duodenum make it impossible to remove the entire head of the pancreas. Neck of pancreas: portal vein (splenic and superior mesenteric vein), and superior mesenteric.

Aberrant Hepatic arteries

The most common source of an aberrant right hepatic artery is the. The most common source of an aberrant left hepatic artery is the left gastric artery

Accessory Spleen(s)

may develop prenatally near the splenic hilum, they may be embedded partly or wholly in the tail of the pancreas. Awareness of the possible presence of an accessory spleen is important because if not removed during a splenectomy, the symptoms that indicated removal of the spleen (e.g., splenic anemia) may persist.

Intraperitoneal Injection and Peritoneal Dialysis

renal failure, waste products such as urea accumulate in the blood and tissues and ultimately reach fatal levels. Peri toneal dialysis may be performed in which soluble substances and excess water are removed from the system. semipermeable membrane with an extensive surface area, much of which (subdiaphragmatic portions in particular) overlies blood and lymphatic capillary beds. Therefore, fl uid injected into the peritoneal cavity is absorbed rapidly.

Hepatic Lobectomies and Segmentectomy

right and left hepatic arteries and ducts, AND right and left hepatic portal veins, DO NOT COMMUNICATE, it became possible to perform hepatic lobectomies, removal of the right or left (part of the) liver, without excessive bleeding. hepatic segmentectomies. This procedure makes it possible to remove (resect) only those segments that have sustained a severe injury or are affected by a tumor. Right, intermediate, and left HEPATIC VEINS serve as guides to the planes (fissures) between the hepatic division

Referred Pain from Diaphragm

two different areas because of the difference in the sensory nerve supply of the diaphragm. referred to the SHOULDER region, the area of skin supplied by the C3-C5 segments of the spinal cord. the inferior intercostal nerves, is more localized, being referred to the skin over the costal margins of the ANTERO-LATERAL abdominal wall.

Splenic Needle Biopsy and Splenoportography

relationship of the costodiaphragmatic recess of the pleural cavity to the spleen is clinically important.

Direct (acquired) inguinal hernia

Older men, weakness of transversals fascia, travels medial to vessels, remains superficial. FELT MEDIAL WHEN FINGER IN INGUINAL CANAL.

Duodenal Ulcers

(peptic ulcers) are inflammatory erosions of the duodenal mucosa. bleeding from duodenal ulcers commonly occurs, erosion of the GASTRODUODENDAL ARTERY (a posterior relation of the superior part of the duodenum) by a duodenal ulcer results in severe hemorrhage into the peritoneal cavity and subsequent peritonitis.

Gallstones in Duodenum

A large gallstone entering the small intestine in this way may become trapped at the ileocecal valve, producing a bowel obstruction (gallstone ileus). A cholecysto-enteric fi stula also permits gas from the gastrointestinal tract to enter the gallbladder, providing a diagnostic radiographic sign

Ileal diverticulum (Meckel's diverticulum)

A remnant of the proximal part of the embryonic omphaloenteric duct (yolk stalk), the diverticulum usually appears as a finger-like pouch.

Position of Appendix

A retrocecal appendix extends superiorly toward the right colic flexure and is usually free. The base of the appendix lies deep to a point that is one third of the way along the oblique line joining the right ASIS (anterior superior iliac spine) to the umbilicus (McBurney point on spino-umbilical line).

Abdominal Paracentesis

After injection of a local anesthetic agent, a needle or trocar and a cannula are inserted through the anterolateral abdominal wall into the peritoneal cavity through the linea alba, for example. The needle is inserted superior to the empty urinary bladder, in a location that avoids the inferior epigastric artery.

Incisional hernia

Along the suture line of a prior abdominal surgical incision. If the muscular and aponeurotic layers of the abdomen do not heal properly

Abdominal hernias

Anterolateral abdominal wall is a frequent site of hernia (usually inguinal, umbilical, and epigastric regions).

Appendicitis

Appendicitis in young people is usually caused by hyperplasia of lymphatic follicles in the appendix that occludes the lumen. In older people, the obstruction usually results from a fecalith (coprolith), a concretion that forms around a center of fecal matter. The pain of appendicitis usually commences as a vague pain in the peri-umbilical region because afferent pain fi bers enter the spinal cord at the T10 level.

caput medusae

Dilated veins around the umbilicus, associated with cirrhosis of the liver. portal obstruction, the veins of the anterior abdominal wall (normally caval tributaries) that anastomose with the para-umbilical veins (normally portal tributaries) may become varicose and look somewhat like small snakes radiating under the skin around the umbilicus.

Colitis, Colectomy, Ileostomy, and Colostomy

Chronic infl ammation of the colon (ulcerative colitis, Crohn disease)... An ileostomy is then constructed to establish a stoma, an artificial opening of the ILEUM through the skin of the anterolateral abdominal wall. Following a partial colectomy, a colostomy or sigmoidostomy is performed to create an artifi cial cutaneous opening for the terminal part of the COLON.

Hematocele of Testis

Collection of blood in the cavity of the tunica vaginalis; results from trauma to testicular arteries. NO TRANSLUMINATION (unlike hematocele).

Gallstones

Concretion in the gallbladder, cystic duct, or bile duct composed chiefly of cholesterol crystals (cholelithiasis). A stone lodged in the cystic duct causes biliary colic (intense, spasmodic pain)= cholecystitis (inflammation). If bile cannot leave the gallbladder, it enters the blood and causes jaundice.

Characteristics of inguinal hernias

DIRECTL: Herniating bowel passes MEDIAL to inferior epigastric vessels, pushing through peritoneum and transversalis fascia in inguinal triangle to enter inguinal canal. INDIRECT: Herniating bowel passes LATERAL to inferior epigastric vessels to enter deep inguinal ring.

Gastric Ulcers, Peptic Ulcers, Helicobacter pylori, and Vagotomy

GASTRIC ulcers are open lesions of the mucosa of the STOMACH, whereas PEPTIC ulcers are lesions of the mucosa of the PYLORIC canal or, more often, the DUODENUM. H. pylori erodes the protective mucous lining of the stomach, inflaming the mucosa and making it vulnerable to the effects of the gastric acid and digestive enzymes (pepsin) produced by the stomach. Because the secretion of acid by parietal cells of the stomach is largely controlled by the vagus nerves, VAGOTOMY (surgical section of the vagus nerves) is performed in some people with chronic or recurring ulcers to reduce the production of acid. POSTERIOR GASTRIC ULCER may erode through the stomach wall into the pancreas, resulting in referred pain to the back. In such cases, erosion of the splenic artery results in severe hemorrhage into the peritoneal cavity.

Blockage of Hepatopancreatic Ampulla and Pancreatitis

Gallstone passing along the extrahepatic bile passages may lodge in the constricted distal end of the ampulla, where it opens at the summit of the major duodenal papilla. BOTH the biliary and pancreatic duct systems are blocked and neither bile nor pancreatic juice can enter the duodenum. Bile may back up and enter the pancreatic duct, usually resulting in pancreatitis (inflammation of the pancreas).

Hydrocele of Spermatic Cord and/or Testis

HYDROCELE is the presence of excess fluid in a persistent processus vaginalis. Hydrocele of the testis is confined to the scrotum and distends the tunica vaginalis. Hydrocele of the spermatic cord is confined to the spermatic cord and distends the persistent part of the stalk of the processus vaginalis

Brief Review of Embryological Rotation of Midgut

For 4 weeks, the rapidly growing midgut, supplied by the SMA, is physiologically herniated into the proximal part of the umbilical cord. Attached to the umbilical vesicle (yolk sac) by the omphalo-enteric duct (yolk stalk). As it returns to the abdominal cavity, the midgut rotates 270° around the axis of the SMA. Some mesenteries shorten and others disappear (e.g., most of duodenal mesentery).

Variations in the Cystic and Hepatic Ducts

High union of the cystic and common hepatic ducts near the porta hepatis. important for surgeons when they ligate the cystic duct during cholecystectomy (surgical removal of the gallbladder).

Hepatomegaly

IVC and hepatic veins lack valves... Rise in central venous pressure is directly transmitted to the liver, which enlarges as it becomes engorged with blood.

Section of a Phrenic Nerve

In Neck, complete paralysis and eventual atrophy of the muscular part of the corresponding half of the diaphragm. Complete paralysis and eventual atrophy of the muscular part of the corresponding half of the diaphragm.

Hiccups

Involuntary, spasmodic contractions of the diaphragm, causing sudden inhalations that are rapidly interrupted by spasmodic closure of the glottis. irritation of afferent or efferent nerve endings, or of medullary centers in the brainstem that control the muscles of respiration, particularly the diaphragm. PHRENIC NERVE DISTURBED.

Rupture of Diaphragm and Herniation of Viscera

Large increase in either the intrathoracic or intra-abdominal pressure DUE TO severe trauma to the thorax or abdomen during a motor vehicle accident. Most diaphragmatic ruptures are on the left side (95%) because the substantial mass of the liver.

Spigelian hernia

Lateral to linea semilunaris. Older people and associated with obesity.

Clinical significance of fascia and fascial spaces of Abdominal wall

Liposuctions the tube inserted SUBDERMALLY. superficial fatty layer (Camper fascia, continues to thigh) and the deep membranous layer (Scarpa fascia, continues to PERINEAL but not thigh) of subcutaneous tissue Suturing BELOW umbilicus, surgeons include MEMBRANOUS (Scarpa deep) subcutaneous tissue. Between this layer and the deep fascia covering the rectus abdominis and external oblique muscles is a potential space where fluid may accumulate. it cannot spread inferiorly into the thigh because the deep membranous layer of subcutaneous tissue fuses with the deep fascia of the thigh (fascia lata) along.

Inguinal hernias

MOST COMMON. Protrusion of parietal peritoneum and viscera, such as the small intestine, through a normal (INDIRECT) or abnormal opening (DIRECT).

Longitudinal incision

Median or paramedian for EXPLORATORY. Median: made rapid without cutting muscle , blood vessels or nerves. ANY PART OF LINEA ALBA FROM XIPHOID PROCESS TO PUBIC SYMPHYSIS. Paramedian (lateral to median plane): from costal margin to pubic hairline.

Diverticulosis

Multiple false diverticula (external evaginations or out-pocketings of the mucosa of the colon) develop along the intestine; common in SIGMOID.

Umbilical hernia

Neonates because anterior abdominal wall is WEAK. Increase intra-ab pressure leads to INCOMPLETE closure of anterior wall and herniation occurs through ring. Acquires: mostly women or obese, with extra peritoneal fat or peritoneum protrude.

Protuberance of Abdomen

Normal in infants and young children (due to air in GI); abnormal in adults....the six causes all begin with "f" (food, fluid, fat, feces, flatus, and fetus). -eversion of the umbilicus ("outsie" belly button) is a sign of increased intra-abdominal pressure due to ascites (abnormal accumulation of serous fluid in the peritoneal cavity) or a mass (tumor, fetus, or enlarged organ)

Visceral Referred Pain

Organic pain arising from an organ such as the stomach varies from dull to severe; however, the pain is poorly localized. It radiates to the dermatome level, which receives visceral afferent fi bers from the organ concerned. Visceral referred pain from a gastric ulcer, for example, is referred to the epigastric region because the stomach is supplied by pain afferents that reach the T7 and T8 spinal sensory ganglia and spinal cord segments through the greater splanchnic nerve.

Pancreatic Cancer

Pancreatic head accounts for most cases of extrahepatic obstruction of the biliary ducts. Cancer of the head often compresses and obstructs the bile duct and/or the hepatopancreatic ampulla. Obstruction, resulting in the retention of bile pigments, enlargement of the gallbladder, and obstructive jaundice. Ductular adenocarcinoma. Severe pain in the back is frequently present. may cause hepatic portal or inferior vena caval obstruction because the pancreas overlies these large veins.

Displacement of Stomach

Pancreatic pseudo-cysts and abscesses in the omental bursa may push the stomach anteriorly. Following pancreatitis (inflammation of the pancreas), the posterior wall of the stomach may adhere to the part of the posterior wall of the omental bursa.

Flow of Ascitic Fluid and Pus

Paracolic gutters are of clinical importance because they provide pathways for the fl ow of ascitic fluid and the spread of intraperitoneal infections into the PELVIS, especially when the person is upright

Cholecystectomy

People with severe biliary colic usually have their gallbladders removed. Laparoscopic cholecystectomy often replaces the open-incision surgical method. Cystic artery most commonly arises from the RIGHT hepatic artery in the cystohepatic triangle. Cystohepatic triangle is defined inferiorly by the cystic duct, medially by the common hepatic duct, and superiorly by the inferior surface of the liver.

Functions of Greater Omentum

Prevents the visceral peritoneum from adhering to the parietal peritoneum.

Rupture of Spleen

Protected by 9-12 ribs but MOST FREQUENTLY INJURED.

Epigastric hernia

Protrusion of abdominal structures presents as a small, fatty nodule at epigastrium in midline, through the LINEA ALBA. Usually one can feel it rather than observe it. May be palpable only when standing.

Hiatal (hiatus) hernia

Protrusion of part of the stomach into the thorax through the esophageal hiatus (T10; vagal trunks, left inferior phrenic vessels, left gastric branched).

splenectomy

Repair of a ruptured spleen is difficult; consequently, splenectomy (REMOVAL of the spleen) is often performed to prevent the person from bleeding to death. does not produce serious effects, since FUNCTIONS assumed by other reticuloendothelial organs (e.g., LIVER AND BONE MARROW), but there is a greater susceptibility to certain bacterial infections.

subphrenic abscess

Subphrenic abscesses are more common on the right side because of the frequency of ruptured appendices and perforated duodenal ulcers. may drain into one of the hepatorenal recesses

Gastrectomy and Lymph Node Resection

Total gastrectomy (removal of the entire stomach) is uncommon. Partial gastrectomy (removal of part of the stomach) may be performed... anastomoses of the arteries supplying the stomach provide good collateral circulation,

Postnatal Patency of Umbilical Vein

Umbilical vein carries well-OXYgenated, nutrient-RICH blood from the placenta to the fetus. "Occluded" umbilical vein forming the ROUND LIGAMENT (TERES) of the liver BUT the umbilical vein is patent for some time after birth and is used for umbilical vein catheterization.

Indirect (congenital) Inguinal Hernia

Young adults and children, Patent processus vaginalis as the internal inguinal ring does not close, protrudes through deep inguinal ring and travels laterally to vessels FINGER IN DILATED SUPERFICIAL RING FELT AT THE TIP OF THE FINGER (LATERAL TO INFERIOR EPIGASTRIC).

Splenomegaly

accompanies hypertension (high blood pressure).

Anesthetizing Scrotum

anterior third of scrotum is supplied by the ilioinguinal nerve while the posterior 2/3 is supplied by posterior femoral cutaneous nerve. Thus, an anesthetic must be administered superiorly to anesthetize the anterior surface of the scrotum.

Pyrosis

burning sensation in the abdominal part of the esophagus is usually the result of regurgitation of small amounts of food or gastric fl uid into the lower esophagus (gastroesophageal refl ux disorder; GERD). Pyrosis may also be associated with hiatal hernia (see "Hiatal Hernia").

Paraesophageal hiatal hernia

cardia remains in its normal position (Fig. B2.8A). However, a pouch of peritoneum, often containing part of the fundus of the stomach, extends through the esophageal hiatus anterior to the esophagus. NO REGURGITATION.

Peritonitis and Ascites

contamination occurs during laparotomy, or when the gut is traumatically penetrated or ruptured as the result of infection and infl ammation (e.g., appendicitis) = PERITONITIS. severe abdominal pain, tenderness, nausea and/or vomiting, fever, and constipation. Excess fluid in the peritoneal cavity is called ascitic fluid. Due to mechanical injury (which may also produce internal bleeding) or other pathological conditions, such as portal hyper tension (venous congestion), widespread metastasis of cancer cells to the abdominal viscera, and starvation (plasma proteins ALBUMIN fail to be produced)

Severance of Cystic Artery

cystic artery must be ligated or clamped and then severed during cholecystectomy, removal of the gallbladder. Sometimes, however, the artery is accidentally severed before it has been adequately ligated. The surgeon can control the hemorrhage by compressing the hepatic artery as it traverses the hepatoduodenal ligament. The index fi nger is placed in the omental foramen and the thumb on its anterior wall (Fig. 2.29). Alternate compression and release of pressure on the hepatic artery allows the surgeon to identify the bleeding artery and clamp it.

Accessory Hepatic Ducts

danger during cholecystectomy. An accessory duct is a normal segmental duct that joins the biliary system outside the liver instead of within it. Because it drains a normal segment of the liver, it leaks bile if inadvertently cut during surgery

Abdominal surgical incisions

follow the cleavage lines (Langer lines), AVOID nerves, opposite to muscle fibers.

External Supravesical Hernia

hernia leaves the peritoneal cavity through the supravesical fossa; the site of this hernia is medial to that of a direct inguinal hernia (iliohypogastric nerve is at risk)

Cysts and Hernias of Canal of Nuck

indirect inguinal hernias occur in women (rarely); a persistent processus vaginalis may form a small peritoneal pouch (canal of Nuck) in the inguinal canal which may extend to the labium majus. Later, this can enlarge to form cysts which may herniated as indirect inguinal hernias

Mobile Ascending Colon

inferior part of the ascending colon has a mesentery, the cecum and proximal part of the colon are abnormally mobile. volvulus of the colon (L. volvo, to roll), an obstruction of the intestine resulting from twisting. Cecopexy (fi xation) may avoid volvulus and possible obstruction of the colon.

Portal Hypertension

large volume of blood fl owing from the portal system to the systemic system at the sites of portal-systemic anastomoses may produce varicose veins, especially in the LOWER ESOPHAGUS, RECTUM, PARAUMBILICAL. Bleeding from esophageal varices (abnormally dilated veins) at the distal end of the esophagus is often severe and may be fatal.

Cremasteric Reflex

lightly stroking the skin on the MEDIAL aspect of the superior part of the thigh. Ilio-inguinal nerve

Cirrhosis of Liver

liver is the primary site for detoxification of substances absorbed by the gastrointestinal tract. There is progressive destruction of hepatocytes in hepatic cirrhosis and replacement of these cells by fat and fibrous tissue. Fibrous tissue surrounds the intrahepatic blood vessels and biliary ducts, making the liver fi rm, and impeding the circulation of blood through it (portal hypertension).

Lumbocostal triangle

lumbocostal triangle usually occurs between the costal and lumbar parts of the diaphragm (see Figs. 2.91 and 2.97). This part of the diaphragm is normally formed only by fusion of the superior and inferior fascias of the diaphragm. When a traumatic diaphragmatic hernia occurs, the stomach, small intestine and mesentery, transverse colon, and spleen may herniate through this area into the thorax.

Metastasis of uterine cancer to labium majus

lymphatic vessels follow the course of the round ligament through the inguinal canal. Thus, while occurring less often, metastatic uterine cancer cells (especially from tumors adjacent to the proximal attachment of the round ligament) can spread from the uterus to the labium majus (the developmental homolog of the scrotum and site of distal attachment of the round ligament.

Accessory Pancreatic Tissue

not unusual for ectopic accessory pancreatic tissue to develop in the stomach, duodenum, ileum, or an ileal diverticulum (Merkels).

Oblique and transverse incisions

oblique and transverse incisions is related to muscle fiber orientation, nearby hard tissue (costal margin or iliac or pubic crest), or minimizing potential nerve damage. Gridiron (muscle-splitting) incisions are often used for an appendectomy. The oblique McBurney incision is made at the McBurney point, approximately 2.5 cm superomedial to the ASIS on the spino-umbilical line. IN THE DIRECTION of external oblique fibers. Iliohypogastric preserved. Suprapubic (pfannenstiel) is at pubic hairline. linea alba and anterior layers of the rectus sheaths are transected and resected superiorly (iliohypogastric and ilio-inguinal nerves are identifi ed and preserved.) Transverse incisions through the anterior layer of the rectus sheath and rectus abdominis provide good access and cause the least possible damage to the nerve supply of the rectus abdominis. Subcostal incisions provide access to the gallbladder and biliary ducts on the right side and the spleen on the left

Volvulus of Sigmoid Colon

obstruction of the lumen of the descending colon and any part of the sigmoid colon proximal to the twisted segment. CONSTIPATION AND ISCHEMIA leads to FECAL IMPACTION (immovable collection of compressed).

Congenital Diaphragmatic Hernia

part of the stomach and intestine herniate through a large posterolateral defect (foramen of Bochdalek) in the region of the lumbocostal trigone of the diaphragm

Peritoneal Adhesions and Adhesiotomy

peritoneal surfaces become inflamed, making them sticky with FIBRIN. fibrin may be replaced with FIBROUS tissue. This tethering may cause chronic pain or emergency complications.

Congenital Diaphragmatic Hernia pic

pic

Hiatal Hernia

protrusion of a part of the stomach upward through the opening in the diaphragm. 2 types

Spermatocele and Epididymal Cyst

spermatocele is a retention cyst (collection of fl uid) in the epididymis (Fig. B2.5A), usually near its head. Spermatoceles contain a milky fluid and are generally asymptomatic. An epididymal cyst is a collection of fluid anywhere in the epididymis

Endoscopic Retrograde Cholangiopancreatography

standard procedure for the diagnosis of both pancreatic and biliary disease First, a fiberoptic endoscope is passed through the mouth, esophagus, and stomach. Then the duodenum is entered and a cannula is inserted into the MAJOR DUODENDAL PAPILLA and advanced under fluoroscopic control into the duct of choice (bile duct or pancreatic duct) for injection of radiographic contrast medium.

Esophageal Varices

submucosal veins of the inferior esophagus drain to both the portal and systemic venous systems, they constitute a portosystemic anastomosis. unable to pass through the liver via the hepatic portal vein, causing a reversal of fl ow in the esophageal tributary. The large volume of blood causes the submucosal veins to enlarge markedly, forming esophageal varices (Fig. B2.7). These distended collateral channels may rupture and cause severe hemorrhage that is life-threatening and difficult to control surgically.

Venous Flow and Collateral Pathways of Superficial Abdominal Veins

superior or inferior vena cava is obstructed, anastomoses between the tributaries of these systemic veins, such as the thoraco-epigastric vein, may provide collateral pathways by which the obstruction may be bypassed

Torsion of spermatic cord

surgical emergency because necrosis (pathologic death) of the testis may occur -> obstructs the venous drainage, with resultant edema and hemorrhage!

Sliding hiatal hernia

the cardia, and parts of the fundus of the stomach slide superiorly.

Congenital Hypertrophic Pyloric Stenosis

thickening of the pylorus, results in obstruction and the stomach becomes distended (proximally but stenosis distally); associated with projectile vomiting.

Undescended (Cryptorchid) Testis

undescended testis usually lies somewhere along the normal path of its prenatal descent, commonly in the inguinal canal. The importance of cryptorchidism is a greatly increased risk for developing malignancy i

Palpation of anterolateral abdominal wall

warm hands when palpating the abdominal wall as cold hands will cause guarding (TENSE MUSCLES). Uncontrollable guarding occurs when an inflamed organ is being palpated (due to involuntary muscle spasms which attempt to protect the organ). important for patient to be supine with legs flexed!