Clinical anatomy

1. Savinaya
Abdominal wall & pelvic wall
Clinical Anatomy

2. Anterior abdominal wall
 Surgical Incisions and Lines
of Cleavage:
 If possible, all surgical
incisions should be made in
the lines of cleavage where
the bundles of collagen fibers
in the dermis run in parallel
rows.
 An incision along a cleavage
line will heal as a narrow
scar, whereas one that crosses
the lines will heal as wide or
heaped-up scars.

3. Anterior abdominal wall- umbilicus
 The umbilicus is the most
obvious feature of the
anterior abdominal wall.
 It is a scar representing the
site of attachment of the
umbilical cord in the fetus.
 The position of umbilicus
is variable.
 In adults it lies at the level
of intervertebral disc
between L3 and L4
vertebrae.

4. Anatomical Significance Of Umbilicus
 It serves as water-shed
line for venous and
lymphatic drainage.
 It indicates the level of
T10 dermatome, i.e., skin
around the umbilicus is
supplied by the 10th
spinal segment.
 It is one of the important
sites of portocaval
anastomosis.

5. Anterior abdominal wall- umbilicus
 Umbilicus:
 The skin around the umbilicus is supplied by T10 spinal
segment.
 Visceral pain of appendicitis is referred to the umbilicus
(note the appendix is supplied by T10 spinal segment).

6. Anterior abdominal wall- Caput Medusae
 Portal Vein Obstruction and Caput Medusae:
 In cases of portal vein obstruction ,the superficial veins around
the umbilicus and the paraumbilical veins become grossly
distended.
 The distended subcutaneous veins radiate out from the umbilicus,
producing in severe cases the clinical picture referred to as caput
medusae.

7. Congenital anomalies of Umblicus
 The important congenital anomalies of the umbilicus
are fistulae and exomphalos.
 Faecal fistula
 Urinary fistula
 Exomphalos (or omphalocele)
 Congenital umbilical hernia

8. Congenital anomalies of Umblicus
 Faecal fistula:
 Failure of vitello-intestinal duct to obliterate results in
faecal fistula at the umbilicus.

9. Congenital anomalies of Umblicus
 Urinary fistula:
 Failure of urachus to obliterate leads to urinary fistula at
the umbilicus.

10. Congenital anomalies of Umblicus
 Exomphalos (or omphalocele):
 Failure of midgut loop to return in the abdominal
cavity.

11. Congenital anomalies of Umblicus
 Congenital umbilical hernia:
 In this condition the intestine protrudes through the
umbilicus due to weakness of umbilical scar.

12. Anterior abdominal wall
 Membranous Layer (Scarpa’s fascia)of the
Superficial Fascia and a Healing Skin Wound:
 When closing abdominal wounds, it is usual for a
surgeon to put in a continuous suture uniting the divided
membranous layer of superficial fascia.
 This strengthens the healing wound, prevents stretching
of the skin scar, and makes for a more cosmetically
acceptable result.

13. Anterior abdominal wall
 Membranous Layer of
Superficial Fascia and the
Extravasation of Urine:
 The membranous layer of the
superficial fascia is important
clinically because beneath it is a
potential closed space that does
not open into the thigh but is
continuous with the superficial
perineal pouch via the penis and
scrotum.
 It prevents the passage of
extravasated urine due to
urethral rupture backward into
the ischiorectal fossae and
downward into the thighs.

14. Anterior abdominal wall: Lymph Vessels
 Clinical significance of cutaneous lymph vessels of
anterior abdominal wall:
 The infection or malignant tumor of the skin in the
lower part of the anterior abdominal wall may cause
swelling in the groin due to enlargement of superficial
inguinal lymph nodes.
 Similar lesions in the upper part of the abdomen may
produce swelling in the axilla due to enlargement of
axillary lymph nodes.

15. Anterior abdominal wall:Rectus sheath
 Hematoma of the Rectus Sheath:
 Hematoma of the rectus sheath is
uncommon but important, since it is
often overlooked.
 Sometimes the superior and inferior
epigastric arteries are unduly stretched
during a severe bout of coughing or in
later months of pregnancy.
 Ruptures if they are exposed to blunt
trauma to the anterior abdominal wall
leading to the formation of hematoma
within the rectus sheath.

16. Anterior abdominal wall:Rectus sheath
 Divarication of the recti
(separation of the
rectiabdominis muscles):
 The separation of two
rectus muscles
 Usually occur in elderly
multiparous woman with
weak abdominal muscles

17. Anterior abdominal wall:
 Cremasteric reflex:
 Upon stroking the skin of
the upper medial aspect
of thigh, there is reflex
contraction of cremaster
muscle leading to reflex
elevation of the testis.
 The reflex is more brisk
in children.

18. Abdominal Herniae
 A hernia is the protrusion of part of the abdominal contents
beyond the normal confines of the abdominal wall.

19. Abdominal Herniae
 Abdominal herniae are of the following common types:
 Inguinal (indirect or direct)
 Femoral
 Umbilical (congenital or acquired)
 Epigastric
 Separation of the recti abdominis
 Incisional hernia
 Hernia of the linea semilunaris (Spigelian hernia)
 Lumbar hernia (Petit’s triangle hernia)
 Internal hernia

20. Inguinal Hernia
 Inguinal hernias: A protrusion of abdominal viscera (e.g.,loops
of intestine) into the inguinal canal is termed inguinal hernia.
 Clinically it presents as a pear-shaped swelling above and medial
to pubic tubercle, above the inguinal ligament.
 There are two types of inguinal hernias:
 Direct hernia
 Indirect hernia.

21. Inguinal Hernia
 Indirect Inguinal Hernia through Inguinal Canal:
 The indirect inguinal hernias occur if the hernial sac enters the
inguinal canal through the deep inguinal ring, lateral to the
inferior epigastric artery.
 It is common in children and young adults.
 The predisposing factor for this type of hernia is the complete or
partial patency of the processus vaginalis.
 The indirect inguinal hernias are more common than the direct
inguinal hernias and occur more often in males than females.
 The indirect inguinal hernia may be congenital or acquired.

22. Indirect inguinal hernia

23. Direct inguinal hernia
 The direct inguinal hernia occurs if the hernial sac enters the
inguinal canal directly by pushing the posterior wall of the
inguinal canal forward, medial to inferior epigastric artery
through the Hesselbach’s triangle.
 The direct inguinal hernias are common in elderly due to weak
abdominal muscles.
 The direct hernia leaves the triangle through its lateral part or
medial part, and therefore it is of two types:
 (a) lateral direct inguinal hernia
 (b) medial direct inguinal hernia.

24. Direct inguinal hernia

25. Femoral Hernia
 The hernial sac descends through the femoral canal
within the femoral sheath.
 A femoral hernia is more common in women than in
men (possibly because of a wider pelvis and femoral
canal).
 The neck of the hernial sac always lies below and
lateral to the pubic tubercle.

26. Femoral Hernia

27. Epigastric Hernia
 Epigastric hernia occurs through the widest part of the linea alba,
anywhere between the xiphoid process and the umbilicus.
 Usually small and starts off as a small protrusion of
extraperitoneal fat between the fibers of the linea alba.
 It is common in middle-aged manual workers.

28. Incisional Hernia
 It is most likely to occur in patients in whom it was
necessary to cut one of the segmental nerves supplying
the muscles of the anterior abdominal wall.
 Postoperative wound infection with death (necrosis) of
the abdominal musculature is also a common cause.

29. Abdominal Pain
 Abdominal pain is one of the most important
problems facing the physician.
 Three distinct forms of pain exist: somatic, visceral,
and referred pain.

30. Somatic Abdominal Pain
 Somatic abdominal pain in the abdominal wall can
arise from the skin, fascia, muscles, and parietal
peritoneum.
 It can be severe and precisely localized.

31. Somatic Abdominal Pain
 The somatic pain impulses from the abdomen reach
the central nervous system in the following
segmental spinal nerves:
 Central part of the diaphragm: phrenic nerve (C3,
4,and 5)
 Peripheral part of the diaphragm: intercostal
nerves(T7–11)
 Anterior abdominal wall: thoracic nerves (T7–12)
and the first lumbar nerve
 Pelvic wall: obturator nerve (L2, 3, and 4)

32. Visceral Abdominal Pain
 Visceral abdominal pain arises in abdominal organs,
visceral peritoneum, and the mesenteries.
 The causes of visceral pain:
 Stretching of a viscus or mesentery
 Distension of a hollow viscus
 Impaired blood supply (ischemia) to a viscus, and
chemical damage to a viscus or its covering peritoneum.
 Pain arising from an abdominal viscus is dull and poorly
localized.

33. Referred Abdominal Pain
 It is the feeling of pain at a location other than the
site of origin of the stimulus but in an area supplied
by the same or adjacent segments of the spinal cord.
 Both somatic and visceral structures can produce
referred pain.

34. Referred Abdominal Pain
 Example of referred somatic pain:
 Pleurisy involving the lower part of the costal
parietal pleura can give rise to referred pain in the
abdomen
 The lower parietal pleura receives its sensory
innervation from the lower five intercostal nerves,
which also innervate the skin and muscles of the
anterior abdominal wall.

35. Referred Abdominal Pain
 Examples of referred visceral pain:
 Visceral pain from the stomach is commonly
referred to the epigastrium(T5-T9)
 Visceral pain from the appendix is referred to
umbilicus (T10)
 Visceral pain from the gallbladder is referred to the
dermatomes (T5–9) on the lower chest and upper
abdominal walls

36. Referred Abdominal Pain

37. Anterior Abdominal Nerve Blocks
 Area of anesthesia: Skin of the anterior abdominal
wall.
 The nerves of the anterior and lateral abdominal
walls are the anterior rami of the seventh through
the twelfth thoracic nerves and the first lumbar
nerve.
 An abdominal field block is most easily carried out
along the lower border of the costal margin and then
infiltrating the nerves as they emerge between the
xiphoid process and the tenth or eleventh rib along
the costal margin.

38. Cleavage Lines of Skin in the Anterior
Abdominal Wall
 The cleavage lines
(Langer’s lines) in the
anterior abdominal wall run
horizontally.
 Topological lines drawn on
a map of the human body.
 They correspond to the
natural orientation of
collagen fibers in the
dermis, and are generally
parallel to the orientation of
the underlying muscle
fibers.

39. Clinical Notes(Cleavage Lines of Skin )
 If possible, all surgical
incisions should be made
in the lines of cleavage
where the bundles of
collagen fibers in the
dermis run in parallel
rows.
 An incision along a
cleavage line will heal as
a narrow scar, whereas
one that crosses the lines
will heal as wide or
heaped-up scars.

40. Surgical Incisions
 A surgical incision is an aperture into the body to
permit the work of the planned operation to proceed.
 In abdominal surgery, the routinely used incisions
include the Lanz incision, midline and paramedian
incisions, and the Kocher incision.

41. Surgical Incisions
 The length and direction of surgical incisions
through the anterior abdominal wall to expose the
underlying viscera are largely governed by
 a)the position and direction of the nerves of the
abdominal wall,
 b)the direction of the muscle fibers,
 c)and the arrangement of the aponeuroses forming
the rectus sheath.

42. Surgical Incisions
 The following incisions are
commonly used:
 Paramedian incision
 Pararectus incision
 Midline incision
 Transrectus incision
 Transverse incision
 Muscle splitting, or
McBurney’s incision
 Abdominothoracic incision

44. Paramedian Incision:
 It was originally used to access much of the lateral viscera,
such as the kidneys, the spleen, and the adrenal glands.
 The incision runs 2-5cm away from the midline, cutting
through the skin, subcutaneous tissue, and the anterior rectus
sheath.
 The anterior rectus is separated from the fascia and moved
laterally, before the excision is continued through the
posterior rectus sheath (if above the arcuate line) and the
transversalis fascia, reaching the peritoneum and abdominal
cavity.
 The incision will take a long time and is difficult, however it
does prevent any division of the rectus muscle and provides
access to lateral structures. A paramedian incision can
damage the muscles’ lateral blood and nerve supply, which
may result in the atrophy of the muscle medial to the
incision.

46. Pararectus incision:
 The anterior wall of the rectus sheath is incised medially
and parallel to the lateral margin of the rectus muscle.
 The rectus is freed and retracted medially, exposing the
segmental nerves entering its posterior surface.
 The posterior wall of the sheath is then incised, as in the
paramedian incision.
 The great disadvantage of this incision is that the
opening is small
 Any longitudinal extension requires that one or more
segmental nerves to the rectus abdominis be divided,
with resultant postoperative rectus muscle weakness.

48. Midline incision
 The midline incision is used for a wide array of abdominal
surgery, as it allows the majority of the abdominal viscera to
be accessed.
 A midline laparotomy can run anywhere from the xiphoid
process to the pubic symphysis, passing around the
umbilicus.
 The incision will cut through the skin, subcutaneous tissue,
and fascia, the linea alba and tranversalis fascia, and the
peritoneum before reaching the abdominal cavity.
 As well as obtaining significant exposure of the viscera, this
incision causes minimal blood loss or nerve damage, and can
be used for emergency procedures.
 Its positioning however does make it susceptible to
significant scars.

50. Transrectus incision
 The technique of making and closing this incision is
the same as that used in the paramedian incision,
except that the rectus abdominis muscle is incised
longitudinally and not retracted laterally from the
midline.
 This incision has the great disadvantage of
sectioning the nerve supply to that part of the
muscle that lies medial to the muscle incision.

52. Transverse incision:
 This can be made above or below the umbilicus and can
be small or so large that it extends from flank to flank.
 It can be made through the rectus sheath and the rectus
abdominis muscles and through the oblique and
transversus abdominis muscles laterally.
 It is rare to damage more than one segmental nerve so
that postoperative abdominal weakness is minimal.
 The incision gives good exposure and is well
 tolerated by the patient.

54. Muscle splitting, or McBurney’s incision
 This is chiefly used for cecostomy and appendectomy.
 An oblique skin incision is made in the right iliac region
about 2 in. (5 cm) above and medial to the anterior
superior iliac spine.
 The external and internal oblique and transversus
muscles are incised or split in the line of their fibers and
retracted to expose the fascia transversalis and the
peritoneum.
 The latter are now incised and the abdominal cavity is
opened.
 The incision is closed in layers, with no
postoperativeweakness.

56. Abdominothoracic incision:
 This is used to expose the lower end of the
esophagus, as, for example, in esophagogastric
resection for carcinoma of this region.
 An upper oblique or paramedian abdominal incision
is extended upward and laterally into the seventh,
eighth, or ninth intercostal space, the costal arch is
transected, and the diaphragm is incised.

57. Kocher Incision
 A Kocher incision is a subcostal incision used to
gain access for gall bladder and/or biliary tree
pathology.
 The incision is made to run parallel to the costal
margin, starting below the xiphoid and extending
laterally.
 The incision will then pass through the all the rectus
sheath and rectus muscle, internal oblique and
transversus abdominus, before passing through the
transversalis fascia and then peritoneum to enter the
abdominal cavity.

59. Abdominal wall -Endoscopic Surgery
 It involves the passage of the endoscope into the peritoneal cavity
through small incisions in the anterior abdominal wall.
 Endoscopic surgery on the gallbladder, bile ducts, and appendix
has become a common procedure.
 Advantages: anatomic and physiologic features of the anterior
abdominalwall are disrupted only minimally and, consequently,
convalescenceis brief.

60. Abdominal paracentesis
 Abdominal paracentesis is a simple bedside or clinic
procedure in which a needle is inserted into the
peritoneal cavity through anterior abdominal wall
and ascitic fluid is removed.

61. Pelvic wall
 Prominence of hips in multiparous females:
 During pregnancy (particularly in the last trimester),
the pelvic joints are relaxed by relaxin hormone to
provide smooth passage of the baby.
 After childbirth these ligaments tighten up again but
never regain their original efficiency.
 As a result, the pelvis widens and hips become more
prominent in a multiparous female.

62. Pelvic wall
 Gait in late pregnancy:
 During late pregnancy due to relaxation of ligaments
and additional body weight due to gravid uterus, the
upper end of the sacrum tilts forward during walking
and woman tends to fall forward.
 This, she prevents by walking with backward tilt of
her lumbar vertebral column and shoulders, i.e., she
walks like a lord.

63. Pelvic wall
 Fractures of the pelvis:
 Cause: a direct violence of high velocity.
 The weak sites of the pelvis are sacroiliac region,
pubic rami, and pubic symphysis.
 Lateral compression of pelvis usually results in
fracture through both pubic rami or Clinical
correlation fracture of pubic ramus on one side
associated with dislocation of pubic symphysis.

65. Pelvic wall
 Fractures of the pelvis:
 Anteroposterior compression may cause dislocation
of pubic symphysis or fracture through pubic rami
accompanied by dislocation of the sacroiliac joints.
 The displacement of part of the pelvic ring indicates
that the ring is broken at two places.
 The soft tissues likely to injure in pelvic fracture are
urinary bladder, urethra, and rectum.

66. Pelvic wall
 Injury of pelvic diaphragm:
 The pelvic diaphragm may be injured (tearing of perineal body)
during difficult childbirth.
 As a result it becomes weak and can no longer provide sufficient
support to the pelvic viscera.
 This may lead to uterine prolapse and rectal prolapse.

67. Any questions ?