Clinicals related to abdomen

1. Clinicals
related to
abdomen

2. Umbilical cord
• At birth, the cord is tied off close to the umbilicus. About 2 in. (5 cm) of cord is left
between the umbilicus and the ligature, because a piece of intestine may be present as
an umbilical hernia in the remains of the extraembryonic coelom. After application of
the ligature, the umbilical vessels constrict and thrombose. Later, the stump of the cord
is shed and the umbilical scar tissue becomes retracted and assumes the shape of the
umbilicus, or navel.

3. Patent Urachus
• The urachus is the remains of the allantois of the
fetus and normally persists as a fibrous cord that
runs from the apex of the bladder to the
umbilicus. Occasionally, the cavity of the allantois
persists, and urine passes from the bladder
through the umbilicus onto the body surface. In
newborns, it usually reveals itself when a
congenital urethral obstruction is present. More
often, it remains undiscovered until old age,
when enlargement of the prostate may obstruct
the urethra.

4. Vitelline Duct
• The vitelline duct connects the developing gut to the yolk sac in the early embryo As normal
development proceeds, the duct is obliterated, severs its connection with the small intestine, and
disappears. Persistence of the vitelline duct can result in an umbilical fecal fistula. If the duct
remains as a fibrous band, a loop of bowel can become wrapped around it, causing intestinal
obstruction. Meckel’s diverticulum is a congenital anomaly representing a persistent portion of the
vitelline duct. It occurs in 2% of patients, is located on the antimesenteric side of the small
intestine about 2 ft (61 cm) from the ileocolic junction and is about 2 in. (5 cm) long. It can
become ulcerated or cause intestinal obstruction.

5. Meckel’s diverticulum

6. Abdominal Herniae
• A hernia is the protrusion of part of the abdominal contents beyond the normal
confines of the abdominal wall. It consists of three parts: the sac, the contents of the
sac, and the coverings of the sac. The hernial sac is a pouch (diverticulum) of
peritoneum and has a neck and a body. The hernial contents may consist of any
structure found within the abdominal cavity and may vary from a small piece of
omentum to a large viscus such as the kidney. The hernial coverings are formed from
the layers of the abdominal wall through which the hernial sac passes.

7. Abdominal Herniae
The common types of abdominal herniae are:
• Inguinal (indirect or direct)
• Femoral
• ‘Umbilical (congenital or acquired)
• Epigastric
• Separation of the recti abdominis
• Incisional Hernia of the linea semilunaris (spigelian hernia)
• Lumbar (Petit’s triangle hernia)
• Internal

8. Indirect Inguinal Hernia
The indirect inguinal hernia is the most common form of hernia and is believed to be congenital in origin. The
hernial sac is the remains of the processus vaginalis (an outpouching of peritoneum that in the fetus is
responsible for the formation of the inguinal canal). It follows that the sac enters the inguinal canal through the
deep inguinal ring lateral to the inferior epigastric vessels. It may extend part of the way along the canal or the
full length, as far as the superficial inguinal ring. If the processus vaginalis has undergone no obliteration, then
the hernia is complete and extends through the superficial inguinal ring down into the scrotum or labium majus.
Under these circumstances, the neck of the hernial sac lies at the deep inguinal ring lateral to the inferior
epigastric vessels, and the body of the sac resides in the inguinal canal and scrotum (or base of labium majus).
An indirect inguinal hernia is about 20 times more common in males than in females, and nearly one third are
bilateral. It is more common on the right (normally, the right processus vaginalis becomes obliterated after the
left; the right testis descends later than the left). It is most common in children and young adults.

9. The indirect inguinal hernia can be
summarized as follows:
• It is the remains of the processus vaginalis and therefore is congenital in origin.
• It is more common than a direct inguinal hernia.
• It is much more common in males than females.
• It is more common on the right side.
• It is most common in children and young adults.
• The hernial sac enters the inguinal canal through the deep inguinal ring and lateral to the inferior epigastric vessels.
• The neck of the sac is narrow.
• The hernial sac may extend through the superficial inguinal ring above and medial to the pubic tubercle. (Femoral
hernia is located below and lateral to the pubic tubercle.)
• The hernial sac may extend down into the scrotum or labium majus.

10. Indirect
inguinal
hernia

11. Direct Inguinal Hernia
• The direct inguinal hernia makes up about 15% of all inguinal hernias. The sac of a
direct hernia bulges directly anteriorly through the posterior wall of the inguinal canal
medial to the inferior epigastric vessels. Because of the presence of the strong conjoint
tendon (combined tendons of insertion of the internal oblique and transversus muscles),
this hernia is usually nothing more than a generalized bulge; therefore, the neck of the
hernial sac is wide. Direct inguinal hernias are rare in women and most are bilateral. It
is a disease of old men with weak abdominal muscles.

12. A direct inguinal
hernia can be
summarized as
follows:
• It is common in old men with weak
abdominal muscles and is rare in women.
• The hernial sac bulges forward through the
posterior wall of the inguinal canal medial
to the inferior epigastric vessels.
• The neck of the hernial sac is wide.

13. An inguinal hernia can be distinguished
from a femoral hernia by the fact that the
sac, as it emerges through the superficial
inguinal ring, lies above and medial to the
pubic tubercle, whereas that of a femoral
hernia lies below and lateral to the
tubercle.
INGUINAL VS
FEMORAL

14. Femoral Hernia
• In a femoral hernia, the hernial sac descends through the femoral canal within the femoral sheath. The
femoral sheath is a protrusion of the fascial envelope lining the abdominal walls and surrounds the
femoral vessels and lymphatics for about 1 in. (2.5 cm) below the inguinal ligament. The femoral artery,
as it enters the thigh below the inguinal ligament, occupies the lateral compartment of the sheath. The
femoral vein, which lies on its medial side and is separated from it by a fibrous septum, occupies the
intermediate compartment. The lymph vessels, which are separated from the vein by a fibrous septum,
occupy the most medial compartment. The femoral canal, the compartment for the lymphatics, occupies
the medial part of the sheath. It is about 0.5 in. (1.3 cm) long, and its upper opening is referred to as
the femoral ring. The femoral septum, which is a condensation of extraperitoneal tissue, plugs the
opening of the femoral ring.

15. Femoral hernia
• A femoral hernia is more common in women than
in men (possibly because of a wider pelvis and
femoral canal). The hernial sac passes down the
femoral canal, pushing the femoral septum before
it. On escaping through the lower end, it expands
to form a swelling in the upper part of the thigh
deep to the deep fascia. With further expansion,
the hernial sac may turn upward to cross the
anterior surface of the inguinal ligament.

16. Femoral hernia
The neck of the sac always lies below and lateral to the pubic tubercle which serves to distinguish it
from an inguinal hernia. The neck of the sac is narrow and lies at the femoral ring. The ring is related
anteriorly to the inguinal ligament, posteriorly to the pectineal ligament and the pubis, medially to the
sharp free edge of the lacunar ligament, and laterally to the femoral vein. Because of the presence of
these anatomic structures, the neck of the sac is unable to expand. Once an abdominal viscus has passed
through the neck into the body of the sac, it may be difficult to push it up and return it to the
abdominal cavity (irreducible hernia). Furthermore, after straining or coughing, a piece of bowel may be
forced through the neck and the femoral ring may compress its blood vessels, seriously impairing its
blood supply (strangulated hernia). A femoral hernia is a dangerous disease and should always be treated
surgically

17. A femoral hernia
can be
summarized as
follows:
• It is a protrusion of abdominal parietal peritoneum
down through the femoral canal to form the hernial
sac.
• It is more common in women than in men.
• The neck of the hernial sac lies below and lateral to
the pubic tubercle.
• The neck of the hernial sac lies at the femoral ring
and at that point is related anteriorly to the
inguinal ligament, posteriorly to the pectineal
ligament and the pubis, laterally to the femoral vein,
and medially to the sharp free edge of the lacunar
ligament.