Operative Surgery and Topographic Anatomy - 2016

Content Module No. 3. Topographic Anatomy and Operative Surgery of the Abdominal Wall and Abdominal Cavity Organs

Topic 10. Surgical anatomy of the anterolateral abdominal wall. Regional division. Layered structure. Blood supply, innervation, and lymphatic drainage. Surgical approaches to abdominal cavity organs and their anatomophysiological rationale. Classification of hernias

1. Relevance of the topic: training physicians requires a solid understanding of the anatomophysiological, age, and sex-related Structural Features of the anterolateral abdominal wall to correctly interpret pathological processes and justify rational surgical approaches to Internal Organs.

2. Specific objectives:

1. Explain the regional division of the anterolateral abdominal wall and the surface projection of Abdominal cavity organs.

2. Analyze the layered Topography of the anterolateral abdominal wall, along with the age- and sex-related characteristics of its Blood supply, innervation, and lymphatic drainage.

3. Explain The formation of weak points in the anterolateral abdominal wall (linea alba, umbilical ring).

4. Analyze rational surgical approaches to the abdominal cavity organs.

5. Classify hernias of the anterolateral abdominal wall.

3. Tasks for independent work during preparation for the Class.

3.1. List of basic terms, parameters, and characteristics that students must master when preparing for the class:

3.2. Theoretical questions for the class:

1. What are the superior, inferior, and lateral BOUNDARIES OF THE abdomen?

2. Name the Regions of the abdomen.

3. What are the surface projections of the vermiform Appendix, Gallbladder, pyloric and cardiac PARTS OF THE Stomach, Spleen, Liver, loops of the small and Large Intestine, and Urinary Bladder?

4. What are the structural Features of the umbilical region and the linea alba?

5. What are the structural features of the rectus abdominis sheath at different levels (above and below the umbilical ring)?

6. Where are the NERVES OF THE anterolateral abdominal wall Muscles located?

7. How do nerves and Blood Vessels reach the rectus abdominis Muscle?

8. What surgical approach through the rectus abdominis sheath is the most rational?

9. What are the Advantages and disadvantages of surgical approaches to the vermiform appendix? Evaluate the McBurney (Volkovych–Dyakonov) and Lennander (pararectal) incisions.

10. Provide a comparative description of longitudinal and transverse incisions.

11. Define the term «hernia».

12. What types of hernias do you know?

3.3. Practical skills acquired during the class:

1. Determine the boundaries of the abdomen, its regions, external landmarks, and organ projections.

2. Justify and perform rational surgical approaches to the abdominal cavity organs.

4. Content of the topic

The xiphoid process and the costal margin, which form the upper boundary of the anterolateral abdominal wall, as well as the iliac crests, inguinal folds, pubic tubercles, and the upper margin of the Pubic Symphysis, which form the lower boundary of the abdominal wall, are palpated on the cadaver; the lateral boundary is represented by a vertical line drawn from the edge of the 11th rib to the iliac crest.

Two horizontal lines are drawn: the upper one connecting the lower points of the 10th Ribs, and the lower one between the two anterior superior iliac spines, along with two vertical lines along the lateral edges of the rectus abdominis muscles. As a result, the abdomen is divided into 9 regions: 3 paired (hypochondriac, lateral, inguinal) and 3 unpaired (epigastric, umbilical, pubic). Attention is drawn to the relationship between abdominal contours and human body constitution.

External landmarks are identified: the umbilicus, linea alba, and the projections of the appendix (McBurney's point, Lanz's point), gallbladder (Kerr's point), stomach, liver, spleen, and intestines are determined.

Next, dissection and review of the layered topography are carried out. For this purpose, the following skin incisions are made: the upper one along the upper margin of the 9th rib, the lower one along the inguinal folds, and the vertical one along the linea alba, bypassing the umbilicus on the left. First, the skin is separated from the subcutaneous adipose tissue. Attention is drawn to the fibrous septa connecting it to the linea alba, and their role in the spread of purulent-inflammatory processes is emphasized.

Superficial Vessels and nerves are located within the subcutaneous tissue: Branches of the lower intercostal Arteries and nerves (VI–XII), the superficial epigastric artery, the superficial circumflex iliac artery, and the cutaneous branches of the iliohypogastric and ilioinguinal nerves.

Dissection of the muscles begins from the lateral border of the abdomen by detaching the muscles from the ribs. First, the external oblique muscle is separated, followed by the Separation of the internal oblique from the transversus abdominis muscle.

It should be noted that the intercostal nerves (VII–X pairs) lie beneath the perimysium of the transversus abdominis muscle; the 11th and 12th intercostal, iliohypogastric, and ilioinguinal nerves lie beneath the perimysium of the internal oblique abdominal muscle. The intercostal arteries are arranged similarly.

To dissect the rectus abdominis muscle, an incision is made in the anterior wall of its sheath, extending from the edge of the costal margin to the pubic bone. Superiorly and inferiorly, the vertical incision is supplemented with horizontal ones. Attention is drawn to the adhesion of the sheath to the muscle at the level of the tendinous intersections, as well as the presence of the intercostal vein, artery, and nerve passing through them. By bluntly retracting the rectus abdominis muscle toward the midline, the branches of the VI–XII intercostal nerves passing through it in an oblique-transverse direction are exposed; attention is drawn to the presence of a fascial cleft along the entire length of the rectus sheath, through which abscesses and hematomas can spread. It is emphasized that for nerve blockades, the procaine solution is injected into the interfascial space. Attention is drawn to the arcuate line on the posterior wall of the rectus abdominis sheath.

Between the medial edges of the rectus muscles, the linea alba and the arrangement of its tendinous fibers are examined. The potential for hernia formation is reviewed. The structural features of the umbilical ring are studied in detail. It is identified after removing the fibrous tissue and is incised upward and downward to expose the obliterated vessels and the urachus in the posterior part of the anterolateral abdominal wall. Then, the transversalis fascia and parietal Peritoneum are examined. Students' attention is focused on the presence of preperitoneal adipose tissue and its clinical significance.

Surgical approaches to the abdominal organs are performed and studied practically on an undissected cadaver. Under the instructor's guidance, students independently master the techniques of midline, paramedian, transrectal, pararectal, oblique, transverse, and combined incisions.

The McBurney's grid-iron (muscle-splitting) oblique incision (through McBurney's point) is analyzed in detail, emphasizing its physiological validity.

When studying the linea alba, it is noted that it contains small clefts through which vessels and nerves pass together with adipose tissue. In certain cases, these clefts can become hernial rings through which preperitoneal adipose tissue and parietal peritoneum protrude, forming hernias of the linea alba.

5. Self-assessment Materials:

A. Self-assessment tasks:

Test No. 1

During a median laparotomy, the surgeon accidentally damaged the round ligament of the liver. Which vessel could have been injured?

а. Umbilical artery

в. Umbilical vein

c. Paraumbilical vein

d. Superior epigastric vein

e. Portal vein

Test No. 2

Which Anatomical Structure lies above the peritoneal fold running downwards from the umbilicus along the midline?

a. Umbilical vein

в. Umbilical artery

c. Inferior epigastric artery

d. Superior epigastric artery

e. Urachus

Test No. 3

A physician is palpating the cecum. To which region of the anterolateral abdominal wall does it predominantly project?

a. Left lateral region

в. Right lateral region

c. Left inguinal region

d. Right inguinal region

e. Suprapubic region

Test No. 4

A surgeon makes an incision along the linea alba within the epigastric region. What are the CHARACTERISTICS OF THE linea alba in this area compared to the lower abdomen?

a. Thin, narrow

в. Thin, wide

c. Thick, narrow

d. Thick, wide

e. Absent

Test No. 5

A patient has sustained trauma to the anterolateral abdominal wall. Injury to which tissue layer classifies a wound of the anterolateral abdominal wall as penetrating?

a. Deep Layer of the superficial fascia

b. Walls of hollow internal organs.

c. Musculo-aponeurotic layer

d. Intra-abdominal fascia

e. Parietal peritoneum

Test No. 6

A surgeon performed an approach to The Stomach vertically downwards from the apex of the xiphoid process within the epigastric region. What is this type of laparotomy called?

a. Median

b. Upper midline

c. Middle median

d. Upper transverse

e. Transrectal

B. Self-Assessment Tasks

Task 1. A patient with a closed abdominal trauma was admitted to the surgical department. A midline laparotomy was performed to explore the abdominal cavity. Indicate the landmarks for performing a midline laparotomy. Name the layers of tissue dissected by the surgeon layer by layer. On which side is the umbilicus usually bypassed and why?

Task 2. While operating on a 7-year-old child for an incarcerated umbilical hernia, the surgeon made a vertical access to the hernial sac, enlarging the hernial ring. Consequently, the hernial sac spontaneously reduced into the abdominal cavity. The surgeon performed Sapezhko's hernioplasty and closed the surgical wound layer by layer. What was the surgeon's mistake?

Task 3. A patient with a penetrating wound of the abdominal cavity in the umbilical region was admitted to the surgical clinic. Name the layers of the abdominal wall injured in this case.

Task 4. A patient with a penetrating wound of the abdominal cavity in the left inguinal region was admitted to the surgical clinic. Name the injured layers of the abdominal wall.

Task 5. A 28-year-old female patient was brought to the surgical department by an ambulance. Two hours ago, she experienced severe pain in the right inguinal region. The patient is obese. There is diffuse tenderness of the abdominal wall, predominantly around the umbilicus and in the right inguinal region, accompanied by slight muscular defense and mild peritoneal irritation. Temperature is 38° C. There was vomiting. Pulse rate is 80-90 bpm. Vaginal examination reveals marked tenderness of the right uterine appendages. There is a three-month history of Amenorrhea. What Diagnosis should the surgeon establish? What type of incision should be used to enter the abdominal cavity?

References

Essential

1. Operative Surgery and Topographic Anatomy; ed. by M.S. Skrypnikov. — K.: Vyshcha Shkola, 2000. — P. 282-286.

2. Operative Surgery and Topographic Anatomy; ed. by M.P. Kovalsky. — K.: Medytsyna, 2010. — P. 190-198.

Supplementary

1. Kovanov V.V. Operative Surgery and Topographic Anatomy / V.V. Kovanov. — M., 2001. — P. 151-158.

2. Operative Surgery and Topographic Anatomy; ed. by G.E. Ostroverkhov. — Rostov-on-Don, 1998. — P. 521-540.

3. Operative Surgery and Topographic Anatomy; ed. by K.I. Kulchytsky. — K., 1994. — P. 168-176.

4. Elizarovsky, S.I. Operative Surgery and Topographic Anatomy / S.I. Elizarovsky, R.N. Kalashnikov. — M., 1979.

5. Matyushin, I.F. Introduction to the Course of Operative Surgery and Topographic Anatomy / I.F. Matyushin. — Gorky, 1976.

6. Tomashuk, I.P. Guide to Surgical Technique for Beginning Surgeons / I.P. Tomashuk, I.I. Tomashuk. — Kyiv: European University Press, 2001. — 860 p.

7. Frauhi, V.Kh. Course of Topographic Anatomy and Operative Surgery / V.Kh. Frauhi. — M., 1976.