Dr goston Szl Surface Anatomy of the Abdomen

Dr. Ágoston Szél Surface Anatomy of the Abdomen, Peritoneal Relations Department of Anatomy, Histology and Embryology Semmelweis University March 5, 2019

Abdominal wall

External oblique abdominal muscle

Internal oblique abdominal muscle

Transverse abdominal muscle

The broad abdominal muscles ext. obl. abd. m. int. obl. abd. m. iliac crest inguinal lig. transv. abd. m. lumbar fascia inguinal lig. pubic tubercle inguinal lig. (v) lumbar fascia 6

Rectus abdominal muscle Pyramidalis muscle

Structure of the abdominal wall skin rectus abd. m. superficial fascia pectoralis major m. aponeurosis of ext. obl. abd. intercostal muscles xyphoid process rectus abd. m. ext. obl. abd. m. linea alba int. obl. abd. m. transv. abd. m. extraperitoneal fat transversalis fascia peritoneum ext. obl. abd. m. int. transv. abd. m. 8 transversalis fascia

Rectus sheath rectus abdominis muscle lateral abdominal muscles inferior epigastric a&v. urinary bladder vagina external iliac artery. rectum

Arrangement of the fatty and membranous layers of the superficial fascia of the abdominal wall aponeurosis of external oblique muscle membranous layer (Scarpa’s fascia) line of fusion superficial fascia fatty layer (Camper’s fascia) position of penis fascia lata position of scrotum spermatic cord

Arrangement of fasciae in the lower abdominal wall *fatty layer (Camper’s fascia) symphysis perineal membrane *membranous layer (Scarpa’s fascia) urethra **Colles’s fascia dartos muscle *superficial fascia external spermatic, cremasteric, internal spermatic fasciae **membranous layer of the superficial fascia

Insertion of abdominal muscles in the loop system of the body musculature Rhomboideus Serratus ant. Pectoralis major Int. obl. abd. Gluteus maximus Ext. obl. Abd. Adductors Sartorius 12

Functions of the abdominal muscles Movements of the trunk Bending of the trunk (forwards, sideways), rotation of the trunk – in collaboration with the muscles of the back. Stiffening the abdominal wall Fixation of internal organs in position – according to the variation of the content of the stomach, urinary bladder and bowels. Breathing Diaphragm + abdominal muscles. Maintaining the abdominal pressure Expiration, urination, defecation, coughing, sneezing, vomiting, exertion of high muscular force, birth. 13

Visceral topography

Visceral topography Apex of right lung Diaphragm Right lobe of liver Gall bladder Pylorus Duodenum, desc. Ascending colon Cecum Ant. inf. iliac spine Clavicle Left lung Left lobe of liver Spleen Pancreas, body Stomach Transverse colon Ileum Jejunum Descending colon Urinary bladder

Topographical coordinate system for surface anatomy (from in front) Medioinguinal plane Medioclavicular (pararectal) plane Jugular notch 1/2 Transpyloric plane (L 1) Subcostal plane (L 2 -3) Supracristal plane (L 4) Intercristal distance (L 5) Interspinal line 1/2 Symphysis

Topographical coordinate system for surface anatomy (from behind) Medioinguinal plane Vertebra prominens Transpyloric plane (L 1) Subcostal plane (L 2 -3) Supracristal plane (L 4) Intercristal distance (L 5) Interspinal line

Abdominal regions for physical examinantion Medioclavicular (pararectal) plane Hypochondriac region EPIGASTRIUM Epigastric region Subcostal plane Mc. Burney (1/2 -1/3) MESOGASTRIUM Lanz (1/3) Ant. sup. iliac spine HYPOGASTRIUM umb. Lateral abd. region Umbilical region Interspinal plane Inguinal region Pubic region

Abdominal regions for physical examination Mediclavicular (pararectal) plane Epigastric r. Umbilical r. Pubic r. Diaphragm Subcostal Interspinal Hypochondriac r. Lat. abd. r. Inguinal r.

Abdominal regions for physical examination Anterior axillary fold – navel line Medioclavicular (pararectal) line Murphy Monroe-line Mc. Burney (1/3) Lanz (1/3) Sonnenburg: crossing of interspinal line & lateral edge of rectus 9 th rib Morris (2/3) Interspinal l.

Location of visceral organs in the coordinate system Medioinguinal plane Transpyloric plane (L 1) Subcostal plane (L 2 -3) Supracristal plane (L 4) Intercristal distance (L 5)

Variations of the topography of stomach projected onto the anterior abdominal wall cardia 10 th rib xyphoid proc. cardia fornix 10 th rib body pylorus xyphoid proc. fornix pylorus body ant. sup. iliac spine hook-shaped (letter J) stomach ptotic (atonic) stomach

Variations of the topography of stomach projected onto the anterior abdominal wall Tp Sc Scr Dcr hook-shaped (letter J) stomach ptotic (atonic) stomach

Projection of internal organs Lung Heart Stomach Liver Duodenum Gall bladder Ascending colon Cecum Descending colon

Head-zones: irradiation of visceral pain Diaphragm (C 4) Heart (T 3 -4) Esophagus (T 4 -5) Stomach (T 8) Liver, gall bladder (T 8 -11) Small intestines (T 10) Large intestines T 11) Urinary bladder (T 11 -L 1) Testis, kidney (T 10 -L 1) 25

Abdominal guarding, „défense musculaire” Tensing (hardening) of the abdominal wall muscles is a reflex mechanism. To protect inflamed organs from the pain of pressure upon them. The tensing is detected when the abdominal wall is pressed. Guarding is a characteristic finding in the physical examination for an abruptly painful abdomen (an acute abdomen). It accompanies the inflammation of the inner abdominal (visceral and parietal peritoneal) surface due to appendicitis or diverticulitis. The tensed muscles of the abdominal wall automatically go into spasm to keep the tender underlying tissues from being disturbed.

Position of appendix spine-navel (Monroe’s) line retrocecal position (e) anteroparietal position (b) Mc. Burney’s point (1/2 -1/3), Morris (2/3) lumbar position (d) interspinal line ant. sup. iliac spine Lanz’s point (1/3) Ilioinguinal position (c) pelvic position (a) inguinal lig.

Position of appendix Lumbar position (d) Retrocecal position (e) Ilioinguinal position (c) Pelvic position (a) Anteroparietal position (b)

Change of position of appendix during pregnancy

Tipical pressure points in appendicitis

Rovsing-signal: upon vigorously pressing the abdomen counterclockwise, the pain felt on the appendix region becomes more intensive.

Branches of abdominal aorta esophageal hiatus (Th 11) inf. phrenic artery coeliac trunk suprarenal artery sup. mesenteric artery renal artery median arcuate ligament aortic hiatus (Th 12 -L 1) left crus gonadal arteries psoas major muscle lumbar arteries inf. mesenteric artery bifurcation of aorta (L 4) common iliac artery bifurcation (sacroiliac joint) median sacral artery external iliac artery internal iliac artery

The prjection of the abdominal aorta and branches inferior vena cava (Th 12) coeliac trunk (L 1) superior mesenteric artery (L 3) inferior mesenteric artery abdominal aorta common iliac a&v. anterior superior iliac spine external iliac a. &v. internal iliac a. &v.

Projection of colon cecum left colic flexure right colic flexure transverse colon ascending colon ileum cecum descending colon distantia cristarum colon sigmoideum rectum appendix medioinguinal plane medioclavicular plane

Projection of liver and gall bladder Medioinguinal plane Left lobe Right lobe Gall bladder 5 th rib 8 th rib Transpyloric plane Gall bladder

Projection of duodenum and pancreas Superior part (L 1) Descending part (L 1 -3) Head (L 2) Inferior part (L 3) Tail (L 1) Body (L 1 -2) Duodenojejunal flexure (L 1 -2) Ascending part (L 3 -2)

Position of small intestine Duodenum: horseshoe shaped, in the upper right quadrant Ileum: rather horizontal, in the lower right quadrant Jejunum: rather vertical, in the upper left quadrant

Skeletotopy of the spleen (from in front) ribs

Topography of spleen (as seen from the left) costo-diaphragmatic recess diaphragm liver stomach transverse colon left lung spleen (rib 8/9 th-11 th)

Topography of the lung, pleura, kidney and spleen medioinguinal plane right: 12 th rib: upper pole left: 12 th rib: 1/3 -2/3 transpyloric plane (L 1) subcostal plane (L 2 -3) supracristal plane (L 4) intercristal plane (L 5)

Posterior projection of kidneys 11 th rib 12 th rib left kidney right kidney crista iliaca post. sup. iliac spine

The peritoneum

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