Abdominal-wall.pptx

Abdominal wall山东大学医学院山东大学医学院 解剖教研室解剖教研室李振华李振华Anterior wall Layers(from superficial to deep)nSkin nSuperficial fascianAnterolateral musclesnTransversalis fascia 腹腹横筋膜横筋膜nExtraperitoneal fascia 腹膜下筋膜腹膜下筋膜nParietal peritoneum 壁腹膜壁腹膜 Superficial fasciadivisions below umbilicusnSuperficial fatty layer(Campers)nMembranous layer(Scarpas)Muscles of abdomenAnterolateral groupnObliquus externus absominis 腹外斜肌腹外斜肌nOblequus enternus abdominis腹内斜肌腹内斜肌nTransversus abdominis腹横肌腹横肌nRectus abdominis 腹腹直肌直肌Posterior group nQuadiatus lumborum 腰腰方肌方肌nPsoas major 腰大肌腰大肌Obliquus externus absominis 腹外斜肌腹外斜肌General direction of fibers:downward,forward and medially(run down and inward)StructuresnInguinal ligament 腹股沟韧带腹股沟韧带nLacunar ligament 腔隙韧带腔隙韧带nSuperficial inguinal ring 腹股沟浅环腹股沟浅环 triangular-shaped defect in aponeurosis of obliquus externus abdominis above pubic tubercleObliquus internus abdominis 腹内斜肌腹内斜肌nDeep to obliquus externus abdominisnGeneral direction of fibres:upwards,forwards and mediallyTransversels abdominis 腹横肌腹横肌nDeep to obliquus internus nInguinal falx 腹股沟镰腹股沟镰:arch over spermatic cord,inserted with transverses abdominis fiber into medial part of pecten of pubis nCremaster 提睾肌提睾肌:around the spermatic cord and testisRectus abdominis 腹直肌腹直肌nPosition:lie on to either of midlinenOrigin:pubic crest and symphysisnInsertion:xiphoid and 5th-7th costal cartilagesnHas 3-4 tendinous intersections 腱划腱划nlinea semiluaris 半月线半月线 Similar functions for above four pairs of musclesnSupport and compress the abdominal visceranIncrease intra-abdominal pressure,aid in expulsive efforts-vomiting,coughing,sneezing,defecation,urination and childbirth.nDepress ribs,assist in(the act of force(4)expiration.nFlex,lateral flex,and rotate vertebral columnSheath of rectus abdominis 腹直肌鞘腹直肌鞘Ant layerformed by fusion of aponeurosis of obliquus externus abdominis and anterior leaf of aponeurosis of obliquus internus abdominisPost layernFormed by fusion of posterion leaf of aponeurosis of obliquus internus abdominis and aponeurosis of transverses abdominisnAbsent in about 4-5cm below the umbilicus,where aponeuroses of all three muscles form anterior layer the lower free border named arcuate linenBelow this line rectus abdominis in contact with transverse fasciaLinea alba 白线白线tendinous raphe between right and left recti from xiphoid to pubic symphysis.Inguinal region 腹股沟区腹股沟区Boundaries nInguinal ligament nLateral margin of rectus abdominisnA horizontal line stretching from anterior iliac spine to laeral margin of rectus abdominisDescent of testesSeven-week embryo showing the testis before its descent from the dorsal abdominal wallFetus at 28 week the testis passing through the inguinal canalNewborn Inguinal canal 腹股沟管腹股沟管Position:oblique passage,4cm long,located 1.5cm above medial half of inguinal lig.BoundariesnAnt wallqAponeurosis of obliquus externus abdominisqObliquus internus abdominis(lateral third of wall)nPost wallqTransverse fascia qInguinal flax mediallynRoofarched lower fibers of obliquus internus and transversua abdominisnFlooringuinal lignTwo openingsqSuperficial inguinal ring 腹股腹股沟浅环沟浅环qDeep inguinal ring 腹股沟深环腹股沟深环 defect in transverse fascia 1.5cm above midpoint of inguinal ligamentnStructures passing through the inguinal canal qSpermatic cord 精索精索 and ilioinguinal nerve髂腹股沟神经髂腹股沟神经 in males qRound ligament of uterus 子宫圆韧带子宫圆韧带and ilioinguinal nerve髂腹股髂腹股沟神经沟神经 in females Inguinal Triangle(of Hesselbach)腹股沟三角腹股沟三角 Boundaries nInguinal ligament inferiorlynLateral border of rectus abdominis medially nInferior epigastric artery laterallyIndirect inguinal heinia and direcet inguinal heinia Superficial vessels and cutaneous nerves nArteries qSuperficial epigastric a.qSuperficial iliac circumflex a.nVeins qThoracoepigastric v.qSuperficial epigastric v.nCutaneous nervesqAnterior and lateral cutaneous n.of lower six thoracic qIliohypogastric n.(first lumb nerves)Deep vessels and nervesArteres nSuperior and inferior epigastric arterisnLower posterior intercostal a.nSubcostal a.nFour lumbar a.Nerves nIliohypogastric n.髂腹下神经髂腹下神经qArises from lubar plexusqPasses forward in the interval between obliquus internus and tranversus abdominisqPieces obliquus internus abdominis 2.5 cm medial to anterior superior iliac spineqPieces aponeurosis of obliquus externus abdominisabout 2.5 cm above superficial inguinal ringnIlioinguinal n.髂腹股沟神经髂腹股沟神经qRuns parallel with iliohypogastric n.at a lower levelqEnters inguinal canal and emerges through superficial inguinal ringnGenitofemoral n.生殖股神经生殖股神经Subcostal incision Muscle-splitting incisionTransverse incision Median or midline incisionLeft paramedian incisionLayer?Suprapubic incisionAbdomen 2山东大学医学院山东大学医学院 解剖教研室解剖教研室李振华李振华Abdominal aorta 腹主动脉腹主动脉nContinuation of thoracic aorta at aortic hiatus of diaphragm in front of T12 nTerminates at lower border of L4 vertebra by dividing into right and left common iliac arteries Parietal branchesnInferior phrenic a.膈膈下动脉下动脉(one pair)nLumbar a.腰动脉腰动脉(four pairs of arteries that supply the posterior abdominal wall)nMedian sacral a.骶骶正中动脉正中动脉Visceral branches nPaired branches qMiddle suprarenal artery 肾上腺中动脉肾上腺中动脉qRenal artery 肾动脉肾动脉qTesticular(ovarian)artery 睾丸（卵巢）动脉睾丸（卵巢）动脉nUnpaired branches q Celiac trunk 腹腔干腹腔干 a short thick vessel that arises from the front of aorta,at the level of T12qSuperior mesenteric a.肠系膜上动脉肠系膜上动脉arises from the front of aorta,at the level of L2qInferior mesenteric a.肠肠系膜下动脉系膜下动脉 arises from the front of aorta,at level of L3Left gastric a.Common hepatic a.Splenic a.Gastroduodenal a.Proper hepatic a.Right gastric a.Left branchRight branchCystic a.Short gastric a.Left gastrioeploic a.Right gastroepiploic a.Superior pancreaticoduodenal aSplemic branches Celiac trunk Celiac trunk Superior mesenteric a.Inf.pancresticodudenal a.Jejunal and ileal a.Ileocolic a.Appendicular a.Right colic a.Middle colic a.Superior Mesenteric v.Inferior mesenteric a.Left colic a.Sigmoid a.Superior rectal a.Inferior mesenteric v.Colic marginal arteryRelations of abdominal aortanAnteriorly(from above downward)qPancreas qAscending part of duodenum qRadix of mesenterynPosteriorly qUpper four lumber vertebrae nOn its right qInferior vena cavanOn its left qLeft sympathetic trunkVeins of abdomen and pelvisInternal iliac vein 髂内静脉髂内静脉nParietal tributaries:accompany with arteriesnVisceral tributaries superior rectal veininferior mesenteric v.Rectal venous plexus inferior rectal veininternal iliac v.直肠静脉丛直肠静脉丛 anal veininternal pudendal v.Vesical venous plexus 膀胱静脉丛膀胱静脉丛vesical v.Uterine venous plexus 子宫静脉丛子宫静脉丛uterine v.nExternal iliac vein 髂外静脉髂外静脉 accompany the arterynCommon iliac vein 髂总静脉髂总静脉 formed by union of internal and external iliac veins in front of sacroiliac joint,end upon L4L5 by uniting each other to form inferior vena cavaInferior vena cava 下腔静脉下腔静脉nFormed by union of two common iliac veins anterior to and just to the right of L4L5nAscends on the right side of aorta,pierces vena cava foramen of diaphragm opposite the T8 and drains into the right atriumnConveys blood from the whole body below the diaphragm to the right atrium Chief tributariesnParietalqPaired inferior phrenic v.膈膈下静脉下静脉qpaired lumbar v.腰静脉腰静脉(four)nVisceralqRight and left renal veins 左、左、右肾静脉右肾静脉qRight suprarenal vein 右肾上腺静脉右肾上腺静脉(left drain into left renal vein)qRight testicular or ovarian v右睾丸（卵巢）静脉右睾丸（卵巢）静脉.(left drain into left renal vein)qHepatic veins 肝静脉肝静脉:right,left and intermediateRelations of inferior vena cavanAnteriorly(cranially to caudally)qLiverqHead of pancreasqHorizontal part of duodenumqRight testicular(or ovarian)a.qRadix of mesenterynPosteriorly qRight crus of diaphragmqUpper four lumber vertebraeqLeft sympathetic trunkqParietal branches of abdominal aorta nOn its right qPsoas majorqRight kidneyqRight suprarenal glandnOn its left qAbdominal aortaHepatic portal vein 肝门静脉肝门静脉General featuresnFormed behind the neck of pancreas by the union of superior mesenteric vein and splenic vein nAscends upwards and to the right,posterior to the first part of duodenum and then enters the lesser omentum to the porta hepatis,where it divides into right and left branches nThere are no functioning valves in hepatic portal system nDrains blood from gastrointestinal tract from the lower end of oesophagus to the upper end of anal canal,pancreas,gall bladder,bile ducts and spleenVariation and anomalies of hepatic portal veinTributaries of hepatic portal vein 1.Superior mesenteric v.肠系膜上静脉肠系膜上静脉2.Inferior mesenteric v.肠系膜下静脉肠系膜下静脉3.Splenic v.脾静脉脾静脉4.Left gastric v.胃左静脉胃左静脉5.Right gastric v.胃右静脉胃右静脉6.Cystic v.胆囊静脉胆囊静脉7.Paraumbilical v.附脐静脉附脐静脉Portal-systemic anastomoses1.At the lower end of the oesophagus Hepatic portal vein left gastric vein esophageal venous plexus esophageal vein azygos vein superiorvena cava2.At rectal venous plexus Hepatic portal vein splenic vein inferior mesenteric vein superior rectal vein rectal venous plexus inferior rectal and anal veins internal iliac vein inferior vena cava3.At periumbilical venous plexus Hepatic portal veinparaumbilical veinperiumbilical venous plexusqthoracoepigastric and superior epigastric vein superiorvena cavaqsuperficial epigastric and inferior epigastric veins inferior vena cava4.Portal-retroperitoneal anastomosis Between the retroperitoneal branches of the colic veins and the lumbar veins,pancreaticoduodenal veins with the renal veins and the subcapsular veins of the liver with the phrenic veins twigs of colic veins(portal)anastomosing with systemic retroperitoneal veins The lymphatic drainage of abdomenLymphatic drainage of abdominal wallnTo axillary lymph node from region above umbilicusnTo superficial inguinal lymph node from region below umbilicusnTo lumbar lymph node from post wall of abdomenLymphatic drainage of abdominal visceranLumbar lymph nodes 腰淋巴结腰淋巴结qLie on posterior abdominal wall,along the abdominal aorta and inferior vena cavaqReceive lymph from kidneys,suprarenal glands,testes,ovarirs,fundus of uterus,ovary,and common iliac nodesqRight and left lumbar trunks formed by efferent vesselqPaired visceradrain to the lumbar lymph nodesnCeliac lymph nodes 腹腔淋巴结腹腔淋巴结 situated around the celiac trunk nSuperior mesenteric lymph node 肠系膜上淋巴结肠系膜上淋巴结 situated around superior mesenteric a.nInferior mesenteric lymph node 肠系膜下淋巴结肠系膜下淋巴结 situated around inferior mesenteric a.nIntestinal trunk 腹腔干腹腔干 formed by efferent vessel of celiac,superior and inferior lymph nodesThoracic duct 胸导管胸导管nBegins in front of L1 as a dilated sac,the cisterna chyli,which formed by joining of left and right lumbar trunks and intestinal trunknEnter thoracic cavity by passing through the aortic hiatus of the diaphragm and ascends along on the front of the vertebral column,between thoracic aorta and azygos veinnTravels upward,veering to the left at the level of T5nAt the roof of the neck,it turns laterally and arches forwards and descends to enter the left venous anglenJust before termination,it receives the left jugular,subclavian and bronchomediastinal trunksnDrains lymph from lower limbs,pelvic cavity,abdominal cavity,left side of thorax,and left side of the head,neck and left upper limbSpleen 脾脾Location:lies in the left hypochondriac region(between stomach and diaphragm)deep to the 9th to 11th rib,its long axis corresponds roughly to the 10th ribShapereddish in colourTwo surfaces nDiaphragmatic:smooth,convexnVisceral:concave,hilum of spleenTwo extremities nAnteriorwidernPosteriorrounderTwo border nSuperiorhas 2-3 splenic notch 脾切迹脾切迹,which serve as a landmark on palpation when it is enlarge;normally it is not palpablenInferiorrounderFunctions:the spleen is considered to be important in:nFormation of lymphocytes and monocytenPhagocytosis of bacteria,inert particles and white blood cells and plateletsnDestroying effete or abnormal red blood cellsnMaking antibodiesRalationships of spleennDiaphragmatic surfacediaphragmnVisceral surfaceqAnteriorlyfundus of stomachqPosteriorlyleft suprarenal gland and kidneyqInferiorlytail of pancreas and left colic flexure Nervers of abdomen Lumbar plexus 腰丛腰丛nFormation:formed by anterior rami of L1-L3,a part of anterior rami of T12and L4nPosition:lies within substance of psoas majorBranches nIliohypogastric n.髂腹下神经髂腹下神经Supplies lower part of anterior abdominal wallnIlioinguinal n.髂腹股沟神经髂腹股沟神经Passes through inguinal canal to supply skin of the groin and scrotum nLateral femoral cutaneous 股外侧皮神经股外侧皮神经nFemoral n.股神经股神经nObturator n.闭孔神经闭孔神经nGenitofemoral n.生殖股神经生殖股神经Lumbar sympathetic trunk 腰交感干腰交感干nMade up of paired chains with four to five lumbar ganglia anterolateral to vertebral columnnEnters abdomen via the diaphragm and as a continuation of he thoracic partnPasses inferiorly behind common iliac vessels and terminations by joining to form unpaired ganglion impar,anterior to sacrumAbdomen 3山东大学医学院山东大学医学院 解剖教研室解剖教研室李振华李振华Relationships of abdominal viscera nFirst layerlive,gallbladder,stomach nSecond layerduodenum,pancreas,spleennThird layersuprarenal gland,kidney,ureter,inferior vena cava,abdominal aorta,nerves and lymphatics Relationships of the stomachnAnterior:qLive(right part)qDiaphragm(left upper part)qAnterior abdominal wall(left lower part)nPosteriorseparated by peritonum of lesser sac from the following(“stumach-bed”)qPancreas qLeft suprarenal glandqLeft kidneyqSpleen qTransverse colon and transvers mesoclonArteries of stomachnLeft and right gastric arteries arise from celiac trunk and proper hepatic artery,repectively.These two vessels run in lesser omentum along lesser curvature,and anastomose end-to-end.nRight and left gastroepiploic arteries arise from the gastroduodenal and splenic artery,repectively.These two vessels pass into the greater omentum,run parallel to the greater curvature,and anastomose end-to-end.nShort gastric arteries,branches of splenic artery,course through the gastrosplenic ligament and supply the fundus of stomach.nPosterior gastric artery(72%)arise from the splenic artery,course through the gastrophrenic ligament and supply the posterior wall of fundus of stomach.Venous drainagenRight and left gastric veins empty directly into hepatic portal vein.nLeft gastroepiploic and short gastric veins drain into hepatic portal vein via the splenic vein.nRight gastroepiploic vein join either superior mesenteric vein.Lymphatics of stomach nRight and left gastric ln.lie along the same vessels and finally to the celiac ln.nRight and left gastroomental ln.lie along the same vessels,the former drain into subpyloric ln.,the latter drain into splinic ln.nSupra-and subpyloric ln.receive lymphatics from pyloric part and finally to the celiac ln.nSplenic ln.receive lymphatics from fundus and left third of stomach,and finally to the celiac lnNerve supplyParasympathetic innervation by anterior(left)and posterior(right)vagal trunksnThe anterior trunk divides into anterior gastric and hepatic branchesnThe posterior trunk divides into posterior gastric and celiac branchesnThe anterior and posterior gastric branches descend on the anterior