Transcript Lecture Forum Andomenx

L
M
Direct – medial to inferior
epigastric vessels ; does not
pass thru deep inguinal ring; can
pass thru superficial ring
External spermatic fascia, bowel,
fat; Adults
Indirect – lateral to inferior
epigastric vessels; passes thru
deep and superficial ring; 3
fascial layers
Bowel, fat; congenital
Femoral hernia
Femoral hernia – inferior to
inguinal ligament into femoral
canal; not common; irreducible
with bowel being trapped
Abdominal wall incisions
Median or midline: Cut through the linea alba
superior or inferior to umbilicus; minimal
blood loss, avoids major nerves;
Anterior cutaneous nerves T7-12,
iliohypogastric, Ilioinguinal
Paramedian incisions: Cut to the
right or left of the midline. Benefit:
Avoid nerves, frees the rectus
abdominal muscle which decreases
tension to the muscle. Gives access
to the peritoneal cavity. (Anterior
cutaneous branches)
Anterior cutaneous nerves T7-12,
iliohypogastric, Ilioinguinal
Gridiron (muscle splitting)/McBurney incisions: Incision of the external oblique
aponeurosis in direction of its fibers; then internal oblique and transversus
abdominis are incised in direction of fibers. Littlle muscle damage and avoids
damage to local nerves.
Pfannenstiel (suprapubic incision): This transverse, slightly convex cut transects the
linea alba and anterior layer of the rectus sheath at the pubic hairline. Separate the
underlying rectus muscles via the tendons (to allow better reattachment) and identify the
surrounding nerves. Benefits: Use for most gynecologic surgeries. Iliohypogastric nerve
at greatest risk
Transverse incision: Cuts through the anterior rectus sheath and rectus abdominis m.
Causes least amount of nerve damage; muscle segments can be rejoined. Dissection
above umbilicus
Appendectomy – Iliohypogastric and Ilioinguinal n.
Inguinal hernia - Ilioinguinal
Superficial Fascia
Superficial layer – Campers fascia – Dartos fascia in male, labia majora in female
Deep layer - Scarpa’s fascia – laterally and inferiorly it continues as fascia lata of
thigh
Medially it attaches to linea alba and pubic symphysis; continues anteriorly
over perineum as Colle’s fascia (superficial perineal fascia) Deep and
superficial layers of superficial fascia fuse over penis and continue on as
dartos fascia of the scrotum. Extensions of Scarpa’s fascia pass onto dorsum
and sides of penis as fundiform ligament
Ext.oblique – external spermatic
fascia
Internal oblique – cremasteric fascia
Transverse abdominis – internal
spermatic fascia
Process vaginalis – 2 layers of tunica
vaginalis
Superficial and deep layers of superficial
fascia – Dartos fascia
Portal Hypertension - Portal hypertension is an increase in the pressure
within the portal vein due to the restriction of blood flow thru liver.
Increased pressure in the portal vein causes varices, which are fragile and
subject to bleeding, to develop across the esophagus and stomach to
bypass the blockage.
Classified as suprahepatic, intrahepatic, infrahepatic
Suprahepatic - Outflow obstruction
• Right-side heart failure, constrictive pericarditis, Budd-Chiari syndrome
• Often portal hypertension is matched by systemic (caval) hypertension
Intrahepatic – Obstruction within the liver (90% of cases)
• Cirrhosis most common
Infrahepatic - Obstruction of extrahepatic portal system
• Portal (or splenic) v. thrombosis
• Cavernomatous transformation of portal vein
• Tumor, infection, compression
Portal Hypertension
Esophageal varices
Splenomegaly
Caput medusae
Ascites
Portacaval Anastomoses
(Netter 1957)
(Moore & Dalley 1999)
• Esophageal anastomosis: azygos
(caval) — coronary or short gastric
(portal)
• Paraumbilical anastomosis:
paraumbilical vv. (portal) —epigastric
vv. (caval)
• Rectal anastomosis: sup. rectal
(portal) — inf. & rectal vv. (caval)
• Retroperitoneal anastomosis:
visceral vv. of Retzius (portal) —
parietal vv. (caval)
Veins of Retzius are small veins that supply retroperitoneal organs.
Esophageal anastomosis: azygos (caval) — coronary or short
gastric (portal)
Paraumbilical anastomosis: paraumbilical vv. (portal) —
epigastric vv. (caval)
Retroperitoneal anastomosis: visceral vv. of Retzius (portal) —
parietal vv. (caval)
Rectal anastomosis: sup. rectal (portal) — inf. & middle rectal vv.
(caval)
Identify the problem shown in this radiograph. Refer back to
your PBL case.
Double bubble sign – gas in
stomach and doudenum.
Symptomatic of duodenal
atresia
Ultrasound
Intussuseption – telescoping of bowel, characterized
by bloody mucus in stool “currant jelly stool”
Barium Enema
Now What?
Intussusception
6-year old presents with rectal in the stool. The childs
mother states that he is intermittently constipated and now
his stool smells very foul. The attending physician on your
clerkships orders a technetium-99 m scan of the abdomen
looking for gastric tissue. The scan turns out positive. The
attending physician asks you if you are familiar with the rule
of 2’s? To what problem is she referring?
Rule of 2s: 2% (of the population). 2 feet (from the ileocecal
valve). 2 inches (in length). 2% are symptomatic. 2 types of
common ectopic tissue (gastric and pancreatic). 2 years is
the most common age at clinical presentation. 2 times
more boys are affected.
Meckel’s Diverticulum- remnant of vitelline duct
Many individuals with Meckel’s diverticulum are asymptomatic.
• A 55 yr old obese male presents to your
office complaining of heartburn, frequent
belching, difficulty swallowing and a mild
discomfort in his chest? His EKG shows
no abnormalities. What is the potential
source of this problem?
Hiatal hernia
Procedure uses the
fundic stomach to serve
as the lower
esophageal sphincter.
Used to treat GERD
when medications fail
Malrotation
Lap Ladd's Procedure
Esophageal Atresia
Esophageal Atresia Repair
Problem?
Congenital Diaphragmatic Hernia
Repair