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Superficial fascia of
Anterior Abdominal Wall
1. Superficial
layer of the superficial fascia (Camper's fascia) Continues over the
inguinal ligament to merge with the superficial fascia of the thigh.Continues
over the pubis and perineum as the superficial layer of the superficial
perineal fascia.
2. Deep layer
of the superficial fascia (Scarpa's fascia)
is attached to the fascia lata just below the inguinal ligament.Continues over
the pubis and perineum as the membranous layer (Colles' fascia) of the
superficial perineal fascia.
Continues over the
penis as the superficial fascia of the penis and over the scrotum as the tunica
dartos, which contains smooth muscle.
May contain
extravasated urine between this fascia and the deep fascia of the abdomen,
resulting from rupture of the spongy urethra.
Deep fascia Covers
the muscles and continues over the spermatic cord at the superficial inguinal
ring as the external spermatic fascia.
Continues over the
penis as the deep
fascia of the penis (Buck's fascia) and over the pubis and perineum
as the deep perineal fascia.
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Iliopectineal arcus or ligament is a fascial
partition that separates the muscular (lateral) and vascular (medial) lacunae
deep to the inguinal ligament.
The muscular lacuna transmits the iliopsoas muscle.
The vascular lacuna transmits the femoral sheath and its
contents, including the femoral vessels, a femoral branch of the genitofemoral
nerve, and the femoral canal.
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Indirect inguinal hernia is found more
commonly on the right side in men
and is more common than direct inguinal hernia. It is congenital (present at birth), associated with the persistence of
the processus vaginalis, and covered by the peritoneum and the coverings of the
spermatic cord.
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Spermatic cord has several fasciae:
External
spermatic fascia, derived from the aponeurosis of the external oblique muscle.
Cremasteric
fascia (cremaster muscle and fascia), originating in the internal oblique muscle.
Internal
spermatic fascia, derived from the transversalis
fascia.
ICE
= TIE
Clinical:
Indirect Inguinal Hernia has all the covering of Spermatic Cord.
Whereas
Direct Inguinal Hernia is b/w Ext Spm Fascia & Cremasteric fascia.
Bith
Hernia emerge through Sup Ing Ring, but only Indirect also come out through
Deep Ing Ring.
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Gubernaculum testis
is homologous to the ovarian ligament and the round ligament of the uterus.
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Inferior epigastric artery arises from the
external iliac artery above the inguinal ligament, enters the rectus sheath,
and ascends between the rectus abdominis and the posterior layer of the rectus
sheath.
Anastomoses with the superior epigastric artery, providing
collateral circulation between the subclavian and external iliac arteries.
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Lesser omentum Acts as a route for the left and
right gastric vessels, which run between its two layers along the lesser
curvature.
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Greater omentum transmits the right and left
gastroepiploic vessels along the greater curvature.
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Gastric ulcers may perforate into the lesser sac
and erode the pancreas and the splenic artery, causing fatal hemorrhage.
Duodenal ulcers may erode the pancreas or the gastroduodenal artery, causing
burning and cramping epigastric pain, and are three times more common than
gastric ulcers.
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FYI : Duodenum is the WIDEST part of S.I.
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Duodenojejunal junction is fixed in position by
the suspensory
ligament of Treitz, a surgical
landmark. This fibromuscular band is attached to the right crus of the
diaphragm.
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FYI : The ileocecal
fold is the bloodless fold of Treves (surgeon at the London Hospital who
drained the appendix abscess of King Edward VII in 1902).
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The quadrate lobe receives blood from the left hepatic
artery and drains bile into the left hepatic duct, whereas the caudate lobe
receives blood from the right and left hepatic arteries and drains bile into
both right and left hepatic ducts.
CAUDATE LOBE is Medical Superior and QUADRATE LOBE is
Medical Inferior in Left Lobe. Thus keep in
MIND that CAUDATE is not Caudal here.
Liver: side with ligamentum venosum/
caudate lobe vs. side with quadrate lobe/ ligamentum teres "VC goes with VC": The Venosum and Caudate is on same side as Vena
Cava [posterior]. Therefore,
quadrate and teres must be on anterior by default.
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Pringle's maneuver: is a temporary
cross-clamping (intermittent soft vascular clamping) of the hepatoduodenal
ligament containing portal triads at the foramen of Winslow for control of
hepatic bleeding during liver surgery or donor hepatectomy for living liver
transplantation.
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Superior rectal artery is the termination of
the inferior mesenteric artery, descends into the pelvis, divides into two
branches that follow the sides of the rectum, and anastomoses with the middle
and inferior rectal arteries. The middle and inferior rectal arteries arise from
the internal iliac and internal pudendal arteries, respectively.
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superior suprarenal artery from the inferior
phrenic artery, the middle suprarenal artery from the abdominal
aorta, and the inferior
suprarenal artery from the renal artery.
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PORTAL VEIN is formed by the union of the
splenic vein and the superior mesenteric vein posterior to the neck of the
pancreas. The inferior mesenteric vein joins either the splenic or the superior
mesenteric vein or the junction of these two vein.
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Two pelvic kidneys may fuse to form a solid
lobed organ because of fusion of the renal anlagen, called a cake (rosette)
kidney.
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Nephroptosis: is downward displacement of the
kidney, dropped kidney, or floating kidney caused by loss of supporting fat.
The kidney moves freely in the abdomen and even into the pelvis. It may cause a
kink in the ureter or compression of the ureter by an aberrant inferior polar
artery, resulting in hydronephrosis.
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Aorta bifurcates at L4.
IVC starts at L5.
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Para-aortic bodies (Zuckerkandl's bodies) are
small masses of chromaffin cells found near the sympathetic chain ganglia along
the abdominal aorta and serve as chemoreceptors responsive to lack of oxygen,
excess of carbon dioxide, and increased hydrogen ion concentration that help to
control respiration.
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Solar plexus: is the combined nerve plexus of the
celiac and superior mesenteric plexuses.
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Apertures through
the diaphragm
1. Vena caval hiatus (vena caval foramen)
Lies in the central tendon of the diaphragm at the level of T8 and transmits the IVC and occasionally the right phrenic nerve.
2. Esophageal hiatus
Lies in the muscular part of the diaphragm (right crus) at
the level of T10 and transmits the esophagus and anterior and posterior trunks of the vagus
nerves.
3. Aortic hiatus
Lies behind or between two crura at the level of T12 and transmits the aorta, thoracic duct, azygos vein, and occasionally
greater splanchnic nerve.
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Portal-systemic anastomoses
1. Left
gastric → azygous (esophageal varices)
2.
Superior → inferior rectal (external hemorrhoids)
3.
Paraumbilical → inferior epigastric (caput medusae at navel)
4.
Retroperitoneal → renal
5.
Retroperitoneal → Paravertebral
Varices
of gut, butt, and caput are commonly seen with portal
hypertension.
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COUINAUD'S
CLASSIFICATION
it divides liver into 8 segments principally on the
position of 3 hepatic veins and the main portal veins
segment 1- caudate lobe
segment 2 and 3- lateral segment of left lobe
segment 4- medial segment of the left lobe
segment 5 and 8- anterior segment of right lobe
segment 6 and 7- posterior segment of the right lobe
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Aganglionic
megacolon (Hirschsprung's disease) is caused by the absence of enteric ganglia
parasympathetic postganglionic neuron cell bodies) in the lower part of the
colon.
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The right and left
hepatic veins drain into the inferior vena cava. The right gastroepiploic vein
drains into the superior mesenteric vein, but the left one drains into the
splenic vein. The right gonadal and suprarenal veins drain into the inferior
vena cava, whereas the left ones drain into the left renal vein. The right
colic vein ends in the superior mesenteric vein, but the left one terminates in
the inferior mesenteric vein.
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Pain sensation originating
from peritoneal irritation by gastric contents in the lesser sac is carried by
lower intercostals nerves. The vagus nerves carry sensory fibers associated
with reflexes in the gastrointestinal (GI) tract. The greater splanchnic nerves
and white rami communicantes carry pain (general visceral afferent [GVA])
fibers from the wall of the stomach and other areas of the GI tract. The gray
rami communicantes contains no sensory fibers but contain sympathetic
postganglionic fibers.
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The efferent limb of
the reflex arc is the genital branch of the genitofemoral nerve, whereas the
afferent limb is the femoral branch of the genitofemoral nerve.
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The left
gastroepiploic artery runs through the lienogastric ligament. The splenic
artery is found in the lienorenal ligament. The right and left gastric arteries
run within the lesser omentum. The gastroduodenal artery descends between the
duodenum and the head of the pancreas.
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The left colic vein
is a tributary of the inferior mesenteric vein. The middle colic, inferior
pancreaticoduodenal, and ileocolic veins drain into the superior mesenteric
vein. The left gastroepiploic vein empties into the splenic vein.
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The superficial
inguinal lymph nodes receive lymph from the scrotum, penis, buttocks, and lower
part of the anal canal, and their efferent vessels enter primarily to the
external iliac nodes and ultimately to the lumbar (aortic) nodes. The deep
inguinal nodes receive lymph from the testis and upper parts of the vagina and
anal canal, and their efferent vessels enter the external iliac nodes.
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The genitofemoral
nerve descends on the anterior surface of the psoas muscle and gives rise to a
genital branch, which enters the inguinal canal through the deep inguinal ring
to supply the cremaster muscle, and a femoral branch, which supplies the skin
of the femoral triangle. The genitofemoral nerve is not a branch of the femoral
nerve but arises from the lumbar plexus and does not supply the testis. It is
the ilioinguinal nerve that gives rise to an anterior scrotal branch.
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The third part of
the duodenum (transverse portion) crosses anterior to the inferior vena cava.
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