Ministry of Health of Ukraine
BUKOVINIAN STATE MEDICAL UNIVERSITY
“APPROVED”
on methodical meeting of the Department of
Anatomy, Topographical anatomy and Operative
Surgery
“………”…………………….2008 р. (Protocol №……….)
The chief of department
professor ……………………….……Yu.T.Achtemiichuk
“………”…………………….2008 р.
METHODICAL GUIDELINES
for the 3d-year foreign students of English-spoken groups of the Medical Faculty
(speciality “General medicine”)
for independent work during the preparation to practical studies
THE THEME OF STUDIES
“Clinical anatomy and operative surgery of the umbilical, femoral and
linea alba hernias”
MODULE I
Topographical Anatomy and Operative Surgery
of the Head, Neck, Thorax and Abdomen
Semantic module 3
“Topographical Anatomy and Operative Surgery of the Abdomen”
Chernivtsi – 2008
1. Actuality of theme:
The topographical anatomy and operative surgery of the abdomen are very
importance, because without the knowledge about peculiarities and variants of
structure, form, location and mutual location of abdominal anatomical structures,
their age-specific it is impossible to diagnose in a proper time and correctly and to
prescribe a necessary treatment to the patient. Surgeons usually pay much attention to
the topographo-anatomic basis of surgical operations on the abdomen.
2. Duration of studies: 2 working hours.
3. Objectives (concrete purposes):
To know the definition of regions of the abdomen.
To know classification of surgical operations on the abdomen.
To know the topographical anatomy and operative surgery of the organs of the
abdomenal cavity.
4. Basic knowledges, abilities, skills, that necessary for the study themes
(interdisciplinary integration):
The names of previous disciplines
1. Normal anatomy
2. Physiology
3. Biophysics
The got skills
To describe the structure and function of the
different organs of the human body, to determine
projectors and landmarks of the anatomical
structures. To understand the basic physical
principles of using medical equipment and
instruments.
5. Advices to the student.
5.1. Table of contents of the theme:
The Linea Alba and Rectus Sheath. These structures have been mentioned several times
and have been briefly described; however, owing to their clinical importance, a more detailed
description and summary of the rectus sheath and its relationship to the linea alba follows. The
rectus sheath is the strong, incomplete fibrous compartment of the rectus abdominis muscle. It
forms by the fusion an separation of the aponeuroses of the flat abdominal muscles. At its lateral
margin, the internal oblique aponeurosis split: into two layers, one passing anterior to the rectus
muscle an the other passing posterior to it. The anterior layer joins with the aponeurosis of the
external oblique to form the anterior wall of the rectus sheath. The posterior layer joins with the
aponeurosis of the transversus abdominis muscle to form the posterior wall of the rectus sheath. The
fibers of the anterior and posterior walls of the sheath interlace in the anterior median line to form a
complex tendinous raphe, called the linea alba, which is an intermixture of the aponeurotic fibers of
this oblique and transverse abdominal muscles. It is narrow inferior to the umbilicus, but is wide
superior to it A groove is visible in the skin superficial to it in thin muscular persons. The linea alba
lies between the two parts of the rectus abdominis muscle; the umbilicus is located just inferior to
its midpoint. Superior to the costal margin, the posterior wall of the rectus sheath is deficient
because the transversus abdominis muscles passes internal to the costal cartilages and the internal
obliqus muscle is attached to the costal margin. Hence, superior to the costal margin, the rectus
muscle lies directly on the thoracic wall. The inferior one-fourth of the rectus sheath is also
deficient because the internal oblique aponeurosis does not split here to enclose the rectus muscle.
The inferior limit of the posterior wall of the rectus sheath is marked by a crescentic border called
the arcuate line. The position of this line is usually midway between the umbilicus and the pubic
crest. Inferior to the arcuate line, the aponeuroses of this three flat muscles pass anterior to the
rectus muscle to form this anterior layer of the rectus sheath.
Important structures in the rectus sheath, in addition to this rectus abdominis muscle, are the
superior and inferior epigastrh vessels, and the terminal parts of the inferior five intercostal and
subcostal vessels and nerves.
Umbilical Hernia
Umbilical hernia, is associated with failure of complete closure of the umbilical orifice
during the 1st year of postnatal life. It is often noticed when the infant cries, which raises the intraabdominal pressure and causes protrusion of part of the intestine. Surgery becomes essential when
the defect is relatively large and persists beyond the age of 4, or becomes incarcerated. In the adult,
umbilical hernia may develop more commonly in women, usually postpartum, and a pose serious
danger due to the rigid walls of the linea alba, which predisposes the hernial sac to strangulation and
incarceration. Herniation immediately above or below the umbilicus is known as paraumbilical
hernia, and occurs in women with multiple pregnancies. It is usually prone to incarceration and
usually contains part of the greater omentum.
Omphalocele
Omphalocele is a rare but severe congenital umbilical hernia in which part of a visceral
organ protrudes through the umbilical ring into the base of the umbilical cord. This condition begins
when the cranial limb of the gut loop coils and rapidly increases in length, protruding through the
umbilical ring into the extraembryonic coelomic cavity. This physiological herniation occurs around
the 6th week of development, followed by the return of the protruding part of the gut into the
enlarged abdominal cavity around the 10th week. Retention of the herniated gut outside the
abdomen beyond the 10th week of development is designated as omphalocele. The hernial sac in
this case is covered by the combination of a thin layer of peritoneum and by the amnion. In a study
involving a large number of consecutive births, the overall survival rate was much lower for
omphalocele than for gastroschisis. The same study confirmed that omphalocele is usually
associated with older maternal age pregnancies, and is more often complicated by threatened
abortion.
Femoral Hernia
A femoral hernia presents a hernial sac that protrudes anterior to the pectineal (Cooper’s)
ligament and through the femoral canal, a potential space between the lacunar ligament and the
femoral vein. The femoral ring, which is the upper margin of the femoral canal, is the medial
portion of the lacuna vasorum. It is bounded anteriorly by the extension of the transversalis fascia,
and posteriorly by the continuation of the pectineal fascia. The neck of the hernial sac is always
distal and lateral to the pubic tubercle, a bony landmark between the site of inguinal and femoral
hernia. The fundus of the hernial sac (lower part) usually occupies themedial part of the femoral
triangle.
The hernial sac traverses the femoral canal and descends vertically posterior to the inguinal
ligament, displacing the femoral vein, to exit through the saphenous opening. It tends to ascend
from this point proximally, by following the superficial epigastric vessels anterior to the inguinal
ligament and the lower part of the external oblique. The hernial sac may turn medially and toward
the scrotum or major labium. It may also descend anterior (prevascular hernia) or posterior
(retrovascular hernia) to the femoral vessels. It is prevented from descending further down by the
attachment of the femoral sheath and the superficial fascia of the thigh to themargins of the
saphenous opening. The course of progression of the hernial sac should be taken into consideration
and reduction of femoral hernia should be directed in the reverse direction with the thighs passively
flexed. Femoral hernia is more common in female than male at the ratio of 3:1. It affects
approximately 35% of the female population particularly in women over 50 years of age. This
gender-based difference is attributed to the unique shape of the pelvis, the size of the ring, and the
dramatic changes exerted during pregnancy. Its incidence is far lower than that of inguinal hernia
and can be easily missed during physical examination. There is a dramatic correlation between
inguinal hernial repair and the incidence of femoral hernia. The scientists reported a 15-fold greater
incidence of femoral hernia postinguinal herniorrhaphy compared with spontaneous incidence. Due
to the rarity of the femoral hernia in children and the similarity of its manifestations to that of the
indirect inguinal hernia, femoral hernia in this population remains a challenging clinical problem.
Misdiagnosis of femoral hernia may be perpetuated by the presence of a patent processus
vaginalis and incidental indirect inguinal hernia. A variety of conditionsmust be excluded in the
differential diagnosis of femoral hernia such as lipoma, psoas abscess, obturator hernia, lipoma, and
hydrocele. The femoral hernial sac consists of the parietal peritoneum, femoral septum
(extraperitoneal tissue), femoral sheath, cribriform fascia (covers the saphenous opening),
superficial fascia, andskin. It frequently contains the small intestine and omentum, but the presence
of an inflamed appendix, Meckel’s diverticulum, or portion of the bladder should also be expected.
Occasionally the ureter or broad ligament of the uterus may also be found. Femoral hernial sac
becomes irreducible when it attains a large size, protruding anterior to the inguinal ligament. Due to
the ligamentous boundaries, the hernial sac carries a higher risk of strangulation and should be
considered part of the differential diagnosis in pregnant women and in individuals with intestinal
obstruction. The strangulation is a frequent manifestation at the saphenous opening, the femoral
ring, or at the junction of the inguinal ligament and falciform margin of the saphenous opening.
An incisional hernia is a protrusion of an organ or tissue through a surgical incision. The
surgeon who has a thorough knowledge of the anatomy of the anterolateral abdominal wall and
makes incisions accordingly will only occasionally have to operate on this kind of hernia. However,
if the muscular and tendinous layers of the abdomen do not heal properly, an incisional hernia can
result. Infection and/or obesity are predisposing factors. Because the inferior intercostal nerves (T11
and T12) and the iliohypogastric and ilioinguinal nerves (LI) supply the abdominal musculature,
injury to them during surgery or an accident could result in weakening of muscles in the inguinal
region, creating a predisposition to development of direct inguinal hernia. The ilioinguinal nerve
also gives off motor branches to the fibers of the internal oblique muscle, which are inserted into the
lateral border of the conjoint tendon. Division of this nerve paralyzes these fibers and weakens the
conjoint tendon; this may also result in a direct inguinal hernia.
5.2. Theoretical questions to studies:
1. The structure of the umbilical region.
2. The layer structure of the umbilical region.
3. The nerve and blood supplay of the umbilical region.
4. Fascias of the umbilical region.
5. The structure of the linea alba.
6. The structure of the femoral region.
7. Surgical anatomy of the umbilical hernias.
8. Surgical anatomy of the linea alba hernias.
9. Surgical anatomy of the femoral hernias.
10.Principles of surgical treatment of the umbilical hernias.
11.Principles of surgical treatment of the femoral hernias.
12.Principles of surgical treatment of the linea alba hernias.
5.3. Materials for self-control:
1.
Diffuse pain referred to the epigastric region and radiating circumferentially around the chest
is the result of afferent fibers that travel via which of the following nerves?
A
B
C
D
E
2.
Greater splanchnic
Intercostal
Phrenic
Vagus
None of the above
In the patient described, the subsequent localization of the pain in the right hypochondriac
region is the result of inflammatory stimulation of fibers that are extensions of which of the
following nerves?
A
B
C
D
E
Greater splanchnic
Intercostal
Phrenic
Vagus
None of the above
3.
The patient receives a general anesthetic in preparation for a cholecystectomy. A right
subcostal incision is made, which begins near the xiphoid process, runs along and immediately
beneath the costal margin to the anterior axillary line, and transects the rectus abdominis
muscle and rectus sheath.
At the level of the transpyloric plane, the anterior wall of the sheath of the rectus
abdominis muscle receives contributions from the
A aponeuroses of the internal and external oblique muscles
B aponeuroses of the transversus abdominis and internal oblique muscles
C aponeuroses of the transversus abdominis and internal and external oblique muscles
D transversalis fascia
E transversalis fascia and aponeu-rosis of the transversus abdominis muscle
4.
At this level of incision, liga-tion of the superior epigastric artery probably will result in little,
if any, necrosis of the rectus abdominis muscle because the superior epigastric artery
anastomoses with the
A
B
C
D
E
5.
Exploration of the peritoneal cavity disclosed a distended gallbladder. It is located
A
B
C
D
E
6.
deep circumflex iliac artery
inferior epigastric artery
intercostal arteries
internal thoracic artery
musculophrenic artery
between the left and caudate lobes of the liver
between the right and quadrate lobes of the liver
in the falciform ligament
in the lesser omentum
in the right anterior leaf of the coronary ligament
Numerous stones could be palpated. A finger was inserted into the omental foramen (of
Winslow), and the common bile duct was palpated for stones. Structures that bound the
omental foramen include all the following EXCEPT the
A
B
C
D
E
7.
caudate lobe of the liver
common bile duct
hepatic vein
inferior vena cava
superior part of the duodenum
Before closure of the incision, it is felt that a drain should be left in place in the abdominal
cavity so that any leakage of bile from the sutured stump or from inadvertent injury to the duct
system can be detected. This drain would most advantageously be located in the
A
B
C
D
E
omental bursa
pelvic cavity
pouch of Morison
right paracolic gutter
right subphrenic recess
Literature
1. Snell R.S. Clinical Anatomy for medical students. – Lippincott Williams &
Wilkins, 2000. – 898 p.
2. Skandalakis J.E., Skandalakis P.N., Skandalakis L.J. Surgical Anatomy and
Technique. – Springer, 1995. – 674 p.
3. Netter F.H. Atlas of human anatomy. – Ciba-Geigy Co., 1994. – 514 p.
4. Ellis H. Clinical Anatomy Arevision and applied anatomy for clinical
students. – Blackwell publishing, 2006. – 439 p.