Lecture 1 Posterior Abdominal Wall PDF

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 Copyright notice Material which is made available by way of an electronic database may be subject to certain licensing conditions. These conditions normally entail that you may only use the material for your own private study and research at the University and not for any other purpose. It is expected of you to adhere to these conditions at all times. Printed material is also only made available for class discussion, private study and research purposes. Further reproduction of such material is prohibited /Materiaal wat by wyse van elektroniese databasis aan u beskikbaar gestel is, mag onderhewig wees aan bepaalde lisensievoorwaardes. Sulke voorwaardes behels normaalweg dat u die materiaal slegs vir u eie private studie en navorsing aan die Universiteit kan gebruik en vir geen ander doeleindes hoegenaamd nie. Daar word van u verwag om te alle tye aan hierdie voorwaardes gehoor te gee. Gedrukte materiaal word eweneens slegs vir klasbespreking, private studie en navorsingsdoeleindes beskikbaar gestel. Die verdere reproduksie daarvan is ontoelaatbaar.  Outcomes – posterior abdominal wall Name the bony components of the posterior abdominal wall. Name and describe the muscles forming the posterior abdominal wall including their origin, insertion, action, innervation and blood supply. Name all the structures situated on the posterior abdominal wall, including nerves, arteries, veins & lymphatics. 3 Recommended resources https://www-clinicalkey- com.ez.sun.ac.za/#!/content/bo ok/3-s2.0- B9780323934237000046?scroll To=%23hl0004265 Primal Pictures 4  Posterior abdominal wall 5 Overview 6 Posterior abdominal wall - overview 5 Lumbar Bony vertebrae & Osteology intervertebral components discs Psoas major & minor, iliacus, Origin & Muscles & quadratus lumborum, Attachments Actions fascia transversus abdominus, Nerve supply diaphragm Nerves Middle of posterior Arteries abdominal wall, Structures Veins mostly close to bodies of lumbar Lymphatics vertebrae 7 Bony components 8  Lumbar vertebrae Five Intervertebral discs between adjacent vertebrae Spinous processes: short and horizontal Bodies: large and kidney shaped - weight bearing Facets orientation: superior facets medially, inferior faces laterally allows flexion, extension and lateral flexion, no rotation Ligaments & muscle attachment Know all features: revise from BBHC/MSK 9  Pelvis Revise features of pelvis from BBHC/MSK  Sacrum & Coccyx Five fused vertebrae Triangular with apex inferior (articulates with coccyx) Base superior (body articulates with L5) Ala laterally (represents transverse processes) Concave anterior surface & convex posterior surface Anterior and posterior sacral foramina: for anterior & posterior rami of spinal nerves Auricular surface: articulates with pelvic bones Sacral hiatus (injection of anesthetic) Coccyx: 3 or 4 fused vertebrae Muscles 12  Psoas major & minor Muscles of posterior abdominal wall Iliacus Quadratus lumborum 13  Psoas Major Origin: lateral surface of bodies, intervertebral discs and transverse processes of lumbar vertebrae (& T12) Insertion: lesser trochanter of femur Innervation: Anterior rami of L1, https://www.getbodysmart.com/anterior- thigh-muscles/psoas-major-muscle L2, L3 Action: Flexes thigh at hip 14 Psoas Minor Origin: lateral surface of bodies of T12 & L1, intervertebral disc Insertion: Pectineal line, iliopublic eminence Innervation: Anterior rami of L1 Action: weak flexor of vertebral column 15  Origin: Transverse process of L5, Quadratus Lumborum iliolumbar ligament, iliac crest Insertion: Transverse processes of L1- L4, inferior border of rib 12 Innervation: Anterior rami of T12, L1, L2, L3, L4 Action: Depresses and stabilizes rib 12, lateral flexion of trunk https://www.getbodysmart.com/back- muscles/quadratus-lumborum-muscle 16  Iliacus Innervation: Femoral nerve Action: Flexes thigh at hip https://www.getbodysmart.com/anterior-thigh-muscles/iliacus-muscle 17  Muscles of posterior abdominal wall Summary 18  Diaphragm Position varies (breathing, posture, abdominal viscera) Structure & attachments: Central tendon Surrounding muscular part Sternal Costal Lumbar 19 Diaphragm median arcuate ligament: attachment over the aorta medial arcuate ligament: attachment over psoas muscles lateral arcuate ligament: attachment over quadratus lumborum 20  Diaphragm Blood supply (inferior surface): inferior phrenic arteries & veins Nerve supply: phrenic nerves (nerve root origin: C3, C4, C5) 21  Diaphragm Openings and vertebral levels: Caval opening: Inferior Vena Cava: T8 (O)Esophageal hiatus: T10 Aortic hiatus: T12 I ATE 10 EGGS AT 12 https://s3.amazonaws.com/passmrcs- production/answers/379/original/mrcs_b _lungs_diaphragm_openings.jpg?134263 2849 22 Diaphragm: Neurovascular structures (Revise from Resp block) Structures Inferior surface Details Arteries Inferior phrenic. Arise from abdominal aorta. Veins Right inferior Right drains into IVC phrenic. Left drain into IVC 2 x Left inferior and left suprarenal phrenic. vein. Lymphatic drainage Superior lumbar Lymphatic plexuses nodes. on superior and inferior surfaces communicate freely. Innervation Motor: Phrenic Nerve root origin: nerve. C3, C4, C5. Sensory: Centrally by phrenic, peripherally by intercostal & 23 subcostal nerves. 24 25 Retroperitoneal space & fascia 26  Retroperitoneal space & fascia Retroperitoneal space: behind peritoneum Retroperitoneal structures: peritoneum on anterior side only Fascia lining posterior abdominal wall: continuous with fascia that lines transversus abdominis muscle Lies between parietal peritoneum & muscles Named according to structure it covers: o Psoas fascia: Forms medial arcuate ligament - thickening of fascia Fuses laterally with quadratus lumborum and thoracolumbar fascias Continuous inferiorly with iliac fascia Thoracolumbar o Quadratus lumborum fascia (anterior layer fascia of thoracolumbar fascia) Psoas fascia Quadratus lumborum Forms lateral arcuate ligament fascia 27 Structures 28  Structures on posterior abdominal wall Nerves: lumbar plexus, sympathetic nerves Arteries: Abdominal aorta & branches. Veins: Inferior vena cava & tributaries Lymphatic vessels and lymph nodes 29 Nerves: Lumbar plexus Anterior rami of L1, L2, L3 and L4 Formed anterior to lumbar transverse processes, within attachment of psoas major Nerves of the lumbar plexus: described in relation to psoas major T12: forms subcostal nerve – arises in thorax 30 Nerve Ori Description Innervates gin Subcostal T1 From thorax, passes External 2 posterior to lateral oblique arcuate ligament, on muscle, skin of anterior surface of anterolateral quadratus lumborum, abdominal pass through transversus wall. abdominis & internal oblique. Ilio- L1 Posterior to medial Internal hypogastric arcuate ligament, on oblique & anterior surface of transversus quadratus lumborum, abdominis, superior & parallel to iliac skin of crest, pass through suprapubic transversus abdominis. region & posterolateral gluteal region. 31 Nerve Ori Description Innervates gin Ilio-inguinal L1 Posterior to medial arcuate Internal oblique ligament, on anterior & transversus surface of quadratus abdominis, lumborum, superior & skin of the parallel to iliac crest, pass superior through transversus anteromedial abdominis close to the thigh & genital ASIS, traverses inguinal region – canal through superficial scrotum and inguinal ring, superficial to labia majora, spermatic cord/round root of ligament. penis/clitoris. Genito- L1, Pierces psoas major, Genital – femoral L2 courses on anterior cremaster surface, divides into genital muscle, skin of and femoral branches. external Genital passes through genitalia. inguinal canal (deep & Femoral – skin superficial rings). Femoral of superior part below inguinal ligament, of femoral enters femoral sheath, triangle. fascia lata. 32 Nerve Ori Description Innervates gin Lateral L2, Posterolateral border of Skin of cutaneous L3 psoas major, passes under anterolateral nerve of inguinal ligament medial to thigh. thigh ASIS. Femoral L2, Lateral border of psoas Iliacus, flexors nerve L3, major, passes under of hip, L4 inguinal ligament medial to extensors of ASIS, lateral to femoral knee. artery. Obturator L2, Medial border of psoas Adductor nerve L3, major, enters lesser pelvis, muscles of L4 passes through obturator medial thigh. foramen to medial thigh. Lumbosacra L4, Passes over ala of sacrum, Joins with l trunk L5 descends into pelvis. sacral plexus. 33 Autonomic nerve supply Sympathetic, parasympathetic, visceral afferent Splanchnic nerves and ganglia: supply abdominal & pelvic viscera Sympathetic trunk and ganglia (sympathetic chains) Hypogastric/pelvic plexuses and nerves More info here: https://sites.google.com/a/umich.ed u/bluelink/curricula/first-year- medical-curriculum/sequence-5- gastrointestinal/perineum/perineum- lo-10 34  Arteries: Abdominal Aorta Starts at T12 – aortic hiatus of diaphragm Ends at L4 – bifurcation into left and right common iliac arteries Anterior to vertebral bodies, inferior vena cava on right side Left lumbar veins pass posterior to aorta Common iliac arteries – on medial border of psoas major to pelvic brim: Divide into external and internal iliac arteries 35 Three vascular planes: Abdominal Aorta - Branches 1. Anterior midline - Unpaired visceral branches – digestive system – celiac, Median sacral – unpaired parietal superior mesenteric, inferior branch mesenteric arteries 2. Lateral - Paired visceral branches – urogenital and endocrine organs – suprarenal, renal, gonadal arteries 3. Posterolateral – Paired parietal branches – diaphragm, body wall – subcostal, inferior phrenic, lumbar arteries 36 Veins: Inferior Vena Cava Begins anterior to L5: union of common iliac veins Ascends on right side of L3, L4 &L5 vertebral bodies, on the right psoas major, on the right of the aorta Passes through the caval opening of the diaphragm (T8) Tributaries: correspond to the paired visceral and paired parietal branches of abdominal aorta Unpaired branches from digestive tract – drain into hepatic portal vein Left suprarenal & left gonadal vein (& sometimes inferior phrenic) drain into left renal vein Ascending lumbar & azygous veins connect inferior & superior vena cavae 37  Lymphatics: nodes Lymph nodes & lymphatic vessels: lie along aorta, inferior vena cava, and iliac vessels Common iliac nodes: lymph from external & internal lymph nodes lumbar (aortic) lymph nodes Lymph from digestive organs: pre- aortic lymph nodes: celiac, superior mesenteric, inferior mesenteric (around the origins of the arteries) 38  Lymphatic drainage Intestinal lymphatic trunks: pre-aortic nodes Lumbar lymphatic trunks: from lumbar nodes Thoracic duct: all the lymph from below the diaphragm Inferior end – dilation called cisterna chyli – anterior to L1, L2 Ascends through aortic hiatus in diaphragm Ultimately enters venous system: junction of left subclavian & internal jugular veins 39 40 41 Posterior abdominal wall - recap 5 Lumbar Bony vertebrae & Osteology intervertebral components discs Psoas major & minor, iliacus, Origin & Muscles & quadratus lumborum, Attachments Actions fascia transversus abdominus, Nerve supply diaphragm Nerves Middle of posterior Arteries abdominal wall, Structures Veins mostly close to bodies of lumbar Lymphatics vertebrae 42 43 THANK YOU FOR LISTENING 44