Lidia Ionescu

Cl.III chirurgie
Abdomen

Region of the trunk, between the diaphragm

and the inlet of the pelvis.
Abdomen
Diaphragm=primary muscle of respiration, dome-
shaped: right dome-upper border 5th rib,
left dome-lower border 5th rib.
Openings:
 aorta opening,
 esophageal opening,
 caval opening

Pelvic inlet: sacral promontory, ileopectineal lines

and symphysis pubis.
 xiphoid process X
 costal cartilages (ribs 7-10)
 tips of ribs 11 and 12
 vertebrae L1-L5
 iliac crests IC
 tubercle of the crest TC
 anterior superior iliac spine
ASIS
 anterior inferior iliac spine
AIIS
 inguinal ligament IL
 pubic tubercle PT
 pubic crest PC
 pubic symphysis PS
 the separation of the
abdomen from the pelvis,
the pelvic brim PB
Rectus sheath
 Is a covering envelope over the rectus abdominis m.(RA) created by the
aponeurosis of the other three musc.
Above arcuate line – ant.- RA has aponeurosis of EO, and ant half of IO
aponeurosis .
- behind it, is the post half of IO aponeurosis, TA.
aponeurosis and TF.
Below arcuate line - all musc aponeurosis run in front of RA m., leaving only
transversalis fascia behind it.
 The idea is that - to keep the tension of the ant wall of abdomen.

 Where the hell is the Arcuate line? About 1/3 of the way between the
umbilicus and the pubic crest.
Surface landmarks
Xiphoid process
Costal margin
Iliac crest
Symphysis pubis
Inguinal ligament
Superficial inguinal ring
Linea alba
Umbilicus
Rectus abdominis
Linea semilunaris
NORMAL ABDOMEN
NORMAL ABDOMEN
 Use your knowledge to project
the anatomy onto the surface of
the abdomen.

 You will want to be able to

visualize the relative positions of
abdominal organs as they lie
within the abdomen.

 By subdividing the surface into

regions, one person can tell
another person exactly where to
look for possible problems
Layers of the abdominal wall

- skin
- superficial fascia
- deep fascia
- muscle
- subserous fascia
- peritoneum
 These regions are formed by
two vertical planes and two
horizontal planes.

 The two vertical planes are

the lateral lines LLL and RLL.

These lines are dropped from a

point half way between the
jugular notch and the
acromion process.

 The two horizontal planes are

the transpyloric plane TPP
and the transtubercular plane
TTP.
The tubercles are the tubercles
of the iliac crests.
As you examine the abdomen in thin
subjects, you may be able to see
the superficial veins that drain the
abdominal wall.
These veins drain into one of two
major veins: subclavian and
femoral (F)
and also into a minor, but important
vein, the paraumbilical vein PU.

 The paraumbilical vein drains into

the portal vein and then through
the liver. This is an important
clinical connection.
 The lower abdominal wall is
drained by way of the superficial
epigastric SE and superficial
circumflex iliac SCI veins into the
femoral vein.
 The upper abdominal wall is
drained by way of the
thoracoepigastric TE and lateral
thoracic LT veins into the
subclavian.
 The most superficial layer of
anterolateral muscles are the:
external abdominal obliques EAO

 The cutaneous nerves to the

abdomen are mainly continuations
of the lower intercostal nerves (T7
- T12).
 The lowermost part of the
abdominal wall is supplied by a
branch of L1, the iliohypogastric
IH nerve. Its other branch is the
ilioinguinal II nerve.
 Linea alba LA. is where the
aponeuroses of the external
abdominal oblique, internal
abdominal oblique, and transverse
abdominis muscles converge at
the midsagittal part of the
abdominal wall.
 In the image, the left external
abdominal oblique has been cut away
at the white dotted line and removed in
order to show the internal abdominal
oblique IAO.

 You can also see lower cut edge of the

external abdominal oblique at the
inguinal ligament IL

 The anterior wall of the rectus sheath

RS has also been removed on the right
side in order to see the underlying
right rectus abdominis RA muscle.

 Note that the rectus abdominis muscle

is subdivided into small sections by so
called tendinous inscriptions TI.

 You may also see a small muscle

overlying the inferior end of the rectus
abdominis muscle, the pyramidalis
muscle PY. This small muscles tenses
the lower part of the linea alba.
 The rectus abdominis muscle,
internal abdominal oblique and
anterior rectus sheath have been
removed. You can identify the
posterior rectus sheath and its
lower free margin, the arcuate line
AL.
 What you see below this line is the
transversalis fascia and running in
the fascia is the inferior epigastric
artery IEA, a branch of the
external iliac artery. This artery
enters the rectus sheath posterior
to the rectus abdominis muscle
and supplies the anterior
abdominal wall. Extending from
the top, is a branch of the internal
thoracic (or mammary) artery, the
superior epigastric artery.
 Also note that the cutaneous
nerves are found to lie between
the internal abdominal oblique and
the transversus abdominis
muscles.
Good abdominal examination
Good light
Relaxed patient
Full exposure of the abdo. from xiphoid
process to the SP.
The groin should be visible although the
genitalia should be kept draped
Inspection

Note the shape of the abdomen

Look for scars, sinuses, fistulae
Look for distended veins
Look for visible peristalsis- Bowel obstruction
Inspection
Inspection is always
an important first
step in any physical
examination. Look at
the abdominal
contour and note any
asymmetry. Record
the location of scars,
rashes, or other
lesions.
ABDOMEN DRAPING
ASCITES
CAPUT MEDUSA
HEPATOMEGALY
OBESITY
ASSYMETRIC ABDOMEN
UMBILICAL HERNIA
Auscultation
Unlike other regions
of the body,
auscultation comes
before percussion
and palpation (the
sounds may change
after manipulation).
Record bowel sounds
as being present,
increased,
decreased,
or absent.
Auscultation
Bowel sounds- gurgling noises if it contains a
mixture of fluid and gas
Normal bowel sounds- low-pitched gurgles
No bowel sounds- silent abdomen
High-pitched bowel sounds- “tinkling
sounds”-mechanical bowel obstruction
Systolic bruits over the aorta and iliac arteries
ABDOMINAL ASCULTATION
Bruits
In addition to bowel
sounds, abdominal bruits
are sometimes heard.
Listen over the aorta,
renal, and iliac arteries.
Bruits confined to systole
do not necessarily indicate
disease. Don't be fooled by
a heart murmur
transmitted to the
abdomen.
Palpation
Begin by feeling the area that you might
otherwise forget:
Feel the supraclavicular fossa for lymph nodes
Feel the hernial orifices at rest and when the
patient coughs.
Feel the femoral pulses
Examine the external genitalia
PALPATION
Light palpation
Begin with light
palpation. At this point
you are mostly looking
for areas of
tenderness. The most
sensitive indicator of
tenderness is the
patient's facial
expression.
Deep palpation
Proceed to deep
palpation after
surveying the
abdomen lightly.
Try to identify
abdominal masses or
areas of deep
tenderness.
Palpation of the liver
To palpate the liver
edge, place your
fingers just below the
costal margin and
press firmly.
Ask the patient to take
a deep breath. You
may feel the edge of
the liver press against
or slide under your
hand. A normal liver is
not tender.
Alternate method for liver palpation
An alternate method
for palpating the
liver uses hands
"hooked" around the
costal margin from
above.
The patient should
be instructed to
breath deeply to
force the liver down
toward your fingers.
Palpation of the aorta
The aorta is easily
palpable on most
individuals.
You should feel it
pulsating with deep
palpation of the
central abdomen.
An enlarged aorta
may be a sign of an
aortic aneurysm.
Palpation of the spleen
Press down just below
the left costal margin
with your right hand
while asking the
patient to take a deep
breath.
It may help to use
your left hand to lift
the lower rib cage and
flank. The spleen is not
normally palpable on
most individuals.
Palpation
Tenderness

Guarding

Rigidity
Palpate for masses
Site
Shape
Size
Surface
Edge
Consistence
Mobility
Tenderness
Percussion

Shifting dullness- ascitis

Tympanism- hyperresonance- bowel

distension

Measure the height of the liver dullness

Percussion
Tympany is normally
present over most of
the abdomen in the
supine position.

Unusual dullness
may be a clue to an
underlying
abdominal mass.
Liver span
Measure the liver
span by
percussing hepatic
dullness from
above (lung) and
below (bowel).
A normal liver
span is 6 to 12 cm
in the
midclavicular line.
Splenic enlargement
To detect an
enlarged spleen,
percuss the lowest
interspace in the left
anterior axillary line.
Ask the patient to
take a deep breath
and repeat. A change
from tympany to
dullness suggests
splenic enlargement
Rebound tenderness
This is a test for
peritoneal irritation.
Palpate deeply and
then quickly release
pressure.
If it hurts more
when you release,
the patient has
rebound tenderness.
Costo vertebral angle tenderness

CVA tenderness is
often associated with
renal disease.
Use the heel of your
closed fist to strike
the patient firmly
over the
costovertebral
angles.
Shifting dullness

If dullness on
percussion shifts
when the patient is
rolled on the side,
peritoneal fluid
(ascites) may be
present.
Abdominal pain

The significance of the site of abdominal pain:

Upper abdominal pain
Central abdominal pain
Lower abdominal pain
Acute appendicitis
 The position of the
appendix is highly variable.
 In addition to its "normal"
position it can be found
against the abdominal wall
(anterior), below the pelvic
brim (pelvic), behind the
cecum (retrocecal), or
behind the terminal ilium
(retroilial).
 The pain associated with
appendicitis varies with the
anatomy.
Appendicular point
The picture on the left shows a swollen appendix attached to the cecum.
Note the stress on the blood vessels caused by the swelling.
The picture on the right is a cross section through the appendix showing
an appendicolith blocking the lumen.
Blockage of the lumen is one of the most common causes of acute
appendicitis.
Acute cholecystitis
Localized or diffuse
RUQ pain
Radiation to right
scapula
Vomitting and
constipation
Fever
Acute renal colic
Severe flank pain
Radiation to groin
Vomitting and
urinary symptoms
Blood in the urine
Things to remember
Consider inguinal/rectal examination in
males.

Consider pelvic/rectal examination in females.

Disorders in the chest will often manifest with

abdominal symptoms. It is always wise to
examine the chest when evaluating an
abdominal complaint
Anorectal examination
Preparation
Ensure adequate privacy
Uncover the patient from the waist to the knee
Left lateral position, hips flexed to 90º , knees
flexed less than 90º
Anorectal examination

Equipment
Glove
Lubricating jelly
Good light
Position for PR
Position of the finger
Digital rectal examination- PR
Indications:
 for the diagnosis of rectal
tumors and other forms of
cancer;
 in males, for the diagnosis of
prostatic disorders, notably
tumors and
benign prostatic hyperplasia;
 for the diagnosis of
appendicitis or other examples
of an acute abdomen (i.e.
acute abdominal symptoms
indicating a serious underlying
disease);
Digital rectal examination
Indications:

 for the estimation of the tonicity of

the anal sphincter, which may be
useful in case of fecal incontinence
or neurologic diseases, including
traumatic spinal cord injuries;
 in females, for gynecological
palpations of internal organs
 for examination of the hardness
and color of the feces (ie. in cases
of constipation, and fecal impaction
);
 prior to a colonoscopy or
proctoscopy.
 to evaluate haemorrhoids
Do not do like that
Anorectal examination
Inspection:perianal skin:
Skin rashes
Fecal soiling, blood,mucus
Scars or fistula openings
Polyps, papillomata, prolapsed piles
Ulcers, fissures
Palpation:
The anal canal
The rectum
Perianal abscess
 The anus and rectum (which form
the back passage) are common
sites of abscess formation.
 Anorectal abscesses are more
common in men and often develop
from anorectal fistulas or sexually
transmitted infections.
 They present as painful, tender
swellings and are easily accessible
for surgical treatment. The image
below shows a magnified view of a
perianal abscess on the skin
surrounding the anal opening.
 This should be picked up by your
doctor on careful examination of
the anus and rectum.
Perianal inspection
 Extensive perianal condyloma
acuminata (arrow).

 This condition is generally caused

by infection with human
papillomavirus .
Perianal condiloma acuminata
 Patients are often unaware that condylomata can arise around the
anal area .
 In a sexually active population, the prevalence of the human
papillomavirus (HPV, or "wart virus") is around 50 percent.
 Once infected with HPV, the entire anogenital tract is involved.

 The majority of patients with perianal condylomata have not

engaged in anal intercourse.
 Infection is believed to occur due to pooling of secretions in the
anal area. Condylomata can reach substantial size, and multiple
lesions are common.
 If one lesion is present, a complete genital and anorectal
examination is indicated to detect additional growths.
Acute fissure
 Anterior and posterior fissures are most
common.
 If fissures are located laterally, other
etiologies must be considered.
 Fissures can often be identified by
merely spreading the glutei but generally
require anoscopy.
 A fissure is a small cut or split in the
anoderm . It may be induced by a hard
bowel movement or straining at stool.
Fissures are most commonly located
anterior or posterior to the anus.
 When fissures are found laterally,
syphilis, tuberculosis, occult abscesses,
leukemic infiltrates, carcinoma, herpes,
acquired immunodeficiency syndrome
(AIDS) or inflammatory bowel disease
should be considered as causes.
Acute fissure

Sphincter tone is markedly increased, and digital

examination produces extreme pain.
Most fissures can be observed with gentle lateral
retraction around the anus.
If the patient can tolerate anoscopic examination,
a tear may be seen in the mucosa, and frequently
there is bleeding.
Chronic fissure-anoscopy
 Chronic fissures may
present as an external
perianal tag, or sentinal tag
(black arrow).
 The proximal end may also
have granulation tissue
that appears as an anal
polyp (white arrow).
 When the condition is this
advanced, a lateral
sphincterotomy is usually
required.
External site of perianal fistula
 The most common cause of anal
fistula is cryptoglandular infection.
 Infections that begin in the anal
glands can evolve and present as
either abscesses or fistulas.
 Fistulas are common in patients with
Crohn's disease.
 The track of anal fistulas can be
extensive . Flexible sigmoidoscopic
examination is indicated to evaluate
the mucosa of the distal colon for
signs of inflammatory bowel disease.
The index of suspicion for Crohn's
disease is increased by a history of
episodes of diarrhea, abdominal
cramping and weight loss, and the
appearance, location and multiplicity
of the fistulas
Probing of perianal fistula

 When anoscopy revealed no

anal pathology, closer
inspection allowed the
physician to identify this
papular area.
 The wooden end of a cotton-
tipped applicator was inserted
3 cm. confirming a fistula, and
the patient was referred for
surgery.
Perianal abscesses
Thrombosed external hemorrhoids and
perianal tags from "old" disease
Anal polyp
 Anal polyps require
removal and, if they are
confirmed to be
adenomatous (tubular,
tubular-villous or villous),
colonoscopy is required to
rule out the existence of
proximal lesions.
Anal cancer
 This anal cancer had been
treated for three months
with steroid suppositories
although the patient had
never had a physical
examination.
 Simple inspection of the
external anal area allowed
the physician to identify
this aggressive tumor.
Case report
A case of a man with uncommon, but
surgically significant cause of abdominal pain
is presented
Case report
A 22-year-old man came to our ED with a chief
complaint of lower abdominal pain with a history
of 8 hours.
 Physical examination showed tenderness sharply
localized to the left lower quadrant, and marked
rebound tenderness in an area corresponding to
McBurney's point but on the left side.
His temperature was 37°C.
Case report
 Laboratory examinations showed a white blood cell count of
14.7x103/µl with 91.3% neutrophils.
 A chest radiograph demonstrated dextrocardia without other
abnormalities
 Abdominal ultrasonography showed a left-sided liver and
gallbladder, and a right-sided spleen.
 The appendix was not visualized.
DEXTROCARDIA
Case report
An emergency operation was performed within 4
hours from his admission to the ED.
At operation, a left paramedian incision was
made, and an acutely inflamed appendix was
removed from the caecum located in the left iliac
fossa.
A quick exploration revealed the liver to be on the
left side and the viscera to be completely
transposed.
Recovery was uneventful
Appendicitis
Appendicitis, including both right-sided and left-
sided, has an annual incidence of 1:1,000
population.
The classical presentation includes the gradual
onset of vague peri-umblical abdominal pain
localizing to the right lower quadrant over
approximately 24 h, associated with nausea,
vomiting, anorexia, and diarrhea.
This typical presentation occurs only in about
60% of patients.
Case report
Situs inversus totalis is a rare anatomic anomaly
with an estimated incidence of 1:20,000 in the
general population and an autosomal recessive
mode of inheritance.
Visceral situs inversus can occur with or without
dextrocardia.
Situs inversus is caused by a clockwise rotation of
the viscera during early embryonic life, resulting
in a “mirror image” of the normal bowel
Case report
 The diagnosis of acute appendicitis in situs inversus totalis
can be difficult because of abnormal pain localization.
 Malrotation of the intraabdominal viscera is not
accompanied by corresponding changes in the nervous
system; and in about 31% of the patients the first signs of
acute left-sided appendicitis are pain and rebound
tenderness in the right lower quadrant of the abdomen.
 This led to an incorrect incision in 45% of these cases; in
1/3 a second correct incision had to be made.
Case report
Electrocardiogram,
Radiographic studies,
Computed tomography (CT) scan with oral and
intravenous contrast,
Ultrasound, and
Barium studies can help to diagnose situs
inversus.
In this case, we diagnosed it by a chest
radiograph and an abdominal ultrasonography.
Case report 2
 A twelve-year-old male presented to the ED with a 36-hour history
of periumbilical and right lower quadrant (RLQ) abdominal pain
and anorexia.
 The patient's white blood count (WBC) and differential were within
normal limits and his abdominal films were unremarkable.
 The physical exam was significant for guarding and rebound
tenderness in the RLQ.
 The patient was taken to the operating room for diagnostic
laparoscopy and laparoscopic appendectomy. At that time, two
cecal appendices were noted, both of which showed signs of
inflammation without evidence of perforation or abscess.
Laparoscopic appendectomies were performed without difficulty.
 The final pathology report revealed acute appendicitis for both
appendices.
Acute appendicities
Acute appendicitis
Although rare, anomalies of the appendix do
occur and may have serious clinical and
medicolegal implications.

Fewer than 100 cases have been reported in

the literature
Acute appendicitis

Appendiceal anomalies include:

 agenesis,
duplication,
triplication,
anomalous location of a single appendix