•Terminologies in surgical practice

  Anatomical Directions

•Anterior (ventral) = toward front of body

•Posterior (dorsal) = toward back of body

•Medial = toward midline of body

•Lateral = toward side of body

•Proximal = nearer to reference point

•Distal = farther from reference point

Body Regions

•Imaginarily divided into 9 regions

•Midline sections:

–Epigastric = above stomach

–Umbilical = umbilicus or navel

–Hypogastric = below the stomach

Body Regions (con’t)

•Lateral sections:

–Right and left hypochondriac

–Positioned near ribs, specifically cartilages

•Right and left lumbar

–Positioned near small of back (lumbar region)

•Right and left iliac

–Named for upper bone of hip (ilium)

–Also called inguinal region (referring to groin)

Body Positions

•Anatomical

–Standing erect, facing forward, arms at sides, palms forward, toes pointed forward

•Prone

–Lying face down

•Supine

–Lying face up

2.1.1 Surface anatomy

•Identify and name the bony landmarks of the abdomen which are palpable on abdominal examination

•Schematically illustrate and discuss the nine abdominal regions and list which organs lie approximately in each region

Right Hypochondrium

•Liver

•Gall bladder

•Subphrenic space

•Duodenum

•Hepatic flexure of the colon

•Kidney (right)

•Suprarenal head of pancreas

Epigastrium

•Liver

•Subphrenic space

•Lesser sac

•Stomach and duodenum

•Greater and lesser omentum

•Pancreas

•Transverse colon

•Lymph nodes retroperitoneal tissues

Left hypochondrium

•Spleen

•Liver (left lobe) subphrenic space

•Stomach

•Lesser sac

•Splenic flexure of the colon

•Tail of the pancreas

•Kidney (left)

Right lumbar

•Ascending colon

•Kidney (right)

•Paracolic gutter (right)

•Extension from the neighbouring structures

•Liver

•Gall bladder

•Appendix

Umbilical

•Stomach

•Duodenum

•Transverse colon and mesocolon

•Omentum

•Small intestine and its mesentery

•Pancreas

•Lymph nodes

•Aorta

•Kidneys

•Retroperitoneal tissues

•Horse-shoe kidney

•Urachus

Left lumbar

•Descending colon

•Kidney (left)

•Paracolic gutter (left)

•Extension of the neighbouring structures-spleen

Right iliac fossa

•Appendix

•Caecum

•Lymph nodes

•Iliac artery

•Retroperitoneal tissues

•Ilium

Hypogastrium

•Urinary bladder

•Small intestine

•Sigmoid colon

•Ureters

•Fallopian tube

•Ovary

Left iliac fossa

•Sigmoid colon

•Small intestinal loops

•Lymph nodes

•Iliac artery

Related anatomy

•Thoraco-abdomen:        

Upper border= nipple (anterior), scapular tip (posterior)

Lower border= inferior costal margin

Related anatomy

•Anterior abdomen:

Upper border=anterior costal margin

Lower border=inguinal crease

Lateral border=anterior axillary's line

Related anatomy

•Back:

Upper border=scapular tip

Lower border=iliac crest

Lateral border= posterior axillary line

2.1.1 Surface anatomy

•Identify and name in which of the nine surface anatomical regions you would expect to feel tenderness in appendicitis, cholecystitis, gastritis and cystitis

•Identify other surface anatomy lines e.g. transpyloric line, transumbilical line, linea alba and linea semilunaris.  You should be able to say how these lines are formed and to discuss the intra-abdominal events occurring on the transpyloric line

•Transpyloric plane

–Hilum of the kidneys

–Pylorus of the stomach

–Body of pancreas

–Fundus of the gall bladder

2.2 Anterior abdominal wall

2.2.1       Skin and superficial fascia

2.2.2       Muscles

2.2.3       Transversalis fascia

2.2.4       Peritoneum

2.2.5       Rectus sheath

2.2.6       Inguinal area

2.2.7       Osteology

2.2.1 Skin and superficial fascia

•Identify the fatty superficial layer (Camper's fascia)

•Identify and shortly discuss the membranous superficial layer (Scarpa's fascia) according to its distribution and borders. State what this fascia is called inferior to the superficial inguinal ring

2.2.2 Muscles

•Identify and discuss the three major abdominal muscles as follows:

–Major attachments to the following points: Linea alba, crista iliaca and inguinal ligament where applicable,

–Direction of fibres,

–Nerve supply and

–Function

•Identify the neurovascular plane

•Identify the ilio-inguinal and iliohypogastric nerves. Also state their origin and area of supply

External oblique

Internal oblique

Transverse abdominis

Neurovascular plane

2.2.3 Transversalis fascia

•Identify the transversalis fascia

2.2.4 Peritoneum

•Identify the folds and associated underlying structures of the peritoneum on the posterior aspect of the anterior abdominal wall: [2.3.3]

–Plica umbilicalis mediana,

–Plica umbilicalis medialis,

–Plica umbilicalis lateralis,

–Falciform ligament

2.2.5 Rectus sheath

•Identify the rectus sheath and how it is formed on the following levels:

–Superior to the arcuate line

–Inferior to the arcuate line 

•Identify and briefly discuss rectus abdominis as follows:

–major attachments,

–nerve supply and

–function

•Name and identify the structures on the posterior      wall of the rectus sheath

2.2.6 Inguinal area

•Identify and briefly discuss the inguinal canal as follows: 

–Surface anatomy,

–Borders,

–Openings

Inguinal canal
Surface anatomy

Indirect inguinal hernia

Inguinal canal
Borders

2.2.6 Inguinal area

•Know the positions of the superficial and deep inguinal rings and femoral canal.

•Identify the inguinal ligament and the structures posterior to it from lateral to medial.

Femoral canal

Femoral hernia

N.A.V.E.L

2.2.6 Inguinal area

•List the contents of the spermatic cord.  Compare the content in males and females

•Identify the inferior epigastric artery and its relation to the deep inguinal ring

•Identify and list the borders of the inguinal triangle (Hesselbach's triangle)

•Name and identify the inguinal falx (conjoint tendon)

Spermatic cord

•3 Fascia layers

–External spermatic fascia

–Cremasteric fascia

–Internal speratic fascia

•3 Arteries

–Testicular artery

–Cremasteric artery

–Artery to ductus deferens

•3 Nerves

–Genito-femoral nerve

–Ilio-inguinal nerve

–Sympathetic autonomic plexus

•3 Other structures

–Lymphatic vessels

–Ductus deferens

–Pampiniform venous plexus

Spermatic cord

Hesselbach’s triangle

2.2.7 Osteology

•Identify the following bony points of the os coxa:

–Anterior superior iliac spine (ASIS)

–Anterior inferior iliac spine (AIIS)

–Crista iliaca

–Posterior superior iliac spine (PIIS)

–Pubic tubercle

–Pubic crest

–Symphysis pubis

Appendix

•Mc Burneys point

              junction between the medial two third and the lateral one third  on the line joining the ASIS and umbilicus

ANATOMY OF THE BREAST

MILK STREAK

LYMPHATIC DRAINAGE

ARTERIAL SUPPLY

•composed of large numbers of closed follicles filled with colloid and lined with a layer of cuboidal epithelioid cells.

•The thyroid hormones are synthesized and secreted by the epithelioid cells but stored in colloid

II. Production of Thyroid Hormones

•Iodide (I-) actively transported into the follicle and secreted into the colloid.

•Oxidized to iodine (Io).

•Iodine attached to tyrosine within thyroglobulin chain.

–Attachment of 1 iodine produces monoiodotyrosine (MIT).

–Attachment of 2 iodines produces diiodotyrosine (DIT).

•Within the colloid, enzymes modify the structure of MIT and DIT and couple them together.

•When two DIT molecules are coupled together, a molecule of tetraiodothyronine, T4, or thyroxine, is produced.

•The combination of one MIT with one DIT forms triiodythyronine, T3

Thyroid Hormone Synthesis

•III. Biological Actions of Thyroid Hormones

•T3 and T4 (Almost all is deiodinated by one iodide ion, forming T3) bind with nuclear receptor,

•activate and initiate genetic transcription. ---- mRNA

•protein synthesis in cytoplasmic ribosomes ----

•general increase in functional activity throughout the body.

•On Metabolism

•Calorigenic action of thyroid hormones

•Thyroid hormones increase O2 consumption of most tissues in the body, increasing heat production and BMR.

•The mechanism of calorigenic effect of thyroid hormones may be:

•A: Enhances Na+-K+ ATPase activity

•B: Causes the cell membrane of most cells to become leaky to Na+ ions, which farther activates sodium pump and increases heat production.

Effect on metabolism of protein, carbohydrate and fat

1)       On Protein Metabolism.

Normally, T4 and T3 stimulates synthesis of proteins and enzymes, increasing anabolism of protein and causing positive balance of nitrogen.

In patient with hyperthyroidism, catabolism of protein increases, especially muscular protein, which leads weigh-loss and muscle weakness.

In patients with hypothyroidism, myxedema develops because of deposition of mucoprotein binding with positive ions and water molecules in the interstitial spaces while protein synthesis decreases.

On carbohydrate metabolism

A: Increase absorption of glucose from the gastrointestinal tract

E: Enhance glycogenolysis, and even enhanced diabetogenic effect of glucagon, cortisol and growth hormone.

C: Enhancement of glucose utilization of peripheral tissues.

On fat metabolism

Thyroid hormones accelerate the oxidation of free fatty acids by cells and increase the effect of catecholamine on decomposition of fat.

Thyroid hormones not only promote synthesis of cholesterol but also increase decomposition of cholesterol by liver cells.

The net effect of T3 and T4 is to decrease plasma cholesterol concentration because the rate of synthesis is less than that of decomposition.

Effect of Thyroid Hormones on Growth and Development

Thyroid hormone is essential for normal growth and development especially skeletal growth and development.

Thyroid hormones stimulate formation of dendrites, axons, myelin and neuroglia.

A child without a thyroid gland will suffer from critinism, which is characterized by growth and mental retardation.

Without specific thyroid therapy within three months after birth, the child with cretinism will remain mentally deficient throughout life.

Effects of Thyroid Hormone on Nervous System

Thyroid hormones increase excitability of central nervous system

In hyperthyroidism, the patient is likely to have extreme nervousness, many psychoneurotic tendencies including anxiety complexes, extreme worry and paranoia, and muscle tremor.

In addition, thyroid hormones can also stimulate the sympathetic nervous system.

The hypothyroid individual is to have fatigue, extreme somnolence, poor memory and slow mentation.

Other Effects of Thyroid Hormone

(1)     Effect on cardiovascular system

Thyroid hormones have a significant effect on cardiac output because of increase in heart rate and stroke volume, (may through enhance calcium release from sarcoplasmic reticulum).

Effect on gastrointestinal tract

Thyroid hormones increase the appetite and food intake by metabolic rate increased.

Thyroid hormones increase both the rate of secretion of the digestive juices and the motility of the gastrointestinal tract.

Lack of thyroid hormone can cause constipation.

•          Hyponatremia

•          Low serum sodium levels occurs when there is an excess of extracellular water relative to sodium.

•          It can be due to Na depletion, Na dilution or even in a normal volume status

•          Normal – 135- 145 meq /L

•          Causes of Hyponatremia

•          Dilution:

•          increased fluid intake {oral or i.v}

•          Drugs: antipsychotics , tricyclic antidepressants , ACE inhibitors

•          Post operative ADH secretion

•           

•          Sodium depletion:

•          Decreased intake

•          G.I.T loss { vomiting , prolonged nasogastric suctioning , diarrhea}

•          Renal loss { diuretics , primary renal disease

•           

Due to excess solute relative to free water

•          Hyperglycemia{ for every 100mg/dl increment of glucose the Na should decrease by 1.6mEq/l}

•          Increased lipids or proteins

•          SIADH

Clinical features

•          CNS : headache , confusion, seizures , coma ,

•          Musculoskeletal : weakness , cramps , fatigue, twitching

•          GIT : anorexia , nausea ,

•          CVS : hypertension and bradycardia {due to increase in intra cranial pressure}

•          Tissue : lacrimation salivation

•          Renal: oliguria

Treatment

•          Identification of the cause

•          Correction of the Na deficit with oral or i.v Nacl

Hypernatremia

Causes

•          Iatrogenic : giving i.v fluids with Na

•          Increased mineral corticoids { Cushing's syndrome , hyper aldosteronism }

•          Water loss {diabetes  insipidus , GIT or skin loss of fluids}

•          Symptoms when the S.Na more than 160 mEq/l

Clinical features of hypernatremia

•          CNS : restlessness, lethargy , ataxia , delirium        ,seizures , coma

•          Muscular: pain in the muscles

•          CVS:tachycardia, hypotension , syncope

•          Tissue: dry skin red swollen tongue , decreased saliva and tears

•          Renal : oliguria

•          Metabolic: fever

•           

•           

•          Treat the water deficit

•          Water deficit[L]=serum Na -140÷ 140 ×total body weight

•          Estimate TBW is 50% lean body mass in men and 40 % in women

•         

Hypokalemia

CAUSES

Inadequate intake

Excessive loss

•          Hyperaldosteronism

•          Drugs{amphotericin , aminoglycosides , cisplatin }

•          Loss through the GIT or the kidneys

C/F

•          GIT: ileus , constipation

•          Neuromuscular: decreased reflex , fatigue , weakness , paralysis

•          CVS: cardiac arrest

•          ECG:U waves , T  wave flattening ST segment changes , arrhythmias

Treatment

•          Find the cause and treat it

•          Oral correction

•          i.v correction

Hyperkalemia

INCREASED INTAKE:

•          Potassium supplements

•          Blood transfusion

•          Hemolysis , rhabdomyolysis , crush injury , GIT hemorrhage

INCREASED RELEASE:

•          Acidosis, hyperglycemia

IMPAIRED EXCRETION:

•          Potassium sparing diuretics

•          Renal insufficiency

C/F

•          GIT: nausea , vomiting , colicky pain

•          Muscular: weakness , paralysis  respiratory failure

•          CVS : arrthymias , arrest

Treatment

•          Inhalation of a beta agonist {salmetrol}

•          i.v Ca gluconate 10 ml , 10 % , given slowly over 10 min

•          Kayexalate orally

•          100 ml of 25% dextrose with 10 units plain insulin

Types of fluids for replacement therapy

•          Ringer lactate

•          0.9 % sodium chloride

•          5% dextrose with 0.45% of sodium chloride

•          5% dextrose

•          3% sodium chlorid

ALTERNATIVE RESUSCITATIVE FLUIDS

•          Hypertonic saline7.5%

•          5% albumin

•          25% albumin

•          Dextran 40

•          Dextran 70

•          Hextand

•          Hetastarch

Electrolyte abnormalities in specific surgical patients

NEUROLOGIC PATIENTS

•          Syndrome of inappropriate secretion of anti diuretic hormone

•          Diabetes insipidus

CANCER PATIENTS:

•          Hyponatremia due to hypovolemia

•          Hypernatremia due to diabetes insipidus

•          Hypokalemia due to GIT loss of K due to diarrhea post radiation , post chemotherapy , due to villous adenomas of the colon

•          Tumor lysis syndrome

•          Hypocalcemia after surgery

•          Hungry bone syndrome

•          Hypercalcemia in malignancy