Anatomy - Hernias and Peritoneal Cavity

Question 1

What is a hernia?

Answer 1

When an organ or structure protrudes through a wall that normally confines it

Question 2

What are the 2 types of inguinal hernias? Describe their respective relationships with the inguinal canal.

Answer 2

Direct: Bowel is not travelling through the inguinal canal

Indirect: Bowel enters the inguinal canal

Question 3

What are the borders of Hesselbach’s triangle?
Medial border
Superolateral border
Inferior border

Answer 3

Medial border: Lateral margin of rectus abdominis

Superolateral border: Inferior epigastric vessels

Inferior border: Inguinal ligament

Question 4

Which type of inguinal hernia occurs WITHIN Hesselbach’s triangle?

Answer 4

Direct inguinal hernias

Question 5

Which type of inguinal hernia occurs outside of the Hesselbach’s triangle?

Answer 5

Indirect inguinal hernias (protrude through the abdominal wall ABOVE the epigastric vessels)

Question 6

Superficial inguinal ring is…
a) on the inside of the abdomen
b) on the outside of the abdomen

Answer 6

b) on the outside of the abdomen

Question 7

What about the abdominal wall region defined by Hesselbach’s triangle is special?

Answer 7

The Hesselbach’s triangle marks a weakness in the abdominal wall, where there is a deficiency in the strong muscle layers of the abdominal wall because this is where the inguinal canal is coursing.

Question 8

In terms of the inferior epigastric artery, where do direct vs indirect inguinal hernias occur?

Answer 8

Direct: Occurs MEDIAL to the inferior epigastric artery, i.e. within Hesselbach’s triangle

Indirect: Occurs LATERAL to the inferior epigastric, i.e. outside Hesselbach’s triangle

Question 9

Which type of inguinal hernia is usually present in adults? Which is more common in children?

Answer 9

Adults: direct hernia
Children: indirect hernia

Question 10

What is the most common inguinal hernia (in both males and females)

Answer 10

Indirect inguinal hernia

Question 11

What is the main reason for developing a direct inguinal hernia?

Answer 11

It usually results from a weakening in the conjoint tendon and/or transversalis fascia.

Question 12

What is the main reason for developing an indirect inguinal hernia?

Answer 12

It is facilitated by a patent processus vaginalis.

Question 13

What is a distinctive feature of direct inguinal hernias?

Answer 13

Usually reduces when a patient lies down.

Question 14

What is a distinctive feature of indirect inguinal hernias?

Answer 14

Passes THROUGH the deep inguinal ring and into the canal. May extend far enough to emerge from the superficial inguinal ring.

Question 15

Which type of inguinal hernia tends to be acquired? Which one tends to be congenital?

Answer 15

Acquired: direct

Congenital: indirect

Question 16

The processus vaginalis is a temporary process formed when the testes drag down layers of the abdominal wall during embryological development.
Normally, what happens to the processus vaginalis after birth?

Answer 16

It normally obliterates shortly after birth.

Question 17

Before the processus vaginalis obliterates, it allows communication between…

Answer 17

the scrotal region and the abdominal cavity.

Question 18

What can happen if the processus vaginalis DOES NOT obliterate (i.e. remains patent)?

Answer 18

The scrotal region and abdominal cavity remain connected and can communicate with one another.

This patent processus vaginalis can then allow a loop of bowel to go through it and enter the inguinal canal.

This is how an indirect inguinal hernia occurs!

Question 19

A 3rd type of groin hernia, unrelated to the inguinal canal.

Answer 19

Femoral hernia

Question 20

Where do femoral hernias occur?

Answer 20

Just inferior to the inguinal ligament.

Question 21

What abdominal wall weakness can result in femoral hernias?

Answer 21

In the case of femoral hernias, abdominal contents can pass through a natural weakness in the anterior abdominal wall called the FEMORAL CANAL.

Question 22

How frequent are femoral hernias in men vs women?

Answer 22

Men: very rare
Women: account for ~25% of groin hernias

Question 23

What is the femoral ring?

Answer 23

An opening through which the femoral artery and vein exit the abdominal cavity to reach the thigh (creates a weakness in the abdominal wall below the inguinal ligament).

Question 24

What is an aberrant obturator artery?

Answer 24

Normally, the obturator artery (in the thigh region) branches off of the internal iliac artery.

However, sometimes, it may branch off of the epigastric artery.

Question 25

What is the risk of having an aberrant obturator artery in the context of a femoral hernia?

Answer 25

It is at risk of ligation during femoral hernia repair (surgery) - this can lead to downstream problems.

Question 26

Overall, groin hernias are more common in... a) men b) women

Answer 26

a) men (80:20 ratio)

Question 27

True or false: The processus vaginalis only develops in males.

Answer 27

FALSE: Processus vaginalis develops both in males and females.

Question 28

Compare the incidence of femoral, direct and indirect hernias in men vs women.

Answer 28

Men: * Most hernias are indirect * ~33% are direct * Femoral are very rare Women: * Most (~50%) hernias are indirect * ~25% femoral * ~25% direct

Question 29

Most common type of groin hernia (both for men and women)

Answer 29

Indirect hernias

Question 30

What is a common cause of anterior abdominal wall hernias?

Answer 30

Weaknesses in the anterior abdominal wall caused by past surgical procedures (postoperative, incisional).

Question 31

The peritoneal cavity shares common origin with... (2)

Answer 31

pleural cavity (lungs) pericardial cavity (heart) *Note: The peritoneal space is a potential space that is normally empty (free air), but could be penetrated and filled with xyz.*

Question 32

What is the mesentery?

Answer 32

It is a fold of the peritoneum that suspend certain organs in the abdominal cavity. *Note: Mesentery is a double sheet of peritoneal membrane.*

Question 33

Intraperitoneal organs are ... by the visceral peritoneum

Answer 33

Nearly entirely covered by the visceral peritoneum. *They move around freely in the abdomen*

Question 34

What are retroperitoneal organs?

Answer 34

Organs that only have peritoneum on their anterior surface and cannot move freely in the abdomen.

Question 35

What are the 2 types of retroperitoneal organs? Define these two types.

Answer 35

Primarily retroperitoneal: Structures that were retroperitoneal during the entirety of development Secondarily retroperitoneal: Structures that were originally suspended within the abdominal cavity by mesentery, but during development migrated posterior to become retroperitoneal.

Question 36

Name the 6 primarily retroperitoneal organs

Answer 36

* adrenal glands * kidneys * ureters * bladder * aorta * inferior vena cava

Question 37

Name 4 secondarily retroperitoneal organs

Answer 37

* ascending colon * descending colon * duodenum (2nd and 3rd parts) * pancreas (except tail)

Question 38

Which regions of the duodenum are intraperitoneal? Which regions are retroperitoneal?

Answer 38

Intraperitoneal: 1st and 4th part Retroperitoneal: 2nd and 3rd part

Question 39

What is the greater Omentum?

Answer 39

It is a peritoneal fold that hangs down from the greater (inferior) curvature of the stomach and covers the small intestine, like an apron.

Question 40

The greater omentum hangs down from the stomach and reflects back onto...

Answer 40

the transverse colon

Question 41

What is the Mesentery proper?

Answer 41

Fold of the peritoneum that suspends the jejunum and ileum (regions of the small intestine)

Question 42

Other than securing the SI to the posterior abdominal wall, what is another importance of the Mesentery proper?

Answer 42

The blood supply to the intestines travels through this structure!

Question 43

What is the lesser Omentum?

Answer 43

Peritoneal fold that stabilizes the stomach and provides a route for neurovasculature to reach the liver

Question 44

What is the transverse mesocolon?

Answer 44

A peritoneal fold that supports the transverse colon, extending from the pancreas on the posterior wall of the abdomen

Question 45

What is the sigmoid mesocolon?

Answer 45

A peritoneal fold that supports the sigmoid colon

Question 46

The greater sac and lesser sac are both regions of the peritoneal cavity. They are connected by a thin recess called...

Answer 46

epiploic foramen

Question 47

What is the Pringle Maneuver?

Answer 47

When you clamp down the portal triad, allowing your finger into the lesser sac of the peritoneal cavity.

Question 48

2 ligaments of the lesser omentum

Answer 48

Hepatogastric ligament (liver to lesser curvature of the stomach) Hepatoduodenal ligament (liver to duodenum)

Question 49

What is the name of the ligament (part of the greater omentum) that connects the the greater curvature of the stomach to the transverse colon?

Answer 49

Gastrocolic ligament

Question 50

Gastrocolic ligament

Answer 50

Part of the greater omentum Connects the greater curvature of the stomach to the transverse colon

Question 51

The lesser omentum (specifically the hepatoduodenal lig.) contains....

Answer 51

the portal triad (bile duct, hepatic artery, portal vein) *vasculature runs through the omenta, allowing the organs to be supplied with blood despite being suspended in the cavity*

Question 52

The spleen and stomach are connected by..

Answer 52

gastrosplenic ligament

Question 53

The spleen and kidney are connected by...

Answer 53

splenorenal ligament

Question 54

Falciform ligament

Answer 54

Ligament that attaches the liver to the anterior body wall (broad and thin peritoneal fold)

Question 55

Coronary ligament

Answer 55

Connect the liver to the diaphragm

Question 56

Triangular ligaments

Answer 56

continuous with coronary ligament, help attach the liver to the diaphragm

Question 57

The round ligament is a fetal remnant of...

Answer 57

fetal umbilical vein (contained within falciform ligament)

Question 58

What is the "bare area" of the liver

Answer 58

A region of the liver (on the posterior side) that is not covered by peritoneum, but is in direct contact with the diaphragm. *This is where the blood vessels can access the liver*

Question 59

What do we call peritoneal recesses that lie lateral to the ascending and descending colon?

Answer 59

Right and left paracolic gutter

Question 60

The right paracolic gutter may facilitate...

Answer 60

the spread of infection

Question 61

The 9 abdominal regions are delineated by 3 lines/planes...

Answer 61

1. Midclavicular line 2. Subcostal plane 3. Intertubercular plane

Question 62

Which abdominal quadrant encompasses the following organs: * Liver * Gallbladder * Duodenum * Pancreas * Kidney * Ascending colon * Transverse colon

Answer 62

Right upper quadrant

Question 63

Which abdominal quadrant encompasses the following organs: * Stomach * Spleen * Liver * Pancreas * Kidney * Transverse colon * Descending colon

Answer 63

Left upper quadrant

Question 64

Which abdominal quadrant encompasses the following organs: * Descending colon * Sigmoid colon * Reproductive organs

Answer 64

Left lower quadrant

Question 65

Which abdominal quadrant encompasses the following organs: * Cecum * Appendix * Ascending colon * Reproductive organs

Answer 65

Right lower quadrant

Question 66

Name the 8 abdominal regions, going from top-to-bottom and right-to-left

Answer 66

1. Right hypochondriac 2. Right lumbar 3. Right iliac (inguinal) 4. Epigastric 5. Umbilical 6. Hypogastric 7. Left hypochondriac 8. Left lumbar 9. Left iliac (inguinal)