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Fig.153: The IVC. Source [153].
Lumbar region:
Borders:
Superior; XII rib.
Inferior; The iliac crest.
Medial; Line of spinous processes (corresponds to the projection of m. erector spinae)
Lateral, Lesgaft’s line (corresponding to the mid-axillary line).
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Layered structure of the lumbar region:
A) Medial division:
1) Skin; dense.
2) Subcutaneous tissue; poorly developed, loose.
3) Superficial fascia; in the lower part, an additional layer of fiber separates (lumbosacral fat
pad).
4) Surface the leaf of thoracolumbar fascia (F. thoracolumbalis).
5)Erector spinae m. (M. erector spinae), lies in a trough formed by the spinous and transverse
processes of the vertebrae (or the initial segments of the ribs). Covered with 2 leaves of
thoracolumbar fascia (f. thoracolumbalis).
6) Deep leaf of thoracolumbar fascia (f. thoracolumbalis).
7)The square muscle of the lower back (m. quadratum lumborum), and anteriorly from it and
closer to the spine – m. psoas major.
8) Intra-abdominal fascia (f. endoabdominalis); above the corresponding muscles is called
quadratus fascia (f. quadratus) and psoas fascia (f. psoatis). Between the f. quadratus and the
square muscle pass from above; Subcostal n. (n. subcostalis), from below; Ilioinguinal n. and
Iliohypogastric n. (nn. ilioinguinalis et iliohypogastricum).
These 2 fasciae, compacting on the bony protrusions, form 2 ligaments, passing 1 into another:
Medial and lateral lumbocostalis arches (arcus lumbocostalis medialis et lateralis).
Above these arches, there is a gap between the lumbar and costal parts of the diaphragm – the
Bogdalek opening (where the intra-abdominal and intra-thoracic fascia are loosened).
9)The first layer of retroperitoneal tissue (textus cellulosus retroperitoneale); anteriorly passes
into the preperitoneal tissue, down – into the pelvic tissue, up – into the sub-phragmatic cell.
10)Retroperitoneal fascia (f. retroperitonealis) – approaching the kidney, it is divided into 2
leaves prerenal and retrorenal fasciae (ff. prerenalis et retrorenalis). They are connected at the
lower pole by jumpers, and then form a capsule for the ureter. Therefore, retroperitoneal fascia
divides the retroperitoneal space into 2 sections; anterior (which contains the Aorta, IVC, the
lumbar plexus, etc.), and posterior (contains the kidneys and ureter).
11) The second layer of retroperitoneal tissue surrounds the kidney and ureter (paranephron
and paraureterium). These spaces are separate from others.
12) The third layer of retroperitoneal tissue (paracolon) is located anteriorly from prerenal f.
(f. prerenalis).
13) Coelomic lining of the peritoneum; paracolic f. (f. paracolica or (Toldt's fascia).
141
1. Trapezius muscle.
2.The widest back muscle.
3.Posterior inferior dentate line.
4.The eleventh edge.
5Intrercostal muscle.
6.Thoracolumbar fascia.
th
7.The 12
rib.
8. Aponeurosis of the transverse
abdominalis muscle.
Th
9.11
intercoastal nerve.
10.Subsostal vessels and nerves.
11.Internal oblique abdominal muscle.
12.extarenal oblique abdominal muscle.
13.The gluteus muscle.
14. The middle gluteus muscle.
15. The petit triangle.
16. Spinous processes of the lumbar
vertebrae.
Fig.154: The posterior abdominal wall. Source
[154].
B) Lateral division:
The layered structure of the lateral division is the same as medial division except for:
1)The first muscular layer is m. latissimus dorsi and inferior quadratus abdominus m. (inferior
quadratum abdominis musculus). Near the iliac crest, their edges sometimes diverge; Petit
triangle (a triangle of PTI) is formed (bounded by them and the crest, the bottom is the
superiorem abdominis quadriceps).
2)The second muscular layer: above – m. serratus post. inf., below; superior abdominal
quadrant. These muscles do not touch, resulting in a Lesgaft-Grunfeld rhombus (bounded
above by the lower edge of the MSRI and sometimes by the edge of the 12 rib), below by the
superior abdominal quadrant, medially by; erector spinae m. (m. erector spinae). Its bottom
forms an aponeurosis for permanent residence. It has openings through which subcoastal AVN
(a.v.n. subcostales) exit.
3)Transverse abdominal muscle; medially passes into aponeurosis, which is a continuation of
the deep leaf thoracolumbar f. (f. thoracolumbalis). Due to aponeurosis on the permanent
residence, lumbocostalis lig. (Lig. lumbocostale) is formed (stretched between the 12th rib and
L1).
4)Intra-abdominal fascia.
142
Fig.155: Triangle of Petit. Source [155].
Posterior abdominal muscles:
1.Quadratus Lumborum: Located laterally in the posterior abdominal wall. It is a thick muscular
sheet which is quadrilateral in shape.
Origin: From the iliac crest and iliolumbar ligament.
Direction of fiber: The fibres travel superomedially.
Insertion: Into the transverse processes of L1 – L4 and the inferior border of the 12th rib.
Actions: Extension and lateral flexion of the vertebral column. It also fixes the 12th rib during
inspiration, so that the contraction of diaphragm is more efficient.
Innervation: Anterior rami of T12 – L4 nerves.
2.Psoas Major: The psoas major is located near the midline of the posterior abdominal wall,
immediately lateral to the lumbar vertebrae.
Origin: from the transverse processes and vertebral bodies of T12 – L5.
Direction of fibers: It then moves inferiorly and laterally, running deep to the inguinal ligament.
Insertion: To the lesser trochanter of the femur.
Actions: Flexion of the thigh at the hip and lateral flexion of the vertebral column.
Innervation: Anterior rami of L1 – L3 nerves.
3.Psoas Minor: The psoas minor muscle is only present in 60% of the population. It is located
anterior to the psoas major.
Origin: From the vertebral bodies of T12 and L1.
Insertion: To a ridge on the superior ramus of the pubic bone, known as the pectineal line.
Actions: Flexion of the vertebral column.
Innervation: Anterior rami of the L1 spinal nerve.
4.Iliacus: The iliacus muscle is a fan-shaped muscle that is situated inferiorly on the posterior
abdominal wall. It combines with the psoas major to form the iliopsoas – the major flexor of the
thigh.
Origin: From the surface of the iliac fossa and anterior inferior iliac spine.
Insertion: Into the lesser trochanter of the femur.
Actions: Flexion and lateral rotation of the thigh at the hip joint.
Innervation: Femoral nerve (L2 – L4).
143
Fig.156: Posterior abdominal wall muscles. Source [156].
5.The diaphragm:
Origin: Xiphoid process, ribs 7-12, upper lumbar vertebrae.
Insertion: All fibers converge to the central tendon at its depressed middle part.
Function: It is the primary muscle of respiration.
Innervation: Phrenic nerve (C3-C5).
The diaphragm shows three openings:
1.The caval hiatus at the T8 level; passing the IVC and the terminal branch of the right prince
nerve.
2. The esophageal hiatus at the T10 level; passing the oesophagus, right and left vagus nerves
and the esophageal branches of left gastric artery/vein.
3.The aortic hiatus at the T12 level; passing the aorta, thoracic duct and azygous vein.
Fig.157: The inferior surface of the diaphragm. Source [157].
144
Nerves of the posterior abdominal wall:
Are primarily originated from the lumbar plexus (L1-L4 spinal nerves and sometimes includes
T12).
1.Iliohypogastric nerve:
Origin: It is from the ventral primary rami of T12-L1 spinal nerves
Course: The Iliohypogastric nerve emerges from the psoas major and travels between the
quadratus lumborum and kidneys to the iliac crest. It later pierces the transversus abdominis and
then divides into two cutaneous branches, lateral and anterior.
Motor innervation: It supplies the internal oblique and transversus abdominis muscles.
Sensory innervation: Sensations come from the lateral gluteal region and suprapubic region.
2.Ilioinguinal nerve:
Origin: This nerve forms from ventral primary rami of L1.
Course: Similar to the Iliohypogastric nerve, the ilioinguinal nerve emerges from the psoas major
and courses to the iliac crest to pierce the transversus abdominis. From there, it travels through
the deep inguinal ring and into the spermatic cord.
Motor innervation: It supplies the internal oblique and transversus abdominis muscles along with
the iliohypogastric nerve.
Sensory innervation: The cutaneous sensation is received from the anteromedial aspect of the
thigh, and parts of external genitalia.
3.Genitofemoral nerve:
Origin: Ventral primary rami of L1-L2 spinal nerves
Course: Travels within the psoas major tissue and emerges on the anterior surface of the psoas,
where it then divides into the genital and femoral branches. The genital branch travels within
the spermatic cord, and the femoral branch travels to the area of the saphenous opening.
Motor innervation: This nerve supplies only one muscle known as the cremaster muscle (by its
genital branch).
Sensory innervation: Cutaneous sensation comes from the superomedial aspect of the thigh
(femoral branch), or femoral triangle.
The genitofemoral nerve is responsible for both sensory and motor components of the cremasteric
reflex.
4.Lateral femoral cutaneous nerve:
Origin: Dorsal primary rami of L2-L3 spinal nerves
Course: Emerges from the lateral border of the psoas major and passes inferolateral across the
iliacus muscle, under the inguinal ligament, and then across the sartorius muscle. It then divides
into anterior and posterior branches.
Motor innervation: This nerve has no motor innervation.
Sensory innervation: The cutaneous sensations are brought from the anterolateral part of the thigh.
5.Obturator nerve:
Origin: Anterior division of the ventral primary rami of L2-L4 spinal nerves
Course: Descends through the psoas major and emerges medially near the pelvic brim. It then
travels through the obturator canal and divides into anterior and posterior branches. It is the
primary nerve supplying the adductor compartment of the thigh.
Motor innervation: Obturator externus, adductor longus, adductor brevis, adductor magnus,
gracilis, and pectineus.
Sensory innervation: The cutaneous sensations are brought from the medial part of the thigh by
the cutaneous branch of the subsartorial plexus.
Joints: It supplies both the knee and hip joints.
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6.Femoral nerve:
Origin: Posterior division of ventral rami of L2-L4 spinal nerves. It is the biggest branch of the
lumbar plexus
Course: Travels through the psoas major, adjacent to the iliacus, then below the inguinal
ligament. It then courses lateral to the femoral vessels within the femoral triangle and then
branches into anterior and posterior divisions.
Motor innervation: It supplies many muscles, including iliacus, pectineus, sartorius, rectus
femoris, vastus lateralis, vastus medialis, and vastus intermedius.
Sensory innervation: It gives rise to the medial cutaneous nerve and intermediate cutaneous nerve
of the thigh, which supply the anterior and medial aspect of the thigh. It also gives rise to a very
long cutaneous nerve, the saphenous nerve.
Joints: It supplies both the hip joint and knee joints. This is clinically important as the hip joint
pains are usually referred to as knee joint leading to misdiagnosis by orthopedic surgeons.
Fig.158: Lumbar plexus. Source [158].
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CHAPTER SIX: RETROPERITONEAL HERNIAS.
M.Y.Persov, M.Sh F .Mekhaeel ,S.Sameh
Incidence:
Retroperitoneal hernias are exceedingly rare (account for 2% of all abdominal wall hernias).
Hernial gate: A posterolateral, parietal wall defect in the lumbar region.
Sac: Thoracolumbar and transversalis fasciae.
Contents: Retroperitoneal fat or viscera.
Classification:
A) Anatomical:
1.The superior lumbar triangle, describe by Grynfetl in 1886; commoner due to greater surface
area compared to the inferior triangle.
Borders:
Superior: The 12th rib.
Medial border; The quadratus lumborum or sacrospinalis muscle.
Lateral border; The internal oblique muscle and the superior border.
Roof: the external oblique muscle.
Floor: The transversus abdominis aponeurosis and the transverse fascia
2.The inferior lumbar triangle or Petit triangle, first described in 1783;
Borders:
Anterior: External oblique muscle and aponeurosis.
Posterior: latissimus dorsi muscle.
Inferior: Iliac crest.
Floor: internal oblique muscle.
B) Etiological:
1.Congenital;
Usually diagnosed during the pediatric age, and are most often associated with other congenital
anomalies such as the lumbocostovertebral syndrome and spina bifida.
2.Acquired:
A) Primary: 80%.
Risk factors for developing a primary hernia are obesity, connective tissue disease, poor nutritional
status, and increase intra-abdominal pressure, as the persistent cough.
B) Secondary: 20%
1.Iatrogenic:
Injury to the retroperitoneal fascia in renal transplant surgery, retroperitoneal nephrectomies,
radical cystectomy, obtaining bone graft from the iliac crest, spinal surgery associated with lateral
approaches to the thoracolumbar spine or secondary to anterior retroperitoneal lumbar spinal
exposure.
2.Traumatic:
Although post-traumatic lumbar wall herniations are relatively rare injuries, but they should be
suspected in patients with high-energy torso injuries. Only one case of retroperitoneal hernia
secondary to a lumbar vertebral fracture was described by Huang et al. in a patient who had
suffered a traffic accident.
3.Postinflammatory.
147
Fig.159: The borders of superior and inferior lumbar triangles. Source [159].
Complications:
1.Intestinal obstruction.
2.Intestinal strangulation (very rare) which can be life-threatening because of intestinal necrosis,
because of delayed diagnosis due to atypical clinical symptoms.
Management:
Aim:
Prevention of complications; intestinal and nerve injury.
Technique:
Endoscopic retroperitoneal approach and using a self-gripping mesh implant for hernia
alloplasty.
Fig.160: MDCT; retroperitoneal fat herniation through Grynfetl triangle (Grynfeltt-Lesshaft hernia).
Source [160].
148
CHAPTRER SEVEN: THE PELVIC CAVITY.TOPOGRAPHO-SURGICAL ANATOMY,
REVISIONAL NOTES.
M.Sh F .Mekhaeel ,S.Sameh
The pelvis:
The pelvis is a part of human body limited by hip bones, sacrum, and coccyx; it contains genitalia
and terminal parts of the gastroenteric tract and urinary tracts.
The pelvic outlet is closed by several layers of soft tissues which are a special part of the body the perineum, perineum.
The greater (false) pelvis:
¾ The greater pelvis is formed posteriorly by the sacrum, and from the flanks - by alae of the
iliac bones. The greater pelvic bones are lined with the iliopsoas muscle, m. iliopsoas which
comes out upon the thigh through lacuna musculorum and attaches to the lesser trochanter
of the femur. The fascial capsule of this muscle accretes with the lateral part of the inguinal
ligament and arcus iliopectineus.
¾ The greater pelvis is a continuation of the abdominal cavity and contains the organs of the
inferior compartment of the peritoneal cavity. In the right iliac fossa, the caecum with the
vermiform process sits, in the left one - the sigmoid colon.
¾ The place where the greater pelvis proceeds as the lesser one is at linea terminalis which
limits the pelvic inlet, apertura pelvis superior.
¾ The pelvic outlet, apertura pelvis inferior is limited by the coccyx posteriorly, by
sacrotuberous ligaments and ischial tuberosities laterally, and by inferior branches of pubic
bones and pubic symphysis anteriorly.
Fig.161: The greater (False) pelvis.
Source [161].
The lesser pelvis:
¾ The walls of the lesser pelvis are pubis, ilium, ischium, sacrum, and coccyx.
¾ Anteriorly pubic bones are connected by the pubic symphysis, symphysis pubica; it is
supported superiorly by the superior pubic ligament, lig. pubicum superius and along the
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