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Fig.70: component separation of the abdominal wall. Source [70].
5. LeBlanc in 1991 reported the first laparoscopic incisional hernia repair.
Incidence of recurrence: Is (1.1%).
7.Truamatic hernia: The incidence of TAWH is much higher in males <50 years of age.
Historical background:
Wood et al. in 1988, categorized traumatic abdominal wall hernia into three groups according to
three etiologies: The first category; composed of ruptures of the abdominal musculature due to a
sudden increase of the intra-abdominal pressure caused by energy transfer is situations like motor
vehicle accidents or falling from high. The second category; composed of ruptures of the
abdominal musculature because of a lower energy exerted by a blunt object with a small surface
such as handlebar. The third category is caused my deceleration type of injuries.
Landry et al. in 1956 was the first to describe a very rare type of traumatic abdominal wall hernia
caused by a direct trauma from handlebar like objectives striking a local area of the abdomen
causing a disruption of the underlying abdominal wall muscles and fascia without necessarily
disrupting the overlying skin, which is called (Handlebar hernia).
It is presented as either ecchymosis (49%) or a localizing palpable hernia (31%).
Timing of surgery mainly depends on the concomitant injuries that require treatment priority.
Delayed exploration, as well as delays in diagnosis, can lead to incarceration and strangulation
(10%_25%). The incidence of recurrence is (13%).
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Fig.71: Seat belt sign due to a motor car accident resulting in blunt trauma to the left shoulder
region, thoracic and abdominal cavities resulting in traumatic hernia occurrence. Source [71].
8.Sports hernia (athletic pubalgia):
The incidence of sports hernia is (5%) among athletics per year, with a male predominance (85%97%).
The term sports hernia (athletic pubalgia, and Gilmore’s groin) is in fact a misnomer as there is
no classical herniation of soft tissue, was first reported in the early 1980s. Other synonyms are;
core injury, hockey hernia, hockey groin, or groin disruption.
Sports hernias involve a set of injuries to the abdominal and pelvic musculature outside of the ball
and socket hip joint that causes a weakness of the posterior wall of the inguinal canal. It causes a
chronic, activity-related groin pain that rarely responds to non-operative treatment but significantly
improves with operative intervention.
Mangment:
Open surgical repair (Bassini, Shouldice, or Lichtenstein) accompanied by an adductor longus
tenotomy is the gold standard of sports hernia repair.
Laparoscopic repair involves reinforcement of the posterior abdominal wall with mesh; either
(TEP) or (TAPP).
Recurrence:
Recurrence rate after laparoscopic repair (4%) Vs. (7.2%) for open surgical techniques.
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Rare abdominal hernias:
Hernias of the xiphoid process:
Are formed due to the presence of a defect in the xiphoid process. Both preperitoneal lipoma and
true hernias can protrude through holes in the xiphoid process. The diagnosis is made on the basis
of the detected seal in the xiphoid process, the presence of a defect in it and X-ray data of the
xiphoid process.
Fig.72: Hernia of the xiphoid process. Source [72].
Lumbar hernias:
Their exit points are the upper and lower lumbar triangles between the XII rib and the crest of the
ilium along the lateral edge of the latissimus dorsi (m. latissimus dorsi). Hernias can be congenital
or acquired; they are prone to infringement. They should be differentiated from abscesses and
tumors.
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CHAPTER THREE: THE ABDOMONAL CAVITY.TOPOGRAPHO-SURGICAL
ANATOMY, CLINICAL NOTES.
M.Sh F .Mekhaeel ,S.Sameh
Definition:
The abdominal cavity is a large cavity in the body that contains abdominal viscera.
It is located below the thoracic cavity, and above the pelvic cavity.
It is divided into abdominal cavity proper and pelvic cavity.
Borders of the abdominal cavity:
1. Superior: The diaphragm.
2. Inferior: Iliac bones and pelvic diaphragm.
3. Anterolateral: External abdominal wall muscle.
4. Posterior: Lumbar spines, psoas major and quadratus lumborum muscles.
Fig.73: The borders of the abdominal cavity. Source [73].
Floors of the abdominal cavity:
The abdominal cavity is divided into two floors; upper and lower, which are divided by the
transverse colon and its mesentery.
(I) Upper abdominal floor organs:
Bounded from above by the diagram and below by the transverse colon and its mesentery.
1. Liver.
2. Gall bladder.
3. Stomach.
4. Upper half of the duodenum.
5. Spleen.
6. Pancreas.
(II) Lower abdominal floor organs:
Bounded from above the transverse colon and its mesentery and from below by the pelvic inlet.
1. Lower half of the duodenum. 2. Jejunum.
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3. Ileum.
5. The colon.
4. Vermiform appendix.
Structure of the abdominal cavity:
1. Peritoneum
2. Mesentery
3. Omenta
4. Organs.
¾ The peritoneum:
Definition:
The peritoneum is a protective and a supportive serous membrane lining the abdominal and
pelvic cavities as well as the abdominal viscera.
Divisions:
1.The parietal peritoneum; Covering the abdominopelvic cavity.
2.The visceral peritoneum; covering the abdominopelvic organs.
3.The peritoneal cavity; between the visceral and parietal peritoneum is the peritoneal cavity,
which is a potential space, containing serous fluid that allows motion of the gastrointestinal tract.
Fig.74: The peritoneal cavity. Source [74].
The peritoneum divides the cavity into numerous compartments. One of these the lesser sac is
located behind the stomach and joins into the greater sac via the foramen of Winslow.
Some of the organs are attached to the walls of the abdomen via folds of peritoneum and ligaments,
such as the liver and others use broad areas of the peritoneum, such as the pancreas. The peritoneal
ligaments are actually dense folds of the peritoneum that are used to connect viscera to viscera or
viscera to the walls of the abdomen. They are named in such a way as to show what they connect
typically. For example, the gastrocolic ligament connects the stomach and colon and the
splenocolic ligament connects the spleen and the colon, or sometimes by their shape as the round
ligament or triangular ligament.
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Fig.75: Foramen of Winslow. Source [75].
Peritoneal sacs and pockets:
1.The Subphrenic recess of the peritoneum;
Lies in-between the front of the liver and the diaphragm. Divided by a sickle-shaped ligament.
2.The right hepatic sac;
Borders: top and front-Aperture
Bottom-upper-Posterior surface of the right lobe of the liver
Behind-the Right part of the coronal and right triangular ligaments of the liver.
On the left - a Sickle-shaped ligament.
CLINICAL NOTE: In this situation, subdiaphragmal abscesses may occur, more often as a
complication of cholecystitis, perforated stomach ulcers, and duodenal ulcers. Exudate enters from
the subhepatic depression along the outer edge of the liver. In appendicitis the exudate may go on
the right side of the sulcus. When gas enters, hepatic dullness disappears (Clark's symptom).
3.The left part of the sub-phragmatic depression consists of communicating sacs: the prepancreatic and left hepatic.
4.Left liver sac.
Borders: top and front - aperture.
Bottom-Left the share
Right - sickle-shaped ligament
Behind-Left coronal and triangular ligament
Left and front - passes into the pre-ventricular bag
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5.Pre-pancreatic bag.
Borders:
Back-small omentum and stomach
Front and top-Diaphragm, Left lobe of the liver, anterior wall of the abdomen.
It also contains a spleen bounded by lig. phrenicocolicum
6.Extraperitoneal subphrenic space. Located in the retroperitoneal space under the diaphragm
behind the liver.
Borders: Below by the transverse colon and its mesentery. Adjacent to the lower surface of the
gallbladder and the upper outer surface of the duodenum.
7.Hepatic depression. Contains the right kidney and the right adrenal gland.
CLINICAL NOTE: Abscesses, as a complication of perforation of the duodenal ulcer, purulent
cholecystitis, collections of pus from the omentum are located first in the subhepatic depression,
while, peri-appendicular abscess extends mainly into the hepatic-renal depression. Here in the end
gets the fluid from the subhepatic recess.
8.Omental sac behind the stomach and lesser omentum.
Anterior wall - small omentum, posterior wall of the stomach and lig. Gastrocolicum.
Posterior wall parietal peritoneal leaf covering pancreas et aorta, vena cava inferior, et sinister,
glandula suprarenalis sinistra, nervus plexus.
Upper wall - caudate lobe of the liver and diaphragm-The bottom wall of the mesentery of the
transverse colon
The left wall - the Spleen and its ligaments: the Lig. Gastrosplenicum et phrenicosplenicum Omentum - communicates the bag cavity with the peritoneal cavity.
Borders: front - lig. Hepatoduodenale
Posterior - parietal peritoneum covering V. cava inferior, lig hepatorenale
Top - caudate lobe of the liver
Bottom - lig. Duodenorenale, pars superior duodeni
Fig. 76: Lesser sac and recesses. Source [76].
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¾ The mesentery:
The mesentery is a double layer of peritoneum that suspends the bowel to the posterior
abdominal wall and conduit neurovascular and lymphatic structures.
Contents of the mesentery:
1. Superior mesenteric artery.
2. Superior mesenteric vein.
3. Superior mesenteric vein
4. Inferior mesenteric vein.
5. Coils of small intestine.
6. Extraperitoneal tissue and fat.
7. Sympathetic nerve fibers.
8. Mesenteric lymph nodes.
The mesentery could be furtherly divided into:
A) True mesentery: Connected to the posterior wall.
1. Mesentery for the small intestine.
2. Mesentery the transverse mesocolon.
3. Mesentery of the sigmoid mesocolon.
B) Specialized mesentery: Not-connected to the posterior wall.
1. The greater omentum; attaches the stomach to the transverse colon (Gastrocolic ligament).
2. The lesser omentum; attaches the stomach to the liver (Gastroheaptic ligament).
3. Mesoappendix; attaches the appendix to the ileum.
Other classification of the mesentery: THE FOUR MESENTRIES.
1. Mesentery, parietal peritoneum of the small intestine; is a fan-shaped peritoneal fold
which has an anterior border which contains the jejunum and ileum and a posterior
attached border; the root of the mesentery which is attached to the posterior abdominal
wall (15 cm length)
2. Mesocolon; parietal peritoneum of the colon.
3. The greater omentum.
4. The lesser omentum.
Fig.77: The structures in the root of the mesentery. Source [77].
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¾ The Omenta:
The omentum are specialized folds of peritoneum that enclose nerves, blood vessels, lymph
channels, fatty tissue, and connective tissue.
There are two omenta:
A) The greater omentum, that hangs off of the transverse colon and greater curvature of the
stomach and contains the following ligaments:
1. Lig. Hepatophrenicum
2. Lig. Hepatoesophageale
3. Lig. Hepatogastricum
4. Lig. Hepatoduodenale Large
B) The lesser omentum, that extends between the stomach and the liver and contains the
following ligaments:
1. Lig. Gastrophrenicum
2. Lig. Gastrosplenicum
3. Plica presplenica
4. Lig. Gastrocolicum
5. Lig. Phrenicosplenicum
6. Lig. Splenorenal
7. Lig. Pancreaticosplenicum
8. Lig. Pancreaticocolicum
9. Lig. Splenocolicum
10. Lig. Phrenicocolicum
Fig.78: The greater and lesser omenta. Source [78].
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¾ Abdominal organs:
The abdominal cavity is divided into two floors; upper and lower, which are divided by the
transverse colon and its mesentery.
(I) Upper abdominal floor organs:
Bounded from above by the diagram and below by the transverse colon and its mesentery.
1. Liver.
2. Gall bladder.
3. Stomach.
4. Upper half of the duodenum.
5. Spleen.
6. Pancreas.
1) The liver:
Surfaces of the liver:
1.The superior surface: Lies immediately below the diaphragm, separated from it by peritoneum,
except for a small triangular area where the two layers of the falciform ligament diverge.
2.The anterior surface: Is approximately triangular and convex, and is covered by peritoneum,
except at the attachment of the falciform ligament.
3. The right surface: Is covered by peritoneum and lies adjacent to the right dome of the diaphragm,
which separates it from the right lung and pleura and the seventh to eleventh ribs.
4.The posterior surface: Is convex, wide on the right but narrow on the left.
5.The inferior surface: It blends with the posterior surface in the region of the origin of the lesser
omentum, the porta hepatis and the inferior layer of the coronary ligament.
Fig.79: The surfaces of the liver. Source [79].
Gross anatomical lobes:
1.The right lobe; It is divided from the left lobe by the falciform ligament anteriorly and superiorly
and the ligamentum venosum and fissure for the ligamentum teres inferiorly.
2.The left lobe; It lies to the left of the falciform ligament with no subdivisions.
3.The quadrate lobe; It lies anterior to the porta hepatis and is bounded by the gallbladder fossa to
the right, a short portion of the inferior border anteriorly, the fissure for the ligamentum teres to
the left, and the porta hepatis posteriorly.
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