white line. Both rectus muscles are moved to the sides. There is no posterior leaf of the sheath of the rectus muscles, so that in order to penetrate into the abdominal cavity, it remains to open longitudinally only the transverse fascia and the parietal peritoneum. The incisions in the layers in front of and behind the rectus abdominis are perpendicular to each other, resulting in a very strong scar.
Advantages. Multilayer closure of the surgical wound gives a strong scar. Flaws. Limited ability to examine the abdominal cavity.
4. Surgical anatomy of the inguinal and femoral canal.
Within the inguinal region there is an inguinal triangle, limited by:
From below the inguinal ligament;
Medially, the outer edge of the rectus abdominis muscle;
From above, a perpendicular dropped from a point between the outer and middle thirds of the inguinal ligament to the rectus abdominis.
Within the inguinal triangle is the inguinal canal, which has two openings and four walls.
openings of the inguinal canal
The outer opening - the superficial inguinal ring - is limited laterally and medially, respectively, by the lateral and medial legs, formed by divergent fibers of the aponeurosis of the external oblique muscle of the abdomen; from above by interpeduncular fibers; from below a bent ligament.
The inner opening - a deep inguinal ring - corresponds to the external inguinal fossa and is limited: from the outside by the inguinal ligament; from the inside with two formations:
Interfoveal ligament;
Outer umbilical fold.
Walls of the inguinal canal
The anterior wall of the canal is formed by the aponeurosis of the external oblique muscle of the abdomen. The back wall is the transverse fascia. The lower wall is the inguinal ligament.
The upper wall is the overhanging edge of the internal oblique and transverse muscles.
In the inguinal canal pass:
In men, the spermatic cord, in women, the round ligament of the uterus; ilioinguinal nerve, which runs along the anterior surface of the spermatic cord or round uterine ligament; the genital branch of the femoral-genital nerve, perforates the transverse fascia near the superficial inguinal ring and lies on the posterior surface of the spermatic cord or round uterine ligament.
The vascular lacuna is a weak point in the lower abdominal wall. It is limited:
In front of the inguinal ligament;
Behind the pectinate ligament lying on the crest of the pubic bone;
Medially by the lacunar ligament;
Laterally, the iliopectineal arch.
Pass through the vascular lacuna femoral vessels, and the vein lies medial to the artery. In the medial angle of the vascular lacuna, there is a femoral ring, which limits the femoral canal from above.
Borders of the femoral ring:
Anterior, posterior and medial coincide with the same boundaries of the vascular lacunae and are quite strong;
Lateral - the femoral vein is pliable and can be pushed outward during the formation of a femoral hernia. The distance between the lacunar ligament and the femoral vein in men is on average 1.2 cm, in women -1.8 cm. The greater this distance, the more likely the occurrence of a femoral hernia, so femoral hernias are much more common in women than in men. The femoral ring from the side of the abdominal cavity is covered with a transverse fascia, which here is called the "femoral septum". A lymph node is usually located within the femoral ring. The obturator branch of the inferior epigastric artery can go around the femoral ring anteriorly and medially, located above the lacunar ligament. This variant of the outlet of the obturator artery is called the "crown of death", since the dissection of the lacunar ligament with a herniotome blindly with a strangulated femoral hernia often led to damage to this vessel and life-threatening bleeding.
During the passage of the hernia, the walls of the femoral canal are formed:
Anterior - wide fascia of the thigh;
Posterior - comb fascia; lateral - femoral vein.
The length of the femoral canal is 1-3 cm. From below, the femoral canal ends with a subcutaneous fissure, limited: laterally by a sickle-shaped edge;
Above and below the upper and lower horns
The subcutaneous fissure is covered in front by the cribriform fascia.
5. Surgical anatomy of the umbilical ring and the white line of the abdomen.
In the midline, the aponeurosis of the oblique and transverse muscles of the right and left sides grows together with the formation of a white line stretching from the xiphoid process to the pubis.
Navel. The white line of newborns has a defect - the umbilical ring, in the lower part of which the primary urinary passage and umbilical arteries pass, and in the upper part the umbilical vein and umbilical-intestinal duct. After the umbilical cord falls off and the navel is epithelized, the umbilical ring is closed by only three relatively easily extensible layers - skin, umbilical fascia and peritoneum, which explains the frequent formation of umbilical hernias in children. During the first year of life, this defect is closed by a dense scar tissue adherent to the skin. As a result, an umbilical fossa is formed on the skin of the anterior abdominal wall, where there are no fatty deposits.
Literature:
2. S.V. Doroshkevich, E.Yu. Doroshkevich. Practical skills in operative surgery. Tutorial. Gomel.: GoGMI, 2000. - 52 p.
3. V.I. Sergeenko, E.A. Petrosyan, I.V. Frauci. Topographic anatomy and operative surgery. - M: "GEOTAR-MED", 2001. - V.2. – P.7-25.
4. G.E. Ostroverkhov et al. Operative surgery and topographic anatomy. - Kursk; M: AOZT "Litera", 1998 - S.502-512, 113-114.
5. Operative surgery and topographic anatomy / Ed. V.V. Kovanova. -M.: "Medicine", 1995. - S. 47-48, 143-150.
MUSCLE AND VASCULAR GAPS
Behind the inguinal ligament are the muscular and vascular lacunae, which are separated by the iliopectineal arch. The arc is thrown from the inguinal ligament to the iliopubic eminence.
muscle gap located laterally from this arc, bounded in front and above by the inguinal ligament, behind - by the ilium, on the medial side - by the iliopectineal arch. Through the muscle gap from the cavity of the large pelvis to the anterior region of the thigh, the iliopsoas muscle exits along with the femoral nerve.
Vascular lacuna located medially from the iliopectineal arch; it is limited in front and above by the inguinal ligament, behind and below by the pectinate ligament, on the lateral side by the iliopectineal arch, and on the medial side by the lacunar ligament. The femoral artery and vein, lymphatic vessels pass through the vascular lacuna.
On the anterior surface of the thigh femoral triangle (Scarpa's triangle), bounded at the top by the inguinal ligament, on the lateral side by the sartorius muscle, medially by the long adductor muscle. Within the femoral triangle, under the superficial sheet of the fascia lata, a well-defined iliopectineal groove (fossa) is visible, bounded on the medial side by the pectinate, and on the lateral side by the iliopsoas muscles covered by the iliopectineal fascia (deep plate of the wide fascia of the thigh) . In the distal direction, the indicated groove continues into the so-called femoral groove, on the medial side it is limited by the long and large adductor muscles, and on the lateral side - by the medial broad muscle of the thigh. Below, at the top of the femoral triangle, the femoral groove passes into the adductor canal, the inlet of which is hidden under the tailor's muscle.
femoral canal is formed in the region of the femoral triangle during the development of a femoral hernia. This is a short section medial to the femoral vein, extending from the femoral inner ring to the subcutaneous fissure, which, in the presence of a hernia, becomes the external opening of the canal. The inner femoral ring is located in the medial part of the vascular lacunae. Its walls are in front - the inguinal ligament, behind - the pectinate ligament, medially - the lacunar ligament, laterally - the femoral vein. From the side of the abdominal cavity, the femoral ring is closed by a section of the transverse fascia of the abdomen. Three walls are distinguished at the femoral canal: the anterior - inguinal ligament and the upper horn of the falciform edge of the wide fascia of the thigh fused with it, the lateral - the femoral vein, the posterior - a deep plate of the wide fascia covering the comb muscle.
Control questions to the lecture:
1. Anatomy of the abdominal muscles: attachment and function.
2. Anatomy of the white line of the abdomen.
3. Relief of the posterior surface of the anterior abdominal wall.
4. The process of formation of the inguinal canal in connection with the lowering of the gonad.
5. The structure of the inguinal canal.
6. The process of formation of direct and oblique inguinal hernias.
7. Structure of lacunae: vascular and muscular; scheme.
8. The structure of the femoral canal.
Table of contents of the subject "Femoral canal (canalis femoralis). Abdominal hernia.":1.
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femoral canal located between the superficial and deep leaves of the broad fascia. femoral canal It has two holes- deep and superficial, and three walls. The deep opening of the femoral canal is projected onto the inner third of the inguinal ligament. The superficial opening of the femoral canal, or subcutaneous fissure, hiatus saphenus, is projected 1-2 cm downward from this part of the inguinal ligament.
A hernia emerging from the abdominal cavity penetrates into the canal through deep hole - hip ring, anulus femoralis. It is located in the medial part of the vascular lacuna and has four edges.
front hip ring limits the inguinal ligament, behind - the comb ligament, lig. pectineale, or Cooper's ligament, located on the crest of the pubic bone (pecten ossis pubis), medial - lacunar ligament, lig. lacunarelocated in the corner between the inguinal ligament and the crest of the pubic bone. On the lateral side, it is limited by the femoral vein.
hip ring facing the pelvic cavity and on the inner surface of the abdominal wall is covered by the transverse fascia, which here looks like a thin plate, septum femorale. Within the ring is a deep inguinal lymph node Pirogov-Rosenmuller.
Superficial femoral canal ring (hole) is subcutaneous fissure, hiatus saphenus, a defect in the superficial layer of the fascia lata. The hole is closed by a cribriform fascia, fascia cribrosa (Fig. 4.8).
Femoral canal and femoral hernia.1 - m. iliacus; 2 - m. psoas major,
3 - spina iliaca anterior superior; 4 - n. femoralis;
5 - arcus ilio-pectineus; 6-lig. inguinale;
7 - margo falciformis et cornu superior, 8 - a, v. femoralis;
9 - os pubis; 10 - saccus herniae (hernial sac);
11-v. saphena magna.
Walls of the femoral canal
Walls of the femoral canal are a triangular pyramid.
Anterior wall of the femoral canal formed by a superficial sheet of the broad fascia between the inguinal ligament and the upper horn of the subcutaneous fissure - cornu superius.
Lateral wall of the femoral canal- medial semicircle of the femoral vein.
Posterior wall of the femoral canal- a deep leaf of the broad fascia, which is also called fascia iliopectinea.
Medial wall of the femoral canal no, since the superficial and deep layers of the fascia at the long adductor muscle grow together.
Femoral canal length(the distance from the inguinal ligament to the upper horn of the hiatus saphenus) ranges from 1 to 3 cm.
The femoral canal (canalis femoralis) is 1-3 cm long and has three walls. The lateral wall of the canal is formed by the femoral vein, the anterior wall is formed by the crescent-shaped edge and the upper horn of the fascia lata (thigh). The posterior medial wall of the canal is formed by a deep sheet of fascia lata, covering the pectineus muscle in this place. The subcutaneous ring (anulus saphenus) of the femoral canal is limited on the lateral side by a sickle-shaped edge and closed by a thin cribriform fascia (fascia cribrosa). The deep femoral ring, which normally contains a small amount of loose fiber and the Pirogov-Rosenmuller lymph node, has four walls. The anterior wall of the deep ring is the inguinal ligament, the lateral wall is the femoral vein, the medial wall is the lacunar ligament (lig.lacunare), the posterior wall is the pectinate ligament (lig.peclinale), which is a periosteum reinforced with fibrous fibers in the region of the pubic crest. The lacunar ligament is formed by connective tissue fibers that extend from the medial end of the inguinal ligament posteriorly and laterally along the edge of the superior branch of the pubic bone. These fibrous fibers round off the acute angle between the medial end of the inguinal ligament and the pubic bone.
On the anterior surface of the thigh are important topographic formations. It is primarily the femoral triangle bounded by the long adductor femoris (medially), the sartorius (laterally), and the inguinal ligament (above). Through this triangle under the skin and under the superficial sheet of the wide fascia of the thigh passes iliopectineal groove(sulcus iliopectineus), limited on the lateral side by the iliopsoas muscle, and on the medial side by the comb muscle. The femoral artery and femoral vein are adjacent to this groove. The furrow continues downward into the femoral-popliteal, or adductor (gunter), canal (canalis adductorius), through which the femoral artery, vein and saphenous nerve pass. The walls of the adductor canal are the medial wide muscle of the thigh (laterally), the large adductor muscle (medially). The anterior wall of the adductor canal is a fibrous plate stretched between these muscles (lamina vastoadductoria, BNA). In this plate there is a hole - a tendon gap (hiatus tendineus), through which the saphenous nerve and the descending knee artery exit the canal to the anterior medial wall of it. Through the lower opening of the canal, formed by the tendon of the large adductor muscle and the posterior surface of the femur and opening into the popliteal fossa from above, the femoral artery and vein pass. The muscles on the thigh are covered with a wide fascia.
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