7. A. SUPERFICIAL LAYER -
move upper extremity
Trapezius.
Latissimus dorsi.
Levator scapulae.
Rhomboideus major.
Rhomboideus minor.
B. INTERMEDIATE
LAYER- Respiratory muscles
levator costrum
Serratus posterior superior.
Serratus posterior inferior
C. DEEP LAYER - movetrunk and back
1. SPLENIUS
2. ERECTOR SPINAE
3. TRANSVERSO-SPINALIS –
deep to Erector Spinae
8. Anterior Group
Rectus Abdominis
Pyramidalis
Lateral Group
External Oblique
Internal Oblique
Transversus
9. RECTUS ABDOMINIS
Origin: Symphasis pubis, pubic crest
Insertion: 5th, 6th and 7th costal cartilage and xiphoid
process.
Nerve Supply: Lower six thoracic nerves.
Rectus Sheath: made up of the aponeuroses of the
three anterolateral abdominal muscles as they
converge at the linea alba.
Linea Alba: fusion of the aponeuroses of the
abdominal muscles, and it separates the left and
right rectus abdominis muscles.
10. External Oblique
Origin: lower 8 ribs.
Insertion: Xiphoid process, Linea alba, pubic crest,
pubic tubercle, iliac crest.
Nerve Supply: Lower six thoracic nerves, iliohypgastric
n., ilioinguinal n.
Internal Oblique
Origin: Lumbar Fascia, iliac crest, lateral two thirds of
inguinal ligament.
Insertion: Lower three ribs, costal cartilage, Xiphoid
process, Linea alba, symphasis pubis.
Nerve Supply: Lower six thoracic nerves, iliohypgastric
n., ilioinguinal n.
11. Transversus Abdominis
Origin: lower six costal cartilage, lumbar fascia,
anterior two thirds of iliac crest, lateral third
of inguinal ligament.
Insertion: Xiphoid process, Linea alba,
symphasis pubis.
Nerve Supply: Lower six thoracic nerves,
iliohypgastric n., ilioinguinal n.
12. SERRATUSPOSTERIOR SUPERIOR -
Origin: Vertebrae(cervical and upperthoracic
spines)
Insert: Ribs
Action: Raise ribs ininspiration
3. SERRATUS POSTERIORINFERIOR -
Origin: Vertebrae lumbarand lower thoracic
spines;
Insert: Ribs
Action: Lower ribs in expiration
Innervation: both muscles by
Intercostal Nerves
13. Psoas major
Origin: inter vertebral discs T12/L1 to L4,5
bodies of L1-5 transverse prossesL1-5
Insertion: lesser trochanter
Nerve supply:L1 ,2,3
Psoas minor
Origin: bodies of T12/L1
Insertion: fascia over Psoas major behind inguinal
ligament
Nerve supply:L1
15. Extraperitoneal Fascia
The thin layer of fascia and adipose tissue
between the peritoneum and fascia
transversalis.
Thoracolumbar Fascia
Triangular-shaped sheet of tough connective
tissue.
Partial site of origin of latissimus dorsi and
abdominal oblique muscles.
21. The incision begins posterior at the angle of the11th
rib and may extend as far as the border of the rectus
abdominus.
The skin and subcutaneous tissues are opened
Transecting the latissimus overlying the 11th rib.
incision of the periosteum, along the length of the rib
..
A periosteal elevator is used to remove the
periosteum
The Doyen rib instrument slides into the plane
between
rib and periosteum. to complete the rib dissection.
ELEVENTHRIBINCISION
22.
23. The skin and subcutaneous tissues are opened
Incision of the external abdominal oblique
muscle and latissimus dorsi.
opening the internal oblique muscle
The lumbodorsal fascia (the fusion of the
internal oblique andtransversalis muscle sheaths
posteriorly) is incised to enter the retro
peritoneum.
Peritoneum is then swept awayfrom the anterior
abdominal wall.
The transversalis fibers are separated bluntly.
24.
25. . The incision is limited by the 12th rib
superiorly and the iliac crest inferiorly, so
there is no option to extend it.
26.
27. Incision parallel with the costal margin.
(started at the midline, 2 to 5 cm below
the xiphoid and extends downwards,
outwards and parallel to and about 2.5
cm below the costal margin)
The external oblique, internal
oblique,
and transversalis muscles are opened
to expose the peritonium
28.
29. Excellent exposure to the upper abdominal
cavity andRetroperitoneum
The incision may be continued across the
midline into a double Kocher incision
As with any bilateral incision, care should be
taken to assure the incision is symmetrical
with respect to the midline and to the costal
margins.
The abdomen is entered inthe same manner
as in the unilateral subcostal transperitoneal
incision.
30.
31. Thoracoabdominal incision offers wide exposure of theupper
abdomen, chest, and retroperitoneum for largerenal, adrenal, or
retroperitoneal tumors or
incision is made through the eighth or ninth intercostal space
extending inferomedially to or across the midline..
The abdominal portion of the incision is opened first .
The costal cartilage between the tips of the two ribs on either
side of the incision is then divided with heavy scissorsor rib
cutters.
Dissection is carried through the intercostalmuscles along the
upper border of the adjacentlower rib in order to avoid the
neurovascular bundle.
The pleura is opened under direct visualization.
The diaphragm is incised.
With the diaphragm opened, the liver can be retracted into the
thorax to maximize exposure of the underlyingstructures
32.
33.
34. A 12th rib incision carries less risk of pleural injur
The positioning should be similar to an 11th rib
incision,but the patient should be rotated slightly
dorsad.
The 12thrib is marked, and the bed developed in the
same manner as the 11th rib incision.
the incision is angled downwardalong the lateral
border of the ipsilateral rectus muscle.If required,
2 cm above the pubis can be made for better bladder
exposure.
Reflecting the peritoneum medially by blunt
dissection
gives excellent visualization of the retroperitoneum.
35.
36.
37. Upper Midline Incision
From xiphoid to above umbilicus.
Skin superficial and deep fascia linea alba extraperitoneal fat
(abundant and vascular) peritonium.
Division of the peritoneum is best performed at the lower end of the
incision, just above the umbilicus so that falciform ligament can be seen
and avoided
Lower Midline Incision
From the umbilicus superiorly to the pubic symphysis inferiorly.
the peritoneum should be opened in the uppermost area to avoid
possibleinjury to the bladder.
Allow access to pelvic organs.
Full Midline Incision
Great exposure is needed.
38. Advantages:
◦ It is almost bloodless.
◦ No muscle fibres are divided.
◦ No nerves are injured.
◦ Good access to the upper abdominal viscera.
◦ It is very quick to make as well as to close.
Disadvantages:
◦ More painful.
◦ Chest complications.
◦ Wound infection……Ugly scar…… Incisional
hernia…. etc
39.
40. Now used mainly for renal transplantation.
In the supine position, an incision is made 2–3 cm
medial to the line from the anterior superior iliac
spine to the pubis. .
The external oblique aponeurosis is exposed. An
incisionis made along the lateral border of the
rectus abdominus.
.
41. If more medial exposure is needed, the rectus
maybe transected across its tendinous attachment
to the pubis.
The inferior epigastric artery may be ligated and
divided as it passes along the posterior aspect of
therectus.
The transversalis fascia is incised to expose the
bladder are swept medially to develop the
extraperitoneal space
The peritoneum and bladder are swept medially to
develop the extraperitoneal space
42.
43. The incision is carried through the skin and
subcutaneous
The rectus fasciais incised.
Ending the fascial incision at the lateral borders of
therecti limits the risks of injury to the ilioinguinal
nerve andcontents of the inguinal canal.
.
44. Each leaf of the divided rectus fascia is grasped
approx1 cm lateral to the midline with Allis clamps
and retracted ventrally.
. A curved clamp bluntly separates the two recti,
which are retracted laterally.
Incising the transversalis fascia,
opens the proper plane of dissection. Sweeping the
plane
between bladder and pelvis exposes the obturator
nervesand vessels