Author: Petr Valášekpvala@lf1.cuni.cz

Univerzita Karlova v Praze – 1. léka ská fakultař

Diaphragm and its developmentBack muscles

Operative approaches

Diaphragm and its developmentBack muscles

Operative approachesInstitute of Anatomy

Muscles of the chest • thoraco-humeralm. pectoralis major et minorm. subclavius, m. serratus anterior

• thoracicmm. intercostales externi, interni, intimi, mm. subcostales, m. transversus thoracis

• diaphragm

uddiyana bandhahttp://users.telenet.be/ananda/images/thumbnails/ub.htm

Hemidiaphragm domesright – 4. intercostal, left – 5. intercostal

http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/cxr/atlas/cxratlas_f.htm

Sternal, costal, and lumbar part; centrum tendineumForamen venae cavae, hiatus oesophageus,hiatus aorticus

Right and left crus

Medial arcuate ligament(psoatic arcade)

Lateral arcuate ligament(over quadratus lumborum)

Phrenic nerve – C4

Lumbocostal and sternocostal triangle

Diaphragmaticsurfaceof the heart

Phrenic nerve C4, directly above forelimb limbbud… then differential growth of neck…Mouse embryo stained for neurofilaments (=axons)and Sonic Hedgehog (notochord and endoderm)Craniocaudal direction of development.

Sacral parasymp.Red=autofluorescence of blood in the heart.

Descent and initial innervation of developing diaphragm.

Greer J J et al. J Appl Physiol 1999;86:779-786

©1999 by American Physiological Society

Development of the diaphragm

3-layered embryonic disc‚folding ‘ or rather relative differential growth of the embryo around the umbilicusDescent - relative growth of neck and heart towards the umbilicusTransverse septum - central tendon beneath the heart pleuroperitoneal folds add from dorsal and lateral aspects (these were inhabited by myogenic cells from cervical somites C4) in final caudal position, the material of internal thoracic wall will join (plus material around oesophagus)

Defects - diaphragmatic hernias (do not mix with hiatus hernia)not covered by hernial sac (false hernia)prevalence 1:3000, mortality 25%80 % of all congenital lung anomalies95 % on left (Bochdalek’s hernia – lumbosacral)5 % on right (Morgagni hernia – sternocostal)

Correlation between the extent of phrenic nerve intramuscular branching and myotube formation.

Greer J J et al. J Appl Physiol 1999;86:779-786

©1999 by American Physiological Society

1. layer - spinohumeral muscles trapezius (from neck) n. XI latissimus dorsi brachial pl.

2. layer - spinohumeral muscles levator scap, rhomboidei brachial pl.

3. layer – spinocostal muscles intercostal nn.

4. layer – back musclesdorsal rami of spinal nerves

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Rami dorsales of spinal nerve

1. & 2. layer spinohumeral

Name Origin Insertion Function Innervation

Auscultation triangle

1. & 2. layer spinohumeral

Function of m. trapezius and latissimus dorsi

1. & 2. layer spinohumeral

M. levator scapulae

M. rhomboideus minor

M. rhomboideus major

1. & 2. layer spinohumeral

3. layer spinocostalName Origin Insertion Function Innervation

Musculilevatorescostarum(auxilliary inspiratory)

3. layer spinocostal

Deep back muscles aka. M. erector trunciFour layers total – different course of fibers and function

Spi – Tr Spi – Spi Tr – Spi

4. layer-group

4. layer-group - ST

Name Origin Insertion Function Innervation

4. layer-group - SSName Origin Insertion Function Innervation

4. layer-group - TSName Origin

4. layer-group - sacrospinalName Origin Insertion

Deep muscles of the neck

Trigonum suboccipitale:a. vertebralis + r.dorsalis C1

Innervation: dorsal primary rami

Draw it yourself

Spinotransversal: m.iliocostalis , m.longissimus, m.splenius –ipsilateral rotation Spinospinal: m.spinalis - extensionTransversospinální m.semispinalis, mm.rotatores, m multifidus – contralateral rotation

M.latissimus dorsi

M.trapezius

M.serratus post. sup.

Summary of function

M. quadratus lumborum

Trigonum lumbale (Petiti)crista iliacam. obliquus externus abd. m. latissimus dorsi

Spatium tendineum lumbale-tetragon Krausei12th ribm. seratus post. Inf.m. sacrospinalism. obliquus abd. internus

- hernias (rare)

Fascia thoracolumbalisPovrchový a hluboký listChirurgický přístup k ledvině (donora)

Midline laparotomyupperlower

TransrectalPararectal

Mc Burneyho (Lanz=transv)

subcostal

Common abdominal surgical incisions

Midline laparotomyPararectal incision

Pfanenstiel (bladder, Caesarian)

Laparoscopic operationVeress needlecapnoperitoneum - CO2

Space for manouvreCO2 gets absorbed in embolisation and mainly - does not burn

ComplicationsDamage of epigastric blood vessels, and gutPuncture of aorta = can be lethal

Equipment for laparoscopic surgery

Advantages of laparoscopy

EarlyLess pain, faster healing, collaboration in rehabilitaton

Long-termPreserves integrity of abdominal wall, less scarring, adhesions, hernias in scar

http://www.indiaroboticsurgery.com/icrs-news-details?cname=7/

Robotic surgery

http://medical-dictionary.thefreedictionary.com/dermatome

Innervation:nn. intercostales 5.-12.

pl. lumbalis:n. subcostalisn. iliohypogastricusn. ilioinguinalis

Head’s zonesof referred pain (1898)

diaphragm,gallbladder

stomach

liver, gallbladder

small intestine

large intestine

urinary bladderkidney, testicle

v. thoracoepigastrica

vv. paraumbilicales

v. epigastrica superficialis

v. circumflexa ilium superficialis

Vessels of theabdominal wall(superficial)

=> cavo-caval anastomoses!

inferior epigastric

superior epigastric

aa. intercostales V - XII

Vessels of theabdominal wall(deep)

internal thoracic a.

Abdominal wallblood vessels- view from inside

=> cavo-caval anastomoses

http://blog.yogasynergy.com/2012/09/spinal-movement-sequence-part-21-uddiyana-bandha-mueller-manouvre-with-mula-bandha-including-external-obliques-on-exhalation-retention/

ReferenceČihák: Anatomie 1, 3

Sobotta: Atlas of anatomy

Grim M, Druga R et al.: Základy anatomie 1. Pohybový systém

Netter F: Atlas of Human Anatomy, 4th ed., Saunders, 2006