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I everyone. Uh So we are about to start. Um A is one of our registrars and she will present uh about abdominal wall anatomy and some basics about hernias. So I think it's very good to attend for the uh foundation doctor sh level will be a good revision for the reg trials. Um Let me serve this present. Yeah. And a close. Yours close. Hello, everyone. Um My name is I'm one of the uh general surgical registrars. Um So this is gonna be really simple. So, apologies to maybe the registrars. It might be a little bit basic. Um But I just thought it would be good um for some of the hernias because we do quite a lot of them here for um the F and S to know a bit about them. So, uh we are going to start cool. So the abdominal wall not to be a bit boring, but it's just a fixed boundary at the, at the front of your abdomen. Um and it keeps everything inside, protects the abdominal viscera from injury. And of course, it's got um other um other functions like forceful expiration, coughing, vomiting that you can use it to increase intraabdominal pressure. So, we're gonna go through these four steps. So you've got the skin, you've got the fascia, you've got um muscles and associated fascia and then you've got your parietal peritoneum and then your organs underneath. So let's focus on the superficial fascia. So above the umbilicus, um you've got a sheet of connective tissue and then below the umbilicus, let's focus on that because that's usually where we're operating And usually when you're gonna be tested as to what layers are we cutting through now. So I've given there'll be more uh interaction later, but I'll start ease you into it slowly by giving you the answers. So you go through your skin, then you go through fatty camper fascia and then you'll get a more um membranous deep layer, which is your scar, that's fascia. Um and the vessels and nerves run between these two these two layers. So when you're doing as in this picture, you're doing your inguinal hernia, just remember that's where your vessels are. So as soon as you start to see that scarps fascia, you're looking out for your vessels to make sure that you're not going through, through them or you're diming them, they're as you go through them cool. And then now this is, this is probably the meat of it. Um So three muscles laterally and two mid in the midline. So, does anyone know what the three are laterally? Should be something with let's do this. Do you have any idea? Good. Excellent. That's the most, that's the most, that one. And then the one in from that, yeah. There you go. And then the one in, from that, right. So, it's easy in the lungs because it's called the innermost. But it's not, it's not the same in the, in the abdomen beans with t anyone. So, it is the transversus abdominis. Ok. And each of these come with a fascia. So what does that mean? It means like a covering. So a a covering on the front and a covering on the back. Basically, muscles sit in bags of covering and that's what the fascia is. There'll be diagrams later to make that a bit more obvious. Now, anyone know the two midline ones? Rectus Abdominis well done and there's a tiny one which you might not know anyone that's fine. It's I'll sh so these are your three. So um your external oblique is going out like you're putting your going down here and then your internal oblique is coming in. Um And then your re transversus abdominis goes transverse. So it's like hands in pockets, um and then hands up and then hands crossed. Ok. Perfect. And then the two in the midline are your Rectus Abdominis which you identified and then come on in and then your um pyramidalis which is on, it's of the opposite side. So it sort of sits under your Rectus Abdominis at the midline, if you can see that, that is your pubic synthesis. Um So for those that have just come in, I'll just do a very, very quick recap, we're just going through the different layers. So uh these are the muscles that sit laterally. So your external oblique, internal oblique, transverse abdominis and then in the midline, you've got these two and all muscles sit in their fascia, which is their bag like here. So on the side here, you can see this is external oblique and this is its fascia. So it's got a a posterior fascia and an anterior fascia which comes out at the front and joins the anterior part of internal oblique to create. Does anyone know what these two fascist when they join up? What do they make? Surgery is super simple. What would you think? I think I've said that already. So, so in the middle. So it's the anti. So this whole thing is your rectus sheath. So it forms your anterior. OK. But good, it's all this is all your rectus sheath anatomy. So these are the different layers and at the middle here, this is the little white lines. Do you know what we call this here? OK. So white line, does anyone know what white line is in Latin linea, linea alba? Yeah. Um good. So your anterior sheath is formed from the fascia from the external oblique and the anterior portion of the internal oblique fascia, then your posterior sheath is formed by the fascia from the transversus abdominis and from the posterior side of internal oblique. This is really important to remember, but this is all superior to the arcuate line. OK, which sits here. So anything above that has this anatomy below the arcuate line, all of the fascia goes anterior. So when you're below the line, there's no posterior fascia. OK. So really important to remember that when you're doing next time any of you are in a laparotomy, look at it when you're closing. So when you're closing, when you're superior up here, they're taking bites of anterior and posterior sheath, all usually all in one and then closing and when or down at the bottom, it's usually just the anterior sheath that you need to get. And then you will see a little bit of a layer which will be your transversalis fascia and your peritoneum there. So don't be fooled because there is a layer below those muscles, but it's not sheath. OK? And it's not strong. So, sheath is strong. So anyway, right now, what I've basically given you the answers, but what layers are you gonna come across when you're doing an open appendix? So let's start right at the top. What's the, what start skin skin good? So you got skin, then what were the fascia layers that I told you about? Campers? Well done and then scarpers? Fantastic. And then so yeah, but what does that? The sheath? Fantastic. So anterior sheath is what you're gonna come across then because you're out at the side. So we're talking about our lateral muscles. What are you gonna come across then? External oblique? Fantastic and what you do with external oblique. So all, all till now we've cut, but muscles are painful when we cut them. So we don't like to cut them. What we like to do is, is split them. So you'll make, using a little mins or something and then getting your L and be here and you'll spread them and they'll spread in the direction they run. So external oblique goes from out in like this. So along the fibers, you'll, you'll split them and then perpendicular to them, you get your lichen and spread them. OK. Um So then what comes next? It's actually over here. But what, what muscle is next? External oblique? Yeah. OK. And then next. Yeah. OK. And then we are below the arcuate line. So what is next? Below the transverse abdominis? There's no, so think back below the arcuate line, there's no posterior sheath. So what's next? So you get a little bit of transversalis fascia and then peritoneum. OK. So that is, that is what's important to. So there's no posterior sheath. I was actually gonna meant to make that red, but there's no posterior sheath there. It's trans basalis fascia and, and basically peritoneum. So it's thin. So when you get there, it'll be, it'll be a thin layer of peroneum. So I know you will have all seen this in med school. These are your incisions just, you know, we describe them all the time. We see the midline most often a cocker is what we use for um for, for uh um these are the ones that we can use for the appendix. So your l incision here and then your mcburney's here. So they're just slightly orientated differently. Um And then your um F steel and your R Morrison for kidney. Ok. This is what we're talking about though. So we're talking about these hernias. So I'm not gonna concentrate on inguinal and femoral because it's a whole other topic. So we're just talking about in a wall so you can get them due to incisions. Um So if you're describing it due to an incision, just use this to describe it. So it's an incisional hernia through this. The other one is also a port site. Ok. Um You can get an umbilical hernia here, which is a or paraumbilical around the umbilicus or epigastric is anything superior to that. Now, I just wanna focus very quickly on this lateral hernia here. You might see this bit also being called a spigelian hernia. Now, one thing is, remember our muscles here, these are our lateral muscles and these are our midline muscles. There's a little bit of fascia. So basically not muscle but membranous tissue that runs in between them and that is a weak point for things to come through. Not often because fascia is actually still quite strong, but sometimes, and this is called your semilunar line. You can get spigelian hernias through this. So if below the umbilicus, um here you see AAA bit of a lateral hernia, just always think spigelian and they can get um incarcerated and strangulated a little bit more. So just be cautious of them. Cool. And then I just wanna talk very quickly about what di verification, um, variation of recti is. So you might see people in clinic with that and you wouldn't be wrong to assume that that's a hernia. But what that actually is is it's a widening of the gap between the two rectus abdominis muscles. Can you see this gap here? So there's no breach in the abdominal wall. It's just, it's got a bit weak and it sort of looks like this quite difficult to tell sometimes. So you wouldn't be amiss to scan them. But, um, you'd be able to tell on the scan. Um, and I think I've given it away, but is this a hernia? No, no. And why is it not a hernia? Yeah. So there's no defect. So, a hernia is, um, uh, an organ that sits in a space that it basically doesn't belong to. And this, it's not sitting in a, um, a space that doesn't belong to. It's just the wall boundary is weak. So it's protruding a bit. So it's not a hernia. Now it happens in old age. Um, there's no actual like lump that you can get, um, and we don't really operate on them. You can do things for them. And, um, there are plastic surgery operations where you can basically tighten them and, and make it look nice because some people don't like how it looks or when you're doing a bigger hernia, if they've also got a diver of the reptile, you can broke and close it. So this is slightly more advanced, but you'll hear these words and see them in the op notes. So I thought it would be good to try and go through now that you know the anatomy. Now you can picture where the measures go. So let's start from top to bottom. So this one here is outside. So let's say you've gone through campers, you've gone through scarpers and the anterior sheath is in front of you. If you put a mesh in front of the anterior sheath, basically on top of the abdominal wall, it's called an onlay mesh. We don't use it that often, but you will definitely see it used in the past and you will definitely have patients who will come back from it. OK. Then we go through the anterior sheath um and you can, you can fit, um you can put a mesh in that space, which is called sort of erectus here. OK? And then the one that we all really really like, which is the one that I want you to remember is um where is it retro, I've called it retro muscular but uh retrorectus. So behind the rectus muscle. So we want to um keep the posterior sheath there. So this one recto Rectus. Can you see this one guys? So this one here, it sits behind the rectus muscle. Um and it sits behind the um internal oblique, but it sits in front of your um either your posterior sheath higher up or your um transverse abdominis. But that is the one that is gold standard and you might see a lot of Mr G doing in the um or um Mister Villa, some of the bigger hernias, OK? But basically, what I want to show you this for is that there are lots and lots of names that are floated around and actually the consensus is quite poor on what it is. But if you ask for where it sits in the anatomy, then you'll have a much better understanding of what you're doing. But I think for now just remember Recta Rectus Onlay and Inlay, OK. The other ones are all a little bit too complicated. OK. Great. And that's a, that's probably a simpler er diagram. So we've got onlay. Um It's also to demonstrate that people don't use the same terms at all and it can get really confusing. So if you're confused, don't worry, the whole field is confused. So, Onlay is above the anterior sheath. Inlay is here and rep directus is also sometimes called sub. Again, it's, it's madness out there. But the best thing is Onlay inlay, retroactive. And you might also see I poms dotted around which are inside the peritoneum. Ok. So if you've done like a laparoscopic procedure, so you've gone inside and you're in the, in the abdomen, you find your hernia, you pull it out and you just stick something from the inside to cover the hole. We don't really like to do these anymore. And there's been a lot, a lot of literature that maybe they're not the best, however, you'll see them around and you'll see people with meshes here with lots of Ts all around. So I don't expect you to remember all of that now. But now, at least now you know what to look up and what to think about when you see it. So this is an example of an, of an old school ipo where they've just gone in and they've put these tacks and in the, sometimes these tacks are metal as well. So when you scan them, you'll see lots of like bright things on the CT scan and be like what, what's going on. So think about that and then um you've got a VRX as well, which is what we would probably call, would go inside it. It can fit in different layers so you can make the space for it to fit um, but it's, you'll, you'll see it in theaters, ok? Um, the principles are when you've got an umbilical hernia as well. If it's less than one centimeter, you can feature it. If it's more than one centimeter, you, you're gonna wanna put a mesh and you can put something like this or you can just put a plain mesh that you cut cool. And this was the rec rec. So just to really hammer it in the anatomy, um You've gone in, you've, you've cut your anterior sheath as it's shown here. You've got your posterior sheath here. Obviously, the hernia is gonna have been coming out here. So you push the hernia back in if your, then you close your posterior sheath because it will have had a breach because you've had a hernia. Um So you close that and then you put your mesh. So if anyone asks you a rectal rectus is a mesh that put anterior to the posterior sheath behind the rectus muscle. OK. And it's also called a Reeve stopper. So it has three names. Basically Rectus, Reeve Stopper sub. It's not 100% sure. It's everywhere, it's super messy. So when you read the op note, it's also really important to not just say, oh, this is the name. Now, I understand it's important to read what, where they put it and they should be describing it in their note really because we can't assume in this field. And uh this is more for the, um, Rogers bad. You might know more about this than I do. Um, there's other fancier things that you can get when you've got a really big hernia and you can't close everything because it's been spread apart for so long, it's just too tight to pull across. Um, so you can do two things. One, you can put Botox in before to make everything and Botox instead of making things tight, makes everything loose. Ok? So it paralyzes all the muscles. So a month or a month before you can have Botox all in your abdominal wall. And then when it comes to the operation, it's like a, a sac that you can just pull over. How you doing that. Any ideas just think out of the box while you Yeah. So you get the muscle paralyzed here. So when you stretch it, you won't OK. That's one thing but one other important thing for postoperative. So you reduce the risk of building abdominal pressure that would make it um her again. Excellent. So you have the muscle paralyzed. So it gives you a bit of space beforehand because the muscle will be relaxer, could be more stretches. So the she everything will be structure. So it will allow you preoperative. The T gets bigger. OK? And then when you put the things together, they can get together and postoperatively when you push everything back, you don't get build up of of BP or getting a respiratory compromise. Yeah. So it's, it's really good. And then if you're still not able to close, there's another trick that you can do in the operation, which is basically that last muscle, that transverse abdominis, it's called a release. You basically sort of cut it and then your whole abdominal wall can be pulled over. But these are quite advanced things. You're not gonna be seeing them all the time. But it's just good to know like, oh if someone's had that, it's a really big operation. So then sometimes you need plastics as well for the really big ones and they can come and help with scars. Um Do abdominoplasty which an abdominoplasty is basically pulling up a fleur de lease which you might hear banded around cos it looks like a flower. You cut this out and then join this to here, join this to here and then it's closes and pulls in. So it pulls up and in and then obviously they can go freestyle in, in plastics and they can do a lot. So this is, this is quite common. I've seen this quite a lot associated with us plastic. It was kind of thing. Yeah. So you can, they're not, they're not that difficult. We've, we've done a few for them. So hernias can be a huge range. You can have a tiny little umbilical hernia or you can have something like this. So it's becoming a specialty of its own basically. Um And it's super, super interesting. Um But I wanted you guys to have a basic understanding. So just to drive home the message, a Recor Rectus is a mesh work. Fantastic. OK. And if all of you remember that, I don't really care what else you remember from the teaching. But as long as you do that and have a basic understanding of the anatomy, even if, when you're involved in this, you just need to quickly look at the anatomy the day before or something. It will make your understanding of hernias so much better. Um And you can take this principle into all of the operations that you go into. So, does anyone have any questions? Ok. I have to get off of that. I don't know how to use Mac, any questions. Was that vaguely helpful? Is there anything that's not clear? Nine. Yeah, anatomy is, it's actually really simple, but you just need someone to, you to like go about it stepwise. And hopefully I've shown that it's not just useful in hernias, but knowing the abdominal wall anatomy, you need to know for every single laparotomy that you do. Um, you need to know for open appendixes if you're doing any open surgery and you need to know for inguinal hernias, cos it continues down there. So that's it short and sweet. Ok. No problem guys. Um Any questions anything about seven years ago? Yeah. Yeah, I kept it, I kept it short because I, you're in the middle of your work day. I don't want you guys to be. Oh, sorry, I had some interaction from, from people. Thanks guys. Any questions from anyone watching as much? Ok. Oh God. Ok. Bye guys.