Anterior abdominal wall and inguinal region Flordeliza M.

De Jesus, MD The abdomen The region of the trunk between the thorax and pelvis

Surface landmark Superiorly xiphisternal joint and costal arches Inferiorly, symphysis pubis, inguinal folds, and iliac crest Posteriorly, lumbar paravertebral musculature of the back

Skeletal support of abdomen Subcostal arch Last rib Lumbar vertebrae Pubic symphysis Pubic crest Iliac crest

Abdominal wall The abdominal wall Refers to the anterolateral abdominal wall only The major part of the anterolateral abdominal wall is formed by the 3 pairs of broad and flat muscles and their aponeuroses. On each side of the midline, strap-like muscle, the rectus abdominis spans the abdominal wall between the rib cage and symphysis pubis

Superficial fascia of abdominal wall The superficial fascia of the abdominal wall consists for the most part a single layer that contains a variable amount of fat. In the lower part of the abdomen, the fascia differentiate into a superficial and deep layer. Superficial blood vessels and nerves are between these layers. Superficial layer of superficial fascia of the abdominal wall The superficial layer (Camper s fascia) is thick, areolar in texture and contains a variable amount of fat in its meshes Deep layer of superficial fascia of abdominal wall The deep layer of superficial fascia (Scarpa s fascia) is more membranous than the

superficial layer and contains elastic fibers. It is loosely attached to the underlying aponeurosis of external oblique but adherent to the linea alba and symphysis pubis. Muscles of abdominal wall Three anterolateral abdominal muscles External oblique Internal oblique Transversus abdominis Anterior abdominal muscle Rectus abdominis Pyramidalis External oblique abdominis Largest and most superficial of the 3 flat muscles in the abdominal wall Direction of fibers: downward and medially Origin: Arises by 8 fleshy slips from the external surfaces and inferior borders of the lower 8 ribs Insertion: Posterior fibers insert into the anterior half of the iliac crest Remaining fibers end in an aponeurosis that insert medially into the linea alba, inferiorly into the symphysis pubis, pubic crest and tubercle Internal oblique abdominis Lies beneath the external oblique for much of its extent Thinner and less bulky Direction of fibers - upward and medially Origin: Arise from the lateral 2/3 of the upper surface of inguinal ligament, iliac crest beneath the insertion of the external oblique and from the thoracolumbar fascia Insertion: Posterior fibers insert into the last 3 or 4 ribs Inferior fibers insert into the pubic crest and medial part of the pecten pubis Intermediate fibers diverge and end in an aponeurosis . This aponeurosis pass medially and inserts into the linea alba

Transversus abdominis Innermost among the 3 flat muscles of the abdominal wall Origin: Lateral 3rd of inguinal ligament Anterior 2/3 of the iliac crest Thoracolumbar fascia 12th rib and inner lip of the lower 6 costal cartilages Insertion: The muscle ends in an aponeurosis Lower fibers curved downward and medially and joins with aponeurosis of internal oblique (conjoint tendon) and insert into the crest of pubis and pecten of pubis The rest of the aponeurosis pass medialward and end at the linea alba

The linea alba A tendinous raphe along the midline extending from the xiphoid process to the symphysis pubis and pubic crest Lies between the rectus abdominis Formed by the interlacing fibers of the oblique and transverse muscles Wider above the umbilicus and narrow below Rectus abdominis Long strap-like muscle that extends along the whole length of the front of the abdomen Separated in the midline by linea alba Origin: Upper border of pubis Insertion: 5th 7th costal cartilages

Rectus abdominis Tendinous intersections The tendinous intersections are 3 fibrous bands that cross the fibers of rectus abdominis at different levels Level of umbilicus, level of tip of xiphoid process and another one between the 2 Rectus sheath The rectus abdominis is enclosed between the aponeuroses of the oblique and transversus muscles, which form the so-called rectus sheath. Formation of the rectus sheath

The aponeurosis of the internal oblique splits at the lateral border of the rectus abdominis The anterior lamina blending with the aponeurosis of the external oblique passes in front of rectus abdominis; The posterior lamina blending with the aponeurosis of the transversus abdominis passes behind the rectus abdominis Formation of the rectus sheath The combined aponeuroses come together at the medial border of the rectus abdomins and contribute to the linea alba. This is the arrangement of the rectus sheath from the costal margin down to about halfway between the umbilicus and symphysis pubis Rectus sheath Arcuate line The posterior layer of the rectus sheath ends in a curved line called the arcuate line at the level midway between umbilicus and symphysis pubis, or level with thw anterior superior iliac spine. Rectus sheath below the arcuate line Below the arcuate line the rectus sheath is absent posteriorly. Aponeurosis of all 3 flat muscles, 2 oblique and a transversus all pass in front of rectus abdominis. The rectus abdominis is covered posteriorly by transversalis fascia that separates it from the peritoneum. Contents of the rectus sheath Rectus abdominis Pyramidalis muscle Superior and inferior epigastric vessels Terminal portions of lower intercostal nerves Functions of the anterior abdominal muscles 1. Support the abdominal viscera 2. Compress the abdomen 3. Move the trunk Blood supply of abdominal wall Superior epigastric from the internal thoracic artery Inferior epigastric from the external iliac

Lower 2posterior intercostal arteries and subcostal Lumbar arteries (4 pairs) from abdominal aorta Deep circumflex iliac from external iliac artery Superficial epigastric from femoral artery Venous drainage of the abdominal wall Thoracoepigastric vein Superior epigastric vein Inferior epigastric vein Lower 2 posterior intercostal vein Subcostal vein Deep circumflex iliac Superficial epigastric

from thoracic aorta

Nerves of anterior abdominal wall Ventral rami of T6 T11 , continuation of the intercostal nerves T12, the subcostal nerve Branches of L1, iliohypogastric and ilioinguinal Inguinal region Externally, the inguinal region is the meeting place of the anterior abdominal wall and the thigh Internally, the anterior and posterior walls of the abdomen meet each other in the inguinal region. Inguinal triangle The inguinal triangle (Hesselbach s triangle) Boundaries Medially lateral boder of rectus abdominis Laterally inferior epigastric vessels Inferiorly inguinal ligament Significance: site of direct inguinal hernia Inguinal region The key to the anatomy of the inguinal region is the inguinal ligament. The inguinal ligament is not a true ligament. It is the inferior free border of the external oblique aponeurosis, thickened and reinforced by collagen fiber bundles that run from the anterior superior iliac spine to the pubic tubercle

Inguinal canal An oblique passageway through the anterior abdominal wall connecting th extraperitoneal space of the abdomen to the scrotum or the labia majora The canal commences at the deep inguinal ring and terminates at the superficial inguinal ring, 4 5 cm long Wall of the inguinal canal Anterior wall formed by the external oblique aponeurosis throughout the length of the canal, the anterior wall of the lateral part is reinforced by fibers of the internal oblique. Posterior wall formed by the transversalis fascia; the posterior wall of the medial part is reinforced by the merging of the pubic attachments of the internal oblique and transversus abdominis aponeurosis into a common tendon, the inguinal falx (conjoint tendon). Roof formed laterally by transversalis fascia, centrally by the arching fibers of the internal oblique and transversus abdominis; medially by the medial crus of the external oblique apaoneurosis Floor formed by the iliopubic tract, centrally by the superior surface of the inguinal ligament and medially by the lacunar ligament. Deep inguinal ring An oval opening in the transversalis fascia. Transmits the spermatic cord in male and the round ligament of uterus The transversalis fascia is prolonged anteriorly from the margins of the deep inguinal ring into the inguinal canal. This is the internal spermatic fascia Superficial inguinal ring A triangular gap in the aponeurosis of the external oblique aponeurosis, formed by the separation of its fibers The base is the triangle is the pubic crest, the sides are the crura of the ring. Lateral crus inguinal ligament Medial crus part of the external oblique aponeurosis attached to the pubic symphysis and body of pubis Indirect inguinal hernia A form of hernia where abdominal viscera protrude through the deep inguinal ring The hernia is lateral to the inferior epigastric vessels Direct inguinal hernia A form of inguinal hernia where abdominal viscera protrude into the inguinal triangle (medial to the inferior epigastric vessels

Anterior abdominal wall Quadrants of abdomen Regions and planes of abdomen