Anterior Abdominal Wall

Layer of anterior abdominal wall: A- Lateral: 1- Skin. 2- Subcutaneous tissue. 3- External oblique muscle. 4- Internal oblique muscle. 5- Transversus abdominis muscle. 6- Fascia transversalis. 7- Peritoneum.

A- Lateral

1- Skin

A- Lateral

2- Subcutaneous tissue

Fascia
Superficial:
Campers fascia Continuous with fascia over thorax and thigh. Fatty layer.

Fascia
Deep Superficial:
Scarpas fascia Membranous layer. Continues into perineum as:
Superficial perineal fascia = Colles fascia.

Deep:
Thin layer covering abdominal muscles.

A- Lateral

3- External Oblique m.

A- Lateral

4- Internal Oblique m.

A- Lateral

5- Transversus abdominis m.

A- Lateral

6- Fascia Transversalis m

A- Lateral

7- Peritoneum

Anterior Abdominal Wall

B- Medial:
1- Skin. 2- Superficial fascia. 3- Anterior wall of rectus sheath. 4- Rectus muscle. 5- Posterior wall of rectus sheath. 6- Peritoneum.

Layer of anterior abdominal wall:

B- Medial

1- Skin

B- Medial

2- Subcutaneous tissue

B- Medial

3- Ant. Wall of Rectus sheath

B- Medial

4- Rectus Muscle

B- Medial

5- Post. Wall of Rectus sheath

B- Medial

6- Peritoneum

External Oblique Muscle

Origin
Fleshy digitations from the lower 8 ribs

External Oblique Muscle

Insertion
The muscle is inserted by fleshy fibers as well as aponeurosis, as follows:
Xiphoid Process

A- Fleshy fibers:
Outer lip of the iliac crest

B- Aponeurosis:
1. Medial part linea alba from xiphoid process to symphysis pubis 2. Lateral part folded upwards & backwards upon itself to form the inguinal ligament (ASIS pubic tubercle)

Symphysis Pubis

External Oblique Muscle

Direction of fibers

Downward
Forwards

Medially

External Oblique Muscle

Nerve Supply
Intercostal nerves (T7 -T11) & Subcostal nerve (T12)

External Oblique Muscle

A triangular shaped defect in the external oblique

aponeurosis lies immediately above and medial to the pubic tubercle, known as superficial inguinal ring
Between the anterosuperior iliac spine and the pubic

tubercle, the lower border of the aponeurosis is folded backward on itself, forming the inguinal ligament

Internal Oblique Muscle

Origin
1. Anterior 2/3 of the intermediate line of the iliac crest
2. The lateral 2/3 of the inguinal ligament 3. Lumbar fascia

Insertion
1. 2. 3. 4. Lower 6 costal cartilages Xiphoid process Linea Alba Pubic crest

Internal Oblique Muscle

Direction of fibers

Upwards
Forwards

Medially
Nerve Supply
T7-T12 Iliohypogastric n. Ilioinguinal n.

Transversus Abdominis Muscle

Origin
1- Lower 6 intercostal cartilages

4- Lat. 1/3 of inguinal ligament

2- Lumbar Fascia

3- Ant. 2/3 of inner lip of iliac crest

Transversus Abdominis Muscle

Insertion

1- Xiphoid Process

3- Linea Alba
2- Pubic Crest

Transversus Abdominis Muscle

Direction of fibers
Horizontally

Transversus Abdominis Muscle

Nerve Supply
T7-T12 Iliohypogastric n. Ilioinguinal n.

The part of the fascia which lines the inner surface of the transverse abdominus muscle is called the fascia tranversalis.

The main arteries of the abdominal wall and pelvis lie deep to the fascia tranversalis,while the main nerves are superficial to it

Rectus Abdominis Muscle

Insertion
7th, 6th, 5th costal cartilages Xiphoid process

Origin
From the pubic crest

Rectus Abdominis Muscle

The muscle is divided into segments by tendinous intersections, Which indicate that the muscle arises from a number of myotomes, fused together

Surgical Importance
1- Segmental nerve supply. 2- Hematoma of rectus m. is localized

Pyramidalis Muscle
It is a landmark of linea alba intraoperative

Rectus Sheath

Is a long fibrous sheath Encloses the rectus abdominis and pyramidalis muscle (if present) Contains the anterior rami of lower six thoracic nerves and the superior and inferior epigastric vessels and lymph vessels Formed mainly by aponeurosis of three lateral abdominal muscles

Rectus Sheath
Linea Alba

Medially

Arcuate Line

Linea Semilunaris

Laterally

Above Arcuate Line

External Oblique
Internal Oblique Transversus Abdominis

Rectus Sheath
Ant. Layer of Rectus Sheath

Rectus Abdominis

SKIN

Falciform Ligament Transverslais Fascia

Peritoneum

Post. Layer of Rectus Sheath

Below Arcuate Line

External Oblique
Internal Oblique Transversus Abdominis

Rectus Sheath
Ant. Layer of Rectus Sheath

Rectus Abdominis

SKIN

Transverslais Fascia
Urachus in Median Umbilical Fold Medial Umbilical Ligament

Peritoneum

It is formed by the fusion of the aponeurosis of the abdominal muscles and it separates the left and right rectus abdominus muscles.

Applied anatomy
In multiparae the upper part of the linea alba becomes

streched out and weak,so that fingers can be insinuated between the two recti.the condition known as Divarication of recti.

It is a curved tendinous line placed one on either side of the rectus abdominus,extends from the 9th rib to the pubic tubercle.

Actions of Anterior Abdominal Wall Muscles

They assist in raising the intra abdominal pressure (so,

they help in vomiting, cough, delivery, etc.) Keep the abdominal viscera in position. Rectus abdominis flexes the trunk, while the 2 oblique muscles bend the trunk laterally. Act as accessory expiratory muscles.

- II Descending Aorta

-IInternal Mammary a.

10th, 11th intercostal a.

Superior epigastric a.

Subcostal a.

- III External Iliac a.

Deep circumflex iliac a.

Inferior epigastric a.

Lymphatic Drainage
Above the umbilicus:

Drain into the axillary and sternal nodes.

Below the umbilicus:

Drain into the superficial inguinal nodes.

Venous Drainage
Superficial veins are paired with arteries.
Above the umbilicus:

Drain into the azygos venous system.

Below the umbilicus:

Drain into the femoral system (via great saphenous).

Caput Medusae
The superficial veins around the umbilicus and the paraumbilical veins connecting them to the portal vein may become grossly distended in case of portal vein obstruction The distended subcutaneous veins radiate out from the umbilicus, producing in severe cases the clinical picture called Caput Medusae

INGUINAL CANAL

Inguinal canals why have them?

Allow contents of the scrotum to communicate with

intra-abdominal contents Prevent mobile intra-abdominal contents (e.g. intestine) from entering the scrotum and possibly becoming damaged, while at the same time permitting blood vessels, nerves, lymphatics, vas deferens etc. to supply the scrotal contents

Dr C Slater, Department of Human Biology, University of Cape Town

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A Box?

Lateral

Floor Imagine the right side inguinal canal viewed from the front as a box with anterior & posterior walls, a roof & floor. The arrow indicates that structures can run through it from lateral to medial e.g. in males it transmits the spermatic cord, and in females, the round ligament of the uterus.
Medial

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Inguinal canal
Deep inguinal ring

Lateral

Medial

Here are the posterior wall, which has the DEEP inguinal ring situated laterally, and the floor. (Roof and anterior wall removed).

Floor

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Inguinal canal

Lateral

Medial

Superficial inguinal ring Here are the anterior wall (which has the SUPERFICIAL inguinal ring situated medially), and the roof.
Floor

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Inguinal canal
Deep inguinal ring

Spermatic cord enters the inguinal canal through the deep inguinal ring

Lateral Medial

Superficial inguinal ring

Spermatic cord exits through the superficial inguinal ring

Floor

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Inguinal canal

The anterior wall is made up of the external oblique muscle throughout, and is reinforced by the internal oblique m. laterally. The transversus abdominus m. lies even more laterally as part of the anterior abdominal wall.

Lateral Medial

Superficial inguinal ring

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Inguinal canal
Conjoint tendon

The conjoint tendon attaches to the pubic crest, reinforces the posterior canal wall medially and also forms the ROOF of the canal

Lateral Medial

The transversus abdominis and internal oblique mm. combine to form the CONJOINT tendon that arches over the contents of the inguinal canal

Floor

Spermatic cord
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Posterior wall of the inguinal canal

Posterior wall Deep inguinal ring Conjoint tendon medially

Lateral

Medial

The posterior wall is formed by transversalis fascia (orange) throughout and the conjoint tendon (red) medially. The wall is particularly weak over the deep inguinal ring

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Floor of the inguinal canal

Lateral

Medial

The floor is formed by an incurving of the inguinal ligament, which is part of the external oblique muscle, forming a gutter. (Medially it forms the lacunar ligament).

Floor

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Roof and anterior wall of the inguinal canal

Superficial inguinal ring

Lateral

Medial

The anterior wall of the canal is formed by external oblique muscle (orange) throughout and by internal oblique muscles (red/black/white) laterally. This wall is weak medially because of the hole in the external oblique muscle (= superficial inguinal ring).
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Pressures on the inguinal canal

= areas where reinforcement is present Deep inguinal ring

Conjoint tendon

intra abdominal pressure

Lateral

Reinforced anterior wall by internal oblique m.

Reinforced posterior wall

Pressure on anterior wall

Superficial inguinal ring

Medial

Spermatic cord
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Pressures in the inguinal canal

Deep inguinal ring

Conjoint tendon

intra abdominal pressure

Lateral

Reinforced anterior wall

Reinforced posterior wall

Superficial inguinal ring

Weakness here leads to direct inguinal hernias

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S.C.

Deep Inguinal Ring

inch above the ligament
Midway between ASIS and the Symphysis Lateral to the inferior epigastric vessels Margins of ring give origin to the internal spermatic

fascia

Superficial Inguinal Ring

Triangular defect in the aponeurosis of the external

oblique Immediately above and medial to the pubic tubercle Margins give origin to the external spermatic fascia

Mechanics of the inguinal Canal

A potential weakness
A design to lessen weakness: Oblique passage weakest areas lying some distance apart Anterior reinforcement by Int. oblique in front of deep ring Posterior reinforcement by Conjoint tendon behind superficial ring

Mechanics of the inguinal Canal Cont.

On coughing/straining (defecation,

parturition etc.) Int. oblique and transversus abdominis muscles contract flattening the roof canal is virtually closed

Inguinal hernias
The posterior wall of the canal is particularly weak

laterally because of the deep inguinal ring The anterior wall opposite the deep ring is reinforced laterally by the internal oblique m. A hernia (e.g. of small bowel) that comes through the deep inguinal ring will have to travel along the inguinal canal as it cannot push into the reinforced layers of muscle in the anterior wall of the canal directly opposite the deep inguinal ring

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Inguinal hernias
The anterior wall of the canal is weak medially where

the superficial inguinal ring is situated The posterior wall, opposite the superficial ring, is reinforced medially by the conjoint tendon that is formed by fibres of the internal oblique and transversus abdominis muscles Abdominal contents cannot normally force themselves through the superficial ring directly because of the reinforced posterior wall medially

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Indirect inguinal hernias

Pass through the deep ring
Travel along the canal Exit the superficial ring above and medial to the pubic

tubercle .Since the incurved inguinal ligament forms the floor of the canal, the contents of the canal could not emerge below or lateral to the public tubercle (useful in surgical diagnosis). An example is congenital inguinal hernia. Coverings of indirect hernias
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Coverings of indirect hernias

Peritoneum
Internal spermatic fascia

(from transversalis fascia) Cremaster muscle & fascia

(from transversus abdominis and internal oblique mm.)

External spermatic fascia

(from external oblique m.) Superficial fascia Skin

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Direct inguinal hernias

If the posterior wall of the canal is weakened medially

(e.g. by chronically increased intra-abdominal pressure), it can stretch and bulge out through the superficial ring The contents of the hernia do not travel along the length of the canal but push directly on the stretched posterior inguinal canal wall and through the superficial ring. Coverings of direct hernias

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Coverings of direct hernias

Peritoneum
Transversalis fascia Conjoint tendon External oblique aponeurosis Superficial fascia Skin

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Abdominal Quadrants
Formed by two intersecting lines:

Intersect at umbilicus.
Quadrants:

Upper left. Upper right. Lower left. Lower right.

Abdominal Regions
Divided into 9 regions by two pairs of planes:
Vertical Planes: Left and right lateral planes = midclavicular planes Horizontal Planes: Transpyloric plane: Midway between jugular notch and pubic symphysis (between xiphoid and umbilicus). Intertubercular plane: Through tubercles of iliac crests.

Regions of the abdomen

R hypochondrial Epigastric L hypochondrial

R Lumbar

Umbilical

L Lumbar

R iliac

Suprapubic/Hypo L iliac gastric

Abdominal Regions
Right and left hypochondriac:
Contain liver

Epigastric:
Contains: liver, stomach, pancreas

Right and left lateral (lumbar):

Right contains ascending colon. Left contains descending colon.

Abdominal Regions
Umbilical:
Contains small intestine and transverse colon.

Right and left inguinal:

Right contains ileocecal junction and appendix. Left contains sigmoid colon.

Hypogastric:
Contains small intestine, urinary bladder (full), pregnant uterus.

 Protuberance of the abdomen. The five common

causes (5F)
Fat, Faeces, Fetus, Flatus And Fluid

Abdominal Hernias Anteriolateral abdominal wall may be the site of hernias Inguinal, umbilical and epigastric regions

Common Sites
Inguinal Hernia Umbilical Hernia Femoral Hernia Incisional Hernia

Less common Hernia

Epigastric Hernia Recurrent Hernia

Umbilical Hernia
Fascial defect at the umbilicus with

peritoneal sac covered by skin

Paediatric umbilical hernias
Adult umbilical hernias

Pediatric Umbilical Hernia

Present in 10-30% of babies 80% close spontaneously by age 2

Indications for primary suture repair Hernia present after ages 2-4 Large (5 cm) defect at age 1

Adult Umbilical Hernia

Increased intra-abdominal pressure Pregnancy Obesity Ascites Differential diagnosis (rare) Embryologic remnants Metastatic cancer

Adult Umbilical Hernia

Symptoms relate to cosmesis, traction on the sac,

or trapped contents
Omentum Small or transverse colon

Acute incarceration: reduction en masse

problematic

Adult Umbilical Hernia Repair

Assess contents and manage

appropriately based on viability Open hernia repair

< 1 cm defect: primary suture repair

> 1 cm defect: mesh repair lowers recurrence

Laparoscopic hernia repair: size of access

ports often > hernia incision

Epigastric Hernia
Fascial defect in supraumbilical linea alba Most < 1 cm 20% with multiple defects Beware diastasis recti
Men: Women 2:1

Epigastric Hernia
Contents
Incarcerated preperitoneal fat or falciform ligament Peritoneal sac

Repair
Open repair similar as for umbilical hernia Must palpate or visualize entire supraumbilical linea alba Laparoscopic approach is suboptimal

Spigelian Hernia
Defect through transversus abdominus and

internal oblique muscles

Occurs at junction of arcuate line and linea semilunaris Fascial defect 1-2 cm Covered by external oblique aponeurosis

Spigelian Hernia
Presentation
Lower abdominal swelling lateral to rectus

Focal discomfort/pain

May require imaging studies for diagnosis

Ultrasound or CT

Repair: open or laparoscopic, on-lay mesh

Incisional Hernia
Bulge in region of scar from surgery or

penetrating trauma
Chronic wound failure
Up to 20% of abdominal incisions

Subcutaneous sac may be more complex

Multi-loculated Contents adhesed within sac

Incisional Hernia: Risk Factors

Previous incisional hernia repair Obesity Smoking

Chronic lung disease

Diabetes Malnutrition Wound infection

Incisional Hernia Repair

Fix conditions that promoted hernia occurrence
Open repair
Primary suture: < 52% recurrence

Mesh: < 24% recurrence

Common Clinical Features

The features of all hernias are:
They occur at weak spot

They reduce on lying down or with

pressure

direct

They have an expansile cough impulse

Untreated hernia may develop following complications:

Complications

(a) intestinal obstruction (b) strangulation (c) incarceration

ABDOMINAL WALL DEFECTS

Omphalocele
Membrane sac arising from the umbilical cord covers intestines Outer membrane layer consists of amnion and inner lining of peritoneum Size ranging from small->giant defects containing liver, small and large bowel, stomach, spleen, ovaries, and testes Associated with foreshortened bowel and malrotation Small abdominal cavity and pulmonary hypoplasia

Gastroschisis
No membrane covering
Abdominal wall defect typically 2-4cm diameter Lateral to the right side of the umbilical cord

Usually contains midgut and stomach

Thickened, atretic, and possibly ischemic bowel Associated with malrotation

ABDOMINAL WALL DEFECTS

omphalocele
Membrane covered 1-15 cm defect size Centre of the membrane Bowel-normal Associated abnormalities-

gastroschisis
Open defect 2-5 cm Left of the defect Bowel-edematous,serositis 10%

60%