Anatomy of Anterior abdominal muscles
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Anatomy of Anterior abdominal muscles

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Anatomy of Anterior abdominal muscles Presentation Transcript

  • 1. MOB TCD Anterior Abdominal Muscles Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
  • 2. MOB TCD Anterior Abdominal Wall • The muscles of the anterior abdominal wall play a major role in movements of the trunk • Protecting the abdominal organs • Increase the intra-abdominal pressure, aid in expiration and all straining activities such as micturition, coughing and vomiting • Supplied by lower five intercostal and subcostal nerves
  • 3. MOB TCD Anterior Abdominal Muscles • Strong abdominals are important in helping to stabilise the trunk • Support the spine • They flex and rotate the trunk • Acting with the adductors and abductors of the hip • They help to stabilise the pelvis during walking and running
  • 4. MOB TCD Anterior Abdominal Wall • Superficial fatty layer • Membranous layer of superficial fascia • Below umbilicus • Continuous with Colles’ fascia in the perineum
  • 5. MOB TCD Skin of Anterior Abdominal Wall • Lower five intercostal nerves • Subcostal nerve T12 • 10th intercostal nerve is at the level of the umbilicus • Iliohypogastric nerve L1 • Ilioinguinal nerve L1
  • 6. MOB TCD Blood Supply and Lymphatics • Intercostal vessels • Skin above umbilicus superficial veins and lymphatics drain to axilla • Skin below umbilicus superficial veins and lymphatics drain to long saphenous vein • Superficial inguinal glands
  • 7. MOB TCD Inguinal Glands • Proximal group parallel to inguinal ligament • Enlarged tender inguinal glands • Part of a generalised lymphadenopathy • Secondaries
  • 8. MOB TCD Inguinal Glands • Proximal group • Lesions in local structures • Skin of lower anterior abdominal wall • Gluteal region • Skin of scrotum or labia Distal superficial glands • Skin of leg area drained by long saphenous vein • All drain to deep inguinal glands along femoral vein
  • 9. MOB TCD Abdominal Muscles • • • • • • • External oblique Internal oblique Transversus Rectus abdominus Pyramidalis Nerves and vessels Lie between internal oblique and transversus MOB TCD
  • 10. MOB TCD External Oblique • Origin • Outer surfaces lower borders lower eight ribs • Interdigitating with serratus anterior and latissimus dorsi • Fibres pass medially and inferiorly
  • 11. MOB TCD External Oblique Insertion • Inserted into anterior half of anterior two thirds outer lip of iliac crest • Aponeurosis in the inguinal region passes anterior to rectus muscle • Forms the inguinal ligament • Lacunar ligament • Reflected portion of inguinal ligament
  • 12. MOB TCD Inguinal and Lacunar Ligaments • Inguinal ligament aponeurosis is folded back from anterior superior iliac spine to pubic tubercle to form inguinal ligament • Lacunar ligament triangular, attached to pectineal line. lateral free border medial margin of femoral ring
  • 13. MOB TCD Insertion External Oblique • Pubic crest • Gap for superficial inguinal ring • Pubic bone • Linea alba • Anterior wall of the rectus sheath • Zyphoid process
  • 14. MOB TCD External Oblique • Acting separately • The external oblique flexes the vertebral column laterally and rotates it to the opposite side • If the thorax is fixed by contracting both external obliques, you can tilt the symphysis pubis superiorly and flex the trunk, posterior pelvic tilt • Movement of the iliac crests determines the direction of the tilt
  • 15. MOB TCD Internal Oblique • Muscular origin lateral two thirds of inguinal ligament • Anterior two thirds intermediate lip of iliac crest • Lumbar fascia • Muscular fibres arch over contents of inguinal canal anterior to rectus muscle • Fibres pass medially and superiorly
  • 16. MOB TCD Insertion Internal Oblique • Into coastal margin, upper three as fleshy fibres • Next three as aponeurotic • Inserted into linea alba • Between zyphoid and half way between umbilicus and pubic symphysis aponeurosis splits • Anterior layer fuses with external oblique • Posterior layer fuses with transversus
  • 17. MOB TCD Internal Oblique Conjoint Tendon • Half way between umbilicus and pubic symphysis • Aponeurosis of the internal oblique and transversus fuse to form conjoint tendon • Anterior portion of rectus sheath • Inserted into pectineal line behind superficial inguinal ring
  • 18. MOB TCD Internal Oblique • The right side of the muscle twists to the right and the left side twists to the left • The lower six intercostals nerve • Subcostal nerve • Iliohypogastric nerves
  • 19. MOB TCD Transversus Abdominus • Origin • Lateral one third of inguinal ligament • Anterior two thirds of inner lip of iliac crest • Lumbar fascia • Lower border and inner surfaces lower six ribs interdigitating with diaphragm
  • 20. MOB TCD Insertion Transversus Abdominus • Into zyphoid, linea alba • Half way between umbilicus and pubic symphysis • Fuses with posterior lamella of internal oblique • Below forms conjoint tendon • Inserted into pectineal line behind superficial inguinal ring
  • 21. MOB TCD Transversus Abdominus • The transversus abdominus helps to support the abdominal viscera • Maintain intra-abdominal pressure • Stabilises the lumbar spine • It is supplied by the lower six intercostals nerves • Subcostal nerves • Iliohypogastric nerves
  • 22. MOB TCD Rectus Abdominus • • • • • Segmental muscle Two heads Anterior pubic symphysis Pubic crest Inserted anterior aspect of 5, 6, 7th costal cartilages • Adhesions anterior surface • Segmental blood and nerve supply from Intercostals • The rectus abdominus flexes the trunk
  • 23. MOB TCD Rectus Abdominus • The rectus muscles (recti) are the most powerful flexors of the vertebral column • When raising the head from a supine position • A movement often used to strengthen the abdominals • It is the recti that contract first • When the shoulders start to rise upwards, the obliques start to contract
  • 24. MOB TCD Rectus Sheath • Above zyphoid • Anterior wall is the external oblique • Posterior, costal cartilages • From ziphoid and half way between umbilicus and pubic symphysis • Anterior is external oblique and anterior lamella of internal oblique • Posterior lamella internal oblique and transversus
  • 25. MOB TCD Rectus Sheath • Below half way between umbilicus and pubic symphysis • The aponeurosis of the external oblique, internal oblique and transversus (conjoint tendon) pass anterior to the rectus • Posterior lies the transversalis fascia
  • 26. MOB TCD Rectus Sheath • • • • Contents Rectus muscle Pyramidalis Superior and inferior epigastric vessels • Lower five intercostal vessels and nerves
  • 27. MOB TCD Transversalis Fascia • Lines deep aspect of transversus abdominus • Fuses with inguinal ligament • Continuous with iliac fascia • Except in the region of the femoral vessels • Forms anterior wall of femoral sheath
  • 28. MOB TCD Extraperitoneal Tissue • Extraperitoneal connective tissue • If fatty, it separates the transversalis fascia from the peritoneum • If thin, they are in close contact with one another
  • 29. MOB TCD Peritoneal Pouches • Peritoneal pouches are found in the region of the deep inguinal ring • Medial portion of the posterior wall Posterior aspect anterior abdominal wall
  • 30. MOB TCD Inguinal Canal • Intra muscular canal • Lower portion of anterior abdominal wall From • Deep inguinal ring • Superficial inguinal ring • Transmits spermatic cord in male • Round ligament in female
  • 31. MOB TCD Superficial Inguinal Ring • Triangular opening in aponeurosis of external oblique • Base, pubic crest • Superior crus attached to the pubic crest • Inferior attached to pubic tubercle • External spermatic fascia arises from its margins
  • 32. MOB TCD Deep Inguinal Ring • Oval opening 2.5 cm • Above the middle of inguinal ligament • Inferior epigastric artery passes medial to the deep ring
  • 33. MOB TCD Interfoveolar Ligament • The interfoveolar ligament is an inconstant band • Medial to deep inguinal ring • Anterior to inferior epigastric vessels • From lower margin of transversus abdominus • To pectineal line McVay & Anson, 1949
  • 34. MOB TCD Inguinal Canal • • • • • Anterior Wall External oblique forms Whole anterior wall Internal oblique forms Lateral half only
  • 35. MOB TCD Inguinal Canal • • • • • Posterior Wall Transversalis fascia Whole of wall Medial half conjoint tendon Medial quarter reflected portion of inguinal ligament
  • 36. MOB TCD Roof of Inguinal Canal • Roof • Arching fibres of internal oblique • Transversus as they both arise from the inguinal ligament
  • 37. MOB TCD Floor of Inguinal Canal • Floor • Inguinal ligament forms whole of floor • Medial half by the lacunar ligament • Reflected part of inguinal ligament forms medial quarter
  • 38. MOB TCD Passing Through Deep Ring Male • • • • • Vas Deferens Testicular artery Pampiniform plexus of veins Remains of processus vaginalis Genital branch of genitofemoral nerve • Lymphatics from testes • Cremaster artery
  • 39. Passing through Superficial Ring Male • Everything that went through deep ring • Plus • Ilioinguinal nerve • Internal spermatic fascia from margins of the deep ring • Cremaster muscle and fascia MOB TCD
  • 40. Passing through Deep Ring Female • Round ligament of uterus • Remains of processus vaginalis • Genital branch of genitofemoral nerve • Lymphatics from uterus, region of cornu MOB TCD
  • 41. Passing through Superficial Ring Female • Everything that went through deep ring • Plus ilioinguinal nerve MOB TCD
  • 42. MOB TCD Inguinal Canal • Contraction of the abdominal muscles increases the obliquity of the inguinal canal • Protecting the two rings Lytle, 1945
  • 43. MOB TCD Increase in Intra-Abdominal Pressure • Pain aggravated by an increase in intraabdominal pressure • Hernia • Inguinal or femoral hernia • Entrapment of the ilioinguinal nerve
  • 44. MOB TCD Hernia • Chronic pain in the groin in an athlete may be due to a hernia or a potential hernia
  • 45. MOB TCD Inguinal Hernia • Sudden severe pain in lower abdomen • Associated with lifting a heavy object • Common history of a direct inguinal hernia
  • 46. MOB TCD Indirect Inguinal Hernia • Passes through • Deep inguinal ring • May extend to pass through the superficial ring into the scrotum • Congenital or acquired • Congenital inside the tunica vaginalis (serous membrane, covers part of testes) • Acquired outside
  • 47. MOB TCD Direct Inguinal Hernia • Enters through posterior wall of the inguinal canal • Leaves through superficial inguinal ring • Above and medial to the pubic tubercle
  • 48. MOB TCD Inguinal Hernia
  • 49. MOB TCD Inguinal Versus Femoral Hernia • Inguinal hernia above and medial to pubic tubercle • Femoral hernia below and lateral to the tubercle • More common in females and more likely to strangulate
  • 50. MOB TCD Femoral Ring
  • 51. MOB TCD Femoral Hernia • Enters through femoral ring • Enters femoral canal • Medial compartment of femoral sheath • More common in women
  • 52. MOB TCD Femoral Hernia
  • 53. MOB TCD Saphenous Varix • Swelling is soft and diffuse • Empties on minimal pressure • Refills on release • Cough impulse is present
  • 54. MOB TCD Gilmore’s Groin • Common cause of chronic groin pain in field sports • Particularly soccer players • Pain on any sudden change of movement, sneezing, coughing
  • 55. MOB TCD Gilmore’s Groin • Trying to sprint • Will increase the pain • Pain is worse getting out of bed • The day after a match or a training session
  • 56. MOB TCD Gilmore’s Groin • Pain is increased by external rotation • Or hyperextension of hip • Pain is localised to lower anterior abdominal wall • Adductor or perineal region
  • 57. MOB TCD Gilmore’s Groin • Torn external oblique aponeurosis • Torn conjoint tendon • A dehiscence between conjoint tendon and the inguinal ligament • The absence of a hernial sac • Superficial inguinal ring on the affected side is dilated and tender • Cough impulse
  • 58. MOB TCD Gilmore’s Groin Surgery • Treatment is surgical • 90% return to sport • Strengthen lower abdominal muscles 1. Plication of the transversalis fascia in “Shouldice hernia repair” 2. Repair of torn conjoint tendon
  • 59. MOB TCD Gilmore’s Groin Surgery 3. Approximation of conjoint tendon to the inguinal ligament 4. Repair of the external oblique 5. Reconstitution of the superficial inguinal ring
  • 60. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”