Anatomy of Anterior abdominal muscles

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  • Anatomy of Anterior abdominal muscles

    1. 1. MOB TCD Anterior Abdominal Muscles Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
    2. 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. 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. 4. MOB TCD Anterior Abdominal Wall • Superficial fatty layer • Membranous layer of superficial fascia • Below umbilicus • Continuous with Colles’ fascia in the perineum
    5. 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. 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. 7. MOB TCD Inguinal Glands • Proximal group parallel to inguinal ligament • Enlarged tender inguinal glands • Part of a generalised lymphadenopathy • Secondaries
    8. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 26. MOB TCD Rectus Sheath • • • • Contents Rectus muscle Pyramidalis Superior and inferior epigastric vessels • Lower five intercostal vessels and nerves
    27. 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. 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. 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. 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. 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. 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. 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. 34. MOB TCD Inguinal Canal • • • • • Anterior Wall External oblique forms Whole anterior wall Internal oblique forms Lateral half only
    35. 35. MOB TCD Inguinal Canal • • • • • Posterior Wall Transversalis fascia Whole of wall Medial half conjoint tendon Medial quarter reflected portion of inguinal ligament
    36. 36. MOB TCD Roof of Inguinal Canal • Roof • Arching fibres of internal oblique • Transversus as they both arise from the inguinal ligament
    37. 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. 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. 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. 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. 41. Passing through Superficial Ring Female • Everything that went through deep ring • Plus ilioinguinal nerve MOB TCD
    42. 42. MOB TCD Inguinal Canal • Contraction of the abdominal muscles increases the obliquity of the inguinal canal • Protecting the two rings Lytle, 1945
    43. 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. 44. MOB TCD Hernia • Chronic pain in the groin in an athlete may be due to a hernia or a potential hernia
    45. 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. 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. 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. 48. MOB TCD Inguinal Hernia
    49. 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. 50. MOB TCD Femoral Ring
    51. 51. MOB TCD Femoral Hernia • Enters through femoral ring • Enters femoral canal • Medial compartment of femoral sheath • More common in women
    52. 52. MOB TCD Femoral Hernia
    53. 53. MOB TCD Saphenous Varix • Swelling is soft and diffuse • Empties on minimal pressure • Refills on release • Cough impulse is present
    54. 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. 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. 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. 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. 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. 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. 60. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

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