Muscles of abdomen and important incision along with PT management

1. ABDOMINAL
INCISIONS
BY:- RAJIV KUMAL
BPT 4th year

2. Ventral abdominal wall
• The muscles of ventral abdominal wall surrounds the
abdominal cavity protecting the internal abdominal organs
from any damage.
• The ventral abdominal wall is attached :-
1. Superiorly by xiphiod process and the costal margins,
2. Posteriorly by vertebral column and
3. Inferiorly by pelvic bone and inguinal ligament.

3. Quadrants and regions of abdomen

4. Layers of the abdominal wall
• From superficial to deep:-
1. Skin
2. Superficial fascia
3. Muscles
4. Transversalis fascia
5. Extra peritoneal fat
6. Peritoneum

5. Function of the abdominal wall
• Protection of the internal abdominal organs
• Stabilization and rotation of the trunk
• Increase of the intra-abdominal pressure involved in counghing,defecating,
vomiting.

6. Antero lateral abdominal wall muscles
• Anterior abdominal wall muscles surrounds the abdominal cavity laterally also, so we
can say it anterolateral abdominal wall muscles.
I. Transversus abdominus
II. Internal oblique muscle
III.Rectus abdominus
IV.External obliques
V. Pyramidalis muscle
Inconsistent muscle within rectus sheath originates from pubic symphysis and
pubic crest & inserts into the linea alba.

7. Origin and insertion
• Originates from 5th to 12th ribs and its fibers are in medio-
caudal direction. (inferiorly and anteriorly)
• Inserts into the iliac crest, linea alba, and forms the inguinal
ligament
• Nerve supply T7-L1
• Function:-To pull the chest downwards and compress the
abdominal cavity, which increases the intra-abdominal pressure

8. ORIGIN AND INSERTION
• Originates from the iliac crest and its fibers are in medio-proximal
direction.
• Inserts onto the costal cartilages of the 8th through 12th ribs and the
linea alba.
• Nerve supply:- Thoracoabdominal nerve T7-T11

9. Origin and insertion
• Originates from the lower 6 ribs, lumbodorsal fascia and iliac crest and
its fibers are directed horizontally.
• The muscle end sin front in a broad aponeurosis.
• Nerve supply lower intercostal nerves

10. Note
• Fibers of external obliques and internal obliques
rarely deviates > 30°.
• Aponeurosis of external oblique , internal oblique
and transversus abdominis forms a sturdy rectus
sheath which encloses the 4th abdominal wall
muscle.

11. Origin and insertion
• Originates from pubic crest
• Inserts into the 5th 6th and 7th ribs superiorly and on the pubic bone
inferiorly.
• Its fibers are directed vertically and is interrupted by 3 or 4 tendinous
intersection.
• In between both the muscles rectus sheath joins to form relatively
avascular LINEA ALBA.

12. Linea alba is a vertical avascular line in between both the Rectus abdominis muscle.The
direction opf the LA is equal to that of the aponeurosis of obliques and transverse muscle i.e.
medio-proximal, medio-caudal and horizontal.
The width of linea alba is approx..15-20mm above the umbilicus, 20-25 mm at the level of
umbilicus and 0-5 mm below the umbilicus

13. Blood supply
• Initially the superior and inferior epigastric artery which forms
deep epigastric arcade which is situated between rectus muscle
and its posterior sheath.
• Supplies to both muscles and to linea alba.
• Secondly, B/S to transverse and obliques by transverse
segmental arteries

14. Common incisions
1.Mid-line incision
• Vertical incision through the skin, sct.fat, linea alba & peritoneum.
• Most of the fibers are cut transversely in linea alba.
• Easy to perform incision with minimum blood loss ?
• Average time for incision -7min.
• Better exposure of cavity and extension can be made.
• Suitable for emergency and exploratory surgeries.

15. 2.Para-median incision
• Alternative to mid-line incision. It has 2 types :-
I. Conventional medial para-median incision
• Rectus sheath and rectus muscle are transected near the linea alba.
II. Lateral para-median incision
• Longitudinal incision near the lateral border of rectus sheath.
• Average time -13 min. and comparitable increase blood loss.
• Extension of the incision superiorly is limited ?

16. 3.Transverse incision
Supra umbilical
• Excellent exposure to upper abdomen ,extending incision is difficult.
• During a full length T-incision the obliques, transvers ms. As well as
rectus abdominis &linea alba are cut in horizontal plane.
• Procedure obliques are partly cut and partly split and rectus ms.
Perpendicularly cut along its fibers and transverse ms is split.
• More blood loss and time consuming .

17. Transverse incision conti…
Infra-umbilical incision
• K/A Pfannenstiel incision
• Good exposure for lower abdomen
• Often used in gynaecological and obstetrics procedures.
• Transverse incision with convexity downward to avoid dissection of blood
vessels& nerves.
• The muscle and skin are incised in the same plane but in some case
abdominal cavity is opend in vertical direction. (mix)

18. 4.Oblique incision
• Sub-costal or kocher incision
• Follows direction of costal margins and are in medio-proximal direction.
• Provides good exposure for biliary & bariatric surgery can be extended
bilaterally if needed.
• Fibers of rectus abdominis, external oblique & transverse muscle are
dissected .
• Mcburney and gridiron incision in medio-caudal direrction.

20. Post-operative complications of abdominal surgery
Post-operative pain
• More pain in midline than any other incision.
• Post-operative analgesia required.
Wound infection
• Due to this incisional hernia may occur.
Pulmonary complications
• Decreased respiratory muscle movement
• Atelectasis, pneumonia.

21. Continued…..
Difficulty in removing lung secretions.
Incisional hernia
Venous stasis
Intestinal obstruction
• Abdominal surgery may cause the small bowel to become paralyzed during the early
postoperative period, a condition called paralytic ileus.
Urinary retention
• Postoperative urinary retention, caused by spasms of the bladder sphincter, occurs most
often after lower abdominal, rectal, anal or vaginal procedures.

22. Post-operative PT management
• Not only post-operatively, properly applied pre-operatively is of equal
impotance as its use in post-operative stage.
• Pre-operativre readings and training
 (dec.vital capacity, atelectasis,thrombosis,embolism)
• Post-operative pt management
Abdominal breathing
Lower costal breathing

23. Pt management continued…..
Upper costal breathing
Leg exercise
 Ankles flexed & extended
 Toes flexed & extended
 Ankles rotated
 Knees flexed, abducted & adducted against force
 Hips flexed , extended & rotated.

24. Continued….
• Arm exercises
 Fingers flexed and extended
 Wrist flexed, extended & rotated
 Elbows flexed
 Shoulders flexed, extended & rotated
• Neck flexed & extended
• Head moved from side to side.

25. Contractions of the skeletal muscles speed up the flow of blood, and full excursion of
the diaphragm, firstly, produces the negative intra-thoracic pressure where by the blood
is drawn up into the thorax, and secondly, by effecting full movements of the liver,
impel the blood out of the intra abdominal channels into the chest.