anterior abdominal wall

University of dongola
Faculty of medicine
Anterior abdominal wall
By: Dr.mohammed A.rheem.
Lecturer of clinical anatomy
Vascular surgery Resident
Mohammed Rheem MBBS,M.Sc

Anterior Abdominal Wall

Think about this
Nadir is 22-year-old house officer, he
was attending his first day in the
hospital after graduation when the
senior doctor asked him to write
down the operation sheet for
several surgeries done at that
morning, he faced some difficulties
in the following:

By the end of this lecture, try to answer
these questions about the previous
story:
1.What are the nine areas dividing the
anterior abdominal wall in surface
anatomy?
2.Mention the suitable incision for the
following surgical operations:
A.Appendectomy.
B.Cholecystectomy.
C.Cesarean Section. Mohammed Rheem MBBS,M.Sc

3.Mention the site of the pain in the
following conditions:
A.Appendicitis.
B.Cholecystitis

Layers of anterior abdominal wall : (Lateral side)
1- Skin.
2- Superficial fascia.
3- External oblique muscle.
4- Internal oblique muscle.
5- Transversus abdominis muscle.
6- Fascia transversalis.
7- Extraperitoneal fascia
8- Partial peritoneum.

1-Skin
Lateral Side

2-superficial fascia
Lateral Side

3-External Oblique m.
Lateral Side

4-Internal Oblique m.
Lateral Side

5-Transversus abdominis
m.
Lateral Side

6- Fascia Transversalis
Lateral Side

Lateral Side

8- partial peritoneum
Lateral Side

Layers of anterior abdominal wall : (Medial side)
1-1- Skin.
2- Superficial fascia.
3- Anterior wall of rectus sheath.
4- Rectus muscle.
5- Posterior wall of rectus sheath.
6- Fascia transversalis.
7- Extraperitoneal fascia.
8- Partial peritoneum.

1-Skin
Medial Side

2-Superficial fascia
Medial Side

3-Ant. Wall of Rectus
sheath
Medial Side

4-Rectus Muscle
Medial Side

Medial Side
5-Post. Wall of Rectus
sheath

6-Fascia Transversalis
Medial Side

Medial Side

Medial Side
8-partial peritoneum

Skin of the anterior abdominal wall
 Lines of cleavage in the skin run downward and forward
almost horizontally around the trunk
 An incision along a cleavage line will heal as a narrow
scar, while one that crosses the lines will heal as a wide
scar

Cutaneous nerves of anterior abdominal wall
 It is derived from the anterior
rami of the lower six thoracic
and first lumbar nerves
 Thoracic nerves are the
lower five intercostal and
the subcostal nerves
 First lumbar nerve is
represented by the
iliohypogastric and
ilioinguinal nerves

Dermatomes of the anterolateral abdominal wall

Cutaneous arteries of anterior abdominal wall
 Skin near the midline is
supplied by branches of the
superior epigastric artery
( internal thoracic artery)
and the inferior epigastric artery
( external iliac artery)
 Skin of the flanks is
supplied by branches from
intercostal, lumbar and deep
circumflex iliac arteries

Cutaneous veins of anterior abdominal wall
 Venous blood is collected
into a network of veins that
radiate from the umbilicus
 The network is drained
above into the axillary vein via
the lateral thoracic vein
 Below into the femoral vein
via the superficial epigastric
and the great saphenous veins
 Few small veins, the paraumbilical
veins form a clinically important portal-system
venous anastomosis

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

Superficial Lymphatics of anterior abdominal wall
 Lymph drainage of the skin
of the anterior abdominal wall
above the umbilicus is upward
to the anterior axillary
(pectoral group of nodes)
 Below the level of umbilicus
drains downward and laterally
to the superficial inguinal nodes
 A few drain medially and
deeply to the parasternal
and anteriordiaphragmatic
lymph nodes Mohammed Rheem MBBS,M.Sc

Superficial fascia of anterior abdominal wall
 Superficial fatty layer (Camper’s fascia)
 Deeper membranous layer (Scarpa’s fascia)

Clinical note: fluids leak deep to the
membranous layer.
Deep to Membranous layer is a potential
space where fluid may accumulate
(e.g., urine from a ruptured urethra).
Fluids cannot spread inferiorly into the
thigh because the membranous layer
fuses with the deep fascia of the thigh
(fascia lata).

Muscles of the anterior abdominal wall
The muscles of the anterior abdominal wall includes
 External Oblique Muscle
 Internal Oblique Muscle
 Transversus Abdominis Muscle
 Rectus Abdominis Muscle
 Pyramidalis Muscle

External Oblique Muscle
OriginOrigin
Fleshy digitations from
the lower 8 ribs

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

Direction of fibers
Downwards
Forwards
Medially

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

Internal Oblique Muscle
Origin
Insertion
1. Anterior 2/3 of the intermediate line of the iliac
crest
2. The lateral 2/3 of the inguinal ligament
3. Lumbar fascia
1. Lower 6 costal cartilages
2. Xiphoid process
3. Linea Alba
4. Pubic crest
5. Pectineal line

Internal Oblique Muscle
Direction of fibers
Upwards
Forwards
Medially
Nerve Supply
T7-T12
Iliohypogastric n.
Ilioinguinal n. Mohammed Rheem MBBS,M.Sc

Transversus Abdominis Muscle
Origin
1- Lower 6 costal cartilages
2- Lumbar Fascia
3- Ant. 2/3 of inner lip of iliac crest
4- Lat. 1/3 of inguinal ligament

Insertion
1- Xiphoid Process
2- Pubic Crest
and Pectineal
line
3- Linea Alba

Direction of fibers
Horizontally

Nerve Supply
T7-T12
Iliohypogastric n.
Ilioinguinal n.

Rectus Abdominis
Muscle
Origin
From the pubic crest
Pubic symphysis
Insertion
7th, 6th, 5th costal cartilages
Xiphoid process
Nerve Supply
Intercostal nerves (T7 -T11)
&
Subcostal nerve (T12)

Rectus Abdominis
Muscle
The muscle is divided intoThe muscle is divided into
segments by tendinoussegments by tendinous
intersections, Which indicate thatintersections, Which indicate that
the muscle arises from a number ofthe muscle arises from a number of
myotomes, fused togethermyotomes, fused together

Pyramidalis Muscle
It is a landmark of linea
alba intraoperative

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.
 Movements of the trunk
 Flexion of the trunk by rectus abdominis
 Lateral flexion by on sided contraction of 2 oblique
muscles
 Rotation of the trunk by a combined action of the external
oblique with the opposite internal oblique muscles.
 Act as accessory expiratory muscles.

Medially
Laterally
Rectus Sheath
Linea AlbaLinea Alba
Linea Semilunaris
Arcuate Line

Rectus Sheath
Falciform Ligament
External Oblique
Internal Oblique
Transversus AbdominisTransversus Abdominis
Ant. Layer of Rectus Sheath
Post. Layer of Rectus SheathPost. Layer of Rectus Sheath
Rectus Abdominis
Above Arcuate Line
SKINSKIN
PeritoneumPeritoneum
Transverslais FasciaTransverslais Fascia

Rectus Sheath
External Oblique
Internal Oblique
Transversus Abdominis
Ant. Layer of Rectus Sheath
Rectus Abdominis
Below Arcuate Line
Urachus in Median Umbilical Fold
Medial Umbilical Ligament
Transverslais Fascia
SKIN
Peritoneum

Contents of
Rectus Sheath
Function of
Rectus Sheath

Deep arteries of the anterior abdominal wall

Deep nerves of the anterior abdominal wall

Regions of the abdomen

Abdominal incision
 Median or midline incisions
 Paramedian incisions
 Oblique and transverse incisions
 Gridiron (muscle-splitting) incisions
 Suprapubic (Pfannenstiel) incisions
 Subcostal incisions

Surface anatomy of the anterior abdominal wall

Inguinal canal

Inguinal Canal
 It is an oblique passage
through the lower part of
the anterior abdominal wall
 Present in both sexes
 In male it permit the
passage of the spermatic cord
 In females it permits the
passage of the round ligament
of the uterus
 Transmits ilioinguinal
nerve in both sexes

Inguinal Canal
 It is about 1 ½ inches or 4cm long in the adults
 Extends from the deep inguinal
ring downward and medially
to the superficial inguinal ring
 Lies parallel to and immediately
above the inguinal ligament
 Function of the inguinal canal

Deep Inguinal Ring
 It is an oval opening in the fascia transversalis
 Lies about ½ inch (1.3cm) above the inguinal
ligament midway between the anterosuperior iliac
spine and the symphysis pubis

Superficial Inguinal Ring
 Is triangular in shape
 Lies in the aponeurosis of the external oblique muscle
 Lies immediately above and medial to the pubic tubercle

Walls of the inguinal canal
Anterior wall
Mainly by the external
oblique aponeurosis and reinforced
laterally internal oblique muscle
Posterior wall
Fascia transversalis and conjoint
tendon and reflected part of the
inguinal ligament
Roof
Arching fibers of the internal
oblique and transversus abdominis
Floor
Inguinal ligament and lacunar ligamentMohammed Rheem MBBS,M.Sc

Anterior wall of the inguinal canal

Posterior wall of the inguinal canal

Roof of the inguinal canal

Floor of the inguinal canal

The structures of the spermatic cord
 Constituents
 Duct deferens
 Arteries
 Veins
 Lymphatics
 Nerves
 Remnants of the processus vaginalis
 Covering (spermatic fasciae)
 Internal spermatic fascia
 Cremasteric fascia and cremasteric muscle
 External spermatic fascia

A Brief Mention of Hernias
Hernias are abnormal outpouchings of the
abdominal contents (such as the small
intestine(
from the cavity in which they belong.
There are two main types of hernias that
occur at the inguinal region. Direct hernia
and indirect hernia

Direct inguinal:
Occurs in older men (rarely women(.
Due to weakness in abdominal wall
behind or lateral to superficial inguinal ring.
Passes directly through abdominal wall to
superficial inguinal ring.
Does not extend into scrotum.
Has sac formed by peritoneum

HESSELBACH’S TRIANGLE
Hesselbach’s (Inguinal) Triangle is an
important structure as it is the site for
direct hernias. The triangle has the
following borders:
1)Medial border of rectus
abdominus(medially)
2)Inguinal ligament (inferiorly)
3)Inferior epigastric vessels(laterally)

Direct inguinal hernia

DIRECT INGUINAL HERNIA

Indirect inguinal hernia

Indirect inguinal:
An indirect hernia occurs when a hernial
sac enters the deep inguinal ring lateral to
the inferior epigastric artery and passes
indirectly to the superficial ring through
the inguinal canal.
Indirect hernias are the most common type of
hernia in both men and women
CAUSE: Persistence of all or part of the
embryonic processus vaginalis results in
various inguinal anomaliesMohammed Rheem MBBS,M.Sc

LARGE INDIRECT INGUINAL HERNIA

Thank you

anterior abdominal wall

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