Anterolateral Abdominal wall and Regions

Surface markings
Regions of abdominal wall

• 2 transverse & 2 vertical lines divide

abdominal wall into 9 regions, i.e.

 3 median unpaired region

 3 paired left & right regions

Alternative transverse
planes
Note location of
transpyloric plane – runs thru
pyloric sphincter

**List structures in this plane

Transumbilical
plane
 Abdominal wall

Superficial structures

they include:

 cutaneous nerves

 superficial veins
Cutaneous
nerves

 lateral & anterior

cutaneous
branches
of 8 – 12th
intercostal nn.

 cutaneous
branch of
iliohypogastric
nerve
 Superficial veins

• they anastomose freely

 thoracoepigastric vv.

 paraumbilical vv.

 superficial epigastric
vv.

 superficial circumflex
iliac vv
Paraumbilical veins & caput medusae

umbilicus is one of the significant sites of anastomosis

between portal & systemic venous systems

paraumbilical veins (portal) anastomose with veins of the

anterior abdominal wall (systemic)

paraumbilical veins:

 small veins accompanying round lig. Of the liver to the left

branch of portal vein

 drain blood from anterior abd. wall around umbilicus to the

left branch of portal vein
Paraumbilical veins & caput medusae

engorged veins are caused by increased hepatic portal

pressure (portal hyper- tension) due to portal obstruction

hypertension causes retrograde flow in paraumbilical veins to

the superficial abdominal cutaneous veins

retrograde flow leads to enlargement of these veins

 liver cirrhosis is one cause of portal obstruction

 it is due to massive fibrosis of liver tissue

Medusae…Greek god with serpents on head

Caput medusae in advanced liver cirrhosis
Layers of anterolateral abdominal wall:

• from without to within:

(i) Skin (ii) External fascia

(iii) Muscles (iv) Internal fascia

(v) Peritoneum
Layers of anterolateral abdominal wall
1. Skin:

•elastic & collagenous fibers within the dermis

are arranged in definite patterns

•pull of these fibers produces lines of tension

in the skin

•this, in turn, provides skin tone

Clinical
significance?

Langer’s lines
of cleavage
2. External fascia

• comprises:

 superficial fascia

 deep fascia

Superficial fascia:

has two components:

 fatty (superficial) layer (Camper’s fascia)

 membranous (deep) layer (Scarpa’s fascia)

Superficial fascia

(i) superficial layer (Camper’s fascia)

 favourite site for fat deposition -

hence also known as fatty layer

 becomes continuous with superficial

fascia of thigh
Deep layer (Scarpa’s fascia)

• attaches to, & fuses with:

 deep fascia of thigh (fascia lata) just below the inguinal

ligament (Holden’s line)

 thoraco-lumbar fascia

Scarpa’s fascia continues over the:

 pubis & perineum as Colle’s fascia

 penis as the superficial fascia of the penis

 scrotum as the tunica dartos
Membranous layer of superficial fascia (Scarpa’s fascia - green) continuing as
superficial fascia of the penis, tunica dartos on the scrotum, & Colle’s fascia on the
perineum.
NB: Fatty layer is absent in penis and scrotum
Special note:

• potential space exists between membranous layer &

deep fascia

 fluid, e.g., urine & blood may occupy potential space &
extend superiorly

 fluid due to ruptured urethra==extravasation of urine

(read more)

•what part of urethra would have ruptured?

• fluid does not extend into the thigh, why?

*
Deep fascia
• very thin
• invests & adheres to superficial abdominal muscles
Anterolateral Abdominal wall muscles:

• External oblique abdominal m.

• Internal oblique abdominal m.

• Transverse abdominal m.

• Rectus abdominis m

•**Pyramidalis m
Abdominal muscles – transverse section
(i) External oblique abdominal muscle:
most superficial
• originates as digitations from outer surfaces of lower 8 ribs
Origin of
external oblique
abdominal
muscle (red lines)
Origin & insertion
of external oblique abdominal
muscle

• fleshy
fibres generally
run from
superolateral to
inferomedial

• has free posterior

border

 i.e., most posterior

fibres run from 12th
rib to anterior half
of iliac crest
 Free border of
Ext.oblique

Trunk – posterior view

External oblique abdominal muscle (contn.)

• more oblique-running fibres become aponeurotic

towards midline

• here, it fuses with its counterpart at linea alba

• lower free margin coils on itself forming thick cord: cord

known as inguinal ligament

 latter extends between anterior superior iliac

supine/ASIS & pubic tubercle/crest

 aponeurosis contributes anterior layer of rectus sheath

External oblique abd. muscle: fleshy fibres = brown; aponeurosis = gray
ii) Internal oblique abdominal muscle
(

• fleshy muscle fibres generally fan out

towards midline

• origin:

 thoracolumbar fascia

 anterior 2/3 of iliac crest

 lateral 1/3 of inguinal ligament

 ii) Internal oblique
abdominal muscle

•fleshy muscle fibres

generally fan out
towards midline

• origin:

 thoracolumbar fascia

 anterior 2/3 of iliac

crest

 lateral 1/3 of inguinal

Origin of internal oblique abdominal muscle
ligament
 Origin & insertion
of internal oblique
abdominal muscle

1/3rd
Internal oblique abdominal
muscle (contn.)
•becomes aponeurotic a
few cms to midline

• attaches on linea alba

• most superior fleshy

fibres run superiorly to
attach to costal margin
 *

Internal oblique abdominal muscle (contn.)

• lowermost fibres join those of transverse abdominal muscle
 hence they form conjoint tendon aponeurosis forms part of anterior layer of
(iii) Transversus abdominis

• extensive origin:

 deep surface of costal margin

 thoracolumbar fascia

 anterior 2/3 of iliac crest

 lateral half of inguinal ligament

Origin (solid red line and dotted red line) of transversus abdominis muscle.
Transversus abdominis (contn.)

• fibres run predominantly transversely

(horizontally)

• become aponeurotic towards linea alba and

attaches to it

• lowest fibres contribute to formation of conjoint

tendon

• aponeurosis contributes to rectus sheath

(iv) Rectus abdominis:

• vertical, strap-like; on either side of linea alba

• broad superiorly; narrow inferiorly

• superiorly attaches to 5 – 7th costal cartilages

• inferiorly attaches to pubic crest & pubic symphysis

• 3 – 4 tendinous intersections run transversely across mm

• intersections adhere to anterior layer of rectus sheath

• (no adhesions to posterior layer)

Rectus abdominis
(on right side of
image). Note
tendinous
intersections.
Pyramidalis muscle

•small & inconstant; may be absent in 20% of

cases

•passes between aponeuroses of both

oblique abdominal mm.

 or in rectus sheath from pubic

symphysis to linea alba

• tenses linea alba; nerve = subcostal n

Note pyramidalis muscle & arcuate line.
Rectus sheath

• accommodates rectus abdominis m.

• anterior & posterior layer of sheath recognized

• sheath formed by fusion of aponeuroses of the 3 lateral

abdominal muscles

arrangement may be divided into 3/4 parts:

(find out if arrangement of sheath is of any clinical significance)
 superior third

 middle third

 inferior third
Superior third:

 anterior layer is formed by aponeurosis of external

oblique

 posterior layer is deficient, hence rectus abdominis

muscle lies directly on the costal cartilages==no sheath

Middle third:

 starts below costal margin

 internal oblique splits so that 1 lamina joins anterior layer

& 1 lamina joins posterior layer
 Rectus Sheath
middle third.

 anterior layer formed by aponeurosis of

external oblique & anterior lamina of the internal
oblique

 posterior layer formed by posterior lamina

of internal oblique & aponeurosis of
Transverse section through central part of abdominal wall.
Aponeurosis of internal oblique muscle splits to form anterior and
posterior layers of rectus sheath.
Aponeurosis of external oblique muscle joins anterior layer of
sheath; aponeurosis of transversus abdominis muscle joins posterior
layer.
 Anterior and posterior layers of rectus sheath unite medially to form
Rectus sheath (contn.)

• inferior third:

 midway between umbilicus & pubic symphysis,

posterior layer of the sheath ends abruptly

abrupt ending of posterior layer forms

an arched border; the arcuate line*

remaining part of transversus abdominis

aponeurosis now passes in front of rectus
abdominis
Rectus sheath –
external & internal
oblique muscles
have been cut.

Note that the upper two

thirds of transverse
abdominis aponeurosis
passes behind rectus
abdominis, forming
posterior layer of the
rectus sheath.

In the lower third, this

aponurosis passes entirely
in front of rectus
abdominis, contributing to
the anterior layer of the
rectus sheath.
Lower anterior abdominal wall – posterior view: note arcuate line. On the right,
fascia transversa is intact, but has been removed on the left.
 *

Anterior abdominal
wall – posterior view.
Rectus sheath (contn.)

• inferior to arcuate line, all 3

aponeuroses form anterior layer

• hence inferior 1/3 of posterior

layer is deficient

• only fascia transversalis is left

Abdominal wall – anterior view. Note contribution of
transversus abdominis aponeurosis to the rectus sheath
above & below the arcuate line. Part of rectus abdominis
muscle has been removed.
 KENHUB-RECTUS SHEATH
Multilayered aponeurosis that encloses the rectus abdominis and pyramidalis muscles
Definition

Walls of upper three-quarters Anterior wall:

- Aponeurosis of external abdominal oblique muscle
- Aponeurosis of internal abdominal oblique muscle
Posterior wall:
- Aponeurosis of internal abdominal oblique muscle
- Aponeurosis of transversus abdominis muscle

Walls of lower quarter Anterior wall:

- Aponeurosis of external abdominal oblique muscle
- Aponeurosis of internal abdominal oblique muscle
- Aponeurosis of transversus abdominis muscle
Posterior wall:
- Absent

Function Protection of anterior abdominal muscles and vessels.

Provides maximal compression and support of abdominal organs.

Clinical relations Spigelian hernia, rectus sheath hematoma

 Cunningham
In the upper 3/4th Internal oblique splits into 2.

The anterior part goes in front of the rectus and fuses with
the aponeurosis of external oblique. This part contributes
to the formation of the anterior wall of the rectus sheath.

The posterior part goes behind the rectus and fuses with
the aponeurosis of transversus abdominis. This part
contributes to the formation of the posterior wall of the
rectus sheath.

In the lower 1/4th of the abdomen, the internal oblique

aponeurosis passes in front of the rectus abdominis,
contributing only to the anterior wall.
Actions of abdominal mm.

• abdominal muscles may be involved in following actions:

 act on contents of abdominopelvic cavity

 may be involved in forced expiration

 may carry out movements of the trunk

• maintain tone which determines tension of abdominal wall

• tone adjusted reflexly to changing external & internal

influences, e.g.,
 body position
 filling of gut, etc.
• abdominal press:

 in conjunction with diaphragm,

abdominal mm. contribute to
abdominal press
= raising intra-abdominal pressure

 used in evacuation of rectum

 emptying of urinary bladder

 expulsion of fetus at birth

 sneezing & coughing, etc.

**** (how is abdominal press effected?)

Abdominal press
Actions of abdominal mm. (contn.)

• abdominal mm. can cause forward flexing of trunk,

especially recti muscles

• lateral abdominal mm. produce rotation & lateral flexion

of trunk to side of
contracting muscles
Nerves of abdominal mm.

• innervated by:
 lower 5 intercostal nn. (thoraco-
abdominal nerves)

 subcostal nerve

 iliohypogastric & ilioinguinal nerves

(branches of lumbar plexus)
•nerves & blood vessels run together between:
 internal oblique abdominal m. And
 transversus abdominis m.
 hence known as neurovascular plane
Internal abdominal fascia

• called fascia transversalis

• thin layer of connective tissue; lines inner

surface of abdominal mm.

• peritoneum lies deeper to it

• firmly connected to subserous connective

tissue of peritoneum
Transverse section through abdominal wall. Note fascia
transversalis.
Linea alba (white line)

• strong tendinous raphe, formed when:

 tendinous fibres of 3 lateral abdominal muscles
interlace in midline
 tendinous fibres unite with fibres of opposite side
• hence also acts as point of insertion for the mm
 extends from xiphoid process to pubic sympysis

•midline incision made thru linea alba

• linea alba consists of fibrous tissue only - hence
incision should be almost bloodless
 • Clinicals
•a surgeon has to compromise between :

 requiring maximum access &

 causing minimal damage to abdominal muscles & their
nerve supply

 nerves and blood vessels of lateral abdominal mm. form a

rich communicating network
- hence severing 1 or 2 unlikely to cause clinical ill-effects

NB: nerves to rectus m. have little cross- communication

- hence, damage to these nerves should be avoided as
much as possible
xx Different types of surgical incisions thru
the abdominal wall

END