Clinical Anatomy of the Anterior Abdominal Wall in its Relation to Hernia

Handout download: http://www.oucom.ohiou.edu/dbms-witmer/gs-rpac.htm

26 April 2011

Lawrence M. Witmer, PhD Professor of Anatomy Department of Biomedical Sciences College of Osteopathic Medicine Ohio University, Athens witmerL@ohio.edu

Anatomical Overview
External oblique Internal oblique Transversus abdominis Rectus abdominis

fleshy portion

rectus sheath

aponeurotic portion

inguinal ligament

tendinous intersections

Three flat abdominals: attach to trunk skeleton, inguinal lig., linea alba, etc.; fleshy laterally and aponeurotic medially, forming rectus sheath medially Two vertical abdominals: rectus abdominis and pyramidalis (not shown)
Moore et al. 2010

Anatomical Overview
intramuscular exchange of contralateral external oblique fibers intermuscular exchange of contralateral external & internal oblique

right external oblique left internal oblique

continuity of external oblique fibers across midline blending of superficial & deep fibers on opposite side

continuity of fibers across midline digastric muscle with central tendon torsion of trunk

Moore et al. 2010

Anatomical Overview
linea alba rectus abdominis rectus sheath

transv. abd. int. obl. ext. obl.

semilunar line transversalis fascia

peritoneum

tendinous intersections

aponeuroses of abdominal mm.

fasciae: Scarpas, Campers
Moore et al. 2010

Anatomical Overview
anterior lamina of rectus sheath inferior epigastric vessels internal oblique

semilunar line (of Spiegel)

posterior lamina of rectus sheath (aponeurotic)

arcuate line (semicircular) line of Douglas) posterior lamina of rectus sheath (transversalis fascia)
Moore et al. 2010

iliohypogastric n.
ilioinguinal n.

Anatomical Overview
Anterior Abdominal Hernias
rectus sheath linea alba

umbilicus

semilunar line superficial inguinal ring femoral canal

hernia.tripod.com/types.html Moore et al. 2010

Epigastric (Ventral) Hernia

thachers.org/images/epigastric_hernia.jpg thachers.org/images/hernia_repair.jpg

linea alba

scar

repaired hernia hernial sac

health.enotes.com/images/ medicine/gem_03_img0340.jpg

rectus abdominis

anterior rectus sheath posterior rectus sheath peritoneum

Skandalakis Surgical Anatomy 2004

hernial sac

Umbilical (Para-umbilical) Hernia

Congenital Umbilical Hernia Acquired Umbilical Hernia
occur after closure of umbilical ring 2 to obesity, pregnancy, cirrhosis, ascites, masses
medicine.ucsd.edu/clinicalimg/ abdomen-umbo-hernia4.jpg

incomplete closure of umbilical ring

Omphalocele 2 to ascites

1988 Moore Developing Human 4th edition

Skandalakis Surgical Anatomy 2004

Spigelian (Lateral Ventral) Hernia

CT semilunar line
rectus sheath: posterior & anterior lamina

arcuate line
frequent hernial site

www.e-radiography.net/ibase5/Abdomen/ slides/Abdomen_spigelian_hernia_ct.jpg

Skandalakis Surgical Anatomy 2004

rectus abdominis

transversalis fascia

Moore et al. 2010

Case Presentation
A 3-year-old boy presents with a walnut-sized bulge in his left groin, particularly when he stands, strains, or cries. With the patient horizontal, the lump disappears. When the skin of the scrotum is invaginated by a little finger, a definite impact is felt on coughing. The diagnosis of hernia is made. How would this hernia be best characterized?

at rest

upon straining

reducible, congenital, indirect inguinal hernia

pediatriconcall.com/forpatients/commonchild/images/inguinal_hernia.jpg

Embryological Basis of Indirect Inguinal hernia

Week 7
testis in abdomen

Moore et al. 2010

Embryological Basis of Indirect Inguinal hernia

Week 28
testis descends

patent processus vaginalis

Moore et al. 2010

Embryological Basis of Indirect Inguinal hernia

Week 36
testis in scrotum

processus vaginalis closed

Moore et al. 2010

Embryological Basis of Indirect Inguinal hernia

transversalis fascia & peritoneum abdominal muscles hernial sac within spermatic cord

partially obliterated processus vaginalis

vas deferens
pampiniform plexus epididymis testis
Cahill 1997

tunica vaginalis

Inguinal Anatomy
ASIS external oblique aponeurosis & Gallaudets fascia
intercrurual fibers medial crus

superficial circumflex iliac vessels

superficial epigastric vessels great saphenous v.

lateral crus & inguinal lig.

ilioinguinal n. (L1)

external pudendal spermatic cord vessels

superficial (external) inguinal ring

Moore et al. 2010

Inguinal Anatomy
inguinal lig. (of Poupart)
internal inguinal ring

myopectineal orifice of Fruchaud

reflected inguinal lig.

femoral n. external iliac vessels

femoral canal

pectineus

pectineal lig. (of Cooper)

lacunar lig. (of Gimbernat)

Moore et al. 2010

Inguinal Anatomy
testicular vessels
P TF TA IO EO

vas deferens
internal ring Space of Bogros

external ilioinguinal n. conjoint tendon ring Moore et al. 2010

Inguinal Anatomy

shelving edge of ing. lig.

Moore et al. 2010

Inguinal Anatomy

iliopubic tract

shelving edge of inguinal ligament

Skandalakis Surgical Anatomy 2004

parasagittal section through right side

lateral umbilical fold

arcuate line

inferior epigastric vessels

iliopubic tract iliopsoas external iliac vessels

iliopubic tract

Hesselbachs Triangle
posterior view of anterior abdominal wall

testicular vessels deep ing. ring

femoral canal vas deferens
Moore et al. 2010

Hesselbachs (Inguinal) Triangle

posterior view of anterior abdominal wall

internal inguinal ring

indirect inguinal hernia

direct inguinal hernia

Moore et al. 2010

Femoral Hernia
femoral canal

lacunar lig. (of Gimbernat)

Skandalakis Surgical Anatomy 2004

References
Cahill, D. R. 1997. Lachmans Case Studies in Anatomy, 4th Ed. Oxford University Press, New York. Moore, K. L., A. F. Dalley, and A M. R. Agur. 2010. Clinically Oriented Anatomy, 6th Ed. Lippincott, Williams & Wilkins, Baltimore. Moore, K. L. and T. V. N. Persaud. 2003. The Developing Human. Clinically Oriented Embryology, 7th Ed. Lippincott, Williams & Wilkins, Baltimore. Skandalakis, J. E., G. L. Colborn, T. A. Weidman, R. S. Foster, A. N. Kingsnorth, L. J. Skandalakis, N. P. Skandalakis, P. Mirilas (Editors). 2004. Surgical Anatomy: The Embryologic And Anatomic Basis Of Modern Surgery. McGraw-Hill, New York.