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Abdominal Wall Learning Objectives

1. List the 3 muscle layers of the anterolateral abdominal wall order from
superficial to deep. What is the orientation of their fibers? What is the
innervation of these muscle layers?
Superficial
o External oblique
Fibers run inferomedially (pocket muscles)
Middle
o Internal oblique
Fibers run inferolaterally
o Rectus abdominis
Deep to internal oblique
Fibers run vertically
Deep
o Transverse abdominal
Fibers run horizontally
Innervation
o Ventral rami of T7-T12
2. How does each layer of the anterior abdominal wall contribute to the
formation of the rectus sheath above the level of the umbilicus?
Anterior rectus sheath
o External oblique aponeurosis + Anterior lamina of internal oblique
aponeurosis
Posterior rectus sheath
o Posterior lamina of internal oblique aponeurosis + Transverse
abdominal aponeurosis + Transversalis fascia
3. What is the arcuate line? What forms the posterior aspect of the rectus
sheath below this line?
Arcuate line
o Demarcates the transition between the posterior rectus sheath
covering the superior of rectus abdominis and the transversalis
fasica covering the inferior
Below the arcuate line
o Anterior rectus sheath
External oblique aponeurosis + internal oblique aponeurosis +
Transverse abdominal aponeurosis
o Posterior rectus sheath
Only the transversalis fascia
4. Where does the inferior epigastric artery arise?
Inferior epigastric artery
o Arises from the external iliac artery
o Runs superiorly and enters the rectus sheath
5. Where does the inferior epigastric artery run within the rectus sheath?
Deep to the rectus abdominis within the sheath, superficial to transverse
abdominal in the area of the sheath
6. With what vessel does the inferior epigastric artery anastomose?

The inferior epigastric a. anastomoses with the superior epigastric artery


(from the internal thoracic a.)

7. Why is compression of the abdominal contents functionally important?


Compression of the abdominal contents serves to maintain or increase intraabdominal pressure
o Compression of abdominal viscera elevates the relaxed diaphragm to
expel air during respiration
Coughing, burping, yelling, etc.
o Aids in expiration
Acts as an antagonist to the diaphragm to produce expiration
(forced expiration)
8. Why is the anatomy of the inguinal region/canal clinically important?
Clinical significance of inguinal canal
o The inguinal area extends between the anterior inferior iliac spine and
the pubic tubercle
Serves as a region where structures enter and exit the
abdominal cavity
o Common site for herniation
9. What forms the inguinal ligament? How? To which bony structures does
the inguinal ligament attach?
Inguinal ligament
o Inferior-most part of the external oblique aponeurosis
Splits into the lateral and medial crura
form the lateral and medial margins of the superficial
inguinal ring
Held together by intercrural fibers
o Forms the wall and roof of the inguinal canal
Bony attachments
o Extends from the ASIS to the pubic tubercle
10. A deficiency in each of the three layers on the anterolateral abdominal
wall, in the region of the inguinal ligament, forms what specific passage?
Inguinal canal
o Formed in relation to the descent of the gonads during fetal
development
o Origin deep inguinal ring
o Exit superficial ring
o Contents
Males spermatic chord
Females round ligament of uterus
Ilioinguinal Nerve
11. In which layers are the superficial and deep inguinal rings formed?
Deep inguinal ring invagination of the transversalis fascia
o Lateral to the inferior epigastric vessels
o Entrance into inguinal canal
Superficial inguinal ring opening between medial and lateral crura of the
inguinal ligament

o Superolateral to the pubic tubercle


Superficial and deep inguinal rings do not overlap
o Oblique pathway of inguinal canal connects the two
12. What structures form the floor and posterior wall of the inguinal
canal? In the adult male, what structure is found within the inguinal canal?
In the adult female, what structure is found within the inguinal canal?
Floor of inguinal canal
o Lateral iliopubic tract
Thickened inferior edge of transversalis fascia
o Central superior surface of inguinal ligament
o Medial lacunar ligament
Hammock ligament that cradles the spermatic cord
Connects from pectineal ligament to inguinal canal
Posterior wall
o Primarily made from the transversalis fascia
Reinforced by the conjoint tendon on the medial side attaches
to pectineal ligament
Major contents
o Males spermatic cord
o Females round ligament of uterus
o Ilioinguinal n.
13. Which layer(s) of the anterior abdominal wall contribute to the sheaths
of the spermatic cord?
Contributions from every layer except transversus abdominis
14. What does each participating layer of the anterior abdominal wall
contribute to the spermatic cord?
Transversalis fascia internal spermatic fascia
Internal oblique m. cremaster fascia and muscle
External oblique m. external spermatic fascia
15. Which layer of the anterior abdominal wall does not contribute to the
spermatic cord? What are the main components found within the
spermatic cord?
Transversus abdominis does NOT contribute to spermatic chord
Main components of spermatic chord
o *Shit for another test*
16. What typically extends from the body cavity in a hernia?
Protrusion of deep abdominal fascia and sometimes intestines
17. What is the clinical implication of an inguinal hernia?
Inguinal hernia
o Common site for hernias because it is weakened by the passage of
vessels
o The loop of the bowel may become trapped in the inguinal canal,
squeezed by intra-abdominal pressure on the canal walls and cause
ischemia
Gangrene can ensue
18. How does an acquired inguinal hernia differ from the congenital type?
Acquired Inguinal Hernia Direct Hernia

Travels directly out of the abdominal wall through a defect that


develops in the conjoint tendon and out through the superficial
inguinal ring
o Does NOT enter spermatic chord or inguinal canal
o Occurs medial to the inferior epigastric vessels though Hasselbecks
triangle
Congenital Inguinal Hernia Indirect Hernia
o Takes an indirect route out of the abdominal wall
o Travels through the inguinal canal and enters spermatic cord
Can protrude down into scrotum/labia majorum
o Occurs lateral to inferior epigastric vessels
o More common than a direct hernia
Way more common in males
o

19. Through what component of the inguinal canal does the hernia
protrude?
Indirect hernia
o Deep and superficial inguinal ring (within cord)
Direct hernia
o Superficial inguinal ring only
20. Where is the location of the deep inguinal ring with relation to the
inferior epigastric artery? Where is the inferior epigastric artery going?
Deep inguinal ring
o Lateral to inferior epigastric a.
Inferior epigastric a.
o Arises from external iliac a. just superior to the inguinal ligament
travels superiorly through the transversalis fascia to enter the rectus
sheath inferior to the arcuate line
Branches enter rectus abdominis and anastamose with superior
epigastric a.
21. Which type of inguinal hernia is most common in older men? Are
inguinal hernias more common in men or women?
Older men
o Direct (acquired) hernias are most common
o Inguinal hernias are much more common in men than women
22. Describe the attachments, actions, innervation, and blood supply of
each abdominal muscle
External Oblique m.
o Origin external surface of ribs 5-12
o Insertion Linea alba + pubic tubercle + Anterior half of iliac crest
o Action compress abdomen + flex and rotate trunk + active in forced
expiration
o Innervation Ventral rami of T7-T12
Internal Oblique m.
o Origin lateral 2/3 of inguinal ligament + iliac crest + thoracolumbar
fascia

Insertion lower margins of 9th-12th ribs + pubic crest + linea alba


Action compress abdomen + flex and rotate trunk + active in forced
expiration
o Innervation Ventral rami of T7-12 + iliohypogastric n. (L1) +
Ilioinguinal n. (L1)
Transverse Abdominal
o Origin lateral 1/3 of inguinal ligament + iliac crest + thoracolumbar
fascia + costal cartilages 7-12
o Insertion Linea alba + pubic crest + pectin pubis
o Action compress abdomen + depresses ribs
o Innervation Ventral rami of T7-12 + iliohypogastric n. (L1) +
Ilioinguinal n. (L1)
Rectus Abdominis
o Origin Pubic crest + pubic symphysis
o Insertion Xiphoid process + costal cartilages 5-7
o Action Depresses ribs + flexes trunk
o Innervation Ventral rami of T7-12 + subcostal n. (T12)
Blood Supply
o Arteries
Internal thoracic a. musculophrenic a. + superior epigastric a.
External iliac a. inferior epigastric a. + deep circumflex iliac a.
+ superior epigastric a.
o
o

Veins
Follow retrograde course same names as arteries
Paraumbilical vv. potential portal system anastomosis
o Caput medusa = bulging of superficial venous
network
23. Diagram the layers of the anterior abdominal wall and their
contributions to the inguinal region
o

PP Parietal peritoneum

TF transversalis fascia
o Deep inguinal ring
TA Transverse abdominal
o Conjoint tendon
IO internal oblique
o Conjoint tendon
EO external oblique
o Superficial inguinal ring
24. Determine between what two layers the neurovascular structures
travel along the anterolateral abdominal wall
Nerves
o Thoracoabdominal (T7-T11) between 2nd and 3rd layers of abdominal
muscles (between internal abdominal m. and transverse abdominal m.)
o Subcostal n. (T12) pierces transverse abdominal m. and follows
same path as IC nerves
o Iliohypogastric n.(L1) runs between Internal oblique (pierces at distal
end) and transverse abdominal m.
o Ilioinguinal n. (L1) runs between Internal oblique and transverse
abdominal m.
Vasculature
o Musculophrenic a. pierces transverse abdominal m. anterior to
posterior
o Superior epigastric a. runs mostly behind Transverse abdominal m.
o Inferior epigastric a. runs mostly behind Transverse abdominal m.
o 10th and 11th posterior IC aa. runs between IO and TA
o Subcostal inferior epigastric a. enters rectus sheath and runs deep
to rectus abdominis
o Deep circumflex iliac a. deep to TA
o Superficial epigastric a. superficial to EA
25. Diagram the contributions of the layers of anterior abdominal wall to
the rectus sheath above and below the arcuate line
Above arcuate line
o Anterior rectus sheath
External oblique aponeurosis + Anterior lamina of internal
oblique aponeurosis
o Posterior rectus sheath
Posterior lamina of internal oblique aponeurosis + Transverse
abdominal aponeurosis + Transversalis fascia
Below arcuate line
o Below the arcuate line
Anterior rectus sheath
External oblique aponeurosis + internal oblique
aponeurosis + Transverse abdominal aponeurosis
Posterior rectus sheath
Only the transversalis fascia
26. Outline the path of lymphatic drainage for the abdominal wall.
Above umbilicus axillary nodes

Below umbilicus Superficial inguinal nodes