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ANATOMY

4.01 ABDOMEN IN GENERAL


Dr. Idelfa Saputil-Elevazo, MD. | January 6, 2017
LE 4
OUTLINE a.Name the musculature of the posterior
abdominal wall
I. Anterior Abdominal Wall 4. Peritoneum
A. Bony Framework of the Abdomen a. Describe the peritoneum and its disposition
B. Surface Landmarks: Abdomen b. Define the peritoneal cavity and spaces/fossae
C. Abdominal Cavity c. Name the peritoneal derivatives
D. Four Quadrants Scheme
E. Nine Regions Scheme Legend:
F. Anterolateral Abdominal Wall Remember Previous
G. Anterior Abdominal Wall Muscles Lecturer Book Trans Com
(Exams) Trans
H. Rectus Sheath
I. Arterial Supply G ! & 4 !
J. Venous Drainage
K. Nerve Supply
L. Lymphatic Drainage I. ANTERIOR ABDOMINAL WALL
M. Internal Surface
N. Internal Aspect A. Bony Framework of the Abdomen
O. Abdominal Incisions
II. Inguinal Region
A. Inguinal Region
B. Important Structures
C. Openings
D. Boundaries
E. Development
F. Inguinal Triangle
G. Layers of the Inguinal Region
H. Types of Hernias
III. Posterior Abdominal Wall
A. Contents
B. Muscles
C. Arteries
D. Veins
E. Lymph Vessels and Lymph Nodes
IV. Peritoneum
A. Peritoneal Cavity Figure 1. Bony Framework of Abdomen
B. Peritoneal Ligament
C. Peritoneal Fold Xiphoid process corresponds at the level of T11 or
D. Peritoneal Recess/Fossa T12
E. Gutter Costal margin or costal arch formed by the fusion
F. Pathologies or union of costal cartilages 7-10 ribs
5 Lumbar vertebrae and the disc in between the right
OBJECTIVES: and left pelvis
At the end of the lecture, the student should be able to: o In between posteriorly, are the sacrum and
1. Anterior abdominal wall coccyx
a. Identify anatomical landmarks o Bony pelvis is attached or joined together
b. Describe quadrants and regions of the anteriorly by the pubic symphysis
abdomen and the clinical applications
c. Define extent of layers and musculature from
superficial (outside) to deep (inside)
d. Describe formation and contents of rectus
sheath
e. Describe the vasculature, lymphatic drainage,
and innervations
2. Inguinal Region
a. Name the layers of musculature and other
pertinent structures
b. Describe the extent and boundaries of the
inguinal canal
c. Define the superficial and deep inguinal rings
d. Differentiate the types of inguinal hernia
e. Describe other forms of hernia in the abdomen
3. Posterior Abdominal Wall

TRANSCRIBERS Quero, Raymundo, Regala, Reyes, EDITOR Crisostomo, So 1 of 22


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4.01 ABDOMEN IN GENERAL ANATOMY 2020C

B. Surface Landmarks: Abdomen

Figure 3. Pelvis

The pelvis is divided into lesser/minor or


greater/major pelvis
o Below the pelvic brim is the
true/lesser/minor pelvis
o Above the brim, which forms part of the
abdominal cavity, is the false/greater/major
pelvis (houses lower parts of GI tract)
Figure 2. Surface Landmarks of the Abdomen

Area of xiphisternal joint


Joint formed by the body of the sternum and
xiphoid process
Xiphoid process
Area of costal margin
Lateral margin of the rectus abdominis muscle,
forming the semilunar line
Iliac crest lies at the level of L4
o Highest point between anterior-superior
and posterior-superior iliac spines
Iliac tubercle 5cm posterior to the ASIS
Area of inguinal canal located just above the
inguinal ligament, which extends from the iliac crest
up to the area of the pubic tubercle
Linea alba groove at the midline; seen in lean
individuals or well-developed abdominal muscles
In the midline is the umbilicus, a scar that used to
serve as the entrance/exit of umbilical vessels to and
from the placenta to the fetus Figure 4. Abdominal Cavity

C. Abdominal Cavity D. Four Quadrants Scheme

Part of the Abdominopelvic cavity, which ranges from Abdomen divided into 4 quadrants - done by drawing
the diaphragm to pelvic floor 2 imaginary lines:
The abdominal cavity is separated from the pelvic o Median plane or median line separates the
cavity by the pelvic brim, which is composed of: body into right and left halves
Anterior margin of sacral o Transumbilical plane or line divides the
promontory
body into upper and lower halves
Arcuate line
Pecten pubis (pectineal line) These 2 planes or lines bisect each other at the
Pubic crest umbilicus
Pubic symphysis End result: right upper quadrant (RUQ), left upper
quadrant (LUQ), right lower quadrant (RLQ) and
left lower quadrant (LLQ)

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4.01 ABDOMEN IN GENERAL ANATOMY 2020C

E. Nine Regions Scheme


Dividing the abdomen into 9 regions via midclavicular
lines and the transpyloric and transtubercular planes

Figure 5. Abdominal Quadrants

4 quadrants are helpful for:


Knowing the location of the organs
Possible cause/source of abdominal pain

Table 1. Quadrants of the Abdomen


Right Upper Quadrant Left Upper Quadrant (LUQ)
(RUQ)
Liver: right lobe Liver: left lobe
Gallbladder Spleen Figure 6. Nine Abdominal Regions
Stomach: pylorus Stomach
Duodenum: parts 1-3 Jejunum and proximal ileum Transpyloric Plane
Pancreas: head Pancreas: body and tail th
Passes through tips of 9 costal cartilage
Right suprarenal gland Left kidney Clinically important as a landmark for:
Right kidney Left suprarenal gland 1. Pylorus of stomach
Right colic (hepatic flexure Left colic (splenic) flexure 2. Fundus of the gallbladder right side where the
Ascending colon: superior Transverse colon: left half
semilunar line bisect the transpyloric plane
part Descending colon: superior
Transverse colon: right half part 3. Root of the transverse mesocolon
4. Duodenojejunal junction
Right Lower Quadrant Left Lower Quadrant (LLQ) 5. Neck of the pancreas
(RLQ) 6. Hila of the kidneys
Cecum Sigmoid colon 7. Origin of the superior mesenteric artery
Vermiform appendix Descending colon: inferior 8. Origin of portal vein
Most of ileum part
Ascending colon: inferior part Left ovary
Right ovary Left uterine tube
Right uterine tube Left ureter: abdominal part
Right ureter: abdominal part Left spermatic cord:
Right spermatic cord: abdominal part
abdominal part Uterus (if enlarged
Uterus (if enlarged) Urinary bladder (if very full)
Urinary bladder (if very full)

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4.01 ABDOMEN IN GENERAL ANATOMY 2020C

Note: (See Netter Plate 244 for a more detailed partitioning) Derivative of the deep fascia of the
anterior abdominal wall
To divide the abdomen into nine regions, variations in the o Also attached to the fascia lata of the thigh,
pairing with the transverse and horizontal lines are made to such that there is a potential space between
delineate the boundaries the deep fascia and scarpas fascia
R and L Midclavicular lines paired with If there is a penile fracture and
Transpyloric plane and
there is a break in the Bucks
Transtubercular/Intertubercular plane
o Transtubercular/Interubercular plane fascia expect blood and urine to
passes through the iliac tubercles collect in the scrotum and in the
Alternatively, R and L Lateral Rectus Plane area of the lower abdominal wall.
(semilunar line) paired with Subcostal and Blood and urine cannot collect at
Interspinous planes the area of the lower limbs because
o Subcostal plane: Line passing through the scarpas fascia and deep fascia
th
the lower margin of the 10 rib attach to the fascia lata of the thigh
o Interspinous plane: Line passing through If the fundiform ligament is cut, the
the ASIS suspensory ligament of the penis
will be exposed
F. Anterolateral Abdominal Wall Derivative of deep fascia
Extends from the thoracic cage to the pelvis and and suspends the penis to
th th
bounded superiorly by the 7 to 10 costal the symphysis pubis and
cartilages and xiphoid process; inferiorly by the the arcuate ligament of the
inguinal ligament and the pubic bones pubic bone
Transversalis fascia (of endoabdominal fascia)
Layers (See Moore Figures 2.4 to 2.6) o Endothoracic fascia continuous with
Skin endoabdominal fascia
Superficial fascia o Transversalis fascia covers the transversus
o Campers (superficial fatty layer) abdominis muscle
Extends all the way up to the area
Extra/pre-peritoneal fat
of the thorax and down to the area
Parietal peritoneum
of the lower limbs
o Innermost layer
In the area of the perineum (area
between anus and scrotum/vulva), it Panniculi protuberance of the abdomen
forms the superficial perineal 5 common causes (5Fs): Fat, Feces, Fetus, Flatus,
fascia and Fluid
At the area of the scrotum, it forms
the Dartos muscle and fascia G. Anterolateral Abdominal Wall Muscles
Area of the ischiorectal fossa, it
forms the ischiorectal fat 3 Flat Muscles (strong sheet like aponeuroses)
o Scarpas (deep membranous layer) 1. External Oblique
o Becomes the Colles fascia at the area o From the external surfaces of ribs 5 to 12
of the urogenital triangle o Direction of muscle fibers: inferomedially
o Extends one finger-breath under the o Ends in an aponeurosis that attaches to
inguinal ligament to attach to the fascia the linea alba, pubic tubercle, and iliac
lata crest (cannot attach to the inguinal
o Fundiform Ligament derivative of ligament because the inguinal ligament is
Scarpas fascia; suspends the penis formed from the thickening of the
dorsally from its dorsum and from its lowermost fibers of the aponeurosis of the
side external oblique)
Investing (deep) fascia o Inguinal ligament extends from the ASIS
o Very thin and very difficult to separate from up to the area of the pubic tubercle
the fascia that individually encloses the 2. Internal Oblique
anterolateral abdominal muscles o Comes from the thoraco-lumbar fascia
o Becomes the Bucks fascia at the area of (deep back), iliac crest, inguinal
the penis ligament

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4.01 ABDOMEN IN GENERAL ANATOMY 2020C

o Muscle fibers: go towards ribs 10-12, The pyramidalis keeps the linea alba taut during the
aponeurosis attach to the linea alba to process flexion and rotation of the trunk
the pectin pubis through conjoint All muscles EXCEPT the pyramidalis muscle
tendon (formed by the lowermost fibers compress and support the viscera
of the internal oblique and transverse
abdominis muscle before they insert to Example: Valsalva maneuver compressing the abdominal
the pubic crest) viscera that happens during vaginal delivery, defecation, and
o Direction: urination
Fibers arising above the iliac
crest are directed
superomedially
Fibers arising below the iliac
crest are directed transversely
3. Transversus Abdominis
o Arises from the internal surfaces of ribs
7-12, thoracolumbar fascia, iliac crest,
and inguinal ligament
o Inserts to the linea alba, pubic crest, and
pubic tubercle/pectin pubis via conjoint
tendon
o As they insert the linea alba, they form
the rectus sheath (within are the rectus
abdominis muscle and pyramidalis

2 Vertical Muscles Figure 7. Functions of Anterior Abdominal Wall Muscles


1. Rectus Abdominis
o Extends from the symphysis pubis and Linea Alba a fibrous band formed by the
the pubic crest up to the area of the aponeuroses, in entire abdominal length; transmits
xiphoid process (up to ribs 5-7) vessels and nerves
o On the anterior surface of the upper half Rectus Sheath formed by the insertion of the
of the muscle are the tendinous oblique muscles and the transversus abdominis
intersections (attaches the rectus muscles to the linea alba; strong and incomplete
abdominis muscle to the anterior rectus fibrous compartment
sheath). This is very prominent in lean o Encloses the rectus abdominis and
or muscular individuals (i.e. 6-pack abs) pyramidalis muscles
o Note: o Formed by the aponeuroses of 3 flat
Semilunar line corresponds to abdominal muscles
the lateral margin of the rectus
abdominis muscle
Arcuate line lower end of the
aponeurosis that forms the posterior
rectus sheath
2. Pyramidalis
o Keeps the linea alba taut

Very important among surgeons since pyramidalis muscle will


serve as a landmark that the abdominal wall has been cut
symmetrically in the midline

Functions of the anterolateral abdominal muscles


The oblique muscles laterally flex and rotate the
trunk
The rectus abdominis flexes the trunk and stabilizes
the pelvis

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4.01 ABDOMEN IN GENERAL ANATOMY 2020C

H. Rectus Sheath I. Arteries of the Anterior Abdominal Wall


(See Appendix)
Formation of the Rectus Sheath
1. Medial Part:
Blood supply comes from the anastomosis of
superior and inferior epigastric arteries
o They anastomose shortly above arcuate
line.
From above: Subclavian a. internal thoracic
musculophrenic and superior epigastric as
From below: Aortic bifurcation common iliac
external iliac inferior epigastric
2. Lateral Part:
External iliac a. deep circumflex iliac
anastomose with lower intercostal, subcostal and
lumbar as
Femoral a. superficial circumflex iliac and
superficial epigastric a.
3. Groin and Inguinal regions
Figure 8. Formation of the Rectus Sheath
Branches of femoral a.
i. superior external pudendal
Table 2. Rectus Sheath Structures ii. deep external pudendal
Anterior Wall Posterior Wall iii. superficial epigastric a.
st
1 Part iv. superficial circumflex iliac
External oblique Thoracic Wall
th th th
(Above the aponeurosis 5 , 6 , & 7 costal
costal J. Veins of the Anterior Abdominal Wall
cartilages
margin) (See Appendix)
nd
2 Part External oblique Posterior Internal
(Costal aponeurosis Oblique Deep Veins
margin to Anterior Internal Transverse o Will just be following the course of the
ASIS) Oblique Abdominal arterial supply except that the blood flow will
aponeurosis aponeurosis be reversed
rd
3 Part External oblique Absent Superficial Veins
(ASIS to aponeurosis aponeurosis o Above umbilicus: thoracoepigastric v.
Pubis) Internal oblique Rectus abdominis lateral thoracic axillary axillary
aponeurosis is in direct contact subclavian braciocephalic superior
with transversalis vena cava
Transverse
fascia o Below umbilicus: thoracoepigastric v.
abdominal
superficial epigastric femoral and great
aponeurosis
saphenous external iliac v. common
iliac v. inferior vena cava
Note: o If SVC is obstructed, blood will take the route
below umbilicus to reach the heart
Anterior Rectus Sheath is completely o Thoraco-epigastric vein
aponeurotic Connects the lateral thoracic vein
Posterior rectus sheath is not completely to the superficial epigastric vein
aponeurotic; it ends at the arcuate line Should not be dilated and tortuous
The arcuate line marks the entrance of the in humans (otherwise, one may
inferior epigastric vessels into the rectus sheath have superior or inferior vena cava
See Moore Figure 2.6 and Netter 248 for cross-section obstruction)
of the rectus sheath above and below arcuate line o Network of veins around the umbilicus
anastomose with paraumbilical vein
(connects with portal vein along
Contents of the Rectus Sheath Ligamentum Teres)
1. Rectus abdominis muscle Note: forms portal-systemic
2. Pyramidalis muscle venous anastomosis
3. Anterior rami of T7-T12 spinal nerve Paraumbilical v. pass through
T7-T11 are intercostal nerve round ligament of the liver
T12 is subcostal nerve hepatic sinusoids hepatic vs
4. Superior and inferior epigastric vessels IVC
5. Lymph vessels o In case of blocked portal v., there will be
retrograde flow of blood from the portal vein

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4.01 ABDOMEN IN GENERAL ANATOMY 2020C

to the paraumbilical veins and to the Superficial lymphatic vessels accompany the
subcutaneous veins around the area of the subcutaneous veins
umbilicus Superior to the transumbilical plane drain mainly to
o This produces the so-called Caput the axillary lymph nodes; few to the parasternal
Medusae. This condition is more commonly lymph nodes
seen in patients with alcoholic cirrhosis of Inferior to the transumbilical plane drain to the
the liver superficial inguinal lymph nodes

M. Internal Surface of the Anterior Abdominal Wall


Peritoneal fold a reflection of peritoneum that is
raised from the body wall by underlying blood vessels,
ducts, and obliterated fetal vessels (medial and lateral
umbilical folds)
Above the umbilicus, there is the round ligament of
the liver that houses the paraumbilical veins

N. Internal Aspect of the Anterior Abdominal Wall


(See Appendix)

Below the umbilicus, there are 5 peritoneal folds:


Median umbilical fold--from the apex of the bladder,
covers median umbilical ligament (obliterated
Figure 9. Caput Medusae urachus)
o Encloses median umbilical ligament
K. Nerves of the Anterior Abdominal Wall (remnant of urachus attaches the fetal
(See Appendix) bladder to the umbilicus)
Right and Left Medial umbilical folds--lateral to
Cutaneous Innervation: Anterior Abdominal Wall median umbilical fold, covers medial umbilical
T7-T9 supply the skin superior to the umbilicus ligament
T10 innervates the skin around the umbilicus o Encloses the right and left medial umbilical
ligaments (remnants of right and left
T11 and the cutaneous branches of the subcostal
umbilical arteries)
(T12), iliohypogastric, and ilioinguinal (L1), supply the
Right and Left Lateral umbilical folds lateral to
skin inferior to the umbilicus
medial umbilical folds, covers the inferior epigastric
o Branches of L1 do not enter the rectus
sheath vessels
o Iliohypogastric nerve: pierces the anterior o Encloses the right and left inferior
rectus sheath just above the superficial epigastric vessels such that if the lateral
inguinal ring to supply the skin over the area umbilical folds are cut, it is expected that the
inferior epigastric vessels will bleed
of the pubis
o Ilioinguinal nerve: enters the inguinal canal
Peritoneal Fossae/Recesses
together with the spermatic cord (males) and
round ligament of the uterus (females) to Located between umbilical folds
supply the scrotum, labia majora, inner Supravesical fossa between the median and
aspect of the thigh and the root of the penis medial umbilical folds; goes up and down with the
Note: Innervation is segmental filling and emptying of the urinary bladder
o Example: if a portion of the anterolateral Medial inguinal fossae between the medial and
abdominal muscles is supplied by T12 - the lateral umbilical folds; also called inguinal triangles
skin, fascia, and the parietal peritoneum has (Hesselbach triangles), potential sites of direct
also the same innervation inguinal hernia
Lateral inguinal fossae lateral to the lateral
Motor Innervation of Anterior Abdominal Wall (Netter 254) umbilical fold, includes the deep inguinal ring; site of
indirect hernia
T7 to T11 intercostal nerves thoracoabdominal o Deep inguinal ring located just above the
nerves anterolateral abdominal wall ms.s inguinal ligament and lateral to the inferior
Spinal nerve T12 subcostal nerves anterolateral epigastric vessels
wall See Moore pp. 212 to 214

L. Lymphatic Drainage of the Anterior Abdominal Wall


Umbilicus serves as the landmark in the anterior
abdominal wall; Iliac crest serves as the landmark
for the posterior abdominal wall

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O. Abdominal Incisions B. Important Structures


1. Inguinal Ligament
The external oblique aponeurosis is continuous and
forms a fibrous band, the inguinal ligament
(Pouparts Ligament)
Lacunar Ligament of Gimbernat
o Arched deeper fibers that pass posteriorly to
attach to the superior pubic rams lateral to
the tubercle
o Forms the medial boundary of the
subinguinal space
Pectineal Ligament of Cooper
o Most lateral of the Lacunar fibers that
continue to run along the pecten pubis

2. Iliopubic Tract
Thickened inferior margin of the transversalis fascia
Counterpart of inguinal ligament
Appears as a fibrous band running parallel and
posterior (deep) to the inguinal ligament

3. Inguinal Canal
An oblique passage, approximately 4cm long, directed
Figure 10. Abdominal Incisions Internal View inferomedially through the inferior part of the
anterolateral abdominal wall, and lies parallel and
McBurneys Point: superior to the medial half of the inguinal ligament
o Used for appendectomy Main occupant: spermatic cord in males, the round
o Location: drawing an imaginary line from the ligament of the uterus in females, and blood and
umbilicus to the ASIS, and divide the line into lymphatic vessels and the ilioinguinal nerve in both
3 portions, the junction of between the sexes
middle third and lateral third is the From deep inguinal ring to superficial inguinal ring
McBurneys Point
o Ruptured appendicitis: McBurneys C. Openings
Incision (blue) Deep (Internal) Inguinal Ring
o Ruptured with washing of abdominal o Entrance to the inguinal canal
cavity: Median or midline incision o Located superior to the middle of the inguinal
ligament and lateral to the inferior epigastric
artery
o Through this opening, the extraperitoneal
II. INGUINAL REGION ductus (vas deferens) and testicular vessels
in males or round ligament of the uterus in
A. Inguinal Region (See Appendix) females pass to enter the inguinal canal
-
Extends between the ASIS and pubic tubercle o Defect in the transversalis fascia that forms
-
Anatomical importance: it is a region where structures an oval opening like the entrance to a cave
exit and enter the abdominal cavity o Transversalis fascia continues into the canal,
-
Clinical importance: the pathways of exit and entrance forming the innermost covering (internal
are potential sites of herniation fascia) of the structures traversing the canal
-
The inguinal ligament and iliopubic tract, extending Retroinguinal Space/Space of Bogros
from the ASIS to the pubic tubercle, constitute a o Space between the transversalis fascia and
bilaminar anterior (flexor) retinaculum of the hip joint parietal peritoneum
-
The retinaculum spans the subinguinal space, through o Where prosthetic mesh is overlaid in hernia
which the flexors of the hip and neurovascular repairs
structures serving much of the lower limb pass Superficial (External) Inguinal Ring
-
The fibrous bands are the thickened inferolateral-most o A diagonal split of EOM
portions of the external oblique and aponeurosis and o Exit by which the spermatic cord in males, or
the inferior margin of the transversalis fascia the round ligament in females, emerges from
the inguinal canal
o Split that occurs in the diagonal, otherwise
parallel fibers of the external oblique
aponeurosis just superolateral to the pubic
tubercle

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Figure 11. Inguinal region

D. Boundaries

Table 3. Boundaries of the Inguinal Region


Anterior Wall External Oblique Aponeurosis
Internal Oblique Muscle
Fibers

Posterior Wall Transversalis Fascia


Conjoint Tendon
Roof Transversalis Fascia Figure 12. Development of inguinal canal
Transversus Abdominis
Internal Oblique
Medial Crux (External General Steps:
Oblique) 1. Processus vaginalis descends through the layers
Floor Iliopubic Tract of the anterior abdominal wall:
Inguinal Ligament Fascia transversalis obtains the layers for
Lacunar Ligament the internal spermatic fascia and consequently
forms the deep inguinal ring
Internal oblique obtains the cremasteric muscle
E. Development and fascia from the muscular and fascial portion of
Important Structures: the IO respectively
o Processus vaginalis outpouching of the abdominal External oblique obtains the external spermatic
peritoneum that will turn into the gubernaculum fascia and consequently forming the superficial
o Gubernaculum band of condensed mesenchyme inguinal ring
connecting the developing testes/ovaries to the 2. The processus vaginalis becomes a labioscrotal
labioscrotal swelling derived from the processus vaginalis swelling
3. The testis or ovaries in the posterior abdominal wall
th th
(at around L 1) descend at around the 7 or 8
month following the gubernaculum (as if it was being
pulled)
4. These sex-specific organs then stop at different
th
points on its way down (usually at the end of the 8
mo.)
Testis descends in front of the pubic
tubercle and rests behind the processus
vaginalis: the processus vaginalis then
becomes the tunica vaginalis
Ovaries descend and stops at the
level of the uterus where the
gubernaculum becomes attached to the
side of the uterus; the remains of the
gubernaculum from the uterus to the
labia majora is the round ligament of the
uterus

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o The coverings of the spermatic cord include the following:


F. Inguinal Triangle o Internal spermatic fascia: derived from the
- Important in identifying and differentiating direct and transversalis fascia
indirect hernias o Cremasteric fascia: derived from the investing fascia
o Indirect inguinal hernia: loop of bowel will of both the superficial and deep surfaces of the
pass through the inguinal canal lateral to internal oblique muscle
inf. Epigastric vessels o External spermatic fascia: derived from the external
o Direct inguinal hernia: passes medial to oblique aponeurosis and its investing fascia
inferior epigastric vesses.
- Boundaries:
Inferior: inguinal ligament
Medial: lateral border of rectus abdominis
muscle
Superior: inferior epigastric vessels

Figure 13. Inguinal triangle

G. Layers of the Inguinal Region


- The neurovascular bundle is located between
the internal oblique and transversus abdominis
- External oblique aponeurosis becomes the
inguinal ligament

During incision:
1. Remove the flap of the external oblique (usually just a
tendon)
2. Be careful not to damage the ilioinguinal nerve when
cutting the internal oblique
3. Underneath to that, the joint tendon of both the internal
oblique and transverses abdomens muscle are seen
followed by the deep inguinal ring Figure 14. Layers of inguinal region and covering of spermatic cord

The spermatic cord contains structures running to and from H. Types of Hernias
the testis and suspends the testis in the scrotum.
- Begins at the deep inguinal ring lateral to the inferior Two Types of Inguinal Hernia:
Indirect Hernia crosses through the inguinal canal;
epigastric vessels, passes through the inguinal canal,
outside inguinal triangle
exits at the superficial inguinal ring, and ends in the Direct Pointing towards position of inguinal triangle
scrotum at the posterior border of the testis
- Provides the floor and sometimes the anterior wall of Other Types of Abdominal Hernias:
the inguinal canal Epigastric Epigastric area
- Fascial coverings derived from the anterolateral Umbilical At umbilicus
abdominal wall during prenatal development surround Incisional Post-operative problems due to opening of
the spermatic cord investing fascia during surgery
Femoral Occurs in femoral canal

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4 Table 3. Characteristics of Indirect and Direct Hernia 3. Quadratus Lumborum


Characteristic Indirect Direct (Acquired) Quadrilateral
(Congenital) Forms a thick muscular sheet in the posterior
Predisposing Patency of Weakness of anterior abdominal wall
Factors processus abdominal wall to Lies adjacent to the lumbar transverse processes and
vaginalis inguinal triangle broader inferiorly
Frequency More common Less common
Exit (Abdominal Peritoneum of Peritoneum + C. Arteries of the Posterior Abdominal Wall(see Appendix)
Cavity) persistent transversalis fascia
processus ONLY 1. Abdominal Aorta
vaginalis + ALL 3 ! If the parietal peritoneum is removed the aorta will be
fascial coverings exposed. It passes through the aortic hiatus at the level of T12
Course Traverses inguinal Through or around and it divides into the right and left common iliac artery in front
canal inguinal cavity of the body of L4.
Exit (Anterior Via superficial Via superficial ring:
Abdominal ring: inside cord, lateral to cord, rarely
Branches from the top going down:
Wall) passing into enter scrotum/
scrotum/ labium majus o Right and Left inferior phrenic arteries
labium majus o Right and left subcostal arteries
o Celiac trunk
o Right and left middle suprarenal arteries.
III. POSTERIOR ABDOMINAL WALL The branches are classified as visceral or parietal, and paired
or unpaired:
A. Contents
Unpaired visceral branches of the aorta:
o Centrally: Five lumbar vertebrae and associated IV o Celiac trunk
discs o Superior mesenteric artery
o Laterally: Posterior abdominal wall muscles- psoas, o Inferior mesenteric artery
quadratus lumborum, iliacus, transversus abdominis,
and oblique muscles Paired visceral branches:
o Superiorly: superior part of the abdominal wall o Middle suprarenal arteries
o Fascia including thoracolumbar fascia o Renal arteries
o Lumbar plexus composed of the anterior rami of o Gonadal arteries
lumbar spinal nerves
o Fat, nerves, vessels (such as aorta and IVC), and Paired parietal branches:
lymph nodes o R and L inferior phrenic
o R and L subcostal
Structures that forms it: o 4 pairs of lumbar arteries
5 lumbar vertebrae and disc o There are 5 pairs of lumbar artery. The
Psoas major and minor t
first 4 are branches of abdominal aorta,
Quadratus Lumborum th
the 5 pair comes from median sacral
Iliacus Muscle artery which arises from the junction of
Posteroinferior aspect of the diaphragm the right and left common iliac arteries.
Transversus Abdominis muscle
Only the middle suprarenal arteries are direct branches of
B. Muscles
the aorta. The superior and inferior suprarenal arteries are
1. Psoas Major not branches of abdominal aorta.
Pass inferolaterally, deep to the inguinal ligament to o Superior suprarenal arteries are branches of the
reach lesser trochanter of the femur inferior phrenic artery, while the inferior suprarenal
Long, thick, fusiform psoas major lies lateral to the arteries are branches of the renal artery.
lumbar vertebrae
Psoas (Greek) for muscle of the loin At the junction between right and left common iliac artery is
th
Lumbar plexus of nerves embedded in the posterior the median sacral artery giving off the 5 pair of lumbar
part of psoas major artery.
Produce movement (flexion) of the lumbar vertebral
column 2. Common iliac arteries:
2. Iliacus o Diverge and run inferolaterally following the medial
Large triangular muscle border of psoas muscle to the pelvic brim
Lies along the lateral sides of the inferior part of psoas o Divides into internal and external iliac arteries
major Internal iliac arteries- enter pelvis
Psoas major and Iliacus form Iliopsoas (chief flexor of thigh, External iliac arteries- follows iliopsoas muscle;
stabilizer of hip joint and helps maintain erect posture) also supply anterior

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Ascending lumbar veins are continuations of lateral sacral


veins (Netter 260)

Clinical Correlation:
Ascending lumbar veins also anastomose with epidural
venous sinuses at subdural space. Their interconnections
mean that if theres infection/cancer/thrombi, easy to
spread to spine and to brain, or to lungs.

Remember: Blood from abdominal viscera passes through


the portal venous system and liver before entering the IVC
via the hepatic veins

Figure 15. Branches of the Abdominal Aorta. Green: unpaired visceral


branches; orange: paired visceral branches; lavender: paired parietal
branches

D. Veins (see Appendix)


1. Inferior vena cava (IVC)
Largest vein in the body
Begins anterior to L5 vertebra by union of common
iliac veins
Leaves the abdomen by passing through the caval
opening in diaphragm and enters thorax at the level of
T8 vertebra
Tributaries correspond to paired parietal and visceral
branches of abdominal aorta

Branches:
Paired visceral branches
Figure 16. IVC and its tributaries
o Right suprarenal vein
o Right and left renal veins
E. Lymph Vessels and Lymph Nodes
o Right gonadal vein
o Left suprarenal and left gonadal veins drain Lie along the aorta, IVC and iliac vessels
indirectly into IVC tributaries of left renal vein
Paired parietal branches 1. Intestinal lymphatic trunks
o Inferior phrenic veins a. Common iliac lymph nodes
o L3 and L4 lumbar veins o Receive lymph from external and internal

rd th
Only 3 and 4 pairs of lumbar iliac lymph nodes
veins drain to IVC o Lymph will pass to right and left lumbar

st
1 pair: renal v. lymph nodes
nd rd
2 pair drains into 3 pair
Lumbar vs R and L ascending b. Pre-aortic lymph nodes (celiac and superior and
lumbar v.s*. subcostal vein inferior mesenteric nodes)
azygos on R and hemiazygos on L o Lymph from alimentary tract, liver, spleen
SVC and pancreas pass along celiac and superior
o Common iliac veins and inferior mesenteric arteries to this area
Veins to unpaired visceral branches of aorta are
tributaries of the hepatic portal vein 2. Lumbar lymphatic trunks
a. Right and left lumbar (caval and aortic) lymph
nodes
o Lie on both sides of the IVC and aorta
o Receive lymph directly from posterior
abdominal wall, kidneys, ureters, testes or
ovaries, uterus, uterine tubes, descending
colon, pelvis, and lower limbs through inferior
mesenteric and common iliac lymph nodes

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3. Thoracic duct 1. Greater sac


Lies anterior to the bodies of the L1 and L2 vertebrae Main and larger part of the peritoneal cavity
between the right crus of the diaphragm and the aorta Extends from the diaphragm down into the pelvis
Begins with the convergence of the main lymphatic (whole abdominal cavity)
ducts of the abdomen (Cisterna chyli) Surgical incision through anterolateral abdominal
Drains all the lymphatic drainage from the lower half wall leads to the greater sac
of the body (deep lymphatic drainage inferior to the When the abdominal wall is dissected, that area
level of the diaphragm and all superficial drainage is actually the great sac
inferior to the level of the umbilicus) Divided by the transverse mesocolon (attaches
Ascends through the aortic hiatus in the diaphragm the transverse colon to the posterior body wall):
into the posterior mediastinum collecting drainage 1. Supracolic compartment above;
from the left upper quadrant of the body consisting of the stomach, liver and spleen
Ultimately ends by entering the venous system at the 2. Infracolic compartment below; consisting
junction of the left subclavian and internal jugular of the jejunum, ileum, ascending and
veins (the left venous angle) descending colon
- further divided into right and left infracolic
IV. PERITONEUM space by intestinal mesentery
Serous membrane that covers the internal aspect of
the anterior abdominal wall and reflecting the 2. Lesser sac/Omental bursa (see Appendix)
abdominal viscera Extensive sac-like cavity
Composed of Mesothelium single layer of simple Lies posterior to the stomach, lesser omentum
squamous epithelium and between the layers of greater omentum
Lines the peritoneal cavity and abdominopelvic Permits free movement of the stomach on the
viscera structures posterior and anterior to it
2 layers: One of the areas affected with potential infection
1. Parietal peritoneum glistening layer of the and accumulation of fluids
abdominal wall formed by a single layer of Communicates with the greater sac through the
epithelial cells and supporting connective omental (epiploic) foramen of Winslow
tissue o Connects greater sac to lesser sac
- Lines the abdominopelvic wall o Opening situated posterior to the free
2. Visceral peritoneum layer investing on edge of the lesser omentum =
the viscera that is sensitive to stretching and hepatoduodenal ligament
chemical irritation Attaches to the first portion of
- Lines the abdominopelvic viscera the pylorus to the liver
Derivative of the peritoneum
A. Peritoneal Cavity o Can be located by running a finger along
Between the parietal and visceral peritoneum the gall bladder to the free edge of the
Found within the abdominal cavity and continues lesser omentum
inferiorly into the pelvic cavity. o Usually admits two fingers
Portion of the abdominal cavity that goes with the o Bounded by (from Moore):
peritoneum Anteriorly: Hepatoduodenal
Bursal sac or lined potential space between the parietal ligament (contains portal triad
and visceral layers of the peritoneum. hepatic portal vein, hepatic
artery, bile duct)
Contains no organs but contains a thin film of
Posteriorly: IVC and a
peritoneal fluid composed of water, electrolytes and
muscular band, the right crus of
other substances derived from interstitial fluid in
the diaphragm, covered
adjacent tissues
anteriorly with parietal
Completely closed in males
peritoneum (retroperitoneal or
In females, there is a communication to the exterior of found behind the peritoneal
the body through the uterine tubes, uterine cavity and cavity)
vagina- a potential pathway of infection Superiorly: Liver, covered with
Air in the peritoneal cavity is called visceral peritoneum
pneumoperitoneum Inferiorly: Superior or first part
Fluid in the peritoneal cavity is called ascites of the duodenum
Subdivisions of the Peritoneal Cavity
Due to the rotation and exuberant growth of the
intestine during development, the disposition of the
peritoneal cavity became complex.

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3. Peritoneal fluid
Lubricates the peritoneal surfaces, enabling the
viscera to move over each other without friction and
allowing movements of digestion
Contains leukocytes and antibodies that resist
infection
Absorbed by lymphatic vessels, particularly on the
inferior surface of the constantly active diaphragm

4. Peritoneal Formations
A. Mesentery
Double layer of peritoneum that occurs as a result
of the invagination of the peritoneum by an organ
Originates at the level of L2
Around to 20cm
Continuity of the visceral and parietal peritoneum
Provides means of neurovascular communications
between the organ and the body wall
Goes downward obliquely to reach the sacroiliac
joint and iliocolic junction
As it crosses the midline, it passes through the
Figure 17. Sagittal section showing adult mesenteries ascending and horizontal portion of the duodenum
Structures being traversed by intestinal mesentery
4 Omental bursa boundaries: 1. abdominal aorta
Superiorly - diaphragm 2. inferior vena cava
Posteriorly - coronary ligament of the liver 3. psoas major
Inferiorly - between the inferior layers of the 4. right ureter
greater omentum
5. testicular vessels
a. Superior recess Connects an intraperitoneal organ to the body
Limited superiorly by the diaphragm and wall- usually the posterior abdominal wall
posterior layers of the coronary ligament of the Have a core of connective tissue containing blood
liver and lymphatic vessels, nerves, lymph nodes, and
fat
b. Inferior recess Examples: Mesentery (small bowel),
Found between the superior parts of the layers Mesoesophagus, Transverse and sigmoid
of the greater omentum mesocolons (large bowel), Mesogastrium,
Most become sealed off from the main part Mesoappendix
posterior to the stomach after adhesion of the
anterior and posterior layers of the greater
omentum

Figure 19. Mesentery (blue arrow), Transverse mesocolon


Figure 18 Omental Bursa (Red Arrow) (yellow arrow), Sigmoid mesocolon (green arrow)

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B. Omentum B. Peritoneal Ligament


Double-layered extension or fold of peritoneum that Double layer of peritoneum that connects an organ
passes from the stomach and proximal part of the with another organ or to the abdominal wall
duodenum to adjacent organs in the abdominal cavity o Falciform ligament - connects liver to anterior
abdominal wall
a. Greater Omentum o Hepatogastric ligament - connects liver to
Prominent, four-layered peritoneal fold stomach; membranous portion of lesser omentum
Hangs down like a folded apron from the o Hepatoduodenal ligament - connects liver to
greater curvature of the stomach and proximal duodenum; thickened free edge of lesser
part of duodenum omentum
Folds back and attaches to the anterior surface of o Gastrophrenic ligament - connects stomach to
the transverse colon and its mesentery inferior surface of the diaphragm
Can be seen upon the removal of the whole o Gastrosplenic ligament - connects stomach to
abdominal wall spleen as reflected in the hilum of spleen
A bodyguard which guards the abdominal o Gastrocolic ligament - connects stomach to
viscera from possible herniation or infection transverse colon; apron-like part of the greater
Means for neurovascular communication omentum
Prevents visceral peritoneum from adhering to
parietal peritoneum C. Peritoneal Fold
Organ cushioning Reflection of peritoneum that is raised from the body
Insulation vs loss of body heat wall by underlying blood vessels, ducts and ligaments
Composed of the gastrophrenic, gastrosplenic, formed by obliterated fetal vessels (e.g. umbilical
and gastrocolic ligament folds)
Some contain blood vessels and bleed if cut (e.g.
b. Lesser Omentum lateral umbilical folds which contain the inferior
Much smaller, double-layered peritoneal fold epigastric arteries)
Connects lesser curvature of stomach and the One median fold, two medial umbilical folds and two
proximal part of the duodenum to the liver lateral umbilical folds
Composed of hepatogastric and hepatoduodenal o Median umbilical fold from the apex of
ligaments the bladder, covers median umbilical
Connects stomach to a triad of structures that run ligament (obliterated urachus)
between the duodenum and liver in the free edge o Medial umbilical folds lateral to median
of the lesser omentum umbilixal fold, cover medial umbilical
o Portal triad: Hepatic portal vein, ligament
Hepatic artery, Bile duct o Lateral umbilical folds lateral to medial
Composed of hepatogastric ligament and umbilical folds, cover the inferior epigastric
hepatoduodenal ligament vessels
Median umbilical ligament
o Should be an obliterated urachus
(connection between umbilicus and urinary
bladder)
o If pediatric patient or neonate is seen with
urine coming out of the umbilicus, urachus is
still patent.

D. Peritoneal Recess/Fossa
Pouch of peritoneum formed by peritoneal fold
o Supravesical fossa bet. median and the
medial umbilical folds
o Medial inguinal fossae bet. medial &
lateral umbilical folds, also called inguinal
triangles (Hesselbach triangles), potential
sites of direct hernia
o Lateral inguinal fossae lateral to the
lateral umbilical fold, include the deep
inguinal ring, site of indirect hernia

Figure 20. Lesser Omentum (yellow arrow);Greater E. Gutter !


Omentum (blue arrow) Spaces in between
Right and left colic gutter

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Space in pelvis and above diaphragm


(infradiaphragmatic or subphrenic spaces) Ascites Presence of excess fluid (ascetic fluid) in
the peritoneal cavity (Moore, Dalley, & Agur, 2014)
Most dependent area (where most fluids accumulate) of May occur as a result of mechanical injury
abdominal cavity in supine position is posterior of liver. Causes distention of peritoneal cavity,
But for standing or upright individual, the most dependent area interfering with movements of viscera
is the pelvis (where bowel is located). Counterpart in thorax is pleural effusion

F. Pathologies 4
QUIZ
Pneumoperitoneum Presence of air inside the
peritoneal cavity (Moore, Dalley, & Agur, 2014)
1. True or False. The Pouparts ligament forms the
Symptoms include drawing in of abdomen
medial boundary of the subinguinal space
as chest expands (also known as
2. True or False. The superior part of the posterior
paradoxical abdominothoracic rhythm), and
abdominal wall contains the 5 lumbar vertebrae and
muscle rigidity
its associated IV disc.
Can be due to perforation of viscera
3. True or False. The hepatic portal vein, bile duct, and
Counterpart in the thorax is pneumothorax hepatic artery forms the bile duct.
Different from gastric bubble, which is
normal and can be seen in the fundus of
the stomach
REFERENCES:
1. Lecture Notes
2. Dr. Elevazos presentation
3. 2019As trans
4. 2018As trans
5. Moore, K.L. & A.F. Dalley. (1999). Clinically Oriented
Anatomy. Philadelphia: Lippincott Williams & Wilkins.
th
6. Netter, F.H. (2011). Atlas of Human Anatomy. 6 ed.
Philadelphia: Elsevier.

Figure 21. Example of Pneumoperitoneum (yellow superimpositions)


7.

Answers: F, F, T

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APPENDIX

Appendix 1. Arteries of the Anterior Abdominal Wall

Appendix 2. Veins of the Anterior Abdominal Wall

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Appendix 3. Nerves of the Anterior Abdominal Wall

Appendix 4. Internal Aspect of the Anterior Abdominal Wall

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Appendix 5. Dissection of the Inguinal Region

Appendix 6. Posterior Abdominal Wall

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Appendix 7. Veins of the Posterior Abdominal Wall

Appendix 8. Arteries of the Posterior Abdominal Wall

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Appendix 9. Lymph Vessels and Nodes of the Posterior Abdominal Wall

Appendix 10. Nerves of the Posterior Abdominal Wall

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Appendix 11. Omental bursa

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