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Abdominal incision sites – surgical scars important for patient McBurney’s Point – relate to appendicitis
medical history/physical exam Rectus sheath hematoma
Recommendation:
**Link the anatomical and clinical information provided in the lecture to the gross anatomy laboratories** 2
Skeletal Framework of the Abdomen
Inferior thoracic aperture:
• Xiphisternal joint → some sources reference xiphoid process Xiphisternal joint
• Costal margin
− Costal cartilages of 7th to 10th ribs Costal margin
T12
• 11th and 12th ribs
• T12 vertebra
Sacral promontory
Inferior
Inferiorly: Posteriorly: thoracic
aperture
• Pelvic inlet • Vertebrae
Abdominal
− Pubic symphysis • Posterior abdominal wall muscles wall
− Pubic crest Pelvic inlet Iliac crest
− Quadratus lumborum m.
− Pubic tubercle
− Psoas major m.
− Iliopectineal line
− Iliacus m. Inguinal
− Sacral alae ligament
− Sacral promontory
4
Abdominopelvic Cavity: Lined with Peritoneum
Cranial cavity Cranial
cavity
Vertebral canal
Left
Superior Thoracic
mediastinum
pleural cavity cavity
Pericardial cavity within
Thoracic cavity
middle mediastinum
Diaphragm
Diaphragm Vertebral
canal
Abdominal cavity Abdominal cavity
Abdominopelvic Pelvic inlet
Pelvic cavity
cavity Pelvic cavity marks the division
between the abdominal
& pelvic cavities
• Peritoneum is defined as a serous membrane (that secretes fluid to reduce friction when organs move) which:
− lines the cavity and walls of the abdomen → Parietal layer of peritoneum
− covers the abdominal organs → Visceral layer of peritoneum 5
Peritoneal Cavity: Potential space within the abdominal cavity
Peritoneal cavity is a “potential”
space between parietal and visceral
peritoneum
Liver
• Parietal layer of peritoneum covers and lines
Stomach the internal walls of the abdomen
Portal v.
→ Pain is well localized (very sensitive)
• Visceral layer of peritoneum covers and
IVC
invests abdominal organs that protrude into
Right
T12
Kidney
the peritoneal cavity
→ Pain is generalized (is referred)
① Anterior group
Xiphoid − Rectus abdominis m.
process
− Pyramidalis m. (if present)
② Lateral group
2
− External oblique m.
Anterior superior 1 − Internal oblique m.
iliac spine
− Transversus abdominis m.
7
Surface Anatomy: Anterior Abdominal Wall
Linea alba is a white tendinous line that:
• Forms in the midline
• Runs from the xiphoid process to pubic
symphysis
• Separates the right and left rectus abdominis
mm.
Surface Anatomy:
The external oblique m. has a hands-in-pocket
muscle fiber orientation and interdigitates with
Inguinal Ligament:
Forms from the lower free-edge of the fibers serratus anterior m. 9
Internal Abdominal Oblique: Anterolateral muscle
▪ Origin:
• Thoracolumbar fascia
• Anterior iliac crest
• Inguinal ligament
▪ Insertion:
• Linea alba via the rectus sheath
• Ribs 10-12
• Pubis via the conjoint tendon
▪ Innervation:
• Anterior rami of T6-L1 spinal nerves
▪ Action:
• Bilateral: Flexion of trunk & compression of abdominal viscera
• Unilateral: Lateral flexion & ipsilateral rotation of the trunk
Conjoint tendon:
Forms when the medial fibers of the internal oblique aponeurosis unite with the
deeper fibers of the transversus abdominis aponeurosis 10
Transversus Abdominis: Anterolateral muscle
▪ Origin:
• Costal cartilages of ribs 7-12
• Thoracolumbar fascia
• Iliac crest
• Inguinal ligament
▪ Insertion:
• Linea alba via the rectus sheath
• Pubis via the conjoint tendon
▪ Innervation:
• Anterior rami of T6-L1 spinal nerves
▪ Action:
• Maintains posture & compresses/supports abdominal viscera
Arcuate line:
Located 1/3rd of the distance from the umbilicus to the pubic symphysis and
forms when the aponeurotic fibers of transversus abdominis m. no longer travel
posterior to the rectus abdominis m. and instead course anterior to the muscle 11
Rectus Abdominis: Anterior muscle
▪ Origin:
• Pubis
▪ Insertion:
• Costal cartilages of ribs 5-7
▪ Innervation:
• Anterior rami of T6-T12 spinal nerves
▪ Arterial supply:
• Superior epigastric artery
• Inferior epigastric artery
▪ Action:
• Flexion of trunk & compression of abdominal viscera
Tendinous intersections:
Segment the rectus abdominis m. and attach to the anterior layer of the rectus
sheath, so that when the muscle contracts and tenses it does not lift
(prevents bow stringing) 12
Pyramidalis: Anterior muscle
Rectus
abdominis
Linea alba
▪ Origin: m.
• Pubic crest
Anterior
▪ Insertion: layer of the
rectus
• Linea alba sheath
(reflected)
▪ Innervation:
• Anterior rami
of T12 spinal nerve
▪ Action:
Pyramidalis • Tenses the linea alba
muscle Spermatic cord
Pyramidalis muscle:
A small triangular-shaped muscle anterior to rectus
abdominis muscle that is absent in
approximately 20% of individuals
13
Anterior Abdominal Wall: Overview of muscles
Muscle Origin Insertion Action Innervation
External abdominal oblique Lower 8 ribs Iliac crest, Contralateral rotation T7-12
Pubic tubercle, and lateral flexion.
Linea alba When BOTH right and left
contract: Flexion of trunk and
compression of abdominal
viscera
Internal abdominal oblique Thoracolumbar fascia, Lower 3 ribs, Ipsilateral rotation T6-L1
Iliac crest, Linea alba, and lateral flexion.
Inguinal ligament Pubis When BOTH right and left
contract: Flexion of trunk and
compression of abdominal
viscera
Transversus abdominis Lower 6 costal cartilages, Linea alba, Compression and support T6-L1
Thoracolumbar fascia, Pubis of abdominal viscera
Iliac crest,
Inguinal ligament
Skin
Subcutaneous tissue: External oblique m.
• Camper’s fascia
Internal oblique m.
• Scarpa’s fascia
Linea
alba Transversus
abdominis m.
Camper’s fascia
Transversalis
Rectus fascia
Scarpa’s fascia abdominis m.
Skin
Camper’s fascia
Scarpa’s fascia
External oblique m.
16
Rectus Sheath
The aponeuroses of the external oblique, internal oblique and transversus abdominis mm.
have to pass superficial or deep to the rectus abdominis mm. to insert on the linea alba
• The anterior lamina (wall) of the rectus sheath is Anterior lamina Posterior lamina
of rectus sheath of rectus sheath
formed by the aponeurotic fibers that
pass superficial to rectus abdominis m.
• The posterior lamina (wall) of the rectus sheath
is formed by the aponeurotic fibers that
pass deep to rectus abdominis m.
Linea semilunaris Linea alba
• Contents:
• Rectus abdominis muscles Sheath:
• Superior epigastric vessels Defined as a close fitting cover that
envelops a structure and has a
• Inferior epigastric vessels
protective role
• Anterior rami of the T7-12 spinal nn. 17
Rectus Sheath: Above the arcuate line
Skin
Camper’s fascia
Scarpa’s fascia
External oblique aponeurosis
Internal oblique aponeurosis
Rectus abdominis m.
Intervertebral Internal oblique aponeurosis
disc Transversus abdominis aponeurosis
L3/L4
Transversalis fascia
Extraperitoneal fat
Parietal layer of Peritoneum
18
Rectus Sheath: Above the arcuate line
Anterior lamina:
• External oblique aponeurosis Skin
• Internal oblique aponeurosis (half)
Camper’s fascia
Scarpa’s
Rectus abdominis muscle
fascia
Internal oblique aponeurosis
Transversus abdominis aponeurosis
RA m. Transversalis fascia
Extraperitoneal fat
Parietal layer of Peritoneum
Peritoneum
Transversalis fascia
19
Rectus Sheath: Below the arcuate line
Anterior lamina:
• External oblique aponeurosis Skin
• Internal oblique aponeurosis
• Transversus abdominis aponeurosis Camper’s fascia
Scarpa’s fascia
Posterior lamina:
External oblique aponeurosis
• Not present! Internal oblique aponeurosis
Transversus abdominis aponeurosis
Scarpa’s
fascia Rectus abdominis muscle
Transversalis fascia
RA m.
Extraperitoneal fat
Parietal layer of Peritoneum
Peritoneum
Transversalis fascia 20
Arcuate Line: Internal view of anterior abdominal wall
Posterior
rectus sheath
The arcuate line marks the point at
Umbilicus
which the aponeuroses of all three
lateral abdominal muscles pass
anterior to the rectus abdominis m.
External oblique m.
Transversalis
Internal oblique m.
fascia
Transversus abdominis m.
Peritoneum
Inferior epigastric (intact)
artery
External iliac vein
Spermatic cord (cut)
Remnant of the
umbilical a. Urinary bladder
Great saphenous
Remnant of the vein
urachus
23
Reference: Medial umbilical folds and the umbilical arteries
Fetal circulation is different from
circulation after birth: Foramen ovale
Arch of the Aorta
Left umbilical vein Ductus arteriosus
• Fibroses to form the
round ligament of the liver Pulmonary trunk
Ductus venosus
• Fibroses to form Umbilical vein Inferior vena cava
ligamentum venosum
Ductus venosus
Musculophrenic a.
Inferior epigastric artery
• Branches directly from the external iliac artery Superior epigastric a.
• Travels deep to rectus abdominis m.
• Forms an anastomosis (connection) with the
superior epigastric artery Branches of
intercostal, subcostal
& lumbar aa.
• Link to Inguinal Region, Testes and Scrotum lecture for the
following clinical correlate: Inferior epigastric a.
➢ Hesselbach’s inguinal triangle
Paraumbilical v.
Paraumbilical veins located within the round
ligament of the liver
• Are located parallel to the umbilicus
• Drain into the hepatic portal vein
Anterior
diaphragmatic l.n.
Deep lymphatic drainage
Level of the
• Accompany the deep veins umbilicus
T12:
Subcostal nerve runs
under the 12th rib
• General somatic efferent (GSE) axons
carry motor information to initiate
L1: contraction of muscle fibers
Divides to form
• Iliohypogastric nerve • General somatic afferent (GSA) axons
carry sensory information from the
• Ilioinguinal nerve skin
→ Lateral cutaneous nerves
→ Anterior cutaneous nerves
30
Review: Anterior Abdominal Wall
Rectus abdominis m.
External oblique m.
Costal cartilage
Posterior rectus sheath
Linea alba
Internal oblique m.
Linea semilunaris
Thoracoabdominal n. (T10)
Tendinous intersection
Transversus abdominis m.
Iliac tubercle
Arcuate line
Anterior superior
iliac spine Inferior epigastric artery
Transversalis fascia
Inguinal ligament
31
Transumbilical Plane
L1
Umbilicus is often used as a key landmark: Costal margin
L3
• Dermatome T10
Iliac crest
L5
Iliac tubercle
• Vertebral level L3/L4 (widest part of
iliac crest)
Anterior superior
• Midline iliac spine
• Incision site
Pubic tubercle
(e.g. for breast augmentation)
32
Why is it useful to divide the abdomen
into distinct areas?
Abdominal Abdominal
Quadrants Regions
33
Abdominal Quadrants
The 4 abdominal
quadrants are divided
according to two lines 2
2. Median plane:
• Vertical line through Right Lower Left Lower
the midline Quadrant Quadrant
• Divides into right and left
34
Reference: Right Upper Left Upper
Overview of Quadrants Quadrant Quadrant
• Liver • Liver
• Gallbladder • Spleen
• Stomach: Pylorus • Pancreas: Body & Tail
• Pancreas: Head • Left kidney
• Small intestine: Duodenum • Left adrenal gland
RUQ LUQ • Right colic flexure • Abdominal esophagus
• Ascending colon • Stomach
• Transverse colon • Small intestine: Jejunum
• Right kidney • Left colic flexure
RLQ LLQ • Right adrenal gland • Transverse colon
• Descending colon
c
C
C. Transtubercular plane - L5:
• One horizontal line through the iliac tubercles
• Alternatively, some definitions use the interspinous plane instead (S1)
→ denoted by the dashed line labeled c which transects each ASIS
36
Abdominal Regions
Epigastric
Region
Hypogastric
Region 37
Reference: Right Hypochondriac Epigastric Left Hypochondriac
Overview of Regions Region Region Region
• Liver • Abdominal esophagus • Stomach
• Gallbladder • Stomach • Liver (tip)
• Right kidney • Pancreas • Gallbladder
• Right colic flexure • Small intestine • Spleen
(ascending & transverse colon) • Liver • Pancreas (tail)
• Gallbladder • Left kidney
• Right and left kidneys • Left colic flexure
• Right and left adrenal glands (transverse & descending colon)
• Jejunum
• Ileum Diaphragm
• Cecum
➢ Appendix
• Ascending colon
• Transverse colon
• Descending colon
• Sigmoid colon
“Alimentary” • Rectum
Relating to nourishment/nutrition • Anus 40
Clinical
Correlates
41
Preview: Palpation of the Abdomen
The muscles of the anterior abdominal wall play a vital role in the
physical examination of a patient
Guarding:
• Voluntary contraction of the abdominal wall
• Often accompanied by a grimace, however, this may diminish if the patient is distracted
Rigidity:
• Involuntary reflex contraction of the abdominal wall from inflammation of the peritoneum
42
McBurney’s Point
Umbilicus
1. Initial appendicitis:
• When secretions of the appendix become trapped, the
appendix swells and stretches the VISCERAL peritoneum
covering this intraperitoneal organ
• General visceral afferent (GVA) axons enter the spinal
cord at the T10 vertebral level
• Vauge pain is referred to the peri-umbilical region!
2. Acute appendicitis:
• When appendicitis progresses, the inflammation
becomes transmural and irritates the PARIETAL
peritoneum
• General somatic afferent (GSA) axons (supplying the muscles
and skin) localize the pain at McBurney’s point:
Anterior
→ Indicates the base of the appendix superior iliac
→ 1/3rd of the way from ASIS to umbilicus spine
→ Right Lower Quadrant (RLQ)
Abdominal Incision Sites
Median / Midline
Muscle-splitting • No muscle damage
• Also known as McBurney Gridiron • No nerve damage
• Minimal muscle damage
Left paramedian
• Nerves most at risk of damage:
• Access to lateral organs
• Iliohypogastric n.
• Closure is more secure
• Ilioinguinal n.
• Risks nerve damage
Subcostal
Laparoscopic • Gallbladder
• Several small incisions for • Spleen
equipment
Transverse / Oblique
• Minimal blood loss
• Children
• Obese
• Less risk of nerve damage
Suprapubic
• Also known as Pfannenstiel
• Cesarean section 44
• Hysterectomy
Rectus Sheath Hematoma
Damage to the inferior or superior
epigastric arteries
could result in blood accumulating in
the rectus sheath
Potential Symptoms:
▪ Sudden, acute abdominal pain and swelling
▪ Fever
▪ Nausea
▪ Vomiting (a.k.a. emesis)
▪ Palpable mass
Right Iliac / Right Inguinal Hypogastric / Suprapubic Left Iliac / Left Inguinal
Region Region Region
• Small intestine • Small intestine • Descending colon
• Appendix • Sigmoid colon • Sigmoid colon
• Cecum • Rectum • Small intestine
• Ascending colon • Urinary bladder • Left ovary and uterine tube
• Right ovary and uterine • Uterus, ovaries & uterine tubes
tube • Prostate, seminal vesicles &
vas deferens 47