POSTERIOR ABDOMINAL WALL

Formation
Structures present
Applied aspects

Dr. Aparna Muraleedharan

Associate Professor
Dept. of Anatomy, P.I.M.S
Osseo-musculo-fascial wall - formation
• Bony part
• Bodies of 5 lumbar vertebrae
• Lower ribs
• Iliac fossae and alae of sacrum
• Muscular part
• Paravertebral gutter - Psoas major, psoas minor, quadratus lumborum,
transversus abdominis
• Iliacus
• Fascial part
• Fascia iliaca (iliac and psoas parts), thoracolumbar fascia
 ALAE

ILIAC
FOSSA
SACRUM
Upper Posterior Lower Posterior
Abdominal Wall Abdominal Wall
PSOAS MAJOR

TRANSVERSUS
ABDOMINIS

QUADRATUS
LUMBORUM

PSOAS MINOR

ILIACUS
ILIOPSOAS - PSOAS MAJOR &ILIACUS

• Origin
• Insertion
• Nerve supply
• Actions

Lumbosacral triangle of
Marcille
 Lumbosacral triangle of Marcille
• Deep (OILS)
• Sympathetic trunk
• Lumbosacral trunk
• Iliolumbar artery
• Obturator nerve
• Intermediate
• Common iliac vessels
• Superficial
• Ureter
• Ovarian vessels
• Inferior mesenteric vessels (left)
• Hypogastric nerve plexus
Lumbar triangle of Petit
• Lumbar hernia
 ILIAC FASCIA &
PSOAS FASCIA

• Medial arcuate ligament

• Femoral sheath
Applied aspects
• Psoas abscess (Usually cold abscess)
• Cope’s Psoas test, Baldwing sign
• May present as swelling in femoral triangle
• Abscess beneath fascia iliaca
• Helpless position in #NOF
QUADRATUS LUMBORUM
• Origin
• Insertion
• Nerve supply
• Actions

• Enclosed within thoracolumbar fascia

MUSCLES OF BACK
THORACOLUMBAR FASCIA
• Fascia covering the intrinsic muscles
of back
• 3 layers in the lumbar region
• Anterior
• Middle
• Posterior
• Thoracic part
• 1 layer (continuation of posterior layer)
• Fuses with deep Cervical fascia in the
neck
 Anterior layer
• Inferior – iliac crest and iliolumbar ligament
• Superior – lateral arcuate ligament
• Medial – Anterior surface of transverse process of
lumbar vertebra
• Lateral – Blends with middle layer
 Middle layer
• Inferior – Iliac crest and iliolumbar
ligament
• Superior – 12 th rib, lumbocostal
ligament
• Medial – tip of transverse process of
lumbar vertebrae
• Lateral – blends with anterior layer &
posterior layer, the line of fusion is X
shaped
 Posterior layer
• Inferior – Iliac crest and sacrum (U -
shaped)
• Superior – thoracic vertebrae and
angles of ribs, continues with deep
cervical fascia
• Medial - Spines of lumbar vertebrae
• Lateral – blends with middle layer
Thoracolumbar Fascia – 3 layers
Muscles & Thoracolumbar fascia
Structures in the posterior
abdominal wall
• Abdominal aorta and its branches
• Veins - Inferior vena cava and its tributaries,
ascending lumbar veins, azygos system
• Lymphatics and lymph nodes
• Nerves – somatic (lumbar plexus and its
branches), autonomic (lumbar sympathetic
chain and ganglia and plexuses)
• Kidneys, ureters, suprarenal glands
ABDOMINAL AORTA
 Inferior phrenic
Coeliac trunk
Middle suprarenal

SMA
• Continuation of descending thoracic aorta at Renal

T12
• L4 – divides into 2 common iliac arteries IMA Gonadal
• Branches – 4 groups
• Ventral – coeliac trunk, SMA, IMA
• Lateral – Inferior phrenic, middle suprarenal, renal,
gonadal
• Dorsal – 4 pairs of lumbar, median sacral
• Terminal – right and left common iliac
 Anteriorly
Coeliac plexus,
Relations Lesser sac, liver,
pancreas, splenic vein,
left renal vein, 3rd part
of duodenum, root of
mesentery

Left
DJ flexure, Left
sympathetic trunk, Left
Abdominal
crus of diaphragm and
left coeliac ganglion
Right
IVC, Cisterna chyli,
Thoracic duct, Azygos
aorta
vein, Right crus of
diaphragm and right
coeliac ganglion

Posteriorly
L1 to L4, lumbar veins,
left psoas major
Coeliac trunk & SMA SMA, IMA& Marginal artery of
Drummond
INFERIOR VENACAVA
 Course and tributaries
• Formation – At L5, 2.5 cm to the right of median
plane
• Groove for IVC on liver
• Central tendon of diaphragm at T8 level
• Right atrium – Eustachian valve
• 20-25cm, 2.5 cm wide
• Tributaries – common iliac, median sacral, renal,
inferior phrenic, hepatic, right gonadal, right
suprarenal
 Anteriorly
Epiploic foramen, liver, right free

Relations margin of lesser omentum,

pancreas, splenic vein, right
gonadal vessels, 3rd part of
duodenum, root of mesentery,
right common iliac artery

Left Right
Abdominal aorta, right crus Right ureter, 2nd part of
of diaphragm, cisterna chyli, duodenum, medial border
thoracic duct, lesser sac, IVC of right kidney, hepatorenal
caudate lobe pouch of Morrison, Bare
area of liver

Posteriorly
L1 to L4, right lumbar arteries, right
psoas major, right sympathetic
trunk, Right crus of diaphragm and
right coeliac ganglion, right renal
artery, right suprarenal glnd
• Ascending lumbar veins
• Connects common iliac, iliolumbar, 4
lumbar veins
• Unite with subcostal vein to form
azygos/hemiazygos veins
• lumbar azygos vein from IVC/ left renal
vein – drain into above vein or forms
azygos system
• Azygos system
• Lumbar azygos vein, subcostal vein,
ascending lumbar vein
• Drains posterior body wall
 Applied importance
• Azygos system starts from IVC and
drains into SVC
• Can act as collaterals in IVC or SVC
obstruction
ACV Anastomosis
DEVELOPMENT
OF
CCV Sinus venosus INFERIOR
PCV VENACAVA

A
O

Supra CV
SubCV

Anastomosis
R
T
A SupraSub
anastomosis

Anastomosis
 1. Right Posterior cardinal vein
2. Right supracardinal vein
3. Right suprasubcardinal anastomosis
4. Right subcardinal vein
5. Hepatocardiac channel
6. Right vitelline vein
Hepatocardiac channel

6
5

4
3

1
I
V
C 7. Preaortic subcardinal anastomosis Lt.
9
8. Left subcardinal vein

9. Left suprasubcardinal anastomosis

Renal
7 8 Vein

Gonadal veins drain into suprasubcardinal anastomosis

Hence, on the right side it drains into IVC
On the left side it drains into Left renal vein
 AZYGOUS
SYSTEM
• Azygos vein
• Right azygous
venous line
• Arch of Azygous
vein – Cranial end of
right posterior
cardinal vein
Retrocaval ureter – Double IVC –
persistent right posterior cardinal vein persistent left supracardinal vein
Development of posterior
abdominal wall veins
• IVC – 6 sources
• Right posterior cardinal
• Right supracardinal
• Right suprasubcardinal anastomosis
• Right subcardinal
• Hepatocardiac channel
• Right vitelline vein
• Azygos vein
• Right azygous venous line
• Arch – Terminal part pf right posterior
cardinal vein
LYMPHATICS & LYMPH NODES
 PREAORTIC COELIAC NODES
PARA PARA
AORTIC AORTIC SUP. MESENTERIC
NODES

INF. MESENTERIC
NODES

COMMON
ILIAC
 CISTERNA CHYLI

INTESTINAL LYMPH
Lateral Lateral

TRUNK
branches branches
Right paraaortic/
Dorsal Caval Preaortic Left paraaortic Dorsal
branches Coeliac branches
Sup. Mesenteric
Inf. mesenteric

Common iliac Common iliac

External iliac Internal iliac Internal iliac External iliac

Lower anterior abdominal Pelvis Pelvis Lower anterior abdominal

wall, Lower limb wall, Lower limb
Posterior abdominal wall lymph nodes/ terminal nodes

• Lumbar lymph nodes - 4 groups

• Pre aortic → Intestinal lymph trunks
• Right Para aortic → Lumbar trunk
• Left Para aortic → Lumbar trunk
• Retro aortic
• Cisterna chyli
CISTERNA CHYLI
• 5-7cm long
• L1
• Between abdominal aorta and IVC
• Intestinal lymph trunks and lumbar
lymph trunks
• Thoracic duct
 NERVES
• Somatic – Subcostal nerve (T12),
5 lumbar nerves

• Autonomic (ganglia and plexuses)

• Sympathetic – 6 splanchnic nerves
– Greater, lesser, 4 lumbar
• Parasympathetic – Vagus (mainly
right), Pelvic splanchnic nerve
(S2,3,4)
 LUMBAR PLEXUS
• Ventral rami of Lumbar nerves
• Within the substance of Psoas major
• L4 – larger cranial part – lumbar plexus,
lower caudal part joins L5 to form
lumbosacral trunk that joins sacral
plexus
• Nervi furcalis
• Prefixed
• Postfixed
 Branches
Muscular - Quadratus lumborum (T12-L4),
Psoas major (L2-4), Psoas minor (L1), Iliacus
(L2,3)
Iliohypogastric, Ilioinguinal – L1
Genitofemoral – L1,2
Lateral cutaneous nerve of thigh – L2,3
Femoral nerve – L2,3,4
Obturator nerve – L2,3,4
Accessory obturator nerve – L3,4
Lumbosacral trunk – L4,5
• Medial border – Obturator,
lumbosacral trunk

• Lateral border –
Iliohypogastric, ilioinguinal,
Lateral cutaneous nerve of
thigh, femoral

• Pierces – genitofemoral
nerve
• Meralgia paraesthetica
• Cheiralgia paraesthetica
 SYMPATHETIC NERVES

• Sympathetic trunk – 4
lumbar ganglia
• Splanchnic nerves – Greater,
lesser, least, 4 lumbar
 • Lateral horn→Ventral root→white ramus
communicans→sympathetic ganglia(T1-L2)→ 4
Sympathetic system fates
1. Synapse→postsynaptic fibres→grey
ramus→corresponding spinal nerve→vasomotor,
sudomotor, pilomotor
2. Do not synapse → Ascend up in the chain to
cervical level→reach cervical ganglia→
Synapse→postsynaptic fibres→grey
ramus→corresponding spinal nerve→vasomotor,
sudomotor, pilomotor
3. Do not synapse→descend down to lumbar and
sacral ganglia→ Synapse→postsynaptic
fibres→grey ramus→corresponding spinal
nerve→vasomotor, sudomotor, pilomotor
4. Do not synapse→ Exit from medial aspect of
ganglia→ Splanchnic nerves - Greater – T5-9,
Lesser (T10-11), Least (T12), lumbar→terminate
in prevertebral plexus → synapse→distribute
along branches of aorta
Prevertebral autonomic plexuses
COELIAC PLEXUS/ SOLAR PLEXUS
• Around coeliac trunk
• Coeliac and aorticorenal ganglia
• Afferent – Greater Splanchnic N, Lesser splanchnic N, L1 and L2
splanchnic nerve, Vagus (mainly right)
• Efferents – form various plexus – around arteries – supply muscles,
vessels and glands - Phrenic, hepatic, splenic, pancreatic, gastric,
renal, gonadal, superior mesenteric (has a ganglion),
Aortic/intermesenteric, Suprarenal (Preganglionic – terminate in
adrenal medulla)
COELIAC GANGLION
SUPERIOR HYPOGASTRIC PLEXUS
• Along Inferior mesenteric artery
• Afferents – aortic/intermesenteric plexus, L3 and L4 splanchnic
nerves, Pelvic splanchnic nerves (S2,3,4 – parasympathetic)
• Efferents – supply hindgut, hypogastric nerve (joins inferior
hypogastric plexus which supplies pelvic viscera)