Abdominal wall

Anterior Abdominal Wall

Boundaries

 bounded above by the costal margins and the xiphoid process of the sternum
 only the costal cartilages of ribs 7, 8, 9 and 10 takes part in this boundary, for the 11th and the 12th ribs
do not reach the margin.
 bounded below and on each side by the portion of the iliac crest lying between the iliac tubercle and the
anterior superior iliac spine, by the inguinal ligament, the pubic crests and the upper end of the pubic
symphysis.
 The xiphoid process lies at the bottom of the depression between the two 7th costal cartilages
 its edges and tip afford attachment for the aponeurosis of the transversus abdominis muscle
 Since it is painful and at times difficult to palpate the xiphoid, the lower end of the body of the sternum
serves as preferable landmark.

Surface Anatomy

 The skin of the abdomen is loosely attached to the

underlying structures except at the umbilicus where it is
normally firmly adherent.
 The linea alba extends in the midline from the xiphoid to
the symphysis pubis
 it is divided by the umbilicus into a :
a) supra-umbilical portion- is a band about ½ inch
wide
b) infraumbilical part- is so narrow that the recti
almost touch.
 This is important surgically, since a midline incision
placed above the umbilicus comes directly onto this broad
band, but in an infraumbilical midline incision it is
difficult to find the threadlike midline.
 The linea alba is a fibrous raphe formed by the
decussation of the 3 lateral abdominal muscles, since it contains few or no blood vessels, it can be
incised with very little bleeding.

 Clinically, the anterolateral abdominal wall has been divided into 9 regions created by 2 horizontal and
2 vertical lines.
 The 2 horizontal lines are constructed in the following way: the upper line is placed at the level of the
9th costal cartilages, and the lower at the top of the iliac crests.
 The 2 vertical lines extend upward from the middle of the inguinal (Poupart’s) ligament to the
cartilage of the 8th rib. The 9 regions thus constructed are:
a) 3 upper regions- left hypochondria, epigastric and right hypochondriac
b) 3 middle regions- left lumbar, umbilical and right lumbar
c) 3 lower regions- left iliac, hypogastric and right iliac.
  Identifying the regions in this way aids in the description and the location of the viscera and the
abdominal masses.
 The umbilicus or navel, is located in the linea alba, little nearer the symphysis than the xiphoid, usually
its level is between the disks of the 3rd and 4th lumbar vertebrae. But since it may vary in position, it is
not too reliable a landmark.
 It is puckered scar which marks the site of the umbilical cord, through which 4 tubes passed in fetal
life:
a) Urachus
b) the right and left umbilical arteries
c) left umbilical vein.
 They are situated in the properitoneal fat layer of the anterior abdominal wall and produce peritoneal
folds. When the peritoneal aspect is studied in the adult, these 4 tubes are present as 4 atrophic fibrous
cords. In the embryo, a structure called the vitello-intestinal duct is present; this connects the small
bowel with the umbilicus.
 If this structure is not obliterated at the time of birth, feces will discharge at the umbilicus; if the urachus
is not completely obliterated at birth, urine will be noted at the same site.
 The hypogastric arteries of the fetus become the obliterated hypogastric arteries of the adult and pass
over the lower abdominal wall as they proceed from the internal iliac arteries to the umbilicus; they may
remain open and supply superior vesical branches to the urinary bladder.
 The umbilical vein becomes the round ligament, or ligamentum teres of the liver. The physiologic
communication between the peritoneal cavity and the umbilical cord may persist, resulting in umbilical
hernias.
 The umbilicus may be the site for the collection and the discharge of the bile and pus and may be the
location of new growths such as papillomas or metastases from gastrointestinal carcinomas.
 The well-known but infrequently seen caput medusa is located in this region and is the result of the
communication between the portal and the systemic circulations when the former is impaired.
 The rectus abdomonis muscle stands out on each side of the
median line in the well- developed individual and forms a
longitudinal prominence which is broader above than below;
its lateral margin, which slightly convex, is indicated by a
groove on the skin known as the linea semilunaris.
 This line extends from the pubic tubercle to the costal
margin from the pubic tubercle to the costal margin of the 9th
costal cartilage.

Nerves and Superficial Fascia

 Nerves. The skin of the anterior abdominal wall is supplied

by the lower 6 thoracic nerves give off anterior and
lateral branches, but the lateral branch of the last thoracic
nerve becomes the ilio-hypogastric nerve, which pierces
the external oblique aponeurosis about 1inch above the
superficial inguinal ring, and the ilio-inguinal nerve, which
passes directly through the superficial inguinal ring.
 The level of the umbilicus marks the 10th thoracic nerve.
  The superficial fascia appears as single layer in the
upper part of the anterior abdominal wall, but in the
lower region, especially between the umbilicus and
the symphysis pubis, it is easily divided into 2
distinct layers:
a) A superficial layer of superficial fascia,
which is a fatty stratum known as
Camper’s fascia
b) A deeper membranous layer called
Scarpa’s fascia, which is in contact with
the deep fascia.
 The superficial layer contains small blood vessels
and nerves. This fatty connective tissue gives
roundness to the body, thus preventing unsightly angularity. The superficial nerve distribution of the
 The deep layer of superficial fascia is uite devoid of fat anterolateral abdominal wall
and bleed vessels and descends on each side in front of
the inguinal ligament to blend with the fascia lata of the
thigh immediately below and nearly parallel with the
ligament.
 In the region of the pubic bone it is carried downward
over the spermatic cords, the penis and the scrotum into
the perineum, where it is known as Colles’ Fascia

Arteries, veins and Lymphatics

 The superficial arteries accompany the cutaneous

nerves;
 those which accompany the lateral cutaneous nerves are
branches of the lateral cutaneous nerves are branches of
the posterior intercostal arteries
 Those which travel with the anterior cutaneous nerves
are derived from the superior and the inferior epigastric vessels.
 ,3 small branches of the femoral artery are found in the superficial fascia of the groin.
a) the superficial external pudendal
b) the superficial epigastric The superficial veins and lymphatics of anterior
c) superficial circumflex iliac arteries. abdominal wall
 The superficial veins on each side of the anterior abdominal wall are divided into 2 groups:
a) The upper group returns the blood via the lateral thoracic and the internal thoracic
( mammary) veins to the superior vena cava
b) the lower group returns its blood via the femoral vein to the inferior vena cava
 Both groups anastomose freely through the thoracoepigastric vein; the superficial veins may dilate and
compensate for an obstruction of the external or the common iliac veins.
 The paraumbilical vein communicates with both of these groups and constitutes an important
connection between the portal and the systemic venous systems.
  The superficial lymph vessels are divided into
a) supraumbilical vessels drain into the
pectoral lymph glands
b) infraumbilicalvessels drain into the
superficial inguinal glands

MUSCLES

 3 lateral flat muscles of the anterior abdominal

wall
a) external oblique
b) internal obliques
c) transversus abdominis
 There are the recti and the pyramidalis.

Rectus Abdominis Muscle.

 This appears as a long, broad, muscular

band, which stretches between the pubis and
the thorax on each side of the linea alba.
 It originates by tendinous fibers from the pubic crest and the anterior pubic ligament.
 As it ascends it widens and become thinner; it inserts on the thorax as fleshy muscular fibers.
 This insertion takes place along the anterior surfaces of the 5th, the 6th and the 7th costal cartilages and
the xiphoid process.
 The insertion which is onto the front of chest can be visualized along a horizontal line that extends
from the xiphoid process to the end of the 5th ribs; it is approximately 3 times as broad (3inches) as the
origin from the front of the symphysis.
 Its medial border is separated from that of its fellow by the linea alba.
 Below the umbilicus, where the linea alba is a fine line, the 2 recti are practically in contact with each
other, but above the umbilicus, they are about ½ inch apart.
 The anterior surface of the muscle is crossed by 3 tendinous intersections:
a) one at the costal margin
b) one at the umbilicus
c) one between these two
 A 4th may be present below the umbilicus, but it is not constant.
 The muscle is adherent to the anterior wall of the rectus sheath where these intersections appear, but
since they do not penetrate the entire muscular depth, the rectus is nowhere adherent posteriorly. By
this arrangement a long muscle

RECTUS SHEATH

A. Above the rib margin.

 the anterior wall of the sheath is made up of the aponeurosis of the external abdominal oblique
muscle
 the posterior wall is absent. Since the rectus muscle lies directly on cartilage.
B. From the rib margin to midway between the umbilicus and the pubis:
  anterior wall of the sheath consists of the aponeurosis of the external oblique plus the anterior layer
of the aponeurosis of the internal oblique;
 posterior wall consists of the posterior layer of the aponeurosis of the internal oblique, the
aponeurosis of the transversus abdominis muscle and the transversalis fascia.
 The transversus, where it extends behind the rectus, is muscular almost to the midline. Where the
posterior sheath ends, midway between the umbilicus and the pubis, an arched lower border, which is
called the linea semicircularis (Douglas), is formed.
 This line is an important dividing point, since cephalad to it the internal oblique aponeurosis splits
into its 2 leaves, but below this point no such division takes place
 The inferior epigastric artery enters the sheath by crossing this edge

C. From midway between the umbilicus and pubis to the pubis

 the anterior wall is formed by the
aponeurosis of the external and the internal
obliques and the transversus;
 here, all the aponeurosis pass in front of the
rectus.
 The transversus and internal oblique are
fused, but the external oblique does not
fuse until it nearly reaches the midline.
 the posterior wall is formed by the
tranversalis fascia.
 The contents of the rectus sheath are
a) The rectus and the pyramidalis
muscles
b) The superior and the inferior
epigastric vessels
c) The termination of the lower 5
intercostals and the 12th thoracic
nerves with their accompanying
vessels
 The nerves enter the sheath by piercing the posterior wall near the lateral margin and then run for a short
distance between the posterior sheath and the rectus before entering the muscle proper
 The superior epigastric artery enters the rectus sheath behind the 7th costal cartilage and anastomoses
with the inferior epigastric artery, which enters in the front of the arcuate line
 In this way the vessels of the upper and the lower limbs are brought into communication. Their branches
are cutaneous, muscular and anastomotic.

Pyramidalis Muscle

 This triangular muscle lies in front of the rectus

 It is frequently absent
 It arises from the front of the pubis and is inserted into the lower part of the linea alba between the rectus
and the anterior wall of its sheath. It is supplied by the last thoracic nerve and acts as a tensor of the
linea alba
SURGICAL CONSIDERATION

Abdominal Incisions

 The incisions most commonly used are:

1. Rectus
a) Paramedian
b) Pararectus
c) Transrectus (muscle-
splitting)
2. Oblique
a) McBurney
b) Kocher’s Subcostal
c) Iliac
3. Vertical: Midline
a) Above the umbilicus
b) Below the umbilicus
4. Transverse
a) Epigastric
b) Pfannenstiel

Rectus Incisions

 Incisions through the rectus sheath and muscle may either above or below the umbilicus
A. Paramedian incision
 Made about 1inch to the right or the left of the midline
 The skin and the fascia is divided to the rectus sheath
 The opening of the sheath exposes the rectus muscle
 The medial border of the rectus is retracted laterally, exposing the posterior rectus sheath and
the peritoneum
 These are divided in the same line as the skin the wound is sutured in 3 layers
a) The peritoneum and the posterior rectus sheath
b) The anterior rectus sheath
c) The skin
 The muscle returns of its own accord (trap-door action) over the posterior suture line.
 Injury to the vessels and nerves is minimal, and the exposure of the pelvic structures is
excellent.
B. Pararectus Incision
 Similar to the paramedian, except that the lateral border instead of the medial border of the
rectus muscle.
 This incision has the disadvantage of encroaching on the nerves which enter and supply the
rectus muscle laterally
 The closure is accomplished in 3 layers
 If the incision must be enlarged downward toward the pubis, the deep epigastric vessels may
be encountered.
 Should this be the case, the artery and its 2 accompanying veins can be ligated and divided.
Transrectus (muscle splitting) incision

 performed in the same manner as the other 2 rectus incisions but differs in that the muscle is divided
longitudinally through its medial third.
 The medial third is chosen in order to minimize injury to the nerve fibers.
 The muscle is divided in the line of its fibers, the tendinous inscriptions are clamped and ligated, and the
posterior sheath and the peritoneum are incised.
 The incision is closed in layers.

Oblique Incisions

 These have been utilized especially in surgery on the appendix and the gall bladder.

***McBurney Incision
 An oblique muscle-splitting incision which passes through the lateral abdominal musculature and
is supposed to minimize post-operative weakness of the abdominal wall by incising the muscles
in the direction of their fibers.

 The level and the length of this incision will vary according to the position of the appendix and
the size of the patient.

 In general way, however, it may be stated that it is made at the junction of the middle and the
outer thirds at the right angles to an imaginary line joining the anterior superior iliac spine with
the umbilicus.

 One third of the incision is placed above this line, and two thirds below it; the incision is usually
about 3 inches long.

 The skin is incised in the direction of the fibers of the external abdominal oblique; this incision is
carried to the superficial fascia until the fibers of the external oblique aponeurosis is seen.

 Usually this incision is closed in 3 layers:

1. including the peritoneum and the fascia
2. aponeurosis of the external oblique
3. closes the skin

Kocher’s subcostal incision

 Used for operations on the biliary tract, but a similar incision may be placed on the left side
for operations on the spleen or the cardiac end of the stomach.
 The incision is made parallel with and about 1 inch from the costal margin; it commences at
the base of the xiphoid and is carried into the flank as far as is deemed necessary.

Iliac Incision

 Utilized in exposure of the ureter or larger pelvic vessels.

  It is made parallel with and directly in front of the anterior portion of the iliac crest; aims to reach the
extraperitoneal structures below the brim of the pelvis.
 It is carried directly through the musculature and the transversalis fascia.
 The peritoneum is not opened but is mobilized and retracted medially.
 The necessary procedures are carried out extra-peritoneally.

Vertical Incisions

 The midline incision above the umbilicus is made directly in the linea alba, which can be located easily
by the depression or pigmentation present. It begins just below the xiphoid cartilage, extends to the
umbilicus and is usually 4 to 5 inches long.
 The skin and the superficial fascia are incised to the aponeurosis.

Advantages of this incision are:

almost bloodless
no muscle fibers are encountered
no nerves are injured
gives access to both sides of the abdomen

Disadvantage: only 1 layer is available for repair because of the fusion of the aponeuroses in the midline;
therefore, it cannot be relied upon and may result in weakness and herniation.

Midline Incision

 below the umbilicus is employed almost routinely in gynecologic operations.

 Since the recti below the umbilicus are so close together, and because the linea alba is only a fine line,
the right and left rectus sheath is entered routinely, and the muscle is retracted literally.
 Because of this, it is not exactly in the midline, and the repair is made in layers.
 Such a repair will result in a strong abdominal wall and does not have the disadvantage of weakness that
a midline incision above the umbilicus would have.

Transverse Incisions

 These abdominal incisions give excellent exposure but entail more time in execution and repair.
 They result in nicer-looking scars and produce less injury to the nerves and the blood vessels, since they
run parallel with them.

Transverse Epigastric Incision

 Extends from the lateral edge of one rectus to the lateral edge of the other.
 The underlying anterior rectus sheath, the rectus muscles, the posterior rectus sheath and the peritoneum
are divided transversely on each side.
 If further exposure is required, the incision may be extended laterally beyond the lateral edge of the recti
by splitting the oblique muscles.
 The individual layers of the abdominal wall are sutures separately, but it is to be recalled that only one
fused layer is found in the region of the linea alba.
  This same incision has been modified by Sanders, who utilizes lateral retraction of the recti rather than
division of these muscles.

Pfannenstiel incision

 A suprapubic transverse incision which is placed at or in the upper pubic hair line in this way becomes
concealed.
 The skin, the subcutaneous tissue and the right and the left anterior rectus sheaths are divided
transversely.
 The cut edges of the sheaths are dissected upward and downward for a short distance; this exposes the
recti and the pyramidalis when latter is present.
 The exposed recti are freed from the underlying transversalis fascia and then are retracted laterally.
 The transversalis fascia, properitoneal fat and the peritoneum are incised longitudinally.
 In closing the wound, the layers are sutured separately in the line of division.

***INCISIONAL HERNIAS

 Cattell has described a method which results in a 5-layer repair in which various components of the
abdominal wall are not separated at the hernial ring.
 It has the advantage that no dissection is carried out at a point where it is most difficult to identify the
layers, and its repair results in great strength at the point of greatest potential weakness.
 The old scar is excised by an elliptical incision, and the sac which usually lies immediately
subcutaneous is identified; this is freed down the hernial ring. The fascia is exposed. The sac is opened,
and the contents are freed carefully and reduced; frequently, resection of the omentum is necessary.

Inguinal Region

The 9 Abdominal Layers

 This region has been called the inguinoabdominal region and the inguinal trigone, the trigone being
bounded by the inguinal ligament, the lateral margin of the rectus muscle and a horizontal line drawn
fron the anterior superior iliac spine to the rectus margin.
 9 abdominal Layers make up this region; these layers appear and are discussed in the following order:
1. Skin
2. Superficial fascia (Camper’s layer)
3. Superficial fascia (Scarpa’s layer)
4. External oblique muscle
5. Internal oblique muscle
6. Tranversus abdominis muscle
7. Transversalis fascia
8. Properitoneal fat
9. Peritoneum

Skin of this region

  Smooth and movable and presents 3 particular landmarks for surface anatomy
 They are:
Anterior superior iliac spine, which is readily palpable
Pubic tubercle, which is less easily palpated, esp. in the obese
Umbilicus

Superficial Fascia

Divided into 2 layers:

Superficial fascia of superficial fascia (Camper’s Fascia)

Deep layer of superficial layer (Scarpa’s Fascia)

Camper’s Fascia

 The fatty layer which is continuous with the adipose tissue covering the body generally.
 It is also called the panniculus adiposus, its thickness depending on the amount of fat present; the
cutaneous vessels and nerves run in this layer.
 The arteries found here are derived from the femoral artery and ascend from the thigh.
 They are:
 Superficial epigastric
-which bisects the inguinal ligament and runs toward the navel

 Superficial external pudendal

-which runs medially across the spermatic cord and supplies the scrotum

 Superficial circumflex iliac artery

- which passes laterally below the inguinal ligament

Scarpa’s Fascia

 Membranous layer of superficial fascia; contains no fat.

 The attachments of this fascia are clinically important because it is under this layer that extravasations of
urine and blood take place.
 Passes over the inguinal ligament and attaches to the deep fascia of the thigh ( fascia late).
 This attachment takes place about the finger’s breadth below and parallel with the inguinal ligament.
 Medially, it attaches along a line that passes with, but lateral to, the spermatic cord; this line extends
from the pubic tubercle to the pubic arch.
 The fixation occurs lateral to the pubic tubercle.
 Urine, blood or an exploring finger cannot extend beyond this attachment.
 Medial to the tubercle, Scarpa’s fascia does not attach but continues over the penis and the scrotum; it
continues as Colle’s fascia, which covers the superficial compartment of the perineum.

External Abdominal Oblique Muscle

  Arises from the lower 8 ribs (5 to 12); its fibers are directed downward, forward and medial.
 It interdigitates with the serratus anterior above; continuous sheet of fascia covers both muscles.
 The most posterior fibers run vertically downward and insert into the anterior half of the iliac crest.
 Between the last ribs and the iliac crest a free border forms the lateral boundary of the lumbar (Petit’s)
triangle.
 The muscle fibers become tendinous below the joining the anterior superior iliac spine to the pubic spine
the aponeurosis forms the free border which is called the inguinal (Poupart’s) ligament, under which
vessels, nerves and muscles pass the abdomen to the thigh.

External Oblique Aponeurosis

>Forms the inguinal, the lacunar, Cooper’s and the reflected inguinal ligaments

Inguinal ligament (Poupart’s)

 Tendinous part of the external oblique aponeurosis which extends from the anterior superior iliac spine
to the pubic tubercle.
 The muscles which lie below it are the iliac, the psoas major and the pectineus.
 The ligament folds back on itself, forming a groove; the lateral half of this is not seen because it is
obscured by the origin of the internal oblique and the transversus muscles.
 However the medial half forms the gutterlike floor of the inguinal canal

LACUNAL LIGAMENT (GIMBERNAT’S)

 Part of the inguinal ligament which is reflected downward, backward and lateral
 It attaches to the pectineal line, its free crescentic margin forms the medial boundary of the femoral ring
 It is pectineal part of the inguinal ligament.

COOPER’S LIGAMENT

 Lateral continuation of the lacunar ligament

 It extends from the base of the lacunar ligament laterally along the pectineal line to which it is attached.

REFLECTED INGUINAL LIGAMENT (TRIANGULAR LIGAMENT)

 Consists of reflected fibers which take their origin from the inferior crus of the superficial inguinal ring
and the lacunar ligament
 They pass medially behind the spermatic cord and continue medially between the superior crus of the
superficial inguinal ring and the conjoined tendon; they insert into the linea alba.
 Because of its triangular shape, this ligament has been called the triangular fascia.
SUPERFICIAL INGUINAL “RING” (SUBCUTANEOUS INGUINAL “RING”/ EXTERNAL
ABDOMINAL “RING”)

 Has had the term “RING” applied to it, but this is unfortunate.
 In reality, the triangular thinned-out part of the aponeurosis of the external oblique muscle through
which the spermatic cord in the male and the round ligament in the female pass.
 The apex of the triangle lies lateral to the pubic tubercle; its base, formed by lateral half of the pubic
crest, lies medial to the tubercle.
 The 2 sides are called CRURA.
 inferior crus (external pillar)
- is the medial end of the inguinal ligament; it attaches to the pubic tubercle.
 superior crus (internal pillar)
- part of aponeurosis which attaches to the pubic crest and the symphysis
 The “ring” is not an open defect, since it is covered by the intercrural (intercolumnar) fibers which
passes from one crus to the other.
 As the testicle made its descent, it encountered these intercrural fibers at the external “ring”.
 The fibers were pushed ahead by the descending testicle and formed a covering for the cord which is
known as the external spermatic fascia.

INTERNAL ABDOMINAL OBLIQUE MUSCLE

 Lies between the external oblique and the transversus abdominis muscles.
 This fan-shaped muscle has a narrow ORIGIN and a broad insertion.
 Ti originates from the outer half of the inguinal ligament, from the intermediate line on the iliac crest
and from the posterior lamella of the lumbodorsal fascia through which gains attachment to the lumbar
spines.
 Because of this last fact, the muscle has no free posterior border.

The uppermost fibers run almost vertically upward and inserted into the lower 4 ribs and their cartilages.
The intermediate fibers form an aponeurosis which divides above the semicircular line (of Douglas)
into 2 lamellae at the lateral border of the rectus muscle.
The anterior lamella accompanies the external oblique aponeurosis to form the anterior rectus sheath,
and the posterior lamella accompanies the aponeurosis of the transversus abdominis to form the rectus
sheath.
Below the semicircular line the combined aponeurosis of all the 3 lateral abdominal muscles fuse and
pass in front of the rectus muscle as the anterior rectus sheath.
Those fibers which originate from the inguinal ligament arch above the spermatic cord in the male and
the round ligament in the female and become tendinous.
They insert conjointly with those of the transversus abdominis into the crest of the pubis.
It is this fusion of the tendinous portions of the internal oblique and transversus muscles that results in
the structure known as CONJOINED TENDON (inguinal aponeurotic falx).
TRANSVERSUS ABDOMINIS (TRANSVERSALIS) MUSCLE

 deepest of the 3 lateral abdominal muscle

 arises from outer 3rd of inguinal ligament, inner lip of iliac crest, middle layer of lumbodorsal fascia
and inner surface of the lower 6 costal cartilages
 located into linea alba and through conjoined tendon into the public crest
 aponeurosis passes behind rectus muscle to the level of linea semicircularis, but from this level
downward passes in front of that muscle
 most fibers pass in lateral half of inguinal ligament and transversalis abdominis originates from lateral
3rd of ligament, testicles in descent misses transversus fibers but comes in contact w/ internal oblique
fibers, dragging the latter downward
 these form muscle loops along the spermatic cord known as cremaster muscle- action is to draw testicle
upward
 nerves are found in the internal between internal oblique and TA m.
 7th and 8th nerves pierce the posterior lamella of the internal oblique aponeurosis at the costal margin
then pass upward and medially
 9th nerve passes medially and slightly downward
 10th, 11th and 12th nerves take a more downward course as they travel medially
 last 4 nerves pierce the posterior layer of the internal oblique aponeurosis at lateral edge of rectus sheath
 these nerves supply the 3 lateral muscle as well as the rectus abdominis
 the 3 flat abdominal muscle form muscular corset, helps to maintain intrabdominal pressure
Transversalis fascia
 “endoabdominal fascia”
 connective tissue layer w/c covers the entire internal surface of abdomen
 its thickness is variable, but that part w/c is below the inferior margins of the internal oblique and
transversus abdominis muscle is well developed
 it is in this unprotected area that forms the floor of Hasselbach’s triangle and when torn/weakened,
predisposes to the development of a direct inguinal hernia
 the fascia lies between the transversus abdominis muscle and peritoneal fat layer
 Anson and Daseler suggested that the abdominal fasciae in adult be divided into 3 layers:
 Internal layer for GIT w/ its vessels and nerves
 Intermediate layer for the urogenital system, adrenals and their associated vessels and nerves, the
aorta and vena cava
 External layer for parietal musculature (body wall) w/ its nerves and vessels
Descent of testicles
 factors responsible for descent is not understood
 scrotum: undeveloped, testis: located in abdomen (lumbar region) in early months of intrauterine life
 testicles develops between transversalis fascia and peritoneum in stratum of properitoneal fat
 in 3rd mo. of intrauterine life it descends from the loin to the iliac fossa
 from 4th-7th mos., rests at the site of internal (abdominal) inguinal ring
 7th mo., it passes through inguinal canal into scrotum, proceded by peritoneal diverticulum- “processus
vaginalis” (its vessels, nerves and duct are dragged after it)

\
Gubernaculum testis
 triangular structure
 the base is attached to the testis (epididymis)
 apex to the bottom of scrotum
 remnants of the gubernaculum become the scrotal ligament- short band that connects the inferior pole of
the testicle to the bottom of the scrotum
 prior to the descent of testicles, the vaginal process of the peritoneum extends into the scrotum
Tunica vaginalis testis (vaginal protion)
 part of vaginal process w/c is applied to testicle; it remains patent
Funicular process
 part of the vaginal process w/c is applied to the spermatic cord, between the tunica vaginalis testis and
abdominal (deep) inguinal ring
 it loses its patency and becomes a fibrous cord known as the vaginal ligament
Internal spermatic fascia (infundibuliform fascia)
 evaginated portion of the transversalis fascia w/c supplies a covering for the spermatic cord
Cremaster muscle
 second covering of the cord
External spermatic fascia
 comes in contact w/ the aponeurosis of the external oblique muscle
 it evaginates the aponeurosis
 another covering of the spermatic cord
*thus the testis and cord have aquired 3 coverings:
 internal spermatic fascia from transversalis fascia
 cremaster muscle from the internal oblique
 external spermatic fascia from aponeurosis
*the so-called “rings” are not true rings or defects
 internal ring- thinned-out portion of transversalis fascia
 external ring- thinned-out portion of the aponeurosis of the external abdominal oblique aponeurosis
*the testicle pushes Scarpa’s fascia ahead of it; becomes the Colles’ fascia of the perineum
*Camper’s fascia- paniculus adiposus; a fatty layer and replaced by dartos muscle since there’s no fat in
scrotum
*testicle reaches the scrotum at 9th month
Inguinal canal
 fully developed inguinal canal is not a canal but is a cleft w/c takes an oblique course through
inguinoabdominal region
 length in adult: 4-5cm
 entrance through canal is through abdominal (deep) inguinal ring, located a little above the center of
iguinal ligament
 exit through the subcutaneous (superficial) inguinal ring
 internal wall: formed by aponeurosis of external abdominal oblique (entire length) and fleshy fibers of
internal oblique (lateral half)
 posterior wall: formed by transversalis fascia (entire length) and conjoined tendon (medial half); latter
structure lies in front of transversalis fascia and behind the cord
 roof: formed by arched lower border of internal oblique and to lesser degree by transversus abdominis
 floor: groove w/c is formed by fusion of the upper grooved surface of inguinal ligament, lacunar
ligament and transversalis fascia; the cord rests on this groove
Types of inguinal hernias
the processus vaginalis becomes occluded at 2 points:
 first at internal abdominal ring
 second, directly above the testis
part of vaginal process situated between these 2 points- funicular process, becomes obliterated

 vaginal (congenital) indirect inguinal hernia- vaginal process remains patent throughout its entire course
and the opening above is wide enough, bowel or omentum may enter this process and pass through
scrotum
 funicular indirect hernia- only the proximal of funicular portion of vaginal process remains open
 encysted hernia- same as vaginal type plus a process of peritoneum w/c lies in front of the sac and
extends up to external ring
 infantile type- same as funicular type plus a process of peritoneum w/c is found in front of hernia as high
as external ring
 interstitial types- due to a diverticulum of the processus vaginalis w/c becomes caught between layers of
developing abdominal wall; rare and found associated w/ imperfectly descended testicles; the sac may
be:
 proparietal (extraparietal), between the superficial facia and external oblique muscle
 interparietal (intramuscular), between internal and external oblique muscles
 retroparietal (intraparietal), between transversalis fascia and peritoneum
Types of Hydroceles
In true hydrocele, there is a collection of fluid in some part of processus vaginalis

 vaginal type- presents a collection of fluid, not due to any fault of development in tunica vaginalis; it is
acquired, becomes important to determine whether it is so-called common “idiopathic” variety or
secondary to some disease of the testis or epididymis such as malignancy or tuberculosis.
 congenital type- “intermittent hydrocele”-due to tiny communication between the processus vaginalis
and peritoneal cavity w/c permits the escape of fluid.
 infantile type- processus vaginalis is occluded only at internal abdominal ring.
 hydrocele of the cord- funicular process fails to shrink to a fibrous cord so that a tubular cavity results.
SURGICAL CONSIDERATIONS
Inguinal Hernias, Indirect and Direct
Indirect hernias
Points on herniorhaphies: conjoined tendon (doubting its existence), importance of transversalis fascia,
management of the sac

 Incision is made from a point which joins the middle and the outer thirds of a line between the anterior
superior iliac spine and the umbilicus to a point which marks the pubic tubercle. It is difficult to feel this
tubercle since the spermatic cord passes through it; hence, the pubic bulge is the landmark used.
 The incision is deepened through Camper’s and Scarpa’s fascia until the aponeurosis of the external
abdominal oblique is exposed.
 The external inguinal ring is identified, and the continuation of the external abdominal oblique over this
ring, namely, the external spermatic fascia, is incised.
 Then the external oblique aponeurosis is incised, and its edges are held apart and dissected free from the
underlying internal oblique muscle.
 The iliohypogastric and ilioinguinal nerves usually can be demonstrated at this point.
 The lower border of the internal oblique becomes visible, and its continuation, the cremaster muscle
loops, should be elevated.
 These are severed, and the internal oblique is freed from the underlying transversalis fascia.
 The lateral cut edge of the external oblique aponeurosis is retracted outward, thus exposing the Poupart’s
ligament.
 Since the hernia sac is found at the upper inner quadrant of the spermatic cord, lateral retraction on the
cord tenses the transversalis fascia.
 The properitoneal fat serves as an excellent guide because the peritoneum lies immediately subjacent to
this far. However, the transversalis fascia, properitoneal fat and peritoneum may be fused into one layer,
especially in thin individuals.
 The defect in the transversalis fascia must be repaired to prevent the development of a direct hernia.
Accomplished by a purse- string suture which incorporates the fascia overlying the spermatic cord.
 The free edge of the transversalis fascia is sutured to the Poupart’s ligament.
 No sutures are placed in the internal oblique muscle.
Direct hernias

 Underlying cause is a weakness of or defect in the transversalis fascia

 Operation is same for indirect hernia
 Repair by mattress sutures
 The free edge of the transversalis fascia is then sutured to the Poupart’s ligament.
 Anton Wolfler originated the relaxing incision of Halsted
 Numerous modifications such as cutis grafts, wire mesh and fascia lata
Umbilical Region
- Occupies the central part of the anterolateral abdominal wall
Embryology

 The cloaca is a part of the hindgut which separates into a dorsal (rectum) and ventral part.
 The ventral part divides into:
1. Cranial part which becomes the urachus (allantois)
2. Middle part which becomes the bladder
3. Caudal part which becomes the urethra and, in the female, part of vagina
 The upper allantois is continued into the umbilicus and the umbilical cord; the intraabdominal portion of
the allantois is called the urachus.
 The urachus and the allantois become a solid cord, which develop into characteristic cyst-like
dilatations.
 If the urachus remains patent at birth, a urinary umbilical fistula results.
 The peritoneal surface of the umbilical region has 4 fibrous cords. These are remains of 4 tubes:
urachus, right and left umbilical arteries and the left umbilical vein.
 The alimentary tract communicates with the yolk sac by a vitello-intestinal (omphalomesenteric) duct. It
disappears when the embryo is 6-12mm in length. But its vessels persist even after the duct has
disappeared. If patent, an umbilical fecal fistula results. If only the inner end remains patent, a Meckel’s
diverticulum develops.
 Rarely, the median portion persists, and the duct becomes obliterated at both ends, then an intestinal cyst
develops.
 When the omphalomesenteric vessels perists as fibrous cords, they will result to intestinal obstruction.
Vessels

 2 arteries and 2 veins

 Left vein is larger and persists
 Smaller right vein disappears before the embryo is 10mm long
 2 umbilical arteries pass from the internal iliac artery to the umbilicus.
 They run to either side of the urachus but soon become obliterated and are known as obliterated
hypogastric (umbilical) arteries.
 The left umbilical vein occupies the free border of the falciform ligament forming a “mesentery” for this
vessel.
 At birth when the umbilical cord is cut, the left umbilical vein becomes obliterated and thereafter is
known as the round ligament or ligamentum teres of the liver.
Umbilicus

 Umbilical structures: duct, vessels, urachus

 Umbilical structures atrophy and umbilical ring becomes reduced to a small orifice.
 Heals rapidly, fibrous changes take place and a puckered scar called umbilicus (navel) results.
 Retraction of the umbilical vein draws the scar against the uppermost circumferences of the umbilical
ring; this is the weak spot where umbilical hernias occur.
 Umbilical papilla is usually circular; may bulge in newborn but is retracted in adults.
 Umbilical fascia, when it exists, is derived from the transversalis fascia.
 The superficial lymphatics of the umbilical region pass in the subcutaneous fat and pass in 4 directions:
-upper set passes to the axillary lymph glands
-lower ones to the superficial inguinal group
Types of Umbilical Hernias
Hernias of the Umbilical Cord

 May contain abdominal viscera

 Coverings: amnion, Wharton’s jelly and peritoneum
 Also referred to as exomphalos
 Subdivided into complete or partial
Umbilical Hernia of Adults

 Acquired umbilical hernia

 Umbilical cicatrix becomes greatly stretched, allowing a process of peritoneum with coils of gut or
omentum to escape through it.
Congenital Hernia of Children

 Causes: persistence of a small peritoneal process into the umbilical cord or an imperfect closure in the
linea alba immediately above the umbilicus.
 Straining during defecation and coughing may be additional predisposing factors.
Repair of Umbilical Hernias

 A wide, elliptical, transverse incision is made, including the umbilicus at its central point.
 The incision is deepened to the rectus sheaths, and the neck of the sac is defined and freed from all
adjacent tissues.
 Horizontal incisions are made at each end of the rectus sheaths.
 The sac is opened at its neck.

POSTEROLATERAL WALL (LUMBAR OR ILIOCOSTAL REGION)

 Quadrilateral area situated between the lowest rib, the iliac crest, vertebral column and a vertical line
erected at its anterior superior iliac spine.
 The superficial fascia is arranged in 2 layers between which a large amount of fat is deposited.
Musculature (Superficial, Middle and Deep Layers)
Superficial
1. Latissimus dorsi
2. External abdominal oblique
Middle
1. Serratus posterior inferior
2. Sacrospinalis (erector spinae)
3. Internal oblique muscle
Deep
1. Quadrates lumborum
2. Psoas major
3. Transverses abdominis
Superficial muscles

 Latissimus dorsi arises from the lower 6 thoracic vertebrae, from all the lumbar and upper sacral spines
and from the supraspinous ligament through the posterior layer of the lumbodorsal fascia.
 It also has an origin in fleshy fibers from the outer lip of the iliac crest (posterior), last 3 or 4 ribs, and an
additional origion from the inferior angle of the scapula.
 Inserts by a tendon, 1 inch broad, into the floor of the intertubercular sulcus of the humerus.
 The muscle passes upward and laterally to its insertion, twists around the lower border of the teres
major.
 The upper border of the muscle forms a muscular pocket for this swcapular angle. Paralysis of this
muscle is one of the causes of “winging” of the scapula.
 The muscle takes part in the formation of the lumbar triangle of Petit. Bounded in front by the posterior
border of the external oblique, behind by the anterior border of the latissimus dorsi and below by the
iliac crest.
 Actions: adduction of the humerus, extension of the arm at the shoulder and medial rotation.
 Supplied by subscapular artery and thoracodorsal nerve.
 Tested by grasping the posterior axillary fold and asking the patient to cough vigorously; the muscle will
contract.
 External abdominal oblique descends downward and forward and presents free posterior border.
 Arises from the 9th, 10th and 11th ribs.
Middle Group of Muscles

 The serratus posterior superior is a flat muscle that lies under the rhomboids. Arises from the lower
cervical and upper thoracic spines, passes downward and laterally and inserts into ribs 2,3,4,5. Supplied
by intercostals nerves.
 The serratus posterior inferior is an important landmark in kidney operations because its lowermost
fibers lie superficial to the posterior lumbocostal ligament and mark this ligament.
 The sacrospinalis (erector spinae) muscle is elongated, extend upward from the dorsum of the sacrum
and posterior of iliac crest. 3 subdivisions:
-iliocostalis: lumbar, thoracic and cervical portions. Most lateral group
-longissimus is intermediate in position and widest and bulkiest. Its uppermost part is the
longissimus capitis
-spinalis is the most medial and shortest
 In kidney incisions only the lateral (iliocostalis) of the sacrospinalis muscle is encountered. Incision
should be made transversely, slightly below and parallel with the 12th rib.
 Internal oblique muscle forms the floor of the Petit’s triangle (lumbar trigone).
 The transverses spinalis is made up of 3 muscle masses which lie deep to the sacrospinalis and extend
from the 4th piece of sacrum to the skull. From superficial to deep: semispinalis, multifidus, and rotators.
Deep Group of Muscles

 Quadrates lumborum is flat and lies lateral to the psoas. Nerve supply is from lumbar nerves 1,2,3,4.
 Psoas minor is present in approximately 50% of individuals.
 Psoas major muscle arises from the 12th thoracic and all of the lumbar vertebra. Supplied by lumbar
nerves 2,3,4 and is a powerful flexor of the thigh.
 The sheath of the psoas is a stout membranous covering which is situated around the muscle.
  The transverses abdominis muscle arises from the fusion of 3 aponeurotic layers of lumbodorsal fascia
and extends over the anterolateral wall of the linea alba, where it becomes muscular. 12th thoracic and 1st
lumbar nerves. The 1st lumbar nerve gives rise to the larger iliohypogastric and smaller ilioinguinal
nerves. 12th intercostals artery (subcostal) and the lumbar artery and vein. The 12th intercostals artery is
the last parietal branch of the thoracic aorta.
 The subcostal vein lies above the artery, close to the last rib. Therefore, the order is: vein, artery, nerve.
Deep group of muscles

Quadratus lumburum
-flat muscle which lies lateral to the psoas.
-arises from the iliolumbar ligament (extends from the 5 th transverse process to the posterior part of the
iliac crest) from the adjoining part of the iliac crest and from the tips of the lower lumbar transverse
process.
-it takes an upward and medial course and inserted into the lower border of 12th rib.
-fixes the last rib, it assists the action of the diaphragm in inspiration and bends the vertebral column to
the side.
-anterior and middle layers of lumbar fascia surrounds this muscle.
-anterior layer of lumbosacral fascia separates it from the transversus fascia.
-upper portion is strengthened anteriorly by the lateral lumbocostal ligament.
-kidney extends 1inch lateral to the margin of this muscle, muscle can be drawn medially, only rarely is
it necessary to sacrifice its lateral bundles for exposure in kidney operations.

 Nerve supply
-lumbar nerves 1,2,3 and 4.

 Psoas major muscle

-considered part of iliacus muscle which migrated to iliac crest (psoas minor, present in approx. 50% of
individuals).
-occupies bony trough situated between the bodies and the transverse processes of lumbar vertebrae.
-arises from the 12th thoracic and all of the lumbar vertebrae and passes downward and laterally along
the margin of the pelvic brim.
- continues beneath the inguinal ligament, enters the thigh and inserts onto the traction epiphysis of the
lesser trochanter of the femur.
*this muscle is placed deeply and medially, does not come directly into view in kidney surgery.

 Nerve supply
-lumbar nerves 2, 3 and 4
-powerful flexor of the thigh
-assists in medial rotation of the thigh and flexes the trunk on the lower limb.

 Sheath of the psoas

-stout membranous covering which is situated around the muscle.
-attached medially to the bodies of the lumbar vertebrae, laterally it bends with the anterior layer of
lumbosacral fascia.
-extends behind the femoral artery into the thigh where it blends with the psoas tendon, above is kept
open by its upper attachment to the body of the second lumbar vertebra medially and the first lumbar
transverse process laterally.

 Transverse abdominis muscle

-arises from the fusion of the three aponeurotic layers of lumbodorsal fascia and extends over the
anterolateral wall toward the linea alba, where it becomes muscular
 -upper part of the transversus aponeurosis is strengthened by the posterior lumbocostal ligament
-peritoneum is separated from this muscle by extraperitoneal fat and transversalis fascia.

 Nerve supply
-12th thoracic and 1st lumbar
-1st lumbar nerve gives rise to the larger iliohypogastric and the smaller ilioinguinal nerve, these travels
between the psoas major and the quadratus lumborum muscles.
-iliohypogastric nerve pierces the transversus abdominis aponeurosis and then continues between it and
the internal oblique.
-ilioinguinal nerve travels along the inner surface of the transversus aponeurosis until it perforates that
muscle near the anterior part of the iliac crest, then pierces the internal oblique and continues through
the inguinal canal.

 Vessels
-12th intercostal artery (subcostal) and the lumbar artery and vein: last parietal branch of the thoracic
aorta, passes behind the lateral arcuate ligament above the subcostal nerve and accompanies that nerve
across the quadratus lumborum and through transversus muscle, ends in twigs to the transversus and the
internal oblique muscles.
-subcostal vein lies above the artery close to last rib (vein, artery, nerve).
-vein passes behind the lateral arcuate lig. to join the azygos vein or the inferior hemiazygos.

KIDNEYS
 Fascial relations
-closely related to the lumbodorsal and renal fasciae.

 Lumbodorsal fascia
-3 layers: anterior, middle, posterior- which fill the gap between the 12th rib and the iliac crest.
-posterior and middle are very dense and are stronger than the anterior.
1. Posterior layer arises from the tips of the spines of the lumbar, sacral and thoracic vertebrae.
2. Middle layer arises from the tips of transverse processes of lumbar vertebrae
3. Anterior layer arises from the anterior surfaces of the transverse processes near their roots.
*Psoas fascia springs from this layer
-As the three layers pass laterally they fuse near the outer boarder of the quadratus lumborum muscle;
the fusion results in the formation of a dense tendinous structure- aponeurosis of origin of the
transversus abdominis muscle.
-from this structure internal oblique muscle partly arises.
-between the posterior and middle layers of lumbodorsal fascia the sacrospinalis muscle group (erector
spinae) is found, between the middle and anterior layer, quadratus lumborum is found.

 Renal fascia
-derived from the transversalis fascia.
*Tobin (name ni sya) - renal fascia is derived from retroperitoneal tissue (opinion)
-at the lateral border of the kidney the transversalis fascia splits into an anterior (prerenal) and a
posterior (retrorenal) layer; in this way the perirenal fascial space of Gerota is formed.
-anterior layer is carried medially in front of the kidney and its vessels, aorta and the vena cava and
becomes continuous with its corresponding layer of the opposite side.
-posterior layer extends medially behind the kidney and blends with the fascia of quadratus lumborum
and psoas major muscle (through this layer, it gains attachment to vert. column)
-Two layers of renal fascia fuse at the upper pole of the kidney but remain separated at the lower pole
 This arrangement explains two facts:
1. It is possible to shell out the kidney within its capsule, leaving the suprarenal gland in situ, because
this fascia forms a separate chamber for the suprarenal gland
2. Diminution of the perirenal fat predisposes to mobility (floating of the kidney); since the renal fascia
does not fuse at the lower pole the kidney drops caudal but does not carry the suprarenal gland with
it.
*Mitchell (name) - anterior and posterior layers of renal fascia fuse superiorly and laterally, and united
medially and inferiorly (opinion)

 Fat surrounding the kidney

- arranged in two separate fat planes:
1. Pararenal fat (retrorenal fat)
- layer of fat which lies behind the kidneys, located between the aponeurosis of origin of the transversus
abdominis muscle and posterior layer of renal fascia (5mm thick).

2. Perirenal fat
-second fat layer, specialized layer, lies in the fascial space of Gerota
-forms fatty capsule of the kidney and runs completely around it, passing medially into hilum and
insulating itself between renal vessels, consistency is almost semiliquid- because of this, it gives the
kidney a certain amount of movement transmitted to it by the diaphragm.

 Kidney proper (vessels and nerves)

3 capsules:
1. Renal fascia (transversalis fascia)
2. Adipose capsule (perirenal fat)
3. Capsule proper (fibrous membrane which normally strips easily from the kidney

 Kidney
-reddish-brown in color and soft in consistency.
- 4 to 5 inches long, 2.5 inches wide and 1 inch thick at the middle.
-“bean- shaped” having upper and lower poles, anterior and posterior surfaces, medial and lateral border.

 Hilus
-vertical slit on medial border, bounded by thick lips of renal substance.
-through it, renal artery enter the gland, veins and ureter leave.
-Leads to a wide space inside the kidney- Sinus of the kidney

Structures that lie in the sinus:

1. Branches of renal artery
2. Tributaries of renal veins
3. Short funnel shaped tubes- calyces ( w/c unite to form the ureter)
4. Dilated proximal end of the ureter- pelvis of the ureter
5. Lymph vessels, nerve and fat

 Renal artery
-may divide into many branches before entering the gland, also send a branch behind the ureter-
retroureteric branch of the renal artery.
 *Anson, Cauldwell, Pick and Beaton (names) - stated that supernumerary renal arteries are more likely
to be present than absent and the arrangement of these vessels varies greatly.
*commonly, the main artery is accompanied by lesser accessory renals which may give off an internal
spermatic.
Accessory renals arise from the main renal, phrenic and suprarenal arteries, they are small and go to the
upper pole of the kidney; if large, they usually are arranged in serial manner and affect both the poles as
well as the hilus of the kidney.
-these vessels pass to the kidney either in front of or behind the inferior vena cava or may clasp the renal
vein

 Kidney “pedicle”
-ladder of vessels, arise from the aorta over an area which correspond to the entire height of the kidney

 Veins
-emerge through walls of the sinus and are quite small; unite to form larger veins which lie in front of
the arteries but may come to lie between the arteries and even behind the ureter.
*Anson and coworkers- state that the pattern of renal veins does not follow that of the renal arteries in
number or in course. Right renal vein may be single, double or triple; however, duplication of the left
renal vein is rare.
- division of single renal vein en route to the inferior vena cava is common, and division surround the
aorta to form a circumaortic venous ring.

 Left renal vein

-appears to be at the center of a huge venous network
*this makes nephrectomy hazardous and permits the spread of infectious materials and neoplasms.
-LRV is longer than the right; has greater distance to travel to the IVC, which lies to the right of midline.
-lymph vessels follow the veins and drain into nearby glands in the region of IVC and aorta.

 Nerves
-derived from 12th thoracic (subcostal nerve) and the 1 st lumbar (iliohypogastric and ilioinguinal nerves);
they run more or less parallel with the last rib

o Subcostal nerve
-accompanied by the subcostal vessels.
-3 nerves lie in pararenal fat; as they run forward, they come to lie between the transversus abdominis
and internal oblique muscles.
-both kidneys lie above the level of umbilicus; right kidney reaches the upper border of the 12 th rib, left
reaches the lower border of the 11th rib and can be placed approx. opposite the last thoracic and upper 2
lumbar vertebrae.

*rule: right organ lies somewhat lower than the left because of the volume of the right lobe of the liver.
-occasionally, kidneys occupy the same level, and in rare instances their relations are reversed.
-long axes of the organs are not parallel but are oblique to the spine; therefore, the upper poles are closer
to each other than are the lower.
-lower poles are about 1 inch above the highest point of the iliac crest; the outer border of the organ lies
about ½ inch lateral to the outer border of the sacrospinalis muscle.
 Kidneys rest on four muscles

1. Diaphragm above
2. Transversus muscle laterally
3. Psoas muscle medially
4. Quadratus lumborum (between the preceding two)
 o 12th rib
-important landmark in kidney anatomy, separated from kidney by the pleura and diaphragm. It takes an
oblique course downward, while lower border of the pleaura is horizontal; therefore, these two lines
cross like “X”
-very short so that sacrospinalis muscle covers it completely, 11th rib is often mistaken for the 12th
-12th rib and the outer border of the sacrospinalis muscle form an angle- kidney angle. Pressure over this
angle usually elicits tenderness in the kidney lesions; lumbar incisions for kidney operations commence
here.

 Relations
-anterior surface of kidneys differ, both capped by the suprarenal glands, right kidney’s anterior surface
is related to liver above, hepatic flexure of colon below, second part of duodenum near kidney hilum.
-lower pole is crossed by ascending branch of the right colic artery. Covered with peritoneum except at
its extreme upper, inner, and lower parts.
-coil of small intestine may come into relation with the inferior pole.
-left kidney has in front of it the stomach above, spleen laterally, pancreas transversely across it from the
hilum to the splenic area, and the transverse colon below
-lower pole is in contact anteriorly and medially with coils of jejunum. Crossed by the ascending branch
of the left colic artery.
-only gastric, splenic and jejunal surfaces are covered by peritoneum.

o Diaphragm
-separates the upper pole of the kidney from the pleura. Dorsal to the pleura are the 12 th rib and the
muscles of the back.

o Kidneys
- are kept in place by attached vessels, pressure of surrounding organs, fat and fascia.
-move downward with respiration for an excursion of about 2cm.
-At times, lower poles of the kidneys are fused across the midline by thick bridge of kidney tissue which
crosses in front of the IVC and aorta – horseshoe kidney

o Anomalies of the urinary tract

-aplasia- extreme form of hypoplasia

SURGICAL CONSIDERATIONS
 Nephrectomy
*Furcolo (name) - describe a transfascial approach which gives excellent exposure and produces
minimal damage.
-incision begins about 1 inch above the junction of the last rib and erector spinae muscle group. This
passes almost vertically downward, with a slight inclination forward, to a point about halfway between
the 12th thoracic rib and the iliac crest. From here it curves inward and forward and runs parallel with the
iliac crest about 2 inches from it. Incision is carried through the skin and the subcutaneous tissue until
the musculature is exposed.

o Muscle layer consist of:

-Latissimus dorsi and serratus posterior inferior at the posterior end of the wound and the external
oblique at the anterior extremity.
 -latissimus dorsi, serratus posterior inferior, external oblique, internal oblique and transversus abdominis
are divided until the lumbar fascia is exposed. Deep to this fascia is exposed.
-Deep to this fascia are the 12th dorsal nerve and vessels which cross from above downward and forward.
*If possible they should be spared.
-A well-developed layer of pararenal (retrorenal) fat will be found between the lumbar aponeurosis and
the retrorenal leaf of perinephric fascia.
-retrorenal leaf of renal fascia is opened and another fat layer, perirenal layer comes into view– this is
the Surgeon’s cleavage plane since it is the fat which immediately surrounds the kidney.
-this fat continues around the pelvis, great vessels and ureter.
-peritoneum is pushed forward as fat is wiped away, both poles are mobilized and kidney is delivered
into the wound.
-Nephrectomy can be accomplished after exposing and delivering the pedicle with its contained vessels
and ureter. These are clamped and divided, kidney is removed and pedicle is ligated.

 Kidney transplantation
-iliac fossa is exposed retroperitoneally through an incision made above and parallel with the inguinal
ligament.
-renal artery is anastomosed end-to-end to the hypogastric artery and the renal vein end-to-side to the
external iliac vein.
-donor ureter is passed through the bladder wall and a submucosal tunnel is made for the
ureteroneocystostomy, placed towards the patient’s right ureter.
*It is advisable to ligate or cauterize the lymphatic vessels to avoid lymphoceles.

 Adrenal glands
-Two: situated on each side, in the epigastric region
-flattened from before backward, broad from side to side and set upon the superior extremity of the
corresponding kidney.
-They have separate fascial capsules; a) permits the removal of kidney without the removal of the
suprarenal. b) An adrenal does not move with the floating kidney
*Davie (name) - found that in 6 out of 1,500 post-mortem examinations the adrenal and the kidney were
fused so intimately that nephrectomy in these cases would have resulted also in suprarenalectomy.

 The right adrenal

-pyramidal in shape and smaller than the left
-situated between the diaphragm and right lobe of liver
-anterior surface is related to the inferior vena cava medially and the bare area of the liver laterally.
-posterior surface is related to the kidney inferiorly and the crus of the diaphragm superiorly.
-the right celiac ganglion lies on the medial side of the right adrenal gland.

 The left adrenal

-semilunar in shape and seems to have slipped down on the medial border of the kidney as far as the
renal vessels.
-Therefore, its lower pole is in contact with the renal vessels and its upper pole in in contact with the
spleen
-anterior surface is related to the stomach superiorly and to the pancreas inferiorly.
-posterior surface is related to the crus of the diaphragm medially and the kidney laterally.

 New approaches to the adrenal glands

-3 basic approaches, choice is depending on the habitus of the patient and exposure of the surgeon.
1. Transabdominal approach- advantage of permitting simultaneous bilateral exploration of the adrenals
through a single incision. Time consuming and difficult procedure.
2. Thoracoabdominal approach- excellent exposure to a single adrenal and its surrounding anatomy.
3. Bilateral posterior approach- done with the patient in the prone position. It is necessary to resect the
11th and 12th ribs. *postoperative morbidity is said to be less in this operation, disadvantage is the
limited exposure