Abdominal Wall

Introduction
An abdominal wall formed of skin, fascia, and muscle encases the
abdominal cavity and viscera.

The abdominal wall does not only contain and protect the intra-abdominal
organs but can distend, generate intrabdominal pressure, and move the
vertebral column.

Detailed knowledge of the components of the abdominal wall is essential

for surgeons both in understanding the pathology affecting it and planning
surgical access to the abdominal cavity.

Abdominal wall defects may be either congenital or acquired and can have
a significant impact on patients' quality of life.

The abdominal wall connects to the skeletal framework at the thoracic cage
superiorly and pelvic bones inferiorly.

The abdominal wall has several different layers that are essential to
understand when making surgical incisions.

From superficial to deep, these layers include:

Skin
Subcutaneous tissue, which can further subdivide into: Camper's fascia - a
superficial fatty layer and Scarper's fascia - a deep membranous layer.
Abdominal muscles, their investing fascia, and aponeuroses
Transversalis fascia
Parietal peritoneum .
The abdominal wall performs several vital functions.

The abdominal muscles may be divided broadly into anterolateral and

posterior components.

The abdominal muscles contribute to movements of the trunk, including

flexion, extension, lateral flexion, and rotation.

Simultaneous contraction of abdominal muscles can facilitate the

generation of intraabdominal and intrathoracic pressure critical in sneezing,
coughing, vomiting, and defecating.

Surface Anatomy
The external surface of the abdominal wall can be subdivided into regions
to allow an accurate description of examination findings.

The internal surface of the anterior abdominal wall can be appreciated

clearly when the peritoneal space is entered and inflated during
laparoscopic surgery.

Embryology
The mesoderm develops into the musculature and fascia of the abdominal
wall.

Blood Supply and Lymphatics

Superiorly, the abdominal wall ultimately receives blood from and drains to
tributaries of the subclavian vessels.

The lateral abdominal wall and lumbar regions receive vascular supply from
branches of the thoracic aorta, including the tenth and eleventh posterior
intercostal arteries and the subcostal.

Inferiorly, the anterior abdominal wall is supplied superficially by branches

of the femoral artery, and deeply by branches of the external iliac artery.

The inferior epigastric artery ascends the inner surface of the abdominal
wall in the lateral umbilical folds on the deep surface of rectus abdominis to
supply the deep suprapubic and umbilical regions.
The major veins draining the anterior inferior abdominal wall follow the
same routes as their arterial counterparts.

In cases of severe portal hypertension, these anastomoses may become a

site of a portosystemic shunt, becoming engorged and visible on the
abdominal surface as the "Caput medusae" sign.

An understanding of the anatomy of superficial epigastric and deep

epigastric vessels is particularly crucial for surgeons constructing free flaps
from the inferior abdominal wall to use in reconstructive surgery.

The posterior abdominal wall receives blood from branches of the

abdominal aorta.

Superficial lymphatic drainage of the skin and subcutaneous tissue of the

anterolateral abdominal wall gets divided by the transumbilical plane.

Deep lymphatic drainage of the anterolateral abdominal wall muscles

follows the deep blood vessels.

Nerve Supply
Innervation of the muscles of the anterolateral abdominal wall derives
primarily from the T7-T12 intercostal nerves.

A "Transversus abdominis plane" block is an option to provide regional

anesthesia of the anterolateral abdominal wall.

Muscles
Anterolateral Abdominal Wall Muscles
Anterior chest wall strength and movement receive contributions laterally
by three layers of large flat paired muscles: the external oblique, internal
oblique, and transversus abdominis.

External Oblique
The external oblique is the most superficial of the anterolateral abdominal
wall muscles.

Inferiorly, all fibers travel anterior to the rectus abdominal muscle.

Its upper portion travels posteriorly to the rectus abdominal muscles,

contributing to the posterior rectus sheath.

The contraction of the transversus abdominis causes compression of

abdominal contents.

Surgical Considerations
When planning the approach to the abdominal cavity, a surgeon must
balance considerations of ease of access to complete the operation against
morbidity caused by the approach.

An emergency exploratory laparotomy will involve a sizeable vertical

midline incision to allow quick access and a broad view of the abdominal
contents.

Incisions require careful planning to avoid significant motor nerves as

denervation and paralysis of abdominal wall musculature will increase the
risk of hernias.

Clinical Significance
Knowledge of the working anatomy of the abdominal wall is required to
understand its pathology and potential for surgical repair.

Defects in the abdominal wall will affect its ability to contain abdominal
contents, which can manifest clinically as a congenital or acquired hernia -
an abnormal protrusion of tissue through an opening.

Congenital hernias may occur due to weak spots in the neonatal abdominal
wall or embryological malformations during development.
Umbilical hernias involve herniation of abdominal contents through a patent
umbilical ring after birth.

An omphalocele occurs due to malrotation of the abdominal contents

causing them to be outside the abdominal wall, covered only by
peritoneum.

In gastroschisis, the intestines lie outside the abdominal wall with no

overlying membrane due to a failure of fusion of the lateral body wall folds
in embryonic development.

Acquired hernias of the abdominal wall occur in areas of weakness and

may cause complications, including pain, bowel obstruction, and
strangulation.

Figure 1. Abdomen Muscles, [SATA]. Contributed by Steve Bhmji, MS, MD,

PhD.
Reference
Flynn, William, and Paula Vickerton. “Anatomy, Abdomen and Pelvis,
Abdominal Wall.” StatPearls, StatPearls Publishing, 2020. PubMed,
http://www.ncbi.nlm.nih.gov/books/NBK551649/.

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