ANTERIOR ABDOMINAL WALL,

PERITONEUM AND HERNIA AGBAJE MOJEED ADEDOYIN

 INTRODUCTION
It’s a multiple muscular and fascia layer

It forms the protective layer that protects the viscera

organs

It encloses the abdominal cavity and holds the

abdominal visceras such as; liver, stomach, kidney,
pancreas, spleen, suprarenal gland, ureter etc

The AAW constitutes a hexagonal area

 Boundary:

 Superiorly: costal margin and Xiphoid process

 Laterally: Midaxillary line

 Inferiorly: Iliac crest, pubis and pubic symphysis

 ABDOMINAL AREAS
The abdominal areas are classified into two
 Quadrants
 Regions

The abdomen is divided into 4quadrants by a

vertical and horizontal plane
 Right upper
 Right Lower
 Left upper
 Left lower
REGIONS OF THE ABDOMEN
The abdomen is divided into 9 regions by :
 Two vertical lines at the level of:

 Midclavicular point superiorly

 Midinguinal point inferiorly

 Two horizontal lines at the level of:

 Subcostal edges superiorly

 Right and left iliac tubercles inferiorly

The regions;
 Right hypochondrium

 Epigastic

 Left hypochondrium

 Right Lumbar

 Umbilical

 Left Lumbar

 Right inguinal/groin

 Pubic

 Left inguinal/groin
 ANTERIOR ABDOMINAL WALL
The Layers of the abdominal wall from out side to inside.

 Skin

 Soft tissue

 Muscles and connective tissue

 Extraperitoneal fascia

 Parietal peritoneum.
 SKIN
Its attached to the underlying structure except at the umbilicus where
its attached to the scar tissue
The umbilicus is a scar representing the site of attachment of the
umbilical cord in the fetus; it is situated in the linea alba.
SOFT TISSUE/SUPERFICIAL FASCIA
Lies between the skin and the
muscles of AAW
In the lower part the superficial
fascia differentiates into;
 Superficial fatty layer (camper’s
fascia)
 Deep membanous layer
Between this fascia the
superficial vessels and nerves lies
and the superficial lymph nodes
at the groin region
 SUPERFICIAL FATTY LAYER (CAMPER’S LAYER)
Is a thick, areolar in texture and contains
variable amount of fat

Continuous with the superficial fascia over the

rest of the abdomen

In male its continuous over the penis and outer

surface of the spermatic cord into the scrotum

In the scrotum it changes to a thin smooth

muscle fibre called the DARTOS MUSCLE

In the female, its continues from the suprapubic

skin of the abdomen into the labia majora and
perineum
 DEEP MEMBRANOUS LAYER (SCARPA’S LAYER)
It’s a membranous fascia and contains elastic fibres

Histologically, it measures about 0.5-1.0mm

Superiorly, its continuous with the superficial fascia over the remainder of the trunk

Its loosely connected by areolar tissue to the aponeurosis of external oblique muscle

In the midline, its adherent to the linea alba and pubic symphysis
Inferiorly, fuses with the iliac crest

It extends on the scrotum, where its continuous with the membranous layer of the superficial
fascia of the perineum (Colle’s Fascia)

In Male, it extends to the dorsum of the penis to form the FUNDIFORM LIGAMENT OF
THE PENIS
SCHEMATIC DIAGRAM OF THE LAYERS OF THE AAW
MUSCLES OF ANTERIOR ABDOMINAL WALL
All the muscles of the AAW act together to perform a range of functions, some of
which involves the generation of a positive pressure within one or more body
cavities

This is required by activity such as expiration, defecation, micturition, coughing,

vomiting and parturition.

The AAW muscle consist of 3 broad thin sheet muscles that are aponeurotic
anteriorly; External Oblique Muscle, Internal Oblique Muscle and transversus
abdominis muscle

On either side of the midline anteriorly is in addition a wide vertical muscle called
the Rectus abdominis
As the aponeurosis of the three sheets pass forward they enclose the rectus abdominis
to form the Rectus Sheath

The lower part of the rectus sheath contains a small muscle called the pyramidis
 CLASSIFICATION OF AAW MUSCLES
It can be classified based on the shape or position
 Based on shape

 Flat: transversus abdominis muscle, Internal Oblique Muscle and External Oblique
Muscle (TIE) from internal to external arrangement

 Vertical: Rectus Abdominis muscle, Pyramidalis muscle

 Based on position

 Anterolateral: transversus abdominis muscle, Internal Oblique Muscle and

External Oblique Muscle (TIE) from internal to external arrangement

 Anterior: Rectus Abdominis muscle, Pyramidalis muscle

 EXTERNAL OBLIQUE MUSCLE
Largest and most superficial of the three anterolateral muscles

ORIGIN
 External surface and inferior border of the lower eight ribs (5th – 12th ribs)

INSERTION
 Lateral lips of iliac crest, pubic crest and pubic tubercle
 Aponeurosis ending in midline raphe(linea alba)

BLOOD SUPPLY
 Branches from the lower posterior intercostal and subcostal areties
 Superior and inferior epigastric arteries
 Superficial and deep circumflex arteries
 Posterior Lumbar arteries
INNERVATION
 Anterior rami of lower six thoracic
spinal nerve(T6- T12)

 Terminal branches of the lower five

intercostal nerves

FUNCTION
 Maintenance of abdominal tone

 Increasing intra-abdominal pressure

 Lateral flexion of the trunk against

resistance
There is a triangular-shaped defect in the external oblique aponeurosis that lies immediately
above and medial to the pubic tubercle known as superficial inguinal ring

The spermatic cord (or round ligament of the uterus) passes through this opening and carries the
external spermatic fascia (or the external covering of the round ligament of the uterus) from the
margins of the ring

Between the anterior superior iliac spine and the pubic tubercle, the lower border of the
aponeurosis is folded backward on itself, forming the inguinal ligament .
 INTERNAL OBLIQUE MUSCLES
Broad, thin, muscular sheet that lies deep to the external oblique.

Most of its fibers run at right angles to those of the external oblique.

ORIGIN :
 It arises from the lumbar fascia, the anterior two thirds of the iliac crest, and the lateral two thirds
of the inguinal ligament.
 The muscle fibers radiate as they pass upward and forward.

INSERTION :
 The muscle is inserted into the lower borders of the lower three ribs and their costal cartilages, the
xiphoid process, the linea alba, and the symphysis pubis.

VASCULAR SUPPLY :
 Branches from the lower posterior intercostal and subcostal arteries,
 the superior and inferior epigastric arteries,
 the superficial and deep circumflex arteries
 the posterior lumbar arteries.
INNERVATION :

 The terminal branches of the lower five intercostal nerves

 the subcostal nerve from the ventral rami of the lower six thoracic spinal nerves,

 in addition to a small contribution from the iliohypogastric and ilioinguinal nerves from
the ventral ramus of the first lumbar spinal nerve.

ACTIONS :

 Internal oblique contributes to the maintenance of abdominal tone

 increasing intra-abdominal pressure

 enables lateral flexion of the trunk against resistance.

 TRANSVERSUS ABDOMINIS
The deepest of the lateral abdominal muscles

Its fibers run horizontally forward .

ORIGIN :

 It arises from the deep surface of the lower six

costal cartilages (interdigitating with the
diaphragm),

 the lumbar fascia,

 the anterior two thirds of inner lip of the iliac crest

 the lateral third of the inguinal ligament. •

INSERTION :

 It is inserted into the xiphoid process, the linea

alba, and the symphysis pubis
VASCULAR SUPPLY :

 Branches from the lower posterior intercostal and subcostal arteries,

 the superior and inferior epigastric arteries,

 the superficial and deep circumflex arteries

 the posterior lumbar arteries.

INNERVATION :

 The terminal branches of the lower five intercostal nerves,

 the subcostal nerve

 the iliohypogastric and ilioinguinal nerves.

ACTIONS :

 Transversus abdominis contributes mainly to the maintenance of abdominal tone

 increasing intra abdominal pressure.

Lower fibres of internal oblique are joined by similar fibers from the transversus to
form the conjoint tendon .

As the spermatic cord (or round ligament of the uterus) passes under the lower border
of the internal oblique, it carries with it some of the muscle fibers that are called the
cremaster muscle.
 PYRAMIDALIS
ORIGIN
 anterior surface of the pubis.

INSERTION
 Linea alba

Vascular supply :
 Pyramidalis is supplied by branches of the
inferior epigastric artery, with some
contribution from the deep circumflex iliac
artery.

INNERVATION
 Twelvth thoracic nerve T12

ACTION
 Tenses the linea alba
 RECTUS ABDOMINIS
The rectus abdominis is a long strap muscle that extends along the whole length of the
anterior abdominal wall.

It is broader above and lies close to the midline, being separated from its fellow by the linea
alba.

ORIGIN :

 The rectus abdominis muscle arises by two heads, from the front of the symphysis pubis
and from the pubic crest.

INSERTION :

 It is inserted into the fifth, sixth, and seventh costal cartilages and the xiphoid process .

 When it contracts, its lateral margin forms a curved ridge that can be palpated and often
seen and is termed the linea semilunaris. This extends from the tip of the ninth costal
cartilage to the pubic tubercle.
The rectus abdominis muscle is divided into distinct segments by three transverse tendinous intersections:
 one at the level of the xiphoid process,

 one at the level of the umbilicus

 one halfway between these two.

 These intersections are strongly attached to the anterior wall of the rectus sheath.

The rectus abdominis is enclosed between the aponeuroses of the external oblique, internal oblique, and
transversus, which form the rectus sheath.

VASCULAR SUPPLY :
 Rectus abdominis is supplied principally by the superior and inferior epigastric arteries

 Small terminal branches from the lower three posterior intercostal arteries,

 the subcostal artery,

 the posterior lumbar arteries

 the deep circumflex artery may provide some contribution, particularly to the lateral edges and the lower
attachments, and they form small anastomoses with the lateral branches of the epigastric arteries.
INNERVATION :
 Rectus abdominis is innervated by the terminal branches of the ventral rami of the lower six or
seven thoracic spinal nerves via the lower intercostal and subcostal nerves.

ACTIONS :
 The recti contribute to the flexion of the trunk.
 They also contribute to the maintenance of abdominal wall tone required during straining.
 Rectus abdominis provides an excellent myocutaneous flap, either pedicled or free, because of
the excellent vascularity provided by the epigastric vessels and because the muscle belly is
separated from surrounding tissue within the rectus sheath.
 RECTUS SHEATH
The rectus sheath is a long fibrous sheath that encloses the rectus abdominis muscle and
pyramidalis muscle (if present)

formed from the aponeuroses of all three lateral abdominal muscles

anterior portion fuses with periosteum and ligaments at sites of the muscle’s
attachments
Description the rectus sheath is considered at three levels :

Above the costal margin, the anterior wall is formed by the aponeurosis of the
external oblique. The posterior wall is formed by the thoracic wall that is, the
fifth, sixth, and seventh costal cartilages and the intercostal spaces.

Between the costal margin and the level of the anterior superior iliac spine, the
aponeurosis of the internal oblique splits to enclose the rectus muscle; the
external oblique aponeurosis is directed in front of the muscle, and the
transversus aponeurosis is directed behind the muscle.

Between the level of the anterosuperior iliac spine and the pubis, the
aponeuroses of all three muscles form the anterior wall. The posterior wall is
absent, and the rectus muscle lies in contact with the fascia transversalis.
 LINEA ALBA
The linea alba is a tendinous raphe extending from the xiphoid process to the
symphysis pubis and pubic crest.

It lies between the two recti and is formed by the interlacing and decussating
aponeurotic fibres of external oblique, internal oblique and transversus
abdominis.

15–22 mm along its course

widest at or just above the umbilicus and narrowing at superior and inferior
extremes

Below the umbilicus, the linea alba narrows progressively as the rectus muscles
lie closer together.
The linea alba has two attachments at its lower end:
 its superficial fibres are attached to the symphysis pubis,

 its deeper fibres form a triangular lamella that is attached behind rectus
abdominis to the posterior surface of the pubic crest on each side.

 This posterior attachment of linea alba is named the ‘adminiculum lineae

albae'.

The linea alba is crossed from side to side by a few minute vessels.

It is visible only in the lean and muscular, as a slight groove in the anterior
abdominal wall.
 LINEA SEMILUNARIS
Extends from the tip of the ninth costal
cartilage to the pubic tubercle.

site of transition from the aponeurotic part

to the muscular part of the transverse
abdominal muscle
LINEA SEMICIRCULARIS (ARCUATE LINE OF DOUGLAS)
Located one-third of the distance between the umbilicus and the pubis

the arcuate line represents the lower limit of the posterior rectus sheath

Below the arcuate line only the transversalis fascia remains between the rectus abdominis and
peritoneum

Here, both Spigelian and arcuate line hernias may occur

arcuate line also serves as a landmark where the inferior epigastric vessels perforate the rectus
abdominis

The arcuate line must be incised at its lateral-most point in order to enter the space of Retzius
and Bogros from within the rectus sheath
 UMBILICA
It consists of skin, a fibrous layer (representing the area of fusion between the round ligament
of the liver, the median umbilical ligament, and two medial umbilical ligaments), the
transversalis fascia,

the umbilical fascia surrounding the urachal remnant, and peritoneum A fibrous cicatrix, the
umbilicus, lies a little below the midpoint of the linea alba, and is covered by an adherent area
of skin.

In the fetus, the umbilicus transmits the umbilical vessels, urachus and, up to the third month,
the vitelline or yolk stalk.

It closes a few days after birth, but the vestiges of the vessels and urachus remain attached to
its deep surface.
The remnant of the fetal left umbilical vein forms the round ligamentum of the liver.

The obliterated umbilical arteries form the medial umbilical ligaments, enclosed in
peritoneal folds of the same name.

The partially obliterated remains of the urachus persist as the median umbilical ligament.
 TRANSVERSALIS FASCIA
thin layer of connective tissue lying between the deep surface of transversus
abdominis and the extraperitoneal fat

Posteriorly, it fuses with the thoracolumbar fascia

transversalis fascia is prolonged as the internal spermatic fascia

 BLOOD SUPPLY
The skin near the midline is supplied by branches of the superior and the inferior epigastric
arteries.

The skin of the flanks is supplied by branches of the

 Intercostal arteries

 Lumbar arteries

 Deep circumflex iliac arteries

The superior epigastric artery, one of the terminal branches of the internal thoracic
artery, enters the upper part of the rectus sheath It descends behind the rectus muscle,
supplying the upper central part of the anterior abdominal wall, and anastomoses with
the inferior epigastric artery.

The inferior epigastric artery is a branch of the external iliac artery just above the
inguinal ligament. the rectus muscle, supplying the lower central part of the anterior
abdominal wall, and anastomoses with the superior epigastric artery.

The deep circumflex iliac artery is a branch of the external iliac arteryjust above the
inguinal ligament. It supplies the lower lateral part of the abdominal wall.

The lower two posterior intercostal arteries, branches of the descending thoracic
aorta, and the four lumbar arteries, branches of the abdominal aorta, pass forward
between the muscle layers and supply the lateral part of the abdominal wall
 VENOUS DRAINAGE
SUPERFICIAL VEINS
 The superficial veins form a network that radiates out from the umbilicus.

 Above, the network is drained into the axillary vein via the lateral thoracic vein.

 Below, into the femoral vein via the superficial epigastric and great saphenous veins.

DEEP VEINS
 The deep veins of the abdominal wall, the superior epigastric, inferior epigastric, and
deep circumflex iliac veins, follow the arteries of the same name and drain into the
internal thoracic and external iliac veins.
 LYMPHATICS
Superficial lymphatics above the umbilicus

pass in a superior direction to the axillary

nodes

below the umbilicus passes in an inferior

direction to the superficial inguinal nodes.

The deep lymph vessels follow the arteries and

drain into the internal thoracic, external iliac,

posterior mediastinal, and para-aortic (lumbar)

nodes.
 NERVE SUPPLY
The skin and muscles of the anterolateral abdominal wall are supplied by T7 to T12

and L1 spinal nerves

Dermatomes of the abdominal wall.
 in the epigastrium over the xiphoid process : T7

 The umbilicus: T10

 just above the inguinal ligament and the symphysis pubis : L1