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Abdominal Wall and

Cavity

Irwan

Content:

Surface Anatomy
Muscular Wall
Review vascularisation and
innervation
Inguinal region
Peritoneum and Peritoneal Cavity

Surface Anatomy
Bony Landmarks
around
Abdomen
Iliac crest
Anterior superior iliac
spine (ASIS)
Pubic crest
Inguinal ligament
Costal margin
Xiphoid process

Abdominal Wall from


surface

Rectus
abdominis
Linea alba
Iliac crest

Abdominal Wall from


surface

Linea Alba

Median raphe
Extends from xiphoid to pubic
symphysis.
Lies between paired rectus
abdominus muscles.
= fusion of aponeuroses of
transversus abdominus, internal
oblique, and external oblique.

Abdominal Wall from


surface

Linea semilunaris:
Along lateral margin of rectus
abdominus.
Crosses costal margin near tip of
9th costal cartilage.
Arcuate line:
Lower free edge of posterior
lamina.
Lies midway between umbilicus
and pubis.

Abdominal Wall from


surface

Inguinal ligament:

Thickened lower border of external


oblique aponeurosis.
From anterior superior iliac spine to
pubic tubercle.

Borders of the Abdomen


Superior:
Costal cartilages 7-12.
Xiphoid process:
Level of 10th cartilage = L3

Inferior:
Pubic bone and iliac crest:
Level of L4.

Umbilicus:
Level of IV disc L3-4

Abdominal Quadrants
Formed by two intersecting lines:
Intersect at umbilicus.
Quadrants:
Upper left.
Upper right.
Lower left.
Lower right.

Abdominal Regions
Right and left
hypochondriac:
Contain liver -Fig. 1

Epigastric:
Contains: liver, stomach,
pancreas

Right and left lateral


(lumbar):
Right contains ascending

Fig. 1 Regio abdomen

Abdominal Regions
Umbilical:
Contains small intestine and transverse
colon.
Right and left inguinal:
Right contains ileocecal junction and
appendix.
Left contains sigmoid colon.
Hypogastric:
Contains small intestine, urinary bladder
(full), pregnant uterus.

Cutaneous Nerves
Derived from ventral rami of T7
through L1.
Pass inferiorly and medially in plane
between transverse and internal
oblique muscles.
Motor innervation:
To abdominal muscles.

Cutaneous innervation:
Lateral cutaneous branches.
Anterior cutaneous branches:
Penetrate rectus sheath.- Fig. 2

Cutaneous Nerves
Ventral rami of T7 through T11: Fig. 3

= thoracoabdominal nerves.
T7 to dermatome over xiphoid process.
T10 at level of umbilicus.
Subcostal nerve
Ventral ramus of L1: Fig. 2

Gives rise to:


iliohypogastric nerve.
ilioinguinal nerve.

Fig. 2 Nerves

Fig. 3 Thoracoabdominal nerve

Fascia
Superficial:
Campers fascia
Continuous with fascia over thorax
and thigh.
Fatty layer.

Fascia
Deep Superficial:
Scarpas fascia
Membranous layer.
Continues into perineum as:
Superficial perineal fascia = Colles
fascia.

Deep:
Thin layer covering abdominal
muscles.

Abdominal wall divided into:


1. Anteriolateral abdominal wall
Anterior wall
Right lateral wall (Right Flank)
Left lateral wall (Left Flank)
2. Posterior abdominal wall

1. Anteriolateral Abdominal Wall


This extended from the thoracic cage to the
pelvis and bounded :
Superiorly
7th through 10th costal cartilages and and
xiphoid process
Inferiorly
Inguinal ligaments and the pelvic bones.
The wall consists of skin, subcutaneous
tissues (fat), muscles, deep fascia and
parietal peritoneum.

1. Anteriolateral Abdominal Wall


MusclesFig. 4 & Fig. 5
3 Flat Muscles with strong sheet like
aponeuroses
External Oblique (hands-in-pocket)
Internal Oblique (fibers perpendicular to

external)
Transversus Abdominis (wraps around)
2 Vertical Muscles
Rectus Abdominis - vertical midline
Pyramidalis

Fig. 4 Anterolateral abdominal muscles

Fig. 5 Anterolateral abdominal muscles

Rectus sheath:
Encloses rectus abdominis.
Formed by fusion of fascia of other three layers
of abdominal muscles.
Anterior and posterior laminae. (layers)
Arcuate line is the lower free edge of the
posterior lamina
Lies midway between umbilicus and pubis.

Muscle Layers: Innervations


Lower intercostal spinal nerve.
Subcostal spinal nerve.
First lumbar spinal nerve.

1. Anteriolateral Abdominal Wall


Arteries
Internal Thoracic Artery
Superior Epigastric Artery
External Iliac Artery
Inferior Epigastric Artery
Deep Circumflex Iliac Artery
Femoral Artery
Superficial Epigastric Artery
Superficial Circumflex Artery

1. Anteriolateral Abdominal Wall


Veins

External iliac vein:


Receives from epigastric and deep
circumflex iliac veins.
Femoral vein:
Receives superficial circumflex iliac vein,
Superficial epigastric vein,
Superficial external pudendal vein.
Superior epigastric vein:
Drains to brachiocephalic vein.

1. Anteriolateral Abdominal Wall


Functions

Form strong expandable support.


Protect the abdominal viscera from injury
such as low below in boxing
Compress the abdominal content
Helps to maintain or increase the
intraabdominal pressure.
Move the trunk and help to maintain posture.

Posterior Abdominal Wall


Lumbar vertebrae and IV discs.
Muscles
Psoas, quadratus lumborum, iliacus
Lumbar plexus
Ventral rami of lumbar spinal nerves.
Fascia
Diaphragm
Contributing to the superior part of the
posterior wall

Fat, nerves, vessels (IVC, aorta) and


lymph nodes.

Posterior Abdominal Wall


Between the parietal peritoneum
and the muscles (retroperitoneal
space) Fig. 6
The psoas fascia or psoas sheath.
The quadratus lumborum fascia.
The thoracolumbar fascia.

Fig. 6 posterior abdominal muscles

Posterior Abdominal Wall


Muscles
Three paired muscles
Psoas major
Iliacus
Quadratus Lumborum

Posterior Abdominal Wall


Nerves
Somatic nerves
The sub costal nerves
The lumbar nerves
The lumbar plexus of nerves branches are:
(a) The obturator nerves (L2 L4)
(b) The femoral nerves (L2 through
L4)
(c) Ilio inguinal and ilio hypogastric
nerves (L1)
(d)
Gentio femoral (L1 L2)
(e)
Lateral femoral cutaneous nerves

Posterior Abdominal Wall


Nerves
Autonomic nerves
One cranial nerve (the vagus)
Several different splanchnic
nerves that deliver presynaptic
sympathizer and
parasympathetic fibers to the
plexus and sympathetic ganglia.

Posterior Abdominal Wall


Nerves
Sympathetic Nerves
Abdomino-pelvic splanchic N. from the thoracic and
abdominal sympathetic trunks
Prevertebral sympathetic ganglia
Periarterial plexus
Abdominal autonomic plexus
Celiac plexus
Superior mensentric plexus
Inferior mensentric plexus.
Celiac plexus
Superior hypogastric plexus
Inferior hypogastric plexus

Posterior Abdominal Wall


Blood Vessels
Aorta and its branches
IVC and its tributeries

Applied Anatomy
Posterior abdominal pain:
Ilio-psoas has relationship to kidney, ureters,
caecum, appendix, colon, pancreas.etc.
When any of these structures is diseased
movement of the ilio psoas usually causes pain.
When intra abdominal inflammation is
suspected the Ilio Psoas Test performed by
moving ileopsoas muscle and if positive if it
causes pain.

Psoas Abscess
Hematogenous
spread to the
lumbar
vertebrae may
form an abscess
which may
spread from the
vertebrae into
the Psoas
sheath
producing a
Psoas abscess.

Partial Lumbar Sympethectomy


Some patients with arterial disease
in the lower limbs (ischaemia)
may include partial lumbar
sympathectomy by removal of
two or more lumbar sympathetic
ganglia

IVC Obstruction
Three collateral routs formed by
valveless veins of the trunk are
available for venus blood to
return to the heart.

the

inferior epigastric vein


superficial epigastric vein
epidural venous plexus inside
vertebral column.

Inguinal Region
Inguinal Canal:
Oblique passage through lower
abdominal wall.
Site of potential weakness.
Transmits:
Spermatic cord in males.
Round ligament of uterus in
females.
Extends between superficial and
deep inguinal rings.

Inguinal Region
Inguinal Canal:
1. Superficial inguinal ring:
Triangular defect in the
aponeurosis of the external oblique
muscle layer.
Superficial opening of the inguinal
canal.
Lies above and lateral to pubic
tubercle.
Larger in males:
Transmits spermatic cord in
males.

Inguinal Region
Inguinal Canal:
2. Deep inguinal ring:
Opening of the evagination of
the transversalis fascia.
Lies above inguinal ligament
midway between anterior iliac
spine and pubic tubercle.

Inguinal Region
Inguinal Canal:
* Male: spermatic cord:
Vas deferens.
Ilioinguinal nerve.
Genital branch of genitofemoral
nerve.
Testicular arteries and veins.
Pampiniform plexus
Lymph vessels.
Cremaster muscle.

Inguinal Region
Inguinal Canal:
* Female:
Round ligament.
Ilioinguinal nerve.
Lymph vessels.

Inguinal Region
Inguinal Canal:
* Female:
Round ligament.
Ilioinguinal nerve.
Lymph vessels.

Abdominal Hernia
Orifices
Hernia is defined as the protrusion of an organ
through its containing wall. It can occur because of
Normal weakness found in everyone and related to
anatomy of the area e.g., place where vessel or
viscus enters or leaves the abdomen, muscles fail to
overlap or there is only scar tissue (Umbilicus)
Abnormal weakness caused by congenital
abnormality or acquired as result of trauma or
diseases.
High intraabdominal pressure from Coughing /
Strains / Abdominal distention

Common Sites Fig. 7


1.
2.
3.
4.

Inguinal Hernia
Umbilical Hernia
Femoral Hernia
Incisional Hernia
Less common Hernia
Epigastric Hernia
Recurrent Hernia

Fig. 7 Site of hernia

Common Clinical
Features

The features of all hernias are:


They occur at weak spot
They reduce on lying down or
with direct pressure
They have an expansible cough
impulse

Inguinal Hernia

Anatomy of inguinal region

Inguinal canal with boundaries,


contents and orifices

Types

Treatment

Clinical aspect

Inguinal Hernia Fig. 8


Indirect inguinal hernia pass via deep
inguinal ring along the canal then if large
enough emerges through the external ring
and descends into scrotum.
Direct hernia pushes through the posterior
wall of the inguinal canal via Hesselbechs
triangle, which is boundary base inguinal
ligament medial border midline laterally by
inferior epigastric vessels.
However, the inferior epigastric vessels
demarcate the indirect hernia sac pass
lateral and direct hernia medial to these
vessel.

Inguinal Hernia Fig. 8


Indirect inguinal hernia:
Tranverses deep and superficial
inguinal rings and inguinal canal.
Lies within coverings of spermatic
cord.
May descend into scrotum.
More common than a direct
inguinal hernia.
More common in boys and young
men.
May be congenital.

Inguinal Hernia Fig. 8


Direct inguinal hernia:
Occurs in older men (rarely
women).
Due to weakness in abdominal
wall behind or lateral to superficial
inguinal ring.
Passes directly through abdominal
wall to superficial inguinal ring.
Does not extend into scrotum.
Has sac formed by peritoneum.

Fig. 8

Inguinal Region
Hernias:
Femoral:
Occurs within femoral canal.
More common in females.
Umbilical:
Occurs at site where umbilical
cord
penetrates between
muscles and
fascia of anterior
abdominal wall.

Peritoneal Lining of the


Abdominal Walls

The walls of the abdomen are


lined with parietal
peritoneum.Fig. 9
This is a thin serous membrane
consisting of a layer of
mesothelium resting on
connective tissue. It is
continuous below with the
parietal peritoneum lining the
pelvis.

Fig. 9 Sagittal section of the abdomen

Peritoneal Lining of the


Abdominal Walls
The peritoneum can be regarded as a balloon.
The parietal peritoneum lines the walls of the
abdominal and pelvic cavities, and the
visceral peritoneum covers the organs.
The potential space between the parietal and
visceral layers is called the peritoneal cavity.
In males, this is a closed cavity, but in
females, there is communication with the
exterior through the uterine tubes, the
uterus, and the vagina.

Peritoneal Lining of the


Abdominal Walls
Between the parietal peritoneum and
the fascial lining of the abdominal
and pelvic walls is a layer of
connective tissue called the
extraperitoneal tissue; in the area
of the kidneys this tissue contains a
large amount of fat, which supports
the kidneys

Peritoneal Lining of the


Abdominal Walls
The peritoneal cavity is the largest cavity in
the body and is divided into two parts:
the greater sac and
the lesser sac.

The greater and lesser sacs are in free


communication with one another through
an oval window called the opening of the
lesser sac, or the epiploic foramen.
The peritoneum secretes a small amount of
serous fluid, the peritoneal fluid, which
lubricates the surfaces of the peritoneum
and allows free movement between the
viscera.

Peritoneal Lining of the


Abdominal Walls
Intraperitoneal and Retroperitoneal
Relationships.
Intraperitoneal when it is almost totally
covered with visceral peritoneum.
Retroperitoneal organs lie behind the
peritoneum and are only partially
covered with visceral peritoneum.
Pancreas
The ascending and descending parts of
the colon

Peritoneal Lining of the


Abdominal Walls
Peritoneal Ligaments
Peritoneal ligaments are two-layered
folds of peritoneum that connect
solid viscera to the abdominal walls.
The liver, for example, is connected to
the diaphragm by the falciform
ligament, the coronary ligament,
and the right and left triangular
ligaments.

Peritoneal Lining of the


Abdominal Walls
Omenta are two-layered folds of
peritoneum that connect the
stomach to another viscus.
The greater omentum connects the
greater curvature of the stomach to
the transverse colon.
The lesser omentum suspends the
lesser curvature of the stomach from
the fissure of the ligamentum
venosum and the porta hepatis on
the undersurface of the liver

Peritoneal Lining of the


Abdominal Walls
Mesenteries are two-layered folds of
peritoneum connecting parts of the
intestines to the posterior abdominal
wall, for example, the mesentery of
the small intestine, the transverse
mesocolon, and the sigmoid
mesocolon.
The peritoneal ligaments, omenta, and
mesenteries permit blood, lymph
vessels, and nerves to reach the
viscera.

Peritoneal Pouches, Recesses, Spaces,


and Gutters.

The lesser sac lies behind the


stomach and the lesser omentum.
The opening into the lesser sac
(epiploic foramen).
Duodenal Recesses
Close to the duodenojejunal junction,
there may be four small pocketlike
pouches of peritoneum called the
superior duodenal, inferior duodenal,
paraduodenal, and retroduodenal
recesses

Peritoneal Pouches, Recesses, Spaces,


and Gutters.

Cecal Recesses
Folds of peritoneum close to the
cecum produce three peritoneal
recesses called the superior
ileocecal, the inferior ileocecal, and
the retrocecal recesses.

Intersigmoid Recess
The intersigmoid recess is situated
at the apex of the inverted, Vshaped root of the sigmoid
mesocolon.

Peritoneal Pouches, Recesses, Spaces,


and Gutters.

Subphrenic Spaces
The right and left anterior subphrenic
spaces lie between the diaphragm and
the liver, on each side of the falciform
ligament.
The right posterior subphrenic space
lies between the right lobe of the liver,
the right kidney, and the right colic
flexure.
The right extraperitoneal space lies
between the layers of the coronary
ligament and is therefore situated

Peritoneal Pouches, Recesses, Spaces,


and Gutters.

Paracolic Gutters
The paracolic gutters lie on the
lateral and medial sides of the
ascending and descending colons.
The subphrenic spaces and the
paracolic gutters are clinically
important because they may be sites
for the collection and movement of
infected peritoneal fluid

Peritoneum
Nerve Supply of the
Peritoneum
Parietal peritoneum is sensitive
to pain, temperature, touch, and
pressure.
Visceral peritoneum is sensitive
only to stretch and tearing and is
not sensitive to touch, pressure,
or temperature.

Peritoneum
Nerve Supply of the
Peritoneum
Parietal peritoneum is sensitive
to pain, temperature, touch, and
pressure.
Visceral peritoneum is sensitive
only to stretch and tearing and is
not sensitive to touch, pressure,
or temperature.

Functions of the Peritoneum

Peritoneal fluid ensures that the


mobile viscera glide easily on one
another.
The peritoneal coverings of the
intestine tend to stick together in
the presence of infection. In this
manner, many of the
intraperitoneal infections are
sealed off and remain localized.
greater omentum is often referred
abdominal policeman.

Functions of the Peritoneum

The peritoneal folds play an


important part in suspending the
various organs within the
peritoneal cavity and serve as a
means of conveying the blood
vessels, lymphatics, and nerves to
these organs.
Large amounts of fat are stored in
the peritoneal ligaments and
mesenteries, and especially large
amounts can be found in the

Applied Anatomy
Some important skin areas involved in referred visceral pain.