ABDOMINAL WALL

& INGUINAL
REGION
with question

Asso Prop Dr G M
Kibria
UPNM7
21/2/18
4/5/20 1
 LEARNING OBJECTIVES

At the end of this session you should be able to describe

1. nine abdominal regions & the important land-marks on
abdominal wall (tip of left 9th costal cartilage, McBurney’s point,
umbilicus, linea semilunaris).
2. the cutaneous vessels & innervations, the dermatomes of
abdominal wall.
3. the different layers of abdominal wall & the rectus sheath & its
contents.
4. describe the inguinal ligament, inguinal canal & inguinal rings.
5. describe the inguinal hernia.

4/5/20 2
 e1
j e c ti v
Abdominal
4 imaginary wall
planesis a musculo-aponeurotic
divide nine abdominal regions
Abdominal wall is a musculo-aponeurotic wall wall
Ob
4 imaginary planes divide nine abdominal regions
4 imaginary planes divide nine abdominal regions
• Midclavicular
1. plane/line
Midclavicular plane/line: Right, Left
1. Midclavicular plane/line: Right, Left
2. Transpyloric plane: L1 vertebra
•2. Transpyloricplane
3. Transpyloric
plane: L1 vertebra
Transtubercular plane: tubercle of
3. Transtubercular plane: tubercle of
iliac crest, L5 vertebra
iliac crest, L5 vertebra
• Subcostal plane: lower border of 10th
• Subcostal plane: lower border
costal cartilage, L3 vertebra. of 10 th

costal cartilage, L3 vertebra.

• Transtubercular
plane
Nine abdominal regions:
Nine abdominal regions:
Right hypochondrium Epigastrium Left hypochondrium
Right hypochondrium Epigastrium
Umbilical region Left
Lefthypochondrium
lumbar/flank
Right lumbar/flank
Right lumbar/flank Umbilical
Pubic region
(hypogastrium) Left
Leftlumbar/flank
inguinal (iliac fossa)
Right inguinal(iliac fossa)
Right inguinal(iliac fossa) Pubic (hypogastrium)
4/5/20 Left inguinal (iliac fossa)
3
 e2
j e c ti v
Structures at transpyloric plane
Ob• Pylorus of stomach
• Fundus of gallbladder
• Tip of 9th costal
e num
cartilage D u od
• e as
Neck of pancreas Pan
c r

• Origin of superior S
me uper
sen ior
mesenteric artery & ve teric
s se
hepatic portal vein ls

• Duodenojejunal Root of the

junction mesentery

• Root of transverse
mesocolon
• Hila of kidneys

4/5/20 **Q. List the structures lie at transpyloric plane. 5

 ve2
j e c ti Land-marks on abdominal wall
Ob
Median furrow marks the position
of underlying linea alba.
Linea semilunaris: From tip of 9th
costal cartilage & pubic tubercle.
It marks the lateral border of
rectus abdominis muscle. Position of
the 9
th

costal
Tip of right 9th costal cartilage: cartilage tip
Position of gallbladder fundus
McBurney’s point: Position of the
base of appendix.
Umbilicus at level between L3 & L4.

**Q. List the structures at the level of tip of left 9th costal cartilage
4/5/20 6
 ve1
j e c ti
ABDOMINAL CAVITY: two parts
Ob

• Abdominal cavity
proper (above) &
pelvic cavity (below).

• Abdominal cavity
extends superiorly up
to 4th intercostal space.

• Abdominal cavity is
divided into 9 regions.

cav ic
ity
v
Pel
t
nle
ic i
lv
Pe
4/5/20 7
 e 3
v
je cti
Ob
D Cutaneous Nerves
e
r Thoracoabdominal nerves (T7-T11)
m Subcostal nerve (T12)
a
t
o
Iliohypogastrin nerve (L1)
m
e Ilioinguinal nerve (L1)

 Cutaneous innervation & dermatome: Subcostal region by T-7, at

umbilical region by T-10, at inguinal region by L-1
 T-12: subcostal nerve & L-1: iliohypogastric & ilioinguinal nerves
4/5/20 8
Objective 4
Cutaneous vessels

tric
• Cutaneous branches of:

pigas
- Lower intercostal & subcostal

y
arter
rior e
arteries.

Supe
- Superior & inferior epigastric

Lower intercostal
arteries.

& subcostal
• Superficial inguinal branches of
femoral artery:

Infe artery
Cutaneous veins accompany the

rior
corresponding arteries.

epig
Superficial inguinal veins open in great
saphenous vein. astr
ic
4/5/20
a. = artery 10
 4
ctiv
e Venous & Lymphatic drainage from abdominal wall
je
Ob WATER-SHED
Venous blood flow in 3 directions:
• Above the umbilicus: Blood drained
to superior vena cava.
• Below the umbilicus pass to inferior
vena cava. (water-shed).
• Paraumbilical vein runs along the
ligamentum teres & passes to portal
vein.
So around umbilicus there is portocaval
anastomosis.
Lymph vessels pass to axillary & inguinal
lymph nodes (water-shed).
Lymphatics Vein
4/5/20 11
 ve4
je cti Venous engorgement in abdominal wall/ Caput medusa
Ob
Obstruction of either superior vena cava or inferior vena cava or portal
vein causes dilatation of superficial veins around umbilicus for collateral
circulation. (what will be direction of blood-flow?)
Portal obstruction causes dilation of cutaneous veins radiating from
umbilicus (caput medusa).

4/5/20 12
 ve5
cti
Ob je SIX LAYERS IN ABDOMINAL WALL
• Skin
• Superficial fascia: 2 sublayers
- Fascia Camper (outer fatty
layer)
-Fascia Scarpa (deeper
membranous layer)
• Muscles & their aponeuroses
• Fascia transversalis
(endoabdominal fascia)
• Extraperitoneal fat
• Parietal peritoneum
**Q. List the layers in the abdominal wall (outer to inner).
4/5/20 14
 ve5 Abdominal wall muscles
je cti
Ob

Anterior/external Peritoneum
Fascia Transversalis

Fascia Camper
Extraperitoneal fat
Fascia Scarpa
Space of Bogros (retroinguinal)
Inguinal ligament
Conjoint tendon

4/5/20 15
 e 5
cti
v SUPERFICIAL FASCIA has TWO layers
je
Ob (NO deep fascia)

Fascia Camper: Outer fatty layer, a major site of fat storage.

Fascia Scarpa: Inner membranous layer, many elastic & collagen
fibers. This layer continues inferiorly into perineum as fascia
Colles.

Q. What are the characteristic features of superficial fascia of

4/5/20 abdominal wall? 17
 5
je ctiv
e
Muscle Layers in abdominal wall
Ob
Laterally (outer to inner):
Rectus abdominis (anteriorly)
1. External oblique
Aponeuroses abdominis
External oblique ms. 2. Internal oblique
Internal oblique ms. abdominis
Transverse section Transversus 3. Transversus
abdominis ms. abdominis
These 3 are flat muscle &

om nte .
bd n i L-1

s. l
become aponeuroses

ini rna
s a ee l &
anteriorly.

rsu tw ta
ve be cos
b Anteriorly: muscles are
tra plan 1, su

vertical
T-1
ns e:

4. Rectus abdominis
liq scu to
ob ova T-7

5. Pyramidalis
r
ue la
ur on:

(These 2 muscles are

&
Ne ati

within Rectus sheath)

rv
ne

**Q. List the muscles in the abdominal18wall.

In

4/5/20
 ve5 MUSCLES OF ANTEROLATERAL WALL
je cti
Ob

Ext. Oblq.
From ribs: Tran. Abd.
downward &
medially

Rect. Abd.

Int. Oblq. From pubis

From iliac crest: to xiphoid
upward & medially

Crisscross arrangement of muscles give a good strength.

Actions of abdominal-wall muscles:
• flex & rotate the trunk.
• compress & support the abdominal viscera.
4/5/20 • forceful expulsive actions. 19
 ve5 MUSCLES OF ANTEROLATERAL WALL (Contd.)
je cti
Ob Intersections

Rectus abdominis
Pyramidalis

Tendinous intersections: Rectus abdominis is intersected by 3 tendinous

bands, & are firmly attached with anterior wall of rectus sheath.
Pyramidalis: Small triangular muscle anterior to lower part of rectus
abdominis.
4/5/20 20
 e5
je cti
v Muscles & their aponeuroses
Ob
• All three flat muscles are continued
anteromedially as strong aponeuroses.

• These aponeuroses form the rectus sheath &

enclose Rectus abdominis & Pyramidalis.

• At midline these aponeuroses interweave with

that of opposite side forming a midline raphe,
the linea alba.

• Inguinal ligament: thickened lower border of

external oblique aponeurosis. It extends from
ASIS to pubic tubercle.

4/5/20 21
 e 6
cti
v **RECTUS SHEATH
b je
O Rectus abdominis enclosed
• Strong fibrous compartment,
by rectus sheath
Aponeuroses Formed by aponeuroses.
• Two walls: Anterior wall &
posterior wall.
• Anterior wall is complete &
Posterior wall is incomplete.
• Arcuate line: lower free border of
posterior wall, curved upward.

Contents of rectus sheath:

• Rectus abdominis & pyramidalis,
• Superior & inferior epigastric
vessels,
• Thoracoabdominal nerves (T7-T12)
4/5/20 22
 ve6
je cti
Ob • Rectus sheath

• Arcuate line
• Rectus abdominis muscle
& pyramidalis muscle

• Epigastric vessels

• Thoracoabdominal nerves
During surgical incision through rectus
sheath the rectus abdominis muscle is
retracted laterally to prevent the injury
of the nerves
Linea alba extends from xiphoid process to pubic symphysis & lest vascular.
4/5/20 23
 ve6
je cti
Ob How the rectus sheath is formed?

4/5/20 24
 Understanding for the inguinal canal

4/5/20 26
 1
ve INGUINAL LIGAMENT
cti
je
Ob

Formation: Lower border of

external oblique aponeurosis.
Attached to anterior-superior iliac
spine & to pubic tubercle.
Forms the floor of inguinal canal.

Femoral vessels & nerve pass deep

to this ligament.
Inguinal
ligament
Internal oblique & transversus Ex. Oblique
abdominis take origin from its aponeurosis
lateral part.

? Mid-inguinal point
?Midpoint of inguinal ligament
4/5/20 27
 1
ve
cti
je
Ob

Co
n
ten join
do t
n

Q. How the inguinal ligament is formed?

4/5/20 28
 1
ve Lacunar ligament &
cti
je
Ob

Pectineal ligament are

the extensions of
inguinal ligament.

• Q. How the inguinal

Inguinal lig. ligament is formed?
Lacunar lig. Pectineal lig.
• Q. What are its bony
4/5/20
attachments? 29
 l

2
a
ve
cti ui n ep Inf
In g iga eri
je
l str or
Ob

ci a ic a
rfi rte
e ry
Sup ings
nd r
a

g
p in p
rin
e
g u ee
De al
In D
al al
in c i
g
rin
fi
gu r
In upe
S

Deep inguinal ring:

• In fascia transversalis, immediately lateral to inferior epigastric artery.
• Internal spermatic fascia is the extension of fascia transversalis.
• Surface marking: Situated 1.2 cm above mid-inguinal point.
Superficial inguinal ring:
• In external oblique aponeurosis. External spermatic fascia is its extension.
• Surface marking: Situated just above the pubic tubercle.
4/5/20 30
 3
ve Inguinal canal
cti
je
Ob

• Passage situated just above

the medial half of inguinal
ligament.
• From deep inguinal ring to
superficial inguinal ring. Deep inguinal ring

• Length: 4 cm long
Superficial
• In infants: canal is shorter, inguinal ring
less oblique & both the
rings almost overlaps.
• So inguinal hernia is
common in infant.
• In male the canal is wider
than in female, & thus
inguinal hernia is more in
male than in female.
4/5/20
(Remember the layers in the abdominal wall)31
 Ob
Ductus deferens

je
cti
Genital branch of GF nerve

ve
3
Testicular vessels
Fs. Transversals

Ex Ob
Aponeurosis

Contents of inguinal canal:

• spermatic cord: ductus
deferens, testicular vessels &
nerve (or round ligament in
female) & its covering fascia
• genital branch of
genitofemoral nerve Testis
• ilioinguinal nerve.
4/5/20 32
 ve3
Ob
jec
ti Boundary of inguinal canal

ique
Anterior wall:

l obl
• Skin

na
• Superficial fascia Co

Inter
n
of joint
i
• External oblique aponeurosis tra ntern tend
nsv al o
ers ob. n

Arc rnal s abd

Tra
• Internal oblique muscle

Int vers
us &
ab.

he obl om
e
ns

d fi iqu in
reinforces the lateral part of

b e e & is
u
anterior wall.

rs
of
Posterior wall:
• Parietal peritoneum
• Extraperitoneal tissue
• Fascia transversalis
• Conjoint tendon of internal oblique & transversus
abdominis reinforces the medial part.
4/5/20 34
 3
Rela
ve
abd x
omi ation o
cti
je
n al f
Ob

mus
cle
Roof:
• Arched fibres of
internal oblique &
transversus abdominis
muscles
Floor: Con
• Inguinal ligament abd tracti
om
inal on of
• Lacunar ligament mus
cle

4/5/20 36
 3
veMechanism of inguinal canal during increased
cti
je
Ob

intra-abdominal pressure
• Deep & superficial rings do not overlap in adult. Consequently,
increased intra-abdominal pressure presses the posterior wall of
the canal against the anterior wall.
• Contraction of external oblique approximates the anterior wall
toward the posterior wall. It also increases tension on medial &
lateral crura resisting the dilation of superficial ring.
• Contraction of the arched musculature of the roof of the canal
makes the roof descend, constricting the canal.

4/5/20 37
 3
ve
cti
Coverings of spermatic cord
je
Ob

• Internal spermatic fascia: extension from fascia

transversalis
• Cremasteric fascia: extension of muscle fibers from lower
part of internal oblique muscle
• External spermatic fascia: extension from external
oblique aponeurosis

Q. What are the contents of spermatic cord?

Q. What are the coverings of the spermatic cord?

4/5/20 39
 3
ve
cti
Cremasteric reflex
je
Ob

• Lightly stroking the skin on the medial aspect of upper

thigh Contraction cremaster muscle & elevation of testis.
• Sensory supply of this area of thigh is by Ilioinguinal nerve
(L1) & femoral branch of genitofemoral nerve (L1-2).
• Cremaster motor supply is by genital branch of
genitofemoral nerve (L1-2).
• This reflex is extremely active in children.

4/5/20 40
 4
ve Inguinal hernia
cti
je
Ob

• Abnormal protrusion of parietal peritoneum & abdominal

viscera into inguinal canal.
• More common in male than in female.
• Commonly associated with frequent increased intra-
abdominal pressure.

• Two types: Direct & indirect inguinal hernia. Two third are
indirect hernia.
• Viscera that herniate is called the content.
• The peritoneal covering is the hernial sac.
• Other layers lying external to sac are the coverings of hernia.

4/5/20 41
 4
ve
cti
Direct hernia Indirect hernia
je
Ob

Inferior epigastric

ct
ire
ct
vessels

d
e

In
Dir

Peritoneal
bulge

Peritoneal sac
lateral medial

4/5/20 42
 Ob
jec
Coverings of inguinal tiv
e4
hernia
Indirect hernia:
peritoneum & all three
spermatic fascia,
superficial fascia, skin.

Direct hernia:
peritoneum, fascia
transversalis, cremasteric
fascia &/or external
spermatic fascia,
superficial fascia, skin.

4/5/20 43
 Ob
jec
Difference between direct & indirect hernia tiv
e4

Direct inguinal hernia: Indirect inguinal hernia:

• Acquired, incidence is ⅓ to ⅟₄.
• Due to weakness of anterior
abdominal wall, e.g., distended
superficial ring, narrow conjoint
tendon, attenuated aponeurosis.
• Common in old male (>40yrs).
• Passes through posterior wall of
inguinal canal (medial part).
• Congenital, incidence is ⅔ to
¾ (Moore).
• Due to patency of processus
vaginalis.
• In infant inguinal canal is less
oblique & 2 rings almost
overlap each other, so this
hernia common in young
male.
• Passes through deep
inguinal ring, whole length
of canal.

4/5/20 44

Difference (contd.)
Direct inguinal hernia:
• Coverings: peritoneum,
fascia transversalis, outer
one or two fascial
coverings of spermatic
cord.
• Rarely enters scrotum.
4/5/20
Ob
jec
tiv
e4
Indirect inguinal hernia:
• Coverings: peritoneum & all
three spermatic fascia.
• Exit via superficial ring,
commonly passing into scrotum
(complete hernia).
Funicular hernia: contents lie above
the testis.
Bubonocele: hernia confined to the
inguinal canal.
45
 ?

TQ

4/5/20 47