Abdominal Wall & Pelvic

Budi Justitia MD
Abdominal Wall & Pelvic
Otot dinding abdomen
Peritoneum
Pelvis :
Tulang
Otot & diafraghma pelvis
n
Abdominal Wall & Pelvic
Key facts about the abdomen and pelvis
Abdome Boundaries: anterolateral and posterior
abdominal walls, diaphragm, pelvic inlet
Contents: stomach, small intestine, large
intestine, vermiform appendix, pancreas, spleen,
liver, gallbladder, kidneys, ureters, adrenal
glands
Pelvis Boundaries: pelvic inlet, pelvic girdle, pelvic
diaphragm
Contents: internal genitalia, external genitalia,
urinary bladder, urethra, rectum and anus

Blood Abdomen: celiac trunk, superior mesenteric

supply artery, middle suprarenal arteries, renal arteries,
inferior mesenteric artery, inferior phrenic artery
and lumbar arteries; inferior vena cava, hepatic
portal vein
Pelvis: internal iliac arteries, gonadal arteries,
median sacral artery and the superior rectal
artery; inferior vena cava, hepatic portal vein

Innervati Abdomen: vagus nerve (CN X), prevertebral

on ganglia, lower thoracic, pelvic and lumbar
splanchnic nerves; they form plexuses:
myenteric, celiac, superior mesenteric, inferior
mesenteric, superior hypogastric and inferior
hypogastric plexuses.
Pelvis: lumbosacral trunk (L4, L5), lumbar
plexus (L1-L4), sacral plexus (L4-S4), coccygeal
plexus (S4-Co), lumbar, sacral and pelvic
splanchnic nerves
Boundaries
 The abdomen is the body region found between the thorax and the pelvis.
Its superior aperture faces towards the thorax, enclosed by the diaphragm.
 Inferiorly the abdomen is open to the pelvis, communicating through the
superior pelvic aperture (pelvic inlet).
 These two apertures, together with abdominal walls, bound the abdominal
cavity.
 There are two musculofascial abdominal walls; anterolateral and posterior.
 They attach to the surrounding bony structures; vertebral column, inferior
margin of the thoracic cage and superior margins of the bony pelvis.
 The predominantly soft tissue structure of the abdominal walls gives them
the flexibility to adjust to the dynamics of the abdominal viscera.
Abdominal region
Key points about the regions of the abdomen

Four- Quadrans superior dexter, quadrans superior sinister,

quadrant quadrans inferior dexter, quadrans inferior sinister.
scheme

Nine- Regio hypochondriaca dextra et sinistra, regio

region epigastrica, regio umbilicalis, regio abdominis
scheme lateralis dextra et sinistra, regio hypogastrica, regio
inguinalis dextra et sinistra.
Contents Regio hypochondriaca sinistra: Ren sinister, splen,
cauda pancreatis; parts of gaster, lobus sinister
hepatis, intestinum tenue, colon transversum and
colon descendens.
Regio hypochondriaca dextra: Lobus dexter hepatis,
vesica biliaris, flexura dextra coli, upper half of ren
dexter, part of duodenum.
Regio epigastrica: Pars abdominalis oesophagi,
pylorus of gaster, splen, pancreas, glandula
suprarenalis dextra et sinistra; parts of duodenum,
hepar, ren dexter et sinister and ureter.
Regio umbilicalis: part of gaster, pancreas, lower part
of duodenum, part of jejunum and ileum, cisterna
chyli, colon transversum, part of ren and ureter.
Regio lateralis abdominis sinistra: lower part of ren
sinister, colon descendens and parts of jejunum and
ileum.
Regio lateralis abdominis dextra: part of lobus dexter
hepatis, vesica biliaris, colon ascendens, lower part of
ren dexter and parts of duodenum.
Regio hypogastrica: ileum, colon sigmoideum,
rectum, ureter and vesica urinaria.
Abdominal region
Key facts
Four region Principle: vertical line through linea alba (median plane) crosses
scheme horizontal line through the umbilicus (transumbilical plane) -> four
quadrants: right upper quadrant (RUQ), right lower quadrant (RLQ),
left upper quadrant (LUQ), left lower quadrant (LLQ)
Quadrants:
RUQ - LUQ
  |         |
RLQ - LLQ

Nine region Principle: two vertical midclavicular lines (left and right) cross
scheme two horizontal: subcostal (through lower edge of 10th costal
cartilage) and transtubercular (through tubercles of iliac crests) -
> nine segments: right and left hypochondrium, epigastrium,
right and left lumbar regions, umbilical region, right and left
inguinal regions, hypogastrium
Segments:
right hipochondrium - epigastrium - left hipochondrium
right lumbar - umbilical - left lumbar
right inguinal - hypogastrium - left inguinal
Clinical Grey-Turner's sign, Cullen's sign
relations
Abdominal region
The regions of the abdomen are theoretical divisions used
by clinicians to help localize, identify and diagnose a
patients symptoms. There are two main forms of
categorization, the first which is simpler and is mapped
out by dividing the abdomen into four quadrants, while
the second method divides it into nine segments.
Abdominal region
Abdominal organs include parts of the:
• Digestive system - stomach, small intestine, large intestine
, exocrine pancreas, liver and gallbladder
• Urinary system - kidneys and ureters
• Immune system - spleen
• Endocrine system - adrenal glands, endocrine pancreas
Abdominal muscles
Abdominal muscles
Quadratus lumborum muscle
The quadratus lumborum muscle is a muscle of the
posterior abdominal wall lying deep inside the abdomen and dorsal to the
iliopsoas.
It is the deepest muscle of the posterior abdominal wall, and it is often
mistakenly referred to as one of the muscles of the back.
Its shape is irregular, but is generally quadriangular, which is the reason
why it is described as 'quadratus' in latin.
Besides the spine, it also attaches to the twelwth rib, which makes it very
important for stabilization of both vertebral column and the rib during
various movements of the spine.
In order to palpate the muscle one needs place the fingers above the
posterior iliac crest at the level of the hip.
Key facts about the quadratus
lumborum muscle

Abdominal Muscles
Origi Iliac crest, iliolumbar
n ligament

Inser Inferior border of rib 12,

tion transverse processes of
vertebrae L1-L4

Inner Subcostal nerve (T12),

vatio anterior rami of spinal nerves
n L1-L4

Bloo Lumbar, median sacral,

d iliolumbar and subcostal
suppl arteries
y

Func Bilateral contraction - fixes

tion Ribs 12 during inspiration,
trunk extension
Unilateral contraction -
lateral flexion of trunk
(ipsilateral)
Abdominal Muscles
(Quadratus lumborum )
Origin and insertion
Quadratus lumborum originates from the iliolumbar ligament and iliac
crest. It runs craniomedially, attaching to the inferior border of 12th
rib and the transverse processes of the 1st to 4th lumbar vertebrae. All
fibers together give the muscle a rectangular appearance.
Relations
The quadratus lumborum fills a great amount of space within the
abdomen and is therefore in close proximity to many structures.
The colon, the kidneys and the diaphragm are located ventrally to the
muscle, whereas the intrinsic back muscles lie dorsomedially.
Both the iliohypogastric and ilioinguinal nerves course on the ventral
surface of the quadratus lumborum after exiting the lumbar plexus and
continue towards the lateral abdominal muscles.
Abdominal Muscles
(Quadratus lumborum )
Innervation
Quadratus lumborum is innervated by the subcostal nerve (T12) and anterior
rami of spinal nerves L1-L4.
Blood supply
Blood supply to quadratus lumborum comes from the branches of lumbar,
subcostal, median sacral, and iliolumbar arteries.
Function
Essentially, the quadratus lumborum contributes to the stabilization
and movement of the spine and the pelvis. A bilateral contraction leads to an
extension of the lumbar vertebral column. When the muscle is only activated on
one side, the trunk is bent towards that direction (lateral flexion).
In addition, the muscle fixes the 12th rib during movements of the thoracic cage
and this way supports expiration (accessory muscle of expiration).
Abdominal Muscles
(Pyramidalis )
Relations
Pyramidalis muscle lies within the rectus sheath, a multilayered fascial
compartment composed of the aponeuroses of the external abdominal oblique,
internal abdominal oblique and transversus abdominis muscles. Within the
sheath, pyramidalis lies superficially to the inferior part of rectus abdominis
muscle.
Function
Pyramidalis muscle tenses the linea alba. The muscle usually contracts together
with the other abdominal muscles, contributing to contracting the abdominal
wall and increasing the positive abdominal pressure. 
These actions play a dual role. The first is as an important defense mechanism,
whereby contraction of the abdominal muscles physically protects the
abdominal organs. The second is to support certain physiological processes such
as forced respiration, singing, micturition and defecation.
Abdominal Muscles
(Pyramidalis )
Key facts about the pyramidalis muscle
Origi Pubic crest, pubic symphysis
n
Insert Linea alba
ion
Actio Tenses linea alba 
n
Inner Subcostal nerve (T12) 
vatio
n
Blood Inferior epigastric artery
suppl
y
Abdominal Muscles
(Internal Abdominal oblique)

Internal abdominal oblique is a broad thin muscular sheet

found on the lateral side of the abdomen.
Going from superficial to deep, the external abdominal oblique
, internal abdominal oblique and transversus abdominis
comprise the three distinct layers of the lateral abdominal wall.
As its name suggests, the direction of its fibers are obliquely
oriented, perpendicular to those of the external abdominal
oblique.
Together with the other abdominal muscles, the internal
abdominal oblique is important for movements of the trunk,
maintaining normal abdominal tension, and increasing intra-
abdominal pressure. 
Abdominal Muscles
(Internal Abdominal oblique)
Key facts about the internal abdominal oblique

Origin Anterior two-thirds of iliac crest, iliopectineal arch, thoracolumbar

fascia

Insertion Inferior borders of ribs 10-12, linea alba, pubic crest & pectin pubis (via
conjoint tendon)

Action Bilateral contraction - Trunk flexion, compresses abdominal viscera,

expiration
Unilateral contraction - Trunk lateral flexion (ipsilateral), trunk
rotation (ipsilateral)

Innervation Intercostal nerves (T7-T11), subcostal nerve (T12), iliohypogastric

nerve (L1), ilioinguinal nerve (L1)

Blood Lower posterior intercostal and subcostal arteries, superior and

supply inferior epigastric arteries, superficial and deep circumflex
arteries,posterior lumbar arteries
Abdominal Muscles
(Internal Abdominal oblique)
Origin and insertion
Internal abdominal oblique muscle has multiple sites of origin, which are distributed along  the
anterolateral side of the trunk.
According to their origin, the muscle fibers can be divided into the anterior, lateral and posterior
fibers.
• Anterior fibers: traditionally are thought to arise from the lateral two-thirds of the superior surface of
the inguinal ligament, forming a common attachment with the iliac fascia. However it is now known
that they arise from a deeper structure known as the iliopectineal arch. The fibers pass inferomedially,
arching over the inguinal canal and merge with the tendinous fibres of the transversus abdominis
muscle to form the conjoint tendon. This tendon then inserts into the pubic crest and pecten pubis. In
males, some of the anterior fibers extend into the spermatic cord and form the cremaster muscle.
• Lateral fibers: originate from the anterior two-thirds of iliac crest and then diverge superiorly and
medially. The fibers then extend into an aponeurosis that contributes to the formation of the
rectus sheath and inserts at the linea alba.
• Posterior fibers: originate from the posterior end of the iliac crest and the thoracolumbar fascia. The
fibers then ascend superolaterally and insert into the inferior borders and tips of the lower three or four
ribs and their cartilages. Here, these merge with the internal intercostals of the aforementioned ribs.
Abdominal Muscles
(Internal Abdominal oblique)
Relations
The internal abdominal oblique muscle lies on the lateral abdominal wall, comprising one of its
three layers. It is found deep to the external abdominal oblique and superficial to the transverse
abdominis.
The lateral fibres of the internal abdominal oblique muscle are continuous with the rectus sheath,
the large aponeurosis of the anterior abdominal wall . The rectus sheath largely encloses the
rectus abdominis and pyramidalis muscles, as well as many neurovascular structures of the
anterior abdominal wall.
Below the costal margin, the upper three quarters of the aponeurosis of internal abdominal
oblique muscle split into deep and superficial layers around the rectus abdominis muscle. The
deep layer, together with the aponeurosis of transversus abdominis, form the posterior layer of
the rectus sheath. The superficial layer, on the other hand, merges with the aponeurosis of
external abdominal oblique to form the anterior layer of the rectus sheath.
Around the level of the lower quarter of the aponeurosis of internal abdominal oblique muscle,
the aponeuroses of the external abdominal oblique, internal abdominal oblique and transversus
abdominis converge and lie anterior to the rectus abdominis muscle. The point at which they
converge is known as the arcuate line, and is located roughly 2.5cm below the umbilicus
Abdominal Muscles
(Internal Abdominal oblique)
Function
Internal abdominal oblique muscle has several functions that are dependent upon which parts of
the muscle contracts.
Upon bilateral contraction, the internal abdominal oblique flexes the trunk.
Simultaneously, it causes compression of the intra-abdominal viscera thereby increasing the
intra-abdominal pressure.
This action is utilized for functions such as forced expiration, micturition, defecation etc.
If the rib cage is fixed, the bilateral contraction of the internal abdominal oblique lifts the
anterior part of the pelvis and alters the degree of pelvic tilt.
Upon unilateral contraction, internal abdominal oblique causes ipsilateral flexion of the trunk,
as well as ipsilateral rotation of the trunk.
Along with other muscles of the abdominal wall, internal abdominal oblique muscle is
important for maintaining normal abdominal wall tension.
Therefore the tonic contraction of these muscles has a protecting as well as a supporting role.
Additionally, weakness of the internal abdominal oblique or other abdominal muscles increases
the risk for abdominal hernia
Abdominal Muscles
(External Abdominal oblique)

External abdominal oblique is a paired muscle located on the lateral

sides of the abdominal wall. Along with internal abdominal oblique and
transversus abdominis, it comprises the lateral abdominal muscles. In a
broader picture, these muscles make up the anterolateral abdominal wall
together with two anterior abdominal muscles; the rectus abdominis and
pyramidalis.
Abdominal muscles work together to produce movements of the spine as
well as to compress the abdominal viscera. External abdominal oblique
in particular causes ipsilateral lateral flexion of the trunk and
contralateral rotation of the trunk when it contracts unilaterally. Bilateral
contraction flexes the trunk anteriorly, increasing intra abdominal
pressure, which is useful in processes such as breathing, singing and
defecation.
Abdominal Muscles
(External Abdominal oblique)

Key facts about the external abdominal oblique muscle

Origin External surfaces of ribs 5-12

Insertion Linea alba, pubic tubercle, anterior half of iliac crest 

Action Bilateral contraction - Trunk flexion, compresses abdominal

viscera, expiration
Unilateral contraction - Trunk lateral flexion (ipsilateral), trunk
rotation (contralateral)

Innervation Motor: Intercostal nerves (T7- T11), Subcostal nerve (T12) 

Sensory: Iliohypogastric nerve (L1)
Blood Lower posterior intercostal arteries, subcostal artery, deep
supply circumflex iliac artery
Abdominal Muscles
(External Abdominal oblique)

Relations
External abdominal oblique is the largest and the most superficial of the
lateral abdominal muscles. It lies beneath the thoracic and abdominal skin,
covering the internal abdominal oblique and anterior halves of the ribs and
intercostal muscles. Its muscular part contributes to the lateral part of the
abdominal wall. Its aponeurotic part, however, contributes to the anterior
abdominal wall, as it contributes to the anterior layer of the rectus sheath.
The superior, medial and inferior margins of the muscle relate to their
respective attachment points while the posterior margin is free. This is in
contrast to the other lateral abdominal muscles, all of which attach to the
thoracolumbar fascia at their posterior ends. The portion of the inferior
margin of this muscle that extends between the ASIS and pubic tubercle
curves posteriorly, forming a thick incurve, or channel called the
inguinal ligament (of Poupart)which constitutes the floor of inguinal canal.
Abdominal Muscles
(External Abdominal oblique)

Function
External abdominal oblique muscle has a variety of
functions depending if it contracts unilaterally or
bilaterally. When acting unilaterally and in synergy with
the contralateral internal abdominal oblique, it rotates the
trunk to the opposite side. Working together with the
ipsilateral abdominal and back muscles, it contributes to
lateral flexion of the trunk on the same side.
Abdominal Muscles
(Transversus abdominis)

The transversus abdominis is a broad

paired muscular sheet found on the lateral
sides of the abdominal wall.
Along with the external abdominal oblique
and the internal abdominal oblique , it
comprises the lateral abdominal muscles .
Combined with the two
anterior abdominal muscles (rectus
abdominis and pyramidalis), these muscles
make up the anterolateral abdominal wall.
As its name suggests, the fibers of
transversus abdominis are oriented
transversely, perpendicular to the linea alba
.
Together with the other abdominal muscles,
transversus abdominis is important for
maintaining normal abdominal tension and
increasing intra-abdominal pressure.
Abdominal Muscles
(Transversus abdominis)

Key facts about the transversus abdominis muscle

Origin Internal surfaces of costal cartilages of ribs 7-12, thoracolumbar
fascia, anterior two thirds of iliac crest, iliopectineal arch
Insertion Linea alba, aponeurosis of internal abdominal oblique muscle;
pubic crest, pectinal line of pubis
Action Bilateral contraction - Compresses abdominal viscera, expiration
Unilateral contraction - Trunk rotation (ipsilateral)
Innervation Intercostal nerves (T7-T11), subcostal nerve (T12), iliohypogastric
nerve (L1), ilioinguinal nerve (L1)
Blood Lower posterior intercostal and subcostal arteries, superior and
supply inferior epigastric arteries, superficial and deep circumflex
arteries,posterior lumbar arteries
Abdominal Muscles
(Transversus abdominis)

Relations
Trasversus abdominis lies on the lateral abdominal wall, deep to the internal abdominal
oblique and external abdominal oblique muscles. It comprises the deepest layer of the
lateral abdominal wall.
The aponeurosis of the transversus abdominis muscle participates in comprising the
rectus sheath.
This is a multilayered aponeurosis that encloses the biggest portion of the rectus
abdominis and pyramidalis muscles on their anterior and posterior sides.
The transversus abdominis aponeurosis makes up the posterior wall of the rectus sheath
which covers the posterior upper three quarters of rectus abdominis, together with the
aponeurosis of the internal abdominal oblique muscle.
On the other hand, the aponeuroses of the transversus abdominis and internal abdominal
oblique converge with the aponeurosis of external abdominal oblique anterior to the
rectus abdominis and form the the lower quarter of the anterior wall of the rectus sheath.
The point at which they converge is known as the arcuate line, and is located 2.5cm
below the umbilicus.
Abdominal Muscles
(Transversus abdominis)

Function
Along with other muscles of the abdominal wall, transversus
abdominis plays an important role in maintaining normal abdominal
wall tension.
Therefore, these muscles have a protective as well as a supportive
role, holding the abdominal organs in place.
Additionally, weakness of transversus abdominis or other abdominal
muscles increases the risk for abdominal hernias.
The lateral abdominal muscles, including transversus abdominis, also
cause compression of the intra-abdominal viscera thereby increasing
the intra-abdominal pressure.
This action is facilitating expulsive functions such as forced
expiration, micturition, defecation and final stages of childbirth.
Abdominal Muscles
(Rectus abdominis)
Peritoneum and peritoneal cavity
The peritoneum is a two-layered membranous sac that: 

• Covers the abdominal walls with its parietal layer

• Lines most of the abdominal viscera with its visceral layer 

Between the sheets is a thin space called the peritoneal cavity containing
small amounts of serous peritoneal fluid.
Since the peritoneal layers are continuous with each other, they form
recesses (pouches) on sites where the parietal reflects to the visceral layer.
Some organs such as the kidney, adrenal glands and ureters are not covered
with the visceral peritoneum, and thus are called retroperitoneal organs.
The remainder of the abdominal organs are entirely covered with the
visceral layer and are called intraperitoneal organs.
Peritoneum and peritoneal cavity
(Parietal & Visceral)
 Peritoneal cavity

The peritoneal cavity is a space between the parietal and

visceral peritoneum, which are the two membranes that
separate the organs from the abdominal wall.
Peritoneum and peritoneal cavity
 The peritoneum has two divisions; greater sac
and lesser sac (omental bursa).
 The lesser sac is the smaller of the two, it is a
hollow space posterior to the stomach
intended to cushion its movements.
 The greater sac forms the main abdominal
cavity and is further divided by the transverse
colon into the supracolic and infracolic
compartments.
 The liver, stomach and spleen sit within the
supracolic compartment, while the small
intestine, ascending and descending colon are
held within the infracolic.
 The lesser and greater sacs communicate via
the omental foramen. 
Peritoneum and peritoneal cavity
Besides sacs, the peritoneum features peritoneal formations; the
mesentery, greater and lesser omentum and peritoneal ligaments.
• Mesentery attaches an organ to the abdominal wall and carries its
neurovascular bundle (mesentery proper, transverse mesocolon,
sigmoid mesocolon, mesoappendix)
• Greater and lesser omenta hang from the greater and lesser
curvatures of the stomach and attach to the transverse mesocolon
and the liver, respectively. 
• Peritoneal ligaments fixate organs to other viscera or to the
abdominal wall, and carry their vessels and nerves. Based on where
they originate, they are grouped into either splenic, gastric or
hepatic ligaments. 
 Linea alba

Linea alba (Latin ‘white line’) is a tendinous, fibrous raphe that

runs vertically down the midline of the abdomen.
It extends between the inferior limit of the sternum and the pubis,
separating the rectus abdominis muscles.
In leaner, more muscular individuals, it is visible externally as a
longitudinal, shallow groove. 
Even though the linea alba is not a muscle, Terminologia
Anatomica lists it under abdominal muscles.
It’s because the linea alba is formed by the interlacing aponeuroses
of three vertical abdominal muscles: external oblique,
internal oblique and transversus abdominis muscles.
Linea alba

Key facts about the linea alba

Origin Tip of xiphoid process

Insertion Anterior fibres: pubic symphysis

Posterior fibres: pubic crests on both sides
Structure Formed by aponeuroses of external oblique, internal oblique and
transversus abdominis
Function Attachment site for: - Fundiform ligament of penis
- Pyramidalis, internal oblique, external oblique and transversus
abdominis muscles
- Parietal peritoneum via extraperitoneal connective tissue
Linea alba

Relations and function

Linea alba separates the rectus abdominis muscles in the midline.

It is also an attachment site for several structures and muscles: 

• Fundiform ligament of penis
• The small pyramidalis muscle, which tenses the linea alba. The importance and true function of
this action are still questioned.
• Anterior abdominal muscles whose aponeuroses form the linea alba: internal oblique, external
oblique and transversus abdominis.
A few tendinous structures in the surrounding area have fibers which blend with the linea alba:
• Upward directed medial fibers from the inguinal ligament, close to its attachment.
• Extraperitoneal connective tissue anchors the parietal peritoneum to the linea alba.
• The overlying membranous layer of abdominal subcutaneous tissue (Scarpa’s fascia) of the
anterior abdominal wall blends with the linea alba in the midline. The fatty layer of abdominal
subcutaneous tissue (Camper’s fascia) is located on top of the membranous layer and is
continuous over the linea alba, whereas the deep adipose layer is absent at the fusion site between
the membranous layers and the linea alba.
Inguinal ligament
The inguinal ligament (also ligamentum inguinale, arcus
inguinalis or Pouparts’s ligament) is a band of connective
tissue that extends from the anterior superior iliac spine of
the ilium to the pubic tubercle on the pubic bone.
It is formed by the free inferior border of the aponeurosis
of the external oblique muscle which attaches to these two
points.
The inguinal ligament is closely related to a number of
structures and forms a boundary of the femoral triangle
and inguinal canal in the pelvic region.
Inguinal ligament
Key facts about the inguinal ligament
Attachment Anterior superior iliac spine, public tubercle
s
Extensions Lacunar ligament, pectineal ligament

Function Attach external oblique muscle to the pelvis, protect structure

passing between the pelvis and thigh/external genitalia, forms
boundary of femoral triangle and inguinal canal
Relations Iliopsoas, pectineus, femoral artery, femoral vein, femoral nerve,
lateral cutaneous nerve of thigh, lymphatics
Clinical Inguinal hernia
notes
Inguinal ligament
Function
The function of the inguinal ligament is to anchor the aponeurosis of the external
oblique muscle to the pelvis.
It also protects a number of important structures as they pass from the pelvic cavity
into the thigh and inguinal canal.
 Additionally, the inguinal ligament forms the base of the femoral triangle and the
floor of the inguinal canal.
Relations
As the inguinal ligament extends between its points of attachment, it crosses
anterior to a number of structures that are passing between the pelvis and thigh.
These are the iliopsoas and pectineus muscles, the femoral nerve, the lateral
cutaneous nerve of the thigh and inguinal lymph nodes. The inguinal ligament is
also the point where the external iliac artery becomes the femoral artery and the
femoral vein becomes the external iliac vein.
Inguinal canal

The inguinal canal is a slit-like passage connecting the abdominal

cavity to structures located in the groin.
The medial half of the inguinal ligament forms the floor of the canal
There is an opening on either end of the canal allowing the entry and
exit of the structures passing through.
The deep inguinal ring lies superior to the inguinal ligament at the
mid-inguinal point.
The superficial inguinal ring is located superior and slightly lateral to
the pubic tubercle.
Passing through the inguinal canal are the spermatic cord (males
only), the round ligament of the uterus (females only), the ilioinguinal
nerve and the genital branch of the genitofemoral nerve.
 . 
Pelvis

The pelvis is classified as a region of the trunk.

It extends between the abdomen and the lower extremities, bounded by
the bones of the pelvic girdle (hip bones, sacrum and coccyx).
The pelvis opens superiorly to the abdomen through the pelvic inlet,
while its inferior opening (the pelvic outlet) is closed by the
pelvic floor (levator ani and coccygeus muscles).
The pelvic inlet is the boundary between the greater pelvis superiorly
and lesser pelvis inferiorly.
The greater pelvis contains the inferior parts of some abdominal
viscera (terminal ileum, cecum, sigmoid colon).
 The lesser pelvis contains the internal genital organs, distal portions of
the urinary system (urinary bladder and urethra) and the perineum. 
Pelvis (ossa)
Pelvis (ossa)

Oss Coxxae
Pelvis (ossa)
Pelvis

The pelvic floor is primarily made up of thick skeletal muscles along

with nearby ligaments and their investing fascia.
It is a basin-shaped muscular diaphragm that helps to support the
visceral contents of the pelvis.
The main focus of this article will be the pelvic floor muscles.

On that topic, there are several important questions that need to be
answered:
• Which muscles make up the pelvic floor?
• What arteries and nerves supply the muscles of the pelvic floor?
• What causes pelvic floor dysfunction?
• What is the best exercise for the pelvic floor?
Pelvis
Key facts about the muscles of the pelvic floor
Gross A variably thick muscular membrane called a diaphragm
anatomy Coccygeus and levator ani muscles (iliococcygeus, puborectalis,
pubococcygeus)
Pubococcygeus can be further separated into – puboperinealis,
puboprostaticus (male), pubovaginalis (female), puboanalis
Mnemonic:  Could I Please Peek?

Attachment Laterally – attached to the tendinous arch of levator ani

s Posterolaterally – attached to the ischial spine
Posteriorly – attached to the caudal sacrum and coccyx
Anteriorly – attached to the posterior surface of the pubis
Midline – fibers form a midline levator raphe

Blood Branches of the anterior division of the internal iliac artery:

supply inferior vesical, pudendal, inferior gluteal

Innervation Pudendal nerve (S2, S3)

Direct branches from S4 (nerve to levator ani)

Embryolog Hypaxial division of the sacrococcygeal myotome

y

Function Prevents pelvic organ prolapse

Childbirth – supports and guides the presenting fetal part
Helps maintain continence (both urinary and fecal)

Clinical Pelvic organ prolapse

significance Kegel exercises
Pelvis
Gross anatomy
The pelvis marks an important transition point between the thoracoabdominal
region and the lower limbs. Not only is it important for walking, but it also houses
organs of the urogenital and distal digestive systems and acts as a conduit for
arteries, veins, lymphatic vessels, and nerves necessary for daily functioning. The
pelvis is a musculoskeletal structure that is made up of hip and sacrococcygeal
bones, along with several muscular layers. It is further divided into the greater
(false) and lesser (true) pelvis. The false pelvis is the wide-area just above the inlet
between the ala of the ilia while the true pelvis is the area between the inlet and the
outlet. It has two lateral walls, a posterior wall (sacrococcygeal bones), and a
muscular floor.
The lower part of the pelvis is sealed off by a muscular diaphragm and perineal
membrane known as the pelvic floor. There are two (males) or three (females)
openings that allow passage of the outlet components of the pelvic viscera in the
pelvic floor. The muscles of the pelvic floor contribute to maintaining continence
and help prevent the contents of the pelvic cavity from falling through its outlet. 
Pelvis
(Muscles)
Muscles
The muscles of the pelvic floor are collectively referred to as the levator ani and coccygeus
muscles.
They form a large sheet of skeletal muscle that is thicker in some areas than in others.
The muscles are attached along the inner walls of the true pelvis to a condensed area of the
obturator fascia known as the tendinous arch of levator ani muscle.
They can be subdivided based on their points of attachment as well as the pelvic organs
with which they are associated. Note that the levator ani is made up of the puborectalis,
pubococcygeus, and iliococcygeus muscles. The coccygeus (also referred to as
ischiococcygeus) is not part of the levator ani. 
The pelvic surface of the levator ani is separated from the visceral organs by their
associated fascia.
The perineal surface functions as the medial and superior walls of the ischioanal fossa and
its associated anterior recess respectively.
There is loose connective tissue between the posterior border of the muscle and the coccyx.
Finally, the outlets of the visceral organs separate the medial border of the two muscles. 
Pelvis Floor muscles
Summary of the pelvic floor muscles
Puborectali Origin: Posterior surface of bodies of pubic bones
s Insertion: None (forms 'puborectal sling' posterior to rectum)
Innervation: Nerve to levator ani (S4)

Pubococcy Origin: Posterior surface of bodies of pubic bones (lateral to

geus puborectalis)
Insertion: Anococcygeal ligament, Coccyx, Perineal body and
musculature of prostate/vagina
Innervation: Nerve to levator ani (S4); branches via inferior
rectal/perineal branches of the pudendal nerve (S2-S4)

Iliococcyge Origin: Tendinous arch of the internal obturator fascia, Ischial

us spine
Insertion: Anococcygeal ligament, Coccyx
Innervation: Nerve to levator ani (S4)
Coccygeus Origin: Ischial spine
(ischiococc Insertion: Inferior end of sacrum, Coccyx
ygeus) Innervation: Anterior rami of spinal nerves S4-S5
Pelvis Floor muscles

Mnemonic
There is an easy way to
remember the muscles of
the pelvic floor. The
mnemonic ' Could I Please
Peek?' will help you recall
the following structures:
• Coccygeus
• Iliococcygeus
• Pubococcygeus
• Puborectalis
Pelvis Floor muscles

Coccygeus (ischiococcygeus)
The coccygeus (ischiococcygeus) muscle is sometimes
considered as a part of the levator ani complex rather than as a
separate muscle. However, this muscle is actually a separate
entity that is situated at the most posterosuperior aspect of the
muscle complex. 
It is a triangular sheet of muscle with its apex inserted on the
tip and pelvic surface of the ischial spine and the base is
attached to the 5th sacral segment and the lateral margins of
the coccyx. The remaining fibers of the muscle converge at
the midline. The muscle is anteriorly related to the pelvic
surface of the sacrospinous ligament. 
Pelvis Floor muscles
Coccygeus (ischiococcygeus)
Pelvis Floor muscles

Iliococcygeus
Anococcygeal ligament (inferior view)The iliococcygeus part of
levator ani is anteroinferior to coccygeus muscle and posterosuperior to
pubococcygeus. The muscle extends laterally to the tendinous arch of
the levator ani. The posterolateral fibers have attachments to the ischial
spine (just inferior and anterior to the coccygeus muscle attachment),
while the anterolateral fibers attach at the obturator canal. The posterior
midline fibers are attached to the lower part of the sacrum and coccyx. 
The majority of fibers of iliococcygeus meet with fibers of the
contralateral half of the muscle to form a midline raphe. The raphe – a
groove where the two halves of the muscle unite – is continuous with
the anococcygeal ligament and provides a strong posterior attachment
for the pelvic floor. 
Pelvis Floor muscles
Iliococcygeus
Pelvis Floor muscles

Pubococcygeus
The pubococcygeus is the intermediate part of the levator ani muscles. The anterior fibers
arise from the posterior surface of the pubic arch and travel posteriorly in the horizontal
plane. The fibers then decussate to meet with the fibers from the contralateral side, to
form a sling around the distal parts of the pelvic organs. Pubococcygeus can be further
subdivided based on the structures that the fibers are immediately associated with:
• Puboperinealis - The innermost fibers travel adjacent to the urethra and its associated
sphincter as it exits the pelvic floor. In some instances, the muscle is called pubourethralis
because it is associated with the proximal half of the urethra and forms part of its
sphincter complex
• Puboprostaticus (males) and pubovaginalis (females) - Another group of muscle fibers
passes around the inferior part of the prostate (in males) or posterior wall of the vagina
(in females). 
• Puboanalis - A few fibers cross to the other side and blends with the fibers of the
longitudinal rectal muscles and fascia to form the conjoint longitudinal coat of the
anal canal. 
Pelvis Floor muscles
Pubococcygeus
Pelvis Floor muscles

Puborectalis
The puborectalis passes
behind the rectum along the
levator raphe as a muscular
sling curving around the
anorectal junction.
Collectively, the
subdivisions of
pubococcygeus and the
puborectalis muscle
together are referred to as
the pubovisceralis.
TERIMA KASIH