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Anatomy of anterior abdominal wall and hernia Dr.Munirah Batarfi MD, MSc & PhD 1 Layers of the Anterior Abdominal Wall 1- Skin. 2- Superficial fascia: a- Superficial fatty layer, (Camper’s fascia) b- Deep membranous layer, (Scarpa’s fascia) No Deep Fascia in the anterior abdominal wall 3- External oblique muscle. 4- Internal oblique muscle. 5- Transversus abdominis muscle. 6- Fascia Transversalis. 7- Extraperitoneal fatty Tissue. 8- Peritoneum. 2 Layers of anterolateral abdominal wall: 1- Skin. 2- Superficial fascia: a- Superficial fatty layer (Camper’s fascia). b- Deep membranous (Scarp’s fascia). 4- Muscular layers: (External & internal oblique and transversus abdominis. 5- fascia transversalis. 6- Space of Bogros, (extra peritoneal fatty tissue). 7- Parietal peritoneum. 3 Layers of the abdominal wall Its layers consist of skin, superficial fascia (subcutaneous tissue), muscles and their associated deep fascias, extraperitoneal fascia, and parietal peritoneum. 4 5 6 External Oblique • Origin: outer surface of the lower 8 ribs. (by 8 fleshy digitations which interdigitate with serratus anterior and latissimus dorsi. • Insertion: Xiphoid process, Linea alba, Pubic crest, Pubic tubercle, ASIS. & anterior ½ of the outer lip of the iliac crest. • Direction of its fibers : Downward, Forward, and Medially. 7 8 9 10 11 Internal Oblique Origin: lateral 2/3 of the inguinal ligament, anterior 2/3 of iliac crest, and lumbar fascia. Insertion: Lower border of lower 3 ribs and their costal cartilages, xiphoid process, linea alba, symphysis pubis, pubic crest and Pectineal line. Direction of its Fibers: upward forward and medially (at right angle with the fibers of the external oblique). 12 Transversus Abdominis Origin: Lateral 1/3 of inguinal ligament, anterior 2/3 of inner lip of iliac crest, lumber fascia and lower 6 costal cartilages. Insertion: Xiphoid Process, Linea alba, Pubic crest, and Pectineal line. Direction of its fibers: Horizontally. 13 14 15 16 17 18 19 20 21 Rectus Abdominis Origin: By 2 heads from pubic crest, pubic and front of symphysis pubis. tubercle Insertion: Into 5th,6th,and 7th costal cartilages, and xiphoid process. It is a strap muscle that extend along the whole length of the anterior abdominal wall. It shows a transverse tendinous intersection. It is enveloped in Rectus Sheath. 22 Contents of Rectus Sheath 2 Muscles: Rectus Abdominis & Pyramidalis. 2 Vessels : Superior & inferior epigastric vessels. 2 nerves: Lower 5 intercostal & Subcostal nerves Lymph Vessels. 23 24 25 26 27 Abdominal wall muscles 28 Inguinal Canal An oblique passage through the lower part of the anterior abdominal wall Extends from the deep inguinal ring to the superficial inguinal ring Present in both sexes About 4 cm long in the adult ( very short in children as the two rings lie near each other) Lies parallel to and above the inguinal ligament Has anterior, posterior, inferior (floor) and superior (floor) walls 29 Superficial inguinal ring • Triangular aperture in the aponeurosis of external oblique muscle • Base formed by the pubic crest • Margins called the ‘crura’ give origin to external spermatic fascia 30 Deep inguinal ring An oval opening in the fascia transversalis Lies about ½ inch above the midinguinal point Related medially to the inferior epigastric vessels Margins give origin to internal spermatic fascia in male, and covering of round ligament of uterus in female 31 Anterior Wall Formed along its entire length by the aponeurosis of external oblique Reinforced in its lateral third by the fibers of the origin of the internal oblique Anterior wall is strongest in the lateral part where it lies opposite the weakest part of the posterior wall, namely the deep inguinal ring 32 Posterior Wall Formed along its entire length by the fascia transversalis Reinforced in the medial third by the conjoint tendon Posterior wall is strongest in the medial part where it lies opposite the weakest part of the anterior wall, namely the superficial inguinal ring 33 Superior Wall (Roof) Formed by the arching lowest fibers of the internal oblique and transversus abdominis muscles 34 Inferior Wall (Floor) Formed by the inguinal ligament and its medial end, the lacunar ligament 35 Inguinal canal: Mechanics Though a weak area of the abdominal wall, but in normal conditions: Anterior and posterior walls are reinforced against weak areas When abdominal muscles contract, superior arched fibers close the canal In squatting position, anterior surface of thigh lies against the abdomen, thus supporting the wall 36 Contents of the Inguinal canal Spermatic cord and Ilioinguinal nerve in male Round ligament of uterus and ilioingunal nerve in female 37 Spermatic Cord Collection of structures that traverse the inguinal canal and pass to and from the testis Covered by three layers of fascia derived from the layers of the abdominal wall Begins at the deep inguinal ring, lateral to inferior epigastric vessels, and ends at the testis 38 39 Inguinal hernias (Cont’d) 40 Hernia Hernia is the protrusion of part of abdominal viscera beyond the normal confines of the abdominal walls It has three parts: The sac Contents of the sac Coverings of the sac 41 Hernia: Types cont’d Diaphragmatic/Hiatal Lumbar (Petit’s triangle) ObturatorEpigastric Umbilical: congenital (omphalocele) or acquired Inguinal: direct or indirect Femoral Incisional 42 Surgical abdominal incisions • Gridiron (muscle‐splitting) incisions are often used for an appendectomy. • The oblique McBurney incision is made at the McBurney point, approximately 2.5 cm superomedial to the ASIS on the spinoumbilical line. This incision is currently less popular than an almost transverse incision in the line of a skin crease. • Suprapubic (Pfannenstiel) incisions (“bikini” incisions) are used for most gynecological and obstetrical operations. • Transverse incisions. • Subcostal incisions. High‐Risk Incisions Pararectus incisions along the lateral border of the rectus sheath are undesirable because they are likely to cut the nerve supply to the rectus abdominis. Blood supply from the inferior epigastric artery also may be compromised. Inguinal incisions for repairing herniasmay injure the ilioinguinal nerve directly or it may be inadvertently included in the suture during closure of the incision. In such cases, people may feel pain in the L1 dermatome region, which includes the scrotum (or the labium majus). 43 Inguinal Hernia Herniation of the abdominal viscera (usually small intestinal coils) through the inguinal region It is of two type: Direct Indirect 44 Indirect Inguinal hernia Most common form of hernia Most common in children & young adults About 20 times more common in male than in female 1/3rd are bilateral More common on the right side 45 Indirect Inguinal hernia cont’d Hernial sac: Formed of remains of processus vaginalis Enters inguinal canal through deep ring Lies lateral to the inferior epigastric artery Can be complete, extending to the scrotal sac, or incomplete, arrested in the inguinal canal 46 Direct Inguinal hernia Comprise about 15% of inguinal hernia, Rare in females Common in old men with weak abdominal muscles Hernial sac: Bulges directly anteriorly through the posterior wall of the inguinal canal i.e.through the inguinal (Hasselbach’s) triangle. This triangle is bounded medially by lateral edge of rectus abdominis muscle, laterally by inferior epigastric artery, infeiorly by inguinal ligament. Lies medial to the inferior epigastric vessels Usually nothing more than a generalized bulge 47 48 Femoral Hernia Protrusion of abdominal viscera through the femoral ring into the upper part of the thigh More common in women (wider femoral ring) Neck of the sac lies below and lateral to the pubic tubercle 49 Relation of inguinal & femoral hernial sacs to pubic tubercle Inguinal: sac lies above and medial to the pubic tubercle Femoral: sac lies below and lateral to the pubic tubercle 50 Inguinal hernias 51 52 Relation of inguinal hernia to Inferior epigastric vessels Right inguinal triangle. A. Internal view. B. Laparoscopic view showing the parietal peritoneum still covering the area. Other types of Hernias • Femoral hernias • Umbilical hernias • Para-umbilical hernias • Incisional hernias 53 References Gray's Anatomy for Students- Second edition Clinically Oriented Anatomy , Keith L. Moore- Sixth edition 54