Download Anatomy and physiology of the abdominal wall

01
CHAPTER
Handbook of Complex
Abdominal Wall
Anatomy
and physiology
of the abdominal
wall
Álvaro Robín Valle de Lersundi, MD, PhD
Arturo Cruz Cidoncha, MD, PhD
1.1.
Anatomy of the abdominal wall
1.1.1. Introduction
The abdominal wall is delimited by muscle structures than can be classified in 5 anatomical areas: lateral, anterior, posterior, diaphragmatic and perineal (Table 1.1). We
will describe the first four due to their relevance in surgical repair of complex abdominal wall.
These groups of muscles are enclosed by several bone structures: last ribs, chondrocostal
joints, xyphoid, pelvis and costal apophysis of lumbar vertebrae.
Layers of the anterior and lateral abdominal wall include skin, subcutaneous tissue, superficial fascia, deep fascia, muscles, extraperitoneal fascia and peritoneum.
Table
1.1.
Muscular limits of the abdominal wall
POSTERIOR
∙ Quadratus lumborum
∙ Psoas
∙ Iliac muscle
LATERAL
∙ External oblique
∙ Internal oblique
∙ Transversus abdominis
ANTERIOR
∙ Rectus abdominis
∙ Piramidalis
SUPERIOR
∙ Diaphragm
INFERIOR
∙ Perineal muscles
1.1.2. Muscles of the abdominal wall
CONTENTS
1.1. Anatomy of the abdominal
wall
1.2. Physiology
y gy
Muscles of the anterolateral wall
Rectus abdominis
The rectus abdominis (m. rectus abdominis) is a long and thick muscle that is extended
from the anterolateral thorax to the pubis close to the midline (Figure 1.1).
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Handbook of Complex Abdominal Wall
Figure
1.1.
External oblique
Rectus abdominis
The external oblique muscle (m. obliquus externus abdominis) is
the most superficial and thickest of the three lateral abdominal
wall muscles (Figure 1.2).
Figure
1.2.
External oblique muscle
Cranially, the rectus abdominis muscles originates from 3 digitations that insert on the 5th-7th costal cartilages, the xyphoid
process and costoxyphoid ligament. Caudally, it inserts on the
anterior surface of the superior border of the pubis, symphysis
and pubic crest.
The muscle is packed between the anterior and posterior rectus
sheaths, except on the lower third of the abdomen where it is only
covered by the anterior sheath. Laterally, the rectus sheath merges within the aponeurosis of the external oblique muscles to form
the linea semilunaris.
Three to four horizontal tendinous structures, that closely adhered
to the anterior rectus sheath, interrupt the rectus abdominis along
its length. These intersections make difficult the dissection between
the anterior rectus sheath and the muscle and explain why hematomas and abscesses mainly extend over the posterior rectus sheath.
Table
1.2.
Relevant characteristics of the rectus abdominis
Characteristics
∙ Originates on the anterior surface of 5, 6, 7 costal cartilages and xyphoid
∙ Insertion on the anterior surface of pubis and symphysis of pubis
∙ Packed in their sheaths except in the lower third where the posterior
sheath is missing
∙ Difficulty of dissection between the anterior rectus sheath and the muscle
∙ The most important muscle for flexion of the trunk
∙ Used for pedicled muscle flaps
Its muscle fibers originate from the anterior surface of the lower
eight ribs that intertwine with insertions of the serratus anterior
and latissimus dorsi.
It runs vertically and medially and the muscular tendinous boundary descends in such a way that, approaching the midline and
also below the anterosuperior iliac spine, the muscle becomes
completely aponeurosis. Inferiorly the aponeurosis bends in itself
to form the inguinal ligament, which extends between the anterior
superior iliac spine and pubic tubercle.
Anteriorly the aponeurosis joins the aponeurosis of internal oblique
and contributes to form the anterior rectus sheath and linea alba,
crossing the midline with fibers of the other side.
Insertion on the pubis is made through the pillars of the superficial inguinal ring, the inguinal ligament and Gimbernat´s
ligament.
Table
1.3.
Relevant characteristics of external oblique
Pyramidalis
Characteristics
The pyramidalis (m. pyramidalis) is a small muscle that can be
found inferiorly overlaying the rectus (Figure 1.1). It is a rudimentary muscle that can be missing in 20% of subjects.
It originates from the pubis and inserts into the lateral borders of
linea alba, inferior to the umbilicus.
2
∙
∙
∙
∙
∙
∙
Originates from the anterior surface of the last 8 ribs
The thickest muscle of the lateral abdominal wall
Inferior and medial direction of fibers of muscle and aponeurosis
The aponeurosis contributes to form anterior rectus sheath
Boundary between muscle and aponeurosis
It bends in itself to form the inguinal ligament
Anatomy and physiology of the abdominal wall
Some inferior fibers form the cremaster muscle at the level of the
inguinal canal.
Internal oblique
The internal oblique muscle (m. obliquus internus abdominis) lies
between the external oblique muscle and transversus abdominis
(Figure 1.3). Posteriorly, it is covered by the latissimus dorsi.
Figure
1.3.
CHAPTER
01
There is an avascular layer of loose connective tissue between
external oblique and internal oblique muscles that allows easy
dissection between these muscle layers.
Transversus abdominis
Internal oblique muscle
The transversus abdominis muscle (m. transversus abdominis) is
the deepest of the three lateral abdominal wall muscles and runs
in a horizontal direction (Figure 1.4). Fleshy in the middle and
tendinous at the extremities, it covers the entire lateral half of the
abdominal wall, from the spine to the linea alba.
Figure
1.4.
Transversus abdominis
It originates from the thoracolumbar fascia (fascia toracolumbaris), anterior two thirds of the iliac crest, and lateral half of the
inguinal ligament.
The internal oblique muscle runs in a superomedial direction, perpendicular to the external oblique muscle.
At the level of linea semilunaris, it becomes a wide aponeurosis.
In the superior two-thirds the aponeurosis splits medially to form
the anterior and the posterior rectus sheaths. In the inferior third,
the aponeurosis does not split, joins the anterior aponeurosis of
external oblique muscle and only comprises the anterior rectus
sheath. The inferior border of the posterior rectus sheath is the
arcuate line.
The internal oblique inserts on the inferior border of the 10th to 12th
ribs superiorly. Inferiorly, the internal oblique inserts with aponeurotic fibers from the transversus abdominis, forming the conjoined
tendon, which inserts on the pubic crest.
Table
1.4.
Relevant characteristics of internal oblique
Characteristics
∙ Originates from thoracolumbar fascia, iliac crest and inguinal ligament.
∙ Fibers run perpendicular to the external oblique muscle
∙ Easy dissection between the muscle layers of external oblique and
internal oblique
∙ The aponeurosis does not form the posterior rectus sheath below the
arcuate line
∙ It has insertions on the inferior border of 10th-12th ribs
∙ Involved in the composition of the conjoined tendon
It originates from the thoraco-lumbar fascia, the iliac crest, the inguinal ligament and from the inner surface of the lower six costal
cartilages, interdigitating with the insertions of fibers of the diaphragm (Figure 1.5). Posteriorly, the transversus abdominis also
starts from a wide aponeurosis of insertion in the thoraco-lumbar fascia, over the cuadratus lumborum, which has been termed
posterior aponeurosis of the transversus abdominis. In posterior
component separation technique, the mesh can be laid on this
posterior aponeurosis (Figure 1.6).
The muscle runs horizontally and ends medially in a broad flat
aponeurosis in the linea semilunaris, with a shape of a curve line
with medial concavity. Above the arcuate line, the aponeurosis
joins the internal oblique aponeurosis and the linea alba.
In the superior third of the abdomen the fibers of the muscle extend behind the rectus abdominis muscle approaching the midline.
Below the arcuate line, the aponeurosis of the muscle contributes
to form the conjoined tendon with the internal oblique. At this level,
the differentiation between the fibers of internal oblique and transversus is quite difficult.
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Handbook of Complex Abdominal Wall
Figure
1.5.
Anatomical relationships between transversus
abdominis and diaphragm
It is not an easy task to separate the layer of the transversus abdominis from the internal oblique because the neurovascular bundles are intercalated in this space.
Muscles of the posterior wall
Quadratus lumborum
The quadratus lumborum (m. Quadratus lumborum) is a flat and
quadrangular muscle situated between the last rib and the iliac
crest (Figure 1.7).
It originates in the iliac crest and iliolumbar ligament and its fibers
ascend to insert on the 12th rib and transverse apophysis of the
first lumbar vertebrae.
The lateral fibers are more vertical than the medial ones that are
oblique.
It is covered by the posterior aponeurosis of transversus abdominis muscle.
Figure
1.6.
Extension of the mesh following the plane behind
the transversus abdominis and laying on the posterior aponeurosis
of transversus abdominis and quadratus lumborum. 1: transversus
abdominis; 2: mesh; 3: thoracolumbar fascia; 4: posterior fascia
of transversus abdominis; 5: quadratus lumborum; 6: psoas
Figure
1.7.
Quadratus lumborum and psoas iliacus
Iliopsoas
Table
1.5.
Relevant characteristics of transversus abdominis
Characteristics
∙ Originates from thoracolumbar fascia, iliac crest, inguinal ligament and
inner side of last 6 costal cartilages
∙ Fibers run horizontal
∙ The muscle fibers reach behind the rectus abdominis near the midline in
the upper third
∙ In the retrocostal space, the retromuscular dissection can be extended
between the peritoneum and diaphragm
∙ The lumbar neuro-vascular bundles come across the space between
transversus abdomins and internal oblique
∙ Involved in the composition of the conjoined tendon
4
The iliopsoas muscle (m. iliopsoas) is made of 2 muscles: psoas
major and iliacus.
The iliacus muscle (m. iliacus) originates in the iliac fossa and
its fibers descend to form the tendon of the psoas that inserts on
lesser trochanter.
The psoas major (m. psoas major) starts on the bodies and transverse apophysis of 1-4 lumbar vertebrae.
Its fibers come down to join iliacus muscle to form the tendon of
the psoas.
It is interesting to remember the anatomic relationships of these
muscles with the lumbar plexus. The iliohypogastric and ilioinguinal
nerves run between quadratus lumborum and lateral border of psoas major. The lateral femoral cutaneous nerve arises from the convex border of the psoas major and the genitofermoral nerve emerges in the medial border of the psoas major at the level of the 4th
lumbar vertebra. The obturator nerve runs the medial border of the
psoas major before entering the lesser pelvis. The femoral nerve
comes posteriorly between the psoas major and the iliacus muscle.
CHAPTER
01
Anatomy and physiology of the abdominal wall
complex way to form the anterior and posterior rectus sheaths
and, weaving in the center, they constitute the linea alba (Figura 1.9).
Figure
1.9.
Myofascial limits of lateral abdominal muscles.
T: transversus; IO: internal oblique; EO: external Oblique
Diaphragm
It is a dome-shaped flat and thin muscle that separates thorax
from abdomen. The origins of the diaphragm are found along the
lumbar vertebrae, inferior border of the ribs and sternum.
It has a peripheral part of muscle and a central part (central tendon) of flat aponeurosis.
The peripheral muscle is divided according to its origin: sternal,
costal and lumbar. The sternal origin is made up of 2 small muscles that are attached to the posterior side of the xyphoid. The
costal origin is made up of several wide muscles that originate in
the internal surface of the 7-12 ribs. These fibers interlace with insertions of the transversus abdomnis in the last 6 ribs. The lumbar
origin is made up of the pillars of the diaphragm.
In lateral hernias, in the retrocostal dissection, following the retromuscular layer behind the transversus abdominis, a space between the diaphragm and the peritoneum can easily be created
allowing the extension of the mesh in this position (Figure 1.5).
1.1.3. Other components
of the abdominal wall
The muscles previously described are enveloped by a fascia and
has an aponeurosis of insertion.
Linea alba
The linea alba (linea alba) is a tendinous median line formed
by the crossing and fusion of the anterior and posterior rectus
sheaths made up of the intersection of the bilaminar aponeuroses
of the three abdominal flat muscles.
Different ways of decussation in the midline have been described
without any surgical relevance so far.
Rectus sheaths
Commonly, the fascia has a thin connective tissue that makes the
dissection difficult to perform (Figure 1.8). On the contrary, the
aponeurosis works like an authentic tendon of insertion and has a
very strong and resistant tissue.
Figure
1.8.
Drawing showing the concept of fascia
and aponeurosis. F: fascia; M: muscle; A: aponeurosis
The bilaminar aponeuroses of the three muscles of the anterolateral abdominal wall are flat tendons that contribute in a
Rectus sheaths (vagina musculi recti abdominis) are fibrous
sheaths that envelope recti abdominis on each side.
In the superior two-thirds the rectus sheath is formed anteriorly by the external oblique aponeurosis and the anterior aponeurosis of the internal oblique muscle and, posteriorly, by the
posterior aponeurosis of the internal oblique muscle and the
aponeurosis of the transversus muscle. In the lower third, the
aponeurosis of the external oblique, internal oblique and transversus abdominis pass anteriorly to form the anterior rectus
sheath. At this level the rectus abdominis is only covered posteriorly by the transversalis fascia. The semicircular line that divides these areas of the abdomen is the arcuate line of Douglas
(linea arcuata) and can be found to the mid-point between the
umbilicus and the pubis.
The semilunar line (linea semilunaris) or line of Spiegel is made
up of the fusion of the aponeurosis of the 3 lateral flat muscles on
the lateral border of the rectus muscle. It can be identified from the
9th costochondral arch to the pubis tubercle.
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Handbook of Complex Abdominal Wall
Fascia transversalis
It is simply the inner fascia of the transversus abdominis muscle
and was so-called by Sir Astley Cooper.
The fascia transversalis is the deepest parietal layer situated over
the parietal peritoneum. It is a fine and resistant lamina of connective tissue and is part of the intraabdominal fascia (fascia endoabdominalis). It is covered by the internal surface of the transversus
abdominis muscle that closely adheres to it.
obturator arteries or veins (obturatoria accesoria) or anastomotic
vessels that connect external iliac or inferior epigastric vessels
with the obturator vessels (r. obturatorius or corona mortis). Hemostasia can be achieved by electrocautery, other energy devices
or with the stitch used for mesh fixation.
Superficial fascias
Between the skin and muscles there is a single layer of thin connective tissue above the umbilicus.
When making the transversus abdominis release in the posterior component separation technique, the surgeon may make the
dissection over or under the fascia transversalis. If the dissection
over this fascia is made, the peritoneum will be protected by the
fascia and will be more difficult to be torn. However the plane is
irrigated by very small vessels that easily bleed. If the dissection
is made under the fascia transversalis, this plane will be avascular
but opening of the peritoneum will be more probable to occur.
Below the umbilicus, the fascia is divided in a fatty outer layer
(Camper´s fascia) and a deeper membranous layer (Scarpa´s
fascia).
Posteriorly, the fascia transversalis joins the thoracolumbar fascia
(fascia thoracolumbalis) and, superiorly, blends the diaphragmatic fascia (fascia diaphragmatica). It is denser at the level of the
posterior wall of the inguinal area and continues inferiorly with the
endopelvic (fascia pelvica) and iliac fascias (fascia iliaca).
Knowledge of the blood supply to the abdominal wall is important
when planning incisions and surgical repair of complex abdominal
wall.
Cooper ligament
The Cooper´s pecten ligament (lig. pectineum) is a fixed and rigid
structure made up of the thickening of the upper branch of pubis periosteum, the sheath of the pectineous muscle, the ileopubic tract (inguinal ligament) and the insertion aponeurosis of the
transversus abdominis muscle (Figure 1.10).
Figure
1.10.
Dissection on the cadaver of Cooper ligaments
This fascia can be used to appropriately close the subcutaneous
tissue after incisional hernias repair.
1.1.4. Vascular supply
There is an inferior superficial vascularization of the abdominal
wall provided by a superficial system made up of superficial epigastric, superficial circumflex and superficial pudendal arteries,
branches of the femoral artery.
The rest of the vascular supply to the abdominal wall is provided
by deep vascular axes:
• A vertical axis of the epigastric vessels along the posterior
surface of the rectus muscle.
• A horizontal axis made up of the last 6 intercostal and lumbar
arteries.
• A vertical lateral axis formed by ascending branches of the
deep circumflex artery.
Inferior epigastric artery
The inferior epigastric artery irrigates the rectus muscle and the
subcutaneous tissue and skin by means of a medial and lateral
row of musculo-cutaneous perforators.
It arises from the medial side of the external iliac artery, behind the
deep inguinal ring, pierces the transversalis fascia and ascends
cranially and medially enveloped in perivascular fatty tissue as far
as the linea arcuata where it passes between the rectus muscle
and the posterior rectus sheath.
This ligament is the one of the most important sites for mesh fixation in incisional hernias. It can be easily found following laterally
the retropubic space close to the iliac vessels.
The surgeons who use this ligament to fix the mesh should be
aware that some vessels could be found crossing the Cooper
ligament in almost 20% of patients. These vessels are aberrant
6
When making the lateral retrorectus dissection below the linea
arcuata, the surgeon should coagulate 2-3 medial branches to the
midline from the inferior epigastric artery that may cause bleeding and the potential ligation of the inferior epigastric vessels. To
avoid injury to these vessels, the dissection should elevate the fatty tissue that surrounds the vessels leaving below the peritoneum
and the fascia transversalis.
The deep epigastric artery finally divides above the umbilicus in 1-3
branches, which anastomose the superior epigastric artery branches.
CHAPTER
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Anatomy and physiology of the abdominal wall
Several musculocutaneous perforators arise from the deep epigastric artery giving a metameric subdivision of lateral and medial
rows of perforators, usually 4 above and 3 below the umbilicus.
These perforators supply the subcutaneous tissue and skin.
The genitofemoral nerve arises from the first and second lumbar
nerves and contributes to the sensory innervation of the root of
the external genital organs. It is also the motor nerve of the cremaster.
Superficial epigastric artery
The lateral cutaneous nerve of the thigh (the laterla femorcutaneous nerve), originating from the second lumbar, is not involved in
the superficial innervation of the abdominal wall.
It arises the external iliac artery, distal to inguinal ligament and ascends about 2 cm laterally to the linea semilunaris over the muscles in
the subcutaneous tissue between the fascias of Camper and Scarpa.
Intercostal and lumbar arteries
These vessels come laterally along with the nerves in the space
between the internal oblique and transversus muscle. They give
several posterior perforators, medially and laterally.
Some diaphragmatic branches from the internal thoracic artery
anastomose the superior intercostal vessels. The lumbar arteries
also anastomose branches of the deep circumflex iliac artery.
1.2.
Physiology
Veins
The abdominal wall is a myofascial complex that can resist the
continuous variation in intraabdominal pressure. The sheaths of
the muscles are responsible for abdominal wall continence in rest,
while the muscle contraction protects the wall from the sudden
changes in intraabdominal pressure.
The venous system is patterned parallel to arteries, accompanying the perforators and, subsequently, the main veins, by means
of the thoracophrenic, phrenic, lower intercostal, lumbar and epigastric veins.
The abdominal wall must be considered as a unitary functional
system. Andres de Laguna wrote in 1535 that “this wall of the body
is made up of eight muscles by means of which it attracts, holds
back, prepares, expels and accomplishes many other functions”.
They finally drain into the azygous, subclavian and iliac veins.
1.2.1. Protection
1.1.5. Innervation
The lower intercostal nerves and the nerves of the lumbar plexus
suply the innervation of the anterolateral abdominal wall.
The last 6 intercostal nerves (T7-T12) and the iliohypogastric and
ilioinguinal nerves run with the homologous vessels in the layer
between the internal oblique and transversus abdominis. They all
give motor and sensory innervation.
The T7-T12 nerves divide in two branches. One branch runs
along the cartilaginous costal margin, terminates in the wall of
the thorax and innervates the internal intercostal space. These
intercostal nerves are in a relatively protected position under the
chondrocostal margin. The other abdominal branch crosses the
cartilaginous costal margin and penetrates in the space between
the internal oblique and transversus muscle.
When the nerves come close to the linea semilunaris, they pierce
the posterior rectus sheath slightly medial to its lateral margin, to
innervate the rectus muscle. This lateral row of perforators must
be preserved during the posterior component separation technique.
The two abdominogenital nerves (iliohypogastric and ilioinguinal
nerves) supply sensory innervation to the oblique area of the abdominal wall comprising the lower part of the iliac fossa, the inguinal region and part of the external genital organs. The motor
branch of the iliohypogastric nerve reaches the inferior part of the
rectus and the pyramidalis, while the ilioinguinal nerve terminates
in the flat abdominal muscles.
The muscles on both sides of the abdominal wall work synkinetically with their aponeuroses containing and protecting the abdominal
contents. It also maintains the correct anti-gravitational position.
1.2.2. Body actions
This myoaponeurotic system participates in several functions:
• Flexion, extension and rotation of the trunk.
In association with the diaphragm, lattissimus dorsi, trapezius,
iliopsoas and quadratus lumborum muscles, combines upper
and lower body movements, allowing coordinated movement,
overall balance of the spine and weight shifts.
• Increases of intraabdominal pressure by muscle contractions:
- Micturition
- Defecation
- Cough
- Valsalva
- Delivery
•
Pelvic stabilization:
Together with the psoas and the quadratus lumborum, the
rectus abdominis muscle stabilizes the pelvis during walking,
running and jumping.
1.2.3. Respiration
Together with the diaphragm, the abdominal wall muscles work as
a functional system in respiration. Abdominal muscular contraction
pushes the viscera upwards and participates in expiration, both at
rest and forced. The essential component is the transversus ab-
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Handbook of Complex Abdominal Wall
dominis muscle, which acts as an antagonist to the diaphragm.
While the diaphragm contracts in inspiration, the muscles of the
abdominal wall relax and vice versa. So that, the diaphragm and
abdominal wall muscles work antagonistically during respiration,
except in coughing or other actions that need an increase of intraabdominal pressure, when they act synergistically. In fact, the
voluntary contraction of the abdominal wall muscles blocks respiration.
1.2.4. Specific functions
In the inguinal region, the myoaponeurotic arch of the transversus
abdominis and internal oblique protects the posterior wall of the
inguinal canal.
1.2.5. Consequences of large abdominal
wall defects
The external oblique and internal oblique muscles are wall tensors and costal depressors; their main contribution is protection of
viscera and help in the flexion and rotation of the trunk.
The first consequence of loss of abdominal wall continence is the
lack of protection of viscera and the decrease in intraabdominal
pressure.
The transversus abdominis muscle is also a tensor of the wall and
a costal depressor of the ribs; it participates in expiration.
In the presence of a large parietal defect, there is a creation a second cavity with respiratory, visceral, vascular and vertebral consequences. This second cavity has also been named loss of domain
or abdominal volet.
The rectus abdominis muscle is a tensor, act in flexion of the trunk;
it contributes to stabilizing the pelvis during walking, protects the
abdominal viscera and is active during forced respiration.
The pyramidalis muscle is a tensor of the linea alba.
The modification of synergism makes the great incisional hernias
a respiratory disease with major concerns in ventilation, diffusion
and perfusion.
The quadratus lumborum muscle flexes the spinal column ipsilaterally.
The mechanical separation of muscles also causes deterioration of the
muscular part and sheaths leading to muscular atrophy and fibrosis.
The psoas major muscle flexes and turns the thigh laterally and
inclines the spine laterally.
The alteration on the vascularization of viscera may produce impaired vena cava and portal venous return.
Table
1.6.
Summary of abdominal wall muscles
Name
8
The diaphragm muscle is the main respiratory muscle; it flattens
during contraction enlarging the thoracic cage.
Origin
Insertion
Innervation
Function
Rectus abdominis
∙ Anterior surface 5-7
costochondral archs
∙ Xyphoid
∙ Pubis
∙ 7-12 intercostal
∙
∙
∙
∙
Pyramidalis
∙ Pubis
∙ Linea alba, between
umbilicus and pubis
∙ 12 intercostal
∙ Tension of linea alba
External oblique
∙ External surface 5-12 ribs
∙ Rectus sheath and linea alba ∙ 5-12 intercostal
∙ Iliac crest
∙
∙
∙
∙
Internal oblique
∙ Thoraco-lumbar fascia, iliac
crest and inguinal ligament
∙ Rectus sheath
∙ 10-12 ribs
∙ 8-12 intercostal
∙ Iliohipogastric
∙ Ilioinguinal
∙ Descend of ribs
∙ Lateral and ventral flexion
of the trunk
∙ Tension of the abdomen
Transversus abdominis
∙
∙
∙
∙
∙ Linea alba
∙ Rectus sheaths
∙
∙
∙
∙
7-12 intercostal
Iliohipogastric
Ilioinguinal
Genito-femoral
∙ Tension of the abdomen
Psoas
∙ Iliac fossa
∙ 1-4 lumbar vertebrae
∙ Trochanter minor
∙ Femoral
∙ Lumbar plexus
∙ Flexion, rotation of thigh
Quadratus lumborum
∙ Iliac crest
∙ Lumbar vertebrae
∙ 12 rib
∙
∙
∙
∙
∙ Descend of ribs
∙ Lateral flexion
Diaphragm
∙ Vertebrae
∙ Arcuate ligaments
∙ 7-12 costal arches
∙ Phrenic center
∙ Phrenic
Inner surface 7-12 ribs
Thoraco-lumbar fascia
Iliac crest
Inguinal ligament
7-12 intercostal
Iliohipogastric
Ilioinguinal
Genito-femoral
Flexion of trunk
Descend of thorax
Pelvis elevation
Tension of the wall
Rotation of trunk
Descend of thorax
Lateral flexion
Tension of the wall
∙ Separation of thorax from
abdomen
∙ Respiration
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Anatomy and physiology of the abdominal wall
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 Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications.
Plast Reconstr Surg 2009; 124: 1529-44. doi: 10.1097/PRS. 0b013e3181b98a6c. http://www.ncbi.nlm.nih.gov/pubmed/20009839
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