Anterolateral Abdominal Wall Flashcards
What are the quadrants of the abdomen?
Top: R. Hypochondriac (RH), epigastric (E), LH
Middle: R. Lumbar (RL), Umbilical (U), LL
Bottom: R. Iliac (RI), hypogastric (P), Left Iliac (LI)
What are the layers of the anterior abdominal wall from superficial to deep?
- Skin
- Subcutaneous tissue of superficial fascia
- External oblique
- Internal oblique
- Fascia of both superficial an deep surfaces of the internal oblique
- Transverse abdominal m.
- Transversalis fascia
- Extraperitoneal fat
- Peritoneum
What are the layers covering the testis?
- Skin
- Subcutaneous tissue (dartos fascia) and dartos muscle
- External spermatic fascia
- Cremaster muscle
- Cremasteric fascia
- Internal spermatic fascia
- Tunica vaginalis : parietal and visceral layer
What are the layers of the spermatic cord?
- Scrotum (and scrotal septum)
- External spermatic fascia
- Cremasteric muscle
- Cremasteric fascia
- Internal spermatic fascia
- Vestige of precessus vaginalis
Skin incision made over what lines heal with a minimum of scarring?
Tension lines. They are also called cleavage or Langer’s lines
What are the two layer of the superficial fascia (subcutaneous tissue)?
Camper’s fascia (superficial fatty layer)
Scarpa’s fascia (deep membranous layer)
What does the deep investing fascia cover?
What’s it also called?
Each muscle and its aponeurosis separately and superficially.
Epimysium or Gallaudet’s fascia
What is the transversalis fascia?
A thin aponeurotica membrane which lies between the inner surface of the transversus abdominus muscle and endoabdominal fascia
What is the endo-abdominal fascia or extr-peritoneal fat layer?
A membranous sheet of varying thickness covering internal aspects of the transversalis fascia. It has parietal and visceral components (prominent in the posterior abdominal wall, especially around the kidneys)
What is the largest of the serous membrane of the body? (It has a parietal and visceral part)
The peritoneum
What covers the entire abdomen extending from the inferior half of the thorax and is dependent on
hormonal influence with differences in both sexes?
Campers fascia (superficial layer of the superficial fascia or fatty layer)
What fascia continues over the inguinal ligament as the superficial fascia of the thigh, and over the pubis and
perineum as the subcutaneous fascia of perineum or Cruveilhier fascia?
Campers fascia
What fascia attaches to the fascia lata of the thigh about one inch below the inguinal ligament ?
Scarpa’s fascia
Scarpa’s fascia continues over the pubis & perineum as ____ or deep layer of the superficial fascia of the
perineum.
Colle’s fascia
What fascia continues over the penis in males as the superficial fascia of the penis and scrotum as part of Dartos fascia (Dartos tunic); and contains smooth muscle (one of the components of the Cremasteric reflex which will be discussed in male genital system).
Scarpa’s fascia
What does the deep fascia of Gallaudet consist of?
Of inner and outer investing fascia layers.
Note: The inner investing layer is well formed, whereas the outer layer is thin.
What are the flat muscles of the abdominal wall?
External oblique, internal oblique and tranversus abdominis
What are the longitudinal muscles of the abdominal wall?
Rectus abdominis and pyramidalis
What’s the insertion and origin of the external oblique muscle?
Origin: Anterior surface of ribs 5th - 12th (inferior 8 ribs)
Insertion: Iliac Crest where the aponeuroses of all flat abdominal muscles are commonly inserted
posterolaterally and linea alba anteriorly,
Where does the aponeurosis of the external oblique lie?
Between the mid-clavicular line and the abdominal midline
What is the linea alba (white line)?
Line in the midline
What happens to the linea alba during pregnancy?
Turns dark (“linea nigra”) during pregnancy due to progesterone.
What is the inguinal ligament?
The lower border of the tendinosas part (of external oblique) folds inward to form the inguinal ligament (Poupart’s ligament)
It is attached between the ASÍS and the pubic tubercle
What continues inferiorly into the scrotum surrounding the spermatic cord as the external spermatic
fascia.
Inguinal ligament
What is the innervation and action of the external oblique?
Innervation: thoracoabdominal nerves (ventral primary rami of T7 – 12 nerves)
Actions: flexion, lateral rotation and increase in intra-abdominal pressure.
What muscle joins to form the rectus sheath, linea alba, inguinal ligament, superficial inguinal ring and external spermatic fascia.
external oblique
What direction do the internal oblique muscles rune?
Perpendicular to the external oblique muscles
What is the origin and insertion of the internal obliques?
Origin: Thoraco-lumbar fascia, anterior 2/3 of iliac crest, and inguinal ligament
(Shares the aponeurosis and linea alba with all anterolateral muscles)
Insertion: Inferior borders of 10th - 12th ribs, linea alba, and pecten pubis via the conjoint tendon
What forms the conjoint tendon?
the conjoint tendon is formed by the tendons of the internal oblique and transverse abdominis muscles
What is the innervation and action of the internal oblique muscle?
Innervation – Ventral primary rami of T7-T12 and L1 nerves (Ilioinguinal & Iliohypogastic nerves)
Actions: same as External oblique
What does the internal oblique continue as?
The cremasteric fascia and muscle
What is the cremasteric muscle formed by?
The lowermost fascicles of the internal oblique muscle, arising from lateral portion of the inguinal ligament
What is the innervation of the cremasteric muscle?
The genital branch of the genitofemoral nerve
What is the innermost layer of the anterolateral abdominal muscles ?
Transversus abdominis muscle
Fibers of what muscle run almost horizontally with the exception of the most inferior fibers which run
inferiorly together with the internal oblique muscle to form the conjoint tendon
Transversus abdominus muscle
What is the origin and insertion of the transversus abdominis muscle?
Origin: Internal surfaces of the 7th - 12th ribs/costal cartilages, thoraco-lumbar fascia, iliac crest, and
inguinal ligament
Insertion: Linea alba (with aponeurosis of EO & IO), pubic crest, and pecten pubis via conjoint tendon
What is the innervation and action of the tranversus abdominis?
Innervation: same as IO {Ventral primary rami of T7-T12 and L1 nerves (Ilioinguinal & Iliohypogastic
nerves)}
Actions: same as External oblique
What is the function of the rectus abdominus?
Flexión of the lumbar spine and rotation of the trunk
Origin and insertion of the rectus abdominus ?
Origin: Pubic symphysis and pubic crest
Insertion: Xyphoid process and 5th - 7th costal cartilages
How does crossing over of the rectus abdominis work?
Origin: Pubic symphysis and pubic crest
Insertion: Xyphoid process and 5th - 7th costal cartilages
Where do spigelian hernias occur?
Where the linea semilunaris meets the linea semicircularis
What is the linea semilunaris?
A curved line along the lateral border of the RA
What is the innervation of the RA?
Ventral primary rami of t7-t12
What is the function of the pyramidalis muscle?
Tenses the linea alba in the midline pulling the Tendinous intersections inferiorly forming the
indented midline appearance on sculptured abdomens
Innervation of the pyramidalis muscle?
Subcostal nerve (ventral rami of T12)
What forms the rectus sheath?
Fusion of the aponeuroses of EO, IO and TA muscles
What does the rectus sheath enclose?
The RA, Pyramidalis, superior and inferior epigastric vessels, lymphatic vessels and the anterior
ends of thoracoabdominal nerves
What is the arcuate line? (Line semilunaris)
a curvilinear almost horizontal line (concave inferiorly) that demarcates the lower limit of the posterior layer of the rectus sheath, just below the level of iliac crest
What is the line alba?
a tendinous median raphe formed by the aponeuroses of EO, IO and TA, and lies between the
two Rectus abdominis muscles, and extends from xiphoid process to the pubic symphysis.
What does the linea alba provide to surgeon?
An easy and “bloodless” surgical access to the abdominal cavity
What forms the anterior rectus sheet above the arcuate line? Below?
Above: EO and IO muscles
Below: EO, IO and transversus
What forms the posterior rectus sheath above the arcuate line. Below?
Above: aponeurosis of IO and TA
Below: transversalis fascia
When the conjoint muscle (lateral) contracts, the conjoint tendon (medial & roof of inguinal canal)
descends on the floor, thereby narrowing or even closing the inguinal canal, thus preventing _______.
Herniation
What nerves innervate the anterolateral abdominal wall?
Thoracoabdominal nerves: ventral primary rami of T7-T12. (T12 is subcostal)
The first ventral primary ramus of L1
What two nerves does the L1 give rise to that innervate the anterolateral abdominal wall?
The ilioinguinal and iliohypogastric nerves which innervate IO and TA only
What are the branches of the internal thoracic artery in the anterolateral abdominal wall?
Superior epigastric
Músculophrenic
What are the branches of the external iliac artery that affect the anterolateral abdominal wall?
Inferior epigastric (and cremasteric)
Deep circumflex iliac
What are the branches of the femoral artery that affect the anterolateral abdominal wall?
Superficial epigastric
S. Circumflex iliac
S. External pudendal
Deep external pudendal
What are the arteries of the anterolateral abdominal wall?
Branches of internal thoracic, external iliac and femoral artery
Intercostal
Subcostal
The skin and superficial fascia of the abdominal wall ultimately drain _____ into the superior vena cava via the internal thoracic vein medially, and lateral thoracic vein laterally; and ____ into the IVC through the inferior epigastric and superficial epigastric veins. Cutaneous veins surrounding the umbilicus anastomose with small tributaries of the hepatic portal vein.
Superiorly
Inferiorly
The skin and superficial fascia of the abdominal wall ultimately drain superiorly into the superior vena cava via what veins?
The internal thoracic vein medically and lateral thoracic vein laterally
The skin and superficial fascia of the abdominal wall drain Inferiorly into the IVC through what veins?
The inferior epigastric and superficial epigastric veins.
Where do the lymphatic drain above and below the umbilicus?
Above: into the axillary lymph nodes along the thoracoepigastric veins
Below: superficial inguinal nodes (SIN)
Where do the SIN receive lymph from?
The lower abdominal wall, buttocks, external genitalia, lower part of the vagina and anal canal.
Where do the efferent vessels of the SIN go?
External iliac nodes (whence they reach the lumbar/aortic nodes)
Where do the deep or regional nodes of the anterolateral thoracic wall drain?
Into the cisterna chili and thoracic duct
What are the peritoneal folds?
Lateral, medial and median
What forms the lateral umbilical fold?
The inferior epigastric vessels
What forms the medial umbilical fold?
The umbilical ligament ( a remnant of the umbilical artery)
What forms the median umbilical fold?
The urachus ligament (a remnant of the urinary connection of the fetus to the placenta during development)
What do the peritoneal folds form in between them?
Fossae:
Lateral inguinal fossa
Medial inguinal fossa
Supra-vesical fossa
Where is the lateral inguinal fossa?
Lateral to the inferior epigastric artery
Where is the medial inguinal fossa?
Medial to the inferior epigastric artery or between the middle and median fold
Where is the supra-vesical fossa?
Medial to the medial fold or superior to the bladder
What may an open umbilicus cause?
A uruchal cyst or fistula, or create a weakened area for the development of an umbilical hernia
What are paramedian incisions?
Lateral but parallel to the midline right or left
Note: these incision have a higher incidence of disrupting thus creating an incisional herniation
What are the oblique incisions of the abdominal wall?
Grid iron or muscle-splitting
Mcburney
Rockey-Davis
Kocher’s subcostal
What is a mcburney incision?
Oblique incision, used for appendectomies, incision is made one third in of an imaginary line between ASIS and the umbilicus
What is a Rockey-Davis incision?
Transverse incision, same place as Mcburney
What are Kocher’s subcostal incision’s used for?
Used for cholecystectomies on right subcostal region
What are the transverse incision of the anterolateral thoracic wall?
Suprapubic
Maylard
Pfannenstiel incision
What is a Maylard (Mackenrodt) incision used for?
Mainly used for deep pelvic surgeries (prostate or gynecological)
Note: it is a type of Pfannenstiel in which the rectus abdominis is transected in order to make enough room
What is a Pfannenstiel incision?
Used for many female obstetrical and gynecological procedures, some deep male
pelvis prostatic procedures, and both sexes for urologic procedures
What surgery are abdomino-thoracic incisions used for?
Liver, esophageal, splenic or renal surgeries
What are the diagnostic uses of laparoscopy or endoscopic surgeries?
For pathological identification
What are the surgical reasons for laparoscopy or endoscopic surgery?
Used with other instruments for removal of masses, repair of tissue (hernias or cystocele)?
What is an abdominal hernia?
A Hernia is defined as a protrusion of an organ or part of an organ through a weakened normal or abnormal opening or wall (Ex: Loop of bowel).
Examples are umbilical, incisional, inguinal, femoral and spigelian.
What is a congenital umbilical hería?
Baby is born with weakness on abdominal wall
Note: doubly equal among children of both sexes and surgically corrected after 2 years of birth if it persists
What is an acquired umbilical hernia?
Developed at an older age secondary to other processes
In what sex re acquired umbilical hernias more common? Why?
3X more frequent in females than males, (secondary to pregnancies) and surgically
corrected for cosmetic or pathological processes
What is an acquired umbilical hernia the direct results of?
increase of intra-abdominal pressure (6
F’s and weakening of the abdominal wall), and usually caused by obesity, heavy lifting, a
long history of coughing, or multiple pregnancies
What is an incisional (ventral) hernia?
A hernia in an area of weakness caused by an imperfect healing of a surgical wound
Note: sometimes a
mesh is required to repair the weakness of the abdominal wall
In what group of people is a spigelian hernia more common?
In males on the right side of the abdomen, and between 40-70 years old
Where does a spigelian hernia occur?
Through spigelian fascia
(i.e.aponeurotic layer between the rectus abdominis muscle medially, and the semilunar line laterally or
between the linea semilunaris and linea semicircularis)
Where do spigelian hernias occur with respect to arcuate line?
At or below arcuate line (because of lack of posterior rectus sheath)
What is a femoral hernia?
a protrusion of a loop of bowel through the femoral canal, seen inferior to the inguinal region and protruding from the posterior aspect of the inguinal ligament, running alongside medial to the femoral vein, artery, and nerve, (VAN from medial to lateral).
What are femoral hernias confused with?
Inguinal due to the close proximity to the inguinal canal
Note: inguinal hernias are more common in men
What is caput medosa?
A collateral venous pathway in patients with portal hypertension
Note: cirrhosis is the main cause. The umbilical veins are seen radiating from the umbilicus across the abdomen to join systemic veins
What does chronic liver disease interfere with? (Cause of caput medusa)
Interferes with normal venous return
Note: small anastomotic veins become distended and engorged because of the overflow distal to the obstructed portal vein system
The normal direction of blood flow in abdominal veins is upward above the umbilicus, and downward below the umbilicus. In portal hypertension the direction of flow is normal; in SVC obstruction, the flow is all ____; and in IVC obstruction the flow is all ____.
Downward
upward
What are the caval veins involved in caput medusa?
The thoraco-epigastric veins
Note: they drain into the lateral thoracic vein or superficial epigastric veins which drains into the external iliac vein, (these veins anastomose making this arrangement visible when the portal vein is obstructed due to obstructive liver disease such as cirrhosis).
What are the landmark dermatomes of the anterolateral abdominal wall?
T7 (epigastric), T10 (umbilicus), L1
Cutaneous veins surrounding the umbilicus anastomoses with small tributaries of the _____.
Hepatic portal vein
What is one of the most important function of the abdominal wall?
To assist in breathing:
- It relaxes in inspiration
- It contracts in expiration
______ is part of external oblique aponeurosis from ASIS to pubic tubercle
Inguinal ligament
Is the sharp free edge of inguinal ligament that lies below the inguinal ligament proper.
Lacunar ligament (of Gimbernat)
What is the part of the lacunar ligament that reaches the pecten pubis?
Pectine ligament (of Astley Cooper)
What are the 6 F’s for protuberance of the abdomen?
Food Fluid Fat Feces Flatus Fetus
