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  1. The Anterolateral Abdominal Wall
  2. Introduction • The abdominal wall encloses the abdominal cavity, and can be divided into anterolateral and posterior sections. • Its key functions include: – Forms a firm, flexible wall which keeps the abdominal viscera in the abdominal cavity. – Protects the abdominal viscera from injury. – Maintains the anatomical position of abdominal viscera against gravity. – Assists in forceful expiration by pushing the abdominal viscera upwards. – Involved in any action (coughing, vomiting) that increases intra-abdominal pressure.
  3. Layers of anterolateral abdominal wall • The anterolateral abdominal wall consists of four main layers (external to internal): – Skin – superficial fascia – muscles and associated fascia – peritoneum.
  4. Summary of layers anterior abdominal wall • There are Nine layers to the abdominal wall: i. skin, ii. subcutaneous tissue, iii. superficial fascia, iv. external oblique muscle, v. internal oblique muscle, vi. transversus abdominis muscle, vii. transversalis fascia, viii. preperitoneal adipose and areolar tissue, and ix. peritoneum • parietal peritoneum • visceral peritoneum
  5. Superficial Fascia • The superficial fascia consists of fatty connective tissue. • The composition of this layer depends on its location: – Above the umbilicus – a single sheet of connective tissue. It is continuous with the superficial fascia in other regions of the body. – Below the umbilicus – divided into two layers; • the fatty superficial layer (Camper’s fascia) and • the membranous deep layer (Scarpa’s fascia). • The superficial vessels and nerves run between these two layers of fascia.
  6. The layers of the anterolateral abdominal wall. Below the umbilicus, there are two layers of superficial fascia – Camper’s and Scarpa’s.
  7. Muscles of the Abdominal Wall • The muscles of the anterolateral abdominal wall can be divided into two main groups: – Flat muscles – three flat muscles, situated laterally on either side of the abdomen. – Vertical muscles – two vertical muscles, situated near the mid-line of the body.
  8. Flat Muscles • There are three flat muscles located laterally in the abdominal wall, stacked upon one another. • Their fibres run in differing directions and cross each other – strengthening the wall, and decreasing the risk of herniation. • In the anteromedial aspect of the abdominal wall, each flat muscle forms an aponeurosis (a broad, flat tendon), which covers the vertical rectus abdominis muscle. • The aponeuroses of all the flat muscles become entwined in the midline, forming the linea alba (a fibrous structure that extends from the xiphoid process of the sternum to the pubic symphysis).
  9. Flat muscles 1. External Oblique • The external oblique is the largest and most superficial flat muscle in the abdominal wall. Its fibres run inferomedially. – Attachments: Originates from ribs 5-12, and inserts into the iliac crest and pubic tubercle. – Functions: Contralateral rotation of the torso. – Innervation: Thoracoabdominal nerves (T7-T11) and subcostal nerve (T12).
  10. Flat Muscles 2. Internal Oblique • The internal oblique lies deep to the external oblique. It is smaller and thinner in structure, with its fibres running superomedially (perpendicular to the fibres of the external oblique). – Attachments: Originates from the inguinal ligament, iliac crest and lumbodorsal fascia, and inserts into ribs 10-12. – Functions: Bilateral contraction compresses the abdomen, while unilateral contraction ipsilaterally rotates the torso. – Innervation: Thoracoabdominal nerves (T6-T11), subcostal nerve (T12) and branches of the lumbar plexus.
  11. Flat muscles 3. Transversus Abdominis • The transversus abdominis is the deepest of the flat muscles, with transversely running fibres. Deep to this muscle is a well-formed layer of fascia, known as the transversalis fascia. – Attachments: Originates from the inguinal ligament, costal cartilages 7-12, the iliac crest and thoracolumbar fascia. Inserts into the conjoint tendon, xiphoid process, linea alba and the pubic crest. – Functions: Compression of abdominal contents. – Innervation: Thoracoabdominal nerves (T6-T11), subcostal nerve (T12) and branches of the lumbar plexus
  12. The muscles of the anterolateral abdominal wall. Note how the flat muscles form aponeuroses medially.
  13. Vertical Muscles • There are two vertical muscles located in the midline of the anterolateral abdominal wall: – the rectus abdominis and – pyramidalis.
  14. Rectus Abdominis • The rectus abdominis is long, paired muscle, found either side of the midline in the abdominal wall. • It is split into two by the linea alba. • The lateral border of the two muscles create a surface marking, known as the linea semilunaris. • At several places, the muscle is intersected by fibrous strips, known as tendinous intersections. • The tendinous intersections and the linea alba give rise to the ‘six pack’ seen in individuals with a well-developed rectus abdominis.
  15. Rectus Abdominis • Attachments: Originates from the crest of the pubis, before inserting into the xiphoid process of the sternum and the costal cartilage of ribs 5-7. • Functions: As well as assisting the flat muscles in compressing the abdominal viscera, the rectus abdominis also stabilises the pelvis during walking, and depresses the ribs. • Innervation: Thoracoabdominal nerves (T7-T11)
  16. Pyramidalis • This is a small triangular muscle, found superficially to the rectus abdominis. It is located inferiorly, with its base on the pubis bone, and the apex of the triangle attached to the linea alba. – Attachments: Originates from the pubic crest and pubic symphysis before inserting into the linea alba. – Functions: It acts to tense the linea alba. – Innervation: Subcostal nerve (T12).
  17. Rectus Sheath • The rectus sheath is formed by the aponeuroses of the three flat muscles, and encloses the rectus abdominis and pyramidalis muscles. • It has an anterior and posterior wall for most of its length: – The anterior wall is formed by the aponeuroses of the external oblique, and of half of the internal oblique. – The posterior wall is formed by the aponeuroses of half the internal oblique and of the transversus abdominis.
  18. Rectus Sheath • Approximately midway between the umbilicus and the pubic symphysis, all of the aponeuroses move to the anterior wall of the rectus sheath. • At this point, there is no posterior wall to the sheath; the rectus abdominis is in direct contact with the transversalis fascia. • The area of transition between having a posterior wall, and no posterior wall is known as the arcuate line.
  19. Surface Anatomy • The abdominal cavity contains numerous organs – many of which can be palpated through the abdominal wall, or their position can be visualised by surface markings. • The umbilicus is the most visible structure of the abdominal wall, and is the scar of the site of attachment of the umbilical cord. It is usually located midway between the xiphoid process and the pubis symphysis.
  20. Surface Anatomy • The rectus abdominis muscle gives rise to abdominal markings. • The lateral border of this muscle is indicated by the linea semilunaris, a curved line running from the 9th rib to the pubic tubercle. • The linea alba is a fibrous line that splits the rectus abdominis into two. • It is visible as a vertical groove extending inferiorly from the xiphoid process.
  21. Surface Anatomy • The abdomen is a large area, and so it split into nine regions – these are useful clinically for describing the location of pain, location of viscera and describing surgical procedures. • The nine regions are formed by two horizontal and two vertical planes
  22. Surface Anatomy • Horizontal planes: – Transpyloric plane – Horizontal line halfway between the xiphoid process and the umbilicus, passing through the pylorus of the stomach. – Intertubercular plane – Horizontal line that joins the iliac crests. • Vertical planes – run from the middle of the clavicle to the mid-inguinal point (halfway between the anterior superior iliac spine of the pelvis and the pubic symphysis). These planes are the mid-clavicular lines.
  23. The nine regions of the abdomen
  24. Clinical Relevance: Surgical Incisions in Abdominal Wall Vertical Incisions • Median – An incision that is made through the linea alba. It can be extended the whole length of the abdomen, by curving around the umbilicus. – The linea alba is poorly vascularised, so blood loss is minimal, and major nerves are avoided. – All can be used in any procedure that requires access to the abdominal cavity. • Paramedian – Similar to the median incision, but is performed laterally to the linea alba, providing access to more lateral structures (kidney, spleen and adrenals). – This method ligates the blood and nerve supply to muscles medial to the incision, resulting in their atrophy.
  25. Transverse Incisions • Transverse – This incision is made just inferior and laterally to the umbilicus. – This is a commonly used procedure, as it causes least damage to the nerve supply to the abdominal muscles, and heals well. – The incised rectus abdominis heals producing a new tendinous intersection. – It is used in operations on the colon, duodenum and pancreas. • Suprapubic (Pfannenstiel) – Suprapubic incisions are made 5cm superior to the pubis symphysis. – They are used when access to the pelvic organs is needed. – When performing this incision, care must be taken not the perforate the bladder (especially if it is not catheterised), as the fascia thins around the bladder area.
  26. Transverse Incisions • Subcostal – This incision starts inferior to the xiphoid process, and extends inferior parallel to the costal margin. – It is mainly used on the right side to operate on the gall bladder and on the left to operate on the spleen. • McBurney – This is a ‘grid iron’ incision, because it consists of two perpendicular lines, splitting the fibres of the muscles without cutting them – this allows for excellent healing. – McBurney incision is performed at McBurney’s point (1/3 of the distance between the ASIS and the umbilicus). It is mostly used in appendectomies.
  27. Common surgical incisions
  28. The Posterior Abdominal Wall
  29. The Posterior Abdominal Wall • It is formed by the lumbar vertebrae, pelvic girdle, posterior abdominal muscles and their associated fascia. • Major vessels, nerves and organs are located on the inner surface of the posterior abdominal wall.
  30. Posterior Abdominal Muscles • There are five muscles in the posterior abdominal wall: – the iliacus, – psoas major, – psoas minor, – quadratus lumborum and – the diaphragm • NB: The posterior aspect of the diaphragm is considered to be part of the posterior abdominal wall
  31. Quadratus Lumborum • The quadratus lumborum muscle is located laterally in the posterior abdominal wall. • It is a thick muscular sheet which is quadrilateral in shape. • The muscle is positioned superficially to the psoas major. – Attachments: It originates from the iliac crest and iliolumbar ligament. The fibres travel superomedially, inserting onto the transverse processes of L1 – L4 and the inferior border of the 12th rib. – Actions: Extension and lateral flexion of the vertebral column. It also fixes the 12th rib during inspiration, so that the contraction of diaphragm is not wasted. – Innervation: Anterior rami of T12- L4 nerves
  32. Quadratus Lumborum
  33. Psoas Major • The psoas major is located near the midline of the posterior abdominal wall, immediately lateral to the lumbar vertebrae. – Attachments: Originates from the transverse processes and vertebral bodies of T12 – L5. It then moves inferiorly and laterally, running deep to the inguinal ligament, and attaching to the lesser trochanter of the femur. – Actions: Flexion of the thigh at the hip and lateral flexion of the vertebral column. – Innervation: Anterior rami of L1 – L3 nerves.
  34. Psoas Minor • The psoas minor muscle is only present in 60% of the population. It is located anterior to the psoas major. – Attachments: Originates from the vertebral bodies of T12 and L1 and attaches to a ridge on the superior ramus of the pubic bone, known as the pectineal line. – Actions: Flexion of the vertebral column. – Innervation: Anterior rami of the L1 spinal nerve.
  35. Iliacus • The iliacus muscle is a fan-shaped muscle that is situated inferiorly on the posterior abdominal wall. It combines with the psoas major to form the iliopsoas – the major flexor of the thigh. – Attachments: Originates from surface of the iliac fossa and anterior inferior iliac spine. Its fibres combine with the tendon of the psoas major, inserting into the lesser trochanter of the femur. – Actions: Flexion of the thigh at the hip joint. – Innervation: Femoral nerve (L2 – L4).
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  37. Clinical Relevance: Psoas Sign • The psoas sign is a medical sign that indicates irritation to the iliopsoas group of muscles. • The sign is elicited by flexion of the thigh at the hip. • The test is positive if the patient reports lower abdominal pain. • A right sided psoas sign is an indication of appendicitis. • As the iliopsoas contracts, it comes into contact with the inflamed appendix, producing pain.
  38. Fascia of the Posterior Abdominal Wall • A layer of fascia (sheet of connective tissue) lies between the parietal peritoneum and the muscles of the posterior abdominal wall. • This fascia is continuous with the transversalis fascia of the anterolateral abdominal wall. • Whilst the fascia is one continuous sheet, it is anatomically correct to name the fascia according to the structure it overlies: – Psoas Fascia – Thoracolumbar fascia
  39. Psoas Fascia • The psoas fascia covers the psoas major muscle. • It is attached to the lumbar vertebrae medially, continuous with the thoracolumbar fascia laterally and continuous with the iliac fascia inferiorly
  40. Thoracolumbar fascia • The thoracolumbar fascia consists of the three layers; – Posterior – middle and – anterior. • Muscles are enclosed between these layers: • Quadratus lumborum – between the anterior and middle layers. • Deep back muscles – between the middle and posterior layers. • The posterior layer extends between the 12th rib and the iliac crest posteriorly. • Laterally the fascia meets the internal oblique and transversus abdominis muscles, but not the external oblique. • As it forms these attachments it covers the latissimus dorsi.
  41. . • The anterior layer attaches to the anterior aspect of the transverse processes of the lumbar vertebrae, the 12th rib and the iliac crest. • Laterally the fascia is continuous with the aponeurotic origin of the transversus abdominis muscle. • Superiorly the fascia thickens to become the lateral arcuate ligament, which joins the iliolumbar ligaments inferiorly.
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