Anterior Abdominal Wall Lecture_Nov2015.pptx

8/17/2019 Anterior Abdominal Wall Lecture_Nov2015.pptx

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Anterior

Abdominal WallKATRINA BALMORES, MDNOVEMBER 04, 2015


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References

Moore, Clinically Oriented Anatomy, 7th edition

Netter’s Atlas of Human Anatomy, 6th edition


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The Abdomen

• Flexible, dynamic container

• Respiration

• Posture

• Locomotion


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The Abdomen

• Anterolaterally: Musculoaponeuroticwalls

• Superorly: iaphra!m

• In!erorly: Muscles of the pel"is


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The Abdomen

#uspended and supportedby:

• $nferior mar!in of thoracics%eleton

• Pel"ic !irdle

Lin%ed by lumbar "ertebralcolumn in posteriorabdominal wall


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The Abdomen

• &oluntary'in"oluntary contraction

• Muscular roof, anterolateral walls, and(oor can raise intraabdominal pressurefor:

• Respiration

• #trainin!

• &omitin!

• )rinatin!

• *i"in birth


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The Abdomen

istendsconsiderably+

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The Abdominal Wall

• Peritoneum -serosa. continues ontoa"#o$nal or%an&

• /ursal sac or lined potential space

- peritoneal cavity .• 0xtracellular -parietal. (uid to lubricate

"isceral mo"ement occurs freely

• ouble1layered re(ections of peritoneum

passa!e for blood "essels, lymphatics, andner"es

• Fat


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The Abdominal 2a"ity

• #uperior and ma3orpart

• Pel"ic inletplane'superior pel"icaperture

• Superor: 4th

intercoastal space

• In!eror' *reaterpel"is


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Abdominal Re!ions


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Abdominal Re!ions 5 4 Planes

VERTI(AL)LANES

M#*la+*ularplane&

• Midpoint of cla"icle-67cm from

midline. tomidin!uinal points-midpoints of A#$#and pubic tubercles.

TRA8#&0R#0'

9R$;8TAL PLA80#

#ubcostal plane

Transtubercular plane

Transpyloric planes

$nterspinous plane


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#A*$TTAL'

&0RT$2AL PLA80#

< Midcla"icularplanes

Midpoint of cla"icle-67cm from

midline.

midin!uinal points-midpoints of A#$#and pubic tubercles.

TRANSVERSE)LANES

Tran&pylor*

plane&• #up border

manubrium andL=

Su"*o&tal plane

• $nf border =>th costal cartila!e


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#A*$TTAL'

&0RT$2AL PLA80#

< Midcla"icularplanes

Midpoint of cla"icle-67cm from

midline.

midin!uinal points-midpoints of A#$#and pubic tubercles.

TRANSVERSE)LANES

Tran&tu"er*ular

plane• Throu!h iliac

tubercles -6?cmposterior to A#$#

and body of L?.

Inter&pnou&plane

• Passes throu!h


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Abdominal Reference

Planes

Moore and Dally. Clinically Oriented Anatomy, 5th Editi


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Transpyloric plane

LANDMARK OR'

• *allbladder fundus

• Pancreas nec%

• #uperior mesenteric arteryori!ins

• 9epatic portal "ein

• Root of trans"ersemesocolon

• uodeno13e3unal 3unction

• @idney hila


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7 Abdominal Re!ions

Moore and Dally. Clinically Oriented Anatomy, 5th Edition

Transpyloric$nterspinous


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4 uadrants

Tran&u$"l*al plane

)mbilicus

inter"ertebral disc LBand L4 "ertebrae

Me#an plane

Lon!itudinallythrou!h body

T


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4 uadrants

Tran&+er&etran&u$"l*al plane

)mbilicus andinter"ertebral discbetween LB and L4

"ertebraeVert*al $e#an plane

Lon!itudinally throu!hbody


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The Abdominal Wall

• Musculoaponeurotic wall

• CAnterolateral abdominalwallD

• Superor: Eth1=>th ribs,xiphoid process

• In!eror' in!uinal

li!ament, superiormar!ins of iliac crest,pubic crest, pubicsymphysis


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The Abdominal Wall

#%in

#ubcutaneous tissue -supercial fascia.

Fat Muscle

Aponeuroses

eep fascia

0xtraperitoneal fat

Parietal peritoneum


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#%in

Attaches loosely tosubcutaneous tissueexcept at UMBILICUS

B musculotendinouslayers

Fibers run in diGerent

directions


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#urface Anatomy


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As we !o deeperH


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Fascia of Anterolateral

Abdominal Wall


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Abdominal Wall• #ubcutaneous tissue

• Ma3or site of fat storage

(Males>Females)

-Mor"# o"e&ty

• &ery thic% fat

• Panniculi'sa!!in! folds


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Abdominal Wall• $8F0R$R to

umbilicus

• Reinforced by elasticI colla!en bers

• (a$per.& !a&*a

• #upercial fatty

• S*arpa.& !a&*a

• eep membranous

• 2ontinues inferiorly

as (olle& !a&*a


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Abdominal WallLAYERS OF

INVESTING

FASCIA

#upercial

$ntermediate

eep

Jepimysium


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Abdominal Wall

$nternal

aspectmembrano

us

and areolar

sheets


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Abdominal Wall

Lines deep

surface oftrans"ersusabdominismuscle and

itsaponeurosi

s


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Abdominal Wall0xtraperitonealfat in betweentrans"ersalisfascia and

parietalperitoneum


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Muscles of Anterolateral

Abdominal Wall• ? paired muscles

• / at

• 0xternal obliKue• $nternal obliKue

• Trans"ersusabdominis

• 2 +ert*al

• Rectus abdominis

• Pyramidalis


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-re*tu& &eat-lnea al"a


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0xternal bliKue

Lar!est

Most supercial

$n!uinal'Poupart Li!ament

Lacunar Li!ament


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0xternal bliKue

The contralateral external and internalobliKue muscles to!ether form aCdi!astric muscle,D a two1bellied musclesharin! a common central tendon thatwor%s as a unit


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0xternal obliKueIg!"al l"gamet )oupart l%a$ent3

$nferior mar!in of the external obliKueaponeurosis

Thic%ened as an undercur"in! brous band witha free posterior ed!e

#pans between the A#$# and the pubic tubercle


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$nternal bliKue

Fleshy bers run perpendicularto those of external obliKue,runnin! &upero$e#ally

Participate in the formation ofthe rectus sheath


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$nternal bliKue

Fans out anteromedially Lowermost bers arise from lateral half of

in!uinal li!ament


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Trans"ersus Abdominis

8euro"ascualr planebetween


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$nferior ones runparallel to those ofthe internal obliKue

2ontributes to theformation of therectus sheath


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J8euro+a&*ular plane o! te anterolaterala"#o$nal all

/etween internal obliKue and trans"ersus

abdominis 8er"es and arteries supplyin! anterolateral

abdominal wall

Anterior part of the abdominal wall ner"es and"essels lea"e the neuro"ascular plane and lie

mostly in the subcutaneous tissue


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Rectus Abdominis

Powerful (exorof the thoracicand especiallylumbar re!ionsof the"ertebralcolumn


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Rectus Abdominis

Principal "ertical muscle ofthe anterior abdominal wall

Paired

#eparated by linea alba

Mostly enclosed in rectussheath

Tendinous insertions1 pac%

abs

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Pyramidalis

#mall, insi!nicant,trian!ular

Absent in

Anterior to inferior part ofrectus abdominis

Attaches to anterior surfaceof pubis and anterior pubicli!ament

0nds in linea alba

Tenses linea alba

Attachment of the

pyramidalis to the linea alba


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Rectus #heath

#tron!, incomplete brous compartment of therectus abdominis and pyramidalis muscles

2ontents:

#uperior and inferior epi!astric arteries and "eins

Lymphatic "essels

Abdominal portions of the anterior rami of spinalner"es TE5T=<


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Rectus #heath

#uperior


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Rectus #heath


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Arcuate Line 2rescentic

emarcates transition between:

Aponeurotic posterior wall of sheath: superior of the rectus

Trans"ersalis fascia: inferior ='4


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Linea Alba

Throu!hout len!th of rectus sheath

Fibers of anterior and posterior layers ofsheath interlace in anterior median line

#uperior to costal mar!in: rectus abdominislies

directly on the thoracic wall


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)mbilical Rin!

efect in linea alba throu!h which fetalumbilical "essels passed to and from theumbilical cord and placenta


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Nervous Supply


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&0##0L# F A8T0RLAT0RAL

A/M$8AL WALL)r$ary "loo# +e&&el&

Internal tora** +e&&el&: #uperior epi!astric "esselsand branches of musculophrenic "essels

Eternal la* +e&&el&' $nferior epi!astric and deepcircum(ex iliac "essels

e$oral artery' #upercial circum(ex iliac

6reater &apenou& +en: #upercial epi!astric "essels Posterior intercostal "essels of the ==th intercostal

space

Anterior branches of subcostal "essels


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Lymphatic raina!e

Superfcial lymphatic vessels accompanysubcutaneous "eins

Superor to the transumbilical plane drainto allary ly$p no#e&

Few drain to para&ternal ly$p no#e&


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Lymphatic raina!e

#upercial lymphatic "essels n!eror totransumbilical plane drain to &uper7*aln%unal ly$p no#e&8

#ee$ l%m$&at"' essels accompany deep"eins of abdominal wall and drain to theexternal iliac, common iliac, and riht and

le!t lum"ar -caval and aortic. lymph nodes.


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&0##0L# F

A8T0RLAT0RALA/M$8ALWALL

istribution of deep "esselsre(ects muscle arran!ement

#uperior epi!astric artery:direct continuation ofinternal thoracic artery


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&0##0L# F A8T0RLAT0RAL

A/M$8AL WALL


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2linical 2orrelation

Palpation of abdominal "iscera

Patient supine with thi!hs and %nees semi(exedto enable adeKuate relaxation of the

anterolateral abdominal wall

eep fascia of the thi!hs pulls on themembranous layer of abdominal subcutaneoustissue, tensin! the abdominal wall


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$n!uinal Re!ion -*roin.

/etween A#$# and pubic tubercle


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$n!uinal Li!ament

ense band constitutin! inferiormost part of externalobliKue aponeurosis

Deep

La*unar l%a$ent: attach to superior pubic ramus

Forms medial boundary of subin!uinal space

)e*tneal l%a$ent: run alon! pecten pubis

Superior

Ree*te# n%unal l%a$ent: blend with contralateralexternal obliKue


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$n!uinal Re!ion -*roin.

/etween A#$# and pubic tubercle


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$liopubic Tract Thic%ened inferior mar!in of

trans"ersalis fascia

Runs parallel and posterior-deep. to the in!uinal li!ament

Reinforces posterior wall and(oor of in!uinal canal as itbrid!es the structures passin!

the subin!uinal space


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$n!uinal 2anal

#permatic cord in males

Round li!ament of the uterus in females

Also contains

blood and lymphatic "essels

$lio1in!uinal ner"e

eep'internal rin!

#upercial'external rin!


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Deep nternal3

n%unal rn% 0ntrance to the in!uinal canal

Located superior to the middle of the in!uinalli!ament and lateral to the inferior epi!astric

artery /e!innin! of an e"a!ination in the trans"ersalis

fascia that forms an openin! li%e the entranceto a ca"e


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Super7*al eternal3

n%unal rn% 0xit by which the spermatic cord in males, or the

round li!ament in females, emer!es from in!uinalcanal

A split occurs in the dia!onal bers of the externalobliKue aponeurosis 3ust superolateral to the pubictubercle

Lateral crus attaches to the pubic tubercle

Medial crus attaches to the pubic crest

$ntercrural bers hel re"ent the crura from


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Most !roin hernias in males pass superior to theiliopubic tract -in!uinal hernias.

Most pass inferior to it in females -femoralhernias.


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irect !n"uinal Hernia


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T9A8@ Q)+

Documents

Anterior Abdominal Wall Lecture_Nov2015.pptx