Clinical Anatomy of the Anterior Abdominal Wall in its ...

Clinical Anatomy of theClinical Anatomy of theAnterior Abdominal WallAnterior Abdominal Wallin its Relation to Herniain its Relation to Hernia

Lawrence M. Witmer, PhDLawrence M. Witmer, PhDProfessor of AnatomyDepartment of Biomedical SciencesCollege of Osteopathic MedicineOhio UniversityAthens, Ohio 45701 [email protected]

Handout download:http://www.oucom.ohiou.edu/dbms-witmer/gs-rpac.htm

24 April 2007

Anatomical OverviewAnatomical Overview

Moore & Dalley 2006

Externaloblique

Internaloblique

Transversusabdominis

Rectusabdominis

inguinal ligamentinguinal ligament

tendinousintersections


• Three flat abdominals: attach to trunk skeleton, inguinal lig., linea alba, etc.;fleshy laterally and aponeurotic medially, forming rectus sheath medially

• Two vertical abdominals: rectus abdominis and pyramidalis (not shown)

aponeuroticportion

aponeuroticportion

rectussheathrectussheath

fleshyportionfleshyportion

Moore & Dalley 2006

intramuscular exchange ofcontralateral external oblique fibers

intermuscular exchange ofcontralateral external & internal oblique

• continuity of fibers across midline• “digastric” muscle with central

tendon• torsion of trunk

• continuity of external oblique fibers across midline

• blending of superficial & deep fibers on opposite side

rightexternaloblique

leftinternaloblique


Moore & Dalley 2006

linea alba rectus sheath transv. abd.int. obl.ext. obl.

peritoneumtransversalis fascia

aponeuroses ofabdominal mm.

fasciae: Scarpa’s, Camper’s

rectus abdominis



semilunar line


Moore & Dalley 2006

inferior epigastricvessels

internaloblique

anterior laminaof rectus sheath

iliohypogastric n.

ilioinguinal n.

arcuate line(semicircular)

line of Douglas)

semilunar line (of Spiegel)

posterior laminaof rectus sheath

(aponeurotic)

posterior laminaof rectus sheath

(transversalis fascia)


linea alba

umbilicus

semilunar line

hernia.tripod.com/types.html

Anterior Abdominal Hernias

rectus sheath

superficialinguinal ring

femoralcanal

Moore & Dalley 2006

linea alba

health.enotes.com/images/medicine/gem_03_img0340.jpg

thachers.org/images/epigastric_hernia.jpgthachers.org/images/hernia_repair.jpg

hernial sachernial sacrepaired herniarepaired hernia

scarscar

Epigastric (Ventral) HerniaEpigastric (Ventral) Hernia

Skandalakis’ Surgical Anatomy 2004 hernial sachernial sac peritoneum

posterior rectussheath

anterior rectussheathrectus

abdominis

1988 Moore Developing Human 4th edition

OmphaloceleOmphalocele

CongenitalCongenitalUmbilicalUmbilical

HerniaHernia

Acquired Umbilical HerniaAcquired Umbilical Hernia

• incomplete closure of umbilical ring

• occur after closure of umbilical ring• 2° to obesity, pregnancy, cirrhosis, ascites, masses

medicine.ucsd.edu/clinicalimg/abdomen-umbo-hernia4.jpgmedicine.ucsd.edu/clinicalimg/medicine.ucsd.edu/clinicalimg/abdomenabdomen--umboumbo--hernia4.jpghernia4.jpg

2° to ascites2° to ascites

Umbilical (ParaUmbilical (Para--umbilical) Herniaumbilical) Hernia

Skandalakis’ Surgical Anatomy 2004

www.e-radiography.net/ibase5/Abdomen/slides/Abdomen_spigelian_hernia_ct.jpg

CT semilunarline

arcuateline

frequenthernial

site

rectusabdominis

rectusabdominis

rectus sheath:posterior & anterior lamina

rectus sheath:posterior & anterior lamina

transversalisfascia

transversalisfascia

Spigelian (Lateral Ventral) HerniaSpigelian (Lateral Ventral) HerniaSpigelian (Lateral Ventral) Hernia

Moore & Dalley 2006

Skandalakis’ SurgicalAnatomy 2004

Case PresentationCase PresentationCase PresentationA 3-year-old boy presents with a walnut-sized bulge in his left groin, particularly when he stands, strains, or cries. With the patient horizontal, the lump disappears. When the skin of the scrotum is invaginated by a little finger, a definite impact is felt on coughing. The diagnosis of hernia is made. How would this herniabe best characterized?

pediatriconcall.com/forpatients/commonchild/images/inguinal_hernia.jpg

upon strainingupon strainingat restat rest

reducible, congenital, indirect inguinal herniareducible, congenital, indirect inguinal hernia

testis intestis inabdomenabdomen

Week 7

Embryological Basis of Indirect Inguinal herniaEmbryological Basis of Indirect Inguinal herniaEmbryological Basis of Indirect Inguinal hernia

Moore & Dalley 2006

testistestisdescendsdescends


Week 28

patent processus vaginalispatent processus vaginalis

Moore & Dalley 2006


Week 36testis intestis inscrotumscrotum

processus vaginalis closedprocessus vaginalis closed

Moore & Dalley 2006


Cahill 1997

abdominalmuscles

tunicavaginalis

hernial sachernial sacwithinwithin

spermaticspermaticcordcord

vas deferens

pampiniformplexus

testis

epididymis

partiallypartiallyobliteratedobliteratedprocessusprocessusvaginalisvaginalis

transversalis fascia& peritoneum

Inguinal AnatomyInguinal AnatomyInguinal Anatomy

superficialepigastricvessels

superficialcircumflex

iliacvessels

externalpudendalvessels

greatsaphenous

v.

spermatic cord

ilioinguinaln. (L1)superficial (external)

inguinal ring

externaloblique

aponeurosis& Gallaudet’s

fascia

intercrurualfibers

medialcrus

lateralcrus &

inguinal lig.

Moore & Dalley 2006

ASIS


Moore & Dalley 2006

inguinal lig.(of Poupart)

iliopsoas

external iliacvessels

femoral n.

internalinguinal ring

femoral canal pectineus lacunar lig.(of Gimbernat)

pectineal lig.(of Cooper)

reflectedinguinal lig.

myopectineal orificeof Fruchaud


EOEO

IOIOTATATFTF

Moore & Dalley 2006

PP

testicular vessels vas deferens

Space ofSpace ofBogrosBogros

internalring

ilioinguinal n.“conjoint tendon”

externalring


shelving edgeof ing. lig.

Moore & Dalley 2006



parasagittal sectionthrough right side

iliopubic tract

shelving edgeof inguinalligament

Moore & Dalley 2006

posterior view ofanterior abdominal wall

externaliliac vessels

iliopsoas

lateral umbilical fold

Hesselbach’sTriangle

inferior epigastric vesselsarcuate line

iliopubictract

femoral canal

vas deferens

testicularvessels

deeping. ring

iliopubictract

HesselbachHesselbach’’s (Inguinal) Triangles (Inguinal) Triangle

direct inguinal herniadirect inguinal hernia

indirectindirectinguinal herniainguinal hernia

posterior viewof anterior

abdominal wall

internalinguinal

ring

Moore & Dalley 2006

Femoral HerniaFemoral HerniaFemoral Hernia


femoral canal

lacunar lig.(of Gimbernat)

ReferencesReferences

• Cahill, D. R. 1997. Lachman’s Case Studies in Anatomy, 4th Ed. Oxford University Press, New York.

• Moore, K. L. and A. F. Dalley. 2006. Clinically Oriented Anatomy, 5th Ed. Lippincott, Williams & Wilkins, Baltimore.

• Moore, K. L. 1988. The Developing Human. Clinically Oriented Embryology, 4th Ed. Lippincott, Williams & Wilkins, Baltimore.

• Skandalakis, J. E., G. L. Colborn, T. A. Weidman, R. S. Foster, A.N. Kingsnorth, L. J. Skandalakis, N. P. Skandalakis, P. Mirilas(Editors). 2004. Surgical Anatomy: The Embryologic And Anatomic Basis Of Modern Surgery. McGraw-Hill, New York.

Clinical Anatomy of the Anterior Abdominal Wall in its ...

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