Clinical Anatomy of the

Anterior Abdominal Wall

in its Relation to Hernia

Lawrence M. Witmer, PhD

Professor of Anatomy

Department of Biomedical Sciences

College of Osteopathic Medicine

Ohio University, Athens

witmerL@ohio.edu

Handout download:

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

26 April 2011

Anatomical Overview

External

oblique

Internal

oblique

Transversus

abdominis

Rectus

abdominis

inguinal

ligament

tendinous

intersections

• 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)

aponeurotic

portion

rectus

sheath

fleshy

portion

Moore et al. 2010

intramuscular exchange of

contralateral external oblique fibers

intermuscular exchange of

contralateral 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

right

external

oblique left

internal

oblique

Anatomical Overview

Moore et al. 2010

linea alba rectus sheath transv. abd.

int. obl.

ext. obl.

peritoneum

transversalis fascia

aponeuroses of

abdominal mm.

fasciae: Scarpa’s, Camper’s

rectus abdominis

tendinous

intersections

Anatomical Overview

semilunar line

Moore et al. 2010

Anatomical Overview

inferior epigastric

vessels

internal

oblique

anterior lamina

of rectus sheath

iliohypogastric n.

ilioinguinal n.

arcuate line

(semicircular)

line of Douglas)

semilunar

line (of Spiegel)

posterior lamina

of rectus sheath

(aponeurotic)

posterior lamina

of rectus sheath

(transversalis fascia) Moore et al. 2010

Anatomical Overview

linea alba

umbilicus

semilunar line

hernia.tripod.com/types.html

Anterior Abdominal Hernias

rectus sheath

superficial

inguinal ring

femoral

canal

Moore et al. 2010

linea alba

health.enotes.com/images/

medicine/gem_03_img0340.jpg

thachers.org/images/epigastric_hernia.jpg

thachers.org/images/hernia_repair.jpg

hernial sac

repaired hernia

scar

Epigastric (Ventral) Hernia

Skandalakis’ Surgical Anatomy 2004 hernial sac peritoneum

posterior rectus

sheath

anterior rectus

sheath rectus

abdominis

1988 Moore Developing

Human 4th edition

Omphalocele

Congenital

Umbilical

Hernia

Acquired 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.jpg

2° to ascites

Umbilical (Para-umbilical) Hernia

Skandalakis’ Surgical Anatomy 2004

www.e-radiography.net/ibase5/Abdomen/

slides/Abdomen_spigelian_hernia_ct.jpg

CT semilunar

line

arcuate

line

frequent

hernial

site

rectus

abdominis

rectus sheath:

posterior & anterior lamina

transversalis

fascia

Spigelian (Lateral Ventral) Hernia

Skandalakis’ Surgical

Anatomy 2004

Moore et al. 2010

Case Presentation

A 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 hernia

be best characterized?

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

upon straining at rest

reducible, congenital, indirect inguinal hernia

testis in

abdomen

Embryological Basis of Indirect Inguinal hernia

Week 7

Moore et al. 2010

testis

descends

Embryological Basis of Indirect Inguinal hernia

Week 28

patent processus vaginalis

Moore et al. 2010

Embryological Basis of Indirect Inguinal hernia

Week 36 testis in

scrotum

processus vaginalis closed

Moore et al. 2010

Embryological Basis of Indirect Inguinal hernia

Cahill 1997

vas deferens

pampiniform

plexus

testis

abdominal

muscles

epididymis

tunica

vaginalis

hernial sac

within

spermatic

cord

partially

obliterated

processus

vaginalis

transversalis fascia

& peritoneum

Inguinal Anatomy

superficial

epigastric

vessels

superficial

circumflex

iliac

vessels

external

pudendal

vessels

great

saphenous

v.

spermatic cord

ilioinguinal

n. (L1) superficial (external)

inguinal ring

external

oblique

aponeurosis

& Gallaudet’s

fascia

intercrurual

fibers

medial

crus

lateral

crus &

inguinal lig.

ASIS

Moore et al. 2010

Inguinal Anatomy inguinal lig.

(of Poupart)

external iliac

vessels

femoral n.

internal

inguinal ring

femoral canal pectineus lacunar lig.

(of Gimbernat)

pectineal lig.

(of Cooper)

reflected

inguinal lig.

myopectineal orifice

of Fruchaud

Moore et al. 2010

Inguinal Anatomy

EO

IO

TA TF P

testicular vessels vas deferens

Space of

Bogros

internal

ring

ilioinguinal n.

“conjoint tendon”

external

ring Moore et al. 2010

Inguinal Anatomy

shelving edge

of ing. lig.

Moore et al. 2010

Inguinal Anatomy

Skandalakis’ Surgical Anatomy 2004

parasagittal section

through right side

iliopubic tract

shelving edge

of inguinal

ligament

posterior view of

anterior abdominal wall

external

iliac vessels

iliopsoas

lateral umbilical fold

Hesselbach’s

Triangle

inferior epigastric vessels arcuate line

iliopubic

tract

femoral canal

vas deferens

testicular

vessels

deep

ing. ring

iliopubic

tract

Moore et al. 2010

Hesselbach’s (Inguinal) Triangle

direct inguinal hernia

indirect

inguinal hernia

posterior view

of anterior

abdominal wall

internal

inguinal

ring

Moore et al. 2010

Femoral Hernia

Skandalakis’ Surgical Anatomy 2004

femoral canal

lacunar lig.

(of Gimbernat)

References

• Cahill, D. R. 1997. Lachman’s Case Studies in Anatomy, 4th Ed.

Oxford University Press, New York.

• Moore, K. L., A. F. Dalley, and A M. R. Agur. 2010. Clinically

Oriented Anatomy, 6th Ed. Lippincott, Williams & Wilkins,

Baltimore.

• Moore, K. L. and T. V. N. Persaud. 2003. The Developing Human.

Clinically Oriented Embryology, 7th 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.