Ashan Bopitiya Surgery Notes 2017

Abdominal Wall
Structure of the Anterior Abdominal Wall
Skin Superficial Fascia Deep Fascia Muscles Fascia Transversalis
Extra-Peritoneal fat Parietal Peritoneum
Skin

Loosely attached to the underlying structures except at the area of the

umbilicus where it is tethered to the scar Tissue.
Nerve Supply
Cutaneous Nerve Supply to the A.Abdominal wall is from the anterior rami
of the Lower 6 thoracic and the 1st Lumbar Nerves.
Dermatome of T7 In the epigastric region above the Xiphoid process
Dermatome of T10 In the Umbilical region
Dermatome of L1 Lies above the inguinal Ligament
Blood Supply
[Arterial] The skin near the midline is supplied by the Superior and the
inferior epigastric Arteries.
The Skin in the flanks Intercostal arteries, Lumbar Arteries , & the Deep
Circumflex iliac arteries.
The Skin in the Inguinal Regions Superficial Circumflex iliac arteries,
Superficial epigastric arteries , and the superficial external pudendal
arteries.
[Veins] Drains into the axillary vein above via the lateral thoracic vein.
And bellow it drains to the femoral vein via the Superficial epigastric vein
and the greater saphenous veins.
Superficial Fascia
Consists of 2 Parts
Superficial Fatty Layer (Fascia of Camper)
Deep Membranous Layer (Scarpas Fascia)
The Fatty layer is continuous with the superficial fat over the rest of the body. Can be
extremely thick in the obese.
Note In the scrotum the fatty layer of the superficial fascia is represented as a
thin layer of smooth muscle known as the Dartos Muscle.
Membranous Layer (Scarperss Fascia) is thin.
Spreads above to become continuous with the superficial fascia of the thorax.
Spreads laterally to become continuous with the superficial fascia of the back.
Inferiorly it passes onto the front of the thigh one Finger-breadth bellow the
inguinal ligament and fuses with the deep fascia. It is not attached to the pubis
but forms a tubular sheath around the penis. Bellow in the perineum it enters the
wall of the scrotum or Labia Majora in females. It further passes to be attached to
the margins of the pubic arch (Here its refereed as the Colles Fascia). It then
moves posteriorly to be attached to the Perineal body and the perineal
Membrane.
Deep Fascia

A Thin layer of connective tissue covering the Muscles. Lies immediately deep to the
membranous and Superficial fascia.
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Muscles of the Abdominal wall

There are 3 main muscles in the anterior abdominal wall that are aponeurotic in the
front.
From Exterior to Interior : External Oblique Internal Oblique Transversus
On either side of the midline there are 2 wide-vertical muscles known as the Rectus
Abdominis. The aponeurosis of the 3 muscles (E.O , I.O , Transversus) encloses the
rectus abdominis to form the rectus sheath. Lower part of the Rectus sheath contains a
small muscle known as the Pyramidalis.
External Oblique
Broad thin muscular sheet that arises from the Outer Surfaces of the Lower-eight
Ribs and inserts into the Xiphoid Process , Linear Alba , Pubic Crest , Pubic
Tubercle & the Ant. Half of the Iliac Crest.
Insertion of most of the fibers are through aponeurosis. Posteriorly its not
connected to the Lumbar Fascia therefore forms a free border. The Fibres run
Infero-medially
A Triangular defect in the E.O aponeurosis lies immediately above and medial to
the pubic tubercle. This is known as the Superficial Inguinal Ring. The Spermatic
cord or the round ligament of the uterus passes through this opening and also
carries the external spermatic fascia which is the external covering of the
spermatic cord or the round ligament.
Between the Ant. Superior iliac spine and the pubic tubercle - the lower border of
the E.O aponeurosis folds backwards and forms the inguinal ligament. At the
Medial end of this ligament, the lacunar ligament arises which extends along the
pectineal line and becomes continuous with the pectineal ligament.
The lateral part of the inguinal ligament gives origin to a part of the I.O and
Transversus muscles. The inferior rounded border of the Inguinal ligament is
attached to the deep fascia of the thing which is known as the Fascia Lata !
Internal Oblique
Broad thin muscular sheet which lies deep to the E.O & arises from the Lumbar
Fascia , Ant. Part of the iliac crest, & lateral two-thirds of the inguinal ligament
and Inserts into the lower border of the lower 3 ribs and their costal cartilages ,
xiphoid process , linear alba and the Pubic Symphysis. The Fibers pass Upwards
and Medially.
The I.O has a lower free border that arches over the spermatic cord , descends
behind it to attach into the Pubic crest and the pectineal line.
The lowest tendinous fibers are joined by similar fibres from the Transversus
abdmonis muscle to form the Conjoint tendon and gets attached medially to the
Linea Alba.
As the spermatic cord or the round ligament of the uterus passes under the lower
border of the I.O it carries with it some muscle fibres known as the Cremasteric
Muscle. The Cremasteric Fascia is the term used to describe the Cremasteric
Muscle and its Fascia.
Transversus Muscle
A Thin sheet of muscle that lies deep to the I.O. Arises from the lower 6 costal
cartilages , lumbar fascia & Anterior iliac crest , lateral part of the inguinal
ligament and inserts into the Xiphoid process, linear alba , pubic symphysis.
The lowest tendinous fibres are joined by the I.O to form the Conjoint Tendon
which is fixed to the Pubic Crest and Pectineal line.
Rectus Abdominis
It is 2 long strap muscles that lies close to the midline and extends along the
whole length of the Anterior Abdominal wall and is separated by the linear alba.
 Ashan Bopitiya Surgery Notes 2017
Arises from 2 heads from the Symphysis Pubis and the Pubic crest & inserts
into the Costal cartilages of 5 , 6 and 7 ribs and the Xiphoid process. When it
contracts a Palpable , curved ridge is formed in the lateral margin and this is
known as the Linea Semilunaris
Rectus abdominis is divided into segments by 3 transverse tendinous
intersections. (1) At the level of the Xiphoid Process (2) At the level of the
umbilicus (3) One halfway between these two.
These intersections are attached strongly to the anterior wall of the Rectus
Sheath
The Rectus Abdominis is enclosed in the Rectus sheath which is made up of the
aponeurosis of the E.O , I.O and the transversus.
Rectus Sheath
Long fibrous sheath that encloses the Rectus Abdominis and the Pyramidalis (If
present).
Contains the Anterior Rami of the lower 6 thoracic nerves, the Inferior and
superior epigastric vessels and the lymph vessels.
Mainly formed by the aponeurosis of the E.O , I.O and Transversus.
The Rectus sheath is considered at 3 important levels
1. Above the Costal Margin The anterior wall of the R.S is formed by the
aponeurosis of the External oblique. The Posterior wall is formed by the
thoracic wall that is the 5th , 6th & 7th Costal cartilages and the intercostal
spaces.
2. Between the costal margins and the Anterior superior iliac spine, the
Aponeurosis of the Internal oblique splits into 2 and encloses the rectus
muscle. The external oblique aponeurosis lies in front of the rectus muscle
while the transversus aponeurosis lies behind it.
3. Between the level of the anterior superior iliac spine and the pubis the
aponeurosis of all three muscles run in front of the rectus muscle and
forms the anterior wall of the rectus sheath. The Posterior wall is absent
and the rectus muscle lies in contact with the Fascia Transversalis.
At the level of the anterior superior iliac spine the posterior wall of the rectus
sheath forms a Free curved lower border known as the Arcuate Line. It is
basically where the aponeurosis forming the posterior wall of the rectus sheath
passes in front of the rectus muscles. At this site the inferior epigastric vessels
enter the rectus sheath and travel upwards to anastomose with the superior
epigastric vessels.
The Posterior wall of the rectus sheath is not attached to the rectus abdominis
while the anterior wall of the R.S is firmly attached to the tendinous intersections
of the rectus muscle.
Fascia Transversalis

A thin layer of fascia that lines the transversus abdominis muscle

Continuous with a similar layer lining the diaphragm and the iliacus muscle.
The femoral sheath (for the femoral vessels) is formed by this fascia transversalis and
the fascia illica that covers the iliacus muscle
Extraperitoneal Fat

The extraperitoneal fat is a thin layer of connective tissue with a variable amount of fat
and lies between the fascia transversalis and the parietal peritoneum.
Parietal Peritoneum

The walls of the abdomen are lined with parietal peritoneum. This is a thin serous
membrane and is continuous bellow with the parietal peritoneum lining the pelvis.
Arteries of Anterior Abdominal Wall
 Ashan Bopitiya Surgery Notes 2017
The Superior epigastric artery (Terminal.A. of the Internal Thoracic.A) enters the upper
parts of the rectus sheath between the Costal and sternal origins of the diaphragm.
Descends behind the rectus muscle supplying the upper-central parts of the anterior
abdominal wall and anastomoses with the inferior E.A
Inferior E.A a branch of the external iliac artery. Runs upward and medially along the
medial side of the Deep inguinal ring. Pierces the Fascia transversalis and enters the
rectus sheath through the anterior part of the arcuate line. Ascends behind the rectus
muscle supplying the lower central parts of the Anterior abdominal wall and
anastomose with the superior epigastric artery
Deep circumflex artery (A branch of the external iliac artery) travels above the inguinal
ligament upward and laterally towards the anterior superior iliac spine, travels along
the iliac crest & Supplies the lower lateral parts of the Ab. Wall. The lower 2 posterior
intercostal arteries and the 4 lumbar arteries pass forward b/w the muscle layers and
supply the lateral parts of the Ab.wall !
Veins of the Anterior Abdominal wall

Superficial Veins
Superficial veins forms a network that radiate out from the umbilicus. Above this
network the blood drains to the axillary vein through the lateral thoracic vein and
bellow to the femoral vein through the superior epigastric vein and the great
saphenous vein.
A Few small veins the para-umbilical veins connect the network through the
umbilicus to the portal vein. This forms a very important portal-systemic
anastomosis. In the case of portal obstruction the veins around the umbilicus and
the paraumbilical veins become grossly distended. These grossly subcutaneous
veins radiate out from the umbilicus leading to the clinical picture known as
Caput Medusa.
Deep Veins
The deep veins: Inferior Epigastric vein , Superior Epigastric vein , Deep
Circumflex iliac vein drain into the internal thoracic vein and the external iliac
veins.
The posterior intercostal veins drain into the azygous vein while the lumbar veins
drain into the inferior vena cava.

Nerves of the Anterior Abdominal wall

The nerves of the anterior abdominal wall are the anterior rami of the lower 6 thoracic
and the 1st lumbar nerves.
The Thoracic nerves are the lower 5 intercostal nerves and the Subcostal nerves(from
T12)
The Lumbar nerves are the Illio-inguinal and ilio-hypogastric nerves.
They supply the skin of the anterior abdominal wall, the muscles & the parietal
peritoneum.
Course : They both pass forward in the space between the Internal oblique and the
Transversus muscle. The lower 6 thoracic nerves pierce the posterior wall of the rectus
sheath and enters the rectus muscle to supply it. They then terminate by piercing the
anterior wall of the rectus sheath and supplying the skin. The Lumbar nerve has a
similar course but do NOT enter the rectus sheath. It is represented by the Ilioinguinal
nerve (Which emerges through the superficial inguinal ring) and the Ilio-hypogastric
nerve which pierces the external oblique aponeurosis above the superficial inguinal ring
and end up supplying the Skin just above the inguinal ligament and symphysis pubis
Lymph drainage of the Anterior Abdominal wall

Superficial Lymph Vessels

 Ashan Bopitiya Surgery Notes 2017
Lymph drainage of the skin of the anterior abdominal wall above the
umbilicus drain into the anterior axillary group of nodes while bellow the
umbilicus lymph drainage occurs downwards and laterally to the Superficial
inguinal nodes.
Lymph drainage of the Posterior skin above the level of the iliac crests are
drained to the Posterior axillary group of nodes and the lymph drainage
bellow the iliac crest occurs to superficial inguinal lymph nodes.
Deep Lymph Vessels
The deep lymph vessels follow the arteries and rain into the Internal thoracic,
External Iliac, Posterior mediastinal and para-aortic(Lumbar) Nodes

Inguinal Canal

The inguinal canal is a passage through the lower part of the anterior abdominal wall.
It is about 1.5in.(4cm) long in the adult and extends from the deep inguinal ring to the
superficial inguinal ring
Deep Inguinal Ring
An oval opening in the fascia transversalis above the inguinal ligament in the
midline between the anterior superior iliac spin and the symphysis pubis.
Medial to the Deep Inguinal ring is the inferior epigastric vessels that asses
upwards from the external iliac vessels.
The margins of this ring give rise to the internal spermatic fascia or the internal
covering of the round ligament
Superficial Inguinal Ring
The Superficial inguinal ring lies medial and above to the Pubic tubercle and is a
triangular defect of the external oblique aponeurosis.
The margins of this ring(A.K.A Crura) also gives rise to the External Spermatic
Fascia
Walls of the Inguinal Canal

Anteriorly :
External Oblique Aponeurosis reinforced laterally by the origin of the Internal
Oblique from the inguinal ligament
Posterior wall :
Conjoint tendon medially and laterally Fascia Transversalis
Roof or the Superior wall :
Arching lowest fibres from the internal oblique and the transversus abdominis
muscles
Floor or the inferior wall :
Upturned lower edge of the inguinal ligament and medially the lacunar ligament.

The strongest part of the anterior wall lies opposite to the weakest part of the posterior
wall. Deep Inguinal ring area
The Strongest part of the Posterior wall lies opposite to the weakest part of the anterior
wall Superficial inguinal ring
 Ashan Bopitiya Surgery Notes 2017
Function of the Inguinal Canal allows structures of the spermatic cord to pass from the
abdomen to the testis in male and the round ligament of the uterus to the labia majus in the
females.

When Coughing and straining, as in micturition, defecation and parturition the arching
lower fibres of the internal oblique and the transversus abdominis contract flattening
out the arched roof so that it is lowered towards the floor. The roof may actually
compress the contents of the canal against the floor so that the canal is virtually
closed.
Spermatic Cord

The structures of the spermatic cord :

1. Vas deferens
2. Testicular Artery
3. Testicular Veins
4. Testicular Lymph vessels
5. Autonomic nerves
6. Remains of the processus vaginalis
7. Genital branch of the Genitofemoral nerve (Supplies the cremaster muscle)