Anterior Abdominal Wall Applied Anatomy

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Anterior Abdominal WallApplied Anatomy
Dr. S. M. AL SALAMAH B.Sc, MBBS, FRCS
Associate Prof. Consultant General Surgeon
Dept of Surgery, College of Medicne, KSU.
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• Abdominal wall divided into-
• ? Anteriolateral abdominal wall
• Anterior wall
• Right lateral wall (Right Flank)
• Left lateral wall (Left Flank)
• ? Posterior abdominal wall

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Antrolateral Abdominal Wall

• This extended from the thoracic cage to the
  pelvis and bounded
• Superiorly
• 7th through 10th costal cartilages and and
  xiphoid process
• Inferiorly
• Inguinal ligaments and the pelvic bones.
• The wall consists of skin, subcutaneous tissues
  (fat), muscles, deep fascia and parietal
  peritoneum.

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Antrolateral Abdominal Wall Fascia
Subcutaneous Tissues

• The subcutaneous tissues over most of the wall
  consists of layer of connective tissues that
  contains a variable amount of fat.
• In the inferior part of the wall , the
  subcutaneous tissue is composed of two layers
• Fatty superficial layer (Campers fascia)
• Membranous deep layer (Scarpas fascia)

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Antrolateral Abdominal Wall Muscles

• 3 Flat Muscles with strong sheet like aponeuroses
• External Oblique
• Internal Oblique
• Transversus Abdominus
• 2 Vertical Muscles
• Rectus Abdomius
• Pyramidalis

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Antrolateral Abdominal Wall Nerves

• T7 T11 Thoracoabdominal Nerves
• T12 Sub-costal nerve
• L1 Ilio-hypogastric Nerve
• Ilio inguinal Nerves

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Antrolateral Abdominal Wall Arteries

• Internal Thoracic Artery
• Superior Epigastric Artery
• External Iliac Artery
• Inferior Epigastric Artery
• Deep Circumflex Iliac Artery
• Femoral Artery
• Superfecial Epigastric Artery
• Superfecial Circumflex Artery

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Applied Anatomy

• Abdomen is divided into 9 regions via four
  planes
• Two horizontal sub-costal (10th) and trans
  tubercules plane (L5).
• Two vertical (midclavicular planes).
• They help in localization of abdominal signs and
  symptoms

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Anterior Abdominal WallFunctions

• Form strong expandable support.
• Protect the abdominal viscera from injury such as
  low below in boxing
• Compress the abdominal content
• Helps to maintain or increase the intraabdominal
  pressure.
• Move the trunk and help to maintain posture.

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• Protuberance of the abdomen. The five common
  causes (5F)
• Fat, Faeces, Fetus, Flatus And Fluid
• Abdominal Hernias
• Anteriolateral abdominal wall may be the site of
  hernias
• Inguinal, umbilical and epigastric regions

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Posterior Abdominal Wall

• Lumbar vertebrae and IV discs.
• Muscles
• Psoas, quadratus lumborum, iliacus, transverse,
  abdominal wall oblique muscles.
• Lumbar plexus
• Ventral rami of lumbar spinal nerves.
• Fascia
• Diaphragm
• Contributing to the superior part of the
  posterior wall
• Fat, nerves, vessels (IVC, aorta) and lymph
  nodes.

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Posterior Abdominal WallFascia

• Between the parital peritoneum and the muscles
• The psoas fascia or psoas sheath.
• The quadratus lumborum fascia.
• The thoracolumbar fascia.

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Posterior Abdominal WallMuscles

• Three paired muscles
• Psoas major
• Iliacus
• Quadratus Lumborum

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Posterior Abdominal WallNerves

• Somatic nerves
• ?The sub costal nerves
• ?The lumbar nerves
• ?The lumbar plexus of nerves branchus are
• (a) The obturator nerves (L2 L4)
• (b) The femoral nerves (L2 through
  L4)
• (c) Ilio inguinal and ilio
  hypogastric nerves (L1)
• (d) Gentio femoral (L1 L2)
• (e) Lateral femoral cutaneous nerves (L2
  L3)

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Posterior Abdominal WallNerves

• Autonomic nerves
• One cranial nerve (the vagus)
• Several different splanchnic nerves that deliver
  presynaptic sympathizer and parasympathetic
  fibers to the plexus and sympathetic ganglia.

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Posterior Abdominal WallNerves

• Sympathetic Nerves
• ? Abdomino-pelvic splanchic N. from the
  thoracic and abdominal sympathetic trunks
• ? Prevertebral sympathetic ganglia
• ? Periarterial plexus
• ? Abdominal autonomic plexus
• ? Celiac plexus
• ? Superior mensentric plexus
• ? Inferior mensentric plexus.
• ? Celiac plexus
• ? Superior hypogastric plexus
• ? Inferior hypogastric plexus

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Posterior Abdominal WallBlood Vessels

• Aorta and its branches
• IVC and its tributeries

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Applied Anatomy

• Posterior abdominal pain
• Ilio-psoas has relationship to kidney, ureters,
  caecum, appendix, colon, pancreas.etc.
• When any of these structures is diseased
• movement of the ilio psoas usually causes pain.
  
• When intra abdominal inflammation is suspected
  the Ilio Psoas Test performed by moving ileopsoas
  muscle and if positive if it causes pain.

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Psoas Abscess

• Hematogenous spread to the lumbar vertebrae may
  form an abscess which may spread from the
  vertebrae into the Psoas sheath producing a Psoas
  abscess.

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Partial Lumbar Sympethectomy

• Some patients with arterial disease in the lower
  limbs (ischaemia) may include partial lumbar
  sympathectomy by removal of two or more lumbar
  sympathetic ganglia

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IVC Obstruction

• Three collateral routs formed by valveless
  veins of the trunk are available for venus blood
  to return to the heart.
• ? inferior epigastric vein
• ? superficial epigastric vein
• ? epidural venous plexus inside the vertebral
  column.

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Abdominal Incisions

• Definition incision defined as cut made with
  knife for surgical purposes.

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Types of Incisions

• The vertical incisions
• ? Midline incision
• ? Para median
• The transverse abdominal incisions
• ? Upper and lower transverse incision
• ? Pfannenstiel incision
• ? LANZ incision (appendectomy)
• The oblique abdominal incisions
• ? The subcostal or Kochers incision
• ? Rutherford Morison incision
• ? McBurney incision (appendicectomy)
• The thoracolumbar incisions

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Applied Anatomy

• The correct diagnosis will enable the surgeon to
  choose the correct incision.
• But laparotomy for undiagnosed abdominal disease
  is most usefully approached through vertical
  incision equidistant above and below the
  umbilicus
• Once the diagnosis confirmed, the incision may be
  enlarged in an upward or downward direction.

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Choosing the Incision

• Choice of incision depends on many factors these
  includes-
• The organs to be investigated
• The type of surgery to be preformed
• Whether speed is an essential consideration
• The build of the patient
• The degree of obesity
• The presence of previous abdominal incisions

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Closing the Incision

• The ideal method of abdominal wound closure has
  not been discovered.
• However it should be free from complications
  such as-
• Burst abdomen
• Incisional hernia
• Persistent sinuses
• It should be comfortable to the patient
• Should leave reasonably good scar

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Incisional Hernia

• It is a protrusion of omentum or organ through
  surgical incision.
• If the muscles and aponeurotic layers of the
  abdomen doesnt heal properly an incisional
  hernia can result
• Prredisposing factors include
• Infection
• bowel obstruction
• obesity

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Abdominal Hernia Orifices

• Hernia is defined as the protrusion of an organ
  through its containing wall. It can occur
  because of
• Normal weakness found in everyone and related to
  anatomy of the area e.g., place where vessel or
  viscus enters or leaves the abdomen, muscles fail
  to overlap or there is only scar tissue
  (Umbilicus)
• Abnormal weakness caused by congenital
  abnormality or acquired as result of trauma or
  diseases.
• High intraabdominal pressure from Coughing /
  Strains / Abdominal distention

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Common Sites

• ? Inguinal Hernia
• ? Umbilical Hernia
• ? Femoral Hernia
• ? Incisional Hernia
• Less common Hernia
• ? Epigastric Hernia
• ? Recurrent Hernia

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Common Clinical Features

• The features of all hernias are
• ? They occur at weak spot
• ? They reduce on lying down or with direct
  pressure
• ? They have an expansile cough impulse

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History

• History is very important
• Age Occurs at all ages may be present at
  birth or appear suddenly at any age.
• Occupation
• Local symptoms Discomfort and pain the
  commonest
• Systemic symptoms
• If the hernia obstructing the patient has
  cardinal symptoms of intestinal obstructions
  (colicky abdominal pain, vomiting, abdominal
  distension, constipation)

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Examination

• Ask the patient to stand up and look to the
  site of the Lump (inspection) and ask the
  patient to cough look for cough impulse, if
  positive or negative.
• Then palpitate the lump and whether its
  reducible or not.

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Complications

• Untreated hernia may develop following
  complications
• (a) intestinal obstruction
• (b) strangulation
• (c) incarceration

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Perop or Post op Complications

• (a) Haemorrhage haematoma formation
• (b) Bowel injuries
• (c) Wound infections
• (d) Recurrent of Hernia

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Inguinal Hernia

• Anatomy of inguinal region
• Inguinal canal with boundaries, contents and
  orifices
• Types
• Treatment
• Clinical aspect

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• Indirect inguinal hernia pass via deep inguinal
  ring along the canal then if large enough emerges
  through the external ring and descends into
  scrotum.
• Direct hernia pushes through the posterior wall
  of the inguinal canal via Hesselbechs triangle,
  which is boundary base inguinal ligament medial
  border midline laterally by inferior epigastric
  vessels.
• However, the inferior epigastric vessels
  demarcate the indirect hernia sac pass lateral
  and direct hernia medial to these vessel.

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