Anterior

Abdominal Wall
KATRINA BALMORES, MD
NOVEMBER 04, 2015

References

Moore, Clinically Oriented Anatomy, 7th edition

Netters Atlas of Human Anatomy, 6th edition

The Abdomen

Flexible, dynamic container

Respiration

Posture

Locomotion

The Abdomen

Anterolaterally: Musculoaponeurotic
walls

Superiorly: Diaphragm

Inferiorly: Muscles of the pelvis

The Abdomen
Suspended and supported
by:

Inferior margin of thoracic

skeleton

Pelvic girdle

Linked by lumbar vertebral

column in posterior
abdominal wall

The Abdomen

Voluntary/involuntary contraction

Muscular roof, anterolateral walls, and

floor can raise intraabdominal pressure
for:

Respiration

Straining

Vomiting

Urinating

Giving birth

The Abdomen
Distends
considerably!

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The Abdominal Wall

Peritoneum (serosa) continues onto

abdominal organs

Bursal sac or lined potential space

(peritoneal cavity)

Extracellular (parietal) fluid to lubricate

visceral movement occurs freely

Double-layered reflections of peritoneum

passage for blood vessels, lymphatics, and
nerves

Fat

The Abdominal Cavity

Superior and major

part

Pelvic inlet
plane/superior pelvic
aperture

Superior: 4th
intercoastal space

Inferior: Greater
pelvis

Abdominal Regions

Abdominal Regions 4 Planes

VERTICAL
PLANES

TRANSVERSE/

HORIZONTAL PLANES

Midclavicular
planes

Midpoint of clavicle
(~9cm from
midline) to
midinguinal points
(midpoints of ASIS
and pubic tubercles)

Subcostal plane

Transtubercular plane

Transpyloric planes

Interspinous plane

Abdominal Regions 4 Planes

SAGITTAL/

VERTICAL PLANES

2 Midclavicular
planes

Midpoint of clavicle
(~9cm from
midline)
midinguinal points
(midpoints of ASIS
and pubic tubercles)

TRANSVERSE
PLANES
Transpyloric
planes

Sup border
manubrium and
L1

Subcostal plane

Inf border 10th

costal cartilage

Abdominal Regions 4 Planes

SAGITTAL/

VERTICAL PLANES

2 Midclavicular
planes

Midpoint of clavicle
(~9cm from
midline)
midinguinal points
(midpoints of ASIS
and pubic tubercles)

TRANSVERSE
PLANES
Transtubercular
plane

Through iliac
tubercles (~5cm
posterior to ASIS
and body of L5)

Interspinous
plane

Passes through

Abdominal Reference
Planes

Moore and Dally. Clinically Oriented Anatomy, 5th Editio

Transpyloric plane
LANDMARK FOR:

Gallbladder fundus

Pancreas neck

Superior mesenteric artery

origins

Hepatic portal vein

Root of transverse
mesocolon

Duodeno-jejunal junction

Kidney hila

Transpyloric
Interspinous

9 Abdominal Regions

Moore and Dally. Clinically Oriented Anatomy, 5th Edition

4 Quadrants
Transumbilical plane

Umbilicus
intervertebral disc L3
and L4 vertebrae

Median plane

Longitudinally
through body

4 Quadrants

Transverse
transumbilical plane
Umbilicus and
intervertebral disc
between L3 and L4
vertebrae
Vertical
median plane

Longitudinally through
body

The Abdominal Wall

Musculoaponeurotic wall

Anterolateral abdominal
wall

Superior: 7th-10th ribs,

xiphoid process

Inferior: inguinal
ligament, superior
margins of iliac crest,
pubic crest, pubic
symphysis

The Abdominal Wall

Skin

Subcutaneous tissue (superficial fascia)

Fat

Muscle

Aponeuroses

Deep fascia

Extraperitoneal fat

Parietal peritoneum

Skin

Attaches loosely to
subcutaneous tissue
except at UMBILICUS

3 musculotendinous
layers

Fibers run in different

directions

Surface Anatomy

As we go deeper

Fascia of Anterolateral
Abdominal Wall

Fascia of Anterolateral
Abdominal Wall

Subcutaneous tissue

Major site of fat storage

(Males>Females)

*Morbid obesity

Very thick fat

Panniculi/sagging folds

Fascia of Anterolateral
Abdominal Wall

INFERIOR to
umbilicus

Reinforced by elastic
& collagen fibers

Campers fascia

Superficial fatty

Scarpas fascia

Deep membranous

Continues inferiorly
as Colles fascia

Fascia of Anterolateral
Abdominal Wall
LAYERS OF
INVESTING
FASCIA

Superficial

Intermediate

Deep

*epimysium

Fascia of Anterolateral
Abdominal Wall
Internal
aspect
membrano
us
and areolar
sheets

Fascia of Anterolateral
Abdominal Wall
Lines deep
surface of
transversus
abdominis
muscle and
its
aponeurosi
s

Fascia of Anterolateral
Abdominal Wall
Extraperitoneal
fat in between
transversalis
fascia and
parietal
peritoneum

Muscles of Anterolateral
Abdominal Wall

5 paired muscles

3 flat

External oblique

Internal oblique

Transversus
abdominis

2 vertical

Rectus abdominis

Pyramidalis

*rectus sheath
*linea alba

External Oblique

Largest

Most superficial

Inguinal/Poupart Ligament

Lacunar Ligament

External Oblique

The contralateral external and internal

oblique muscles together form a
digastric muscle, a two-bellied muscle
sharing a common central tendon that
works as a unit

External oblique
Inguinal ligament (Poupart ligament)

Inferior margin of the external oblique

aponeurosis

Thickened as an undercurving fibrous band with

a free posterior edge

Spans between the ASIS and the pubic tubercle

Internal Oblique

Fleshy fibers run perpendicular

to those of external oblique,
running superomedially

Participate in the formation of

the rectus sheath.

Internal Oblique

Fans out anteromedially

Lowermost fibers arise from lateral half of

inguinal ligament

Transversus Abdominis

Neurovascualr plane
between

Transversus Abdominis

Inferior ones run

parallel to those of
the internal oblique

Contributes to the
formation of the
rectus sheath

Transversus Abdominis
*Neurovascular plane of the anterolateral
abdominal wall

Between internal oblique and transversus

abdominis

Nerves and arteries supplying anterolateral

abdominal wall

Anterior part of the abdominal wall nerves and

vessels leave the neurovascular plane and lie
mostly in the subcutaneous tissue.

Rectus Abdominis
Powerful flexor
of the thoracic
and especially
lumbar regions
of the
vertebral
column

Rectus Abdominis

Principal vertical muscle of

the anterior abdominal wall

Paired

Separated by linea alba

Mostly enclosed in rectus

sheath

Tendinous insertions- 6 pack

abs

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Pyramidalis

Small, insignificant,
triangular

Absent in 20%

Anterior to inferior part of

rectus abdominis

Attaches to anterior surface

of pubis and anterior pubic
ligament

Ends in linea alba

Tenses linea alba

Attachment of the
pyramidalis to the linea alba

Rectus Sheath

Strong, incomplete fibrous compartment of the

rectus abdominis and pyramidalis muscles

Contents:

Superior and inferior epigastric arteries and veins

Lymphatic vessels

Abdominal portions of the anterior rami of spinal

nerves T7T12

Rectus Sheath

Superior 2/3 of internal oblique aponeurosis splits

into two layers (laminae)

Anterior lamina + aponeurosis of external oblique = anterior

layer of the rectus sheath.

Posterior lamina + aponeurosis of the abdominis = posterior

layer of the rectus sheath

Rectus Sheath

Arcuate Line

Crescentic

Demarcates transition between:

Aponeurotic posterior wall of sheath: superior

of the rectus

Transversalis fascia: inferior 1/4.

Linea Alba

Throughout length of rectus sheath

Fibers of anterior and posterior layers of

sheath interlace in anterior median line

Superior to costal margin: rectus abdominis

lies
directly on the thoracic wall

Umbilical Ring

Defect in linea alba through which fetal

umbilical vessels passed to and from the
umbilical cord and placenta.

Nervous Supply

VESSELS OF ANTEROLATERAL
ABDOMINAL WALL
Primary blood vessels

Internal thoracic vessels: Superior epigastric vessels

and branches of musculophrenic vessels

External iliac vessels: Inferior epigastric and deep

circumflex iliac vessels

Femoral artery: Superficial circumflex iliac

Greater saphenous vein: Superficial epigastric vessels

Posterior intercostal vessels of the 11th intercostal

space

Anterior branches of subcostal vessels.

Lymphatic Drainage
Superficial

lymphatic vessels accompany

subcutaneous veins

Superior

to the transumbilical plane drain

to axillary lymph nodes

Few

drain to parasternal lymph nodes

Lymphatic Drainage
Superficial

lymphatic vessels inferior to

transumbilical plane drain to superficial
inguinal lymph nodes.

Deep

lymphatic vessels accompany deep

veins of abdominal wall and drain to the
external iliac, common iliac, and right and
left lumbar (caval and aortic) lymph nodes.

VESSELS OF
ANTEROLATERAL
ABDOMINAL
WALL

Distribution of deep vessels

reflects muscle arrangement

Superior epigastric artery:

direct continuation of
internal thoracic artery

VESSELS OF ANTEROLATERAL
ABDOMINAL WALL

Clinical Correlation

Palpation of abdominal viscera

Patient supine with thighs and knees semiflexed

to enable adequate relaxation of the
anterolateral abdominal wall.

Deep fascia of the thighs pulls on the

membranous layer of abdominal subcutaneous
tissue, tensing the abdominal wall.

Inguinal Region (Groin)

Between ASIS and pubic tubercle

Inguinal Ligament

Dense band constituting inferiormost part of external

oblique aponeurosis

Deep

Lacunar ligament: attach to superior pubic ramus

Forms medial boundary of subinguinal space

Pectineal ligament: run along pecten pubis

Superior

Reflected inguinal ligament: blend with contralateral

external oblique

Inguinal Region (Groin)

Between ASIS and pubic tubercle

Iliopubic Tract

Thickened inferior margin of

transversalis fascia

Runs parallel and posterior

(deep) to the inguinal ligament

Reinforces posterior wall and

floor of inguinal canal as it
bridges the structures passing
the subinguinal space

Inguinal Canal

Spermatic cord in males

Round ligament of the uterus in females

Also contains

blood and lymphatic vessels

Ilio-inguinal nerve

Deep/internal ring

Superficial/external ring

Deep (internal)
inguinal ring

Entrance to the inguinal canal.

Located superior to the middle of the inguinal

ligament and lateral to the inferior epigastric
artery

Beginning of an evagination in the transversalis

fascia that forms an opening like the entrance
to a cave

Superficial (external)
inguinal ring

Exit by which the spermatic cord in males, or the

round ligament in females, emerges from inguinal
canal

A split occurs in the diagonal fibers of the external

oblique aponeurosis just superolateral to the pubic
tubercle.

Lateral crus attaches to the pubic tubercle

Medial crus attaches to the pubic crest.

Intercrural fibers help prevent the crura from

Most groin hernias in males pass superior to the

iliopubic tract (inguinal hernias)

Most pass inferior to it in females (femoral

hernias).

Direct Inguinal Hernia

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