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Dr. Bea/September 2, 2013
Prepared by: Katrina Kabigting

Abdominal wall lower part of the torso

Divided into 9 regions by drawing:
2 vertical lines along the side of the neck
2 imaginary lines at the level of the subcostal margin and
at the level of the anterior superior iliac spine

Figure 1. Nine regions of the


RH Right Hypochondriac
E Epigastric
LH Left Hypochondriac
RL - Right Lumbar
U - Umbilical
LL Left Lumbar
RI Right Inguinal
P Pubic/Hypogastric
LI Left Inguinal

These quadrants give us an idea about the positions of the
different organs. However, nowadays we divide the abdomen
into four quadrants by drawing:
1 vertical line exactly in the middle, passing through the
1 horizontal line at the level of the umbilicus

Figure 2. Four quadrants of the abdomen

External Oblique

Internal Oblique

Transverse abdominis

Rectus abdominis


2 types of muscles in the abdominal wall:
Muscles found in the middle, fibers oriented vertically (i.e.
Muscles found at the side, fibers oriented obliquely or
transverse (i.e. obliques)

Rectus abdominis muscle occupying the midline or the
middle part of the abdominal wall (rectus straight, i.e. straight,
vertical fibers)

Rectus abdominis fibers are vertical but are not continuous. At
some point, along the length of the muscle, they have these
fibrous or tendinous insertions. This is the reason why the rectus
abdominis is divided into segments.

Pyramidalis not always present, present at the midline,
tenses the linea alba

Oblique muscles (external, internal, and transverse
abdominis) are examples of flat muscles.
Flat muscles muscles that attach via aponeurosis

The rectus sheath is a sheath of fibrous tissue that covers the
rectus abdominis. This is derived from the aponeurosis of the
oblique muscles. As the oblique muscles insert themselves by
means of aponeurosis, they also create a covering for the rectus

2 Layers:

Anterior rectus sheath

Posterior rectus sheath

The two layers create a compartment inside wherein we can see
the rectus abdominis and blood vessels.

Blood vessels:

Inferior epigastric artery branch of the external

iliac artery and arises just above the inguinal ligament.
It will pierce the rectus abdominis and go upward
into the rectus sheath. It is located inside the sheath,
specifically behind the rectus abdominis and in front
of posterior rectus sheath.
o Gives off the cremasteric artery that goes
along the spermatic cord.

Internal thoracic artery found on the side of the sternum,
origin is the subclavian artery, and branches into
musculophrenic artery and superior epigastric artery.

Superior epigastric artery enters the rectus

sheath superiorly through its posterior layer and
supplies the superior part of the rectus abdominis
and anastomoses with the inferior epigastric artery
approximately in the umbilical region (Moore, Dalley
& Agur, 2010).

The posterior rectus sheath does not extend up to the symphysis
The arcuate line or the semilunar line of Douglas is the point
of termination of the posterior rectus sheath. What covers the
area between the umbilicus and symphysis pubis now is the
transversalis fascia.

Figure 3. Cross-section of the anterior abdominal wall above the arcuate
line. The anterior rectus sheath is formed by the aponeurosis of the
external oblique and partly by the aponeurosis of the internal oblique.
Posterior rectus sheath is formed partly by the aponeurosis of the
internal oblique and that of the transverse abdominis. Below the
posterior rectus sheath is the transversalis fascia.

Figure 4. Cross-section of the anterior abdominal wall below the arcuate
line. The posterior rectus sheath is absent in the region below the arcuate
line. Three ligaments are found in this region. The one in the middle is
called the median umbilical ligament, while the two at its side are
called medial umbilical ligaments.

Median umbilical ligament remnant of urachus once it has

obliterated during birth. This is attached to the umbilicus. In
some individuals, the urachus does not obliterate and persists
throughout adulthood. This is called a patent urachus.

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In patent urachus, there is discharge coming out of the
umbilicus because there is still a connection between the
umbilicus and the urinary bladder.

Medial umbilical ligament obliterated umbilical artery.

The three ligaments only extend up to the level of the umbilicus.
At this point, the ligament that extends up beyond the
umbilicus is called the ligamentum teres hepatis, a remnant
of the umbilical vein.

As the transversalis fascia goes over the inferior epigastric
vessel, it also creates the lateral umbilical ligament.

In the area between the inferior epigastric vessel (lateral
border), lateral border of the rectus abdominis (medial border),
and the inguinal ligament (inferior border), we have now what
we call Hesselbachss triangle. This triangle is a point of
weakness in the lower abdominal wall. This is a potential site
for direct inguinal hernia. Constant stretching of the abdominal
walls, thereby increasing the intraabdominal pressure, may
cause this hernia.

Direct hernia does not go the scrotal area, medial to the
inferior epigastric vessels
Indirect hernia manifests lateral to the inferior epigastric


Superficial epigastric artery derived from the

femoral artery

Superior epigastric artery derived from the internal

thoracic artery

Inferior epigastric artery from the external iliac


Deep circumflex iliac artery direct branch of the

external iliac artery

Superficial circumflex iliac artery comes from the


External pudendal artery from the femoral artery,

supplies partly the peritoneal area

Lower 4 intercostal arteries

4 lumbar arteries

VENOUS DRAINAGE use the umbilicus as the central point:
venous drainage will either be going up to the superior
epigastric vein or down towards the external iliac vein

Venae commitantes

Paraumbilical veins veins beside the umbilicus.

o Sometimes these veins dilate and will allow
venous blood to flow to the superficial veins
of the abdominal wall. This happens in
certain cases when there is portal
o Patients with advanced cases of liver
cirrhosis, portal hypertension develops
when there is obstruction in flow of portal
blood into the liver. Blood will backflow into
the portal veins, and this blood will
eventually go back into the peripheral veins.
This is what we call centrifugal circulation.
o Patients with advanced cases of liver
cirrhosis and portal hypertension develop
what is known as caput medusae.

Figure 5. In severe cases of portal obstruction, the veins of the anterior

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wall (normally caval tributaries) that anastomose with the
paraumbilical veins (normally portal tributaries) may become varicose
and look somewhat like small snakes radiating under the skin around the
umbilicus. This condition is referred to as caput medusae because of its
resemblance to the serpents on the head of Medusa, a character in Greek
mythology (Moore, Dalley & Agur, 2010).

Subcutaneous tissue in the abdominal wall has two layers:

Campers fascia contains lots of adipose tissue

Scarpas fascia deeper to the Campers fascia, is

more membranous, and contains less adipose tissue

Deep to the Scarpas fascia will be the muscles.

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supply of the anterior abdominal wall is derived from
the anterior rami of the lower 6 thoracic and the 1st lumbar
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Motor component of spinal nerve would innervate

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the abdominal wall muscles.

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Sensory component will innervate the skin covering
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the abdominal wall. Sensory innervation is also by
dermatomal level.

If there is numbness over the:

o Xiphoid problem with T7
o Umbilicus problem with T10
o Inguinal region problem with L1

These spinal nerves pass through between the internal oblique
and the transverse abdominis to supply the abdominal skin and
muscles. Once it pierces the rectus sheath, it will emerge in the
rectus abdomins muscle and supply sensory innervation to the

The inguinal canal is located in the inguinal region. The
inguinal region is a triangular area found in the lower
abdominal wall, bounded by the anterior superior iliac spine,
pubic tubercle, and the scrotum or the labia majora.

The inguinal canal is bounded by the two inguinal rings: the
superficial and deep inguinal rings.

The deep inguinal ring is located at the level of the

transversalis fascia.

The superficial inguinal ring is located at the level

of the external oblique aponeurosis.

4 walls of the inguinal canal:

Anterior: aponeurosis of external and internal oblique

Posterior: transversalis fascia (continuous with the

femoral sheath) and the conjoint tendon

Superior: internal oblique and transverse abdominis


Inferior: inguinal and lacunar ligament

Note: The inguinal canal is NOT the spermatic cord. The

spermatic cord is found inside the inguinal canal.

Direct inguinal hernia passes through the Hesselbachs
manifests as a bulge in the Hesselbachs triangle but
will not go to the scrotum, at least during the initial
Hesselbachs triangle is potentially weak because the
muscles do not overlap each other.

Indirect inguinal hernia enters the deep inguinal ring,
passes through the inguinal canal and out through the
superficial inguinal ring
bulge going to the scrotum
starts at the lateral to the inferior epigastric vessel


Spermatic cord in males or the round ligament in

o The spermatic cord is the pedicle of the
testis, while the round ligament of the
uterus attaches to the labia majora
o Contents of the spermatic cord:
1. Vas deferens
2. Testicular vessels
3. Deferential artery
4. Cremaster artery (branch of the inferior
epigastric artery)
5. Ilioinguinal nerve
6. Genital branch of the genitofemoral
7. Autonomic nerves around the testicular

Testicular veins form a plexus of veins around the scrotum
known as pampiniform venous plexus. In some individuals,
they develop dilated pampiniform venous plexuses in the
scrotal sac. They are like varicose veins of the scrotum, and this
condition is known as varicocoele.