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Name: lab section:

Abdominal Walls
3rd year medical student :

You must know the following structures :


The anterior abdominal wall is made up of: (Skin, Superficial fascia,
Deep fascia, Muscles, Extraperitoneal fascia, Parietal peritoneum).

Skin:
A. Nerve Supply to the Skin: the anterior rami of the lower 6 thoracic
and the 1st lumbar nerves.
B. Arterial Supply to the Skin:
1) The skin near the midline is supplied by:
The superior epigastric arteries , one of the terminal branches
of the internal thoracic artery.
The inferior epigastric arteries , is a branch of the external iliac
artery .

2) The skin of the flanks is supplied by:


The intercostal arteries, branches of the descending thoracic
aorta.
The lumbar arteries, branches of the abdominal aorta.
The deep circumflex iliac arteries, is a branch of the external
iliac artery.

3) The skin in the inguinal region by:


The superficial epigastric arteries.
The superficial circumflex iliac arteries.
The superficial external pudendal arteries.
C. Venous Drainage of to the Skin:

Superficial Veins:
1) Above mainly into the axillary vein via the lateral thoracic vein.
2) Below into the femoral vein via the superficial epigastric and the
great saphenous veins.
3) The paraumbilical veins, connect the network to the portal vein.
Deep Veins:
1) follow the arteries of the same name and drain into the internal
thoracic and external iliac veins .
2) The superior epigastric veins .
3) The inferior epigastric veins.
4) The deep circumflex iliac veins.
5) The posterior intercostal veins drain into the azygos veins.
6) The lumbar veins drain into the inferior vena cava.
Superficial Fascia: It is divided into:
A. A superficial fatty layer (Camper's fascia)
B. A deep membranous layer (Scarpa's fascia)

Muscles of the Anterior Abdominal Wall:


External oblique Transversus
abdominis

Aponeurotic portion

Internal oblique

Inguinal ligament

Rectus abdominis
Tendinous intersections
Lymph Drainage of the Anterior Abdominal Wall:

A. Superficial Lymph Vessels:


1) Above the level of the umbilicus is upward to the anterior axillary
group of nodes.
2) Below the level of the umbilicus, the lymph drains downward and
laterally to the superficial inguinal nodes.

B. Deep Lymph Vessels:


1) The internal thoracic.
2) External iliac nodes.
3) Posterior mediastinal nodes.
4) Para-aortic (lumbar) nodes.
Lymph Drainage of the Anterior Abdominal Wall
Identify the pointed structures in the diagram below:
Answer Sheet:

10

11

12

13

14
The posterior abdominal wall is formed by:

a) The five lumbar vertebrae and their intervertebral discs

b) The 12th rib.

c) The upper part of the bony pelvis.

d) The psoas muscles.

e) The quadratus lumborum muscles.

f) The iliacus muscles lie in the upper part of the bony pelvis.

g) The aponeurosis of origin of the transversus abdominis muscles.

Posterior abdominal wall muscles:


Inguinal canal :
It extends from the superficial inguinal ring, a hole in the
aponeurosis of the external oblique muscle, to the deep inguinal
ring, a hole in the fascia transversalis.
It lies parallel to and immediately above the inguinal ligament.
It contains spermatic cord in males, or round ligament in female.

Walls of the Inguinal Canal:

Anterior wall: External oblique aponeurosis, the origin of the internal


oblique, the inguinal ligament.

Posterior wall: Conjoint tendon medially, fascia transversalis laterally.

Superior wall (Roof): Arching lowest fibers of the internal oblique


and transversus abdominis muscles.

Inferior wall (floor): Upturned lower edge of the inguinal ligament


and, at its medial end, the lacunar ligament.
Clinical case :
A 28-year-old woman in her 36th week of pregnancy arrived in the emergency room
following an automobile accident. Immediately following the accident she went into
labor. The accident had broken her pelvis such that the emergency room physician
deemed a vaginal delivery would be hazardous. An obstetrician was called, and she
agreed with the ER physician's initial assessment.

A Cesarean section was performed, resulting in the delivery of a healthy baby girl.
During the operation, the obstetrician used a Pfannenstiel incision to open the
abdomen. This incision involves making a transverse, slightly convex cut large
enough to deliver a child at approximately the pubic hairline.
1. What abdominal wall layers must be incised
at the pubic hairline (near the midline) in order to
access the abdominal cavity?
2. Why is the incision made in a convex manner
instead of straight across?
3. What vascular structures might be cut during
a Pfannenstiel incision?
4. Where in the abdomen could a surgeon make a
large vertical incision with minimal detrimental effect?

Clinical case :
A 35-year-old man, was carrying furniture out to a moving van in preparation
for his family's move to a new home. When S.T. strained to pick up a particularly
heavy coffee table, he suddenly felt a sharp pain in his right groin. Later, he
noticed that a painful bulge had developed in his groin which disappeared when
he laid on his back. He did not like going to the doctor, so he ignored the
condition. After several months, the pain and the bulge in his groin increased and
he finally consented to see a physician. On examination, the physician observed a
swelling which began about midway between the anterior superior iliac
spine and the midline, progressed medially for about 4 cm, and then turned
toward the scrotum . Taking the history and physical findings into account, the
physician made a diagnosis of indirect inguinal hernia and scheduled S.T. for
surgery . The hernia was successfully repaired, and S.T. was released from the
hospital a few days later.
Questions to consider:

1. What abdominal wall layers must be incised with a small midline incision in
order to access the abdominal cavity?

2. What defines this hernia as an indirect inguinal hernia rather than a direct
inguinal hernia? List the key features of each.

3. What caused the bulge? What body layers would surround it as it


proceeded into the scrotum and what abdominal layers are they derived
from?

4. Why would it be necessary to repair a hernia like the one described above
as quickly as possible?

5. How is the inguinal canal formed, and which structures are associated with
the inguinal canal in the male? in the female?

6. What other abdominal or pelvic regions, aside from the inguinal canal, are
susceptible to herniation ?

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