ANTERIOR ABDOMINAL WALL

has a protective mechanism/function for major visceral organs with several layers of : 1. Fascia 2. Muscles 3. Mesothelium Boundaries: Superior - costal margins (7th-10th rib) and xiphoid process Highest point Inferior - iliac crest, inguinal ligament, pubic crest and upper end of symphysis pubis Lowermost Point *Posterior abdominal wall is only concerned with the musculoskeletal system and the urinary tract. Surface Anatomy Skin loosely attached except in the umbilicus Linea alba from the xiphoid to symphysis pubis; divided into supraumbilical and infraumbilical part; fibrous raphe formed by the decussation of 3 lateral abdominal muscles Umbilicus navel; puckered scar marking site/ remnant the of umbilical cord it is only a depression of the skin that varies in size and shape in individuals -

DIVISIONS OF THE ANTERIOR ABDOMINAL WALL divided into 9 regions by two horizontal and vertical lines horizontal line drawn at the level of 9th costal cartilage and superior border of iliac crest vertical line drawn from middle of subcostal margin(midclavicular) and middle of inguinal ligament can also be divided into four quadrants by 2 perpendicular imaginary lines that will pass through the umbilicus

ANTERIOR ABDOMINAL WALL *Foregut Distal esophagus to the 2 portion of te duodenum Blood supply: Branches of the Celiac Trunk *Midgut 2nd portion of the duodenum to the transverse colon Blood Supply: Sup. Mesenteric Artery *Hindgut distal transverse colon to the rectum Blood Supply: Inf. Mesenteric Artery
nd

Skin Cutaneous Nerve Supply: Anterior rami of lower six thoracic and first lumbar nerves - thoracic (lower five intercostals and subcostal nerves) - lumbar (iliohypogastric and ilioinguinal nerves) 1

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Dermatome: T7 epigastrium over xiphoid process T10 umbilicus L1 just above inguinal ligament and xiphoid process Blood Supply: superior and inferior epigastric arteries branches from intercostal, lumbar and deep circumflex iliac arteries Venous Drainage: axillary vein via lateral thoracic vein femoral vein via superior epigastric vein and great saphenous veins Lymphatics: above umbilicus anterior axillary nodes below umbilicus superficial inguinal nodes -

branch of external iliac artery; runs upward and laterally toward the ASIS supplies the lower lateral part of abdominal wall

4. Lower two posterior intercostal arteries (from descending thoracic aorta) and four lumbar arteries (from abdominal aorta) supplies lateral part of anterior abdominal wall superficial epigastric artery, superficial circumflex iliac artery and superficial external pudendal artery branch of femoral artery also supply the lower anterior abdominal wall

BLOOD SUPPLY OF THE ANTERIOR ABDOMINAL WALL 1. Superior Epigastric Artery arises from the internal thoracic artery an enters the rectus sheath descends behind the rectus muscle and supplies upper central part of anterior abdominal wall anastomoses with inferior epigastric artery 2. Inferior Epigastric Artery - arises from external iliac artery above the inguinal ligament - runs medial to deep inguinal ring and enters rectus sheath - ascends behind the rectus muscle and supplies lower central part of anterior abdominal wall - anastomoses with superior epigastric artery 3. Deep Circumflex Iliac Artery

VENOUS DRAINAGE OF THE ANTERIOR ABDOMINAL WALL 1. Superior and Inferior Epigastric Veins and Deep Circumflex Iliac Veins - follow the arteries and drain into internal thoracic and external iliac veins 2. Posterior intercostal veins drain into azygos veins 3. Lumbar Veins drain into IVC 4. Superficial epigastric, superficial circumflex iliac, and superficial external pudendal veins drain into the great saphenous vein then to femoral vein 5. Thoracoepigastric vein - anastomoses between the lateral thoracic vein and superficial epigastric vein, a tributary of the great saphenous vein - alternative path for venous blood in case of obstruction in the SVC or IVC

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NERVE SUPPLY OF THE ANTERIOR ABDOMINAL WALL Anterior Rami of Lower Six Thoracic and First Lumbar Nerves - run downward and forward between the internal oblique and transversus abdominis muscles - supply the skin, muscles, and parietal peritoneum of anterior abdominal wall - lower six thoracic nerves pierce the posterior wall of the rectus sheath - first lumbar is represented by the iliohypogastric and ilioinguinal nerves, which do not enter the rectus sheath - iliohypogastric nerve pierces the external oblique aponeurosis above the superficial inguinal ring - ilioinguinal nerve passes through the inguinal canal to emerge through the ring *Medial to lateral arrangement: Vein, Artery, Nerve (VAN)

SUPERFICIAL FASCIA 1. Campers Fascia (Superficial Fatty Layer) - continuous with the superficial fascia over rest of the body and extremely thick in obese individuals - represented as a thin layer of smooth muscle in the scrotum (Dartos muscle) 2. Scarpas Fascia (Deep Membranous Layer) - fades out laterally and above; passes over inguinal ligament to fuse with deep fascia of the thigh(fascia lata) - not attached to pubis in the midline but forms a tubular sheath for the penis (clitoris) - attached to one side to margins of pubic arch (Colles Fascia) - fuses posteriorly with perineal body and posterior margin of perineal membrane

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*Superficial to deep arrangement of abdominal wall coverings (1st) Subcutaneous -> Campers fascia ->Scarpas fascia-> Rectus Sheath -> different layers of Muscle -> Ext. abd. Oblique -> Int. abd. Oblique -> Tranversus Abdominis DEEP FASCIA - thin layer of areolar tissue covering the muscle Muscles of Anterior Abdominal Wall - Three broad thin sheets that are aponeurotic in front - External Oblique, Internal Oblique, Transversus Abdominis - Rectus Abdominis: found on either side of midline - *aponeurosis of three sheets pass forward and enclose Rectus Abdominis to form the Rectus Sheath - Pyramidalis Muscle: may be present in the lower part of the Rectus Sheath

Rectus Sheath - long fibrous sheath that encloses rectus abdominis and pyramidalis (if present) - contains anterior rami of lower six thoracic nerves and superior and inferior epigastric vessels and lymph vessels - internal oblique aponeurosis splits to form an anterior and posterior laminae - external oblique aponeurosis fuses with anterior lamina - transversus abdominis aponeurosis fuses with posterior lamina at level of ASIS, all 3 aponeurosis past anteriorly to the rectus muscle (sheath becomes deficient posteriorly) - arcuate line: lower crescent-shaped edge of posterior wall of rectus sheath - all aponeurosis fuse with each other and with the other side to form the linea alba - anterior wall of rectus sheath attached to tendinous intersections of rectus abdominis *xiphoid, umbilicus and in between Linea Semilunaris: lateral edge of rectus muscle Conjoint Tendon: union of internal oblique and transversus abdominis muscle; strengthens medial half of floor of inguinal canal

Inguinal (Pouparts) Ligament - connects ASIS to pubic tubercle - formed by lower border of external oblique aponeurosis Lacunar (Gimbernats) Ligament - extends from medial end; goes backward and upward to the Pectineal Line on superior ramus of pubis; where it becomes continuous with pectineal ligament (periosteal thickening) - lower border attached to the fascia lata Coopers Ligament - lateral continuation of lacunar ligament - extends from base of lacunar ligament laterally along the pectineal line to which it is attached Fascia Transversalis - thin layer that lines transversus abdominis - continuous with a similar layer lining the diaphragm and iliacus muscle - forms femoral sheath together with fascia iliac

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SPERMATIC CORD - collection of the following structures that pass through the inguinal canal to and from the testis 1. Vas Deferens 2. Testicular Artery 3. Testicular Vein (pampiniform plexus) 4. Testicular Lymph nodes 5. Autonomic Nerves 6. Remains of the Processus vaginalis 7. Cresmasteric Artery 8. Artery of the Vas Deferens 9. Genital branch of genitofemoral nerve, which supplies cremasteric muscle

homologous to female round ligament of the ovary and round ligament of the uterus

Coverings: 1. External Spermatic Fascia external oblique muscle 2. Cremasteric Fascia internal oblique muscle 3. Internal Spermatic Fascia - fascia trasnversalis

PROCESSUS VAGINALIS - peritoneal diverticulum formed in the fetus that passes through the layers of lower abdominal wall to form the inguinal canal - normally, cavity of tunica vaginalis is shut off from the upper part of processus and peritoneal cavity just before birth; becomes a closed sac invaginated from behind by the testis - homologue in females = Canal of Nuch GUBERNACULUM TESTES - muscular ligamentous cord that connects the fetal testis to the floor of developing scrotum - plays an important role in the descent of the testis

SCROTUM - outpouching of the lower part of the anterior abdominal wall and contains the testis, epididymis, and lower ends of the spermatic cord Layers: 1. Skin 2. Superficial Fascia: Dartos muscle (smooth muscle)replaces fatty layer *Dartos muscle - responsible for the corrugated appearance of the scrotum 3. External Spermatic Fascia from external oblique 4. Cremasteric Fascia from internal oblique *cremasteric muscle & fascia supplied by genital branch of genitofemoral nerve responsible for raising the testis in response to cold temp. & stress 5. Internal Spermatic Fascia from fascia transversalis 6. Tunica Vaginalis: closed sac that covers the anterior, medial and lateral surface of each testis TESTIS - paired ovoid organ responsible for the production of spermatozoa and testosterone. *descent to abdominal cavity allows normal spermatogenesis to take place - outer fibrous capsule is called tunica albuginea EPIDIDYMIS - lies on each side, posterior to the testis - has head, body and tail 5

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coiled tube about 20 feet (6 m) long vas deferens emerges from the tail

BLOOD SUPPLY/DRAINAGE/LYMPHATICS - supplied by testicular artery which is a branch of the abdominal aorta - testicular veins emerges from testis and epididymis as a venous network called pampiniform plexus - right testicular vein drains to IVC and left joins left renal vein - lymphatics: para-aortic nodes at L1 level INGUINAL CANAL - oblique passage through the lower part of anterior abdominal wall present in both sexes - about 4 cm long in adults; extends from deep inguinal ring, (hole in the fascia transversalis) downward and medially to superficial inguinal ring (hole in external oblique aponeurosis) - deep inguinal ring: oval opening in the fascia transversalis, about 1.3 cm above the inguinal ligament; margins of the ring give attachment to internal spermatic fascia - superficial inguinal ring: triangular-shaped defect in the external oblique aponeurosis; lies immediately above and medial to the pubic tubercle; margins give attachment to external spermatic fascia

WALLS OF THE INGUINAL CANAL Anterior: external oblique aponeurosis, reinforced laterally by origin of internal oblique from inguinal ligament Posterior: conjoint tendon medially, fascia transversalis laterally Roof or Superior: arching fibers of internal oblique and transversus abdominis Floor or Inferior: inguinal ligament and lacunar ligament FUNCTIONS OF INGUINAL CANAL - allows passage of structures to and from the testis to the abdomen in males or round ligament of uterus from uterus to labium major in females - transmits ilioinguinal nerve in both sexes

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arch so that the roof of the canal is lowered toward the floor and the canal is virtually closed

Hasselbachs Triangle most common site of the Hernia Boundaries: Superior side: Epigastric Vessels Medial side: Lateral border of the rectus sheath Inferior side: Inguinal Ligament HERNIA - protrusion of a viscus through an opening in the wall of the cavity in which it is contained - important features: hernial orifice and sac - hernial orifice: defect in the innermost aponeurotic layer of the abdomen - hernial sac: outpouch of the peritoneum can be internal or external INGUINAL HERNIA occurs above the inguinal ligament two types: direct and indirect

MECHANICS OF INGUINAL CANAL - site of potential weakness in both sexes - arching lowest fibers of internal oblique and trasnversus abdominis muscles contract during coughing and straining, which flattens out the

Indirect Inguinal Hernia - hernial sac is the remains of processus vaginalis - most common form of hernia; more common in males or females 7

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more common on the right side usually seen in children and young adults hernial sac enters the inguinal canal through deep inguinal ring and lateral to inferior epigastric vessels; neck is narrow hernial sac may extend through the superficial inguinal ring above and medial to pubic tubercle hernial sac may extend down to scrotum or labia majora

Direct Inguinal Hernia - common in elderly men with weak abdominal muscles sac bulges forward through the posterior wall of the inguinal canal medial to the inferior epigastric vessels neck is wide

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PERITONEUM - serous membrane lining the abdominal and pelvic cavities and clothing the viscera - may be regarded as a balloon into which organs are pressed into from the outside - parietal layer lines the walls of the abdominal and pelvic cavities - visceral layer covers the organs - potential space between the parietal and visceral layer is called peritoneal cavity *closed cavity in males only *communicates in the open in females through the fallopian tubes, uterus and vagina *Pringles Maneuver done to control bleeding, clamping of the vessel (not sureness, better check nalang) Peritoneal Cavity - divided into two parts: greater and lesser sac - greater sac: main component of the peritoneal cavity and extends from the diaphragm down into the pelvis - lesser sac: smaller and lies behind the stomach - greater and lesser sac communicates through the epiploic foramen or foramen of Winslow - peritoneum secretes a small amount of serous fluid, which lubricates the surfaces of the peritoneum and facilitates free movement between the viscera Boundaries of epiploic foramen - anteriorly: free border of lesser omentum, bile duct, hepatic artery and portal vein - posteriorly: inferior vena cava - superiorly: caudate process of the caudate lobe of the liver - inferiorly: first part of the duodenum

PERITONEAL LIGAMENTS, OMENTA AND MESENTERIES - permits blood, lymphatic vessels and nerves to reach the viscus Peritoneal Ligaments - two-layered folds of peritoneum that connect solid viscera to the abdominal walls eg. Liver is connected to diaphragm by the falciform ligament, coronary ligament, and right and left triangular ligaments Omenta - two-layered folds of the peritoneum that connect the stomach to another viscus - greater omentum connects the greater curvature of the stomach to the transverse colon; hangs down like an apron in front of the cells of the small intestines and is folded back in itself - lesser omentum suspends the lesser curvature of the stomach to the fissure of the ligamentum venosum and porta hepatis of the liver - gastrosplenic omentum (ligament) connects the stomach to the hilus of the spleen Mesenteries - two-layered folds of peritoneum connect parts of the intestines to the posterior abdominal wall eg. Mesentery of the small intestines, transverse mesocolon, sigmoid mesocolon *Ligament of Treitz fold found at the duodejejunal Junction which connects the small intestines to the posterior wall *White line of Toldt fold of the perineum at the paracolic gutter Lesser Sac - lies behind the stomach and lesser omentum

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extends upward as far as the diaphragm and downward between the layers of the greater omentum left margin is formed by the spleen, the gastrosplenic omentum, lienorenal ligament right margin of the sac opens into the greater sac through the epiploic foramen

PERITONEAL FOSSAE, SPACES AND GUTTERS Duodenal Fossae close to the duodenojejunal junction, there may be four small pouches of peritoneum called superior duodenal fossa, inferior duodenal fossa, paraduodenal fossa and retroduodenal fossa Cecal Fossae - folds of peritoneum close to the cecum produce three peritoneal fossa called the superior ileocecal, inferior ileocecal and retrocecal fossae Subphrenic Space - lies between the diaphragm and the liver and are called the right and left anterior and posterior subphrenic spaces are important since they may provide sites for the accumulation of pus Paracolic Gutter - lies on the lateral and medial sides of the ascending and descending colons respectively; provides channels for the movement of infected fluid in the peritoneal cavity NERVE SUPPLY OF THE PERITONEUM Parietal Peritoneum (for pain, temperature, touch and pressure) - supplied by the lower six thoracic and first lumbar nerves - parietal peritoneum in the pelvis is mainly supplied by the obturator nerve Visceral Peritoneum (for stretch only) - supplied by autonomic nerves that supply the viscera or are traveling in the mesenteries

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