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Anast
Ascending branch
of deep cir
ic a.
circumflex iliac a.
49 Anatomy oftheVentral Region
Axillary a.
497
Lateral thoracic a.
Anterior
intercostal aa.
omoses with
lower intercostal,
subcostal, and
lumbar aa.
Transversus
abdominis m.
cumflex
iliac a
Superficial
circumflex iliac a.
Subclavian a.
Internal thoracic
aa.
Musculophrenic
aa.
Superior epigastric
aa.
Diaphragm
Transversus
abdominis m. and
aponeurosis
Rectus abdominis
mm.
External oblique m.
Posterior layer of
rectus sheath
Arcuate line
Inferior epigastr
Superficial
epigastric a.
Superficial
Fig. 49.5 Arteries and nerves network of the ventral region
from intercostal arteries, the lower part is supplied by arteries coming from deep circumex
iliac artery or the iliolumbar artery.
bers run opposite to the one from the external
oblique upward and forward. Its proximal insertions are on the medial two thirds of the iliac
crest, the aponeurosis of the lumbosacral muscle,
the anterosuperior iliac spine, the lateral third of
inguinal ligament, and the iliopsoas fascia. Its
cranial insertions stand on the lateral surface of
10th, 11th, and 12th ribs. It is of note that the
bers of the internal oblique coming for its
medial pelvic insertions participate to the forma-
As the upper part of the muscle receives blood
The internal oblique is the second layer. Its
tion of the conjoint tendon and that the cremaster
muscle is composed by the lower bers of the
internal oblique muscle (see anatomy of the
inguinal region chapter). Internal oblique plays a
major role in the constitution of the rectus sheath
(see below).
Even if its bers’ direction is opposite to the
ones of the external oblique, its contraction also
results in pulling down the ribs. But in case of
unilateral contraction of the muscle, the thorax is
attracted to the side of contraction and rotates.
The muscle is innervated by branches from
lower intercostal nerves (upper part) and iliohypogastric and ilioinguinal nerves (lower part).
Blood supply comes from subcostal arteries.
498
Cremaster
fibers
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Cranial
insertion
Distal
insertion
Pubic
spine
Fig. 49.6 Internal oblique muscle insertions. 1 cranial inser-
tion, 2 distal insertion, 4 pubic spine, 5 and 6 cremaster bers
The transverse muscle (transversus abdomi-
nis muscle) is the deepest at muscle of the
abdominal wall. As its direction is horizontal, it
can be described as caudally inserted on ve
transverse apophyses and ending medially as an
aponeurosis contributing to the rectus sheath (see
J. Loriau
below). Cranially, the transverse is inserted on
the internal face of the 7th to 12th ribs cartilage.
Those six palms are entwined with the other ones
coming from the diaphragm insertion. Caudally,
it is inserted on the two anterior thirds of the iliac
crest and the external third of the inguinal ligament and iliac fascia. At that part, bers contribute with one from the internal oblique to the
conjoint tendon formation. It also contributes to
the cremaster muscle (see above).
Transverse muscle is innervated by both lower
intercostal nerves (thoracic nerve roots T7–T11)
and iliohypogastric and ilioinguinal nerves.
Blood supply comes from subcostal arteries.
The transverse muscle is known as the “corset
muscle.” Acting like a horizontal muscular belt,
the transverse compresses the visceras inside the
abdomen and stabilizes together the pelvis, spine,
and thoracic chest. This action is particularly signicant during lifting efforts but also in expiration
or during birth giving. The transverse is therefore
the most antagonist of the diaphragm. Even if its
role in back pain occurrence is debated, its action
in releasing pressure on the vertebral discs by its
contraction in lifting efforts is well recognized [4].
For the surgeon, performing a midline incision “opens” the transverse muscle belt and
impaired highly respiration movements. In the
mechanism of incisional hernia occurrence,
transverse retraction attracts laterally the rectus
muscle impairing both its function and enlarging
the incisional hernia gap.
m
l
Transverse muscle Muscle layers
Actions of the muscles Flexion of the trunk
Transverse muscle
49 Anatomy oftheVentral Region
499
Sternum
Light.
lombocostal
de henle
Tendinous
inscriptions
Rectus abdominis
Sheath of rectus
(its posterior
lamella)
Linea alba
Pyramidalis
Pubis
Fig. 49.7 Transverse muscle insertions and position of the muscles
5th
6th
7th
8th
9th
10th
11th
12th
Lumbodorsa
fascia
Crest of iliu
Inguinal ligament
Falx inguinalis
Fig. 49.8 Green line transverse muscle contraction, blue line external oblique contraction, red line internal oblique
contraction
a
contraction
External oblique
contraction
Internal oblique
contraction
b
500
Inclination of the trunkRotation of the trunk
cd
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J. Loriau
Fig. 49.8 (continued)
49 Anatomy oftheVentral Region
501
As all the at muscles of the abdominal
wall are “connected” together at the midline as they contribute to the rectus sheath
formation, they act synchronously to allow
thoracoabdominal movements.
Rectus Sheath and Linea Alba: The central
point of the ventral region
Stretched from the xiphoid appendix to the
pubis, the rectus runs vertically wrapped in
a close aponeurotic sheath.
This structure is a complex network of
collagen tissues formed by the aponeurosis
of the at muscles (external oblique, internal oblique, transverse).
The external oblique aponeurosis constantly passes in front of the rectus muscles, composing the anterior lamina of the
sheath. Fibers from both sides are arranged
in a chevron pattern responsible for the
solidity of the lamina.
The internal oblique and transverse aponeurosis don’t behave that constantly and
lead to distinguish different area cranial to
caudal.
The internal oblique aponeurosis (from
about hallway between xiphoid and umbilicus) splits its bers in an anterior and a
posterior layer. The anterior layer joins the
bers of the external oblique in front of
rectus muscle to constitute the anterior
lamina. But some centimeters below the
umbilicus, there is no split in the bers, and
all the aponeurosis of the internal oblique
join the external oblique and transverse
aponeurosis in constituting the anterior
sheath. Below this level, one should understand that there is no more posterior layer
of the sheath (can we still call it a sheath!)
and that all the at muscle aponeuroses
have joined themselves to constitute the
anterior lamina.
The transverse muscle aponeurosis also
behaves differently from cranial to caudal.
Cranially the bers constantly remains posterior to the rectus and constitutes the deep
layer of the sheath, but at a variable level
some centimeters below the umbilicus,
they go anteriorly will all other at muscle
aponeurosis.
This level where “everything changes”
is known as the arcuate line (see below).
Another point of interest is the lateral
margin of the rectus sheath, where lateral
muscles aponeurosis joins themselves.
Indeed from costal edge to pubis, the muscle aponeurosis doesn’t join on a vertical
line due to different myoaponeurotic
boundaries. But the shape of that junction
can be described as a medially concave line
running at the lateral edge of the rectus
muscle and called Semilunar or Spigelius
line.
The surgeon has to know that this area
is crossed by various nerves and pedicles
and that entering or dividing it can be
hazardous and provide unexpected
damage.
On the opposite side of the rectus muscle, medially, the muscles are joined
together by a solid brous structure called
the Linea Alba. It is made of collagen connective tissue coming from the aponeurosis
of all the at muscles. Its length and breadth
is highly variable between people, but the
breadth is constantly higher below the
umbilicus than under where rectus muscles
can be joined together or joined by the
pyramidal muscle. The breadth of the linea
alba enlarges with age, and, for example,
after 45years old, it can reach 12–14mm
above the umbilicus, 19–23mm at the level
of the umbilicus, and 9–11mm below the
umbilicus. If the distance exceeds this
ranges, diagnosis of rectus diastasis should
be considered [5].
502
Transverse muscle
Epigastric
nal abdominal
Section above arcuate line
int
fold
J. Loriau
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Rectus
abdominis
muscle
Posterior
layer of
rectus sheath
Rectus
abdominis
muscle Skin
Urachus
(in median
umbilical fold)
Linea
alba Skin
Falciform
ligament
Umbilical
prevesical
fascia
Subcutaneous
fat (superficial
fascia)
ligament and
Aponeurosis of
internal abdominal
oblique muscle
Aponeurosis of
transversus
abdominis muscle
Peritoneum
Aponeurosis of
ernal abdominal
oblique muscle
Aponeurosis of
transversus
abdominis muscle
Peritoneum
Aponeurosis of
external abdominal
oblique muscle
Extraperitoneal
(subserous) tissue
Aponeurosis of
external abdominal
oblique muscle
Extraperitoneal
(subserous) tissue
Anterior
layer of
rectus sheath
Transversalis
fascia
Section below arcuate line
Anterior
layer of
rectus sheath
Transversalis
fascia
Fig. 49.9 Sectional view of the ventral region above and below the arcuate line
Medial
umblical
Exter
oblique muscle
Internal abdominal
oblique muscle
Transversus
abdominis muscle
Subcutaneous fat
(superficial fascia)
External abdominal
oblique muscle
Internal abdominal
oblique muscle
Transversus
abdominis muscle
Fig. 49.10 Points of
weakness of the ventral
region
Linea alba
Semilunar line
Douglas’ arch or
semicircular line
Internal oblique
muscle
Aponeurosis of
external oblique
muscle
(fascia and
aponeurosis)
Umbilical
Spigelian
49 Anatomy oftheVentral Region
The Arcuate Line (Semi Circular Line of
Douglas)
The lower third of the rectus muscle is not
contained in a circumferential sheath but only
cover by an anterior layer composed by internal oblique muscle aponeurosis (see above).
This means that the posterior lamina of
the sheath ends upper than the anterior one
leaving the deeper face of the rectus muscle
only covered by the transversalis fascia.
This end or limit of the posterior lamina
located about halfway (or upper third)
between the pubis and the umbilicus forms
a semicircular line called the Douglas line.
Its exact level is highly variable, and moreover the arcuate line is inconstant [6].
The existence of the arcuate line can limit
the lateral access to the Space of Bogros and
Retzius in case of retrorectus dissection; thus,
it might be necessary to release its lateral
attachment to enlarge the dissected space. In
that dissection, be aware of discriminating the
arcuate line from the peritoneal edge.
49.2 Points ofWeakness
oftheVentral Region
As the solidity of the ventral region is a result of
muscle and aponeurotic crossing, areas of weakness take place where this crossing process is less
effective or absent.
For that reason at the umbilicus, the Spigelian
line below the arcuate line and the linea alba of
the ventral wall offers possible exit doors.
– Umbilical Frailty
Once you look at the linea alba, you can
divide it by 100, and then starting at the top,
count to the 56 to reach the umbilicus (Testut
1896)! In case of three transversal tendinous
intersections on the rectus, it is usually the
level of the lower one.
The umbilicus is a cicatricial whole in the
linea alba. The size and shape of that orice are
503
highly variable, and even it has been described as
measuring 2–8mm, it can be totally occluded as
age advances.
At the umbilicus, the peritoneum is only separated from the subcutaneous tissues by the umbilical fascia. Inconstant and only present in about
two thirds of cases, the fascia consists in a reinforcement of the transverse aponeurosis (constituting the linea alba). But even when present, its
location and connections with the umbilical
brous ring might not or only partially cover the
surface of weakness of the ring. This might predispose to umbilical hernia occurrence.
Some brous structures also contribute to
“close” the umbilical ring. The round ligament
of the liver divided its self at the top in two cords
that are inserted on the umbilical ring. At its
umbilical insertion, the round ligament of the
liver is rather gurative and provides poor solidity. On the opposite side, the urachus is supposed
to end at the bottom of the umbilical ring. Indeed,
when present (one out of three patients), the
urachus ends before reaching the umbilical ring
and splits in brous stripes. These bers join the
one coming from the umbilical artery that run
downward laterally in a brous network of poor
solidity. The presence of the arteries also
strengthens a little the area, but nevertheless, this
solidity remains actually poor allowing hernia
formation. Due to the adherence of the peritoneum to the umbilical ring, it might be difcult
to divide them in order to place a pre-peritoneal
mesh in order to cure an umbilical hernia.
– Linea Alba
Also called “epigastric hernia,” there might
be a defect inside the aponeurotic bers constituting the linea alba. Inside the medial solid
insertion of the at muscles, some bers can be
spread allowing fatty tissues to protrude
through that whole. This occurrence is only
possible between the umbilicus and the xiphoid
process. Under the umbilicus, the rectus muscles are close from each other enough to avoid
this opportunity.
One must warmly be aware that this is
totally different from diastasis recti. Diastasis
504
Aponeurosis of
h
abdominis m.
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J. Loriau
recti consists of an enlargement of the linea
alba that is stretched but remains totally continuous. Surgical options are debated elsewhere but as there’s no whole in the linea alba,
there cannot be strangulation! In other terms,
diastasis recti is never a life-threatening disease, and surgery (plastic surgeon? Hernia surgeon?) must be wisely selected.
– Spigelian Hernia
• Lateral to the rectus muscle, the semilunar
line (Spigelian line), the lateral muscles
have joined bers in an aponeurotic fascia in
which bers are going to constitute the rectus sheath. This vertical band as it is not covered by muscular structures is a site of
possible weakness. This is particularly true
below the arcuate line where the boundaries
of the rectus and lateral muscles are more
distant delimitating a weak area just above
the inguinal region (about 90% of Spigelian
hernia). As they cross the area from the midline, the inferior epigastric vessels don’t
give any additional solidity to that region. As
in this kind of hernia, the sac can stay for a
long time “intraparietally” and if there,
doesn’t approach the subcutaneous tissue, it
might stay for a long time asymptomatic,
which is difcult to diagnose. Indeed, A.Van
der Spiegel described the semilunar line in
1645, but Josef Klinkosch described this
kind of hernia in 1764. It is of note that this
can of defect has been described as possibly
associated with ipsilateral cryptorchidism
and testis malposition in Spigelian-
cryptorchidism syndrome and Raveenthiran
syndrome [7, 8].
external oblique m.
Fig. 49.11 Spigelian
Hernia
Internal
oblique m.
Transversus
Skin
Fat
Anterior
rectus sheat
Rectus
abdominis m.
Transversalis
fasica
Peritoneum
e
49 Anatomy oftheVentral Region
Fig. 49.12 Spigelian
line. Green line internal
oblique body edge,
yellow line transverse
muscle body edge, red
curve external oblique
body edge
505
Constitution
of semi lunar lin
Transverse muscle
body edge
Internal oblique
body edge
External oblique
body edge
Surgical take-home message about the
anatomy of ventral region
– The anterior muscles aren’t only com-
ponents of a barrier but play an irreplaceable role in many vital actions like
breathing, standing, and laughing!
– Opening the “transverse belt” by mak-
ing midline incision is an important
issue due to the consequences that can
ensue from it.
– Knowing the precise “architecture” of
the linea alba and muscle fascia is mandatory for a surgeon who planes com-
plex abdominal wall reconstruction.
– Diastasis recti is not a hernia!
– Whether the way you approach the
abdominal wall laparoscopically for
TEP hernia repair or open for retromus-
cular repair, the arcuate line is a frontier
between two spaces you’ll have to con-
References
1. Dickson MJ. The pyramidalis muscle. J Obstet
Gynaecol. 1999;19(3):300.
2. Anson BJ, Beaton LE, McVay CC. The pyramidalis
muscle. Anat Rec. 1938;72:405–11.
3. Tokita K.Anatomical signicance of the nerve to the
pyramidalis muscle: a morphological study. Anat Sci
Int. 2006;81(4):210–24.
4. Hodges PW, Richardson CA. Contraction of the
abdominal muscles associated with movement of the
lower limb. Phys Ther. 1997;77(2):132–42.
5. Chevrel JP. Hernias and surgery of the abdominal
wall. 2nd ed. Berlin: Springer; 1998. p.22–3.
6. Mwachaka PM, Saidi HS, Odula PO, Awori KO,
Kaisha WO.Locating the arcuate line of Douglas: is
it of surgical relevance? Clin Anat. 2010;23(1):84–6.
https://doi.org/10.1002/ca.20877.
7. Rushfeldt C, Oltmanns G, Vonen B. Spigeliancryptorchidism syndrome: a case report and discussion of the basic elements in a possibly new congenital
syndrome. Pediatr Surg Int. 2010;26(9):939–42.
8. Raveenthiran V. Congenital Spigelian hernia with
cryptorchidism: probably a new syndrome. Hernia.
2005;9(4):378–80.
sider and deal with.
Umbilical Hernia Repair
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KarlA.LeBlanc
50
50.1 Introduction
The repair of hernias at the umbilicus has undergone a multitude of changes over the years. Most
surgeons have heard of the “pants over vest”
repair that was described in the early 1900s.
Numerous other techniques have been described
since then. More recently, the use of a prosthetic
material has nearly become the standard of treatment in most areas of the world. While the choice
of mesh is relegated to the surgeon, this chapter
will detail the various techniques for this
operation.
In general, the results obtained in repairing
these hernias have demonstrated that the use of a
mesh of some type has improved results [1–4].
Because of the universal fact that the population
of the world has grown much larger and heavier,
this should not be unexpected. However, there are
papers that contradict this statement [5]. A recent
consensus conference has even opined that the
ventral hernias in patients with a body mass index
of greater than 50 should have surgery delayed
until weight loss has lowered the BMI [6]. This,
of course, is not always practical in symptomatic
patients, but this reinforces the concept that morbid obesity is a signicant risk factor.
K. A. LeBlanc, MD, MBA, FACS, FASMBS
Associate Medical Director, Our Lady of the Lake
Physician Group, Baton Rouge, LA, USA
In general, I prefer to limit the tissue repair to
normal weight, thin individuals with smaller
defects. In the heavier patients (BMI>30), I usually prefer to use the laparoscopic/robotic
approach. However, if the BMI is under 35 in
patients with defects less than 3cm, I will consider an open approach. If the hernia is greater
than 3–4cm, the minimally invasive approach is
preferred in my hands regardless of weight.
These are general guidelines and each patient and
hernia will need to be individualized.
All patients are placed under general endotracheal anesthesia. Nasogastric and bladder catheterization are not required in most cases. In most
cases, it is important to have the patient cleanse
the umbilical area prior to surgery. This will
apply to the non-open repairs should the need
arise to convert to open, and most often a central
positioning suture is used in the robotic repair.
50.2 Open Repair
The patients are prepped and draped to provide
an adequate amount of exposure of the abdominal wall. A curvilinear incision can be made
either supraumbilically or subumbilically. I prefer the former. Dissection will continue to expose
the entire fascial defect and an appropriate
amount of adjacent fascia. Management of the
hernia sac varies according to the size and thickness of the tissue. An attempt to keep the sac
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_50
507
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