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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_718_Библиотеки_им_академика_М_И_Перельмана
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5.The inguinal cutaneous fold (The inguinal skin crease):
Separating the anterior abdominal wall from the anterior surface of the thigh.
The surgical significance of the inguinal skin crease, that it is the projection of the inguinal
ligament.
Fig 9: The inguinal skin crease. Source [9].
The anterior abdominal wall consists of seven layers; from superficial to deep as follows:
1.Skin.
2.Superficial Fascia.
3.External oblique muscle.
5.Transversus abdominis muscle.
6.The transversalis fascia.
7.The Parietal peritoneum.
4.Internal oblique muscle.
Fig. 10: Layers of the anterolateral abdominal wall. Source [10].
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1. Skin.
The skin covering the anterior abdominal wall is relatively thin, relatively elastic, could be folded,
and relatively mobile except for the umbilical skin which it is fixed.
Kraissl’s lines; neutral elastic traction lines of the skin (also known as skin tension lines) allow
distention of the anterior abdominal wall during pregnancy and obesity.
Surgical incisions done along or parallel to these lines tend to heal with minimal scarring on the
contrary to surgical incisions that cut through these lines which result in the widening of the scars.
2. Superficial Fascia.
The composition of this layer depends on its location:
Above the umbilicus – a single sheet of connective tissue. It is continuous with the superficial
fascia in other regions of the body.
Below the umbilicus – divided into two layers.
1.The superficial fatty layer - superficial layer (Camper’s fascia).
Superficial Camper’s fascia, which is a thicker fatty layer that can have a variable degree of
thickness. For example, it is greatly increased in obese individuals and very thin in people with
low body fat.
In men, the Camper’s fascia continues over the penis and blends with the Scarpa’s fascia to form
the superficial fascia of the penis.
In women it continues into the labia majora and anterior perineum.
2.The membranous deep layer (Scarpa’s fascia).
Deep Scarpa's fascia, which is a thinner and denser membranous layer overlying the muscle layer
of the abdominal wall.
Superiorly, crosses the costal margin to become continuous with the retromammary fascia.
Inferiorly, it crosses over the inguinal ligament to be blinded with the deep fascia of the thigh of
about 1 cm distal to the inguinal ligament, then prolong below the level of the pubic symphysis to
become quietly districted into the scrotum (becomes the dartos fascia) and the penile shaft to be
known as Colle’s fascia (superficial perineal fascia) in males, however, such a prolongation is less
demonstrable in female’s perineum.
Laterally, it fades out at the mid-axillary line.
CLINICAL NOTE: There is no deep fascia in the anterior abdominal wall
expansion during respiration and pregnancy.
to
allow abdominal
The differences between superficial and deep layers of the superficial abdominal fascia (table 1):
1. Thickness. Thick. Thin.
2. Texture. Fatty. Membranous
3. Consistency. Adipose tissues. Elastic tissues.
Superficial layer
(Fascia of Camper) (Fascia of
Thomson's)
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Deep Layer
(Fascia of Scarpa)
4.Attachments. 1.Inguinal ligament.
2.Superficial fascia of the thigh.
3.Root of the penis and outer the
surface of the spermatic fascia over
the scrotum; sharing in the dartos m.
in males.
4.Labia majora in females.
1.Fascia Lata of the thigh below the
inguinal ligament.
2.Aponeurosis of the external oblique
muscles.
3.Linea alba.
4.Symphsis pubis.
5.Dorsum of the penis, scrotum
sharing the dartos m. in males.
6.Labia majora in females.
7.Superficial fascia of the trunk.
The three overlapping flat sheet-like muscles forming the anterior abdominal wall are: outer
external oblique, middle internal oblique and an inner transversus abdominis, which are
aponeurotic anterolaterally, while medially these aponeuroses fuse together in the midline at the
Linea alba to form the rectus sheath.
3. External oblique muscle.
Origin:
From the outer surface of the 5th-12th ribs, which is interdigitated with serratus anterior muscle.
Direction of fibers:
Its fibers descend infromedially downwards.
Insertion:
To the Linea alba, pubic tubercle and the anterior half of the iliac crest.
Nerve supply:
Lower six intercostal nerves T6-T12.
Iliohypogastric nerve (L1) and the ilioinguinal nerve (L1)
Action.
Contralateral rotation of the trunk.
Blood supply.
Lower posterior intercostal arteries, subcostal arteries and deep circumflex iliac artery.
Fig. 11: External oblique muscle. Source [11].
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4. Internal oblique muscle.
Origin:
Thoracolumbar fascia, anterior iliac crest, lateral two-thirds of the inguinal ligament.
Direction of fibers:
Its fibers ascend superolaterally (opposite to the direction of the fibers of the external oblique).
Insertion:
To the external surface of the 10th-12th ribs, Linea alba and the pubic crest via the conjoint tendon.
Nerve supply:
Intercostal nerves (T7-T1)
Subcostal nerve (T12).
Iliohypogastric nerve (L1) and the ilioinguinal nerve (L1).
Action:
Bilateral contraction compressing the abdomen while bilateral contraction ipsilaterally rotates the
trunk.
Blood supply:
Lower posterior intercostal, subcostal arteries, superior and inferior epigastric arteries, superficial
and deep circumflex arteries, posterior lumbar arteries.
Fig. 12: Internal oblique muscle. Source [12].
5. Transversus abdominis muscle.
Origin:
1. lateral one third of the inguinal ligament.
2. Anterior 2/3 of the inner lips of the iliac crest.
3. Thoracolumbar fascia, between the iliac crest and the 12
th
rib.
4. Internal aspect of the lower 6 ribs and their costal cartilages.
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Direction of fibers:
Runs horizontally towards the midline, perpendicular to the Linea alba.
Insertion:
1.joins the aponeurosis of the internal oblique forming the conjoined tendon.
2.Linea alba.
3.Pubic crest.
4.Pectineal line of pubis.
Nerve supply.
Lower 5 intercostal nerves, subcostal nerve.
Ilioinguinal n. (L1) and Iliohypogastric n. (L1).
Blood supply:
Lower posterior intercostal, subcostal, superior and inferior epigastric a., superficial and deep
circumflex iliac a. and posterior lumbar arteries.
Actions:
1.Abdominal tension.
2.Increase IAB.
3.Support the trunk.
4.Unilateral action, ipsilateral trunk rotation
Fig. 13: Transversus abdominis muscle. Source [13].
6. The transversalis fascia.
Superiorly, continuous with the inferior diaphragmatic fascia.
Posteriorly, continuous with the thoracolumbar fascia.
Inferiorly, continuous with to the iliac crest and posterior margin of the inguinal ligament by a
fibrous tissue that forms the iliopubic tract,
Medially, to the femoral vessels it attaches to the pubis and pectineal line where it descends and
forms the anterior part of the femoral sheath.
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It is pierced by the deep inguinal ring which conduct the spermatic cord in males and round
ligament in females.
Fascia transversalis is the posterior cover of the rectus abdominis muscle as the rectus sheath
passes Infront of the rectus abdominis, at the arcuate line below the umbilicus.
CLINICAL NOTE: Surgeon’s debate about the proper anatomical planes for dissection and mesh
placement truly preperitoneal, pre-fascial or inter-fascial during laparoscopic hernia repair, thus
complicates the performance and accurate discrimination between total extraperitoneal preperitoneal (TAP/TEPP) hernioplasty because of the inadequate understanding of extra-peritoneal
anatomy & improper dissection, which is the surgical significance of transversalis fascia.
Fig. 14: Abdominal fasciae. Source [14].
7. The Parietal peritoneum.
The parietal peritoneum is the inner most layer of the anterior abdominal wall.
Is derived from the somatic mesoderm.
15
The parietal peritoneum extends to:
1. Superiorly, diaphragm
2. Posteriorly, the retroperitoneal cellular space.
3. Anteriorly, the anterior abdominal wall.
4. Inferiorly, inguinal ligament.
CLINICAL NOTE: During laparoscopic hernia repair the parietal peritoneum is a landmark when
deciding to perform laparoscopic approaches either transabdominal pre-peritoneal (TAPP) or total
extra pre-peritoneal (TEPP), where it is penetrated in the first and conserved in the second
technique respectively, this fact to be considered as the surgical significance of the parietal
peritoneum in hernial surgery.
¾ Blood supply of the anterolateral abdominal wall:
A) Arterial supply:
From the iliac, lumbar, epigastric, and intercostal arteries.
Fig. 15: Arterial blood supply of the anterolateral abdominal wall. Source [15].
B) Venous drainage:
By corresponding veins to the inferior vena cava.
¾ Lymphatic drainage of the anterolateral abdominal wall:
A) Superficial lymphatics:
Above the umbilicus, pass superiorly to the axillary nodes.
Below the umbilicus, passes inferiorly to the superficial inguinal nodes.
B) Deep lymphatics:
Drainage follows the deep arteries back to parasternal nodes along the internal thoracic artery,
lumbar nodes along the abdominal aorta, and external iliac nodes along the external iliac artery.
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¾ Somatic innervation of the anterolateral abdominal wall:
Is from spinal nerves (T10 - L1) allowing pain and temperature localization.
Fig. 16: Venous and lymphatic drainage of the anterolateral abdominal wall. Source [16].
Fig. 17: Cutaneous innervation of the anterolateral abdominal wall. Source [17].
17
The rectus abdominis muscle:
Is a strap-like muscle which is enclosed within the rectus sheath alongside the midline together
with the superior and the inferior epigastric vessels and the anterior rami of (T7-T12).
Origin: From the xiphoid process and the 5th, 6th and 7th costal cartilages.
Direction of fibers: Runs downwards.
Insertion:
To the anterior layer of the rectus sheath by three tendinous intersections; situated at the xiphoid
process, the umbilicus and midway in-between them- to be attached distally to the pubic symphysis
and pubic crest.
Nerve supply: Anterior rami of the lower intercostal nerves T7-T12.
Actions:
1.Stabilization and flexion of the trunk and spine.
2.Bending forward, lifting hips, and stabilization of movement through the entire body through a
variety of movements.
3.Works closely with internal oblique and external oblique, lower back, and hip flexors to hold the
spine in an upright posture.
4.Help to transfer force between our upper and lower body.
5.Involved in Abdominal Bracing, which occurs in most exercises that are focused on increasing
muscle mass and strength.
The pyramidalis muscle (musculus pyramidalis):
Pyramidalis is a paired triangular muscle of the anterior abdominal wall found on each side of the
linea Alba, and it can be absent in approximately 20% of the population.
Origin: From the pubic symphysis (ligamentous fibers) and pubic crest (tendinous fibers).
Course: The muscle belly narrows as it courses superiorly.
Insertion: To the Linea alba, midway between the umbilicus and pubis.
Nerve supply: The anterior ramus of spinal nerve (T12).
Function:
The defined function of pyramidalis muscle is vague, however, erection of the penis or
assumptions of upright posture in humans are related to pyramidalis muscle.
Fig. 18: Muscles of the anterolateral abdominal wall. Source [18].
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The rectus sheath:
The medial flat tendon of the external oblique muscle “aponeurosis” forms the anterior part of the
rectus sheath, while the inferior part is stretched between iliac crest and pubic tubercle is rolled
and thickened forming the inguinal (Poupart's) ligament, from which arises the proper fascia of
the thigh “fascia Lata”.
Form the internal border of the inguinal ligament, fibers of the external obliques aponeurosis split
into 2 crura; lateral, which is attached to the pubic tubercle and the medial which is attached to the
symphysis pubis, in-between them is formed the internal (deep)inguinal ring.
Below, runs 2 nerves; Iliohypogastric n.; pierces the muscular fibers of the muscle and branches
off in the S.C tissue of the inguinal and pubic regions and the ilioinguinal nerve, enters the inguinal
canal through deep ring and after leaving the canal becomes superficial and innervates the skin of
the scrotum or labia pudenda magnae.
The internal oblique splits into 2 laminae; anterior and posterior enveloping the rectus abdominis
muscle, thus share in the rectus abdominis sheath at its upper two thirds, while in the lower third
it takes part only anteriorly.
¾ The anterior lamina.
1. External abdominis aponeurosis; whole length.
2. External & Internal abdominis aponeurosis; upper two thirds.
3. All aponeurosis; lower third.
¾ The posterior lamina.
1. Internal and transversus oblique aponeurosis; upper two thirds.
2. All aponeurosis; lower third.
Fig. 19: The rectus sheath. Source [19].
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