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Anast

Ascending branch

of deep cir

ic a.

circumflex iliac a.

49 Anatomy oftheVentral Region

Axillary a.

497

Lateral thoracic a.

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 circumex 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 signicant 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.

Transverse muscle Muscle layers

Actions of the muscles Flexion of the trunk

Transverse muscle

49 Anatomy oftheVentral 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

External oblique

contraction

Internal oblique

contraction

500

Inclination of the trunkRotation of the trunk

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J. Loriau

Fig. 49.8 (continued)

49 Anatomy oftheVentral 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 45years old, it can reach 12–14mm above the umbilicus, 19–23mm at the level of the umbilicus, and 9–11mm 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

layer of

rectus sheath

Transversalis

fascia

Section below arcuate line

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 oftheVentral 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 ofWeakness

oftheVentral 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 orice are

503

highly variable, and even it has been described as measuring 2–8mm, 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 difcult 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

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 difcult 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

49 Anatomy oftheVentral 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 signicance 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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KarlA.LeBlanc

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 signicant 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 3cm, I will consider an open approach. If the hernia is greater than 3–4cm, 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

507

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