anatomy of the anterior abdominal wall2 (edited)

Anatomy of the Anterior Anatomy of the Anterior Abdominal WallAbdominal Wall

Dr Leroy CampbellDr Leroy Campbell

Embryological developmentEmbryological developmentAnatomical features of anterior Anatomical features of anterior

abdominal wallabdominal wallRelationship between structure and Relationship between structure and

functionfunctionClinical and surgical relevanceClinical and surgical relevance

DiseaseDiseaseCongenital or acquiredCongenital or acquired

incisionsincisions

Embryology of the Embryology of the anterior abdominal wallanterior abdominal wall

During the 4th to 5th week of During the 4th to 5th week of development, the flat embryonic development, the flat embryonic disk folds in four directions disk folds in four directions and/or planes:and/or planes:CephalicCephalicCaudalCaudalRight lateralRight lateralleft lateral left lateral

1.1. Amniotic cavityAmniotic cavity

2.2. EctodermEctoderm

3.3. Umbilical vesicleUmbilical vesicle

4.4. EndodermEndoderm

5.5. Body stalkBody stalk

6.6. AllantoisAllantois

7.7. Extraembryonic mesodermExtraembryonic mesoderm

8.8. Cloacal membraneCloacal membrane

9.9. Notochordal processNotochordal process

10.10. Primitive streakPrimitive streakShrinking Primitive streakShrinking Primitive streak

11.11. Neural plateNeural plateNeural foldsNeural folds

14.14. notochord notochord 20.20. Fused neural tubeFused neural tube

Septum transversum Septum transversum

29.29. AortasAortas30.30. Umbilical veinsUmbilical veins

31.31. Intraembryonic mesodermIntraembryonic mesoderm

32.32. Paraxial mesodermParaxial mesoderm

33.33. Intermediate mesodermIntermediate mesoderm

34.34. Lateral plate mesodermLateral plate mesoderm

35.35. Canalis centralisCanalis centralis

36.36. SomiteSomite

37.37. Nephrogenic cord Nephrogenic cord

Each fold converges at the site of the umbilicus. Each fold converges at the site of the umbilicus. The lateral folds form the lateral portions of the The lateral folds form the lateral portions of the

abdominal wallabdominal wall lateral abdominal wall lateral abdominal wall future umbilical ring future umbilical ring

cephalic and caudal folds make up the epigastrium cephalic and caudal folds make up the epigastrium and hypogastrium :and hypogastrium : Cephalic Cephalic

Anterior Anterior Contains: Contains:

foregut foregut stomach stomach mediastinal/thoracic contents mediastinal/thoracic contents

Caudal: Caudal: Posterior Posterior Contains: Contains:

colon colon rectum rectum bladder bladder

Rapid growth of the intestines and liver Rapid growth of the intestines and liver also occurs. also occurs. During the 6th week of development (or During the 6th week of development (or

eight weeks from the last menstrual eight weeks from the last menstrual period), the abdominal cavity temporarily period), the abdominal cavity temporarily becomes too small to accommodate all of becomes too small to accommodate all of its contentsits contents

resulting in protrusion of the intestines into the resulting in protrusion of the intestines into the residual extraembryonic coelom at the base of residual extraembryonic coelom at the base of the umbilical cord. the umbilical cord.

This temporary herniation is called This temporary herniation is called physiologic midgut herniation (PMH) physiologic midgut herniation (PMH) and is sonographically evident between and is sonographically evident between the 9th to 11th postmenstrual weeks. the 9th to 11th postmenstrual weeks.

Dy 41- physiologic umbilical Dy 41- physiologic umbilical herniahernia

Dy 53Dy 53

Reduction of Reduction of this hernia this hernia occurs by the occurs by the 12th 12th postmenstrual postmenstrual week.week.

Congenital Abdominal Congenital Abdominal Wall DefectsWall Defects

Omphalocele/ExomphalosOmphalocele/Exomphalos:: Congenital herniation of abdominal contents at the umbilicus (i.e. into the umbilical cord). Congenital herniation of abdominal contents at the umbilicus (i.e. into the umbilical cord).

Occasionally divided into: Occasionally divided into: <4cm - umbilical cord hernia <4cm - umbilical cord hernia >4cm - omphalocele. >4cm - omphalocele.

Rarely occurs above or below umbilicus.Rarely occurs above or below umbilicus. Amniotic sac (amnion & peritoneum) is Amniotic sac (amnion & peritoneum) is alwaysalways present but it may have ruptured at or before present but it may have ruptured at or before

birth exposing the contents.birth exposing the contents.

Gastroschisis:Gastroschisis: Full thickness abdominal wall defect Full thickness abdominal wall defect situated almost always to the situated almost always to the right right of the umbilicus of the umbilicus without without a covering membrane. a covering membrane. A bridge of skin separates it from the umbilicus.A bridge of skin separates it from the umbilicus.

Prune Belly Syndrome: Prune Belly Syndrome: Congenital deficiency of abdominal musculature, urinary tract dilatation and cryptorchidism. Congenital deficiency of abdominal musculature, urinary tract dilatation and cryptorchidism. There are three grades: There are three grades:

I. Severe renal and pulmonary disease incompatible with life. I. Severe renal and pulmonary disease incompatible with life. II. Severe uropathy requiring extensive reconstruction. II. Severe uropathy requiring extensive reconstruction. III. Healthy neonates requiring little or no surgery.III. Healthy neonates requiring little or no surgery.

Others:Others: e.g. Bladder extrophy.- defect in caudal fold e.g. Bladder extrophy.- defect in caudal fold

Omphalocele Omphalocele

gastroschisisgastroschisis

Prune BellyPrune Belly

Bladder extrophyBladder extrophy

Anatomy Anatomy

Anterior abdominal wallAnterior abdominal wall

The anterior abdominal The anterior abdominal wall extends from the wall extends from the costal margins and costal margins and xiphoid process xiphoid process superiorly to the iliac superiorly to the iliac crests, pubis and pubic crests, pubis and pubic symphysis inferiorly.symphysis inferiorly.

It overlaps and is It overlaps and is connected to both the connected to both the posterior abdominal posterior abdominal wall and paravertebral wall and paravertebral tissues.tissues.

It forms a continuous but flexible It forms a continuous but flexible sheet of tissue across the anterior sheet of tissue across the anterior and lateral aspects of the abdomen. and lateral aspects of the abdomen.

The anterior abdominal wall is The anterior abdominal wall is composed of:composed of: the integumentthe integumentMusclesMusclesconnective tissue lining the peritoneal connective tissue lining the peritoneal

cavity. cavity.

skin skin

non-specializednon-specializedvariably hirsutevariably hirsute

depending on the sex and race. depending on the sex and race. All individuals have some extension of the All individuals have some extension of the

pubic hair onto the anterior abdominal pubic hair onto the anterior abdominal wall skinwall skin

this is commonly most pronounced in this is commonly most pronounced in males, in whom the hair may extend males, in whom the hair may extend almost up to the umbilicus in a triangular almost up to the umbilicus in a triangular pattern. pattern.

Subcutaneous tissueSubcutaneous tissue

The subcutaneous tissue over most of the The subcutaneous tissue over most of the wall includes a variable amount of fat. wall includes a variable amount of fat.

It is a major site of fat storage. It is a major site of fat storage.

Males are especially susceptible to Males are especially susceptible to subcutaneous accumulation in the lower subcutaneous accumulation in the lower anterior abdominal wall and may have anterior abdominal wall and may have

disproportional amounts of fat here while disproportional amounts of fat here while having more normal amounts elsewhere.having more normal amounts elsewhere.

Subcutaneous tissueSubcutaneous tissue

Inferior to the umbilicus, the deepest part Inferior to the umbilicus, the deepest part of the subcutaneous tissue is reinforced by of the subcutaneous tissue is reinforced by many elastic and collagen fibers, so the many elastic and collagen fibers, so the subcutaneous tissue here has two layers:subcutaneous tissue here has two layers:

a superficial fatty layer (Camper fascia) a superficial fatty layer (Camper fascia) a deep membranous layer (Scarpa fascia)a deep membranous layer (Scarpa fascia)

It is loosely connected by areolar tissue to the It is loosely connected by areolar tissue to the aponeurosis of external oblique, but in the aponeurosis of external oblique, but in the midline it is intimately adherent to the linea midline it is intimately adherent to the linea alba and symphysis pubis.alba and symphysis pubis.

the anterolateral muscles of the the anterolateral muscles of the abdomen (five pairs):abdomen (five pairs):

Vertical Vertical 1.1. Rectus abdominisRectus abdominis

2.2. PyramidalisPyramidalis FlatFlat

1.1. external obliqueexternal oblique

2.2. internal obliqueinternal oblique

3.3. transversus abdoministransversus abdominis

Rectus abdominis Rectus abdominis long, strap-like musclelong, strap-like muscle Origin:Origin:

Pubic symphysis and Pubic symphysis and pubic crestpubic crest

Insertion: Insertion: Xiphoid process and 5Xiphoid process and 5thth

and 7th costal cartilagesand 7th costal cartilages

extends along the entire extends along the entire length of the anterior length of the anterior abdominal wallabdominal wall

widest in the upper widest in the upper abdomen and lies just to abdomen and lies just to the side of the midline. the side of the midline.

The paired recti are The paired recti are separated in the midline separated in the midline by the linea alba by the linea alba

Rectus abdominisRectus abdominisThe muscle fibres of The muscle fibres of

rectus abdominis are rectus abdominis are interrupted by three interrupted by three fibrous bands or fibrous bands or tendinous intersections. tendinous intersections.

One is usually situated One is usually situated at the level of the at the level of the umbilicus, umbilicus,

opposite the free end of opposite the free end of the xiphoid process the xiphoid process

a third about midway a third about midway between the other two between the other two

Rectus abdominisRectus abdominis They are rarely full-They are rarely full-

thickness and may thickness and may extend only half-way extend only half-way through the body of the through the body of the muscle. muscle.

They usually fuse with They usually fuse with the fibres of the anterior the fibres of the anterior lamina of the sheath of lamina of the sheath of the muscle. the muscle.

Sometimes, one or two Sometimes, one or two incomplete intersections incomplete intersections are present below the are present below the umbilicus. umbilicus.

linea albalinea alba

The linea alba is a The linea alba is a tendinous raphe tendinous raphe extending from the extending from the xiphoid process to the xiphoid process to the symphysis pubis and symphysis pubis and pubic crest. pubic crest.

It lies between the two It lies between the two recti and is formed by recti and is formed by the interlacing and the interlacing and decussating aponeurotic decussating aponeurotic fibres of the three flat fibres of the three flat muscles. muscles.


linea alba has two linea alba has two attachments at its lower attachments at its lower end:end: its superficial fibres are its superficial fibres are

attached to the symphysis attached to the symphysis pubispubis

deeper fibres form a deeper fibres form a triangular lamella that is triangular lamella that is attached behind rectus attached behind rectus abdominis to the posterior abdominis to the posterior surface of the pubic crest surface of the pubic crest on each side. on each side.

This posterior attachment of This posterior attachment of linea alba is named the linea alba is named the 'adminiculum lineae 'adminiculum lineae albae' albae'


It is visible only in It is visible only in the lean and the lean and muscular, as a muscular, as a slight groove in the slight groove in the anterior abdominal anterior abdominal wall.wall.


A fibrous cicatrix, A fibrous cicatrix, the umbilicus, the umbilicus, lies a little below lies a little below the midpoint of the midpoint of the linea alba, the linea alba, and is covered by and is covered by an adherent area an adherent area of skin. of skin.

Rectus abdominisRectus abdominis

Its lateral border may be Its lateral border may be visible on the surface of the visible on the surface of the anterior abdominal wall as a anterior abdominal wall as a curved groove, the curved groove, the linea linea semilunarissemilunaris which extends from the tip of the which extends from the tip of the

ninth costal cartilage to the pubic ninth costal cartilage to the pubic tubercle. tubercle.

In a muscular individual it is In a muscular individual it is readily visible, even when the readily visible, even when the muscle is not actively muscle is not actively contractingcontracting

but in many normal and obese but in many normal and obese individuals it may be individuals it may be completely obscured.completely obscured.

RECTUS SHEATHRECTUS SHEATH

Rectus abdominis on each Rectus abdominis on each side is enclosed by a side is enclosed by a fibrous sheath:fibrous sheath:

rectus sheath is formed rectus sheath is formed from decussating fibres from decussating fibres from all three lateral from all three lateral abdominal muscles abdominal muscles

The anterior portion of this The anterior portion of this sheath extends the entire sheath extends the entire length of the muscle and length of the muscle and fuses with the periosteum fuses with the periosteum of the muscle attachments. of the muscle attachments. Posteriorly, the sheath is Posteriorly, the sheath is

complete in the upper two-complete in the upper two-thirds of the muscle. thirds of the muscle.

Arcuate lineArcuate line

In the lower one-third, In the lower one-third, the posterior layer of the the posterior layer of the sheath stops sheath stops approximately midway approximately midway between the umbilicus between the umbilicus and the pubis. and the pubis.

The lower border of The lower border of the posterior sheath the posterior sheath is called the is called the arcuate arcuate line.line.

In most individuals this In most individuals this is a clearly defined line, is a clearly defined line, although the transition although the transition may not always be clear-may not always be clear-cut in others.cut in others.

Level of arcuate Level of arcuate lineline

PyramidalisPyramidalis a triangular muscle that lies in front of the lower part a triangular muscle that lies in front of the lower part

of rectus abdominis within the rectus sheath. of rectus abdominis within the rectus sheath. It is attached by tendinous fibres to the front of the It is attached by tendinous fibres to the front of the

pubis and to the ligamentous fibres in front of the pubis and to the ligamentous fibres in front of the symphysis. symphysis.

it diminishes in size as it runs upwards, and ends in a it diminishes in size as it runs upwards, and ends in a pointed apex that is attached medially to the linea pointed apex that is attached medially to the linea alba. alba.

This attachment usually lies midway between the This attachment usually lies midway between the umbilicus and pubis, but may occur higher. umbilicus and pubis, but may occur higher.

The muscle varies considerably in size. It may be The muscle varies considerably in size. It may be larger on one side than on the other, absent on one or larger on one side than on the other, absent on one or both sides, or even doubled. both sides, or even doubled.

absent in approximately 20% of people absent in approximately 20% of people

Flat musclesFlat muscles

External oblique is the largest and External oblique is the largest and the most superficial of the three the most superficial of the three lateral abdominal muscles. lateral abdominal muscles.

External ObliqueExternal Oblique

Origin:Origin:External surfaces of 5External surfaces of 5thth-12th ribs-12th ribs

Insertion:Insertion:Linea albaLinea albapubic tuberclepubic tubercleouter lip of the anterior half of iliac crestouter lip of the anterior half of iliac crest


The attachments The attachments rapidly become rapidly become muscular and muscular and interdigitate with the interdigitate with the lower attachment of lower attachment of serratus anterior and serratus anterior and latissimus dorsi latissimus dorsi along an oblique line along an oblique line that extends that extends downwards and downwards and backwards. backwards.


The attachments The attachments rapidly become rapidly become muscular and muscular and interdigitate with interdigitate with the lower the lower attachment of attachment of serratus anterior serratus anterior and latissimus and latissimus dorsi along an dorsi along an oblique line that oblique line that extends extends downwards and downwards and backwardsbackwards


The muscle The muscle fibers become fibers become aponeurotic aponeurotic approximately at approximately at the the MCL medially MCL medially spinoumbilical spinoumbilical

line (line running line (line running from the from the umbilicus to the umbilicus to the ASIS) inferiorly ASIS) inferiorly

External ObliqueExternal Oblique the posteriormost fibers the posteriormost fibers

from rib 12 are nearly from rib 12 are nearly vertical as they run to the vertical as they run to the iliac crestiliac crest

the more anterior fibers the more anterior fibers fan out, taking an fan out, taking an increasingly medial increasingly medial directiondirection

most of the fleshy fibers most of the fleshy fibers run inferomediallyrun inferomedially

Similar to fingers when Similar to fingers when the hands are in one's the hands are in one's side pocketsside pockets with the most anterior and with the most anterior and

superior fibers approaching superior fibers approaching a horizontal course. a horizontal course.


The aponeurosis forms a sheet of The aponeurosis forms a sheet of tendinous fiberstendinous fibers

Fibers decussate at the linea alba, most Fibers decussate at the linea alba, most becoming continuous with tendinous fibers becoming continuous with tendinous fibers of the contralateral internal oblique. of the contralateral internal oblique.

Thus the contralateral external and Thus the contralateral external and internal oblique muscles together form a internal oblique muscles together form a digastric muscle.digastric muscle. a two-bellied muscle sharing a common central a two-bellied muscle sharing a common central

tendon that works as a unit.tendon that works as a unit.


The inferior margin of The inferior margin of the external oblique the external oblique aponeurosis is aponeurosis is thickened as an thickened as an undercurving fibrous undercurving fibrous band with a free band with a free posterior edge that posterior edge that spans between the spans between the ASIS and the pubic ASIS and the pubic tubercle as the inguinal tubercle as the inguinal ligament (Poupart ligament (Poupart ligament) ligament)

Internal obliqueInternal oblique

Origin:Origin: Thoracolumbar fasciaThoracolumbar fascia anterior two-thirds of anterior two-thirds of

iliac crestiliac crest lateral half of inguinal lateral half of inguinal

ligamentligament Insertion:Insertion:

Inferior borders of 10Inferior borders of 10thth--12th ribs12th ribs

linea albalinea alba pecten pubis via conjointpecten pubis via conjoint


Except for its Except for its lowermost fibers, lowermost fibers, which arise from the which arise from the lateral half of the lateral half of the inguinal ligament, its inguinal ligament, its fleshy fibers run fleshy fibers run perpendicular to those perpendicular to those of the external obliqueof the external oblique running superomedially running superomedially

(like your fingers when (like your fingers when the hand is placed over the hand is placed over your chest). your chest).


Its fibers also Its fibers also become become aponeurotic in aponeurotic in roughly the same roughly the same (midclavicular) (midclavicular) line as the line as the external oblique external oblique and participate in and participate in the formation of the formation of the rectus the rectus sheath.sheath.

Transverse abdominalTransverse abdominal

Origin:Origin: Internal surfaces of 7Internal surfaces of 7thth-12th costal cartilages-12th costal cartilages thoracolumbar fasciathoracolumbar fascia iliac crestiliac crest lateral third of inguinal ligamentlateral third of inguinal ligament

Insertion: Insertion: Linea alba with aponeurosis of internal obliqueLinea alba with aponeurosis of internal oblique pubic crest, and pecten pubis via conjoint pubic crest, and pecten pubis via conjoint

tendontendon

Transverse abdominalTransverse abdominal

the innermost of the three the innermost of the three flat abdominal muscles flat abdominal muscles

Fibres run more or less Fibres run more or less transversally except for transversally except for the inferior ones, which the inferior ones, which run parallel to those of run parallel to those of the internal oblique. the internal oblique.

The fibers of the The fibers of the transverse abdominal transverse abdominal muscle also end in an muscle also end in an aponeurosis which aponeurosis which contributes to the contributes to the formation of the rectus formation of the rectus sheathsheath

Functions and Actions of the Functions and Actions of the Anterolateral Abdominal Muscles Anterolateral Abdominal Muscles 1.1. Form a strong expandable support for the Form a strong expandable support for the

anterolateral abdominal wall.- anterolateral abdominal wall.- allall Facilitate expansion during respirationFacilitate expansion during respiration

2.2. Protect the abdominal viscera from injury.- Protect the abdominal viscera from injury.- allall3.3. Compress the abdominal contents to maintain Compress the abdominal contents to maintain

or increase the intra-abdominal pressure and, in or increase the intra-abdominal pressure and, in so doing, oppose the diaphragm- so doing, oppose the diaphragm- oblique and oblique and transverse muscles, acting together transverse muscles, acting together bilaterallybilaterally

expel air during respiration and more forcibly for expel air during respiration and more forcibly for coughing, sneezing, nose blowing, voluntary eructation coughing, sneezing, nose blowing, voluntary eructation (burping), and yelling or screaming(burping), and yelling or screaming

produce the force required for defecation, micturition, produce the force required for defecation, micturition, vomiting, and parturition.vomiting, and parturition.

4.4. Move the trunk and help maintain posture.- Move the trunk and help maintain posture.- allall• Antilordosis, flexion and twisting of the spine

internal (posterior) surfaceinternal (posterior) surface

covered with covered with transversalis fasciatransversalis fasciaa variable amount of extraperitoneal fata variable amount of extraperitoneal fatparietal peritoneum parietal peritoneum

transversalis fasciatransversalis fascia

It is part of the general layer of fascia between the It is part of the general layer of fascia between the peritoneum and the abdominal wall.peritoneum and the abdominal wall.

Posteriorly, it is continuous with the anterior layer Posteriorly, it is continuous with the anterior layer of the thoracolumbar fasciaof the thoracolumbar fascia

it forms a continuous sheet anteriorlyit forms a continuous sheet anteriorly Inferiorly, it is continuous with the iliac and pelvic Inferiorly, it is continuous with the iliac and pelvic

fasciaefasciae superiorly it blends with the fascial covering of the superiorly it blends with the fascial covering of the

inferior surface of the diaphragm. inferior surface of the diaphragm. It is attached to the entire length of the iliac crest It is attached to the entire length of the iliac crest

between the origins of transversus abdominis and between the origins of transversus abdominis and iliacus and to the posterior margin of the inguinal iliacus and to the posterior margin of the inguinal ligament.ligament.

transversalis fasciatransversalis fascia

The spermatic cord in the male/round The spermatic cord in the male/round ligament of the uterus in the female, ligament of the uterus in the female, pass through the transversalis fascia pass through the transversalis fascia at the deep inguinal ring.at the deep inguinal ring.

the transversalis fascia is prolonged the transversalis fascia is prolonged on these structures as the internal on these structures as the internal spermatic fascia spermatic fascia

peritoneumperitoneum

single layer of serosa single layer of serosa supported by a thin layer of supported by a thin layer of

connective tissue that lines the connective tissue that lines the abdominal cavity. abdominal cavity.

Five vertical folds are formed by Five vertical folds are formed by underlying ligaments or vessels that underlying ligaments or vessels that converge at the umbilicusconverge at the umbilicus

Peritoneum Peritoneum median umbilical fold extends median umbilical fold extends

from the apex of the urinary from the apex of the urinary bladder to the umbilicusbladder to the umbilicus covers the median umbilical covers the median umbilical

ligamentligament the remnant of the urachus, which the remnant of the urachus, which

joined the apex of the fetal bladder joined the apex of the fetal bladder to the umbilicus to the umbilicus

Two medial umbilical foldsTwo medial umbilical folds lateral to the median umbilical foldlateral to the median umbilical fold cover the medial umbilical cover the medial umbilical

ligamentsligaments formed by occluded parts of the formed by occluded parts of the

umbilical arteries. umbilical arteries. Two lateral umbilical foldsTwo lateral umbilical folds

lateral to the medial umbilical foldslateral to the medial umbilical folds cover the inferior epigastric cover the inferior epigastric

vessels and therefore bleed if cut.vessels and therefore bleed if cut.

Blood supplyBlood supply

The blood supply of the abdominal wall:The blood supply of the abdominal wall: superficial vasculaturesuperficial vasculature

supply the tissues above the external oblique supply the tissues above the external oblique aponeurosis and the anterior rectus sheath.aponeurosis and the anterior rectus sheath.

located in the subcutaneous tissues and consists of located in the subcutaneous tissues and consists of branches of the femoral artery including the:branches of the femoral artery including the: superficial inferior epigastricsuperficial inferior epigastric superficial external pudendalsuperficial external pudendal superficial circumflex arteries.superficial circumflex arteries.

Deep vasculatureDeep vasculature the inferior and superior deep epigastric arteries the inferior and superior deep epigastric arteries the deep circumflex artery. the deep circumflex artery. These vessels are located in the musculofascial layers.These vessels are located in the musculofascial layers.

superior deep epigastric superior deep epigastric arteryartery

a terminal branch of the a terminal branch of the internal thoracic arteryinternal thoracic artery

descends between the descends between the costal and xiphoid slips costal and xiphoid slips of the diaphragm, of the diaphragm, accompanied by two or accompanied by two or more veins more veins

enters the rectus sheath enters the rectus sheath behind rectus abdominis behind rectus abdominis and runs down to and runs down to anastomose with the anastomose with the inferior epigastric artery inferior epigastric artery at the level of the at the level of the umbilicus umbilicus

superior epigastric arterysuperior epigastric artery

anastomoses with the anastomoses with the same contralateral same contralateral branch via a branch branch via a branch given off in the upper given off in the upper rectus sheath which rectus sheath which passes anterior to the passes anterior to the xiphoid process of the xiphoid process of the sternum sternum This vessel may give This vessel may give

rise to troublesome rise to troublesome bleeding during bleeding during surgical incisions that surgical incisions that extend up to and extend up to and alongside the xiphoid alongside the xiphoid process process

superior epigastric arterysuperior epigastric artery Obstruction of the Obstruction of the

aorta or iliac artery aorta or iliac artery results in considerable results in considerable collateral circulation collateral circulation through the epigastric through the epigastric vessels. vessels.

If they are ligated, If they are ligated, ischemia of the lower ischemia of the lower extremity may result. extremity may result. Therefore, it is Therefore, it is important to important to temporarily occlude the temporarily occlude the arteries and then arteries and then palpate the dorsal palpate the dorsal pedis pulse before pedis pulse before transecting them.transecting them.

Musculophrenic artery Musculophrenic artery

The musculophrenic The musculophrenic artery is also a artery is also a branch of the internal branch of the internal thoracic artery. thoracic artery.

It lies behind the It lies behind the costal cartilage to costal cartilage to supply the intercostal supply the intercostal spaces and upper spaces and upper abdominal wall. abdominal wall.

Inferior deep epigastric Inferior deep epigastric arteriesarteries

branches from the external iliac artery as it passes branches from the external iliac artery as it passes under the middle of the inguinal ligament.under the middle of the inguinal ligament.

ascends medial to the inguinal ring and superficial to ascends medial to the inguinal ring and superficial to the transversalis fascia. the transversalis fascia.

It then proceeds toward the umbilicus and crosses It then proceeds toward the umbilicus and crosses the lateral border of the rectus muscle at the arcuate the lateral border of the rectus muscle at the arcuate line where it enters the posterior rectus sheath. line where it enters the posterior rectus sheath.

Once the artery enters the sheath, it branches Once the artery enters the sheath, it branches extensively. extensively.

The angle between the vessels and lateral border of The angle between the vessels and lateral border of the rectus forms the apex of the inguinal the rectus forms the apex of the inguinal (Hasselbach's) triangle, the base of which is the (Hasselbach's) triangle, the base of which is the inguinal ligament.inguinal ligament.

Inferior deep epigastric Inferior deep epigastric arteriesarteries

The inferior deep epigastric vessels are The inferior deep epigastric vessels are bounded only by loose areolar tissue bounded only by loose areolar tissue below the arcuate line. below the arcuate line.

Trauma to this portion of the inferior deep Trauma to this portion of the inferior deep epigastric artery may result in epigastric artery may result in considerable hemorrhage. considerable hemorrhage.

Because hematomas commonly dissect Because hematomas commonly dissect into the retroperitoneal space, large into the retroperitoneal space, large quantities of blood may be lost before quantities of blood may be lost before outward evidence of hematoma is outward evidence of hematoma is detectable.detectable.

deep circumflex iliac arterydeep circumflex iliac artery

branches from the branches from the external iliac arteryexternal iliac artery

less frequently, from a less frequently, from a common root including common root including the inferior epigastric the inferior epigastric artery. artery.

Its course is lateral Its course is lateral and vertical behind and vertical behind the inguinal ligament. the inguinal ligament. It then turns medially It then turns medially at the iliac crest where at the iliac crest where it pierces the it pierces the transversus abdominis transversus abdominis muscle. muscle.

deep circumflex iliac arterydeep circumflex iliac artery

numerous numerous connecting branches connecting branches supply the lower and supply the lower and lateral abdominal lateral abdominal wall. wall.

Anastomoses with Anastomoses with the intercostal and the intercostal and lumbar vessels lumbar vessels supply branches to supply branches to all the flank muscles.all the flank muscles.

Posterior intercostal, subcostal Posterior intercostal, subcostal and lumbar arteriesand lumbar arteries

give off muscular branches to the overlying give off muscular branches to the overlying internal and external oblique, before internal and external oblique, before anastomosing with the lateral branches of anastomosing with the lateral branches of the superior and inferior epigastric arteries the superior and inferior epigastric arteries at the lateral border of the rectus sheath. at the lateral border of the rectus sheath.

Perforating cutaneous vessels run vertically Perforating cutaneous vessels run vertically through the muscles to supply the overlying through the muscles to supply the overlying skin and subcutaneous tissue. skin and subcutaneous tissue.

Superficial arteriesSuperficial arteries The superficial vessels follow the The superficial vessels follow the

general pattern of the deep general pattern of the deep vessels and arise from the iliac vessels and arise from the iliac or femoral vessels. The or femoral vessels. The exception is that the superficial exception is that the superficial inferior epigastric have no inferior epigastric have no superior counterparts. superior counterparts.

The superficial inferior epigastric The superficial inferior epigastric vessels run diagonally in the vessels run diagonally in the subcutaneous tissues from the subcutaneous tissues from the femoral artery toward the femoral artery toward the umbilicus. umbilicus. They can be identified on a line They can be identified on a line

between the palpable femoral between the palpable femoral pulse and umbilicus just pulse and umbilicus just superficial to Scarpa's fascia. superficial to Scarpa's fascia.

As they approach the umbilicus, As they approach the umbilicus, the arteries branch extensively. the arteries branch extensively.

external pudendal external pudendal arteries have a medial arteries have a medial and diagonal course from and diagonal course from the femoral artery and the femoral artery and supply the region of the supply the region of the mons pubis. mons pubis. These vessels branch These vessels branch

extensively as they extensively as they approach the midline. approach the midline.

Bleeding is typically Bleeding is typically heavier here than in other heavier here than in other subcutaneous areas of the subcutaneous areas of the abdomen.abdomen.

superficial circumflex superficial circumflex iliac vessels proceed iliac vessels proceed from the femoral vessels from the femoral vessels to the flank. to the flank.

VeinsVeins

Veins typically follow arteries. Veins typically follow arteries. Above the umbilicus they drain to the Above the umbilicus they drain to the

subclavian vesselssubclavian vesselsBelow the umbilicus they drain to the Below the umbilicus they drain to the

external iliac vessels. external iliac vessels.

Lymphatic drainageLymphatic drainage

Superficial Superficial Deep Deep

The superficial lymphatic vesselsThe superficial lymphatic vessels

accompany the subcutaneous blood accompany the subcutaneous blood vesselsvessels

Those from the infra-umbilical skin run Those from the infra-umbilical skin run with the superficial epigastric vessels. with the superficial epigastric vessels. They drain into the superficial inguinal nodes. They drain into the superficial inguinal nodes.

The supra-umbilical region is drained by The supra-umbilical region is drained by vessels running obliquely up to the vessels running obliquely up to the pectoral and subscapular axillary nodespectoral and subscapular axillary nodes there is some drainage to the parasternal there is some drainage to the parasternal

nodes nodes

The deep lymphatic vesselsThe deep lymphatic vessels

accompany the deep arteriesaccompany the deep arteriesVessels from the upper anterior Vessels from the upper anterior

abdominal wall run with the superior abdominal wall run with the superior epigastric vessels to the parasternal epigastric vessels to the parasternal nodes. nodes.

Vessels of the lower abdominal wall Vessels of the lower abdominal wall drain into the circumflex iliac, inferior drain into the circumflex iliac, inferior epigastric and external iliac nodes. epigastric and external iliac nodes.

Nerve supplyNerve supply


the anterior rami of spinal nerves T7-the anterior rami of spinal nerves T7-T12, which supply most of the T12, which supply most of the abdominal wall, do not participate in abdominal wall, do not participate in plexus formation. plexus formation. The map of dermatomes of the The map of dermatomes of the

anterolateral abdominal wall is almost anterolateral abdominal wall is almost identical to the map of peripheral nerve identical to the map of peripheral nerve distribution distribution


T7-T9 supply the skin T7-T9 supply the skin superior to the superior to the umbilicus.umbilicus.

T10 innervates the skin T10 innervates the skin around the umbilicus.around the umbilicus.

T11plus the cutaneous T11plus the cutaneous branches of the branches of the subcostal (T12), subcostal (T12), iliohypogastric, and iliohypogastric, and ilioinguinal (L1), supply ilioinguinal (L1), supply the skin inferior to the the skin inferior to the umbilicus.umbilicus.

Clinical relevanceClinical relevance

Abdominal ObesityAbdominal ObesityVeinous distentionVeinous distentionExcessive lardosisExcessive lardosisDistension Distension herniasherniasTenderness/Guarding/ReboundTenderness/Guarding/Rebound

Abdominal ObesityAbdominal Obesity

In morbid obesity, the superficial fat In morbid obesity, the superficial fat is many inches thick, often forming is many inches thick, often forming one or more sagging folds (L. one or more sagging folds (L. panniculi; singular = panniculus, panniculi; singular = panniculus, apron). apron).

Veinous distentionVeinous distention

Veins may be Veins may be dilated in patients dilated in patients with obstructed with obstructed blood flow through blood flow through the liver and porta the liver and porta hepatis. They may hepatis. They may also be engorged also be engorged in patients with in patients with large pelvic large pelvic massesmasses

Caput medusaCaput medusa

Excessive lardosisExcessive lardosis Anterior abdominal wall maintains postureAnterior abdominal wall maintains posture underdeveloped or atrophic anterior abdominal underdeveloped or atrophic anterior abdominal

musclesmuscles old age old age insufficient exerciseinsufficient exercise Pregnancy/ abdominal distensionPregnancy/ abdominal distension

Ant. abdominal muscles have insufficient tonus to resist the Ant. abdominal muscles have insufficient tonus to resist the increased weight of a protuberant abdomen on the anterior increased weight of a protuberant abdomen on the anterior pelvis. pelvis.

The pelvis tilts anteriorly at the hip joints when The pelvis tilts anteriorly at the hip joints when standing (the pubis descends and the sacrum standing (the pubis descends and the sacrum ascends) producing excessive lordosis of the lumbar ascends) producing excessive lordosis of the lumbar region of the vertebral column region of the vertebral column

backachebackache

DistensionDistension

Eversion of the umbilicus Eversion of the umbilicus may be a sign of increased may be a sign of increased intra-abdominal pressure intra-abdominal pressure resulting from eg. ascites or resulting from eg. ascites or a large massa large mass

Clinical maneuvers as well Clinical maneuvers as well as inx may prove useful in as inx may prove useful in identifying the cause of identifying the cause of anterior adominal wall anterior adominal wall distension: distension: Palpation of massesPalpation of masses Tympanic percussion- gas Tympanic percussion- gas Eliciting flank and shifting Eliciting flank and shifting

dullness in ascitesdullness in ascites Imaging: xrays, ct-scan.Imaging: xrays, ct-scan.

Hernias Hernias

defined as an abnormal protrusion of defined as an abnormal protrusion of an organ or tissue through a defect an organ or tissue through a defect in its surrounding walls in its surrounding walls

The basic pathophysiology The basic pathophysiology underlying distension is increased underlying distension is increased intraabdominal pressure This as well intraabdominal pressure This as well as congenital or acquired weakness as congenital or acquired weakness in the anterior abdominal wall may in the anterior abdominal wall may predispose to herniaspredispose to hernias

Hernias Hernias Most hernias occur in the:Most hernias occur in the:

inguinal- through the inguinal inguinal- through the inguinal canal (direct vs indirect)canal (direct vs indirect)

umbilical- through the umbilical- through the umbilical ringumbilical ring

epigastric regions- through a epigastric regions- through a weakness in the linea alba- weakness in the linea alba- between the xiphoid and the between the xiphoid and the umbilicus. umbilicus.

Uncommonly encountered Uncommonly encountered are Spigelian hernias are Spigelian hernias occurring along the occurring along the

semilunar lines. These types semilunar lines. These types of hernia tend to occur in of hernia tend to occur in people > 40 years and are people > 40 years and are usually associated with usually associated with obesity obesity

Incisional herniasIncisional hernias a protrusion of omentum a protrusion of omentum

(a fold of peritoneum) or (a fold of peritoneum) or an organ through a an organ through a surgical incision surgical incision

if the muscular and if the muscular and aponeurotic layers of the aponeurotic layers of the abdomen do not heal abdomen do not heal properly, an incisional properly, an incisional hernia can result hernia can result

Factors predisposing a Factors predisposing a patient to incisional patient to incisional hernia include:hernia include: advanced ageadvanced age debility of the patientdebility of the patient ObesityObesity postoperative wound postoperative wound

infection infection

Divarication of the rectus Divarication of the rectus abdominisabdominis

Thinning and widening of the upper linea albaThinning and widening of the upper linea alba most commonly as a result of obesity or chronic straining. most commonly as a result of obesity or chronic straining.

This process disrupts the arrangement of the This process disrupts the arrangement of the fibres of the bilaminar aponeurosis. fibres of the bilaminar aponeurosis.

Contraction of the anterolateral abdominal Contraction of the anterolateral abdominal muscles fails to be transmitted across the midline muscles fails to be transmitted across the midline through the linea alba and increased intra-through the linea alba and increased intra-abdominal pressure causes the abdominal viscera abdominal pressure causes the abdominal viscera to protrude beneath the thinned tissue as a broad to protrude beneath the thinned tissue as a broad midline bulge. midline bulge.

The recti become widely separated or divaricated. The recti become widely separated or divaricated. This is not true herniation, as all the layers of the This is not true herniation, as all the layers of the abdominal wall in that region are intact. abdominal wall in that region are intact.

1) Epigastric1) Epigastric2) Diastasis (not a true 2) Diastasis (not a true hernia)hernia)3) Supra-umbilical hernia3) Supra-umbilical hernia4) Umbilical hernia4) Umbilical hernia5) Incisional hernia5) Incisional hernia6) Scar (previous inguinal 6) Scar (previous inguinal hernia op)hernia op)7) Recurrent inguinal 7) Recurrent inguinal herniahernia8) Spigelian hernia (very 8) Spigelian hernia (very rare)rare)9) Femoral hernia9) Femoral hernia10) Inguinal hernia10) Inguinal hernia11) Pubic bone11) Pubic bone12) Inguinal ligament - 12) Inguinal ligament - groin skin crease groin skin crease

Abdominal Abdominal tenderness/guarding/reboundtenderness/guarding/rebound

Irritation of the Parietal peritonium Irritation of the Parietal peritonium results in pain/guarding/rebound results in pain/guarding/rebound corresponding to the segmental corresponding to the segmental nerve roots innervating the nerve roots innervating the peritoneum and tends to be sharp peritoneum and tends to be sharp and well localized and well localized

Surgical relevanceSurgical relevance

Incisions Incisions

A well selected incision provide:A well selected incision provide:1.1. Accessibility Accessibility 2.2. Extensibility Extensibility 3.3. Preservation of function Preservation of function 4.4. SecuritySecurity

Additional considerations in selecting the type Additional considerations in selecting the type of incision include:of incision include:

Need for speed upon entry Need for speed upon entry Certainty of the diagnosis Certainty of the diagnosis Body habitus Body habitus Location of previous scars Location of previous scars Potential for problems with hemostasis Potential for problems with hemostasis Cosmetic outcomeCosmetic outcome

Vertical vs TransverseVertical vs Transverse

Vertical incisionsVertical incisions

Midline Midline ParamedianParamedianLateral paramedianLateral paramedianPararectus Pararectus

Vertical/Midline incisionVertical/Midline incision Advantages:Advantages:

Only terminal branches of the Only terminal branches of the abdominal wall blood vessels abdominal wall blood vessels and nerves are located at the and nerves are located at the linea albalinea alba

Limits the risk of significant Limits the risk of significant vascular or nerve injuryvascular or nerve injury

provides the quickest entry, provides the quickest entry, which is especially important if which is especially important if

the patient is unstable or the patient is unstable or seriously ill, seriously ill,

Provides best exposure and Provides best exposure and extensibilityextensibility

particular importance if the particular importance if the diagnosis is uncertain. diagnosis is uncertain.

deep tissue planes are not deep tissue planes are not openedopened

may be ideal for patients who may be ideal for patients who are anticoagulatedare anticoagulated

who have enlarged epigastric who have enlarged epigastric vessels that may be injuredvessels that may be injured

who have intraabdominal who have intraabdominal infection infection

Disadvantages:Disadvantages: Less cosmetic than Less cosmetic than

tranverse incisions.tranverse incisions. Greater skin tension. Greater skin tension.

Crossing the lines of Crossing the lines of langerhanslangerhans

Classically it was believed Classically it was believed that midline incisions that midline incisions increased the risk of wound increased the risk of wound dehiscence and herniadehiscence and hernia

Current literature does not Current literature does not support this belief.support this belief.

Cochrane review 2005 Cochrane review 2005 found no difference found no difference between tranverse and between tranverse and vertical incisionsvertical incisions

Possibly due to Possibly due to improvements in closure improvements in closure techniquestechniques

Important pointsImportant points Extension of a midline incision above the umbilicus can be Extension of a midline incision above the umbilicus can be

made toward the left in order to avoid the ligamentum teres. made toward the left in order to avoid the ligamentum teres. Reentry incisions should be made through the pre-existing Reentry incisions should be made through the pre-existing

scar scar placement of parallel longitudinal incisions may result in tissue placement of parallel longitudinal incisions may result in tissue

ischemia, even when incisions are performed many years apart ischemia, even when incisions are performed many years apart When entering the abdominal cavity inferior to the umbilicus, When entering the abdominal cavity inferior to the umbilicus,

care should be taken to incise the peritoneum slightly off the care should be taken to incise the peritoneum slightly off the midline since the bladder is highest in the midline and the midline since the bladder is highest in the midline and the urachus may communicate with it. urachus may communicate with it. This will reduce the risk of bladder injuryThis will reduce the risk of bladder injury eliminate the risk of urine leaking from an incised persistent eliminate the risk of urine leaking from an incised persistent

urachusurachus provide better exposure. provide better exposure. Alternatively, the urachus can be divided and ligated Alternatively, the urachus can be divided and ligated

The bladder can be identified because of its opaqueness and The bladder can be identified because of its opaqueness and markedly increased vascularity. markedly increased vascularity.

Paramedian incision Paramedian incision

(A) The anterior rectus (A) The anterior rectus sheath is opened for the sheath is opened for the full length of the incision 2 full length of the incision 2 to 3 cm from the midline. to 3 cm from the midline. The rectus muscle is The rectus muscle is

retracted laterally and the retracted laterally and the posterior sheath is incised posterior sheath is incised longitudinally under the longitudinally under the muscle bed. muscle bed.

(B) The lateral paramedian (B) The lateral paramedian incision is placed near the incision is placed near the lateral border of the lateral border of the rectus. rectus. When the muscle is retracted When the muscle is retracted

laterally, the inferior deep laterally, the inferior deep epigastric artery is seen. epigastric artery is seen.

Paramedian incision Paramedian incision

Advantages:Advantages: Paramedian incisions can be extended into the Paramedian incisions can be extended into the

upper abdomen without the difficulties of upper abdomen without the difficulties of curving around the umbilicus. curving around the umbilicus.

PRCT cox et al. sugested decrease the risk of PRCT cox et al. sugested decrease the risk of dehiscence or hernia as compared to midline dehiscence or hernia as compared to midline incisionsincisions

Overall evidence conflictingOverall evidence conflicting Disadvantages:Disadvantages:

take longer to performtake longer to perform restrict access to the contralateral pelvisrestrict access to the contralateral pelvis risk injury to the epigastric vessels.risk injury to the epigastric vessels. nerve injury may result in rectus paralysis. nerve injury may result in rectus paralysis.

Pararectus incisionPararectus incision

(also known as Battle's incision) (also known as Battle's incision) placed at the lateral border of the rectus placed at the lateral border of the rectus

muscle, which is retracted medially.muscle, which is retracted medially. infrequently utilized infrequently utilized primarily used for appendectomy or primarily used for appendectomy or

drainage of pelvic abscesses. drainage of pelvic abscesses. causes denervation of the rectus, resulting causes denervation of the rectus, resulting

in paralysis and ultimately atrophy of the in paralysis and ultimately atrophy of the muscles.muscles.

The length of this incision must be The length of this incision must be restricted to no more than two dermatomes restricted to no more than two dermatomes to prevent weakness of the abdominal wall to prevent weakness of the abdominal wall

Transverse incisions Transverse incisions for pelvic surgery are for pelvic surgery are of four types:of four types:

1.1. Pfannenstiel's incision, Pfannenstiel's incision, a muscle-separating a muscle-separating operation operation

2.2. Cherney's incision, a Cherney's incision, a tendon-detaching tendon-detaching operation operation

3.3. Maylard's incision, a Maylard's incision, a true muscle-cutting true muscle-cutting incision incision

4.4. Küstner's incision, a Küstner's incision, a median incision using a median incision using a transverse skin incision.transverse skin incision.

Pfannenstiel's incision Pfannenstiel's incision (A) "Low" Pfannenstiel: the skin (A) "Low" Pfannenstiel: the skin

incision is placed lower for incision is placed lower for cosmetic reasons. cosmetic reasons. The subcutaneous tissues are The subcutaneous tissues are

dissected to allow standard dissected to allow standard placement of rectus sheath placement of rectus sheath incision.incision.

(B) Fascia is separated from (B) Fascia is separated from rectus muscle superiorly and rectus muscle superiorly and inferiorly. inferiorly.

(C) The rectus muscle is (C) The rectus muscle is separated in the midline and the separated in the midline and the peritoneum is incised peritoneum is incised longitudinally. longitudinally.

(D) Sutures may be placed in the (D) Sutures may be placed in the rectus muscle to close a rectus rectus muscle to close a rectus diastasis. diastasis.

(E) Sheath is closed with (E) Sheath is closed with continuous suture. continuous suture.

Skin is approximated with a Skin is approximated with a subcuticular suture.subcuticular suture.

Pfannenstiel's incision Pfannenstiel's incision

Advantages:Advantages: Pfannenstiel's incision Pfannenstiel's incision

provides excellent provides excellent strength and cosmesisstrength and cosmesis

exposure is adequate for exposure is adequate for procedures limited to the procedures limited to the pelvis pelvis

Disadvantages:Disadvantages: minimal opportunity to extend the minimal opportunity to extend the

incision if wider exposure is desiredincision if wider exposure is desired Restricted speed of entryRestricted speed of entry

several tissue planes must be several tissue planes must be openedopened

the risk of seroma, hematoma, and the risk of seroma, hematoma, and wound infection may be increasedwound infection may be increased

Because of these considerations, this Because of these considerations, this incision is relatively contraindicated incision is relatively contraindicated in the presence of active abdominal in the presence of active abdominal infection or if speed is of the essenceinfection or if speed is of the essence

iliohypogastric and ilioinguinal iliohypogastric and ilioinguinal nerves injury if the incision is nerves injury if the incision is extended beyond the rectus muscleextended beyond the rectus muscle

Neuromas can occur if these nerves Neuromas can occur if these nerves are traumatized are traumatized

some patients will experience some patients will experience chronic pain severe enough to limit chronic pain severe enough to limit daily activities. daily activities.

Cherney's incision Cherney's incision (A) Transverse incision (A) Transverse incision

of rectus sheath. of rectus sheath. (B) Lower sheath is (B) Lower sheath is

separated from rectus separated from rectus muscles. muscles.

Tendons are exposed Tendons are exposed and incised 0.5 cm and incised 0.5 cm above periosteum of above periosteum of symphysis. symphysis.

(C) Tendons are sutured (C) Tendons are sutured to lower rectus sheath to lower rectus sheath above symphysis with above symphysis with permanent suture permanent suture material. material.

(D) Sheath is closed in a (D) Sheath is closed in a continuous manner. continuous manner.

Cherney's incisionCherney's incision

Cherney's incision provides excellent Cherney's incision provides excellent exposure to the retropubic space of exposure to the retropubic space of Retzius, making it a good choice for Retzius, making it a good choice for retropubic urethropexy. A retropubic urethropexy. A Pfannenstiel incision may be Pfannenstiel incision may be converted to a Cherney incision to converted to a Cherney incision to enhance exposure enhance exposure

Maylard's incision (Mackenrodt Maylard's incision (Mackenrodt incision) incision)

Transverse muscle-Transverse muscle-cutting incision. cutting incision.

(A) Incision of rectus (A) Incision of rectus sheath is extended sheath is extended laterally to iliac spine laterally to iliac spine to expose rectus to expose rectus muscle. muscle.

Rectus muscles are Rectus muscles are cut transversly. cut transversly.

(B) Cut edges of (B) Cut edges of muscles are sutured muscles are sutured to the rectus sheath. to the rectus sheath.

Transversalis fascia Transversalis fascia and peritoneum are and peritoneum are incised transversely. incised transversely.

Maylard's incision (Mackenrodt Maylard's incision (Mackenrodt incision)incision)

Provides slightly increased exposure over Provides slightly increased exposure over pfannensteilpfannensteil

patients with significant aortoiliac occlusion patients with significant aortoiliac occlusion (eg, aortic atherosclerosis or coarctation) (eg, aortic atherosclerosis or coarctation) depend upon collateral flow from the depend upon collateral flow from the epigastric vessels for perfusion of the lower epigastric vessels for perfusion of the lower extremities.extremities.

ligation of these vessels during a Maylard ligation of these vessels during a Maylard incision may cause worsening symptoms incision may cause worsening symptoms (claudication) and potentially ischemia (claudication) and potentially ischemia

Another complication of Maylard's incision is Another complication of Maylard's incision is delayed bleeding from the cut edge of the delayed bleeding from the cut edge of the rectus muscle or deep epigastric vessels. rectus muscle or deep epigastric vessels.

Küstner's incisionKüstner's incision

Transverse Transverse incision to sheath, incision to sheath, subcutaneous subcutaneous tissue separated tissue separated from linea alba. from linea alba. Midline incision in Midline incision in linea alba linea alba

Küstner's incisionKüstner's incision

Küstner's incision combines the Küstner's incision combines the disadvantages of both midline and disadvantages of both midline and transverse incisions and therefore transverse incisions and therefore has limited utility has limited utility

Turner-Warwick's incision Turner-Warwick's incision

Transverse skin Transverse skin incision. incision.

Subcutaneous tissue is Subcutaneous tissue is dissected from the dissected from the anterior sheath to a anterior sheath to a point at least 2 cm point at least 2 cm below the pubis. below the pubis.

The sheath is incised 2 The sheath is incised 2 cm below the pubis and cm below the pubis and at least 4 cm in length. at least 4 cm in length.

The incision is The incision is extended cephalad extended cephalad along the borders of along the borders of the rectus muscles. the rectus muscles.

Peritoneum is incised Peritoneum is incised longitudinally.longitudinally.

Turner-Warwick incisionTurner-Warwick incision

provides excellent exposure to the provides excellent exposure to the retropubic spaceretropubic space

upper pelvis and abdominal exposure upper pelvis and abdominal exposure is severely limited. is severely limited.

McBurney's incisionMcBurney's incision

McBurney's incisionMcBurney's incision

provides excellent access to the provides excellent access to the ipsilateral lower quadrantipsilateral lower quadrant

ideal for appendectomyideal for appendectomyeasily expandedeasily expandedcosmesis is excellentcosmesis is excellentThe incision may be placed lower for The incision may be placed lower for

extraperitoneal drainage of a pelvic extraperitoneal drainage of a pelvic abscess. abscess.

Summary Summary

A detailed knowledge of the anatomy A detailed knowledge of the anatomy and function of the anterior and function of the anterior abdominal wall is critically important abdominal wall is critically important to the accurate diagnosis of to the accurate diagnosis of abdominal and pelvic pathology as abdominal and pelvic pathology as well as the safe practice of well as the safe practice of abdominal and pelvic surgeryabdominal and pelvic surgery

Thank youThank you

References References Brown, SR, Goodfellow, PB. Transverse verses midline incisions for abdominal

surgery. Cochrane Database Syst Rev 2005; :CD005199. Fassiadis, N, Roidl, M, Hennig, M, South, LM, Andrews, SM. Randomized clinical

trial of vertical or transverse laparotomy for abdominal. Br J Surg 2005; 92:1208. Seiler, CM, Deckert, A, Diener, MK, et al. Midline versus transverse incision in

major abdominal surgery: a randomized, double-blind equivalence trial (POVATI: ISRCTN60734227). Ann Surg 2009; 249:913.

Hendrix, SL, Schimp, V, Martin, J, et al. The legendary superior strength of the Pfannenstiel incision: a myth?. Am J Obstet Gynecol 2000; 182:1446.

Cox, PJ, Ausobsky, JR, Ellis, H, Pollock, AV. Towards no incisional hernias: lateral paramedian versus midline incisions. J R Soc Med 1986; 79:711.

Am J Med Genet C Semin Med Genet. 2008 Aug 15;148C(3):180-5. Online course in embryology for medicine students

developed by the universities of Fribourg, Lausanne and Bern (Switzerland)with the support of the Swiss Virtual Campus

Grays textbook of anatomy, 39th edition Te Linde’s Operative Gynaecology, Ninth edition Moore - clinically oriented anatomy, 5th edition

anatomy of the anterior abdominal wall2 (edited)

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