Download - Anterior Abdominal Muscles BMJ
-
7/28/2019 Anterior Abdominal Muscles BMJ
1/61
-
7/28/2019 Anterior Abdominal Muscles BMJ
2/61
MOB TCD
Anterior Abdominal Muscles
Professor Emeritus Moira OBrien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
-
7/28/2019 Anterior Abdominal Muscles BMJ
3/61
Anterior Abdominal Wall
The muscles of the anteriorabdominal wall play a major role
in movements of the trunk
Protecting the abdominal organs
Increase the intra-abdominalpressure, aid in expiration and
all straining activities such as
micturition, coughing and
vomiting
Supplied by lower five intercostal
and subcostal nerves
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
4/61
Anterior Abdominal Muscles
Strong abdominals are important inhelping to stabilise the trunk
Support the spine
They flex and rotate the trunk
Acting with the adductors andabductors of the hip
They help to stabilise the pelvis
during walking and running
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
5/61
Superficial fatty layer Membranous layer of
superficial fascia
Below umbilicus
Continuous with Collesfascia in the perineum
Anterior Abdominal WallMOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
6/61
Lower five intercostal nerves Subcostal nerve T12
10th intercostal nerve is at the
level of the umbilicus
Iliohypogastric nerve L1 Ilioinguinal nerve L1
Skin of Anterior Abdominal WallMOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
7/61
Blood Supply and Lymphatics
Intercostal vessels Skin above umbilicus
superficial veins and
lymphatics drain to axilla
Skin below umbilicussuperficial veins and
lymphatics drain to long
saphenous vein
Superficial inguinal glands
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
8/61
Inguinal Glands
Proximal group parallel toinguinal ligament
Enlarged tender inguinal
glands
Part of a generalisedlymphadenopathy
Secondaries
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
9/61
Proximal group Lesions in local structures
Skin of lower anterior
abdominal wall
Gluteal region Skin of scrotum or labia
Distal superficial glands
Skin of leg area drained by
long saphenous vein
All drain to deep inguinal
glands along femoral vein
Inguinal GlandsMOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
10/61
Abdominal Muscles
External oblique Internal oblique
Transversus
Rectus abdominus
Pyramidalis Nerves and vessels
Lie between internal oblique and
transversus
MOB TCD
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
11/61
External Oblique
Origin Outer surfaces lower
borders lower eight ribs
Interdigitating with serratus
anterior and latissimus dorsi Fibres pass medially and
inferiorly
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
12/61
External Oblique Insertion
Inserted into anterior half ofanterior two thirds outer lip
of iliac crest
Aponeurosis in the inguinal
region passes anterior to
rectus muscle
Forms the inguinal ligament
Lacunar ligament
Reflected portion of inguinalligament
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
13/61
Inguinal and Lacunar Ligaments
Inguinal ligamentaponeurosis is folded
back from anterior
superior iliac spine to
pubic tubercle to forminguinal ligament
Lacunar ligament
triangular, attached to
pectineal line. lateral
free border medial
margin of femoral ring
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
14/61
Insertion External Oblique
Pubic crest Gap for superficial
inguinal ring
Pubic bone
Linea alba Anterior wall of the
rectus sheath
Zyphoid process
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
15/61
External Oblique
Acting separately
The external oblique flexes the
vertebral column laterally and
rotates it to the opposite side
If the thorax is fixed by
contracting both externalobliques, you can tilt the
symphysis pubis superiorly and
flex the trunk, posterior pelvic tilt
Movement of the iliac crestsdetermines the direction of the tilt
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
16/61
Internal Oblique
Muscular origin lateral twothirds of inguinal ligament
Anterior two thirds
intermediate lip of iliac
crest
Lumbar fascia
Muscular fibres arch over
contents of inguinal canal
anterior to rectus muscle
Fibres pass medially and
superiorly
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
17/61
Insertion Internal Oblique
Into coastal margin, upper threeas fleshy fibres
Next three as aponeurotic
Inserted into linea alba
Between zyphoid and half waybetween umbilicus and pubic
symphysis aponeurosis splits
Anterior layer fuses with
external oblique Posterior layer fuses with
transversus
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
18/61
Internal Oblique Conjoint Tendon
Half way between umbilicusand pubic symphysis
Aponeurosis of the internal
oblique and transversus
fuse to form conjoint tendon
Anterior portion of rectus
sheath
Inserted into pectineal line
behind superficial inguinal
ring
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
19/61
Internal Oblique
The right side of the muscle
twists to the right and the left
side twists to the left
The lower six intercostals nerve Subcostal nerve
Iliohypogastric nerves
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
20/61
Transversus Abdominus
Origin Lateral one third of inguinal
ligament
Anterior two thirds of inner lip of
iliac crest Lumbar fascia
Lower border and inner
surfaces lower six ribs
interdigitating with diaphragm
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
21/61
Insertion Transversus Abdominus
Into zyphoid, linea alba Half way between umbilicus
and pubic symphysis
Fuses with posterior lamella of
internal oblique Below forms conjoint tendon
Inserted into pectineal line
behind superficial inguinal ring
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
22/61
Transversus Abdominus
The transversus abdominushelps to support the abdominal
viscera
Maintain intra-abdominal
pressure Stabilises the lumbar spine
It is supplied by the lower six
intercostals nerves
Subcostal nerves Iliohypogastric nerves
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
23/61
Rectus Abdominus
Segmental muscle Two heads
Anterior pubic symphysis
Pubic crest
Inserted anterior aspect of 5, 6, 7thcostal cartilages
Adhesions anterior surface
Segmental blood and nerve
supply from Intercostals
The rectus abdominus flexes the trunk
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
24/61
Rectus Abdominus
The rectus muscles (recti)are the most powerful
flexors of the vertebral
column
When raising the head froma supine position
A movement often used to
strengthen the abdominals
It is the recti that contract first When the shoulders start to rise upwards, the
obliques start to contract
MOB TCD
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
25/61
Rectus Sheath
Above zyphoid Anterior wall is the external
oblique
Posterior, costal cartilages
From ziphoid and half waybetween umbilicus and pubic
symphysis
Anterior is external oblique and
anterior lamella of internaloblique
Posterior lamella internal
oblique and transversus
MOB TCD
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
26/61
Below half way betweenumbilicus and pubic symphysis
The aponeurosis of the
external oblique, internal
oblique and transversus
(conjoint tendon) pass anterior
to the rectus
Posterior lies the transversalis
fascia
Rectus SheathMOB TCD
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
27/61
Contents Rectus muscle
Pyramidalis
Superior and inferior epigastric
vessels Lower five intercostal vessels and
nerves
Rectus SheathMOB TCD
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
28/61
Transversalis Fascia
Lines deep aspect oftransversus abdominus
Fuses with inguinal ligament
Continuous with iliac fascia
Except in the region of thefemoral vessels
Forms anterior wall of
femoral sheath
MOB TCD
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
29/61
Extraperitoneal Tissue
Extraperitoneal connectivetissue
If fatty, it separates the
transversalis fascia from
the peritoneum If thin, they are in close
contact with one another
MOB TCD
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
30/61
Peritoneal Pouches
Peritoneal pouches arefound in the region of the
deep inguinal ring
Medial portion of the
posterior wall
Posterior aspect anteriorabdominal wall
MOB TCD
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
31/61
Inguinal Canal
Intra muscular canal Lower portion of anterior
abdominal wall
From
Deep inguinal ring Superficial inguinal ring
Transmits spermatic cord
in male
Round ligament in female
MOB TCD
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
32/61
Superficial Inguinal Ring
Triangular opening inaponeurosis of external
oblique
Base, pubic crest
Superior crus attached tothe pubic crest
Inferior attached to pubic
tubercle
External spermatic fasciaarises from its margins
MOB TCD
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
33/61
Deep Inguinal Ring
Oval opening 2.5 cm Above the middle of inguinal
ligament
Inferior epigastric artery
passes medial to the deepring
O C
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
34/61
Interfoveolar Ligament
The interfoveolar ligament isan inconstant band
Medial to deep inguinal ring
Anterior to inferior epigastric
vessels From lower margin of
transversus abdominus
To pectineal lineMcVay & Anson, 1949
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
35/61
Inguinal Canal
Anterior Wall External oblique forms
Whole anterior wall
Internal oblique forms
Lateral half only
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
36/61
Posterior Wall Transversalis fascia
Whole of wall
Medial half conjoint tendon
Medial quarter reflectedportion of inguinal ligament
Inguinal Canal
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
37/61
Roof Arching fibres of internal oblique
Transversus as they both arise
from the inguinal ligament
Roof of Inguinal Canal
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
38/61
Floor Inguinal ligament
forms whole of floor
Medial half by the
lacunar ligament Reflected part of
inguinal ligament
forms medial
quarter
Floor of Inguinal Canal
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
39/61
Passing Through Deep Ring Male
Vas Deferens Testicular artery
Pampiniform plexus of veins
Remains of processus vaginalis
Genital branch of genitofemoralnerve
Lymphatics from testes
Cremaster artery
Passing throughMOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
40/61
Passing through
Superficial Ring Male
Everything that went throughdeep ring
Plus
Ilioinguinal nerve
Internal spermatic fascia from
margins of the deep ring
Cremaster muscle and fascia
Passing throughMOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
41/61
Passing through
Deep Ring Female
Round ligament of uterus Remains of processus vaginalis
Genital branch of genitofemoral
nerve
Lymphatics from uterus, regionof cornu
Passing throughMOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
42/61
Passing through
Superficial Ring Female
Everything that wentthrough deep ring
Plus ilioinguinal nerve
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
43/61
Inguinal Canal
Contraction of the
abdominal muscles
increases the obliquity of
the inguinal canal
Protecting the two ringsLytle, 1945
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
44/61
Increase in Intra-Abdominal Pressure
Pain aggravated by anincrease in intra-
abdominal pressure
Hernia
Inguinal or femoral hernia Entrapment of the
ilioinguinal nerve
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
45/61
Hernia
Chronic pain in the groin in anathlete may be due to a hernia
or a potential hernia
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
46/61
Inguinal Hernia
Sudden severe pain in
lower abdomen
Associated with lifting a
heavy object
Common history of a
direct inguinal hernia
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
47/61
Passes through Deep inguinal ring
May extend to pass
through the superficial
ring into the scrotum Congenital or acquired
Congenital inside the
tunica vaginalis (serous
membrane, covers partof testes)
Acquired outside
Indirect Inguinal Hernia
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
48/61
Enters through posterior wall
of the inguinal canal
Leaves through superficial
inguinal ring
Above and medial to the pubic
tubercle
Direct Inguinal Hernia
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
49/61
Inguinal Hernia
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
50/61
Inguinal Versus Femoral Hernia
Inguinal hernia above
and medial to pubic
tubercle
Femoral hernia below
and lateral to the
tubercle
More common in
females and more likely
to strangulate
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
51/61
Femoral Ring
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
52/61
Femoral Hernia
Enters through femoral ring
Enters femoral canal
Medial compartment of femoral
sheath
More common in women
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
53/61
Femoral Hernia
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
54/61
Saphenous Varix
Swelling is soft anddiffuse
Empties on minimal
pressure
Refills on release Cough impulse is
present
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
55/61
Gilmores Groin
Common cause of chronic
groin pain in field sports
Particularly soccer players
Pain on any sudden change
of movement, sneezing,
coughing
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
56/61
Trying to sprint
Will increase the pain
Pain is worse getting out of
bed
The day after a match or atraining session
Gilmores Groin
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
57/61
Pain is increased byexternal rotation
Or hyperextension of hip
Pain is localised to lower
anterior abdominal wall Adductor or perineal
region
Gilmores Groin
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
58/61
Torn external obliqueaponeurosis
Torn conjoint tendon
A dehiscence between
conjoint tendon and theinguinal ligament
The absence of a hernial sac
Superficial inguinal ring on the
affected side is dilated andtender
Cough impulse
Gilmores Groin
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
59/61
Treatment is surgical
90% return to sport
Strengthen lower
abdominal muscles
1. Plication of the
transversalis fascia in
Shouldice hernia repair
2. Repair of torn conjointtendon
Gilmores Groin Surgery
G G S
MOB TCD
-
7/28/2019 Anterior Abdominal Muscles BMJ
60/61
3. Approximation of conjoint
tendon to the inguinal
ligament
4. Repair of the external
oblique
5. Reconstitution of the
superficial inguinal ring
Gilmores Groin Surgery
-
7/28/2019 Anterior Abdominal Muscles BMJ
61/61
BMJ Publishing Group Limited (BMJ Group) 2012. All rights reserved.