Far Eastern University

Nicanor Reyes Medical Foundation

Biochemistry
Anterior Abdominal Wall
Dr. Bea (August 18, 2014)

*Rationale behind division indicate exact site of patients

pain/tenderness/etc. (pinpoint the region); estimate the
organs that are bound within the region; make the
description of signs and symptoms more exact/specific

Abdomen

region of the body

lower part of the trunk (thorax upper part of trunk)
boundaries
o
superior

subcostal margin surface

diaphragm abdominal/peritoneal cavity

o
inferior

pelvic inlet

Divisions of the Abdomen

Regions
o
traditional
o
divided into nine regions by two pairs of lines

two vertical lines

pass through midpoint between

anterior superior iliac spine and
symphysis pubis
along the margin of the rectus
abdominis
right and left lateral rectus plane (linea
semilunaris) (Netter)

two horizontal lines

one at the level of rib cage margin,
another at the spine (anterior superior
iliac spine)
subcostal plane
o
joins lowest point of costal margin
on each side (10th costal cartilage)
o
lies at the level of 3rd lumbar
vertebrae
intertubercular plane (based on Snells
figure 4.12, p. 122)
o
joins tubercles on iliac crests
o
lies at the level of 5th lumbar
vertebra
OR
interspinous plane (based on Netters
plate 244, p. 244 below)

Quadrants
o
common practice now
o
divided into four quadrants
by a vertical and horizontal
line
o
epigastrium loosely used
to indicate area below
xiphoid process and above
umbilicus
o
periumbilical loosely used
to indicate umbilicus and
the area around it
o
contents (based on Stephen
Gabasans trans [2013]; they werent discussed
though)

Right
Upper
Quadrant

head of pancreas
gallbladder
pylorus
first three parts of duodenum
superior part of ascending
colon

Left
Upper
Quadrant

body and tail of pancreas

spleen
most of the stomach,
jejunum and proximal ileum
superior part of the
descending colon
cecum
appendix
most of the ileum
inferior part of the
ascending colon
sigmoid colon
inferior part of the
descending colon

Right
Lower
Quadrant
Left
Lower
Quadrant

right lobe of liver

right suprarenal gland
right kidney
right colic (hepatic)
flexure
right half of transverse
colon
left lobe of liver
left suprarenal gland
left kidney
left colic (splenic) flexure
left half of transverse
colon
right ovary
right uterine tube
right ureter
right spermatic cord
left ovary
left uterine tube
left ureter
left spermatic cord

Abdominal Wall

made up of skin, superficial fascia, deep fascia,

muscles, extraperitoneal fascia, and parietal
peritoneum

loosely attached to underlying structures, except at

umbilicus (tethered to the scar tissue)
umbilicus
o
scar that represents site of attachment of
umbilical cord in fetus
o
situated at linea alba
linea alba
o
vertically running fibrous band
o
extends from symphysis pubis to xiphoid process
and lies in midline
o
formed by fusion of aponeuroses of lateral
muscles of the two sides

Skin

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Alyssa Willis L. Ng, 1E, A.Y. 2014-2015

Fascia

Superficial Fascia
o
Superficial layer

Campers Fascia
fatty layer of subcutaneous fascia
continuous with the superficial fat over
rest of the body
may be extremely thick
o
Deep layer

Scarpas Fascia
deep membranous layer
thin and fades out laterally and above
(becomes continuous with superficial
fascia of back and thorax)
adherent to underlying structures
easily identified on lateral aspect of
abdominal wall

Colles fascia
Scarpas fascia attached on each side
of pubic archs margins (below in the
perineum, after entering wall of
scrotum/labia majora)
Deep Fascia
o
Transversalis Fascia

thin layer of fascia

lines the transversus abdominis muscle

continuous with similar layer lining the

diaphragm and iliacus muscle

lies immediately deep to the Campers

fascia

Muscles

Lateral side/Oblique muscles

o
External Oblique

broad, thin, muscular sheet

posterior border is free

o
Internal Oblique

broad, thin, muscular sheet lying deep to

external oblique

fibers run at right angles to those of external

oblique

posterior borders of muscles are attached to

lumbar vertabrae
o
Transversus Abdominis

thin sheet of muscle that lies deep to internal

oblique

fibers run horizontally forward

posterior borders of muscles are attached to

lumbar vertabrae
Middle
o
Rectus Abdominis

long strap muscle

extends along the whole length of the

anterior abdominal wall

broader above and lies close to the midline

separated from its fellow by linea alba

divided into distinct segments by three

transverse tendinous intersections
(intersections are strongly attached to
anterior wall of rectus sheath)
at level of xiphoid process
at level of umbilicus
at halfway between the two

Rectus Sheath

long fibrous sheath that encloses rectus abdominis

muscle and pyramidalis muscle (if present)
formed mainly by the aponeuroses of the three
lateral abdominal muscles (external and internal
oblique and transversus abdominis)
contains the anterior rami of the lower six thoracic
nerves
contains the superior and inferior epigastric vessels
and lymph vessels
separated from its fellow on the opposite side by
linea alba
considered at three levels (A, B, C)
A
o
above costal margin
o
anterior wall aponeurosis of external oblique
o
posterior wall thoracic wall (5th, 6th, and 7th
costal cartilages and intercostal spaces)

B internal oblique splits into two

o
between costal margin and level of anterior
superior iliac spine (above arcuate line)
o
anterior wall aponeurosis of external oblique,
anterior aponeurosis of internal oblique
o
posterior wall posterior aponeurosis of internal
oblique, aponeurosis of transverse aponeurosis

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Alyssa Willis L. Ng, 1E, A.Y. 2014-2015

Hesselbachs Triangle
found on lower abdominal wall
boundaries

medially: lateral border of rectus abdominis

laterally: inferior epigastric vessels

inferiorly: inguinal ligament

o
potential site for direct inguinal hernia

weakened portion because there are less

overlapping muscles

increase in pressure when there is strain

(lifting heavy weight, defecation), organs
protrude outward to the abdominal wall
o
o

C
o
o
o
o
o

between level of anterior superior iliac spine

and pubis (section below arcuate line)
anterior wall - aponeuroses of all three muscles
posterior wall absent; replaced by
transversalis fascia
rectus muscle lies in contact with transversalis
fascia
arcuate line/semilunar line of Douglas

pt. of termination of posterior rectus sheet

between umbilicus and symphysis pubis

Ligaments

found posterior to the anterior abdominal wall

o
median umbilical ligament

from obliterated allantois (urachus)

connects umbilicus to urinary bladder

o
medial umbilical ligament

from obliterated distal umbilical arteries

located laterally in reference to median

umbilical ligament

differs from lateral umbilical ligament part

of peritoneum that is folded as it goes over
the inferior epigastric vessels; not an
obliterated structure
o
ligamentum teres hepatis from obliterated left
umbilical vein

Blood Supply of the Abdominal Wall

Blood vessels in the compartment of the rectus

sheath:
o
Superior Epigastric Artery from internal thoracic
artery (originates from subclavian artery)

entrance: upper part of rectus sheath, bet.

sternal and costal origins of diaphragm

descends behind rectus muscle

supplies upper central part of anterior

abdominal wall

branches anastomoses with inferior

epigastric artery
o
Inferior Epigastric Artery from external iliac
artery

runs upward and medially along medial side

of deep inguinal ring

entrance: pierces fascia transversalis,

anterior to arcuate line

ascends behind rectus muscle

supplies lower central part of anterior

abdominal wall

branches anastomoses with superior

epigastric artery
o
Superior Epigastric Vein drains to internal
thoracic vein
o
Inferior Epigastric Vein drains to external iliac
vein

superior epigastric artery (from internal

thoracic/mammary artery)
inferior epigastric artery (from external iliac artery)
deep circumflex iliac artery lateral; from external
iliac artery
o
supplies lower lateral part of abdominal wall
o
form anastomosis with musculophrenic artery
superficial circumflex iliac artery, superficial
epigastric artery and superficial external pudendal
artery from femoral artery
lower two posterior intercostals arteries, branches of
descending thoracic aorta, four lumbar arteries,
and branches of abdominal aorta supply lateral
part of abdominal wall

Blood Drainage

Superficial veins
o
above: lateral thoracic vein axillary vein
o
below: superficial epigastric and great
saphenous vein femoral vein
o
paraumbilical veins

located around umbilicus

connect network through umbilicus and

along ligamentum teres to portal vein,
which forms the portal-systemic venous
anastomosis
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Alyssa Willis L. Ng, 1E, A.Y. 2014-2015

usually collapsed/normally closed but can

dilate in cases such as liver cirrhosis

caput medusa and spider angiomatas

seen in portal hypertension
centrifugal circulation happens blood
backflows to the portal vein and
eventually goes back to peripheral
veins; this is to reduce hepatic portal
vein pressure)
Deep veins
o
superior epigastric vein internal thoracic vein
o
inferior epigastric and deep circumflex iliac
veins external iliac veins
o
posterior intercostals veins azygos veins
o
lumbar veins inferior vena cava

Nerve Supply

Anterior rami of lower six thoracic and 1st lumbar

nerves
o
thoracic nerves lower 5 intercostal nerves and
subcostal nerve

pierces posterior wall of rectus sheath to

supply rectus muscle and pyramidalis (T12
only)

terminates by piercing anterior wall of the

sheath
o
1st lumbar nerve - represented by
iliohypogastric and ilioinguinal nerves (branches
of lumbar plexus)

doesnt enter rectus sheath

pierces external oblique aponeurosis

above superficial inguinal ring
o
Motor compartment

passes forward in the interval between the

internal oblique and transversus abdominis
muscles

innervate the muscles

o
Sensory compartment

reflections of motor component

dermatomal segments
T7 xiphoid process
T10 umbilicus
L1 inguinal region

Inguinal Region

triangular area on lowermost end of abdominal wall

from anterior superior iliac spine to pubic tubercle
and down to the scrotum/labia majora
inguinal canal
o
portion of the inguinal region
o
made up of aponeurosis of the abdominal wall
muscles
o
parallel to and immediately above inguinal
ligament

o
o

oblique passage through the lower part of the

anterior abdominal wall

males: allows structures to pass to and from

testis to the abdomen

females: allows the round ligament of the

uterus to pass from the uterus to the labium
majus
about 1.5 in (4 cm) long in the adult
from the deep inguinal ring, a hole in the fascia
transversalis extends downward and medially
to the superficial inguinal ring, a hole in the
aponeurosis of the external oblique muscle
in newborns, the deep ring lies almost directly
posterior to the superficial ring (canal is shorter
at this age); as child grows, deep ring moves
laterally
deep inguinal ring

oval opening in transversalis fascia

above the inguinal ligament, midway bet.

anterior superior iliac spine and symphysis
pubis

related to it medially inferior epigastric

vessels, which pass upward from external
iliac vessels

internal spermatic fascia/internal covering

of the round ligament of the uterus
attaches to the rings margins
superficial inguinal ring

triangular-shaped defect in the

aponeurosis of external oblique muscle

lies immediately above and medial to the

pubic tubercle

crura margins of the ring

external spermatic fascia attaches to the

crura
walls of inguinal canal

inferior wall
inguinal ligament and lateral ligament
of mediastinum

superior wall
arching over fibers of transversus
abdominis and internal oblique

anterior wall
external oblique aponeurosis
reinforced laterally by origin of internal
oblique from the inguinal ligament
weakest part: superficial inguinal ring
strongest where it lies opposite the
weakest part of the posterior wall (DIR)

posterior wall
medially: conjoint tendon made by
lower fibers of internal oblique and
transversalis fascia
laterally: fascia transversalis
weakest part: deep inguinal ring
strongest where it lies opposite the
weakest part of the anterior wall (SIR)
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Alyssa Willis L. Ng, 1E, A.Y. 2014-2015

contents of inguinal canal

spermatic cord (collection of structures
that pass through inguinal canal to
and from the testis; begins at the deep
inguinal ring lateral to inferior epigastric
artery and ends at testis)
o
vas deferens
o
testicular artery
o
testicular veins (pampiniform
plexus) drains to left renal vein
(on the left side) and inferior vena
cava (on the right side); when
dilated, can cause varicose veins
(varicocoele) in the scrotum
o
testicular lymph vessels
o
autonomic nerves
o
remains of the processus vaginalis
o
genital branch of the
genitofemoral nerve supplies the
cremaster muscle
round ligament (attached to uterus up
to labia majora)

Abdominal Incisions

vertical incision
oblique or transverse incision
thoracoabdominal incision
midline incision
o
very versatile
o
can use this to explore the entire abdomen
limited incision (if more certain of the pathology);
limited area of exposure
o
McBurney

for appendectomy

oblique
o
Pfannenstiel

CS section

oblique

Bikini incision

Hernia

protrusions of the abdominal contents beyond

normal confines of the abdominal wall
3 contents
o
sac
o
sacs contents
o
sacs coverings
Indirect inguinal hernia
o
most common
o
passes to the inguinal canal
o
bulge: lateral to the inferior epigastric vessel,
sometimes extend all the way to the scrotum
Direct inguinal hernia
o
15% of all inguinal hernias
o
more common in old men than women (rare in
women)
o
hernia sac bulges forward in the area called
Hesselbachs triangle
o
bulge: medial to the epigastric vessel; does not
extend to the scrotum
o
caused: weakened muscles, frequent straining

Cremasteric Reflex

stroke inner side of the thigh

causes contraction
testis goes upward for warmth

Quotable Jokes
We know that the Campers is more superficial because it
Campers.
(On Pfannenstiel) Natatago daw ng bikini iyon. I dont know
nowadays kung matatago pa ng bikini iyon, okay? Kasi yung
mga bikini ngayontalagangkini! kini na lang.
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Alyssa Willis L. Ng, 1E, A.Y. 2014-2015