Abdominal Wall

Surface Anatomy of the Abdomen

Before getting into

the nitty gritty of
the abdomen, keep
in mind that you
want to be able to
use your
knowledge to
project the
anatomy onto the
surface of the
abdomen. You will
want to be able to
visualize the
relative positions
of abdominal
organs as they lie
within the
abdomen.
Clinicians might
use several
different ways of
subdividing the
surface of the
anterior abdominal
wall but I will only
present two of
them here. By
subdividing the
surface into
regions, one person
can tell another
person exactly
where to look for
possible problems.

The easiest is to
separate the surface
into 4 quadrants:

• upper left
quadrant
ULQ
• lower left
quadrant
LLQ
• upper right
quadrant
URQ
• lower right
quadrant
LRQ

These quadrants
are developed by
dropping a vertical
line down the
middle of the
sternum MSP and a
horizontal line
across and through
the umbilicus TUP
The second way of
dividing the
abdominal surface
is into 9 regions:

• left
hypochondr
iac LH
• left lumbar
LL
• left iliac LI
• epigastric E
• umbilical U
• hypogastric
H
• right
hypochondr
iac RH
• right
lumbar RL
• right iliac
RI

These regions are

formed by two
vertical planes and
two horizontal
planes. The two
vertical planes are
the lateral lines
LLL and RLL.
These lines are
dropped from a
point half way
between the jugular
notch and the
acromion process.

The two horizontal

planes are the
transpyloric plane
TPP and the
transtubercular
plane TTP. The
tubercles are the
tubercles of the
iliac crests.

As a student of anatomy, it is sometimes fun to pretend that you are going to be a surgeon
and are, at this point, considering entering the abdominal cavity to remove or reconstruct
something in the abdominal cavity. It would helpful if you knew what makes up the wall
of the abdomen so that you would be able to judge how deep you have gone with each
knife cut. This brings us to the discussion of the abdominal wall.

When considering the abdominal wall, you will need to know where, specifically it is that
you want to enter.

Layers of the Abdominal Wall

The layers of
the abdominal
wall vary,
depending on
where it is you
are looking.
For instance, it
is somewhat
different along
the lateral sides
of the abdomen
than it is at the
anterior side. It
is also
somewhat
different at its
lower regions.
Lets start out
along the
lateral side of
the abdomen:

• skin

• superfic
ial
fascia

• deep
fascia
 • muscle

• subsero
us
fascia

• peritone
um

At the lateral
side of the
abdomen (1)
there is a
dotted line
passing
through the
abdominal
wall. Note the
layers a
surgeons knife,
a criminal
knife or a
anatomy
student's knife
must pass
through to get
to the
peritoneal
cavity:

1. skin
2. superfic
ial
fascia
(this
may be
as thin
as or
less
than a
half
inch or
as thick
 as 6
inches
or
more)
3. deep
fascia
(all
skeletal
muscle
is
surroun
ded
within
its own
deep
fascia).
The
deep
fascia
of the
abdomi
nal wall
is
differen
t than
that
found
around
muscles
of the
extremi
ties,
howeve
r. It is
of the
loose
connect
ive
tissue
variety.
It is
necessa
ry in
the
abdomi
nal wall
 because
it offers
more
flexibili
ty for a
variety
of
functio
ns of
the
abdome
n. At
certain
points,
this
fascia
may
become
aponeur
otic and
serve as
attachm
ents for
the
muscle
to bone
or to
each
other,
as is the
case at
the
linea
alba.
4. subsero
us
fascia
also
known
at
extraper
itoneal
fascia
(a layer
of loose
connect
ive
tissue
that
serves
as a
glue to
hold the
peritone
um to
the
deep
fascia
of the
abdomi
nal wall
or to
the
outer
lining
of the
GI
tract. It
may
receive
differen
t names
dependi
ng on
its
location
(i.e.
transver
salis
fascia
when it
is deep
to that
muscle,
psoas
fascia
when it
is next
to that
muscles
, iliac
fascia,
 etc.)

5. peritone
um (a
thin one
cell
thick
membra
ne that
lines
the
abdomi
nal
cavity
and in
certain
places
reflects
inward
to form
a
double
layer of
peritone
um)
Double
layers
of
peritone
um are
called
mesente
ries,
omenta,
falcifor
m
ligamen
ts,
lienoren
al
ligamen
t, etc.)
At the anterior
wall of the
abdomen, in
the midline
there is no
muscle so a
knife would
only go
through the:

1. skin
2. superfic
ial
fascia
3. deep
fascia
(in this
case a
thicken
ed area
of deep
fascia
called
the
linea
alba)
4. subsero
us
fascia

5. peritone
um
If we look
at the wall
inferior to
the level of
the belly
button
(umbilicus)
, you will
see that the
superficial
fascia has
become
divided
into to
parts:

• a
sup
erfi
cial
fatt
y
part
that
is
con
tinu
ous
wit
h
the
sam
e
laye
r
ove
r
the
rest
of
the
bod
y
(Ca
mp
er's
fasc
ia)

• a
dee
p
me
mbr
ano
us
laye
r
that
is
con
tinu
ous
do
wn
into
the
peri
neu
m
to
surr
oun
d
the
pen
is
and
to
for
ma
laye
r of
the
scro
tum
.
(Sc
arp
a's
fasc
ia)
As you examine
the abdomen in
thin subjects, you
may be able to see
the superficial
veins that drain
the abdominal
wall. These veins
drain into one of
two major veins:

• subclavian
(not
shown)
• femoral (F)

and also into a

minor, but
important vein, the
paraumbilical vein
PU. The
paraumbilical vein
drains into the
portal vein and
then through the
liver. This is an
important clinical
connection.

The lower
abdominal wall is
drained by way of
the superficial
epigastric SE and
superficial
circumflex iliac
SCI veins into the
femoral vein.

The upper
abdominal wall is
drained by way of
the
thoracoepigastric
TE and lateral
thoracic LT veins
into the
subclavian.

Muscles of the Abdominal Wall

It is now time to consider the muscles that make up the anterior and anterolateral
abdominal wall. There are 4 pairs of muscles to consider. We will remove layers
carefully to see the deeper levels. As we go deeper through the layers, you should be
aware of the cutaneous veins and nerves that travel in the layers.
The most superficial layer of
anterolateral muscles are the:

• external abdominal
obliques EAO

Notice on the right side of the

specimen that the lower part
of the superficial fascia has
been left behind so that you
might see its two layers, the
fatty layer (Camper's fascia)
CF and the membranous layer
(Scarpa's fascia) SF. Running
through the fatty layer are the
superficial veins, the
superficial epigastric SE, the
paraumbilical veins radiating
out from the umbilicus and
the thoracoepigastric vein TE.

The cutaneous nerves to the

abdomen are mainly
continuations of the lower
intercostal nerves (T7 - T12).
An important level to
remember is that the
umbilical region is supplied
by the 10th intercostal nerve.
The lowermost part of the
abdominal wall is supplied by
a branch of L1, the
iliohypogastric IH nerve. Its
other branch is the
ilioinguinal II nerve.

You should also identify the

linea alba LA. This white line
is where the aponeuroses of
the external abdominal
oblique, internal abdominal
oblique, and transverse
abdominis muscles converge
at the midsagittal part of the
abdominal wall.
In the image, the left external
abdominal oblique has been
cut away at the white dotted
line and removed in order to
show the internal abdominal
oblique IAO. You can also
see lower cut edge of the
external abdominal oblique at
the inguinal ligament IL

The anterior wall of the rectus

sheath RS has also been
removed on the right side in
order to see the underlying
right rectus abdominis RA
muscle. Note that the rectus
abdominis muscle is
subdivided into small sections
by so called tendinous
inscriptions TI. This
arrangement is what forms
the wash-board abs in well-
exercised people.

We will discuss the formation

of the rectus sheath in a
moment.

You may also see a small

muscle overlying the inferior
end of the rectus abdominis
muscle, the pyramidalis
muscle PY. This small
muscles tenses the lower part
of the linea alba.
In this specimen, the rectus
abdominis muscle, internal
abdominal oblique and
anterior rectus sheath have
been removed. You can
identify the posterior rectus
sheath and its lower free
margin, the arcuate line AL.
What you see below this line
is the transversalis fascia and
running in the fascia is the
inferior epigastric artery IEA,
a branch of the external iliac
artery. This artery enters the
rectus sheath posterior to the
rectus abdominis muscle and
supplies the anterior
abdominal wall. Extending
from the top, is a branch of
the internal thoracic (or
mammary) artery, the
superior epigastric artery.

Also note that the cutaneous

nerves are found to lie
between the internal
abdominal oblique and the
transversus abdominis
muscles.