Anatomy of the Anterior

Abdominal Wall
Dr Leroy Campbell
 Embryological development
 Anatomical features of anterior abdominal
wall
 Relationship between structure and
function
 Clinical and surgical relevance
 Disease
 Congenital or acquired
 incisions
Embryology of the anterior
abdominal wall
 During the 4th to 5th week of
development, the flat embryonic disk
folds in four directions and/or
planes:
 Cephalic
 Caudal
 Right lateral
 left lateral
1. Amniotic cavity

2. Ectoderm

3. Umbilical vesicle

4. Endoderm

5. Body stalk

6. Allantois

7. Extraembryonic mesoderm

8. Cloacal membrane

9. Notochordal process

10. Primitive streak

Shrinking Primitive streak

11. Neural plate

Neural folds

14. notochord
20. Fused neural tube
Septum transversum

29. Aortas
30. Umbilical veins

31. Intraembryonic mesoderm

32. Paraxial mesoderm

33. Intermediate mesoderm

34. Lateral plate mesoderm

35. Canalis centralis

36. Somite

37. Nephrogenic cord

1. Amniotic cavity

2. Ectoderm

3. Umbilical vesicle

4. Endoderm

5. Body stalk

6. Allantois

7. Extraembryonic mesoderm

8. Cloacal membrane

9. Notochordal process

10. Primitive streak

Shrinking Primitive streak

11. Neural plate

Neural folds

14. notochord
20. Fused neural tube
Septum transversum

29. Aortas
30. Umbilical veins

31. Intraembryonic mesoderm

32. Paraxial mesoderm

33. Intermediate mesoderm

34. Lateral plate mesoderm

35. Canalis centralis

36. Somite

37. Nephrogenic cord

1. Amniotic cavity

2. Ectoderm

3. Umbilical vesicle

4. Endoderm

5. Body stalk

6. Allantois

7. Extraembryonic mesoderm

8. Cloacal membrane

9. Notochordal process

10. Primitive streak

Shrinking Primitive streak

11. Neural plate

Neural folds

14. notochord
20. Fused neural tube
Septum transversum

29. Aortas
30. Umbilical veins

31. Intraembryonic mesoderm

32. Paraxial mesoderm

33. Intermediate mesoderm

34. Lateral plate mesoderm

35. Canalis centralis

36. Somite

37. Nephrogenic cord

 Each fold converges at the site of the umbilicus.
 The lateral folds form the lateral portions of the abdominal
wall
 lateral abdominal wall
 future umbilical ring
 cephalic and caudal folds make up the epigastrium and
hypogastrium :
 Cephalic
 Anterior
 Contains:
 foregut
 stomach
 mediastinal/thoracic contents
 Caudal:
 Posterior
 Contains:
 colon
 rectum
 bladder
 Rapid growth of the intestines and liver
also occurs.
 During the 6th week of development (or eight
weeks from the last menstrual period), the
abdominal cavity temporarily becomes too
small to accommodate all of its contents
 resulting in protrusion of the intestines into the
residual extraembryonic coelom at the base of the
umbilical cord.
 This temporary herniation is called
physiologic midgut herniation (PMH) and
is sonographically evident between the 9th
to 11th postmenstrual weeks.
Dy 41- physiologic umbilical hernia
Dy 53
 Reduction of
this hernia
occurs by the
12th
postmenstrual
week.
 Congenital Abdominal Wall
Defects
 Omphalocele/Exomphalos:
 Congenital herniation of abdominal contents at the umbilicus (i.e. into the umbilical cord). Occasionally divided
into:
 <4cm - umbilical cord hernia
 >4cm - omphalocele.
 Rarely occurs above or below umbilicus.
 Amniotic sac (amnion & peritoneum) is always present but it may have ruptured at or before birth exposing
the contents.

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

 Prune Belly Syndrome:

 Congenital deficiency of abdominal musculature, urinary tract dilatation and cryptorchidism.
 There are three grades:
 I. Severe renal and pulmonary disease incompatible with life.
 II. Severe uropathy requiring extensive reconstruction.
 III. Healthy neonates requiring little or no surgery.

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

Omphalocele
gastroschisis
Prune Belly
Bladder extrophy
Anatomy
 Anterior abdominal wall

 The anterior abdominal

wall extends from the
costal margins and
xiphoid process superiorly
to the iliac crests, pubis
and pubic symphysis
inferiorly.
 It overlaps and is
connected to both the
posterior abdominal wall
and paravertebral tissues.
 It forms a continuous but flexible sheet of
tissue across the anterior and lateral
aspects of the abdomen.
 The anterior abdominal wall is composed
of:
 the integument
 Muscles
 connective tissue lining the peritoneal cavity.
 skin
 non-specialized
 variably hirsute
 depending on the sex and race.
 All individuals have some extension of the
pubic hair onto the anterior abdominal wall
skin
 this is commonly most pronounced in males,
in whom the hair may extend almost up to the
umbilicus in a triangular pattern.
 Subcutaneous tissue
 The subcutaneous tissue over most of the
wall includes a variable amount of fat.
 It is a major site of fat storage.
Males are especially susceptible to
subcutaneous accumulation in the lower
anterior abdominal wall and may have
disproportional amounts of fat here while
having more normal amounts elsewhere.
 Subcutaneous tissue
 Inferior to the umbilicus, the deepest part of the
subcutaneous tissue is reinforced by many
elastic and collagen fibers, so the subcutaneous
tissue here has two layers:
 a superficial fatty layer (Camper fascia)
 a deep membranous layer (Scarpa fascia)
 It is loosely connected by areolar tissue to the
aponeurosis of external oblique, but in the midline it
is intimately adherent to the linea alba and symphysis
pubis.
 the anterolateral muscles of the
abdomen (five pairs):
 Vertical
1. Rectus abdominis
2. Pyramidalis
 Flat
1. external oblique
2. internal oblique
3. transversus abdominis
 Rectus abdominis
 long, strap-like muscle
 Origin:
 Pubic symphysis and pubic
crest
 Insertion:
 Xiphoid process and 5th and
7th costal cartilages

 extends along the entire

length of the anterior
abdominal wall
 widest in the upper
abdomen and lies just to
the side of the midline.
 The paired recti are
separated in the midline by
the linea alba
 Rectus abdominis
 The muscle fibres of
rectus abdominis are
interrupted by three
fibrous bands or
tendinous intersections.
 One is usually situated at
the level of the umbilicus,
 opposite the free end of
the xiphoid process
 a third about midway
between the other two
 Rectus abdominis
 They are rarely full-
thickness and may extend
only half-way through the
body of the muscle.
 They usually fuse with the
fibres of the anterior
lamina of the sheath of
the muscle.
 Sometimes, one or two
incomplete intersections
are present below the
umbilicus.
 linea alba
 The linea alba is a
tendinous raphe extending
from the xiphoid process to
the symphysis pubis and
pubic crest.
 It lies between the two recti
and is formed by the
interlacing and decussating
aponeurotic fibres of the
three flat muscles.
 linea alba
 linea alba has two
attachments at its lower
end:
 its superficial fibres are
attached to the symphysis
pubis
 deeper fibres form a
triangular lamella that is
attached behind rectus
abdominis to the posterior
surface of the pubic crest on
each side.
This posterior attachment of
linea alba is named the
'adminiculum lineae albae'
 linea alba
 It is visible only in the
lean and muscular, as
a slight groove in the
anterior abdominal
wall.
 linea alba
 A fibrous cicatrix,
the umbilicus, lies a
little below the
midpoint of the
linea alba, and is
covered by an
adherent area of
skin.
 Rectus abdominis

 Its lateral border may be visible on

the surface of the anterior
abdominal wall as a curved groove,
the linea semilunaris
 which extends from the tip of the ninth
costal cartilage to the pubic tubercle.
 In a muscular individual it is readily
visible, even when the muscle is
not actively contracting
 but in many normal and obese
individuals it may be completely
obscured.
 RECTUS SHEATH
 Rectus abdominis on each side
is enclosed by a fibrous sheath:
 rectus sheath is formed from
decussating fibres from all
three lateral abdominal
muscles
 The anterior portion of this
sheath extends the entire
length of the muscle and fuses
with the periosteum of the
muscle attachments.
 Posteriorly, the sheath is complete
in the upper two-thirds of the
muscle.
 Arcuate line
 In the lower one-third, the
posterior layer of the
sheath stops approximately
midway between the
umbilicus and the pubis.
 The lower border of the
posterior sheath is
called the arcuate line.

In most individuals this is a

clearly defined line,
although the transition may
not always be clear-cut in
others.
 Level of arcuate line
 Pyramidalis
 a triangular muscle that lies in front of the lower part of
rectus abdominis within the rectus sheath.
 It is attached by tendinous fibres to the front of the pubis
and to the ligamentous fibres in front of the symphysis.
 it diminishes in size as it runs upwards, and ends in a
pointed apex that is attached medially to the linea alba.
 This attachment usually lies midway between the
umbilicus and pubis, but may occur higher.
 The muscle varies considerably in size. It may be larger
on one side than on the other, absent on one or both
sides, or even doubled.
 absent in approximately 20% of people
 Flat muscles
 External oblique is the largest and the
most superficial of the three lateral
abdominal muscles.
 External Oblique
 Origin:
 External surfaces of 5th-12th ribs
 Insertion:
 Linea alba
 pubic tubercle
 outer lip of the anterior half of iliac crest
 External Oblique
 The attachments
rapidly become
muscular and
interdigitate with the
lower attachment of
serratus anterior and
latissimus dorsi along
an oblique line that
extends downwards
and backwards.
 External Oblique
 The attachments
rapidly become
muscular and
interdigitate with
the lower
attachment of
serratus anterior
and latissimus dorsi
along an oblique
line that extends
downwards and
backwards
 External Oblique
 The muscle fibers
become
aponeurotic
approximately at
the
 MCL medially
 spinoumbilical line
(line running from
the umbilicus to the
ASIS) inferiorly
 External Oblique
 the posteriormost fibers from
rib 12 are nearly vertical as
they run to the iliac crest
 the more anterior fibers fan
out, taking an increasingly
medial direction
 most of the fleshy fibers run
inferomedially
 Similar to fingers when the
hands are in one's side
pockets
 with the most anterior and
superior fibers approaching a
horizontal course.
 External Oblique
 The aponeurosis forms a sheet of tendinous
fibers
 Fibers decussate at the linea alba, most
becoming continuous with tendinous fibers of
the contralateral internal oblique.
 Thus the contralateral external and internal
oblique muscles together form a digastric
muscle.
 a two-bellied muscle sharing a common central
tendon that works as a unit.
 External Oblique
 The inferior margin of the
external oblique
aponeurosis is thickened
as an undercurving fibrous
band with a free posterior
edge that spans between
the ASIS and the pubic
tubercle as the inguinal
ligament (Poupart
ligament)
 Internal oblique
 Origin:
 Thoracolumbar fascia
 anterior two-thirds of iliac
crest
 lateral half of inguinal
ligament
 Insertion:
 Inferior borders of 10th-12th
ribs
 linea alba
 pecten pubis via conjoint
 Internal oblique
 Except for its lowermost
fibers, which arise from
the lateral half of the
inguinal ligament, its
fleshy fibers run
perpendicular to those
of the external oblique
 running superomedially
(like your fingers when
the hand is placed over
your chest).
 Internal oblique
 Its fibers also
become
aponeurotic in
roughly the same
(midclavicular) line
as the external
oblique and
participate in the
formation of the
rectus sheath.
 Transverse abdominal
 Origin:
 Internal surfaces of 7th-12th costal cartilages
 thoracolumbar fascia
 iliac crest
 lateral third of inguinal ligament
 Insertion:
 Linea alba with aponeurosis of internal oblique
 pubic crest, and pecten pubis via conjoint tendon
 Transverse abdominal
 the innermost of the three
flat abdominal muscles
 Fibres run more or less
transversally except for the
inferior ones, which run
parallel to those of the
internal oblique.
 The fibers of the transverse
abdominal muscle also end
in an aponeurosis which
contributes to the
formation of the rectus
sheath
 Functions and Actions of the
Anterolateral Abdominal Muscles
1. Form a strong expandable support for the
anterolateral abdominal wall.- all
 Facilitate expansion during respiration
2. Protect the abdominal viscera from injury.- all
3. Compress the abdominal contents to maintain or
increase the intra-abdominal pressure and, in so
doing, oppose the diaphragm- oblique and
transverse muscles, acting together bilaterally
 expel air during respiration and more forcibly for coughing,
sneezing, nose blowing, voluntary eructation (burping), and
yelling or screaming
 produce the force required for defecation, micturition, vomiting,
and parturition.

4. Move the trunk and help maintain posture.- all

• Antilordosis, flexion and twisting of the spine
 internal (posterior) surface
 covered with
 transversalis fascia
 a variable amount of extraperitoneal fat
 parietal peritoneum
 transversalis fascia

 It is part of the general layer of fascia between the

peritoneum and the abdominal wall.
 Posteriorly, it is continuous with the anterior layer of the
thoracolumbar fascia
 it forms a continuous sheet anteriorly
 Inferiorly, it is continuous with the iliac and pelvic
fasciae
 superiorly it blends with the fascial covering of the
inferior surface of the diaphragm.
 It is attached to the entire length of the iliac crest
between the origins of transversus abdominis and iliacus
and to the posterior margin of the inguinal ligament.
 transversalis fascia
 The spermatic cord in the male/round
ligament of the uterus in the female, pass
through the transversalis fascia at the
deep inguinal ring.
 the transversalis fascia is prolonged on
these structures as the internal spermatic
fascia
 peritoneum
 single layer of serosa
 supported by a thin layer of connective
tissue that lines the abdominal cavity.
 Five vertical folds are formed by
underlying ligaments or vessels that
converge at the umbilicus
 Peritoneum
 median umbilical fold extends from
the apex of the urinary bladder to
the umbilicus
 covers the median umbilical ligament
 the remnant of the urachus, which
joined the apex of the fetal bladder to
the umbilicus
 Two medial umbilical folds
 lateral to the median umbilical fold
 cover the medial umbilical ligaments
 formed by occluded parts of the
umbilical arteries.
 Two lateral umbilical folds
 lateral to the medial umbilical folds
 cover the inferior epigastric vessels and
therefore bleed if cut.
 Blood supply
 The blood supply of the abdominal wall:
 superficial vasculature
 supply the tissues above the external oblique aponeurosis and
the anterior rectus sheath.
 located in the subcutaneous tissues and consists of branches
of the femoral artery including the:
 superficial inferior epigastric
 superficial external pudendal
 superficial circumflex arteries.
 Deep vasculature
 the inferior and superior deep epigastric arteries
 the deep circumflex artery.
 These vessels are located in the musculofascial layers.
 superior deep epigastric artery
 a terminal branch of the
internal thoracic artery
 descends between the
costal and xiphoid slips of
the diaphragm,
accompanied by two or
more veins
 enters the rectus sheath
behind rectus abdominis
and runs down to
anastomose with the
inferior epigastric artery at
the level of the umbilicus
 superior epigastric artery
 anastomoses with the
same contralateral
branch via a branch
given off in the upper
rectus sheath which
passes anterior to the
xiphoid process of the
sternum
 This vessel may give
rise to troublesome
bleeding during surgical
incisions that extend up
to and alongside the
xiphoid process
 superior epigastric artery
 Obstruction of the aorta
or iliac artery results in
considerable collateral
circulation through the
epigastric vessels.
 If they are ligated,
ischemia of the lower
extremity may result.
Therefore, it is important
to temporarily occlude
the arteries and then
palpate the dorsal pedis
pulse before transecting
them.
 Musculophrenic artery
 The musculophrenic
artery is also a
branch of the internal
thoracic artery.
 It lies behind the
costal cartilage to
supply the intercostal
spaces and upper
abdominal wall.

 Inferior deep epigastric arteries
 branches from the external iliac artery as it passes under
the middle of the inguinal ligament.
 ascends medial to the inguinal ring and superficial to the
transversalis fascia.
 It then proceeds toward the umbilicus and crosses the
lateral border of the rectus muscle at the arcuate line
where it enters the posterior rectus sheath.
 Once the artery enters the sheath, it branches
extensively.
 The angle between the vessels and lateral border of the
rectus forms the apex of the inguinal (Hasselbach's)
triangle, the base of which is the inguinal ligament.
 Inferior deep epigastric arteries
 The inferior deep epigastric vessels are bounded
only by loose areolar tissue below the arcuate
line.
 Trauma to this portion of the inferior deep
epigastric artery may result in considerable
hemorrhage.
 Because hematomas commonly dissect into the
retroperitoneal space, large quantities of blood
may be lost before outward evidence of
hematoma is detectable.
 deep circumflex iliac artery
 branches from the
external iliac artery
 less frequently, from a
common root including
the inferior epigastric
artery.
 Its course is lateral and
vertical behind the
inguinal ligament. It
then turns medially at
the iliac crest where it
pierces the transversus
abdominis muscle.
 deep circumflex iliac artery
 numerous connecting
branches supply the
lower and lateral
abdominal wall.
 Anastomoses with the
intercostal and lumbar
vessels supply branches
to all the flank muscles.
 Posterior intercostal, subcostal and
lumbar arteries

 give off muscular branches to the overlying

internal and external oblique, before
anastomosing with the lateral branches of the
superior and inferior epigastric arteries at the
lateral border of the rectus sheath.
 Perforating cutaneous vessels run vertically
through the muscles to supply the overlying skin
and subcutaneous tissue.
 Superficial arteries
 The superficial vessels follow the
general pattern of the deep vessels
and arise from the iliac or femoral
vessels. The exception is that the
superficial inferior epigastric have no
superior counterparts.

 The superficial inferior epigastric

vessels run diagonally in the
subcutaneous tissues from the
femoral artery toward the umbilicus.
 They can be identified on a line
between the palpable femoral pulse
and umbilicus just superficial to
Scarpa's fascia.
 As they approach the umbilicus, the
arteries branch extensively.
 external pudendal arteries
have a medial and diagonal
course from the femoral
artery and supply the
region of the mons pubis.
 These vessels branch
extensively as they approach
the midline.
 Bleeding is typically heavier
here than in other
subcutaneous areas of the
abdomen.
 superficial circumflex iliac
vessels proceed from the
femoral vessels to the flank.
 Veins
 Veins typically follow arteries.
 Above the umbilicus they drain to the
subclavian vessels
 Below the umbilicus they drain to the
external iliac vessels.
 Lymphatic drainage
 Superficial
 Deep
 The superficial lymphatic vessels
 accompany the subcutaneous blood vessels
 Those from the infra-umbilical skin run with the
superficial epigastric vessels.
 They drain into the superficial inguinal nodes.
 The supra-umbilical region is drained by vessels
running obliquely up to the pectoral and
subscapular axillary nodes
 there is some drainage to the parasternal nodes
 The deep lymphatic vessels
 accompany the deep arteries
 Vessels from the upper anterior abdominal
wall run with the superior epigastric
vessels to the parasternal nodes.
 Vessels of the lower abdominal wall drain
into the circumflex iliac, inferior epigastric
and external iliac nodes.
Nerve supply
 Nerve supply
 the anterior rami of spinal nerves T7-T12,
which supply most of the abdominal wall,
do not participate in plexus formation.
 The map of dermatomes of the anterolateral
abdominal wall is almost identical to the map
of peripheral nerve distribution
 Nerve supply
 T7-T9 supply the skin
superior to the umbilicus.
 T10 innervates the skin
around the umbilicus.
 T11plus the cutaneous
branches of the
subcostal (T12),
iliohypogastric, and
ilioinguinal (L1), supply
the skin inferior to the
umbilicus.
Clinical relevance
 Abdominal Obesity
 Veinous distention
 Excessive lardosis
 Distension
 hernias
 Tenderness/Guarding/Rebound
 Abdominal Obesity
 In morbid obesity, the superficial fat is
many inches thick, often forming one or
more sagging folds (L. panniculi; singular
= panniculus, apron).
 Veinous distention
 Veins may be dilated
in patients with
obstructed blood flow
through the liver and
porta hepatis. They
may also be
engorged in patients
with large pelvic
masses
 Caput medusa
 Excessive lardosis
 Anterior abdominal wall maintains posture
 underdeveloped or atrophic anterior abdominal muscles
 old age
 insufficient exercise
 Pregnancy/ abdominal distension
 Ant. abdominal muscles have insufficient tonus to resist the
increased weight of a protuberant abdomen on the anterior pelvis.

 The pelvis tilts anteriorly at the hip joints when standing

(the pubis descends and the sacrum ascends) producing
excessive lordosis of the lumbar region of the vertebral
column
 backache
 Distension
 Eversion of the umbilicus may
be a sign of increased intra-
abdominal pressure resulting
from eg. ascites or a large mass
 Clinical maneuvers as well as inx
may prove useful in identifying
the cause of anterior adominal
wall distension:
 Palpation of masses
 Tympanic percussion- gas
 Eliciting flank and shifting dullness
in ascites
 Imaging: xrays, ct-scan.
 Hernias
 defined as an abnormal protrusion of an
organ or tissue through a defect in its
surrounding walls
 The basic pathophysiology underlying
distension is increased intraabdominal
pressure This as well as congenital or
acquired weakness in the anterior
abdominal wall may predispose to hernias
 Hernias
 Most hernias occur in the:
 inguinal- through the inguinal
canal (direct vs indirect)
 umbilical- through the umbilical
ring
 epigastric regions- through a
weakness in the linea alba-
between the xiphoid and the
umbilicus.

 Uncommonly encountered are

Spigelian hernias
 occurring along the semilunar
lines. These types of hernia tend
to occur in people > 40 years and
are usually associated with
obesity
 Incisional hernias
 a protrusion of omentum
(a fold of peritoneum) or
an organ through a
surgical incision
 if the muscular and
aponeurotic layers of the
abdomen do not heal
properly, an incisional
hernia can result
 Factors predisposing a
patient to incisional hernia
include:
 advanced age
 debility of the patient
 Obesity
 postoperative wound
infection
 Divarication of the rectus abdominis
 Thinning and widening of the upper linea alba
 most commonly as a result of obesity or chronic straining.
 This process disrupts the arrangement of the fibres of
the bilaminar aponeurosis.
 Contraction of the anterolateral abdominal muscles fails
to be transmitted across the midline through the linea
alba and increased intra-abdominal pressure causes the
abdominal viscera to protrude beneath the thinned
tissue as a broad midline bulge.
 The recti become widely separated or divaricated. This is
not true herniation, as all the layers of the abdominal
wall in that region are intact.
 1) Epigastric
2) Diastasis (not a true hernia)
3) Supra-umbilical hernia
4) Umbilical hernia
5) Incisional hernia
6) Scar (previous inguinal
hernia op)
7) Recurrent inguinal hernia
8) Spigelian hernia (very rare)
9) Femoral hernia
10) Inguinal hernia
11) Pubic bone
12) Inguinal ligament - groin
skin crease
 Abdominal
tenderness/guarding/rebound
 Irritation of the Parietal peritonium results
in pain/guarding/rebound corresponding
to the segmental nerve roots innervating
the peritoneum and tends to be sharp and
well localized
Surgical relevance
 Incisions
 A well selected incision provide:
1. Accessibility
2. Extensibility
3. Preservation of function
4. Security
 Additional considerations in selecting the type of
incision include:
 Need for speed upon entry
 Certainty of the diagnosis
 Body habitus
 Location of previous scars
 Potential for problems with hemostasis
 Cosmetic outcome
Vertical vs Transverse
 Vertical incisions
 Midline
 Paramedian
 Lateral paramedian
 Pararectus
 Vertical/Midline incision
 Advantages:
 Only terminal branches of the
abdominal wall blood vessels and
nerves are located at the linea alba
 Limits the risk of significant
vascular or nerve injury
 provides the quickest entry,
 which is especially important if the
patient is unstable or seriously ill,
 Provides best exposure and
extensibility
 particular importance if the
diagnosis is uncertain.
 deep tissue planes are not opened
 may be ideal for patients who are
anticoagulated
 who have enlarged epigastric
vessels that may be injured
 who have intraabdominal infection
 Disadvantages:
 Less cosmetic than tranverse
incisions.
 Greater skin tension. Crossing
the lines of langerhans
 Classically it was believed that
midline incisions increased the
risk of wound dehiscence and
hernia
 Current literature does not
support this belief.
 Cochrane review 2005 found
no difference between
tranverse and vertical incisions
 Possibly due to improvements
in closure techniques
 Important points
 Extension of a midline incision above the umbilicus can be made
toward the left in order to avoid the ligamentum teres.
 Reentry incisions should be made through the pre-existing scar
 placement of parallel longitudinal incisions may result in tissue ischemia,
even when incisions are performed many years apart
 When entering the abdominal cavity inferior to the umbilicus, care
should be taken to incise the peritoneum slightly off the midline
since the bladder is highest in the midline and the urachus may
communicate with it.
 This will reduce the risk of bladder injury
 eliminate the risk of urine leaking from an incised persistent urachus
 provide better exposure.
 Alternatively, the urachus can be divided and ligated

 The bladder can be identified because of its opaqueness and

markedly increased vascularity.
 Paramedian incision
 (A) The anterior rectus
sheath is opened for the full
length of the incision 2 to 3
cm from the midline.
 The rectus muscle is retracted
laterally and the posterior
sheath is incised longitudinally
under the muscle bed.
 (B) The lateral paramedian
incision is placed near the
lateral border of the rectus.
 When the muscle is retracted
laterally, the inferior deep
epigastric artery is seen.
 Paramedian incision
 Advantages:
 Paramedian incisions can be extended into the upper
abdomen without the difficulties of curving around
the umbilicus.
 PRCT cox et al. sugested decrease the risk of
dehiscence or hernia as compared to midline incisions
 Overall evidence conflicting
 Disadvantages:
 take longer to perform
 restrict access to the contralateral pelvis
 risk injury to the epigastric vessels.
 nerve injury may result in rectus paralysis.
 Pararectus incision
 (also known as Battle's incision)
 placed at the lateral border of the rectus muscle,
which is retracted medially.
 infrequently utilized
 primarily used for appendectomy or drainage of
pelvic abscesses.
 causes denervation of the rectus, resulting in
paralysis and ultimately atrophy of the muscles.
 The length of this incision must be restricted to
no more than two dermatomes to prevent
weakness of the abdominal wall
 Transverse incisions for
pelvic surgery are of
four types:
1. Pfannenstiel's incision, a
muscle-separating
operation
2. Cherney's incision, a
tendon-detaching
operation
3. Maylard's incision, a true
muscle-cutting incision
4. Küstner's incision, a
median incision using a
transverse skin incision.
 Pfannenstiel's incision
 (A) "Low" Pfannenstiel: the skin
incision is placed lower for
cosmetic reasons.
 The subcutaneous tissues are
dissected to allow standard
placement of rectus sheath
incision.
 (B) Fascia is separated from rectus
muscle superiorly and inferiorly.
 (C) The rectus muscle is separated
in the midline and the peritoneum
is incised longitudinally.
 (D) Sutures may be placed in the
rectus muscle to close a rectus
diastasis.
 (E) Sheath is closed with
continuous suture.
 Skin is approximated with a
subcuticular suture.
 Pfannenstiel's incision
 Advantages:
 Pfannenstiel's incision
provides excellent strength
and cosmesis
 exposure is adequate for
procedures limited to the
pelvis
 Disadvantages:
 minimal opportunity to extend the
incision if wider exposure is desired
 Restricted speed of entry
 several tissue planes must be
opened
 the risk of seroma, hematoma, and
wound infection may be increased
 Because of these considerations, this
incision is relatively contraindicated in
the presence of active abdominal
infection or if speed is of the essence
 iliohypogastric and ilioinguinal nerves
injury if the incision is extended
beyond the rectus muscle
 Neuromas can occur if these nerves
are traumatized
 some patients will experience chronic
pain severe enough to limit daily
activities.
 Cherney's incision
 (A) Transverse incision of
rectus sheath.
 (B) Lower sheath is
separated from rectus
muscles.
 Tendons are exposed and
incised 0.5 cm above
periosteum of symphysis.
 (C) Tendons are sutured to
lower rectus sheath above
symphysis with permanent
suture material.
 (D) Sheath is closed in a
continuous manner.
 Cherney's incision
 Cherney's incision provides excellent
exposure to the retropubic space of
Retzius, making it a good choice for
retropubic urethropexy. A Pfannenstiel
incision may be converted to a Cherney
incision to enhance exposure
 Maylard's incision (Mackenrodt
incision)
 Transverse muscle-
cutting incision.
 (A) Incision of rectus
sheath is extended
laterally to iliac spine to
expose rectus muscle.
 Rectus muscles are cut
transversly.
 (B) Cut edges of
muscles are sutured to
the rectus sheath.
 Transversalis fascia
and peritoneum are
incised transversely.
 Maylard's incision (Mackenrodt
incision)
 Provides slightly increased exposure over
pfannensteil
 patients with significant aortoiliac occlusion (eg,
aortic atherosclerosis or coarctation) depend
upon collateral flow from the epigastric vessels
for perfusion of the lower extremities.
 ligation of these vessels during a Maylard
incision may cause worsening symptoms
(claudication) and potentially ischemia
 Another complication of Maylard's incision is
delayed bleeding from the cut edge of the rectus
muscle or deep epigastric vessels.
 Küstner's incision

 Transverse incision
to sheath,
subcutaneous tissue
separated from linea
alba. Midline incision
in linea alba
 Küstner's incision
 Küstner's incision combines the
disadvantages of both midline and
transverse incisions and therefore has
limited utility
 Turner-Warwick's incision
 Transverse skin incision.
 Subcutaneous tissue is
dissected from the
anterior sheath to a point
at least 2 cm below the
pubis.
 The sheath is incised 2
cm below the pubis and
at least 4 cm in length.
 The incision is extended
cephalad along the
borders of the rectus
muscles.
 Peritoneum is incised
longitudinally.
 Turner-Warwick incision
 provides excellent exposure to the
retropubic space
 upper pelvis and abdominal exposure is
severely limited.
McBurney's incision
 McBurney's incision
 provides excellent access to the ipsilateral
lower quadrant
 ideal for appendectomy
 easily expanded
 cosmesis is excellent
 The incision may be placed lower for
extraperitoneal drainage of a pelvic
abscess.
 Summary
 A detailed knowledge of the anatomy and
function of the anterior abdominal wall is
critically important to the accurate
diagnosis of abdominal and pelvic
pathology as well as the safe practice of
abdominal and pelvic surgery
Thank you
 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
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 Grays textbook of anatomy, 39th edition

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