Anatomy of Abdomen

The abdomen is divided into regions that are defined by lines on the
surface of the anterior abdominal wall.

Using these four lines, three central regions are defined from above
downwards: epigastric, umbilical and hypogastric (or suprapubic).
Similarly there are three lateral regions on each side: hypochondrial,
lumbar and iliac.

Layers- Skin

Subcutaneous tissue

Superficial fascia-

Above the level of the line joining the two anterior superior iliac spines the
superficial fascia consists of a single layer but below this line it consists of
two layers.

a) A superficial fatty layer (Camper’s fascia)- continuous with the

superficial fascia of the adjoining areas of the body. Over the penis,
it is devoid of fat, and in the scrotum, it is replaced by an
involuntary dartos muscle.
b) (b) a deep membranous layer (Scarpa’s fascia).

It crosses the inguinal ligament and gets attached to the fascia lata of the
thigh immediately below and parallel to the ligament.

It is prolonged over the penis to enclose it up to the base of the glans

and forms the fascia of the penis(Buck’s fascia).

It covers the scrotum where it is replaced by dartos muscle and then

continues with the superficial fascia of perineum—the Colles’ fascia. The
Colles’ fascia stretches across the margins of pubic arch and is attached
to the posterior edge of the urogenital diaphragm/posterior border of the
perineal membrane, which also stretches across the pubic Arch. The space
between the perineal membrane and Colles’ fascia is known as superficial
perineal Pouch.

The space between the two layers contains superficial epigastric,

circumflex iliac, external pudendal vessels, and superficial inguinal lymph
nodes.

Anterolateral abdominal muscles

The three muscle layers of the body wall are separate in the flanks.

External oblique
The muscle arises by eight digitations, one from each of the lower eight
ribs just lateral to their anterior extremities.

The muscle has a free posterior border which extends from the twelfth rib
to its insertion by fleshy fibres into the anterior half of the outer lip of the
iliac crest. Attachment is aponeurotic.

Posterior border of the muscle forms the anterior boundary of the lumbar
triangle (of Petit) that is floored in by the internal oblique and bounded
behind by the anterior border of latissimus dorsi and below by the iliac
crest. The triangle may be the site of a rare lumbar hernia.

The lower border, lying between the anterior superior iliac spine and the
pubic tubercle, forms the Inguinal ligament (of Poupart). Its edge is
rolled inwards to form a gutter; the lateral part of this gutter gives origin
to part of the internal oblique and transversus abdominis muscles.

The fascia lata of the thigh is attached to the inguinal ligament and when
the thigh is extended the fascia lata pulls the inguinal ligament
downwards into a gentle convexity.

Above and lateral to the pubic tubercle is an oblique, triangular gap, the
superficial inguinal ring, in the aponeurosis . The base of the gap is the
pubic crest, and the margins are the crura of the ring

Medial end of the inguinal ligament the triangular lacunar ligament (of
Gimbernat) extends horizontally backwards to the pectineal line on the
pubis.

The crescentic free lateral edge of the lacunar ligament is the medial
margin of the femoral ring.

Internal oblique

Fleshy fibres of the muscle arise from the whole length of the lumbar
fascia, from the intermediate area of the anterior two-thirds of the iliac
crest and from the lateral two-thirds of the inguinal ligament. From the
lumbar fascia the muscle fibres run upwards along the costal margin, to
which they are attached, becoming aponeurotic at the tip of the ninth
costal cartilage.

This aponeurosis is fused with a similar arrangement of the transversus

aponeurosis to form the conjoint tendon. The internal oblique therefore
has a free lower border, which arches over the spermatic cord:

Laterally the margin consists of muscle fibres in front of the cord; medially
the margin consists of tendinous fibres behind the cord.
The lowest fibres of the internal oblique arise from the inguinal ligament
and arch medially to reach the conjoint tendon, forming the roof of the
inguinal canal.

Transversus abdominis

The muscle arises in continuity from the lateral third of the inguinal
ligament, the anterior two-thirds of the inner lip of the iliac crest, the
lumbar fascia, the twelfth rib, and from the inner aspects of the lower six
costal cartilages.

The muscle fibres become aponeurotic and pass behind the rectus to fuse
with the internal oblique aponeurosis in the linea alba. The lower fibres of
the aponeurosis curve downwards and medially with those of the internal
oblique as the conjoint tendon, to insert on the pubic crest and the
pectineal line.

Rectus abdominis and pyramidalis

Rectus abdominis arises by two heads: a medial from in front of the pubic
symphysis and a lateral from the upper border of the pubic crest. They are
inserted on to the front of the fifth to seventh costal cartilages.

The small triangular pyramidalis muscle arises from the body of the pubis
and the symphysis between rectus abdominis and its sheath. It converges
with its fellow into the linea alba 4 cm or so above its origin.

Rectus sheath

The aponeurosis of the internal oblique splits into anterior and posterior
layers to enclose the rectus muscle . The external oblique aponeurosis
fuses with the anterior layer to form the anterior layer of the sheath, and
the transversus aponeurosis fuses with the posterior layer to form the
posterior layer of the sheath.

Contents

Apart from the rectus and pyramidalis muscles, the sheath contains the
ends of the lower six thoracic nerves and their accompanying posterior
intercostal vessels, and the superior and inferior epigastric vessels.

The superior epigastric artery, a terminal branch of the internal thoracic ,

enters the sheath by passing between the sternal and highest costal fibres
of the diaphragm. It supplies the rectus muscle and anastomoses within it
with the inferior epigastric artery. This vessel leaves the external Iliac at
the inguinal ligament , passes upwards behind the conjoint tendon, slips
over the arcuate line and so enters the sheath. Veins accompany these
arteries, draining to internal thoracic and external iliac veins respectively.
Anterolateral abdominal muscles also receive a blood supply from the
lumbar and deep circumflex iliac arteries.

The deep circumflex iliac artery arises from the external iliac t the anterior
superior iliac spine it gives off an ascending branch which may be at risk
in a gridiron incision.

Lymph drainage: Umbilicus

Superficial above umbilicus- pectoral group of axillary nodes.

Superficial below umbilicus- superficial inguinal nodes.

Deep above- mediastinal

Deep below- external iliac and Para aortic.

Nerves-

Rectus and external oblique, internal oblique- lower intercostal and

subcostal nerves (T7–T12). Pyramidalis- T12

Lower fibres of internal oblique- L1 ilioinguinal and iliohypogastric . The

lowest fibres of the internal oblique and qtransversus that continue
medially as the conjoint tendon receive the L1 innervation, which thus
helps to maintain the integrity of the inguinal canal.

Tests. Rectus abdominis can be tested by lying flat on the back and raising
the head (without using the Arms).

Beevors sign- abnormal upward movement of the umbilicus on attempting

to raise the head from a supine position by the patient being assessed. It
signifies lower abdominal muscle weakness and has been traditionally
described in dorsal myelopathy at T-10 spinal cord level, infarct, tumors.

Inguinal ligament

The inguinal ligament is a thick, fibrous band extending from anterior

superior iliac spine to the pubic tubercle.

Extensions-

Lacunar ligament- From the medial end the deep fibres of the inguinal
ligament curves horizontally backward to the medial part of the pecten
pubis. Its lateral edge forms the medial border of femoral canal.

Pectineal Ligament (Ligament of Cooper)

It is the extension of the posterior part of the lacunar ligament along the
pecten pubis up to the iliopectineal eminence.

Reflected Part of Inguinal Ligament

The superficial fibres from the medial end of the inguinal ligament expand
upward and medially to form this ligament.

Ilioinguinal ligament

The space between the inguinal ligament and the hip bone is called
pelvifemoral/subinguinal space . The muscles (psoas major and iliacus)
and neurovascular structures of Posterior abdominal wall/pelvis pass into
the femoral region of the thigh through this space.

The external iliac vessels in abdomen become femoral vessels as they

pass through the medial part of the subinguinal space.

The fascial lining of the abdomen is prolonged into the qthigh to enclose
the upper 3.75 cm of the femoral vessels forming the femoral sheath.

Inguinal Canal-

The inguinal canal is an oblique intermuscular slit about 4 cm long lying

above the medial half of the Inguinal ligament. It commences at the deep
inguinal ring, ends at the superficial inguinal ring.

Its anterior wall is formed by the external oblique aponeurosis, assisted

laterally by the internal oblique muscle . Its floor is the inrolled lower edge
of the inguinal ligament, reinforced medially by the lacunar ligament . Its
roof is formed by the lower edges of the internal oblique and transversus
muscles, which arch over from infront of the cord laterally to behind the
cord medially.

The posterior wall of the canal is formed by the strong conjoint tendon
medially and the weak transversalis fascia throughout.

The deep inguinal ring lies about 1.25 cm above the midpoint of the
inguinal ligament and is an opening in the transversalis fascia.

Contents in males- spermatic cord: These are the vas deferens and its
artery, the testicular artery and the accompanying veins(pampiniform
plexus) , the obliterated remains of the processus vaginalis, the genital
branch of the genitofemoral nerve(cremaster), sympathetic nerves and
lymphatics.

Spermatic cord has three coverings-internal spermatic fascia is derived

from the transversalis fascia at the deep inguinal ring. Second covering,
the cremaster muscle and cremasteric fascia. The third covering, the
external spermatic fascia, is acquired from the external oblique
aponeurosis as the cord passes between the crura of the superficial ring.
Females- round ligament of uterus, obliterated remains of processus
vaginalis, lymphatics from the uterus.

The ilioinguinal nerve, although a content of the Inguinal canal, does not
enter the canal through the deep ring, but by piercing the internal oblique,
leaves through superficial.ring to supply skin of the inguinal region, upper
part of the thigh, anterior third of the scrotum (or labium majus) and root
of the penis.

At the deep ring the inferior epigastric artery gives off the cremasteric
branch to supply that muscle and the coverings of the cord.

The area bounded laterally by the inferior epigastric artery, medially by

the lateral border of the rectus muscle, and below by the inguinal
ligament is the inguinal triangle (of Hesselbach). By definition a hernial
sac passing lateral to the artery (i.e. through the deep ring) is an indirect
hernia, one passing medial to the artery (through the inguinal triangle) is
a direct hernia .

Superficial inguinal ring- contents spermatic cord, round ligament and

ilioinguinal nerve.

Mechanisms for integrity of inguinal canal-

Flap-valve Mechanism

The canal is oblique hence its deep and superficial inguinal rings do not lie
opposite to each other. As a result when intra-abdominal pressure is raised
the anterior and posterior walls of the canal are approximated like a flap.

Guarding of the Inguinal Rings

The deep inguinal ring is guarded anteriorly by the internal oblique

muscle, and superficial inguinal ring is guarded posteriorly by the conjoint
tendon and reflected part of the inguinal ligament.

Shutter Mechanism

The internal oblique surrounds the canal in front, above, and behind like a
flexible mobile arch and thus forming it anterior wall, roof, and posterior
wall. Consequently, when it contracts, the roof is pulled and approximated
on the floor like a shutter.

Slit-valve Mechanism

The contraction of external oblique muscle approximates the two crura

medial and lateral of superficial inguinal ring like a slit valve. The
intercrural fibres also help in this act.

Ball-valve Mechanism
Contraction of cremaster muscle pulls the testis up and the superficial
inguinal ring is plugged by the spermatic cord.

In addition to the above mechanisms, the interfoveolar ligament also

helps to maintain the integrity of the inguinal canal by strengthening
fascia transversalis laterally.

Femoral Sheath-

It is a funnel-shaped fascial sheath enclosing upper 3.75 cm of femoral

vessels. The base of the sheath is directed upward toward the abdominal
cavity and apex merges with the tunica adventitia of the femoral vessels .

The anterior wall of the femoral sheath is formed by the downward

prolongation of the fascia transversalis and the posterior wall by the
downward prolongation of the fascia Iliaca.

Contents-

Lateral compartment lodges the femoral artery and genital branch of the
genitofemoral nerve. Middle compartment contains the femoral vein.

Medial compartment is relatively empty and called Femoral canal. It

contains lymph node of Cloquet and fibrofatty tissue

Femoral canal-

It is a short fascial tube (medial compartment of femoral Sheath). The

upper end of the femoral canal, which opens into the abdominal cavity is
called femoral ring. A fatty areolar tissue called femoral septum normally
closes it.

It provides a dead space for the expansion of femoral vein during

increased venous return.

Boundaries-

Anterior- Inguinal ligament

Posterior- pecten pubis

Medial- lacunar ligament

Lateral- Femoral vein

The canal lies posterior to the saphenous opening and thin cribriform
fascia, and anterior to the fascia covering the pectineus muscle.

Abdominal Incisions
Midline incision, above or below the umbilicus (or both, skirting the
umbilicus). No major vessels or nerves are involved, but a few small
vessels may cross the midline of the peritoneum.

Paramedian incision, the anterior wall of the rectus sheath is incised

vertically 2 cm from the midline and the rectus muscle retracted laterally
so that the posterior wall of the sheath can be iqncised.

Right subcostal (Kocher’s) incision is made 3 cm parallel to and below the

right costal margin, from the midline to beyond the lateral border of the
rectus sheath.