Anterior Abdominal Muscles BMJ

7/28/2019 Anterior Abdominal Muscles BMJ

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MOB TCD

Anterior Abdominal Muscles

Professor Emeritus Moira OBrien

FRCPI, FFSEM, FFSEM (UK), FTCD

Trinity College

Dublin


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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

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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

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Superficial fatty layer Membranous layer of

superficial fascia

Below umbilicus

Continuous with Collesfascia in the perineum

Anterior Abdominal WallMOB TCD


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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


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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

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Inguinal Glands

Proximal group parallel toinguinal ligament

Enlarged tender inguinal

glands

Part of a generalisedlymphadenopathy

Secondaries

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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


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Abdominal Muscles

External oblique Internal oblique

Transversus

Rectus abdominus

Pyramidalis Nerves and vessels

Lie between internal oblique and

transversus

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External Oblique

Origin Outer surfaces lower

borders lower eight ribs

Interdigitating with serratus

anterior and latissimus dorsi Fibres pass medially and

inferiorly

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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

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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

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Insertion External Oblique

Pubic crest Gap for superficial

inguinal ring

Pubic bone

Linea alba Anterior wall of the

rectus sheath

Zyphoid process

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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


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Below half way betweenumbilicus and pubic symphysis

The aponeurosis of the

external oblique, internal


(conjoint tendon) pass anterior

to the rectus

Posterior lies the transversalis

fascia

Rectus SheathMOB TCD

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Contents Rectus muscle

Pyramidalis

Superior and inferior epigastric

vessels Lower five intercostal vessels and

nerves

Rectus SheathMOB TCD

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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

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Extraperitoneal Tissue

Extraperitoneal connectivetissue

If fatty, it separates the

transversalis fascia from

the peritoneum If thin, they are in close

contact with one another

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Peritoneal Pouches

Peritoneal pouches arefound in the region of the

deep inguinal ring

Medial portion of the

posterior wall

Posterior aspect anteriorabdominal wall

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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

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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

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Deep Inguinal Ring

Oval opening 2.5 cm Above the middle of inguinal

ligament

Inferior epigastric artery

passes medial to the deepring

O C

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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

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Inguinal Canal

Anterior Wall External oblique forms

Whole anterior wall

Internal oblique forms

Lateral half only

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Posterior Wall Transversalis fascia

Whole of wall

Medial half conjoint tendon

Medial quarter reflectedportion of inguinal ligament

Inguinal Canal

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Roof Arching fibres of internal oblique

Transversus as they both arise

from the inguinal ligament

Roof of Inguinal Canal

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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

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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


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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



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Passing through

Deep Ring Female

Round ligament of uterus Remains of processus vaginalis

Genital branch of genitofemoral

nerve

Lymphatics from uterus, regionof cornu



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Passing through

Superficial Ring Female

Everything that wentthrough deep ring

Plus ilioinguinal nerve

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Inguinal Canal

Contraction of the

abdominal muscles

increases the obliquity of

the inguinal canal

Protecting the two ringsLytle, 1945

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Increase in Intra-Abdominal Pressure

Pain aggravated by anincrease in intra-

abdominal pressure

Hernia

Inguinal or femoral hernia Entrapment of the

ilioinguinal nerve

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Hernia

Chronic pain in the groin in anathlete may be due to a hernia

or a potential hernia

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Inguinal Hernia

Sudden severe pain in

lower abdomen

Associated with lifting a

heavy object

Common history of a

direct inguinal hernia

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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

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Enters through posterior wall

of the inguinal canal

Leaves through superficial

inguinal ring

Above and medial to the pubic

tubercle

Direct Inguinal Hernia

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Inguinal Hernia

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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

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Femoral Ring

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Femoral Hernia

Enters through femoral ring

Enters femoral canal

Medial compartment of femoral

sheath

More common in women

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Femoral Hernia

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Saphenous Varix

Swelling is soft anddiffuse

Empties on minimal

pressure

Refills on release Cough impulse is

present

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Gilmores Groin

Common cause of chronic

groin pain in field sports

Particularly soccer players

Pain on any sudden change

of movement, sneezing,

coughing

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Trying to sprint

Will increase the pain

Pain is worse getting out of

bed

The day after a match or atraining session

Gilmores Groin

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Pain is increased byexternal rotation

Or hyperextension of hip

Pain is localised to lower

anterior abdominal wall Adductor or perineal

region

Gilmores Groin

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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

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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

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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

Anterior Abdominal Muscles BMJ

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