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Home , Linea alba (abdomen), Pyramidalis muscle, Rectus abdominis muscle, Rectus sheath

001 1.1.2. Musclesoftheabdominalwall fi cial ,deepmuscles,extraperitoneal fasciaand Layers of the anterior and lateral include , joints, xyphoid,pelvisandcostalapophysisoflumbarvertebra These groups of muscles are enclosed by several bone structures anterior,lateral, areas: tomical posterior, and diaphragmatic b can than structures muscle by delimited is wall abdominal The 1.1.1. Introduction Anatomy oftheabdominalwall 11.1. from theanterolateralthoraxtopubisclosemidline abdominis rectus The Rectus abdominis Muscles oftheanterolateralwall Abdominal Wall Handbook ofComplex inal wall. fithe describe will surgical in relevance their to due four rst . POSTERIOR ANTERIOR SUPERIOR INFERIOR LATERAL 1 1.1. Table .

Muscular limitsoftheabdominalwall 1 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙

(m. rectusabdominis) Perineal muscles Diaphragm Piramidalis abdominis Rectus Transversus abdominis Internal oblique oblique External muscle Iliac Psoas Quadratus lumborum

CHAPTER wall of theabdominal and physiology Anatomy is a long and thick muscle that is extended is that muscle thick and long a is Álvaro Robín Valle deLersundi, MD, PhD Arturo CruzCidoncha,MD,Arturo PhD . subcutaneous tissue, super-

(Figure 1.1). repair of complex abdom- complex of repair e. perineal : last ribs, chondrocostal e classifie ana- 5 in ed (Table1.1). We .. Physiology 1.2. Anatomy oftheabdominal 1.1. wall ygy CONTENTS 1 2 Handbook of Complex Abdominal Wall mas and abscesses mainly extend over the posterior rectus sheat the anterior and the muscle and explain why hemat its length. These intersections make diffi a abdominis rectus the interrupt sheath, rectus anterior the to adh closely that structures, tendinous horizontal four to Three the lineasemilunaris. es withintheaponeurosis covered by the anterior sheath. Laterally, the rectus sheath me sheaths, except on the lower third of the where it is o rectus posterior and anterior the between packed is muscle The and pubiccrest. symphysis , the of border superior the of surface anterior the on inserts it Caudally, ligament. costoxyphoid and process ,inferiortotheumbilicus. borde lateral the into inserts and pubis the from originates It tary musclethatcanbemissingin20%ofsubjects. found inferiorly overlaying the rectus pyramidalis The Pyramidalis 5 the on insert that itations dig- 3 from originates muscles abdominis rectus the Cranially, ∙ ∙ ∙ ∙ ∙ ∙

Used for pedicledmuscleflaps musclefor flThe mostimportant exion ofthetrunk Diffi sheath ismissing Packed intheirsheaths except inthelower third where theposterior ofpubisandsymphysis ofpubis ontheanterior surface Insertion and xyphoid of5,6,7costalOriginates cartilages ontheanterior surface culty of dissection between theanterior sheath rectus andthemuscle ofdissection culty Figure 1.2. 1.1. Table (m. pyramidalis) Relevant characteristics oftherectus abdominis Relevant characteristics Rectus abdominis Rectus Characteristics of theexternaloblique th -7 th otl atlgs te xyphoid the cartilages, costal is a small muscle that can be can that muscle small a is (Figure 1.1). cult the dissection between muscles tofo It is a rudimen- rs of rs ered ered long long nly rg- rm o- h.

crossing themidlinewithfi bers ofthe otherside. al linea and sheath rectus anterior the form to contributes and Anteriorly the joins the aponeurosis of internal ob superior iliacspineandpubictubercle. to form the , which extends between the anteri its in bends aponeurosis the Inferiorly aponeurosis. completely becomes muscle the spine, iliac anterosuperior the below and also midline the approaching that, way a such in descends ary It runsverticallyandmediallythemusculartendinousboun and latissimusdorsi. ante serratus the of insertions with intertwine that ribs eight lo the of surface anterior fithe muscle from Its originate bers wall muscles abdomina lateral three the of thickest superfi and most cial the is abdominis) externus obliquus (m. muscle oblique external The External oblique ligament. Gimbernat´s and ligament inguinal the perfisu- ring, inguinal the cial of pillars the through made is pubis the on Insertion ∙ ∙ ∙ ∙ ∙ ∙

It bendsinitselfto formIt theinguinalligament between muscleandaponeurosis Boundary The aponeurosis contributes to form anterior sheath rectus Inferior offi andmedialdirection bers ofmuscleandaponeurosis The thickestmuscleofthelateral abdominal wall Originates ofthelast8ribs from theanterior surface Figure 1.3. 1.2. Table (Figure 1.2). Relevant characteristics of external oblique ofexternal Relevant characteristics External obliquemuscle External Characteristics lique wer rior ba, elf or d- l

Anatomy and physiology of the abdominal wall 0011 CHAPTER Internal oblique Some inferior fi bers form the at the level of the . The internal oblique muscle (m. obliquus internus abdominis) lies between the external oblique muscle and transversus abdominis There is an avascular layer of loose between (Figure 1.3). Posteriorly, it is covered by the latissimus dorsi. external oblique and internal oblique muscles that allows easy dissection between these muscle layers.

Figure Transversus abdominis 1.3. Internal oblique muscle The transversus abdominis muscle (m. transversus abdominis) is the deepest of the three lateral abdominal wall muscles and runs in a horizontal direction (Figure 1.4). Fleshy in the middle and tendinous at the extremities, it covers the entire lateral half of the abdominal wall, from the spine to the linea alba.

Figure 1.4. Transversus abdominis

It originates from the thoracolumbar fascia (fascia toracolum- baris), anterior two thirds of the iliac crest, and lateral half of the inguinal ligament.

The internal oblique muscle runs in a superomedial direction, per- pendicular to the external oblique muscle.

At the level of linea semilunaris, it becomes a wide aponeurosis. In the superior two-thirds the aponeurosis splits medially to form the anterior and the posterior rectus sheaths. In the inferior third, It originates from the thoraco-lumbar fascia, the iliac crest, the in- the aponeurosis does not split, joins the anterior aponeurosis of guinal ligament and from the inner surface of the lower six costal external oblique muscle and only comprises the anterior rectus cartilages, interdigitating with the insertions of fi bers of the dia- sheath. The inferior border of the posterior rectus sheath is the phragm (Figure 1.5). Posteriorly, the transversus abdominis also arcuate line. starts from a wide aponeurosis of insertion in the thoraco-lum- bar fascia, over the cuadratus lumborum, which has been termed The internal oblique inserts on the inferior border of the 10th to 12th posterior aponeurosis of the transversus abdominis. In posterior ribs superiorly. Inferiorly, the internal oblique inserts with aponeu- component separation technique, the mesh can be laid on this rotic fi bers from the transversus abdominis, forming the conjoined posterior aponeurosis (Figure 1.6). tendon, which inserts on the pubic crest. The muscle runs horizontally and ends medially in a broad fl at aponeurosis in the linea semilunaris, with a shape of a curve line Table with medial concavity. Above the arcuate line, the aponeurosis 1.4. Relevant characteristics of internal oblique joins the internal oblique aponeurosis and the linea alba.

Characteristics In the superior third of the abdomen the fi bers of the muscle ex- ∙ Originates from thoracolumbar fascia, iliac crest and inguinal ligament. tend behind the approaching the mid- ∙ Fibers run perpendicular to the external oblique muscle line. ∙ Easy dissection between the muscle layers of external oblique and internal oblique ∙ The aponeurosis does not form the posterior rectus sheath below the Below the arcuate line, the aponeurosis of the muscle contributes arcuate line to form the conjoined tendon with the internal oblique. At this level, ∙ It has insertions on the inferior border of 10th-12th ribs the differentiation between the fi bers of internal oblique and trans- ∙ Involved in the composition of the conjoined tendon versus is quite diffi cult.

3 4 Handbook of Complex Abdominal Wall of transversus abdominis; abdominis; of transversus abdominisandquadratus lumborum. the transversus abdominisandlaying aponeurosis ontheposterior ∙ ∙ ∙ ∙ ∙ ∙

Involved inthecomposition oftheconjoined tendon transversus abdominsandinternal oblique The bundlescome lumbarneuro-vascular across thespace between between theperitoneum anddiaphragm theretrocostalIn space, theretromuscular canbeextended dissection the upperthird The musclefibers reach abdominisnearthemidlinein behindtherectus Fibers runhorizontal inner sideoflast6costal cartilages Originates from thoracolumbar fascia,iliaccrest, inguinalligamentand Figure Figure 1.5. 1.6. 1.5. Table 2: mesh; Relevant characteristics oftransversus abdominis Relevant characteristics Extension ofthemeshfollowingExtension theplanebehind abdominis anddiaphragm Anatomical relationships transversus between 3: thoracolumbarfascia; 5: quadratuslumborum; Characteristics 4: posterior fascia posterior 6: 1: psoas transversus inis muscle. abdom transversus of aponeurosis posterior the by covered is It oblique. that fiones lateral medial The the than vertical more are bers fi rst lumbarvertebrae. ascend to insert on the 12 the on insert to ascend It originates in the iliac crest and iliolumbar ligament and it crest iliac the and rib last the between situated muscle quadrangular lumborum quadratus The Quadratus lumborum Muscles oftheposteriorwall dles areintercalatedinthisspace. dominis from the internal oblique because the neurovascular bun transversus the of layer the separate to task easy an not is It The muscle iliopsoas The Iliopsoas the psoas. tendon the form to muscle fiiliacus Its join to down come bers verse apophysisof1-4lumbarvertebrae. The psoas major lesser trochanter. fiinserts its that psoas the of tendon the form to descend bers muscle iliacus The major andiliacus. (Figure1.7). Figure 1.7. (m.psoasmajor) Quadratus lumborumandpsoasiliacus (m. iliacus) (m.iliopsoas) (m. Quadratuslumborum) th rib and transverse apophysis of the of apophysis transverse and rib rgnts n h iic os and fossa iliac the in originates starts on the bodies and trans- is made of 2 muscles: psoas muscles: 2 of made is is a fla is and at s fi bers ab- are on of - -

Anatomy and physiology of the abdominal wall 0011 CHAPTER It is interesting to remember the anatomic relationships of these complex way to form the anterior and posterior rectus sheaths muscles with the lumbar plexus. The iliohypogastric and ilioinguinal and, weaving in the center, they constitute the linea alba (Fig- run between quadratus lumborum and lateral border of pso- ura 1.9). as major. The lateral femoral cutaneous arises from the con- vex border of the psoas major and the genitofermoral nerve emerg- es in the medial border of the psoas major at the level of the 4th Figure lumbar vertebra. The obturator nerve runs the medial border of the 1.9. Myofascial limits of lateral abdominal muscles. psoas major before entering the lesser . The femoral nerve T: transversus; IO: internal oblique; EO: external Oblique comes posteriorly between the psoas major and the .

Diaphragm

It is a dome-shaped fl at and thin muscle that separates thorax from abdomen. The origins of the diaphragm are found along the , inferior border of the ribs and sternum.

It has a peripheral part of muscle and a central part (central ten- don) of fl at aponeurosis.

The peripheral muscle is divided according to its origin: sternal, costal and lumbar. The sternal origin is made up of 2 small mus- cles that are attached to the posterior side of the xyphoid. The costal origin is made up of several wide muscles that originate in the internal surface of the 7-12 ribs. These fi bers interlace with in- sertions of the transversus abdomnis in the last 6 ribs. The lumbar origin is made up of the pillars of the diaphragm.

In lateral , in the retrocostal dissection, following the ret- romuscular layer behind the transversus abdominis, a space be- Linea alba tween the diaphragm and the peritoneum can easily be created allowing the extension of the mesh in this position (Figure 1.5). The linea alba (linea alba) is a tendinous median line formed by the crossing and fusion of the anterior and posterior rectus 1.1.3. Other components sheaths made up of the intersection of the bilaminar aponeuroses of the abdominal wall of the three abdominal fl at muscles.

Different ways of decussation in the midline have been described The muscles previously described are enveloped by a fascia and without any surgical relevance so far. has an aponeurosis of insertion. Rectus sheaths Commonly, the fascia has a thin connective tissue that makes the dissection diffi cult to perform (Figure 1.8). On the contrary, the Rectus sheaths (vagina musculi recti abdominis) are fi brous aponeurosis works like an authentic tendon of insertion and has a sheaths that envelope recti abdominis on each side. very strong and resistant tissue. In the superior two-thirds the rectus sheath is formed anteri- orly by the external oblique aponeurosis and the anterior apo- Figure neurosis of the internal oblique muscle and, posteriorly, by the 1.8. Drawing showing the concept of fascia posterior aponeurosis of the internal oblique muscle and the and aponeurosis. F: fascia; M: muscle; A: aponeurosis aponeurosis of the transversus muscle. In the lower third, the aponeurosis of the external oblique, internal oblique and trans- versus abdominis pass anteriorly to form the anterior rectus sheath. At this level the rectus abdominis is only covered pos- teriorly by the . The semicircular line that di- vides these areas of the abdomen is the arcuate line of Douglas (linea arcuata) and can be found to the mid-point between the umbilicus and the pubis.

The semilunar line (linea semilunaris) or line of Spiegel is made up of the fusion of the aponeurosis of the 3 lateral fl at muscles on The bilaminar aponeuroses of the three muscles of the an- the lateral border of the rectus muscle. It can be identifi ed from the terolateral abdominal wall are fl at tendons that contribute in a 9th costochondral arch to the pubis tubercle.

5 6 Handbook of Complex Abdominal Wall ligament in almost 20% of patients. These vessels are aberrant are vessels These patients. of Cooper 20% almost the in ligament crossing found be could vessels some that aware be should fimesh to the ligament x this use who surgeons The the retropubicspaceclosetoiliacvessels. la following found easily be can It hernias. incisional in tion This ligament is the one of the most important sites for mesh fi The Cooper´s pecten ligament Cooper ligament endopelvic posterior wall of the inguinal area and continues inferiorly wi fascia ic (fascia thoracolumbalis) Posteriorly, the fascia transversalis joins the thoracolumbar f but openingoftheperitoneumwillbemoreprobabletooccur. is made under the fascia transversalis, this plane will be avas disse the If bleed. easily that vessels small very by irrigated plane the diffiHowever more torn. be be will to and cult fascia t by protected be will peritoneum the made, is fascia this over disse the If transversalis. fascia the under or over dissection the make may surgeon the technique, separation component or posteri- the in release abdominis transversus the making When abdominis musclethatcloselyadherestoit. dominalis) tive tissue and is part of the intraabdominal fascia the parietal peritoneum. It is a fi ne and resistant lamina of c The fascia transversalis is the deepest parietal layer situated and wasso-calledbySir Astley Cooper. musc abdominis transversus the of fascia inner the simply is It Fascia transversalis transversus abdominismuscle of aponeurosis insertion the and ligament) (inguinal tract bic ileopu the muscle, pectineous the of sheath the periosteum, pu- bis of branch upper the of thickening the of up made structure 1.10. Figure (fascia diaphragmatica). . It is covered by the internal surface of the transversus (fascia pelvica) Dissection onthecadaverDissection ofCooper ligaments and, superiorly,diaphragmat- and, the blends and iliacfascias (lig.pectineum) (Figure1.10). It is denser at the level of the of level the at denser is It (fascia iliaca). is a fi xed and rigid (fascia endoab- onnec- terally th the ascia over cular ction ction xa- the he is le - • A vertical lateral axis formed by ascending branches of the of branches ascending by formed axis lateral vertical A • A horizontal axis made up of the last 6 intercostal and lumbar posterior • the along vessels epigastric the of axis vertical A • by deepvascularaxes: provid is wall abdominal the to supply vascular the of rest The branches ofthefemoralartery. superfi arteri superfi circumflgastric, pudendal and cial cial ex superfisuperfia of by up provided made wall system ep cial cial abdomin the superfi of inferior vascularization an cial is There wall. when planning incisions and surgical repair of complex abdomina Knowledge ofthebloodsupplyto 1.1.4. Vascular supply tissue afterincisionalherniasrepair. subcutaneous the close appropriately to used be can fascia This (Scarpa´s fascia). layer membranous deeper a and lay fascia) outer (Camper´s fatty a in divided is fascia the umbilicus, the Below nective tissueabovetheumbilicus. co thin of layer single a is there muscles and skin the Between Super branches, which anastomose the superior epigastric branc fi artery epigastric deep The and thefasciatransversalis. ty tissue that surrounds the vessels leaving below the peritone avoid to these vessels, the dissection should elevate th vesse epigastric inferior the of ligation potential the and ing blee cause may that artery epigastric inferior the from midline arcuata, the surgeon linea should coagulate 2-3 medial the branches to th below dissection retrorectus lateral the making When and theposteriorrectussheath. muscle rectus the between passes it where arcuata linea the as cranially and medially enveloped in perivascular fatty tissue a ascend and fascia transversalis the pierces ring, inguinal deep It arises from the medial side of the external iliac artery, be row ofmusculo-cutaneousperforators. lateral and medial a of means by skin and tissue subcutaneous and muscle rectus the irrigates artery epigastric inferior The Inferior epigastricartery or withthestitchusedformeshfi xation. mostasia can be achieved by electrocautery, other energy device with the obturator vessels obturator the with vess epigastric inferior or iliac external connect that vessels veins or obturator

deep circumfl ex artery. arteries. surface oftherectusmuscle. fi cial (r. obturatoriusorcoronamortis). (obturatoria accesoria) nally divides above the umbilicus in 1-3 1-3 in umbilicus the above divides nally the abdominalwallisimportan or anastomotic or hind the ls. Tols. e fat- He- s far the um es, els hes. hes. ed er n- d- al e i- s s t l

Anatomy and physiology of the abdominal wall 0011 CHAPTER Several musculocutaneous perforators arise from the deep epi- The genitofemoral nerve arises from the fi rst and second lumbar gastric artery giving a metameric subdivision of lateral and medial nerves and contributes to the sensory innervation of the root of rows of perforators, usually 4 above and 3 below the umbilicus. the external genital organs. It is also the motor nerve of the cre- These perforators supply the subcutaneous tissue and skin. master.

Superfi cial epigastric artery The lateral cutaneous nerve of the thigh (the laterla femorcutane- ous nerve), originating from the second lumbar, is not involved in It arises the external iliac artery, distal to inguinal ligament and as- the superfi cial innervation of the abdominal wall. cends about 2 cm laterally to the linea semilunaris over the muscles in the subcutaneous tissue between the fascias of Camper and Scarpa. Intercostal and lumbar arteries 11.2..2. These vessels come laterally along with the nerves in the space between the internal oblique and transversus muscle. They give Physiology several posterior perforators, medially and laterally.

Some diaphragmatic branches from the internal thoracic artery The abdominal wall is a myofascial complex that can resist the anastomose the superior intercostal vessels. The lumbar arteries continuous variation in intraabdominal pressure. The sheaths of also anastomose branches of the deep circumfl ex iliac artery. the muscles are responsible for abdominal wall continence in rest, while the muscle contraction protects the wall from the sudden Veins changes in intraabdominal pressure.

The venous system is patterned parallel to arteries, accompany- The abdominal wall must be considered as a unitary functional ing the perforators and, subsequently, the main veins, by means system. Andres de Laguna wrote in 1535 that “this wall of the body of the thoracophrenic, phrenic, lower intercostal, lumbar and epi- is made up of eight muscles by means of which it attracts, holds gastric veins. back, prepares, expels and accomplishes many other functions”.

They fi nally drain into the azygous, subclavian and iliac veins. 1.2.1. Protection

1.1.5. Innervation The muscles on both sides of the abdominal wall work synkinetical- ly with their aponeuroses containing and protecting the abdominal The lower and the nerves of the lumbar plexus contents. It also maintains the correct anti-gravitational position. suply the innervation of the anterolateral abdominal wall. 1.2.2. Body actions The last 6 intercostal nerves (T7-T12) and the iliohypogastric and ilioinguinal nerves run with the homologous vessels in the layer This myoaponeurotic system participates in several functions: between the internal oblique and transversus abdominis. They all • Flexion, extension and rotation of the trunk. give motor and sensory innervation. In association with the diaphragm, lattissimus dorsi, trapezius, iliopsoas and quadratus lumborum muscles, combines upper The T7-T12 nerves divide in two branches. One branch runs and lower body movements, allowing coordinated movement, along the cartilaginous costal margin, terminates in the wall of overall balance of the spine and weight shifts. the thorax and innervates the internal intercostal space. These • Increases of intraabdominal pressure by muscle contractions: intercostal nerves are in a relatively protected position under the - Micturition chondrocostal margin. The other abdominal branch crosses the - Defecation cartilaginous costal margin and penetrates in the space between - Cough the internal oblique and transversus muscle. - Valsalva - Delivery When the nerves come close to the linea semilunaris, they pierce the posterior rectus sheath slightly medial to its lateral margin, to • Pelvic stabilization: innervate the rectus muscle. This lateral row of perforators must Together with the psoas and the quadratus lumborum, the be preserved during the posterior component separation technique. rectus abdominis muscle stabilizes the pelvis during walking, running and jumping. The two abdominogenital nerves (iliohypogastric and ilioinguinal nerves) supply sensory innervation to the oblique area of the ab- 1.2.3. Respiration dominal wall comprising the lower part of the iliac fossa, the in- guinal region and part of the external genital organs. The motor Together with the diaphragm, the abdominal wall muscles work as branch of the iliohypogastric nerve reaches the inferior part of the a functional system in respiration. Abdominal muscular contraction rectus and the pyramidalis, while the ilioinguinal nerve terminates pushes the viscera upwards and participates in expiration, both at in the fl at abdominal muscles. rest and forced. The essential component is the transversus ab-

7 8 Handbook of Complex Abdominal Wall inclines thespinelaterally. and laterally thigh flthe muscle turns major and psoas exes The erally. flmuscle lumborum quadratus The ipsilat- column spinal the exes The pyramidalismuscleisatensorofthelineaalba. abdominal visceraandisactiveduringforcedrespiration. protec walking, during pelvis the stabilizing to contributes it The rectus abdominis muscle is a tensor, act in fl exion of the a costaldepressoroftheribs;itparticipatesinexpiration. The transversus abdominis muscle is also a tensor of the wall a viscera andhelpinthefl exion androtationofthetrunk. sors and costal depressors; their main contribution is protecti ten- wall are muscles oblique internal and oblique external The 1.2.4. Specificfunctions ration. resp blocks muscles wall abdominal the of contraction voluntary fact, synergistically.In act they when pressure, traabdominal in of increase an need that actions other or coughing in except respiration during antagonistically work muscles wall abdominal and diaphragm the that, So versa. vice and relax wall abdominal th of muscles the inspiration, in contracts diaphragm the While diaphragm. the to antagonist an as acts which muscle, dominis sa Psoas etsadmns abdominis Rectus udau ubrmQuadratus lumborum iprg Diaphragm yaiai Pyramidalis xenlolqe oblique External nenlolqeInternal oblique rnvru boii Transversus abdominis aeOii neto nevto Function Innervation Insertion Origin Name 1.6. Table Summary ofabdominalwallmuscles Summary ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙

1-4 lumbarvertebrae fossaIliac Xyphoid costochondral archs 5-7 Anterior surface Lumbar vertebrae crestIliac 7-12 costal arches Arcuate ligaments Vertebrae ui Pubis xenlsrae51 is 5-12ribs surface External crest andinguinalligament fascia,iliac Thoraco-lumbar Inguinal ligament Inguinal crestIliac fascia Thoraco-lumbar 7-12ribs surface Inner ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙

Rectus sheaths Rectus rcatrmnrTrochanter minor ui Pubis 2rb12 rib hei etrPhrenic center umbilicus andpubis Linea alba,between Iliac crestIliac sheath andlineaalba Rectus 10-12 ribs sheath Rectus Linea alba trunk; ts the ts on of the nd e i- - ,

paired venacavaandportalvenousreturn. The muscular partandsheathsleadingtoatrophyfi The mechanical separation of muscles also causes deterioration and perfusion. diffu ventilation, in concerns major with disease respiratory a modifiThe incisional great the makes synergism of cation or abdominalvolet. quences. This second cavity has also been named loss of domain ond cavity with respiratory, visceral, vascular and vertebral c In the presence of a large parietal defect, there is a creation intraabdomina pressure. in decrease the and viscera of protection of lack fi The wall defects 1.2.5. Consequencesoflargeabdominal inguinal canal. t of wall posterior the protects oblique internal and abdominis In the inguinal region, the myoaponeurotic arch of the transver during contractionenlargingthethoraciccage. flit muscle; respiratory main the atten is muscle diaphragm The alteration on the vascularization of viscera may produce im- produce may viscera of vascularization the on alteration rst consequence of loss of abdominal wall continence is the the is continence wall abdominal of loss of consequence rst ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙

Genito-femoral Ilioinguinal Iliohipogastric 7-12 intercostal Lumbar plexus Femoral -2itrotl 7-12 intercostal Genito-femoral Ilioinguinal Iliohipogastric 7-12 intercostal Phrenic 2itrotl 12 intercostal -2itrotl 5-12 intercostal Ilioinguinal Iliohipogastric 8-12 intercostal ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙

Tension oftheabdomen Flexion, rotation ofthigh Flexion oftrunk Descend ofribs Descend ofthorax Lateral flexion Pelvis elevation abdomen ofthoraxfromSeparation Tension ofthewall Respiration Tension oflineaalba Rotation oftrunk Descend ofthorax Lateral flexion Tension ofthewall Descend ofribs of thetrunk Lateral andventral flexion Tension oftheabdomen brosis. a sec- onse- sion of the sus he s s l Anatomy and physiology of the abdominal wall 0011 CHAPTER RReferenceseferences

 Chevrel JP. Hernias and surgery of the abdominal wall. 2nd ed. Springer. 1998; 4-27.

 Rosen MJ. Atlas of abdominal wall reconstruction. Elsevier-Saunders. 2012; 3-20.

 Rouvière H, Demas A. Human anatomy. Descriptive, topographic and functional. Volume II. Trunk. 10th ed. Editorial Masson. 1999; 72-106.

 Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009; 124: 1529-44. doi: 10.1097/PRS. 0b013e3181b98a6c. http://www.ncbi.nlm.nih.gov/pubmed/20009839

 Skandalakis JE, Gray SW, Skandalakis LJ, Colborn GL, Pemberton LB. Surgical anatomy of the inguinal area. World J Surg 1989; 13: 490-8. PMID: 2815794. http://www.ncbi.nlm.nih.gov/pubmed/2815794

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