ClinicalClinical AnatomyAnatomy ofof thethe AnteriorAnterior AbdominalAbdominal WallWall inin itsits RelationRelation toto HerniaHernia

Handout download: http://www.oucom.ohiou.edu/dbms-witmer/gs-rpac.htm

24 April 2007

LawrenceLawrence M.M. Witmer,Witmer, PhDPhD Professor of Anatomy Department of Biomedical Sciences College of Osteopathic Medicine Ohio University Athens, Ohio 45701 [email protected] AnatomicalAnatomical OverviewOverview External Internal Transversus Rectus oblique oblique abdominis abdominis

fleshyfleshy rectusrectus portionportion sheathsheath

aponeuroticaponeurotic inguinalinguinal tendinoustendinous portionportion ligamentligament intersectionsintersections

• Three flat abdominals: attach to trunk skeleton, inguinal lig., , etc.; fleshy laterally and aponeurotic medially, forming medially • Two vertical abdominals: rectus abdominis and pyramidalis (not shown)

Moore & Dalley 2006 AnatomicalAnatomical OverviewOverview intramuscular exchange of intermuscular exchange of contralateral external oblique fibers contralateral external & internal oblique

right external oblique left internal oblique

• continuity of external oblique • continuity of fibers across midline fibers across midline • “digastric” muscle with central • blending of superficial & deep tendon fibers on opposite side • torsion of trunk Moore & Dalley 2006 AnatomicalAnatomical OverviewOverview transv. abd. linea alba rectus sheath rectus abdominis int. obl. ext. obl.

semilunar line transversalis

aponeuroses of abdominal mm. tendinous fasciae: Scarpa’s, Camper’s intersections Moore & Dalley 2006 AnatomicalAnatomical OverviewOverview anterior lamina of rectus sheath semilunar line (of Spiegel) inferior epigastric vessels posterior lamina internal of rectus sheath oblique (aponeurotic) iliohypogastric n. arcuate line (semicircular) ilioinguinal n. line of Douglas) posterior lamina of rectus sheath () Moore & Dalley 2006 AnatomicalAnatomical OverviewOverview Anterior Abdominal

rectus sheath

linea alba

umbilicus

semilunar line

superficial inguinal ring

femoral canal

.tripod.com/types.html Moore & Dalley 2006 EpigastricEpigastric (Ventral)(Ventral) HerniaHernia linea alba thachers.org/images/epigastric_hernia.jpg thachers.org/images/hernia_repair.jpg

scarscar

repairedrepaired herniahernia

hernialhernial sacsac health.enotes.com/images/ medicine/gem_03_img0340.jpg

anterior rectus rectus sheath abdominis posterior rectus sheath

Skandalakis’ Surgical Anatomy 2004 hernial sac peritoneum UmbilicalUmbilical (Para(Para--umbilical)umbilical) HerniaHernia Congenital Acquired Umbilical Hernia Umbilical • occur after closure of umbilical ring Hernia • 2° to obesity, pregnancy, cirrhosis, ascites, masses medicine.ucsd.edu/clinicalimg/medicine.ucsd.edu/clinicalimg/ abdomenabdomen-umbo-hernia4.jpg-umbo-hernia4.jpg

• incomplete closure of umbilical ring

Omphalocele 2°2° to to ascitesascites

1988 Moore Developing th Human 4 edition Skandalakis’ Surgical Anatomy 2004 SpigelianSpigelian (Lateral(Lateral Ventral)Ventral) HerniaHernia

CT rectusrectus sheath:sheath: semilunar posteriorposterior && anterioranterior laminalamina line

arcuate line

frequent hernial www.e-radiography.net/ibase5/Abdomen/ site slides/Abdomen_spigelian_hernia_ct.jpg

transversalistransversalis fasciafascia rectusrectus Skandalakis’ Surgical Anatomy 2004 abdominisabdominis Moore & Dalley 2006 CaseCase PresentationPresentation A 3-year-old boy presents with a walnut-sized bulge in his left groin, particularly when he stands, strains, or cries. With the patient horizontal, the lump disappears. When the of the scrotum is invaginated by a little finger, a definite impact is felt on coughing. The diagnosis of hernia is made. How would this hernia be best characterized?

atat restrest uponupon strainingstraining

reducible,reducible, congenital,congenital, indirectindirect inguinalinguinal herniahernia

pediatriconcall.com/forpatients/commonchild/images/inguinal_hernia.jpg EmbryologicalEmbryological BasisBasis ofof IndirectIndirect InguinalInguinal herniahernia Week 7 testistestis inin abdomenabdomen

Moore & Dalley 2006 EmbryologicalEmbryological BasisBasis ofof IndirectIndirect InguinalInguinal herniahernia Week 28 testistestis descendsdescends

patentpatent processusprocessus vaginalisvaginalis

Moore & Dalley 2006 EmbryologicalEmbryological BasisBasis ofof IndirectIndirect InguinalInguinal herniahernia Week 36 testistestis inin scrotumscrotum

processusprocessus vaginalisvaginalis closedclosed

Moore & Dalley 2006 EmbryologicalEmbryological BasisBasis ofof IndirectIndirect InguinalInguinal herniahernia transversalis fascia & peritoneum hernial sac within abdominal spermatic muscles cord

partiallypartially vas deferens obliteratedobliterated processusprocessus pampiniform vaginalisvaginalis plexus epididymis

testis tunica vaginalis Cahill 1997 InguinalInguinal AnatomyAnatomy ASIS external oblique aponeurosis & Gallaudet’s superficial fascia circumflex iliac intercrurual vessels fibers

superficial medial epigastric crus vessels lateral crus & great inguinal lig. saphenous v. ilioinguinal external n. (L1) superficial (external) pudendal spermatic cord inguinal ring vessels

Moore & Dalley 2006 InguinalInguinal AnatomyAnatomy inguinal lig. (of Poupart) myopectineal orifice internal inguinal ring of Fruchaud reflected inguinal lig.

ili op soa s femoral n.

external iliac vessels

femoral canal pectineus pectineal lig. lacunar lig. (of Cooper) (of Gimbernat) Moore & Dalley 2006 InguinalInguinal AnatomyAnatomy testicular vessels vas deferens

PP TATATFTF internal IOIO ring EOEO Space of Bogros

ilioinguinal n. external ring Moore & Dalley 2006 “” InguinalInguinal AnatomyAnatomy

shelving edge of ing. lig.

Moore & Dalley 2006 InguinalInguinal AnatomyAnatomy

iliopubic tract shelving edge of inguinal parasagittal section through right side

Skandalakis’ Surgical Anatomy 2004 arcuate line inferior epigastric vessels

iliopubic iliopubic tract tract testicular external vessels iliac vessels deep Hesselbach’s ing. ring Triangle femoral canal posterior view of anterior abdominal wall vas deferens Moore & Dalley 2006 HesselbachHesselbach’’ss (Inguinal)(Inguinal) TriangleTriangle posterior view of anterior abdominal wall internal inguinal ring

indirectindirect inguinalinguinal herniahernia

directdirect inguinalinguinal herniahernia Moore & Dalley 2006 FemoralFemoral HerniaHernia femoral canal

lacunar lig. (of Gimbernat)

Skandalakis’ Surgical Anatomy 2004 ReferencesReferences

• Cahill, D. R. 1997. Lachman’s Case Studies in Anatomy, 4th Ed. Oxford University Press, New York. • Moore, K. L. and A. F. Dalley. 2006. Clinically Oriented Anatomy, 5th Ed. Lippincott, Williams & Wilkins, Baltimore. • Moore, K. L. 1988. The Developing Human. Clinically Oriented Embryology, 4th Ed. Lippincott, Williams & Wilkins, Baltimore. • Skandalakis, J. E., G. L. Colborn, T. A. Weidman, R. S. Foster, A. N. Kingsnorth, L. J. Skandalakis, N. P. Skandalakis, P. Mirilas (Editors). 2004. Surgical Anatomy: The Embryologic And Anatomic Basis Of Modern Surgery. McGraw-Hill, New York.