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Clinical Anatomy of the Anterior Abdominal Wall in Its Relation To 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., linea alba, etc.; fleshy laterally and aponeurotic medially, forming rectus sheath 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 peritoneum transversalis fascia 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 (transversalis fascia) Moore & Dalley 2006 AnatomicalAnatomical OverviewOverview Anterior Abdominal Hernias rectus sheath linea alba umbilicus semilunar line superficial inguinal ring femoral canal hernia.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 skin 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 “conjoint tendon” InguinalInguinal AnatomyAnatomy shelving edge of ing. lig. Moore & Dalley 2006 InguinalInguinal AnatomyAnatomy iliopubic tract shelving edge of inguinal parasagittal section ligament through right side Skandalakis’ Surgical Anatomy 2004 lateral umbilical fold arcuate line inferior epigastric vessels iliopubic iliopubic tract tract iliopsoas 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..
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