Clinical anatomy of the anterior abdominal wall in - Ohio University ...
Clinical anatomy of the anterior abdominal wall in - Ohio University ...
Clinical anatomy of the anterior abdominal wall in - Ohio University ...
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26 April 2011<br />
<strong>Cl<strong>in</strong>ical</strong> Anatomy <strong>of</strong> <strong>the</strong><br />
Anterior Abdom<strong>in</strong>al Wall<br />
<strong>in</strong> its Relation to Hernia<br />
Handout download:<br />
http://www.oucom.ohiou.edu/dbms-witmer/gs-rpac.htm<br />
Lawrence M. Witmer, PhD<br />
Pr<strong>of</strong>essor <strong>of</strong> Anatomy<br />
Department <strong>of</strong> Biomedical Sciences<br />
College <strong>of</strong> Osteopathic Medic<strong>in</strong>e<br />
<strong>Ohio</strong> <strong>University</strong>, A<strong>the</strong>ns<br />
witmerL@ohio.edu
fleshy<br />
portion<br />
External<br />
oblique<br />
aponeurotic<br />
portion<br />
Anatomical Overview<br />
Internal<br />
oblique<br />
rectus<br />
sheath<br />
<strong>in</strong>gu<strong>in</strong>al<br />
ligament<br />
Transversus<br />
abdom<strong>in</strong>is<br />
tend<strong>in</strong>ous<br />
<strong>in</strong>tersections<br />
Rectus<br />
abdom<strong>in</strong>is<br />
• Three flat <strong>abdom<strong>in</strong>al</strong>s: attach to trunk skeleton, <strong>in</strong>gu<strong>in</strong>al lig., l<strong>in</strong>ea alba, etc.;<br />
fleshy laterally and aponeurotic medially, form<strong>in</strong>g rectus sheath medially<br />
• Two vertical <strong>abdom<strong>in</strong>al</strong>s: rectus abdom<strong>in</strong>is and pyramidalis (not shown)<br />
Moore et al. 2010
<strong>in</strong>tramuscular exchange <strong>of</strong><br />
contralateral external oblique fibers<br />
• cont<strong>in</strong>uity <strong>of</strong> external oblique<br />
fibers across midl<strong>in</strong>e<br />
• blend<strong>in</strong>g <strong>of</strong> superficial & deep<br />
fibers on opposite side<br />
Anatomical Overview<br />
<strong>in</strong>termuscular exchange <strong>of</strong><br />
contralateral external & <strong>in</strong>ternal oblique<br />
right<br />
external<br />
oblique<br />
Moore et al. 2010<br />
left<br />
<strong>in</strong>ternal<br />
oblique<br />
• cont<strong>in</strong>uity <strong>of</strong> fibers across midl<strong>in</strong>e<br />
• “digastric” muscle with central<br />
tendon<br />
• torsion <strong>of</strong> trunk
ectus abdom<strong>in</strong>is<br />
tend<strong>in</strong>ous<br />
<strong>in</strong>tersections<br />
Anatomical Overview<br />
l<strong>in</strong>ea alba rectus sheath<br />
transversalis fascia<br />
fasciae: Scarpa’s, Camper’s<br />
Moore et al. 2010<br />
semilunar l<strong>in</strong>e<br />
transv. abd.<br />
<strong>in</strong>t. obl.<br />
ext. obl.<br />
peritoneum<br />
aponeuroses <strong>of</strong><br />
<strong>abdom<strong>in</strong>al</strong> mm.
<strong>anterior</strong> lam<strong>in</strong>a<br />
<strong>of</strong> rectus sheath<br />
<strong>in</strong>ferior epigastric<br />
vessels<br />
<strong>in</strong>ternal<br />
oblique<br />
iliohypogastric n.<br />
ilio<strong>in</strong>gu<strong>in</strong>al n.<br />
Anatomical Overview<br />
Moore et al. 2010<br />
semilunar<br />
l<strong>in</strong>e (<strong>of</strong> Spiegel)<br />
posterior lam<strong>in</strong>a<br />
<strong>of</strong> rectus sheath<br />
(aponeurotic)<br />
arcuate l<strong>in</strong>e<br />
(semicircular)<br />
l<strong>in</strong>e <strong>of</strong> Douglas)<br />
posterior lam<strong>in</strong>a<br />
<strong>of</strong> rectus sheath<br />
(transversalis fascia)
Anatomical Overview<br />
Anterior Abdom<strong>in</strong>al Hernias<br />
hernia.tripod.com/types.html<br />
rectus sheath<br />
l<strong>in</strong>ea alba<br />
umbilicus<br />
semilunar l<strong>in</strong>e<br />
superficial<br />
<strong>in</strong>gu<strong>in</strong>al r<strong>in</strong>g<br />
femoral<br />
canal<br />
Moore et al. 2010
thachers.org/images/epigastric_hernia.jpg<br />
thachers.org/images/hernia_repair.jpg<br />
hernial sac<br />
rectus<br />
abdom<strong>in</strong>is<br />
Epigastric (Ventral) Hernia<br />
scar<br />
repaired hernia<br />
l<strong>in</strong>ea alba<br />
health.enotes.com/images/<br />
medic<strong>in</strong>e/gem_03_img0340.jpg<br />
Skandalakis’ Surgical Anatomy 2004 hernial sac peritoneum<br />
<strong>anterior</strong> rectus<br />
sheath<br />
posterior rectus<br />
sheath
Umbilical (Para-umbilical) Hernia<br />
Congenital<br />
Umbilical<br />
Hernia<br />
• <strong>in</strong>complete closure <strong>of</strong> umbilical r<strong>in</strong>g<br />
Omphalocele<br />
1988 Moore Develop<strong>in</strong>g<br />
Human 4 th edition<br />
Acquired Umbilical Hernia<br />
• occur after closure <strong>of</strong> umbilical r<strong>in</strong>g<br />
• 2° to obesity, pregnancy, cirrhosis,<br />
ascites, masses<br />
medic<strong>in</strong>e.ucsd.edu/cl<strong>in</strong>icalimg/<br />
abdomen-umbo-hernia4.jpg<br />
2° to ascites<br />
Skandalakis’ Surgical Anatomy 2004
CT<br />
www.e-radiography.net/ibase5/Abdomen/<br />
slides/Abdomen_spigelian_hernia_ct.jpg<br />
Spigelian (Lateral Ventral) Hernia<br />
semilunar<br />
l<strong>in</strong>e<br />
arcuate<br />
l<strong>in</strong>e<br />
frequent<br />
hernial<br />
site<br />
Skandalakis’ Surgical<br />
Anatomy 2004<br />
rectus sheath:<br />
posterior & <strong>anterior</strong> lam<strong>in</strong>a<br />
rectus<br />
abdom<strong>in</strong>is<br />
Moore et al. 2010<br />
transversalis<br />
fascia
Case Presentation<br />
A 3-year-old boy presents with a walnut-sized bulge <strong>in</strong> his left<br />
gro<strong>in</strong>, particularly when he stands, stra<strong>in</strong>s, or cries. With <strong>the</strong><br />
patient horizontal, <strong>the</strong> lump disappears. When <strong>the</strong> sk<strong>in</strong> <strong>of</strong> <strong>the</strong><br />
scrotum is <strong>in</strong>vag<strong>in</strong>ated by a little f<strong>in</strong>ger, a def<strong>in</strong>ite impact is felt on<br />
cough<strong>in</strong>g. The diagnosis <strong>of</strong> hernia is made. How would this hernia<br />
be best characterized?<br />
at rest<br />
upon stra<strong>in</strong><strong>in</strong>g<br />
reducible, congenital, <strong>in</strong>direct <strong>in</strong>gu<strong>in</strong>al hernia<br />
pediatriconcall.com/forpatients/commonchild/images/<strong>in</strong>gu<strong>in</strong>al_hernia.jpg
Embryological Basis <strong>of</strong> Indirect Ingu<strong>in</strong>al hernia<br />
Week 7<br />
testis <strong>in</strong><br />
abdomen<br />
Moore et al. 2010
Embryological Basis <strong>of</strong> Indirect Ingu<strong>in</strong>al hernia<br />
Week 28<br />
testis<br />
descends<br />
patent processus vag<strong>in</strong>alis<br />
Moore et al. 2010
Embryological Basis <strong>of</strong> Indirect Ingu<strong>in</strong>al hernia<br />
Week 36<br />
testis <strong>in</strong><br />
scrotum<br />
processus vag<strong>in</strong>alis closed<br />
Moore et al. 2010
Embryological Basis <strong>of</strong> Indirect Ingu<strong>in</strong>al hernia<br />
transversalis fascia<br />
& peritoneum<br />
<strong>abdom<strong>in</strong>al</strong><br />
muscles<br />
partially<br />
obliterated<br />
processus<br />
vag<strong>in</strong>alis<br />
tunica<br />
vag<strong>in</strong>alis<br />
Cahill 1997<br />
hernial sac<br />
with<strong>in</strong><br />
spermatic<br />
cord<br />
vas deferens<br />
pamp<strong>in</strong>iform<br />
plexus<br />
epididymis<br />
testis
superficial<br />
circumflex<br />
iliac<br />
vessels<br />
superficial<br />
epigastric<br />
vessels<br />
great<br />
saphenous<br />
v.<br />
external<br />
pudendal<br />
vessels<br />
Ingu<strong>in</strong>al Anatomy<br />
spermatic cord<br />
Moore et al. 2010<br />
ASIS<br />
superficial (external)<br />
<strong>in</strong>gu<strong>in</strong>al r<strong>in</strong>g<br />
external<br />
oblique<br />
aponeurosis<br />
& Gallaudet’s<br />
fascia<br />
<strong>in</strong>tercrurual<br />
fibers<br />
medial<br />
crus<br />
lateral<br />
crus &<br />
<strong>in</strong>gu<strong>in</strong>al lig.<br />
ilio<strong>in</strong>gu<strong>in</strong>al<br />
n. (L1)
femoral n.<br />
external iliac<br />
vessels<br />
Ingu<strong>in</strong>al Anatomy<br />
<strong>in</strong>gu<strong>in</strong>al lig.<br />
(<strong>of</strong> Poupart)<br />
femoral canal<br />
<strong>in</strong>ternal<br />
<strong>in</strong>gu<strong>in</strong>al r<strong>in</strong>g<br />
myopect<strong>in</strong>eal orifice<br />
<strong>of</strong> Fruchaud<br />
reflected<br />
<strong>in</strong>gu<strong>in</strong>al lig.<br />
pect<strong>in</strong>eus pect<strong>in</strong>eal lig. lacunar lig.<br />
(<strong>of</strong> Cooper) (<strong>of</strong> Gimbernat)<br />
Moore et al. 2010
Ingu<strong>in</strong>al Anatomy<br />
testicular vessels vas deferens<br />
EO<br />
TA TF<br />
P<br />
IO<br />
<strong>in</strong>ternal<br />
r<strong>in</strong>g<br />
Space <strong>of</strong><br />
Bogros<br />
ilio<strong>in</strong>gu<strong>in</strong>al n.<br />
external<br />
“conjo<strong>in</strong>t tendon” r<strong>in</strong>g<br />
Moore et al. 2010
Ingu<strong>in</strong>al Anatomy<br />
shelv<strong>in</strong>g edge<br />
<strong>of</strong> <strong>in</strong>g. lig.<br />
Moore et al. 2010
shelv<strong>in</strong>g edge<br />
<strong>of</strong> <strong>in</strong>gu<strong>in</strong>al<br />
ligament<br />
Skandalakis’ Surgical Anatomy 2004<br />
Ingu<strong>in</strong>al Anatomy<br />
iliopubic tract<br />
parasagittal section<br />
through right side
lateral umbilical fold<br />
iliopubic<br />
tract<br />
iliopsoas<br />
external<br />
iliac vessels<br />
Hesselbach’s<br />
Triangle<br />
posterior view <strong>of</strong><br />
<strong>anterior</strong> <strong>abdom<strong>in</strong>al</strong> <strong>wall</strong><br />
arcuate l<strong>in</strong>e<br />
vas deferens<br />
<strong>in</strong>ferior epigastric vessels<br />
femoral canal<br />
iliopubic<br />
tract<br />
testicular<br />
vessels<br />
deep<br />
<strong>in</strong>g. r<strong>in</strong>g<br />
Moore et al. 2010
posterior view<br />
<strong>of</strong> <strong>anterior</strong><br />
<strong>abdom<strong>in</strong>al</strong> <strong>wall</strong><br />
Hesselbach’s (Ingu<strong>in</strong>al) Triangle<br />
direct <strong>in</strong>gu<strong>in</strong>al hernia<br />
Moore et al. 2010<br />
<strong>in</strong>ternal<br />
<strong>in</strong>gu<strong>in</strong>al<br />
r<strong>in</strong>g<br />
<strong>in</strong>direct<br />
<strong>in</strong>gu<strong>in</strong>al hernia
Femoral Hernia<br />
Skandalakis’ Surgical Anatomy 2004<br />
lacunar lig.<br />
(<strong>of</strong> Gimbernat)<br />
femoral canal
References<br />
• Cahill, D. R. 1997. Lachman’s Case Studies <strong>in</strong> Anatomy, 4th Ed.<br />
Oxford <strong>University</strong> Press, New York.<br />
• Moore, K. L., A. F. Dalley, and A M. R. Agur. 2010. <strong>Cl<strong>in</strong>ical</strong>ly<br />
Oriented Anatomy, 6th Ed. Lipp<strong>in</strong>cott, Williams & Wilk<strong>in</strong>s,<br />
Baltimore.<br />
• Moore, K. L. and T. V. N. Persaud. 2003. The Develop<strong>in</strong>g Human.<br />
<strong>Cl<strong>in</strong>ical</strong>ly Oriented Embryology, 7th Ed. Lipp<strong>in</strong>cott, Williams &<br />
Wilk<strong>in</strong>s, Baltimore.<br />
• Skandalakis, J. E., G. L. Colborn, T. A. Weidman, R. S. Foster, A.<br />
N. K<strong>in</strong>gsnorth, L. J. Skandalakis, N. P. Skandalakis, P. Mirilas<br />
(Editors). 2004. Surgical Anatomy: The Embryologic And Anatomic<br />
Basis Of Modern Surgery. McGraw-Hill, New York.
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