CLINICAL ANATOMY OF
ANTERIOR ABDOMINAL WALL
& RECTUS SHEATH
By: Dr. Mujahid Khan
Structure of Abdominal Cavity
Superiorly it is formed by diaphragm which
separates the abdominal cavity from the
thoracic cavity
Inferiorlythe abdominal cavity is
continuous with the pelvic cavity through
the pelvic inlet
Structure of Abdominal Wall
Anteriorly:
Theabdominal wall is formed above by
lower part of the thoracic cage
Below by the rectus abdominis, external
oblique, internal oblique, and transversus
abdominis muscles and fasciae
Structure of Ant. Abdominal Wall
Itis made up of skin, superficial fascia,
deep fascia, muscles, extraperitoneal
fascia and parietal peritoneum
The abdominal walls are lined by a fascial
envelope and the parietal peritoneum
Skin
Natural
lines of cleavage in the skin are
constant and run almost horizontally
around the trunk
Anincision along a cleavage line will heal
as a narrow scar, while one that crosses
the lines will heal as a wide scar
Cutaneous Nerve Supply
Isderived from the anterior rami of the
lower six thoracic and first lumbar nerves
Thoracic nerves are the lower five
intercostal and the subcostal nerves
First lumbar nerve is represented by the
iliohypogastric and ilioinguinal nerves
Blood Supply
Skin near the midline is supplied by
branches of the superior epigastric artery
(br. of int. thoracic artery) and the inferior
epigastric artery ( br. of external iliac
artery)
Skinof the flanks is supplied by branches
from the intercostal, lumbar, and deep
circumflex arteries
Superficial Fascia
Fatty layer or fascia of camper is
continuous with the superficial fat over the
rest of the body and may be extremely
thick in obese patients
The membranous layer or scarpas fascia
is thin and fades out laterally and above
Becomes continuous with the superficial
fascia of the back and the thorax
Superficial Fascia
Inferiorly the membranous layer passes onto the
front of the thigh, where it fuses with the deep
fascia
In the midline inferiorly forms a tubular sheath
for the penis or clitoris
Below in the perineum, enters the wall of the
scrotum or labia majora
From there it passes to be attached on each
side to the margins of pubic arch, here it is
called Colles fascia
Superficial Fascia
Posteriorly
it fuses with the perineal body
and the margin of the perineal membrane
The
fatty layer is represented as a smooth
muscle in the scrotum, the dartos muscle
Themembranous layer persists as a
separate layer
Deep Fascia
Deep fascia in the anterior abdominal wall
is merely a thin layer of connective tissue
covering the muscles
It
lies immediately deep to the
membranous layer of the superficial fascia
Muscles
Consists of Three broad thin sheets that are
aponeurotic in front
From exterior to interior they are:
External oblique, internal oblique, and
transverse
A wide vertical muscle, the rectus abdominis
They lie on either side of the midline anteriorly
Muscles
Asthe aponeurosis of three sheets pass
forward, they enclose the rectus
abdominis to form the rectus sheath
Thecremaster muscle which is derived
from the lower fibers of internal oblique,
passes inferiorly as a covering of the
spermatic cord and enters scrotum
External Oblique Muscle
Is a broad, thin, muscular sheet
Origin: Lower 8 ribs
Insertion: Xiphoid process, linea alba, pubic tubercle,
iliac crest
Nerve Supply: Lower 6 thoracic nerves, iliohypogastric &
ilioinguinal nerves
Action: Supports abdominal contents, assist in forced
expiration, micturition, defecation, parturition, vomiting
External Oblique Muscle
A triangular shaped defect in the external
oblique aponeurosis lies immediately
above and medial to the pubic tubercle,
known as superficial inguinal ring
Between the anterosuperior iliac spine and
the pubic tubercle, the lower border of the
aponeurosis is folded backward on itself,
forming the inguinal ligament
Internal Oblique Muscle
Origin: Lumbar fascia, iliac crest, lateral two-
thirds of inguinal ligament
Insertion: Lower three ribs and costal cartilages,
xiphoid process, linea alba, symphysis pubis
Nerve Supply: Lower six thoracic nerves,
iliohypogastric & ilioinguinal nerves
Action: Supports abdominal contents, assist in
forced expiration, micturition, defecation,
parturition, vomiting
Transversus Abdominis
Origin: Lower six costal cartilages, lumbar fascia,
iliac crest, lateral third of inguinal ligament
Insertion: Xiphoid process, linea alba, symphysis
pubis
Nerve Supply: Lower six thoracic nerves,
iliohypogastric & ilioinguinal nerves
Action: Compresses abdominal contents
Rectus Abdominis
Origin: Symphysis pubis and pubic crest
5th, 6th and 7th costal cartilages
Insertion:
and xiphoid process
Nerve Supply: Lower six thoracic nerves
Action: Compresses abdominal contents,
flexes vertebral column, accessory muscle
of expiration
Lymph Drainage
Lymph drainage of the skin of the anterior
abdominal wall above the umbilicus is upward to
the anterior axillary (pectoral group of nodes)
Below the level of umbilicus drains downward
and laterally to the superficial inguinal nodes
Swelling in the groin is may be due to enlarged
superficial inguinal node
Venous Drainage
Venous blood is collected into a network of veins
that radiate from the umbilicus
The network is drained above into the axillary
vein via the lateral thoracic vein
Below into the femoral vein via the superficial
epigastric and the great saphenous veins
Few small veins, the paraumbilical veins form a
clinically important portal-system venous
anastomosis
Caput Medusae
Thesuperficial veins around the umbilicus
and the paraumbilical veins connecting
them to the portal vein may become
grossly distended in case of portal vein
obstruction
The distended subcutaneous veins radiate
out from the umbilicus, producing in
severe cases the clinical picture called
Caput Medusae
Nerves
Nerves of the anterior abdominal wall supply the
skin, muscles and the parietal peritoneum
They are derived from the anterior rami of lower
six thoracic and the first lumbar nerves
Inflammation of parietal peritoneum causes pain
in the overlying skin and also a reflex increase in
tone of the abdominal musculature in the same
area
Rectus Sheath
Is a long fibrous sheath
Encloses the rectus abdominis and pyramidalis
muscle (if present)
Contains the anterior rami of lower six thoracic
nerves and the superior and inferior epigastric
vessels and lymph vessels
Formed mainly by aponeurosis of three lateral
abdominal muscles
Rectus Sheath
For description it is considered at three
levels:
Above the costal margin the anterior wall
is formed by the aponeurosis of the
external oblique and posterior wall is
formed by the thoracic wall
Thatis the 5th , 6th and 7th costal cartilages
and the intercostal spaces
Rectus Sheath
Between the costal margin and the level of
the anterosuperior iliac spine, the
aponeurosis of the internal oblique splits to
enclose the rectus muscle
The external oblique aponeurosis is
directed in front of the muscle
Transversusaponeurosis is directed
behind the muscle
Rectus Sheath
Between the level of the anterosuperior
iliac spine and the pubis, the aponeurosis
of all three muscles form the anterior wall
The posterior wall is absent
The rectus muscle lies in contact with the
fascia transversalis
Rectus Sheath
The posterior wall of the rectus sheath is
not attached to the rectus abdominis
muscle
Theanterior wall is firmly attached to it by
the muscles tendinous intersections
Linea Alba
The rectus sheath is separated from its
fellow on the opposite side by a fibrous
band called the linea alba
Extends
from the xiphoid process to the
symphysis pubis
