Clinical Anatomy of theClinical Anatomy of theAnterior Abdominal WallAnterior Abdominal Wallin its Relation to Herniain its Relation to Hernia
Lawrence M. Witmer, PhDLawrence M. Witmer, PhDProfessor of AnatomyDepartment of Biomedical SciencesCollege of Osteopathic MedicineOhio UniversityAthens, Ohio 45701 [email protected]
Handout download:http://www.oucom.ohiou.edu/dbms-witmer/gs-rpac.htm
24 April 2007
Anatomical OverviewAnatomical Overview
Moore & Dalley 2006
Externaloblique
Internaloblique
Transversusabdominis
Rectusabdominis
inguinal ligamentinguinal ligament
tendinousintersections
tendinousintersections
• 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)
aponeuroticportion
aponeuroticportion
rectussheathrectussheath
fleshyportionfleshyportion
Moore & Dalley 2006
intramuscular exchange ofcontralateral external oblique fibers
intermuscular exchange ofcontralateral external & internal oblique
• continuity of fibers across midline• “digastric” muscle with central
tendon• torsion of trunk
• continuity of external oblique fibers across midline
• blending of superficial & deep fibers on opposite side
rightexternaloblique
leftinternaloblique
Anatomical OverviewAnatomical Overview
Moore & Dalley 2006
linea alba rectus sheath transv. abd.int. obl.ext. obl.
peritoneumtransversalis fascia
aponeuroses ofabdominal mm.
fasciae: Scarpa’s, Camper’s
rectus abdominis
tendinousintersections
Anatomical OverviewAnatomical Overview
semilunar line
Anatomical OverviewAnatomical Overview
Moore & Dalley 2006
inferior epigastricvessels
internaloblique
anterior laminaof rectus sheath
iliohypogastric n.
ilioinguinal n.
arcuate line(semicircular)
line of Douglas)
semilunar line (of Spiegel)
posterior laminaof rectus sheath
(aponeurotic)
posterior laminaof rectus sheath
(transversalis fascia)
Anatomical OverviewAnatomical Overview
linea alba
umbilicus
semilunar line
hernia.tripod.com/types.html
Anterior Abdominal Hernias
rectus sheath
superficialinguinal ring
femoralcanal
Moore & Dalley 2006
linea alba
health.enotes.com/images/medicine/gem_03_img0340.jpg
thachers.org/images/epigastric_hernia.jpgthachers.org/images/hernia_repair.jpg
hernial sachernial sacrepaired herniarepaired hernia
scarscar
Epigastric (Ventral) HerniaEpigastric (Ventral) Hernia
Skandalakis’ Surgical Anatomy 2004 hernial sachernial sac peritoneum
posterior rectussheath
anterior rectussheathrectus
abdominis
1988 Moore Developing Human 4th edition
OmphaloceleOmphalocele
CongenitalCongenitalUmbilicalUmbilical
HerniaHernia
Acquired Umbilical HerniaAcquired Umbilical Hernia
• incomplete closure of umbilical ring
• occur after closure of umbilical ring• 2° to obesity, pregnancy, cirrhosis, ascites, masses
medicine.ucsd.edu/clinicalimg/abdomen-umbo-hernia4.jpgmedicine.ucsd.edu/clinicalimg/medicine.ucsd.edu/clinicalimg/abdomenabdomen--umboumbo--hernia4.jpghernia4.jpg
2° to ascites2° to ascites
Umbilical (ParaUmbilical (Para--umbilical) Herniaumbilical) Hernia
Skandalakis’ Surgical Anatomy 2004
www.e-radiography.net/ibase5/Abdomen/slides/Abdomen_spigelian_hernia_ct.jpg
CT semilunarline
arcuateline
frequenthernial
site
rectusabdominis
rectusabdominis
rectus sheath:posterior & anterior lamina
rectus sheath:posterior & anterior lamina
transversalisfascia
transversalisfascia
Spigelian (Lateral Ventral) HerniaSpigelian (Lateral Ventral) HerniaSpigelian (Lateral Ventral) Hernia
Moore & Dalley 2006
Skandalakis’ SurgicalAnatomy 2004
Case PresentationCase PresentationCase PresentationA 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 herniabe best characterized?
pediatriconcall.com/forpatients/commonchild/images/inguinal_hernia.jpg
upon strainingupon strainingat restat rest
reducible, congenital, indirect inguinal herniareducible, congenital, indirect inguinal hernia
testis intestis inabdomenabdomen
Week 7
Embryological Basis of Indirect Inguinal herniaEmbryological Basis of Indirect Inguinal herniaEmbryological Basis of Indirect Inguinal hernia
Moore & Dalley 2006
testistestisdescendsdescends
Embryological Basis of Indirect Inguinal herniaEmbryological Basis of Indirect Inguinal herniaEmbryological Basis of Indirect Inguinal hernia
Week 28
patent processus vaginalispatent processus vaginalis
Moore & Dalley 2006
Embryological Basis of Indirect Inguinal herniaEmbryological Basis of Indirect Inguinal herniaEmbryological Basis of Indirect Inguinal hernia
Week 36testis intestis inscrotumscrotum
processus vaginalis closedprocessus vaginalis closed
Moore & Dalley 2006
Embryological Basis of Indirect Inguinal herniaEmbryological Basis of Indirect Inguinal herniaEmbryological Basis of Indirect Inguinal hernia
Cahill 1997
abdominalmuscles
tunicavaginalis
hernial sachernial sacwithinwithin
spermaticspermaticcordcord
vas deferens
pampiniformplexus
testis
epididymis
partiallypartiallyobliteratedobliteratedprocessusprocessusvaginalisvaginalis
transversalis fascia& peritoneum
Inguinal AnatomyInguinal AnatomyInguinal Anatomy
superficialepigastricvessels
superficialcircumflex
iliacvessels
externalpudendalvessels
greatsaphenous
v.
spermatic cord
ilioinguinaln. (L1)superficial (external)
inguinal ring
externaloblique
aponeurosis& Gallaudet’s
fascia
intercrurualfibers
medialcrus
lateralcrus &
inguinal lig.
Moore & Dalley 2006
ASIS
Inguinal AnatomyInguinal AnatomyInguinal Anatomy
Moore & Dalley 2006
inguinal lig.(of Poupart)
iliopsoas
external iliacvessels
femoral n.
internalinguinal ring
femoral canal pectineus lacunar lig.(of Gimbernat)
pectineal lig.(of Cooper)
reflectedinguinal lig.
myopectineal orificeof Fruchaud
Inguinal AnatomyInguinal AnatomyInguinal Anatomy
EOEO
IOIOTATATFTF
Moore & Dalley 2006
PP
testicular vessels vas deferens
Space ofSpace ofBogrosBogros
internalring
ilioinguinal n.“conjoint tendon”
externalring
Inguinal AnatomyInguinal AnatomyInguinal Anatomy
shelving edgeof ing. lig.
Moore & Dalley 2006
Inguinal AnatomyInguinal AnatomyInguinal Anatomy
Skandalakis’ Surgical Anatomy 2004
parasagittal sectionthrough right side
iliopubic tract
shelving edgeof inguinalligament
Moore & Dalley 2006
posterior view ofanterior abdominal wall
externaliliac vessels
iliopsoas
lateral umbilical fold
Hesselbach’sTriangle
inferior epigastric vesselsarcuate line
iliopubictract
femoral canal
vas deferens
testicularvessels
deeping. ring
iliopubictract
HesselbachHesselbach’’s (Inguinal) Triangles (Inguinal) Triangle
direct inguinal herniadirect inguinal hernia
indirectindirectinguinal herniainguinal hernia
posterior viewof anterior
abdominal wall
internalinguinal
ring
Moore & Dalley 2006
Femoral HerniaFemoral HerniaFemoral Hernia
Skandalakis’ Surgical Anatomy 2004
femoral canal
lacunar lig.(of Gimbernat)
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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