USLS COLLEGE OF MEDICINE 2.

Infraumbilical group
III. CLINICAL NOTES

ANATOMY
ABDOMINAL WALL
DATE: 11/19/20
LECTURER: Seralde, MD ● vertical and horizontal line - intersecting at ​umbilicus​ (​L3​ or ​L4​)
○ Upper and Lower Right
○ Upper and Lower Left
I. ABDOMINAL WALL ● epigastrium - below xiphoid process and above umbilicus
A. Surface Anatomy ● periumbilical - around the umbilicus
1. Abdominal Lines and Planes
2. Abdominal Quadrants ● vertical​ lines of division:
3. Surface Landmarks of the Abdominal Wall ○ Right & Left ​midclavicular lines
II. ANTEROLATERAL ABDOMINAL WALL ● horizontal​ lines of division:
A. Layers ○ Subcostal Plane​ – upper plane
1. Skin ■ passes through the inferior margin of the ribs
2. Superficial Fascia (10th costal cartilage, L3)
a) Camper’s Fascia ○ Transtubercular Plane​ – lower plane
b) Scarpa’s Fascia ■ traverses the pubic tubercle (L5)
3. Deep Fascia ○ Transpyloric Plane​ – sometimes used
4. Muscles ■ halfway between the jugular notch and pubic
a) Anterior: bone (9th costal cartilage; L1)
(1) Rectus Abdominis ■ structures passing transpyloric plane:
(a) Rectus Sheath Gallbladder, Liver, Pylorus of the Stomach, First
(2) Pyramidalis part of the duodenum, body & tail of the
b) Lateral: pancreas, kidney, spleen
(1) External Oblique
(a) Aponeurosis
(b) Inguinal Canal
(c) Lacunar or Gimbernat Ligament
(d) Cooper’s or Pectineal Ligament
(2) Internal Oblique
(a) Conjoined Tendon ​(Falx inguinalis)
(b) Cremasteric muscle
(c) Cremasteric Fascia
(3) Transversus Abdominis
5. Transversalis Fascia
6. Extraperitoneal Fascia
7. Parietal Peritoneum
B. Arteries
1. Superior Epigastric boundaries:
2. Inferior Epigastric ● superior: Diaphragm
3. Deep circumflex artery ● inferior: Pelvic Brim (at the edge of the pelvic inlet)
4. Lower 2 posterior intercostal and lumbar arteries ● anterior: Lower part of the thoracic cage and the abdominal
C. Veins muscles (rectus abdominis, external oblique, internal oblique, &
1. Superficial veins transversus abdominis)
2. Deep veins ● posterior: Five lumbar vertebrae (L1 –L5)
D. Nerve supply ● laterally: 12th rib, upper part of the pelvis, psoas muscle,
1. Anterior Cutaneous nerve quadratus lumborum, & aponeurosis of the transversus
2. Ilio-hypogastric nerve abdominis muscle
3. Subcostal nerve
ppt​:
4. Ilio-inguinal nerve
● abdominal wall - represents boundaries of the abdominal cavity
E. Lymph vessels ○ split into posterior, lateral and anterior walls
1. Supraumbilical group

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
1
R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT
 1. Xiphoid process
● thin cartilaginous lower part of the sternum
● palpated in the depression where the costal margins meet
in the upper part of the anterior abdominal wall
● xiphisternal junction - ​identified by feeling the lower edge
of the body of the sternum
○ opposite the body of ​T9
2. Costal margin
● curved lower margin of the thoracic wall
○ anterior - cartilages of 7th, 8th, 9th and 10th ribs
○ posterior - cartilages of 11th and 12th ribs
● reaches its lowest level at the 10th costal cartilage
○ opposite the body of ​L3
● 12th rib - may be be difficult to palpate
3. Iliac crest
● can be felt along its entire length and ends in:
○ anterior - ​anterior superior iliac spine (ASIS)
○ posterior - ​posterior superior iliac spine
● highest point - opposite the body of ​L4
ppt​: ● outer margin - projects to form ​tubercle of the crest ​at
● Linea alba - ​median band of interlacing fibers under cover of the about 2 in. (5cm) posterior to the anterior superior iliac
skin and fascia spine
○ represented by a linear depression extending from the ● tubercle​ - at the level the body of ​L5
xiphoid process​ to the​ symphysis pubis 4. Pubic tubercle
■ infra-umbilical part​ - very narrow ● small protuberance along the ​superior surface of the pubis
■ supra-umbilical part - gradually widens towards 5. Symphysis pubis
sternal end ● cartilaginous joint that lies in the midline between the
● Umbilicus or Navel​ - depression along the linea alba bodies of the pubic bones
○ site if passage of the umbilical cord ● solid structure beneath the skin in the midline at the lower
○ found at the level of ​L3 intervertebral disk extremity of the anterior abdominal wall
● Symphysis pubis - union of 2 pubic bones along the medial ● Pubic crest - ridge on the superior surface of the pubic
plane bones medial to the pubic tubercle
● Pubic crest - ridge that extends horizontally from the top of the 6. Inguinal ligament
symphysis pubis to the pubic tubercle ● lies beneath a skin crease in the groin
● Pubic tubercle -​ lateral prominent projection of the pubic crest ● rolled-under inferior margin of the aponeurosis of the
● Inguinal sulcus - slight groove external oblique muscle
extending from the pubic tubercle ● attached laterally to anterior superior iliac spine
to the anterior superior iliac spine ● curves downward and medially to be attached to the pubic
○ location of the ​inguinal tubercle
ligament​ which lies beneath 7. Superficial inguinal ring
● Anterior superior iliac spine ​- ● triangular aperture in the aponeurosis of the external
prominent anterior end of the iliac oblique muscle and is situated above and medial to the
crest pubic tubercle
● Posterior superior iliac spine ● adult ​male​: margins of the ring can be felt by invaginating
the skin of the upper part of the scrotum with the tip of
the little finger
○ soft tubular ​spermatic cord - felt emerging from the
ring and descending over or medial to the pubic
tubercle into the scrotum
■ palpated in the upper part of the scrotum
between the the finger and thumb
■ note the presence of the ​vas deferens (​firm
cordlike) in the posterior part
● female​: smaller and difficult to palpate
○ transmits the ​round ligament of uterus
8. Scrotum
● pouch of skin and fascia containing the testes, epididymis
and the lower ends of the spermatic cords

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
2
R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT
 ● skin is wrinkled and covered with sparse hair
● bilateral origin - indicated by ​scrotal raphe (dark line in the ● ppt​: loosely attached to the underlying structures
midline) along the line of fusion ○ except at the umbilicus (where it is tethered to the scar
● testis - firm, ovoid body surrounded on its lateral, anterior tissue)
and medial surfaces by the 2 layers of ​tunica vaginalis ● umbilicus - scar representing the ​site of attachment of
● epididymis - ​elongated structure posterior to the testis umbilical cord
○ head and body - enlarged upper end ○ situated in the​ linea alba
○ tail - narrow lower end ● natural lines of cleavage - constant and run downward and
● vas deferens - ​emerges from the tail & ascends medial to forward almost horizontally around
the epididymis to enter the spermatic cord at the upper the trunk
end of the scrotum Nerve supply
9. Linea alba ● anterior rami of the lower six
● vertically running fibrous band thoracic ​and 1st lumbar nerves -
● extends from the symphysis pubis to the xiphoid process cutaneous nerve supply to the
and lies in the midline anterior abdominal wall
● formed by the fusion of the aponeuroses of the muscles of ○ thoracic nerves - lower five
the anterior abdominal wall intercostal and ​subcostal
● represented on the surface by a slight median groove nerves
10. Umbilicus or Navel ○ 1st lumbar nerve -
● lies in the linea alba and is inconstant in position iliohypogastric and ​ilioinguinal
● puckered scar nerves
● site of attachment of the umbilical cord in the fetus ● dermatomes:
11. Rectus abdominis ○ T7 ​- ​epigastrium over the
● lie on either side of the linea alba xiphoid process
● run vertically in the abdominal wall ○ T10​ - ​umbilicus
● made prominent by asking patient to raise the shoulders ○ L1 ​- above ​inguinal ligament
while in supine position without using the arms and symphysis pubis
● tendinous intersections: Arterial supply
○ 3 in number and run across the rectus abdominis ● branches of the ​superior and
muscle inferior epigastric arteries - skin
○ in muscular individuals: palpated as transverse near midline
depressions at the level of the tip of the xiphoid ● branches of the ​intercostal,
process, and halfway between the two lumbar, and deep circumflex iliac
12. Linea semilunaris arteries​ - skin of the flanks
● lateral edge of the rectus abdominis muscle ● superficial epigastric, superficial
● crosses the costal margin at the tip of 9th costal cartilage circumflex iliac, and the superficial
● to accentuate: patient is asked to lie on the back and raise external pudendal arteries
the shoulders off the couch without using the arms (branches of the femoral artery) -
○ contracts the rectus abdominis muscles so that their skin in inguinal region
lateral edges stand out Venous drainage
● lateral thoracic vein - ​above
ppt​: mainly into ​axillary vein
● integrity of the anterior abdominal wall - dependent upon the ● superficial epigastric and great
abdominal muscles and their conjoined tendons saphenous veins - ​below into
● assist with respiration and control of expulsive efforts of femoral vein
urination, defecation, coughing and parturition
● work with back muscles to flex and extend trunk at the hips,
rotate trunk at the waist, and protect viscera by becoming rigid

● very obese individual: heavily laden with fat

● above umbilicus: fascia is thin and continuous with that of
thorax
● below umbilicus: 2 distinct parts
○ superficial ​fatty layer​ (​fascia of Camper​)
■ continuous with superficial fat over the rest of the
body and may be extremely thick

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
3
R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT
 ■ in the scrotum: represented as a thin layer of smooth ○ internal oblique ​(internal intercostal) - run superior and anterior
muscle “​dartos muscle” ○ transversus abdominis - ​pass transversely
ppt​: where superficial blood vessels and nerves are found

1. RECTUS ABDOMINIS
○ deep ​membranous layer​ (​Scarpa’s fascia​) ● long strap muscle that extends along the whole length of
■ thin and fades out laterally above, where it becomes the anterior abdominal wall
continuous with the superficial fascia of the back and ● broader above and lies close to the midline, being
thorax separated from its fellow by ​linea alba
■ inferiorly: passes onto the front of the thigh, where it ● when rectus contracts: lateral margin forms a curved ridge
fuses with the deep fascia one fingerbreadth below -> ​linea semilunaris​ can be palpated and often seen
the inguinal ligament ○ extends from tip of 9th costal cartilage to pubic
■ in the midline inferiorly: not attached to the pubis but tubercle
forms a tubular sheath for the penis or clitoris ● enclosed between aponeuroses of the external oblique,
■ below the perineum: enters the wall of the scrotum internal oblique, and transversus abdominis, which form
(or labia majora) the ​rectus sheath
● passes to be attached on each side to the ppt:
margins of the pubic arch RECTUS ABDOMINIS
● referred to as ​Colles’ fascia ● long, broad muscular band lying on each side of the linea alba
■ posteriorly: fuses with the perineal body and the ● narrow at its pubis attachment and wider at its sternocostal end
posterior margin of the perineal membrane ● crossed by ​3 transverse tendinous intersections:​ (​same w/ the book)
■ highest​ - level of the xiphoid process
ppt​: ■ middle​ - halfway or midway between these two
● greater amount of elastic tissue ■ lowest​ - level of the umbilicus
● after crossing the inguinal ligament anteriorly: blends with ● O: ​symphysis pubis and
fascia lata of the thigh just beyond the ligament pubic crest
● over the pubis: continued over the spermatic cord, penis, ● I: 5th, 6th and 7th costal
scrotum, blending with the ​fascia of Colles ​of the peritoneum cartilages and xiphoid
process
● A:
○ compresses abdominal
● thin layer of connective tissue covering the muscles contents
● lies immediately deep to the membranous layer of superficial ○ flexes vertebral column
○ accessory muscle of
fascia
expiration
● NS: ​anterior branches of the
lower 5 or 6 intercostals and
subcostal nerves
● BS​: inferior epigastric,
superior epigastric artery
and lower 6 intercostal
arteries

2. PYRAMIDALIS
● small triangular muscle that lies above the symphysis pubis
and in front of the lower part of the rectus abdominis
● occasionally absent
ppt:
PYRAMIDALIS
● O: ​anterior surface
of pubis
● I: ​linea alba
● A: ​tenses the linea
alba
ppt: ● NS​: subcostal
● anterior​ muscles ● BS​: inferior
○ rectus abdominis - ​fibers run vertically epigastric and deep
○ pyramidalis circumflex arteries
● lateral​ muscles
○ external oblique ​(external intercostal) - run inferior and anterior
(inserting a hand in a pocket)

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
4
R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT
RECTUS SHEATH ppt:
● long fibrous envelope RECTUS SHEATH
that encloses the ● aponeurotic envelope that encloses rectus abdominis and pyramidalis
rectus abdominis and muscles
pyramidalis (if present) ○ except for a very small portion along the posterior-superior part
muscles where the sheath is either deficient or not
● has 2 walls (anterior ● derived from the aponeurosis of the lateral series of abdominal muscles as
they pass in front or behind the rectus muscles to the linea alba
and posterior)
● contents​:
● contents​: ○ anterior series of abdominal muscle
○ anterior rami of ■ rectus abdominis and pyramidalis
the lower six ○ terminal parts of the anterior cutaneous nerves
thoracic nerves ■ lower intercostals and subcostal
○ superior and ○ superior and inferior epigastric arteries, branches and their
inferior epigastric corresponding veins
vessels
○ lymph vessels
● formed mainly by the aponeurosis of the 3 lateral abdominal
muscles
● composition of the walls changes at different levels
○ above costal margin
■ anterior wall - formed by ​aponeurosis of external
oblique
■ posterior wall - formed by ​thoracic wall (eg. ​5th, 6th,
and 7th costal cartilages and intercostal spaces​)
○ between ​costal margin and ​arcuate line (level of anterior
superior iliac spine)
■ internal oblique aponeurosis - splits to ​enclose the
rectus muscle
■ external oblique aponeurosis ​- directed in ​front of
the muscle
■ transversus aponeurosis ​- directed ​behind​ the muscle
○ between the level of ​arcuate line (level of anterior
superior iliac spine) and ​pubis
■ anterior wall - formed by ​aponeuroses of all 3
muscles
■ posterior wall - absent
■ rectus muscle - lies in contact with transversalis fascia
● Arcuate line - aponeuroses forming the posterior wall pass in
front of the rectus at the level of the anterior superior iliac
spine, the posterior wall has a free, curved lower border called
the
○ where inferior epigastric vessels enter the rectus sheath
and pass upward to anastomose with the superior
epigastric vessels
○ beneath the umbilicus

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
5
R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT
 1. EXTERNAL OBLIQUE medially to the superficial inguinal ring, a hole in the
● broad, thin, muscular sheet aponeurosis of the external oblique muscle
● most of its fibers inserting by means of a wide aponeurosis ○ lies parallel to and immediately above the inguinal
○ most posterior fibers passing down to the iliac crest form a ligament
posterior free border ● newborn: deep ring lies almost directly posterior to the
ppt:
superficial ring so that the canal is considerably shorter at this
EXTERNAL OBLIQUE age
● O: ​outer surface of the lower 8 ribs, interdigitating with the fibers of the ● as result of growth: deep ring moves laterally
serratus anterior and latissimus dorsi muscle ● has 4 walls:
● I: 1. anterior
○ directly - posterior fibers by fleshy insertion into the outer lip of the ○ formed by ​external oblique aponeurosis ​and
anterior half of the iliac crest reinforced laterally by the origin of ​internal oblique
○ indirectly - upper and middle fibers through the external oblique
from the inguinal ligament
aponeurosis to the xiphoid process, linea alba and the symphysis pubis
● A: ○ wall is strongest where it lies opposite the weakest
○ supports the abdominal part of the posterior wall, deep inguinal ring
viscera 2. posterior
○ helps in expiration ○ formed by conjoint tendon medially and ​transversalis
○ helps in flexion of the spinal fascia ​laterally
column ○ wall is strongest where it lies opposite the weakest
○ rotates the pelvis when the part of the anterior wall, superficial inguinal ring
thorax is fixed
3. superior​ (roof)
● NS: ​7th​
​ – 11​th​ intercostal nerves
● BS: ○ formed by the arching lowest fibers of ​internal
○ cranial portion - lower oblique​ and ​transversus abdominis​ muscles
intercostal arteries 4. inferior​ wall
○ caudal portion - deep ○ formed by the upturned lower edge of ​inguinal
circumflex iliac artery or the ligament​ and, at its medial end, ​lacunar ligament
iliolumbar artery
● take note of the i​ nguinal ligament
and​ superficial inguinal ring

● Superficial inguinal ring – triangular-shaped defect, lies

immediately above and medial to the pubic tubercle
○ Spermatic cord or ​Round ligament of uterus - passes
through the opening
○ carries external spermatic fascia or external covering of
the round ligament of the uterus from the margins of the
ring
● Inguinal ligament – lower border of the aponeurosis that
folded backward on itself between anterior superior iliac spine
and pubic tubercle
○ Lacunar ligament ​- extends backward and upward to the
pectineal line on the superior ramus of the pubis from the
medial end of the inguinal ligament
■ Femoral ring - sharp free crescentic edge of the
lacunar ligament ppt:
■ Pectineal ligament - continuation of the lacunar EXTERNAL OBLIQUE APONEUROSIS
ligament with a periosteum thickening at the ● covers rectus abdominis
pectineal line ● passes ​anterior to the
rectus abdominis
● inferior edge extends
INGUINAL CANAL
from the anterior
● oblique passage through the lower part of the anterior superior iliac spine to
abdominal wall the pubic tubercle
○ in males: allows structures of the spermatic cord to pass to ○ inguinal
and from the testis and abdomen ligament!!
○ in females: smaller canal allows the round ligament of the ● continues ​posterior
uterus to pass from the uterus to the labium majus toward the superior
● adult: about 1.5 in. (4 cm) long and extends from the deep pubic ramus
○ lacunar ligament
inguinal ring, a hole in the transversalis fascia, downward and

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
6
R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT
● further extension ​laterally along the pecten pubis of the superior pubic structures passing through or contents of the canal:
ramus 1. spermatic cord ​in males or
○ pectineal ligament round ligament of the
● lateral to the pubic tubercle​ divides into medial and lateral crura uterus​ in females
○ diverge to form ​superficial inguinal ring ● enters the inguinal
■ may be found by pushing the scrotal skin upward along the canal through the deep
spermatic cord to a point immediately above the pubic inguinal ring
tubercle, and then passing the finger backward ● passes out through the
■ normally admits the tip of the little finger superficial inguinal ring
■ site of inguinal hernia 2. ilioinguinal nerve
● enters the canal
Superficial inguinal ring through the interval
(external abdominal ring) between the external
● triangular opening on and internal oblique
the lower medial part muscles
of the external oblique ● passes out through the superficial
aponeurosis inguinal ring
● lateral??? to the pubic
tubercle Inguinal ligament (Poupart’s ligament)
○ through which the ● thickened lower border of the external
spermatic cord oblique aponeurosis folded backwards
(male) and round upon itself, producing a groove, the
ligament of the uterus (female) pass medial of which forms the floor of the
● larger in males because spermatic cord is thicker inguinal canal
● lateral half of the pubic crest forms its base, while apex is directed ● extends from the ASIS to the pubic
upwards and laterally tubercle
○ presents a curved margin whose
INGUINAL CANAL – Rings convexity is directed inferiorly,
1. superficial inguinal ring ​(same w/ the book) giving attachment to the fascia lata of the thigh
● triangular-shaped opening in the aponeurosis of external oblique
muscle Lacunar ligament (Gimbernat’s ligament)
● lies immediately above and medial to the pubic tubercle ● pectineal part of the inguinal ligament
● margins of the ring, sometimes called ​crura (medial & lateral) - give ● triangular expansion that spreads backwards from the medial part of the
attachment to the external ​spermatic fascia inguinal ligament to the pectineal line of the pubis
● crura are held by ​intercrural fibers​ at the apex of the ring ○ apex​: attached to
2. deep inguinal ring ​(same w/ the book) the pubic tubercle
● oval opening in the fascia transversalis ○ base​: free
● lies about 0.5 inch (1.3 cm) above the inguinal ligament crescentic margin
● midway between the ASIS and symphysis pubis (mid-inguinal point) that forms the
● medial to it: ​inferior epigastric vessels medial boundary of
● margins of the ring - give attachment to ​internal spermatic fascia (or the femoral ring
internal covering of round ligament of uterus)
boundaries: Cooper’s ligament (Pectineal
● anterior:​ external oblique aponeurosis and conjoined muscle laterally ligament)
● posterior: inferior epigastric artery, fascia transversalis and conjoined ● lateral continuation of
tendon medially the base of the lacunar
● superior:​ conjoined muscles (arched fibers of internal oblique ligament forming a
● inferior:​ inguinal ligament strong ridge of the
fibrous tissue attached
along the pectineal line
of the pubis

2. INTERNAL OBLIQUE
● broad, thin, muscular sheet beneath the external oblique
● fibers run at right angles to the external oblique
● has a lower free border that arches over the spermatic
cord or round ligament of the uterus, and descends behind
it to be attached to the pubic crest and pectineal line
● Conjoint tendon – attaches medially to the linea alba;
Internal oblique + transversus abdominis fibers
● Cremaster muscle - muscle fibers carried by the spermatic
cord as it passes under the lower border of the internal
oblique

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
7
R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT
ppt: ● BS:​ cremasteric artery (branch of inferior epigastric artery)
INTERNAL OBLIQUE Cremasteric Fascia (Cooper’s Fascia)
● flat fan-shaped muscle forming the middle layer of the lateral series ● thin membranous layer of areolar CT occupying the intervals between the
● O​: cremaster muscular fasciculi, completing the envelope for the cord and
○ lat ⅔ of the inguinal ligament testis
○ ant ⅔ of the iliac crest
○ lumbo-sacral fascia and lumbar
spines
● I:
○ uppermost and posterior fibers ​-
inserted into the lower 4 ribs and
cartilage.
○ middle fibers - run towards the lat
border of the rectus abdominis
muscle.
○ lower most fibers - becomes
tendinous and are inserted
conjointly with similar fibers from
the transversus abdominis to the
oubic crest, pubic tubercle and pectineal line
● A:
○ support amd compress the viscera; 3. TRANSVERSUS ABDOMINIS
○ depresses the thorax to help in expiration ● thin muscle sheet deep to the internal oblique
○ flexes the spinal column and abducts it ● fibers run horizontally forward
○ flexes and rotates the pelvis when the thorax is fixed ● lowest tendinous fibers join with the internal oblique –
● NS: fixed to the pubic crest and pectineal line
○ last 3-5 intercostal Ns ● posterior borders (together with internal oblique) –
○ ilio-hypogastric and ilio-inguinal
● BS:
attached to the lumbar vertebrae
○ lower posterior intercostal ppt:
and the subcostal artery TRANSVERSUS ABDOMINIS
○ superior and inferior ● muscle forming the deepest and
epigastric artery innermost layer of the lateral series
○ superficial and deep ● O:
circumflex iliac arteries ○ costal margin
○ posterior lumbar arteries ○ lumbar fascia
○ iliac crest (anterior ⅔)
Conjoined Tendon (Falx Inguinalis) ○ inguinal ligament (lateral half)
● O: ​formed from the lower part of ● I:
the common aponeurosis of the ○ aponeurosis of rectus sheath
internal abdominal oblique and (anterior and posterior)
the transverse oblique ○ conjoint tendon to pubic crest
● I: ​crest of the pubis and pectineal ○ pectineal line
line immediately behind the ● A:
superficial inguinal ring ○ support abdominal wall and contents
○ aids forced expiration
Direct inguinal hernia - protrude ○ aids in raising intra abdominal pressure
through ​Hasselbach’s​ ​triangle ○ conjoint tendon supports posterior wall of inguinal canal
○ borders​: ○ compression of abdominal cavity
■ medially -​ rectus abdominis ○ stabilize the lumbar spine by creating tension thro the
■ superolaterally - ​inferior thoracolumbar fascia
epigastric artery and vein ● NS:
■ inferiorly -​ inguinal ligament ○ last 6 thoracic spinal Ns
○ hernia will lie medial to the inferior ○ ilio-hypogastric As
epigastric artery ○ genito-femoral N
● BS:
Cremasteric muscle ○ posterior intercostal and subcostal As
● slender muscle fasciculi ○ superior and inferior epigastric As
● extensions of the lowermost fibers of the internal oblique muscle ○ superficial and deep circumflex As
● well developed in males, forming loops about the lateral and anterior ○ posterior lumbar arteries
surfaces of the spermatic cord and testis
● O: ​inferior edge of the internal oblique and adjacent inguinal ligament
● I: ​pubic tubercle after forming the oops about the cord and testis
● A: ​supports and lift the testis
● NS: ​external spermatic of the genito-femoral and ilio-inguinal nerves

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT
 ● pass forward between the muscle layers
● component of an extensive thin layer of fascia ● supply the lateral part of the abdominal wall
● lies between the muscle layer of the abdominal wall and the
parietal peritoneum ppt​:
● continuous below with a similar fascial layer lining the pelvic 1. Superior epigastric artery
walls ● medial terminal branch and direct prolongation of the ​internal
mammary artery
ppt: ● enters abdomen behind 7th costal cartilage thru the
Endo-Abdominal Fascia costoxiphoid space of the diaphragm
● thin layer of CT that lines the inner surface of the transversus ● descends between posterior rectus sheath and rectus mm
abdominis and its aponeurosis which it later pierces at a lower level to establish anastomosis
● behind linea alba: becomes continuous with that of the opposite side with the inferior epigastric artery
and forms a continuous membrane covering the entire internal 2. Inferior epigastric artery
surface of the abdomen ● arises from ​external iliac artery​ above the inguinal ligament
● above: continuous with the diaphragmatic fascia linen the inferior ● passes upward and medially between fascia transversalis and
surface of the diaphragm peritoneum
● posteriorly: blends with the loose fascia around the kidney, and its ● after crossing linea semicircularis, turns upward between rectus
continuous with the fascia surrounding the quadratus lumborum and abdominis and posterior rectus sheath
psoas muscle ● pierces the mm to anastomose with superior epigastric artery
3. Posterior Intercostal Artery​ toxic na daw
● accompanying the lateral cutaneous nerves with those for the
10th and 11th spaces anastomosing with the lumbar and
● thin layer of connective tissue epigastric arteries
● contains variable amount of fat 4. Subcostal artery
● lies between transversalis fascia and parietal peritoneum ● follows the same course as the posterior intercostal artery
● on the abdominal wall: anastomose with lumbar and deep
circumflex iliac artery
● thin serous membrane
● continuous below with the parietal peritoneum lining the pelvis
1. Superficial Veins
● above umbilicus​:
1. Superior Epigastric Artery ○ drains into axillary vein via the ​lateral thoracic vein
● one of the terminal branches of the ​internal thoracic ● below umbilicus​:
artery ○ drains into femoral vein via the ​superficial epigastric
● enters the upper part of the rectus sheath between the and ​great saphenous veins
sternal and costal origins of the diaphragm ● few small veins, ​paraumbilical veins​, connect the network
● descends behind the rectus abdominis muscle: through the umbilicus and along the ligamentum teres to
○ supplying upper central part of anterior abdominal the portal vein -> forms an important ​portal–systemic
wall venous anastomosis
○ anastomoses with inferior epigastric artery
2. Inferior Epigastric Artery ppt​:
SUPERFICIAL VEINS
● branch of the ​external iliac artery ​just above the inguinal
● above umbilicus​: empty
ligament into ​SVC thru ​lateral
● runs upward and medially along the medial side of the thoracic vein and
deep inguinal ring internal mammary vein
● pierces the transversalis fascia to enter the rectus sheath ● below umbilicus​: empty
anterior to the arcuate line into ​long saphenous
● ascends behind the rectus muscle: vein​; ​femoral vein into
○ supplying the lower central part of the anterior the ​IVC
● both groups anastomose
abdominal wall
freely on lateral part of
○ anastomoses with the superior epigastric artery the body thru the
3. Deep Circumflex Iliac Artery thoraco-epigastric vein
● branch of the external iliac artery just above the inguinal
ligament
● runs upward and laterally toward the anterior superior
iliac spine and then continues along the iliac crest 2. Deep Veins
● supplies the lower lateral part of the abdominal wall ● superior epigastric, inferior epigastric, and deep
4. Lower 2 Posterior Intercostal Arteries and 4 Lumbar Arteries circumflex iliac veins
● branches of the descending thoracic aorta and abdominal ○ follow the arteries of the same name
aorta ○ drain into the internal thoracic and external iliac veins

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT
 ● posterior intercostal veins ○ upon reaching lateral border of rectus abdominis: pierce
○ drain into the azygos veins posterior rectus sheath and pass the substance of rectus mm
● lumbar veins abd the anterior rectus sheath to become cutaneous
○ drain into the inferior vena cava ○ supply skin between xiphoid processes and region below the
umbilicus
2. Anterior cutaneous branch of the​ Ilio-hypogastric nerve
○ terminal branch from the main trunk
● anterior rami of the lower six thoracic and the first lumbar ○ runs forward and downward piercing the internal oblique
nerves ​- supply anterolateral abdominal wall ○ an inch in front of the anterior superior iliac spine, and the
● thoracic nerves - continuations of lower five intercostal nerves external oblique aponeurosis, an inch above the superficial
and the subcostal nerves beyond the costal margins inguinal ring
○ pass forward in the interval between the internal oblique ○ supply skin over the pubic region
and the transversus muscles 3. Anterior cutaneous branch of the ​Subcostal nerve
● lower six thoracic nerves ○ passing anterior to the rectus muscle
○ pierces anterior rectus sheath to supply skin between umbilicus
○ pierce the posterior wall of the rectus sheath to supply the and symphysis pubis
rectus muscle and the pyramidalis (T12 only) 4. Ilio-inguinal nerve ​- very important
○ terminate by piercing the anterior wall of the sheath and ○ pierces internal oblique above the lateral part of the inguinal
supplying the skin ligament
● first lumbar nerve ○ passes between internal oblique and external oblique
○ branch of the lumbar plexus aponeurosis to enter the inguinal canal
○ similar course as the thoracic nerves, but does not enter ○ become cutaneous after passing through superficial inguinal
ring
the rectus sheath
○ supply skin over the pubis, external genitalia and
○ divides into the​ iliohypogastric​ and​ ilioinguinal nerves: proximo-medial aspect of thigh
■ iliohypogastric nerve ● dermatomes of the anterolateral abdominal wall
● pierces the external oblique aponeurosis above ○ T4​: nipple area
the superficial inguinal ring ○ T6​: xiphoid process
■ ilioinguinal nerve ■ T7​ sa snell’s
● emerges through the ring ○ T10​: umbilicus
● end by supplying the skin just above the inguinal ○ L1​: pubis
ligament and symphysis pubis

● above level of the umbilicus​: upward to ​anterior axillary

(pectoral) group of nodes
○ can be palpated just beneath the lower border of the
pectoralis major muscle
● below level of the umbilicus​: downward and laterally to
superficial inguinal nodes
ppt: ● skin of the ​back above the level of the iliac crests​: upward to
1. Anterior cutaneous nerve
○ anterior branches of the 7th - 11th intercostal nerves
posterior axillary group of nodes
○ leave their corresponding spaces to enter the abdominal wall ○ palpated on the posterior wall of the axilla
lying between transversus and internal oblique ● below level of the iliac crests​: downward to the ​superficial
inguinal nodes
● deep lymph vessels

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT
 ○ follow the arteries
Clinical Notes
○ drain into the internal thoracic, external iliac, posterior
mediastinal, and para-aortic (lumbar) nodes Abdominal Wall Defects

Surgical Incisions

ppt:
● divided into 2 groups:
○ supraumbilical​ - into ​pectoral glands
○ infraumbilical​ - into ​superficial inguinal glands

Umbilical Vessel Catheterization

Indirect Inguinal Hernia

● remains of the processus vaginalis -> congenital in origin
● more common than a direct inguinal hernia
● more common in males than females
● more common on the right side
● most common in children and young adults
● hernial sac enters the inguinal canal through the deep inguinal ring and
lateral​ to the ​inferior epigastric vessels
○ neck of the sac is narrow
○ may extend through the superficial inguinal ring above and medial to
the pubic tubercle
○ in Femoral hernia - located below and lateral to the pubic tubercle
■ may extend down into the scrotum or labium majus
Direct Inguinal Hernia
● common in old men with weak abdominal muscles
○ rare in women
● hernial sac bulges forward through the posterior wall of the inguinal canal
medial​ to the ​inferior epigastric vessels
● neck of the hernial sac is wide

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
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R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT
 ○ sac as it emerges through the superficial inguinal ring - lies above and
medial to the pubic tubercle
● in femoral hernia - sac lies below and lateral to the tubercle

End of Transcription

T​RANSCRIBER​: A​NTOLO​, P., A​RDIENTE​, J., C​ARAM​, M., E​STANOL​, A., G​ONZAGA​, E., K​RAFT​, R., T​ABABA​, R.
12
R​EFERENCES​: S​NELL​’S​ ​ C​LINICAL​ A​NATOMY​ B​Y​ R​EGIONS​ 10​TH​, D​OC​’S​ ​ PPT