Anterior Abdominal Wall

Prof Dr Nilesh Kumar

NileshKumar@imu.edu.my
Lecture Outcomes
At the end of the lecture, students should be able to
i. Describe the bony landmarks around anterior abdominal wall
ii. Describe the 9 topographical regions of abdomen
iii. Describe the skin and muscles of anterior abdominal wall (attachments,
actions, nerve supply)
iv. Describe the role of anterior abdominal wall muscles in movement of
vertebral column and trunk
v. Describe the blood supply and nerve supply of anterior abdominal wall
• Bony Surface landmarks:
•Xiphoid process (level T9)
•Costal Margin (7th, 8th, 9th, 10th
costal cartilages)-subcostal plane
•Midaxillary Line
•Midclavicular line
•Subcostal plane (L3 vertebral level)
•Subcostal angle
•Iliac Crest—highest point (L4)
•Anterior Superior Iliac Spine
(ASIS)
•Tubercle of Iliac Crest-5cm behind
ASIS—Transtubercular plane
•Symphysis pubis
•Pubic crest
•Pubic tubercle
•Pectineal line Pubis
• Boundaries of Anterior Abdominal Wall:
• --Above: xiphi-sternum, Right & left Costal Margin
• --Below: Iliac Crest, Fold of Groin (inguinal
ligament), pubic tubercle, pubic crest, symphysis
pubis
• UMBILICUS--scar represents site of attachment of
tumbilical cord
• EXOMPHALOS (congenital umbilical hernia)
• Linea alba: Median white fibrous band (avascular)
• Surgical incision place (emergency)

Linea Semilunaris (vertical grove

from 9th costal cartilage to pubic
tubercle along lateral border of
Rectus abdominis muscle);
 Topographic Regions of abdomen
• two horizontal and two vertical lines
• Subcostal line, lowest point of the subcostal arch
(tenth rib)
• Transtubercular line, between two rough tubercles
(5 cm behind Anterior Superior Iliac spine over iliac
crest)
• 2 Vertical lines, drawn from midway between the
anterior superior spine and the pubic symphysis on
each side, vertically upward to mid-clavicle
Nine regions:
Right Hypochondrium:
Epigastric
Left Hypochondrium:

•Transpyloric line of Addison, Right Lumbar:

halfway between suprasternal Umbilical:
notch and Pubic symphysis, : Left Lumbar:
pyloric opening of the stomach,
HILUM of Kidney, Lower limit Right Inguinal/Right Iliac fossa
of spinal cord, Formation of Suprapubic
portal vein) Left Inguinal/Left iliac Fossa
Segmental innervation of abdominal wall
•T7 to T11 spinal nerves, Subcostal nerve (T12),
IlioHypogastric nerve (L1)
All nerve run forward in the NEURO-VASCULAR PLANE
(Between Internal Oblique & Transversus Abdominis)
•supplies band of skin, muscles and pariétal peritoneum in
serial order from above downwards

•UMBILICUS: supplied by T10 nerve

•From Xiphi-sternum to Umbilicus: segmentally by 7th, 8th,
9th thoracic nerves
•Below Umbilicus: T11, Subcostal, L1 nerves up to symphysis
pubis

•DERMATOME: (Xiphoid: T7, Umbilicus: T10)

Area of skin supplied by a single spinal Segment via
corresponding pair of spinal nerves
Layers of Anterior Abdominal Wall
• Constitution of layers of anterior abdominal
wall
(Superficial to deep)
1. Skin
2. Camper’s Fascia (Fatty layer of Superficial
Fascia)
3. Scarpa’s Fascia (Membranous layer of
Superficial Fascia)
4. External Oblique Muscle & aponeurosis
5. Internal Oblique Muscle & aponeurosis
6. Transversus Abdominis Muscle & aponeurosis
7. Transversalis Fascia
8. Extraperitoneal Fat
9. Parietal Peritoneum
NO DEEP FASCIA so that expansion of viscera can
occur
EXTERNAL OBLIQUE MUSCLE

Origin by 8 slips from LOWER 8 RIBS

(upper 4 interdigitate with Serratus anterior,
lower 4 with Latissimus Dorsi)
Run Downwards, Forwards & Medially
Insertion:
•Most of muscle fibres—broad
aponeurosis—inserted to Xiphoid process,
Linea Alba, Pubis Symphysis, Pubic crest,
Pecten pubis
•Lower part to: Iliac Crest—Ant 2/3rd
REMEMBER:
FREE INFERIOR BORDER of
aponeurosis= INGUINAL LIGAMENT (ASIS
to Pubic tubercle)
Nerve Supply: Lower 6 thoracic (T7-T12)
nerves
• Inguinal Ligament
•Thickened lower border of external oblique
aponeurosis
•Folded Backwards, with grooved upper surface
(Floor of Inguinal canal)
•12 cm-14 cm
•Lateral- to Ant sup illiac spine
•Medial—to Pubic Tubercle
•Lateral part OBLIQUE, Medial part horizontal

•Muscles attached:
•Lateral 2/3rd—Internal Oblique
•Lateral 1/3rd---Transversus Abdominis
•Middle—Cremaster (derived from detached
fbres of Internal Oblique)
 External Oblique
Origin Insertion
outer surfaces Lateral lip of iliac crest;
of the lower aponeurosis ending in
eight ribs midline raphe (linea
(ribs 5-12) alba)
Inferiorly, it folds back on
itself to form the inguinal
ligament between the
anterior superior iliac
spine and pubic tubercle.
Just superior to the
medial part of the inguinal
ligament, there is an
opening in the
aponeurosis called
superficial inguinal ring.
Innervation Function
lower six Compress abdominal
contents-Protection of
thoracic
abdominal viscera;
spinal
nerves (T7 to Forced Expiration-coughing,
T12) sneezing, vomiting, and
straining
Acting together, increase intra-
abdominal pressure.
defecation, micturition
(urination), and parturition
(childbirth).
both muscles flex trunk;
each muscle bends trunk to
same side, turning anterior
part of abdomen to opposite
side
 • Internal Oblique
• Origin from lateral 2/3rd of inguinal ligament, Anterior
2/3rd of Iliac Crest, Thoracolumbar Fascia
• Direction (diagonally opposite to external oblique):
Upwards, Forwards & Medially
• Insertion:
Upper fibres to lower 3 ribs
Most parts –aponeurosis—to 7, 8, 9 costal cartilages,
xiphoid process, linea alba, pubic crest & pecten pubis

the aponeurosis splits to form a sheath for the rectus

abdominis muscle along with ext oblique anteriorly &
trans abdomonis posteriorly

REMEMBER:
•Forms Anterior wall & Arched Roof of Inguinal canal, then
its aponeurosis blends with Transversus →Conjoint
tendon → attach to Pubic Crest, Pecten Pubis

Nerve Supply: Lower 6 thoracic (T7-T12) nerves

 • Tranversus Abdominis
Fibres are Horizontal
Origin:
Inguinal Ligament (lateral 1/3rd)
Iliac Crest (Anterior 2/3rd)
Thoracolumbar Fascia

Insertion:
• Linea alba, Pubic crest, Pectineal line
• Inguinal fibres (roof of Inguinal canal with Internal oblique)
Then forms Conjoint Tendon (posterior wall & strength to Inguinal
Canal)
• aponeurosis contributes to the formation of posterior layer of
rectus sheath.

Nerve Supply: Lower 6 thoracic (T7-T12) nerves

 Quiz
• Which of the following muscle forms Inguinal Ligament?
A. External oblique
B. Internal oblique
C. Transversus abdominis
D. Rectus abdominis
• Conjoint tendon is formed by
A. Fascia transversalis
B. External oblique
C. Internal oblique
D. Rectus abdominis
• Umbilicus corresponds to_________ dermatome.
A. T8
B. T9
C. T10
D. T11
ACTIONS of ANTERIOR ABDOMINAL WALL OBLIQUE MUSCLES

1. Compress abdominal contents-Protection of abdominal

viscera;

2.Forced Expiration-coughing, sneezing, vomiting, and straining

3. Acting together, increase intra-abdominal pressure. defecation,

micturition (urination), and parturition (childbirth).

4. both muscles flex trunk;

each muscle bends trunk to same side, turning anterior part of
abdomen to opposite side, supports lateral bending, flexion,
extension or protrusion and twisting.

ACTIONS or Rectus:
•Flexion of Trunk, Lumbar Vertebral Column, Stabilize
Pelvis
•Compression, Maintain intra-abdominal pressure
•Protection of viscera
•Nerve supply: Lower 5 thoracic nerves
• Rectus Abdominis
Long Strap-like Muscle
Origin:
Two heads: Medial Head (Symphysis Pubis), Lateral Head
(Pubic Crest & Pubic Tubercle)
Insertion:
4 Fleshy slips upwards
Medial part—Xiphoid Process
Lateral Part—5th, 6th, 7th costal cartilages
Three Intersections attached to Anterior layer of Rectus
sheath (level: Xiphoid process, Umbilicus, Midway from
umbilicus to symphysis pubis)→ 6 ‘abs’ of masculine person
• Pyramidalis triangular
Symphysis Pubis to Umbilicus (Linea alba)
Action: Tensor of Linea Alba, Sometimes ABSENT
Nerve supply: subcostal nerve
 RECTUS SHEATH

Strong, incomplete fibrous compartment for the

Rectus Abdominis muscle.

At lateral margin, the internal oblique aponeurosis

splits into two layers
one passing anterior to the rectus muscle
other passing posterior to it.
Anterior layer joins with external oblique aponeurosis
Posterior layer joins with aponeurosis of transverse
abdominis to form the posterior wall of the rectus
sheath.

Anterior, Posterior Layer interlace in the mid line to

form a complex tendinous raphe, called linea alba,
The linea alba lies between two parts of the rectus
abdominis. Umbilicus is located just inferior to its
midpoint.
.
 RECTUS SHEATH

• Inferior one-fourth of rectus sheath is deficient

(Midway between umbilicus & symphysis pubis)
• Internal oblique aponeurosis does not split to
enclose the rectus muscle.
• A crescentic border called ARCUATE LINE marks
the inferior limit of the posterior wall of the rectus
sheath.

• Inferior to arcuate line, all 3 aponeuroses pass

anterior to the rectus muscle to form the anterior
layer of the rectus sheath.
• Posterior layer is formed by Fascia Transversalis
 Posterior lamina of
RECTUS SHEATH
In Anterior Lamina of rectus Sheath
 Superior Epigastric

Branches of
Subcostal &
Lumbar Inferior
Arteries Epigastric
Superficial Circumflex Iliac

Superficial External Superficial Epigastric

Pudendal All 3 are br.
Of FEMORAL art
Umbilicus is a site of
porta-caval ansastomosis,
during portal
hypertension—caput
medusae—dilated veins
radiating from midline

Water-Shed line: Veins &

Lymphatics flow above or
below umbilicus but never
cross umbilical plane

Above umbilicus to
Axillary lymph nodes
Below umbilicus to
Inguinal lymph nodes