ANTERIOR ABDOMINAL WALL

AND RECTUS SHEATH

Prof Francis I.O Duru
Dept of Anatomy
 OUTLINE
 Introduction
 Surface anatomy
 Structures
 Muscles
 Rectus sheath
 Functions
 Blood supply and lymphatics
 Clinical correlation
 Paper review
 Critics
 References
 INTRODUCTION
The anterior abdominal wall forms the
anterior limit of the abdominal viscera
Runs superiorly from the xiphoid process
and costal cartilages of the 7 th, 8th, 9th and
10th ribs to the iliac crest, inguinal ligament,
anterior superior iliac spine, pubic tubercle,
pubic crest and pubic symphysis inferiorly

(Kenhub, 2019)
SURFACE ANATOMY OF ANTERIOR
ABDOMINAL WALL(AAW)
The AAW is also
important because
it is used in
clinical surface
anatomy for the
localization of
abdominal viscera
(Kenhub, 2019)

Figure 1: Surface anatomy of

the AAW (Oluwadiya, 2015)
 BORDERS
 Superior: Costal cartilages 7-12.
 Xiphoid process: Level of 10th cartilage =
L3
 Inferior: Pubic bone and iliac crest: Level
of L4.
 Umbilicus: Level of IV disc L3-4

(Kenhub, 2019)
 ABDOMINAL QUADRANTS
 Formed by two •

intersecting lines:
Intersect at umbilicus.
Quadrants: Upper left,
Upper right, Lower left,
Lower right.
(Oluwadiya, 2015)

Figure 2: Abdominal quadrants

(Oluwadiya, 2015)
 ABDOMINAL REGIONS
 Divided into 9 regions by two pairs of
planes:
 Vertical Planes: Left and right lateral planes
(midclavicular planes)
 Horizontal Planes: Transpyloric plane:
Midway between jugular notch and pubic
symphysis (between xiphoid and
umbilicus).
 Intertubercular plane: Through tubercles of
iliac crests.
(Kenhub, 2019)
 •

Figure 3: Regions and quadrants of abdominal wall

(Kenhub, 2019)
 ABDOMINAL REGIONS CONT’D
 Right and left hypochondriac: Contain liver
 Epigastric: Contains: liver, stomach,
pancreas
 Right and left lateral (lumbar): Right
contains ascending colon, Left contains
descending colon.
(Kenhub, 2019)
 ABDOMINAL REGIONS CONT’D
 Umbilical: Contains small intestine and
transverse colon.
 Right and left inguinal: Right contains ileocecal
junction and appendix, Left contains sigmoid
colon.
 Hypogastric: Contains small intestine, urinary
bladder (full), pregnant uterus.
(Kenhub, 2019)
 LINES ON AAW
 Linea alba: Located along the midline
and separates right and left rectus
abdominis.
 Linea semilunaris: Along each lateral
border of rectus abdominis.
 Linea transversa: Tendinous bands of
rectus abdominis.
(Kenhub, 2019)
Figure 4: Lines on anterior abdominal wall (Jones, 2019)
 STRUCTURE OF AAW
The anterior
abdominal wall
consists of four
main layers: Skin,
superficial fascia,
muscles and
associated fascia,
parietal peritoneum.
(Jones, 2019)
Figure 5:Layers of AAW
(Jones, 2019)
 SKIN
The skin is the most superficial layer and
shows creases which represent lines of
orientation of collagen fibers in the
dermis of the skin. These lines are
referred to as langer’s lines

(Kenhub, 2019)
 SUPERFICIAL FASCIA
A connective tissue and its composition
depends on location:
 Above the umbilicus: single sheet of
connective tissue and continuous with the
superficial fascia in the other regions of the
body.
(Jones, 2019)
 SUPERFICIAL CONT’D
 Below the umbilicus:
divided into two
layers; the fatty
superficial layer
(camper’s fascia) and
membranous deep
layer (scarpa’s fascia)
(Jones, 2019)

Figure 6: Superficial fascia

(Oluwadiya, 2015)
 SUPERFICIAL CONT’D
Runs inferiorly into lower limbs where it
changes name to the fascia lata of the
thigh and also continuous with superficial
perineal fascia called colles’ fascia and
also with the fascia which invests the
scrotum and penis in males
The superficial vessels and nerves run
between these two layers of fascia

(Jones, 2019; Kenhub 2019)

 MUSCLES OF AAW
General Characteristics:
 Five bilaterally paired muscles
 Three large flat sheets connecting rib cage
to hip bone.
 Two vertical muscles
 Muscular posteriorly and laterally.
 Aponeurotic anteriorly and medially
(Jones, 2019)
Figure 7: Muscles of Anterior abdominal wall (Smith, 2015)
 EXTERNAL OBLIQUE MUSCLE
Largest and most superficial.
Its fibres run inferomedially.
Originates from ribs 5-12, and inserts into
the iliac crest and pubic tubercle.
Helps in contralateral rotation of the torso.
Innervation: Thoracoabdominal nerves
(T7-T11) and subcostal nerve (T12).

(Jones, 2019)
Figure 8: External Oblique Muscle (Oluwadiya, 2015)
 INTERNAL OBLIQUE MUSCLE
Lies deep to the external oblique
Smaller and thinner in structure
Its fibres run superomedially
Originates from the inguinal ligament, iliac
crest and lumbodorsal fascia, and inserts
into ribs 10-12
Innervation: thoracoabdominal nerves (T7-
T11), subcostal nerve (T12) and branches
of the lumbar plexus. (Jones, 2019)
•

Figure 9: Internal Oblique Muscle (Oluwadiya, 2015)

 TRANSVERSUS ABDOMINIS
Deepest of the flat muscles with
transversely running fibres
Deep to it is a well-formed layer of fascia
known as transversalis fascia.
Originates from the inguinal ligament,
costal cartilages 7-12, iliac crest and
thoracolumbar fascia.

(Jones, 2019)
 TRANSVERSUS CONT’D
Inserts into the conjoint tendon, xiphoid
process, linea alba and the pubic crest
Helps in compression of abdominal
contents.
Innervation: Thoracoabdominal nerves
(T7-T11), subcostal nerve (T12) and
branches of the lumbar plexus.

(Jones, 2019)
 • •

Figure 10: Transversus Abdominis (Oluwadiya, 2015)

 RECTUS ABDOMINIS
Long, paired
muscle found
either side of the
midline in the
abdominal wall
Split into two by
linea alba
(Jones, 2019)
Figure 11: Anterior abdominal
wall muscles (Jones, 2019)
 RECTUS CONT’D
Lateral borders of this muscle create a
surface marking known as linea semilunaris
At several places, the muscle is intersected
by fibrous strips, known as tendinous
intersections.
Tendinous intersection and linea alba give
rise to the “six packs” seen in individuals
with a well developed rectus abdominis.
(Jones, 2019)
 RECTUS CONT’D
 Originates from crest of the
pubis, before inserting into
the xiphoid process of the
sternum and the costal
cartilage of ribs 5-7.
 Stabilizes pelvis during
walking and depresses the
ribs.
 Innervation:
Thoracoabdominal nerves
(T7-T11). (Jones, 2019)
Figure 12: Rectus abdominis muscle
(Oluwadiya, 2015)
 PYRAMIDALIS
Small triangular muscle superficial to rectus
abdominis
Located inferiorly with its base on the pubis
bone and apex of the triangle attached to the
linea alba.
Originates from the pubic crest and pubic
symphysis before inserting into the linea alba.
It acts to tense the linea alba
Innervation: Subcostal nerve (T12)
(Jones, 2019)
 RECTUS SHEATH
 Strong, incomplete fibrous compartment of the
rectus abdominis and pyramidalis muscles.
 Formed by aponeuroses of the three flat
muscles
 Has an anterior and posterior wall for most of
its length.
 Anterior wall: formed by aponeuroses of
external oblique and half of the internal oblique
 Posterior wall: aponeuroses of half the internal
oblique and transversus abdominis
(Richard et al., 2015; Jones, 2019)
 RECTUS SHEATH CONT’D
Also found in the rectus sheath are;
 Superior and inferior epigastric arteries and
veins
 lymphatic vessels, and
 distal portions of the thoracoabdominal
nerves (abdominal portions of the anterior
rami of spinal nerves T7—T12).

(Richard et al., 2015)

Figure 13: Organisation of Rectus sheath (Richard et al., 2015)
 FUNCTIONS
 Forms a strong expandable support.
 Protects the abdominal viscera from injury
such as low below in boxing.
 Compresses the abdominal content.
 Helps to maintain or increase the
intraabdominal pressure.
 Moves the trunk and help to maintain
posture.
(Oluwadiya, 2015)
 ARTERIES OF AAW
 Superior epigastric:  Inferior epigastric:
 Terminal branch of  Arises from external
internal thoracic. iliac artery.
 Descends in rectus  Enters rectus sheath at
sheath posterior to arcuate line.
muscle.  Branches: Cremasteric
 Anastomoses with artery, Pubic branch
inferior epigastric.
(Oluwadiya, 2015)
ARTERIES OF AAW CONT’D
 Deep circumflex iliac
artery: Branch of
external iliac.
 Superficial epigastric
artery: Arises from
femoral artery.
 Superficial circumflex
iliac artery: Arises
from femoral artery.
 Superficial external
pudendal artery:
Arises from femoral Figure 14: Blood supply of AAW
artery. (Oluwadiya, 2015)
 VEINS OF AAW
 External iliac vein: Receives from
epigastric and deep circumflex iliac veins.
 Femoral vein: Receives superficial
circumflex iliac vein, Superficial epigastric
vein, Superficial external pudendal vein.
Superior epigastric vein: Drains to
brachiocephalic vein

(Oluwadiya, 2015)
 CLINICAL CORELLATION
Tap block: peripheral nerve block used to
do anaesthetize the nerves in the AAW.
Tap block means transverse abdominis
plane block; it is performed by injecting
anaesthesia on the fascia between the
transverse abdominis and internal oblique
muscles.
Kenhub 2019
 CLINICAL CORELLATION
The retroinguinal space: space between
the parietal peritoneum and the
transversalis fascia. It can be used for
putting a prosthesis when treating an
inguinal hernia
Hernias: abnormal protrusion in the
abdominal wall, can be umbilical,
inguinal, and/or epigastric hernias
Kenhub 2019
CLINICAL CORELLATION
Abdominal incisions: incisions depend
on the type of surgery
Nerve injury to the AAW: nerves such
as the ilioinguinal, iliohypogastric and
inferior thoracic nerves are prone to the
injury because they are spread across
the AAW. Injury to these nerves results
in muscle weakness of the AAW
Kenhub 2019
JOURNAL:
JOURNAL REVIEW

J Pediatr Gastroenterol Nutr. 2016

Mar;62(3):399-402.
TITLE OF ARTICLE:
Prevalence of Anterior Cutaneous Nerve
Entrapment Syndrome in a Pediatric
Population With Chronic Abdominal Pain.
AUTHORS: Siawash M, DE JAGER-
KIEVIT JW, TEN WT, ROUMEN RM,
SCHELTINGA MR
 OBJECTIVE
To investigate the rate of Anterior cutaneous
nerve entrapment syndrome (acnes) in a
pediatric outpatient cohort with chronic

abdominal pain (cap)

JOURNAL REVIEW (CONTD)
RESULTS
Twelve of 95 adolescents with CAP were
found to be experiencing ACNES. Carnett
sign was positive at the lateral border of the
rectus abdominus muscle in all 12. Altered
skin sensation was present in 11 of 12
patients with ACNES. Six weeks after
treatment (1-3 injections, n = 5; neurectomy,
n = 7), pain was absent in 11 patients
JOURNAL REVIEW (CONTD)
CONCLUSION:
ACNES is present in 1 of 8 adolescents
presenting with CAP to a pediatric outpatient
department of a teaching hospital
 CRITICISM
No mention of the population among
whom the study was done
It is MISLEADING to just state THAT “1
of 8 adolescents presenting with CAP to a
pediatric outpatient department of a
teaching hospital HAS ACNES”
TEACHING HOSPITAL ???
POPULATION ???
 CRITICISM (CONTD)
Retrospective study that utilized patient’s
record documented by other individuals
Data utilized is subjective, bearing in mind
the possibility of misdiagnosis (HUMAN
ERROR)
A prospective study in which the authors
participated directly would have been more
objective
 REFERENCES
 D. Harmonon, H. P. Friezelle, S.S. Navparkass, F.
Colreavy, M. Griffin: Periopretive Diagnostic and
international Ultrasopund, (2008), p. 183.
 I. Singh: Textbook of Anatomy Thorax, Abdomen and
pelvis, 5th edition, (2008) Volume 2, p. 509-510.
 Swenson R., DC, MD, PHD: Chapter 25: Abdominal
walls. O’Rahilly 2008.
 V. Singh: Textbook of Anatomy Abdomen and Lower
limb, 2nd edition, (2014), volume 2, p. 43-44
 REFERENCES
 Richard L. Drake, A. Wayne Vogl, Adam W.M.
Mitchell. Gray’s Anatomy for students 3rd edition,
2015. Elsevier Churchill Livingstone Publishers.
 Moore , K.L., Dalley, A.F. Clinically oriented anatomy. 8
th edition. Lippincott, Williams, Wilkins, Philadelphia;
2017 (p. 186-190).
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