Download - Anatomy of Anterior abdominal muscles
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MOB TCD
Anterior Abdominal Muscles
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
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Anterior Abdominal Wall
• The muscles of the anterior abdominal wall play a major role in movements of the trunk
• Protecting the abdominal organs• Increase the intra-abdominal
pressure, aid in expiration and all straining activities such as micturition, coughing and vomiting
• Supplied by lower five intercostal and subcostal nerves
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Anterior Abdominal Muscles
• Strong abdominals are important in helping to stabilise the trunk
• Support the spine• They flex and rotate the trunk • Acting with the adductors and
abductors of the hip• They help to stabilise the pelvis
during walking and running
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• Superficial fatty layer• Membranous layer of
superficial fascia• Below umbilicus• Continuous with Colles’
fascia in the perineum
Anterior Abdominal Wall MOB TCD
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• Lower five intercostal nerves• Subcostal nerve T12• 10th intercostal nerve is at the
level of the umbilicus• Iliohypogastric nerve L1• Ilioinguinal nerve L1
Skin of Anterior Abdominal Wall MOB TCD
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Blood Supply and Lymphatics
• Intercostal vessels• Skin above umbilicus
superficial veins and lymphatics drain to axilla
• Skin below umbilicus superficial veins and lymphatics drain to long saphenous vein
• Superficial inguinal glands
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Inguinal Glands
• Proximal group parallel to inguinal ligament
• Enlarged tender inguinal glands
• Part of a generalised lymphadenopathy
• Secondaries
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• Proximal group• Lesions in local structures• Skin of lower anterior
abdominal wall• Gluteal region • Skin of scrotum or labia
Distal superficial glands• Skin of leg area drained by
long saphenous vein• All drain to deep inguinal
glands along femoral vein
Inguinal Glands MOB TCD
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Abdominal Muscles
• External oblique• Internal oblique• Transversus• Rectus abdominus• Pyramidalis• Nerves and vessels • Lie between internal oblique and
transversus
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External Oblique
• Origin • Outer surfaces lower
borders lower eight ribs• Interdigitating with serratus
anterior and latissimus dorsi• Fibres pass medially and
inferiorly
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External Oblique Insertion
• Inserted into anterior half of anterior two thirds outer lip of iliac crest
• Aponeurosis in the inguinal region passes anterior to rectus muscle
• Forms the inguinal ligament• Lacunar ligament• Reflected portion of inguinal
ligament
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Inguinal and Lacunar Ligaments
• Inguinal ligament aponeurosis is folded back from anterior superior iliac spine to pubic tubercle to form inguinal ligament
• Lacunar ligament triangular, attached to pectineal line. lateral free border medial margin of femoral ring
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Insertion External Oblique
• Pubic crest• Gap for superficial
inguinal ring• Pubic bone • Linea alba • Anterior wall of the
rectus sheath• Zyphoid process
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External Oblique• Acting separately• The external oblique flexes the
vertebral column laterally and rotates it to the opposite side
• If the thorax is fixed by contracting both external obliques, you can tilt the symphysis pubis superiorly and flex the trunk, posterior pelvic tilt
• Movement of the iliac crests determines the direction of the tilt
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Internal Oblique
• Muscular origin lateral two thirds of inguinal ligament
• Anterior two thirds intermediate lip of iliac crest
• Lumbar fascia• Muscular fibres arch over
contents of inguinal canal anterior to rectus muscle
• Fibres pass medially and superiorly
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Insertion Internal Oblique
• Into coastal margin, upper three as fleshy fibres
• Next three as aponeurotic• Inserted into linea alba• Between zyphoid and half way
between umbilicus and pubic symphysis aponeurosis splits
• Anterior layer fuses with external oblique
• Posterior layer fuses with transversus
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Internal Oblique Conjoint Tendon
• Half way between umbilicus and pubic symphysis
• Aponeurosis of the internal oblique and transversus fuse to form conjoint tendon
• Anterior portion of rectus sheath
• Inserted into pectineal line behind superficial inguinal ring
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Internal Oblique
• The right side of the muscle twists to the right and the left side twists to the left
• The lower six intercostals nerve• Subcostal nerve• Iliohypogastric nerves
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Transversus Abdominus
• Origin• Lateral one third of inguinal
ligament• Anterior two thirds of inner lip of
iliac crest• Lumbar fascia• Lower border and inner
surfaces lower six ribs interdigitating with diaphragm
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Insertion Transversus Abdominus
• Into zyphoid, linea alba• Half way between umbilicus
and pubic symphysis• Fuses with posterior lamella of
internal oblique • Below forms conjoint tendon• Inserted into pectineal line
behind superficial inguinal ring
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Transversus Abdominus
• The transversus abdominus helps to support the abdominal viscera
• Maintain intra-abdominal pressure
• Stabilises the lumbar spine• It is supplied by the lower six
intercostals nerves• Subcostal nerves• Iliohypogastric nerves
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Rectus Abdominus
• Segmental muscle• Two heads• Anterior pubic symphysis• Pubic crest• Inserted anterior aspect of 5, 6, 7th
costal cartilages • Adhesions anterior surface• Segmental blood and nerve
supply from Intercostals• The rectus abdominus flexes the trunk
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Rectus Abdominus
• The rectus muscles (recti) are the most powerful flexors of the vertebral column
• When raising the head from a supine position
• A movement often used to strengthen the abdominals
• It is the recti that contract first • When the shoulders start to rise upwards, the
obliques start to contract
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Rectus Sheath
• Above zyphoid• Anterior wall is the external
oblique• Posterior, costal cartilages• From ziphoid and half way
between umbilicus and pubic symphysis
• Anterior is external oblique and anterior lamella of internal oblique
• Posterior lamella internal oblique and transversus
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• Below half way between umbilicus and pubic symphysis
• The aponeurosis of the external oblique, internal oblique and transversus (conjoint tendon) pass anterior to the rectus
• Posterior lies the transversalis fascia
Rectus Sheath MOB TCD
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• Contents• Rectus muscle • Pyramidalis• Superior and inferior epigastric
vessels• Lower five intercostal vessels and
nerves
Rectus Sheath MOB TCD
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Transversalis Fascia
• Lines deep aspect of transversus abdominus
• Fuses with inguinal ligament• Continuous with iliac fascia• Except in the region of the
femoral vessels• Forms anterior wall of
femoral sheath
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Extraperitoneal Tissue
• Extraperitoneal connective tissue
• If fatty, it separates the
transversalis fascia from
the peritoneum• If thin, they are in close
contact with one another
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Peritoneal Pouches
• Peritoneal pouches are found in the region of the deep inguinal ring
• Medial portion of the posterior wall
Posterior aspect anterior abdominal wall
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Inguinal Canal
• Intra muscular canal• Lower portion of anterior
abdominal wall
From • Deep inguinal ring• Superficial inguinal ring• Transmits spermatic cord
in male • Round ligament in female
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Superficial Inguinal Ring
• Triangular opening in aponeurosis of external oblique
• Base, pubic crest• Superior crus attached to
the pubic crest• Inferior attached to pubic
tubercle• External spermatic fascia
arises from its margins
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Deep Inguinal Ring
• Oval opening 2.5 cm• Above the middle of inguinal
ligament• Inferior epigastric artery
passes medial to the deep ring
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Interfoveolar Ligament
• The interfoveolar ligament is an inconstant band
• Medial to deep inguinal ring• Anterior to inferior epigastric
vessels• From lower margin of
transversus abdominus • To pectineal lineMcVay & Anson, 1949
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Inguinal Canal
• Anterior Wall• External oblique forms• Whole anterior wall• Internal oblique forms• Lateral half only
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• Posterior Wall• Transversalis fascia• Whole of wall• Medial half conjoint tendon• Medial quarter reflected
portion of inguinal ligament
Inguinal Canal MOB TCD
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• Roof• Arching fibres of internal oblique • Transversus as they both arise
from the inguinal ligament
Roof of Inguinal Canal MOB TCD
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• Floor• Inguinal ligament
forms whole of floor• Medial half by the
lacunar ligament• Reflected part of
inguinal ligament forms medial quarter
Floor of Inguinal Canal MOB TCD
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Passing Through Deep Ring Male
• Vas Deferens• Testicular artery• Pampiniform plexus of veins• Remains of processus vaginalis• Genital branch of genitofemoral
nerve• Lymphatics from testes• Cremaster artery
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Passing through Superficial Ring Male
• Everything that went through deep ring
• Plus• Ilioinguinal nerve• Internal spermatic fascia from
margins of the deep ring• Cremaster muscle and fascia
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Passing through Deep Ring Female
• Round ligament of uterus• Remains of processus vaginalis• Genital branch of genitofemoral
nerve• Lymphatics from uterus, region
of cornu
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Passing through Superficial Ring Female
• Everything that went through deep ring
• Plus ilioinguinal nerve
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Inguinal Canal
• Contraction of the abdominal muscles increases the obliquity of the inguinal canal
• Protecting the two ringsLytle, 1945
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Increase in Intra-Abdominal Pressure
• Pain aggravated by an increase in intra- abdominal pressure
• Hernia• Inguinal or femoral hernia• Entrapment of the
ilioinguinal nerve
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Hernia
• Chronic pain in the groin in an athlete may be due to a hernia or a potential hernia
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Inguinal Hernia
• Sudden severe pain in lower abdomen
• Associated with lifting a heavy object
• Common history of a direct inguinal hernia
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• Passes through• Deep inguinal ring• May extend to pass
through the superficial ring into the scrotum
• Congenital or acquired • Congenital inside the
tunica vaginalis (serous membrane, covers part of testes)
• Acquired outside
Indirect Inguinal Hernia MOB TCD
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• Enters through posterior wall of the inguinal canal
• Leaves through superficial inguinal ring
• Above and medial to the pubic tubercle
Direct Inguinal Hernia MOB TCD
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Inguinal Hernia MOB TCD
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Inguinal Versus Femoral Hernia
• Inguinal hernia above and medial to pubic tubercle
• Femoral hernia below and lateral to the tubercle
• More common in females and more likely to strangulate
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Femoral Ring MOB TCD
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Femoral Hernia
• Enters through femoral ring• Enters femoral canal• Medial compartment of femoral
sheath• More common in women
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Femoral Hernia MOB TCD
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Saphenous Varix
• Swelling is soft and diffuse
• Empties on minimal pressure
• Refills on release• Cough impulse is
present
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Gilmore’s Groin
• Common cause of chronic groin pain in field sports
• Particularly soccer players• Pain on any sudden change
of movement, sneezing, coughing
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• Trying to sprint• Will increase the pain • Pain is worse getting out of
bed• The day after a match or a
training session
Gilmore’s Groin MOB TCD
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• Pain is increased by external rotation
• Or hyperextension of hip• Pain is localised to lower
anterior abdominal wall• Adductor or perineal
region
Gilmore’s Groin MOB TCD
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• Torn external oblique aponeurosis
• Torn conjoint tendon• A dehiscence between
conjoint tendon and the inguinal ligament
• The absence of a hernial sac• Superficial inguinal ring on the
affected side is dilated and tender
• Cough impulse
Gilmore’s Groin MOB TCD
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• Treatment is surgical • 90% return to sport• Strengthen lower
abdominal muscles
1. Plication of the transversalis fascia in “Shouldice hernia repair”
2. Repair of torn conjoint tendon
Gilmore’s Groin Surgery MOB TCD
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3. Approximation of conjoint tendon to the inguinal ligament
4. Repair of the external oblique
5. Reconstitution of the superficial inguinal ring
Gilmore’s Groin Surgery MOB TCD
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