Anatomy of the Anterior Abdominal Wall

Hardeep Singh Ahluwalia, MD, J. Pim Burger, MD, Thomas H. Quinn, PhD

his issue of Operative Techniques in General Surgery travels within the transversalis fascia until it reaches the
T deals with selected abdominal wall hernias other than
those of the groin. The purpose of this article is to set the
arcuate line where it pierces the rectus sheath. The second
branch of the external iliac, the deep circumflex iliac,
stage for the operative descriptions that follow. To repair runs parallel to the inguinal ligament between the trans-
the hernias that will be discussed, a requisite knowledge versus abdominis and internal oblique muscles. The su-
of the anatomy is essential. Therefore we will illustrate perior epigastric, the terminal branch of the internal tho-
the salient anatomy as it specifically affects surgical deci- racic artery, enters the rectus sheath superiorly (Fig 1A
sion making in the repair of abdominal wall hernias. and B).
The abdomen represents the portion of the trunk be- The cutaneous abdominal wall innervation is consis-
tween the thorax and pelvis. For the purpose of the hernia tent with a segmental dermatomal pattern. The anterior
repairs to be described in this issue, only the anterior and lateral cutaneous branches of the ventral rami of the
abdominal wall is of interest. The abdominal structure 7th to 12th intercostal nerves and the ventral rami of the
will be described from the most superficial layer to the first and second lumbar nerves have important sensory
peritoneum. and motor functions. T7 passes to the area just below the
infrasternal notch, T10 toward the umbilicus, and T12 to
SUPERFICIAL FASCIA, an area just below the umbilicus (Fig 2). The anterior
VESSELS, AND NERVES primary rami of this nerve group innervate the abdominal
wall musculature as well as the intercostal muscles. There
The abdominal wall consists of skin, superficial fascia, fat,
is poor communication between nerves as they run to-
muscles, transversalis fascia, and the parietal peritoneum.
ward the midline. This results in the ability to use trans-
The panniculus adiposus consists of the fat deposits in the
verse incisions through the rectus to gain access to ab-
superficial fascial layer often referred to as Camper’s Fas-
dominal contents (Fig 3A and B). By reflecting the
cia. Scarpa’s fascia is the membranous deeper layer to this,
superficial fascia, the ilioinguinal (L1) and iliohypogas-
which contains more fibrous tissue. The fibrous layer is
tric (T12, L1) nerves can be noted. The iliohypogastric
formed by compacted fibrous strata that are in continuity
nerve innervates the skin just above the pubis after tra-
with the fatty layer. This layer has no intrinsic strength for
versing the external oblique.
hernia repair but is valuable since its closure provides
The superficial anatomy is essential to the laparoscopic
another layer of protection for the underlying hernia re-
surgeon as well. Laparoscopic hernia repair is quickly
pair, especially when a prosthesis is used. This membra-
becoming a well-performed procedure with decreasing
nous deep fascia merges with the deep thigh fascia and
morbidity if performed by those who are suitably trained.
superficial perineal fascia to contribute to the fascia lata
Laparoscopic ventral hernia repair with a self-expanding
and Colles’ fascia, respectively. The blood supply to the
mesh is described later.
superficial layers is derived from branches of the femoral
artery, namely the superficial epigastric arteries. Venous
drainage into the femoral veins is facilitated via the saphe- ANTERIOR
nous hiatus in the thigh. MUSCULATURE AND LIGAMENTS
Three major arterial branches supply blood to either Much of the strength of the abdominal wall is inherent in
side of the anterior abdominal wall, which includes two four paired muscles and their respective aponeuroses.
branches of the external iliac artery and a branch of the These aponeuroses represent sheet-like tendons for the
internal thoracic artery. The inferior epigastric artery insertion of the lateral muscles and also form the sheath of
the rectus abdominis.
From most superficial to deep, the external oblique is
From the Department of Surgery, Biomedical Sciences, Creighton University,
Omaha, NE.
the first layer of the lateral muscles (Figs 4-6). The largest
Address reprint requests to Thomas H. Quinn, PhD, Department of Surgery, of the three, the external oblique arises from the lower 8
Biomedical Sciences, Creighton University, 601 North 30th Street, Omaha, NE ribs posteriorly to interdigitate with both the serratus and
68131. latissimus muscles. The direction of the fibers is approx-
© 2004 Elsevier Inc. All rights reserved.
1524-153X/04/0603-0003$30.00/0 imately horizontal in the uppermost portion only to be-
doi:10.1053/j.optechgensurg.2004.08.001 come oblique in the lowest portions as they fold on them-

Operative Techniques in General Surgery, Vol 6, No 3 (September), 2004: pp 147-155 147

148 Ahluwalia et al

1 (A) Blood supply—anterior abdominal wall.

selves to form the inguinal ligament. The inguinal oblique aponeurosis. Above this level, the aponeurosis of
ligament helps to define the myopectineal orifice, which the internal oblique splits to envelop the rectus abdomi-
is the area contained deep to the inguinal ligament. After nis and subsequently rejoins at the linea alba. The contri-
contributing to the anterior portion of the rectus abdomi- bution to the linea alba inferior to the umbilicus is some-
nis sheath, the remaining fibers insert onto the linea alba, what more direct. Here, the aponeurosis remains intact
which is the dense white line formed by the medial ter- and runs anterior to the rectus to finally contribute to the
mination of all the aponeuroses. linea alba. The entire rectus sheath can now be illustrated
The external and internal oblique muscles both have with the inclusion of the aponeurosis of the transversus
functions in the support of abdominal viscera as well as abdominis muscle.
assisting in flexion and rotation of the trunk (Figs 4-6). As described by Flament, these lateral muscles are im-
The internal oblique arises from the anterior two-thirds of portant in the formation of midline incisional hernias. In
the iliac crest and lateral half of the inguinal ligament to addition to infection of underlying wounds, his group
run essentially at right angles to those of the external found that incisional hernias were in large part due to
oblique. The fibers take the shape of the iliac crest in that disinsertion of these lateral muscles in the midline, result-
they fan out to insert on the 10th to 12th ribs inferiorly. ing in retraction and subsequent atrophy. His recommen-
Spigelian hernias in adults are considered to be acquired dations for repair are outlined in later articles.
through areas of separation of the internal oblique and The final contribution to the rectus sheath arises from
transversus fibers. These fibers arch over the spermatic the innermost of the three lateral abdominal muscles, the
cord (or round ligament) and the most inferior of these transversus abdominis (Figs 4-6). These muscles arise
join with similar aponeurotic fibers of the transversus from the 7th to 12th costal cartilages, iliac crest, and the
abdominis to form the conjoint tendon. The umbilicus lateral third of the inguinal ligament. The muscle bundles
marks an important level in the division of the internal of this group run essentially horizontally, except the
Anatomy of the Anterior Abdominal Wall 149

1 (B) Blood supply—anterior abdominal wall.

lower most medial fibers, which run a more inferomedial of these contributing fibers onto the posterior aspect of
course to their insertion on the pubic crest and pecten the rectus abdominis muscle occurs.
pubis. The umbilicus is an important landmark in the The principal vertical muscle of the anterior abdominal
division of the transversus abdominis muscle fibers. wall consists of a pair of muscles separated by the linea
Above the umbilicus the transversus abdominis aponeu- alba. The rectus abdominis muscle originates from the
rosis joins the internal oblique aponeurosis to form a 5th through 7th costal cartilages to insert on the symphy-
portion of the posterior rectus sheath as mentioned pre- sis pubis and crest. Superiorly, the rectus is wide, broad,
viously. Below the umbilicus, the transversus aponeuro- and thin, becoming narrow and thick inferiorly. The rec-
sis only contributes to the anterior rectus sheath. The tus muscle and sheath form the linea semilunaris later-
arcuate line (of Douglas) is the site at which termination ally. Segmentation of each rectus muscle occurs by tendi-
150 Ahluwalia et al

2 Nerve supply—anterior abdominal wall.

nous intersections that represent attachment of the rectus blood supply to the rectus. Laterally, the 7th through the
muscle with the anterior layer of the rectus sheath. In 80% 12th intercostal nerves provide innervation.
of people there is a small triangular muscle, called the The rectus abdominis is therefore invested within a
pyramidalis, located anterior to the inferior part of the sheath derived from the combined aponeuroses and fas-
rectus. It assists in tensing the linea alba (Fig 5). The ciae of the external oblique, internal oblique, and trans-
superior and inferior epigastric arteries are the principal versus abdominis (Fig 6).
Anatomy of the Anterior Abdominal Wall 151

3 Nerve supply in relation to various incisions.

152 Ahluwalia et al

4 Musculature—anterior abdominal wall.

Anatomy of the Anterior Abdominal Wall 153

5 Musculature—anterior abdominal wall.

154 Ahluwalia et al

6 Musculature—anterior abdominal wall.

Anatomy of the Anterior Abdominal Wall 155

7 The rectus sheath at various levels.

Further delineation of the rectus sheath is important in Inferior to the umbilicus, the external abdominal aponeu-
the understanding of anterior abdominal wall anatomy rosis has no contribution to the formation of the posterior
(Fig 7). The rectus sheath has contributions from all the rectus sheath.
aforementioned aponeuroses only when inferior to the Bleichrodt’s group has taken advantage of these apo-
umbilicus. The anterior sheath superior to the umbilicus neurotic layers to modify the “component separation”
is composed only of aponeuroses from the external and technique described in this text. They use this technique
internal abdominal muscles; the transversalis aponeuro- to close abdominal defects by finely choosing muscle lay-
sis has no contribution to the formation of the anterior ers and their investing aponeurosis while simultaneously
sheath at this level. In effect, the internal oblique aponeu- creating a smaller wound surface.
rosis splits, allowing one layer to pass anterior and one The arcuate line is defined by the most inferior exten-
posterior to the rectus muscle. The anterior layer will sion of the posterior sheath forming a crescent shaped
then join with the external oblique aponeurosis to form border. In the midline, fibers of the anterior and posterior
the anterior wall of the rectus sheath. The anterior sheath sheaths interlace forming the linea alba. It is now recog-
can be truly considered a composite of all three aponeu- nized that mechanical forces acting here contribute to the
rotic layers only at a variable level below the umbilicus. formation of epigastric hernias. As the following articles
The posterior sheath is similarly described in relation to describe, these may be successfully repaired laparoscopi-
the umbilicus. Superior to the umbilicus the posterior cally as well as by using conventional open techniques.
sheath consists of contributions from both the aponeuro- Many groups have also employed laparoscopic mesh re-
ses of the internal oblique and the transversus abdominis. pair and one such technique is outlined in this text.