Subject: Surgery II

Topic: 2.01a Abdominal Wall

Lecturer: Dr. Miguel Mendoza
Date: 20 July 2015

OUTLINE II. Abdominal Wall Muscles

I. Abdominal Wall Anatomy A. Rectus abdominis muscles
II. Abdominal Wall Incisions and Exposure
 Vertical fibers
III. Congenital Abnormalities
IV. Abdominal Wall Hernias  Encased by aponeurotic sheath (anterior/posterior)
a. Ventral Hernias  Linea Alba - midline fusion of the anterior and posterior
b. Special Considerations layers of the rectus aponeurotic sheath
c. Incisional Hernias  Insertions
V. Hernias Repair a. Symphysis pubis - inferiorly
b. 5th and 6th ribs
OBJECTIVES c. 7th costal cartilage
At the end of the lecture, the student should be able to: d. Xiphoid process - superiorly
1. Understand abdominal wall anatomical structure and pathologies  Linea semilunaris – lateral border, curve shaped
2. Understand surgical procedures to address abdominal wall defects
 3 tendinous insertions:
References: Lecture Recording, PowerPoint Presentation and Schwartz a. level of the umbilicus
b. xiphoid process
I. Abdominal Wall Anatomy c. between xiphoid and umbilicus
B. External oblique muscles
 First layer from anterior
 Inferior and medial fibers - fibers run inferiorly and
medially arising from the margins of the lowest eight
ribs and costal cartilages (like inserting your hands on
your pocket)
 Origin
a. lower 8 ribs and costal margins,
b. latissimus dorsi
c. serratus anterior
 Insertion - tendinous portion contiguous with
anterior rectus sheath
 Inguinal ligament – inferiormost edge of the EOM;
reflected posteriorly in the area between ASIS to
pubic tubercle
C. Internal Oblique Muscles
 Lies immediately deep to the external oblique muscle
 Superior and medial fibers
 Origin:
a. lower 8 ribs and costal margins,
Figure 1. Anterior abdominal wall. The abdominal wall is a complex, b. latissimus dorsi
segmentally layered structure with segmentally derived different c. serratus anterior
blood supply and innervations. It is mesodermal in origin and  Insertion - tendinous aponeurosis medially
develops as bilateral migrating sheets that originate in the contributing to the anterior posterior rectus sheath
paravertebral region and envelope the future abdominal.  Lower medial and inferiormost fibers of the internal
oblique course may fuse with the lower fibers of the
A. Borders transversus abdominis muscle, forming the conjoined
 Superiorly: costal margins area. The innermost fibers of the internal oblique
 Inferiorly: symphysis pubis muscle are contiguous with the cremasteric muscle in
 Posteriorly: vertebral column the inguinal canal. Take note of these relationships as
B. Functions they are of critical significance in the management of
 Support inguinal hernia (Schwartz).
 Protection of intraperitoneal (stomach, appendix, D. Transversus abdominis muscles – transverse fibers
liver, transverse colon,1st part of duodenum) and  Deepest of the three lateral muscles
retroperitoneal structures (colon, pancreas,  Origin
kidney, ureter, bladder) a. bilateral lowest 6 ribs
 Enables twisting and flexing motions of truck b. lumbosacral fascia
c. iliac crest
 Insertion - lateral border of the rectus abdominis
musculoaponeurotic structures

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Trans Group: Maribie Minor, Mark Mirabueno, Ginny Misa, Arem Molina
Edited By: H. Palparan
 III. Cross Section of the Abdominal Wall o Superior epigastric vessels -superior epigastric
 The complexities of the anterior and posterior aspects of artery arises from the internal thoracic artery
the rectus sheath are best understood in their relationship o Inferior epigastric vessels - inferior epigastric
to arcuate line or semicircular line of Douglas, which is at artery arises from the external iliac artery
the level of the ASIS (Schwartz).  Majority of the lymphatic drainage of the abdominal wall is
 Borders of the arcuate Line to the major nodal basins in the superficial and axillary
a. Superiorly: WITH posterior rectus sheath areas.
b. Inferiorly: WITHOUT posterior rectus sheath
V. Dermatomal Sensory Innervations
 Dermatomal levels are based on its relationship with
specific spinal levels
 Motor innervation – anterior rami of T6-T12
 Sensory innervation – T4- L1
o Umbilicus – T10

Figure 2. Cross sectional anatomy of the abdominal wall above and

below the arcuate line. The lower right abdominal wall segment
shows clearly the absence of an aponeurotic covering of the posterior
aspect of the rectus abdominis muscle inferior to the arcuate line.
Superior to the arcuate line, there are both internal oblique and
transversus abdominis aponeurotic contributions to the posterior
sheath (Schwartz)

A. ABOVE THE ARCUATE LINE

Figure 3. Dermatomal sensory innervation of the
 Anterior rectus sheath abdominal wall.
a. external oblique aponeurosis
b. external lamina of the internal
VI. ABDOMINAL WALL INCISIONS
oblique aponeurosis
 Orientation of the line of any incision maybe determined
 Posterior rectus sheath
based on expected quality of exposure; closure
a. internal lamina of the internal oblique
considerations, including cosmesis; avoidance of previous
aponeurosis
incision sites and simple surgeon preference.
b. transverses abdominis aponeurosis

B. BELOW THE ARCUATE LINE

 Anterior rectus sheath
a. external oblique aponeurosis
b. laminae of internal oblique aponeurosis
c. transversus abdominis
d. transversalis fascia
 There is no aponeurotic posterior covering of this
lower portion of the rectus muscles, although the
endoabdominal, or transversalis fascia, provides
contiguous coverage of the posterior aspect of the
abdominal above and below the arcuate line.

 Lower abdomen - common site for ventral hernia due to

its weaker layers (i.e. Spigelian Hernia)
Figure 4. Abdominal incisions
IV. Blood Supply and Lymphatics
 Majority of the blood supply to the muscles of the anterior A. Midline incision (Laparotomy) – more common; used to
abdominal wall is derived from the superior and inferior explore the abdomen
epigastric arteries.

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 B. Paramedian incision – lateral to the midline  Right of midline
C. Right subcostal (Kocher); Saber Slash incision– for open  Parts of organs may be free in the amniotic fluid – no sac
gallbladder surgery C. Meckel’s Diverticulum
D. Bilateral subcostal (Bucket Handle, Chevron, Gable);  Persistence of a vitelline duct remnant on the ileal border
“Mercedes Benz” – for upper GI surgery (stomach,  Vitelline duct usually regresses during the 3rd trimester
pancreas)  Can develop into Meckel’s diverticulitis that mimics
E. Rocky-Davis; Weir incision– for appendectomy appendicitis
F. McBurney incision – for appendectomy
G. Transverse incision– for pediatric patients D. Vitelline Duct Fistula
H. Pfannensteil (Bikini Cut) – for obstetric procedures  Complete failure of the vitelline duct to regress
 Associated with drainage of small intestine contents from
VII. ABDOMINAL WALL EXPOSURE the umbilicus

E. Vitelline Duct Cyst

 Occurs if both the intestinal and umbilical ends of the
vitelline duct regress into fibrous cords
 Persistent vitelline duct remnants between the GI tract
and the anterior abdominal wall may be associated with
small intestine volvulus in neonates.
 When diagnosed, vitelline duct fistulas and cysts should be
excised along with any accompanying fibrous cord.
Figure 5. Self-retaining retractor system (“Iron Intern”)
F. Urachal Cyst and Urachal Fistula
 Self-retaining Retractor System  Persistence of urachal elements can result in cysts as
 Bookwalter, Omni-Tract and Thompson Retractors – this well as fistulas to the urinary bladder with drainage of
avoids physical stresses on personnel urine from the umbilicus
 For open surgery, a variety of devices are available to  At the median umbilical ligament
retract the abdominal wall and facilitate peritoneal  treated by urachal excision and closure of any bladder
exposure without subjecting the patient to excessively defect that may be present
large incisions or surgical personnel to exhausting
retraction tasks.

VIII. CONGENITAL ANOMALIES

A. Defects in Abdominal Wall Closure
A. Omphalocoele
 Type of abdominal wall defect in which the intestines,
liver, and occasionally other organs remain outside of the
abdomen in a sac (peritoneum) – sac present/intact

Figure 5.Omphalocoele

 Midline through umbilicus

 Viscera protrude through an open umbilical ring and are
covered by a sac derived from the amnion

B. Gastroschisis
 Viscera protrude through a defect lateral to the umbilicus
 Umbilical cord is not involved

Figure 7. A – Omphalocoele; B- Gastroschisis; C – Meckel’s

diverticulum

Figure 6. Gastroschisis

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 IX. ACQUIRED ABNORMALITIES
A. Rectus Abdominis Diastasis (Diastasis Recti)

Figure 8. Diastesis recti is visible in the mid-epigastrium with Valsalva

maneuver. The edges of the rectus abdominis muscle, rigid with
voluntary contraction, are palpable along the entire length of the
bulging area. This should not be mistaken for a ventral hernia.
Figure 9. Algorithm for management of rectus sheath hematoma
 Clinically evident separation of rectus abdominis muscle
pillars. X. Anterior Abdominal Wall Hernias (Ventral Hernias)
 Bulging of abdominal wall at midline epigastric area
 Represents defects in the parietal abdominal wall fascia and
 Congenital – due to more lateral insertion of rectus
muscle through which intra-abdominal and preperitoneal
abdominis muscle to ribs & costochondral junctions
contents can protrude.
 Acquired – advancing age, obesity, post pregnancy
 May be congenital or acquired
 Treatment
 Acquired hernias may develop through slow architectural
o Observe
deterioration of the muscular aponeuroses or they may develop
o Physical therapy
from failed healing of an anterior abdominal wall incision.
o Surgical plication of broad midline aponeurosis
 Most common finding: mass or bulge on the anterior abdominal
mainly for cosmetic purposes and alleviation of
wall that may increase in size with a Valsalva maneuver
impaired abdominal muscular wall function
 May be asymptomatic or cause a considerable degree of
discomfort, and generally enlarge over time
B. Rectus Sheath Hematoma
 PE reveals a bulge on the anterior abdominal wall that may reduce
A. Possible Causes
spontaneously, with recumbency, or with manual pressure
 History of major or minor blunt trauma
 Incarcerated – irreducible hernia, requires immediate surgical
 Coughing, sneezing, strenuous physical activity
correction
 Spontaneous- elderly & anticoagulant therapy
 Strangulated – blood supply to incarcerated is compromised, may
B. Clinical Features
lead to infarction and perforation
 Sudden onset of abdominal pain (sudden onset of
unilateral abdominal pain that may be confused with
lateralized peritoneal disorders such as appendicitis) XI. Primary Ventral Hernias (Non-Incisional)
 Below the arcuate line, a hematoma may cross the
midline and cause bilateral lower quadrant pain.
History and physical examination alone may be diagnostic.
Pain typically increases with contraction of the rectus
muscles, and a tender mass may be palpated. The ability
to appreciate an intra-abdominal mass is ordinarily
degraded with contraction of the rectus muscles
 Fothergill’s Sign – palpable abdominal mass that
remains unchanged with contraction of the rectus muscles
and is classically associated with rectus hematoma (If
you ask the patient to contract the muscles mimicking
sit-ups exercise, when they contract, the pain is
aggravated)
 Can mimic acute appendicitis – can do abdominal CT scan
to confirm rectus sheath hematoma
C. Management Figure 7. Primary ventral hernias - areas of common occurrence
 Observe
 Anti-coagulation – if stable  True ventral hernias
 If enlarging – angiographic embolization  Named according to the location of occurrence

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A. Epigastric Hernia C. Laparoscopic Ventral Hernia Repair
 Midline between xiphoid and umbilicus  A 5mm incision is made, into which the camera, scope,
 Single or multiple, generally small instruments, and mesh are inserted and the defect
 Contains omentum or falciform ligament patched
 Congenital due to defective midline fusion of lateral  Tension-free, smaller incision
abdominal wall muscles  Technique based on open preperitoneal repair described
 Managed by elective hernia repair by Stoppa and Rives et. Al
B. Umbilical Hernia  Used in the treatment of complicated groin and incisional
 Occurs at umbilical ring hernia, and in the treatment of large eventrations
 May either be present at birth or develop gradually during  Recurrence rate is 3.8% (this is relatively low)
life  Mesh infection rate is 0.6% (low)
 Seen in 10% of newborns, usually premature birth  Wound infection rate is 1.1% (low)
 Closes spontaneously at 5 years of age  Fistula formation is 0.1%
 If closure does not occur by this time, elective surgical
repair usually is advised D. Advantages of LVHR
 Surgery if with pain or incarceration or strangulation  Low rate of conversion to open hernia repair
 Primary suture closure or mesh placement (>2cm)  Shorter hospital star
 Open or laparoscopic methods.  Earlier return to activity
 Less complications
C. Spigelian Hernia  Low risk of infection
 At the area where arcuate line crosses the linea semilunaris  Low risk of recurrence
 Rare, occurs at Spigelian line  Effective in complex patients
 Lateral border of rectus abdominis  Based on available date in literature, it is recommended
 Most common location: slightly above arcuate line that laparoscopic ventral/incisional hernia repair should be
 Usually not clinically evident unless with pain or the standard of care for all ventral hernias
incarceration
Incisional Hernia repair
D. Special Considerations A. Comparative studies of Laparoscopic vs. open incisional
 Patients with liver cirrhosis + ascites + umbilical hernia hernia repair
 Enlargement of the umbilical ring occurs due to increased  Postoperative complication rate is less in the lap group vs
intra-abdominal pressure from the ascites the open group (23.3% vs. 30.2%)
 First line of therapy: control the ascites first with diuretics,  Recurrence rate is 4% for lap approach vs 16.5% for open
dietary management, and paracentesis for tense ascites approach
with respiratory compromise
 Medical management or liver transplantation or TIPS B. LIHR- Risk Reduction Strategies
 Patients with refractory ascites may need transjugular  Overlap defect by up to 3.5 cm
intrahepatic portosystemic shunt or eventual liver  Use composite mesh
transplantation. Umbilical hernia should be deferred until  Use adequate fixation
after the ascites is controlled.  Decrease abdominal pressure when anchoring the mesh
 Watch out for bleeding from epigastric vessels
XII. Ventral Hernia Repair  Close 10mm port sites
A. Open Tissue Repair (“vest over pants”)  Use compressive bandage dressing
 Recurrence rate from this type of repair ranges from 31%-  Long acting local anesthetics at suture fixation sites
54% during long term follow up (high recurrence rate)  Use appropriate techniques in difficult areas
 Has tension and if not treated can lead to incarceration,
strangulation, and gangrene

B. Open Tension-free Repair With Mesh

 Recurrence rate is lower (10%) but infection rate is high
 Wound infection and wound related complications >12%
because in order to cover up the defect with mesh, you
also need a deep incision reaching the subcutaneous layer.
(potential dead space for fluid to accumulate)
 Mesh can be places as an interlay either bridging the gap
between the defective edges or within the abdominal
musculoaponeurotic layers (interparietal), or as an inlay
(superficial to the fascial defect)

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