Clinical Anatomy of the

Anterior Abdominal Wall

in its Relation to Hernia
Handout download:
http://www.oucom.ohiou.edu/dbms-witmer/gs-rpac.htm

Lawrence M. Witmer, PhD

Professor of Anatomy
Department of Biomedical Sciences
26 April 2011 College of Osteopathic Medicine
Ohio University, Athens
witmerL@ohio.edu
 Anatomical Overview
External Internal Transversus Rectus
oblique oblique abdominis abdominis

fleshy
rectus
portion
sheath

aponeurotic inguinal tendinous

portion ligament intersections

Three flat abdominals: attach to trunk skeleton, inguinal lig., linea alba, etc.;
fleshy laterally and aponeurotic medially, forming rectus sheath medially
Two vertical abdominals: rectus abdominis and pyramidalis (not shown)
Moore et al. 2010
 Anatomical Overview
intramuscular exchange of intermuscular exchange of
contralateral external oblique fibers contralateral external & internal oblique

right
external
oblique
left
internal
oblique

continuity of external oblique continuity of fibers across midline

fibers across midline digastric muscle with central
blending of superficial & deep tendon
fibers on opposite side torsion of trunk
Moore et al. 2010
 Anatomical Overview
linea alba rectus sheath transv. abd.
rectus abdominis int. obl.
ext. obl.

semilunar line
peritoneum
transversalis fascia

aponeuroses of
abdominal mm.
tendinous fasciae: Scarpas, Campers
intersections
Moore et al. 2010
 Anatomical Overview

anterior lamina
of rectus sheath semilunar
line (of Spiegel)
inferior epigastric
vessels
posterior lamina
internal of rectus sheath
oblique (aponeurotic)

iliohypogastric n. arcuate line

(semicircular)
ilioinguinal n. line of Douglas)

posterior lamina
of rectus sheath
(transversalis fascia)
Moore et al. 2010
 Anatomical Overview
Anterior Abdominal Hernias

rectus sheath

linea alba

umbilicus

semilunar line

superficial
inguinal ring

femoral
canal

hernia.tripod.com/types.html Moore et al. 2010

 Epigastric (Ventral) Hernia linea alba
thachers.org/images/epigastric_hernia.jpg
thachers.org/images/hernia_repair.jpg

scar

repaired hernia
hernial sac health.enotes.com/images/
medicine/gem_03_img0340.jpg

anterior rectus
rectus sheath
abdominis
posterior rectus
sheath
Skandalakis Surgical Anatomy 2004 hernial sac peritoneum
 Umbilical (Para-umbilical) Hernia
Congenital Acquired Umbilical Hernia
Umbilical occur after closure of umbilical ring
Hernia 2 to obesity, pregnancy, cirrhosis,
ascites, masses
medicine.ucsd.edu/clinicalimg/
abdomen-umbo-hernia4.jpg

incomplete closure of umbilical ring

Omphalocele
2 to ascites

1988 Moore Developing

Human 4th edition Skandalakis Surgical Anatomy 2004
 Spigelian (Lateral Ventral) Hernia
CT rectus sheath:
semilunar posterior & anterior lamina
line

arcuate
line

frequent
hernial
www.e-radiography.net/ibase5/Abdomen/ site
slides/Abdomen_spigelian_hernia_ct.jpg

transversalis
fascia
rectus
Skandalakis Surgical
Anatomy 2004 abdominis
Moore et al. 2010
 Case Presentation
A 3-year-old boy presents with a walnut-sized bulge in his left
groin, particularly when he stands, strains, or cries. With the
patient horizontal, the lump disappears. When the skin of the
scrotum is invaginated by a little finger, a definite impact is felt on
coughing. The diagnosis of hernia is made. How would this hernia
be best characterized?

at rest upon straining

reducible, congenital, indirect inguinal hernia

pediatriconcall.com/forpatients/commonchild/images/inguinal_hernia.jpg
Embryological Basis of Indirect Inguinal hernia

Week 7
testis in
abdomen

Moore et al. 2010

Embryological Basis of Indirect Inguinal hernia

Week 28
testis
descends

patent processus vaginalis

Moore et al. 2010

Embryological Basis of Indirect Inguinal hernia

Week 36
testis in
scrotum

processus vaginalis closed

Moore et al. 2010

Embryological Basis of Indirect Inguinal hernia
transversalis fascia
& peritoneum hernial sac
within
abdominal spermatic
muscles cord

partially vas deferens

obliterated
processus pampiniform
vaginalis plexus

epididymis

testis
tunica
vaginalis
Cahill 1997
 Inguinal Anatomy
ASIS external
oblique
aponeurosis
& Gallaudets
superficial fascia
circumflex
iliac intercrurual
vessels fibers

superficial medial
epigastric crus
vessels
lateral
crus &
great
inguinal lig.
saphenous
v. ilioinguinal
external n. (L1)
superficial (external)
pudendal spermatic cord
inguinal ring
vessels
Moore et al. 2010
 Inguinal Anatomy
inguinal lig.
(of Poupart) myopectineal orifice
internal
inguinal ring of Fruchaud
reflected
inguinal lig.

femoral n.

external iliac
vessels

femoral canal
pectineus pectineal lig. lacunar lig.
(of Cooper) (of Gimbernat)
Moore et al. 2010
Inguinal Anatomy
testicular vessels vas deferens

TF P internal
TA
IO ring
EO Space of
Bogros

ilioinguinal n. external
Moore et al. 2010 conjoint tendon ring
Inguinal Anatomy

shelving edge
of ing. lig.

Moore et al. 2010

 Inguinal Anatomy

iliopubic tract

shelving edge
of inguinal parasagittal section
ligament through right side

Skandalakis Surgical Anatomy 2004

lateral umbilical fold arcuate line inferior epigastric vessels

iliopubic iliopubic
tract tract
iliopsoas
testicular
external vessels
iliac vessels deep
Hesselbachs ing. ring
Triangle femoral canal
posterior view of
anterior abdominal wall vas deferens Moore et al. 2010
 Hesselbachs (Inguinal) Triangle
posterior view
of anterior
abdominal wall
internal
inguinal
ring

indirect
inguinal hernia

direct inguinal hernia

Moore et al. 2010
 Femoral Hernia
femoral canal

lacunar lig.
(of Gimbernat)

Skandalakis Surgical Anatomy 2004

 References

Cahill, D. R. 1997. Lachmans Case Studies in Anatomy, 4th Ed.

Oxford University Press, New York.
Moore, K. L., A. F. Dalley, and A M. R. Agur. 2010. Clinically
Oriented Anatomy, 6th Ed. Lippincott, Williams & Wilkins,
Baltimore.
Moore, K. L. and T. V. N. Persaud. 2003. The Developing Human.
Clinically Oriented Embryology, 7th Ed. Lippincott, Williams &
Wilkins, Baltimore.
Skandalakis, J. E., G. L. Colborn, T. A. Weidman, R. S. Foster, A.
N. Kingsnorth, L. J. Skandalakis, N. P. Skandalakis, P. Mirilas
(Editors). 2004. Surgical Anatomy: The Embryologic And Anatomic
Basis Of Modern Surgery. McGraw-Hill, New York.