Anterior Abdominal

Wall and Surface

Anatomy

Dr. Ashley Stephen

AshleyStephen@RossU.edu
Department of Anatomy

Recommended reading: Practice questions:

Clinically Orientated Anatomy - 7th Edition: Pages 181-199 Located on eCollege below this lecture file
 Learning Objectives
✓ Identify the boundaries of the abdominal cavity
✓ Differentiate parietal peritoneum from visceral peritoneum
✓ Identify the following key surface landmarks: Umbilicus, linea alba, linea semilunaris, iliac tubercles & costal margins
✓ Distinguish the individual muscles that form the anterior abdominal wall (external oblique, internal oblique,
transversus abdominis, rectus abdominis and pyramidalis) using attachment points and understanding their actions
✓ Understand the layers of the anterior abdominal wall from superficial to deep
✓ Understand the concept of the rectus sheath and relate this with the arcuate line
✓ Differentiate the peritoneal folds (median, medial and lateral) on the internal aspect of the abdominal wall and
understand what structure(s) form/underlie the respective folds
✓ Describe the arterial supply, venous drainage, lymphatic drainage and nerves of the anterior abdominal wall
✓ Divide the abdomen into 4 quadrants and 9 regions and understand the relationship with abdominal viscera
✓ Outline the following clinical correlates and relate to the important anatomical structures:

 Abdominal incision sites – surgical scars important for patient  McBurney’s Point – relate to appendicitis
medical history/physical exam  Rectus sheath hematoma

Recommendation:
**Link the anatomical and clinical information provided in the lecture to the gross anatomy laboratories** 2
 Skeletal Framework of the Abdomen
Inferior thoracic aperture:
• Xiphisternal joint → some sources reference xiphoid process Xiphisternal joint
• Costal margin
− Costal cartilages of 7th to 10th ribs Costal margin
T12
• 11th and 12th ribs
• T12 vertebra

Sacral promontory

Pelvic Inlet – demarcated by the pelvic brim:

• Pubic symphysis Sacral ala
• Pubic crest
Iliopectineal line
• Pubic tubercle
• Iliopectineal line → Arcuate line + pectineal line
Pubic crest
• Sacral alae
Pubic tubercle
• Sacral promontory
3
 Boundaries of the Abdomen
Superiorly: Anterolaterally:
• Diaphragm • Anterior abdominal wall muscles
• Inferior thoracic aperture − Rectus abdominis m.
− Xiphisternal joint − External oblique m.
− Costal margin
− Internal oblique m.
− 11th and 12th ribs
− T12 vertebra
− Transversus abdominis m. Diaphragm

Inferior
Inferiorly: Posteriorly: thoracic
aperture
• Pelvic inlet • Vertebrae
Abdominal
− Pubic symphysis • Posterior abdominal wall muscles wall
− Pubic crest Pelvic inlet Iliac crest
− Quadratus lumborum m.
− Pubic tubercle
− Psoas major m.
− Iliopectineal line
− Iliacus m. Inguinal
− Sacral alae ligament
− Sacral promontory
4
 Abdominopelvic Cavity: Lined with Peritoneum
Cranial cavity Cranial
cavity
Vertebral canal

Left
Superior Thoracic
mediastinum
pleural cavity cavity
Pericardial cavity within
Thoracic cavity
middle mediastinum
Diaphragm
Diaphragm Vertebral
canal
Abdominal cavity Abdominal cavity
Abdominopelvic Pelvic inlet
Pelvic cavity
cavity Pelvic cavity marks the division
between the abdominal
& pelvic cavities

Peritoneum is composed of mesothelium and is derived from lateral plate mesoderm;

therefore this covering is similar to the pleura and pericardium in the thorax (it is just given a different name)

• Peritoneum is defined as a serous membrane (that secretes fluid to reduce friction when organs move) which:
− lines the cavity and walls of the abdomen → Parietal layer of peritoneum
− covers the abdominal organs → Visceral layer of peritoneum 5
 Peritoneal Cavity: Potential space within the abdominal cavity
Peritoneal cavity is a “potential”
space between parietal and visceral
peritoneum
Liver
• Parietal layer of peritoneum covers and lines
Stomach the internal walls of the abdomen
Portal v.
→ Pain is well localized (very sensitive)
• Visceral layer of peritoneum covers and
IVC
invests abdominal organs that protrude into
Right
T12
Kidney
the peritoneal cavity
→ Pain is generalized (is referred)

➢ Technically, no structures are contained

in the peritoneal cavity as this “space” is full
of peritoneal fluid to enable peristalsis
6
 Surface Anatomy: Anterior Abdominal Wall
Anterior abdominal wall muscles
Clavicle
are collectively described as
anterolateral but can be subdivided:

① Anterior group
Xiphoid − Rectus abdominis m.
process
− Pyramidalis m. (if present)

② Lateral group
2
− External oblique m.
Anterior superior 1 − Internal oblique m.
iliac spine
− Transversus abdominis m.
7
 Surface Anatomy: Anterior Abdominal Wall
Linea alba is a white tendinous line that:
• Forms in the midline
• Runs from the xiphoid process to pubic
symphysis
• Separates the right and left rectus abdominis
mm.

Lineae semilunaris are curved lines that:

• Mark the lateral borders of the rectus
abdominis muscles
Linea alba
• Run from costal cartilages to pubic tubercles
• Also known as spigelius line →
Linea semilunaris
clinical correlate is a Spigelian hernia
Tendinous
intersection
• Alba → meaning white
• Semilunaris → meaning crescent moon
8
 External Abdominal Oblique: Anterolateral muscle
▪ Origin:
• Ribs 5 to 12
▪ Insertion:
• Linea alba via the rectus sheath
• Pubic tubercle
• Anterior iliac crest
▪ Innervation:
• Anterior rami of T7-T12 spinal nerves
▪ Action:
• Bilateral: Flexion of trunk & compression of abdominal viscera
• Unilateral: Lateral flexion & contralateral rotation of the trunk

Surface Anatomy:
The external oblique m. has a hands-in-pocket
muscle fiber orientation and interdigitates with
Inguinal Ligament:
Forms from the lower free-edge of the fibers serratus anterior m. 9
Internal Abdominal Oblique: Anterolateral muscle
▪ Origin:
• Thoracolumbar fascia
• Anterior iliac crest
• Inguinal ligament
▪ Insertion:
• Linea alba via the rectus sheath
• Ribs 10-12
• Pubis via the conjoint tendon
▪ Innervation:
• Anterior rami of T6-L1 spinal nerves
▪ Action:
• Bilateral: Flexion of trunk & compression of abdominal viscera
• Unilateral: Lateral flexion & ipsilateral rotation of the trunk

Conjoint tendon:
Forms when the medial fibers of the internal oblique aponeurosis unite with the
deeper fibers of the transversus abdominis aponeurosis 10
Transversus Abdominis: Anterolateral muscle
▪ Origin:
• Costal cartilages of ribs 7-12
• Thoracolumbar fascia
• Iliac crest
• Inguinal ligament
▪ Insertion:
• Linea alba via the rectus sheath
• Pubis via the conjoint tendon
▪ Innervation:
• Anterior rami of T6-L1 spinal nerves
▪ Action:
• Maintains posture & compresses/supports abdominal viscera

Arcuate line:
Located 1/3rd of the distance from the umbilicus to the pubic symphysis and
forms when the aponeurotic fibers of transversus abdominis m. no longer travel
posterior to the rectus abdominis m. and instead course anterior to the muscle 11
Rectus Abdominis: Anterior muscle
▪ Origin:
• Pubis
▪ Insertion:
• Costal cartilages of ribs 5-7
▪ Innervation:
• Anterior rami of T6-T12 spinal nerves
▪ Arterial supply:
• Superior epigastric artery
• Inferior epigastric artery
▪ Action:
• Flexion of trunk & compression of abdominal viscera

Tendinous intersections:
Segment the rectus abdominis m. and attach to the anterior layer of the rectus
sheath, so that when the muscle contracts and tenses it does not lift
(prevents bow stringing) 12
 Pyramidalis: Anterior muscle
Rectus
abdominis

Linea alba
▪ Origin: m.

• Pubic crest
Anterior
▪ Insertion: layer of the
rectus
• Linea alba sheath
(reflected)

▪ Innervation:
• Anterior rami
of T12 spinal nerve
▪ Action:
Pyramidalis • Tenses the linea alba
muscle Spermatic cord

Pyramidalis muscle:
A small triangular-shaped muscle anterior to rectus
abdominis muscle that is absent in
approximately 20% of individuals
13
 Anterior Abdominal Wall: Overview of muscles
Muscle Origin Insertion Action Innervation
External abdominal oblique Lower 8 ribs Iliac crest, Contralateral rotation T7-12
Pubic tubercle, and lateral flexion.
Linea alba When BOTH right and left
contract: Flexion of trunk and
compression of abdominal
viscera

Internal abdominal oblique Thoracolumbar fascia, Lower 3 ribs, Ipsilateral rotation T6-L1
Iliac crest, Linea alba, and lateral flexion.
Inguinal ligament Pubis When BOTH right and left
contract: Flexion of trunk and
compression of abdominal
viscera

Transversus abdominis Lower 6 costal cartilages, Linea alba, Compression and support T6-L1
Thoracolumbar fascia, Pubis of abdominal viscera
Iliac crest,
Inguinal ligament

Rectus abdominis Pubis Costal cartilages of Flexion of trunk & T6-T12

ribs 5-7 compression and support
of abdominal viscera

Pyramidalis Pubis Linea alba Tenses the linea alba T12

14
 Layers: External view of anterior abdominal wall

Skin
Subcutaneous tissue: External oblique m.
• Camper’s fascia
Internal oblique m.
• Scarpa’s fascia
Linea
alba Transversus
abdominis m.

Camper’s fascia
Transversalis
Rectus fascia
Scarpa’s fascia abdominis m.

Peritoneum Extraperitoneal fat/fascia

Aponeurosis: Subcutaneous tissue:

A sheet-like fibrous membrane, resembling a flattened tendon,
that serves as a thickened fascia to bind muscles together or as a
• Camper’s fascia → superficial fatty layer
means of connecting muscle to bone. • Scarpa’s fascia → deep membranous layer
Typically has a shiny, silvery appearance (difficult to see)
15
 Anterolateral Wall: Layers

Skin

Camper’s fascia

Scarpa’s fascia

External oblique m.

IVC Internal oblique m.

Descending
colon Intervertebral
disc
Transversus abdominis m.
L3/L4
Transversalis fascia
Erector Extraperitoneal fat
spinae Parietal layer of Peritoneum

16
 Rectus Sheath
The aponeuroses of the external oblique, internal oblique and transversus abdominis mm.
have to pass superficial or deep to the rectus abdominis mm. to insert on the linea alba

• The anterior lamina (wall) of the rectus sheath is Anterior lamina Posterior lamina
of rectus sheath of rectus sheath
formed by the aponeurotic fibers that
pass superficial to rectus abdominis m.
• The posterior lamina (wall) of the rectus sheath
is formed by the aponeurotic fibers that
pass deep to rectus abdominis m.
Linea semilunaris Linea alba

• Contents:
• Rectus abdominis muscles Sheath:
• Superior epigastric vessels Defined as a close fitting cover that
envelops a structure and has a
• Inferior epigastric vessels
protective role
• Anterior rami of the T7-12 spinal nn. 17
Rectus Sheath: Above the arcuate line

Skin

Camper’s fascia

Scarpa’s fascia
External oblique aponeurosis
Internal oblique aponeurosis

Rectus abdominis m.
Intervertebral Internal oblique aponeurosis
disc Transversus abdominis aponeurosis
L3/L4
Transversalis fascia
Extraperitoneal fat
Parietal layer of Peritoneum

18
 Rectus Sheath: Above the arcuate line
Anterior lamina:
• External oblique aponeurosis Skin
• Internal oblique aponeurosis (half)
Camper’s fascia

Posterior lamina: Scarpa’s fascia

• Internal oblique aponeurosis (half) External oblique aponeurosis
• Transversus abdominis aponeurosis Internal oblique aponeurosis

Scarpa’s
Rectus abdominis muscle
fascia
Internal oblique aponeurosis
Transversus abdominis aponeurosis
RA m. Transversalis fascia
Extraperitoneal fat
Parietal layer of Peritoneum
Peritoneum

Transversalis fascia
19
 Rectus Sheath: Below the arcuate line
Anterior lamina:
• External oblique aponeurosis Skin
• Internal oblique aponeurosis
• Transversus abdominis aponeurosis Camper’s fascia

Scarpa’s fascia
Posterior lamina:
External oblique aponeurosis
• Not present! Internal oblique aponeurosis
Transversus abdominis aponeurosis

Scarpa’s
fascia Rectus abdominis muscle
Transversalis fascia
RA m.
Extraperitoneal fat
Parietal layer of Peritoneum

Peritoneum

Transversalis fascia 20
 Arcuate Line: Internal view of anterior abdominal wall
Posterior
rectus sheath
The arcuate line marks the point at
Umbilicus
which the aponeuroses of all three
lateral abdominal muscles pass
anterior to the rectus abdominis m.

Parietal • Located 1/3rd of the distance between

Transversus
abdominis m.
peritoneum the umbilicus and the pubic symphysis

• At this level, the internal aspect of the

rectus abdominis muscle is in direct
contact with the transversalis fascia
Rectus
abdominis m.
Transversalis fascia
21
 Peritoneal Folds: Internal aspect of umbilical folds
Median umbilical fold (x1):
• Midline
• Under this fold lies the median umbilical ligament
• Remnant of the embryological urachus 3

→ travels from the apex of the urinary bladder to the umbilicus 2

1

Medial umbilical folds (x2):

• Paired on either side of the midline
• Under these folds lie the medial umbilical ligaments Supravesical fossa
1
• Remnant of the embryological part of the umbilical arteries
→ Blood traveled from the internal iliac arteries of the fetus back to the placenta 2 Medial inguinal fossa

Lateral umbilical folds (x2): 3 Lateral inguinal fossa

• Paired on either side of the medial umbilical folds
• Under these folds lie the inferior epigastric vessels Peritoneal fossae:
→ Inferior epigastric artery branches directly from the external iliac artery Depressions (fossae) are created lateral to
→ Inferior epigastric vein typically drains into the external iliac vein the raised peritoneal folds and may be
potential sites for inguinal hernias 22
 Peritoneal Folds: External aspect of umbilical folds

External oblique m.
Transversalis
Internal oblique m.
fascia
Transversus abdominis m.

Peritoneum
Inferior epigastric (intact)
artery
External iliac vein
Spermatic cord (cut)
Remnant of the
umbilical a. Urinary bladder

Great saphenous
Remnant of the vein
urachus

23
 Reference: Medial umbilical folds and the umbilical arteries
Fetal circulation is different from
circulation after birth: Foramen ovale
Arch of the Aorta
Left umbilical vein Ductus arteriosus
• Fibroses to form the
round ligament of the liver Pulmonary trunk

Ductus venosus
• Fibroses to form Umbilical vein Inferior vena cava
ligamentum venosum
Ductus venosus

Umbilical arteries: Placenta

• Proximal part remains in the adult as Umbilical
the umbilical artery cord Umbilical
• Distal part (that runs towards the arteries
umbilicus) becomes a fibrotic cord
called the
medial umbilical ligament
24
 Arteries: Anterior Abdominal Wall
Superior epigastric artery
• Branches directly from the internal thoracic artery
• Travels deep to rectus abdominis m.
Internal thoracic a.

Musculophrenic a.
Inferior epigastric artery
• Branches directly from the external iliac artery Superior epigastric a.
• Travels deep to rectus abdominis m.
• Forms an anastomosis (connection) with the
superior epigastric artery Branches of
intercostal, subcostal
& lumbar aa.
• Link to Inguinal Region, Testes and Scrotum lecture for the
following clinical correlate: Inferior epigastric a.
➢ Hesselbach’s inguinal triangle

Superficial epigastric artery: Superificial

Branches directly from the femoral artery just distal to the inguinal ligament epigastric a.
and travels superficial to the rectus sheath 25
 Superficial Veins: Anterior Abdominal Wall
Superficial epigastric veins:
• Drain directly into the great saphenous vein
• Travels with the superficial epigastric artery
Axillary v.

Thoracoepigastric veins Lateral thoracic v.

• Drain directly into the lateral thoracic vein
• Does not have a corresponding artery
Thoracoepigastric v.

Periumbilical veins Periumbilical v.

• Are located around the umbilicus
• Communicate with the thoracoepigastric veins
• Communicate with the paraumbilical veins
Superficial epigastric v.
• Link to Anatomy of the Abdomen lecture for the following
clinical correlate: Great saphenous v.
➢ Caput medusa
26
 Deep Veins: Anterior Abdominal Wall

Superior epigastric veins

• Drain directly into the internal thoracic vein
• Travel with the superior epigastric artery

Inferior epigastric veins Internal thoracic v.

• Drain directly into the external iliac vein
• Travel with the inferior epigastric artery Superior epigastric v.

Paraumbilical v.
Paraumbilical veins located within the round
ligament of the liver
• Are located parallel to the umbilicus
• Drain into the hepatic portal vein

• Link to Anatomy of the Abdomen lecture for the Inferior epigastric v.

following clinical correlate:
➢ Portocaval anastomoses
27
 Lymphatic Drainage: Anterior Abdominal Wall
Superficial lymphatic drainage Parasternal l.n.

• Accompany the superficial veins

ABOVE the umbilicus → Axillary lymph nodes

Axillary l.n.
BELOW the umbilicus → Superficial inguinal lymph nodes

Anterior
diaphragmatic l.n.
Deep lymphatic drainage
Level of the
• Accompany the deep veins umbilicus

Typically drain to the external iliac lymph

nodes first Superficial
inguinal l.n.
External iliac → Common iliac → Lumbar →
Cisterna chyli → Thoracic duct
28
 Innervation: Anterior Abdominal Wall
The anterior abdominal wall is
innervated by the
anterior rami
of spinal nerves T7 to L1:
• Intercostal nerves travel in the
neurovascular plane between
internal and innermost intercostal mm. Posterior Anterior
ramus ramus
• When the intercostal nerves pass the
costal margin, they change name to
thoracoabdominal nerves
and typically travel in the
neurovascular plane between
internal oblique and transversus
abdominis mm.
29
 Thoracoabdominal Nerves
T7 - T11:
Thoracoabdominal nerves
enter the abdominal wall
at the costal margin

T12:
Subcostal nerve runs
under the 12th rib
• General somatic efferent (GSE) axons
carry motor information to initiate
L1: contraction of muscle fibers
Divides to form
• Iliohypogastric nerve • General somatic afferent (GSA) axons
carry sensory information from the
• Ilioinguinal nerve skin
→ Lateral cutaneous nerves
→ Anterior cutaneous nerves
30
 Review: Anterior Abdominal Wall
Rectus abdominis m.

External oblique m.

Costal cartilage
Posterior rectus sheath
Linea alba
Internal oblique m.
Linea semilunaris
Thoracoabdominal n. (T10)
Tendinous intersection
Transversus abdominis m.
Iliac tubercle
Arcuate line
Anterior superior
iliac spine Inferior epigastric artery

Transversalis fascia
Inguinal ligament

31
 Transumbilical Plane
L1
Umbilicus is often used as a key landmark: Costal margin

L3
• Dermatome T10
Iliac crest
L5
Iliac tubercle
• Vertebral level L3/L4 (widest part of
iliac crest)

Anterior superior
• Midline iliac spine

• Incision site
Pubic tubercle
(e.g. for breast augmentation)
32
 Why is it useful to divide the abdomen
into distinct areas?

Abdominal Abdominal
Quadrants Regions
33
 Abdominal Quadrants
The 4 abdominal
quadrants are divided
according to two lines 2

1. Transumbilical plane: Right Upper Left Upper

• Horizontal line through Quadrant Quadrant
the umbilicus
• Divides into upper and lower 1

2. Median plane:
• Vertical line through Right Lower Left Lower
the midline Quadrant Quadrant
• Divides into right and left
34
 Reference: Right Upper Left Upper
Overview of Quadrants Quadrant Quadrant
• Liver • Liver
• Gallbladder • Spleen
• Stomach: Pylorus • Pancreas: Body & Tail
• Pancreas: Head • Left kidney
• Small intestine: Duodenum • Left adrenal gland
RUQ LUQ • Right colic flexure • Abdominal esophagus
• Ascending colon • Stomach
• Transverse colon • Small intestine: Jejunum
• Right kidney • Left colic flexure
RLQ LLQ • Right adrenal gland • Transverse colon
• Descending colon

Right Lower Left Lower

Quadrant Quadrant
• Small intestine: Ileum • Small intestine: Jejunum & ileum
• Cecum • Descending colon
• Appendix • Sigmoid colon
• Ascending colon • Rectum
LUQ RUQ • Urinary bladder • Urinary bladder
• Uterus • Uterus
• Right ovary and uterine tube • Left ovary and uterine tube
LLQ RLQ • Prostate • Prostate
• Right seminal vesicle and vas deferens • Left seminal vesicle and vas deferens
35
 Abdominal Regions
The 9 abdominal regions are divided
according to four lines
A. Midclavicular planes:
A A
• Two vertical lines through the midpoint of each clavicle
• Divides into right, midline and left

B. Subcostal plane - L3: b

B
• One horizontal line at the lowest point of the costal margin
• Alternatively, some definitions use the transpyloric plane instead (L1)
→ denoted by the dashed line labeled b which transects the pylorus of the stomach

c
C
C. Transtubercular plane - L5:
• One horizontal line through the iliac tubercles
• Alternatively, some definitions use the interspinous plane instead (S1)
→ denoted by the dashed line labeled c which transects each ASIS
36
 Abdominal Regions
Epigastric
Region

Right Hypochondriac Left Hypochondriac

Region Region

Right Lumbar Umbilical Left Lumbar

Region Region
Region

Right Iliac Left Iliac

Region Region

Hypogastric
Region 37
 Reference: Right Hypochondriac Epigastric Left Hypochondriac
Overview of Regions Region Region Region
• Liver • Abdominal esophagus • Stomach
• Gallbladder • Stomach • Liver (tip)
• Right kidney • Pancreas • Gallbladder
• Right colic flexure • Small intestine • Spleen
(ascending & transverse colon) • Liver • Pancreas (tail)
• Gallbladder • Left kidney
• Right and left kidneys • Left colic flexure
• Right and left adrenal glands (transverse & descending colon)

Right Lumbar Umbilical Left Lumbar

Region Region Region
RH E LH • Liver • Stomach • Left kidney
• Gallbladder • Pancreas • Descending colon
• Right kidney • Transverse colon • Small intestine
• Ascending colon • Small intestines
• Small intestine • Right and left kidneys
RL U LL
Right Iliac / Right Inguinal Hypogastric / Suprapubic Left Iliac / Left Inguinal
Region Region Region
RI H LI
• Small intestine • Small intestine • Descending colon
• Appendix • Sigmoid colon • Sigmoid colon
• Cecum • Rectum • Small intestine
• Ascending colon • Urinary bladder • Left ovary and uterine tube
• Right ovary and uterine • Uterus, ovaries & uterine tubes
tube • Prostate, seminal vesicles &
vas deferens 38
 Preview: Abdominal Organs

Transverse section at Transverse section at

T12 vertebral level L3/L4 vertebral level 39
 Preview: Gastrointestinal Tract a.k.a. “GI” tract
• Oral cavity
• Esophagus
• Stomach
• Duodenum
➢ Liver
Trachea
➢ Biliary apparatus
➢ Pancreas
 Spleen Left lung

• Jejunum
• Ileum Diaphragm
• Cecum
➢ Appendix
• Ascending colon
• Transverse colon
• Descending colon
• Sigmoid colon

“Alimentary” • Rectum
Relating to nourishment/nutrition • Anus 40
 Clinical
Correlates

41
 Preview: Palpation of the Abdomen
The muscles of the anterior abdominal wall play a vital role in the
physical examination of a patient
Guarding:
• Voluntary contraction of the abdominal wall
• Often accompanied by a grimace, however, this may diminish if the patient is distracted

Rigidity:
• Involuntary reflex contraction of the abdominal wall from inflammation of the peritoneum

42
 McBurney’s Point
Umbilicus
1. Initial appendicitis:
• When secretions of the appendix become trapped, the
appendix swells and stretches the VISCERAL peritoneum
covering this intraperitoneal organ
• General visceral afferent (GVA) axons enter the spinal
cord at the T10 vertebral level
• Vauge pain is referred to the peri-umbilical region!

2. Acute appendicitis:
• When appendicitis progresses, the inflammation
becomes transmural and irritates the PARIETAL
peritoneum
• General somatic afferent (GSA) axons (supplying the muscles
and skin) localize the pain at McBurney’s point:
Anterior
→ Indicates the base of the appendix superior iliac
→ 1/3rd of the way from ASIS to umbilicus spine
→ Right Lower Quadrant (RLQ)
 Abdominal Incision Sites
Median / Midline
Muscle-splitting • No muscle damage
• Also known as McBurney Gridiron • No nerve damage
• Minimal muscle damage
Left paramedian
• Nerves most at risk of damage:
• Access to lateral organs
• Iliohypogastric n.
• Closure is more secure
• Ilioinguinal n.
• Risks nerve damage
Subcostal
Laparoscopic • Gallbladder
• Several small incisions for • Spleen
equipment
Transverse / Oblique
• Minimal blood loss
• Children
• Obese
• Less risk of nerve damage
Suprapubic
• Also known as Pfannenstiel
• Cesarean section 44
• Hysterectomy
Rectus Sheath Hematoma
Damage to the inferior or superior
epigastric arteries
could result in blood accumulating in
the rectus sheath

Potential Symptoms:
▪ Sudden, acute abdominal pain and swelling
▪ Fever
▪ Nausea
▪ Vomiting (a.k.a. emesis)
▪ Palpable mass

Not all patients will have visible bruising on their abdomen!

45
Template: Right Upper Left Upper
Quadrants Quadrant Quadrant
• Liver • Liver
• Gallbladder • Spleen
• Stomach: Pylorus • Pancreas: Body & Tail
• Pancreas: Head • Left kidney
• Small intestine: Duodenum • Left adrenal gland
• Right colic flexure • Abdominal esophagus
• Ascending colon • Stomach
• Transverse colon • Small intestine: Jejunum
• Right kidney • Left colic flexure
• Right adrenal gland • Transverse colon
Anterior view • Descending colon

Right Lower Left Lower

Quadrant Quadrant
• Small intestine: Ileum • Small intestine: Jejunum & ileum
• Cecum • Descending colon
• Appendix • Sigmoid colon
• Ascending colon • Rectum
• Urinary bladder • Urinary bladder
• Uterus • Uterus
• Right ovary and uterine tube • Left ovary and uterine tube
• Prostate • Prostate
• Right seminal vesicle and vas deferens • Left seminal vesicle and vas deferens
Posterior view 46
Template: Right Hypochondriac
Region
Epigastric
Region
Left Hypochondriac
Region
Regions • Liver • Abdominal esophagus • Stomach
• Gallbladder • Stomach • Liver (tip)
• Right kidney • Pancreas • Gallbladder
• Right colic flexure • Small intestine • Spleen
(ascending & transverse colon) • Liver • Pancreas (tail)
• Gallbladder • Left kidney
• Right and left kidneys • Left colic flexure
• Right and left adrenal glands (transverse & descending colon)

Right Lumbar Umbilical Left Lumbar

Region Region Region
• Liver • Stomach • Left kidney
• Gallbladder • Pancreas • Descending colon
• Right kidney • Transverse colon • Small intestine
• Ascending colon • Small intestines
• Small intestine • Right and left kidneys

Right Iliac / Right Inguinal Hypogastric / Suprapubic
Region Region
• Small intestine • Small intestine
• Appendix • Sigmoid colon
• Cecum • Rectum
• Ascending colon • Urinary bladder
• Right ovary and uterine • Uterus, ovaries & uterine tubes
tube • Prostate, seminal vesicles &
vas deferens
Left Iliac / Left Inguinal
Region
• Descending colon
• Sigmoid colon
• Small intestine
• Left ovary and uterine tube
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