Abdomen, Pelvis and Perineum

ANA 301
Course Outline
• Anterior abdominal wall (femoral and inguinal hernias)
• Peritoneal reflections and mesenteries
• Esophagus and stomach
• Small intestine
• Cecum, appendix, colon, anal canal and rectum
• Liver, gallbladder, biliary tracts
• Vasculature of the abdomen (portocaval system)
• Pancreas and spleen
• Posterior abdominal wall – kidney and adrenal gland
• Lumbar plexus and sacral plexus
• Osteology of the pelvis (sex differences / clinical importance)
• Pelvis and perineum
• Levator ani muscles
• Male internal and external genitalia
• Female internal and external genitalia 2
Abdomen
• Part of the trunk between the thorax and the pelvis.
• Houses organs of the alimentary system and part of
the urogenital system.
• Containment of these organs and their contents is
provided by musculo-aponeurotic walls
anterolaterally, the diaphragm superiorly, and the
muscles of the pelvis inferiorly.
• Anterolateral musculo-aponeurotic walls are
suspended by the inferior margin of the thoracic
skeleton superiorly and the pelvic girdle inferiorly
and lumbar vertebral column in the posterior
abdominal wall. 3
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Overview of viscera of thorax and abdomen 5
• Musculo-aponeurotic abdominal walls contract to
increase intra-abdominal pressure and distend to
accommodate expansions

• Anterolateral abdominal wall (AAW) and several

organs lying against the posterior wall are covered
on their internal aspects with serosa that reflects
onto the abdominal viscera.

• Peritoneal cavity is formed between the walls and

the viscera

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Abdominal cavity
• Forms the superior and major part of the
abdominopelvic cavity
• Extends between the thoracic diaphragm and pelvic
diaphragm.
• Extends to the 4th intercostal space.
• Superiorly placed abdominal organs (spleen, liver,
part of the kidneys, and stomach) are protected by
the thoracic cage.
• Greater pelvis (expanded part of the pelvis superior
to the pelvic inlet) supports and protects the lower
abdominal viscera (part of the ileum, cecum,
appendix, and sigmoid colon). 7
 9 Regions
• Four planes: two sagittal and two transverse planes.
• Two sagittal planes are the midclavicular planes that pass
from the midpoint of the clavicles to the midinguinal
points.
• Two transverse planes are the subcostal plane, passing
through the inferior border of the 10th costal cartilage on
each side and behind through the upper part of L3
• Transpyloric plane passes through the tips of the ninth
costal cartilages at the lower border of L1
• Transtubercular plane, passing through the iliac tubercles
and the body of L5 vertebra.
• Interspinous plane passes through the ASIS on each side.
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Vertebral levels of important abdominal planes
• Transpyloric plane: lower border of L1 vertebra

• Subcostal plane: upper part of body of L3 vertebra

• Plane passing through the highest point of iliac

crest: L4

• Intertubercular plane: upper part of the body of L5

• Transtubercular plane, passing through the iliac

tubercles and the body of L5 vertebra. 9
Structures present at the transpyloric plane
Midway between the superior borders of the manubrium
of the sternum and the pubic symphysis (L1 vertebral level),
• Pylorus of stomach
• Neck of pancreas
• Duodeno-jejunal flexure
• Fundus of gallbladder
• Hilum of kidneys
• Origin of superior mesenteric artery
• Tip of ninth costal cartilage
• Termination of the spinal cord
• Origin of hepatic portal vein
• Root of the transverse mesocolon
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Four quadrants of the abdominal cavity defined by
two planes:

• Transumbilical plane, passing through the umbilicus

(and the intervertebral [IV] disc between the L3 and
L4 vertebrae), dividing it into upper and lower
halves

• Median plane, passing longitudinally through the

body, dividing it into right and left halves.

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• Abdominal wall is subdivided into the anterior wall,
right and left lateral walls, and posterior wall
• Boundary between the anterior and lateral walls is
indefinite, therefore the term anterolateral
abdominal wall.
- Bounded superiorly by the cartilages of the 7th–
10th ribs and the xiphoid process of the sternum
- Bounded inferiorly by the inguinal ligament and the
superior margins of the anterolateral aspects of the
pelvic girdle
- Consists of skin and subcutaneous tissue
- Three musculotendinous layers.
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Subdivisions of
the
anterior
abdominal wall

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Superficial Fascia of the Anterolateral Abdominal Wall
• Major site of fat storage, fat forms sagging folds
(panniculi).
• 2 layers inferior to the umbilicus:
- Superficial fatty layer (Camper fascia).
- Deep membranous layer (Scarpa fascia).
• Membranous layer continues into the perineal region
as the superficial perineal fascia (Colles fascia).

• Internal aspect of AAW constitute endoabdominal

fascia.
• Transversalis fascia lines transversus abdominis muscle
and its aponeurosis 16
Muscles of Anterolateral Abdominal Wall
• Five (bilaterally paired) muscles in the AAW: three flat muscles
and two vertical muscles.
• Flat muscles are the external oblique, internal oblique, and
transversus abdominis.
• Fibers of the outer two layers runs diagonally and perpendicular
to each other, and the fibers of the deep layer runs transversely.
• Between the midclavicular line and the midline, the
aponeuroses form the rectus sheath enclosing the rectus
abdominis muscle.
• Aponeuroses interweave with their fellows of the opposite side,
forming the linea alba extends from the xiphoid process to the
pubic symphysis.
• Contained within the rectus sheath, are rectus abdominis and
the pyramidalis.
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Layers of AAW
• Skin
• Superficial fascia
• Outer fatty layer (Camper’s fascia)
• Inner membranous layer (Scarpa’s fascia)
• Muscles
• Fascia transversalis
• Extraperitoneal tissue
• Peritoneum (parietal layer)
No deep fascia in the AAW

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Layers of the anterior abdominal wall

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EXTERNAL OBLIQUE MUSCLE
• Largest and most superficial of the three flat AAW
muscles.
• Fibers run inferomedially, approaching a horizontal
course.
• Muscle fibers become aponeurotic at the MCL
decussating at the linea alba
• Contralateral external and internal oblique muscles form
a “digastric muscle”
• Inferiorly, it attaches to the pubic crest medial to the
pubic tubercle.
• Inferior margin is thickened and spans between the ASIS
and the pubic tubercle as the inguinal ligament (Poupart
ligament). 20
Internal oblique
• A thin muscular sheet that fans out anteromedially.

• Fibers run perpendicular to those of the external

oblique

• Fibers also become aponeurotic at the MCL and

participate in the formation of the rectus sheath.

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TRANSVERSUS ABDOMINIS MUSCLE
• Innermost of the three flat abdominal muscles

• Runs transversally

• Fibers end in an aponeurosis, which contributes to

the formation of the rectus sheath.

• Between the internal oblique and the transversus

abdominis muscles is a neurovascular plane
containing the nerves and arteries supplying the
AAW.
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RECTUS ABDOMINIS MUSCLE
• A long, broad, strap-like muscle

• Principal vertical muscle of the AAW

• Paired rectus muscles and separated by the linea

alba.

• Broad and thin superiorly and narrow and thick

inferiorly.

• Enclosed in the rectus sheath. 23

PYRAMIDALIS
• Small, triangular muscle
• Absent in approximately 20% of people.
• Lies anterior to the inferior part of the rectus
abdominis and attaches to the anterior surface of
the pubis and the anterior pubic ligament.
• Ends in the linea alba
• Tenses the linea alba.
• When present, surgeons use the attachment of the
pyramidalis to the linea alba as a landmark for
median abdominal incision.
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RECTUS SHEATH, LINEA ALBA, AND UMBILICAL RING
Rectus sheath
• Compartment of the rectus abdominis and pyramidalis
muscles.
• Contains superior and inferior epigastric arteries and veins,
lymphatic vessels and abdominal portions of the anterior
rami of spinal nerves T7–T12.
• Formed by the decussation and interweaving of the
aponeuroses of the flat abdominal muscles.
Arcuate line
• Demarcates the transition between the posterior wall of
the sheath covering the superior three quarters of the
rectus and the transversalis fascia covering the inferior
quarter.
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Contents of the rectus sheath
• Muscles
- Rectus abdominis
- Pyramidalis

• Blood vessels
- Superior and inferior epigastric vessels

• Nerves
- Terminal part of five intercostal nerves
- Subcostal nerves
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FUNCTIONS OF ANTEROLATERAL ABDOMINAL
MUSCLES
• Support the abdominal viscera and protect them
from most injuries.
• Help in forced expiration during coughing, sneezing,
vomiting
• Compress the abdominal contents to maintain or
increase the intra-abdominal pressure helping in
micturition and parturition
• Move (rotate and flex) the trunk and maintain
posture.
• Depress the ribcage
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Linea alba
• Avascular fibrotendinous raphe formed by the
interlacing fibers of the aponeurosis of the three
lateral muscles of the AAW
• Extends from the xiphoid process to the pubic
symphysis
Linea semilunaris
• Curved fibrous line at the lateral margin of the
rectus sheath that extends from the tip of the ninth
costal cartilage to the pubic symphysis

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Umbilicus
• Depressed scar in the midline of AAW, between xiphoid
process and pubic symphysis or between L3 and L4
• Site of attachment of the fetal end of the umbilical cord
• Innervated by T10 spinal segment
• Acts as a water-shed line with respect to lymph and
venous flow
• Sites of portocaval anastomosis
• Fibrous cords attach to the inner aspect of umbilicus:
- Ligamentum teres hepatitis: remnant of left umbilical vein
- Median umbilical ligament (urachus) remnant of allantois
- Medial umbilical ligaments: remnant of umbilical arteries
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Neurovasculature of Anterolateral Abdominal Wall
• DERMATOMES OF ANTEROLATERAL ABDOMINAL WALL
• Anterior rami of spinal nerves T7–T12
• Dermatome T10 includes the umbilicus, whereas
dermatome L1 includes the inguinal fold.
NERVES OF ANTEROLATERAL ABDOMINAL WALL
Skin and muscles of AAW are supplied by:
• Thoraco-abdominal nerves: Anterior rami of the inferior six
thoracic spinal nerves (T7–T11)
• Anterior and Lateral (thoracic) cutaneous branches:
thoracic spinal nerves T7–T9 or T10.
• Subcostal nerve: anterior ramus of spinal nerve T12.
• Iliohypogastric and ilio-inguinal nerves: terminal branches
of the anterior ramus of spinal nerve L1. 36
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Neurovasculature of the AAW

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Blood vessels of the AAW
• Superior epigastric vessels and branches of the
musculophrenic vessels from the internal thoracic
vessels.
• Inferior epigastric and deep circumflex iliac vessels
from the external iliac vessels.
• Superficial circumflex iliac and superficial epigastric
vessels from the femoral artery.
• Posterior intercostal vessels of the 11th intercostal
space and the anterior branches of subcostal vessels.
• Superior epigastric artery anastomoses with the
inferior epigastric artery approximately in the
umbilical region (rectus abdominis). 39
VESSELS OF ANTEROLATERAL ABDOMINAL WALL
• Drains superiorly to the internal thoracic vein medially and
the lateral thoracic vein laterally and inferiorly to the
superficial and inferior epigastric veins, tributaries of the
femoral and external iliac veins.
• Cutaneous veins surrounding the umbilicus anastomose
with para-umbilical veins and tributaries of the hepatic
portal vein.
• Thoraco -epigastric vein between the superficial epigastric
vein (a femoral vein tributary) and the lateral thoracic vein
(an axillary vein tributary).
• Anastomosis between the inferior epigastric vein (from
external iliac vein) and the superior epigastric/internal
thoracic veins (subclavian vein tributaries) afford collateral
circulation during blockage of either vena cava. 40
Lymphatic drainage
• Superficial lymphatic vessels accompany the
subcutaneous veins
- Those superior to the transumbilical plane drain to
the axillary lymph nodes
- A few drain to the parasternal lymph nodes.
- Superficial lymphatic vessels inferior to the
transumbilical plane drain to the superficial inguinal
lymph nodes.
• Deep lymphatic vessels accompany the deep veins of
the abdominal wall
- Drain to the external iliac, common iliac, and right
and left lumbar (caval and aortic) lymph nodes. 41
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Abdominal Hernias
• AAW may be the site of abdominal hernias
Umbilical hernias
• Common in neonates because the anterior abdominal
wall is weak in the umbilical ring.
• Small
• Result from increased intra-abdominal pressure in the
presence of weakness and incomplete closure of the
anterior abdominal wall after ligation of the umbilical cord
at birth.
Acquired umbilical hernias
• Occur most commonly in women and obese people.
• Extraperitoneal fat and/or peritoneum protrude into the
hernial sac. 43
INGUINAL HERNIA
• Protrusion of an organ or fascia through the walls
that normally contains it eg inguinal region of the
abdominal wall.

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Indirect inguinal hernia
• Commoner
• Pass through the deep inguinal ring into the inguinal canal,
emerge through the superficial inguinal ring into the scrotum
• Can be congenital due failure of processus vaginalis to regress or
acquired due to increased intraabdominal pressure during weight
lifting
• Peritoneal sacs and loops of bowel enter or expand the inguinal
canal through the deep inguinal ring (transversalis fascia)
• When the hernia reaches the scrotal sac it is complete and
remains in the canal and does not pass through the superficial
inguinal ring is said to be incomplete
• Neck of hernia sac lies lateral to the inferior epigastric vessels.
• Small hernias are covered by the spermatic cord, internal
spermatic fascia, external spermatic fascia and cremasteric muscle
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Direct inguinal hernia
• Peritoneal sac bulges into the inguinal canal via the posterior
wall into the Hesselbach’s triangle
• Caused by weakness of the inguinal triangle in the medial
posterior wall of the canal
• Neck of the hernia sac lies medial to the inferior epigastric
vessels.
• Acquired, usually in adulthood
• Extend through the anterior wall of the canal or superficial
ring.
• Protrude through the transversalis fascia, between the conjoint
tendon and the inferior epigastric vessels, and enter the
inguinal canal.
• Arise either between the fibres of the conjoint tendon
• Covered by external spermatic fascia. 46
Femoral hernia
• Protrudes through the femoral ring closed by a femoral
septum, a weak spot.
• Ring is large and subject to changes during pregnancy,
more common in women.
• Section of intestine bulges through the ring and descends
along the femoral canal to the saphenous opening.
• Coverings of a femoral hernia are: peritoneum, femoral
septum and sheath, cribriform fascia, superficial fascia
and skin.
• When intestine reaches only to the saphenous opening it
is incomplete femoral hernia.
• Site of strangulation may be at the neck of the hernial
sac; or it may be at the saphenous opening. 47
• Inguinal hernia emerges through the superficial
inguinal ring it lies above and medial to the pubic
tubercle

• While the neck of a femoral hernia is below and

lateral to the pubic tubercle.

• Pubic tubercle distinguishes inguinal from femoral

hernias

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Injury to Nerves of Anterolateral Abdominal Wall
• AAW is supplied by inferior thoracic spinal nerves
(T7–T12) and the iliohypogastric and ilio-inguinal
nerves (L1)

• This nerves are susceptible to injury in surgical

incisions or from trauma at any level of the
abdominal wall.

• Injury to these nerves may result in weakening of

the muscles predisposing to development of an
inguinal hernia.
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Abdominal Surgical Incisions
• Allows access to the abdominal cavity.
• Follow the cleavage lines (Langer lines) in the skin.
• Allows adequate exposure, and the best possible cosmetic
effect, is chosen.
• Surgeon avoids injury to motor nerves, maintenance of
blood supply, and minimizes injury to muscles and fascia of
the abdominal wall while aiming for favorable healing.
• Surgeon considers the direction of the muscle fibers and
the location of the aponeuroses and nerves.
• Muscles and viscera are retracted toward, not away from,
their neurovascular supply.
• Cutting a motor nerve paralyzes the muscle fibers supplied
by it, thereby weakening the anterolateral abdominal wall.
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LONGITUDINAL INCISIONS
• Median and paramedian incisions offer good
exposure and access to the viscera
• Median incisions can be made along any part or the
length of the linea alba from the xiphoid process to
pubic symphysis.
• Linea alba transmits only small vessels and nerves
to the skin
• Midline incision is relatively bloodless, and avoids
major nerves.
• Paramedian incisions (lateral to the median plane)
are made in a sagittal plane and may extend from
the costal margin to the pubic hairline. 51
Abdominal Incisions

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OBLIQUE AND TRANSVERSE INCISIONS
• Direction of oblique and transverse incisions is
related to muscle fiber orientation and minimizes
nerve damage.

• Gridiron (muscle-splitting) incisions are often used

for an appendectomy. Oblique McBurney incision is
made at the McBurney point, approximately 2.5 cm
superomedial to the ASIS on the spino-umbilical
line.

• Iliohypogastric nerve, running deep to the internal

oblique, is identified and preserved. 53
• Suprapubic (Pfannenstiel) incisions (“bikini”
incisions) are made at the pubic hairline. These
incisions—horizontal with a slight convexity—are
used for most gynecological and obstetrical
operations (e.g., for cesarean section).
- The iliohypogastric and ilio-inguinal nerves are
identified and preserved.

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• Transverse incisions through the anterior layer of
the rectus sheath and rectus abdominis provide
good access and cause the least damage to the
nerve supply of the rectus abdominis.

• Subcostal incisions provide access to the gallbladder

and biliary ducts on the right side and the spleen on
the left. The incision is made parallel but at least 2.5
cm inferior to the costal margin to avoid the 7th and
8th thoracic spinal nerves.

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HIGH-RISK INCISIONS
• Pararectus incisions along the lateral border of the
rectus sheath are undesirable because they may cut
the nerve supply to the rectus abdominis.
• Inguinal incisions for repairing hernias may injure
the ilio-inguinal nerve.
INCISIONAL HERNIA
• A protrusion of omentum or an organ through a
surgical incision.
• If the muscular and aponeurotic layers of the
abdomen do not heal properly, an incisional hernia
can result.
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