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Anatomy of Anterior abdominal muscles
1.
2. MOB TCD
Anterior Abdominal Muscles
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
3. MOB TCD
Anterior Abdominal Wall
• The muscles of the anterior
abdominal wall play a major role
in movements of the trunk
• Protecting the abdominal organs
• Increase the intra-abdominal
pressure, aid in expiration and
all straining activities such as
micturition, coughing and
vomiting
• Supplied by lower five intercostal
and subcostal nerves
4. MOB TCD
Anterior Abdominal Muscles
• Strong abdominals are important in
helping to stabilise the trunk
• Support the spine
• They flex and rotate the trunk
• Acting with the adductors and
abductors of the hip
• They help to stabilise the pelvis
during walking and running
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Anterior Abdominal Wall
• Superficial fatty layer
• Membranous layer of
superficial fascia
• Below umbilicus
• Continuous with Colles’
fascia in the perineum
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Skin of Anterior Abdominal Wall
• Lower five intercostal nerves
• Subcostal nerve T12
• 10th intercostal nerve is at the
level of the umbilicus
• Iliohypogastric nerve L1
• Ilioinguinal nerve L1
7. MOB TCD
Blood Supply and Lymphatics
• Intercostal vessels
• Skin above umbilicus
superficial veins and
lymphatics drain to axilla
• Skin below umbilicus
superficial veins and
lymphatics drain to long
saphenous vein
• Superficial inguinal glands
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Inguinal Glands
• Proximal group parallel to
inguinal ligament
• Enlarged tender inguinal
glands
• Part of a generalised
lymphadenopathy
• Secondaries
9. MOB TCD
Inguinal Glands
• Proximal group
• Lesions in local structures
• Skin of lower anterior
abdominal wall
• Gluteal region
• Skin of scrotum or labia
Distal superficial glands
• Skin of leg area drained by
long saphenous vein
• All drain to deep inguinal
glands along femoral vein
11. MOB TCD
External Oblique
• Origin
• Outer surfaces lower
borders lower eight ribs
• Interdigitating with serratus
anterior and latissimus dorsi
• Fibres pass medially and
inferiorly
12. MOB TCD
External Oblique Insertion
• Inserted into anterior half of
anterior two thirds outer lip
of iliac crest
• Aponeurosis in the inguinal
region passes anterior to
rectus muscle
• Forms the inguinal ligament
• Lacunar ligament
• Reflected portion of inguinal
ligament
13. MOB TCD
Inguinal and Lacunar Ligaments
• Inguinal ligament
aponeurosis is folded
back from anterior
superior iliac spine to
pubic tubercle to form
inguinal ligament
• Lacunar ligament
triangular, attached to
pectineal line. lateral
free border medial
margin of femoral ring
14. MOB TCD
Insertion External Oblique
• Pubic crest
• Gap for superficial
inguinal ring
• Pubic bone
• Linea alba
• Anterior wall of the
rectus sheath
• Zyphoid process
15. MOB TCD
External Oblique
• Acting separately
• The external oblique flexes the
vertebral column laterally and
rotates it to the opposite side
• If the thorax is fixed by
contracting both external
obliques, you can tilt the
symphysis pubis superiorly and
flex the trunk, posterior pelvic tilt
• Movement of the iliac crests
determines the direction of the tilt
16. MOB TCD
Internal Oblique
• Muscular origin lateral two
thirds of inguinal ligament
• Anterior two thirds
intermediate lip of iliac
crest
• Lumbar fascia
• Muscular fibres arch over
contents of inguinal canal
anterior to rectus muscle
• Fibres pass medially and
superiorly
17. MOB TCD
Insertion Internal Oblique
• Into coastal margin, upper three
as fleshy fibres
• Next three as aponeurotic
• Inserted into linea alba
• Between zyphoid and half way
between umbilicus and pubic
symphysis aponeurosis splits
• Anterior layer fuses with
external oblique
• Posterior layer fuses with
transversus
18. MOB TCD
Internal Oblique Conjoint Tendon
• Half way between umbilicus
and pubic symphysis
• Aponeurosis of the internal
oblique and transversus
fuse to form conjoint tendon
• Anterior portion of rectus
sheath
• Inserted into pectineal line
behind superficial inguinal
ring
19. MOB TCD
Internal Oblique
• The right side of the muscle
twists to the right and the left
side twists to the left
• The lower six intercostals nerve
• Subcostal nerve
• Iliohypogastric nerves
20. MOB TCD
Transversus Abdominus
• Origin
• Lateral one third of inguinal
ligament
• Anterior two thirds of inner lip of
iliac crest
• Lumbar fascia
• Lower border and inner
surfaces lower six ribs
interdigitating with diaphragm
21. MOB TCD
Insertion Transversus Abdominus
• Into zyphoid, linea alba
• Half way between umbilicus
and pubic symphysis
• Fuses with posterior lamella of
internal oblique
• Below forms conjoint tendon
• Inserted into pectineal line
behind superficial inguinal ring
22. MOB TCD
Transversus Abdominus
• The transversus abdominus
helps to support the abdominal
viscera
• Maintain intra-abdominal
pressure
• Stabilises the lumbar spine
• It is supplied by the lower six
intercostals nerves
• Subcostal nerves
• Iliohypogastric nerves
23. MOB TCD
Rectus Abdominus
•
•
•
•
•
Segmental muscle
Two heads
Anterior pubic symphysis
Pubic crest
Inserted anterior aspect of 5, 6, 7th
costal cartilages
• Adhesions anterior surface
• Segmental blood and nerve
supply from Intercostals
• The rectus abdominus flexes the trunk
24. MOB TCD
Rectus Abdominus
• The rectus muscles (recti)
are the most powerful
flexors of the vertebral
column
• When raising the head from
a supine position
• A movement often used to
strengthen the abdominals
• It is the recti that contract first
• When the shoulders start to rise upwards, the
obliques start to contract
25. MOB TCD
Rectus Sheath
• Above zyphoid
• Anterior wall is the external
oblique
• Posterior, costal cartilages
• From ziphoid and half way
between umbilicus and pubic
symphysis
• Anterior is external oblique and
anterior lamella of internal
oblique
• Posterior lamella internal
oblique and transversus
26. MOB TCD
Rectus Sheath
• Below half way between
umbilicus and pubic symphysis
• The aponeurosis of the
external oblique, internal
oblique and transversus
(conjoint tendon) pass anterior
to the rectus
• Posterior lies the transversalis
fascia
28. MOB TCD
Transversalis Fascia
• Lines deep aspect of
transversus abdominus
• Fuses with inguinal ligament
• Continuous with iliac fascia
• Except in the region of the
femoral vessels
• Forms anterior wall of
femoral sheath
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Extraperitoneal Tissue
• Extraperitoneal connective
tissue
• If fatty, it separates the
transversalis fascia from
the peritoneum
• If thin, they are in close
contact with one another
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Peritoneal Pouches
• Peritoneal pouches are
found in the region of the
deep inguinal ring
• Medial portion of the
posterior wall
Posterior aspect anterior
abdominal wall
31. MOB TCD
Inguinal Canal
• Intra muscular canal
• Lower portion of anterior
abdominal wall
From
• Deep inguinal ring
• Superficial inguinal ring
• Transmits spermatic cord
in male
• Round ligament in female
32. MOB TCD
Superficial Inguinal Ring
• Triangular opening in
aponeurosis of external
oblique
• Base, pubic crest
• Superior crus attached to
the pubic crest
• Inferior attached to pubic
tubercle
• External spermatic fascia
arises from its margins
33. MOB TCD
Deep Inguinal Ring
• Oval opening 2.5 cm
• Above the middle of inguinal
ligament
• Inferior epigastric artery
passes medial to the deep
ring
34. MOB TCD
Interfoveolar Ligament
• The interfoveolar ligament is
an inconstant band
• Medial to deep inguinal ring
• Anterior to inferior epigastric
vessels
• From lower margin of
transversus abdominus
• To pectineal line
McVay & Anson, 1949
37. MOB TCD
Roof of Inguinal Canal
• Roof
• Arching fibres of internal oblique
• Transversus as they both arise
from the inguinal ligament
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Floor of Inguinal Canal
• Floor
• Inguinal ligament
forms whole of floor
• Medial half by the
lacunar ligament
• Reflected part of
inguinal ligament
forms medial
quarter
39. MOB TCD
Passing Through Deep Ring Male
•
•
•
•
•
Vas Deferens
Testicular artery
Pampiniform plexus of veins
Remains of processus vaginalis
Genital branch of genitofemoral
nerve
• Lymphatics from testes
• Cremaster artery
40. Passing through
Superficial Ring Male
• Everything that went through
deep ring
• Plus
• Ilioinguinal nerve
• Internal spermatic fascia from
margins of the deep ring
• Cremaster muscle and fascia
MOB TCD
41. Passing through
Deep Ring Female
• Round ligament of uterus
• Remains of processus vaginalis
• Genital branch of genitofemoral
nerve
• Lymphatics from uterus, region
of cornu
MOB TCD
43. MOB TCD
Inguinal Canal
• Contraction of the
abdominal muscles
increases the obliquity of
the inguinal canal
• Protecting the two rings
Lytle, 1945
44. MOB TCD
Increase in Intra-Abdominal Pressure
• Pain aggravated by an
increase in intraabdominal pressure
• Hernia
• Inguinal or femoral hernia
• Entrapment of the
ilioinguinal nerve
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Hernia
• Chronic pain in the groin in an
athlete may be due to a hernia
or a potential hernia
46. MOB TCD
Inguinal Hernia
• Sudden severe pain in
lower abdomen
• Associated with lifting a
heavy object
• Common history of a
direct inguinal hernia
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Indirect Inguinal Hernia
• Passes through
• Deep inguinal ring
• May extend to pass
through the superficial
ring into the scrotum
• Congenital or acquired
• Congenital inside the
tunica vaginalis (serous
membrane, covers part
of testes)
• Acquired outside
48. MOB TCD
Direct Inguinal Hernia
• Enters through posterior wall
of the inguinal canal
• Leaves through superficial
inguinal ring
• Above and medial to the pubic
tubercle
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Inguinal Versus Femoral Hernia
• Inguinal hernia above
and medial to pubic
tubercle
• Femoral hernia below
and lateral to the
tubercle
• More common in
females and more likely
to strangulate
54. MOB TCD
Saphenous Varix
• Swelling is soft and
diffuse
• Empties on minimal
pressure
• Refills on release
• Cough impulse is
present
55. MOB TCD
Gilmore’s Groin
• Common cause of chronic
groin pain in field sports
• Particularly soccer players
• Pain on any sudden change
of movement, sneezing,
coughing
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Gilmore’s Groin
• Trying to sprint
• Will increase the pain
• Pain is worse getting out of
bed
• The day after a match or a
training session
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Gilmore’s Groin
• Pain is increased by
external rotation
• Or hyperextension of hip
• Pain is localised to lower
anterior abdominal wall
• Adductor or perineal
region
58. MOB TCD
Gilmore’s Groin
• Torn external oblique
aponeurosis
• Torn conjoint tendon
• A dehiscence between
conjoint tendon and the
inguinal ligament
• The absence of a hernial sac
• Superficial inguinal ring on the
affected side is dilated and
tender
• Cough impulse
59. MOB TCD
Gilmore’s Groin Surgery
• Treatment is surgical
• 90% return to sport
• Strengthen lower
abdominal muscles
1. Plication of the
transversalis fascia in
“Shouldice hernia repair”
2. Repair of torn conjoint
tendon
60. MOB TCD
Gilmore’s Groin Surgery
3. Approximation of conjoint
tendon to the inguinal
ligament
4. Repair of the external
oblique
5. Reconstitution of the
superficial inguinal ring