ABDOMINAL WALL
Subcostal and Lumbar Arteries
Layers of the Abdomen
●
1
Skin
2
Subcutaneous Tissue
3
Superficial Fascia
4
External Oblique
5
Internal Oblique
6
Transversus Abdominis
7
Transversalis Fascia
8
Peritoneal Adipose and Areolar Tissue
9
Peritoneum
●
Motor
Derived From
Superior Epigastric Artery
ITA: Internal
Thoracic Artery
Inferior Epigastric Artery
EIA: External Iliac
Artery
Anterior rami of
spinal nerves at
T6 to T12
Trasversus Abdominis
>Begins at: costal
margin & lumbar fascia
>Inserts: linea alba,
xiphoid process, pubic
symphisis
Sensor
y
Skin
Afferent
branches of
T4 to L1
T10 (umbilicus)
●
👐🏽
Arterial Supply
Rectus
Oblique
Internal - orig fr
thoracolumbar fascia
Surgical Anatomy
Abdominal wall comes from the mesoderm
●
Rectus abdominis muscles inserts from
●
Superior: 5th/6th ribs, 7th coastal cartilages, xiphoid
○
process
Inferior: pubic bones
○
Lateral: linea semilunaris
○
Muscles lateral to the rectus sheath
●
External Oblique - INFEROMEDIALLY (hands in pocket
○
)
Internal Oblique - SUPEROMEDIALLY (arms crossed
○
chest
)
Transversus Abdominis - runs from the
○
lower 6 ribs
■
lumbosacral fascia
■
iliac crest
■
lateral border of the rectus abdominis
■
Blood Supply
●
🤝
Lymphatic Drainage
Superficial Inguinal Lymph Nodes
○
Axillary Lymph Nodes
○
Innervation
SEGMENTAL INNERVATION: Anterior Abdominal Wall
○
Physiology
Rectus and Obliques - anteriorly and laterally
○
Trunk Rotation - contraction of
○
Unilateral External Oblique
■
Contralateral Internal Oblique
■
Valsalva Maneuver
○
Abdomen and diaphragm - (+) contracted
■
abdominal pressure which aids in
■
Micturition
●
Defecation
●
Childbirth
●
Schwartz Abdominal Wall
⬆️
●
Fascial Layers
External
Oblique
Aponeurosis
Throughout its length Anterior Rectus
Sheath
Internal
Oblique
Aponeurosis
Above arcuate line: Anterior and
Posterior Rectus Sheath
Below Arcuate Line: Only Anterior
Rectus Sheath
Transversus
Abdominis
●
PRIMARY SUTURE REPAIR
Less than 2 cm diameter
○
PROSTHETIC MESH VIA OPEN OR LAP TECH
●
Greater than 2 cm
○
Surgical treatment is offered to adults if
●
Hernia is enlarged
○
(+) Symptoms; pain
○
Incarceration occurs
○
In adults, umbilical hernias form because of:
Increased abdominal pressure due to pregnancy,
●
obesity, or ascites
Female > Male
●
Surgery: pain, increases in size, incarcerates
●
Above Arcuate line: Posterior Rectus
Sheath
Below Arcuate line: Anterior rectus
sheath
●
Therefore, below the arcuate line, all the aponeurotic layers of the lateral
musculature form the anterior sheath, leaving the transversalis fascia as
the only posterior fascial covering. This layer is a weak fibrous layer
separated from the peritoneum by preperitoneal fat,
ABDOMINAL WALL HERNIAS
Protrusion on intra-abdominal or pre-peritoneal contents
●
Reducible - reduces spontaneously
○
Incarcerated - requires surgical correction
○
Pain, nausea, vomiting
■
Incarcerated intestine may cause bowel obstruction
■
Strangulated - compromised blood supply
○
May lead to localized ischemia > infarction >
■
perforation
Contributing Factors:
●
obesity
○
primary wound healing defects
○
multiple prior procedures
○
prior incisional hernias
○
💗
🤎
B.
Incisional Hernias (most common)
Incisional hernias mean these are hernias that develop at sites of
previous abdominal incisions
Repair
Primary Closure
Repair by simple suture for <3cm defect
with high recurrence rate
RF:
primary suture repair
●
post-op wound infection
●
prostate problems
●
surgery for abdominal aortic
●
aneurysm
Mesh Closure
Onlay - Superficial to the fascial defect
Onlay
Interlay
Underlay
Interlay - Bridging the gap between defect
edges or within abdominal wall
musculoaponeurotic layer
💚
A.
Epigastric
Loc: midline between xiphoid process and umbilicus
May be congenital and due to a defective midline fusion
RF: muscle weakness, congenitally weakened epigastric facsia
or increase abdominal pressure
Repair is for symptomatic patients only
Spigelian
Loc: Spigelian line or zone (linea semilunaris)
Most frequent location is at/above ‘arcuate line’ (⅓ from the
pubic crest to the umbilicus)
This ccurs due to anatomic weakness of lack of a posterior
sheath below the arcuate line
(+) pain and swelling of the mid to lower abdomen
Umbilical
Underlay - Deep to the fascial defect
Primary Ventral Hernias (Non-Incisional)
Loc: at the umbilicus; thes may be congenital or acquired
Most congenital umbilical hernias - closes by 5 years old
Indications for repair: incarceration, symptomatic hernia,
failure to decrease in size, fails to close 5 years old
Surgical Treatment:
Mesh Implants
Treatment
Components
Separation
Decreases suture line tension
Creates
1.
large subcutaneous flaps lateral
to the fascial defect
2.
Bilateral Incision of the external
oblique aponeurosis
3.
Bilateral Incision of the posterior
rectus sheath
Permanent
Prolene, Propylene, and Polyester - better,
sturdier, more permanent, and durable
Biologic and
Absorbable
High recurrence rate, (+) contamination
Composite
Used during intra-peritoneal repairs
Open Repair
Primary vs. Mesh Repair
Laparoscopic
Repair
Robotic Assisted
Less wound infection, smaller incision,
lower recurrence
eliminates repeated abdominal incisions
improves detection of 2ndary defects
endoscopic component separation
Adv: see defect from the
●
posterior area that you can not
see in open surgery
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