Superficial fascia of the abdomen

Layer of fatty connective tissue

Is a single layer that is continuous with the superficial fascia
throughout the body, however below the umbilicus , it forms two
layers: a superficial fatty layer and a deeper membranous layer
Campers Fascia: superficial fatty layer of superficial layer
contains fat and varies in thickness
o Continuous over inguinal ligament with the superficial
fascia of the thigh and with similar layer in the perineum
Scarpas Facia: thin and membranous; contains little or no fat
o Just below the inguinal ligmanet, it fuses with the deep
fascia of the thigh
o In the midline, it is firmly attached to the linea alba and the
symphysis pubis. It continues into the anterior part of the
perineum where it firmly attaches to the ischiopubic rami
and to the posterior margin of the perineal membrane
(referred to as Colles fascia)

Anterolateral Muscles

Three flat muscles whose fibers begin posterolaterally, pass

anteriorly and are replaced by an aponeurosis as the muscle
continues towards the midline
o External oblique, internal obliqUe and transversus
abdominis muscle.
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Two vertical muscles, near the midline, which are enclosed within
a tendinous sheat formed by the aponeurosis of the flat muscles
o Rectus abdominis and pyramidalis muscle
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All of these muscles form a firm and flexible wall that keeps the
abdominal viscera within the abdominal cavity
Contraction of these muscles assists in both quiet and forced
expiration ( by pushing the viscera upwards and in
coughing/vomiting) in addition to childbirth, urination and
defection.
External Oblique (innervated by anterior rami of lower six
thoracic spinal nerves T7 to T12): most superficial of all flat
muscles (3).
o Immediately deep to the superficial fascia
o Its laterally placed muscle fibers pass in an inferomedial
direction, while its large aponeurotic component covers the

anterior part of the abdominal wall to the midline forming

the linea alba which extends from the xiphoid process to
the public symphysis.
o Lower border of the external oblique aponeurosis forms the
inguinal ligament on each side, which passes between
the anterior superior iliac spine laterally and the pubic
tubercle medially.
From the inguinal ligament, we have several
extensions:
the lacunar ligament at the medial end that
passes backwards to attach to the pectin pubis
on the superior ramus of the pubic bone.
From the lacunar ligament, along the pectin
pubis, we have Coopers ligament
Internal oblique (Anterior rami of lower six thoracic spinal
nerves T7 to T12 and L1): is smaller and thinner than its
external counterpart and passes into the superomedial direction
(up and to the middle). Its aponeurosis blends into the linea alba
at the midline
Transversus abdominis (Anterior rami of lower six
thoracic spinal nerves T7 to T12 and L1): deepest of all
three flat muscles. It ends in an anterior aponeurosis, which
blends with the linea alba at the midline
Transversalis fascia : a fascia covers all three of the flat
muscles anteriorly and posteriorly. The one posterior to the
transversus abdominis muscle is the transversalis fascia, which
lines the abdominal cavity and continues into the pelvic cavity
Rectus Abdominis (Anterior rami of lower six thoracic
spinal nerves T7 to T12): long flat muscle that extends the
length of the anterior abdominal wall. It is separated at the
midline by the linea alba, and it widens and thins as it ascends
from the pubic symphysis to the costal margin. Along its course,
it is intersected by three or four transvers fibrous bands or
tendinous intersections.
Pyramidalis (Anterior ramus of T12): triangle muscle, which
may be absent, is anterior to the rectus abdominis, has its base
on the pubis, and its apex is attached superiorly and medially to
the linea alba, and it widens and thins as it ascends from the
pubic symphysis to the costal margin. Along its course, it is
intersected by three or four transverse fibrous bands or
tendinous intersections. Its apex is attached superiorly and
medially to the linea alba.
Rectus Sheath: a tendinous sheat formed by a unique layering
of the aponeuroses of the external and internal oblique, and
transversus abdominis muscles

o It encloses the upper of the rectus abdominis and covers

the anterior surface of the lower of the muscle. There is
no sheath covering theposterior surface of the lower
quarter, so the muscle connects directly with the
transversalis fascia.
o The formation of the rectus sheat surrounding the upper
of the rectus abdominis muscle has the following pattern:
Anterior wall: aponeurosis of the external oblique and
half of the aponeurosis of the internal oblique, which
splits at the lateral margin of the rectus abdominus
Posterior wall: consists of the other half of the
internal oblique aponeurosis and the aponeurosis of
the transversus abdominis
At a point between the umbilicus and pubic
symphysis, all aponeuroses move anterior to the
rectus muscle from this point, the rectus abdominis
muscle is in direct contact with the transversalis
fascia marking the arcuate line.
Arcuate line: where rectus sheath ends all
that covers the rectus abdominis muscle is the
transversalis fascia
Extraperitoneal Fascia

Deep to the fascia transversalis essentially separates it from

the peritoneum and lines the abdominal cavity
Continues over organs covered by peritoneal reflections and
extends into mesenteries with the blood vessels
Clinical note: in description of specific surgical procedures, the
terminology used to describe the extraperitoneal fascia is further
modified: the fascia towards the anterior side of the body is
preperitoneal and towards the posterior side is retroperitoneal.

Peritoneum

Deep to the extraperitoneal fascia is the peritoneum. The

peritoneum lining the body wall is parietal and the peritoneum
covering the viscera is the visceral peritoneum.
The sac formed in the peritoneum (peritoneal sac) is closed in
men but has two openings in women where the uterine tubes
provide a passage to the outside.
Innervation:
o parietal peritoneum of the anterolateral abdominal wall (T7
to T12 and L1) these nerves pass from the posterior to
anterior, in an inferomedial direction (down and to the

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middle) then give off the lateral cutaneous branch and end
as an anterior cutaneous branch.
Intercostal nerves (T7 to T11) pass deep to the costal
cartilages and continue onto the anterolateral abdominal
wall between the internal oblique and trasnversus
abdominis muscles. They enter the rectus sheath and
pass to the posterior aspect of the rectus abdominis
muscle approaching the midline, an anterior cutaneous
branch passes through the rectus abdominis muscle and
the anterior wall of the rectus sheath to supply the skin.
Spinal nerve T12 (subcostal nerve) follows similar course.
Branches of L1 (iliohypogastric and ilio-inguinal nerve)
originate from the lumbar plexus follow a similar course
but deviate from this patern near their final destination.
All nerves terminate by supplying the skin
Nerves T7-79: skin from the xiphoid process to just above
the umbilicus
T10: skin around the umbilicus
T11,T12,L1: below umbilicus to the pubic region (inclusive)
Ilioinguinal nerve: supplies the anterior surface of the
scrotum or labia majora, and sends a small cutaneous
branch to the thigh

Arterial Supply and Venous Drainage

Musculophrenic artery (terminal branch of internal

thoracic artery): superior part of the abdominal wall
Superficial epigastric artery supplies the medial side (branch
of femoral artery)
Superficial circumflex iliac artery supplies the lateral side
(branch of femoral artery)
At a deeper level:
Superior epigastric artery supplies the superior part (branch
of internal thoracic artery)
10th and 11th intercostal + subcostal artery supplies the
lateral side
Inferior epigastric artery and deep circumflex iliac artery
(branches of external iliac artery) supply the inferior.
Superior and inferior epigastric arteries both enter the
rectus posterior to the rectus abdominis muscle throughout their
course, and anastomose with each other.

Lymphatic drainage

Groin

The junction between the abdominal wall and the thigh quite
susceptible to inguinal hernia
Peritoneal outpunching in abdominal wall eventually forms
testes/ovaries, protruding through the various layers of the
anterior abdominal wall and acquiring coverings from each
o The transversalis fascia forms its deepes covering, followed
by musculature of internal oblique and the most external
covering is the aponeurosis of the external oblique
o This structure forms into a tubular structure knows as the
inguinal canal.
Processus vaginalis
In men, the accompanying vessels, ducts, and nerves pass
through the inguinal canal and are therefore surrounded by the
same fascial layers of the abdominal wall, forming the spermatic
cord
In women, the overaies descend into the pelvic caity and become
associated with the developing uterus therefore the only
relevant structure passing through the inguinal canal is the
round ligament of uterus.
Inguinal Canal

Begins at the deep inguinal ring and continues for approximately

4 cm, ending at the superficial inguinal ring.
o Contents: genital branch of the genitofemoral nerve, the
spermatic cord in men and the round ligament of the
uterus in women. Additionally the ilio-inguinal nerve
passes through part of the canal

Deep Inguinal Ring

Beginning of the inguinal canal and is midway point between the

anterior superior iliac spine and the pubic symphysis
Just above the inguinal ligament and is the beginning of the
tubular evagination of transversalis fascia that forms one of the
coverings of the spermatic cord in men and round ligament in
women.

Superficial Inguinal Ring

End of the inguinal canal

The triangular opening of the aponeurosis of the external oblique

Ends of the triangle are the medial and lateral crus and are
attached to the pubic symphysis and the pubic tubercle,
respectively; prevent widening of the superficial ring.

Anterior Wall of Inguinal Canal

Formed along its entire length by the aponeurosis of the external

oblique muscle.
Reinfroced laterally by the lower fibers of the internal oblique,
which contributes a layer to to the deep inguinal ring
(cremasteric muscle/fascia)

Posterior Wall of Inguinal Canal

Formed by the transversalis fascia

Reinforced along medial one-third by the conjoint tendon ( a
combined tendon of the transversus abdominis and internal
oblique)

Roof of Inguinal Canal

Formed by arching fibers of the transversus abdominis and

internal oblique muscles

Floor of the Inguinal Canal

Medial of the inguinal ligament

Lowest part of the aponeurosis of the external oblique. Forms
the trough on which the contents of the inguinal canal are
position.
The lacunar ligament reinforces most of the medial part of the
trough.

Contents of Inguinal Canal

The spermatic cord in men

The round ligament of the uterus and genital branch of the
genitofemral nerve in women
Ilio-inguinal nerve enters the theinguinal canal and continues
down the canal to exit through the superficial inguinal ring.
All structures enter through the deep inguinal ring and exit
through the superficial inguinal ring.

Spermatic Cord

Begins proximally at the deep inguinal ring and consists of

structures passing between the abdominopelvic cavities and the
testis, and the three fascial coverings that enclose these
structures. Structures of spermatic cord:
o Ductus deferers (+ artery), testicular artery, pampiniform
plexus of veins, cremasteric artery and vein, genital branch
of genitofemoral nerve, sympathetic and visceral afferent
nerve fibers.
Structures acquire the three fascial coverings during their
journey:
o Internal spermatic fascia (deepest) arises from
transversalis fascia
o Cremaster fascia associated with cremasteric muscle
o External spermatic fascia (superficial covering of the
spermatic cord); arises from the aponeurosis of external
oblique

Round Ligament of Uterus

Passes from the uterus to the deep inguinal ring where it enteres
the iguinal canal
Exists through the superficial inguinal ring
As it traversus through the inguinal canal, it acquires the same
coverings as the spermatic cord in men.
Continues to the ovary as the ligament of the overy.
Clinical Note: cremaster muscle and fascia form the middle
covering of the spermatic cord (supplied by genitofermoral
nerve)
o Cremaster reflex: gentle touch at and around the skin of
the medial aspect of the superior part of the thigh
stimulates the sensory fibers of the ilio-inguinal nerve
sensory fibers to L1 response from motor fibers of
genital branch of the genitofemoral nerve
Clinical note:
o Indirect Inguinal Hernia: peritoneal sac enters the
inguinal canal by passing through the deep inguinal ring
just lateral to the inferior epigastric vessels
Congenital in origin
o Indirect Inguinal Hernia: peritoneal sac enters the
medial end of the inguinal canal directly through a
weakened posterior wall
Does not traverse the entire length of the inguinal
canal

Is acquired and develops when abdominal

musculature has weakened
Bulging occurs medial to the inferior epigastric
vessels in the inguinal (Hasselbachs) triangle
bounded laterally by the inferior epigastric artery,
medially by the rectus abdominis muscle and
inferiorly by the inguinal ligament.
o Clinical Note: Determining Masses Around Groin
The key to groin examination is determining the
location of the inguinal ligament
Passes between the anterior superior iliac spine
laterally and the pubic tubercle medially.
Inguinal hernias are above the inguinal
ligament and are usually apparent upon
standing
Scrotal masses in men, in tandem with the
inability to feel its upper edge suggests that it
may originate from the inguinal canal and
might be a hernia. Upon coughing, the lump
bulges outwardly
Inguinal hernia location: through superficial
inguinal ring above the pubic tubercle
Femoral hernia location: through the femoral
canal below and lateral to the pubic tubercle.
Usually acquired.
Umbilical hernia: result from the failure of the
small bowel to return to the abdominal cavity
from the umbilical cord during development
Incisional hernias: occur from a defect in a scar
of a previous abdominal operation
Spigelian hernia: passes upward from the
arcuate line into the lateral border at the lower
part of the posterior rectus sheath.

Peritoneum

A thin membrane lines the walls of the abdominal cavity and

covers much of the viscera. Between the parietal and visceral
layers of peritoneum is a potential space (peritoneal cavity)
o Abdominal organs are either suspended in peritoneal cavity
by folds of peritoneum (mesenteries) or are outside the
peritoneal cavity.
o Innervation:
Parietal peritoneum: somatic afferents carried in
branches of the associated spinal nerves; sensitive to
well-localized pain.
Visceral peritoneum: visceral afferents that
accompany autonomic nerves (sympathetic and
parasympathetic). Activation can lead to referred
and poorly localized sensations of discomfort,and to
reflex visceral motor activity

Peritoneal Cavity

Subdivided into greater sac and omental bursa

o Greater sac accounts for most of the space, beginning
superiorly at the diaphgragm and continuing inferiorly into
the pelvic cavity (you enter it as you penetrate the parietal
peritoneum).
o Omental Bursa: smaller subdivision of the periteoneal
cavity posterior to the stomach and liver and is continuous
with the greater sac through an opening called the omental
foramen
Surrounding the omental (epiploic) foramen are
Anteriorly: the portal vein, hepatic artery
proper, and bile duct d
Posteriorly: vena cava
Superiorly: caudate liver of the lobe
Inferiorly: first part of the duodenum
o Clinical Note:
Ventriculoperitoneal shunts: excessive CSF in the
cerebral ventricular system. Clinical drainage
requires a fine-bore catheter through the skull into
the cerebral ventricles and placing the extracranial
part of the tube beneath the scalp and skin of the
chest wall and passing it to the peritoneal cavity
from where it is drained.
Peritoneal Dialysis: peritoneum is used as dialysis
membrane a small tube is inserted from the
abdominal wall and dialysis fluid is injected into the

peritoneal cavity. Electrolytes and molecules are

exchanged aross the peritoneum between the fluid
and blood.
Peritoneal spread of disease: if malignant cells
enter the peritoneal cavity by direct invasion, spread
may be rapid. It can also act as a barrier to contain
the disease
Omenta, mesenteries and ligaments

Throughout peritoneal cavity numerous peritoneal folds connect

organs to each other or to the abdominal wall. They are known
as omenta, mesenteries and ligaments.
o They develop from the original dorsal and ventral
mesenteries, which suspend the developing
gastrointestinal tract in the embryonic coelomic cavity
Omenta: consists of two layers of peritoneum, which pass from
the stomach and the first part of the duodenum to other viscera.
o Greater Omentum: derived from dorsal mesentery
Attaches to the greater curvature of the stomach and
first part of duodenum
Drapes over transverse colon and the coils of the
jejunum and ileum
It associates with the peritoneum on the superior
surface of the transverse colon and the anterior layer
of the transverse mesocolon before arriving at the
posterior abdominal wall
Usually contains an accumulation of fat
Contains right and left gastro-omental vessels.
Clinical Note: when a laparotomy is performed and
the peritoneal cavity is opened, the first structure
usually encountered is the greater omentum.
An important site for metastatic tumors
o Lesser Omentum: derived from the ventral mesentery
Extends from lesser curvature of the stomach and
the first part of the duodenum to the inferior surface
of the liver
Divided into:
Medial hepatogastric ligament
o Passes between stomach and liver
Hepatoduodenal ligament
o Passes between duodenum and liver
Mesenteries: attach viscera to the posterior abdominal wall.
o The mesentery: associated with parts of the small intestine

Connects the jejunum and ileum to the posterior

abdominal wall
Attaches superiorly at the duodenojejunal junction
Ends at the ileocecal junction
Incases the arteries, veins , nerves and lymphatics
that supply the jejunum and ileum.
o The transverse mesocolon: associated with the transverse
colon
connects transverse colon to the posterior abdominal
wall
Traverses the head and body of the pancreas and
surround the transverse colon.
Incases the arteries, veins, nerves and lymphatics
that supply the transverse mesocolon
o The sigmoid mesocolon: associated with the sigmoid colon
Attaches the sigmoid colon to the abdominal wall
Shaped in a V whose apex is near the division of the
left common iliac artery and divides it into its internal
and external branches, with the left limb of the V
along the medial border of the left psoas major
muscle and the right limb descending into the pelvis
to end at the level of vertebra S3.