1.

ANTEROLATERAL ABDOMINAL WALL AND THE ABDOMINAL

CAVITY
8
INTRODUCTION

• We start off with the anterolateral

abdominal wall and the abdominal cavity.
• Objective: use anatomical landmarks
when performing PE; clinical correlations
of disease; distinguish anatomical
structures of the antero-lateral abdominal
wall

THE ABDOMEN

TABLE OF CONTENTS BOUNDARIES

1. The Abdomen
2. Divisions of the Anterior Abdominal Wall
3. Layers of the Anterolateral Abdominal Wall
4. Blood Supply
5. Venous Drainage
6. Lymphatic Drainage
7. Innervation
8. Internal Surface of the Anterolateral Wall
9. Inguinal Hernias
10. Contents of the Spermatic Cord
11. Subdivisions of the Peritoneal Cavity
12. Muscles of the Posterior Wall
13. Branches of the Abdominal Aorta
14. Tributaries of the Inferior Vena Cava

• Region located posterior to the thorax TRANSCRIBERS: Group 12B

reaching the level of the sternum SUBTRANSHEAD: Suguru
• Continuous with the pelvic cavity through Figure 1. Body Cavities
an imaginary boundary called the pelvic
inlet

Figure 2. Key Landmarks inthe Abdominal Cavity

1
• Costal margins and xiphoid process o Some o Aponeurosis formed by the three flat
structures are beneath some of the ribs muscles
• Diaphragm o Separates abdominal cavity from • Costal Margins
the thoracic cavity
• Plane of the pelvic inlet o Separates abdominal DIVISION OF THE ANTERIOR ABDOMINAL
cavity from pelvic cavity WALL
o There is no anatomic barrier between
abdomen and pelvic cavity 1. QUADRANTS
o Sacral promontory and symphysis pubis - to • 4 quadrants
know plane of pelvic inlet • Use umbilicus as midpoint and
• Bones of the pelvis and the inguinal ligament o midline
Inguinal Ligament – “singit” • RUQ, LUQ, RLQ, LLQ
• Ribs – protect liver and spleen primarily 2. REGIONS
SURFACE ANATOMY • 9 regions
• Use midclavicular or mid-inguinal
1. Umbilicus line to create 9 divisions
• Unreliable as a landmark • Epigastric Region, R
structure and L
• Marks the T10 dermatome Hypochondrium, Umbilical Region, R
between and L Lumbar, Hypogastric
L3 and L4 Region, R and L Iliac Region

2. Linea Alba
• separates right and left rectus
abdominis muscle
• “White line” – because it has the
least blood vessels;
• Region where there is least amount
of blood loss when surgeons cut into
it
• Composed of aponeuroses of the
three flat muscles of the abdomen

3. Linea transversae
• Interdigitations of the rectus
abdominis muscle
• Tendinous intersections

4. Linea semilunaris
• lateral borders of rectus abdominis
• area where the aponeurosis of the flat
muscles meet before it forms the rectus
sheath

Other structures to take note of:

• Xiphoid Process
• Inguinal Ligament o Aponeurotic fibers of
the external
oblique muscle
• Symphysis Pubis
• Rectus Abdominis Muscle o “six packs”
o Inside the rectus sheath Figure 3. Planes of Reference
o Core muscle which provides stability
to an individual DESCRIPTIVE PLANES USED IN CLINICAL
• Iliac Crest o Mid-axillary line limits MEDICINE
the anterolateral abdominal wall
a. Transpyloric Plane
TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity 2
LECTURER: Dr. Patricia Sy-Santos
 •To locate using anatomic palpation tenderness but no rebound tenderness
landmarks: Mid-way between (pain upon release of palpation and by coughing).
jugular notch and pubic symphysis 6 hours after admission, (+) rebound tenderness.
• At the level of the L1 and 9th costal Labs confirm your DX: ACUTE
cartilage midway between the APPENDICITIS
jugular notch and symphysis pubis • Divided by the sagittal plane and the
• With clinical importance since it is at transumbilical plane
the level of:
i. Pylorus of the Stomach
ii. 1st part of the Duodenum
iii. Neck of the Pancreas
iv. Root of the
Superior
Mesenteric Artery
v. Hilum of the Kidney
b. Subcostal Plane
• At the level of the lower edge of the
10th costal cartilage
Figure 4. Abdominopelvic Quadrants

FOUR-QUADRANT DESCRIPTIVE REFERENCE

c. Intertubercular Plane
• Quadrants o RUQ (right upper
• At the level of the tubercle of the
quadrant)
iliac crest
Contains the liver, gallbladder,
d. Transumbilical Plane
part of duodenum, pylorus
of the stomach
McBurney’s Point
o LUQ (left upper quadrant)
Majority of the stomach,
spleen, part of transverse
colon
o RLQ (right lower
quadrant)
Appendix, Ascending colon o
LLQ (left lower quadrant)
Descending colon, Sigmoid
colon
Pain on each region has specific origin.
1. Epigastric region – foregut structures
2. Periumbilical region – midgut structures are
inflamed
3. Hypogastric region – hindgut structures

Clinical significance: location of appendix In

LAYERS OF THE ANTERIOR ABDOMINAL
between the imaginary line of anterior superior
• 5 MAJOR SOFT TISSUE LAYERS:
iliac spine (ASIS) and umbilicus Lateral third from
1. Skin
(ASIS) and ⅔ from umbilicus
2. Subcutaneous Tissue
3. Muscle and their overlapping sheet-
Clinical Correlation:
like tendon
25 y/o male, complaining of periumbilical pain 4 4. Tranversalis Fascia
hours prior to consult that he would describe as on
and off (Cholicky Pain: in medical terms such as
that in dysmenorrhea). On examination, you find
that he has a 38C fever and (+) vomiting.
Admitted but nothing per orem (NPO). An hour
after admission, he still has fever and he
complains that he has RLQ pain. Upon abdominal
PE, normal bowel sounds were heard, on deep
TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity 3
LECTURER: Dr. Patricia Sy-Santos

Figure 5. Langer's Lines on Abdominal Skin

SKIN
 5. Peritoneum knowing the layers of
the abdominal wall is essential in
abdominal surgery where there is a
need to close a wound or incision per
layer
FASCIA
1. Fatty Fascia (Camper’s Fascia in old books)
• If patient is lean, this is thin
• Body fat is continuous with fats in
the leg area unlike in Scarpa’s
Fascia

2. Membranous Fascia (Scarpa’s Fascia in old

books)
• Strong fascia
• Individually closed during surgery to
ensure integrity
• Continuous with penis and the
scrotum (as Dartos Fascia)
• Stops at the inguinal ligament
• Implication: Any internal bleeding
within the Scarpa’s Fascia may
reach the thigh area due to inguinal
ligament
• Clinical Considerations in
Surgical 3. Inguinal Ligament
Incisions Langer’s Line • Continuous with the fascia lata of
• Lines created by the direction of collagen the thigh
fibers that when cut through, there will be • Implication: In internal bleeding,
keloid formation or scarring after surgery the inguinal ligament will prevent
• Incisions made parallel to Langer’s lines will blood from being deposited to the
tend to gape less and leaves smaller scars thigh region
when healed
• Consideration especially for aesthetic
surgery
• If you disturb collagen fibers, they will
regenerate again. How?
o HAPHAZARDLY if you don’t follow
Langer’s lines
• For people who undergo exploratory
laparostomy - cut through midline of
abdomen that’s why the scar is very
prominent
• Innervation: Dermatomes o T6-T7:
Epigastrium o T9-T10: Umbilicus
o T12-L1: Hypogastric

SUBCUTANEOUS TISSUES (SUPERFICIAL

TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity 4

LECTURER: Dr. Patricia Sy-Santos
 Conjoint tendon

Figure 6. Location of Subcutaneous Tissues and their Continuities

Figure 7. Muscles and Aponeuroses of the Anterior Abdomen
Cremasteric muscle in the
MUSCLES AND THEIR DERIVATIVES
scrotal area
1. FLAT MUSCLES OF THE ANTEROLATERAL Cremasteric Reflex:
ABDOMEN Stimulation of the abdomen
results in the contraction of
• External oblique o Direction is the cremasteric muscle,
diagonal towards medial (fibers are resulting in the lifting of the
like putting your hand in your pocket) scrotum
o Aponeurosis contributes to the
rectus sheath, linea semilunaris, • Transversus Abdominis o Horizontal Fibers
and linea alba o Aponeurosis found posterior to
o Responsible for forming inguinal the rectus abdominis muscle
ligament, superficial inguinal ring, o Derivatives:
and lacunar ligament Conjoint tendon – together
o Inguinal ligament with the internal oblique
(Poupart’s Ligament) (Note: kumbaga love team
Produced by the rolling of the ang internal oblique and
external oblique transversus abdominis)
Connects to
anterior superior iliac spine 2. VERTICAL MUSCLES OF THE ANTEROLATERAL
(ASIS) to symphysis pubis ABDOMEN
o Superficial Inguinal Ring
Causes wall defect in male • Rectus Abdominis o Long, broad,
strap-like muscle o Principal vertical
• Internal oblique o Direction is muscle of the anterior abdominal wall
diagonal towards lateral (fibers are o Most of the Rectus Abdominis is
like putting your hand in your back pocket) enclosed in the rectus sheath
o Aponeurosis contributes to the o It is anchored transversely by
formation of rectus sheath attachment to the anterior layer of
o Derivatives:
TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity 5
LECTURER: Dr. Patricia Sy-Santos
 rectus sheath at three or more Above the arcuate line, it is
tendinous intersections directed behind/posterior to
the rectus abdominis muscle
• Pyramidalis o Small, insignificant together with the posterior
triangular muscle that is lamina of IO to form the
absent in approximately 20% of people posterior layer of rectus
o Lies anterior to the inferior part of the sheath, at the level of
rectus abdominis and attaches to the arcuate line, the two
anterior surface of the pubis and the aponeurosis merge and pass
anterior pubic ligament; anteriorly to the rectus
ends in the linea alba abdominis muscle
• Arcuate line o Crescentic line that demarcates
RECTUS SHEATH the transition between the aponeurotic
posterior wall of the sheath covering the
• Rectus sheath is the strong incomplete superior ¾ of the rectus and the transversalis
fibrous compartment of the rectus abdominis fascia covering the inferior quarter.
and pyramidalis muscles o Formed by the fusion of the
• Also contains superior and inferior epigastric aponeuroses of the 3 flat muscles at
arteries and veins, lymphatic vessels and the level above the pubic symphysis
distal portions of the thoracoabdominal o Throughout the length of the
nerves sheath, the fibers of the anterior and
• Formed by the decussation and interweaving posterior layers of the sheath
of the aponeuroses of the flat abdominal interlace in the anterior median
muscles line forming the linea alba
• Linea Alba – created by the aponeurosis of
the 3 flat muscles
• Rectus sheath above the arcuate line:

o Aponeurosis of external oblique

– passes anterior to the rectus
abdominis muscle throughout its
length
o Aponeurosis of Internal Oblique
- splits into 2 (anterior lamina, and
posterior lamina). Anterior lamina
Figure 8. Aponeuroses wrapping around Rectus Abdominis muscle contributes to the anterior wall of
the sheath while the posterior
• Aponeuroses that comprises the rectus lamina contributes to the posterior
sheath: o External Oblique contributes wall of the sheath
to the anterior wall of the o Aponeurosis of transversus
sheath throughout its length abdominis
o Internal Oblique -passes posterior to the rectus
superior 2/3 of its abdominis muscle. Contributes to
aponeurosis splits into two the posterior wall of the sheath.
layers at the lateral border of
the rectus abdominis (one layer
passes anterior to the RA muscle
and the other passes posterior • Rectus sheath below the arcuate line:
to it)
o Transversus abdominis

TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity 6

LECTURER: Dr. Patricia Sy-Santos
 aponeurosis of rectus abdominis (all three
aponeurosis).
4. Below the arcuate line, what are the layers
posterior to the RA muscle? Answer:
Transversalis Fascia, Peritoneal
Fascia

BLOOD SUPPLY
o Note that all three aponeuroses make • Blood supply zones of the abdomen
up the rectus sheath that is now are established for surgical
only anterior to the rectus procedures on the basis of blood
abdominis and the rectus supply received by each zone
abdominis rests directly on the
transversalis fascia/fascia
transversalis

Sample questions:

1. Above the arcuate line, what are the

aponeuroses present anterior to the rectus
abdominis muscle? Answer: Aponeuroses
of EO and IO
Zone 3 Lateral most Intercostal
2. Above the arcuate line, what are the layers
aspect of anterior and Lumbar
found right behind (posterior) to the RA
abdominal wall Arteries
muscle?
Answer: Aponeurosis of IO, Transversalis
Fascia, Peritoneal Fascia
3. Below the arcuate line, what are the layers
anterior to the RA muscle? Answer: Skin,
Camper’s Fascia, Scarpa’s Fascia,

• Zone 1 o Midline
o Deep inferior and superior epigastric arteries
o Occupied by rectus abdominis muscle
RA is important as it is used as a flap because of
its good arterial supply o Majority is supplied by deep
inferior epigastric artery
• Zone 2
o Caudal aspect of anterior abdominal wall
Table 1. Blood Supply distribution of the Abdomen o Perforators from
deep circumflex
iliac artery

Figure 9. Blood Distribution Zones of the Abdomen

TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity 7

LECTURER: Dr. Patricia Sy-Santos
Zone 1 Anterior midline; Deep • Zone 3 o Musculophrenic and ascending branch
vicinity of the Epigastric of deep
rectus abdominis arteries- o Circumflex iliac artery
superior and • Importance: in an abdominal wall surgery, the zones
inferior allow the surgeon o know what artery to ligate considering
epigastric the area it supplies to avoid shutting the blood flow which
may result in avascular necrosis.

• Drainage fall to subclavian vein • Upper group:

VENOUS DRAINAGE
Zone 2 Caudal aspect of o Lateral thoracic and internal thoracic veins
(Hypogastric anterior Superficial • Lower group:
Area) abdominal wall External o Femoral vein
Pudendal • Paraumbilical Vein o Connection between portal and
systemic circulation o Collateral circulation
Superficial
Epigastric
LYMPHATIC DRAINAGE
• Structures above umbilicus:
Inferior
o Anterior axillary lymph nodes
Epigastric
• Structures below the umbilicus:
o Superficial inguinal lymph nodes
Deep
Circumflex INNERVATION
Arteries
• Dermatomes: o Dermatomes overlap
o Portal system: the veins that drain your each other
digestive tract will go thru here then to o T10: area of umbilicus
the liver before going back to the o T7-T9: area below xiphoid and
systemic circulation above the umbilicus
o T10-T12: area below the umbilicus
• Importance: the integrity of the spinal
cord may be checked using the
dermatomes in patients with spinal injury
INTERNAL SURFACE OF THE

Figure. Caput Medusae

Clinical Correlation: Patient has liver cirrhosis. As a
consequence of liver injury, liver tends to regenerate
but haphazardly thus it becomes cirrhotic. Since liver
is being destroyed, first it would expand then shrink Figure 10. Umbilical Folds
and will have scar tissues inside. If liver is cirrhotic
ANTEROLATERAL WALL
and has scar tissues, blood will have difficulty to pass
through the systemic circulation. Blood will then black a. UMBILICAL PERITONEAL FOLDS
flow. It will either congest the digestive tract but it 1. Median Umbilical Fold
has to go somewhere so it goes to the paraumbilical • Embryonic urachus
vein (varicose). • Extends from the apex of the urinary
bladder to the umbilicus
Note: can also be present in Hepatitis, or any other 2. Medial Umbilical Folds (L and R)
disease that affects the liver

TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity 8

LECTURER: Dr. Patricia Sy-Santos
 • Obliterated umbilical arteries
• Lateral to the median umbilical cord
3. Lateral Umbilical Folds
• Inferior epigastric arteries
b. PERITONEAL FOSSAE
• Created by the peritoneal folds
• SUPRAVESICAL FOSSA
o Above the urinary bladder
• MEDIAL INGUINAL FOSSA
o Forms the inguinal triangles
(Hesselbach’s triangle)
o Boundaries of the
triangle:
1. Inferior epigastric vessels
2. Lateral margin of RA
3. Inguinal ligament o Site of
direct herniation
o Protected by conjoint tendon
o Significant in inguinal
herniation • LATERAL
INGUINAL FOSSA
o Forms the deep inguinal ring
INGUINAL HERNIAS
• Protrusion of peritoneal contents through
the abdominal wall in the groin
• Classified according to their relationship with
inferior epigastric vessels
INDIRECT (Congenital) HERNIAS
● Occur lateral to the inferior epigastric
vessels 
and pass through the deep inguinal
ring and may enter the inguinal canal as a
protrusion along the spermatic
cord 
 BOUNDARIES OF THE INGUINAL CANAL
● May go to the scrotum
● Danger: Strangulated due to inflammation
DIRECT (Acquired) HERNIAS
● Occurs medial to the inferior epigastric vessels
and passes through the posterior wall of the
inguinal canal
● Due to laxity of the conjoint tendon
TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity
LECTURER: Dr. Patricia Sy-Santos
● Does not pass thru the deep inguinal ring
c. DEEP INGUINAL RING
• Where the testicular vessels exit
the abdomen to enter the scrotum
• Significant in herniation
d. RECTUS DIASTASIS
• Separation of the rectus abdominis
muscle as a result of physiologic
factors tearing the linea alba
e. INCISIONAL HERNIATION
• Iatrogenic; caused by the failure
to close the fascial layers after
surgery or poor healing of the
wound, which causes herniation
INGUINAL CANAL
• Region where structures from the
abdomen wither enter or exit
• Oblique passageway through the
anterior abdominal wall for the
spermatic cord (male) or round
ligament (female) and ilioinguinal
nerve
EMBRYOLOGIC DESCENT OF THE TESTES
• At the beginning, the gonads are
inside the abdominal cavity
• During development, the male
testis migrates down the
processus vaginalis, where the
environment is more favorable for
spermatogenesis
• Failure of descent of the male
gonads pose susceptibility to
disorders involving the testis
• For the females, the gonads
remain inside the abdominal
cavity
• Notice the muscle and fascial
layers of the abdomen which
descended together with
the gonads
Anterior wall External Oblique
aponeurosis
Posterior wall Transversalis fascia and conjoint
tendon
Floor Inguinal and Lacunar
Ligament
9
Roof IO & TA muscles
APPENDICITIS
BLOOD SUPPLY OF THE TESTES • There is a vague pain from the umbilical
region of patients with symptoms of
• Testicular artery (gonadal artery) appendicitis, which shifts to the RLQ after
which are branches of the abdominal some time 

aorta • Appendix is part of the midgut; located
descends with the testes regionally to the right lower quadrant 
 •
Irritation of the visceral peritoneum:
o Pain is referred vaguely to the
INGUINAL CANAL FORMATION periumbilical region as a result of
● Superficial inguinal ring, inguinal ligament the inflammation of the appendix


and lacunar ligament formed by the
(Concept: as part of the
aponeurosis of the external oblique
midgut, pain 
 is referred to the umbilical
region) 
 • Irritation of the
Hydrocele – peritoneal fluid in the tunica vaginalis parietal peritoneum:
o As the inflammation continues to
worsen, the pain is shifted from
the umbilical region to the right
lower quadrant, where the
appendix becomes more adherent
PERITONEUM AND PERITONEAL CAVITY
and irritates the
PERITONEUM parietal 
 peritoneum concept: as
• Serous membrane that lines the abdominal the parietal peritoneum
wall (parietal peritoneum) and covers the becomes innervated by
organs (visceral peritoneum) nerves from the abdominal
wall, the pain becomes more
• Consists of mesothelium and connective tissue
somatic, resulting in a more
specific sensation to the
• Importance: loss of mesothelial layer leads to
region where the appendix is
adherence of underlying tissues and interferes located
with visceral functions o Happens during
abdominal surgery
with symptoms of gut obstruction

TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity 10

LECTURER: Dr. Patricia Sy-Santos
 PERITONEAL CAVITY

• Two layers of peritoneum create the peritoneal

cavity
• A potential space
• Normally holds 100 mL of fluid but can hold as
much as 5 L

• Importance: in peritoneal dialysis, a more

indirect dialysis than hemodialysis, the cavity
is taken advantage as a semipermeable
dialysis membrane to exchange water and
soluble substances for patients with kidney
failure

Figure12. Closed peritoneal cavity of males

• Females: there is a communication to

the exterior by way of uterine tubes,
ovaries, uterine cavity and vagina

o Any infection in reproductive

system can cause peritonitis

Figure11. peritoneal cavity: potential space between parietal and

visceral peritoneum

BLOOD AND NERVE SUPPLY

• Parietal Peritoneum: comes from the region of

the wall it lines
o Same with thoracic cavity
• Visceral Peritoneum: comes from the organ it
covers



PERITONEAL ORGANS

• Intraperitoneal Organs: completely covered

with 
 visceral peritoneum 

• Extraperitoneal Organs: external to the
parietal 
 peritoneum 


VARIATIONS IN MALE AND FEMALE

Figure 13. Open peritoneal cavity of females
• Male: completely closed peritoneal cavity

TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity 11

LECTURER: Dr. Patricia Sy-Santos
 PERITONEAL DERIVATIVES SUBDIVISIONS OF THE PERITONEAL CAVITY

• Mesentery: 1. Greater Sac:

o Peritoneal reflection from the body o Comprises most of the
wall to the small intestine abdominopelvic cavity
o Where we can find blood supply of 2. Lesser Sac:
the intestines a. Also called omental bursa;
• Omenta: b. Irregular part if the peritoneal
o From the stomach to other cavity that forms a space
abdominal organs posterior to the stomach and
o Peritoneum connected to the anterior to the
stomach to the other organs retroperitoneal pancreas
• Peritoneal Ligaments: o Double layer of
peritoneum o Connects an organ to another
organ or to the abdominal wall

• Epiploic Foramen of Winslow: o

Communication between the
greater sac and the lesser sac
(omental bursa)

3. Supracolic Compartment:
a. Greater sac compartment superior
to the transverse colon
4. Infracolic Compartment:
a. Greater sac compartment inferior
to the transverse colon

Paracolic gutter

• Lateral edge of the colon. Communicates with

hepatorenal recess and peritoneal cavity

Importance: Can be a passageway of infection

from the pelvic organ, especially in the RIGHT.
In the LEFT, the phrenicocolic ligament can
somehow inhibit it the passage.

FORAMEN OF WINSLOW

• Epiploic/Omental Foramen)
• Communication between the greater sac and the
lesser sac (omental bursa)

BOUNDARIES OF THE FORAMEN OF

WINSLOW
Anterior Portal Vein, Hepatic
artery, bile duct
Posterior IVC, right curs of
dipahragm
Supierior Caudate lobe of the
liver
Inferior 1st part of
the duodenum

TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity 12

LECTURER: Dr. Patricia Sy-Santos
 Notes:

Take note of the: Vertical anterior abdominal muscles;

Flat anterolateral abdominal muscles; Flat
aponeuroses at the end of flat REFERENCES:

1. Lecture Notes
2. PPT
3. Books

TOPIC: 1. Anterolateral Abdominal Wall and Abdominal Cavity 13

LECTURER: Dr. Patricia Sy-Santos