Abdominal wall , rectus-sheath - PowerPoint Presentation

Slide1

Abdominal wall, rectus-sheath, subinguinal opening, inguinal canal, femoral and adductor canals

Department of Anatomy, Histology and EmbryologySemmelweis UniversityNovember, 2019

Dr. Ágoston Szél

Slide2

The abdominal wall

Slide3

External abdominal oblique

muscle

Origin:

5-12. ribs

Insertion:

iliac crest, linea alba, inguinal lig., pubic tubercle.

Slide4

Internal

abdominal oblique muscle

Origin:

iliac crest,

thoracolumbar fascia, inguinal lig.

Insertion:

9-12. ribs, linea alba.

Slide5

Transverse abdominal muscle

Origin:

6 lower ribs, thoracolumbar fascia, proc. costarius, iliac crest, inguinal lig. Insertion: linea alba.

Slide6

Rectus abdominal muscle

Pyramidal

muscle

Origin:

5-7. ribs, xyphoid process.

Insertion:

iliac crest, symphysis, linea alba.

Slide7

7

E

xt.

abd. obl.

Int. abd. obl.

T

ransv

.

abd.

Transversalis fascia

Transversalis fascia

Peritoneum

Linea alba

Skin

Superficial fascia

Rectus abd.

Rectus abd.

Intercostal muscles

Pectoralis major muscle

Extraperitoneal fat

Aponeurosis of ext. abd. obl.

Xyphoid process

Structure

of

the

abdominal

wall

,

rectus

sheath

E

xt.

abd. obl.

Int. abd. obl.

T

ransv

.

abd.

Slide8

8

E

xt. abd. obl.

Int. abd. obl.

T

ransv

.

abd.

Inguinal lig.

Inguinal lig.

Inguinal lig.

Broad

abdominal

muscles

Iliac crest

Lumbar fascia

Lumbar fascia

Pubic tubercle

(v)

(v)

Slide9

9

Layers of thoracic wall

Skin Subcutaneous adipose tissue

Structure of Wall of Trunk

Serratus anterior, etc.

External thoracic fascia –

Periosteum of ribs

Layers of abdominal wall

Skin

Subcutaneous adipose tissue

(Rectus abdominis)

Superficial abdominal fascia

Slide10

10

External intercostal(V-shaped)(Anterior intercostal membrane)

Internal intertercostal

(

A-shaped

)

(Posterior intercostal membrane)

Space of vessels and nerves

Structure of Wall of Trunk

External abdominal oblique

(

V-shaped

)

(Aponeurosis)

Internal abdominal oblique

(

A-shaped

)

Space of vessels and nerves

Slide11

11

Tranversus abdominis (horizontal) Transversalis fascia Parietal peritoneumPeritoneal cavityVisceral peritoneum Visceral wall

Transversus thoracis

(

horizontal

)

Endothoracic fascia

Parietal pleura

Pulmonary pleura

Lung

Pleural cavity

Structure of Wall of Trunk

Slide12

12

Linea alba

T

ransv

.

abd. m.

Arcuate line

Fascia transv.

Funiculus spermaticus

Inf. epigastric artery

Fascia transv.

Peritoneum

Skin

Symphysis

Xyphoid process

Rectus

abd

. m.

Fascia abd. spf.

Apo. of obl. int. abd. m.

Apo. of t

ransv

. abd. m.

Intersections

Apo. of obl. ext. abd. m.

Arcuate line

Adipose tissue

Conjoint tendon

Structure

of

abdominal

wall

Slide13

Inguinal ligament. The anatomical basis of herniation

Slide14

14Exits of the

pelvis

Greater sciatic foramen

Lesser sciatic foramen

Inguinal ligament

Sacrotuberal ligament

Sacrospinal ligament

Obturator canal*

Obturator membrane

Subinguinal opening*

Slide15

15

iliac fossa

L5

lumbosacral joint

iliac crest

ant. sup. iliac spine

symphyseal surface

pubic tubercle

4. obturator foramen

SACROTUBEROUS LIGAMENT

3. lesser sciatic foramen

coccygeal bone

SACROSPINOUS LIGAMENT

2. greater sciatic foramen

sacroiliac joint

sacrum

intervertebral foramen

linea terminalis

Exits

and

openings

of

pelvis

INGUINAL LIGAMENT

1. subinguinal opening

pecten of pubic bone

arcuate line

5. inferior pelvic aperture

ant. inf. iliac spine

Slide16

16

piriformis

ischiococcygeus

gluteus max.

int. obturator

iliacus

psoas maj. & min.

tendinous arch (levator ani removed)

suprapiriform opening

infrapiriform opening

muscular and nervous, lacunae, vascular lacuna, lymphatic lacuna

4a. obturator canal

Openings

and

muscular

components

of

pelvis

4. obturator foramen

3. lesser sciatic foramen

2. greater sciatic foramen

intervertebral foramen

1. subinguinal opening

5. inferior pelvic aperture

Slide17

*

Lacunar lig. of Gimbernat

Iliopectineal arch

Subinguinal

opening

N.

cut

.

fem

. lat.

M

. iliopsoas

F

emoral

nerve

Muscul

ar lacuna

Vascular l

acuna

Femoral

a

.

&

v

.

G

enitofemoral

nerve

Lymphatic

(herni

al

)

l

acuna

Lymphatic vessels and node

(F

emoral

ring)

Inguinal l

ig.

M

.

pectineus

*Ext. abd. obl. m.

Slide18

Skin

Peritoneum

Ext. abd. obl. m. (aponeurosis)

Int. abd. obl. m.

Transversalis fascia

Transv. abd. m.

Inguinal canal

Inguinal ligament

Lymph node

Cribriform fascia

Great saphenous vein, saphenous opening

Fascia lata

Iliac fascia

M. iliopsoas

Femoral septum

Femoral vein

Superior ramus of pubic bone

Pectineal fascia

M. pectineus

Inguinal

canal

Slide19

Inguinal canalInternal abdominal oblique muscle

External abdominal oblique muscle (aponeurosis)

Transverse abdominal muscle

Parietal peritoneum

Transversalis fascia

M. pectineus

Fascia lata

Inguinal ligament (Poupart)

Superficial abdominal fascia

Ilioinguinal nerve

Pectineal ligament (Cooper)

Lacunar ligament

Superior ramus of os pubis

Spermatic cord

Subserosa

Slide20

Lateral umbilical fold (epigastric artery)

Medial umbilical fold (umbilical artery)

Median umbilical fold (

urachus

)

Lat. inguinal fossa

Med. inguinal fossa (Hesselbach)

Supravesical fossa

E

xt.

abd. obl. m.

Int. abd. obl. m.

T

ransv

.

abd. m.

Transversalis fascia

Rectus abd. m.

Horizontal

section

of

the

abdominal

wall

Slide21

Lat. inguinal fossa

Med. inguinal fossa (Hesselbach)

Supravesical fossa

Subinguinal opening

Lateral umbilical fold (

epigastric a.

)

Medial umbilical fold (

umb. artery

)

Median umbilical fold (

urachus

)

Anterior superior iliac spine

Pubic tubercle

Peritoneum

Inguinal lig.

M. iliopsoas

M. pectineus

A.

Abdominal

layers

building

the

inguinal

region

Slide22

fascia transversalis

M. iliopsoas

M. pectineus

Subinguinal opening

Deep inguinal ring

Inguinal ligament

Ant. sup.

iliac spine

Pubic tubercle

Linea alba

Rectus abd. m.

Inf. epigastric a.

Lacunar lig. (Gimbernat)

Trigone of Hesselbach

Line of Spiegel

Transversalis fascia

Abdominal

layers

building

the

inguinal

region

B.

Slide23

m. obl. int. abd.

Transv. abd. m.

Transversalis fascia

Pectineal fascia

Lacunar ligament

Lower edges of Int. abd. obl. & Transv. abd. muscles

Conjoined tendon

Int. abd. obl. m.

Abdominal

layers

building

the

inguinal

region

C.

Slide24

Ext. abd. obl. m.

Rectus abd. m.

Superior crus

Inferior crus

Inguinal lig.

Intercrural fibers

Lacunar ligament

Reflected ligament

Superficial ing. ring. In the depth: transv. & int. abd. obl. m. (conjoined tendon)

Abdominal

layers

building

the

inguinal

region

D.

Slide25

A

B

C

D

Deep inguinal ring

(hole on trasversalis fascia)

Slit

between lower edge of

transv. abd. m.

and inguinal lig.

Slit

between lower edge of

int. abd. obl. m.

inguinal lig.

Superficial inguinal ring

(hole on apo. of ext. abd. obl.)

Slide26

Ext. abd. obl. m.

Int. abd. obl. m.

Transversalis fascia

Transverse abd. m.

Fascia lata

Great saphenous vein

Superior ramus of pubic bone

Fascia lata

Inguinal canal

M. pectineus

Femoral artery

Femoral vein

Cribriform fascia

*

*

*

Conjoined tendon

Iliac fascia

M. ilio-psoas

Femoral septum

A

B

C

D

Inguinal

canal

in

four

paramedian

sagittal

sections

Slide27

Inguinal canal and subinguinal opening

Slide28

Large

inguinal hernia

Incarcerated abdominal hernia (obstruction or strangulation)

Slide29

Deep inguinal ring(lateral inguinal fossa)

Superficial inguinal ring(medial inguinal fossa)

Ext. abd. obl. m.

Int. abd. obl. m.

Transv. abd. m.

Transversalis fascia

Preformed

opening

(

indirect

hernia

)

Pressed against the abdominal wall (direct hernia)

Lig. inguinale

Direct

and

indirect

inguinal

hernia

Medial inguinal fossa

Slide30

Musculus iliacus

Femoral nerve

Femoral artery

Femoral vein

Sac of femoral hernia

Sac of inguinal (indirect) hernia

Pubic tubercle

Deep inguinal ring

Superficial inguinal ring

Inferior epigastric a. & v.

Inguinal

and

femoral

hernia

Inguinal ligament

Slide31

Medial inguinal fossaLateral inguinal fossa

Superficial inguinal ring

Deep and superficial inguinal ring

(acquired)

(inherited or acquired)

Direct

and

indirect

inguinal

hernia

Slide32

Direct and indirect

inguinal hernia

Inf. epigastric vessels

Peritoneum

Peritoneum

Depp

ing. ring

Deep ing. ring

Extraperi-toneal fat

Testis

Testis

Superficial inguinal ring

„peritoneal cavity”

„Peritoneal cavity”

Conjoined tendon

Conjoined tendon

Superficial inguinal ring

Extraperi-toneal fat

Inf. epigastric vessels

Slide33

Femoral and adductor canal

Slide34

Fascia lata

Femoral vein

Femoral artery

Inguinal lig.

Iliac fascia

Ant. sup. iliac

spine

Femoralis nerve

Great saphenus vein

Iliopsoas muscle

Iliopectineal arch

Lymph node

Saphenous opening

Lymphatic vessel

Femoral sheath

Fascia lata

Lacunar ligament

Femoral ring

Femoral canal

Pectineal ligament

Femoral

canal

Slide35

Inguinal lig.

Fascia lata (lamina libera)

Fascia lata (M. adductor longus)

Fascia lata (M. sartorius)

Femoral a. & v.

Superior horn

Inferior horn

Falciform margin

Ext. abd. obl. m. (aponeurosis)

Medial crus

Lateral crus

Intercrural fibers

Lig. reflexum

Pectineal fascia

Lymph node

Iliopsoic fascia

Iliopectineal fascia

Saphenous

opening

:

exit

of

femoral

canal

Slide36

Femoral artery

Femoral vein

Genitofemoral nerve (femoral branch)

Lymph node (Cloquet/Rosenmüller)

Femoral sheath (derivative of transversalis fascia)

Femoral canal

Femoral

sheath

,

femoral

canal

Slide37

Femoral vein

Femoral sheath

Femoral artery

Superficial femoral ring

Poplitealvein

Hiatus adductorius

Popliteal artery

Adductor canal

Femoral canal, lymph node

Adductor

canal

,

femoral

and

popliteal

vessels

Slide38

Adductor canal, cross section

of thigh

Adductor canal

M. vastus medialis

M. sartorius

M. adductor longus

M. vastus lateralis

M. vastus intermedius

M. rectus femoris

M. gracilis

M. biceps femoris

M. semimembranosus

M. semitendinosus

Slide39

Inguinal lig.

Symphysis

Femoral trigone

M. pectineus

M. adductor longus

M. gracilis

M. adductor magnus

M. sartorius

Hiatus adductorius (tendineus)

Femorale trigone

Adductor canal

M. adductor magnus (flesh)

M. adductor magnus (tendon)

Entrance

and

exit

of

adductor

canal

:

femoral

trigone

and

hiatus

adductorius

A

hasüri

nyomást fenntartó szerkezetek

A

hasüri

nyomást fenntartó szerkezetek

Slide40

Inf. epigastric artery

Obturator artery

Obturator branch (Corona mortis)

Pubic branch

Pubic branch (corona mortis)

Internal iliac artery

External iliac artery

Dangerous

anastomosis

(„

corona

mortis

”

or

”

crown

of

death

”)

Slide41

Femoral canal

Virtual canal in the medial part of iliopectineal fossa (does not exist in healthy individuals, only allows for its distension in case of increased venous return of femoral vein).Content: connective tissue, lymphatic vessels and nodes.Femoral nerve, artery and vein do not take their course in it.Clinical significance: Potential canal for herniation (femoral hernia).Shape: inverted pyramid (cone-shaped). Length: 1-2 cm.Entrance: femoral ring (lymphatic or hernial – lacuna), subinguinal openingFemoral septum (part of transversalis fascia) closes it towards the peritoneal cavity.

Exit: saphenous opening (fascia lata, cribriform fascia)Borders: Superior: Inguinal ligament, Anterior: fascia lata (cribriform fascia)

Posterior:

M. pectineus, pectineal fascia

Lateral:

Femoral vein,

Medial:

Lacunar ligament

Slide42

Adductor canal

Nerve-vessel canal (subsartorial canal, Hunter’s canal)Leads from iliopectineal fossa (femoral trigone) into popliteal fossa.Shape: conical, 15 cm in length.Femoral trigone: inguinal lig. (above), m. adductor longus (med.), m. sartorius (lat.)Content: femoral artery & vein, branch of femoral nerve (saphenous nerve). At the exit: popliteal artery & veinEntrance: apex of femoral trigoneExit: hiatus adductorius (tendineus)Borders:

Anterior: M. sartorius, M. vastus medialis, vastoadductor membranePosterior: M. adductor longus et magnusLateral: M. sartorius, M. vastus medialisMedial: M. adductor longus, M. adductor magnus

Slide43

BibliographyDrake: Gray’s Anatomy for Students, Churchill Livingstone, Elsevier, 2009Lippert H: Lehrbuch Anatomie, Urban & Fischer, München, 2000Mac Kinnon P, Morris J: Oxford Lehrbuch der klinischen Anatomie, Hans Huber, Bern, 1997Moore KL, Dalley AF: Clinically Oriented Anatomy, Lippincott, 1999Putz R, Pabst R: Sobotta. Alliter, Budapest, 2004.Patel R: Applied Peritoneal Anatomy, www.myESRorg.Renz-Polster H, Krautzig S, Braun J: Innere Medizin, Urban & Fischer, München, 2004Snell RS, Clinical Anatomy, Little, Brown & Co, Boston, 1995Tirkes T et al: Peritoneal Anatomy. Gastrointestinal Imaging, https://doi.org/10.1148/rg.322115032.https://www.kenhub.com/en/start/anatomy.

Slide44

Inguinal canal and subinguinal opening

Slide45

Content: Ilioinguinal nerve, spermatic cord, round ligament of uterusInguinal canal

anterior: E

xt. abd. oblique (aponeurosis)

superior:

In

t

. abd. o

bliqu

e, t

ransv

erse

a

bd

.

inferior:

I

nguina

l l

igament

posterior:

T

ransversalis

f

ascia

Slide46

Ext. abd. obl. m.

Int. abd. obl. m.

Transv. abd. m.

Transversalis fascia

Peritoneum

Layers

of

the

abdominal

wall

Slide47

Superficial fascia

Adipose fascia (Camper)

Penis

Spermatic cord

Scrotum

Fascia lata

Line of unification

Fibrous fascia (Scarpa)

Int. abd. obl. (

apo.)

Superficial

fascia

of

abdominal

wall

: (

adipose

fascia

) and

connective

tissue

(

fascia

fibrosa

)

Slide48

*Adipose fascia (Camper)

*Fibrous fascia (Scarpa)

Perineal membrane

Tunica dartos

Symphysis

urethra

Structure

of

lower

abdominal

fasciae

*Superficial fascia

Superficial perineal fascia (Colles)

Slide49

49

Ext. abd. obl. m.

A

dductors

Rhomboideus

S

erratus

ant.

Pectoralis major

Int. abd. obl. m.

Gluteus maximus

Sartorius

Position

of

abdominal

muscles

in

mantaining

the

loop-system

of

the

skeletal

muscles

Slide50

50Functions of the abdominal

muscles

Movements of the trunk

Bending of the trunk (forwards, sideways), rotation of the trunk – in collaboration with the muscles of the back.

Stiffening the abdominal wall

Fixation of internal organs in position – according to the variation of the content of the stomach, urinary bladder and bowels.

Maintaining the abdominal pressure

Expiration, urination, defecation, coughing, sneezing,

vomiting, exertion of high muscular force, birth.

Breathing

Diaphragm + abdominal muscles.

Slide51

51

thoracic diaphragm

pelvic diaphragm

abdominal wall

Maintenance

of

the

intraabdominal

pressure

Slide52

52

thoracic diaphragm

pelvic diaphragm

abdominal wall

Maintenance

of

the

intraabdominal

pressure

Slide53

Ext. abd. obl. m.

Int. abd. obl. m.

Transversalis fascia

Peritoneum

Femoral artery

Femoral vein

Inguinal ligament

Spermatic cord

Inguinal

canal

T

ransv

.

abd. m.

Slide54

54

iliolumbal

superior gluteal

lateral sacral

obturator

external iliac

inferior gluteal

common iliac

internal iliac

uterine

internal pudendal

middle rectal

umbilical (sup. vesical)

inf. vesical

Internal

iliac

artery

Slide55

55Internal pudendal

artery

common iliac

external pudendal

external

iliac

internal iliac

femoral

dorsal penile

(subarcuate hiatus)

deep penile

(uro-genital diaphragm)

ant. scrotal

post. scrotal

internal pudendal

(greater sciatic foramen)

lateral sacral laterales

inf. rectal

perineal

a. of bulb of penis

(pelvic sacral foramens)

internal pudendal

(lesser sciatic foramen)

Slide56

Rectus-sheath

Urinary bladder

Vagina

Rectum

Rectus abdominis muscle

Inferior epigastric A&V

Broad abdominal muscles

External iliac artery