The inner surface of the anterior abdominal wall. Abdominal wall

86481 0

The anterior abdominal wall is bounded by the costal arch from above, the lower edge of the symphysis, inguinal folds and the iliac crest from below.

The structure of the anterior abdominal wall:
1 - umbilical ring; 2 - external oblique muscle; 3 - internal oblique muscle; 4 - transverse muscle; 5 - white line of the abdomen; 6 - rectus abdominis muscle; 7 - pyramidal muscle; 8 - superficial epigastric artery; 9 - Spigelian line

The lateral borders of the anterior abdominal wall run along the mid-axillary lines.

There are the following layers of the anterior abdominal wall:
1. Superficial layer: skin, subcutaneous fatty tissue and superficial fascia.
2. Middle layer: abdominal musculature with associated fascia.
3. Deep layer: transverse fascia, preperitoneal tissue and peritoneum.

The skin of the abdomen is a thin, flexible and flexible tissue. Subcutaneous adipose tissue can be expressed to a greater or lesser extent in all departments, with the exception of the navel, where there is practically no adipose tissue.

Next is the thin superficial fascia of the abdomen. In the thickness of the superficial and deep sheets of the superficial fascia, there are superficial blood vessels of the anterior abdominal wall (aa. Epigastricae superfacialies, extending from aa.femoralis towards the navel).

The abdominal muscles are formed in front by paired rectus abdominis muscles, and laterally - by three layers of muscles: the external oblique, internal oblique and transverse. The rectus abdominis muscle from above is attached to the costal arch, and from below to the pubic bones between the pubic tubercle and the pubic plexus. Paired pyramidal muscles, located anterior to the straight lines, start from the pubic bones and go up, woven into the white line of the abdomen.

Both muscles are located in the fascial sheath formed by the aponeuroses of the oblique and transverse abdominal muscles. In this case, in the upper third of the abdominal wall, the fibers of the aponeurosis of the external oblique muscle of the abdomen and part of the fibers of the internal oblique muscle form the anterior wall of the sheath of the rectus abdominis muscles. The posterior wall is formed by a part of the fibers of the aponeurosis of the internal oblique muscle and the fibers of the aponeurosis of the transverse muscle.

In the lower third of the abdomen (approximately 5 cm below the navel), the fibers of the aponeuroses of the superficial and deep oblique muscles and the transverse muscle run in front of the rectus abdominis muscles. The back wall of their vagina is formed by the transverse fascia and the peritoneum.

The lateral border of the rectus abdominis muscle (the so-called lunate line) is formed by the fascia of the lateral muscles. In the midline of the abdomen, the fibers of the fascial sheaths intersect, forming a white line of the abdomen, passing from the symphysis to the xiphoid process and separating the rectus abdominis muscles from each other.

Approximately in the middle between the xiphoid process and the pubis (which corresponds to the cartilage between the III and IV lumbar vertebrae) there is an opening - the umbilical ring. Its edges are formed by the fibers of the aponeurosis, and the bottom (umbilical plate) is a low-elastic connective tissue covered from the abdominal cavity with a transverse fascia, with which the peritoneum of the anterior abdominal wall is closely spliced ​​around the umbilical ring at a distance of 2-2.5 cm from its edges. It should also be noted that the white line is wider in the navel area than in other regions.

The blood supply to the rectus abdominis muscles is carried out mainly from a. epigastrica inferior, extending from a. iliaca externa at the level of the entrance to the inguinal canal. A. epigastrica inferior goes medially and upward, forming an arc located with a bulge downward, passes along the back wall of the vagina of the rectus abdominis muscle in the region of its middle and at the level of the navel anastomoses with a. epigastrica superior from system a. mammalia interna.

Blood supply to the rectus abdominis muscles:
1 - external iliac artery; 2 - lower epigastric artery; 3 - round ligament of the uterus; 4 - internal thoracic artery; 5 - navel; 6 - median umbilical fold; 7 - middle umbilical fold

Immediately after leaving a. iliaca externa a. the epigastrica inferior intersects with the round ligament entering the inguinal canal. Internal landmark a. epigastrica inferior - pl. umbilicalis lat., in which this artery is accompanied by the veins of the same name.

From the inside, the muscle layer of the anterior abdominal wall is lined with a transverse fascia passing from above to the diaphragm, then to m. iliopsoas, the anterior side of the lumbar spine and descends further into the pelvis. The transverse fascia is considered as part of the connective tissue layer that serves as the basis for the peritoneum. Between the transverse fascia and the peritoneum is the preperitoneal tissue, a layer of which grows downward and passes into the parietal tissue of the pelvis.

Thus, the parietal peritoneum, which covers the inside of the anterior abdominal wall, is weakly connected to the underlying layers, with the exception of the umbilical ring, where it is closely fused with the transverse fascia and the fascia of the white line of the abdomen on an area 3-4 cm in diameter.

G.M. Savelieva

Normal anatomy of the anterior abdominal wall

The anterior abdominal wall of a person performs very important functions:

• Abdominal support;
• Resistance to fluctuations in intra-abdominal pressure;
• Participation in the movements of the trunk, shoulder, and pelvic girdle;
• Maintaining body positions;
• Also, the abdominal muscles are involved in the process of urination and defecation;

The human abdominal wall is a multilayer structure, which includes skin, subcutaneous fatty tissue, muscles and thin layers of connective tissue (fascia) separating them. The abdominal muscles have tendons that connect in the middle of the abdomen to form a white line - the joint tendon of the abdominal muscles (aponeurosis).

The skin is the very first layer of the anterior abdominal wall. The properties of the skin directly depend on the number of years, genetics and the patient's lifestyle. Patients who come to the surgeon to have abdominal plastic surgery have stretched and inelastic skin.

Adipose tissue is the next layer just below the skin. The thickness of the fat layer is different for all people. The average thickness of adipose tissue is 2-5 cm, but it can be much thinner or thicker. Adipose tissue consists of two layers:

• surface layer
• deep layer.

Between the superficial and deep layers, there is a thin plate of connective tissue - the superficial fascia.

The superficial layer is supplied with blood better than the deep one and is characterized by a dense type of fat.

Behind the layer of fatty tissue are the abdominal muscles. Vertical rectus muscles run on both sides of the abdomen.

There are several forms of the rectus muscles and the white line of the abdomen.

1 form - in the navel;

The first form of the white line is the most common. It is inherent in half of men and 3/4 of women.

2 form - above the navel;

It occurs in 1/3 of men and very rarely in women with a male abdomen.

3 form - below the navel

This form is quite rare and is characteristic only of the fair sex.

4 form - in shape it resembles a narrow, even tape, which tapers in the hypogastrium.

The 4th type of white line is characteristic for the cylindrical shape of the abdomen and occurs in 15-16% of men and women.

In women, during pregnancy, the rectus abdominis muscles diverge so that the fetus feels comfortable. The degree of divergence of the rectus abdominis muscles is different for everyone, and depends on the physical fitness of women.

As a rule, after childbirth, the rectus abdominis muscles contract, and they begin to converge back towards the center. But not all of them are restored to their original state, which leads to diastasis (divergence) of the rectus abdominis muscles.

In addition to the rectus muscles, the musculo-aponeurotic layer of the anterior abdominal wall includes:

6 broad lateral abdominal muscles

These include the right and left external obliques, internal oblique and transverse muscles,

Muscle tendons (aponeuroses).

All these muscles are closely related to each other, they are the same nerves;

The peritoneum is located under the layers of muscles. The peritoneum is a membrane behind which the internal organs are located.

Saturation of the abdominal wall with blood is provided by a large number of arteries extending from the chest and pelvis. Among all the arteries supplying the abdominal cavity, the main ones are the upper epigastric arteries, which are located in the rectus abdominis muscles.

In the very middle of the rectus muscle, the upper epigastric arteries meet with the lower epigastric arteries and form many connections between themselves. These major arterial vessels, in addition to the muscular system of the abdomen, supply blood to the skin and subcutaneous fat.

From these vessels, along their entire length, the perforating arteries depart. The perforating arteries, heading up, supply blood to the superficial tissues. The largest number of perforating vessels is concentrated in the navel.

The lower parts of the abdominal wall are supplied with blood through the lower epigastric arteries. Its lateral sections are supplied with blood coming from the intercostal arteries, which, due to a branch from the aorta, have a very intense blood flow.

Thanks to such a number of large arteries and many connections (anastomoses) between them, excellent conditions are created for the blood supply to the abdominal wall in its various parts.

The abdominal wall should be understood as all the walls surrounding the abdominal cavity, that is, not only in front and from the sides, but also in the lower thoracic region, in the pelvis, lumbar regions, spine and diaphragm. However, in practice, speaking about diseases of the abdominal wall, they always mean only the anterior and lateral parts of it, consisting mainly of musculo-connective tissue formations.

When examining each patient, a number of characteristic features of the anterior abdominal wall should be taken into account, which affect the configuration of the shape of the abdomen. The latter depends on gender, this or that body type, on the deposition of fat and on a number of random moments. With satisfactory or excessive development of subcutaneous adipose tissue, the outlines of the muscle layers are usually not clearly outlined, or almost completely invisible. In persons with a very weak development of subcutaneous fat, especially if they have well-developed muscles, characteristically located linear grooves are visible on the anterior abdominal wall. This is the so-called white line (from the xiphoid process to the symphysis), in the form of vertically running grooves along the edges of the rectus muscles, according to the location of the so-called lunar spigelian line and in the form of 2 zigzag lines-grooves located on both sides in the lateral sections of the wall at the border of the transition from the abdominal wall to the chest wall. These last furrow lines are due to the interlacing of the bundles of the external oblique muscle and the anterior dentate. On the territory of the location of both rectus muscles, one can see individually expressed then 2, then 3 oblique-transverse or zigzag retracted furrow lines at the location of the tendon bridges,

In the lateral sections of the trunk in non-obese and muscular patients, the abdominal wall usually forms symmetrical lumbar notches on both sides. The clarity of their contours depends on the tone of the lateral muscles of the abdominal wall, especially the transverse one, on the presence or absence of diastasis of the rectus muscles and on the degree of deposition of subcutaneous adipose tissue in the lumbar regions.

An important property of the anterior abdominal wall is its constant participation in respiratory movements. Normally, this participation is distinct; under pathological conditions, it changes significantly. In men, these respiratory movements are distinct, in women, due to their inherent thoracic type of breathing, they are often almost imperceptible.

Areas of the anterior abdominal wall

For the convenience of research and description, it is customary to conventionally divide the anterior abdominal wall into several sections. The most satisfactory for practical purposes is the modified Tonkov scheme. According to this scheme, horizontal lines are drawn: one through the lowest points of the tenth ribs, the second through the highest points of the iliac crests. These 2 lines outline the boundaries of 3 horizontally located areas of the anterior abdominal wall: epigastric, mesogastric and hypogastric.

The other two, now vertical, lines are drawn along the edges of the rectus muscles from the ribs to the tubercles of the pubic bone. Thanks to these lines, 3 sections are outlined in each of the mentioned horizontally located areas. It is more correct to call them exactly the departments of the mentioned areas.

Thus, in epigastric the area of ​​the anterior abdominal wall should be distinguished from the epigastric region (the area of ​​the left lobe of the liver, stomach, lesser omentum), the right hypochondrium (the area of ​​the gallbladder, the right lobe of the liver, hepatic flexure of the large intestine and duodenum) and the left hypochondrium (the area of ​​the spleen , splenic flexure of the colon).

V mesogastric areas of the anterior abdominal wall, vertical lines limit the umbilical region (the area of ​​the loops of the small intestines, the greater curvature of the stomach, the transverse colon, the greater omentum, the pancreas), the right flank (the area of ​​the ascending colon, part of the small intestines, the right kidney with the ureter) and the left flank (the area of ​​the descending colon, part of the small intestine and the left kidney with the ureter).

Finally, in hypogastric the areas of the anterior abdominal wall will be outlined: the supralonline (the area where the loops of the small intestine, bladder, uterus are located), the right ileal-inguinal region (the area where the cecum is located with the appendix), and the left ileo-inguinal region (the area where the sigmoid colon is located).

When examining the anterior abdominal wall in profile, the outlines of its anterior border can be very different. The most correct should be considered such outlines, when in the epigastric region a slightly slight depression is noticeable deeper than the costal arch, in the mesogastric region there is a slight anterior stand, and in the hypogastric region there is a distinct standing anteriorly with a noticeable rounding and even with some tendency to overhang.

The aponeuroses of the lateral muscles, as you know, surround the rectus muscles in front and behind in the form of a case called the vagina of the rectus muscles (vagina m. Recti abdominis) and extending upward almost to the xiphoid process (more correctly - to the Genke line), downward - a few centimeters below the navel to semicircular (arcuate) lines of Douglas (linea arcuata - Douglasii). Downward, these aponeuroses no longer play the role of a sheath of the rectus muscles, since their posterior plate, which previously encircled each rectus muscle from behind, is now absent and is merged with the anterior plate; together with it, it is now located only on the front surface of the rectus muscles. Thus, below the Douglas lines, the rectus muscles in the back do not have a sheath from the aponeuroses of the lateral stretching muscles. During this length, the white line and rectus muscles almost do not experience stretching and therefore diastasis of the rectus muscles below the Douglas lines almost never occurs. The resulting traumatic hematomas of the rectus muscles, spreading behind them, usually tend to remain limited for a long time by the posterior layer of the vagina, retain more delineated boundaries and slightly irritate the parietal layer of the peritoneum. On the contrary, the same hematomas, when they are located in the rectus muscle or behind it, tend to acquire vague outlines, intensively spread along the preperitoneal tissue upward, to the sides, in front of the bladder into the tissue of the prevesical reticular space - (spatium praevesicale seu cawum Retzii) and are accompanied by more pronounced signs of irritation of the parietal layer of the peritoneum. The same applies to the course of various suppurative or other inflammatory processes.

If the longitudinal gluttony is performed along the white line from the xiphoid process to the Douglas lines, the gaping of the surgical wound is always more pronounced. It depends on the fact that here the columns of the rectus muscles undergo a powerful stretching under the influence of lateral traction carried out by both plates of the aponeuroses of the lateral muscles. When gluttonous below the Douglas lines, such a gaping does not work. Therefore, suturing the wound of the anterior abdominal wall after a longitudinal ventral section along the midline meets great difficulties when it is performed above the Douglas lines, and is extremely easy to carry out in the hypogastric region, because at this level of the posterior sheath of the vagina there are no longer rectus muscles, and the stretching effect of the lateral muscles becomes negligible ... For the same reason, all transverse incisions can be sewn very easily.

The article was prepared and edited by: surgeon

BASIC HERNIZATION

I. Hastinger, V. Husak, F. Köckerling,

I. Horntrich, S. Schwanitz

With 202 pictures (16 color) and 8 tables

MUNTSEKH, KITIS Hannover - Donetsk - Cottbus

General information

About hernias of the abdominal wall

With her surgical anatomy

A hernia of the abdominal wall is a disease in which there is a protrusion of the viscera, covered by the parietal leaf of the peritoneum, in the area of ​​areas not protected by muscles or covered by them, but with fewer layers ("weak" spots).

The exit of internal organs not covered by the peritoneum is called prolapse or eventration with damaged skin.

The "weak" areas, for example, include: the inguinal gap, the medial third of the vascular lacuna, the navel area, the white line of the abdomen, the lunate (spigelian) line, the opening or gap in the xiphoid process of the sternum, and others (Fig. 1.1).

The protrusions that have arisen here are respectively called inguinal, femoral, umbilical, white line, spi-helium and xiphoid process external hernias. The last two types of hernias are observed, according to various authors, in 0.12-5.2% of cases (Krymov A. 1950; Voskresensky N., Gorelik S. 1965).

Hernias are also classified as congenital and acquired. The latter are traumatic, pathological and artificial. Traumatic hernias occur after trauma to the abdominal wall.

This also includes postoperative and recurrent hernias. Pathological hernias are formed when

the loss of the integrity of individual layers of the abdominal wall due to various diseases.

Hernias are distinguished between complete and incomplete, reducible and irreducible, complicated and uncomplicated.

The most formidable complication is the entrapment of the viscera in the area of ​​the hernial orifice. In this case, the organs can be viable or with irreversible pathological changes, as well as with a phlegmonous process in the area of ​​hernial protrusion.

In the origin of hernias, the primary role belongs to the factor of increased intra-abdominal pressure (functional prerequisite) and the presence of a "weak" spot (nonmuscular area) of more than average size (anatomical prerequisite). Hernia formation is possible only with a simultaneous combination of the above prerequisites.

Factors that increase intra-abdominal pressure include: frequent crying in infancy and childhood; debilitating cough; constipation, diarrhea; various diseases that make it difficult to urinate; hard physical labor; frequent vomiting; playing wind instruments; repeated difficult childbirth, etc.

Thus, the formation of hernias can be due to local and general causes.

The latter can be subdivided into predisposing and producing. Predisposing factors are heredity, age, sex, degree of fatness, physique, insufficient physical education, etc.

Productive causes include increased intra-abdominal pressure and weakening of the abdominal wall. Local causes are due to the peculiarities of the anatomical structure of the area where the hernia formed.

Of the local predisposing reasons, the following should be noted: noninfection of the vaginal process of the peritoneum, weakness of the posterior wall and deep opening of the inguinal canal, etc.

Understanding of the above provisions and surgical treatment of hernias are associated with knowledge of the topographic anatomy of the anterior abdominal wall. A lot of studies have been devoted to this issue (Fruchaud H., 1956; Lanz T. von, Wach-smuth W, 1972; Spaw AT, Ennis BW, SpawLR, 1991; Loeweneck H., Feifel G., 1993; Sobotta J., Becher H ., 1993; Mame-ren HV, Go PM, 1994; Annibali Ft., 1995).

Therefore, we consider it necessary to dwell only on the basic, practically important details of the surgical anatomy of the area under consideration.

Layers of the anterior abdominal wall

The layers of the anterior abdominal wall are: skin, subcutaneous fatty tissue, superficial and intrinsic fascia, muscles, transverse fascia, pre-peritoneal tissue, parietal peritoneum.

The skin in the navel is firmly fused with the umbilical ring and scar tissue, which is the remainder of the umbilical cord.

The superficial fascia consists of two sheets.

The superficial layer passes to the thigh without attaching to the inguinal ligament. The deep leaf (Thomson's plate) is better expressed in the hypogastric region and contains more fibrous fibers.

A deep leaf is attached to the inguinal (pupartovoy) ligament, which must be taken into account when surgery for an inguinal hernia.

When suturing the subcutaneous tissue, the deep layer of the fascia should be grasped as an anatomical supporting tissue.

The intrinsic fascia of the abdomen covers the external oblique muscle, its aponeurosis, the anterior wall of the rectus sheath and attaches to the inguinal ligament.

It is an anatomical obstacle for the lowering of the inguinal hernia below the pupar ligament and also does not allow the femoral hernia to move upward.

A well-defined leaf of its own fascia in children and women is sometimes mistaken for the aponeurosis of the external oblique muscle of the abdomen.

Vessels the anterior abdominal wall form a superficial and deep network, have a longitudinal and transverse direction (Fig. 1.2).

The surface longitudinal system is formed by: a. epigastrica superficialis, departs from the femoral artery, and superficial branches of a. epigastrica superior, from the internal thoracic artery.

The superficial epigastric artery crosses the front of the inguinal ligament at the border of the inner and middle third of it and goes to the navel, where it anastomoses with the superficial and deep branches of the superior epigastric artery, as well as with a. epigastrica inferior, from the deep web.

Rice. 1.1."Weak" places of the anterior abdominal wall

1 - inguinal gap; 2 - the medial third of the vascular lacuna and the outer ring of the femoral canal; 3 - navel area; 4 - white line of the abdomen; 5 - crescent (spigelian) line

Rice. 1.2. Blood vessels and nerves of the superficial layer of the anterior abdominal wall (according to Voilenko V.N. et al.)

1 - rr. cutanei anteriores et laterales nn. intercostales; 2 - rr. cutanei anteriores et laterales nn. iliohypogastricus; 3 - a. et v. pudenda externa; 4 - v. femoralis; 5 - a. et v. epigastrica superficialis; 6 - rr. laterales cutanei aa. intercostales posteriores; 7 - v. thoracoepigastrica

Rice. 1.3. Muscles of the anterior abdominal wall. On the left, the anterior wall of the vagina was partially removed m. recti abdominis and exposed pyramidal muscle (according to Voilenko V.N. et al.)

1 - m. obliquus externus abdominis; 2 - T. rectus abdominis; 3 - intersectio tendinea; 4 - aponeurosis m.obliqui externi abdominis; 5 - m. piramidalis; 6 - funiculus spermaticus; 7 - n. ilioinguinalis; 8 - n. iliogipogastricus; 9 - anterior wall of the vagina m. recti abdominis; 10 - nn. intercostales

Rice. 1.4. The anterior abdominal wall. Removed m on the right. obliquus externus abdominis and the vagina is partially excised m. recti abdominis; on the left, the so-called transversus abdominis and the posterior wall of the vagina m. recti abdominis (according to Voilenko V.N. et al.)

1 - a. et v. epigastrica superior; 2 - posterior wall of the vagina m. recti abdominis; 3 - aa., Vv. et nn. intercostales; 4 - m. transversus abdominis; 5 - n. iliogipogastricus; 6 - linea arcuata; 7 - a. et v. epigastrica inferior; 8 - m. rectus abdominis; 9 - n. ilioinguinalis; 10 - m. obliquus internus abdominis; 11 - aponeurosis t. Obliqui interni abdominis; 12 - anterior and posterior walls of the vagina m. recti abdominis

The transverse superficial blood supply system includes: superficial branches of the six lower intercostal and four lumbar arteries, a. cir-cumflexa ilium superficialis, a.pudenda externa.

The superficial artery surrounding the ilium goes up and outward, to the anterior superior iliac spine. The external pudendal artery goes to the external genital organs, branching into separate branches at the place of attachment of the pupar ligament to the pubic tubercle.

Deep blood supply to the abdominal wall: longitudinal - deep branches a. epigastrica superior and a. epi-gastrica inferior - lie behind the rectus muscle (first on the back wall of its vagina, then on the back surface of the muscle itself or in its thickness).

Transverse deep system - deep branches of the six lower intercostal and four lumbar arteries (located between the internal oblique and transverse muscles), a. circumflexa ilium profunda, from the external iliac artery, lies with a. epigastrica inferior in the preperitoneal fat between the transverse fascia and the peritoneum.

Venous outflow is carried out through the veins of the same name, providing a connection between the axillary and femoral vein systems, forming extensive cava-caval anastomoses. In addition, the venous network of the anterior abdominal wall in the navel anastomoses with vv. pa-raumbilicales, located in the round ligament of the liver; as a result, a connection is formed between the portal system and the vena cava (portocaval anastomoses).

Lymphatic vessels lymph is diverted from the upper half of the abdominal wall to the axillary, from the lower to the inguinal lymph nodes. They are coming

along the superior and inferior epigastric arteries. The first flow into the anterior intercostal nodes accompanying a. thoracica interna, the second - in the lymph nodes, which are located along the external iliac artery.

Innervation the superficial layer of the anterior abdominal wall is carried out by the branches of the six lower intercostal nerves (pass between the internal oblique and transverse muscles), as well as the branches of the ilio-hypogastric and ilio-inguinal nerves. The latter innervates the skin in the pubic area, and item iliohypogastricus - in the area of ​​the external opening of the inguinal canal (Mandelkow H., Loeweneck H., 1988) (Fig. 1.2, 1.3).