Anatomy of the anterior abdominal wall. Surgical anatomy of the anterior abdominal wall Posterior surface of the anterior abdominal wall

TOPOGRAPHIC ANATOMY OF THE ANTERIOR ABDOMINAL WALL.

HERNIA SURGERY.

AREA OF THE ANTERIOR ABDOMINAL WALL

2 horizontal lines (linea bicostarum et linea bispinarum) divide the anterior abdominal wall into 3 sections: I – epigastrium; II – womb; III - hypogastrium

2 vertical lines passing

Along the outer edge of the rectus muscles, the sections are divided into areas:

Epigastric region: 1 - epigastric; 2 – left and right hypochondrium.

Womb: 3 – umbilical; 4 - left and right side.

Hypogastrium: 5 – pubic; 6 - left and right inguinal.

STRUCTURE OF THE ANTERIOR ABDOMINAL WALL

Layers: skin – thin, easily stretchable; PZhK –

expressed individually; superficial fascia –

below the navel it splits into 2 leaves;

own fascia; muscles - external and internal

oblique, transverse, straight; fascia endoabdominalis; preperitoneal tissue; parietal peritoneum

Blood supply. Arteries have longitudinal and transverse directions and are distinguished:

Superficial: superficial epigastric; superficial, circumflex ilium; branches of the external genitalia and superficial branches of the intercostal

Deep: superior epigastric; inferior epigastric;

deep, encircling the ilium; 6 lower intercostal; 4 lumbar

Innervation (nerves have only an oblique direction): 6 lower intercostal; iliohypogastric nerve; ilioinguinal nerve

VAGINA OF RECTUS ABDOMINUS MUSCLES

ABOVE BUTTON:

Front wall:

Aponeurosis of the external + anterior layer of the aponeurosis of the internal oblique muscles

Back wall:

Posterior leaf of the aponeurosis of the internal oblique + aponeurosis of the transverse muscles + transverse fascia

BELOW BUTTON:

Front wall:

Aponeurosis of the external + internal oblique + aponeurosis of the transverse muscles

Back wall:

Transversalis fascia

ACCESS TO THE ABDOMINAL ORGANS (LAPAROTOMY)

Groups of cuts:

longitudinal;

transverse;

oblique;

corner;

combined.

INNER SURFACE OF THE ANTERIOR ABDOMINAL WALL

PERITONEAL FOLDS:

plica umbilicalis mediana (unpaired) - a fold of the peritoneum above the overgrown urinary duct -1;

plica umbilicalis medialis (paired) - fold above obliterated a. umbilicalis – 2;

plica umbilicalis lateralis (paired) fold of peritoneum above a. and v. epigastrica inferior – 3.

Between the folds of the peritoneum are located

POTS:

Supravesical fossa, fossa supravesicalis – 1;

Medial inguinal fossa, fossa inguinalis medialis – 2;

Lateral inguinal fossa, fossa inguinalis lateralis – 3.

Below the inguinal fold is the femoral fossa, fossa femoralis - 4.

The pits are where hernias emerge.

Weak spots in the abdominal wall

- these are places where there are holes or gaps in the fascia and aponeuroses or between the edges of the muscles and where there is an absence of some elements of the muscular aponeurotic layers of the abdominal wall.

highlight:

1) holes and crevices in the linea alba of the abdomen

2) umbilical ring

3) fossae of the anterior abdominal wall (supravesical, medial, lateral, femoral)

4) Spigelian line

Linea alba

Formed by the interweaving of tendon fibers of the aponeuroses of all three pairs of broad abdominal muscles

With a long-term increase in the volume of the abdominal cavity, the tendon fibers of the white line can stretch and move apart, which leads to the formation of weak spots.

Hernias of the linea alba most often occur above the umbilicus, where the linea alba is thin and wide

NAVLIK AREA

Retracted scar at the site of the umbilical ring.

The layers in the navel area consist of tightly fused together:

skin;

scar tissue;

transverse (umbilical) fascia;

peritoneum.

Anatomical features predisposing to the formation of umbilical hernias are:

increasing the diameter of the ring;

incomplete closure by the umbilical fascia;

the presence of peritoneal diverticula in the area of ​​the umbilical ring (more common in men).

INGUINAL CANAL

Located in the inguinal triangle

Boundaries of the inguinal triangle:

Above - a horizontal line along the border between the middle and outer 1/3 of the inguinal ligament;

From the inside - the outer edge of the rectus abdominis muscle;

Outside below is the inguinal ligament.

The channel has 2 rings:

Superficial (formed by fibers of the aponeurosis of the external oblique abdominal muscle, which split into two legs)

Deep (corresponds to the lateral inguinal fossa - an opening in the intra-abdominal fascia through which the spermatic cord passes in men and the round ligament of the uterus in women)

The channel has 4 walls:

anterior – aponeurosis of the external oblique muscle

posterior – transverse (intra-abdominal) fascia

upper - lower edges of the internal oblique and transverse abdominal muscles

inferior - inguinal ligament

FEMORAL CHANNEL (NO NORMAL)

The superficial ring of the femoral canal corresponds to the hiatus saphenus in the superficial layer of the fascia lata, which is limited by the falciform margin.

The femoral canal has 3 walls:

Anterior – superficial layer of fascia lata (superior horn of the falciform margin);

External – sheath of the femoral vein;

Posterior – deep layer of fascia lata (f. pectinea).

The length of the canal is from 1 to 3 cm.

Hernia - exit of internal organs covered with parietal peritoneum through weak spots or artificial openings of the anterolateral abdominal wall outside the abdominal cavity .

Hernia elements:

1. Hernial orifice - a gap or hole in the abdominal wall through which the abdominal organs emerge;

2. Hernial sac - formed by the parietal layer of the peritoneum. It is distinguished: neck; body and bottom;

3. Contents of the hernial sac - abdominal organ

CLASSIFICATION OF HERNIA

by time of appearance and development features:

- purchased

- congenital

by localization:

- external

- internal

at exit point:

- inguinal (oblique, straight)

- femoral

- umbilical

- linea alba

- lumbar

- ischial

- perineal

- diaphragmatic

Factors contributing to the occurrence of hernias:

1) the presence of “weak spots” in the muscular aponeurotic layer of the abdominal wall (“predisposing factor”).

2) a sharp increase in intra-abdominal pressure (“production factor”)

INGUINAL HERNIA

OBLIQUE. Hernial orifice – lateral inguinal fossa

DIRECT. Hernial orifice - medial inguinal fossa

PURCHASED. The hernial sac is the parietal peritoneum. The testicle has a tunica vaginalis

CONGENATE. Hernial sac - ungrown vaginal process of the peritoneum

HERNIA

The operation should be radical, simple and least traumatic

It consists of three stages:

1) access to the hernial orifice and hernial sac;

2) treatment and removal of the hernial sac;

3) elimination of the abdominal wall defect (closing the hernial orifice).

1ST STAGE - ACCESS

requirements:

Simplicity;

Safety;

Possibility of a wide view of the hernial canal or hernial opening.

The condition of the tissues in the area of ​​the hernial orifice (inflammation, scars) must be taken into account.

STAGE 2 – TECHNIQUES:

1. Careful isolation of the hernial sac from the surrounding tissues to the hernial orifice (the “hydraulic preparation” method, injection of 0.25% novocaine around the wall of the sac)

2. Opening the hernial sac in the fundal area and repositioning the hernial contents

3. Stitching and ligation of the neck of the hernial sac with its subsequent cutting off

3rd STAGE: METHODS OF PLASTIC HERNIA ORUTA

1) simple;

2) reconstructive;

3) plastic.

Simple ways - closing the abdominal wall defect with sutures.

Reconstructive methods - changing the design of the hernial orifice in order to strengthen them.

according to Girard (1).

a - suturing the internal oblique and transverse abdominal muscles to the inguinal ligament;

b - suturing the upper flap of the aponeurosis of the external oblique abdominal muscle to the inguinal ligament;

c - suturing the lower aponeurosis flap onto the upper one.

according to Spasokukotsky

simultaneous placement of sutures through the upper flap of the aponeurosis of the external oblique muscle of the abdomen, the transverse and internal oblique muscles and the inguinal ligament in front

spermatic cord

KIMBAROVSKY SEAM (2)

Plastic surgery of the inguinal canal according to Martynov (1) suturing the internal flap of the aponeurosis of the external oblique muscle of the abdomen to the inguinal ligament and the external to the internal

REAR WALL PLASTY

Plastic surgery of the inguinal canal according to Bassini (2):

a - suturing the internal oblique, transverse and rectus abdominis muscles to the inguinal ligament behind the spermatic cord;

b - suturing the internal and external flaps of the aponeurosis of the external oblique muscle of the abdomen in front of the spermatic cord.

Plastic surgery according to Postempsky (in old age with flabbiness of the anterior abdominal wall)

The upper flap of the aponeurosis of the external oblique muscle and the internal oblique, transverse muscle are sutured behind the spermatic cord to the inguinal ligament, and the lower flap is placed on the upper one.

The cord is located under the skin.

PLASTY FOR FEMORAL HERNIA

With femoral access.

According to Bassini - placing sutures connecting the inguinal ligament with the pectineal (Cooper) ligament.

When accessed through the inguinal canal.

According to Ruji - suturing the inguinal ligament to the pectineal (Cooper) ligament from the side of the abdominal cavity.

PLASTY FOR UMBILICAL HERNIA AND LINE ABDOMINAL HERNIA

according to Mayo

a - suturing the lower flap of the aponeurosis to the upper flap with a row of U-shaped sutures;

b - suturing the upper aponeurosis flap to the lower flap with a series of interrupted sutures

according to Sapezhko

a - suturing the edge of the right aponeurosis flap to the posterior wall of the vagina of the left rectus abdominis muscle;

b - suturing the left aponeurosis flap to the anterior wall of the vagina of the right rectus abdominis muscle.

according to Lexer

a - placing a purse-string suture around the umbilical ring;

b - application of interrupted sutures to the anterior wall of the sheaths of the rectus abdominis muscles.

SLIDING HERNIA

The hernial sac is partially formed by the wall of a hollow organ, mesoperitoneally covered with peritoneum (bladder, cecum, less often other organs)

Features of operational technology:

1. The hernial sac is widely opened at a distance from the organ;

2. The hernial contents are reduced and a purse-string suture is placed from the inside of the hernial sac at the junction of the peritoneum with the organ;

3. Excess hernial sac is cut off

STARGED HERNIA

Infringement options:

Parietal or Richter (incarceration of one wall of the intestine without disrupting the movement of contents)

Antegrade (the strangulated loop of intestine is located in the hernial sac)

Retrograde (the strangulated loop of intestine is located in the abdominal cavity).

The latter are accompanied by the development of the clinic of intestinal obstruction.

You can't set it!

sequence of stages of their surgical treatment:

Operative access to the hernial sac

Opening the hernial sac

Fixation of hernial contents

Dissection of the strangulating ring (hernia orifice)

Inspection of hernial contents and assessment of organ viability by color, luster, peristalsis, pulsation of mesenteric vessels)

Normal anatomy of the anterior abdominal wall

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

• Organ support abdominal cavity;
• Resistance to fluctuations in intra-abdominal pressure;
• Participation in movements of the torso, 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 fat, muscles and thin layers separating them. connective tissue(fascia). The abdominal muscles have tendons that connect down the middle of the abdomen to form the linea alba, the conjoined abdominal muscle tendon (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 lifestyle of the patient. Patients who come to the surgeon for a tummy tuck have stretched and inelastic skin.

Adipose tissue represents the next layer, lying directly under the skin. The thickness of the fat layer is different for all people. The average thickness of adipose tissue is 2-5 cm, but 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. The vertical rectus muscles run on both sides of the abdomen.

There are several forms of the rectus muscles and linea alba.

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

2 form - above the navel;

Occurs in 1/3 of men and very rarely in women with a male abdominal shape.

3 form - below the navel

This form is quite rare and is typical only for the fair sex.

4 form – the shape resembles a narrow, even ribbon, which tapers in the hypogastrium.

Type 4 of the white line is typical for a cylindrical abdomen and occurs in 15-16% of men and women.

In women, during pregnancy, the rectus abdominis muscles diverge to make the fetus feel 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 to the center. But not everyone recovers to their original state, which leads to diastasis (divergence) of the rectus abdominis muscles.

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

6 broad lateral abdominal muscles

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

Muscle tendons (aponeuroses).

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

Beneath the layers of muscle is the peritoneum. The peritoneum is a membrane behind which the internal organs are located.

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

In the very middle of the rectus muscle, the superior epigastric arteries meet the inferior epigastric arteries and form many connections with each other. These main arterial vessels, in addition to the abdominal muscular system, supply blood to the skin and subcutaneous fat.

Perforating arteries extend from these vessels along their entire length. Perforating arteries, going upward, supply blood to the superficial tissues. The largest number of perforating vessels is concentrated in the umbilical region.

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

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

Borders and areas of the anterior abdominal wall. The anterior abdominal wall is bounded above by the costal arches, below by the inguinal ligaments and the upper edge of the symphysis. It is separated from the posterior abdominal wall by lines running from the anterior ends of the 12th ribs vertically down to the crests of the iliac bones.

The anterior abdominal wall is divided into three main regions: epigastric, celiac and hypogastric. The boundaries between these areas are two horizontal lines, one of which connects the ends of the X ribs, and the other - the anterior superior iliac spines. Each of these main areas is subdivided into three more areas by two vertical lines running along the outer edges of the rectus abdominis muscles. Thus, 9 regions are distinguished: regio epigastrica, regio hypochondriaca dextra et sinistra, regio umbilicalis, regio lateralis dextra et sinistra, regio pubica, regio inguinalis dextra et sinistra (Fig. 1).

1. Abdominal areas.

1 - regio epigastrica; 2 - regio hypochondriaca sinistra; 3 - regio umbilicalis; 4 - regio lateralis sinistra; 5 - regio inguinalis sinistra; 6 - regio pubica; 7 - regio inguinalis dextra; 8 - regio lateralis dextra; 9 - regio hypochondriaca dextra.

Layers of the anterior abdominal wall. The anterior abdominal wall is divided into superficial, middle and deep layers.

Surface layer. The superficial layer includes the skin, subcutaneous tissue and superficial fascia.

The skin of the anterior abdominal wall is thin, elastic and mobile. In the area of ​​the navel, it is firmly fused with the umbilical ring and scar tissue, which is a remnant of the umbilical cord. Subcutaneous fatty tissue is expressed differently; It reaches greater development in the lower parts of the abdominal wall. The superficial fascia runs through the fiber, consisting of two layers: superficial and deep. The superficial layer of fascia continues downwards to the anterior region of the thigh, while the deep layer is attached to the inguinal ligament.

Blood supply superficial layer is carried out through six lower intercostal and four lumbar arteries, which go to subcutaneous tissue, perforating the muscle layer. In addition, the superficial epigastric artery branches out in the subcutaneous tissue of the lower abdominal wall, as well as branches of the superficial artery surrounding the ilium and the external pudendal artery. Superficial epigastric artery, a. epigastrica superficialis, a branch of the femoral artery, crosses the inguinal ligament in front at the border of its inner and middle third and goes to the umbilical region, where it anastomoses with the superior and inferior epigastric arteries. Superficial artery surrounding the ilium, a. circumflexa ilium superficialis, goes up and outward, to the anterior superior iliac spine. External pudendal artery, a. pudenda externa, usually double, arises from the femoral artery and goes to the external genitalia; its individual branches branch near the place of attachment of the inguinal ligament to the pubic tubercle.

Venous drainage carried out through veins, which, anastomosing among themselves, form a superficial venous network. In the lower part of the anterior abdominal wall there are veins that accompany the arteries of the same name and flow into the femoral vein (v. epigastrica superficialis, vv. pudendae externae, v. circumflexa ilium superficialis). In the upper part of the anterior abdominal wall there is v. thoracoepigastrica, in the umbilical area it anastomoses with v. epigastrica superficialis, and then, heading upward and outward, flows into v. thoracalis lateralis or in v. axillaris.

Thus, the venous network of the anterior abdominal wall communicates with both the superior and inferior vena cava and can be considered as an extensive cavacaval anastomosis. In addition, the venous network of the anterior abdominal wall in the umbilical area anastomoses with vv. paraumbilicales, located in the round ligament of the liver; As a result, a connection is formed between the portal vein system and the vena cava: portacaval anastomosis.

In cases of congestion in the inferior vena cava or in the portal vein, the network of saphenous veins of the anterior abdominal wall expands and forms collateral pathways that drain blood from lower limbs and abdominal organs into the superior vena cava. With thrombosis of the portal vein or cirrhosis of the liver, the veins of the anterior abdominal wall increase in size so much that they are sometimes quite clearly visible under the skin, especially in the navel area (caput Medusae).

Lymphatic vessels superficial layer drains lymph from the upper half of the abdominal wall to the axillary The lymph nodes, nodi lymphatici axillares, from the lower - to the inguinal lymph nodes, nodi lymphatici inguinales superficialis. Besides, lymphatic vessels The superficial layer is anastomosed with the lymphatic vessels of the middle (muscular) and deep layer.

Innervation The superficial layer of the anterior abdominal wall is carried out by the branches of the six lower intercostal nerves, as well as by the branches of the iliohypogastric and ilioinguinal nerves. From the intercostal nerves into the subcutaneous tissue and further into the skin are sent. cutanei abdominis laterales et years. cutanei abdominis anteriores. The former pierce the external oblique muscle of the abdomen along the anterior axillary line and are divided into anterior and posterior branches that innervate the skin of the anterolateral abdominal wall, the latter pass through the sheath of the rectus abdominis muscle and innervate the skin in the anterior abdominal wall. The iliohypogastric nerve, n. iliohypogastricus, innervates the skin in the area of ​​the external opening of the inguinal canal, the ilioinguinal nerve, n. ilioinguinalis, innervates the skin in the area of ​​mons pubis.

Superficial nerves, arteries and veins are shown in Fig. 2.

2. Blood vessels and nerves of the superficial layer of the anterior abdominal wall.

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

Middle layer. The middle, muscular layer of the anterior abdominal wall consists of the rectus, oblique and transverse abdominal muscles (Fig. 3, 4). They are located along the entire length of the anterior abdominal wall and represent a rather thick muscular plate that supports the abdominal viscera.

In the anterior section of the abdominal wall there are the rectus abdominis muscles, in the anterolateral section there are the external and internal oblique muscles and the transverse abdominis muscles.

Rectus abdominis muscle, m. rectus abdominis, starts from the outer surface of the cartilages of the V-VII ribs and the xiphoid process. Its flat muscular belly in the lower abdomen narrows and is attached by a powerful tendon to the pubic bone along the length from the tuberculum pubicum to the symphysis pubicae. Muscle fibers m. rectus abdominis are interrupted by transversely located connective tissue bridges, intersectiones tendineae; two of them are located above the navel, one is at the level and one is below the navel.

3. Anterior abdominal wall. The skin, subcutaneous fat and superficial fascia are removed. On the left, the anterior vaginal wall m. was partially removed. recti abdominis and exposed m. pyramidalis.

1 - m. obliquus externus abdominis; 2 - m. rectus abdominis; 3 - inter-sectio tendinea; 4 - aponeurosis m. obliqui extemi abdominis; 5 - m. pyramidalis; 6 - funiculus spermaticus; 7-n.ilioinguinalis; 8-rr.cutanei anteriores et laterales n. iliohypogastricus; 9 - anterior wall of the vagina m. recti abdominis; 10 - rr. cutanei anteriores et laterales nn. intercostales.

4. Anterior abdominal wall. On the right is removed m. obliquus externus abdominis and the vagina m. was partially excised. recti abdominis; m is exposed on the left. transversus abdominis and posterior wall of the vagina m. recti abdominis.

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

Anterior to m. rectus abdominis is located the pyramidal muscle, m. pyramidalis; it starts from the anterior surface of the g. superioris ossis pubis along the length from tuberculum pubicum to symphysis pubicae and is woven into the linea alba of the abdomen. The pyramidalis muscle is not always pronounced; in 15-20% of cases it is absent. Its degree of development also varies.

The rectus abdominis and pyramidal muscles are located in the vagina formed by the aponeuroses of the external and internal oblique, as well as the transverse abdominal muscle. The anterior wall of the vagina in the lower section is somewhat thicker than in the upper. The posterior wall of the vagina has an aponeurotic structure only in the upper and middle third. Approximately 4-5 cm below the navel, the aponeurotic fibers end, forming an upwardly curved arcuate line, linea arcuata. Below this line, the posterior wall of the vagina is represented only by the transversus abdominis fascia. In places where intersectiones tendineae are located, the rectus abdominis muscle is quite firmly fused with the anterior wall of the vagina.

The aponeurotic fibers of the oblique and transverse muscles intertwine along the midline and form the linea alba, which stretches from the xiphoid process to the symphysis pubis. The maximum width of the white line at the navel level is 2.5-3 cm; in the direction of the pubic symphysis it narrows. The linea alba contains slit-like openings through which blood vessels and nerves pass. Preperitoneal fatty tissue can exit into these slit-like openings, forming preperitoneal lipomas, lipoma praeperitonealis. The holes in such cases increase in size and can become the site of formation of hernias of the white line of the abdomen.

Approximately halfway between the xiphoid process and the symphysis pubis, in the linea alba, there is an umbilical ring, anulus umbilicalis, bounded by aponeurotic fibers. In front, the umbilical ring is fused with skin and scar tissue, which is a remnant of the umbilical cord. There is no subcutaneous fatty tissue here, so a depression is formed on the side of the skin in the navel area. On the side of the abdominal cavity, the umbilical ring is fused with the transverse fascia, fascia transversalis, which often thickens here and turns into a fairly strong connective tissue plate (Fig. 5).

5. Transverse section of the anterior abdominal wall at the level of the navel.

1 - umbilicus; 2 - leather; 3 - subcutaneous fatty tissue; 4 - anterior wall of the vagina m. recti abdominis; 5 - t. obliquus externus abdominis; 6 - t. obliquus internus abdominis; 7 - m. transversus abdominis; 8 - fascia transversalis; 9 - tela subserosa; 10 - peritoneum; 11 - m.rectus abdominis; 12 - posterior wall of the vagina m. recti abdominis; 13 - vv. parumbilicales; 14 - aponeurosis m. obliqui interni abdominis; 15 - aponeurosis m. transversi abdominis; 16 - aponeurosis m. obliqui externi abdominis.

The anterior abdominal wall in the area of ​​the umbilical ring consists of skin, connective tissue, transverse fascia and peritoneum; There are no dense aponeurotic and muscle fibers here, so hernias often occur in the navel area.

Blood supply The rectus abdominis muscle is carried out by branches of the six lower intercostal arteries, as well as the superior and inferior epigastric arteries (see Fig. 4).

The intercostal arteries enter the rectus abdominis muscle from the lateral side, perforating its vagina. Inferior epigastric artery, a. epigastrica inferior, arises from the external iliac artery near the inguinal ligament. It crosses the vas deferens in front and is initially located between the peritoneum and the transverse fascia of the abdomen, then, heading upward, it pierces the transverse fascia and enters the rectus muscle. Superior epigastric artery, a. epigastrica superior, which is a branch of a. thoracica interna, pierces the posterior wall of the rectus sheath at the site of attachment of the VII costal cartilage to the sternum and, heading down, into

thicker than the rectus muscle, it anastomoses with both the inferior epigastric artery and the intercostal arteries.

Venous drainage blood flows through the veins of the same name: v. epigastrica superior et inferior, vv. intercostales.

Innervation The rectus abdominis muscle is carried out by the branches of the six lower intercostal nerves, which, like the arteries of the same name, enter the rectus abdominis muscle from its lateral edge.

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

In the anterolateral abdomen, the muscle layer consists of the external oblique, internal oblique and transverse muscles (see Fig. 3, 5).

External oblique abdominal muscle, m. obliquus externus abdominis, begins with teeth on the front surface of the chest from the eight lower ribs. The five upper teeth alternate with the teeth of the serratus anterior muscle, the three lower ones alternate with the teeth of the vastus dorsi muscle. The muscle fiber bundles are mainly directed from top to bottom, from back to front. In the lateral abdomen they attach to the labium externum cristae iliacae, and approaching the rectus muscle, they pass into a wide aponeurosis. The line of transition of muscle fibers into aponeurotic ones above the navel corresponds to the lateral edge of the rectus abdominis muscle; below the navel it arches, deviating outward, and goes to the middle of the inguinal ligament. In the lower abdomen, the aponeurotic fibers thicken and pass into the inguinal ligament, which is stretched between the anterior superior iliac spine and the pubic tubercle.

Internal oblique abdominal muscle, m. obliquus interims abdominis, covered throughout by the external oblique muscle. It starts from the deep layer of the fascia thoracolumbalis, linea intermedia cristae iliacae and the lateral half of the inguinal ligament. The muscle fibers of this muscle fan out. The posterior muscle bundles are attached to the lower edge of the XII, XI, X ribs, the anterior ones pass into the aponeurosis. The lowest muscle bundles, starting from the inguinal ligament, pass to the spermatic cord. The aponeurosis of the internal oblique muscle of the abdomen, approaching the rectus muscle, bifurcates into two leaves. The superficial leaf is part of the anterior wall of the vagina of the rectus muscle, the deep one is part of the posterior wall, and below the linea arcuata, the deep leaf joins the superficial one and participates in the formation of the anterior wall of the vagina of this muscle.

Transverse abdominis muscle, m. transversus abdominis, located under the internal oblique muscle and begins with six teeth from the inner surface of the six lower costal cartilages, the deep layer of the fascia thoracolumbalis, the labium internum cristae iliacae and the lateral third of the lig. inguinalis. The muscle bundles run in a transverse direction, approach the rectus abdominis muscle and pass into the aponeurosis, forming a line curved outward, linea semilunaris. The lowest muscle fibers are fused with the fibers of the previous muscle and pass onto the spermatic cord, forming m. Cremaster.

The aponeurosis of the transverse abdominal muscle is involved in the formation of the posterior wall of the vagina m. rectus abdominis above linea arcuata.

The muscles of the anterior abdominal wall are covered with fascial sheets in front and behind. The external oblique muscle of the abdomen is adjacent to its own fascia. It consists of thin fibrous fibers that pass into the inguinal ligament below. The transversalis fascia is adjacent to the posterior surface of the transverse muscle. Between the external and internal obliques, as well as between the internal oblique and transverse abdominal muscles, intermuscular fascial sheets are located.

Blood supply to muscles The anterolateral region of the abdominal wall is carried out by six lower intercostal and four lumbar arteries, which pass in the segmental direction between the internal oblique and transverse abdominal muscles (see Fig. 4). The outflow of venous blood occurs through the veins of the same name.

Innervation of muscles carried out by six lower intercostal nerves, which accompany the vessels of the same name, as well as n.iliоhypogastricus and n. ilioinguinalis.

Lymphatic vessels go in the direction of the intercostal neurovascular bundles and flow into the lumbar lymph nodes and into the thoracic duct.

Deep layer. The deep layer of the anterior abdominal wall consists of the transverse fascia, preperitoneal tissue and peritoneum.

The transversus abdominis fascia is a thin connective tissue plate that is adjacent to the transverse abdominis muscle from the inside.

Preperitoneal tissue is located between the transverse fascia and the peritoneum. It is more developed in the lower parts of the abdominal wall and passes posteriorly into the retroperitoneal tissue. In the navel area and along the linea alba, the preperitoneal tissue is weakly expressed, as a result of which the peritoneum in these places is more firmly connected to the transverse fascia of the abdomen. The initial segments of a. pass through the preperitoneal tissue. epigastrica inferior and a. circumflexa ilium profunda, as well as the accompanying veins. In addition, four connective tissue cords are directed to the umbilical ring; the peritoneum, covering them, forms ligaments and folds: lig. teres hepatis, plicae umbilicales mediana, media et lateralis. Round ligament of the liver, lig. teres hepatis, goes from the navel upward to the lower edge of the lig. falciformis hepatis and contains the deserted umbilical vein. Down from the navel along the midline is the plica umbilicalis mediana, which contains an overgrown urinary duct, urachus. Somewhat outward from it is the plica umbilicalis media, in which the overgrown umbilical artery of the embryo is located. Outward from the plica umbilicalis media runs the plica umbilicalis lateralis, which contains a. epigastrica inferior, going from the external iliac artery to the rectus abdominis muscle.

Inguinal triangle. The inguinal triangle belongs to the groin region and is located above the ligament of the same name in the lateral hypogastric region. Due to the fact that here the anterior abdominal wall has some topographic and anatomical features, this triangle deserves a separate description.

The inguinal triangle is bounded at the top by a horizontal line drawn from the border between the outer and middle third of the inguinal ligament to the rectus abdominis muscle, medially by the outer edge of the rectus abdominis muscle and below by the inguinal ligament.

The skin here is thin, has many sweat and sebaceous glands, and is covered with hair closer to the midline.

Subcutaneous fatty tissue is more pronounced than in the upper abdomen. Sheets of superficial fascia pass through it, dividing the fiber into several layers. In the subcutaneous tissue there are superficial blood and lymphatic vessels: a. et v. epigastrica superficialis, branches of a. et v. circumflexa ilium superficialis and a. pudenda interna, as well as branches of n. iliohypogastricus and n. ilioingumalis (Fig. 6).

6. Topography of the inguinal triangle (layer I).

1 - aponeurosis m. obliqui externi abdominis; 2 - a. et v. epigastrica superficialis; 3 - anulus inguinalis superficialis; 4 - crus mediale; 5 - crus laterale; 6 - funiculus spermaticus; 7 - n. ilioinguinalis; 8 - a. et v. pudenda externa; 9 - v. saphena magna; 10 - n. cutaneus femoris lateralis; 11 - superficial inguinal lymphatic vessels and nodes; 12 - a. et v. circumflexa ilium superficialis; 13 - lig. inguinal.

The muscular aponeurotic layer consists of the aponeurosis of the external oblique abdominal muscle, muscle fibers of the internal oblique and transverse muscles.

The aponeurosis of the external oblique muscle in the lower abdomen passes into the inguinal ligament, lig. inguinale (Pouparti), which is stretched between the anterior superior iliac spine and the pubic tubercle. The length of this ligament is variable (10-16 cm) and depends on the shape and height of the pelvis.

In some cases, the inguinal ligament is a well-defined groove formed by longitudinal shiny aponeurotic fibers. In other cases, it is flabby, weakly stretched and consists of thin aponeurotic fibers. The inguinal ligament is divided into superficial and deep parts; the latter forms an iliopubic cord, which has a fibrous structure and is very firmly fused to the transverse fascia of the abdomen (N. I. Kukudzhanov).

At the pubic tubercle, two bundles of aponeurotic fibers depart from the inguinal ligament, one of which is directed upward and inward and is woven into the linea alba of the abdomen, forming a wrapped ligament, lig. reflexum, the other goes down to the pecten ossis pubis and is called the lacunar ligament, lig. lacunare.

Continuing outward, the fibers that make up lig. lacunare, spread along the upper horizontal part of the pubic bone, closely fuses with its periosteum and form the iliopubic ligament. The aponeurosis of the external oblique muscle near the inguinal ligament splits into two legs: medial, crus mediale, and lateral, crus laterale, limiting the external opening of the inguinal canal, anulus inguinalis superficialis. The first of these legs is attached to the anterior surface of the symphysis pubicae, the second to the tuberculum pubicum. The slit-like opening between the crus mediale et laterale is limited from above and from the outside by fibrae intercrurales, which are aponeurotic fibers running from the middle of the inguinal ligament upward and medially to the white line of the abdomen. Below and on the medial side, the gap between the legs of the external oblique muscle is limited by lig. reflexum.

The dimensions of the external opening of the inguinal canal are variable: in the transverse direction 1.2-4.3 cm, in the longitudinal direction - 2.2-4 cm (S. P. Yashinsky). Sometimes the external opening of the inguinal canal is divided by a tendon cord into two openings: lower and upper. In such cases, the spermatic cord passes through the lower opening, and a hernia (hernia parainguinalis) can pass through the upper opening.

Its own fascia is attached to the edges of the external opening of the inguinal canal, which passes to the spermatic cord as fascia cremasterica.

Under the aponeurosis of the external oblique abdominal muscle are the internal oblique and transverse muscles (Fig. 7, 8). The lower bundles of fibers of these muscles near the inguinal ligament pass onto the spermatic cord and form m. cremaster. In addition, part of the lower fibers of the internal oblique and transverse abdominal muscles, which are aponeurotic in nature, go in an arcuate manner from top to bottom and inward, intertwining with the outer edge of the rectus abdominis sheath and the inguinal ligament. These fibers form the crescent-shaped aponeurosis of the inguinal region, falx inguinalis, the width of which reaches 1-4 cm. Another part of the aponeurotic fibers of the internal oblique and transverse abdominal muscles sometimes surrounds the internal opening of the inguinal canal from the inside and below and is woven into the inguinal and lacunar ligaments, forming lig. interfoveolare (see Fig. 10).

7. Topography of the inguinal triangle (layer II).

1 - aponeurosis m. obliqui extern! abdominis; 2 - m. obliquus internus ab-dominis; 3 - n. iliohypogastricus; 4 - n. ilioinguinalis; 5 - funiculus spermaticus; 6 - a. et v. pudenda externa; 7 - v. saphena magna; 8 - anulus inguinalis superficialis; 9 - m. cremaster; 10 - lig. inguinal.

8. Topography of the inguinal triangle (III layer).

1 - aponeurosis m. obliqui externi abdominis; 2 - fascia transversalis; 3 - a. et v. epigastrica inferior; 4 - preperitoneal tissue; 5 - m. cre-master; 6 - funiculus spermaticus; 7 - a. et v. pudenda externa; 8 - v. sa-phena magna; 9 - anulus inguinalis supernciafis; 10 - m. obliquus internus abdominis (partially cut off and turned outward); 11 - m. transversus abdominis.

10. Posterior surface of the lower part of the anterior abdominal wall.

1 - m. rectus abdominis; 2 - lig. interfoveolare; 3 - anulus inguinalis profundus; 4 - lig. inguinal; 5 - a. et v. epigastrica inferior; 6 - lymph nodes; 7 - lig. lacunare; 8 - a. et v. iliaca externa; 9 - foramen obturatorium; 10 - n. obturatorius; 11-a. et v. obturatoria; 12 - ureter dexter; 13 - ductus deferens; 14 - vesica urinaria; 15 - peritoneum; 16 - fossa supravesicalis; 17 - fossa inguinalis medialis; 18 - lig. inguinal; 19 - fossa inguinalis lateralis; 20 - plica umbilicalis media; 21 - plica umbilicalis medialis; 22 - plica umbilicalis lateralis.

This ligament is sometimes supported by a muscle bundle coming from the internal oblique and transverse abdominal muscles.

Directly posterior to the transverse fascia in the preperitoneal tissue runs the trunk of the inferior epigastric artery, medially of which there is a fibrous cord - the empty umbilical artery and the reduced urinary duct,

urachus. The peritoneum, covering these formations, forms folds: plicae umbili-cales lateralis, media et mediana. The folds limit the pits that are important in practical terms above the inguinal ligament: fossae inguinales medialis, lateralis et supravesicalis. The pits are places where the viscera protrude during the formation of hernias. The external inguinal fossa, fossa inguinalis lateralis, is located outward from the plica umbilicalis lateralis and corresponds to the internal opening of the inguinal canal; in it, under the peritoneum, there passes the ductus deferens, which crosses a. et v. iliaca externa and is directed into the pelvic cavity. The internal spermatic vessels are also directed to the external inguinal fossa, which, before entering the internal opening of the inguinal canal, are located on the m. psoas major outward from a. et v. iliaca externa. The internal inguinal fossa is located between the plica umbilicalis lateralis and plica umbilicalis media. This fossa corresponds to the external opening of the inguinal canal. Inward from the plica umbilicalis media, between it and the plica umbilicalis mediana there is fossa supravesicalis (Fig. 10).

Inguinal canal.

The gap between the inferior edge of the internal oblique muscle and the inguinal ligament is called the inguinal space. There are two shapes of the inguinal space: triangular and oval (Fig. 9). The length of the triangular inguinal space is 4-9.5 cm, height - 1.5-5 cm; the dimensions of the oval gap are somewhat smaller: length 3-7 cm, height - 1-2 cm (N. I. Kukudzhanov).

9. Inguinal space. A - triangular shape; B - slit-oval shape.

1 - m. rectus abdominis; 2 - aponeurosis m. obliqui externi abdominis; 3 - mm. obliquus internus abdominis et transversus abdominis; 4 - inguinal space; 5 - lig. inguinal.

Between the aponeurosis of the external oblique muscle of the abdomen and the internal oblique muscle there passes n. ilioinguinalis and n. iliohypogastricus. The first is located on the lateral side of the spermatic cord, exits through the external opening of the inguinal canal and innervates the skin in the mons pubis area. The second passes slightly above the inguinal canal.

Behind the muscle layer is the transverse fascia, preperitoneal tissue and peritoneum.

The transverse fascia in the inguinal area is reinforced by aponeurotic fibers: inside - falx inguinali, outside - lig. interfoveolare. The part of the transverse abdominal fascia free from these aponeurotic bundles, limited below by the inguinal ligament, corresponds to the external opening of the inguinal canal.

Directly posterior to the transverse fascia in the preperitoneal tissue runs the trunk of the inferior epigastric artery, medially of which there is a fibrous cord - the deserted umbilical artery and the reduced urinary duct, urachus. The peritoneum, covering these formations, forms folds: plicae umbili-cales lateralis, media et mediana. The folds limit the pits that are important in practical terms above the inguinal ligament: fossae inguinales medialis, lateralis et supravesicalis. The pits are places where the viscera protrude during the formation of hernias. The external inguinal fossa, fossa inguinalis lateralis, is located outward from the plica umbilicalis lateralis and corresponds to the internal opening of the inguinal canal; in it, under the peritoneum, there passes the ductus deferens, which crosses a. et v. iliaca externa and is directed into the pelvic cavity. The internal spermatic vessels are also directed to the external inguinal fossa, which, before entering the internal opening of the inguinal canal, are located on the m. psoas major outward from a. et v. iliaca externa. The internal inguinal fossa is located between the plica umbilicalis lateralis and plica umbilicalis media. This fossa corresponds to the external opening of the inguinal canal. Inward from the plica umbilicalis media, between it and the plica umbilicalis mediana there is fossa supravesicalis (Fig. 10).

The size and shape of the supravesical fossa are variable and depend on the position of the plica umbilicalis mediana (Fig. 11). In cases where the plica umbilicalis mediana runs medially from the outer edge of the rectus abdominis muscle, the supravesical fossa is very narrow. In other cases, when this fold approaches the epigastric vessels, the supravesical fossa is wide and extends onto the posterior wall of the inguinal canal (N.I. Kukudzhanov).

11. Shapes of the supravesical fossa. A - narrow; B - wide.

1 - plica umbilicalis mediana; 2 - plica umbilicalis medialis; 3 - plica umbilicalis lateralis; 4 - fossa inguinalis lateralis; 5 - fossa inguinalis medialis; 6 - fossa supravesicalis; 7 - ductus deferens; 8 - vesica urinaria.

Inguinal canal. Directly above the inguinal ligament is the inguinal canal, canalis inguinalis (see Fig. 7, 8). It has four walls and two holes. The upper wall of the inguinal canal is the lower edge of the internal oblique and transverse abdominal muscles, the anterior one is the aponeurosis of the external oblique abdominal muscle and fibrae intercrurales, the lower one is the groove of the inguinal ligament and the posterior one is the transverse abdominal fascia.

The external opening of the inguinal canal, anulus inguinalis superficialis, is located above the inguinal ligament in the aponeurosis of the external oblique abdominal muscle. The internal opening, anulus inguinalis profundus, is a depression in the transverse fascia corresponding to the external inguinal fossa. The length of the inguinal canal in men reaches 4 cm, in women it is slightly less (V.P. Vorobyov, R.D. Sinelnikov).

Abdominal cavity(cavum abdominalis) is limited by the intraperitoneal fascia (f. endoabdominalis) and includes the abdominal cavity and retroperitoneal space.

• The upper wall of the abdominal cavity is formed by the diaphragm,
• anterolateral - abdominal muscles,
• posterior - spine and muscles of the lumbar region.

Below, the abdominal cavity directly passes into the pelvic cavity, which is essentially separated out conditionally. There is a wide connection between these cavities, and the abdominal organs (intestines and omentum) freely descend into the pelvis.

Walls of the abdominal cavity not only perform a supporting function in relation to adjacent organs, but also play an important role in the life of the body. The diaphragm and abdominal muscles are the leading link in the implementation of external respiration, contribute to the regulation of blood circulation, intrathoracic and intra-abdominal pressure, and motor activity gastrointestinal tract. Participating in breathing, movements of the torso, shoulder girdle and pelvis, the walls of the abdomen withstand great physical stress.

This chapter reflects only the main features anatomical structure abdominal walls, knowledge of which will help the practical surgeon to more easily navigate the issues of pathogenesis, clinical picture and treatment of ventral hernias.

Anterolateral abdominal wall from above it is limited by the xiphoid process and costal arches, on the right and left - by the posterior axillary line (1. axillaris posterior), from below - by the symphysis of the pubic bones, the inguinal fold and the iliac crest to the posterior axillary line. Musculoskeletal landmarks are the xiphoid process, costal arches, the end of the XII rib, the iliac crests, the superior anterior iliac spines, the pubic tubercles, the symphysis, the umbilicus, and the relief of the rectus abdominis muscle.

The anterolateral wall of the abdomen is usually divided into several sections and areas (Fig. 1). In relation to hernias, this facilitates topical diagnosis, and in some cases (with umbilical and postoperative hernias) it allows one to clarify the size of the hernial protrusion. Conventionally, two horizontal lines are drawn: at the top, between the lowest points of the costal arches (linea bicostalis), and at the bottom, between the upper anterior iliac spines (linea bispinalis). Thus, the anterolateral wall of the abdomen is divided into three sections: the upper - epigastrium, the middle - mesogastrium and the lower - hypogastrium. Two vertical lines drawn along the edges of the rectus abdominis muscles divide each of these sections into three areas. In the upper section, the epigastric region itself (regio epigastrica propria), as well as the right and left hypochondrium (regio hypochondriaca dextra et sinistra) regions are distinguished. Middle section consists of the umbilical (regio umbilicalis), right and left lateral (regio lateralis abdominalis dextra et sinistra) areas. There are also three areas in the lower section: the pubic region (regio pubica), the right and left ilioinguinal (regio inguinalis dextra et sinistra).

Rice. 1. Abdominal areas. 1 - right hypochondrium; 2 - epitastral proper; 3 - left hypochondrium; 4 - right side; 5 - periumbilical; 6 - left side; 7 - right ilioinguinal; 8 - inguinal triangle; 9 - suprapubic; 10 - left ilioinguinal; 11 - left lumbar.

The skin of the abdominal wall is thin and mobile, with the exception of the navel (umbilicus), where it forms a retraction and is firmly fused with the underlying layer.

Subcutaneous fat , loose, it reaches its greatest development in the lower abdomen, especially in women. In the navel area and along the midline of the abdomen in the epigastric region itself, the subcutaneous fat layer is always less pronounced. Passes through the fiber superficial fascia , which in the lower abdomen consists of two layers: superficial and deep. The superficial layer continues downwards to the anterior region of the thigh, the deep one is attached to the inguinal ligament. Between the layers of the superficial fascia pass: a. epigastrica superficialis, crossing the Poupartian ligament in front at the border of the inner and middle third and heading towards the navel, a. circumflexa ilium superficialis, running upward and outward to the anterior superior iliac spine, and a. pudenda externa, individual branches of which branch near the external opening of the inguinal canal. All these arteries arise from a. femoralis and are accompanied by veins of the same name flowing into v. saphena or in v. femoralis.

Muscle layer The anterolateral abdominal wall is represented by the external oblique (m. obliquus abdominis externus), internal oblique (m. obliquus abdominis internus), transverse (m. transversus abdominis) and rectus (m. rectus abdominis) muscles. The abdominal muscles are paired, have their own fascial sheaths, and differ in length, direction of muscle fibers and functions performed.

The external oblique muscle begins in separate bundles from the outer surface of the eight lower ribs and occupies the most superficial position. The bundles of muscle fibers are directed from top to bottom and from behind to the front. The line of their transition to the aponeurosis in the middle parts of the abdomen runs parallel to the outer edge of the rectus abdominis muscle and is 1.5-2 cm outward from it. The wide aponeurosis of the external oblique muscle of the abdomen lies on the anterior surface of the rectus muscle and takes part in creating the anterior wall of its vagina, and also fuses with the aponeurosis of the same name opposite side, white line of the abdomen. Below, between the anterosuperior iliac spine and the pubic tubercle, the free edge of the aponeurosis, attached to these bony protrusions, is tucked inward, forming a tightly stretched groove - the inguinal ligament (Lig. inguinale s. Pouparti).

The internal abdominal muscle is located under the external oblique muscle. It starts from the deep layer of the fascia thoracolumbalis, linea intermedia cristae iliacae and the lateral half of the inguinal ligament. The muscle fibers of the internal oblique muscle have the opposite direction to the direction of the fibers of the external oblique muscle, and fan out like a fan from the bottom up and from the outside to the inside. Top part muscle fibers are attached to the lower edge of the X-XII ribs, middle part, not reaching the rectus muscle, passes into the aponeurosis, which immediately splits into two leaves, taking part in the formation of the anterior and posterior walls of the rectus muscle vagina. The lower edges of the internal oblique muscle are involved in the formation of the upper and anterior walls of the inguinal canal. Part of the fibers of the internal oblique abdominal muscle forms m. cremaster, which is one of the membranes of the spermatic cord.

M. transversus abdominis is the deepest muscular layer of the abdominal press, it begins in six bundles from the inner surface of the six lower costal cartilages, the deep layer of the fascia thoracolumbalis, the labium internum cristae iliacae and the lateral third of the inguinal ligament. Spreading in the transverse direction, the muscle bundles approach the rectus abdominis muscle and pass into the aponeurosis, forming an outwardly curved line (Linea semilunaris) - the Spigelian line. In the upper abdomen, the aponeurosis of the transverse muscle passes behind the rectus abdominis muscle and fuses with the deep plate of the aponeurosis of the internal oblique muscle, participating in the formation of the posterior wall of the rectus sheath. In the lower abdomen, the aponeurosis of the transverse muscle passes to the anterior surface of the rectus abdominis muscle, where, fused with the aponeurosis of the internal oblique muscle, it participates in the formation of the anterior wall of the rectus sheath. In the area of ​​transition of the aponeurosis of the transverse muscle to the anterior surface of the rectus abdominis muscle, an arcuate line (Linea arcuata), or line of Douglas, is formed. Research by V.I. Larin showed the absence of clearly defined cracks and holes in the aponeurosis of the transverse muscle along the Spigelian line and their presence at the outer edge of the line of Douglas. This allowed the author to believe that hernias in this section are more correctly called hernias of the line of Douglas rather than Spigelian.

M. rectus abdominis start from the cartilages of the III-IV ribs and the xiphoid process of the sternum, go down in the form of two wide cords lying on either side of the midline of the abdomen, and are attached to the upper edge of the pubic bone. Along the muscle there are three or four transverse tendon bridges, two of which are located above the navel, one at the level of the navel, and the last one is unstable, below it. As we have already indicated, the rectus abdominis muscles lie in the sheath, formed by tendon stretches of the vastus lateralis muscles. In the upper section, above the linea arcuata, the aponeurosis of the external oblique muscle and the superficial layer of the split aponeurosis of the internal oblique muscle take part in the formation of the anterior wall of the vagina. The posterior wall of the vagina above the umbilicus is formed by the second part of the split aponeurosis of the internal oblique muscle and the aponeurosis of the transverse muscle. 2-5 cm below the navel (below the linea arcuata), the aponeuroses of all the broad muscles pass to the anterior surface of the rectus abdominis muscles and participate in the formation of the anterior wall of their vagina. The posterior wall here is formed by the transverse fascia.

Behind each rectus muscle there is a. epigastrica superior. A larger a is heading towards it from below. epigastrica inferior. These arteries widely anastomose with each other and are accompanied by veins of the same name.

The next layer of the anterolateral abdominal wall is the transversalis fascia (fascia transversa). It is part of the fascia endoabdominalis and has a transverse fiber direction. The strength of the transverse fascia varies in different sections. In the upper parts of the abdominal wall it is tender and thin. As it approaches the inguinal ligament, parallel to its deep part, the transverse fascia becomes thicker and denser, forming a ligament up to 0.08-1 cm wide. N. I. Kukudzhanov considers it as an iliopubic cord (tractus iliopubicus).

Parietal peritoneum (peritoneum parietale) is separated from the transverse fascia by a thin layer of preperitoneal tissue. It lines the walls of the abdomen from the inside, forming several folds and pits below the navel (Fig. 2). From the top of the bladder to the navel along the midline there runs a cord - an overgrown urachus. The peritoneum covering it forms a fold - plica umbilicalis mediana. Laterally, two more cords are directed from the lateral parts of the bladder to the navel - obliterated a. a. umbilicales, and the peritoneum covering them forms the medial umbilical folds - plicae umbilicales mediales. Even more outward, also on both sides, the peritoneum forms lateral umbilical folds - plicae umbilicales laterales - above the lower epigastric arteries located underneath it. Between the folds of the peritoneum there are depressions, or pits, from which the overlying bladder outward from the plica umbilicalis mediana is called fovea supravesicalis (place of exit of supravesical hernias), located lateral from plica umbilicalis medialis - fovea inguinalis medialis (place of exit of direct inguinal hernias) and, finally, lying outward from the plica epigastrica - fovea inguinalis lateralis (the place of exit of oblique inguinal hernias). If you prepare the peritoneum in the area of ​​the lateral umbilical fossa, as shown in Fig. 2, then the internal (deep) opening of the inguinal canal opens with the artery entering it (a. testicularis) and the exiting veins of the same name and ductus deferens.

Rice. 2. Posterior surface of the lower part of the anterior abdominal wall.

1 - plica umbilicalis lateralis; 2 - fovea inguinalis lateralis; 3 - plica umbilicalis medialis; 4 - fovea inguinalis medialis; 5 - plica umbilicalis mediana; 6 - fovea supravesicalis; 7 - a. et v. epigastrica inferior; 8 - ductus deferens; 9 - bladder.

Blood supply of the anterolateral abdominal wall carried out by the superior and inferior epigastric arteries, six lower pairs of intercostal arteries, as well as the superficial branches of the femoral artery (a. epigastrica superficialis, a. circumflexa ilium superficialis, a. pudenda externa). Outflow of venous blood through the veins of the same name in v. cava superior, v. cava inferior, v. femoralis.

Innervation of the anterolateral wall carried out by six lower pairs of intercostal nerves (p. intercostales), as well as p. ilioinguinalis and p. iliohypogastricus from the lumbar plexus.

Lymph drainage from the upper sections of the anterolateral wall of the abdomen occurs in the epigastric lymph nodes (nodi lymphatici epigastrici) and the nodes of the anterior mediastinum (nodi lymphatici mediastinales anteriores), and from the middle and lower sections - in the lumbar nodes (nodi lymphatici lumbales), iliac (nodi lymphatici iliaci) and deep inguinal (nodi lymphatici inguinales profundi) lymph nodes.

Linea alba (linea alba abdominis) is the junction of the tendon sprains of the broad abdominal muscles. It is a narrow tendon plate located along the midline of the body from the xiphoid process to the pubis. The width of the white line throughout its entire length is different and ranges from 1.5 to 2.5 cm in men. In women, the white line reaches its greatest width at the level of the umbilical ring, in men - in the middle of the distance between the navel and the xiphoid process. Down from the navel, the white line quickly narrows and at a distance of 1.5-2 cm below the navel turns into a narrow cord no more than 0.2-0.3 cm wide, but much thicker. The linea alba in the upper abdomen is a “weak spot.” Between its intersecting tendon fibers, diamond-shaped gaps are formed, filled with fatty tissue directly connected to the preperitoneal tissue. These gaps serve as the exit point for blood vessels and nerves, and often for hernial protrusions.

Umbilical ring (anulus umbilicus) - an opening in the abdominal wall, bounded on all sides by the tendon fibers of the white line. The size of the hole varies: almost complete absence lumen and a well-defined open ring into which the peritoneal diverticulum is embedded. On the surface, the umbilical ring corresponds to a crater-shaped retraction of the skin, which here is fused with scar tissue, umbilical fascia and peritoneum. The umbilical vein approaches the umbilical ring from above, and two umbilical arteries and the urinary duct (urachus) from below.

Inguinal canal (canalis inguinalis) is located within the inguinal triangle (see Fig. 1), the boundaries of which are a horizontal line drawn from the point between the outer and middle third of the inguinal fold to the outer edge of the rectus abdominis muscle, from below - the inguinal fold, from the inside - the outer edge of the rectus abdominis abdominal muscles. The canal is projected over the inner half of the inguinal ligament and is directed from top to bottom, from outside to inside and from back to front. The length of the inguinal canal is 4-4.5 cm. In women it is slightly longer, but narrower; in children it is shorter, wide and straight [Krymov A.P., Lavrova G.F., 1979].

The inguinal canal has four walls and two openings. The anterior wall is the aponeurosis of the external oblique, and in the lateral part - the fibers of the internal oblique muscle [Kukudzhanov N.I., 1979]. "The upper wall of the inguinal canal is formed by the lower edge of the transverse abdominal muscle. The lower wall is the groove of the inguinal ligament, and the posterior wall is the transverse fascia.

The inguinal canal contains the spermatic cord (funiculus spermaticus) in men and the round ligament of the uterus (lig. teres uteri) in women. Outside, along the spermatic cord (or round ligament of the uterus) nerves pass: above the n. ilioinguinalis, below - n. spermaticus externus.

The space between the upper and lower walls of the inguinal canal is called the inguinal gap, the shape and size of which vary over a fairly wide range. N.I. Kukudzhanov (1969) distinguishes two extreme forms of the inguinal space: slit-oval and triangular. With a slit-oval shape, the height of the inguinal gap is 1-2 cm, with a triangular shape - 2-3 cm. In women, the inguinal gap is lower than in men [Lavrova T. F., 1979].

In the lower medial part of the anterior wall of the inguinal canal there is a superficial inguinal ring (anulus inguinalis superficialis), through which the spermatic cord in men or the round ligament of the uterus in women emerges from the canal. The superficial inguinal ring is bounded by two legs of the aponeurosis of the external oblique muscle, the first of which (eras mediale) is attached to the anterior surface of the symphysis, and the second (eras laterale) is attached to the pubic tubercle. The formed gap is rounded into a ring from above and outside by aponeurotic fibers running from the middle of the Poupart ligament up and medially to the white line of the abdomen (fibrae intercrurales), and below and from the inside - lig. reflexum (Fig. 3). The dimensions of the superficial inguinal ring of a healthy man allow the tip of the index finger to be inserted into it during palpation by intussusception of the scrotum.

The deep inguinal ring (anulus inguinalis profundus) is the lateral part of the posterior wall of the inguinal canal. It is located 1-1.5 cm above the middle of the Pupart ligament and is an opening in the transverse fascia through which the spermatic cord passes. The hole occurs during the descent of the testicle into the scrotum by protrusion of a leaf of the transverse fascia, which subsequently forms the inner membrane of the spermatic cord (fascia spermatica interna). Thus, the internal opening of the inguinal canal is a funnel-shaped protrusion of the transverse fascia. In men, the height of the deep opening of the inguinal canal is 1 cm, width 1.5 cm, it allows the tip of the index finger to pass through [Kukudzhanov N.I., 1969]. From the outside, the deep inguinal ring is limited by the inguinal ligament, from the inside by the interfoveal ligament (lig interfoveale s. Hasselbachii) (see Fig. 3). Adjacent to the deep inguinal ring is a section of the parietal peritoneum in the area of ​​the fovea inguinalis lateralis, while the superficial ring is projected onto the area of ​​the fovea inguinalis medialis.

Rice. 3. Ligamentous apparatus of the inguinal region.

a - front: 1 - fibrae intercrurales, 2 - leg. inguinale (Pouparti); 3 - lig. lacunare, 4 - lig. iliopectineum; b - behind: I - muscular part of the transverse muscle, 2 - spermatic cord, 3 - lig. Hesselbachii, 4 - aponeurosis of the transverse muscle, 5 - Hg. inguinale (Pouparti), 6 - femoral vessels, 7 - lig lacunare, 8 - lig. Cooperi, 9 - attachment of the rectus abdominis muscle.

Toskin K.D., Zhebrovsky V.V. Abdominal hernia, 1983

The walls of the abdominal cavity - so in medical literature denote a set of muscles, aneuroses and fascia that serve a person to hold the abdominal organs and protect their effects external factors.

The walls of the abdominal cavity are divided into upper (consists of the diaphragm - a muscle that separates the abdominal and chest cavity and serves to expand the lungs) to the front and rear walls, as well as to the rear and side walls. They consist of skin, as well as from the abdominal muscles.

The lateral walls of the abdomen are formed by three large muscles:
– external oblique muscle;
– internal oblique muscle;
– transverse muscle;

The anterior wall consists of the rectus abdominis muscle, as well as the pyramidal muscle. The posterior wall consists of the quadratus lumborum muscle.

The peritoneum is a translucent membrane of serous tissue that covers the plane internal organs, as well as the internal walls of the abdominal cavity. Also, the peritoneum is the deepest layer of all the walls of the abdomen.

Front wall

The anterior wall consists of several layers, including: skin, subcutaneous fat, fascia (connective membranes covering organs that form cases for muscles), pre-abdominal tissue, as well as muscles and the peritoneum itself.

The skin here is quite elastic and very thin, it easily lends itself to various movements and folds. Subcutaneous tissue contains a large amount of fat deposits. Especially a lot of fatty tissue is present in the lower abdomen.

The front wall is equipped with a large number nerve endings And blood vessels, there are also lymph nodes (organs that act as a filter; enlarged nodes mean that the body is susceptible to disease; nodes are a barrier to infections, as well as cancer).

The anterior abdominal wall is conventionally divided into three regions: hypogastric, celiac and epigastric.

Back wall

The posterior wall consists of the lower thoracic and lumbar spine, as well as the muscles adjacent to them: the quadratus muscle, the iliopsoas muscle, the latissimus dorsi muscle, and the muscle that extends the spine.

Behind the abdominal walls are the following organs: stomach, gallbladder, liver, spleen, and intestines (jejunum, ileum, sigmoid, cecum, appendix). The retroperitoneal space also contains: kidneys, pancreas, adrenal glands, as well as ureters and duodenum.

The muscles of the anterior abdominal wall, especially in quadrupedal primates, are subject to severe loads that require a certain strength from the muscles, and this can be developed by performing various exercises.

If the muscles of the anterior abdominal wall are not subject to any stress, this can lead to its deformation. The most common deformity is obesity. It may also be caused poor nutrition and disorders of the body's endocrine system.

Deformities can also occur due to the accumulation of large amounts of fluid directly in the abdominal cavity, a condition called ascites. This can accumulate more than 20 liters of liquid. This causes many problems: in digestion, in the functioning of the heart and lungs, as well as severe swelling of the legs and coughing. The cause of ascites may be cirrhosis (75%) of the liver or cancer.

In pregnant women and other primates, the anterior wall is often subject to frequent and severe stress, and it is quite stretched. Constant training will help protect the front wall from various types of deformations. Sports exercises such as flexion and extension of the abdominal muscles will perfectly help keep your muscles in excellent shape.

However, you should not overload the muscles of the anterior abdominal cavity, as an abdominal hernia may occur (the exit of the peritoneal organs from the cavity into anatomical formations under the skin).

Aneuroses are tendon plates that consist of dense, strong collagen and elastic fibers. In aneuroses, blood vessels and nerve endings are almost completely absent. The most significant are considered to be aneuroses of the anterior wall. Aneuroses have a white-silver color that is slightly shiny, this is due to the large amount of collagen.

In their structure, aneuroses are quite similar to tendons.

Aneuroses fuse with each other and thereby form the so-called white line of the abdomen. The linea alba is a fibrous structure that is located right on the midline of vertebrates. It separates the right and left abdominal muscles. Like other aneuroses, the linea alba is practically devoid of blood vessels and nerve endings. There is no fat in this area completely.

Since it is practically devoid of blood vessels and nerve endings, it is very often amenable to surgical incisions during operations in the abdominal area.