Abdominal wall. Topographic anatomy of the anterior abdominal wall. hernia surgery Where is the anterior abdominal wall

The abdominal wall, located in front, has a complex structure and consists of many layers. The ability to identify the affected area is of important diagnostic importance, as is understanding the boundaries of the abdominal cavity and the location of the organs that are located in it.

Department areas and boundaries

Front area abdominal wall

IN medical practice To describe symptoms and diseases, it is customary to divide the anterior abdominal wall into regions. For this, the scheme proposed by Tonkov is used. Horizontal lines are drawn: through the low points of the tenth ribs and through the highest points of the iliac crests. Next, make horizontal lines. Using lines, the boundaries of the anterior abdominal wall are created:

Epigastric. It contains the epigastric region, which includes the left lobe of the liver, the lesser omentum and the stomach. Also in the epigastric region is the right hypochondrium, which belongs to gallbladder, right part of the liver, suprahepatic colon and duodenum. The epigastric region includes the left hypochondrium, which contains the spleen and the splenic flexure of the large intestine.
Mesogastric. This zone includes the umbilical region with the small intestine and stomach, as well as the transverse colon, pancreas and greater omentum. This also includes the right and left flank, in which the right and left kidneys, the ascending and descending parts of the colon are located.
Hypogastric. In this zone, the suprapubic region is distinguished, in which there is small intestine, bladder and uterus, right ilioinguinal with cecum and left ilioinguinal with sigmoid colon.

The profile of the anterior abdominal wall differs significantly among patients. The most correct position is when in the epigastrium there is a slight recess under the costal arch, and in the mesogastric there are protrusions forward. In the hypogastric zone, anterior protrusion with rounding should be visible.

Muscles and layers of the abdominal wall

Topographic anatomy also includes the layers of the object being studied. The abdominal wall is located between the pelvis and the diaphragm; its main component is the muscle layers that perform the function of supporting the abdominal organs.

The longest muscle is the external oblique, it is located closest to the surface and consists of the flat abdominal muscles. The oblique muscle begins under the skin and subcutaneous fat. Also next to the external oblique muscle lie the internal, transverse and rectus muscles.

In total, the following layers of the anterior abdominal wall are distinguished:

skin – natural stripes run along most of the abdominal wall;
superficial fat layer - can be thin or thick, creating large folds of the abdominal walls in obese people;
surface membrane layer - a very thin connecting section;
the external, internal and transverse muscles form the muscle layer;
transverse fascia - a membrane strip passing through the abdomen and connecting to part of the diaphragm above and the pelvis below;
fat - the layer lies between the peritoneum and the transverse fascia;
peritoneum – a thin, smooth lining of the abdominal cavity that covers most of the internal organs.

Subcutaneous fatty tissue covers all areas of the abdomen, but in most patients it is almost completely absent in the umbilical area.

In the superficial fascia of the abdomen, including its deep layers, there are blood vessels abdominal wall. The muscle layers are attached as follows: the straight line connects to the costal arch and the pubic bones in the area of the tubercle and plexus, and the paired pyramidal muscles start from the pubic bone and go upward, deepening into the linea alba.

Both muscle fibers lie in the facial sheath, which is formed by the aponeuroses of the transverse and oblique muscles. 5 cm below the navel, the fibers of the aponeuroses pass from the rectus muscles.

The umbilical ring is located at a distance from the III to IV lumbar vertebrae (in the area of the xiphoid process). The edges of the umbilical ring are formed by an aponeurosis, and the umbilical plate is formed by inelastic connective tissue. At 2-2.5 from the edges, the peritoneum fuses with the wall.

The structure of the anterior abdominal wall from the inside looks like a transverse fascia, passing to the diaphragm and lumbar region. This fascia belongs to the connective tissues. Between the transverse fascia and the peritoneum there is fiber, the layer of which increases downward.

The abdominal wall is a multilayered formation consisting of powerful long muscle fibers, closely intertwined with each other and extending from the upper ribs to the lower pelvis. Connective tissues here are presented in thin layers.

Blood supply to the abdominal wall

The abdominal wall is supplied with blood in 2 ways, which are separated from each other: the deep and superficial layers receive blood from different sources. Thus, the skin and subcutaneous tissue are supplied by the cutaneous branches of the artery, which arises from the internal mammary artery. Also, their nutrition occurs through 7-12 pairs of intercostal vessels.

The lower sections and subcutaneous layer receive nutrition from the subcutaneous arteries ascending in the upper and medial direction. Additionally, they are fed by the intercostal, pudendal and epigastric arteries.

The deep sections of the wall receive blood from the inferior and deep epigastric arteries, which originate from the iliac source. The weakest point where bleeding often occurs is the intersection of the superior and inferior epigastric arteries. Blood loss occurs when this area is ruptured.

Innervation also depends on the part of the abdominal wall. The upper zones are provided with impulses from 7-12 pairs of intercostal nerves. middle part innervated by the ilioinguinal and iliohypogastric nerves. And the external sciatic nerve is responsible for the lower sections.

Possible pathologies and diseases of the abdominal wall

The anterior wall has many functions; it is responsible not only for supporting organs, but also for normal breathing. In acute inflammation of the abdominal cavity, its range of motion is sharply limited or completely disappears, due to which symptoms of irritation are determined. The asymmetry of the element is important for making a diagnosis for various diseases.

Developmental defects

Most common congenital pathology abdominal wall - incomplete fusion of myotimas. However, their development may continue after birth, causing intestinal malposition to change with age.

Underdeveloped myotimas lead to the formation of congenital diastasis of the rectus muscles. If local underdevelopment occurs, then a child's umbilical hernia. Underdevelopment of the white line of the abdomen is often combined with disorders in the bladder. As the child grows, this defect decreases.

Another possible pathology is a hernia of the umbilical cord. With the disease, there is a failure of the layers of the abdominal wall, which is why instead of a full-fledged connective tissue The abdominal organs are covered only by a translucent membrane. Treatment requires surgery on the first days of the postnatal period. Peritonitis develops due to rupture of the membranes. Lack of obliteration of the vitelline duct leads to the development of fistulas and cysts in the umbilical zone.

An abdominal hernia is a common pathology that occurs against the background of improper development of the abdominal wall. Most often, pathology is formed due to defects in the anterior wall, but can arise due to underdevelopment of the posterior section.

Damage to the wall can be open or closed (without violation skin). Closed pathologies most often occur when blunt trauma abdomen and are combined with damage to internal organs.

Inflammatory diseases

Inflammatory pathologies occur in acute or chronic form, may be a consequence of other disorders or primary sources of processes:

boils, abscesses, erysipelas;
navel diseases in newborns and adults;
omphalitis of newborns - the most dangerous inflammation of the navel, which can lead to peritonitis;
purulent complications after operations;
acute appendicitis;
intestinal tumors;
strangulated hernia.

Tuberculosis of the abdominal wall - rare disease, relating to secondary violations.

The main vessel providing blood supply to the abdominal walls, abdominal organs and retroperitoneal space is the abdominal aorta (aorta abdominalis), which is located in the retroperitoneal space. The unpaired visceral branches of the abdominal aorta supply blood to the abdominal organs, and its paired visceral branches carry blood to the retroperitoneal organs and gonads. The main venous collectors are represented by v. cava inferior (for the retroperitoneum and liver) and v. porta (for unpaired abdominal organs). There are numerous anastomoses between the three main venous systems (superior and inferior vena cava and portal veins). The main sources of somatic innervation of the abdominal walls, abdominal organs and retroperitoneal space are the lower 5-6 intercostal nerves and the lumbar plexus. The centers of sympathetic innervation are represented by nucl. intrmediolateralis Th 6 -Th 12, L 1 -L 2 segments spinal cord, from where preganglionic fibers reach the thoracic nodes of the sympathetic trunk and, without switching, form n. splanchnicus major et minor, which pass through the diaphragm and become postganglionic in the second-order vegetative nodes of the abdominal cavity. Preganglionic fibers from the lumbar segments reach the lumbar ganglia of the sympathetic trunk and form the nn. splanchnici lumbales, which follow to the autonomic plexuses of the abdominal cavity. The centers of parasympathetic innervation are the autonomic nuclei of the X pair of cranial nerves and nucl. parasympathicus sacralis S 2 -S 4(5) segments of the spinal cord. Preganglionic fibers switch in the terminal nodes of the periorgan and intramural plexuses. The main collectors of lymph from these areas are the lumbar trunks (trunci lumbales), as well as the intestinal trunk (truncus intestinalis), which collect lymph from the parietal and visceral lymph nodes and flow into the ductus thoracicus.

Abdominal wall

Blood supply The abdominal wall is carried out by superficial and deep arteries. Superficial arteries lie in the subcutaneous tissue. In the lower abdomen there is a superficial epigastric artery (a. epigastrica superficialis), going to the navel, a superficial artery, bending around the ilium (a. circumflexa ilium superficialis), going to the iliac crest, external genital arteries (aa. pudendae externae), going to external genitalia, inguinal branches (rr. inguinales), located in the area of the inguinal fold. The listed arteries are branches of the femoral artery (a. femoralis).

In the upper abdomen, the superficial arteries are small in caliber and are the anterior branches of the intercostal and lumbar arteries. The deep arteries are the superior and inferior epigastric arteries and the deep circumflex iliac artery. The superior epigastric artery (a. epigastrica superior) arises from the internal thoracic artery (a. thoracica interna). Heading down, it penetrates the vagina of the rectus abdominis muscle, passes behind the muscle and in the navel area connects with the rectus abdominis muscle inferior artery. The inferior epigastric artery is a branch of the external iliac artery. It is directed upward between the fascia transversalis in front and the parietal peritoneum behind, forming the lateral umbilical fold, and enters the sheath of the rectus abdominis muscle. By back surface muscle, the artery goes upward and in the navel area connects with the superior epigastric artery. The inferior epigastric artery gives artery to the muscle that lifts the testicle (a. cremasterica). The deep artery circumflexing the ilium (a. circumflexa ilium profunda) is most often a branch of a. iliaс externa and parallel to the inguinal ligament in the tissue between the peritoneum and the transverse fascia is directed to the iliac crest.

The five lower intercostal arteries (aa. intercostales posteriores), arising from the thoracic part of the aorta, go obliquely from top to bottom and medially between the internal oblique and transverse abdominal muscles and connect with the branches of the superior epigastric artery.

Anterior branches of the four lumbar arteries (aa. lumbales), from abdominal aorta, are also located between these muscles and run in the transverse direction, parallel to one another, taking part in the blood supply to the lumbar region. They connect with the branches of the inferior epigastric artery.

Vienna The abdominal walls are also divided into superficial and deep. Superficial veins are more developed than arteries and deep veins, forming a dense network in the fatty layer of the abdominal wall, especially in the navel area. They connect to each other and to the deep veins. Through the thoracoepigastric veins (vv. thoracoepigastricae), which flow into the axillary vein, and the superficial epigastric vein (v. epigastrica superficialis), which opens into the femoral vein, the systems of the superior and inferior vena cava are connected (cavacaval anastomoses). Veins of the anterior abdominal wall through vv. paraumbilicales, located in the amount of 4-5 in the round ligament of the liver and flowing into the portal vein, connect the v. system. portae with system v. cavae (portocaval anastomoses).

The deep veins of the abdominal wall (vv. epigastricae superiores et inferiores, vv. intercostales and vv. lumbales) accompany (sometimes two) arteries of the same name. The lumbar veins are the sources of the formation of the ascending lumbar veins, which continue into the azygos and semi-gypsy veins.

Lymphatic drainage carried out through lymphatic vessels located in the superficial layers of the anterolateral wall of the abdomen and flowing from the upper sections into the axillary (lnn. axillares), from the lower - into the superficial inguinal lymph nodes (lnn. inguinales superficiales). Deep lymphatic vessels from the upper parts of the abdominal wall flow into the intercostal (lnn. intercostales), epigastric (lnn. epigastrici) and mediastinal (lnn. mediastinales) lymph nodes, from the lower - into the iliac (lnn. iliaci), lumbar (lnn. lumbales) and deep inguinal (lnn. inguinales profundi) lymph nodes. The superficial and deep draining lymphatic vessels are connected to each other. From the listed groups of lymph nodes, lymph collects in the lumbar trunks (trunci lumbales) and enters the ductus thoracicus.

Innervation The anterolateral wall of the abdomen is carried out by the branches of six (or five) lower intercostal (subcostal), iliohypogastric (n. iliohypogastricus) and ilioinguinal (n. ilioinguinalis) nerves. The anterior branches of the intercostal nerves, together with the vessels of the same name, run parallel obliquely from top to bottom and anteriorly, located between m. obliquus internus abdominis and m. transversus and innervating them. Next, they pierce the sheath of the rectus muscle, reach the posterior surface and branch in it.

The iliohypogastric and ilioinguinal nerves are branches of the lumbar plexus (plexus lumbalis). The iliohypogastric nerve appears in the thickness of the anterolateral abdominal wall 2 cm above the anterior superior iliac spine. Next, it goes obliquely downwards between the internal oblique and transverse muscles, supplying them with branches, and branches in the inguinal and pubic region. N. ilioinguinalis lies in the inguinal canal parallel to the previous nerve above the inguinal ligament and exits under the skin through the superficial inguinal ring, branching in the area of the scrotum or labia majora.

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 external respiration, contribute to the regulation of blood circulation, intrathoracic and intra-abdominal pressure, 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. The 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, the middle part, not reaching the rectus muscle, passes into the aponeurosis, which immediately splits into two layers, taking part in the formation of the anterior and posterior walls of the rectus muscle sheath. 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 Bladder A cord, an overgrown urachus, runs to the navel along the midline. 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

To prevent injury to blood vessels and nerves and to adequately close the wound to prevent dehiscence

Sutures require a good knowledge of the anatomy of the anterior abdominal wall. From the main end, the anterior abdominal wall is limited by the edge of the ribs and the xiphoid process of the sternum, laterally by the crests of the iliac bones, caudally by the inguinal ligaments, the pubis and the upper edge of the symphysis. The main anatomical structures of the anterior abdominal wall are the skin, subcutaneous adipose tissue, muscles, fascia, nerves, as well as the vessels of all these structures. Numerous factors, namely: age, muscle tone, obesity, intra-abdominal pathology, previous pregnancies, constitution - can change the anatomy of the anterior abdominal wall.

Leather. Contains small blood and lymphatic vessels and nerves. Any incision in the abdominal wall, especially a transverse one, can impair the sensitivity of the skin. In addition, due to the developed lymphatic drainage of the lower part of the abdominal wall into the inguinal and club lymph nodes, a transverse suprapubic incision can disrupt lymphatic drainage, which leads to temporary edema, which continues until collateral lymphatic drainage is restored. Skin stretch lines (Langer) are almost transverse. Vertical scars tend to tighten, while horizontal scars become more cosmetic over time.

Muscles and fascia. Two muscle groups form the musculature of the anterior abdominal wall. The so-called flat muscles include the external and internal oblique and transverse muscles. their fibers are directed transversely or diagonally. The second group consists of the rectus and pyramidal muscles, which have vertical fibers. The rectus muscles with their gracilis fascia are involved in walking and standing. The paired pyramidal muscles begin from the bony crest of the pubic symphysis and end in the lower part of the white line of the abdomen (linea alba). Preservation of these muscles is not necessary in case of surgical intervention in this area.

The external oblique muscle and its aponeurosis form the most superficial layer of flat muscles. The fibers of this muscle originate from the lower edge of the eighth rib and pass transversely from above, and then are directed in an oblique downward direction. Some of these muscles give rise to a wide fibrous aponeurosis that runs in front of the rectus muscle. The next one, the internal oblique muscle, originates from the iliac crest, thoracolumbar fascia and inguinal ligament. The middle part of this muscle passes upward in an oblique direction and gives rise to the aponeurosis of the internal oblique muscle. At the lateral edge of the rectus muscle, the aponeurosis splits, forming a sheath around the rectus muscle and merges again around its medial edge, participating in the formation of the linea alba.

The third “flat” muscle, the transverse muscle, originates from the lower part of the cartilage of the sixth rib, the thoracolumbar fascia and the inner part of the iliac crest and actually runs transversely. Above the middle of the distance between the navel and the symphysis, the aponeurosis of this muscle passes along the rectus muscle, entering the posterior layer of its sheath. Below this point, the aponeurosis is located in front of the rectus muscle and participates in the formation of the anterior sheet of the rectus muscle sheath. Medial to the rectus muscle, the fascia of all three flat muscles joins and enters the linea alba.

The lower edge of the upper part of the aponeurosis of the transverse muscle, located behind the rectus muscle, forms an arcuate line with the apex at the top. In the arcuate line, at the level of the superior anterior iliac spines, the posterior layer of the rectus muscle sheath is absent. Consequently, in the absence of adequate matching and suturing of the edges of the anterior abdominal wall, this place is most vulnerable to the occurrence of a hernia.

The rectus abdominis muscles originate from the pubic crest and go up to the cartilages of the fifth, sixth and seventh ribs and the xiphoid process. Their upper part is three times wider than the lower. It contains three or four fibrous inclusions - transverse lines (linea transversa). One of them passes at the level of the navel, and the rest - of course, in the middle of the distance between the navel and the first line. It is important that these fibrous inclusions fit tightly to the anterior sheet of the rectus muscle sheath, due to which the retraction of the rectus muscles when crossing them is limited, so there is no need to compare them. As already noted, the rectus muscles are included in the aponeurotic sheath, formed by the fascia of the three flat muscles. The pyramidal triangular muscles are usually localized in front of the rectus muscles. The middle part of these muscles has an avascular space, which makes it easier to dissect them to access the space of Retzius.

Blood supply. The upper part of the anterior abdominal wall has an abundant blood supply from the superior epigastric, deep musculodiaphragmatic, circumflex iliac and inferior epigastric arteries. The middle section of the abdominal wall receives blood from the epigastric artery, its lateral part - from the musculophrenic and deep circumflex iliac arteries. Lumbar: and intercostal arteries also participate in the blood supply to the anterior abdominal wall. Due to the numerous anastomoses, lack of blood supply is rarely a complication of abdominal incisions (1.2). Only the white line is relatively poor in blood vessels. Consequently, in the case of using vertical incisions, healing of the wound of the anterior abdominal wall can be prolonged, so reliable sutures are necessary to prevent evisceration and incisional hernias.

When opening the anterior abdominal wall, the epigastric vessels may be damaged, especially if the muscles are crossed. With extraperitoneal access, the deep circumflex iliac or musculophrenic arteries may be injured. In addition, the inferior epigastric and deep circumflex iliac arteries can be damaged if the trocar insertion sites are incorrectly selected.

The superior epigastric artery is a continuation of the internal mammary artery. It enters the rectus muscle sheath along the cartilage of the seventh rib and descends behind the rectus muscle. It has numerous branches to the rectus muscle and anastomoses with the inferior epigastric artery. In the upper abdomen, above the navel, the main branch of this artery runs predominantly posterior to the middle part of the rectus muscle. The inferior epigastric artery arises from the external iliac artery near the middle of the inguinal fold and ascends cranially to the posterolateral part of the rectus muscle, where it anastomoses with the superior epigastric artery. So, the lower the transverse incision is made, the more laterally the inferior epigastric arteries go. The veins pass in close proximity to the arteries of the same name. If the inferior epigastric arteries are damaged below the arcuate line, bleeding may occur inferolaterally into the retroperitoneal space, leading to the formation of a large hematoma and symptoms of an acute abdomen.

The musculophrenic artery originates from the internal thoracic artery. It runs along the costal margin behind the cartilages and anastomoses with the deep circumflex iliac artery (a branch of the external iliac artery) at almost the same level as the inferior epigastric artery. The deep circumflex iliac artery follows the inguinal ligament along the iliac crest, sometimes giving branches to the transverse muscle, and is located between it and the internal oblique muscle. Before the anastomosis with the musculophrenic artery, it is relatively large, which should be taken into account when cutting these muscles in the lateral direction.

Innervation. The nerves innervating the anterior abdominal wall can be easily damaged by any section. The anterior abdominal wall is innervated by the Thoracoabdominal, iliohypogastric, and ilioinguinal nerves. The thoracoabdominal nerves, which are the 7th-11th intercostal nerves, leave the intercostal space and pass caudally and anteriorly between the transverse and internal oblique muscles, innervating them and the external oblique muscle, enter the fascial sheath of the rectus muscle, innervate it and the skin above it. Most nerves have multiple trunks. The remaining nerves of the anterior abdominal wall contain fibers from the last two or three intercostal nerves. If the autopsy is performed lateral to the midline, especially transversely, then nerves are often damaged.

A vertical incision, especially one made lateral to the rectus muscle or through the muscle, leads to denervation of the underlying tissues, depending on the length of the section. This can sometimes cause atony or muscle atrophy. The iliohypogastric and ilioinguinal nerves perform a sensory function (1.4), so their damage can lead to changes in the sensitivity of the skin above the pubis and labia majora. These nerves originate from the first lumbar ganglion. Although they are located at a distance between the internal oblique and transverse muscles, they do not fall into the sheath of the rectus muscle. Both nerves innervate the lower fibers of the internal oblique and transverse muscles. If the nerves are damaged at the level of the anterosuperior iliac spine, these muscle fibers become denervated, which can cause the formation of an inguinal hernia.

The anterior abdominal wall along its entire length, except for the linea alba, has the following layers: skin, subcutaneous fat, fascia, muscles, preperitoneal tissue and peritoneum (Fig. 47). There are no muscles in the linea alba area. The thickness of subcutaneous fat is 3-10 cm or more. Between its upper layer adjacent to the skin and the lower one near the aponeurosis there is a fascial layer. In some cases, it is thickened and resembles a muscle aponeurosis. With an inferomedial longitudinal incision, which is most often used in gynecological practice, the skin, subcutaneous fat, aponeurosis of the abdominal muscles along the white line, transverse fascia of the abdomen, preperitoneal tissue and peritoneum are dissected.

When the fascial aponeurosis is dissected on the side of the linea alba, the vagina of one of the rectus abdominis muscles is opened, which are intimately adjacent to each other towards the womb and slightly diverge (by 20-30 mm) at the navel. Closer to the clonus of the rectus muscles are pyramidal muscles, which are easily separated from the midline. It is important to remember that the incision is made strictly along the white line without damaging the muscles. After dividing the rectus muscles, preperitoneal tissue is visible in the lower part of the incision, since here the posterior layer of the rectus sheath is absent, and the transverse fascia along the midline is not expressed and is not always detected. The posterior wall of the rectus sheath is well defined above the navel and 4-5 cm below it, ending in a semicircular line, convex upward, and below this line there is a thin transverse fascia.

The dissection of the preperitoneal tissue is carried out carefully, its edges are moved apart, after which the peritoneum is exposed and dissected. Closer to the womb, when opening the abdominal cavity, the risk of damage to the bladder increases, which is accompanied by bleeding, since in this place the fiber is tightly attached to the peritoneum. Therefore, dissection of the preperitoneal tissue and peritoneum should begin closer to the navel and everything should be done only under eye control. Above the semicircular line, the transversalis fascia is intimately connected to the peritoneum, so they are cut together at the same time. At the upper edge of the womb, in the process of rupture, the prevesical tissue (cavum Retzii) is opened, which communicates with the preperitoneal tissue of the anterior abdominal wall. It is important to remember that when inserting speculums, they do not fall between the peritoneum and the abdominal wall, since a cavity may form here, reaching the neck of the bladder. Due to the fusion of the transverse fascia with the peritoneum, when suturing the latter at the navel, tension often occurs, which is not observed in the middle and lower parts of the wound.

Often there is a need to extend the incision upward, above the navel. Therefore, you should remember some of its features. From the inner surface of the abdominal wall in the umbilical area, the umbilical arteries, vein and urachus are visible. They usually overgrow and appear as strands of connective tissue. The arteries form two lig.vesicalia lateralis, the urachus - lig.vesicale medium and the umbilical vein - lig.tereshepatis. To avoid damaging the hepatic ligament and blood vessels, the incision should be extended, bypassing the navel on the left. The urachus can remain passable, therefore, when cutting the abdominal wall, it is better not to damage it, and in case of dissection, bandage it, especially the lower segment.

In the area of the suprapubic fold, the thickness of the subcutaneous fat layer is much thinner (than in the upper sections), therefore this area was chosen for making a transverse incision of the abdominal wall (according to Pfannenstiel). And this made it possible to include among its indications the excessive development of the subcutaneous fat layer in women.

In gynecological practice, situations arise that require surgical interventions in the area of the inguinal or femoral canals (shortening of the round ligaments using extraperitoneal access, removal of gonads in Morris syndrome, etc.). Through inguinal canal in women, the round ligament, its artery, ilioinguinal and external spermatic nerves pass through. The walls of the inguinal canal are: in front - the aponeurosis of the external oblique muscle of the abdomen and the fibers of the internal oblique; behind - transverse fascia; above - the lower edge of the transverse abdominal muscle; from below, the inguinal ligament is in the form of a groove due to the fibers bent backwards and upwards. The inguinal canal has internal and external inguinal rings, the distance between which (canal length) is 5 cm.

The internal inguinal opening with a diameter of 1.0-1.5 cm is located on the posterior surface of the anterior abdominal wall in the form of a depression of the peritoneum 1.0-1.5 cm above the middle of the inguinal ligament behind the plicae umbilicales lateralis genitalis, which extend from the middle of the inguinal ligaments, covering is the deep epigastric artery (arteria gastrica profunda).

The round ligament passes through the inner ring of the inguinal canal, carrying the transverse fascia with it. When the round ligament is pulled along with the transverse fascia, the peritoneum is pulled out from the area of the internal ring of the inguinal canal in the form of a sac-like protrusion, which is called processus vaginalis peritonei.

When making incisions in the area of the inguinal canal, there is a danger when it is made below the inguinal ligament (it is better to do this above). Below it is the base of the femoral triangle, bounded on the medial side by the lacunar ligament, with the lateral side by the iliopectineal ligament, which is a compacted area of the iliac fascia. It divides the entire space between the inguinal ligament, ilium and pubic bones into two sections: the large muscular lacunae and the small vascular lacunae. The m.iliopsoas, n.femoralis and n.cutaneus femoris lateralis pass through the muscular lacuna, and the femoral vessels (artery and vein) with the lumboinguinal nerve pass through the vascular lacuna. The femoral vessels fill only the outer two thirds of the vascular lacuna, and its inner third, located between the femoral vein and the lacunar ligament, is called the internal femoral ring.

It is made of fatty tissue, lymphatic vessels and lymph node. The internal femoral ring with a diameter of 1.5-1.8 cm is limited in front by the inguinal ligament, behind by the iliopubic ligament and the pectineal fascia starting from it, inside by the lacunar ligament and outside by the sheath of the femoral vein. The internal femoral ring on the side of the perinatal peritoneum corresponds to the oval fossa, located under the inguinal ligament. When the insides come out through this ring, a femoral canal triangular in shape, 1.5-2.0 cm long. Its walls are: the falciform process of the fascia lata in front, the pectineal fascia behind and inside, and the sheath of the femoral vein outside. The hernial orifice is surrounded by a ring of vessels: the femoral vein on the outside, the inferior epigastric artery on top and the obturator artery medially (if it arises from the inferior epigastric artery).

All this should be taken into account when performing operations in the groin areas.

Borders of the entire abdominal wall are: the xiphoid process and costal arches (top), pubic bones, symphysis, inguinal ligaments and iliac crests (bottom), posterior axillary line (lateral).

Abdomen extends beyond the marked boundaries due to its increase due to the dome of the diaphragm and the pelvic cavity.

By two vertical lines along the outer edge of the rectus abdominis muscles and two horizontal lines drawn through the anterior superior iliac spines and through the cartilages of the tenth ribs, the anterior abdominal wall is divided into 9 regions. The two hypogastric and hypogastric regions constitute the hypogastrium, the umbilical, right and left lateral regions form the mesogastrium, and the suprapubic, right and left ilioinguinal regions form the epigastrium.

Muscles of the anterior abdominal wall: the straight line starts from the xiphoid process and costal arch and attaches to the posterior surface of the pubic bone; the transverse one begins in the form of an aponeurosis from the cartilages of the lower ribs, the lumbar-dorsal fascia and the iliac crest, and at the outer edge of the rectus muscle it passes into the anterior aponeurosis, forming Spigel's line (the weakest point of the abdominal wall); the internal oblique originates from the superficial layer of the lumbodorsal aponeurosis, the iliac crest and the upper half of the inguinal ligament. It is fan-shaped from back to front and from bottom to top, passing at the inner edge of the rectus muscle into the aponeurosis and forming the levator testis muscle along the inguinal ligament at the spermatic cord with its lower fibers; The external oblique originates at the 8 lower ribs and the wing of the ilium, moving forward and downward, near the outer edge of the rectus abdominis muscle it becomes a wide aponeurosis.

The part of the aponeurosis stretched between the superior anterior iliac spine and the pubic tubercle is called the inguinal ligament. The fibers of the aponeurosis above the inguinal ligament diverge into 2 legs, the lateral one of which is attached to the pubic tubercle, and the medial one to the symphysis, forming the external inguinal ring.

Blood supply The anterior abdominal wall is carried out separately for the deep and superficial sections. Blood supply to the skin and subcutaneous tissue comes from the cutaneous branches of the superior epigastric artery (departs from the internal thoracic) and the terminal branches of the 7-12th pairs of intercostal arteries. The lower sections of the skin and subcutaneous tissue of the abdomen are provided by three subcutaneous arteries (from the femoral artery system), running in the ascending and medial directions, anastomosing with arteries (superior epigastric, intercostal, internal pudendal) emanating from the upper basins.

Blood supply to the deep parts of the anterior abdominal wall occurs due to the inferior and deep epigastric arteries (starting from the external iliac). The greatest bleeding occurs when the branches of the inferior epigastric artery are crossed during incisions of the abdominal wall according to Cherny or according to Pfannenstiel when extending the incision beyond the lower edge of the rectus muscle and others.

Innervation the anterior abdominal wall differs by department. Its upper sections are innervated by intercostal nerves (7-12th pairs). The iliohypogastric and ilioinguinal nerves, arising from the lumbar plexus, provide innervation to the mid-abdominal wall. Its lower parts are innervated by the external sciatic nerve(genital branch of the genital femoral nerve). Depending on which part of the abdominal wall the incisions are made, the branches of these nerves are damaged.