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1.1
Introduction
The abdominal wall encompasses an area of the body
bounded superiorly by the xiphoid process and costal
arch, and inferiorly by the inguinal ligament, pubic
bones and the iliac crest.
Epigastrium
Visualization, palpation, percussion, and ausculta- Right Left
tion of the anterolateral abdominal wall may reveal ab- hypochondriac hypochondriac
normalities associated with abdominal organs, such as Transpyloric T12
Plane L1
the liver, spleen, stomach, abdominal aorta, pancreas
L2
and appendix, as well as thoracic and pelvic organs.
Visible or palpable deformities such as swelling and Right L3 Left
Subcostal Lumbar (Lateral) Lumbar (Lateral)
Plane L4
scars, pain and tenderness may reflect disease process-
L5
es in the abdominal cavity or elsewhere. Pleural irrita- Intertuber- Left
tion as a result of pleurisy or dislocation of the ribs may cular Iliac (inguinal)
Plane Hypogastrium
result in pain that radiates to the anterior abdomen.
Pain from a diseased abdominal organ may refer to the Right Umbilical
Iliac (inguinal) Region
anterolateral abdomen and other parts of the body, e.g.,
cholecystitis produces pain in the shoulder area as well
as the right hypochondriac region. The abdominal wall Fig. 1.1. Various regions of the anterior abdominal wall
should be suspected as the source of the pain in indi-
viduals who exhibit chronic and unremitting pain with
minimal or no relationship to gastrointestinal func- the lower border of the first lumbar vertebra. The sub-
tion, but which shows variation with changes of pos- costal plane that passes across the costal margins and
ture [1]. This is also true when the anterior abdominal the upper border of the third lumbar vertebra may be
wall tenderness is unchanged or exacerbated upon con- used instead of the transpyloric plane. The lower hori-
traction of the abdominal muscles (positive Carnett’s zontal plane, designated as the intertubercular line, tra-
sign). Abdominal wall pain can be the result of local- verses the anterior abdomen at the level of fifth lumbar
ized endometriosis, rectus sheath hematoma, or ab- vertebra, and connects the iliac tubercles on both sides.
dominal incision or hernia. A second lower horizontal plane, the interspinous
plane, may also be used, interconnecting the anterior
superior iliac spines on both sides and running across
1.2 the sacral promontory. Of the nine areas, the centrally
Regions of the Abdominal Wall placed zone is the umbilical region. This region sur-
rounds the umbilicus and usually corresponds to the
To accurately describe the locations of visible abnor- location of the jejunum, transverse part of the duode-
malities, masses, and pain in a typical clinical write-up, num, terminal ileum, transverse colon, ureter and the
the anterolateral abdomen is divided into nine regions greater curvature of the stomach.
by four imaginary planes: two verticals (midclavicular/ The epigastrium is the upper middle part of the ante-
midinguinal) and two horizontal (transpyloric/intertu- rior abdomen between the umbilicus below and the cos-
bercular) planes (Fig. 1.1). The transpyloric plane cor- tal arches and the xiphoid process above. It contains the
responds to the midpoint between the umbilicus and stomach, left lobe of the liver, and part of the pancreatic
xiphoid process, crossing the pylorus of the stomach at head. The pubic region known as the hypogastrium de-
2 1 Anatomy of the Abdominal Wall
fines the zone immediately distal to the umbilical region between the third and fourth vertebrae. However, lower
and contains the ileum and sigmoid colon. The hypo- levels are observed in obese individuals and in condi-
chondriac regions flank the epigastrium and are occu- tions that reduce abdominal tone. In the fetus, the um-
pied on the right side by the liver, gallbladder, right colic bilicus transmits the vitelline and umbilical vessels and
flexure, descending duodenum, right kidney and supra- yolk stalk.
renal gland. On the left side these regions contain the The umbilicus can be the site of an acquired umbili-
spleen, left kidney and suprarenal gland, tail of the pan- cal hernia or omphalocele [2, 3]. It is surrounded by the
creas, left colic flexure, and fundus of the stomach. Most paraumbilical veins that establish connections with
of the hypochondriac and parts of the epigastric regions both the portal vein and the inferior vena cava (porta-
are protected by the lower ribs. Areas immediately to caval anastomosis) through a series of venous chan-
the right and left of the umbilical region are designated nels. It is also the site of attachment of the umbilical lig-
as the right and left lumbar (lateral) regions, containing aments that consist of the median umbilical (remnant
the ascending and descending colon, respectively. The of the urachus), medial umbilical (obliterated umbilical
right and left iliac regions surround the hypogastrium. arteries) and lateral umbilical (inferior epigastric ves-
The right iliac region contains the appendix and cecum, sels) ligaments/folds. A patent urachus may discharge
and the left iliac region corresponds to locations of the urine because of its connection to the urinary bladder,
sigmoid colon and left ureter. and it can be associated with outflow obstruction or
A simplified division of the anterolateral abdomen pus from an infected urachal cyst or with fecal matter if
uses two imaginary planes that run through the umbili- it is connected to part of the large intestine.
cus, one passing horizontally and the other vertically. The umbilicus may also receive the embryological
The four quadrants separated by these planes divide remnant of the vitelline duct known as Meckel’s diver-
the anterior abdomen into the right and left upper and ticulum. This diverticulum occasionally protrudes
lower quadrants. through the anterolateral abdomen and produces Lit-
In summary, the regions described above help medi- tre’s hernia. The umbilicus also receives the round liga-
cal practitioners to accurately describe the pathological ment of the liver, a remnant of the umbilical vein. The
processes associated with the anterior abdominal wall umbilical vein remains patent for some time during
and to document the findings in the differential diag- early infancy and allows blood transfusion through
nosis. For example, periumbilical and hypogastric pain catheterization in individuals with hemolytic diseases
is felt during the initial stage of appendicitis, while pain such as erythroblastosis fetalis [4].
in the right iliac region occurs at a later phase in this The superficial abdominal reflex refers to deviation
condition. Pancreatic or esophageal disorders produce of the umbilicus toward the stimulated side when the
pain that projects to the epigastrium. skin of the anterolateral abdomen is stimulated by a
blunt object applied to the flank at the midaxillary line
inward toward the umbilicus. This reflex, which in-
1.3 volves contraction of the abdominal muscles and sub-
Layers of the Abdominal Wall sequent deviation of the umbilicus, reveals the condi-
tion of the ninth through the eleventh spinal cord seg-
The anterolateral abdominal wall consists, from the ments. Disappearance of this reflex is associated with
outside in, of the skin, superficial fascia, deep fascia, postoperative pain following thoracotomy [5]. Absence
external and internal abdominal oblique, transverse of this reflex can be an early sign of syringomyelia in in-
abdominis and associated aponeuroses, rectus abdo- dividuals with scoliosis [6, 7].
minis and pyramidalis, as well as the transversalis fas- The linea alba (white line) is formed by the midline
cia. fusion of the aponeuroses of flat abdominal muscles
and may be visible through the skin of muscular indi-
viduals. The linea semilunaris (Spigelian line) marks
1.3.1
the lateral border of the rectus abdominis, extending
Skin
from the costal arch near the ninth costal cartilage to
The skin is of average thickness, and loosely attaches to the pubic tubercle. This line marks the sites of entry of
the underlying tissue. It exhibits certain surface mark- motor nerves to the rectus abdominis, rendering it a
ings such as the umbilicus, linea alba, linea semiluna- surgically undesirable site for incisions. Spigelian her-
ris, epigastric fossa, and McBurney’s point. nia, which consists of extraperitoneal fat covered by the
The umbilicus, a midline fibrous cicatrix covered by skin, superficial fascia and the aponeurosis of the exter-
a folded area of skin, is an important anatomical land- nal oblique, may be hidden at the junction of the linea
mark in the anterior abdomen that marks the original semilunaris and arcuate line of Douglas. The small de-
attachment of the fetal umbilical cord. In young adults, pression below the infrasternal angle is termed the epi-
it is usually located at the level of the intervertebral disc gastric fossa. McBurney’s point marks the junction of
1.3 Layers of the Abdominal Wall 3
the lateral and middle third of a line that connects the on the nutritional status of the individual. In the male,
anterior superior iliac spine to the pubic tubercle. This it continues inferiorly with the dartos layer of the scro-
topographic landmark on the anterior abdomen corre- tum and outer layer of the penis and spermatic cord,
sponds to the common location of the appendix. where it becomes thinner, lacking adipose tissue. In the
The horizontal directions of the connective tissue fi- female, it continues with the superficial fascia covering
bers beneath the epidermis form the visible Langer’s the labia majora. Approximation of Camper’s fascia at
cleavage lines. Due to the elastic quality of the connec- closure of the abdominal incision during cesarean de-
tive tissue, an incision will produce retraction of the livery appears to prevent postoperative superficial
connective tissue and eventual gapping of the skin. An wound disruption [8].
incision made perpendicular to the direction of Lan- In the lower wall of the anterior abdomen, a deeper
ger’s lines is most likely to gape and result in prominent membranous layer known as Scarpa’s fascia becomes
scarring. Since the course of the nerves and vessels that visible [9]. This layer remains connected, though loose-
supply the anterolateral abdomen parallels the cleavage ly, to the deep fascia that covers the aponeurosis of the
lines of the skin, transverse incisions of the abdomen external abdominal oblique muscle. The strength of the
are surgically more favorable. They are less likely to Scarpa’s fascia can stabilize sutures placed when clos-
gape or cause damage to nerves or vasculature and heal ing incisions of the abdominal wall. The space between
faster without visible scarring. The dermis of the skin of the deep fascia that covers the external oblique and
the anterolateral abdomen is resilient, permits some de- Scarpa’s fascia (superficial inguinal pouch) occupied
gree of stretch, and is able to counteract the prolonged by loose connective tissue may serve as a frequent site
tearing pressure. However, stretch exerted by the preg- for retracted ectopic testis in children.
nant uterus can disrupt the connective tissue fibers of Scarpa’s fascia (Fig. 1.2) firmly attaches to the linea
the dermis and produce striae perpendicular to the alba and symphysis pubis and forms the fundiform lig-
Langer’s lines, commonly known as ’stretch marks’. ament of the penis or the clitoris. In the male, it joins
the Camper’s fascia and continues into the scrotum as a
single smooth muscle containing a layer known as the
1.3.2
dartos. This deep and tough collagenous layer is con-
Superficial Fascia
tinuous with Colle’s fascia of the perineum, and with
The superficial fascia (Fig. 1.2) is a soft and movable the inferior wall of the superficial perineal pouch or re-
layer, which comprises, to a great extent, a single vari- cess. In the upper thigh, it is attached to the fascia lata
ably fatty superficial layer known as Camper’s fascia.
The amount of fat in Camper’s fascia varies depending
Internal Intercostal Muscle
Skin
(Cut)
Serratus
Anterior
Muscle Camper's
Fascia
Latissimus (Cut)
Dorsi
External
Intercostal
Muscle
Cut Edge of
the Superficial
Fascia and Skin
Scarpa's Fascia
Iliac Crest
Subclavian Artery
Internal
Thoracic Artery
Anterior
Intercostal
Arteries
Superior Epigastric
Artery
Subcostal Artery
Rectus Abdominus (cut)
Superficial Circumflex
Iliac Artery
Deep Circumflex
Iliac Artery
Inferior Epigastric
Artery Fig. 1.3. The diverse origin of the arterial supply to the abdomen
1.4 Blood Supply of the Abdominal Wall 5
1.4.6 1.4.8
Inferior Epigastric Artery Subcostal Artery
The inferior epigastric artery (Fig. 1.3) is a branch of the The subcostal artery courses inferior to the last rib and
external iliac artery that ascends obliquely along the anterior to the 12th thoracic vertebra. It lies posterior
medial margin of the deep inguinal ring, posterior to to the sympathetic trunk, thoracic duct, pleura and dia-
the spermatic or round ligament. It may arise from the phragm. Then, it descends into the posterior abdomi-
femoral artery, or, very rarely from the obturator artery. nal wall posterior to the lateral arcuate ligament ac-
It pierces the transversalis fascia to enter into the poste- companied by the corresponding vein and nerve. As it
rior wall of the rectus abdominis at the level of the arcu- continues anterior to the quadratus lumborum and
ate line. This vessel penetrates the posterior sheath near posterior to the kidney, the right subcostal artery
the middle of the lower abdomen and the anterior courses behind the ascending colon, whereas the left
sheath in an area ranging from the upper third of the subcostal artery travels behind the descending colon.
6 1 Anatomy of the Abdominal Wall
The subcostal artery establishes anastomoses with the lumborum. After they pierce the transverse abdominis,
lower posterior intercostal, superior epigastric and running between this muscle and the internal oblique,
lumbar arteries. the lumbar arteries anastomose with the iliolumbar,
subcostal, deep circumflex, inferior epigastric and low-
er posterior intercostal arteries. Spinal branches of the
1.4.9
lumbar arteries supply the conus medullaris, cauda
Musculophrenic Artery
equina, and spinal meninges.
The musculophrenic artery, a terminal branch of the
internal thoracic artery, runs inferiorly and laterally
posterior to the seventh to ninth costal cartilages and 1.5
gives rise to the lower two anterior intercostal arteries Venous Drainage of the Anterolateral Abdomen
to the corresponding intercostal spaces. It supplies the
pericardium and anterior abdominal muscles, anasto- The anterior abdominal wall is drained via the superfi-
mosing with the deep circumflex iliac and the lower cial epigastric, thoracoepigastric, paraumbilical and
two posterior intercostal arteries. the superficial circumflex iliac veins (Fig. 1.4).
1.4.10 1.5.1
Lumbar Arteries Superficial Epigastric Vein
The lumbar arteries arise from the abdominal aorta an- The superficial epigastric vein drains the inferior part
terior and to the left of the lumbar vertebrae. A fifth of the anterior abdominal wall and is connected to the
pair of lumbar arteries may arise from the middle sa- paraumbilical and thoracoepigastric veins. This vessel
cral artery. They run posterior to the sympathetic drains via the great saphenous vein into the femoral,
trunk and the tendinous origins of the psoas major external iliac and common iliac veins and eventually
muscle. On the right side they travel posterior to the in- into the inferior vena cava. It also drains into the portal
ferior vena cava but only the upper two pairs of lumbar vein through the paraumbilical veins and the partially
arteries course posterior to the corresponding crus of obliterated umbilical vein. Through this venous linkage
the diaphragm. The upper three pairs run anterior, to both the inferior vena cava and portal vein, a porta-
while the lowest course runs posterior, to the quadratus caval anastomosis is established. Occlusion of the por-
Lateral Cutaneous
Thoracoepigastric Branches of 8th to
Vein 12th Intercostal
Nerves
Anterior Cutaneous
Branches of 6th to
Superficial 12th Intercostal Nerves
Epigastric Vein
Camper's Lateral Cutaneous
Fascia Branch of
Iliohypogastric
Nerve (L1)
Scarpa's Fascia
Reflected
Rectus
T 10 intercostal nerve Abdominis
T 11 intercostal nerve
T 12 intercostal nerve Umbilicus
Iliac Crest
tercostal artery. Each intercostal nerve is connected to Since thoracoabdominal nerves also convey sensa-
an adjacent sympathetic ganglion by a white communi- tion from the costal and peripheral diaphragmatic
cating ramus conveying presynaptic sympathetic fi- pleura, pleural inflammation can produce pain felt in
bers, and by a gray communicating ramus that trans- the abdominal wall. Appendicitis induced pain and ri-
mits postsynaptic sympathetic fibers. gidity in the abdominal are due to the fact that the sym-
pathetic innervation of the abdominal viscera is de-
rived from the same segments that supply the derma-
1.6.1
tomes of the anterolateral abdomen. Tuberculosis af-
Thoracoabdominal Nerves
fecting the lower five thoracic vertebrae can also pro-
The seventh and eight intercostal nerves, as is the case duce pain that projects to the anterior abdominal wall.
with the rest of the intercostal nerves, divide into lateral Similarly, shingles of the lower ganglia of the thoracic
and anterior cutaneous branches. The lateral branch spinal nerves produce diffuse pain and vesicular erup-
further divides into anterior and posterior branches, tions in the anterolateral abdominal wall. Referred ab-
piercing the flat abdominal muscles in the midaxillary dominal pain may also occur as a result of subluxation
line to reach the skin. The anterior cutaneous branches, of the interchondral joints that entraps the intercostal
which represent the terminal branches of the ventral nerves. Constrictive pain, felt as a tight cord around the
rami of the intercostal nerves, pierce the rectus sheath abdomen, is usually a manifestation of a lesion that has
laterally and emerge anteriorly to reach the skin. They affected a single pair of intercostal nerves. Clicking rib
pursue a curved course toward the lateral border of the syndrome, which results from subluxation of the inter-
rectus abdominis, and perforate the transverse abdo- chondral joints of the lower ribs, may cause compres-
minis to reach the internal abdominal oblique aponeu- sion of the lower intercostal nerves and produce pain in
rosis. After piercing the internal abdominal oblique, the anterior abdomen.
they run parallel to the costal margin, enter the posteri- Thoracoabdominal nerves that supply the abdomi-
or surface of the rectus abdominis to continue in its nal muscles form an extensive communicating network
sheath to reach and supply the skin. that allows considerable overlap. This type of overlap is
The ninth to eleventh intercostal nerves pierce the responsible for the limited or complete lack of percepti-
diaphragm and transverse the abdominis and enter the ble clinical deficits upon damage to one or two nerves.
gap between the transverse and internal oblique, where In contrast, the segmental innervation of the rectus ab-
they pierce the posterior layer of the internal abdomi- dominis has no or very little cross-linkage. Conse-
nal oblique aponeurosis near its lateral border. Beyond quently, individual nerve damage associated with the
this point, they travel in a similar manner to the sev- rectus abdominis is likely to produce deficits in the af-
enth and eight intercostal nerves. The ninth intercostal fected area.
nerve is much larger and should be preserved in a sub- Tapping the anterior abdominal wall produces con-
costal (Kocher’s) incision, which is usually done one traction of the abdominal muscles and thereby reveals
inch below the costal arch in individuals with a wider the conditions of certain spinal segments. A quick tap
infrasternal angle. The downward and forward direc- at the midclavicular line below the costal arch assesses
tion of the anterior branches of the intercostal nerves the integrity of the seventh through the ninth spinal
brings the tenth intercostal nerve to the umbilicus. The segments. Tapping the area immediately lateral to the
lower intercostal nerves may be entrapped as they umbilicus appraises the condition of the ninth to the
pierce the rectus sheath and cause rectus abdominis eleventh spinal segments. Imparting a quick tap imme-
syndrome, which is characterized by numbness and diately above the inguinal ligament at the midclavicular
paresthesia in the median and paramedian areas of the line discloses information about the eleventh through
abdomen. the first lumbar spinal cord segments [13].
The subcostal nerve, the ventral ramus of the 12th
thoracic spinal nerve, is much larger than the intercos-
1.6.2
tal nerves and runs inferior to the corresponding rib
Iliohypogastric Nerve
with corresponding vessels. It passes posterior to the
lateral arcuate ligament and kidney, and anterior to the The iliohypogastric nerve courses posterior to the psoas
quadratus lumborum. It pierces the aponeurosis of the major and exits through its lateral border posterior to
transverse abdominis and internal abdominal oblique the kidney and anterior to the quadratus lumborum and
and then assumes a course similar to that of the lower the iliacus muscles. Near the iliac crest, it pierces and
intercostal nerves. After crossing the iliac crest imme- provides innervation to the transverse abdominis and
diately posterior to the anterior superior iliac spine, the internal abdominal oblique muscles, and splits into lat-
subcostal nerve supplies the pyramidalis via the medial eral and anterior branches. The lateral branch distrib-
branch and the anterior gluteal skin via its lateral utes cutaneous branches to the gluteal region, while the
branch. anterior branch pierces the internal and external oblique
1.9 Musculature of the Anterior Abdominal Wall 9
nal muscles, usually indicates that the cause of the pain double fascial layer that covers the internal surface of
is in the anterolateral abdominal wall and not due to in- the external abdominal oblique and the external sur-
testinal dysfunction. face of the internal abdominal oblique muscle.
The muscles of the anterolateral abdomen maintain The portion of the muscle that inserts into the outer
intra-abdominal pressure and the position of the vis- margin of the iliac crest has a free posterior border,
cera, by exerting compressive and twisting force. They which forms the anterior wall of the inferior lumbar tri-
facilitate certain physiologic functions such as parturi- gone of Petit. This trigone is bounded anteriorly by the
tion, vomiting, defecation, urination and coughing. external abdominal oblique muscle, posteriorly by the
Contraction of these muscles also promotes expiration latissimus dorsi, and inferiorly by the iliac crest. It is a
by depressing and compressing the lower thorax. weak zone in the abdominal wall can that tends to her-
niate (Petit’s hernia), and the hernial sac is usually
broad and less likely to incarcerate.
1.9.1
Three different groups of arteries were identified in
External Abdominal Oblique
a study conducted by Schlenz et al. [18] as the sources
The external abdominal oblique muscle (Figs. 1.6, 1.7) is of blood supply to the external abdominal oblique. The
the most superficial abdominal muscle that originates cranial part of this muscle is supplied by the intercostal
from the external surfaces of the lower seven or eight arteries. In 94.7 % the deep circumflex iliac artery and
ribs and interdigitates with the serratus anterior and la- in 5.3 % the iliolumbar artery is responsible for the
tissimus dorsi muscles. Most of the muscle fibers run blood supply to the caudal of the muscle. The lateral
downward and medially, forming an aponeurosis near branches of these arteries run on the outer surface of
the lateral border of the rectus abdominis. The muscle the muscle, while the anterior branches enter the mus-
fibers from the lower two ribs descend vertically down- cle from its inner surface. Arterial injection studies
ward to attach to the iliac crest. Muscle fibers are rarely conducted by Kuzbari et al. [19] have also confirmed
found inferior to the line that connects the umbilicus to the significant contribution of the deep circumflex iliac
the anterior superior iliac spine. The vessels and nerves artery to the blood supply of the external abdominal
that supply the abdominal wall are contained in the oblique muscle.
Pectoralis
Minor
External
Abdominal
Oblique
Muscle Tendinous
Intersection
Anterior Layer
of Rectus Sheath
Linea Alba
Inlingual Ligament
Linea Alba
Anterior Superior
Iliac Spine
External Oblique
Abdominis Muscle and
Aponeurosis
Inguinal Ligament
Acetabulum Transverse
Intercrural
Fibers
Lateral Crus
Spermatic
Obturator Cord
Foramen i
nste
n
Fig. 1.7. Aponeurosis of the external Medial Crus D e b o ra h R u b e
oblique, superficial inguinal ring, and
the inguinal ligament Lacunar Ligament Fundiform Ligament
Interfoveolar
Arcurate (Semicircular) Ligament
Line of Douglas
Epigastric Artery
and Vein
Rectus Abdominis
Muscle
Testicular Vessels
Deep Inguinal Ring
Iliacus Muscle
External Iliac Artery
The aponeurosis of the external abdominal oblique Inferiorly, the external oblique aponeurosis attaches
(Fig. 1.7) runs anterior to the rectus abdominis and to the pubic tubercle, pubic symphysis and crest. The
joins the aponeurosis of the internal and transverse ab- aponeurosis infolds backward and slightly upward up-
dominis at the linea alba. The linea alba is a tendinous on itself between the anterior superior iliac spine and
midline raphe that extends between from the xiphoid the pubic tubercle to form the inguinal (Poupart) liga-
process to the symphysis pubis and pubic crest. It is ment (Figs. 1.6, 1.7). This ligament, which measures ap-
wider above the umbilicus, separating the recti proximately 15 cm, marks the transition between the
completely. However, this demarcation may not be eas- abdominal wall and thigh. Its curved surface consti-
ily felt inferior to the umbilicus. As a fibrous structure, tutes the floor of the inguinal canal, and maintains an
it is virtually a bloodless line along which a surgical in- oblique angle to the horizontal.
cision can be made. The triangular part of the linea al- The reflected part of the inguinal ligament is repre-
ba that attaches to the pubic crest is known as the admi- sented by the fibers of the external oblique aponeurosis
niculum linea alba (Fig. 1.8). that course superiorly and medially to join the rectus
12 1 Anatomy of the Abdominal Wall
sheath and linea alba (Figs. 1.9, 1.10). This ligament ex- As the inguinal ligament runs from the anterior su-
tends from the lateral crus of the superficial inguinal perior spine toward the pubic tubercle, it leaves a poste-
ring toward the linea alba anterior to the conjoint ten- rior gap occupied by vessels and nerves that supply the
don. thigh (Fig. 1.8). This gap is divided by the iliopectineal
A medially and horizontally aligned extension of the arch, a septum continuous with the iliopsoas fascia and
inguinal ligament, which is best seen from the abdomi- inguinal ligament into vascular (lacuna vasorum) and
nal side, extends posterolaterally to attach to the medial muscular (lacuna musculorum) compartments. The
end of the pecten pubis and is known as the lacunar vascular compartment contains the femoral vein and
(Gimberant’s) ligament (Figs. 1.7, 1.8). This triangular artery, and the femoral ring, whereas the muscular
ligament (pectineal part of the inguinal ligament) mea- compartment encloses the femoral nerve and iliopsoas
sures 2 cm from base to apex, and forms the medial muscle.
border of the femoral canal, separating it from the fem-
oral vein. A second lacunar ligament, known as the fas-
cial lacunar ligament, can be seen as an extension of the 1.10
fascia lata that joins the inguinal ligament, pectineal Innervation
fascia and the periosteum of the pecten pubis, and re-
ceives fibers from the transversalis fascia. The fascial The external oblique muscle receives innervation from
lacunar ligament forms a thickening around the femo- the anterior primary divisions of the lower five or six
ral sheath. It is approximately 1 cm anterior and inferi- intercostal nerves.
or to the pecten pubis and 3 cm lateral to the pubic tu-
bercle.
1.10.1
The superficial inguinal ring (Fig. 1.7), the outer
External Oblique Muscle
opening of the inguinal canal, appears superior to the
inguinal ligament and superolateral to the pubic tuber- 1.10.1.1
cle. Although the superficial inguinal ring does not as a Action
rule stretch beyond the medial third of the inguinal lig- Contraction of the external abdominal oblique muscle
ament, it shows some variation in size. In the female it flexes the vertebral column and helps to rotate the tho-
is usually much smaller, accommodating the thin rax and pelvis. It depresses the thorax in expiration,
round ligament. The base of the superficial inguinal and supports the abdominal viscera. Other abdominal
ring is at the pubic crest and its sides are formed by the muscles share many of these actions.
medial and lateral crura. The thin medial crura inter-
digitate anterior to the symphysis pubis while the much
1.10.2
stronger lateral crus attaches to the pubic tubercle. In-
Internal Abdominal Oblique Muscle
tercrural fibers cross the apex of the superficial ingui-
nal ring and resist widening of this gap. As the spermat- The internal abdominal oblique (Figs. 1.9, 1.10) muscle
ic cord passes through the superficial inguinal ring, it is much thinner and lies deep to the external abdominal
rests upon the lateral crus and becomes invested by the oblique. It arises from the iliac crest and the lateral two-
external spermatic fascia, which is an extension of the thirds of the inguinal ligament, as well as from the tho-
external abdominal aponeurosis. racolumbar fascia. Fibers of this muscle, particularly
A robust fibrous band, the Cooper’s ligament, ex- those from the iliac crest and thoracolumbar fascia,
tends laterally along the sharp edge of the pecten pubis pursue a reverse course perpendicular to that of the ex-
and connects the base of the lacunar ligament to the ternal abdominal oblique, extending for the most part
pecten pubis. It receives fibers from the pectineal fascia upward and medially.
and adminiculum albae (lateral extension from the The part of the muscle that originates from the ingui-
lower end of the linea alba) and is considered as a firm nal ligament becomes aponeurotic and arches over the
structure to which sutures can be anchored. The find- spermatic cord in the male, or the round ligament in the
ings of Faure et al. [20] and Rousseau et al. [21] empha- female. It joins the aponeurosis of the transverse abdo-
sized the role of the ligament of Cooper in laparascopic minis muscle anterior to the rectus abdominis muscle to
surgery of the inguinal region and female urinary in- form the conjoint tendon (falx inguinalis). It attaches to
continence. They confirmed the fact that this ligament the pubic crest and for a variable distance to the medial
is a thickening of the pectineal fascia rather than the part of the pecten pubis. In the Bassini technique of her-
periosteum. In McVay’s technique of repair of inguinal niorrhaphy [24 – 26], the conjoint tendon is sutured to
hernia [22, 23], the Cooper’s ligament is sutured to the the transversalis fascia and the reflected part of the in-
transversalis fascia. The close proximity of this liga- guinal ligament. The conjoint tendon joins medially the
ment to the femoral vessels must always be remem- anterior wall of the rectus sheath and unites laterally
bered. with the interfoveolar ligament, an inconstant fibrous
1.10 Innervation 13
Deltoid
Muscle
External Oblique
Abdominis
Rectus Abdominis
Rectus Sheath
Symphysis
Pubis Pubic Tubercle
Camper's
External Intercostal Fascia
Muscle
Skin
Internal Abdominal
Oblique
Rectus Abdominis
band that connects the transverse abdominis to the su- the transverse abdominis. The cremasteric, a striated
perior pubic ramus. However, variations do exist in re- muscle with a lateral and a medial part, is an involun-
gard to the extent of attachment of the conjoint tendon tary muscle innervated by the genital branch of the ge-
and its structural characteristics. The part of the tendon nitofemoral nerve (L1, L2). The lateral part is thicker,
that inserts on the pecten pubis extends posterior to the directly arises from the inguinal ligament, and extends
superficial inguinal ring, forming a natural barrier that to the anterior superior iliac spine. The medial part of
prevents the occurrence of inguinal hernia. A direct in- the internal abdominal oblique, which is sometimes
guinal hernial pouch may pass through this tendon, ac- absent, arises from the pubic tubercle, conjoint tendon,
quiring the coverings of this structure. and possibly the transverse abdominis.
The posterior fibers of the internal abdominal ob- From the inferior edge of the internal abdominal
lique muscles that gain origin from the iliac crest ex- oblique, the cremasteric muscle and fascia loop over
tend upward and laterally to the inferior border of the the spermatic cord and testis to terminate at the pubic
lower three or four ribs, continuing with the internal tubercle and merge with the anterior layer of the rectus
intercostal muscles. They become aponeurotic towards sheath. This muscle is considered to have internal and
the midline and contribute to the formation of the linea external components separated by the internal sper-
alba by joining the aponeurosis of the flat abdominal matic fascia [27]. Redman [28] concluded that expo-
muscles of the same and opposite side. sure of the inguinal canal and deep inguinal ring in her-
Superior to the midpoint between the umbilicus and nial repair is greatly enhanced by careful dissection of
the symphysis pubis (upper two-thirds), the internal the cremasteric muscle and fascia.
oblique aponeurosis divides into two layers. The anteri- In the female, the round ligament is invested by the
or layer covers the anterior surface of the rectus abdomi- sporadic fibers from the lateral part of the cremasteric
nis and the posterior layer invests the posterior surface muscle. Contraction of the cremasteric muscle medi-
of the rectus abdominis. Distal to this site (lower one- ates the cremasteric reflex, a brisk reflex, particularly in
third), the aponeurosis of the internal oblique remains a children, which involves elevation of the testicles to-
single layer anterior to the rectus abdominis (Fig. 1.11). wards the superficial inguinal ring upon stimulation of
The loosely arranged fasciculi of the internal ob- the inner thigh.
lique muscle and its aponeurosis, which extend around
the spermatic cord and testis, constitute the cremaste-
ric muscle and fascia that invariably receive fibers from
Rectus Abdominis
External Abdominal
Oblique Muscle
External Abdominal
Oblique Aponeurosis Costal
Anterior Layer of the cartilage
Camper's Fascia Rectus Abdominis Rectus Sheath
External Abdominal
Oblique Muscle
Internal Abdominal
Oblique
Posterior Layer of Deb
ora
Rectus Sheath Transversalis Fascia hR
uben
s t ei
n
Anterior Layer of the Transverse
Rectus Sheath Internal Abdominal Abdominis
Rectus Abdominis Camper's Fascia Oblique Muscle
External Abdominal
Oblique Muscle
De
bo
ra
Transversalis Fascia hR
ub
en
s te
in
Transverse
Abdominis Fig. 1.11. Patterns of lamina-
Muscle tion of the rectus sheath
1.10 Innervation 15
1.10.2.1 1.10.2.2
Action Innervation
Bilateral contraction of the external abdominal oblique The internal abdominal oblique is innervated by the
muscles, in conjunction with the internal oblique and ventral rami of the lower six intercostal, iliohypogastric
rectus abdominis, produces flexion of the vertebral col- and ilioinguinal nerves.
umn. Ipsilateral contraction of the external and inter-
nal abdominal oblique muscles produces abduction of
1.10.3
the trunk (lateral flexion to the same side). Contraction
Transverse Abdominis Muscle
of the external abdominal oblique on one side and the
internal oblique on the opposite side results in rotation The transverse abdominis (Figs. 1.2, 1.12 – 1.16) is a
of the lumbar vertebral column. wide thin muscular layer that assumes a nearly hori-
Skin (Cut)
Serratus
Anterior
Muscle
Camper's
Latissimus Fascia
Dorsi (Cut)
External
Intercostal
Muscle
Iliac Crest
Transverse
Abdominis
Muscle and
Aponeurosis
Fig. 1.12. Transverse abdominis muscle and aponeu-
rosis
Sternal Angle of Louis the aponeurosis of the internal abdominal oblique and
the external oblique to form the anterior layer of the
rectus sheath. Inferior to the midpoint, the transverse
aponeurosis runs posterior to the rectus abdominis
Xyphoid and anterior to the muscle. The lower fibers of the apo-
Process neurosis curve downward and medially and join the
aponeurosis of the internal abdominal oblique at the
Linea Alba pubic crest to form the conjoint tendon.
Rectus
Abdominis
Muscle Tendinous
Umbilicus Intersections
Pubic Symphuysis
Skin (Cut)
Latissimus
Dorsi
External
Intercostal
Muscle
Tendinous
Rectus Abdominis Intersection
Posterior Layer
of the Rectus Transverse
Sheath Abdomonis
Muscle
Transverse
Abdominis
Muscle
Internal Internal
Abdominal Abdominal
Oblique Oblique
Arcurate Line
of Douglas Anterior Layer
of the Rectus
Transversalis Sheath
Fascia
Spermatic Cord Spermatic Cord
Pyramidalis
Rectus Abdominis
(Cut)
Fig. 1.16. Posterior layer of the rectus sheath, arcuate line of Douglas, internal abdominal oblique, and transverse abdominis
It is believed that the actions of the transverse abdomi- The recti muscles are completely separated in the mid-
nis are basically common to the internal and external line above the umbilicus by the linea alba and less so
abdominal oblique muscles. The transverse abdominis below it. Its lateral border forms the semilunar line, a
is believed to respond more to increases in chemical or curved groove that extends from the pubic tubercle to
volume-related drive than the rectus abdominis and the ninth costal cartilage, which is particularly visible
external abdominal oblique. This is supported by neu- in muscular individuals. This muscle is usually inter-
roanatomical studies that have demonstrated many rupted by three transversely running tendinous inter-
more inputs to, and outputs from, the motor neurons sections that assume a zigzag path and firmly adhere to
that innervate the transverse abdominis muscle than the anterior layer of the rectus sheath. The upper tendi-
can be accounted for by its respiratory role [29]. nous intersection is usually near the xiphoid process;
the lower one is at the level of the umbilicus and is seg-
mentally related to the tenth rib and tenth intercostal
1.10.4
nerve; and the middle one is found between the above
Rectus Abdominis
intersections.
The rectus abdominis (Figs. 1.5, 1.6, 1.8 – 1.10, 1.16), a In order to gain access to the rectus abdominis, the
paired longitudinal muscle on both sides of the mid- rectus sheath should carefully be dissected off the rec-
line, widens as it descends through the rectus sheath, tus muscle and the associated segmental artery and
maintaining distal and proximal attachments. Proxi- vein are severed at each of the intersections. A parame-
mally, it attaches to the xiphoid process and the costal dian incision that cuts through the anterior layer of the
cartilages of the fifth through the seventh ribs. Distally rectus sheath and rectus abdominis carries the advan-
it attaches via a medial tendon to the pubic symphysis, tage of protecting the sutured peritoneum when the
interlacing with the opposite muscle and via a lateral rectus abdominis slips back into its proper anatomical
tendon to the pubic crest, extending to the pecten pubis position. Since this muscle receives innervation
and pubic tubercle. The site of intersection of the lateral through its lateral border (Figs. 1.4, 1.5) by piercing the
border of the right rectus and costal arch marks the to- tendinous intersections, incisions immediately lateral
pographic location of the fundus of the gallbladder. to the rectus abdominis near the linea semilunaris can
18 1 Anatomy of the Abdominal Wall
carry a great risk of denervation and atrophy. There- cartilages, and the anterior layer of the sheath at this
fore, the rectus abdominis can surgically be transected level is formed only by the external oblique aponeuro-
anywhere other than the sites of these fibrous intersect- sis. Immediately below the costal margin, the trans-
ions, without possible threat of herniation. Cosmetic verse abdominis muscle extends posterior to the rectus
[30] results are greatly enhanced when the approxima- muscle. The rectus sheath contains the pyramidalis
tion of the recti muscles is combined with a flap ad- muscle, the superior and inferior epigastric vessels and
vancement and rotation of the external abdominal the terminal branches of the lower five or six intercostal
oblique muscle. nerves.
The rectus sheath (Figs. 1.8, 1.11, 1.16) consists of Although spontaneous hematoma into the rectus
the aponeuroses of the external and internal oblique sheath as a result of a rupture of the epigastric vessels is
and transverse abdominis muscles, exhibiting two pri- rare in pregnancy, acute abdominal pain in the third
mary patterns of laminations demarcated by the arcu- trimester or at the beginning of the postpartum period
ate line of Douglas (Figs. 1.8, 1.16). This line corre- should alert the surgeon for this very possibility [31,
sponds to the midpoint between the umbilicus and the 32]. Diastasis recti, a symptomatic separation of the
symphysis pubis. Proximal to the arcuate line the apo- recti by a stretching or widening of the linea alba, is
neuroses of the external abdominal oblique and the an- commonly associated with parturition.
terior layer of the internal abdominal oblique form the
anterior layer of the rectus sheath. At this level, the pos-
1.10.4.1
terior layer comprises the aponeuroses of the trans-
Innervation
verse abdominis and the posterior layer of the internal
abdominal oblique as well as the transversalis fascia. The rectus abdominis muscle is segmentally innervat-
Distal to the arcuate line, the anterior layer of the rectus ed by the ventral rami of the lower six or seven thoracic
sheath is formed by the combined aponeuroses of the spinal nerves.
external and internal oblique and the transverse abdo-
minis. At this level, the posterior layer is only formed by
1.10.4.2
the transversalis fascia that separates the rectus abdo-
Actions
minis from the peritoneum.
Since the aponeuroses of the internal oblique and With the pelvis fixed, the recti act as flexors of the lum-
transverse abdominis only extend to the costal margin, bar vertebral column; with the thorax fixed, they draw
the rectus abdominis above this level rests on the costal the pelvis upward. The recti come to action as flexors,
Transverse Abdominis
Muscle
Hernial Sac
Fig. 1.17. Course of a hernial sac in the indirect inguinal hernia. Observe the inguinal canal, inferior epigastric vessels and the pro-
truding hernial sac
1.13 Peritoneum 19
particularly in the supine position, overcoming gravi- consists of an internal and an external layer; the inter-
tational pull. nal layer contributes to the sphincteric mechanism that
reduces the size and strengthens the deep inguinal ring.
The role of the transversalis fascia in inguinal hernial
1.10.5
repair and reinforcement of the dorsal wall of the ingui-
Pyramidalis Muscle
nal canal has been suggested by Morone et al. [36] and
The pyramidalis (Fig. 1.17), an inconstant small muscle Witte et al. [37]. The study conducted by Teoh [38] con-
which is absent in approximately 25 % of the popula- firmed the presence of the iliopubic tract as a thicken-
tion, originates from the symphysis pubis and pubic ing of the transversalis fascia that runs parallel to the
crest and inserts into the linea alba as far as one-third of inguinal ligament and believed to be a significant
the distance to the umbilicus. This triangular muscle structure in various approaches to repair of inguinal
lies anterior to the lower end of the rectus abdominis hernia. It attaches to the superomedial part of the pubic
and becomes smaller and pointed as it ascends towards bone medially, but laterally it joins the iliac fascia with
the junction of the linea alba and the arcuate line. Al- no bony attachments.
though the significance of this muscle is not clear, it is
thought to tense the linea alba.
1.12
1.10.5.1 Extraperitoneal Fatty Tissue
Innervation
The extraperitoneal tissue (subserous fascia) is a gener-
The pyramidalis muscle is innervated by the subcostal ally thin connective tissue layer that occupies the area
nerve and occasionally by branches of the iliohypogas- between the peritoneum and the transversalis fascia in
tric and ilioinguinal nerves. the abdomen, and between the peritoneum and the en-
dopelvic fascia in the pelvis. It is loose and fatty in the
lowest portion, allowing for the expansion of the blad-
1.11 der. The potential space represented by this loose pre-
Transversalis Fascia peritoneal layer, the space of Bogros, is used for the
placement of prostheses in the repair of inguinal her-
The transversalis fascia [33, 34] is a segment of the en- nia. This layer is particularly thick and fatty in the pos-
doabdominal fascia that forms the lining of the entire terior abdomen as it surrounds the major vessels and
abdominal cavity. It contributes to the posterior wall of also the kidney to form the perinephric renal capsule.
the rectus sheath and contains the deep inguinal ring The extraperitoneal tissue also shows thickening
midway between the anterior superior iliac spine and around the iliac crest and pubic bone.
the symphysis pubis. It lies between the transverse ab-
dominis and the extraperitoneal fat and continues infe-
riorly with the iliac and pelvic fascia and superiorly 1.13
with the fascia on the inferior surface of the diaphragm. Peritoneum
Although it is a very thin layer on the inferior surface of
the diaphragm, it shows some thickening in the ingui- The peritoneum is part of the coelomic cavity that be-
nal region. In the posterior abdominal wall it joins the comes separated from the pleural cavities by the devel-
anterior layer of the thoracolumbar fascia. The trans- opment of the diaphragm. The free surface of this ex-
versalis fascia attaches to the iliac crest and to the pos- tensive membrane is covered by a layer of mesotheli-
terior margin of the inguinal ligament as well as to the um, saturated by a thin film of serous fluid. The perito-
conjoint tendon and the pecten pubis. Its prolongation neum is a serous membrane that resembles, but is
around the spermatic cord, known as the internal sper- much more complicated than, the pleura essentially
matic fascia, fuses with the parietal layer of the tunica due to the fact that in the course of fetal development
vaginalis. It blends with the iliac fascia as it forms the rotations of the gut allow certain parts of the abdomi-
anterior layer of the femoral sheath. nal viscera to variably invaginate into the peritoneum.
Anterior to the femoral vessels, the transversalis fas- However, this process does not occur in the thoracic
cia is augmented by the transverse crural arch, a hori- cavity and the pleura maintains a much simpler ar-
zontally disposed layer that descends to attach medially rangement. In general the peritoneum consists of pari-
to the pecten pubis and laterally to the anterior superi- etal and visceral layers separated by the peritoneal cavi-
or iliac spine. The transverse crural arch plays an im- ty. The parietal layer forms the lining of the abdominal
portant role in strengthening the medial and inferior walls and the diaphragm separated from the transver-
margins of the deep inguinal ring. Menck and Lierse salis fascia by an extraperitoneal connective tissue. Al-
[35] have demonstrated that the transversalis fascia though loosely attached to the abdominal wall, it is
20 1 Anatomy of the Abdominal Wall
denser and firmly adherent to the linea alba and inferi- gans include the spleen, stomach, initial part of the du-
or surface of the diaphragm. It converts the umbilical odenum, tail of the pancreas, jejunum, ileum, trans-
ligaments into folds. The median umbilical fold covers verse colon, and sigmoid colon. Conversely, a retroper-
the urachus, an embryological remnant of the allantois, itoneal organ is covered by the peritoneum anteriorly
which is connected to the apex of the urinary bladder. and laterally or only anteriorly. Retroperitoneal organs
The medial umbilical fold, located lateral to the median include the kidney, ureter, suprarenal gland, inferior
umbilical fold, is formed by the (upper) obliterated vena cava, abdominal aorta, ascending and descending
part of the umbilical artery. The lower (non-obliterat- colon, most of the duodenum, and the rectum.
ed) part of the umbilical artery remains functional in The visceral peritoneum is innervated by sympa-
the adult. The lateral umbilical (epigastric) fold is lo- thetic and parasympathetic fibers. Since sympathetic
cated lateral to the medial umbilical fold, covering the fibers are the principal carriers of visceral pain, inflam-
inferior epigastric vessels. mation of the visceral peritoneum produces referred
Since the lower five intercostal nerves and branches pain in the dermatomes that correspond to the seg-
of the first lumbar spinal segment innervate the skin, mental sympathetic innervation of the affected organs.
muscles and also the parietal peritoneum, peritonitis
may stimulate these nerves, thereby producing pain,
involuntary spasmodic contraction of all abdominal 1.14
muscles, and palpable rigidity (guarding). These im- Inguinal Canal
portant manifestations signify inflammation of the pa-
rietal peritoneum. The inguinal canal [39] is an oblique tunnel that bor-
In contrast, the visceral peritoneum invests the ab- ders the anterior thigh and extends from the superficial
dominal viscera to various degrees. An organ which is to the deep inguinal ring, running parallel to and above
completely invested by the visceral peritoneum is con- the inguinal ligament. It develops between the 5th and
sidered an intraperitoneal organ. Intraperitoneal or- the 32nd week of prenatal life, initially as the processus
Peritoneum
Testis Peritoneum
Epididymis Testis
Epididymis
Peritoneal
Sac
Epididymis
vaginalis, a peritoneal evagination that extends into the External Transverse Abdominis
Abdominal
transversalis fascia. The processus vaginalis (Fig. 1.18) Oblique Processus Vaginalis
eventually loses its connection with the peritoneal cavi- and Aponeurosis Peritoneum
ty of the abdomen and persists as a double-walled se- Internal Ureter
rous layer, the tunica vaginalis, anterior and lateral to Abdominal
Oblique and
the testis. The transversalis fascia continues with the Aponeurosis
internal spermatic fascia in the form of a tubular sheath
D
that travels forward, first by passing between the Cremasteric Muscle
and Fascia
arched fibers of the aponeuroses of the transverse ab-
dominis and internal abdominal oblique abdominis,
Ductus (Vas)
and finally through the external abdominal oblique Internal Deferens
Spermatic
aponeurosis (Fig. 1.19). During the passage of the pro- Fascia Dartos layer
(Subcutaneous Tissue)
cessus vaginalis and internal spermatic fascia through
Skin
the aponeuroses of the internal and external abdominal
Parietal & Visceral External Spermatic
oblique, they acquire additional coverings from the Layers of Tunica Fascia
cremasteric muscle and fascia, and the external sper- Vaginalis Epididymis
matic fascia. Testis Internal Spermatic fascia
The triangular gap proximal and lateral to the pubic
Fig. 1.19. Coverings of the testis and spermatic cord
crest that marks the continuation of the external sper-
matic fascia with the external abdominal oblique apo-
neurosis is known as the superficial inguinal ring. This
opening, formed by a division of the fibers of the exter- ness of the anterior abdominal wall. Presence of the
nal abdominal oblique aponeurosis, is bounded by me- conjoint tendon and the reflected inguinal ligament di-
dial and lateral crura. The medial crus passes supero- rectly posterior to the superficial inguinal ring also
medially to join with the corresponding fibers of the play an important role in counteracting the weakness
contralateral side. The fibers of the lateral crus extend in the inguinal area. Contraction of the abdominal
inferolateral to the superficial inguinal ring, forming muscles forces the wall of the inguinal canal to collapse
the medial end of the inguinal ligament. Variable fi- and thus act as a safety valve, preventing the occur-
brous strands that run across the upper part of the su- rence of hernia in normal individuals.
perficial inguinal ring form the intercrural fibers. The inguinal canal is bounded superiorly (on its
These fibers play a role in strengthening the superficial roof) by the arched lower free fibers of the internal ab-
inguinal ring and preventing further splitting of the fi- dominal oblique and the transverse abdominis muscles
bers of the external oblique aponeurosis. and inferiorly (on its floor) by a combination of the in-
The deep inguinal ring is a funnel-shaped opening guinal and lacunar ligaments and the transversalis fas-
in the transversalis fascia; it is located lateral and supe- cia. It is enclosed anteriorly by the aponeurosis of the
rior to the inferior epigastric vessels, and inferior to the external and abdominal internal oblique muscles and
arched lower margin of the aponeurosis of the trans- posteriorly by the transversalis fascia, falx inguinalis,
verse abdominis. Although size variations do exist, the and the reflected inguinal ligament. This canal contains
deep inguinal ring is almost always larger in the male to the spermatic cord and ilioinguinal nerve in the male,
accommodate the spermatic cord and its components. and the round ligament of the uterus and ilioinguinal
It is approximately 2.54 cm above the midpoint of the nerve in the female.
inguinal ligament, corresponding to the site of passage In the male (Fig. 1.18), descent of the gonads from
of the femoral artery under the inguinal ligament. The the posterior abdominal wall follows the gubernacu-
precise location of the deep inguinal ring as 0.52 cm lat- lum hunteri [41], a mesenchymal tissue that extends
eral to the midinguinal point and 0.46 cm medial to the from the posterior abdominal wall to the deep inguinal
midpoint of the inguinal ligament has been document- ring. The processus vaginalis, guided by the guberna-
ed by Andrews et al. [40]. Neither the midinguinal culum, protrudes through the deep inguinal ring and
point nor the midpoint of the inguinal ligament can ac- descends to the scrotum, as additional fascial coverings
curately predict the position of the deep inguinal ring. are added to it. Variations in the attachments of the gu-
The force exerted by the contraction of the internal bernaculum to the testis may determine the location of
abdominal oblique muscle on the margins of the deep the testis. A recent study [42] found the proximal por-
inguinal ring may play an important role in preventing tion of the gubernaculum to be attached to the testes
herniation. The oblique direction of the inguinal canal, and epididymis in all fetuses that did not exhibit con-
the strength of the abdominal muscles, and the traction genital malformations or epididymal alterations, such
exerted by the internal oblique abdominis muscle dur- as tail disjunction or elongated epididymis. In unde-
ing strenuous activity appear to compensate for weak- scended (cryptorchid) testes, an increased incidence of
22 1 Anatomy of the Abdominal Wall
gubernacular attachment anomalies was accompanied The blood supply, venous and lymphatic drainage,
by paratesticular structural malformations compared and innervation of the testis are associated with the
to the testes of normal fetuses. Cryptorchid testes are posterior abdominal wall and are contained within the
frequently located in the inguinal canal, sometimes in spermatic cord (Figs. 1.7, 1.18, 1.19). This cord is a
the femoral canal and suprapubic region (at the base of composite bundle that contains the vas deferens (duc-
the penis), and rarely found in the contralateral scro- tus deferens), testicular artery, pampiniform venous
tum or perineal region [43]. Tanyel et al. [44] reported plexus, deferential artery, and the genital branch of the
neurogenic changes within all cremasteric muscles of genitofemoral nerve. It is covered by the external sper-
boys with cryptorchid testis. matic fascia, cremasteric muscle and fascia and the in-
In the female, the gonads follow a much shorter ternal spermatic fascia. Separation of the vas deferens
course, and the gubernaculum attaches to the ovary and and associated vessels within the spermatic cord from
the uterus during its descent toward the anterolateral the processus vaginalis and attainment of inguinal or-
abdomen. The portion of the gubernaculum that con- chiplexy can successfully be accomplished by division
nects the ovary to the uterus becomes the proper ova- of the internal spermatic fascia [46].
rian ligament. The remaining part, which extends The vas deferens (Figs. 1.18, 1.19), a cord-like struc-
through the anterolateral abdomen, develops into the ture rich in smooth muscle fibers, begins as a direct
round ligament of the uterus that travels through the in- continuation of the tail of the epididymis and ascends
guinal canal to the major labium. Since the round liga- in the center of the spermatic cord, entering the ab-
ment attaches to the anterolateral abdomen before the dominal wall via the superficial inguinal ring. Subse-
inguinal canal is completely formed, it does not have the quent to its course through the deep inguinal ring into
same fascial coverings as the processus vaginalis in the the pelvis, it joins the duct of the seminal vesicle to
male. In the female, the coverings are so thin that they form the ejaculatory duct. Bilateral congenital absence
are indistinguishable from the round ligament itself. of the vas deferens is associated with azoospermia and
In the male, obliteration of the processus vaginalis, may determine the likelihood of cystic fibrosis [47].
and thus the connection between the peritoneal cavity The testicular artery (Fig. 1.19) emanates from the
in the abdomen and scrotum, is usually complete at abdominal aorta and descends anterior to the ureter,
birth. However, this process may begin late, and when it coursing within the inguinal canal to supply the testis.
does, it becomes completed by the first few weeks of The angle between the ductus deferens and the testicu-
postnatal life. Closure begins at the deep inguinal ring lar vessels, and the thickness of the adjacent tissue
and extends downward to involve all the intervening re- around the deep inguinal ring, show great variations.
gions. This angle, which constitutes the apex of what is called
The only postnatal remnant of the processus vagina- the “triangle of doom”, may be used as a point of refer-
lis is a closed sac anterior and lateral to the testis, ence to predict the position of the ductus deferens,
known as the tunica vaginalis. Failure of the processus thereby preventing accidental surgical stapling of the
vaginalis to close (patent processus vaginalis) may al- underlying external iliac vessels during herniorraphy
low part of the abdominal viscera to protrude through [48]. The thickness of the peritoneum, transversalis
the deep inguinal ring and follow the course of the in- fascia, and intervening connective tissue is greatest lat-
guinal canal to the superficial inguinal ring, producing eral to the testicular vessels and least over the ductus
an indirect inguinal hernia. Kahn et al. [45] published a deferens.
report that objectively confirms that presence of a pat- The deferential artery, a branch of the inferior vesi-
ent processus vaginalis is not a prerequisite to the de- cal artery, forms an extensive anastomosis with the tes-
velopment of indirect inguinal hernia. ticular and the cremasteric arteries. The cremasteric
The tunica vaginalis (Fig. 1.18) consists of visceral artery arises from the inferior epigastric artery and
and parietal layers separated by a cavity that contains a supplies the cremasteric muscle and fascia. The pampi-
thin film of fluid. Accumulation of fluid in this cavity niform plexus (Fig. 1.18) travels through the inguinal
produces hydrocele, a condition that exhibits transillu- canal and gives rise to a number of veins that coalesce
minating scrotal swelling anterior to the testis. Hydro- to form the right and left testicular veins, which drain
cele can be a primary (idiopathic) or secondary condi- into the inferior vena cava and the left renal vein, re-
tion. A primary hydrocele is usually large and rigid, oc- spectively. Dilation of the pampiniform plexus pro-
curs over the age of 40, and develops slowly. A second- duces varicocele, a condition that is usually visible
ary hydrocele tends to occur in younger individuals as when standing or straining. It is associated with defec-
a sequel to inflammation or tumors of the testis. A con- tive valves in the plexus, thrombosis of the left renal
genital hydrocele associated with indirect inguinal her- vein, renal diseases, and rarely with superior mesenter-
nia is usually large and full during the day and shrinks ic artery syndrome.
during the night. A spermatic cord hydrocele tends to The round ligament of the uterus, a remnant of the
move downward when traction is applied to the testis. gubernaculum, follows the inguinal canal from the
1.15 Abdominal Hernias 23
deep to the superficial inguinal ring and eventually so pursue a much shorter path, passing only through
reaches the major labium. It is considerably stretched the superficial inguinal ring. The hernial sac appears
during pregnancy and maintains the anteverted posi- above and medial to the pubic tubercle. Herniation that
tion of the uterus. The wall of this ligament contains follows the entire length of the inguinal canal is an indi-
great numbers of smooth muscle fibers near the uterus; rect inguinal hernia; it commonly results from persis-
these diminish toward the deep inguinal ring, convert- tent processus vaginalis and therefore is known as an
ing into fibrous strands as it reaches the major labium. indirect (congenital) inguinal hernia. The Hessert’s tri-
The round ligament courses diagonally within the me- angle, formed by the intersection of the aponeurosis of
sometrium toward the pelvic floor anterior to the exter- the internal oblique and transverse aponeuroses and
nal iliac, obturator, and vesical vessels, and the obliter- the rectus sheath, may play an important role in the eti-
ated umbilical artery. The round ligament allows some ology of the inguinal hernia [49]. This triangle may be
lymphatics from the cervix and fundus of the uterus to occluded upon contraction of the abdominal muscles
follow its course to the superficial inguinal lymph and by their movement toward the inguinal ligament.
nodes. However, when a larger triangle exists, the occlusion
cannot be complete, a condition that leads to hernia-
tion.
1.15 Inguinal hernia is often asymptomatic, but some pa-
Abdominal Hernias tients, particularly the middle-aged and elderly, experi-
ence aching pain in the lower abdominal quadrants
A hernia, meaning “sprouting forth”, is an outpouch- that radiates to the medial thigh. Others relate the sud-
ing of a visceral organ or a part of organ through an den occurrence of the condition to strenuous activity.
opening that it does not normally transverse. When Patients may report an intermittent, reducible or non-
hernias are associated with the abdomen, they may oc- reducible groin mass. In infants, it is thought that thick-
cur through the inguinal canal, lumbar trigone of Petit, ening of the spermatic cord at the superficial inguinal
femoral canal, or umbilicus. Nerve damage and weak- ring on one side is an important sign of an inguinal her-
ening of the muscles, as a postsurgical complication, nia. The infrequent occurrence of inguinal hernia in
may lead to herniation. A variety of other situations the female is commonly attributed to the small size of
such as pregnancy, constipation, peritoneal dialysis, the superficial inguinal ring and the fatty composition
ascites, and asthma may predispose an individual to of the major labium.
herniation. Each hernia consists of a sac, usually a di- Laparoscopic procedures in the repair of inguinal
verticulum of the parietal peritoneum that invests the hernia have produced an increase in the frequency of
hernial contents, and a protruded tissue or organ with debilitating neuropathies, most notably those of the ge-
its coverings. The proximal tapered end of the sac that nitofemoral, ilioinguinal, and lateral femoral cutane-
marks the site of herniation is known as the neck of the ous nerves. The highly variable course of the lateral
hernial sac. Although the ratio of the length of the in- femoral cutaneous nerve and its branches within the
guinal canal to the circumference of the hernial sac may pelvis may directly account for this complication [50].
define the clinical picture best, this parameter cannot Aszman [51] demonstrated five different types of rela-
be the sole determinant of the clinical outcome. Ab- tionships of the lateral femoral cutaneous nerve to soft
dominal wall hernias are usually asymptomatic, dis- tissue and bony structures. Four percent (type A)
covered incidentally on routine physical examination. maintained a course posterior to the anterior superior
However, complications of abdominal hernia may be iliac spine and across the iliac crest; 27 % (type B) trav-
life threatening and require urgent medical attention. eled anterior to the anterior superior iliac spine, within
the inguinal ligament and superficial to the origin of
the sartorius muscle. In 23 % (type C) the nerve ran me-
1.15.1
dial to the anterior superior iliac spine within the tendi-
Inguinal Hernia
nous origin of the sartorius, and in 26 % (type D) the
The bony attachments of the inguinal region counter- nerve was found deep to the inguinal ligament between
act abdominal thrust, and the presence of natural gaps the iliopsoas fascia and the sartorius muscle. In the
that exist in this region may allow peritoneal diverticu- same study 20 % (type E) pursued a course deep to the
la to externalize and appear as hernias. Inguinal hernia inguinal ligament within the soft tissue anterior to the
sac, which represents approximately 95 % of abdominal iliopsoas muscle, joining the femoral branch of the ge-
wall hernias in the male and 50 % in the female, has the nitofemoral nerve. This study has suggested that the lat-
highest incidence of onset in the 1st year of life followed eral femoral cutaneous nerve is most prone to damage
by a second peak between the ages of 16 and 20. Hernial when it pursues a course indicated by types A, B, or C.
sac traverses the entire length of the inguinal canal In a study conducted by Rosenberg et al. [52], the
from the deep to the superficial inguinal ring. It may al- course of the genitofemoral, lateral femoral, and ilioin-
24 1 Anatomy of the Abdominal Wall
guinal nerves and their relationships to the deep ingui- Surgical relief may require a superolateral cut to avoid
nal ring, iliopubic tract, and anterior superior iliac any possible injury to the inferior epigastric vessels.
spine were carefully examined. The findings indicate It may appear in infancy or early adult life subse-
that both branches of the genitofemoral nerve pene- quent to forced opening of a preexisting or partially
trate the abdominal wall lateral to the deep inguinal patent processus vaginalis during a strenuous activity,
ring and cranial to the iliopubic tract. The ilioinguinal such as lifting of heavy objects, or repeated stresses on
and lateral femoral cutaneous nerves pursued a course the wall during sneezing, coughing or vomiting. Pediat-
immediately lateral to the anterior superior iliac spine. ric inguinal hernia is almost always indirect and bilat-
It concluded that placement of staples either cranial to eral with right side predominance, and is prone to in-
the iliopubic tract or lateral to the anterior superior ili- carceration and strangulation.
ac spine is likely to produce injury to these nerves. In the male, the hernial sac descends into the scro-
Hospodar et al. [53] examined, in a series of cadav- tum anterior to the spermatic cord testis, and is usually
eric pelvis, the lateral femoral cutaneous nerve with re- felt as an impulse at the examiner’s fingertip upon a
spect to the ilioinguinal surgical dissection. In approxi- sudden increase in intra-abdominal pressure. In the fe-
mately 10 % of the pelves examined the lateral femoral male, the hernial sac descends through a much narrow-
cutaneous nerve was found either within a half-centi- er canal to the major labium; as a result, palpation of the
meter of the iliopubic tract or in the vertical plane of hernial sac is not adequate. This is particularly evident
the anterior superior iliac spine. These are the principal with women in whom the expanding impulse on cough-
anchoring sites for mesh in laparascopic hernial repair. ing is not easily felt due to the overlying fatty tissue.
In another study, the lateral femoral cutaneous nerve
was most commonly found at 10 – 15 mm from the an-
1.15.3
terior superior iliac spine (ASIS), and as far medially as
Direct Inguinal Hernia
46 mm. Because of this variation, careful dissection
medial to the ASIS may be essential to locate the nerve. Direct inguinal hernia is a form of acquired outpouch-
ing in which the hernial sac runs through the posterior
wall of the inguinal canal and protrudes through the
1.15.2
superficial inguinal ring without entering the deep in-
Indirect Inguinal Hernia
guinal ring. The neck of the hernial sac is medial to the
Indirect inguinal hernia (Fig. 1.19) occurs when the inferior epigastric vessels and within the supravesical
processus vaginalis persists, connecting the peritoneal fossa or the Hesselbach’s (inguinal) triangle. The su-
cavity of the abdomen and that of the scrotum or major pravesical fossa [57 – 59] lies superior to the urinary
labium. Indirect inguinal hernia is common in all ages bladder between the medial and median umbilical liga-
and in both sexes. Kahn and Hamlin [45] concluded ments. Since the conjoint tendon is anterior to the su-
that patent processus vaginalis is not always a prerequi- pravesical fossa and posterior to the superficial ingui-
site for the occurrence of indirect inguinal hernia. It is nal ring, the hernial sac either passes between the fi-
often associated with cryptorchid testis and hydrocele. bers of the conjoint tendon or is completely covered by
Incarcerated indirect inguinal hernia may occur as a this tendon. When the hernial sac pierces the conjoint
complication of spilled gallstones [54 – 56]. Persistent tendon it will be covered by the peritoneum as well as
processus vaginalis may be unmasked by the presence by the aponeurosis of the internal abdominal oblique
of fluid that fills this peritoneal extension and presents and transverse abdominis muscle.
as a scrotal or occasionally as labial edema. In a large Hesselbach’s triangle is bounded medially by the
indirect inguinal hernia, the inguinal canal is no longer rectus abdominis, laterally by the inferior epigastric
oblique due to the close proximity of the dilated super- vessels, and inferiorly by the inguinal ligament [60].
ficial and deep inguinal rings. Since the deep inguinal When the hernial sac passes through Hesselbach’s tri-
ring lies lateral to the inferior epigastric vessels, the angle, it is usually lateral to the conjoint tendon and
neck of the hernial sac protrudes through the lateral in- will be invested by the extraperitoneal fat, transversalis
guinal fossa, shifting these vessels medially. As it tra- fascia, external spermatic fascia, superficial fascia, and
verses the deep inguinal ring, the hernial sac is invested the skin. In individuals with direct inguinal hernia, the
by the internal spermatic fascia. After pushing up the spermatic cord is usually posterolateral to the hernial
arching fibers of the transverse and internal abdominal sac, not posterior to it as in indirect hernia. When the
oblique, it becomes invested by the cremasteric muscle hernial sac is occasionally large, it may protrude into
and fascia. It emerges at the superficial inguinal ring the scrotum or major labium.
and descends to the scrotum, where it is covered by the Direct inguinal hernia is a commonly bilateral con-
external spermatic fascia, superficial fascia, and the dition that occurs as a result of weakness of the trans-
skin. The hernial sac may be strangulated and the versalis fascia. Since the path of the hernial sac does not
blood supply compromised at the deep inguinal ring. involve the muscular layers or tendinous borders and
1.15 Abdominal Hernias 25
the neck of the hernial sac is wide, the risk of incarcera- dramatic changes exerted during pregnancy. Its inci-
tion is low. On standing, the hernial sac is felt as a dif- dence is far lower than that of inguinal hernia and can
fuse medial outpouching over the inguinal canal, which be easily missed during physical examination.
is not controlled by digital pressure applied immediate- There is a dramatic correlation between inguinal
ly proximal to the femoral artery. Direct inguinal her- hernial repair and the incidence of femoral hernia.
nia is a less common type of hernia, is age related, usu- Mikkelsen et al. [61] reported a 15-fold greater inci-
ally affects men over age 40, and is rare in women. It is dence of femoral hernia postinguinal herniorrhaphy
an acquired condition associated with obesity, consti- compared with spontaneous incidence. Due to the rar-
pation, and benign prostatic hypertrophy. It is usually ity of the femoral hernia in children and the similarity
asymptomatic and is even less noticeable than the indi- of its manifestations to that of the indirect inguinal her-
rect type. This type of hernia is not contained in the nia, femoral hernia in this population remains a chal-
spermatic cord, and unless the hernial sac is large it lenging clinical problem.
rarely extends to the scrotum or major labium. The her- Misdiagnosis of femoral hernia may be perpetuated
nial sac protrudes anteriorly and pushes the side of the by the presence of a patent processus vaginalis and in-
examiner’s index finger forward. Both direct and indi- cidental indirect inguinal hernia [62, 63]. A variety of
rect inguinal hernia may protrude on each side of the conditions must be excluded in the differential diagno-
inferior epigastric vessels as pantaloon hernia. sis of femoral hernia such as lipoma, psoas abscess, ob-
turator hernia, lipoma, and hydrocele.
The femoral hernial sac consists of the parietal peri-
1.15.4
toneum, femoral septum (extraperitoneal tissue), fem-
Femoral Hernia
oral sheath, cribriform fascia (covers the saphenous
A femoral hernia presents a hernial sac that protrudes opening), superficial fascia, and skin. It frequently con-
anterior to the pectineal (Cooper’s) ligament and tains the small intestine and omentum, but the pres-
through the femoral canal, a potential space between ence of an inflamed appendix, Meckel’s diverticulum,
the lacunar ligament and the femoral vein. The femoral or portion of the bladder should also be expected. Oc-
ring, which is the upper margin of the femoral canal, is casionally the ureter or broad ligament of the uterus
the medial portion of the lacuna vasorum. It is bound- may also be found. Femoral hernial sac becomes irre-
ed anteriorly by the extension of the transversalis fas- ducible when it attains a large size, protruding anterior
cia, and posteriorly by the continuation of the pectineal to the inguinal ligament. Due to the ligamentous
fascia. The neck of the hernial sac is always distal and boundaries, the hernial sac carries a higher risk of
lateral to the pubic tubercle, a bony landmark between strangulation and should be considered part of the dif-
the site of inguinal and femoral hernia. The fundus of ferential diagnosis in pregnant women and in individu-
the hernial sac (lower part) usually occupies the medial als with intestinal obstruction. The strangulation is a
part of the femoral triangle. frequent manifestation at the saphenous opening, the
The hernial sac traverses the femoral canal and de- femoral ring, or at the junction of the inguinal ligament
scends vertically posterior to the inguinal ligament, and falciform margin of the saphenous opening [64].
displacing the femoral vein, to exit through the saphe-
nous opening. It tends to ascend from this point proxi-
1.15.5
mally, by following the superficial epigastric vessels an-
Umbilical Hernia
terior to the inguinal ligament and the lower part of the
external oblique. The hernial sac may turn medially Umbilical hernia, common among African-American
and toward the scrotum or major labium. It may also children, is associated with failure of complete closure
descend anterior (prevascular hernia) or posterior of the umbilical orifice during the 1st year of postnatal
(retrovascular hernia) to the femoral vessels. It is pre- life [2]. It is often noticed when the infant cries, which
vented from descending further down by the attach- raises the intra-abdominal pressure and causes protru-
ment of the femoral sheath and the superficial fascia of sion of part of the intestine. Surgery becomes essential
the thigh to the margins of the saphenous opening. The when the defect is relatively large and persists beyond
course of progression of the hernial sac should be taken the age of 4, or becomes incarcerated. In the adult, um-
into consideration and reduction of femoral hernia bilical hernia may develop more commonly in women,
should be directed in the reverse direction with the usually postpartum, and a pose serious danger due to
thighs passively flexed. the rigid walls of the linea alba, which predisposes the
Femoral hernia is more common in female than male hernial sac to strangulation and incarceration.
at the ratio of 3 : 1. It affects approximately 35 % of the fe- Herniation immediately above or below the umbilicus
male population particularly in women over 50 years of is known as paraumbilical hernia, and occurs in women
age. This gender-based difference is attributed to the with multiple pregnancies. It is usually prone to incarcer-
unique shape of the pelvis, the size of the ring, and the ation and usually contains part of the greater omentum.
26 1 Anatomy of the Abdominal Wall
1.15.6 1.15.9
Omphalocele Lumbar Hernias
Omphalocele is a rare but severe congenital umbilical Lumbar herniation may occur through the superior or
hernia in which part of a visceral organ protrudes inferior lumbar spaces. It is classified as congenital and
through the umbilical ring into the base of the umbili- acquired; the acquired lumbar hernia is subdivided in-
cal cord. This condition begins when the cranial limb of to primary and secondary types. The hernial sac usual-
the gut loop coils and rapidly increases in length, pro- ly consists of the peritoneum, or extraperitoneal tissue,
truding through the umbilical ring into the extraem- and may contain part of the intestine, kidney, omen-
bryonic coelomic cavity [2]. This physiological hernia- tum, or mesentery. The hernia produces mild symp-
tion occurs around the 6th week of development, fol- toms and can easily be surgically reduced and very
lowed by the return of the protruding part of the gut in- rarely becomes strangulated. The superior lumbar her-
to the enlarged abdominal cavity around the 10th week. nia occurs through Gynfelt’s triangle [66], which is
Retention of the herniated gut outside the abdomen be- bounded superiorly by the 12th rib and the serratus
yond the 10th week of development is designated as posterior inferior muscle, laterally by the internal
omphalocele. The hernial sac in this case is covered by oblique, and medially by the erector spinae muscle. In-
the combination of a thin layer of peritoneum and by ferior lumbar hernia [67] is very rare and occurs
the amnion. In a study involving a large number of con- through Petit’s triangle, bounded anterolaterally by the
secutive births [3], the overall survival rate was much external abdominal oblique, inferiorly by the iliac crest,
lower for omphalocele than for gastroschisis. The same and posteromedially by the latissimus dorsi muscle.
study confirmed that omphalocele is usually associated
with older maternal age pregnancies, and is more often
1.15.10
complicated by threatened abortion.
Spigelian Hernia
The Spigelian hernia is a defect in the aponeurosis of
1.15.7
the transverse abdominis muscle between the semilu-
Epigastric Hernia
nar line and the lateral border of the rectus abdominis
Epigastric hernia refers to a protrusion of the peritone- (Spigelian aponeurosis). The semilunar (Spigelian) line
al fat, usually without peritoneal sac, through the linea represents the transition of the transverse abdominis
alba of the epigastrium. The hernial sac may be in the from muscle to aponeurosis. The hernial sac and the
form of a reducible midline nodule that becomes evi- opening cannot usually be palpated because of the in-
dent in the standing position. It usually contains extra- tramural location of the hernial sac posterior to the
peritoneal fat or it may contain part of the greater aponeurosis of the external oblique aponeurosis [68]. It
omentum or small intestine. Epigastric hernia may can present synchronously with inguinal hernias in ne-
produce severe pain, due to ischemia that mimics onates, and regardless of age of presentation is almost
chronic peptic ulcer. always congenital in origin [69].
1.15.8 1.15.11
Incisional Hernia Richter’s Hernia
Incisional hernia occurs up to 5 years following surgi- Richter’s hernia, which was first described in 1598, re-
cal procedures at a site of previous laparatomy where fers to the hernial protrusion that contains only a por-
healing was not complete. Postlaparascopy incisional tion of the intestinal wall at any site in the anterolateral
hernia is generally a minor complication and rarely abdomen. The involved segment incarcerates or stran-
strangulates [65]. It can be visualized by having the pa- gulates and may undergo gangrene, but symptoms of
tient perform the Valsalva maneuver or raise his or her ischemic bowel or complete intestinal obstruction are
head while in the supine position. It is the most com- often absent. The hernial sac most commonly occurs at
mon type of hernia among all ventral abdominal herni- the femoral and inguinal rings and is associated with a
as, and is associated with old age, obesity, improper su- high mortality rate [70]. Richter’s femoral hernia ex-
turing techniques, postoperational strain, cirrhosis, hibits vague abdominal signs, groin swelling, but with
steroid therapy, infection, hematoma, and ileus. Due to no intestinal obstruction [71].
the relatively large size of the neck of the hernial sac,
strangulation is rare.
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