Anatomy - Changing negative pressure wound dressings in open abdomen - general and visceral surgery

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  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Anatomy of the anterior abdominal wall

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    The large region of the anterior abdominal wall from the xiphoid process and costal arches to the pelvic bones has a typical layered architecture: Below the skin and subcutaneous fat tissue are superficial fascias, muscles and their fascias, then the extraperitoneal fascia and finally parietal peritoneum.

    Particularly in the anterior wall inferior to the umbilicus, the otherwise typical single-layered superficial abdominal fascia in the fatty subcutaneous tissue (panniculus adiposus abdominis) transitions into a dual-lamina structure comprising a superficial lamina (Camper fascia) and a deeper, membranous layer (Scarpa fascia or fascia investiens abdominis). The five abdominal muscles comprise:
    3 oblique muscles (1. external oblique muscle of abdomen, 2. internal oblique muscle of abdomen, and 3. transverse abdominal muscle).
    2 straight muscles (4. M. rectus abdominis muscle and the inconstant 5. Pyramidal muscle).

    • External muscle
      Located just below the superficial fascia, it extends mediocaudad to the abdominal aponeurosis, with both sides fusing midline to the white line (linea alba). Caudad It is bordered by the inguinal ligament from the superior anterior iliac spine to the pubic tubercle, which in turn divides mediad into the lacunar ligament and the pectineal ligament (Cooper).
    • Middle muscle
      Its fibers run craniomediad, fusing with fibers from 1. to the white line
    • Internal muscle
      transverse fibers, also radiating into the white line.

    Each of the three oblique abdominal muscles is invested by its own thin fascia , 3. on its inner aspect the strong transverse fascia. This fascia lines the abdominal cavity and fuses craniad with the diaphragmatic fascia and posteriad with the thoracolumbar fascia. Caudad, it is attached to the iliac crest and fuses with the endopelvic fascia.

    Long straight paired abdominal muscle, interrupted by 3 - 4 transverse tendinous intersections ("six-pack").

    Triangular rudimentary muscle caudad and anteriad to 4. between the pubic bone and white line.

  • Fascias and peritoneum

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    Muscles 4. and 5. are invested by the rectus sheath made up by the 3 oblique abdominal muscles 1. to 3. The rectus sheath completely invests the superior ¾ of 4., covering the inferior ¼ below the arcuate line only anteriorly, whereas here the posterior aspect of 4. only comprises the transverse fascia and the peritoneum. The superior ¾ of the anterior lamina of the rectus sheath is formed by 1. and half of 2., while half the posterior lamina is made up of 2. and the other half of 3.

    The transverse fascia and peritoneum are separated by the extraperitoneal space, which may vary in extent depending on its location. The retroperitoneum is where the retroperitoneal abdominal organs are located. On the anterior abdominal wall, it is a narrow space and is repeatedly referred to (e.g., on the deep inguinal ring) as the preperitoneal space.

    The peritoneum (parietal serosa) invests the completely closed peritoneal cavity (exception: opening of the tube in women) and extends as visceral peritoneum to cover the intraperitoneal organs. Inferior to the umbilicus, it develops three folds:
    the single median umbilical fold (obliterated urachus)
    the paired medial umbilical fold (vestige of the umbilical artery)
    the paired lateral umbilical fold (inferior epigastric vessels)

  • Innervation and blood supply

    The anterior abdominal wall is innervated by the anterior branches of the spinal nerves T7–11, T12 (subcostal nerve), and L1 (iliohypogastric nerve, and ilioinguinal nerve).

    Craniad the internal thoracic artery (→ musculophrenic artery) provides the superficial blood supply, while the inferior abdominal wall is supplied by the superficial epigastric artery and superficial circumflex iliac artery respectively (both branches of the femoral artery). The deep cranial blood supply is via the superior epigastric artery (← internal thoracic artery), laterad via the intercostal vessels, and caudad via  the inferior epigastric artery and deep circumflex iliac artery, respectively (both branches of the external iliac artery). Venous drainage is via homonymous veins.