Anterolat Bodywall.pdf

8112019 Anterolat Bodywallpdf

httpslidepdfcomreaderfullanterolat-bodywallpdf 114

Section II BODY WALL





69

Chapter 7 Anterolateral Body Wall

There bee tenne muscles which couer the nether Belly on either side fiue called the muscles of the Abdomen

CROOKEBody of Man 796 1615

DEVELOPMENT OF THE ABDOMINAL WALL MUSCLES

The extraembryonic mesoderm divides longitudinally into aparaxial part from which the dorsal muscles will developand a lateral plate the precursor of the muscles of theabdominal wall

Somites

The paraxial mesoderm becomes segmented transverselyinto somites each of which appears as a mass of mesodermalcells arranged around a central somite cavity in continuity with the intermediate mesoderm (Fig 7-1A)

Except for the cervical and cranial ones the somites dif-ferentiate into three portions (1) a dermatome from theouter wall to form the skin (2) a myotome from the dorsalpart of the inner wall to form the muscles of the body walland limbs and (3) a sclerotome from the ventral part of theinner wall which forms the skeleton (Fig 7-1B)

Myotomes

Around 5 weeks the myotomes divide into a ventral division and a smaller dorsal division each of which will be suppliedby an anterior or posterior branch of the corresponding

spinal nerve (Fig 7-2) The individual myotomes formed bythe dorsal division remain arranged segmentally but thoseformed by the anterior division (on the lateral plate) losetheir segmentation before the age of 3 weeks

Trunk Muscles

From the anterior myotomes precursor cells separate inthe thoracic area as discrete buds and emigrate to stagingareas in the flank to form large premuscle masses Primitivemyotubes from the myoblasts in these masses assume theorientation that the muscle fibers will later take As differ-entiation progresses these premuscle masses split longitu-dinally or tangentially into the primordia of individualmuscles and fuse with mesodermal material from adjacentmyotomes

As the ribs develop the ventral extension of the myo-tomes in the thoracic area moves anteriorly to form themuscles of the anterior abdominal wall Those in the lum-bar area form the psoas and quadratus lumborum whichare involved in flexing the vertebral column and those inthe sacral area form the musculature of the pelvic dia-phragm The dorsal myotomes develop into the extensormuscles of the back The lumbodorsal fascia forms overthem and separates them from the latissimus dorsi andparts of the serratus which are migratory muscles of theanterior division (see Fig 8-2)

Development proceeds through final shifting andgrowth to reach the fully differentiated state (Fig 7-3) Therectus abdominis is formed by longitudinal splitting of the ventral end of the fused myotomes The external oblique and the serratus posterior superior and inferior arise

A B

FIGURE 7-1



SECTION II 983150 BODY WALL70

through a tangential split of the lateral sheet and the inter-nal oblique and transversus arise from the medial sheet theremaining part of the myotomal processes form the internaland external intercostals At 6 weeks the muscles are dif-ferentiated although in a more lateral position than in theadult In fact the recti are still widely separated at 10 weeksa condition that if persistent would result in diastasis rectiSome of the myotomal material degenerates and disappearsentirely or remains as vestigial fibrous structures to formthe aponeuroses of the anterior trunk muscles or as thenonmuscular sacrotuberous ligament In contrast the ten-dons do not originate from the muscles but develop fromthe local connective tissue to become secondarily attachedto the muscles

The number of muscle fibers is established in the neona-tal period but the fibers may grow by the addition of sarco-meres at either end or by an increase in diameter Satellite

cells are added to the muscle fiber syncytium as the fibersgrow It is from these cells that muscle fibers may regenerateafter surgical or other injury

The mesenchyme underlying the rectus abdominisand transversus abdominis is continuous with that cover-ing the levator ani The transversalis fascia will develop

from this portion of the retroperitoneal tissue a layerthat is separate from the epimysium of the muscles of thebody wall

ANOMALIES

Prune Belly Syndrome

Although several theories have been championed theembryogenesis of this anomaly (absence or hypoplasia ofthe abdominal muscles distention of the bladder uretersand renal pelves and cryptorchidism) is not understoodMuscular change secondary to distention of the urinarytract with or without ascites is a doubtful cause an obstruc-tive lesion is not found and known obstructive lesions suchas urethral valves do not result in the syndrome A primarymesodermal defect may be at fault because both of theinvolved systemsmdashthe urinary tract and the abdominal wallmdasharise from the mesoderm of the paraxial intermediateand lateral plates

The defect starts before the seventh week when the sev-eral muscles differentiate from the somatic mesoderm ofthe anterior division of the myotomes (see Fig 7-3) Thefirst lumbar segment has been implicated in the dysgenesisbecause normally much of the oblique and transverse mus-cles develop from this location the hypoplasia is maximumhere and is less pronounced above and below Howeverdefects of the lower limbs indicate that the dysgenesis mayextend to the lower lumbar and sacral segments and absenceof the upper portion of the rectus suggest involvement of thelower thoracic region

The effects of the anomaly vary from minimal hypoplasiato complete absence of muscle fiber but the medial and

lower portions of the abdomen are uniformly involved Asheet of fibrous tissue which is firmly attached to the perito-neum takes the place of the muscles (Fig 7-4) Occasionallycongenital megalourethra is found The bladder is large andthick walled often with a pseudodiverticulum on the domeand is attached to the umbilicus (Fig 7-5) The trigone is

FIGURE 7-2

A B

FIGURE 7-3 A Oblique view BTransverse cut at the level of the 1stlumbar vertebra






groin the fascia separates into two layers (1) a superficiallayer (Camperrsquos fascia) and (2) a deep or membranouslayer (Scarparsquos fascia) (see Chapter 9 for details of the ingui-nal area) The deep layer sutured during wound closurebrings the fatty layers together which is especially desirablein obese patients

External Oblique and its Attachments

The external oblique the most superficial of the anteriormuscles after rising as narrow fleshy slips from ribs 5 to 12 runs obliquely forward and downward (Fig 7-7A) The up-per slips fit between similar slips of the serratus anteriorinferior near their attachment to the upper ribs the lowerdeeper ones arise among similar slips from the latissimus

dorsi that are attached to the lower ribs (Fig 7-7B) Theexternal oblique inserts in part on the anterior half of theiliac crest and in part in a broad external oblique aponeuro-sis that extends to the midline after participating in theformation of the anterior rectus sheath of which it formsthe most superficial part It fuses with the opposite aponeu-rosis as part of the linea alba This layer of the sheath can beseparated from the underlying layer derived from the inter-nal oblique usually to the mid-belly of the rectus abdominisThe free inferior border of the external oblique forms theinguinal ligament that extends from the anterior superioriliac spine to the pubic tubercle and attaches to the symphy-sis and the pubic crest Laterally it is attached to the ilio-psoas fascia and medially to the pectineus fascia An openingoccurs above the medial end of the ligament the superficial

LAYERS OF THE BODY WALL

T A B L E

7 - 1

SKIN AND SUPERFICIAL FASCIA

Dermis Supports the epidermis

Subcutaneous fascia superficial (dartos) deep (Scarparsquos Buckrsquos Collesrsquo)

Deep muscular fascia external investment of body wall muscles (external oblique internaloblique transversus abdominis)

MUSCLES OF BODY WALL RETROPERITONEAL TISSUE

Outer stratum investment of body wall muscles (transversalis fascia and its pelvic extensions)

Intermediate stratum investment of urinary tract organs (Gerotarsquos fascia prostatic sheath lateral vesical pedicle broad ligament)

Inner stratum investment of intestinal tract (supporting connective tissue of the peritoneum)

PERITONEUM

FIGURE 7-6



CHAPTER 7 983150 ANTEROLATERAL BODY WALL 73

inguinal ring from which the ilioinguinal nerve emerges(see Chapter 9 for details of the inguinal area) Dorsally theexternal oblique joins the posterior lamella of the lum-bodorsal fascia Innervation is from the ventral (motor)rami of the lower six spinal nerves

The deep fascia covering the external oblique the innomi-nate fascia of Gallaudet is a distinct layer separable not onlyfrom the muscle but also from its aponeurosis Below the ingui-nal ligament the innominate fascia continues as the fascia lataof the thigh

Internal Oblique and its Attachments

A smaller thinner muscle than the overlying external obliquethe internal oblique has a fan shape with the convergencelying posteriorly It arises from three sites (1) the lateral halfof the upper surface of the inguinal ligament (or from theiliopsoas fascia) in association with the transversus abdominis

(2) the anterior two-thirds of the middle lip of the iliaccrest and (3) the posterior lamella of the lumbodorsal fascia(Fig 7-8A) The lumbodorsal fascia in turn covering theerector spinae connects the internal oblique indirectly tothe spines of the lumbar vertebrae The internal oblique alsoattaches to the costal margin extending from the 9th to the12th ribs Anteriorly the muscle continues as the internaloblique aponeurosis Part of the aponeurosis passes anteriorto the rectus abdominis to form the middle part of the ante-rior rectus sheath (Fig 7-8B) Another part passes posteriorto form part of the posterior layer of the rectus sheath Afterforming the sheaths the aponeurosis attaches to the lineaalba and merges with its contralateral counterpart The low-est fibers of the aponeurosis curve medially and downward toform part of the roof of the inguinal canal and join with thedominant fibers from the transversus abdominis to form theconjoined tendon running to the pubis on the pectineal lineThe iliohypogastric nerve emerges from beneath the internal

A

B

FIGURE 7-7




oblique proximal to the inguinal canal the ilioinguinal nerve exits distal to the margin of the canal

The nerve supply to the internal oblique is the same asthat to the external oblique but in addition includes someinnervation from the first lumbar nerve

Intercostal Muscles

The 11 external intercostals are actually of the same layer asthe external oblique and like its fibers they run downwardand forward as they connect the lower and upper borders ofthe ribs Over the cartilages and extending to the sternum anaponeurosis the external intercostal membrane substitutesfor the muscle Similarly the internal intercostals beneathlike the internal oblique run upward and forward Posteriorto the costal angle an internal intercostal membrane substi-tutes for this muscle

Transversus Abdominisand its Attachments

Lying under the internal oblique muscle the transversusabdominis runs in a transverse direction as its name impliesIt arises from three areas The upper part arises from the

inner surface of the lower six costal cartilages the middle partfrom fusion with the posterior and middle lamella of the lum-bodorsal fascia and the lower part from the lateral third ofthe inguinal ligament and the anterior two-thirds of the innerlip of the iliac crest (Fig 7-9A) It interdigitates with slips fromthe diaphragm on the costal cartilages The fleshy fibers runhorizontally forward to become the transversus abdominisaponeurosis near the lateral border of the rectus abdominis(Fig 7-9B) The lower fibers of the aponeurosis curve downward and fuse with fibers from the aponeurosis of the internaloblique as they insert into the crest of the pubis and pectinealline as the conjoined tendon The upper part of this broadaponeurosis fuses with the posterior layer of the aponeurosisfuses with the posterior layer of the aponeurosis of the inter-nal oblique muscle to form the posterior rectus sheathCaudal to the arcuate line the aponeurosis passes over therectus abdominis to form the deep part of the anterior rectussheath Although in the illustration it is represented as a sepa-rate layer the transversus abdominis is actually fused with theoverlying part of the sheath that is derived from the internaloblique The lowest fibers of the aponeurosis attach to thelateral part of the inguinal ligament arch over the inguinalligament and the inguinal canal and in combination with theinternal oblique make up a portion of the conjoined tendon

A

B

FIGURE 7-8




Conjoined Tendon

The conjoined tendon of the internal oblique and transver-sus composed principally of the aponeurosis of the lattermuscle inserts into the crest and usually to the ridge of thepubis Medially it joins the rectus sheath

Serratus Anterior

The serratus anterior inferior inserts on ribs 7 and 8 afteremerging from beneath the latissimus dorsi

Blood Supply

Besides that from the lower intercostal vessels blood issupplied by the superior epigastric artery that lies on theposterior rectus sheath and goes to the rectus and part ofthe transversus abdominis

Nerve Supply

The ventral rami of the lower six thoracic and the firstlumbar nerves innervate the skin muscles and peritoneumover the anterior abdomen Intercostal nerves 7 to 11 exit

from the intercostal space to enter the neurovascular planelying between the internal oblique and transversus abdomi-nis Intercostal nerves 7 and 8 slope upward the 9th courseshorizontally and the 10th and 11th run obliquely downwardThey terminate medially as anterior cutaneous branchesin the skin after passing through the rectus abdominis andanterior rectus sheath The 12th or subcostal nerve runsforward under the 12th rib then enters the neurovascularplane over the transversus abdominis The six lowest inter-costal nerves give off lateral cutaneous nerves that separateinto an anterior branch to supply the skin up to the lateraledge of the rectus abdominis and a posterior branch toinnervate the skin over the latissimus dorsi

The ventral ramus of the first lumbar nerve forms twobranches The upper branch is the iliohypogastric nerve which divides just above the iliac crest to form the lateralcutaneous branch to the buttock and the anterior cutane-ous branch to the suprapubic region The lower branch theilioinguinal nerve after running in the neurovascular planegoes through the internal oblique above the iliac crest toreach the spermatic cord (or the round ligament of theuterus) in the inguinal canal Its final distribution is to theskin of the medial side of the upper thigh of the proximalportion of the penis and of the top of the scrotum (or in

A

B

FIGURE 7-9




the female the mons pubis and anterior part of the labiamajora)

Surgeons Note that the intercostal nerves and accompa-nying vessels lie on the surface of the investing fascia of thetransversus abdominis as does the iliohypogastric nerve andthe terminal part of the ilioinguinal nerve These nervesrun at an angle downward in the lower part of the abdomen

but in the upper portion their course is obliquely upwardmaking denervation of the rectus possible with chevron-type incisions

Rectus Abdominis

The two long muscles of the rectus abdominis run verticallyon either side of the linea alba which is a dense midline in-terlacing of the several aponeuroses particularly condensedaround the umbilicus (Fig 7-10) Attachment of the rectusabdominis superiorly is by three unequal slips to the anteriorsurfaces of the costal cartilages 5 6 and 7 Occasional con-nections occur with the 4th or 3rd rib above and with thecostoxiphoid ligaments The attachment inferiorly is by twotendons a smaller medial one attaches to the anterior aspectof the symphysis pubis and a larger lateral tendon attaches tothe pubis often as far laterally as the pubic crest The semilu-nar line marks its lateral margin Several tendinous intersec-tions one of which is usually at the level of the umbilicus witha second midway to the xiphoid and another at the level ofthe xiphoid (rarely are they found below the umbilicus) zig-zag incompletely across the muscle to divide it transverselyThey are densely adherent to the anterior rectus sheath

The paired pyramidalis muscles arising from the anteriorsurface of the symphysis pubis insert in the linea alba insidethe rectus sheath They are supplied by the 12th intercostalnerve

Rectus Sheath

The sheath containing each rectus abdominis is formedfrom combined aponeuroses of the anterior abdominal wallmuscles (Fig 7-11)

The anterior rectus sheath covers the muscle for its fulllength and is firmly attached to it at the tendinous intersec-tions Above the costal margin the anterior sheath is com-prised solely of the external oblique aponeurosis From thecostal margin to the arcuate line (linea semicircularisDouglas) it is composed of the aponeuroses of the externaloblique and that of the anterior half of the aponeurosis ofthe internal oblique Below the arcuate line the aponeuro-sis of the transversus abdominis contributes a deep partto the anterior sheath However considerable variation maybe found in the contributions of the aponeuroses to thesheaths and in the level of the arcuate line

The posterior rectus sheath is composed of the deep partof the aponeuroses of the internal oblique and the aponeu-rosis of the transversus abdominis Superiorly the sheathends at the costal margin to permit attachment of the rectusabdominis directly to the costal cartilages Inferiorly theposterior sheath stops just below the level of the umbilicusforming the arcuate line although the level may vary Thisleaves the investing fascia of the lower third of the muscle in

FIGURE 7-10




contact with the intermediate stratum of the retroperitonealconnective tissue

Inside the sheath under the muscle are the superior andinferior epigastric vessels and the ends of the lower six inter-costal nerves that supply the muscle and the overlying skin About halfway between symphysis and umbilicus perforat-ing vessels from the inferior epigastric arteries run into therectus muscle vessels that may be used to form the pediclefor rectus flaps

Linea Alba

The linea alba lies between the rectus muscles and extendsfrom the xiphoid to the symphysis It is composed of inter-lacing fibers from the aponeuroses of the three majorabdominal muscles The structure is narrower below theumbilicus than above because the rectus muscles diverge in

the epigastrium to leave a relatively weak area for the gen-eration of midline hernias (Fig 7-12) Its superficial fibersattach to the symphysis anteriorly its deeper fibers form atriangular layer that adheres to the posterior surface of thepubic crest The linea alba is especially dense where it ispenetrated by the umbilicus

Transversalis Fascia ExtraperitonealTissues and Peritoneum

The three layers of the retroperitoneal fascias develop (1)an inner stratum (2) an intermediate stratum and (3) anouter stratum (see Chapter 12 Retroperitoneal Fascias andSpaces section) Anteriorly only the inner stratum andouter stratum are present

Inner Stratum

The inner stratum envelops the intestinal tract The originand distribution of these fascias are described in detail inChapter 12

Outer Stratum

The outer stratum of retroperitoneal connective tissue as thetransversalis fascia covers the muscle surfaces within the bodycavity (Fig 7-13) Deep to this fascial layer lies the pararenal

fat layer continuous anteriorly with the properitoneal fat

A thin layer of fascia the transversalis fascia is intimatelyassociated with the investing layer (epimysium) of the internalsurface of the muscles of the abdominal wall It is continuous with the iliac and pelvic fascias inferiorly and the anteriorlamella of the lumbodorsal fascia posteriorly Beneath it inthis area lies the intermediate stratum of the extraperitonealconnective tissue Above the middle of the inguinal ligamentthe transversalis fascia is dense and is supplemented by theaponeurosis of the transversus abdominis It has an openingthat forms the lateral margin of the inguinal canal at the deepinguinal ring (see Fig 9-8) It attaches posteriorly to the iliaccrest between the origins of the iliacus and the transversuscontinues along the posterior margin of the inguinal ligamentpast the femoral artery and vein to become continuous withthe iliac fascia

Fibroareolar tissue associated with the outer stratum ofretroperitoneal connective tissue covers the internal surfaceof the transversalis fascia forming the posterior pararenalspace that lies between it and the posterior lamina of therenal (Gerotarsquos) fascia Laterally with a greater content of

fat it constitutes the properitoneal fat layer The fat layer is

FIGURE 7-12 These sections are from the linea alba ina case of umbilical hernia The open area at top is theperitoneal cavity On the left are bundles of densefibroconnective tissue composed of the interlacingfibers of the aponeuroses of the three major abdominal

muscles most likely from a region above the umbilicusOn the right the fibroconnective tissue bundles appearless dense this tissue may be from an area below theumbilicus that was structurally weaker and thereforeprone to hernia formation

FIGURE 7-11




thickest in the renal area superficial to the posterior layer ofthe renal fascia and in the pelvis it is thinnest beneath thetransversalis fascia anteriorly above the umbilicus Superiorlyit surrounds the round ligament of the liver (ligamentumteres) the remnant of the umbilical vein Below the ura-chus (urachal ligament or median umbilical ligament) aremnant of the allantois is imbedded in it in the midlineOn either side the obliterated umbilical arteries (medialumbilical ligaments) lie within it

Peritoneum

The peritoneum is more than a layer of mesothelial cells Itincludes a basement membrane and some of the closely ad-herent connective tissue that contains the vessels and nervesthat end in the peritoneum proper (Fig 7-14) It is distinctanatomically and surgically from the intermediate stratum ofthe extraperitoneal connective tissue It encases the visceraand forms the adventitia of the gastrointestinal organs Theportion of the peritoneum associated with the body wallthe parietal peritoneum covers the properitoneal fat andencloses the abdominal contents by lining the cavities of theabdomen and pelvis Its somatic sensory nerves that registerpain are found in greater numbers on the anterior portionIt receives its blood supply from the terminal branches of the vessels supplying the abdominal wall The visceral perito-neum in contrast has no sensory nerves the autonomicnerves respond to distention It takes its blood supply fromthe organ that it encloses through the celiac trunk and thesuperior and inferior mesenteric arteries

Blood Supply to the Anterior Abdominal Wall

The superior epigastric artery supplying the upper portionof the rectus abdominis originates from the internal mam-

mary artery (internal thoracic artery) that runs anterior to

the upper margin of the transversus abdominis to passthrough the rectus sheath behind the rectus abdominisnear its lateral border As it runs caudad on the anteriorsurface of the posterior rectus sheath it penetrates themuscle to supply it and then passes through the anteriorrectus sheath to supply the overlying skin (Fig 7-15) Thefalciform ligament supporting the liver contains vesselsfrom a branch of the superior epigastric artery that aredestined to reach the hepatic artery thus requiring ligation

after division

FIGURE 7-13

FIGURE 7-14 This image is from the umbilical herniacase illustrated in Figure 7-12 Peritoneum overlies thedense fibroconnective tissue The only component ofthe peritoneum that is clearly visible is a single layer ofmesothelial cells The mesothelial cells in this image are

reactive and readily seen frequently mesothelial cellsare flat and inconspicuous in tissue sections









69






Somites



Myotomes



Trunk Muscles




A B

FIGURE 7-1









ANOMALIES






FIGURE 7-2

A B












T A B L E

7 - 1









PERITONEUM

FIGURE 7-6









A

B

FIGURE 7-7






Intercostal Muscles





A

B

FIGURE 7-8




Conjoined Tendon


Serratus Anterior


Blood Supply


Nerve Supply




A

B

FIGURE 7-9







Rectus Abdominis



Rectus Sheath




FIGURE 7-10






Linea Alba





Inner Stratum


Outer Stratum








FIGURE 7-11





Peritoneum






after division

FIGURE 7-13









69






Somites



Myotomes



Trunk Muscles




A B

FIGURE 7-1









ANOMALIES






FIGURE 7-2

A B












T A B L E

7 - 1









PERITONEUM

FIGURE 7-6









A

B

FIGURE 7-7






Intercostal Muscles





A

B

FIGURE 7-8




Conjoined Tendon


Serratus Anterior


Blood Supply


Nerve Supply




A

B

FIGURE 7-9







Rectus Abdominis



Rectus Sheath




FIGURE 7-10






Linea Alba





Inner Stratum


Outer Stratum








FIGURE 7-11





Peritoneum






after division

FIGURE 7-13















ANOMALIES






FIGURE 7-2

A B












T A B L E

7 - 1









PERITONEUM

FIGURE 7-6









A

B

FIGURE 7-7






Intercostal Muscles





A

B

FIGURE 7-8




Conjoined Tendon


Serratus Anterior


Blood Supply


Nerve Supply




A

B

FIGURE 7-9







Rectus Abdominis



Rectus Sheath




FIGURE 7-10






Linea Alba





Inner Stratum


Outer Stratum








FIGURE 7-11





Peritoneum






after division

FIGURE 7-13

















T A B L E

7 - 1









PERITONEUM

FIGURE 7-6









A

B

FIGURE 7-7






Intercostal Muscles





A

B

FIGURE 7-8




Conjoined Tendon


Serratus Anterior


Blood Supply


Nerve Supply




A

B

FIGURE 7-9







Rectus Abdominis



Rectus Sheath




FIGURE 7-10






Linea Alba





Inner Stratum


Outer Stratum








FIGURE 7-11





Peritoneum






after division

FIGURE 7-13















T A B L E

7 - 1









PERITONEUM

FIGURE 7-6









A

B

FIGURE 7-7






Intercostal Muscles





A

B

FIGURE 7-8




Conjoined Tendon


Serratus Anterior


Blood Supply


Nerve Supply




A

B

FIGURE 7-9







Rectus Abdominis



Rectus Sheath




FIGURE 7-10






Linea Alba





Inner Stratum


Outer Stratum








FIGURE 7-11





Peritoneum






after division

FIGURE 7-13















A

B

FIGURE 7-7






Intercostal Muscles





A

B

FIGURE 7-8




Conjoined Tendon


Serratus Anterior


Blood Supply


Nerve Supply




A

B

FIGURE 7-9







Rectus Abdominis



Rectus Sheath




FIGURE 7-10






Linea Alba





Inner Stratum


Outer Stratum








FIGURE 7-11





Peritoneum






after division

FIGURE 7-13












Intercostal Muscles





A

B

FIGURE 7-8




Conjoined Tendon


Serratus Anterior


Blood Supply


Nerve Supply




A

B

FIGURE 7-9







Rectus Abdominis



Rectus Sheath




FIGURE 7-10






Linea Alba





Inner Stratum


Outer Stratum








FIGURE 7-11





Peritoneum






after division

FIGURE 7-13










Conjoined Tendon


Serratus Anterior


Blood Supply


Nerve Supply




A

B

FIGURE 7-9







Rectus Abdominis



Rectus Sheath




FIGURE 7-10






Linea Alba





Inner Stratum


Outer Stratum








FIGURE 7-11





Peritoneum






after division

FIGURE 7-13













Rectus Abdominis



Rectus Sheath




FIGURE 7-10






Linea Alba





Inner Stratum


Outer Stratum








FIGURE 7-11





Peritoneum






after division

FIGURE 7-13












Linea Alba





Inner Stratum


Outer Stratum








FIGURE 7-11





Peritoneum






after division

FIGURE 7-13











Peritoneum






after division

FIGURE 7-13













Documents

Anterolat Bodywall.pdf